Early orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION:

There is an on going discussion among orthodontists as to the optimal time to initiate
orthodontic treatment under various clinical situations. Since the objectives of
orthodontic care must include the minimal amount of treatment that achieves the
maximum benefit for the patient, the timing of the commencement of treatment becomes
of paramount importance. Patient should expect and receive only that amount of
treatment that minimizes both the biologic and financial cost to them and yet obtain the
optimal outcome.


2 -phase treatment became plausible with the emergence of the functional matrix
hypothesis by Moss in 1960s. This theoretical basis provided a rationale to shift
from the restrictive genomic paradigm of Brodie, who considered that the pattern
of craniofacial growth was established by 3 months in the infant and was
immutable, to the functional matrix paradigm of the 1970s, which provided a
rational basis to promote functional appliances to correct the skeletal pattern
during growth.

The challenge facing orthodontists in the 21st century is the need to integrate the
scientific evidence into practice. It needs to be evaluated from 2 perspectives:

•

EFFECTIVENESS: how well it works?

•

EFFICIENCY: how much it benefits patient in terms of cost and risk.


EARLY TREATMENT OF CLASS II
Growth modification is advocated as an early intervention in the treatment of
growing Class II patients. These include the various functional appliances
like Twin Blocks, Activators, Functional regulators etc.

It would appear that functional appliances will be more successful during a
period of rapid growth. Bjork found as patients grew older the effectiveness
of functional appliances reduced. Broadbent stated that skeletal maturity
influenced the treatment outcome.


Pancherz & Hagg on using Herbst appliance, found that there was an increrased
condular growth response when the functional appliance treatment was carried out
close to the period of most rapid growth in stature,ie; Peak Height Velocity.
Therefore the major consensus seems to be that treatment should be carried out

GROWTH / UNIT TIME

during the Peak height Velocity stage.

AGE 2

PHV

adult
juvenile

adolescent
10 / 12
14 / 18


An RCT conducted by Tulloch etal(1998) evaluated the benefit of early
Class II treatment and concluded that for children with moderate to
severe class II problems, early treatment followed by later
comprehensive treatment on an average does not produce major
differences in jaw relationship or dental occlusion compared with those
treated with one later stage treatment.
Tulloch and Proffit(2004) published the outcomes of their 2 phase RCT and
concluded that:
• 2phase treatment started before adolescence in mixed dentition might not be an
more clinically effective than a single phase treatment started during adolescence.
• Early class II treatment is effective but not efficient
• The difference in skeletal and dental morphology achieved in early treatment
disappeared almost completely after comprehensive treatment with fixed appliances.


Kevin O’Brien et al (2003) assessed the effectiveness of early
treatment with twin block (RCT), and concluded that:
• Early treatment with twin block appliance is effective in reducing
overjet and severity of malocclusion.
•Small change in skeletal relation might not be clinically
significant
The Evidence from a Meta Analysis by J Y.Chen et al (2004)
1.

Most important changes from treatment were dentoalveolar

2.

Skeletal change was not clinically significant

3.

Similar response to ANB changes in both headgear and functional
groups !!

4.

Functional appliances do not modify or enhance growth

Some authors argue that an early phase of treatment will help in building up
of patients Self Esteem. But the impact of early treatment on psychosocial
development does not appear to warrant early intervention on the average.
The University of North Carolina in their prospective trials failed to
demonstrate the improvement in self concept with early treatment.


EARLY TREATMENT OF CLASS III
Rationale:
1. To prevent progressive irreversible soft tissue or bony changes
2. To improve skeletal discrepancies
3. To improve occlusal function
4. To simplify phase II comprehensive treatment
5. To provide more pleasing facial esthetics.
Indications:

Turpin developed a list of positive and negative factors such as•

Good facial esthetics

•

Mild skeletal disharmony

•

No familial prognathism

•

A-P functional shift

•

Convergent facial type

•

Symmetric condylar growth

•

Poor cooperation


TIMING FOR CLASS III TREATMENT:
Timing of chin cup treatment for class III malocclusion appears to be irrelevant
for growth modification and stability. This treatment intervention at best
provides temporary results for mandibular protrusion [Sugawara(1997) and
Sakamoto(1987)]
The timing of protraction face mask for class III skeletal maxillary deficiency is
advised during early mixed dentition treatment [Bacetti etal (1998) and Baik
(1987) ]


Early Intervention in the Transverse Dimension
(Gianelly [2004])

 No added benefit of RPE in the absence of cross
bites in relieving crowding.

 Inadequate data to justify routine usage in class II
malocclusions with a view to self correct the mandible !!( Foot
and shoe principle by Mc Namara)


Absolute Indications of Early Treatment Include:
[Ghafari etal (1998)]
• Functional posterior cross bites
• Anterior crossbites
• Openbites
• Early loss of teeth compromising the integrity of arch
• Proclined anteriors that are susceptible to trauma
• Functional disturbances
• Transverse discrepancies


CONCLUSION
Early treatment has its own advantages and indications in specific
conditions as discussed. Case selection is very important. GENETICS
plays an important role in the response of the patient to treatment. Thus
we can only alter the environmental factors and allow the natural growth
to express itself !
It may be advisable to change the terminology

“EARLY TREATMENT”
TO
“EARLY TIMELY TREATMENT”

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Early orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

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