First Phase Treatment (Interceptive)
The Goals of the first phase of treatment are:

1. To develop both the upper and lower jaws sufficiently to accommodate all of the permanent teeth.

2. To improve the relationship of the upper and lower jaws to each other.

Children sometimes exhibit early signs of jaw problems as they grow and develop. An upper or lower jaw that is growing too much or not enough, or is too wide, too narrow, or crooked can be recognized at an early age. If children over four years of age have these jaw discrepancies, they are usually candidates for early orthodontic / orthopedic evaluation and treatment.

Because children are growing rapidly, they can benefit enormously from an early (interceptive) phase of orthodontic / orthopedic treatment. Orthodontic appliances can be used to correct the jaw shape and direct the growth toward an ideal relationship between the upper and lower jaws.
A good foundation can be established thereby providing adequate room for eruption of all the permanent teeth.

Early interceptive treatment can often prevent:

1. The later removal of permanent teeth to correct overcrowding.

2. Surgical procedures to align the upper and lower jaws.

Interceptive treatment can also decrease the time necessary for the second phase of treatment. Leaving a malocclusion untreated until all of the permanent teeth erupt could result in a jaw discrepancy too severe to allow achievement of an ideal result with braces alone.

Orthodontic / orthopedic records will be necessary to determine the diagnosis, treatment plan type of appliances needed, duration of the treatment, and frequency of visits. Records consist of models of the teeth, radiographs, photographs and clinical evaluation.

Intermediate Retention Period

During this period the remaining permanent teeth are allow to erupt. Retention and/or tooth guidance appliances may be recommended at the end of the first phase.

Often times retainers may be used, however, usually for only a short period as they may interfere with the eruption of the adult teeth. In this case it is best to allow the existing permanent teeth some freedom of movement while final eruption of the teeth takes place.
A successful first phase will have created enough room for the teeth to find an adequate eruption path and prevent possible impaction and displacement problems.

It is important to understand that at the end of the first phase of treatment, all teeth are not in their ideal final positions.
This will be determined and accomplished in the second phase of treatment (corrective).

Occasionally when a patient is treated with a two-phase treatment program, the permanent teeth erupt more rapidly than anticipated. Should this occur, the parents will be advised and the patient will continue directly into the second phase of treatment without removal of the orthodontic appliances.

Second Phase Treatment (Corrective)

Each tooth has an exact location in the mouth where it is in harmony with the cheeks, tongue, jaws, jaw joints and other teeth When this equilibrium is established, the teeth will function together properly. With good home care and retainer wear your teeth should stay healthy, stable, comfortable and look attractive. This is the goal of the second and corrective phase of treatment.

At the beginning of the first phase, orthodontic records were made and a diagnosis and treatment plan is established. Certain types of appliances were used in the first phase, as dictated by the problem. The second phase is initiated when most of the permanent teeth have erupted, and usually require braces on all of the teeth for an average of 12 to 18 months.
Retainers are worn after this phase to hold the teeth in their new corrected positions.

Advantages of Two-Phase Orthodontic Treatment

The two-phase orthodontic / orthopedic treatment is very specialized process that encompasses jaw and facial changes (orthopedics) and tooth straightening (orthodontics).
The emphasis today on living longer, staying healthy, and looking attractive requires optimum treatment results.
The major advantages of two-phase treatment is to maximize the opportunity to accomplish the ideal healthy, functional, aesthetic, and comfortable result that will remain stable.

Have you ever noticed the uncanny ability of a toddler or young child to triple their physical strength and will power when they don’t want their teeth brushed?

Tooth brushing can be a frustrating ritual for many parents. So much, that many parents acquiesce to the child’s demands or compromise by brushing less than they should. Such was the case with the author’s first child, Brennan. Weighing in at the 95th percentile for both height and weight with will power to match, Brennan challenged us to find an effective brushing technique that would start and end the day on a happier note…

Here’s the formula:

1. Use a mentor.
At 18 months, Brennan was in awe of his 3 year old friend, Eric. Eric proudly allowed Brennan to watch him brush his teeth. Eric demonstrated standing very still with his mouth open wide while his mommy took a turn. We named this method “Eric’s way”.

2. At home.
We attempted to brush “Eric’s way”. When the hands flew up, the mouth refused to open and the head seemed to spin 360 degrees (or so it seemed) we brushed “the other way”.
“The other way” is not punitive and should not be suggested with anger or disappointment. Present this method as simply “the other way” that teeth are brushed. The adult sits on the floor with legs outstretched in a v-shape. Place the child’s head snugly between your inner thighs so that the head can not turn abruptly. Tuck the child’s arms under your thighs. Our son’s mouth opened readily as he protested.

* Caution:
Don’t brush with toothpaste as toothpaste shouldn’t be used until the child can spit effectively to prevent ingesting excess fluoride. A soft toothbrush applied with firm pressure will accomplish the job.
The adult should be wary of flying feet.

The Healey children’s tooth brushing technique has been shared with hundreds of frustrated parents in our dental practice. A typical concern of parents is that tooth brushing will be viewed negatively by the child and cause greater resistance later on. By taking a few precautions, parents can guide their child to becoming a helpful, happy tooth brusher…..

1. Make tooth brushing a happy time
Count teeth, sing a song, regardless of whether you brush at the sink or on the floor.

2. Remember brushing “the other way” is not punitive!
It’s just “the other way”.

3. After brushing on the floor, give your child a hug.
Tell them you know how hard brushing is for them and that you love them too much to let the sugar bugs bite holes in their teeth. Brushing brushes the sugar bugs away so they will have strong, healthy teeth.

When and how do the teeth form?
The 20 primary (baby) teeth begin to form the first trimester of pregnancy. In these early months, many of the first layers of calcium have been laid; they eventually will become your child’s future permanent teeth. All teeth start as a soft-tissue bell having one layer that grows outward to become enamel and one layer that grows inward to become dentin. As the cells grow daily, the foundation for the mature tooth is laid. As time passes, calcium is deposited in each layer.
As you can see, the teeth develop long before you can see them.

During this long period, there are many variables which influence the development of these important teeth. Certain childhood illnesses can alter the density and thickness of the enamel layer. For example, a child who has jaundice at birth may have a problem in the permanent incisors or molars at age seven. Falls where a child hits the mouth and fevers common with childhood illnesses are examples of short-term health problems that can alter the development of permanent teeth.

Other long-term health problems, such as diabetes or hormonal insufficiency, can alter the correct development of the teeth. Unfortunately, many of these circumstances are not preventable. However, when detected early, most dental problems are easily remedied.

When will my baby start getting teeth?
Babies “cut” their teeth at different ages. Most children erupt their first tooth at six months and add one tooth per month until all 20 primary teeth erupt. The diagram (shown below) provides a general guideline for eruption. If by age 12 months your baby does not have the first tooth, you and your baby should visit a pediatric dentist for an evaluation.

Often the teeth just need a little help to push through the fibrous gum tissue. Imagine that — a baby with tough gums! When the tooth first shows in the mouth, the root is not completely formed. The pressure of the developing root causes the eruption. When the root is completed, no more eruptive pressure will be applied and the tooth will stay where it is.
It typically takes 1.5 years for the root to complete formation once the first tooth appears.

How important are primary (baby) teeth?
Aside from the obvious function of chewing food, the primary teeth serve as guides for the permanent teeth. They hold the position for the permanent tooth and help direct the permanent tooth into position. Premature loss of a baby tooth can affect the position of the permanent tooth in the mouth and create a need for or compromise the result of braces in the future.

The front teeth in particular are vital for teaching your young child proper swallowing habits and proper speech. imagine trying to say “TH,” as in “thank you,” with no front teeth! The front teeth function as a stop when properly pushing the tongue forward for correct pronunciation. Notice where the position of your tongue is when you close your mouth and swallow: it pushes on the roof of your mouth just behind the front teeth.
Without the presence of these front teeth, some children may develop undesirable habits, such as “tongue-thrusting” during swallowing and while pronouncing many words. When swallowing 1,000 times per day, compounded day after day, a subtle but significant imbalance begins to take place. The tongue is one of the strongest muscles of the face. When it more frequently pushes out during tongue- thrusting instead of up in the normal swallowing pattern, a change occurs within the harmony of the facial musculature. You see, the muscles are attached to the bone. The pull of the muscle on the bone is what directs the growth of the bone.

Therefore, this change in muscle can redirect the growth of a child’s jaw resulting in a less prominent chin, larger overbite or gummy smile. Many of these problems, when addressed early, can be corrected. However, it is far better to prevent such occurrences and maintain the balance and facial profile that nature intended.
All parents want to help their children develop a healthy sense of self-worth. Children’s self-esteem is influenced by their perception of how they relate to their peer group. Premature loss of teeth, particularly the front teeth, can affect the way children are perceived by others and how they feel about themselves. Many feel it’s unfortunate, but it’s a fact in our society that looks matter. Children who lose their front teeth to trauma or decay might consider replacing them so they can smile like other children their age. Treatment involving the fabrication of a fixed pediatric partial is available for children missing front teeth. The partial looks like the original teeth it replaces.

What should I know about the effects of fluoride on my child’s teeth?
Perhaps the single most significant event of the twentieth century for improving the oral health of Americans was the discovery of fluoride’s effect in reducing cavities. In 1952 researchers found dental decay was lowest in areas where fluoride was in the drinking water. The fluoride works by being absorbed through the body and into the saliva that bathes the teeth.

Because the enamel on your child’s teeth is vulnerable, it is important that growing children have a fluoride-rich environment during their formative years (through age 14). Acidulated phosphate fluoride, provided in the dental office, should be applied to the teeth twice a year. This type of fluoride bonds weakly to the teeth and releases slowly over the next two weeks. These in-office fluoride treatments have proven to reduce dental decay by 80%.

It is possible for children to receive too much fluoride, most commonly from swallowing fluoridated toothpaste. Too much fluoride causes fluorosis, a brilliant white coating on the tooth surface. Fluorosis can be cosmetically repaired.

Families with water filter systems in the home — which may filter out fluoride — should provide prescription fluoride supplements to their children. If you are concerned about the level of fluoride in your drinking water, have it tested for fluoride concentration.

Thanks to the proper use of fluoride, many of today’s children will never know the frustrations of extensive restorative dentistry. They can enjoy the comfort and pride that accompanies a healthy, attractive smile.

Children seem to get braces at an earlier age now. Why?
Children of the 50s, 60s and 70s frequently waited until most of their permanent teeth were erupted before starting orthodontic treatment — usually at about age 12 or 13. Back then, little was known about how the face develops. With today’s knowledge, children are evaluated in terms of their skeletal development as well as the development of their occlusion or “bite.”

Today, if a child’s jaws are relating well and the teeth are simply crooked, an orthodontic correction still begins at about age 12. However, if a child presents a significant overbite or under- bite, or if there is insufficient room for all the permanent teeth to fit the bone that has grown to date, that child will usually undergo an orthopedic correction. Placement of the braces on the teeth and/or the use of removable or fixed dental appliances utilize the growth of a child to obtain more ideal jaw relations. Treatment usually spans 12-24 months.

Afterward, the child will wear adjustable retainers while the rest of the permanent teeth erupt. Then the patient often receives braces again. However, this time the braces are perfecting the position of the permanent teeth and not correcting the shape, length and position of the jaws. When recommended, this two-phase philosophy of treatment provides not only a more aesthetic result, but also a more stable result because the teeth, jaws and muscles of the face remain in balance and harmony. —-

–Michael Healey, DDS, PC, practices pediatric dentistry in Dunwoody.**
HealthScope WINTER 1994

–As of time of original printing.
Currently (Year 2000) Micheal Healey is practicing in Atlanta

• As soon as your child erupts the first tooth, clean it twice a day with a wash cloth or a soft brush. Decay-causing bacteria are present in the mouth, regardless of your child’s diet.
• Visit your dentist when your child is 24 months old for the first dental exam. By this time, many children have had some teeth for 18 months, and no one should go a year and a half without a dental exam. Your pediatric dentist will not only screen for early problems, but provide excellent advice for proper toothbrushing techniques as your child enters “the terrible twos”.
• A common place for decay is the tongue side of the front teeth. Until your child develops the manual dexterity to reach all surfaces of the teeth, you will need to assist with brushing. Many children get their first cavity by age two.
• Never put your children to bed with juice, milk, or any sugar in their mouth. At night, the flow of saliva is reduced, allowing bacteria to multiply more rapidly. Sugar feeds the bacteria on the teeth which releases acid that dissolves the enamel. This is also true for liquid medication and breast milk–which is loaded with sugar. Many breast-feeding mothers express surprise when their children have rampant tooth decay. “The breast milk is so natural,” they exclaim. Unfortunately, when allowed to bathe the teeth throughout the night it leads to “natural” decay.
• It is natural to suck on a pacifier or thumb, and we expect this habit to end by age four. However, too much of a good thing can cause problems. These comforting activities can interfere with the growth of the upper jaw creating a crossbite and/or open bite. Should your child have a pacifier or thumb habit, facial development should be evaluated by age two to screen for any developmental problems related to the habit.
• Red disclosing liquid is available within most dental practices as a teaching aid for parents and young children to use at home. Bacteria is white and so are teeth. By staining the bacteria red, young children are better able to visualize the germs and more clearly understand what their parents mean when they say, “do a good job!”.
• Your child should visit a dentist every six months (unless more frequent visits are advised) for professional cleaning, fluoride treatment and examination. The enamel on the primary teeth is thinner than on the permanent, and fluoride treatments will provide resistance to disease-carrying bacteria. Should your child have a problem, early detection will prevent the need for more extensive treatment. Parents should realize that the “watch & see” attitude about dental problems is even less successful with children than adults because the enamel shell is thinner and more vulnerable to decay.

–Michael Healey, DDS, PC
Originally published in the ATLANTA HEALTHSCOPE 2000
WINTER 1994

Temporomandibular joint problems that are the focus of treatment for so many adult patients often begin in childhood. Accurate diagnosis of joint dysfunction in children, however, relies heavily upon the practitioner’s knowledge of joint development, mandibular growth and development of the cranio-facial complex.

All the TMJ components are histologically identifiable by the twenty-second week of prenatal development. From birth until the age of 14 months, the joint is located at the level of the occlusal plane. The mandible does not grow as a linear bone.

Comparison of Mandible from birth to adult.

The ramus of the mandible forms a more acute angle with the body of the man dible as it develops. Early attempts to explain mandibular growth described a complex pattern of resorption and apposition of bone. This theory would not only give the mandi ble the distinction of being the only bone that grows with massive resorptive patterns, but it incorrectly predicts the position of the developing third molar bud, which lies super ficially on the bony surface at the age of eight.
When the orientation shifts from the in ferior border of the mandible to the corpus axis, a different growth pattern can be seen. Viewing the mandible from the neurotropic bundle of the mandibular foramen, the body of the mandible grows at an average of 2mm annually in a straight line.
The condylar head grows in a logarithmic fashion at the anterior head of the condyle approximately 1.2mm per year. This logarithmic growth pattern results in the ramus developing a more acute angle as it develops. The alveolar process grows dur ing this developmental process. As long as the growth is in a healthy balance, the length of the condylar head to the mandibular foramen (Xi point) will be in a 1:1.618 ratio to the length of Xi point to Protuberance Menton (PM point). The occlusal plane will bisect the mandibular foramen and essentially be a straight line.

The incidence of TMJ noises in children in creases with age. Studies have ranged from 11 to 25 percent of children under age eight to 20 to 51 percent of children at age 15 ex hibiting joint sounds. Joint sounds can be a derangement dislocation of the joint, synovial membrane changes, bone and disk surface changes, or loose bodies within the joint space. The orthopedic literature has reported that dislocation of a joint in itself will not significantly alter the growth of the bone; however, compression of a growing joint that is dislocated will decrease the bony develop ment. Thus, if a dislocated TM joint is com- pressed from macro trauma (traumatic blow to the mandible) or micro trauma (chronic bruxism), the body of the mandible will con tinue to grow at approximately 2mm per year, while the condylar head growth will either cease, slow down or degenerate. This will lead to a smaller ramus-either bilaterally or unilaterally depending on the specific insult.

Treatment for TM disorders in children keys on proper diagnosis. A complete analysis of the entire cranio-facial structure is required before treatment begins.

Intra-oral signs of problems are:

• an increase in attrition of the primary dentition
• an increase in vertical overbite
• a unilateral occlusion on the side of a solitary injury to one condyle

Ankylosis of teeth may be indicative of a prior trauma that damaged the periodontal ligament of the deciduous teeth, resulting in a bony union and freezing the position of the teeth at the time of the original insult. The occlusal plane may not be parallel with the eyes in antero-postero orientation. Scars to the face remind one of prior trauma that may have been forgotten.
Extra-oral radiographs include a panorex that shows the morphology of the condyle.

Antero-postero and siibmental vertex cranial films show asymmetries and changes in morphology, and the classic lateral cephalometric view is critical in both diagnosis and treatment planning. Any alteration in mandibular form or function will change the muscle pull on the maxillae and will alter its growth. When sufficient signs and symptoms exist, appropriate joint films are indicated. Accurate records are indispensable in monitoring progress and ef ficacy of treatment, or if the decision to delay active treatment is chosen, to ensure that facial growth has not been altered.
Treatment for TM disorders in children varies according to the needs of the child. Mandibular repositioning appliances, either removable or fixed, add support to the dysfunctioning joint, and accelerated growth and healing have been reported. Cervical pull headgear has had a similar effect in some cases. High pull headgear dislocates the posterior dental support and results in additional force delivered to the TM joint, so anterior repositioning splints or functional appliances are used in conjunction with this appliance. The practitioner must be acutely aware that any intra-oral appliance that changes the position of the mandible to a for- ward position will place a retrusive force on the rnaxillae and rnaxillary teeth and will change their development. Comprehensive facial treatment planning is therefore required prior to initiation of treatment, and periodic re-evaluation of the changing facial environment is key to successful treatment. Children patients who develop TM disorders may or may not completely recover from this problem, but the earlier diagnosis and treatment begin, the greater control the practitioner will have in delivering a well-balanced occlusion to give support to the properly positioned joint.

Small children are expected to fall and bump their faces in the course of growing up. However, the standard of care dictates that dentists continue to examine the effects of these bumps and bruises long after the dental emergency has subsided.

Most children tolerate restorative dental care with either local anesthesia, or a combination of Nitrous Oxide inhalation sedation and a local anesthetic. Every dentist is trained in these two arenas. However, there are children whose behavior is combative, their ability to comprehend limited, the treatment plan is very extensive, or they have a medical condition that complicates their dental treatment where additional efforts are required. The choices available are physical restraint with a papoose board, conscious sedation, or general anesthesia.

The dental specialties that are formally trained in physical medicine and anesthesia are oral and Maxillofacial Surgery and Pediatric Dentistry. Oral Surgery is a procedure specific specialty that limits treatment to extraction of teeth, treatment of facial infection, bony fractures secondary to facial trauma, and orthognathic surgery. Pediatric dentistry is an age specific specialty that includes restoration of the teeth, facial trauma, orthodontic care, and uncomplicated extractions. Both specialties have in their training programs the mandate to perform a physical assessment and medical history prior to anesthesia, and are hospital trained in both IV sedation and general anesthesia. The Georgia Board of Dentistry has a licensing program in both general anesthesia and conscious sedation for every dentist who plans to deeply sedate patients in their office. This includes an oral examination of the doctor’s knowledge and a facility examination during a sedative procedure.

Most dentists choose to limit office procedures to patients who are physical status 1 or and asymptomatic, mild PS II. All other patients should be treated in a hospital setting. Some hospitals still require the primary care physician to provide a written history and physical examination for all patients who undergo a general anesthetic in their facility where others allow the dentist to provide the H&P for relatively healthy patients. The tertiary care physician is always encouraged to give a current written note for active PS II or PS III patients. If a child’s parents have any questions directed to the pediatrician concerning their child’s treatment, a telephone call by the pediatrician to the dentist is appropriate.

Extensive treatment plans often require conscious sedation to minimize the possibility of lidocaine toxicity. The few deaths that have occurred in Georgia over the past twenty years have been due to an overdose of local anesthetic. The safest rule of thumb is “The Rule of 25” which states you can safely give 1 carpule of any commercially prepared local anesthetic (2.2cc) for every 25 pounds of body weight and stay within a good margin of safety.

The use of fluoride to reduce dental decay has been a controversy since the early 1950s. The benefits of fluoride were first noted in the 1930s. There were farms in the Midwest where the natural sugar in the cow’s diet caused the cows to develop badly decayed teeth. In one area a fertilizer factory was built and the cows downwind stopped getting cavities. A soil analysis showed fluoride being given off by the factory’s smokestack was now in the cow’s food supply. That led to a study that revealed that the natural fluoride level found in the United State’s water supply ranged from nothing in the East coast to 5 parts per million (ppm) in Colorado and West Texas. The people living in Colorado and in Texas had very low dental decay rates but also had some staining in their teeth (Colorado brown stain). No systemic disturbances have ever been noticed in these areas. In China there is one location where the water has 15ppm and the residents there have developed brittle bones and have had kidney problems. In India, those people who drink brick tea (very high in fluoride) have had the same systemic problems the Chinese have noted. The U.S. communities that have 1ppm fluoride have a reduction in dental decay without the mottling of teeth. It was decided by the U.S. Public Health Dept. that this 1ppm would be the ideal level to achieve and water fluoridation began. Locations with excessive fluoridation have often placed deionizers to remove all the fluoride and reintroduced it at the 1ppm level. From a public health standpoint, Fluoridation has saved billions of dollars and has offered mass protection of our teeth from our high-sugar diets.

The way fluoride works is the enamel of your teeth is a crystal called hydroxyapatite. It is a spiral of calcium ions with (OH)-ions projecting and trying it together. Acids have a free hydrogen ion (H) + and this polar molecule takes very little energy to combine and create H2O. The calcium dissolves out of the teeth. This opens the pores in the enamel and allows bacteria to enter and decay the dentin of the teeth. The fluoride ion (F) – is the same size and charge as the (OH) – ion and is round rather than oval in shape. It will compete for the sites in the crystal. It takes much more energy to create hydrogen fluoride (HF) than water (H2O) and it does not dissolve as fast. When you swallow fluoride it eventually gets into your saliva and is incorporated in the outer enamel layer of your teeth.

Many people object to having foreign substances introduced into their bodies. Fluoridation has been accused of being anything from a communist plot to a cheap way to get rid of nuclear waste. None of these accusations have been accepted as valid. It is a passive way to get some protection to the masses and it can be removed by the appropriate filters. Your child’s dentist can test the fluoride content of your water for a nominal fee ($25 on average).

Fortunately, protection of the teeth can be achieved without systemic ingestion of fluoride. Fluoridated toothpaste contains 1000ppm fluoride and has been shown to be very effective. It should not be swallowed and is reserved for children who can spit it out. A higher concentration is found in the fluoride mouth rinses such as Act or Fluoroguard. This is great for children who have little resistance to the Streptococcus Mutans bacteria that cause dental decay, those children in braces, those having GI Reflux, or decreased salivary flows. A prescription fluoride (0.4% Stannous Fluoride) not only remineralizes the teeth but the tin creates a defective protein in the bacteria and they do not give as concentrated an acid as they usually do. The best fluoride protection is given as a topical application by your child’s dentist called APF fluoride (Acidulated Flurophosphate). It is applied twice a year starting at age 2, before the eruption or the primary second molar teeth. When the teeth erupt the enamel only has 45% of the calcium they will have 6 months later. The APF is absorbed on the teeth as calcium fluoride and slowly released over the next 2 weeks into the gum tissue. None of these topical solutions should be swallowed. A professional suction is used for infants and small children to evacuate the APF.

In conclusion, people who get no fluoride applied to their teeth and have a moderate sugar supply (either processed or natural) generally will spend much time and resources in restorative dentistry. Fluoride applied to the teeth can make a huge difference in their oral health. Avoiding all fluoride can doom a child to a lifetime of dental decay. Too much fluoride can also be harmful. It is a lot like table salt. If your diet has absolutely no salt you would be lightheaded and might eventually die. Too much salt creates hypertension; kidney problems and you might die also. But in moderation, salt can be very beneficial to your health.

DR Michael Healey is a Pediatric Dentist practicing in Atlanta, Georgia. He is the past president of the Georgia Academy of Pediatric Dentists and an Honorable Fellow of the Georgia Dental Association.