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
clinical problem in orthodontics, with approxi-
mately 15% to 30% of North American children
and 20% to 30% of all orthodontic patients having this
type of dentoskeletal imbalance.1 Of the various treat-
ment strategies for Class II treatment, headgear associ-
ated with fixed appliances is probably the most widely
used, and it has been a dependable method of Class II
correction for many decades.2,3 This nonextraction
technique is 1-phase comprehensive therapy of the mal-
occlusion with the adjunct of Class II elastics during the
final phase of treatment.3
Despite of the popularity of this protocol, there is
a relative paucity of information in the literature about
the dentoskeletal changes of 1-phase nonextraction
Class II therapy in either adolescents or young adults.
a
Assistant professor, Department of Orthodontics, University of Florence, Flor-
ence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics
and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann
Arbor.
b
Clinical instructor, Department of Orthodontics and Pediatric Dentistry,
School of Dentistry, University of Michigan, Ann Arbor; private practice,
Ann Arbor, Mich.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Lorenzo Franchi, Dipartimento di Odontostomatologia,
Universita` degli Studi di Firenze, Via del Ponte di Mezzo, 46-48, 50127, Fire-
nze, Italy; e-mail, lorenzo.franchi@unifi.it.
Submitted, March 2007; revised and accepted, August 2007.
0889-5406/$36.00
Copyright 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.08.029
A few cephalometric studies reported short-term effects
of nonextraction treatment with extraoral forces and
Class II elastics in Class II patients.4-7 They all agreed
in describing significantly favorable changes in the sag-
ittal position of both the maxilla and the mandible,
together with the extrusion of the maxillary molars
and proclination of the mandibular incisors. Bishara
et al5 indicated that nonextraction Class II treatment
induced overall normalization of the skeletal rela-
tionships. LaHaye et al7 found that nonextraction head-
gear treatment produced normal dental relationships
and restricted anteroposterior maxillary growth with
inadequate effects on the sagittal position of the chin.
The number of studies with posttreatment observation
is even more limited. Overall long-term stability of
the investigated protocol is reported to be relatively
good,8,9 with a tendency to forward rebound of the max-
illa after Class II correction with headgear and fixed
appliances.8
Most of the short-term and long-term studies that in-
vestigated the effectiveness of headgear therapy com-
bined with fixed appliances and Class II elastics did
not include a control group of untreated Class II sub-
jects.4,6,8,9 Bishara al5 used untreated subjects with nor-
mal dentoskeletal relationships as controls, since the
aim of that investigation was to test the hypothesis
that treatment could induce normalization of the den-
toskeletal relationships in Class II patients. Moreover,
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
Three samples of white patients with Class II Divi-
sion 1 malocclusion were treated consecutively by the
same operator with the same treatment protocol of head-
gear combined with fixed appliances and Class II elas-
tics. Lateral cephalograms were taken of all subjects
with the same x-ray machine before therapy (T1) and
at an average interval of 6 months after therapy (T2).
The first sample started and finished therapy before
the pubertal growth spurt: the subjects showed cervical
stage (CS) 1 at T1 and CS 3 at T2.17 The second sample
received therapy during the pubertal growth spurt: the
subjects had CS 3 at T1 and CS 5 at T2. The subjects
of the third sample were treated at a postpubertal stage
of development: they had CS 5 at T1 and CS 6 at T2.
The average T1 to T2 interval was approximately 30
months for all patients, with an average treatment dura-
tion of 24 months.
The pretreatment Class II characteristics of the
patients in the 3 treatment groups were bilateral full-
cusp Class II molar relationship, excessive overjet (.5
mm), and ANB angle greater than 4 . These features
matched those of the control subjects with untreated Class
II malocclusion whose longitudinal growth changes were
reported previously.20 Consecutive observations of the
untreated Class II subjects provided control data for eval-
uation of the treatment effects at the 3 skeletal maturation
intervals. Table I gives mean ages at T1 and T2, sex
distributions, skeletal maturation at T1 and T2 (according
to the CVM method),17 and average durations of the T1 to
T2 intervals for the treated and control groups.
1-phase nonextraction Class II therapy. After an initial
period with brackets in the maxillary arch to derotate
the molars (when needed), cervical-pull headgear was
worn on average 14 hours a day for 12 months with fixed
appliance therapy (.018-in slot). In patients with high-
angle vertical relationships (5 patients with a Frankfort
horizontal to mandibular plane angle equal to or greater
than 30 2), the pull of the headgear was more vertical.
The use of the headgear was followed by Class II elastics
(either 5/16-in, 4-oz elastics, or 5/16-in, 6-oz elastics).
The period of Class II elastics wear was 6 to 10 months.
Patients were asked to wear the elastics full time.
A customized digitization regimen and analysis with
cephalometric software (Viewbox, version 3.0, dHAL
Software, Kifissia, Greece) was used for all cephalograms
examined in this study. The cephalometric analysis re-
quired the digitization of 77 landmarks and 4 fiducial
markers. The customized cephalometric analysis in-
cluded measurements from the analyses of Steiner,21
Jacobson,22 Ricketts,23 and McNamara,24 generating 33
variables11 angular and 22 linearfor each tracing.
All sets of cephalograms were traced at the same
time. A preliminary tracing was made for each film in
the series, with particular attention to tracing the out-
lines of the maxilla and the mandible, including the
mandibular condyle. Then each set of consecutive films
was checked thoroughly, beginning with the second and
third films in the series. Fiducial markers were placed in
the maxilla and the mandible on the third tracing and
transferred to second tracing in each subjects cephalo-
metric series, based on superimposition of internal
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 4
Fig. Soft-tissue cephalometric analysis. Vertical line
(VL) is perpendicular to the Frankfort plane and traced
through subnasale (Sn). Profile points measured to VL:
soft-tissue A-point (A0 ), upper lip anterior (ULA), lower
lip anterior (LLA), soft-tissue B-point (B0 ), and soft-tissue
pogonion (Pog0 ).
maxillary or mandibular structures. The locations of the
fiducial markers were transferred to the first and subse-
quently the fourth through the sixth films similarly.
The maxillae were superimposed along the palatal
plane by registering on the bony internal details of the
maxilla superior to the incisors, and the superior and in-
ferior surfaces of the hard palate. Fiducial markers were
placed in the anterior and posterior parts of the maxilla
along the palatal plane. This superimposition describes
the movement of the maxillary dentition relative to the
maxilla.
The mandibles were superimposed posteriorly on the
outline of the mandibular canal. Anteriorly, they were
superimposed on the anterior contour of the chin and
the bony structures of the symphysis. A fiducial marker
was placed in the center of the symphysis and another in
the body of the mandible near the gonial angle. This
superimposition facilitated measuring the movement of
the mandibular dentition relative to the mandible.
For the analysis of soft-tissue profile changes, the
method of Arnett et al25 was used with modifications.
The system consists of measurements with a reference
vertical line (VL) that is perpendicular to the Frankfort
Baccetti, Franchi, and Kim 503
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.).
Any disagreements were resolved by retracing the land-
mark or structure to the satisfaction of both observers. A
total of 42 lateral cephalograms randomly chosen from
all observations were retraced and redigitized to calcu-
late method error with Dahlbergs formula.26 The error
for linear measurements ranged from 0.2 (overjet) to 0.8
mm (Pg to nasion perpendicular), and the error of the
angular measurements varied from 0.4 (ANB) to 1.6
(interincisal angle).
The stages of the CVM on each subjects lateral
cephalograms were assessed by 1 investigator (T.B.)
and verified by a second (L.F.).17 Any disagreements
were resolved to the satisfaction of both observers.
The magnifications of the data sets regarding the
treated Class II patients and the untreated Class II sub-
jects were different, with the lateral cephalograms of
treated subjects having 11% enlargement, and those
from the control group either 12.9% or 4%. The lateral
cephalograms of all treated and untreated subjects were
corrected to an 8% enlargement factor.
Statistical analysis
Descriptive statistics of craniofacial measurements
in all treated and untreated Class II samples at T1 and
T2 were calculated, as well as the between-stage
changes. The Kolmogorov-Smirnov test showed a lack
of normality of distribution for several measurements.
Therefore, nonparametric statistics with the Mann-
Whitney U tests were used (version 12.0, SPSS, Chi-
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
group vs the untreated Class II group (CS 1) at T1; (2)
the peak treated group vs the untreated Class II group
(CS 3) at T1; (3) the postpeak treated group vs the un-
treated Class II group (CS 5) at T1; (4) T2 to T1 changes
in the prepeak treated group vs the untreated Class II
group (CS 1-CS 3 interval); (5) T2 to T1 changes in
the peak treated group vs the untreated Class II group
(CS 3-CS 5 interval); and (6) T2 to T1 changes in the
postpeak treated group vs the untreated Class II group
(CS 5-CS 6 interval).
The comparisons of soft-tissue profile measure-
ments were performed with the Kruskal-Wallis test
among the 3 treated groups and the Tukey post-hoc
test (P \0.05) (SigmaStat version 3.1, Systat Software,
Point Richmond, Calif).
Since the success of therapy was not a factor for in-
clusion of the treated patients in this study and because
patients were treated consecutively by the same operator
with a standardized protocol, an analysis of treatment-
induced corrections of initial dentoskeletal Class II
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
was calculated as the percentage of improvement or
worsening at T2 with respect to T1 in the 3 groups for
these dentoskeletal variables: Wits appraisal, overjet,
and molar relationship. Finally, success or unsuccess
(excessive overjet and full-cusp or half-cusp Class II mo-
lar relationship) at T2 was assessed in the 3 treated
groups.
The statistical comparisons on starting forms be-
tween the 3 treated groups and their respective control
groups showed no significant differences for any den-
toskeletal measurement.
The statistical comparison of the T2 to T1 changes
in the prepeak treated group vs the prepeak untreated
Class II group (Table II) showed significant restriction
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
a significant increase in the maxillomandibular differen-
tial and a decrease in the ANB angle. The angulation of
the palatal plane to the Frankfort plane was significantly
increased in the prepeak treated group, thus leading to
significant reduction of the inclination of the palatal
plane to the mandibular plane. Lower anterior facial
height was significantly increased in the treated group.
Overjet and overbite decreased significantly, and molar
relationship improved significantly. Significant dentoal-
veolar changes in the prepeak treated group consisted of
extrusion of the maxillary molars, extrusion and mesial
movement of the mandibular molars, and proclination
of the mandibular incisors.
The statistical comparison of the T2 to T1 changes
in the peak treated group vs the peak untreated Class
II group (Table III) showed a significant increase in
the maxillomandibular differential and a decrease in
the Wits appraisal. These significant differences were
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
the Frankfort plane and the lower anterior facial height
were significantly increased in the peak treated group.
Overjet and overbite decreased significantly, and molar
relationship improved significantly. Significant dentoal-
veolar changes in the peak treated group consisted of
retroclination of the maxillary incisors, proclination of
the mandibular incisors, and extrusion and mesial
movement of the mandibular molars.
The statistical comparison of the T2 to T1 changes
in the postpeak treated group vs the postpeak untreated
Class II group (Table IV) showed significant dentoal-
veolar changes only, with the exception of a larger in-
crease in lower anterior facial height. Overjet and
overbite decreased significantly, and the molar rela-
tionship improved significantly. Other significant
changes in the postpeak treated group consisted of ret-
roclination of the maxillary incisors, extrusion of the
maxillary molars, proclination of the mandibular inci-
sors, and extrusion and mesial movement of the man-
dibular molars.
The analysis of soft-tissue measurements (Table V)
showed no significant difference for any variable in the
3 treated groups.
The amounts of correction in overjet were 48%
in the prepeak sample, 65% in the peak sample,
and 57% in the postpeak sample. The amounts of
correction in molar relationship were 81% in the
prepeak sample, 100% in the peak sample (with
a full Class I molar relationship), and 61% in the
postpeak sample. For the Wits appraisal, the prepeak
sample had improvement of 67%, the peak sample
exhibited full correction of the initial discrepancy
with the addition of a 28% hypercorrection, and
the postpeak sample had worsening of the initial dis-
crepancy by 33%.
The percentages of successful patients were 64%
(17 of 23) in the prepeak sample, 92% in the peak sam-
ple (22 of 24), and 85% in the postpeak sample (11 of
13).
DISCUSSION
Our aim in this study was to assess the role of timing
in relation to skeletal maturity on the outcomes of
a widely used nonextraction protocol for Class II treat-
ment (headgear combined with fixed appliances and
Class II elastics).2,3 A peculiar feature of this study
was the use of untreated Class II controls at the same
skeletal maturation phases as the treated subjects.
Independently from the skeletal maturity of the
treated patients, this treatment regimen proved to be ef-
fective on occlusal parameters (overjet, overbite, and
molar relationship), agreeing with previous short-term
and long-term reports.4-9 Different timing of therapy,
however, influenced significantly the relative contribu-
tions of dentoskeletal changes to the final occlusal out-
comes. When headgear therapy, fixed appliances, and
Class II elastics were used in the prepeak period, a sig-
nificant effect was seen in the maxilla, with about 1.5
of restriction in maxillary advancement. This favorable
result was not achieved in either the peak or postpeak
periods. Treatment during the peak period induced a sig-
nificant increase in mandibular length compared with
the untreated Class II controls (2.1 mm), whereas nei-
ther prepeak nor postpeak treatment produced any sup-
plementary elongation of the mandible. The favorable
maxillary change in the prepeak treated group and the
favorable mandibular change in the peak group caused
significant modifications in the sagittal skeletal relation-
ships in both groups. The absence of significant skeletal
change in the maxilla or the mandible in the postpeak
group was reflected in the lack of significant modifica-
tion in maxillomandibular relationships for this group.
These data provide additional evidence for the role of
treatment timing on the clinical responsiveness of
508 Baccetti, Franchi, and Kim
skeletal structures to dentofacial orthopedics. It was
demonstrated that the effects of therapies aimed to en-
hance or restrict mandibular growth are greater at the
growth spurt compared with earlier intervention,
whereas the effects of therapies aimed to alter the max-
illa orthopedically are greater at prepubertal stages.17
The different responsiveness has been ascribed to the
different biologic features of the maxillary sutures27,28
vs the mandibular condyle29 at different developmental
phases. These results confirmed that maxillary growth
can be restricted at a prepubertal stage of development
and mandibular growth can be enhanced during the pu-
bertal growth spurt. Treatment after the pubertal growth
spurt cannot produce significant skeletal changes in
either the maxilla or the mandible.
The enhancement in mandibular growth produced
by this treatment protocol in the peak group appears
to be of special interest when analyzing the overall ef-
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
mandibular growth spurt has been shown previously to
produce a favorable orthopedic effect of mandibular
lengthening.30 In addition, LaHaye et al7 analyzed the ef-
fects of a similar treatment protocol to ours and reported
increases in mandibular advancement of about 2.0 mm in
2 years in treated patients compared with untreated Class
II controls.
When the outcomes of the examined treatment proto-
col were analyzed in terms of clinical correction of the
pretreatment dentoskeletal relationships, the peak treated
sample showed a consistently higher prevalence of cor-
rected patients than did the prepeak or postpeak samples.
All Class II patients treated during the pubertal growth
spurt achieved a full Class I molar relationship at the
end of therapy. Moreover, at the skeletal level, the peak
sample exhibited overcorrection of the initial skeletal in-
termaxillary discrepancy (Wits appraisal), whereas the
postpeak sample had relative worsening of the initial skel-
etal discrepancy. These results emphasize the influence of
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-
ing of cervical headgear treatment based on individual
skeletal maturation. They stated that more favorable
results were found during maturational periods that
were associated with greater incremental growth velocity.
Headgear therapy associated with fixed appliances
and Class II elastics induced significant dentoalveolar
changes in all 3 groups investigated. In general, therapy
produced retroclination of the maxillary incisors, procli-
nation of the mandibular incisors, and extrusion and me-
sial movement of the mandibular molars. Dentoalveolar
American Journal of Orthodontics and Dentofacial Orthopedics
October 2009
modifications were associated with skeletal changes in
the prepeak and peak treated samples, whereas they rep-
resented the only significant dentofacial modification in
the patients treated after the pubertal growth spurt. Pre-
vious investigations reported similar dentoalveolar find-
ings for this type of nonextraction comprehensive Class
II therapy.4,6,7 In addition, studies have reported extru-
sion of the maxillary molars as a consequence of ther-
apy.4,7 In our study, this was found only for the group
treated before the pubertal growth spurt.
The analysis of soft-tissue measurements did not
show significant differences for any examined variable
among the 3 treated groups according to timing of ther-
apy. Therefore, the differential dentoskeletal contribu-
tions to overall Class II correction and the different
amounts of occlusal correction that were significantly
related to treatment timing had no significant impact
on the soft-tissue profile.
CONCLUSIONS
The principal findings of this cephalometric study
on the influence of treatment timing on the outcomes
of 1-phase nonextraction therapy of Class II malocclu-
sion were the following.
1. Class II treatment before or during the pubertal
growth spurt induces significant favorable skeletal
changes (restriction of maxillary advancement in
prepubertal patients and enhancement of mandibu-
lar growth in pubertal patients) in addition to pre-
dominant dentoalveolar modifications. Patients
treated after the pubertal growth spurt exhibit
only significant dentoalveolar changes.
2. The greatest amount of dentoskeletal correction of
the malocclusion occurs in patients treated during
the pubertal growth spurt.
We thank John Clinthorne, who treated all Class II
patients consecutively with the examined treatment pro-
tocol at his private practice in Ann Arbor, Mich.
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