EARLY TREATMENT SYMPOSIUM

Early intervention in the

P
articipating in the erally and posteriorly). In contrast, by intervening
International Sym- during the mixed dentition period, the clinician can take
posium on Early advantage of the leeway space that exists during the
Orthodontic Treatment al- transition to the permanent dentition. According to Ann
lowed me to review our Arbor standards,3 4 mm of space is typically available
long-term studies of ortho- in the maxillary arch and 5 mm in the mandibular arch
dontic and orthopedic in- during the exchange of the second deciduous molars
tervention in patients in and the second premolars. We routinely place a trans-
the mixed and early per- palatal arch before the maxillary second deciduous
manent dentition periods molars are lost (⬎90% of patients), and we use a
who present with tooth mandibular lingual arch if conservation of the leeway
size-arch length discrep- space is necessary in the mandible.
ancies. I hope this brief Tooth size-arch length discrepancies can be divided
synopsis of that research will spur the reader to examine arbitrarily into 3 categories4: clear-cut extraction (mandib-
our textbook,1 a short conceptual article on maxillary ular crowding ⬎6 mm), clear-cut nonextraction (crowd-
transverse deficiency,2 and the clinical studies summa- ing ⬍3 mm), and borderline crowding problems. Patients
rized below for more detailed explanations of our overall with severe crowding in the mixed dentition are often best
approach to early treatment. treated with a serial extraction protocol; large tooth size
Much of the discussion concerning the efficacy and (eg, maxillary central incisors ⬎10.0 mm wide3) is a
effectiveness of early treatment has centered on the primary indication for this treatment. Interproximal reduc-
timing of intervention in Class II malocclusion. In our tion can be used effectively to resolve mild-to-moderate
practice, however, aggressive treatment of sagittal crowding problems, but we use this procedure primarily
Class II problems in the early mixed dentition stage during phase II treatment.
now involves relatively few patients, with intervention Orthopedic expansion of the maxilla often is indicated
restricted to young patients with psychologically or in patients with maxillary constriction (eg, when the
physiologically handicapping malocclusions. Rather, maxillary intermolar width is ⱕ30 mm). Rapid maxillary
we frequently encounter patients with discrepancies expansion (RME) can be used effectively to correct
between tooth size and available arch space, typically transverse and sagittal crossbite problems and to provide
manifested as crowding. sufficient arch space to resolve borderline crowding in
It is well known that there are only 3 ways to some mixed dentition patients. (As with any treatment
manage crowding problems in an adolescent: extrac- protocol, orthopedic expansion must be undertaken with a
tion, interproximal reduction, and expansion (both lat- healthy dose of common sense. Just as all patients should
not be treated with extraction, neither should all be treated
Thomas M. and Doris Graber Endowed Professor of Dentistry, Department of
Orthodontics and Pediatric Dentistry, School of Dentistry; Professor of Anat-
with RME.) In addition, this procedure can be used to
omy and Cell Biology, School of Medicine; Research Scientist, Center for facilitate maxillary canine eruption, flatten the curve of
Human Growth and Development, The University of Michigan; and private Wilson, improve nasal airflow, and “broaden the smile,”
practice, Ann Arbor, Mich.
Presented at the International Symposium on Early Orthodontic Treatment,
and for other purposes to be mentioned later.2
February 8-10, 2002; Phoenix, Ariz. Although RME has been used routinely as a treat-
Am J Orthod Dentofacial Orthop 2002;121:572-4 ment modality for crossbite correction for over 3
Copyright © 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 ⫹ 0 8/1/124167 decades, it only recently has come into regular use for
doi:10.1067/mod.2002.124167 patients without crossbites. In addition, there have been
572
American Journal of Orthodontics and Dentofacial Orthopedics McNamara 573
Volume 121, Number 6

surprisingly few studies of the long-term stability of spective sample has been the basis of several publica-
this procedure, both in children and adolescents. Our tions7,8 and master’s theses.9-12 For example, Geran10
group has been involved in these investigations, 4 of evaluated the serial study models of 51 patients who
which are summarized below. underwent early treatment with a bonded acrylic splint
expander (customary expansion, 7 to 9 mm transpala-
RME AND FIXED APPLIANCE THERAPY IN THE tally) followed by a removable palatal plate as a
MIXED AND EARLY PERMANENT DENTITION retainer. About 50% of the patients had 4 brackets
In the first study, we examined the treatment effects placed temporarily on the maxillary anterior teeth to
produced by a Haas-type RME followed by fixed achieve incisal alignment. Phase II treatment with fixed
appliance therapy.5 An attempt was made to recall all appliances was completed when the patients were about
patients treated during a specific time interval in a 14 years old, and follow-up records were obtained
single private practice who had undergone RME fol- about age 20 years. Geran10 found that the increases in
lowed by standard edgewise orthodontic treatment and transpalatal width at the end of active treatment were
who were 5 or more years posttreatment. Longitudinal maintained at follow-up. In addition, the residual max-
dental casts from 70 late mixed dentition patients and illary arch perimeter was 3.8 mm greater in the treated
41 early permanent dentition patients were obtained group than in the controls. Similarly, the residual
and analyzed. On average, subjects were 11 years old at mandibular arch perimeter was 2.6 mm greater in the
the time of initial records, 14 years old at the end of RME group than in the controls, although no active
treatment, and 20 years old at the time of long-term expansion of the mandibular dental arch was attempted
records. For controls, the longitudinal dental casts from in phase I.
19 untreated mixed dentition subjects and 24 untreated O’Grady12 studied the long-term records of 35
permanent dentition subjects were matched according patients who were treated with a Schwarz appliance
to age and analyzed at the same time periods. When the followed by RME and later by phase II fixed appliance
normally occurring decreases in arch perimeter in the treatment. He compared the changes in dental arch
control group were considered, the residual increases in dimensions of these patients with 31 patients treated
maxillary and mandibular arch perimeter were 5 to 6 with RME and fixed appliances and 31 matched con-
mm and 6 mm, respectively, in the treated group at age trols. As in Geran’s study,10 patients began treatment at
20 years; these are clinically relevant amounts. about 9 years of age, finished fixed appliance treatment
Chang et al6 analyzed a randomly chosen subgroup at about 14 years of age, and were recalled at about 20
of patients from the previously described sample. The to 21 years of age. Preliminary analysis of these data
purpose of this study was to examine cephalometrically indicated that the Schwarz-RME protocol resulted in
the long-term effects of RME on bite opening and on about a 4-mm increase in both maxillary and mandib-
the anteroposterior position of the maxilla. The sample ular arch perimeters compared with the control values.
comprised 25 patients who had undergone RME with The evaluation of the long-term data from this
the Haas-type expander followed by treatment with rather large study of patients treated primarily in a
standard edgewise appliances. This RME sample was private practice is ongoing; however, the analysis of the
compared with a group of 25 patients who had under- data thus far is very promising regarding the long-term
gone single-phase edgewise treatment and an untreated stability of those with borderline crowding problems
control group of 23 subjects. The results indicated that managed with these treatment protocols. In addition,
RME therapy followed by treatment with fixed appli- RME has been shown to have additional benefits,
ances had little long-term effect on either the vertical or including facilitating the spontaneous correction of
the anteroposterior dimensions of the face (ie, no Class II and Class III malocclusion.2 For example, we
clinically significant side effects). found that, after our initial efforts to expand the maxilla
of Class II patients in the early mixed dentition period,
SCHWARZ APPLIANCE THERAPY AND RME IN a spontaneous correction of the Class II malocclusion
THE MIXED DENTITION sometimes occurred during the retention period. These
The next group of studies involved the treatment of patients had either an end-to-end or a full-cusp Class II
mixed dentition patients. Since 1981, we have gathered molar relationship and reasonably well-balanced skel-
cephalometric and dental cast data on all young patients etal structures at the beginning of treatment. At the time
undergoing RME therapy, with or without prior dental of expander removal, they had a strong tendency
decompensation with a Schwarz appliance, in our toward a buccal crossbite, with only the lingual cusps
private practice and in the Graduate Orthodontic Clinic of the maxillary posterior teeth contacting the buccal
at the University of Michigan. This longitudinal pro- cusps of the mandibular posterior teeth. It was noted
574 McNamara American Journal of Orthodontics and Dentofacial Orthopedics
June 2002

several appointments later that, even though the pa- used appropriately, is an efficient and effective option
tients were wearing maxillary stabilization plates full for treating the mixed dentition patient.
time, the tendency toward a buccal crossbite often
REFERENCES
disappeared; some patients displayed a solid Class I
occlusal relationship. The shift in molar relationship in 1. McNamara JA Jr, Brudon WL. Orthodontics and dentofacial
orthopedics. Ann Arbor (Mich): Needham Press; 2001.
these patients occurred before the transition from the
2. McNamara JA Jr. Maxillary transverse deficiency. Am J Orthod
mandibular second deciduous molars to the second Dentofacial Orthop 2000;117:567-70.
premolars, the point at which an improvement in Angle 3. Moyers RE, van der Linden FPM, Riolo ML, McNamara JA Jr.
classification sometimes occurs in untreated subjects Standards of human occlusal development. Monograph 5.
because of the forward movement of the mandibular Craniofacial Growth Series. Ann Arbor: Center for Human
Growth and Development; University of Michigan; 1976.
first molar into the leeway space. 4. Luppanapornlarp S, Johnston LE Jr. The effects of premolar
This phenomenon has led us to rethink our concept extraction: a long-term comparison of outcomes in “clear-cut”
of Class II molar correction. Our experience with the extraction and nonextraction Class II patients. Angle Orthod
post-RME correction of Class II problems in growing 1993;63:257-72.
5. McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid
patients indicates that many Class II malocclusions
maxillary expansion followed by fixed appliances: long-term
have a strong transverse component. The overexpan- evaluation of changes in arch dimensions. In press 2002.
sion of the maxilla, which subsequently is stabilized 6. Chang JY, McNamara JA Jr, Herberger TA. A longitudinal study
with a removable palatal plate, disrupts the occlusion. It of skeletal side-effects induced by rapid maxillary expansion.
appears that the patient becomes more inclined to Am J Orthod Dentofacial Orthop 1997;112:330-7.
7. Spillane LM, McNamara JA Jr. Maxillary adaptations follow-
posture his or her jaw slightly forward, thus eliminating ing expansion in the mixed dentition. Semin Orthod 1995;1:
the tendency toward a buccal crossbite and improving 176-87.
the sagittal occlusal relationship. Presumably, subse- 8. Brust EW, McNamara JA Jr. Arch dimensional changes concur-
quent mandibular growth makes this initial postural rent with expansion in mixed dentition patients. In: Trotman CA,
McNamara JA Jr, editors. Orthodontic treatment: outcome and
change permanent. If not, definitive orthopedic or
effectiveness. Monograph 30. Craniofacial Growth Series. Ann
orthodontic Class II correction can be undertaken as the Arbor: Center for Human Growth and Development; University
first step of phase II treatment. of Michigan; 1995.
9. Wendling LK. Short-term skeletal and dental effects of the
acrylic splint rapid maxillary expansion appliance [thesis]. Ann
CONCLUSIONS Arbor: University of Michigan; 1997.
10. Geran RG. The long-term effects of rapid maxillary expansion in
Of many adjunctive treatment modalities, the appli- the early mixed dentition [thesis]. Ann Arbor: University of
ance I have used most effectively to treat young Michigan; 1998.
patients is the acrylic splint RME. This appliance 11. Wright NS. A comparison of the treatment effects of the Schwarz
produces many treatment effects that are not limited to appliance and the lower lingual holding arch [thesis]. Ann Arbor:
University of Michigan; 2000.
correcting a crossbite or increasing arch perimeter. 12. O’Grady PW. Long-term stability of rapid maxillary expansion
Thus, the cornerstone of our early treatment protocols concurrent with Schwarz appliance therapy in the mixed denti-
is RME, a dentofacial orthopedic approach that, when tion [thesis]. Ann Arbor: University of Michigan; 2002.