Early Orthodontic Treatment in Children: When Should It Start?

Orthodontic treatment usually brings to mind the braces fitted during adolescence. Yet for some alignment and jaw relationship problems, assessment while a child is still growing, and short interventions where needed, can influence the scope of later treatment. In this article we look at when children should have an orthodontic assessment, when early treatment comes into consideration and how it is carried out.

At What Age Should the First Orthodontic Assessment Be Made?

The period generally recommended for an orthodontic assessment is around the age of seven, when the first permanent molars and front incisors begin to erupt. This is not the age at which treatment starts; it is the point at which the relationship between the jaws and the pattern of eruption are reviewed by a specialist. For most children the outcome of this assessment is "no intervention is needed now, let us follow the development". The aim is to notice things early where necessary, not to treat every child early.

A child's first meeting with a dentist is expected to happen much earlier than this. Our article on the first dental visit for children gives detailed information.

Why Does Early Treatment Come Up?

The distinguishing feature of childhood is that the jaws are still growing. During this period, approaches that guide jaw development or prevent space loss are possible. Once the permanent dentition is complete, the same problem may not be manageable with the same methods and some cases require more extensive treatment. The main situations that can be addressed early are:

• Crossbite: Upper teeth closing inside the lower teeth. When it is one-sided, the child may shift the jaw to one side when closing; because this can affect development, early assessment is advised.
• Markedly protruding front teeth: Upper front teeth angled far forward can increase the risk of trauma during play and sport.
• Open bite: Front teeth not meeting when the mouth closes, often related to thumb sucking or tongue thrusting.
• Early loss of baby teeth: A space maintainer may be needed to prevent space loss.
• Marked lack of space: Recognising early that permanent teeth will not find room to erupt can bring options such as arch expansion into consideration.
• Tendency to remain impacted: The eruption direction of some permanent teeth can be noticed early on a radiograph.
• Baby teeth blocking eruption: Baby teeth that do not fall out on time can direct the permanent tooth elsewhere.

Which Signs Call for an Earlier Visit?

Some findings parents may notice at home can be a reason for an assessment sooner than planned:

• Baby teeth falling out very early or unusually late
• Difficulty biting or chewing, frequent tongue biting
• The jaw shifting to one side when closing
• The mouth being kept constantly open and breathing through the mouth
• Thumb sucking that continues past the age of four
• Teeth clearly overlapping or large gaps forming between them
• Difficulty producing certain sounds in speech

Approaches Used in the Early Period

Space Maintainers

Fixed or removable appliances that prevent the space left by an early-lost baby tooth from being closed by neighbouring teeth. They are removed once the permanent tooth erupts.

Arch Expansion Appliances

In cases where the upper jaw is narrow and accompanied by a crossbite, appliances that increase upper jaw width may be used. The fact that these can be applied during the growth period is one of the reasons for early assessment.

Habit-Breaking Appliances

Appliances used to support a child in stopping thumb sucking or tongue thrusting when the habit persists. They are not a form of punishment; the aim is to reduce the effect of the habit on the dental arch.

Jaw-Guiding Appliances

In cases with a marked difference in position between the lower and upper jaws, functional appliances used while growth continues may come into consideration. Suitability is assessed according to the child's skeletal development stage.

Limited Bracket Treatment

In some cases a short course of brackets involving only a few teeth may be carried out. For general information about the systems used, see our article on bracket types.

Does Early Treatment Remove the Need for a Second Course?

In most cases it does not. Treatment in the early period is usually a first phase; a second phase may be required to arrange alignment once all the permanent teeth have erupted. The aim of early treatment is not to make the second phase unnecessary but to limit the progression of the problem and influence the scope of later treatment. This two-phase planning is something that should be explained clearly to families from the outset.

Adolescence and Beyond

Treatment carried out after all permanent teeth have erupted is the classic period of orthodontic practice. At this stage the options include metal brackets, clear aligners and inner surface systems. For details, see our articles on metal braces and clear aligner treatment. For the causes of crowding and general treatment options, our article on crowded teeth offers a comprehensive framework.

Whatever age treatment is carried out, a retention (retainer) stage is needed afterwards so that teeth keep their new positions.

Oral Care During Treatment

Orthodontic appliances increase the number of surfaces that have to be cleaned. Plaque accumulating around brackets can set the stage for white spot lesions and decay on the tooth surface. So during treatment:

• Brushing should cover the area around the brackets and follow the technique described by the dentist.
• Interdental brushes and orthodontic floss threaders are recommended.
• Toothpaste with a fluoride content determined by the dentist may come into consideration; see our article on fluoride toothpaste.
• Avoiding hard and sticky foods reduces appliance breakages.
• Keeping follow-up appointments directly affects the duration of treatment.

For approaches to preventing decay in children, our articles on fissure sealants and fluoride application and preventing tooth decay in children may be a useful guide.

Summary

An orthodontic assessment is advised for children at around the age of seven; this is not the start of treatment but a review of development. There are approaches that can be applied early in situations such as crossbite, marked lack of space, early loss of baby teeth and persistent habits. In most cases early treatment does not remove the need for a second phase; it aims to limit the progression of the problem.

This article is for general information. Determining the right timing and approach for your child requires clinical examination and radiological assessment.