Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62:(1 Suppl): 11–19

doi: 10.1111/adj.12474

Timing orthodontic treatment: early or late?

PS Fleming
Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.

ABSTRACT
The timing of orthodontic interventions has been a contentious topic for many years with early treatment to address or
indeed to prevent skeletal discrepancies in all three spatial planes and to alleviate crowding in common practice. In terms
of effectiveness, however, broadly speaking early intervention has not been shown to be superior to later intervention.
As such, in view of the additional burden and duration of early intervention, the weight of evidence points to reserving
early treatment for localized problems and specific situations with definitive treatment typically initiated in the late
mixed or early permanent dentition.
Keywords: Crowding, Interceptive Orthodontic, Early treatment.

Early Treatment: Theoretical Basis

INTRODUCTION
A range of potential indications for early orthodontic
The appropriate timing of orthodontic intervention
intervention commencing prior to the late mixed den-
has sparked considerable debate with a body of spe-
tition phase have been proposed and include:
cialist and non-specialist providers wedded to the rou-
A dental health benefit: Early intervention to
tine provision of ‘early’ treatment.1 However,
address crowding may improve access for oral
definitive orthodontic treatment is most commonly
hygiene measures. While this may certainly be the
started in the late mixed or early permanent dentition.
case, there is no evidence that crowding in the
This phase typically coincides with a period of maxi-
mixed dentition is incompatible with periodontal
mal growth, allowing efficient correction of growth-
health in the long-term.6 There is some evidence
related occlusal anomalies; may permit beneficial use
that early intervention to address increased overjet
of the leeway space; and offers the availability of per-
may translate into a reduced risk of incisor
manent teeth for retention of appliances and definitive
trauma; however (See Class II correction).7
correction of a malocclusion.
Psychosocial considerations/benefit: There is a pro-
Interceptive orthodontics constitutes any measure
ven association between a range of dental anoma-
performed to correct a developing malocclusion or to
lies including increased overjet and overbite,
simplify later orthodontic care. It has been suggested
anterior spacing and open bites with teasing and
that developing problems in the mixed dentition
bullying.8 Persistent teasing is known to affect
could be fully corrected with simple interceptive
self-perceptions and so a malocclusion may have a
treatment in 15% and improved in 49% of cases.2
negative socio-psychological impact. Given that
Therefore, targeted implementation of simple inter-
targeting arises on an individual and often unpre-
ceptive measures is important and cost-effective with
dictable basis, early treatment to address occlusal
the general practitioner perfectly placed to identify
issues in those affected rather than as a blanket
and occasionally correct developing occlusal prob-
measure has been recommended on the basis of
lems in a timely manner. However, blanket prescrip-
high-quality prospective research.9
tion of early treatment either to prevent or treat a
Growth response: The plasticity of the skeleton
malocclusion at a young age does not appear to be
both in the short- and medium- term has been the
indicated.3 The value of early intervention to inter-
subject of lengthy, often vociferous debate. Early
cept localised problems has variously been
research involving cephalometry alluded to the
reviewed;4, 5 the present review will therefore focus
‘immutability’ of the facial skeleton contrary to
on the relative merits of early treatment in the
what had previously been propounded by
management of generalised malocclusion and growth-
orthodontic pioneers.10 Contemporary research,
related issues.
© 2017 Australian Dental Association 11
PS Fleming

most notably randomised studies carried out in the Table 1. Timing of eruption
U.S. and the U.K. with prolonged follow-up peri-
Typical eruption Range Maxillary Mandibular
ods of up to 10 years, have confirmed that overjet date (Years) (Years)
reduction, for example, during functional appli-
6 6–7 First molar
ance therapy is attributable both to skeletal (30%) 6 6–7 First molar
and dento-alveolar changes (70%) in the short- 6 6–7 Central incisor
term. However, in the longer term these skeletal 7 7–8 Central incisor
7 7–8 Lateral incisor
changes appear to dissipate with little difference in 8 8–9 Lateral incisor
mandibular length or position relative to untreated 10 9–10 Canine
groups.11–13 Nevertheless, there remains a school 10 10–12 First premolar First premolar
11 10–12 Second premolar Second premolar
of thought that more sustained intervention might 11 11–12 Canine
translate into more meaningful levels of skeletal
change. There is currently, no prospective evidence
to support this theory and a growing acceptance
that early intervention in Class II malocclusion NORMAL OCCLUSAL DEVELOPMENT IN THE
cases is no more effective, but less efficient, than MIXED DENTITION
later treatment.14 The ability to recognise occlusal anomalies is predi-
Aetiology: Proponents of early intervention, partic- cated on an understanding of normal occlusal devel-
ularly those advocating sustained growth modifica- opment in the mixed dentition.17 The mixed dentition
tion, typically consider malocclusion to be spans the period from eruption of the first permanent
essentially environmental in origin. For example, tooth at 5-6 years to exfoliation of the last primary
soft tissue behaviour and position, and aberrant tooth at 12-13 years, with a variation of up to 18
habits have variously been linked to growth- months being common. Common eruption sequences
related disturbances.15 While the environmental and timing are provided in Table 1.
aetiology of certain malocclusions is undeniable,
with, for example digit sucking, known to induce
localised malocclusions, most are a manifestations Intra-arch features:
of genetic and environmental interactions. More- Crowding of the incisors is typical in the mixed denti-
over, craniofacial growth is governed by a com- tion as the combined width of the permanent incisors
plex interplay of signalling molecules, is 7mm and 5mm more than the primary incisors in
transcription factors and extra-cellular matrix pro- the maxillary and mandibular arches, respectively18.
teins. It is known that transcription factors A resolution or improvement often arises naturally
encoded by Dlx genes are instrumental in the mor- due to widening of the inter-canine dimension,
phogenesis of the maxilla and mandible within the increased arch length due to proclination of the per-
first branchial arch. Perturbations of these events manent incisors, and closure of primate spacing.
are known to induce dramatic skeletal facial Distal fanning of permanent maxillary incisors,
changes.16 known as the ‘ugly duckling’ or ‘Broadbent’ stage,

(a) (b) (c)

Fig. 1 (a) Lip trap involving maxillary central incisors. (b) Lip trap leading to isolated proclination of UR1 and UL2 as the lip functions palatal to these
teeth. The lower lip, however, is labial to UL1; this tooth is therefore not proclined. (c) Lip trap related to a skeletal II pattern with mandibular
retrognathia

12 © 2017 Australian Dental Association


(a)
(b)
(c)
Fig. 2 Treatment was commenced in the mixed dentition to address a
large overjet relatively early (2a) as there was a profound lip trap and
associated teasing (See Figure 1a). The Class II relationships were
addressed with a functional appliance over a 12 months (2b). Detailing
of the occlusion was undertaken following eruption of the permanent
dentition with treatment undertaken over a 5-year period.
occurs prior to the eruption of maxillary lateral inci-
sors and canines due to the proximity of the erupting
teeth to the distal root surfaces of the more mesial
adjacent teeth. An associated maxillary midline dia-
stema prior to eruption of the maxillary canines is
also regarded as physiological. Intervention to address
this spacing prior to the eruption of the maxillary
canines is therefore not warranted.
© 2017 Australian Dental Association
Timing orthodontic treatment
The eruption of the canines and premolars is
expected between 9 and 13 years of age. In the pres-
ence of crowding, available space is used on a ‘first
come, first served’ basis with impaction of the canines
and second premolars therefore, common. Primary
crowding may cause displacement, for example, of
lateral incisors or the buccal impaction of maxillary
canines, in particular. This may be compounded in
the second premolar region by early loss of the second
primary molars and subsequent mesial migration and
rotation of the first permanent molar.
Inter-arch features:
Typically first permanent molars erupt into a one-half
unit II molar relationship guided by the flush terminal
plane between the second primary molars seen in
76% of individuals in the primary dentition19. A
Class I molar relationship may develop naturally by
“early” or “late mechanisms”. Early establishment of
a Class I molar relationship arises due to mesial
migration of the mandibular first molar in the open
mixed dentition to close the primate spacing present
distal to the lower primary canines. The later mecha-
nism occurs in an unspaced dentition following loss
of the second primary molars as the permanent denti-
tion becomes established. This facilitates greater
mesial migration of the lower first molar, as there is a
greater discrepancy between the mesio-distal widths
of the mandibular primary molars and the succeeding
premolars than is the case in the maxilla. The emer-
gence of the permanent incisors is normally accompa-
nied by a transient anterior open bite prior to their
complete eruption. Subsequent to incisor eruption,
changes in the magnitude of an overjet are usually
limited but may be influenced by the soft tissue
environment.
CLASS II CORRECTION
Early intervention to address an excessive overjet has
proven no more effective than postponing treatment
until adolescence. The primary indication for early
intervention in Class II malocclusions remains psy-
chosocial problems and teasing.20 However, a recent
Cochrane review has suggested that early reduction of
an overjet does have a protective effect in relation to
dental trauma.7 Incompetent lips, a markedly
increased overjet and increased incisal exposure at rest
predispose, in particular, to dental trauma and may
derive some benefit from early intervention (Fig-
ure 1).21
The decision to address increased overjet ‘early’ is
undertaken on an individual basis, with the weight of
evidence suggesting that early intervention does not
result in enhanced mandibular growth. The arbitrary
13
PS Fleming
use of chronological age, typically 10 to 13 years in
females and 11 to 14 years in males, continues to be
an acceptable yardstick for the timing of most efficient
and effective growth modification in Class II subjects.
Little difference in the skeletal effects associated with
functional appliances at the age of 10 years relative to
a group treated just after the onset of puberty (mean
age 12.9 years) has been shown.22 Moreover, demon-
strable, albeit limited skeletal changes with the Herbst
appliance have been reported based on magnetic reso-
nance imaging of the temporo-mandibular joints.23
There is, however, clearly an increase in treatment
duration with early treatment. This relates to the
reduced rate of mandibular growth observed in
pre-adolescents and to the requirement for dental
eruption to permit complete and optimal occlusal
inter-digitation. A period of intermittent appliance
wear may be required following an early full-time
functional phase to limit relapse of the initial Class II
correction (Figure 2). In contrast, when Class II cor-
rection is undertaken in the late mixed or early per-
manent dentition, the fixed phase can either be
undertaken concurrent with Class II correction or
may follow the initial phase in a relatively seamless
manner (Figure 3).
(a)
(c)
Fig. 3 (a-d). Seamless progress to fixed appliances following an initial functional phase facilitating efficient Class II correction in the early permanent dentition.
14
CLASS III MALOCCLUSION
Anterior crossbites are a common finding in the mixed
dentition with maxillary lateral or central incisors dis-
placed in lingual occlusion. Localised crossbites of
dental origin can be easily corrected with either
removable or fixed appliances. Indications for correc-
tion include: aesthetics, as anterior crossbites predis-
pose to a Class III profile; incisal wear, associated
with occlusal displacement; and periodontal attach-
ment loss labial to the lower incisors related to con-
tinued forward mandibular displacement (Figure 4).
The correction of an anterior crossbite may be
achieved by an upper removable appliance incorporat-
ing posterior capping to disengage the occlusion and
‘T-’ or ‘Z-’springs made from 0.5mm stainless steel
wire to procline the involved maxillary incisor. This
provides a simple means of correction, but, a com-
plete or partial fixed appliance (2 X 4 appliance) can
be used to achieve more controlled tooth movement.
This may be appropriate if more than one incisor is in
crossbite or if dental rotations require correction.
Both treatment approaches have been shown to be
effective and stable, although the use of fixed appli-
ances may provide a more predictable outcome.24, 25
(b)
(d)
© 2017 Australian Dental Association
 Timing orthodontic treatment

(a) (b)

(c) (d)

(e)

Fig. 4 An untreated Class III malocclusion with anterior displacement from RCP (a) to centric occlusion (b) with associated incisal wear (a-c). This was
subsequently treated with fixed appliances to camouflage the mild underlying skeletal III discrepancy (d, e). Earlier interception may have prevented the
occurrence of the incisal wear.

An anterior crossbite affecting two or more teeth or
presenting with a reverse overjet in the absence of a
functional displacement, may signify an underlying
skeletal discrepancy. Skeletal problems of this nature
might well indicate specialist referral for assessment
and possible growth modification with maxillary pro-
traction devices (Figure 5). Early referral may be
advised as maxillary protraction, using face-mask
therapy, is thought to be most successful when per-
formed in the early mixed dentition.26 Patients treated
in the late mixed dentition may still derive benefit,
but to a lesser extent. The overall skeletal effect, of
early maxillary protraction is unlikely to exceed 3mm
of change, although in selected cases, this may be suf-
ficient to obviate the need for orthognathic surgery at
skeletal maturity.27

© 2017 Australian Dental Association 15

PS Fleming

(a) (b)

(c) (d)

(e) (f)

(g)

Fig. 5 A Class III malocclusion on a significant skeletal III pattern with the maxillary incisors in crossbite in the mixed dentition. The mandibular incisors
were retroclined indicating an antero-posterior compensation for the underlying skeletal discrepancy. There was also significant maxillary arch crowding
(a-c). Protraction headgear was used in conjunction with a fixed appliance in the maxillary arch to effect Class III correction and relief of maxillary arch
crowding, respectively (d, e). A second phase of fixed appliance treatment was undertaken 3 years following initial treatment to detail the final occlusion
and consolidate Class III correction (f, g).

16 © 2017 Australian Dental Association


VERTICAL ISSUES
Early correction of an anterior open bite may be
attempted by a range of fixed or removable appli-
ances. In common with much early treatment, the
prognosis depends on the aetiology with open bites
related to aberrant habits, such as digit sucking,
responding well. Growth-related, skeletal open bites
require more complex intervention and, depending on
later growth, may be more amenable to definitive cor-
rection in the permanent dentition.
Persistent digit sucking is found in up to 12% of 9-
year olds and 2% of 12-year olds.28 The impact of
digit sucking hinges on the frequency, intensity and
duration of the habit with 6 hours daily regarded as a
threshold level above which significant effects are
expected. With the exception of a narrowing of the
palatal vault, the effects of digit sucking are confined
to the dento-alveolar complex and typically include
an increased overjet, asymmetric anterior open bite
and a unilateral posterior crossbite. Conservative
methods including education, dissuasion and use of
barriers, such as plasters, varnishes or gloves, are con-
sidered the first line of treatment. If the use of
(a)
(c)
Fig. 6 A significant anterior open bite (9mm) in the permanent dentition (a, b). Temporary anchorage devices were used to facilitate both Class II correc-
tion, with distal movement of the maxillary molars, in conjunction with posterior intrusion to effect closure of the anterior bite.
© 2017 Australian Dental Association
Timing orthodontic treatment
reminders is unsuccessful, simple fixed orthodontic
appliances including palatal arches with one of a vari-
ety of projections including inverted goalposts, beads
or cribs may be used as a deterrent for 6 to 12
months. The use of removable orthodontic appliances
may also be effective in these cases but their effects
may be negated by poor compliance.
Anterior open bites have also been attributed to soft
tissue behaviour and pattern. The use of fixed
adjuncts such as tongue spurs to alter tongue posture
has been advocated with some retrospective evidence
supporting their effectiveness. The early use of
myofunctional treatment in an effort to alleviate aber-
rant neuromuscular behaviour has received some
attention, particularly in Europe. Treatment is based
on the premise that a malocclusion is related to mus-
cular behaviour and oral function, although further
research is needed to confirm its utility. Van Dyck
et al.29 in a pilot study comprised of 22 children aged
between 7 and 11 years, reported a marginal improve-
ment in tongue elevation and posture with an associ-
ated increase in the prevalence of a complete overbite.
No improvement in speech or transverse changes was
noted.
(b)
(d)
17
PS Fleming
Skeletal open bites present a more significant chal-
lenge. Similar to the management of sagittal skeletal
discrepancies, the ability to alter vertical facial growth
appears to be limited and may require sustained inter-
vention, which correspondingly taxes patient compli-
ance and risks adverse effects. Many treatment
methods have been advocated including high-pull
orthopaedic headgear directed through the centre of
the resistance of the maxilla, vertical-pull chincup and
high-angle functional appliance variants, with limited
evidence of skeletal effectiveness.30 The advent of
temporary anchorage devices has also raised the possi-
bility of posterior intrusion of the dentition to induce
open bite closure (Figure 6). The latter, however,
more correctly represents a compensation for vertical
skeletal excess and while the net effect may well be a
decrease in the vertical dimension, the effect is pro-
duced through dental intrusion.
TRANSVERSE CORRECTION
Posterior crossbite correction can be undertaken with
fixed or removable appliances, including auxiliaries
such as rapid palatal expanders or quadhelix appli-
ances. Early crossbite correction may be undertaken,
in particular, if there is an associated occlusal dis-
placement as this may predispose to occlusal wear,
periodontal problems and facial asymmetry, if left
untreated. There is, however, no comparative evidence
concerning the effectiveness or stability of crossbite
correction in different age groups. While retrospective
research has indicated that early crossbite correction
is effective in the primary dentition, later correction is
the more accepted approach.31 Similarly, in a ran-
domised trial, a fixed appliance (quadhelix) and a
removable appliance were successful in addressing a
posterior crossbite, although the removable appliance
was slightly less effective. Both of these approaches
are known to produce dental rather than skeletal
change.32
ALLEVIATION OF CROWDING
The relief of crowding is normally performed in the
late mixed or permanent dentition. In the permanent
dentition space may be generated either by a decrease
in the amount of tooth structure (extractions or inter-
proximal reduction) or by increasing the arch length
either by transverse expansion, advancement of the
incisors or distal movement of the molars. In the late
mixed dentition, however, the leeway or ‘E’ space
may also be utilised. This represents the difference in
width of the primary canine and molars compared
with the permanent canines and premolars. In the
mandibular arch this space amounts to 2-2.5mm per
quadrant during the transition to the permanent
18
dentition with slightly less space available in the max-
illary arch, although inter-individual variation does
exist. Fixed appliances such as palatal and lingual
arches may be useful in leeway space preservation
leading to the resolution of crowding in 60% of
patients while perfect space preservation would have
eliminated crowding in 68% in one study.33 In view
of the availability of teeth, in the absence of other fea-
tures of malocclusion, the optimal timing for correc-
tion of dental crowding would appear to be in the
late mixed or early permanent dentition.
CONCLUSIONS
The philosophical debate concerning the merits of
early orthodontic treatment has been characterised by
dogmatic opinion with a dearth of robust or indeed
prospective evidence. Direct comparison of the merits
of early or later commencement is complicated by
inevitable differences relating to discrepancies in den-
tal, skeletal and overall maturation and development
inherent in differing age groups. However, at present,
there is little evidence to suggest that initiating treat-
ment prior to the age of 10 years is of greater benefit
than later treatment other than to intercept localised
malocclusions in a targeted manner.
CONFLICT OF INTEREST
The author declares no conflict of interest.
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Address for correspondence:
Barts and The London School of Medicine and Dentistry
Queen Mary University of London
London E1 2AD
Email: padhraig.fleming@gmail.com
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