Child orthodontic intervention




The nature of the problem, as revealed by the process of proper differential diagnosis and treatment planning, determines whether interventions are best begun early (early mixed dentition) or late (late mixed or permanent dentition).

Moyer (1988) suggests that early treatment can take advantage of normal growth to correct malocclusions before they become severe. It can eliminate or modify skeletal, muscular, and dentoalveolar abnormalities before the eruption of the full permanent dentition.

Orthodontic therapies in primary dentition contribute to oral health and avoid patients more complicated treatments in permanent dentition. By initiating treatment in the mixed dentition, many of the skeletal and dentoalveolar problems associated with malocclusion often are eliminated or reduced substantially, thus lessening the need for prolonged fixed appliance therapy in the adolescent years. Compliance is also believed to be greater because younger patients are considered to be more cooperative and attentive than adolescents.


Early treatment is defined as the treatment started in either the primary or mixed dentition to enhance the dental and skeletal development before the establishment of the permanent dentition. Its purpose is to correct or intercept a malocclusion, thereby reducing the need for or the complexity of any treatment in the permanent dentition


Review of Literature

Ricketts (JCO 1979), supports the theory that an early treatment is easier and guides the physiological dental exfoliation, a functional/orthopaedic treatment is advisable in deciduous and/or early-mixed dentition to reduce the need for extractions of permanent teeth.
Harvold et al (AJO 1981), suggests that some habits, such as persistent dummy or fingers sucking, can cause alterations of the occlusion and oral breathing associated to respiratory obstructions may cause alterations to the physiological patterns of the craniofacial growth.
Pietila et al (1992), found that the conditions most likely to be treated with Phase I orthodontics were Class II malocclusion, lateral crossbite and crowding which are not necessarily functional problems.
Viazis (AJO 1995), recommends treatment of dental habits in primary dentition and crossbite in early mixed dentition.
Dugoni and Lee (AJO 1995), discussed the advantages of initiating treatment in the mixed dentition and suggest that the time required for treatment in the second phase can be reduced by initiating Phase I treatment between the ages of 7 and 9 years.
Ghafari (AJO 1997), noted that crossbites and overjet that could cause trauma of the maxillary incisors should be treated in early or mid-childhood.
Nelson (AJO 1997), concurs that crossbites, overjet greater than 8 mm in females, maxillary midface deficiency, moderate crowding, congenitally missing teeth, management of supernumerary teeth, some midline discrepancies and habits would likely benefit from Phase I treatment.
Long et al (2000), Orthodontic treatment of cleft-lip and palate patients during the deciduous and mixed dentition period has been recommended to create more favourable conditions for midfacial growth, normalize the intermaxillary basal relationship and prevent or eliminate functional disturbances.


Rationale for early treatment

During development of dentition, the facial structures are passing through a period of rapid development with growth centers that are at peak of their activity.


Early orthodontic treatment should be allowed to take advantage of this developmental phase. If early treatment is not undertaken then the structural imbalance will increase as well as muscular imbalance, leading to misdirected forces.


Reasons to address in the early age

Treatment in the primary dentition is undertaken for the following reasons:

  1. a) To remove obstacles to normal growth of the face and dentition.
  2. b) To maintain or restore normal function.
  3. c) All habits or malfunctions which may distort growth.


The goal of such early treatment is to correct existing or developing skeletal, dentoalveolar, and muscular imbalances to improve the orofacial environment before the eruption of the permanent dentition is complete.

By initiating orthodontic and orthopedic treatment at a younger age, the overall need for complex orthodontic treatment involving permanent tooth extraction and orthognathic surgery presumably is reduced.



The basic principles of early intervention are to eliminate any primary etiological factors, to manage arch length discrepancies and to correct skeletal dysplasia.

Factors such as

  • Non-nutritive sucking habits
  • Premature loss of deciduous molars
  • Anterior open bites
  • Posterior functional crossbites and signs of ectopic erupting canines.

Conditions that should be treated in the primary dentition are:


Early orthodontic treatment should be instituted in malocclusions in which there is no reasonable likelihood of self-improvement or self-correction. Following are some of the conditions which make early orthodontic treatment imperative: 

  • Anterior and posterior crossbites.
  • To avoid adverse occlusal and dental consequences, which are effects of premature extraction, exfoliation or accidental loss of any deciduous teeth 6-8 months prior to eruption of its predecessor.
  • The early loss of primary molars can lead to a loss of arch space.
  • Unduly retained primary incisors which interfere with the normal eruption of the permanent incisors.
  • Malpositioned teeth which interfere with normal occlusal function or induce faulty patterns of mandibular closure.
  • Lower lip trapped behind upper incisors
  • Pronounced constriction of arches
  • Open bites due to tongue-thrusting or digital sucking habits.



Conditions that may be treated:

 Distocclusions that are partly positional. Occlusal equilibration or tooth movements may restore normal function. The rest of the problem may be treated at this time or later.

  • Certain distocclusions of a skeletal nature are best treated at this age, but the patient must be socially mature, and the cases must be carefully chosen.


  • Extreme Class-II Div-1 or Class-I showing maxillary protrusion
  • Class-III malocclusions [true or Pseudo].


  • Early treatment for prominent upper front teeth in children reduces trauma as well as poor self-esteem and social adjustment.

Contraindications to treatment in the primary dentition:


Most pre-adolescent irregularities are rarely self-corrective. With the passage of time, these tend to become more severe and continue to follow the same unfavourable course if not intercepted by proper orthodontic treatment during mixed dentition developmental stages.


Certainly, there are contraindications to treatment in the primary dentition is when:

  • there is no assurance that the results will be sustained,
  • a better result can be achieved with less effort at another time,
  • the social immaturity of the child makes treatment impractical.


Improper early treatment can be harmful, and two-phase treatment may lengthen treatment time. Early treatment not only may do some damage or prolong therapy, it may exhaust the child’s spirit of cooperation and compliance.


Benefits of early orthodontic treatment

  1. a) Facial growth and development:

Facial development involves growth of facial skeleton (jaws and associated structures) and eruption of dentition. Both these processes are synchronized with a range of variability.

If orthodontic treatment is started early, there is an opportunity to direct and correlate the treatment with the growth and allow the natural developmental forces to fulfil their potential for each patient. The rate gradient of facial growth reduces with age.

Any interferences or inhibiting factors would lead to malocclusion. Therefore, it is apparent that any such factors should be removed as early as possible to start the orthodontic treatment.

Thus, depending upon the inhibitory factors and their severity some malocclusions may be treated in deciduous dentition, others in mixed dentition and the remaining in permanent dentition. Therefore, the timing of orthodontic treatment should be focused depending upon the degree of growth and maturation in an individual and family pattern.


  1. b) Tissue response: When the patient is young, one may be able to remove etiologic factors, enlist natural growth forces, provide differential growth responses and obtain a balanced profile prior to eruption of most permanent teeth.


  1. c) Preventive and Interceptive: The orthodontist should prevent or intercept the development of an existing malocclusion in their incipient stages.

For example- Based on studies, those cases that are definitely caused by sucking habits and in which the habit is corrected by early orthodontic treatment about 50% require no further attention. In the remaining 50%, progress of deformity is markedly arrested and an extensive deformity is reduced to a simple proportion which may require second period of treatment for final tooth positional adjustment.

Interceptive orthodontic therapies are performed in order to restore a normal occlusion once a malocclusion has developed. Therefore, in cases where an early treatment is indicated and instituted timely then there is sufficient reduction in the severity of secondary malocclusion.


  1. d) Psychological: Occasionally, the dental malocclusion leads to skeletal malocclusion, if left untreated. Also, from psychological point of view, the facial deformities often create a serious mental hazard in young children. Preventive therapies in orthodontics aim at promoting a physiological development of a good occlusion and avoid the progress of a malocclusion.



According to Proffit (2006), early orthodontic treatments are carried with the aim of reducing the length and the severity of orthodontic treatments with conventional fixed appliances.


According to a study conducted by Grippaudo C. et al (2014), which was designed to determine the prevalence of malocclusions treatable at an early stage using the Baby – ROMA index (Risk of Malocclusion Assessment Index) suggest that early orthodontic treatment could

be advisable in the following cases,

  • Malformation syndromes.
  • Maxillofacial trauma (e.g., condylar fractures).
  • Facial asymmetries.
  • Skeletal Class III malocclusion with anterior crossbite.
  • Severe crossbite (which could lead to asymmetric development of the jaw).
  • Scissor bite.
  • Early loss of deciduous teeth due to caries.


According to various studies,


  • Early treatments of Class III malocclusion due to maxillary hypoplasia have showed better clinical results in primary or early mixed dentition.
  • In Class II malocclusions the debate regarding the benefits from a dual-phase treatment is still open. But some patients with intra-arch tooth-size/arch-size discrepancy problems also exhibit Class II malocclusion or a strong tendency toward a Class II malocclusion. Generally, these patients do not have severe skeletal imbalances but rather may be characterized clinically as having either slight mandibular skeletal retrusion or an orthognathic facial profile with minimal neuromuscular imbalances.
  • Studies have found that “spontaneous” improvement of mild Class II and Class III malocclusions after using function jaw orthopedic appliances in early phases of treatment.
  • An early treatment for the correction of posterior crossbites with jaw shifting is often advisable in order to prevent a facial asymmetry. Although some studies found that 45% of the posterior crossbites with lateral mandibular displacement resolves spontaneously with growth.
  • Space maintainers prevent the premature loss of deciduous teeth or crowded primary dentition loss of space, thereby allowing the eruption of permanent teeth in their natural position and preserving the leeway space when the dental arches are crowded.
  • Early treatment of an open bite is very controversial. It is important to identify if the open bite is determined by a skeletal base or a dental base in order to choose the correct treatment option. In children with average vertical patterns the open bite is determined just by environmental factors and can be treated more successfully during growth, while in subjects with malocclusion associated with increased skeletal vertical patterns the prognosis is less favourable.


According to a review by Gadgil (2012), the possible milestone appointment for Early Orthodontic Intervention;

Skeletal component in any malocclusions should be considered to be dealt with immediate effect whereas the dental component, can be handled at a later date.

Thus, an ideal age to start orthodontic treatment would be the age at which if the treatment of malocclusion is undertaken, it would create a more favourable occlusion and which in time would influence the dental and skeletal development in the direction of balance and harmony with the surrounding structures.



Prevention and early orthodontic intervention are generally successful in minimizing the detrimental dental and occlusal effects of non-nutritive sucking habits and early loss of primary molars.

Interception and early treatment of functional posterior crossbites and signs of ectopic canine eruption have been equally successful.

On the surface, this concept seems reasonable because it appears more logical to prevent an abnormality from occurring than to wait until it has become developed fully. In general terms, an initial phase of treatment is provided that is approximately 1 year in duration followed by intermittent observation during the transition from the mixed to the permanent dentition. treatment.

In many conditions, the advantages and limitations of early intervention must be considered individually for each patient, without omitting psychological factors such as patient cooperation and self-esteem in the decision-making.



  • Graber, Vanarsdall- Orthodontic Current Principles and Techniques (6th edition)
  • Grippaudo C. et al, Early orthodontic treatment: a new index to assess the risk of malocclusion in primary dentition, European Journal of Paediatric Dentistry vol. 15/4-2014
  • Heidi Kerosuo, The Role of Prevention and Simple Interceptive Measures in Reducing the Need for Orthodontic Treatment, Med Principles Pract 2002;11(suppl 1):16–21
  • Moyers- Handbook of Orthodontics (4th edition)
  • PS Fleming, Timing orthodontic treatment: early or late?, Australian Dental Journal 2017; 62:(1 Suppl): 11–19
  • Yang and Kiyak, Orthodontic treatment timing: A survey of orthodontists, Am J Orthod

Dentofacial Orthop 1998;113:96-103.


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