Oral Health Group

Letters to the Editor (December 01, 2001)

December 1, 2001
by Oral Health

Re: Editorial entitled, “One Phase or Two Phase Orthodontic Treatment – Which is Best?” by Randy Lang, DDS, D. Ortho. Oral Health, September 2001.

Routinely, my days begin with seeing and retreating patients with TM disorder, collapsed arches, vertically inclined maxillary incisors and retruded mandibles. I often wonder, while eating my popcorn and thinking about the last movie I went to, perhaps if these patients were seen during the early mixed dentition stage and had phase I arch development, they would not have the aforementioned problems, including two to four missing bicuspids.

I have been doing this for 17 years. I feel that, because of early treatment, the need for extraction is often not necessary. Dr. Fedon Livicratos states that there was no measurable difference between Class II non-extraction cases treated early or late. I wonder this: How many non-extraction cases were treated non-extraction later because phase I treatment had been done early on?

I am very surprised that in the article, supported by university orthodontists, nothing was mentioned about the TMJ. After all, are we not also treating the joint? Or, are we just straightening teeth? If it’s the latter, then sure–go ahead and wait and save money for the patient. But are we now treatment planning based on cost and patient burnout? If I see an orthopedic/TM disorder in the making at age six, then you bet I will “capture” the patient for orthopedic/orthodontic treatment and prevent them from going elsewhere, because I know I am doing the right treatment. I would rather “capture” a patient early then try to “re-capture” a disc later.

So, to answer your question, does two phase orthodontic treatment work? Yes. Does it cost more? I really do not know. Does it take longer? I do not think so, if diagnosed properly. Should parents be informed and given a choice? You bet. But let’s also tell them what could happen if we do not recognize an early orthopedic TM disorder, and maybe when your two-phase patients reach age twenty-eight, they can eat popcorn at a movie, too.

Martin Fraschetti, DDS

St. Clair Shores, MI

I too spend time in lines observing and wondering why does a child not have braces yet. Surely, defining which is best depends at least on the proper diagnosis and the wishes of the patient and the parents.

Phase 1 treatment usually is approximately 1 year with a retention period to allow for permanent tooth eruption. Intervention at this age allows for non-surgical treatment of orthopedic problems, cooperation is usually good, reduces need for long treatment times in teen years and kids don’t have to look “goofy”. With proper jaw and tooth alignment, Phase 2 rarely takes longer than one year. Performing 2-Phase Functional Orthodontics may in fact cost more to the patient however; the patient will have a full compliment of teeth and no surgery. Most parents are willing to pay the “extra” to ensure their children are not subjected to unnecessary surgery.

Are we providing a health service to our children patients if we do not even consider 2-Phase orthodontics as a treatment modality? The Canadian Dental Association recently produced a definition of oral health. “Oral health is a state of the oral and related tissues and structures that contribute positively to physical, mental and social well-being and the enjoyment of life possibilities, by allowing the individual to speak, eat, and socialize, unhindered by pain, discomfort or embarrassment.” Goleman and Goleman’s study in 1987 showed that good-looking children are better students, athletes and socializers. Children with crowded teeth and narrow arches can be helped both from a functional and social standpoint by initiating early orthodontic treatment. Proper arch form encourages normal muscle function, proper nasal breathing, normal tongue function and normal swallowing. If we truly are “Mouth Doctors” we can help children with oral habits such as airway problems, tongue habits, snoring and sleep apnea. Studies have shown that early intervention while the child is still growing can positively affect their oral development. The Burlington Growth Study, a University of Toronto study, provides us with information about growing individuals and how and when we can harness the growth potential of these individuals. The ideal time for functional appliances is during the mixed dentition stage of a child’s development. Using this data means that we must have 2-Phase orthodontic treatment as part of our treatment plan.

Which treatment modality is “best” will ultimately depend on your philosophy. Do we elect to watch a malocclusion form over the years, then inform the parents that extensive orthodontics and surgery are needed or do we recommend early intervention to prevent more aggressive treatment in the critical, formative teen years of the child? For my children, I elected early intervention. This will take a major paradigm shift in the orthodontic community, just as the restorative community has gone from the theory of G.V. Black cavity preparation to adhesive dentistry. Just as Dr. Lang asks if those using 2-Phase orthodontic treatment will re-examine their approach, I ask will those who do not use 2- Phase orthodontic treatment re-examine their approach?

Dennis Marangos DDS


The time has come for all orthodontic practitioners including orthodontists, pedodontists and general dentists to utilize functional appliances in the primary and mixed dentitions to correct functional as well as skeletal malocclusions. The Burlington Growth Study reported that 70% of children by age 12 have some form of malocclusion. Phase I treatment involves the use of functional appliances to solve the following problems:

1. Posterior Crossbites – Can cause facial asymmetries and TMJ problems and crowding problems.

2. Anterior Crossbites – Can cause traumatic occlusions, TMJ problems, and premature recession that may need a gingival graft.

3. Constricted Airways – Causes constricted maxillary and mandibular arches with resultant crowding, posterior crossbites and the development of Class II malocclusions.

4. Class II Div 2 – The lingually inclined maxillary central incisors need to be torqued forward in order to allow the mandible to come forward to its proper position. If allowed to continue, these patients can suffer from TM dysfunction.

5. Class II Skeletal – Patients present with a constricted maxillary arch, retrognathic mandible and deep overbite. The treatment of choice is to advance the mandible with a functional appliance such as a Twin Block and do the case non-surgically.

6. Habits – Thumb sucking and tongue thrusting habits can cause anterior open bites that are extremely difficult to correct after all the permanent teeth erupt. These problems must be corrected any time after age 5 when cooperation levels are high.

Brock Rondeau, DDS

London, ON

You have questioned the 2 or multi-phased orthodontic treatment approach for mainly Class II malocclusion, in efficacy, cost and result. You have quoted several articles to support your opinion, which is that there is no benefit for a phase 1 early mixed dentition treatment for Class II malocclusions.

I do have a different opinion regarding this topic. I look at these cases obviously different than you do. I will quote a segment of your article (first paragraph) ” I look around at kids’ teeth “. As a dentist I also have the habit to look around, but I am not looking around at kids’ teeth, I look around at kids’ FACES. I am sure that without early treatment you will not have the same result, which is a healthy broad smile with ample airway and healthy TM Joints.

I am very pleased to read the article, “Butterfly Expander for use in the mixed Dentition” and “The modified Bluegrass Appliance”. Both articles support my opinion about early treatment in Class II cases. I might not agree with the rate of expansion, but I agree completely with the treatment approach. Both articles apply for class II cases, mostly with narrow maxilla and often maintained by thumb sucking. And I agree completely with the highlighted quote “and we prefer to correct the direction of growth as early as possible” (page 26).

As a member of the editorial board, I assume you are supporting these articles.

Edmund Liem, DDS

Chilliwack, BC

It has been my experience in orthodontics that 2-phase treatment for Class II malocclusion has the following benefits:

Improved skeletal relationship. Most of these kids have retruded mandibles that can optimally be corrected while the child is most actively growing. This further improves the profile, which makes the mothers even happier.

Healthier TMJs. Correcting Class II skeletal relationships in early mixed dentition with functional appliances gives the child the greatest chance for healthier jaw joints , again while they are growing. Preventing head, neck and face pain, or at least treating it early on can only be considered a favourable approach.

Open airways. Many of these kids suffer from airway obstructions due to enlarged tonsils and adenoids or posterior positioning of the tongue. Treatment of Class II skeletal patterns with functional appliances tends to open the airway space. Increased oxygen to the brain appears to have a positive influence on a child’s total health as well as improving social and academic function.

Self-Esteem. Many of these kids do have “maxillary incisors out so far they come around the corner about five seconds before you see the rest of the child’s face.” They frequently are subject to ridicule and senseless name-calling that can set them up for many negative social issues. No parent on earth will object to treatment that can prevent emotional abuse of their child.

Any parent, given the opportunity to optimize a child’s health, will choose to go for an early, preventative approach, even if it means a second phase of treatment and additional expense. Whether it means arch development for mixed dentition, braces for baby teeth or functional appliances, the benefits of early treatment far outweigh the potential additional cost of treatment and additional treatment time. Why wait for health?

Dawne E. Slabach, DDS

Columbus, OH

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