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Daniel Merwin, DDS, MS, a Peter Ngan, DMD, b Urban Hagg, DDS, Odont. Dr., c Cynthia Yiu, BDS, MDS, d and Stephen H.Y. Wei, DDS, MS e
Memphis, Tenn., Morgantown, W,Va., and Hong Kong
Class III malocclusion with retrusive maxilla can be orthopedically corrected in the deciduous and mixed dentition, with reverse-pull headgear in combination with rapid palatal expansion. The literature recommends this procedure be carried out before the patient is 8 years old to obtain the optimal orthopedic result. This statement, however, has not been supported by scientific data. The current study examined the treatment effects of patients younger than 8 years old (5 to 8 years) and patients older than 8 years old (9 to 12 years). Thirty patients treated with maxillary protraction and expansion in the Department of Children's Dentistry and Orthodontics, University of Hong Kong were included in this study. Cephalometric radiographs were taken 6 months before the initiation of treatment (To), at the initiation of treatment (T1), and after 6 months of treatment (T2). In this way, (T2-T1) represented cephalometfic changes during the treatment period and (T1-To) represented 6 months of growth changes without treatment. Experimental subjects served as their own control in this study. A grid system consisting of maxillary occlusal plane ((31_) and a line perpendicular to OL through sella (OLp) was used for linear measurements. A total of 15 linear and 3 angular cephalometric measurements were made. A multivariate analysis of variance (MANOVA), which used age and treatment time as its factors, was used to determine effect of age and/or treatment on each cephalometric parameter. Results indicated strikingly similar therapeutic response between the younger and older age groups. These data suggest that similar skeletal response can be obtained when maxillary protraction was started either before age 8 (5 to 8 years) or after age 8 years (8 to 12 years). (Am J Orthod Dentofac Orthop 1997;112:292-9.)
Reverse-pull h e a d g e a r in combination with rapid palatal expansion devices has b e e n shown to be effective in correcting Class I I I malocclusion with maxillary retrusion. 1-3 However, the timing for effective application of anteriorly directed orthopedic force remains unclear. According to McN a m a r a , 4 the optimal time to begin an early Class I i I t r e a t m e n t regimen is in the early mixed dentition coincident with the eruption of the u p p e r permanent central incisors. H i c k h a m 5 advised that for optimal orthopedic result, this t r e a t m e n t should be initiated before the patient is 8 years old. Proffit 6 r e c o m m e n d e d that maxillary protraction be initiaOrthodontic Resident, Department of Orthodontics, Universityof Tennessee Collegeof Dentistry. UProfessorand Chair, Departmentof Orthodontics,WestVirginiaUniversity, Schoolof Dentistry. CProfessorand Head, Department of Children's Dentistry and Orthodontics, Facultyof Dentistry, The Universityof Hong Kong. aClinicalDental Surgeon,Department of Children'sDentistry and Orthodontics, Facultyof Dentistry, The Universityof HongKong. CProfessorand Dean, Departmentof Children'sDentistry and Orthodontics, Facultyof Dentistry, The Universityof Hong Kong. Reprint requests to: Dr. Peter Ngan, Department of OrthodonticsWest VirginiaUniversity,Schoolof Dentistry,HealthScienceCenter North,PO Box 9480,Morgantown,WV 26506 Copyright© 1997by the AmericanAssociationof Orthodontists. 0889-5406/97/$5.00 + 0 8/1/75990 292
ated before the age of 9 years to p r o d u c e m o r e skeletal change and less dental movement. H o w ever, no data were presented to support these statements. Recently, T a k a d a 7 r e p o r t e d that maxillary protraction and chincup therapy were effective t h r o u g h puberty. T h e p u r p o s e of this study was to determine the effect of maxillary protraction when t r e a t m e n t was initiated before and after 8 years of age in the mixed dentitions. W e hypothesized that greater orthopedic effect and less dental m o v e m e n t would be obtained by initiating t r e a t m e n t before the age of 8 years. MATERIALS AND METHODS Thirty patients who were treated with maxillary protraction and expansion in the Department of Children's Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong were divided into two groups. Fig. 1 shows the age distribution of the 15 patients in each group. The first group comprised of 10 girls and 5 boys between ages 5 and 8 years at the start of treatment (mean = 6.8 +_ 0.9 years). The second group comprised of 10 girls and 5 boys between ages 9 and 12 years at the start of treatment (mean= 10.2 +1.2 years). Criteria for patient selection included: (1) mixed dentition, (2) reverse overjet, (3) cephalometric
9 3. NO. 3 Merwin et al.) (Figs.4 3.7 SD 3.25 mm per turn) for 10 days.8 90.6 22. *p < 0. ***p < 0. All radiographs were traced and measured twice. immediately before treatment (T 0 and 6 months after treatment (T2) To Mean Maxillary position (SNA) Mandibular position (SNB) Sagittal jaw relation (ANB) Palatal plane (Ans-Pns/SN) Mandibular plane angle (Tgo-M/SN) Occlusal plane angle (OL/SN) Lower face height (Arts-Me) Maxillary incisal angle Mandibular incisal angle 81.0 80.05. 293 [-] younger group g.4 2. **p < 0. Frequency of distribution of subject age at treatment initiation (T1). In this way.9 104. not significant. The headgear was worn 12 to 14 hours per day for at least 6 months.0 3.5*** 9.4"* * 2.0** 3. The cephalometric landmarks and constructed lines were shown in Fig.5*** 2.4 36.0 NS 6. Mean values and standard deviations were reported.9 7.5 90.9 104.7 2.0 108. The expansion appliance was activated twice daily (0. with a method described by Buschang et al.0*** 3.9 81. Treatment continued until attainment of a positive overjet and Class I molar relationship. 4.6 SD 3. Patients were treated with a Hyrax rapid palatal expansion appliance and a Tubinger reverse-pull headgear (Dentaurum.6 63. 5 6 7 8 Age 9 10 11 12 Fig. and after 6 months of treatment (T2).3 SD 3. The grid was traced on the first radiograph (To). Standardized lateral cephalograms of each patient were taken at the following time periods: 6 months before the initiation of treatment (To). Conventional cephalometric measurements (Table I) and a cephalometric measurements described by Pancherz 8'9 (Tables II and III) were used to describe changes with growth and treatment.8 8.2 58.8 3.2 85.5 20.9 0.001.6 59. p values at T 2 refer to tests for significant differences between treatment (Ta to T2) and control (T o to T1) time periods. 1. A multivariate analysis of variance (MANOVA). 2 and 3). Table I.American Journal of Orthodontics and Dentofacial Orthopedics Volume 112.3 8. 1° A total of 15 linear and 3 angular cephalometric measurements were used. Changes of cephalometric measurements in 30 patients 6 months before the start of treatment (To).0 9.4 34. Inc. data indicating a Class III skeletal pattern with maxillary retrusion.6 1.3 79. Table I shows the pretreatment skeletal and dental structure of the 30 patients and the cephalometric measurements with 6 months of growth and 6 months of treatment. Comparison of (T2TI) and (T1-To) showed effects as a result of appliance therapy alone. which .2* 4.7 2.5 Mean 80.2 Mean 82.2 3.01.0 9.1 3. Elastics were worn from the soldered buccal hooks on the expansion appliance to the headgear and delivered 380 gm of anterior force per side at an angle of 30 ° downward from the occlusal plane.1 -0. Thus experimental subjects served as their own controls in this study.3 4. (T2-T1) represented cephalometric changes during the treatment period and (T1-To) represented 6 months of growth changes without treatment.3 34. and (4) completion of at least 6 months of headgear wear. at the initiation of treatment (T 0.6** NS.2 9.8 22.0 3.1 11.5 2. then superimposed onto the second and third radiographs ( T 1 and T2) . The Pancherz method used a grid system that consisted of a maxillary occlusal plane (OL) and a line perpendicular to OL through sella (OLp) for linear measurements.4** 3.
American Journal of Orthodontics and Dentofacial Orthopedics September 199"7 Fig.2 mm in the younger group and 0. T1. both the younger and older age groups presented with 2.1 ram) as a result of the skeletal and dental changes.9 mm in the older group. and mandibular plane angle (ML-NSL). labial tipping of the maxillary incisors (Is-OLp).1 mm in the older group. 0. used age and treatment time as factors.8 mm in the older group. the older group showed slightly greater values for most of the linear measurements. Tubinger reverse-pull headgear with elastics that delivered 380 gm of maxillary protraction force each side.4 mm in the older group. 0. occlusal plane angle (OL-NSL). was used to determine whether there was any significant effect of age and/or treatment on each of the cephalometric parameters tested. with a concomitant decrease in overbite (Ii-OL) when treatment (T2-T1) was compared with control (T1-To) periods. and lingual tipping of the mandibular incisors (Ii-OLp).3 mm in the younger group. older group: 3. RESULTS Pretreatment Structure of the Two Groups Tables II and III show the sagittal and vertical cephalometric measurements. Dental movement was also similar in both age groups. and downward 0. Treatment versus Control Fig. No significant difference was found in either maxillary or mandibular growth changes during the control period. (ANS-Me). The test was conducted at a 5% significance level. 30°o downward from occlusal plane. Comparison of Control Period (TO to TI) Between the Two Age Groups After 6 months of treatment. For vertical measurements. significantly greater changes were observed in 14 of the 18 cephalometric variables. both groups showed an increase in lower facial height Fig. 0.2 mm in the younger group.0 mm in the younger age group vs. No significant differences were found in any of the sagittal or vertical measurements at T o between the two age groups. 5 compares the sagittal and vertical changes between the two age groups during the control period (To to T1). for the two age groups at time periods To. This included significant forward movement of the maxilla (A-OLp). respectively. posterior movement of the chin (Pg-OLp).9 mm) and corrected molar relationship (0.0 mm in the younger group. and downward 0. and T a. Hyrax rapid palatal expansion appliance with labial wire soldered to maxillary molar bands and extended to canine area for attachment to elastics. Before treatment (To). mandibular molar height (Mic-ML).5 mm in the older group.) . The mandible grew forward 1. 0.3 and -4. Both groups attained a positive overjet (younger group: 4.6 mm. In general.4 mm reverse overjet and a Class III molar relationship (-3. Significant difference between the two groups was found only in the anterior movement of the mandibular first molar (1. respectively).0. 2. 3. The maxilla grew 0. when treatment (T2-T~) was compared with the control (T1-T0) periods in both the younger and older age groups (Tables II and III).294 Merwin et al.2 ram. 0.
1 23.6 ± 3.1"* *p < 0.6 35.2 2.2 36.8 2.3.2"** Angular changes Mandibular plane (deg) ML-NSL Nasal plane (deg) NL-NSL Occlusal plane (deg) OL-NSL 35.2 .2 38.8 70.001.01.4 38.9 -+ 3.8 ± 3.5 ± 3.9 + 2.2 35.0 +.1 19.5** 4.7*** 77.5 10. Comparison of Treatment Effects (T 1 to T~ Between the Two Age Groups Fig.2 26.1 -+ 2.6 ± 5.0 ± 1.1 ± 1.1 -4.9 ± 3.5 28.6"** 75.0 ± 3.6*** 68.5 -+ 3.9 2.6 37.3.1 ± 2.1 ± 1.4*** 0.4 47.3** 30.2 126.96.36.199 .5 ± 3.4 -2.5 ± 4.2 ± 3.0 ~ 3.7 "** 0.7 77.6 ± 3.7 9.5 +.6* 35.9 -+ 3.7 ± 3. p values at T 2 refer to tests for significant differences between treatment (T1 to Ts) and control (To to T 0 time periods.7 ± 3.7 22.5** 51.4 ± 3.1 +.5 + 6.4 ± 1.0 +.4 51.6 -3.3.3. 295 Table II.4. 3 Merwin et al.3.1 19.6 .9 71.9 ± 4.0 69.2 81.2 31.2*** 76.3 +. 6 compares the sagittal changes between the two age groups during the treatment period and their contributions to overjet corrections.1"* 29.0 78.2.3 ~ 3.7 78.0 19.8 20.0 ± 5.6 ± 2.4 .3 ± 3.5 ± 4.2 29.4 -+ 2.7 3.8 ± 4.4 +.4 -3. maxillary and mandibular molar movements be- .0 +.1 24.3 ± 5.3 -~ 1.4 _+ 4.0 ± 2.0 60.3 ± 2.2.4 _+ 4.1 ± 1.0 ± 3.0 +.4 65.0 35.0*** 0.3.7*** 77.1 +_ 2. maxillary incisal movement. ***p < 0.1 ± 3.9*** Older age group (>8 years old) T2 T2 Dental changes Maxillary incisor (mm) Is-OLp Mandibular incisor (ram) Ii-OLp Maxillary molar (ram) Ms-OLp Mandibular molar (mm) Mi-OLp Overjet (mm) Is-OLp minus Ii-OLp Molar relation (ram) Ms-OLp minus Mi-OLp 75.0 -+ 2.8* 8.8 28.1 ± 5.3 28.2 ± 3.3 ± 2.3 + 1.5 -+ 2.4 -1.05.3 ± 4.4 ± 3.4 + 3.6 22.6 ± 2.2 ~ 3. mandibular movement. Table III.American Journal of Orthodontics and DentofaciaI Orthopedics Volume 112.1 m 1.6 61.0 50.6*** Older age group (>8 years old) T2 TO t r~ r~ Dental changes Maxillary incisor (ram) Is-NL Mandibular incisor (mm) Ii-ML Maxillary molar (mm) Msc-NL Mandibular molar (ram) Mic-ML Overbite (ram) Ii-OL 25.05.0 28.7 78.1" 9.7 _+ 3.4 + 2.6 59.0*** 78.0 ± 2.7 21. D e s c r i p t i v e statistics for sagittal c e p h a l o m e t r i c m e a s u r e m e n t s with c o m p a r i s o n s b e t w e e n t r e a t m e n t a n d c o n t r o l t i m e p e r i o d s Younger age group (<8 years old) Sagittal cephalometric measurements Skeletal changes Maxillary base (mm) A-OLp Mandibular base (ram) eg-OLp 69.0* 1. No.0 .8** 25.5 ± 4.7 58.3 ± 2.6 ± 1.2 78.-+ 2.5 ± 2.2 .6 80.7 79.0 39.8 21.3.01.2 ± 3.6 +.0 ± 3.5 -+ 4.7 + 2.0*** 50.2 +.9 47.9** 51.1 49.2 18.7 ± 0.9 .0 ± 1.1.6 _+ 3.1 + 2.8 9.6 52.6 ± 2.3 ± 4.4 ± 1.0 .2 31.5 10.3 ± 2.1 76.7"** *p < 0.2 +.6 79.7 25.2 +_ 2.1 ± 3.1 68.0 23.1 46. **p < 0.6 61.9 -+ 2.2 ± 3.1 ± 2.0 ± 2.001. ***p < 0.5 +.1 20. No significant differences were found in maxillary movement.9 ± 3.5 ± 4.3 79.2 25.0 + 3.6 -+ 3.9 47. 7 ± 1. p values at T 2 refer to tests for significant differences between treatment (T1 to T2) and control (T o to T1) time periods.3 -+ 4.4 76.9 + 1.1 ~ 1.8*** 51. Descriptive statistics for vertical c e p h a l o m e t r i c m e a s u r e m e n t s with comparisons b e t w e e n t r e a t m e n t and control time periods Younger age group (<8 years old) Sagittal cephalometnc measurements Skeletal changes Maxillary base (ram) A-OL Lower facial height (mm) ANS-Me 24. **p < 0. 2 _+ 2.6 36.3 ± 4. 4 ± 1.9 ± 4.9 36.4 ± 2.1 ± 2.8** 3.4 26.
In both groups. SNB. Cephalometric landmarks and construction lines for cephalometric measurements according to Pancherz. because the form of location of sella turcica and nasion have been shown to vary with growth. \ \ ~ ©~_C--J~ ~ ii ~. 0. and ANB angles. 2. with the loss of deciduous molars and closure of . 8 tween the two age groups. 52% of overjet change was contributed by skeletal change in the younger age group and 63% in the older group because of a larger backward movement in the latter group. DISCUSSION Both conventional cephalometric measurements and the method by Pancherz s'9 were used in the current study to describe cephalometric changes with growth and development. p < 0. Within 6 months of maxillary protraction and expansion. sagittal correction of Class III malocclusion was primarily a result of forward movement of the maxilla and clockwise rotation of the mandible. The only significant differences was the lingual movement of mandibular incisors. The occlusal line (OL) was chosen because it is closest to most of the landmarks measured. In both groups. Maxillary and mandibular growth rates were not statistically different between the younger and older age groups. previous studies have shown that sagittal measurements that used S-N line as a reference are inherently inaccurate. with mandibular growth exceeding maxillary growth. The accuracy of cephalometric landmarks used in the current study had been investigated on the skulls that originated in southern China.05). 11-14 The use of a construction grid eliminates the need for the reference line./'. During treatment. Significant difference was found only in mesial movement of the mandibular first molar. The comparison of vertical treatment changes between the younger and older age groups is shown in Fig. The accuracy of locating the sagittal and vertical landmarks with or without the use of the steel ball markers was compared. These findings are in accordance with previous studies. 2.7 ram. However. Dental changes during this period were found to be similar in both age groups.7 mm vs.16-~9 Growth rate between the two age groups can be compared by measuring the cephalometric changes (T1-T0) before treatment./' __~_J Fig. maxillary and mandibular growth was forward and downward. Most clinicians are familiar with angular measurements such as the SNA. In general. Overjet correction was contributed by both skeletal and dental changes in both age groups. The skeletal and dental contributions to overjet correction were slightly different in the two groups. Maxillary molar extrusion resulted in increased lower face height. which was greater in the younger age group.1 mm vs. significantly greater maxillary molar extrusion was found in the older age group (1. 15 A series of cephalograms were taken with reference steel ball markers glued on the skulls to represent the "true" skeletal and dental landmarks.7. and no significant differences were found between the two series of cephalograms. The older group also showed a significantly greater increase in lower facial height than the younger group (4. The pretreatment structure of the two age groups are quite comparable.296 M e r w i n et al. This is unusual because greater mesial movement is expected in the late rather than early mixed dentition. and posterior movement of mandible.4 mm vs. 7. except for the slightly larger linear measurements in the older group. 1. 48%) because of a smaller forward movement of maxillary incisors in the older group. p < 0.01). (1.4 mm.01). American Journal of Orthodontics and Dentofacial Orthopedics September 1997 '\ . increased mandibular plane angle. The dental contribution in the older group was less than the younger group (37% vs. These data suggest comparable amounts of jaw growth in both younger and older age groups during a 6-month period. Both age groups presented with a reverse overjet and a negative (Class III) molar relationship before treatment. forward movement of maxilla in both groups was accompanied by labial movement of incisors and increase in vertical measurements. p < 0. 4.8 mm.
***p < 0. 0. maxillary molar extrusion was greater in the older age group (1. Overjet correction was achieved by 52% skeletal movement and 48% incisor tipping in the younger group and 63% skeletal movement and 37% incisor tipping in the older group.1mm / 0.05.8 ram) along with a greater increase in lower facial height (4. a difference was found in vertical response between the two age groups. Tm ).) O l d e r A g e G r o u p (>8 y. This effect may be contraindicated in patients with vertical growth pattern.American Journal of Orthodontics and Dentofacial Orthopedics Volume 112.No. " .mm *p < 0.01.o. Nearly equal overjet correction occurred in both groups. **p < 0.4 ram). 5. Schematic illustration of mean changes during control period with comparisons between two age groups.1 vs.1o 0. . A possible explanation for this finding could be that there was a greater forward drift of the lower molar during the development of an anterior crossbite in the younger age group. 2. These data suggest that similar skeletal response can be expected in both the early (5 to 8 years old) and late (8 to 12 years old) mixed dentition with the use of reverse-pull headgear in combination with rapid maxillary expansion.) % ~ \ 0 k""t~ .001 Fig.9 mm 02 ° 0. . . A bonded expansion appliance .3 ° 0. N ~ 1.. 3 M e r w i n et aL 29"7 Y o u n g e r A g e G r o u p (<8 y.2ram i m . . . .. Cephalometric changes during the treatment period were strikingly similar between the two age groups. During treatment. 2 mm -"". Maxillary and mandibular skeletal changes were very similar for the two age groups.o. .2 o i i 0. However. leeway space.0 mm / % ().7 vs.
) Older Age Group (>8 y..001 Overjet correction skeletal contribution maxilla mandible dental contribution maxillary mandibular 2.. ***p < 0..o.**p<0...05.1o t L4mm 41mm *p < 0.o.001 Fig. 9 m m . Apparently.5 m m (100%) 2..o.~'PP-4.1 m m (32%) 2.. 7. with a posterior bite-block may be used instead of a banded expansion appliance. Schematic illustration of mean changes in vertical dimensions during treatment with comparisons between two age groups. Our data show that treatment of maxillary deficiency with reverse-pull headgear and rapid palatal expansion may be effective in younger (5 to 8 years old) and older (9 to 12 years old) patients.3 m m (21%) Overjet correction skeletal contribution maxilla mandible dental contribution maxillary mandibular 1.298 Merwin et aL American Journal of Orthodontics and Dentofacial Orthopedics September 1997 Younger Age Group (<8 y.***p <0. ? . 6. . m .) 2:3o 2.7 m m (26%) 0.8 m m (46%) 0..7 mm \ ..1 mm (100%) 1.01.05. These findings are in agreement . **p < 0.) l ~ ~ l . 38 m *p<0.1 m m ( 2 % ) 6... Schematic illustration of mean changes in sagittal dimensions during treatment with comparisons between two age groups.7mm (11%) 6.9 m m (31%) 1. Younger Age Group (<8 y.o...) Older Age Group (>8 y. circumpubertal maxillary deficient growth patterns can be intercepted and altered to produce responses similar to those seen in early childhood.01.0 m m (31%) Fig. 2° The results of this study may help in revising the current clinical recommendations4-6for treatment of maxillary deficiency..
Swed Dent J 1982. Int J Adult Orthod Orthog Surg 1988. Tanguay R. Vanarsdall RL.6 to 11. 10. Proffit WR. . 7 who demonstrated very similar therapeutic results . J Clin Orthod 1991. 12.3:81-6. Hagg U. Am J Orthod 1975.15:189-96.25:102-13. Vertical dentofacial changes during Herbst appliance treatment: a cephalometric investigation. Tug TH. Takeucbi Y. 15. Ishii H. Morita S. Pancherz H. p. 3. Nakamura S.78:125-39.16:213-34. J Clin Orthod 1988. Sakuda M.22:314-25. Am J Orthod 1987. The human face: an account of the postnatal growth and development of the craniofacial skeleton. 18. Results indicated strikingly similar therapeutic response between the younger and the older age groups. 20. Mixed dentition treatment.8: 152-6. 1992. 13. 17. McNamara JA.between prepubertal (ages 6. Orthopedic correction of Class III malocclusion with palatal expansion and custom protraction headgear. Andreaseu G. a basic consideration in the interpretation of cephalometric radiographs.67:377-92. Validity of cephalometric landmarks: an experimental study on human skulls.4 years) female patients who were treated with reverse-pull headgear in combination with chincup forces. 5. Maxillary protraction therapy: diagnosis and treatment. The sella point and postnatal growth of the human cranial base. 16. 4. Orthodontics-current principles and techniques. Frankfort horizontal. Eur J Orthod 1993. CONCLUSIONS The current study investigated whether there were a greater orthopedic effect and less dental movement when Class III malocclusion was treated with maxillary expansion and protraction before and after 8 years of age in the mixed dentition. 11. Petdachai S.3 to 9. Ellis E III. Demirjian A. Moorrecs DFA. Stickel B. Biomechanical and clinical considerations of a modified protraction headgear. 14. These data suggest that similar skeletal response can be obtained when maxillary protraction was initiated either before age 8 years (5 to 8 years) or after age 8 years (8 to 12 years). Eur J Orthod 1986.82:107-13. Eur J Orthod 1994. 1968. Cephalometric reference planes--sella nasion vs. Full CA. 299 with Takada and associates. this study does not consider the effects of maxillary protraction on patients who are over 12 years old. Am J Phys Anthropol 1956.92:304-12. McNamara JA Jr. 19.15:211-21.16:110-20.American Journal of Orthodontics and Dentofacial Orthopedics Volume 112. Am J Orthod Dentofac Orthop 1989. LaPalme L. 2. Nanda R. St Louis: Mosby-Year Book. Data from Takada and coworkers v suggest that this mode of therapy does not produce significant orthopedic results in postpubertal age ranges. REFERENCES 1. An orthopedic approach to the treatment of Class IIl malocclusion in young patients. 9. Nakamura S. J Clin Orthod 1987. Orthopedic approach to severe skeletal Class IU malocclusion. Irie M. Turley P. Pancherz H. St Louis: CV Mosby. 508. 3 Merwin et al. Am J Orthod Dentofac Orthop 1990. Enlow DH. Am J Orthod 1982. Hickham JH. Mermigos J. Effect of protraction headgear on Class n I malocclusion. Readers should be cautious. Treatment effect of combined maxillary protraction and chincap appliance in severe skeletal Class III cases. Ngan P. Latham RA.98:47-55. Wei SHY. Johnston MW. The mechanism of Class II correction in Herbst appliance treatment: a ccphalometric investigation. Natural head position. 6. Changes in deutofacial morphology in skeletal Class III children treated by a modified maxillary protraction headgear and chin cup: a longitudinal study.3 years) and midpubertal (ages 8. Buschang PH. Takada K. In: Graber TM. Sarver DM. Contemporary Orthodontics. No.21:598-608. Skeletal changes in vertical and anterior displacement of the maxilla with bonded rapid palatal expansion appliances. 8. McNamara JA. Yiu CKY.61:156-62. 1994. Kean MR.95:462-6. New York: Harper & Row. Quintessence Int 1992. Protraction of the maxillofacial complex. Am J Orthod 1980. Am J Orthod 1972. editors.23:197-207. 7. The technical reliability of superimposition on cranial base and mandibular structures. Merwin D.
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