Orthopedics versus orthodontics in Class

II treatment: An implant study

Leenerd Bernstein, D.M.D., Richard W. Uibrich, D&D., and
An#hony A. Gianelly, D.M.D., Ph.D., M.D.
Boston, Mass.

I n most instances, the resolution of Class II malocclusions requires dis.

tal movement of the maxillary posterior teeth. For this purpose, a number of
procedures have been proposed. Basically, they can be divided into two types:
(1) orthodontic mechanisms designed to move teeth and (2) orthopedic mecha-
nisms that presumably reposition the entire maxillary complex distally by either
“growth manipulation” or distal movement of the complex.
Orthodontically, the teeth apparently can be moved distally without dif-
ficu1ty.l Yet, the clinical evidence supporting orthopedic movement is not so
clear, even though dramatic distal repositioning of the entire nasome,xillary
complex has been demonstrated in primate studies.2-4 Clinically, the backward
displacement of the maxilla has been suggested by some.“, 6slo Others proposed
that growth retardation and/or redirection may have been responsible for the
presumed orthopedic relocation of the ma.xillary complex.7
On the other hand, a recent report suggested that tooth movement rather than
orthopedic change was the principal factor in resolving Class II malocclusions
in growing patienks In that study, growth retardation was effectively ruled
out since the changes noted weke recorded in less than 6 months.
One possible reason for this conflict of opinion is that the data from meet
reports were gained by conventional cephalometric comparisons which, one could
argue, may not be adequate to determine the relatively small orthopedic and/or
orthodontic changes recorded.
For this reason, the present clinical study was conducted to determine the
orthopedic and/or orthodontic component of Class II correction by means of an
orthopedic appliance in patients (Fig. 1). Implants were placed in the maxillas
of the patients to serve as the “reference point” to delineate the changes noted.

From the Department of Orthodontics, Boston University School of Graduate

Dentistry.

549
550 Bernstein, Ulbrich, and Gianelly Am. J. Orthod.
November 1917

Fig. 1. A, Acrylic Cervical Occipital Appliance (ACCO) consisting of a straight-pull gear

(B) attached to the anterior aspect of a removable appliance (C).

Materiols and methods

Four implants were placed in the maxillas of eight 7- to lo-year-old subjects

who had Class II, Division 1 malocclusions. Seven of the eight patients were in
the mixed dentition ; the eighth was in the early permanent dentition. The im-
plants, which were inserted according to the method described by Mitchell and
Kinder9 were located in four zoljes (Fig. 3) :
1. In the midpalatal region at the approximate level of the first premolar.
2. In the labial aspect of the alveolar bone of the permanent first molar
and
3. The inferior aspect of the right zygomatic process
4. At point A.
After complete orthodontic records were taken, the subjects were fitted with
an Acrylic Cervical Occipital Appliance (ACCO) (Fig. 1) as described by
Margolis, which had been reported as having moved entire maxillas distal1y.l’
Extraoral traction, exerting approximately 1,000 Cm. per side (2+ pounds per
side), was worn from 14 to 24 hours per day for 3 to 5 months. Two of the pa-
tients wore the gear approximately 14 hours a day; three wore the gear from
 Orthopedics versus orthodontics in Class II treatment 551

Fig. 2. Case 1. Lateral views of pretreatment and posttreatment models of a patient with
a Class II malocclusion. The patient wore the gear between 23 and 24 hours a day
for 3 months and the Class II relationships were converted to a Class I pattern.

Fig. 3. Case 1. A, Cephalometric tracing. Superimposition on the anterior crankt bases

indicated that the molars were moved distally 5 mm. while the implants remained
stationary. Superimposition of the maxilla on the implants also illustrated 5 mm. of
distal molar movement. B and C, Original and final ceephalographs. Arrows point to the
implants. Note change in axial inclinations of the teeth.
552 Bernstein, Ulbrich, and Gianelly Am. J. Orthod.
November 1977

Fig. 4. Case 2. Lateral views of pretreatment and posttreatment models of a patient with
a Class Ii malocclusion who wore the gear approximately 20 hours a day for 5 months.
The Class Ii dental pattern was changed to a Class I.

Fig. 5. A, Anterior cranial base superimposition of cephalometric tracings indicated 4

mm. of distal movement of the molars and stability of the implants. Superimposition of
the maxilla on the implants also demonstrated 4 mm. of distal molar movement. B
and C, Original and final cephalographs.
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Number
72
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Orthopedics versus orthodontics in Class II treatment 553

Fig. 6. Case 3. Lateral views of pretreatment and posttreatment models of a patient

with a Class II malocclusion who wore the gear approximately 14 hours a day for 5
months. The dental relationships were not fully converted to a Class I pattern.

14 to 18 hours a day ; two wore the gear approximately 20 hours a day ; and
one wore the gear 23 to 24 hours a day. Following the treatment period, complet,e
records were taken.
All pre- and posttreatment cephalographs were compared by superimpo&ng
pre- and posttreatment tracings in two ways. The first comparison was made by
superimposing the tracings on the anterior cranial base, using the internal con-
tour of the brain case. The second comparison was made by superimposing the
maxillas, using the implants as the point of reference. In addition a comparison
was made of all pre- and posttreatment study models.
Findin,gs
Comparison of the cephalograms.
CRANIAL BASE SUPERIMPOSITION. When tracings of cephalograms were super-
imposed on the anterior cranial base, the implants in seven of the eight patients
showed no change while the teeth were moved distally from 3 to 5 mm. (Figs.
3, 5, 7, and 10). In this group, one patient wore the gear 23 to 24 hours a day
(Figs. 2 and 3), and the molars were distally repositioned 5 mm. in 3 months.
One patient wore the gear approximately 20 hours a day, and 4 mm. of molar
distal movement was noted in 5 months (Figs. 4 and 5). The other five patienti
wore the gear from 14 to 18 hours a day, and the molars were moved distally 3
to -1mm. in the 5-month treatment period (Figs. 6, ‘7, and 10).
In the eighth patient, who wore the gear from 20 to 22 hours a day, the im-
plants after treatment were located approximately 1 mm. posteriorly relative
to the cranial base (possibly indicating distal movement of the nasomaxillary
554 Bernstein, Ulbrich, and Giawlly Am. J. Orthod.
November 1977

Fig. 7. Case 3. A, Cephalometric tracings. Cranial base superimpositions revealed 3 to 4

mm. of distal molar movement while the implants remained stable. Superimposition of
the maxilla on the implants also illustrated 3 to 4 mm. of distal molar movement. B and
C, Original and facial cephalographs.

complex). In this patient 6 mm. of molar distal movement was recorded (Figs.
8 and 9).
In the eight patients, larger amounts of movement appeared to be associated
with increased use of the gear. Ho’wever, from the small sample size, generaliza-
tions can be made only cautiously.
No appreciable change could be detected in the palatal planes of all eight
patients.
MAXILLARY SUPERIMPOSITION. When tracings of the maxilla were superimposed
on the implants, the molars were more distal in relation to the implants in all
instances (Figs. 2 to 10). In addition, comparable movement of most of the other
teeth in the maxillary arch was noted. An exception was the movement of the
second molars. When they moved, they appeared to move only slightly.
In the seven patients in whom the implants were stable, the recorded distal
movement was essentially the same relative to both the maxillary implants and
the cranial base (Figs. 2 to 7, 10). In the eighth patient in whom the implants
were moved distally 1 mm., the molar movement relative to the maxillary im-
plants was 1 mm. less than the molar movement relative to the cranial base
(Figs. 8 and 9).
Comparison of the study models. The Class II dental pattern of all patients
yh&we&2 Orthopedics versus orthodontics in Class II treatment 555

Fig. 8. Case 4. Lateral views of pretreatment and posttreatment models of a patient with a
Class II malocclusion. The gear was worn approximately 20 hours a day for 5 months, and
the Class II dental pattern was converted to a Class I.

was changed (Figs. 2 to 9). In some, the Class II relationships were converted
to a Class I pattern, including complete reduction of overjet. In others, only
partial correction occurred. Essentially, the model analysis was consistent with
the cephalographic determinations. More change was noted with increasing use
of the gear.
Other than slight space created by the clasps of the ACCO appliance, no
spaces were apparent in the dental arches.
Discussion

An important aspect of the treatment procedure was to produce an effect in

a 3- to 5-month period in which little to no craniofacial growth could be antici-
pated. Thus, a treatment result could be achieved without the complications of
a growth analysis and the role of growth on the treatment effect. In addition,
each patient could act as his/her control.
The use of intramaxillary implants was based on the following premise. If
the implant-tooth relationship remained constant and distal movement occurred,
the movement would represent orthopedic repositioning of the nasomaxillary
complex, carrying the teeth to their new position. Conversely, a change in the
implant-tooth relationship in which the teeth were moved distally more than the
implants would indicate a component of tooth movement.
In seven of the eight patients, the maxillary implants were stable while the
teeth were moved distally. In addition, the distal movement relative to both the
cranial base and the maxilla was the same. Therefore, it appears that the changes
556 Bernstein, Ulbrich, and Giafaelly Am. J. Orthod.
November 1977

01

Fig. 9. Case 4. A, Cranial base superimposition of cephalometric tracings demonstrates

6 mm. of distal molar movement and 1 mm. of distal movement of the implants. Maxillary
superimposition demonstrated 5 mm. of molar movement. B and C, Pretreatment and
posttreatment cephalographs with arrows pointing to implants. Note the change in im-
plant-tooth relationships.

in tooth position induced by an extraoral force reflected tooth movement rather

than maxillofacial orthopedics. In the eighth patient in whom 6 mm. of distal
molar movement was noted, the maxilla appeared to have been orthopedically
repositioned distally approximately 1 mm. Since the time period was too short to
detect measurable growth, the orthopedic movement may represent distal move-
ment of the maxillary complex, presumably involving suture activation,2-4 rather
than growth retardation and/or redirection. Also, the orthopedic component of
the 6 mm. change recorded was responsible for only approximately 15 per cent of
the total movement. Thus, even in this instance, tooth movement constituted the
principal event in the distal movement of the maxillary arch.
Our conclusion, then, is that the “orthopedic” force system used in this
study produced tooth movement almost exclusively. This analysis represents a
departure from the often stated proposition that appropriately applied forces
can produce mainly an orthopedic chs,nge.5* 7 One might argue that differences
in appliance systems might account for the discrepancy. Our response is that it
would be exceedingly difficult to test all extraoral appliances. Yet the basic com-
monality of most systems tends to negate this argument.
 Orthopedics versus

Fig. 10. Cephalometric comparisons of four patients who wore the gear approximately
14 hours a day (A), 16 hours a day (B) and 18 hours a day (C and D). In each instance,
the implants were stable. Distal movement of the molars was comparable relative to
both the anterior cranial base and the maxilla. Treatment time for each patient was 5
months.

On the other hand, methods of documentation might also account for the
apparent differences of opinion. In the present study, maxillary implants were
used for two reasons: First, maxillary implants have been considered the best
reference points to document changes in maxillary tooth position’l Second, other
studies citing evidence for orthopedic changes used conventional cephalometrir
a.nalysis recording the distal movement of the PTMG aad the movements of
point A.” We considered these methods somewhat imprecise. For example,
Mitchell and Kinder” have shown that point A moved distally up to 2.5 mm. when
the maxillary incisor roots were torqued. Thus, the use of point A to delineate
orthopedic change may at times be hard to justify. The PTM is, at times, difficult
to identify accurately. For this reason, its use as a reference point may be sus-
pect.
Although the sample size was small, it was interesting to note that both in-
termittently applied (14 to 16 hours per day) and constantly applied traction
produced tooth movement exclusively. The only notable difference was the mag-
nitude of movement; the larger amount of movement was associated with the
increased use of the gear. This observation tends to disagree with the opinion
558 Bernstein, Ulbrich, and Gimelly Am. J. Orthod.
November 1977

that intermittent “orthopedic” forces preferentially produce orthopedic changes

with little or no tooth movement.7
The results of the present study also differ from the reports in which dramatic
orthopedic/orthodontic movement occurred in monkeys as a result of constantly
applied extraoral traction.2-4 A number of possible reasons for this discrepancy
arise. For example, the movements recorded in monkeys were proportionally
greater. In one study, the maxillary dentition was moved distally three premolar
widths. In man, most distal movements are limited to 5 to 6 mm. (the mesiodistal
width of one molar cusp), or slightly less than the usual premolar width. Thus,
it could be that the initial 5 to 6 mm. may involve mainly tooth movement rather
than maxillary orthopedic distal movement, as suggested in a recent study.8
Also, the force magnitudes of the applied force relative to body weight were
usually much higher in monkeys than those conventionally used in human pa-
tients. For example, Droschl” calculated that the 100 grams of gear force applied
per side on a 400 gram monkey might represent a force equivalent in man of 7
to 8 kg. per side. (Comparisons of sutural and ligament surface areas of man
and monkeys might provide a better basis for comparing respective forces.)
In the present study, the Class II relationships were completely resolved in
a 3- to 5-month treatment period in some instances. This finding is consistent with
DewelW2 observations that Class II relationships can be changed to a neutro-
elusion pattern in as little as 3 to 12 months when treatment is done in patients
in the mixed-dentition stage of development,
In summary, the application of an extraoral appliance exerting approximately
2 pounds of force per side (1,000 grams) and worn to varying periods of 14 to
24 hours per day essentially did not produce a significant orthopedic change in
the nasomaxillary complex. Rather, relatively rapid tooth movement occurred,
and the entire maxillary dentition was moved distally cn masse up to 5 to 6 mm.
in a period of 3 to 5 months.

REFERENCES
1. Armstrong, M. M.: Controlling the magnitude, direction, and duration of extraoral force,
AM. J. ORTHOD. 69: 217-243, 1971.
2. Drosohl, H.: The effect of heavy orthopedic forces on the maxilla in the growing
Saimiri scizlreus (squirrel monkey), AM. J. ORTHOD. 63: 449-461, 1973.
3. Elder, J. R., and Tuenge, R. H.: Cephalometric and histologic changes produced by
extraoral high-pull traction to the maxilla in Macacca mzllatta, AX J. ORTHOD. 66: 599-
617, 1974.
4. Meldrum, R. J.: Alterations in’ the upper facial growth of Macacca mzllatta resulting
from the high-pull headgear, AM. J. ORTHOD. 67: 393-411, 1975.
5. Rick&s, R. M.: The influence of orthodontic treatment on facial growth and develop
ment, Angle Orthod. 30: 103-133, 1960.
6. Weislander, L.: The effect of force on craniofacial development, AM. J. ORTHOD. 65:
531-538, 1974.
7. Graber, T. M.: Dentofacial orthopedics. In Graber, T. M., and Swain, B. (editors) : cur-
rent orthodontic concepts and techniques, ed. 2, Philadelphia, 1975, W. B. Saunders
Company, vol. 2.
8. Gianelly, A. A., and Valentini V.: The role of orthopedics and orthodontics in the treat-
ment of Class 11, Division 1 malocclusions, AM. J. ORTHOD. 69: 668-678, 1976.
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9. Mitchell, D. L., and Kinder, J. D.: A comparison of two torquing techniques on the
maxillary central incisors, AM. J. ORTHOD. 63: 407-413, 1973.
10. Bernstein, L.: The ACCO appliance, J. Pratt. Orthod. 3: 461-468, 1969.
11. Isaacson, R. J., Worms, F. W., and Speidel, T. M.: Measurement of tooth movement,
A&f. J. ORTHOD. 70: 290-303, 1976.
12. Dewel, B. F.: Objectives of mixed dentition treatment in orthodontics, AM. J. ORTHOD.
50: 504-519, 1964.

100 E. Newton J’t. (01118)

Technically, general dentistry may be said to have arrived at its full stature; educationally,
it has been admitted within the portals of our universities and perhaps reached the
adolescent period of its growth; clinically and scientifically, it needs to more fully utilize
its opportunities. The same applies to the special branch of dental orthopedics. Its future
development as a worthy professional pursuit should be a matter of great concern to
every one of us. (L&her, B. E.: Discussion of President’s Address, Transactions of the First
[ 19261 International Dental Congress, St. Louis, 1927, The C. V. Mosby Company, p. 11.)