Introduction
Almost every dentoskeletal malocclusions initiate and develop during the transitional dentition and as studies suggests that genetic factors works more during embryonic life, while environmental factors influence the developing occlusion.1, 2 Contrary to the general concept of only prevention or interception, early orthodontic treatment includes all types of preventive, interceptive, or corrective treatments applied during the primary or mixed dentition, before the complete development of occlusion. 3
Early treatment has various benefits for patients and practitioners, such as better patient compliance, better final esthetic results due to growth modification, more stable results, less damage to teeth and supporting structures, the availability of more treatment options, a better chance to prevent extraction, and better use of growth potential. 4
Untreated malocclusions are susceptible to many problems such as dental caries, periodontal disease, bone loss, and temporomandibular joint problems. The most significant detrimental effect of the untreated malocclusion is on the appearance of the patient as shown in studies by Shaw et al 5, 6 that severe malocclusion is likely to be a social handicap. Facial esthetics have also been found to be a significant determinant of self- and social perceptions and attributes. Tung and Kiyak 7 and Kilpeläinen et al 8 concluded that perceptions of facial esthetics influence psychologic development from early childhood to adulthood.
Case Report
10-year-old male patient with late mixed dentition came to the dentistry department with a Class II div. 1, deep bite and proclined anteriors in both arches.
Patient’s guardian also complained about lack of self confidence in the patient due to the abnormal facial appearance which was hampering the studies and participation with his peers in all other activities. The sad looking eyes was clearly indicating the psychological status of the patient.
The patient was diagnosed with a dento-skeletal Class II div. 1 malocclusion, dental deep bite and a mandibular retrusion. She reported bilateral molar and canine Class II, 6 mm of deep bite, 11mm overjet, severe proclination of the upper incisors and coincident midlines. His facial features consisted of convex profile for an evident retrusion of mandible. Figure 1, Figure 2
Because of rural setup and poor economic conditions of the patient, radiographic records of the patient were not available.
Treatment objectives
Although our the main treatment objectives were:
To correct the Class II dento-skeletal relationship.
To obtain an ideal overbite and overjet.
To promote an anterior repositioning of the mandible.
But in this case, Our initial goal was to provide early treatment as it not only to reduce the time and complexity of fixed appliance therapy but also to eliminate or reduce the damage to occlusion that can be produced if treatment is postponed. Also To help the patient psychologically.
Additional treatment goals included leveling and aligning, optimizing the posterior occlusion, aiming at Class I molar and canine relationship, improving the facial profile and obtaining a natural lip position.
Treatment plan
Due to lack of specialized materials and instruments at the rural setup and poor economic conditions, we could not plan for either myofunctional therapy or fixed orthodontic treatment. We decided to give an interception device i.e. Anterior Inclined plane to correct the malocclusion and to achieve our treatment goals as much as possible to achieve. Figure 3, Figure 4
Treatment results
After 6 months of active phase, treatment objectives set in the pretreatment plan were achieved. The Class II malocclusion had been completely corrected; proper overbite and overjet were achieved. In particular, the overbite was reduced to 2 mm. The extraoral records show improvement of the profile.
The same appliance was used as a retention appliance. Figure 5, Figure 6
Discussion
The main aim of early orthdodontic treatment is to prepare an conducive environment for normal occlusal development, more essentially to eliminate or control any environmental factor disturbing normal occlusal development.
There are varied opinions regarding long-term benefits of orthodontic treatment at an early age for Class II malocclusion. One school of thought is that it is better to intervene early in Class II situations when the problem is skeletal and especially if the problem is the result of mandibular retrusion. While Others found no difference in the final result and prefers a single-phase treatment approach due to reduced overall treatment time. The questions related to early treatment have led to the need for critical analyses of the effectiveness of such an approach.
Many Studies 9, 10, 11 concluded that, for children with moderate to severe Class II problems, treatment seems to be as effective in late childhood as it is at an earlier age. Therefore both the single- and two-phase approaches are effective in the correction of Class II malocclusion. They also emphasized that this correction is the result of both skeletal and dental changes.
Functional appliances continue to be a controversial topic. Their use, effectiveness, and mode of action have been discussed by many authors.
Advocates of functional appliances cite stimulation of mandibular growth caused by forward positioning of the mandible 12, 13 Histologic studies shows a significant increase in cellular activity when the mandible is hyperpropulsed, 14, 15, 16 thus aiding in the correction of Class II malocclusions. However, some investigators disagree with these findings, claiming that the changes might be only those expected with normal growth or conventional fixed therapy. 17, 18
Anterior glenoid fossa remodeling and spontaneous anterior mandibular displacement that occurs after elimination of a functional retrusion also have been accredited to Class II correction. 19, 20
Conclusion
The main advantage of starting early is to utilize growth potential to modify skeletal growth, and to eliminate the need for or reduce the duration of second-phase of treatment as considerable amount of midfacial and mandibular growth occurs during the transitional dentition. 21
While the lack of success with myofunctional appliance treatment has been attributed to a lack of patient compliance and the inability to control the amount and direction of mandibular growth, proper motivation and education of the patient and their parents are essential in achieving desired results.
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