Recognizing and Correcting Developing Malocclusions E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 554

Veröffentlichungsjahr: 2024

Beschreibung

Comprehensive reference providing an evidence-based approach to the early treatment, recognition, and correction of developing malocclusions

Recognizing and Correcting Developing Malocclusions, Second Edition provides an evidence-based approach to early treatment of developing malocclusions, presenting treatment protocols for mixed-dentition patients with various malocclusions and other orthodontic problems. Class I, Class II, and Class III malocclusions are covered extensively, along with eruptive deviations and different malocclusions.

The literature is comprehensively reviewed to ensure that the reader thoroughly understands the development, phenotypic characteristics, and etiology of each type of malocclusion. Taking a problem-oriented approach, the authors provide detailed information for each case, develop comprehensive problem lists, and then present evidence-based treatment solutions.

This newly revised and updated Second Edition contains comprehensive updates to all chapters and sections, including dental trauma and its consequences and sleep apnea in children.

Containing figures, tables, patient pictures, and 3D rendered illustrations throughout to elucidate key concepts, Recognizing and Correcting Developing Malocclusions, Second Edition explores topics including:

• Assessing the degree of severity of a developing malocclusion and recognizing and correcting intra-arch deviations
• Genetics of dental occlusions and malocclusions and mixed dentition orthodontic mechanics
• Strategies for managing missing second premolar teeth in young patients and principles and techniques of premolar autotransplantation
• Abnormal eruption, function, and aesthetics, congenitally missing teeth, autotransplantation, and habits
• Construction of a diagnosis, treatment plan, and estimation of prognosis based on available diagnostic records produced by both old and new technologies

Practical in approach but grounded in the literature, Recognizing and Correcting Developing Malocclusions, Second Edition is equally useful as a patient-side guide for clinicians and as a detailed reference for orthodontic and pediatric specialists and residents.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

Dedication Page

List of Contributors

Foreword

Preface

1 A guide for timing orthodontic treatment

1.1 Occlusal deviations with indications for interceptive orthodontic treatment

1.2 Ideal timing for early treatment

References

2 Development of the occlusion: what to do and when to do it

2.1 Stage 1—eruption of deciduous teeth

2.2 Stage 2—completion of the deciduous dentition

2.3 Stage 3—eruption of first permanent molars

2.4 Stage 4—eruption of permanent incisors

2.5 Stage 5—eruption of mandibular canines and first premolars

2.6 Stage 6—eruption of second premolars

2.7 Stage 7—eruption of maxillary canines and second molars

2.8 Conclusions

References

3 Mixed dentition diagnosis: assessing the degree of severity of a developing malocclusion

3.1 Assessing treatment need, complexity, and outcome

3.2 Assessing interceptive treatment outcome

References

4 The genetics of the dental occlusion and malocclusion

4.1 Introduction

4.2 Chromosomal abnormalities

4.3 Single gene defects

4.4 Multifactorial inheritance

4.5 Genetics of nonsyndromic malocclusion

4.6 Altered tooth number

4.7 Altered tooth structure

4.8 Altered eruption

4.9 Radiographic deviations associated with genetic conditions

4.10 Conclusion

References

5 Class I: Recognizing and correcting intraarch deviations

5.1 Section I: The development and etiology of a Class I malocclusion

5.1 Introduction

5.2 Prevalence of Class I malocclusion and changes in arch form

5.3 Class I malocclusion and the dental compensatory mechanism

5.4 What is anterior mandibular malalignment is related to?

References

5.2 Section II: Intercepting developing Class I problems

5.5 Tooth size arch length discrepancy (TSALD)

5.6 The assessment of crowding in the mixed dentition

References

6 Recognizing and correcting Class II malocclusions

6.1 Section I: The development, phenotypic characteristics, and etiology of Class II malocclusion

6.1 Introduction

6.2 Characterization of the Class II, division 2 phenotype

6.3 Characterization of the Class II division 1 phenotype

6.4 Developmental changes of Class IIs

6.5 Class II developmental changes

6.6 Etiology

References

6.2 Section II: Class II treatment: problems and solutions

6.7 Early Class II adjustment

6.8 Treatment

References

7 Recognizing and correcting Class III malocclusions

7.1 Section I: The development, phenotypic characteristics, and etiology of Class III malocclusion

7.1 Introduction

7.2 Characterization of the Class III phenotype

7.3 Class III development

7.4 Etiology

References

7.2 Section II: Class III treatment: problems and solutions

7.5 Diagnosis

7.6 Communication

7.7 Early intervention

7.8 Orthopedic maxillary expansion

7.9 Face mask and/or chincup orthopedics

7.10 Leeway space control

7.11 Orthodontic mechanics

7.12 Finishing

7.13 Retention

7.14 Growth reevaluation

References

8 Special topics

8.1 Section I: Habit control: the role of function in open‐bite treatment

8.1 Nutritive vs. nonnutritive sucking habits

8.2 Tongue physiology

8.3 Tongue thrusting and forward resting posture of the tongue

8.4 Breaking the habit

8.5 Treatment

References

8.2 Section II: Eruption deviations

8.6 Eruption deviations

8.7 Eruption deviation and PIOM: what are the most frequent eruption disturbances in each stage of dental development?

References

8.3 Section III: Strategies for managing missing second premolar teeth in the young patient

8.8 General concepts

8.9 Longevity of the second deciduous molar, resorption, and infraocclusion

8.10 The alveolar ridge in extracted deciduous molars

8.11 Overall dental health and cost

8.12 Case histories

8.13 Summary

References

8.4 Section IV: Principles and techniques of premolar autotransplantation

8.14 Class II malocclusion with congenitally missing lower second premolars

8.15 Traumatic loss of upper incisor/s

8.16 Uneven tooth distribution with multiple agenesis

8.17 Surgery

8.18 Selection of anesthesia (local vs. general)

8.19 Premolar to premolar transplantation

8.20 Premolar to anterior maxilla transplantation

8.21 Postoperative instructions

8.22 Follow‐up

8.23 Pulp healing

8.24 Periodontal healing

8.25 Root growth

8.26 Reshaping to incisor morphology

8.27 Alveolar bone after autotransplantation

References

8.5 Section V: Dental trauma: revisiting posttrauma protocols and long‐term follow‐ups

8.28 An overview of dental trauma

8.29 Orthodontic treatment and dental trauma

8.30 Managing traumatized teeth and preserving bone width – The decoronation approach

8.31 Final considerations

References

8.6 Section VI: Sleep‐disordered breathing (SDB) in the growing child

8.32 The need for sleep

8.33 Diagnosis and management of sleep‐disordered breathing (SDB) and obstructive sleep apnea (OSA) in children

8.34 Risk factors for OSA in children

8.35 Consequences of SDB in children

8.36 Treatment options for the dental and skeletal consequences of SDB in children

8.37 New technologies: the use of apps and devices for SDB and OSA in children

8.38 Conclusion

References

8.7 Section VII: Mixed dentition orthodontic mechanics

8.39 Definitions and terminology [1–3]

References

Index

End User License Agreement

List of Tables

Chapter 2

Table 2.1 Clinical stages of occlusal development.

Table 2.2 Mesiodistal measurements of deciduous and permanent incisors, dis...

Table 2.3 Orthodontic interceptive procedures and their indication in each ...

Chapter 3

Table 3.1 Overall DI score differences.

Table 3.2 Percentages of change (%).

Table 3.3 Discrepancy Index Score differences for the Class I group.

Table 3.4 Discrepancy Index Score differences for the Class II group.

Table 3.5 Discrepancy Index Score differences for the Class III group.

Chapter 6_1

Table 6.1 Cross‐sectional studies characterizing untreated Class II divisio...

Table 6.2 Literature comparing AP maxillary and mandibular positions of Cla...

Table 6.3 Differences (Class II minus Class I) in maxillary size and positi...

Table 6.4 Differences (Class II minus Class I) in mandibular size and posit...

Table 6.5 Differences (Class II minus Class I) in the anterior, posterior, ...

Table 6.6 Differences (Class II minus Class I) in cranial base angulation, ...

Chapter 7_1

Table 7.1 Percentages (most prevalent in bold) of Class IIIs with problems ...

Table 7.2 Differences (Class III vs. Class I) in maxillary protrusion, maxi...

Table 7.3 Studies comparing Class IIIs and Class Is for differences in maxi...

Table 7.4 Differences (Class III minus Class I) in mandibular protrusion, t...

Table 7.5 Differences (Class III minus Class I) in upper incisor angulation...

Table 7.6 Differences (Class III minus Class I) in cranial base angulation,...

Table 7.7 Differences (Class III minus Class I) in the anterior, posterior,...

Chapter 8_6

Table 8.1 The average sleep needs according to each age.

Table 8.2 Summary of some of the risk assessment questionnaires for OSA in ...

Table 8.3 Summary of values for classification of obstructive sleep apnea (...

List of Illustrations

Chapter 1

Figure 1.1 (a) A 8‐year‐old boy during “ugly duckling” phase presenting labi...

Figure 1.2 (a, b) A 9‐year‐old girl presenting deep bite and positive space ...

Figure 1.3 (a–c) A 9‐year‐old mixed dentition boy with a Class II/1 malocclu...

Figure 1.4 (a) Posterior crossbite with mandibular shift. (b) Posterior cros...

Figure 1.5 (a) A 8‐year‐old boy, Class I dental‐skeletal pattern, presenting...

Chapter 2

Figure 2.1 Stage 1: eruption of deciduous teeth.

Figure 2.2 Panoramic radiograph of 3‐year‐old child.

Figure 2.3 Normal characteristics of the deciduous dentition.

Figure 2.4 Interdental spacing closure in the deciduous dentition.

Figure 2.5 A 3‐year‐old mouth‐breathing girl. (a) Night before adenotonsille...

Figure 2.6 Bruxism in the deciduous and early mixed dentition. (a) Severe ab...

Figure 2.7 Deciduous dentition: anterior and posterior crossbite. (a) Pretre...

Figure 2.8 Untreated Class II malocclusion. (a) Age 4, deciduous dentition. ...

Figure 2.9 Skeletal Class III malocclusion in the deciduous dentition.

Figure 2.10 Posterior crossbite after the eruption of the first permanent mo...

Figure 2.11 Incisors crowding associated with arch width reduction.

Figure 2.12 (a, b) An 8‐year‐old child presenting early loss of mandibular d...

Figure 2.13 An 8‐year‐old child presenting increased overjet and a Class II ...

Figure 2.14 E‐space maintenance with a lower lingual holding arch.

Figure 2.15 E‐space preservation in the maxillary arch of Class II malocclus...

Figure 2.16 E‐space preservation in the mandibular arch of Class III maloccl...

Chapter 4

Figure 4.1 Minor anomalies detected by the area of discovery.

Figure 4.2 Approximately 15–20% of newborn infants in the United States are ...

Figure 4.3 The continuum of dysmorphogenesis. Refer to text on principles of...

Figure 4.4 Phenotypic heterogeneity of enamel defects.

Figure 4.5 The orofacial manifestations of Marfan syndrome includes dolichoc...

Figure 4.6 Cleidocranial dysplasia (CCD) patients demonstrate enlarged calva...

Figure 4.7 Delayed craniofacial development in cleidocranial dysplasia compl...

Figure 4.8 Orthodontic patient with a diagnosis of craniosynostosis and sign...

Figure 4.9 Hemifacial microsomia (HFM) or craniofacial microsomia (CFM) is o...

Figure 4.10 Orthodontic patient exhibits amelogenesis imperfecta, cranial an...

Figure 4.11 This pedigree shows proband from Figure 4.10 and her twin sister...

Figure 4.12 Orthodontic concerns of dentinogenesis imperfecta (DGI) include ...

Figure 4.13 Primary failure of eruption (PFE) is most often an isolated cond...

Figure 4.14 This 7‐year‐old patient presented with molar and incisor enamel ...

Figure 4.15 Diagnosis of fibrous dysplasia was made after referral for evalu...

Chapter 5_1

Figure 5.1 Development of Class I molar relationships between the deciduous ...

Figure 5.2 Percentages of boys and girls 4–6 years of age with spacing and c...

Figure 5.3 Average ages at which first and second phases of permanent tooth ...

Figure 5.4 Time required for the permanent maxillary left central and mandib...

Figure 5.5 Maxillary (a) and mandibular (b) intercanine width changes betwee...

Figure 5.6 Maxillary (a) and mandibular (b) arch perimeter (first molar to f...

Figure 5.7 Annualized (total Δ/total duration) rates of malalignment of untr...

Figure 5.8 (a) Anterior TSALD and (b) arch length changes of untreated subje...

Figure 5.9 Anterior contact irregularity (distances between contacts) of unt...

Figure 5.10 (a) Horizontal growth displacement and drift and (b) vertical gr...

Figure 5.11 Improvements in anterior alignment when only lip bumper therapy ...

Figure 5.12 Factors that cause anterior alignment problems.

Chapter 5_2

Figure 5.13 Anterior crossbite affecting the mandibular anterior arch and it...

Figure 5.14 (a, b) Unilateral crossbite in the mixed dentition. Notice that ...

Figure 5.15 Severe dental deep bite on the left and developing dental open b...

Figure 5.16 (a) A straight lower lingual holding arch (LLHA), (b) a LLHA wit...

Figure 5.17 Left a Nance button and on the right a removable TPA.

Figure 5.18 (a–c) Type I, open dentition and bottom. (d–f) Type II, closed d...

Figure 5.19 (a) Early mesial shift in a Type I occlusion and (b) late mesial...

Figure 5.20 Possible adjustments from deciduous to mixed dentition (Arya et ...

Figure 5.21 (a) Representation of the changes of dentition from deciduous to...

Figure 5.22 Lingual (left) and buccal (right) crossbites.

Figure 5.23 Patient One Initial Records.

Figure 5.24 Nance Button and Lower Lingual Holding Arch.

Figure 5.25 Patient One Initial and Final Records.

Figure 5.26 Patient Two Initial Records.

Figure 5.27

Figure 5.28

Figure 5.29

Figure 5.30

Figure 5.31

Figure 5.32

Figure 5.33

Figure 5.34

Figure 5.35

Figure 5.36

Figure 5.37

Figure 5.38

Figure 5.39

Figure 5.40

Figure 5.41 Biomechanics of the lip bumper.

Figure 5.42 Effect of the lip bumper on arch length and mandibular molar in ...

Figure 5.43 Effect of lip bumper therapy on arch length and mandibular incis...

Figure 5.44 The effect of lip bumper therapy on transverse arch dimensions a...

Figure 5.45 The effect of lip bumper therapy on the irregularity index.

Figure 5.46 The Schwarz appliance.

Figure 5.47

Figure 5.48

Figure 5.49

Figure 5.50

Figure 5.51

Figure 5.52

Figure 5.53

Figure 5.54

Figure 5.55

Figure 5.56

Figure 5.57

Figure 5.58

Figure 5.59 Representation of the classic serial extraction sequence when th...

Figure 5.60 Alternative extraction sequence: in cases in which the mandibula...

Figure 5.61

Figure 5.62

Figure 5.63

Figure 5.64

Figure 5.65

Figure 5.66

Figure 5.67

Figure 5.68

Figure 5.69

Chapter 6_1

Figure 6.1 Development of Class II molar relationships between the deciduous...

Figure 6.2 Occlusal characteristics of Class II division 1 (a &c) and Class ...

Figure 6.3 Anteroposterior and vertical skeletal characteristics of subjects...

Figure 6.4 Percentages of individuals with normal occlusion, Class I maloccl...

Figure 6.5 Prevalence of Class II malocclusion among US children, youths, an...

Figure 6.6 Changes in vertical skeletal relationships and incisor angulation...

Figure 6.7 Mandibular plane angles (MPAs) of Class Is and Class IIs (Adapted...

Figure 6.8 Differences in maxillary and mandibular intermolar widths of male...

Figure 6.9 The anteroposterior changes in the position of gonion (Go) and po...

Figure 6.10 True rotation of the mandible’s implant or stable structure line...

Figure 6.11 The horizontal and vertical (hor/vert) growth and modeling chang...

Figure 6.12 Frequencies of Class II malocclusion among Finns born around the...

Figure 6.13 Flow chart showing the development of the hyperdivergent retrogn...

Chapter 6_2

Figure 6.14 Extreme crowding and protrusion. Patient is unable to close her ...

Figure 6.15 Severe deep bite, crowding with difficulty in chewing.

Figure 6.16 Severe Class II division 2 compromising normal growth and ...

Figure 6.17 Hyperdivergence, accentuated protrusion, emotional...

Figure 6.18 Class II deep with Brodie bite, buccal crossbite...

Figure 6.19 Class II, open bite, severe hyperdivergence, unilateral crossbit...

Figure 6.20 Distal step adaptation (Arya et al. [30]/with permission of Else...

Figure 6.21 Class II combinations. (a) Normal, (b) maxillary dental protract...

Figure 6.22 Class II division 1 treated with compliance and favorable growth...

Figure 6.23 Vertical control (intrusion) with MSI and TPA supported device....

Figure 6.24

Figure 6.25

Figure 6.26

Figure 6.27

Figure 6.28

Figure 6.29

Figure 6.30

Figure 6.31

Figure 6.32

Figure 6.33

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Figure 6.55

Figure 6.56

Chapter 7_1

Figure 7.1 Development of Class III molar relationships between the deciduou...

Figure 7.2 Median particle sizes (arrows) and interquartile ranges of subjec...

Figure 7.3 Worldwide prevalence estimates of Class III malocclusion based on...

Figure 7.4 Differences (Class III minus Class I) in overall mandibular lengt...

Figure 7.5 Total condylar growth and condylar growth direction based on mand...

Figure 7.6 Changes in overall mandibular length (

L

) depending on 10 mm of co...

Figure 7.7 Lateral (a, c, d, and f) and frontal (b and e) intraoral views sh...

Figure 7.8 NHANES III estimates of Class III malocclusion among US children,...

Figure 7.9 Longitudinal changes of the ANB, Wits appraisal, maxillomandibula...

Figure 7.10 Nongenetic disturbances and genetic factors that explain the eti...

Figure 7.11 Pretreatment records of a patient who habitually postures her ma...

Figure 7.12 Cranial base angle (N‐S‐Ba) of subjects with Class I, Class II, ...

Figure 7.13 Relative effects of a smaller cranial base angle, bringing the m...

Figure 7.14 Importance of cusp–fossa relationships to the development of Cla...

Figure 7.15 Etiological factors that explain the development of Class III ma...

Chapter 7_2

Figure 7.16 Self‐esteem evaluation (Graber and Lucker [10]/with permission o...

Figure 7.17 Untreated Class III, (a, b) prepubertal and (c, d) postpubertal....

Figure 7.18 Intraoral composite of untreated Class III: (a–c) prepubertal an...

Figure 7.19 Initial (a–f) and end of phase I (g–l).

Figure 7.20 Induced cranium deformation (from [15]).

Figure 7.21 Induced neck elongation with metal rings? A Thailand ancient tra...

Figure 7.22 Pretreatment facial and cephalometric views: (a, b) centric occl...

Figure 7.23 Cephalometric wigglegram with measurements derived from several ...

Figure 7.24 (a, b) Composite of pretreatment records.

Figure 7.25 Examples of bite registrations in (a) CO and (b) CR. Note the mi...

Figure 7.26 Unfavorable development of an anterior shift as demonstrated on ...

Figure 7.27 Hereditary analysis: cephalometric comparison of parents and chi...

Figure 7.28 Facial resemblance between father and daughter.

Figure 7.29 Early intervention: (a–f) Initial and (g–l) End of phase I and s...

Figure 7.30 Palatal expanders: top row (a), miniexpander and (b) bonded expa...

Figure 7.31 From left to right Petite (a), Delaire (b), Hickham (c), and sof...

Figure 7.32 Direction of force for the protraction face mask.

Figure 7.33 Soft chincup (a) and modified Class III Hawley (b).

Figure 7.34 Bolton relationship for different occlusion types.

Figure 7.35

Figure 7.36

Figure 7.37

Figure 7.38

Figure 7.39

Figure 7.40

Figure 7.41

Figure 7.42

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Figure 7.79

Chapter 8_1

Figure 8.1 (a–f) 9y 2m girl with history of thumb sucking.

Figure 8.2 (a–c) Reminders for habit control.

Figure 8.3 (a–d) The award preparation and final trophy.

Figure 8.4 (a–g) Referred by her family dentist, this 5y 10m girl was initia...

Figure 8.5 (a–e) After the initial steps of making the patient conscious of ...

Figure 8.6 (a–c) The patient 2 years later, prephase II.

Figure 8.7 (a–k) This 5y 6m boy presented with a very severe open bite due t...

Figure 8.8 (a–e) The Araújo protocol was applied, the maxilla was ...

Figure 8.9 (a–e) The patient after 1 year of treatment. showing that the...

Figure 8.10 (a–h) The patient 18 years later.

Figure 8.11 (a–h) Six‐year‐old girl with a severe digit sucking ...

Figure 8.12 (a–d) The results after 15 months of treatment with high...

Figure 8.13 After 20 months of treatment.

Chapter 8_2

Figure 8.14 (a) Stage 2 girl (4y 6m) presented with an infraoccluded left de...

Figure 8.15 Ectopic eruption of both permanent maxillary first molars. The r...

Figure 8.16 (a) An 8‐year‐old girl presented with a bilateral ectopic erupti...

Figure 8.17 (a) A 7‐year‐old girl presented with a submerged mandibular left...

Figure 8.18 (a) An 8y 3m boy presented a PFE of the permanent mandibular rig...

Figure 8.19 (a) An 8‐year‐old girl presented severe negative space discrepan...

Figure 8.20 No signs of eruption of the right permanent maxillary central in...

Figure 8.21 (a) Panoramic radiography of a 5y 9m girl showing the presence o...

Figure 8.22 (a) A 9y 10m girl with delayed eruption of the maxillary incisor...

Figure 8.23 (a) Severe negative space discrepancy in the mandibular arch of ...

Figure 8.24 (a) A 7‐year‐old girl presented with the permanent mandibular le...

Figure 8.25 (a) Panoramic view of a 9‐year‐old boy showing the absence of th...

Figure 8.26 (a) Panoramic radiograph of an 11‐year‐old girl showing delayed ...

Figure 8.27 (a, b) Intraoral frontal view and panoramic radiography of an 11...

Figure 8.28 (a) An 11‐year‐old girl presented with severe negative space dis...

Figure 8.29 (a, b) Periapical radiograph and computed tomography of an 11‐ye...

Figure 8.30 (a) Panoramic radiograph of an 11‐year‐old boy suggested that a ...

Figure 8.31 Permanent mandibular second molar impaction associated with the ...

Chapter 8_3

Figure 8.32 Retained infraoccluded deciduous molars compromise occlusion, al...

Figure 8.33 Spaces left in the maxillary arch allow Class I molar and canine...

Figure 8.34 Panoramic X‐ray shows the effects of infraoccluded deciduous mol...

Figure 8.35 (a) Mildly infraoccluded retained deciduous molar has had mesial...

Figures 8.36–8.38 Class I deep bite malocclusion with absent mandibular seco...

Figures 8.39 and 8.40 Class I crowded malocclusion with absent mandibular le...

Figures 8.41–8.43 Class I mixed dentition crowded malocclusion with absent m...

Figures 8.44–8.46 Class II Division 1 mixed dentition crowded malocclusion w...

Figures 8.47–8.49 Class I minimally crowded malocclusion. Absent all second ...

Figure 8.50 Class I crowded. (a) Panoramic X‐ray with mandibular crowding an...

Figures 8.51–8.53 8.51) Pre‐treatment records show absent maxillary right, a...

Chapter 8_4

Figure 8.54 A 11y 5m girl was seeking orthodontic treatment (a–d). She had c...

Figure 8.55 An 11‐year‐old boy had avulsion of his upper right central incis...

Figure 8.56 An 11‐year‐old girl with congenitally missing lower second premo...

Figure 8.57 A 10‐year‐old boy after traumatic loss of the upper left central...

Chapter 8_5

Figure 8.58 Predisposing factors for dental traumatic injuries.

Figure 8.59 Predisposing factors for dental traumatic injuries.

Figure 8.60 Predisposing factors for dental traumatic injuries.

Figure 8.61 Postphase I and decreased risk of trauma.

Figure 8.62 Early loss of central incisor and the impairment on the patient ...

Figure 8.63 (a–c) Decoronation follow‐up (8, 11, 19 months).

Figure 8.64 Initial facial, intraoral, and cephalometric features.

Figure 8.65 Periapical radiographic and the external root resorption.

Figure 8.66 Intraoral pictures, 6 months follow‐up.

Figure 8.67 Periapical X‐ray, 6 months follow‐up.

Figure 8.68 Records at the debond.

Figure 8.69 (a–c) Records at decoronation.

Figure 8.70 (a, b) Records at decoronation.

Figure 8.71 One‐month postdecoronation.

Figure 8.72 Maryland bridge delivery.

Figure 8.73 (a–d) 1 month; 5 months; 2 years, and 3 years postdecoronation....

Figure 8.74 Five‐year retention records.

Figure 8.75 Panoramic X‐ray – 5‐year retention records.

Chapter 8_6

Figure 8.76 Scores of the modified Mallampati classification that can be use...

Figure 8.77 Tonsils’ scores according to Brodsky scale: Grade 0 – tonsils re...

Figure 8.78 Images showing the mouth of a 9‐year‐old boy exhibiting prominen...

Figure 8.79 Ten‐year‐old boy exhibiting characteristics of habitual mouth‐br...

Figure 8.80 Images of a 5.10‐year‐old girl presenting a convex profile, retrognathic ...

Figure 8.81 Tomographic images of the 5.10‐year‐old girl showing the class II ...

Figure 8.82 Images of an 11‐year‐old boy presenting SDB and long face syndrome ...

Figure 8.83 Tomographic images of the 11‐year‐old boy showing the class II m...

Chapter 8_7

Figure 8.84 A force acting directly in line and through the center of resist...

Figure 8.85 Tooth rotation from a kinematic perspective describes rotation f...

Figure 8.86 A tooth that receives a force not acting through the CRes feels ...

Figure 8.87 Moment of a couple (

M

C

) resulting in first‐order (a) and second‐...

Figure 8.88 Moment of a couple (

M

C

) resulting in a third‐order rotation wher...

Figure 8.89 Canine retraction with 100‐g force acting 10‐mm coronal to the C...

Figure 8.90 Patient 1 Time 1.

Figure 8.91 Patient 1 Time 2.

Figure 8.92 Patient 2 Time 1.

Figure 8.93 Patient 2 Time 2.

Figure 8.94 Mixed dentition root convergence. This is achieved by mesial gin...

Figure 8.95 Mixed dentition root convergence. The maxillary centrals have “0...

Figure 8.96 Time 1 mixed dentition anterior alignment.

Figure 8.97 Time 1 mixed dentition anterior alignment using 0.012 nitinol wire anterior segment.

Figure 8.98 Time 1 and Time 2 mixed dentition anterior alignment using 0.012 nitinol ...

Figure 8.99 Time 1 and Time 2 mixed dentition anterior alignment using 0.012...

Figure 8.100 Forces and moments present in a two‐bracket, two‐couple system....

Figure 8.101 A case with congenitally missing permanent maxillary lateral in...

Figure 8.102 Clinical use of a centered gable bend 16 × 22 stainless steel segment with...

Figure 8.103 Overcorrected positions of the central incisors and bonded ling...

Figure 8.104 Two‐bracket, two‐couple system with an asymmetrical V‐bend in t...

Figure 8.105 Two‐bracket, two‐couple system with additive force step bends i...

Figure 8.106 Mixed dentition lower incisor “additive force” extrusion utilit...

Figure 8.107 Additive system mechanics and approximate schematic vectors pre...

Figure 8.108 Mixed dentition lower incisor extrusion using 16 × 22 stainless...

Figure 8.109 Emergence of the lower left second bicuspid and subsequent root...

Figure 8.110 Superimposing on the corpus at PM point (Ricketts’s method) rev...

Figure 8.111 Two‐year postorthodontic treatment. Using maxillary and mandibu...

Figure 8.112 Dental facial balance 2‐year postphase 2 orthodontic treatment....

Guide

Cover Page

Table of Contents

Title Page

Copyright Page

Dedication Page

List of Contributors

Foreword

Preface

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Recognizing and Correcting Developing Malocclusions

A Problem‐Oriented Approach to Orthodontics

Second Edition

Edited by

Eustáquio A. Araújo, DDS, MDS

Professor Emeritus – Saint Louis University

Clinical Professor – University of Pittsburgh

Professor – Faculdade de Ciências Médicas de Minas Gerais

Peter H. Buschang, MA, PhD

Regents Professor and Director of Orthodontic Research

Department of Orthodontics

Texas A&M University Baylor College of Dentistry

Dallas, TX, USA

Copyright © 2025 John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies.

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Cover Design: WileyCover Images: © Eustáquio A. Araújo

Dedications

To my family, particularly my wife Teresa, my daughter Kika, my son Chico, his wife Veronica, and my grandchildren Julia and Davi for the support and constant inspiration. To my parents, especially my father who, through his example, led me into dentistry. To each of my mentors, alumni from PUCMinas, Ciências Médicas de Minas Gerais and Saint Louis University, present residents, colleagues, and to each one of my patients who helped me to become a better clinician and professor. In addition, a special thanks to Drs. Orlando Tanaka, Jose Mauricio Vieira, Roberto Vieira, Júnia Lucia Vieira, and Gabriel Miranda for their help and friendship.

Eustáquio A. Araújo

Also to my family, particularly my wife Joyce, whose support and wisdom has sustained me. And to the orthodontic faculty, alumni, and residents that I have been privileged to work with – they have helped me to see the way. Together, they have made it all worthwhile.

Peter H. Buschang

List of Contributors

Ildeu Andrade Jr., DDS, MS, PhD

Department of Orthodontics, School of Dental MedicineUniversity of PittsburghPittsburgh, PAUSA

Eustáquio A. Araújo, DDS, MDS

Department of Orthodontics, Center for Advanced Dental EducationSaint Louis UniversitySt. Louis, MOUSA

Peter H. Buschang, MA, PhD

Department of OrthodonticsTexas A&M University School of DentistryDallas, TXUSA

Ewa M. Czochrowska, DDS, PhD

Department of OrthodonticsMedical University of WarsawWarsawPoland

David B. Kennedy, BDS, LDS (RCSEng), MSD, FRCD(C)

Faculty of DentistryUniversity of British ColumbiaVancouver, BCCanada

Mary MacDougall, PhD

Faculty of DentistryUniversity of British ColumbiaCanada

Luciane M. de Menezes, PhD

Department of OrthodonticsCase Western Reserve UniversityCleveland, OHUSA

Pontifical Catholic University of Rio Grande do SulPorto Alegre/RSBrazil

Gabriel Miranda, DDS, MS

Department of OrthodonticsSaint Louis UniversitySt. Louis, MOUSA

Juan Martin Palomo, DDS, MDS

Department of OrthodonticsCase Western Reserve UniversityCleveland, OHUSA

Paweł Plakwicz, DDS, PhD

Department of PeriodontologyMedical University of WarsawPoland

Gerald S. Samson, DDS

Department of Orthodontics, Center of Advanced Dental EducationSaint Louis UniversitySt. Louis, MOUSA

Robyn Silberstein, DDS, PhD

Department of Orthodontics, College of Dentistry (retired)University of Illinois at ChicagoChicago, ILUSA

Bernardo Q. Souki, DDS, MSD, PhD

Department of DentistryPontifical Catholic University of Minas GeraisBelo HorizonteBrazil

Foreword

Orthodontic educators are often confronted by loaded questions where the questioners really just want to know if their biases are shared by the educator. One of the most common questions is: “Do you teach early treatment to your students?” From experience, I know that the answer either lines up with the questioner’s bias and a conversation of great agreement will follow, or the answer does not line up with their bias and a conversation of great disagreement will follow, so I prefer to provide neither expected answer, but instead aim to stimulate thought. So my answer might well be “Yes, we teach early treatment and late treatment and also very early and very late treatment. We also perform 1‐phase treatment, 2‐phase treatment, 3‐phase, 4‐, 5‐, 6‐, 7‐, 8‐, and even 9‐phase treatment … or more, if need be.”

Of course, this answer is very perplexing and I am asked to explain what I mean – which I am happy to do. To provide support to my answer, I provide several examples. For one of these, I talk about a study that was performed long ago by a former graduate student named Greg Dyer [1]. He took a sample of treated adolescent females and a similar sample of treated adult females and compared the outcomes of the treatments performed. Importantly, in the adolescent group he found that growth provided 70% of the correction (i.e. the mandible outgrew the maxilla) while only 30% of the correction was due to tooth movement. In the adult sample, the growth was nil, or in some cases the maxilla outgrew the mandible and the amount of tooth movement that was necessary to correct the malocclusion was 119% – that is, the practitioner had to do all the work, and more, to make up for the poor growth, in order to correct the problem. For me, this is ample evidence that it is better to treat early (as an adolescent) as opposed to late (as an adult) in this particular situation. This example points to the meaning of my response to the question posed initially. It is not whether I am biased so that I believe only in early treatment or only in late treatment as a single choice that must be made, but rather it is that the question can only be answered in the context of the situation that is presented. In this example, my answer would be to treat early (in this case, adolescence) when you are confronted by a Class II female adolescent; don’t wait till they become adults.

In the case of treatment performed in multiple phases, again it is the context of the patient’s situation that dictates what to do. There is plenty of research and clinical experience available that suggests that a cleft palate patient is best treated early and often over many years, according to the many types of treatments that are arranged across many phases. There are also questions as to how many phases of treatment should be involved in an orthognathic surgery case.

So, the point that I am trying to make is that it matters little whether a practitioner “believes” in early treatment or not, and it makes little difference whether the practitioner “believes” in single‐phase treatments or some other number of phases. What really matters is that the practitioner evaluates the condition that the patient presents and then applies the best available evidence to the situation in deciding if, when, and how the treatment should be rendered. To believe otherwise suggests that the doctor can decide the approach before even seeing the patient. But adopting a prefabricated approach is seldom the best choice because patients are all custom‐made.

What follows in the pages to come is blended (some old, but mostly new) information concerning genetics, normal, and abnormal growth of the craniofacial skeleton, and the development of the occlusion. Such information will form the basis for understanding and determining the timing of treatment.

You will also find important information on the construction of a diagnosis, treatment plan, and estimation of prognosis, all based on available diagnostic records produced by both old and new technologies. All three types of Angle classes will be considered in terms of development, etiology, and treatment; that is the meat of this book.

Finally, information will be provided with regard to certain overriding topics such as biomechanics, and what might be considered “orphan topics” including problems attendant to abnormal eruption, function, aesthetics, congenitally missing teeth, autotransplantation, and habits.

So, how is this book different from previous books on the topic of early and preventive orthodontic treatment? Considering the comments made earlier in this preface, this book is based on available evidence, not bias, passion, or faith; it is meant to make you think and then apply what is proven. This book is also different in that the authors are very knowledgeable each in their own areas, and each is cognizant of the value of current science and the knowledge that science generates.

Those readers who are open to the development of new information and new ideas should enjoy and embrace the knowledge and direction contained within. For those who are very biased in their thoughts and actions do not be afraid to read this book; it will open your mind and help you adjust your thoughts and actions in a positive way.

Have a good read; I think you will find it worth the effort in terms of thought and then reasoned actions that will prove beneficial to your patients.

Rolf G. Behrents

Reference

1

Dyer, GS. Age effects of orthodontic treatment: adolescents contrasted with adults. MS Thesis, The University of Tennessee, 1989.

Preface

Recognizing and Correcting Development Malocclusions: A Problem‐Oriented Approach to Orthodontics, in its second edition, continues to provide evidence‐based approach to early age orthodontics, an often controversial topic. Based on decades of experience in clinical practice and education, Drs. Araujo and Buschang with the support of an outstanding team of contributors, present treatment protocols for early age orthodontics treatment with various malocclusions and other problems.

Class I, Class II, and Class III malocclusions are extensively covered, along with eruption deviations and developing hyperdivergence growth and open bites. This second edition brings new topics such as Trauma and Sleep Apnea in children. The literature is comprehensively reviewed to ensure that the reader thoroughly understands the development, phenoptic characteristics, and etiology of each type of malocclusion.

Taking a problem‐oriented approach, the editors and contributors provide detailed information for each case, develop comprehensive problem lists, and then provide evidence‐based treatment solutions.

The clinical focus of the text is ideally suited for the private practice clinician, with numerous references and academic underpinnings to ensure its suitability for orthodontic and pediatric dentistry residents.

Eustáquio A. Araújo

Center for Advanced Dental Education

Saint Louis University, St. Louis, MO, USA

19 September 2024

Peter H. Buschang

Regents Professor and Director of Orthodontic Research

Department of Orthodontics

Texas A&M University Baylor College of Dentistry

Dallas, TX, USA

19 September 2024

1A guide for timing orthodontic treatment

Eustáquio A. Araújo, DDS, MDS1 and Bernardo Q. Souki, DDS, MSD, PhD2

1 Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St. Louis, MO, USA

2 Department of Dentistry, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil

When the decision was made to work on this book, the heavy responsibility of embracing the topic without bias or radicalism increased. Clinicians and academicians were initially consulted and asked to provide questions that would help establish priorities for early interventions. The responses came rapidly and contained all the sorts of questions one would imagine. Recognizing and Correcting Developing Malocclusions will try to address the collected questions and themes.

The term “early treatment” has been used for a long time, and it seems now to be fixed. Although “early” could suggest “too soon,” for the sake of practicality it will be used in this book. The text will eventually also refer to timely or interceptive treatment.

Initiating orthodontic treatment during the growth spurt was often used to be considered the “gold standard” for treatment timing. The pendulum that regulates the initiation of orthodontic treatment has been swinging in different directions for many years. At present, this balance seems to have been shifting, as the pendulum appears to be swinging toward an earlier start, preferably at the late mixed dentition. The possibility of successfully managing the E‐space has dramatically influenced the decision‐making on the timing of orthodontic treatment [1].

At the beginning of the 20th century, some consideration was given to early treatment. A quote from Lischer [2] in 1912 says,

Recent experiences of many practitioners have led us to a keener appreciation of the “golden age of treatment” by which we mean that time in an individual’s life when a change from the temporary to the permanent dentition takes place. This covers the period from the sixth to the fourteenth year.

Soon after, in 1921, a publication [3] titled “The diagnosis of malocclusion with reference to early treatment,” discusses the concepts of function and form and gives notable consideration to the role of heredity in diagnosis—so the topic with its controversies is an old one.

“The emancipation of dentofacial orthopedics,” an editorial by Hamilton [4] supports early treatment. In summary, he states that:

healthcare professionals must do everything possible to help their patients, including early treatment;

it is irresponsible and unethical to prescribe treatment for financial betterment and for the sake of efficiency;

if the orthodontist is not willing to treat patients at a young age, others in the dental profession will, and it is in the patients’ best interest that we, as specialists, treat these patients. After all, our flagship journal includes “Dentofacial Orthopedics” in its title;

it is the highest calling of healthcare professionals to incorporate prevention as a primary means of treatment, and therefore early treatment is important;

pediatric dentists and other health professionals are incorporating early treatment in their practice because orthodontists are waiting too long to initiate treatment;

orthodontic programs have the responsibility to educate orthodontists about early treatment.

On the other hand, Johnston [5] indicates in “Answers in search of questioners” that:

little evidence exists that two‐phase early treatment has a significantly greater overall treatment effect compared with treating in one phase and considering E‐space preservation;

treatment aimed at the mandible typically has an effect on the maxilla;

early treatment is not efficient for the patient or doctor and results in an increased burden of treatment;

functional appliances do not eliminate the need for premolar extraction, as bone cannot grow interstitially and arch perimeter is not gained with their use;

patients occasionally endure psychological trauma due to dental deformity, but these isolated instances are not enough to “support what amounts to an orthodontic growth industry.”

In an effort to establish grounds to initiate treatment earlier or later, we must try to answer two key questions:

Should developing problems be intercepted and treated in two phases?

Which malocclusions should receive consideration for treatment at an early age?

Undoubtedly, there is much agreement on what to treat, but there is still great disagreement on when to intervene.

What are achievable objectives for early treatment? Some of the most relevant ones are using growth potential appropriately, taking advantage of the transitional dentition, improving skeletal imbalances, eliminating functional deviations, managing arch development, improving self‐esteem, minimizing trauma, and preventing periodontal problems.

Early orthodontic treatment offers several potential advantages, including better patient compliance, emotional satisfaction, and the ability to harness growth potential. It may also simplify the second phase of treatment and reduce the need for extractions. Additionally, early treatment can benefit practice management. However, there are also disadvantages, such as inefficiency, prolonged treatment time, patient immaturity, challenges with maintaining oral hygiene, difficulty in caring for appliances, and higher costs. It is crucial for orthodontists to carefully weigh these benefits and risks, providing evidence‐based and well‐reasoned recommendations on whether or not to initiate treatment. This chapter offers guidance on the optimal timing for orthodontic interventions.

The ideal timing for treating malocclusions in growing patients has been a controversial and widely discussed topic throughout the history of orthodontics [16–10]. One of the most important debates in our field is whether to interrupt the development of problems with early treatment or to postpone therapy until later [1, 9]. Such controversies are likely due to the lack of a scientific basis for therapeutic clinical decisions [8]. Historically, dentistry has been an empirical science. Even today, most dentists choose to employ solutions and techniques that were first learned in dental school or those that they believe will work [1, 9]. In such cases, there is a high probability of treatment failure or a low‐quality treatment outcome.

During the search for excellence in orthodontics, the concepts of effectiveness and efficiency have been emphasized [1]. Orthodontic clinical decisions should be scientifically based. Accordingly, treatment must be postponed until strong arguments in favor of beginning the therapy are present [9].

A follow‐up protocol in which patients are re‐examined periodically during growth and the development of occlusion allows the clinician to decide whether the cost/benefit of early treatment is justifiable. At this time, the program “preventive and interceptive orthodontic monitoring,” or simply PIOM, as devised by Souki [11] is introduced.

Conceptually, PIOM is a program of sequential attention that aims to monitor the development of “normal” occlusion and seeks to diagnose any factors that may compromise the quality or quantity of orthodontic treatment and the establishment of an appropriate occlusion. Seven objectives govern PIOM:

Provide prospective monitoring with a minimal intervention philosophy;

Provide comprehensive orthodontic care with functional and esthetically harmonious adult occlusion as the ultimate goal;

Establish parameters so that orthodontists are not in a hurry to start treatment but are able to have a deadline to complete treatment;

Establish scientific parameters as guidelines for beginning therapy at each stage of maturation;

Respect the normal range of occlusal development;

Reduce dependence on patient compliance;

Delay phase II, if possible, until the time when second permanent molars can be included in the final occlusion.

During the years that separate the eruption of the first deciduous tooth and the full intercuspation of the second permanent molars, many morphogenetic influences and environmental factors act on the maturation of the dental arches and the occlusal pattern. Therefore, human occlusion should be viewed dynamically.

Clinicians must understand that during occlusal development, there is not just one line of ideal characteristics but a wide range of normal characteristics. In the mixed dentition, a larger variety of normal characteristics compared to the deciduous and permanent dentitions is encountered. Knowledge of normal features of occlusal maturation is important for the practice of orthodontics within PIOM. Throughout the history of medicine/dentistry, identifying signs or symptoms of a deviation from normal has been viewed as a situation requiring interceptive action. In lay terms, it has been thought that allowing a disease to evolve naturally (without therapy) may possibly make the disease more difficult to treat or even make it incurable [7]. This belief, when applied to orthodontics, may produce unnecessary interventions for occlusal characteristics that are totally within the range of normal (Figure 1.1), treatment of transitional deviations for which interceptive treatment (phase I) is not needed (Figure 1.2), and interceptive treatment before the appropriate time (Figure 1.3).

As mentioned earlier, the orthodontist should focus on two key questions: the first deals with the ideal timing for interceptive orthodontics, incorporating the decision between one‐ and two‐phase treatments and the second hinges on identifying malocclusions that would benefit from an early intervention.

1.1 Occlusal deviations with indications for interceptive orthodontic treatment

Interceptive problems are those that, if not stopped during the course of their maturation, may become sufficiently severe to increase the complexity and difficulty of definitive treatment, compromise the final quality, or expose the individual to psychosocial conditions while waiting for a final corrective solution. Disagreements certainly exist among scholars regarding the clinical situations with indications for early orthodontic treatment. The list of issues presented by the American Association of Pediatric Dentistry [12] may serve as the starting point for this guideline. Based on their list, the following situations are suggested as candidates for early treatment: 1) prevention and interception of oral habits; 2) space management; 3) interception of deviations in eruption; 4) anterior crossbite; 5) posterior crossbite; 6) excessive overjet; 7) Class II malocclusion, when associated with psychological problems, increased risk of traumatic injury and hyperdivergence; 8) Class III malocclusion.

Figure 1.1 (a) A 8‐year‐old boy during “ugly duckling” phase presenting labial‐distal displacement of maxillary lateral incisors and a diastema between the central incisors. (b) Same patient 3 years later without any orthodontic treatment. The incisors’ alignment and leveling were naturally achieved.

Figure 1.2 (a, b) A 9‐year‐old girl presenting deep bite and positive space discrepancy. Such transitional deviations (deep bite and positive space discrepancy) have no indication of interceptive orthodontics unless palatal soft tissue impingement is observed or aesthetics is a major concern. (c, d) Same girl 5 years later presenting significant natural improvements in the deep bite and space discrepancy with no phase I treatment.

Figure 1.3 (a–c) A 9‐year‐old mixed dentition boy with a Class II/1 malocclusion but no psychosomatic concerns. The evaluation of a low/moderate risk of traumatic injuries in the maxillary front teeth indicated postponing to a single‐phase orthodontic treatment. (d–f) Patient at 12 years old, during early permanent dentition. No interceptive orthodontic treatment was performed. After 5 months of headgear appliance, the patient is now going into the 12–18 months multibrackets comprehensive orthodontic treatment. Efficiency was achieved by postponing the Class II correction to a single‐phase approach.

1.2 Ideal timing for early treatment

Several aspects must be considered by the clinician when deciding on the ideal timing for early treatment. Four basic considerations are: 1) psychosocial aspects; 2) the severity and etiology of the malocclusion; 3) the concepts of effectiveness and efficiency; 4) the patient’s stage of the development.

1.2.1 Psychological aspects

Psychological aspects are often neglected by orthodontists and unfortunately have not been routinely considered during the early treatment decision‐making process [13, 14].

At a time when bullying has been extensively discussed [15] and has been widely studied by psychopedagogues, clinicians must be constantly aware of the fact that, as providers, they can in many instances improve the self‐esteem and quality of life (QoL) of their patients [16].

For many, the relationship between a patient’s well‐being and his/her malocclusion, along with possible associated sequelae has been thought to be of only minor importance [17]. Consideration must be given to each patient’s QoL and the associated impact that postponement or avoidance of treatment may carry. Although somewhat vague and abstract, the concept of QoL is current and should be emphasized in orthodontics [18].

The literature provides evidence of an association between QoL and malocclusions. The methodologies of QoL studies, however, have not been homogeneous, and the samples are often constructed based on convenience, making it difficult to offer a reliable analysis. The lack of randomized samples hinders the interpretation of the evidence [18, 19].

Young people are motivated to seek orthodontic treatment because of their esthetic dissatisfaction [13], referrals from dentists [20], parental concerns [13], and the influence of peers [21]. Orthodontic treatment does improve QoL [19], but over time, the gain in QoL may be lost. When a malocclusion causes discomfort to a patient with the potential for generating a psychological imbalance [20], there is certainly an indication for early treatment [13], despite the fact that efficiency may be adversely affected [1].

1.2.2 Severity of the malocclusion

Malocclusions differ among patients presenting a wide range of severity. Therefore, it seems reasonable to think that, in infancy and adolescence, a mild malocclusion has a lower interceptive priority than a more severe one. For example, a posterior crossbite with mandibular shift (Figure 1.4a) should have treatment priority as compared to malocclusions with minor shift or not associated with functional deviations (Figure 1.4b). In the first scenario, the deviation can lead to asymmetric facial growth, making future therapy more complex [22]. There is less urgency for treatment of a single lateral incisor crossbite than a two‐central‐incisor crossbite (Figure 1.5), although there is a lack of evidence in the current literature about postponing interceptive approach of crossbites. It must be understood that the severity of the malocclusion is not the only criterion for deciding on interceptive treatment. For example, if a Class III malocclusion is very severe in childhood, with skeletal components indicating that surgical correction may be required in the future, it is reasonable to consider delaying treatment until the end of growth to reduce extensive interceptive treatment [23, 24]. In other words, in some situations, it is advisable to postpone the correction of the malocclusion until a single‐phase orthodontic‐surgical treatment can be undertaken. On the other hand, many other Class III malocclusions in children may benefit greatly from an interceptive approach [24, 25].

Figure 1.4 (a) Posterior crossbite with mandibular shift. (b) Posterior crossbite with no mandibular shift.

Figure 1.5 (a) A 8‐year‐old boy, Class I dental‐skeletal pattern, presenting a single lateral incisor crossbite. (b) A 7‐year‐old girl, Class I dental‐skeletal pattern, presenting two central incisors crossbite. Because periodontal and dentofacial growth impairments are more likely to happen in “b,” it is reasonable to infer that interceptive approach should be addressed urgently.

1.2.3 Effectiveness and efficiency concepts

The decision on the best time for orthodontic treatment must also consider the aspects of effectiveness and efficiency [10]. Effectiveness is a concept that expresses the ability to effectively solve a problem. Will it work at all? How much improvement will be produced? This concept is important in the search for excellence in orthodontics. Orthodontic interceptive actions should be considered if there is evidence that the problem to be treated will, in fact, be solved by early treatment. If the problem is not intercepted, will it lead to a less acceptable final result or cause greater difficulty in obtaining a good result?

Efficiency is a formula that correlates result with time. How much time will be needed to achieve the goals? Will the financial, biological, and interpersonal burden be worth the outcome? In the contemporary world, the concept of efficiency has been an important criterion in deciding implementations of actions and services. If the cost–benefit of a phase I is unfavorable, should one consider the benefits of early orthodontic treatment?

In summary, the treatment of malocclusions in children should be considered an acceptable option if there is evidence that the outcome will add quality (effectiveness) and will be obtained with less effort (efficiency). Be sure to get the best result in the shortest amount of time possible.

1.2.4 Maturational stage of development

The orthodontist should consider several maturational aspects [26–28]. The presence of a minimal emotional maturity is essential for beginning any orthodontic procedure, even in patients with low‐complexity malocclusions [29]. These considerations are essential to improve patient comfort [30] and to reduce the risk of accidents in young children. Thus, the cooperation of the child in the clinical examination becomes the first parameter used by orthodontists in judging the potential for early treatment. Depending on the child’s behavior and compliance, the clinician will decide if orthodontic records should be taken. Psychosocial maturity is normally associated with chronological age. The American Association of Orthodontists (AAO) in its brochure Your Child’s First Check‐up recommends that children have a check‐up with an orthodontic specialist no later than age 7. However, decisions about early treatment should be undertaken on an individual basis. Other parameters of maturity should also be considered. Assessment of the dental age should be made when intra‐arch problems suggest early treatment. On the other hand, skeletal age should be used as a guide for the best time to intercept sagittal and vertical interarch problems [26, 27].

In conclusion, it seems clear that a thorough consideration of all the factors described here will serve two purposes: 1) to determine whether or not early treatment is necessary and 2) to provide guidelines for determining when treatment should be initiated.

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Johnston L Jr. Answers in search of questioners.

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7