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Cervical Headgear in Class Ii Division 1 Correction in Children

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Cervical Headgear in Class Ii Division 1 Correction in Children Department of Orthodontics, Institute of Dentistry University of Helsinki, Finland CERVICAL HEADGEAR IN CLASS II DIVISION 1 CORRECTION IN CHILDREN Mirja Kirjavainen ACADEMIC DISSERTATION to be publicly discussed with the permission of the Faculty of Medicine of the University of Helsinki in the Main Auditorium of the Institute of Dentistry on September 17th, 2010, at 12 noon. Helsinki 2010 SUPERVISED BY Docent Turkka Kirjavainen Department of Pediatrics, Helsinki University Central Hospital Helsinki, Finland REVIEWED BY Professor Juha Varrela Department of Oral Development and Orthodontics Institute of Dentistry University of Turku Turku, Finland and Professor Emeritus Lassi Alvesalo Department of Oral Developmet and Orthodontics Institute of Dentistry University of Oulu Oulu, Finland ISBN 978-952-92-7472-7 (PRINT) ISBN 978-952-10-6341-1 (PDF) Painosalama Oy-Turku, Finland 2010 “I have finished my work. It is as perfect as I can make it.” Edward Hartley Angle (1855-1930) To my grandchildren 4 CONTENTS CONTENTS 1. ABSTRACT ................................................................................................................... 6 2. LIST OF ORIGINAL PUBLICATIONS ....................................................................... 7 3. INTRODUCTION .......................................................................................................... 8 4. REVIEW OF THE LITERATURE ................................................................................ 9 4.1 Definitions of normal occlusion and malocclusions ............................................. 9 4.1.1 Weaknesses of Angle’s Classification ...................................................... 10 4.1.2 Development of the diagnostic methods of occlusion ............................. 10 4.1.3 Roentgen cephalometry ............................................................................ 11 4.2 Description of Class II division 1 malocclusion ................................................. 12 4.2.1 The maxillary and mandibular incisors and molar positions in Class II malocclusion ................................................................................ 15 4.3 The natural course of Class II malocclusion ....................................................... 16 4.3.1 Class II division 1 malocclusion in the deciduous dentition ................... 16 4.3.2 Class II division 1 malocclusion in the mixed dentition .......................... 17 4.3.3 Development of vertical dimensions in Class II malocclusion ............... 18 4.3.4 Soft tissue relationship of Class II division 1 malocclusion .................... 18 4.4 Respiratory pattern in children with Class II division 1 malocclusion .............. 19 4.5 Consequences of untreated Class II malocclusion .............................................. 19 4.6 Prevalence of Class II division 1 malocclusion .................................................. 21 4.7 Correction of Class II division 1 malocclusion ................................................... 21 4.7.1 Class II correction by cervical traction ..................................................... 23 4.7.2 Results of correction of Class II malocclusion ......................................... 25 4.7.3 Timing of correction ................................................................................. 26 4.7.4 Cooperation ............................................................................................... 26 5. AIMS OF THE STUDY ............................................................................................... 28 6. SUBJECTS AND METHODS .................................................................................... 29 6.1 Subjects ................................................................................................................ 29 6.2 Control cohorts ..................................................................................................... 29 6.3 Methods ................................................................................................................ 31 6.3.1 Cervical headgear treatment ..................................................................... 31 6.3.2 Dental cast analyses (I, II, III) .................................................................. 32 6.3.3 Cephalometric analyses (II-V) .................................................................. 33 6.3.3.1 Posteroanterior cephalometry (III) ............................................. 33 6.3.3.2 Lateral cephalometry (II, IV, V) ................................................. 33 6.3.4 Statistical methods .................................................................................... 36 6.3.5 Method error .............................................................................................. 36 CONTENTS 5 7. RESULTS ..................................................................................................................... 38 7.1 Dental arch measurements and dental cast analysis (I, II, III) ............................ 39 7.2 Cephalometry (II, III, IV, V) ................................................................................ 41 7.2.1 Posteroanterior cephalometry (III; n = 40) ............................................... 41 7.2.2 Lateral cephalometry (II, IV, V) ............................................................... 43 7.2.3 Soft tissue profile (IV; n = 40) .................................................................. 49 7.2.4 Upper airway dimensions (V, n = 40) ....................................................... 51 8. DISCUSSION ............................................................................................................... 53 8.1 Maxillary widening .............................................................................................. 54 8.2 Lateral cephalometric changes in maxilla, mandible, and facial height ............ 55 8.3 Headgear treatment and soft tissue profile .......................................................... 56 8.4 Upper airway structure in Class II malocclusion ................................................ 57 8.5 Treatment time and need for phase 2 treatment .................................................. 58 8.6 Molar extrusion .................................................................................................... 58 8.7 Study limitations .................................................................................................. 59 9. CONCLUSIONS .......................................................................................................... 60 10. ACKNOWLEDGEMENTS ......................................................................................... 61 11. REFERENCES ............................................................................................................. 63 12. ORIGINAL PUBLICATIONS ...................................................................................... 71 6 AbsTrAcT 1. ABSTRACT Class II division 1 malocclusion occurs in 3.5 to 13 percent of 7–12–year-old children, and is the most common reason for orthodontic treatment in Finland. There are several different treatment approaches to Class II correction. In Finland, Class II correction is most commonly performed using headgear treatment. The aim of this study was to investigate the effects of cervical headgear treatment on dentition, facial skeletal and soft tissue growth, and upper airway structure, in children. Sixty-five schoolchildren were studied, 36 boys and 29 girls with a mean age of 9.3 (range 6.6 – 12.4) years at the onset of treatment. All the children were consequently referred to an orthodontist in Forssa because of Class II division 1 malocclusion, and they were treated by the author. The included children had protrusive maxilla indicated by an A point being in front of the Nasion-Pogonion line and an overjet of more than 2mm (3 to 11 mm). The children were treated with a Kloehn-type cervical headgear as the only appliance until Class I first molar relationships were achieved. The essential features of the headgear were cervical strong pulling forces, a long upward bent outer bow, and an expanded inner bow. Dental casts and lateral and posteroanterior cephalograms were taken before and after the treatment. The results were compared to a historical, cross-sectional Finnish control cohort or to historical, age- and sex- matched, normal Class I controls with analyzed dental casts and cephalograms. Posteroanterior cephalometric results were compared to a historical, cross-sectional Austrian control cohort. The Class I first molar relationships were achieved in all the treated children. The mean treatment time needed was 1.7 (range 0.3-3.1) years. Phase 2 treatments were needed in 52% of the children, most often because of excess overjet or overbite. The treatment decreased maxillary protrusion by inhibiting alveolar forward growth, while the rest of the maxilla and mandible followed normal growth. Both SNA and ANB angles were decreased, and the maxillary A-point seemed to remain at virtually the same place without any forward movement. Despite the restricted forward growth of the maxilla at the level of the A-point, the length of the palatal plane (ANS-PNS) grew forward at a normal rate, but the palate was rotated anteriorly downward. The expansion of the inner bow of the headgear induced widening of the maxilla and the upper and lower dental arches. The widening of the maxilla was also seen as increased nasal width. Class II division 1 malocclusion was
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