Our goal in orthodontic treatment is to provide the best possible outcome in the shortest possible time with the least biological, financial, and psychosocial cost to our patients. When those results are functionally necessary and beneficial to the psychosocial well-being of our patients, we would like to begin as soon as possible. However, if we think that beginning earlier extends the duration of treatment and increases costs without sufficient warrant, we would delay treatment. Deciding when to initiate treatment may be complicated, and this certainly has been debated in the orthodontic literature. In this chapter, we review the differing opinions of appropriate timing, discuss the research findings on this topic, and, based on these findings, formulate a guideline for various specific orthodontic problems.
1 What is the definition of early treatment and what does it involve?
Early treatment, or Phase I orthodontic treatment, is defined as “treatments started in either the primary or mixed dentitions that are performed to enhance the dental and skeletal development before the eruption of the permanent dentition. Its purpose is to either correct or intercept a malocclusion and to reduce the need or the time for treatment in the permanent dentition.”< ?xml:namespace prefix = "mbp" />1
As opposed to the conventional late orthodontic treatment, when orthodontic therapy is initiated on children in the late mixed dentition stage, early treatment is often a two-phased treatment. Phase I treatment typically begins when the child is about 8 years or younger and lasts about 6 to 12 months. This is followed by intermittent observation of transition from the mixed to the permanent dentition. Phase II treatment, usually with the fixed orthodontic appliances on permanent teeth, begins 6 to 9 months before the eruption of the second molars.2 It has been estimated that one fourth of all patients, and one third of all children, are treated in a two-phase manner.3,4
Single phase treatments have gained popularity in contemporary orthodontics.2 Here early treatment is initiated in the late mixed dentition, just before the loss of the deciduous second molars, and is followed immediately by banding and bonding of the permanent teeth. Reduction in the total treatment time and better control of the leeway spaces in the transitional dentition are some advantages of this methodology.
2 What are some perceived advantages of early treatment?
In 2001, the Diplomates of the American Board of Orthodontics were asked about their perception of early treatment. The following points were listed1:
Ability to modify skeletal growth is one of the strongest perceived benefits of early treatment.
Better and more stable treatment results are another presupposed advantage of early treatment. By correcting the malocclusion as soon as it develops, we are establishing more normal function and development.
Less iatrogenic tooth damage may be another benefit of early treatment. The less developed roots of permanent teeth may mean more favorable biologic responses to orthodontic forces.
Better cooperation is another possible justification for early treatment. Patients may be more cooperative if they are treated before they reach high school. Older children tend to have more outside interests or parental conflicts at home, making orthodontic treatment a lesser priority in their lives.5 Earlier treatment can mean an earlier finish. Patients who begin orthodontic or orthopedic treatment in the second or third grade are likely to finish Phase II before high school. Furthermore, scheduling of appointments for these patients may be easier when they are in middle school as opposed to high school.
Improved patient self esteem and parental satisfaction are also listed as benefits of early treatment. There is a clear correlation between improved esthetics and psychosocial well-being. Malocclusion is listed as one of the most common reasons for teasing in children.6 Moreover, parents, teachers, and peers are more likely to respond positively to attractive children. From this standpoint, early treatment is especially beneficial to children with debilitating malocclusions.
3 What are the perceived disadvantages of early treatment?
The Diplomates of the American Board of Orthodontics were also asked to list the perceived disadvantages of early treatment1:
Variation in results and stability is listed as a major disadvantage.
Increased financial cost to the patient is another drawback of a two-phase treatment.
Patient “burnout” from longer total treatment duration is a concern.
Iatrogenic problems may be more prevalent when starting treatment early. These problems may include dilacerations of roots, decalcification under bands, impaction of maxillary canines by prematurely up-righting the roots of the lateral incisors, and impaction of the maxillary second molars from the distalization of first molars.
Moreover, treatment of younger patients may be more uncertain because of the unpredictable dynamics of growth. Treatment goals can be more definitive in older children.5
4 What are the controversies concerning early treatment?
There have been many debates about the justifications of early treatment. Orthodontists have asked if early treatment is worth the extra cost, time, and energy involved. If early treatment is effective, just how early can treatment begin in the primary, early mixed, or late mixed dentition?
Interestingly, orthodontists are more likely to recommend Phase I if they are more experienced with early treatment, or if their practices have younger children.5 Yet according to Johnston, clinicians “have a responsibility, individually and collectively, to sift through and evaluate the available evidence with an eye toward the delivery of ‘evidence-based’ treatment.”7 The early treatment proposals should be based less on perceived benefits or personal experiences and more on current research findings.
So what are the scientific studies suggesting about early treatment? The following questions are reviews of studies on treatment timing, as well as suggestions of when to begin.
5 What are the problems that can be treated in the primary dentition?
DIGITAL AND PACIFIER HABITS
In most cases, treatment for a prolonged digital or pacifier habit should be initiated between the ages of 4 and 6 years, before the eruption of the permanent incisors. Keep in mind that anteroposterior dental and skeletal changes are less likely to self-correct than are the vertical dental changes.8 Anterior open bites resulting from digital sucking do not generally need to be treated because they will likely correct spontaneously if the habit ceases before 9 years of age.8 Skeletal open bite and distal step molar relationship, on the other hand, may worsen unless treated early.
POSTERIOR CROSSBITE WITH A FUNCTIONAL SHIFT
It is important that a posterior crossbite with the presence of a functional shift be treated as soon as it is diagnosed to prevent the asymmetrical positioning and growth of the condyles.9 The true cause of such a crossbite is a bilateral constriction of the maxillary arch. In order to have at least one side of functioning posterior occlusion, the condyles are positioned asymmetrically within their respective fossae, resulting in the characteristic midline discrepancy in centric occlusion. If left untreated, this condition can lead to asymmetrical growth of the mandible and possible remodeling of the glenoid fossa.10 A permanent facial asymmetry may result and persist, even though the constricted maxillary arch is corrected at a later date.9
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