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Running head: THE CHOICE OF EARLY ORTHODONTIC TREATMENT
The Choice of Early Orthodontic Treatment
Manal Shehada
Madonna University
ESL 5230 – Argumentative paper (D2)
April 1, 2015
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THE CHOICE OF EARLY ORTHODONTIC TREATMENT
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The Choice of Early Orthodontic Treatment
A young woman in her twenties entered the orthodontic clinic seeking help. She was
annoyed by her appearance; she was suffering from upper jaw protrusion. Her jaws had
affected badly on her profile and diminished her beauty. She was suffering whenever she ate or
laughed. The orthodontist examined her and asked her why she had not sought for treatment
earlier in her childhood, but the strange answer, which surprised the doctor, was that she did
but was asked to wait until she grew up and her growth would fix the problem. Unfortunately,
the prediction of lower jaw growth was not enough to fix the problem, actually the situation
was more complicated than it was imagined, and now she will face hard time until she finishes
her treatment. Since Edward Augustus Bogue first called to initiate orthodontic treatment
earlier in primary dentition (Philippe, 2012), orthodontists have been facing the same question
whenever a child enters their clinic: is it better for him to initiate orthodontic treatment earlier
or later. Although some orthodontists may think that early treatment costs more money and
time, its numerous benefits should be considered; as it eliminates malocclusion factors,
modifies abnormal growth pattern, and increase the outcome and the stability of the orthodontic
treatment.
One of the greatest benefits of early orthodontic treatment is eliminating the causes of
malocclusion in the early stages of forming the occlusion. Interceptive treatment is considered a
type of early treatment; even Kerosuo, Heikinheimo, Nyström, and Väkiparta (2013) stated that
early treatment has been considered as interceptive treatment. Interceptive treatment aims to
stop pathogenic factors from initiating malocclusion or exacerbating the existing malocclusion.
King and Brudvik (2010) found that interceptive treatment improved malocclusion in children
without having detailed finishing of the occlusion (as cited in Kerosuo et al., 2013). Functional
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problems are the major factors to cause malocclusion in children. Al-Shayea (2014) explained
the influence of early treatment on functional problems "could be due to the benefits of early
treatment, which include improved facial profile, smile, speech, and self esteem" (P.122). For
that, most orthodontists who responded to the Al-Shayea survey (2014) prefer to treat most of
the functional problems in early stages.
Initiating orthodontic treatment at early stage increases the efficiency of the orthodontic
treatment as early treatment has the ability to modify the growth pattern of the jaws, increase
the orthodontic treatment outcome, and increase the stability treatment of results.
The ability of modifying the growth pattern is considered an exclusive feature for early
orthodontic treatment. Al-Shayea (2014) stated that early orthodontic treatment "takes
advantage of normal growth to modify skeletal growth and corrects the malocclusion" (p.119).
Also, Prabhakar, Saravanan, Karthikeyan, Vishnuchandran, and Sudeepthi (2014) stated that
"many conditions are easier to treat at early stage, when children`s natural growth processes are
intense" (p. ZC60). In addition, Almuhtaseb, Jing, Hong, and Bader (2014) called to remember
that as the patient grows the ability to have skeletal growth modification is reduced, and
delaying treatment will limit the results into more dental effects. That is why they see the
ability to modify skeletal growth as a big benefit of early treatment.
Another feature for early treatment is the increase in the total orthodontic treatment
outcome. Some researchers found that using some orthodontic appliances have more positive
results when they are used in early treatment that what Pirttiniemi et al. (2005) noticed when
using headgear in early treatment; it had a long term positive outcome on crowding as it
increases the length and the width of the dental arches (as cited in Kerosuo et al., 2013).
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Although some have doubts about the influence of the orthodontic treatment timing on
the value of the treatment results, early treatment has some benefits which cannot be noticed in
other treatments. That is what Kerosuo et al. (2013) stated when they said that most studies
have found the results of early and late treatments of class II are similar, still early treatment
was found to reduce the difficulties and the need for second phase in these cases.
Relapsing and losing the stability after finishing the treatment is a nightmare for both
the orthodontist and the patient. Orthodontists make all their efforts to insure that their
treatment results will last after they remove the orthodontic appliances, and the patient will not
need to restart the treatment once again. An important benefit of early treatment is increasing
the stability of the orthodontic treatment results. Kerosuo et al. (2013) claimed that "early
timing of treatments may have contributed to the good long-term stability of treatment results"
(p.188). They reported that cases treated as early treatment in their study was more stable
compared with previous reports 5 years post retention. They founded that extracting premolar
during early treatment resulted in increasing stability comparing to treatment started in
permanent dentition. In addition, both Reitan (1969) and Bergersen (1988) found that
establishing correct occlusion at early stages improve long term stability of the treatment
results (as cited in Kerosuo et al., 2013).
Some researchers found that early treatment effects are not limited to improve child
occlusion and treating his malocclusion. Early treatment also has a positive effect on the child`s
psychological health. It enhances the self-esteem in the child as it improves his or her facial
appearance and stops some bad habits which are a result of his or her psychological condition
such as thumb sucking. O`Brien et al. (2003) noticed that early treatment of patients with class
II has a good influence on young patients as it improves their self concept and positive social
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experience (as citied in Pietilä, Pietilä, Pirttiniemi, Varrela, and Alanen, 2008). In addition,
Kayak (2006) showed that young patients and their parents have high hopes and expectations
toward orthodontic treatment and its effect on the patient psychosocial developing. He also
emphasized the necessity to communicate with patients in the early stages of the treatment to
recognize the children who get benefit from early treatment (as citied in Pietilä et al., 2008).
Early orthodontic treatment benefits from the fact that its patients are younger. It is
known that those younger patients are more cooperative with the doctors, and as a result, the
treatment will take less time and the outcome of the treatment will be higher. Al-Shayea (2014)
mentioned that early treatment is "associated with greater patient compliance among
preadolescent children as they tend to be more adherent to treatment instructions" (p.119).
In general, the many advantages of early orthodontics treatment exceed what has been
noted. Prabhakar et al. (2014) mentioned some of these advantages including, "Minimizing
severe protrusion, Correcting dental and skeletal malformation, Reducing severe over jet,
Creating space for erupting permanent teeth, Modifying aberrant muscle morphology, [and]
Reducing the second phase of treatment" (p. ZC60). Also, Al-Shayea (2014) explained that
early treatment has many advantages such as adjusting skeletal growth to correct malocclusion,
reducing the time and the severity to correct malocclusion in phase II, having better and more
stable outcome, increasing patient self-esteem, and reducing the possibility of tooth damage.
On the other hand, there are some orthodontists who think that the early orthodontic
treatment advantages are not enough of an excuse to overlook its disadvantages. They argue
that the treatment outcomes from early treatment are not so different from those of late
treatment. They believe that early treatment takes a long time and costs more money, and for
that they prefer later orthodontic treatment.
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One of the main accusations against early treatment is that its results are not
significantly better than later treatment results. Hsieh, Pinskaya, and Roberts (2005) concluded
in their study that treatment time did not have essential effects on the final results of the
treatment, and the later treatment is preferred due the benefits of reducing treatment time. They
noticed that occlusion could be finished in both early and late treatment with the same quality.
Pietila et al. (2008) showed that there three clinical studies about the timing of class II division
I take place in the United States. These studies pointed out the improvement in the dental and
skeletal variables after early orthodontic treatment comparing with the control group, but at the
end of treatment the differences between the results of the early and late orthodontic treatment
were minimal. The problem with such accusation is it depends on treating one type of cases,
class II, which have been under controversy for long time, and ignores all the other cases and
the advantages of early treatment on treating them. In fact, some studies showed that the
treatment in the mixed dentition increase the possibility to have better long-term outcome
compared to treatment started in permanent dentition (Kerosuo et al., 2013).
Early orthodontic treatment takes a long treatment time and it is considered as an
important disadvantage of early treatment (Kerosuo et al., 2013). In some cases such as class II
early orthodontic treatment takes a long time. As Hseih et al. (2005) explained that early
intervention to treat class II mostly need two phases. The first one takes place at preadolescent
years and it has restricted purposes and it is usually range from 12-18 months. The second
phase takes place within adolescence and it aims to give the final details for the occlusion and
usually takes from six to 18 months. The duration of treatment depends on the malocclusion,
patient corporation, and growth pattern. There is usually a space between the two phases. On
the other hand, late treatment, which is referred as single phase, takes place in adolescence at
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permanent dentition. Not all cases have to wait to initiate the second phase; Hseih et al. (2005)
founded that 36% of early treatment group had waited to start the second phase while 64% of
them did not have waiting time between the two phases and the extended treatment reached 96
months. As the time of treatment gets longer, the patient compliance reduces; furthermore,
patients begin to miss appointments, neglect oral hygiene, and forget to use elastics or headgear
(Hseih et al., 2005). In addition, Beckwith explained that missing appointments, losing brackets
or bands, and neglecting oral hygiene contributes in increasing the duration of the treatment (as
cited in Hseih et al., 2005). As a result of the long duration of early treatment the patient often
ends treatment prematurely (Hseih et al., 2005). Pinskaya believed that continuing treatment to
patients with a long duration of treatment time and less corporation reverses the treatment goals
and he advised to end the treatment in such cases instead of continuing and ending with poor
results (as cited in Hseih et al., 2005). Hseih et al. (2005) concluded that early treatment group
had longer duration of treatment, worse outcome, and higher rate of unfinished termination
than the late treatment group. The long duration of the treatment has many reasons. Some
orthodontic appliances require patient`s cooperation, but if the patient does not corporate with
the orthodontist the treatment will take more time than expected. For example, using the
headgear in the treatment appears to increase the duration of the treatment. Table 1 shows how
the type of orthodontic appliances affects the duration of the treatment. In addition, such
appliances needing the patient cooperation have the possibility to discontinue the treatment
before achieving the treatment goals (Pietila, Pietila, Svedström-Oristo, Varrela, & Alanen,
2013). It is unfair to just refer the length of the duration of treatment to the early treatment.
Most of the accusations against early treatment because it takes too long depends on treating
class II and ignores other malocclusions which early treatment improves in a short time and
avoids the complications of the patient delaying the treatment.
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Table 1
Comparison between orthodontic appliances according to their mean total treatment time.
Note. From " Assessment of orthodontic treatment outcomes: Early treatment versus late
treatment, by Hsieh, Pinskaya, and Roberts, 2005, Angle Orthodontist, 75(2), 162-170.
Some think that early treatment costs too much and it is more expensive than later
treatment. One of the reasons to think so is that early treatment could have two phases and that
what Al-Shayea (2014) expressed it when she says that "one- phase is lower cost than twophase treatment" (p.119). Another reason for this assumption is that some appliances used in
early treatment are mostly manufactured in lab especially for the patient which increases the
cost; furthermore, the orthodontist may use more than one appliance during early treatment
especially in cases with two phases, which also increases the cost of the treatment. On the other
hand, the efficiency of the early orthodontic treatment could not be so high if we considered the
benefits gained from early treatment and the other factors which affect on the cost of the
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treatment. Pietila et al.(2013) found in their research that there is a distinguish differences
among health centers in cost effective measures, but the difference in the cost of acceptable
morphology between early and late treatment was not so big; on the other hand, the cost of
acceptable function was higher in the late treatment. They noticed that the decreasing in the
operational cost had an effect on efficiency of the cost but did not interpret it completely. In
addition, Pietila et al. (2013) noticed that there many factors that have an influence on the cost
efficiency such as volume and work division, orthodontist skills, and the variety in the
providers expertise. In addition, orthodontic appliances have a big influence on the basic costs
and patient cooperation which affect the duration of the treatment (Pietila et al., 2013). As some
research showed that there is no difference between the costs of early and later treatment, the
advantages of early treatment make it the best choice. Pietila et al. (2013) stated clearly that the
costs of orthodontic treatment, when taking into account the cost-effectiveness, are similar in
early or late treatment, but the results of early treatment seem to achieve better functional levels.
In conclusion, early orthodontic treatment is preferred by many orthodontists because it
has many advantages such as eliminating pathogenic factors of malocclusion, increasing the
efficiency of the orthodontic treatment, and enhancing self esteem in child. Although some
accused early treatment being more expensive and take long time, the numerous advantages of
early treatment are able to refute such accusations. The choice of treating children at early
stages gives them the chance to be treated before it is too late or becomes too complicated, and
enjoy their childhood with better functional and psychological health. It is necessary to have a
clear definition for early treatment which will help researchers to clarify its advantages and will
end the controversy about it.
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References
Almuhtaseb, E., Jing, M., Hong, H., & Bader, R. (2014). The recent about growth modification
using headgear and functional appliances in treatment of class ii malocclusion: A
contemporary review. OSR Journal of Dental and Medical Science, 13(4), 39-54.
Al-Shayea, E. I. (2014). A survey of orthodontists’ perspectives on the timing of treatment: A
pilot study. Journal of Orthodontic Science, 3(4), 118–124. doi:10.4103/22780203.143232
Hsieh, T., Pinskaya, Y., & Roberts, W. E. (2005). Assessment of orthodontic treatment
outcomes: Early treatment versus late treatment. Angle Orthodontist, 75(2), 162-170. doi:
10.1043/0003-3219(2005)075<0158:AOOTOE>2.0.CO;2
Kerosuo, H, Heikinheimo, K., Nyström, M., Väkiparta, M. (2013). Outcome and long-term
stability of an early orthodontic treatment strategy in public health care. The European
Journal of Orthodontics, 35(2),183-9. doi: 10.1093/ejo/cjs087
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Pietila, I., Pietila, T., Svedström-Oristo, A.-L., Varrela, J., & Alanen, P. (2013). Comparison of
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doi:10.7860/JCDR/2014/8604.4394
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