What is Conservative Treatment for Children?
Why does the American Association of Orthodontists and the American Board of Orthodontists recommend children be evaluated by an accredited orthodontist by age 6?
It may surprise you that “Modern” Orthodontic Braces have been around since 1925 with the American Association of Orthodontists being established even earlier in 1900. Over the last hundred plus years, there have been many changes and improvements to the way Orthodontists approach treatment. Initially various headgears were a primary mode of treatment used to pull front teeth by way of bars locked around the front and back of whole segments of teeth. This gave way to individual brackets and wires which were used to expand out arches increasing the circumference until the individual teeth were straight. When many of these cases failed (collapsing back inward), Orthodontists began to remove a bicuspid in each quadrant to create symmetrical spaces and prevent dental expansion during alignment with fixed “braces”. Unfortunately as many of these patients aged, the spaces re-opened and even when teeth remained stable, the dental arches were narrow and the patients’ faces continued to grow without lip support creating a typical concave or “witch” profile.
Since then, Orthodontists have learned to find middle ground. If crowding is severe and the face is full (teeth are pushed forward), we will likely still recommend removal of four bicuspids and full braces as before. But as is the case many times, if there is only moderate crowding and a narrow upper jaw early, or if the lower jaw is recessed and there is severe overjet with a narrow upper jaw, we have learned to expand the upper jaw and restore ideal arch width (or even place more advanced appliances that can further modify growth and development); this increases the circumference of the bone itself and allows alignment of teeth into a more stable position, usually without removing permanent teeth. Since the arch was narrow to begin, any facial changes only improve the esthetics if they are noticeable at all.
We have also learned that the development of the lower arch and even growth in the lower jaw is affected by constriction from the upper jaw; removing constriction by expanding a narrow upper arch allows the lower jaw to grow without impediment and allows the tongue to push naturally on the lower teeth, uprighting them into a more full arch form. When needed, the earlier the expansion, the more time the tongue has to push on the lower arch and upright lower teeth and the longer the jaw has to “catch-up” during growth. In the long run, these patients have less crowding, a full smile and a straighter (more ideal) profile. Additionally there are far fewer impacted teeth while stability is dramatically increased since any future tooth movement is minimized to simple alignment versus large tooth movements to pull teeth back into the arch or close extraction spaces.
Does this mean every patient needs expansion or early interceptive treatment? The answer is of course, no. However there are many borderline cases that will need some space (i.e.3 to 6mm) where removal of bicuspids produces too much space (16mm). If nothing is done to increase the jaw size then the Orthodontist must either reshape teeth or remove some altogether. As a specialty, we have learned to make compensations when we have to; not every patient can receive a 100% result since most patients don’t get to the Orthodontists until growth is near complete (age 12 to 13) and a 90% correction is normally acceptable but most patients have a “best-time” to treat to minimize treatment and sometimes prevent extractions or even later surgery. There are many adults who have had acceptable results as a child which relapsed later due to this jaw size discrepancy.
Is early treatment more expensive? First, early treatment is typically around half or less v. the cost of traditional braces. Preventing pending extraction of permanent teeth will save nearly 50% of the early treatment fee and the reduction in time required for braces later may also save money. Some cases can end up thousands of dollars cheaper (consider if you are able to avoid later full braces, or prevent the need for surgery in a more
severe malocclusion), some are a wash and some may be a slightly more expensive due to the added cost of future full braces to finish alignment once all teeth have erupted into the new arches.
What you get from the effort will be greater stability with a more natural and esthetic smile and fewer compensations in the angulation and alignment of the teeth. Braces may still be recommended as the remaining permanent teeth erupt and growth subsides however movements required will be greatly reduced which generally reduces cost of the braces. In some cases the early treatment alone may prevent later braces.
So when is early intervention necessary? Are braces necessary at all? Should we replace missing teeth or just close the space? Should we correct underbites or excessive overjet? Is it for esthetics or function (or perhaps a combination)? What is the most Conservative treatment? I would say the question really should be: How can my child have the best and most stable smile possible with the least possible effort and most possible stability? In other words if you plan of fixing your child’s smile, why wouldn’t you want the best options presented?
As a Board Certified Orthodontist, I offer to every patient what I would do/have done for my own children; I offer the best possible outcome for each individual situation. I will not tell you it is the only way if there are options but I will tell you what to expect with different options. Does that mean you have to go with 100% of what can be done? No, but we do want you as the parent to understand your child’s developing occlusion while we still have time to correct developmental issues. There are considerations (time, behavior of the child, expected compliance, cost, etc.) that may lead us away from early treatment and we will always show you multiple finished cases so you know what we can provide and have provided for many years. This is not to say accredited Orthodontists (including myself) cannot or will not provide treatment later with compensations such as extractions/surgery/more extensive braces, but I will leave the options to you as the informed parent.
So what does this all mean for you and your children? Keep in mind there are many well qualified Orthodontists and we all do things a little different; a good accredited Orthodontist will always be able to provide a successful correction and a beautiful smile at any age, whether it be with removal of permanent teeth, surgical movement of the jaw or with comprehensive braces/invisible trays. But as long as kids get there traits from two parents there will be a high probability that jaws don’t match each other and/or tooth size doesn’t fit jaw size; additionally there are factors we cannot control affecting development such as allergies, swallowing patterns, tongue thrust, thumb-sucking that all can and will greatly alter upper jaw size during growth (before the teeth have a chance to erupt). The more adverse the development, the more important timing of treatment will play in the overall correction result.
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 down at my North-central Austin location on 35th street.
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. Dr. Waters and his wife of 18 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.