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The Art of Orthodontics: Does My Child Need Braces? Part 2

March 13, 2016



One of the most confusing things for parents when considering orthodontic treatment for their child is the difference of opinions of when is the best age to start treatment.  I addressed the question of early treatment in our last blog.  This post will focus on the the second phase of a 2 phase treatment or comprehensive orthodontic treatment, when only one complete stage of treatment is indicated.   When families get more than one orthodontic consultation (a second opinion) they can sometimes hear two completely different answers on when to start treatment and what type of treatment.  How can two seemingly equally qualified doctors offer such different approaches to the same problem? Not only are their treatment plans different, many times they disagree about the best time to start treatment. Why this disagreement and what should you do with your child?

Having treated thousands of patients over the last 28 years, I’ve found that the most common question that I get from my patients and their families during treatment is

“When can I get these braces off?”

Patients and their families want efficient care at a fair price.  Often times the answer to this question is directly related to a similar question of

“When do I get my braces on?”

My typical orthodontic patient will usually have his braces on 12 to 30 months (depending upon complexity). Very few problems require longer than this. Extended treatment times not only frustrate patients and their parents, they are also bad for the health of the teeth. Longer treatment can also can make the cost of treatment more than is necessary.

In my experience, the most common reasons for treatment times extending beyond 30 months are:

(1) Placing the braces before the last baby teeth are lost and the 12-year molars are erupted,

(2) Patients not getting their teeth extracted or necessary surgical procedures performed in a timely fashion after treatment has begun

(3) Mid-course deviations from the original treatment plan or the orthodontist not having developed a complete plan before starting treatment

             (4) Patients compliance with appointments and wearing elastics

Sometimes changes in the treatment plan are unavoidable. Delays in getting surgeries and extractions are also many times beyond the control of the patient and the doctor. Choosing the appropriate time to start treatment, however, is determined by the parents and ultimately the orthodontist.

In my practice, the majority of my full-treatment orthodontic patients do not get their braces on until they are in the final stages of loosing their primary teeth and their 12-year molars are all at least partially erupted. This is especially true of patients whose problems are not as serious. A simple 12-month treatment can easily drag on to 18 or 24 months if the braces are placed on the teeth with several baby teeth remaining or the 12-year molars are not visible at all. Teeth cannot be bracketed or moved unless they have erupted into the mouth!

Although these guidelines are applicable to the majority of my patients, there are, of course, exceptions. The most common is when the patient has a severe malocclusion that will obviously take two years or more to fix (impacted canines, excessive overbites, severe crowding, etc.). Patients with these problems will have extra time during treatment to allow for the eruption of their remaining permanent teeth.

Other examples of when early starts are appropriate include

1. When a patient has a condition so severe that it is causing social issues (i.e. other children making fun of them)

2. The teeth protrude so far that they are in danger of being damaged

3. Problems preventing normal development (a crossbite with a shift, crowding due to arch constriction, etc.).


In these situations it is justified to begin treatment before the last baby tooth is lost or the 12-year molars are fully erupted.

The teeth and jaws do not develop at the same pace within one child and are not influenced by the same set of genes. In other words, the chronologic age, the age of development of the teeth, and the age of development of the jaw bones may be over 2 years apart on a growth/ development chart.  This is knowledge that a well trained orthodontist is aware of and should be part of the information they consider in their diagnosis for your child.

One situation that requires even further delay in beginning treatment are patients with an underbite or Class III relationship. Children with these growth patterns tend to continue growing a few years beyond those with normal bites or overbites. Girls may continue growing until they are 16. Boys may grow until they are 18 or older. If an underbite growth pattern continues after braces have been removed, patients may outgrow their correction and require additional unwanted treatment. To prevent this, we will usually monitor these patients’ growth and begin only after it has stabilized.

Every patient is different and each orthodontist has unique training, experience, and treatment goals which may influence their decisions.  While most dentists and orthodontists do have the well-being of their patients in mind, unfortunately there are those that will put braces on anyone that walks through their doors just so they don’t “lose them.” There is nothing wrong with questioning your doctor’s rationale, especially when it comes to treatment timing. If you receive different opinions from two doctors about the same patient, ask them each to explain their recommendations. The appropriate treatment, provided at the appropriate time, is the best recipe for a happy patient and a great result.

As always, we offer a complimentary new patient exam to discover the best options for you and your family.

                                                                                                                                                                                                                                              Dr. David J. Birdwell