ROTH PHILOSOPHY

02R07

Cases Requiring Early Treatment

Early treatment is not necessary for every case, but prompt intervention is recommended in the following situations:

• When treatment would become difficult if delayed
• When leaving the condition untreated places a significant burden on masticatory function or the TMJs

In particular, when there is an abnormality in the positional relationship between the maxilla (upper jaw) and mandible (lower jaw), we aim to intervene during the early growth phase (around ages 6 to 9). Specific case examples will be presented to illustrate when early intervention is necessary.

[7 years and 5 months]
[Face]The patient sustained a blow to the lower jaw around age 4. The mandible (lower jaw)is shifted to the left, and the chin is significantly deviated to the left.[Intraoral]The midline of the lower anterior teeth is shifted to the left. There is an anteroposterior and vertical discrepancy between the upper and lower anterior teeth, along with a slight open bite.

As initial treatment, a splint was fitted to the mandible to stabilize its position and promote normal growth.

[After 1 year and 6 months of splint therapy]
[Face] The leftward deviation of the chin has improved and is no longer noticeable. [Intraoral] The dental midlines are now nearly aligned, and the open bite has improved.

The only treatment performed was the use of a jaw-stabilization splint; no individual tooth movement was carried out. In this way, we create conditions that support normal growth. Splint wear is continued (with reduced wear time) until the start of Phase II treatment.

[14 years and 10 months]
n Phase II, orthodontic treatment was performed without extractions.

Cephalometric X-ray

Following splint therapy, the deviation of the chin to the left has improved. The lengths of the mandibular rami are now nearly equal on both sides.

Following splint therapy, the deviation of the chin to the left has improved. The lengths of the mandibular rami are now nearly equal on both sides.

Summary

• This approach to early treatment helps:
• effectively utilize the body’s natural growth potential
• increase the likelihood of guiding mandibular growth in a favorable direction
• prevent the condition from becoming more severe and increase the likelihood that standard orthodontic treatment will be sufficient.

[6 years 4 months]
Although the patient appears normal at first glance, she had a subconscious habit of protruding the jaw forward (until the upper and lower teeth made firm contact) when biting. [TMJ CBCT Images] The condyles are significantly displaced forward from the glenoid fossae (a condition known as posturing).

Since this condition deeply affects future growth, detailed examination and diagnosis—including assessment of the TMJs—are essential. In particular, MRI is necessary to assess the state of disc displacement in the TMJs. During the growth spurt, our goal is to maximize mandibular growth.

[After 1 year of splint therapy]
During mandibular position assessment, her true mandibular position was identified. [TMJ CBCT Images] The condyles were seated in the glenoid fossae. [Face] In this jaw position, the mandible (lower jaw) and chin were retruded. An anteroposterior gap was formed between the upper and lower anterior teeth.

She continued to wear the splint (primarily at night) until transitioning to Phase II treatment involving tooth movement. Our aim was to proceed with the treatment while paying close attention until the very end to keeping the condyles seated in the glenoid fossae.

[16 years and 1 month / After 2 years and 9 months of orthodontic treatment]
[Face] The mandible (lower jaw) continued to grow during treatment, and the chin moved forward significantly, resulting in a balanced facial profile. [Intraoral] The anteroposterior gap between the upper and lower anterior teeth was resolved, achieving a stable dental alignment.

By utilizing the premolar extraction spaces and the growth mechanics promoting counterclockwise rotation of the mandible, we aimed for a synergistic effect with the growth spurt, resulting in further favorable mandibular growth.

Although the mandible (lower jaw) was repositioned posteriorly during splint therapy, it is evident that the mandible subsequently grew significantly with counterclockwise rotation. This demonstrates how the process of stabilizing the jaw position (splint therapy) led to such substantial mandibular growth afterward.

Summary

• The TMJs were stabilized with a splint in preparation for the growth acceleration phase.
• Emphasis was placed on maximizing mandibular growth.
• Accurate diagnosis and a treatment plan with clearly defined goals are essential.

[10 years and 3 months]
The patient presented to our clinic while undergoing Phase I treatment elsewhere. [Intraoral] The lower anterior teeth protruded forward, covering the upper anterior teeth. [Face] At first glance, the mandible (lower jaw) appears protruded; however, upon closer inspection, rather than the mandible being significantly protruded, the maxilla (upper jaw) appeared retruded or underdeveloped. Because the area around the ala of the nose was retruded, the mandible appeared to be protruding.

The growth patterns of the maxilla and mandible differ; maxillary growth is largely complete by around age 12, while mandibular growth continues thereafter (with some variation between sexes). The window for guiding maxillary growth forward is generally between the ages of 5 and 10. In this patient, who was already 10 years and 3 months old, prompt intervention was necessary.

As an initial treatment, the maxillary sutures were loosened, followed by protraction of the maxilla. Splint therapy was performed simultaneously to correct the instability of the mandibular position while providing functional stimulation to the maxilla to promote growth. This approach stabilized the occlusion and protected the TMJs from sudden changes in the occlusion relationship. Consequently, both the occlusal relationship between the upper and lower anterior teeth and the skeletal relationship between the maxilla and mandible were improved.

Mandibular growth was monitored until growth was nearly complete. Phase II treatment was initiated at age 15 to align the teeth (treatment duration: 1 year and 7 months).

The area around the ala of the nose was advanced forward, and the cheeks appeared fuller.

As a result of guiding the maxilla (upper jaw) to grow forward, a significant improvement was achieved in the facial profile. Before treatment, the facial appearance resembled that of an elderly person who had lost teeth; after treatment, it transformed into a fuller and more youthful facial appearance.

Summary

The timing of orthodontic treatment varies by case, and early intervention is essential when skeletal discrepancies are present. Treating during this early period allows us to guide growth and expand treatment options.

Although attention tends to focus on the maxilla in such cases, it is equally important to monitor the mandible (lower jaw) to ensure that it grows normally. Regardless of when orthodontic treatment is performed, we first conduct comprehensive examinations and diagnoses that include the TMJs to fully understand the patient’s condition. We then provide the appropriate treatment at the optimal time—treatment that can only be performed at that specific stage—and proceed with tooth alignment in Phase II. Until then, our primary focus is on monitoring jaw growth.

One important consideration in patients with anterior crossbites is that those with a large mandible may exhibit excessive mandibular growth compared to average growth patterns; in such cases, surgical intervention may need to be considered.