After spending roughly $40,000 and a decade visiting orthodontists to fix her two children’s teeth, Deborah Holcomb wonders whether she did the right thing.
Holcomb’s daughter was in kindergarten when an orthodontist advised braces and a jaw expansion device to correct an overbite. “We were amazed that she’d need braces so early on,” says Holcomb, a longtime Bethesda resident now living in Jackson, N.H. When Holcomb asked why, she was told the work would help contour her daughter’s jaw and face so she wouldn’t have problems later. “We kind of bought into it,” she says.
Now 15, her daughter had braces removed a year ago and wears a retainer, says Holcomb, who asked that her children’s names not be used. Her 17-year-old son, who began treatment of an underbite in second grade, has a retainer and “still has orthodontist appointments to this day,” she says.
“Their profiles look good, but I have always been curious about what would have happened if we’d waited,” Holcomb says.
A generation ago, wearing braces was something you did in high school. Today, kids are more likely to sport a mouthful of metal beginning in elementary school. The American Association of Orthodontists recommends evaluation by age 7 and says most kids begin treatment between 9 and 14. Younger kids often undergo two phases of treatment—with the first beginning as early as age 6, and the second between 11 and 13, when all the adult teeth have erupted.
Though most orthodontists agree that early treatment can be helpful for treating underbites, crossbites and severe crowding, there is growing disagreement over whether it is necessary for those with overbites or buck teeth.
Proponents of early treatment say there’s a small window, usually before a child turns 10, in which they can adjust the jaw to make room for permanent teeth and correct problems. That can reduce the need for extraction or jaw surgery later on.
“Unless we’re proactive, nature is not going to do it,” says Bethesda orthodontist Dr. Peter Coccaro.
But problems that may be corrected by early treatment alone only occur in a tiny percentage of children, and most early-treatment patients will require a second phase, says Dr. William Proffit, a professor at the University of North Carolina School of Dentistry in Chapel Hill and author of several books on orthodontics. A third of young patients seeking orthodontic treatment suffer from Class II malocclusions, commonly known as buck teeth or overbite, and early treatment provides no benefit over waiting until adult teeth come in, he says.
“It’s a pretty big, expensive waste of time,” says Proffit, who co-authored a 10-year clinical trial published in 1998 that found little advantage in treating kids early for Class II malocclusions. He notes that two subsequent major clinical trials came to the same conclusion.
The only reason to start treatment early for Class II malocclusions would be if “a child were being abused by other children” because of his teeth’s appearance, Proffit says.
He does agree, though, that early treatment may benefit kids with Class I malocclusions, or severely crooked or crowded teeth. These kids usually undergo two phases of treatment with a break in between, Proffit says.
Early treatment entails wearing a device, such as one that expands the palate, head gear that’s worn at night and, sometimes, braces. The second phase of treatment, if needed, usually is aimed at straightening teeth and establishing a proper bite once all the adult teeth are in. It includes braces followed by the use of a retainer, according to several local orthodontists.
“It used to be just making teeth pretty,” says Dr. Amy Light, a pediatric dentist and orthodontist in Potomac who has been treating kids for 20 years. “Now it’s looking at function, it’s looking at growth. Sometimes early intervention minimizes orthodontic problems later on.”
Light says she tells patients they’ll probably need two treatment phases, although some may not need the second. “The true answer is we don’t know until everything comes in,” she says.
About a third of her patients undergo first-phase treatment at age 9 or younger. The first phase costs $3,000 to $4,800; the second, usually less than $6,500.
Coccaro, an orthodontist for 30 years, says parents may be skeptical about treating young children, especially if braces will be needed when they hit adolescence.
“It’s the question that everybody asks. People coming in are of the era when it was age 13, 14 that you had braces and that was it,” Coccaro says. “The fact of the matter is that it is sort of like going to grammar school and high school. You successfully go through eight years of grammar school. It’s not like you do it again in high school. You’re enhancing what’s already done.”
Dr. Carmine Petrarca, a 30-year practitioner whose office is in Bethesda, says determining when to begin treatment depends on a child’s “dental age,” and there can be as much as a year’s difference between development in girls and boys. He agrees that early treatment of many Class II malocclusions can be a “waste of time.” Treatment for crowding or an overbite should begin when only four baby teeth remain, he says. Adult molars usually erupt between ages 11 and 13.
“There’s no sense starting until the 12-year molars come in, unless there is a severe crowding problem and you want to prevent taking teeth out,” says Petrarca, who charges $4,000 to $6,000 for a variety of treatments.
After researching orthodontists for her two daughters, Charlotte Troup of Glen Echo chose one who recommended early treatment over another who didn’t for 8-year-old Lucy’s overcrowded mouth.
“You can’t always leave crowding, even when you might want to wait,” she says.
Troup knew Lucy might need two phases of treatment and still have to have teeth pulled. Her daughter, now 9, wore braces for a year and has a retainer. She will wear braces again for her second course of treatment when her adult teeth are in.
“We were trying to get around extractions later. To be honest, her mouth is so small she’ll still need extractions,” Troup says. But “we gave it our best shot.”
Twelve-year-old Morgan’s problems with crowding and slightly protruding teeth were largely solved during a first phase of treatment that included aligning her teeth with braces, expanding her jaw using archwires and giving her a retainer beginning in second grade. Her orthodontist determined that she needed braces again after her permanent teeth came in. So she got them in March and will wear them for a year or so, according to Troup, who spent about $3,000 for each girl’s first phase.
Morgan says she thinks it’s easier to have braces now than it would be as a teenager. “No one really makes fun of you,” she says. “It’s not a big deal because lots of kids actually have them.”
Amy Egan of Chevy Chase chose not to treat her 10-year-old daughter, Sally, until her permanent teeth come in. One orthodontist recommended starting a first phase immediately, followed by another when Sally had her adult teeth. But when Egan asked if that would eliminate the need for treatment later, the orthodontist said, “Not necessarily.”
Since Sally didn’t have severe crowding or speech problems, Egan “didn’t really see the point” in spending thousands of dollars now. “[The orthodontist] was saying, ‘You need to do this stuff right now,’ but he couldn’t say it would reduce what would come later,” Egan says.
For those who start treatment early, it can seem as if they’ve spent their entire childhood in braces by the time they’re done, parents say.
Deb Ferrin of Silver Spring says her 17-year-old son, Will, began treatment in third grade with a metal device attached to his top back teeth for two years to correct an overbite. He got braces in fifth grade and had them removed his freshman year of high school. He then was told to wear a plastic molded retainer over his top and bottom teeth indefinitely to keep them aligned—and that was a problem, Ferrin says. After a few days, her son refused to wear the retainer because it was so uncomfortable.
“I feel like they don’t take into account that kids are kids, and why is a ninth-grade boy wearing a retainer and he can’t talk? All that money and all that time hinges on a retainer…,” Ferrin says.
Making sure that children remain compliant can be an issue as they get older, parents and orthodontists say. Holcomb says her 17-year-old son hasn’t been wearing his retainer at night. And she’s finding it more difficult to schedule visits to the orthodontist because of her high school junior’s busy life.
“You think you’re only in it for a little while, and then you’re in it for the child’s life,” she says.
Julie Rasicot lives in Silver Spring. Her work has appeared in The Washington Post, among other publications.
