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.
Great articles and great layout. Your blog post deserves all the positive feedback it receives. I feel very grateful for the valuable information and insights you provide here.
ReplyDeleteOrthodontic Treatment
All on 4 treatment
Laser Root Canal Treatment In Chennai
Full mouth implant treatment
Root Canal Treatment In Chennai