The American Association of Orthodontists (AAO) recommends that all children have a screening with an orthodontist no later than age seven. For certain individuals, treatment at a young age (before all the permanent teeth have come in) is very important. Treatment in young children is called “phase I (one)” treatment. Failure to treat particular problems early can result in undesirable consequences, including:

  • Increased risk for tooth trauma
  • Destructive tooth wear
  • Dental impaction (teeth stuck in bone, unable to come in by themselves)
  • Permanent gum recession
  • Development of jaw/facial irregularities
  • Need to extract permanent teeth later
  • Need to perform jaw surgery later
  • Psychosocial problems

If such problems are not caught early, their correction can require lengthy, complex, and expensive orthodontic and dental treatments later. For example, if a crossbite is not corrected, the teeth involved may experience significant wear—all the way through the enamel—or get fractured; and the gums and bone around the involved teeth may recede significantly—all irreversible problems. In this example, which I have actually seen multiple times, correction will require orthodontic treatment, then potentially dental restorations (fillings or crowns) and grafting of gum tissue. The dental treatment will help, for sure, but it is much better long-term to have healthy teeth without crowns or fillings, and healthy gum tissue without grafting, because, in general, “there’s nothing like the real thing.” Also, dental treatment will require maintenance and eventual replacement (multiple replacements in a young patient with a long life ahead of him or her). It would be much better to fix the causative problem—the crossbite—with phase I orthodontics before the potential consequential problems develop.

Evidence-Based Orthodontics

Not all patients are candidates for early treatment. In fact, when we determine that specific orthodontic problems don’t affect your child, we prefer to wait to start treatment until he or she is nearing puberty, when we can better modify jaw growth and fix bigger bite problems. Research has shown that in these situations, waiting to start treatment—until all the permanent teeth are in or nearly in—and tackling all the orthodontic problems at once and correcting everything in one fell swoop means shorter and less expensive overall orthodontic treatment. Which parent wouldn’t want that?

For most patients, the opportunity for periodic evaluation by the orthodontist during growth and development will allow the appropriate treatment to be initiated at the appropriate time.

Phase I Treatment

Let me explain a little bit more about “phase I (one)” treatment. Phase I orthodontic treatment is usually carried out on in patients between the ages of 7 and 10, and treatment time is generally limited to around one year or less. Since the name itself is numbered—“phase one”—there is the implication that there will be a second phase. It is true that the vast majority of patients that require a “phase I” treatment will also require a “phase II” treatment—that it, comprehensive treatment when they are adolescents. If you think about it, it makes sense—if your 7-10 year old has orthodontic problems that are serious enough to require limited treatment before all the permanent teeth are in, they will likely require comprehensive (“phase II”) treatment when all the permanent teeth are in.

Let me clarify what “phase I” treatment is and what it isn’t. Phase I treatment is typically for functional and developmental purposes; it is generally not for cosmetic purposes (although if a child has serious psychosocial concerns and is teased, etc., then phase I for cosmetic purposes is completely justified). Yes, your child will get some beautiful, straight teeth because several braces will be placed, but this is like icing on the cake. The real reason for phase I treatment is to intervene when the teeth or jaws are developing abnormally, and if you do not take action, your child may have significant dental or orthodontic problems. However, by allowing us to step in and do the phase I treatment, you may prevent or correct your child’s immediate problem in the initial stages when it is much more manageable. It is important to remember that phase I treatment happens before all the permanent teeth erupt, and although we can create space to help guide teeth into approximately the right spot before they erupt, obviously we can’t magically straighten a permanent tooth that is unerupted and entirely embedded in the bone, to which we can’t attach a bracket. Phase I treatment will not make the unerupted permanent teeth straight when they come in, but it can help those teeth come in in the first place (i.e., not become impacted—stuck in the bone), and it can help those teeth come into approximately the right spot.

So, if phase I treatment is indicated, does this mean that the “phase II (two)” treatment (typically in the teen years, when all the permanent teeth are in or nearly in), will be much shorter? No, it doesn’t. It may be shorter than it otherwise would have been, but not necessarily. “Then why should I invest in phase I treatment?” a parent might wonder. If phase I treatment wasn’t completed, it doesn’t mean comprehensive orthodontic treatment can’t be “successful,” but it may involve compromises, or it may involve more complex and ultimately expensive treatments. Failure to complete phase I treatment when it is indicated may mean that later comprehensive orthodontic treatment might require extraction of permanent teeth, it could require jaw surgery, it may require oral surgery to bring in impacted teeth, perhaps otherwise unnecessary dental treatments (fillings/crowns, gum grafting, etc.) will be necessary, and the list goes on—all of which may have been prevented with a phase I treatment. So, the aim of phase I treatment is often preventive in nature—to prevent certain problems in growth and development of the jaws and in the development of the permanent dentition. Phase I treatment will not solve all the orthodontic problems—indeed, many problems can’t be solved until the remaining permanent teeth are in or until the patient is nearing the pubertal growth spurt.