Orthodontic Treatment for Children

Author: Assoc. Prof. Dr. Halise Aydemir, Orthodontic Specialist.

Orthodontic treatment in children does not always mean having braces at an early age. Early assessment aims to monitor jaw development, the direction of tooth eruption, the bite and habits in a timely manner. While only follow-up is sufficient in some children, in other cases, limited intervention at the appropriate time can help reduce the progression of a more extensive problem.

When should the first orthodontic check be done?

The American Association of Orthodontists recommends that the first orthodontic evaluation be performed no later than age seven. At this age, primary and permanent teeth may coexist; examination helps to detect developing bite and tooth eruption problems. The first check-up does not mean braces will be fitted that day: options may include monitoring, timely limited intervention or comprehensive treatment later.

If crossbite, jaw shifting to the side when closing, protruding front teeth, early primary tooth loss, or tooth eruption from unexpected places are noticed, do not wait until the age of seven. If your child snores persistently or sleeps with their mouth open, mention this during the examination; for breathing symptoms, a pediatrician or ear, nose and throat evaluation may be required.

How can the family prepare for the first examination?

Note the child's history of teething and primary tooth loss, previous dental treatments, and any changes that concern the family. Observations such as unilateral chewing, front teeth standing forward, lower jaw appearing forward, sleeping with mouth open or thumb sucking may be useful during the consultation. The orthodontist explains which of these may be related to teeth and which may be related to jaw development. A photo taken at home may give an idea; it does not replace an examination for diagnosis.

The examination assesses tooth eruption, the bite and the relationship between the jaws; imaging is selected according to clinical need. The American Association of Orthodontists describes three possible outcomes: no treatment is expected, future treatment may be needed and development is monitored, or a problem is suitable for early intervention. A finding that no treatment is currently needed is not a missed opportunity. Ask what development should be monitored and when another assessment would be appropriate.

What findings are examined in early evaluation?

• The position of the lower and upper jaw relative to each other
• Unilateral or bilateral crossbite
• Protruding upper front teeth and the risk of injury
• Whether there is enough space for the permanent teeth to erupt
• Habits such as thumb sucking, long-term pacifier use, tongue thrusting and mouth breathing

Does every child need early treatment?

No. Early orthodontic evaluation and early treatment are not the same decision. If there is no time-sensitive problem during the examination, tooth eruption and growth can be monitored. Instead of using a device without a target, it should be determined what is being monitored and which changes would prompt reassessment.

The child's dentition makes this decision easier to understand:

Period	Main assessment focus	What cannot be inferred from this alone
Primary dentition	Health of primary teeth, early loss, habits and bite	Orthodontic evaluation is not unnecessary just because there are primary teeth.
Mixed dentition	Space and tooth eruption direction in the period when milk and permanent teeth are present together	The irregular appearance of the newly erupted tooth does not immediately require comprehensive braces treatment.
Permanent dentition	More comprehensive tooth alignment and bite goals	The fact that all permanent teeth erupt does not indicate that growth is at the same stage in everyone.

The boundaries of these periods are not determined by age alone; tooth eruption and growth vary from person to person. In some children, findings such as sideways shifting of the jaw when closing, crossbite or tooth eruption path of a particular tooth may make earlier intervention worth considering. For another child, the priority may be to preserve healthy teeth and monitor development.

Hypothetical example: Two children may both have newly erupted front teeth that look crooked. Monitoring as the teeth continue to erupt may be appropriate for one child; the other may have a crossbite with a sideways jaw shift that calls for a different discussion about timing. Visible crowding alone does not show which situation applies.

AAPD's guide to the developing dentition addresses diagnosis and timing along with dentition development. When early intervention is recommended, there should be a clear answer to: “Which problem needs to be addressed now?” Even when intervention is not recommended, the purpose of the check-up and the findings to be monitored should be stated. Monitoring does not mean waiting without a plan; it is a way of reassessing according to the developmental stage.

How do monitoring, early intervention and comprehensive treatment differ?

Different stages of the orthodontic plan in children serve different goals. Monitoring follows the direction of growth and eruption; limited early intervention addresses a specific problem; comprehensive treatment covers a wider range of tooth alignment and bite targets. Performing one step does not mean that the other is absolutely necessary or unnecessary.

Approach	Example goal	What is assessed afterwards
Monitoring	To follow tooth eruption and available space of permanent teeth	Does the direction of tooth eruption, loss of space or bite change?
Limited early intervention	Addressing specific crossbite or space issue	Has the initial goal been met, how is progress continuing?
Growth modification treatment	Aiming to direct the jaw relationship in the appropriate patient	Growth response, use and dental changes
Comprehensive orthodontics	Aligning the dental arches and correcting the bite more comprehensively	Final positions and preservation of the result

Hypothetical example: In a child who undergoes early maxillary expansion, the goal may be to correct a specific crossbite. Recommending a second stage to align the teeth later when the permanent teeth erupt does not necessarily mean that the first goal has failed. If the family knows the scope of the first stage in advance, they can evaluate this distinction more easily.

Before treatment, the starting finding and intended change should be recorded. A specific goal, such as correcting a particular bite relationship or addressing an eruption problem, is more useful than asking for the jaw to be “fixed”. Reviews assess that goal rather than simply counting the months of appliance use.

Review appointments assess appliance use and hygiene as well as the bite. Tell the team if your child struggles to wear the appliance. The plan needs to be workable in daily life, and progress should be assessed alongside any difficulties with use. Repeating the instruction to wear an appliance does not, by itself, identify the problem.

The BOS functional appliance leaflet explains that further fixed-appliance treatment may be needed. Ask about the purpose and limits of each stage and how the result will be reviewed. Retention after treatment should also be discussed as part of the overall plan.

What goals do the approaches used with children serve?

In pediatric orthodontics, the name of the device should be explained along with the purpose of the treatment. A space maintainer, an expander and a functional appliance do not solve the same problem. Being fixed or removable does not make an appliance better for every child. The choice depends on the stage of dental development, bite findings, oral health and the child’s ability to use it.

Approach	Main purpose	Important limitation
Space maintainer	Suitable for preserving available space in case of early primary tooth loss	It does not recover space that has already been lost.
Expansion appliance	Addressing a relevant transverse deficiency or crossbite	Not all crowding requires skeletal expansion.
Functional appliance	Guiding the jaw and teeth relationship during the selected growth period	Growth response and use vary by individual.
Habit-oriented approach	Assessing and managing habits that may affect the bite	Not every open-mouth posture is simply a habit.
Limited fixed-appliance or comprehensive treatment	Achieving the planned tooth movements and bite goals	Maintenance, review and, if necessary, retention are required for results.

A space maintainer is not automatically needed after every early loss of a primary tooth. The decision considers which tooth was lost, the time since its loss, the space available and development of the permanent successor. Oral health, hygiene and the child’s ability to manage the appliance also matter.

If there is mouth breathing, it is important to first investigate the cause. Just because a device targets the jaw relationship does not mean that it alone treats nasal congestion or sleep-related breathing problems. This distinction is explained in the mouth breathing guide.

The family's job is not to choose or make adjustments to devices at home. Helping the child get used to the given usage pattern, supporting cleanliness, encouraging reports of damage or pain, and attending check-ups facilitate the implementation of the plan. When the child cannot wear the device, rather than blaming the child, it is necessary to find out where the difficulty lies: discomfort, difficulty removing it, school routine or forgetfulness may require different solutions.

AAPD guide also emphasises monitoring hygiene, tooth eruption and appliance integrity in space maintainers. Being a fixed device does not eliminate the need for review. Contact the team if an appliance loosens or breaks; do not try to repair it at home.

Before proceeding, the family should know the answer to: “Which change will show that this stage is complete?” This helps you assess progress against your child’s own starting records and goals, rather than another child’s experience.

Which symptoms should be checked early?

Arrange an assessment promptly for a unilateral crossbite, a jaw shift on closing, injury to a front tooth after a fall or impact, a permanent tooth erupting in an unexpected position, or early loss of a primary tooth. If there is pain or swelling, a relevant dentist evaluation is required first. Suspicion of persistent snoring, mouth breathing or sleep apnea may also require an orthodontic examination as well as a pediatrician or ear, nose and throat evaluation.

The presence of one of these symptoms does not necessarily mean that the child will need braces. But since the timing of the problem may change the treatment option, it is useful to see a specialist. Read about the relationship between mouth breathing and jaw development in the separate article and sleep symptoms in the snoring guide.

What can families pay attention to at home?

Support toothbrushing and daily oral care; orthodontic reviews do not replace regular dental check-ups. Briefly note an unexpectedly early primary tooth loss, changes in eruption, chewing preferences, sleeping with the mouth open or persistent habits. Explaining how long you have noticed a change is more useful than trying to diagnose it at home.

If your child uses an appliance, help them follow the prescribed wear and cleaning plan. Report new pain, damage or difficulty using it to the team. The aim is to support a workable daily routine, rather than constantly look for faults.

What questions should the family ask if treatment is recommended?

Ask for a specific goal: is the plan intended to make room for a tooth, correct a crossbite or monitor growth? Ask whether the proposed device will be fixed or removable, the child's daily use and cleaning responsibilities, and why checks are necessary. It should also be explained at the beginning how to proceed if the goal cannot be achieved or device use is disrupted.

Monitoring is also a plan: ask how development determines the next review and which changes should prompt earlier contact. At the end of treatment, also ask whether retention is required to maintain the new position of the teeth. This way, the family is not stuck in a false dilemma between "immediate treatment" and "doing nothing".

Frequently asked questions

Can you go to an orthodontist when you have primary teeth?

Yes. Assessment during primary and mixed dentition provides information about tooth eruption and jaw development.

When should thumb sucking be evaluated?

If the habit persists or is thought to affect the bite, the opinion of a pediatric dentist and orthodontist may be sought.

Should a crossbite be left to wait?

Early evaluation is helpful when crossbite is recognized; the appropriate approach is determined during the examination.

Note: This content is for general information. Clinical examination is required for planning specific to your child. For more detailed information, see the preventive orthodontic treatment page.

Source

The American Association of Orthodontists: First orthodontic check-up in children

Related reading

• Mouth breathing and jaw development
• Preventive orthodontic treatment