TREATMENT PLANNING IN THE PRIMARY DENTITION 1.

Reasons for Treatment* Treatment in the primary dentition is undertaken for the following reasons: a) To remove obstacles to normal growth of the face and dentition. b) To maintain or restore normal function. 2. Conditions That Should Be Treated in the Primary Dentition Are: a) Anterior and posterior crossbites. b) Cases in which primary teeth have been lost and loss of arch space may result. c) Unduly retained primary incisors which interfere with the normal eruption of the permanent incisors. d) Malpositioned teeth which interfere with normal occlusal function or induce faulty patterns of mandibular closure. e) All habits or malfunctions which may distort growth. 3. Conditions That May Be Treated a) Distoclusions that are at least partly positional. Occlusal equilibration or tooth movements may restore normal function. The rest of the problem may be treated at this time or later. b) Certain distocclusions of a skeletal nature are best treated at this age, but the patient must be socially mature, and the cases must be carefully chosen. c) Open bites due to tongue-thrusting or digital sucking habits. 4. Contraindications to Treatment in the Primary Dentition Treatment in the primary dentition is contraindicated when: a) there is no assurance that the results will be sustained, b) a better result can be achieved with less effort at another time, and/or c) the social immaturity of the child makes treatment impractical. TREATMENT PLANNING IN THE TRANSITIONAL DENTITION The mixed dentition period is the time of greatest opportunity for occlusal guidance and interception of malocclusion. At this time, the dentist has the greatest challenges and finest opportunities for efficient orthodontic therapy. 1. Reasons for Treatment Any case may be treated in the mixed dentition provided that: a) The treatment does not impede normal growth of the dentition. b) The malocclusion cannot be treated more efficiently in the permanent dentition. Emphasis should be placed on guidance of growth, interception of a developing malocclusion, and elimination of the first symptoms of what might become more serious malocclusions in the permanent dentition. 2. Conditions That Should Be Treated Conditions that should be treated in the mixed dentition are: a) Loss of primary teeth endangering the available space in the arch. b) Closure of space due to the premature loss of primary teeth; the lost space in the arch must be regained. c) Malpositions of teeth that interfere with the normal development of occlusal function, cause faulty patterns of eruption or mandibular closure, or endanger the health of the teeth. d) Supernumerary teeth that may cause malocclusion. e) Crossbites of permanent teeth. f) Malocclusions resulting from deleterious habits. g) Oligodontia, if closure of space is preferable to prosthesis.

h) Localized spacing between the maxillary central incisors for which orthodontic therapy is indicated. i) Neutroclusion with extreme labioversion of the maxillary anterior teeth (maxillary dental protraction). j) Class II (distoclusion) cases of a functional type. k) Class II (distoclusion) cases of a dental type. I) Class II (distoclusion) cases of a skeletal type, particularly if diphasic treatment is indicated. m) Space supervision problems. 3. Conditions That May Be Treated Conditions that may be treated in the mixed dentition are: a) Class II malocclusions of a skeletal type, particularly if diphasia treatment is indicated. b) Class III malocclusions, where early treatment is feasible. c) All malocclusions accompanied by extremely large teeth. If serial extractions are to be undertaken, treatment must be instituted in the mixed dentition. d) Gross inadequacies or disharmonies of the apical bases. TREATMENT PLANNING IN THE PERMANENT DENTITION All mal occlusions possible to correct may be treated in the permanent dentition of the young adult, although, as,noted earlier, that is- not necessarily the best time for some problems. Orthodontic therapy can be carried out for older healthy adults, but the strategies and tactics change radically when periodontal disease and/or loss of teeth has occurred. UNDERSTANDING EARLY TREATMENT 1. Rationale for Early Treatment a) Some malocclusions can be prevented or intercepted. The words "prevent" and "intercept" may lead to misunderstanding. Neither term can be used properly in the generic sense to embrace all early orthodontic treatments. It is as misleading to promote enthusiastic advocacy of early treatment of all malocclusions because some might be intercepted as it is to denounce interceptive treatment because early development of all malocclusions cannot be halted. The theory and rationale underlying the concepts associated with each term vary and are not generally interchangeable, so one should not, as has been done, argue against the practice of one strategy using the theory of another. All are good terms when properly applied, the clinical (and semantic) problem is when and to what extent each is appropriate. Only a few studies give accurate reports on those malocclusions which can be prevented or intercepted Popovitch and Thompson at the Burlington Orthodontic Research Centre in Canada, judge that while few malocclusions can truly be prevented,. roughly 25% can be intercepted. One-fourth is a significant amount, and many can be intercepted with theory; appliances, and knowledge now readily available to the family dentist. b) It is the dentist's responsibility to obviate. when possible. lengthy or complicated treatment.-In the past, some who did not know how to improve severe skeletal dysplasia in young children chose to wait and camouflage it later by positioning of teeth. Now, diphasic treatment is sometimes considered more logical and sensible. During phase one, craniofacial skeletal growth is controlled and the morphology improved so that later tooth positioning (phase two) is relatively easier.

c) Treatment is easier in some cases. -Early orthopedic control of skeletal mOrPhology is easier in some cases than later correction of the craniofacial skeleton, and often easier than positioning teeth to camouflage skeletal dysplasia. d) More alternative methods are available for treating patients at a young age. -When growth has largely ceased, treatment options are limited to moving teeth or orthognathic surgery. When the patient is young, one may be able to remove etiologic factors, enlist natural growth forces, provide differential growth responses, and obtain a balanced profile prior to eruption of most permanent teeth. Appliances used are varied, sophisticated, and practical. Some of the orthopedic appliances used look simple, and therein lies a trap for the inexperienced, for guidance of the developing dentition and growing craniofacial skeleton is a very complicated matter: the construction may be simple, the applied biology is generally more sophisticated and difficult than after pubescence. The traditional precision bracketed appliances used in treatment during the newly completed adult dentition involve very sophisticated biomechanical theories (see Chapters 13 and 16), and our knowledge of these appliances is well advanced. Ironically, the theory and treatment effects of "functional" or "orthopedic" appliances are less understood. Similarly, we know more about the biology of tooth movements, which is utilized with precision bracketed appliances, than we do about the biologic alteration of facial growth, which is the basis of early functional orthopedics. e) The clinician can utilize growth better in the young. And there is more growth available.-Growth can only be controlled while growth is happening. The earlier one starts treatment, the more total growth one can effect. 2. Benefits of Early Treatment ,_ Many reasons have been advanced for considering early treatment. The following are some of the more compelling: a) The possibility of achieving a better result .-With modem precision bracketed appliances beautiful results are obtained routinely if the skeletal dysplasia is not too severe. However, it is difficult to camouflage gross craniofacial morphology by tooth movements alone. b) Some forms of treatment can only be done at an early age. c) Early treatment of serious deleterious habits is easier than treatment after years of ingrained habit reinforcement. d) There are psychological advantages to early treatment in some children. e) Younger patients are often more cooperative and attentive. f) Compromise of quality of treatment is less apt to be necessary. There are two reasons why early treatment may obviate compromise of quality: (1) it may remove etiologic factors and restore normal growth and (2) it may reduce the severity of the skeletal pattern, making possible easier and more precise tooth positioning in the adolescent. 3. Difficulties in Early Treatment a) Misperceptions exist about the goals of early treatment.This is an important difficulty in defining clearly the goals. Early treatment has sometimes been equated with a naive attempt to "prevent" or intercept all malocclusions. More logical goals are

the removal of primary etiologic factors and"the correction of skeletal dysplasias prior to the eruption of teeth, neither of which necessarily results in precise positioning of teeth. Misperceptions about goals of early treatment arise when the focus is on the particular appliance itself rather than the purposes of treatment. It is not a question of functional or orthopedic appliances versus bracketed appliances but of the goals of early versus later treatment. Because mistakes are made in either treatment period or with one appliance system, one cannot argue that the use of the other is, ipso facto, justified or better. In recent years, some enthusiastic proponents of functional jaw orthopedics have urged the use of those appliances by describing alleged deficiencies and misuses of precision bracketed appliances, implying such problems do not occur with their favorite systems. But there are problems with any appliance, which may be related to misperceptions about the goals of treatment, not the appliance itself. b) Improper early treatment can be harmful. -Just as growth can be directed advantageously, it can also be misdirected. It does no good to drive faster if you're on the wrong road. Nor does it help to start early if you do not know where you are going or have no map. c) Diphasic treatment may lengthen the chronologic treatment time. -Time of treatment is properly measured by the number of hours spent by the dentist and patient together: treatment time is not measured on the calendar. Frequently, diphasic treatment achieves better results with less' 'clinic time" but longer' 'calendar time." When the chronologic time is lengthened, patient cooperation may wane. Ill-conceived or improph early treatment not only may do damage or prolong therapy, it may exhaust 'the spirit of .cooperation, making Later treatment more difficult. d) The subleties of early ma~occlusion introduce chance in the diagnosis and treatment plannlng.-When growth has diminished, the features of a malocclusion are clearly seen and the diagnosis is more certain. Early diagnosis and treatment planning are more tentative, and periodic cephalometric reassessment is a necessity. Too much emphasis has been placed on particular appliances, and insufficient attention has been paid to the difficulties of diagnosis and treatment planning for early treatment. There is a far greater need for better treatment planning than there is for new functional-appliance" gadgetry. " The best car is useless without a map and a driver who knows where to go. Those who do no more planning for early treatment than to choose a single {avorite appliance for most treatments do so because they are ignorant of the subtle variabilities and difficulties of orthodontic practice in the young patient.