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ORIGINAL ARTICLE

Duration of orthodontic treatment and


mandibular lengthening by means of
distraction or bilateral sagittal split osteotomy
in patients with Angle Class II malocclusions
K. Hero Breuning,
a
Peter J. van Strijen,
b
Birte Prahl-Andersen,
c
and D. Bram Tuinzing
d
Tiel, Ede, and Amsterdam, The Netherlands
Background: The purpose of this study was to investigate the duration of treatment of patients with skeletal
Angle Class II malocclusions treated with orthodontic appliances and surgical lengthening of the mandible
to close residual overjets. Methods: In this retrospective study, the patients were divided into 3 groups.
Group A consisted of 10 patients (5 boys, 5 girls; mean age, 10.11 years; range, 9.1-13.9 years at the
beginning of treatment) who were treated with a headgearactivator, xed appliances, and intraoral
osteodistraction of the mandible. Group B consisted of 19 patients (10 boys, 9 girls; mean age, 12.3 years;
range, 9.6-16.1 years) treated with xed appliances and intraoral distraction. In group C, 13 patients (4 men,
9 women; mean age, 27.3 years; range, 12.11-40.7 years) were treated with xed appliances and bilateral
sagittal split osteotomy (BSSO). Results: In patients treated with orthodontic appliances and surgical
lengthening of the mandible, treatment time was inuenced by the appliances and the surgical technique
used. Patients treated with a headgearactivator, xed appliances, and intraoral distraction osteogenesis
(group A) needed signicantly more treatment time than patients treated with xed orthodontic appliances
and intraoral distraction (group B) or xed appliances and BSSO (group C). Duration of treatment with
intraoral mandibular distraction (group B) was signicantly (P .05) shorter compared with mandibular
lengthening with BSSO (group C). However, no denitive conclusions can be drawn, because of the
retrospective study design. Conclusions: The best time and the best surgical procedure for correcting
mandibular length have yet to be determined, and a prospective randomized trial is recommended. (Am J
Orthod Dentofacial Orthop 2005;127:259)
A
n Angle Class II malocclusion is commonly
observed in orthodontic ofces and hospital
clinics. Patients might complain about incom-
petent lip closure, mouth breathing and sleep apnea,
difculty with chewing, speech problems, and en-
hanced danger of dental trauma. Patients often seek
orthodontic or surgical treatment for this condition. In
most orthodontic clinics in Europe and North America,
the correction of excessive overjet accounts for more
than half of treated patients.
1
Numerous variations of
treatment for a Class II malocclusion have been advo-
cated.
In Europe, the orthodontist usually starts treatment
with functional appliances before the patient reaches
skeletal maturity. These appliances induce mandibular
repositioning. Presumably, this alteration in jaw posi-
tion in growing children leads to skeletal and dentoal-
veolar alterations.
2,3
In these subjects, functional appli-
ances resolve part of the underlying malocclusion.
Correction of the length of the mandible with functional
appliances in patients with a retruded mandible is not
always predictable or successful.
3,4
Treatment with xed orthodontic appliances com-
bined with headgear is a different approach to the
treatment of an existing skeletal discrepancy. However,
the length of the mandible is not directly addressed
during xed-appliance therapy.
If both the overjet and the prole are unacceptable
after a rst phase of orthodontic treatment, and retrac-
tion of maxillary anterior teeth is not indicated, it might
be more appropriate to lengthen the mandible surgi-
cally. In patients for whom only mandibular decien-
a
Private practice in orthodontics, Tiel, The Netherlands.
b
Department of Oral and Maxillofacial Surgery, Gelderse Vallei Hospital, Ede,
The Netherlands.
c
Department of Orthodontics, Academisch Centrum Tandheelkunde Amster-
dam University, Amsterdam, The Netherlands.
d
Department of Oral and Maxillofacial Surgery, Vrije Universiteit Medical
Center/ACTA, Amsterdam, The Netherlands.
Reprint requests: Dr K. H. Breuning, Tolhuiswal 33, Tiel 4001 LL, The
Netherlands; e-mail, breuning@orthodontics.nl
Submitted, July 2003; revised and accepted, November 2003.
0889-5406/$30.00
Copyright 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2003.11.024
25
cies need to be corrected surgically, bilateral sagittal
split osteotomy (BSSO) is the most common procedure.
Experience and follow-up studies of orthodontic and
surgical treatment are reported in the literature.
5
Intraoral distraction osteogenesis during orthodontic
treatment as a solution for a Class II malocclusion has
been proposed as an alternative to BSSO.
6-10
Intraoral
distraction has even been proposed as a farewell to major
osteotomies.
11
The introduction of a new technique
requires evaluation.
12
Evaluation of intraoral distraction in
patients with Angle Class II malocclusion is only useful
when some other questions have been answered. Accord-
ing to Drummond,
13
these questions include the follow-
ing: Can the health procedure/intervention work? Is the
procedure efcient? Is the procedure/intervention effec-
tive, and is the service available for those who need it?
There are few examples of evaluation of efcacy in
orthognathic surgery.
14,15
The effectiveness of intraoral
distraction to correct a mandibular deciency has been
reported.
6,8
However, the duration of treatment in patients
with Angle Class II malocclusion treated with intraoral
osteodistraction of the mandible has not been studied.
The aims of this study were to assess treatment time
in patients with an Angle Class II malocclusion in
whom intraoral osteodistraction or a BSSO procedure
was used to correct the length of the mandible during
orthodontic treatment.
MATERIAL AND METHODS
In this retrospective study, all patients with surgical
lengthening of the mandible for correction of overjet
and facial convexity treated by the same orthodontist
and the same maxillofacial surgeon between April 1997
and January 2000 were studied. Patients who needed
additional surgical procedures were excluded. One
patient was excluded from the study because of thumb
sucking after distraction.
These patients were divided into 3 groups (A, B,
and C). Group A consisted of 10 subjects (5 girls, 5
boys) with a mean age at the start of orthodontic
treatment of 10.11 years (range, 9.1-13.9 years) who
were treated with high-pull headgear and activators
during a rst phase of orthodontic treatment, followed
by xed-appliance therapy. Group B consisted of 19
patients (10 boys, 9 girls) with a mean age of 12.3 years
at the start of orthodontic treatment (range, 9.6-16.1
years) in whom only xed appliances were used to
correct their occlusions. Intraoral mandibular distrac-
tion was used for correcting overjet and facial convex-
ity. Group C consisted of 13 subjects (four men, nine
women) with a mean age of 27.3 years (range, 12.11-
40.7 years) at the start of orthodontic treatment. In this
group, BSSO was used to correct the overjet and facial
convexity.
Before treatment, the groups were comparable with
regard to skeletal convexity (the angles SNA, SNB, and
ANB and the Wits value). All patients in group A had
an Angle Class II Division 1 malocclusion at the start of
treatment. In group B, 12 patients originally had a Class
II Division 1 and 7 a Class II Division 2 malocclusion.
In group C, 9 patients had a Class II Division 1 and 4 a
Class II Division 2 malocclusion.
The decision to use intraoral distraction or BSSO
for mandibular lengthening primarily depended on the
patients age. Generally, younger patients were treated
with intraoral distraction and older patients with BSSO.
However, an older patient (a boy 17.2 years old at the
time of surgery) preferred the distraction procedure
because he wanted to observe the facial changes during
jaw lengthening, and a girl 13.1 years of age at the time
of surgery preferred BSSO because the parents would
not activate the distraction devices.
Orthodontic treatment procedure
In group A, orthodontic treatment was started with
a headgearactivator. The headgearactivator was con-
structed and used according to the instructions de-
scribed by van Beek.
16
Patients were instructed to wear
the headgearactivator at least 12 hours per day. The
orthodontic treatment in this group was continued with
xed appliances, with the straight wire technique of
Bennett and McLaughlin.
17
Orthodontic treatment in groups B and C was
started with xed appliances. In all groups, palatal bars,
Class II elastics, and headgear were used during xed-
appliance treatment in an attempt to correct both the
dental arches and the occlusion without surgery.
Surgical mandibular lengthening
In groups A and B, the third molars, if present, were
removed under general anesthesia, and bone cuts made in
the superior, lateral, and inferior mandibular cortex in the
third molar region during the same operation. After
completion of the osteotomy with an osteotome, bilateral
intraoral distractors were attached to the buccal mandib-
ular cortex in the third-molar region.
6
After a latency
period of 6 days, the distractor devices were activated
twice per day, at rst by the surgeon and later by the
patients parents. Activation resulted in a 0.5-mm length-
ening of the distractor. Distraction was continued until the
canine relationship was corrected to a Class I occlusion
with no overcorrection.
For distraction, 3 types of monodirectional distrac-
tor devices were used (intraoral distractor, Stryker
Leibinger, Freiburg, Germany; horizontal distractor,
American Journal of Orthodontics and Dentofacial Orthopedics
January 2005
26 Breuning et al
Martin Medizin-Technik, Tuttlingen, Germany; in-
traoral titanium distractor, Medicon eG, Tuttlingen,
Germany). During distraction, orthodontic treatment
continued with elastic traction to inuence the vector of
distraction and guide the occlusion. The devices were
removed under general anesthesia, on average 47 days
after the end of the distraction period.
In group C, the third molars were removed before
the operation. BSSO was performed with rigid xation.
Intermaxillary xation after the operation was not used.
Elastic traction was used to support the occlusion.
RESULTS
The mean treatment times were 44.2 months (range,
29-63 months) for group A, 28.6 months (range, 16-40
months) for group B, and 34.7 months (range, 19-55
months) for group C.
The results were tested for statistical signicance
with the conventional t test for averages and the F test
for variance. The F test is not the alternative version of
this t test but a test for equality of variation between
groups. As the F test for variance indicates, the random
tests for treatment time differ in variance. The differ-
ence in treatment time between groups A and B was
signicant (P .05). The F test for variance gave a
value of 0.041. The nal t test is signicant for an of
.05 (a 1-sided t test for an of .05 gave a value of
0.0165). The difference in treatment time between
groups A and C was signicant (P .05, F 0.053).
Furthermore, the difference between groups B and C
was signicant (P .005, F 0.045).
Other factors, such as missed appointments during
xed-appliance treatment and breakage of appliances,
were recorded. No signicant differences between the
groups were found.
Hospitalization between the 2 types of surgical
treatment was compared. The patients in the distraction
group stayed in the hospital for 1 day before surgery for
the preoperative physical assessment. Most distraction
patients stayed in the hospital for 1 night after the
operation. The removal of the distraction devices as an
outpatient procedure resulted in a mean hospitalization
time of 3.4 days (range, 2-4 days). In the BSSO group,
the patients were hospitalized for 3 to 7 days (mean, 4.4
days).
DISCUSSION
Patients and their parents are often interested in
resolving esthetic and functional dental problems as
quickly as possible, without incurring unnecessary
costs. Thus, the question of which orthodontic and
which surgical treatment is the most effective for a
patient with a skeletal Class II malocclusion is relevant.
Studies reporting duration of treatment vary consid-
erably in their denition of treatment time and end of
treatment. Therefore, comparison of this study with
other studies can only be done in general terms. The
average duration of treatment in 5 orthodontic clinics in
the United States was 28.6 months, with a range of 23.4
to 33.4 months.
18
Von Bremen and Pancherz
19
reported
orthodontic treatment time in 207 patients with Class II
Division 1 malocclusions in relation to the dental
development; the mean duration of treatment was 37
months. They were treated with orthodontic appliances
only.
The number of treatment phases inuences the total
treatment time. Vig et al
20
and Beckwith et al
18
reported
13.5 and 8 months extended treatment time, respectively,
when more than 1 treatment phase was used. Tulloch et
al
21
concluded that patients treated early and those treated
with a 2-phase approach need more prolonged treatment.
These ndings are conrmed by the results reported in this
study: in group A (treatment with a headgear-activator),
the mean treatment time was longer than in patients
treated with xed appliances only (groups B and C). On
average, starting treatment with xed-appliance therapy
with an indication for mandibular lengthening leads to
shorter treatment.
The active treatment time in this study was less than
reported because all patients had surgery during holi-
days, according to patient preference, and the extra
treatment time spent was included in the total treatment
time.
The difference in treatment time between groups A
and B could have been caused by factors other than the
surgical procedure, because these 2 groups were not
selected at random.
Patients in group A had Class II Division 1 maloc-
clusions. In group B, 7 patients had Class II Division 2
malocclusions. Because of the position of the maxillary
incisors in these group B patients, treatment was started
with xed appliances.
The skeletal relationships of patients in groups B
and C before treatment were comparable. Both groups
were treated with xed appliances by the same ortho-
dontist. Therefore, the difference in treatment time was
most likely caused by the difference in surgical tech-
nique used. Treatment time in the mandibular distrac-
tion group was signicantly shorter compared with the
BSSO group. This is remarkable because intraoral
distraction is a relatively new treatment alternative.
Complications in some of the rst patients in this group
might have extended treatment time.
The differences in treatment time between groups B
and C could have been caused by factors other than the
surgical procedure. The 2 groups could not be matched
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 127, Number 1
Breuning et al 27
for age because age was discriminative for the surgical
procedure used. However, the inuence of differences
in age on the length of orthodontic treatment with xed
appliances seems to be limited.
22
In the opinion of maxillofacial surgeons, the use of
BSSO at an early age has some disadvantages.
23
Nevertheless, BSSO can be used in adolescent patients,
just as mandibular distraction can be used in adult
patients. The best time and the best surgical procedure
to correct the length of the mandible have yet to be
determined, and a prospective randomized trial would
be the preferred means to accomplish this.
What can be done by orthodontic means, versus
what constitutes the most practical or expedient treat-
ment, should be discussed with both patient and parents
before the start of treatment. The ultimate objective is
to identify patients who will not respond to conven-
tional orthodontic treatment alone and to start presur-
gical orthodontic treatment followed by distraction
osteogenesis as soon as possible.
After the introduction of intraoral distraction
osteogenesis for lengthening of the mandible,
24
this
procedure was proposed as an alternative to osteot-
omy. In a relatively short period, the use of distrac-
tion in orthognathic surgery has become a common
treatment option. Distraction has allowed new pos-
sibilities for treating dentofacial and craniofacial
deformities. There are several reasons for its popu-
larity in mandibular lengthening. The size of the
mandible can be increased to a greater extent than
can be achieved by conventional surgery. Further-
more, a reduced risk of permanent nerve damage
after intraoral distraction is reported, and soft-tissue
changes during gradual lengthening might positively
inuence the stability of the procedure.
25
The shorter hospital stay and minimal immobiliza-
tion of the jaws after distraction allow patients to
resume daily activities sooner. Patients in groups A and
B were treated in the hospital, even though distraction
in an outpatient setting as a 1-day procedure is possi-
ble.
9,10
Removing the distraction devices is a relatively
easy procedure, comparable to removing third molars.
Mandibular distraction without general anesthesia was
used for mandibular lengthening, but only for adult
patients (M. Y. Mommaerts, personal communica-
tion).
6,7
Results of treatment are important. A report on the
stability of 50 patients after distraction osteogenesis to
lengthen the mandible has recently been published.
26
High-angle patients treated with intraoral mandibular
distraction are still at risk of relapsing. For low-angle
patients, however, distraction is a safe and predictable
procedure. Large mandibular advancements with BSSO
are believed to be more liable to relapse.
27,28
Because
none of the patients who had undergone lengthening of
the mandible by 10 mm or more with distraction
osteogenesis showed any relapse, this technique seems
preferable for patients who need considerable length-
ening of the mandible.
26
In terms of health care economics, the costs of
treatment should be studied. In this study, the costs of
treatment ideally should have been calculated individ-
ually. However, in The Netherlands, individual ortho-
dontic treatment costs are not documented. The costs of
surgical intervention with intraoral distraction have
been compared with the cost of BSSO.
29
Greater
operation time (37% longer for distraction surgery) and
greater cost (the distraction procedure is 36% more
expensive, mainly because of the costs of the distrac-
tion devices) make intraoral distraction for correcting a
mandibular deciency in orthodontic patients with an
Angle Class II malocclusion an expensive and time-
consuming procedure compared with BSSO.
In this study, patients in groups A and B were not
planned for mandibular lengthening at the outset of
treatment. They only underwent surgical treatment
because the orthodontic outcome was not as intended.
Only through prospective studies will evaluation of
new techniques be possible.
CONCLUSIONS
In patients with Class II malocclusions treated with
orthodontic appliances and surgical lengthening of the
mandible, treatment time was inuenced by the appliances
and surgical technique used. Patients treated with head-
gear-activator, xed appliances, and intraoral distraction
osteogenesis (group A) needed signicantly more treat-
ment time compared with patients treated with xed
orthodontic appliances and intraoral distraction (group B)
and xed appliances and BSSO (group C). The duration
of mandibular lengthening with intraoral mandibular dis-
traction (group B) was signicantly shorter compared
with mandibular lengthening with BSSO (group C). How-
ever, no denitive conclusions can be drawn because this
material was studied retrospectively. The best time and the
best surgical procedure for correcting mandibular length
have yet to be determined, and a prospective randomized
trial is recommended.
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