The Dilemma of Early Orthodontic Treatment:
To Treat or Not To Treat

To treat or not to treat, that indeed is the question! Many parents are confused by the mixed messages they receive regarding the best time to begin their child’s orthodontic treatment. Is it best to start before any permanent teeth have come in, when just a few permanent teeth have erupted, or wait until all the baby teeth have gone and all the adult teeth have fully grown? The answer to this question is there is not one best time for every child we see! Each patient presents us with a unique problem and as such, each patient will benefit from a treatment plan unique to their needs. Our goal as orthodontists is to provide each patient with the most appropriate treatment at the most appropriate time.

The American Association of Orthodontics recommends that all children have an orthodontic check-up no later than age 7. Why age 7? By age 7, a few key landmarks have been reached by most children:

1. The back permanent molars have usually erupted and the presence of these teeth allows the orthodontist to evaluate the bite, as well as the width, height and front to back relationships of the upper and lower jaws and teeth.
2. The front teeth have begun to erupt and the orthodontist can evaluate for problems such as crowding (not enough space for all the new teeth which will be coming in), open bites (where the top front teeth do not cover the bottom front teeth), deep bites (where the top teeth cover most, if not all, of the bottom front teeth) and asymmetries in the face, teeth and bite.
3. Oral habits, if they exist, such as thumb sucking, finger sucking, tongue thrusting or mouth breathing will have had a deleterious affect on the growth and development of the jaws and/or teeth, which will be noticeable to the patient and parent by this age.

Let’s take a look at some specific problems to watch for in your child, as their teeth are coming in:

ANTERIOR CROSSBITE Here you can see that one (often more) front tooth is coming out in front its partner on the top. This can be particularly damaging to the health of the gums of the teeth in crossbite, as well as to the bite.	POSTERIOR CROSSBITE This time, the crossbite is in the back of the mouth, where the top teeth on one side are biting on the inside of the bottom teeth on that side. Left untreated, a posterior crossbite can cause a permanent asymmetry to the bite and to the face, because the crossbite forces the growing lower jaw to position itself to one side. This results in relatively more lower jaw growth on the side away from the crossbite and relatively less lower jaw growth on the side of the crossbite. Some studies have shown that an untreated crossbite can be a contributing factor in TMJ (temperomandibular joint) problems in an adult.
CROWDING In this picture, we see severe crowding in the lower arch. Not only does such crowding look unsightly, but it is extremely difficult to clean efficiently and effectively around such crooked teeth. Poor oral hygiene will result in gum bleeding, bone loss and ultimately, tooth loss.	OPEN BITE An open bite is often associated with habits such as thumb or finger sucking, mouth breathing or with disharmonious growth between the upper and lower jaw. Instead of the forces of eating and chewing being distributed amongst all the teeth, those forces in an open bite patient are only on the back teeth. Such uneven distribution of forces may result in gum and bone loss around the back teeth, tooth fracture, early tooth loss and future TMJ dysfunction. Quite often, open bite patients have associated speech problems.
PROTRUSION OF THE TEETH OR "OVERBITE" Excessively protruding front teeth are obviously more prone to trauma. What a heartache it is to see that patient in our office with their front teeth broken off because of a fall or a sports injury. Children with upper tooth protrusion are commonly very self conscious of their appearance.	RETRUSION OF THE TEETH OR "UNDERBITE" An underbite is a condition where the upper jaw is too small and often too narrow to match with the size of the lower jaw, and consequently, when the upper teeth come in, they fall behind the lower teeth. Here again, we see uneven distribution of forces with resulting premature bone and tooth loss, as well as TMJ dysfunction. If not treated in a growing child, an underbite will usually require corrective jaw surgery in the late teens or early adulthood.

A healthy, stunning smile is the most obvious result of orthodontic treatment at whatever age, but how much easier it is to attain a balanced, stable, functional and healthy occlusion in a child, who has the available growth to make it all happen! Growth is critical to an ideal treatment result. As such, orthodontists are not only tooth movers but facial orthopaedists, using the patient’s growth to idealize the position of the upper and lower jaws, so that the erupting teeth will drop into the best possible position. To treat or not to treat? Hopefully, that’s not the question any longer!

Note: Photos courtesy of the American Association of Orthodontics. Available upon request.

Copyright © 1997, 2005 by Mairead M O'Reilly. All rights reserved. No reproduction without written permission.

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About the author: Dr. O'Reilly practices orthodontics and dentofacial orthopaedics in Annapolis, Maryland. Dr. O'Reilly's unique expertise includes early interceptive orthodontic treatment for children ages 6 to 10, adolescent and adult orthodontic treatment, employing growth modification techniques, traditional metal braces, ceramic (tooth-colored) braces, and the latest in orthodontic technology: self-ligating braces. She is also a certified provider of Invisalign, the invisible way to straighten teeth.

She has worked extensively with children with craniofacial deformities in London, England; Rochester, New York; Washington, D.C.; and Baltimore and Annapolis, Maryland. Dr. O'Reilly's emphasis is on people and the difference her profession can make in their lives. Good orthodontic care can greatly enhance the way people feel about themselves. The changes are more than cosmetic, however. Orthodontics can substantially prolong tooth longevity, prevent periodontal (gum) problems, and successfully treat TMJ problems, jaw deformities, and those related symptoms such as chronic headaches, clicking and grinding. In addition the improved appearance one enjoys from treatment also dramatically affects self-esteem. Dr. O'Reilly sees her patients as partners in treatment and brings sincere concern for each individual.

Dr. O'Reilly welcomes any questions or comments you may have regarding this, or any other article, in our series. We are happy to provide reprints. Contact our office at the address, phone, or email address at the top of the article.