Three Circles

Are you loving this amazing Caribbean, oops, I mean Northern Ohio warm spell?!

By the time you read this on Saturday, we’ll be eighteen days without measurable rain. The low humidity has been great for sleeping, if we could just get a drop in the pollen count!

While you were fireside with your family last weekend, did you happen to catch the strikingly red strawberry moon just as it arose from the horizon? According to NASA, the upper atmosphere is full of ash from the Canadian wildfires and all conditions were right for the early ascent of the moonrise to make it appear exceptionally red this year. It was pretty Stephen King-ish. (A point of clarification here, the term strawberry moon comes from the fact that wild strawberries in our area are to begin ripening this week. The name has nothing to do with the color of the moon this year.)

June is also the busiest month of the year for orthodontic and oral surgeon offices across the country with the ending of the school year…

Over the last several weeks, we have had a large influx of new exam patients, and many of the parents have expressed concern that if their child was under ten, were they in our office too early? The increased frequency of this question over the last month prompted this week’s blog; and thus, I will attempt to clear the air, pun intended, on early orthodontic intervention.

I feel the questions on the value of early orthodontic intervention therapy arise in part from the fact that 30 years ago, when a lot of parents were going to the orthodontist for their treatment, it was when they were in eighth or ninth grade (or later).

Early orthodontic treatment didn’t start to come into its own until 20 or so years ago! There were those pockets of maverick orthodontists in various universities advocating early treatment in the 70s and 80s. But it wasn’t until the mid-90s that the research really began to point to the value of intercepting and reducing orthodontic issues at an early age, rather than waiting until the crowding and dental issues required more severe solutions!

Europe has always been more holistic and prevention-oriented in their approach to medical and dental solutions. As more American universities hired European professors, early approaches to the treatment of medical and dental issues became more the norm.

Ohio has always been on the cutting edge in medicine and dentistry, being the home to OSU and Case Western Reserve University (as well as great surrounding healthcare universities such as University of Kentucky and University of Michigan). Ohio orthodontists in the 70s and 80s, when I had braces, almost exclusively used surgery and extractions to free up impacted teeth, unravel crowding, and correct over and under bites. Today, we can expand, stretch, depress, or elongate the facial bones to functionally get the foundation in place for a larger dental footprint to accept the imminent eruption of the child’s permanent dentition.

Let’s take a closer look at the multi-factorial aspects of intercepting a child’s malocclusion (or misaligned bite). In simpler terms, “How do I fix Johnny’s darn smile?”

What I’m about to say next is purely my opinion. It comes from 35+ years of working with young people in Medina. But whether I’m in my study group in Dallas, TX, or Ann Arbor, Mich., orthodontists agree… not all young people are candidates for early orthodontic treatment.

I have developed an approach in my practice and all of my staff are well-groomed to begin analyzing prospective orthodontic patients right from the first hello and handshake! Our evaluation involves Three Circles, or areas of interest, in the form of an orthodontic Triple Venn Diagram that needs to be evaluated and discussed before a parent or child says yes to treatment.

Let’s look at each of these circles and realize that the center or overlap of the three circles is successful treatment…

For early orthodontic treatment to be right for your child, it must have a biological benefit.

The first area of interest for early treatment (and easiest to assess) is the biological benefit.

Not all overbites or crowded teeth need to be treated early! This may sound like hearsay, but let me explain. My readers need to know that a human’s upper jaw grows roughly from six to twelve years of age and the lower jaw grows with puberty. Once a woman starts monthly cycling, her lower jaw does most of its growing over the next 24 months. So three to four millimeters difference between the upper and lower jaw is no big deal in a nine-year-old, but needs to be evaluated for treatment in a 16-year-old.

However, one of the functional rules we have come to understand over the last decade or so is that lower jaws cannot grow forward with a narrow upper jaw holding them back. Lower jaws also cannot grow forward if the upper front teeth point backwards toward the lower jaw or significantly overlap the lower jaw! The analogy that I find very helpful in explaining this — the upper jaw is like a shoe and the lower jaw is like a foot. It’s easier for a foot to fit into (and move around in) a DD than a AA shoe. A little crowding in the lower arch may be no big deal, whereas crowding in the upper can press against the lower teeth, again preventing its growth during the critical pubertal years.

And herein lies the true benefit to early treatment that we missed out on for so many years — if a child’s lower jaw is given the freedom to grow, usually by expanding the upper jaw, during these critical pubertal years… the lower jaw can finally reach its genetic potential! Just as thumb-sucking can accentuate an upper jaw and flare the teeth, retroclined and crowded upper teeth can suppress a lower jaw’s growth. Once lost, natural pubertal growth can never be regained and the options for overbite and crowding involve removing teeth to fit the deficient jaw or electing surgery after 18 years of age to augment or decrease the length of the jaws.

Another biological benefit of early treatment is freeing up the eruption of the child’s permanent teeth by early selective premature removal of poorly positioned baby teeth. Europe has been doing this for years… removing the blocking baby teeth and watching the permanent teeth erupt into a beautiful position without braces. I get more push-back from recommending the early removal of baby teeth than all other recommendations combined. Please don’t feel that baby teeth will always fall out at the proper time. They don’t! And I have made a career out of the results when they don’t.

It’s important that a child is psychologically ready for early orthodontic treatment.

Let’s now look at the second area of interest that I feel is the most important and most difficult to ascertain and accept by parents — the child’s psychological readiness to have an appliance and orthodontist’s fingers in their mouth!

Many early interceptive appliance approaches required significant patient involvement and cooperation. Thankfully today, except for Invisalign®, most early treatment appliances are cemented in. But let me tell you, if that child has been spooked by prior negative dental experiences, Santa Clause himself isn’t going to be able to work in that child’s mouth!

We have tried scheduling a hesitant young patient back every month for two to three visits to try and establish a relationship prior to initiating treatment. It has been successful with some and others have required a couple of years to “warm up” to treatment. Since Covid, I have noticed an increase in skittish, hesitant-to-trust young patients and an increase in attachment to mom.

Just this week, I had a mom very determined to keep up with her neighborhood, since according to her all the young children had expanders, by starting interceptive orthodontics this summer with her seven-year-old son. But every time we tried to look in his mouth, he started crying. So we ended up talking about Star Wars, his favorite topic, and we’ll see him back in July and hope to move a little further ahead in the dental expansion department. Mom, at first, was embarrassed; and then she was a bit upset with her son. But eventually, she explained his bullheadedness was from the father’s side of the family and agreed to come back in six weeks!

Personally, I had very poor early dental experiences growing up in Hinckley (dentist was in Parma), so I have always tried not to propagate that which kept me out of dental offices for years.

Which leads me to the last circle of the Venn Diagram, which is not one that everyone feels comfortable talking about (but I feel needs to be out on the table)…

The third area of interest for early treatment is finance or, as some of my dads phrase it, “What’s my return on investment?”

Over the years, I have surprised some of my patients by bringing up the cost aspect before they do. Let’s face it — we all have a certain amount of money put aside for healthcare or dental care and most of us have a family budget that we work within. If a patient feels comfortable, some will say your program A is too much for the budget; is there a program B or C that could achieve some of the orthodontic goals we are striving for?

Most orthodontists will present several options… and doing nothing but watching to see what Nature will do is many times not a bad idea. Another less expensive approach may be to just put a retainer or space maintainer in to hold the current position until the child is more comfortable with more aggressive treatment or finances improve. Be careful of inexpensive cosmetic-enhancement-only interceptive approaches. Most orthodontic treatment has some cosmetic value, but in early treatment it needs to be balanced with functional correction and future space enhancement to be a good investment!

In closing, I would like to address a misconception that I hear quite a bit, more from dads than moms. “If we do an interceptive approach at an early age, we won’t need to do braces or Invisalign in the future, will we?”

That is an excellent question that unfortunately has several unknown variables associated with it. How early was the interceptive approach started? (Usually, the earlier the better.) Were baby teeth extracted when needed? (Just increasing the size of the jaw’s width doesn’t totally change the eruption trajectory of permanent teeth as successfully as extractions.) The biggest unknowns will always lie with patient cooperation and genetics, which are usually exhibited most profoundly during puberty.

In the end, I tell parents to talk to other family members who have had treatment to see how successful it was for them, considering they have similar genetics. Most of my parents, however, talk to fishing buddies or yoga friends; and then we all know there is always social media to save (or confuse) the day!

That said, I hope I have shed some light on early orthodontic treatment through the concept of The Three Circles.

If you find your child in the center of those three circles, I’ll see you soon, as they might just be ready for early treatment.

In the meantime, no matter where you are in your journey to a better smile, do things that make you smile this summer. It’s good for the soul.

Stay classy readers,

Dr. Pfister