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Despite the known inuence of early treatment on the facial appearance of growing patients with skeletal Class III
malocclusion, few comparative reports on the long-term effects of different treatment regimens (1-phase vs
2-phase treatment) have been published. Uncertainty remains regarding the effects of early intervention on
jaw growth and its effectiveness and efciency in the long term. In this case report, we compared the effects
of early orthodontic intervention as the rst phase of a 2-phase treatment vs 1-phase xed appliance treatment
in identical twins over a period of 11 years. Facial and dental changes were recorded, and cephalometric superimpositions were made at 4 time points. In spite of the different treatment approaches, both patients showed
identical dentofacial characteristics in the retention phase. Through this case report, we intended to clarify the
benets of undergoing 1-phase treatment against 2-phase treatment protocols for treating growing skeletal
Class III patients. (Am J Orthod Dentofacial Orthop 2012;141:e11-e22)
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Fig 1. Clinical practice guideline for the treatment of a developing Class III malocclusion. Obs, Observation.
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Fig 4. Skeletofacial types developed from the cephalometric analyses for the twins. They were judged
as skeletal Class III short face. Note that the short-face tendency was more pronounced in Patient 2.
Fig 5. Timing intervals of the comparisons of treatment progress and results. MIP, Maxillary incisors
protractor; MBS, multi-bracketed system; SAS, skeletal anchorage system.
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Fig 6. The twins at the initial time. Their dentofacial proles were almost identical.
TREATMENT ALTERNATIVES
Because the twins were skeletal Class III growing patients, growth modication treatments and functional appliances could be alternatives, but they were not included
with our options for the reasons previously mentioned.
Treatment alternatives in the postadolescent phase
could have included conventional camouage treatment
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Patient 1
79.6 ( 0.4)
79.8 (1.3)
0.2 (0)
34.6 ( 0.8)
127.0 ( 0.5)
93.6 ( 1.7)
85.8 ( 1.4)
149.9 (2.8)
6.5 mm
105.1 mm ( 1.1)
47.5 mm ( 0.7)
58.2 mm ( 1.4)
Patient 2
79.0 ( 0.6)
80.0 (1.3)
1.0 (0)
35.4 ( 0.8)
125.2 ( 0.8)
89.4 ( 2.4)
79.1 ( 2.5)
156.1 (4.0)
7.7 mm
104.0 mm ( 1.4)
46.0 mm ( 1.3)
58.6 mm ( 1.3)
TREATMENT PROGRESS
At this stage, we superimposed the cephalometric radiographs from 9 and 16 years of age based on the natural reference structures suggested by Skieller et al9 and
Bj
ork and Skieller.10 Cephalometric tracings were made
in detail and superimposed carefully. In Patient 1, the
superimposition showed correction of the anterior crossbite, with a signicant amount of jaw growth. However,
the amount of jaw growth from 13 to 16 years of age was
negligible. In Patient 2, the cephalometric superimpositions showed that the maxilla and the mandible had signicant amounts of downward and forward growth
during the adolescent growth period. Her overbite had
improved over time.
To correct the rest of Patient 1's orthodontic problems, preadjusted xed appliance treatment was started,
and short Class III elastics were used to improve the Class
III denture bases and prevent proclination of the mandibular incisors during leveling and aligning. Treatment
for Patient 2 started with bonding brackets on the mandibular teeth and placing resin caps on the maxillary molars to open the bite for maxillary bonding. Open-coil
springs were used to make space and procline the maxillary incisors. Simultaneously, distalization of the mandibular posterior teeth was started with the skeletal
anchorage system, which uses an orthodontic miniplate
as a temporary anchorage device.11 Within several
months, her anterior crossbite was completely corrected,
and the distalized mandibular posterior teeth were retained with the help of ligature wires connected to the
miniplates.
After 12 months of active xed appliance treatment,
Patient 1's malocclusion was corrected. She obtained
a balanced prole, with adequate overjet and overbite,
proper anterior guidance, and rigid posterior intercuspation of the teeth. On the other hand, Patient 2's treatment with the skeletal anchorage system lasted 18
months. She also achieved an acceptable Class I occlusion and a satisfactory prole at debonding.
The dentofacial changes during the second phase of
treatment were minimal in Patient 1; only the uprighting
of the mandibular molars was observed. On the other
hand, the cephalometric superimposition in Patient 2
before and after treatment with the skeletal anchorage
system showed that her anterior crossbite was largely
corrected by proclination of the maxillary incisors and
clockwise rotation of the mandible, causing extrusion
of her maxillary and mandibular molars. The mandibular
molars were slightly distalized, and the retroclination of
her mandibular incisors was improved purely by lingual
root torque. After 30 months of retention, both twins
have maintained a good occlusion except for a minor relapse of the maxillary right rst premolar in Patient 2.
Overall, satisfactory results were achieved.
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Fig 7. Signicant dentofacial differences were observed at the age of 10. After the rst phase of mechanics in Patient 1, her anterior crossbite was corrected after the aring of her maxillary incisors, the
forward displacement of the maxilla, and the clockwise rotation of the mandible. Consequently, her
skeletal facial type became much closer to a Class I average face.
COMPARISON OF TREATMENT PROGRESS AND
RESULTS IN THE TWINS
1.
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Fig 8. Skeletal differences between the sisters at 10 years old gradually disappeared during the pubertal growth period, and almost no difference was observed between their skeletal proles at age 16
years. The only difference was in the position of Patient 1's maxillary incisors; this was an orthodontic
effect from the facemask. Before 2nd Phase Tx, After the rst phase of treatment (ie, facemask therapy); Before ortho. Tx, after growth observation only (no interceptive treatment was done).
2.
of early intervention for her. Cephalometric superimposition shows signicant dentofacial differences
between the sisters at this stage. Patient 1's crossbite
was corrected by proclinatoin of her maxillary incisors, forward displacement of the maxilla, and
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Fig 9. The twins in the retention period. Interestingly, although they underwent orthodontic treatment at
different times and with different modalities, their dentofacial morphologies and skeletofacial types at
the nal records were identical.
3.
4.
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Patient 1
81.1 ( 0.7)
78.8 ( 0.3)
2.3 ( 0.9)
37.1 (0.1)
122.0 ( 0.8)
107.8 (0.6)
91.7 (0.2)
123.4 ( 0.6)
1.4 mm
123.3 mm (1.0)
52.8 mm ( 0.8)
71.4 mm (2.8)
Patient 2
82.0 ( 0.4)
80.2 (0.3)
1.8 ( 1.2)
36.4 ( 0.1)
122.9 ( 0.6)
112.6 (1.5)
92.7 (0.4)
118.2 ( 1.2)
2.7 mm
121.8 mm (0.4)
52.3 mm ( 1.0)
70.4 mm (2.3)
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2.
3.
sults. This implies that early treatment had no impact on jaw growth in the pubertal growth period.
Although phase 1 treatment had no impact on jaw
growth, it made the phase 2 treatment simpler
and easier. Therefore, 2-phase treatment might be
more suited for mild to moderate Class III patients
than 1-phase treatment.
The criteria for the selection of 1-phase or 2-phase
treatment depend entirely on the patients requirements. Because the biologic outcome is the same,
the basis for opting for a particular treatment regimen can be complicated. Cultural, environmental,
and psychosocial factors need to be considered
more carefully.
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