ORIGINAL ARTICLE

Long-term mandibular skeletal and dental effects of standard edgewise treatment

Burcu Bayirli,a James L. Vaden,b and Lysle E. Johnston Jrc Seattle, Wash, Knoxville, Tenn, and Ann Arbor, Mich Introduction: The purpose of this investigation was to examine the effect of Tweed edgewise treatment on the expression of mandibular growth in the horizontal direction through maintenance of vertical control. Methods: We studied 36 patients who had 4 premolars extracted during treatment. Pretreatment, posttreatment, and postretention records of these patients were matched by age (6 6 months), sex, malocclusion, and treatment interval (6 6 months) to untreated controls from the Bolton-Brush Growth Study Center, Cleveland, Ohio. The cephalograms of the 2 samples were traced, digitized, and analyzed by descriptive cephalometric analysis and detailed regional superimposition. Results: Tweed edgewise treatment can prevent clockwise rotation but was not observed to enhance the normal forward rotation of the mandible. The mandible did not rotate forward in the treated patients who underwent a greater chin advancement. Conclusions: The pattern of skeletal change was favorable both during treatment and in later years. A feature of this effect was an improved pattern of mandibular growth displacement, when mandibular change was compared with maxillary change. (Am J Orthod Dentofacial Orthop 2013;144:682-90)

alocclusion can occur, at least in part, as a result of an unfortunate pattern of facial growth. The translation and transformation of the components of the orofacial complex, however, cannot be attributed solely to genetics.1 Bone responds to its environment as it grows.1 This fact does not mean that growth can be modied in a controlled and predictable way.1 Orthodontists seek treatment methods that can, in some measure, create an environment to ameliorate qualitative or quantitative growth deciencies. Many orthodontists use a rst phase of functional therapy, rather than rely solely on some form of xed appliance treatment, largely because they assume that multibonded treatments can have no effect on growth. In contrast, some clinicians who use the Tweed-Merrield edgewise

a Afliate associate professor, Department of Orthodontics, School of Dentistry, University of Washington, Seattle, Wash. b Professor, Graduate Orthodontic Program, College of Dentistry, University of Tennessee, Knoxville, Tenn. c Professor emeritus, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, Mich. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported. Address correspondence to: Burcu Bayirli, 509 Olive Way, Suite 824, Seattle, WA 98101; e-mail, bayirli@uw.edu. Submitted, July 2011; revised and accepted, July 2013. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.07.008

technique have argued that their method of treatment controls the vertical dimension and thereby modies the vector of mandibular growth, leading to counterclockwise mandibular rotationan advancement of the chin at the expense of facial height. To this end, vertical-control mechanics are designed to inhibit an increase in anterior facial height by preventing molar extrusion.2,3 A goal of their treatment, therefore, is to control forward and downward maxillary growth to facilitate counterclockwise mandibular rotation.4 In 2 studies of the effects of orthodontic therapy on the vertical dimension, anterior facial height increased signicantly during treatment.5,6 These ndings disagree with a signicant increase in the posterior facial height:anterior facial height ratio reported during treatment by other researchers.7,8 Similarly, vertical control has been studied in animals as well. Altuna and Woodside9 showed that molar intrusion resulted in a pattern of maxillary growth that featured minimal change in the vertical dimension, thereby leading to a more horizontal direction of mandibular growth in monkeys. Clinical studies suggest that the amount or direction of mandibular growth can be altered by a variety of treatments, including, in the opinion of many, the edgewise appliance. The purpose of this investigation, a long-term comparison of 36 edgewise patients and untreated controls matched for age, sex, malocclusion, and treatment interval, was to examine the effect of a traditional edgewise treatment that attempts to increase the

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horizontal component of mandibular growth with techniques designed to control the vertical dimension.
MATERIAL AND METHODS

In this study, we included 36 edgewise patients treated by a clinician (J.L.V.) who uses the Tweed directional force mechanics and 36 matched, untreated control subjects. The subjects were recruited as they returned for retention records. The criteria for inclusion in the study were that all subjects had pretreatment, posttreatment, and retention records, taken at average ages of 12.6 (range, 10.9-14.8 years), 14.8 (range, 12.4-16.11 years), and 23.4 (range, 18.1-26.8 years), respectively; Class I or Class II malocclusions; and the extraction of 4 premolars as part of their treatment. Patients treated without premolar extractions were not included in the sample. The treated group comprised 9 boys and 27 girls. Selection was unrelated to outcome, although a willingness to participate implies that the subjects were satised with their treatment. All patients were treated with a nontorqued, nonangulated, 0.022-in edgewise appliance.10 In this technique, the maxillary and mandibular arches were leveled and aligned, and after canine retraction had been completed in both arches, 0.019 3 0.025-in maxillary and mandibular closing-loop archwires were inserted.11 High-pull J-hook headgear force (recommended for approximately 10-12 hours per day) was applied to hooks soldered to the archwire between the maxillary central and lateral incisors. After mandibular space closure, mandibular anchorage usually was prepared, and the patients were instructed to wear the mandibular high-pull headgear against hooks soldered mesially to the canines on the mandibular archwire. A mandibular stabilizing archwire was then placed, and Class II elastics, anterior vertical elastics, and a high-pull headgear to the maxillary archwire were instituted. The intraoral elastics were supposed to be worn 24 hours a day during this treatment phase. Treatment averaged 26 months (range, 19-30 months). Records from the untreated controls were obtained from the archives of the Bolton-Brush Growth Study Center, Case Western Reserve University, Cleveland, Ohio. A control subject was chosen to match each patient in the treated group with respect to age (66 months), sex, malocclusion, and treatment interval (66 months). Accordingly, there was a control group of 36 subjects against which to assess the effects of treatment. The pretreatment and posttreatment (T1 and T2) and postretention (T3) lateral cephalograms, as well as the cephalograms from the control subjects, were traced, superimposed, and digitized to examine the skeletal and dental effects of treatment. Adjustment was made for magnication differences between radiographs. The 3 lms from each series were traced in pairs

Fig 1. Digitizing regimen: cranial base, and maxillary and mandibular ducial lines are dened by points 67, 68, and 40; and 41, 47, and 46, respectively. Point 65 is used in conjunction with the mesial contact points of maxillary and mandibular molars (43, 44) to construct a line parallel to the functional occlusal plane.

(T1 and T2; T2 and T3) so that outlines of the anatomic structures in the radiographs could be traced in a coordinated fashion and in sufcient detail to support a meaningful best-t superimposition. Each tracing and superimposition was inspected by a second observer (L.E.J.). A digitizing regimen (Fig 1) of 71 points was used to generate a descriptive cephalometric analysis composed of conventional angular and linear measures and ratios in each series (Dentofacial Planner, version 32; Dentofacial Software, Toronto, Ontario, Canada). Regional structural superimpositions in the cranial base, maxilla, and mandible were used to measure the dental and skeletal components of the changes in molar relationship and overjet during and after treatment. In the structural method developed by Baumrind et al,12 an arbitrary ducial line was drawn above the cranial base of the second tracing. After a best-t superimposition on the stable structures described by the study of rk and Skieller,13 this line was then carried through Bjo to the rst and third tracings. Fiducial lines permit the analysis of basal translation and rotation. As with the cranial base superimposition, arbitrary ducial lines were drawn above the maxilla and below the mandibular border of the second tracing and passed through to the rst and third tracings based on stable trabecular details. These maxillary and mandibular ducial lines were used to show the pattern of structural rotation of maxillary

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and mandibular basal bones relative to the cranial base. Surface deposition and resorption mask much of this rotation; accordingly, it is assumed that basal rotation will exceed that measured from surface landmarks. An aim of our analysis was to measure the anteroposterior skeletal and dental effects of growth and treatment. To this end, the pitchfork analysis was used to measure skeletal and dental changes parallel to the mean functional occlusal plane, here dened as the average of rst and third functional occlusal planes with the maxillae superimposed.14 The functional occlusal plane is a best-t line passing through the occlusal intercuspation of the rst molars and rst and second premolars. Anteroposterior skeletal and dental changes were then measured parallel to the mean functional occlusal plane based on regional superimpositions in the cranial base, maxilla, and mandible. Apical base change is the excess mandibular advancement relative to the maxilla. It is, therefore, a summary of the skeletal component of molar and overjet correction. All skeletal and dental movements were given positive or negative signs according to their contribution to the anteroposterior correction. A positive sign indicated a contribution to the correction of a Class II relationship or a reduction in overjet, as with forward growth of the mandible or mesial movement of the mandibular teeth. A negative sign meant an effect that caused the Class II relationship or the overjet to become worse, as with forward maxillary growth or mesial movement of the maxillary teeth. The most clearly visualized maxillary and mandibular rst molars from any radiograph in the series were chosen and used to trace individual rst molar and incisor templates. The dentition was traced with the aid of these standardized tracings. Dental movement was then measured parallel to the mean functional occlusal plane in each series. With a maxillary superimposition, maxillary tooth movement relative to maxillary basal bone was measured as the distance between the mesial contact points of the rst molars and gave the total molar movement. Bodily molar movement was measured at the root apices: the movement of a point at which a line connecting the molar apices intersects the long axis of the tooth. A tipping component then can be resolved by subtracting bodily movement from crown movement.
Statistical analysis

Fig 2. Pitchfork diagram (modied from Johnston14) summarizing the skeletal and dental components of the molar and overjet corrections: apical base change (ABCH) is the displacement of the mandible relative to the maxilla and equals the algebraic sum of the maxillary and mandibular displacements; the molar and overjet corrections equal the algebraic sum of ABCH, maxillary and mandibular molars and ABCH, and maxillary and mandibular incisors, respectively.

Means and standard deviations were calculated for the descriptive cephalometric and regional superimposition measurements. Pitchfork diagrams also were used to depict schematically the skeletal and dental components of the molar and overjet corrections as estimated from the regional superimposition (Fig 2).14

The results of the multivariate analysis of the control or treatment differences showed that the 2 groups were signicantly different (F 5 6.1; P \0.01) at T1 (Tables I and II). Because of this initial morphologic difference, subsequent analysis was directed toward an analysis of the increments of change between T1 and T2, T2 and T3, and overall, between T1 and T3. Such comparisons were assumed to be meaningful because the increments of change are generally unrelated to initial size and shape.15,16 The Hotelling T2 was used to test the hypothesis that the pairwise control and treatment differences in the various increments of change are zero, both during and after treatment. With a signicant T2, the source of the difference was then explored with individual paired t tests. Because 1 objective of this study was to compare the skeletal and dental components of molar and overjet corrections in the treated group and the untreated controls, paired t tests were used to test for signicant betweengroups differences in the skeletal and dental measurements from the regional superimpositions. Although the pitchfork diagram summarized how much of the correction was accomplished by growth or dental movement, the results of the paired t tests indicated whether these effects differed between the treated and control groups. Records of 5 patients were randomly selected to be retraced, redigitized, and remeasured. Intraclass correlation was then used to characterize the reliability of the various cephalometric measurements.

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Table I. Descriptive statistics for groups at start (angular measures)

Groups Treated Variable ( ) SNA SNB ANB Upper 1 to SN Lower 1 to NB FMIA IMPA Interincisal FOP to SN FOP to FH FMA Upper Z Lower Z Structural rotation Mandibular ducial line Maxillary ducial line


Table III. Descriptive statistics for treatment change (angular measures)

Groups Treated Control SD 1.8 1.8 1.2 6.6 3.6 4.2 4.2 8.4 3.0 3.6 3.0 3.6 4.8 Paired t test Difference Mean SD t 2.3 2.4 6.0y 0.9 2.4 2.4* 1.6 1.8 5.6y 4.8 8.4 3.3y 4.0 6.0 4.1y 4.2 6.6 3.8y 4.1 4.8 4.8y 8.1 10.2 4.7y 0.7 3.6 1.1 1.8 4.2 2.5* 0.1 4.2 0.1 5.9 4.8 7.7y 6.5 6.0 6.5y 1.1 1.7 2.4 2.4 2.6* 4.6y

Paired t test Difference Mean 3.4 2.8 0.4 0.9 1.0 3.6 2.9 6.9 1.7 3.5 2.7 4.9 5.5 SD 4.2 3.6 3.0 9.0 8.4 9.6 9.6 13.2 4.8 6.0 6.6 9.0 12.0 t 5.1y 4.4y 0.8 0.6 0.7 2.3* 1.9 3.2y 2.2* 3.7y 2.5* 3.3y 2.7y 2.2* Variable ( ) SNA SNB ANB Upper 1 to SN Lower 1 to NB FMIA IMPA Interincisal FOP to SN FOP to FH FMA Upper Z Lower Z Structural rotation Mandibular ducial line Maxillary ducial line


Control Mean 86.0 81.2 4.7 105.9 26.4 65.2 97.3 133.0 16.0 5.5 21.6 79.7 79.2 SD 3.0 3.0 2.4 8.4 6 6.6 7.2 10.2 3.6 3.6 4.8 6.0 8.4

Mean 82.4 78.2 4.2 106.9 25.3 61.6 94.3 126.1 17.6 9.0 24.1 74.6 73.8

SD 3.0 3.0 2.4 8.4 6.0 6.6 7.2 10.2 4.2 3.6 4.8 6.0 8.4

Mean SD Mean 1.9 1.8 0.4 0.3 1.8 0.5 1.6 1.2 0.0 4.6 6.6 0.2 4.6 3.6 0.8 5.0 4.2 0.8 4.7 4.2 0.7 9.0 62.4 0.9 1.7 3.0 1.0 2.2 4.2 0.5 0.4 3.0 0.3 5.5 3.6 0.4 6.9 4.8 0.5 0.1 1.6

46.0 7.8 13.4 4.8

42.2 7.8

3.7 10.2

1.8 1.3 1.8 1.8 0.2 1.8

13.9 4.8 0.5

6.6 0.5

FOP, Functional occlusal plane; FH, Frankfort horizontal. *P \0.05; y P \0.01.

FOP, Functional occlusal plane; FH, Frankfort horizontal. *P \0.05; y P \0.01.

Table II. Descriptive statistics for groups at start

(linear measures)
Groups Treated Mean Variable (mm) Upper 1 to NA 4.5 Lower 1 to NB 4.8 Wits appraisal 0.7 Lower 1 to A-Pog 1.2 Pog to NB 1.7 Co to A-point 90.2 A-point to N 1.1 perpendicular Co to Gn 115 Ar to Gn 106.3 N to Me 116.8 Lower lip to E-plane 0.6 Overjet along FOP 6.0 Overbite along FOP 2.9 Molar class 0.1 Rotation surface measures AFH 66.4 PFH 61.7 Control Paired t test Difference SD t 3.0 4.8y 2.4 1.0 4.2 1.5 2.4 2.4* 1.8 0.4 5.4 1.4 5.4 3.5y 6.0 2.5* 6.0 1.7 7.2 2.9y 3.6 1.7 3.0 3.3y 2.4 1.2 1.8 0.7 7.2 2.5* 5.4 0.8

Table IV. Descriptive statistics for treatment change (linear measures)

Groups Treated Mean Variable (mm) Upper 1 to NA 2.0 Lower 1 to NB 1.5 Wits appraisal 0.4 Lower 1 to A-Pog 1.1 Pog to NB 1.8 Co to A-point 1.2 A-point to N 1.4 perpendicular Co to Gn 6.8 Ar to Gn 6.9 N to Me 7.2 Lower lip to E-plane 2.9 Overjet along FOP 2.8 Overbite along FOP 1.1 Molar class 1.6 Rotation surface measures AFH 4.4 PFH 5.6 PFH:AFH ratio 0.8 Control Paired t-test Difference SD 3.0 1.8 3.0 1.8 1.2 4.2 3.0 4.8 5.4 3.6 2.4 3.0 2.4 2.4 t 4.7y 4.6y 0.9 2.6* 5.5y 3.8y 3.6y 2.0 1.9 4.2y 6.1y 5.8y 3.1y 4.6y

SD Mean SD Mean 3.0 2.0 3.0 2.6 2.4 4.4 2.4 0.4 3.6 1.8 3.6 1.1 1.8 0.4 1.8 0.9 1.8 1.9 1.8 0.1 4.8 88.9 4.8 1.3 3.6 4.3 4.8 3.2 5.4 112.5 5.4 2.5 5.4 104.6 5.4 1.7 6.0 113.2 6.0 3.6 2.4 1.6 2.4 1.0 2.4 4.3 2.4 1.8 1.8 3.5 1.8 0.5 1.8 0.4 1.8 0.2 5.4 4.2 63.5 5.4 2.9 62.4 4.2 0.7

SD Mean SD Mean 1.8 0.0 2.4 2.1 1.2 0.1 1.2 1.4 2.4 0.3 2.4 0.5 1.2 0.3 1.2 0.8 1.2 0.5 1.2 1.2 3.0 3.7 3.0 2.6 2.4 0.4 2.4 1.8 4.2 5.2 4.2 5.2 3.6 4.6 1.8 0.5 2.4 0.3 1.8 0.4 1.8 0.1 2.4 3.6 2.4 4.2 1.6 4.2 1.7 3.6 2.7 1.8 2.4 2.4 3.2 1.8 1.4 1.8 1.8

FOP, Functional occlusal plane; AFH, anterior face height; PFH, posterior face height. *P \0.05; yP \0.01.

2.4 2.4 1.9 3.9 3.6 1.7 1.0 1.8 0.3

3.6 3.4y 3.6 2.7* 3.0 0.6

FOP, Functional occlusal plane; AFH, anterior face height; PFH, posterior face height.*P \0.05; yP \0.01.

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RESULTS

Means and standard deviations for the changes in various dimensions are summarized in Tables III and IV. As might be expected of a comparison between treated and untreated subjects, the pairwise control or treatment differences were highly statistically signicant (F 5 84.5; P \0.01). Specically, the mean increments of change for maxillary incisor to SN, mandibular incisor to NB, FMIA, IMPA, interincisal angle, upper and lower Z angles, maxillary incisor to NA (mm), mandibular incisor to NB (mm), mandibular incisor to A-Pog (mm), lower lip to E-plane, molar relationship, and overjet and overbite corrections showed signicant between-groups differences. Changes in SNA, SNB, ANB, functional occlusal plane to Frankfort horizontal, Co to A-point, A-point to N perpendicular, N to Me, pogonion to NB, posterior face height, anterior face height, and both maxillary and mandibular rotations were also signicantly different. Descriptive statistics for posttreatment changes are summarized in Tables V and VI. A simultaneous comparison of the mean increments for the various cephalometric dimensions by the Hotelling T2 showed signicant between-groups differences (F 5 64.7; P \0.01). There were statistically signicant differences in posttreatment changes for mandibular incisor to NB, FMIA, interincisal angle, upper and lower Z angles, maxillary incisor to NA (mm), mandibular incisor to NB (mm), Wits appraisal, Co to A-point, Ar to Gn, lower lip to E-plane, overjet, and overbite. In addition, mandibular length showed a signicantly greater increase in the treated group. The Hotelling T2 showed that the overall pattern of change was signicantly different (F 5 10.0; P \0.01) between the 2 samples. There were statistically signicant differences of the mean increments of SNA, pogonion to NB, mandibular length, posterior face height, anterior face height, upper face height, total face height, and maxillary and mandibular rotations between the groups. The skeletal and dental components of molar and overjet corrections during treatment measured along the mean functional occlusal plane are depicted in the pitchfork diagrams of Figure 3. Descriptive and inferential statistics for the pitchfork analysis are summarized in Table VII. As would be expected, paired t tests showed that molar and overjet corrections were greater in the treated group; however, apical base change and mandibular displacement also were signicantly greater in the treated group than the controls. Posttreatment anteroposterior changes measured along the mean functional occlusal plane are illustrated in Figure 4. The results of the paired t tests for the pitchfork

Table V. Descriptive statistics for posttreatment change (angular measures)

Groups Treated Variable ( ) SNA SNB ANB Upper 1 to SN Lower 1 to NB FMIA IMPA Interincisal FOP to SN FOP to FH FMA Upper Z Lower Z Structural rotation Mandibular ducial line Maxillary ducial line


Paired t test Difference Mean 0.1 0.4 0.4 0.3 1.7 2.3 1.2 2.6 0.6 0.4 0.8 1.9 3.5 SD 1.8 1.2 1.2 4.8 1.8 4.2 4.2 7.2 3.0 3.0 3.0 4.2 5.4 t 0.4 1.5 1.7 0.3 2.6* 3.1y 1.6 2.2* 1.3 0.9 1.6 2.8y 3.8y 0.2

Control Mean 0.1 0.0 0.0 0.8 0.5 0.6 1.2 0.1 0.7 0.6 0.9 1.1 0.3 SD 1.2 1.2 0.6 3.6 3.0 3.0 3.6 4.8 1.8 3.0 2.4 3.0 4.2

Mean 0.0 0.4 0.4 1.0 1.3 1.7 0.0 2.7 0.1 0.1 1.6 3.2 3.7

SD 1.2 1.2 0.6 3.6 3.0 3.0 3.6 4.8 1.8 2.4 2.4 3.0 3.6

0.8 1.8 0.8 1.8 0.2 1.2

0.1 2.4

0.3 1.2 0.1 1.8 0.2

FOP, Functional occlusal plane; FH, Frankfort horizontal. *P \0.05; y P \0.01.

Table VI. Descriptive statistics for posttreatment change (linear measures)

Groups Treated Mean Variable (mm) Upper 1 to NA 0.4 Lower 1 to NB 0.3 Wits appraisal 0.6 Lower 1 to A-Pog 0.3 Pog to NB 0.6 Co to A-point 1.6 A-point to N 0.0 perpendicular Co to Gn 3.2 Ar to Gn 2.6 N to Me 2.0 Lower lip to E pl 1.6 Overjet along FOP 0.4 Overbite along FOP 1.2 Molar llass 0.2 Rotation-surface measures AFH 0.8 PFH 2.7 PFH:AFH ratio 1.3 Control Paired t test Difference

SD Mean SD Mean SD t 1.2 0.2 1.2 0.7 1.8 2.6* 1.2 0.3 1.2 0.6 1.2 2.7* 1.8 0.5 1.2 1.3 2.4 3.4y 0.6 0.1 0.6 0.3 1.2 1.6 0.6 0.5 0.6 0.1 1.2 0.7 1.8 0.4 1.8 1.8 3.0 3.8y 1.8 0.0 1.8 0.1 2.4 0.4 2.4 3.0 2.4 1.2 1.2 1.2 1.2 1.8 2.4 1.8 1.4 1.2 1.5 0.1 0.4 0.1 0.1 2.4 3.0 2.4 1.8 1.2 1.2 0.2 1.8 1.4 0.6 1.6 0.7 1.3 0.3 0.1 0.8 0.3 3.0 3.8y 3.0 2.7y 3.6 1.9 2.4 4.3y 1.2 3.3y 1.8 4.8y 1.8 1.0 2.4 0.2 3.0 1.6 1.8 1.0

1.0 1.8 2.0 2.4 1.1 1.8

FOP, Functional occlusal plane; AFH, anterior face height; PFH, posterior face height. *P \0.05; yP \0.01.

analysis measures are summarized in Table VIII. Incisor movementreboundwas signicantly greater in the

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Fig 3. Pitchfork analysis of treatment change. ABCH and mandibular displacement and molar and overjet corrections were signicantly greater in the treated sample. *P \0.05; **P \0.01. Table VII. Pitchfork analysistreatment change
Paired t test Treated Measure Skeletal displacement Maxillary displacement Mandibular displacement Apical base change Upper tooth movement Total U6 movement Bodily Tipping U1 movement (incisal edge) Lower tooth movement Total L6 movement Bodily Tipping L1 movement (incisal edge) Total molar correction Total overjet correction Control Difference t 1.5 2.6* 3.5y

Fig 4. Pitchfork analysis 8.6-years after treatment. ABCH and mandibular displacement were signicantly greater in the treated sample. *P \0.05; **P \0.01. Table VIII. Pitchfork analysis, 8.6-year posttreatment

change
Paired t test Treated Measure Skeletal displacement Maxillary displacement Mandibular displacement Apical base change Upper tooth movement Total U6 movement Bodily Tipping U1 movement (incisal edge) Lower tooth movement Total L6 movement Bodily Tipping L1 movement (incisal edge) Total molar correction Total overjet correction Control Difference t 0.0 2.6* 4.5y

Mean SD Mean SD Mean SD 1.4 1.4 1.5 1.4 4.4 3.3 2.7 2.8 3.1 2.6 1.2 1.9 3.4 2.2 1.3 3.3 2.4 1.8 1.8 2.7 1.5 0.7 0.8 0.8 0.2 1.6 1.7 3.9 1.9 3.2

Mean SD Mean SD Mean SD 0.7 1.3 0.7 1.0 2.2 2.4 1.3 1.8 1.6 1.6 0.6 1.0 1.2 0.5 0.8 1.0 1.4 0.8 1.6 0.0 1.3 0.8 1.2 0.1 0.0 1.6 1.0 2.2 1.0 1.3

1.4 1.9 2.7 4.3y 1.3 1.5 2.3 4.0y 1.5 0.6 2.3 1.5 0.9 4.2 2.7 9.1y

1.2 0.4 1.5 1.5 1.4 0.5 2.0 1.5 1.3 0.0 0.0 0.5 0.7 0.9 1.2 4.2y

2.7 3.9 1.1 3.4

1.4 0.4 2.4 1.0 2.1 0.6 2.2 0.7

1.3 2.3 1.5 3.0 1.1 0.5 1.5 2.7

2.1 6.4y 2.9 6.2y 2.3 1.4 2.5 6.4y 5.1y 6.7y

0.2 0.1 0.1 1.0

1.1 0.2 1.2 0.2 1.3 0.1 1.4 0.2

1.0 1.1 1.0 0.9

0.4 0.3 0.0 0.7

1.7 1.7 1.5 1.6

1.4 1.2 0.1 2.8

2.1 2.0 0.1 1.6 3.0 2.7 0.3 0.9

2.0 2.3 3.3 3.0

*P \0.05; yP \0.01.

0.2 1.0 0.4 1.0

0.0 1.0 0.3 1.5 1.0 0.2 0.8 0.5 1.1 3.4y

*P \0.05; yP \0.01.

edgewise patients. As with the treatment changes, there were signicantly more apical base changes and mandibular displacements in the treated sample.
DISCUSSION

The nding that the treated and control samples were not identical initially was not an insuperable problem

because increments of change are largely unrelated to facial form.15,17,18 Thus, between-groups comparisons were executed with regard to increments of change. Differences between groups during treatment were not limited to the dentition. The increases in posterior face height, anterior face height, and total face height, the amount that the mandible outgrew the maxilla, and

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the amount that the chin moved forward were all significantly greater in the treated group than in the untreated controls. All of these differences are consistent with an increase in the horizontal vector of mandibular growth in the treated group. The pitchfork analysis shows that the anteroposterior changes were aided by mandibular advancement and apical base change that were signicantly greater in the treated sample. The molar and overjet corrections in the edgewise patients were brought about mostly by these skeletal changes, rather than by tooth movement. These differences, however, occurred without statistically signicant mandibular length (Co to Gn) and positional (Ar to Gn) differentials during treatment and thus might be due in some way to the geometry of measuring change parallel to the occlusal plane and to the effects of treatment, which in this study produced signicant closure of the occlusal plane (functional occlusal plane-Frankfort horizontal angle). The skeletal ndings raise the question of whether the increased apical base change was due to forward mandibular rotation secondary to the maintenance of anterior facial height by vertical control. It has been suggested by many researchers that vertical control is necessary for counterclockwise mandibular rotation.8,11,19 To test this hypothesis, mandibular and maxillary basal rotations were assessed with respect to stable bony landmarks. Measurements of the changes in angles between the maxillary and mandibular ducial lines and the cranial base ducial lines during treatment, however, did not show increased counterclockwise mandibular basal rotation in the treated group. Although mandibular and maxillary superimpositions are technically difcult, the pattern of rotation seen here is, at the least, consistent with common expectations. The rotation of mandibular basal bone was forward in the untreated controls, as is usually the case with normal growth.20 There was, however, a signicant betweensamples difference during the treatment period: on average, the mandibles of the treated group showed essentially no rotation (ie, the rotation did not differ from 0; H0:d 5 0; P .0.05). This mandibular stability in the treated group was accompanied by a small, but statistically signicant, clockwise maxillary rotation. Usually, orthodontic treatment mechanics tend to be extrusive. In our sample, however, the vertical dimension was controlled well enough to hold the mandible in place. The mandibular ducial angle was held constant throughout treatment, whereas the occlusal plane angle (functional occlusal plane-Frankfort horizontal) closed. The jaws of the controls, on the other hand, rotated forward as was observed rk and Skieller13 for untreated subjects. by Bjo Between-groups differences in the maxillary and mandibular rotation patterns were not signicant during

the posttreatment period. Both mandibles rotated forward, in amounts that were similar and signicantly different from zero. Signicantly, a pattern of forward mandibular basal rotation was not reected by changes in posterior and anterior face height ratios measured from surface landmarks. Although both anterior and posterior face heights increased more in the treated sample during treatment, the change in this ratio was not signicantly different between the groups, not only during treatment but also during the posttreatment period. In short, measurement of changes in anterior-to-posterior face-height ratio does not appear to be an adequate method of assessing mandibular rotation. Surface changes mask basal rotation, both forward and backward. If the mandible rotates forward, apposition along the symphysis and anterior mandibular border and resorption at the gonial angle hide the effect of the forward basal rotation on the mandibular and occlusal planes. Because of these transformative changes, the shape of the mandible remains relatively unchanged during growth.13 It is not possible, therefore, to detect rotational changes from increments of change in Frankfort-mandibular plane angle (FMA) or posteriorto-anterior face height ratios. In this study, FMA change during treatment was not signicantly different between the groups, even though there was a between-groups difference in the increment of change in the angle between the mandibular basal bone and the cranial base during treatment. Skeletal change also had an impact on tooth movement. Apparently, as a result of dentoalveolar compensation, the mesial movement of the maxillary buccal segments in the controls was almost identical to apical base change; this relationship also was seen in the edgewise patients during the posttreatment period.16,21 Mesial movement of the maxillary buccal teeth was signicantly more than that in the controls during treatment. A signicant difference during treatment is expected because of the closing of the maxillary extraction spaces; however, the extra mesial movement at posttreatment might be a dentoalveolar compensation for the excess mandibular advancement that continued. It would seem appropriate, therefore, to examine mechanisms that could have led to the signicant differences in mandibular advancement or mandibular growth. Most cephalometric analyses rely on measures of chin position rather than actual mandibular length. Our analysis used both; however, the data do not support a clear explanation of why the chin advanced more in the treated group than in the control group, both during and after treatment. Condylion is notoriously difcult

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to localize; in this study, Co to Gn showed no betweengroups difference during treatment. This nding, however, cannot support the inference that the chin advancement was just a functional shift: Ar to Gn, a measure of position, did not show a signicant difference either. Sufce it to say that the chin advanced more, perhaps due to growth, both during and after treatment. The exact cause of this advancement cannot be inferred from these data. The skeletal changes were favorable, but their origin was not the forward rotation of the mandible. Although the rotation patterns of the 2 groups were not signicantly different during the posttreatment period, mandibular advancement and chin protrusion were greater in the treated group than in the control group. Thus, the greater advancement might be a byproduct of increased mandibular growth. Johnston16 reported greater mandibular advancement and apical base change during treatment in an edgewise premolarextraction sample compared with untreated controls. However, he could not differentiate between a functional shift and actual mandibular growth, nor assess the long-term signicance of this increased mandibular advancement. In contrast, we gathered long-term follow-up data an average of 8.6 years after treatment. These results seem to support Johnston's claim that treatment with vertical control has some favorable effect on mandibular growth. An examination of the overall changes from the start of treatment to the end of the retention period also demonstrated a signicantly greater increase in mandibular length in the edgewise patients. Although treatment did not enhance the forward rotation of the mandible, it did prevent clockwise rotation of both the mandible and the occlusal plane during treatment. After treatment, the mandible rotated forward normally, as if there had been no treatment. There was no catch-up forward rotation. However, the treated sample experienced more mandibular changes, in both size and advancement, resulting in a better jaw relationship in the treated group (Fig 5) than in the control group (Fig 6). These ndings appear to support the suggestion that many kinds of treatment can affect the pattern of facial growth. For example, Livieratos and Johnston22 compared 1-stage edgewise treatment to 2stage functional and xed appliance treatment and found no signicant posttreatment differences, thereby suggesting that both treatments had similar effects on growth. Because they did not nd any longterm differences, it is also possible that the similar effects included some sort of impact on the increment of mandibular growth.

Fig 5. Edgewise group. Superimposition of averaged tracings from the start of treatment (black lines), the end of treatment (red lines), and an average of 8.6 years after treatment (blue lines).

Fig 6. Control group. Superimposition of averaged tracings from the start of treatment (black lines), the end of treatment (red lines), and an average of 8.6 years after treatment (blue lines). CONCLUSIONS

Although the literature seems to agree that under certain circumstances the horizontal vector of mandibular growth can be increased, the results of our study do not support this idea. Chin advancement occurring simultaneously with increased mandibular length and a lack of rotation, as was seen here, argues instead for an increase in mandibular growth. In this study, vertical control conferred by mandibular anchorage preparation and directional forces might have led to an increase in mandibular growth.

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The pattern of skeletal change was favorable, both during treatment and in later years. A feature of this effect was an improved pattern of mandibular growth displacement. This improvement, however, did not take the form of a mandibular responsea forward rotation facilitated by vertical control. Furthermore, rotation cannot be inferred from surface landmarks. Rotation must be measured from structural superimposition.
REFERENCES 1. Carlson DS. Growth modication: from molecules to mandibles. In: McNamara JA Jr, editor. Growth modication: what works, what doesn't and why? Monograph 35. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1999. 2. Gebeck TR, Merrield LL. Analysis: concepts and values, part I. J Charles Tweed Int Found 1989;17:19-48. 3. Merrield LL, Gebeck TR. Analysis: concepts and values, part II. J Charles Tweed Int Found 1989;17:49-64. 4. Merrield LL, Klontz HA, Vaden JL. Differential diagnostic analysis system. Am J Orthod Dentofacial Orthop 1994;106:641-8. 5. Hultgren WB, Isaacson RJ, Erdman AG, Worms FW. Mechanics, growth, and Class II corrections. Am J Orthod 1978;74:388-95. 6. Yamaguchi K, Nanda RS. The effects of extraction and nonextraction treatment on the mandibular position. Am J Orthod Dentofacial Orthop 1991;100:443-52. 7. Vaden JL, Harris EF, Sinclair PM. Clinical ramications of posterior and anterior facial height changes between treated and untreated Class II samples. Am J Orthod Dentofacial Orthop 1994;105:438-43. 8. Gebeck TR, Merrield LL. Orthodontic diagnosis and treatment analysisconcepts and values. Part I. Am J Orthod Dentofacial Orthop 1995;107:434-43. 9. Altuna G, Woodside DG. Occlusal forces. Angle Orthod 1985;55: 251-63. 10. Merrield LL. Edgewise sequential directional force technology. J Charles Tweed Int Found 1985;14:22-37.

11. Vaden JL, Dale JG, Klontz HA. The Tweed-Merrield edgewise appliance: philosophy, diagnosis, and treatment. In: Graber TM, Vanarsdall RL, editors. Orthodontics: current principles and techniques. 2nd ed. Philadelphia: Saunders; 1994. p. 627-84. 12. Baumrind S, Korn EL, Isaacson RJ, West EE, Molthen R. Superimpositional assessment of treatment associated changes in the temporomandibular joint and the mandibular symphysis. Am J Orthod 1983;84:443-65. 13. Bj ork A, Skieller V. Postnatal growth and development of the maxillary complex. In: McNamara JA, editor. Factors affecting the growth of the midface. Monograph 6. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development, University of Michigan; 1976. p. 61-9. 14. Johnston LE. Balancing the books on orthodontic treatment: an integrated analysis of change. Br J Orthod 1996;23:93-102. 15. Johnston LE. A statistical evaluation of cephalometric prediction. Angle Orthod 1968;38:284-304. 16. Johnston LE. A comparative analysis of Class II treatment. In: McNamara JA, Carlson DS, Vig PS, Ribbens KA, editors. Science and clinical judgment in orthodontics. Monograph 18. Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1986. 17. Greenberg LZ, Johnston LE. Computerized prediction: the accuracy of a contemporary long-range forecast. Am J Orthod 1975; 67:243-52. 18. Hixon E, Klein P. Simplied mechanics: a means of treatment based on available scientic information. Am J Orthod 1972;62: 113-41. 19. Schudy FF. The rotation of the mandible resulting from growth: its implications in orthodontic treatment. Angle Orthod 1965;35: 36-50. 20. Bj ork A, Skieller V. Normal and abnormal growth of the mandible. A synthesis of longitudinal cephalometric implant studies over a period of 25 years. Eur J Orthod 1983;5:1-46. 21. Solow B. The dentoalveolar compensatory mechanism: background and clinical implications. Br J Orthod 1980;7:145-61. 22. Livieratos FA, Johnston LE. A comparison of one-stage and twostage nonextraction alternatives in matched Class II samples. Am J Orthod Dentofacial Orthop 1995;108:118-31.

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