Early treatment – does my child need it

Submitted by junction-orthod... on Mon, 2017-01-30 00:24

Early treatment is that which is carried out during the time when there is a mix of baby and permanent teeth. Advocates of early treatment promote reduced need for extractions, reduced need for braces, improved aesthetics and function and a myriad of other benefits.
Early treatment is aimed at expansion of the jaws (arch development) and improvement of the bite, both which are reasonable goals. Appliances that are used are many and varied and range between off the shelf fit one-fit all (eg Myobrace) to individually custom made. Claims and counterclaims espouse the benefits or otherwise of early orthodontic treatment but unfortunately, almost all of the claims are anecdotal and not subject to rigorous peer reviewed research. (I can make any claim and if it sounds plausible, it is likely to be believed -peer review of properly researched treatment and outcomes is the only way to validate the claim.) As anyone with a dental degree is permitted to offer orthodontic treatment, there has been an explosion in the provision of orthodontic services outside of what is mainstream orthodontics and typically specialist territory, much of which is aimed at early intervention.
It is reasonable for parents of young children to protect and do what is best for them. A rightful concern is the unnecessary extraction of teeth particularly when the average child enjoys good dental health. It is reasonable to want protrusive teeth corrected to avoid trauma and it is reasonable to fix a bad bite to foster better growth, function and aesthetics. It is also a financial incentive if expensive braces can be avoided.
The reality is however somewhat bleak. Early expansion requires persistent and dedicated wear of a removable appliance, often full time for a year or more and continuing night time wear to maintain the expansion. While 4 mm of expansion can be achieved (average) during the full time phase, this has reduced to 1.6mm (average) by the time that braces would be necessary. That's a lot of work for minimal gain and hardly sufficient to justify the expense and effort. Should we routinely undertake early expansion to make space? No......There are smarter ways to gain space.

Early treatment of severe "overbite" with functional appliances does not reduce brace time or grow jaws in any permanent fashion although early treatment of the overbite may reduce the incidence of trauma to the upper incisors by 30%. So, should we treat overbite early? Certainly yes! There is strong evidence that supports improvement in psychosocial wellbeing after treatment of severe overbite, particularly where there are self esteem or bullying issues. If a child wants to have the overbite corrected then treatment is justified, if we are treating overbite for the sake of treatment, then it is not.
So is there a need for early treatment? The answer is yes. Many cases warrant early intervention for a variety of issues.
1) Severe overbite or underbite problems. Not necessarily because further treatment will be unnecessary or less complex but to reduce self image problems that often accompany severe malocclusions.
2) Maintenance / preservation of space where deciduous teeth are lost early and in some cases, reopening lost space for unerupted permanent teeth where baby teeth have been lost early.
3) Maintaining leeway space where available (leeway space is the difference between the size of the baby 2nd molar and the premolar that will eventually replace it. Believe it or not, the baby tooth is larger so we can use this space differential to help resolve crowding problems). 
4) Expansion of narrow jaws, not routine expansion of crowded jaws.
5) Interception of teeth that are erupting incorrectly or impacting. 
The following case is an example of early treatment and the benefits gained in timely intervention. Thanks to Emily and her mum for allowing me to use these images.
Emily presents with concerns regarding her narrow jaw and overbite. Clinical examination reveals a narrow top jaw and associated crossbite on the left hand side of the mouth (top teeth inside the bottom teeth), protrusion of the top teeth and openbite. Emily is a mouthbreather.

Early treatment is indicated to expand the narrow top jaw thus correcting the crossbite, to provide room for developing teeth and to improve the nasal airway. Note the blue rings between the top back teeth-these are separator elastics that allow us to temporarily cement the expander to the teeth reducing the need for compliance and  allows us to speed up the process.

The expander was inserted in February and removed 4 months later. Emily was then placed on recall and 20 months later when the baby teeth had fallen out, braces were fitted as the final phase of her treatment. Note that during nearly 2 years of doing no more than observing, the expansion has held up well remembering that we have to date only treated with 4 months of expansion.

Braces were placed in February 2011 and removed September 2012. Treatment time in braces was 19 months.

The final result demonstrates well aligned teeth that fit the face, sit in harmony with the lips so that just the correct amount of gum and lower teeth are exposed while filling the corners of the mouth.