EARLY VS LATE ORTHODONTIC TREATMENT

Dr Santosh Verma
Professor and Head
Department of Orthodontics and Dentofacial Orthopedics
Kothiwal Dental College and Research Centre
Moradabad


Abstract: Orthodontists have made remarkable progress in their understanding of physiology, growth, tissue response, increasingly sophisticated diagnostic techniques, available materials, and information. Nevertheless, with all these advances, many practitioners still find themselves at a total loss when confronted with that eternal dilemma: to intervene or not to intervene before the eruption of the complete permanent dentition. The objective of early treatment is to avoid or to simplify treatment of the permanent dentition. The therapeutic devices available for this endeavor are not complex, but deciding which ones to use and when to employ them is far from simple.

Introduction

The concept of ‘‘early treatment’’ is controversial. Some define it as removable or fixed appliance intervention in the primary, early mixed (permanent first molars and incisors present), or mid-mixed (inter-transitional period, before the emergence of first premolars and permanent mandibular canines). Others define early treatment as late–mixed dentition stage treatment (before the emergence of second premolars and permanent maxillary canines) ₁

Proponents of early treatment believe in the fact that “hindsight is better than foresight”. Applying this adage to Orthodontic treatment it can be said that hindsight should serve as a foundation upon which to develop a better foresight.₂

Orthodontists have made remarkable progress in their understanding of physiology, growth, tissue response, increasingly sophisticated diagnostic techniques, available materials, and information. Nevertheless, with all these advances, many practitioners still find themselves at a total loss when confronted with that eternal dilemma: to intervene or not to intervene before the eruption of the complete permanent dentition₂

Beginning orthodontic treatment early seems eminently logical because it enables the complete or partial correction of many incipient discrepancies or, at least, a reduction in their capacity to grow worse. Interception—or early intervention—employs simple therapeutic techniques that do not overtax the limited stores of cooperation young patients can bring to the therapeutic encounter. Its objective is eliminating or minimizing dentoalveolar and skeletal disorders that interfere with growth, function, esthetics, and the psychological well-being of children.₂

Orthodontic treatment should be in harmony with modern medical thought: ‘It is better to prevent than to cure’. We should not treat the symptom; we should treat the cause. The therapeutic devices available for this endeavor are not complex, but deciding which ones to use and when to employ them is far from simple. The therapeutic choice is nothing more than the last act in a complete diagnostic process. To be capable of determining the optimum moment to begin treatment, orthodontists must possess a profound comprehension of fundamental information that forms the basis of understanding the pathogenesis of different malocclusions: normal and pathologic craniofacial growth, orofacial functional behavior, morphogenesis of the dental arches, and child psychology. Armed with this knowledge, orthodontists can accurately discern which discrepancies would benefit from early treatment and not fall into the trap of indiscriminately treating every patient they examine during the mixed dentition stage.₂

These treatments will be followed eventually by retention and reevaluation after eruption of the permanent dentition is completed: Has the intervention completely resolved the problem, or will a second phase of treatment be needed to finish aligning the teeth? The objective of early treatment is to avoid or to simplify treatment of the permanent dentition.2Therefore, clinicians must decide, on a case by case basis when to provide orthodontic treatment.

DEFINING THE PROBLEM

The key to successful phase I treatment is a comprehensive approach to early treatment3.The recommendation for early treatment is most frequently based on empirical judgment rather than evidence from sound clinical research. Part of the problem is due to differences in the definition of early treatment that can include periods spanning the primary through the mixed dentition.

The benefits of early/interceptive treatment regarding functional crossbite, maxillary canine eruption, and excessive overjet with a trauma risk have been accepted. Regarding Class II malocclusion, studies have not shown early Orthodontic treatment to be more beneficial than treatment started later in adolescence in the permanent dentition. Early Class II treatment has, however, been considered effective in reducing the difficulty of and priority for Phase 2 treatment (King GJ, Wheeler 1999)₃

Treatment in the primary dentition may be indicated for correction of a posterior and/or anterior cross-bite, class II or III malocclusions, premature loss of primary tooth, a cleft palate or crowding. Primary dentition treatment could begin at age 4 to 53. This may be followed up with additional care in the early mixed dentition and more Orthodontic treatment in the permanent dentition. The patient could potentially require three phases of Orthodontic care from the ages of 4 to 15. Another approach to early treatment is a two-phase approach. The first phase begins in the early mixed dentition at approximately age 8, and the second phase starts in the permanent dentition at approximately age 12. Some Orthodontists maintain that early mixed dentition treatment with phase I Orthodontic care can reduce or eliminate the need for full-banded phase II Orthodontic treatment at a later age₄

Others contend that Phase 1 treatment cannot produce lasting treatment results and that the patient will require a second phase of comprehensive care, which increases the number of office visits₅

Orthodontic researchers have analyzed patients’ compliance with early treatment and have shown different results. Some authors state that cooperation is better in the mixed dentition with younger patients than the older adolescent patients4. Others argue that early Orthodontic treatment prolongs Orthodontic care and the patient will tend to “burn out” by the second phase of treatment6. Orthodontic treatment could begin in the late mixed dentition, at approximately age 11, and treatment would then be limited to one phase of Orthodontic care. This approach can be effective in correcting many malocclusions; however, occasionally initiating Orthodontic treatment in the late mixed dentition phase can extend treatment time as much as four years while waiting for eruption of all permanent teeth. Patients can experience “burn out” with this potential prolonged treatment time. Lastly, treatment could begin in the permanent dentition, which could shorten the treatment time and lessen the costs to the patient. The permanent dentition treatment would start upon eruption of the second molars, which may occur from the ages of 10 to 14. Initiating treatment at this stage could present a problem with the physically mature female patient who might complete her growth before eruption of the second molars. If full-banded Orthodontic care is initiated with little or no growth remaining, correcting the class II malocclusion could become very difficult. There may be more need for extractions, surgical Orthodontics, or compromised Orthodontic treatment when the patient has finished his or her facial growth.

One reason for the controversy is that the accepted "cost" of an early treatment time is a two-phase protocol. Phase 1 generally involves 6 to 12 months of active treatment with the intent to change skeletodental relationships. Phase 2 is the "finishing" process after the eruption of appropriate permanent teeth. Thus, risk/reward analysis becomes inevitable. Do the benefits of early intervention justify the cost of two-phase treatment?

Two reports are of interest to define the scope of the problem. The Journal of Clinical Orthodontics survey of diagnosis and therapeutics7 noted that approximately 25% of all patients are treated in a two-phase manner. The AAO May Bulletin indicated that approximately 1.3 million persons in 1992 elected Orthodontic treatment. At 25% penetration, at least 300,000+ patients are in a two-phase treatment program. There are only 900,000+ growing patients since adults comprise 20% to 25% of the patient population. Essentially, a third of all children are treated in two phases.

The premise is that at least 90% of all growing patients can be treated successfully in only one phase by starting treatment in the late mixed dentition stage of development—identified by the exfoliation of all deciduous teeth except the deciduous second molars or the "E"s. Implicit in this view is that there are few, if any, benefits that are unique to and dependent on earlier treatment. Also implicit is that habit control, the use of passive appliances such as space maintainers and minor alignment of incisors for esthetic or trauma reasons, is not considered part of conventional two-phase treatment. The other 5% to 10% of patients includes those with crossbites complicated by a mandibular shift and certain patients with Class III malocclusions who could benefit from immediate resolution of the problem.₇

At the Department of Orthodontics, University of Pacific Arthur A. Dugoni School of Dentistry8, a comprehensive mixed dentition treatment approach is taught to the Orthodontic graduate students. This approach teaches the stu¬dents to closely evaluate the entire mal¬occlusion of patients who are approxi¬mately 7 to 8 years old. After thorough review of diagnostic records, a treatment plan is established to address most or all of the problems present in the early mixed dentition. Treatment with the first phase is designed to correct all the problems. The goal is to eliminate or significantly reduce the need for phase II Orthodontic care. This approach helps to produce a less complicated problem in the second phase, shortening the overall treatment time.

The objectives of early treatment could include establishing ideal overjet and overbite, aligning the upper and lower incisors, establishing ideal torque, tip of the upper and lower incisors, adequate arch length, and obtaining a class I molar position. Treatment typi¬cally uses fixed Orthodontic appliances, including bands on the maxillary first molars and brackets on the upper inci¬sors. Headgear would be used for cor¬rection of most class II malocclusions. A facemask would be used to protract the maxilla forward in a class III skeletal pattern. The mandibular arch is usu¬ally treated with a lingual arch that is removable and adjustable. If crowding is present in the maxillary and/or man¬dibular arch, the first primary molars or primary cuspids are extracted to gain room for alignment of the incisors. The mandibular lingual arch is adjusted at each visit until alignment of the incisors is obtained₈

At the conclusion of the first phase of Orthodontic treatment, the patient will enter a supervision stage until the eruption of permanent teeth. During this supervision stage the patient wears a removable retainer and continues lingual arch to maintain the align¬ment of the lower incisors. Occasionally, headgear is worn during the supervision stage to continue correction of class II molar position or to prevent rebound toward a class II problem.

The investigators believe that the key to successful early treatment includes thorough and accurate diagnosis, comprehensive treatment planning, and continued care during supervision until the eruption of the permanent dentition. The best timing of Orthodontic treatment is a decision made by the Orthodontist, the parent, and the patient based on all the factors that impact success. All options should be reviewed with the parent in order that he or she may make an informed decision. The American Association of Orthodontists, www.braces.org, recommends that all children get a check up with an Orthodontist no later than age ₇

An early exam allows the Orthodontist to offer advice and guidance as to when the optimal time to start treatment would be for that specific patient. ¬¬
“The earlier treatment begins, the more the face will adapt to your standards; the later treatment begins, the more your standards will have to adapt to the face.”—C. Gugin.Recent concepts – The 20th Century

The 1997 Workshop Discussion on Early Treatment cautioned that “iatrogenic problems may occur with early treatment such as dilaceration of roots, decalcification under bands left for too long, and impaction of maxillary second molars from distalizing first molars, and patient burnout.”₉

A recent study at the University of North Carolina concluded that “for children with moderate to severe Class II problems, early treatment followed by later comprehensive treatment does not produce major differences in jaw relationship or dental occlusion compared with later 1-stage treatment”14 . Ferguson 15 wrote that 2-phase treatment “is merely a means to capture patients for Orthodontic treatment and prevent them from going elsewhere.” Bowman16 believed that today’s trends are to treat earlier and often. He ridicules braces for baby teeth and asks, “Can in utero treatment be far off?” Turpin17 summarized the results of the 2002 International Symposium on Early Orthodontic Treatment. ‘Class II correction—a delay in treating Class II problems— might not compromise treatment results, and it can increase efficiency. Patients with severe skeletal disharmony, excessive vertical development, and lack of cooperation obviously make it more difficult to achieve all objectives when treatment is limited to a single phase. A delay in starting treatment allows for self-correction of open bites in some patients, but this is unpredictable. Incisal contact is unlikely in most of these patients in the long term. Examine early to manage arch-length problems, including the need for disking deciduous teeth and selected extractions in some patients. Start treatment before the loss of the deciduous second molars, if possible. To correct Class III disharmony, diagnose and consider early treatment because of the unpredictability of growth. Don’t expect total success in most patients in the long term. If disharmony is severe, delay treatment until you have proof that growth has ceased and include Orthognathic surgery as a treatment option. Diagnose impaction and transposition and consider the need for early treatment because of the severity of complications that can be caused by unerupted and impacted teeth.’

In summary, the main objectives of early treatment lie in 5 concepts:

1. Obtaining a skeletal change (structural).
2. Providing the opportunity of a functional change in the environment.
3. Utilization of the individual growth expression toward the correction.
4. Elimination of detrimental habits (breathing, etc)
5. Taking advantage of the forces of occlusal development toward the correction.

The best timing of orthodontic treatment is a decision made by the orthodontist, the parent, and the patient based on all the factors that impact success. All options should be reviewed with the parent in order that he or she may make an informed decision. An early exam allows the orthodontist to offer advice and guidance as to when the optimal time to start treatment would be for that specific patient.


REFERENCES


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