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Long - and Short-Term Effects of Headgear Traction With and Without The Maxillary Seconds Molars PDF
Long - and Short-Term Effects of Headgear Traction With and Without The Maxillary Seconds Molars PDF
Long - and Short-Term Effects of Headgear Traction With and Without The Maxillary Seconds Molars PDF
Introduction: A quantitative assessment of maxillary rst molar distalization with and without the maxillary sec-
ond molar (M2) was carried out. Methods: Fifty-six cervical headgear patients undergoing xed appliance ortho-
dontic treatment were divided into 2 groups: before (G M2) and after (G 1 M2) eruption of the maxillary second
molars (ages, 11.87 6 1.20, and 13.05 6 1.55 years, respectively). The tightness of the dental contact point
(TDCP) and the space between the second premolar and the maxillary rst molar were measured at 6 levels
of headgear force (0-15 N) at 3 intervals 6 months apart (T0, T1, T2). Results: Relationships were found be-
tween space and TDCP, time, and presence or absence of the maxillary second molar at T1 and T2
(P \0.001). The TDCP decreased and space increased with increase in initial headgear force. An increase in
initial force beyond 6 to 9 N did not signicantly increase the initial maxillary rst molar distalization. The
G M2 TDCP and space measurements were similar to those of G 1 M2 at T2 with the eruption of the maxillary
second molar. From T0 to T1, maxillary rst molar distalization was greater in G M2. In comparison with our
previous headgear-alone study, initial distalization with a fully bonded appliance was reduced by 4-fold.
Conclusions: Headgear therapy is more effective before the eruption of the maxillary second molar. Once it
erupts, the distalization pace of the maxillary rst molar is reduced, but it can nevertheless be pursued at a slower
pace when the maxillary second molar is present. (Am J Orthod Dentofacial Orthop 2014;146:467-76)
I
t is an accepted treatment modality to direct extra- different HG loading conditions as well as in the pres-
oral forces through the maxillary permanent rst ence or absence of teeth distal to the maxillary perma-
molar to cause its distalization via headgear (HG). nent rst molar.1 The presence of the second molar
However, this effect can vary considerably under (M2) and third molar in different developmental and
eruptive stages can also act as a physical impediment
to the extent and direction of maxillary permanent rst
a
Chair, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
b
Chair, Department of Oral Biology, the Maurice and Gabriela Goldschleger molar distalization.2-5
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. Kloehn6 advocated early HG treatment to distalize the
c
Private practice, Tel Aviv, Israel. maxillary teeth into correct occlusion with the mandibular
d
Instructor, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. dentition. It has also been proposed that treatment of
e
Lecturer, Department of Orthodontics, the Maurice and Gabriela Goldschleger Class II malocclusions should be performed before the
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. eruption of the maxillary permanent second molars and
f
Senior researcher, Department of Oral Technology, Center of Dento-Maxillo-
Facial Medicine, Faculty of Medicine, University of Bonn, Bonn, Germany. canines, since the latter might affect treatment ef-
g
Endowed professor, Center of Dento-Maxillo-Facial Medicine, Faculty of Medi- ciency.7,8 Previous studies with noncompliance
cine, University of Bonn, Bonn, Germany. appliances have reported that before maxillary second
h
Professor, Department of Orthodontics, the Maurice and Gabriela Goldschleger
School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. molar eruption, the maxillary rst molar can be
Nir Shpack and Tamar Brosh are joint rst authors and contributed equally to this distalized by 1 to 2 mm per month with little anchorage
work. lossie, forward displacement of the anterior
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported. segment.2,9 It has been shown when using the
Supported in part by a grant from the GIF (German-Israeli Foundation) (grant no. pendulum appliance that once the maxillary second
01910911). molars have erupted, distal movement of the maxillary
Address correspondence to: Nir Shpack, Department of Orthodontics, the
Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv Univer- rst molar is slowed, and anchorage loss is more
sity, Tel Aviv, Israel; e-mail, nshpack@post.tau.ac.il. common,4 producing mesial movement of the anterior
Submitted, September 2013; revised and accepted, June 2014. teeth.10 Ten Hoeve2 and Jeckel and Rakosi3 concluded
0889-5406/$36.00
Copyright 2014 by the American Association of Orthodontists. that distalization of the maxillary permanent rst molar
http://dx.doi.org/10.1016/j.ajodo.2014.06.015 is restrained by the maxillary second molar; consequently,
467
468 Shpack et al
they recommended distalization before second molar distal movement of the maxillary rst molar, the magni-
eruption. Similar ndings have been reported for several tude of the HG force, and maxillary second molar eruption.
intraoral molar distalization appliances.11,12 The null hypotheses were that at all stages of
On the other hand, Muse et al,13 using a Wilson rapid treatment, the amount of distalization of the maxillary
molar distalization appliance, and Ghosh and Nanda,14 rst molar is not affected by the presence or absence
using the pendulum appliance, found that the presence of the maxillary second molar, and the initial force
of the maxillary second molar did not signicantly affect magnitude has no effect on initial maxillary rst molar
the rate of rst molar movement. Additional studies with distal displacement.
repelling magnets15 and the pendulum appliance10,16
support the latter claims of the minor effect of the MATERIAL AND METHODS
maxillary second molar on rst molar distalization. The study sample comprised 56 patients presenting for
This diversity could be related to the interrupted force treatment at the Department of Orthodontics, University
regimen produced by HG compared with the of Tel Aviv in Israel, diagnosed as having an Angle Class
continuous force of noncompliance appliances. II malocclusion and treated without extractions with
In a previous study, we demonstrated that an incre- cervical HG for at least 1 year for a minimum of 12 hours
mental increase in cervical HG force, applied per se, per day. Subjects were included in the study when part of
caused differences in the gap created between the maxil- their malocclusion was related to maxillary dentoskeletal
lary rst molar and the second premolar, and that rst protrusion (SNA, .83 ; mean, 85.9 6 2.03 ). Syndromic
molar distalization was inuenced by the absence or patients (eg, cleft lip) were excluded, as were those with
presence of the maxillary second molar.2 In this study, early mesial drift of the maxillary rst molar (eg,
we investigated whether similar effects on molar distal- congenitally missing second premolar) and adults
ization can be expected when HG traction is applied (age, .16.5 year). The Class II severity ranged from a
during full-arch xed appliance therapy and over a half-step to a full-step molar relationship. All treatments
longer period of time. Furthermore, we investigated included the use of fully bonded edgewise appliances
whether HG therapy is affected by short-term (initial without intermaxillary or intramaxillary elastics. Data
periodontal ligament [PDL] reaction to HG placement) were gathered at 3 time points: T0, start of HG therapy;
and long-term (bone remodeling) changes, and we T1, 6 months after T0; and T2, 12 months after T0.
determined the range for the initial HG force. The sample was divided into 2 groups: (1) G M2:
With respect to the latter, few previous studies have both maxillary second molars were unerupted at T0 or
examined this issue, mostly describing the orthopedic showed both clinically and radiographically no contact
effects of diverse HG forces. For example, Zentner point between the rst and second molars (21 subjects:
et al17 studied orthopedic forces of 5.6 N (Newton 5 9 boys, 12 girls; mean age, 11.87 6 1.20 years), and (2)
101.97 gram-force 5 3.597 oz) vs orthodontic forces G 1 M2: at T0, both maxillary second molars were
of 3.5 N on a macerated human skull using holographic present in the oral cavity, with both clinically and radio-
interferometry. They reported that lower HG forces pro- graphically an interproximal contact point between the
duced signicantly greater deformations than did higher rst and second molars (35 subjects: 18 boys, 17 girls;
forces; this indicates that there might be an upper limit mean age, 13.05 6 1.55 years).
to the optimal force level. In addition to determining the presence or absence of
Dental changes caused by HG therapy have been the second molars, we examined the Nolla19 stage of
reported in the literature. Andreasen and Johnson18 maxillary second molar development radiographically.
applied diverse forces in each side and found that over A 0.022 3 0.028-in preadjusted appliance was
a 12-week period the molar receiving 4 N of HG force bonded to the maxillary dentition, into which was
distalized 2.5 times more than did the other molar, which inserted an uncinched nickel-titanium archwire. The
received 2 N of force. After 8 weeks in the 2-N side, no archwires were changed according to the progress in
further increase in molar distalization was found, leveling, from 0.014 to 0.018 in. A Kloehn type of cervical
whereas the 4-N side demonstrated continuation of HG was delivered to the bands on the permanent rst
molar distalization at the same pace to end of the study molars. The HG consisted of a medium outer bow, with
(12 weeks). This suggests that there might be a lower U loops (3M Unitek, Monrovia, Calif); the outer arm
limit to the optimal force level. was positioned horizontally (with no adjusted upward
The objectives of this study were to evaluate HG tilt). The HG force was increased gradually from 0 to
distalization efcacy concomitant with edgewise xed 15 N in 3-N increments (0, 3, 6, 9, 12, and 15 N). Zero re-
appliance treatment in relation to 4 variables: the absence ected the measurement when the facebow was inserted
or presence of the maxillary second molar, the amount of in the mouth without attaching the (activation) neck
October 2014 Vol 146 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Shpack et al 469
strap. Upon activation, the force created by the neck strap D is the random error, di is the difference between the
was measured by a force gauge (weighing scale, spring rst and the second measurements, and N is the sample
type WS072; Narang Medical, New Delhi, India) (Fig 1). size that was remeasured.
Displacement of the maxillary right rst molar was For repeated measures of the TDCP, the random error
measured by 2 direct methods at T0, T1, and T2. The rst was 0.209 N (13%); for the space measurements, it was
method was as a function of the change in tightness of 0.012 mm (8.6%). The larger error calculated in the
the contact point between the second premolar and the former was caused by stretching of the PDL during the
rst molar using the tightness of dental contact point initial TDCP measurements; this affected subsequent
(TDCP) device, according to the method of Vardimon measurements. Therefore, only the rst TDCP measure-
et al20-23 (Fig 2, A). Briey, the device measures the ments were considered. No signicant differences were
amount of force required to insert a metal strip found in the paired t tests between the rst and second
(0.15 mm) between 2 adjacent dental contact points in measurements, conrming the absence of systematic
TDCP units (Fig 2, B). The TDCP was measured on the error.
right side and could be measured as long as the maxillary Analysis of variance (ANOVA) with repeated measures
rst molar displacement was smaller than 0.15 mm. with the post hoc Tukey test was used to analyze each
In the second method, custom-made metal gauges parameter (TDCP and space), where the HG force (0-
(leaves) were inserted at the contact point of the second 15 N) and time (T0, T1, T2) were within factors, and
premolar and the rst molar in serial fashion. The gauges maxillary second molar presence or absence (G 1 M2,
(made at workshop of the Faculty of Physics, Tel Aviv G M2) was the between factor. Since the TDCP values
University) differed in thickness from 0.1 to 0.6 mm, in did not show a normal distribution, the formula 1/(7
0.05-mm increments (totaling 11 gauges) (Fig 3). Dis- TDCP) was used to normalize the results: 7 reects the
placements less than 0.1 mm were considered to be no maximum TDCP value (in Newtons) that can be regis-
displacement. Each of the 2 methods was measured while tered by the TDCP device.
the subject was seated in a dental chair reclined to 135 , Pearson correlation analysis was used to analyze the
and the HG force was increased gradually. The total time correlations between TDCP and space for each time
for TDCP and space measurements for the 6 force mag- point at all HG forces.
nitudes was about 12 minutes. The measurements were
taken continuously. All measurements were taken by RESULTS
the same investigator (Y.M.). The average HG force
Nolla stages of maxillary second molar development
worn by the patient during the 12 hours of wear was 4 N.
were 7.6 6 0.5 (1/3 to 2/3 of the root was completed) for
G M2 and 9.5 6 0.5 (root completed with open or
Statistical analysis
closed apex) for G 1 M2. These values correspond to
The random errors (calculated using the Dahlberg previous studies.25,26
formula24) and the systematic error (calculated using a At T0, there was no signicant difference in TDCP be-
paired t test) of the 2 instruments were examined on 5 tween G 1 M2 and G M2. At no HG load force (0 N),
subjects from each group; the 2 sets of measurements the 2 groups had similar contact point tightness. In both
were taken at 1-week intervals. groups, a nonsignicant decrease in contact point tight-
The Dahlberg formula is the following. ness was found as the HG force was increased; however,
q2
PN di the decrease was greater in subjects without the second
D5 i5I 2N molar (G M2) (Fig 4).
American Journal of Orthodontics and Dentofacial Orthopedics October 2014 Vol 146 Issue 4
470 Shpack et al
October 2014 Vol 146 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Shpack et al 471
American Journal of Orthodontics and Dentofacial Orthopedics October 2014 Vol 146 Issue 4
472 Shpack et al
Treatment me (months)
0 0 6 6 12 12
6.00 T0 T1 T2
6 months
6 months
5.00
P2-M1 TDCP (N)
4.00
3.00
2.00
G+M
M TDCP
1.00
G-M
M TDCP
0.00
0 3 6 9 12 15 0 3 6 9 12 15 0 3 6 9 12 15
Head gear force (N)
Fig 4. Change in TDCP at the contact point of the second premolar and the rst molar at 6 HG forces
(0-15 N) applied at 6-month intervals at 3 time points (T0, T1, T2) in the 2 groups, G M2 and G 1 M2
(patients without and with second molars).
friction developed within the molar tube increases with HG only. Because this study was conducted over a
increasing crown tip and archwire size.34 This might 3-month period, we cannot compare HG treatment per
explain the decrease in the HG effect in our study. se with 1 year of treatment of HG with brackets (T2).5
Thus, HG treatment combined with a preadjusted Most likely, in spite of the low force magnitude that light
bracket system might control the bodily distal movement nickel-titanium archwires exert, the counterclockwise
of the rst molar but profoundly reduce the distalization moment acting by these archwires on the rst molar
ability. (counteracting the clockwise moment: ie, distal tip of
At T1, both short-term and long-term HG effects the HG) was effectual in decreasing the initial pace of
were present. The long-term effect was evident after distalization, probably due to the time factor (24-hour
the rst molar accomplished some distal movement dur- archwire vs 12-hour HG). Additionally, the friction pro-
ing the rst 6-month period. This was observed by the duced by the archwire is not present when HG is used.
decline in TDCP at the HG force of 0 N from T0 to T1 At T1, the short-term effect was found to be similar
(15% and 50% for G 1 M2 and G M2, respectively). in the 2 groups. The peak change occurred at 3 N of HG
Thus, after 6 months of HG treatment, more initial space initial force for both TDCP and space. The pattern of
was obtained in G M2, which was measured as a change in TDCP and space with the increase in HG force
3-fold greater TDCP decline than in G 1 M2. That is, was the same for both groups; ie, a decrease in TDCP
the initial space at the contact point of the second pre- was highly correlated with an increase in space (R,
molar and the rst molar signicantly increased after approximately 0.7). The fact that TDCP values were
6 months of HG traction from T0 to T1 at no force signicantly lower and space values higher in G M2
load (0 N) by 70.5% in G M2 and by 35.7% in G 1 M2. in comparison with G 1 M2 is a product of the long-
Comparing the long-term effect of HG with xed ap- term effect: ie, the already accomplished rst molar
pliances (present study) vs HG alone (previous study) distal movement during the 6-month period that is
demonstrated that initial distalizations of 0.2 mm for characterized by bone remodeling and PDL widening,
G M2 and 0.13 mm for G 1 M2 were accomplished which was more distinct in G M2.29-31 Although it
after 6 months of treatment in the former and 3 months was not measured, most likely the distal relocation of
in the latter.5 That is, a 2-fold extension in time is the rst molar is not a pure translation; in the absence
needed for the combined HG and brackets treatment of the second molar, more tipping of the rst molar
to accomplish the same initial distalization as with was expected.4
October 2014 Vol 146 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Shpack et al 473
Table I. TDCP and space (mm) measurements with progressive increases in HG force (015 N) at 3 times and post hoc
analysis (Tukey)
Group Time 0 3 6 9 12 15
TDCP G 1 M2 T0 5.66 6 0.18 5.55 6 0.19 5.40 6 0.19 5.32 6 0.20 5.20 6 0.20 4.97 6 0.19
T1 4.78 6 0.27 3.95 6 0.24 3.72 6 0.25 3.43 6 0.23 3.31 6 0.23 3.17 6 0.22
T2 4.43 6 0.27 3.76 6 0.25 3.50 6 0.24 3.24 6 0.23 3.11 6 0.23 2.84 6 0.20
Tukey T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2
signicance P \0.001 P \0.001 P \0.001 P \0.001 P \0.001 P \0.001
G M2 T0 5.47 6 0.35 5.24 6 0.36 4.82 6 0.36 4.36 6 0.34 4.28 6 0.32 4.21 6 0.32
T1 2.69 6 0.53 1.98 6 0.42 1.83 6 0.40 1.77 6 0.38 1.67 6 0.37 1.65 6 0.36
T2 5.19 6 0.24 4.01 6 0.21 3.66 6 0.18 3.49 6 0.17 3.45 6 0.17 3.03 6 0.17
Tukey T0, T2s T1 T0 s T1 s T2 T0 s T1 s T2 T0, T2 s T1 T0, T2 s T1 T0 s T1 s T2
signicance P 5 0.001 P 5 0.02 P 5 0.03 P 5 0.002 P 5 0.001 P 5 0.008
Space (mm) G 1 M2 T0 0.14 6 0.01 0.15 6 0.01 0.16 6 0.01 0.16 6 0.01 0.16 6 0.01 0.17 6 0.01
T1 0.19 6 0.01 0.24 6 0.01 0.25 6 0.01 0.26 6 0.01 0.26 6 0.01 0.27 6 0.01
T2 0.23 6 0.01 0.27 6 0.01 0.30 6 0.01 0.30 6 0.01 0.29 6 0.01 0.30 6 0.01
Tukey T0 s T1s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2
signicance P \0.001 P \0.001 P \0.001 P \0.001 P \0.001 P \0.001
G M2 T0 0.17 6 0.01 0.18 6 0.01 0.20 6 0.02 0.21 6 0.01 0.21 6 0.01 0.22 6 0.01
T1 0.29 6 0.02 0.35 6 0.00 0.36 6 0.02 0.36 6 0.02 0.36 6 0.02 0.36 6 0.02
T2 0.13 6 0.01 0.23 6 0.01 0.26 6 0.01 0.26 6 0.01 0.26 6 0.01 0.28 6 0.01
Tukey T0 s T1 s T2 T0 s T1 s T2 T0 s T1 s T2 T0, T2 s T1 T0, T2 s T1 T0 s T1 s T2
signicance P 5 0.035 P 5 0.017 P 5 0.018 P 5 0.001 P \0.001 P 5 0.03
Treatment me (months)
0 0 6 6 12 12
0.45 T0 T1 T2
6 months
6 months
0.40
0.35
P2-M1 space (mm)
0.30
0.25
0.20
0.15
0.10 G+M
M space
0.05 M space
G-M
0.00
0 3 6 9 12 15 0 3 6 9 12 15 0 3 6 9 12 15
Head gear force (N)
Fig 5. Change in space at the contact point of the second premolar and the rst molar at 6 HG forces
(0-15 N) applied at 6-month intervals at 3 time points (T0, T1, T2) in the 2 groups, G M2 and G 1 M2
(patients without and with second molars).
At T2, because the mean dental age of G M2 at T2 (erupted second molar) was demonstrated by a par-
reached that of G 1 M2 at T1, the presence of the erupted allel marked decrease in the TDCP reading and an increase
second molar in G M2 was evident by the signicant in- in space readings with HG force elevation from 3 to 15 N.
crease in TDCP at 0 N of HG force from T1 to T2. This pro- Besides the eruption of the second molar in G M2, at
duced a resistance to distalization in G M2 as reected T2, this tooth most likely reached the Nolla tooth devel-
by a sharp reduction in space at G M2 at 0 N of HG force opment stage of G 1 M2 at T0 (root completed with
from T1 to T2 (61%). The similarity between the 2 groups open or closed apex). Consequently, it is suggested that
American Journal of Orthodontics and Dentofacial Orthopedics October 2014 Vol 146 Issue 4
474 Shpack et al
Treatment me (months)
0 0 6 6 12 12
6.00 0.50
T1 T2
6 months
T0
6 months
0.45
5.00
0.40
0.30
3.00 0.25
0.20
2.00
0.15
0.10
1.00 G-M
M TTDCP
0.05
G-M
M space
0.00 0.00
0 3 6 9 12 15 0 3 6 9 12 15 0 3 6 9 12 15
Head gear force (N)
Fig 6. TDCP vs space at the contact point of the second premolar and the rst molar at 6 HG forces
(0-15 N) applied in 6-month intervals at 3 time points (T0, T1, T2) in the G M2 group (patients
without second molars).
Treatment me (months)
0 0 6 6 12 12
6.00 0.50
T0 T1 T2
6 months
0.45
6 months
5.00
0.40
4.00
0.30
3.00 0.25
0.20
2.00
0.15
G+M
M TDCP 0.10
1.00
G+M
M space 0.05
0.00 0.00
0 3 6 9 12 15 0 3 6 9 12 15 0 3 6 9 12 15
Head gear force (N)
Fig 7. TDCP vs space at the contact point of the second premolar and the rst molar at 6 HG forces
(0-15 N) applied in 6-month intervals at 3 time points (T0, T1, T2) in the G 1 M2 group (patients with
second molars).
the enlargement in second molar root length contributed However, our study demonstrates that the initial dis-
to the increase in resistance to distalization. In spite of the talization potential of the rst molar for G 1 M2 was the
increased resistance to initial distalization of the rst same at T1 and T2; this is supported by the ndings of
molar, molar distalization continued but at a slower Abed and Brin,35 who reported on the eruption path of
pace. This nding corresponds with other studies that the second molar during HG treatment, and can be
found on average a decrease in rst molar distalization explained by the same stage of crown development of
by second and third molar buds.2-4,10 the third molar at this age (13-14 years).36 Therefore,
October 2014 Vol 146 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Shpack et al 475
Table II. Pearson correlations between TDCP and space at 3 times for all HG forces (015 N)
Time Pearson correlation and P value 0 3 6 9 12 15
T0 r 0.216 0.258 0.472 0.491 0.507 0.532
P 0.109 0.054 0.001 0.001 0.001 0.001
T1 r 0.739 0.787 0.795 0.742 0.759 0.866
P 0.001 0.001 0.001 0.001 0.001 0.001
T2 r 0.570 0.659 0.662 0.643 0.643 0.773
P 0.001 0.001 0.001 0.001 0.001 0.001
our study does not support the recommendations of 4. The initial effective HG force level is 3 to 6 N and
Kinzinger et al4 of prior germectomy of the third molar should not exceed 9 N.
when a simultaneous distalization of the rst and second 5. HG per se is 4 times more effective than HG com-
molars is required. bined with an edgewise xed appliance.
Regarding the effective initial HG force, at T0 (treat-
ment initiation), G M2 had nonsignicant changes in
ACKNOWLEDGMENTS
the TDCP and space measurements at 6 to 9 N. In
G 1 M2, only a small change was observed for all force We thank Ilana Gelernter from the Department of
levels. That is, initial force elevation was effective up to Statistics, Tel Aviv University, for her assistance.
6 N for G M2, whereas for G 1 M2 the effect was not
signicant. Our T0 data support those of Andreasen and
Johnson,18 who reported decreased effectiveness below REFERENCES
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