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The Truth About Phase I Orthodontics by Donna Galante, DMD

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One of the most controversial issues today in orthodontics is whether early orthodontic treatment, also known as phase I treatment, is ultimately beneficial for patients who are still growing and in the deciduous early mixed-dentition stage of development.

This controversy stems from two main concerns, voiced by orthodontists and parents. The extra expense of a two-phase orthodontic treatment and the extra time the patient will be in some sort of orthodontic appliance are major concerns for both parties. As a result, doctors often are reluctant to provide phase I treatment, and parents are hesitant as well.

However, some doctors feel it is absolutely necessary to handle certain types of problems in the early mixed dentition, especially as they relate to growth and jaw development.

Many doctors feel that if they do not have the opportunity to handle a specific type of growth problem while the child is still growing, the window of opportunity will be lost as growth is completed. As a result, the only way to handle the problem is through more advanced, complicated and potentially even more expensive procedures, such as surgery and extractions.

So what is the bottom line when it comes to phase I treatment and its indications and benefits?

While I do not promise to solve the issue, my goal is to present information from both sides of the aisle from respected leaders in the field and let you decide for yourself. Like most things in orthodontics, there are two sides to this story!

The two sides
In the November 1995 issue of the American Journal of Orthodontics and Dentofacial Orthopedics, Dr. Anthony Gianelly concluded that about 90 percent of all orthodontic problems could be treated in a single phase of treatment and phase I intervention was not necessary. Further, he states that 5 percent to 10 percent of patients who show up with crossbites leading to a shift in the lower jaw and certain types of Class III malocclusions "could benefit from immediate resolution of the problem."1

Another prominent researcher and respected orthodontist, Dr. William Proffit, has compiled research showing early treatment of Class II malocclusions with either headgear or a functional appliance. This study looked at children at least one year away from peak pubertal growth spurts with overjet greater than 7mm. While initially it looked as though there had been some success in resolving the Class II malocclusion, he ultimately found that "the differences created between the treated children and untreated control group by phase I treatment before adolescence disappeared when both groups received comprehensive fixed-appliance treatment during adolescence." His team concluded that two-phase treatment of Class II malocclusions "might be no more clinically effective than one-phase treatment started during adolescence in the early permanent dentition."2

On the other side of the table, Dr. James McNamara—who has contributed to more than 68 books on orthodontics and craniofacial development, and participated in many studies on the benefits of early intervention—is very much a proponent for treating crowding, crossbites and even Class III malocclusions in young, growing patients.

In an article he coauthored in 2006 and published in the AJO-DO on the long-term effects of rapid maxillary expansion in the early mixed dentition, his team found compelling-enough results to suggest that "this protocol is effective and stable for the treatment of modest deficiencies in arch perimeter."3 In another study, researchers looked at children as young as 8 years of age who exhibited skeletal Class III malocclusions. These children were treated with a combination of rapid maxillary expansion and a facemask to help orthopedically move the maxilla forward and at the same time expand. The children were followed post-treatment until almost 15 years of age at which point they were determined to be in a deceleration of growth, and stable.

They concluded, "Aggressive over-correction of the Class III skeletal malocclusion, even toward a Class II occlusal relationship, appears to be advisable, with the establishment of positive overbite and overjet relationships essential to the long-term stability of the treatment outcome.4

My perspective on phase I treatment is that it is neither black nor white. In a growing child, some problems should be managed at an early age, but others can wait until the child is in the late mixed dentition; for example, if it is not a problem of growth, but instead just alignment issues and mild crowding.

I was fortunate to study at the University of Pennsylvania, where we were exposed to patients with certain types of growth and development problems and encouraged to treat these patients early. I was also very fortunate during my residency to attend many of Dr. McNamara's courses on early treatment of Class III malocclusions, and I have followed his protocol over the last 30 years in my private practice. Using many of the protocols developed by Dr. McNamara, we have had tremendous success in treating Class III problems early and helping patients avoid more extensive orthodontics—such as jaw surgery—later.

Case presentations
Here, our patient Travis began treatment in our office at age 7 (Figs. 1-5). You can see from the initial photos his anterior crossbite and Class III occlusion. We fitted him with a maxillary rapid palatal expander with hooks for a facemask, which was worn about 12-14 hours per day. His treatment started in October 2005 and ended in November 2006, at which time all appliances were removed and retainers provided.

He was placed into our growth evaluation program and monitored until all of his adult teeth were in place.

These photos were taken in April 2011 at the age of 15 (Figs. 6-10). At that time we had recommended a second phase of treatment to finalize some tooth positions and possibly set him up for restoring #7 and #10, as they were small in size. The parents declined any further treatment. We provided him with some Essix retainers to wear at night and invited them back for follow-up care if they saw his bite relapsing.

We treated another patient, Peyton, for a severe skeletal Class III as she presented at age 17 to our office (Figs. 11-15 are on p. 19). We placed her into full-fixed appliances and she subsequently had jaw surgery. Her parents stated she had never had phase I treatment and were never offered that as an option. They were waiting for her growth to stop and then planned on surgery from the start. We were a second opinion, and of course we agreed that surgery was the only solution.

Shortly after Peyton's surgery was completed, her mother said that her youngest son, Bradley, at age 7 had the same type of bite that Peyton had at that age and wanted to know if we could do something to prevent surgery for him down the road (Figs. 16-20). We immediately began the same protocol with maxillary expansion, facemask and partial braces for Bradley. His parents have so far declined any further treatment or a second phase.

Conclusion
Of course, not all of our cases end up needing just a phase I treatment. The vast majority do need a second phase to finish the final alignment and take care of other issues that may have surfaced later as the child continued to grow. However, in both these cases, it is safe to say that early intervention certainly made the second phase of treatment less involved (no surgery needed) and sometimes no further treatment is needed or at most, a very limited second phase.

The truth about phase I treatment is that, while it may cost more time and money, the benefits can certainly outweigh the overall time and expense, especially if done in an efficient manner. With the right types of appliances, the right timing and with excellent cooperation from both the child and the parent, phase I treatment can prove to be very successful.

References
  1. One Phase Versus Two Phase Treatment. Gianelly, Am J Orthod Dentofacial Orthopedics 1995; 108:556-59
  2. Outcomes in a 2-Phase Randomized Clinical Trial of Early Class II Treatment. Tulloch, Proffit. AJO, 2006 June 125 (6): 651-67
  3. A Prospective Long-Term Study on the Effects of Rapid Maxillary Expansion in the Early Mixed Dentition. Geran, McNamara,Baccetti,Shapiro, Am J Orthod Dentofacial Orthopedics 2006:129:631-40
  4. Long Term Effects of Class 3 Treatment With Rapid Maxillary Expansion and Facemask Therapy Followed by Fixed Appliances. Westwood, McNamara, Baccetti, Franchi, Sarver, Am J Orthod Dentofacial Orthop 2003;123:306-20



Dr. Donna Galante owns four orthodontic practices in northern California and is a member of the Orthotown Magazine advisory board. In 1986, Galante received her orthodontic specialty certification at the University of Pennsylvania and opened her first private practice in King Of Prussia, Pennsylvania. From 1986 through 1993, she was a clinical instructor at the University of Pennsylvania's Department of Orthodontics where she worked directly with graduate students. She was twice voted "Instructor of the year" by the orthodontics residents. In 1992, Galante became a diplomate of the American Board of Orthodontics.
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