Finishing (How do I Get Out of This Pickle? Part II)

© 2018 Dr Chris Baker

The In-Treatment-Presenting Posterior Crossbite

Pickles can be sweet, tart, bitter, or sour.

“Dr.  Chris, when do I get my braces off?”

“Let’s look,” I say to the pretty teenage girl in the orthodontic chair.  She has worn her elastics well, kept her plaque under control, and wants to be finished with orthodontics.

Back to the beginning.  The way it works is, an awful lot of young patients today want braces.  Either their teeth and smile are not ‘Hollywood’ beautiful, OR all their friends have braces and they want them too.

No matter, the two questions asked by these young people are,

1. “When can I get my braces?”, and
2. “Do I get to pick colors?”​

Two Q’s with easy answers.  “As soon as you get your records done, give me a few days, your mom and I can conference - sit down and review what’s going on with your growth, bones and teeth, then as soon as it’s ok with your parents.”

And, “Yes.”

Not many months later, sometimes only 4 or 5, the Q is more difficult to answer:
“When do I get them off?”

I formulate the answer from two areas of information.  The first, I pick up the chart, and study the original treatment plan, with time estimate, goals, and steps of treatment planned, as well as look at the original or most recent pano.  The second, I give the assistant status notes.  She is charting the information, as to alignment and spacing, overbite, overjet, all teeth erupted and accounted for, canine relationship and molar relationship.

And this pretty, sweet teenage girl is waiting expectantly for my answer, hoping it is some version of  “Soon or very soon.”  (She can always hope, can’t she?)

On our treatment plan, the time estimate is on the same page as the parent’s signature.  That can help them, because the child or parent notices the signature and hopefully familiar page, when I say, “Our estimate was in February to May next year,” though the eager patient is disappointed, they handle the un-hoped-for answer better.

But - what if your estimated time is about now?  And what about if the patient is looking pretty darn good?  And what if, as you are calling off the status to the assistant, “alignment good, overbite 3, overjet 3, no spaces left, right molar and canine Class I, left molar” - UH OH!.    You notice a lingual cross bite of the left six year molars.

Your mind races. “Where did that come from?  She’s about done, she and her mother want the braces off, and we have a crossbite. In this case, perhaps the lower molar is kicked out buccally a bit….”  It’s a crossbite. Or, you have done Class II correction and distalized upper molars in reference to lowers, and the lower arch width is wider “back there”.   What to do??

What options are there?
Here are three for you:

1. Cross elastics, from the lingual hook or cleat on the upper molar, to the buccal hook on the lower molar tube. Wear 24/7 and re-evaluate 2-3 weeks or more later.  This is a good option if the patient is compliant (she wants to get her braces off, so she just may be,) if tipping the molars a bit will be acceptable in alignment and occlusion, and IF the cross bite is basically just the molars.  It’s also when you have a labially positioned lower molar.
2. NPE - Nitanium Palate Expander if the 4,5 or 7’s are also a bit edge to edge, cross bite or tendency, OR the upper 6 in cross bite needs a bit of rotation, the NPE can do that, along with some expansion, if you remove the arm of the expander.  Watch closely so that the rotation and expansion are not overdone.  See every 2-3 weeks.  (You are getting mostly tipping, as with all of these corrections, so if you truly need expansive movement, gotta think RPE.)
3. If the crossbite entails several teeth in the quadrant, this is an option.  From our dear friend Dr. Larry White, turn a rectangular NiTi arch wire backward into the maxillary tubes.  The curve of the wire can expand (tip) the teeth - careful again - check in a month, then in another if needed.

Your patient is still waiting for your answer.  Do not rush your answer.  Get your information in order.  Evaluate everything and carefully.  Then, be brave (avoid approval-addiction).  Be straight-forward (tell it like it is).   Your patient and parent will cope.  They usually want it right.  (At least the parent usually does.)  Either way, you want it right -  so just say it.

Just sayin’.

Images and text © 2018 Dr Chris Baker

Dr Chris Baker's book, "Your Child's Smile" (right) is an excellent guide for parents to help guide their children to optimal oral  health. 

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