Controversies in Early Orthodontic Treatment

Controversies
in early
orthodontic
treatment
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contents
Definition
Introduction
Timing of treatment
Controversies
Class II
Class III
Transverse deficiencies
-cross bites
 Anterior open bite
 Posterior open bite
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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


 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.


 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

 Lyman Wagers – prevention and
interception are misnomers.
 Prevention – preorthodntic guidance
 Interception –corrective orthodontic t/t


 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.

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


 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.


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

Progression of learning
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Period of skepticism
Period of optimism
Period of reality


Timing of treatment
 Primary dentition
 Mixed dentition
- early
- late
 Permanent dentition


Timing of treatment
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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


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

Treatment –primary dentition
 Advantages
 Rapid change in skeletal and dental
structures
 Moderate biomechanical forces
 Significant improvement –with skeletal class
II problems


Disadvantages
 Continued rapid growth can easily erase the
treatment effects unless active retention
 Child behavior- can be challenging
 Treatment time longer and more costly


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.

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

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.


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.

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.

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


 Class II elasticscause the mandible
to position forward
and therefore to
grow
 Better correction
 Guide planes –
used to advance
the mandible

 Advent of
cephalometrics –
correction mostly by
displacing mand teeth
mesially than by
stimulating mand growth
 Undesirable – dental
protrusion
 Unstable- lower incisor
crowding

 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


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
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1.
2.


1980s – clinical success
with functional
appliances
Response to functional
appliances
Absolute stimulation
Temporal stimulation
Ceph analysis- inc mand
growth-first months of
func.app wear

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Soft tissue elasticity-head gear effect
Affect the maxilla
By late 1980s
headgear or functional appliance


Randomized clinical trials
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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


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

 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

 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

RESULTS
 No. of control and headgear patients
requiring extractions or surgery were quite
similar
 Functional appliance t/t increased –the need
for extractions


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

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


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.


 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.

 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.

 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.

 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.

E space


 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.

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.


 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.

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


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.


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.


Transverse dimension expanded
– Actively
 Concluded
- No difference in intercanine dimension b/w
the groups, indicating total relapse of the t/t
gain.


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.


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.

 Aged dependence related to distal molar
movement.
 This reinforces that appropriate time to
start treating class II malocclusions is
LMD.


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.

 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.

 Weislander and Pancherz
-Herbst appliance for 4-6mnts
-Was not age dependent.

 Concluded
- Mandibular growth does not justify early
intervention.


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.

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.


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

Inclusion criteria
 Minimum of 7 mm overjet
 Absence of craniofacial syndrome
 twin block appliance-originally developed by
Clark


Materials and methods
 Study models
 Cephalometric
radiographs


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


Results


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


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

 Inclusion criteria
- Bilateral distoclusion
-min ANB of 4.5
-7-12.5/13 yrs-age group
-no prior orthodontic treatment


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Straight pull headgear-16hrs/day
FR-2 -16hrs/day
Results
-No significant diff existed b/n the two
groups


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.

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.


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.

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.

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.

Result
 Duration
of
t/t
decreased
progressing dental development.
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early mixed dentition – 57mnts.
Late mixed = 33 mnts
Permanent dentition – 21 mnts.

with

 PARscore reduction (improvement) increased with
progressing dental development.

 PAR scores
- Early mixed – 64%
- Late mixed – 73%
- Permanent dentition – 77%
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Pts treated with fixed appliances – 77%
Functional appliances – 60%
Combination of function and multibracket
appliances – 71%

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.


Functional appliances and their
orthopedic effect
- Woodside
 Functional appliances achieve correction of Class
II MO through 8 factors.
– Dentoalveolar changes.
– Restriction of forward growth of midface.
– Stimulation of mand growth beyond that which would
normally occur in growing children.
– Redirection of condylar growth from an upward and
forward directedwww.indiandentalacademy.com direction.
growth to a posterior

– 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.

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.


 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.

 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.

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.

 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.


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.

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

Patients evaluated – after 15 months.
During the phase II patients again randomized – to
receive comprehensive orthodontic treatment in
the permanent dentition.

 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.

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.

Conclusions:
 The expected cost of treatment related to
incisor trauma was small compared with the
expected additional cost of a two phase
orthodontic intervention.


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 –

 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

 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.

 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.

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


 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.

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.


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.


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

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

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 -

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

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

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

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


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.


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

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

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

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


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

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


Efficient Orthodontic treatment
timing – Anthony Viazis, AJO 1995


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Controversies in Early Orthodontic Treatment

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