Controversies in early orthodontic treatment www.indiandentalacademy.com
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Definition Introduction Timing of treatment Controversies Class II Class III Transverse deficiencies -cross bites Anterior open bite Posterior open bite www.indiandentalacademy.com
Definition  Early treatment  It is the treatment initiated during the primary or the mixed dentition stage to enhance dental and skeletal development before the eruption of the permanent dentition
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Corrective mixed dentition treatment is a valid procedure
– Controversies and misconceptions since the time of EH Angle and PR Begg.
Tweed called mixed dentition t/t preorthodontic
guidance. Analysis and treatment of malocclusion in the mixed dentition are more complicated than in permanent dentition.
Saltzman, Moores in agreement with Tweed said Mixed dentition can be the most efficient orthodontic care for a specific patient if warranted by carefully oriented analytical diagnosis.
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 Saltzman - self correction of malocclusion rarely occurs. - Beginning the t/t in deciduous dentition phase – epitome of dynamic orthodontic approach. - why do orthodontist wait until the permanent dentition has developed to begin corrective orthodontic t/t. - Apprehension because of controversies and misconceptions www.indiandentalacademy.com
Lyman Wagers – prevention and interception are misnomers. Prevention – preorthodntic guidance Interception –corrective orthodontic t/t
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Preorthodontic guidance Patients who have MO in the deciduous or mixed dentition but do not need banded corrective orthodontic t/t until they are in the permanent dentition. Corrective orthodontic t/t. - patients who have MO in the deciduous, mixed or permanent dentition and need immediate skeletal or banded teeth correction. Orthodontists – see many patients in MO in mixed dentition. Two treatment periods – mixed dentition permanent dentition Phase 1 and 2 – Usually 4-6 months interval during the inactive treatment. www.indiandentalacademy.com
Why is there fear for mixed dentition t/t 1. Office management problems – 2. After better incisor alignment and appearance have been done in the first phase – orthodontists -Disservice for the patients – Proper conditioning of the patient and the parent
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 Clinically – Less than 5% of corrective mixed dentition patients undergoing first phase corrective mixed dentition t/t failed to finish their second t/t phase.
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History General rise in the level of consciousness The belief that craniofacial skeleton can be moulded Increased interest not only in correcting existing problems but also in intercepting or modifying abnormal orofacial conditions Increasing competition for the orthodontic patient www.indiandentalacademy.com
Progression of learning
Period of skepticism Period of optimism Period of reality
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Timing of treatment Primary dentition Mixed dentition - early - late Permanent dentition
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Timing of treatment
Most patients treated during early adolescence Late mixed dentition or early permanent dentition Treatment time of approx 24 months Reasons
-Self motivation for treatment -Enough growth remaining -Second molars can be controlled to detail occlusion -Limited duration of treatment –tolerance for patients
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Timing of treatment Stability of the results has been highly variable One stage treatment –gold standard for contemporary care - Profitt To be justified two stage treatment –should offer a clear advantage in esthetic ,developmental ,functional, and trauma prevention www.indiandentalacademy.com
Treatment –primary dentition Advantages Rapid change in skeletal and dental structures Moderate biomechanical forces Significant improvement –with skeletal class II problems
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Disadvantages Continued rapid growth can easily erase the treatment effects unless active retention Child behavior- can be challenging Treatment time longer and more costly
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Indications for early treatment Posterior anterior crossbite benefit from early treatment. Ankylosed teeth – Space maintainers to be used till companion permanent tooth on the opposite side erupts. .
Excessive protrusion and diastema that invite injuries Severe anterior and lateral openbites
– Failure – Life time malocclusion and may require surgery later. Ectopic molars most often found as the maxillary 6 year molars erupt. www.indiandentalacademy.com
Indications for early treatment Cleft lip and palate patients often need early treatment. Pseudo Class III patients that present MO that are more dental in nature than skeletal.
Class III malocclusions – due to true maxillary retrusion
Severe skeletal problems www.indiandentalacademy.com
Early Orthodontic Intervention - Larry White – AJO 1998 Purpose : – To correct obvious problems, – To intercept developing problems. – To prevent obvious problems from becoming worse.
Limitations of early treatment: – For class II malocclusion – caution against early use of appliances that can not rely on the presence of sharply occluded premolars to retain the correction.
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Limitations of early treatment: -Not expand the mandible more than 1mm (Little). - Bimaxillary cases with severe arch length discrepancies Extraction in the permanent dentition more sensible approach. – Early removal of second molars to resolve arch length discrepancy. – Limited by patients whose maturity, mouth size or sensitivity threshold is inadequate for the planned therapy. www.indiandentalacademy.com
Advantages of one phase therapy: To prevent an unnecessarily extended treatment time. To prevent patient burnout. To reduce jeopardy of oral tissues. To allow achievement of specific and limited treatment goal. To avoid becoming a two phase treatment for one small fee. www.indiandentalacademy.com
Changing views-Class II problems Early years of 20th century-pressure against the growing face to change the way it grew Late 1800s- head gear used-reasonably effective Later abandoned – Angle views
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Changing views-Class II problems Class II elasticscause the mandible to position forward and therefore to grow Better correction Guide planes – used to advance the mandible www.indiandentalacademy.com
Changing views-Class II problems Advent of cephalometrics – correction mostly by displacing mand teeth mesially than by stimulating mand growth Undesirable – dental protrusion Unstable- lower incisor crowding www.indiandentalacademy.com
Changing views-Class II problems 1940s –head gear reintroduced-class II treatment Mostly as a tooth moving device 1950s –HG has an effect on maxillary growth Less use of cervical force and more use of straight pull & high pull devices
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Changing views-Class II problems
Europe –development of functional appliances Robins monobloc-1907 Andresens-1930s The idea was forcing the patient to function with lower jaw forward to stimulate mand growth Better resistance to forward displacement of lower incisor Mainstay of european orthodontics- mid 20 th century but rejected in united states www.indiandentalacademy.com
Changing views-Class II problems 1. 2.
1980s – clinical success with functional appliances Response to functional appliances Absolute stimulation Temporal stimulation Ceph analysis- inc mand growth-first months of func.app wear www.indiandentalacademy.com
Changing views-Class II problems
Soft tissue elasticity-head gear effect Affect the maxilla By late 1980s headgear or functional appliance
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Randomized clinical trials
University of north Carolina University of Florida University of pennsylvania Aim – to compare outcome of treatment using either a functional appliance to posture the mandible forward or headgear to restrain maxillary growth, to no treatment
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Results Children treated with headgear or functional appliance had a small but stat significant improvement untreated children did not Children divided into -highly favorable - favorable - no response - unfavorable www.indiandentalacademy.com
Why did some children respond well while others did not Why did some children improve even without treatment Concluded favorable responses –in favorable growth pattern Chances of trauma to incisors –less in treated children www.indiandentalacademy.com
UNC trial –extended into second phase of comprehensive fixed appliance treatment for all the groups Results -Changes in skeletal relationships created during early treatment-were partially reversed by later compensatory growth in the exptl groups -Much of the skeletal diff b/n the former controls and early treatment groups had been lost -PAR scores not diff at the end of phase II www.indiandentalacademy.com
RESULTS No. of control and headgear patients requiring extractions or surgery were quite similar Functional appliance t/t increased –the need for extractions
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Conclusions 1. Skeletal changes are likely to be produced but tend to be diminished or eliminated by subsequent growth 2. Alignment and occlusion are very similar in children who did not have early treatment than those who did 3. Chances of trauma to protruding upper incisors are decreased by early treatment 4. Signs of TMD are reduced by early treatment www.indiandentalacademy.com
5. Its likely that enthusiasm for two phase treatment will diminish in class II problems 6. Two phase treatment-indicated only for children with esthetic complains or a propensity for traumatic injury
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One-phase v/s Two phase treatment Do the benefits of early intervention justify the cost of two phase treatment.
Principle concern – benefit of treatment deciduous early mixed dentition stage compared with the treatment in late dentition or early permanent dentition.
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in the when mixed
Cost of an early treatment time is a two phase protocol. Phase I - generally involves- 6-12 months. Phase II - finishing process after eruption of permanent teeth. www.indiandentalacademy.com
According JCO survey 25% of all patients treated in a two phase manner. 1.3 million people elected treatment. Nearly 3 lakh patients in a two phase treatment. Nearly 9 lakh growing patients – 20-25% adult patients. Essentially 1/3rd of all children are treated in a two phase manner. www.indiandentalacademy.com
 Purpose - Atleast 90% of all growing patients can be treated successfully in one phase by starting treatment in late mixed dentition stage.
-Habit control use of passive appliances and minor alignment of incisors – not considered part of conventional two phase treatment. www.indiandentalacademy.com
The other 5-10% patients – cross bites and Class III malocclusion. CROWDING 100 patients in the mixed dentition stage Models evaluated. 85-100 subjects demonstrated averaged b/w 4-5mm.
crowding
which
62 ptns (73%) of these 85 ptns – sufficient space to align the teeth using leeway space. E-space maintenance can be done effectively by starting t/t in the late mixed dentition. www.indiandentalacademy.com
E space
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In the 100 ptns, non extraction rate would be 77%. When the 15 ptns (no crowding) are included.
In 7 of the remaining 23 ptns the crowding did not exceed 2mm. Whereas in 16 ptns the crowding even after Espace preservation exceeded 2mm. www.indiandentalacademy.com
Lower arch development Treatment at an earlier age to develop a lower arch by passive expansion of the arch. - Lip bumper - Rapid palatal expansion. Results in spontaneous expansion of lower arch. Little et al – largest amount of post retention irregularity – t/t involved more than 1mm of arch length expansion.
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Lip bumper t/t
– after eruption of 1st
premolar. - 1mm arch length increase – 2mm of crowding Hence, would reduce crowding in 7 ptns – with 2mm or lesser crowding. www.indiandentalacademy.com
Would earlier intervention with RPE develop the lower arch sufficiently? Expansion of the intercanine width produces most space than any transverse change.
Germane et al – 1mm of ICE – 0.73mm increase in arch perimeter. 1mm of IME – 0.27mm increase
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Would earlier intervention with RPE develop the lower arch sufficiently? 2 relevant studies Sandstrom et al – 1.1mm post retention increase in mand ICD – 28 ptns after RPE. Atkins et al – 0.8mm lower arch expansion after RPE. Thus, lower ICD will not expand >1mm after RPE.
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Transverse dimension expanded – Actively Lutz and Poulten – evaluated transverse changes – 13 ptns Lower arch expanded in the deciduous dentition. 12 controls. Patients followed for 3 yrs post retention.
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Transverse dimension expanded – Actively  Concluded - No difference in intercanine dimension b/w the groups, indicating total relapse of the t/t gain.
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Summary  84% of the ptns need not be started earlier because most the space can be gain through preservation of the E space.  Stability of procedures that are designed to avoid extractions but developing the arches has not been established.
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Class II malocclusion. If t/t started in the late mixed dentition – 90% of all children treated successfully in one phase. Last b/w 2-3 yrs.
Various methods –
Molar distallization- Class II to Class I in 4-6 months. -Molar moved1-2mm /month during late mixed dentition.
Armstrong – noted 4-7mm of distal movement of molars in pts in LMD. www.indiandentalacademy.com
Class II malocclusion.  Aged dependence related to distal molar movement.  This reinforces that appropriate time to start treating class II malocclusions is LMD.
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Class II malocclusion. Weislander et al  Compared the results of extra oral appliance used in pts in the earlier and late mixed dentition and noted 1mm greater orthopedic effect in younger group.  concluded --Cost of 1mm is two phase treatment which to me is not a useful cost / benefit ratio. www.indiandentalacademy.com
Class II malocclusion. McNamara et al Demonstrated an aged dependent mand growth response with use of FR-2. Divided into 2 groups – <10.5 yrs >10.5 yrs 3.2mm / year growth of mandible in younger group. 4mm/year mandibular growth in older pts. Thus mandibular growth favoured later intervention. www.indiandentalacademy.com
Class II malocclusion. ď&#x201A;§ Weislander and Pancherz -Herbst appliance for 4-6mnts -Was not age dependent.
ď&#x201A;§ Concluded - Mandibular growth does not justify early intervention.
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Class II malocclusion Weislander -intensive phase one treatment in young pts with combined application of extraoral and Herbst appliance. -Protrusions reduce rapidly and profiles straightened. -When evaluated after 8-9 yrs - no statistically difference in mandibular length and forward positioning of the mandible. www.indiandentalacademy.com
Conclusion More than 90% of the pts essentially all t/t goes can be accomplished one phase of t/t and t/t is started in the late mixed dentition stage of t/t.
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Effectiveness of early orthodontic treatment with twin block appliance multicentre RCT-dental and skeletal effects-kevin obrien et al –AJO 03 Aim-evaluate the effectiveness of early orthodontic treatment with the twin block appliance for the developing class II div malocclusion Materials and methods -174 children -8-10 years old -Data collected at the start of the study and www.indiandentalacademy.com 15 months later
Inclusion criteria Minimum of 7 mm overjet Absence of craniofacial syndrome twin block appliance-originally developed by Clark
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Materials and methods ď&#x201A;§ Study models ď&#x201A;§ Cephalometric radiographs
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Results Twin block appliance resulted in substantial reduction in overjet Correction of molar relation ship Reduction in severity of malocclusion Mainly dentoalveolar change and some due to favorable skeletal change
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Results
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Conclusion ď&#x201A;§ This study like similar RCTs suggests that early functional appliance t/t does not on average influence the skeletal class II pattern to a clinically significant degree
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Headgear vs. function regulator in the early treatment of class II div1 mal-RCT-J.Ghafari AJO 1998 et al ď&#x201A;§ Aim :To evaluate the early treatment of class II div1 mo in prepubertal children -Facial and occlusal changes after treatment -Headgear or functional regulator ď&#x201A;§ Materials and methods -Data from 63 children www.indiandentalacademy.com
ď&#x201A;§ Inclusion criteria - Bilateral distoclusion -min ANB of 4.5 -7-12.5/13 yrs-age group -no prior orthodontic treatment
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Straight pull headgear-16hrs/day FR-2 -16hrs/day Results -No significant diff existed b/n the two groups
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Results Improvement in the molar and canine relationship towards neutroocclusion was significant with the HG Overjet correction was larger with FR. The maxillary intercanine distance increase significantly in the HG group compared with the FR group. Arch length and circumference increased with the HG and spacing occurred in the anterior region. www.indiandentalacademy.com
Results ď&#x201A;§ Both the HG and FR are effective in correcting the Class II div 1. MO of prepubertal children. ď&#x201A;§ The common mode of action of this appliance is the possibility to generate differential growth between the jaws.
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Results ď&#x201A;§ On average HG has a distal effect on the maxilla and the first molar but not the maxillary incisors. ď&#x201A;§ FR restrains growth of the maxilla and results in retroclination of maxillary incisors and more forward position of the mandible and proclination of mandibular incisors. ď&#x201A;§ Effect of both the appliances on mandibular length seems to be on average similar. www.indiandentalacademy.com
Results This study also shows that treatment in late childhood can be as effective as that in midchildhood. Thus more practical as it reduces early treatment to the first phase of one stage treatment. Timing of treatment in developing malocclusion may be critical just before loss of the primary second molars. www.indiandentalacademy.com
Treatment timing and outcomeHans pancherz University of Giessen Aim how efficient is early class II div. I t/t compared with later t/t. Par index used Materials & methods – Pre-t/t and post-t/t dental casts of 204 pts treated for class II div. I malocclusion. N=54 – early mixed N=104 – late mixed N=46 – permanent dentition. www.indiandentalacademy.com
Result Duration of t/t decreased progressing dental development.
early mixed dentition – 57mnts. Late mixed = 33 mnts Permanent dentition – 21 mnts. www.indiandentalacademy.com
with
PARscore reduction (improvement) increased with progressing dental development.
PAR scores - Early mixed – 64% - Late mixed – 73% - Permanent dentition – 77%
Pts treated with fixed appliances – 77% Functional appliances – 60% Combination of function and multibracket appliances – 71% www.indiandentalacademy.com
Conclusions ď&#x201A;§ With respect to both duration of outcome, late t/t of class II div. I malocclusion in the perm dentition was more efficient than earlier t/t. ď&#x201A;§ T/t with fixed appliances was more efficient than t/t with removable appliances.
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Functional appliances and their orthopedic effect - Woodside Functional appliances achieve correction of Class II MO through 8 factors. – Dentoalveolar changes. – Restriction of forward growth of midface. – Stimulation of mand growth beyond that which would normally occur in growing children. – Redirection of condylar growth from an upward and forward directedwww.indiandentalacademy.com growth to a posterior direction.
– Deflection of ramal form. – Horizontal expression of mandibular growth from downward and forward to horizontal direction. – Changes in the neuromuscular anatomy and function that would induce bone remodelling. – Adaptive changes in glenoid fossa location to a more anterior and vertical position. www.indiandentalacademy.com
Psychological timing of orthodontic treatment – Jay Weiss- AJO 1977 This study examined the proposition that prepubescent children are emotionally for orthodontic therapy and therefore they carry out instructions more faithfully than adolescents.
Tweed – favoured early treatment. – Young people cooperation is on average infinitely better than that of older patients.
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In agreement with psychoanalytical theory. Early years of life – 5 years – oedipal period – inappropriate for orthodontic treatment. At age 12 – children ready physiologically -Oedipal struggle reawakened. www.indiandentalacademy.com
According to this theory – Between ages of 5 and 12 the oedipal conflict remains dormant.
Methods: Questionnaire mailed to 100 practitioners. Total of 274 patients rated. Conclusions: Patients under 12 were more cooperative than other age groups in wearing of HG and other devices. They were less cooperative in keeping appointments and in protecting appliances from breakage. www.indiandentalacademy.com
Incisor trauma and early treatment for Class II Div. 1 Malocclusion – Lorne D., Camilla Tulloch, AJO 2003 Incisor protrusion, maxillary prominence, Class II Div. 1 MO and lip coverage – identified as predisposing factors – incisor trauma. Overjet >6mm – increased risk of trauma. Orofacial trauma – ranges from enamel crown fractures to complex injuries with reduced prognosis. – Compare the risk of increased trauma for children with treatment started in the mixed or permanent dentition. www.indiandentalacademy.com
Aim of the study – – Describe prevalence extent and severity of incisor trauma in preadolescent children in large overjets. – Compare the incidence of new incisor trauma in children whose growth modification started in the mixed dentition with those whose treatment was delayed until the early permanent dentition.
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Methods: Mean age 9.3 years (range 7.9 to 12.6 yrs) Increased overjet ≥ 7mm were randomly assigned. Clinical trial of two phase early orthodontic treatment. – Phase 1. Children randomly assigned to treatment in the mixed dentition in to three groups. – Modified bionatar. – Combination HG. – No treatment.
Patients evaluated – after 15 months. During the phase II patients again randomized – to receive comprehensive orthodontic treatment in the permanent dentition. www.indiandentalacademy.com
29.1% of patients – incisor trauma already present at the start of the trial. During the trial. – There was a increase in trauma in all the three groups. – But the magnitude of this increase was not significantly greater in the group for which treatment was delayed. www.indiandentalacademy.com
Conclusions: Significant no. of patients had trauma to the maxillary incisors but the injuries were minor. Most of the new injuries were minor- could easily be treated at low cost and good long term prognosis. Early growth modification treatment might have some effect on the incidence of trauma but to be effective it might have to be initiated soon after the eruption of maxillary incisors. www.indiandentalacademy.com
Conclusions: ď&#x201A;§ The expected cost of treatment related to incisor trauma was small compared with the expected additional cost of a two phase orthodontic intervention.
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Preadolescent Class II problems Treat now or wait? – William R. Proffit and Camella Tulloch, AJO 2002 Timing of treatment for Class II MO remains a controversial clinical issue. Optimal time – Difficult to ascertain. Ideally treatment would be provided when its most effective and most efficient. Whether early treatment provides superior results to conventional treatment started in the permanent dentition – www.indiandentalacademy.com
Majority of patients with moderate to severe Class II – have some type of skeletal imbalance. Early treatment to modify growth – might allow subsequent t/t to proceed more quickly or by simpler methods. 3 clinical issues: – Can jaw growth really be modified and if so by how much. – Do different appliances produce different effects. – what impact would early intervention have on subsequent orthodontic treatment. www.indiandentalacademy.com – Would later treatment really be simpler
Methods: Trial study at the UNC between 1988 and 2000. Results:
Can you change growth? Both early treatment methods HG and Modified bionator produced a very similar small mean reduction in the jaw relationship when compared with the controls. 75% of the patients in early t/t group had favourable changes while only 25% of those in the control groups similar findings. www.indiandentalacademy.com www.indiandentalacademy.com
Does early treatment make a difference? Skeletal relationships were measured– Linear – Angular – Positional
ANB angle used. The impact of early t/t is described in terms of the change with skeletal jaw relationship and the proportion of patients with convex profiles at the end of the t/t. www.indiandentalacademy.com
Results: No difference b/w the 3 groups in the ANB angles either at the start or after phase II treatment. The early t/t group experienced an early reduction in the ANB angle during phase I. Not sustained during phase II
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PAR system: – There was approx. the same distribution of success and failures with and without early t/t. – Early t/t had only a very small effect in reducing t/t time. – No difference in the quality of dental occlusion b/w the children who had early t/t and those who did not.
Early t/t did not reduce the percentage of children needing extraction of premolars during phase II t/t nor did it influence eventual need for orthognathic surgery. Early t/t had a very small effect in reducing subsequent time in t/t. www.indiandentalacademy.com
Conclusion: Early treatment was not on the average any more effective that conventional later treatment. In correcting skeletal and dental Class II MO
Not only did early treatment failed to provide any advantage in the final treatment outcome or simplication or subsequent procedures but also it took longer and less efficient. www.indiandentalacademy.com
Conclusion: This should not to be taken to negate early t/t some children. For e.g. – Psychological distress. – Accident prone. – Skeletal maturity is well ahead of the dental development. – Children – both vertical and Class II problems.
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Early Orthodontic Treatment – JCO RoundTable Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Optimum time to treat Class II div. 1
If mand deficient – t/t should coincide with prepuberta l growth spurt. If maxilla prognathic – wait until permanent dentition – Extraction t/t
Late mixed dentition Preservation of E space. Single comprehen sive t/t Non compliant techniques, E.g. maxillary molar distalization – successful. Early t/t – significant maxillary protrusion. Incisor trauma and habits.
During the prepuberal growth spurt
Prepubertal growth spurt – Maxilla prognathic HG – 9-10 yrs age Mandible retrognathic – bionator
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Dr. Phipps
Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Severity of the Class II relationship or of his ANB an issue
Rarely use ANB difference for making a decision to treat early. e.g. Large ANB but compensatin g soft tissues. Extreme overjet valid reason for t/t
Greater the ANB difference more likely to consider treating in the transitional dentition. Second phase – much simpler task of correcting tooth alignment with fixed orthodontic appliances. Most class II cases with large ANB values have both dental and skeletal contributing factors were if the maxilla and the maxillary dental arch are restrained the mandible catches up in its growth.
Full cusp class II molar relation – wait for eruption of the permanent dentition – Greater ANB difference less can orthodontics work alone. HG or surgery Maxilla – normal Mandible – Deficient Non extraction with surgical correction in mid teens.
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Dr. Mallerman
Dr. Phipps Late mixed dentition – If overjet >8mm indicated for early t/t
Dr. Gottlieb
Dr. Sarver
Incisor trauma Does incisor trauma justify early treatment
Incisor fracture can be an additional factor but not an indication of early t/t
Dr. Moskowitz
Dr. Brazones Dr. Mallerman
Dr. Phipps
Asks the patient about negative social factors. Otherwise never recommende d early t/t to prevent incisor fracture
No â&#x20AC;&#x201C; Not criteria for early t/t of most patients
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YES -
Dr. Gottlieb
Other reasons treat incisor protrusions early
Dr. Sarver
Dr. Moskowitz
Dr. Brazones Dr. Mallerman
Dr. Phipps
Varies from individual to individual
Spacing or proclination â&#x20AC;&#x201C; To allow the lower incisors to occlude on the lingual surface of the upper To prevent supraeruption of the lower incisors
Use a herbs for class II correction Hence severe class II will receive an early t/t with Herbst If they relapse second phase with Herbst
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Not a determinant for early t/t Intervene early when the problem is skeletal than when it is dental
Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Is there any greater urgency to treat a unilateral class II div. 1 malocclusio n early
Unilateral Herbst
Subdivision does not compel to treat earlier Mandibular asymmetries â&#x20AC;&#x201C; treatment earlier
Dr. Brazones Dr. Mallerman
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If the maxilla is too for forward unilaterally. The earlier the moloars can be positioned back the better it is If mandibular teeth too far back â&#x20AC;&#x201C; wait for eruption of the majority of the permanent teeth
Dr. Phipps
Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones Dr. Mallerman
Dr. Phipps
Do you treat Class II div. 2 malocclusio n before the full permanent dentition is erupted
Late mixed dentition
Late mixed dentition as in maxillary expansion can be done
Phase I to align upper and lower incisors if needed. Evaluate for head gear and bite plane therapy. Objective is to place upper incisors in more ideal position.
Permanent dentition is erupted. Decompensa te and then use a Herbst.
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If the maxillary buccal segments are too far forward early t/t to convert the molar relation If mandible is too far back postpone the t/t till late mixed or early permanent dentition
Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones Dr. Mallerman
Dr. Phipps
Do you depend on appliance such as Headgear in early t/t
Use headgear less frequently mostly Herbst
YES Headgear is the most pure and time honored force delivery system
YES Use head gear frequently If compliance a problem Other options 1.Extraction 2.Jaw surgery
Rarely used headgear Prefer Herbst
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Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Dr. Phipps
Do you use functional appliances
No removable functional appliances
Use to use but not very keen presenting Functional appliances have short term gains Long term stability compromise d
Donâ&#x20AC;&#x2122;t use mandibular advancing appliances
Use functional appliances at the beginning of the prepubertal growth spurt Girls - 9 yrs Boys â&#x20AC;&#x201C; 10 yrs Shows success of 25-50% reduction in ANB
Only Herbst not any removable appliances.
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Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Over treatment of molar distalizatio n in correcting Class II div. 1 malocclusi on
YES Over correct Do not over IF the the molars correct. diagnosis is YES other than mandibular deficiency.
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Dr. Mallerman
Dr. Phipps
Tend to slightly over treat all corrections including Class II to Class I. Because they are seems to be physiologic recovery in the human body that tempers overall treatment results.
YES
Dr. Gottlieb
Dr. Sarver
Do you try YES to maintain the over correction until phase II started
Dr. Moskowitz
Dr. Brazones
YES Hold it in place with a 2/4 or a headgear to upright roots
No If a patient has good growth pattern the correction does hold during growth.
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Dr. Mallerman
Dr. Phipps
YES
Dr. Gottlieb
Dr. Sarver
What is the Class II div. 1 2 phase treatment plan time
Phase 1 – 9 to 12 months Phase 2 – 12 to 18 months Single phase 27 months
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Phase 1 – 2 phase and 12 months single phase Phase 2- 18 similar time to 24 months
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Dr. Phipps
32 to 40 months for 2 phase 28 to 36 months for single phase
Dr. Gottlieb
Dr. Sarver
What Convention Appliances al Hawley do you use retainer. for the period between phase 1 and phase 2
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Dr. Phipps
IF overjet and class II relationships addressed during phase 1 â&#x20AC;&#x201C; headgear should be used Transverse problems some form of fixed palatal appliance
Lower bonded lingual wire and a maxillary Hawley with the labial wire from lateral to lateral
Skeletal corrections are often stabilized after 6 to 9 months of correction After that no retention is required. Dental correction removable or fixed retainers
Maxillary Hawley and mandibular fixed lingual arch
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Dr. Gottlieb What signals the start of second phase
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Second phase starts after eruption of the permanent dentition including the second molars
Second phase of treatment started just before the patient is ready to loose their second deciduous molars. Take advantage of the leeway space
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Dr. Phipps
Dr. Gottlieb
Dr. Sarver
Dr. Moskowitz
Dr. Brazones
Dr. Mallerman
Dr. Phipps
Do you charge separate fees for two phase
YES
YES
YES
YES
YES
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Efficient Orthodontic treatment timing â&#x20AC;&#x201C; Anthony Viazis, AJO 1995
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