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CONTENTS
•
•
•
•
•
•
•
•
•
•

Introduction
Angles philosophy
Calvin case philosophy
Tweed philosophy
Begg philosophy
Extraction related dogmas
Functional appliance dogmas
Retention related dogmas
Timing of treatment
Conclusion

A. INTRODUCTION
• DOGMA:
• Dogma may be defined as :
– System of principles or tenets
–
or
– A doctrine authoritatively laid down
–
or
– A settled opinion, belief or principle.


• Orthodontic dogma can be based on :

Truth

Fiction


• Cults and Charismatic leaders have been more
instrumental in establishing our value systems
than has any demonstrated superiority of one
method over another. The focus has been on
techniques and their empirical value to
practitioners.


• The problem lies in many of the dogmatists
demanding ALL or NONE acceptance. This
type of human nature does not serve to advance
knowledge, understanding, or even tolerance for
opposing views. Until proven otherwise, it seems
that many of our values and hence our decisions
are based essentially on dogma.


• B. ANGLE’S PHILOSOPHY : (1910’s)

•

•
•
•

Edward angle struggled with both facial esthetics and stability of
result as potential complications in his efforts to achieve an idealized
normal occlusion.

Angle was influenced by :
1. Philosophy of Rousseau:
Rousseau emphasized the perfectability of man. His strong
belief that many of the ills of modern man could be traced to the
harmful influences of civilization impressed Angle.


• Wolff’s Law of Bone :

•

Angle was impressed by the discovery that the
architecture of bone responds to the stresses placed on
that part of the skeleton.


• This led Angle to two key concepts:
• a. Skeletal growth could be influenced by external pressures:
• Use of elastics
• Use of extraoral force

• b. Second Concept was that proper function of dentition
would be the key to maintaining teeth in their correct
position.


•

He described his edgewise appliance, the first
appliance capable of fully controlling root position, as
the “BONE GROWING APPLIANCE”.


•

Therefore, for Angle proper Orthodontic Rx for every
patient involved :
•
•

Extraction was not necessary for stability of result or
esthetics.

•

•

Expansion of dental arches.

Use of Elastics to bring teeth into occlusion.

To Angle and his followers, relapse after expansion of the arches
or rubber bands to correct overjet and overbite meant only that an
adequate OCCLUSION had not been achieved.


•

Angle’s postulate :
•

Upper first molars were the KEY to OCCLUSION and
that the U & L molars should be related so that mesiobuccal
cusp of upper molar occludes in buccal groove of lower
molar.

•

If this molar relationship existed and the teeth were
arranged on smoothly curving LINE OF OCCLUSION, then
normal occlusion would result.


•

He believed these teeth were key to occlusion because
they :
• Are the largest teeth.
• Are firmest in their attachment.
• Have a key location in dental arches.
• Help determine dental and skeletal vertical
proportions due to lengths of their crowns.


•

Occupy normal position in arches far more often than
any other teeth because they are first permanent teeth
and are less restrained in taking their position.

•

More or less control positions of other permanent teeth
anterior and posterior to them.

•

Have the consistent timing of eruption of all the
permanent teeth.

•

Determine interarch relationship of all other teeth upon
their eruption and “locking with mandibular 1st molars.

• Angle believed that facial harmony and balance were
only possible with full complement of teeth in “Normal”
occlusion. With emphasis an dental occlusion that
followed less attention was given on facial esthetics.


• C. CALVIN SUVERIL CASE : (1920’s)

•

Strongly criticized Angle’s non extraction dogma
because of its effect on:– Facial esthetics - i.e. excess dental protrusion following extreme
expansion.
– Stability.

•

Advocated first premolar extractions for treatment of
malocclusions.


•

D. TWEEDS PHILOSOPHY (1940’S):

•

Tweed’s dramatic public presentation of consecutively treated cases
with premolar extraction caused a revolution in American
orthodontic thinking and led to widespread reintroduction of
extraction into orthodontic therapy by late 1940’s.

•

Tweed’s studies indicated that the failure both functionally and
facially of the aforementioned non-extraction cases was result of
procumbent lower anterior teeth.

•

Tweed therefore advocated uprighting and even retroclining the
lower anterior incisors for greater stability and esthetics.


• Tweed summarizes his philosophy on which his
appliance therapy is based as follows:– Great majority of malocclusions are characterized by a
deficiency between teeth and “basal bone” which
shows itself in an abnormally forward relationship of
teeth to their respective jaw bases.
– Normal occlusion is best maintained with the
mandibular incisor teeth in their normal axial
inclination when related to Frankfort plane, which is
approx. 65° (FMIA).

•

Ultimate in balance and harmony of facial esthetics is
achieved only when the mandibular incisors are
positioned over basal bone (the medullary bone of
respective basal arches).

•

Normal relationship of mandibular incisor teeth to their
basal bone (basal arch) is most reliable guide in
diagnosis and treatment of class I, class II & Bimaxillary
protrusion malocclusions, and in attainment of balance
and harmony of facial profile and permanence of tooth
position.


Tweed’s diagnostic facial triangle :

• Tweed conceived diagnostic facial triangle as a basis for
diagnosis and treatment planning.
– Tweed establishes
–
25° as a norm for FMA
–
90° as a norm for IMPA
–
65° as a norm for FMIA.


• FMIA FORMULA:
– Tweed adopted an FMA range of 16° -35° with an average norm
of 25°.
– If FMA is 16° - 25° less extraction is necessary than when FMA is
>30°.
– When FMA is 30° the mandibular incisors must be tipped to 85° to
maintain 65° for FMIA.


• Successful treatment according to Tweed, requires that the
triangle should be attainable. He provides following
instructions:– Aim should be to maintain FMIA of 70° - 75° when FMA is 20°.
– FMIA angle of 65° when FMA is 30°.
– When FMA is below 20°, the aim should be not to exceed an
incisor inclination of 92°.


• STABLE ANCHORAGE:
– It is of fundamental importance in prevention of forward
mandibular tooth shifting when intermaxillary force is used and
when attempt is made to move mandibular incisor teeth through
“basal bone”.
– The first and most important step in the treatment of all
malocclusion, therefore according to Tweed is Anchorage
preparation.


E. BEGG’S PHILOSPHY (1940’s):

•

Independently of Tweed, Begg also abandoned non extraction
philosophy due to concerns about relapse rather than profile.

•

Begg or differential force technique is a unique approach to
orthodontic treatment Begg’s philosophy is based on:– Theory of attritional occlusion.
– Theory of differential pressures.


THEORY OF ATTRITIONAL OCCLUSION:

•

Dr. Begg has founded his concept of correct occlusion upon his
studies of ancient skulls of Australian aboriginals (Stone Age man).

•

Dr. Begg discarded the concept of “Text book normal” occlusion and
adapted stone age man’s attritional occlusion as correct occlusion

•

Correct occlusion is not fixed or particular anatomic state but a
changing functional process undergoing continual modification


.
•

Factors in development of anatomically correct
occlusion:
–

1. Changing anatomy of teeth which is dependent on tooth
attrition.

–

2. Tooth movement (migration ):
Continued mesial migration and continued vertical eruption both
of which compensate for tooth attrition.


Characteristics of stone age man dentition:
•

Due to coarse, fibrous and gritty food their dentitions displayed marked
occlusal and interproximal attrition.

•

In anterior region :- incisors had worn down and were in edge to edge bite.

•

With the elimination of incisal over bite, mesial migration of mandibular
teeth could take place without incurring lower incisor imbrication.

•

Lower incidence of caries

•

Total reduction in arch length resulting from attrition amounted
approximate to one bicuspid width either side of dental arches by the time
the aboriginal was 20 years of age.


Civilized man dentition:
•

In present day and age with refined and precooked
food having replaced the former rougher diet there is:
– Correspondingly less dental attrition
– Increased liability to caries and periodontal disease
– Absence of attrition in presence of mesial tooth migration means
that dental over crowding where it exists is unrelieved and seen
clinically in lower incisor region.
– Retention of overbite prevents the escape of lower incisors into
edge to edge relationship with the uppers.

•

Dr. Begg used his findings from his study of Australian
aboriginal occlusion as a justification for extraction.

•

He argues that if this present era tooth material is not
lost through attrition, it would be reasonable to cause
proportionate reduction artificially e.g.: extraction.


THEORY OF DIFFERENTIAL PRESSURE:

•

•

Dr. Begg’s observations were based to a large extent on the work
of Storey and Smith and their experiments on tooth movement
response to different pressure applications.
Light orthodontic forces:
–
–
–
–

Optimal forces
Move teeth rapidly - continuous movement.
Cause less discomfort
Minimum damage to investing tissues.


• Heavy forces cause:
– Undermining resorption
– Intermittent tooth movement
– Patient discomfort and damage to investing tissues.
•

Differential force technique is designed to permit teeth to move toward
their anatomically correct positions in the jaws under the influence of
very light forces - as would naturally occur in presence of attrition.


•

•

•

Since larger posterior teeth are slowly moving “Downstream”
with currents of mesial migration, rapid, distal movement of smaller
anterior teeth is possible with application of light forces in presence
of round arch wires and brackets that permit distal crown tipping.
In Begg technique employment of light intra-oral forces don’t
place undue strain on the anchor molars. This, plus the fact that
posterior teeth are not moved distally.
↓
Precludes the use of distally directed extraoral forces.


F. EXTRACTION RELATED DOGMAS:

•

They can be classified as :
– I. Premolar extraction and TMD.
– II. Second molar extraction.


•

PREMOLAR EXTRACTION AND TEMPOROMANDIBULAR
DISORDERS (TMD) :

•

Vertical dimension collapses

•

Over-retraction and retroclination of incisors.

•
•

Bring about premature anterior contacts
Distally displace the mandible and mandibular condyle.


• Witzig and Spahl:

•

Were critical of premolar extraction, stating that this method of
treatment “was a technique that was never designed with face, the
stability of occlusion, nor the health of TMJ in mind, merely the
decrowding of arches”.


• They proposed that premolar extraction led to :
• - Reduction in vertical dimension.
•
•
•
•

- Overretraction of premaxilla.
- Retroclination of upper incisors.
- Deepening of bite.
- Anterior incisal interferences.


• This in turn led to :
• - Distalization of the mandible.
• - Posterior displacement of condyles and TMD.

•

They recommended that when relief of crowding required
extractions, it was not premolars but SECOND MOLARS that should
be removed which will result in:

• - An increase in vertical dimension.
• - A pleasing full face.
• - Healthy TMJ.

•

With time however drawbacks of biscuspid extraction
started surfacing up.

• They were:
• Effects on facial esthetics.
• TMJ problem
• Effect on 3rd molar eruption.


Facial esthetics:
• Narrow smile line (less teeth).
• Sunken in: appearance due to decreased support to upper lip
• “Old age” appearance due to decreased vertical height.
• “Fish like” appearance - extraction of bicuspids in class II
case and retraction of premaxilla - nose appears longer and
prominent


TMJ Problem
•

Dr. H.F. Wilson, while treating TMJ patients observed and
concluded that 4- biscuspid extraction cases causes TMJ problems due
to retrusion of mandibular arc of closure by:• Mesially tilted posterior teeth.
• Distally tilted canine and lower incisors.
• Persistent deep overbite.

•

He also observed that successful treatment to many of his cases
involved the reverse tooth movement to what was performed in the
original orthodontic treatment.


Third molars

•

Extraction of bicuspids did not help eruption
of impacted 3rd molars, as most of the space
would be used for relief of crowding. The result is
loss of 8 teeth.


PROPOSAL OF SECOND MOLAR EXTRACTION:

•

As an alternative Dr. Wilson proposed 2nd
molar extraction and is regarded as “Father of
2nd molar extraction concept”.


Reasons Given :
– Prevents the retraction of maxillary anteriors as there are no
bicuspid spaces to close. This allows mandible to grow downward
and forward which is compatible with TMJ.
– Faces are fuller and smile lines are broader.
– Increased stability as the gigantic forward thrust of 2nd molar is
replaced by 3rd molars.
– Treatment easier.
– Treatment time is shorter.
– Avoidance of elastics and use of headgears and prolonged use of
fixed appliance or retainers.
– Leaves the patient with 28 intact teeth.

• Finally, Witzik and Spahl comments that, “To avoid
dished - in faces, flattened smiles, unstable occlusion
and compromised TMJ for the patients, needing
orthodontic treatment accompanied by dental
extractions there is no alternative to 2nd molar
extraction; there is no debate”.


G. FUNCTIONAL APPLIANCE DOGMAS:

• I. Roux (1883):
•

Influence of natural forces and functional stimulation on form
were first reported by Roux in 1883 as a result of studies he performed
on tail of dolphins.

•

He described the characteristics of functional stimuli as they build,
mold, remold and preserve tissue.

•

His working hypothesis i.e Shaking the bonding substance of bone
became the background of both general orthopaedic and dentofacial
orthopaedic procedures.

• II. Kingsley (1880) :

•

•

Introduced the term and concept of “Jumping the Bite” for
patients with mandibular retrusion. He inserted a vulcanite palatal
plate consisting of an anterior incline that guided the mandible to a
forward position when patient closed on it.
This maneuver corrected the sagittal relationship without tipping the
lower incisors forward.


• III. Pierre Robin:

•

•

The classic MONOBLOC was used by Pierre Robin at
beginning of twentieth century to treat glossoptotic mandibular
retrognathic syndrome.
He belived that passive repositioning of an underdeveloped structure
would make it conform to the normal and that “CATCH UP” growth
would occur.


• IV. Andresen (1908) :
• “Activator” was originally used by Andresen with vertical extensions
to contact the contiguous lingual surfaces of mandibular teeth.
•

Andresen inspiration for the design of his appliance came from “Bite
jumping appliances” of Norman Kingsley. Andresen thought that
this retention appliance was effective in stimulating jaw development.

•

Andresen modified the Kingsley vulcanite eruption control
appliances to “ACTIVATE” the musculature to create a favorable
environment for functionally induced mandibular change.


•

HYPOTHESIS : Andresen’s working hypothesis was that
protractor muscles of the mandible could be stimulated or
“Activated” to assist in achieving a dental sagittal correction.

•

He envisioned that the stretched muscles just beyond resting length
produced an isotonic contractile force which in turn is transmitted
and distributed to selected teeth in contact with the appliance.


• Andresen made no claim that his “Norwegian system”
was better than other techniques, but he did believe that
it was superior to other orthodontic approaches given the
geographic problems, dental manpower situation and
need for caries prevention.


•

After 25 years of using his mode of orthodontic therapy,
Andresen published following summary :
–

Basis for Norwegian system is neither a single “natural ideal
norm concept” nor a “biometric mean”. Individual variation is
normal for civilized persons. Norwegian system is not bound to
the usual orthodontic goal of normal occlusion coincident with
eruption of second molar teeth.

–

Norwegian system has introduced the “prolonged prognosis” of
the topographic relationship as well as eruption of 3rd molars,
defining the goal as “The functional and cosmetic optimum”
serving as supportive periodontal therapy for patient in later life.


•

Appliances used in Norwegian system can be best
termed “Muscle and Circulation activators”, since
they are based on a reciprocal and mutual effect between
the gnathophysiognomic complex, the circulatory
system and the appliance itself. The activators activate
the appropriate muscles while the muscles in turn,
activate the appliances.


V. Karl Haupl (1934) :
•

Haupl a Periodontist and histologist was impressed with results
obtained by Andresen’s functioning retainer.

•

Haupl became convinced the appliance induced growth changes in
physiologic manner and stimulated or transformed the natural forces
with an intermittent functional action transmitted to jaw, teeth and
investing tissues.

•

Familiar with the work of William Roux who gave “shaking theory”,
Haupl believed that this was a clinical validation of the concept.


According to Haupl :
•

Goal of functional appliance is to use functional stimulus,
channeling it to greatest extent the tissues, jaws, condyles and teeth
allow. The mode of channeling is passive in the sense mechanical –
force producing elements are unnecessary.

•

The forces that arise are purely functional and intermittent. This is
the only mode of force application that can build up tissue because
bone remodeling cannot take place in presence of continuous active
forces.

•

Haupl stated that the only true physiologic tooth movement takes
place under purely muscular influences. On this point he tolerated no
contradiction.

•

Principles of Haupl and their applications to activator therapy had
some detrimental consequences for development of orthodontics in
Europe:

– Many orthodontists were convinced that only tissue – preserving
treatments such as that provided by the activator should be
used. The application of mechanical force was considered
unbiologic and technical error.
– Convictions of European orthodontists were upheld by research
of Oppenheim who published his investigations under title ‘Crisis
in Orthodontics (1933).


•

He noted the potential tissue damaging side effects of heavy
orthodontic forces. This strengthened working hypothesis of Haupl,
who decried the use of artificial, mechanically produced forces on
oral tissues

•

For many schools throughout Europe the activator became the
one universal appliance. Too often, however its widespread use
occurred in absence of differential diagnosis and correct
application.

•

Some European Orthodontists even considered active
removable appliances with screws and springs dangerous to the
teeth and investing tissues.


VI. Frankel and Frankel (1989):
•

They make a sharp contrast between the FR and other so
called “Functional appliances” as the activator and bionator. The
activator or bionator, although thought to transmit “functional
stimuli”, constitutes a foreign body in oral cavity.


• According to Frankel:
– Forces generated by muscles of cheek, lip and tongue can only
have the quality of “functional stimuli” if they are in natural
and direct contact with adjacent dentoalveolar structures and
palate.

– Pressure exerted by any appliance, even produced by muscular
forces is and remains an application of pressure and has nothing to
do with a “functional stimulus”.


•

In terms of orthodontic effect, there is in principle, no
difference whether forces press the appliances against
the teeth and the supporting tissue as a result of
stretching of muscular tissues OR as a result of stretch –
reflex contractions of the related muscles.


H. RETENTION
• Working Definition of Retention :
•

The holding of teeth in ideal esthetic and functional
positions.

•

Much has been written and stated concerning the
retention of corrected malocclusions of the teeth.


•

Different philosophies or schools of thought have developed and our
present day concept generally combine several of these theories :

•

I. SCHOOLS OF RETENTION:
• 1. OCCLUSION SCHOOL:
Kingsley stated, “The occlusion of the teeth is the most
potent factor in determining the stability in a new position”.
•
Many early writers considered that proper occlusion
was of prime importance in retention.
•


2. APICAL BASE SCHOOL

–

In middle 1920s a second school of thought formed around
writings of Axel Lundstrom.

–

He suggested that the apical base was one of the most
important factors in correction of malocclusion and maintenance
of a correct occlusion.

–

McCauley suggested that intercanine width and intermolar
width should be maintained as originally presented to minimize
retention problems.


• 3. MANDIBULAR INCISOR SCHOOL:

•

Grieve and Tweed suggested that the mandibular
incisors must be kept upright and over basal bone.


•

•

4. MUSCULATURE

SCHOOL:

Rogers introduced a consideration of the necessity of
establishing proper functional muscle balance. This type of
thinking has been followed by Dewey, McCoy and by
Allan Broodie.


II. THIRD MOLARS AND LATE CROWDING OF
MANDIBULAR INCISORS

•

The role that mandibular 3rd molars play in lower
anterior crowding has provoked much speculation in dental
literature.

• In 1859, Robinson wrote “The dens sapientiae is
frequently the immediate cause of irregularity of the
teeth”.


•

Laskin (1971) in a survey of more than 600
orthodontists & 700 oral surgeons found that 65% were
of opinion that third molars sometimes produce
crowding of mandibulars anterior teeth.


• Differing views ranged between extremes and can be
expressed as:– Third molars should be removed even on prophylactic basis
because they are frequently associated with future orthodontic and
periodontal complications as well as other pathologic conditions.
– There is no scientific evidence of cause and effect relationship
between presence of third molars and orthodontic and periodontal
problems.


STUDIES RELATING THIRD MOLARS TO CROWDING OF
THE DENTITION: -

• Bergstrom and Jensen (1961):– Study design – Cross sectional
– Material and methods:• 30 had unilateral agenesis of upper third molar.
• 57 dental students
• 27 had agenesis of one lower third molar.


• Plaster casts were used to measure
– Space conditions on both sides of arch.
– M – D asymmetries of lateral arch segments.
– Midline displacement.


• CONCLUSION:
–

Concluded that presence of third molar appeared to
exert some influence on development of dental arch but
not to the extent that would justify extraction of 3rd
molars.


• 2. Vego (1962)
– Design of study – Longitudinal.

• Material and Methods:
–
–
–
–
–
–

Sample size : 65 subjects.
40 individuals with lower third molars present.
25 patients with lower third molars congenitally absent.
Amount of crowding measured at two time intervals.
1st measurement – At 13 years of age.
Another measurement at average age of 19 years.

• Criteria for Measurement of Crowding:
– Closure of space.
– Slipping of contacts causing rotation or adverse movement of
teeth.

• RESULTS:
– Vego found in all 65 cases arch perimeter showed a decrease from
1st to the 2nd casts.


• CONCLUSION:
–

Erupting lower third molars can exert a force on the
neighbouring teeth and also indicated that there are
multiple factors involved in crowding of the arch.


STUDIES INDICATING A LACK OF CORRELATION BETWEEN
MANDIBULAR 3RD MOLARS AND POST RETENTION
CROWDING:

•

1. Kaplan (1974):
–

Materials and Methods:
• Pre treatment, post treatment and 10 years post
retention study models of 75 orthodontically treated
patients.
•

Lateral Cephalograms.


•

Sample was divided into 3 groups :
•
•
•

30 persons – all 3rd molars in good occlusion.
20 persons – bilaterally impacted 3rd molars.
25 persons – bilateral agenesis of 3rd molars.


• CONCLUSION:

– Some degree of crowding occurred but there was no
significant difference between the 3 groups. According
to Kaplan the theory that 3rd molars exert pressure on
the teeth mesial to them could not be substantiated.


I. TIMING OF TREATMENT
•

TIMING OF TREATMENT FOR CLASS II
MALOCCLUSIONS

•

:

Two general strategies prevailing today for timing of
treatment for Class II malocclusion:
• 1 ) two phase treatment
• 2 ) one phase treatment


1. TWO PHASE TREATMENT

• Correction is achieved in two phases.
– First phase : during preadolescence (8 – 11 years).
- EARLY TREATMENT
– Second phase: More definitive intervention during
adolescence (12–15yrs.) designed to finish and detail
the occlusion.


ONE PHASE TREATMENT:
•

Entire correction is accomplished in one-phase
of active treatment during the adolescent years.


• EARLY TREATMENT:
•
Proponents of early treatment claim that :
•

1. Rapid correction can be achieved as clinician has growth to work
with.
– a. Animal studies using FJO (Mc Namara 1973, Moyers et al,
1970, Stockli, 1971) and extraoral forces (Elder 1974, Droschl
1973) have clearly shown that :
• Significant craniofacial modification can be effected in both adult and
young animals.


•

Magnitude and rate with which these changes were achieved were
greater in younger animals.

•

Clinicians have made empirical observation that best orthopaedic
results are obtained when growth is most active and that the
juvenile period has greater growth on the average at its beginning.

•

Skeletal Correction can be achieved with minimal
dentoalveolar change.

•

Early data consisted of animal experiments demonstrating
histologic and radiographic evidence of increased growth of
Condylar Cartilage when mandible was held in a forward position.


•
•

Eg: Petrovic and coworkers (1967, 1969) using rat as models.
Baume (1961), McNamara (1987) using primates.

•

The animal studies of 1960s and 1970s created enormous
enthusiasm in the professional community and played an
important role in rapid acceptance and use of functional
appliances in USA that had been largely ignored up until that time.

•

These were supported by studies on humans using both the Activator
(Domisch, 1972) and the Frankel appliance (Mc Namara et al, 1985)
although increases are more subtle.


•

Patients are more cooperative during the pre-adolescent years.

•

Reduces the treatment time in fixed appliances thus reducing the
iatrogenic risks associated with these appliances.
Eg : Enamel decalcification.

•

•
•
•

Root resorption.
Pulpal injury.
Damage to periodontium.

•

Final result after treatment in teens is more stable.

•

Less need for extraction of permanent teeth.


LATE TREATMENT :
(ONE – PHASE TREATMENT)
• Advocates of late treatment claim that :
– 1. Greater proportion of dentoalveolar change as compared to
skeletal change with use of Functional appliances:
– e.g: Functional regulator and activator correct Class II
malocclusions by encouraging substantial dentoalveolar change.
(Freunthaller, 1967, McNamara 1985). Both reduce overjet by
proclination of lower incisors. (Mc Namara 1985, Creekmore
1983, Ahlgren 1976, Pancherz 1976).


• 2. Amount of Skeletal Change Achieved
Clinically by Use of Functional Appliances:
•
Animal studies in 1960s and 1970s created lot
of enthusiasm about efficacy of Functional
appliances.


•

In 1970s and 1980s various investigators conducted
retrospective clinical studies. A number of these
studies demonstrated that :
–

Some average modest increases in mandibular
growth (2 – 4mm/yr) during treatment with
functional appliances. (Pancherz 1979, McNamara,
1990).


–

Other investigators didn’t consider the effect of functional
appliances on quantitative lengthening of mandible to be
clinically significant (Woodside et al, Stockli 1973,
Creekmore 1983, Gianelly 1983, Nelson 1993).

–

In addition, there still is uncertainity whether discernible
mandibular growth acceleration is merely temporal and
doesn’t result in an absolute final gain in mandibular length
(Tulloch et al, 1998).


• Advocates of delayed treatment feel precious
“Cooperative potential” is consumed by early treatment
approaches leaving less for final stage.
• Cost – Risk / Benefit Analysis:
• The major costs of early treatment may be associated with
tissue damage, abnormal function, abnormal growth,
treatment time and its related financial burden.


•

Anthony A. Gianelly in his article “One phase versus two phase
treatment” in AJO – DO (1995) says that :

– Crowding can be resolved in upto 84% of all patients
with treatment that need be started no earlier than the
late mixed dentition stage of development because
space necessary for alignment in most patients with
crowding is gained principally by “E” space control.


• Class II Malocclusions:
• At least 90% of all children with Class II malocclusions
with or without crowding can be treated successfully in
one phase which lasts between 2 – 3 years.
•
Eg : Distallization of Maxillary molars.
• Routinely successful at this age because molars can be
moved distally 1-2mm per month during this time period
and mandibular growth is apparently sufficient to aid in
correcting the Class II malocclusion.

CONCLUSION:
•

“PHILOSOPHY” AND EVIDENCE BASED ORTHODONTICS:

•

Within this controversial situation we as doctors, as orthodontists, we
have an obligation to be clinical scientists providing the best evidence – based
services for our patients.

•

Why, then this in this “age of science”, do we still hear from time to
time about necessity of embracing a treatment “philosophy” in
orthodontics ?

•

In orthodontics, we seem to be witnessing nothing less than a throwback
to the proprietary era, when someone’s crafty “philosophy” or “School of
thought” could masquerade as a new science. That may have been
acceptable pitch 90 years ago, but now thankfully we have sounder
choices.


• In this factual evidence based age that is ours, do we
really need anyone’s belief system as cornerstone of our
diagnostic treatment methods ?
• Philosophy can be a wonderful guidepost for our personal
lives and our spiritual fulfillment, yet that doesn’t qualify
it as a scientific basis for delivery of the best orthodontic
patient care.


BIBLIOGRAPHY

•
.
•

Profit WR : Contemporary Orthodontics, ed 3, St. Louis, 2000, Mosby

•

Fletcher, G.G.T : The Begg appliance and Technique, London, 1981, John G. Wright.
PSG, Inc.

•

Salzmam JA : Practice of Orthodontics, Vol. 2, Philadelphia, J.B. Lippincott Co.

•

Melsen Birt : Current Controversies in Orthodontics, Chicago, 1991, Quintessence
Publishing Co., Inc.

•

Spalding Peter M : Treatment of Class II Malocclusions. In Bishara SE (Editor) : Text
book of Orthodontics, ed 1, Philadelphia, 2001, W.B. Saunders.

Begg PR, Kesling PC : Begg Orthodontic Theory and Technique, ed 3, Philadelphia,
1977, WB Saunders.


•

Joondeph DB, Riedel RA : Retention. In Graper TM, Vanarsdall RL
(Editors) : Orthodontics : Current Principles and Techniques, ed 3, St.
Louis, Mosby.

•

Graber TM, Rakosi T, Petrovic AG : Dentofacial Orthopaedics with
Functional Appliances, Ed. 2, St. Louis, Mosby.

•

Rinchuse DJ & Rinchuse DJ : Ambiguties of Angle’s Classification, Angle
Orthod 59 : 295 – 298, 1998.

•

Bernstein L : Edward H. Angle Versus Calvin S. Case : Extraction Versus
Non extraction. Historical revisionism. Part II, AJO – DO 102: 546 – 551,
1992.

•

Moore AW : A Critique of Orthodontic Dogma, Angle Orthod 39 : 69–82,
1969.

•

Bramante M.A : Controversies in Orthodontics, Dental Clinics of North
America. 34 : 91 – 102, 1990.

•

Schumth : Milestones in the development and practical application of functional
appliances. AJO 84 : 48 – 53, 1983.

•

Gianelly AA: One Phase versus two-phase treatment, AJO – DO 108 : 556 – 559,
1995.

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Gianelly AA: On Current Issues in Orthodontics. JCO 30: 439 – 446, 1996.

•

Bishara SE: On Growth and Orthodontic Treatment. JCO 32: 361 – 367, 1998.

•

Johnston LE. Jr. : On Orthodontics and Scientific Method. JCO 27 : 201 – 206, 1993.

•

Bishara SE : Third molars : a dilemma ! Or is it ? AJO – DO 115 : 628 – 633, 1999.

•

Riedel RA : Review of Retention Problem, Angle Orthod 30 : 179 – 199, 1960.

•

Shrestha BK : Extractions in Orthodontics, Seminars in Orthodontics, 2002, CODS,
Mangalore.


•

King G.J et al : Timing of treatment for Class II
Malocclusions in Children : a literature review, Angle
Orthod. 87 – 97, 1990.

•

McLaughlin and Benett : The extraction – non extraction
dilemma as it relates to TMD, Angle Orthod. 175 – 186,
1995.

•

Peck Sheldon : “Philosophy” and evidence based
Orthodontics, Angle Orthod 67 : 403, 1997.

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