Orthodontic Considerations in the Paediatric Population - Part 1

Recently we had the pleasure of sitting down with one of our lovely local orthodontists Dr Caitlin Giulieri from Smile Envy on the Sunshine Coast, to have a coffee and chat about all things orthodontics and paediatric dentistry.

Over a few blogs, we will share with you some of the topics we covered.  We have tried to cover some of the more common situations you may encounter. We do appreciate there are divergent opinions on orthodontics/orthotropics/airways etc etc. We aren’t going to get too involved in it…

Dr Caitlin Giulieri

Q:Often we will see a crossbite present in the primary dentition. Is the same pattern likely to occur in the secondary dentition? Do they tend to affect the growth patterns and is there a need for early interventions? 

In terms of early intervention, my philosophy is that crossbites should be treated while the patient is young and growing, but you should not rush to treat them too young and cause a bad experience for the patient. It is well known that the maxillary midline suture fuses during adolescence, but there is no proven “exact age” as every patient’s growth is different – expansion has even been achieved in some adults in the literature.

 The problems I’ve encountered if you treat the patient too young are

  • Poor retention of an expander or

  • Traumatising the child and putting them off future treatment.

A fixed expander is big and bulky and if the kid is scared, it can be hard to get on and harder to get off. Furthermore, if the 6’s aren’t fully erupted, the appliance will not be easy to place or very retentive and can come off early or not fit well in the first place (I look at the distal surface of the upper 6’s - if they are still equi-gingival and the kid is still young, then wait longer). I have seen many cases where an orthodontist has put a fixed expander on around 8 yrs old, it’s fallen off during treatment or not fit, and the crossbite remains or relapses. This can all be avoided by not rushing and waiting until they have more vertical growth of their molars, so that you can fully band the 6’s properly from the start.

We want kids to be mature enough for treatment, especially if you’ve introduced them to the idea of it and they know it’s coming up.  So this can be up to 10 years of age…

There are obviously other types of expanders, such as removable expanders which can be fit earlier, but there needs to be a diagnosis of how big the crossbite/transverse discrepancy is, and if it’s skeletal or dental in origin, as these appliances have their limitations. Regardless, compliance is still essential, so the patient needs to be mature enough to start treatment, otherwise there is no harm in waiting until an older age where they are still growing.  

Q:Increased Overjet – when is the best time to refer? 

There is an abundance of high-quality research (RCT’s and Cochrane Reviews) to show that whether large overjets are treated early (mixed dentition, 2 phase) or late (early permanent dentition, 1 phase), the result is usually the same (same occlusal result, same extraction rate). The difference is that early treatment in 2 phases results in more appointments, more cost and more treatment burnout to the patient, which can actually sometimes even translate to a worse outcome in the end.  

To make the decision of who should have early treatment, it comes down to patient preference - do they want to be treated in one phase or two? The only cases that are found to benefit from early treatment are those with significant aesthetic or trauma concerns, i.e. if they are being bullied or self-conscious, or if they have a high activity lifestyle and are prone to accidents. Keeping in mind the trauma was commonly uncomplicated crown fractures…

A prominent ADJ review on this topic found that treating 10 early cases of increased overjet will only prevent one patient’s dental trauma. Otherwise, if they wait until they are in the full adult dentition, then they can reach the same outcomes with reduced treatment time and costs.  

Part 2 in the next few weeks!

Thanks! If you want to find out more about Caitlin and her practice she is at: Smile Envy Orthodontists | The Smile You've Always Wanted

Tim Keys