“How much do braces cost?”, and “What does Invisalign cost?”, are questions that I am often asked at parties, my kid’s sporting events, and of course during new patient consultations. Here are a number of factors that go into deciding how much braces or Invisalign cost, along with a number of tips that you may find very helpful in budgeting and planning for braces for yourself or your family.

• Every orthodontist is different, but I give estimates based on the complexity and difficulty of a case. This is why it we do not give quotes over the phone before a consultation and full exam. One child may need several months of treatment, while another may require over two years of treatment in braces.
• Adult treatment in our practice is generally not more expensive than treatment for teens or children. Again, it is case by case, and many adult treatments are surprisingly short and relatively inexpensive.
• Whether you have insurance or not, we offer in house, interest free financing that can spread the fee for braces or Invisalign into monthly payments over the course of your treatment. Most families are pleasantly surprised at how affordable braces are.
• If your family has orthodontic insurance, the insurance contribution will be determined by your specific plan. The good news is that if your orthodontist participates with your insurance provider, your fee will be substantially reduced. It is important to ask your orthodontist if they participate (if they are a provider) with your insurance. We all accept insurances, but if we are a provider for your plan, we are contracted to charge a fee that is often lower than our standard fees. Then you get the insurance contribution on top of the reduced fee. If we do not participate with your plan, we set the fee independent of the insurance company’s influence, but there is often a contribution that the insurance company will pay (although this contribution may be less than if you are seeing a participating provider). Insurance and benefits can be very confusing-please feel free to call our office manager, Julie, to answer any questions that you may have!
• Take full advantage of Health Savings Accounts  (HSA’s) or Flex Spending programs. In addition to Insurance benefits, utilizing these plans can save an additional 20-30%! Timing is often important in setting aside funds for these programs, and we will work with you to make sure you take full advantage of this often overlooked area for savings.
• Whenever possible, Dr. Dan prefers to treat in one comprehensive phase of braces. If your child needs early treatment, and will need two phases of braces, we will set out a financial game plan for the entirety of treatment immediately (for everything)- we don’t like our families dealing with surprises.
• Invisalign has advantages and disadvantages compared to braces. In general it tends cost more than braces, but each case is different, and we try to keep prices comparable.
• Please do not feel shy about discussing any financial concerns with us. We are a private, locally owned practice, and we really want to make the experience of getting a new smile enjoyable and stress-free. Dr. Dan and Julie will make you feel comfortable, and will answer any questions you have!

Dr. Dan Rejman is a Board Certified Orthodontic Specialist and Castle Rock, CO. local. He has the best office manager in the world (his wife, Julie!), who will answer any of your financial questions regarding braces, clear braces, or Invisalign.

Just this week I saw several patients for an initial consult, and because of their age and facial structure, each had an entirely different chance of achieving an ideal outcome with braces or Invisalign (a healthy, functioning bite with optimal aesthetic results). One woman was in her 50’s, and she was wondering if she was too old to have her crowded teeth aligned. Because she had a balanced skeletal structure, I informed her that her crowded teeth could be treated to very ideal and beautiful outcome, and her age would have little influence on this outcome.  Later that day, I was visited by a 20 year old young man who also desired to have his teeth aligned with braces. His lower jaw had grown disproportionately less compared to his upper jaw, resulting in an excess “overbite” (as orthodontists we call it “overjet”). Due to his skeletal structure, combined with the fact that at his age his jaw growth was relatively complete and in a stable position, I had to explain to him that the ideal age to treat his condition has passed. Yes, I could greatly improve his bite and appearance, but because of his age and jaw structure, the finished result would have to be a compromise if treated with orthodontics alone (he would require surgery to re-position his upper and lower jaws into an ideal position). The mother of this patient stated that she heard that he could have his teeth corrected after they had all come in, and unfortunately this led to him not having an exam at a younger age.

The two cases above illustrate the misinformation that patients sometimes hear and believe, whether that information comes from the web, family, friends, or just long held beliefs about teeth that still exist. It also demonstrates that older adults can often be treated to ideal, while if younger patients miss a window of opportunity with their growth (especially through adolescence), the chance of treating to an ideal result is greatly diminished.

The American Association of Orthodontics recommends that children have an orthodontic exam no later than age 7. Although I feel that the majority of children I see at this age do not need early treatment with braces, many issues that parents need to be aware can be seen by an orthodontist at this age. The most common examples include:

1) Excess crowding (only severe cases need early treatment). Most often mild to moderate crowding can be treated at a later age when all the teeth have erupted. As the first example above demonstrates, this can often be corrected ideally from adolescence through adulthood. As mentioned, severe cases do need early intervention.

2) A lower jaw that is not growing enough, or a upper jaw that is growing too much (what is referred to by the public as an “overbite”)  We usually like to wait until the adolescent growth spurt to treat this growth pattern, but if a patient waits too long (like the 20 year old above), the bite often cannot be treated ideally.

3) A lower jaw that is growing too much, or upper not enough (known as an “underbite”). It is extremely important to identify this pattern early, and treatment for this pattern often begins at a very young age. Very severe cases are often not treated at all until a patient is ready for a combination orthodontic/surgical correction. The important thing for these cases is early identification, and to try to avoid the need for surgery if possible.

4) An upper jaw that is too narrow. A narrow maxilla is often the cause of crossbites, and if it causes the lower jaw to shift to one side or contibutes to abnormal eruption of teeth, we will often treat this condition early. Expansion of the upper jaw can accomplished before the the two sides of the maxilla fuse together. This fusion usually occurs earlier for girls (early to mid teens) than in boys (mid teens).

The take home message here is the importance of early identification of issues that may exist, and informing parents of the ideal age to address these issues. Even though the majority of children do not need early treatment, some do and the window for achieving a correction is relatively small. For the others, it is important for parents to know the “game plan” for the future treatment of a child’s individual facial skeletal structure. Just as important is letting parents know when treatment is largely aesthetic in nature, and if there is little concern over an “ideal” age for elective treatment.  Always feel free to contact me if you have any questions regarding your child’s teeth or facial growth!

Dr. Dan Rejman is currently the only Board Certified Orthodontist in Castle Rock or Castle Pines, Colorado. He has been a Board Certified Diplomate of the American Board of Orthodontics since 2007.

You may have noticed bright white staining on some peoples teeth after they have their braces removed. These white areas are often permanent, and as an orthodontist it is very disappointing to see after after all the work we have done to get the alignment of the teeth so ideal. It is extremely important for patients and their parents to understand how these stains form, and what can be done to prevent them.

White spots occur on teeth by a process called decalcification,  which will start on any tooth surface where plaque is allowed to sit for an extended period of time (often only several days). Dental plaque’s composition includes a large number of bacteria called Streptococcus Mutans, and Lactobacillus. When these bacteria reproduce and accumulate on the teeth, they appear as a white sticky film (like the bacteria in Petri dishes in school!). This plaque commonly forms and grows near the gum line and around braces if the bacteria are not removed. As living organisms, these bacteria feed on the sugars and carbohydrates that you place in your mouth. After feeding, these bacteria multiply and excrete acid as a waste product for up to 20 minutes. It is this acid excretion that dissolves enamel, and causes a loss of minerals in your teeth.

The white spot that forms is actually the first sign of tooth decay from the loss of minerals from your teeth. Often the outer layer of enamel is hardened from flouride, and the decalcification occurs below the surface of the tooth deeper into the enamel. This is why once damage occurs it is most often a permanent stain on the tooth. Left untreated, this stain can progress to a cavity and will need restoring (or “filling”) by a dentist.

Braces themselves do not cause staining or plaque to form, but they do present a physical barrier to brushing and increase the surface area for plaque to accumulate. This is why from your very first consult with us, we stress them importance of excellent hygiene and brushing technique. It sounds simple, but by just removing this plaque by proper brushing twice a day, these permanent white stains can totally be avoided. But as a father of two kids in braces, I know that most children are not “programmed” to think about medium to long term consequences of leaving plaque on teeth. Since myself and my staff often only see a patient every 6-7 weeks, monitoring the child’s plaque removal must involve the parents (this is probably the most important take home point in this article- I am an orthodontist and my own children need constant checking!) After teeth are perfectly clean, it only takes several days for plaque to build up, and in several weeks can start to permanently stain the teeth!

Several important things to remember:

When brushing, technique is just as important as time spent brushing! Parents often tell me that they see their kids brushing often, but at their orthodontic appointment there is heavy plaque. This is due to a pattern of brushing that consistently misses the same places over and over again. Even if some areas are spotless, the missed areas will form these permanent decalcification stains.

The most common areas that are missed when brushing teeth are near the gingival margin (where the teeth meet the gums), the sides of one or all of the braces on your teeth (which is why the white stains are often shaped in a halo- the braces have protected the enamel under the braces while the plaque surrounding the braces leaves a distinctive mark), and the upper lateral and canine on the side of a child’s dominant brushing hand.- this is usually where they “flip” the tooth brush. These are all points that we cover in depth after the braces are placed, when we review brushing and flossing. Please ask any of us at Meadows Orthodontics if you have any questions!

Once stains are present, they usually cannot be removed. There are several products on the market that claim to reduce white spot lesions, but the research on them have been largely non-conclusive to date. Prevention remains the best option! Other than plaque removal, reducing the amount of processed sugar ingested greatly reduces the chance of staining, as this removes plaque’s food source. The biggest offenders are sugar drinks, including soda, sports drinks, and even sipping on too much fruit juice. Fluoride rises (such as ACT) for at risk patients can often help. We also have a fluoride releasing protective sealant that can be applied for higher risk patients.

Remember, every patient is unique, and each child needs their own level of attention and motivation to ensure their teeth are protected as much as possible while they are wearing braces.

Dr. Dan Rejman is a Board Certified Diplomate of the ABO, and practices at Meadows Orthodontics in Castle Rock, CO.

Thankfully, there are very few medical emergencies that are associated with wearing braces. There are a number of issues of concern that can arise while you are in braces though, and I will discuss the most common “emergencies” and what to do should they occur.

A bracket (or “brace”) has come loose  A bracket that has released from a tooth is the most common concern we see. Brackets are the square metal or ceramic part of braces that are bonded to your teeth with adhesive. This adhesive is designed to release from the tooth if excess force is placed on the braces. This breakage can occur due to a large amount of light “taps” on the braces from chewing (even from foods that might not normally be suspected), or one or two sudden heavy collisions with crunchy, chewy, or tough foods. Patients most often report that they were not eating any chewy or crunchy foods when the braces came off, and we explain that it often takes a day or two before the brace moves and is noticeable. Weakening of the adhesive can accumulate over a period of time before the braces finally releases from an otherwise harmless bite into food (similar to the last “chop” that cuts a tree down). We also explain that the breakage is not necessarily a bad thing, as a stronger adhesive would rip enamel off the tooth with the braces- the release is actually a protective mechanism.

We understand that life happens, and will gladly repair the loose bracket. If we see a pattern of multiple braces coming loose, we will work together with the patient to identify eating habits that are contributing to the breakage. If the bracket is loose, but still attached to the wire, simply use your fingers, a q-tip, or a tooth pick to slide or rotate the brace until it is in a comfortable position. Call our office, and we will help you find the best time to re-attach the bracket.

A wire is poking your cheek.  Occasionally a wire may deform, or move out of place and start to irritate a patients cheeks or lips. First, try using a q-tip (or the end of the plastic mirror handle that was included in your hygiene kit) to push the wire against your teeth or to a more comfortable location away from the cheek. A nail clipper can also trim many poking wires. If this does not work, use a small pea- sized piece of relief wax from your kit, and place it over the irritating piece of wire. If the irritation persists, call our office, and we will likely have to clip or re-position the wire.

 A wire has broke, or a band is loose.  If an arch wire has broke into two pieces, try to remove the broken part if it is loose. A light wire can often easily be pulled out of the mouth with just a light pull. If this cannot be done, try to keep the pieces in a comfortable part of the mouth, and call our office for a repair as soon as possible. If a band around a back tooth, or an expander has come loose, try lightly pushing it back onto the teeth, and call our office as soon as possible.

A colored or clear tie has come off a bracket.  We call the small rubber rings on your braces ligatures, and occasionally one may come off. If everything else appears in place and you have an appointment soon, we will be able to place a new one at your upcoming appointment. If it will be more than a few weeks until your next appointment, call us and we will replace the tie.

Canker sores.  Canker sores, or aphthous ulcers, can be very painful. They are usually not caused by braces, but the braces can irritate them and exacerbate the discomfort. These sores last about two weeks, and there is no known way to make them go away sooner. The best option is to keep the area as comfortable as possible. Try using over the counter topical anesthetic such as Orabase or Ora-gel, and apply as needed with a q-tip.

General tooth and gum pain soon after braces are placed. Discomfort is to be expected the first 4-5 days after braces have been placed. I tell patients to hang in there, they are not alone- this is very common the first week of wearing new braces. For sore teeth, eat a softer diet (mac and cheese, pasta, soup, smoothies…) until things start to feel better. Take Ibuprofen if and as directed by your orthodontist to help with the discomfort. If your lips and cheeks are sore from rubbing on the braces, roll up a small pea sized ball of comfort wax, and press it onto the braces near the area of discomfort.

Dr. Dan Rejman is the owner of Meadows Orthodontics in Castle Rock, Colorado. He is a board certified orthodontic specialist, and provides treatment with clear braces, traditional braces, and Invisalign.

Julie and I just returned from four days at the national American Association of Orthodontists (AAO) convention in San Francisco. I wanted to write a quick blog about the latest and greatest that is going on in the world of Orthodontics, Braces, and Invisalign treatment.

I spent the first day teaching the preparatory course for the American Board of Orthodontics (ABO). I taught both the morning and afternoon preparatory classes to about 25 orthodontists and orthodontic residents who are preparing for their Board exams. What a great group of people. It was an honor to meet and help colleagues who are working so hard to prepare for this exam, many of whom came from around the world (Pakistan was the farthest distance a class member traveled from, while several where from right here in the Denver Metro area). As always, I also learned alot preparing to teach the course.

The American Board of Orthodontics just launched their new web site which is very user friendly, and does a great job explaining to the public and dental professionals the merits of becoming Board Certified (only one in three orthodontists are board certified). You can visit the site at www.americanboardortho.com, and use the orthodontist locator to use your zip code to find nearby Board Certified Orthodontists. The ABO is also addressing the issue of an accepted standard of care for our profession.

I attended a number of continuing education classes, including lectures that reviewed the latest research on early correction of Class II bites (or what the public calls “overbites”, upper teeth that are relatively too far forward compared to the lowers). The research continues to support the rationale for waiting to treat this condition in one phase only, or when most of the permanent teeth have erupted.

On a technological front, the most interesting development is how far optical imaging and impression systems are  coming. At Meadows Orthodontics, we have been using Itero digital impressions to eliminate the goopy impressions that were needed for braces and Invisalign, but they released their newest model at the conference that takes a large leap forward in patient comfort and time needed to capture an image of the patient’s teeth. 3-D printing also continues to proceed forward with many applications in orthodontics that result in higher efficiency and patient comfort.

Julie and I did have time for some fun also. I am a foodie, and there is no better place than San Francisco for eating! We had a great meal in Chinatown (we wished our daughter Nina was with us!), and headed up to Napa and Sonoma for a day and a half. This was my first time in wine country, and it is one of the most beautiful areas I have seen. They really take the quality of food there to another level. As a former farmer, I found it really neat that the area is so rural and agri-based, but so celebrated and world-renowned.

Overall a great educational, fun and filling trip!

Dr. Dan Rejman is orthodontist and owner of Meadows Orthodontics in Castle Rock, Colorado. He was recently named Best-of-the Best, Best Orthodontist in Castle Rock (2014 and 2015), and named a 5280 Top Orthodontist for the 4th year in a row (2012-2015).

All of us at Meadows Orthodontics would like to say happy Mother’s Day to our patient’s moms, and to say thank you for your help in making the task of aligning your children’s teeth possible. Mothers of Castle Rock (and beyond)- here is a partial list of the things you do as a mom that we appreciate at Meadows Orthodontics:

1. You take time out of your busy day to deliver your children to their braces appointments.
2. You often take responsibility to keep your children’s teeth clean, whether reminding them to brush (over and over… and over again!), or taking the time to do it yourself when needed.
3. You listen to Dr. Dan’s bad jokes and usually act amused!
4. (Kids take notice) – Mothers most likely put off getting something that they wanted (A home improvement, a Marc Jacobs purse…) in order to invest in their children’s teeth.
5. By investing in their children’s smiles they are giving them an amazing gift of health and self-confidence (that kids often don’t appreciate until later!)
6. Mothers are Dr. Dan’s “eyes and ears”, monitoring if patients are wearing their elastics and retainers at home and in between appointments.
7. While they wait for their children’s adjustments, they often juggle squirmy siblings that are in tow.
8. If there is a broken bracket, poking wire, or your child was whacked in the mouth at a sporting event, you bring them in to be fixed up.
9. And finally, they maintain a great attitude with all of this while fitting the experience of braces into their very busy lives.

I am very aware of all that you do, and as you child’s orthodontist I sincerely thank you.

Dr. Dan Rejman

P.S. I would like to thank my mother for all the support and love  she has given to me for years, in addition to passing on to me her beautiful teeth!

After writing so many “serious” articles in a row, it is time to lighten things up a bit. Let’s talk about the color choices for your braces! Once your braces are placed, kids and adults are usually very extremely excited to make their first color selection. After all, it is an extremely important decision- this is what the world is going to first notice when they see you in braces! Colors can also be switched at every appointment with us, so if you are ready for a change, it won’t be long before you create a new look. Dr. Dan is a kid at heart, and he usually get just as excited about patients’ color selections as they do.

The colored part of braces are actually called elastomeric ligatures, and these “ties” are what attaches the removable wire to the metal or clear ceramic brackets that are bonded to your teeth. At Meadows Orthodontics we have over 30 different colors to choose from. From the basic ROYGBIV, black and white, to everything in between, there are literally thousands of color combinations that you can create. We even offer neon colors, and ties that glow in the dark!

Here are some fun and interesting ideas and observations about this all important decision. The colors that we order the most due to their popularity include hot pink, black, lime green and navy blue. Popular color combinations are very dependent on the season. In the fall, Broncos blue, orange and white is very popular. Others seasonal combinations include black and orange at Halloween, green and red for Christmas in December, a mix of greens for St Patrick’s Day in March, and Red White and Blue for the 4th of July.

Clear ties are the most popular for patients who have clear ceramic braces, although they also look great and unique with colors on them also. If you want a bolder look we can use many bright colors to create a “rainbow” appearance, or choose all five neon colors for what we call “Neon Deon”. If you want to earn some brownie points with Dr. Dan, choose maize (yellow) and blue for my team, the Michigan Wolverines, and yell GO BLUE! All year long kids wear the colors for their school or club sports teams, in addition to their favorite college and professional sports teams. CV, DC, Dolphins, Warriors, CRMS, Aspen View, American Academy, Air Force, CU, CSU, Nebraska, Oregon, the Avs., Rockies and Nuggets colors are all choices that we send kids happily away with. Dr Dan and his staff love to help getting your selection just right. The only exception? Absolutely no Scarlet (red) and gray allowed!

Dr. Dan’s favorite? Simple sky/baby blue looks great on metal or clear ceramic braces. Whatever your tastes are with color, let your imagination run wild and have some fun with your time in braces!

Dr Dan Rejman is the owner of Meadows Orthodontics in Castle Rock, CO. A resident of Castle Rock, he loves art, design, and making things (especially teeth) look amazing! He has been selected by his peers a 5280 Top Orthodontist in 2012, 2013, 2014 and 2015.

One of the most common things that I hear from my adult patients who come in for an exam is, “I had braces as a teen and my teeth were straight. But then my wisdom teeth came in and caused my front teeth to become crowded.” This belief that wisdom teeth “push” the others forward has existed with patients as long as I have been involved with dentistry, and many patients are encouraged by their dental professionals to have their wisdom teeth (third molars) extracted to prevent future crowding. Is there any validity to this theory?

In short, current research does not support the belief that wisdom teeth cause crowding of the teeth in front of them, or “push” on them enough to cause movement. The vast majority of peer reviewed research shows that even if people have their wisdom teeth removed, teeth (especially the lower anteriors or front teeth) continue to crowd as we age. This is the case whether a person has had braces or not. Research has shown that teeth tend to drift forward throughout life, even in the absence of posterior teeth or molars.

If the wisdom teeth are not major contributors to increased dental crowding as we age, where does it come from? Current theories include late mandibular growth, or continued forward growth of the lower jaw as we grow older, and changing pressures from the tongue, lips and cheeks. Also commonly overlooked is the age that people stop wearing their retainers. Many adults remember being told by their orthodontist to wear their retainers for only several years after they had their braces removed.  By the late teen years a large percentage of orthodontic patients are no longer in retention, and this is the age that the wisdom teeth first start to erupt, or become impacted (stuck below the gums). We have learned that without retention, teeth that were previously crowded will start to revert back towards their previous position (see an earlier blog about why teeth do this). Often wisdom tooth issues that arise at this age are mistakenly blamed, or correlated with the crowding that occurs during these years after retention is stopped.

The take home message, and current standard of care, is that wisdom teeth should not be extracted to decrease the chances of future crowding. There are a number of other reasons that may indicate the need for extracting these teeth, including the inability to properly clean these teeth, tooth decay, pericoronitis (inflammation of the gingiva around partially erupted third molars), and impacted positions that may cause damage to the surrounding jaw structures. Each person is an individual, and the decision to extract the third molars should be discussed with your dentist, orthodontist, or oral surgeon.

Dr. Dan Rejman is the owner of Meadows Orthodontics in Castle Rock, Colorado. He is a Board Certified Diplomate of the American Board of Orthodontics, and is a Councilman on the College of Diplomates of the American Board of Orthodontics, representing the Rocky Mountain and Southwest regions.

This is the second of a two part blog addressing the most current research and options for the treatment of underbites, or what orthodontists and dentists refer to as Class III relatioships. This facial type is one of the most difficult to treat in orthodontics, and the earlier it is identified and diagnosed, the higher the chance of arriving at a succesful outcome.

The first consideration is what age do we start treating anterior crossbites that are skeletal in nature (lower jaw growing too much, upper not enough, or a combination of both)? Most research continues to support treating at an early age for mild and moderate underbites, ideally prior to 8 years old. However, new research indicates that favorable changes can occur with treatment in older children, even well into the adolescent growth spurt. The positive changes appear not to be as dramatic compared to starting treatment earlier, but can still be significant.
In the early 1980’s a protocol for early treatment of underbites became the standard of care that has remained until this day (with some new modifications and options that I will discuss). Treatment usually consists of upper jaw expansion (using an “expander”), followed by facemask therapy. A facemask is a device that has rests on the patient’s forehead and chin, and elastics attach from this facemask to “arms” on the expander that place a forward directed force on the upper jaw. Studies have shown the correction comes from foreward movement of the upper jaw, usually accompanied by downward growth, which makes the lower jaw rotate downward (resulting in a chin position that is further back). This rotation of the lower jaw can also be a negative side effect, and must be monitored closely by the orthodontist.
It is imperative for parents and the child to understand that the success of treatment is dependent on the number of hours a day that the facemask is worn, and the number of months that it is worn. The highest success rates occur when it is worn all day and night, however, most orthodontists are understanding of the social issues of wearing a facemask to school. We ask that it be worn every hour that the child is not in school or sports, which usually is about 16 hours per day, including while they are sleeping. Studies have shown the greatest sucess rates occur when the facemask is worn upwars of 10-12 months, and an over correction is observed where the upper teeth are a ahead of the lower teeth by at least several millimeters.
A very important thing to keep in mind with the treatment of Class III cases is that after early treatment is stopped, the patient will continue to grow like a Class III patient until growth is complete. Since the growth of the lower jaw will continue to be more pronounced, a second phase of treatment is almost always needed, with full braces, rubber bands, and possibly more time with the facemask.
In the last several decades studies have increased our knowledge in treating underbites, and there have been several modifications to the basic protocol. First, the use of a palatal expander has been shown to be useful only if needed for other reasons such as gaining space or correcting a crossbite that exists along with the underbite. A large number of underbite patients have a hyposplastic maxilla (smaller upper jaw), so many continue to have an expander included with their treatment. Second, another viable option to the facemask has emerged that has demonstrated excellent, or even improved results. Skeletal anchorage in the form of surgically placed miniplates can now be placed, which allow the patient to wear elastics entirely within the mouth, and 24 hours a day. The downside is an increased cost due to two surgical proceedures needed to place and remove these miniplates after treatment. This option has been shown to be optimally successful between the ages of 10-12 years of age due to the need for higher bone density to hold these devices secure.
For more severe cases where a very pronounced underbite is detected early, and especially if there is a strong lower jaw component, it may be decided early on that jaw surgery will be needed to obtain a succesful result. These more severe cases cannot be corrected enough by orthodontics alone, but your orthodontist will continue to monitor facial growth, and work in conjunction with an oral surgeon to determine the optimal time to start preparing for a surgical correction. Jaw surgery to correct underbites are usually not performed until the patient’s jaws have completed growing. The best way to determine when this has occured is by taking a series of radiographs called serial lateral cephalograms, and measuring the size of the upper and lower jaws over time. Surgery performed prematurely while the jaws are still growingwill usually result in an unstable result with return of the underbite.
After treatment with full braces is completed, retainers are placed like any other case. However, I do monitor patients with Class III patterns for a longer period of time, as the underbite pattern sometimes returns to varying degrees due to small growth changes that occur throughout life. Yet another challenging aspect to this type of facial growth!
A summary of modern treatment for Class III cases (underbites):
1) Timing is important, with higher sucess rates occuring with early treatment prior to the age of eight. However, later treatment (just before or during puberty) has been shown to be more sucessful than previously believed.
2) Treatment with a facemask and elastics remain the most common forms of treatment. New advancements with surgically placed miniplates have provided another effective option.
3) Success with any treatment option is dependent on number of hours the device is activated, and how many months they are worn. Consistency is the key!
4) This facial growth pattern persists and is often accelerates during the adolescent growth spurt. This must be kept in mind regarding the length of treatment, and is the reason two phases of treatment are usually needed for this facial type.
5) Severe cases detected early usually will need a a surgical correction, usually done in the late teen/early 20’s, and no amount of orthodontic treatment alone can achieve an acceptable result. The earlier parents are informed of these cases, the earlier appropriate plans can be set in place to manage this issue.

Dr. Dan Rejman is the owner of Meadows Orthodontics in his hometown of  Castle Rock, Colorado. Dr. Dan is a Board Certified Diplomate of the American Board of Orthodontics, and is the councilman representing both the Rocky Mountain and Southwest Orthodontic Societies for the College of Diplomates of the American Board of Orthodontics.

The treatment of underbites (or anterior crossbites) in orthodontics is in a special category of its own, both in terms of jaw growth, and the challenge and difficulty in treating these cases. It is very important for patients and their parents to be educated as early as possible about the unique pattern of growth that is to be expected, and to set realistic expectations in treating this condition.

We are all familiar with the typical appearance of people with underbites (Jay Leno comes to mind for most). This appearance is often first seen at a very young age (often before the age of five), and is usually detected by parents or a dentist noticing that the child’s lower teeth are located ahead of, or even with, the upper teeth (the lower teeth should be located behind the upper teeth). ). In orthodontics we refer to this relationship of the teeth as a Class III relationship, which describes the lower teeth as being too far forward when compared to the upper teeth. The underlying cause of an underbite is most often skeletal in nature, and it is believed that genetics play a prominent role in causing the condition. Parents often recall a grandparent with an underbite, or may even have an underbite themselves. Recent research shows that about 68% of Class III patients have an upper jaw (maxilla) that is deficient, and 70% have a lower jaw (mandible) that is protrusive or growing too much. This means that many have both an upper jaw that is not growing enough, and a lower that is growing too much. The front teeth often, but not always, display a distinctive pattern in which the upper teeth are tipped excessively forward (proclined), while the lower teeth are tipped back (retroclined).

The first thing for parents to know is how this growth pattern will progress. All children undergo an adolescent growth spurt, where the body undergoes a rapid increase in the rate of growth, which includes the maxilla and mandible (upper and lower jaws). This spurt usually occurs earlier in girls (ages 9-12) than in boys (ages 10-14), with considerable individual variation. The intensity and duration of growth is on average greater in boys. After this growth spurt, most skeletal growth usually comes to an end in the mid-teens for females, and late teens to early 20’s for males.

When comparing children with Class III patterns with children with Class I (upper and lower jaws growing in harmony) patterns, research has shown that the maxilla (upper jaw) continues to grow less in Class III patients, while the mandible (lower jaw) continues to grow more in relation to the maxilla. What we have learned from the information in these last two paragraphs can be summarized as:

1) Class III patients will continue to be Class III patients as they develop.

2) The appearance of the underbite usually becomes worse with age into the teens, particularly during the growth spurt. This includes the underbite becoming larger, the lower jaw and chin appearing more protrusive, and the profile becoming more concave.

3) A relatively stable relationship occurs when growth stops, which is mid-teens for girls, and late teens to early 20’s for boys. This is why, in general, we treat girls at an earlier age than boys.

4) The earlier we detect an underbite or Class III, the earlier we can put together a plan to tackle this challenging growth pattern, as often there are considerable concerns regarding appearance, social issues, speech patterns, and proper functioning of the jaws.

In the next blog entry, I will discuss the treatment options for Class III patients, and the challenges and potential complications related to this treatment.

Dr. Dan Rejman is a Board Certified Orthodontist with a private practice in Castle Rock, Colorado. He has treated hundreds of Class III cases, ranging from relatively mild cases treated with braces, to severe surgical cases for teens and adults. He has a particular interest in underbites, as his youngest daughter has had a considerable underbite since her first baby teeth erupted!