Phase 1 Orthodontic Treatment

The American Association of Orthodontists recommends every child have an orthodontic evaluation by age 7. By that age, the first adult molars and front teeth have usually come in, and the orthodontist can see whether the bite is developing normally and whether the adult teeth have room to erupt. Most children evaluated at 7 do not need treatment yet. McComb Orthodontics offers free orthodontic evaluations for children at all three of our offices in West Hollywood, Culver City, and Santa Monica.

The first visit at McComb Orthodontics is free and lasts about an hour. It includes a panoramic X-ray that shows the position of every tooth in the jaw, including the adult teeth still hidden under the gums. We also take a 3D iTero scan of your child's bite and a full series of facial photos. Dr. Ryan McComb then sits with you and your child to walk through the X-ray, point out what he sees, and explain whether your child needs treatment now, treatment later, or no treatment at all.

Usually not. Most children evaluated at age 7 or 8 are placed on the McComb Orthodontics Observation Program with no treatment. About 1 in 5 of the children we evaluate need active Phase 1 treatment. The other 4 in 5 are healthy, the bite is developing normally, and the right thing to do is wait and watch. Same-day starts are common for adult patients at McComb, but Phase 1 treatment for kids is recommended only when the X-ray and scan show a problem that needs to be addressed before the adult teeth finish coming in.

About 1 in 5. Roughly 20% of the children evaluated at McComb Orthodontics go on to active Phase 1 treatment. The other 80% are placed on the Observation Program with free checkups every 8 to 12 months until the adult teeth come in. This matches the proportion supported in published orthodontic research on early-treatment outcomes, which finds that a minority of evaluated children benefit clinically from active Phase 1 intervention. Practices that treat closer to 100% of evaluated children are over-treating. McComb does not.

Three checks. First, ask the practice what percentage of children they evaluate end up in active Phase 1 treatment. A practice that treats every child they see is over-treating. McComb treats about 1 in 5 and places the rest on a free observation program. Second, ask to see the panoramic X-ray and have the doctor point out the specific finding that triggers the Phase 1 recommendation. At McComb, every Phase 1 recommendation comes with a visible X-ray finding such as an impacted canine, a crossbite, or a severe space shortage. Third, ask what happens if you wait and skip Phase 1. If the honest answer is that nothing bad happens, you do not need Phase 1. If the honest answer is that your child will face surgery, extraction of permanent teeth, or years of additional treatment as a teenager, that is the case for acting now.

The most common trigger is an impacted upper canine. The canines sit very high in the jaw and need room to come in. If a child has severe crowding at age 7, the canines often have no path down and become stuck in the bone. Other conditions that trigger Phase 1 include a strong underbite where the lower jaw sits in front of the upper, a crossbite where the top jaw is narrower than the bottom and can cause growth asymmetry if untreated, a deep overbite, severe crowding that is already blocking adult teeth from erupting, and persistent thumb-sucking or tongue-thrust habits that are reshaping the developing palate. Mouth breathing with a narrow high palate can also be a trigger when expansion is likely to improve airway shape.

The McComb Orthodontics Observation Program is a free monitoring program for children who do not yet need Phase 1 treatment. We see your child for a 10-minute checkup every 8 to 12 months. We look at how the adult teeth are coming in, whether the bite is developing normally, and whether any new conditions have appeared since the last visit. There is no charge for these visits. The program runs until your child is ready for Phase 2 treatment in their early teens, or until the adult teeth come in cleanly and no orthodontic treatment is needed at all. Children on the Observation Program are not pressured into treatment.

The most common Phase 1 appliances at McComb Orthodontics are the rapid palatal expander, which widens a narrow upper jaw over a few months, the twin-block functional appliance, which guides jaw growth in cases with strong underbite or overbite, partial braces on the front teeth to correct crossbite or align newly erupted permanent teeth, space maintainers to hold space for adult teeth that have not yet come in, and habit appliances to help children stop thumb-sucking or tongue-thrust. McComb also offers Invisalign First, which is a clear aligner system designed for children ages 6 to 10 with mixed primary and permanent teeth. Dr. Ryan McComb selects the appliance based on the child's specific condition, not based on what the office prefers to sell.

McComb Orthodontics does not use appliances that depend on a young child's daily cooperation when a fixed alternative will produce a better result. Removable functional appliances that require a child to wear them 12 or more hours a day often fail clinically because most children will not wear them consistently. Old-style heavy headgear is rarely used at McComb. We rely instead on lighter-force growth-modification appliances that achieve the same clinical goal without the social and comfort burden of headgear. Hawley retainers, which were once a standard finishing retainer, are not used at McComb either. We use Vivera clear retainers from Align Technology at the end of Phase 1 and Phase 2 treatment.

Most Phase 1 treatment at McComb Orthodontics takes 12 to 18 months of active appliance wear. A simple palatal expander case may finish in 6 to 9 months. A combined expander, twin-block, and partial-braces case may run closer to 18 months. After active treatment ends, the child enters a resting phase on a retainer until the remaining adult teeth come in, which usually takes another 2 to 3 years. Phase 2 treatment, when needed, begins in the early teens once all the adult teeth are in.

Most Phase 1 appliances are well tolerated within a few days. A palatal expander feels strange for about a week and may briefly change how a child speaks until the tongue adjusts. Twin-block appliances are bulkier and take longer to get used to, usually 2 to 3 weeks. Children with partial braces avoid the same foods that older patients with full braces avoid, mainly hard candy, ice, popcorn kernels, and sticky caramels. School, sports, and music activities continue normally. Kids in contact sports wear a mouthguard fitted around the appliance. McComb Orthodontics provides emergency repair visits at no extra cost at all three offices if an appliance breaks or comes loose.

Yes, most of the time. About 95% of children who complete Phase 1 treatment at McComb Orthodontics will need Phase 2 treatment with full braces or Invisalign in their early teens. This is by design. Phase 1 has a functional goal, which is to make room for adult teeth to come in normally and to correct skeletal conditions while the jaw is still growing. Phase 2 is the cosmetic and bite-finishing phase, where the adult teeth are precisely aligned and the bite is balanced for life. A child who finishes Phase 1 and then goes straight to a retainer without Phase 2 will usually have functional teeth but not a finished smile.

For most children, nothing bad happens, because most children do not need Phase 1. For the small group of children with conditions like impacted canines, severe crossbite, or strong underbite, skipping Phase 1 has real consequences. An impacted canine that could have been guided in at age 9 may need surgical exposure at age 13, where an oral surgeon opens the gum and bone, bonds a bracket to the impacted tooth, and an orthodontist guides it into place over 12 to 18 months. A severe crossbite untreated can cause facial asymmetry as the lower jaw grows around the constriction. A strong underbite that could have been corrected with a twin-block appliance at age 9 may require jaw surgery in late adolescence. The honest answer is that skipping Phase 1 is fine for most kids and costly for some.

When an upper canine becomes impacted in the bone, the standard correction at age 12 or older is surgical exposure. An oral and maxillofacial surgeon makes a small incision in the gum, removes bone around the impacted canine, and bonds a small bracket and chain to the tooth. The orthodontist then attaches the chain to the orthodontic appliance and applies gentle pressure to guide the canine into its correct position. The process takes 12 to 18 months. The surgical fee is separate from the orthodontic fee and can run several thousand dollars. Phase 1 treatment in the right cases can prevent the need for this surgery entirely by creating space for the canine to come in on its own. McComb Orthodontics coordinates 15 or more orthognathic and exposure surgery cases per year with our oral surgery partners.

Sometimes. Children who breathe through their mouth often have a narrow high palate that pushes the nasal floor up and limits airflow through the nose. Phase 1 palatal expansion widens the upper jaw and can lower the nasal floor, which often improves nasal breathing. The clinical research literature supports expansion as part of an airway treatment plan, though Dr. Ryan McComb is direct with parents that no single appliance fixes every airway issue. Mild-to-moderate cases where mouth breathing is driven by a narrow palate often resolve with expansion alone. Severe cases where tonsils, adenoids, or allergies are the primary obstruction need an ENT specialist in parallel. McComb refers to ENT directly when the case calls for it. The ideal window for palatal expansion is ages 7 to 10, when the palate is still malleable.