Early Class II Treatment (2017) - Brierley

Australian Dental Journal
The official journal of the Australian Dental Association

Australian Dental Journal 2017; 62:(1 Suppl): 4–10
doi: 10.1111/adj.12478
Early Class II treatment

CA Brierley,* A DiBiase,† PJ Sandler‡§
*Senior Registrar, Chesterfield Royal Hospital, Chesterfield, UK.
†Consultant Orthodontist, Kent & Canterbury Hospital, Canterbury, Kent, UK.
‡Orthodontic Registrar, Chesterfield Royal Hospital, Chesterfield, UK.
§Consultant Orthodontist, Chesterfield Royal Hospital, Chesterfield, UK.
ABSTRACT
The treatment of children presenting with a Class II division I malocclusion involves one of two approaches. The first
provides treatment in two phases; one of intervention during the mixed dentition (phase I) followed by a second defini-
tive course of appliance treatment in early adolescence (phase II). The second approach involves providing a single
course of comprehensive therapy during adolescence. The debate for and against early treatment is discussed alongside
key, clinically relevant evidence related to Class II division I malocclusions.
Keywords: Class II, two-phase, early treatment.
Abbreviations and acronyms: NNT = numbers needed to treat; PAR = Peer Assessment Rating; CI = confidence interval.
INTRODUCTION Mixed-dentition treatment

Class II malocclusions affect nearly 25% of 12-year- Typical phase I treatment might involve the use of
olds in the United Kingdom1 and 15% of 12 to fixed appliances when only the permanent incisors and
15-year-olds in the United States,2 making it one of first molars have erupted. Headgear is fitted to bands
the more commonly-treated malocclusions in the Wes- on the first molar teeth to correct the skeletal discrep-
tern world. ancy and to achieve a class I molar relationship. Alter-
In recent decades, the provision of treatment when natively, a functional appliance may be used at this
children are 7 to 11 years old with the aim of inter- early stage. An additional aim might be to achieve a
cepting a Class II division I malocclusion has gained normal overjet and overbite at this time, as well as
a level of popularity particularly in parts of Europe aligning the incisors. During this early phase, an
and the United States. Treatment may involve initial attempt might also be made to manage the arch length
intervention during the mixed dentition (phase I) in the presence of crowding, thereby securing space in
which is usually followed by a second course of the arches for the developing canine and premolar
appliance therapy during early adolescence (phase II). teeth, via the use of palatal and lingual arches.
The proponents of 2-phase treatment suggest that Facial profile considerations drive early orthodontic/
there are significant benefits to early intervention orthopaedic treatment, and claims are also made that
including: the elimination of abnormal function in the perioral
• The normalisation of the skeletal pattern and muscles is possible.3
growth The early treatment is initially planned to last for
• A reduction of the length of any subsequent phase as short a time as possible after which a period of ‘re-
II treatment tention’ is usually required. This might involve the
• Future courses of orthodontic treatment are simpler continued wear of a maxillary removable appliance
and quicker plus night-time headgear, if there is a risk of ‘relapse’
• The need for future extraction of permanent teeth is of the achieved Class II correction. If lingual arches
reduced have been used to maintain arch length, they are often
• The chance of traumatic dental injuries is also sig- maintained during this period to ensure mesial drift of
nificantly reduced the molars does not occur as the deciduous molars
4 © 2017 Australian Dental Association
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exfoliate. It is also believed that a lingual arch will • decreases total treatment time
help maintain the alignment of the lower incisors. In • is carried out at the optimum time which coincides
many cases, the patient is seen every 10-12 weeks with the adolescent growth spurt
until the permanent dentition has fully erupted, at • decreases the patients’ total time off of school
which time a second comprehensive phase of treat- • reduces the parents/carers’ time off work
ment may commence to address any residual maloc- • reduces the total burden of patient cooperation
clusion traits. • avoids the difficulties of retention between phase I
and phase II
Adolescent treatment of Class II division I • reduces the financial burden of treatment
• reduces the unavoidable physiological consequences
A more conventional approach which is the mainstay of a prolonged course of treatment including
of prescribed treatment, involves providing a single enamel demineralisation and root resorption
course of comprehensive care for a child in early ado- In the remainder of this article the scientific evi-
lescence when the late mixed dentition or permanent dence for the benefits of early treatment versus later
dentition is present. treatment for Class II division I malocclusions, are
In the UK and in Australia, the appliance of choice examined.
in the majority of Class II division I cases in the
Twin Block appliance. Treatment involves the place-
IS THERE ANY EVIDENCE TO PROVE THE BENEFITS
ment of the functional appliance at the earliest
OF EARLY TREATMENT?
opportunity usually when the second deciduous
molars are about to exfoliate and, in most cases,
Overjet, ANB, PAR score and self-concept
when the full permanent dentition is established,
which is about 11-12 years old in girls and 12-13 Proponents of early treatment argue that intervention
years old in boys. reduces the need for, and complexity of, later
It is typically requested that the Twin Blocks are orthodontic care. It has also been suggested that the
worn ‘full time’ and removed only for cleaning, for approach results in a more favourable occlusal result
contact sports and if the patients really cannot eat and skeletal correction, along with psychological ben-
with the appliance in place. With a cooperative efits.
patient, it is expected that a 1.5-2 mm overjet reduc- The highest level of evidence in evidence-based den-
tion per visit is achieved and, after 4-5 months, the tistry is a systematic review and ultimately a meta-
Twin Blocks are reactivated by adding predetermined analysis of the available data. A Cochrane Review4 on
self-curing acrylic buttons to the upper block. the early treatment of Class II/I malocclusions will
Twin Block treatment usually lasts 9-12 months, at therefore form the basis of discussion.
the end of which there should be a 0mm overbite and Three randomised clinical trials on the early treat-
overjet, sagittal over correction of the buccal segments ment of Class II division I malocclusion were included
and bilateral, buccal open bites. in the meta-analysis:
Once sagittal correction has been achieved, the The Florida study: a randomised parallel group
patient usually continues into upper and lower fixed study conducted in the University of Florida over 10
appliances to align the teeth, settle the buccal open years.5–8 The mean age at commencement was 9.6
bites and detail the occlusion. Extractions may be years and a Class II malocclusion was defined as
needed at this stage to create space for the relief of having at least a bilateral 1/2 cusp Class II molar
crowding. To facilitate the transition to fixed appli- relationship or one side presenting with less than 1/2
ances, an upper removable appliance may be fitted cusp Class II relationship if the other side was
with a steep, deep inclined anterior bite plane. This greater than 1/2 cusp Class II. The interventions
functions to maintain the sagittal correction achieved applied were a Bionator functional appliance, cervi-
during Twin Block wear and is worn full time except cal pull headgear with a removable bite plane or
when eating. The bite plane is continued during the delayed treatment for the control group. Early treat-
alignment stage of fixed appliance therapy but is dis- ment involved 2 years of active therapy followed by
continued once Class II elastic traction is started, 6 months of retention.
upon the insertion of rigid stainless steel wires. The North Carolina study was a single centre paral-
Fixed appliance therapy is usually continued until lel group, randomised, controlled trial with 2 treat-
the malocclusion is fully treated and encompasses an ment phases. 9–14 The mean participant age was 9.4
overall treatment duration of 24 to 30 months. years. Patients with an overjet of more than 7mm
Clinicians advocating a single phase of treatment were randomly assigned to three groups: 1) Bionator
argue that this approach: treatment 2) combination-pull headgear and 3) a
© 2017 Australian Dental Association 5

CA Brierley et al.
control group. Phase 1 of the trial lasted 15 months The 95% confidence interval is a statistic that has
and phase 2 between 25.5 and 34.5 months. much more relevance in research than the formerly
The Manchester study was a multi-centred parallel questionable use of p-values. The 95% confidence
group, randomised, controlled trial. 15–18 The children interval suggests that, if the study was repeated 100
in the treatment group were 9.7 years of age and 9.8 times, the mean value would fall between two values
years of age in the control group. All patients had an on 95 occasions. This then provides the reader with
overjet of more than 7mm. The interventions were an appreciation of the relevance of the reported result.
either with a Twin-Block appliance (phase 1 of 15 As the 95% CI reported was 0.35 to 0.99, it may be
months, phase 2 of 14 months) or delayed treatment deduced that there is a high degree of uncertainty sur-
with a Twin-Block (24 months). rounding this data because the confidence interval is
The Cochrane Review reported that the effects of wide.
early compared with later treatment revealed no sta- The Cochrane Review also reported the ‘numbers
tistically significant differences in the final overjet, needed to treat’ (NNT) as 10 with a 95% confidence
ANB, PAR score or self-concept score. A similar result interval of 6-175. This result should be regarded with
was found when comparing early treatment with a high degree of suspicion because of the extremely
headgear compared with later therapy. Similarly, there large confidence interval. The NNT is an important
were no statistically significant differences between measure which indicates the number of children who
the final overjet, ANB or PAR scores. The only identi- would need to be treated early to prevent one episode
fiable differences between the early and late treatment of trauma. Therefore, a NNT of 10 indicates that
groups were the overall longer treatment times and early functional appliance treatment prevents a new
the greater number of appointments experienced by incisal trauma in 1 in every 10 patients. The NNT is
the early groups. calculated as 1/Risk difference (for this data 1/0.1).21
Therefore, based on the highest level of available
scientific evidence there is no support for the argu-
Headgear treatment
ments that early treatment followed by a second phase
obtains a more favourable occlusal result, a better The early headgear treatment group had almost half
overall skeletal change or an improvement in the the incidence of new incisal trauma compared with
patients overall psychological health. Delaying treat- the one phase group (23% compared to 39%). The
ment therefore until it can all be performed at a sin- odds ratio was 0.47 which indicated that, in the early
gle, shorter period of time would appear to be the headgear group, the chance of trauma was 53% less
most appropriate and beneficial. likely than for the group whose treatment was delayed
until adolescence. In this case, the 95% CI for the
odds ratio was 0.27 to 0.83 which again reflects a
Traumatic dental injury
high degree of uncertainty surrounding the data and
should be interpreted cautiously. The NNT indicates
Functional appliance treatment
that early headgear treatment prevents one incisal
The Cochrane Review4 however, considered that the trauma incident for every 6 patients treated.
advantage in providing early compared with later Apart from dental caries, traumatic dental injuries
treatment was a reduction in the incidence of incisal comprise a highly significant oral problem with an
trauma. It was determined that 20% of patients who incidence of 1-3%.22 A meta-analysis reported that
received early functional appliance treatment reported the proportion of traumatic dental injuries worldwide
incisal trauma, compared with 29% of patients who attributable to an increased overjet is 21.8% (95% CI
reported incisal trauma following later one phase 9.7-34.5%).23 This review reported at least twice the
treatment. An odds ratio of 0.59 (95% confidence odds of trauma to the permanent teeth if an overjet
interval [CI] 0.35 – 0.99) reflects that, in the early was greater than 3-4mm. The odds ratio for an over-
treatment functional appliance group, the odds of jet of 3-4mm was 2.01 (95% CI 1.39-2.92) and for
incisal trauma was 41% less compared with the one an overjet of 6+/-1mm was 2.24 (95%CI 1.56-3.21).
phase group. From an orthodontic perspective, an overjet of 3-4mm
O’Brien19 highlighted a simple explanation of an is not significantly increased and, despite the best
odds ratio: “When you are interpreting an odds ratio efforts of many clinicians, there are still a number of
(or any ratio for that matter), it is often helpful to patients who ‘finish’ orthodontic treatment with an
look at how much it deviates from 1. So, for example, overjet of this magnitude.
an odds ratio of 0.75 means that in one group an out- This poses the question of the extent to which
come is 25% less likely. An odds ratio of 1.33 means orthodontic treatment can truly reduce the chance of
that, in one group, the outcome is 33% more traumatic dental injuries if patients with an end of
likely.”20 treatment overjet of 3-4mm are still at twice as likely
to experience trauma compared with patients possess- appliances (Figure 2d). Therefore, only one course of
ing a minimal overjet. comprehensive treatment was provided (Figure 2e).
The cephalometric superimposition (Figure 2f) sug-
gests favourable skeletal changes following functional
Case study for early treatment
Twin Block treatment. There has been favourable for-
An 8 year old female, PW, presented with a 12mm ward growth/repositioning of the mandible with rela-
overjet in the mixed dentition (Figure 1a). She tively less maxillary growth. Dentoalveolar changes
reported previous trauma to both upper central inci- show the lower molars have mesialised more than one
sors which had composite restorations to manage the molar tooth width, whilst mesial movement of the
enamel-dentine fractures. She was also experiencing upper molars has been restricted. The upper incisor
significant school bullying related to her teeth. Taking inclination has improved by 3° to 110°, while the
these two factors into consideration, PW opted to lower incisors have proclined by 6° but are still within
embark on a course of early treatment with a Twin normal limits.
Block appliance. Nine months of early twin-block
treatment resulted in a reduction of the overjet to
OTHER CONSIDERATIONS IN THE EARLY CLASS II
3mm (Figure 1b). PW then transitioned to a bite
TREATMENT DEBATE
plane to aid retention of the 3mm overjet (Figure 1c).
Costs and burden of care
Case study for a single course of comprehensive
The cost of treatment for dental injuries has been
treatment
reported to range from US $2–$5 million per 1 mil-
An 11 year old male, LG, presented with a 14mm lion people with patients usually requiring 2–9 dental
overjet in the permanent dentition (Figure 2a). He appointments to complete restorative treatment.22
was treated with a Twin Block appliance for 12 There are, however, a significant proportion of dental
months which reduced the overjet to 3mm (Figure 2b injuries that do not require active intervention. In the
and 2c). As the patient was in the permanent denti- Cochrane Review, the majority of traumatic injuries
tion, it enabled a smooth transition to fixed were graded as minor and involved enamel only. The
(a1) (a2) (a3) (a4)
(a5) (b1) (b2 (b3)
(b4) (b5) (c1) (c2)
Fig. 1 (a) Patient PW, an 8 year old female with a 12mm overjet in the mixed dentition. (b) 9 months into early Twin Block treatment with an overjet of
3mm. (c) Bite plane to aid retention of the reduction in overjet.
CA Brierley et al.
extent that traumatic injuries impact on the costs of

treatment and the burden of care for patients is lar-
gely unknown. The burden of care for both early
orthodontic treatment and the management of dental
trauma includes time away from school for the
patients and time off work for their parents if they
accompany their children to appointments. Treatment
can also be very demanding on compliance, as well as
the psychosocial implications of wearing appliances.
(a1) (a2) (a3)
These factors require consideration as they can lead
to a degree of distress, particularly if the patient is
emotionally immature.
The financial burden for the treatment of incisal
trauma should be weighed against the cost of provid-
(a4) (a5) (b1)
ing two phases of orthodontic therapy purely to
reduce the need for this treatment. In countries in
which treatment is not provided from a public fund, a
full discussion is required between all parties regard-
ing the financial implications of early orthodontic
(b2) (b3) (b4) treatment compared with the management of a trau-
matised incisor.
Mouth guards
(b5) (c1) (c2) None of the trials on early treatment included in
the Cochrane Review reported whether mouth
guards were used by patients or indeed how the
trauma occurred. No account was taken of the
extent of patients’ involvement with sporting activi-
(c3) (c4) (c5)
ties. It has been reported that in pre-school aged
children, falls are the most common cause of oral
injuries whereas in school-aged children, the aetiol-
ogy of oral trauma is more often sports or non-acci-
(d) (e1) (e2) dental injuries.22 Undoubtedly, mouth guard use will
reduce dental trauma caused during contact sporting
activities; however, it is unknown how the use of
mouth guards compares with early orthodontic
treatment in reducing the chance of all traumatic
(e3) (e4) (e5) dental injuries.
This uncertainty should be discussed with patients
and parents, alongside an assessment of the child’s
engagement in sporting activities. The fact that mouth
guards are cheaper and have a significantly reduced
(e6) (e7) (e8)
burden of care, are positive aspects compared with
early orthodontic treatment.
Patient related outcomes

Although self-concept improved initially in patients
receiving early treatment,4 this enhancement was lost
Fig. 2 (a) 11 year old male patient, LG, in the permanent dentition, pre- by the end of subsequent phase 2 therapy. The
sented with a 14mm overjet. (b) A Twin Block appliance was ﬁtted. (c) unknown however, is whether a transient increase in
LG following 12 months of Twin Block treatment which reduced the self-concept following first phase intervention, has any
overjet to 3mm. (d) Smooth transition from the Twin Block appliance to
ﬁxed appliances. (e) LG, post treatment. (f) Cephalometric superimposi- clinical relevance. It would appear to be self-evident
tions. Overall superimposition, registered on Sella-Nasion line at Sella. that enhancing a child’s self-esteem at an early age
(Black = pre-treatment, Green = post-twin block treatment). has to be a positive outcome but scientific evidence is
lacking. The impact on self-esteem and self-concept REFERENCES

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Australian Dental Journal

The official journal of the Australian Dental Association

Early Class II treatment

INTRODUCTION Mixed-dentition treatment

© 2017 Australian Dental Association 5

(a1) (a2) (a3) (a4)

(a5) (b1) (b2 (b3)

(b4) (b5) (c1) (c2)

extent that traumatic injuries impact on the costs of

Patient related outcomes

lacking. The impact on self-esteem and self-concept REFERENCES

© 2017 Australian Dental Association 9

om/?s=what+do+we+know+about+CLass+II+orthodontic+trea in Young Permanent Incisors in Brazilian Schoolchildren: A

10 © 2017 Australian Dental Association

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