A Matter of Focus
I have to confess a certain ambiguity about early orthodontic treatment or interceptive orthodontics or mixed dentition treatment or Phase I orthodontics, or whatever name you give to the myriad forms of early intervention that now seem all the rage in orthodontics.
Philosophically, I can agree with Benjamin Franklin when he advocated an ounce of prevention early rather than a pound of cure later. But with very young orthodontic patients, I've found my expectations outrunning my performance so often that it has caused me to reevaluate the whole concept of early treatment.
I seem to have had the best results with young children when I have had specific and limited objectives, such as the correction of an extreme Class II malocclusion with an accompanying overjet that risked maxillary incisor avulsion, or a Class III malocclusion with a serious midface retrusion, or a pronounced posterior or anterior crossbite. These types of problems provide the kind of focus that begets effective and relatively quick treatment.
On the other hand, whenever I have had a target as fuzzy as increasing arch length to avoid later bicuspid extractions, I've frequently been disappointed. I've grown a little wary of early arch-development techniques such as expansion of the maxillary and mandibular arches and distalization of molars. With expansion, I have often found later arch narrowing, and with molar distalizing, I have usually paid an unacceptable price in incisor advancement.
From the frank conversations I've had around the world with other orthodontists, many have had similar experiences. I don't consider this a failure of tactics. Right now we possess the most effective array of instruments, wires, and techniques for moving teeth ever seen in dental science. I sometimes find myself so dazzled by modern materials and by clinicians with special techniques that I'm blinded to the old-fashioned need for an accurate diagnosis and an understanding of how the malocclusion occurred in the first place.
We have few studies of how malocclusions actually evolve. That could explain why there are so many futile efforts in first-phase treatment, and why we end up totally retreating patients in second phases. In such cases, we may have directed too much of our effort toward goals that at worst have nothing to do with the malocclusion, or at best play a secondary role. The misunderstanding causes us to treat symptoms rather than causes, guaranteeing ineffective therapy.
In this issue, JCO begins a series of three articles by Drs. Jan De Baets and Martin Chiarini that will go a long way toward overcoming our deficit of knowledge about the progression of malocclusions. In their seminal study of what they have named the Pseudo-Class I, they not only describe how these dental irregularities develop, but also outline a relatively simple intervention strategy that minimizes therapy and maximizes effect.
By understanding and applying the information these gentlemen have discovered, clinicians should find their early-treatment strategies bearing more results with less wasted effort. I consider these articles as important a series as JCO has published in recent years, and I invite your close attention to them. They certainly have served as a diagnostic wake-up call for me. I believe these simple principles will finally bring a coherence and efficiency to early orthodontic therapy that we have long needed. Once our focus changes from treatment to diagnosis, none of us will ever look at "Class I, mandibular crowding" patients in quite the same way again.