You are on page 1of 9

ORIGINAL ARTICLE

Effect of timing on the outcomes of 1-phase


nonextraction therapy of Class II malocclusion
Tiziano Baccetti,a Lorenzo Franchi,a and Ludia H. Kimb
Florence, Italy, and Ann Arbor, Mich

Introduction: The aim of this cephalometric study was to evaluate the role of timing in relation to skeletal
maturity on the outcomes of nonextraction comprehensive Class II therapy. Methods: Three samples of
patients with Class II Division 1 malocclusion were treated with headgear combined with fixed appliances
and Class II elastics. Lateral cephalograms were taken of all subjects before therapy (T1) and at an average
interval of 6 months after therapy (T2). The first sample (23 subjects) was treated before the pubertal growth
spurt, the second sample (24 subjects) received therapy during the pubertal growth spurt, and the third sample
(13 subjects) was treated at a postpubertal stage of development. The average T1 to T2 interval was approx-
imately 30 months for all patients, with an average treatment duration of 24 months. Longitudinal observations
of a group of 17 subjects with untreated Class II malocclusions were compared with the treated groups at the 3
skeletal maturation intervals with nonparametric statistics. Results: Class II treatment before or during the
pubertal growth spurt induced significant favorable skeletal changes (restricted maxillary advancement in pre-
pubertal patients and enhanced mandibular growth in pubertal patients). Patients treated after the pubertal
growth spurt had only significant dentoalveolar changes. Conclusions: The greatest amount of dentoskeletal
correction of Class II malocclusion with 1-phase nonextraction treatment occurred in patients treated during
the pubertal growth spurt. (Am J Orthod Dentofacial Orthop 2009;136:501-9)

C
lass II Division 1 malocclusion is a common A few cephalometric studies reported short-term effects
clinical problem in orthodontics, with approxi- of nonextraction treatment with extraoral forces and
mately 15% to 30% of North American children Class II elastics in Class II patients.4-7 They all agreed
and 20% to 30% of all orthodontic patients having this in describing significantly favorable changes in the sag-
type of dentoskeletal imbalance.1 Of the various treat- ittal position of both the maxilla and the mandible,
ment strategies for Class II treatment, headgear associ- together with the extrusion of the maxillary molars
ated with fixed appliances is probably the most widely and proclination of the mandibular incisors. Bishara
used, and it has been a dependable method of Class II et al5 indicated that nonextraction Class II treatment
correction for many decades.2,3 This nonextraction induced overall normalization of the skeletal rela-
technique is 1-phase comprehensive therapy of the mal- tionships. LaHaye et al7 found that nonextraction head-
occlusion with the adjunct of Class II elastics during the gear treatment produced normal dental relationships
final phase of treatment.3 and restricted anteroposterior maxillary growth with
Despite of the popularity of this protocol, there is inadequate effects on the sagittal position of the chin.
a relative paucity of information in the literature about The number of studies with posttreatment observation
the dentoskeletal changes of 1-phase nonextraction is even more limited. Overall long-term stability of
Class II therapy in either adolescents or young adults. the investigated protocol is reported to be relatively
good,8,9 with a tendency to forward rebound of the max-
a
Assistant professor, Department of Orthodontics, University of Florence, Flor- illa after Class II correction with headgear and fixed
ence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann appliances.8
Arbor. Most of the short-term and long-term studies that in-
b
Clinical instructor, Department of Orthodontics and Pediatric Dentistry, vestigated the effectiveness of headgear therapy com-
School of Dentistry, University of Michigan, Ann Arbor; private practice,
Ann Arbor, Mich. bined with fixed appliances and Class II elastics did
The authors report no commercial, proprietary, or financial interest in the prod- not include a control group of untreated Class II sub-
ucts or companies described in this article. jects.4,6,8,9 Bishara al5 used untreated subjects with nor-
Reprint requests to: Lorenzo Franchi, Dipartimento di Odontostomatologia,
Universita` degli Studi di Firenze, Via del Ponte di Mezzo, 46-48, 50127, Fire- mal dentoskeletal relationships as controls, since the
nze, Italy; e-mail, lorenzo.franchi@unifi.it. aim of that investigation was to test the hypothesis
Submitted, March 2007; revised and accepted, August 2007. that treatment could induce normalization of the den-
0889-5406/$36.00
Copyright 2009 by the American Association of Orthodontists. toskeletal relationships in Class II patients. Moreover,
doi:10.1016/j.ajodo.2007.08.029 no articles provide indications on the skeletal maturity
501
502 Baccetti, Franchi, and Kim American Journal of Orthodontics and Dentofacial Orthopedics
October 2009

of the subjects treated with the described regimen. It Table I. Demographics for the treated and untreated
has been demonstrated widely that individual skeletal Class II groups
maturity significantly affects the outcomes of func-
Age at Age at T1-T2
tional jaw orthopedics. Therapy of Class II malocclu- T1 (y) T2 (y) interval (y)
sion with functional appliances (Herbst, Twin-block,
bionator, function regulator-2) at the adolescent Mean SD Mean SD Mean SD
growth spurt induces greater mandibular skeletal Class II treated
effects than therapy at a prepubertal stage.10-18 Also, Prepeak (n 5 23; 9 f, 14 m) 11.3 1.3 13.6 1.3 2.4 0.3
Kopecky and Fishman19 attempted to identify optimal CS 1 at T1, CS 3 at T2
timing of cervical headgear treatment based on skele- Peak (n 5 24; 13 f, 11 m) 11.8 1.0 14.3 1.1 2.5 0.3
CS 3 at T1, CS 5 at T2
tal maturation (determined on hand-wrist films), and Postpeak (n 5 13; 7 f, 6 m) 13.7 1.0 16.2 1.3 2.5 0.6
they reported more favorable results during matura- CS 5 at T1, CS 6 at T2
tional periods that were associated with greater incre- Class II untreated
mental growth velocity. Prepeak (n 5 17; 6 f, 11 m) 10.2 1.3 12.1 1.3 2.0 0.4
The purpose of this study was to evaluate the role of CS 1 at T1, CS 3 at T2
Peak (n 5 17; 6 f, 11 m) 12.1 1.3 14.3 1.4 2.2 0.5
timing in relation to skeletal maturity (prepubertal, CS 3 at T1, CS 5 at T2
pubertal, postpubertal) as assessed with the cervical ver- Postpeak (n 5 13; 6 f, 7 m) 14.3 1.4 16.9 1.7 2.6 0.4
tebral maturation (CVM) method on the outcome of CS 5 at T1, CS 6 at T2
nonextraction Class II therapy with headgear combined
F, Female; m, male.
with fixed appliances and Class II elastics.17

All treated patients underwent the same protocol of


MATERIAL AND METHODS 1-phase nonextraction Class II therapy. After an initial
Three samples of white patients with Class II Divi- period with brackets in the maxillary arch to derotate
sion 1 malocclusion were treated consecutively by the the molars (when needed), cervical-pull headgear was
same operator with the same treatment protocol of head- worn on average 14 hours a day for 12 months with fixed
gear combined with fixed appliances and Class II elas- appliance therapy (.018-in slot). In patients with high-
tics. Lateral cephalograms were taken of all subjects angle vertical relationships (5 patients with a Frankfort
with the same x-ray machine before therapy (T1) and horizontal to mandibular plane angle equal to or greater
at an average interval of 6 months after therapy (T2). than 30 2), the pull of the headgear was more vertical.
The first sample started and finished therapy before The use of the headgear was followed by Class II elastics
the pubertal growth spurt: the subjects showed cervical (either 5/16-in, 4-oz elastics, or 5/16-in, 6-oz elastics).
stage (CS) 1 at T1 and CS 3 at T2.17 The second sample The period of Class II elastics wear was 6 to 10 months.
received therapy during the pubertal growth spurt: the Patients were asked to wear the elastics full time.
subjects had CS 3 at T1 and CS 5 at T2. The subjects A customized digitization regimen and analysis with
of the third sample were treated at a postpubertal stage cephalometric software (Viewbox, version 3.0, dHAL
of development: they had CS 5 at T1 and CS 6 at T2. Software, Kifissia, Greece) was used for all cephalograms
The average T1 to T2 interval was approximately 30 examined in this study. The cephalometric analysis re-
months for all patients, with an average treatment dura- quired the digitization of 77 landmarks and 4 fiducial
tion of 24 months. markers. The customized cephalometric analysis in-
The pretreatment Class II characteristics of the cluded measurements from the analyses of Steiner,21
patients in the 3 treatment groups were bilateral full- Jacobson,22 Ricketts,23 and McNamara,24 generating 33
cusp Class II molar relationship, excessive overjet (.5 variables11 angular and 22 linearfor each tracing.
mm), and ANB angle greater than 4 . These features All sets of cephalograms were traced at the same
matched those of the control subjects with untreated Class time. A preliminary tracing was made for each film in
II malocclusion whose longitudinal growth changes were the series, with particular attention to tracing the out-
reported previously.20 Consecutive observations of the lines of the maxilla and the mandible, including the
untreated Class II subjects provided control data for eval- mandibular condyle. Then each set of consecutive films
uation of the treatment effects at the 3 skeletal maturation was checked thoroughly, beginning with the second and
intervals. Table I gives mean ages at T1 and T2, sex third films in the series. Fiducial markers were placed in
distributions, skeletal maturation at T1 and T2 (according the maxilla and the mandible on the third tracing and
to the CVM method),17 and average durations of the T1 to transferred to second tracing in each subjects cephalo-
T2 intervals for the treated and control groups. metric series, based on superimposition of internal
American Journal of Orthodontics and Dentofacial Orthopedics Baccetti, Franchi, and Kim 503
Volume 136, Number 4

plane; it is traced through subnasale (Sn). This line is


a modification of the true vertical line (TVL) of Arnett
et al.25 Profile points measured to VL were soft-tissue
A-point (A0 ), upper lip anterior (ULA), lower lip ante-
rior (LLA), soft-tissue B-point (B0 ), and soft-tissue
pogonion (Pog0 ) (Fig).
Several methodological aspects of this study need to
be noted.
1. The orthodontist who performed the treatment and
the investigators who traced and digitized the lat-
eral cephalograms of treated subjects at T1 and
T2 were blind to the 3 groups of patients according
to skeletal maturity (prepeak, peak, postpeak).
2. The orthodontist was highly proficient and well
trained in the treatment protocol used.
3. Patients were treated consecutively and indepen-
dently of skeletal maturation stage.
4. The success of therapy was not a discriminant fac-
tor for patients to be included in the study.
Cephalograms were traced by an investigator (L.F.)
and then verified for landmark locations, anatomic con-
tours, and tracing superimpositions by another (T.B.).
Fig. Soft-tissue cephalometric analysis. Vertical line
Any disagreements were resolved by retracing the land-
(VL) is perpendicular to the Frankfort plane and traced mark or structure to the satisfaction of both observers. A
through subnasale (Sn). Profile points measured to VL: total of 42 lateral cephalograms randomly chosen from
soft-tissue A-point (A0 ), upper lip anterior (ULA), lower all observations were retraced and redigitized to calcu-
lip anterior (LLA), soft-tissue B-point (B0 ), and soft-tissue late method error with Dahlbergs formula.26 The error
pogonion (Pog0 ). for linear measurements ranged from 0.2 (overjet) to 0.8
mm (Pg to nasion perpendicular), and the error of the
maxillary or mandibular structures. The locations of the angular measurements varied from 0.4 (ANB) to 1.6
fiducial markers were transferred to the first and subse- (interincisal angle).
quently the fourth through the sixth films similarly. The stages of the CVM on each subjects lateral
The maxillae were superimposed along the palatal cephalograms were assessed by 1 investigator (T.B.)
plane by registering on the bony internal details of the and verified by a second (L.F.).17 Any disagreements
maxilla superior to the incisors, and the superior and in- were resolved to the satisfaction of both observers.
ferior surfaces of the hard palate. Fiducial markers were The magnifications of the data sets regarding the
placed in the anterior and posterior parts of the maxilla treated Class II patients and the untreated Class II sub-
along the palatal plane. This superimposition describes jects were different, with the lateral cephalograms of
the movement of the maxillary dentition relative to the treated subjects having 11% enlargement, and those
maxilla. from the control group either 12.9% or 4%. The lateral
The mandibles were superimposed posteriorly on the cephalograms of all treated and untreated subjects were
outline of the mandibular canal. Anteriorly, they were corrected to an 8% enlargement factor.
superimposed on the anterior contour of the chin and
the bony structures of the symphysis. A fiducial marker Statistical analysis
was placed in the center of the symphysis and another in Descriptive statistics of craniofacial measurements
the body of the mandible near the gonial angle. This in all treated and untreated Class II samples at T1 and
superimposition facilitated measuring the movement of T2 were calculated, as well as the between-stage
the mandibular dentition relative to the mandible. changes. The Kolmogorov-Smirnov test showed a lack
For the analysis of soft-tissue profile changes, the of normality of distribution for several measurements.
method of Arnett et al25 was used with modifications. Therefore, nonparametric statistics with the Mann-
The system consists of measurements with a reference Whitney U tests were used (version 12.0, SPSS, Chi-
vertical line (VL) that is perpendicular to the Frankfort cago, Ill). The following comparisons were carried out
504 Baccetti, Franchi, and Kim American Journal of Orthodontics and Dentofacial Orthopedics
October 2009

Table II. Statistical comparisons of the changes between T1 and T2 (prepeak) in Class II treated and untreated subjects
Class II treated n 5 23 Class II untreated n 5 17

Cephalometric measure Mean SD Mean SD Difference Significance

Cranial base
NSBa ( ) 0.9 2.2 0.0 1.8 10.9 NS
Maxillary skeletal
Co-Pt A (mm) 2.3 2.0 3.5 1.2 1.2 *

SNA ( ) 1.3 2.0 0.3 0.7 1.6
Pt A to nasion perp (mm) 0.8 2.2 0.3 0.5 1.1 NS
Mandibular skeletal
Co-Gn (mm) 5.7 2.2 5.3 1.1 10.4 NS
Co-Go (mm) 3.8 2.8 2.7 1.4 11.1 NS
SNB ( ) 0.1 1.5 0.5 1.0 0.6 NS
Pog to nasion perp (mm) 0.5 3.9 1.0 1.5 0.5 NS
Maxillomandibular
Wits (mm) 0.6 2.2 0.3 1.0 0.9 NS

Max/mand diff (mm) 3.4 2.0 1.9 1.1 11.5

ANB ( ) 1.2 1.4 0.2 0.8 1.0
Vertical skeletal

FH to palatal plane ( ) 1.2 2.5 0.6 1.1 11.8
FH to mandibular plane ( ) 0.1 2.3 0.3 1.2 10.2 NS

Palatal plane to mandibular plane ( ) 1.3 2.0 0.3 1.6 1.6
ArGoMe ( ) 0.5 2.0 0.8 1.6 10.3 NS
CoGoMe ( ) 0.5 1.9 0.3 1.3 0.2 NS
N to ANS (mm) 4.0 2.2 3.2 0.7 10.8 NS

ANS to Me (mm) 3.4 1.7 1.7 1.0 11.7
Interdental

Overbite (mm) 2.6 2.0 0.8 1.4 3.4

Overjet (mm) 2.5 2.2 0.6 1.3 3.1
Interincisal angle ( ) 5.7 10.2 1.7 4.5 7.4 *

Molar relationship (mm) 3.5 2.0 0.4 0.7 13.1
Maxillary dentoalveolar
U1 to Pt A vertical (mm) 0.5 2.2 0.3 0.9 0.8 NS
U1 to FH ( ) 0.5 8.1 0.7 3.5 10.2 NS
U1 horizontal (mm) 0.1 1.6 0.9 0.9 0.8 NS
U1 vertical (mm) 0.5 1.6 0.7 1.0 0.2 NS
U6 horizontal (mm) 0.9 2.3 1.2 1.0 0.3 NS
U6 vertical (mm) 2.1 1.3 1.3 0.8 10.8 *
Mandibular dentoalveolar

L1 to Pt A-pogonion (mm) 2.4 1.5 0.1 0.8 12.5

L1 to mandibular plane ( ) 6.3 4.9 0.6 2.5 16.9

L1 horizontal (mm) 1.6 1.0 0.2 0.6 11.4
L1 vertical (mm) 1.1 1.3 1.4 0.8 0.3 NS

L6 horizontal (mm) 3.0 1.7 1.2 0.9 11.8

L6 vertical (mm) 3.1 1.3 1.1 0.7 12.0

NS, Not significant; *P \0.05; P \0.01; P \0.001.

for the dentoskeletal variables: (1) the prepeak treated The comparisons of soft-tissue profile measure-
group vs the untreated Class II group (CS 1) at T1; (2) ments were performed with the Kruskal-Wallis test
the peak treated group vs the untreated Class II group among the 3 treated groups and the Tukey post-hoc
(CS 3) at T1; (3) the postpeak treated group vs the un- test (P \0.05) (SigmaStat version 3.1, Systat Software,
treated Class II group (CS 5) at T1; (4) T2 to T1 changes Point Richmond, Calif).
in the prepeak treated group vs the untreated Class II Since the success of therapy was not a factor for in-
group (CS 1-CS 3 interval); (5) T2 to T1 changes in clusion of the treated patients in this study and because
the peak treated group vs the untreated Class II group patients were treated consecutively by the same operator
(CS 3-CS 5 interval); and (6) T2 to T1 changes in the with a standardized protocol, an analysis of treatment-
postpeak treated group vs the untreated Class II group induced corrections of initial dentoskeletal Class II
(CS 5-CS 6 interval). discrepancy could be carried out in the 3 groups who
American Journal of Orthodontics and Dentofacial Orthopedics Baccetti, Franchi, and Kim 505
Volume 136, Number 4

Table III. Statistical comparisons of the changes between T1 and T2 (peak) in Class II treated and untreated subjects
Class II treated n 5 24 Class II untreated n 5 17

Cephalometric measure Mean SD Mean SD Difference Significance

Cranial base
NSBa ( ) 0.4 1.8 0.1 1.5 0.3 NS
Maxillary skeletal
Co-Pt A (mm) 3.6 2.9 4.5 2.5 0.9 NS
SNA ( ) 0.3 3.2 0.7 1.0 1.0 NS
Pt A to nasion perp (mm) 0.1 2.9 0.6 0.9 0.7 NS
Mandibular skeletal
Co-Gn (mm) 8.8 2.5 6.7 2.3 12.1 *
Co-Go (mm) 5.9 1.6 5.0 3.1 10.9 NS
SNB ( ) 0.4 2.2 0.9 1.2 0.5 NS
Pog to nasion perp (mm) 1.7 3.8 1.9 1.9 0.2 NS
Maxillomandibular

Wits (mm) 1.8 4.5 0.7 1.0 2.5
Max/mand diff (mm) 5.2 2.4 3.2 1.9 12.0 *
ANB ( ) 0.8 2.0 0.2 0.7 0.6 NS
Vertical skeletal
FH to palatal plane ( ) 0.3 2.0 0.8 1.2 11.1 *
FH to mandibular plane ( ) 0.3 1.9 1.0 1.4 10.7 NS
Palatal plane to mandibular plane ( ) 0.6 1.9 0.2 2.0 0.4 NS
ArGoMe ( ) 0.9 2.2 0.9 2.0 0.0 NS
CoGoMe ( ) 0.1 1.7 0.4 1.8 10.3 NS
N to ANS (mm) 2.9 2.6 2.9 1.4 0.0 NS

ANS to Me (mm) 5.2 2.5 3.1 1.3 12.1
Interdental

Overbite (mm) 3.1 1.6 0.3 1.0 2.8

Overjet (mm) 3.2 1.5 0.4 0.8 3.6
Interincisal angle ( ) 4.6 8.6 1.2 3.9 5.8 *

Molar relationship (mm) 4.7 1.8 0.2 0.8 14.5
Maxillary dentoalveolar

U1 to Pt A vertical (mm) 1.3 2.6 0.3 0.6 1.6
U1 to FH ( ) 1.0 7.9 0.2 2.4 0.8 NS
U1 horizontal (mm) 0.5 2.6 0.8 0.7 1.3 NS
U1 vertical (mm) 1.0 1.5 0.5 0.8 10.5 NS
U6 horizontal (mm) 0.6 2.4 1.6 0.9 1.0 NS
U6 vertical (mm) 2.2 1.7 2.0 0.8 10.2 NS
Mandibular dentoalveolar

L1 to Pt A-pogonion (mm) 2.0 1.3 0.2 0.8 12.2

L1 to mandibular plane ( ) 5.8 4.3 0.1 2.9 15.7
L1 horizontal (mm) 0.6 1.2 0.0 0.8 10.6 NS
L1 vertical (mm) 1.4 1.8 2.0 0.9 0.6 NS

L6 horizontal (mm) 2.5 1.3 1.1 1.0 11.4

L6 vertical (mm) 4.2 1.4 1.7 1.1 12.5

NS, Not significant; *P \0.05; P \0.01; P \0.001.

received treatment at the 3 skeletal maturation periods RESULTS


(prepeak, peak, postpeak). The evaluation of correction The statistical comparisons on starting forms be-
was calculated as the percentage of improvement or tween the 3 treated groups and their respective control
worsening at T2 with respect to T1 in the 3 groups for groups showed no significant differences for any den-
these dentoskeletal variables: Wits appraisal, overjet, toskeletal measurement.
and molar relationship. Finally, success or unsuccess The statistical comparison of the T2 to T1 changes
(excessive overjet and full-cusp or half-cusp Class II mo- in the prepeak treated group vs the prepeak untreated
lar relationship) at T2 was assessed in the 3 treated Class II group (Table II) showed significant restriction
groups. in midfacial length (Co-A) and the sagittal position of
506 Baccetti, Franchi, and Kim American Journal of Orthodontics and Dentofacial Orthopedics
October 2009

Table IV. Statistical comparison on the changes between T1 and T2 (postpeak) in Class II treated and untreated subjects
Class II treated n 5 13 Class II untreated n 5 13

Cephalometric measure Mean SD Mean SD Difference Significance

Cranial base
NSBa ( ) 0.0 1.5 0.1 1.3 0.1 NS
Maxillary skeletal
Co-Pt A (mm) 1.4 1.8 1.7 1.2 0.3 NS
SNA ( ) 0.1 2.0 0.4 0.9 10.3 NS
Pt A to nasion perp (mm) 0.3 2.8 0.3 0.8 0.0 NS
Mandibular Skeletal
Co-Gn (mm) 3.5 2.2 2.9 1.2 10.6 NS
Co-Go (mm) 2.2 1.3 1.6 1.1 10.6 NS
SNB ( ) 0.1 1.3 0.1 0.8 0.0 NS
Pog to nasion perp (mm) 0.3 5.6 0.4 1.3 0.1 NS
Maxillomandibular
Wits (mm) 1.2 3.6 0.7 0.7 10.4 NS
Max/mand diff (mm) 2.3 1.1 2.2 1.0 10.1 NS
ANB ( ) 0.0 1.4 0.3 0.6 10.3 NS
Vertical skeletal
FH to palatal plane ( ) 0.8 2.6 0.7 1.2 10.1 NS
FH to mandibular plane ( ) 0.0 2.0 0.0 0.9 0.0 NS
Palatal plane to mandibular plane ( ) 0.8 2.5 0.7 1.7 0.1 NS
ArGoMe ( ) 1.8 2.2 2.3 1.8 10.5 NS
CoGoMe ( ) 1.2 1.5 0.8 1.2 0.4 NS
N to ANS (mm) 1.3 2.5 1.6 1.0 0.3 NS
ANS to Me (mm) 3.0 1.7 1.3 0.8 11.7 *
Interdental

Overbite (mm) 3.4 1.8 0.3 0.4 3.1

Overjet (mm) 2.4 1.3 0.4 0.7 2.0
Interincisal angle ( ) 5.5 9.2 0.0 2.5 5.5 NS

Molar relationship (mm) 2.5 1.0 0.2 0.5 12.3
Maxillary dentoalveolar

U1 to Pt A vertical (mm) 2.4 1.8 0.0 0.6 2.4
U1 to FH ( ) 2.2 6.4 0.4 1.7 2.6 NS
U1 horizontal (mm) 1.1 1.9 0.1 0.6 1.0 NS
U1 vertical (mm) 0.0 0.9 0.1 0.7 0.1 NS
U6 horizontal (mm) 0.7 2.0 0.2 0.7 10.5 NS
U6 vertical (mm) 1.8 1.4 0.3 0.6 11.5 *
Mandibular dentoalveolar
L1 to Pt A-Pogonion (mm) 1.1 2.0 0.2 0.7 10.9 NS

L1 to Mandibular Plane ( ) 7.7 5.5 0.1 2.4 17.8
L1 horizontal (mm) 0.2 1.4 0.2 1.6 10.4 NS
L1 vertical (mm) 0.1 1.5 0.4 0.7 0.5 NS

L6 horizontal (mm) 1.8 1.1 0.2 0.8 11.6

L6 vertical (mm) 2.5 1.4 0.6 0.7 11.9

NS, Not significant; *P \0.05; P \0.01; P \0.001.

the maxilla (SNA). These changes were reflected by veolar changes in the prepeak treated group consisted of
a significant increase in the maxillomandibular differen- extrusion of the maxillary molars, extrusion and mesial
tial and a decrease in the ANB angle. The angulation of movement of the mandibular molars, and proclination
the palatal plane to the Frankfort plane was significantly of the mandibular incisors.
increased in the prepeak treated group, thus leading to The statistical comparison of the T2 to T1 changes
significant reduction of the inclination of the palatal in the peak treated group vs the peak untreated Class
plane to the mandibular plane. Lower anterior facial II group (Table III) showed a significant increase in
height was significantly increased in the treated group. the maxillomandibular differential and a decrease in
Overjet and overbite decreased significantly, and molar the Wits appraisal. These significant differences were
relationship improved significantly. Significant dentoal- sustained by a significant increase in total mandibular
American Journal of Orthodontics and Dentofacial Orthopedics Baccetti, Franchi, and Kim 507
Volume 136, Number 4

Table V. Descriptive statistics and statistical comparisons of the changes in soft-tissue measurements in the 3 treated
groups
Prepeak Peak Postpeak Prepeak Peak Postpeak
treated treated treated treated treated treated Kruskal-
group at group at group at group at group at group at Wallis
Soft-tissue T1 n 5 23 T1 n 5 24 T1 n 5 13 T2 n 5 23 T2 n 5 24 T2 n 5 13 Prepeak Peak Postpeak and
measure T2-T1 T2-T1 T2-T1 post-hoc
(mm) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD change change change tests

A0 -VL 0.1 1.0 0.2 0.8 0.9 0.9 1.0 1.0 1.1 0.9 1.3 1.2 0.9 0.9 0.4 NS
ULA-VL 2.1 2.0 2.6 1.8 1.7 1.8 1.2 1.8 1.9 2.5 1.2 2.0 0.9 0.7 0.5 NS
LLA-VL 1.1 2.1 0.2 2.2 0.7 2.3 1.2 2.2 0.2 2.3 0.7 2.4 0.1 0.0 0.0 NS
B0 -VL 9.6 2.2 9.3 3.5 8.1 2.5 8.8 2.0 8.0 4.2 7.3 3.3 10.8 11.3 10.8 NS
Pog0 -VL 8.9 3.3 9.3 5.7 7.2 2.9 8.2 3.2 7.9 6.0 6.0 4.0 10.7 11.4 11.2 NS

NS, Not significant.

length (Co-Gn). The angulation of the palatal plane to ple (22 of 24), and 85% in the postpeak sample (11 of
the Frankfort plane and the lower anterior facial height 13).
were significantly increased in the peak treated group.
Overjet and overbite decreased significantly, and molar
relationship improved significantly. Significant dentoal- DISCUSSION
veolar changes in the peak treated group consisted of Our aim in this study was to assess the role of timing
retroclination of the maxillary incisors, proclination of in relation to skeletal maturity on the outcomes of
the mandibular incisors, and extrusion and mesial a widely used nonextraction protocol for Class II treat-
movement of the mandibular molars. ment (headgear combined with fixed appliances and
The statistical comparison of the T2 to T1 changes Class II elastics).2,3 A peculiar feature of this study
in the postpeak treated group vs the postpeak untreated was the use of untreated Class II controls at the same
Class II group (Table IV) showed significant dentoal- skeletal maturation phases as the treated subjects.
veolar changes only, with the exception of a larger in- Independently from the skeletal maturity of the
crease in lower anterior facial height. Overjet and treated patients, this treatment regimen proved to be ef-
overbite decreased significantly, and the molar rela- fective on occlusal parameters (overjet, overbite, and
tionship improved significantly. Other significant molar relationship), agreeing with previous short-term
changes in the postpeak treated group consisted of ret- and long-term reports.4-9 Different timing of therapy,
roclination of the maxillary incisors, extrusion of the however, influenced significantly the relative contribu-
maxillary molars, proclination of the mandibular inci- tions of dentoskeletal changes to the final occlusal out-
sors, and extrusion and mesial movement of the man- comes. When headgear therapy, fixed appliances, and
dibular molars. Class II elastics were used in the prepeak period, a sig-
The analysis of soft-tissue measurements (Table V) nificant effect was seen in the maxilla, with about 1.5
showed no significant difference for any variable in the of restriction in maxillary advancement. This favorable
3 treated groups. result was not achieved in either the peak or postpeak
The amounts of correction in overjet were 48% periods. Treatment during the peak period induced a sig-
in the prepeak sample, 65% in the peak sample, nificant increase in mandibular length compared with
and 57% in the postpeak sample. The amounts of the untreated Class II controls (2.1 mm), whereas nei-
correction in molar relationship were 81% in the ther prepeak nor postpeak treatment produced any sup-
prepeak sample, 100% in the peak sample (with plementary elongation of the mandible. The favorable
a full Class I molar relationship), and 61% in the maxillary change in the prepeak treated group and the
postpeak sample. For the Wits appraisal, the prepeak favorable mandibular change in the peak group caused
sample had improvement of 67%, the peak sample significant modifications in the sagittal skeletal relation-
exhibited full correction of the initial discrepancy ships in both groups. The absence of significant skeletal
with the addition of a 28% hypercorrection, and change in the maxilla or the mandible in the postpeak
the postpeak sample had worsening of the initial dis- group was reflected in the lack of significant modifica-
crepancy by 33%. tion in maxillomandibular relationships for this group.
The percentages of successful patients were 64% These data provide additional evidence for the role of
(17 of 23) in the prepeak sample, 92% in the peak sam- treatment timing on the clinical responsiveness of
508 Baccetti, Franchi, and Kim American Journal of Orthodontics and Dentofacial Orthopedics
October 2009

skeletal structures to dentofacial orthopedics. It was modifications were associated with skeletal changes in
demonstrated that the effects of therapies aimed to en- the prepeak and peak treated samples, whereas they rep-
hance or restrict mandibular growth are greater at the resented the only significant dentofacial modification in
growth spurt compared with earlier intervention, the patients treated after the pubertal growth spurt. Pre-
whereas the effects of therapies aimed to alter the max- vious investigations reported similar dentoalveolar find-
illa orthopedically are greater at prepubertal stages.17 ings for this type of nonextraction comprehensive Class
The different responsiveness has been ascribed to the II therapy.4,6,7 In addition, studies have reported extru-
different biologic features of the maxillary sutures27,28 sion of the maxillary molars as a consequence of ther-
vs the mandibular condyle29 at different developmental apy.4,7 In our study, this was found only for the group
phases. These results confirmed that maxillary growth treated before the pubertal growth spurt.
can be restricted at a prepubertal stage of development The analysis of soft-tissue measurements did not
and mandibular growth can be enhanced during the pu- show significant differences for any examined variable
bertal growth spurt. Treatment after the pubertal growth among the 3 treated groups according to timing of ther-
spurt cannot produce significant skeletal changes in apy. Therefore, the differential dentoskeletal contribu-
either the maxilla or the mandible. tions to overall Class II correction and the different
The enhancement in mandibular growth produced amounts of occlusal correction that were significantly
by this treatment protocol in the peak group appears related to treatment timing had no significant impact
to be of special interest when analyzing the overall ef- on the soft-tissue profile.
fects of comprehensive therapy for Class II malocclusion
that includes forces aimed to restrict maxillary advance-
ment (headgear). The use of Class II elastics during the CONCLUSIONS
mandibular growth spurt has been shown previously to The principal findings of this cephalometric study
produce a favorable orthopedic effect of mandibular on the influence of treatment timing on the outcomes
lengthening.30 In addition, LaHaye et al7 analyzed the ef- of 1-phase nonextraction therapy of Class II malocclu-
fects of a similar treatment protocol to ours and reported sion were the following.
increases in mandibular advancement of about 2.0 mm in
2 years in treated patients compared with untreated Class 1. Class II treatment before or during the pubertal
II controls. growth spurt induces significant favorable skeletal
When the outcomes of the examined treatment proto- changes (restriction of maxillary advancement in
col were analyzed in terms of clinical correction of the prepubertal patients and enhancement of mandibu-
pretreatment dentoskeletal relationships, the peak treated lar growth in pubertal patients) in addition to pre-
sample showed a consistently higher prevalence of cor- dominant dentoalveolar modifications. Patients
rected patients than did the prepeak or postpeak samples. treated after the pubertal growth spurt exhibit
All Class II patients treated during the pubertal growth only significant dentoalveolar changes.
spurt achieved a full Class I molar relationship at the 2. The greatest amount of dentoskeletal correction of
end of therapy. Moreover, at the skeletal level, the peak the malocclusion occurs in patients treated during
sample exhibited overcorrection of the initial skeletal in- the pubertal growth spurt.
termaxillary discrepancy (Wits appraisal), whereas the We thank John Clinthorne, who treated all Class II
postpeak sample had relative worsening of the initial skel- patients consecutively with the examined treatment pro-
etal discrepancy. These results emphasize the influence of tocol at his private practice in Ann Arbor, Mich.
treatment timing on the clinical effectiveness of 1-phase
nonextraction Class II therapy. Similar findings were re-
ported by Kopecky and Fishman,19 who investigated tim-
REFERENCES
ing of cervical headgear treatment based on individual
skeletal maturation. They stated that more favorable 1. Proffit WR, Fields HW, Moray LJ. Prevalence of malocclusion
and orthodontic treatment need in the United States: estimates
results were found during maturational periods that from the NHANES-III survey. Int J Adult Orthod Orthognath
were associated with greater incremental growth velocity. Surg 1998;13:97-106.
Headgear therapy associated with fixed appliances 2. McNamara JA Jr, Brudon WL. Orthodontics and dentofacial
and Class II elastics induced significant dentoalveolar orthopedics. Ann Arbor, Mich: Needham Press; 2001. p. 1-3111.
changes in all 3 groups investigated. In general, therapy 3. Alexander RG. The Alexander discipline: contemporary concepts
and philosophy. Glendora, Calif: Ormco 1986. p. 183-4.
produced retroclination of the maxillary incisors, procli- 4. Cangialosi TJ, Meistrell ME Jr, Leung MA, Ko JY. A cephalomet-
nation of the mandibular incisors, and extrusion and me- ric appraisal of edgewise Class II nonextraction treatment with
sial movement of the mandibular molars. Dentoalveolar extraoral force. Am J Orthod Dentofacial Orthop 1988;93:315-24.
American Journal of Orthodontics and Dentofacial Orthopedics Baccetti, Franchi, and Kim 509
Volume 136, Number 4

5. Bishara SE, Zaher AR, Cummins DM, Jakobsen JR. Effects of ment timing in dentofacial orthopedics. Semin Orthod 2005;11:
orthodontic treatment on the growth of individuals with Class II 119-29.
division 1 malocclusion. Angle Orthod 1994;64:221-30. 18. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr.
6. Ciger S, Aksu M, Germec D. Evaluation of posttreatment changes Mandibular changes produced by functional appliances in Class
in Class II Division 1 patients after nonextraction orthodontic II malocclusion: a systematic review. Am J Orthod Dentofacial
treatment: cephalometric and model analysis. Am J Orthod Orthop 2006;129:599.e1-12.
Dentofacial Orthop 2005;127:219-23. 19. Kopecky GR, Fishman LS. Timing of cervical headgear treatment
7. LaHaye MB, Buschang PH, Alexander RG, Boley JC. Orthodon- based on skeletal maturation. Am J Orthod Dentofacial Orthop
tic treatment changes of chin position in Class II Division 1 1993;104:162-9.
patients. Am J Orthod Dentofacial Orthop 2006;130:732-41. 20. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Longitudinal
8. Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic growth changes in untreated subjects with Class II Division 1
therapy: posttreatment dental and skeletal stability. Am J Orthod malocclusion. Am J Orthod Dentofacial Orthop 2008;134:
Dentofacial Orthop 1987;92:321-8. 125-37.
9. Elms TN, Buschang PH, Alexander RG. Long-term stability of 21. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;
Class II, Division 1, nonextraction cervical face-bow therapy: 39:729-55.
II. Cephalometric analysis. Am J Orthod Dentofacial Orthop 22. Jacobson A. The Wits appraisal of jaw disharmony. Am J
1996;109:386-92. Orthod 1975;67:125-38.
10. Pancherz H, Hagg U. Dentofacial orthopedics in relation to 23. Ricketts RM. Perspectives in the clinical application of cephalo-
somatic maturation. Am J Orthod 1985;88:273-87. metrics. The first fifty years. Angle Orthod 1981;51:115-50.
11. Malmgren O, O mblus J, Hagg U, Pancherz H. Treatment with an 24. McNamara JA Jr. A method of cephalometric evaluation. Am J
appliance system in relation to treatment intensity and growth Orthod 1984;86:449-69.
periods. Am J Orthod Dentofacial Orthop 1987;91:143-51. 25. Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A,
12. Hagg U, Pancherz H. Dentofacial orthopaedics in relation to chro- Worley CM Jr, et al. Soft tissue cephalometric analysis: diagnosis
nological age, growth period and skeletal development: an analy- and treatment planning of dentofacial deformity. Am J Orthod
sis of 72 male patients with Class II Division 1 malocclusion Dentofacial Orthop 1999;116:239-53.
treated with the Herbst appliance. Eur J Orthod 1988;10:169-76. 26. Dahlberg G. Statistical methods for medical and biological stu-
13. Petrovic A, Stutzmann J, Lavergne J, Shaye R. Is it possible to dents. London: G: Allen & Unwin; 1940.
modulate the growth of the human mandible with a functional 27. Melsen B, Melsen F. The postnatal development of the palatomax-
appliance? Int J Orthod 1991;29:3-8. illary region studied on human autopsy material. Am J Orthod
14. Petrovic AG, Stutzmann JJ. New ways in orthodontic diagnosis 1982;82:329-42.
and decision-making: physiologic basis. J Japan Orthod Soc 28. Melsen B. Palatal growth studied on human autopsy material:
1992;51:3-25. a histologic microradiographic study. Am J Orthod 1975;68:
15. Baccetti T, Franchi L. Maximizing esthetic and functional 42-54.
changes in Class II treatment by means of appropriate treatment 29. Petrovic A, Stutzmann J, Lavergne J. Mechanism of craniofacial
timing. In: McNamara JA Jr, Kelly KA, editors. New frontiers growth and modus operandi of functional appliances: a cell-level
in facial esthetics. Craniofacial Growth Series, Volume 38. Ann and cybernetic approach to orthodontic decision making. In: Carl-
Arbor: Center for Human Growth and Development; University son DS, editor. Craniofacial growth theory and orthodontic treat-
of Michigan; 2001. p. 237-51. ment. Craniofacial Growth Series. Volume 23. Ann Arbor: Center
16. Faltin K, Faltin RM, Baccetti T, Franchi L, Ghiozzi B, for Human Growth and Development; University of Michigan;
McNamara JA Jr. Long-term effectiveness and treatment timing 1990. p. 13-74
for bionator therapy. Angle Orthod 2003;73:221-30. 30. Petrovic A. Auxologic categorization and chronobiologic specifi-
17. Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral cation for the choice of appropriate orthodontic treatment. Am J
maturation (CVM) method for the assessment of optimal treat- Orthod Dentofacial Orthop 1994;105:192-205.