434 Dental Update November 2002

Abstract: The time at which orthodontic treatment should be started remains a

matter of conjecture. Anomalies of dental development and functional problems tend to
be addressed in the mixed dentition, while definitive treatment tends to be delayed
until the late mixed dentition to maximize growth potential and patient compliance.
However, some clinicians advocate starting treatment earlier in certain types of
malocclusion. In this article, the current concepts of early treatment, both physiological
and psychological, will be explored and the relevant indications and contraindications
discussed.
Dent Update 2002; 29: 434441
Clinical Relevance: General dental practitioners need to have an understanding of
the timing of orthodontic treatment in different types of malocclusion to maximize the
effectiveness of patient referrals.
T H E B E L L E M A U D S L E Y L E C T U R E 2 0 0 2
ithin the practice environment,
dentists are the first to examine
and screen children for developing
malocclusions. They are often faced with
the dilemma of deciding at what age to
refer for a further opinion and possibly
treatment. This of course depends on the
problem that has been diagnosed and the
dental development of the child, but is
there an ideal time for orthodontic
treatment, if the clinician wants to
maximize the benefits of growth and co-
operation without subjecting every child
to four or more years of treatment?
MANAGING THE
DEVELOPING DENTITION
From the eruption of the first primary
tooth until the development and eruption
of the wisdom teeth, the developing
dentition should be monitored and
interceptive treatment prescribed as
necessary. There is a difference, however,
between treatment decisions that are
thrust upon us due to aberrations of
dental development and types of
malocclusion that we may choose to treat
early by use of appliance therapy or
elective extraction of teeth. Table 1 lists
the problems that should be looked for at
various stages of dental development.
It is obvious from these lists that the
management of certain problems such as
skeletal discrepancies or crowding can be
undertaken at differing times during the
dental development. When early
treatment is contemplated, especially if it
involves the use of active appliances, the
following questions should be asked:
1
l Will early treatment correct the
problem or eliminate the need for
comprehensive treatment at a later
date?
l Will the final result of two-phase
treatment be better than that of a
single course of treatment at a later
stage?
l Will early treatment reduce the risk
of trauma to susceptible incisors?
l Will early treatment result in greater
skeletal change than treatment
during the growth spurt?
l Will early treatment reduce the
severity of the problem to make a
second phase of treatment easier
and of a shorter duration?
l Will early treatment create problems
or reactions that are undesirable?
l Will early treatment have a
beneficial psychological impact on
the patient?
The Timing of Orthodontic
Treatment
ANDREW DIBIASE
Andrew DiBiase, BDS(Hons), MSc, FDS(Orth),
MOrth RCS(Eng), Consultant Orthodontist, Kent
and Canterbury Hospital, Canterbury.
W
Early mixed dentition:
l Delayed eruption of permanent incisors
l Supplemental incisors
l Early loss of deciduous teeth
l Congenital absence of incisors
l One or more incisors in crossbite
l Impaction of first permanent molars
l Severe crowding
l Severe skeletal discrepancy
l Posterior crossbites
Late mixed dentition:
l Severe skeletal problems
l Unfavourably positioned canines or
other teeth
l Congenitally absent permanent teeth
l Poor-quality first permanent molars
l Traumatic overbites
Early permanent dentition:
l Severe skeletal problems
l Impacted teeth
l Crowding
l Hypodontia
Table 1. Problems to look for in the developing
dentition in relation to timing of orthodontic
treatment.
B E L L E M A U D S L E Y L E C T U R E
Dental Update November 2002 435
It is also important to differentiate
between interceptive and definitive
treatment: interceptive treatment is
intervening in the developing dentition
to allow it to achieve the best occlusion
possible, or to make subsequent
treatment as simple and short as
possible. Therefore, although certain
problems may be addressed earlier, there
is a difference between a 6-month
course of treatment in the mixed
dentition followed by later treatment in
the early permanent dentition and a
definitive course of treatment that
commences in the mixed dentition and
extends over several years.
EARLY MANAGEMENT OF
TOOTH SIZE/ARCH SIZE
DISCREPANCIES
Historically, the enforced early loss of
deciduous teeth (usually due to caries)
often necessitated a decision whether to
balance (to maintain the centre line) or
compensate (to maintain the buccal
relationship) with further extractions,
especially when crowding was present.
The advances in restorative techniques
in paediatric dentistry and the more
universal availability of comprehensive
treatment with fixed appliances has
meant these procedures tend to be
carried out less and less. Conversely,
current practice dictates that deciduous
canines are often extracted early in the
hope of correcting the palatal
displacement of their permanent
successors. A more elective choice is
the early extraction of teeth for the
relief of crowding. This can range from
the removal of upper primary canines to
create space for upper lateral incisors
and stop them erupting into crossbite,
to serial extraction. The latter procedure
is rarely undertaken in its entirety now
that comprehensive appliances are more
readily available. Early extraction of
premolar units in the late mixed dentition
before eruption of the canines to allow
alignment of the labial segments,
however, remains a common practice.
The advantages of this are that it allows
for spontaneous alignment of
labiolingual displacement of the incisors
(especially in the lower arch), if the
canines are mesially inclined.
2
In the
upper arch there is little or no
spontaneous alignment of the incisors,
but early loss of first premolars when
the canines are unerupted, buccally
displaced and short of space will allow
for eruption of these teeth into the line
of the arch. There is evidence that early
extraction of first premolars, followed by
active appliance therapy, results in less
lower incisor irregularity than treatment
with first premolar extractions and fixed
appliances, once all the permanent teeth
(except the second molars) have
erupted.
3
If non-extraction treatment is planned
and begins before loss of the second
deciduous molars, in the lower arch the
leeway space can be used for relief of
crowding, as shown in Figures 13. If a
lingual arch is placed during the mixed
dentition only an arch length decrease
of 0.44 mm has been reported, leaving an
average of 4.44 mm leeway space.
4
This
allowed for the resolution of crowding in
60% of 107 patients with an average of
4.85 mm crowding at the start of
treatment. It must be remembered,
Figure 1. Class II division 2 malocclusion with
crowding: (a) right buccal view; (b) labial view;
(c) left buccal view.
a b
c
Figure 2. Treatment for the dentition shown in
Figure 1: commencement before loss of lower
second deciduous molars: (a) right buccal
view; (b) labial view; (c) left buccal view.
a b
c
436 Dental Update November 2002
however, that in patients in the primary
dentition there is often a straight
terminal plane at the distal aspect of the
second deciduous molars. If there is
spacing in the primary dentition as the
permanent maxillary and mandibular
first molars erupt, the space mesial to
lower deciduous molars lets these teeth
move forward, allowing the permanent
molars to erupt into a Class I
relationship. This is called an early
mesial shift (Figure 4). However, if there
is no spacing between the deciduous
teeth (i.e. a closed primary dentition),
there is no mesial movement of the
mandibular deciduous molars as the
permanent molars erupt, and they erupt
into a cusp-to-cusp relationship. The
mandibular leeway space therefore
allows for mesial migration of the lower
first molars into a Class I relationship
as the deciduous molars are shed. This
is called a late mesial shift (Figure 5).
Therefore, if lower arch length is
preserved to use the leeway space to
relieve crowding, correction of the
molar relationship will require
distalization of the maxillary first
molars, often using headgear.
Crowding is thought to be related to
the dimension of the dental arches in
that the greatest crowding exists in the
narrower arches.
5
This has led some
clinicians to advocate active expansion
of the arches in the mixed dentition in
an attempt to create space to
accommodate the complete dentition.
Unfortunately, it appears that lower
arch width, particularly in the
intercanine region, typically decreases
after treatment, regardless of whether a
case was expanded during treatment or
not. This results in higher degrees of
relapse in cases where there has been
enlargement of the mandibular arch.
6
EARLY MANAGEMENT OF
POSTERIOR CROSSBITES
Crossbites with displacement are
generally thought to be a functional
indication for early orthodontic
treatment. The aim is to stop the
crossbite becoming established in the
permanent dentition, as crossbites with
displacement are one of the few
occlusal traits that have a slight
association with the development of
temporomandibular joint dysfunction
later in life.
7
There is evidence of
asymmetric muscle activity and altered
bite force in children with a posterior
crossbite with displacement.
8,9
Treatment in the primary or early mixed
dentition by selective grinding and
active expansion with a removable plate
is thought to decrease the risk of the
crossbite being perpetuated to the
permanent dentition.
10
Figure 3. Dentition shown in Figure 1 at end
of active treatment: after 22 months: (a) right
buccal view; (b) labial view; (c) left buccal
view.
a b
c
Figure 4. Early mesial shift in spaced
primary dentition.
Figure 5. Late mesial shift in closed primary
dentition.
B E L L E M A U D S L E Y L E C T U R E
B E L L E M A U D S L E Y L E C T U R E
Dental Update November 2002 437
One factor that encourages early
treatment is the fact that correction can
often be achieved very simply with
removable appliances and minimal
patient compliance within a reasonably
small time period. As such it is a
procedure that can often be carried out
in general practice. Although fixed
expansion devices such as the
quadhelix may result in orthopaedic as
well as orthodontic expansion,
11
there
is evidence that removable appliances
and quadhelices produce similar
amounts of dental and skeletal
expansion and have similar relapse
rates,
12
but that the use of removable
appliances with midline expansion
screws may result in less buccal tipping
of the posterior teeth.
13
Rapid maxillary
expansion has been found to produce
more bodily movement of teeth.
12
EARLY MANAGEMENT OF
CLASS III MALOCCLUSIONS
The correction of anterior crossbites in
the mixed dentition may prevent loss of
periodontal attachment of the lower
incisors. If only one or two incisors are
in crossbite and there is adequate
space available, a removable appliance
can often be used
14
(Figure 6): if space
needs to created and more bodily
movement of teeth is required, better
results may be achieved with simple
fixed appliances
15
(Figure 7). The
success of either depends on creating a
positive overbite at the end of
treatment.
Both the above scenarios primarily
relate to skeletal I or mild skeletal III
relationships. Other methods of early
correction of severe skeletal
relationships have been described,
including the use of functional
appliances
16,17
(Figures 810),
protraction headgear,
18,19
chin caps
20
and headgear to the lower arch.
21
All of
these treatment modalities surprisingly
seem to have similar clinical effects:
proclination of the upper incisors,
retroclination of the lower incisors and
rotation of the mandible downwards
and backwards. There also appears to
be a slight anterior movement of the
maxilla when protraction headgear is
used, especially when accompanied by
palatal expansion.
18
The skeletal effects
of protraction headgear also appear to
be greater in pre-adolescent patients.
19
Early treatment of Class III
malocclusions is generally not
successful in cases with increased
lower face height and minimal
overbites. The overriding factor in
whether treatment is successful is the
underlying growth pattern, which tends
to re-impose itself following treatment,
especially mandibular prognathism.
EARLY MANAGEMENT OF
CLASS II MALOCCLUSIONS
There is currently a resurgence in
interest in the concept of two-phase
treatment: early use of functional
appliances in the mixed dentition,
followed by a period of retention and
then a second phase of treatment,
usually involving the use of fixed
appliances. The advocates of early
treatment feel that starting early will
maximize the chances of growth
modification (especially in female
patients who tend to reach their
skeletal maturity earlier), allow for two
chances to correct the malocclusion
and avoid problems of compliance
often encountered in adolescents.
22
It has been shown, however, that the
skeletal contribution to correction of
Class II division 1 malocclusions
treated with twin blocks is greater if
treatment is carried out during or
slightly after the onset of the pubertal
peak in growth velocity.
23
Similar
findings have been reported for the
Bass appliance,
24
the Herbst appliance
25
and the FR-2 appliance.
26
Further
research has also shown that the early
a b
Figure 6. Correction of anterior crossbite with removable appliance.
Figure 7. Correction of anterior crossbite with
fixed appliance.
a b
c
438 Dental Update November 2002
use of functional appliances has little
or no long-term benefit in terms of
enhanced growth or better outcome
over later one-stage treatment.
27,28
So, if there are no advantages in early
treatment physiologically, are there any
psychological advantages? There is
substantial evidence that the dental
appearance has an effect on social
perceptions and interaction,
29
and can
be a target of teasing.
30
The negative
impact of malocclusion on self-
perception appears to increase with
age.
31
Despite this, early treatment for
Class II malocclusion has been reported
to have no effect on self-concept,
32
although within this study the children
looked at did not present for treatment
with low selfconcept in the first place.
This is supported by other work which
found that pre-adolescent children
awaiting orthodontic treatment generally
have higher than average self-concept.
33
More recent work, however, may show
that early treatment increases self-
esteem (K. OBrien, personal
communication). Figures 1113 show the
case of a patient in the mixed dentition
who requested treatment as a result of
concerns about teasing at school.
One consistent finding is the
increased incidence of trauma to the
upper labial segment in pre-adolescent
children with increased overjets.
34,35
Increased overjet appears to be a greater
contributor to traumatic injury in girls
than boys, even though traumatic injury
frequency is greater in boys.
35,36
A high
percentage of these injuries occur
before the age of 10 years, especially in
boys
34
(probably due to the rougher
nature of boys activities and their more
active participation in sports).
35
An advantage of starting functional
appliance therapy in the late mixed or
permanent dentition is that the
functional phase of treatment can be
followed almost immediately by the fixed
appliances, which can incorporate
mechanics designed to stabilize the
newly established occlusion. By starting
treatment in the mixed dentition, there
will inevitably be a period when the
clinician is awaiting further dental
development before further treatment
decisions can be made. This will mean
either that treatment will have to be
discontinued during this period or that
some form of retention regime will have
to be implemented. This may consist of
wearing the appliances just at night, the
use of headgear or the use of simple
removable retainers. If the last policy is
pursued, incorporation of an inclined
anterior bite plane on an upper
removable appliance will help to
maintain the sagittal correction and
allow the lateral open bites to improve
as the dentition develops.
37
EARLY TREATMENT AND
COMPLIANCE
Another factor that has been used to
favour early treatment is the greater
compliance obtained from pre-
adolescent patients. This has certainly
been reported for adherence to
instructions given for removable
appliances
38
and for headgear wear,
39
although some studies have found no
correlation between patients age and
level of co-operation.
40,41
Younger
children are usually influenced by their
parents and other adults but
adolescents are more susceptible to
peer pressure, especially in terms of
self-image. Of course this can act in
either direction when trying to
encourage compliance to orthodontic
treatment: if an adolescent has
significant concerns about the
appearance of his or her teeth and has
a
b
Figure 8. Class III malocclusion with anterior
displacement on closing.
Figure 9. Class III Twin Block appliance used to
treat the malocclusion shown in Figure 8.
a
b
Figure 10. Patient shown in Figure 8 at end of
active treatment, after 6 months.
B E L L E M A U D S L E Y L E C T U R E
B E L L E M A U D S L E Y L E C T U R E
Dental Update November 2002 439
440 Dental Update November 2002
a
b
Figure 13. Patient shown in Figure 11: end of
active treatment (after 14 months).
friends who are undergoing
orthodontics, the treatment will have
peer acceptance and compliance may
be forthcoming; however, if no peers
are undergoing treatment, orthodontic
treatment may not be accepted.
Pre-adolescent children seem less
concerned about peer approval and the
here and now.
33
This age group is
generally aware of the reason for
referral for orthodontic treatment, and
understands the perceived benefits of
treatment.
33
There is therefore no
indication that pre-adolescent children
are not psychologically ready for
treatment. One of the disadvantages of
early treatment, however, is often the
requirement for a second phase of
treatment in the early permanent
dentition. Whether the compliance
during this second stage of treatment is
affected by starting treatment in the
mixed dentition is unknown.
CONCLUSIONS
l Expansion of the lower arch in mixed
dentition to address crowding is
inherently unstable.
l When correctly planned, early
extraction of teeth for the relief of
crowding may result in increased
long-term stability particularly in
the lower labial segment and
simplify appliance mechanics during
active treatment.
l Treatment in the mixed dentition is
indicated for anterior and posterior
crossbites with displacements on
dental health grounds.
l If protraction headgear is planned
for treatment of Class III
malocclusions, treatment should
commence in the mixed dentition for
maximum benefit.
l Early treatment with functional
appliances for Class II division 1
malocclusions does not appear to
result in greater skeletal change
than later treatment, and does not
appear to offer any psychological
benefits in the average child.
l Risk of trauma to the upper labial
segment may justify early treatment
of Class II division 1 malocclusions,
especially in girls.
l Most orthodontic treatment can be
started in the late mixed dentition
just before loss of the primary
mandibular second molar. This will
maximize growth potential and
compliance, allow for utilization of
the leeway space and keep overall
active treatment time as short as
possible .
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B E L L E M A U D S L E Y L E C T U R E
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THE BELLE MAUDSLEY 2002
PRESENTATION
Professor C.D.Stephens OBE, Dental Update
Advisory Board member and President of the
British Orthodontic Society, congratulating
Andrew DiBiase on the award of the 2002 Belle
Maudsley Prize following his delivery of the 2002
Belle Maudsley Lecture. The Societys annual
conference was this year held at the Scottish
Exhibition and Conference Centre and was
attended by 1400 delegates including 40 from
overseas.
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