Long-term effects of chincap therapy on skeletal

profile in mandibular prognathism

Junji SuOawara, DDS, DDSc,", Teruo Asano, DDS, DDSc, b Noriaki Endo, DDS, DDSc, c and
Hideo Mitani, DDS, MS, DDSc ~
Sendai, Japan

The purpose of this study was to investigate the long-term changes in the skeletal Class II1 profile
subsequent to chincap therapy. The sample consisted of 63 Japanese girls who had skeletal Class
II1 malocclusions before treatment. All underwent chincap therapy from the beginning of treatment.
The duration of chincap therapy varied but averaged 41/2 years. The samples were divided into the
following three groups according to their ages when chincap therapy was started: A group that
started at 7 years of age (n = 23), a group that started at 9 years of age (n = 20), and one that
started at 11 years of age (n = 20). The data were derived from lateral cephalometric head films,
taken serially at the ages of 7, 9, 11, 14, and 17 years. Skeletal facial diagrams were constructed by
X-Y coordinates of representative cephalometric landmarks. The data were analyzed statistically.
The results of the present study were as follows: (1) The mandible showed no forward growth during
the initial stages of chincap treatment in all three groups. (2) Patients who had entered treatment at
7 and 9 years of age appeared to show. a catch-up manner of mandibular displacement in a forward
and downward direction before growth was completed. (3) There was no statistical difference in the
final skeletal profile between the group that had entered treatment at age 7 and the one that had
entered at age 11. In conclusion, the skeletal profile was greatly improved during the initial stages of
chincap therapy, but such changes were often not maintained thereafter. This finding indicated that
chincap therapy did not necessarily guarantee positive correction of skeletal profile after complete
growth. (AM J ORTHOD DENTOFACORTHOP 1990;98:127-33.)

C h i n c a p therapy has been commonly used
and widely recognized as a useful method for correcting
malocclusion in the still-growing prognathic mandible.
For the last 20 years, a number of clinical and exper-
imental studies H° have reported that chincap force has
several orthopedic effects: (1) redirection of mandibular
growth, (2) backward repositioning of the mandible,
(3) retardation of mandibular growth, and (4) remod-
elingof the mandible.
Those effects may induce permanent skeletal chang-
es and can alter the prognathic skeletal profile, partic-
ularly when applied at early ages. 3"" However, little is
known about whether the improved skeletal profile can
be maintained until craniofacial growth is completed,
since most previous studies have been based either on
relatively short-term results, which were of too short a
duration to determine the final result, or on long-term
results ~2J3 that encompassed too few subjects to be sta-
From the School of Dentistry, Tohoku University.
'Lecturer, Department of Orthodontics.
bSendai, Japan.
Clnstructor, Department of Orthodontics.
aProfessor and Chairman, Department of Orthodontics.
811114846
tistically valid. From this point of view, this study was
undertaken to evaluate the results of chincap therapy on
skeletal profile with longitudinal data on patients of
varying ages with various treatment schedules.
MATERIALS AND METHODS
Longitudinal data from 63 Japanese girls with skel-
etal Class III malocclusions were used in this study.
All patients showed anterior crossbite and Class III
intermaxillary relationships before treatment. The sam-
ples were divided into three groups, according to their
chronological ages at the start of chincap therapy: one
group of patients who entered therapy at age 7 (before
the pubertal growth sPurt), one entering at age 9 (at the
beginning of the growth spurt), and one entering at age
11 (around the peak of the growth spurt). Table I shows
the sample numbers, mean ages for data collection, and
average periods of chincap therapy for each group. The
data were derived from lateral cephalometric head films
taken serially at the ages of 7, 9, 11, 14, and 17 years
for analysis of centric occlusion.
All patients underwent chincap treatment at the be-
ginning of the treatment, but the length of time the
chincap was worn varied, as shown in Table I. Half the
127

128 Su~awara et al.
. . . . . . . . . ,J N
Fig. 1. Chincap appliance used by patients in present study.
The applied force on the chin was oriented along a line from
gnathion to sella turcica. The force magnitude ranged from 250
to 300 gm per side.
patients in the total sample were also treated with an
edgewise orthodontic appliance at a later stage.
All treatment subjects wore basically the same type
of chincap (Fig. 1). The force applied on the chin was
oriented along a line from gnathion to sella turcica. The
force magnitude used for therapy ranged from 250 to
300 gm per side of the chin. Patients were instructed
to wear the chincap for at least 14 hours daily. Although
there was a slight tendency of patients in the present
sample toward decreased cooperation over time, they
were generally very cooperative, particularly during the
initial stages of chincap treatment.
The standard criterion for discontinuation of chin-
cap therapy was based primarily on whether the patient
could obtain good jaw alignment, with normal overjet
and overbite. Therefore, variations in the length of time
the chincap was used were significantly related to the
degree of correction of occlusal and skeletal disharmony
for each patient. All subjects attained a normal anterior
bite through the initial chincap treatment, but two cases
(one in the group beginning treatment at age 7 and one
in the group which had begun at age 11) showed anterior
crossbite. Seven (two from the group which had begun
Am. J. Orthod. Dentofac. Orthop.
August 1990
50
-1( 100
0 50
Fig. 2. Skeletal profile diagram composed of 14 representative
landmarks. The X-axis was constructed by drawing a line par-
allel to the Frankfort horizontal plane through sella turcica, and
the Y-axis is a perpendicular line to the X-axis through sella
turcica.
treatment at age 7, four of those who had begun at age
9, and one of the group entering treatment at age 11)
had edge-to-edge bites at the final observation period.
A skeletal profile diagram was constructed with
fourteen cephalometfic landmarks (Fig. 2) measured in
terms of the X-Y coordinates. The X axis was con-
structed parallel to the Frankfort-horizontal plane
through sella turcica, and the Y axis was perpendicular
to the X axis through sella turcica on the initial ceph-
alograms taken before treatment. The superimposition
of successive overall tracings was made on the detailed
anatomic structures of the anterior cranial base. The
anteroposterior displacement and vertical displacement
of all cephalometric landmarks were measured on the
original X-Y coordinate system. Then the average skel-
etal profile diagram of each group was constructed.
Cross-sectional samples were taken from 500 un-
treated girls with Class III skeletal profiles. The sam-
pies, taken from girls ranging in age from 7 to 19 years,
were used as a control in the present study. These sam-
ples were divided into five groups, based on the ages
Volume 98 Long-term effects of chincap therapy on skeletal profile 129
Number 2

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Fig. 3. Skeletal profile diagrams constructed from 500 cross-
sectional samples taken from untreated girls with skeletal Class
III profiles. These samples were used as the control groups in
this study.
Fig. 4. Longitudinal changes of skeletal profile on the group
that began chincap therapy at age 7, observed at ages 7, 9,
11, 14, and 17. Prognathic profiles in this group were signifi-
cantly improved during the period from 7 to 9 years, as indicated
by the hatched area.

Table I. Sample numbers, mean ages for data collection, and average period of chincap therapy for
each group
Mean ages for data collection Months of
Treatment group O'r-mo) chlncap
(by age each Sample therapy
entered therapy) numbers No. 1 No. 2 No. 3 No. 4 No. 5 (range)

7 years 23 7-0 9-2 I I-3 14-0 17-0 62.6

( 2 2 - 115)
9 years 20 8-11 1 I-2 14-1 17-3 51. I
(22 ~ 96)
11 years 20 11-4 14-4 17-4 49.3
( 1 2 - 73)

of the girls when the study began and corresponding to
the classifications of the treated groups. Their skeletal
profile diagrams are shown in Fig. 3.
All samples were selected from the Department of
Orthodontics, Tohoku University, Sendai, Japan.
RESULTS
In Fig. 3, skeletal profiles from the control groups
have been superimposed according to the ages of the
girls in each group to show the cross-sectional changes
in facial growth among untreated Class III samples.
The figure shows that the prognathic pattern was main-
tained through growth. The remarkable growth that we
observed during the period from 9 to 14 years of age
among these girls was attributed to a spurt of pubertal
growth. After the age of 14 years, the facial growth
was minimal, and no major changes were seen.
Fig. 4 shows the longitudinal changes in skeletal
 Am. I. Orthod. Dentofac. Orthop.
1:30 Su~,awara et al.
August 1 9 9 0

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Fig. 5. Longitudinal changes of skeletal profiles in the group
that began chincap therapy at age 9, observed at ages 9, 11,
14, and 17. Profiles were greatly corrected during the period
from 9 to 11 years, as indicated by the hatched area.
profiles of one group of patients from age 7 up to age
17. The maxilla has been displaced continuously down-
ward and forward through growth while the mandible
changed its direction to downward and backward during
the period from 7 to 9 years as a result of chincap
treatment. Consequently, the prognathic skeletal profile
was significantly improved at age 9. Thereafter, the
mandible, as observed at pogonion, resumed the down-
ward and forward direction. The mandible showed a
great amount of growth during the period from 9 to 14
years of age. During the period from 14 to 17 years of
age, minor growth could still be observed in the man-
dible, but maxillary growth was almost negligible. The
manner of growth among those patients was basically
similar to that of the control group after the age of 14
years.
Fig. 5 shows the longitudinal changes in skeletal
profiles of patients in the group that began treatment at
age 9. The overall changes were similar to those found
in patients who had begun treatment at age 7. The
mandible was displaced downward and backward by
chincap therapy during the period from 9 to 11 years,
while the maxilla showed downward and forward
growth. Therefore the skeletal profile was essentially
corrected by the time the patients were 11 years of age.
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Fig. 6. Longitudinal changes of skeletal profiles for the group
that began chincap therapy at age 11. Note the change of the
mandible, as compared to Fig. 5 and Fig. 6. The mandible does
not show any backward repositioning, as indicated by the
hatched area.
After 11 years, a significant mandibular displacement
was observed in the downward and forward direction
as seen in the group that had begun treatment at age 7.
After the age of 14 years, a small amount of growth,
took place in the mandibles of patients in the gi'oup that
had begun treatment at age 7 and in those who had
begun at age 9, as well as in the members of the control
groups.
Fig. 6 shows the longitudinal changes in skeletal
profile of the group that entered treatment at age I 1. It
shows that the mandible, as observed at pogonion, was
displaced more vertic~illy by the chincap force, while
the maxilla was displaced downward and forward dur-
ing the period from 11 to 14 years. The skeletal profiles
in this group improved considerably when the patients
reached the age of 14, but their profile changes were
less marked than those of the other two groups. The
overall changes during the period from 14 to 17 years
of age were basically similar to those found in the other
two groups and in the control sample.
Fig. 7 shows the differences in skeletal profiles at
age 11, of patients who had begun treatment at age 7
and those who were just entering at age I 1. The latter
Volume 98
Number 2
Long-term effects of chincap therapy on skeletal profile 131

! I I I I
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Fig. 7. Comparison between skeletal profile diagrams for pa-
tients who began chincap therapy at age 7 and those who began
therapy at age 11, observed at age 11. The latter group had
received no orthodontic treatment up to this age.
Fig. 8. Comparison between skeletal profile diagrams for the
group that began chincap therapy at age 7, those who began
therapy at age 11, and the control. There was no statistical
difference between the two treatment groups with respect to
any cephalometric landmarks.

group had received no treatment up until this time.
Between these two groups, statistical differences may
be observed on the anteroposterior position of the man-
dible (by Student t test or Welch t test analysis), but
no significant difference in the maxillary region is ap-
parent. As measured at point B, pogonion, menton, and
gonion, the mandibles of the first group have apparently
been displaced in a backward direction during the 3
years of treatment. The diagram indicates that the chin-
cap force has had significant orthopedic effect on the
mandible in this group.
Fig. 8 shows the differences in skeletal profiles, at
age 17, between patients who began treatment at age
7 and those who began treatment at 11, compared with
the control group of 19-year-olds. The mandibular po-
sition of the group that began treatment at age 11 is
relatively more forward than that of the group that began
at age 7, but statistically there is no significant differ-
ence with respect to any landmarks between these two
groups. Although, as already mentioned, a great dif-
ference may be observed in the skeletal profiles of these
groups at age 11, the differences decrease gradually up
to the age of 17 years. The control group shows the
mandible in a relatively more forward position than in
the other two groups, but anteroposteriorly there is no
significant difference for any specific landmark on the
diagram. However, vertically, point B and Pogonion
show a statistical difference between the group that
entered treatment at age 7 and the control sample. The
lower facial height of the group entering treatment at
age 7 became significantly less than that of the control
by the time patients in both groups had reached 17 years
of age. As to the maxilla, the anteroposterior position
of point ANS in the control group is significantly more
posterior when compared with the other two groups.
This means that the midface is more deficient in the
control sample, which aggravates the anteroposterior
imbalance of the skeletal facial profile.
DISCUSSION
Results of the present study indicate that the pa-
tients' skeletal profiles were significantly improved and
there was retrusion of the chin during the initial stages
of chincap treatment for every group. This is advan-
tageous for correction of anterior crossbite at the be-
ginning of treatment. The study also shows that the
132 Su~awara et al.
skeletal profiles of patients who began treatment at age
7 changed more than did those of the other two groups
in response to the chincap force. During the initial
stages of treatment, the mandibles of patients in the
group that began treatment at age 7 showed more pos-
terior position than those of patients who entered treat-
ment at age 11, indicating that the chincap is more
effective before the pubertal growth spurt. In other
words, it appears that the effects of chincap force
may be offset by rapid growth during puberty, if all pa-
tients receive treatment under the same conditions.
Sakamoto t4 reported that the early-treatment group
showed a more retracted position of the mandible than
the late-treatment group after application of the chincap.
Mitani and Fukazawa ~5reported that the application of
chincap force hardly alters mandibular growth pattern
during puberty. Thus the initial effects of the chincap
vary greatly with different ages and treatment timings.
However, the present study indicates that there was
no significant difference in skeletal profiles, after
growth, between patients in the group which began
treatment at age 7 and those who entered treatment at
age 11. The changes in skeletal profile, although
they represent significant improvement in the younger
children, are not maintained for a long period, in most
cases. This finding suggests that profiles have a ten-
dency to return to their original shapes, which may have
been predetermined morphogenetically. ~6"~7It has been
speculated that some catch-up mandibular growth or
repositioning may occur during or after the puberal
growth period. Mitani TM reported in his clinical study
that it was hard to ascertain whether the mandible
showed any catch-up growth after cessation of chincap
therapy. In his experimental study with rats, Asano ~°
stated that the mandible showed no specific growth
increase after release from the retracting force. No other
clinical study refers to catch-up mandibular growth after
application of orthopedic force. Since this is a critical
point in the evaluation of the effects of chincap therapy,
further investigations, both clinical and experimental,
are needed.
The final skeletal profile of each group in our study,
show no significant difference, between the anteropos-
terior positions of the mandible when compared with
those of the control sample. However, there is a statis-
tical difference between the vertical position of the man-
dibles of patients who began treatment at age 7 and the
mandibles of the control groups. Pearson, ~9Heckman, 2°
and Hirose et al. 2~ reported that the chincap could con-
trol dentoalveolar growth and reduce lower facial
height. Wendel and Nanda t~ also reported that the man-
Am. J. Orthod. Dentofac. Orthop.
August 1990
dible exhibited less downward displacement relative to
the cranial base as a result of chincap therapy. These
findings may indicate that the mandibular position is
more alterable vertically than anteroposteriorly, and
such effects could exist for a longer period in the face.
It is also assumed that the vertical alteration is more
successful when applied to patients at younger ages
because the dentoalveolar region is in a transitional
stage of dentition. Since the chincap pull in the present
study was relatively high, vertical growth of the man-
dible may have been controlled more effectively than
in earlier studies. This difference may explain why the
facial height was significantly inhibited in patients in
this study who began treatment at age 7.
As for the anteroposterior position of the maxilla,
Graber3 and Ritucci and Nanda, 22 indicated that the
chincap has no effect on the anteroposterior growth of
the maxilla. However, the present study shows that at
age 17, the midface is more deficient in patients in the
control than in those of the treatment groups. This find-
ing may support the theory that early correction of an-
terior crossbite prevents retarded anteroposterior max-
illary growth.
CONCLUSIONS
The results of the present study indicate that, on
average, chincap force seldom alters the inherited prog-
nathic characteristics of skeletal Class III profiles after
growth. This finding implies that a favorable profile is
difficult to obtain by orthopedic chincap therapy in pa-
tients who have severe mandibular protrusion.
From the standpoint of long-term results, we should
not overestimate the effects of a chincap appliance to
correct skeletal facial profiles. A chincap should be
applied within limitations on the basis of proper diag-
nosis and treatment objectives.
We are grateful to Dr. Takemi Kawarada for preparation
of part of the clinical records. We also thank Ms. Glenna
Iannetti for assistance with the preparation of the manuscript.
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Reprint requests to:
Dr. Junji Sugawara
Department of Orthodontics
4-1, Seiryo-Cho
Sendal, Japan 980