Expert: Dr. Randolph Myerson - 5/14/2008

Question
QUESTION: Dear Dr. Myerson,

Recently, my ten year old son visited an orthodontist on the advice of his pediatric dentist.  This first orthodontist advised us that our son has an issue with his lower jaw as it is growing more outward than is normal.  This first Dr. advised that we should have him wear a retainer that opens up the upper pallet and that we will have to wait and see how my son's growing progresses until he is 18 at which time he will either need braces or surgery.

Yesterday, we went for a second opinion and were told essentially the same thing however, the treatment was approached differently.  In this case, the Dr. also suggests that my son wear the same retainer, however, she suggests that he wear a device called reverse-pull headgear as she feels this will minimize his chances of having to have surgery after he finishes growing.  When asked the success rate, she said it reduces the risk of surgery by about 50% but since my son is younger, the odds could be even better.  After that, she advises braces to keep the work in tact.  When I saw this device, and my son's reaction to it, I am very concerned.  If I were told the odds were better, maybe I would not be so hesitant, however, this seems like a lot to go through (he would have to wear this every night for many months along with the retainer at all times and then braces- for a period of approx three years total treatment time)for a 50/50 chance of no surgery.  When I look at his mouth, I do not see a huge problem and honestly his teeth seem straight to me...when I told her this, she said that he may not need the braces for very long if at all...

Both Dr's I went to have over 15-20 years experience in this field the first one even longer and came highly recommended.  I am very concerned that I received two totally different treatment options and now do not know what to do.  I will most likely go for a third opinion but I am under the impression I don't have much time...this latest reverse pull procedure is most effective when started at an early age.  Can you please give me some advise on the course of action you have seen most taken?  I would greatly appreciate any help you can give.  Thank you for your time.

Best regards,
Allison

ANSWER: Both treatment plans are valid and quite useful in view of the potential need for jaw surgery in the future and the possibility that early treatment might actually avoid that surgery.  As to the question regarding which plan is more appropriate for your son, that very much depends on the details of his current jaw relationship and the expected pattern of future jaw growth.  I am not priviledged to those details since I've not evaluated your son nor have I seen his diagnostic records.  
I have sucessfully treated actively growing youngsters with palate expanders, with and without maxillary protraction using a reverse headgear.  The use of the reverse headgear depends on the nature of the jaw relationship.  In all cases I've had excellent cooperation with the reverse headgear which produced excellent results and in many cases I've not had to recommend jaw surgery for these patients later on.  It is a very individual situation.
Perhaps a third opinion will clarify your options. I don't believe that delaying treatment for a few weeks will jeopardize potential results and could yield additional information towards your decision.

---------- FOLLOW-UP ----------

QUESTION: Thank you very much for such a quick answer!  Right now I believe his jaw is only 1mm off?  However, we were told when they saw my husband whom I guess has a similar issue that this is hereditary (my husband never had it treated when he was young and it has not been a problem for him, nor was it brought to his attention until he visited a periodontist a few years ago).  We will most likely get a third opinion, but I am wondering for those patients you did not use the reverse-pull headgear with, if they had as positive results as those you did use it with?  Thank you.

Best,
Allison

Answer
Perhaps you did not fully understand my first response.  I'll try to expand my explanation.  Palatal expansion treats one set of problems and the reverse pull headgear deals with something entirely different.  Those patients who received the reverse pull headgear along with palatal expansion did not have the precisely same orthodontic problems as those who got palatal expansion alone.  These were two different sets of problems that required two different treatment plans.  While both groups would benefit from palatal expansion, only one of the groups would benefit from adding the reverse pull headgear.  So it's not a matter of getting better results by adding a reverse pull headgear to the treatment plan.  If your son requires the use of a reverse pull headgear then his treatment plan should reflect that need.

Just to muddy the water a bit, there are some youngsters who would benefit from the use of reverse pull headgear alone. In this group I have found that by adding the palatal expander to the treatment plan the reverse pull headgear works much better than without the expander.  So, to paraphrase this muddy paragraph, palatal expansion can enhance the effect of the reverse pull headgear, but the reverse pull headgear will not enhance the palatal expansion.

Your issue remains, which treatment modalities are appropriate for the treatment of your son's bite problem?