Written by David C. Page, DDS Saturday, 31 January 2004 19:00
|Figure 1. Human jaws grow the fastest during the first year. The jaws are nearly 50% grown by age 1 (yellow), 80% to 90% grown by age 8 (pink), and almost fully grown by age 18 (green).|
Integrating 5 new functional concepts for earlier diagnosis and treatment of orthodontic and orthopedic jaw problems can provide benefits for dentists and patients. While early orthodontic treatment at approximately age 8 is receiving some attention, braces at age 8 can be too late to guide proper jaw and airway development in some children (Figure 1). "Real" early treatment extends from birth to age 8 and includes promoting breast-feeding exclusively, discouraging pacifier and extended bottle use, examining the tonsils and upper airway, minimizing serial extractions, and utilizing a variety of removable and fixed dental arch developing appliances beginning as early as age 3.4
New research has shown that human jaws are smaller now than just 50 years ago.5,6 Millions of teeth extracted for orthodontics serve as a testament to decades of change. Because the jaws (maxilla and mandible) grow to 80% to 90% of their adult size by age 8,7 nurturing the period of growth from birth to age 8 is important if adequate space for adult teeth is to be achieved. Early orthodontic treatment at approximately age 8 can help some children. Many other children can better benefit from earlier action to help guide proper jaw and airway growth and help make room for erupting adult teeth.
|Figure 2. Dental arches, tongue space, and airway space can be guided to collapse (serial extractions) or grow (using new "real" early orthodontic steps).|
Today, single-phase late orthodontics beginning at age 12 to 15 is still championed as being the most effective and efficient time to begin orthodontic therapy. There are reasons to believe otherwise. Single-phase late orthodontics is often preceded by serial extractions—a form of guided dental arch collapse. Serial tooth extraction (actually a subtle form of active orthodontics and orthopedics) reduces arch length, increases tooth removal, and reduces tongue space (Figure 2).8-10 All of these may ultimately affect overall health for life. Single-phase late orthodontics often requires the extraction of adult teeth for orthodontic reasons. For these reasons, earlier arch-developing functional treatment principles should be embraced, not condemned.
|Figure 3. Early orthodontic and orthopedic treatments can help jaws develop to their full potential. Forward forces help jaws grow forward. Backward forces restrict jaw growth.|
Sleep apnea research shows that small jaws create small airways and increase the likelihood of lifelong life-threatening disorders.11,12 Because the upper and lower jawbones form the gateway to the human airway, earlier functional jaw treatments are needed for many patients with small jaws and airways.13 Studies clearly show that early and late orthodontic treatments can stimulate jaw growth and help jaws to develop closer to their full potential (Figure 3).14,15 Missed early treatment opportunities cannot always be easily resolved later.16,17
Recent publications have confirmed that early orthodontic treatment is effective.18 Early treatment can reduce or eliminate the need for major therapy and even surgery at a later age in a variety of malocclusions.19,20 There is also new evidence that certain early treatment techniques are more than just effective; they have psychosocial effects that are good for self-esteem.21 Early orthodontics can save time, money, and pain for young patients and their parents.22
Multiphase orthodontics utilizing functional treatment principles can be more effective, more efficient, and more beneficial for many children.23,24 Early functional treatments starting at age 2 to 3 can help develop dental arches and make room for teeth that would otherwise need to be removed.25 Early phases of functional treatment can help shorten later comprehensive treatment times while enhancing overall later treatment success.26,27 As more and more dentists learn about the benefits of new early treatments and learn to recognize clinical indications for early treatment, they will either provide earlier orthodontic care or refer their young patients to those who do.
|Figure 4. These 2 examples show how patterns of dental arch and jaw growth begin early and continue if left untreated.|
Critical professional orthodontic challenges face dentistry today. Very little research has explored orthodontic treatments beginning at ages 3 to 8, and few dentists have extensive experience providing orthodontic treatment to children between the ages of 3 and 8. Consequently, few dentists can teach early treatment and few can help advance it against the status quo. Adding to the orthodontic quandary are surveys of dental students and general dentists showing that a great void in orthodontic training exists in most dental schools.28-30 If a clubfoot can be diagnosed and treated at or near birth, dentists can be taught to diagnose and treat crooked jaws, small jaws, and small airways at or near birth, before most growth occurs (Figure 4). Dentists can learn about the newer early functional principles, treatments, and benefits and decide which ones to promote and provide. As more dentists gain better diagnostic and treatment skills, they will encourage earlier treatments. This may ultimately decrease orthodontic tooth extractions, save time, money, and pain, and increase effective and efficient comprehensive care.
To understand the basic principles of early functional treatment, dentists must understand the basics of functional jaw orthopedic diagnosis and treatment. Functional jaw orthopedics (FJO) is the newest, most progressive form of orthodontic treatment.31 This approach treats teeth and jaws starting at birth to manage growth, development, and deformation. With this method, various dental techniques are used in one or more phases of treatment to give patients beautiful, broad, healthy smiles.
Newer multiphase FJO treatment approaches can increase early treatment effectiveness, overall efficiency, and long-term stability.32 The main goal of all early orthodontic diagnostic and treatment protocols should always be to provide the highest quality health service to each individual patient. Cost, convenience, and efficiency are factors to consider in any health treatment. However, optimum final patient outcomes—balanced jaws, open airways, reaching genetic potential, and stable occlusion—must remain the priority.
FIVE NEW STEPS TO BETTER CARE
Step No. 1
Preconception and prebirth nutrition counseling is the first step in the new world of preventive early orthodontics. It should also include discouraging social alcohol and drug use. Dentists have a unique opportunity during regular routine preventive dental visits to give patients general nutritional health advice and recommendations.
|Figure 5. Infant palates (and jaws) vary greatly at birth. Some palates are normally shaped and wide, while others are abnormally narrow, high-channeled, high-bubbled, and even cleft.|
New mothers and fathers should be encouraged to eat nutritious meals starting months before conception, not just afterward, in order to increase the chances for a healthy, full-term baby. Some older cultures still make this a priority for mothers-to-be. This action makes good nutritional sense and good sense in terms of bone growth because vitamin deficiency can cause bone deformities and even cleft palates (Figure 5).33,34 Alcohol and some social drugs have also been shown to cause birth defects including small jaws, so caution in their use during pregnancy should also be advised.35,36 All dentists should encourage patients who desire children to consult with a nutritionist and their doctors before conception in order to promote a healthy environment for optimum fetal jaw/airway growth and development.
Step No. 2
Recommend "exclusive" breast-feeding (breast-suckling) for 3 to 6 months. Breast-feeding should continue for 12 months overall because the first year is the most active period of jaw growth.37,38 Discourage long-term bottle, pacifier, and digit sucking, which can deform jaws and restrict proper growth.
|Figure 6. Breast-feeding (true suckling) stimulates proper forward jaw growth.|
|Figure 7. Breast suckling develops dental arches, jaws, and airways.|
|Figure 8. Breast suckling promotes good swallow muscle tone, proper jaw and airway growth, wider dental arches, nasal breathing, and less malocclusion.|
Breast-feeding (true suckling) is usually better for infant jaw growth and development as well as overall lifelong health because it places beneficial orthopedic forces on the jaws.39,40 It can help jump-start proper jaw growth as well as provide positive lifelong health effects. Breast-feeding is early preventive orthodontics and orthopedics because suckling forces impact the jaws during a very rapid period of growth (ie, the first year). Suckling forces act like orthopedic appliances to induce forward and lateral jaw and airway growth early in life (Figure 6). Breast-suckling stimulates positive down and forward growing forces that aid in proper jaw development. It promotes good swallow muscle tone, proper jaw and airway growth, wider dental arches (Figure 7), and less malocclusion (Figure 8).41-42
|Figure 9. Baby bottle and pacifier use (true sucking) puts backward forces on dental arches and jaws and inhibits down and forward jaw growth.|
|Figure 10. Baby bottle and pacifier sucking deforms dental arches, jaws, and airways.|
|Figure 11. Baby bottle and pacifier sucking promotes poor swallow muscle tone, poor jaw and airway growth, narrower dental arches, increased mouth breathing, and more malocclusion.|
Bottle, pacifier, or digit sucking creates backward destructive forces on both upper and lower jaws (Figure 9).43 Sucking forces act to constrict and form narrow dental arches (Figure 10). Sucking promotes poor swallow muscle tone and habits, which interfere with proper jaw and airway growth. Bottle-fed babies (sucking infants) are more likely to develop malocclusion (Figure 11). Studies indicate that pacifier sucking dramatically increases dental cross-bite malocclusion. Pacifiers alone may place the most destructive orthodontic and orthopedic forces on developing infant jaws.44-46
Step No. 3
|Figure 12. Enlarged tonsils can block the airway, cause mouth breathing, deform jaws, and be a chief cause of obstructive sleep apnea, which can lead to heart disease and sudden death.|
Examine airways during routine dental visits. Airway obstruction can deform the jaws and face during development and even be life- threatening (Figure 12).47 Look for enlarged tonsils, and screen for harmful chronic mouth breathing. Utilize intraoral dental cameras to photograph enlarged tonsils, since they can block the airway and cause major illnesses—some obvious and some subtle. Recommend that enlarged tonsils be removed when they appear to block the airway because they can cause mouth breathing and jaw deformation and also be a chief cause of obstructive sleep apnea.48 When indicated, refer patients to an otolaryngologist for examination, consultation, and treatment recommendations when tonsils and/or adenoids are suspected of airway blockage.
Step No. 4
|Figure 13. Dental bonding can be used to correct closed, crooked, or crossed bites as early as age 2 to 3. Studies also show it to be effective in stopping ear problems (otitis media) in children.|
Promote and provide early functional orthodontic diagnosis and treatment, such as the technique of composite bonding, to correct malocclusion. Dentists with an understanding of jaw orthopedics can use early composite bonding to treat closed, crooked, or crossed bites as early as age 2 to 3. Bonding can be used in phases alone or combined with active appliance therapy. Bonding composite resin to primary molars can be used to open closed bites, balance jaws, reduce ear disease (including otitis media), increase tongue space, increase breathing space, allow the mandible room to translate forward, and allow full coronal eruption of secondary teeth (Figure 13).49
|Figure 14. Serial bonding can be used as braces-without-braces to open a closed bite, free up a distally locked mandible, and increase tongue, swallowing, and airway space.|
Serial bonding can be used progressively to act as braces-without-braces. Composite bonding can act like other "fixed" orthodontic appliances to help guide tooth and jaw growth (Figure 14). It has advantages over all other forms of treatment when applied correctly. Application and occlusal shaping of composite on 2 to 4 teeth takes only 30 to 60 minutes, but it can cause changes for months or even years. The biggest advantage is in preparing teeth, jaws, and dental arches for much more routine fixed bracket therapy if and when it is needed later. Serial bonding can reduce or eliminate the need for further orthodontic treatment later.50
Step No. 5
|Figure 15. This full arch dental cross-bite shows the potential for early interceptive treatment.|
Promote and provide early orthodontic and orthopedic removable and fixed appliances when appropriate, which could even be at age 3 (Figure 15).51,52 Multiphased treatment using early appliances can create better patient outcomes, especially when orthopedic changes are desired. Early treatment usually reduces later treatment needs and sometimes overall treatment time, and early orthodontics and orthopedics can even prevent the need for surgery at a later age.53,54
|Figure 16. Early removable and fixed FJO appliances can change faces and self-esteem.|
Integrating 5 new functional concepts for earlier diagnosis and treatment of orthodontic and orthopedic jaw problems can provide benefits for dentists and patients. Parents want progressive treatment for their children and want fewer teeth removed when possible. Children deserve nice, broad smiles (Figure 16). Early orthodontic treatment principles starting as early as birth can help guide proper jaw and airway development in young patients. This article has discussed certain principles of early orthodontic treatment, including prenatal considerations.
1. Wolsky SL, McNamara JA Jr. Orthodontic services provided by general dentists. Am J Orthod Dentofacial Orthop. 1996;110(2):211-217.
2. Huang GJ, del Aguila MA. Distribution of orthodontic services and fees in an insured population in Washington. Am J Orthod Dentofacial Orthop. 2003;
3. Lawrence AJ, Wright FA, Dâ€™Adamo SP. The provision of orthodontic services by general dental practitioners. 1. Methods and descriptive results. Aust Dent J. 1995;40(5):296-300.
4. Page DC. "Real" early orthodontic treatment. From birth to age 8. Funct Orthod. 2003;20(1-2):48-58.
5. Warren JJ, Bishara SE. Comparison of dental arch measurements in the primary dentition between contemporary and historic samples. Am J Orthod Dentofacial Orthop. 2001;119(3):211-215.
6. Warren JJ, Bishara SE, Yonezu T. Tooth size-arch length relationships in the deciduous dentition: a comparison between contemporary and historical samples. Am J Orthod Dentofacial Orthop. 2003;123(6):614-619.
7. Van Der Linden, Frans PGM. Facial Growth and Facial Orthopedics. Chicago, Ill: Quintessence Publishing Co; 1986.
8. Little RM, Riedel RA, Engst ED. Serial extraction of first premolars—postretention evaluation of stability and relapse. Angle Orthod. 1990;60(4):255-262.
9. Ngan PW, Kao EC, Wei SH. Guidance of eruption for general practitioners. Int Dent J. 2003;53(2):100-113.
10. Kim E, Gianelly AA. Extraction vs nonextraction: arch widths and smile esthetics. Angle Orthod. 2003;73(4):354-358.
11. Tong M, Xia X, Cao E. Cephalometric analysis of the craniofacial bony structures in patients with obstructive sleep apnea [in Chinese]. Zhonghua Jie He He Hu Xi Za Zhi. 1999;22(6):335-337.
12. Hunt CE. Familial small upper airways and sleep-disordered breathing: relationship to idiopathic apparent-life-threatening events. Pediatr Res. 2001;50(1):3-5.
13. Caprioglio A, Zucconi M, Calori G, et al. Habitual snoring, OSA and craniofacial modification. Orthodontic clinical and diagnostic aspects in a case control study. Minerva Stomatol.1999;48(4):125-137.
14. Zhou X, Zhao Z, Zhao M. Analysis of the condyle in the state on the mandibular protraction by means of the three-dimensional finite element method. Zhonghua Kou Qiang Yi Xue Za Zhi. 1999;34(2):85-87.
15. Mills CM, McCulloch KJ. Posttreatment changes after successful correction of class II malocclusions with the twin block appliance. Am J Orthod Dentofacial Orthop. 2000;118(1):24-33.
16. Stahl F, Grabowski R. Orthodontic findings in the deciduous and early mixed dentition—inferences for a preventive strategy. J Orofac Orthop. 2003;64(6):401-416.
17. Maheshwari S, Gupta ND. Early treatment of skeletal class III: a case report. J Indian Soc Pedod Prev Dent. 2001;19(4):148-151.
18. O'Brien K, Wright J, Conboy F, et al. Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: dental and skeletal effects. Am J Orthod Dentofacial Orthop. 2003;124(3):234-243.
19. Nidoli A, Lazzati L, Macchi A. Interceptive therapy of Class III [in Italian]. Riv Ital Odontoiatr Infant. 1990;1(2):37-45.
20. Kluemper GT, Spalding PM. Realities of craniofacial growth modification. Atlas Oral Maxillofac Surg Clin North Am. 2001;9(1):23-51.
21. O'Brien K, Wright J, Conboy F, et al. Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: psychosocial effects. Am J Orthod Dentofacial Orthop. 2003;124(5):488-494.
22. Shell TL, Woods MG. Perception of facial esthetics: a comparison of similar class II cases treated with attempted growth modification or later orthognathic surgery. Angle Orthod. 2003;73(4):365-373.
23. Campbell PM. The dilemma of class III treatment. Early or late? Angle Orthod. 1983;53(3):175-191.
24. Thilander B, Lennartsson B. A study of children with unilateral posterior crossbite, treated and untreated, in the deciduous dentition—occlusal and skeletal characteristics of significance in predicting the long-term outcome [published correction appears in J Orofac Orthop. 2002;63(6):516]. J Orofac Orthop. 2002;63(5):371-383.
25. da Silva Filho OG, Ferrari Junior FM, Aiello CA, et al. Correction of posterior crossbite in the primary dentition. J Clin Pediatr Dent. 2000;24(3):165-180.
26. Carapezza LJ. Early treatment of malocclusion: a guidance system for the general dentist. Gen Dent. 2000;48(3):326-332.
27. Steegmayer G, Komposch G. Early orthodontic treatment of the deciduous dentition. The therapeutic potentials and indications [in German]. Fortschr Kieferorthop. 1993;54(4):172-178.
28. Brightman BB, Hans MG, Wolf GR, et al. Recognition of malocclusion: an education outcomes assessment. Am J Orthod Dentofacial Orthop. 1999;116(4):444-451.
29. Welker WA. The dental curriculum: is is relevant to dental practice? J Prosthodont. 1992;1(1):47-50.
30. Stewart BL, Macmillan CH. Survey of dental practice/dental education in Victoria. Part V. One-year follow-up survey of 1988 graduating class. Aust Dent J. 1992;37(3):217-221.
31. Page DC. The orthodontic shift towards functional jaw orthopedics. Funct Orthod. 2000;17(4):14-17.
32. Ricketts RM. The wisdom of the bioprogressive philosophy. Semin Orthod. 1998;4(4):201-209.
33. Schubert J, Schmidt R, Syska E. B group vitamins and cleft lip and cleft palate. Int J Oral Maxillofac Surg. 2002;31(4):410-413.
34. Schubert J, Schmidt R, Raupach HW. New findings explaining the mode of action in prevention of facial clefting and first clinical experience. J Craniomaxillofac Surg. 1990;18(8):343-347.
35. Hernandez-Guerrero JC, Ledesma-Montes C, Loyola-Rodriguez JP. Effects of maternal ethanol intake on second alcoholic generation murine skull and mandibular size. Arch Med Res. 1998;29(4):297-302.
36. Pecina-Hrncevic A, Buljan L. Fetal alcohol syndrome—case report [in Croatian]. Acta Stomatol Croat. 1991;25(4):253-258.
37. Breastfeeding and the use of human milk. American Academy of Pediatrics. Work Group on Breastfeeding. Pediatrics. 1997;100(6):1035-1039.
38. Dittbrenner H. Optimal infant health through breastfeeding. Caring. 1998;17(5):22-24.
39. Page DC. Breastfeeding is early functional jaw orthopedics (an introduction). Funct Orthod. 2001;18(3):24-27.
40. Palmer B. The influence of breastfeeding on the development of the oral cavity: a commentary. J Hum Lact. 1998;14(2):93-98.
41. Agbasi GG. Your decision to breast feed is best. GRMA News. 1992;(14):4, 7.
42. Larsson E. Orthodontic aspects on feeding of young children. 1. A comparison between Swedish and Norwegian-Sami children. Swed Dent J. 1998;22(3):117-121.
43. Finadeeva EV, Dvoriakovskii IV, Sudarova OA, et al. A comparative study of breast feeding and artificial infant feeding by ultrasonic scanning [in Russian]. Stomatologiia (Mosk). 1990;69(2):70-73.
44. Larsson E. Sucking, chewing, and feeding habits and the development of crossbite: a longitudinal study of girls from birth to 3 years of age. Angle Orthod. 2001;71(2):116-119.
45. Warren JJ, Bishara SE. Duration of nutritive and nonnutritive sucking behaviors and their effects on the dental arches in the primary dentition. Am J Orthod Dentofacial Orthop. 2002;121(4):347-356.
46. Ogaard B, Larsson E, Lindsten R. The effect of sucking habits, cohort, sex, intercanine arch widths, and breast or bottle feeding on posterior crossbite in Norwegian and Swedish 3-year-old children. Am J Orthod Dentofacial Orthop. 1994;106(2):161-166.
47. Defabjanis P. Impact of nasal airway obstruction on dentofacial development and sleep disturbances in children: preliminary notes. J Clin Pediatr Dent. 2003;27(2):95-100.
48. Brodsky L, Moore L, Stanievich JF. A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy. Int J Pediatr Otorhinolaryngol. 1987;13(2):149-156.
49. Page DC. The new dental-medical renaissance. Medically efficacious functional jaw orthopedics. Funct Orthod. 1999;16(1):16-25.
50. Page DC. Your Jaws-Your Life. Baltimore, Md: SmilePage Publishing; 2003: 103.
51. Page DC. How to promote & provide functional jaw orthopedics. Funct Orthod. 2001;18(1):22-30.
52. Doual A, Besson A, Cauchy D, et al. Retraining in dento-facial orthopedics. An orthodontist's viewpoint [in French]. Orthod Fr. 2002;73(4):389-394.
53. Rabie AB, She TT, Hagg U. Functional appliance therapy accelerates and enhances condylar growth. Am J Orthod Dentofacial Orthop. 2003;123(1):40-48.
54. Gennari PU, Guastalla C, Fiamminghi L, et al. Preventive and interceptive orthodontics [in Italian]. Ateneo Parmense Acta Biomed. 1978;49(2):213-226.0
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