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Key Steps to Determine If My Child Should See an Orthodontist

By Dr. Eric Phelps

I would guess most people value orthodontic treatment as a way to improve the appearance of the smile. Straight teeth look nice. Now we realize there is so much more! As stated by world renowned orthodontist, Dr. Dwight Damon, “Orthodontics is about far more than straight teeth.”

Proper development of the midface, which includes the upper and lower jaws and helps define the nasal and pharyngeal airway (airway behind the tongue and soft palate, the soft tissue constituting the back of the roof of the mouth), can result in improved health for a lifetime.1 An orthodontist can help evaluate the development of the face in addition to the teeth.

When to See an Orthodontist?

At our practice we used to say, “Eight is great, nine is fine”. That is because the upper permanent front teeth (incisors) typically grow in around age eight. So if a first phase of orthodontics is indicated, eight or nine years old is a decent age to begin treatment because the upper permanent incisors are typically in the mouth and can be moved with braces. The American Association of Orthodontists (AAO) has recommended that children visit the orthodontist for the first time no later than age seven.2 Evaluating children before age seven can be a significant benefit for many reasons. Besides dental development, we can evaluate midface development to better understand functional breathing and muscle balance.

Does My Child Have Breathing or Sleeping Issues?

All of the parent complaints regarding their preschool-aged children listed below are signs and/or symptoms of airway obstruction during sleep.1 If you, as a parent, are observing these issues with your child, it is important to share your concerns with an orthodontist now and not wait until seven or eight years old.

  • Regular, heavy snoring
  • Mouth breathing
  • Drooling during sleep
  • Agitated sleep
  • Nocturnal/nighttime wakenings
  • Confusional arousals
  • Sleepwalking
  • Sleep terrors
  • Nocturnal/nighttime sweating
  • Increased need for napping compared to peers
  • Poor eating
  • Abnormal sleep positions
  • Persistence of bed-wetting
  • Abnormal daytime behavior
    • Aggressiveness
    • Hyperactivity
    • Inattention
  • Daytime fatigue
  • Hard to wake up in the morning
  • Morning headache
  • Growth problems
  • Frequent upper respiratory tract infections

Of great importance is the relationship between attention deficit hyperactivity disorder (ADHD) and sleep problems in children. Dr. Allan Hvolby proposed that ADHD could be a primary condition causing poor sleep and poor sleep could be the primary condition causing ADHD like symptoms.3 As an orthodontist with an airway focus, my role is to find the children with a primary sleep issue who are being treated for ADHD with amphetamines such as Adderall or Ritalin. If a child actually has a sleep problem, then these medications could make sleep worse. I agree with Dr. Hvolby and his recommendation that primary sleep disorders should be ruled out before diagnosing or treating ADHD. And, if there is a primary sleep disorder, then having an orthodontist evaluate for midface deficiency and possible airway obstruction is critical.

Does My Child Have a Bad Bite and Crowding?

Most patients I see lack space for wisdom teeth and many also barely have room for both sets of bicuspids (teeth between the canine and molars). Why do kids have narrow arches, severe crowding, and teeth that generally do not fit together? I believe the answer is poor function and balance of the facial muscles often due to airway/breathing issues.4 For example, a child that breathes through his/her mouth while sleeping will often end up with a narrow upper jaw (maxilla) because the tongue is not resting at the roof of the mouth to help develop the maxillary arch. And when the upper jaw does not develop properly, teeth on the lower arch tend to tip in towards the tongue leading to a narrow lower arch as well.4 And the result is crowding of the teeth. In decades past, it was common to extract bicuspids to resolve the crowding. At our practice, we focus on developing the midface to create the space needed to accommodate all teeth (with exception of the wisdom teeth).

What Are the Deficiencies to Look for in the Midface?

Transverse Deficiency (side to side):
In our experience, it is common to see a young patient, 6-7 years old, with a maxilla (upper jaw) that is narrower than normal and the resulting crowding of the developing permanent incisors (front teeth). These kids often have sleep breathing issues and difficulty with nasal breathing in general.1 In my opinion, the sooner we see these kids, diagnose the underlying midface anatomy deficiencies and provide treatment, the greater benefit the patient will experience.

Anterior/Posterior Deficiency (front to back):
When either the upper or lower jaw (or both) have not developed far enough forward, the pharyngeal airway can be compromised. This can cause sleep breathing disorders in kids, and, if the child doesn’t currently have a sleep breathing disorder, this midface deficiency could lead to a sleep breathing disorder in the future.

Vertical Excess or Deficiency (up and down):
If a patient tends to breathe through the mouth, the upper and lower jaws can develop with an excess vertical dimension (longer face). This can worsen the breathing challenges by making it difficult for the lips to seal. Patients can also have a deep bite from a lack of vertical development that can be problematic.

How Orthodontic Treatment Goes Beyond Straightening Teeth?

As an orthodontist, my goal is to straighten teeth, and, when indicated, develop the midface. Treatment goals for the midface include: improving the width of the upper and lower arches, advancing the arches to a more forward position, increasing the vertical height of the face (in cases of a deep bite), or reducing the vertical height of the face (in cases with mouth breathing and lack of lip seal).

It is important that the nasal and pharyngeal airways are adequately developed and functional. The temporomandibular joints (TMJs) should allow for smooth rotation and translation of the lower jaw. The muscles of the face should be relaxed during sleep to minimize stress on teeth and jaw joints, and to prevent nerve impingement. And teeth should fit together nicely at rest and during functional movements of the lower jaw.

Treating the Face for Esthetics and Oral Health

In summary, orthodontic treatment involves developing the midface in addition to creating an esthetic smile. An esthetic smile involves so much more than straightening the teeth. Is there a broad arch so back teeth show in the smile? Are the front teeth positioned nicely in a vertical relationship to the upper lip during smiling? Are the teeth shaped nicely? Is the gum tissue healthy and shaped properly? These are some of the important concepts when considering the smile based on anatomy of dental related structures.

Beyond an esthetic smile, it is helpful to step back and look at the entire face, evaluating midface development and airway anatomy. Does the patient get quality sleep? Does the patient look tired? Are there dark circles under the eyes?

These are key to the Damon System—midface development, facial esthetics, proper bite, can help create healthy smiles for a lifetime.

—Phelps and Cohen Orthodontics


Dr. Eric Phelps (Phelps and Cohen Orthodontics and Nor Cal Airway) is an orthodontist who was trained at the University of California Los Angeles and has practiced in San Jose, California since 2003. Along the journey of discovering that he has severe sleep apnea, Dr. Phelps added ‘Airway Education’ to his professional mission which led to the founding of Nor Cal Airway, a practice focused on helping patients with airway obstruction and sleep breathing disorders and the resultant muscle parafunction that often leads to TMJ dysfunction and chronic pain.

The opinions expressed are those of Dr. Phelps. Ormco is a medical device manufacturer and does not dispense medical advice. Patient results may vary. Clinicians use your own judgment in treating your patients.

1 Christian Guilleminault, MD, BiolD; Ji Hyun Lee, MD; Allison Chan, DO. Pediatric Obstructive Sleep Apnea. Arch Pediatr Adolesc Med. 2005;159:775-785
2 American Association of Orthodontics. https://www.aaoinfo.org/blog/parent-s-guide-post/first-visit/#:~:text=The%20American%20Association%20of%20Orthodontists,even%20in%20their%20earliest%20stages.
3 Allan Hvolby, Associations of sleep disturbance with ADHD: implications for treatment. Atten Def Hyp Disord (2015) 7:1-18
4 Steven Olmos. Comorbidities of chronic facial pain and obstructive sleep apnea. Curr Opin in Pulm Med. 2016; Vol 22 No. 6: 570-75

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