Class i i i Treatment With Ske Let a Anchorage

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One-phase vs 2-phase treatment for developingClass III malocclusion: A comparison of identical

twins

Junji Sugawara,a Zaher Aymach,b Hiromichi Hin,c and Ravindra Nandad

Sendai and Nagoya, Japan, and Farmington, Conn

Despite theknown inuenceof early treatmenton thefacial appearanceof growing patientswith skeletal Class III

malocclusion, few comparative reports on the long-term effects of different treatment regimens (1-phase vs

2-phase treatment) have been published. Uncertainty remains regarding the effects of early intervention on

jaw growth and its effectiveness and efciency in the long term. In this case report, we compared the effects

of early orthodontic intervention as the rst phase of a 2-phase treatment vs 1-phase xed appliance treatment

in identical twins over a period of 11 years. Facial and dental changes were recorded, and cephalometric super-impositions were made at 4 time points. In spite of the different treatment approaches, both patients showed

identical dentofacial characteristics in the retention phase. Through this case report, we intended to clarify the

benets of undergoing 1-phase treatment against 2-phase treatment protocols for treating growing skeletal

Class III patients. (Am J Orthod Dentofacial Orthop 2012;141:e11-e22)

In the treatment of skeletal Class IIIgrowing patients, it

has become a common practice to intervene early withorthodontic or orthopedic treatment modalities as

a part of a 2-phase treatment approach. This approachis claimed to provide early and signicant improvement

in the facial pro

le, require fewer surgical interventionsin the future, and produce signicant psychosocial bene-ts for the patient as well as the parents.1-3 Althoughorthopedic forces that attempt to control or alter theskeletal framework in skeletal Class III patients appear to

be remarkably effective in the initial stages, the results

are rarely maintained in the long term.4,5 Previously, wepresented a clinical practice guideline for the treatmentof developing Class III malocclusions (Fig 1).6,7However,it is still difcult to decide whether a 2-phase treatmentis actually better than a 1-phase treatment, especially in

light of mounting evidence that patients with a skeletalClass III malocclusion show neither excessive mandibulargrowth nor decient maxillary growthwhen compared

with Class I subjects at any growth stage.8 Therefore, thekey question is what differences in jaw growth or

treatment modality and outcome will there be betweenpatients who undergo 1-phase treatment and those whodont? This twin study allowed us to elucidate some

benets of 1-phase treatment rather than waiting untilthe postadolescent period.

DIAGNOSIS AND ETIOLOGY

The patients, monozygotic twin sisters (Fig 2), werereferred to our department at Tohoku University, Sendai,

Japan, in 1996 when they were 9 years old for orthodon-

tic treatment of anterior crossbites. Their medical histo-ries showed no systemic diseases or developmental

anomalies. Not surprisingly, both twins had almost thesame orthodontic problems that included a prognathic

prole, mild mandibular asymmetry, Class III denturebases, deviation of mandibular midlines, and occlusal in-

terference of the incisors (Fig 3). Cephalometrically, theirskeletofacial types were classied as Class III short-facetypes. The short-face tendency was more pronouncedin Patient 2 (Fig 4).

TREATMENT OBJECTIVES

Class III short-face skeletofacial types are consideredto have a good prognosis, because their mild jaw

a

Chief orthodontist, skeletal anchorage system orthodontic center; clinical pro-fessor, Division of Maxillofacial Surgery, Tohoku University, Sendai, Japan.bLecturer and assistant researcher, Division of Maxillofacial Surgery, Tohoku

University, Sendai, Japan.cPrivate practice, Nagoya, Japan.dProfessor and head, Department of Craniofacial Sciences, Division of Orthodon-

tics, University of Connecticut, Farmington.

The authors report no commercial, proprietary, ornancial interest in the prod-

ucts or companies described in this article.

Reprint requests to: Ravindra Nanda, Division of Orthodontics, School of Dental

Medicine, University of Connecticut Health Center, Farmington, CT 06030-1725;

e-mail,[email protected].

Submitted, April 2011; revised and accepted, May 2011.

0889-5406/$36.00

Copyright 2012 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2011.05.023

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CASE REPORT
mailto:[email protected]:[email protected]


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Fig 1. Clinicalpractice guideline forthetreatmentof a developingClass III malocclusion. Obs, Observation.

Fig 2. Pretreatment facial photographs of the twins.

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January 2012 Vol 141 Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics


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disharmony allows downward and backward rotation of

the mandible for correction of the anterior crossbite anddeepbite and, therefore, are good candidates for a treat-ment plan involving 2 phases. This includes correction ofthe anterior crossbite in the rst phase followed by a pe-riod of growth observation and then a second phase oftreatment with xed appliances. In light of our previous

discussion regarding early intervention on jaw growth,the treatment objectives for Patient 1 were established

with the 2-phase treatment approach, whereas Patient2 was managed with a 1-phase treatment concept. In-

formed consents were obtained for both patients fromtheir parents.

The treatment objectives for Patient 1 were (1) phase

1 treatment involving dental correction of the anteriorcrossbite, (2) growth monitoring and oral health care un-til the postadolescent period, (3) xed appliance treat-ment for correction of the remaining orthodonticproblems, and (4) retention and long-term follow-up.

For Patient 2, the treatment objectives were (1) growthmonitoring and oral health care until the postadolescentperiod, (2) correction of the malocclusion with xed appli-ance treatment together with skeletal anchorage that

would allow us to circumvent the need for mandibularpremolar extraction, and (3) retention and long-termfollow-up.

Fig 3. Pretreatment intraoral photographs of the twins.

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American Journal of Orthodontics and Dentofacial Orthopedics January 2012 Vol 141 Issue 1


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Fig 4. Skeletofacial types developed from the cephalometric analyses for the twins. They were judged

as skeletal Class III short face. Note that the short-face tendency was more pronounced in Patient 2.

Fig 5. Timing intervals of the comparisons of treatment progress and results. MIP,Maxillary incisors

protractor; MBS,multi-bracketed system;SAS,skeletal anchorage system.

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TREATMENT ALTERNATIVES

Because the twins were skeletal Class III growing pa-tients, growth modication treatments and functional ap-pliances could be alternatives, but they were not included

with our options for the reasons previously mentioned.Treatment alternatives in the postadolescent phase

could have included conventional camouage treatment

with a multi-bracketed system and premolar extractions

together with Class III elastics. This approach would im-prove the Class III occlusion, but it would undermineesthetics, resulting in a more protruded chin and con-cave prole. Orthognathic surgery is also a viable optionfor improving function, occlusion, and esthetics; how-ever, our patients rejected surgery as an option.

Fig 6. The twins at the initial time. Their dentofacial proles were almost identical.

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TREATMENT PROGRESS

Although a 1-phase treatment protocol was chosenfor Patient 2, there was no denitive treatment untilgrowth completion was conrmed. In Patient 1, therst phase of treatment began with facemask therapyand 2 3 4 appliances. The aim was to correct her an-terior crossbite dentally, not skeletally. The crossbite

and maxillary dental midline shift were corrected in 6months.

At the age of 10 and after the rst phase of treat-ment, Patient 1's prognathic prole and dental maloc-clusion had improved signicantly. At the same time,

growth observation in Patient 2 showed that all herorthodontic problems were exactly as they had beenat the initial examination. At age 13, both twins hadcompleted their permanent dentitions. Patient 1 hadmaintained a positive overjet and overbite after therst phase of treatment, whereas Patient 2 showeda slight improvement in her deepbite without ortho-dontic intervention. Both sisters had the possibilityof postpubertal growth of the mandible; therefore,

we decided to elongate the growth observation perioduntil16 years of age as per our clinical practice guide-

lines.6,7

Before the second phase of treatment, Patient 1 stillhad a prognathic prole, with some minor dental prob-lems, particularly in the mandibular dentition. She hada lateral crossbite on the right side, a mild Class III den-ture base, and mild mandibular incisor crowding. At thesame stage, Patient 2 demonstrated more severe ortho-

dontic problems than her sister did at this age. She hada skeletal Class III malocclusion with a short-face ten-dency, premature contact at the incisors, a dental mid-line shift, an anterior crossbite, severe crowding of the

maxillary anterior teeth, and retroclined mandibularincisors.

At this stage, we superimposed the cephalometric ra-diographs from 9 and 16 years of age based on the nat-ural reference structures suggested by Skieller et al9 and

Bjork and Skieller.10 Cephalometric tracings were made

in detail and superimposed carefully. In Patient 1, thesuperimposition showed correction of the anterior cross-bite, with a signicant amount of jaw growth. However,

the amount of jaw growth from 13 to16 years of age wasnegligible. In Patient 2, the cephalometric superimposi-tions showed that the maxilla and the mandible had sig-nicant amounts of downward and forward growth

during the adolescent growth period. Her overbite hadimproved over time.

To correct the rest of Patient 1's orthodontic prob-lems, preadjustedxed appliance treatment was started,and short Class III elastics were used to improve the ClassIII denture bases and prevent proclination of the man-

dibular incisors during leveling and aligning. Treatmentfor Patient 2 started with bonding brackets on the man-dibular teeth and placing resin caps on the maxillary mo-lars to open the bite for maxillary bonding. Open-coilsprings were used to make space and procline the max-illary incisors. Simultaneously, distalization of the man-

dibular posterior teeth was started with the skeletalanchorage system, which uses an orthodontic miniplateas a temporary anchorage device.11 Within severalmonths, her anterior crossbite was completely corrected,and the distalized mandibular posterior teeth were re-tained with the help of ligature wires connected to the

miniplates.After 12 months of active xed appliance treatment,

Patient 1's malocclusion was corrected. She obtaineda balanced prole, with adequate overjet and overbite,proper anterior guidance, and rigid posterior intercuspa-

tion of the teeth. On the other hand, Patient 2's treat-ment with the skeletal anchorage system lasted 18months. She also achieved an acceptable Class I occlu-sion and a satisfactory prole at debonding.

The dentofacial changes during the second phase oftreatment were minimal in Patient 1; only the uprighting

of the mandibular molars was observed. On the other

hand, the cephalometric superimposition in Patient 2before and after treatment with the skeletal anchoragesystem showed that her anterior crossbite was largelycorrected by proclination of the maxillary incisors andclockwise rotation of the mandible, causing extrusion

of her maxillary and mandibular molars. The mandibularmolars were slightly distalized, and the retroclination ofher mandibular incisors was improved purely by lingualroot torque. After 30 months of retention, both twins

have maintained a good occlusion except for a minor re-lapse of the maxillary right rst premolar in Patient 2.Overall, satisfactory results were achieved.

Table I. Lateral cephalometric measurements (initial,age of 9) with standard deviations from norms

Patient 1 Patient 2

SNA 79.6 (0.4) 79.0 (0.6)

SNB 79.8 (1.3) 80.0 (1.3)

ANB 0.2 (0) 1.0 (0)

Mandibular plane to SN 34.6 (0.8) 35.4 (0.8)

Gonial angle 127.0 (0.5) 125.2 (0.8)

U1 to SN 93.6 (1.7) 89.4 (2.4)

L1 to ma ndibular plane 85.8 (1.4) 79.1 (2.5)

L1 to U1 149.9 (2.8) 156.1 (4.0)

Wits 6.5 mm 7.7 mm

N-Me 105.1 mm (1.1) 104.0 mm (1.4)

N-ANS 47.5 mm (0.7) 46.0 mm (1.3)

ANS-Me 58.2 mm (1.4) 58.6 mm (1.3)

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COMPARISON OF TREATMENT PROGRESS AND

RESULTS IN THE TWINS

The cephalometric and clinical comparisons of thetwin sisters took place at 4 time intervals (Fig 5).

1. The initial examination was at age 9 years. Becausethey are monozygotic twins, it is no surprise thateven their dentitions were almost identical. Cephalo-metrically, although Patient 2's short-face tendency

Fig 7. Signicant dentofacial differences were observed at the age of 10. After the rst phase of me-

chanics in Patient 1, her anterior crossbite was corrected after the aring of her maxillary incisors, the

forward displacement of the maxilla, and the clockwise rotation of the mandible. Consequently, her

skeletal facial type became much closer to a Class I average face.

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was a little more pronounced than her sisters, theirdentofacial proles were almost identical (Fig 6;Table I).

2. After Patient 1's rst phase of treatment (age, 10years), the clinical pictures clearly show the efciency

of early intervention for her. Cephalometric superim-position shows signicant dentofacial differences

between the sisters at this stage. Patient 1's crossbitewas corrected by proclinatoin of her maxillary inci-sors, forward displacement of the maxilla, and

Fig 8. Skeletal differences between thesisters at 10 years oldgradually disappearedduring thepuber-

tal growth period, and almost no difference was observed between their skeletal proles at age 16

years. The only difference was in the position of Patient 1's maxillary incisors; this was an orthodontic

effect from the facemask. Before 2nd Phase Tx,After the rst phase of treatment (ie, facemask ther-

apy); Before ortho. Tx, after growth observation only (no interceptive treatment was done).

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clockwise rotation of the mandible. This gave her anorthognathic facial prole compared with Patient 2(Fig 7).

3. Beforexed appliance treatment (age, 16 years), theskeletal differences between them at 10 yearsgradually disappeared during the pubertal growthspurt, and almost no difference could be observed

between their skeletal proles at 16 years. Theonly difference perhaps was in the position of the

maxillary incisors. The orthodontic effect of thefacemask could still be seen on Patient 1's maxillaryincisors (Fig 8).

4. During the retention period (age, 20 years), we

superimposed the twins nal records. Interestingly,

Fig 9. The twins in the retention period. Interestingly, although they underwent orthodontic treatment atdifferent times and with different modalities, their dentofacial morphologies and skeletofacial types at

the nal records were identical.

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although they underwent orthodontic treatmentwith completely different treatment regimens

(1-phase vs 2-phase), their dentofacial morphol-ogies were identical (Fig 9;Table II).

DISCUSSION

The advantage of using monozygotic twins in sucha comparative case report is that all differences in skeletal

growth, beyond the error of measurement, can be assumedto benongenetic and, therefore, the result of the environ-ment.12,13 Themost powerful oral environmental inuencefor the twins was the treatment itself. Mandibular growthcan be controlled with chincup therapy, by altering the

skeletal framework of growing Class III patients. Ourstudies on the short-term and long-term effects of chin-cup force indicated that the skeletal framework is greatlyimproved during the initial stages of chincup therapy.4,5

However, these changes are rarely maintained during thepubertal growth period; when growth is over, any

treatment with the chincup appliance seldom alters theinherited prognathic characteristics of Class III proles.

The second relevant area to review is jaw surgery. Ourlongitudinal studies have given us every reason to believethat surgical orthodontic treatment is the most effectivemodality to obtain a favorable proleandastable occlu-

sion for severe adult skeletal Class III patients.14,15

Third,we need to look back at what we knew then about jawgrowth. Our group had conducted some longitudinalstudies with untreated Class III subjects.16-20 It wasshown that those with skeletal Class III malocclusion

showed neither excessive mandibular growth nordecient maxillary growth when compared with Class I

subjects at any growth stage. Meanwhile, patients withsevere skeletal Class III malocclusionie, those who areindicated for future orthognathic surgeryreceive notreatment for their dental malocclusion until the end

of the pubertal growth spurt. It is important to

collect growth data from a patient to establishan individual growth data base for determining thetiming of orthognathic surgery, to continuously providepsychosocial care, and to professionally control oralhygiene during the long-term observation period.

Nevertheless, when a patient is diagnosed with severeskeletal Class III, phase 1 treatment is recommended. Ac-cording to the clinical practice guidelines that we haveset for managing Class III malocclusions, we believedthat 2-phase treatment was the most benecial forgrowing patients diagnosed with mild to moderate Class

III jaw relationships, such as the twins.

Table II. Lateral cephalometric measurements (nal,age of 20) with standard deviations from norms

Patient 1 Patient 2

SNA 81.1 (0.7) 82.0 (0.4)

SNB 78.8 (0.3) 80.2 (0.3)

ANB 2.3 (0.9) 1.8 (1.2)

Mandibular plane to SN 37.1 (0.1) 36.4 (0.1)

Gonial angle 122.0 (0.8) 122.9 (0.6)

U1 to SN 107.8 (0.6) 112.6 (1.5)

L1 to ma ndibular plane 91.7 (0.2) 92.7 (0.4)

L1 to U1 123.4 (0.6) 118.2 (1.2)

Wits 1.4 mm 2.7 mm

N-Me 123.3 mm (1.0) 121.8 mm (0.4)

N-ANS 52.8 mm (0.8) 52.3 mm (1.0)

ANS-Me 71.4 mm (2.8) 70.4 mm (2.3)

Fig 10. A, Maxillary growth changes of the twins from

ages 9 to 18. Patient 1, who had the rst phase of treat-

ment, showed more maxillary growth than did Patient 2

until they turned 14, but no difference in maxillary lengths

was observed at 18 years of age. B, Mandibular growth

changes of the twins from ages 9 to 18. Obviously, there

was almost no difference between them in mandibular

growth throughout the various growth periods. (Green

andyellow linesrepresent the average growth changes

of untreated Class I and Class III Japanese teenagers

from ages 9 to 14 years taken from longitudinal data.16-21)

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We also looked at the maxillary growth changes that

occurred from ages 9 to 18 years for the sisters. Patient 1,who had 2-phase treatment, showed more maxillarygrowth than did Patient 2 until they turned 14. However,

no difference in maxillary lengths was observed at 18years of age. Consequently, early correction of the ante-rior crossbite had no impact on maxillary growth. Simi-

larly, there was almost no difference between the twinsin their mandibular growth throughout the observationperiod (Fig 10).

Recent clinical trials have suggested that in the long-

term the improvement in the skeletal malocclusion ob-tained after a rst phase of treatment is not signicant

when compared with a control group that had no growthmodication treatment.21,22 It has also been suggestedthat early intervention does not seem to confera signicant psychosocial benet.3 The rst phase oftreatment for Patient 1 was effective, in that her dento-

facial and functional problems were improved consider-ably, and were much better than her sisters. Signicantdifferences were observed between their skeletal prolesat age 10. Nevertheless, their skeletal differences gradu-ally diminished during the pubertal growth period to thepoint that there was almost no difference in their skeletal

prolesat age16. It was obvious that the early correctionof the anterior crossbite did not make a positive impacton jaw growth. It seems that morphogenetic factors arestill stronger and much more dominant than environ-mental factors in the matter of jaw growth.

Interestingly, despite the differences of treatmenttimings and modalities, the twins achieved almostidentical dentofacial proles, and both had favorableocclusions at age 18. Patient 2 who was managed witha 1-phase treatment, had to undergo treatment with

the skeletal anchorage system. The skeletal anchoragesystem is a viable modality for distalizing mandibularmolars.23,24 It enables en-masse movement of the

mandibular buccal segments and even the entire man-dibular dentition with only minor surgery for placingthe anchor plates at the anterior border of the mandib-ular ramus or the mandibular body. It is particularly ef-

fective for correcting Class III malocclusions, mandibularincisor crowding, and dental asymmetries, and rarelyrequires the extraction of premolars. Without theskeletal anchorage system, this twin study would nothave been possible, and such results could not have

been obtained.

CONCLUSIONS

1. In spite of the differences in treatment timing andmodalities (1-phase vs 2-phase treatment), bothtwin sisters achieved almost identical dentofacial re-

sults. This implies that early treatment had no im-pact on jaw growth in the pubertal growth period.

2. Although phase 1 treatment had no impact on jaw

growth, it made the phase 2 treatment simpler

and easier. Therefore, 2-phase treatment might bemore suited for mild to moderate Class III patientsthan 1-phase treatment.

3. The criteria for the selection of 1-phase or 2-phasetreatment depend entirely on the patients require-

ments. Because the biologic outcome is the same,the basis for opting for a particular treatment regi-men can be complicated. Cultural, environmental,and psychosocial factors need to be considered

more carefully.

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Class i i i Treatment With Ske Let a Anchorage