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Doctor Opinions

Doctor Opinions

One-Phase vs. Two-Phase Orthodontic Treatment

Two-phase orthodontics is a treatment regimen that involves two phases of orthodontic treatment. In time, and with the appropriate patient and parent consents, I hope to present actual cases that I have treated so everyone can see the magnitude of what can be accomplished with orthodontic treatment. Since it seems that on a daily basis, I am asked to provide a second opinion regarding two-phase orthodontic treatment, I think it would be beneficial for all concerned if I express my feelings about two-phase orthodontics and the reason for those feelings on this website. There are two studies that I will refer to in this letter:
  1. "Comparison of one and two stage non extraction alternatives" by Livieratos and Johnston in the August 1995 American Journal of Orthodontics and Dentofacial Orthopedics.
  2. "One phase versus two-phase treatment" by Anthony Gianelly, DMD, PHD, MD in the November 1995 American Journal of Orthodontics and Dentofacial Orthopedics.
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Dr. Lysle Johnston is the Chairman of the Orthodontic Department at the University of Michigan and is one of the most respected lecturers in the U.S. today. Dr. Anthony Gianelly is Chairman of the Department of Orthodontics, Boston University and a very respected worldwide lecturer. Both papers deal with one phase (traditional treatment) vs. two-phased treatment.

Dr. Johnston’s paper is the only study to actually compare the final results of both treatment regimens. He used two hundred similar malocclusions in his study, one hundred one phase, and one hundred two phase. Dr. Gianelly discusses the two techniques and then discusses mandibular expansion, another important topic. I think it would be prudent at this point to define two-phase orthodontics. Two phase orthodontics begins in the age range of 5 to 10 years old. The patient usually has only maxillary and mandibular incisors and maxillary and mandibular first molars erupted. The remaining teeth are deciduous teeth. The goals of phase one of two phase treatment are to correct skeletal discrepancies and to create room for the eruption of the remaining permanent teeth in an effort to avoid extraction.

The first phase of two-phase treatment usually involves a fixed maxillary expansion appliance and braces on the maxillary first molars and incisors, as well as some sort of removable mandibular expansion appliance. Occasionally a functional appliance is also used in an attempt to correct a skeletal problem. This phase of treatment usually lasts for 15 to 18 months followed by a retention phase until the rest of the permanent teeth erupt. The second phase of two-phase treatment begins at this time to finish the orthodontic treatment. This second phase usually lasts for 18 to 24 months followed by a retention phase. It is very similar and sometimes identical to one phase orthodontic treatment. One phase (traditional orthodontic) treatment usually begins when the bicuspids and cuspids have erupted and lasts for 18 to 24 months.

Please do not confuse the first phase of two-phase treatment which costs on the average 3000.00 to 3500.00, with serial extraction and space maintenance which costs on the average 450.00. By contrast, the second phase of two-phase treatment costs on the average 3500.00 to 4000.00, one phase (traditional) treatment costs on the average 5000.00 to 5500.00. Now that I have established that two phase treatment is more expensive and involves a longer treatment time for the patient, it is time to discuss the final results of both techniques. To this end I will quote from Dr. Johnston’s study: "At the completion of treatment, the two groups were essentially identical. Ultimately, there were no significant cephalometric and study model differences, and the two groups underwent almost identical molar and overjet corrections." "...the early phase of functional appliance treatment conferred no obvious, measurable benefits...Therefore, for most non-extraction Class II patients, the choice of treatments may well constitute a practice management, rather than a biologic decision.”

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Dr. Gianelly’s finding mirror those of Dr. Johnston and I quote "...for more than 90% of the patients, essentially all treatment goals can be accomplished in one phase of treatment ..." Dr. Gianelly went further and discussed expansion in the mandibular arch. He states that expansion in the mandible (widening the lower teeth to make room for the alignment of teeth) is never effective more than 1 mm., and even that is rare. There have been numerous studies in the last 20 years that support his findings. Two such studies were done at the University of Tennessee. All resulted in the same findings. Expansion in the mandibular arch will relapse 100 % without permanent lifetime retention. Also, expansion in the mandibular arch stresses the supporting structures and can lead to future periodontal problems (gum disease). The only valid reason I have ever seen published for the use of palatal expanders is to correct posterior crossbites. That was their original purpose and remains their only valid use.

As for functional appliances, Dr. Johnston finds little evidence in the literature to support the claim that they are successful in correcting skeletal problems. Functional appliances were invented in Europe and have been used extensively for over 50 years. The success rate was so poor with these appliances that the European orthodontists are now learning to do what we consider to be traditional orthodontics. The only exception for which I can justify the use of two-phase orthodontic treatment is in those young individuals who have a Class III skeletal relationship (underbite) as a result of a deficient maxilla (short upper jaw) and a normal mandible (lower jaw).

Two-phase treatment, using a reverse pull headgear "may" create enough forward movement of the maxilla to prevent the need for surgery later. This will not work on those individuals who have a true mandibular prognathism (lower jaw that is too long) and a normal maxilla (upper jaw).To summarize the findings of both the quoted studies and my own personal feelings, Two-phase orthodontic treatment takes longer, costs more and delivers the same treatment result as One phase (traditional) orthodontic treatment.

There are papers in the literature that extol the virtues of two-phase treatment; however, none of these studies have compared the final results of the two different regimens. This paper was published in the American Journal of Orthodontics and Dentofacial Orthopedics as a letter to the editor.

Dr. James L. Ferguson Jr., D.D.S., M.S.D. is ready to work for you.

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