NOTES FROM THE CLINIC
One-stage versus two-stage treatment: Are two really
necessary?
S. Jay Bowman, DMD, MSD
Portage, Mich.
I n the February 1997 Notes from the
Clinic,1 Dr. Gerald Nelson examined the heated
controversy surrounding multiphase and single-
stage treatment. On one hand, the argument typi-
cally consists of aggrieved letters from wet-fin-
gered orthodontists questioning the competency of
academic pencil-pushers who appear bent on de-
manding proof and exposing conflicts of interest. In
effect, these critics echo Professor Marvel in asking
us to pay no attention to that man behind the
curtain. They invariably invoke their 20 years of
experience and successful results and argue that
these should outweigh any findings published on
three or four pages of slick paper. As no supporting
data are required, blind faith is encouraged. A
hearty skepticism is hardly unprofessional, but Dr.
Nelson preferred a refreshingly moderate approach.
Dr. Nelson provided a reasonable rationale for
considering Phase I treatment that is similar to that
recommended by Hays Nance2 in 1947: active
treatment in the mixed dentition period is desirable
only in Class III cases, crossbites, and Class II cases
wherein facial appearance is markedly affected.
These sentiments were more recently reiterated by
Anthony Gianelly,3-7 who estimated that only 9% to
10% of all patients might benefit from Phase I care.
Perhaps in our early treatment criteria, we might
also consider reducing the potential for trauma to
air-cooled protrusive incisors8,9 and openbite clo-
sure.10
Unfortunately, todays trends are to treat earlier
and often, in hopes of providing good things for
small children. In my opinion, the resulting array of
techniques runs the gamut from the refuted (arch
development for the deciduous dentition) to the
patentedly (sic) ridiculous (McAndrews braces for
baby teeth). Can in utero treatment be far off? Most
disturbing is that this trend is occurring without
support in the refereed literature. Rather it is driven
by anecdotal reports from the continuing education
circuit and its proprietary professors. If negative
evidence becomes overwhelming or simply awk-
ward, a new organization or journal (often published
Reprint requests to: S. Jay Bowman, DMD, MSD, 1822 West Milham
Road, Suite 1, Portage, MI 49024-1267
Copyright 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 1 0 8/1/84388
by the sales representatives themselves) can be
counted on to be more supportive.
It has been estimated that at least one third of all
children in orthodontic treatment are in a two-stage
regimen.5 Rozene11 and Ferguson12 share a com-
mon concern that in many practices 100% of young
patients undergo two-phases with the earlier stage
designed preemptively to corral and brand the pa-
tient. It is as if American children are suffering from
SADS, systemic acrylic deficiency syndrome, given
the popularity of housing large chunks of plastic in
youngsters mouths. As Orhan Tuncay13 cautioned
in his piece on unorthodox approaches to health
care, earlier treatment is conveniently recom-
mended when the patient is still growing and still has
money.
Referring dentists seem to favor this approach,
so we invent new words (e.g., orthotropics14 amus-
ingly defined by the American Illustrated Medical
Dictionary as ascending into the abdominal cavi-
ty), we take an oath of nonextraction (wouldnt
you rather have 28 instead of 24 teeth?), and we
advertise the use of new appliances. But we seem
just to be maximizing the minimum gain possible.
You might ask, who is really hurt, given that we will
insert the real braces later anyway?
The goals and benefits of Phase I treatment are
said to be substantial: optimal health and func-
tion,15,16 superior facial esthetics, fewer extractions,
a reduction in the duration and difficulty of subse-
quent therapy, fewer treatment risks, consistent and
predictable elimination of Phase II treatment, im-
proved patient self-concept, fewer treatment risks, a
substitute for orthognathic surgery, results that are
unique, specific, and not possible by traditional
approaches alone, and finally, increased profits.17-22
Each of these items, however, begs risk/reward
analysis: do the benefits of early intervention justify
the costs of two-phase treatment? It is certainly one
thing to suspend disbelief, to embrace such ideals in
practice, or even to promote these concepts on the
circuit, but it is quite another to generate support-
ing research, especially when the results could be
bad for business.
Dugoni20 reports that Phase I treatment (i.e.,
headgear, 2 3 4, and lingual arch) might eliminate a
second course in 60% of cases. A casual reader,
111
112 Bowman American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

Table I. References reporting posttreatment intercanine width nostic records if your diagnosis is always nonex-
traction?29
Investigators Intercanine expansion
One would think that the specialty already had
Walter39 2.0 rejected this approach from the works of Case,
Osborn et al.104 2.0 Tweed, Strang, Begg, Nance, and others of our
Brust59 1.6 ancestors. Over the years, the literature continually
Schwarze43 1.6
Graf and Ehmer106 1.6
has cautioned us to respect mandibular arch dimen-
Ulgen et al.107 1.6 sions (e.g., Bishara et al.30). If we prefer, however, to
Nevant et al.108 1.6 return to Angles precepts of non extraction-at-all-
Katz109 1.5 costs and bone-growing devices, we must be pre-
Grossen and Ingervall110 1.3
Sadowsky et al.111 1.2
pared to address the attendant instability, bimaxil-
Moussa et al.112 1.1 lary protrusions, and iatrogenic periodontal
Sandstrom et al.113 1.1 considerations. If we are determined to repeat his-
Herberger114 1.0 tory, at least we can be comforted that these future
Zeigler115 1.0
Weinberg and Sadowsky116 0.9
failures probably will be better documented this
Adkins et al.117 0.8 time than in the past.
Glenn et al.118 0.6 At first glance, the frequently referenced Uni-
Gardner and Chacones119 0.6 versity of Washington studies of extraction and
Dugoni et al.65 0.6
Welch120 0.5
nonextraction therapies appear to say that every-
Ridzon121 0.5 thing relapses, thereby arguing indirectly against
Bishara et al.48 0.2 extraction. It should be noted, however, that ex-
Kahl-Nieke et al.60 0.1 panded and nonexpanded cases were apparently
Lutz and Poulton45 0.0
mixed in these studies, with no effort to control this
Tulley and Campbell105 0
Elms et al.122 20.1 variable (e.g., rtun et al.31). The problem becomes
Rossouw et al.123 20.2 apparent when the Washington samples are com-
rtun et al.31 20.9 pared with the more stable, deliberately nonex-
panded samples of Boley,32,33 Sandusky,34 St. Louis
University,35,36 and the University of Toronto.37 It
might then be reasonable to credit the lack of
however, might miss some details in the fine print. mandibular intercanine expansion in these samples
For example, 60% may still require some later as one possible reason for the clinically significant
partial bracketing or finishing procedures, not to greater stability.
mention the post-Phase I retention period. The If we examine the considerable corpus of studies
remaining 40% must also undergo comprehensive that have looked at the expansion of mandibular
Phase II, at an additional cost of 25% more than a intercanine width, it may be seen that the residual
single comprehensive phase of treatment. Starnes23 expansion, at best, is only about 2.0 mm (Table I).
invokes the same objective of intercepting Phase II, Only Walter38,39 reported stable long-term expan-
but admits that this is rarely achieved. Indeed, sion, a short 2-years postretention. His findings thus
. . . patients and their families are always advised to contrast with the collective experiences of genera-
expect Phase II treatment. Thus, the goals of tions of nonextraction-at-all-costs orthodontists like
two-phase treatment are pursued, despite the high the young Charles Tweed. Some might say that even
probability of dramatically extended treatment 2.0 mm is better than nothing in comparison with
times and more appointments.20,24 A true believer controls and the attendant normally occurring arch
might also find it inconvenient to mention the long collapse,25,40,41 but what practitioner selects no
transition periods of retention with other devices treatment for patients with crowded teeth? My wife
such as space maintainers, passive plates,20,25 activa- saves me money all the time like this when she shops
tors,26 or bite orthotics23 to reduce the negative at sales at the mall.
outcomes from the early treatment.26-28 Like a moving target (or a mutating pathogen),
Can active early intervention produce specific Angles arch development has simply been re-
and unique results to avoid extractions? Dr. Nelson worked for a new audience in search of less demand-
stated that the relationship between mandibular ing and more popular alternatives to premolar ex-
expansion and long-term instability has not been traction. Despite the descriptions of the dramatic
adequately explored in the contemporary orthodon- instability of mandibular arch development,42-55 we
tic literature. This is tantamount to saying to a tempt fate by continuing to use 19th century expan-
patient that we really dont know, so lets just flip a sion into the 21st century. The millenium will be
coin on this one, Oops, you get four-on-the-floor. new, but the biology will be the same.
Parenthetically, one might ask, why even take diag- In this argument, special note should be given
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
the resurrection of the old German technique of
mixed dentition bimaxillary expansion. The bene-
fits from this technique are said to be profound and
unique (e.g., spontaneous improvement of Class II
and III malocclusions, crowding, airways, and devel-
opment of full pleasing profiles and smiles).25,40,56
Interestingly, molar relationships occasionally self-
correct, and minor mandibular crowding disappears
at the end of transitional dentition without treat-
ment.57,58
For example, during efforts to insure that all
youngsters have the opportunity to acquire nor-
mal maxillary intermolar widths (at least 34 mm) by
means of active maxillary expansion, concurrent and
spontaneous mandibular expansion has been re-
ported.25 This observation led to the active expan-
sion of the mandibular arch (although it was noted
we were reluctant to do so).25 Curiously, it may be
noted that Brust59 found no spontaneity of mandib-
ular intercanine expansion in an examination of this
sort of patient.
No matter, perhaps previously narrow and
now expanded (developed?) maxillae will be more
stable when the mandibles are expanded56 as well.
Perhaps, it is the other way around: possibly man-
dibles will not collapse when maxillae are ex-
panded.25 Perhaps, when a mandibular protraction
device (i.e. Herbst or Twin-Block) is then added, the
labial inclination of mandibular incisors will prove
stable. So far, however, these hypothesized effects
have proven smaller than one might hope.60
Active mandibular arch development might
then be useful for resolving 3 to 4 mm of crowd-
ing.25,40,56 Unfortunately, an evaluation of a sample
of these cases after Phase I revealed that a reported
3 to 4 mm increase of intercanine width already had
collapsed back to 1.6 mm before the placement of
second stage fixed appliances.59
If, however, we accept that a gain of 1.6 mm of
intercanine width is both feasible and potentially
permanent, we are left with the question of whether
this gain is worth the costs of two-phase treatment,
especially if the ultimate goal is to resolve crowding
without extractions? According to Germane et al.61
1.6 mm of expansion translates to only 1.2 mm of
arch length, a sum that might be more easily
achieved by a casually expanded arch wire during a
single-stage of comprehensive treatment or even a
brief and dark encounter with a lightning strip.
These simple procedures stand in stark contrast to
several years worth of fixed and removable expand-
ers followed by holding plates, lingual arches, and
lip bumpers.25 Moreover, resolving 4 to 5 mm of
mandibular crowding is easily within the realm of
conservative and passive space management meth-
ods that require no active first phase of treat-
ment.3-7,62-64 In other words, management of leeway
Bowman 113
space, not active expansion, may be a more efficient
approach to early treatment.
Comparing the relative long-term stability of
arch development versus space management, we
find the two ends of the spectrum (irregularity
indexes of 6.06 mm42 and 2.65 mm,65 respectively).
Adding in the potential iatrogenic effects of expan-
sion58,66-69 and the probability that 50% of all young
Class II patients may benefit from some profile
reduction that can be achieved only by lingual
movement of incisors,6 it appears that, in Tullochs
words, the extravagant claims of eliminating extrac-
tions from resolution of moderate crowding with
orthopedic expansion may be more of a pious hope
than a reality.70 Indeed, expansion can be passed
off as redundant treatment for the more than 75% of
mixed dentition patients who can be treated without
extraction anyway.5,71
Can early active intervention produce specific
and unique results for Class II patients? It is at least
a reasonable suggestion that a treatment designed to
increase the horizontal component of mandibular
growth, rather than limit maxillary development,
may simplify later fixed-appliance treatment. De-
spite a lack of proof, this belief has resurrected
functional jaw orthopedics and given rise to a mul-
titude of appliances, mostly removable, often depen-
dent on patient compliance, and generally requiring
extended dual phase treatment and the requisite
transition periods. Patients probably have only a
limited capacity to cooperate, and dual treatments
that require two phases of compliance as well as
protracted two-stage retention may be more than
many patients can handle.28,72 Interestingly enough,
patient cooperation is not well correlated with the
outcome of early functional treatment73 and the
dose-response relationship for orthopedics is poorly
defined.74 In addition, the University of North Caro-
lina prospective Class II trials have failed to dem-
onstrate that improvement in self-concept (by re-
duction of overjet) is a compelling argument for
early treatment.28,75
Despite the rising popularity of a functional
phase of treatment, the literature contains little
support for the notion that it produces extra
mandibular growth compared with traditional meth-
ods (i.e., headgears and fixed appliance Class II
mechanics).76-83 The majority of growth effects ap-
pear to be more vertical rather than horizontal84 and
often more maxillary than mandibular24,26,27,85; these
findings imply a need to re-evaluate the concept of
growth modification or orthopedics,86,87 especially
with respect to the mandible. This conclusion should
come as no surprise, given that growth is also an
important part of traditional treatment, contributing
effects (orthopedic? functional?) nearly identical to
those of functional appliances.76,78,79,83
114 Bowman
In terms of final results that benefit the end user,
68% of early treatment patients gain at least a 30%
improvement in PAR (Peer Assessment Rating In-
dex) score88 and a 30% rate of phase-II avoidance,89
but at a cost of 18 months of care. These may hardly
be the kind of odds on which to challenge the house,
especially when posttreatment PAR scores for the
final results of one-stage versus two-stage care are
essentially identical.90 Indeed, nearly all types of
Class II treatment are indistinguishable when eval-
uated from the standpoint of posttreatment faces
and occlusions.24,90 In addition, perceived benefits
unique to early functional jaw orthopedics tend to
evaporate over the long term.26,27,84,85,91-96 I would
also argue, therefore, that there seems to be little
reason to initiate growth modification procedures
before the late mixed dentition.5,9,24,85,92,97-99 In any
event, although functional appliances do work,
albeit unpredictably,24,80,90,93,100 their use represents
a practice management decision, not a biological
treatment imperative.101,102
One can almost always find something that
needs to be done early; however, is this necessi-
ty truly the mother of all of our early treatment
inventions? Because we can, doesnt imply we
should. Aggressive treatments predicated on earlier
intervention and non-extraction-at-all-costs are
unsupported by the refereed literature and may be
unnecessary, even detrimental, in the long term. As
Huxley observed, this truly is the great tragedy of
science, the slaying of beautiful hypotheses by ugly
facts. The take-home message is not that all Phase
I treatment is contraindicated, but rather that it may
be unnecessary and detrimental on universal appli-
cation.13,24,103 I would argue that in this decision and
in the debate surrounding it, we would be well
served by reference to the existing literature.
REFERENCES
1. Nelson G. Phase I treatment. Am J Orthod Dentofac Orthop 1997;111:239-40.
2. Nance HN. The limitations of orthodontic treatment. I. Mixed dentition diagnosis
and treatment. Am J Orthod 1947;33:177-223.
3. Gianelly AA. Crowding: timing of treatment. Angle Orthod 1994;64:415-7.
4. Gianelly AA. Leeway space and the resolution of crowding in the mixed dentition.
Semin Orthod 1995;1:118-94.
5. Gianelly AA. One-phase versus two-phase treatment. Am J Orthod Dentofac
Orthop 1995;108:556-9.
6. Gianelly AA. Extraction versus nonextraction. In: Bolender CJ, Bounoure GM,
Barat Y, eds. Extraction versus nonextraction. Paris: SID Publisher; 1995. p.
74-184.
7. White LW. JCO Interviews: Dr. Anthony Gianelly on current issues in orthodon-
tics. J Clin Orthod 1996;30:439-46.
8. Tulloch JFC, Phillips C, Profit WR, Early vs. late treatment of Class II
malocclusion: Preliminary results from the UNC clinical trial. In: Trotman C,
McNamara JA Jr, eds. Orthodontic treatment: outcome and effectiveness, Mono-
graph 30. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and
Development, The University of Michigan; 1995. p. 113-38.
9. Wieslander L. Early or late cervical traction therapy of Class II malocclusion in
the mixed dentition. Am J Orthod 1975;67:432-9.
10. Proffit WR. Open bite: current concepts. John Valentin Mershon Memorial
Lecture, 97th Annual Session of the American Association of Orthodontists,
Philadelphia, 1997.
11. Rozene RF. Comment on the phase I versus phase II treatment and counterpoint
articles. Readers Forum. Am J Orthod Dentofac Orthop 1996;109:17A.
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
12. Ferguson JL Jr. Comment on two-phase treatment. Readers Forum. Am J
Orthod Dentofac Orthop 1996;110:14A-15A.
13. Tuncay O. Unorthodox approaches to health care. Am J Orthod Dentofac Orthop
1993;104:611-3.
14. Mew JRC. Orthotropics natural growth guidance. J Alt Complementary Med
1993;11:8-11.
15. Boyd, R. Can two phase orthodontic treatment be justified for periodontal
reasons? 96th Annual Session of the American Association of Orthodontics,
Denver, Colorado, 1996.
16. Keeling SD, Garavan CW, King GJ, Wheeler TT, McGorry S. Temporomandib-
ular disorders after early Class II treatment with bionators and headgears: results
from a randomized controlled trial. Semin Ortho 1995;1:149-64.
17. Broadbent JM. Facing malocclusion: achieving harmony and balance. Dentistry
Today 1990;August:41-5.
18. Bowbeer GRN. The 6th key to facial beauty and TMJ health. Funct Orthod
1987;4:10-35.
19. Starnes LO. Comprehensive middle mixed dentition (phase I) treatment. Unpub-
lished manuscript, 1996.
20. Dugoni SA. Comprehensive mixed dentition treatment: can it avoid full banded
therapy? [Summary of presentation to annual meeting, September 30, 1996,
Monterrey, California] Pac Coast Soc Orthod Bull 1996;68:33-4.
21. Gugino CF. Zero-based bioprogressive philosophy. Unpublished manuscript.
1997.
22. Grummons D. Transverse dimension nonextraction emphasis. In: Bolender CJ,
Bounoure GM, Barat Y, eds. Extraction versus nonextraction. Paris: SID Pub-
lisher; 1995. p. 150-72.
23. Starnes LO. Dentofacial orthropedics: when and where [Summary of presentation
to annual meeting, November 6, 1995, Los Angeles, California] Pac Coast Soc
Orthod Bull 1996;68:37-8.
24. Livieratos FA, Johnston LE Jr. A comparison of one-stage and two-stage
nonextraction alternatives in matched Class II samples. Am J Orthod Dentofac
Orthop 1995;108:118-31.
25. McNamara JA Jr, Brudon WL. Orthodontics and orthopedic treatment in the
mixed dentition. Ann Arbor: Needham Press; 1993. p. 67-177.
26. Wieslander L. Long-term effect of treatment with the headgear-Herbst appliance
in the early mixed dentition: stability or relapse? Am J Orthod Dentofac Orthop
1993;104:319-29.
27. Pancherz H, Fackel U. The skeletofacial growth pattern pre- and post-dentofacial
orthopedics: a long-term study of Class II malocclusions treated with the Herbst
appliance. Europ J Orthod 1990;12:209-18.
28. Keeling SD, King GJ, Wheeler TT, McGorry S. Timing of Class II treatment:
rationale, methods, and early results of an ongoing randomized clinical trail. In:
Trotman C, McNamara JA Jr., eds. Orthodontic treatment: outcome and
effectiveness, Monograph 30. Craniofacial Growth Series. Ann Arbor: Center for
Human Growth and Development, The University of Michigan; 1995. p. 1-112.
29. White LW. The editors corner: professional incivility. J Clin Orthod 1997;31:
141-2.
30. Bishara SE, Jakobsen JR, Treder J, Nowak A. Arch width changes from 6 weeks
to 45 years of age. Am J Orthod Dentofac Orthop 1997;111:401-9.
31. rtun J, Garol JD, Little RM. Long-term stability of mandibular incisors
following successful treatment of Class II, Division 1, malocclusions. Angle
Orthod 1997;66:229-37.
32. Boley JC. Face quiz study. 92nd Annual Session American Association of
Orthodontists (May 11), 1992.
33. Boley JC. Extraction versus nonextraction: Has the pendulum swung too far?
[Summary of presentation to the Southern Region P.C.S.O. meeting June 1991,
Los Angeles, Califomia] Pac Coast Soc Orthod Bull 1991;63:58-9.
34. Sandusky WC: A long term postretention study of Tweed extraction treatment
[Masters thesis]. Memphis: The University of Tennessee; 1983.
35. Paquette DE, Beattie JR, Johnston LE Jr. A long-term comparison of nonextrac-
tion and premolar extraction edgewise therapy in borderline Class II patients.
Am J Orthod Dentofac Orthop 1992;102:1-14.
36. Luppanapornlarp S, Johnston LE Jr. The effects of premolar extraction: a
long-term comparison of outcomes in clear-cut extraction and nonextraction
Class II patients. Angle Orthod 1993;63:257-72.
37. Franklin GS, Rossouw PE, Woodside DG. A longitudinal study of dental and
skeletal parameters associated with stability of orthodontic treatment. Am J
Ortho Dentofac Orthop 1995;108:452-3.
38. Walter DC. Changes in the form and dimensions of dental arches resulting from
orthodontic treatment. Angle Orthod 1953;22:3-18.
39. Walter DC. Comparative changes in mandibular canine and first molar widths.
Angle Orthod 1962;32:232-40.
40. McNamara JA Jr, Mixed dentition treatment. In: Graber TM, Vanarsdall RL, eds.
Orthodontics: current principles and techniques. St. Louis: Mosby; 1994. p.
507-41.
41. Brust EW, McNamara JA Jr. Arch dimensional changes concurrent with expan-
sion in mixed dentition patients. In: Trotman C, McNamara JA Jr., eds.
Orthodontic treatment: outcome and effectiveness, Monograph 30. Craniofacial
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 113, No. 1
Growth Series. Ann Arbor: Center for Human Growth and Development, The
University of Michigan; 1995. p. 193-225.
42. Little RM, Reidel RA, Stein A. Mandibular arch length increase during the mixed
dentition: postretention evaluation of stability and relapse. Am J Orthod Dento-
fac Ofthop 1990;97:393-404.
43. Schwarze CW. Expansion and relapse in long term follow-up studies. Trans Europ
Orthod Soc, 1972:275-84.
44. Dale JG. Interceptive guidance of occlusion with emphasis on diagnosis. In:
Graber TM, Vanarsdall RL, eds. Orthodontics: current principles and techniques.
St. Louis: Mosby; 1994. p. 291-377.
45. Lutz HD, Poulton DR. Stability of dental arch expansion in the deciduous
dentition. Angle Orthod 1985;55:299-315.
46. Bruno EC. Evaluation of post-retention mandibular arch dimensions following
expansion in the deciduous or early mixed dentition [Masters thesis]. San
Francisco: University of the Pacific, 1990.
47. Peak JD. Cuspid stability. Am J Orthod 1956;42:608-41.
48. Bishara SE, Chada JM, Potter RB. Stability of intercanine width, overbite, and
overjet correction. Am J Orthod 1973;63:588-95.
49. Shapiro PA. Mandibular dental arch form and dimension. Am J Orthod 1974;66:
58-70.
50. Kuftinec MM. Effect of edgewise treatment and retention on mandibular incisors.
Am J Orthod 1975;68:316-22.
51. El-Mangoury NH. Orthodontic relapse in subjects with varying degrees of
anteroposterior and vertical dysplasia. Am J Orthod 1979;75:548-61.
52. Sondhi A, Cleall JF, Begole EA. Dimensional changes in the arches of orthodon-
tically treated cases. Am J Orthod 1980;77:60-74.
53. Little RM, Wallen TR, Reidel RA. Stability and relapse of mandibular anterior
alignment-first premolar extraction cases treated by conventional edgewise ortho-
dontics. Am J Orthod 1981;80:349-65.
54. Uhde MD, Sadowsky C, Begole EA. Long term stability of dental relationships
after orthodontic treatment. Angle Orthod 1983;53:240-52.
55. Glenn G, Sinclair PM, Alexander RG. Non-extraction orthodontic therapy:
post-treatment dental and skeletal stability. Am J Orthod Dentofac Orthop
1987;92:321-8.
56. McNamara JA Jr. Treatment of arch length problems in the mixed dentition.
[Summary of presentation to annual session, September 22, 1992, Honolulu,
Hawaii] Pac Coast Soc Orthod Bull 1992;64:42-4.
57. Hagberg C. The alignment of permanent mandibular incisors in children: a
longitudinal prospective study. Eur J Orthod 1994;16:121-9.
58. Proffit WR, Ackerman JL. Orthodontic treatment planning: from problem list to
specific plan. In: Proffit WR, Fields HW, eds. Contemporary orthodontics, St.
Louis: Mosby; 1993. p. 186-224.
59. Brust EW. Arch dimensional changes concurrent with expansion in the mixed
dentition [Masters thesis]. Ann Arbor: The University of Michigan, 1992.
60. Kahl-Nieke B, Fischbach H, Schwarze CW. Treatment and post retention changes
in dental arch width dimensions in a long-term evaluation of influencing cofactors.
Am J Orthod Dentofac Orthop 1996;109:368-78.
61. Germane N, Lindauer SJ, Rubenstein LK, Rever JH, Issacson RJ. Increase in
arch perimeter due to orthodontic expansion. Am J Orthod Dentofac Orthod
1991;100:421-7.
62. Creekmore TD. Teeth want to be straight. J Clin Orthod 1982;16:745-6.
63. Arnold S. Analysis of leeway space in the mixed dentition [Masters thesis].
Boston: Boston University, 1991.
64. Little RM. Orthodontic stability and relapse. [Summary of presentation to annual
session, November 13, 1991, Phoenix, Arizona] Pac Coast Soc Orthod Bull
1991;63:35-8.
65. Dugoni SA, Lee JS, Varela J, Dugoni AA. Early mixed dentition treatment:
postretention evaluation of stability and relapse. Angle Orthod 1995;65:311-20.
66. rtun J, Krogstad O. Periodontal status of mandibular incisors following excessive
proclination. Am J Orthod Dentofac Orthop 1987;91:255-332.
67. Dorfman HS. Mucogingival changes resulting from mandibular incisor tooth
movement. Am J Orthod 1978;74:286-97.
68. Wennstrom JL. Mucogingival considerations in orthodontic treatment. Semin
Orthod 1996;2:46-52.
69. Steiner CG, Pearson JK, Ainamo J. Changes of the marginal periodontium as a
result of labial tooth movement in monkeys. J Periodontol 1981;52:314-20.
70. Tulloch JFC. Review of early treatment for Class II malocclusions. Prac Rev
Orthod 1995; 7-8(0).
71. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic
clinic. Angle Ortho 1994;64:407-14.
72. Berg R. Post-retention analysis of treatment problems and failures in 264
consecutively treated cases. Eur J Orthod 1979;1:55-68.
73. Ramsay DS. Compliance and technology in orthodontics. The 1996 Moyers
Symposium, Ann Arbor, Michigan, 1996.
74. Tulloch JFC, Proffit WR, Phillips C. Influences on the outcome of early treatment
for Class II malocclusion. Am J Orthod Dentofacial Ortho 1997;111:533-42.
75. Dann C, Phillips C, Broder HL, Tulloch JFC. The relationship between self-
concept, Class II malocclusion and early treatment. Angle Orthod 1995;65:411-6.
76. Gianelly AA, Arena SA, Bernstein L. A comparison of Class II treatment changes
Bowman 115
noted with the lightwire, edgewise, and Frankel appliances. Am J Orthod
1984;86:269-76.
77. Gianelly A, Bronson P, Martignoni M, Bernstein L. Mandibular growth, condyle
position, and Frankel appliance therapy. Angle Orthod 1983;53:131-42.
78. Adenwalla ST, Kronman JA. Class II, division 1 treatment with Frankel and
edgewise appliance: a comparative study of mandibular growth and facial
esthetics. Angle Orthod 1985;55:281-98.
79. Righellis EG. Treatment effects of Frankel, activator, and extraoral traction
appliances. Angle Orthod 1983;53:107-21.
80. Tulloch JFC, Phillips C, Koch G, Profill WR. The effect of early intervention on
skeletal pattern in Class II malocclusion: a randomized clinical trial. Am J Orthod
Dentofac Orthop 1997;111:391-400.
81. Creekmore TD, Radney LJ. Frankel appliance therapy: Orthopedic or orthodon-
tic? Am J Orthod 1983;83:89-108.
82. Johnston LE Jr. A critical evaluation of the functional orthodontic approach to
Class II treatment. [Summary of presentation to annual meeting, September 5,
1993, San Francisco, California] Pac Coast Soc Orthod Bull 1994;66:36-7.
83. Johnston LE Jr. A comparative analysis of Class II treatment methods. In:
McNamara JA Jr, Carlson DS, Vig PS, Ribbens KA, eds. Science and clinical
judgement in orthodontics. Monograph 19, Craniofacial Growth Series, Ann
Arbor: Center for Human Growth and Development, The University of Michigan,
1986:103-48.
84. Nelson C, Harkness M, Herbisson P. Mandibular changes during functional
appliance treatment. Am J Orthod Dentofac Orthop 1993;104:153-61.
85. Pancherz H, Anehus-Pancherz M. The headgear effect of the Herbst appliance: a
cephalometric long-term study. Am J Orthod Dentofac Orthop 1993;103:510-20.
86. White LW. The editors corner: What do you mean by that? J Clin Orthod
1996;30:669-80.
87. Aelbers CMF, Dermaut LR. Orthopedics in orthodontics: Part I, fiction or reality:
a review of the literature. Am J Orthod Dentofac Orthop 1996;110:513-9.
88. Kulbersh VP. Efficacy of early treatment. 97th Annual Session of the American
Association of Orthodontists, Philadelphia, 1997.
89. Bondevik O. Treatment needs following activator-headgear therapy. Angle
Orthod 1995;65:417-22.
90. Ghafari JG. Comparisons of extraoral traction and functional appliance therapy.
97th Annual Session of the American Association of Orthodontists, Philadelphia,
1997.
91. Pancherz H, Hansen K. Occlusal changes during and after Herbst treatment: a
cephalometric investigation. Europ J Orthod 1986;8:215-28.
92. Pancherz H. Etude comparative de traitements precoces et tardifs par bielle de
Herbst: staibilite et recidive Kieferothop 1995;29:21-9.
93. Kyger D. Functional appliance treatment and the timing of facial growth.
Research summary from University of California, Department of Orthodontics.
Pac Coast Soc Orthod Bull 1996;68:48-9.
94. Pancherz H. The nature of Class II relapse after Herbst appliance treatment: a
cephalometric long-term investigation. Am J Orthod Dentofac Orthop 1991;100:220-
33.
95. Pancherz H, Littman C. Morphologie und Lage des Unterkiefers bei der
Herbst-Behandlung. Eine kephalometrische Analyse der Veranderungen bis zum
Wachstumabschlub. Inf Ortho Kieferorthop 1989;21:493-513.
96. DeVincenzo JP. Changes in mandibular length before, during and after successful
orthopedic correction of Class II malocclusions using a functional appliance. Am J
Orthod Dentofac Orthop 1991:99:241-57.
97. McNamara JA Jr, Bookstein FL, Shaughnessy TG. Skeletal and dental changes
following functional regulator therapy on Class II patients. Am J Ortho Dentofac
Orthop 1985;88:91-109.
98. Pancherz H. Treatment of Class II malocclusions by jumping the bite using the
Herbst appliance. Am J Orthod 1979;76:423-43.
99. Wieslander L. Intensive treatment of severe Class II malocclusions with a
headgear-Herbst appliance in the early mixed dentition. Am J Orthod 1984;86:
1-13.
100. Tulloch JFC. Alternative timing for Class II treatment. 971h Annual Session of
the American Association of Orthodontists, Philadelphia, 1997.
101. Livieratos FA. Class II treatment: a comparison of one- and two-stage non-
extraction alternatives. In: Trotman C, McNamara JA Jr, eds. Orthodontic
treatment: outcome and effectiveness, Monograph 30. Craniofacial Growth
Series. Ann Arbor: Center for Human Growth and Development, The University
of Michigan. 1995;163-92.
102. Johnston LE Jr. Functional appliances: a mortgage on mandibular position.
Austral Orthod J 1996;14:154-6.
103. Chate RA. The burden of proof: a critical review of orthodontic claims made by
some general practitioners. Am J Orthod Dentofac Orthop 1994;106:96-105.
104. Osborn WS, Nanda RS, Currier GF. Mandibular arch perimeter changes with lip
bumper treatment. Am J Ortho Dentofac Orthop 1991;99:527-32.
105. Tulley WJ, Campbell AC. A manual of practical orthodontics. 3rd ed. Bristol:
John Wright and Sons; 1960. p. 118.
106. Graf H, Ehmer U., Das Rezidiv der transversalen Erweiterung bei Kompres-
sionen mit frontalem Engstand. Fortschr Kieferorthop 1970;31:175-86.
116 Bowman
107. Ulgen M, Schmuth GPF, Schumacher HA. Dehnung und Rezidiv. Fortscher
Kieferorthop 1988;49:324-30.
108. Nevant CT, Buschang PH, Alexander RG, Steffen JM. Lip bumper therapy for
gaining arch length. Am J Orthod Dentofac Orthop 1991;100:330-6.
109. Katz RA. The long term stability of mandibular arch length and width changes
following rapid maxillary expansion [Masters thesis]. Columbus: Ohio State
University, 1990.
110. Grossen J, Ingervall B. The effect of a lip bumper on lower dental arch dimensions
and tooth positions. Eur J Orthod 1995;17:129-34.
111. Sadowsky C, Schneider B J, BeGole EA. Long-term stability after orthodontic
treatment: nonextraction with prolonged retention. Am J Orthod Dentofac
Orthop 1994;106:243-9.
112. Moussa R, OReilly MT, Close JM. Long-term stability of rapid palatal expander
treatment and edgewise mechanotherapy. Am J Orthod Dentofac Orthop 1995;
108:478-88.
113. Sandstrom RA, Klapper L, Papaconstantiou S. Expansion of the lower arch
concurrent with rapid maxillary expansion. Am J Orthod 1988;94:296-302.
114. Herberger RJ. Stability of mandibular intercuspid width after long periods of
retention. Angle Orthod 1981;51:78-83.
115. Zeigler RL. A longitudinal study of long term posttreatment relapse [Masters
thesis]. Memphis: University of Tennessee, 1995.
American Journal of Orthodontics and Dentofacial Orthopedics
January 1998
116. Weinberg M, Sadowsky C. Resolution of mandibular arch crowding in growing
patients with Class I malocclusions treated nonextraction. Am J Orthod Dentofac
Orthop 1996;110:359-464.
117. Adkins MD, Nanda RS, Currier GF. Arch perimeter changes in rapid palatal
expansion. Am J Ortho Dentofac Orthop 1990;97:194-9.
118. Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy:
Posttreatment dental and skeletal stability. Am J Orthod Dentofac Orthop
1987;92:321-8.
119. Gardner S, Chaconas S. Posttreatment and postretention changes following
orthodontic therapy. Angle Orthod 1976;46:151-61.
120. Welch KN. A study of treatment and post-retention dimensional changes in mandib-
ular dental arches [Masters thesis]. Seattle: The University of Washington, 1965.
121. Ridzon JR. A statistical evaluation of moderate dental arch expansion in
nonextraction orthodontic therapy [Masters thesis]. Cleveland, Case Western
University, 1971.
122. Elms TN, Buschang MA, Alexander RG. Long-term stability of Class II, Division
1, nonextraction cervical face-bow therapy: I. Model analysis. Am J Orthod
Dentofac Orthop 1996;109:271-6.
123. Rossouw PE, Preston CB, Lombard CJ, Truter JW. A longitudinal evaluation of
the anterior border of the dentition. Am J Orthod Dentofac Orthop 1993;104:
146-52.