CONTINUING EDUCATION

Benefit of early Class II treatment: Progress report of a

two-phase randomized clinical trial

J.F. Camilla Tulloch, BDS, FDS, DOrth,a Ceib Phillips, PhD, MPH,b and
William R. Proffit, DDS, PhDc
Chapel Hill, N.C.

Preadolescent children with overjet greater than 7 mm were randomly assigned to observation only,
headgear (combination), or functional appliance (modified bionator) and were monitored for 15
months. Of the 166 patients who completed this first phase of the trial, 147 continued to a second
phase of treatment. The data from the first 107 patients to complete phase 2 are available and form
the basis of this progress report. During phase 1, on average there was no change in the jaw
relationship of untreated children, but 5% showed considerable improvement and 15%
demonstrated worsening. Both early-treatment groups had a significant average reduction in ANB
angle, more by change in maxillary dimensions in the headgear group and mandibular growth in the
functional appliance group. There were wide variations in response, however, with only 75% of the
treated children showing favorable skeletal response. Failure to respond favorably could not be
explained by lack of cooperation alone. The preliminary results from phase 2 show that, on
average, time in fixed appliances was shorter for children who underwent early treatment, but the
total treatment time was considerably longer if the early phase of treatment was included. Only
small differences were noted in anteroposterior jaw position between the groups at the completion
of treatment, and the changes in dental occlusion, judged on the basis of Peer Assessment Rating
scores, were similar between groups. Neither the severity of the initial problem nor the duration of
treatment was correlated with the occlusal result. The number of patients who required extraction
of permanent teeth was greater in the early functional appliance group than in the headgear or
control group. The option of orthognathic surgery was presented more often in the cases of
children who did not undergo early treatment, but surgery was accepted or was still being
considered almost as frequently in the previous headgear group as in the controls, less often in the
patients previously treated with functional appliances. (Am J Orthod Dentofacial Orthop 1998;113:
62-72.)

F
or preadolescent children with Class II
malocclusion, the optimal timing for treatment re-
and if this made a difference in terms of the
subsequent treatment duration, treatment complex-
mains controversial, despite long experience and ity, or treatment outcome compared with one-stage
many published findings. Because most patients with treatment during adolescence.
Class II malocclusion have some type of skeletal In this article we present a progress report on a
imbalance, early (preadolescent) treatment often is randomized clinical trial being undertaken at the
aimed mainly at modifying the growth of the jaws. University of North Carolina (UNC) to address
This early phase of treatment is usually followed by some of the issues related to the timing of treatment
a second, and presumably simpler, later stage of for Class II malocclusion. The UNC trial was de-
tooth movement during adolescence. Thus patients signed in two parts (Fig. 1). The first phase of the
with Class II malocclusion would benefit from two- trial addressed the issue of whether the growth
stage treatment if skeletal growth could be modified, pattern of Class II patients can be modified; the
second phase approached the more difficult ques-
From the Department of Orthodontics, School of Dentistry, University of
tion of whether— even if differential growth effects
North Carolina. can be induced during early treatment—these ef-
a
Professor. fects in the end make any difference.
b
Research Professor.
c
Professor.
Reprint requests to: J. F. Camilla Tulloch, BDS, FDS, DOrth, Department MATERIAL AND METHODS
of Orthodontics, School of Dentistry, University of North Carolina, Chapel
Hill, NC 27599-7450.
To review briefly, in the first phase of the trial
Copyright © 1998 by the American Association of Orthodontists. preadolescent children with increased overjet (!7mm)
0889-5406/98/$5.00 " 0 8/5/85971 were randomly assigned (in blocks of six, stratified by

62
American Journal of Orthodontics and Dentofacial Orthopedics Tulloch, Phillips, and Proffit 63
Volume 113, No. 1

Table I. Progress of patients through the two phases of the

UNC trial as of January 1997

Control Functional Headgear

Started phase 1 61 53 52
Completed phase 1 61 53 52
Dropped after phase 1 9 8 2
Moved 4 2 0
Parent decision 1 2 0
No reason 2 2 1
Investigator decision 2 2 1
Started phase 2* 52 41 50
Completed phase 2 38 37 36
1 Year recall 20 17 21
2 Year recall 9 11 12
3 Year recall 1 0 0

*Excludes four patients in functional appliance group who desired no

fixed-appliance treatment in phase 2.

gender) to undergo early growth modification (headgear

or a functional appliance) or no treatment during an
observation period. To reduce the influence of differences Fig. 1. Design of the two-phase randomized clinical
in clinical proficiency on the outcomes of early growth trial used to evaluate benefit of early orthodontic treat-
modification, all phase 1 treatment was provided by one ment for Class II malocclusion.
clinician in accordance with a strict treatment protocol.
All patients (treated and controls) were evaluated at 15
months, which was felt to be a reasonable time frame in
compared with those who did not. The benefits considered
which to demonstrate possible differential growth effects.
in this report are the treatment outcome measured as the
The comparison being made during phase 1 of the trial
amount of skeletal change during late treatment, the
was the skeletal change seen in the two early-treatment
change in Peer Assessment Rate (PAR) score (a summary
groups compared with that seen in the control group.
of the alignment and occlusion of the teeth,2 the duration
Procedures in phase 1 of the UNC clinical trial are
of comprehensive treatment, and the complexity of treat-
presented in detail elsewhere.1
ment as indicated by extraction rate and the orthognathic
The second phase of the trial was designed to address
surgery rate.
the question, “Does early growth modification make a
Phase 2 of the trial is ongoing at this writing. This
difference in the subsequent treatment?” After phase 1,
report is based on the 107 patients (of 147) who had
patients were maintained in their assigned groups until
completed comprehensive treatment as of January 1997.
their primary teeth were lost. The patients were then
At this point, median values are generally reported for
rerandomized, this time in blocks of eight, stratified on the
phase 2 results because these data are less likely than
basis of their phase 1 group assignment, to one of four
mean values to be skewed by the addition of later data;
doctors for completion of treatment. Thus in phase 2 each
only descriptive statistics are reported as interim results.
doctor was assigned approximately equal numbers of
The progress of patients through the trial is shown in
observation only or early growth modification (headgear
Table I.
or functional appliance) patients. This rerandomization
was undertaken to maximize the chance that each doctor
would receive approximately equal distributions of boys RESULTS
and girls, good and poor early-treatment responders, At the start of the trial the three groups formed
compliant and noncompliant children, and children with by the first randomization were equivalent with
other variables that might influence treatment outcome. regard to age, sex, maturity, and morphologic mea-
The treatment protocol during phase 2 was not spec-
sures from the cephalograms and study models. The
ified. Rather, each doctor was permitted to determine
patients, 58% male, were in mixed dentition, with a
what treatment the patient should receive. In this way the
impact of early growth modification on subsequent treat-
mean age of 9.9 years (range 7.7–12.4 years). The
ment and treatment outcome could be reviewed in light of children had moderate to severe Class II problems,
the widely recognized differences between patients and with a mean ANB angle of 6.2° (range 0.4°–12.2°)
differences in clinicians’ proficiency. In phase 2 of the and a mean overjet of 8.33 mm (range 7–15 mm). A
UNC trial the comparisons being made involve benefits bilateral Class II molar relationship was found in
accruing to the patients who underwent early treatment, 90.8%.
64 Tulloch, Phillips, and Proffit American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

Table II. Annualized mean change in the skeletal measures initial skeletal severity, age/maturity at the outset of
during phase 1 treatment, pattern of growth, or general compliance
Control Functional Headgear with treatment.3
Skeletal measures (n $ 61) (n $ 53) (n $ 52) Fig. 3 shows the amount of skeletal change
ANB –0.17 –0.93 –1.07
(measured as the ANB angle) in the three groups at
the different stages of treatment. We detected no
difference in ANB angle among the three groups at
SNA 0.26 0.11 –0.92
the outset of the trial. After phase 1, the two
early-treatment groups had statistically significant
SNB 0.43 1.07 0.15 reductions in ANB angle. The preliminary data from
phase 2(107 of 147 patients) show a larger average
Mandibular 2.36 3.69 2.97 reduction in ANB in the patients who had no
length previous early treatment, so there is only a small
The connecting underlines indicate where statistically significant differ-
difference between the groups at the end of phase 2.
ences exist (p % 0.01) between groups (two-way analysis of variance). The outcome of treatment in terms of the align-
ment and occlusion of the teeth is given in Fig. 4.
The PAR scoring system ranges from 0 (describing a
The maxillary and mandibular skeletal changes perfect occlusion with ideal alignment and tooth
during phase 1 are detailed elsewhere1 and summa- relationships) to 50-plus (which categorizes a very
rized here in Table II. The changes are reported as severe malocclusion). PAR scores below 5 generally
annualized change in an effort to adjust for minor describe near-ideal occlusions, whereas scores be-
differences in the time each patient was observed tween 5 and 10 usually denote acceptable occlusions
and to facilitate comparison with other studies. The and scores of greater than 10 reflect less satisfactory
results of an analysis of variance (ANOVA) indi- alignment or occlusion.2 Although the average im-
cated that, between boys and girls, that there was no provement in occlusion in the early-treatment
difference in their cephalometric measures and no groups was rather modest during phase 1, some
difference in the pattern of change of boys and girls patients benefited greatly and others actually got
in any of the three groups. The comparison between worse. In general, the PAR score for control pa-
the three phase 1 groups showed that early treat- tients increased over this period, most likely reflect-
ment with headgear or functional appliance did, on ing the increase in crowding that occurs as perma-
average, reduce the severity of the skeletal discrep- nent canines erupt. During phase 2 the treatment
ancy. ANB changes were quite similar in the head- changes were such that the average PAR score at
gear and functional appliance groups, but the mech- the end of phase 2 was approximately the same for
anism by which these changes occurred was patients who did not have early treatment as for
different. Headgear patients had a greater tendency those who did. The distribution of near-ideal, ac-
to restricted maxillary forward movement, and the ceptable and less satisfactory final results was also
functional appliance subjects were more likely to quite similar in the three groups (Table III). We
have increased mandibular length and improved found no systematic relationship between the sever-
chin position. ity of the occlusal problem at the start of treatment,
Despite the small but statistically significant dif- as measured by the PAR score, and the occlusion
ferences seen between the three groups, there was and alignment of the teeth at the end of phase 2
wide variation within all three groups. By no means treatment (Fig. 5).
did all patients respond as one might have expected Both the previous controls and the early-treat-
from the pattern of average changes. In the control ment patients were treated in phase 2 in accordance
group, 4% showed highly favorable growth and 15% with their assigned doctors’ preferences. At the start
unfavorable growth. When the magnitude of skele- of phase 2 all children had lost their primary teeth
tal change was categorized from highly favorable to and were therefore at a stage at which full fixed
unfavorable, about 75% of the treated children appliances could be placed. However, in some cases
showed favorable response; 25% did not (Fig. 2). the doctor elected to start phase 2 with preliminary
Even though we noted a statistically significant appliances such as an expansion device, lip bumper,
difference in the distribution of these changes be- headgear, or partial banding with a 2 # 4 setup. The
tween groups, the magnitude of the skeletal change treatment time described here is the total treatment
could not be explained in terms of the patient’s time for phase 2—that is, the time in full fixed
American Journal of Orthodontics and Dentofacial Orthopedics Tulloch, Phillips, and Proffit 65
Volume 113, No. 1

Fig. 2. Percentage of children in each group demonstrating different amounts of change

in ANB angle during phase 1 of the UNC trial. Note the variation in the control and the
treatment groups.

appliances plus any time in preliminary appliances. poor occlusal results, and very short and very long
The time between the end of phase 1 and the start of treatment periods seemed to occur for patients who
phase 2 is not included because we considered this initially had severe or mild occlusal problems.
to be specified more by the research design rather Table IV shows the complexity of phase 2 treat-
than by any clinical imperative. Fig. 6 shows the total ment in terms of the number of extraction decisions or
phase 2 treatment time for the three groups (head- surgical plans. Data are given here for all 147 patients
gear, functional appliance, and control) for each who started phase 2 treatment because, even though
doctor. This graph should be interpreted with some treatment is still ongoing for approximately 28% of the
caution because the number of patients in any one sample, extraction or surgery decisions have already
category may be rather small. In general the phase 2 been made for all, or nearly all, of the patients. The
treatment for patients who had undergone early data show that the extraction rate was only slightly
treatment—whether with headgear or a functional different for patients who did not have early treatment
appliance—was, on average, shorter than the treat- and those who did. The highest extraction rate is
ment time for patients who had no early treatment. reported for the functional appliance patients and the
However, the figure also shows the wide variation in lowest for the headgear group. Surgical options were
treatment time from patient to patient and between discussed most frequently with those patients who had
doctors. no early treatment, least frequently in the functional
Because it is possible that treatment duration is appliance group.
related more to the severity of the initial condition
or to the outcome achieved rather than to any effect DISCUSSION
from early treatment, the duration of each patient’s The UNC trial was designed to address some
phase 2 treatment was plotted against both the specific questions relating to the issue of the optimal
patient’s initial and final PAR score (Fig. 7). These timing for treatment for preadolescent patients with
plots show no systematic relationship between the Class II malocclusion. The trial poses two separate
phase 2 treatment time and the severity of the initial questions: “Can you change growth?” and “Does
occlusal problem or between the treatment time and early growth modification make a long-term differ-
the treatment outcome. Very short and very long ence?” Although we hope the clinical procedures
treatment periods could result in both good and followed in this trial are sufficiently analogous to
66 Tulloch, Phillips, and Proffit American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

Fig. 3. Distribution of subjects by ANB angle at the three different stages of the UNC
trial.

routine practice for clinicians to make useful gener- clinician proficiency than to the efficacy of a partic-
alizations about their own treatment decisions and ular treatment approach. It may be salutary for
practices, the choice of early or later treatment for clinicians to keep in mind the variability in growth
Class II malocclusion must inevitably be based on shown in this and other untreated Class II groups
individual experience and imperfect data. We hope when treatment results are evaluated.
that the evidence from this and similar trials will In this trial one clinician was responsible for
help clinicians reevaluate their beliefs about their phase 1 treatment, using as simple an approach to
current practices. treatment possible. The appliances were designed to
The question of whether early treatment can avoid, or at least minimize, any movement of the
produce statistically significant and clinically rele- anterior teeth and the concomitant alveolar bone
vant changes in growth was approached in phase 1 remodeling that might affect some of the landmarks
with the use of a carefully controlled prospective used to measure skeletal change. Our findings of
study. In the past, comparisons of early treatment small but statistically significant skeletal changes
effect have most frequently been made against ex- during a short period of treatment may reinforce
isting cephalometric standards, alternative treat- widely held beliefs about the effectiveness of both
ment groups, or untreated normals.4-6 We question headgear and functional appliances in reducing the
the validity of such comparisons, particularly in the severity of Class II malocclusion. However, even
evaluation of the effect of treatment on growth. Not though the two early-treatment groups showed an
surprisingly, few investigators have monitored un- increase in the proportion of patients experiencing
treated Class II children longitudinally. The few favorable growth, the magnitude of the differential
reports of untreated patients that do exist suggest effects was small, there was much variability, and so
that growth is highly variable,7-9 difficult to predict,10 far we have been unable to identify any patient
and “different” from that in normal subjects.11,12 characteristics that could serve as useful predictors
Much of the “success” or “failure” of treatment that of treatment response.3 Although it can be argued
clinicians deal with on a day-to-day basis may in fact that different appliances or different clinicians
be more attributable to differences in growth and would have produced superior or different results,
American Journal of Orthodontics and Dentofacial Orthopedics Tulloch, Phillips, and Proffit 67
Volume 113, No. 1

Fig. 4. Distribution of PAR scores for each group at different time points in the UNC
trial.

this carefully controlled trial was designed to ex- Table III. Number of patients at the end of phase 2 of the
UNC trial with near-ideal, acceptable, and less satisfactory
plore the differential effects of two common meth- PAR scores
ods of Class II correction, controlling for variation
resulting from growth, clinician proficiency, or both. PAR category Control Functional Headgear
Questions such as the effect of change in magnitude !5 (ideal) 18 16 20
or direction of the headgear force, the amount of 6–10 (good) 7 11 7
bite opening from a functional appliance, or the !10 (less satisfactory) 11 8 8
impact of continuous compared with intermittent
wear—although important clinical issues—were not
considered in this trial. The ability to carry out such ment was delayed? Alternatively, will the effects of
subgroup analyses would greatly increase the num- early treatment gradually diminish so the early- and
ber of children who would have to be enrolled and late-treatment groups become once more indistin-
monitored. If these or other variables are believed guishable?
to be critical issues in determining treatment re- The preliminary data from this trial suggest
sponse or treatment benefit, separate well-con- that the skeletal effects of early treatment, on
trolled trials addressing such specific issues could be average, are not maintained. Instead, the ANB
planned. differences between the early-treatment and ob-
Phase 2 of the trial addresses the question of servation groups diminish, so that little if any
whether it makes a difference if treatment for Class difference remains after comprehensive treatment
II malocclusion is started sooner or later, provided is completed. It has been suggested that the
effective treatment occurs at some point. Will small skeletal changes in early treatment, particularly
skeletal changes produced by early treatment be the increase in mandibular growth seen with
sustained over time, making the subsequent man- functional appliances, may simply represent an
agement of and treatment outcomes for these pa- acceleration in growth rather than a net gain.13
tients different from those of children whose treat- The data lend some support to this contention.
68 Tulloch, Phillips, and Proffit American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

Fig. 5. Initial severity of each patient’s malocclusion, plotted against treatment outcome,
both measured by PAR score.

Fig. 6. Total time for phase 2 treatment (time in full fixed appliances plus preliminary
appliances such as expansion devices or partial banding) for each group, by each doctor.
American Journal of Orthodontics and Dentofacial Orthopedics Tulloch, Phillips, and Proffit 69
Volume 113, No. 1

Fig. 7. A, Total phase 2 treatment time for each patient, plotted against initial severity of
patient’s malocclusion. B, Total phase 2 treatment time for each patient, plotted against
outcome of treatment.
70 Tulloch, Phillips, and Proffit American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

Table IV. Complexity of phase 2 treatment presented for all oral health. It is also possible for two patients to
147 patients starting phase 2 treatment have the same PAR score with different relation-
Control Functional Headgear ships of tooth to basal bone. Although this possibil-
Parameters (n $ 52) (n $ 45) (n $ 50) ity poses a special problem in the comparison of the
Number of extraction cases 9 14 7
outcome of treatment across groups of children who
Surgical options have sustained more-or-less successful growth mod-
Discussed 20 5 9 ification during early treatment, the distribution of
Accepted* 3 0 3
Undecided 4 1 2
PAR scores (both percentiles and categories) do not
seem different for the children who had early treat-
*As of January 1997, only two patients (both in the control group) have ment than for those who did not. This finding,
had surgery, with BSSO and rigid fixation.
together with the observed changes in ANB, sug-
gests that, with regard to the issue of whether early
The growth effects of early treatment (or no treatment makes a difference in treatment outcome,
treatment), however, were far from uniform, and there is little difference in the effectiveness of early
this variability must be kept in mind when long- and delayed treatment for correction of Class II
term skeletal effects are evaluated. It is possible malocclusion. The lack of any systematic relation-
that children who sustained large changes in ship between the initial severity of the malocclusion
skeletal jaw relationship during phase 1 showed and treatment outcome shown in Fig. 5 suggests that
a different response during phase 2 than those excellent treatment outcomes occur almost as often
that did not—that is, the children who responded for patients who initially had severe malocclusion as
most favorably to phase 1 treatment (about 25% for those with more moderate problems. Similarly,
of those who underwent phase 1 treatment) less satisfactory results can occur across a wide
achieved a benefit that those with less favorable or range of initial occlusal severity.
no response did not. It will not be possible to fully Clearly many of the children with high final PAR
evaluate these findings until the total data set for scores (!10) were those for whom treatment was
the trial is available. discontinued early, frequently at the request of the
Treatment response is judged in two ways: to parent or patient. Several of these patients and
some extent as the improvement in skeletal relation- parents discussed but declined surgical correction.
ship, but to a much larger extent as the improvement Although the distribution of boys and girls with high
in dental alignment and occlusion. Many of the few final PAR scores was approximately equal in the two
previous studies whose authors attempted to quan- early-treatment groups, 8 of the 11 control “fail-
tify the success (or failure) of orthodontic treatment ures” were male. It may well be that delay in the
involved different indexes and operational defini- start of treatment for boys compromises their ability
tions, making it difficult to compare success to cope with complex extended treatments as they
rates.14-18 approach adolescence. Growth modification itself
The PAR index was specifically developed to may not be so important as the child’s ability to
assess not only the severity of malocclusion but the cooperate with the treatment regimens given all the
outcome of treatment.2 This index, tested and vali- other changes occurring in their lives.
dated in both European19 and American20 settings, The findings of previous studies have suggested
reflects clinicians’ beliefs about the importance of that two-phase treatments generally take longer
the various components of occlusion. The use of an than treatment provided as a single phase;13,22 our
objective measure of the changes in alignment and data support this. Comparing the duration of phase
occlusion of teeth that result from treatment should 2 treatment for children who started treatment in
remove much of the subjectivity in comparison of mixed dentition with that in patients for whom
responses to alternative treatment approaches. treatment was delayed until the permanent teeth
However, the PAR index can only be regarded as a erupted, we see that in these initially equivalent
measure of the proximate outcomes of care21—that groups, the average phase 2 treatment time was
is, the extent to which the clinician has succeeded in almost always shorter for the headgear and func-
the immediate goal of improving the patient’s dental tional appliance groups than for the control pa-
alignment. Little evidence relates reduction in PAR tients. However, when the time in early treatment
scores with the ultimate outcomes of treatment that (approximately 15 months) is also included, on
patients are presumed to care about, such as im- average the two-phase treatments are longer than
proved appearance, sociopsychologic well-being, or the single phase undertaken by the controls. This
American Journal of Orthodontics and Dentofacial Orthopedics Tulloch, Phillips, and Proffit 71
Volume 113, No. 1

result must be viewed with some caution; the pro- variability in change in lower-incisor angulation.
tocol of the trial mandated a separation of phase 1 The high extraction rate, then, may have been a
and phase 2. It is possible that phase 1 could have response to dental changes that clinicians believed
been shorter for several of these patients or that could compromise esthetics, stability, or gingival
comprehensive treatment could have been phased in health.
earlier. The question is one of patient preference Surgical options were discussed frequently at the
and practice efficiency: Even if some treatment time start of phase 2, most frequently with the control
is spent wearing simpler appliances and perhaps patients who had had no early treatment and who
making less frequent office visits, is an increase in were considerably older than the two early-treat-
overall treatment time justified? ment groups at the start of appliance therapy. This
A second consideration is the variation in treat- finding most likely reflects not only the clinician’s
ment time seen from patient to patient (some desire to fully inform the patients of all treatment
patients being treated in as little as 11 months and options but the prevalent belief that age and maloc-
others taking as long as 60 months) and between clusion severity interact to reduce the chances of
doctors (one doctor consistently taking a shorter successful correction with orthodontic treatment
time to treat all groups of patients). It has been alone. Whether such a belief is entirely justified in
suggested that the initial severity of the malocclu- the early-adolescent group is not clear.26 The func-
sion is one of the most important factors in the tional appliance group—who, on average, had the
determination of treatment duration.22 Our prelim- smallest ANB angle at the end of phase 2—also had
inary findings do not support this. The plots in Fig. the lowest rate of surgery. The preliminary data
6 show no simple systematic relationship between from this trial suggest that early treatment may
duration of treatment and initial severity. Less sur- influence both the rate of extraction and the need
prisingly, the final treatment outcome also seems to for orthognathic surgery, but not in the pattern that
bear no systematic relation to treatment time. Per- might have been expected. It is not yet clear whether
haps clinicians have an ideal occlusion as a goal for these differences will prove statistically significant
treatment and fight to achieve this goal; for some when all the data are available, or how they might be
patients their persistence works, whereas for others explained if they do prove significant. Further anal-
“potential” finally expires. It may well be that the ysis of the data set will permit more detailed evalu-
between-doctor differences prove in the end to have ation of these important clinical questions.
more of an effect on treatment time than does the
effect of early growth modification. These conclu- CONCLUSION
sions are tentative at best; approximately 25% of the We conclude that, for children with moderate to
patients are still in treatment. severe Class II problems, early treatment followed by later
One of the goals of mixed-dentition treatment is comprehensive treatment on average does not produce
that later treatment should be simpler, perhaps major differences in jaw relationship or dental occlusion,
compared with later one-stage treatment. The severity of
requiring fewer extractions and less surgery.23,24 If
the initial problem and the treatment time, surprisingly,
early treatment does significantly alter growth and are not important influences on the final outcome. Vari-
improve jaw relationships, the rates of extraction to ability in skeletal growth pattern appears to be a major
camouflage a Class II skeletal pattern or orthog- contributor to variability in treatment response. Differ-
nathic surgery to correct jaw relationships should be ences in patient compliance, clinician proficiency, and,
reduced. The extraction rates for the general ortho- probably, other (yet-unidentified) clinical factors also
dontic population have always been hard to esti- must affect treatment outcomes. It is likely that the
mate, with temporal trends reflecting different cur- indications for early treatment can be refined in the future
rent clinical beliefs and practices. In the 1990s the to permit better selection of those patients most likely to
extraction rate for patients attending the UNC benefit from this type of intervention.
orthodontic clinic (all types of patients, any extrac- REFERENCES
tion pattern) is about 30%.25 In the UNC Class II
1. Tulloch JFC, Phillips C, Koch G, Proffit WR. The effect of early intervention on
trial the extraction rate was somewhat lower than skeletal pattern in Class II malocclusion: a randomized clinical trial. Am J Orthod
that in all three groups, with the highest rate found Dentofac Orthop 1997;111:391-400.
2. Richmond S, Shaw WC, O’Brien KD, Buchanan IB, Jones R, Stephens CD, et al.
in the functional appliance group. This group had, The development of the PAR index (Peer Assessment Rating): reliability and
on average, approximately 3° more proclination of validity. Eur J Orthod 1992;14:125-39.
3. Tulloch JFC, Proffit WR, Phillips C. Influences on the outcome of early treatment
the lower incisors than the control or headgear for Class II malocclusion. Am J Orthod Dentofac Orthop 1997;111:533-42.
groups during phase 1 and showed the greatest 4. Tulloch JFC, Medland W, Tuncay OC. Methods used to evaluate growth
72 Tulloch, Phillips, and Proffit American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

modification in Class II malocclusion. Am J Orthod Dentofac Orthop 1990;98: 15. Eismann D. Reliable assessment of morphological changes resulting from ortho-
340-7. dontic treatment. Eur J Orthod 198;2:19-25.
5. Johnston LE, Paquette DE, Beattie JR, Cassidy DW, McCray JF, Killiany DM. The 16. Berg R, Fredlund A. Evaluation of orthodontic treatment results. Eur J Orthod
reduction of susceptibility bias in retrospective comparisons of alternative treat- 1981;3:181-5.
ment strategies. In Vig KD, Vig PS, editors. Clinical research as the basis of clinical 17. Nashed RR, Reynolds IR. A cephalometric investigation of overjet changes in fifty
practice. Monograph 25, Craniofacial Growth series. Ann Arbor, Mich.: Center for severe Class II Division 1 malocclusions. B J Orthod 1989;16:31-7.
Human Growth and Development, University of Michigan, 1991. 18. Tahir E, Sadowsky C, Schneider BJ. An assessment of treatment outcome in American
6. Harrison JE, Ashby D, Lennon MA. An analysis of papers published in the British Board of Orthodontic cases. Am J Orthod Dentofac Orthop 1997;111:335-42.
and European Journals of Orthodontics. B J Orthod 1996;23:203-9. 19. Richmond S, Shaw WC, Roberts CT, Andrews M. The PAR index (Peer
7. Bjork A. Prediction of mandibular growth rotation. Am J Orthod 1969;55:578-599. Assessment Rating): methods to determine outcome of orthodontic treatment in
8. Carter NE. Dentofacial changes in untreated Class II division 1 subjects. B terms of improvement and standards. Eur J Orthod 1992;14:180-7.
J Orthod 1987;14:225-34. 20. DeGuzman L, Bahiraei D, Vig KWL, Vig PS, Weyant RJ, O’Brien K. The
9. Mills JRE. The effect of functional appliances on the skeletal pattern. B J Orthod validation of the Peer Assessment Rating index for malocclusion severity and
1991;18:267-75. treatment difficulty. Am J Orthod Dentofac Orthop 1995;107:172-6.
10. Johnston LE. Correlation and prediction: interpreting the significance of r. Angle 21. Antczak-Bouckoms AA, Tulloch JFC. Measuring outcomes in clinical research. In:
Orthod 1993;63:273-6. Vig KWV, Vig PS, editors. Clinical research as the basis of clinical practice.
11. Buschang PH, Tanguay R, Turkewicz J, Demirjian A, LaPalme L. A polynomial Monograph 25, Craniofacial Growth series. Ann Arbor, Mich.: Center for Human
approach to craniofacial growth: description and comparison of adolescent males Growth and Development, University of Michigan, 1991.
with normal occlusion and those with untreated Class II malocclusion. Am J 22. O’Brien KD, Robbins R, Vig KWL, Vig PS, Shnorhokian H, Weyant R. The
Orthod Dentofac Orthop 1986;90:437-44. effectiveness of Class II Division 1 treatment. Am J Orthod Dentofac Orthop
12. Buschang P Tanguay R, Demirjian A, LaPalme L, Turkewicz J. Mathematical 1995;107:329-34.
models of longitudinal mandibular growth for children with normal and untreated 23. Dugoni SA, Lee JS, Varela J, Dugoni AA. Early mixed dentition treatment:
Class II division I malocclusion. Eur J Orthod 1988;10:227-34. postretention evaluation of stability and relapse. Angle Orthod 1995;65:311-20.
13. Livieratos FA, Johnston LE. A comparison of one-stage and two-stage non- 24. Starnes LO. Dentofacial orthopedics: when and how? PCSO Bull 1996;68:37-8.
extraction alternatives in matched Class II samples. Am J Orthod Dentofac Orthop 25. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic
1995;108:118-31. clinic. Angle Orthod 1994;64:407-14.
14. Berg R. Post-retention analysis of treatment problems and failures in 264 consec- 26. Lenz B, Tulloch C, Rogers L, Phillips C. Age and treatment outcome for Class II
utively treated cases. Eur J Orthod 1979;1:55-68. malocclusion. J Dent Res 1997;76(suppl):927.