UNIVERSITY OF CAMPANIA Luigi Vanvitelli POSTGRADUATE PROGRAM IN ORTHODONTICS
Chairman: Prof. Le@zia Perillo
www.ortodonzia.unicampania.it LP, 2018
#3 Long-‐term outcomes
#1 Differen@al diagnosis
#2 Fränkel-‐2 appliance
#4 Clinical Cases
MANDIBULAR RETRUSION outline
www.ortodonzia.unicampania.it LP, 2018
McNamara JA.
Components of Class II malocclusion in children 8-‐10 years of age. Angle Orthod. 1981; 51:177-‐202.
153 124
8 -‐ 10 yrs
277 skeletal Cl II malocclusions
Ø Mandibular skeletal retrusion was the most common single characteris@c
MANDIBULAR RETRUSION common finding
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Horizontal Typing Ver@cal Typing
A normal max & mdb posi@on -‐ U incisor proclina@on 1 CW mdb, occl, pal plane Long face
B max prognathism -‐ U incisor proclina@on 2 flat mdb, occl, pal plane Square face
C max & mdb retrognathism -‐ U & L incisor proclina@on 3 CW mdb, ccw pal plane
D max & mdb retrognathism & U incisor proclina@on 4 CW mdb, occl, pal plane
E max prognathism -‐ U & L incisor proclina@on 5 flat mdb, occ plane, CW pal plane
F mdb retrognathism: heterogeneous group of disorders, not well typified
Moyers RE, Riolo ML, Guire KE, Wainright RL, Bookstein FL. Differen@al diagnosis of class II malocclusions. Facial types associated with class II malocclusions.
Am J Orthod. 1980;78:477-‐94.
697 12 -‐ 16 yrs
MANDIBULAR RETRUSION not a single diagnostic entity
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Ø Rota@onal Ø Posi@onal Ø Dimensional
Go-‐Pg < Se-‐N + 3 mm (7-‐12 yrs)
SN^Go-‐Me > 36° NS^Ar > 123°
S N
Go
Me
Ar
N
S Se
Pg
Go
N
Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with func@onal appliances.
St. Louis: Mosby; 1997.
MANDIBULAR RETRUSION different phenotypes
DMR RMR PMR
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Micro mandible Retrusive mandible
Underdeveloped mandible
Posteriorly dispaced glenoid fossa
Posteriorly placed mandible to cranial anatomy
Retroposi@oned mandible
Distally posi@oned mandible Retruded mandible
Posterior posi@oned mandible
Short mandible
“The best outcome begins with a complete and accurate diagnosis” Ikeda K. et al, 2009
MANDIBULAR RETRUSION need of differential diagnosis
www.ortodonzia.unicampania.it LP, 2018
MANDIBULAR RETRUSION the blending of class II
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MANDIBULAR RETRUSION aim
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DIMENSIONAL 28.9%
POSITIONAL 6.6%
Perillo L, Padricelli G, Isola G, Femiano F, Chiodini P, Matarese G. Class II malocclusion division 1: a new classifica@on method by cephalometric analysis.
Eur J Paediatr Dent. 2012;13:192-‐6.
DIMENSIONAL ROTATIONAL
27.6%
DIMENSIONAL POSITIONAL 12.5%
Se
Pg Go
N
Ar
N S S
N
Go Me
ROTATIONAL 7.2 %
ROTATIONAL POSITIONAL
5.9%
DIMENSIONAL ROTATIONAL POSITIONAL 12.5 %
MANDIBULAR RETRUSION 7 different phenotypes
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MANDIBULAR RETRUSION conclusions
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Fränkel R. The treatment of Class II, Division 1 malocclsuion with func@onal correctors.
Am J Orthod. 1969;55:265-‐75.
MANDIBULAR RETRUSION dimensional type
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MANDIBULAR RETRUSION end of growth
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MANDIBULAR RETRUSION
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www.ortodonzia.unicampania.it LP, 2018
MANDIBULAR RETRUSION
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MANDIBULAR RETRUSION treatment
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MANDIBULAR RETRUSION treatment
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Short-‐term outcomes X Chadwick SM et al, 2001 X O’ Brien K et al, 2003 X O’ Brien K et al, 2003 X Tulloch JFC et al, 2004 X Dolce C et al, 2005 X O’ Brien K et al, 2009 X Thiruvenkatachari B et al, 2010 X Chen DR et al, 2011 X Baysal A et al, 2013 X Chhibber A et al, 2013 X Guimaraes CH Jr et al, 2013 X Candir M et al, 2017 X Oh H et al, 2017
Systema@c review & Meta-‐analysis X Chen JY et al, 2002 X Koretsi V et al, 2014 X Bock NC et al, 2015 X D’Antò V et al, 2015 X Pacha MM et al, 2015 X Thiruvenkatachari B et al, 2015 X Zymperdikas VF et al, 2015
MANDIBULAR RETRUSION if
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Short-‐term outcomes
www.ortodonzia.unina2.it
ü Mc Namara JA et al, 1985 ü Falck F et al, 1989 ü Mc Namara JA et al, 1990 ü Nelson C et al, 1993 ü Mc Namara JA et al, 1996 ü Moss JP et al, 1997 ü Tulloch JFC et al, 1997 ü Ghafari J et al, 1998 ü Illing HM et al, 1998 ü Morris DO et al, 1998 ü Franchi L et al, 1999 ü Rushforth CDJ et al, 1999 ü Toth LR et al, 1999 ü Tumer N et al, 1999 ü Baccev T et al, 2000 ü Ucuncu N et al, 2001 ü De Almeida MR et al, 2002 ü De Almeida MR et al, 2002 ü Patel HP et al, 2002 ü Wheeler TT et al, 2002 ü Basciwci FA et al, 2003 ü Janson G et al, 2003 ü Pangrazio KV et al, 2003 ü Singh GD et al, 2003 ü Araujo AM et al, 2004 ü Cozza P et al, 2004 ü Schaefer AT et al, 2004 ü Ruf et al, 2006 ü Almeida RR et al, 2007
Systema@c reviews & Meta-‐analysis
MANDIBULAR RETRUSION if
www.ortodonzia.unicampania.it LP, 2018
ü Perinev G et al, 2015 ü Yang X et al, 2015 ü Bock NC et al, 2016 ü Madurantakam P, 2016 ü Santamaría A et al, 2017
ü Cozza P et al, 2006 ü Antonarakis GS et al, 2007 ü Marsico E et al, 2011 ü Perillo L et al, 2011 ü Ehsani S et al, 2014
Long-‐term outcomes ü Falck F, 1991 ü Perillo rt al, 1996 ü Omblus J et al, 1997 ü Mills CM et al, 2000 ü Fal@n K et al, 2003 ü Berger JL et al, 2005 ü Bock NC et al, 2006 ü VanLaecken R et al, 2006 ü Nelson B et al, 2007 ü Freeman DC et al, 2009 ü Malta LA et al, 2010 ü Perillo L et al, 2011 ü Angelieri F et al, 2014 ü De Abreu F et al, 2014 ü Pancherz H et al, 2014 ü Pancherz H et al, 2015 ü Bigliazzi R et al 2015 ü Bock NC et al, 2016 ü Franchi L et al, 2016 ü Pavoni C et al, 2017 ü Bock NC et al, 2017
ü Marsan G, 2007 ü Baccev T et al, 2009 ü Siara-‐Olds NJ et al, 2010 ü Jamilian A et al, 2011 ü Wigal T et al, 2011 ü Biava@ A et al, 2012 ü Booij JW et al, 2013 ü Franchi L et al, 2013 ü Mar@na R et al, 2013 ü Perillo L et al, 2013 ü Showkatbahsh R et al, 2013 ü Li L et al, 2014 ü Burhan AS et al, 2015 ü Cheung RNY et al, 2015 ü Giun@ni V et al, 2015 ü Cirgic E et al, 2015 ü Bassarelli T et al, 2016 ü Khoja A et al, 2016 ü Schulz S et al, 2016 ü Tomblyn T et al, 2016 ü Aras I et al, 2017 ü Baazhia AS et al, 2017 ü Ba@sta KBSL et al, 2017 ü Ciaravella D et al, 2017 ü Eissa O et al, 2017 ü Spalj S et al, 2017 ü Arora V et al, 2018 ü Idris G et al, 2018 ü Kinzinger GSM et al, 2018
MANDIBULAR RETRUSION treatment
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Dento-‐skeletal
changes
MANDIBULAR RETRUSION why
Environmental
factors
Transverse discrepancy
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MANDIBULAR RETRUSION treatment
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Baccev T, Franchi L, McNamara JA Jr. The Cervical Vertebral Matura@on (CVM) method for the assessment of op@mal treatment
@ming in dentofacial orthopedics. Seminars in Orthodon@cs. 2005;11:119-‐29.
1 year -1 yr -2 yrs +1 yr +2 yrs
Mandibular growth peak
CVMS 3 -‐ 4
Perinev G, Primozic J, Franchi L, Contardo L. Treatment Effects of Removable Func@onal Appliances in Pre-‐Pubertal and Pubertal Class II Pa@ents:
A Systema@c Review and Meta-‐Analysis of Controlled Studies. PLos One. 2015; 10(10): e0141198.
MANDIBULAR RETRUSION when
during pubertal age
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1 year -1 yr -2 yrs +1 yr +2 yrs
Suresh M, Ratnaditya A, Kavmani VS, Karpe S. One phase versus two phase treatment in mixed den@@on: a cri@cal review.
J. Int. Oral Health. 2015; 7(8): 144-‐147.
MANDIBULAR RETRUSION when
during pre-‐pubertal age
Mandibular growth peak
CVMS 2 -‐ 3
www.ortodonzia.unicampania.it LP, 2018
Barber SK, Forde KE, Spencer RJ. Class II division 1: an evidence-‐based review
of management and treatment @ming in the growing pa@ent.
Dent Update. 2015; 42(7): 632-‐4, 637-‐8, 641-‐2.
MANDIBULAR RETRUSION treatment
www.ortodonzia.unicampania.it LP, 2018
Fränkel-‐2
Ac@vator Bionator II
Sander
High Pull Head Gear
Teuscher Twin-‐Block
Class II elas@cs
Herbst
Jusper Jumper
MANDIBULAR RETRUSION how
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MANDIBULAR RETRUSION how
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MANDIBULAR RETRUSION how
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Frankel R. The treatment of Cl II, Division 1 malocclusion with
func@onal correctors. Am J Orthod. 1969;55(3):265-‐75.
FR-‐2 appliance
ü McNamara J et al, 1985 ü Falck F et al, 1989 ü McNamara J et al, 1990 ü McNamara J et al, 1996 ü Ghafari J et al, 1998 ü Toth LR et al, 1999 ü Rushforth CDJ et al, 1999
ü De Almeida MR et al, 2002 ü De Almeida MR et al, 2002 ü Patel HP et al, 2002 ü Janson G et al, 2003 ü Silvestrini A et al, 2012 ü Perillo L et al, 2013 ü Showkatbahsh R et al, 2013 ü Schulz S et al, 2016
MANDIBULAR RETRUSION FR-2
FR-‐2 short-‐term outcomes
www.ortodonzia.unicampania.it LP, 2018
SHORT-‐TERM FR-‐2 TREATMENT EFFECTS meta-‐analysis
www.ortodonzia.unicampania.it LP, 2018
ü Falck F, 1991 (10 yrs) ü Perillo L et al, 1996 (5 yrs) ü Berger JL et al, 2005 (3 yrs)
ü Freeman DC et al, 2009 (10 yrs) ü Perillo L et al, 2011 (10 yrs) ü Angelieri F et al, 2014 (7 yrs)
MANDIBULAR RETRUSION FR-2
FR-‐2 long-‐term outcomes
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MANDIBULAR RETRUSION after 5 year
after the end of treatment
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MANDIBULAR RETRUSION after 10 year
after the end of treatment
To verify the stability of the dento-‐skeletal changes
awer FR-‐2 treatment at the end of growth
in a sample of class II malocclusion
by Dimensional Mandibular Retrusion
MANDIBULAR RETRUSION aim
www.ortodonzia.unicampania.it LP, 2018
LONG-‐TERM FR-‐2 TREATMENT EFFECTS selec@on sample
FR-‐2 treated pa@ents from 1988 to 1998
Class II, div 1 malocclusion Ø at least an end-‐to-‐end molar rela@onship Ø OVJ > 4 mm
Skeletal class II malocclusion Ø ANB > 4° Ø SNB < 78°
Dimensional Mandibular Retrusion Ø Go-‐Pg < Se-‐N + 3 mm Age 8-‐10 yrs Ø mixed den@@on / CVMS 1-‐2
FR-‐2 Treatment Ø at least 1 yr Ø 16-‐18 hrs/day Ø 2-‐3 mm ac@va@on every 6 mos Post FR-‐2 Treatment Ø fixed appliances Ø no Cl II elas@cs Ø 2-‐yr reten@on High quality LL X-‐rays Ø pre FR-‐2 Ø post FR-‐2 Ø end of growth (min. 13 yrs awer FR-‐2 è un risultato )
Ø previous orthodon@c tx / max protrusion / cw mdb rota@on / posterior mdb posi@on
www.ortodonzia.unicampania.it LP, 2018
20 11 9 24.4 yrs – CS 6 10.6 yrs -‐ CS 3 or 4 26.1 yrs / CVMS 6
9 yrs / CS 1-‐2
10.6 yrs / CVMS 2-‐3
Long-‐term
15.7 yrs T0 1.9 yr T2 T1
same inclusion criteria sex, age, CVMS, and observa@onal period
8.9 yrs / CVMS 1-‐3
LONG-‐TERM FR-‐2 TREATMENT EFFECTS dimensional mandibular retrusion samples
Ø comparison of changes T2-‐T1 within FR-‐2 sample
www.ortodonzia.unicampania.it LP, 2018
N N
Ar
S
A
B
Me
Go
Se
SNP SNA
Go
Me
A
Gn
Pg
Co S
Dimensional Mandibular Retrusion (DMR) Go-‐Pg < Se-‐N + 3 mm from 7 to 12 yrs
Graber TM, Rakosi T, Petrovic AG.
Dentofacial orthopedics with func@onal appliances. St. Louis: Mosby; 1997.
LONG-‐TERM FR-‐2 TREATMENT EFFECTS cephalometric analysis
www.ortodonzia.unicampania.it LP, 2018
Con@nuous variables Ø Mean and standard devia@on Ø Un-‐paired t-‐test for comparison between groups Ø Paired t-‐test for comparison
of change increments
within groups
Sta@s@cal Analysis System
Ø SAS version 9.2
Ø Sta@s@cal Significance p < 0.05
Categorical variables Ø Absolute numbers and
percentages Ø Chi-‐square test
Error study Ø Dahlberg’s formula Ø 10 LL X-‐rays at random Ø 0.21-‐ 0.64
LONG-‐TERM FR-‐2 TREATMENT EFFECTS sta@s@cal analysis
www.ortodonzia.unicampania.it LP, 2018
8.4 yrs 9.8 yrs 23.0 yrs
9.4 yrs 10.6 yrs 23.8 yrs
8.5 yrs 10.1 yrs 28.5 yrs
11.9 yrs 30.2 yrs 9.11 yrs
10.1 yrs 25.4 yrs
8.9 yrs
9.8 yrs 11.7 yrs 33.8 yrs
LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases
www.ortodonzia.unicampania.it LP, 2018
8.4 yrs 9.8 yrs 23.0 yrs
9.4 yrs 10.6 yrs 23.8 yrs
8.5 yrs 10.1 yrs 28.5 yrs
11.9 yrs 30.2 yrs 9.11 yrs
10.1 yrs 25.4 yrs
8.9 yrs
9.8 yrs 11.7 yrs 33.8 yrs
LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases PROVA
www.ortodonzia.unicampania.it LP, 2018
LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases
9.9 yrs 11.6 yrs 27.7 yrs
9.4 yrs 11.3 yrs 24.7 yrs
9.5 yrs 23.6 yrs
8.5 yrs
9.6 yrs 25.8 yrs
8.1 yrs
9.6 yrs 11.0 yrs 24.8 yrs
9.3 yrs 8.1 yrs 22.5 yrs
9.11 yrs 11.9 yrs 25.8 yrs www.ortodonzia.unicampania.it
9.9 yrs 23.1 yrs
8.2 yrs
8.7 yrs 10.4 yrs 27.9 yrs
9.3 yrs 10.5 yrs 23.7 yrs
9.10 yrs 11.9 yrs 25.0 yrs
10.3 yrs 32.4 yrs
8.4 yrs
LONG-‐TERM FR-‐2 TREATMENT EFFECTS clinical cases
9.6 yrs 23.3 yrs 8.5 yrs
www.ortodonzia.unicampania.it LP, 2018
LONG-‐TERM FR-‐2 TREATMENT EFFECTS agreement
ü De Almeida MR et al, 2002 ü Patel HP et al, 2002 ü Janson G et al, 2003 ü Silvestrini A et al, 2012 ü Perillo L et al, 2013 ü Showkatbahsh R et al, 2013 ü Schulz S et al, 2016
ü Falck F, 1991 ü Perillo L et al, 1996 ü Berger JL et al, 2005 ü Freeman DC et al, 2009 ü Perillo L et al, 2011 ü Angelieri F et al, 2014
Long-‐term outcomes Short-‐term outcomes
www.ortodonzia.unicampania.it LP, 2018
ü McNamara J et al, 1985 ü Falck F et al, 1989 ü McNamara J et al, 1990 ü McNamara J et al, 1996 ü Ghafari J e al, 1998 ü Toth LR et al, 1999 ü Rushforth CDJ et al, 1999 ü De Almeida MR et al, 2002
LONG-‐TERM FR-‐2 TREATMENT EFFECTS agreement
www.ortodonzia.unicampania.it LP, 2018
AFTER FR-‐2 TREATMENT
AT THE FOLLOW-‐UP, AFTER 15.7 YRS OF FR-‐2 TREATMENT
LONG-‐TERM FR-‐2 TREATMENT EFFECTS conclusions
Ø mandibular increments Ø intermaxillary rela@onship improvements Ø incisor compensa@on
Ø stability of mandibular changes Ø no rebound Ø mandibular body, ramus and total length con@nued to increase over@me Ø slight lower incisor compensa@on
www.ortodonzia.unicampania.it LP, 2018
Leonardo, 9.3 yrs
www.ortodonzia.unicampania.it LP, 2018
CEPHALOMETRIC ANALYSIS
MEASUREMENTS INITIAL
SNA 82° SNB 75.5° ANB 6.5° Se-‐N 76 mm PNS-‐A 50 mm Go-‐Pg 73.5 mm Co-‐Go 52 mm Co-‐Gn 109 mm
Ar-‐Go-‐Me 128° SN-‐Go-‐Me 34°
1/SN 110° 1/Go-‐Me 85°
www.ortodonzia.unicampania.it LP, 2018
Leonardo, 10.8 yrs awer 1.5 yr of FR-‐2
www.ortodonzia.unicampania.it LP, 2018
CEPHALOMETRIC ANALYSIS
MEASUREMENTS INITIAL AFTER FR-‐2
SNA 82° 82° SNB 75.5° 78° ANB 6.5° 4° Se-‐N 76 mm 76 mm PNS-‐A 50 mm 50 mm Go-‐Pg 73.5 mm 76 mm Co-‐Go 52 mm 55 mm Co-‐Gn 109 mm 112 mm
Ar-‐Go-‐Me 128° 128° SN-‐Go-‐Me 34° 33°
1/SN 110° 99° 1/Go-‐Me 85° 87°
www.ortodonzia.unicampania.it LP, 2018
Leonardo, 9.3 yrs before…
Leonardo, 10.8 yrs …and awer
… 1.5 yr awer FR-‐2 treatment
www.ortodonzia.unicampania.it LP, 2018
Leonardo, 25.9 yrs 15.1 yrs awer FR-‐2 treatment
www.ortodonzia.unicampania.it LP, 2018
CEPHALOMETRIC ANALYSIS
MEASUREMENTS INITIAL AFTER FR-‐2 LONG-‐TERM
SNA 82° 82° 81.5° SNB 75.5° 78° 79° ANB 6.5° 4° 2.5° Se-‐N 76 mm 76 mm 81 mm PNS-‐A 50 mm 50 mm 54.5 mm Go-‐Pg 73.5 mm 76 mm 84 mm Co-‐Go 52 mm 55 mm 65 mm Co-‐Gn 109 mm 112 mm 124 mm
Ar-‐Go-‐Me 128° 128° 124° SN-‐Go-‐Me 34° 33° 31°
1/SN 110° 99° 100° 1/Go-‐Me 85° 87° 90°
www.ortodonzia.unicampania.it LP, 2018
TODAY
Leonardo, 26 yrs
www.ortodonzia.unicampania.it LP, 2018
This is longest follow-‐up of FR-‐2 appliance (15.7 yrs)
“In vitro” research
Animal research
Ideas, Editorials, Opinions
Case Report
Case Series
Case Control Studies
Cohort Studies RCT
SR and MA
Ø Small sample
Ø Pre-‐pubertal age
LONG-‐TERM FR-‐2 TREATMENT EFFECTS progress & limita@ons
Ø Follow-‐up included fixed appliance and reten@on
Ø Biased sample
Ø Retrospec@ve study
www.ortodonzia.unicampania.it LP, 2018
LONG-‐TERM FR-‐2 TREATMENT EFFECTS future prospec@ves
Ø Prospec@ve study
Ø Larger sample
Ø Pre-‐pubertal vs pubertal sample
www.ortodonzia.unicampania.it LP, 2018
Ø Differen@al diagnosis of mandibular retrusion
Ø S@mulate mandibular growth only in case of dimensional mandibular retrusion
Ø Use FR-‐2 for long-‐las@ng skeletal and dental changes
Ø Treat the phenotype but don’t forget the genotype
LONG-‐TERM FR-‐2 TREATMENT EFFECTS Take Home Message
LONG-‐TERM STABILITY OF FR-‐2 TREATMENT MAY STILL BE CONSIDERED AN ACHIEVABLE GOAL
www.ortodonzia.unicampania.it LP, 2018
UNIVERSITY OF CAMPANIA Luigi Vanvitelli POSTGRADUATE PROGRAM IN ORTHODONTICS
Chairman: Prof. Le@zia Perillo
[email protected]@unicampania.it
LP, 2018 www.ortodonzia.unicampania.it
AAO Donated Orthodon@c Services (DOS) Program
All that is missing is You!
• Introduced in 2009, the DOS program provides access to care for children in need. Access to quality orthodon@c care is missing in many children’s lives. The AAO DOS program mission is to serve low income children without insurance coverage or that do not qualify for other assistance in their state of residence.
• The program has expanded to include 10 state programs and currently serves children in Illinois, Indiana, Kansas, Michigan, New Jersey, North Carolina, Rhode Island, Tennessee, Texas and Virginia.
• In addi@on to the state programs, orthodon@sts from all across the U.S. have volunteered to provide treatment to DOS pa@ents not residing in one of the areas served by state programs.
• In order to expand further, we need you to help us by volunteering to serve as a provider orthodon@st or help iden@fy orthodon@sts willing to lead efforts to establish a DOS chapter in your state.
• Contact Ann Sebaugh at [email protected] with ques@ons.