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.