CASE REPORT

One-phase vs 2-phase treatment for developing

Class III malocclusion: A comparison of identical
twins
Junji Sugawara,a Zaher Aymach,b Hiromichi Hin,c and Ravindra Nandad
Sendai and Nagoya, Japan, and Farmington, Conn

Despite the known inuence of early treatment on the facial appearance of growing patients with skeletal Class III
malocclusion, few comparative reports on the long-term effects of different treatment regimens (1-phase vs
2-phase treatment) have been published. Uncertainty remains regarding the effects of early intervention on
jaw growth and its effectiveness and efciency in the long term. In this case report, we compared the effects
of early orthodontic intervention as the rst phase of a 2-phase treatment vs 1-phase xed appliance treatment
in identical twins over a period of 11 years. Facial and dental changes were recorded, and cephalometric super-
impositions were made at 4 time points. In spite of the different treatment approaches, both patients showed
identical dentofacial characteristics in the retention phase. Through this case report, we intended to clarify the
benets of undergoing 1-phase treatment against 2-phase treatment protocols for treating growing skeletal
Class III patients. (Am J Orthod Dentofacial Orthop 2012;141:e11-e22)

I
n the treatment of skeletal Class III growing patients, it
has become a common practice to intervene early with
orthodontic or orthopedic treatment modalities as
a part of a 2-phase treatment approach. This approach
is claimed to provide early and signicant improvement
in the facial prole, require fewer surgical interventions
in the future, and produce signicant psychosocial bene-
ts for the patient as well as the parents.1-3 Although
orthopedic forces that attempt to control or alter the
skeletal framework in skeletal Class III patients appear to
be remarkably effective in the initial stages, the results
are rarely maintained in the long term.4,5 Previously, we
presented a clinical practice guideline for the treatment
of developing Class III malocclusions (Fig 1).6,7 However,
it is still difcult to decide whether a 2-phase treatment
is actually better than a 1-phase treatment, especially in
a
Chief orthodontist, skeletal anchorage system orthodontic center; clinical pro-
fessor, Division of Maxillofacial Surgery, Tohoku University, Sendai, Japan.
b
Lecturer and assistant researcher, Division of Maxillofacial Surgery, Tohoku
University, Sendai, Japan.
c
Private practice, Nagoya, Japan.
d
Professor and head, Department of Craniofacial Sciences, Division of Orthodon-
tics, University of Connecticut, Farmington.
The authors report no commercial, proprietary, or nancial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Ravindra Nanda, Division of Orthodontics, School of Dental
Medicine, University of Connecticut Health Center, Farmington, CT 06030-1725;
e-mail, nanda@uchc.edu.
Submitted, April 2011; revised and accepted, May 2011.
0889-5406/$36.00
Copyright 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.05.023
light of mounting evidence that patients with a skeletal
Class III malocclusion show neither excessive mandibular
growth nor decient maxillary growth when compared
with Class I subjects at any growth stage.8 Therefore, the
key question is what differences in jaw growth or
treatment modality and outcome will there be between
patients who undergo 1-phase treatment and those who
dont? This twin study allowed us to elucidate some
benets of 1-phase treatment rather than waiting until
the postadolescent period.
DIAGNOSIS AND ETIOLOGY
The patients, monozygotic twin sisters (Fig 2), were
referred to our department at Tohoku University, Sendai,
Japan, in 1996 when they were 9 years old for orthodon-
tic treatment of anterior crossbites. Their medical histo-
ries showed no systemic diseases or developmental
anomalies. Not surprisingly, both twins had almost the
same orthodontic problems that included a prognathic
prole, mild mandibular asymmetry, Class III denture
bases, deviation of mandibular midlines, and occlusal in-
terference of the incisors (Fig 3). Cephalometrically, their
skeletofacial types were classied as Class III short-face
types. The short-face tendency was more pronounced
in Patient 2 (Fig 4).
TREATMENT OBJECTIVES
Class III short-face skeletofacial types are considered
to have a good prognosis, because their mild jaw
e11
e12 Sugawara et al

Fig 1. Clinical practice guideline for the treatment of a developing Class III malocclusion. Obs, Observation.

Fig 2. Pretreatment facial photographs of the twins.

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Sugawara et al
Fig 3. Pretreatment intraoral photographs of the twins.
disharmony allows downward and backward rotation of
the mandible for correction of the anterior crossbite and
deepbite and, therefore, are good candidates for a treat-
ment plan involving 2 phases. This includes correction of
the anterior crossbite in the rst phase followed by a pe-
riod of growth observation and then a second phase of
treatment with xed appliances. In light of our previous
discussion regarding early intervention on jaw growth,
the treatment objectives for Patient 1 were established
with the 2-phase treatment approach, whereas Patient
2 was managed with a 1-phase treatment concept. In-
formed consents were obtained for both patients from
their parents.
American Journal of Orthodontics and Dentofacial Orthopedics
e13
The treatment objectives for Patient 1 were (1) phase
1 treatment involving dental correction of the anterior
crossbite, (2) growth monitoring and oral health care un-
til the postadolescent period, (3) xed appliance treat-
ment for correction of the remaining orthodontic
problems, and (4) retention and long-term follow-up.
For Patient 2, the treatment objectives were (1) growth
monitoring and oral health care until the postadolescent
period, (2) correction of the malocclusion with xed appli-
ance treatment together with skeletal anchorage that
would allow us to circumvent the need for mandibular
premolar extraction, and (3) retention and long-term
follow-up.
January 2012  Vol 141  Issue 1
e14 Sugawara et al

Fig 4. Skeletofacial types developed from the cephalometric analyses for the twins. They were judged
as skeletal Class III short face. Note that the short-face tendency was more pronounced in Patient 2.

Fig 5. Timing intervals of the comparisons of treatment progress and results. MIP, Maxillary incisors
protractor; MBS, multi-bracketed system; SAS, skeletal anchorage system.

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Sugawara et al
Fig 6. The twins at the initial time. Their dentofacial proles were almost identical.
TREATMENT ALTERNATIVES
Because the twins were skeletal Class III growing pa-
tients, growth modication treatments and functional ap-
pliances could be alternatives, but they were not included
with our options for the reasons previously mentioned.
Treatment alternatives in the postadolescent phase
could have included conventional camouage treatment
American Journal of Orthodontics and Dentofacial Orthopedics
e15
with a multi-bracketed system and premolar extractions
together with Class III elastics. This approach would im-
prove the Class III occlusion, but it would undermine
esthetics, resulting in a more protruded chin and con-
cave prole. Orthognathic surgery is also a viable option
for improving function, occlusion, and esthetics; how-
ever, our patients rejected surgery as an option.
January 2012  Vol 141  Issue 1
e16 Sugawara et al

At this stage, we superimposed the cephalometric ra-

Table I. Lateral cephalometric measurements (initial,
diographs from 9 and 16 years of age based on the nat-
age of 9) with standard deviations from norms
ural reference structures suggested by Skieller et al9 and
Patient 1 Patient 2 Bjork and Skieller.10 Cephalometric tracings were made
SNA 79.6 ( 0.4) 79.0 ( 0.6) in detail and superimposed carefully. In Patient 1, the
SNB 79.8 (1.3) 80.0 (1.3) superimposition showed correction of the anterior cross-
ANB 0.2 (0) 1.0 (0)
bite, with a signicant amount of jaw growth. However,
Mandibular plane to SN 34.6 ( 0.8) 35.4 ( 0.8)
Gonial angle 127.0 ( 0.5) 125.2 ( 0.8) the amount of jaw growth from 13 to 16 years of age was
U1 to SN 93.6 ( 1.7) 89.4 ( 2.4) negligible. In Patient 2, the cephalometric superimposi-
L1 to mandibular plane 85.8 ( 1.4) 79.1 ( 2.5) tions showed that the maxilla and the mandible had sig-
L1 to U1 149.9 (2.8) 156.1 (4.0) nicant amounts of downward and forward growth
Wits 6.5 mm 7.7 mm
during the adolescent growth period. Her overbite had
N-Me 105.1 mm ( 1.1) 104.0 mm ( 1.4)
N-ANS 47.5 mm ( 0.7) 46.0 mm ( 1.3) improved over time.
ANS-Me 58.2 mm ( 1.4) 58.6 mm ( 1.3) To correct the rest of Patient 1's orthodontic prob-
lems, preadjusted xed appliance treatment was started,
and short Class III elastics were used to improve the Class
III denture bases and prevent proclination of the man-
TREATMENT PROGRESS dibular incisors during leveling and aligning. Treatment
Although a 1-phase treatment protocol was chosen for Patient 2 started with bonding brackets on the man-
for Patient 2, there was no denitive treatment until dibular teeth and placing resin caps on the maxillary mo-
growth completion was conrmed. In Patient 1, the lars to open the bite for maxillary bonding. Open-coil
rst phase of treatment began with facemask therapy springs were used to make space and procline the max-
and 2 3 4 appliances. The aim was to correct her an- illary incisors. Simultaneously, distalization of the man-
terior crossbite dentally, not skeletally. The crossbite dibular posterior teeth was started with the skeletal
and maxillary dental midline shift were corrected in 6 anchorage system, which uses an orthodontic miniplate
months. as a temporary anchorage device.11 Within several
At the age of 10 and after the rst phase of treat- months, her anterior crossbite was completely corrected,
ment, Patient 1's prognathic prole and dental maloc- and the distalized mandibular posterior teeth were re-
clusion had improved signicantly. At the same time, tained with the help of ligature wires connected to the
growth observation in Patient 2 showed that all her miniplates.
orthodontic problems were exactly as they had been After 12 months of active xed appliance treatment,
at the initial examination. At age 13, both twins had Patient 1's malocclusion was corrected. She obtained
completed their permanent dentitions. Patient 1 had a balanced prole, with adequate overjet and overbite,
maintained a positive overjet and overbite after the proper anterior guidance, and rigid posterior intercuspa-
rst phase of treatment, whereas Patient 2 showed tion of the teeth. On the other hand, Patient 2's treat-
a slight improvement in her deepbite without ortho- ment with the skeletal anchorage system lasted 18
dontic intervention. Both sisters had the possibility months. She also achieved an acceptable Class I occlu-
of postpubertal growth of the mandible; therefore, sion and a satisfactory prole at debonding.
we decided to elongate the growth observation period The dentofacial changes during the second phase of
until 16 years of age as per our clinical practice guide- treatment were minimal in Patient 1; only the uprighting
lines.6,7 of the mandibular molars was observed. On the other
Before the second phase of treatment, Patient 1 still hand, the cephalometric superimposition in Patient 2
had a prognathic prole, with some minor dental prob- before and after treatment with the skeletal anchorage
lems, particularly in the mandibular dentition. She had system showed that her anterior crossbite was largely
a lateral crossbite on the right side, a mild Class III den- corrected by proclination of the maxillary incisors and
ture base, and mild mandibular incisor crowding. At the clockwise rotation of the mandible, causing extrusion
same stage, Patient 2 demonstrated more severe ortho- of her maxillary and mandibular molars. The mandibular
dontic problems than her sister did at this age. She had molars were slightly distalized, and the retroclination of
a skeletal Class III malocclusion with a short-face ten- her mandibular incisors was improved purely by lingual
dency, premature contact at the incisors, a dental mid- root torque. After 30 months of retention, both twins
line shift, an anterior crossbite, severe crowding of the have maintained a good occlusion except for a minor re-
maxillary anterior teeth, and retroclined mandibular lapse of the maxillary right rst premolar in Patient 2.
incisors. Overall, satisfactory results were achieved.

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Sugawara et al e17

Fig 7. Signicant dentofacial differences were observed at the age of 10. After the rst phase of me-
chanics in Patient 1, her anterior crossbite was corrected after the aring of her maxillary incisors, the
forward displacement of the maxilla, and the clockwise rotation of the mandible. Consequently, her
skeletal facial type became much closer to a Class I average face.

COMPARISON OF TREATMENT PROGRESS AND 1. The initial examination was at age 9 years. Because
RESULTS IN THE TWINS they are monozygotic twins, it is no surprise that
The cephalometric and clinical comparisons of the even their dentitions were almost identical. Cephalo-
twin sisters took place at 4 time intervals (Fig 5). metrically, although Patient 2's short-face tendency

American Journal of Orthodontics and Dentofacial Orthopedics January 2012  Vol 141  Issue 1
e18 Sugawara et al

Fig 8. Skeletal differences between the sisters at 10 years old gradually disappeared during the puber-
tal growth period, and almost no difference was observed between their skeletal proles at age 16
years. The only difference was in the position of Patient 1's maxillary incisors; this was an orthodontic
effect from the facemask. Before 2nd Phase Tx, After the rst phase of treatment (ie, facemask ther-
apy); Before ortho. Tx, after growth observation only (no interceptive treatment was done).

was a little more pronounced than her sisters, their
dentofacial proles were almost identical (Fig 6;
Table I).
2. After Patient 1's rst phase of treatment (age, 10
years), the clinical pictures clearly show the efciency
of early intervention for her. Cephalometric superim-
position shows signicant dentofacial differences
between the sisters at this stage. Patient 1's crossbite
was corrected by proclinatoin of her maxillary inci-
sors, forward displacement of the maxilla, and

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Sugawara et al e19

Fig 9. The twins in the retention period. Interestingly, although they underwent orthodontic treatment at
different times and with different modalities, their dentofacial morphologies and skeletofacial types at
the nal records were identical.

clockwise rotation of the mandible. This gave her an
orthognathic facial prole compared with Patient 2
(Fig 7).
3. Before xed appliance treatment (age, 16 years), the
skeletal differences between them at 10 years
gradually disappeared during the pubertal growth
spurt, and almost no difference could be observed
between their skeletal proles at 16 years. The
only difference perhaps was in the position of the
maxillary incisors. The orthodontic effect of the
facemask could still be seen on Patient 1's maxillary
incisors (Fig 8).
4. During the retention period (age, 20 years), we
superimposed the twins nal records. Interestingly,

American Journal of Orthodontics and Dentofacial Orthopedics January 2012  Vol 141  Issue 1
e20 Sugawara et al

Table II. Lateral cephalometric measurements (nal,

age of 20) with standard deviations from norms
Patient 1 Patient 2
SNA 81.1 ( 0.7) 82.0 ( 0.4)
SNB 78.8 ( 0.3) 80.2 (0.3)
ANB 2.3 ( 0.9) 1.8 ( 1.2)
Mandibular plane to SN 37.1 (0.1) 36.4 ( 0.1)
Gonial angle 122.0 ( 0.8) 122.9 ( 0.6)
U1 to SN 107.8 (0.6) 112.6 (1.5)
L1 to mandibular plane 91.7 (0.2) 92.7 (0.4)
L1 to U1 123.4 ( 0.6) 118.2 ( 1.2)
Wits 1.4 mm 2.7 mm
N-Me 123.3 mm (1.0) 121.8 mm (0.4)
N-ANS 52.8 mm ( 0.8) 52.3 mm ( 1.0)
ANS-Me 71.4 mm (2.8) 70.4 mm (2.3)

although they underwent orthodontic treatment

with completely different treatment regimens
(1-phase vs 2-phase), their dentofacial morphol-
ogies were identical (Fig 9; Table II).

DISCUSSION
The advantage of using monozygotic twins in such
a comparative case report is that all differences in skeletal
growth, beyond the error of measurement, can be assumed
to be nongenetic and, therefore, the result of the environ-
ment.12,13 The most powerful oral environmental inuence
for the twins was the treatment itself. Mandibular growth
can be controlled with chincup therapy, by altering the
skeletal framework of growing Class III patients. Our
studies on the short-term and long-term effects of chin-
cup force indicated that the skeletal framework is greatly
improved during the initial stages of chincup therapy.4,5
However, these changes are rarely maintained during the
pubertal growth period; when growth is over, any
treatment with the chincup appliance seldom alters the
inherited prognathic characteristics of Class III proles.
The second relevant area to review is jaw surgery. Our
longitudinal studies have given us every reason to believe
that surgical orthodontic treatment is the most effective
modality to obtain a favorable prole and a stable occlu-
sion for severe adult skeletal Class III patients.14,15 Third,
we need to look back at what we knew then about jaw
growth. Our group had conducted some longitudinal
studies with untreated Class III subjects.16-20 It was
shown that those with skeletal Class III malocclusion
showed neither excessive mandibular growth nor
decient maxillary growth when compared with Class I
subjects at any growth stage. Meanwhile, patients with
severe skeletal Class III malocclusionie, those who are
indicated for future orthognathic surgeryreceive no
treatment for their dental malocclusion until the end
of the pubertal growth spurt. It is important to
Fig 10. A, Maxillary growth changes of the twins from
ages 9 to 18. Patient 1, who had the rst phase of treat-
ment, showed more maxillary growth than did Patient 2
until they turned 14, but no difference in maxillary lengths
was observed at 18 years of age. B, Mandibular growth
changes of the twins from ages 9 to 18. Obviously, there
was almost no difference between them in mandibular
growth throughout the various growth periods. (Green
and yellow lines represent the average growth changes
of untreated Class I and Class III Japanese teenagers
from ages 9 to 14 years taken from longitudinal data.16-21)
collect growth data from a patient to establish
an individual growth data base for determining the
timing of orthognathic surgery, to continuously provide
psychosocial care, and to professionally control oral
hygiene during the long-term observation period.
Nevertheless, when a patient is diagnosed with severe
skeletal Class III, phase 1 treatment is recommended. Ac-
cording to the clinical practice guidelines that we have
set for managing Class III malocclusions, we believed
that 2-phase treatment was the most benecial for
growing patients diagnosed with mild to moderate Class
III jaw relationships, such as the twins.

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Sugawara et al
We also looked at the maxillary growth changes that
occurred from ages 9 to 18 years for the sisters. Patient 1,
who had 2-phase treatment, showed more maxillary
growth than did Patient 2 until they turned 14. However,
no difference in maxillary lengths was observed at 18
years of age. Consequently, early correction of the ante-
rior crossbite had no impact on maxillary growth. Simi-
larly, there was almost no difference between the twins
in their mandibular growth throughout the observation
period (Fig 10).
Recent clinical trials have suggested that in the long-
term the improvement in the skeletal malocclusion ob-
tained after a rst phase of treatment is not signicant
when compared with a control group that had no growth
modication treatment.21,22 It has also been suggested
that early intervention does not seem to confer
a signicant psychosocial benet.3 The rst phase of
treatment for Patient 1 was effective, in that her dento-
facial and functional problems were improved consider-
ably, and were much better than her sisters. Signicant
differences were observed between their skeletal proles
at age 10. Nevertheless, their skeletal differences gradu-
ally diminished during the pubertal growth period to the
point that there was almost no difference in their skeletal
proles at age 16. It was obvious that the early correction
of the anterior crossbite did not make a positive impact
on jaw growth. It seems that morphogenetic factors are
still stronger and much more dominant than environ-
mental factors in the matter of jaw growth.
Interestingly, despite the differences of treatment
timings and modalities, the twins achieved almost
identical dentofacial proles, and both had favorable
occlusions at age 18. Patient 2 who was managed with
a 1-phase treatment, had to undergo treatment with
the skeletal anchorage system. The skeletal anchorage
system is a viable modality for distalizing mandibular
molars.23,24 It enables en-masse movement of the
mandibular buccal segments and even the entire man-
dibular dentition with only minor surgery for placing
the anchor plates at the anterior border of the mandib-
ular ramus or the mandibular body. It is particularly ef-
fective for correcting Class III malocclusions, mandibular
incisor crowding, and dental asymmetries, and rarely
requires the extraction of premolars. Without the
skeletal anchorage system, this twin study would not
have been possible, and such results could not have
been obtained.
CONCLUSIONS
1. In spite of the differences in treatment timing and
modalities (1-phase vs 2-phase treatment), both
twin sisters achieved almost identical dentofacial re-
American Journal of Orthodontics and Dentofacial Orthopedics
e21
sults. This implies that early treatment had no im-
pact on jaw growth in the pubertal growth period.
2. Although phase 1 treatment had no impact on jaw
growth, it made the phase 2 treatment simpler
and easier. Therefore, 2-phase treatment might be
more suited for mild to moderate Class III patients
than 1-phase treatment.
3. The criteria for the selection of 1-phase or 2-phase
treatment depend entirely on the patients require-
ments. Because the biologic outcome is the same,
the basis for opting for a particular treatment regi-
men can be complicated. Cultural, environmental,
and psychosocial factors need to be considered
more carefully.
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