Does My Child Need Braces?

It seems children today get braces or other types of orthodontic treatment earlier than their parents did. Is that the case and, if so, why?
Perhaps one can say there was a paradigm shift in the early ’80s. There is better understanding today of the underlying causes of orthodontic problems, many of which begin in early childhood. As a result, orthodontists pay greater attention to the ideal timing of treatment. We have learned that early intervention may, in many cases, lead to better outcomes.
Orthodontists do much more than just straighten crooked teeth. Orthodontists make sure the top and bottom teeth fit together properly. They are trained to guide and influence the eruption of teeth, as well as growth of the bones in the face and jaw, which can be achieved before an individual stops growing.
The older model – waiting for all the baby teeth to fall out and all the permanent teeth to come in before seeing an orthodontist for the first time – resulted in what today would be considered missed opportunities in many cases. Delaying treatment until adolescence increased the incidence of extraction of permanent teeth because, as the bones became more rigid and growth ceased, the window of opportunity for expansion or growth modification closed. Many correctable habits or skeletal mismatches were allowed to continue, while earlier intervention could have led to a more stable, and less invasive correction. In addition, as a result of increased public awareness of dental and orthodontic health, many more young children are seen by pediatric dentists than ever before. Pediatric dentists have additional training in growth and development and recognize developing dental and skeletal problems in young children. This has led to an earlier referral of their younger patients for an orthodontic evaluation.
At what age should your child see an orthodontist? How do you know to do so?
 
The American Association of Orthodontists (AAO) recommends that all children get a check-up with an orthodontist at the first recognition of an orthodontic problem, but no later than age 7. Orthodontists can identify subtle problems with jaw growth and emerging teeth while some baby teeth are still present. While a child’s teeth may appear to be straight, there could be a problem that only a proper orthodontic evaluation may detect. A panoramic X-ray may reveal many existing or developing problems. Early treatment may prevent or intercept more serious problems from developing and may make treatment at a later age shorter and less complicated. In some cases, orthodontists will be able achieve results that may not be possible once the face and jaws have finished growing.
 
Early treatment may give your orthodontist the chance to: guide jaw growth, lower risk of trauma to protruded front teeth, correct harmful oral habits, guide eruption of permanent teeth into a more favorable position, improve appearance of teeth, lips and face, and minimize the possibility of bullying and teasing. If your child is older than 7, it is certainly not too late for an orthodontic check-up. It is also important to understand that having a child being evaluated around age 7 does not mean that the child will necessarily need immediate treatment. The orthodontist can tell you if it is safe to delay treatment until the permanent teeth are in place (age 12-14). Because patients differ in physiological development, dental eruption and treatment needs, the orthodontist’s goal is to provide each patient with the most appropriate treatment at the most opportune time.&pagebreaking&Many orthodontic referrals come from general or pediatric dentists, but it is important to know that this is not a prerequisite. If a parent notices a problem, they can reach out to an orthodontist without a dentist’s referral. Many orthodontic offices offer low cost or complimentary orthodontic consultation. Anyone looking for an orthodontist should use the “Find an Orthodontist” service at the American Association of Orthodontists’ (AAO) website, www.mylifemysmile.org, to locate nearby AAO members. This is also good resource if you are seeking a second opinion. When choosing an AAO member, the public is assured that the doctor is an orthodontist because the AAO only accepts orthodontic specialists for membership. An orthodontist is a specialist who has graduated from a dental school and then goes on for an additional two- to three-year specialty education to study orthodontics and dentofacial orthopedics. This training must be successfully completed in an accredited orthodontic residency program (only 66 in the entire United States
 
In addition to teeth straightening, why might orthodontics be needed?
 
In addition to straightening teeth, an orthodontic evaluation should be made for management and correction of malocclusions (“bad bites”), when the teeth meet improperly. Some of these conditions include but are not limited to: growth guidance and correction of disproportionate jaw growth, crossbite of front or back teeth, crowding and spacing of the teeth, correction of protruded front teeth to minimize likelihood of accidental fracture of these teeth, deep bite (i.e., excessive overbite), open bite, underbite, late eruption or impaction of a permanent tooth and elimination of harmful oral habits such as finger sucking or tongue thrusting. In addition, any of the following conditions may benefit from an orthodontic evaluation: early or late loss of baby teeth, difficulty in chewing or biting, mouth breathing adversely affecting jaw growth, facial imbalance or asymmetries, cleft lip/palate, jaws that shift or make sounds, speech difficulties, detection and management of extra or missing teeth, biting the cheek or teeth contacting the roof of the mouth, and grinding or clenching of the teeth.
 
Other than braces, what are some of the more common orthodontic treatments parents might expect?
 
Some of the more commonly used orthodontic devices in younger children in mixed dentition, and some of the terms that you might hear that describe these devices, include (but are not limited to): removable or fixed palatal expanders, space maintaining or dental arch development devices such as a holding lingual arch, Crozat device, or a Nance holding arch, different types of headgears for correction of an excessive overjet (sometimes called “buck teeth”), protraction facemask for correction of an underbite due a underdeveloped upper jaw, bite jumping devices such a Bionator, twin block or Herbst for correction of a deficient lower jaw resulting in a deep bite or excessive overjet. These devices are used to make changes in the transverse (width), horizontal or vertical dimensions of the jaws to either create more space for permanent teeth to erupt or redirect pattern of jaw growth.
 
What about extractions? Are they necessary?
 
Despite the fact that early treatment and judicious and timely arch expansion may increase the likelihood of non-extraction correction for many patients, sometimes extractions are necessary to achieve the most ideal dental and facial outcome. There are also several other considerations such as periodontal status, facial and lip balance that factor into an extraction vs. non-extraction decision. Excessive expansion to fit in crooked teeth can stress the gum tissue or poorly affect the appearance. Sometimes extraction of certain baby teeth, followed by removing a few permanent teeth (referred to as “serial extraction”), can be used to create a much improved eruption path for the permanent teeth in severely crowded situations.&pagebreaking&What are the options for braces now?
 
Conventional orthodontic brackets made of stainless steel are still the most common braces used, especially in young children. Some patients ask for tooth-colored (ceramic) or gold-plated braces, and the orthodontist can advise whether it would be appropriate. For patients who are allergic to nickel or latex, there are also nickel-free brackets, latex-free ties (also called ligatures) and latex-free rubber bands. Ligature ties, which are used to secure the wire to the brackets, come in many different colors and are generally changed at every appointment. Kids love the idea of changing their tie colors to highlight favorite sports teams, school colors, Halloween, national holidays, etc., which makes the orthodontic experience more fun for them. Customizing retainer colors, patterns and decals is another way kids love to show off their orthodontic devices. 
 
Older kids who have all their permanent teeth and adults have many corrective options available to them: conventional (metal, gold or ceramic tooth-colored) brackets, self-ligating brackets (which do not require a ligature to secure the wire into bracket), lingual (back side of the teeth) brackets and clear aligners (such as Invisalign and ClearCorrect). All have pros/cons that could be discussed with the orthodontist.
 
What are some of the latest advances in orthodontics?
 
Research and technology move pretty fast these days. In the orthodontic specialty, many improvements are available that enhance the experience of the patient and make the treatment more efficient. Some examples include:
 
• Smaller, sleek brackets as opposed to bands on all the teeth (good bye tin grin!)
 
• Pre-adjusted brackets that allow for more precise tooth movement in all three dimensions of space and make the adjustments easier for the patient and reduce the length of time in the chair at each appointment.
 
• Longer acting and softer nickel titanium wires that make it possible to stretch the interval between appointments, which now average six to eight weeks, so that youngsters miss less school and parents miss less work.
 
• Self-ligating brackets not requiring any ligature ties to secure the wire to the bracket, which will reduce friction in the system and may potentially allow quicker alignment of the teeth in the initial months of treatment.
 
• Although tried-and-true devices (like different types of headgears or functional appliances) are still used and are very effective in many orthodontic applications for correction of overbites and overjets (buck teeth), a number of devices that require less compliance from a patient have been introduced. They include molar distalizers, which push the upper molars back, which then creates the space necessary for the correction of buck teeth, and bite-advancing devices that help to correct an excessive overjet by promoting forward positioning of the lower teeth.
 
• Temporary Anchorage Devices (TADs) are mini-screws that are temporarily inserted in the jawbone surface, between roots of certain teeth, and act as an anchor to move teeth in ways not previously possible.
 
• Lasers are being used by many orthodontists to make minor adjustments in the gum tissue that improve esthetics and expose teeth that are not coming into the mouth because they are being covered by thick gum tissue.
 
• CAD/CAM (computer-aided design and computer-aided manufacture) imaging and the advent of clear aligner therapy have helped many adults and teenagers who were reluctant to have braces consider orthodontic treatment.
 
• Digital X-ray imaging has significantly reduced radiation when compared to the use of X-ray films.
 
• Cone Beam Computed Tomography (CBCT), or 3D X-ray imaging, has facilitated much better analysis of orthodontic problems and has consequently resulted in much better treatment decisions.&pagebreaking&• 3D technology and robotic-assisted wire bending and computer- assisted, patient-customized bracket and wire systems have improved precision and efficiency of tooth movement and the overall orthodontic treatment.
 
• 3D technology is also making it possible to scan teeth with a digital scanning wand, instead of taking impressions of teeth, to make clear aligners and/or orthodontic retainers. Patients who are gaggers will love this technology! Current research is focused on digital 3D printing to make it possible to create in-office aligners or retainers from these 3D scans.
 
• Reducing overall length of treatment and accelerating the rate of tooth movement using pulsating forces and micro-osteoperforations have lately gained some recognition.
 
What do orthodontic treatments typically cost?
Fees can range from a few hundred dollars to several thousand dollars depending on the extent of problem and scope of treatment (limited, adjunctive, interceptive, comprehensive, etc.). Many orthodontic offices offer a low-cost or complimentary (initial examination. This will be the best way to determine the extent of the patient’s problem, ideal timing for treatment and cost of the recommended orthodontic care.
Orthodontic care is very affordable. There are a variety of options to pay for orthodontic treatment depending on one’s budget and financial capability. Many offices offer an administrative courtesy discount if the entire treatment fee is paid up front. If this is not possible, the usual and customary payment plan is to pay a percentage of the total fee as a down payment and the remaining balance financed in incremental payments (monthly or quarterly) over the course of treatment. Many orthodontic offices offer interest-free financing. Some offices may be willing to stretch payments over a longer period to make the monthly fees more affordable and within the family’s budget either through in-house interest financing or third-party financing. Some third-party financial providers (such as the AAO-endorsed Springstone, Carecredit and Chase) make it possible for families to start orthodontic treatment with little or no money down.
 
Some employers offer dental insurance as an employee benefit, but not every dental plan includes orthodontic benefits. Having insurance benefits can help with the overall financing, but it is important to understand that rarely do the insurance benefits cover the entire orthodontic contract. There is usually a percentage of a fee allowable for orthodontic benefits. There is always some out-of-pocket portion that the family is responsible for as well, as any unpaid or denied portion by the insurance company. Most insurance companies will have one lifetime figure of benefits to draw from. If there are stages of treatment, the entire benefit may be exhausted with the initial phase of treatment. We generally recommend using benefits when they are available, as they can be reduced or lost if the employer changes benefits or if your employment changes before a second period of treatment is needed.&pagebreaking&Some employers also offer a plan where you can shelter wages from taxes for orthodontic care. Be sure to use FSAs or HSAs, if offered, to set aside a portion of your earnings to pay for anticipated orthodontic care. You can ask your orthodontist if treatment is anticipated in an upcoming year and set aside tax free funds, before your employer’s deadline, to apply towards the orthodontic fees for the following year. Be sure to work with the financial coordinator at your orthodontist’s office to maximize all the benefits available to you.
 
The Affordable Care Act (ACA) requires carrying a dental plan for children under 19 years of age. Unfortunately, routine orthodontic treatment is generally not covered, and the guidelines to evaluate for “medically necessary orthodontics” within an ACA plan require very severe malocclusions to qualify. Your orthodontist would be able to tell you if your child’s orthodontic condition would fit the requirements. Before you drop your orthodontic coverage with the hopes that ACA will replace it, be sure to get a clear assessment of your or your child’s orthodontic needs.
For those patients experiencing financial hardship, there are many programs to help children get the care they need – Smiles Change Lives (smileschangelives.org) and Smile for a Lifetime (s4l.org) are among them. You may contact the California Association of Orthodontists (CAO) www.caortho.org/news-and-legislation/latest-news/T126) to get more information.
Dental schools with graduate orthodontic departments may also be a good choice for care; their fees can be lower than those of orthodontists in private practice. The list of accredited orthodontic programs and their contact information is available through www.aaoinfo.org/education/accredited-orthodontic-programs). The Bay Area is fortunate to have two great dental schools in San Francisco with excellent orthodontic clinics: University of California, San Francisco, (UCSF) and University of the Pacific (UOP) Arthur A. Dugoni School of Dentistry.
Paul Kasrovi, DDS, MS, is an orthodontist in private practice in Berkeley and Orinda, as well as a clinical professor at the University of California, San Francisco School of Dentistry, division of orthodontics. He is past president of the Berkeley Dental Society and the California Association of Orthodontists, and currently serves as secretary-treasurer of the Pacific Coast Society of Orthodontists. He is a Diplomate of the American Board of Orthodontics and a member of the Edward H. Angle Society of Orthodontists.