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Straight Talk Dr. Robert Boyd

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Why Do Early Treatment If It Is Less Efficient?
by Dr. Robert Boyd

One of the most debated issues within the orthodontic profession is whether to do early orthodontic treatment. From a health-care delivery point of view, this issue was significant enough that the U.S. National Institute of Health commissioned two prospective longitudinal controlled clinical trials (PLCCT) of early orthodontic treatment more than 15 years ago at the Universities of North Carolina and Florida. The study focused on two groups of matched Class II malocclusions with more than 5mm overjet. One group was started in the mixed dentition with treatment consisting of a headgear or functional appliance. The other group was deferred and treated later with a single phase in the early permanent dentition. The design was to evaluate the efficiency and effectiveness of the first phase in order to either eliminate a second phase or to create an improved second phase result after both groups had the second phase of treatment. These two studies (and one other study conducted later in the UK) showed no significant benefits from groups who received the early orthodontic treatment. Since these types of studies are considered the highest form of evidence to judge the efficacy of treatment, a logical conclusion is not to do early treatment if it involves more visits to get to the same result.

Early treatment is still a modality I employ in about 15 to 20 percent of the middle mixed dentition patients I see because the results from these studies really only apply to mild and moderate Class II malocclusions that are treated in a manner similar to the treatment techniques employed in these studies. I further believe that these studies' results have been over-generalized to include other forms of early orthodontic treatment such as Class I crowding, more severe Class II patients and even Class III treatment.

At our Arthur A. Dugoni School of Dentistry in San Francisco we have employed early orthodontic treatment techniques based on the approach developed by Dr. Arthur Dugoni which use more comprehensive treatment methods designed to treat moderate to severe Class I, II and III malocclusions in the transverse, vertical and anterior dimensions. We also have protocols that follow these early treatments with a more comprehensive retention program for all three planes of space until the permanent dentition is fully erupted (except for third molars).

Our analysis of these results throughout the years has found certain advantages of the Dugoni early treatment methods on select cases which include being much more likely to avoid extractions in the permanent dentition, entails less root resorption and significantly decreases the need for a second phase of treatment.

Patient and family concerns about early treatment are important to consider as well. I have found that many patients and parents do not want to wait until all permanent teeth have erupted because of aesthetic concerns in the eight- to 10-yearold age group. In addition, recent cross-sectional epidemiological studies by Jon Artun have shown significantly increased incisor trauma in mixed middle dentition ages that have overjet greater than 5mm. In general, one of the most difficult types of orthodontic treatments I have managed in my career is an ankylosed or missing upper incisor(s) which occurred as a result of anterior tooth trauma.

It is important to point out that a number of studies of efficacy of early treatment Class III treatments have shown more effective correction in these patients. However, recent studies of the use of titanium plates as anchorage for Class III treatment developed by De Clerk show excellent results when used in the adolescent permanent dentition.

In summary, we treat many different types of patients who present with very different concerns for aesthetics or functional issues. The over-generalizing of previous early treatment studies about treatment efficacy based on limited types of treatment can restrict our choices to find the common ground needed to create a treatment plan that is optimal for each patient.
Author's Bio
Dr. Boyd received his DDS degree from Temple University, postgraduate certificates in periodontics and orthodontics from the University of Pennsylvania and a master's degree in education from the University of Florida. He is diplomate of the American Board of Orthodontics, a fellow of both the American and International College of Dentists and a member of the Pierre Fauchard Academy. He has published extensively in both periodontics and orthodontics. He was on the original research and development team for the Invisalign system and is on the Clinical Advisory Board. Dr. Boyd is currently the Frederick T. West endowed chair at the Arthur A. Dugoni, UOP Department of Orthodontics.
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September 2025
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