Efficient and Effective Growth Modification: A 30-year Perspective Lorenzo Franchi. Jacob A. Salzmann Award Lecture; AAO June 2021. Episode 91

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2021 Jacob A. Salzmann Award Lecture; Efficient and Effective Growth Modification: A 30-year Perspective Lorenzo Franchi




Class 2


Timing of treatment

·      Mandibular growth (Co-Gn) Pre-pubertal Vs pubertal = pre-pubertal 0.9mm Vs 2.9mm pubertal Systematic review Perinetti 2015

·      What happens in pre-pubertal class 2 treatment

o   Mainly dentoalveolar effects, lip competence improves

o   No change to skeletal structures

·      Case of patient 11 years old at CVM 3

o   9mm of mandibular growth with twinblock appliance


Favourable features at the growth spurt

·      Predictable growth = 3mm from systematic review Perinetti (short term outcomes)

·      Efficient – shorter overall duration 2.5 years Vs 4 years Tulloch 2004

·      Good stability: Baccetti 2009


Long term effects of functional treatment Systematic review Pavoni 2018

·      Treatment and controls of prepubertal Vs pubertal (Prepubertal CVM 1&2, Pubertal CVM 3)

·      Prepubertal group = no difference in mandibular growth in the treatment functional group Vs control

o   Understanding = in prepubertal patients mandibular growth is accelerated  during functional appliances however growth decelerates in the treatment group when compared to the control.

·      Pubertal group = 5.5mm mandibular growth when compared to control

·      Long term growth is maintained when compared to controls approx. age of 18 (CVM 5&6)

o   Understanding = during puberty functional appliance stimulate mandibular growth


Individual response

Predictor factors

·      Mandibular angle Co-Go-Me  Franchi 2006

o   Great responder: >123

o   Good responder: 124-128

o   Poor responder: <128

·      Greater advancement of soft tissue chin with Co-Go-Me less than 123 Baccetti 2009



·      Timing of treatment = CVM 3

·      Predictable outcome = Mandibular angle



Class 3 cases


Treatment timing

·      Franchi 2004 RME and facemask use

o   Before puberty (CVM 1) significant maxillary growth 2mm maxillary advancement

o   At puberty (CVM 3) only significant mandibular growth

·      Explanation

o    Maxillary sutures timing of closing = resistance to protraction

§  Pterygopalatine sutures are open prior to puberty

§  During puberty significant bony interdigitation

§  Zygomaticmaxillary suture can produce a significant resistor to maxillary protraction

·      CBCT classification A-E  Angelieri 2013/2017

·      Least resistance in pre-pubertal patients CVM1 and CVM 2


Individual patient response


Long term outcomes of class 3 cases with RME and facemask, followed by fixed appliances, in pre-pubertal (7.1 years) Souki 2019. Long term age 21 years

·      Clinical outcomes = success, absence crossbite, skeletal 3

·      Successful outcome = 70%

·      Predictor factor

o   Condylar axis – Mandibular plane

§  Condylar axis= from point condyle passing through midpoint : between Ar-Ar anterior

o   Unsuccessful > 147

o   Successful <147

Predictor = Specificity – 98%, sensitivity 86%



·      Treatment time – pre puberty

·      Predictable outcome – Condylar axis <147

·      Longterm success 70%



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