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Orthodontics/braces and explander



My 9 year old daughter saw an orthodontist today, after a dentist referral for possible expander.

The orthodontist wants to install an expander on the roof of her mouth.  He also wants to install braces on the front 4 teeth (some permamenent, some baby) and then use a retainer.  This will cost $3400 with insurance.

He said she will also need full braces when she is older.

This seems like a lot of treatment at a young age to me, especially since we will need to pay for full braces when she is older.  I've read there are differing opinions on aggressive treatment at young ages.  What do you think of this plan?  What would you think of just the expander without the braces or retainer?  Does the cost seem appropriate?



Hi Scott,

Thank you for your question. It is an age old much discussed topic, and whereas in the 1970's early treatment like the one being proposed for your 9 year old daughter was not commonly undertaken, in 2014 I think it is safe to say that the pendulum has swung in the other direction, and early interceptive treatment for a wide range of conditions ranging from anterior crossbites to severe crowding with attendant root resorption is now commonly accepted.

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 the appropriateness of an expander and limited braces for a 9 year old. You asked   What do you think of this plan?  What would you think of just the expander without the braces or retainer?  Does the cost seem appropriate?   .

Let me answer this in specific sections.

1)  Age:  There is no way to precisely gauge treatment to chronological age. At age 9 some children are already experiencing eruption of the second molars ( ie "12 year" molars) whereas other 9 year olds may still have many many baby teeth. Dental development is not directly tied to chronological age.  Girls tend to mature a little earlier than boys. Also, compared to the previous generations, today's youth are maturing earlier and have greater stature as well as, unfortunately, higher prevalences of obesity.

2) Skeletal vs Dental Development :  Your daughter at age 9 is experiencing skeletal development , ie the bones are growing, she is getting taller, and the jaws likewise are getting bigger in anticipation of accommodating the full complement of adult teeth which will eventually erupt into place. Likewise she is experiencing dental development as the adult teeth continue to erupt and the primary ie  baby teeth are lost. Unfortunately, some children experience delayed skeletal growth, or simply never experience sufficient skeletal jaw growth to allow the teeth to erupt without crowding. In other words, if there is an imbalance in the skeletal vs dental development, there will be an orthodontic problem. Too little and/or too late a skeletal growth combined with regular or early dental development ( eruption of adult teeth)creates problems such as severe crowding, impacted teeth, etc. It is as if an area ended up with too much traffic congestion because the road infrastructure did not keep up with the traffic growth.

3)  Growth Sutures:  The use of orthopedic dental appliances can create a change in the size of the upper jaw which in effect is the equivalent in many ways of jaw growth. In this case the transverse dimension of the upper jaw. ie the width, is increased because the growth suture running front to back down the middle of the roof of the mouth has not fused yet. By increasing the width and size of the upper dental jaw or  "arch of teeth" more room is created. Problems like posterior crossbites, severe crowding, and impactions can often be addressed in this manner.

Summarizing Remarks. I believe that based on hat little information you have provided, I can not rule out the possibility that the proposed treatment of an expander and four anterior brackets on the adult upper incisors is in fact an excellent proposal. This form of treatment is commonly performed, and I am a proponent of it as well if the conditions so warrant. Again Scott, I do not have any clinical records of your daughter, and I have not had a chance to clinically examine in person the dentition.

As far as the fee, this is not a clinical issue, and fees are left to the discretion of the doctor. Fees vary widely depending on degree of difficulty, geographic location, impact of third party reimbursement policies, etc.  I thank you for an interesting question Scott.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health  


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Paul Supan, DDS, MA, MPH


First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites and are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.


Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

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BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

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