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30 Orthodontics KCE Reports 77 Figure 2: Class I malocclusion In a Class I malocclusion, a normal sagittal occlusion at the molars and the canines is present (Figure 2.). According to Angle's classification, Class I malocclusions can comprise all intra-arch deviations superimposed on the normal sagittal occlusion (crowding, impaction, spacing, ankylosis, rotations....). The treatment of Class I malocclusions is comprised in the different treatment types for these different features and will be discussed further. However, all intra-arch deviations can occur in the different types of Angle’s malocclusion. CLASS II DIVISION 1 MALOCCLUSION In a Class II division 1 malocclusion, the lower molars and canines occlude too far distally relative to the upper molars: this type of occlusion is also called a distoocclusion (Figure 3). Besides the deviation in the sagittal occlusion, all intra-arch deviations can also be superimposed on Cl II, div 1 malocclusions. Figure 3: Class II division 1 malocclusion For many decades already, Class II division 1 malformation is one of the most common features seen by orthodontic practitioners in North Western Europe. The upper front teeth may be in normal position or proclined in combination with a lower lip interposition, a retruded mandible and/or a prominent maxilla. The appearance of prominent upper front teeth is often a cause for teasing. An increased overjet, may increase the risk for trauma of the upper front teeth (see section 2.3.1.1). A Cochrane review about the orthodontic treatment for prominent upper front teeth in children was published in 2007. The evidence suggests that providing early orthodontic treatment (Phase I) for children with prominent upper front teeth is no more effective than providing one course of orthodontic treatment when the child is in early adolescence (Phase II). Evidence from 3 trials found that when orthodontic treatment is provided for children with prominent upper front teeth, when they are aged 7 to 9 years old (early treatment, Phase I),
KCE Reports 77 Orthodontics 31 this results in clinically and statistically significant reduction in incisor prominence (-4.04 mm (95% CI -7.47 to -0.6) for functional appliance; -1.07 mm (95% CI -1.63 to -0.51) for headgear; no significant difference is found between the two treatment types. This treatment also resulted in some changes in the relationship of the upper and lower jaws. However, while these changes or differences were statistically significant they were unlikely to be clinically significant. As these studies were of high/moderate quality, carried out in several different countries, using different functional appliances on children who were representative of the population, the resuls are generalisable. When the final outcome of treatment (4 studies) was considered at the end of a second phase of treatment when the child was in early adolescence (Phase II), it was found that the treatment was effective, in that incisor prominence had been reduced. There were no differences in treatment outcome between the groups of children who had received one or two phases of treatment. As a result, it appears that two-phase treatment does not have any advantages over one phase treatment in early adolescence. Two studies measured the effect of treatment with functional appliance versus untreated controls. The analysis revealed that the treatment resulted in a significant reduction of overjet (- 5.22 mm; 95% CI -6.51 to -3.93). Several investigators compared the effect of the Twin Block functional appliance against other similar appliances, for example, the Bionator and Herbst appliances, but no significant differences were found. The quality of the trials in this review was fair with 50% being considered at low risk of bias, the remainder at moderate risk. This was mainly due to the lack of blinding of the outcome assessors. 16 . Cozza et al 17 found in their systematic review of the literature 4 RCT’s as well as 18 prospective and retrospective controlled clinical trials of Class II treatment and with a control group of untreated subjects that 2/3 of the samples in the 22 studies reported a clinically significant supplementary elongation in total mandibular length as a result of overall active treatment with functional appliances. The amount of supplementary mandibular growth appears to be significantly larger if the functional treatment is performed at the pubertal peak in skeletal maturation. None of the 4 RCT’s 17 reported a clinically significant change in mandibular length induced by functional appliances (moderate quality). p The quality of evidence for clinically significant effect after treatment of prominent upper front teeth in Class II division 1, can be considered moderate. Early treatment of this malocclusion is no more effective than providing one course of orthodontic treatment when the child is in early adolescence. The quality of evidence for this statement is moderate. CLASS II, 2 MALOCCLUSION Despite a similar occlusal pattern in the buccal segments (molars and canines also show a distal occlusion as in Cl II division 1 malocclusions), the upper front teeth are retroclined in case of Cl II division 2 malocclusion (Figure 4). Besides the deviation in the sagittal occlusion, all intra-arch deviations can also be superimposed on Cl II, div 2 malocclusions. p Much debate is going on in the literature on the long term effects of functional appliances, especially on bone growth. The “Council on Scientific Affairs” or COSA published a meta-analysis on this subject in the “Reader’s Forum” of the Am J Orthod Dentofacial Orthop 2005; 128:271-272. It reviewed 5 publications and concluded that there is no evidence that functional appliances significantly increase horizontal growth of the mandibula when evaluated in the long term.
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