A while back I wrote an article titled, “Why do I see so many eight year-olds in braces these days?” I believe it is imperative that a parent knows why early treatment has been recommended by an orthodontist, as there should be a clearly defined reason that treatment cannot wait for one comprehensive phase when the majority of the permanent teeth have erupted.

The questions I ask myself when evaluating a younger child’s facial and dental development before all of their permanent teeth have erupted are:

• If I do not treat this patient now, will a window of opportunity be missed that will negatively affect their facial structure, bite, or esthetics in the future?
• If we do two phases of braces, will I achieve a better or more stable result than if we treated with one phase?
• Will the patient look or function differently as an adult if we treated in one phase versus two?

If the answer to any of these questions is “yes”, then early, or phase 1 treatment may be indicated. Whenever possible, I prefer to treat patients in a single phase of treatment (this is not always the case with all orthodontists), because a second phase is usually needed to fully align the teeth when the child is older. When early treatment is recommended, I like parents to know exactly why. Here are the most common reasons (it important to note that I see many of these cases, but they are not the most common types of jaw/dental orthodontic problems- more about that later!)

• Posterior crossbites with a functional shift.  Posterior crossbites are when the back teeth are biting on the wrong side of one another, usually due to an upper jaw that is too narrow compared to the lower jaw. Why is early treatment recommended?  Early treatment is recommended if the lower jaw is shifting to one side for the child to find a comfortable bite. If left untreated, this can result in permanent asymmetric lower jaw growth to one side. If your child has a posterior crossbite without a shift, I will discuss the magnitude of the problem with your family- not all posterior crossbites require early treatment!
• Anterior crossbites due to skeletal growth issues.  Anterior crossbites are when the lower front teeth are located in front of, or edge to edge with the lower teeth. If this is caused by the lower jaw growing too much or the upper jaw not enough, early treatment is almost always recommended for these cases (unless it is so severe that facial surgery is the only option). Teeth will often tip to try to compensate for this growth, and it is possible to not have full crossbites, but have the skeletal pattern detected early (my youngest daughter has this  skeletal pattern).This type of bite is one of the most complicated and difficult types of treatment, and is distinctly different than teeth that have merely erupted in the wrong place. Why is early treatment recommended?  Underbites that are skeletal in nature usually become more severe as children enter their adolescent growth spurt. We try to reduce or eliminate the need for a surgical correction, or identify surgical cases as early as possible.(Please ask about previous articles that I have written about the complications with this type of skeletal pattern).
• Severe crowding that leads to impacted teeth, severe misplacement, or compromises the periodontal (gum) structures hold the teeth stable.  Crowding and misaligned teeth are the most common reasons that patients seek orthodontic treatment, but only a minority need early or phase 1 treatment. This is where it is up to the ethics and integrity of the orthodontist to properly guide the family, and not to treat early because it is good for the practice’s bottom line. But at times, teeth cannot even enter the mouth due to crowding, and treatment is indicated. Why is early treatment recommended? If teeth cannot enter the mouth, or are in extreme positions, Phase 1 treatment may be needed. Examples include canines that are becoming impacted (an would need a future surgery to correct without intervention), incisors and premolars that cannot enter the mouth properly, loss attachment (gums and bone) on the lower front teeth, or severely protruding upper teeth (often from thumb sucking) that is a clear trauma risk. Other reasons can include severe deep bites where the lower teeth are biting against the top of the mouth, severe open bites or permanent teeth that are becoming excessively worn at an early age. I will show parents the specific problems present, and relate them to the three Phase 1 criteria listed above if I believe that phase 1 treatment is needed for these reasons.

Now, just as importantly, things that should not require early, or Phase 1 treatment:

• Most crowding, spacing and misalignment of teeth at an early age. As stated above, these are the most common reasons children are brought in for an exam, and the vast majority do not need early treatment for this reason. Why not?  Simply put, most crowding, spacing and misalignment is most efficiently, and just as effectively treated when the majority of permanent teeth have erupted (usually ages 10-13 for girls, and slightly later for boys). If possible, less time in braces is healthier for the teeth and gums, reduces family stress (retainers are needed to hold phase 1 corrections until kids are ready for full braces), and reduces “burnout” from being in treatment too long. Also, space can be gained from skeletal maxillary expansion anytime before the maxillary suture fuses, near the end of the adolescent growth spurt (early teens for girls, mid-teens for boys). Again, proper, well informed guidance is needed to not treat too early, or at times too late– once the maxillary suture fuses expansion is no longer possible.
• Excessive overbites (Orthodontists and dentists refer to this as “Overjet”).  Overjet is actually the term for how far the upper teeth stick out forward from the lower teeth, and this is the second most common concern I see for young kids in my practice. The vast majority of kids with this issue do not need phase 1 treatment. Why not? Vast amounts of research have shown that correction of this issue is most efficiently treated in one phase of treatment, usually during the adolescent growth spurt, and when most of the permanent teeth have erupted. Now, I do see a number of kids each year where the overjet is severe and they are having social problems, and there is a clear risk of trauma to the upper teeth and lips. In these relatively few cases, early treatment is certainly indicated.
• Upper canines (and other teeth) that are erupting at an angle when seen on a radiograph.  I often hear parents say this was the reason their kids received early treatment, but this is usually not an indication for phase 1 treatment. Why not?  Early treatment should only be started for this reason when the canines have started to actually cross over the roots of the neighboring incisor teeth, or are otherwise severely off course. Canines that are erupting at an angle is usually age appropriate.

My next article will explain what to expect from Phase 1 treatment if it is needed, what to expect immediately after the treatment (retainers), and how early treatment is related to full braces when your child is older.

Dr. Dan Rejman is the owner of Meadows Orthodontics, a private specialty practice in Castle Rock, Colorado. He has treated over 6,000 patients with braces and Invisalign, and has been Board Certified since 2007.

A rapid palatal expander (RPE), is very commonly used in orthodontics as a means to gain space for crowded teeth, and to correct crossbites. This device may look a bit intimidating, but treatment with an RPE is actually very gentle and is usually quite comfortable for the patient. Here is what to expect if Dr. Dan recommends an expander for your child.

• Placing separators: Dr. Dan will check if there is enough space between the upper molars to comfortably and accurately fit bands around these teeth. If the teeth are really tight together, we will place “separators” in between the back teeth to create a small space. Patients often describe separators as feeling like there is food caught between their teeth for several days. If the separators fall out with several days off being placed, let us know-you may need new ones placed. If it is only several days until the next appointment, you don’t need to call us!
• Band fitting appointment:  Bands are like “rings” around the upper molars, and act as an anchor to keep things in place and stable. We will find the exact band that is the right size for your teeth. We will then take an impression of your teeth with the bands on them, remove the bands, and send everything to a lab where your expander is created. Your expander is custom for your mouth only, and it takes about two weeks make.
• Appointment for placing the expander: At this visit, your expander will be delivered by cementing or bonding it to your upper teeth. We will teach parents how to turn the expander at home, and let them know how many turns are needed. We will also discuss hygiene and diet tips for keeping the expander secure and clean.
• First expansion check appointment: After a week or two (depending on the amount of expansion Dr. Dan determines is needed) you will return, and Dr. Dan will check to make sure the amount of expansion is just right. Sometimes he will ask for several more turns to be made.
• Your RPE will stay in place (without turning) for 6-9 months: This gives the maxilla, or upper jaw, time to remodel and make the changes remain after the expander is removed. We often slightly over-expand to account for relapse that usually occurs after the expander is removed.

Common questions and concerns

Kids are usually surprised that there is relatively little discomfort associated with the above appointments. Separators usually cause soreness for several days after they are placed, and there is a pushing sensation when we fit the bands. Patients most commonly report a “tight” sensation for several minutes after their parents turn the expander, but pain is relatively rare. Also, expect a small space to form between the front teeth (a sign that the upper jaw is expanding!).  If your “S” sounds are a bit slurred when speaking, read out loud as often as you can, and in several days your original speech will be very close! If you have any concerns at all, give us a call- we are always happy to answer any questions you may have!

Dr. Dan Rejman is the owner of Meadows Orthodontics, and is a board certified specialist in orthodontics and dentofacial orthopedics. Meadows Orthodontics serves patients from Castle Rock, Castle Pines, Franktown, Elizabeth, Larkspur, Parker, Highlands Ranch and Lonetree.