Seattle's Child

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In Orthodontia, Sometimes It’s Best to Start Early

When I got braces in the eighth grade, I wrote in my diary that the day the hated metal went on “would be my last normal day for two years.”

But for Alexis Maund, 8, getting braces was “the most exciting, coolest thing ever,” says her mother, Toshia Maund of Redmond. The four brackets on the front teeth are shaped like stars and the bands are pink. “Everyone says they’re getting braces,” enthused Alexis after her first day of wearing them to school. She’ll have them on for eight to 12 months.

The number of children in braces or other orthodontic treatment has increased by 46 percent in the last decade to 3.8 million children in 2008. Since 1990, when the American Association of Orthodontics began recommending orthodontic check-ups at age 7, more children ages 7 to 9 are getting early treatment. Usually they’ll still need braces in their teens, thus the process is also called two phase orthodontics.

Alexis has such crowded top teeth that her eye (canine) teeth were coming in sideways because there was no room for them. Maund’s dentist and orthodontist advised that treatment is less invasive when children are young and may prevent extractions later. The only drawback for Alexis is that she can’t have popcorn or gum.

Dr. Greg King, a researcher and professor of orthodontics at the University of Washington, has a long perspective on the field, having practiced for more than 30 years. The advantages of having early orthodontic treatment are that some conditions can be improved when the jaws are malleable that would require surgery or extractions later, he says. The disadvantages are that it may cost more overall to have two phases of treatment, and the child may burn out from having so many trips to the orthodontist and be less compliant with treatment later.

Costs for the appliances and orthodontic care range from $1,100-$3,000 for a palatal expander and $900-$5,000 for braces to $2,000-$4,000 for a headgear or face mask and $200-$500 for extractions. “If there’s a one-time lifetime limit (on your insurance policy), you could use it all up for stage one treatment,” King notes. This is the case for Maund, who has dental insurance through Microsoft.

However, Dr. Donald Joondeph, a Bellevue orthodontist, professor emeritus in the Department of Orthodontics at the University of Washington and past president of the American Association of Orthodontics, says that “a lot of orthodontists treat two phases for the same cost as one phase treatment.” This is the case for Jessica Light of Maple Valley, who has two boys in early orthodontic treatment. The price for her sons’ early treatment will be deducted from the cost of later braces. “Another orthodontist in the area doesn’t offer one price for both treatments, so parents should shop around,” Light says.

In the case of the most common type of orthodontic problem, Class II malocclusion (an overbite or “buck teeth”), 15 years’ worth of studies and clinical trials in North Carolina, Florida, Manchester, England and elsewhere have shown no benefit in appearance, jaw relationships or the number of extractions in doing two phases of treatment. There are a couple of reasons to do early treatment anyway: because severely protruding teeth may be damaged and because the child is being teased or feels self-conscious about her appearance, King adds.

For example, Light’s son, Josiah, now 10, had four braces on his front teeth when he was 9, and kept them on for 13 months. His front teeth stuck way out, where they could be damaged easily, and there was a huge gap between them. The improvement was noticeable right away, Light says.

Light’s younger son, 9-year-old Elijiah, has a palatal expander. It is a metal devise that widens the top jaw before the bones fuse to leave more room for emerging teeth. He has a severe crossbite so that teeth are overlapping in strange ways, and he is actually missing the roots to eight permanent teeth. He has just had braces placed on four front teeth.

Both boys tolerate the braces, but don’t share Alexis’ excitement with them as a fashion accessory. They’re mad that they can’t eat certain candies, Light says. Both will need more treatment later.

Joondeph outlines four examples in which children can benefit from early treatment.

  1. The top jaw is narrower than the lower jaw. “In children, the right and left side of the jaw are not yet joined together. The expansion needs to be done before the sutures close up and growing stops – which can be as young as 12 or 13 years old for girls. If we wait until all of the permanent teeth come in, it may be too late,” Joondeph explains. A palatal expander, which fits on the roof of the mouth and can be widened with a screw, is the most common method used. King agrees that this is a primary reason to “jump in early” with orthodontic treatment to prevent painful surgery later. He adds that if a child compensates for teeth that do not line up by chewing or biting on one side of the mouth, his jaw could grow asymmetrically.
  1. An overbite is caused by a larger upper jaw. “If they’re 9 or 10 and the overbite is really bad, we want to slow down the growth of the upper jaw while the lower jaw grows normally,” Joondeph says. A Herbst appliance, that fits inside the mouth and is worn all of the time, or a headgear, worn only at night, are most commonly used. In the case of an overbite, “the time to do two-phase treatment is when (jaw) growth makes a difference,” he says.
  1. Teeth are severely crowded. “As the child loses baby back teeth, the permanent teeth will slide forward and there won’t be enough room (in the front of the mouth),” Joondeph says. A space maintainer – like a retainer on the roof of the mouth – “holds space during the transition between baby and permanent teeth.” Crowding may also be eased by strategic, serial extractions of baby teeth so that permanent teeth have a space to grow into, King and Joondeph note. Permanent teeth can become impacted when there’s no space for them to come down and gum tissue may recede, King adds.
  1. An underbite is caused by upper jaw being too far back. An underbite (Class III malocclusion), in which the lower teeth overlap the upper ones, is less common than an overbite and is more prevalent in Asians. About a third of underbites are caused by an upper jaw that’s too far behind the lower jaw, and those can be helped by a headgear or face mask that pulls the upper jaw forward, Joondeph explains. “We need to do it at age 7 to 8, no older than 10,” he notes. “It prevents surgery in 70 percent of patients (with that condition).”

“Thirty to forty years ago, people didn’t look at mouths until adolescence when permanent teeth were all in,” Joondeph says. “Now we get earlier referrals from dentists, and parents are more educated and are bringing their children in at younger ages. We have more evidence that some things are easier to treat at an earlier age.” In the “old days,” he notes that 80 percent of orthodontic patients ended up having extractions; now 80 percent do not.