Please take a moment to answer one question. Other than cost, what is the first thing you think of when I say the words, ‘your child needs braces’? Crooked teeth, right? Fair enough, we all want our children to have straight teeth and these days it is considered an expectation. It seems like every child needs braces. Absolutely, we all want straight teeth and a beautiful smile. Smiling is good for us as it gives us confidence and makes us happy. But what if I told you, a face that develops well will grow straight teeth. We are now learning so much more about the factors that impact dentofacial growth than ever before. Dentofacial development goes through its biggest growth phase in the first 3-5 years of life. Breastfeeding, mouth play activities, drinking and swallowing properly, chewing hard foods, nasal breathing and good lip and tongue function all impact growth. Absolutely no doubt genetics plays a significant role here but the more focus we can place on the environmental factors that contribute to beneficial growth, the better chance we have of avoiding or reducing the need for braces later in life.
It has long been accepted that crowded teeth are purely and exclusively a genetic problem. This is still promoted today by many dentists and orthodontists. Environment vs genetics is still a hot topic of debate within the professional dental community. I have witnessed very heated debates between incredibly skilled specialists who recite research, crediting and discrediting information on this topic. I truly believe you need to find the right orthodontist that follows the same beliefs as you. It’s important to find the right fit and someone you can discuss openly what you want for your child. I am an advocate for early or ‘interceptive’ orthodontic intervention because we have so much opportunity to create positive change while the face is growing. Once growth is complete, things become a whole lot more complex and potentially limiting.
Are Straight Teeth an Illusion?
We need to get it right before we even look at the teeth. In fact, this isn’t even about the teeth. The teeth are almost an illusion. What we want is for the upper and lower jaws to develop outward and forward. When this happens, the middle of the face develops beautifully, the lower jaw comes forward. Voila! 20 baby teeth with lots of spacing and the ideal vertical relationship. When I see this in a young child I’m filled with joy. Yes! These kids are on track. When you see bite changes in young children, we should be looking a little deeper. However, we are currently trained to say nothing or say, “don’t worry, let’s fix it later”. We currently do nothing and wait for the problem to get worse. The issue with ‘fixing’ later is that we may just be ‘fixing’ a symptom. If we see a bite problem in baby teeth we need to discover why. Are they mouth breathing or snoring? Are they eating and swallowing properly? Do they have a ‘normal’ oral rest posture? Who do they need to see, or what do they need to do to address any functional issues that may be contributing? I can tell you right now, it’s probably not going to be an orthodontist, not yet. Orthodontics rarely start before 7 or 8 years of age and for good reason. Orthodontists cannot get stable or predictable results and it’s very difficult, if not impossible, to expect a young child to cope with treatment. However, we can intervene and intercept functional problems. There is enough research and evidence linking airway obstruction to craniofacial growth changes that we need to look deeper. Yet, many dentists and orthodontist still don’t act. If we see a problem, let’s see what measures we can reasonably implement to reduce that impact. Do these kids need to see an Ear, Nose and Throat Specialist to manage a physical airway obstruction? Nasal breathing is a fundamental right. It is a non-negotiable. Do they need to see a feeding therapist to manage an eating issue? Do they need to see a bodyworker to address a postural issue? Do they need to see a myofunctional therapist to address abnormal oral rest posture or eliminate oral habits? Our goal should always be lips closed and nasal breathing at any age.
Why Early Orthodontic Treatment is Essential
I refer patients to orthodontists on a daily basis. They are incredibly skilled and talented professionals and have access to training, technology and tools that can have a profound effect on growth, health and beauty. The difference between what we can achieve with good oral function and what we can achieve with orthodontics is age and timing. Please know this is a generalisation and not a rule. There are genetic and developmental factors such as cleft lip and palate, missing teeth, extra teeth, impacted teeth, syndromes and traumas that require specialist care regardless. I am in awe of those oral maxillofacial surgeons and specialists who conduct life-changing surgeries. Especially for our children and babies – thank you.
Roughly age six is when the adult teeth start to erupt. The lower central incisors come through and the first adult molars erupt behind the last baby tooth. Adult teeth are much bigger and if there is no spacing between the baby teeth then all of a sudden you have crowding with teeth coming through in different places and sometimes retained baby teeth. It’s about now that orthodontic issues are becoming more noticeable. It’s not that they weren’t there before, it’s that our profession isn’t trained to address these issues any earlier. Between 6 and 8 years the upper and lower central incisors will come through and the issues become more visible. This is also a time when children are becoming mature enough to cope with dental appointments and can reasonably manage with treatment. If there is a bite problem at this age, we need to be looking at orthodontic interventions that maximise growth potential and make more space for the teeth and the tongue.
Do It Early
Please have your child assessed early. It is easy to wait if needed but it is an entirely different approach when growth is finished. At around 8-12 years of age your orthodontist will form a treatment plan to get the best results in the most predictable way. As the old saying goes, there are multiple ways to skin a cat! Your orthodontist’s approach will very much depend on their philosophies, experience, training and opinions. Very basically, there are two directions. One way is to wait until growth is complete and rearrange the teeth in the space that is already there. Often, adult teeth need to be removed to create space and then braces pull the teeth in line for an aesthetically-pleasing result.
The other option is to use appliances such as a plate or expander to make space or essentially ‘grow’ the jaw or guide it into the right position during natural growth. This idea is about creating the space and the functional alignment that you need to get a nice aesthetic result. This might require multiple phases of treatment and can require varying amounts of patient compliance. However, when you make more space for the teeth, you also make more space for the tongue. The tongue can rest comfortably with enough space so that its not pushing excessively on the teeth or worse, forced back into the airway. Also, the roof of the mouth is the floor of the nose and expansion can assist in creating healthier airways for better breathing. Science is still exploring this and is now looking at evidence that suggests palate expansion reduces airflow resistance through the nasal sinus which is incredibly important for quality sleep. As science progresses, we are moving more in this direction. Please consider this as an option.
Forget About Straight Teeth
There is one thing that orthodontists all have in common. They all want predictable results in the shortest time. However, individual opinions and what their goals are for their results may differ depending on the clinician. All orthodontists will get you straight teeth. Aesthetics are absolutely essential. But some will also look at airway and growth issues. It really depends on what you want to achieve and your goals for treatment. Orthodontic treatment is expensive and your professional wants stable results as much as you do.
Many orthodontists still choose to treat once the jaws have finished growing. The word ‘compliance’ is scary for an orthodontist and I don’t blame them. I rely heavily on compliance for ALL of my results. I don’t get compliance, I don’t get results. It’s that simple. When an orthodontist places fixed braces on your teeth, it takes ‘compliance’ out of the equation. They have complete control of the movement process and again, can achieve predictable results. You are paying them for results at the end of the day. All clinicians want happy patients. When kids are wearing appliances such as a removable expander, there is a level of compliance which is always a factor for predictable results. If you are going to pay $1500 for an expansion appliance that ends up in your child’s pocket, or worse, lost, no one wins.
My advice is to engage in a discussion with your professionals. Get involved and ask them what they see and what they predict. More importantly, what considerations you would like for your child. When talking to clients I find parents have an orthodontic consultation, get minimal information back and have little discussion on the treatment options. This is not a criticism, just an observation. I think historically, people seek professional advice and just go with it thinking it’s all the same process. Truthfully, each professional works in different ways and parents need to find someone with whom they are comfortable. I think functional appliances should always be a consideration.
Myofunctional Therapy and Orthodontics are Not the Same
For me, I work with the tongue and I want to make as much space as reasonably possible. I would like to avoid adult teeth extractions where possible because I want more tongue space, not less. One of my therapy goals is for the tongue to rest lightly suctioned in the roof of the mouth. Now if the palate is high and narrow – this rest posture is difficult, likely unnatural and sometimes almost impossible. Orthodontic treatment can change this and together we get great stable results.
A common question I get asked is, my child has crowded teeth, can I fix this with myofunctional therapy? The answer is no. By the time your child is 7 or 8 their adult teeth are erupting and you may start to notice crowding or bite problems. This is now an orthodontic issue that requires orthodontic intervention. Myofunctional therapy and orthodontic treatment are not the same thing. Orthodontics is structural and myofunctional therapy is about physiology. They are complimentary, not alternative.
As adults, orthopaedic changes are much more complex and surgery can often be the only option. Adults who have high narrow palates and or receded lower jaws are high risk for obstructive sleep apnoea and surgery is their only option for structural changes. This is advanced maxillofacial surgery, expensive and often a painful experience. There are people who have this surgery because it can be lifesaving. This is why we need to intervene early and avoid surgery later in life. Fix the functional problem and treat early.