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Battagel 1991
Battagel 1991
SUMMARY A retrospective cephalometric study was made of the hard tissue changes in a group of
90 Class III, Skeletal III children, diagnosed as suitable for treatment by orthodontic means alone.
Thirty-two were treated by a combination of upper incisor proclination and headgear to an intact
mandibular dentition (Group 1), while in 28 the overjet was corrected with mid-arch extractions
and Edgewise mechanics (Group 2). The remaining 30 children acted as controls (Group 3).
Children were initially examined as male and female subgroups, and where no significant
differences were seen data were pooled. In order to standardize the results, treatment/observation
effects were presented as average changes per year.
The three groups were essentially comparable pretreatment. Following overjet correction, the
lower incisors uprighted in both groups, with an improved relationship to the A-Po line: the upper
incisors were proclined in Group 1 only. Underlying skeletal changes were restricted to the
relationship on a Skeletal III dental base. The tish Standard Institution, 1983) except for gnath-
British Standard definition was used in the ion, for which the definition given by Riolo et al.
assessment of the incisor relationship (British (1974) was used.
Standards Institution, 1983) and the skeletal The tracings were digitized, re-orientated to
pattern was considered to be Class III where a the Frankfort horizontal, and a vertical reference
corrected ANB analysis showed a difference of line drawn through sella. All measurements were
less than 1.5 degrees. The control group of 30 corrected for X-ray magnification and converted
patients was subjected to the same selection to life size. Twelve angular and eleven linear
criteria and children were included if they had measurements were made (Table 3).
two lateral skull radiographs taken at least 1 year Digitizing error was controlled by the program
apart. All patients with a deep overbite and a at 0.1 mm, and the method error calculated by
reverse overjet exhibited some degree of forward retracing and redigitizing ten film pairs, and
mandibular displacement. They have not been applying Dahlberg's (1940) formula (Table 2).
specifically identified in the analyses since there is The errors found were generally larger than
increasing evidence that little or no residual those quoted by other authors, as film pairs
anterior displacement occurs (Gravely, 1984; rather than single films were tested. As expected,
Kerr and Ten Have, 1988a). they were almost entirely due to difficulties in
Treatment was carried out using one of two landmark identification at the tracing stage. The
different techniques. The first group (Group 1) of Frankfort horizontal was particularly vulner-
32 patients (19 males and 13 females) was treated able.
non-extraction by a combination of upper inci- The data were examined using SPSS.
sor proclination and headgear to an intact Measurements for each sex were examined separ-
Non-extraction—E.O.T.
Untreated controls
Table 2 Error of the method for treatment/observa- 'B' point, pogonion, and the lower incisor to sella
tion change (n = 10) calculated by Dahlberg's formula. vertical. The significance of these findings will be
discussed later. Females showed a similar pattern
Measurement Error of change, but again differences were smaller.
Angular Extraction/Edgewise group (Table 1, and
SNA 0.90° Table 4 columns 5-8). Children in this group
SNB 0.65°
ANB 0.56° were older at the start of treatment, since therapy
SN pogonion 0.65° could begin only once premolars had been
NA pogonion 0.87° extracted (Table 1). The lower incisors were
BaSN 1.01° retroclined and also retracted significantly with
Kaxis 0.75° respect to A-Po. Most other linear measure-
FH to N. pog. 0.73°
MM angle 0.75° ments showed significant increases, in particular
Gonial angle 1.07° mandibular length and prominence, and lower
ljl to max. plane 1.67° face height. The females again showed fewer
TjT to mand. plane 1.25° changes. The lower incisor retraction paralleled
that of the males. Smaller, but significant in-
Linear
Overjet 0.63 m m creases in ANB, mandibular length, and lower
Overbite 0.52 m m face height were seen, but most linear skeletal
Tl to A-Po 0.44 m m measurements showed little change.
Art. to pog. 1.10 m m
'A' to sella vertical 1.62 m m Differences between groups due to treatment or
'B' to sella vertical 0.78 m m
Measurement Mean SD Mean SD MvF Mean SD Mean SD MvF Mean SD Mean SD MvF
Angular
SNA 78.02 3.37 78.89 3.16 77.08 3.65 77.33 3.80 79.14 4.80 79.57 4.32
SNB 79.86 4.20 80.65 3.46 78.33 2.84 78.77 3.94 79.44 3.60 80.44 4.25
ANB -1.69t 2.32 — 1.77| 1.64 -1.26 2.33 -1.45 2.23 0.14t . 1.78 -0.76f 2.05
SN pogonion 80.65 4.22 81.61 3.68 79.22 2.74 79.58 3.74 80.42 3.81 81.26 4.14
NA pogonion 174.19 4.83 173.51 3.35 174.85 4.56 174.69 4.24 175.88 3.02 175.14 3.64
BaSN 130.89 4.71 129.43 4.83 132.39 4.93 131.03 4.73 128.98 5.52 130.44 5.81
/axis 56.98t 3.53 55.42f 1.58 59.36f 3.96 58.25f 3.13 58.44 4.38 57.03 3.80
FH to N-pog. 90.36 2.63 91.06 1.83 89.27 3.15 89.90 3.25 89.21 3.20 90.60 3.58
MM angle 27.27 5.38 23.67t 4.69 30.36 5.83 29.49f 5.29 31.03 4.79 26.42 4.77 •
Gonial angle 132.02 4.78 130.15 4.87 135.13 2.87 132.77 5.52 133.56 3.55 131.83 4.58
1U to max. plane 108.51 6.27 116.25 8.54 *• 111.01 4.18 111.39 6.24 108.66 5.19 114.85 5.94 ••
1|1 to mand. plane 84.35 5.05 86.78 7.16 82.98 6.68 80.40 6.77 82.97 6.97 84.86 6.89
Linear
Overjet -0.94 1.08 0.36 1.44 ** 0.03 2.30 0.39 1.21 0.34 1.91 0.29 1.61
Overbite 2.76 2.08 1.74 1.50 1.96 1.62 1.51 1.44 2.27 1.85 1.09 1.32 •—i
T) to A-Po 3.69 1.37 3.09 1.77 3.49 2.77 2.86 2.47 2.71 1.90 3.02 2.19
Art. to Pog. 99.76 5.80 98.08 6.37 102.29 .5.28 98.08 5.26 • 98.33 4.80 97.82 5.94 2
A to sella vert. 61.80 3.41 62.42 2.91 61.19 4.08 59.94 3.97 62.22 5.42 61.66 4.09 w
B to sella vert. 63.09 5.08 64.14 3.68 61.28 6.77 60.57 6.04 61.16 6.10 62.23 5.43 -i
Pog. to sella vert. 64.52 5.94 65.83 4.41 62.67 6.83 61.91 6.39 62.62 6.90 63.69 6.22 H
J]i tip to S. vert. 64.47 4.10 66.90 3.93 65.05 5.34 64.29 5.52 65.73 6.33 65.69 6.00 om
Ml_ apex to S. vert. 56.78 3.22 57.69 2.76 56.31 3.82 55.65 4.12 57.46 4.27 56.58 4.36
Iff tip to S. vert. 66.47 3.72 66.83 3.55 65.19 5.65 63.53 4.99 65.07 4.86 65.41 5.55 p
Lower face height 58.85t 6.86 55.65J 3.17 62.58| 6.82 60.23t 4.58 61.26 5.49 58.42 6.05 Z
oX
*P<0.05; **P<0.0\.
t Indicates significant differences at the 0.05 level between groups before treatment, as shown by a one-way analysis of variance. For the MM angle, only
females showed a difference. For the other three measurements, the two sexes are combined.
ORTON
o
r1
Table 4 Changes during treatment/observation and significant intra-group differences during this time.
jU to max. plane 4.37* 6.89 2.24 ' ».75 1.50 5.50 -0.99 6.43 1.68 3.35 -0.70 3.27
TfT to mand. plane -4.74*** 4.15 -2.70** 2.38 -8.13** 8.35 -3.01* 5.46 0.05 3.00 -1.09 2.97
Linear
Overjet 2.53*** 1.82 1.19 2.00 1.59 2.49 1.51** 1.73 0.23 0.99 0.08 5.98
Overbite -0.81* 1.44 0.58 .02 -0.78 1.60 0.06 1.53 -0.24 0.63 -0.07 .04
T| to A-Po -2.45** 1.75 -0.63 .14 -2.43* 3.07 -2.01*** 1.91 -0.12 0.81 -0.02 .01
Art. to Pog. 3.21*** 2.70 2.28* 2.70 8.13*** 3.10 1.78*** 1.75 6.09 *** 3.61 4.06*** 3.95
'A" to sella vert. 1.54** 1.72 0.72 .40 2.77* 3.14 0.40 1.64 2.24 ** .56 0.45 .13
'B' to sella vert. -0.21 2.54 0.42 2.59 3.24* 4.29 -0.86 2.44 3.20 **' 3.19 1.41 .70
Pog. to S. vert. 0.72 2.60 1.26 2.92 4.86** 4.98 0.50 2.43 3.87 ' 3.77 1.74** 2.26
JJJ_ tip to S. vert. 3.22*** 2.95 2.09** 2.43 3.79* 4.81 0.17 2.92 2.98 * K 2.26 1.04* .63
JM apex to S. vert 1.72*** 1.88 0.95* 1.47 3.51** 2.93 0.49 1.79 2.22 1 1.75 0.99** .29
TfT tip to S. vert. -1.16 2.44 0.24 1.92 1.21 3.79 -1.64* 2.43 2.72 *• 2.43 0.93 .51
Lower face height 4.40*** 2.73 1.66** 1.83 7.42*** 3.68 2.62*** 2.56 3.49 •* 2.70 1.39** .95
Table 5 Annualized changes (i.e. changes per year) and significance between
groups. Where there are no differences between males and females, data for both
sexes have been pooled. Where differences occur, changes are indicated for each
sex. Significant differences between the groups are indicated in the last column.
In the significance column each group is represented by its own numeral, the
type of numeral indicating the significance: i, ii, iii indicates groups differing at the
0.05 level; 1, 2, 3 indicates groups differing at the 0.01 level; I, II, III indicates
groups differing at the 0.001 level. The group shown outside the brackets differs
from the group or groups within.
Linear
Overjet 1.41 + 1.57 0.59 + 0.79 0.07 + 0.33 I (II, III)
Overbite -0.18±0.80 -0.11 ±0.69 0.00 ±0.31
Tl to A-Po -1.14+1.18 -0.85±0.95 -0.06 ±0.38 III (I, II)
Art. to Pog. 1.34+1.27 1.90+1.71 1.7O±1.38
'A' to sella vert. 0.62 ±0.80 0.52+1.11 0.41 ±0.57
'B' to sella vert.
male -0.22 ±1.54 1.42 ±1.90 1.01 + 1.28 i(ii)
female -0.17+1.48 -0.45 + 0.91 0.60 ±0.76 ii (iii)
Pog. to S. vert. 0.29 ±1.54 0.93 + 1.83 0.89± 1.21
XH tip to S. vert.
male 1.79+1.57 1.57 + 2.00 1.00 ±0.93
female 1.65±2.13 —0.06± 1.31 0.41+0.71 1 (2, 3)
ljl apex toS. vert. 0.80 ±0.90 0.72 ±1.26 0.52±0.57
TfT tip to S. vert.
male —0.83+ 1.61 0.67+1.63 0.89±0.93 1 (2, 3)
female -0.35+1.63 -0.72 ±1.09 0.32±0.59 2(3)
Lower face height
male 2.25+1.22 3.21 + 1.49 1.09 ±0.65 III (I, II)
female 1.30 ±1.46 I.22+I.I2 0.42±0.70 iii (i, ii)
lower incisors moved forwards with antero- lar prominence was seen, as evidenced by a
posterior facial growth; this being more marked decrease in SNB, SN pogonion, and the distance
in the upper arch. of 'B' to sella vertical. The mandibular length
increased less (but not significantly), whereas the
Treatment groups. Following treatment, MM angle and lower face height both showed
several of these changes were minimized or significant increases. This may have been due
reversed, particularly in the non-extraction partly to the effect of the posterior bite planes
group. In these children a reduction in mandibu- used to disengage the occlusion during treat-
CLASS III: WITH AND WITHOUT EXTRACTIONS 219
ment. Facial convexity improved, and the upper and Ten Have's (1988ft) normal control group,
and lower incisors snowed approximately a 5 however, differences in changes over the growth
degree combined angular change, with the upper interval are relatively few. ANB becomes more
teeth proclining and the lowers retroclining by negative, the gonial angle closes less, and the
the same amount. The overjet showed a large lower incisors retrocline to a greater extent.
increase whilst the lower incisor was significantly
retracted with respect to A-Po. Comparison of results. Because of the discre-
pancies in ages and treatment times, it was
In the extraction group, angular changes were decided to annualize each measurement before
similar, but few reached the level of significance. the groups were compared. This provides com-
The antero-posterior dental changes were parability, but also has several limitations: first,
smaller and perhaps because the children were it is artificial because the changes examined are
older, greater increases in mandibular length and unlikely to be linear over the period chosen.
lower face height in males were apparent. Pogo- Secondly, all of the mean changes recorded will
nion, 'B' point, and the lower incisor in males be small and, in most instances, less than their
showed no restraint, growing forwards as much standard deviations. Thus, any statistically sig-
or more than in the controls. Dentally, overjet nificant results will tend to be an under-estimate
correction was less good and the upper incisors of the true situation.
were actually slightly retroclined. Despite the
fact that they were actively retracted, trie lower An alternative method of analysis suggested
incisors showed less uprighting and a poorer by Talass et al. (1987), where control group
relationship to A-Po than those in the non- measurements are subtracted from the treatment
extraction group. group values before these are compared, was
they were mature, there was little growth. to Sakamoto et al., 1984; Mitani and Sakamoto,
affect. The reality is likely to be a combination of 1984), but this is accompanied by wider reaching
these effects, since active growth was apparent in changes in Y axis, gonial angle and mandibular
the linear dento-skeletal measurements for both length. Small improvements in Faxis and articu-
control subgroups (Table 4 columns 9-12). lare to pogonion were seen in the non-extraction/
headgear group, but these were not significant.
Annualized changes: treatment effects The degree of short-term skeletal improve-
ment in ANB was entirely due to alteration of'B'
In general, the pattern of changes observed is in point and compares favourably with changes
line with those reported by other authors reported by Mills (1966) and Slattery (1988), but
(Graber, 1977; Wendell et al., 1985; Juixang et unfavourably with Kerr and Ten Have's (1988ft),
al., 1985; Kerr and Ten Have, 19886). These Frankel and Edgewise groups.
changes were confined to angular and linear Overjet correction in the non-extraction group
alterations in tooth position, together with a was assisted by proclination of the upper inci-
favourable backward rotation of the mandible, sors. However, because of the favourable lower
and increases in facial convexity and lower face incisor response, this labial movement was about
height. half (4.59°) of the 9 or 10 degrees reported by
When the three groups were compared, the Mills (1966), Kerr and Ten Have (1988ft), and
extraction/Edgewise children showed few signifi- Juixang et al. (1985) for upper removable
cant changes: this may have been a feature of appliances alone. Since the degree of incisor
treatment selection, since individuals with pro- proclination is normally considered stable
nounced lower arch crowding were always allo- (Mills, 1966; Slattery, 1988) and excessive procli-
mandible. Long-term clinical reports. Angle Orthodontist nocephalometric study of skeletal changes during and after
54: 93-122 chin cup treatment. American Journal of Orthodontics 85:
Nanda R 1980 Biomechanical and clinical considerations of a 341-350
modified protraction headgear. American Journal of Orth- Slattery D 1988 A comparative analysis of the Class III
odontics 78: 125-139 malocclusion with and without an anterior mandibular
Orton H S, Sullivan P G, Battagel J M, Orton S 1983 The displacement on closure. British Journal of Orthodontics
management of Class III and Class III tendency occlusions 15: 33-40
using headgear to the mandibular dentition. British Jour- Talass M F, Talass L, Baker R C 1987 Soft tissue profile
nal of Orthodontics 10: 2-12 changes resulting from retraction of maxillary incisors.
Riolo M L, Movers R E, McNamara J A, Hunter W S 1974 American Journal of Orthodontics and Dentofacial Orth-
An atlas of craniofacial growth. Monograph No. 2, opedics 91: 385-394
Craniofacial Growth Series, Center for Human Growth Wendell P D, Nanda R, Sakamoto T, Nakamura S 1985 The
and Development, University of Michigan, Ann Arbor, effects of chin cup therapy on the mandible: a longitudinal
Michigan. 14 study. American Journal of Orthodontics 87: 265-274
Sakamoto T, Iwase I, Uka A, Nakamura S 1984 A roentge-