When to start orthodontic treatment

One of the most frequent questions we orthodontists are forced to answer is when a patient should begin treatment. There is a lot of confusion on the part of parents when it comes to assessing when to take their child to an orthodontist, and also on the part of many general dental professionals, there is confusion as to when to orient a patient towards orthodontic treatment. However, it is very important to be clear about this concept, since starting treatment on time or not will often determine its success or failure.

In the following article, Dr. Alió Sanz will attempt, in a very general way, to address this type of question. We are going to see the most important occlusal and functional skeletal alterations, and when orthodontic treatment should be started in each of them.

As a general idea we can say that skeletal alterations require a start during the growth phase of the patient, while purely dental alterations will generally be treated when the permanent eruption is completed.

1. Skeletal disorders

Skeletal disorders can be located at an upper (maxilla) or lower (mandible) level or both combined.

1.1. Maxilla.

a- Forward position of the bone: maxillary prognathism. b- Increase in the relative size of the bone: maxillary hyperplasia.

In both cases, the treatment has to be early because we can achieve an orthopedic result and achieve the absolute normality of the patient.

It is important to treat these alterations as they will affect both masticatory function and facial esthetics and if treatment is not started early, the patient will have to be treated with orthognathic surgery as an adult.

c- Maxillary compression.

This is a narrowing of the apical base of this bone. In order to expand it and recover the normal transverse length it will be necessary to start the treatment also at an early stage.

2.2. Mandible

a- Small and delayed bone: Mandibular hypoplasia.

b- Large bone with high growth potential: Mandibular prognathism.

In cases of mandibular prognathism it is very important to start as soon as possible to stop the growth of this bone, which we can do with certain types of appliances.

In order to make a diagnosis of skeletal alterations and therefore to know if the problem is in the maxilla, in the mandible or in both, it is necessary to resort to cephalometric diagnosis by performing a lateral teleradiography of the skull.

2- Occlusal alterations

2.1. Dental malpositions. Dental malpositions require immediate treatment when they are causing damage to the structure of the tooth or its periodontium.

2.2. Lack of space in one or both arches. Space alterations require immediate treatment when they are likely to increase the arch length and avoid subsequent treatment with extractions.

2.3. Alterations in the eruption. Most of the time they only require immediate treatment when they cause difficulty in the eruption of a tooth.

3- Functional alterations

3.1. Breathing alterations. Oral or buccal breathing instead of nasal breathing leads to the patient’s mouth remaining open, with a lack of lip seal, accompanied by an altered position of the tongue and an alteration in the patient’s growth which leads to an esthetic disharmony.

3.2. Swallowing alterations. The most frequent is the persistence of infantile swallowing, in which the patient interposes the tongue between the upper and lower incisors when swallowing. This produces an open bite that is difficult to treat if not corrected in time.

3.3. Habits. The most frequent is digital sucking. It should be treated immediately, otherwise there will be alterations in the growth of the maxilla, in the mandibular and dental position.

Treatment possibilities according to the age of the patient.

We are going to establish five sections for starting treatment depending on the age of the patient in order to simplify and outline each of the disorders.

1. Early treatment (4-6 years of age)

We call early treatment that which we start at a very early age. Often these are patients at ages when orthodontic treatment would not be suspected, but nevertheless the alteration presented requires it.

The most frequent is the case of mandibular prognathism, which, as previously mentioned, should be started as early as possible in order to slow down mandibular growth. Apical compressions of the maxilla should also be treated at this age since this way the treatment is much quicker and also simpler.

Digital sucking habits should also be corrected at this age.

2. Early treatment (6-8 years of age)

Early treatment should be carried out whenever there are functional alterations, such as oral respiration or infant swallowing. Early correction of functional alterations will prevent the establishment of later skeletal alterations, which are much more difficult to treat.

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We should also start at this age the maxillary compressions that lead to functional deviations of the midline and mandible.

3. Initial treatment (9-10 years of age)

In this section we should include all serious skeletal alterations, lack of space in the arches and alterations in dental eruption.

At this age we can treat severe skeletal disorders with certain types of appliances that will correct the position of the bone. The same occurs when there is a deficit in mandibular growth. There are some types of devices (functional devices) that can induce a greater growth of this bone.

4. Treatment medium time (10-13 years of age)

In this section we introduce all the skeletal alterations mentioned above when they are not particularly serious. This is a very common age for starting treatment and any child should always be examined by their orthodontist at this age, whether or not they appear to have occlusal or skeletal alterations or pathology.

5. Late treatment (from 13 years of age)

Late treatment is that which is performed when the permanent dentition is complete. In this treatment we will correct all occlusal alterations, dental malposition and space alterations. These are exclusively dental correction treatments and it is difficult at this age to perform any type of orthopedic correction. If treatment has not been carried out in time due to space problems, tooth extractions will generally be necessary at this stage.

Phases and duration of orthodontic treatment

Early, early and initial treatments are usually carried out in two phases. The first phase is aimed at treating the specific problem that the patient presents at that age. In the second phase, dental alterations, if any, are solved.

Medium and late treatments are usually carried out in a single phase.

The duration of orthodontic treatment depends on several factors:

1. The severity of the patient. There are functional skeletal or dental alterations that due to their seriousness or severity will make orthodontic treatment complex and usually longer than normal.

2. Dental health. When there is a high incidence of caries or gingivitis problems or even periodontal problems, orthodontic treatment must be performed more slowly and often there are problems that force it to be stopped for some time. This makes these treatments longer and more complicated.

3. Patient hygiene. This is one of the most important factors in making orthodontic treatment shorter. In patients with good hygiene, apart from reducing the susceptibility to caries, there is no gum disease, which makes the treatment easier, the appliances act more quickly and in general the treatment is shorter.

4. Patient collaboration. This is another of the most important factors when calibrating the duration of a treatment. Non-collaborative patients, that is, those who do not follow the instructions we give them in the office and usually have poor hygiene, are patients in whom the treatment is going to take much longer. It is very important to be aware of this in order to achieve maximum collabor
ation.

In general, two-phase treatments last 1.5 years in the first phase and 2 years in the second phase. Single-phase treatments last between 2.5 and 3 years approximately.

The importance of dental hygiene during orthodontic treatment

Fundamentally, hygiene is one of the most important factors in achieving successful orthodontic treatment. This is for several reasons:

  • The accumulation of bacterial plaque increases the incidence of caries.
  • Bacterial plaque leads to gingivitis.
  • Gingivitis affects and hinders tooth movement. We have to be very scrupulous when indicating to the patient the methods of hygiene and how to perform it. It is necessary to brush at least three times a day with a suitable toothbrush and avoid eating certain foods that have a high cariogenic potential. It is also important to periodically apply fluoride during orthodontic treatments.

Types of orthodontic appliances

  • Removable appliances

In general, removable appliances are used for very simple dental movements. Some fall into the category of functional appliances, and in this case they are complex appliances that perform orthopedic treatments generally in the initial or part-time treatment phase.

  • Fixed appliances

They are the fundamental ones to perform a fine and precise dental movement. Generally these types of multibracket appliances are used in the late or mid-term treatment phases.

  • Extraoral appliances

They are devices that go outside the oral cavity and perform orthopedic treatments. They are essential to correct skeletal alterations.