Dr. Fawzi Alqatami
Diplomate of the American Board of Orthodontics
Ministry of Health, Kuwait
During your regular annual visits to the cleft team, the Orthodontist will be monitoring when would be the best time to commence the definitive orthodontic treatment for your child. As stated before, each case is unique and different, hence the time to start is different for each case.
In case your child needed alveolar bone graft, it should have been already completed by this time. There are many factors that would play a role in deciding when to start the definitive orthodontic treatment. The first factor is the presence of baby teeth (primary teeth); this is what we refer to as the dental age and not the numerical age! We usually would like to start the orthodontic treatment just before the last baby tooth on the lower jaw exfoliates (falls out). This tooth is usually the second primary molar. Why? The reason is that there is a difference in the size between this baby tooth and the permanent one that is coming from underneath it. The difference is on average 2.5 mm on each side; 2.5 mm on the right and 2.5 mm on the left. The total is 5 mm; this amount is extremely important, and we can take advantage of it in case your child’s mandibular crowding. It can change our treatment plan from needing to extract some teeth to align the crowded teeth to a non-extraction plan. Hence the dental age and NOT the numerical age is one important deciding factor to when we would start the definitive treatment.
The second factor, which would have started earlier in the monitoring phase, is the presence of any impacted or blocked out tooth or teeth. As discussed earlier, addressing this problem might require an earlier intervention at a younger age. If, however, the impacted tooth or a group of teeth happen to erupt normally at a normal age, we could combine this intervention treatment with the definitive orthodontic treatment phase into a single phase.
The third important factor is the growth of the upper and lower jaw. As we explained earlier, due to the presence of the scar tissue in the palate (roof of the upper jaw), the growth of the upper jaw (maxilla) could be restrained or slowed down. The scar tissue would act as a rubber band holding back or slowing the normal growth of the maxilla. This could lead to a discrepancy between the upper and lower jaw positions. By the same token, the growth of the lower jaw (mandible) might be excessive and cause a discrepancy between the upper and lower jaw. The Orthodontist’s role during the annual checkup from the age of 7 onwards is to monitor the growth and propose the proper options that your child has. Now, in cases where this growth discrepancy between the two jaws is minor, the orthodontic treatment alone might be sufficient to make the teeth have a good alignment with each other. This phase usually takes place at around the age of 12 years old on average. At the same time, your child’s body will be undergoing physiological changes that will add to the mix of factors that would affect growth. That is puberty!
Puberty has a major impact on the growth of the lower jaw (mandible), especially since this phase is accompanied by a significant overall growth in all the bony structures of the body. Usually, girls (11-13 years old) on average hit puberty before boys (12-14 years old). During this major acceleration of growth that occurs in your child’s body, the last bone to stop growing is usually the lower jaw (mandible).
This fact has a major impact on our role as Orthodontists. If you child already has a discrepancy between the upper and lower jaw position prior to puberty, this may or may not get much worse after puberty! This all depends on how much growth is going to take place. Now some parents might raise the question: “Can’t you slow down this growth or stop it?” the simple answer is no. Think for a moment about a young boy that is expected to be 2 meters tall, you can’t stop his growth at 1 meter 70 cm! In a similar manner, the growth of the lower jaw (mandible) cannot be stopped. Sometimes, during the earlier phase, the Orthodontist might use some appliances to accelerate the growth or change the position of the upper jaw (maxilla) to reduce the discrepancy.
In cases where this alignment discrepancy between the two jaws is found to be large and cannot be resolved with orthodontics (braces) alone, another intervention would be indicated; and that is through the help of a surgeon to change the position of the upper jaw only or the lower jaw only or both! This is what we refer to as surgical orthodontics.
