Early vs Late Orthodontic Treatment
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Table of Contents
Introduction Early Rx
Definition Advantages Disadvantages
Phase I Rx
Arch Length Discrepancy Correction
Growth modification
Headgears
Functional appliance
Face Mask
Chin Cup
Open Bite Correction
Serial Extraction Arch Expansion Arch Length Preservation
Eruption Disturbances
Growth Spurts Methods of Analysis Age Growth Pattern Retention & Stability Conclusion
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Introduction
Early vs late the optimal treatment time is still controversial . The only result is now people refer to it as Appropriate treatment time. Mcnamara, Brudon
Early vs late depends on type of malocclusion, treatment response and the viewpoint of the orthodontic practitioner. www.indiandentalacademy.com
ď Ž
Graber, in his textbook, divides orthodontic treatment into three categories: ď Ž
1. Preventive orthodontics which is action taken to preserve and protect the occlusion at a given time. Here we deal with the normal deciduous dentition.
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ď Ž
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2. Interceptive orthodontics which is action taken to intercept a potential or existing early malocclusion in the mixed dentition, and 3. Corrective orthodontics which is the treatment of a definitive malocclusion in the permanent dentition that is no longer amenable to prevention or simple interception. www.indiandentalacademy.com
Early Treatment
“ Treatment started in primary or mixed dentition phase that is performed to enhance the dental and skeletal development before the eruption of permanent dentition. Its purpose is to either correct or intercept malocclusion and reduce the need of time for treatment in the permanent dentition”. S.E. Bishara et al AJO 1998 www.indiandentalacademy.com
Early Treatment
AJODO1997 Nov (523 - 537): Early protrusion reduction–two phase malocclusion correction: A case report R. Don James
There is a difference between early orthodontic treatment and early orthodontic correction. Early treatment does not necessarily mean early correction. a better term for early treatment might be "early management of adverse developmental patterns and problems." www.indiandentalacademy.com
1997 Nov (523 - 537): Early protrusion reduction–two phase malocclusion correction: A case report R. Don James
The "real" correction usually occurs when all the teeth can be placed in their final position with the following objectives accomplished: 1. Esthetic alignment of all the teeth with harmonious arch forms. 2. Functional interdigitation of the teeth within healthy supporting tissues and in harmony with the temporomandibular joints. 3. Proper denture placement in the craniofacial complex for the best soft tissue esthetics and facial balance (think about it . . . for every person, there is one best place for the teeth to be). 4. Stability of the teeth in their new positions. www.indiandentalacademy.com
Disadvantages
1998 Jan (5 - 6): PROCEEDINGS OF THE WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E. Bishara, R. Justus, and T. M. Graber
potential iatrogenic problems that may occur with early treatment such as dilaceration of roots, decalcification under bands left for too long, impaction of maxillary canines by prematurely uprighting the roots of the lateral incisors, impaction of maxillary second molars from distalizing first molars, and patient ”burnout.“ total treatment time is longer when considering the observation period between the two stages.
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Advantages
1998 Jan (5 - 6): PROCEEDINGS OF THE WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E. Bishara, R. Justus, and T. M. Graber
improvement in the patient's self-esteem parent satisfaction, greater ability to modify the growth process, earlier resolution or interception of the developing malocclusion, higher quality, more stable results are achievable,
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Advantages
less extensive therapy, shorter treatment time in the permanent dentition. lesser potential for iatrogenic damage such as tooth fracture, root resorption, decalcification, and periodontal problems. www.indiandentalacademy.com
Advantages
AJODO 1998 Jan (5 - 6): PROCEEDINGS OF THE WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E. Bishara, R. Justus, and T. M. Graber
Intercepts potential developmental problems that in turn improves the stability of the results achieved. Better use of the growth potential, Reduced need for extraction, Better patient compliance, more satisfaction, Better final results. www.indiandentalacademy.com
Advantages
The clinician would have two ”shots“ at solving difficult or complex problems. There will be less need for ”en masse“ tooth movement, torque, and dental compensations in the second phase of treatment. The treatment mechanics in the second phase are simpler, Needs less chair time, Has greater stability. www.indiandentalacademy.com
ADVANTAGES
AJODO 1998 Jan (24 - 28): Early orthodontic intervention Larry White
As suggested by Gianelly, the late mixed dentition offers the best time for intervention for several reasons: • The E space still exists. • Approximately 80% of the patients are still treatable by nonextraction. • The treatment can be completed in one phase.
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Advantages
• • • •
To prevent an unnecessarily extended treatment To prevent patient burnout To reduce jeopardy of oral tissues To allow achievement of specific and limited treatment goals To avoid becoming a two-phase treatment for one small fee. www.indiandentalacademy.com
Phase I Treatment
Growth modification Headgears
Functional appliance Face Mask Chin Cup
Open Bite Correction
Arch Length Discrepancy Correction Serial Extraction Arch Expansion Arch Length Preservation
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Eruption Disturbances
Growth Modification ď Ž
Treatment for Class II or Class III skeletal problems with the intent to alter the unacceptable skeletal relationships by modifying the patients remaining facial growth to favorably change the size or position of the jaws. Textbook of Orthodontics-S.E. Bishara
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Headgears ď Ž
Appliance used in orthodontics to modify growth of the maxilla, distalize maxillary teeth or reinforce anchorage. Textbook of Orthodontics- S.E. Bishara
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Types of Headgears ď Ž
Head gears selected based on:ď Ž
Anchorage location- a highpull headcap will place a superior and distal force on the teeth and maxilla. A cervical neck strap will place an inferior and distal force on the teeth and skeletal structures. When the headcap and neck strap are combined the force direction can be varied by altering the proportion of the total force provided by each component. www.indiandentalacademy.com
Contemporary Orthodontics-Proffit
Types of Headgears ď Ž
Head gears selected based on:ď Ž
Headgear attachment to dentition- The usual arrangement is a facebow to tubes on the permanent first molars.Alternatively a removable appliance can be fitted to the maxillary teeth and the facebow attached to this appliance. Contemporary Orthodontics-Proffit
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Types of Headgears ď Ž
Head gears selected based on:ď Ž
Bodily or tipping movement of the maxilla:Since the center of resistance for the molar is estimated to be in the midroot region,force vectors above this point should result in distal root movement. Forces through the center of resistance of the molar should cause bodily movement, and vectors below this point should cause distal crown tipping. www.indiandentalacademy.com
Contemporary Orthodontics-Proffit
Melsen et al (AJO-1978)
10 patients in two groups selected based on distoocclusion, facial morphology and dental maturity. Kloehn type cervical headgear used. One group with outer bow above occlusal plane and other group outer bow below occlusal plane. Molar correction faster where outer bow bent downward. In both groups maxilla moved downward and backward and mandible rotated posteriorly. www.indiandentalacademy.com
Cook (AJO-1994)
Studied growing patients with cervical headgear. Extrusion of molars beyond normal growth and opening. Rotation of mandible did not occur even in dolicofacial subjects . Cervical headgear produced orthopeadic and dental changes. www.indiandentalacademy.com
Hubbard (AO-1994)
He examined 85 cases of patients treated by Dr. Kloehn. He found that mandibular plane angle did not change. The headgear was effective in controlling Antero-Posterior growth of maxilla however. www.indiandentalacademy.com
Melsen (AJO-2003) ď Ž
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She did a long term study on intermaxillary molar displacement. The first time in the year 1978 and then again 7 years later with patients treated with the Kloehn headgear along with cervical traction. A strong tendency of the molars to return to the class II relationship was demonstrated. www.indiandentalacademy.com
Melsen (AJO-2003)
No evidence that a Class I relationship obtained by extraoral traction was more stable that that obtained by functional or intermaxillary appliances. It was noted, however, that the variation in the vertical development was related more to each patient’s growth pattern than to the force system applied. After cessation of the headgear, intramaxillary displacement of the molars was noted, and the total displacement of the molars did not differ from that of the untreated group. www.indiandentalacademy.com
Meldrum (AJO 1975)
Conducted a primate study on a dental splint, facebow, acrylic helmet and implants. Histologic section showed responses in various sutures
Frontomaxillary Frontozygomatic Zygomaticomaxillary Zygomaticotemporal
Resorption at sutures were observed both in histological section and from decreased distances between implants. Very little vertical growth of the maxilla seen. www.indiandentalacademy.com
Firouz (AJO-1992)
This was a long term study Studied 12 adolescent patients with class II div I malocclusion wearing a high pull headgear with 500 gms of force. There was relative restriction of both horizontal and vertical maxillary growth. www.indiandentalacademy.com
Caldwell (AJO-1984) ď Ž
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Studied 47 patients with full coverage maxillary occlusal splints and orthopaedic headgears. Inhibition of vertical development of the maxilla and lack of change in the mandibular plane with overjet reduction of 4mm when compared with 52 controls. www.indiandentalacademy.com
Result
Maxillary traction can result in restriction of growth clearly shown in animal studies. Choosing appropriate appliances to reach specific human treatment objectives is not a simple matter of showing a force diagram and implementing biomechanical strategy based of calculations. Human data fails to show predictable outcomes and there are considerable inconsistencies in treatment outcomes. www.indiandentalacademy.com
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Growth Modification Devices Future- ? 1940’s-Andresen’s Activator
Present- Twin Block
1990’s- Fixed functional appliance
1980’s- Frankel’s functional regulator
1950’s- Activator Modification
1970’s- Bionator and Modifications
1960’s- Bimmler’s elastic
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How do they work?
Functional appliance therapy accelerates and enhances condylar growth A. B. M. Rabie, T. T. She, and Urban Ha¨ gg, The present study was designed to quantitatively assess the temporal pattern of expression of Sox 9, the regulator of chondrocyte differentiation and type II collagen, the major component of the cartilage matrix during forward mandibular positioning, and compare it with the expression during natural growth. Results showed that the expression of Sox 9 and type II collagen are accelerated and enhanced when the mandible is positioned forward. Furthermore a substantial increase was observed in the amount of newly formed bone when the mandible was positioned forward. No significant difference in new bone formation could be found after the appliance was removed when compared with natural growth. Thus, functional appliance therapy accelerates and enhances condylar growth by accelerating the differentiation of mesenchymal cells into chondrocytes, leading to an earlier formation and increase in amount of cartilage matrix. This enhancement of growth did not result in a subsequent pattern of subnormal growth for most of the growth period; this indicates that functional appliance therapy can truly enhance condylar growth. (Am J Orthod Dentofacial Orthop 2003;123: 40-8) www.indiandentalacademy.com
How do they work? ď Ž
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Replicating mesenchymal cells in the condyle and the glenoid fossa during mandibular forward positioning A. B. M. Rabie, Louise Wong, and Marjorie Tsai, The purpose of this study was to identify and quantify the temporal sequence of replicating mesenchymal cells during natural growth and mandibular advancement in the condyle and the glenoid fossa. The results showed that the numbers of replicating mesenchymal cells during natural growth were highest in the posterior region of the condyle and the anterior region of the glenoid fossa. In the experimental groups, the posterior region had the highest number of replicating cells for both the condyle and the glenoid fossa, with the condyle having 2 to 3 times more replicating cells than the glenoid fossa. The number of replicating mesenchymal cells, which is genetically controlled, influences the growth potential of the condyle and the glenoid fossa. Mandibular protrusion leads to an increase in the number of replicating cells in the temporomandibular joint. Individual variations in the response to growth modification therapy could be a result of the close correlation between mesenchymal cell numbers and growth. (Am J Orthod Dentofacial Orthop 2003;123:49-57) www.indiandentalacademy.com
Activator
AJO-DO 1997 Sep (282 - 286): Predicting functional appliance treatment outcome in Class II malocclusion–a review Susi Barton, Paul A. Cook
CRITERIA FOR CASE SELECTION
1. A well-aligned lower arch. 2. A well-aligned upper arch. 3. A Class I-mild Class II skeletal pattern. 4. Forward posture of the mandible by the patient will give a satisfactory soft tissue profile. www.indiandentalacademy.com 5. A person who is undergoing active growth.
Bionator
Used to Treat Class II div I cases.
AJO-DO 1990 Feb (113 - 120): Mandibular response to orthodontic treatment with the Bionator appliance - Mamandras and Allen
A group of 20 subjects who underwent successful Bionator treatment was compared with 20 subjects who were treated less successfully with the same appliance. Both groups had similar advancements in their bite registrations, as well as similar treatment times and growthprediction parameters. Success was judged not on the final occlusion but on the posttreatment position of skeletal pogonion. The successful group experienced 3.5 mm or more of advancement in skeletal pogonion, whereas the less successful group had less than 3 mm of advancement of this point.
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The results of this study suggest that persons who have small mandibles may benefit more from functional appliance therapy than patients with normal-sized mandibles. The subjects with delayed growth may experience more mandibular development than those with average growth during treatment under the favorable growth environment created by functional appliance therapy. www.indiandentalacademy.com
Bionator
Used to treat open bite cases AJODO 1992 Apr ( Cephalometric changes during treatment with the open bite bionator - Weinbach and Smith)
The results of the present investigation confirm that the open bite bionator can assist in the correction of a Class II malocclusion while not leading to bite opening, and often decreasing the open bite tendency. www.indiandentalacademy.com
Bionator
Used to treat Class II div II malocclusions AJODO 1990 Feb (106 - 112): Correction of Class II, Division 2 malocclusions through the use of the Bionator appliance: Report of two cases - Rutter and Witt
The correction of two Class II, Division 2 malocclusions during the mixed dentition phase with the use of a Bionator appliance is presented. The suggestion that correction of Class II, Division 2 malocclusions may be achieved in the absence of fixed appliances is supported in these case reports. www.indiandentalacademy.com
Bionator
Used to treat Class III malocclusion AJODO 1998 Jul (40 - 44): Skeletal and dental modifications produced by the Bionator III appliance Giovanna Garattini, Luca Levrini.
The therapeutic results of a functional orthopedic treatment with a Balters' Bionator III appliance were evaluated. The sample group included 39 white growing subjects with a dentoskeletal Class III malocclusion. A 2-year study compared results with a control group. The results showed that the Bionator III is effective, especially when the malocclusion is mainly the result of a midfacial deficiency and when there is a hypodivergent growth pattern. www.indiandentalacademy.com
(AJO-1998)
Observation
Conducted by King, Keeling et al Used 325 subjects with class II malocclusions. All subjects examined at 9 years of age.
Headgear +bite plate Restricts maxilla and disoccludes mandible allowing it to express full growth
Bionator Mandible positioned forward
After 20 months a reducedwww.indiandentalacademy.com class II molar relationship was seen and improved apical base relationships
University of North Carolina(AJODO 1997)
It was a prospective long term study. It had an almost ideal research design. Conducted by Drs. Camilla Tulloch and William Proffit All subjects were children with overjet of 7mm
PHASE I Observation
Randomized Functional Appliances
Headgear
End of Phase I in 15 months
Retention Phase for 1 year
Assigned to four different orthodontists for phase II www.indiandentalacademy.com
University of North Carolina(1997-2004) Results
There was no difference between the groups with regard to ANB angle either at the start or after phase II of treatment. No difference in the quality of dental occlusion between the children who had early treatment and those who did not. There was approximately the same distribution of success and failure with and without www.indiandentalacademy.com early treament.
University of North Carolina(AJODO 1997) Results
Early treatment did not reduce the number of children needing extraction of premolars or other teeth during phase II of treatment. Early treatment did not reduce the eventual need for orthognathic surgery. There was little influence on the time duration that both groups spent wearing fixedwww.indiandentalacademy.com appliances.
University of North Carolina(AJODO 1997) Results
Early treatment did reduce severity of class II malocclusion. Overjet did decrease in the treated groups whether the appliance was a headgear restricting the maxilla or a functional one positioning the mandible forward. Still doubt whether early treatment is better or not as long as treatment is provided at some point in time. www.indiandentalacademy.com
University of Florida (AJO 2003)RESULTS ď Ž
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Part two of initial study where phase two treatment was undertaken. There were no significant differences in the final PAR score when patients who wore a headgear or bionator as a retention appliance between phase I and II were compared with patients who did not wear any appliances and went straight to fixed appliance therapy www.indiandentalacademy.com
University of Florida (AJO 2003)RESULTS ď Ž
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Most of the changes in PAR scores came from finished results achieved regardless of protocol or initial severity of malocclusion. Patients who underwent two phase orthodontic treatment do not achieve better results than patients who undergo one phase therapy in permanent dentition. www.indiandentalacademy.com
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Frankel
Frankel 1 – Class 1 malocclusion, Class 2 div1 malocclusion. Frankel 2 – Class 1 malocclusion, Class 2 div 1 malocclusion, Class 2 div 2 malocclusion. Frankel 3 – Class 3 malocclusion + skeletal open bite. Frankel 4- Open bite, Bimaxillary protrusion www.indiandentalacademy.com
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University of Pennsylvania (AJO1998) Conducted by Ghafari et al to check effectiveness of appliances in class II corrections
Frankel
Headgear
Restricted maxillary growth and retroclined maxillary incisors
Distalization effect on maxilla and maxillary 1st molars No significant difference on mandible with frankel or headgear www.indiandentalacademy.com
Frankel
1983 Jul (54 - 68): Functional approach to treatment of skeletal open bite - Fränkel and Fränkel
A comparison of a series of lateral cephalograms of thirty patients with skeletal open bite who were treated with functional regulators developed by Fränkel and those of eleven untreated open bite cases suggests that some dentofacial deformities in the skeletal open bite cases can be corrected to the average norms. In addition, as a result of overcoming the poor postural pattern of the orofacial musculature and re-establishment of a competent lip seal, a considerable change in the soft-tissue profile occurred. www.indiandentalacademy.com
Functional Regulator(EJO-2004)
Conducted by Almaida using 44 patients
22 control
22 treated
•No significant restriction of maxillary growth. •1.1 mm increase in mandibular length and this could have happened even without the appliance.
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Twin Block ď Ž
Used in Class II div I occlusions by moving it into a Class III. Orthodontics & Dentofacial Orthopedics-McNamara Brudon
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Lund and Sandler (AJO1998)
Conducted research on the twin block appliance. 36 treated cases compared with 27 untreated cases. Treated cases demonstrated increase in mandibular length. No effect on maxillary skeletal growth. There was distal movement of molars. Mesial movement and superior eruption of molars www.indiandentalacademy.com Tipping of anterior teeth in both arches.
Trenouth (EJO2002)
This was a long term prospective study. Found that twin block allows vertical correction of the buccal segment along with dentoalveolar correction. Increase in anterior and posterior facial height. No significant increase in mandibular length and most of the change due to mandibular position. www.indiandentalacademy.com
O’Brien (AJO2003)
Multi-centric randomized controlled clinical trial. Treated 174 patients with a twin block and another 174 were observed. Patients were matched for age, sex and severity of malocclusion. The final analysis showed that the twin block does not affect skeletal class II malocclusion. www.indiandentalacademy.com
Face Mask ď Ž
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AJO-DO 1998 Nov (492 - 502): Assessment of skeletal and dental changes by maxillary protraction Sang J. Sung, DDS, MSD, and Hyoung S. Baik, DDS, ... The principle of maxillary protraction is to apply tensile force on the circumaxillary sutures and thereby stimulate bone apposition in the suture areas; in doing so, the maxillary teeth become the point of force application, and the face (forehead, chin, zygoma) or occipital area becomes the anchorage source. In animal and biomechanical studies, histologic changes and stress distribution in suture areas strongly suggest the application in human subjects. www.indiandentalacademy.com
Face Mask ď Ž
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JCO 1991 Feb(102 - 113): Maxillary Protraction Therapy: Diagnosis and Treatment - JOHN H. HICKHAM,
Orthopedic effects require greater forces than orthodontic movements. Maxillary sutural protraction generally requires 600-800g per side, depending on the patient. To move the maxillary anterior teeth forward, 400g per side is adequate. Forward movement of lower molars requires 500-600g per side. www.indiandentalacademy.com
Face Mask
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Advantages of Face Mask
Source: AJO-DO on CD-ROM (Copyright © 1998 AJO-DO), Volume 1988 May (388 394): Use of face mask in treatment of maxillary skeletal retrusion - Roberts and Subtelny if treatment to promote maxillary development is implemented in the mixed or early permanent dentition before the peak pubertal growth, the need for orthognathic surgery may be eliminated. www.indiandentalacademy.com
Advantages of Face Mask ď Ž
ď Ž
AJO-DO 1998 Nov (492 - 502): Assessment of skeletal and dental changes by maxillary protraction Sang J. Sung, Hyoung S. Baik,.
The effects of maxillary protraction that are seen on the lateral cephalogram include forward and downward movement of the maxillary bone and dentition, lingual inclination of mandibular teeth, and downward and backward rotation of the mandible. These effects tend to turn Class III malocclusion into Class I occlusion and produce an orthognathic profile in a short www.indiandentalacademy.com
Advantages & Disadvantages of a Face Mask ď Ž
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JCO 1991 Feb(102 - 113): Maxillary Protraction Therapy: Diagnosis and Treatment - JOHN H. HICKHAM,
The facial mask is the easiest protraction device to fit, but is easily dislodged by a restless sleeper.
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Disadvantages of face mask ď Ž
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1998 Nov AJODO (492 - 502): Assessment of skeletal and dental changes by maxillary protraction Sung, and Baik
whether maxillary protraction can actually stimulate growth is still obscure, and questions have been raised as to the orthopedic effect in prepubertal or pubertal subjects.
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Disadvantages of face mask
JCO 1988 May(314 - 325): Orthopedic Correction of Class III Malocclusion with Palatal Expansion and Custom Protraction Headgear - PATRICK K. TURLEY
Class III malocclusions experience latent growth and a return to pretreatment conditions. Compromised results can also be due to poor patient cooperation, since orthopedic appliances for Class III treatment can be uncomfortable and unesthetic. Another factor may be practitioners' lack of experience in managing Class III malocclusions in postgraduate training and in practice. Class III cases make up only about 5% of the orthodontic population. www.indiandentalacademy.com
Face Mask Research
AJODO 1998 Apr (453 - 462): Profile changes in patients with class III malocclusions after Delaire mask therapy Hülya KiliçoJlu,.
The purpose of this study was to make a detailed evaluation of hard and soft tissue changes after Delaire orthopedic mask therapy .The following results were obtained: (1) After maxillary protraction, the maxilla was displaced anteriorly, whereas the mandible rotated posteriorly; (2) the maxillary incisors moved in the anterior direction, whereas the mandibular incisors moved posteriorly; www.indiandentalacademy.com
Face Mask Research
(3) the mandibular plane angle and anterior lower and total face heights increased; (4) these changes were reflected in the profile, whereby the skeletal profile convexity increased. (5) the Class III concave profile became more balanced, with the upper lip area becoming more marked. www.indiandentalacademy.com
Face Mask Research
AO 1994 No. 2, 145 - 150: Face mask therapy of preadolescents with unilateral cleft lip and palate P. H. Buschang, C. Porter, E. Genecov, D. G...
This study evaluates 21 children treated with maxillary expansion and protraction appliances for skeletal discrepancies associated with unilateral cleft lip and palate The subjects were treated by the same orthodontist, using the same techniques and appliances. Mean preand posttreatment ages were 7.3 and 8.7 years, respectively. We conclude that differences between the control and UCLP groups are primarily related to mandibular clockwise rotation and secondarily to anterior maxillary repositioning.
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Face Mask Research
The results showed definite protraction of the maxilla for the UCLP group. The posterior maxilla of the UCLP group underwent anterior displacement; the posterior maxilla of the control group displayed posterior growth changes. The maxillary incisor tips of the UCLP group demonstrated greater anterior movement than expected for untreated controls. Vertical changes of the maxilla showed no significant group differences. www.indiandentalacademy.com
The mandible of the UCLP group was rotated inferiorly and posteriorly; the control group showed inferior/anterior changes. The lower incisor of the UCLP and control groups remained stable and moved anteriorly, respectively. The UCLP group showed significantly greater inferior movements of the anterior mandible than the control group. www.indiandentalacademy.com
Chin Cup
“A restraining device which inhibits the growth of the mandible, at least preventing it from projecting forward as much as otherwise would have occurred” Contemporary Orthodontics-Proffit
Chin cup therapy primarily works on the hypothesis that a force directed through the condyles will inhibit as well as redirect the condylar growth. 1980 Aug-Nanda www.indiandentalacademy.com
Advantages of Chin Cup ď Ž
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Changes direction of mandibular growth by rotating the chin downwards and backwards. Lingual tipping of lower incisors as a result of pressure of appliance on lower lip and dentition. Contemporary Orthodontics-Proffit
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Disadvantages of chin cup ď Ž
Cannot be used in patients with excessive LAFH. Contemporary Orthodontics-Proffit
ď Ž
This therapy alone may not be indicated for a fair percentage of patients in skeletal Class III who show a small midfacial bone or a retropositioned maxilla with relatively normal mandibular dimensions. 1980 Aug-Nanda
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Chin Cup Research ď Ž
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AJO-DO 1980 Aug (125 - 139): A modified protraction headgear - Nanda Appliances resembling chin cups have been in use since the early 1800's. According to Graber, the early attempts with the chin cup were not successful because of incomplete knowledge of mandibular and facial growth, its use on nongrowing patients, and an inadequate understanding of the forces generated by the chin cup. www.indiandentalacademy.com
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Armstrong applied 500 Gm. of force via chin cups on 100 adolescent patients with mandibular prognathism. He reported that half of his patients showed improvement in the Class III profile, whereas none of the control, nontreated patients showed any favorable change.
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Thilander treated sixty patients with chin cups for 1 to 6 years. A significant percentage of patients did not improve. The patients who showed improvement were comparatively young and showed favorable dental changes. The force generated by the chin cup in his study was only 150 to 200 Gm. www.indiandentalacademy.com
Chin Cup Research ď Ž
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Graber, Chung, and Aoba reported results in patients treated with chin cups for 12 to 14 hours each day with a force of 1.5 to 2 pounds on each side. They showed that mandibular growth could be redirected with a chin cup. They asserted that continuous use of the appliance for a long period or through active growth was necessary to achieve stable results. Graber treated 35 Class III malocclusions in children between the ages of 5 and 8 years with chin cup therapy for 3 years. He found that the therapy was particularly effective in patients with increased vertical growth of the face. www.indiandentalacademy.com
Mitani (AJODO 2002)
Did some work with the chin cup. Found that first 2 years of chin cup therapy produces more changes. If chin cap therapy is stopped before complete facial growth the decreased pressure cause increased condylar growth. Chin cap should be worn at night as the condyle should be still when compressive force is applied. Chin cap therapy seems to enhance forward growth of maxilla maybe by correcting malocclusion. Chin cup must be worn till growth completes. www.indiandentalacademy.com
Phase I Treatment
Growth modification Headgears
Functional appliance Face Mask Chin Cup
Open Bite Correction
Arch Length Discrepancy Correction Serial Extraction Arch Expansion Arch Length Preservation
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Eruption Disturbances
Open Bite ď Ž
Condition in which the incisal edges of the upper and lower incisors do not overlap. Textbook of Orthodontics-S.E. Bishara
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Sanky et al (AJODO 2003)
Retrospective cephalometric study 38 patients around 8.2 years.Control group matched for age, sex and mandibular plane angle. The subjects who entered the study with open bites exhibited an average 2.7mm reduction in overbite. www.indiandentalacademy.com
Sanky et al (AJODO 2003) ď Ž
Found that there was no significant differences for those who wore a chin cup and those who did not.
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Phase I Treatment
Growth modification Headgears
Functional appliance Face Mask Chin Cup
Open Bite Correction
Arch Length Discrepancy Correction Serial Extraction Arch Expansion Arch Length Preservation
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Eruption Disturbances
Arch Length Discrepancy
AJO-DO 1988 Jul (50 - 56): Dental crowding - Radnzic Nance described dental crowding as the difference between the space needed in the dental arch and the space available in that arch— that is, the space discrepancy. www.indiandentalacademy.com
Serial Extraction
“Procedure used when a patient is diagnosed with a class I malocclusion and a severe tooth size arch length discrepancy of 8-10mm or greater during the early mixed dentition that involves the removal of primary canines and first molars first, followed by extraction of first premolars once they are visible.” www.indiandentalacademy.com
Textbook of Orthodontics S.E. Bishara
Serial Extraction
“Removal of deciduous teeth to achieve a better alignment of the permanent teeth”. Orthodontics:Principles & Practice T.M. Graber
“Involves the timed extraction of primary and ultimately permanent teeth to releive severe crowding”. Contemporary Orthodontics-William Proffit www.indiandentalacademy.com
Serial Extraction Criteria
Source: AJO-DO on CD-ROM (Copyright © 1998 AJO-DO), Volume 1954 Dec (906 - 926): Serial extraction in orthodontics: Indications, objectives and treatment procedures - Dewel -------------------------------conditions that show so little promise of potential development that an early decision should be made on some form of compromise treatment. Conditions characterized by shortened arches, blocked-out or malposed incisors, a shift in the median line, and frequently early loss of one or both of the mandibular deciduous cuspids. Facial contours and dental appearance are still acceptable; esthetics has not yet become a problem.
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The molars usually retain a Class I relation. In these cases the maxillary and mandibular incisors are vertical, over apical base, and present a reasonably normal overjet and overbite. Other cases may be protrusive with poor skeletal patterns and disturbed facial musculature, and still others are potential Class II malocclusions. www.indiandentalacademy.com
Serial Extraction Criteria
Serial Extraction applies to patients who meet the following criteria:No Skeletal disproportion Class I molar relationship Normal Overbite Large arch perimeter deficiency. Contemporary Orthodontics-William Proffit www.indiandentalacademy.com
Serial Extraction Procedure
Extraction of primary lateral incisors as the permanent central incisors erupt. Extraction of primary canines as the permanent laterals erupt. Extraction of primary first molars, usually 612 months before their normal exfoliation at the point when underlying premolars have one half to two thirds of their roots formed. Extraction of permanent first premolars before eruption of permanent canines. Contemporary Orthodontics-William www.indiandentalacademy.com
Proffit
Serial Extraction Procedure
AJO-DO 1969 Jun (87 - 93): Prerequisites in serial extraction Dewel
correction by serial extraction are accomplished in three separate stages for three separate purposes:
(1) premature extraction of the deciduous canines provides the space for the incisors to assume normal positions in an even alignment directly over supporting bone;
(2) subsequent extraction of the first deciduous molars permits the desirable early eruption of the first premolars;
(3) the final extraction of the first premolars makes it possible for the canines to erupt in a favorable direction into the spaces formerly occupied by the first premolars. The interval between extractions varies from 6 to 15 months.
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Advantages of Serial Extraction
AJO-DO 1954 Dec (906 - 926): Serial extraction in orthodontics: Indications, objectives and treatment procedures - Dewel Growth once lost cannot be regained, but delayed treatment with periodic observation enables the orthodontist to determine developmental trends which, if favorable, provide the necessary diagnostic information to return to standard ideal treatment methods when indicated. By judicious serial extraction in cases with an unfavorable outlook, eruption of the remaining permanent teeth in a desirable direction is encouraged and the severity of individual tooth malpositions is reduced. Eliminates excessive stress on dental anchorage units and shortens the period of active treatment for cases that fall in this category. It also reduces the necessity for prolonged retention and often eliminates it entirely. www.indiandentalacademy.com
Disadvantages of Serial Extraction
AJODO 1955 Nov (819 - 826): The significance of early loss of deciduous teeth in the etiology of malocclusion - Lundström
it is particularly the earlier extractions that contribute to the development of crowding.
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Serial Extraction Research
Little- cases treated with serial extraction when compared with those treated with premolar extraction in full permanent dentition showed identical results. 1 in 3 cases considered success at 10 years post retention. Conclusion- Serial extraction of deciduous teeth to temper a developing arch length followed by premolar extraction and routine treatment yields no long term improvement over premolar extraction in permanent dentition and routine treatment. Long term retention must be a part of premolar extraction strategy whether teeth are extracted in mixed or full www.indiandentalacademy.com dentition. Little
Serial Extraction Research ď Ž
University of Washington- 4 studies
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Arch Expansion
“Can be used to correct transverse and sagittal crossbite problems and to provide sufficient arch space to resolve borderline crowding in some mixed dentition patients”. McNamara-AJODO 2002
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Arch Expansion Procedures
“The most aggressive approach to early expansion uses maxillary and mandibular removable lingual arches in the complete primary dentition”. “A less aggressive approach in terms of timing is to expand the upper arch in early mixed dentition using a lingual arch to produce dental and skeletal changes.” “Another alternative is to use a functional appliance that incorporates lip and buccal shields or a lip bumper”.
www.indiandentalacademy.com Contemporary Orthodontics-William
Proffit
Arch Expansion Procedures
A combination of maxillary lingual arch appliances to rotate upper molars; headgear, sometimes supplemented by fixed or removable appliances to distalize upper molars; and a mandibular lip bumper to increase lower arch dimensions by moving incisor and buccal segments facially and lower molars distally.” Finally arch expansion can be obtained by aligning the anterior teeth with bonded attachments and archwires”. www.indiandentalacademy.com Contemporary Orthodontics-William
Proffit
Arch Expansion Procedures
Placement of TPA and Lingual arch to take advantage of leeway space of 4mm in maxilla and 5mm in mandible. Orthopeadic expansion of the maxilla with RME. McNamara-AJODO 2002
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Arch Expansion Procedures
AJO-DO 1991 Nov (421 - 427): Increase in arch perimeter due to orthodontic expansion - Germane, Líndauer, Rubenstein, Revere, and Isaacson
Various appliance systems have been advocated for achieving this goal. The types of tooth movement they can effect are dependent on the force systems produced. Numerous appliances, including the quad-helix and rapid palatal expanders, for example, apply lateral forces to the molars and therefore cause widening of the posterior dental arch. Other mechanisms, such as the utility arch, may be adjusted to effect primarily incisor advancement. Combinations of types of expansion can be achieved by a variety of appliances, including the function regulator, the lip bumper, removable expanders, and fixed appliance systems. www.indiandentalacademy.com
Advantages of Arch Expansion
AJO-DO 1991 Nov (421 - 427): Increase in arch perimeter due to orthodontic expansion - Germane, Líndauer, Rubenstein, Revere, and Isaacson
Orthodontic expansion can cause increases in arch perimeter and is therefore sometimes used for the correction of dental crowding www.indiandentalacademy.com
Disadvantages of Arch Expansion
“Early expansion with both functional appliance components (including the lip bumper) and/or fixed appliances has three major limitations: the long duration of treatment from the primary or early mixed dentition through the eruption of permanent teeth ; the possibility of creating unaesthetic dentoalveolar protrusion; and the uncertain stability of the long term Contemporary Orthodontics-William Proffit outcome”. www.indiandentalacademy.com
Arch Expansion Research ď Ž
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McNamara et al- Haas RME with fixed therapy produced 5-6mm arch perimeter increase in maxillary arch and 6mm in mandibular arch. Geran et al- Bonded acrylic splint expander followed by Phase II Rx maxillary arch perimeter post Rx 3.8mm greater in treated group and mandibular 2.6mm. www.indiandentalacademy.com
Arch Expansion Research
Little – 26 cases with 6 years post retention records all showed high degree of relapse and showed that expansion was the worst of space gaining strategies. Conclusion” Without lifetime retention the strategy of arch development will yield unacceptable results. Little AJODO 2002 www.indiandentalacademy.com
Arch Length Preservation ď Ž
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Arch Length is the distance around the arch from the most distal surface on the last tooth on one side through the region of the interproximal contacts to the most distal surface on the opposite side. It may and does change during the growth period. Arch length actually decreases in the mandibular arch during the growth period. Text book of orthodontics (S.E.Bishara)
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Arch Length Preservation Procedures ď Ž
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lip bumper and rapid palatal expansion (RPE) treatment to induce spontaneous expansion of the lower arch as the maxillary arch widens. placement of a passive lingual arch to preserve arch length when a deciduous canine is lost prematurely. 1995 Nov Gianelly www.indiandentalacademy.com
Arch Length Preservation Procedures ď Ž
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Band and Loop maintainers are used most frequently to maintain the space of a primary first molar before eruption of the permanent first molar. It can also be used to maintain the space of either a primary first or second molar after the permanent first molar has erupted. Partial denture space maintainers are most useful for posterior space maintenance when more than one tooth has been lost per segment and the permanent incisors have not yet erupted. Distal shoe space maintainers are the appliance of choice when a primary second molar is lost before eruption of the permanent first molar. www.indiandentalacademy.com Contemporary Orthodontics-William Proffit
Advantages of Arch Length Preservation ď Ž
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AJODO 1995 Nov (556 - 559): One-phase versus two-phase treatment Gianelly
The leeway space can provide adequate space to accommodate an aligned dentition in the vast majority of patients. For example, an evaluation of the mandibular models of 100 patients in the mixed dentition stage of development revealed that 85 of the 100 subjects demonstrated crowding, which averaged between 4 to 5 mm. However, 62 (73%) of these 85 patients with crowding had sufficient space to align the teeth when the leeway space gain was included in the analysis. Thus, crowding can be resolved in 73% of patients with crowding in the mixed dentition stage of development simply by preserving and using the leeway space. www.indiandentalacademy.com
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(Since the combined mesiodistal diameters of the deciduous canine and first molar are essentially the same as the mesiodistal diameters of the permanent canine and first premolar, the space gain, in actuality, represents the "E" space.) Maintaining the "E" space can readily be accomplished by starting treatment in the late mixed www.indiandentalacademy.com dentition stage.
Arch Length Preservation Research
AJO-DO 1997 Oct (449 - 456): Lower arch perimeter preservation using the lingual arch Joe Rebellato, Steven J. Lindauer
The purpose of this investigation was to determine whether the placement of a mandibular lingual arch maintained arch perimeter in the transition from the mixed to the permanent dentition, and if so, whether it was effective at preventing mesial migration of first permanent molars, or whether this migration still occurred en masse, by increased lower incisor proclination.
Statistically significant differences between groups were found for positional changes of mandibular first molars and incisors, and changes in arch dimensions.
The results indicate that the lingual arch can help reduce arch perimeter loss, but at the expense of slight mandibular incisor proclination. www.indiandentalacademy.com
Arch Length Preservation Research ď Ž
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According to Ann Arbor standards,3 -4 mm of space is typically available in the maxillary arch and 5 mm in the mandibular arch during the exchange of the second deciduous molars and the second premolars. We routinely place a transpalatal arch before the maxillary second deciduous molars are lost (90% of patients), and we use a mandibular lingual arch if conservation of the leeway space is necessary in the mandible. McNamara-AJODO 2002 www.indiandentalacademy.com
Phase I Treatment
Growth modification Headgears
Functional appliance Face Mask Chin Cup
Open Bite Correction
Arch Length Discrepancy Correction Serial Extraction Arch Expansion Arch Length Preservation
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Eruption Disturbances
Eruption Disturbance ď Ž
Teeth emerging significantly outside the specified time ranges should be considered as abnormal and indicative of some fault in eruptive movement. Orban’s Oral Histology
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Etiology: Eruption Disturbances
Systemic:
Nutritional deficiencies Genetic defects Endocrine deficiencies
Local
Premature loss of deciduous dentition Trauma to dental follicle Cysts of developing tooth germ Ankylosis www.indiandentalacademy.com
Orban’s Oral Histology
Kurol (AJO 2002)
Ectopic eruption can be handled with 2 phase treatment and should be handled early due to chances of resorption in central incisor roots. Early extraction of 46 palatally placed deciduous canines was done in people age 10 to 13. The permanent canine in 78% of the cases normalized after the extraction. This reduced the need for orthodontic treatment later on. Power et al found the same thing in their study (BJO 1993) www.indiandentalacademy.com
Kurol (AJO 2002)
Mesiodens can be handled with 2 phase treatment but author is against it due to possible pathology to developing central incisors. In rare cases with spontaneous eruption the mesiodens can be extracted with little damage to the to permanent incisor roots. Author has not prescribed removal of mesiodens for last 20 years. www.indiandentalacademy.com
Kurol (AJO 2002)
Ankylosis or impaction can be handled with 2 phase treatment. Prospective clinical trial performed with extraction of ankylosed deciduous 1st molars, Molar on one side extracted on the other side left to shed normally. In most cases there was no difference between the two side but in some cases there was space deficiency. Therefore space maintainers should be considered. www.indiandentalacademy.com
Nutritional Deficiencies ď Ž
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Regional differences in tooth and bone development - Mappes, Harris, and Behrents
less tangible effects, such as climate, nutrition and socioeconomic levels, and urbanization, may also influence the rates of maturation. AJODO 1992 Feb
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Genetic Deficiencies ď Ž
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AJO-DO 1957 Dec (891 - 918): A critical anaylsis of orthodontic concept and objectives - Wilson A study of family histories and monozygotic twins provides ample proof that many factors are directly attributable to genetic causes. For example, tooth size and shape and eruption schedule are clearly so. Likewise, congenitally missing teeth Which are of genetic and not congenital origin run clear-cut family histories. Missing maxillary lateral incisors are perhaps the most common, with mandibular second premolars running next. These are obviously due to the action of a dominant gene, which is sometimes sex linked. One can find this characteristic running throughout family histories for several generations. The so-called peg lateral incisor is an incomplete expression of that dominant gene.
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Endocrine Deficiencies ď Ž
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Disturbances in the development of the upper jaw and the middle face (Part I) - Korkhaus
The fact that the lower skull is frequently accompanied by further degenerative disturbances in development arouses the suspicion that endocrine causes, primarily the hypophysis, are at least partly responsible. It is possible that this endocrine factor is secondary as a result of hereditary factors. AJO-DO 1998, Nov (848 - 868) www.indiandentalacademy.com
Endocrine Deficiencies ď Ž
Influence of growth hormone on tooth formation Ito, Vig, Garn, Hopwood, Loos, Spalding, Deputy, and Hoard
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A matched control sample for tooth development was derived from untreated children. Tooth formation was initially delayed although the degree of reduction in stature exceeded the initial degree of delay in tooth formation. During this 2-year study, rhGH therapy had a significant influence on acceleration or gain in stature, but did not have a significant influence on tooth formation. (AM J ORTHOD 1993;103:358-64.)
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Premature loss
AJODO 1955 Nov (819 - 826): The significance of early loss of deciduous teeth in the etiology of malocclusion - Lundström The results suggest that it is particularly the earlier extractions that contribute to the development of crowding. It is evident also that, even in such cases, it is not infrequent that normal spacing conditions eventually may be obtained. The reduction in normal spacing for the whole dental arch after extractions at 7 or 8 years of age appears to be about 22 per cent in the upper arch and 13 per cent in the lower. Otherwise expressed, it seems as if about one-third of the patients develop crowding in the maxilla and about one-fourth in the mandible as a result of such extractions. www.indiandentalacademy.com
Trauma
Incisor trauma and early treatment for Class II Division 1 malocclusion Lorne D. Koroluk, J. F. Camilla Tulloch, and Ceib Phillips
This study investigated incisor trauma in children with overjets greater than or equal to 7 mm who were enrolled in a clinical trial of 2-phase early orthodontic treatment for Class II malocclusion. In phase 1, children were randomly assigned to treatment in the mixed dentition with either modified bionator or combination headgear or to a group in which treatment was delayed until the permanent dentition.
(Am J Orthod Dentofacial Orthop 2003;123:117-26)
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At the start of the trial, 29.1% of the patients had already had some incisor trauma. This was not significantly related to dental developmental age. During the trial, there was an increase in trauma in all 3 groups, but the magnitude of this increase was not significantly greater in the group for which treatment was delayed until the permanent dentition. This might suggest that orthodontic intervention aimed at reducing trauma should begin very soon after the eruption of the maxillary incisors. However, the injuries tended to be minor, and the expected cost of treatment related to incisor trauma was small compared with the expected additional cost of a 2-phase orthodontic intervention.
(Am J Orthod Dentofacial Orthop 2003;123:117-26)
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Dentigerous Cyst ď Ž
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AJO-DO 1992 Sep CASE REPORT - Sain, Hollis, and Togrye
Diagnostic records revealed impacted and displaced teeth resulting from a large radiolucent lesion. The patient was referred to an oral surgeon. The lesion was diagnosed as a dentigerous cyst and marsupialized over 12 months. After decompression of the cyst, the impacted teeth were exposed and orthodontically brought into their proper position. www.indiandentalacademy.com
Ankylosis
AJODO 1998 Jan (24 - 28): Early orthodontic intervention Larry White Ankylosed teeth are another mixed dentition problem that needs orthodontic therapy because it seldom self-corrects. It is probably best not to treat this condition too early because space maintenance will usually be needed for several months or even years. By the time the companion permanent tooth on the opposite side of the mouth is ready to erupt, the ankylosed tooth should be extracted and the underlying permanent tooth uncovered if necessary. www.indiandentalacademy.com
Growth Spurt ď Ž
Acceleration in the incremental changes in a body that occurs at a certain age. Textbook of Orthodontics-S.E. Bishara
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"A spurt was defined as a growth acceleration up to a maximum, where the annual amount of growth exceeded the previous one by at least 0.7mm". Ekstrom(1982)
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Growth Spurts- Influences ď Ž
Our best clue to change in this period lies in evaluating the family's hereditary pattern where reasonably informative comparisons can be made between mother-daughter and father-son. Sistersister is less reliable and brotherbrother the least. www.indiandentalacademy.com
GROWTH SPURTS: Influences
JCO 1971 Apr(191 - 199): Treatment Timing Onset or Onslaught? - HARRY G. BARRER. Growth and maturation move on a curve of spurts that vary in time and amount because they are influenced by ethnic and racial factors, family characteristics, sex, deprivation, and even socio-economic background. During puberty, growth is greater than at any other period except infancy. www.indiandentalacademy.com
GROWTH SPURTS: Influences
JCO 1971 Apr(191 - 199): Treatment Timing Onset or Onslaught? - HARRY G. BARRER, D
Sex offers us our best clues to rate of growth, at least on a comparative basis. Girls start earlier, go faster, and finish first, at an approximate age of 16 years. Usually they are ahead of boys by two years at all levels. With boys, growth progresses more slowly, there are more surprises and variability and during puberty, changes in direction of growth are not uncommon.
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GROWTH SPURTS
AO 1987 No. 1, 50 - 62: Early Facial Growth Accelerations A Longitudinal Study William L. Krieg.
Growth accelerations also occur at younger ages, and it is becoming increasingly important that we have a better understanding of preadolescent facial growth and the growth spurts that may occur during the early childhood years. Early facial growth spurts, in contrast to the adolescent facial growth spurt, are characterized by greater variability in their occurrence and magnitude ( NANDA 1955, BAMBHA 1961, HARRIS 1962, WOODSIDE 1975, EKSTRÖM 1982). www.indiandentalacademy.com
AO 1987 No. 1, 50 - 62: Early Facial Growth Accelerations A Longitudinal Study William L. Krieg.
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They are not always accompanied by the distinct acceleration in general somatic growth and stature that is normally observed during the adolescent growth spurt ( BAMBHA 1961, SINGER 1980). These factors have tended to result in a lack of documentation of the juvenile facial growth spurts, which remain a little-known phenomenon. www.indiandentalacademy.com
Growth Spurt : Research
Angle Orthodontist, 1987, 50 - 62: Early Facial Growth Accelerations A Longitudinal Study William L. Krieg.
Serial lateral cephalometric radiographs of 21 male and 19 female orthodontically untreated white children were obtained from the Center for Human Growth and Development, University of Michigan, Ann Arbor. Radiographs were exposed annually on the subjects’ birthdays over the age range from 5 to 12 years. www.indiandentalacademy.com
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Evidence based Orthodontics Meta Analysis Randomized Prospective Trials Retrospective Study
Longitudinal Studies
Cross Sectional Studies www.indiandentalacademy.com
Meta Analysis
Basically it combines the results of several studies that address a set of related research hypotheses. It was first used in medicine in 1955. This is an observational research where clinical findings from different studies are grouped on the basis of evidence rather than opinion used collectively. The study rather than the patient becomes the unit of analysis.( If research design is strong then the study is valid). www.indiandentalacademy.com
Meta Analysis ď Ž
The fundamental objective of meta analysis in clinical research is to use accumulates information to provide guidance in the treatment of future patients.
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Randomized Prospective Clinical Trial ď Ž
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The randomized prospective clinical trial means the only method of treatment assignment that produces a strong reassurance. A randomized clinical trial has the advantage of allowing comparisons of treatment among groups for which pretreatment equivalence has been statistically achieved by a process that avoids solution bias and defines groups so that differences in their observed experience can be attributed to treatment effect. www.indiandentalacademy.com
O’Brien (AJO2003)
randomized controlled clinical trial. Treated 174 patients with a twin block and another 174 were observed. Patients were matched for age, sex and severity of malocclusion. The final analysis showed that the twin block does not affect skeletal class II malocclusion. www.indiandentalacademy.com
Prospective study ď Ž
A prospective cohort study measures exposures in a sample of individuals (a cohort) and then follows the cohort for a period of time; disease outcomes are monitored.
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Retrospective Study ď Ž ď Ž
Definition In a retrospective cohort study, the investigator looks into the exposure records of individuals to form a historic cohort population. The occurrence of outcomes in the population would then be investigated based on existing information, thus eliminating the necessity of a follow-up period, which is required for a prospective cohort study. www.indiandentalacademy.com
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Longitudinal Study ď Ž
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A longitudinal study is a research study that involves observations of the same items over long periods of time, often many decades. Longitudinal studies track the same people, and therefore the differences observed in those people are less likely to be the result of cultural differences across generations. www.indiandentalacademy.com
Cross Sectional Study
A cross-sectional study is a study in which disease and exposure status are measured simultaneously in a given population. Cross-sectional studies can be thought of as providing a "snapshot" of the frequency and characteristics of a disease in a population at a particular point in time. This type of data can be used to assess the prevalence of acute or chronic conditions in a population. However, since exposure and disease status are measured at the same point in time, it may not always be possible to distinguish whether the www.indiandentalacademy.com exposure proceeded or followed the disease.
Age? ď Ž
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No useful correlation seen between the magnitude of skeletal change during early growth modification and a patient’s skeletal or dental maturity, chronological age or various markers for malocclusion severity could be determined. McNamara has mentioned that there is an appropriate treatment time but no valid literature seen. www.indiandentalacademy.com
Age
Gianelly (AO 1994) Mandibular models of 100 patients in mixed dentition stage were taken with crowding present in 85 models. When leeway space was added 77% had enough space. Crowding can be resolved non-extraction in at least 85% of cases with treatment beginning after eruption of first premolars. Author however feels extraction is the preferred route. www.indiandentalacademy.com
Age
Gianelly (AO 1994) Ringenberg found no difference in treatment results obtained in a group of patients treated according to a serial extraction protocol when compared with those patients whose premolars were extracted after eruption of permanent teeth. Active treatment for serial extraction group was six months shorter. www.indiandentalacademy.com
Age ď Ž ď Ž
Tulloch et al (AJODO 1997) Age & Maturity does not seem to play a major role as within the patient sample there does not appear to be a linear association between age & maturity vs magnitude of treatment response.
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AGE
The Angle Orthodontist: Vol. 75, No. 2, pp. 162–170. Assessment of Orthodontic Treatment Outcomes: Early Treatment versus Late Treatment:Tsung-Ju Hsieh, Yuliya Pinskaya, W. Eugene Roberts,
Comparison of the final results between earlyvs late-treatment groups showed that the early-treatment group had significantly longer treatment time and worse CCA scores than the late-treatment group. There was no significant difference between early- and late-treatment groups regarding the ABO OGS score. www.indiandentalacademy.com
AGE
Prematurely terminated treatment was more prevalent in the early-treatment group than in the late-treatment group. the disadvantages of early treatment was prolonged treatment time, a higher incidence of premature termination of treatment, which was attributed to patient/parent “burn-out.” www.indiandentalacademy.com
Growth Pattern ď Ž ď Ž
Tulloch et al(AJODO 1997) Found that a highly favourable skeletal correction is as likely or even more likely in children whose growth is predominantly vertical.
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Growth Pattern
AJODO 2002 Oct:-Managing the developing class III malocclusion with palatal expansion and facemask therapyTurley(349-52)
Face mask therapy does not normalize growth. Treated pt resume class III growth pattern characterized by deficient maxillary growth Found that palatal expansion does not significantly aid in class III correction. Latent mandibular growth seen as primary cause of post treatment relapse. www.indiandentalacademy.com
Retention & Stability
Little (AJODO 1981) 65 cases, 10 years post treatment . Treated with edgewise in permanent dentition stage with 1st premolar extractions. No supracrestal fibrotomy performed. All subjects 10 years post retention www.indiandentalacademy.com
Retention & Stability
Little (AJODO1981) Results Irregularity- dropped from 7mm Pre-Rx to 4.6 mm Post Rx. Arch width- 60 of 65 cases showed canine expansion more than 1mm during RX but constriction of 2mm after Rx. Arch Length- Due to extractions this reduced but continued reducing Post Rx. Overbite- Reduced during Rx but incresed significantly post Rx. Overjet-Reduced during Rx and continued to stay the same Post Rx. www.indiandentalacademy.com
Retention & Stability
Dugoni et al(AO 1995) 25 mixed dentition patients with records Used passive lingual arch to maintain leeway space. 8 males and 17 females Treated in early mixed dentition No edgewise orthodontic treatment in permanent dentition. www.indiandentalacademy.com
Retention & Stability
Dugoni et al(AO 1995) Results Irregularity Index- dropped sharply during treatment then rose again slightly post treatment. Intercanine width- Increased during treatment then decreased significantly post treatment. Intermolar width – increased significantly during treatment then remained unchanged Post Rx. Arch length- did not change during treatment but reduced Post Rx. Overjet- Decreased significantly during Rx but increased Post Rx. www.indiandentalacademy.com
Retention & Stability
Dugoni et al(AO 1995) Overbite- significant reduction during treatment but significant statistical increase post Rx. Conclusion- Lingual arch just as good as edgewise for reduction of anterior crowding?. Overjet? www.indiandentalacademy.com
Early vs Late: The Past ď Ž
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JCO 1971 Apr(191 - 199): Treatment Timing Onset or Onslaught? - HARRY G. BARRER, D
Guilford, in 1898, said, "The line of distinction between the advisability of early and late interference is not always plainly marked."It would seem that in the last 72 years, we have not been able to improve the markings because although we know what we would like to do, we have not yet developed the technical ability of accomplishment. www.indiandentalacademy.com
Early Vs Late : The Present David Turpin (AJODO 2002)
At the international symposium on early orthodontics. “I came away with the understanding that early treatment is seldom efficient – but often effective.”
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The Future
David Carlson(AJODO2002) The future of orthodontic orthopedic treatment of dentofacial deformities will see an increased emphasis on the gene therapy combined with mechanotherapy. Molecular genetic techniques will be used to determine the developmental status of patients by assessing the presence or absence and the characterization of genetic polymorphisms of key molecular mediators of growth. www.indiandentalacademy.com
The Future ď Ž
In the more distant future methods will be developed for targeted use of molecular mediators to influence development, growth, and maturation of craniofacial structures.
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CONCLUSION ď Ž
Two-stage treatment: an outcomes-based assessment Gianelly A.A.1Progress in Orthodontics, Volume 1, Number 1, 1 January 2000, pp. 3-9(7)
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Neither self-concept nor the ability to modify growth is improved by stage-one treatment, also, there are no skeletodental differences between the results obtained by one-stage and two-stage treatments. Accordingly, two-stage treatment cannot be endorsed on the basis of providing unique and characteristic psychological or skeletodental benefits. www.indiandentalacademy.com
Conclusion
Semin Orthod 2005 (112-8): Controversies in the timing of Orthodontic Treatment – Jang, Fields,Vig & Beck
The timing of treatment interventions was influenced by the severity of malocclusion and the age and maturation of the patient at the time the patient presented for treatment.
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References
AJODO:1990 Feb (106 - 112): Correction of Class II, Division 2 malocclusions through the use of the Bionator appliance: Report of two cases - Rutter and Witt JCO: 1971 Apr(191 - 199): Treatment Timing Onset or Onslaught? - HARRY G. BARRER, D Angle Orthodontist :1987 No. 1, 50 - 62: Early Facial Growth Accelerations A Longitudinal Study William L. Krieg.
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References
Textbook of Orthodontics-S.E. Bishara Contemporary Orthodontics – William Proffit Orthodontics Principles and Practice – T.M. Graber Removable Orthodontic Appliances – Graber & Neumann Orthodontics & Dentofacial Orhtoopedics – McNamara & Brudon Handbook of Orthodontics – Robert Moyers
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References
AJODO: 2002 ; Editor's choice David L. Turpin, 7A AJODO: 2002 ; Skeletal Class II patterns in the primary dentition Arndt Klocke, Ram S. Nanda, Bärbel KahlNiEke, (596-601) AJODO: 2002 ; Congenitally missing teeth: Orthodontic management in the adolescent patient Vincent O. Kokich, Jr, (594-595) www.indiandentalacademy.com
References
AJODO: 2002 ;Early treatment of tootheruption disturbances Jüri Kurol, (588-591) AJODO: 2002 ; Early treatment for impacted maxillary incisors Adrian Becker, (586-587) AJODO: 2002 ; Early application of chincap therapy to skeletal Class III malocclusion Hideo Mitani, (584-585) www.indiandentalacademy.com
References
AJODO: 2002 ; Biomechanics of maxillary expansion and protraction in Class III patients Peter Ngan, (582-583) AJODO: 2002 ; Stability and relapse: Early treatment of arch length deficiency Robert M. Little, (578-581) AJODO: 2002 ; Serial extraction revisited: 30 years in retrospect Jimmy C. Boley, (575-577) AJODO: 2002 ; Early intervention in the transverse dimension: Is it worth the effort? James A. McNamara, Jr, (572-574) AJODO: 2002 ; Treatment of crowding in the mixed dentition Anthony A. Gianelly, (569-571) AJODO: 2002 ; Stability of open bite treatment Peter A. Shapiro, (566-568) www.indiandentalacademy.com
References
AJODO: 2002 ; Early treatment of skeletal open bite malocclusions Jeryl D. English (563-565) AJODO: 2002 ; Preadolescent Class II problems: Treat now or wait? William R. Proffit, J. F. Camilla Tulloch, (560-562) AJODO: 2002 ; Treatment timing and outcome Hans Pancherz, 559 AJODO: 2002 ; Biological rationale for early treatment of dentofacial deformities David S. Carlson 554-558 AJODO: 2002 ; Answers in search of questioners Lysle E. Johnston, Jr, (552-554) www.indiandentalacademy.com
References
AO:1995 Early mixed dentition treatment: postretention evaluation of stability and relapse Steven A. Dugoni, Jetson S. Lee, (311 – 320) Am J Orthod 1981; Little R, Wallen T, Riedel R. Stability and relapse of mandibularanterior alignment: first premolar extraction cases treated by traditional edgewise orthodontics. (349-65). Angle Orthod1994; Gianelly AA. Crowding, www.indiandentalacademy.com
References
AJO-DO 1992 Sep CASE REPORT - Sain, Hollis, and Togrye (270-6). Am J Orthod Dentofacial Orthop 2003; Incisor trauma and early treatment for Class II Division 1 malocclusion -Lorne D. Koroluk, J. F. Camilla Tulloch, and Ceib Phillips (117-26). AJODO 1955 : The significance of early loss of deciduous teeth in the etiology of malocclusion – Lundström. Nov (819 - 826) AM J ORTHOD 1993;Influence of growth hormone on tooth formation - Ito, Vig, Garn, Hopwood, Loos, Spalding, Deputy, and Hoard.(358-64) www.indiandentalacademy.com
References
AJO-DO 1998, Nov ;Disturbances in the development of the upper jaw and the middle face (Part I) – Korkhaus (848 - 868) AJODO 1992 Feb;Regional differences in tooth and bone development - Mappes, Harris, and Behrents (145-151). AJO-DO 1957 Dec: A critical anaylsis of orthodontic concept and objectives - Wilson (891 - 918). AJO-DO 1997 Oct: Lower arch perimeter preservation using the lingual arch Joe Rebellato, Steven J. Lindauer (449 - 456). www.indiandentalacademy.com
References
AJODO 1995 Nov: One-phase versus two-phase treatment - Gianelly (556 - 559). AJO-DO 1991 Nov: Increase in arch perimeter due to orthodontic expansion - Germane, Líndauer, Rubenstein, Revere, and Isaacson (421 - 427). AJO-DO 1954 Dec: Serial extraction in orthodontics: Indications, objectives and treatment procedures Dewel (906 - 926). AJO-DO 1969 Jun: Prerequisites in serial extraction Dewel (87 - 93). www.indiandentalacademy.com
References
AJO-DO 1988 Jul : Dental crowding - Radnzic (50 56). European Journal of Orthodontics 2002; Proportional changes in cephalometric distances during Twin Block appliance therapy-M. J. Trenouth .484-91 AJO-DO 1980 Aug: A modified protraction headgear Nanda (125 - 139). AO 1994 No. 2, 145 - 150: Face mask therapy of preadolescents with unilateral cleft lip and palate P. H. Buschang, C. Porter, E. Genecov, D. G... AJODO 1998 Apr: Profile changes in patients with class III malocclusions after Delaire mask therapy www.indiandentalacademy.com Hülya KiliçoJlu. (453 - 462)
References
AJO-DO 1998 Jan (40 - 50): Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear Stephen D. Keeling, Timothy T. Wheeler, Gregory J. King (40 - 50) . JCO 1988 May: Orthopedic Correction of Class III Malocclusion with Palatal Expansion and Custom Protraction Headgear - PATRICK K. TURLEY (314 325). JCO 1991 Feb(102 - 113): Maxillary Protraction Therapy: Diagnosis and Treatment - JOHN H. HICKHAM, www.indiandentalacademy.com
References
AJO-DO 1998 Nov : Assessment of skeletal and dental changes by maxillary protraction Sang J. Sung, Hyoung S. Baik, (492 502). AJO-DO1984 May: Maxillary traction splint - Caldwell, Hymas, and Timm (376 - 384). AJO-DO1992 Sep Dental and orthopedic effects of high-pull headgear in treatment of Class ll, Division 1 malocclusion Firouz, Zernik, and Nanda (197-205). AJODO 1998 Jan : The effects of Twin Blocks: A prospective controlled study - David Ian Lund, (104 - 110). AJODO 1975:Meldrum, R.: Alterations in the upper facial growth of Macaca mulatta resulting from highpull head gear.393–441. www.indiandentalacademy.com
References
AO 1994 : A cephalometric evaluation of nonextraction cervical headgear treatment in Class II malocclusions Gregory W. Hubbard. 359 - 370. AJO-DO1994 Oct : Cervical headgear and lower utility arch treatment - Cook, Sellke, and BeGole (376 - 388). AJODO 1998 Jan : Early orthodontic intervention Larry White (24 - 28). AJODO 1998 Jan (5 - 6): PROCEEDINGS OF THE WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E. Bishara, R. Justus, and T. M. Graber AJODO 1997 Nov: Early protrusion reduction–two phase malocclusion correction: A case report R. Don James (523 537). www.indiandentalacademy.com
References
AJODO 2002 Oct:-Managing the developing class III malocclusion with palatal expansion and facemask therapyTurley(349-52) Two-stage treatment: an outcomes-based assessment -Gianelly A.A.1Progress in Orthodontics, Volume 1, Number 1, 1 January 2000, pp. 3-9(7) Semin Orthod 2005 (112-8): Controversies in the timing of Orthodontic Treatment – Jang, Fields,Vig & Beck Am J Orthod Dentofacial Orthop 2003 Apr:- Distal molar movement with Kloehn headgear:Is it stable?:-Birte Melsen, and Michel Dalstra(374-8)
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AJODO 1992 Apr Cephalometric changes during treatment with the open bite bionator - Weinbach and Smith(367-74)
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