Download Dentofacial Orthopedics – Reality or Fantasy!

REVIEW ARTICLE
Dentofacial Orthopedics – Reality or
Fantasy!
Sudheer Kapoor*, Praveen Mehrotra**, Nikhil Malviya***, Sushma Shenoy***, Anchit
Thukral****
(Kapoor S, Mehrotra P, Malviya N, Shenoy S, Thukral A. Dentofacial Orthopedics – Reality or
Fantasy! www.journalofdentofacialsciences.com, 2014; 3(3): 27-30.
Introduction
It has long been the goal of orthodontics to
correct anteroposterior tooth discrepancies. Many
times the problem is only one of tooth
relationships, but often the malocclusion is due to
basal bone dysplasia. Certainly, treatment results
are easier and more stable if the basic and deeper
skeletal units can be altered. It must be decided
whether the developing facial structures should be
considered immutable and genetically controlled
growth patterns or whether they can be
permanently changed by the use of forces applied
to the bone.1
In dentofacial orthopedics, orthodontists
attempt to influence growth by applying an
external force (Figure 1), generally for 2 or 3 years.
*Professor & Head, **Professor & Director, ***Senior
Lecturer, ****PG Student, Department of Orthodontics
& Dental Orthopedics, Sardar Patel Postgraduate
Institute of Dental & Medical Sciences, Lucknow.
Address for Correspondence:
Dr Anchit Thukral, “Thukral House” C-21/30B, Pishach
Mochan, Varanasi-221010
e-mail: [email protected].
Almost all orthopedic appliances act intermittently.
The growth of the jaws in the growing child might
be influenced if the therapy starts at a very young
age and if it continues until growth has stopped.
Duterloo defines orthopedic effect in
orthodontics as a change in the position of bones
in the skull in relation to each other induced by
therapy.
According
to
Isaacson,
orthopedic
appliances
provide a new
muscular and
functional
environment for
the facial bones
that encourages
growth changes
of either the
mandible or the
Figure 1: Headgear
maxilla.
Mandibular and Maxillary Changes with
Functional Appliances – Conflicting Views
One of the most controversial topics in
orthodontics relates to the effectiveness of
functional appliances on mandibular growth. In
skeletal Class II malocclusion, mandibular retrusion
28
seems to be a major contributing factor; it occurs
in about one third of the population.2
Functional appliances encompass a range of
removable and fixed devices that are designed to
alter the position of the mandible, both sagittally
and vertically, to
induce
supplementary
lengthening of the mandible by stimulating
increased growth at the condylar cartilage.3
Experiments
have
demonstrated
that
appliances that positionthemandible anteriorly
stimulate significant mandibular growth by condyle
remodelling in animal models, but the effects
produced in humans are not the same.4 Evidence
shows that favourable growth responses are not
always achieved with functional therapy; some
authors reported increases in overall mandibular
length5and changes in the amount of condylar
growth,6but others believe that mandibular length
cannot be altered by such therapy.7It has been
claimed that most of the correction of the
malocclusion is due to dentoalveolar changes with
a small but statistically insignificant amount of
skeletal effects.4,8,9 There are also controversies
concerning the effects of functional appliances on
the maxilla. Many studies indicate that forward
growth of the maxilla might be inhibited10but other
authors stated that there is no appreciable effect
on the position of the maxilla.4,11
Class II Correctors
A literature survey was performed by applying
the Medline database (Entrez PubMed). The
survey covered the period from January 1966 to
January 2005 and used the medical subject
headings (MeSH). The following study types that
reported data on treatment effects were included:
randomized clinical trials (RCTs), and prospective
and retrospective longitudinal controlled clinical
trials (CCTs) with untreated Class II controls. The
search strategy resulted in 704 articles. After
selection according to the inclusion/exclusion
criteria, 22 articles qualified for the final analysis.
Four RCTs and 18 CCTs were retrieved. The
quality standards of these investigations ranged
from low (3 studies) to medium/high (6 studies).
Two-thirds of the samples in the 22 studies
reported a clinically significant supplementary
elongation in total mandibular length (a change
greater than 2.0 mm in the treated group
compared with the untreated group) as a result of
overall active treatment with functional appliances.
www.journalofdentofacialsciences.com
Mohapatra et al.
The amount of supplementary mandibular growth
appears to be significantly larger if the functional
treatment is performed at the pubertal peak in
skeletal maturation. None of the 4 RCTs reported
a clinically significant change in mandibular length
induced by functional appliances; 3 of the 4 RCTs
treated subjects at a prepubertal stage of skeletal
maturity. The Herbst appliance showed the highest
coefficient of efficiency (0.28 mm per month)
followed by the Twin-block (0.23 mm per
month).12
On the basis of available evidence, it cannot
be concluded that functional appliances are
effective in stimulating and increasing mandibular
growth in the long term. Although favorable
growth changes have been reported following
phase 1 therapy, they are generally not substantial
and long term stability appears to be poor.13
The matter on correction of skeletal Class II
discrepancies in growing children remains
controversial despite extensive research. However
most authors agree on the fact that major
contributions derive from dento-alveolar changes
rather than from skeletal ones.14
A systematic review of mostly Englishlanguage orthodontic articles reporting treatment
of Class II malocclusions with different orthopedic
appliances was carried out. According to this
review, only Herbst therapy was able to change
mandibular growth to a clinically significant
extent.15
A statistical comparison of treatment changes
in twenty patients treated with a Fränkel appliance
and twenty treated with the Edgewise mechanism.
Both groups showed similar improvements, with
no significant differences in mandibular growth.16
Rapid Maxillary Expansion
When a skeletal constricted maxillary arch is
diagnosed, orthopaedic skeletal expansion
involving separation of the mid-palatal suture is
the treatment of choice. Three treatment
alternatives are available for this purpose: rapid
maxillary expansion (RME) (Figure 2), slow
maxillary expansion (SME), and surgical-assisted
RME (SARME). Both SME and RME are indicated
for growing patients, whereas SARME is the
alternative selected for non-growing adolescent
and young adult patients.Even though RME
treatments were reported to bring clinically stable
results, 17 others reported relapse after expansion
was attained.18 Years later, other studies
demonstrated that the attained changes were
Vol. 3 Issue 3
Mohapatra et al.
29
produced primarily in the underlying structures
and, therefore, stable results were expected.19
Figure 2:
Rapid
Maxillary
Expansion
Long-term transverse skeletal maxillary
increase is approximately 25% of the total dental
expansion for pre-pubertal adolescents. Better
long-term outcomes are expected in transverse
changes because of RME in less skeletally mature
patients. RME appears not to produce clinically
significant anteroposterior or vertical changes in
the position of the maxilla and mandible.20
Class III Correctors
Class III malocclusion is associated with a
deviation in the sagittal relationship of the maxilla
and the mandible, characterized by a deficiency
and/or a backward position of the maxilla, or by
prognathism and/or forward position of the
mandible.21
The etiology of Class III malocclusion is
multifactorial because of an interaction of both
hereditary and environmental factors. The
contributions of the cranial base, maxilla,
mandible, and temporomandibular articulation
have been described in detail in the literature.22
Class III malocclusions associated with craniofacial
disharmonies are much
more difficult to treat
and tend to relapse.23
In
a
systematic
review article the quality
standard of the retrieved
investigations
ranged
from low (four studies)
to medium/high (five
studies). Data derived
from
medium/high
quality
research
described over 75% of
success of orthopaedic
treatment of Class III
Figure 3: Facemask
malocclusion (RME and
www.journalofdentofacialsciences.com
facial mask therapy)at a follow-up observation 5
years after the end of orthopaedic treatment.24
(Figure 3)
The orthopaedic effects of chin cap appliances
(Figure 4), which were thought to improve facial
growth in Class III patients with mandibular excess,
became of great interest to clinical orthodontists in
the 1960s. Since then, chincap therapy has been
widely used as a method for treating developing
Class III malocclusions in young patients. A
number of clinical and experimental studies25 have
reported that chincap force had several short-term
orthopaedic effects:
1. Redirection of mandibular growth
2. Backward repositioning of the mandible
3. Retardation of mandibular growth
4. Remodeling of the mandible and the
temporomandibular joint.
Sugawara
et
al26
reported long-term growth
changes of patients treated
by chincap therapy at
various
age
groups
employing
various
treatment schedules. The
possibility
that
these
treatment
effects
may
induce permanent skeletal
changes and alter the
prognathic skeletal profile,
particularly when applied
at an early age, has Figure 4: Chin Cap
maintained an interest in
chincap therapy among orthodontists. However,
little is known about whether the improved skeletal
profile could be maintained until craniofacial
growth was complete. Most studies have been
based on either relatively short-term results or
long-term results that included too few subjects to
be statistically valid.
As for treatment with chincap appliances, the
study on short-term and long-term effects indicates
that, on average, the skeletal profile is greatly
improved during the initial stages of chincap
therapy. However, such changes are rarely
maintained during pubertal growth period.
Treatment with chincap appliances seldom alters
the inherited prognathic characteristics of skeletal
Class III profiles after completion of growth.27
Vol. 3 Issue 3
30
Conclusion
This review might enhance the understanding
of functional and orthopedic therapy by the
general practitioner. Timing of treatment with
functional and orthopedic appliances should be
individualized by the occurrence of pubertal
growth spurt and the overall clinical effect must be
regarded as a combination of skeletal and dentoalveolar changes.
References
1. Chaconas SJ, Capeto AA, Davis JC. The effect of
orthopedic forces on the craniofacial complex
utilizing cervical and headgear appliances. Am J
Orthod. Volume 69, Issue 5, May 1976, Pages
527–539
2. McNamara JA Jr. Components of Class II
malocclusions in children 8-10 years of age. Angle
Orthod 1981; 51:177-202.
3. Johnson LE. Orthodontics: state of the art, essence
of the science. St Louis: C V. Mosby; 1986. p. 8899.
4. Woodside DG, Altuna G, Harvold E, Herbert M,
Metaxas A. Primate experiments in malocclusion
and bone induction. Am J Orthod Dentofacial
Orthop 1983; 83:460-8.
5. Mills JR. The effect of functional appliances on the
skeletal pattern. J Orthod 1991; 18:267-75.
6. Baltromejus S, Ruf S, Pancherz H. Effective
temporomandibular joint growth and chin position
changes: activator versus Herbst treatment. A
cephalometric roentgenographic study. Eur J
Orthod 2002; 24:627-37.
7. Creekmore TD, Radney LJ. Frankel appliance
therapy: orthopaedic or orthodontic? Am J Orthod
Dentofacial Orthop 1983; 83:89-108.
8. Robertson NRE. An examination of treatment
changes in children treated with the functional
regulator of Frankel. Am J Orthod Dentofacial
Orthop 1983; 83:299-310.
9. Janson GR, Toruno JL, Martins DR, Henriques JF,
de Freitas MR. Class II treatment effects of the
Frankel appliance. Eur J Orthod 2003; 25:301-9.
10. Vargervik K, Harvold EP. Response to activator
treatment in Class II malocclusions. Am J Orthod
Dentofacial Orthop 1985; 88:242-51.
11. Basciftci FA, Uysal T, Buyukerkmen A, San Z. The
effects of activator treatment on the craniofacial
structures of Class II division 1 patients. Eur J
Orthod 2003; 25:87-93.
12. Cozza P, Baccetti T, Franchi L, De Toffol
L, McNamara JA Jr. Mandibular changes produced
by functional appliances in Class II malocclusion: a
systematic review. Am J Orthod Dentofacial
Orthop. 2006 May; 129(5):599.e1-12; discussion
e1-6.
www.journalofdentofacialsciences.com
Mohapatra et al.
13. Collett AR. Current concepts on functional
appliances and mandibular growth stimulation.
Aust Dent J. 2000 Sep; 45(3):173-8.
14. Aelbers C, Dermaut L .Orthopedics in orthodontics:
fiction or reality? Literature review. Med Dent 1994;
49(4):26-40
15. Aelbers CM, Dermaut LR. Orthopedics in
orthodontics: Part I, Fiction or reality--a review of
the literature. Am J Orthod Dentofacial
Orthop. 1996 Nov; 110(5):513-9.
16. Adenwalla ST, Kronman JH. Class II, division 1
treatment with Fränkel and Edgewise appliances—a
comparative study of mandibular growth and facial
esthetics. Angle Orthod. 1985 Oct; 55(4):281-98
17. Haas AJ. Palatal expansion: just the beginning of
dentofacial orthopedics. Am J Orthod. 1970;
57:219–255.
18. Timms DJ. An occlusal analysis of lateral maxillary
expansion with midpalatal suture opening. Dent
Pract Dent Rec.1968; 18:435–441.
19. Haas AJ. Long-term post-treatment evaluation of
rapid palatal expansion. Angle Orthod. 1980;
50:189–217.
20. Manuel O. Lagravere , Paul W. Major and Carlos
Flores-Mir. Long-term Skeletal Changes with Rapid
Maxillary Expansion: A Systematic Review Angle
Orthodontist: November 2005, Vol. 75, No. 6, pp.
1046-1052
21. Proffit WR. Contemporary Orthodontics. 4th ed. St
Louis, Mo: Mosby; 2007:689–707.
22. Jacobson A, Evans WG, Preston CB, Sadowsky
PL. Mandibular prognathism. Am J Orthod. 1974;
66:140–471.
23. Arun T, Nalbantgil D, Sayinsu K. Orthodontic
treatment protocol of Ehlers-Danlos syndrome type
VI. Angle Orthod. 2006; 76:177–183.
24. Laura De Toffol; Chiara Pavoni; TizianoBaccetti;
Lorenzo Franchi; Paola Cozza Orthopedic
Treatment Outcomes in Class III Malocclusion A
Systematic ReviewAngle Orthodontist, Vol 78, No
3, 2008
25. Sawa S. Roentgeno-cephalometric study on the
dentocraniofacial growth of the individuals with
reversed occlusion. J Jpn Orthod Soc 1978;
37:237-68
26. Sugawara J, Asano T, Endo N, et al. Long-term
effects of chincap therapy on skeletal profile in
mandibular prognathism. Am J Orthod Dentofac
Orthop 1990; 98:127-133.
27. Junji Sugawara and Hideo Mitani. Facial Growth of
Skeletal Class III Malocclusion and the Effects,
Limitations,
and
Long-Term
Dentofacial
Adaptations to Chin cap Therapy. Semin Orthod
1997; 3:244-254
Vol. 3 Issue 3