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A Retrospective Cephalometric Study of the Effect of the Frankel Appliance, the Clarktwin Block and the Activator on Class II Di

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A Retrospective Cephalometric Study of the Effect of the Frankel Appliance, the Clarktwin Block and the Activator on Class II Di Y \'?'t\'<{"[ A RETROSPECTIVE CEPHALOMETRIC STUDY OF THE EFFECT oF THE rnÄNrnt-, APPLTANcE, THE CLARI( T\MIN BLOCK AND THE ACTIVATOR ON CLASS II DIVISION 1 PATIENTS ***l* A Thesis Submitted in Partial Fulfilment for the Degree of Master of Dental Surgery by Con Laparidis Dental School Faculty of Health Sciences University Of Adelaide South Australia 1999 Tnsre or CoNrexts 2 TABLE OF CONTENTS TABLE OF CONTENTS 2 List of Tables............. 5 List of Figures .......... 9 Summary T3 I AIMS t6 2. LITERATURE REVIEV/.............. t7 2. 1 Introduction......... t7 2.2 Summary of adolescent growth changes 18 2.3 Comparison between "normals" and Class II patterns '. 26 2.4 Functional appliance effects.... 27 2.5 Conclusion......... 68 3. MATERIALS AND METHODS .... 69 3.1 Selection of sample........ 69 3.2 Radiography 72 3.3 Tracing technique 74 3.4 Superimposition technique...... 75 3.5 Computerised cephalometrics and digitising 78 3.6 Reference points. 79 3.7 Thevariables 82 3.8 Statistical analyses.............. 84 3.9 Errors of the method............. 87 4. RESULTS 90 4.1 The error study 90 4.2 Pre-freatment ages and treatment times......... 96 4.3 Sex comparisons of pre-treatment hard and soft tissue variables ..........97 4.4 Sex comparisons of post-treatnent hard and soft tissue variables....... 104 4.5 Hard and soft tissue treatment changes for the activator, the Clark Twin Block and the Fråinkel .... TABLE OF CONTENTS J 4.6 Sex comparisons in treatrnent changes..... '..'.. 118 4.7 Comparison of different appliances: two'way analysis of variance .. 118 4.8 Comparison of different applainces: one-way analysis of variance ...12t 4.9 Comparison to published controls..... 125 4.10 Pre- and post-treatment composite tracings 126 5. 131 5.1 The sample 131 5.2 Age of patients ............... ..131 5.3 Treatment time ........ t32 5.4 Limitationsofretrospectivecephalometricstudies ......'....133 5.5 Erors in cephalometrics...... r39 5.6 Sexual dimorphism..... r42 5.1 The activator with headgear 142 5.8 The Clark Twin Block 151 5.9 The Fråinkel r59 5.10 Comparison of the results from the present study with published untreated subjects ....... 165 5.11 A comparison of the activator with headgear, the Clark Twin Block, and the Fråinkel ........ 172 5.12 Compa¡ison of skeletal and dental changes contributing to overjet and molar correction. .. 6. CONCLUSIONS........ ...182 6.I Futr¡re resea¡ch. 185 7. REFERENCES : Literature cited.. 187 8. APPENDICES 8.1 Landmarks 2r2 8.2 Calculation of angular and linear variables. 2t6 8.3 Correlations and coeffrcients of determination 224 8.4 Cranial base superimposition- treatment changes for landmarks using Taslg or CoNreNrs 4 SN-7o Cartesian rxes.......... 229 8.5 Summary of signifrcant differences between males and females pre- and post-treatrnent ..... .238 8.6 Comparison with untreated subjects 240 8.7 Individual treatnent changes for selected variables... 258 Teerp or CoNrBNrs 5 LIST OF TABLES Table 1 Attainment of adult size for various soft tissue variables and three skeletal base measurements (Nanda et a1.,1990)........ ......23 Table2 Sexual dimorphism in adolescence ................... ......25 Table 3 Advantages of the Cla¡k Twin Block ......58 Table 4 Breakdown of the functional appliance sample numbers and ages... ......71 Table 5 Cephalometric radiographs with visible metric rulers ......72 Table 6 Facilities from which cephalometric radiographs were obtained 73 TableT Mean magnifications of cephalometric radiographs ....... 74 Table 8 Hard tissue cephalometric landmarks and abbreviations 81 Table 9 Soft tissue cephalometric landmarks and abbreviations 82 Table 10 Hard tissue cephalometric variables and abbreviations..................... 83 Table 11 Soft tissue cephalometric va¡iables and abbreviations .......... 84 Table 12 Error Study : Results for double determinations of landmark identification. Hard Tissue Landmarks 9T Table 13 Enor Study : Results for double determinations of landmark identifi cation. Soft tissue landma¡ks. 93 Table 14 Error Study : Results of double determinations for va¡iables. Hard tissue variables 94 Table 15 Enor Study : Results of double determinations for variables. Soft tissue variables 95 Table 16 Tables of pre-treatment age (in years) and length of treatment (in days) 96 Table 17 Activator : Sex comparisons of pre-treatment hard tissue variables.... 98 Table l8 Activator : Sex comparisons of pre-treatment soft tissue variables..... 99 Table 19 Cla¡k Twin Block : Sex comparisons of pre-treatment hard tissue variables 100 Table 20 Clark Twin Block : Sex comparisons of pre-treatment soft tissue variables.... 101 Table2l Fråinkel : Sex comparisons of pre-treatment hard tissue variables........... 102 Table 22 Frânkel : Sex comparisons of pre-treatrnent soft tissue variables... 103 TABLE OF CoNTENTS 6 Table 23 Activator : Sex comparisons of post-treatment hard tissue variables . ...105 Table 24 Activator : Sex comparisons of post-treatment soft tissue variables.. ...106 TabLe 25 Clark Twin Block : Sex comparisons of post-treatment hard tissue variables ...t07 Table 26 Clark Twin Block : Sex comparisons of post-treatment soft tissue variables 108 Table 27 Fränkel : Sex comparisons of post-treatment hard tissue variables 109 Table 28 Fränkel : Sex comparisons of post-treatment soft tissue variables 1r0 Table 29 Activator : Means and standard deviations for treafinent changes. Hard tissues tt2 Table 30 Activator : Means and standard deviations for treatment changes. Soft tissue variables lr3 Table 31 CTB : Means and standard deviations for treatment changes. Hard tissues....... .tt4 Table 32 CTB: Means and standard deviations for treatment changes. Soft tissue variables 115 Table 33 Fråinkel : Means and standard deviations for treatment changes Hard tissues................. tt6 Table 34 Fråinkel : Means and standard deviations for treatment changes. Soft tissue variables r17 Table 35 Comparison of the changes in craniofacial and soft tissue variables from pre-to post-treatment between males and females 118 Table 36 Two-way analysis of variance, with functional appliance groups and sexes as factors. Hard tissue variables. .. 119 Table 37 Two-way analysis of variance, between functional appliance groups and gender. Soft tissue variables... ........120 Table 38 Pre-treatment one-way analysis of variance comparisons .............. ........r22 Table 39 Po st-treatment one-way analysis of variance comparisons............. ........123 Table 40 Pre- to post-treatment differences: one-way analysis of variance .. ........t24 Table 41 Summary of statistically significant differences between the three fimctional appliance groups .184 Table 42 Significant correlations between age and craniofacial / soft tissue variables.. 224 Table 43 Significant correlations between treatment time and craniofacial / soft tissue variables. 226 Teel,e or CoureNrs 7 Table 44 Craníal Base Superimposition: treatment changes for activator / headgear ha¡d tissue landmarks. 229 Table 45 Cranial Base Superimposition: treatment changes for activator / headgear soft tissue landmarks. 23t Table 46 Cranal Base Superimposition: treatment changes for the Clark Twin Block hard tissue landmarks. ..232 Table 47 Cranal Base Superimposition: treatment changes for the Clark Twin Block soft tissue landmarks. 234 Table 48 Cranial Base Superimposition: treatment changes for the Fränkel hard tissue landmarks. 235 Table 49 CrantalBase Superimposition: treatment changes for the FrZinkel soft tissue landma¡ks. ..237 Table 50 Significant differences between males and females pre-treatment.... ..238 Table 51 Significant differences between males and females post-treatment. ..239 Table 52 Age comparison of the three functional appliance grouPs with the Illing et al. (1998) and Monis et al. (1998) control group. 240 Table 53 Control comparison with the pre-treatment male activator group ...........241 Table 54 Control comparison with the pre-treatment female activator group... .242 Table 55 Control comparison with the pre-treatment male Clark Twin Block group. ..243 Table 56 Control comparison with the pre-treatment female Clark Twin Block group........ 244 Table 57 Control comparison with the pre-treatment male Fränkel group.............245 Table 58 Control comparison with the pre-treatrnent female Fråinkel group..........246 Table 59 Control comparison with the post-treatment male activator group.... .247 Table 60 Control comparison with the post-treatment female activator group ...248 Table 61 Control comparison with the post-treatment male Clark Twin Block group........ ...249 Table 62 Control comparison with the post-treatment female Cla¡k Twin Block group. ...250 Table 63 Control comparison with the post-treatrnent male Fråinkel group ........ ...251 Table 64 Control comparison with the post-treatrnent female Fränkel group..... ...252 Table 65 Lange et al. (1995) control comparison wittr the post-treatment activator group ...253 T¡,erp OF CONTENTS 8 Table 66 Lange et al. (1995) control with the ctlrent post- treatrnent Clark Twin Block 2s5 Table 67 Lange et al. (1 995) control comparison with the post-treatment Fråinkel group 257 TABLE OF CONTENTS 9 LIST OF FIGURES Figure I Expected changes ofthe nasal dorsum 2l Figure 2 The total increments of size increases for males and females aged 7 to l8 years..... .............26 Figure 3 The effect of the latera] pterygoid muscle. .............34 Figr:re 4 Control mechanisms of condylar cartilage gro'rth rate in rats. .............37 Figure 5 Bone adaptation due to mechanoreception
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