Two-phase orthodontic treatment (also known as early, preventative, or interceptive orthodontics) seems to be more popular today than ever before. It is not uncommon to see braces on elementary school children. Why is this so?
The American Association of Orthodontists, The American Dental Association, and the American Academy of Pediatric Dentstry all recommend that all children be seen by an orthodontist by age 7 so that the growth and development of their teeth and smile can be evaluated. By age 7 most children have grown in all four of their 6-year-molars as well as all four of their permanent upper and lower incisors. With these teeth in place, your doctor can identify most of the orthodontic problems your child may have, and can predict how growth will impact your child’s overall dental development, and can counsel you on whether early treatment would be beneficial.
What kinds of dental problems should be addressed early when your child still has lots of baby teeth?
The first type of problem has to do with the amount of space available. Crowded and crooked teeth overlap each other and they cannot be lined up straight. Teeth with too much space or with excessive flaring may actually prevent other permanent teeth from coming into the mouth. Crowding in the front of the mouth is obvious. Crowding in the back of the mouth is not so obvious, and may only be visible with the aid of an x-ray radiograph. Moderate crowding and spacing problems should be addressed at an early age so that the remaining permanent teeth can come in correctly. If treatment is delayed, some of the teeth may become impacted (do not erupt) or can damage the root of adjacent teeth. I am a believer that if you make room for the permanent teeth to erupt, you give those teeth the best chance to erupt where they belong. This I feel leads to long-term stability.
The second type of problem has to do with upper and lower jaw coordination and harmony. Normally, the teeth of the upper are positioned on the outside of the lower teeth, when lined up correctly. When the top back teeth sit inside of the lower ones (crossed-over), we call that a posterior crossbite. When the upper front teeth are behind the lower front teeth, we call this an anterior crossbite, negative overjet, or an underbite. Teeth in crossbite may reveal an underlying jaw problem that is best addressed at a young age.
The opposite of an underbite is an “overbite” (also called excessive overjet) where the upper teeth stick to far out, often making it difficult to chew or even to close the lips together. Mild overbites are common and not a concern until all the permanent teeth are in. Moderate to severe overjets can cause significant social problems for young patients and make them more susceptible to dental injuries because the teeth stick out. Although overbites cannot be totally eliminated until a child has finished growing, it is advisable to “get a head start” to reduce their severity for safety and self-esteem reasons.
Ideally the top front teeth vertically overlap the bottom front teeth about half way. If they overlap too much, we call this a deep overbite or deep bite. If they don’t overlap at all, we call this an open bite. Both conditions may hint that there may be underlying jaw problems that need attention at a young age. An open bite may also be due to oral habits such as thumb- or finger-sucking that can harm your child’s dental development. Orthodontists can help young patients break such harmful habits.
Finally, it should be noted that in the past, extractions of bicuspids were often required for an orthodontist to be able to correct the bite. Simply the patient waited too long to start treatment, and had to accept the pre-existing, and usually constricted skeletal dimensions. There has been some recent scientific evidence that shows that expansion of the upper jaw actually opens up the nasal passages to aid in clearer breathing. A more open airway can vastly reduce snoring or heavy night-time breathing, and can reduce incidences of ear and sinus infections. Scientific evidence also shows that a constricted upper jaw can have a significant restraining-effect on the way the lower jaw grows. In essence, a narrow upper jaw prevents the lower jaw from growing forward normally, resulting in a deficient or weak chin. Think of this analogy: Have you ever tried on shoes that were too narrow? The narrowness of the shoe prevents the foot from sliding forward to be fully sitting inside the shoe.
What is involved with the first phase of treatment?
Many first phase treatments use some type of growth modification device like a palatal expander, habit appliance (to stop thumb or finger sucking), or a functional appliance (to reduce an overbite). First phase treatments allow your orthodontist to take advantage of your child’s inherent growth potential, to harness it into a way to resolve dental issues before they truly become a problem. Following the first phase of treatment, retainers are used to maintain the results achieved, and to help guide the eruption of the remaining permanent teeth.
Will early treatment guarantee that a child will not need treatment later?
The answer is almost always no. Early treatment is commonly called two-phase treatment because more than 90 percent of children who undergo treatment at age seven or eight must finish when the remaining permanent teeth are in place. The typical Phase 1 patient finishes the first phase of treatment with 12 primary teeth still remaining. The second phase cannot begin until all of those remaining primary teeth are gone and the permanent ones have come in fully (around age 11-13). If a child has problems so severe at age 7 that they need interceptive care, the chances are pretty good that he or she will need to have the second phase of treatment to finish their smile.
The best way to look at two-phase treatment is this. Instead of waiting until your child is a 13 years old and then putting him or her through two to three years of difficult treatment, your orthodontist is recommending an easier approach. Why not let him help your child over some of the biggest hurdles now, so that when all the adult teeth are in (junior high and high school) treatment will be easier, better, and faster? That is the goal of early treatment.
Between the two phases of treatment, patients are seen at regular intervals so that the orthodontist can check the condition of the retainers, the loss of the baby teeth, and the arrival of the remaining permanent ones. Periodic x-rays help your doctor make sure that everything is developing as desired. It is also an opportunity for the orthodontist to repair the retainers and refer you back to your general dentist if primary teeth are not being lost on schedule.
The second phase of treatment begins ideally after the last primary tooth is lost, about the same time the 12-year-molars make their appearance. Treatment may begin earlier if the patient is having social problems due to their smile, the orthodontic problems are severe, or there are teeth that cannot take their place without help. Treatment will take too long if started too soon, and it will not be finished before the end of high school if started too late. It is all about timing!
So doesn’t two-phase treatment cost more?
The answer is yes, for most offices. Putting braces on twice, making two sets of retainers, as well as the extra observation visits all cost money. However, at Wheeler Orthodontics, I consider two-phases of treatment as being two parts of one treatment—just divided over two different time periods. Our fees for the 2 phases of treatment, when added together, will cost the same as doing one long phase later. We do not want to make doing a two-phase treatment approach to be a financial disadvantage to our patients and parents. We want our patients to benefit from the upside of two-phases of treatment, when indicated for the reasons aforementioned.
The key factor is we want to take advantage of growth (which we can orthodontically direct in our favor). Waiting too long for all permanent teeth to erupt may disqualify us from being able to orthopedically expand the dental arches. Early treatment allows the orthodontist to achieve results he cannot get in a single treatment later. Many girls, who tend to mature faster than boys, finish growing before their second molars are in place. Teeth that erupt into the wrong place, through the wrong tissue, may never look as good even if their position is corrected later on. Furthermore, overall long-term stability of teeth that erupt out of alignment is less than if the teeth are allowed to erupt through good tissue in the arch. Extractions and surgery that might have been avoided with early intervention may become necessary—which in itself is an added expense that can be quite pricey. Most important however is the improvement in self-esteem that occurs when a child is given a pretty smile to go with them through the socially awkward junior high years. How much is your child’s self-esteem worth to you?