Interceptive Orthodontic Treatment for Children: A Guide for General Practitioners

Dr Song Yi Lin, Senior Consultant, Department of Orthodontics, National Dental Centre Singapore

Interceptive orthodontic treatment (or Phase I orthodontic treatment) refers to the early identification and management of developing malocclusions during the mixed dentition phase in children typically between the ages of 7-12. While dental health is typically the domain of a dentist, certain developmental issues of the teeth and jaws may present as observable signs during a routine paediatric examination by general practitioners.

This article aims to provide a basic understanding of interceptive orthodontic treatment, the common conditions suitable for early intervention and guidance on how to refer patients for specialist (orthodontist) evaluation.

WHAT IS INTERCEPTIVE ORTHODONTIC TREATMENT?

Unlike comprehensive orthodontic treatment that typically commences only when the full permanent dentition is present, interceptive orthodontic treatment also known as Phase I or early orthodontic treatment is carried out before the full permanent dentition has erupted to improve dental and skeletal development.¹

The intention is not to align every tooth perfectly but to identify and address a developing problem to simplify future treatment in the permanent dentition.

THEORETICAL BENEFITS OF EARLY ORTHODONTIC TREATMENT2

• Simplifies future orthodontic treatment: Early intervention to create space for impacted teeth may facilitate eruption, possibly avoiding future invasive excision surgeries. 
• Improves dental health: Uprighting partially erupted impacted teeth will prevent possible food trap and facilitate better oral hygiene maintenance.
• Reduce risk of trauma to teeth: Early treatment of protruding upper incisors may decrease the risk of teeth injury due to their more prominent position.
• Psychosocial benefit: Early correction of dentofacial growth disharmonies can improve confidence levels in children, especially those who may have been teased/bullied for their appearance.
• Corrects bad oral habits that worsen malocclusions: Digit-sucking and tongue thrusting habits are known to contribute to open bites.
• Better growth response: Functional or orthopaedic appliances work better when worn during the optimal period of growth. Early identification may improve aberrant growth and development of the jaw.

Common Dental Conditions Suitable for Referral

During a routine medical paediatric check-up, it is certainly challenging to diagnose for intra-oral conditions without adequate lighting. Although an orthodontic diagnosis is not required, recognising a malocclusion or extra-oral skeletal growth disharmony may allow the initiation of the referral process and timely management by a dental specialist.

The American Association of Orthodontists (AAO) recommends that every child have an orthodontic screening at around seven years of age. This is because the first permanent molars and permanent incisors have typically erupted by then, establishing the patient’s occlusion, allowing for an initial assessment of the overjet and overbite.

‘Overjet’ is the term for the horizontal measurement of the distance from the upper incisors to the lower incisors. Ideally, from an antero-posterior view, the upper incisors should bite in front of the lower incisors for an ideal overjet of about 1-3 mm (Figure 1).

‘Overbite’ on the other hand, is the term for the amount of vertical overlap between the upper and lower incisors. From a frontal view, upper incisors should cover the lower incisors by up to about one third of its height, for an ideal overbite of about 1-3 mm (Figure 2).

During a paediatric examination, a simple screening for common dental conditions suitable for interceptive orthodontic treatment can be done by watching out for certain extra-oral or intra-oral features as shown in Tables 1 and 2.

Intra-oral features may be identified by asking the child to bite down on his/her molars in maximum intercuspation.

PREVALENCE AND RELEVANCE IN SINGAPORE

Prevalent Diagnosis

In a local study³ on interceptive orthodontic treatment done during a six-year period at the National Dental Centre of Singapore (NDCS), amongst the 1324 patient records analysed, results showed that the most prevalent diagnosis was anterior crossbite, followed by Class II skeletal growth pattern.

This is consistent with findings from other research⁴ that the most common reasons for starting early orthodontic treatment in the public healthcare system were crossbite and increased overjet.

Treatment

Correspondingly, the most common appliance used was the bite plate to correct the anterior crossbite, followed by the twin block, which is typically used to improve a Class II skeletal growth pattern.

Interceptive orthodontic treatment methods included fixed and removable orthodontic appliances or even a combination.

Some examples of fixed appliances used are: a goldplated eyelet and chain, brackets, Hyrax expander, quad-helix expander, transpalatal arch, lower lingual arch and the Halterman appliance. Examples of removable appliances used include the twin block, headgear, bionator, reverse bionator, facemask and bite plate.

Outcomes

Interceptive orthodontic treatment has an overall short-term success rate of 75.5%,³ with failure of treatment usually attributed to patient noncompliance.

The average treatment duration was 7.5 months for removable appliances and 11 months for fixed appliances.

WHEN AND HOW TO REFER

The various dental conditions suitable for interceptive orthodontic treatment illustrated above are selected for their ease of detection in a medical GP setting and are by no means exhaustive.

GPs may refer potential patients to the Orthodontic department at NDCS for further evaluation by the Orthodontist (dental specialist in braces treatment):

Tel: 6324 8802
Email: appointment@ndcs.com.sg

There are other indications for interceptive orthodontic treatment like tooth eruption problems or impactions that may be more practically detected and confirmed by a dentist with the help of a thorough intra-oral dental charting and further radiographical investigations.

When in doubt, especially when the child or parent has a presenting dental issue, a referral to any primary care dental clinic may also be made.

KEY TAKEAWAYS FOR GPs

• By recognising the key indications for interceptive orthodontics and facilitating a timely referral, you play a vital role in preventing more complex dental problems later in life.
  
  
• Children can be referred to the orthodontist at around seven years of age for an orthodontic assessment if there are any early dental conditions detected.
  
  
• Early orthodontic treatment can greatly benefit patients when correctly indicated as it may reduce the need for future orthodontic treatment or make it more straightforward when the child is older.

REFERENCES

1. Bishara SE, Justus R, Graber TM. Proceedings of the workshop discussions on early treatment. Am J Orthod Dentofacial Orthop. 1998;113(1):5-6. doi:10.1016/S0889- 5406(98)70269-0
2. Fleming PS, Andrews J. Orthodontic treatment: Getting the timing right. Semin Orthod. 2023;29(2):137-145. doi:10.1053/j.sodo.2023.03.003
3. Song YL, Tan ELY, Chua BCJ, Ng RJY, Lam NKP. Interceptive orthodontic treatment in Singapore: A descriptive study: Proc Singap Healthc. Published online May 18, 2020. doi:10.1177/2010105820922569
4. Väkiparta MK, Kerosuo HM, Nyström ME, Heikinheimo KAK. Orthodontic treatment need from eight to 12 years of age in an early treatment oriented public health care system: a prospective study. Angle Orthod. 2005;75(3):344-349. doi:10.1043/0003-3219(2005)75%5B344:OTNFET%5D2.0.CO;²

Dr Song Yi Lin is an orthodontist at the National Dental Centre Singapore (NDCS), and carries out orthodontic work on both children and adults with malocclusions or jaw growth discrepancies.

She is currently also the Associate Programme Director for the NUS Orthodontic Residency Programme, Director of Graduate Education for the Oral Health Academic Clinical Programme at NDCS and also the chairperson of the College of Clinical Dentistry with SingHealth Academy.

GP Appointment Hotline: 6324 8798