Recognizing and Correcting Developing Malocclusions

A Problem-Oriented Approach to Orthodontics

Eustáquio A. Araújo, Peter H. Buschang, Eustáquio A. Araújo, Peter H. Buschang

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118925256
• Edition: 1
• Topic: Medicina
• Subtopic: Ortodoncia

Recognizing and Correcting Developing Malocclusions: A Problem-Oriented Approach to Orthodontics provides an evidence-based approach to early treatment, an often-controversial topic. Based on decades of experience in clinical practice and education, Drs. Araújo and Buschang clearly present treatment protocols for mixed-dentition patients with various malocclusions and other orthodontic problems. Class I, Class II, and Class III malocclusions are covered extensively, along with eruptive deviations and open-bite malocclusions. The literature is comprehensively reviewed to ensure that the reader thoroughly understands the development, phenotypic characteristics and etiology of each type of malocclusion. Taking a problem-oriented approach, the authors provide detailed information for each case, develop comprehensive problem lists, and then provide evidence-based treatment solutions. The clinical focus of the text is ideal suited for private-practice clinician, with numerous references and academic underpinnings to ensure its suitability for orthodontic and pediatric dentistry residents.

• Focuses solely on mixed dentition orthodontic treatments
• Great variety of case studies—5 to 10 cases per chapter
• Each case is presented in the format of a problem list and evidence-based solutions
• More than 300 clinical photographs and radiographs

Chapter 1
A Guide for Timing Orthodontic Treatment

Eustáquio Araújo, DDS, MDS¹ and Bernardo Q. Souki, DDS, MSD, PhD²,

¹Center for Advanced Dental Education, Saint Louis University, St. Louis, MO, USA

²Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil

When the decision was made to work on this book, the heavy responsibility of embracing the topic without bias or radicalism increased. Clinicians and academicians were initially consulted and asked to provide questions that would help to establish priorities for early interventions. The responses came rapidly and contained all the sorts of questions one would imagine. Recognizing and Correcting Developing Malocclusions will try to address the collected questions and themes.

The term “early treatment” has been used for a long time, and it seems now to be fixed. Although “early” could suggest “too soon,” for the sake of practicality it will be used in this book. The text will eventually also refer to timely or interceptive treatment.

Initiating orthodontic treatment during the growth spurt was often used to be considered as the “gold standard” for treatment timing. The pendulum that regulates the initiation of orthodontic treatment has been swinging in different directions for many years. At present, this balance seems to have been shifting, as the pendulum appears to be swinging toward an earlier start, preferably at the late mixed dentition. The possibility of successfully managing the E-space has dramatically influenced the decision-making on the timing of orthodontic treatment [1].

At the beginning of the 20th century, some consideration was given to early treatment. A quote from Lischer [2] in 1912 says,

Recent experiences of many practitioners have led us to a keener appreciation of the “golden age of treatment” by which we mean that time in an individual's life when a change from the temporary to the permanent dentition takes place. This covers the period from the sixth to the fourteenth year.

Soon after, in 1921, a publication [3] titled “The diagnosis of malocclusion with reference to early treatment,” discusses concepts of function and form, and gives notable consideration to the role of heredity in diagnosis – so the topic with its controversies is an old one.

“The emancipation of dentofacial orthopedics,” an editorial by Hamilton [4] supports early treatment. In summary, he states that:

1. healthcare professionals must do everything possible to help their patients, including early treatment;
2. it is irresponsible and unethical to prescribe treatment for financial betterment and for the sake of efficiency;
3. if the orthodontist is not willing to treat patients at a young age, others in the dental profession will, and it is in the patients' best interest that we, as specialists, treat these patients. After all, our flagship journal includes “Dentofacial Orthopedics” in its title;
4. it is the highest calling of healthcare professionals to incorporate prevention as a primary means of treatment, and therefore early treatment is important;
5. pediatric dentists and other health professionals are incorporating early treatment in their practice because orthodontists are waiting too long to initiate treatment;
6. orthodontic programs have the responsibility to educate orthodontists about early treatment.

On the other hand, Johnston [5] indicates in “Answers in search of questioners” that:

1. little evidence exists that two-phase early treatment has a significantly greater overall treatment effect compared with treating in one phase and considering E-space preservation;
2. treatment aimed at the mandible typically has an effect on the maxilla;
3. early treatment is not efficient for the patient or doctor and results in an increased burden of treatment;
4. functional appliances do not eliminate the need for premolar extraction, as bone cannot grow interstitially and arch perimeter is not gained with their use;
5. patients occasionally endure psychological trauma due to dental deformity, but these isolated instances are not enough to “support what amounts to an orthodontic growth industry.”

In an effort to establish grounds to initiate treatment earlier or later we must try to answer two key questions:

1. Should developing problems be intercepted and treated in two phases?
2. Which malocclusions should receive consideration for treatment at an early age?

Undoubtedly, there is much agreement on what to treat, but there is still great disagreement on when to intervene.

What are achievable objectives for early treatment? Some of the most relevant ones are using growth potential appropriately, taking advantage of the transitional dentition, improving skeletal imbalances, eliminating functional deviations, managing arch development, improving self-esteem, minimizing trauma and preventing periodontal problems.

Among possible advantages are higher compliance, emotional satisfaction, growth potential, the possibility of a more simplified second phase, a possible reduction of extractions in the second phase and, of course, issues related with practice management. Disadvantages also exist such as inefficiency, extended time of treatment, immaturity, inefficient oral hygiene, inability to take care of appliances, and cost. It is important for the orthodontist to weigh each of these benefits and risks to offer sound evidence and convincing reasoning for their decision to treat or not to treat. In this chapter a guide to timing orthodontic treatment is presented.

The ideal timing for treating malocclusions in growing patients has been a controversial and widely discussed topic throughout the history of orthodontics [1,6–10]. One of the most important debates in our field is whether to interrupt the development of problems with early treatment or to postpone therapy until later [1,9]. Such controversies are likely due to the lack of a scientific basis for therapeutic clinical decisions [8]. Historically, dentistry has been an empirical science. Even today, most dentists choose to employ solutions and techniques that were first learned in dental school, or those that they believe will work [1,9]. In such cases, there is a high probability of treatment failure or a low-quality treatment outcome.

During the search for excellence in orthodontics, the concepts of effectiveness and efficiency have been emphasized [1]. Orthodontic clinical decisions should be scientifically based. Accordingly, treatment must be postponed until strong arguments in favor of beginning the therapy are present [9].

A follow-up protocol in which patients are re-examined periodically during growth and the development of occlusion allows the clinician to decide whether the cost/benefit of early treatment is justifiable. At this time, the program “preventive and interceptive orthodontic monitoring,” or simply PIOM, as devised by Souki [11] is introduced.

Conceptually, PIOM is a program of sequential attention that aims to monitor the development of “normal” occlusion and seeks to diagnose any factors that may compromise the quality or quantity of orthodontic treatment and the establishment of an appropriate occlusion. Seven objectives govern PIOM:

1. Provide prospective monitoring with a minimal intervention philosophy;
2. Provide comprehensive orthodontic care with functional and aesthetically harmonious adult occlusion as the ultimate goal;
3. Establish parameters so that orthodontists are not in a h...