Early vs late orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

Early vs Late Orthodontic
Treatment

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Table of Contents
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Introduction
Early Rx
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Definition
Advantages
Disadvantages

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Phase I Rx
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Growth modification

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Headgears

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Functional appliance

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Face Mask

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Arch Length Discrepancy
Correction

Chin Cup

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Open Bite Correction

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Serial Extraction
Arch Expansion
Arch Length
Preservation

Eruption Disturbances

Growth Spurts
Methods of Analysis
Age
Growth Pattern
Retention & Stability
Conclusion


Introduction
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Early vs late the optimal treatment time
is still controversial .
The only result is now people refer to it
as Appropriate treatment time.
Mcnamara, Brudon

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Early vs late depends on type of
malocclusion, treatment response and
the viewpoint of the orthodontic
practitioner. www.indiandentalacademy.com

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Graber, in his textbook, divides
orthodontic treatment into three
categories:
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1. Preventive orthodontics which is action
taken to preserve and protect the occlusion
at a given time. Here we deal with the
normal deciduous dentition.


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2. Interceptive orthodontics which is
action taken to intercept a potential or
existing early malocclusion in the mixed
dentition, and
3. Corrective orthodontics which is the
treatment of a definitive malocclusion in
the permanent dentition that is no
longer amenable to prevention or
simple interception.

Early Treatment
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“ Treatment started in primary or mixed
dentition phase that is performed to
enhance the dental and skeletal
development before the eruption of
permanent dentition. Its purpose is to
either correct or intercept malocclusion
and reduce the need of time for
treatment in the permanent dentition”.
S.E. Bishara et al AJO 1998

Early Treatment
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AJODO1997 Nov (523 - 537): Early protrusion reduction–two
phase malocclusion correction: A case report R. Don James

There is a difference between early
orthodontic treatment and early orthodontic
correction. Early treatment does not
necessarily mean early correction.
a better term for early treatment might be
"early management of adverse
developmental patterns and problems."

1997 Nov (523 - 537): Early protrusion reduction–two
phase malocclusion correction: A case report
R. Don James
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The "real" correction usually occurs when all the teeth
can be placed in their final position with the following
objectives accomplished:
1. Esthetic alignment of all the teeth with harmonious
arch forms.
2. Functional interdigitation of the teeth within healthy
supporting tissues and in harmony with the
temporomandibular joints.
3. Proper denture placement in the craniofacial
complex for the best soft tissue esthetics and facial
balance (think about it . . . for every person, there is
one best place for the teeth to be).
4. Stability of the teeth in their new positions.

Disadvantages
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1998 Jan (5 - 6): PROCEEDINGS OF THE WORKSHOP
DISCUSSIONS ON EARLY TREATMENT S. E. Bishara, R.
Justus, and T. M. Graber

potential iatrogenic problems that may occur with
early treatment such as dilaceration of roots,
decalcification under bands left for too long,
impaction of maxillary canines by prematurely
uprighting the roots of the lateral incisors,
impaction of maxillary second molars from distalizing
first molars, and
patient ”burnout.“
total treatment time is longer when considering the
observation period between the two stages.

Advantages
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1998 Jan (5 - 6): PROCEEDINGS OF THE
WORKSHOP DISCUSSIONS ON EARLY
TREATMENT S. E. Bishara, R. Justus, and T. M.
Graber

improvement in the patient's self-esteem
parent satisfaction,
greater ability to modify the growth process,
earlier resolution or interception of the
developing malocclusion,
higher quality,
more stable results are achievable,

Advantages
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less extensive therapy,
shorter treatment time in the
permanent dentition.
lesser potential for iatrogenic damage
such as tooth fracture, root resorption,
decalcification, and periodontal
problems.

Advantages
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AJODO 1998 Jan (5 - 6): PROCEEDINGS OF THE
WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E.
Bishara, R. Justus, and T. M. Graber

Intercepts potential developmental problems
that in turn improves the stability of the
results achieved.
Better use of the growth potential,
Reduced need for extraction,
Better patient compliance, more satisfaction,
Better final results.

Advantages
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The clinician would have two ”shots“ at
solving difficult or complex problems.
There will be less need for ”en masse“ tooth
movement, torque, and dental compensations
in the second phase of treatment.
The treatment mechanics in the second
phase are simpler,
Needs less chair time,
Has greater stability.

ADVANTAGES
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AJODO 1998 Jan (24 - 28): Early orthodontic intervention Larry White

As suggested by Gianelly, the late mixed
dentition offers the best time for
intervention for several reasons:
• The E space still exists.
• Approximately 80% of the patients are
still treatable by nonextraction.
• The treatment can be completed in one
phase.
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Advantages
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•
•
•
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To prevent an unnecessarily
extended treatment
To prevent patient burnout
To reduce jeopardy of oral tissues
To allow achievement of specific
and limited treatment goals
To avoid becoming a two-phase
treatment for one small fee.

Phase I Treatment

Growth
modification
Headgears

Functional appliance
Face Mask
Chin Cup

Open Bite
Correction

Arch Length
Discrepancy
Correction
Serial Extraction
Arch Expansion
Arch Length Preservation


Eruption
Disturbances

Growth Modification
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Treatment for Class II or Class III
skeletal problems with the intent to alter
the unacceptable skeletal relationships
by modifying the patients remaining
facial growth to favorably change the
size or position of the jaws.
Textbook of Orthodontics-S.E. Bishara


Headgears
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Appliance used in orthodontics to
modify growth of the maxilla, distalize
maxillary teeth or reinforce anchorage.
Textbook of Orthodontics- S.E. Bishara


Types of Headgears
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Head gears selected based on:

Anchorage location- a highpull headcap
will place a superior and distal force on the
teeth and maxilla. A cervical neck strap will
place an inferior and distal force on the
teeth and skeletal structures. When the
headcap and neck strap are combined the
force direction can be varied by altering the
proportion of the total force provided by
each component.

Contemporary Orthodontics-Proffit

Types of Headgears



Headgear attachment to dentition- The
usual arrangement is a facebow to tubes
on the permanent first molars.Alternatively
a removable appliance can be fitted to the
maxillary teeth and the facebow attached
to this appliance.


Types of Headgears



Bodily or tipping movement of the maxilla:Since the center of resistance for the 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.


Melsen et al (AJO-1978)
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10 patients in two groups selected based on
distoocclusion, facial morphology and dental
maturity.
Kloehn type cervical headgear used.
One group with outer bow above occlusal
plane and other group outer bow below
occlusal plane.
Molar correction faster where outer bow bent
downward.
In both groups maxilla moved downward and
backward and mandible rotated posteriorly.

Cook (AJO-1994)
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Studied growing patients with cervical
headgear.
Extrusion of molars beyond normal
growth and opening.
Rotation of mandible did not occur even
in dolicofacial subjects .
Cervical headgear produced
orthopeadic and dental changes.

Hubbard (AO-1994)
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He examined 85 cases of patients
treated by Dr. Kloehn.
He found that mandibular plane angle
did not change.
The headgear was effective in
controlling Antero-Posterior growth of
maxilla however.

Melsen (AJO-2003)
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She did a long term study on
intermaxillary molar displacement. The
first time in the year 1978 and then
again 7 years later with patients treated
with the Kloehn headgear along with
cervical traction.
A strong tendency of the molars to
return to the class II relationship was
demonstrated.

Melsen (AJO-2003)
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No evidence that a Class I relationship obtained by
extraoral traction was more stable that that obtained
by functional or intermaxillary appliances.
It was noted, however, that the variation in the
vertical development was related more to each
patient’s growth pattern than to the force system
applied.
After cessation of the headgear, intramaxillary
displacement of the molars was noted, and the total
displacement of the molars did not differ from that of
the untreated group.

Meldrum (AJO 1975)
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Conducted a primate study on a dental splint,
facebow, acrylic helmet and implants.
Histologic section showed responses in various
sutures
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Frontomaxillary
Frontozygomatic
Zygomaticomaxillary
Zygomaticotemporal

Resorption at sutures were observed both in
histological section and from decreased distances
between implants.
Very little vertical growth of the maxilla seen.

Firouz (AJO-1992)
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This was a long term study
Studied 12 adolescent patients with
class II div I malocclusion wearing a
high pull headgear with 500 gms of
force.
There was relative restriction of both
horizontal and vertical maxillary growth.

Caldwell (AJO-1984)
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Studied 47 patients with full coverage
maxillary occlusal splints and
orthopaedic headgears.
Inhibition of vertical development of the
maxilla and lack of change in the
mandibular plane with overjet reduction
of 4mm when compared with 52
controls.

Result
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Maxillary traction can result in restriction of
growth clearly shown in animal studies.
Choosing appropriate appliances to reach
specific human treatment objectives is not a
simple matter of showing a force diagram and
implementing biomechanical strategy based
of calculations.
Human data fails to show predictable
outcomes and there are considerable
inconsistencies in treatment outcomes.

Growth Modification Devices
Future- ?
1940’s-Andresen’s
Activator

Present- Twin Block

1990’s- Fixed
functional appliance

1980’s- Frankel’s
functional regulator

1950’s- Activator
Modification

1970’s- Bionator
and Modifications

1960’s- Bimmler’s
elastic


How do they work?
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Functional appliance therapy accelerates and enhances condylar
growth
A. B. M. Rabie, T. T. She, and Urban Ha¨ gg,

The present study was designed to quantitatively assess the temporal pattern of
expression of Sox 9, the regulator of chondrocyte differentiation and type II
collagen, the major component of the cartilage matrix during forward mandibular
positioning, and compare it with the expression during natural growth. Results
showed that the expression of Sox 9 and type II collagen are accelerated and
enhanced when the mandible is positioned forward. Furthermore a substantial
increase was observed in the amount of newly formed bone when the mandible
was positioned forward. No significant difference in new bone formation could be
found after the appliance was removed when compared with natural growth.
Thus, functional appliance therapy accelerates and enhances condylar growth
by accelerating the differentiation of mesenchymal cells into chondrocytes,
leading to an earlier formation and increase in amount of cartilage matrix. This
enhancement of growth did not result in a subsequent pattern of subnormal
growth for most of the growth period; this indicates that functional appliance
therapy can truly enhance condylar growth. (Am J Orthod Dentofacial Orthop
2003;123: 40-8)

How do they work?
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Replicating mesenchymal cells in the condyle and the glenoid fossa
during mandibular forward positioning
A. B. M. Rabie, Louise Wong, and Marjorie Tsai,
The purpose of this study was to identify and quantify the temporal
sequence of replicating mesenchymal cells during natural growth and
mandibular advancement in the condyle and the glenoid fossa. The
results showed that the numbers of replicating mesenchymal cells
during natural growth were highest in the posterior region of the
condyle and the anterior region of the glenoid fossa. In the
experimental groups, the posterior region had the highest number of
replicating cells for both the condyle and the glenoid fossa, with the
condyle having 2 to 3 times more replicating cells than the glenoid
fossa. The number of replicating mesenchymal cells, which is
genetically controlled, influences the growth potential of the condyle
and the glenoid fossa. Mandibular protrusion leads to an increase in the
number of replicating cells in the temporomandibular joint. Individual
variations in the response to growth modification therapy could be a
result of the close correlation between mesenchymal cell numbers and
growth. (Am J Orthod Dentofacial Orthop 2003;123:49-57)

Activator
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AJO-DO 1997 Sep (282 - 286): Predicting functional appliance
treatment outcome in Class II malocclusion–a review Susi Barton, Paul
A. Cook

CRITERIA FOR CASE SELECTION

1. A well-aligned lower arch.
2. A well-aligned upper arch.
3. A Class I-mild Class II skeletal pattern.
4. Forward posture of the mandible by the
patient will give a satisfactory soft tissue
profile.
5. A person who is undergoing active growth.

Bionator
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Used to Treat Class II div I cases.

AJO-DO 1990 Feb (113 - 120): Mandibular response to orthodontic
treatment with the Bionator appliance - Mamandras and Allen

A group of 20 subjects who underwent successful Bionator
treatment was compared with 20 subjects who were treated less
successfully with the same appliance.
Both groups had similar advancements in their bite registrations,
as well as similar treatment times and growth-prediction
parameters. Success was judged not on the final occlusion but
on the posttreatment position of skeletal pogonion.
The successful group experienced 3.5 mm or more of
advancement in skeletal pogonion, whereas the less successful
group had less than 3 mm of advancement of this point.


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The results of this study suggest that persons
who have small mandibles may benefit more
from functional appliance therapy than
patients with normal-sized mandibles.
The subjects with delayed growth may
experience more mandibular development
than those with average growth during
treatment under the favorable growth
environment created by functional appliance
therapy.

Bionator
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Used to treat open bite cases
AJODO 1992 Apr ( Cephalometric changes during treatment
with the open bite bionator - Weinbach and Smith)

The results of the present investigation
confirm that the open bite bionator can
assist in the correction of a Class II
malocclusion while not leading to bite
opening, and often decreasing the open
bite tendency.

Bionator
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Used to treat Class II div II malocclusions

AJODO 1990 Feb (106 - 112): Correction of Class II, Division 2
malocclusions through the use of the Bionator appliance: Report
of two cases - Rutter and Witt

The correction of two Class II, Division 2
malocclusions during the mixed dentition
phase with the use of a Bionator appliance is
presented. The suggestion that correction of
Class II, Division 2 malocclusions may be
achieved in the absence of fixed appliances
is supported in these case reports.

Bionator
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Used to treat Class III malocclusion

AJODO 1998 Jul (40 - 44): Skeletal and dental modifications
produced by the Bionator III appliance Giovanna Garattini, Luca
Levrini.

The therapeutic results of a functional orthopedic
treatment with a Balters' Bionator III appliance were
evaluated. The sample group included 39 white
growing subjects with a dentoskeletal Class III
malocclusion. A 2-year study compared results with a
control group. The results showed that the Bionator
III is effective, especially when the malocclusion is
mainly the result of a midfacial deficiency and when
there is a hypodivergent growth pattern.

(AJO-1998)
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Observation

Conducted by King, Keeling et al
Used 325 subjects with class II
malocclusions.
All subjects examined at 9 years of age.

Headgear
+bite plate
Restricts maxilla and
disoccludes mandible
allowing it to express full
growth

Bionator
Mandible
positioned
forward

After 20 months a reduced class II molar relationship was seen and
improved apical base relationships

University of North
Carolina(AJODO 1997)
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It was a prospective long term study.
It had an almost ideal research design.
Conducted by Drs. Camilla Tulloch and William Proffit
All subjects were children with overjet of 7mm

PHASE I
Observation

Randomized
Functional Appliances

Headgear

End of Phase I in 15
months

Retention Phase for 1 year

Assigned to four different
orthodontists for phase II

University of North
Carolina(1997-2004) Results
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There was no difference between the
groups with regard to ANB angle either
at the start or after phase II of
treatment.
No difference in the quality of dental
occlusion between the children who had
early treatment and those who did not.
There was approximately the same
distribution of success and failure with
and without early treament.

University of North
Carolina(AJODO 1997) Results
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Early treatment did not reduce the
number of children needing extraction
of premolars or other teeth during
phase II of treatment.
Early treatment did not reduce the
eventual need for orthognathic surgery.
There was little influence on the time
duration that both groups spent wearing
fixed appliances.

University of North
Carolina(AJODO 1997) Results
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Early treatment did reduce severity of
class II malocclusion.
Overjet did decrease in the treated
groups whether the appliance was a
headgear restricting the maxilla or a
functional one positioning the mandible
forward.
Still doubt whether early treatment is
better or not as long as treatment is
provided at some point in time.

University of Florida (AJO 2003)RESULTS
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Part two of initial study where phase
two treatment was undertaken.
There were no significant differences in
the final PAR score when patients who
wore a headgear or bionator as a
retention appliance between phase I
and II were compared with patients who
did not wear any appliances and went
straight to fixed appliance therapy

University of Florida (AJO 2003)RESULTS
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Most of the changes in PAR scores
came from finished results achieved
regardless of protocol or initial severity
of malocclusion.
Patients who underwent two phase
orthodontic treatment do not achieve
better results than patients who
undergo one phase therapy in

Frankel
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Frankel 1 – Class 1 malocclusion, Class
2 div1 malocclusion.
Frankel 2 – Class 1 malocclusion, Class
2 div 1 malocclusion, Class 2 div 2
malocclusion.
Frankel 3 – Class 3 malocclusion +
skeletal open bite.
Frankel 4- Open bite, Bimaxillary
protrusion

University of Pennsylvania (AJO1998)
Conducted by Ghafari et al to check effectiveness of appliances in
class II corrections

Frankel

Headgear

Restricted maxillary
growth and
retroclined maxillary
incisors

Distalization
effect on maxilla
and maxillary 1st
molars
No significant difference on
mandible with frankel or
headgear

Frankel
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1983 Jul (54 - 68): Functional approach to treatment of skeletal open
bite - Fränkel and Fränkel

A comparison of a series of lateral cephalograms of
thirty patients with skeletal open bite who were
treated with functional regulators developed by
Fränkel and those of eleven untreated open bite
cases suggests that some dentofacial deformities in
the skeletal open bite cases can be corrected to the
average norms. In addition, as a result of overcoming
the poor postural pattern of the orofacial musculature
and re-establishment of a competent lip seal, a
considerable change in the soft-tissue profile
occurred.

Functional Regulator(EJO-2004)
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Conducted by Almaida using 44
patients

22 control

22 treated

•No significant restriction of maxillary growth.
•1.1 mm increase in mandibular length and this could
have happened even without the appliance.


Twin Block
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Used in Class II div I occlusions by
moving it into a Class III.
Orthodontics & Dentofacial Orthopedics-McNamara Brudon


Lund and Sandler (AJO1998)
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Conducted research on the twin block
appliance.
36 treated cases compared with 27 untreated
cases.
Treated cases demonstrated increase in
mandibular length.
No effect on maxillary skeletal growth.
There was distal movement of molars.
Mesial movement and superior eruption of
molars
Tipping of anterior teeth in both arches.

Trenouth (EJO2002)
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This was a long term prospective study.
Found that twin block allows vertical
correction of the buccal segment along
with dentoalveolar correction.
Increase in anterior and posterior facial
height.
No significant increase in mandibular
length and most of the change due to
mandibular position.

O’Brien (AJO2003)
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Multi-centric randomized controlled
clinical trial.
Treated 174 patients with a twin block
and another 174 were observed.
Patients were matched for age, sex and
severity of malocclusion.
The final analysis showed that the twin
block does not affect skeletal class II
malocclusion.

Face Mask
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AJO-DO 1998 Nov (492 - 502): Assessment of
skeletal and dental changes by maxillary protraction
Sang J. Sung, DDS, MSD, and Hyoung S. Baik,
DDS, ...
The principle of maxillary protraction is to apply
tensile force on the circumaxillary sutures and
thereby stimulate bone apposition in the suture
areas; in doing so, the maxillary teeth become the
point of force application, and the face (forehead,
chin, zygoma) or occipital area becomes the
anchorage source. In animal and biomechanical
studies, histologic changes and stress distribution in
suture areas strongly suggest the application in
human subjects. www.indiandentalacademy.com

Face Mask
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JCO 1991 Feb(102 - 113): Maxillary Protraction
Therapy: Diagnosis and Treatment - JOHN H.
HICKHAM,

Orthopedic effects require greater forces than
orthodontic movements. Maxillary sutural
protraction generally requires 600-800g per
side, depending on the patient. To move the
maxillary anterior teeth forward, 400g per
side is adequate. Forward movement of lower
molars requires 500-600g per side.

Face Mask


Advantages of Face Mask
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Source: AJO-DO on CD-ROM (Copyright ©
1998 AJO-DO), Volume 1988 May (388 394): Use of face mask in treatment of
maxillary skeletal retrusion - Roberts and
Subtelny
if treatment to promote maxillary development
is implemented in the mixed or early
permanent dentition before the peak pubertal
growth, the need for orthognathic surgery
may be eliminated.

Advantages of Face Mask
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AJO-DO 1998 Nov (492 - 502): Assessment of skeletal and dental
changes by maxillary protraction Sang J. Sung, Hyoung S. Baik,.

The effects of maxillary protraction that are
seen on the lateral cephalogram include
forward and downward movement of the
maxillary bone and dentition, lingual
inclination of mandibular teeth, and downward
and backward rotation of the mandible. These
effects tend to turn Class III malocclusion into
Class I occlusion and produce an
orthognathic profile in a short period of time.

Advantages & Disadvantages of
a Face Mask
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JCO 1991 Feb(102 - 113): Maxillary Protraction Therapy: Diagnosis
and Treatment - JOHN H. HICKHAM,

The facial mask is the easiest
protraction device to fit, but is easily
dislodged by a restless sleeper.


Disadvantages of face mask
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1998 Nov AJODO (492 - 502): Assessment of
skeletal and dental changes by maxillary protraction
Sung, and Baik

whether maxillary protraction can
actually stimulate growth is still obscure,
and questions have been raised as to
the orthopedic effect in prepubertal or
pubertal subjects.


Disadvantages of face mask
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JCO 1988 May(314 - 325): Orthopedic Correction of Class III
Malocclusion with Palatal Expansion and Custom Protraction
Headgear - PATRICK K. TURLEY

Class III malocclusions experience latent growth and
a return to pretreatment conditions.
Compromised results can also be due to poor patient
cooperation, since orthopedic appliances for Class III
treatment can be uncomfortable and unesthetic.
Another factor may be practitioners' lack of
experience in managing Class III malocclusions in
postgraduate training and in practice. Class III cases
make up only about 5% of the orthodontic population.

Face Mask Research
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AJODO 1998 Apr (453 - 462): Profile changes in patients with
class III malocclusions after Delaire mask therapy Hülya
KiliçoJlu,.

The purpose of this study was to make a detailed
evaluation of hard and soft tissue changes after
Delaire orthopedic mask therapy .The following
results were obtained:
(1) After maxillary protraction, the maxilla was
displaced anteriorly, whereas the mandible rotated
posteriorly;
(2) the maxillary incisors moved in the anterior
direction, whereas the mandibular incisors moved
posteriorly;

Face Mask Research
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(3) the mandibular plane angle and anterior
lower and total face heights increased;
(4) these changes were reflected in the
profile, whereby the skeletal profile convexity
increased.
(5) the Class III concave profile became more
balanced, with the upper lip area becoming
more marked.

Face Mask Research
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AO 1994 No. 2, 145 - 150: Face mask therapy of
preadolescents with unilateral cleft lip and palate P. H.
Buschang, C. Porter, E. Genecov, D. G...
This study evaluates 21 children treated with
maxillary expansion and protraction appliances for
skeletal discrepancies associated with unilateral cleft
lip and palate
The subjects were treated by the same orthodontist,
using the same techniques and appliances. Mean preand posttreatment ages were 7.3 and 8.7 years,
respectively.
We conclude that differences between the control and
UCLP groups are primarily related to mandibular
clockwise rotation and secondarily to anterior
maxillary repositioning.

Face Mask Research
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The results showed definite protraction of
the maxilla for the UCLP group.
The posterior maxilla of the UCLP group
underwent anterior displacement; the
posterior maxilla of the control group
displayed posterior growth changes.
The maxillary incisor tips of the UCLP group
demonstrated greater anterior movement
than expected for untreated controls.
Vertical changes of the maxilla showed no
significant group differences.

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



The mandible of the UCLP group was
rotated inferiorly and posteriorly; the
control group showed inferior/anterior
changes.
The lower incisor of the UCLP and
control groups remained stable and
moved anteriorly, respectively.
The UCLP group showed significantly
greater inferior movements of the
anterior mandible than the control
group.

Chin Cup


“A restraining device which inhibits the growth
of the mandible, at least preventing it from
projecting forward as much as otherwise
would have occurred”




Chin cup therapy primarily works on the
hypothesis that a force directed through the
condyles will inhibit as well as redirect the
condylar growth.

1980 Aug-Nanda


Advantages of Chin Cup




Changes direction of mandibular growth
by rotating the chin downwards and
backwards.
Lingual tipping of lower incisors as a
result of pressure of appliance on lower
lip and dentition.


Disadvantages of chin cup


Cannot be used in patients with excessive
LAFH.



This therapy alone may not be indicated for a
fair percentage of patients in skeletal Class III
who show a small midfacial bone or a
retropositioned maxilla with relatively normal
mandibular dimensions.
1980 Aug-Nanda

Chin Cup Research




AJO-DO 1980 Aug (125 - 139): A modified
protraction headgear - Nanda
Appliances resembling chin cups have been
in use since the early 1800's. According to
Graber, the early attempts with the chin cup
were not successful because of incomplete
knowledge of mandibular and facial growth,
its use on nongrowing patients, and an
inadequate understanding of the forces
generated by the chin cup.





Armstrong applied 500 Gm. of force via chin cups on
100 adolescent patients with mandibular
prognathism. He reported that half of his patients
showed improvement in the Class III profile, whereas
none of the control, nontreated patients showed any
favorable change.
Thilander treated sixty patients with chin cups for 1 to
6 years. A significant percentage of patients did not
improve. The patients who showed improvement
were comparatively young and showed favorable
dental changes. The force generated by the chin cup
in his study was only 150 to 200 Gm.

Chin Cup Research




Graber, Chung, and Aoba reported results in patients
treated with chin cups for 12 to 14 hours each day
with a force of 1.5 to 2 pounds on each side. They
showed that mandibular growth could be redirected
with a chin cup. They asserted that continuous use of
the appliance for a long period or through active
growth was necessary to achieve stable results.
Graber treated 35 Class III malocclusions in children
between the ages of 5 and 8 years with chin cup
therapy for 3 years. He found that the therapy was
particularly effective in patients with increased
vertical growth of the face.

Mitani (AJODO 2002)











Did some work with the chin cup.
Found that first 2 years of chin cup therapy produces
more changes.
If chin cap therapy is stopped before complete facial
growth the decreased pressure cause increased
condylar growth.
Chin cap should be worn at night as the condyle
should be still when compressive force is applied.
Chin cap therapy seems to enhance forward growth
of maxilla maybe by correcting malocclusion.
Chin cup must be worn till growth completes.

Open Bite


Condition in which the incisal edges of
the upper and lower incisors do not
overlap.


Sanky et al (AJODO 2003)





Retrospective cephalometric study
38 patients around 8.2 years.Control
group matched for age, sex and
mandibular plane angle.
The subjects who entered the study
with open bites exhibited an average
2.7mm reduction in overbite.

Sanky et al (AJODO 2003)


Found that there was no significant
differences for those who wore a chin cup
and those who did not.


Arch Length Discrepancy




AJO-DO 1988 Jul (50 - 56): Dental
crowding - Radnzic
Nance described dental crowding as
the difference between the space
needed in the dental arch and the
space available in that arch— that is,
the space discrepancy.

Serial Extraction


“Procedure used when a patient is
diagnosed with a class I malocclusion
and a severe tooth size arch length
discrepancy of 8-10mm or greater
during the early mixed dentition that
involves the removal of primary canines
and first molars first, followed by
extraction of first premolars once they
are visible.”

Textbook of Orthodontics S.E. Bishara

Serial Extraction


“Removal of deciduous teeth to achieve
a better alignment of the permanent
teeth”.
Orthodontics:Principles & Practice T.M. Graber



“Involves the timed extraction of primary
and ultimately permanent teeth to
releive severe crowding”.
Contemporary Orthodontics-William Proffit

Serial Extraction Criteria









Source: AJO-DO on CD-ROM (Copyright © 1998 AJO-DO),
Volume 1954 Dec (906 - 926): Serial extraction in orthodontics:
Indications, objectives and treatment procedures - Dewel
-------------------------------conditions that show so little promise of potential development
that an early decision should be made on some form of
compromise treatment.
Conditions characterized by shortened arches, blocked-out or
malposed incisors, a shift in the median line, and frequently
early loss of one or both of the mandibular deciduous cuspids.
Facial contours and dental appearance are still acceptable;
esthetics has not yet become a problem.








The molars usually retain a Class I relation. In
these cases the maxillary and mandibular
incisors are vertical, over apical base, and
present a reasonably normal overjet and
overbite.
Other cases may be protrusive with poor
skeletal patterns and disturbed facial
musculature, and still others are potential
Class II malocclusions.

Serial Extraction Criteria







Serial Extraction applies to patients who
meet the following criteria:No Skeletal disproportion
Class I molar relationship
Normal Overbite
Large arch perimeter deficiency.

Serial Extraction Procedure








Extraction of primary lateral incisors as the
permanent central incisors erupt.
Extraction of primary canines as the
permanent laterals erupt.
Extraction of primary first molars, usually 6-12
months before their normal exfoliation at the
point when underlying premolars have one
half to two thirds of their roots formed.
Extraction of permanent first premolars before
eruption of permanent canines.
Contemporary Orthodontics-William

Proffit

Serial Extraction Procedure












AJO-DO 1969 Jun (87 - 93): Prerequisites in serial extraction Dewel
correction by serial extraction are accomplished in three separate
stages for three separate purposes:
(1) premature extraction of the deciduous canines provides the
space for the incisors to assume normal positions in an even
alignment directly over supporting bone;
(2) subsequent extraction of the first deciduous molars permits the
desirable early eruption of the first premolars;
(3) the final extraction of the first premolars makes it possible for
the canines to erupt in a favorable direction into the spaces formerly
occupied by the first premolars.
The interval between extractions varies from 6 to 15 months.

Advantages of Serial
Extraction








AJO-DO 1954 Dec (906 - 926): Serial extraction in orthodontics:
Indications, objectives and treatment procedures - Dewel
Growth once lost cannot be regained, but delayed treatment
with periodic observation enables the orthodontist to determine
developmental trends which, if favorable, provide the necessary
diagnostic information to return to standard ideal treatment
methods when indicated.
By judicious serial extraction in cases with an unfavorable
outlook, eruption of the remaining permanent teeth in a
desirable direction is encouraged and the severity of individual
tooth malpositions is reduced.
Eliminates excessive stress on dental anchorage units and
shortens the period of active treatment for cases that fall in this
category. It also reduces the necessity for prolonged retention
and often eliminates it entirely.

Disadvantages of Serial
Extraction




AJODO 1955 Nov (819 - 826): The significance of early loss of
deciduous teeth in the etiology of malocclusion - Lundström

it is particularly the earlier extractions
that contribute to the development of
crowding.


Serial Extraction Research






Little- cases treated with serial extraction when
compared with those treated with premolar extraction
in full permanent dentition showed identical results.
1 in 3 cases considered success at 10 years post
retention.
Conclusion- Serial extraction of deciduous teeth to
temper a developing arch length followed by
premolar extraction and routine treatment yields no
long term improvement over premolar extraction in
permanent dentition and routine treatment. Long term
retention must be a part of premolar extraction
strategy whether teeth are extracted in mixed or full
dentition.
Little AJODO2002

Serial Extraction Research


University of Washington- 4 studies


Arch Expansion


“Can be used to correct transverse and
sagittal crossbite problems and to
provide sufficient arch space to resolve
borderline crowding in some mixed
dentition patients”.
McNamara-AJODO 2002


Arch Expansion Procedures






“The most aggressive approach to early
expansion uses maxillary and mandibular
removable lingual arches in the complete
primary dentition”.
“A less aggressive approach in terms of
timing is to expand the upper arch in early
mixed dentition using a lingual arch to
produce dental and skeletal changes.”
“Another alternative is to use a functional
appliance that incorporates lip and buccal
shields or a lip bumper”.


Proffit





A combination of maxillary lingual arch
appliances to rotate upper molars; headgear,
sometimes supplemented by fixed or
removable appliances to distalize upper
molars; and a mandibular lip bumper to
increase lower arch dimensions by moving
incisor and buccal segments facially and
lower molars distally.”
Finally arch expansion can be obtained by
aligning the anterior teeth with bonded
attachments and archwires”.
www.indiandentalacademy.comOrthodontics-William
Contemporary

Proffit





Placement of TPA and Lingual arch to
take advantage of leeway space of
4mm in maxilla and 5mm in mandible.
Orthopeadic expansion of the maxilla
with RME.
McNamara-AJODO 2002






AJO-DO 1991 Nov (421 - 427): Increase in arch perimeter due
to orthodontic expansion - Germane, Líndauer, Rubenstein,
Revere, and Isaacson
Various appliance systems have been advocated for achieving
this goal. The types of tooth movement they can effect are
dependent on the force systems produced. Numerous
appliances, including the quad-helix and rapid palatal
expanders, for example, apply lateral forces to the molars and
therefore cause widening of the posterior dental arch. Other
mechanisms, such as the utility arch, may be adjusted to effect
primarily incisor advancement. Combinations of types of
expansion can be achieved by a variety of appliances, including
the function regulator, the lip bumper, removable expanders,
and fixed appliance systems.

Advantages of Arch
Expansion




AJO-DO 1991 Nov (421 - 427): Increase in arch
perimeter due to orthodontic expansion - Germane,
Líndauer, Rubenstein, Revere, and Isaacson

Orthodontic expansion can cause
increases in arch perimeter and is
therefore sometimes used for the
correction of dental crowding

Disadvantages of Arch
Expansion


“Early expansion with both functional
appliance components (including the lip
bumper) and/or fixed appliances has
three major limitations: the long duration
of treatment from the primary or early
mixed dentition through the eruption of
permanent teeth ; the possibility of
creating unaesthetic dentoalveolar
protrusion; and the uncertain stability of
the long term outcome”.

Proffit

Arch Expansion Research




McNamara et al- Haas RME with fixed
therapy produced 5-6mm arch
perimeter increase in maxillary arch and
6mm in mandibular arch.
Geran et al- Bonded acrylic splint
expander followed by Phase II Rx
maxillary arch perimeter post Rx 3.8mm
greater in treated group and mandibular
2.6mm.

Arch Expansion Research




Little – 26 cases with 6 years post
retention records all showed high
degree of relapse and showed that
expansion was the worst of space
gaining strategies.
Conclusion” Without lifetime retention
the strategy of arch development will
yield unacceptable results.

Little AJODO 2002







Arch Length is the distance around the arch
from the most distal surface on the last tooth
on one side through the region of the
interproximal contacts to the most distal
surface on the opposite side.
It may and does change during the growth
period.
Arch length actually decreases in the
mandibular arch during the growth period.
Text book of orthodontics (S.E.Bishara)


Procedures




lip bumper and rapid palatal expansion
(RPE) treatment to induce spontaneous
expansion of the lower arch as the
maxillary arch widens.
placement of a passive lingual arch to
preserve arch length when a deciduous
canine is lost prematurely.
1995 Nov Gianelly

Procedures






Band and Loop maintainers are used most frequently
to maintain the space of a primary first molar before
eruption of the permanent first molar. It can also be
used to maintain the space of either a primary first or
second molar after the permanent first molar has
erupted.
Partial denture space maintainers are most useful for
posterior space maintenance when more than one
tooth has been lost per segment and the permanent
incisors have not yet erupted.
Distal shoe space maintainers are the appliance of
choice when a primary second molar is lost before
eruption of the permanent first molar.

Advantages of Arch Length
Preservation




AJODO 1995 Nov (556 - 559): One-phase versus two-phase treatment
Gianelly

The leeway space can provide adequate space to
accommodate an aligned dentition in the vast majority of
patients. For example, an evaluation of the mandibular
models of 100 patients in the mixed dentition stage of
development revealed that 85 of the 100 subjects
demonstrated crowding, which averaged between 4 to 5
mm. However, 62 (73%) of these 85 patients with
crowding had sufficient space to align the teeth when the
leeway space gain was included in the analysis. Thus,
crowding can be resolved in 73% of patients with crowding
in the mixed dentition stage of development simply by
preserving and using the leeway space.



(Since the combined mesiodistal
diameters of the deciduous canine and
first molar are essentially the same as
the mesiodistal diameters of the
permanent canine and first premolar,
the space gain, in actuality, represents
the "E" space.) Maintaining the "E"
space can readily be accomplished by
starting treatment in the late mixed
dentition stage.

Research








AJO-DO 1997 Oct (449 - 456): Lower arch perimeter preservation using the
lingual arch Joe Rebellato, Steven J. Lindauer

The purpose of this investigation was to determine whether the
placement of a mandibular lingual arch maintained arch
perimeter in the transition from the mixed to the permanent
dentition, and if so, whether it was effective at preventing mesial
migration of first permanent molars, or whether this migration
still occurred en masse, by increased lower incisor proclination.
Statistically significant differences between groups were found
for positional changes of mandibular first molars and incisors,
and changes in arch dimensions.
The results indicate that the lingual arch can help reduce arch
perimeter loss, but at the expense of slight mandibular incisor
proclination.

Research




According to Ann Arbor standards,3 -4 mm of
space is typically available in the maxillary
arch and 5 mm in the mandibular arch during
the exchange of the second deciduous
molars and the second premolars.
We routinely place a transpalatal arch before
the maxillary second deciduous molars are
lost (90% of patients), and we use a
mandibular lingual arch if conservation of the
leeway space is necessary in the mandible.

McNamara-AJODO 2002


Eruption Disturbance


Teeth emerging significantly outside the
specified time ranges should be
considered as abnormal and indicative
of some fault in eruptive movement.
Orban’s Oral Histology


Etiology: Eruption
Disturbances


Systemic:





Nutritional deficiencies
Genetic defects
Endocrine deficiencies

Local





Premature loss of deciduous dentition
Trauma to dental follicle
Cysts of developing tooth germ
Ankylosis

Orban’s Oral Histology

Kurol (AJO 2002)










Ectopic eruption can be handled with 2 phase
treatment and should be handled early due to
chances of resorption in central incisor roots.
Early extraction of 46 palatally placed
deciduous canines was done in people age
10 to 13.
The permanent canine in 78% of the cases
normalized after the extraction.
This reduced the need for orthodontic
treatment later on.
Power et al found the same thing in their
study (BJO 1993)

Kurol (AJO 2002)






Mesiodens can be handled with 2
phase treatment but author is against it
due to possible pathology to developing
central incisors.
In rare cases with spontaneous eruption
the mesiodens can be extracted with
little damage to the to permanent incisor
roots.
Author has not prescribed removal of
mesiodens for last 20 years.

Kurol (AJO 2002)








Ankylosis or impaction can be handled with 2
phase treatment.
Prospective clinical trial performed with
extraction of ankylosed deciduous 1st molars,
Molar on one side extracted on the other side
left to shed normally.
In most cases there was no difference
between the two side but in some cases there
was space deficiency. Therefore space
maintainers should be considered.

Nutritional Deficiencies




Regional differences in tooth and bone development Mappes, Harris, and Behrents

less tangible effects, such as climate,
nutrition and socioeconomic levels, and
urbanization, may also influence the
rates of maturation.
AJODO 1992 Feb


Genetic Deficiencies




AJO-DO 1957 Dec (891 - 918): A critical anaylsis of orthodontic
concept and objectives - Wilson
A study of family histories and monozygotic twins provides
ample proof that many factors are directly attributable to genetic
causes. For example, tooth size and shape and eruption
schedule are clearly so. Likewise, congenitally missing teeth
Which are of genetic and not congenital origin run clear-cut
family histories. Missing maxillary lateral incisors are perhaps
the most common, with mandibular second premolars running
next. These are obviously due to the action of a dominant gene,
which is sometimes sex linked. One can find this characteristic
running throughout family histories for several generations. The
so-called peg lateral incisor is an incomplete expression of that
dominant gene.


Endocrine Deficiencies




Disturbances in the development of the upper jaw and the
middle face (Part I) - Korkhaus

The fact that the lower skull is frequently
accompanied by further degenerative
disturbances in development arouses the
suspicion that endocrine causes, primarily the
hypophysis, are at least partly responsible. It
is possible that this endocrine factor is
secondary as a result of hereditary factors.
AJO-DO 1998, Nov (848 - 868)

Endocrine Deficiencies




Influence of growth hormone on tooth formation - Ito,
Vig, Garn, Hopwood, Loos, Spalding, Deputy, and
Hoard
A matched control sample for tooth development was
derived from untreated children. Tooth formation was
initially delayed although the degree of reduction in
stature exceeded the initial degree of delay in tooth
formation. During this 2-year study, rhGH therapy
had a significant influence on acceleration or gain in
stature, but did not have a significant influence on
tooth formation.

(AM J ORTHOD 1993;103:358-64.)


Premature loss




AJODO 1955 Nov (819 - 826): The significance of
early loss of deciduous teeth in the etiology of
malocclusion - Lundström
The results suggest that it is particularly the earlier
extractions that contribute to the development of
crowding. It is evident also that, even in such cases,
it is not infrequent that normal spacing conditions
eventually may be obtained. The reduction in normal
spacing for the whole dental arch after extractions at
7 or 8 years of age appears to be about 22 per cent
in the upper arch and 13 per cent in the lower.
Otherwise expressed, it seems as if about one-third
of the patients develop crowding in the maxilla and
about one-fourth in the mandible as a result of such
extractions.

Trauma







Incisor trauma and early treatment for Class II Division 1 malocclusion
Lorne D. Koroluk, J. F. Camilla Tulloch, and Ceib Phillips

This study investigated incisor trauma in children
with overjets greater than or equal to 7 mm who
were enrolled in a clinical trial of 2-phase early
orthodontic treatment for Class II malocclusion.
In phase 1, children were randomly assigned to
treatment in the mixed dentition with either
modified bionator or combination headgear or to
a group in which treatment was delayed until the

(Am J Orthod Dentofacial Orthop 2003;123:117-26)










At the start of the trial, 29.1% of the patients had
already had some incisor trauma. This was not
significantly related to dental developmental age.
During the trial, there was an increase in trauma in all 3
groups, but the magnitude of this increase was not
significantly greater in the group for which treatment
was delayed until the permanent dentition.
This might suggest that orthodontic intervention aimed
at reducing trauma should begin very soon after the
eruption of the maxillary incisors.
However, the injuries tended to be minor, and the
expected cost of treatment related to incisor trauma
was small compared with the expected additional cost
of a 2-phase orthodontic intervention.


(Am J Orthod Dentofacial Orthop 2003;123:117-26)


Dentigerous Cyst




AJO-DO 1992 Sep CASE REPORT - Sain, Hollis, and Togrye

Diagnostic records revealed impacted and
displaced teeth resulting from a large
radiolucent lesion. The patient was referred to
an oral surgeon. The lesion was diagnosed
as a dentigerous cyst and marsupialized over
12 months. After decompression of the cyst,
the impacted teeth were exposed and
orthodontically brought into their proper
position.

Ankylosis








AJODO 1998 Jan (24 - 28): Early orthodontic
intervention Larry White
Ankylosed teeth are another mixed dentition problem
that needs orthodontic therapy because it seldom
self-corrects.
It is probably best not to treat this condition too early
because space maintenance will usually be needed
for several months or even years.
By the time the companion permanent tooth on the
opposite side of the mouth is ready to erupt, the
ankylosed tooth should be extracted and the
underlying permanent tooth uncovered if necessary.

Growth Spurt


Acceleration in the incremental changes
in a body that occurs at a certain age.



"A spurt was defined as a growth
acceleration up to a maximum, where
the annual amount of growth exceeded
the previous one by at least 0.7mm".
Ekstrom(1982)


Growth Spurts- Influences


Our best clue to change in this period
lies in evaluating the family's hereditary
pattern where reasonably informative
comparisons can be made between
mother-daughter and father-son. Sistersister is less reliable and brotherbrother the least.

GROWTH SPURTS: Influences






JCO 1971 Apr(191 - 199): Treatment
Timing Onset or Onslaught? - HARRY G.
BARRER.
Growth and maturation move on a curve
of spurts that vary in time and amount
because they are influenced by ethnic and
racial factors, family characteristics, sex,
deprivation, and even socio-economic
background.
During puberty, growth is greater than at
any other period except infancy.

GROWTH SPURTS: Influences






JCO 1971 Apr(191 - 199): Treatment Timing
Onset or Onslaught? - HARRY G. BARRER, D
Sex offers us our best clues to rate of growth, at
least on a comparative basis. Girls start earlier,
go faster, and finish first, at an approximate age
of 16 years. Usually they are ahead of boys by
two years at all levels.
With boys, growth progresses more slowly, there
are more surprises and variability and during
puberty, changes in direction of growth are not
uncommon.

GROWTH SPURTS






AO 1987 No. 1, 50 - 62: Early Facial Growth Accelerations A Longitudinal
Study William L. Krieg.

Growth accelerations also occur at younger ages,
and it is becoming increasingly important that we
have a better understanding of preadolescent facial
growth and the growth spurts that may occur during
the early childhood years.
Early facial growth spurts, in contrast to the
adolescent facial growth spurt, are characterized by
greater variability in their occurrence and magnitude
( NANDA 1955, BAMBHA 1961, HARRIS 1962,
WOODSIDE 1975, EKSTRÖM 1982).

AO 1987 No. 1, 50 - 62: Early Facial Growth
Accelerations A Longitudinal Study William L. Krieg.



They are not always accompanied by the
distinct acceleration in general somatic
growth and stature that is normally
observed during the adolescent growth
spurt ( BAMBHA 1961, SINGER 1980).
These factors have tended to result in a
lack of documentation of the juvenile
facial growth spurts, which remain a littleknown phenomenon.

Growth Spurt : Research




Angle Orthodontist, 1987, 50 - 62: Early
Facial Growth Accelerations A Longitudinal
Study William L. Krieg.
Serial lateral cephalometric radiographs of 21
male and 19 female orthodontically untreated
white children were obtained from the Center
for Human Growth and Development,
University of Michigan, Ann Arbor.
Radiographs were exposed annually on the
subjects’ birthdays over the age range from 5
to 12 years. www.indiandentalacademy.com

Evidence based Orthodontics
Meta Analysis
Randomized Prospective Trials
Retrospective Study

Longitudinal Studies

Cross Sectional Studies

Meta Analysis







Basically it combines the results of several
studies that address a set of related research
hypotheses.
It was first used in medicine in 1955.
This is an observational research where
clinical findings from different studies are
grouped on the basis of evidence rather than
opinion used collectively.
The study rather than the patient becomes
the unit of analysis.( If research design is
strong then the study is valid).

Meta Analysis


The fundamental objective of meta
analysis in clinical research is to use
accumulates information to provide
guidance in the treatment of future
patients.


Randomized Prospective Clinical
Trial




The randomized prospective clinical trial means
the only method of treatment assignment that
produces a strong reassurance.
A randomized clinical trial has the advantage of
allowing comparisons of treatment among groups
for which pretreatment equivalence has been
statistically achieved by a process that avoids
solution bias and defines groups so that
differences in their observed experience can be
attributed to treatment effect.

O’Brien (AJO2003)







randomized controlled clinical trial.
Treated 174 patients with a twin block
and another 174 were observed.
Patients were matched for age, sex and
severity of malocclusion.
The final analysis showed that the twin
block does not affect skeletal class II
malocclusion.

Prospective study


A prospective cohort study measures
exposures in a sample of individuals (a
cohort) and then follows the cohort for a
period of time; disease outcomes are
monitored.


Retrospective Study



Definition
In a retrospective cohort study, the
investigator looks into the exposure records
of individuals to form a historic cohort
population. The occurrence of outcomes in
the population would then be investigated
based on existing information, thus
eliminating the necessity of a follow-up
period, which is required for a prospective
cohort study.

Longitudinal Study




A longitudinal study is a research
study that involves observations of the
same items over long periods of time,
often many decades.
Longitudinal studies track the same
people, and therefore the differences
observed in those people are less likely
to be the result of cultural differences
across generations.

Cross Sectional Study








A cross-sectional study is a study in which disease
and exposure status are measured simultaneously in
a given population.
Cross-sectional studies can be thought of as
providing a "snapshot" of the frequency and
characteristics of a disease in a population at a
particular point in time.
This type of data can be used to assess the
prevalence of acute or chronic conditions in a
population.
However, since exposure and disease status are
measured at the same point in time, it may not
always be possible to distinguish whether the
exposure proceeded or followed the disease.

Age?




No useful correlation seen between the
magnitude of skeletal change during
early growth modification and a
patient’s skeletal or dental maturity,
chronological age or various markers
for malocclusion severity could be
determined.
McNamara has mentioned that there is
an appropriate treatment time but no
valid literature seen.

Age









Gianelly (AO 1994)
Mandibular models of 100 patients in mixed
dentition stage were taken with crowding
present in 85 models.
When leeway space was added 77% had
enough space.
Crowding can be resolved non-extraction in
at least 85% of cases with treatment
beginning after eruption of first premolars.
Author however feels extraction is the
preferred route.

Age





Gianelly (AO 1994)
Ringenberg found no difference in treatment
results obtained in a group of patients treated
according to a serial extraction protocol when
compared with those patients whose
premolars were extracted after eruption of
permanent teeth.
Active treatment for serial extraction group
was six months shorter.

Age



Tulloch et al (AJODO 1997)
Age & Maturity does not seem to play a
major role as within the patient sample
there does not appear to be a linear
association between age & maturity vs
magnitude of treatment response.


AGE







The Angle Orthodontist: Vol. 75, No. 2, pp. 162–170.
Assessment of Orthodontic Treatment Outcomes: Early
Treatment versus Late Treatment:Tsung-Ju Hsieh, Yuliya
Pinskaya, W. Eugene Roberts,

Comparison of the final results between earlyvs late-treatment groups showed that the
early-treatment group had significantly longer
treatment time and worse CCA scores than
the late-treatment group.
There was no significant difference between
early- and late-treatment groups regarding
the ABO OGS score.

AGE




Prematurely terminated treatment was
more prevalent in the early-treatment
group than in the late-treatment group.
the disadvantages of early treatment
was prolonged treatment time, a higher
incidence of premature termination of
treatment, which was attributed to
patient/parent “burn-out.”

Growth Pattern



Tulloch et al(AJODO 1997)
Found that a highly favourable skeletal
correction is as likely or even more
likely in children whose growth is
predominantly vertical.


Growth Pattern










AJODO 2002 Oct:-Managing the developing class III
malocclusion with palatal expansion and facemask therapyTurley(349-52)

Face mask therapy does not normalize
growth.
Treated pt resume class III growth pattern
characterized by deficient maxillary growth
Found that palatal expansion does not
significantly aid in class III correction.
Latent mandibular growth seen as primary
cause of post treatment relapse.








Little (AJODO 1981)
65 cases, 10 years post treatment .
Treated with edgewise in permanent
dentition stage with 1st premolar
extractions.
No supracrestal fibrotomy performed.
All subjects 10 years post retention













Little (AJODO1981)
Results
Irregularity- dropped from 7mm Pre-Rx to 4.6 mm
Post Rx.
Arch width- 60 of 65 cases showed canine expansion
more than 1mm during RX but constriction of 2mm
after Rx.
Arch Length- Due to extractions this reduced but
continued reducing Post Rx.
Overbite- Reduced during Rx but incresed
significantly post Rx.
Overjet-Reduced during Rx and continued to stay the
same Post Rx.









Dugoni et al(AO 1995)
25 mixed dentition patients with records
Used passive lingual arch to maintain
leeway space.
8 males and 17 females
Treated in early mixed dentition
No edgewise orthodontic treatment in













Results
Irregularity Index- dropped sharply during treatment
then rose again slightly post treatment.
Intercanine width- Increased during treatment then
decreased significantly post treatment.
Intermolar width – increased significantly during
treatment then remained unchanged Post Rx.
Arch length- did not change during treatment but
reduced Post Rx.
Overjet- Decreased significantly during Rx
but increased Post Rx.








Overbite- significant reduction during
treatment but significant statistical
increase post Rx.
Conclusion- Lingual arch just as good
as edgewise for reduction of anterior
crowding?.
Overjet?

Early vs Late: The Past




JCO 1971 Apr(191 - 199): Treatment Timing Onset or
Onslaught? - HARRY G. BARRER, D

Guilford, in 1898, said, "The line of distinction
between the advisability of early and late
interference is not always plainly marked."It
would seem that in the last 72 years, we have
not been able to improve the markings
because although we know what we would
like to do, we have not yet developed the
technical ability of accomplishment.

Early Vs Late : The Present
David Turpin (AJODO 2002)




At the international symposium on early
orthodontics.
“I came away with the understanding that
early treatment is seldom efficient – but
often effective.”


The Future





David Carlson(AJODO2002)
The future of orthodontic orthopedic
treatment of dentofacial deformities will see
an increased emphasis on the gene therapy
combined with mechanotherapy.
Molecular genetic techniques will be used to
determine the developmental status of
patients by assessing the presence or
absence and the characterization of genetic
polymorphisms of key molecular mediators of
growth.

The Future


In the more distant future methods will be
developed for targeted use of molecular
mediators to influence development,
growth, and maturation of craniofacial
structures.


CONCLUSION




Two-stage treatment: an outcomes-based
assessment Gianelly A.A.1Progress in
Orthodontics, Volume 1, Number 1, 1 January 2000,
pp. 3-9(7)
Neither self-concept nor the ability to modify growth is
improved by stage-one treatment, also, there are no
skeletodental differences between the results
obtained by one-stage and two-stage treatments.
Accordingly, two-stage treatment cannot be endorsed
on the basis of providing unique and characteristic
psychological or skeletodental benefits.

Conclusion




Semin Orthod 2005 (112-8): Controversies in the timing of Orthodontic
Treatment – Jang, Fields,Vig & Beck

The timing of treatment interventions was influenced
by the severity of malocclusion and the age and
maturation of the patient at the time the patient
presented for treatment.


References






AJODO:1990 Feb (106 - 112): Correction of Class II,
Division 2 malocclusions through the use of the
Bionator appliance: Report of two cases - Rutter and
Witt
JCO: 1971 Apr(191 - 199): Treatment Timing Onset
or Onslaught? - HARRY G. BARRER, D
Angle Orthodontist :1987 No. 1, 50 - 62: Early Facial
Growth Accelerations A Longitudinal Study William
L. Krieg.


References









Contemporary Orthodontics – William Proffit
Orthodontics Principles and Practice – T.M. Graber
Removable Orthodontic Appliances – Graber &
Neumann
Orthodontics & Dentofacial Orhtoopedics –
McNamara & Brudon
Handbook of Orthodontics – Robert Moyers


References






AJODO: 2002 ; Editor's choice
David L. Turpin,    7A
AJODO: 2002 ; Skeletal Class II
patterns in the primary dentition
Arndt Klocke, Ram S. Nanda, Bärbel KahlNiEke,    (596-601)
AJODO: 2002 ; Congenitally missing
teeth: Orthodontic management in the
adolescent patient
Vincent O. Kokich, Jr,    (594-595)

References






AJODO: 2002 ;Early treatment of
tooth-eruption disturbances
Jüri Kurol,    (588-591)
AJODO: 2002 ; Early treatment for
impacted maxillary incisors
Adrian Becker,   (586-587)
AJODO: 2002 ; Early application of
chincap therapy to skeletal Class III
malocclusion
Hideo Mitani,    (584-585)

References












AJODO: 2002 ; Biomechanics of maxillary expansion
and protraction in Class III patients
Peter Ngan,    (582-583)
AJODO: 2002 ; Stability and relapse: Early treatment
of arch length deficiency
Robert M. Little,    (578-581)
AJODO: 2002 ; Serial extraction revisited: 30 years in
retrospect
Jimmy C. Boley,    (575-577)
AJODO: 2002 ; Early intervention in the transverse
dimension: Is it worth the effort?
James A. McNamara, Jr,    (572-574)
AJODO: 2002 ; Treatment of crowding in the mixed
dentition
Anthony A. Gianelly,    (569-571)
AJODO: 2002 ; Stability of open bite treatment
Peter A. Shapiro,    (566-568)

References










AJODO: 2002 ; Early treatment of skeletal
open bite malocclusions
Jeryl D. English   (563-565)
AJODO: 2002 ; Preadolescent Class II
problems: Treat now or wait?
William R. Proffit, J. F. Camilla Tulloch,    (560-562)
AJODO: 2002 ; Treatment timing and
outcome
Hans Pancherz, 559
AJODO: 2002 ; Biological rationale for early
treatment of dentofacial deformities
David S. Carlson   554-558
AJODO: 2002 ; Answers in search of
questioners
Lysle E. Johnston, Jr, (552-554)

References






AO:1995 Early mixed dentition treatment:
postretention evaluation of stability and
relapse Steven A. Dugoni, Jetson S. Lee,
(311 – 320)
Am J Orthod 1981; Little R, Wallen T, Riedel
R. Stability and relapse of mandibularanterior
alignment: first premolar extraction cases
treated by traditional edgewise orthodontics.
(349-65).
Angle Orthod1994; Gianelly AA. Crowding,

References








AJO-DO 1992 Sep CASE REPORT - Sain, Hollis,
and Togrye (270-6).
Am J Orthod Dentofacial Orthop 2003; Incisor trauma
and early treatment for Class II Division 1
malocclusion -Lorne D. Koroluk, J. F. Camilla
Tulloch, and Ceib Phillips (117-26).
AJODO 1955 : The significance of early loss of
deciduous teeth in the etiology of malocclusion –
Lundström. Nov (819 - 826)
AM J ORTHOD 1993;Influence of growth hormone on
tooth formation - Ito, Vig, Garn, Hopwood, Loos,
Spalding, Deputy, and Hoard.(358-64)

References








AJO-DO 1998, Nov ;Disturbances in the development
of the upper jaw and the middle face (Part I) –
Korkhaus (848 - 868)
AJODO 1992 Feb;Regional differences in tooth and
bone development - Mappes, Harris, and Behrents
(145-151).
AJO-DO 1957 Dec: A critical anaylsis of orthodontic
concept and objectives - Wilson (891 - 918).
AJO-DO 1997 Oct: Lower arch perimeter
preservation using the lingual arch Joe Rebellato,
Steven J. Lindauer (449 - 456).

References








AJODO 1995 Nov: One-phase versus two-phase
treatment - Gianelly (556 - 559).
AJO-DO 1991 Nov: Increase in arch perimeter due to
orthodontic expansion - Germane, Líndauer,
Rubenstein, Revere, and Isaacson (421 - 427).
AJO-DO 1954 Dec: Serial extraction in orthodontics:
Indications, objectives and treatment procedures Dewel (906 - 926).
AJO-DO 1969 Jun: Prerequisites in serial extraction Dewel (87 - 93).

References










AJO-DO 1988 Jul : Dental crowding - Radnzic (50 56).
European Journal of Orthodontics 2002; Proportional
changes in cephalometric distances during Twin
Block appliance therapy-M. J. Trenouth .484-91
AJO-DO 1980 Aug: A modified protraction headgear Nanda (125 - 139).
AO 1994 No. 2, 145 - 150: Face mask therapy of
preadolescents with unilateral cleft lip and palate P.
H. Buschang, C. Porter, E. Genecov, D. G...
AJODO 1998 Apr: Profile changes in patients with
class III malocclusions after Delaire mask therapy
Hülya KiliçoJlu. (453 - 462)

References






AJO-DO 1998 Jan (40 - 50): Anteroposterior skeletal
and dental changes after early Class II treatment with
bionators and headgear Stephen D. Keeling, Timothy
T. Wheeler, Gregory J. King (40 - 50) .
JCO 1988 May: Orthopedic Correction of Class III
Malocclusion with Palatal Expansion and Custom
Protraction Headgear - PATRICK K. TURLEY (314 325).
JCO 1991 Feb(102 - 113): Maxillary Protraction
Therapy: Diagnosis and Treatment - JOHN H.
HICKHAM,

References










AJO-DO 1998 Nov : Assessment of skeletal and dental changes
by maxillary protraction Sang J. Sung, Hyoung S. Baik, (492 502).
AJO-DO1984 May: Maxillary traction splint - Caldwell, Hymas,
and Timm (376 - 384).
AJO-DO1992 Sep Dental and orthopedic effects of high-pull
headgear in treatment of Class ll, Division 1 malocclusion Firouz, Zernik, and Nanda (197-205).
AJODO 1998 Jan : The effects of Twin Blocks: A prospective
controlled study - David Ian Lund, (104 - 110).
AJODO 1975:Meldrum, R.: Alterations in the upper facial growth
of Macaca mulatta resulting from highpull head gear.393–441.

References










AO 1994 : A cephalometric evaluation of nonextraction cervical
headgear treatment in Class II malocclusions Gregory W.
Hubbard. 359 - 370.
AJO-DO1994 Oct : Cervical headgear and lower utility arch
treatment - Cook, Sellke, and BeGole (376 - 388).
AJODO 1998 Jan : Early orthodontic intervention Larry White
(24 - 28).
AJODO 1998 Jan (5 - 6): PROCEEDINGS OF THE
WORKSHOP DISCUSSIONS ON EARLY TREATMENT S. E.
Bishara, R. Justus, and T. M. Graber
AJODO 1997 Nov: Early protrusion reduction–two phase
malocclusion correction: A case report R. Don James (523 537).

References








AJODO 2002 Oct:-Managing the developing class III
malocclusion with palatal expansion and facemask therapyTurley(349-52)
Two-stage treatment: an outcomes-based assessment
-Gianelly A.A.1Progress in Orthodontics, Volume 1, Number 1,
1 January 2000, pp. 3-9(7)
Semin Orthod 2005 (112-8): Controversies in the timing of
Orthodontic Treatment – Jang, Fields,Vig & Beck
Am J Orthod Dentofacial Orthop 2003 Apr:- Distal molar
movement with Kloehn headgear:Is it stable?:-Birte Melsen, and
Michel Dalstra(374-8)




AJODO 1992 Apr Cephalometric
changes during treatment with the open
bite bionator - Weinbach and
Smith(367-74)


Early vs late orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

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