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ORIGINAL ARTICLE
Year : 2018  |  Volume : 36  |  Issue : 2  |  Page : 206-212
 

Early treatment of pseudo-class III malocclusion with modified swallowing occlusal contact intercept appliance (S.O.C.I.A.)


Department of Clinical and Experimental Medicine, School of Dentistry, University of Foggia, Italy

Date of Web Publication2-Jul-2018

Correspondence Address:
Domenico Ciavarella
Via Rovelli, 50, 71122 Foggia
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_83_17

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   Abstract 


Aims: The aim of the present work was to evaluate the dentoskeletal effects of swallowing occlusal contact intercept appliance (SOCIA) III in pseudo Class III malocclusion treatment. Materials and Methods: Thirty-six patients (mean age: 9.46 years old) with pseudo-Class III malocclusion and 22 pseudo-Class III untreated controls (mean age: 8.7 years old) were selected and examined. All patients presented with a cervical stage CS2, CS3, or CS4. Patients with CS5 were not enrolled in the study. Cephalometric analysis was performed before phase 1 treatment (T1) and immediately following phase 2 treatment (T2). Statistical Analysis: Paired t-test and independent t-test. Results: SOCIA III had skeletal and dental effects. The main effects of SOCIA III were on the midface with an effective increase of the sagittal growth (cranial base P < 0.001, anterior cranial base (ACB) P < 0.001, and maxilla growth P < 0.001) and vertical growth (anterior facial height P < 0.001). The effects of SOCIA on the mandible were a control of mandibular postrotation (P = 0.82) and the sagittal growth (P < 0.007). At the end of the treatment, a normal overjet was achieved (P < 0.001). Conclusions: The SOCIA III effects are resumed as follow: (a) an effective maxillary sagittal increase on the sagittal plane; (b) a vertical mandibular control; (c) a resolution of overjet; (d) no increase of overbite; (e) a stimulation of ACB growth.


Keywords: Functional appliance, pseudo-class III malocclusion, swallowing occlusal contact intercept appliance


How to cite this article:
Ciavarella D, Mastrovincenzo M, Tepedino M, Laurenziello M, Guida L, Montaruli G, Troiano G, Muzio LL. Early treatment of pseudo-class III malocclusion with modified swallowing occlusal contact intercept appliance (S.O.C.I.A.). J Indian Soc Pedod Prev Dent 2018;36:206-12

How to cite this URL:
Ciavarella D, Mastrovincenzo M, Tepedino M, Laurenziello M, Guida L, Montaruli G, Troiano G, Muzio LL. Early treatment of pseudo-class III malocclusion with modified swallowing occlusal contact intercept appliance (S.O.C.I.A.). J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Jul 22];36:206-12. Available from: http://www.jisppd.com/text.asp?2018/36/2/206/235688





   Introduction Top


Class III malocclusion is a condition characterized by an inverse relationship between maxilla and jaw.[1] The prevalence of angle Class III malocclusion varies among the populations ranging from 0% to 26%.[2] An alteration of the facial profile with a concave profile caused by a deficiency of the facial middle third is often observed.[3] Tweed classified Class III malocclusion into two categories: Category A was defined as a pseudo-Class III malocclusion with a conventionally shaped mandible, and Category B was defined as a skeletal Class III malocclusion with a large mandible or an underdeveloped maxilla.[4] A pseudo-Class III malocclusion is characterized by the presence of an anterior crossbite due to a forward functional displacement of the mandible. In this type of malocclusion, the upper incisors are palatally inclined whereas the mandibular incisors are labially proclined and with diastemas.[5]

Many type of treatment are suggested in dental literature for the treatment of Class III malocclusion and pseudo-Class III malocclusion such as rapid maxillary expansion with face mask (RME/FM),[6] reverse twin block and FM,[7] FM therapy with alternate RME and constriction (Alt-RAMEC) protocol,[8] the Eschler appliance with chin cup,[9] and orthodontic-surgical treatment at the end of growth.[10]

In the present paper, authors showed the dentoskeletal effects of swallowing occlusal contact intercept appliance (SOCIA) III in pseudo-Class III malocclusion treatment.


   Materials and Methods Top


Thirty-six patients (mean age: 9.46 years old) with pseudo-Class III malocclusion and 22 control patients (mean age 8.7 years old) were selected and examined. The control group was composed of age-matched untreated pseudo-Class III patients. The participants and their parents provided written informed consent to be involved in the study.

Inclusion criteria were ANB <0°; overjet mm 0, pseudo-Class III relationship, anterior crossbite or edge to edge incisor contact, medial step type deciduous molar relationship,[11] late mixed or permanent dentition, and adequate growth potential. The growth potential was evaluated using the cervical vertebral maturation method. All patients presented with a cervical stage CS2, CS3, or CS4. Patients with CS5 were not enrolled in the study.

Exclusion criteria included Class II malocclusion, crossbite, bilateral crossbite, oral or systemic diseases, missing teeth, congenital malformations, CS5 step, and previous orthodontic treatment.

Pre and posttreatment records included maxillary and mandibular dental casts, photographs, panoramic radiograph, and a lateral head film (Gendex GXDP-700). Head films were taken with the patients' head held with a cephalostat, in centric occlusion, with adequate visualization of reference structures, and no appreciable rotation of the head. Cephalometric analysis was performed before phase 1 treatment (T1) and immediately following phase 2 treatment (T2). Landmarks are shown in [Figure 1]. Twelve dentoskeletal parameters were evaluated: Two about the vertical growth, five about the sagittal growth, and five of dental position. The sagittal data collected were about the effects of SOCIA III on the maxillary-mandibular relation and on the anterior cranial base (ACB). To calculate the error of the method, cephalometric radiographs were selected randomly and reanalyzed 30 days later by the same examiner (B. G. and M. M.).
Figure 1: Cephalometric landmarks and measurements

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The swallowing occlusal contact intercept appliance

SOCIA appliances were custom made for each patient by a dental technician. Acrylic components consisted of a palatal body with a 60° tilted lingual plane with respect to an occlusal plane ending with a hole near the palatal spot, and a vestibular pad set 4.0 mm buccally to the deciduous molars with metallic posterior bite-blocks embedded in them. The vestibular components were attached using a 1.0 mm labial wire running adjacent to the dentition and a 1.1 mm diameter wire crossing the occlusal plane and ending in the palatal acrylic body. The SOCIA III [Figure 2] had no dental retention and was held in place solely by stimulation of the masticatory muscles.
Figure 2: Swallowing Occlusal Contact Intercept Appliance III appliance. (a) Upper view; (b) lower view; (c) right intraoral view; (d) frontal intraoral view; (e) left intraoral view

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The patients were instructed to wear the SOCIA for 16 h/day, during the night and afternoon, removing it only to eat and brush. Active treatment lasted 24 months for all patients.

Statistical analysis

For each of the two groups, a paired sample t-test was performed (GraphPad Prism version 6.04 for Windows, GraphPad Software, La Jolla California, USA) to compare the T1 and T2 dentoskeletal cephalometric values to evaluate if any statistically significant difference was present. Then, the T2–T1 difference for every variable was calculated for both SOCIA and control group, and an independent samples t-test was used to evaluate any statistically significant difference between the two groups. The first type error was set as P < 0.05.


   Results Top


The effect of the SOCIA III was evaluated after 24 months of treatment as well as the matched control group [Table 1], [Table 2], [Table 3]. SOCIA III had skeletal and dental effects. Eight out of the twelve parameters evaluated were found to be statistically significant.
Table 1: Cephalometric angular and linear measurements

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Table 2: Descriptive statistics and statistical comparisons for cephalomeric skeletal measurements patients treated control

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Table 3: Descriptive statistics and statistical comparisons for cephalomeric skeletal measurements patients treated with SOCIA III

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Skeletal and dental modifications of both controls and SOCIA III are resumed in [Table 3]. On the vertical plane, the modification was about the facial height (+4.177 mm; P < 0.001). On the sagittal plane, ANB correction (+1.32°; P < 0.001), CB growth (+4.12 mm; P < 0.001), ACB growth (+2.458 P < 0.001), Co-A modification (+5.58 mm; P < 0.001), and Co-Gn (+7.11 mm; P < 0.007) were evaluated.

The most important modifications regarding the dental parameters were: The upper and lower incisors inclination (U1-SN +4.16°; P < 0.01 and L1-MP-5.63°; P < 0.007) and overjet (+2.6 mm; P < 0.001) [Figure 3].
Figure 3: Dentoskeletal effect of Swallowing Occlusal Contact Intercept Appliance III treatment; a) before the treatment with SOCIA, b) after the treatment with SOCIA

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   Discussion Top


SOCIA III is a functional appliance with no intraoral retention. By actively biting on the posterior bite-blocks, molar extrusion is prevented, and vertical growth of the mandibular ramus is induced. Stimulation from the palatal button trains, the tongue to reach its physiologic position near the upper incisors. The maxillary expansion is induced by the tongue position, and by the vestibular buttons, which relieve pressure generated from the oral musculature on the dentition. An Eschler arch is used to control the mandibular growth. The Eschler arch is built to touch the labial surface of the lower incisors. The aim of the appliance is to increase the midpart of the cranium and control the sagittal growth of the mandible and its postrotation. The active part of the functional appliance is the tongue positioner in the palatal part of the appliance.[12] This type of functional appliance in growing patients has a lot of function: (a) a new chewing pattern (i.e., posterior bite-blocks); (b) tongue positioning (i.e., the central tongue retainer); (c) maxillary expansion (i.e., the vestibular button; and (d) mandibular growth control (i.e., the Eshler arch). The maxillary growth and upper incisor position were modified by the tongue pressure as suggested by Delaire, who stated that “from the age of 4–10 pressure of the tongue against the palatal vault and occlusal forces on the upper dental arch contribute to development of the anterolateral part of the maxilla.”[13]

Swallowing occlusal contact intercept appliance III effects on the maxilla

To achieve the maxillary expansion, SOCIA III was built with the following components:

  1. A tongue positioner
  2. Two vestibular buttons
  3. Two occlusal metallic bite-blocks.


Each component has a rehabilitating function since the tongue pressure on the maxilla, the occlusal forces, and the pressure of peripheral muscles act as stimuli for the maxillary growth. The tongue positioner is built with a 60° inclined plane with a hole corresponding to the palatal spot.[14] The continue pressure of the tongue on the maxilla stimulates its expansion in the three planes of space. Another important aspect of tongue position is the control on the sagittal and vertical growth of the mandible by mean of the genioglossus muscle stress.[15] The stabilization of the mandible on the vertical plane is increased by the posterior bite-blocks that produce a continue exercise that increases the vertical control produced by SOCIA III. Many authors suggest to use posterior bite-blocks to control the vertical growth of the mandible in addition to the orthopedic treatment.[16]

Swallowing occlusal contact intercept appliance III effects on the mandible

The mandibular growth control is achieved using three components: (a) posterior bite-blocks; (b) the Eschler arch; and (c) genioglossus stress.[15],[17],[18] The presence of the posterior bite-blocks and the genioglossus stress allow to displace the mandible backward, without modifications of mandibular incisors' inclination, as well as the reverse vestibular arch (Eschler arch).[19]

Swallowing occlusal contact intercept appliance III effects on the cranial base

The pressure produced by the tongue and the stimulation of the anterior teeth have an important role in the sagittal growth of the cranial base: Van der Klaauw suggested that the forces coming from the deciduous dentition and subsequently mixed dentition were transmitted through the maxillary buttresses to the anterior cortex of the frontal bone, promoting its forward movement.[20] This was confirmed by Delaire, who also suggested that the occlusal forces and the pressure of the tongue against the palatal vault contribute to the development of the anterolateral part of the maxilla.[13] SOCIA III with the central tongue positioner emphasizes the stress on the anterior part of the maxilla. The anterior hole is positioned in correspondence to the palatal spot to stimulate the maxillary sutures.

Swallowing occlusal contact intercept appliance III effects on pseudo-Class III malocclusion compared to controls

The effects of SOCIA III on growth were compared with Class III control patients. The main differences observed in the present study were about: The anterior facial height (AFH), ANB modification, midface growth (growth of the cranial base and the maxilla), lower incisors inclination, and overjet increase.

Comparing the T2–T1 changes of the SOCIA group with those of the control group, revealed a real effect of this functional appliance on the sagittal and vertical increase of midface [Table 4]. The midface increase was evaluated through changes in the cranial base and the maxilla. The patients treated with SOCIA III showed an increase of the mid-cranial base of 3.75 mm compared to the controls and an effective increase of the ACB (from the foramen cecum to nasion) of 1.84 compared to the untreated patients. The maxilla showed an increase of 2.71 mm compared to the controls. These cranial base changes generated an ANB modification in SOCIA III patients and an increase of AFH. The overjet correction (2.6° SOCIA III patients, −0.091 mm in case control group) in SOCIA III patients was due to the reduction of lower incisors' proclination. The treated patients showed a 5.03° reduction of the labial inclination with respect to the control group.
Table 4: Descriptive statistics and statistical comparisons for cephalometric skeletal measurements patients treated with SOCIA III and case controls

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Swallowing occlusal contact intercept appliance III effects and other functional appliances

Comparing the outcomes of SOCIA III treatment evaluated in the present study to the effects of other appliances used for the treatment of pseudo-Class III malocclusion, as reported on the literature, a greater effect on the sagittal maxillary growth of the SOCIA III (+5.06 mm Co-A distance increase, P < 0.001) with respect to FM/Alt-Ramec combined treatment (+2.14 mm)[21] or Frankel III (+4.0 mm).[22] The ANB increase was lower with SOCIA III appliance (+1.32°, P < 0.001) than the RME/FM treatment (Maspero et al. +4.64 mm;[23] Canturk et al. +5.25 mm;[21] Seehra et al. +3.8 mm [24]), but higher than what measured for other functional appliances such as Twin Block (+1°),[24] Frankel III (+1.1°),[22] or other functional orthopedic appliances (−0.47°).[25] The sagittal growth of the upper maxilla was related to an increase of upper incisors' inclination: After 24 months of treatment with SOCIA III, patients showed a modification of U1-SN angle of +4.16°. Levin et al. showed an increase of upper incisor inclination of 12°,[22] while Godt et al. showed an increase of 6.18°.[25] The mean increase with FM and RME was about 2.05–4.27 mm.[21],[23],[25] On the vertical plane, SOCIA III showed a good control over mandibular postrotation (NSL/MP −0.133°; P = not significant [NS]). These data were significantly better than what other authors found with RME/FM (+0.95°;[23] +1.77°;[21] +1.12°;[25] +1.29°[26]) and functional orthopedic appliances (−1°;[25] +2.5°[9]). The vertical control over the maxillary and mandibular growth allowed to achieve after 24 months of treatment an overbite modification of 0.5 mm (P = NS). An important overbite modification with other appliances was observed by many authors (−2.58 mm to 0.5 mm).[21],[22],[25],[26]

The most important effect of SOCIA III appliance in the mandible regarded the lower incisor inclination (i.e., L1-MP), with a T2–T1 lingual inclination of −5.63° (P < 0.001). Other functional appliances produced a modification of –5.3° (Reverse Twin Block),[24] −2.1° (Frankel III),[22] and +3.1° (FOA).[25] The L1-MP change was smaller using RME/FM (−0.7° to −2.2°).[21],[24],[25] A decrease of −6.08° was demonstrated by Sar et al.[26] Another important aspect of the effect of SOCIA III was the influence on ACB growth. Enlow showed that at 8 years of age the part of the cranial base between the pituitary point and the foramen cecum was well-established.[27],[28] Before this age, the part of the cranial base develops from foramen cecum to nasion. Ford showed how the distance between foramen cecum and the nasion between the age of 7–14 years old increased of about 1.7 mm.[29] In the present paper, an increase of the distance from foramen cecum to nasion of 2.46 mm was measured, compared to 0.62 mm in the control group, suggesting an effective influence of SOCIA III in the development of the maxilla and the ACB.


   Conclusion Top


The present study evaluated the effects of SOCIA III in the treatment of pseudo-Class III malocclusion, compared to a group of untreated age-matched pseudo-Class III patients. The main effects of SOCIA III are resumed as follow:

  • An increase of sagittal maxillary growth
  • Vertical control over mandibular growth
  • Overjet correction
  • No increase of overbite
  • Stimulation of ACB growth.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

Thanks to the technician Fabio Salcuni for his dedication and professionality.



 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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