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. 

 
 
 
 

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