Orthodontics/orthodontic reverse pull headgear after 10
My Daughter, 10, was in orthodontic reverse pull headgear for an underbite and a year after treatment her orthopedist says the lower jaw has grown but not the upper, and that after age 10 further headgear has poor results and she should have tabs/bands between the lower and upper jaws. I of course want to spare her surgery in later years but would prefer not to have surgery now, either, if headgear might still be useful. I imagine that mere chronological age is not the governing factor but the maturation of the upper-jaw bone (but I don't know). Are results from 10 forward so poor that we should move to the tabs/band treatment? Is there a way to determine if she might be a candidate for more headgear? And what would be the risk at age 10 to trying headgear again and delaying tabs/bands for a year? (Thanks in advance for your opinion)
Pardon the delay, I was again traveling over the New Year. The notion of using reverse head gear is a very complex topic, and I will answer it as best I can. I have actually used this appliance extensively, especially with patients suffering certain overwhelming conditions including unilateral and bilateral cleft palates.
What I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation. Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.
Okay… having said that… your questions focused on using reverse headgear ( aka face masks ) in conjunction with orthodontic treatment.
" My Daughter, 10, was in orthodontic reverse pull headgear for an under-bite and a year after treatment her orthopedist says the lower jaw has grown but not the upper, and that after age 10 further headgear has poor results and she should have tabs/bands between the lower and upper jaws. "
A true classic Class III skeletal malocclusion aka "under-bite" is one of the most difficult to manage conditions in all of orthodontics. The use of reverse headgear can help to address this discrepancy, although it may not necessarily completely succeed in resolving the problem, The timing of such reverse headgear in part may hinge upon the severity of the problem. The extent and timing of skeletal jaw growth is somewhat unpredicable. It can be said that when early as well as later adolescent growth spurts kick in, the orthopaedic appliances can have their greatest impact.
Patients with a Class III skeletal pattern ( under-bite ) can have this due to three conditions:
1) The upper jaw is normally sized and the lower is overly sized ie protruded causing the "under-bite"
2) The upper jaw is undersized and the lower jaw is normal, therefore again resulting in an "under-bite"
3) A combination of the previous two conditions, namely that the upper jaw is undersized and the lower jaw is over-sized, again resulting in the so called Class III " under-bite".
The reverse headgear is likely not helpful in situation #1, since the upper jaw is normal. Assuming your daughter has either condition # 2 or #3, a reverse headgear may be useful. Even if it does not resolve the condition completely, it may provide "some limited" improvement, thereby minimizing the extent to which future jaw surgeries, if any, will need to correct the jaw discrepancy. In other words if 25 mm of jaw surgery correction can be reduced to say 10 or 15, this may be desirable and my result in less potential relapse.
In situation like # 2 where the upper jaw is undersized and the lower jaw is relatively normal, reverse head gear has improved chances of succeeding. Such undersized jaw not only often have anterior - posterior discrepancies, but transverse ie width, discrepancies as well. These jaws ore often very narrow and therefore have skeletal cross-bites whereby the teeth do not mesh properly on either the left and/or right sides. Palatal expanders such as a HYRAX appliance can be used to expand the jaw transversely. by so doing the growth sutures in the upper jaw/palate are made increasingly mobile. if a reverse head gear is used in conjunction with a HYRAX appliance there may be a enhanced effect.
You also wrote:
" I of course want to spare her surgery in later years but would prefer not to have surgery now, either, if headgear might still be useful. I imagine that mere chronological age is not the governing factor but the maturation of the upper-jaw bone (but I don't know). "
I do not know the extent of the discrepancy. There may be gross anatomical, functional, and or other psychological factors being considered for having the surgery done this early. I will say that no one can fully predict the extent or timing for your daughter's later adolescent growth spurts. at age 10 she still likely has A LOT OF POTENTIAL GROWTH remaining. Perhaps it would be unwise to completely rule out waiting until the mid teens before committing to surgery. In other words, balance the pros and cons of waiting for the mid to late teens before deciding if indeed surgery is necessary, and to what extent.
You also wrote:
" Are results from 10 forward so poor that we should move to the tabs/band treatment? "
It is unclear to me what this tabs/band treatment means. If she has a narrow and undersized upper jaw, an expansion appliance, possibly in conjunction with a reverse head gear may be helpful at this time. Expansion appliances and head gear/reverse headgear can be used repeatedly if needed. They are not limited to being used only once.
You also wrote:
" And what would be the risk at age 10 to trying headgear again and delaying tabs/bands for a year? (Thanks in advance for your opinion) "
I find very little to objectionable to waiting, although as I said earlier there may be other extenuating variables of which I am not aware that may impact this decision. It is outside of my 30 year experience to hear anyone say that headgear or reverse headgear results in necessarily poor results after age 10. Such timing should NOT be made solely on a chronological basis, but on skeletal growth and maturation factors. You may wish to google the topic of skeletal maturation indices. A very respected Orthodontist/Pediatric Dentist dual specialist named Dr. Leonard Fishman at the University of Rochester for example has published widely on this topic. He has worked extensively with another famed Orthdontist Dr. Dan Subtelny who is a nationally respected expert in the area of Cleft Palate treatment where the use of orthopedic appliances is commonly needed.
Rick, I hope I have not over burdened you with too much detail. My advice is to go see an Orthodontist and possible also a Pediatric Dentist for more information and opinions. they will be able to, unlike myself, examine your daughter personally, review needed radiographs and other diagnostic records, and give you a much more sound opinion on how to proceed.
Paul Supan, DDS, MA, MPH
Board Certified Orthodontist
Specialist in Orthodontics
Specialist in Dental Public Health