Early Orthopedic Treatment Research Articles

Early treatment of Class III malocclusion: Is it worth the burden?

Protraction facemask therapy has been advocated in early treatment of Class III malocclusions with maxillary deficiency. The dental and skeletal effects of this appliance are well documented in the literature.1-5 One reason that clinicians are sometimes reluctant to render early orthopedic treatment in Class III patients is the inability to predict mandibular growth.6 Patients receiving early orthodontic or orthopedic treatment might need surgical treatment at the end of the growth period. Is it worth the burden to treat a Class III malocclusion early? If so, what type of Class III malocclusions will benefit from early facemask treatment? When is the best time to start treatment? Can early treatment help to predict excessive mandibular growth?

A Modern Rationale for Orthopedics and Orthopedic Retention

Growth modification has been used in orthodontics for many years, however, there has been recent increased debate about the appropriate timing and value of early phase orthopedic treatment in patients with Class II skeletal patterns. While orthopedic appliances have proven their effectiveness in correcting Class II malocclusions, the value of such treatment has recently been challenged by randomized clinical trials (RCTs) that suggest relapse of gains made in the early phase of treatment, minimizing long-term benefits. Although RCTs are a powerful tool for clinicians and researchers, they are not without their limitations and the design of such studies should be carefully considered. Relapse of orthopedic improvement may involve skeletal components, but has been found to be largely dentoalveolar in nature. Despite recent questions of the effectiveness of early treatment, it is generally recognized that the use of growth modification still has a place in modern orthodontic practices. Thus, if early phase treatment is warranted in a growing patient, greater consideration must be given to retention of not only the skeletal change, but maintenance of the dental relationship as well.

Early Timely Treatment of Class III Malocclusion

The protraction facemask has been widely used in the treatment of Class III malocclusion with maxillary deficiencies. However, the benefit of this early treatment modality is not clear. One of the reasons orthodontists are reluctant to render early orthopedic treatment in Class III patients is the inability to predict mandibular growth. The use of a single cephalometric radiograph to predict excessive mandibular growth has severe limitations. The use of serial cephalometric radiographs taken a few years after facemask treatment, and a Growth Treatment Response Vector (GTRV) analysis to individualize and enhance the accuracy in predicting excessive mandibular growth, is presented and proposed. This article discusses the rationale for early timely treatment of Class III malocclusion, the indications and contraindications for early Class III treatment, and provides a method of predicting excessive mandibular growth using the GTRV analysis.

Cephalometric variables to predict future success of early orthopedic Class III treatment

The objective of this study was to select a model of cephalometric variables to predict future Class III growth patterns based on the results of early orthopedic treatment with a protraction facemask. Sixty-four patients with Class III malocclusion were treated with a protraction facemask. Cephalometric radiographs were taken before treatment and a minimum of 3 years after treatment. The sample was divided into 2 groups: successful and unsuccessful according to overjet and molar relationships. Eleven linear and 5 angular measurements were made on the pretreatment radiograph. A logistic regression model was used to identify the dentoskeletal variables most responsible for the prediction of successful and unsuccessful outcomes in subjects receiving treatment. Stepwise variable selection generated 4 variables significant in predicting successful treatment outcomes: position of the condyle with reference to the cranial base (Co-GD, P = .02), ramal length (Co-Goi, P = .03), mandibular length (Co-Pg, P = .01), and gonial angle (Ar-Goi-Me, P < .0001). The gonial angle was found to be significantly larger in the unsuccessful group. Controlling for other variables, the probability of successful treatment is an increasing function of Co-GD and Co-Goi, and a decreasing function of Co-Pg and Ar-Goi-Me. A logistic equation was established that is accurate in predicting successfully treated Class III patients 95.5% of the time and unsuccessful ones 70% of the time. These results suggest that Class III growing patients with forward position of the mandible, small ramal length, large mandibular length, and obtuse gonial angle are highly associated with unsatisfactory treatment outcomes after pubertal growth.

Correction of a severe class III malocclusion

The success of early orthopedic treatment in patients with Class III anomalies depends on facial skeletal development and type of treatment. This case report describes the treatment of a 12.6-year-old girl who had a severe Class III malocclusion with a 6-mm anterior crossbite, a deep overbite, a narrow maxilla, and unerupted maxillary canines. The treatment plan included rapid palatal expansion to expand the maxilla, reverse headgear to correct the maxillary retrognathia, a removable anterior inclined bite plane to correct the anterior crossbite and the deep overbite, and fixed edgewise appliances to align the teeth. One canine was brought into alignment, but the other was placed in occlusion in its transposed position. Ideal overjet and overbite relationships were established, and the final esthetic result was pleasing.

Commentary

Commentary

Speed of sound measurements in mandibular and phalangeal bone during growth

The micromechanical and elastic properties of bone, its structural maturity and, indirectly, mineral density are important factors for the planning and assessment of orthodontic and/or jaw orthopaedic treatment. This clinical study was undertaken to evaluate age-related changes in the anterior mandibular body. The speed of sound (SOS) has demonstrated age dependency in various peripheral bones and has been proposed as an alternative method for investigating bone parameters without the use of radiation. The ultrasound transmission velocity was measured in 184 healthy subjects (93 females, 91 males; mean age 17.6 +/- 13.7 years). According to the statistical analysis, the data did not reveal any gender-related differences, but were significantly age-dependent. Different kinetics were established between the maturity of the phalanx and the anterior mandible. Further clinical investigations of age-dependent structural changes in bone maturation parameters may provide information that should be taken into account for early functional jaw orthopaedic treatment.

Realities of Craniofacial Growth Modification

Facial growth modification can be an effective method of resolving skeletal discrepancies. There still is much controversy regarding our understanding of the nature and extent of skeletal orthopedic change possible in individual patients and the most effective appliances and timing of such treatment. In the treatment of class II patients, growth modification can lead to an improvement, if not complete correction of the class II malocclusion. Although two-phase treatment with an early first prepubertal phase can be effective, a later single-phase approach during early puberty seems to be equally effective. Certainly, before surgical correction of the mild to moderate skeletal class II problem in a growing patient is considered, an orthopedic phase of treatment prior to the pubertal growth spurt is an appropriate first step. Skeletal class III patients with a maxillary deficiency stand to gain significant benefits from early orthopedic treatment. However, such therapy may produce more favorable changes for older children and adolescents than previously thought. Nevertheless, orthopedic correction of the mild to moderate skeletal class III should be accompanied by regular progress evaluations to avoid creating significant dental compensations in the face with little skeletal change that ultimately requires surgery anyway. Skeletal class III patients with mandibular excess and/or vertical excess are poor candidates for growth modification. Orthopedic palatal expansion appears to be effective and stable at any time prior to late puberty, a stage of development when ossification of the maxillary sutures is more advanced. Consequently, the timing for expansion may be better determined by the specific needs of each patient. A functional shift resulting from a crossbite is optimally corrected early, so that asymmetric growth of the mandible can be reduced or even prevented. Postpubertal orthopedic expansion is likely to result in bone bending, which will reverse itself over time, potentially leaving periodontal compromise of the maxillary posterior teeth. Therefore, surgically assisted expansion should be considered in such cases. Vertical maxillary excess is challenging to treat with growth modification. The combination of interocclusal acrylic bite blocks combined with a high-pull headgear presently appears to be the best means available. Unfortunately, this treatment has limited success, it must be continued over many years owing to the long-term nature of vertical growth, and it is counterproductive in achieving a balanced sagittal jaw relationship in class I or class III patients with vertical excess. Future research will permit us to have a greater understanding of the nature and extent of facial growth modification possible in individual patients and the optimal appliances and timing of treatment to achieve the best outcome. The development of intraoral osseointegrated attachments such as implants and onplants hold promise for a future means of dissipating orthopedic forces to prevent unwanted dentoalveolar changes that presently occur with our tooth-borne appliances. Analogous attachments presently are undergoing clinical testing for surgically assisted orthopedic movements associated with distraction osteogenesis.

Comparison Between the Palatal Configurations in Complete and Incomplete Unilateral Cleft Lip and Palate Infants Under 18 Months of Age

Abstract Objective: The purpose of this study was to examine the three-dimensional characteristics of the palatal configurations in incomplete unilateral cleft lip and palate (UCLP) patients and to determine whether there are differences in the effect of early orthopedic treatment between complete and incomplete UCLP patients. Design: Eight infants with incomplete UCLP and 12 infants with complete UCLP, selected at random, wore Hotz plates, and 8 other infants with complete UCLP did not. Palatal impressions were taken of these patients immediately after birth and at 1, 2, 3, 4 (just before cheiloplasty), 6, and 18 months of age (just before palatoplasty). Using our measuring system, the palatal casts were measured and compared three-dimensionally. Results and Conclusions: The palate of the incomplete UCLP patients measured immediately after birth, compared with complete UCLP, showed: (1) smaller posterior arch width; (2) sagittal arch length did not differ; (3) incisal point was located more mesially; (4)...

Evaluation of treatment and posttreatment changes of protraction facemask treatment using the PAR index

The purpose of this study was to use the Peer Assesment Rating (PAR) index score to evaluate the treatment and posttreatment changes of Class III patients treated by protraction facemask. The sample consisted of 20 Chinese children, 6 to 11 years old, with Class III skeletal malocclusion who had been treated with maxillary expansion and a protraction facemask. The average treatment time was 8.2 months, followed by 1 year of retention with a Class III functional appliance. Study casts were taken pretreatment (T1), posttreatment (T2), 1 year follow-up (T3), and 2 years follow-up (T4). After treatment, PAR scores were calculated for each time period. Differences among the 4 time periods were analyzed with the Wilcoxin matched-pairs test. Significant reductions in PAR scores were found at T2 (56%), T3 (70%), and T4 (63%) compared with T1. Immediately posttreatment (T2), 17 (85%) of 20 patients had improved PAR scores by a reduction of at least 30%. Reductions were caused primarily by correction of the anterior crossbite. One year after treatment (T3), further reductions in PAR score were noted (P <.01) as a result of better alignment of the anterior segment, improvement of the buccal occlusion, and overbite and midline corrections. Two years after treatment (T4), PAR scores were higher than at the previous time period. The increases were due to relapses in overjet (4 of 20 patients), overbite, and centerline corrections. These results indicate that significant reductions in the severity of Class III malocclusion can be achieved with early orthopedic facemask treatment. In most cases, further improvement in the PAR score can be expected 1 and 2 years after treatment. In a few patients, the benefits of early treatment are negated by relapses in overjet, overbite, and centerline corrections during the follow-up period. (Am J Orthod Dentofacial Orthop 2000;118:414-20)

Effects of early treatment on maxillary arch development in BCLP. A study on dental casts between 0 and 4 years of age

The present investigation analyses longitudinally the effects of early orthopaedic and/or surgical treatment on maxillary alveolar arch development in 30 children with a complete bilateral cleft lip and palate (BCLP). Palatal arch dimensions were measured on dental casts and their growth velocities during different treatment periods were calculated. Differences in growth velocities between consecutive treatment periods were examined and tested statistically. Furthermore, growth velocities were compared with those of 80 non-cleft children. Before lip closure, growth of the intercanine width of children with a BCLP and non-cleft children was comparable. Only for arch length significantly was less growth observed in BCLP patients in comparison with the control group. After lip closure, intercanine width, arch length and segmental angle diminished. During the intersurgical period, arch form seemed to adapt to a new muscular balance. Immediately after soft palate surgery, growth of the intercanine width and intertuberosity width was restricted. This negative growth was compensated in the postsurgical period, where a catch-up growth of intertuberosity width was even observed.

Rheumatoid Metatarsus. The original evolution of the first metatarsal

Three hundred and eight unselected rheumatoid feet underwent a weight-bearing X-ray examination. If the malformations of the forefoot studied here present a statistical association, the primus metatarsus adductus is closely connected with tarsal arthritis and flattened foot but does not depend on the duration of the disease. The spread forefoot is indeed related to the duration of the disease and the presence of a metatarsal erosion at the foot level, but is not affected by the lesions of the midfoot. It appears then that an early orthopaedic treatment should be prescribed, once the first signs of involvement of the first ray or pronounced pronation of the hindfoot are noticed; it must affect the hindfoot, the midfoot and the first ray which progress together.

Behandlung von Kindern mit Lippen-Kiefer-Gaumen-Spalten-ein Beitrag zur psychosozialen Rehabilitation

The long-term treatment of cleft palate patients starts immediately after birth and is pursued in orderly fashion [correction of persecuted orderly] to adolescence. The results of anonymous survey of the opinion of parents of cleft palate children who undergo or underwent early treatment procedures, up to seven years of age, are presented. Questions concerned mother's or parent's experience of birth, first medical information, early orthopedic care and treatment, and psychosocial adjustment of the children as well. This study suggests that objective findings in children and subjective conditions of parents do not correlate in the beginning, as is to be seen in cleft palate versus cleft lip palate group. One other conclusion indicates the existence of a small quantity of parents able to accept their affected child without additional problems arising from the cleft.

Frühbehandlung von Kindern mit Lippen-Kiefer-Gaumen-Spalten—kieferorthopädische Aspekte

Maxillary alveolar arch morphology and growth was studied in 15 children with complete unilateral cleft lip and palate treated with passive orthopaedic plates. Nine patients were treated to the "Zurich concept" and compared to six children who had lip surgery and primary bone-grafting at about six months of age and complete palate closure at 18 months. Maxillary alveolar arch morphology was described at birth, at six months, at 18 months and at 4.5 years. After early orthopaedic treatment the alveolar and palatal cleft width decreased significantly, the major segment was relocated into a more normal position and the midline deviation was reduced, whereas the minor segment rotated towards the palate.

Cleft Lip and Palate Patients Prior to Delayed Closure of the Hard Palate: Evaluation of Maxillary Morphology and the Effect of Early Stimulation of Pre-School Speech

Speech and maxillary development were analysed in two groups of patients with unilateral cleft lip and palate; both groups had early jaw orthopaedic treatment and a surgical regimen that included two-stage lip surgery (mean ages of 2 and 19 months) and soft palate repair (8 months). Closure of the hard palate was postponed until the children were 8 to 10 years of age. The first group comprised 10 consecutive patients who were analysed at 5 and 7 years of age, and the second group seven patients who were studied at the age of 5. Both groups were thus investigated before the repair of the cleft in the hard palate. In addition to surgical and jaw orthopaedic treatment, the second group of patients received early stimulation of lip and tongue tip movements. Our results indicated that hypernasality was less a problem than was retracted palatal or velar articulation of dental consonants. These deviations tended to be reduced, however, after early stimulation. There seemed to be no clear association between the size of the residual cleft in the hard palate and the extent of speech development. The average size of the residual cleft in our patients was comparatively small, and decreased further during follow up. We conclude that preschool children with unilateral cleft lip and palate may develop good speech, in spite of the residual cleft, if they use an intraoral plate and are given extra lip and tongue tip stimulation, together with early speech therapy if necessary.

Syndrome patients within the framework of the early orthodontic treatment of infants with cheilognathopalatoschisis

The orthodontist's early orthopaedic treatment of the newborn focuses on cleft palate infants and children with Down's syndrome. In more than 100 malformation syndromes, orofacial clefting occurs. The problem of syndrome diagnosis is discussed by way of clinical examples (Robin syndrome, Stickler syndrome). A case of orofacial digital syndrome serves to demonstrate the orthodontists contribution to syndromic diagnosis in early cleft rehabilitation.

Scoliosis in Friedreich's ataxia.

SUMMARY:The preliminary results based on a three year study on the evolution and management of scoliosis in Friedreich’s ataxia are presented. Thirty-two patients were followed in the Neuromuscular Disease Clinic at Sainte-Justine Hospital where standardized spinal radiographs were taken periodically with the Scoliosis Chariot and the Throne.Pathomechanics — Between the age groups I (5 – 10 years) and II (10 – 15 years), a substantial increase in the Cobb values occurs. Associated with it, an increase was observed in the thoracic and thoraco-lumbar projected surface area indices. The relative torsion between the thoracic and lumbar segments was associated with a sudden increase in the Cobb measurements.A computer program which generates a tri-dimensional display of the spine from the coordinates obtained from the standardized radiographs has been adapted to study the importance and influence of the thoracic torsion on the progress of the scoliosis and on the evolution of the total spinal deformity.Management — Prevention of the progression of established curves was our main objective. Careful examination of the spine, depending on the age of the child, in our preliminary study, stimulated early orthopaedic treatment in any curve of 20° or more. There was always concern for curves of 30° or more. In the growing child, bracing which was recommended is now under a more thorough investigation. The use of spinal pacemakers is being clinically evaluated.In the older child, the curve was usually stable after sixteen years of age. Surgery was usually attempted in curves over 40° in the growing child. The same curve was usually stable after the growth period.For the non-ambulatory patients, the present study suggested the prescription of a molded seat with the following characteristics: i) a posterior lumbar support, ii) low thoracic lateral supports and Hi) a slight inclination of the seating system. This was presumed to be beneficial in maintaining stability of the spine.

Orthodontic Treatment of Malocclusion Associated with Repaired Complete Clefts of the Lip and Palate

The literature concerning orthodontic treatment of malocclusion associated with cleft lip and palate has been reviewed. The aims of treatment and a number of skeletal, soft tissue, dento-alveolar and general care factors which influence treatment planning are discussed. The effect of early orthopaedic treatment, examined solely on the grounds of eventual arch form in the deciduous dentition, reveals a prophylactic benefit in some, but not all reports. There would appear to be little benefit in carrying out orthodontic treatment in the deciduous dentition but it is suggested that the progressive development of severe overclosure during the mixed dentition phase should be intercepted using simple appliances. The most important phase of treatment follows eruption of the permanent dentition and appliances are described which are capable of substantial radial and vertical corrections in preparation for a permanent prosthesis.

Early Orthopaedic Treatment of Unilateral Cleft Lip and Palate

Serial frontal and lateral cephalometric radiographs with implants and study models of 31 infants' who received orthopaedic treatment for unilateral cleft lip and palate, were analysed with an electronic XY reader. Partial data for 50 normal infants and 10 isolated palatal cleft patients were included to allow certain comparisons. The records at birth indicate that the size of the alveolar cleft in unilateral cleft cases is governed mainly by the degree of transverse segmental separation which is present and only to a lesser extent by deficiency of alveolar tissue, except in a minority of cases. It is clear that in the early months of life, the divided maxillary arch can be made to assume near normal dimensions by inward rotation of the anterior ends of the segments, at the alveolar and basal level, around axes in the tuberosity regions. Appositional growth of the cleft margins makes little contribution to the reduction in cleft size. The significance of the findings is discussed.

Prediction of abnormal growth in Class III malocclusions

Four significant factors have been identified in the lateral cephalometric head film which would indicate the likelihood of the patient growing in an abnormal Class III manner. The normal person grows approximately the same amount from basion to nasion as he does on the corpus axis of the mandible. The abnormal Class III syndrome grows greater increments on the mandible than at the cranial base. For the purpose of determining the accuracy of computer prediction of abnormal growth, fourteen skeletal Class III cases were selected from the files of the Hokkaido University Orthodontic Department. A significant relationship was shown between abnormal growth and the sum of the standard deviations from the normal of the four cephalometric “predictor measurements”. These data would give the clinician insight as to which patients might require early orthopedic treatment (chin cup), conventional orthodontic treatment, or surgical orthodontic correction after growth is complete. This is the first published demonstration of computerized cephalometric methods showing the ability to distinguish between normal and abnormal growth in a particular patient type. It is hoped that, through the comparison of thousands of predictions with actual data, more recognizable abnormal growth patterns will appear in the future.