One of the most confusing things about getting more than one orthodontic consultation (a second opinion) is that two seemingly qualified doctors can offer such different approaches to the same problem. Not only are their treatment plans different, many times they even disagree about the best time to start treatment. Why this disagreement and what should you do with your child? (Note: This discussion refers to single-phased, comprehensive orthodontics. Two-phase early treatment is discussed separately in earlier blog entries.)

Treatment length is directly related to start time
Having treated thousands of patients over more than 25 years, I’ve found that the most common question that I get from my patients is “When can I get these braces off?” The answer to this question is directly related to a similar question “When do I get my braces on?” My typical orthodontic patient will usually have his braces on 12 to 30 months (depending upon complexity). Very few problems require longer than this. Extended treatment times not only frustrate patients and their parents, they are also bad for the teeth.

3 reasons treatment time may go longer than estimated
In my experience, the most common reasons for treatment times extending beyond 30 months are 1) placing the braces before the last baby teeth are lost and the 12-year molars are erupted, 2) patients not getting their teeth extracted or necessary surgical procedures performed in a timely fashion after treatment has begun, or 3) mid-course deviations from the original treatment plan. Sometimes changes in the treatment plan are unavoidable. Delays in getting surgeries and extractions are also many times beyond the control of the patient and the doctor. Choosing the appropriate time to start treatment however is usually determined by the parents and the orthodontist.

The best time to get braces on is...
In my practice, the majority of my full-treatment orthodontic patients do not get their braces on until they have lost all of their primary teeth and their 12-year molars are all at least partially erupted. This is especially true of patients whose problems are not as serious. A simple 12-month treatment can easily drag on to 18 or 24 months if the braces are placed on the teeth with several baby teeth remaining or the 12-year molars are not visible at all. Teeth cannot be bracketed or moved unless they have erupted into the mouth!

We may start earlier in complex cases
Although these guidelines are applicable to the majority of my patients, there are of course exceptions. One is when the patient has a severe malocclusion that will obviously take two years or more to fix (impacted canines, excessive overbites, severe crowding, etc.). Patients with these problems will have extra time during treatment to allow for the eruption of their remaining permanent teeth. Even the best estimates of tooth eruption time can take longer than expected however, and parents should be informed of this possibility before the braces go on.

Other reasons we may begin early
Other examples of when early starts are appropriate include when a patient has a condition so severe that it is causing social issues (i.e. other children making fun of them), the teeth protrude so far that they are in danger of being damaged, or there are problems preventing normal development (a crossbite with a shift, crowding due to arch constriction, etc.). In these cases I may feel justified in beginning treatment before the last baby tooth is lost or the 12-year molars are fully erupted.

Underbites are an exception to the rule
One notable exception to these guidelines are patients with an underbite or Class III relationship. Children with these growth patterns tend to continue growing a few years beyond those with normal bites or overbites. Girls may continue growing until they are 16. Boys may grow until they are 18 or older. If an underbite growth pattern continues after braces have been removed, patients may outgrow their correction and require additional unwanted treatment. To prevent this, we will usually monitor these patients’ growth and begin only after it has stabilized.

Every patient is different and each orthodontist has unique training, experience, and treatment goals. While most dentists and orthodontists do have the well-being of their patients in mind, unfortunately there are those that will put braces on anyone that walks through their doors just so they don’t “lose them.” There is nothing wrong with questioning your doctor’s rationale, especially when it comes to treatment timing. If you receive different opinions from two doctors about the same patient, ask them each to explain their recommendations. The appropriate treatment, provided at the appropriate time, is the best recipe for a happy patient.

NOTE: The author, Dr. Greg Jorgensen, is a board-certified orthodontist who is in the private practice of orthodontics in Rio Rancho, New Mexico (a suburb on the westside of Albuquerque). He was trained at BYU, Washington University in St. Louis, and the University of Iowa in the United States. Dr. Jorgensen’s 25 years of specialty practice and 10,000 finished cases qualify him an expert in two-phase treatment, extraction and non-extraction therapy, functional orthodontics, clear aligners (Invisalign), and multiple bracket systems (including conventional braces, Damon and other self-ligating brackets, Suresmile, and lingual braces). This blog for informational purposes only and is designed to help consumers understand currently accepted orthodontic concepts. It is not a venue for debating alternative treatment theories. Dr. Jorgensen is licensed to diagnose and treat patients only in the state of New Mexico. He cannot diagnose cases described in comments nor can he select treatment plans for readers. Because he has over 25,000 readers each month, it is impossible for him respond to all questions. Please read all of the comments associated with each article as most of the questions he receives each week have been asked and answered previously. The opinions expressed here are protected by copyright laws and can only be used with written permission from the author.