The critical article "Early Orthodontic Treatment: What Are the Imperatives?" by Drs. G. Thomas Kluemper, Cynthia S. Beeman and E. Preston Hicks in May JADA did not treat early orthodontic treatment accurately.
In the first paragraph, the authors say, "The goal of many clinicians who provide early treatment is to reduce the time and complexity of fixedappliance therapy." This statement is incorrect.
The goal of early treatment, as taught by Dr. Brehm and published with Dr. Carapezza (
Brehm W, Carapezza LJ. Space age pedodontics: the use of the utility archwire appliance. J Pedod 1987;11[3]:201–29[Medline]
), is to establish normal overbite and overjet anteriorly and posteriorly, normal molar relationship, normal jaw relationship and normal lip seal, thus establishing a state of normalcy for further growth and development.
This, in turn, allows us to maximize positive growth patterns and to minimize distalization mechanics in treatment. Reducing treatment time is not a goal of early treatment.
In paragraph two, the question "Is an early approach worth the extra cost, time and energy involved?" makes some unfounded assumptions. By "extra cost," are we speaking of the dentist’s cost or the patient’s cost? The practitioners of early treatment charge no more than those providing traditional orthodontic care.
Whose time and energy are we speaking of, the dentist’s or the patient’s? The time the patient spends in treatment is longer with early treatment. However, since we establish a state of normalcy at an early age, the complexity of the treatment in the adult dentition is diminished. The total active chair time is not significantly greater.
In the second paragraph, the authors further state, "Are the outcomes significantly improved over those of a single-phase treatment approach?" I know with modern research it is heresy to call into question the buzzword "outcomes," but outcomes can be manipulated by what data are chosen to measure. These choices can dramatically alter the picture that researchers choose to paint.
To contrast early vs. late treatment, one must also quantify as an outcome starting vs. final profiles, frequency of distalization mechanics needed to correct Class II problems and starting vs. final skeletal positions (that is, distal movement of molars can create Class I dental but Class II skeletal final outcomes).
Most important, you need to compare traditional treatment to true early treatment using utility arch-wire mechanics, nitanium palatal expanders, straight-wire principles and the objectives outlined earlier of overjet, overbite, molar relationship, jaw relationship and lip seal, all being brought to normalcy in the mixed dentition. Applying the principles and mechanics of late treatment early does not evaluate early treatment.
With regard to the conclusions expressed in the article by Tulloch and colleagues (
Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial. Am J Orthod Dentofacial Orthop 1998;113[1]:62–72[Medline]
), these conclusions cannot be applied to early treatment as practiced in the manner I described earlier.
Regardless of whether the study was randomized, if late treatment mechanics are applied to all three treatment groups, it is not a surprise that they all looked the same at the end of the treatment.
This "early treatment" was only late treatment early and did not establish the objectives of proper overbite, overjet, molar relationship, jaw relationship and lip seal in the mixed dentition. Its use as a guideline for the efficacy of early treatment is totally inappropriate.
The article by Ghafari and colleagues (
Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL. Headgear versus function regulator in the early treatment of Class II, division 1 malocclusion: a randomized clinical trial. Am J Orthod Dentofacial Orthop 1998;113[1]:51–61[Medline]
) has the exact same problem as the Tulloch article, as well as other problems.
First, if according to Dr. Ghafari "the headgear correction was due primarily to its effect on the maxilla," and according to Dr. McNamara, "retrusion of the mandible is the most commonly occurring factor contributing to Class II malocclusion" (
McNamara JA. Influence of respiratory pattern on craniofacial growth. Angle Orthod 1981;51[4]:269–300[Medline]
), then the final profiles of these patients need to be considered as an outcome, since with distalization, on a percentage basis, the maxilla has been distalized to a retruded mandible, creating a concave profile.
McNamara also reports that "mandibular growth can be increased or decreased by changing the mandibular postural position." Now, I understand that this was in rhesus monkeys, but with this information, I don’t understand how anyone can argue against attaining a state of normalcy as early as possible in the growth and development of a child.
Based on the fact that the studies reviewed did not deliver early treatment, as described in detail in Brehm and Carapezza’s previously mentioned article, how can the authors come to the conclusion that "in fact, these and other recent studies suggest that as long as the patient is treated while he or she is still growing, the time at which treatment begins may not make a difference in the success of the Class II correction"?
When one also considers the fact that these authors view distalizing molars and mandibular advancement as equivalent outcomes in Class II correction—even in light of McNamara’s information on the nature of the Class II problem, and without starting and final profiles being considered as outcomes—how can the authors’ conclusions carry much weight?
One of the most profound enigmas of this article is in the third paragraph of the section on page 617 entitled "Early Treatment of Transverse Discrepancies." When discussing expansion and children exhibiting a lateral functional shift resulting in unilateral crossbite, the authors conclude, "Left untreated, this condition can lead to asymmetrical growth of the mandible and uneven remodeling of the glenoid fossa."
Yet, in the next paragraph they conclude that "maxillary constriction without a lateral shift does not carry the same urgency and, therefore, can be treated closer to adolescence."
Many patients with maxillary constriction exhibit no crossbite but rather a Class II mandibular retrognathism to achieve maximum intercuspation. The authors, by their statement, seem to agree with McNamara that postural position can affect mandibular growth and yet consider bilateral retardation of growth in the condylar area, secondary to posterior posturing, acceptable.
Isn’t it common sense that a child in the mixed dentition with a maxillary constriction and a Class II skeletal relationship be treated to normalcy early to allow normal growth and development of the condylar area, as well as all the other maxillary and mandibular structures?
Although the authors would like to conclude from this review that the "evidence is equally compelling, however, that such an approach [early treatment] is not indicated in many cases, and delaying treatment until later in dental development may be advised," I feel, based on my previous discussion, that this is a fallacious conclusion.
Treating almost all malocclusions to normalcy as early as possible cannot be harmful to the patient. And, based on McNamara’s conclusions that "growth of the mandible can be influenced by alterations in the functional environment," most likely can make a huge contribution to the normal growth and development of children.
