This lecture is for dental professionals requesting more information on when to refer young patients for orthodontic tretment

1. Early Orthodontic Treatment
Victoria J Lynskey, DMD, MDS
Associate Clinical Professor, UCSF

2. Objectives
•Define Early Tx
•When you should refer a patient
•Who is (and is not) a good candidate for Early tx
•What common problems are addressed in Early tx
•What options are available to treat Early Patients
•How to determine success

3. Definitions of Early treatment
• Phase Therapy: early dental problems that left alone will create an
unhealthy environment for the growth and development of the teeth,
gums, bone and jaws
• Preventative/ Prophylactic: Prevent a problem from happening
• Interceptive Orthodontics: Intercept a developing problem
• Growth Modification: timing treatment to maximize and guide the
growth of the jaw bones that support the teeth

4. Treatment Phases
for Early/Interceptive Orthodontics
• Phase I (12-15 months)
• Maintenance Phase (12-24 mo)
• Phase II (12-15months)
Phase I active treatment Maintenance Phase II active treatment
12-15 months 12-24 months 12-18 months
The Big Question is …When and Who is a candidate for
Early Treatment

5. What is normal in a 7-year old
Class I Dental & Skeletal
occlusion
“Ugly-duckling” stage
(spacing and or minor
OB/OJ concerns
During transitional dentition,
perfect tooth alignment is
not to be expected and is
not cause for alarm.

6. Transition from Primary to
Permanent Dentition

7. What is NOT Normal
• Sagital relationships
such as
– Class II, dental and
skeletal
– Class III, dental,
skeletal and
functional shifts

8. Class II Skeletal Relationship
• 32% of malocclusions are Class II, but
they are 70% of what orthodontists treat
•The upper jaw is ahead of the lower jaw
(XS OJ or “buck teeth)
•In skeletal Class II, the jaws are
malaligned. Treatment can include
redirecting the eruption of teeth during jaw
growth Extraction Plan + FFA; or HPHG
•Excessive OJ leads to risk of trauma in
protrusive teeth.
•The upper jaw may be over developed,
but more often, the lower jaw is under-
developed.
•Untreated, skeletal malocclusions may
require orthognathic surgery to correct the
jaw position after growth is complete Growth Plan: Herbst/Forsus, HG

9. Class III Skeletal Relationship
Mandibular Prognathism usually dx in
adult (permanent dentition)
Midface deficiencies and maxillary
constriction is usually dx in the
• Characterized by anterior crossbite mixed dentition
•Approximately 3% of the malocclusions
•Can be caused by lack of growth in the upper jaw or excessive growth in the lower
jaw (seen later in development)
•Early treatment of maxillary sagital problem often includes a transverse component
•Early Class III treatment is best at age 7-10 as it requires significant compliance
with extra-oral headgear

10. Protraction Headgear
•Early Txt for Class III is primarily to affect maxillary growth.
•Requires RPE plus PHG and often FFA. Class III: Protraction/ reverse Pull
(often used with an RPE to aid in skeletal movement)

11. Functional Shifts
The position of the teeth affect the position of the jaw. When there is a
premature contact (see the canine) it can cause the jaw to shift so that
the teeth can contact. This can be habit forming and may result in
unwanted asymmetric growth.

12. Habits, Medical Problems
• Finger, thumb, Tongue thrust
• Speech discrepancies
• Mouth breathing due to airway constriction
(tonsils, adenoids)
• TMJ dysfunction, rheumatoid arthritis, and
growth hormone abnormalities may cause
orthodontic problems

13. Vertical Relationships-Open bites
• Dental vs Skeletal
• Habits such as finger/thumb sucking,
tongue thrust, or airway obstruction
• May result in chewing difficulty and
speech problem
• Tx may require ENT, habit therapy
and habit appliances

14. Vertical Relationships- Deep Bites
• Potential for abnormal tooth
wear and gingival
impingements
• May be skeletal cause:
vertical maxillary excess or
excessive curve of Spee
• This can be one of the most
damaging of malocclusions

15. Crossbite: Anterior
• Skeletal vs dental
• Can result from orthopedic problems or functional shifts
• All of these may damage the teeth and can cause long term gingival
problems
• These need to be corrected early to avoid damage to teeth and
gums

16. Crossbite: Posterior
• Often found in patients with a
narrow maxilla
• A posterior crossbite may also
cause a functional shift
• It may also appear as a
unilateral crossbite
• These are easily treated in the
growing child

17. Arch Length - crowding
• Causes
– Early loss of primary teeth
– Decay, genetics
– Tooth size problems
– Missing teeth
– Eruption problems

18. Arch Length-crowding
Premature loss of Primary Teeth
• Missing primary teeth, but adequate space
for secondary dentition= space maintainer
– Band and loop
– Lingual Arch
– Distal Shoe
– Nance

19. Arch Length-crowding
Irregular lower incisors
• Irregular Incisors, no arch-length/space discrepancy.
• Large Incisors + large primary molars +small premolars=
no space issues, but transient crowding & rotations of
the permanent incisors
• Up to 2mm of crowding may resolve spontaneously
• For 3-4mm of anterior crowding, IPR lower C’s and
place lingual arch **

20. Arch length-Crowding:
Delayed/blocked premolar development
• Aligned Incisors, no arch-length/space discrepancy.
• Erupting canine width+ erupting 1stPM width + large
primary 2nd molar width=transient crowding & rotations of
the erupting canines and premolars
• For posterior arch crowding, IPR lower E’s, hemi-section
or extract and place lingual arch

21. Arch Length-crowding
Localized space loss
• Localized space loss (3mm or less); Space Regaining
• Maxillary Regaining: tipping vs bodily movement
– Headgear or intra-oral appliance
– FFA

22. Arch Length-crowding
Localized space loss
• Localized space loss (3mm or less); Space Regaining
• Mandibular Regaining
– FFA or lip bumper

23. Arch Length-crowding
Midline discrepancy
• Premature loss of a primary tooth results
in a midline shift
• Tx with fingerspring or FFA

24. Arch Length-crowding
Severe
• Serial/Guided eruption (>10mm)
– No skeletal abnormality exists
(Class I)
– >10mm crowding
– Influence first premolars to
erupt prior to canines. For
mandible this means ext D’s
at ½ to 2/3 root formation on
4’s.
– Overbite might increase
during guidance but can be tx
after eruption of all permanent
teeth in a comprehensive
phase.

25. Arch Length - Spacing
Maxillary Midline Diastema
• Normal diastema = “ugly duckling stage”
• Larger diastema: >2mm =FFA
– Supernumeraries
– Missing permanent lateral incisors
– Tooth size discrepancy
– Tongue thrust
– Excessive tissue in the frenum
Tx indicated for 1) when the centrals inhibit
eruption of the laterals or canines, or 2)
esthetic issues (behavioral), 3) protrusion
and trauma risk
Studies prove that stability of the end result
is improved if a large diastema is
corrected before the full eruption of the
permanent dentition

26. Abnormal eruption sequence
Ectopically-erupting teeth
• Lateral incisor/canine
• First molar

27. Congenitally missing
permanent teeth

28. Congenitally missing
permanent teeth
• Mandibular second premolars:
– Retention
– Ankylosis
•Delayed eruption
•Manage until it interferes with eruption or
drift of other teeth, then extracting and
placing space maintainer if necessary
•Monitor 1) tipping of molars over distal
marginal ridges of the ankylosed teeth 2)
super-eruption of opposing teeth

29. Ankylosed Teeth
Ankylosis: Fusion of the tooth to the bone
Primary Failure of eruption: Failure of permanent teeth to grow normally
Result: 1) Adjacent teeth continue to erupt & can tip forward, over the
primary teeth resulting in space loss; 2) the primary molars appear to sink
as the rest of the teeth and jaws continue to grow and develop. This will
cause a significant discrepancy in the alveolar bone height, an issue during
replacement when permanent teeth are missing

30. Early Treatment Rationale
• Phase I (12-15 months)
• Maintenance Phase (12-24 mo)
• Phase II (12-15months)
Phase I active treatment Maintenance Phase II active treatment
12-15 months 12-24 months 12-18 months
The Big Question is …When and Who is a candidate for
Early Treatment

31. Crossbite: Posterior
• Skeletal vs Dental
• Unilateral/ bilateral

32. Orthodontic Terminology
Sagital Dimension (AP)
• Dental (Angle Classification):
– Overjet(OJ): distance between the
upper & lower front teeth(mm)
– Molar position
– Canine position
• Skeletal: relation of maxilla and/or mandible
to the skull
• Goal: to “affect mandibular growth” or dental
compensation.
OJ Class II, Div 1 Class II, Div.2

33. Jaw Deformities
• Class II: Growth modification
Extraction Plan + FFA Growth Plan: Herbst/Forsus, HG

34. Craniofacial Anomalies
• Cleft Lip & Palate
• Syndromes: Hemifacial Microsomia, Craniosynostosis,
Crouzon’s, Treacher-Collins, etc.

35. Benefits of Early Treatment
• Young patients may be more cooperative and
follow instructions
• Increased stability
• Habit modification
• Reduce extractions
• Reduced risk of tooth trauma (protruded teeth)
• Reduced periodontal trauma (crossbites and
guiding eruption into attached gingiva)
• Growth modification (sagitally, transverse,
asymmetric jaw growth)

36. Benefits of Early Treatment

37. Benefits of Early Treatment
• RPE + FFA to create space for U2’s and LR2

38. Benefits of Early Treatment

39. Benefits of Early Treatment

40. Disadvantages
• Time: most patients that require a phase I for
moderate to severe dental or jaw growth
modification will require a second phase.
• Money: increased cost to staging treatment into
2 phases is approximately $600
• OHI: poor motor skills may require more parental
involvement.
• Emergencies: higher risk of working on the
weekend

41. Questions

42. Thank You!