Adolescent Orthodontics

Wisdom teeth and crowding lower incisors

In recent years many studies have investigated the connection between the eruption of wisdom teeth and crowding in the anterior teeth, a phenomenon called "late crowding".

The unequivocal conclusion today is that crowding occurs when no wisdom teeth are present at all, and the pressure applied by these teeth on eruption is not a cause for "pushing" the incisors.

However, in many cases there is no space for the wisdom teeth to erupt, making it necessary to extract them due to malposition and/or recurring infection.

If the wisdom tooth is impacted its proximity to the nerve is dangerous and a surgical procedure may be harmful to the nerve, the wisdom teeth may be left in place, under continued observation by the dentist.

There is nothing preventing orthodontic treatment on front teeth even when wisdom teeth are not extracted. In any event, at the end of treatment it is advised to either affix a wire to the inside of the front teeth (to remain for several years) and/or a retainer for nightwear, in order to avoid further crowding throughout the years.

A "Space Retainer" is an orthodontic appliance used when milk teeth have fallen out prematurely while permanent teeth will erupt only after some months, sometimes years, and adjacent teeth begin to move forward in place of the missing teeth. This appliance is metal or plastic and can be removable or affixed to the teeth. Space Retainers are uni- or bi-lateral and also serve to preserve the arch length in case of future loss of additional milk teeth. The orthodontist, in cooperation with the pediatric dentist, will determine which space retainer is suitable for each individual case.

Uni-lateral space retainer

Bi-lateral space retainer

External appliances

Headgear, face masks and other appliances outside the mouth – why are they necessary?

When is an external appliance necessary with orthodontic treatment?
Most children coming for treatment complain of a protruding jaw, protruding teeth or an irregular arch caused by crowded teeth.

The most well-known external appliance is the headgear, which functions in two principal ways:

1. Pushing the posterior (back) teeth of the upper jaw backwards so that space is made for the crowded teeth to spread out, or push protruding teeth back.
2. The headgear can regulate growth of the upper jaw and enable correction of a protruding jaw.

The headgear comprises two parts: an outside strap and an inner arch

Inner arch
The inner arch is made of two metal arches welded together, the outer one is tied to the strap and the inner is placed inside the mouth. The inner arch can be tied to a plate that has been positioned on the teeth or it can be connected to the brackets attached to the back teeth.

Face Mask
There is also an "Inverted headgear" for cases where the upper jaw is sunken. The aim of the inverted headgear is to pull the jaw and teeth forward.

In cases of a protruding lower jaw, treatment can be with a "chin positioner," which pulls the chin back with the purpose of delaying growth of the lower jaw.

The headgear is effective in children whose jaws are still developing, and is a means of regulating their growth.

What is the recommended orthodontic treatment for a "child with special needs?" 
This group of children includes children with various limitations, such as, mental retardation, Cerebral Palsy, muscular disorders, Down's syndrome, autism and other rarer syndromes.
Amongst these children, malocclusion presents more frequently and more severely than amongst the regular population. Mentally retarded children more often display a Class II occlusion, manifesting in protruding upper teeth as opposed to lower teeth. Children with Cerebral Palsy frequently display Class II usually combined with open bite; Down's syndrome children are characterized with a narrow upper jaw, posterior and/or anterior cross bite, open bite, missing or small teeth. Children with muscular disorders usually suffer from a Class II malocclusion and open bite. 

Malocclusion also affects face esthetics. These children with characteristic face features are defined as "irregular" by the general public without a professional eye. Muscular weakness is a trait of many such children and, together with the disharmony of the jaws, causes disorders in chewing, swallowing and speech, and accumulation of plaque around the neck of the teeth. Usually, dental hygiene is deteriorated in these children as compared to healthy children, and as a result there is an increase of plaque and tooth disease. The incorrect position of the tongue, often accompanied by a characteristic open mouth, is a result of weak muscles, but also of breathing through the mouth common in some cases due to recurring respiratory infections. Excess salivation appears very often, mainly due to defective swallowing of saliva, which causes an appearance that repels and distances the environment.

With the advance of medicine, life expectancy and quality of life for these children has increased . The affluent society has generated new expectations of standard of appearance and behaviour not called for in the past, bringing about a higher demand by these children and their families for orthodontic treatments. Orthodontic treatment can enhance facial appearance, can improve functions of chewing, swallowing or speech and can reduce excessive salivation – thus facilitating the child's acceptance in society. 

Administering orthodontic treatment to a "special needs" child has its challenges. The understanding and coordination required for simple actions, such as effective brushing of teeth, or more complicated actions such as, placing different parts of the appliance, are usually lacking in these children, and therefore the responsibility falls on a third party, the parent or another adult who is the child's caregiver in his day-to-day life. He will have to brush the child's teeth, insert the appliance internally and externally, and see to visits to the clinic once every 3- 6 weeks.

Orthodontic treatment requires the patient's cooperation for a long time. These children have years of experience with hospitals and arrive at our clinic with much apprehension. Mental retardation and lack of understanding, to varying degrees, common relaxation techniques are ineffective. Another treatment restriction results from lack of muscle coordination. The manifestation of involuntary body movements and their inability to sit still without moving, make it difficult to perform the required delicate procedures. For this reason, sometimes the orthodontist is compelled to perform long procedures (such as bonding of brackets) under sedation (laughing gas or IV) or even under general anaesthetic.
As a result, the cost of treatment increases, since an especially skilled team is necessary, the time of treatment is much longer, in comparison with a regular child, and other costs of sedation or general anesthetics are added. 

The key to success lies in the team work of the professionals, in a multidisciplinary center which allows for coordination of the various professions involved in treatment of these children – pedodontics, anesthetics, maxillo-facial surgery, genetics, mouth rehabilitation, periodontics, social workers, etc. Only in this manner is it possible to improve and reduce expenses while maintaining a high standard of treatment. The aim is to make it easier on the child and family by producing quick and effective results concurrant with the range of problems arising, to avoid redundant "running" from doctor to doctor located in different places, and prevent additional consultation costs. At a center of this kind, several procedures that are performed in the best possible way by various experts, can be completed in a single treatment with sedation or under general anesthetic.
In Israel there are a number of centers for treatment of the special needs population:

1.The Center for Treatment of Special Needs Children, at the Orthodontics Department of the Dental School of the Hebrew University in Jerusalem, Hadassah Ein-Karem.

2.The Center for Treatment of Special Needs Children at the Orthodontics Department of the Dental School of the Tel Aviv University.

3. The Center for Healthy Teeth, the Orthodontics Department, Poriah Medical Center, Tiberias.4. The Orthodontics Unit, Sheba Medical Center, Tel-Hashomer.