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Mcnamara in Orthodontics

Mcnamara in Orthodontics

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Growth in the Untreated Class III Subject
Tiziano Baccetti, Lorenzo Franchi, and James A. McNamara, Jr 
The present study was designed to provide an estimate of growth in whitesubjects with Class III malocclusion by means of the analysis of lateralcephalograms in two samples: (1) 22 untreated Class III individuals followedlongitudinally from a prepubertal observation through a postpubertal ob-servation; and (2) a large cross-sectional population (n
1091) of male andfemale untreated subjects at six consecutive developmental periods (CS1through CS6 according to the cervical vertebral maturation method). ClassIII disharmony shows a significant tendency to worsen with growth, asassessed by means of the longitudinal portion of the study. The persistenceof typical Class III growth characteristics well beyond the adolescent growthspurt into early adulthood was confirmed by the results of the large cross-sectional study. A long period of active mandibular growth, the absence ofany catch-up growth in the maxilla, and the significantly more verticaldirection of facial growth during late adolescence appear to be unfavorableaspects of Class III malocclusion in both genders during the postpubertalstages. Treatment planning by means of orthodontic/orthopedic appliancesshould take into account this pattern of prolonged mandibular growth interms of duration of retention and timing for the evaluation of stability oftreatment protocols and eventually for orthognathic surgery. (Semin Orthod2007;13:130-142.) ©
2007 Elsevier Inc. All rights reserved.
nowledge of the physiologic growthchanges of the dentofacial complex is fun-damental to orthodontic treatment planning. Inparticular, growth trends in different malocclu-sions and skeletal disharmonies provide indica-tions for the estimate of growth potential inpatients with the same type of disharmony andrepresent adequate control data when evaluat-ing treatment outcomes.There are three methods of evaluating facialgrowth in individuals diagnosed as having aClass III malocclusion: classical growth studies,longitudinal data of untreated Class III individ-uals, and cross-sectional data from untreatedClass III samples. The large North Americangrowth studies have provided longitudinal datafor untreated individuals with different types of malocclusion. These samples, however, consist primarily of individuals categorized as eitherhaving normal occlusion or Class I or Class IImalocclusions. Individuals diagnosed as having aClass III malocclusion are represented less thanthe expected frequency of 1% to 5%.
In con-trast, longitudinal studies comprised of individ-uals of Asian ancestry contain sample sizes ade-quate to describe Class III craniofacial growth.
 Admittedly, the best method for studying fa-cial growth and development is through theanalysis of longitudinal data. Unfortunately, no
Assistant Professor, Department of Orthodontics, The University of Florence, Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric Dentistry, School of Den- tistry, The University of Michigan, Ann Arbor, MI. Lecturer, De-  partment of Orthodontics, The University of Florence, Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, The University of  Michigan, Ann Arbor, MI. Thomas M. and Doris Graber Endowed Professor of Dentistry, Department of Orthodontics and Pediatric  Dentistry, School of Dentistry; Professor of Cell and DevelopmentaBiology, School of Medicine; and Research Professor, Center for Human Growth and Development, The University of Michigan,Ann Arbor, MI.Address correspondence to Tiziano Baccetti, DDS, PhD, Univer- sità degli Studi di Firenze, Via del Ponte di Mezzo, 46-48, Firenze 50127, Italy. Phone: 011 39 055 354265; E-mail: t.baccetti@ odonto.unifi.it © 2007 Elsevier Inc. All rights reserved.1073-8746/07/1303-0$30.00/0 doi:10.1053/j.sodo.2007.05.006 
Seminars in Orthodontics, Vol 13, No 3 (September), 2007: pp 130-142 
major investigations have been performed inrelation to untreated Class III malocclusion.There are two main reasons for this deficiency inthe literature: the relatively low frequency of itsoccurrence (especially in white populations)and the well-recognized need for early interven-tion by both the public and dental professionals.In response, several investigators have attemptedto contribute to the knowledge of Class III facialgrowth trends by assembling small groups of orthodontically untreated Class III individualsfor use as controls groups when evaluating treat-ment effects. Again investigators evaluating pre-dominantly Asian populations have led the way.
Investigations collecting longitudinaldata on those of Europeanancestry have arisenonly within the last decade.
In an early attempt at quantification of whiteClass III growth, Chong and coworkers
col-lected cephalometric records and study modelsfrom the Burlington Growth Study at the Uni- versity of Toronto and the Bolton-Brush GrowthStudy at Case Western Reserve University inCleveland, Ohio. The assembled records of the13 children suggested that between the ages of 6and 11 and a half years maxillary length in-creased slightly more than 1 mm per year, loweranterior facial height increased more than 2 mmper year, and mandibular length increased by less than 3 mm per year.Baccetti and coworkers
conducted an inves-tigation of untreated Class III children in themixed dentition stage of dental development.Thirty-two untreated Class III individuals fromthe University of Florence were divided intoearly and late mixed dentition groups. No statis-tically significant differences were found be-tween these subgroups. Both samples displayeddeficient maxillary advancement and excessivemandibular growth. Point A was found to ad- vance at a rate of 1 mm per year, while mandib-ular length increased4.5 mm per year. Mac-donald and coworkers
arrived at similar results when they gathered serial cephalometricrecords of Class III subjects from private orth-odontic practices in the United States. They as-sembled cephalometric data from 27 individuals who had not received any orthodontic treat-ment. The total observation period was brokendown into annualized changes, and these ClassIII individuals were compared with matched sub- jects (predominantly Class I) from the University of Michigan Growth Study. The results of thecomparison of untreated Class I and Class IIIsubjects demonstrated significantly less forwardmovement of point A (0.6 mm) and greaterforward movement of t he mandible (1.3 mm) inthe Class III group.
The use of annualizedchanges involves the assumption that growth islinear over the observation interval. The majorlimitation of this method is that it may obscurechanges in the rate of growth.To clarify the weakness of these contributionsfurther, these longitudinal studies are limited inmany ways including the sample size or observa-tion interval (or both), while they usually lackany information about the occurrence of thepubertal growth spurt. As a result, this method-ology restricts the applicability of the outcomesto other Class III individuals meeting the sameinclusion criteria.Other investigators have chosen to collecdata from a large number of Class III subjects at a single time-point and used these to make in-ferences on normal craniofacial growth. In 1986,Guyer and coworkers
attempted to character-ize Class III individuals at different developmen-tal stages by studying lateral cephalograms of 144 Class III children between the 5 and 15 yearsof age. The sample was divided into four groupsaccording to chronological age, and thencom-pared with the so-called Bolton Standards.
Theinvestigators reported that the differences incraniofacial form between Class I and Class IIIindividuals were present in all four age groups.The excessive lower anterior facial height, den-toalveolar compensations, maxillary retrusion,and mandibular prognathism were evident inthe Class III sample as early as 5 years of age. Theearly establishment of Class III characteristicsand the tendency for the intermaxillary relation-ship to worsen is consistent with the findings inother populations.
Tollaro and coworkers
conducted a study of Class III craniofacial development that was cross-sectional in nature. The 69 untreated northernEuropean Class III children between the ages of 4 and 6 included in the study had full primary dentitions. The facial characteristics were com-pared with those of 60 subjects, matched for ageand stage of dentition, presenting with a normalor Class I occlusion.Similar to the findings of Guyer and coworkers,
these investigators ob-served that the signs of Class III skeletal imbal-
Growth in the Untreated Class III Subject 
ance were present during the deciduous denti-tion phase. An investigation of similar methodology wasperformed at the London Hospital Medical Col-lege Dental School.
The study contrasted 285Class III subjects with 210 normal controls; allsubjects were white. Males and females were ex-amined separately in each of four age groups: 7to 10 years, 11 to 12 years, 13 to 14 years, 15 yearsand older. Although the data for the controlsubjects were longitudinal in nature and theClass III data were cross-sectional, their indirect comparison provided an estimation of the dif-ferences between age groups over time. Batta-gel
reported that the Class III males at all agegroups displayed retrusive maxillae and promi-nent mandibular positions relative to male con-trols. The investigator also noted an increase inlower anterior facial height and dentoalveolarcompensations beginning at 11 years of age. With continued development, the Class III malesdemonstrated less forward growth of the maxillaand a more vertical growth pattern than theirnormal counterparts. Finally, the largest incre-ment of change for mandibular length was be-tween the last two age groups, suggesting peakgrowth at this age interval. The females pre-sented a different growth pattern from themales. Relative to controls, the Class III femalesdisplayed more prominent mandibles, moreproclined maxillary incisors, and similar loweranterior facial heights. The maximum changefor facial characteristics occurred between theaverage ages 9.5 and 12 years, but continuedafter the age of 15 years. Although the data forthe control subjects were longitudinal in natureand the Class III data were cross-sectional, theirindirect comparison provided a rough estima-tion of the differences bet  ween age groups overtime. Further, this study 
highlighted the pres-ence of a sexual dimorphism in Class III maloc-clusion that wasconfirmed recently by Baccettiand coworkers.
The largest cross-sectional Class III study todatewas conducted by Miyajima and cowork-ers
on a sample of 1376 Japanese females, 2.7 years to 47.9 years of age. These females weresubdivided into groups based on the stage of dent al development as described by Hell-man.
The results were congruent with theconclusions of other Class III investigations. Inthis sample of Japanese females, the maxilla as-sumed a retrusive position at an early develop-mental stage and retained a fairly constant an-teroposterior relationship to the cranial basestructures with continued development. Like- wise, the mandible was protrusive early in devel-opment and became increasingly prognathic with age. The characteristic of lower anteriorfacial height behaved similarly to the mandible with a steady increase in dimension with matu-ration.Recently, Deguchi and coworkers
used alarge cross-sectional sample (562 subjects) as acontrol group in a long-term study on the effectsof chin-cup therapy on Asian patients with ClassIII malocclusion. Three age periods were inves-tigated (ie, 8 years, 13 years, 17 years), with nodifferentiation between males and females. Both ANB angle and the Wits appraisal worsenedalong with growth, mainly due to excessive man-dibular growth in a forward direction.The current article presents the results of two investigations on the growth characteris-tics of the untreated Class III patient: (1) A longitudinal study on 22 untreated Class IIIsubjects of European ancestry; and (2) a cross-sectional study on a substantial group of indi- viduals with untreated Class III malocclusions.Both investigations cover the circumpubertalperiod from early developmental phases (prepu-bertal) through late adolescence (postpubertal),as assessed by means of a reliable indicator of skeletal maturity, the cervical vertebral matura-tion method.
Longitudinal Data
 A sample of 22 subjects with Class III malocclu-sion (8 females, 14 males) with availability of longitudinal records was obtained from the De-partment of Orthodontics at the University of Florence, The University of Michigan GrowthStudy,
and three private orthodontic practicesin the state of Michigan. The lateral cephalo-grams of the examined subjects were evaluatedat T
and at T
, a long-term observation aftercompletion of active growth. Mean ages were 8 years and 8 months
2 years and 5 months at T
and 15 years and 2 months
1 year and 11months at T
with a mean duration of the ob-servation period T
of 6 years and 5 months
2 years and 2 months. Magnification was cor-rected to an 8% enlargement for all radio-
Baccetti, Franchi, and McNamara, Jr 

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