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TREATMENT PLANNING IN THE PRIMARY DENTITION 1.

Reasons for Treatment* Treatment in the primary dentition is undertaken for the following reasons: a) To remove obstacles to normal growth of the face and dentition. b) To maintain or restore normal function. 2. Conditions That Should Be Treated in the Primary Dentition Are: a) Anterior and posterior crossbites. b) Cases in which primary teeth have been lost and loss of arch space may result. c) Unduly retained primary incisors which interfere with the normal eruption of the permanent incisors. d) Malpositioned teeth which interfere with normal occlusal function or induce faulty patterns of mandibular closure. e) All habits or malfunctions which may distort growth. 3. Conditions That May Be Treated a) Distoclusions that are at least partly positional. Occlusal equilibration or tooth movements may restore normal function. The rest of the problem may be treated at this time or later. b) Certain distocclusions of a skeletal nature are best treated at this age, but the patient must be socially mature, and the cases must be carefully chosen. c) Open bites due to tongue-thrusting or digital sucking habits. 4. Contraindications to Treatment in the Primary Dentition Treatment in the primary dentition is contraindicated when: a) there is no assurance that the results will be sustained, b) a better result can be achieved with less effort at another time, and/or c) the social immaturity of the child makes treatment impractical. TREATMENT PLANNING IN THE TRANSITIONAL DENTITION The mixed dentition period is the time of greatest opportunity for occlusal guidance and interception of malocclusion. At this time, the dentist has the greatest challenges and finest opportunities for efficient orthodontic therapy. 1. Reasons for Treatment Any case may be treated in the mixed dentition provided that: a) The treatment does not impede normal growth of the dentition. b) The malocclusion cannot be treated more efficiently in the permanent dentition. Emphasis should be placed on guidance of growth, interception of a developing malocclusion, and elimination of the first symptoms of what might become more serious malocclusions in the permanent dentition. 2. Conditions That Should Be Treated Conditions that should be treated in the mixed dentition are: a) Loss of primary teeth endangering the available space in the arch. b) Closure of space due to the premature loss of primary teeth; the lost space in the arch must be regained. c) Malpositions of teeth that interfere with the normal development of occlusal function, cause faulty patterns of eruption or mandibular closure, or endanger the health of the teeth. d) Supernumerary teeth that may cause malocclusion. e) Crossbites of permanent teeth. f) Malocclusions resulting from deleterious habits. g) Oligodontia, if closure of space is preferable to prosthesis.

appliances. treatment must be instituted in the mixed dentition.not necessarily the best time for some problems. craniofacial skeletal growth is controlled and the morphology improved so that later tooth positioning (phase two) is relatively easier. Now. j) Class II (distoclusion) cases of a functional type. One-fourth is a significant amount.h) Localized spacing between the maxillary central incisors for which orthodontic therapy is indicated. Only a few studies give accurate reports on those malocclusions which can be prevented or intercepted “Popovitch and Thompson” at the Burlington Orthodontic Research Centre in Canada. when possible. diphasic treatment is sometimes considered more logical and sensible. some who did not know how to improve severe skeletal dysplasia in young children chose to wait and camouflage it later by positioning of teeth. but the strategies and tactics change radically when periodontal disease and/or loss of teeth has occurred. so one should not. During phase one. . k) Class II (distoclusion) cases of a dental type. roughly 25% can be intercepted. argue against the practice of one strategy using the theory of another. If serial extractions are to be undertaken.noted earlier. I) Class II (distoclusion) cases of a skeletal type. UNDERSTANDING EARLY TREATMENT 1. Orthodontic therapy can be carried out for older healthy adults. d) Gross inadequacies or disharmonies of the apical bases. that is. b) It is the dentist's responsibility to obviate. c) All malocclusions accompanied by extremely large teeth. judge that while few malocclusions can truly be prevented. as has been done.. All are good terms when properly applied. Conditions That May Be Treated Conditions that may be treated in the mixed dentition are: a) Class II malocclusions of a skeletal type. i) Neutroclusion with extreme labioversion of the maxillary anterior teeth (maxillary dental protraction). Rationale for Early Treatment a) Some malocclusions can be prevented or intercepted. 3. Neither term can be used properly in the generic sense to embrace all early orthodontic treatments.-In the past. as·. although. and knowledge now readily available to the family dentist. It is as misleading to promote enthusiastic advocacy of early treatment of all malocclusions because some might be intercepted as it is to denounce interceptive treatment because early development of all malocclusions cannot be halted. The words "prevent" and "intercept" may lead to misunderstanding. TREATMENT PLANNING IN THE PERMANENT DENTITION All mal occlusions possible to correct may be treated in the permanent dentition of the young adult. m) Space supervision problems. particularly if diphasia treatment is indicated. particularly if diphasic treatment is indicated. the clinical (and semantic) problem is when and to what extent each is appropriate. lengthy or complicated treatment. and many can be intercepted with theory. where early treatment is feasible. b) Class III malocclusions. The theory and rationale underlying the concepts associated with each term vary and are not generally interchangeable.

Ironically._ Many reasons have been advanced for considering early treatment. b) Some forms of treatment can only be done at an early age. -Early orthopedic control of skeletal mOrPhology is easier in some cases than later correction of the craniofacial skeleton. The following are some of the more compelling: a) The possibility of achieving a better result . which is utilized with precision bracketed appliances. There are two reasons why early treatment may obviate compromise of quality: (1) it may remove etiologic factors and restore normal growth and (2) it may reduce the severity of the skeletal pattern. the theory and treatment effects of "functional" or "orthopedic" appliances are less understood.-Growth can only be controlled while growth is happening. More logical goals are . which is the basis of early functional orthopedics. and therein lies a trap for the inexperienced. for guidance of the developing dentition and growing craniofacial skeleton is a very complicated matter: the construction may be simple. treatment options are limited to moving teeth or orthognathic surgery. Appliances used are varied. e) Younger patients are often more cooperative and attentive. sophisticated. c) Early treatment of serious deleterious habits is easier than treatment after years of ingrained habit reinforcement.c) Treatment is easier in some cases. -When growth has largely ceased. and our knowledge of these appliances is well advanced. When the patient is young. And there is more growth available. Benefits of Early Treatment . The earlier one starts treatment. it is difficult to camouflage gross craniofacial morphology by tooth movements alone. e) The clinician can utilize growth better in the young. we know more about the biology of tooth movements. However. f) Compromise of quality of treatment is less apt to be necessary. provide differential growth responses. Some of the orthopedic appliances used look simple. 2. the applied biology is generally more sophisticated and difficult than after pubescence. Early treatment has sometimes been equated with a naive attempt to "prevent" or intercept all malocclusions. and practical. making possible easier and more precise tooth positioning in the adolescent. and obtain a balanced profile prior to eruption of most permanent teeth. d) More alternative methods are available for treating patients at a young age. one may be able to remove etiologic factors.This is an important difficulty in defining clearly the goals. The traditional precision bracketed appliances used in treatment during the newly completed adult dentition involve very sophisticated biomechanical theories (see Chapters 13 and 16). 3. Difficulties in Early Treatment a) Misperceptions exist about the goals of early treatment. the more total growth one can effect. than we do about the biologic alteration of facial growth.-With modem precision bracketed appliances beautiful results are obtained routinely if the skeletal dysplasia is not too severe. and often easier than positioning teeth to camouflage skeletal dysplasia. d) There are psychological advantages to early treatment in some children. Similarly. enlist natural growth forces.

making Later treatment more difficult. Those who do no more planning for early treatment than to choose a single {avorite appliance for most treatments do so because they are ignorant of the subtle variabilities and difficulties of orthodontic practice in the young patient. neither of which necessarily results in precise positioning of teeth. patient cooperation may wane. the features of a malocclusion are clearly seen and the diagnosis is more certain. It is not a question of functional or orthopedic appliances versus bracketed appliances but of the goals of early versus later treatment. Misperceptions about goals of early treatment arise when the focus is on the particular appliance itself rather than the purposes of treatment. " The best car is useless without a map and a driver who knows where to go. . Frequently. it may exhaust 'the spirit of . There is a far greater need for better treatment planning than there is for new functional-appliance" gadgetry." When the chronologic time is lengthened. Ill-conceived or improph early treatment not only may do damage or prolong therapy. justified or better. c) Diphasic treatment may lengthen the chronologic treatment time. In recent years. It does no good to drive faster if you're on the wrong road. implying such problems do not occur with their favorite systems. it can also be misdirected. diphasic treatment achieves better results with less' 'clinic time" but longer' 'calendar time. b) Improper early treatment can be harmful. and periodic cephalometric reassessment is a necessity. one cannot argue that the use of the other is. and insufficient attention has been paid to the difficulties of diagnosis and treatment planning for early treatment. Nor does it help to start early if you do not know where you are going or have no map.-When growth has diminished.the removal of primary etiologic factors and"the correction of skeletal dysplasias prior to the eruption of teeth. Too much emphasis has been placed on particular appliances. Early diagnosis and treatment planning are more tentative. But there are problems with any appliance. -Time of treatment is properly measured by the number of hours spent by the dentist and patient together: treatment time is not measured on the calendar. -Just as growth can be directed advantageously. Because mistakes are made in either treatment period or with one appliance system. d) The subleties of early ma~occlusion introduce chance in the diagnosis and treatment plannlng.cooperation. not the appliance itself. which may be related to misperceptions about the goals of treatment. ipso facto. some enthusiastic proponents of functional jaw orthopedics have urged the use of those appliances by describing alleged deficiencies and misuses of precision bracketed appliances.