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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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INTRODUCTION:
There is an on going discussion among orthodontists as to the optimal time to initiate orthodontic treatment under various clinical situations. Since the objectives of orthodontic care must include the minimal amount of treatment that achieves the maximum benefit for the patient, the timing of the commencement of treatment becomes of paramount importance. Patient should expect and receive only that amount of treatment that minimizes both the biologic and financial cost to them and yet obtain the optimal outcome.
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2 -phase treatment became plausible with the emergence of the functional matrix hypothesis by Moss in 1960s. This theoretical basis provided a rationale to shift from the restrictive genomic paradigm of Brodie, who considered that the pattern of craniofacial growth was established by 3 months in the infant and was immutable, to the functional matrix paradigm of the 1970s, which provided a rational basis to promote functional appliances to correct the skeletal pattern during growth. www.indiandentalacademy.com
The challenge facing orthodontists in the 21st century is the need to integrate the scientific evidence into practice. It needs to be evaluated from 2 perspectives:
•
EFFECTIVENESS: how well it works?
•
EFFICIENCY: how much it benefits patient in terms of cost and risk.
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EARLY TREATMENT OF CLASS II Growth modification is advocated as an early intervention in the treatment of growing Class II patients. These include the various functional appliances like Twin Blocks, Activators, Functional regulators etc.
It would appear that functional appliances will be more successful during a period of rapid growth. Bjork found as patients grew older the effectiveness of functional appliances reduced. Broadbent stated that skeletal maturity influenced the treatment outcome.
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Pancherz & Hagg on using Herbst appliance, found that there was an increrased condular growth response when the functional appliance treatment was carried out close to the period of most rapid growth in stature,ie; Peak Height Velocity. Therefore the major consensus seems to be that treatment should be carried out
GROWTH / UNIT TIME
during the Peak height Velocity stage.
AGE 2
PHV
adult juvenile
adolescent 10 / 12 14 / 18
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An RCT conducted by Tulloch etal(1998) evaluated the benefit of early Class II treatment and concluded that for children with moderate to severe class II problems, early treatment followed by later comprehensive treatment on an average does not produce major differences in jaw relationship or dental occlusion compared with those treated with one later stage treatment. Tulloch and Proffit(2004) published the outcomes of their 2 phase RCT and concluded that: • 2phase treatment started before adolescence in mixed dentition might not be an more clinically effective than a single phase treatment started during adolescence. • Early class II treatment is effective but not efficient • The difference in skeletal and dental morphology achieved in early treatment disappeared almost completely after comprehensive treatment with fixed appliances.
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Kevin O’Brien et al (2003) assessed the effectiveness of early treatment with twin block (RCT), and concluded that: • Early treatment with twin block appliance is effective in reducing overjet and severity of malocclusion. •Small change in skeletal relation might not be clinically significant The Evidence from a Meta Analysis by J Y.Chen et al (2004) 1.
Most important changes from treatment were dentoalveolar
2.
Skeletal change was not clinically significant
3.
Similar response to ANB changes in both headgear and functional groups !!
4.
Functional appliances do not modify or enhance growth www.indiandentalacademy.com
Some authors argue that an early phase of treatment will help in building up of patients Self Esteem. But the impact of early treatment on psychosocial development does not appear to warrant early intervention on the average. The University of North Carolina in their prospective trials failed to demonstrate the improvement in self concept with early treatment.
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EARLY TREATMENT OF CLASS III Rationale: 1. To prevent progressive irreversible soft tissue or bony changes 2. To improve skeletal discrepancies 3. To improve occlusal function 4. To simplify phase II comprehensive treatment 5. To provide more pleasing facial esthetics. Indications:
Turpin developed a list of positive and negative factors such as•
Good facial esthetics
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Mild skeletal disharmony
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No familial prognathism
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A-P functional shift
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Convergent facial type
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Symmetric condylar growth
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Poor cooperation
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TIMING FOR CLASS III TREATMENT: Timing of chin cup treatment for class III malocclusion appears to be irrelevant for growth modification and stability. This treatment intervention at best provides temporary results for mandibular protrusion [Sugawara(1997) and Sakamoto(1987)] The timing of protraction face mask for class III skeletal maxillary deficiency is advised during early mixed dentition treatment [Bacetti etal (1998) and Baik (1987) ]
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Early Intervention in the Transverse Dimension (Gianelly [2004])
ďƒź No added benefit of RPE in the absence of cross bites in relieving crowding.
ďƒź Inadequate data to justify routine usage in class II malocclusions with a view to self correct the mandible !!( Foot and shoe principle by Mc Namara)
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Absolute Indications of Early Treatment Include: [Ghafari etal (1998)] • Functional posterior cross bites • Anterior crossbites • Openbites • Early loss of teeth compromising the integrity of arch • Proclined anteriors that are susceptible to trauma • Functional disturbances • Transverse discrepancies
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CONCLUSION Early treatment has its own advantages and indications in specific conditions as discussed. Case selection is very important. GENETICS plays an important role in the response of the patient to treatment. Thus we can only alter the environmental factors and allow the natural growth to express itself ! It may be advisable to change the terminology
“EARLY TREATMENT” TO “EARLY TIMELY TREATMENT” www.indiandentalacademy.com
www.indiandentalacademy.com Leader in continuing dental education
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