רפואת הפה והשיניים - עיתון ההסתדרות לרפואת שיניים בישראל - כרך ל"ז, גיליון מס' 2 אייר תש"פ

comfortably and maintain good oral hygiene, supported by regular dental examinations. Cooperation is correlated with age and socio economic status and reduces treatment time, mainly as a result of less absences from doctor appointments and improved oral hygiene (8). Various approaches have been tried, to encourage and motivate young patients to cooperate during treatment (5). One recent intervention even proposes a messaging application, and has reportedly shown good results (9). Thus, including the general dental practitioner in the treatment team is of paramount importance, to ensure that the dental needs are addressed and assist and motivate the young patient to succeed in reaching the treatment goals. Principles Although it is clear that treatment of SkCl3 should commence in the pre-pubertal years, the optimal timing for initiating treatment is controversial. In addition, one of the main purposes is to attempt to influence the growth pattern of the jaw and consequently correct the skeletal imbalance. This approach, known as “growth modification”, is the preferred solution to correct the skeletal discrepancy by inducing differential growth on one jaw compared to the other (10). It is based on either exertion of orthopedic-orthodontic forces on facial sutures (orthopedic treatment) or exploiting muscular activities (functional treatment) (11). Unlike the controversy among orthodontists regarding the early treatment of skeletal Class II anomalies (12), there is consensus regarding the benefits of early treatment of SkCl3 anomalies of maxillary origin (12). Nonetheless, the important role that the general dental practitioner can play cannot be overemphasized. The source of SkCl3 can be pure mandibular prognathism or it can be maxillary hypoplasia and retrognathism or a combination of both (13). Many studies have found that in most patients, a hypoplastic maxilla is often the primary etiology of SkCl3 (1, 13-17). Such anomalies are best treated in the pre-pubertal years. Proffit found high rates of success with commencement of treatment no later than the age of 10 (2), whereas McNamara

recommends that treatment begin even earlier, when the first molars have erupted and the upper central incisors are starting to emerge (18). This is based on a large study cohort where a majority of the patients achieved clinically acceptable results without the need for orthognathic surgery later (19). Even in the cases that required orthognathic surgery despite early treatment, early intervention enables better post-operative stability. Purpose 1. To increase awareness to the challenges of treatment for SkCl3 anomalies based on current treatment norms. 2. To highlight the benefits of promoting and maintaining cooperation of the young patient, throughout the years, and to emphasize a way that the general dental practitioner can contribute. SkCl3 Treatment supported by interdisciplinary coordination The general dental practitioner plays an important role during the SkCl3 orthodontic treatment, ranging from early diagnosis and referral, though hygienic prevention, early identification and treatment of caries and damaging effects of bruxism and importantly through motivation and coaching. Both caries and bruxism are significantly more prevalent in young children with skeletal malocclusion cases compared to the normal population (20). Bruxism is significantly more prevalent among preschool children aged 3-6 years old with primary molar relationships such as a mesial step and flush terminal planes (21). Such a primary molar relationship, which can lead to an Angle Cl III relationship in the permanent dentition requires close monitoring by the general dental practitioner. Importantly, caries and food impaction were found to correlate with bruxism (22). Moreover, there is a higher prevalence of mandibular alveolar defects in SkCl3 patients compared to children with Skeletal Cl I (22), such that periodontal follow-up and close monitoring of oral hygiene are needed. Following diagnosis of SkCl3, orthodontic treatment always requires that the patient uses appliances for

The Journal of the Israel Dental Association, vol. 37, No. 2, April 2020. 9