See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/12486388

Early orthodontic treatment: What are the imperatives?

Article  in  Journal of the American Dental Association (1939) · June 2000

DOI: 10.14219/jada.archive.2000.0235 · Source: PubMed

CITATIONS READS

44 1,841

3 authors:

G Thomas Kluemper Cynthia Beeman

University of Kentucky University of Kentucky
37 PUBLICATIONS   753 CITATIONS    22 PUBLICATIONS   381 CITATIONS   

SEE PROFILE SEE PROFILE

E Preston Hicks
University of Kentucky
27 PUBLICATIONS   653 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Early vs late orthodox treatment View project

Form/Function Interactions View project

All content following this page was uploaded by E Preston Hicks on 15 August 2017.

The user has requested enhancement of the downloaded file.

 EARLY ORTHODONTIC TREATMENT:
WHAT ARE THE IMPERATIVES?
G. THOMAS KLUEMPER, CYNTHIA S.
BEEMAN and E. PRESTON HICKS
J Am Dent Assoc 2000;131;613-620

The following resources related to this article are available online at

jada.ada.org ( this information is current as of March 25, 2010 ):

Downloaded from jada.ada.org on March 25, 2010

Updated information and services including high-resolution figures, can be
found in the online version of this article at:
http://jada.ada.org/cgi/content/full/131/5/613

This article appears in the following subject collections:

Restoratives http://jada.ada.org/cgi/collection/restoratives

Information about obtaining reprints of this article or about permission to

reproduce this article in whole or in part can be found at:
http://www.ada.org/prof/resources/pubs/jada/permissions.asp

© 2010 American Dental Association. The sponsor and its products are not endorsed by the ADA.

EARLY ORTHODONTIC TREATMENT:
WHAT ARE THE IMPERATIVES?
G. THOMAS KLUEMPER, D.M.D., M.S.; CYNTHIA S. BEEMAN, D.D.S., PH.D.; E. PRESTON HICKS, D.D.S.,
M.S., M.S.D.
A B S T R A C T
Background. The authors provide a crit-
ical review of the issues involved in determining
the appropriate timing of orthodontic treatment.
Both single- and two-phase treatments are dis-
cussed and guidelines are offered to assist in for-
mulating treatment plans.
Overview. In providing orthodontic care for
pediatric patients, clinicians often question
whether to begin treatment early—during the pri-
mary or early-transitional dentition—or wait until
all or most of the permanent teeth are present. The
authors review the most current literature (from
1991 to 1999), including several recently completed
and ongoing randomized clinical trials, to critically
evaluate the effectiveness of each approach.
Practical Implications. The con-
Early, or phase I, orthodontic treatment refers to
treatment that precedes the conventional treat-
ment protocol in which brackets and bands are
placed on permanent teeth. This early treatment is
begun during either 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. The goal of many clini-
cians who provide early treatment is to reduce the
time and complexity of fixed-appliance therapy.
Whether, in fact, early treatment is beneficial in
terms of the long-term care of orthodontic patients
is controversial.
Copyright ©1998-2001 American Dental Association. All rights reserved.
CLINICAL
PRACTICE
Downloaded from jada.ada.org on March 25, 2010
troversy surrounding early vs. late orthodontic
treatment is often confusing to the dental commu-
nity. This article reviews both sides of the issue for
orthodontic treatment of Class II and III malocclu-
sions, as well as for the management of Class I
crowding and problems in the transverse dimen-
sion. Early orthodontic treatment is effective and
desirable in specific situations. However, the evi-
dence is equally compelling that such an approach
is not indicated in many cases for which later,
single-phase treatment is more effective. There-
fore, clinicians must decide, on a case-by-case
basis, when to provide orthodontic treatment. For
many patients, delaying treatment until later in
their dental and skeletal development may be
advisable.
The questions related to this two-phase method
of treatment have led to the need for critical anal-
yses of the effectiveness of such an approach. 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?
In a recent survey of the 159 Diplomates of the
American Board of Orthodontics, participants were
asked what they perceived to be the benefits of
JADA, Vol. 131, May 2000 613
CLINICAL PRACTICE
early treatment.1 The most
common responses were as
follows:
dgreater ability to modify
skeletal growth;
dimproved patient self-esteem
and parental satisfaction;
dbetter and more stable result;
dless-extensive therapy is
required later;
dreduced potential for iatro-
genic tooth damage such as
trauma, root resorption and
decalcification.
These responses seem to be
supported by the results of a
recent study in which orthodon-
tists perceived that subjects who
received phase I orthodontic
treatment had less complex mal-
occlusions with a lower treat-
ment priority than subjects in an
untreated control group.2 We will
use these perceptions to evaluate
the actual outcomes of phase I
treatment, as determined by
recent research studies dealing
with this issue.
EARLY TREATMENT OF
CLASS II MALOCCLUSION
Substantial evidence supports
the theory that early growth
modification therapy can lead to
an improvement, if not complete
correction, of the Class II maloc-
clusion.3-5 The mechanisms by
which the correction is achieved,
and whether early correction has
advantages over correction
during phase II treatment lead
to three fundamental questions:
dIs facial growth altered or is
the correction due to dentoalve-
olar changes?
dIf facial growth is altered, do
the changes represent a perma-
nent effect or simply a short-
term response that will be
negated by subsequent growth?
dIs the mechanism of change
acting on the maxilla, the
mandible or both?
614 JADA, Vol. 131, May 2000
Copyright ©1998-2001 American Dental Association. All rights reserved.
Recently, the results of three
randomized clinical trials specifi-
cally designed to address these
important issues were pub-
lished.3-5 The randomized clinical
trial is generally considered to be
the gold standard for clinical
research. Randomization elimi-
nates allocation bias, and a
prospective approach allows for
greater control of confounding
variables.6
Tulloch and colleagues 3 re-
cently published a progress
report from a University of
North Carolina, or UNC, study
of the benefits of two-phase vs.
one-phase Class II treatment. In
Substantial evidence
supports the theory
that early growth
modification therapy
can lead to an
improvement of the
Class II malocclusion.
this randomized clinical trial,
children with a moderate-to-
severe Class II malocclusion
were randomly assigned to one
of three groups: headgear treat-
ment, bionator therapy or an
observational group in which no
treatment was administered.
The results suggested that treat-
ment with either headgear or
bionator can improve the rela-
tionship of the jaws in most chil-
dren (75 percent), although there
was substantial individual varia-
tion noted in both treatment
groups, as well as in the un-
treated control group. Reliable
predictors for a favorable growth
response were not identified.
The second phase of the UNC
study was designed to test
whether these changes repre-
sented long-term differences.
Once the permanent teeth
emerged, the subjects were ran-
domly assigned to orthodontic
fixed-appliance (phase II)
therapy.
At the completion of treat-
ment, the investigators found
no significant differences among
the three groups in regard to
subjects’ skeletal relationships,
as determined by their cephalo-
metric measurements. In addi-
tion, there were no significant
differences in subjects’ occlu-
sions. It appears, then, from the
results of this study that, on
Downloaded from jada.ada.org on March 25, 2010
average, the skeletal changes
that occur with early treatment
are not sustained. The improve-
ment in jaw relationships seems
to represent a period of acceler-
ated growth rather than a per-
manent change.
Tulloch and colleagues 3 also
noted that the number of
patients who required extrac-
tions of permanent teeth was
greater in the bionator group
than in the headgear or control
groups, and that orthognathic
surgery was offered more often
(although not necessarily
accepted) to patients in the con-
trol group than to patients in
either of the two-phase groups.
These authors concluded that
for children with moderate-to-
severe Class II malocclusion,
early (phase I) treatment fol-
lowed by conventional orthodon-
tics later on (phase II) does not
produce skeletal or occlusal
relationships that differ sub-
stantially from those produced
by phase II treatment alone.
Moreover, severity of the
problem and total treatment
time are not important influ-
ences on the final result, while
variations in skeletal growth
patterns do seem to play an
important role.
Ghafari and colleagues 4 con-

ducted another randomized clin-
ical trial of the effectiveness of
early treatment in the correc-
tion of the Class II malocclu-
sion. In this study, conducted at
the University of Pennsylvania,
or UP, 63 patients with Class II
malocclusion who were between
the ages of 7 and 13 years were
randomly assigned to either a
straight-pull headgear group or
a Frankel therapy, or FR-II,
group.
As a result of treatment, the
sagittal discrepancy was
reduced in both groups. Similar
to the UNC study results, the
results of the UP study showed
that the headgear correction
was due primarily to its effect
on the maxilla, while the FR-II
had its greatest influence on
mandibular position. In regard
to the dentition, improvements
in molar and canine relation-
ships were greater in the head-
gear group, while overjet correc-
tion was better in the FR-II
group, although this difference
in overjet correction was not
statistically significant. These
occlusal differences were prob-
ably due in part to the greater
influence of the headgear on the
posterior dentition and the
palatal force exerted on the
maxillary incisors by the labial
bow of the FR-II.
To address the issue of treat-
ment timing, the investigators
further categorized the experi-
mental groups on the basis of
emergence or nonemergence of
the permanent canines, premo-
lars and permanent second
molars. None of the changes
mentioned above was influenced
by these stages of dental devel-
opment. As reported by Ghafari
and colleagues,4 Class II treat-
ment seems to be just as effec-
tive in late childhood as it is at
an earlier age.
Copyright ©1998-2001 American Dental Association. All rights reserved.
Keeling and colleagues 5
reported findings from a similar
randomized clinical trial con-
ducted at the University of
Florida. Their data showed that
both headgear (cervical or occip-
ital anchorage with acrylic
intraoral bite plane) and bio-
nator treatments in preadoles-
cent children can result in
short-term skeletal changes.
Subjects in both treatment
groups demonstrated enhanced
mandibular growth compared
with subjects in the control
group.
One-year follow-up after com-
pletion of treatment in the Uni-
We can conclude
that both the single-
and two-phase
approaches are
effective in
correcting the Class
II malocclusion.
versity of Florida study showed
that the skeletal changes were
stable; however, some of the
dental movements relapsed.
On the basis of these three
ongoing clinical trials we can
conclude that both the single-
and two-phase approaches are
effective in correcting the Class
II malocclusion. This correction
is due to both a skeletal and
dental change, depending on the
particular treatment modality.
Moreover, within the skeletal
changes, different appliances
and therapies seem to exert
more influence on one jaw over
the other.
These studies do not support
the claim that a favorable effect
on skeletal growth patterns is
limited to two-phase orthodontic
treatment. In fact, these and
CLINICAL PRACTICE
other recent studies suggest
that 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 in the success of the
Class II correction.7-9 If this is
true, we can conclude that a
later-stage, single-phase treat-
ment approach is preferable
because of the advantages that
accompany the reduced treat-
ment time. This conclusion, of
course, is made with the pri-
mary criterion for success being
a better, more stable result. If
Downloaded from jada.ada.org on March 25, 2010
the definition of success is
broadened to include improved
self-esteem and reduced suscep-
tibility to dental trauma, then it
may be appropriate to begin
treatment at an earlier age.
However, the impact of early
treatment on psychological
development has yet to be sub-
stantiated. Certainly, these
issues alone can, and do, serve
as impetus for early interven-
tion. The reasons for correcting
the malocclusion at an early age
should be explained to the
patient, but early treatment
should not be mistakenly
referred to as the only way to
achieve a high-quality result.
Johnston 9 has referred to the
decision about when to treat as
“mortgaging the mandible”; a
Class II correction can be
achieved now or later. As long
as the reasons are clear and
supported by sound evidence,
such as the data collected in the
studies discussed above, the
choice of timing comes down to
the clinical judgment of the
orthodontist in consultation
with the patients and families
served.
EARLY CLASS III
TREATMENT
The Class III skeletal pattern is
JADA, Vol. 131, May 2000 615
CLINICAL PRACTICE
Figure 1. Pretreatment Class III malocclusion (transi-
tional dentition).
Figure 2. Pretreatment Class III
profile.
the result of a small and/or pos-
teriorly positioned maxilla, a
large and/or prognathic man-
dible, or a maxilla and mandible
that are normal in the sagittal
plane of space but underdevel-
oped in the vertical dimension.
Most often, the Class III maloc-
clusion is caused by a combina-
tion of two or all three discrep-
ancies. The most common
treatment for this problem in
the growing patient involves the
use of protraction headgear,
with or without prior palatal
expansion. For patients in
616 JADA, Vol. 131, May 2000
Copyright ©1998-2001 American Dental Association. All rights reserved.
Figure 3. Posttreatment Class III occlusion (perma-
nent dentition).
Figure 4. Posttreatment Class III
profile. Figures 1 through 4 illus-
trate the benefit of two-phase
treatment for Class III malocclu-
sion that included skeletal and
dental correction. Notice the
expansion as well as the down-
ward and forward movement of
the maxilla, and downward and
backward rotation of the
mandible.
whom a skeletal crossbite is
present, orthopedic expansion is
appropriate. Some clinicians
suggest that such expansion
also facilitates the anteroposte-
rior response to facemask
therapy, but this thesis has not
been substantiated and, there-
fore, this treatment is not ad-
vised for this purpose alone.10
Downloaded from jada.ada.org on March 25, 2010
The typical protocol in face-
mask 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 ortho-
pedic and orthodontic responses
to this force system include for-
ward and downward movement
of the maxilla, with concomitant
forward and downward move-
ment of the maxillary dentition,
downward and backward rota-
tion of the mandible, and retro-
clination of the mandibular
incisors. All of these changes
improve the three skeletal dis-
crepancies 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.
Orthodontists most often pre-
scribe facemask therapy for
patients in the primary to early-
transitional dentition, in large
part because of the patency of
the circummaxillary sutures
appropriate to this age.11
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 ado-

lescence, the more interdigita-
tion of the sutures that exists,
which results in less skeletal
and more dental response to the
protraction forces. We believe
that the adolescent circummax-
illary 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 perma-
nent 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 face-
mask therapy during the pri-
mary and early-transitional
dentition, although it suggests
that treatment at later stages
is not without merit. Kapust
and colleagues 12 determined the
effects of facemask therapy
combined with palatal expan-
sion in 63 patients ranging in
age from 4 to 13 years. The
results indicated that when
compared with nontreated sub-
jects, patients in the experi-
mental group demonstrated sig-
nificant skeletal changes,
including forward and down-
ward maxillary movement and
downward and backward
mandibular rotation. Dental
changes included extrusion of
the maxillary molars and retro-
clination of the mandibular
incisors. These combined
Copyright ©1998-2001 American Dental Association. All rights reserved.
changes led to a significant
improvement in the soft-tissue
profile. Although a significantly
greater correction of the Class
III pattern was observed in 4-
to 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 sug-
gest that while early treatment
may be more effective, face-
mask therapy does produce
favorable orthopedic and dental
changes in older children.
EARLY TREATMENT
OF TRANSVERSE
DISCREPANCIES
Unilateral or bilateral cross-
bites are caused by dental or
skeletal discrepancies, or a
combination of the two. Correc-
tion of discrepancies in the
transverse plane involves
either dental or palatal
expansion. The former is
accomplished by simple tooth
movement and, therefore, gen-
erally is best done during phase
II treatment. The correction of
a skeletal crossbite via palatal
expansion involves manipula-
tion of the sutures within and
surrounding the maxilla. Con-
sequently, this procedure must
precede the ossification of these
sutures. Once the palatal
suture is fused, correction of a
skeletal crossbite usually
requires surgical intervention.
Although variation exists
among people, ossification of
the midpalatal suture is exten-
sive, but not complete, in late
adolescence.13 However, in the
early stages of skeletal matura-
tion (that is, before the adoles-
cent growth spurt’s peak height
velocity), little-to-no midpalatal
approximation exists. There-
fore, beginning palatal expan-
sion just before the onset of
CLINICAL PRACTICE
puberty is consistent with the
biology of the tissue involved.
In addition, no compelling evi-
dence exists to suggest that a
clinician is any more successful
in achieving palatal expansion
at an earlier age, although
Spillane and McNamara14 have
shown that expansion in the
transitional dentition is stable.
Consequently, other treatment
issues may best determine the
timing of palatal expansion.
A child exhibiting a lateral
functional shift is a candidate
for early orthopedic correction.
Downloaded from jada.ada.org on March 25, 2010
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. In this situation, the
mandible approaches centric
relation with facial and dental
midlines coinciding. However,
because of palatal constriction,
premature contact occurs, usu-
ally in the area of the primary
canines, and the mandible
shifts to one side to avoid this
contact and to achieve centric
occlusion. Consequently, the
condyles are positioned asym-
metrically within their respec-
tive fossae and the mandible is
positioned off-center, with the
lower midline deviated to the
shifted side. This gives the
appearance of a unilateral
crossbite when, in fact, it is
bilateral. Left untreated, this
condition can lead to asymmet-
rical growth of the mandible
and uneven remodeling of the
glenoid fossa.15 This scenario
can lead to permanent facial
asymmetry, even if the con-
stricted maxillary arch is cor-
rected at a later date.
Maxillary expansion is the
indicated treatment for palatal
constriction. Increased maxil-
lary width removes the prema-
JADA, Vol. 131, May 2000 617
CLINICAL PRACTICE
ture contacts, eliminates the
mandibular shift and allows the
mandible to achieve centric
relation with coinciding mid-
lines. When this occurs, occlusal
symmetry is achieved and sym-
metrical growth is no longer
inhibited. Consequently, a
strong argument can be made
for early treatment in such
cases. Maxillary constriction
without a lateral shift does not
carry the same urgency and,
therefore, can be treated closer
to adolescence.
EARLY TREATMENT
OF ARCH-LENGTH
DISCREPANCIES
To determine the need for and
appropriate timing of treatment
for arch-length discrepancies,
clinicians must be knowledge-
able about normal arch develop-
ment. During the period of tran-
sition from the primary to
permanent dentition, minor
incisor crowding is often present
in the normally developing den-
tition (that is, the dentition that
will ultimately have enough
room for all of the permanent
teeth without orthodontic
intervention).
Such crowding is often seen
after the eruption of the suc-
cedaneous mandibular incisors.
With the eruption of the perma-
nent mandibular lateral
incisors, mild incisor crowding
represents a normal stage of
development. Continued growth
and development relieve the
crowding to the extent that
there is enough space available
for the permanent mandibular
canines to erupt. According to
Proffit and Fields,16 there are
three reasons for this space
gain:
dWith normal growth, a slight
increase in arch width occurs
across the canines. This
618 JADA, Vol. 131, May 2000
Copyright ©1998-2001 American Dental Association. All rights reserved.
amounts to about 2 millimeters
of space gain and is due, in part,
to a labially inclined path of
canine eruption. More width is
gained in the maxilla than in
the mandible, and, on average,
it occurs to a greater extent in
boys than in girls.
dAs the succedaneous incisors
replace their primary counter-
parts, they flare forward,
gaining 1 to 2 mm of arch
length.
dIn the mandibular arch, the
primate space is located poste-
rior to the primary canines.
Consequently, the permanent
To determine
the need for and
appropriate timing
of treatment for
arch-length
discrepancies,
clinicians must be
knowledgeable
about normal arch
development.
canines erupt in a more poste-
rior position than their primary
counterparts, leaving the gained
space of about 1 mm on each
side available for the alignment
of the incisors.
In contrast to the transitional
crowding seen in the man-
dibular arch, a transitional
diastema often exists between
the permanent maxillary cen-
tral incisors. At this stage, a
diastema often causes concern
for parents because the teeth
appear to be erupting into unfa-
vorable positions. However, for
most children, this is a natural
transitory state that is self-cor-
recting. With the subsequent
eruption of the maxillary lateral
incisors and canines, a central
diastema of 2 mm or less typi-
cally closes naturally. Larger
diastemata likely will require
orthodontic intervention to
achieve complete closure. How-
ever, if the occlusion is devel-
oping normally otherwise and
the child is not overly concerned
about the space, we recommend
that canine eruption be given a
chance to reduce the space.
Clinicians also can alleviate
crowding of the anterior denti-
tion by using potential posterior
space. Unlike the situation for
Downloaded from jada.ada.org on March 25, 2010
the anterior teeth, the perma-
nent canines and premolars
have a combined mesiodistal
width that is smaller than the
width of the primary teeth they
replace. The combined differ-
ence is, on average, 2.5 mm for
each side in the mandible and
1.5 mm in the maxilla. The
extra space that this represents
is referred to as the leeway
space. If left to nature, this
space will be taken up by mesial
drifting of the permanent first
molars. Orthodontic manage-
ment of this space, however, can
preserve it to relieve crowding
of anterior teeth. Such space
preservation can be achieved by
placing a lingual holding arch
or a lip bumper on the lower
arch and a transpalatal appli-
ance or headgear on the maxilla
(Figures 5 and 6). In his experi-
ence, Gianelly 17 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.
Arch width expansion in the
absence of a transverse discrep-
ancy is sometimes indicated to

Figure 5. Mandibular arch with minor anterior
crowding in the late-transitional dentition.
increase the arch perimeter,
thereby relieving arch-length
discrepancies. In general, begin-
ning the expansion in the late-
transitional dentition is ideal
because it can be followed
immediately with placement of
fixed appliances to direct the
permanent teeth into the newly
created space. However, earlier
intervention sometimes is indi-
cated. When crowding is severe
enough to prevent the natural
eruption of certain teeth—for
example, the permanent maxil-
lary lateral incisors—then ex-
pansion 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 malpo-
sitioning leads to unfavorable
wear patterns. This also would
be an indication for early expan-
sion followed by active align-
ment, rather than for delaying
treatment until more of the per-
manent 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
Copyright ©1998-2001 American Dental Association. All rights reserved.
Figure 6. Same mandibular arch shown in Figure 5
after natural transition of posterior dentition. Note
the relief of minor crowding due to posterior drift of
anterior teeth into leeway space, preserved by the
lingual arch.
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 transi-
tional dentition.
In cases of severe crowding,
extraction of permanent teeth
may be desirable. In these
cases, a serial extraction plan
may be indicated. This protocol
calls for the sequenced extrac-
tion of specific primary teeth to
facilitate the early eruption of
the permanent teeth identified
for extraction. These are usu-
ally the first premolars. In
cases of severe crowding, such
a plan allows for the second
premolars and canines to erupt
well within the alveolus rather
than ectopically. Once the
remaining permanent teeth
have erupted, fixed appliances
are placed to provide ideal
alignment within an arch in
which the space discrepancy
has been eliminated. Ideally,
serial extractions begin in the
early-transitional dentition,
while the placement of fixed
appliances is delayed until the
CLINICAL PRACTICE
Downloaded from jada.ada.org on March 25, 2010
early-permanent dentition.
SUMMARY
Early orthodontic treatment is
effective and desirable in specific
situations. Evidence is equally
compelling, however, that such
an approach is not indicated in
many cases, and delaying treat-
ment until later in dental devel-
opment may be advised.
In the treatment of patients
with Class II malocclusion, cor-
rection at an early or late stage
is equally beneficial. While this
conclusion reflects the statis-
tical comparison of average
treatment responses in the
studies cited, there were large
individual variations within the
treatment groups. We recognize
that caution is in order when
interpreting these mean data.
Such large statistical variances
suggest the possible existence of
significant variables that have
not been identified or controlled
for in these clinical trials. The
immediate effect that early
treatment may have on a
patient’s self-esteem and sus-
ceptibility to dental trauma is
not well-understood and is
likely to vary from patient to
patient. Beginning treatment of
JADA, Vol. 131, May 2000 619
 CLINICAL PRACTICE
Class II discrepancies at an
early age has the potential to
extend the overall treatment
time.
Patients with Class III mal-
occlusion stand to benefit signif-
icantly 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 spe-
cific needs of each patient. A
functional shift resulting from
a crossbite is optimally correct-
ed early so that asymmetrical
growth of the mandible can be
reduced or even prevented.
Expansion for the relief of
crowding is best timed on the
basis of the specific nature of
the crowding. No compelling
evidence exists to suggest that
arch expansion in the primary
dentition will produce a more
stable result than that achieved
at a later time.
Treatment of arch-length dis-
crepancies depends on the
nature of the crowding. Natural
620 JADA, Vol. 131, May 2000
Copyright ©1998-2001 American Dental Association. All rights reserved.
View publication stats
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 accom-
plished in the transitional to
late-transitional dentition.
Severe crowding may warrant
the extraction of permanent
teeth. A serial extraction pro-
tocol may be desirable and the
extraction sequence for such an
approach begins in the early-
transitional dentition, while the
appliance phase occurs in the
early-permanent dentition. ■
Dr. Kluemper is an associate professor, Uni-
versity of Kentucky, College of Dentistry,
Orthodontic Graduate Program, Room D-406
UKMC, 800 Rose Street, Lexington, Ky.
40536-0297. Address reprint requests to Dr.
Kluemper.
Dr. Beeman is an associate professor, Uni-
versity of Kentucky, College of Dentistry,
Orthodontic Graduate Program, Lexington.
Dr. Hicks is an associate professor, Univer-
sity of Kentucky, College of Dentistry,
Orthodontic Graduate Program, Lexington.
1. Bishara SE, Justus R, Graber TM. Pro-
ceedings of the workshop discussions on early
treatment. Am J Orthod Dentofacial Orthop
1998;113:5-6.
2. King GJ, Wheeler TT, McGorray SP,
Aiosa LS, Bloom RM, Taylor MG. Orthodon-
tists’ perceptions of the impact of phase 1
treatment for Class II malocclusion on phase
2 needs. J Dent Res 1999;78:1745-53.
3. Tulloch JF, Phillips C, Proffit WR. Ben-
efit of early Class II treatment: progress
report of a two-phase randomized clinical
trial. Am J Orthod Dentofacial Orthop 1998;
113(1):62-72.
4. Ghafari J, Shofer FS, Jacobsson-Hunt U,
Markowitz DL, Laster LL. Headgear versus
functional regulator in the early treatment of
Class II, division 1 malocclusion: a random-
ized clinical trial. Am J Orthod Dentofacial
Orthop 1998;113(1):51-61.
5. Keeling SD, Wheeler TT, King GJ, et al.
Anteroposterior skeletal and dental changes
after early Class II treatment with bionators
and headgear. Am J Orthod Dentofacial
Orthop 1998;113(1):40-50.
6. Semb G, Roberts CT, Shaw WC. The
scope and limitations of single center research
in cleft lip and palate. In: Vig KW, Vig PS,
eds. Clinical research as the basis of clinical
practice. Ann Arbor, Mich.: Center for Human
Growth and Development, the University of
Michigan; 1991:109-23.
7. Johnston LE Jr. Growth and the Class II
patient: rendering unto Caesar. Semin Orthod
1998;4(1):59-62.
8. Livieratos FA, Johnston LE Jr. A compar-
ison of one-stage and two-stage nonextraction
alternatives in matched Class II samples. Am
J Orthod Dentofacial Orthop 1992;108:118-31.
Downloaded from jada.ada.org on March 25, 2010
9. Johnston LE Jr. Functional appliances: a
mortgage on mandibular position. Aust
Orthod J 1996;14(3):154-7.
10. Proffit WR, Fields HW. Orthodontic
treatment planning: limitations, controversies
and special problems. In: Contemporary
orthodontics. 3rd ed. St. Louis: Mosby;
2000:271.
11. Proffit WR, Fields HW. Skeletal prob-
lems. In: Contemporary orthodontics. 3rd ed.
St. Louis: Mosby; 2000: 257, 508-15.
12. Kapust AJ, Sinclair PM, Turley PK.
Cephalometric effects of face mask/expansion
therapy in Class III children: a comparison of
three age groups. Am J Orthod Dentofacial
Orthop 1998;113:204-12.
13. Revelo B, Fishman LS. Maturational
evaluation of ossification of the midpalatal
suture. Am J Orthod Dentofacial Orthop
1994;105:288-92.
14. Spillane LM, McNamara JA Jr. Maxil-
lary adaptation to expansion in the mixed
dentition. Semin Orthod 1995;1(3):76-87.
15. Pirttiniemi P, Kantomaa T, Lahtela P.
Relationship between craniofacial and condyle
path asymmetry in unilateral cross-bite
patients. Eur J Orthod 1990;12:408-13.
16. Proffit WR, Fields HW. Early stages of
development. In: Contemporary orthodontics.
3rd ed. St. Louis: Mosby; 2000:86-91.
17. Gianelly A. Leeway space and the reso-
lution of crowding in the mixed dentition.
Semin Orthod 1995;1:188-94.