Treatment of skeletal problems in children and preadolescents

TREATMENT OF SKELETAL PROBLEMS IN
CHILDREN AND PREADOLESCENTS—PART 2
Dr Ashitha Aravind
MDS 2nd YEAR
DEPT OF ORTHODONTICS
& DENTOFACIAL ORTHOPAEDICS
DJ COLLEGE OF DENTAL SCIENCES &
RESEARCH,MODINAGAR

CONTENTS
 INTRODUCTION
 TREATMENT OF CLASS II PROBLEMS
 COMPONENTS OF REMOVABLE AND FIXED CLASS II FUNCTIONAL APPLIANCES
 EXTRAORAL FORCE: HEADGEAR
 COMBINED VERTICAL AND ANTEROPOSTERIOR PROBLEMS
 FACIAL ASYMMETRY IN CHILDREN

INTRODUCTION
Reviews the issues in treatment timing that were presented previously but focuses
on clinical treatment aimed at growth modification.
Tooth movement, in addition to any changes in skeletal relationships, is unavoidable
Excessive tooth movement, whether it results from a weakness in the treatment
plan, poor biomechanical control, or poor compliance, can cause growth
modification to be incomplete and unsuccessful.
Proffit WR, Fields Jr HW, Sarver DM. Contemporary Orthodontics, 5e. Elsevier India; 2012 Jul 4

POSSIBLE APPROACHES TO TREATMENT
TREATMENT OF CLASS II PROBLEMS

Major Reasons For This Trend
Angle’s dogmatic
approach to occlusion
Social Welfare Systems
PreCious metal for
fixed appliances
1925
1965
FIXED
APPLIANCES
REMOVABLE
APPLIANCES

FUNCTIONAL APPLIANCES
One that changes
the posture of the
mandible and
causes the patient
to hold it open
and/or forward

Pressures created by
stretch of muscles
and soft tissues
transmitted to dental
&skeletal structures
Moving teeth
&Modifying
growth

MONOBLOC
 Pierre Robin
 1900
 Considered
forerunner of all
functional appliances

ACTIVATOR Andreasen
 Norway
 1920
 First functional
appliance to be widely
accepted
 German school led by
Haupl

FUNCTIONAL APPLIANCES
1960
EGIL PETER HARVOLD

 A modest change in the size of the mandible's
overall length, which, taken over a number of
types of appliances
 A reorientation of the maxilla and the mandible,
usually facilitated by a clockwise tipping of the
occlusal plane and a rotation of either the
maxilla, the mandible, or both.
WHAT DOES HAPPEN IS………………………..

This child was treated with a functional appliance in an
effort to correct her class II malocclusion by changing
the skeletal relationships
A.) Pretreatment Profile
B.) Posttreatment Profile
C.) Cephalometric Superimposition

 Reduction in forward growth of maxilla always
observed with any mandibular effects.
 Occurs because the elasticity of the facial soft
tissues produces a reactive force against the
maxilla when mandible is held forward.
 Twin Block appliances successful.
 Changes are a combination of
 Skeletal (40%)
 Dental (60%)
 Tends to be a strong Class II elastics effect

FIXED CLASS II CORRECTORS
Emil Herbst
HERBST
APPLIANCE
CREATED……1900
REPORTED…….1930
Pancherz
REDISCOVERED &
POPULARISED…..1970
Herbst for early permanent
dentition

TOLL & ECKHART(1990)
 More durable & less bulky
alternative to the Herbst appliance
 Least temporary headgear effect
affects mandible, as measured by
SNB angle, less than TWIN BLOCK
& HERBST.
 Exert protrusive effect on the
mandibular dentition
MARA(Mandibular Anterior Repositioning Appliance)

MAXILLARY DENTAL RETRACTION
MAXILLARY DENTAL PROTRUSION
Class II
elastics
effect
Maxillary Dental Protrusion
+
Mandibular Dental Retrusion
+
Class II Skeletal Problem
Deleterious in patients who
exhibit maxillary dental
retrusion or mandibular dental
protrusion

To facilitate Class II correction, the mesial and vertical eruption of the
mandibular molar can be used advantageously. Rotating the occlusal plane
upward posteriorly will in itself improve the molar relationship.

A poor response to Class II functional appliance treatment
A.) Pretreatment Profile
B.) Posttreatment Profile
C.) Cephalometric Superimpositions
Before treatment the child had a tendency toward increased lower face
height and a convex profile. The cranial base superimposition indicates
that the mandible rotated inferiorly and backward because of excessive
eruption of the lower molar, which further increased the lower face height
and facial convexity

OTHER POSSIBLE TREATMENT FOR MANDIBULAR DEFICIENCY
To restrain growth of the maxilla with extraoral face
This appliance uses a cervical neckstrap and
a facebow to produce distal force on the
maxillary teeth and maxilla.its goal is to
control forward growth of the maxilla while
allowing the mandible to grow forward.
OBIT SILAS KLOEHN
KLOEHN-TYPE OR CERVICAL HEADGEAR

Let mandible continue to grow more or less normally so that it catches up with the maxilla
Headgear can be effective treatment for
patients with mandibular deficiencies if the
mandible grows while they are wearing it.
A.) Facial appearance before
B.) Facial appearance after treatment using
headgear and Class II elastics
C.)Pretreatment posttreatment cephalometric
superimpositions.

PIONEER ORTHODONTISTS(1800’s)
EXTRAORAL FORCE,IN THE
FORM OF HEADGEAR
APPLIANCES VERY SIMILAR TO
THOSE USED TODAY
EDWARD HARTLEY ANGLE and
his followers were convinced
that Class II and Class III elastics
not only moved teeth but also
caused significant skeletal
changes

1940’s
Concept that significant skeletal changes occurred in response to interarch
elastics
First
Cephalometric
evaluations of
the effects of
orthodontic
treatment

1
9
3
6
Revived the idea that
headgear serve as a valuable
adjunct to treatment
1
9
4
0
Extraoral force to the
maxilla again became an
important part of American
Orthodontics.
CEPHALOMETRIC STUDIES
• Kloehn type headgear
• Neckstrap
• 300 to 400 gm force
• Skeletal change in the form of a
reorientation of jaw relationships
did occur
Oppenheim A. Biologic orthodontic therapy and reality. The Angle Orthodontist. 1936 Apr;6(2):69-116.

EARLY VS LATER
Treatment of Class II problems from RCT’S
1990’s
2 major
projects
RCT
UNIVERSITY OF NORTH
CAROLINA
UNIVERSITY OF FLORIDA
MAJOR
TRIAL
UNIVERSITY OF MANCHESTER

RESULTS
Best data that ever have
been available for the
response to Class II
treatment
DATA
On Average, children
treated with either
headgear or functional
appliance had a small but
statistically significant
improvement in their jaw
relationship,while the
untreated children did not

TIMING OF TREATMENT
Did early treatment with a
headgear or functional appliance
produce a long term difference
when early treatment outcomes
are compared to the outcome of
later treatment?
UNC TRIAL
PEER
ASSESMENT
RATING

Early treatment does not reduce the number of children
who require extractions during a second phase of
treatment or the number who eventually require
orthognathic surgery
Skeletal changes account for only a portion of
the treatment effect, even when an effort is
made to minimize tooth movement.
After later comprehensive treatment, alignment and
occlusion are very similar in children who did and did not
have early treatment.
Skeletal changes are likely to be produced by
early treatment with headgear or a functional
appliance but tend to be diminished or eliminated
by subsequent growth and later treatment.
The duration of phase 2 treatment is quite similar in those
who had a first phase of early treatment aimed at growth
modification and those who did not.
Proffit WR, Fields Jr HW, Sarver DM. Contemporary
Orthodontics, 5e. Elsevier India; 2012 Jul 4

EARLY TREATMENT STUDIES
TREATED CONTROL>
Higher Self Concepts
Less Anxiety
Better Physical Appearance
Popularity
Happiness & Satisfaction
 Early Class II treatment is indicated for some
but not all children.
 The data suggest that the primary indication
is a child with psychosocial problems related
to dental and facial appearance.
 If early treatment is pursued, when the
maxillary skeletal and dental effects that go
along with any enhancement of mandibular
growth are considered, functional appliances
usually are preferred for mixed dentition
treatment of mandibular deficiency.
 Headgear probably is a better choice for a
patient with frank maxillary excess.

COMPONENTS OF REMOVABLE AND FIXED CLASS II FUNCTIONAL APPLIANCES
Changes
Observed
Wanted Effects
Unwanted Effects

APPROPRIATE APPLIANCE PRESCRIPTION
APPLIANCE COMPONENTS APPLIANCE DESIGN
IMPRESSION TECHNIQUE
• Selection of appliance
components
• Where they will be placed ?
• Intra arch space
Proffit WR, Fields Jr
HW, Sarver DM.
Contemporary
Orthodontics, 5e.
Elsevier India; 2012
Jul 4

COMPONENTS
TO ADVANCE
THE MANDIBLE
ACTIVE
PASSIVE
Patient has to voluntarily move the
mandible to avoid an interference
Eg : Activator,Bionator,Twin
Block,MARA
Allows only a restricted path of movement
or closure
Eg: Herbst

MANDIBULAR DEFICIENT PATIENTS
BIONATOR OR
ACTIVATOR APPLIANCES
Simplest
Most durable
Most Readily Accepted

Flanges either
against the
mandibular alveolar
mucosa below the
mandibular molars
or lingual pads
contacting the tissue
behind the lower
incisors, provide the
stimulus to posture
the mandible to a
new more anterior
position.

FRANKEL APPLIANCE TWIN BLOCK MARA
Lingual pads against the gingiva below
the lower incisors to stimulate forward
posturing of the mandible to a new
more anterior position.
Ramps supported by the teeth,as in the
twin block are anterior mechanism for
posturing mandible forward.
Elbow
Growth modification is the result of the patient using his or her own musculature to posture the mandible forward(active),as
opposed to mandible being held forward passively by the appliance,which produces external pressure on the teeth while the
patient relaxes

FIXED APPLIANCES
ADVANTAGES DISADVANTAGES
Full time wear
Permanent Postural Change
Pressure against the teeth,
produces compensatory incisor and
molar movements, cannot be
avoided- the patient simply cannot
actively hold the mandible forward
all the time
Active or Passive?
When & How forces are applied to the
teeth
How much dental compensation is built
into treatment
Dental change
Skeletal change

OTHER POSSIBLE COMPONENTS
VERTICAL
CONTROL
COMPONENTS
Occlusal or Incisal Stops
Bite Blocks
Lingual Shield

STABILIZING
COMPONENTS
Clasps
Labial bow
Anterior torquing springs

PASSIVE
COMPONENTS
Plastic buccal shields
Lip pads
Vertical stop

ACTIVE
EXPANSION/
ALIGNMENT
COMPONENTS
Active elements
Springs
Screws

TREATMENT PROCEDURES WITH FUNCTIONAL APPLIANCES
PRETREATMENT
ALIGNMENT

IMPRESSIONS & WORKING BITE

CLINICAL MANAGEMENT OF FUNCTIONAL APPLIANCES
REMOVABLE FUNCTIONAL
One can take advantage of skeletal growth
and either use or inhibit tooth eruption
Worn when growth is occurring and when
teeth are erupting
Having the child wear the appliance only a
short time per day to begin with and
increasing this time gradually over the first
few weeks is a useful method of introduction
Should be checked for correct
construction and fit on the working cast.
The best technique for delivery is to
adjust the appliance and work with the
child to master insertion and removal
before any discussion with the parent.
Proffit WR, Fields Jr HW, Sarver DM.
Contemporary Orthodontics, 5e. Elsevier
India; 2012 Jul 4

If a sore spot develops, the child should be
encouraged to wear the appliance a few hours
each day for 2 days before the appointment,
so the source of the problem can be
determined accurately.
Charts for children to record their “wearing
time” are helpful, both for the data they
provide and because the chart serves as a
reinforcement for the desired behavior.
Recall the child at 1 and 2 weeks after
insertion for inspection of the tissues and the
appliance
Most growth occurs during the evening hours
when growth hormone is being secreted;
active eruption of teeth occurs during the
same time period, typically between 8 pm and
midnight or 1 am.
Should be approximately 12 hours per day

Reevaluate progress at 8 to 10 months after
delivery with new records
Because the initial mandibular advancement
is limited to a modest 4 to 6 mm and many
children require more anteroposterior
correction, a new appliance may be needed
after 6 to 12 months of wear and a favorable
response
Gross adjustments should be avoided because
appliance fit and purpose can be greatly
altered

FIXED FUNCTIONAL
Soft tissue irritation is not a major problem
with the Herbst or Twin-Block, but the teeth
may be more sensitive than with removable
functional appliances
With the Herbst, after a positive treatment
response is noted, changes in the pin and tube
length can be made during treatment to increase
the amount of advancement simply by adding
washer-type sleeves to the pin to restrict insertion
of the pin into the tube
Patients should be instructed that the
appliance is meant to remind them to posture
the mandible forward and not to force the
mandible forward with heavy pressure on the
teeth
With the MARA appliance, advancement is achieved
via shims on the elbow wire to advance it. A fixed (or
removable) Twin-Block appliance can have plastic
resin added to the inclines to increase the
advancement without totally remaking the appliance
Proffit WR, Fields Jr HW, Sarver DM. Contemporary Orthodontics, 5e.
Elsevier India; 2012 Jul 4

When the desired advancement has been achieved with any
of the fixed Class II correctors and the patient is stable
(anticipating 1 to 2 mm of relapse), then the appliance can
be removed.
A Herbst appliance usually is worn for 8 to 12 months, at
which point the desired correction should have been
obtained, and similar timing is expected with the other
fixed functionals.
Records should be obtained at the end of phase 1 growth
modification treatment to document the progress and plan the
details and timing of the second phase of treatment.
If the patient is still in the mixed dentition when the desired correction is
achieved, the Herbst or MARA appliance can be removed at that point, but
it is important to consider use of a removable functional appliance of the
activator or bionator type as a retainer when this is done
Retainer should be worn approximately 12 hours per day until the patient is
ready for the second phase of fixed appliance treatment. Avoiding a
prolonged retention period is a major reason for delaying fixed functional
treatment until the adolescent growth spurt is beginning.

COMPONENTS OF HEADGEAR
 MOLAR TUBE
 Face Bow
Inner Bow
Outer Bow
 Head Strap
 Force Module
www.indiandentalacademy.com

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ANCHORAGE COMPONENT

SUBHEADINGS
EFFECTS OF EXTRAORAL FORCE ON THE MAXILLA

A good response to headgear treatment
A.) Pretreatment
B.) Posttreatment following
approximately 2 years of headgear
treatment
C.) Cephalometric superimpositions

The maxillary superimposition shows that the incisors were retracted and the molar movement and eruption
were limited. All these effects were beneficial for Class II correction, but the mandible rotated down and
backward because of the inferior movement of the maxilla and eruption of the lower molar. As a result, the
profile is more convex than when treatment began and Class II malocclusion is uncorrected.
This child has poor response to
headgear treatment for a Class II
malocclusion. The cranial base
superimposition indicates that the lips
were retracted and the maxilla did not
grow anteriorly.

 Headgear treatment can have several side effects
that complicate correction of Class II malocclusion.
If the child wears the appliance, maxillary skeletal
and dental forward movement will be restricted.
 Although this helps in correction of the Class II
malocclusion, vertical control of maxilla and
maxillary teeth is important, because this
determines the extent to which the mandible is
directed forward and /or inferiorly.
 Downward maxillary skeletal movement or
maxillary and mandibular molar eruption(all
showed in dashed arrows) can reduce or totally
negate forward growth of mandible.

3 MAJOR DECISIONS
1.) Headgear anchorage location
2.) How the headgear is to be attached to the
dentition
3.) Decision has to made as to whether bodily
movement or tipping of the teeth is desired

First, the headgear anchorage
location must be chosen to provide a
preferred vertical component of force
to the skeletal and dental structures.
A high-pull headcap will place a
superior and distal force on the teeth
and maxilla, while a cervical
neckstrap will place an inferior and
distal force on the teeth and skeletal
structures.
HEADGEAR ANCHORAGE LOCATION

HOW THE HEADGEAR IS TO BE ATTACHED TO THE DENTITION ?
The second decision is how the headgear is to be attached to the dentition.
The usual arrangement is a facebow to tubes on the permanent first molars.
Alternatively, a removable maxillary splint or a functional appliance can
be fitted to the maxillary teeth and the facebow attached to it. This may be
indicated for children with vertically excessive growth. Attaching headgear
to an archwire anteriorly is possible but rarely practical in mixed dentition
children and produces relatively heavy forces on anterior teeth.

DECISION HAS TO MADE AS TO WHETHER BODILY MOVEMENT
OR TIPPING OF THE TEETH IS DESIRED
Finally, a decision must be made as to whether bodily movement or tipping of the teeth
is desired. Since the center of resistance for a 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. The length and position of
the outer headgear bow and the form of anchorage (i.e., headcap or neckstrap)
determine the vector of force and its relationship to the center of resistance of the
tooth. These factors determine the molar movement.

These diagrams illustrate effects of four
commonly used types of facebow and
extraoral anchorage attachments. In each
diagram, the inner bow is shown in BLACK,
and the various outer bow possibilities in
RED or dotted RED.

The facebow is usually attached to
the splint in the premolar region, so
that the force can be directed
through the center of resistance of
the maxilla that is estimated to be
located above the premolar roots.

CLINICAL MANAGEMENT OF HEADGEAR

The steps for fitting a facebow for a headgear.
A, Preformed facebows are supplied in a variety of inner bow sizes and
usually also have an adjustment loop as part of the inner bow.
B, After the bow is placed in one molar headgear tube, the rest of the
facebow is examined to see how it fits relative to the other molar tube
and the teeth.
C, By adjusting the loops to expand or contract the inner bow and by
bending the short portion of the bow that fits into the molar tubes and
facial offsets, it is possible to make the bow passive and allow
clearance from the teeth.
D, The facebow should be adjusted so that the junction of the inner
and outer bows rests passively and comfortably between the lips.
E, The outer bow should rest several millimeters from the soft tissue of
the cheek. This adjustment must be checked both before and after the
straps for the headcap or neckstrap are attached.

In order to determine the proper length needed for the outer bow, use
the index fingers to apply pressure in the direction of the headgear
selected.
A, Pushing up and back in the direction of a high-pull headgear.
B, Pushing down and back in the direction of a cervical headgear.
C, If the bow moves up, the roots on the maxillary first molar will
move distally.
D, If the bow moves down on the lower lip the roots of the maxillary
first molar will move mesially and the crown distally.
E, If the bow does not move, the force is through the center of
resistance of the maxillary first molar and the molar will move
bodily and not rotate.
F, After the correct length is chosen and the outer bow cut with a
pliers, a hook is bent at the end with a heavy pliers.

ADJUSTMENT OF THE NECKSTRAP
A, The neckstrap is attached to the facebow and
the proper force obtained from the spring
mechanism by moving the hook to adjacent holes
on the neckstrap.
B, The spring mechanism delivers a predetermined
force when the plastic connector is moved forward
and aligned with a calibration mark.
C, If the connector is stretched farther, such as it
might be if someone grabbed the facebow and
pulled on it, the plastic connector strap will
release, preventing the bow from springing back
into the patient's face and causing injury.
D, The connector can be reassembled by threading
it through the back of the safety release.

COMBINED VERTICAL AND
ANTEROPOSTERIOR
PROBLEMS

Increased vertical development in a child who initially had
decreased lower anterior face height.
A, Pretreatment profile.
B, Posttreatment profile.
C, Cephalometric superimpositions.
This result was accomplished by increasing the maxillary molar
eruption with a cervical-pull headgear, which resulted in downward
movement of the mandible and improved facial esthetics. More
eruption of the upper than the lower molar, however, can make it
more difficult to obtain a good Class I molar relationship.
SHORT FACE/DEEP BITE

Facial changes produced by functional appliance treatment in a boy with a short face,
skeletal deep bite malocclusion.
A and B, Age 10 prior to treatment.
C and D, Age 12 after 26 months of treatment.
E, Prior to treatment
F, Deep bite bionator, constructed to allow eruption of lower posterior teeth and block
eruption of incisors and upper posterior teeth.
G, Dental relationships at the conclusion of phase 1 treatment, age 12.

Posterior bite blocks can be used with any appliance that
advances the mandible in an effort to limit posterior eruption and
take maximum advantage of growth in an anteroposterior direction.
A, The pretreatment occlusal relationships.
B, When the mandible is advanced, bite blocks are incorporated to
prevent posterior eruption.
C, After a phase of appliance therapy that resulted in
anteroposterior changes, there is a posterior open bite, which can be
closed at that point by reducing the plastic bite blocks and allowing
mandibular posterior eruption.

Mandibular-deficient children with
excessive lower face height need
treatment with an appliance that restricts
posterior eruption and limits downward
growth of the maxilla. This allows
mandibular growth to be expressed
anteriorly rather than vertically.
LONG FACE/OPEN BITE

HIGH PULL HEADGEAR TO THE MOLARS
These photos show an excellent response to high-pull
headgear for a patient with excessive lower face height.
C, Cephalometric superimposition tracing.
The cranial base superimposition shows that the maxilla and
the maxillary teeth did not move inferiorly; as a result the
mandible grew forward and not downward. The mandibular
superimposition shows that the lower molar drifted forward
into the leeway space. The incisor positions relative to the
maxilla and mandible did not change.

HIGH PULL HEADGEAR TO A MAXILLARY SPLINT
A and B, A plastic maxillary splint can be connected to a small
conventional inner headgear bow and a high-pull headgear cap to
deliver an upward and backward force to the entire maxilla. The
splint limits dental eruption better than headgear just to the first
molars.

FUNCTIONAL APPLIANCE WITH BITE BLOCKS
This patient demonstrates a good response to
functional appliance treatment designed to
control vertical development with posterior
bite blocks in a child with excessive lower
face height.
C, Cephalometric superimposition tracing.
Note that no posterior eruption occurred, and
all mandibular growth was directed
anteriorly. Face height was maintained, and
anterior eruption closed the open bite.
Maxillary and mandibular molar positions
relative to their supporting bone were
maintained.
During fixed appliance treatment, posterior
eruption can be controlled by using removable
posterior bite blocks to separate the posterior
teeth beyond the resting vertical dimension. This
creates an intrusive force on teeth in contact
with the blocks, which is generated by the
stretch of the facial soft tissues. The appliance is
retained by clasps over the headgear tubes.

HIGH PULL HEADGEAR TO A FUNCTIONAL APPLIANCE WITH BITE BLOCKS
The maximum growth-modification approach to a severe
long face, mandibular deficiency problem is high-pull
headgear attached to a functional appliance with posterior
bite blocks.
A and B, Facial appearance before treatment.
C, High-pull headgear with the facebow inserted into tubes
in a functional appliance with bite blocks.
D and E, Posttreatment facial appearance is improved but
not ideal.

F, Cephalometric superimposition
showing continued downward
movement of the chin but no increase
in the mandibular plane angle. The
major effect of treatment was
retraction of the protruding maxillary
incisors into a premolar extraction
space; little if any modification of the
growth pattern occurred.

A and B, This 5-year-old girl's family dentist noted
her facial asymmetry, with the chin off to the left (she
deviated even more on opening) and referred her for
further evaluation.
C and D, Her buccal occlusion was normal (Class I)
on the right and Class II on the left. E, The panoramic
radiograph showed the classic appearance of a
unilateral condylar fracture.
Note the normal condyle on the right and only a
condylar stub on the left. The injury almost surely
occurred at age 2 when she fell but was not diagnosed
at the time.

F, Note the two mandibular borders on the cephalometric radiograph due to the shorter ramus on the left.
G and H, She was treated with a series of hybrid functional appliances, with buccal and lingual shields on the
left, and a bite block anteriorly and on the right.
I and J, Facial views 2 years later.

K and L, Intraoral views 2 years later.
M, Panoramic and (N) cephalometric progress views.

O and P, Facial and (Q and R) intraoral views at
age 13, with nearly complete resolution of the
facial asymmetry, although the mandible still
deviates to the left on wide opening. Functional
appliance treatment was discontinued at age 10,
and there was no further orthodontic therapy.

CONCLUSION
The material here is
organized in the context of
the child's major skeletal
problem. In such cases, the
therapy must be based on the
solutions to that specific
patient's set of problems. In
particular, dental changes
that would be unwanted side
effects in some patients can
be quite helpful in others.
For this reason, the
secondary (dental), as well
as the primary (skeletal),
effects of the various
appliances are reviewed

CLASSIC CONTEMPORARY
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REFERENCES

Treatment of skeletal problems in children and preadolescents

Treatment of skeletal problems in children and preadolescents

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