Metal Mouth Message Board

My daughter is 5 years old. She had sleep apnea for some time, recently treated with tonsil extraction. She now has an anterior open bite and has ground down her baby molars. Her maxilla is slightly underdeveloped and her incisors fully overlap (I share both bite problems btw). She lacks expected spaces on upper teeth and has mild crowding on lower teeth. These are her baby teeth so I'm told it'll be a lot worse once the adult teeth come in. Her dentist is saying she'll probably need 4-6 teeth extracted. Is there anything I can do at this point?

Most orthodontists we've seen suggested waiting until age 7. If it came to that, I'd probably opt to leave the teeth in and hold out until she can get jaw surgery.

She's only 5. I don't think I'd start her with orthodontic treatment until she's at least 7. She's still growing. So her face will develop a lot more in a couple years. You mentioned her upper jaw is underdevolped, so assuming its narrow, she could get a palatal expander placed and that would fix that. If an ortho doesn't want to fix anything until she's 7, I'd listen to them. They're the experts when it comes to braces and jaw development.
As for the grinding, if she's grinding her teeth at night, you can get a bite splint made for her so she won't damage her teeth further.

I think you'll just have to sit tight until she's old enough to be fitted with some "round 1" braces and you can consult with one or more orthodontists.

I wouldn't worry overmuch about what your dentist is saying; an actual orthodontist is in a better position to say what will and will not be required when the time comes.

That said, the common course of treatment of premolar, (and later, 3rd-molar) extraction is, if needed, quite a bit less traumatic than jaw surgery once she's an adult. It does not sound as if your daughter will be a borderline case for extractions. I think you might be doing her a disservice if you refuse needed extractions... most of them go quite well. (I know my wife's did, and there's a whole thread on this board of celebrities who have had extractions done; it's really easy to tell if you know what to look for.)

I have all my molars so hard for me to imagine it would be like with only 1 set. What are the odds of sleep apnea without molars? Of course, leaving teeth in doesn't change that but they should be correlated and if you're going to need surgery anyway to fix that problem (which I suspect will be a lot less invasive at that point), then may as well keep the teeth if you can.

Who said anything about one set of molars? A regular adult set of teeth have three; most people with any sort of crowding at all eventually have the 3rd molars (a.k.a. "Wisdom Teeth") removed and normal orthodontic extraction is to remove the pre-molars. That leaves two sets of molars.

My 4yo had sleep apnea, diagnosed at 3yrs & treated with tonsil- & adenoidectomy a year ago. She now sleeps through for the first time in her life but has the underdevelopment of the maxilla apparently common with the mouth-breathing sleep apnea kids. She has a crossbite, speech issues and has trouble chewing, apparently all stemming from the poor mouth habits that develop in kids whose adenoids/tonsils interfere with their breathing. She's been seen by a cranio-facial chiro and my neuromuscular dentist, both of whom agree that if we can help correct the poor tongue posture and persistent mouth breathing we can help mitigate the damage to correct down the track. The dentist is keen for her to start on a special mouthguard type trainer, which would help train her tongue to sit at the roof of her mouth instead sticking out between her teeth. Unfortunately Miss B is not a compliant child! She is due to start speech pathology soon to help train her to use the correct facial muscles to produce particular sounds ('s' is difficult, 'm' can be hard as she uses her tongue on her upper lip to produce an 'm' sound, etc). The crossbite makes chewing difficult, so eating can be slow, and she often chokes on her food. Unfortunately she needs to eat chewy things to help develop her facial muscles! Since her operation the crossbite has improved somewhat, and you can no longer hear her incisors sliding against each other as she bites down, which is nice!

Certainly from my experience with my daughter, as well as my own re-treatment following extractions and retractive orthodontics, it's been my experience that there are dental professionals who use non-extractive methods apparently successfully. Since I'm still mid-treatment I can't comment on the final outcome of my own re-treatment but I can say I've improved about 80% since I started seeing my Neuromuscular dentist. The migraines have stopped and the headaches are no longer debilitating. I told my traditional orthodontist during my retractive treatment that my jaw had started clicking, but he didn't really seem to take it on board, just carried on. In comparison, my dentist takes a great deal of time and care to manage the height of my bite, and the effect any changes have on any headaches/clicking/etc. It's a long road back to health though, so from my experience I'd be extremely hesitant to allow extractions for either of my kids. I'm not saying extractions are always bad, or that they are never warranted or successful, just that in my experience they caused enormous damage. I feel that they need to be used only with great consideration of function, and the effect they and the ensuing gap-closure will have on your function. Function is so much more important that asthetics IMHO.

If I were in your situation, I'd be looking for a Neuromuscular Dentist or Functional Orthodontist. These professionals follow a more holistic, function-based approach as opposed to a more Traditional Orthodontic approach which focusses on appearance. At least, in my experience it did. The functional/neuromuscular approach takes into consideration your jaw-to-jaw relationship, and the effect of your dental placement on head posture ('Head Forward Posture' is a common issue in my situation of retracted mandible, which leads to neck strain and headaches, etc). For my own daughter, I suspect she is too young and headstrong to reason with to begin treatment with the mouth-trainer device. My dentist will monitor her, and once she's ready we will start the process. We are lucky in a way that she has no crowding, on the contrary her lower arch are over-spaced, apparently a side-effect from keeping her tongue in her lower arch instead of touching her roof-of-mouth in the 'n' position (apparently the ideal tongue posture is to hold your tongue as if you were saying 'n'; I find that exhausting!). We will be working on her speech muscles with the speech therapist. Some speech pathologists specialise in correct breathing (mouth closed) and correct tongue posture, with experience in dealing with kids post-tonsil-/adenoidectomy. Do some research in your local area. You might also look for a buteko breathing practitioner in your area; they may be able to recommend a good NM dentist/speech pathologist/etc. The old song about the head bone being connected to the neck bone was exactly right; messing with one part of the body's structure can have detrimental effects on another part. I would be very hesitant to consider extractions without multiple functionally-trained opinions.

All the best.

I've mentioned it before, but there is no such thing as a "Functional Orthodontist", at least not as a recognized specialty. The only criteria to be a "functional orthodontist" is an orthodontist deciding to call themselves one. I would not necessarily avoid an actual orthodontist that chooses to call themselves a functional orthodontist, but I wouldn't give any weight on the designation either.

And I'd give even less weight to a general dentist that styles himself a practitioner of "functional orthodontics". Why? It's telling that the first hit in Google I get for "Functional orthodontics" consists of a practice that employs no board-certified orthodontists. But the owner of that practice misleadingly boasts about being a "Board-Diplomate" in orthodontics. ("* Honor designation not currently recognized by the ADA"; this is an actual quote from his website)... this "honor designation" is from...

The 2nd hit: The "International Association for Orthodontics", which is a professional organization explicitly geared towards general dentists instead of actual orthodontists (this is mentioned right on their website.)

The next practitioner in the results list claims to practice "Neuromuscular Orthodontics" (again, not an actual orthodontist... I'm seeing a theme here.) He somehow acquired "four years of extensive post-graduate training" from the "Las Vegas Institute" (which he teaches at.) Which is odd, because the website for said institute only lists a series of Continuing Education courses, none lasting more than three days. The website is quite hilarious: the syllabi for each of their courses promises mastery of a large number of topics, and somehow all of this knowledge is imparted in only 22 hours! Continuing education is valuable for every medical professional, but I'm not sure a series of 3-day courses in Vegas magically enables a dentist to competently expand their practice into a field normally requiring years of additional supervised study and clinic work under actual professors at an actual dental school.

While certainly some orthodontists are better than others (as in any profession), all board-certified orthodontists are trained to consider function. (Indeed, I doubt a board would even accept as "model cases" during the certification process patients that involved nothing more than simple alignment that any dentist could pull off by sending some models off to Invisilign; they are going to demand cases with something other than basic aesthetic issues.) The whole purpose of the P-A and lateral cephalograms (or the CT or cone-beam X-Ray) that are part of a full set of orthodontic records is to take all the appropriate measurements to examine how the upper and lower skeletal structures line up. And most orthodontists also use a wax bite to get the upper and lower models to be aligned as they are in the mouth. If aesthetics were the only, or primary, consideration, nothing more than photos, models, and a panorex would be necessary. (The panorex is to make sure the roots and bone can support treatment; it's faster and cheaper than a set of bitewings.)

The use of an appliance to correct tongue-thrust is also not unique to a particular sort of orthodontist; it's a pretty regular and accepted treatment. (It can be used along with, or as a substitute for, therapy, as appropriate for a particular case.) It's well known that a tongue-thrust can mess up growth, and if not corrected, make orthodontic treatment futile.

If you read the websites of a practice featuring "functional orthodontics", they read as if things like palatal expanders, reverese-pull headgear, and jaw-training appliances are some sort of innovation that you'll only get from a select few practices, and that so-called "conventional orthodontists" will never use anything but extractions, headgear, and brackets. Nothing could be further from the truth; all sorts of appliances are used by all sorts of orthodontists, no matter what name they choose to attach to their practice. I was treated with a palatal expander nearly 30 years ago by an orthodontist at a practice with the exciting name of "Fairfax Dental Associates" and making no mention of any unique treatment; expanders certainly aren't new nor uncommon.

Certainly the OP should, when the time comes, consult with multiple orthodontists, and maybe one of them will have a viable non-extraction plan. But during this process, she should be careful to NOT mention non-extraction as a goal. (This doesn't even need mentioning to the ortho because non-extraction is usually a goal for everybody, the ortho included. They don't get paid extra for extracting teeth, and gaps take a while to fill.) That runs the risk of the doctor simply telling her what she wants to hear, instead of something most likely to work.

Well stated, sirwired.

First, you should probably find out WHY your daughter has sleep apnea. Maybe its enlarged tonsils and adenoids, maybe it's a deviated septum. If you address the breathing problems it will help with the dental treatment.

She is very young and there is still plenty of time to have things corrected (starting at age 7) to get the bite right without having to remove any teeth.