READERS’ FORUM
Letters to the Editor*
Are there any advantages of early
Class II treatment?
The discussion on early orthodontic intervention (2-phase
treatment) of developing Class II malocclusions in patients
with excessive overjet emphasizes that there are few (if any)
advantages for this approach, when compared with 1-phase
treatment started in the early permanent dentition.1 The
comparisons of the results indicated that treatment with either
approach is similar, except that 1-phase treatment achieves
the same objectives in a shorter time. Thus, the 1-phase
approach is more efficient for both patient and clinician. Yet,
in discussions and debates on this subject, 2 important issues
have not been sufficiently considered: external apical root
resorption (EARR) and incisor trauma (IT).
Are there any clinically significant advantages for early
treatment of Class II malocclusions in patients with excessive
overjet?
Brin et al2 used patients from a randomized clinical trial
of early Class II treatment at the University of North Carolina
(UNC) by Tulloch et al.1 The study’s purpose was to
determine whether the maxillary incisors of Class II children
treated in 1 phase in the early permanent dentition would be
more likely to experience moderate to severe (ⱖ2 mm)
EARR. The results indicated that children who had 2-phase
treatment had incidences of EARR of 5% and 11% with
functional appliances and headgears, respectively. The inci-
dence of EARR of 2 mm or greater was approximately 20%
in patients who received 1-phase treatment in the early
permanent dentition. Thus, the 1-phase group had a 2- to
4-times greater risk of developing EARR of 2 mm or greater
than did the 2-phase groups. In addition, the average reduc-
tions of overjet required in the second phase were 1.5 mm for
the functional appliance group, 4.6 mm for the headgear
group, and 5 mm for the 1-phase control group. Brin et al2
found significant associations between EARR, the magnitude
of overjet reduction, and the time spent wearing fixed
appliances. Furthermore, Segal et al,3 in a meta-analysis to
elucidate possible treatment-related etiologic factors for
EARR, concluded that treatment-related causes of root re-
sorption appear to be the total distance the apex had moved
and the time it took to accomplish the movement. Thus, if
minimization of EARR is a goal of orthodontic treatment, as
it should be, clinicians must consider treatment in the mixed
dentition to modify growth and minimize residual tooth
movement needed to correct the large overjet of patients
having a 1-phase approach. It is surprising that little emphasis
was placed on this benefit of early Class II treatment.
How about the magnitude of overjet and IT?
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
In a systematic review of the relationship between overjet
size and IT, Nguyen et al4 found that children with an overjet
larger than 3 mm are approximately twice as much at risk of
injuring their anterior teeth than children with an overjet
smaller than 3 mm. Similarly, Årtun et al,5 in a study of IT in
adolescents, found that the risk of maxillary IT increased by
13% for every millimeter of increase in overjet, and that lip
incompetence was more frequent in subjects with injured
maxillary incisors. Koroluk et al6 evaluated data from the
UNC longitudinal sample and found that 29.1% of the Class
II subjects with a minimum of 7 mm of overjet (average age,
9.8 years) already had enamel craze lines or fractures of the
maxillary incisors before treatment. They concluded that most
of these fractures involved enamel only and that the cost of
repair was relatively inexpensive ($60-$130 at the time). As
a result, they thought that it is not cost effective to treat all
children with large overjets early and suggested that such an
approach— orthodontic treatment before the teeth fracture—
would significantly add to the cost of 2-phase treatment
compared with 1-phase treatment. But is that the only way of
looking at this issue? Kaste et al,7 in a survey in the United
States between 1988 and 1991 (NHANES-III), found that
more than 38 million persons 6 to 50 years of age were
estimated to have anterior tooth trauma and that approxi-
mately a quarter of them had at least 1 traumatized permanent
incisor. Furthermore, 80% of traumatized anterior teeth in-
volved the enamel only at ages 6 to 10 years, but, by age 41
to 50 years, 60% of the sample had pulp involvement.
Therefore, when calculating the cost-benefit analysis of this
problem, it is important to add the long-term cost of repairing
the consequences of IT. Because the study of Kaste et al7 was
cross-sectional, it can only be inferred that most enamel-only
fractures progress to pulp involvement. Regardless, if preven-
tion of IT in children with large overjets is a goal of
orthodontic treatment, as it should be, then treatment should
begin soon after the eruption of the maxillary central inci-
sors— before the 29.1% incidence of fractures occurs, as
shown by the initial records of the UNC study. Early
orthodontic intervention aimed at reducing IT could save
patients the monetary and psychological burdens of extended
and complex dental treatments throughout life.
Our responsibility as orthodontists is to provide early
treatment to Class II patients with large overjets when
weconsider both the relatively high incidence of EARR in
patients treated in 1 phase in the early permanent dentition
and the IT that frequently occurs in them. The benefits to
Class II patients from early treatment will carry throughout
their lives, particularly if IT is avoided. These facts should be
carefully considered by the clinician and the parents when
calculating the cost-benefit ratio of such treatment. The
clinician, when estimating the fees for either 2-phase or
1-phase treatment should consider the preventive service that
the patient will receive. Since my bank account is not as
717
718 Reader’s forum
important as the benefit I wish to give to my patients, I charge
the same fee for 2-phase as for 1-phase Class II treatments. In
the 2-phase treatments, the monthly fee is reduced and
divided into longer periods. By starting treatment after the
maxillary central incisors have erupted and following with a
second phase of treatment at the appropriate time, the
clinician can help minimize the incidence of both EARR and
IT in Class II patients with large overjets. This approach
ensures practicing evidence-based orthodontics by consider-
ing all recent evidence in the literature concerning EARR1-3
and IT.4-7 Thus, the conclusion by Tulloch et al1 that 2-phase
treatment of Class II patients with excessive overjet started
before adolescence in the mixed dentition might be no more
clinically effective than 1-phase treatment in the early per-
manent dentition should be reevaluated, because it does not
take into consideration 2 clinically important variables:
EARR and IT!
Roberto Justus
Mexico City, Mexico
Am J Orthod Dentofacial Orthop 2008;134:717-8
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.09.010
REFERENCES
1. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase
randomized clinical trial of early Class II treatment. Am J Orthod
Dentofacial Orthop 2004;125:657-67.
2. Brin I, Tulloch JFC, Koroluk L, Phillips C. External apical root
resorption in Class II malocclusion: a retrospective review of 1-
versus 2-phase treatment. Am J Orthod Dentofacial Orthop
2003;124:151-6.
3. Segal GR, Schiffman PH, Tuncay OC. Meta analysis of the
treatment-related factors of external apical root resorption. Orthod
Craniofac Res 2004;7:71-8.
4. Nguyen QV, Bezemer PD, Habets L, Prahl-Anderesen B. A
systematic review of the relationship between overjet size and
traumatic dental injuries. Eur J Orthod 1999;21:503-15.
5. Årtun J, Behbehani F, Al-Jame B, Kerosuo H. Incisor trauma in an
adolescent Arab population: prevalence, severity, and occlusal
risk factors. Am J Orthod Dentofacial Orthop 2005;128:347-52.
6. Koroluk L, Tulloch JFC, Phillips C. Incisor trauma and early
treatment for Class II Division 1 malocclusion. Am J Orthod
Dentofacial Orthop 2003;123:117-26.
7. Kaste LM, Gift HC, Bhat M, Swango PA. Prevalence of incisor
trauma in persons 6 to 50 years of age: United States, 1988-1991.
J Dent Res 1996;75(Spec iss):696-705.
A different look at treating a patient
with Binder syndrome
I read with great interest and thoroughly enjoyed the
recent article on Binder syndrome (Kau CH, Hunter LM,
Hingston EJ. A different look: 3-dimensional facial imag-
ing of a child with Binder syndrome. Am J Orthod
Dentofacial Orthop 2007;132:704-9). I believe this article
is the most comprehensive review of Binder syndrome in
the orthodontic literature. However, I would like to com-
ment (not criticize) on the treatment plan mentioned. In a
American Journal of Orthodontics and Dentofacial Orthopedics
December 2008
patient aged 12.5 years with midface deficiency due to
maxillary hypoplasia, facemask therapy is a successful
modality that was not mentioned as a part of treatment
planning in the article.1-3 I agree with the author that
surgery cannot be done before midteenage, but the patient
can be given the benefit of facemask therapy for anterior
maxillary augmentation during the growth phase.
Varun Kumar Gupta
Ashok Utreja
Chandigarh, India
Am J Orthod Dentofacial Orthop 2008;134:718
0889-5406/$34.00
Copyright © 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.10.013
REFERENCES
1. Rune B, Sarnäs KV, Selvik G, Jacobsson S. Posteroanterior
traction in maxillonasal dysplasia (Binder syndrome). A roentgen
stereometric study with the aid of metallic implants. Am J Orthod
1982;81:65-70.
2. Petit HP. Adaptation following accelerated facial mask therapy.
In: McNamara JA Jr, Ribbens KA, Howe RP, editors. Clinical
alterations of the growing face. Monograph 14. Craniofacial
Growth Series. Ann Arbor: Center for Human Growth and
Development; University of Michigan; 1983.
3. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of
facemask/expansion therapy in Class III children: a comparison of
three age groups. Am J Orthod Dentofacial Orthop 1998;113:204-12.
Extraction of peg-shaped lateral
incisors, revisited
I acknowledge differences of opinion when it comes to
evaluating facial profile and harmony. However, are orth-
odontists supposed to push the front teeth out of the bone and
way too far forward in an irrational race to outpace the front
of a nose that, like Pinocchio’s, is way too far forward itself?
This was the overriding implication I took away from the
letter of Sadia Naureen and Ayesha Anwar (Extraction of
peg-shaped lateral incisors. Am J Orthod Dentofacial Orthop
2008;134:332), in response to a previously published case
report by Eve Tausche and Winfried Harzer (Treatment of a
patient with Class II malocclusion, impacted maxillary canine
with a dilacerated root, and peg-shaped lateral incisors. Am J
Orthod Dentofacial Orthop 2008;133:762-70).
Extraction treatment by itself does not have a deleterious
effect unless the orthodontist is so biomechanically inept that
he or she cannot move teeth toward the desired and desirable
end positions. I admit that it might be more difficult to hold
maxillary central incisors where they are after extracting
compromised lateral incisors; however, just because it might
be difficult and more taxing to do at the chair does not mean
that the approach is automatically less desirable than some
apparently easier nonextraction approach, supposedly blessed
with an always more favorable face. Dr Lysle E. Johnston and
others have proven that false.1,2
Size and shape of the nose might be relevant but not
pertinent. We are back to Pinocchio and his nose. Is it wiser