Why Early Referral For Ortho Evaluation?

In our dental education, we were primarily influenced to observe the extent of mal-occlusion when most or all of the permanent teeth had erupted into position (except for 3rd molars). In the past decade, much better emphasis has occurred toward referring patients during the mixed dentition phase with emphasis upon this interceptive treatment. There needs to be even more sharing of information in order to point out the reasons for routinely referring patients by 7 or 8, with many patients needing to be seen at age 3 or 4 when specific conditions or problems are evident. Let’s be specific.

By age 8, 80% head size has been developed. Thus, the dental orthopedist and orthodontist has only 20% of remaining growth to influence and utilize to augment the result orthopedically and occlusally. At age 13, 90% of this head size has developed and thus only 10% remains. The difference of this 10% vs. 20% represents twice the capability for the orthodontist to utilize. Thus we clearly want to have opportunity to be treating these facial orthopedic problems by age 7, 8 or 9 (i.e. skeletal Class II pattern with deficient mandible; maxillary vertical hyperplasia or long faces with gummy smiles; transverse problems with cross bites; facial asymmetries). At age 3, 70% of head size exists and thus an additional 10% of capability (30%) total exists so there is even greater influence and benefit in the patient’s behalf when these little people are referred early for these categories of problems.

Advantages for referral by age 7 or 8 include:

• Prevention better than cure - many problems can be intercepted and better treated at this phase.

• Generally, less treatment is needed at this stage to bring the problem under control, compared to waiting later.

• Psychologically, the patient is receptive, willing and eager to follow instructions; and responds well to supervision and direction and suggestions.

• Clinically, the patient is motivated towards treatment; in the later teen years, the patient is often motivated away from treatment with stigma of social interaction, peer influences and self-esteem concerns.

• Financially, treatment is less expensive since the problems are being caught earlier and less treatment is often needed to resolve or at least bring the problems under control.

• Many times, removable appliances are very effective for treating problems at this stage; fixed appliances are often only partially needed. Thus, oral hygiene can be optimized and the approach is to be physiologic.

• Much more non-extraction treatment can be successful when early intervention occurs. Thus, all 8 bicuspids can more often be retained with a total of 28 teeth in the treatment result rather than 24 as often occurred with the patient referred too late for many orthopedic approaches with functional jaw orthopedics.

Diagnosis cannot occur from models alone. While looking at models and working with some limited removable appliances does indeed improve tooth alignment in most situations, this does not reflect needs in the skeletal component. We must balance and harmonize the facial growth at this very important early age in order that patient is benefiting beyond just having teeth aligned better. Giving fullest attention to analysis of jaw and cranial development, TMJ positioning and concerns, periodontal attachments, and zones that provides patient with results that are life-lasting with the full benefits they deserve, such thorough analysis and specific and appropriate treatment for the problems are evident. Thus, cephalometric, occlusal, often TMJ x-rays are most important for these problems, especially the Class II groups. Periodontal probing and airway analysis in addition to those tongue thrusting and other neuro-muscular concerns are all there to be diagnosed and managed early in the hands of a clinician who fully understands and can do something about these many categories of problems.

Success of treatment is not reflected by putting the before and after models on the table; the true measure is by putting the whole face on the table to analyze the treatment needs and results.