14. Orthodontic Society; 443. 1973. 9. Baume RM, Buschang PH, Weistein S. Stature, head height and growth of the vertical face. Am J Orthod; 83:477, 1983. 10. Buschang P.H. et al.: Incremental growth charts for con- dilar growth between 6 and 16 years of age. Eur J Or- thod; 21: 167-73, 1999. 11. Clark WJ. The twin block technique. A functional or- thopedic appliance system. Am J Orthod Dentofacial Or- thop. 1988 Jan;93(1):1-18. 12. Singh GD, Clark WJ. Localization of mandibular chan- ges in patients with class II division 1 malocclusions trea- ted with twin-block appliances: finite element scaling ana- lysis. Am J Orthod Dentofacial Orthop. 2001 Apr;119(4):419-25. 13. Anmol Kalha. Early treatment with the twin-block ap- pliance is effective in reducing overjet and severity of ma- locclusion. Is the twin-block orthodontic appliance ef- fective in early treatment of developing class II division 1 malocclusion?. Evidence-Based Dentistry (2004) 5, 102–103. 14. O’Brien K, Wright J, Conboy F, Appelbe P, Davies L, Connolly I, Mitchell L, Littlewood S, Mandall N, Lewis D, Sandler J, Hammond M, Chadwick S, O’Neill J, McDade C, Oskouei M, Thiruvenkatachari B, Read M, Robinson S, Birnie D, Murray A, Shaw I, Harradine N, Worthington H. Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi- center, randomized, controlled trial. Am J Orthod Den- tofacial Orthop. 2009 May;135(5):573-9. 15. Lund DI, Sandler PJ. The effects of Twin Blocks: a pro- spective controlled study. Am J Orthod Dentofacial Or- thop. 1998 Jan;113(1):104-10. 16. Mills CM, McCulloch KJ.Treatment effects of the twin block appliance: a cephalometric study. Am J Orthod Den- tofacial Orthop. 1998 Jul;114(1):15-24. 17. Trenouth MJ. Muscle response to the Twin-block ap- pliance. Am J Orthod Dentofacial Orthop. 2000 Apr;117(4):25A. 18. Trenouth MJ. Centroid analysis of twin-block applian- ce treatment for Class II Division 1 malocclusion. World J Orthod. 2006 Summer;7(2):159-64. 19. Illing HM, Morris DO, Lee RT. A prospective evaluation of Bass, Bionator and Twin Block appliances. Part I - The hard tissues. Eur J Orthod. 1998 Oct;20(5):501-16. 20. Morris DO, Illing HM, Lee RT. A prospective evaluation of Bass, Bionator and Twin Block appliances. Part II - The soft tissues. Eur J Orthod. 1998 Dec;20(6):663-84. 21. Toth LR, McNamara JA Jr. Treatment effects produced by the twin-block appliance and the FR-2 appliance of Fränkel compared with an untreated Class II sample. Am J Orthod Dentofacial Orthop. 1999 Dec;116(6):597-609. 22. Baccetti T, Franchi L, Toth LR, McNamara JA Jr. Tre- atment timing for Twin-block therapy. Am J Orthod Den- tofacial Orthop. 2000 Aug;118(2):159-70. 23. Cozza P, Baccetti T, Franchi L, De Toffol L, McNama- ra JA Jr. Mandibular changes produced by functional ap- pliances in Class II malocclusion: a systematic review. Am J Orthod Dentofacial Orthop. 2006 May;129(5): 599.e1-12. 24. Mills CM, McCulloch KJ. Posttreatment changes after successful correction of Class II malocclusions with the twin block appliance. Am J Orthod Dentofacial Orthop. 2000 Jul;118(1):24-33. 25. Dyer FM, McKeown HF, Sandler PJ. The modified twin block appliance in the treatment of Class II division 2 ma- locclusions. J Orthod. 2001 Dec;28(4):271-80. 26. Kim TW, Kim H, Lee SJ. Correction of deep overbite and gummy smile by using a mini-implant with a segmen- ted wire in a growing Class II Division 2 patient. Am J Orthod Dentofacial Orthop. 2006 Nov;130(5):676-85. 27. Bergersen EO. Preventive and interceptive orthodontics in the mixed dentition with the myofunctional eruption guidance appliance: correction of overbite and overjet. J Pedod. 1988 Spring;12(3):292-324. 28. Bergersen EO. The eruption guidance myofunctional ap- pliance: case selection, timing, motivation, indications and contraindications in its use. Funct Orthod. 1985 Jan- Feb;2(1):17-21, 24-5, 28-33. 29. Bergersen EO. The eruption guidance myofunctional ap- pliances: how it works, how to use it. Funct Orthod. 1984 Sep-Oct;1(3):28-9, 31-5. 30. Bergersen EO. Preventive and interceptive orthodontics in the mixed dentition with the myofunctional eruption guidance appliance: correction of crowding, spacing, ro- tations, cross-bites, and TMJ. J Pedod. 1988 Sum- mer;12(4):386-414. 31. Bergersen EO. The eruption guidance myofunctional ap- pliance in the consecutive treatment of malocclusion. Gen Dent. 1986 Jan-Feb;34(1):24-9. 32. Bergersen EO. Preventive orthodontics for the 5- to 7- year-old with the Nite-Guide technique. Int J Orthod Mil- waukee. 2009 Winter;20(4):31-5. 33. Janson GR, Pereira AC, Bergersen EO, Henriques JF, Pin- zan A, de Almeida RR. Cephalometric evaluation of the eruption guidance appliance in Class II, division 1 tre- atment. J Clin Orthod. 1997 May;31(5):299-306. 34. Janson GR, da Silva CC, Bergersen EO, Henriques JF, Pinzan A. Eruption Guidance Appliance effects in the tre- atment of Class II, Division 1 malocclusions. Am J Or- thod Dentofacial Orthop. 2000 Feb;117(2):119-29. 35. Keski-Nisula K, Keski-Nisula L, Salo H, Voipio K, Var- rela J. Dentofacial changes after orthodontic intervention with eruption guidance appliance in the early mixed den- tition. Angle Orthod. 2008 Mar;78(2):324-31. 36. Janson G, Nakamura A, Chiqueto K, Castro R, de Frei- tas MR, Henriques JF. Treatment stability with the erup- tion guidance appliance. Am J Orthod Dentofacial Or- thop. 2007 Jun;131(6):717-28. 37. Keski-Nisula K, Hernesniemi R, Heiskanen M, Keski- Nisula L, Varrela J. Orthodontic intervention in the ear- ly mixed dentition: a prospective, controlled study on the ORAL & Implantology - Anno III - N. 3/2010 original article 24 © CIC Edizioni Internazionali
7. original article ORAL & Implantology - Anno III - N. 3/2010 17 boration equivalent to14 hours was requested (Fig. 1E). In designing the Occlus-o-guide ® , based on the ex- change phase, the G series was chosen and by mea- suring was found to be the most suitable; first, on the plaster model, two Australian 0.14 wire springs were modelled, which were then placed in niches inside the appliance, corresponding to the palatal surface of upper central incisors. This appliance was assi- gned to the patient P.F., of whom it was requested that he wear the device passively for 12 hours du- ring the night, and for 2 hours during the day, do che- wing exercises (Fig. 2E). Under the treatment protocol, monthly clinical, six months photographic and annual radiographic (in- cluding Orthopantomography of dental arches and teleradiography of the skull in latero-lateral pro- jection) controls were carried out. Both patients were monitored for a total period of 18 months. Table 2 - P.R.: Cephalometric analysis at the beginning of treatment. © CIC Edizioni Internazionali
6. ORAL & Implantology - Anno III - N. 3/2010 original article 16 tal and dental growth analyses forecast for both patients (Tables 1, 2). In the second phase of testing we proceeded to the de- sign of two appliances. In the realization of the mo- dified Twin-block by the addition of two distal sna- re springs to the upper lateral incisors and two zeta springs behind the upper central incisors, the bite re- gistration was carried out in a position of overcor- rection, with incisal relationship in a head to head ra- tio (overjet zero or slightly inverted). However, en- suring that the two arches are kept together, separa- ted by a space of 7-8 mm, this does not cause any in- terference when the upper central incisors are labially proclined. The height of the blocks ensures that the patient can assume a protruding and more comforta- ble jaw position, at the same time enabling him to pro- perly close in a centric relationship. This device was assigned to the patient P.R., of whom a daily colla- Table 1 - P.F.: Cephalometric analysis at the beginning of treatment. © CIC Edizioni Internazionali
9. nical use of the modified Twin block obtained: a good correction of the molar ratio, a significant increase in mandibular length and branch height, a significant increase in posterior direction condylar growth with an anterior repositioning of the condyle and im- provement in the overjet and overbite, it still requi- red a further stage of finishing time aimed at ali- gnment resolution, levelling, intercuspidation of den- tal arches, optimization of the dental parameters of overbite and overjet and the stabilization of basal Class I (Figs. 1F, 1G, 1H, 1I). Interceptive treatment performed by using the mo- dified clinical Occlus-o-guide ® permits instead: • the strengthening of condylar growth in both length and degree of mandibular myo-skeletal pro- gress as well as the establishment of basal and dental Class I; • the achievement of optimal intercuspidation for original article ORAL & Implantology - Anno III - N. 3/2010 19 Table 3 - P.F.: Cephalometric analysis at the end of treatment. © CIC Edizioni Internazionali
10. guiding the eruption and maintenance of each in- dividual permanent element in the correct posi- tion until the end of the dental exchange; • the decrease in the overjet and the stabilization of the overbite within the ideal minimum; • the alignment and levelling of the dental arches; • progressive improvement of gingival recession present in correspondence to the vestibular sur- faces of both central mandibular incisors (Figs. 2F, 2G, 2H, 2I, 2L). This gingival recession recognized a multifactorial etiology: the low level of oral hygiene and impro- per brushing techniques carried out favoured the ac- cumulation of bacterial plaque in an area where the anatomy of both the gum and the alveolar bone ap- pears to be too thin, and that the insertion of the la- bial frenulum is quite close to the gumline. Moreo- ver, the presence of severe deep bite and palate-ver- ORAL & Implantology - Anno III - N. 3/2010 original article 20 Table 4 - P.R.: Cephalometric analysis at the end of treatment. © CIC Edizioni Internazionali
15. effects of the eruption guidance appliance. Am J Orthod Dentofacial Orthop. 2008 Feb;133(2):254-60; 38. Methenitou S, Shein B, Ramanathan G, Bergersen EO. Prevention of overbite and overjet development in the 3 to 8 year old by controlled nighttime guidance of inci- sal eruption: a study of 43 individuals. J Pedod. 1990 Summer;14(4):219-30. 39. Margolis HI. Standardized X-Ray ceplalografics. Am. J. Orthod. 26:725-740, 1940. 40. Andlin-Sobocki A, Marcusson A, Persson M.: 3-year ob- servations on gingival recession in mandibular incisors in children. J. Clin. Periodontol. 1991; 18(3): 155-9. 41. Maturo P, Costacurta M, Bartolino M, Docimo R. “Le recessioni gengivali in pedodonzia” Doctor OS 2006 Set;17(7). 42. Persson M, Lennartsson B.: Improvement potential of iso- lated gingival recession in children. Swed. Dent. J. 1986; 10(1-2): 45-51. 43. Nanda RS, Meng H, Kapila S, Goorhuis J. Growth chan- ges in the soft tissue facial profile. Angle Orthod. 1990 Fall;60(3):177-90. 44. Andlin-Sobocki A, Persson M. The association betwe- en spontaneous reversal of gingival recession in man- dibular incisors and dentofacial changes in children. A 3-year longitudinal study. Eur. J. Orthod. 1994; 16(3): 229-39. 45. Ruf S, Hansen K, Pancherz H. Does orthodontic pro- clination of lower incisors in children and adolescents cause gingival recession? Am. J. Orthod. Dentofacial Or- thop. 1998; 114(1): 100-6. Correspondence to: Prof.ssa Raffaella Docimo Paediatric Dentistry PTV - Policlinico Tor Vergata Viale Oxford, 81 - 00133 Rome, Italy Tel. e Fax: 0620900265 E-mail: email@example.com original article ORAL & Implantology - Anno III - N. 3/2010 25 © CIC Edizioni Internazionali
2. ORAL & Implantology - Anno III - N. 3/2010 original article 12 Introduction Functional ortho-paedodontic therapy has long been an important part of treatment methods used in the resolution of dental-facial malocclusions in growth subjects (1). In the paedodontic patient this type of therapy is in- tended to act on abnormal behaviour of the muscu- lature, resolving issues related to the presence of non- physiological functional spaces through the use of re- movable appliances; the ultimate goal is indeed to re- store proper development of the oral-facial complex through functional rehabilitation (2). Many Authors are in agreement that this treatment should be initiated in a specific age group between 11 and 13 years, or puberty, in order to maximize individual growth (3,4,5). The optimal period of therapy should in fact coincide with the period of maximum height growth rate (6,7). Woodside D.G. has shown that the growth rate of facial bones, particularly the jaw, is similar to height growth, and Baume R.M., Buschang P.H. and Weinstein S. argue that the vertical changes to the face occur at rates that reflect the height growth (8,9,10). In this regard, the Authors argue that the Class II di- vision 2 malocclusion from retro-mandibular posi- tioning with deep bite, consisting of a disharmony bet- ween the sagittal and vertical relationships between upper and lower arches, and between the upper ma- xilla and mandible, is one of the most commonly en- countered skeletal alterations in paedodontic patients in the puberty phase with the prevalence estimated between 52% and 56% (9). The purpose of this study was to evaluate, in two iden- tical twins suffering from the same malocclusion, the clinical effectiveness and stability of the functional Class II division 2 interceptive treatment by mandi- bular back-positioning associated with deep bite at puberty, and to compare skeletal and dental and den- to-alveolar changes induced by the application of two different removable appliances: the Clark’s Twin block and Bergersen’s Occlus-o-guide ® . Clark’s Twin Block According to functionalist theory proposed by Clark W.J. and Singh G.D., occlusal strength induced by the masticatory function and transmitted to the teeth is able to provide a continuous stimulus to bone remodelling, affecting the speed of growth (11,12).To this aim, is designed the Twin Block (1982), a re- movable appliance in resin consisting of two pla- tes each provided with opposing lateral planes, in- clined at 70° to the occlusal plane, which come into contact in the distal region of lower second pre- molars, resulting in a protruded position of the jaw and allowing the correct mandibular rotation (11). To date, few studies have been published on the ef- fects induced by the Twin Block interceptive tre- atment of Class II malocclusion (13,14). In studies carried out among control groups and patients treated with this appliance it was demonstrated that it is capable of promoting a significant increase in the length of the mandibular body, even if the lar- ge part of the overjet correction was verified by the induction of a dentoalveolar controlled movement (15,16,17,18). The comparative studies conducted with other types of functional appliances such as Bass, Bionator and Frankel, showed that the Twin Block functional appliance appears to be the most effective in simultaneously producing both the chan- ges to the sagittal and those related to the vertical plane (19,20,21). In fact, the optimal cephalome- tric timing for such treatment turns out to coinci- de with the corresponding period, or shortly the- reafter, of the start of the peak pubertal growth, the last stage of mixed dentition (22). This in fact pro- duces numerous beneficial effects, including: grea- ter skeletal contribution to the correction of molar ratio, significant increase in the mandibular length and branch height and increase in condylar growth in posterior direction (23). Consequently, we are si- multaneously watching a significant mandibular ex- tension and an anterior repositioning of the condyle (22). The stability of the treatment is guaranteed by the angle of the inter-incisor reduction to a value of 125° (16,24). Moreover, in the literature, the small reports on the use of the Twin Block inter- ceptive treatment of Class II division 2 malocclu- sion show that this appliance is able to promote growth and the front repositioning of the jaw, with a negligible effect on the branch height and ma- xillary growth (25,26). © CIC Edizioni Internazionali
5. original article ORAL & Implantology - Anno III - N. 3/2010 15 Figure 1D P.R.: Intraoral image in frontal view, right late- ral, left lateral, superior occlusal and inferior oc- clusal at the beginning of treatment. Figure 2D P.F.: Intraoral image in frontal view, right late- ral, left lateral, superior occlusal and inferior oc- clusal at the beginning of treatment. © CIC Edizioni Internazionali
12. ORAL & Implantology - Anno III - N. 3/2010 original article 22 Figure 1H P.R.: Intraoral image in frontal view, right la- teral, left lateral, superior occlusal and inferior occlusal at the end of treatment. Figure 2H P.F.: Intraoral image in frontal view, right lateral, left lateral, superior occlusal and inferior occlusal at the end of treatment. © CIC Edizioni Internazionali
3. original article ORAL & Implantology - Anno III - N. 3/2010 13 Bergersen’s Occlus-o-guide ® According to the theory of guided occlusion by Ber- gersen E.O., it is possible to achieve simultaneou- sly the ideal occlusion by supporting, intercepting and guiding the innumerable variables of the times and methods of each element of tooth eruption, the- reby exploiting the natural forces of growth to ob- tain harmonic occlusion in a balanced craniofacial context (27). To this aim have been designed The eruption guide appliances EGA (Eruption Guide Ap- pliance), including the Occlus-o-guides ® (28). The- se devices have the basic characteristic of guiding the teeth, initially during the emergence stage and subsequently in the more complex eruption stage, to the correct spatial position within the occlusal pla- ne (29). The objective is therefore to prevent or even- tually correct any development of more or less com- plex malocclusion before the dental exchange is ful- ly completed, gradually guiding the permanent te- eth towards a stable relationship in the Class I nor- mal conformant arches with ideal parameters of over- jet and overbite so as to be as close as possible to the physiology of occlusal development (30). The Oc- clus-o-guide ® in particular is a preformed monoblock appliance, indicated for patients aged between 6 and 12 (30). It is made of soft elastomeric silicone, odour- less and tasteless, according to a head to head inci- sor bite that, if on the one hand it has the ability to promote myoskeletal jaw growth or progress to achie- ve the basic Class I (true characteristic of a functional appliance), on the other hand it is able to guide the eruption of each permanent individual element in its proper place, or niche, ensuring intercuspidation and achieving and maintaining each tooth in the correct position until the end of the dental exchange, (pro- per capability of a positioner) (32).This appliance furthermore subjects the front teeth to intrusive, de- pressive forces and is also capable of promoting the eruption of the posterior sector to the optimal ver- tical position to allow stabilization of the overbite into ideal minimal values, before the periodontal li- gament fibres condition their orthogonal settle- ment (31). Studies to evaluate the clinical efficacy of EGA show that in on the skeletal level, condylar growth is en- hanced, resulting in a significant increase both in length and in the degree of mandibular advancement (33). We also note a significant increase in total an- terior facial height, which in the sagittal maxillo- mandibular and molar relationship, with a significant decrease in the values of overjet and overbite, whi- le not detecting appreciable changes in maxillary growth (33,34,35). The occlusal correction is achie- ved mainly through changes incurred in the alveo- lar region of the mandible, while no effect is observed in the maxilla in terms of position, size, angle and protrusion of the incisors (36,37). In particular, the Occlus-o-guide ® is also able to inhibit the vertical skeletal growth while simultaneously ensuring a good control of the overjet and overbite dental parameters (38). In the Literature there has been no precise re- port on the Occlus-o-guide ® in the treatment of Class II, Division 2 malocclusion. Materials and methods In the department of Paediatric Dentistry of Azien- da Ospedaliera Policlinico Tor Vergata of Rome, du- ring the first paedodontic visit, a pair of homozygous twins was selected, P.F. and P.R., 11 years and 4 months of age, in mixed dentition, with the same ma- locclusion: Class II division 2 caused by mandibu- lar retro-positioning associated with deep bite. The selection criteria was based on radiographic verifi- cation of the existence of further potential craniofacial growth, and on the presence of Class II division 2 dental relationship on a Class II skeletal basis with an ANB including between the 4 ° and 6 ° and man- dibular retro positioning (SNB <78°). The cepha- lometric analysis confirmed that during the treatment, the lower incisors may be proclined while the axial inclination of upper incisors may be initially adju- sted by a labial movement of tipping and subse- quently maintained so during the skeletal correction of malocclusion. The first phase of testing was conducted by recor- ding clinical parameters. For each of the two patients the radiographic documentation complete with or- thopantomography of the dental arches (Figs. 1A, 2A), and teleradiography of the skull in the latero- lateral projection (Figs. 1B, 2B) was in fact collec- ted, followed by registration of the plaster study mo- © CIC Edizioni Internazionali
8. Results Skeletal, dental and Standard (34) cephalometric ana- lysis growth forecast parameters were taken into ac- count the before (Tables 1, 2) and after (Tables 3, 4) treatment. The results show that both appliances were able to promote significant and obvious clini- cal effects. Discussion The Class II division 2 malocclusion is a clinical en- tity that presents considerable difficulties in predicting an outcome that is very stable over time (24). Tra- ditionally, treatment of Class II Division 2, associated with a moderate to severe skeletal discrepancy of the jaw, provides a pre-functional therapy aimed only at correcting the upper labial segment for proclination of the central maxillary incisors and the Class II di- vision 1 incisor conversion ratio (25). The success of this therapy is, therefore, in the simultaneous cor- rection of the transverse, sagittal and vertical di- screpancies (25). The purpose of this study was to evaluate, in two Ho- mozigous twins with the same malocclusion, the cli- nical effectiveness and stability of the interceptive functional treatment of Class II division 2 caused by the mandibular retro-positioning associated with deep bite at puberty, and to compare the skeletal, dental and dento-alveolar changes induced by the appli- cation of two different modified removable ap- pliances: the Clark’s Twin block and Bergersen’s Oc- clus-o-guide ® . The results show that both devices were able to promote significant and obvious clini- cal effects. In the first phase of therapy, the activation of retro- incisor zeta springs added on both appliances allo- wed the dental-alveolar correction of the Upper in- cisor angle ^ PH for the vestibular version of the ma- xillary central incisors and the conversion of the in- cisor relationship from Class II division 2 incisor into Class II division 1. In the second phase of therapy, the most significant effects were those related to the anterior repositio- ning of the main mandibular points with respect to the vertical reference line that indicates clear forward movement and increase in length of the mandibular body. The overjet correction occurred mainly as a re- sult of mandibular growth and minimally because of the induction dento-alveolar type of a controlled mo- vement. The slight proclination of the lower incisors obtained at the end of treatment contributed to both the decrease of the inter-incisor angle, as a guaran- tee of stability of the treatment, and the advancement of the lower lip required for the correction of the pro- file. No significant effect is observed in the upper ma- xilla in terms of position, size, angle and protrusion of the incisors. Although interceptive treatment performed by the cli- ORAL & Implantology - Anno III - N. 3/2010 original article 18 Figure 1E P.R.: Modified Twin block of Clark. Figure 2E P.F.: Modified Occlus-o-guide ® of Bergersen. © CIC Edizioni Internazionali
11. sion of the upper central incisors led to a constant trauma caused by contact between the upper incisors and the vestibular gingival margin of the lower in- cisors. Numerous studies reveal that in mixed den- tition, gingival recession present on the vestibular sur- face of mandibular incisors shows a tendency to di- minish with the passage of time and to improve with increasing chronological age (40,41). This impro- vement seems to be correlated on the one hand to physiological gain in the loss of the attachment, and on the other to dealing with the root causes and/or favouring the recession (42). In particular, Nanda R.S., studying the changes that occur during the lon- gitudinal growth of soft tissues, found that changes involving the development of these tissues are able to make positive modifications after clinical use of Class II functional appliances (43,44,45). Therefo- re, the use of a removable, elastodontic, Class II fun- ctional appliance, with no hard surfaces, able to sup- port and guide the eruption of teeth into ideal oc- clusion with moderate and constant strength, gra- dually allowed correction and stabilization of the overbite and the overjet within minimum ideal va- lues that improve and resolve gingival recession. Conclusions The therapeutic approach of interceptive functional type is indicated for the treatment of Class II Divi- sion 2 deep bite with mandibular retrusion, in which improvement is required not only for occlu- original article ORAL & Implantology - Anno III - N. 3/2010 21 Figure 1F P.R.: Orthopantography of the dental arches at the end of treatment. Figure 1G P.R.: Teleradiography of the skull in latero-lateral pro- jection at the end of treatment. Figure 2G P.F.: Teleradiography of the skull in latero-lateral pro- jection at the end of treatment. Figure 2F P.F.: Orthopantography of the dental arches at the end of treatment. © CIC Edizioni Internazionali
13. sal relationships but also of the skeletal and aesthetic parameters. The treatment performed by using the modified Clar- k’s Twin-block has brought about many important clinical effects, both skeletal and dental. This ap- pliance, if on the one hand allowed to circumvent the pre-functional therapy aimed only at correction of the upper labial segment and to the conversion of in- cisal relationship in Class II Division 1, it however needs a second treatment phase for resolving the ali- gnment, levelling, intercuspidation of the arches, op- timization of the dental overbite and overjet para- meters and stabilization of the basal Class I. Therefore, this study demonstrates that intercepti- ve functional treatment of Class II division 2 cau- sed by mandibular retrusion with deep bite conducted in puberal phase with clinical use of modified Ber- gesen’s Occlus-o-guide ® , allows for simultaneously solving the skeletal, dentoalveolar and dental pro- blems in one single therapy phase. The long-term efficacy of this treatment modality, as well as the possible absence or presence of a per- centage, even a minimal recidiva can be assessed only after the appropriate period of stabilization and post- stabilization. References 1. Arvystas MG. The rationale for early orthodontic treat- ment. Am J Orthod Dentofac Orthop 113:15-18; 1998. 2. Graber TM, Rakosi T, Petrovic AG. Dentofacial ortho- pedic with functional appliance. Am J Orthod Dentofac Orthop,1985 Feb;49(5):96-101. 3. Isaacson K.G., Reed R.T., Stephens C.D.: Apparecchi in ortognatodonzia funzionale. Ed. Masson, Milano, 1992. 4. Kumpler G, Beemen E, Hicks. Early Orthodontic Tre- atment: What Are The Iperatives?. Clinical Practice, Vol.131, 2000. 5. Keski-Nisula K, Lehto R, Lusa V, Keski-Nisula L, Var- rela J. Occurrence of malocclusion and need of ortho- dontic treatment in early mixed dentition. Am J Orthod Dentofacial Orthop. 2003 Dec;124(6):631-8. 6. Viazys AD. Efficient orthodontic timing. Am J Orthod Dentofacial Orthop 108:560-61; 1985. 7. Tung AW, Kiyak HA. Psychological influences on the timing of orthodontic treatment. Am J Orthod Dentofa- cial Orthop. 1998 Jan;113(1):29-39. 8. Woodside DG. Some effects of activator treatment on the mandibole and midface. Transactions of the European original article ORAL & Implantology - Anno III - N. 3/2010 23 Figure 1I P.R.: Image of the face in frontal view, lateral and ¾ with smile at the end of treatment. Figure 2I P.F.: Image of the face in frontal view, lateral and ¾ with smile at the end of treatment. Figure 2L P.F.: Improvement of gingival recession. © CIC Edizioni Internazionali
1. original article ORAL & Implantology - Anno III - N. 3/2010 11 A NALYSIS OF CLINICAL EFFICACY OF INTERCEPTIVE TREATMENT OF C LASS II DIVISION 2 MALOCCLUSION IN A PAIR OF TWINS THROUGH THE USE OF TWO MODIFIED REMOVABLE APPLIANCES R. CONDÒ, C. PERUGIA, M. BARTOLINO, R. DOCIMO Department of Odontostomatologic Science, Paediatric Dentistry University of Rome “Tor Vergata”, Rome, Italy SUMMARY Analysis of clinical efficacy of interceptive treat- ment of Class II division 2 malocclusion in a pair of twins through the use of two modified removable appliances. The interceptive therapeutic approach of a functional type is indicated for the treatment of Class II Division 2 mandibular retrusion with deep bite, where improvement is required not only in occlusal relationships but also in skeletal and aesthetic parameters. Purpose. The aim of this study is to assess, in two iden- tical twins suffering from the same malocclusion, the ef- fectiveness and clinical stability of functional interceptive Class II division 2 treatment during puberty by mandibu- lar retro-positioning associated with deep bite, and to compare skeletal changes and dental and dental-alveo- lar changes induced by the application of two different modified removable appliances: Clark’s Twin block and Bergersen’s Occlus-o-guide ® . Results. The results show that both devices allowed for circumvention of the pre-functional therapy phase aimed at correcting the upper labial segment, and for the con- version of the Class II division 1 incisor relationship, they were able to promote significant and obvious clinical ef- fects. Conclusions. The study shows that Class II Division 2 functional type interceptive treatment of mandibular retrusion with deep bite conducted in the puberal phase through clinical use of modified Bergersen’s Occlus-o- guide ® allowed for simultaneous resolution of the skele- tal, dental-alveolar and dental problems in one step, while that using modified Clark’s Twin-block still requires a second phase of treatment necessary to resolve the alignment, levelling, inter-cuspidation of the arches, op- timization of the dental overjet and overbite parameters and to the stabilization of the basal Class I. Key words: occlus-o guide ® , Twin Block, Class II division 2, paediatric patient. RIASSUNTO Analisi dell’efficacia clinica del trattamento intercet- tivo della malocclusione di Classe II divisione 2 in una coppia di gemelli omozigoti attraverso l’utilizzo di due dispositivi rimovibili modificati. L’approccio terapeutico intercettivo di tipo funzionale trova indi- cazione nel trattamento della Classe II divisione 2 da retrusio- ne mandibolare con morso profondo in cui è richiesto il miglio- ramento non solo dei rapporti occlusali ma anche dei parame- tri scheletrici ed estetici. Scopo. Scopo del presente studio è quello di valutare, in due gemelli omozigoti affetti dal medesimo quadro malocclusivo, l’efficacia e la stabilità clinica del trattamento intercettivo fun- zionale della II Classe divisione 2 da retro-posizionamento mandibolare associata a morso profondo in età puberale e comparare i cambiamenti scheletrici e le modificazioni dentali e dento-alveolari indotte dall’applicazione di due differenti di- spositivi rimovibili modificati: il Twin block di Clark e l’Occlus-o- guide ® di Bergesen. Risultati. I risultati ottenuti dimostrano che entrambi i dispositivi hanno consentito di eludere la fase pre-funzionale di terapia volta alla correzione del segmento labiale superiore e alla con- versione del rapporto incisale in Classe II divisione 1e sono sta- ti in grado di promuovere rilevanti ed evidenti effetti clinici. Conclusioni. Lo studio dimostra che il trattamento intercettivo di tipo funzionale della Classe II divisione 2 da retrusione mandi- bolare con morso profondo condotto in fase puberale attraver- so l’utilizzo clinico dell’Occlus-o-guide ® di Bergesen modifica- to, consente di risolvere simultaneamente le problematiche scheletriche, dentali e dentoalveolari in un’unica fase di terapia, mentre quello eseguito tramite l’utilizzo del Twin-block di Clark modificato richiede comunque una seconda fase di trattamento necessaria alla risoluzione dell’allineamento, livellamento, in- tercuspidazione delle arcate, ottimizzazione dei parametri den- tali di overjet e overbite e alla stabilizzazione della I Classe ba- sale. Parole chiave: occlus-o guide ® , Twin Block, Classe II di- visione 2, paziente pediatrico. © CIC Edizioni Internazionali
4. ORAL & Implantology - Anno III - N. 3/2010 original article 14 dels, and the following photographic documentation was made: • extra-oral, with photos of the face in frontal view, frontal with smile, side and naso-labial-chin pro- file (Figs. 1C, 2C); • intra-oral with photos of frontal view, right side, left side, upper occlusal and lower occlusal (Figs. 1D, 2D). • In accordance with Standard cephalometric ana- lysis (39), parameters were recorded for skele- Figure 1A P.R.: Orthopantography of the dental arches at the be- ginning of treatment. Figure 1B P.R.: Teleradiography of the skull in latero-lateral pro- jection at the beginning of treatment. Figure 1C P.R.: Image of the face in frontal view, frontal with smile, lateral and nasolabial profile at the beginning of treatment. Figure 2C P.F.: Image of the face in frontal view, frontal with smi- le, lateral and nasolabial profile at the beginning of tre- atment. Figure 2B P.F.: Teleradiography of the skull in latero-lateral pro- jection at the beginning of treatment. Figure 2A P.F.: Orthopantography of the dental arches at the be- ginning of treatment. © CIC Edizioni Internazionali
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