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The Transition to Orthodontics
For example, the common problem of moderate crowding of the front teeth in the adolescent or even pre-adolescent child can be treated in one case by “expanding” all the teeth both laterally and forward into a larger arch circumference. The resulting smile would be fuller and broader and probably more esthetically pleasing. However, if the face is somewhat narrow and the lips small and thin, this result might lead to a “toothy” appearance and even an inability of close the lips easily at rest. The expansion treatment for crowding may also have more of a tendency to relapse a little as the cheek and lip muscles tend to push the teeth back in. Thus, long term, even permanent, retention appliances such as lingual wires behind the teeth or removable retainers may need to be placed indefinitely. The two most common orthodontic problems in children are crowding of the teeth and protrusion of the upper incisors (front teeth). Surprisingly, some pediatric dentists and orthodontists don’t agree on just how these problems should be treated. Just as no two children are alike, no two dentists diagnose and treat the same way. Second opinions are often different opinions, resulting in bewildered parents. Parents can avoid some of this potential confusion by developing some perception of what they prefer the final facial and dental appearance to be. And this perception should be communicated to the pediatric dentist or orthodontist before being treated with braces. Fortunately, in practically all cases, the teeth themselves will end up straight, but, depending on the chosen treatment plan, there may be noticeable differences in the width and fullness of the smile, in the profile appearance of the teeth and lips, and in the stability of the end result. This is because, for each of the two common problems of crowding and/or protrusion, and depending on the severity of the problem, there may be two very diverse treatment options with equally diverse results, both dentally and facially. The alternative treatment in another similar or more several instance of crowding often involves the actual extraction of up to four permanent |
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| bicuspid teeth (one in each side of each arch) in order to gain the space needed to align the crowded teeth. In this approach the teeth and arches are not expanded, the facial profile is not changed, and lifetime stabilization is not required. In the 50’s and 60’s the extraction approach was favored in 60-56% of all crowding cases. However, the pendulum has recently swung toward the advocates of the non-extraction expansion plan, which was actually the popular plan in the early 1900’s by the pioneers of the specialty. Unfortunately, many of these non-extraction treatments resulted in the above mentioned concerns about facial appearance and stability. Evidently, we learn by seeing our long term results, but it might take a whole generation of patients to change our approach and start swinging the pendulum back. The protrusion problem also has two very diverse treatment options. Here again, much depends on the severity of the problem, the beginning facial profile and the final esthetic results desired by both the parents and the orthodontist. One plan to correct moderate “buck teeth” attempts to move the lower teeth and jaw forward with special “functional appliances”. This approach is especially indicated in children who have small, short lower jaws and retruded chins to begin with. This approach is termed “dentofacial orthopedics” as it attempts to make the lower jaw grow forward more than it would through normal growth. The long term prognosis is thus always guarded, but if successful can give a dramatic improvement in the profile alignment of the upper and lower jaws. An alternate plan for upper protrusions would be to push all the upper front teeth inward (and the lower incisors forward a little) to reduce the protrusion. This plan might require either pushing back all the upper back teeth first (with headgear etc.) or alternatively, extracting a permanent bicuspid tooth on each side of the upper arch to obtain space for the retraction of the upper incisors. Different treatments, different end results, and different faces. Every child has his or her own unique orthodontic problem. Superimposed on all the treatment options and anticipated results is the fact that during treatment the face and jaws are growing, sometimes for the better, but occasionally in an unfavorable direction which is difficult to predict. Orthodontics is not only a science, but is equally an art and a philosophy. Final treatment decisions will eventually be made by the experienced dentist who understands the true complexities of the diagnosis along with parents who share the same vision of the final dental and facial result.
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