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Orthodontics/Forsus Springs Vs. Head Gear

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Question
Hi

My daughter has a moderate overbite. She is 11 years old. The orthodontists said she will ready for Phase 2 ortho treatment in the next 6 months.

First orthodontist suggests headgear 1 year (at night)
Second orthodontist suggests Forsus Springs 6 months

Both places said my daughter would need to wear braces for 2 years. We dont like headgear option and my daughter does not want to wear it, so we seek second opinion and the second orthodontist suggest Forsus appliance. He said it can help correct overbite.

I am not familiar with Forsus appliance and dont know if it can replace the headgear. Any advice would be appreciate.

Answer
Hi Kate,

I was in the midst of answering your question privately, but changed my mind and am going to answer it here in the open forum. The reason I hesitated is that it is a complex clinical decision, and I do not have enough information from you regarding the radiographs and clinical photos. Feel free to follow it up with more questions and clinical records.

Before going on, I’d like to take a moment here to let readers know that the questions I receive in the orthodontics forum here often involve complex borderline issues.  Treatment options are sometimes guided by very subtle clues in the radiographs, past and predicted growth behaviors and directions, clinical assessment of dynamic opening and closing of the bite by the patient during an exam, etc.   Additionally, the Orthodontist tries not only to create a nice smile and straight teeth, but to achieve a pleasant and acceptable facial profile and aesthetic balance. To assess facial profile takes photos, x-rays of the head to assess the underlying jaw structures, and more. Who wants perfect teeth at the expense of an awkward facial profile that may be too flat or even concave like the facial profile of the Wicked Witch of the West in the movie The Wizard of Oz.

I try to do my best on this forum with the very limited information often given.  I am usually working inthe complete absence of any meaningful radiographs and clinical photos of the teeth.  As such, let me again state my usual, and necessary, disclaimer. As always, what I write here are only my opinions based on limited information. Any comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  As you know Kate, 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.

So now to move on to your question Kate. You wrote:

My daughter has a moderate overbite. She is 11 years old. The orthodontists said she will ready for Phase 2 ortho treatment in the next 6 months.

First orthodontist suggests headgear 1 year (at night)
Second orthodontist suggests Forsus Springs 6 months


This is actually an extremely complex question and to really meaningfully answer it requires cephalometric radiographs and a clinical examination of the patient to relate the X-rays to what a doctor actually sees when examining the actual patient in person.

The "overbite" you talk about is what is actually properly termed an over-jet, and can be due to skeletal reason, dental reasons, or a combination of each.  The end result is a mismatched skeletal and or dental architecture whereby the teeth do not mesh properly, and the person's profile may also be affected.

The "mismatch" for which traditional (and not reverse) headgear would be employed is a dominant and forward positioned upper jaw and a relatively weak and retro positioned lower jaw. This relative upper and lower mismatch however can be due to several combinations. Remember this is an upper jaw forwards & lower jaw backwards appearance when viewed in profile.

Possible Situations:
#1 Normal upper jaw and undersized retro positioned weak lower jaw.
#2 Strong forward positioned oversized upper jaw and normal lower jaw
#3 Strong forward positioned oversized upper jaw and retro positioned weak lower jaw.

In any of these three situations the upper front incisor teeth are likely to be positioned ahead of and forwards of the lower front incisor teeth.

Now head gear, in a growing individual such as an adolescent teen, will reduce the amount of anterior forward growth taking place in the upper jaw while allowing unfettered continuing forward growth of the lower jaw. This is great if the situation being treated is the #2 or # 3 scenario described above.

If on the other hand the upper jaw is normal and the lower jaw in undersized, cervical headgear may end up limiting the upper growth. The result may be matching upper and lower jaws, but they are under sized and may create a flat or dished in lateral profile for the person, many people find a flat or concave lateral profile unaesthetic. The head gear is, in effect, acting as an orthopaedic appliance and impacting skeletal jaw development.

Lower jaw growth can not be "magically initiated". Such a change often requires surgical orthognathic intervention which many feel, if done at all, should only be taken after most of the adolescent jaw growth has had a chance to express itself.

There are appliances such as a Herbst Appliance, that can "reposition" the jaw forwards, within limits. The patient becomes acclimated to biting down while holding the lower jaw forwards into a better bite relationship and with a better net lateral profile.

Again, the specific points are:

First orthodontist suggests headgear 1 year (at night)
Second orthodontist suggests Forsus Springs 6 months


Well, each doctor may be correct, depending on the reasons for your daughters jaw mismatch. If the underlying causes are scenario #2 or #3, then using head gear alone, a combination of Headgear and Forsus springs, or Forsus springs alone may be worth considering. If it is scenario #1, then headgear is probably not the best mode of treatment, because why shorten or limit the jaw growth of the upper normal jaw to match it to an undersized lower jaw. It is as if one had a normal length leg and a short leg and the treatment goal is to make both legs undersized and short,. yes they would match, but...  In the case of a weak lower jaw ( scenarios #1 and # 3, repositioning as well as surgical approaches should be discussed in the orthodontic treatment planning / work up.

The Forsus springs act to reposition the lower jaw forwards, much like a Herbst  Appliances which traditionally uses small piston like arms on a fixed appliance. Depending on which of the three primary jaw combinations, the Forsus may indeed be a viable option.

It is also important to look at the issue of compliance. Headgear, while effective, has been declining in use for many years. Herbst and Forsus appliances do not so much rely on patient compliance for wear. Today’s socially active teens, who are busy with afternoon soccer, sports, and other extra curricular activities  just are not able to show the compliance needed as in years past. Some doctors in Class II ( Prominent upper jaw cases ) attempt to actually move molars posteriors in the mouth to reduce the amount of the “overbite” (actually overjet). The employ surgically implanted “TADS” or temporary anchorage devices.  Others use somewhat complex appliances cemented to the roof of the mouth, such as “Pendulum Appliances” . It gets a bit too involved to discuss all these options here. Best to check with your Orthodontist on this one Kate.  In any case, it does become very involved.

So in the final part of your question Kate you wrote:

Both places said my daughter would need to wear braces for 2 years. We don’t like headgear option and my daughter does not want to wear it, so we seek second opinion and the second orthodontist suggest Forsus appliance. He said it can help correct overbite.

I am not familiar with Forsus appliance and don’t know if it can replace the headgear. Any advice would be appreciated.

So Kate, I would say that given the many complexities of treating Class II pro-gnathic cases involving what the lay person terms “ an overbite”. The use of a Herbst Appliance, Forsus Springs, or other mandibular repositioning appliance certainly presents a viable option which should not be excluded from consideration at this time.  Because I am unable to review any clinical records, and have only your question to go on, I really can’t be more specific.  Approach the second orthodontist, and ask for more details, and particularly ask about his/her diagnosis of your daughter's relative upper vs lower jaw skeletal imbalance, if any. I think that will help guide your decision Kate.

Thank you for writing. Your question is a classic, and remember, different doctors will treat this with varying approaches, often guided by patient preferences and compliance abilities.

I hope my comments have been helpful. As you know Kate,  the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your follow-up consultations,  and thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. 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. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.

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Paul Supan, DDS, MA, MPH

Expertise

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 braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

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.

Experience

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.

Organizations
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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Available upon Request.

Education/Credentials
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.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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