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Running head: DETERMINING FACTORS OF ORTHODONTIC TREATMENT TIMING 1
Determining Factors of Orthodontic Treatment Timing
Manal Shehada
Madonna University
ESL 5230 – Informative paper (D1)
February 25, 2015
DETERMINING FACTORS OF ORTHODONTIC TREATMENT TIMING
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Determining Factors of Orthodontic Treatment Timing
In the early days of orthodontics near the 18th century, the orthodontic treatment was
limited on treating permanent teeth of adolescence and adults. This idea changed by time as
another thoughts revealed that orthodontists should interfere earlier as Angel (1907) declared "the
best time to begin treatment is when the malocclusion first appears. It can start when the first
permanent molars erupt into occlusion" (as cited in Philippe, 2012, p.108). Edward Augustus
Bogue is considered the leader of beginning orthodontic treatment in the primary dentition
(Philippe, 2012). Bogue`s revolution changed the old orthodontic techniques and procedures and
gave a new prospective for orthodontic treatment. His technique depends on maxillary expansion
to overcome arch discrepancy and mouth breathing. Since then the argument about the best time
for starting orthodontic treatment started and is still going on. The decision to define the
beginning of an orthodontic treatment is affected by several factors such as orthodontist
background, treatment objectives, type of malocclusion, and the cost and the duration of the
treatment; that is why this decision should be taken for each case alone.
At the beginning what does early or late orthodontic treatment mean? There is not an
agreement on the definition of early orthodontic treatment. Some consider it as using orthodontic
appliances in the primary to the early mixed dentition or mid-mixed dentition. Others define it as
applying treatment in the late-mixed dentition before the eruption of the second premolars and
permanent maxillary canines (Hsieh, Pinskaya, & Roberts, 2005). The French Social Security
system defined early treatment as "a procedure of limited duration that can be performed either
when patients are quite young or have reached, or are approaching, adulthood" (as cited in
Philippe, 2012, p. 107). On the other hand, late orthodontic treatment could be started at the latemixed dentition or permanent dentition phase. For instance, Hsieh et al. (2005) considered the
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treatment is late if it started in adolescent with permanent dentition. The fact that there is no one
definite definition for early or late orthodontic treatment makes it difficult to compare between
the outcome and the degree of success for each of them. Although there are no standards for
beginning the orthodontic treatment, there are some factors have some influence on the decision
of starting the treatment.
The first and the most influence determinant is the orthodontist`s background. Usually
general dentists or the parents are responsible for making the child visit the orthodontist where he
or she takes the decision whether the patient needs orthodontic treatment or not and when to start
it. Orthodontists may have different opinions on the perfect time to start orthodontic treatment.
These differences are the result of what they learned during their training and what experience
they gained from treating patients.
The institution from which the orthodontist graduated also has a big influence on his or
her treatment decisions. The orthodontist`s decision for treatment time reflects the principles that
he learned and the orthodontic school that he belongs to it. The European orthodontic school
believes in the efficiency of functional appliances to correct skeletal discrepancies while these
appliances are not the first choice for the U.S. orthodontic school. Functional appliances depend
on modifying the growth of the jaws to correct malocclusion but they have to be used before the
end of pubertal spurt that is why they are used in early orthodontic treatment. On the other hand,
U.S. orthodontic school is more known of using fixed appliances and its bias to extracting
permanent teeth to treat malocclusion that is why orthodontists who belong to the U.S. school
prefer late treatment. The collaboration between orthodontists around the world contributed in
decreasing the differences between the two schools (Pietilä, Pietilä, Pirttiniemi, Varrela, &
Alanen, 2008). Also, the year of orthodontist's graduation has an effect on his treatment decisions.
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Pietila et al. (2008) found that orthodontists graduated before 1987 prefer early treatment more
than those recently graduated. They think that this observation could be attributed to the
orthodontist's experience or to the changes that happened in the training that orthodontists
received in the past two decades.
The second affecting factor is the treatment objectives. As the orthodontist examines the
patient and makes his treatment plan, he decides the main objectives for this treatment. Two
objectives are considered sensitive toward treatment timing, and they are the growth modification
and the interceptive or preventive orthodontics. Growth modification aims to correct the growth
of the jaws by motivating, inhibiting, and redirecting jaws` growth, and this helps to correct
skeletal disorders and malocclusion. Growth modification has to be carried out before the end of
jaws` growth which requires early orthodontic interference. In this aspect Boque explained that
"The best constructive dentistry can be performed on six year old children. This will improve
growth of their entire bodies in a way that cannot be achieved at any other age" (as cited in
Philippe, 2012, p.109).
On the other hand, interceptive treatment aims to stop pathogenic factors before they
cause malocclusion. For instance, thumb sucking in children must be stopped early; otherwise it
could cause severe malocclusion which takes more time and effort to be treated. As Jolley et al.
(2010) noted, "Recently, it has been established that early (interceptive) treatment could be an
effective strategy for moving patients’ treatment from the medically necessary category to
elective" (as cited in Shalish et al., 2013, p.454). Most children are suffering from functional
habits such as thumb sucking lead to malocclusion. These functional habits must be stopped
earlier as much as possible. Untreated functional habits cause malocclusion or exaggerate the
existent one, and that could have a bad effect on the normal growth pattern of the jaws and face.
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According to Prabhakar, Saravanan, Karthikeyan, Vishnuchandran, and Sudeepthi (2014),
"Mouth breathing, tongue thrusting and incorrect swallowing patterns are all known causes of
malocclusion and poor facial growth" (p.60). Preventive and interceptive orthodontics are
considered part of early orthodontic treatment as they aim to eliminate and stop any functional
habits from developing to a real malocclusion. In the same direction Boque showed the effects of
leaving such habits without treatment "Faulty functioning begins with open mouth breathing. It
alters the action of the cheeks and the tongue that gives the dental arches their shape" (as cited in
Philippe, 2012, 109). In addition, Prabhakar et al (2014) stated that young patients with bad oral
habits definitely need immediate orthodontic treatment and this elimination of oral habits at early
age is preferred by the majority of the orthodontists.
The type of malocclusion is the third affecting factor on treatment timing. Usually
orthodontic patients are suffering from more than one type of malocclusion which makes it
difficult to isolate each type according to the necessity for early treatment, but there is some
unanimity on some cases according to treatment time. Crossbites, overjet, and class II are the
major types of malocclusion that have been studied in the necessity of starting treatment early. In
normal occlusion the upper teeth overlap lower teeth, but in croossbites the lower teeth overlap
the upper teeth as it can be seen in Figure 1. Crossbites can be seen at anterior teeth or posterior
teeth. There is an agreement among the orthodontists about the necessity of treating crossbites as
early as possible. Pietila et al. (2008) found that Finnish orthodontists insist on treating crossbites
early. They also mentioned three different studies found that the main indication for early
treatment is anterior and posterior crossbite, increased overjet, deep overbite, and crowding.
Hsieh et al.(2005) stated that developmental crossbites, functional shifts, severe crowding and
severe overjet need early treatment. In addition, Kayak et al. (2004) found that most orthodontists
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in three countries, Italy, Turkey and the United States, prefer to treat anterior crossbite and sever
arch constriction as early orthodontic treatment while the opinions about treatment timing were
different toward other cases such as increased overjet and sever crowding (as cited in Pietila et al
2008, p. 47).
The overjet is the horizontal distance between the edge of upper incisor and the lower
incisor, in normal occlusion the overjet equals 2 mm. If the overjet exceeded 2 mm, a type of
malocclusion would be presented and a treatment would be needed. Hsieh et al. (2005) declared
that sever overjet (≥ 10 mm) need an early treatment. Also, early treatment will protect the
anterior teeth from having a trauma (Shalish, Gal, Brin, Zini, & Ben-Bassat, 2013).
1
2
Figure 1. The first photo shows a case with anterior and posterior crossbite , and the second
photo shows the case with normal occlusion after treatment. From "Complete maxilla in cross
bite in primary dentition– a rare case report." by D. Prajapati, R. Nayak, D. Kappadi, and A.
Nayak, 2014, Asian Pacific Journal of Health Sciences, 1(2), p. 58.
On the other hand, there are two points of view about Class II treatment timing. Class II
happens either by maxillary protrusion or mandible retrusion (Figure 2). Hsieh et al, (2005) stated
that class II treatment requires two phases of treatment as some clinical research advised. The
first intervention takes place before puberty (8-11 years) and is limited in correcting molars
relationships, overjet/ overbite relationship, and incisor alignment. This early treatment could be
followed by another intervention in adolescence (12-15 years) to finish the occlusion, but there
are some cases which do not need an intervention after early treatment phase. Tulloch et al. (2004)
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stated that there is a controversy around the perfect time to treat Class II and the decision to treat
class II as early treatment should be upon the individual characteristics of each case (as cited in
Pietila et al 2008, p47). O`Brien et al. (2003) mentioned that early treatment of class II improves
patient`s self estimation (as cited in Pietila et al 2008, p50). The other point of view prefers late
orthodontic treatment to treat class II as in one phase, as they think two phases treatment takes a
long time which makes many patients stop the treatment (Hsieh et al., 2005).
Figure 2. Shows a case with class II division 1. From "Sagittal skeletal and occlusal changes of
class II, division 1 postadolescent cases in the herbst and activator therapy," by N. Nedeljkovic,
2011, Principles in Contemporary Orthodontics, p. 95.
The last factors to be discussed are the cost and the duration of the treatment. The patient
and the parents play big role in this aspect. If the patient and his or her parents prefer the less
expensive and duration procedures, then the orthodontist has to choose one phase treatment as a
part of late treatment plan. Hsieh and his colleagues (2005) declared that the disadvantages of
early treatment were taking a long time for treatment, worse comprehensive clinical assessment
(CCA) scores, and increasing the percentage of ending the treatment before finishing.
In conclusion, there are many factors influencing the decision to start orthodontic
treatment. Some of these factors belong to the dentist and the others belong to the patient and his
condition. As a result of not having a defined definition for early and late orthodontic treatment
and the interference of the previous discussed factors, there are no specific standards for choosing
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the time to initiate orthodontic treatment. The decision of choosing early or late orthodontic
treatment must be taken after studying each case individually. The orthodontist must balance the
pros and cons of each procedure to give the best suitable solution for his patient.
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References
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Nedeljkovic, N. (2011). Sagittal skeletal and occlusal changes of class II, division 1
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