Q&A with orthodontist Dr Anton Bass
Q. My daughter (age five) has an extended frenulum, with a very large gap between her two top baby teeth. Our dentist says it will need correcting, and she will then need orthodontic work when her adult teeth are in. There’s no timescale yet for this. If the frenulum is corrected early, is there any chance she could avoid orthodontic work, or is it inevitable?
A. Anton Bass: I would strongly advise against carrying out any correction to the frenum before orthodontic treatment. Removing it will cause scar tissue between the teeth, which will certainly not encourage the gap to close spontaneously, and may even stop braces from closing the gap.
The frenum quite often disappears when the space is closed with braces. If it remains, this is the time to remove it, the scar tissue at this point will, in fact, help to keep the teeth together.
Q. I have a query about children with special needs. My daughter is nearly six and has not yet lost any teeth. Our NHS dentist has given her a clean bill of health, from what he could see as it can be tricky looking in her mouth and, indeed, teeth cleaning at times. She has microcephaly and I know that a lot of children can have dental issues as they get older and their adult teeth develop. Is there such a thing as a specialist orthodontist who deals with such children and how would I go about finding one?
A. Anton Bass: It doesn’t sound like your daughter needs any orthodontic care at the moment, it is quite normal that she hasn’t lost any teeth yet, six is only the average age for milk teeth to start shedding.
If and when she does need an orthodontist, I would advise taking her to Great Ormond Street Hospital, there is a very good specialist orthodontic team there. Alternatively, you could try a local hospital with an orthodontic team.
Q. My daughter has an overbite but not a severe one. My biggest concern with her is overcrowding and weak teeth. She has always been a slow teether, and it’s the same way now they’re falling out. She’s lost two so far, and it’s taking months and some don’t seem to be coming out at all.
Is this something that should be dealt with now (she’s nearly seven), or is it simply a case of waiting to see how bad the situation gets and her having braces as a teen?
“The longer adult teeth remain in a crooked position, the more bone matures with the teeth in that position. This makes the future orthodontic treatment more difficult and relapse more likely.”
A. Anton Bass: It sounds like a visit to the orthodontist is in order. I like to assess and treat crowding early, the longer the adult teeth remain in a crooked position, the more the surrounding bone matures with the teeth in that position. This makes the future orthodontic treatment more difficult and relapse more likely. Often the adult teeth correct naturally if given enough space by having some of the baby teeth removed at this stage.
Q. My youngest is two and he has a huge overbite. He’s already had minor surgery for tongue tie and is non-verbal, and his upper lip is tied too. The overbite and badly formed jaw have been mentioned a lot, and one consultant mentioned future surgery. What sort of surgery are they talking about? What age can we start dealing with this issue, can anything be done while he’s a child or do we have to wait for his full set of adult teeth to come through?
A. Anton Bass: One of the special interests of my practice is the development of the jaws. From what you describe, it sounds like the surgery discussed is to bring the lower jaw forward. I don’t know the severity of your son’s case, but it does seem a little early to be discussing surgery.
I would be planning to use an orthopaedic appliance, which can enhance and modify the growth of the jaws. He is still very young for this, but I would advise that you take him for an orthodontic assessment at around age six when the first of his adult teeth start coming in.
Q. At what point in a child’s dental development is it possible to diagnose overcrowding? My son is seven, and his adult teeth are well on their way. I keep a close eye on them as I had a dreadfully over-crowded mouth as a child. At what point will I know there is a problem and is it possible to take any pre-emptive action?
A. Anton Bass: Now would be the best time to take your son to an orthodontist, as there is plenty of pre-emptive action which can be done about crowding if diagnosed early, from managing spaces to enhancing the growth of his jaws to allow all the adult teeth to fit.
Q. Can bad orthondontic work be corrected?
My son had two healthy teeth removed from the top and a fixed brace on both the top and bottom teeth for 10 months which straightened a slight protrusion on front top teeth, when he was 12. This has resulted in a receding bottom jaw and the appearance of a double chin. I am distressed by this, can it be corrected. He is 18 now .
We weren’t told there was any alternative treatments at the time but have since read that there are better treatments.
A. Anton Bass: Every orthodontist has a different approach and one of my sub-specialties is the development of the lower jaw. This sounds like your son always had a receding lower jaw and the upper teeth were brought back to meet the lower ones.
Had I seen your son at the right age, usually around nine years old, I would have used a removable orthopaedic appliance to encourage the growth of his lower jaw. The only option for correcting this now would be a surgical procedure to bring his lower jaw forward, as well as orthodontic treatment to get the teeth to fit together when the jaw positions have changed.
Q. My daughter is six and some of her upper teeth (her upper 1s) have grown in at a 90-degree angle to one another and one of her lower teeth (her LL2) is unerupted due to overcrowding. She has seen an orthodontist who is unwilling to do anything until she is at least 12. Is this correct? I just think it is a long time to wait as her upper 1’s are limiting what she can eat.
A. Anton Bass: This sounds like a case for early intervention to me, during this early mixed dentition stage, when the adult teeth start to grow in, and some of the baby teeth remain, crowding can often be recognised and treated.
The problem with leaving crowding problems till later is that treatment is likely to be more complex, sometimes requiring extraction of adult teeth and impacted teeth may develop ectopically, all of which could be avoided if treated early.
Treatment can vary from simply having certain baby teeth removed to allow the adult teeth to come in and unravel on their own, to a short course of removable or fixed braces to straighten them.
Q. My son has just turned seven and has permanent front teeth which have a noticeable gap between them. Dentist has told me that he’ll probably need a frenectomy followed by braces when he’s a bit older, otherwise he’ll end up looking like David Mellor. When would be the best time to do this?
A. Anton Bass: Frenectomies (removal of frenums) were very popular a number of years ago, but are now rarely carried out. Firstly, by creating hard scar tissue between the two teeth, it can be more difficult to push them together with braces and give an unstable result. Secondly, when the teeth are pushed together, the frenum very often disappears naturally. Only if the frenum persists after the gap is gone would a frenectomy be considered.