Early Treatment

Ever wonder why you see so many 3rd Graders running around with braces when they don’t have all of their permanent teeth in yet?  Good question, and one that orthodontic researchers are gaining increasing insight on when this is appropriate and when it might be too much too soon.  At Bentele Orthodontics our philosophy is to limit the time in braces and the number of appointments and therefore cost so this is an important topic for study.  We can’t complete treatment until all the permanent teeth are in so early treatment means a commitment to a 2nd phase of treatment later.

Scenario #1 Underbite:  The evidence 1,2 shows that early correction of the actual bone structure (orthopedic correction) is best accomplished early but can be done later.  Mild cases may only require braces or a modified retainer to correct and in moderate cases a reverse type of headgear.  Severe cases, due to a skeletal disharmony, may best be left until growth is complete and treated with a combination of braces and surgery.
Scenario #2 Posterior crossbite: as Kecik states3 , posterior crossbite, “if left untreated can cause asymmetric mandibular growth, facial disharmony, and severe skeletal crossbite”.   Clearly, early treatment of posterior crossbite is indicated.  There is a variable upper age limit when bone fusion makes orthopedic expansion difficult and failure of orthopedic expansion can occur as early as age 15 in a female. Unmistakable thumbs up for early treatment.
Scenario #3 Spacing: This is a sure thumbs down for early treatment unless it is causing other problems like preventing canines from erupting.  The science4 shows that spacing of the front teeth in your typical 9 year old is, well… typical and tends to go away on its own.
Scenario #4 Crowding: This is the chief concern of the majority of patients who come in for an orthodontic evaluation.  Dr. Little at the University of Washington has spent a lifetime researching5 the stability of teeth after braces and what effect expansion has.  His message is that expanding the dental arches to squeeze the teeth in is unstable and therefore unwise.  Many parents come to us for a 2nd opinion because they have been pressured to do something now for crooked teeth even though all of the permanent teeth are not in yet.  There are some preventive things we can do early to alleviate crowding such as preserving space from the larger baby molars, removing baby teeth early to allow the permanent teeth to erupt more easily or in cases where the upper dental arch is truly narrow to widen it orthopedically.  The lower arch cannot be expanded without surgery.  Full braces in that 8-11 year age range are usually inappropriate because all of the permanent teeth are not yet in.  So yes for prevention, no for full on braces.
Scenario #5 Overbite: or what orthodontists call overjet.  The research on early treatment for excess overbite is pretty clear6,7.  Despite decades of trying various methods it doesn’t appear that early treatment of an excess overbite is any more effective that later treatment.  Orthodontists can definitely improve an excess overbite early but the same can be accomplished later in a single phase for cheaper and with fewer appointments when you have plenty of soccer games to attend now.  It makes sense to address excess overbite early if we are already correcting something like a posterior crossbite, a damaging deep bite or in the case of an active child who is prone to damaging protruding front teeth.

So in summary:  Please don’t feel rushed to start a child in early treatment.  These are not crisis problems that need to be started on immediately and if you’re being made to feel that way then it’s a good time to step back and get a 2nd opinion.  There are also valid psychosocial reasons for early treatment if the child is being teased or feels self conscious about their appearance.  A thumbs up for early treatment for posterior crossbites or underbites; spaced teeth can wait until later; crowding may need to be addressed early to allow eruption of permanent teeth but don’t excessively expand or focus on a perfect alignment of teeth at a young age; excess overjet (overbite) can wait for successful treatment later but may be treated in conjunction with other problems or to reduce the chance for trauma to front teeth.

1. Franchi L, Baccetti T, McNamara J. Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances. AJODO 2004; 126:555-568
2. Ngan P. Early treatment of Class III malocclusion: Is it worth the burden? AJODO 2006,129 Supplement: S82-S85.
3. Kecik D, Kocadereli I, Saatci I. Evaluation of the treatment changes of functional posterior crossbite in the mixed dentition. AJODO 2007; 131: 202-215.
4. Jonsson T, Magnusson TE. Crowding and spacing in the dental arches: Long-term development in treated and untreated subjects. AJODO 2010; 138:384-387.
5. Little RM. Stability and relapse: Early treatment of arch length deficiency; Presented at the International Symposium on Early Orthodontic Treatment, February 8-10, 2002; Phoenix, Ariz. AJODO 2002; 121:578-581.
6. Livieratos F, Johnston LE. Outcomes in a 2-phase randomized clinical trial of early class II treatment. AJODO 1995; 108:118-131.
7. Tulloch CJF, Proffit WR, Phillips C. A comparison of one-stage and two-stage nonextraction alternatives in matched Class II samples. AJODO 2004; 125:657-667.

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