Controversies in early orthodontic treatment /certified fixed orthodontic courses by Indian dental academy


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Controversies in early orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

  1. 1. Controversies in early orthodontic treatment
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. contents Definition Introduction Timing of treatment Controversies Class II Class III Transverse deficiencies -cross bites  Anterior open bite  Posterior open bite       
  4. 4. 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
  5. 5.  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.
  6. 6.  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
  7. 7.  Lyman Wagers – prevention and interception are misnomers.  Prevention – preorthodntic guidance  Interception –corrective orthodontic t/t
  8. 8.  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.
  9. 9. 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
  10. 10.  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.
  11. 11. 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
  12. 12. Progression of learning    Period of skepticism Period of optimism Period of reality
  13. 13. Timing of treatment  Primary dentition  Mixed dentition - early - late  Permanent dentition
  14. 14. 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
  15. 15. 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
  16. 16. Treatment –primary dentition  Advantages  Rapid change in skeletal and dental structures  Moderate biomechanical forces  Significant improvement –with skeletal class II problems
  17. 17. Disadvantages  Continued rapid growth can easily erase the treatment effects unless active retention  Child behavior- can be challenging  Treatment time longer and more costly
  18. 18. 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.
  19. 19. 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
  20. 20. 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.
  21. 21. 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.
  22. 22. 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.
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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    
  28. 28. 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 wear
  29. 29. Changing views-Class II problems    Soft tissue elasticity-head gear effect Affect the maxilla By late 1980s headgear or functional appliance
  30. 30. 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
  31. 31. 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
  32. 32.  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
  33. 33.  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
  34. 34. RESULTS  No. of control and headgear patients requiring extractions or surgery were quite similar  Functional appliance t/t increased –the need for extractions
  35. 35. 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
  36. 36. 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
  37. 37. 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 in the deciduous early mixed dentition stage when compared with the treatment in late mixed dentition or early permanent dentition.
  38. 38.  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.
  39. 39.  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.
  40. 40.  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.
  41. 41.  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.
  42. 42. E space
  43. 43.  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.
  44. 44. 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.
  45. 45.  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.
  46. 46. 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
  47. 47. 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.
  48. 48. 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.
  49. 49. Transverse dimension expanded – Actively  Concluded - No difference in intercanine dimension b/w the groups, indicating total relapse of the t/t gain.
  50. 50. 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.
  51. 51. 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.
  52. 52. Class II malocclusion.  Aged dependence related to distal molar movement.  This reinforces that appropriate time to start treating class II malocclusions is LMD.
  53. 53. 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.
  54. 54. 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.
  55. 55. Class II malocclusion.  Weislander and Pancherz -Herbst appliance for 4-6mnts -Was not age dependent.  Concluded - Mandibular growth does not justify early intervention.
  56. 56. 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.
  57. 57. 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.
  58. 58. 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 15 months later
  59. 59. Inclusion criteria  Minimum of 7 mm overjet  Absence of craniofacial syndrome  twin block appliance-originally developed by Clark
  60. 60. Materials and methods  Study models  Cephalometric radiographs
  61. 61. 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
  62. 62. Results
  63. 63. Conclusion  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
  64. 64. Headgear vs. function regulator in the early treatment of class II div1 mal-RCT-J.Ghafari AJO 1998 et al  Aim :To evaluate the early treatment of class II div1 mo in prepubertal children -Facial and occlusal changes after treatment -Headgear or functional regulator  Materials and methods -Data from 63 children
  65. 65.  Inclusion criteria - Bilateral distoclusion -min ANB of 4.5 -7-12.5/13 yrs-age group -no prior orthodontic treatment
  66. 66.    Straight pull headgear-16hrs/day FR-2 -16hrs/day Results -No significant diff existed b/n the two groups
  67. 67. 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.
  68. 68. Results  Both the HG and FR are effective in correcting the Class II div 1. MO of prepubertal children.  The common mode of action of this appliance is the possibility to generate differential growth between the jaws.
  69. 69. Results  On average HG has a distal effect on the maxilla and the first molar but not the maxillary incisors.  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.  Effect of both the appliances on mandibular length seems to be on average similar.
  70. 70. 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.
  71. 71. 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.
  72. 72. Result  Duration of t/t decreased progressing dental development.    early mixed dentition – 57mnts. Late mixed = 33 mnts Permanent dentition – 21 mnts. with
  73. 73.  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%
  74. 74. Conclusions  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.  T/t with fixed appliances was more efficient than t/t with removable appliances.
  75. 75. 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 direction. growth to a posterior
  76. 76. – 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.
  77. 77. 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.
  78. 78.  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.
  79. 79.  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.
  80. 80. 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.
  81. 81.  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.
  82. 82. 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.
  83. 83.  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.
  84. 84. 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.
  85. 85. Conclusions:  The expected cost of treatment related to incisor trauma was small compared with the expected additional cost of a two phase orthodontic intervention.
  86. 86. 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 –
  87. 87.  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. – Would later treatment really be simpler
  88. 88.  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.
  89. 89.  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.
  90. 90. 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
  91. 91.  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.
  92. 92. 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. 
  93. 93. 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.
  94. 94. 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 Dr. Phipps
  95. 95. 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. Dr. Mallerman Dr. Phipps Late mixed dentition – If overjet >8mm indicated for early t/t
  96. 96. 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 – Not criteria for early t/t of most patients YES -
  97. 97. 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 – 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 Not a determinant for early t/t Intervene early when the problem is skeletal than when it is dental
  98. 98. Dr. Gottlieb Dr. Sarver Dr. Moskowitz Is there any greater urgency to treat a unilateral class II div. 1 malocclusio n early Unilateral Herbst Dr. Brazones Dr. Mallerman Subdivision does not compel to treat earlier Mandibular asymmetries – treatment earlier 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 – wait for eruption of the majority of the permanent teeth Dr. Phipps
  99. 99. 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. 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
  100. 100. 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
  101. 101. 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 Don’t use mandibular advancing appliances Use functional appliances at the beginning of the prepubertal growth spurt Girls - 9 yrs Boys – 10 yrs Shows success of 25-50% reduction in ANB Only Herbst not any removable appliances.
  102. 102. 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. 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
  103. 103. 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. Dr. Mallerman Dr. Phipps YES
  104. 104. 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 Dr. Phipps 32 to 40 months for 2 phase 28 to 36 months for single phase
  105. 105. 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 – 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
  106. 106. 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 Dr. Phipps
  107. 107. 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
  108. 108. Efficient Orthodontic treatment timing – Anthony Viazis, AJO 1995
  109. 109. Leader in continuing dental education