Mrs. Brace Face
After three years of orthodontics in middle school, our writer needed more as an adult. And Invisalign alone wasn't enough.
Illustration by Scott Pollack
If you’re looking for an unvarnished opinion, ask your children. Or don’t ask. Either way, they’ll probably tell you exactly what they think.
A few years ago, my son, who was 12, and daughter, then 9, were both undergoing orthodontic treatment and had braces on the brain. “Really, you had braces?” my son asked me with over-the-top bewilderment. “Your teeth are definitely crooked,” my daughter concluded after a careful inspection with her hand and nose, practically reaching my tonsils. “Thanks,” I responded. “Make your own dinner.”
After a closer look in the mirror, I realized that my kids were annoyingly astute—my teeth did appear crowded and crooked. So I decided to consult their Bethesda orthodontist, Carmine Petrarca, despite being in my early 40s, despite the fact that I had already endured large silver braces and headgear for three years in middle school. Petrarca determined that my teeth had shifted due to factors he sees in many older patients—I had stopped wearing my retainers in college, and I was clenching and grinding my teeth (thanks again, kids). As a result, my face ached and the look and health of my smile were going downhill.
I chose to fix these problems with another round of orthodontics, and an increasing number of adults are right there with me. More than 1.4 million adults in the U.S. and Canada received treatment in 2014, a record high and a 67 percent increase from 1989, according to the most recent data available from the American Association of Orthodontists (AAO). “A lot of people come in caring about cosmetics,” Petrarca says, “but that’s really the icing on the cake.” What’s more important, he explains, is how orthodontics in adults can correct tooth and jaw alignment and improve underlying health problems. Treatment can help with pain, plaque buildup and periodontal disease. It can prevent damage to the teeth, even tooth and bone loss. While I didn’t like the look of my teeth, more worrisome was the misalignment, which was causing my jaw pain and could have led to premature tooth loss.
Leah Ariniello in middle school. Courtesy photo
Still, it was a hard decision. I had flashbacks to my younger years in braces, when I would eat yogurt for breakfast, lunch, dinner and dessert because my teeth were so sore that it was even painful to chew a soft french fry. I mastered smiling with my lips closed since I was certain that my braces drew all eyes to my nose, somehow supersizing its appearance. This time, for a large part of the process I’d be able to use Invisalign, clear aligners that are barely noticeable. No wires, no metal. The popular treatment involves customized and removable plastic trays that snap tightly over the upper and lower teeth. The trays are changed out every week or two, slowly shifting the teeth into alignment. But I couldn’t start Invisalign right away. First I’d need a bite plate and traditional metal braces. Braces. Never did I imagine that I’d be in braces again. What about french fries? And the treatment would be expensive. I could think of a lot of ways to spend that money. There was a used convertible for sale up the street. I’d always wanted to go to Italy. I really needed a new kitchen counter. Instead, I was getting braces. As a grown-up.
Bethesda orthodontist Carmine Petrarca, pictured with patient Amy Jackson, used to treat mostly children. Now about 30 percent of his patients are adults. Photo by Deb Lindsey
When Petrarca started practicing in Bethesda in 1980, he mostly treated children, but adults now account for about 30 percent of his patients. He says adult interest in orthodontics “jumped dramatically once Invisalign came into vogue in 1998,” and most adults who come in, myself included, request it. He treated himself with the technique when he was in his 50s.
At my consultation, Petrarca explained that Invisalign alone wouldn’t be enough for me. My clenching and grinding habits had caused my teeth to collapse inward, creating an overbite. For the first several months of my treatment, before using Invisalign, I had to wear a bite plate, a removable appliance that snapped across the roof of my mouth and slightly shifted the upper teeth away from the bottom. I also needed braces on my bottom teeth for about seven months to help align and level my bottom arch. “You can probably correct an overbite 60 to 70 percent with Invisalign,” Petrarca says. “But you can’t correct it 100 percent unless you use bottom braces to get the lower jaw perfectly level.”
The bite plate reminded me of the college retainer that I wore on my top teeth. I could easily pop it in and out, and mostly wore it in private. On the other hand, wearing braces again felt odd at first—and my kids didn’t help. When they first saw my metal mouth, they gave me that look of, Oh my God, could our mother be any more embarrassing? But besides mortifying my children and the metal making my teeth appear gray, I didn’t really mind them after a few days. At one point, my daughter, son and I were all in metal braces, and it helped expand our dinnertime conversation beyond schoolwork. They were debating what color elastics they should get next, and they both thought it was weird that I wanted the least noticeable color. “Should I try hot pink then?” I asked, just to see their reaction. No, they said, that would be double weird for an adult. Can’t win.
When I finally got Invisalign, I appreciated how easily I could remove the upper and lower trays. I felt very little discomfort, if any, when I started using new ones, and my eagle-eyed kids didn’t even detect them at first. Other people who’ve used Invisalign also found that the trays were virtually invisible, including Erin Mikulak-Raimundo, an assistant vice president at Chevy Chase Trust. The 43-year-old Rockville resident wore the appliances for eight months to correct an alignment issue that was making her top teeth loose. She felt self-conscious the first day and told everyone she came in contact with that she was wearing the aligners. But then she stopped mentioning it. “No one seemed to notice,” she says. “I wore them in meetings and everything.”
I kept my aligners in religiously, taking them out only to brush, floss, eat and drink anything other than water. Invisalign recommends wearing the aligners 20 to 22 hours daily to obtain the best results. As someone who likes to nurse coffee and snack all day, this was challenging. The first few weeks I actually lost 5 pounds. You can’t even get away with sipping a smoothie or spritzer—I tried drinking white wine through a straw with the aligners in place and they yellowed.
I also had to be a dedicated brusher and flosser. That was the one good thing about braces: I could eat whenever I wanted, without having to worry about finding a bathroom to deal with them, like I did with the aligners. I always carried supplies with me in order to clean the aligners before I put them back in after eating and drinking. If I wasn’t diligent, the aligners would quickly become gunky and start to smell. I also needed “attachments” with my Invisalign. Practitioners sometimes use these small bulges of dental bonding to help move or rotate teeth that aligners alone can’t fix. At first the bulges weren’t noticeable, but after several months they stained light brown and my kids would report that I had food stuck in my teeth, not realizing it was just the attachments.
“Invisalign is a great tool for minor crowding and minor spacing issues,” says Rockville orthodontist Frederick Fritz, “but even if Invisalign is not an option, there are a lot of other things we can do that are easy and comfortable for adult patients.” There are traditional metal braces, like I had, which are much improved since my middle school days and tend to be the least expensive choice. Today’s versions use a much smaller bracket attachment on each tooth. Clear braces, generally made of a ceramic material, are also available, and they don’t stain like they once did, Fritz says. I considered clear braces for my bottom teeth, but Petrarca told me they were not an option for my situation. The material in the clear braces is harder than tooth enamel, and because I clench and grind my teeth I would risk chipping them on the clear brackets. With traditional braces, the metal wears down, not the teeth. Orthodontists can also place braces behind, instead of outside the teeth. These “lingual braces” are making a comeback, according to Fritz. Newer versions are gentler on the tongue and are only used on the front top or bottom teeth when the back teeth are in good shape. “It’s a nice aesthetic option that can do a little more than Invisalign without a patient having to undergo a full set of braces,” he says.
There are also ways to speed up treatment, Fritz says, such as wearing “self-ligating” braces. Traditional braces have three parts: the small bracket, which is placed on each tooth; a wire that applies pressure; and a band, usually elastic, that connects the wire to the bracket. Self-ligating braces, which come in a metal or clear version, have special brackets with built-in clips to hold the wire. This eliminates the need for elastics, which can cause friction between the brackets and the wire, slowing the movement of the teeth. The brackets in self-ligating braces are able to slide more freely along the wire, applying a more consistent, lighter force and shortening treatment time. According to Fritz, these systems can cut treatment time by about six months. “It’s a big difference,” he says.
Stephen McCormick, 50, had orthodontic issues that couldn’t be treated with clear aligners, so he had to wear a full set of braces. He says the results far outweighed the inconvenience. The Rockville resident needed braces growing up, but his family couldn’t afford them. For years, McCormick was unhappy with the look of his crooked smile, and the crowding of his teeth led to periodontal issues as he aged. Bacteria can cause gum damage and eventually lead to tooth loss.
“I flossed all the time, but because my teeth were so crowded I still had issues,” he says. At first, braces made McCormick, a nurse, feel self-conscious in public and around his patients. “I felt goofy with braces at my age,” he says. Soon he noticed that the braces opened up a dialogue. “A lot of people were very curious about my treatment and talked to me about how they wanted to improve their own appearance.” After two years of treatment, McCormick’s braces were removed in June 2016. “My periodontal issues have really improved, and even when I had the braces on, people were commenting [on] how nice my teeth look,” he says. “I feel really good about myself.”
Ariniello, pictured after she completed her treatment, went to Petrarca when she was in her early 40s. Photo by Deb Lindsey
Research suggests that many people believe an attractive smile can lead to improved relationships and professional success. A 2012 survey of American adults commissioned by the AAO found that more than one-third of the 1,000 respondents were unhappy with their smile, and many believed that better teeth could lead to a better social life and professional success. The survey revealed that 77 percent of women thought crooked teeth were worse than a receding hairline when it came to a potential love interest. It also found that 22 percent of Americans who were unhappy with their smile thought that fixing their teeth would improve their love life; 14 percent believed they might be missing out on a better job.
In 34 years of practicing, Lisa DeMarco says she has seen how orthodontics can be life-altering at any age. “We have seen amazing transformations,” says DeMarco, an orthodontist who practices in Silver Spring. “People look younger, happier, healthier, and have boosts in confidence.” One of her patients came for treatment at age 83 after taking care of a dying spouse for months. “She said, ‘Now it’s time for me,’ ” DeMarco says. After treatment, the patient went overseas, met someone and remarried.
Although most adults—no matter their age—can benefit from orthodontic treatment, there are some caveats. First, patients need healthy bones and gums to withstand the pressures that are applied to move their teeth, Petrarca says. Bethesda resident Amy Jackson says several orthodontists she consulted told her that she’d need surgery before orthodontic treatment in order to align her jaws. Jackson, 54, had braces at 16, but the treatment didn’t completely fix her bite. Over time it became even worse from clenching and grinding. She experienced pain, and her rear molars were becoming ground down.
“I also noticed that my top teeth were becoming more and more like buck teeth, which was how my teeth looked as a kid,” she says. “I wanted to do something, but I was worried about the risk of surgery.” The procedure, she says, would have required shaving the bone in her upper jaw near the sinuses to realign the teeth and fix her bite. “The surgery is very invasive, and I read that there is a risk for issues and pain afterwards,” she says. Jackson ended up choosing Invisalign, even though she knew the results would not be perfect. “My orthodontist said surgery would be ideal, but if I was really against surgery, I could still improve my bite significantly.” Jackson started her treatment in October 2016, and it was expected to continue for 15 to 18 months. Her pain has diminished already, and her teeth are straighter. “I wish I did this a long time ago,” she says.
Another consideration is the expense. Adult orthodontics typically cost around $5,000 to $7,000, according to the latest survey data from the American Dental Association. I paid around $6,000 for my treatment (including the initial consultation, X-rays, all dental appliances, office visits and my retainers) after receiving 20 percent off as part of a family discount. Dental insurance and flexible spending accounts may help offset the expense, and some practitioners offer payment plans. It can also pay to seek several consultations before deciding on a provider since fees and treatment plans can differ. I met with three orthodontists when my son needed braces, and each offered a different plan and price. I ended up choosing Petrarca to treat my children (and myself) because of his experience.
Some dentists offer clear aligner treatment, but it’s a good idea to check how much extra training they’ve had in orthodontics. A dentist can provide Invisalign after completing a one-day course and some online and self-directed course work. In addition to any Invisalign training, orthodontists complete two to three years of specialized training beyond dental school and have an expertise in straightening teeth and aligning jaws. “I think it makes sense to go to the discipline with the expertise,” says longtime Bethesda orthodontist Peter Coccaro Jr. “I doubt anyone would want me to set their broken arm.”
Once my treatment was complete, I was surprised to find out that I’d need to keep wearing retainers. Forever. In the past, orthodontists recommended that patients wear retainers for maybe a year or two, but Petrarca told me the thinking changed in the 1980s. Wearing retainers for a year after treatment helps keep teeth straight. However, it’s now recommended that adults wear retainers nightly for the rest of their lives, or as long as possible, to prevent any changes that can happen over time. “The majority of people clench or grind their teeth at night, so you need to wear something to prevent that and keep the teeth in place,” Petrarca says. I’ve been wearing my retainers for several months now, and over time they’ve become a comforting habit and seem to help me sleep better. If I happen to nod off without them, I end up jerking awake to put them in.
My treatment wrapped up in the summer of 2016, after nearly two years, but even with the downsides I would do it again. I have no more jaw pain and my teeth are straight. Even my kids are impressed. “They look good,” my daughter told me. “Just a little yellow.”
Leah Ariniello is a science and health writer based in Bethesda.