Role of treatment timing in prognosis and success of orthodontic

treatment

Table of contents

• Introduction

• objectives of treatment

• Principles in treatment timing

• Gold standard in treatment timing

• Cvm method for assesment of growth

• Treatment timing for functional appliances

• Treatment timing for correcting class II and class III

• psychological influences on treatment timing

 Role of treatment timing in prognosis and success of orthodontic
treatment

INTRODUCTION

There is an ongoing discussion among general dentists and orthodontists regarding the optimal

time to initiate orthodontic treatment under various clinical conditions. Since the objectives of

orthodontic care must include the minimal amount of treatment that achieves the maximum

benefit for each patient, the timing of the commencement of treatment becomes of paramount

importance. Each patient should expect and receive only that amount of orthodontic treatment

that minimizes both the biologic and financial cost to them and yet obtain the optimal outcome.

Hence there is a debate and need for information as to which treatment modality is most

effective and can achieve the objectives in an appropriatetime.

Overall goal of early treatment is to improve or correct orthodontic problems that would result in

irreversible damage to the dentition and supporting structure and progress into a more severe

orthodontic problem that would be more difficult to treat in Phase II.

OBJECTIVES OF ORTHODONTIC TREATMENT

Minimal amount of time

Cost effective

Improve or correct orthodontic problems

Effective

Efficient

PRINCIPLES OF TREATMENT THAT AFFECT THE TREATMENT TMING

GROWTH MODIFICATION desirable

Enough remaining growth

 Role of treatment timing in prognosis and success of orthodontic
treatment

Growth must have declined to slow adult level before intervention to control it can end

GROWTH IN THREE PLANES

Transverse growth- ends in adolescent growth spurt

Vertical growth-continues to late teens

Sagittal growth-declines as sexual maturity attained

TOOTH ERUPTION CORRELATION ---WITH SKELETAL GROWTH

Correlation coefficients for facial growth to most developmental stages-0.8

Correlation of dental development with facial growth-0.7

50-50 chances of coincidence b/w tooth eruption and jaw growth

GOLD STANDARD FOR ORTHODONTIC TIMING

Late mixed or early permanent dentition

ADVANTAGES

Enough growth remains

Availability of permanent teeth

Treatment ends as growth spurt ends

 Role of treatment timing in prognosis and success of orthodontic
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fig 1 four stages of treatment timing

Four possible stages of treatment timing (fig 1)

Preschool/ primary dentition; 3-6 years of age

Preadolescent / mixed dentition;

(Early)- 7-9 years of age

(Late)-10 to 11 yrs. of age

Adolescent /early permanent dentition; 12-15 yrs.’ of age

Adult/permanent dentition; >16 yrs. of age

Graber, in his textbook, divides orthodontic treatment into three categories: 

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.

2. Interceptive orthodontics which is action taken to intercept a potential or existing early

malocclusion in the mixed dentition, and

 Role of treatment timing in prognosis and success of orthodontic
treatment

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.

“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”

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.

Growth modification devices (fig 2)

This 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
 Role of treatment timing in prognosis and success of orthodontic
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the cartilage matrix during forward mandibular positioning, and compare it with the expression

during natural growth. (fig 2) 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.

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
 Role of treatment timing in prognosis and success of orthodontic
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ACTIVATOR

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. Activator is a loose fitting appliance which was designed by Andreason and

Haupl to correct retrognathic mandible. Actively growing individual with favorable Growth pattern

are good candidates for the activator

Timing for activator( fig 3)

fig 3 activator

Repetition of the new mandibular closure pattern induced a musculoskeletal

adaptation.restraining effect on the forward growth of the maxilla, while stimulating mandibular

growth . Successful correction of Class II malocclusions-periods of active growth. Initiated

during the middle to late mixed dentition.

 Role of treatment timing in prognosis and success of orthodontic
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Bionator ( fig 4)

Balters (1943) Equilibrium between tongue and circumoral muscles influences shape of dental

arches and intercuspation ,Ease of construction, Optimal timing.Dentoalveolar and skeletal

changes, Significant correction in late group, Increase in gonial angle, ramus height and

condylar length was observed, presented with all the cephalometric signs that demonstrate the

effectiveness of functional treatment of skeletal class-II disharmony

Fig 4 bionator

Frankel

Fig 5 frankle
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This appliance is used during the mixed and early permanent dentition stages to effect changes

in anteroposterior, transverse, and vertical jaw relationships. Arch length resolution-late mixed

or transitional dentition period. On growing children-poor results. Good indication-eruption of 4

upper and lower incisors Treatment timing for frankle (fig 5).7 ½ to 9 yrs. Sagittal and vertical

corrections-middle of mixed dentition to transitional period

Twin block

Fig 6 twin block

The removable twin block is a tooth-born functional appliance that is worn fulltime. It helps in the

advancement of the mandible.( Fig 6) It is a two- piece appliance composed of an upper and

lower bite block. Supplementary lengthening of mandible. Greatest effects- during peak stage.

Various biologic indicators- cvm.

Timing for twin block

Mean age early group (9 ½ yrs.) cvm stage (1-2).Mean age for late group (12-13yrs) cvm stage

(3-5). Optimum treatment timing -after the onset of the pubertal peak in growth velocity

Greater skeletal contribution -molar relation

Significant increments in total mandibular length and in ramus height

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Posterior direction of condylar growth

HERBST

Improves mandibular growth biologically significantly Dental and skeletal changes(. Fig 7)Used

at the end of growth spurt. Ideal period for treating general pattern- prepeak, peak and post

peak
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Fig 7 concepts of class II therapy

Growth – due to remodeling of condylar and glenoid fossa

Alternative to surgery in young adults

Prepeak- skeletal changes

Post peak-dental changes

Permanent dentition- good dental interdigitation

TREATMENT TIMING FOR HERBST APPLIANCE

Peak of pubertal growth or MP3

Late herbst appliance- permanent dentition-after peak of growth velocity

Early treatment in deciduous/ mixed dentition- not recommended

Ideal period- permanent dentition Is early treatment effective than later treatment in class II,no

difference in quality of dental occlusion, early treatment- slightly greater ANB angle, Could not
 Role of treatment timing in prognosis and success of orthodontic
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reduce premolar extraction, Could not reduce Orthognathic surgery, No reduction in length of

phase II treatment

Various treatment options (fig 8)

The timing of the treatment onset may be as critical as the selection of the specific treatment

protocol fig 8 .The issue of optimal timing for dentofacial orthopedics is linked intimately to the

identification of periods of accelerated growth that can contribute significantly to the correction

of skeletal imbalances in the individual patient. Individual skeletal maturity can be assessed by

means of several biologic indicators: increase in body height .skeletal maturation of the hand

and wrist. Dental development and eruption. Menarche or voice changes .cervical vertebral

maturation Introduction: “Timing is the fourth dimension in orthodontics (transverse, sagittal,

vertical)”

Cervical vertebral maturation method for assessment of optimal treatment timing

The main features of the Cervical Vertebral Maturation (CVM) method: The cervical vertebrae

are available on the lateral cephalogram that is used routinely for orthodontic diagnosis and

treatment planning. The estimation of the shape of the cervical vertebrae is straightforward. The
 Role of treatment timing in prognosis and success of orthodontic
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reproducibility of classifying CVM stages is high. The method is useful for the anticipation of the

pubertal peak in mandibular growth. A limited number of vertebral bodies is used to perform the

staging C2, C3, and C4

Two sets of variables are analyzed: 1. Presence or absence of a concavity at the lower border

of the body of C2, C3, and C4 2. Shape of the body of C3 and C4. Four basic shapes:

trapezoid: least mature rectangular horizontal squared rectangular vertical: typical of the adult

life

Fig 9 stages of cvm

Stages of Cervical Vertebral Maturation: fig 9

Cervical stage 1: The lower borders of all the three vertebrae (C2-C4) are flat. The bodies of

both C3 and C4 are trapezoid in shape. The peak in mandibular growth will occur on average 2

years after this stage.

Cervical stage 2: A concavity is present at the lower border of C2 the absence of a concavity at

the lower borders of C3 and of C4. The bodies of both C3 and C4 are still trapezoid in shape.

The peak in mandibular growth will occur on average 1 year after this stage.
 Role of treatment timing in prognosis and success of orthodontic
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Cervical stage 3: The door to the peak Concavities at the lower borders of both C2 and C3 are

present. The bodies of C3 and C4 may be either trapezoid or rectangular horizontal in shape.

Discriminate factor C3 with a lower concavity C4 is not. The peak in mandibular growth will

occur during the year after this stage. The amount of elongation of the mandible is greater than

the 2 years before and the years after puberty. Analyzed in six consecutive annual

observations:

Cervical stage 4: Concavities at the lower borders of C2, C3, and C4 now are present. The

bodies of both C3 and C4 are rectangular horizontal in shape. The peak in mandibular growth

has occurred within 1 or 2 years before this stage. The main characteristic: concavity at lower

border of C4 + The peak interval ends at this stage or has ended.

Cervical stage 5: the concavities at the lower borders of C2, C3, and C4 still are present. At

least one of the bodies of C3 and C4 is squared in shape, others are rectangular horizontal. The

peak in mandibular growth (growth spurt) has ended at least 1 year before this stage.

Cervical stage 6: The concavities at the lower borders of C2, C3, and C4 still are evident. At

least one of the bodies of C3 and C4 is rectangular vertical in shape, others are squared The

peak in mandibular growth has ended at least 2 years before this stage. CS6 Shows you the

timing that you should send a patient to Orthognathic surgery, there’s an exception for CIII..

CS6 is not an indicator for growth ceasing in a CIII pt.

APPLICATION TO DENTOFACIAL ORTHOPEDICS

Treatment Timing for Class II Malocclusion

Intervention should be undertaken when the likelihood for a maximum growth response is high,

that is, during the circumpubertal growth period. When Class II malocclusion is treated too early
 Role of treatment timing in prognosis and success of orthodontic
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(therapy starting at CS1 and completed before the interval of peak velocity in mandibular

growth, i.e., before CS3), the net difference in supplementary growth of the mandible ranges

between 0.4 mm and 1.8 mm. On the contrary, when intervention in a Class II patient includes

the CS3-CS4 interval (growth spurt), the net supplementary growth of the mandible ranges from

2.4 mm to 4.7 mm. The data reported also that in Class II patients, the timing of therapeutic

intervention has a greater impact on supplementary elongation of the mandible than does the

type of appliance used..

The Effect of Treatment Timing on Supplementary Elongation of the Mandible in Class II

Treatment ( fig 10 and 11)

THE RED TABLE fig 10

 Role of treatment timing in prognosis and success of orthodontic
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THE GREEN TABLE Note: for a twin-block to work, the vertical opening should be at least

7mm Fig 11

Treatment Timing for Class III Malocclusions

Early Treatment of Class III Malocclusion

Ngan has described the rationale for Early Timely Treatment of Class III Malocclusions that

includes:

To prevent progressive irreversible soft tissue or bony changes.

To improve skeletal discrepancies and provide a more favorable environment for future growth.

To improve occlusal function. CR/CO discrepancy

To simplify phase II comprehensive treatment.

Early treatment may eliminate necessity for Orthognathic surgery.

To provide more pleasing facial esthetics, thus improving the psychosocial development of a

child.
 Role of treatment timing in prognosis and success of orthodontic
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The timing of chin-cup treatment for Class III malocclusion appears to be irrelevant for growth

modification and stability. This treatment intervention, at best, provides temporary results for

mandibular protrusion.9-11 the timing of protraction face-mask treatment for Class III skeletal

maxillary deficiency is becoming evidence-based with prospective studies and meta-analysis.

Some reports indicate better results in the early mixed dentition treatment, especially in the

unilateral cleft lip/palate patients while others have reported less variation before

adolescence.12-14 A meta-analysis has shown that early transverse expansion appeared to

improve skeletal effects and that treatment should be accomplished before age 11.15 The long-

term stability of this treatment has still not been fully established

Chin cup therapy is advocated in skeletal malocclusion with a relatively normal maxilla and

moderately protrusive mandible. The orthopedic effects of a chin cup on the mandible include

redirection of mandibular growth vertically, backward repositioning (rotation) of the mandible,

and remodeling of the mandible with closure of the gonial angle.

Evidence suggests that treatment of mandibular protrusion is more successful when it is started

in the primary or early mixed dentition.

The protraction facemask has been used in the treatment of patients with Class III

malocclusions with a maxillary deficiency. The main objective of early facemask treatment is to

enhance forward displacement of the maxilla by sutural growth. However, there is always an

ambiguity whether early treatment can sustain subsequent mandibular growth during pubertal

growth spurt.

In a prospective clinical trial, protraction facemask treatment starting in the mixed dentition was

found to be stable 2 years after the removal of the appliances. This is probably due to the

overcorrection and the use of a functional appliance as retainer for 1 year.

Mitani concluded that although the mandibular chin position will be greatly improved
 Role of treatment timing in prognosis and success of orthodontic
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anteroposteriorly during the initial stage (2 years) of chin cap therapy, the changes do not take

place continuously after that, and the initial changes will not be maintained if chin cap use is

discontinued before facial growth is complete. ngan stated that clinicians are sometimes

reluctant to render early orthopedic treatment in Class III patients because of their inability to

predict mandibular growth. Patients receiving early orthodontic or orthopedic treatment might

need surgical treatment at the end of the growth period. A systematic way to diagnose Class III

malocclusion can help in identifying patients who might respond favorably to early orthopedic

treatment. According to him, Discriminant analysis found that the Wits appraisal was most

decisive in distinguishing camouflage treatment from surgical treatment.

A Wits appraisal greater than −5 indicates that the malocclusion might not be resolved by

camouflage treatment with facemask or chin cup therapy. He proposed the use of serial

cephalometric radiographs of patients taken a few years apart after facemask treatment and the

use of a Growth Treatment Response Vector (GTRV) analysis to individualize and enhance the

success of predicting excessive mandibular growth in Class III patients. A GTRV analysis will

then be performed during the early permanent dentition to allow clinicians to decide whether the

malocclusion can be camouflaged by orthodontic treatment or whether a surgical intervention is

necessary when growth is completed.

Pangrazio-Kulbersh compared the long-term stability of early protraction facemask treatment

with later surgical maxillary advancement with LeFort I osteotomy, and to determine whether

early intervention with protraction facemask is an effective treatment modality or whether

surgical treatment after cessation of growth should be advocated. The investigation

demonstrated that Orthodontic and surgical treatments both produced positive changes in the

anteroposterior position of the maxilla, and these changes remained stable over time. Both

treatment modalities produced acceptable clinical improvements and stable long-term results.

Early treatment with orthopedic forces to advance the maxilla might reduce altogether the need
 Role of treatment timing in prognosis and success of orthodontic
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for surgical intervention later. If surgery becomes necessary, it might be restricted to only one

jaw, thereby minimizing complications and increasing the stability.

Timing for Other Treatment Options in Class III Malocclusions

Another option is to treat the slow or nongrowing patient during late adolescence or adulthood,

respectively. This usually is not an option that the practitioner elects, but rather one that is

determined by when patients present for treatment. Postponing treatment may be a decision the

clinician makes because of concern over growth discrepancies such as potential mandibular

protrusion or skeletal open bite. The growth status, esthetics, and severity of the malocclusion

contribute to the decision of whether the patient should have dent alveolar camouflage of the

skeletal discrepancy or Orthognathic surgery. Some Class III patients in whom growth has

stabilized

Maxillary deficiency

3 possible responses of face mask treatment

Forward displacement of maxilla

Forward displacement of maxillary teeth

Downward and backward rotation of mandible

Facemask

Developed over 100 years ago,Hickham claims he was the first to use a reverse headgear.

Made popular by Delaire,Petit shown in fig 12

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Fig 12 face mask

Mandibular prognathism

Use of chin cup

Mandibular rotation

Early treatment –restraint of growth

Both the effectiveness and efficacy are in question

TIMING FOR CLASS III

Prepubertal stage is effective both in maxilla and mandible

Post pubertal stage- mandibular level only

Findings in maxilla-physiology of circummaxillary sutures

Chin Cup

Timing for chincup

 Role of treatment timing in prognosis and success of orthodontic
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Force applied is 600gms- 12hrs/day

AB difference- affected by starting age for treatment and level of disharmony initially

In a study by graber and mc namara- younger age and little disharmony- most effective

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

Treatment of Class III malocclusion by means of efficient protocols (e.g., maxillary expansion

and protraction ) is more effective in the early than in the late mixed dentition At a post pubertal

observation (CS5 or CS6), when active growth of the craniofacial skeleton is completed for the

most part, Class III subjects treated with a rapid maxillary expander and a facial mask well

before the growth spurt (CS1) present with different long-term changes with respect to Class III

subjects treated at a later stage, that is, at the peak in mandibular growth (CS3). Prepubertal

orthopedic treatment of Class III malocclusion is effective both in the maxilla (which shows a

supplementary growth of about 2 mm) and in the mandible (restriction in growth of about

3.5mm), Note: early treatment in CIII cases counteracts the tendency of the maxilla to show

deficiency. Whereas treatment of Class III malocclusion at puberty is effective at the mandibular

level only (restriction in growth of about 4.5mm)

INDICATIONS FOR LATER TREATMENT

Class III

Mandibular prognathism- growth modification is a limited option

Orthodontic camouflage requires accurate prediction

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PERSISTENT ANTERIOR OPEN BITE

Relapse is quite likely

Prognosis for early treatment depends on skeletal proportions

Best plan- to delay until /after adolescent growth spurt

Crowding treatment timing

MANDIBULAR ARCH

Mandibular crowding- mostly resolved by orthodontic treatment

2 strategies –extraction and non-extraction

NONEXTRACTION

Mixed dentition- leeway space

Lip bumper-other choice

OBVIOUS CONCLUSION

Alignment achieved-84% started in mixed dentition stage

Late mixed dentition – preferred after eruption of 1st premolars

Lingual arch – passive appliance

CROZAT APPLIANCE

Arches- stable

Crowding can be resolved in 85% of patients with non-extraction

 Role of treatment timing in prognosis and success of orthodontic
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Late mixed dentition favorable time to begin

Serial extraction

DISADVANTAGES

Long-term follow up

Difficulty to be certain

Most effective in children with exceptionally severe crowding

Maintenance of leeway space

Important step in making non extraction treatment possible. Beginning fixed appliance treatment

for children just before second primary molars are exfoliated – gold standard time.Ganielly also

recommends-passive lingual arch .Maintaining space during mixed dentition. All procedures –

cautiously used in adolescent growth spurt

Treatment Timing for Transverse Maxillary Deficiency

EARLY TRANSVERSE TREATMENT

Evidence suggests that a lateral shift of the mandible into unilateral cross bite occlusion may

promote adaptive remodeling of the TMJ joint and asymmetric mandibular growth. Favorable

improvement of mandibular asymmetry associated with a mandibular shift is seen in patients

treated in the early mixed dentition.

A child exhibiting a lateral functional shift is a candidate for early orthopedic correction. Such a

shift is often the result of compensatory and habitual movement of the mandible to achieve
 Role of treatment timing in prognosis and success of orthodontic
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intercuspation in the face of a constricted maxillary arch. In this situation, the mandible

approaches centric relation with facial and dental midlines coinciding.

Increased maxillary width removes the premature contacts, eliminates the mandibular shift, and

allows the mandible to achieve centric relation with coinciding midlines.

Assuming good balance in sagittal and vertical jaw relationships, selective enameloplasty of 1 or

2 deciduous teeth to eliminate an occlusal interference, mandibular shift, and cross bite is

appropriate in the primary dentition.

The use of the CVM method demonstrated that rapid maxillary expansion before the peak in

skeletal growth velocity is able to induce more pronounced transverse craniofacial changes at

the skeletal level Treatment changes are more dentoalveolar in nature when expansion is

performed during or after the peak.

The key indicator for maxillary transverse deficiency is by an analysis. Distance between the

central fossae of the upper 1 st molars. Compare this measurement with the distance between

the tips of the distobuccal cusps of the lower 1 st molars.. Measurement 1 – Measurement 2 =

transverse discrepancy is ZERO for a normal occlusion because the tips must articulate

together. If the no. is in (-) transverse problem (maxilla is narrow) E.g. . 40mm – 44mm = - 4 mm

TD So if you know that the TD is 4mm. Beneficial because it lets you know how many days u

need to expand.. And with 30% of relapse that usually occurs,, you need 8 days more For

example if you activated .2 / day you need 20 days + 8 = 28 days..

Treatment timing

Infantile stage (up to 10 years of age), juvenile stage (10 to 13), adolescent age (13 to 14 years

of age)
 Role of treatment timing in prognosis and success of orthodontic
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Prepubertal age- (cs1 to cs3) - significantly greater increase in width of maxillary inter molar,

lateronasal, lateroorbitale.

Early treatment-skeletal effects

Late treatment- dent alveolar effects

RME TIMING

Gain in arch length

Early group-lateronasal width, dentoalveolar width, maxillary width increased

Late group-dentoalveolar changes

Early group- skeletal changes

Resistance to maxillary separation- late stages

Early correction –unilateral cross bite

Favorable time- late mixed dentition

Treatment Timing for Increased Vertical Dimension

One of the goals of orthopedic treatment in subjects with increased vertical dimension is the

control of the vertical growth of the mandibular ramus A significantly more favorable effect can

be obtained when treatment is performed at CS3, that is, at the peak in mandibular growth,

when compared with treatment performed at an earlier maturational stage (CS1).

The application of the CVM method has revealed that: 1. Class II treatment is most effective

when it includes the peak in mandibular growth; CS3 – CS 4 and Cl III tt to restrict mandibular

growth 2. Class III treatment with maxillary expansion and protraction is effective in the maxilla
 Role of treatment timing in prognosis and success of orthodontic
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only when it is performed before the peak (CS1 or CS2). 3. Skeletal effects of rapid maxillary

expansion for the correction of transverse maxillary deficiency are greater at prepubertal stages,

(CS1-CS2) while pubertal or post pubertal use of the rapid maxillary expander entails more

dentoalveolar effects 4. Deficiency of mandibular ramus height can be enhanced significantly in

subjects with increased vertical facial dimension when orthopedic treatment is performed at the

peak in mandibular growth (CS3). To summarize, effects of therapies aimed to enhance/restrict

mandibular growth appear to be of greater magnitude at the circumpubertal period during which

the growth spurt occurs in comparison to earlier intervention, while effects of therapies aimed to

alter the maxilla orthopedically (maxillary protraction/maxillary expansion) are greater at

prepubertal stages

Bonded rapid maxillary expander with vertical pull chin cup

CS3 that is at peak of mandibular growth

Goals of orthopedic treatment-control of vertical growth of ramus

Treatment timing for open bite

EARLY OPEN BITE TREATMENT

The diagnosis and treatment of skeletal hyper-divergent open bite ] continues to be one of the

most challenging situations facing orthodontists today. Control of abnormal habits and

elimination of dysfunction should be given top priority in the deciduous dentition. Screening

appliances intercept and eliminate all abnormal perioral muscle function in acquired

malocclusions resulting from abnormal habits, mouth breathing, and nasal blockage.

A removal or fixed appliance can inhibit tongue thrust in a mixed dentition. In such cases, a
 Role of treatment timing in prognosis and success of orthodontic
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stretch reflex is elicited from the closing muscles that enhances the depressing action on the

buccal segments and helps in closing the anterior open bite

Treatment options

Primary / mixed dentition

Treatment time 7-8yrs age

Growth of the Maxilla: Prepubertal CS1- CS2 Midpalatal and Pterygomaxillary Sutures Active

Pubertal CS3-CS4 Postpubertal CS5-CS6 ossified

Growth of the Mandible:

Prepubertal CS1- CS2 Condylar growth decelerated Pubertal CS3-CS4 Condylar

White in 1998 had suggested indications for early treatment which includes posterior and

anterior cross bites, ankylosed teeth, excessive protrusions, severe anterior and lateral open

bites, cleft palates, ectopic molars, Class III with true maxillary retrusions. But however, there

are few limitations and exceptions to early orthodontic intervention which includes Class II

malocclusion with mandibular prognathism and bimaxillary protrusions with severe arch length

discrepancies.

Advantages and disadvantages associated with early treatment as listed by Bishara, Justus,

and Graber in 1998 include reduced incidence of premolar extraction, possible elimination of

the need for a second phase of treatment, minimum need for surgical orthodontics, whereas

disadvantages include potential iatrogenic problems that may occur with early treatment such as

dilacerations of roots, decalcification under bands left for too long, impaction of maxillary

canines by prematurely up righting the roots of the lateral incisors, impaction of maxillary
 Role of treatment timing in prognosis and success of orthodontic
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second molars from distalizing first molars, and patient "burnout" as total treatment time is

longer when considering the observation period between the two stages.

PREDICTORS OF GROWTH STATUS

For the Class II patient there has been another issue in the debate surrounding treatment

timing. Some advocate identifying and capturing the period of most rapid growth determined

from growth markers such as height and weight data, cervical vertebrae maturation, or hand-

wrist ossification to select the most predictable and productive timing of treatment intervention of

Class II malocclusion.7 Conflicting data from other studies have indicated that treatment effects

are variable and not related to growth status during treatment.

TREATMENT DURING PREADOLESCENCE OR ADOLESCENCE

Concern with adherence- child age and sex

Preadolescent children- (age6 – puberty)

Role modeling-greater cooperation

Adolescents-difficulty in long-term adherence

Efficient orthodontic treatment timing( fig 13)

 Role of treatment timing in prognosis and success of orthodontic
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Fig 13 Efficient orthodontic treatment timing

Rationale of early intervention

Elimination of primary etiologic factors

Elimination of occlusal discrepancies

Managing arch length discrepancies

Benefits and goals of early treatment( fig 14)

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Fig 14 Benefits and goals of early treatment

Limitations of early treatment ( fig 15)

Limitations of early treatment ( fig 15)

 Role of treatment timing in prognosis and success of orthodontic
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Various options of late treatment

Camouflage

Orthognathic surgery

Rationale of late intervention

Dentition and occlusion relationship are established

Muscle functions are matured

Functional malocclusions are less frequent

Internal Motivation

Benefits and goals of late treatment

Do not need to counter the unpredictable dynamics of growth

Cost effective, Definitive treatment goals

Straight forward treatment completed in 2-3yrs

Limitations of late treatment ( fig 16)

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VARIOUS STUDIES ON TIMING FOR CLASS II TREATMENT

Substantial evidence supports the theory that early growth modification therapy can lead to an

improvement, if not complete correction, of the Class II malocclusion. Recently, the results of

randomized clinical trials specifically designed to address these important issues were

published.

Tulloch, Phillips, and Proffit conducted controlled clinical trial at university of North Carolina

where patients in the mixed dentition with over jet of 7 mm were randomly assigned to either

early treatment with headgear, or modified bionator, or to observation. Although patients in both

early treatment groups had approximately the same reduction in Class II severity, as reflected

by change in the ANB angle, the mechanism of this change was different. The headgear group

showed restricted forward movement of the maxilla, and the functional appliance group showed

a greater increase in mandibular length.

Keeling in 1998 examined anteroposterior cephalometric changes in children enrolled in a

randomized controlled trial of early treatment for Class II malocclusion in University of Florida.

He concluded that both bionator and head-gear treatments corrected Class II molar

relationships, reduced over jets and apical base discrepancies, and caused posterior maxillary

tooth movement. The skeletal changes, largely attributable to enhanced mandibular growth in

both headgear and bionator subjects, were stable a year after the end of treatment, but dental

movements relapsed.

Brien did a multicentered, randomized controlled trial to evaluate the effectiveness of early

orthodontic treatment with the Twin-block appliance. Results showed that early treatment with

the Twin block reduced over jets, corrected molar relationships and reduced the severity of

malocclusions. Most of this correction was due to dentoalveolar changes and small amounts of
 Role of treatment timing in prognosis and success of orthodontic
treatment

favorable skeletal change. He concluded that early treatment with Twin-block appliances

resulted in an increase in self-concept and a reduction of negative social experiences.

Bremen and Pancherz assessed the efficiency of early and late Class II Division 1 treatment in

the mixed and permanent dentition and stated that treatment of Class II Division 1

malocclusions is more efficient in the permanent dentition (late treatment) than it is in the mixed

dentition (early treatment).

Pirttiniemi did an 8 year randomized trial to determine the long-term effects of early headgear

(HG) treatment on craniofacial structures. The results showed that the most evident difference

between the groups was the wider and longer dental arches in the HG group, which could only

partly be explained by the higher rate of extractions in the control group. Peer assessment

rating (PAR) score, showing the general outcome of treatment, was at the same level in both

groups at follow-up.

Kerosuo et al examined whether definite need for orthodontic treatment could be eliminated in

public health care by systematically focusing on early intervention. Treatment need was

assessed according to the Dental Health Component (DHC) of the Index of Orthodontic

Treatment Need and treatment outcome by the Peer Assessment Rating Index (PAR). The

results suggest that an early treatment strategy may considerably reduce the need for

orthodontic treatment in public health care with limited specialist resources.

Hsieh compared the treatment outcome of early treatment with that of late treatment using the

American Board of Orthodontics Objective Grading System (ABO OGS) and Comprehensive

Clinical Assessment (CCA) method developed at IUSD. Result showed that the early-treatment

group had significantly longer treatment time and worse CCA scores than the late-treatment

group.

Controversies in the Timing of Orthodontic Treatment

 Role of treatment timing in prognosis and success of orthodontic
treatment

The timing of orthodontic treatment has evoked contentious debates and questioned clinical

convictions and beliefs. Part of these controversies relate to whether patients with Class II and

Class III skeletal malocclusions should be treated in the early, late mixed, or preadolescent

dentition. Those who support early growth modification believe the early correction or

improvement of the skeletal discrepancy results in a shorter and an ultimately more stable result

following comprehensive orthodontic treatment in the preadolescent dentition.

Growth modification has as its goal to correct the skeletal pattern. For a Class II malocclusion,

previous reports in the early mixed dentition have documented success, while others have

reported the same success during the late mixed dentition transitional years

Conclusions

The timing of treatment interventions was influenced by the severity of the malocclusion and the

age and maturation of the patient at the time the patient presented for treatment. In treating at

early age, the orthodontist can reasonably become a "re-director" of growth patterns rather than

solely a worrier of tooth position.

Too often, discussions of treatment timing become debates about early treatment versus late

treatment when in truth, neither of these procedures exist as entities. Therefore, orthodontists

should consider it as "Treatment Sequence" and define this as a reasonable temporal order for

instituting a treatment procedure developed from the diagnostic facts and projections pertaining

to the case under examination.

The resolution of the malocclusion and stability of the correction is not an accident of early or

late treatment. It is the result of a planned treatment sequence designed to suffer a minimum

effect from the limiting factors of orthodontic treatment while taking a maximum assist from the

positive factors.
 Role of treatment timing in prognosis and success of orthodontic
treatment

References

Orthodontic treatment timing in growing patients. C. Grippaudo, European Journal of paediatric

dentistry vol. 14/3-2013

Controversies in the timing of orthodontic treatment. Ji chul jang . Semin orthod 11;112- 118

2005

The timing of orthodontic treatment: Effectiveness and Efficiency. William R. PROFFIT .Rev

Odont Stomat 2003; 32:171-189

The timing for class II treatment. AJODO vol- 129 no-4. Wheeler et ol.

Efficient orthodontic treatment timing .Anthony D. Viazi American Journal of Orthodontics and

Dentofacial Orthopedics Volume 108, No. 5

Timing of orthodontic treatment. Mahesh Jain, Nidhi Dhakar. Review article

Assessment of Orthodontic Treatment Outcomes: Early Treatment versus Late Treatment

Tsung-Ju Hsieh, DDS, MSDa; Yuliya Pinskaya, (Angle Orthod 2005; 75:162–170.)

Early orthodontic treatment: what are the imperatives? G. thomas kluemper, d.m.d., M.S clinical

practise

Early intervention in the transverse dimension: Is it worth the effort? James A. McNamara, Jr,

DDS, PhD 2002. International symposium of early orthodontics

Orthodontists’ views on indications for and timing of orthodontic treatment in Finnish public oral

health care. European Journal of Orthodontics 30 (2008) 46–51

(Text book) Early age orthodontic treatment .aliakhar bahreman