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Wheeler Orthodontics • 4568 Feather River Drive Suite D • Stockton, CA 95219 • Phone: (209) 951-0151 • Fax: (209) 951-1235 • www.wheelerortho.com

Thursday, July 25, 2013

What to Expect With Your Child’s Palatal Expander

One of the most common orthodontic appliances used in young and growing children is the palatal expander. These appliances can look a little intimidating and barbaric at first to patients and parents and the very thought of having to “do the turns” every day at home can seem scary to a lot of parents. Trust me, they are not as bad as they seem.  I have been using expanders successfully in my practice for years and have been thrilled at how well they work for my patients.  So I wanted to share some things with those of you who might have just received, or will be receiving your expander on what can you can expect of having an expander as part of your orthodontic treatment?
Arch expansion is one of the most common ways to eliminate crowding and correcting crossbites in growing patients. I call it a game changer in the realm of orthodontics.  Expanders can easily solve some orthodontic problems that were difficult to solve in orthodontic cases of the past. Expanders have greatly reduced the need for routine extractions, and have eliminated the need for many jaw surgical procedures.
To work successfully, palatal expansion requires that the growth plate in the roof of the mouth (specifically, the mid-palatal suture) has not yet fused. Typically, this fusion usually occurs between 12 and 16 years of age, and usually occurs earlier in girls than in boys.

An expander is attached to the upper arch by bands placed around the upper first molar teeth. There are many variations of expanders being used today in modern orthodontic offices, but at Wheeler Orthodontics we prefers the “HYRAX”—which is short for HYgenic RApid eXpander.  Although there are removable expanders on the market, glued in ones have a very important advantage in that they cannot be lost, taken out, or forgotten.  Hyrax-expanders are easily cleaned!  Also important is that glued in expanders like the HYRAX maintain an intimate contact with the teeth, and the gentle force of the expansion does not overpower the ability of a removable expander to maintain its position in the mouth, where removable ones can be easily dislodged.

While there may be some initial discomfort right after an expander has been placed--just because there has never been anything like that attached to the teeth before--for the most part upper arch expansion is painless. Patients report that they feel a little “pressure” on the teeth, in the roof of the mouth, behind the nose, and even between the eyes as their expander is activated. This pressure fades within minutes.  And keep in mind that an expander does its job in about 3-4 months, then it is removed, so it is not in the mouth for a long time.

Besides pressure, you can also expect your child to speak a little funny for the first couple of days—which will quickly pass.  Additionally, you may hear them slurping as their mouth creates extra saliva after expander cementation. One of the most visible signs that the suture is opening (the desired effect) is the appearance of a space between the upper central incisors. The space is created as the expander pushes the two halves of the palate in opposite directions. Once you have stopped activating the expander, it is normal for the space to close quickly. This occurs by active closing forces that the braces will provide, combined with the help of elastic fibers in the surrounding gum tissues together working to return the teeth together and to close the gap. 

To make the first couple of days more bearable for your child as they adapt to their new expander, you may want to find some fun foods for them to eat that don’t require a lot of chewing. Examples include yogurt, pudding, mashed potatoes, ice cream, etc. A day or two after their delivery appointment, the expander will feel natural in their mouth and normal eating will resume. While expanders are more forgiving of hard and sticky foods than are braces, it is still recommended that patient avoid anything that would get stuck in the expansion screw.  However, we got you covered that situation, as we will give you a gadget that will help you remove anything that gets accidentally stuck around the expander.
Because there is always a potential relapse (movement back towards the original size) if expansion is made to fast, Dr. Wheeler recommends that the expander is only turned once every other day.  This allows for a nice, continuous, and harmonious rate of expansion that is biologically compatible with the tissue of the growth plate and your child’s inherent rate of growth.

One really cool thing expanders can do, besides the obvious effect of making room for the eruption of permanent teeth and in creating jaw harmony, is the ability an expander has of widening the nasal passages and upper airway.  The bone of the palate, is the same bone that makes the floor of the nasal passages.  So orthodontically widening the palate also widens the nasal airway. So you might see this nice side-effect:  Improved nasal breathing in your child.  This improvement can be significant! This can have a life-long improvement in reducing the risk of sleep apnea, sinus and ear infections, mouth-breathing, and snoring, especially as your child moves into adulthood. Sleep can be improved!!

When Do I Get My Braces Off?

The absolute, single most most common question I get as an orthodontist is this:  “When do I get my braces off?” 
Although treatment is unique for every patient, there are some basic objectives and steps of orthodontic treatment that are similar for the majority of the patients I see in my office.  If you have braces now and want to know how you are progressing, please read on…
In my office there are three distinct phases of treatment through which every patient must pass. Although their order may be switched or there may be some overlap between them, the three steps of orthodontic include resolving the crowding/spacing, aligning the teeth, and correcting the bite.

In the first step, crowding is corrected by either expanding the arches or by removing teeth through extractions. Teeth cannot be aligned if there is simply not enough room for them. The decision to expand or extract is determined by a number of variables including the size of the teeth, the size of jaws, the amount of bone and gum tissue supporting the roots, and the profile and facial esthetics. The first step is to create room so that the teeth can be aligned. If a patient has extra space at the start of treatment, that space must be closed during this step.  If the teeth are crowded, then space must be created for them.

Once there is room, the second step is to align or straighten the teeth. Aligning the arches is accomplished using wires, elastic chains, springs, and other auxiliaries that rotate, tip, torque, tweak and tease the teeth into their desired positions. Another common step in the alignment process is “repositioning” individual brackets. Sometimes brackets cannot be put in the right place on the first day because of the bite, the alignment, or the shape of the teeth. After the teeth have been partially aligned however, the brackets can then be moved to better positions.

The third step of treatment is correcting the bite or making the upper teeth fit the lower ones. This must be accomplished in all three planes or dimensions of space, front to back (overbite or underbite), side to side (crossbites), as well as top to bottom (open bite or deep bite). Making the upper match the lower is accomplished with wires, rubber bands, springs, or in extreme cases surgery. When the bite is right, the backs of the top teeth rest lightly on the fronts of the bottom ones and the teeth should interdigitate nicely, such as how the teeth of a zipper fit together.
The “When do I get my braces off?” question usually arises during the third or “bite step” of treatment. By that time the crowded, crooked teeth are gone, the smile looks great, and the patient is generally happy with how things look. I have to admit that the first half of treatment exhibits more dramatic changes and is more exciting than the last half. But I must stress that it is during the final phase however where the overall bite is corrected so that the results will be healthy and stable.  I admit, this can be a hard sell to some people.  But rest assured that these small tweaks and adjustments are very important.  I am a big believer that the best long-term retainer is a good bite.

If you are wondering if you’re getting close to getting your braces off, compare what you see in your mouth with this quick checklist:
        1. Are the teeth straight?
        2. Are the spaces between the teeth closed completely?
        3. Do the upper front teeth overlap the lower front teeth appropriately (not too deep, but no visible   space between them)?
        4. Are the outer cusps of the upper teeth resting on the outside of the corresponding ones in the lower?
         5. Is the overbite or underbite corrected?

If it is obvious that your teeth are still crooked, have spaces between them, or you still have a deep bite or overbite, you probably still have some time remaining. If your treatment time is longer that was originally estimated, check out another article I wrote about that at http://wheelerortho.blogspot.com/ entitled Dr. Wheeler’s Formula for Successful Orthodontic Treatment.  If you have specific questions about your smile or your treatment, ask me to explain what objectives remain in your treatment.  Rest assured that your braces will come off when the best result is achieved and not before. 

--- Doc W

What is the Purpose of a "Recall" or an "Orthodontic Observation" Appointment?

Life at times can be very hectic. Moms and dads have busy schedules.  Picking their children up from school and taking them to the orthodontist is no simple task. Sometimes the appointments are very short and can seem meaningless. One of these appointments is the observation or recall visit. These appointments are usually less than 15 minutes and many wonder if they are really necessary at all. Recall or observation appointments are very important, and here’s why…

Observation or recall visits are scheduled for orthodontic patients who are either not yet quite ready for braces (where we may be waiting for a tooth or two to erupt) or have had a first phase of treatment already and are waiting for their remaining permanent teeth to come in so they can finish their orthodontic treatment. The orthodontist often will take a progress x-ray at this appointment to help him evaluate your child’s dental development. There are three things that I look for when your son or daughter is in my chair.

First, if the patient has had an interceptive phase of treatment, the first order of business is checking the condition of the retainers. Our Phase 1 retainers removable retainers designed to hold the correction of the teeth me made with braces, and to hold the space so the remaining permanent teeth can erupt into position as best as possible.  If a retainer comes loose or is lost, the teeth would be free to shift or move and the result of the initial treatment compromised. It only takes a couple of minutes to adjust a loose retainer. If the teeth have shifted it is not so easy to realign teeth without putting the braces back on. Another type of retainer we use in young patients is called a space maintainer. It is designed to preserve the space necessary for the eruption of a permanent tooth after the corresponding tooth is lost early. It is at a recall appointment that we determine when it is appropriate to remove a space maintainer.

The second objective of this appointment is to evaluate the loss of primary teeth and the eruption of the permanent replacements. Losing primary teeth on time and in the right order can help the permanent teeth come in straighter. If I notice that a baby tooth is not falling out on time, or I identify in an x-ray that the permanent teeth are headed in the wrong direction, I usually recommend that a patient see their family dentist to get the baby tooth in question removed. Evaluating the loss of primary teeth and the eruption of permanent ones really doesn’t take much time, but ignoring developing problems can add months or years to a patient’s orthodontic treatment.

The third objective of any observation appointment is to counsel with the family about the timing of the next phase of treatment. My philosophy is that I will begin no treatment before a patient is ready. This might mean waiting a few months or even years. If we start too early, your son or daughter may have the braces on too long. If we wait too long, we might miss the opportunity to keep treatment as short as possible or end up extending it high school years where important  prom or graduation events happen, which interfering with them is not too popular with patients or their families!

Having your orthodontist follow your child’s development will help them receive the care they need when they need it. Although observation and recall appointment are short and sometimes seem like a wasted trip, your orthodontist knows exactly  what to look for at an observation or recall appointment and will make sure that your child is progressing towards an excellent orthodontic result. Next time your son or daughter has an observation visit with your orthodontist, make sure and ask for an explanation of the things he was looking for and what he found. I think you’ll find that these short, to-the-point appointments are as important as any appointment you’ll ever have.