There’s been a lot of chatter recently in the orthodontics-sphere about two-phase treatment. A lot of it is highly technical, of course. Orthodontists, however, tend to be very practical people. And busy, too. We do keep up-to-date in our profession’s research and development, though. We must. In any event, when a new approach or technology comes along, we mainly want to know three things about it. What is it? Does it work? Should I use it? The two-phase orthodontic treatment model is a definite trend. Let’s ask those three questions, and see what we learn.
WHAT IS TWO-PHASE ORTHODONTIC TREATMENT?
The basic concept is simple enough. It’s just like it sounds. A patient is treated twice, at two different times, rather than once. In other words, two treatment periods, or phases, with a break in between them. Each of the two phases has distinctive treatment goals and methods.
Two-phase orthodontic treatment is for kids. Kids only. This approach strives to intervene in the growth and development of a child’s jaw bones and teeth. The strategy is one of early intervention to set the table for better outcomes from treatment later. To “surf” the child’s growth and development, rather than “clean up” after it.
Teeth, after all, are with us all of our lives. The first buds of our primary (“baby”) teeth develop about five weeks after conception. When we’re born, we have a full set of 20 baby teeth. They’re hidden inside our gums, of course, except in the cases of 0.05% of newborns with “natal”- erupted – teeth. Thus begins the tale. Our teeth and our jaw bones interact with each other from this early beginning. The size and shape of the jaw bones affect the eruption and alignment of teeth. In turn, tooth alignment can shape developing jaw bones. If a child’s tooth eruption races ahead of bone growth, crowding and misalignment of teeth may be the result. Conversely, if the upper and lower jaws develop unevenly, the bite, and tooth alignment can be altered.
That’s one of the reasons the American Association of Orthodontists recommends that children undergo orthodontic evaluation by the age of seven. Pediatric dentists refer kids younger than that when issues become apparent at earlier ages. Interventions range from extracting baby teeth from crowded mouths, through removable appliances, to the installation of full-fledged braces.
AN ASIDE – GOALS OF PHASE I
The goal of Phase I treatment is to correct or mitigate developing skeletal or muscular issues before the child’s permanent teeth erupt. The treatment, in other words, isn’t for immediate cosmetic purposes. Rather, it’s to normalize the child’s orofacial development. There are some immediate payoffs, though, in the form of improved biting, chewing, and even speech.
ANOTHER ASIDE- GOALS OF PHASE II
Since Phase I treatment is done when baby teeth still rule the roost, it’s obviously time limited. By ages 6 or 7 they start to wobble and fall out. This is a signal for the orthodontist to ring down the curtain on Phase I. Time for a break. For the kid and for the parents, as well. We call this break the retention phase. We’re waiting for more primary teeth to fall out, and more permanent teeth to grow in. This retention phase can last for months or for years, depending on the patient. When conditions are right, the orthodontist initiates the conventional treatment best suited to the child’s particulars.
The goals of Phase II treatment are those we usually think of when we think of braces. Normal alignment, good bite, a perfect smile. The impetus for two-phase treatment is the belief that for the outcomes of Phase II will be better than those of a conventional one-phase treatment started at the same age.
DOES TWO-PHASE ORTHODONTIC TREATMENT WORK?
Yes, absolutely, but…Here it gets a little frustrating. There’s still plenty of debate going on. More than a few orthodontists are skeptical of the two-phase treatment concept. They point to a lack of strong research evidence that supports the theoretical benefits. Nobody is saying it doesn’t work. It absolutely does work. The problem for the skeptics is that it’s been hard to produce evidence that it works any better than the conventional one-phase approach.
SHOULD MY CHILD HAVE TWO-PHASE ORTHODONTIC TREATMENT?
The critics note that absent any evidence that the two-phase approach produces better outcomes, its negatives make it a poor choice. If the orthodontic outcomes are no better than those of conventional treatment, our attention turns to the negatives.
By its nature and design, two-phase treatment means a longer overall involvement with orthodontic treatment. The Phase I interventions begin earlier – sometimes a lot earlier – than orthodontic treatment normally does. The researcher studies don’t support the idea that Phase II will be any shorter than a normal treatment, started at the same age, will be. While we orthodontists are charming people, we understand that we’re the only people who love to spend time in our practices. Our patients and their families have lives to live. The longer A-to-Z of two-phase treatment is a definite thumbs down.
Then there’s the matter of cost to the patient. Two-phase orthodontic treatment costs more than conventional one-phase treatment. It would since there’s more of it, namely, Phase I. Another thumbs-down. Why pay more for what apparently will be a similar or identical outcome?
Finally, there’s a lurking kind of thumbs down that we have to consider. Iatrogenic problems are those medical problems caused by medical care. A common example is a patient in the hospital for a sprained ankle who catches a staph infection in the hospital environment. There are potential iatrogenic risks in orthodontic treatment. Some of these are decalcification under the bands of braces, enamel fractures when removing bands, and gum damage. While the risks are low, critics of two-phase treatment argue that the re’s added risk in Phase I with no measurable payoff. Why take unnecessary risks? they ask.
WHY ARE WE EVEN TALKING ABOUT IT, THEN?
The advocates of two-phase orthodontic treatment have some reasonable arguments of their own. Regardless of the present lack of support from the researchers, they say, there’s value in thinking in terms of two phases of treatment. In fact, they argue, orthodontists have always been doing a multi-phase treatment. They just haven’t thought through and defined the goals and methods of the different phases as sharply as we’re doing now.
Another counter-argument the supporters make is that the researchers have lumped together all kinds of patients in their studies. The two-phase approach, they say, is indeed not going to benefit all patients, or perhaps not even most patients. Supporters suggest that two-phase treatment is the better choice for.certain very specific types of orthodontic issues. There’s pretty widespread agreement, for example, that it’s advantageous in cases of what we call Class II malocclusion with extreme protrusion of maxillary incisors. Very bad buck teeth, in other words. In addition to the potential for better final outcomes, there may well be another, more immediate benefit to young patients with this condition. Those buck teeth are very exposed to physical injury. From flying baseballs, for example. They also may attract taunting and teasing. Hence, early Phase I treatment can have psychosocial and safety benefits for these kids.
The buzz about two-phase orthodontic treatment doesn’t like it’ll die down anytime soon. Parents are going to read about it and hear about it. Your Lake Worth orthodontist keeps up to date with developments and encourages parents to ask about it. Maybe the supporters are right, and someday it’ll be the norm.