Talk about early: It has been theorized that around 400 to 500 BC, Hippocrates and Aristotle contemplated ways to straighten teeth. Ancient mummies have been discovered with metal bands around their teeth and cat gut strung between them to provide the force used to move the teeth and close spaces.
A French dentist, Pierre Savagn, took dentistry out of the Dark Ages. He published a book called The Surgeon Dentist in 1728, which included methods for straightening teeth. Savagn used an appliance called the "Blandeau," which was an iron horseshoe-shaped device used to help expand the arch. He recommended that the patient eat a lot of grapes while the appliance was being worn because he thought, erroneously, that the acid in the grapes would prevent the appliance from rusting in the mouth.
We have certainly come a long way in our profession since then. However, some of the basic principles, if not the appliances, remain similar.
The following is my philosophy on early orthodontic treatment: We can do our patients a great service with early intervention in certain types of developing malocclusions. We must also understand, however, that not all patients that come to us in mixed dentition need our services. It is up to us as clinicians and good diagnosticians to make that distinction.
Here’s what I look for when a new patient arrives in my consultation room:
1) How does the young patient feel about his appearance? If he is old enough to evaluate himself in the mirror, it will give the clinician good insight as to the avenue of treatment to follow. Remember that patients’ perception of themselves is more important then our perception of patients.
2) Is there is a skeletal issue present? If so, can we correct it with functional orthopedics? Here we see crossbites, open bites, Class II malocclusions with protrusions, developing Class III malocclusions, etc.
3) From there we look at musculature. Are there thin vermillion borders, tight orbicularis and masseteric musculature, tongue habits (either thrusting or reverse swallowing)? This could mean that some of our functional orthopedics may be nullified. So we must overcorrect in these instances or hold longer in the retention phase of our first-phase treatment.
4) Are the teeth in harm’s way? If so, we must begin treatment to retract the maxillary anterior teeth so they can avoid injury.
5) Is there a psychological implication? As we know, kids can be cruel to other kids, especially if they find a sensitive area that can be picked on. For example, a young lady came to see us who had very square teeth, blond hair, freckles, and diastemata between all the anterior teeth. She was taunted with the name "Sponge Bob" so much that she did not want to go to school. Once we closed the diastemas, the name-calling ceased and she was once again happy.
6) If a patient comes in with severe crowding, we will use holding arches along with selective deciduous extraction until we can do a full treatment.
7) The last intervention we will do is to correct an occluded airway by suggesting tonsillectomy and/or adenoidectomy. The patient is then placed on regular recall so we can watch her development. Many times Mother Nature will do a wonderful job in helping to correct the malocclusion once the airway has been restored.
If it can possibly be avoided, we try not to place brackets in a Phase I treatment. There are a myriad of reasons for this, most of which I am sure you have already faced.
Orthodontists certainly have the armamentarium to help many young patients on their way with a beautiful smile, which in turn will help to build their self-esteem early in life.
We, as practitioners, can’t ask for more than that.
—Phillip M. Goodman, DDS, MSc, PhD