Better Bites: Kids' Braces

Josh Miller came to see orthodontist Chris Carpenter with a severe overbite at age 9. His father had needed jaw surgery and extractions when he was a teenager to correct the same condition. But because Josh began treatment early, Carpenter was able to use orthodontic appliances to guide bone growth, then apply braces to straighten his teeth - eliminating the need for surgery or extractions. At 15, Josh is now out of braces and wearing a retainer to maintain his new alignment.

Josh's case illustrates the current trend toward beginning orthodontic treatment earlier and completing it in two phases:

  • Phase 1 corrects the shape, width or alignment of the jaw (dentofacial orthopedics).
  • Phase 2 moves and straightens the teeth (traditional orthodontics).

The American Association of Orthodontists (AAO) recommends that all children receive an orthodontic screening by age 7.

"You may not treat them at age 7, but you can begin a strategy," explains Don Joondeph, D.D.S., M.S., an orthodontics professor and a member of the AAO board of trustees. At age 7, permanent teeth are beginning to come in and orthodontic problems become apparent. At the same time, bones are still growing, giving the orthodontist the chance to "sequence and orchestrate" treatment, Joondeph says.

"If the patient is not seen until all the permanent teeth come in, growth is finished and it's too late," Joondeph says. The orthodontist loses the opportunity to correct jaw alignment. The result is often a longer period in braces later and more extractions of permanent teeth. This is especially true for girls, who finish growing earlier.

The AAO estimates that 75 percent of Americans suffer from malocclusion (literally "bad bite") and could benefit from orthodontic treatment. Orthodontia not only improves appearance, but makes teeth easier to clean, prevents uneven wear on teeth, reduces stress on bones and gums, and can prevent headaches and jaw pain due to poor alignment. Currently, nearly 5 million people in the United States and Canada are in orthodontic treatment; 80 percent are under age 18.

Treatment at Different Ages

For most children, an initial visit at age 7 will be low-key and inexpensive, Joondeph says. Often the strategy will be a "wait and see" approach.

Here is an age-by-age guide to what to expect from orthodontic evaluation and treatment.

  • Ages 2 to 3 - In very rare cases, children as young as 2 or 3 with extremely distorted bites may need to begin treatment.
  •  Ages 5 to 7 - This is the ideal time to counsel children to stop bad habits, such as thumb-sucking and tongue-thrusting, according to Jeffrey Ahlin, D.D.S., who has taught at Tufts and Harvard universities and is the online editor for the American Orthodontic Society. Although most malocclusions are hereditary, habits can make problems worse if they continue after permanent teeth have come in.
  • Ages 6 to 8 - This is the time to correct crossbite (when teeth overlap each other, most commonly when the upper teeth bite inside the lower teeth, toward the tongue), Ahlin says. This condition makes it difficult for children to bite and chew properly. If the lower jaw is jutting out, the upper jaw will need to be brought forward, and the window of opportunity for doing that is at a young age, Joondeph notes.
  • Ages 8 to 10 - This is the target age range for correcting most other jaw problems connected with overbites, protruding upper teeth or open bites (upper and lower front teeth do not touch when back teeth are biting down).

"I usually try to get to the skeletal parts of the problem first, at age 8 to 10, before putting on the brackets, if needed," Ahlin says.

Sometimes a child will have headaches because the muscle next to the temple is connected to the lower jaw and gets a kind of "charlie horse" if the jaw is misaligned, Ahlin explains. In those cases, treatment should begin at the younger end of the age range.

The orthodontist will use fixed or movable appliances to widen the jaw or change its alignment. For example, a headgear, the most common of several appliances used to correct jaw-growth problems,is often used to correct an overbite, usually caused by the lower jaw being too short. Usually worn for 10 to 12 hours a day, a headgear slows the growth of the upper jaw by putting backward pressure on the upper teeth, allowing the lower jaw to catch up, Joondeph explains. Other appliances may advance - or push forward - the lower jaw, opening up the airway and preventing later problems with snoring or sleep apnea, Ahlin says.

• Ages 10 to 13 (before braces go on) - It is usually best to begin to deal with crowded teeth caused by the dental arch being too small and/or teeth being too big before age 12, Joondeph says. If this isn't treated before permanent teeth come in, the bone and gums over the roots of extremely crowded teeth may become thin and recede and permanent teeth will become impacted. A space maintainer - an orthodontic device with a fixed wire - may be placed between teeth to hold the place after a baby tooth comes out. An expansion appliance can be fixed to the back teeth to widen the upper jaw. Sometimes baby teeth may have to be extracted or the middle permanent molar removed to make room.

These first-phase treatments may take a few months to a couple of years, depending on the severity of the problem.

Ages 10 to 14 - The most common time to put on braces is after all the permanent teeth have come in. But some children get braces as young as 8, and some aren't ready until their late teens. Orthodontists take multiple X-rays, photographs and plaster models before fitting appliances or braces. Many create computer models to show patients how their teeth will move and what they will look like after treatment.

Braces usually stay on for 12 to 18 months, depending on the orthodontic problems and the patients' cooperation. A child will usually be in braces longer if he hasn't had any first phase treatment.

Not Their Father's Braces

Braces traditionally consist of three pieces:

  • bands that go around each tooth;
  • brackets on the fronts of the bands to attach the wire; and
  • wire, which runs through all the brackets and exerts pressure on the teeth.

The principles of correcting teeth alignment with pressure are ancient: Archeologists have discovered mummies with crude metal bands wrapped around individual teeth, and Hippocrates wrote about straightening teeth in 400 B.C. Early "wires" were made of catgut.

But orthodontics really took off in the early 1900s, when bands, brackets and wires were made of malleable gold. They had to be changed often. Bands were later converted to stainless steel, still the material of choice today.

Baby boomers and Gen-Xers may remember spacers - rubber inserts that forced teeth apart so that the bands could fit around them - as the most agonizing part of orthodontic treatment. Today's patients no longer suffer the pain: bands for back teeth are thinner, and high-tech adhesives affix brackets directly onto the surfaces of front teeth. The adhesives can withstand moisture, and some even release fluoride to help protect tooth enamel.

Less obtrusive brackets, including ceramic or plastic ones in clear or tooth-colored tones, have virtually eliminated the "tin grin." Lingual braces, with brackets bonded behind the teeth, are almost invisible.

Wires are also thinner and less noticeable. They're often made of alloys of nickel, titanium, copper and cobalt, rather than stainless steel. Heat-activated nickel-titanium wire, developed by NASA, maintains a gradual, precise, gentle pressure and becomes more flexible as the mouth warms up, so braces don't have to be tightened as often. Manufacturers are working on developing a clear orthodontic wire.

Many younger patients don't want unobtrusive braces. Some choose colored brackets for front teeth. Ties, which connect the brackets to the corrective wire, "are kind of like jewelry now," Joondeph notes. "Ninety-nine percent of my younger patients have colored ties to go with the season or sports teams or school colors. Little kids who come in actually want braces; they love to look at the color charts," he says. "Rubber bands, which are sometimes attached to brackets to pull teeth backward, also come in colors. Retainers are no longer all roof-of-the-mouth pink: they're available in glow-in-the-dark shades or emblazoned with logos, emblems or pictures of spiders or snakes.

Some orthodontists, including Ahlin, include a bleach treatment at the end of the orthodontic treatment, making the bleach tray out of the same mold used to make the retainer.

Wenda Reed is an editor at United Parenting Publications (a Dominion Parenting Media property), and a former orthodontic patient and the parent of two children who went through braces.

Should Your Child Have an Orthodontic Examination?

The American Association of Orthodontists recommends that all children receive an orthodontic screening by age 7, especially if they exhibit the following signs or habits:

  • Early or late loss of baby teeth
  • Difficulty in chewing or biting
  • Mouth breathing
  • Thumb- or finger-sucking
  • Crowding, misplaced or blocked out teeth
  • Jaws that shift or make sounds
  • Biting the cheek or roof of the mouth
  • Teeth that meet abnormally or not at all
  • Jaws and teeth that are out of proportion to the rest of the face.

©, used with permission.

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