Q&A with orthodontist Dr Anton Bass
Anton Bass joined us in September 2011 to answer a host of questions about orthodontics. He tackled queries from overbites and crowded mouths to divergent opinions on early intervention and concerns about the emotional impact on children and adults.
Anton is a graduate in dentistry from Guy's Hospital, London, and received his specialist orthodontic training at the University of Pennsylvania in the United States, where he obtained a Master's in clinical orthodontics. In 2001 he joined his father at Bass Orthodontics, an established family practice and one of the first specialist orthodontic practices in London's West End.
Q. Hiddenathome: Will my eldest son's teeth ever fall out? He's 13 in November and he still has all his primary molars and his canines. He also has a gap that's been there for two years and only now seems to have a tooth coming through. Why are his teeth so lethargic?
A. Anton Bass: There is great variation in the timing at which the baby teeth are lost and adult teeth grow in. Yes, 12 is the average age for all the remaining baby teeth to be lost and most of the adult teeth to come in, but there is a range of about two years either side of 12 year olds in which is it perfectly normal.
Q. Essentialfattyacid: My daughter has just had twin block braces fitted. She will be unable to close her mouth or to smile for six to nine months. Can this be necessary? Is there a more humane treatment available?
A. Anton Bass: The twin block brace is very widely used, however there are always alternatives, such as the Bionator or the Dynamax. Personally, I find the Dynamax orthopaedic appliance not only the most effective in bringing the lower jaw forward, but the most streamlined and comfortable appliance, too. It allows the mouth to fully close and rarely stops my patients from smiling.
Q. Hattifatner: Can braces help with teeth grinding? My daughter's orthodontist says that they may help her bruxism but at huge cost, over £3,000. She would need the brace for 18 months, plus a retainer for a further two years. She actually has nice teeth except that they are being worn down. Our dentist has doubts, but suggests we have a nightguard made instead (£400). What would you advise?
A. Anton Bass: Bruxism is a fairly complex issue as the cause isn't yet fully understood and, unfortunately, it seems to be getting more common these days. The fit of the teeth may only be one theoretical cause, another may be stress or that it is a simple habit, like cracking your knuckles.
I would always advise a patient that tooth grinding may persist after orthodontic treatment. You should start with the nightguard, which would at least protect her teeth from damage and if it stops the bruxism, this may be an indication that the fit of the teeth is a key cause, which the orthodontist can improve. Indeed, I often start with nightguard therapy before starting with orthodontic treatment in the case of bruxism or jaw ache.
Q. Nickocka: My nine year old has protruding front teeth and is teased about it. I've discussed it with our dentist and her view is that 12 is about the right age to address this. Do you think this is a normal approach? I can imagine that it's something to do with jaw development, but would you take account of the teasing as a reason for earlier intervention?
A. Anton Bass: I'm a strong believer in early intervention for many reasons, not only for psychological ones like teasing, but if the upper teeth are protruding, there is a greater risk that they can become damaged by trauma - I know what kids are like in the playground.
There is also the consideration that dental problems at this age may be a sign that there is an issue with the jaws, not just the teeth, which can usually be remedied if dealt with at this age, or even earlier. Protruding front teeth may indicate that the lower jaw isn't growing quick enough to catch up with the upper jaw, therefore the front teeth appear to be forward relative to the lower teeth and jaw. I think nine is an ideal age to encourage the growth of the lower jaw with an orthopaedic appliance, and that waiting until the age of 12 is often too late.
Q. Weblette: My daughter had a removable brace for a year when she was eight to widen her upper palate and correct a cross bite - we paid for it privately (ouch!) as we were advised that correcting it then would reduce the need for extractions when older. Now she's almost 11, her teeth are almost all in and she hasn't had to have the trauma of removing any. It strikes me that doing work earlier could cut down costs and upset for a lot of children!
A. Anton Bass: There is the common misconception that children don't need to see the orthodontist until all baby teeth have fallen out at around 12 years. I encourage patients from as early as six, when the first adult teeth start coming in, to assess for crowding and jaw development.
There are many treatments available before the age of 10, such as space management and enhancing jaw growth, which can make future treatment much more simple, reduce the need for extracting adult teeth and sometimes negate the need for treatment at all. So, as you say, doing work earlier could cut down cost and upset for a lot of children.
Q. Mumach: My 10-year-old son has a cross bite. How will this be treated, and have we left it too late? How long will it take to correct?
A. Anton Bass: A cross bite is often caused by the upper jaw being narrow in relation to the lower jaw, making the upper side teeth sit inside the lower teeth, which is the reverse of the normal relationship. This can be treated in boys up to about 12 years and in girls until about 10 years, depending on individual growth. However, the earlier the better.
This can easily be remedied with a simple appliance fixed to the upper teeth, called a rapid palatal expander (RPE). The RPE enhances the growth in the width of the upper jaw over about two to four weeks and the device is kept in place for a further six months to a maintain the result.
This is usually beneficial on two levels: first, it corrects the cross bite, allowing for a healthier bite; second, it gives more space for the upper adult teeth to grown in, thus reducing the likelihood of upper crowding and the need to extract upper adult teeth.
Q. JustineMumsnet: Do you have any advice for my eight-year-old son? We've just found out that he is missing his two bottom front teeth - so his milk teeth there won't be pushed out. Is there anything in particular we should do? My dentist doesn't seem bothered.
A. Anton Bass: You should consider having the two milk teeth removed, when the remaining milk teeth have been lost, and closing the space, by bringing the adult teeth forward. He may even have potentially crowded teeth anyway, so it could be an advantage to be missing two teeth.
The bottom line is that this will need some careful planning, so I do advise that you seek an orthodontist in the next year or so.
Q. Beautifulgirls: My daughter (aged seven) has an open bite and so far the dentist has said 'see how things go' as she grows. I am concerned that we are missing an opportunity to deal with this while she is young enough and may only be left with a surgical option later if things are not improving. The same dentist seemed to think this was all caused by prolonged bottle and dummy use, but she didn't use a dummy and was off bottles by 16 months, so I don't have very much faith in their decision making.
A. Anton Bass: There are many causes of open bites - from thumb sucking and strong tongues to genetics. In one case I've seen, a severe open bite was caused by a comfort blanket which spent a long time in the mouth! The solution was to cut the blanket in half every week until it disappeared, the open bite soon disappeared too.
In your daughter's case, it could be simply that her front teeth haven't yet fully grown in. But if there is another cause, it should be stopped sooner rather than later, so you should have this checked by an orthodontist soon.
Q. Giddly: My daughter (age five) has an extended frenulum, with a very large gap between her two top baby teeth. Our dentist says it will need correcting, and she will then need orthodontic work when her adult teeth are in. There's no timescale yet for this. If the frenulum is corrected early, is there any chance she could avoid orthodontic work, or is it inevitable?
A. Anton Bass: I would strongly advise against carrying out any correction to the frenum before orthodontic treatment. Removing it will cause scar tissue between the teeth, which will certainly not encourage the gap to close spontaneously, and may even stop braces from closing the gap.
The frenum quite often disappears when the space is closed with braces. If it remains, this is the time to remove it, the scar tissue at this point will, in fact, help to keep the teeth together.
Q. Mavend: I have a query about children with special needs. My daughter is nearly six and has not yet lost any teeth. Our NHS dentist has given her a clean bill of health, from what he could see as it can be tricky looking in her mouth and, indeed, teeth cleaning at times. She has microcephaly and I know that a lot of children can have dental issues as they get older and their adult teeth develop. Is there such a thing as a specialist orthodontist who deals with such children and how would I go about finding one?
A. Anton Bass: It doesn't sound like your daughter needs any orthodontic care at the moment, it is quite normal that she hasn't lost any teeth yet, six is only the average age for milk teeth to start shedding.
If and when she does need an orthodontist, I would advise taking her to Great Ormond Street Hospital, there is a very good specialist orthodontic team there. Alternatively, you could try a local hospital with an orthodontic team.
Q. SummerRain: My daughter has an overbite but not a severe one. My biggest concern with her is overcrowding and weak teeth. She has always been a slow teether, and it's the same way now they're falling out. She's lost two so far, and it's taking months and some don't seem to be coming out at all.
Is this something that should be dealt with now (she's nearly seven), or is it simply a case of waiting to see how bad the situation gets and her having braces as a teen?
A. Anton Bass: It sounds like a visit to the orthodontist is in order. I like to assess and treat crowding early, the longer the adult teeth remain in a crooked position, the more the surrounding bone matures with the teeth in that position. This makes the future orthodontic treatment more difficult and relapse more likely. Often the adult teeth correct naturally if given enough space by having some of the baby teeth removed at this stage.
Q. SummerRain: My youngest is two and he has a huge overbite. He's already had minor surgery for tongue tie and is non-verbal, and his upper lip is tied too. The overbite and badly formed jaw have been mentioned a lot, and one consultant mentioned future surgery. What sort of surgery are they talking about? What age can we start dealing with this issue, can anything be done while he's a child or do we have to wait for his full set of adult teeth to come through?
A. Anton Bass: One of the special interests of my practice is the development of the jaws. From what you describe, it sounds like the surgery discussed is to bring the lower jaw forward. I don't know the severity of your son's case, but it does seem a little early to be discussing surgery.
I would be planning to use an orthopaedic appliance, which can enhance and modify the growth of the jaws. He is still very young for this, but I would advise that you take him for an orthodontic assessment at around age six when the first of his adult teeth start coming in.
Q. Only1inthevillage: At what point in a child's dental development is it possible to diagnose overcrowding? My son is seven, and his adult teeth are well on their way. I keep a close eye on them as I had a dreadfully over-crowded mouth as a child. At what point will I know there is a problem and is it possible to take any pre-emptive action?
A. Anton Bass: Now would be the best time to take your son to an orthodontist, as there is plenty of pre-emptive action which can be done about crowding if diagnosed early, from managing spaces to enhancing the growth of his jaws to allow all the adult teeth to fit.
Q. worryornot: Can bad orthondontic work be corrected? My son had two healthy teeth removed from the top and a fixed brace on both the top and bottom teeth for 10 months which straightened a slight protrusion on front top teeth, when he was 12. This has resulted in a receding bottom jaw and the appearance of a double chin. I am distressed by this, can it be corrected. He is 18 now . We weren't told there was any alternative treatments at the time but have since read that there are better treatments.
A. Anton Bass: Every orthodontist has a different approach and one of my sub-specialties is the development of the lower jaw. This sounds like your son always had a receding lower jaw and the upper teeth were brought back to meet the lower ones.
Had I seen your son at the right age, usually around nine years old, I would have used a removable orthopaedic appliance to encourage the growth of his lower jaw. The only option for correcting this now would be a surgical procedure to bring his lower jaw forward, as well as orthodontic treatment to get the teeth to fit together when the jaw positions have changed.
Q. neenpeen: My daughter is six and some of her upper teeth (her upper 1s) have grown in at a 90-degree angle to one another and one of her lower teeth (her LL2) is unerupted due to overcrowding. She has seen an orthodontist who is unwilling to do anything until she is at least 12. Is this correct? I just think it is a long time to wait as her upper 1's are limiting what she can eat.
A. Anton Bass: This sounds like a case for early intervention to me, during this early mixed dentition stage, when the adult teeth start to grow in, and some of the baby teeth remain, crowding can often be recognised and treated.
The problem with leaving crowding problems till later is that treatment is likely to be more complex, sometimes requiring extraction of adult teeth and impacted teeth may develop ectopically, all of which could be avoided if treated early.
Treatment can vary from simply having certain baby teeth removed to allow the adult teeth to come in and unravel on their own, to a short course of removable or fixed braces to straighten them.
Q. AnyoneButLulu: My son has just turned seven and has permanent front teeth which have a noticeable gap between them. Dentist has told me that he'll probably need a frenectomy followed by braces when he's a bit older, otherwise he'll end up looking like David Mellor. When would be the best time to do this?
A. Anton Bass: Frenectomies (removal of frenums) were very popular a number of years ago, but are now rarely carried out. Firstly, by creating hard scar tissue between the two teeth, it can be more difficult to push them together with braces and give an unstable result. Secondly, when the teeth are pushed together, the frenum very often disappears naturally. Only if the frenum persists after the gap is gone would a frenectomy be considered.
Q. Madhairday: My daughter sucked her thumb and has a 1cm overbite, very crooked top teeth and receding bottom jaw. She has seen an orthodontist but apparently nothing can be done until she has completely stopped sucking her thumb and all her adult teeth are through. She's nearly 11. Is this true, and if so do you have any strategies up your sleeve for the thumb thing that we might not have thought of?
A. Anton Bass: I agree with your orthodontist that the thumb sucking has to stop before orthodontic treatment can start. In my opinion, the problem with thumb sucking is that it is usually a sub-conscious habit, so all the techniques I recommend are ones to make my patient aware of the thumb sucking.
Have you tried a 'thumb diary'? Split the day in three: morning, afternoon and night. She can put a tick for when she doesn't suck her thumb or a cross when she does (or use coloured stars, just get creative), this will make her aware when the thumb goes in and quite often this is enough to stop the habit.
Give it six months, and then if this doesn't make a difference, then consider having an orthodontist make a 'thumb plate', this is a simple removable plate which fits in the roof of her mouth, just to make the thumb feel different and again make her aware that it's in.
I would also be concerned about the receding lower jaw, which could be improved with an orthopaedic appliance to enhance the growth of the jaw. This is best used when patients are younger, but as long as she still has significant growth, there is a chance it could work and perhaps the presence of the appliance may even discourage the thumb sucking.
Q. NotSoRampantRabbit: I hate my teeth. I have sucked my thumb since I was baby and although I hardly ever suck it now, I have an overbite and very crowded lower teeth. In the last year or so I feel constant pressure in my front lower teeth as one tooth is being pushed back by two adjacent teeth falling in. It is not yet painful but it is uncomfortable. I also notice that I have increasing pressure on my molars at the back - seem to wake up having bitten down hard on them.
From both an aesthetic and a pain/pressure point of view I think I need to do something about this. The cost is a real worry - what is the ballpark figure I would be looking at? Is this something that can be corrected without surgery? And how do I find a really good orthodontist locally. The thought of having a good smile makes me feel quite tearful. I would really love to sort this out.
A. Anton Bass: Unfortunately, without seeing your teeth in the flesh it is difficult for me to advise fully, so I'm not sure if this is a tooth problem alone, or a tooth and jaw issue which would require surgery. The cost is something that would be very difficult to comment on too, as this is all dependent on the severity and how much you would like done. Simple treatment may cost surprisingly less than you anticipated. You should start with a visit to an orthodontist for an assessment and then you can discuss the treatment options. Best to get a referral from your general dentist or you can do an internet search for a local orthodontist and refer yourself.
Q. Gluttondressedaslamb: Obviously it is difficult to prevent very young babies from sucking their fingers or thumbs, but from what age does it begin to impact on the development of their gums/jaws/teeth? Is it better to try to encourage a baby to use a dummy?
A. Anton Bass: General rule of thumb (excuse the pun!) with digit or object sucking is to try to stop it around the time that the first adult teeth start to grow in, which is usually around the age of six, as it could start to impact tooth and jaw development at this stage.
When our older daughter started showing signs of thumb sucking at a few months old, we encouraged the pacifier (orthodontic type). Sure enough, on her third birthday, the 'pacifier fairy' came along and took all her pacifiers, after a couple of weeks she never asked for it again and it hasn't been replaced by a thumb or finger.
Q. Tenabrist: We're all seriously stressed out with my daughter's braces! We were told from an early age that my elder daughter would need orthodontic work to correct her jaw, and that if it wasn't sorted with braces while she's growing she would need an operation at 18 or afterwards. So she started wearing one aged eight (initially one of those over the head wire constructions at night), moving on to a removable one and two-piece plastic things, some you screw tighter once a week. Now she's 13, and she's been with a one-piece bionator for a while.
She's supposed to wear it as much as possible - at least 15-16 hours per day - but it's as much as we can do to get her to wear it while sleeping, ie 8-9 hours. I would describe her attitude as passive resistance. She hates the thing. I've just been told by her orthodontist that she will have to move on to a Delaire mask with a fixed metal bit in her top jaw for 3-6 months. And that there's no point doing it for any less than 16 hours per day. And that if this doesn't work (ie because she doesn't wear it enough) she will almost certainly need the jaw operation at 18.
At what point do you say, this whole brace thing isn't working, it's damaging my child? Given that she has the brace for medical reasons, not merely cosmetic, are we right to insist that she persists, even against her will?
A. Anton Bass: I can see why you and your daughter are stressed! It sounds like every form of treatment and appliance has been used on your daughter and in some instances it sounds like opposing types of appliances, which I find a little confusing. Also, it is my opinion, that a 13-year-old girl has completed most of her growth and these type of appliances may not be successful at this stage.
You should do what is best for your daughter's general well-being, psychological included, and your relationship with her. She is old enough to understand the situation and make some of her own choices. I would never treat a patient unless they are 100% on board with it. After all, none of this is life-threatening.
I have many patients who just weren't ready for treatment in their early teens, but have returned as young adults, been great enthusiastic patients and we have achieved wonderful results.
And the reason for these results? They were ready.
Q. Drummersma: My daughter is 14 and she had beautifully straight teeth until a year ago, at which point they started to shift and twist behind each other. Our dentist dismissed her concerns, saying "there's no such thing as perfect teeth". What do we do now? My daughter doesn't like watching them get progressively worse but we have been told we need a referral from a dentist to see an orthodontist.
A. Anton Bass: Unfortunately, it's one of life's certainties, like death and taxes, that teeth will progressively shift and become crooked.
There are two courses of action I'd recommend for your daughter: the movement could be stopped with upper and lower retainers, often just worn for one night a month. Alternatively, she could have her teeth straightened, perhaps with clear removable braces, and then wear a retainer to maintain the straight teeth.
If your dentist won't refer you to an orthodontist, you can always refer yourselves. You don't necessarily need a referral to see an orthodontist and these days I see more and more patients who "let their fingers do the walking" and found us on the internet or by word of mouth.
Q. MetalSian: When I was younger I had a removable brace when at primary school, and a type of train track (with open/close doors, not elastic bands) at secondary. I went on to wear my retainers for longer than was suggested to me, every night for over a year, then cut down wearing them one or two nights a week until they broke.
My teeth now, however, have moved and seem to be even worse than before I had the braces.
To me it seems completely pointless to have gone through the years of wearing braces, then following the instructions of my orthodontist, for my teeth to look almost worse now than they did before I started treatment.
To rectify this problem would it mean having to have even more braces? And is there any way to guarantee the teeth not moving back? Or could I even complain to my original orthodontist?
A. Anton Bass: As I said to Drummersma, one of life's certainties is that teeth will progressively shift and become crooked, whether someone has had braces or not.
The only way I can guarantee the teeth not moving after orthodontic treatment is for my patients to wear retainers for life. However, once my patients have been out of braces for a couple of years, the retainer usually only needs to be worn one night a month. Fixed retainers are also available, which are small wires fitted behind the teeth out of sight, I almost always fit a lower fixed retainer.
If you would like to bring your teeth back to their former glory, the only way is with braces again. These days there are many subtle, almost invisible and removable options instead of the traditional fixed-metal type.
Q. HettySpaghetti: I'm 38 and I have extremely crooked teeth. They're very hard to clean. I had shocking dentists as a kid, which now reduces me to a gibbering wreck when I go to the dentist. I have recently booked my first dentist appointment in years. Is there anything they can do to straighten my teeth that won't cost silly money?
A. Anton Bass: Firstly, you need to keep in mind that a visit to the orthodontist is a very different experience from a visit to the general dentist, and that there are none of those familiar sights and smells you remember from your childhood. Secondly, there are many options available for straightening your teeth - from nearly invisible removable braces to fixed ones, some more cost-effective than others.
However, the options which are possible for you depends on the severity of the problems and how much you would like done, I always tailor my treatment to individual needs. It is best that you start with an orthodontic consultation to explore all your options.
Q. Xstargirl: When I was younger the dentist referred me to the orthodontist as one of my teeth was growing sideways. But due to mistakes, I never got it looked at. I still only have the milk tooth where the errant tooth should be, should I get this looked at now, or is it too late?
Also, I have a very small jaw and very large upper front teeth in particular, and they have overlapped considerably since my early teens. Can this be corrected now, and if so would it be available on the NHS as it's considered "cosmetic" work?
A. Anton Bass: I would strongly advise that you have this errant tooth assessed, it is probably too late to encourage it to grow into your mouth, but there is risk that it could be growing ectopically and causing damage to the roots of teeth and other structures.
With regards to your orthodontic treatment, which is a separate issue, It is unlikely that this could be carried out in an NHS practice, however, treatment may be available at a teaching hospital.
Your priority is to have the errant tooth looked at by your general dentist, he may need to refer you to have it removed. At the same time seek advice about local dental teaching hospitals for orthodontic treatment.
Q. Meala: I have protruding front teeth and hate my smile. I have a large overbite and have two natural bite positions. As a teenager my orthodontist used fixed braces to move my bite back but the overbite is back, and worse than ever.
I have plucked up courage and have seen two orthodontists who advise that the only option is fixed braces for one year, jaw surgery and then more braces. Is there any alternative? I am wary of surgery but also depressed by the state of my teeth.
A. Anton Bass: Unfortunately, your teeth have relapsed since your orthodontic treatment as a teenager, which is likely due to continued growth of your jaws, which can't be controlled, even with retainers. It certainly sounds like you are very bothered by your teeth and smile, which is reason enough to do something about it.
It is difficult to advise on alternatives as I haven't assessed your case, but if two orthodontists have both advised on surgery, this is probably considered the best option to give you the results you would like. It may help to meet the potential surgeon (if you haven't already) to discuss the procedure and put your mind at rest. I always advise this for my patients and they are usually much happier after.
The alternative treatments may be just to straighten the teeth without changing the jaw positions, however this will be a compromise and you will continue to have two natural bite positions. This is a very important decision, which you have to make for yourself by weighing the relative risks of the surgery and the gains from having your teeth and jaws corrected.
Q. Mercibucket: If children need braces, how do you choose a good orthodontist? Is there a register? Where can you find feedback from previous clients etc?
A. Anton Bass: Traditionally the best way to find an orthodontist is to get a referral from your general dentist, as there is already a relationship of trust between you and your dentist. However, many patients we see nowadays are self-referred, they've seen us on the internet and heard about us through word of mouth.
The best place to find a register of specialist orthodontists is the General Dental Council (GDC) website. Unfortunately, I don't know of any official places to find client feedback, but I wouldn't be surprised if there was a website or two where you could read about patients' experiences.