CE: Phase I Treatment by Dr. Daniel J. Grob

Start Discussion More by this author (5)

A case for three-dimensional diagnosis and treatment

by Dr. Daniel J. Grob

Short course introduction
This course explores the published history and recommendations of Phase I or early orthodontic treatment, which is still controversial among orthodontic professionals. The author shares seven case studies of varying levels of Phase I treatment—from “Phase None” to comprehensive and early treatment, depending upon each patient’s specifics upon presentation—and explains the rationale behind each approach.

Objectives
At the end of this course, you should be able to:

Name the four factors of malocclusion.
Identify the three time points for treatment of malocclusion.
Understand the difference between when teeth are too large and when jaws are too small.

Introduction
The topic of Phase I or early treatment continues to draw attention in the professional and social media universe. New and sometimes obscure diagnoses are appearing regularly, particularly outside of the orthodontic profession, while there are few clinical articles to support or refute the practice of a structured method to determine if Phase I treatment is warranted or successful.

Most clinical papers are anecdotal, featuring a patient treatment case that worked well, with many detractors saying it was unnecessary. On the other hand, many Phase I treatments deliver the goals of Phase I treatment without picture-perfect results, so the complete clinical case and description with records are not offered up for review in publications and by peers for fear of repercussions and shaming.

Since the initiation of orthodontics as a specialty, orthodontists have spent most of their time and energy diagnosing, treating and evaluating success or failure in the sagittal dimension. Most probably, this has been because the founder of modern orthodontics, Dr. Edward Hartley Angle, created a system of classification that operates in that dimension; however, Angle also identified the most probable reason for malocclusion and treatment failures, namely, mouth breathing.

It is interesting to note that newer, low-dosage CBCT radiographic machines allow for us to visualize the patient in three dimensions, allowing diagnosis, treatment and evaluation to be accomplished in many planes of space. The following case presentations identify how visualizing patients in all these planes allows for a different treatment approach than what is commonly employed with stone casts, photographs and two-dimensional imaging.

Background
I have written several articles explaining my thoughts on treatment timing and early treatment in particular. A list of references documenting how published and respected authors approach the subject was included in these articles.

“Treatment by Twelves” was a general summary of clinical orthodontics identifying the four key issues clinicians deal with on every patient in diagnosis treatment and retention—the skeleton, the teeth, the temporomandibular joint and the soft-tissue envelope surrounding the teeth. The article concludes that there are three key timepoints when orthodontic treatment to address these concerns is warranted:

When the first 12 permanent teeth appear.
When the next 12 teeth appear.
Eruption of the 12-year molars.

An Office Visit profile highlighted my venture into the combination practice of pediatric dentistry and orthodontics and identified some of the concerns of both specialties and respective practitioners.
“A Pediatric Protocol” summarizes my thoughts on the first contact parents and patients have with the orthodontic department of a combined practice or group setting, and outlines the key elements of a pediatric new-patient exam.

Why?
The appearance of multispecialty group practices and combination pediatric dental and orthodontic practices forces the need to manage patients in a time and cost-efficient manner, optimizing the clinical result. Having a structured approach aids in time and cost management, training of auxiliaries, and explanations to parents and patients.

An organized, easily described and effective method of treating patients from early age through adulthood is the goal. We would probably all agree that “When should my child visit the orthodontist?” is probably the most-asked question of us, next to “How much does it cost?”

There are many thoughts on the decision to pursue Phase 1 or early treatment in youngsters.

Barrer¹ quotes Ricketts by identifying seven reasons for early treatment:

Reduces extractions.
Eliminates habits.
Anterior protrusion worsens without treatment.
Moves away from uncooperative age.
Offers a better orthopedic response.
Treatment is simplified.
Prevents fracture of teeth.

Dugoni’s approach² is to perform treatment early, possibly eliminating the need for treatment later.
McNamara³ focuses on the transverse dimension, believing that this care yields removal of the crowding, with a bonus finding that widening of the upper arch allows for the mandible to position farther forward in some slight Class II situations, thereby eliminating some of the overjet. He advocates delaying most Class II treatment until more teeth are erupted during adolescence.
Gianelly’s approach⁴ is to relieve crowding in most situations in the lower arch with the use of a fixed lingual arch, which can eliminate the need for permanent tooth removals by up to 90%.

During the past five years, I have noticed that most young patients with narrow maxillas have some contributing muscular imbalance when viewed in comparison with their siblings or parents without that narrow maxilla. If one looks at thousands of new young patient exams and extrapolates what’s seen in adolescent patients, a pattern emerges—namely, that if patients are seen early, intercepting oral habits and medical conditions can make orthodontic correction easier and more successful later. Most of these oral and medical conditions concern breathing and abnormal face and tongue muscle posture or habits, including tongue tie.

I have previously quoted and regularly refer to Angle’s 1907 textbook, where he writes, “Of all the various causes of malocclusion, mouth breathing is the most potent, constant and varied in results.”⁵ It is for this reason that early intervention to eliminate habits and encourage an environment for healthy soft-tissue interaction with the dentition is the first service offered.

When?
In most instances, the pediatric patient is referred because of lack of room for teeth, usually while the first 12 permanent teeth are erupting. For better or worse, this is what parents and patients can identify with and, even though there is usually more to the story, this finding gets them in the door. The common phrase among parents and dentists alike is that the “teeth are too big for the jaws.”

This may indeed be the case, but after examining thousands of young patients and having the opportunity to observe and interview the parents, I must say that more times than not, the alveolar housing (or “smile bones”) are too small for the teeth. This topic is introduced by Rose in an anthropological study⁶ and serves as the backdrop for much of what is done in my clinic. This concept is relatively new to this seasoned practitioner of 40 years and is rarely discussed in the literature or mentioned in lectures, presentations or even training programs.

In my early career, using traditional diagnostic and treatment regiments, my Phase I treatment rate was 10–20%, which I’m sure aligns with many across the country. However, with the advent of CBCT and following advice and protocols from Carlson⁷ and others, I have become a firm believer in the benefits of complete early exams and treatment in a large percentage of 6- to 9-year-olds, to be followed later with a round of Phase II care. Carlson cites evidence and bench studies from Ludlow,⁸ who shows that modern CBCT machines with ultralow-dose settings irradiate patients no more than traditional panoramic surveys.

Goals?
A practice goal has been established for entering Phase I or early treatment.

Create room for all upper permanent teeth when tooth mass allows, according to McNamara,⁹ by trying to achieve 36 mm of distance between the maxillary molars when the central incisors are less than 10 mm wide.
Do not discontinue until a clear path of eruption is established for all teeth—especially the cuspids, as discussed by Becker and Chaushu.¹⁰
Work to eliminate harmful habits and other contributing factors such as tongue and lip tie.
Create space for the tongue to be placed on the roof of the mouth.
In some cases of skeletal Class II or Class III, provide for “pretreatment” to allow for better treatment later, subject to cosmetics and function.
Eliminate asymmetrical opening and closing.
Finish with an attractive smile and stable transitional occlusion.
Retain with a lingual arch, expanded to match the width of maxillary molars.

How?
Our practice has used various expanders^11,12 during the past several years, following up with fixed appliances or aligners.

Initially, Haas expanders were used, with a conventional RPE Hyrax when more skeletal results were desired. Based on experience supported by literature, we have moved in the direction of a leaf-spring expander for most patients, to create more comfort for the patients and lessen the demands on the parents. Although good expansion is often achieved within a few weeks, we generally leave the expander in place for up to six months to stabilize, and to make sure the lateral incisors are in plain view and we have had time to expand and upright the mandibular molars with a modified lingual arch similar in function to the Arnold expander described by Kravitz.¹³

Unlike the Arnold expander, which widens the lower arch, no active expansion is attempted in the anterior portion of the mouth. It has been our observation that the increase in maxillary width allows some spontaneous eruption and space gain into the free-way space, especially when done with bite turbos in Phase II. Recently, in a two-part series of CE courses for Orthotown, Dr. Michael DeLuke outlined the differences between rapid and slow maxillary expansion and also discussed the advantages and controversies of mandibular arch expansion.

Patient case reports
The patients in these cases presented for exams, at which point a diagnosis and treatment plan were determined. Each patient’s skeletal balance, tooth position, TM joint and soft-tissue habits were considered and their pertinent history is noted—chief complaints, contributing factors such as mouth breathing, palatal width across the maxillary molars, and presence of oral habits. Particular attention is paid to erupting cuspids and second molars for a clue to the need to intervene.

As you’ll see, the treatments range from “Phase None” (as it’s referred to in social media posts) to comprehensive and extensive early treatment. Supporting photos and X-rays serve to clarify and support the treatment goals and results.

Case 1: 9½-year-old boy, Class I, recall patient
There are times when parents ask for advice regarding care later and a careful assessment is made as to whether early intervention is required. This patient, a sibling of a patient in treatment, was evaluated.

Chief complaint: Teeth appeared crooked and parents wanted a checkup.
Contributing factors included occasional mouth breathing.
Palatal width: 33 mm, with an acceptable buccal corridor.
Habit: Nail biting.
Slight ectopic eruption of maxillary cuspids and second molars.

Because of the reasonable width (Fig. 1a), presence of maxillary lateral incisors (Fig. 1b), favorable eruption patterns of cuspids and second molars (Fig. 1c), and minimal Class II tendency (Fig. 1d), it was determined to not treat the patient at this time.

Recommendations were made to remove the primary cuspids that remained; visit with an ear, nose and throat specialist; and stop nail-biting. Care will be initiated when all permanent teeth erupt. The follow-up photos and X-ray indicate all teeth have erupted (Figs. 1e–1g), and comprehensive treatment is now under way.

Fig. 1a

Fig. 1b

Fig. 1c

Fig. 1d

Fig. 1e

Fig. 1f

Fig. 1g

Case 2: 9-year-old boy, Class I, habit elimination

One of the most beneficial services to be provided is the elimination of digit habits. Often, these habits are at the root cause of palate narrowness, poor tongue posture and bad breathing. While not a predictable solution, palate expansion in conjunction with a “habit appliance” can lead to success.

In this situation, the patient did not need the palate widened; fortunately, he broke the habit and is currently awaiting the beginning of Phase II treatment, where we will finish alignment and creation of a smile arc. Personally, I find this treatment in general to be dependent on the patient’s willingness to quit the habit. It was decided to only treat the habit and not expand because of adequate width, good path of eruption for the cuspids, basically straight teeth and good growth expected.

Chief complaint: Parents were concerned with habit and open bite with poor tongue posture.
Contributing factors: Tongue tie (however, the mother experienced no issues during breastfeeding).
Palatal width: 32.5 mm, with a dark buccal corridor.
Habits: Thumb sucking with poor tongue posture.
Favorable eruption potential of cuspids and second molars.

The evaluation of the face indicated good width and symmetry (Figs. 2a and 2b). Lack of wear of the incisal edges was noted, as was the favorable eruptive potential of the cuspids and molars (Fig. 2c).

Treatment included a habit appliance cemented to the upper molars for six months (Figs. 2d–2f). The patient and family responded well, and we are awaiting eruption of the remaining permanent teeth. Evaluation of the result indicated an eliminated anterior open bite with better tongue posture and wear of the mamelons, indicating movement toward a mutually protected occlusion (Figs. 2g–2i).

Fig. 2a

Fig. 2b

Fig. 2c

Fig. 2d

Fig. 2e

Fig. 2f

Fig. 2g

Fig. 2h

Fig. 2i

Case 3: 8-year-old boy, Class I, crossbite with braces

When patients present with crossbites, either singular or bilateral, a midline deviation is also frequently noted. Having the parent stand behind the examiner’s back observing the opening and closing motion is a great visual, as well as capturing this on a photograph. The intermolar measurement is often in the mid- to high-20-mm range, up to 30 or 31 mm. A contributing factor is often mouth breathing, tongue tie or digit habits. Treatment for most of these patients involves maxillary expansion and a lower lingual arch or Arnold expander to upright the mandibular dentition to match the upper molars, which helps to stabilize the maxillary expansion while waiting for lower teeth to erupt and begin Phase II.

Chief concern: Crooked teeth with a crossbite and a midline shift.
Contributing factor: Mouth breathing.
Palatal width: 26.5 mm, with a dark buccal corridor.
Habit: Nail biting.
Favorable eruption potential of the cuspids and second molars.

This patient presented with a crooked and narrow smile with a dark buccal corridor (Figs. 3a and 3b). The X-rays showed favorable direction of eruption and postion of upper incisors (Figs. 3c and 3d), and the palatal width was 26.5mm (Fig. 3e).

A Haas expander was used with limited appliances and a lingual arch to widen the mandibular molars and stabilize (Figs. 3f–3j). Treatment took 14 months and included removing lower Cs for symmetry, discouraging nail biting and making a referral to an ENT specialist. The final facial features indicate a straighter head-on appearance, 31.5 mm of maxillary width and a more complete buccal corridor (Figs. 3k–3n). The permanent cuspids and second molars are in a favorable eruption pattern.

The patient is awaiting Phase II treatment to begin.

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 3e

Fig. 3f

Fig. 3g

Fig. 3h

Fig. 3i

Fig. 3j

Fig. 3k

Fig. 3l

Fig. 3m

Fig. 3n

Case 4: 8-year-old girl, Class I, crossbite with aligners

Chief concern: No room for teeth.
Contributing factor: Narrow airway.
Palatal width: 26.5 mm, with a dark buccal corridor.
Habits: None.
The eruption patterns of the upper cuspids were ectopic and the second molars were favorable.

This patient presented with a narrow smile, crooked teeth, ectopic eruption of the cuspids and favorable molar position (Figs. 4a–4e).

A Haas expander was followed with Invisalign First to widen the smile and help to direct the maxillary cuspids (Figs. 4f–4h). Evaluation of the treatment result indicates an attractive smile with width 31.8 mm—much larger than before—as well as a maxillary and mandibular midline that are coincident (Figs. 4i and 4j). It is also noted that the eruption of cuspids and second molars is favorable (Figs. 4k–4m). Primary cuspids have been removed. The remaining expansion will be accomplished during Phase II.

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 4d

Fig. 4e

Fig. 4f

Fig. 4g

Fig. 4h

Fig. 4i

Fig. 4j

Fig. 4k

Fig. 4l

Fig. 4m

Case 5: 8-year-old girl, Class I, with possible impaction

Occasionally, it appears as if the permanent canines will be impacted to the buccal or palatal side of the dentition.

Chief complaint: No room.
Contributing factors: None.
Palatal width 28.8 mm, with a dark buccal space.
Habit: Nail biting.
Eruption pattern showed good second molar eruption, but the cuspids were on top of the lateral incisors. Wear was noted on the primary cuspids.

The patient presented with obvious crowding and a narrow smile (Figs. 5a and 5b), probably accentuated by the nail biting. The X-rays indicated Class I molars with impacted maxillary cuspids (Figs. 5c–5e).

Even though it had been suggested to remove the primary canines and primary molars for impaction on the palate, the buccal placement was somewhat different. In this case, palate expanders with aligners were used to widen the arch, then limited appliances were used to align the anterior teeth (Figs. 5f and 5g). After space gain, the centrals were brought together, then the laterals. A laser uncovering was accomplished, followed by traction to move the canines distal before the laterals were included in the upper fixed appliance.

Almost two years of treatment shows that the upper cuspids erupted into position without damage to the adjacent lateral incisors (Figs. 5h–5k). Adequate space of 32.2 mm is available to treat the patient with fixed appliances without removing permanent teeth, and the remaining width can be accomplished with archwires.

Fig. 5a

Fig .5b

Fig. 5c

Fig. 5d

Fig. 5e

Fig. 5f

Fig. 5g

Fig. 5h

Fig. 5i

Fig. 5j

Fig. 5k

Case 6: 7-year-old girl, Class II tendency

As McNamara has suggested, Class II treatments are usually best left to comprehensive or later care—during the “next 12” or “12-year molar” stage of the Treatment by Twelves philosophy. However, in certain situations with extreme flaring or functional issues, a modest attempt at early intervention may be warranted.

As this patient demonstrated, widening the upper smile can allow for forward migration of the lower jaw and some retraction may be achieved. Also, as McNamara has suggested, expansion of the upper unlocks the lower to allow for forward posturing of the mandible.

Chief complaint: Crowding and protrusion.
Contributing factors: Mouth breathing, small airway and under medical supervision for sleep-disordered breathing.
Palatal width: 29.5 mm, with a dark buccal corridor.
Habit: Grinding.
Eruption pattern somewhat compromised in the cuspid region and favorable in the molar area.

This patient presented with a narrow smile, flaring of the teeth and Class II molars (Figs. 6a–6e).

Phase I treatment, including RME and limited fixed appliances with an expanded lingual arch, was undertaken to expand the arches, the nasal cavity and encourage mandibular growth or posturing (Figs. 6f–6h). Treatment took about two years, and the results of care showed a favorable width of 36 mm and mandibular position, as well as reduction of the flaring of the front teeth (Figs. 6i–6o). Breathing also improved.

Fig. 6a

Fig .6b

Fig. 6c

Fig. 6d

Fig. 6e

Fig. 6f

Fig. 6g

Fig. 6h

Fig. 6i

Fig. 6j

Fig. 6k

Fig. 6l

Fig. 6m

Fig. 6n

Fig. 6o

Case 7: 7-year-old boy, Class III

Probably the malocclusion that attracts the most attention in patients, parents and dentists is the Class III. Often the three preceding stakeholders feel the obligation to “do something” early in order to “prevent” surgery at a later date. I’m not so sure! In my opinion, if the mandibular incisors can be made to touch the maxillary incisors in the centric relation position, there is a chance.

Chief complaint: Class III occlusion.
Contributing factors: None.
Palatal width: 31.2 mm, with a dark buccal corridor.
Habit: Nail biting.
Eruption pattern showed a lack of room for the maxillary lateral incisors and cuspids.

This patient presented with an anterior crossbite as well a familial tendency toward Class III. His teeth were crooked and uneven, with lack of room to erupt (Figs. 7a–7e).

Treatment consisted of an arch expander with a bite turbo and limited appliances (Figs. 7f and 7g). Results of care showed a corrected anterior crossbite, a widened smile of 37 mm and favorable eruption of the cuspids and molars (Figs. 7h–7j).

Fig. 7a

Fig. 7b

Fig. 7c

Fig. 7d

Fig. 7e

Fig. 7f

Fig. 7g

Fig. 7h

Fig. 7i

Fig. 7j

Observations
All patients were treated so the goals established were met. Some were expanded more than others, resulting in either extra space for cuspids or barely enough. It is expected that none of the patients shown will need permanent teeth removed later.

Conclusion
The rationale and effects of Phase I treatment have been made. There will be many who question the decisions to pursue early treatment in these patients. I’m also sure many will question the results of this care; certainly, by orthodontic finish standards, there is much yet to be accomplished.

While 3D-printed bands are available for an easy start with an intraoral scan, we have found the adhesion and removal to be quite uncomfortable, so our current procedure is separators, scan for a fitted appliance, and traditional removal. This explains not following McNamara’s procedure of using a bonded expander. We find that adding bite turbos to the posterior occlusal serves pretty much the same objective.

Our mission has been to achieve the stated goals of the practice in a cost- and time-efficient manner, given the complexities and variability of growth and cooperation. Our practice is constantly evaluating methods and materials to make the process smoother, less uncomfortable and more time-efficient.

Claim Your CE Credit

References
1. Barrer HG. Treatment timing–onset or onslaught? J Clin Orthod. 1971 Apr; 5(4):191–9.
2. Dugoni SA. Comprehensive mixed dentition treatment. Am J Orthod Dentofacial Orthop. 1998 Jan; 113(1):75–84.
3. McNamara JA Jr. Early intervention in the transverse dimension: Is it worth the effort? Am J Orthod Dentofacial Orthop. 2002 Jun; 121(6):572–4.
4. Gianelly AA. Treatment of crowding in the mixed dentition. Am J Orthod Dentofacial Orthop. 2002 Jun; 121(6):569–71.
5. Angle, Treatment of Malocclusion of the Teeth, 1907.
6. Rose JC, Roblee RD. Origins of dental crowding and malocclusions: an anthropological perspective. Compend Contin Educ Dent. 2009 Jun; 30(5):292–300.
7. Carlson SK, Graham G, Mah J, Molen A, Paquette DE, Quintero, J-C. Let the truth about CBCT be known. Am J Orthod Dentofacial Orthop. 2014 Apr; 145(4):418–419.
8. Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013 Dec; 144(6):802–17.
9. McNamara presentation, 2015 AAO Winter Conference.
10. Becker A, Chaushu S. Etiology of maxillary canine impaction: A review. Am J Orthod Dentofacial Orthop. 2015 Oct; 148(4):557–67.
11. Bishara SE, Staley RN. Maxillary expansion: Clinical implications. Am J Orthod Dentofacial Orthop. 1987 Jan; 91(1):3–14.
12. Lanteri V, Farronato M, Ugolini A, Cossellu G, Gaffuri F, Parisi FMR, Cavagnetto D, Abate A, Maspero C. Volumetric changes in the upper airways after rapid and slow maxillary expansion in growing patients: A case-control study. Materials (Basel). 2020 May 13; 13(10):2239.
13. Kravitz ND. Treatment with the mandibular Arnold expander. J Clin Orthod. 2014 Nov; 48(11):689–96.

Author Bio

Dr. Daniel J. Grob completed his dental, orthodontic and prosthodontic schooling at the Marquette University School of Dentistry. He has practiced in Tucson and Phoenix, Arizona, for more than three decades.

Grob is a diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontics and the American Dental Association, and the former editorial director of Orthotown.

Start Discussion More by this author (5)

September 2025

Read Current Issue Read Archived Issues

Subscribe / Renew

	Cutting through the clutter, our new AI-powered summary feature harnesses the power of Artificial Intelligence to condense marathon message board discussions into snappy summaries. Now, at the top of every topic page, with at least 100 replies, you will see a new "View Summary" button. Click that button to got to our new topic summary page, because who has time for endless scrolling when you can get the bite-sized brilliance at a glance?	03/11/24



	We're super exited to announce another small feature to enhance your site experience - YouTube embedded videos. Now, any YouTube video you put into your post will automatically be viewable within the post itself. No longer will a link redirect you to YouTube, rather you can simply watch YouTube videos directly from within your posts. You're welcome!!	03/09/24



	We like nothing better than giving you more freedom and ease when using our site. To that end, we just added a new "Quick Reply" section at the bottom of the thread view page. We did this to give you a fast, simple way to quickly reply to a thread. However, don't expect all the bells and whistles on this new Quick Reply feature. It's designed for speed and ease vs complex functionality.	07/25/23



	To help you stay better connected with the topics you're interested in, we expanded our notification system to notify you when an inactive thread that you've participated on becomes active again. These New Activity emails are sent when there is new activity on a topic that has been dormant for 30 days or more. Of course, as with all our other notifications, you can opt out of this new feature from your Profile page if you don't want to receive these emails.	06/28/23



	They say perfection is in the details, that's why we like adding even small features to our site to make a more robust user experience. In our latest update we expanded on our "Thumbs Up" message board feature (indicating you liked a post), to allow members to also give a "Thumbs Down" to posts. Thumbs up and thumbs down are a feature found on many online communities and social media sites. This is a quick easy way to express your like or dislike of content, creating opportunities for you to have a more personalized experience.	06/22/23



View All

What's Current

Popular Categories

Current Issue

Featured Articles

Recently Added Courses

Popular Categories

Most Recent Podcasts

New Podcast Episodes

Recent Classifieds

Classified Categories

Townie Choice Awards

2024 Results By Category

Latest News

Townie News Wire

Most Recent Blogs

New Blog Posts

Upcoming Events

Townie Webinars

Free e-Books

Monthly Townie^® Polls

Townie Perks

CE: Phase I Treatment by Dr. Daniel J. Grob

A case for three-dimensional diagnosis and treatment

September 2025


Ergonomics for the Dental Office
	Dr. Leslie Hovda
	Health, Wellness and Erg...


3 Wire Treatment - An Efficiency Game
	Dr. Chad Foster
	Orthodontics

	Solventum Oral Care
	Why Choose Clarity™ Precision Grip Attachments

	Gaidge Announces New Consult Manager

Popular Categories

Classified Categories

2024 Results By Category

CE: Phase I Treatment by Dr. Daniel J. Grob

A case for three-dimensional diagnosis and treatment

September 2025

Sign up for Newsletter

Message

Error

What's New?