2012-04 113511 2012-04 11-02


For Marcel Korn, DMD, redirecting eruption is about orthodontists being doctors, not just mechanics.

Orthodontic Products: What sparked your interest in early treatment?

Marcel Korn, DMD: I’ve been in practice in Boston for 42 years and teaching at Tufts University all that time. I’ve also lectured around the world about early treatment, postural orthodontics, and bi-dimenstional-segmental mechanics. Early treatment is one of my passions.

Early in my career, I became interested in treating early, and allowing growth, development, and the eruption process to be involved in treatment. I was fortunate to be exposed to the European functional methods, and started thinking less mechanically.

Over the years, I developed the concepts of “postural orthodontics” and “early treatment using redirection of eruption” to manage the correction of most malocclusions early, during the active periods of growth, development, and the eruption years. I became passionate about the idea that we really can and should treat problems earlier, and not allow them to develop completely into full-blown malocclusions. Orthodontics was permitting malocclusions to develop and become complete malocclusions, then later managing the problems in the permanent dentition phase or in the more adult teen years.

Very early in my career, I was saddened to learn that my specialty’s image and the perception of orthodontics by both the public and by our own colleagues is “the profession which straightens teeth with braces.” I started on my current journey when, sadly, I saw that we orthodontists had become mechanics and had lost both our image as doctors and the biologic/natural approaches to problem-solving. I wanted to feel like a “doctor” again, rather than a mechanic. I needed to use individualized treatment designs and the more biological processes in treating my patients.

OP: What is early treatment as you practice it?

MK: First and foremost, when I talk about early treatment, I am talking about the guidance of eruption—redirection of eruption. There truly is something orthodontists can do during the eruption process to alter the course of eruption and to change the final arrival of the teeth. Early treatment calls for prioritizing crowding, deep overbite, and molar rotation; and then secondarily managing the Class II and Class III issues.

Early treatment has always been thought of as prioritizing the skeletal issues first—managing them with functional appliances, rather than managing crowding, deep overbite, and molar rotation first. The redirection of eruption element, which addresses crowding, deep overbite, and molar rotation, has been totally neglected by our profession.

With early treatment as I practice it, kids finish treatment at a younger age. While other kids are just starting with braces at 12 or 13 years of age, the early treatment kids are finishing phase two by age 12 or 13. Their permanent teeth arrive in the mouth earlier and are better aligned. We use the extraction of primary teeth in our treatment to allow the permanent teeth to redirect, to erupt sooner, at a younger age, and to better align. We preserve space with lip bumpers as space maintainers. The teeth remarkably redirect their eruption paths and just arrive straighter. Patients still need braces, or phase two treatment, to idealize and complete the treatment, but they are in braces a much shorter period of time, and they finish at a much younger age. That is what I experience with my patients.

OP: At what age do you recommend early treatment?

MK: It’s not so much the age of the child as it is the stage of development. That varies from child to child. I base it on the maturity of the roots of the permanent bicuspid teeth. I use panoramic film to check whether the first bicuspid roots are half-developed. If they are half-developed, we begin early treatment.

OP: Why hasn’t early intervention as you talk about it been embraced by the orthodontic community?

MK: The conflict arose between those orthodontists who believed in early intervention and asked the basic question: “Can we do anything before the teeth arrive in the mouth?”—and those orthodontists who did not believe we could influence development. I’ve always felt that orthodontics was missing the boat on this issue.

Over the years, this controversy grew. Bill Proffitt and Lysle Johnston’s prospective clinical trials compared functional appliances, Bionators versus headgear, and then evaluated molar position, length of treatment time, and the cost of treatment between the two methods. They both concluded that an early treatment approach didn’t make much sense in the way it was being done. They concluded that molar correction was the same with headgear as with functionals and that early treatment took longer, cost more, and still required a lengthy second phase.

The problem was that their studies weren’t really looking at early treatment in totality. They only treated Class II problems with functional appliances. They did not address the major areas of crowding, molar rotation, and deep overbite. Yet the results were presented to the orthodontic community as “early treatment” and not as early treatment of only class II with functionals or only of comparing bionators versus headgear.

Imagine this: If a child’s teeth stick out, it could be that the upper teeth stick out only, it could be that the lower jaw is retruded, or it could be a combination of both. Now, it could also be that the teeth are very straight in each jaw and the jaws are just not above each other; or it could be that simultaneously the teeth are also crowded and there isn’t enough room for them while they’re protruded or retruded as well. So if you treat the protrusion or retrusion early, which they did with this study, and do not address the crowding issue, then the teeth arrive in the mouth later and still crowded, and you still need to straighten them. This makes the process very long, cumbersome, and costly. In this they were correct.

While I don’t disagree with their outcomes, it really does not represent all early treatment and it really misled the entire American orthodontic community in that regard. They did not attack crowding, deep overbites, and molar rotation, which are present in about 90% to 95% of all our cases. They sort of jumbled all the early treatment into their conclusion. This upset me immensely. I had been doing early treatment all that time, and I came to a different conclusion with our treatment approaches.

OP: What is the benefit of early treatment?

MK: There are three benefits to early treatment—first, finishing at a younger age; second, a much shorter time in full fixed appliances; and third, less invasive and less mechanical forces are delivered to the teeth which have already erupted earlier and straighter.

If we make crowding the priority issue in orthodontics, as opposed to skeletal issues such as protrusion, retrusion, and Class II, we would have treated 85% of all cases. Yes, we are still left with some Class II problems to manage later. But crowding, overbite, and molar rotation must be resolved first. It cannot and should not be universally said that early treatment is inappropriate for all orthodontic cases and situations. Case choices and treatment timing are critical.

Now, the overall length of treatment includes phase one (early treatment), phase two (braces), and a transition phase in between (waiting for eruption). During the transition phase, the patient wears some kind of holding appliance while waiting for the teeth to erupt.

Another flaw of the Proffitt and Johnson studies is that they never really accounted for this transition phase. They just counted everything as phase one and phase two. That made total treatment time very lengthy.

OP: Where has early treatment gone?

MK: As time went on, we noticed that pedodontists and general dentists started doing more and more orthodontics because the orthodontist was avoiding early treatment. The orthodontic specialty in a way gave early treatment away. Now, there are certainly a large number of orthodontists who practice early treatment. But, one of the major reasons for the early treatment failure within orthodontics is because the orthodontic specialty never really took early treatment on, nor did it study or develop reasonable ways of treating kids early. Both the academic community and organized orthodontics failed to develop a unified and logical approach to the problem.

OP: What is academia’s attitude to early treatment?

MK: They are not really against it, but they tend to be negative about it; and I think falsely so. The “evidence-based era” has led them astray and to the conclusion that there is no difference between doing treatment early and doing it later, and that if they do it early, it takes longer and costs more. This is what they teach their students. Not teaching early treatment to orthodontic residents essentially gives the pedodontic departments the ability to capture the issue, teach it, and control its future in the specialty. That has not been the case in my practice.

One real problem is that if you gave a test to all our orthodontic senior residents on the “eruption of teeth” and asked them questions related to eruption, they would not be well informed. They do not study eruption. That is the real issue. That’s what I think has been lacking. No one is studying development or eruption, and we all should be.

Orthodontics should be taking the lead on early treatment, so that nobody—neither general dentists nor pedodontists—can take these issues from us and own them. This is an educational issue. It has to change.

OP: What would you say to the orthodontist who is reluctant to do early treatment?

MK: I would say to really study growth, development, and the eruption of teeth. Learn to use the eruption process to your advantage. Consider that as erupting teeth travel from within the bone into the mouth you can change and control eruption. Consider eruption to be tooth movement—movement with eruption rather than with braces—and ask the question: Can you as an orthodontist influence the eruption of teeth so that any particular case you are looking at is treated at a younger age, finished with and in braces for a shorter time, while overall cost remains the same?

I would tell orthodontists that there is something they can do vis-À-vis redirection of eruption, resolution of crowding, molar rotation, and deep overbite. There is something they can do vis-à-vis Class III, maxillary insufficiency, and mandibular prognathism. There is something they can do vis-À-vis Class II protrusion or retrusion of the jaws. But most importantly, they have to address crowding, deep overbite, and molar rotation first. Manage the Class II and Class III issues second. This is not the way it has been presented previously. This protocol will completely change their perspective on early treatment.

OP: Why are you speaking out about this?

MK: I’m 71 years old. I’ve been in this profession for a long time, and I truly love it. This issue isn’t going to affect me or my career at this time. I want and need to bring attention to this issue because I want to give back, so to speak. Orthodontics has really missed the boat on early treatment. When I first started in orthodontics, we were so busy learning how to put bands on because we didn’t have bonding. We were still fabricating braces. We were so busy with the mechanical stuff that we really gave up the title of doctor.

Today, we have much simpler ways of putting braces on teeth. Anybody can learn the mechanical aspects of orthodontics. You don’t have to go to school for 2 years just to learn how to move teeth. But you do have to go to school for 2 or 3 years to learn mechanics, plus the biology of eruption, growth, and development. You do have to go to school and learn these areas in order to become a real doctor, not just a mechanic. My argument is that if orthodontics becomes more doctor-oriented, it will regain its status as a real specialty and orthodontics will once again own early treatment.

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Marcel Korn, DMD, is a diplomate of the American Board of Orthodontics, a member of the College of Diplomates of the American Board of Orthodontics, a member of the Angle Society of Orthodontists, and a fellow in the International College of Dentists. He maintains private practices in Boston and Fitchburg, Mass, and he is on the faculty at Tufts University School of Dental Medicine (Boston) in both the Department of Postgraduate Orthodontics and the Gelb Cranio-Mandibular Pain Center.