Embrace Progress: The Rise of Early Treatment by Dr. Daniel Grob

by Dr. Daniel Grob, DDS, MS, editorial director

As if practicing the “new” concept of cosmetic orthodontics isn’t enough, I recently found myself being nudged into practicing early treatment, commonly known as “Phase 1.” I’m sure many will have as much to say about this as they do about cosmetic orthodontics, such as:

• It’s a fad that comes and goes.
• You’re doing it for the money.
• Just wait and get it done in one phase.
• Tell the parents that crooked or gapped teeth are normal at this stage.

After all, they didn’t title chapters in orthodontic textbooks “The ‘Ugly Duckling’ Stage” for no reason. I even heard a well-respected and excellent clinician denounce early treatment at a recent AAO meeting. This led to my clinical assistants immediately quizzing me on the reasons, methods and motivation behind our recently adopted treatment approaches.

The topic has been controversial, to say the least. Only 10–15% of my previous practice life was spent on early treatment. In fact, it was a marketing strategy when approaching general dentists who resented orthodontists jumping in too early to fix something that they thought would go away, be taken care of later or just preferred to ignore. (Tell that to the 15-year-old girl who finally was referred when her maxillary cuspids failed to erupt.)

I’m not sure what’s being taught at the leading orthodontic programs these days regarding early treatment, but judging from message boards and other online postings, an awful lot of orthodontists are still caught up in the arguments about how many teeth, if any, to take out to fix an issue. Or they’re looking at what can be done in 16 months after waiting for all of the teeth to come in scary-crooked, only to be taken care of with a certain bracket system.

Well, parents, dentists and patients are not that simple-minded these days. Mothers and fathers who bring their 2-year-old children to the dentist are concerned about their kids’ appearance! After all, why else are they taking care of their smile? Most are not satisfied to be told that it is normal or that they can wait.

My philosophy

Our association has been preaching for years about the need to send a young patient to the orthodontist for an evaluation at age 7. Yet, how many orthodontists have created a welcoming environment, systematic evaluation and straightforward treatment plan to take care of these patients if and when they are referred? How many are aware of the services and screening we could or should be providing at this age?

I practice with a pediatric dentist, so of course my view is tilted. This is a growing trend that is underappreciated by pediatric dentists and orthodontists from a quality-of-care standpoint and the obvious and legitimate profitability arguments. So when in Rome, do as the Romans do and create a systematic method to treat these patients in a moral, ethical and time-efficient manner.

I set out to create a system that could manage the needs and expectations of efficient Phase 1 treatment, followed by a reasonable period of waiting and culminating in Phase 2 treatment. The goal is to treat Phase 1 in 9–15 months and Phase 2 in less than 18 months. We all know that the techniques and technology are available, but we need to adapt and practice them.

Over the years, my absolute favorite and common-sense researchers, clinicians and educators have been:

• Dr. Adrian Becker, for his work on impacted cuspids and proactive avoidance of this situation.
• Dr. Anthony Gianelly, for his endorsement and statistical evaluation of the bilateral lingual arch and its benefit for non-extraction treatment in the lower arch.
• Dr. James McNamara, for his method to evaluate the transverse dimension of the maxilla, the size of the dentition and his slick way to treat the transitional dentition.
• Drs. Sean Carlson and Juan-Carlos Quintero, for their commitment to educating orthodontists about treating volumes and not just the Angle malocclusion with their work and citations on crossbites, overt and covert, as well as arch length.

Be on the lookout for upcoming articles with photos and tracings to support these statements.

• My system involves the following steps:
• Patients are referred from the pediatric dentist after age 7, or when a couple of incisors have erupted, and the first permanent molars are visible.
• Not all 7-year-olds are referred.
• My pediatric dentist and I have come to an understanding regarding the need for evaluation.
• When possible, the records are gathered at the same appointment for an upcoming conference and start. (We are beginning to move
• to a virtual model.)
• The exam is conducted in a conference room with comfortable chairs, allowing for the family to be seated across from me with the patient to the side.

We explain:

• Why they are there and what we are looking for regarding jaws, dentition, habits and medical conditions.
• Why Phase 1 and what happens if we delay.

If it is determined to proceed with either interceptive or Phase 1 treatment, the child is taken to be scanned and have spacers placed or, in some instances, have impressions made. Treatment is directed in almost all situations at expanding, developing or harnessing the maxilla and or mandible. Primary teeth are rarely removed, unless they are exfoliating asymmetrically, permanent teeth are erupting ectopically or there is difficulty placing appliances. The mandibular incisors are rarely bonded and most likely primary canines, self-alignment and lingual arches are placed. Severe Class 2 issues are addressed; however, as per McNamara, the final molar and skeletal positioning may be delayed until final treatment.

The goals are:

• A well-expanded maxilla with erupted incisors with room and a pathway for cuspids to erupt.
• Straight, attractive front teeth!
• Good molar position with midlines as close as possible at this stage. (Can’t stress too much or treatment gets needlessly extended.)
• Close-to-ideal overbite and overjet.
• Deband and retention with Essex and/or bonded lingual (space permitting).
• Recall.

My final thoughts

It can’t be stated enough that a systematic approach to Phase 1 treatment is essential with proper communication. Expectations need to be managed and questions addressed. Be on the lookout for a mixture of cases on the message boards and in publication spaces. I am enthusiastic about these patients and feel that a true benefit is achieved with properly timed, executed and managed early treatment.