Early, treatment refers to treatment that precedes the conventional treatment protocol in which brackets and bands are placed on permanent teeth. This early treatment is begun during the primary or transitional dentition to intercept malocclusions in a manner that will ultimately lead to a better, more stable result than that which would be achieved by starting treatment later. For example, does early treatment work better than a later, singular phase of orthodontic treatment? Is an early approach worth the extra cost, time and energy involved? Are the outcomes significantly improved over those of a single‑phase treatment approach? If 'some orthodontic problems are better treated early, should all problems be corrected early?
reduced potential for iatrogenic tooth damage such as trauma, root resorption and decalcification.
early treatment is beneficial in terms of the long‑term care of orthodontic patients is controversial
Is facial growth altered or is the correction due to dentoalveolar changes?
If facial growth is altered, do the changes represent a permanent effect or simply a short-term response that will be negated by subsequent growth?
Is the mechanism of change acting on the maxilla, the mandible or both?
As long as the patient is treated while he or she is still growing, the time at which treatment begins may not make a difference.
a later-stage, single-phase treatment approach is preferable because of the advantages that accompany the reduced treatment time.
improved self-esteem and reduced susceptibility to dental trauma, may be appropriate to begin treatment at an earlier age.
The Class III skeletal pattern is the result of a small and/or posterior positioned maxilla, a large and/or pragmatic mandible, or a maxilla and mandible that are normal in the sagittal plane of space but underdeveloped in the vertical dimension. Most often, the Class III malocclusion is caused by a combination of two or all three discrepancies
The typical protocol in facemask therapy is the application of approximately 12 ounces of force on the maxilla for 14 hours a day in a forward and slightly downward direction. The orthopedic and orthodontic responses to this force system include forward and downward movement of the maxilla, with concomitant forward and downward movement of the maxillary dentition, downward and backward rotation of the mandible, and retroclination of the mandibular incisors. All of these changes improve the three skeletal discrepancies contributing to the Class III malocclusion (Figures 1 through 4). The only Class III pattern for which these changes would be contraindicated is one with excessive vertical development.
Growth modification of this kind is based on the premise that applying tension to these immature sutures is a stimulus for the formation of new bone. The closer the patient is to adolescence, the more interdigitation of the sutures that exists, which results in less skeletal and more dental response to the protraction forces. We believe that the adolescent circummaxillary sutures are amenable to tensile forces, but that the elastic nature of the facemask force system simply is not capable of delivering high enough force levels to affect these sutures.
In addition to the importance of sutural patency, timing of treatment involving protraction headgear depends, although to a lesser degree, on the developing dentition. Primary or permanent teeth with adequate roots are required for protraction force application. Consequently, the late‑transitional dentition presents challenges to facemask therapy, since this stage of dental development may not provide the clinician with an adequate anchor for headgear.
A recent study of Class III treatment supports using facemask therapy during the primary and early‑transitional dentition, although it suggests that treatment at later stages is not without merit. Kapust and colleagues" determined the effects of facemask therapy combined with palatal expansion in 63 patients ranging in age from 4 to 13 years. The results indicated that when compared with nontreated subjects, patients in the experimental group demonstrated significant skeletal changes, including forward and downward maxillary movement and downward and backward mandibular rotation. Dental changes included extrusion of the maxillary molars and retroclination of the mandibular incisors. These combined
changes led to a significant improvement in the soft‑tissue profile: Although a significantly greater correction of the Class III pattern was observed in 4to 10‑year‑olds than in 10‑ to 13‑year‑olds, the effect of age on treatment response was less than would be commonly expected. These findings suggest that while early treatment may be more effective, facemask therapy does produce favorable orthopedic and dental changes in older children.
. The results indicated that when compared with nontreated subjects, patients in the experimental group demonstrated significant skeletal changes, including forward and downward maxillary movement and downward and backward mandibular rotation. Dental changes included extrusion of the maxillary molars and retroclination of the mandibular incisors. These combined
changes led to a significant improvement in the soft‑tissue profile: Although a significantly greater correction of the Class III pattern was observed in 4to 10‑year‑olds than in 10‑ to 13‑year‑olds, the effect of age on treatment response was less than would be commonly expected. These findings suggest that while early treatment may be more effective, facemask therapy does produce favorable orthopedic and dental changes in older children.
Although a significantly greater correction of the Class III pattern was observed in 4to 10‑year‑olds than in 10‑ to 13‑year‑olds, the effect of age on treatment response was less than would be commonly expected. These findings suggest that while early treatment may be more effective, facemask therapy does produce favorable orthopedic and dental changes in older children.
Unilateral or bilateral crossbites are caused by dental or skeletal discrepancies, or a combination of the two.
A child exhibiting a lateral functional shift is a candidate for early orthopedic correction. Such a shift is often the result of compensatory and habitual movement of the mandible to achieve intercuspation in the face of a constricted maxillary arch
Maxillary expansion is the indicated treatment for palatal constriction. Increased maxillary width removes the premature contacts, eliminates the mandibular shift and allows the mandible to achieve centric relation with coinciding midlines.
In his experience, Gianelly has found that management of the leeway space alone can resolve the crowding problems in more than 80 percent of orthodontic patients
. Optimal timing for this treatment should coincide with exfoliation of the primary second molars, typically in the late‑transitional dentition.
When crowding is severe enough to prevent the natural eruption of certain teeth‑for example, the permanent maxillary lateral incisors‑then expansion would be indicated at the age of 6 or 7 years. In addition, eruption of teeth into a crowded arch may have occurred, but their malpositioning leads to unfavorable wear patterns. This also would be an indication for early expansion followed by active alignment, rather than for delaying treatment until more of the permanent teeth erupt, which may cause continued harmful wear of the enamel. In most cases, if expansion is chosen to relieve crowding, it can be delayed until the late‑transitional dentition. Common exceptions to this have been described above. In these cases, timing will center on the eruption of the affected teeth. There is no scientific evidence to support the idea that expansion in the primary dentition is more stable than that in the early‑to‑late transitional dentition.
Beginning treatment of Class II discrepancies at an early age have the potential to extend the overall treatment time.
Patients with Class III malocclusion stand to benefit significantly from early orthopedic treatment. However, such therapy may produce more favorable changes for older children (aged 11 and 12 years) and adolescents (aged 13 and 14 years) than previously thought.
Palatal expansion appears to be effective and stable at any time before late adolescence, a stage of development when ossification of the midpalatal suture begins. Consequently, the timing of expansion may be better determined by the specific needs of each patient Natural arch development has the potential to correct early mild incisor crowding. Management of the leeway space will resolve a majority of cases of crowding. This approach is best accomplished in the transitional to late-transitional dentition. Severe crowding may warrant the extraction of permanent teeth