EARLY TREATMENT SYMPOSIUM

The timing of Class II treatment

Timothy T. Wheeler,a Susan P. McGorray,b Calogero Dolce,c and Gregory J. Kingd
Gainesville, Fla, and Seattle, Wash

I
n our presentation at collection to examine early treatment effects occurred
the Early Treat- at different time intervals. The UNC trial examined
ment Symposium, phase 1 outcomes after 15 months of treatment, and the
we attempted to summa- UF trial examined phase 1 outcomes after correction of
rize results from prospec- the Class II molar relationship or 24 months, whichever
tive randomized clinical occurred first. Finally, in the UNC trial, phase 2
trials at the Universities treatment plans were determined by 1 of 4 participating
of North Carolina and orthodontists, whereas the UF trial attempted to formu-
Florida that examined the late a “consensus” treatment plan from records sent to
timing of treatment for randomly selected orthodontists throughout the US.
Class II malocclusions. Therefore, although the issue examined was similar in
However, the actual pre- the studies, there were some differences in their de-
sentation became a live signs.
example of randomiza- Many outcomes were examined at the end of phases
tion: an untimely Trojan horse virus randomly distrib- 1 and 2 of the clinical trial including skeletal and dental
uted figures generated from data tables during the changes, incisor trauma, and physical maturation, and
PowerPoint presentation. I hope this summary will these will be discussed here.
clarify the results that were supposed to be clarified at At both UNC and UF, at the end of phase 1
the Early Treatment Symposium. treatment, skeletal changes as measured by both angu-
The main goal of both trials was to determine lar (ANB angle) and linear anteroposterior changes
whether growth can be modified during the early (Johnston analysis) showed significant improvement in
treatment of children with Class II malocclusions and, children who had received phase 1 treatment (Fig 1).3
if so, would this modification affect the subsequent care However, by the end of phase 2, the differences
and treatment outcomes. Details on the designs of those between those who had received phase 1 treatment and
studies are published elsewhere,1,2 so I will just high- those who had not was indistinguishable (Tables I and
light the key differences here. In selecting subjects for II).2 Furthermore, the range of changes in each group
their respective trials, the University of North Carolina was similar, and each group had extremes—from great
(UNC) used overjet, whereas the University of Florida improvement to severe worsening of the Class II
(UF) used molar class. Both studies had an observation
relationship (Table I).
group and early treatment groups treated with either
Traditionally, an important reason to consider phase
bionator or headgear. However, the UF study used an
1 treatment has been to reduce the incidence of incisor
anterior biteplane to disclude the posterior occlusion. In
trauma in children. UNC found that, after 15 months,
addition, the UNC trial used a combi-headgear,
there were no significant differences between those
whereas the UF trial used either high-pull or cervical-
who had phase 1 treatment and those who had not for
pull headgear based on mandibular plane angle. Data
new maxillary incisor trauma.4 Likewise at UF, after 3
a
Professor and chair, Department of Orthodontics, University of Florida, years, there were no significant correlations with new
Gainesville.
b
incisal injury and age, overjet, change in overjet, or
Assistant research professor, Department of Statistics, University of Florida,
Gainesville.
years in treatment.
c
Associate professor, Department of Orthodontics, University of Florida, Examining the length of phase 2 treatment, the
Gainesville. researchers at UF found that those who had phase 1
d
Professor and chair, Department of Orthodontics, University of Washington,
Seattle.
treatment finished phase 2 about 6 months faster than
Presented at the Early Treatment Symposium, January 21-23; Las Vegas, Nev. those treated in a single phase. At UNC, there were no
Am J Orthod Dentofacial Orthop 2006;129:S66-70 noticeable differences in the phase 2 treatment time
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists. (Fig 2).2 When the total treatment time for phases 1 and
doi:10.1016/j.ajodo.2005.09.015 2 was examined at UF, 2-phase treatment took signif-
S66
American Journal of Orthodontics and Dentofacial Orthopedics Wheeler et al S67
Volume 129, Number 4, Supplement 1

Fig 1. Phase 1 changes in relation to apical base expressed at UNC as ANB change per year3 and
at UF as millimeter change per year in relation to functional occlusal plane. Numbers of subjects
listed in parentheses.

Table I. Mean (range) phase 1 and phase 2 skeletal changes in UF groups

Control Bionator Headgear
Skeletal measure n ⫽ 47 n ⫽ 60 n ⫽ 59

Maxilla (mm) –0.94 (–1.7 to –0.14) –0.85 (–1.8 to –0.07) –0.88 (–2.4 to 0.18)
Mandible (mm) 1.59 (–0.42 to 3.21) 1.55 (–0.36 to 3.68) 1.49 (–0.73 to 3.84)
Apical base change (mm) 0.65 (–0.76 to 2.17) 0.70 (–1.19 to 2.15) 0.61 (–0.92 to 1.82)

Negative value indicates negative impact on Class II correction.

icantly longer than 1 phase. However, this might have Table II. Mean phase 1 and phase 2 skeletal changes in
been caused by the protocol, which allowed for a UNC groups2
maximum treatment time in phase 1 of 24 months Control Bionator Headgear
regardless of cooperation. Skeletal measure n ⫽ 51 n ⫽ 39 n ⫽ 47
At the end of phase 2 treatment in both studies,
SNA (°) 82.41 81.59 81.59
there were no significant differences in the distribution of
SNB (°) 78.06 77.84 77.60
peer assessment rating (PAR) scores between those who ANB (°) 4.36 3.79 4.0
had phase 1 treatment and those who had not (Fig 3).5
At UF, transverse changes during treatment were
examined. There was significantly more expansion at
S68 Wheeler et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2006

Fig 2. Length of time in phase 2 treatment for patients treated with bionator or headgear during
phase 1 or not treated during that time (control) at UF and UNC.2

Fig 3. Distribution of PAR scores at end of phase 2 treatment for those who had phase 1 treatment
and those who did not (control). PAR scores: ⬍ 5, very good finish; 6-10, good finish; and ⬎ 10,
could have been finished better.
American Journal of Orthodontics and Dentofacial Orthopedics Wheeler et al S69
Volume 129, Number 4, Supplement 1

Fig 4. Maxillary canine transverse change during phase 1, phase 2, and total change.

Fig 5. Change in SNA, SNB, and ANB angles posttreatment. Numbers of subjects in parentheses.
Mean posttreatment times were 3.6 years for bionator group and 3.2 years for headgear/biteplane
and control groups.

the canines in those treated at the end of phase 1 icant differences between those who received phase 1
compared with those who had no treatment (Fig 4). treatment and those who had not, for either angular (Fig 5)
This expansion was passive and not as the result of any or linear changes. Similarly, changes in PAR scores after
active force to expand the arch. These effects were phase 2 treatment were not significantly different.
reversed during phase 2 treatment, when those who had Although patients receiving phase 1 treatment can
not received phase 1 treatment showed a greater in- have better skeletal and dental changes than those who
crease in the transverse dimension, and, by the end of do not receive treatment, there are no differences in
phase 2, there was no difference in transverse changes skeletal and dental outcomes at the end of phase 2
between the groups (Fig 4). These changes were similar treatment between those treated in a single phase and
for the transverse dimension at the molars as well as in those treated in 2 phases. Furthermore, there is no
the mandibular arch (data not shown). difference in postphase 2 skeletal or dental stability.
The researchers at UF continued to collect data on Although there are certainly other reasons to consider
their subjects after phase 2 to examine stability. Ap- phase 1 treatment for a Class II malocclusion, an
proximately 3 years posttreatment, there were no signif- improved skeletal or dental outcome is not one.
S70 Wheeler et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2006

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intervention on skeletal pattern in Class II malocclusion: a randomized
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Comparison of peer assessment ratings (PAR) from 1-phase and 4. Koroluk LD, Tulloch JF, Phillips C. Incisor trauma and early
2-phase treatment protocols for Class II malocclusions. Am J treatment for Class II Division 1 malocclusion. Am J Orthod
Orthod Dentofacial Orthop 2003;123:489-96. Dentofacial Orthop 2003;123:117-26.
2. Tulloch JF, Proffit WR, Phillips C. Outcomes in a 2-phase 5. Tulloch JF, Phillips C, Proffit WR. Benefit of early Class II
randomized clinical trial of early Class II treatment. Am J Orthod treatment: progress report of a two-phase randomized clinical trial.
Dentofacial Orthop 2004;125:657-67. Am J Orthod Dentofacial Orthop 1998;113:62-72.