Second Opinion: The Fine Line of Phase I by Dr. Robert Kazmierski

Categories: Orthodontics;
Second Opinion: The Fine Line of Phase I 

Three conditions to determine the early-treatment decision

by Dr. Robert Kazmierski

Much of the controversy over Phase I treatment stems from a fact we all seem to agree upon: Phase I treatment rarely avoids the need for Phase II treatment. As a result, we need a good justification for doing Phase I.

While Phase I treatment isn’t the most controversial or oldest topic in orthodontic, it has shown staying power. Newer forms of Phase I even seem to be gaining some traction! Unfortunately, this resurgence is sometimes promoted for reasons that are not with the best intentions for patients.

Let’s put others’ intentions aside for a moment and ask a question: For those of us in the majority just trying to do the right thing by our patients, how do we determine when Phase I treatment should be provided and when it should not?

I do think there is an answer, and we first have to consider the philosophy of what we are trying to do; consideration as to how we do something and what appliance is appropriate is then secondary. To start, it will be helpful to define and agree on the boundaries. Hopefully, we can then agree upon some rules and indications within those boundaries that will guide us safely and ethically down the middle.

Eliminating the extremes

Right off, I believe we should eliminate the extremes on either side. Some appear to advocate for nearly never doing Phase I treatment; others seem inclined toward the opposite side. To those who say never, I’d ask what they’d recommend for a 7-year-old patient with a constricted palate, bilateral crossbite and a functional shift into unilateral crossbite. Is there any advantage to not treating this patient now? Not treating this patient with an appliance (e.g., fixed expander) capable of orthopedic palatal expansion would only let the suture fuse more and allow the unwanted side effects of the functional shift to increase. Palatal expansion is Phase I treatment. If we can agree that this patient should receive orthopedic palatal expansion, then we also agree that sometimes Phase I treatment is indicated.

Likewise, even for the most ardent interceptive practitioner, can anyone come up with a valid reason to treat a 7-year-old patient with Class I occlusion, very mild anterior crowding or spacing, no crossbite and no parafunctional habit present? Hopefully, we can also agree that there are patients for whom Phase I treatment is not indicated.

Common ground

Those are of course the extremes, but they illustrate the vast majority of us agree with Phase I treatment as sometimes indicated and sometimes not. So now, outside of the extremes, where is the correct middle ground? Irrespective of the appliances we use, we can develop a set of three rules or conditions that can guide us. Patients with these conditions should have Phase I treatment and patients without them should not. If I am correct, this will have significant implications for certain companies and key opinion leaders (KOLs) who push products and treatments seemingly only because they’re profitable, not because they are actually of help to our patients. I will present these three conditions in descending order, starting with the conditions that I expect we will most agree upon.

First condition

The first condition where Phase I treatment would be indicated is when a patient’s teeth or malocclusion is causing psychosocial issues. If a patient is being teased, this is more than adequate reason to provide Phase I treatment to help them. We all went into the health professions because we wanted to help people. Who wouldn’t want to help a child in this situation?

There are obvious caveats. The correction desired has to be something that we can do. It has to be something that will not cause any immediate or long-term harm. Also, the parents and patient must be fully aware that this treatment is elective and is being done now only for this reason, and that Phase II treatment will still be needed later.

For this first condition, treatment could be provided with braces, any number of appliances or clear aligner treatment.

Second condition

The second condition would be one in which not doing something for the patient early would allow something to become irreversibly worse or cause a secondary ill effect to develop.

Examples in this category abound. One example would be that of a primary tooth being prematurely lost in a location where the mesial drift of the distal molars is anticipated. For this patient, the crowding is minimal, and the patient may be treated non-extraction later on if only the space is maintained. For this example, I would consider a holding arch Phase I.

A second example might be a patient with a maxillary central incisor in crossbite. Untreated, this could ultimately cause the loss of a lower incisor, among other problems. There may be some debate whether certain situations qualify under this category. However, I suspect that most of us fall into the middle of a fairly steep bell curve in opinion on this. Treatments in this category would seem to be mostly done with fixed or removable appliances; occasionally braces or clear aligners could be indicated.

Third condition

As promised, the third condition will likely be the most controversial. This condition is where doing something in Phase I will improve the quality or duration of the final result at the end of Phase II. An additional consideration is that this correction cannot be achieved with Phase II treatment alone.

Examples of patients in this category would be the previous 7-year-old patient who needed palatal expansion, or a 7-yearold patient growing Class III and treated with a protraction headgear. The younger a patient is, the greater the percentage of their correction will be orthopedic when protraction headgear is used. The Phase I goal with Class III patients we’re trying to treat nonsurgically is to maximize the orthopedic correction and to minimize the dental compensations that result. Early Phase I treatment accomplishes this. Dental compensations are then reserved for Phase II and only applied as needed. This is because these compensations are limited in scope and are almost always in the category of being compromises.

Whether or not you agree with the above treatments is beside the point. The real point is that almost all justified treatments in this third category are orthopedic. Treatments that are not orthopedic are rarely indicated under this third condition. That is because most nonorthopedic movements can be done more efficiently in Phase II alone.

This is the bombshell thought that many companies and KOLs don’t want us thinking about. This is because this philosophy eliminates a broad swath of treatments that are being done under the misleading claim that they somehow are of benefit to the patient long term.

Unmaking the unproven

At this point, I must deal with the all too prevalent and unproven claim that braces themselves, special types of archwires, special arch forms, removable appliances or clear aligner treatment in any way increase the bony base, or bone facial to the tooth roots in the alveolar ridge. Despite decades of claims to the contrary, there are zero prospective randomized controlled trials published in peer-reviewed journals to justify this claim, so it must be presumed false until proven otherwise.

What does this mean for this third condition for Phase I treatments? This means that when we “develop the arch” with braces, wires, arch forms, removable appliances or clear aligners, we are at best tipping the crowns to the facial. Despite how pretty the pictures look, we are not growing the bony base and we aren’t creating space.

However, these treatments are not necessarily bad! Sometimes lingually inclined posterior teeth need to be uprighted and the arch “developed” within limits. However, there is a limit to how much this can be done and still keep the roots in the bone without causing dehiscence or fenestration.

Among the shames of our profession is that this sometimes acceptable limited movement has been taken to extremes in order to attempt non-extraction treatment with patients.

Notes on arch development

Another key is that there is no evidence and no reason to believe that these nonorthopedic “arch development” or tipping movements are any better done for the patient in Phase I than they are if just done in Phase II. At best, these KOLs are doing something early that should be done later. At worst, this early treatment may cloud our diagnosis at the beginning of Phase II and cause us to incorrectly treat some patients without extraction. I have recently seen examples of this overdevelopment or overtipping being done to patients in a way that made me feel sick.

We are now at a point where partial braces (2-by-4s), many appliances, and clear aligners are seldom justified to be done because of this third condition.

However, we frequently see doctors treating and posting Phase I aligner cases where aligners are used in the mixed dentition to bring teeth into the arch for no other purpose than to relieve the current crowding. Once admiration of the results subsides, the postings and statements seem to center around how much to charge, the profit per visit, and how this can sometimes be timed so that both Phase I and Phase II are within a single five-year billing period.

Instead, the first and main question we need to ask ourselves is: Why this is even being done in the first place? Is it being done because the patient is benefitting, or because a company and KOL are benefitting? All too frequently, I believe the answer is the latter.

Demand evidence

Partial evidence for when we see this is the actual lack of evidence or records. While a KOL should be expected to have thousands of fully completed cases to show, rarely will we see complete records for any time point, and possibly never for all time points, pretreatment, post-Phase I, and post-Phase II. If these KOLs are treating thousands of these patients, why aren’t they presenting full records for all time points? In answer, I’ll share a phrase used by my friend Dr. Mark Wertheimer: “selection for projection.” That is, nearly any treatment can be made to look appropriate or well done if only selected records are presented.

I do believe that Phase I treatment is sometimes very beneficial. and sometimes should not be done. Depending upon the circumstances, this can be best done with braces, appliances and clear aligners.

There are corporate interests at play trying to guide us into doing these treatments on patients when it is not appropriate. We need to see this for what it is, resist it and do what is right for our patients. Determining the best treatment for patients is something that should leave us constantly questioning. Doing what we believe at the time is best for our patients is something that should never be questioned.

Agree or disagree?

Verified members of the Orthotown community can post their thoughts, concerns and ideas in the Comments section under this column—and every other article!

Author Bio
Dr. Robert Kazmierski Dr. Robert Kazmierski graduated from the University of Pittsburgh in 1983 with a bachelor’s degree in philosophy. Afterward, he attended the University of Pittsburgh School of Dental Medicine and graduated in 1987 with a DMD degree and a certificate in anatomy. He completed his orthodontic residency in 1989 at Washington University in St. Louis. Kazmierski has a special interest in treating orthognathic surgery patients and open-bite patients
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