Are your child’s upper permanent teeth failing to grow in? Part 1

One or both upper permanent lateral incisors are congenitally missing 1.5% of the time, which causes the upper permanent central incisors to spread apart. If only one permanent lateral is missing, usually the midline will shift to that side after the baby lateral is lost. The permanent laterals usually grow in by age 8, so after that if no permanent laterals are present, you might be suspicious and request an x-ray.

Once it is known that a lateral is missing, an orthodontist should help with the decision of whether to open the space for an implant or bridge, or to close it and reshape the cuspid to look like a lateral.

Upper permanent laterals often erupt backward (behind the central incisors) if they are too crowded. The same is true of lower laterals, but in the lower jaw, the tongue then pushes the laterals forward.  Not so in the upper jaw.

 

However, in the upper jaw, if an incisor is too far backward, it may incorrectly bite behind the lower incisors, and tend to push the lower incisors too forward, even causing recession of the outside gums of the lower incisors.  Treatment of this dangerous crossbite is often urgent, by moving the upper incisor forward to in front of the lower incisors.

 

The most frequently impacted permanent tooth (other than the lower third molar) is the upper cuspid. If it is correctly positioned you can usually feel it before it grows in by pressing your finger on the gums high above the baby cuspids.  The most frequent problem is for a semi-impacted cuspid to be mis-positioned  too close to the midline and to push on the root tips of the permanent lateral incisors, causing the lateral incisor crowns to tip toward the lips and away from the midline, and occasionally it damages the lateral incisor’s root by eroding it.

Failure of Permanent Teeth to Grow Into the Mouth Part II

Occasionally permanent lower cuspids impact.  Their position can usually be felt by finger pressure against the jawbone under the lip. However, discovering an impaction is more often done by x-ray, and the impaction may lie horizontally along the lower border of the lower jaw, where it cannot be felt.  An orthodontist and oral surgeon need to decide how to handle this problem. Early detection may save the impaction from getting worse and allow the tooth to be brought in with orthodontic treatment.

The most common delayed eruption in the lower jaw is the second bicuspid.   The tooth is missing 1% of the time, and even if present the unerupted tooth is commonly seen on  x-rays to be growing in a backward angle instead of vertically, jamming it into the erupted first permanent molar.  Detection of these problems in children is by x-ray (usually a panorama x-ray).  The need for an x-ray is realized because either the space is too small for the tooth to grow in, or the tooth is too slow to grow in.

 

The lower second bicuspids do not normally grow in until age 12-13.  When a problem is detected earlier (by x-ray or space shortage), have an orthodontist decide whether, if the tooth is missing, to keep the baby tooth, or remove the baby tooth and close the space, or if the tooth is impacting, whether to have an oral surgeon attach a gold chain to it so it can be brought in.  The bicuspids need to have 50% root development before intervening surgically, or else the surgery may inhibit full root development.

If three of the first permanent molars have erupted and the fourth one has not, the unerupted one may be incorrectly erupting under the adjacent second baby molar, instead of behind it. X-rays will show whether the baby tooth needs to be removed to allow the permanent molar to erupt. After the permanent molar then grows in, it will need to be pushed backward to allow space for the permanent second bicuspid to grow in, and then a space maintainer will need to be placed.  An orthodontist should be consulted, because if the permanent molar can be guided to grow in without loss of the baby molar, there will not need to be a space maintainer.

 

Failure of Permanent Teeth to Grow Into the Mouth Part I

There are two reasons why permanent teeth do not grow in.  Either they are impacted (meaning they cannot grow in because there is insufficient room, or they are growing in a wrong direction), or they are missing.

The presence of only three lower permanent incisors, and no visable lump in the fourth one, might cause you to suspect that one is missing.  X-rays and careful counting will answer this.  An Orthodontist should be consulted immediately because either the impacted tooth will need to be brought in with braces or else the effect of the missing tooth will need to be planned for in the bite.

Similarly, the presence of only two permanent lower incisors while two permanent cuspids are already erupted probably implies the absence of the other two incisors (since there are normally four incisors).  A decision must be made early by an Orthodontist whether to open the space for later replacement of the missing teeth with implants, or to close the space if that would be better.  Space closure might involve substituting the cuspids as lateral incisors, and substituting the first bicuspids as cuspids by partially reshaping them.

If this decision is delayed, or improperly made, excessive protrusion of the upper incisors or excessive vertical overlap of the upper incisors over the lower incisors may result, leading to long orthodontic treatment, and contributing to an unpleasing lip profile.

See the full gallery on Posterous

Gap Between the Upper and Lower Back Teeth Because the Baby Teeth Stop Erupting While the Face Grows

When a single baby molar appears submerged relative to its neighbors, or when the baby back teeth do not chew against the opposing teeth but are in openbite, you might suspect either that the baby tooth root has frozen to the bone, or else there may be an absent bicuspid underneath.  An x-ray will ascertain if it is a missing permanent tooth,

If a missing permanent tooth is overlooked in the absence of an x-ray, it might be a big mistake to extract the submerged baby tooth, because the resulting space might require a bridge or an implant, or braces to close the space.

On the other hand, if the submerged baby molar is saved into adulthood, and has not submerged too severely, it may recieve a restoration to raise it up to the level of the chewing plane, and be useful for many years.  However, a baby molar that "submerges" early may be too deeply sunken by the relative eruption of the adjacent permanent teeth, to be restorable, and may create such an uncleanable gumline environment for its neighbors that extraction is its eventual best fate.

Since early discovery of a submerged baby molar sometimes means a poor future for that tooth, it is best to involve an orthodontist early in that situation, so that extraction and space closure can be considered.  Another occasional cause of a posterior openbite is a later tongue thrust, where the tongue bulges out sideways and creates a gap between the upper and lower back teeth.  This can be treated with a screen appliance by an orthodontist, and speech therapy to retrain the tongue.

See the full gallery on Posterous

Premature Loss of a Baby Second Molar

The baby second molar is the most important tooth in the back part of the mouth during the time the permanent teeth are growing in.  These teeth must be preserved until they are pushed out by their replacement teeth (the second bicuspids), because if the baby second molar is lost early, the first permanent molar will drift forward into its space and block eruption of the second bucuspid, and the teeth in front of that site will drift backward, creating an asymmetry in the dental arch.  A space maintainer or a lingual arch retainer wire attached to the permanent molar will prevent this drifting.

If space has already been lost, it should be referred to an orthodontist immediately.  Braces and space opening coils will be placed to re-open the lost space so the second bicuspid can grow in.

Premature Loss of a Baby First Molar

If a baby first molar is lost early due to advanced decay, chances are that its replacement permanent tooth (the first bicuspid or premolar) may not be ready to grow in yet.  Some thought must be given to the space resulting from the lost tooth.  If the first permanent molar has already grown in, the missing-baby-tooth space can be left alone because the second baby molar will not usually drift forward.  However, if the first permanent molar has not yet grown in, it may, as it erupts, push the second baby molar into the space of the missing baby first molar, thereby blocking the eruption path and creating crowding of the first bicuspid (the permanent tooth that should replace the missing baby first molar.)

In such a case, a space maintainer attached to the baby second molar is excellent until the first permanent molar erupts.

Early Loss of a Baby Cuspid on Only One Side

This problem usually happens because of decay of the baby cuspid (not too common) or because of crowding of the permanent incisors (more common), in which the crowded incisors push out a baby cuspid on one side.  This is damaging to the symmetrical development of the dental arch because the incisors then drift into the space of the missing baby cuspid, which blocks the path for the permanent cuspid to erupt, and also shifts the dental midline.  This asymmetry of the dental arch is difficult to correct and requires braces and rubber bands in the front of the mouth.

The proper thing to do when one baby cuspid is lost early is either to regain the lost space immediately with partial braces, or to remove the baby cuspid on the other side of the mouth and then place a lingual arch retainer wire to prevent the incisors from tipping backward from the pressure of the lip.

If a midline shift has already occured, take the child immediately to an orthodontist

See the full gallery on Posterous

Too early loss of both baby cuspids (canines)- this is an often overlooked orthodontic problem.

Frequently, early loss of the lower baby cuspids is a diagnostic sign of (and is caused by) crowded lower permanent incisors (front teeth),  The permanent cuspids will not be able to grow in if their space has already been used by the permanent incisors, which grow in first. If not corrected by an orthodontist, this early crowding may lead to severe permanent teeth crowding, impacted cuspids (unable to grow in), gum recession (lowering), and increase in overbite (vertical overlap of the upper front teeth over the lower front teeth0 and increase in overjet (protrusion of the upper front teeth beyond the lower front teeth), and may cause the need for extraction of permanent teeth later on.

This type of crowding should be reviewed by an orthodontist once the four lower permanent incisors have erupted.  Unless the lip profile (fullness) or gum recession require that teeth be extracted (which is somewhat unusual), early jaw expansion with braces will salvage this crowded condition and avoid later extractions.

Expansion is usually done by widening the dental arch laterally and pushing the incisors forward and the molars backward using braces.  After the treatment, retention is important to prevent collapse of the expansion from cheeck and lip pressure, and it is best done with a semi-permanent wire behind the teeth.

The benefits of early expansion treatment are that extractions of permanent teeth are avoided and more growing time occurs after the expansion, to help stabilize it.  The dental arch and smile have more lateral width, which looks better.

Crowding involving significant loss of the lower baby cuspid space is a condition that worsens with time.  It is not advisable to "wait and see."  This space needs to be regained early with active therapy.

Do your upper gums display too much? An Orthodontist can advise you how to improve it.

This is very displeasing to the eye and is due to over eruption of the upper front teeth and jaw.  To make it look better, the upper teeth need to be intruded (pushed upward into their sockets), or the upper jaw may need to be pushed upward.  As the teeth move upward, the bone and gums remodel and the smile looks much nicer

See the full gallery on Posterous

See the full gallery on Posterous

Is your child's chin receded (weak) in appearance? This is a challenging orthodontic problem.

Suprisingly, when the lower jaw is receded (backward), the upper jaw and teeth are also usually retruded (backward).  A retruded upper jaw can sometimes be recognized by the angle between the upper lip and the uperside of the nose being greater than 90 degrees.  If the child's bite requires it, the lower jaw can be advanced with an orthodontic bite advance.  Before the lower jaw is advanced with a permanently-attached orthodontic device, it may be necessary to advance the upper teeth with braces to a normal position first, which makes the overjet worse temporarily.

If an overbite is corrected in a growing child, it can make an improvement of half an inch in the forward chin position of the adult.  Tools used to correct short chins include various combinations of braces, elastics, jaw expanders, and semi-permanent orthodontic bite advancers.  Sometimes jaw surgery is warranted, to advance the lower jaw.

Are your child’s lips protrusive (stick out too far)? Get help from an orthodontist.

A certain amount of fullness of the lips is desirable in a child, because their

nose and chin will become more prominent as they mature.  Excessive fullness

of the lips is usually caused by the  teeth being too protrusive, forcing both lips

forward.  If the angle between the under side of the nose and the upper lip is

less than 90 degrees, it may mean the teeth are too forward.  There are

measurements that can be made on head x-rays or photos for evaluating lip

fullness, but parents’ and patient’s opinions are more important.

If they want the lips flatter, it is achievable, and if they like them the way

they are, that is important to recognize too.

If the lips are to be flattened, a common approach is to remove 4 bicuspids

(one from each quarter of the mouth) and retract the front teeth with braces. 

 The child can be referred to an orthodontist at any time after age 8, but generally

 treatment would not begin until age 12, when the permanent teeth have grown in.

Is your child’s chin too forward, or does the lower lip protrude in front of the upper lip? This is an orthodontic problem.

Around five percent of the population has an underbite, where the lower teeth are too forward compared to the uppers. It is easy to spot, because of the distinctive face appearance. It does not usually provoke teasing from the schoolmates, but rather is usually spotted and referred by dentists.

It is routine for orthodontists to treat underbites early, sometimes as early as age four, but more often at age eight after the permanent incisors have grown in. The reasons treatment is done early are that the teeth and face bones are more easily moved at a younger age, and it is easier to get a child to wear the necessary devices (braces etc.) at an earlier age. It is assumed that they will still need orthodontic treatment again in a second stage at age 12 or so, but the early treatment is felt to give them a result that would not have been attainable if they had waited.

Treatment of underbites will often involve upper jaw expansion in order to loosen the bone sutures, and simultaneous facemask headgear to pull the upper jaw forward. In eight-year-old children who wear the facemask 12 hours per night, underbites can be corrected in less than a year. They are sometimes overcorrected in anticipation of relapse and partial return of the underbite.

Years ago it used to be taught that underbites should not be treated until growth was complete (age 18), and then jaw surgery would correct the underbite. It is now preferred to treat children early while the sutures are immature, but with the understanding that two stages will be needed.

Does your child’s chin deviate to one side? An orthodontist is trained to look for this.

The usual reason the chin is not directly under the center of the nose is that it has shifted to one side in order for the upper

and lower teeth to fit together better, due to a narrowness of the upper jaw.  The upper jaw, being just a little too narrow,

does not bite well against the lower, so a slight shift of the lower jaw to the right or left makes the bite normal on one side

and full crossbite on the other, providing more tooth contact and a sense of stability.

 

If allowed to remain, the chin may permanently grow into that unsymmetrical position.  Orthodontists are usually quite

alert to this occurrence and recommend widening the upper jaw immediately.  Once the upper jaw is widened sufficiently,

the lower jaw will usually seek equilibrium with it and the chin re-centers itself.  The widened upper jaw is best maintained

with a holding wire for an extended time, since the cause of the narrow arch may still exist.

An orthodontist invites you to look. Does your child’s chin pucker in order for the child to close their lips together?

It is common for the upper incisors to protrude. When a child swallows, the lips normally come together to form a seal,

but this seal is hard to achieve if the upper teeth protrude excessively.  The chin muscle then puckers in order to push the

lower lip up far enough to meet the upper lip, and the resulting facial expression is somewhat unattractive.

 

The  puckering of the chin muscle in order to extend the lower lip up to form a lip seal causes the lower lip muscle

to increase in size.  This increase in bulk of the lower lip will cause crowding of the lower incisors.  It can be avoided

by referral to an orthodontist experienced in treatment of young children. Treatment may include expansion of the jaws

to reduce the incisor protrusion. Or treatment may consist of correcting the incisor protrusion by advancing the lower jaw. 

 Sometimes removal of 2 or 4 teeth is desirable.  The faces created are better than if untreated and the stability of the

results is remarkable once correct jaw posture and tongue posture have been created.

See the full gallery on Posterous

Do the upper front teeth protrude beyond the lips, or is the lower lip behind the upper incisors, or does the lower lip curl downward? Time to see an Orthodontist.

Protruding incisors are at risk for being fractured or knocked out by any of the common activities and accidents of childhood.  Even if they somehow avoid damage, they can be the object of considerable teasing from other children.

A common cause for protruding upper incisors is thumb or finger sucking, which if done long enough will make the upper front teeth flare forward and will tip the lower front teeth backward. 

 

Most children stop thumb/finger sucking once they get into the social pressure environment of school, but if they have already created a deformity in tooth position with the thumb, the deformity will be maintained even after stopping the thumb habit by the tongue protruding into the anterior open bite, and worse, the lower lip parking behind the upper incisors will push them even further forward horizontally.

Most parents are aware of the chili pepper sauce on the thumb regimen, but it does not always work well.  Another treatment involves taking a sock, folding its top down and sewing it into a channel through which is passed a shoestring to be used as a drawstring, and the sock is tied onto the hand at bedtime (sometimes both hands have to be so covered, individually).  For younger kids, the sock can have a face drawn or sewn onto it and the sock can become a personality, such as “Mr. Wizard,” who helps the child.  The sock prevents the thumb or any finger from being extended to be sucked.  It takes considerable discipline from the parent to do this every night for several months (and possibly daytimes after school), but it can work, especially for the child who only sucks at bedtime.

Another fun therapy that can be piggybacked onto that one (or which can stand alone) is to play a game where any day and night that no thumbsucking happened, a happy face sticker is put onto a calendar, and 5 happy faces in a week earns a trip to 31 Flavors, and 25 happy faces in a month earns a trip to Chuck E. Cheese with a friend!

 

A tried-and-true orthodontic therapy, for those who need it, is to place a permanent wire screen device in the mouth, soldered to bands which are cemented to the upper molars, and which forms a physical barrier to keep the thumb and fingers out and to keep the tongue from protruding forward.  It must be left for several months, because if removed too soon the habit has been seen to return.  While the device is in place, the front teeth will usually erupt and the open bite will usually close.  If the upper incisors are flared severely forward, they may need a brief period of braces to upright them, but care must be used not to tip them back into the unerupted permanent canines.

Are Your Childs Lips Apart?

Lips are normally closed together when not speaking.  If the lips are seen to be constantly apart, chances are that the nasal airway is impaired and the child

is mouth-breathing.  If they are, it is possible that specific face changes will happen.  When the mouth is held open to breathe, the tongue drops down

because the tongue is attached to the inside of the lower jaw, so it no longer rests against the roof of the mouth.  The absence of tongue pressure on the

roof of the mouth causes the upper jaw not to widen from growth.  This is made worse by the tightness of the cheeks against the outside surfaces of the

teeth caused by holding the mouth open, pushing inward on the upper teeth and causing them to narrow.  Constant mouth-breathers tend to have narrow

upper jaws, which are easily recognized because one or both sides will be in crossbite, biting inside the lower teeth instead of outside.

 

Mouthbreathing may be because the nose if stuffy from allergies, or the nasal septum is deviated, or the adenoids are large, or the tonsils are large, or the

soft palate/uvula is oversized.  Dentists can recognize long soft palate/uvula and large tonsils by depressing the tongue with a mouth mirror and telling the

child to say “Ahh”. 

 

Large adenoids can be detected by the nasal sound of the speech, and can be viewed easily with an x-ray of the head.  Parents can notice if the child snores,

which often accompanies throat airway problems. 

 

It is not usually helpful to take a child’s airway problem to a pediatrician, because they are taught that tonsillectomy and adenoidectomy are to be avoided in

order to preserve a child’s ability for immunity in adulthood.  They are taught little about the growth of the face and the adverse effect of a blocked airway

on the shape of the jaws and appearance of the face.  It is often effective, however, to take a child to an ear-nose-throat specialist, because in general these

doctors will consider tonsil and adenoid surgery if medication does not suffice to keep the airway open.

 

 

If mouthbreathing has resulted in a narrow upper jaw, the jaw can be widened by an orthodontist using palatal expansion.  It has been shown that widening

the upper jaw also widens the base of the nose and reduces nasal resistance, improving nasal airflow, and the most common reason orthodontists widen the

upper jaw is to correct crossbite(s) caused  by a narrow upper jaw.

 

Mouthbreathing left undetected and untreated may result in a long thin face, with the chin more backward, and with the roof of the mouth apparently high

and narrow due to the failure of the jaw to widen because the tongue is too low.

 

                                                                     ©2011  James E. Eckhart, D.D.S.,  Inc.

                                                                                                   www.eckhartorthodontics.com

                                                                                               1101 N. Sepulveda Blvd,  Suite 202, 

                                                                                          Manhattan Beach,  Ca.  90266  (310) 546-4724

                                                                                21210 Anza Ave., Torrance, CA 90503 (310) 540-5911  

Are Braces Expensive?

It may save you money in the long run - less dental care, less time off work. Nothing is too expensive if you want it bad enough or if you have to have it. Straight teeth for the balance of one's life, assuming 60 years left, is only $50 a year, or $0.15 a day.   Many people regard this as a better use of their money than a trip to Mexico. Orthodontists don't like to see money get in the way of your health. They adapt the payment plan to your particular needs and come up with an affordable solution.  Of all medical services, orthodontic treatment has gone up the least.  Shorter treatment time and greater efficiency has reduced the cost.   Even people of limited means are getting their teeth straightened too, including secretaries, single parents, etc.  It may actually make you money; with the increased self confidence you may gain from knowing your teeth look their best.  The doctor doesn’t live in Beverly Hills, he lives and works locally and is in touch with what local people can afford.

 

 

Copyright 2004  James E. Eckhart, D.D.S.,  Inc.

1101 N. Sepulveda Blvd,  Suite 202, 

Manhattan Beach,  Ca.  90266  (310) 546-4724

21210 Anza Ave., Torrance, CA 90503 (310) 540-5911

 

Am I to old for Braces or aren't Braces for kids?

Around 50% of Orthodontic patients are adults.  A lot of adults are looking for long term solutions rather than settling for "quick fixes" or "patches".  For adults, the main dental disease is breakdown of the gums, not cavities.  By aligning your teeth, you not only improve your appearance, but also improve your hygiene because brushing and flossing is now easier and more effective, This can save the health of your gums.If you lose your teeth, you'll look even older. 

Many adults are realizing that now that their children have finished braces, and that they can afford braces for themselves understand its value, they are entering treatment too.  Some adults needed orthodontic treatment as a child but it was unavailable to them, so now that they have the means they pursue it.  Nobody is really too old.  If a person assumes that they are going to live the next 2-3 years anyway, they might as well harness the time, get their teeth straight, and enjoy the results the rest of their life.

©2011  James E. Eckhart, D.D.S.,  Inc.

www.eckhartorthodontics.com

1101 N. Sepulveda Blvd,  Suite 202, 

Manhattan Beach,  Ca.  90266  (310) 546-4724

21210 Anza Ave., Torrance, CA 90503 (310) 540-5911  

Straightening Teeth With Invisalign Part V

Future Advances In Invisalign

 

In the future, it is probable that impressions of the teeth will no longer be necessary for starting Invisalign treatment, but that instead the teeth will be scanned by an intra-oral device, and the data will be collected electronically instead of physically.

As technology improves, the plastic of the aligners will probably vary in stiffness depending on which tooth that section of the plastic is attaching to.The locations and shapes of bumps on the teeth (attachments) will continue to evolve, and the ability to correct certain types of overbites and underbites will improve as more use of elastics and bone screws are integrated in with Invisalign.

 

©2011  James E. Eckhart, D.D.S.,  Inc.

www.eckhartorthodontics.com

1101 N. Sepulveda Blvd,  Suite 202, 

Manhattan Beach,  Ca.  90266  (310) 546-4724

21210 Anza Ave., Torrance, CA 90503 (310) 540-5911  

 

 

Straightening Teeth With Invisalign Part IV

Differing Opinions Among Orthodontists Regarding Invisalign

 

Invisalign has evolved tremendously over the past 12 years.  One of the main tools Invisalign has developed to make the aligners more effective in moving teeth is the temporary addition of tooth-colored plastic bumps onto the tooth surface. These bumps are called “attachments”, and there are different sizes and shapes of them, but their purpose is to allow the aligners to grasp the tooth more effectively in order to produce the desired tooth movements.  These “attachments” have evolved in recent years into shapes that have proven to help produce otherwise difficult tooth movements.  They have been created by a team of nearly 200 engineers hired by Invisalign to find effective ways to move teeth with aligners.  Invisalign continues to study the most effective way to use attachments to control tooth movements, and averages 1-2 new software releases per year as knowledge accumulates.  Doctors who used Invisalign years ago and quit, or who have  only done a few cases (less than 100, say), probably have not stayed current with the advances made by Invisalign, and may not have developed the experience to see the wide range of applicability Invisalign now offers.  It is quite clear to this writer that the profession of orthodontics is evolving into much more of an Invisalign delivery system, and much less of a braces delivery system, over the next few years.

 

©2011  James E. Eckhart, D.D.S.,  Inc.

www.eckhartorthodontics.com

1101 N. Sepulveda Blvd,  Suite 202, 

Manhattan Beach,  Ca.  90266  (310) 546-4724

21210 Anza Ave., Torrance, CA 90503 (310) 540-5911