Orthotown November 2022 - 48

Many orthodontists who treat only a
small percentage of pediatric patients fail
to appreciate that special concerns need to
and should be addressed when examining
youngsters. Let's review the history of this
train of thought by summarizing some of
the statements made and published through
the years and introducing some concepts I
believe are applicable to the examination
and treatment of the pediatric population.
Previously published
recommendations
Treatment as early as the primary dentition
has been discussed for years.
* In 1995, Drs. Peter Ngan and
Henry Fields emphasized the need
to maintain space in early dentition
and evaluate and limit treatment
to specifically diagnosed issues,
including some severe crossbites or
Class III problems.2
article, Ngan and Fields cautioned
against much more treatment for
Class II, crowding or nonnutritive
sucking habits during this early
period.
* A 1997 workshop on space analysis
in pediatric dentistry confirmed the
need for knowledge of growth and
the variabilities of predicting the
same,3
emphasizing the importance
on the face, its changing during
time and the validity of maintaining
leeway space.
* In 1998, Dr. Steven Dugoni
supported early treatment and
extended the reach of such treatment
to include most modalities offered
to adolescents and adults, including
Class I, II and III treatment for
crowding and crossbites.4
Dugoni
noted that Phase 2 treatment may
not be necessary, except for occlusal
perfecting sometimes accomplished
with a tooth positioner. His apparent
goal was to treat earlier in the
transitional dentition, eliminating
or severely lessening later care-in
other words, treat early for a problem
identified as needing treatment later.
* In a 2000 American Journal of
Orthodontics and Dentofacial
Orthopedics article, Drs. Mathew
Brennan and Anthony Gianelly
Other considerations
warrant examination
Advances in 3D digital imaging and
evidence of its value12,13
have led us to view
patients' facial skeletons in terms of volumes
rather than planes in space. Especially
important is the finding and confirmation
that maxillary deficiency need not exhibit
a crossbite to be present. The term superior
and inferior convergence of the maxilla to the
mandible allows for visualization of maxillary
deficiency without overt crossbite findings.
MacNamara14
suggested this in his lecture
An orderly process for
Phase I examinations
How can we overcome objections from
parents, dentists, parents and patients that
are obstacles to building a successful practice
that focuses first on young children, and
eventually stress-free adolescent treatment
with some adults along the way? How can
we combine the best of both early and late
took a simplified approach to incisor
crowding in the lower arch, proposing
a simple lingual arch to preserve
leeway space.5
The authors stated
that up to 68% of patients could
be treated nonextraction this way,
a figure confirmed by Dugoni.6
* A 2007 review by Dr. David
Turpin7
concluded that true skeletal
malocclusions are rarely completely
intercepted, and coupled with twophase
treatment often result in more
appointments and cost.
* During a 2002 AAO-sponsored
symposium on early treatment,
Drs. William Proffit,8
James
McNamara9 and others discussed
In their journal
methods and rationales for care.
The goal of these modalities seems
to be limited to eliminating and
preventing crowding and creating a
Class I occlusion. Many papers by
Proffit10
at the 2015 AAO winter conference, where
he described the desired distance between
the lingual of the upper molars as being
36-39 millimeters. Crossbites were not
required for treatment nor viewed as the only
finding requiring maxillary arch expansion.
In discussing the ramifications and
treatments for sleep apnea, Dr. Lou Chmura15
lists numerous symptoms often observed
in patients with this pervasive disorder,
including mouth breathing and aberrant
frena attachments and tongue role. CBCT
imaging has a value in identifying airway
space, but is limited to patient positioning,
growth and other variables.
Angle, of course, paid much attention
et al. shun this treatment as
adding cost and time in treatment
and conclude the effort is not
warranted; however, most of these
papers are concerned with crowding
and Class I, II and III correction
only, and viewed in the sagittal plane.
* Speaking at the 2018 AAO/AAPD
Early Treatment Midwinter
Conference, Dr. Stella Chaushu
advocated for early prevention of
impacted cuspids by involving
limited appliances and removal of
primary canines and first molars to
avoid the lengthy and often times
serious complications of impacted
canines.11
interceptive treatment would often
become more time-consuming.
to the influence of mouth breathing and
habits in malocclusions. Quoting from
his textbook: " Of all the various causes of
malocclusion, mouth breathing is the most
potent, constant and varied in its results. " 16
It is most prevalent between the ages of 3
and 14, according to Drs. J.L. Paul and R.S.
Nanda.17
Kotlow18
Authors such as Dr. Lawrence
and speech-language pathologist
Dawn Moore19 are well known for describing
tongue tie and other anomalies but do not
directly link them to malocclusion, a link
that should be further explored.
The debate regarding temporomandibular
disorder (TMD) in children and
adolescents persists, and numerous articles
have been written to identify issues that may
arise on young patients. A position paper
by the American Academy of Pediatric
Dentistry20
stresses the need for evaluating
Chaushu did mention this
TMD history and signs and symptoms in the
young population and states the prevalence
can be around 10%, with an increase
with age to upwards of 30%, especially in
adolescent girls.
Thus, it would appear that there can
be a benefit to examining, diagnosing
and treating many patients before all the
permanent teeth have erupted.
Orthotown November 2022

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