Chairman:Prof.LeziaPerillo › wp-content › ...IkedaK.etal,2009 MANDIBULAR RETRUSION need of differential diagnosis ... clinical!cases!PROVA! !!!!! LP,2018! LONGKTERMFR2!TREATMENT!EFFECTS!

UNIVERSITY OF CAMPANIA Luigi Vanvitelli POSTGRADUATE PROGRAM IN ORTHODONTICS

Chairman: Prof. Le@zia Perillo

www.ortodonzia.unicampania.it LP, 2018

#3 Long-‐term outcomes

#1 Differen@al diagnosis

#2 Fränkel-‐2 appliance

#4 Clinical Cases

MANDIBULAR RETRUSION outline


McNamara JA.

Components of Class II malocclusion in children 8-‐10 years of age. Angle Orthod. 1981; 51:177-‐202.

153 124

8 -‐ 10 yrs

277 skeletal Cl II malocclusions

Ø  Mandibular skeletal retrusion was the most common single characteris@c

MANDIBULAR RETRUSION common finding


Horizontal Typing Ver@cal Typing

A normal max & mdb posi@on -‐ U incisor proclina@on 1 CW mdb, occl, pal plane Long face

B max prognathism -‐ U incisor proclina@on 2 flat mdb, occl, pal plane Square face

C max & mdb retrognathism -‐ U & L incisor proclina@on 3 CW mdb, ccw pal plane

D max & mdb retrognathism & U incisor proclina@on 4 CW mdb, occl, pal plane

E max prognathism -‐ U & L incisor proclina@on 5 flat mdb, occ plane, CW pal plane

F mdb retrognathism: heterogeneous group of disorders, not well typified

Moyers RE, Riolo ML, Guire KE, Wainright RL, Bookstein FL. Differen@al diagnosis of class II malocclusions. Facial types associated with class II malocclusions.

Am J Orthod. 1980;78:477-‐94.

697 12 -‐ 16 yrs

MANDIBULAR RETRUSION not a single diagnostic entity


Ø  Rota@onal Ø  Posi@onal Ø  Dimensional

Go-‐Pg < Se-‐N + 3 mm (7-‐12 yrs)

SN^Go-‐Me > 36° NS^Ar > 123°

S N

Go

Me

Ar

N

S Se

Pg

Go

N

Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with func@onal appliances.

St. Louis: Mosby; 1997.

MANDIBULAR RETRUSION different phenotypes

DMR RMR PMR


Micro mandible Retrusive mandible

Underdeveloped mandible

Posteriorly dispaced glenoid fossa

Posteriorly placed mandible to cranial anatomy

Retroposi@oned mandible

Distally posi@oned mandible Retruded mandible

Posterior posi@oned mandible

Short mandible

“The best outcome begins with a complete and accurate diagnosis” Ikeda K. et al, 2009

MANDIBULAR RETRUSION need of differential diagnosis


MANDIBULAR RETRUSION the blending of class II


MANDIBULAR RETRUSION aim


DIMENSIONAL 28.9%

POSITIONAL 6.6%

Perillo L, Padricelli G, Isola G, Femiano F, Chiodini P, Matarese G. Class II malocclusion division 1: a new classifica@on method by cephalometric analysis.

Eur J Paediatr Dent. 2012;13:192-‐6.

DIMENSIONAL ROTATIONAL

27.6%

DIMENSIONAL POSITIONAL 12.5%

Se

Pg Go

N

Ar

N S S

N

Go Me

ROTATIONAL 7.2 %

ROTATIONAL POSITIONAL

5.9%

DIMENSIONAL ROTATIONAL POSITIONAL 12.5 %

MANDIBULAR RETRUSION 7 different phenotypes


MANDIBULAR RETRUSION conclusions


Fränkel R. The treatment of Class II, Division 1 malocclsuion with func@onal correctors.

Am J Orthod. 1969;55:265-‐75.

MANDIBULAR RETRUSION dimensional type


MANDIBULAR RETRUSION end of growth


MANDIBULAR RETRUSION


MANDIBULAR RETRUSION treatment


Short-‐term outcomes X Chadwick SM et al, 2001 X O’ Brien K et al, 2003 X O’ Brien K et al, 2003 X Tulloch JFC et al, 2004 X Dolce C et al, 2005 X O’ Brien K et al, 2009 X Thiruvenkatachari B et al, 2010 X Chen DR et al, 2011 X Baysal A et al, 2013 X Chhibber A et al, 2013 X Guimaraes CH Jr et al, 2013 X Candir M et al, 2017 X Oh H et al, 2017

Systema@c review & Meta-‐analysis X Chen JY et al, 2002 X Koretsi V et al, 2014 X Bock NC et al, 2015 X D’Antò V et al, 2015 X Pacha MM et al, 2015 X Thiruvenkatachari B et al, 2015 X Zymperdikas VF et al, 2015

MANDIBULAR RETRUSION if


Short-‐term outcomes

www.ortodonzia.unina2.it

ü  Mc Namara JA et al, 1985 ü  Falck F et al, 1989 ü  Mc Namara JA et al, 1990 ü  Nelson C et al, 1993 ü  Mc Namara JA et al, 1996 ü  Moss JP et al, 1997 ü  Tulloch JFC et al, 1997 ü  Ghafari J et al, 1998 ü  Illing HM et al, 1998 ü  Morris DO et al, 1998 ü  Franchi L et al, 1999 ü  Rushforth CDJ et al, 1999 ü  Toth LR et al, 1999 ü  Tumer N et al, 1999 ü  Baccev T et al, 2000 ü  Ucuncu N et al, 2001 ü  De Almeida MR et al, 2002 ü  De Almeida MR et al, 2002 ü  Patel HP et al, 2002 ü  Wheeler TT et al, 2002 ü  Basciwci FA et al, 2003 ü  Janson G et al, 2003 ü  Pangrazio KV et al, 2003 ü  Singh GD et al, 2003 ü  Araujo AM et al, 2004 ü  Cozza P et al, 2004 ü  Schaefer AT et al, 2004 ü  Ruf et al, 2006 ü  Almeida RR et al, 2007

Systema@c reviews & Meta-‐analysis

MANDIBULAR RETRUSION if


ü  Perinev G et al, 2015 ü  Yang X et al, 2015 ü  Bock NC et al, 2016 ü  Madurantakam P, 2016 ü  Santamaría A et al, 2017

ü  Cozza P et al, 2006 ü  Antonarakis GS et al, 2007 ü  Marsico E et al, 2011 ü  Perillo L et al, 2011 ü  Ehsani S et al, 2014

Long-‐term outcomes ü  Falck F, 1991 ü  Perillo rt al, 1996 ü  Omblus J et al, 1997 ü  Mills CM et al, 2000 ü  Fal@n K et al, 2003 ü  Berger JL et al, 2005 ü  Bock NC et al, 2006 ü  VanLaecken R et al, 2006 ü  Nelson B et al, 2007 ü  Freeman DC et al, 2009 ü  Malta LA et al, 2010 ü  Perillo L et al, 2011 ü  Angelieri F et al, 2014 ü  De Abreu F et al, 2014 ü  Pancherz H et al, 2014 ü  Pancherz H et al, 2015 ü  Bigliazzi R et al 2015 ü  Bock NC et al, 2016 ü  Franchi L et al, 2016 ü  Pavoni C et al, 2017 ü  Bock NC et al, 2017

ü  Marsan G, 2007 ü  Baccev T et al, 2009 ü  Siara-‐Olds NJ et al, 2010 ü  Jamilian A et al, 2011 ü  Wigal T et al, 2011 ü  Biava@ A et al, 2012 ü  Booij JW et al, 2013 ü  Franchi L et al, 2013 ü  Mar@na R et al, 2013 ü  Perillo L et al, 2013 ü  Showkatbahsh R et al, 2013 ü  Li L et al, 2014 ü  Burhan AS et al, 2015 ü  Cheung RNY et al, 2015 ü  Giun@ni V et al, 2015 ü  Cirgic E et al, 2015 ü  Bassarelli T et al, 2016 ü  Khoja A et al, 2016 ü  Schulz S et al, 2016 ü  Tomblyn T et al, 2016 ü  Aras I et al, 2017 ü  Baazhia AS et al, 2017 ü  Ba@sta KBSL et al, 2017 ü  Ciaravella D et al, 2017 ü  Eissa O et al, 2017 ü  Spalj S et al, 2017 ü  Arora V et al, 2018 ü  Idris G et al, 2018 ü  Kinzinger GSM et al, 2018

Dento-‐skeletal

changes

MANDIBULAR RETRUSION why

Environmental

factors

Transverse discrepancy


Baccev T, Franchi L, McNamara JA Jr. The Cervical Vertebral Matura@on (CVM) method for the assessment of op@mal treatment

@ming in dentofacial orthopedics. Seminars in Orthodon@cs. 2005;11:119-‐29.

1 year -1 yr -2 yrs +1 yr +2 yrs

Mandibular growth peak

CVMS 3 -‐ 4

Perinev G, Primozic J, Franchi L, Contardo L. Treatment Effects of Removable Func@onal Appliances in Pre-‐Pubertal and Pubertal Class II Pa@ents:

A Systema@c Review and Meta-‐Analysis of Controlled Studies. PLos One. 2015; 10(10): e0141198.

MANDIBULAR RETRUSION when

during pubertal age


1 year -1 yr -2 yrs +1 yr +2 yrs

Suresh M, Ratnaditya A, Kavmani VS, Karpe S. One phase versus two phase treatment in mixed den@@on: a cri@cal review.

J. Int. Oral Health. 2015; 7(8): 144-‐147.

MANDIBULAR RETRUSION when

during pre-‐pubertal age

Mandibular growth peak

CVMS 2 -‐ 3


Barber SK, Forde KE, Spencer RJ. Class II division 1: an evidence-‐based review

of management and treatment @ming in the growing pa@ent.

Dent Update. 2015; 42(7): 632-‐4, 637-‐8, 641-‐2.

Fränkel-‐2

Ac@vator Bionator II

Sander

High Pull Head Gear

Teuscher Twin-‐Block

Class II elas@cs

Herbst

Jusper Jumper

MANDIBULAR RETRUSION how




Frankel R. The treatment of Cl II, Division 1 malocclusion with

func@onal correctors. Am J Orthod. 1969;55(3):265-‐75.

FR-‐2 appliance

ü McNamara J et al, 1985 ü  Falck F et al, 1989 ü  McNamara J et al, 1990 ü  McNamara J et al, 1996 ü  Ghafari J et al, 1998 ü  Toth LR et al, 1999 ü  Rushforth CDJ et al, 1999

ü De Almeida MR et al, 2002 ü De Almeida MR et al, 2002 ü  Patel HP et al, 2002 ü  Janson G et al, 2003 ü  Silvestrini A et al, 2012 ü  Perillo L et al, 2013 ü  Showkatbahsh R et al, 2013 ü  Schulz S et al, 2016

MANDIBULAR RETRUSION FR-2

FR-‐2 short-‐term outcomes


SHORT-‐TERM FR-‐2 TREATMENT EFFECTS meta-‐analysis


ü  Falck F, 1991 (10 yrs) ü Perillo L et al, 1996 (5 yrs) ü Berger JL et al, 2005 (3 yrs)

ü Freeman DC et al, 2009 (10 yrs) ü Perillo L et al, 2011 (10 yrs) ü Angelieri F et al, 2014 (7 yrs)

MANDIBULAR RETRUSION FR-2

FR-‐2 long-‐term outcomes



MANDIBULAR RETRUSION after 5 year

after the end of treatment


MANDIBULAR RETRUSION after 10 year

after the end of treatment

To verify the stability of the dento-‐skeletal changes

awer FR-‐2 treatment at the end of growth

in a sample of class II malocclusion

by Dimensional Mandibular Retrusion

MANDIBULAR RETRUSION aim


LONG-‐TERM FR-‐2 TREATMENT EFFECTS selec@on sample

FR-‐2 treated pa@ents from 1988 to 1998

Class II, div 1 malocclusion Ø  at least an end-‐to-‐end molar rela@onship Ø  OVJ > 4 mm

Skeletal class II malocclusion Ø  ANB > 4° Ø  SNB < 78°

Dimensional Mandibular Retrusion Ø  Go-‐Pg < Se-‐N + 3 mm Age 8-‐10 yrs Ø  mixed den@@on / CVMS 1-‐2

FR-‐2 Treatment Ø  at least 1 yr Ø  16-‐18 hrs/day Ø  2-‐3 mm ac@va@on every 6 mos Post FR-‐2 Treatment Ø  fixed appliances Ø  no Cl II elas@cs Ø  2-‐yr reten@on High quality LL X-‐rays Ø  pre FR-‐2 Ø  post FR-‐2 Ø  end of growth (min. 13 yrs awer FR-‐2 è un risultato )

Ø  previous orthodon@c tx / max protrusion / cw mdb rota@on / posterior mdb posi@on


20 11 9 24.4 yrs – CS 6 10.6 yrs -‐ CS 3 or 4 26.1 yrs / CVMS 6

9 yrs / CS 1-‐2

10.6 yrs / CVMS 2-‐3

Long-‐term

15.7 yrs T0 1.9 yr T2 T1

same inclusion criteria sex, age, CVMS, and observa@onal period

8.9 yrs / CVMS 1-‐3

LONG-‐TERM FR-‐2 TREATMENT EFFECTS dimensional mandibular retrusion samples

Ø  comparison of changes T2-‐T1 within FR-‐2 sample


N N

Ar

S

A

B

Me

Go

Se

SNP SNA

Go

Me

A

Gn

Pg

Co S

Dimensional Mandibular Retrusion (DMR) Go-‐Pg < Se-‐N + 3 mm from 7 to 12 yrs

Graber TM, Rakosi T, Petrovic AG.

Dentofacial orthopedics with func@onal appliances. St. Louis: Mosby; 1997.

LONG-‐TERM FR-‐2 TREATMENT EFFECTS cephalometric analysis


Con@nuous variables Ø Mean and standard devia@on Ø Un-‐paired t-‐test for comparison between groups Ø Paired t-‐test for comparison

of change increments

within groups

Sta@s@cal Analysis System

Ø  SAS version 9.2

Ø  Sta@s@cal Significance p < 0.05

Categorical variables Ø Absolute numbers and

percentages Ø Chi-‐square test

Error study Ø  Dahlberg’s formula Ø  10 LL X-‐rays at random Ø  0.21-‐ 0.64

LONG-‐TERM FR-‐2 TREATMENT EFFECTS sta@s@cal analysis


8.4 yrs 9.8 yrs 23.0 yrs

9.4 yrs 10.6 yrs 23.8 yrs

8.5 yrs 10.1 yrs 28.5 yrs

11.9 yrs 30.2 yrs 9.11 yrs

10.1 yrs 25.4 yrs

8.9 yrs

9.8 yrs 11.7 yrs 33.8 yrs

LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases


8.4 yrs 9.8 yrs 23.0 yrs

9.4 yrs 10.6 yrs 23.8 yrs

8.5 yrs 10.1 yrs 28.5 yrs

11.9 yrs 30.2 yrs 9.11 yrs

10.1 yrs 25.4 yrs

8.9 yrs

9.8 yrs 11.7 yrs 33.8 yrs

LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases PROVA



9.9 yrs 11.6 yrs 27.7 yrs

9.4 yrs 11.3 yrs 24.7 yrs

9.5 yrs 23.6 yrs

8.5 yrs

9.6 yrs 25.8 yrs

8.1 yrs

9.6 yrs 11.0 yrs 24.8 yrs

9.3 yrs 8.1 yrs 22.5 yrs

9.11 yrs 11.9 yrs 25.8 yrs www.ortodonzia.unicampania.it

9.9 yrs 23.1 yrs

8.2 yrs

8.7 yrs 10.4 yrs 27.9 yrs

9.3 yrs 10.5 yrs 23.7 yrs

9.10 yrs 11.9 yrs 25.0 yrs

10.3 yrs 32.4 yrs

8.4 yrs


9.6 yrs 23.3 yrs 8.5 yrs


LONG-‐TERM FR-‐2 TREATMENT EFFECTS agreement

ü  De Almeida MR et al, 2002 ü  Patel HP et al, 2002 ü  Janson G et al, 2003 ü  Silvestrini A et al, 2012 ü  Perillo L et al, 2013 ü  Showkatbahsh R et al, 2013 ü  Schulz S et al, 2016

ü  Falck F, 1991 ü Perillo L et al, 1996 ü  Berger JL et al, 2005 ü  Freeman DC et al, 2009 ü  Perillo L et al, 2011 ü Angelieri F et al, 2014

Long-‐term outcomes Short-‐term outcomes


ü  McNamara J et al, 1985 ü  Falck F et al, 1989 ü  McNamara J et al, 1990 ü  McNamara J et al, 1996 ü  Ghafari J e al, 1998 ü  Toth LR et al, 1999 ü  Rushforth CDJ et al, 1999 ü De Almeida MR et al, 2002

LONG-‐TERM FR-‐2 TREATMENT EFFECTS agreement


AFTER FR-‐2 TREATMENT

AT THE FOLLOW-‐UP, AFTER 15.7 YRS OF FR-‐2 TREATMENT

LONG-‐TERM FR-‐2 TREATMENT EFFECTS conclusions

Ø  mandibular increments Ø  intermaxillary rela@onship improvements Ø  incisor compensa@on

Ø  stability of mandibular changes Ø  no rebound Ø  mandibular body, ramus and total length con@nued to increase over@me Ø  slight lower incisor compensa@on


Leonardo, 9.3 yrs


CEPHALOMETRIC ANALYSIS

MEASUREMENTS INITIAL

SNA 82° SNB 75.5° ANB 6.5° Se-‐N 76 mm PNS-‐A 50 mm Go-‐Pg 73.5 mm Co-‐Go 52 mm Co-‐Gn 109 mm

Ar-‐Go-‐Me 128° SN-‐Go-‐Me 34°

1/SN 110° 1/Go-‐Me 85°


Leonardo, 10.8 yrs awer 1.5 yr of FR-‐2



MEASUREMENTS INITIAL AFTER FR-‐2

SNA 82° 82° SNB 75.5° 78° ANB 6.5° 4° Se-‐N 76 mm 76 mm PNS-‐A 50 mm 50 mm Go-‐Pg 73.5 mm 76 mm Co-‐Go 52 mm 55 mm Co-‐Gn 109 mm 112 mm

Ar-‐Go-‐Me 128° 128° SN-‐Go-‐Me 34° 33°

1/SN 110° 99° 1/Go-‐Me 85° 87°


Leonardo, 9.3 yrs before…

Leonardo, 10.8 yrs …and awer

… 1.5 yr awer FR-‐2 treatment


Leonardo, 25.9 yrs 15.1 yrs awer FR-‐2 treatment



MEASUREMENTS INITIAL AFTER FR-‐2 LONG-‐TERM

SNA 82° 82° 81.5° SNB 75.5° 78° 79° ANB 6.5° 4° 2.5° Se-‐N 76 mm 76 mm 81 mm PNS-‐A 50 mm 50 mm 54.5 mm Go-‐Pg 73.5 mm 76 mm 84 mm Co-‐Go 52 mm 55 mm 65 mm Co-‐Gn 109 mm 112 mm 124 mm

Ar-‐Go-‐Me 128° 128° 124° SN-‐Go-‐Me 34° 33° 31°

1/SN 110° 99° 100° 1/Go-‐Me 85° 87° 90°


TODAY

Leonardo, 26 yrs


This is longest follow-‐up of FR-‐2 appliance (15.7 yrs)

“In vitro” research

Animal research

Ideas, Editorials, Opinions

Case Report

Case Series

Case Control Studies

Cohort Studies RCT

SR and MA

Ø Small sample

Ø Pre-‐pubertal age

LONG-‐TERM FR-‐2 TREATMENT EFFECTS progress & limita@ons

Ø Follow-‐up included fixed appliance and reten@on

Ø Biased sample

Ø Retrospec@ve study


LONG-‐TERM FR-‐2 TREATMENT EFFECTS future prospec@ves

Ø  Prospec@ve study

Ø  Larger sample

Ø  Pre-‐pubertal vs pubertal sample


Ø  Differen@al diagnosis of mandibular retrusion

Ø  S@mulate mandibular growth only in case of dimensional mandibular retrusion

Ø  Use FR-‐2 for long-‐las@ng skeletal and dental changes

Ø  Treat the phenotype but don’t forget the genotype

LONG-‐TERM FR-‐2 TREATMENT EFFECTS Take Home Message

LONG-‐TERM STABILITY OF FR-‐2 TREATMENT MAY STILL BE CONSIDERED AN ACHIEVABLE GOAL


UNIVERSITY OF CAMPANIA Luigi Vanvitelli POSTGRADUATE PROGRAM IN ORTHODONTICS

Chairman: Prof. Le@zia Perillo

[email protected]@unicampania.it

LP, 2018 www.ortodonzia.unicampania.it

AAO Donated Orthodon@c Services (DOS) Program

All that is missing is You!

•  Introduced in 2009, the DOS program provides access to care for children in need. Access to quality orthodon@c care is missing in many children’s lives. The AAO DOS program mission is to serve low income children without insurance coverage or that do not qualify for other assistance in their state of residence.

•  The program has expanded to include 10 state programs and currently serves children in Illinois, Indiana, Kansas, Michigan, New Jersey, North Carolina, Rhode Island, Tennessee, Texas and Virginia.

•  In addi@on to the state programs, orthodon@sts from all across the U.S. have volunteered to provide treatment to DOS pa@ents not residing in one of the areas served by state programs.

•  In order to expand further, we need you to help us by volunteering to serve as a provider orthodon@st or help iden@fy orthodon@sts willing to lead efforts to establish a DOS chapter in your state.

•  Contact Ann Sebaugh at [email protected] with ques@ons.

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Chairman:Prof.LeziaPerillo › wp-content › ...IkedaK.etal,2009 MANDIBULAR RETRUSION need of differential diagnosis ... clinical!cases!PROVA! !!!!! LP,2018! LONGKTERMFR2!TREATMENT!EFFECTS!