Two-phase orthodontic treatment provides substantial benefits for many patients, but at the same time we have found it to be a source of much confusion for patients and parents. Symptoms of this confusion are evident in comments such as: “My neighbor’s son had early treatment and they had to do it over again because they started too soon,” or “My dentist suggested that we come to your office sooner, but our son/daughter still had baby teeth and we could not see the sense in straightening baby teeth,” or “Why should we do treatment now and then have to do it all over again?” Hopefully this information will clear the air on some of these issues and provide some understanding of the advantages and disadvantages of the two-phase orthodontic approach.
The two-phase orthodontic approach actually involves three separate phases, two treatment phases often separated by a period of observation.
The goals of the first phase of treatment include:
- Establishment of a good skeletal base upon which the teeth can develop
- Providing additional space for the development of crowded teeth
- Elimination of etiologic factors (causes), for example: thumb and finger habits, tongue thrusting and lip entrapment.
- Management of teeth that are developing into the wrong position which may lead to crowding or increase the risk of impactions.
A two-phase approach is not always indicated but some patients who may benefit are as follows:
- Patients with significant jaw growth disharmony or unmatched growth of the upper jaw and the lower jaws.
- Patients with crossbites: the upper front or back teeth are positioned inside of the lower teeth. These crossbites may result in shifting of the jaw forward or to the side and may additionally complicate the orthodontic problem if left untreated.
- Patients with habits such as finger or thumb sucking, tongue thrusting, or lip entrapment that may worsen the orthodontic problem.
- Patients with moderate to severe crowding that may result in the need to extract teeth if treatment of the orthodontic problem is not started until all of the baby teeth are lost.
- Patients with very deep overbites or openbites (inadequate overlap of the front teeth).
- Patients with teeth developing out of position that may complicate further treatment or lead to impacted teeth if untreated.
Some of the advantages of early treatment include:
- Growth modification can only be accomplished when there is significant growth taking place. This modification process must be accomplished over time. With early treatment there is sufficient time and growth available. In addition there is opportunity for additional intervention if necessary whereas with a single stage approach there is only one shot at growth modification.
- Our younger patients are our best cooperators and this is crucial to achieving good results.
- Some treatments, such as expansion of the upper jaw, are better tolerated with less biologic resistance and greater stability.
- Less treatment should be required at a time when the patient is much less enthusiastic about orthodontic treatment.
What two-phase treatment does not promise and what are some of the disadvantages of starting treatment early?
- The goal of phase 1 treatment IS NOT to avoid any treatment in the future. This would not be a reasonable expectation with all of the dental development that is yet to occur. It is reasonable to hope for less treatment or less complicated treatment of a shorter duration but it is best to expect the need for a second phase of treatment to accomplish a good orthodontic result.
- It should be understood at the outset of treatment that the approach requires more visits and will be extended over a longer period of time.
- There is the risk of patient “burnout” resulting in less enthusiasm to proceed with the second phase of treatment. Therefore we try to keep very specific and limited treatment goals for the first phase of treatment in order to minimize the treatment time.
When does the second phase of treatment begin?
- The second phase of active treatment begins at the time the last baby teeth are lost. This tooth alignment phase typically takes 18 to 24 months. This procedure is a separate investment from the Phase I fee. Final correction of tooth position, space closure, root paralleling, bite correction, and other refinements, which are important to function and stability, are achieved during this stage of treatment.