Perhaps one can say there was a paradigm shift in the early ’80s. There is better understanding today of the underlying causes of orthodontic problems, many of which begin in early childhood. As a result, orthodontists pay greater attention to the ideal timing of treatment. We have learned that early intervention may, in many cases, lead to better outcomes.
Orthodontists do much more than just straighten crooked teeth. Orthodontists make sure the top and bottom teeth fit together properly. They are trained to guide and influence the eruption of teeth, as well as growth of the bones in the face and jaw, which can be achieved before an individual stops growing.
The older model – waiting for all the baby teeth to fall out and all the permanent teeth to come in before seeing an orthodontist for the first time – resulted in what today would be considered missed opportunities in many cases. Delaying treatment until adolescence increased the incidence of extraction of permanent teeth because, as the bones became more rigid and growth ceased, the window of opportunity for expansion or growth modification closed. Many correctable habits or skeletal mismatches were allowed to continue, while earlier intervention could have led to a more stable, and less invasive correction. In addition, as a result of increased public awareness of dental and orthodontic health, many more young children are seen by pediatric dentists than ever before. Pediatric dentists have additional training in growth and development and recognize developing dental and skeletal problems in young children. This has led to an earlier referral of their younger patients for an orthodontic evaluation.
The American Association of Orthodontists (AAO) recommends that all children get a check-up with an orthodontist at the first recognition of an orthodontic problem, but no later than age 7. Orthodontists can identify subtle problems with jaw growth and emerging teeth while some baby teeth are still present. While a child’s teeth may appear to be straight, there could be a problem that only a proper orthodontic evaluation may detect. A panoramic X-ray may reveal many existing or developing problems. Early treatment may prevent or intercept more serious problems from developing and may make treatment at a later age shorter and less complicated. In some cases, orthodontists will be able achieve results that may not be possible once the face and jaws have finished growing.
Early treatment may give your orthodontist the chance to: guide jaw growth, lower risk of trauma to protruded front teeth, correct harmful oral habits, guide eruption of permanent teeth into a more favorable position, improve appearance of teeth, lips and face, and minimize the possibility of bullying and teasing. If your child is older than 7, it is certainly not too late for an orthodontic check-up. It is also important to understand that having a child being evaluated around age 7 does not mean that the child will necessarily need immediate treatment. The orthodontist can tell you if it is safe to delay treatment until the permanent teeth are in place (age 12-14). Because patients differ in physiological development, dental eruption and treatment needs, the orthodontist’s goal is to provide each patient with the most appropriate treatment at the most opportune time.
Many orthodontic referrals come from general or pediatric dentists, but it is important to know that this is not a prerequisite. If a parent notices a problem, they can reach out to an orthodontist without a dentist’s referral. Many orthodontic offices offer low cost or complimentary orthodontic consultation. Anyone looking for an orthodontist should use the “Find an Orthodontist” service at the American Association of Orthodontists’ (AAO) website, www.mylifemysmile.org, to locate nearby AAO members. This is also good resource if you are seeking a second opinion. When choosing an AAO member, the public is assured that the doctor is an orthodontist because the AAO only accepts orthodontic specialists for membership. An orthodontist is a specialist who has graduated from a dental school and then goes on for an additional two- to three-year specialty education to study orthodontics and dentofacial orthopedics. This training must be successfully completed in an accredited orthodontic residency program (only 66 in the entire United States.)
In addition to straightening teeth, an orthodontic evaluation should be made for management and correction of malocclusions (“bad bites”), when the teeth meet improperly. Some of these conditions include but are not limited to: growth guidance and correction of disproportionate jaw growth, crossbite of front or back teeth, crowding and spacing of the teeth, correction of protruded front teeth to minimize likelihood of accidental fracture of these teeth, deep bite (i.e., excessive overbite), open bite, underbite, late eruption or impaction of a permanent tooth and elimination of harmful oral habits such as finger sucking or tongue thrusting. In addition, any of the following conditions may benefit from an orthodontic evaluation: early or late loss of baby teeth, difficulty in chewing or biting, mouth breathing adversely affecting jaw growth, facial imbalance or asymmetries, cleft lip/palate, jaws that shift or make sounds, speech difficulties, detection and management of extra or missing teeth, biting the cheek or teeth contacting the roof of the mouth, and grinding or clenching of the teeth.
Some of the more commonly used orthodontic devices in younger children in mixed dentition, and some of the terms that you might hear that describe these devices, include (but are not limited to): removable or fixed palatal expanders, space maintaining or dental arch development devices such as a holding lingual arch, Crozat device, or a Nance holding arch, different types of headgears for correction of an excessive overjet (sometimes called “buck teeth”), protraction facemask for correction of an underbite due a underdeveloped upper jaw, bite jumping devices such a Bionator, twin block or Herbst for correction of a deficient lower jaw resulting in a deep bite or excessive overjet. These devices are used to make changes in the transverse (width), horizontal or vertical dimensions of the jaws to either create more space for permanent teeth to erupt or redirect pattern of jaw growth.
Despite the fact that early treatment and judicious and timely arch expansion may increase the likelihood of non-extraction correction for many patients, sometimes extractions are necessary to achieve the most ideal dental and facial outcome. There are also several other considerations such as periodontal status, facial and lip balance that factor into an extraction vs. non-extraction decision. Excessive expansion to fit in crooked teeth can stress the gum tissue or poorly affect the appearance. Sometimes extraction of certain baby teeth, followed by removing a few permanent teeth (referred to as “serial extraction”), can be used to create a much improved eruption path for the permanent teeth in severely crowded situations.
Conventional orthodontic brackets made of stainless steel are still the most common braces used, especially in young children. Some patients ask for tooth-colored (ceramic) or gold-plated braces, and the orthodontist can advise whether it would be appropriate. For patients who are allergic to nickel or latex, there are also nickel-free brackets, latex-free ties (also called ligatures) and latex-free rubber bands. Ligature ties, which are used to secure the wire to the brackets, come in many different colors and are generally changed at every appointment. Kids love the idea of changing their tie colors to highlight favorite sports teams, school colors, Halloween, national holidays, etc., which makes the orthodontic experience more fun for them. Customizing retainer colors, patterns and decals is another way kids love to show off their orthodontic devices.
Older kids who have all their permanent teeth and adults have many corrective options available to them: conventional (metal, gold or ceramic tooth-colored) brackets, self-ligating brackets (which do not require a ligature to secure the wire into bracket), lingual (back side of the teeth) brackets and clear aligners (such as Invisalign and ClearCorrect). All have pros/cons that could be discussed with the orthodontist.
