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Treat Now or Wait for Surgery?

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Categories: Orthodontics;
Treat Now or Wait for Surgery?

Orthos debate early expansion versus future surgery in a crowded Class I

A 10-year-old boy presents with a skeletal Class I (ANB 2), anterior and posterior crossbite, impacted UR3 and severe crowding in both arches (Figs 1-12). The original poster proposed beginning with a rapid palatal expander (RPE) to correct the crossbite and create space for the impacted canine. But the big question: Should orthodontic treatment proceed post-expansion or should this case be held for possible surgical intervention in the future?
Treat Now or Wait for Surgery?
Fig. 1
Treat Now or Wait for Surgery?
Fig. 2
Treat Now or Wait for Surgery?
Fig. 3
Treat Now or Wait for Surgery?
Fig. 4
Treat Now or Wait for Surgery?
Fig. 5
Treat Now or Wait for Surgery?
Fig. 6
Treat Now or Wait for Surgery?
Fig. 7
Treat Now or Wait for Surgery?
Fig. 8
Treat Now or Wait for Surgery?
Fig. 9
Treat Now or Wait for Surgery?
Fig. 10
Treat Now or Wait for Surgery?
Fig. 11
Treat Now or Wait for Surgery?
Fig. 12
Is this a non-surgical case in the making?
One Townie offered a comprehensive breakdown, noting maxillary width deficiency, anterior open bite, lingual inclinations of mandibular teeth and labial flaring of maxillary posteriors. His concern extended to potential airway issues seen in the ceph and pano.

The proposed treatment included:
  • Skeletal expansion of ~10mm, possibly with sequential expanders or a TAD-anchored device
  • ENT referral post-expansion to evaluate airway concerns
  • Bracketing maxillary teeth to open space for cuspids
  • Considering bone-anchored maxillary protraction
  • Stepwise elastic traction with careful force control
If favorable growth follows, the doctor believes this case could avoid extractions and orthognathic surgery. However, unfavorable growth or tongue thrusting could require mandibular surgery down the line.

Keep it simple (and kid-friendly)?
Another orthodontist proposed a more conservative, comfort-focused approach, advocating for simple RPE with four bands (UR4/5 and UL4/6) and extraction of the decayed UR6, which appeared non-restorable on the pano. That would allow for mesial movement of the UR7 into the UR6 space, with the UR4/5 distalizing to create room for the UR3. For the lower arch, he’d extract the lower 5s to preserve IMPA and use vertical elastics to address open bite.

Their perspective, “Keep things simple for this kid … no needle, no TAD, no pain.” And yes, a surgical option might still be on the table at age 18, but there’s a lot of growth and progress that can happen before then.

Other considerations: Surgical access, surgeon skill
An additional voice added a practical concern: Extracting the LR5 may not be so simple. Depending on impaction position and access, some oral surgeons might balk. The contributor responded that, in their practice, they work with a trusted oral surgeon who is confident in handling this level of impaction.

The takeaway: Expand first, then reassess
Orthodontists agree that the case should be addressed now, but how aggressively and with what future expectations is where opinions split.
  • Some recommend aggressive skeletal expansion, airway evaluations and TAD-assisted techniques in hopes of avoiding surgery
  • Others prefer a simpler route that minimizes discomfort and risk in the early years, with surgery as a long-term contingency if needed
  • Most agree the key is to stage treatment step-by-step, reevaluating growth and occlusion along the way
As one clinician summarized, “With the extreme variability of Class III growth responses, it is necessary to take each step and re-evaluate before continuing on.” For now, expansion seems like the safest bet, and whether the path leads to elastics or surgery remains to be seen.

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