Changes in dental arch dimensions by use of an orthopedic cervical headgear in Class H correction

Mirja Kirjavainen, DDS, a Turkka Kirjavainen, MD, b and Kaarina Haavikko, DDS, PhD a

Helsinki, Finland
Orthopedic cervical headgears are commonly used in Finland for early treatment of the Class II malocclusion, but there is a lack of follow-up studies on the effect of this treatment. We have evaluated the effects of the cervical headgear therapy with an expanded inner bow to treat Class II malocclusion and dental arches. Forty children, 20 boys and 20 girls, with Class II, Division 1 malocclusion, were treated with the orthopedic cervical headgear. No other appliances were used. The mean age of the subjects in the beginning of the treatment was 9.3 + 1.3 years (range 6.6 to 12.4 years). The mean treatment time was 1.8 _+ 0.6 years (range 0.8 to 3.1 years). The cervical headgear was used with a 10 mm expanded inner bow and a 15 upward bend of the long outer bow, 12 to 14 hours a day with a force of 500 gm per side. Class I relationships were achieved in all subjects. At the same time, the maxillary and mandibular dental arches were widened. The annual increment in the intercanine and intermolar distances was significantly greater than in healthy control subjects (literature data), except for the mandibular intercanine distance in boys. The maxillary arch lengths were also significantly increased; there were no consistent changes of the mandibular arch lengths. Class II malocclusion may be treated with the orthopedic cervical headgear. The treatment results in increased growth of the dental arch widths by expansion of the inner bow of the headgear. The widening of the maxilla is followed by spontaneous widening of the mandible. (Am J Orthod Dentofac Orthop 1997;111:59-66.)

C e r v i c a l headgear traction is a common treatment of Class II, Division 1 malocclusion in Finland. The cervical headgear is easy to produce, well accepted by patients, and simple to use. Kloehn 1 reported already in 1947 the impressive results with headgear treatment of Class II malocclusion. He used a "head cap" for extraoral pull. However, he and Ricketts2 later recognized that a downward pull is needed to enhance the orthopedic effect and ultimately cervical traction became the mainstay. Over the years, different traction forces have been applied through the cervical headgear and different effects on the teeth and jaws have resulted. Light forces (150 to 200 gm) may be used to move teeth. 3-5 On the other hand, strong forces (> 450 gm) are assumed to surpass the tooth-moving threshold and therefore they have been used to control teeth anchorage. 3-6 Strong forces are also needed to produce orthopedic skeletal effects on the maxilla, which are essential in the treatment of Class II malocclusion.614 The use of the cervical headgear has been liraaDepartment of Pedodontics and Orthodontics, University of Helsinki. bDepartments of Medicine and Physiology, Turku University, Finland. Reprint requests to: Dr. Mirja Kirjavainen, Venhontie 7, FIN-31300 Tammela, Finland. Copyright 1997 by the American Association of Orthodontists. 0889-5406/97/$5.00 + 0 8/1/70375

ited, since it has been claimed to produce an extrusion of molars and downward and backward rotation of the mandible. 9'1521 However, it has recently been shown that, if the headgear therapy is used bioprogressively with strong forces, a long upward bent outer bow and expanded inner bow, 22 these unwanted effects can be avoided.23 The best age of the patients to be treated may be the time of early mixed dentition, because at that time the skeletal system is dynamic and is easy to remodel. 6,24 Haas 8 has shown that it is essential to widen the maxillary arch to obtain a permanent orthopedic effect on the entire maxilla in the treatment of Class II malocclusion. This expansion can be achieved, for example, by quad-helix or rapid palatal expansion. Bench 22 and Ricketts 2 have suggested that maxillary widening can also be produced by the cervical headgear without any other appliances, if the inner bow of the headgear is widened. However, this effect has not been studied. The purpose of this study was to evaluate the effects on the maxillary and mandibular dental arches of the cervical headgear with a widened inner bow and an upward bent long outer bow.
SUBJECTS

Forty consecutive healthy schoolchildren, 20 boys and 20 girls, who fulfilled the followingcriteria were included:
59

60 Kirjavainen et aL

American Journal of Orthodontics and Dentofacial Orthopedics January 1997

the authors (M.K.) as part of the routine clinical orthodontic treatment, during the years 1984 to 1992. The mean age of the boys at the beginning of the treatment was 9.8 -+ 1.2 (7.2 to 12.4) years and of the girls 8.9 -+ 1.2 (6.6 to 11.2) years. All subjects, except one boy, were of mixed dentition age.

METHODS
A cervical headgear of the Kloehn type, with a large inner bow and a long outer bow, was used to treat all subjects. The inner bow required 4 mm bayonet bends to keep the teeth out of cheek or lip contact. The inner bow was engaged 3 mm ahead of the anterior teeth and was thus not in contact with the anterior teeth. By bending the ends of the inner bow inward, the first molars were rotated to the correct position. The inner bow of the headgear was expanded 10 mm larger than the distance between the first maxillary molar tubes and was made parallel to the occlusal plane. To prevent distal tipping of the first molar crowns and extrusion of the first molars over the normal eruption and an ultimate increase in the lower facial height, the resultant force vector of the cervical traction was brought above the center of resistance of the upper molarsY ,26 This direction of force traction was achieved by bending the long outer bow 15 upward. For cervical traction a force of 500 gm, measured by a force gauge, was applied on each side. The expansion of the inner bow and the amount of traction force were controlled at every appointment, i.e., every 6 to 8 weeks. The subjects were asked to wear the headgear 12 to 14 hours a day, mainly during the nights, and to keep a diary of their headgear wearing. Cooperation was assessed by the diary notes and by the physical signs of use in the headgear, e.g., tearing of the elastic band and neck strap. The treatment was considered complete when the Class II malocclusion was corrected and a Class I molar relationship had been established.

Fig. 1. Dental arch measurements. (1) Intercanine arch width (teeth 13 - 23 and 33 - 43): distance between cusp tips of deciduous or permanent canines. (2) and (3) Two intermolar arch widths (16 - 26 and 36 - 46): distance between mesiolingual cusp tips of first permanent molars, and distance between lingual grooves of first molars at gingival level. Arch lengths were measured as distance between most gingival interincisal point, and (4) line connecting distal surfaces of canines (anterior arch length), (5) line connecting middle mesial surfaces of first molars (posterior arch length), (6 and 7) middle mesial surfaces of first molars (right (6) and left (7) arch lengths). Equal points were selected both from maxilla and mandible.

Analysis of Dental Casts

Fig. 1 shows the points where the width and length of the dental arch were measured. The points for measuring the arch widths were those recommended by Moorrees, 27 but the arch points for measuring the lengths were slightly modified from those of Moorrees. To eliminate the error introduced by axial tipping of incisors, the most gingival interincisal point was selected instead of a tangent to the middle area of the labial surfaces of the central incisors. The modified measuring point was also chosen with the intent to get a better quantification of the basic structure of the dental arch. To evaluate more precisely any changes in the position of first molars, a central mesial point on the first molars was selected, instead of the most dorsal point on the distal surfaces of the second premolars. The average annual increments of the intercanine and intermolar distances were expressed as the change in these

(a) All had Class II, Division 1 malocclusion with an overjet more than 2 ram, (b) pretreatment and posttreatment plaster models and lateral cephalograms were obtained of all, (c) all essential measuring points were identified, and (d) cooperation was likely to be good or at least moderate. The subjects were treated exclusively with the cervical headgear in one healthcare center by one of

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Table I. Pretreatment and posttrcatment values of intercanine and intermolar widths (ram) and changes in widths (mm) during
tr eatmen t of the maxilla and mandible with headgear

Boys Pretreatrnent Width Maxilla

Intercanine Intermolar Cuspal Gingival 32.4 39.3 34.3 26.8 33.9 32.2 1.9 1.7 1.4 2.1 1.7 1.5 37.3 45.9 39.9 27.9 37.3 35.1 1.9 2.7 2.4 1.7 2.7 2.2 4.9*** 6.6*** 5.6*** 1.1"* 3.4*** 2.9*** 2.3 2.8 2.7 2.0 2.1 1.5 31.1 38.3 33.7 26.0 32.9 31.5 2.3 2.5 2.3 2.4 2.4 1.8

Girls Pretreatment Change SD Mean SO Posttreatment Mean

36.0 43.4 38.1 27.9 35.4 33.2

Posttreatment Mean SO

Mean

SO

SD
2.0 3.0 2.9 2.0 2.3 1.9

Change
5.0*** 5.1"** 4.4*** 1.8"** 2.5*** 1.7"**

SD
2.1 2.3 2.4 1.6 1.3 0.9

Mandible
Intercanine Intermolar Cuspal Gingival

**p < 0.01; ***p < 0.001.

distances during the treatment, divided by the treatment time. Overjet was measured from the labial surface of the maxillary central incisor to the labial surface of the mandibular central incisor. 27 Overbite was quantified as the fraction of the crown height of the mandibular incisors that was overlapped by the maxillary incisors. Overlapping was assumed to describe overbite better than overbite measured in millimeters, because the crown size of the incisors varies. Overbite was categorized as follows: open bite, end-to-end, normal (1/~ to 1/2 overlapped), or deep bite (>2B overlapped).27 All of these measurements were taken with a sliding digital calliper (Digit-Cal SI, Tesa, Switzerland) by the same person (M.K.). Crowding of teeth was estimated as mild, moderate, or severe. The measured dental arch widths were related to the reference values of 9-year-old Finnish children. 2s The calculated annual changes of the maxillary and mandibular intercanine and intermolar distances were compared with the reference values presented in the publication. 27

Linear correlations were calculated with BMDP 1R program (BMDP Statistical Software Inc.). 29 P-values less than 0.05 were considered statistically significant. The results are presented in the form of: mean _+ SD (range).

RESULTS
In all subjects, the Class II, Division 1 malocclusion was successfully corrected to the Class I molar relationship. The m e a n duration of the treatment was 1.9 _+ 0.7 years (0.9 to 3.1 years) in boys and 1.8 _+ 0.7 years (0.8 to 3.0 years) in girls. The average number of control visits for the boys was 8.4 _+ 1.4 (6.3 to 11.1) per year and for the girls 8.7 + 1.5 (5.0 to 11.1) per year. Thirteen boys and 17 girls cooperated well, and 7 boys and 3 girls moderately well.

Changes in Overjet, Overbite, and Crowding

All subjects had changes in overjet toward the normal occlusal relationship at the horizontal level. On average, the overjet decreased from 6.4 _+ 2.0 m m (4 to 11 m m ) to 4.2 _+ 1.4 m m (2 to 8 m m ) (p < 0.001) in boys and from 5.3 + 2.3 m m (3 to 11 m m ) to 3.2 _+ 1.3 m m (2 to 6.5 ram) (p < 0.001) in girls. The overbite did not change considerably during the treatment. Twelve boys and 13 girls had a normal vertical overbite before treatment and this remained unchanged during the treatment. Of the remaining 15 children, 7 boys and 5 girls had deep overbite before the treatment. The bite became normal in three of these boys and four girls after treatment; the deep overbite remained unchanged in four boys and one girl. Three children had an

Measurement Repeatability
To assess repeatability, serial measurements were taken from plaster models of five boys and five girls. The average difference in the readings was 0.11 _+ 0.03 ram, ranging from the difference in the mandibular left arch length of 0.06 _+ 0.08 mm (0 to 0.3 ram) to the difference in the maxillary cuspal intermolar distance of 0.18 0.24 mm (0 to 0.7 ram). The measurements were free of systematic errors.

Statistical Methods
The paired Student's t test was used to compare the changes in the dental arch dimensions and the unpaired t test was used to compare the dental arch widths with the control values of 9-year-old children? s The same test was used to compare the recorded growth to control values. 27

62 Kirjavainen et al.

American Journal of Orthodontics and Dentofacial Orthopedics January 1 9 9 7

40

....... +2SD Normal Mean . . . . . . . . 2SD -=

' I ' I I ' I ' I ' I

30
0

: Boys ~ Girls

0.5

1.5

2.5

3.5

_.E 50
"-3
X &,9

40

- ~[ ~Y ~TI~IYt ~v1"ITT~t tt
l ' I ' I '

:=T 30
0.5

3;

Treatment Time (years)

Fig. 2. Individual maxillary intercanine (C-distance) and intermolar (M~-distance) distances before (A) and after (T) treatment. The results are plotted against average _+2 SD values of healthy 9-year-old Finnish children. 28

E
It

-~o

wE
CJ

30

....... +2SD Normal Mean . . . . . . . . 2SD : Boys ~ Girls

'

-t"20
' I ' I

-] ........ 1I

0.5 E E
-"

]1.5

21.5

3.5

~w
,m

40

- YYv

./1

=g
I

0.5

11.5

215

31.5

Treatment Time (years)

Fig. 3. Individual mandibular intercanine (C-distance) and intermolar (Ml-distance) distances before (A) and after (V) treatment. Results are plotted against average _+2 SD values of healthy 9-year-old Finnish children. 28

edge-to-edge overbite before the treatment. In two of these children, a normal overbite was achieved with treatment, one remained unchanged. Only 8 of the 40 children had maxillary crowding before the treatment; two children had moderate and six had mild crowding. Nine children had mandibular crowding; one was severe, two moderate, and six mild.

All, except one boy, achieved good teeth alignment and enough space for all crowded teeth.
Changes in Dental Arch Widths

Table I and Figs. 2 and 3 show the maxillary and mandibular intercanine and intermolar widths before and after treatment. Before treatment, the

American Journal of Orthodontics and Dentofacial Orthopedics Volume 111, No. 1

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63

BOYS

GIRLS
96 |
. . . . . ..%.

=!
~
C) f

9-

......... +2SD Normal

Mean
.......... 2SD
. " .....

.E~ 3
0.

.........~._...~.~

..T

........

02
"'"'-.... ........ .Y'*" ................ I --3 ' I ' t ' r ' I ' I ' I ' I

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-3

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11

12

13

14

10

11

12

13

14

9.

9-

"~
x E

6.
3.

62
II

._=~

3 0

oe
-..

41............. ~-.
.........................................

-3

-3

11 12 Age (years)

10

13

14

10 11 12 Age (years)

13

14

Fig. 4. Average annual increment of maxillary intercanine (upper panel) and intermolar (lower panel) widths. Values obtained at mean age of each subject during treatment are presented. Boys are shown in left column and girls in right column. Results are plotted against normal annual increments _+2 SD limits according to Morrees. 26

maxillary intercanine and intermolar distances were significantly smaller than the reference values of 9-year-old Finnish children 28 (/) < 0.01). After treatment, the widths were larger than the reference values (p < 0.001). The mandibular intercanine distances, on the other hand, did not differ from the reference values before treatment, but were significantly greater than normal values after the treatment (p < 0.01). The mandibular intermolar distances were smaller than among the Finnish 9-year-old control children before treatment (p < 0.001), but were close to the reference range after treatment. The changes in the arch widths were similar in boys and girls. The average annual increments of the maxillary intercanine, and maxillary and mandibular intermolar distances exceeded the normal growth (p < 0.001, Figs. 4 and 5). This indicates that the treatment caused widening of dental arches. The age of the subjects did not significantly affect the growth of the maxillary and mandibular arches. Treatment time influenced the growth of the maxillary intermolar width; as treatment time increased, the maxillary intermolar width increased in both boys (P = 0.45, p < 0.005) and girls (r 2 = 0.23,

p < 0.05). The intercanine (r 2 = 0.21, p < 0.05) and intermolar (r2 = 0.46, p < 0.001) mandibular widths also increased among the boys, as treatment time went on. In contrast, the treatment time did not affect the maxillary intercanine width.
Changes of Dental Arch Lengths

The maxillary and mandibular arch lengths before and after treatment are presented in Table II. The anterior and posterior arch lengths of the maxilla were significantly longer both in boys and in girls after therapy (p < 0.01). The treatment did not have any consistent effect on the arch lengths of the mandible. The only significant change in the mandibular arch lengths was a reduced posterior arch length in boys and the increased anterior arch length in girls. As treatment time increased, the lengths also grew in the anterior (r 2 = 0.26, p < 0.05), right (r 2 = 0.31,p < 0.05) and left (P -- 0.34, p < 0.01) dental arches of the boys and in the posterior (r 2 = 0.24, p < 0.05) and right (r 2 = 0.33, p < 0.05) dental arches of the girls. The treatment time did not affect the changes in mandibular arch lengths.

64

Kirjavainen et al.

American Journal of Orthodontics and Dent@cial Orthopedics January 1997

BOYS
99-

GIRLS

6~
"'....
3~

- - - v

......... +2SD Normal Mean .......... 2SD

"ii-- .......

-@,..

~ 5.

o2
.................
.

., ......... /../

-...g ..... ......_.......-"*"

"-

- 3

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"(

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10

11

12

13

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......,..~....~....~..,~.......
. = -

...............................

"''-,.,

10 11 12 Age (years)

13

14

10 11 12 Age (years)

13

14

Fig. 5. Average annual increment of mandibular intercanine (upper panel) and intermolar (lower panel) widths. Values obtained at mean age of each subject during treatment are presented. Boys are shown in left column and girls in right column. Results are plotted against normal annual increments _+2 SD limits according to Morrees. 26

Table ft. P r e t r e a t m e n t a n d p o s t t r e a t m e n t arch lengths ( m m ) a n d c h a n g e s in lengths (ram) d u r i n g t r e a t m e n t of the maxilla and

m a n d i b l e with h e a d g e a r

Boys Pretreatment Arch length Maxilla Anterior Posterior Right Left Mandible Anterior Posterior Right Left Mean SD Posttreatment Mean SD Change SD Pretreatment Mean SD

Girls Posttreatrnent Mean SD Change SD

12.9 28.8 35.9 36.0 7.6 24.2 30.8 30.9

1.7 2.1 1.9 2.1 1.8 1.8 1.7 2.0

14.1 30.4 39.6 39.8 8.0 23.3 31.1 31.1

1.2 2.2 2.3 2.2 1.7 2.1 2.0 2.2

1.2"* 1.6"* 3.6*** 3.8*** 0.4 -0.9** 0.3 0.1

1.5 2.3 2.5 2.7 1.5 1.4 1.4 1.5

12.6 28.5 35.5 35.0 7.0 24.3 30.7 30.7

2.1 2.1 2.2 1.8 1.3 1.6 2.0 1.5

13.7 29.9 38.8 38.1 8.1 24.0 31.1 31.1

2.1 2.7 2.9 2.3 0.9 1.7 1.9 1.6

1.1"* 1.4"* 3.3*** 3.2*** 1.0'** -0.3 0.4 0.4

1.4 1.7 2.0 2.0 1.1 1.3 1.4 1.3

**p < 0.01; ***p < 0.001.

DISCUSSION

In the current study, using orthopedic cervical headgear, a Class I relationship was achieved with the treatment. Significant increases in maxillary and mandibular arch widths were obtained by an expanded inner bow of the headgear. The effects of treatment were similar in boys and girls. The treatment was easy to carry out. Only a

small number of visits were needed and they were of short duration, lasting only '10 to 15 minutes. The procedures during the visits were also simple. In the current study, the average treatment time was 1.8 years, which is somewhat longer than in a previous study by Cook et al. 23 (1.6 years) who used similar headgear therapy. The wide range in the treatment times is probably explained by the fact

American Journal of Orthodontics and Dentofacial Orthopedics Volume 111, No. 1

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65

that children with only moderate cooperation potential were included in this study. The age of the subjects did not affect the results. However, all subjects were within a relatively narrow age range at the start of the treatment (6.6 to 12.4 years) and hence the treatment response was expected to be consistent within this group? '4 A marked increase of the arch widths was achieved by expanding the inner bow by 10 ram, which resulted in a widening of the maxilla that was significantly greater than normal growth. Although the intermolar widening increased over time, the treatment time did not affect the increase of intercanine distance. The widening of the maxilla was followed by a spontaneous, smaller widening of the mandible. This finding is in agreement with implant studies on normal subjects. 3,31 A significant increase in the maxillary arch lengths, albeit smaller than the arch widths, was observed in subjects undergoing headgear treatment. Unfortunately, we were not able to compare the final arch lengths with normal growth because of lack of reference data. Normally, a shortening of the mandibular arch lengths is observed in boys. This is probably caused by the mesial drift of the lower molars, as they take up the greater leeway present in the lower arch, after exchange of the deciduous molars? 2-34 The increased dental arch widths and lengths improved tooth alignment and the dental crowding disappeared with the treatment. To ensure that the intermolar width results were reliable and that the increase in this width was not due to the change in axial inclination of the molars seen in many subjects, the distances were measured both from the cusp tips and from the lingual grooves at the gingival level. A similar widening was observed in both of these measurements. This demonstrates that the widening was due to genuine widening of the dental arches. The only available reference data in the Finnish population were used to compare the dental arch widths with the widths in healthy control subjects (Figs. 2 and 3). Although this data presented by Huggare et al. 28 considers only 9-year-old children, the annual increment of the arch widths is relatively small and probably does not significantly affect the current results. Thus, the comparison remains quite valid. According to Moorrees, 27 the average annual increment of the intercanine distance of the maxilla is 0.5_+ 0.4 mm per year and of the mandible 0.3 + 0.5 mm per year, and of the intermolar distance in the maxilla 0.3 _+ 0.2 mm per year and in

the mandible 0.1 _+ 0.1 mm per year. Similar values have been recorded by Moyers et al? 5 and Sillman. 32 The overjet decreased on average 2.2 mm with treatment. This result was achieved despite the fact that the headgear did not have any contact with the upper incisors. Thus, we suggest that an extraoral force of 500 gm delivered through a headgear of the Kloehn-type to the maxillary molars produces an orthopedic effect on maxillary growth increments and growth direction. The treatment had a minor effect on overbite. Normal overbite remained unchanged and deep overbite either remained same or was affected favorably; edge-to-edge overbite was changed to normal overbite in two subjects. This supports the findings presented by Cook et al. 23 that the cervical headgear treatment, as used in this study, does not produce more extrusion of the upper molars than what is seen in normal dental eruption and does not lead to an opening rotation of the mandible.
CONCLUSION

In conclusion, Class II, Division 1 malocclusion was corrected to Class 1 relationship with the orthopedic cervical headgear. With the expanded inner bow of the headgear, a marked widening of the dental arches was achieved. The widening of the maxillary dental arch was followed by a spontaneous widening of the mandibular arch.
REFERENCES

1. Kloehn SJ. Guiding alveolar growth and eruption of teeth to reduce treatment time and produce a more balanced denture and face. Am J Orthod 1947;17:10-33. 2. Ricketts RM, Bench RW, Gugino CF, Hilgers J J, Schulhof RJ. Bioprogressive therapy. Denver: Rocky Mountain Orthodontics, 1979. 3. Bowden DEJ. Theoretical condiderations of headgear therapy: a literature review. Br J Orthod 1978;5:145452. 4. Bowden DEJ. Theoretical condiderations of headgear therapy: a literature review, 2--clinical response and usage. Br J Orthod 1978;5:173-81. 5. Reitan K. Biomechanical principles and reactions. In: Graber TM, Swain BF, editors. Current orthodontic concepts and techniques. VoL 1. Philadelphia: WB Saunders, 1975:111-228. 6. Graber TM. Dentnfacial orthopaedics. In: Graber TM, editor. Current orthodontic concepts and techniques. Vol 2. Philadelphia: WB Saunders, 1969:919-88. 7. Armstrong MM. Controlling the magnitude, direction and duration of extraoral force. Am J Orthod 1971;59:217-43. 8. Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod 1970;57:219-55. 9. Klein PL. An evaluation of cervical traction on the maxilla and the upper first permanent molar. Angle Orthod 1957;27:61-8. 10. Moore AW. Orthodontic treatment factors in Class II malocclusion. Am J Orthod 1959;45:323~52. 1l Poulton DR. Changes in Class II malocclusions with and without occipital headgear therapy. Angle Orthod 1959;29:234-50. 12. Ricketts RM. The influence of orthodontic treatment on facial growth and development. Angle Orthod 1960;30:103-33. 13. Sandusky- WC. Cephalometric evaluation of the effects of the Kloehn type of cervical traction used as an auxiliary with the edgewise mechanism following Tweed's principles for correction of Class II, Division i malocclusion. Am J Orthod 1965;51:262-87. i4. Wiestander L. The effect of orthodontic treatment on the concurrent development of the craniofaciaI complex. Am J Orthod 1963;49:15-27.

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American Journal of Orthodontics and Dentofacial Orthopedics January 1997

26. Kuhn RJ. Control of anterior vertical dimension and proper selection of extraoral anchorage. Angle Orthod 1968;38:340-9. 27. Moorrees CFA. The dentition of the growing child. Cambridge: Harvard University Press, 1959:1-230. 28. Huggare J, Lahtela P, Viljamaa P, Nystr0m M, Peck L. Comparison of dental arch dimensions in children from southern and northern Finland. Proc Finn Dent Soc 1993;89(3-4):95-100. 29. Dixon WJ, Brown MB, Engelman L, Jennrich RI. BMDP statistical software manual, v. 1-2. Berkeley: University of California Press, 1990. 30. Bj6rk A, Skieller V. Facial development and tooth eruption: an implant study at the age of puberty. Am J Orthod 1972;62:339-83. 31. Bj6rk A, Skieller V. Growth of the maxilla in three dimensions as revealed radiographiea/ly by the implant method. Br J Orthod 1977;4:53-64. 32. Sillman JH. Dimensional changes of the dental arches: longitudinal study from birth to 25 years. Am J Orthod 1964;50:824-42. 33. Nance HN. The limitations of orthodontic treatment: part I. Am J Orthod Oral Surg 1947;33:177-223. 34. Nonce HN. The limitations of orthodontic treatment: part II. Am J Orthod Oral Surg 1947;33:253-301. 35. Moyers RE, van der Linden F, Riolo ML, McNamara JA. Standards of human occlusal development. Monograph 5. Ann Arbor: Center for Human Growth and Development, University of Michigan, 1976.

15. Baumrind S, Korn EL, West EE, Molthen R. Quantitative analysis of the orthodontic and orthopedic effects. Am I Orthod 1983;84:384-98. 16. Baumrind S, Korn EL, Molthen R, West EE. Changes in facial dimensions associated with use of forces to retract the maxilla. Am J Orthod 1981;80:17-30. 17. Baumrind S, Molthen R, West EE, Miller DM. Mandibular plane changes during maxillary retraction. Am 3"Orthod 1978;74:32-40. 18. Melsen B. Effects of cervical anchorage during and after treatment: an implant study. Am J Orthod 1978;73:526-40. 19. Poulton DR. The influence of extraoral traction. Am J Orthod 1967;53:8-18. 20. Schudy FF. Vertical growth versus anteroposterior growth as related to function and treatment. Angle Orthod 1964;34:75-93. 21. Silverstein A. Changes in the bony facial profile coincident with treatment of Class II, division 1 malocclusion. Angle Orthod 1954;24:214-37. 22. Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive therapy, part V. J Clin Orthod 1978;12:48-69. 23. Cook AH, Sellke TA, BeGole EA. Control of the vertical dimension in Class II correction using a cervical headgear and lower utility arch in growing patients: part I. Am J Orthod Dentofac Orthop 1994;106:376-88. 24. Gianelly AA ,Valentini V. The role of "orthopedics" and orthodontics in the treatment of Class II, Division 1 malocclusions. Am J Orthod 1976;69:668-78. 25. Greenspan RA. Reference charts for controlled extraorai force application to maxillary molars. Am J Orthod 1970;58:486-91.

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