COUNTERPOINT
Efficient orthodontic treatment timing
Anthony D. Viazis, DDS, MS a
Los Angeles; Calif.
T h e ideal time to treat a malocclusion has
been debated many times in the orthodontic literature. '-22 One of the dilemmas facing the orthodontic clinician is whether or not to intervene b e f o r e
the eruption of the permanent dentition. 1"2 It has
been well documented that some malocclusions,
such as skeletal crossbites (resulting in a functional
shift) are best treated as early as possible; others,
such as Class I! malocclusions, 2 are best left untreated until a later stage of dental transition to
best use growth and avoid patient burnout, unnecessary overtreatment, number of appointments,
and overall inefficient therapy.
It is my opinion that one may approach the
treatment of malocclusions based on the concept of
"Efficient Treatment Timing" (Table I). According
to this concept, a malocclusion should be treated as
soon as possible when postponement of treatment
~Associate Clinical Professor, Department of Orthodontics, U.S.C. School
of Dentistry, Los Angeles, Calif.
AM J ORTHOD DENTOFAC ORTHOP 1995;108:560-1.
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would lead to severe functional or esthetic concerns. On the other hand, treatment of certain
malocclusions may take place at a later stage as
long as any such later treatment would have the
same effects with less overall treatment time involved. Thus the therapeutic benefits are maximized with optimal doctor time, continuous patient
cooperation, and satisfaction.
As shown in Table I, habit control, functional
crossbite correction, and alleviation of possible
crowding, especially in deep bite cases, should be
initiated as soon as they are detected. A deficient
maxilla (Class Ill) should be protracted (facemask)
as soon as the upper permanent first molars erupt
and often times, right after the eruption of the
upper permanent incisors. True mandibular prognathism is best treated surgically after completion
of growth. Mild mandibular prognathism can be
effectively addressed in the deciduous dentition
with chincap therapy. Open and deep bite tendencies should be addressed by the late mixed dentition stage. Class II malocclusions, especially those
requiring distal molar movement, may be best
treated by nonextraction with a continuous treat-
Table I. Efficient "treatment-time" table*
Efficient treatment period
Problem
Habit
Crossbite with shift
Crowding
Class II
Deciduous
dentition
4-6 ),ears
Late mixed
(8-11 yrs.)
Permanent
(growing)
Discontinuation
Class III maxillary deficiency Facemask
Class III mandibular progChincap
nathism
Deep bite
Open bite (skeletal)
Limited treatment
TMD treatment
Early mixed
(6-8 yrs.)
Maxillary expansion (ME)
E-space control expansion
Headgear/springs functional
Fixed appliances
Fixed appliances
Fixed appliances
Fixed appliances
Space maintenance/biteplate
Headgear/vertical corrector/tooth guidance
Fixed appliances
Fixed appliances
Any time
Conservative approach on detection
*Treatment may continue from one period to the next if necessary. Care should be taken to avoid patient burnout.
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American Journal of Orthodontics and Dentofacial Orthopedics
Volume 108, No. 5
m e n t of 11/2 to 2 y e a r s t h a t starts in t h e l a t e m i x e d
dentition, especially on the eruption of the upper
first p r e m o l a r s . 2 Finally, any l i m i t e d t r e a t m e n t
(single t o o t h crossbite, d i a s t e m a , spacing) c a n be
a d d r e s s e d individually p e r p a t i e n t at any age. A n y
d y s f u n c t i o n a n d / o r p a i n to t h e t e m p o r o m a n d i b u l a r
j o i n t s h o u l d b e a d d r e s s e d as s o o n as it is d e t e c t e d .
F i x e d a p p l i a n c e t h e r a p y s h o u l d use t h e n e w technology wires, springs, a n d efficient b r a c k e t designs.
I n conclusion, t h e objectives of any t r e a t m e n t
b e f o r e e r u p t i o n of all p e r m a n e n t t e e t h a r e to
c o r r e c t t h e s k e l e t a l d i s c r e p a n c y b e t w e e n t h e jaws
a n d i m p r o v e f u n c t i o n a n d facial esthetics by allowing t h e m to d e v e l o p normally, to c r e a t e an ideal
o v e r b i t e a n d overjet r e l a t i o n s h i p , to align t h e a n t e r i o r p e r m a n e n t t e e t h (incisors) a n d r e d u c e t h e
c h a n c e of t r a u m a to t h e s e t e e t h , to i m p r o v e t h e
w i d t h o f t h e d e n t a l a r c h e s a n d to r e d u c e t h e risk
for (1) e x t r a c t i o n o f p e r m a n e n t t e e t h on n o r m a l
e r u p t i o n of t h e full p e r m a n e n t d e n t i t i o n a n d (2) for
surgery (in severe cases). U n a t t e n d e d o r t h o d o n t i c
p r o b l e m s c a n l e a d to i m p a i r m e n t s in s p e e c h , chewing, a n d loss or t r a u m a of t e e t h . O r t h o d o n t i c s can
e n h a n c e a p e r s o n ' s s e l f - e s t e e m as t r e a t m e n t b r i n g s
t e e t h , jaws, a n d soft tissue into c o r r e c t position.
This is a c c o m p l i s h e d with a g o o d level of c o o p e r a tion t h a t a child d e m o n s t r a t e s d u r i n g this p e r i o d .
A t r e a t m e n t will b e successful only w h e n t h e
p a t i e n t a n d t h e g u a r d i a n a r e satisfied a n d h a p p y
a b o u t t h e r e s u l t of t h e r a p y . This is always accomp l i s h e d in an e n v i r o n m e n t of caring t h a t o u r y o u n g
patients need.
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Reprint requests to:
Dr. Anthony D. Viazis
1307 8th Ave., Suite 403
Ft. Worth, TX 76104