The Tooth About Braces

July 19, 2007 — -- The question of the proper age at which a child should get braces and other orthodontic work is one that has irked parents for decades.

Take Marguerite Cronin. Wednesday morning, when she brought her 9-year-old son, William, to Manhattan orthodontist Margot Jaffee's office, she was told that her son would need a metal plate in his mouth to adjust his palate.

William's too-narrow palate must be widened to ensure that his teeth come in properly. Later on, he will need an appliance to adjust his overbite, and braces.

When Cronin's 12-year-old daughter, Caitlin, started with her braces at an older age, she had several teeth correctively removed. While her palate was fine, her mouth was not large enough to accommodate everything.

So, which approach is correct? Both, apparently.

According to an article published this week by the Cochrane Library in the United Kingdom, children with overbites can have equally successful treatment whether they start late or early. Orthodontists say that it reinforces what they have felt all along — that treatment needs to be tailored to the individual.

After having teeth removed in the course of her own orthodontic treatment, Cronin sees this approach as a positive.

"Dr. Jaffee is an excellent orthodontist," she said. "She just doesn't do automatic intervention — she just does each case at a time."

"As long as you're treating somebody that's growing, it doesn't matter if you treat them early or late — it will lead to successful treatment," said Don Joondeph, a Seattle-area orthodontist and former president of the American Association of Orthodontists.

Joondeph explained how orthodontic treatment for overbites generally involves two processes: one with an appliance — like headgear — designed to slow growth of the upper jaw, and the second with braces, to align the teeth.

An orthodontist should base the decision of when to start the treatments on the severity of the overbite for starting the jaw positioning treatment, and when a child has his or her adult teeth, for braces, Joondeph said.

This is because overbite treatment aligns the jawbones by slowing the growth of the upper jaw, so it would only work while the jaws are still growing.

Ideally, Joondeph said, the treatment of jaw position and tooth alignment would take place at the same time, since it minimizes treatment time. But doing the two together might force some children to wear braces longer than they otherwise would.

Why Not to Wait

While orthodontists recommend having treatments take place at the same time, they cite several reasons why parents may want their children to start with braces sooner.

"Young patients are very cooperative as young as 6," said T. Gerald Bradley, an associate professor of orthodontics at the Marquette University school of dentistry. "We often times have more difficulties with teenage patients, who resent having braces."

But, he added that maturity needs to be considered as well.

"The ability to have and maintain good oral hygiene is essential to avoid undesirable consequences that can be associated with orthodontic appliances," Bradley said.

Jaffee, who also serves as an assistant clinical professor at the Columbia University College of Dental Medicine, feels that patients will typically benefit by waiting.

While the Cochrane Library study only looked at overbites, some treatments, Jaffee said, should be started earlier. Asymmetric growth of teeth, and problems that involve the palate, should be started while a child is as young as 4, because the mouth and the surrounding bones have not hardened yet.

"I don't think it's a good idea to move the teeth early," Jaffee said. And while she feels earlier treatments may sometimes be warranted, "it has to be for a reason and it has to be for a short treatment."

Jaffee added she would consider earlier treatments in cases where a child's teeth are very misshapen, creating an aesthetic problem, or the teeth protrude so far that there is a risk of them breaking if the child is hit in the mouth.

She sees a risk in having children in treatment for too long, though.

"By the time they're ready for real braces, you could burn them out and they could be uncooperative because they're sick of it," Jaffee said.

Cronin's daughter, Caitlin, will have her braces off well before she starts high school, and Cronin thinks Caitlin has benefited from having her orthodontic work done at an age when children are less worried about their appearance.

Lee Graber, who has an orthodontic practice in the northern Chicago suburb of Vernon Hills, added a few more reasons why to start early.

For some children, he said, the teeth protrude far enough that the muscles keep the lips from closing properly — a problem that will worsen without early intervention.

"By intervening earlier, we can break up that muscle pattern so the muscles are working for us rather than against us," Graber said.

He also noted that children who are concerned about their appearance feel better once they get braces, since they feel the problem is being corrected.

To Each His Own Teeth

In the end, Graber said, a good orthodontist will tailor the treatment for the growth of an individual child, which he jokingly refers to as "making the punishment fit the crime."

"When we look at patients, one thing that's important to look at is there's a lot of individual variation," Graber said.

He also recommends early screening for children — well before they would need braces — so that the orthodontist can determine any problems the child might potentially have.

Recent advances in dental technology, Graber explained, allow parents greater choice in how their children are treated.

The costs of braces have dropped significantly in the past 20 years, he said, and half of the families he sees have some form of insurance. So, cost considerations are no longer as much of a problem as they once were, allowing for a course of care that fits the individual better.

Graber's three daughters each had a very different course of orthodontic care.

"The goal for orthodontists," Graber said, "is to get the best results in the shortest amount of treatment time."