Can We Grow Mandibles? In 1879 Norman Kingsley first Who ... · FIXED&(+/*FFA) Systematic Review n...

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Can We Grow Mandibles? Who? How? When?

Department of Orthodontics,

The University of Florence, Italy, and

“T.M. Graber Visiting Scholar” Department of Orthodontics and Pediatric Dentistry

The University of Michigan

Lorenzo Franchi, DDS, PhD

“I declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing education presentation, nor do I have a financial interest in any commercial product(s) or services I will discuss in this presentation.”

In 1902 the French physician Pierre Robin described a “monobloc” to treat the Pierre Robin Sequence

In 1879 Norman Kingsley first used a removable appliance with an anterior inclined plane. “The object was not to protrude the lower teeth, but to jump the bite in the case of an excessively retreating lower jaw.”

Whal L Am J Orthod Dentofacial Orthop 2006;129:829-33

Pierre Robin Sequence (PRS) - small mandible (micrognathia) - posterior displacement of the tongue (glossoptosis) - upper airway obstruction Pierre Robin’s “Monobloc”

Robin P. Observation sur un nouvel appareil de redressement. Rev Stomatol 1902;9:423-32

In 1902 Pierre Robin described a “monobloc” in vulcanite that was able to induce:

-  forward repositioning of the mandible, -  improvement in airway patency -  expansion the arches

In Europe the concepts of FJO were developed by Andresen and Häupl Andresen V, Häupl K. Funktionskieferorthopädie. Leipzig, H. Meusser, 1936

Andresen Häupl Activator

Balters Bionator

1952 Fränkel

FR-2

1962

1936

Twin Block

1977

Clark

1979

Herbst

Pancherz

1969

FJO in the US was introduced in 1969 Mechanism of Action of Functional Appliances

All functional appliances induce a change in the postural activity of the craniofacial musculature

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Change in Level of Postural Activity

Change in Nature of Skeletal Adaptations

Change in Growth of the TMJs

Pre-Treatment Functional Jaw Orthopedic Treatment

CG female 12 y 2 mo

Post-Treatment

CG female 14 y 2 mo

Courtesy of Dr. F. Leishman

Pre-Treatment Post-Treatment Functional Jaw Orthopedic Treatment

CG female 12 y 2 mo

CG female 14 y 2 mo

Functional Jaw Orthopedics for Class II Malocclusion

Functional Appliances ? Controversy

Are they effective in improving

significantly mandibular length

and sagittal position??

During treatment of Class II malocclusion with functional appliances, does the mandible grow more than in matched untreated controls?

Mandibular Changes Produced by Functional Appliances in Class II Malocclusion: A Systematic Review Paola Cozza, MD, DDS, MS, Tiziano Baccetti, DDS, PhD, Lorenzo Franchi, DDS, PhD, Laura De Toffol, DDS, MS, James A. McNamara Jr, DDS, PhD (Am J Orthod Dentofac Orthop 2006, May -electronic)

Only 11 out of 37 samples (30%) in 28 studies described outcomes that exceeded 3.0 mm of supplementary growth at the completion of active treatment

The amount of supplementary growth of the mandible when compared to untreated Class II controls varied widely among studies (range 0.5 mm - 6.5 mm)

No one of the 4 RCTs reported a clinically significant change in mandibular length induced by functional appliances

During treatment of Class II malocclusion with functional appliances, does the mandible grow more than in matched untreated controls?

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1.  Timing of Treatment: Stage of Skeletal Maturity

2. Individual Patient Responsiveness



Treatment timing for functional jaw orthopedics in growing Class II patients: A systematic review and meta-analysis of controlled studies Franchi L., Contardo L., Primozic J., Perinetti G. In: The 40th Moyers Symposium: looking back…looking forward. Editor: McNamara JA Jr. Monograph 50, Craniofacial Growth Series, The University of Michigan, Ann Arbor, 2014, 263-285

Inclusion criteria 1. Longitudinal controlled studies, either prospective or retrospective, on healthy growing patients treated for a skeletal Class II malocclusion due to mandibular retrusion

4. Use of removable or fixed functional appliances (NO headgear!)

3. Use of a reliable indicator of skeletal maturity for the assessment of treatment timing

2. Use of a matched control group of subjects with untreated Class II malocclusion

Systematic Review and Meta-analysis on Treatment Timing for FJO

Database Search Strategy Medline, Entrez PubMed www.ncbi.nlm.nih.gov

"Orthodontic appliances, Functional"[Mesh] OR "Orthodontic appliances"[All Fields] OR "functional"[All Fields] AND ("Malocclusion, Angle Class II"[Mesh] OR "jaw"[All Fields] OR "orthop*"[All Fields]) AND (("Class"[All Fields] AND "II"[All Fields] AND "Malocclusion"[All Fields]) OR ("Angle"[All Fields] AND "Class"[All Fields] AND "II"[All Fields]))

SCOPUS www.scopus.com

TITLE-ABS-KEY(((orthodontic appliance) OR (functional jaw orthopedics)) AND ((class ii malocclusion) OR (angle class ii))) AND (LIMIT-TO(DOCTYPE, "ar") OR LIMIT-TO(DOCTYPE, "ip")) AND (LIMIT-TO(SUBJAREA, "DENT") OR LIMIT-TO(SUBJAREA, "MULT"))

LILACS http://lilacs.bvsalud.org

((Orthodontic appliance) or (Functional jaw orthopedics)) AND ((Class II malocclusion) or (Angle Class II))

SciELO http://www.scielo.org Cochrane Library (Registered Controlled trials) www.thecochranelibrary.com


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Medline n = 1,870

SCOPUS n = 2,334

LILACS n = 196

Cochrane n = 179

SciELO n = 20

FIXED (+/-‐FFA)

Systematic Review n = 15

Meta-analysis (+FFA) n = 6

Systematic Review n = 14

Meta-analysis n = 12

REMOVABLE

TOTAL (without duplicate entries)

n = 2,456

Mandibular Length


Baccetti et al., 2000 CCT

Malta et al., 2010 CCT

Faltin et al., 2003 CCT

Singh et al., 2010 CCT

Cui et al., 2010 CCT

Martina et al., 2013 RCT

Overall PEAK

Tulloch et al., 1997 RCT

Almeida-Pedrin et al., 2007 CCT


Singh et al., 2010 CCT

Faltin et al., 2003 CCT

Brunharo et al., 2011 RCT

Perillo et al., 2012 CCT

Perillo et al., 2013 CCT

Overall PRE-PEAK

Twin-Block, 17 months

Bionator, 12 months

Bionator, 28 months



Sander BJA, 14.5 months

Bionator, 15 months (a)

Bionator, 18 months



Bionator, 22 months

Twin-Block, 12 months FR-2, 12 months

FR-2, 19 months

-2 0 2 4 6 8

-2 0 2 4 6 8

mm

Amount of Supplementary Mandibular Growth Removable Functional Appliances

1.3 mm

4.3 mm

Peak

Sam

ples

Pr

e-Pe

ak S

ampl

es

-2 0 2 4 6 8

-2 0 2 4 6 8

Franchi et al., 2011 CCT

Franchi et al., 1999 CCT

Huanca et al., 2012 CCT


Phelan et al., 2012 CCT Overall PEAK

Huanca et al., 2012 CCT Oztoprak et al., 2012 CCT Oztoprak et al., 2012 CCT Overall POST-PEAK

mm

Peak

Sam

ples

Po

st-P

eak

Sam

ples

Forsus+FFA, 29 months

Herbst+FFA, 29 months

MARA+FFA, 28 months

Herbst+FFA, 32 months

Magnog+FFA, 24 months

MARA+FFA, 24 months SUS+FFA, NA

Forsus+FFA, NA

0.3 mm

2.5 mm

Amount of Supplementary Mandibular Growth Fixed Functional Appliances

Amount of Supplementary Mandibular Growth at the pubertal growth spurt

-2 0 2 4 6 8

mm

-2 0 2 4 6 8

mm

REMOVABLE FIXED

4.3 2.5

Statistically Significant Difference

Treatment effects produced by the Twin-Block appliance versus the Forsus Fatigue Resistant

Device in growing Class II patients

Giuntini V, Franchi L, Vangelisti A, Masucci C, McNamara JA Jr, Defraia E The Angle Orthodontist, submitted for publication

vs

Twin Block Forsus

Demographics Age at T1

(ys) Age at T2

(ys)

T1-T2 interval

(ys) Mean SD Mean SD Mean SD

Twin Block (n=28 19f 9m) 18% prepubertal, 64% pubertal, 18% postpubertal

12.4 1.0 14.7 1.0 2.3 0.5

Forsus (n=36, 16f 20m) 15% prepubertal, 70% pubertal, 15% postpubertal

12.3 1.2 14.6 1.2 2.4 0.4

Controls (n=27, 13f, 14m) 18% prepubertal, 64% pubertal, 18% postpubertal

12.2 0.8 14.5 0.8 2.3 0.5

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Maxillary Sagittal Changes (vs ctrls) SNA (°)

Twin Block

-0.8ns -1.8***

Forsus

Analysis of skeletal correction

Diff

+1.0**

Mandibular Growth Changes (vs ctrls) Co-Gn (mm)

+3.4*** 1.4ns

Diff

+ 2.0*

Twin Block Forsus

Mandibular sagittal changes (vs ctrls) SNB (°)

1.5*** -0.4ns

Diff

+ 1.9***

Twin Block Forsus

Proclination of the lower incisor L1-Mand. Pl. (°)

5.6***

Diff

- 2.9*

Twin Block Forsus

2.7ns

Treatment effects produced by the Twin Block appliance versus the Forsus Fatigue Resistant

Device in growing Class II patients

Giuntini V, Franchi L, Vangelisti A, Masucci C, McNamara JA Jr, Defraia E The Angle Orthodontist, submitted for publication

The Twin Block produced greater skeletal effects than the Forsus in terms of mandibular advancement and growth stimulation

The Class II correction induced by the FDR was more dentoalveolar than the TB with a larger amount of proclination of the lower incisors

CONCLUSIONS



5th Dimension in Dentofacial Orthopedics

Transverse

Sagittal

Vertical

Timing

Patient Responsiveness

Why different subjects with similar dentoskeletal Class II disharmony respond to FJO differently, even when treated at the RIGHT time (CS 3) ?

Is it possible to predict individual responsiveness to FJO?

Biannualized increases in Co-Gn

14121086420

patie

nts

3029282726252423222120191817161514131211109876543210

27 Class II pts treated with the FR-2 at CS 3

(mm)

Baccetti & Franchi, 2001 Biannulized increases in Co-Gn (mm)

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PREDICTIVE VARIABLE TO BE ASSESSED BEFORE Tx:

Co-Go-Me° Co

Me

Go

Good Responders: “Small” Co-Go-Me angle

Bad Responders: “Large” Co-Go-Me angle

Prediction of individual mandibular changes induced by functional jaw orthopedics followed by fixed appliances in Class II patients.

Franchi L., Baccetti T. The Angle Orthodontist, vol. 76, n.6, 950-4, 2006

DISCRIMINANT VARIABLE: Co-Go-Me°

Co

Me

Go

Bad Responders: Co-Go-Me angle > 128°

Measurement Error: 1.5° Classification Error: 23%

Error in Discrimination: 20% ( Δ compliance, management of the appliance, intensity of hormonal factors at puberty, etc.)

Average amount of mandibular growth +4.2 mm


Co

Me

Go

Good Responders: 124° < Co-Go-Me angle < 128°




Co

Me

Go

Best Responders: Co-Go-Me angle < 123°





MANDIBULAR MORPHOLOGY

Co

Me

Go

Peak in mandibular

growth

TIMING OF

TREATMENT

CS 1 CS 3 CS 4 CS 5 CS 6 CS 2

AJO-DO 1994;105:192-205

Petrovic A

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AJO-DO 1994;105:192-205

Petrovic A

AJO-DO 1994;105:192-205

Petrovic A

1. Effectiveness (>3 mm extra mandibular growth) 2. Short duration of active therapy

2.5 ys (vs 4 ys, when FJO is used as Phase I Tx)

3. Good stability (end of Tx at postpubertal stage; optimal final intercuspation)

FJO at the Adolescent Growth Spurt followed by Fixed Appliances

? Can mandibular growth be altered

in a clinically significant way with FJO in the long term?

A Critical Question:

% O

F A

DU

LT M

AN

DIB

ULA

R S

IZE

Growth curve for true stimulation

Growth curve for temporary acceleration

Expected growth without

treatment

10 15 20 25 30 35

100

90

80

AGE Modified from Proffit Fields, and Sarver 2013

Evidence

Clinical Studies

Experimental Studies

Evidence Based Treatment

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Primate Functional Protrusion

Studies

The University of Michigan

Long-Term Mandibular Adaptations to Protrusive Function in the Rhesus Monkey (Macaca mulatta)

McNamara JA Jr, Bryan FA Am J Orthod Dentofac Orthop 92:98-108, 1987

Control Experimental (N =12) (N =9)

Mean S.D. Mean S.D. 78.7 3.7 83.6 2.9

Difference 4.9 mm ***

*** p < .001

Mandibular Length (144 Weeks)

% O

F A

DU

LT M

AN

DIB

ULA

R S

IZE



Expected growth without

treatment

10 15 20 25 30 35

100

90

80

AGE

Non-human primate studies

5 mm

Evidence

Clinical Studies

Experimental Studies

Evidence Based Treatment

Long-term Treatment Effects of the FR-2 Appliance of Fränkel

Freeman DS, McNamara JA Jr, Baccetti T, Franchi L, Fränkel C Am J Orthod Dentofacial Orthop

2009;135:570.e1-6

Samples

Treated with FR-2 30 Untreated Class II 20

Groups N

Timing of Tx: Prepubertal-Pubertal

Long-term observation: CS5-CS6 (18 ys)

Freeman et al., 2009

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Mandibular Length (Co-Gn)

Difference FR-2 vs Untreated Cl II Controls

+3.0 mm Freeman et al., 2009

Long-term Changes Long-term Dentoskeletal Effects

Induced by Bionator Therapy

Malta LA, Baccetti T, Franchi L, Faltin K Jr, McNamara JA Jr

Angle Orthod 2010;80:10-17

Samples

Treated with Bionator 34 Untreated Class II 32

Groups N


Long-term observation: CS5-CS6 (18.5 ys)

Malta et al., 2010


Difference Bionator vs Untreated Cl II Controls

+3.3 mm Malta et al., 2010

Long-term Changes

Long-term Dentoskeletal Effects and Treatment Timing for

Functional Appliances

Franchi L, Pavoni C, Faltin K Jr, McNamara JA Jr, Cozza P


Samples

Treated with Activator or Bionator 40 Untreated Class II 20

Groups N


Long-term observation: CS6 (18.6 ys)

Franchi et al., 2013

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Difference FJO vs Untreated Cl II Controls

+3.6 mm

Long-term Changes


Long-term Treatment Effects of the FR-2 Appliance:

a prospective evaluation 7 years post-treatment

Angelieri F, Cevidanes L, Franchi L, Goncalves JR,

Benavides E, McNamara JA Jr

Eur J Orthod 2014;36:192-9

Samples

Treated with FR-2 17 Untreated Class II 17

Groups N


Long-term observation: CS5-CS6 (19 ys)

Angelieri et al., 2014


Difference FR-2 vs Untreated Cl II Controls

+3.7 mm Angelieri et al., 2014

Long-term Changes

% O

F A

DU

LT M

AN

DIB

ULA

R S

IZE

10 15 20 25 30 35

100

90

80

AGE

Long-term Evaluations Clinical studies



Expected growth without treatment

3-3.5 mm

Freeman et al, 2009 Malta et al, 2010 Franchi et al., 2013 Angelieri et al., 2014

Role of Timing on Long-Term Outcomes of Class II Treatment ?

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Long-term Dentoskeletal Effects and Treatment Timing for

Functional Appliances

Franchi L, Pavoni C, Faltin K Jr, McNamara JA Jr, Cozza P


Samples

Prepeak Group (T1 CS 1; T2 CS 1-2) 20 Peak Group (T1 CS 3; T2 CS 4-5) 20

Groups N

Long-term observation T3: CS6 (18.6ys)



Difference Peak vs Prepeak Groups

+4.3 mm

Long-term Changes


% O

F A

DU

LT M

AN

DIB

ULA

R S

IZE

10 15 20 25 30 35

100

90

80

AGE

Long-term Evaluations Franchi et al, 2013 FJO Treatment at Puberty



Expected growth without treatment

4.3 mm

Advancement of the chin (Pog to Nperp)


+3.9 mm

Long-term Changes


NPerp


Long-term Changes


NPerp

FJO treatment completed BEFORE the pubertal growth spurt

is NOT able to produce a significant advancement of the chin

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Long-term Changes


NPerp

FJO treatment performed DURING the pubertal growth spurt

is able to produce a significant advancement of the chin



+3.9 mm

Long-term Changes


NPerp

HMI 2mm 4mm 6mm

Patient 9.0 10 10 9.0 Lay People 6.5 7.0 7.5* 7.0 Orthodontist 5.0 6.0* 7.0 7.0

* p<0.05 * p<0.05

Barroso et al., Prog Orthod, 2012;13:141-7 Patients begin to perceive a change in the sagittal position of the chin only beyond an improvement > 4 mm

012345678

MHI 2mm 4mm 6mm

Mandibular advancement

Scor

e

Lay People Orthodontist

*

In Class II patients Tx timing can influence the effectiveness of treatment on mandibular growth: optimal timing is at puberty

Mandibular morphology should be evaluated to assess patient responsiveness: good responders have a small mandibular angle

Treatment of Class II malocclusion with functional appliances

Functional appliances are effective in altering mandibular length also in the long term

Can We Grow Mandibles? In 1879 Norman Kingsley first Who ... · FIXED&(+/*FFA) Systematic Review n...

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