Soft tissue & dentofacial skeletal changes with headgear

““Soft tissue and DentoskeletalSoft tissue and Dentoskeletal
profile changes associated withprofile changes associated with
Protraction Headgear treatment –Protraction Headgear treatment –
A cephalometric study”A cephalometric study”
Department of Orthodontics & DentofacialDepartment of Orthodontics & Dentofacial
orthopedicsorthopedics
www.indiandentalacademy.comwww.indiandentalacademy.com

INTRODUCTIONINTRODUCTION

 One of the most perplexing malocclusion toOne of the most perplexing malocclusion to
diagnose and treat, particularly in mixed anddiagnose and treat, particularly in mixed and
late deciduous dentition is the developinglate deciduous dentition is the developing
skeletal class III malocclusion. It is one ofskeletal class III malocclusion. It is one of
the most challenging problem confrontingthe most challenging problem confronting
the practicing orthodontist.the practicing orthodontist.

 Although treatment dates back toAlthough treatment dates back to
1800’s,many practitioners continue to avoid1800’s,many practitioners continue to avoid
early intervention because they believe theearly intervention because they believe the
condition is caused by overgrowth ofcondition is caused by overgrowth of
mandible and they do not believe it ismandible and they do not believe it is
possible to control mandibular growth.possible to control mandibular growth.
Therefore they rationalize that mandibularTherefore they rationalize that mandibular
surgery is inevitable.surgery is inevitable.

 A large number of clinicians feel that a developingA large number of clinicians feel that a developing
mandibular prognathism will reach amandibular prognathism will reach a
predetermined genetic potential that cannot bepredetermined genetic potential that cannot be
altered by early treatment.altered by early treatment.
 This approach predetermines that many youngThis approach predetermines that many young
people must experience facial & dentalpeople must experience facial & dental
disfigurements which could have far reachingdisfigurements which could have far reaching
physical & psychological ramifications duringphysical & psychological ramifications during
some of the most important formative years ofsome of the most important formative years of
their livestheir lives

 Class III malocclusion can haveClass III malocclusion can have
components of –components of –
 Maxillary size deficiencyMaxillary size deficiency
 Maxillary retropositioningMaxillary retropositioning
 True mandibular excessTrue mandibular excess
 Mandibular forward positioningMandibular forward positioning
 Combination of these possibilitiesCombination of these possibilities

 The most important factor to consider aboutThe most important factor to consider about
the protraction treatment is optimal timing,the protraction treatment is optimal timing,
the only possible disadvantage of earlythe only possible disadvantage of early
intervention is the potential for extendedintervention is the potential for extended
total treatment time.total treatment time.

Aims & ObjectivesAims & Objectives

 The aim of the present study was toThe aim of the present study was to
evaluate for sagittal & vertical changesevaluate for sagittal & vertical changes
contributing to class III correction withcontributing to class III correction with
protraction headgear.protraction headgear.
 This investigation was attempted speciallyThis investigation was attempted specially
to determine the inter relationship of the softto determine the inter relationship of the soft
tissue & dentoskeletal profile changestissue & dentoskeletal profile changes
following protraction headgear treatment.following protraction headgear treatment.

Material & MethodsMaterial & Methods

 Pre & post treatment lateral cephalogramsPre & post treatment lateral cephalograms
of 7 patients who had been successfullyof 7 patients who had been successfully
treated at Dept. of Orthodontics &treated at Dept. of Orthodontics &
dentofacial orthopedics , Bapuji Dentaldentofacial orthopedics , Bapuji Dental
college & hospital Davangere werecollege & hospital Davangere were
obtained.obtained.
 Age group of the patients ranged fromAge group of the patients ranged from 6-126-12
yrs. With a mean age of 9 yrs.yrs. With a mean age of 9 yrs.

 All the patients used in the study wereAll the patients used in the study were
treated by reverse pull headgear with thetreated by reverse pull headgear with the
line of force 30line of force 3000
to the occlusal plane,to the occlusal plane,
obliquely downwards .obliquely downwards .
 In all the casesIn all the cases expansion appliance wasexpansion appliance was
also used to disrupt the maxillary & circumalso used to disrupt the maxillary & circum
maxillary sutures.maxillary sutures.

Materials used in the studyMaterials used in the study
 Standardized pre & post treatmentStandardized pre & post treatment
cephalogramscephalograms
 0.3 mm acetate tracing paper.0.3 mm acetate tracing paper.
 0.3 mm lead pencil.0.3 mm lead pencil.
 Geometry boxGeometry box
 Scotch tapesScotch tapes
 Tracing boardsTracing boards
 Scissors & calculatorsScissors & calculators

Criteria for selection of the patientsCriteria for selection of the patients
 Patients were growing individualsPatients were growing individuals
 Patients demonstrated skeletal class IIIPatients demonstrated skeletal class III
malocclusion with deficient maxilla alongmalocclusion with deficient maxilla along
with normal or prognathic mandible evidentwith normal or prognathic mandible evident
from ANB of -1from ANB of -100
to -6to -600
 Protraction of the maxilla was done in all theProtraction of the maxilla was done in all the
patients using reverse pull headgear &patients using reverse pull headgear &
expansion using RMEexpansion using RME

Angular parameters for hard tissueAngular parameters for hard tissue
evaluationevaluation
 SNA angleSNA angle
 SNB angleSNB angle
 ANB angleANB angle
 N-A-Pg angle ( angle of facial convexity)N-A-Pg angle ( angle of facial convexity)
 Facial axis angleFacial axis angle
 Gonial angleGonial angle
 Mandibular plane angleMandibular plane angle

 AB plane angle (AB-NPg)AB plane angle (AB-NPg)
 Facial angle ( NPg – FH )Facial angle ( NPg – FH )
 Basal plane angle ( Pal – MP )Basal plane angle ( Pal – MP )
 Angle of inclinationAngle of inclination

Angular parameters for dentalAngular parameters for dental
 IMPAIMPA
 Interincisal angleInterincisal angle
 U1 – SN planeU1 – SN plane

Angular parameters for soft tissueAngular parameters for soft tissue
 Naso labial angle (Cm-Sn-Ls)Naso labial angle (Cm-Sn-Ls)
 Angle of facial convexity (G-Sn-Pg)Angle of facial convexity (G-Sn-Pg)
 Cant of upper lipCant of upper lip
 Z- angleZ- angle
 H- angleH- angle
 Nasomental angleNasomental angle
 Mento cervical angleMento cervical angle

ResultsResults

TABLE - I : SKELETAL MEASUREMENTS
(ANGULAR)
PRE POSTSl.
No.
Measurement
Range Mean ± SD Range Mean ± SD
Diff.
Mean ± SD
t P
1. SNA 72-81 77.3 ± 3.8 76-87 81.9 ± 3.6 4.6 ± 1.5 8.00 <.001 S
2. SNB 74-84 80.3 ± 3.5 79-85 81.9 ± 2.4 1.6 ± 2.6 1.58 0.17
3. ANB -6-1 -3.0 ± 2.4 -3 – 2 0.0 ± 2.0 3.0 ± 2.4 3.33 0.02 S
4. MPA (SN-MP) 23-37 31.4 ± 4.8 26-37 31.6 ± 3.7 0.2 ± 3.2 0.12 0.91 NS
5. GONIAL ANGLE 122-134 128.4 ± 4.3 121-130 126.9 ± 3.1 1.6 ± 4.5 0.92 0.39 NS
6. BASAL PLANE ANGLE 17-29 23.1 ± 4.1 19-29 24.4 ± 3.9 1.3 ± 3.9 0.86 0.42 NS
7. FACIAL AXIS -4-4 0.1 ± 2.9 -4-5 0.6 ± 3.6 0.4 ± 2.1 0.53 0.62 NS
8. ANGLE OF INCLINATION 81-89 84.1 ± 3.1 79-90 86.0 ± 3.7 1.9 ± 2.7 1.84 0.12 NS
9.
ANGLE OF FACIAL
CONVEXITY
-8-8 -3.7 ± 5.8 -6-11 0.7 ± 6.0 3.0 ± 2.5 3.15 0.02 S
10. AB PLANE (AB-NPA) 2-8 4.0 ± 2.5 -6-4 -0.1 ± 3.7 4.1 ± 4.3 2.53 0.04 S
11. FACIAL ANGLE 84-98 88.7 ± 4.5 87-91 88.6 ± 1.3 0.1 ± 3.8 0.10 0.92 NS
* Paired t-test p<0.05, p<0.01  Significant, p<0.001  Highly significant, p>0.05  Non significant

TABLE – II : DENTAL MEASUREMENTS
(ANGULAR)
PRE POSTSl.
No.
Measurement
Diff.
Mean ± SD
t P
1. INTER INCISAL ANGLE 128-154 13.6 ± 14 113 – 140 125.7 ± 10.9 10.9 ± 16.6 1.73 0.13 NS
2. IMPA 80-115 88.4 ± 12.2 80-95 85.0 ± 4.9 3.4 ± 13.3 0.68 0.52 NS
3. U1-SN 95-117 102.3 ± 7.1 104-123 114.3 ± 6.9 12.0 ± 8.3 3.32 <.01 S
* Paired t-test p<0.05, p<0.01  Significant, p<0.001 Highly significant, p>0.05  Non significant

TABLE – III : SOFT TISSUE MEASUREMENTS
(ANGULAR)
PRE POSTSl.
No.
Measurement
Diff.
Mean ± SD
t P
1. NASOLABIAL ANGLE 85-124 100.6 ± 17.1 68-118 96.1 ± 17.5 4.5 ± 10.0 1.17 0.29 NS
2. CANT OF UPPER LIP 1-25 12.9 ± 7.5 4-20 14.4 ± 5.6 1.6 ± 4.6 0.91 0.40 NS
3. Z-ANGLE 75-83 78.1 ± 3.7 70-76 73.0 ± 2.4 5.0 ± 5.1 2.73 0.03 S
4. H-ANGLE 6-10 7.1 ± 1.5 10-15 13.3 ± 2.1 6.1 ± 2.1 7.68 <.001 S
5. NASO MENTAL 131-144 136.1 ± 4.6 126-134 129.6 ± 2.6 6.6 ± 3.6 4.83 <.001 S
6.
SOFT TISSUE ANGLE OF
CONVEXITY
08-10 -1.4 ± 6.2 7-15 10.7 ± 3.4 12.1 ± 5.8 5.58 <.001 S
7.
MENTO-CERVICAL
ANGLE
90-116 102.6 ± 9.9 103-115 109.4 ± 4.8 6.9 ± 9.7 1.87 0.11 NS
* Paired t-test p<0.05, p<0.01  Significant, p<0.001  Highly significant, p>0.05  Non significant

TABLE – IV : CORRELATION ANALYSIS
SNA ANB UPPER 1 TO SN INTERINCISALSoft Tissue
Landmarks r b r b r b r b
Nasolabial angle .75 5.01 .21 .88 -.94 -1.13 -.04 -.023
Z-Angle .26 .84 .15 .32 -.42 .254 .25 .076
H-Angle .33 .47 .43 .38 -.25 -.063 -.74 -.095
Nasomental angle .07 .17 -.58 -88 .36 .157 .22 .048
Soft tissue angle of
Convexity
.10 .40 .36 .88 -.63 .437 .001 .001
Mento-Cervical
Angle
-.03 .25 -.18 -.74 .25 .295 -.75 -.44
Cant of upper lip .35 2.39 .17 .32 -.96 .531 .19 .052
r =Pearson’s co-relation value (r>6 = Good correlation, r=3 – 6 : Fair Co-relation, r >3 : Poor Co-relation
b = Regression co-efficient value

GRAPH - I
77.3
80.3
-3
81.9 81.9
0
-10
0
10
20
30
40
50
60
70
80
90
SNA SNB ANB
PRE POST

GRAPH II
31.4
128.4
23.1
31.6
126.9
24.4
0
20
40
60
80
100
120
140
MPA(SN-MP) GONIALANGLE BASALPLANEANGLE
PRE POST

GRAPH - III
0.1 0.6
84.1 86
0
10
20
30
40
50
60
70
80
90
100
PRE POST
FACIALAXIS ANGLEOFINCLINATION

GRAPH- IV
136.6
88.4
102.3
125.7
85
114.3
0
20
40
60
80
100
120
140
160
INTER INCISALANGLE IMPA U1-SN
MEAN+/-SD
PRE POST

GRAPH - V
-3.7
0.7
4
-0.01
-5
-4
-3
-2
-1
0
1
2
3
4
5
PRE POST
ANGLEOFFACIALCONVEXITY ABPLANE(AB-NPA)

GRAPH - VI
100.6
12.9
88.7
96.1
14.4
88.6
0
20
40
60
80
100
120
NASOLABIALANGLE CANT OFUPPERLIP FACIALANGLE
PRE POST

GRAPH - VII
78.1
7.1
136.1
73
13.3
129.6
0
20
40
60
80
100
120
140
160
Z-ANGLE H-ANGLE NASO-MENTAL
PRE POST

GRAPH - VIII
-1.4
10.7
102.6
109.4
-20
0
20
40
60
80
100
120
PRE POST
SOFT TISSUEANGLEOFCONVEXITY MENTO-CERVIALANGLE

DiscussionDiscussion

 One of the most challenging problemsOne of the most challenging problems
confronting a practicing orthodontist isconfronting a practicing orthodontist is
diagnosing & treating a developing skeletaldiagnosing & treating a developing skeletal
class III malocclusion, particularly in mixedclass III malocclusion, particularly in mixed
or late deciduous dentition.or late deciduous dentition.

 Although this developing malocclusionAlthough this developing malocclusion
becomes obvious at a very early age (Anglebecomes obvious at a very early age (Angle
1907,Salzmann 1966), diagnosing the1907,Salzmann 1966), diagnosing the
condition correctly is the trump factor incondition correctly is the trump factor in
planning treatment for such conditions.planning treatment for such conditions.

 It is evident from the studies now that mostIt is evident from the studies now that most
of the patients with skeletal class IIIof the patients with skeletal class III
malocclusion have some degree ofmalocclusion have some degree of
maxillary deficiency in addition to a moremaxillary deficiency in addition to a more
obvious mandibular excess.obvious mandibular excess.

 so it became obvious that management ofso it became obvious that management of
most class III cases should include maxillarymost class III cases should include maxillary
protraction as the major objective & earlyprotraction as the major objective & early
interception of class III malocclusion shouldinterception of class III malocclusion should
be attempted in all the patients & therebe attempted in all the patients & there
should be no dilemma in reaching such ashould be no dilemma in reaching such a
decision( Bell, Profitt, Campbell & Turleydecision( Bell, Profitt, Campbell & Turley
1983)1983)

 Treatment of class III malocclusion datesTreatment of class III malocclusion dates
back in 1800’s.back in 1800’s.
 Chin cup was advocated for the correctionChin cup was advocated for the correction
of class III ( Kingsley 1878,Caseof class III ( Kingsley 1878,Case
1920,Graber 1969,77).1920,Graber 1969,77).
 It was believed that this condition was dueIt was believed that this condition was due
to overgrowth of the mandible.to overgrowth of the mandible.

 Genetics was also considered as 1 of theGenetics was also considered as 1 of the
major factors in determining the occurrencemajor factors in determining the occurrence
of mandibular prognathism ( Turpin 1981)of mandibular prognathism ( Turpin 1981)
 Extra oral force in form of protractionExtra oral force in form of protraction
headgear was used to correct the skeletalheadgear was used to correct the skeletal
class III characterized by maxillaryclass III characterized by maxillary
deficiency.deficiency.

 It was observed that maxilla was displacedIt was observed that maxilla was displaced
anteriorly by 1-3mm & maxillary dentition byanteriorly by 1-3mm & maxillary dentition by
1-4mm.( Nanda 1980)1-4mm.( Nanda 1980)
 Cozzani(1981) analysed increase in SNA byCozzani(1981) analysed increase in SNA by
3.50.3.50.
 On the other hand few studies showed noOn the other hand few studies showed no
significant differences in horizontal &significant differences in horizontal &
vertical changes at pt. A ( Shanker et alvertical changes at pt. A ( Shanker et al
1990)1990)

 The present study was a retrospective studyThe present study was a retrospective study
& pre & post treatment cephalograms were& pre & post treatment cephalograms were
used.used.
 In the study only theIn the study only the angular measurementsangular measurements
were taken into consideration,so to rule outwere taken into consideration,so to rule out
the possibility of magnification errors in thethe possibility of magnification errors in the
cephalograms ,which were taken fromcephalograms ,which were taken from
different mechines at different times.different mechines at different times.

 Unfortunately no control group was usedUnfortunately no control group was used
because of unavailability of comparablebecause of unavailability of comparable
class III untreated samples.class III untreated samples.
 Considering the values from previous studyConsidering the values from previous study
which had a control group (Mc Donaldwhich had a control group (Mc Donald
1999) it was evident that the changes seen1999) it was evident that the changes seen
in the presentin the present study were result of thestudy were result of the
appliance therapy rather than normalappliance therapy rather than normal
growth.growth.

 Apart from the changes in the angularApart from the changes in the angular
parametersparameters co-relation betweenco-relation between
dentoskeletal & soft tissue parametersdentoskeletal & soft tissue parameters werewere
also checked. which showed results inalso checked. which showed results in
accordance with the present study.accordance with the present study.
 Some recent studies have been done onSome recent studies have been done on
modifying the design of appliance so as tomodifying the design of appliance so as to
eliminate the drawbacks.eliminate the drawbacks.

 Which suggested to apply protraction forcesWhich suggested to apply protraction forces
above the FH plane to produce downward &above the FH plane to produce downward &
backward rotation of the maxilla (Torosbackward rotation of the maxilla (Toros
Alcan 2000). This article can stand as aAlcan 2000). This article can stand as a
reference for comparison with the presentreference for comparison with the present
study in future.study in future.

ConclusionConclusion

The conclusions derived from the study were-The conclusions derived from the study were-
 The facial convexity in regard to relationshipThe facial convexity in regard to relationship
of hard & soft tissue chin to upper face, wasof hard & soft tissue chin to upper face, was
decreased as a result of protractiondecreased as a result of protraction
treatment & facial esthetics was improved.treatment & facial esthetics was improved.
 The maxilla was repositioned anteriorlyThe maxilla was repositioned anteriorly
significantly in all cases & intremaxillarysignificantly in all cases & intremaxillary
relationship was improved.relationship was improved.

 The soft tissue contour of upper lip & itsThe soft tissue contour of upper lip & its
relationship with lower lip & other soft tissuerelationship with lower lip & other soft tissue
structures was altered by protractionstructures was altered by protraction
treatment.treatment.

Thank youThank you

Soft tissue & dentofacial skeletal changes with headgear

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