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Dr. Gio Explains Functional Orthodontics

Dr. Gio Iuculano, DDS

In this interview, Dr. Gio explains the basics of functional orthodontics—what it is, how it works, when to begin, who can benefit, and why it’s important.

What is functional orthodontics? How does it differ from traditional orthodontics?
I always like to tell parents—especially moms when they bring their children in and we are evaluating for orthodontics—that we do something I call functional orthodontics. When we do traditional orthodontics, it’s really focused just on teeth—getting straight teeth for a cosmetically pleasing appearance. But functional orthodontics, really, encompasses so much more, depending on the age at which you start. It addresses several things: creating an effective airway (both nasal and pharyngeal); moving the TMJ (jaw joints) into the proper position; allowing the mandible to sit in the correct location (this creates a pleasing facial profile); and lastly expanding the palate, which allows for a broader and more appealing smile. The palate is the center bone for all development, so with a narrow palate you can develop breathing problems and TMJ problems. With the use of functional orthodontics, we can correct several things. This allows the face to grow the way it was intended to.

Okay, so it’s more than just looking at the appearance. Most parents would bring their children in and say, “I want to make sure their smile is straight,” looking at the aesthetics. It sounds like this is more making sure everything is in order so they don’t have issues later.
Correct, because the palate makes the nasal floor. What we find is with a mandible that’s protruded (when the lower jaw juts forward), and a vaulted palate (when the roof of the mouth is high and constricted), a bone is poking up and intruding into the nasal airway. A retruded mandible (when the lower jaw is positioned too far back) and a vaulted palate cuts back on the airway space, creating a condition of sleep breathing disorders. This can even cause sleep apnea in some cases. In about half the cases we see where children have this problem, once we expand and place everything where it should be, we see the breathing improve and the apnea or the breathing disorder improve, without medication. We see children with ADD or ADHD, for example—a lot of it is misdiagnosed; it’s just a breathing disorder. The children can’t breathe, and once they can breathe again at night we notice their hyperactivity goes away.

They become more focused?
Yes, they really do.

Is this all corrected with braces, or are there other appliances used as well?
It depends on the child’s age, but frequently we have to use braces and retainer-like appliances to expand the palate. If we are starting with a young child, between 5 and 7 years old, we are waiting for permanent teeth. We’ll expand the palate, let all the teeth come in, and then when the child is 14, we’ll evaluate them to see if they need braces. If a child is between 12 and 14, where they have some baby teeth and some permanent ones, we usually just expand a little until we get all the permanent teeth. If we are seeing an older child who has all his or her permanent teeth, we frequently combine the retainer and the braces to save time. So instead of a process that takes three to four years, we’re able to do it all in two years.

How important is the age at which a child begins functional orthodontics? Is it better to start earlier or later?
Younger is always better. It’s most important to note that by the time a child is four years old, 60% of his or her facial growth is complete. At age six, 80% of the facial growth is complete; and by age 11, 90% of the facial growth is complete. So by beginning while children’s faces are still developing, we have the opportunity to promote proper development instead of having to correct it later.

Catching children young also gives us the chance to complete their orthodontics before they start high school—because we all know how important it is with peer pressure and all—so we try to get everything done early. Beginning at age five or six, we can create a proper palate and lay the right foundation for the teeth to come in. About 10% of children treated with Phase 1 orthodontics (expanding the palate) will not need Phase 2 later on in life. These percentages increase the younger children are when we start. Frequently we start early and make the room for the teeth, and then Mother Nature takes over and the teeth come into place properly; everything looks good, and we’re done with one little retainer. So less is more, and we always aim to do smaller amounts of work.

At what age do most children have all their permanent teeth?
Around age 12 -14 years is about average. Sometimes we have cases where we will put the retainer in first and give the patient a month or two to get used to that before we put the braces on. In those cases, we’re expanding the palate and straightening the teeth all at the same time. But if the child only has baby teeth, I’m not really worried about lining up the baby teeth, just worried about expanding the palate, and we’ll just use a retainer to expand the palate. Typical treatment time for that is about a year to a year and a half. And typical treatment time for braces is anywhere from one year to two years, depending on if we’re just doing braces or if we are doing the expansion and the braces.

So the expansion is really the purpose of looking at young children’s baby teeth, because they are going to lose them anyway. This information will help people to realize how this kind of evaluation can help in the long run.
That’s what I tell a lot of parents. When children are young, I’m evaluating them for orthodontics—or for orthopedics really, because the younger they are, the more it is really about the bones. When children are between five and ten years old, I’m not really concerned with the teeth. What I’m looking at is all the other bones: the face, the palate, the jaw, the jaw joints, and the airway. Those are my concerns, and if I see they are not developing properly and any of those are compromised, we recommend Phase 1 orthodontics or orthopedics: “Let’s look at the bones.”

I concentrate on the teeth at age 13-14, when all the permanent teeth are in. Then I’m looking to see if everything is laid out properly. If they are not matching right or they don’t look good, we want to improve their appearance. Phase 2 is about cosmetics, while Phase 1 is about form and function. We want the face to develop properly. We want craniofacial bones to be where they should be, so that the bones and the soft tissue follow for a properly proportioned face and proper breathing, which is important for everyone, and critical for children who participate in athletics. All the top professional athletes instinctively breathe through their noses. If they are mouth breathing they are not as efficient, so they are not performing to their peak.

That’s all really good information. How long does this type of treatment take?
Parents usually ask about timeframes. It is possible to rush phase 1 orthodontics in as quick as four months, but to expand the palate we have them turn a little screw on the oral appliance that causes the palate to expand—traditional orthodontics calls for two turns a day, which is half a millimeter a day, and it’s painful. Instead, we like parents to do two turns a week, so we go very slowly, and that takes away all of the pain. Children always ask if this is going to hurt, but no one has ever complained it hurt; no one even has to take Tylenol or Advil. The slower we go, the more stable that bone in the palate is going to be, and the more stable the teeth are going to be when we do straighten them out. I typically project 12-24 months’ treatment time for Phase 1, and Phase 2 can be as short as a year or as long as two years. If we have to expand the palate during Phase 2, it may well take two years.

The turning of the device; is that something the parents are taught to do at home?
Yes, most parents do this at home, and I typically tell them to turn on Wednesdays and Saturdays. Every Wednesday you go and just turn the screw one turn, and then on Saturdays you do one turn, and the child doesn’t even notice it. That way it’s gradual, steady, and stable.

Does turning less frequently make a big timeframe difference?
Yes, if you’re turning it twice a day, you can get all the expansion you want in as little as four months, but in some cases we find it’s too fast, and in addition to the pain it can cause, children do not develop bone, but develop something more like scar tissue in the palate. Then when the appliances come out, a lot of children relapse, so I tell parents we just can’t rush it. We just have to do this slowly, and depending on how much palate expansion a child needs, it will be a year at quickest, because I like to expand slowly. Then after the palate is expanded, I leave the retainer in for another six months to allow for the bone to fill in and form, and make a nice solid palate. That way, everything is more stable, and then it will stay that way until the child is ready for braces. If the airway is not compromised, and there is proper tongue function, that will keep everything nice and expanded. But if the child is not breathing properly or has a tongue tie, then that causes the expansion to relapse. That’s why after it’s expanded, we wait six months for the bone to fill in while we keep a careful watch on everything.