one-phase vs 2-phase treatment for developing class iii ...class iii malocclusion: a comparison of...

CASE REPORT

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

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

Sendai and Nagoya, Japan, and Farmington, Conn

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Despite the known influence of early treatment on the facial appearance of growing patients with skeletal Class IIImalocclusion, few comparative reports on the long-term effects of different treatment regimens (1-phase vs2-phase treatment) have been published. Uncertainty remains regarding the effects of early intervention onjaw growth and its effectiveness and efficiency in the long term. In this case report, we compared the effectsof early orthodontic intervention as the first phase of a 2-phase treatment vs 1-phase fixed appliance treatmentin identical twins over a period of 11 years. Facial and dental changes were recorded, and cephalometric super-impositions were made at 4 time points. In spite of the different treatment approaches, both patients showedidentical dentofacial characteristics in the retention phase. Through this case report, we intended to clarify thebenefits of undergoing 1-phase treatment against 2-phase treatment protocols for treating growing skeletalClass III patients. (Am J Orthod Dentofacial Orthop 2012;141:e11-e22)

In the treatment of skeletal Class III growing patients, ithas become a common practice to intervene early withorthodontic or orthopedic treatment modalities as

a part of a 2-phase treatment approach. This approachis claimed to provide early and significant improvementin the facial profile, require fewer surgical interventionsin the future, and produce significant psychosocial bene-fits for the patient as well as the parents.1-3 Althoughorthopedic forces that attempt to control or alter theskeletal framework in skeletal Class III patients appear tobe remarkably effective in the initial stages, the resultsare rarely maintained in the long term.4,5 Previously, wepresented a clinical practice guideline for the treatmentof developing Class III malocclusions (Fig 1).6,7 However,it is still difficult to decide whether a 2-phase treatmentis actually better than a 1-phase treatment, especially in

orthodontist, skeletal anchorage system orthodontic center; clinical pro-, Division of Maxillofacial Surgery, Tohoku University, Sendai, Japan.rer and assistant researcher, Division of Maxillofacial Surgery, Tohokursity, Sendai, Japan.te practice, Nagoya, Japan.ssor and head, Department of Craniofacial Sciences, Division of Orthodon-niversity of Connecticut, Farmington.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Ravindra Nanda, Division of Orthodontics, School of Dentaline, University of Connecticut Health Center, Farmington, CT 06030-1725;l, [email protected], April 2011; revised and accepted, May 2011.5406/$36.00ight � 2012 by the American Association of Orthodontists..1016/j.ajodo.2011.05.023

light of mounting evidence that patients with a skeletalClass III malocclusion show neither excessive mandibulargrowth nor deficient maxillary growth when comparedwith Class I subjects at any growth stage.8 Therefore, thekey question is “what differences in jaw growth ortreatment modality and outcome will there be betweenpatients who undergo 1-phase treatment and those whodon’t?” This twin study allowed us to elucidate somebenefits of 1-phase treatment rather than waiting untilthe postadolescent period.

DIAGNOSIS AND ETIOLOGY

The patients, monozygotic twin sisters (Fig 2), werereferred to our department at Tohoku University, Sendai,Japan, in 1996 when they were 9 years old for orthodon-tic treatment of anterior crossbites. Their medical histo-ries showed no systemic diseases or developmentalanomalies. Not surprisingly, both twins had almost thesame orthodontic problems that included a prognathicprofile, mild mandibular asymmetry, Class III denturebases, deviation of mandibular midlines, and occlusal in-terference of the incisors (Fig 3). Cephalometrically, theirskeletofacial types were classified as Class III short-facetypes. The short-face tendency was more pronouncedin Patient 2 (Fig 4).

TREATMENT OBJECTIVES

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

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Fig 1. Clinical practiceguideline for the treatmentof adevelopingClass IIImalocclusion.Obs,Observation.

Fig 2. Pretreatment facial photographs of the twins.

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Fig 3. Pretreatment intraoral photographs of the twins.

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disharmony allows downward and backward rotation ofthe mandible for correction of the anterior crossbite anddeepbite and, therefore, are good candidates for a treat-ment plan involving 2 phases. This includes correction ofthe anterior crossbite in the first phase followed by a pe-riod of growth observation and then a second phase oftreatment with fixed appliances. In light of our previousdiscussion regarding early intervention on jaw growth,the treatment objectives for Patient 1 were establishedwith the 2-phase treatment approach, whereas Patient2 was managed with a 1-phase treatment concept. In-formed consents were obtained for both patients fromtheir parents.

American Journal of Orthodontics and Dentofacial Orthoped

The treatment objectives for Patient 1 were (1) phase1 treatment involving dental correction of the anteriorcrossbite, (2) growth monitoring and oral health care un-til the postadolescent period, (3) fixed appliance treat-ment for correction of the remaining orthodonticproblems, and (4) retention and long-term follow-up.

For Patient 2, the treatment objectives were (1) growthmonitoring and oral health care until the postadolescentperiod, (2) correction of the malocclusion with fixed appli-ance treatment together with skeletal anchorage thatwould allow us to circumvent the need for mandibularpremolar extraction, and (3) retention and long-termfollow-up.

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Fig 4. Skeletofacial types developed from the cephalometric analyses for the twins. They were judgedas skeletal Class III short face. Note that the short-face tendency was more pronounced in Patient 2.

Fig 5. Timing intervals of the comparisons of treatment progress and results. MIP, Maxillary incisorsprotractor; MBS, multi-bracketed system; SAS, skeletal anchorage system.

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

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TREATMENT ALTERNATIVES

Because the twins were skeletal Class III growing pa-tients, growthmodification treatments and functional ap-pliances could be alternatives, but they were not includedwith our options for the reasons previously mentioned.

Treatment alternatives in the postadolescent phasecould have included conventional camouflage treatment


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


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

Patient 1 Patient 2SNA 79.6� (�0.4) 79.0� (�0.6)SNB 79.8� (1.3) 80.0� (1.3)ANB �0.2� (0) �1.0� (0)Mandibular plane to SN 34.6� (�0.8) 35.4� (�0.8)Gonial angle 127.0� (�0.5) 125.2� (�0.8)U1 to SN 93.6� (�1.7) 89.4� (�2.4)L1 to mandibular plane 85.8� (�1.4) 79.1� (�2.5)L1 to U1 149.9� (2.8) 156.1� (4.0)Wits �6.5 mm �7.7 mmN-Me 105.1 mm (�1.1) 104.0 mm (�1.4)N-ANS 47.5 mm (�0.7) 46.0 mm (�1.3)ANS-Me 58.2 mm (�1.4) 58.6 mm (�1.3)

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TREATMENT PROGRESS

Although a 1-phase treatment protocol was chosenfor Patient 2, there was no definitive treatment untilgrowth completion was confirmed. In Patient 1, thefirst phase of treatment began with facemask therapyand 2 3 4 appliances. The aim was to correct her an-terior crossbite dentally, not skeletally. The crossbiteand maxillary dental midline shift were corrected in 6months.

At the age of 10 and after the first phase of treat-ment, Patient 1's prognathic profile and dental maloc-clusion had improved significantly. At the same time,growth observation in Patient 2 showed that all herorthodontic problems were exactly as they had beenat the initial examination. At age 13, both twins hadcompleted their permanent dentitions. Patient 1 hadmaintained a positive overjet and overbite after thefirst phase of treatment, whereas Patient 2 showeda slight improvement in her deepbite without ortho-dontic intervention. Both sisters had the possibilityof postpubertal growth of the mandible; therefore,we decided to elongate the growth observation perioduntil 16 years of age as per our clinical practice guide-lines.6,7

Before the second phase of treatment, Patient 1 stillhad a prognathic profile, with some minor dental prob-lems, particularly in the mandibular dentition. She hada lateral crossbite on the right side, a mild Class III den-ture base, and mild mandibular incisor crowding. At thesame stage, Patient 2 demonstrated more severe ortho-dontic problems than her sister did at this age. She hada skeletal Class III malocclusion with a short-face ten-dency, premature contact at the incisors, a dental mid-line shift, an anterior crossbite, severe crowding of themaxillary anterior teeth, and retroclined mandibularincisors.

January 2012 � Vol 141 � Issue 1 American

At this stage, we superimposed the cephalometric ra-diographs from 9 and 16 years of age based on the nat-ural reference structures suggested by Skieller et al9 andBj€ork and Skieller.10 Cephalometric tracings were madein detail and superimposed carefully. In Patient 1, thesuperimposition showed correction of the anterior cross-bite, with a significant amount of jaw growth. However,the amount of jaw growth from 13 to 16 years of age wasnegligible. In Patient 2, the cephalometric superimposi-tions showed that the maxilla and the mandible had sig-nificant amounts of downward and forward growthduring the adolescent growth period. Her overbite hadimproved over time.

To correct the rest of Patient 1's orthodontic prob-lems, preadjusted fixed appliance treatment was started,and short Class III elastics were used to improve the ClassIII denture bases and prevent proclination of the man-dibular incisors during leveling and aligning. Treatmentfor Patient 2 started with bonding brackets on the man-dibular teeth and placing resin caps on the maxillary mo-lars to open the bite for maxillary bonding. Open-coilsprings were used to make space and procline the max-illary incisors. Simultaneously, distalization of the man-dibular posterior teeth was started with the skeletalanchorage system, which uses an orthodontic miniplateas a temporary anchorage device.11 Within severalmonths, her anterior crossbite was completely corrected,and the distalized mandibular posterior teeth were re-tained with the help of ligature wires connected to theminiplates.

After 12 months of active fixed appliance treatment,Patient 1's malocclusion was corrected. She obtaineda balanced profile, with adequate overjet and overbite,proper anterior guidance, and rigid posterior intercuspa-tion of the teeth. On the other hand, Patient 2's treat-ment with the skeletal anchorage system lasted 18months. She also achieved an acceptable Class I occlu-sion and a satisfactory profile at debonding.

The dentofacial changes during the second phase oftreatment were minimal in Patient 1; only the uprightingof the mandibular molars was observed. On the otherhand, the cephalometric superimposition in Patient 2before and after treatment with the skeletal anchoragesystem showed that her anterior crossbite was largelycorrected by proclination of the maxillary incisors andclockwise rotation of the mandible, causing extrusionof her maxillary and mandibular molars. The mandibularmolars were slightly distalized, and the retroclination ofher mandibular incisors was improved purely by lingualroot torque. After 30 months of retention, both twinshave maintained a good occlusion except for a minor re-lapse of the maxillary right first premolar in Patient 2.Overall, satisfactory results were achieved.

Journal of Orthodontics and Dentofacial Orthopedics

Fig 7. Significant dentofacial differences were observed at the age of 10. After the first phase of me-chanics in Patient 1, her anterior crossbite was corrected after the flaring of her maxillary incisors, theforward displacement of the maxilla, and the clockwise rotation of the mandible. Consequently, herskeletal facial type became much closer to a Class I average face.

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COMPARISON OF TREATMENT PROGRESS ANDRESULTS IN THE TWINS

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


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


Fig 8. Skeletal differences between the sisters at 10 years old gradually disappeared during the puber-tal growth period, and almost no difference was observed between their skeletal profiles at age 16years. The only difference was in the position of Patient 1's maxillary incisors; this was an orthodonticeffect from the facemask. Before 2nd Phase Tx, After the first phase of treatment (ie, facemask ther-apy); Before ortho. Tx, after growth observation only (no interceptive treatment was done).

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was a little more pronounced than her sister’s, theirdentofacial profiles were almost identical (Fig 6;Table I).

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


of early intervention for her. Cephalometric superim-position shows significant dentofacial differencesbetween the sisters at this stage. Patient 1's crossbitewas corrected by proclinatoin of her maxillary inci-sors, forward displacement of the maxilla, and


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

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

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


between their skeletal profiles at 16 years. Theonly difference perhaps was in the position of themaxillary incisors. The orthodontic effect of thefacemask could still be seen on Patient 1's maxillaryincisors (Fig 8).

4. During the retention period (age, 20 years), wesuperimposed the twins’ final records. Interestingly,


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

Patient 1 Patient 2SNA 81.1� (�0.7) 82.0� (�0.4)SNB 78.8� (�0.3) 80.2� (0.3)ANB 2.3� (�0.9) 1.8� (�1.2)Mandibular plane to SN 37.1� (0.1) 36.4� (�0.1)Gonial angle 122.0� (�0.8) 122.9� (�0.6)U1 to SN 107.8� (0.6) 112.6� (1.5)L1 to mandibular plane 91.7� (0.2) 92.7� (0.4)L1 to U1 123.4� (�0.6) 118.2� (�1.2)Wits �1.4 mm �2.7 mmN-Me 123.3 mm (1.0) 121.8 mm (0.4)N-ANS 52.8 mm (�0.8) 52.3 mm (�1.0)ANS-Me 71.4 mm (2.8) 70.4 mm (2.3)

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although they underwent orthodontic treatmentwith completely different treatment regimens(1-phase vs 2-phase), their dentofacial morphol-ogies were identical (Fig 9; Table II).

Fig 10. A, Maxillary growth changes of the twins fromages 9 to 18. Patient 1, who had the first phase of treat-ment, showed more maxillary growth than did Patient 2until they turned 14, but no difference in maxillary lengthswas observed at 18 years of age. B, Mandibular growthchanges of the twins from ages 9 to 18. Obviously, therewas almost no difference between them in mandibulargrowth throughout the various growth periods. (Greenand yellow lines represent the average growth changesof untreated Class I and Class III Japanese teenagersfrom ages 9 to 14 years taken from longitudinal data.16-21)

DISCUSSION

The advantage of using monozygotic twins in sucha comparative case report is that all differences in skeletalgrowth, beyond the error ofmeasurement, can be assumedto be nongenetic and, therefore, the result of the environ-ment.12,13 Themost powerful oral environmental influencefor the twins was the treatment itself. Mandibular growthcan be controlled with chincup therapy, by altering theskeletal framework of growing Class III patients. Ourstudies on the short-term and long-term effects of chin-cup force indicated that the skeletal framework is greatlyimproved during the initial stages of chincup therapy.4,5

However, these changes are rarely maintained during thepubertal growth period; when growth is over, anytreatment with the chincup appliance seldom alters theinherited prognathic characteristics of Class III profiles.

The second relevant area to review is jaw surgery. Ourlongitudinal studies have given us every reason to believethat surgical orthodontic treatment is the most effectivemodality to obtain a favorable profile and a stable occlu-sion for severe adult skeletal Class III patients.14,15 Third,we need to look back at what we knew then about jawgrowth. Our group had conducted some longitudinalstudies with untreated Class III subjects.16-20 It wasshown that those with skeletal Class III malocclusionshowed neither excessive mandibular growth nordeficient maxillary growth when compared with Class Isubjects at any growth stage. Meanwhile, patients withsevere skeletal Class III malocclusion—ie, those who areindicated for future orthognathic surgery—receive notreatment for their dental malocclusion until the endof the pubertal growth spurt. It is important to


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

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


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We also looked at the maxillary growth changes thatoccurred from ages 9 to 18 years for the sisters. Patient 1,who had 2-phase treatment, showed more maxillarygrowth than did Patient 2 until they turned 14. However,no difference in maxillary lengths was observed at 18years of age. Consequently, early correction of the ante-rior crossbite had no impact on maxillary growth. Simi-larly, there was almost no difference between the twinsin their mandibular growth throughout the observationperiod (Fig 10).

Recent clinical trials have suggested that in the long-term the improvement in the skeletal malocclusion ob-tained after a first phase of treatment is not significantwhen compared with a control group that had no growthmodification treatment.21,22 It has also been suggestedthat early intervention does not seem to confera significant psychosocial benefit.3 The first phase oftreatment for Patient 1 was effective, in that her dento-facial and functional problems were improved consider-ably, and were much better than her sister’s. Significantdifferences were observed between their skeletal profilesat age 10. Nevertheless, their skeletal differences gradu-ally diminished during the pubertal growth period to thepoint that there was almost no difference in their skeletalprofiles at age 16. It was obvious that the early correctionof the anterior crossbite did not make a positive impacton jaw growth. It seems that morphogenetic factors arestill stronger and much more dominant than environ-mental factors in the matter of jaw growth.

Interestingly, despite the differences of treatmenttimings and modalities, the twins achieved almostidentical dentofacial profiles, and both had favorableocclusions at age 18. Patient 2 who was managed witha 1-phase treatment, had to undergo treatment withthe skeletal anchorage system. The skeletal anchoragesystem is a viable modality for distalizing mandibularmolars.23,24 It enables en-masse movement of themandibular buccal segments and even the entire man-dibular dentition with only minor surgery for placingthe anchor plates at the anterior border of the mandib-ular ramus or the mandibular body. It is particularly ef-fective for correcting Class III malocclusions, mandibularincisor crowding, and dental asymmetries, and rarelyrequires the extraction of premolars. Without theskeletal anchorage system, this twin study would nothave been possible, and such results could not havebeen obtained.

CONCLUSIONS

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


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

2. Although phase 1 treatment had no impact on jawgrowth, it made the phase 2 treatment simplerand easier. Therefore, 2-phase treatment might bemore suited for mild to moderate Class III patientsthan 1-phase treatment.

3. The criteria for the selection of 1-phase or 2-phasetreatment depend entirely on the patient’s require-ments. Because the biologic outcome is the same,the basis for opting for a particular treatment regi-men can be complicated. Cultural, environmental,and psychosocial factors need to be consideredmore carefully.

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Class III open bite patients. Int J Adult Orthod Orthognath Surg2000;15:309-19.

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19. Sakamoto M, Sugawara J, Umemori M, Mitani H. Craniofacialgrowth of mandibular prognathism during pubertal growth periodin Japanese boys—longitudinal study from 10 to 15 years of age.J Jpn Orthod Soc 1996;55:372-86.


20. Bandai M, Sugawara J, Umemori M, Mitani H. Craniofacial growthof mandibular prognathism in Japanese girls during pubertalgrowth period—longitudinal study from 9 to 14 years of age.Orthod Waves 2000;59:77-89.

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