Thursday, October 12, 2017

What to Expect when re-locating with kids in Braces


What to expect when relocating with Kids already in Braces

 

It is not uncommon at all to be in the middle of braces and end up having to move for a job or family.  As an Orthodontist in a busy city like Austin, we have patients moving in and out at all times.  I also have a lot of kids going into college that have to be finished or retained.  For the Orthodontist it can be challenging but for the patient and parents of patients it can be downright frustrating.  I wanted to provide something of a “help guide” for these patients to help them navigate through the process and the pitfalls (with some explanation from the Orthodontist’s side) of relocating and finding a new Orthodontist.
 
First, most reputable Orthodontists will not accept in-town transfers without a good cause and a call from the treating doctor.  Also, most (including me) will not accept a case in treatment from a general dentist or Pedodontist no matter the situation as they are untrained and may add significant liability to any case.  As I have written many times, it is so very important to choose a good Orthodontist from the start.  This is why I suggest a private practitioner with his/her own free standing practice (not a strip center company or “dental center”).  Once you begin treatment, you will be bound to the doctor except for extreme circumstances and any change you may want to make will likely cost you in time and dollars.  Orthodontists know these patients are already unhappy and will be, by definition, a challenge to finish.  They also know that they will be partially liable for all work, not just their own efforts so they will be careful before going down that road.
 
“most reputable Orthodontists will not accept in-town transfers without a good cause and a call from the treating doctor.  Also, most (including me) will not accept a case in treatment from a general dentist or Pedodontist no matter the situation”
 
Also, make sure if there are several parents with custody concerns that you provide adequate informed consent from all parties that are custodians even if the ex-spouse is in another city or state.  Putting your Orthodontist in the middle of a divorce/custody battle is in no one’s interest.     
 

 

 
If one party wants to treat and another does not (especially if money is involved, the Orthodontist will likely o accept your child as a patient no matter the need.  This is because even if you agree to pay the Orthodontist, when you as parent #1 go to send a bill to parent #2, they will reject it and say they never consented.  Believe me it happens all of the time.  Ultimately it become a mess and can even go to the local state board for adjudication.  No Orthodontist deserves or wants this.
 
 

Second, it is important to give your treating Orthodontist as much notice as possible.  If you know you will be relocating in less than 6mo it is probably best to wait until you move though there are circumstances that make starting braces immediately very important such as premature loss of baby teeth or impaction of teeth.  If you are in treatment and know you will be moving, let your doctor know where you will be moving so he/she can start researching the area for a similar practice for you to transfer.  Keep in mind that different Orthodontists may use different braces; if there is significant time remaining or the new Orthodontist just isn’t comfortable with your brackets type, he/she may replace all of the braces which will cost you as the patient.  I try to never replace all brackets/braces BUT I have done so on several cases where I felt there was more than 18mo of treatment remaining or I felt that the braces needed to be moved anyway (raised up from the gumline for hygiene, etc.).  In fact, I review my own cases at 12mo with X-Rays just for this reason, to re-position any brackets that don’t look right at that time.
 
 

 
 
Next, allow your Orthodontist to recommend a new Orthodontist and send records and notes directly.  This shows the new Orthodontist that everyone is on the same page and it keeps the treatment plan consistent.  Cases transferring mid-treatment will not look the same as they started; it is important to know where a patient came from just as much as knowing what the teeth look like at the time of transfer.  Until the new doctor has accepted your family, make sure kids are brushing well.
 

  
Finally, don’t be afraid to talk about the insurance and money with both your current Orthodontist and the new Orthodontist.  I always fill out a financial sheet for the new Orthodontist so thay know our initial fee, what the insurance has/will pay and what the patient has/still needs to pay.  I don’t charge interest for payment plans at my office so it is relatively easy to stop payments and leave the remaining payments (plus a fee for retentions, usually $450 at my office) for the next office.  If the patient tells me they are moving in a few months and I fell they have over-paid a few months, I can stop payments early and even bring them in a little more often to get some more done before they move.  This leaves more money for the new office and may give the patient a lower fee at the new office if more is complete.
 



 
Regardless, every patient should expect to pay more for a transferred case v. finishing with the original Orthodontist.  It can go the other way or can be a wash, but do not expect that.  And the worst thing you can do is start off complaining to the new Orthodontist that you are paying them too much.  Remember that they are estimating time remaining from where the patient stands now; they do not have the down payment to carry them if a case is going longer than estimated (can be from missed appointments, compliance, slow eruptions, unexpected growth or just a tough case with really solid bone slowing movements).  The original Orthodontist would likely not increase a fee midstream but you cannot expect a new orthodontist to eat that extra time.
 
If I get a financial sheet from a transferring Orthodontist, I try very hard to keep the treatment the same assuming progress has been consistent and the fee structured fairly.  I also try to give a complete fee to finish a case if it is longer than 6mo (versus a monthly fee).  It will generally be prorated based on my fee schedule with consideration of the previous doctor’s fees and collected fees.  If a case requires debonding and then placement  of new braces, there will be a significantly higher fee (probably still less than full fee but still significant, maybe 75 to 90% fee).  IF there is only a few months remaining, I will likely charge $150/mo plus retention ($450).  IF they are already in retainers, we will set up a retention protocol based on what they have (retainers) and how their teeth look, cost will likely be around $450.
 
Just recently I had a patient transfer in with easily 12 to 15mo remaining in an 18 to 24months plan.  Treatment was initiated out of town 12months previously but it had been a few months since the patient saw the previous Orthodontist.  I took new records (something you should always expect from the new Orthodontist as a standard of care) and had a full consult to discuss treatment and present our fee.  In this case, I gave them a 50% discount from my original fee plus a full retention fee (totaling $2875 + $450 for this type of case) as I planned on using their brackets with only repositioning a few based on the films even though they are an unusual blend of two different types of braces that I do not use.  This left them with a down payment of @$800 and monthly fees for the remainder plus a $450 retainer fee. This is likely a little more than what the original Orthodontist would charge because he/she collected several months of insurance without treatment and because now the case is extended beyond the original estimate.  In this case, it looks like the estimate was also about 3 to 6mo off due to excessive patient growth.  Even though the original Orthodontist can probably finish for a little less by taking the hit for the extra time in treatment, I cannot treat for less than half the fee due to the amount of time and treatment remaining.
 
One thing to remember for the patient above is that you really want to see the new Orthodontist without two months of your previous visit.  Hopefully your old Orthodontist will take fresh records so you can avoid a records fee (usually @$250 to $350) and the new Orthodontist can hit the ground running.
 
The last thing to remember is that Orthodontics is a science AND an art.  One Orthodontist will likely treat just a little differently that every other Orthodontist.  Sometimes treatment plan and philosophies can very wildly.  This is why it is important for your transferring Orthodontist to help you locate a doctor with similar brackets/prescriptions./philosophies so you don’t end up paying for new treatment just to arrive at the same correction some other way.  Most Orthodontists know if there is another local doctor that can treat a case differently so don’t be afraid to look around if it sounds like a totally new plan after the consult.  And remember that every Orthodontist is trying to give you an excellent result; if they do something a little different, you can trust a certified Orthodontist, especially a Board Certified Orthodontist, will get the job done right.
 
 
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.
 
Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 21 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 
 
 

Friday, September 29, 2017

What to expect after a bonded Expander is removed.


Congratulations, your expander is out! (Now what?)

 

The day has finally arrived; your child’s expander is finally out!  After 6mo to 10mo, you no longer have to hear that slurping or see your child drool when watching TV or drinking.  But what can you expect now?
 

These are the expectations we give our patients following removal of a bonded expander (RPE) as seen below:
 
 


First, expect a lot of redness around where the acrylic portion of the expander touched the gums; this made a great seal during treatment but after months, the gum tissue gets a bit irritated if not outright angry.  But rest assured this is completely temporary and will pass after only a few days.  In the meantime, have your child rinse with a mouthwash a few times a day.

 

It is possible a baby tooth (or teeth) may come out with the expander since the roots resorb naturally; these will heal and provide little if any discomfort because the roots are already gone but they can be rough under the tooth.

 

You may see some bleeding when your child brushes for the first couple of days; this is completely normal.  In fact, you really want to avoid a professional cleaning for at least a month after removing an expander.  We will clean the teeth at removal.  You may also see a few pieces of glue that we didn’t get; your child can spit these pieces out if they show up (this isn’t normal but it does happen).

 

Your child will notice that their teeth “do not fit right”, that there are premature contacts in the back that seem to change daily.  This will be normal for about a month or until a retainer is placed.

Your child’s gums may be too irritated to eat rough foods such as toast or hard sandwiches; Try to keep somewhat of a soft diet for one to two days until the irritated gum tissue heals.

Next, If your child is in limited braces on upper teeth, we will normally place orthodontic metal bands around some of the molars.  To do this, we normally have the child back 1 to 2 weeks after removing the expander to let them heal.  We will then either place spacers for another week or go ahead and band the molars right away.  Then we will extend the wire from front teeth back to the molars for anchorage as we finish our Phase I plan.
 

If your child does not have braces and there is no plan for early braces, we will take impressions for a clear retainer 1 to 2 weeks after removal.  Then we will deliver a clear retainer a few days later.  Once in the retainer, we will ask that your child wears the retainer @1 week full time (day and night) to get used to it and then to continue wearing the retainer when they sleep for another 6 to 12months (we will monitor)

After expansion, there is going to be considerably more space for teeth to erupt and they will usually erupt looking better.  There may be baby teeth that can be removed to assist eruptions or reason to recommend further treatment; we will be monitoring your child’s development now until all teeth are erupted or until further treatment might be necessary.   So figure a few days to feel back to normal and a lifetime worth of results to enjoy!
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac. 
 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 
 




 


 

Wednesday, September 27, 2017

Phase I Treatment (Early Intervention Braces) and Costs


Phase Treatment (Early Intervention/Early braces) and Costs

 

There are many different types of malocclusion in the developing dentition.  Kids may present with mild spacing to severe crowding, missing teeth to extra teeth and even impacted teeth (present but turned at an angle and unable to erupt).  Baby teeth may be in too long or lost too early allowing space to be lost.  Growth may be irregular, unfavorable or disproportionate with the patient’s face or between upper and lower arches.

 
“The most qualified doctor to ascertain this will be an Orthodontist so it is important for patient to get to an Orthodontist for a screening exam early, usually around age 7.”
 

Whatever the malocclusion may be, there is almost always a “Best Time” to treat.  The most qualified doctor to ascertain this will be an Orthodontist so it is important for patient to get to an Orthodontist for a screening exam early, usually around age 7.  Keep in mind also that this may not always mean the entire correction can be done at the same time as some problems are best treated at different ages.  It also doesn’t completely mandate that you treat every aspect of the bite at different times just because you see one problem early however when the benefit outweighs the cost and risks, then it is best to separate treatment into two “Phases”. 

“Whatever the malocclusion may be, there is almost always a “Best Time” to treat.”

 

I recently had a consult between Phases (after Phase I but before Phase II full braces) where the parents felt slighted that we asked for a new fee to progress into Phase II braces.  They swore up and down that I had promised them to treat at the sibling’s same fee from 7 years past.  So imagine their surprise and disgust when I told them I was discounting a full 50% of the Phase I cost toward the Phase II braces (bringing the fee less than the seven year old fee).  In doing so, I gave up all my profit and then some toward the full braces (I can do this because we prevented removal of permanent teeth, corrected an impacted cuspid and brought her mandible forward a half tooth (Class II to Class I). Unfortunately there was still enough crowding and the original angle of the cuspids allowed them to erupt too far forward and out of the arch so braces were needed to finish alignment.

 
So we all knew that full braces would be needed, this was not in dispute.  Neither was the fact that I informed them before Phase I that a second Phase was likely and would be at additional cost.  But they still could not understand an additional fee beyond the total single-Phase treatments (from 7 years ago!). 
 

In truth, this does not happen to me very often but after 2 to 3 years, parents do forget the details and since we have no idea how much work may be remaining, there is really no way to give a good estimated future cost.  We do document in the consult and the parents get copies however these are forgotten and/or lost by the parents over the years.  So I wanted to put a quick post out so the public has a better understanding of Phase treatment.
 

First, a typical Phase I may cost anywhere from $450 to hold minor space to $1500 to $1800 for an expander or more extensive space maintenance and retention thereafter to $3000 for limited braces or even up to $4400 for extensive Phase I efforts/appliances to avoid surgery or expose an impacted tooth and force its eruption early/on time.  Many times these Phase I treatments will prevent removal of permanent teeth, prevent impaction of teeth and ultimately lay the foundation for a much more stable and more esthetic overall outcome.

So let’s go over some more common questions:
 

Can I avoid braces later by treating with a Phase I now?

The answer is, sometimes.  Holding space allows teeth to erupt straighter (teeth take the path of least resistance,

they will tend to erupt straight up into the space provided).  Even a case with a large skeletal discrepancy may be treated fully in a Phase I if the skeletal discrepancy is corrected and then the teeth erupt correctly.  I have corrected many early underbites that need minimal to no later treatments, same with overjets due to narrow palates, but it is never completely predictable and there are factors to consider such as compliance, oral hygiene and size of teeth.

For a perfect dentition (if there is such a thing), it is likely that there will be some form of Phase II; this can be from small rotations/size discrepancies in teeth or just a really tough case that is not fully corrected.  Just as I have prevented cases from needing Phase II at all, there are many cases where I recommended minor

 

If I treat early can I avoid removal of permanent teeth?

Most of the time, cases that would go to extraction treatment are somewhat borderline; but removing teeth may produce too much space making stability difficult later.  If the crowding is minimal and the upper jaw is narrow, it is likely that correcting the width of the upper jaw with expansion will restore space for teeth and alleviate future crowding to the point  This also helps alleviate crowding in the lower by removing the constriction from a narrow upper arch.  It can prevent braces and certainly can lead us away from removal of permanent teeth later but usually there is some rotation or persistent crowding or deepbite that still warrants a second Phase later.  I will almost always discount my regular price for patients I treated with a Phase I by 25% to 50% of the Phase I fee charged.  This is not a standard practice with all offices and there are circumstances that still warrant a significant fee for Phase II (number of appointments/actual cost of Phase I/severity of initial and current malocclusions) but generally I try to reward parents for making a decision that provides an easier correction without removal of teeth/impaction of teeth.

 

Why do I have to pay again; why not just wait and treat at one time?

Phase I treatment is to re-establish normal development, crate space for future eruptions to prevent removal of teeth and/or impaction of teeth, to improve the growth of the jaws and possibly even prevent surgery.  The goal of course is to reduce needs later and improve overall stability of any correction but it is still likely there will may be full braces recommended as a second phase of treatment, Phase II.  Money paid for the Phase I covers appliances, time and expertise to set the foundation for good development and a better eruption of teeth.  Phase II braces will have their own expenses, time and overhead to correct; they will still carry a fee for braces though it may be less than normal since the idea is the doctor now has an easier case to finish.  Any discount or reduction in the normal fee for braces is subjective and up to the provider because he/she will be the one estimating time remaining and judging previous compliance/oral hygiene/growth to make the recommendation.

The answer to the second part is dependent on the reason for the Phase I.  If extraction of teeth was prevented by an early correction of jaw size, then Phase I saved @$1000 of dental work and provided a more stable dentition with better lip support and a full profile; even if a patient opts out of a recommended Phase II later, the benefits of the Phase I will likely remain.

If a tooth (typically a canine) was impacted and is now erupted after expansion or other Phase I treatment, then surgical exposure could have been prevented saving $2500 to $3000 in dental surgery as well as another $2000 or more in added orthodontic treatment to assist the eruption after any surgery.  Consider the following patient:



 
Age 9y 8mo presenting with a narrow upper jaw and crowding, the panograph (X-Ray) revealed even more severe crowding with impacted canines crossing the incisors and lying at 45 degree angles
 
Panograph taken during expansion with limited braces (4 months into treatment); note the space now opening.
 
Now 10mo into treatment, the expander has been removed and limited upper braces have moved the roots of adjacent teeth away from the erupting canines.
 
 
 
This Panograph taken at 15mo now shows the canines both erupting relatively straight and now into the correct position (not transposed with adjacent roots as in the initial films)
 
 
One year after removal of the Phase I limited braces at age 12y 0mo, you can see the previously impacted canines are now erupting normal and straight; impaction has been prevented as well as any need to remove permanent teeth; there is some minor crowding to correct in the lower arch and a few rotated teeth into the upper arch but now Phase II braces will be more optional, less costly, less time and more stable if employed to finish the correction.
If severe overbite/overjet or an underbite was corrected with the Phase I treatment, then the profile may be restored and surgery of the jaw(s) prevented saving upwards of $40,000 in dental surgery plus another $2000+ in added Orthodontic treatment as surgery cases are more expensive than regular braces. Consider the following cases with changes in their respective jawlines/profile simply from early intervention and no later braces or Phase II treatment.
 
PATIENT 1.

This 7y 6mo young lady presented with a developing underbite and midface deficiency in profile, all from an under-developed upper jaw.
 


 
After 15mo of Early treatment, note the change in her face as well as the restored overjet in the X-Ray.
 
PATIENT 2

This 9 year old developed a very severe underbite leaving no upper lip support and teeth at risk of fracture.
 

At age 10, just one year later, you can see the changes in the lip support and correction of the underbite with Early Phase I limited treatment.
PATIENT 3
 
Patient started Phase I at age 7y 7mo and finished at age 9; note the facial change in the pictures taken one year after removal of Phase I appliances.
  
PATIENT 4

This patient presented at age 7 with a very severe overjet, over 12mm.  Phase I was planned with the objective of simply reducing the amount of any future work and maybe reducing the need for surgery though we still expected some overjet and full braces.
 


 
This same patient after an aggressive Phase I course of treatment for 24mo; note the jaw is forward and the previous 12mm overjet has been fully corrected.  We then placed a type of retainer that helps “settle” the remaining teeth as they erupt (see results below).



The same patient at age 12y, a full 2 years following retention with a positioner to settle teeth.  No braces were ever used on this patient; this demonstrates how much of her original malocclusion was due to skeletal (Orthopedic) discrepancies and not actual dental issues.  Once the jaws were aligned and the geometry of the arch returned to normal, it was relatively simple to get the teeth to erupt straight and in good occlusion.

 

The benefits long-term may include a more stable bite with less relapse, a more esthetic and full smile, a more favorable chin and jaw line, less wear on teeth by restoring the conditions for better function and less risk of joint pain/TMD; some of these improvements can literally be priceless.

Summary

Early Intervention or Early braces for children can be beneficial and may prevent much more severe malocclusions from developing  This can lead to a much better correction including better function, a more full smile and preventing of extractions or even surgery.  Because of the nature of the eruption of teeth and specific growth of individual children, there is no definite time to start Phase I or make a decision when it is too late; every patient is different.  The American Dental Association, the American Association of Orthodontists and the American Board of Orthodontics all recommend young patients be screened by an accredited Orthodontist by age 7 (when the permanent 1st molars are erupted) to determine if early treatment would be beneficial.
 

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com. 

 
 
 
 

Thursday, May 18, 2017

Airway Obstruction and the Developing Dentition


Airway Obstruction and the Developing Dentition

 

There has been research around for years demonstrating that soft-tissue airway obstruction in a developing child leads to under-development of their upper jaw and constriction of dental arches; this in turn leads to crowding and many times a backward shift of their lower jaw.  The obstruction can be from chronic inflammation, swollen tonsils and adenoids, adverse tongue posturing or just anatomical thick tissue. If severe enough, it can lead us to recommend removal of permanent teeth or even surgery to re-position one or both jaws. We are also seeing that over time, this constriction affects the tongue space and can ultimately lead to Chronic Snoring and Sleep Apnea.

 
As a practicing Board Certified Orthodontist, I have treated thousands of patients with varying malocclusions that could be traced back partially if not wholly to airway obstructions.  Recently however there is a trend in our medical community to address these airway obstructions early to reduce the prevalence of Sleep Apnea and improve the long-term health of young patients before the symptoms of the airway restriction become severe.  Several local ENT’s in my community have become very proactive and I believe the research is continuing to demonstrate early removal of soft tissue obstructions in the nasal airway is absolutely warranted and helps in overall development and later quality of life.

Anatomy of the Nasal Airway with computerized imaging of airway space.



What we are really seeing in the literature is a merging of medicine and dental; perhaps something that is less common than it should be but nonetheless this sharing of data is now helping educate providers and push for better patient care and more successful outcomes.  From my practice, experience shows that by the time a patient sees the Orthodontist by General Dental referral, much of the damage is already done.  That is because most dentists gauge the need for braces by the crowding of the teeth and they tend to want to wait until most or all baby teeth are lost (which is entirely too late for more severe problems).  In these now adolescent cases, we use traditional braces (with or without expansion/removal of permanent teeth/surgical repositioning) to undo what we can and work to establish a new arch form with alignment of teeth while providing the best esthetics and function possible.  

 
“… experience shows that by the time a patient sees the Orthodontist by General Dental referral, much of the damage is already done.”


 
This adolescent was referred only after once all permanent teeth erupted; patient had a history of breathing problems and chronic airway obstruction that went untreated.
 


 
Following extensive Orthodontic treatment including Rapid Palatal (Maxillary) Expansion and removal of the upper right 2nd bicuspid; although the teeth are corrected and arches restored, stability will never be possible without long-term nightly retainer wear; following treatment, the patient was referred to an ENT for removal of excessive soft tissue for added stability.


Correcting a narrow maxilla or a smaller (retrusive) lower jaw due to an airway issue can be time consuming and expensive to correct later in life; stability is sometimes based not only on early intervention and good dental correction but also on alleviating any airway construction before or after the orthodontic correction.  Patients and parents of patients should understand that the development of the dental arches are usually only a reflection of the forces in the mouth; whatever causes a severe malocclusion will still be affecting the teeth following the correction.  Therefore it is important to consider the airways when determining if a correction can be maintained without long-term appliances/retainers.
 
 
At 7 years old, this young patient was identified as having large tonsils and an obstructed airway with under-developed upper jaw and retrusive lower jaw.


Following expansion of her upper  jaw, you can see the lower jaw has come forward; patient reports improved breathing and parents report correction of snoring.

 
At this point, patient is referred to an ENT for possible removal of tonsils and will be monitor as we await the remaining permanent teeth. 
 
 
 
 
For younger patients, an Orthodontist can identify the early signs of damage from an airway obstruction
and they can take records to confirm and quantify such narrowing in the airways.  If seen early enough, the effects of the airway obstruction can easily be corrected by expanding the upper jaw and freeing the lower jaw to come forward as well as referring the patient to a knowledgeable ENT for closer evaluation and possible removal of soft tissue.  Along with expansion, the Orthodontist may even choose to set upper front teeth (which erupt around age 6 to 8) into an ideal arch form while clearing a path and opening space for future eruption of commonly impacted teeth due to this problem.  We know from the literature and from experience that many impacted canines that would require surgical exposure can be prevented by simply restoring a narrow upper arch with a fixed (not removable) palatal expander.
 
Consider the following case with a severely impacted and transposed tooth.  Already late getting to us, it took expansion with limited braces in the early mixed dentition to correct the impaction and save the adjacent tooth from more damage.
 
 
Note the narrow upper arch secondary to chronic airway Obstruction and Allergies.
 
 
Panograph X-Ray shows the impaction of the canine (on the upper left side in the film)
which is erupting on the wrong side of the adjacent lateral incisor.  The following films
show the sequential movements to correct the impacted and transposed canine.






Review of sequential X-Rays shows the correction of the impacted cuspid following expansion and opening space for the blocked out teeth; the photograph shows the new smile as we now await the remaining teeth.  Airways have n=been increased from the process and we expect a stable long-term correction.
In a Februrary 2013 study published in the Journal of the American Association of Orthodontics (AJODO) (http://dx.doi.org/10.1016/j.ajodo.2012.09.014 ) entitled Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: A cone-beam computed tomography study, investigators using computer tomography imaging on patients treated with palatal expansion measured the before and after airways and tongue posturing known to affect development and contribute to sleep apnea.
 
In this study, researchers pointed out that  Rapid maxillary expansion (RME) is known to improve nasal airway ventilation. Recent evidence suggests that RME is an effective treatment for obstructive sleep apnea in children with maxillary constriction.”
 
 
  Yellow arrows show the nasal airway space in four patients each with varying
amounts of resistance from soft tissue.
 
 

This study wanted to confirm these findings but also investigate the effects of Expansion on tongue position which have also been shown to cause sleep apnea.
In their conclusion, the authors stated that In children with nasal obstruction, RME not only reduces nasal obstruction but also raises tongue posture and enlarges the pharyngeal airway.” 
 
 




Yellow arrows show the varying size of tonsils and how they affect the airway space
in five different patients.


In other words, expansion opened air ways and improved tongue posturing in children.  Of course it also increases the arch length and regains space for future teeth thereby reducing crowding and risks of impactions.
 

A more recent study published this month in the AJODO, (http://dx.doi.org/10.1016/j.ajodo.2016.10.027) was undertaken to clarify the relationships between upper airway factors (nasal resistance, adenoids, tonsils and tongue posture) and certain facial patterns seen when treating patients with Orthodontics, specifically patients with small lower jaws (Class II) v. those with excessive growth of the lower jaw or underbite tendencies (Class III).  The findings revealed that the relationship of upper airway factors are different between different facial types.  The data suggested that patients with small lower jaws (Class II) had significantly more nasal obstruction/resistance and that decreased width of the upper jaw measured at the molars related to an increase in nasal airway resistance/obstruction and a less favorable tongue position.



Imaging showing molar widths, measured and compared to obstructive airways.
Combining the results of these two papers, Orthodontists can now show definitively that not only does a narrow upper jaw cause crowding and increased risks of impaction of teeth, but it also is correlated with reduced airflow, poor tongue posturing and an increased risk of sleep apnea.
 
What does this mean to parents?
First, it means all kids should be screened early by someone who is knowledgeable (Certified Orthodontist) and can see the signs of airway obstructions before problems become too severe; General Dentists are not trained to specifically identify this problem in developing children.
 
Second, Orthodontists must not only treat the symptoms of airway obstructions but they should also include their ENT colleagues in consultation to determine if soft tissue removal may be necessary either before or after palatal expansion.
 
Third, expansion is not just about the teeth.  If an upper jaw is narrow, it can lead to a smaller lower jaw, it can lead to further airway resistance and can even contribute to Sleep Apnea later in life. Expansion, when necessary, increases airway space and improves airflow in children.
 
In summary, only an expert in development (i.e. a Certified Orthodontist) is going to be able to determine when expansion may be necessary for restoring restricted airways.  Even without crossbite, an upper jaw can be significantly narrow as the lower jaw is pushed backward or the lower teeth fold inward to stay within the upper jaw arch form.  Waiting on a referral from someone who is not fully trained or experienced can lead to severe crowding, impactions and even Sleep Apnea.


 
If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35th street and MoPac.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 21 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com.