REVIEW ARTICLE

Orthopedics in orthodontics: Part I, fiction or realityma

review of the literature
C. M. F. Aelbers, DDS, a and L. R. Dermaut, DDS, PhD b
Gent, Belgium

The purpose of this review is to investigate the orthopedic effect of functional appliances such as
activators and Herbst appliances, and the orthopedic effect of extraoral traction appliances. A
systematic review of mostly English-language orthodontic articles reporting treatment of Class II
malocclusions with different orthopedic appliances was carried out. According to this review, only
Herbst therapy was able to change mandibular growth to a clinically significant extent.
In part II of this study, the long-term effect of these changes will be evaluated. (Am J Orthod
Dentofac Orthop 1996;110:513-9.)

A l t e r a t i o n of the patient's facial profile has
been a challenge for orthodontists over the years.
Many investigations have been carried out to evaluate
the possibilities of growth modification with orthope-
dic appliances. However, the results have generally
been a subject of debate.
The first question deals with what one understands
by an "orthopedic effect." Duterloo 1 defines orthope-
dic effect in orthodontics as a change in the position of
bones in the skult in relation to each other induced by
therapy. Of course, this change in amount and direction
of growth should be permanent in nature. According to
Isaacson, 2 orthopedic appliances provide a new mus-
cular and functional environment for the facial bones
that encourages growth changes of either the mandible
or the maxilla.
Cultural behavior in some ethnic groups has al-
ready shown that it is possible to change growth
permanently to some extent through external pressure.
The force application has to be continuous for a long
period and has to start as early as possible.
In dentofacial orthopedics, orthodontists attempt to
influence growth by applying an external force, gen-
erally for 2 or 3 years. Almost all orthopedic appli-
ances act intermittently. The growth of the jaws in the
growing child might be influenced if the therapy starts
at a very young age and if it continues until growth has
stopped. However, no patient will be willing to coop-
From the Department of Orthodontics, State University Gent, Belgium.
%enior resident
UCha~rman
Reprint requests to: Dr. L. R. Dermaut, Department of Olxhodontics, State
University Gent, Universitair Ziekenhuis, De Pintelaan 185, B-9000 Gent,
Belgium.
Copyright © 1996 by the American Association of Orthodontists.
0889-5406/96/$5.00 + 0 8/1163855
erate for 15 years or more. From clinical experience,
we know that it is difficult enough to get good
cooperation for as little as 2 or 3 years. The main
question remains whether orthodontists are able to alter
growth within a limited time period in a complex
craniofacial skeleton that is growing and remodeling
over 20 years.
In this review of the literature, a systemic review of
mostly English-language orthodontic articles that re-
ported treatment of Class II malocclusions with differ-
ent orthopedic appliance systems was carried out. Only
those articles that reported scientific d a t a 3"71 (including
statistics) obtained from radiographs of growing pa-
tients were selected. Case reports or articles that were
purely descriptive, in which no attempt had been made
to quantify treatment changes, were not included. We
will try to evaluate whether there is any scientific
evidence of orthopedic change in both the maxilla and
the mandible as a result of orthopedic therapy. We did
not want to make an evaluation of the vertical skeletal
orthopedic changes, because they cannot be investi-
gated separately.
MEASURING THE ORTHOPEDIC EFFECT
Cephalometrics and Its Shortcomings
Cephalometric radiographs are used extensively in
orthodontics, both in the assessment of the malocclu-
sion and the management of treatment. It must be
remembered that a cephalogram is a magnified two-
dimensional image of a three-dimensional object.
Analyses of the cephalograms are carried out with
several standard anatomic landmarks. Usually, tracings
are made to measure angular and linear variables.
According to several a u t h o r s , 72-75 the main source
of error in the conventional process of compiling data
513
514 Aelbers and Dermaut
Table I.Combined standard error for
angular measurements
SNA 1.0 °
SNB 0.6 °
ANB 0.7 °
PPL 0.7 °
PNS-ANS 0.6 m m
AR-Gn 0.8 m m
Co-Gn 1.7 m m
Co-Gn open 0.6 irma
from radiographic headplates is landmark identifica-
tion. In this study, we determined the measurement
error for the most commonly used angular and linear
measurements used in this review. Ten patients, of
whom their cephalograms in habitual occlusion and
with open mouth were available, were randomly cho-
sen. The measurements were performed at an interval
of several weeks. The landmarks were recorded by a
digitizer and the measurements calculated by com-
puter.
The combined standard error (Dahlberg 76) for the
angular measurements was 1° or less (Table I). The
measurement error was calculated according to:
~/Ed2
S= 2n
where d is the difference between two identical mea-
surements and n is the number of double registrations
(10). For the linear measurements, the error did not
exceed 1 mm except for the measurement Go-Gn on
the cephalogram in habitual occlusion. According to
Baumrind and Frantz, 77 the observed difference as a
result of therapy should at least be twice the standard
deviation of the estimating error. They found, for
example, a standard deviation of 0.62 ° for the ANB
angle, which is comparable to what we found, namely,
0.7 ° (Table I). Baumrind and F r a n t z 77 claim that in any
single clinical case, one can not be sure that an
observed difference in the ANB angle is biologic rather
than a measurement error, unless it exceeds 2 x s or
1.2 ° . This is not an unreasonably rigorous demand,
particularly when one remembers that in each compari-
son there are two estimations made and, hence, two
opportunities to err. According to Chaconas, 78"79 the
average standard deviation for the ANB angle is even
higher, 0.9 ° to 1.0 ° .
Some authors use the mandibular and maxillary
length to show possible orthopedic effects. Mandibular
length is usually expressed as the distance between
condylion (Co) and gnathion (Gn) or pogonion (Pg).
One of the problems encountered with this assessment
is the difficulty in defining the head of the condyle on
American Journal of Orthodontics and Dentofacial Orthopedics
November 1996
a cephalogram. Adenwalla 8° claims that, if the man-
dibular condyle has to be used as an important
landmark in any cephalometric study, the open mouth
cephalogram should be taken and superimposed on the
respective cephalogram in habitual occlusion, to obtain
the most accurate and reliable measurements. This is
in contradiction to the findings of Moore et a l . 8I The
average error in mandibular length, expressed by
Co-Gn in the open mouth position, was only 0.5 mm
less than condylion in the closed position, which was
found to be 2.3 mm. These results seem to indicate
that the open mouth method does not significantly
change the recognition of condylion. However, it does
increase the accuracy of landmark identification, but
this is not clinically significant, according to Moore
et al. 8' These results are in contradiction with those
we found, where an error for the distance Co-Gn in
the open mouth position equal to 0.6 m m was found.
The error in open mouth position was two and a half
times smaller than the error in closed position, being
1.7 mm. Other investigators tried to avoid the problem
of condylion by using articulare (Ar) because of the
high reproducibility of this landmark. However, ar-
ticulare does not show full mandibular length. More-
over, a change in the amount or the direction of growth
does not necessarily create the same positional change
of articulare.
Measuring mandibular length with articulare intro-
duces the possibility that anterior positioning of the
condyles out of the glenoid fossae could be interpreted
as an increase in mandibular length. The maxillary
length can be measured in several ways. Usually, it is
measured as the displacement of PTm point, spinal
point (Sp, ANS), or point A to a reference grid (x-y
axes). These landmarks cannot be located very accu-
rately. Point A is not a good skeletal reference point,
because it is influenced by dental changes as well.
Retroclination of the upper incisors usually creates a
change in position of point A. Because most functional
appliances induce a large dentoalveolar change, point
A has a limited value to evaluate orthopedics.
To avoid errors in adequate landmark identifica-
tion, some investigators 62'68'82-86 use implants. This is
especially useful in the maxilla, because stable ana-
tomic reference structures are hard to find.
Maxillary unit length is sometimes expressed as the
distance condylion to point A or ANS. As condylion is
not the most reliable landmark on a classical cephalo-
gram, this distance is not the best way to express
maxillary length. To conclude, the limitations of
cephalometrics have to be taken into consideration by
critically assessing cephalometric data, as will be done
in this study.
American Journal of Orthodontics and Dentafacial Orthopedics Aelbers and Dermaut 515
Volume 110, No. 5

Table II. Compilation of the material used in this review s t u d y s-71

Activator group EO group Chincap group

AC HAC He HG-He Total CHG HP-HG Class III therapy*

Mixed studies 38 7 6 51 22 9
Male studies 7 0 7 14 0 0
Female studies 7 0 0 7 0 4
Total studies 52 7 13 72 22 13
Control group 39 2 9 50 12 10
Class n, Div, 1 24 1 8 33 9 --
Class I 5 0 0 5 2 5
Class II, Div 1 + Class I 1 0 0 2 0 --
Growth study 5 0 1 6 0 3
No mentioned 4 1 0 5 0 --
Class III . . . . . 2
No control group (n) 13 5 4 22 10 3
Experiment samples: X (s) 29 (23) 38 (24) 25 (18) 31 (200) 33 (21) 24 (15)
Control samples: 2 (s) 28 (15) 49 (2) 16 (8) 27 (15) 37 (15) 83 (150)
ANB reported before therapy 50% 86% 92% 61% 31% 54%
(ANB) before therapy (s) 5.6 ° (0.8 °) 6.8 ° (0.7 °) 6.7 ° (2.0 °) 6.1 ° (1.4 °) 6.0 ° (0.8 °) -0.6 ° (I,8 °)

*Will be discussed in Part II.

AC, Activator; HAC, headgear activator; He, Herbst; HGHe, headgear Herbst; CHG, cervical headgear; HPHG, high-pull headgear; and E.O. group, extraoral traction
group.

APPLIANCE with comparable malocclusions, who were treated with

Different orthopedic appliances will be evaluated
in this review. No distinction has been made between
different types of activators. First of all, there are many
modifications of this appliance introduced by different
clinicians in an attempt to improve treatment quality.
All of them, however, aim to alter growth of the jaws.
Therefore, in the referred studies, the type of activator
was not described. On the other hand, the use of
headgear activators, as well as of Herbst appliances,
has been reported because these appliances are claimed
to have a different mode of action.
Studies on headgear therapy are discussed sepa-
rately. 18'25'26'aa'4°'61-71A distinction has been made be-
tween cervical and high-pull headgear therapy.
PROBLEMS OF RESEARCH
Study methods on human material are very lim-
ited. 2 The only practical way to investigate therapeu-
tically induced changes is the use of lateral skull
radiographs. As mentioned earlier, those radiographs
do not always give the best information. Moreover, for
ethical reasons, radiography must usually be limited to
those films that can be said to be essential for the
proper treatment of the patient. 2
There is the additional problem of finding suitable
control groups. Obvious difficulties exist in obtaining a
matched group of untreated children with severe mal-
occlusions w]ho have received no orthodontic treatment
and from whom a suitable series of lateral skull
radiographs are available.
Some investigators 5'27'3°'87'88 have used patients
conventional appliances, for control subjects. Oth-
e r s 14'z8"31'44'47'5°'56 have used randomly selected samples
from published growth studies (for example Michigan
or Burlington growth studies, Rocky Mountain Data
Systems, Bolton standards). A control group, consist-
ing of Class I malocclusions, is also frequently
u s e d . 9':~°':za'4°'61'81 Buschang et al. 89 indicated that man-
dibular growth rate differed between Class I and Class
II malocclusions: At the age of 15 years, the cumula-
tive mandibular length may be 2 mm shorter in girls
with Class II malocchisions. This has also been sug-
gested by Harris, 9° although several reports found no
difference. 91-94 Many authors have dispensed with the
use of a control sample.*
Even when a suitable control group is available, it
must be remembered that human facial growth differs
between genders 95-9~ and at different ages. Control
cases must therefore be carefully matched by age and
gender to correspond to the subjects used in the
treatment group. Sometimes the same cases are used as
both a control group and an experimental group, by
following the natural development for several years (2
or more) before carrying out treatment. In this case, of
course, the experimental and control groups are not
matched for age. Moreover, to exclude rare or atypical
results, the experimental and control groups should be
large enough: 30 or more patients. 2 Unfortunately,
large experimental groups are not always so easy to
find. Implant studies 62'68 are limited by ethical consid-
*References 8,11,12,24,34,36,41,43,45,54,57,63,64,66,69,71.
516 Aelbers and Dermaut American Journal of Orthodontics and Dentofacial Orthopedics
November 1996

(S) or nonsignificant (NS) difference between

Table IlL Compilation of the number of articles indicating a significant
experimental and control groups for ASNA, ASNB, AANB, A palatal plane, A maxillary length; A mandibular
length during the treatment period
Activator group EOT group

AC HAC He HGHe Total CHG HPHG

S NS S NS S NS S NS S NS

ASNA 14 8 2 0 3 4 19 12 4 0
ASNB 9 13 2 0 5 0 16 13 2 1
AANB 17 3 1 0 7 i 25 3 3 1
APPL 0 11 0 0 1 6 1 17 3 3
A maxillary length 6 10 0 2 1 2 7 14 7 0
A mandibular length 16 10 1 1 7 0 24 i1 2 4

erations, and the number of subjects involved in those
studies is usually quite small.
FINDINGS
Sagittal Treatment Changes
Table II lists the number of reported studies used in
this review report.
Because measurements were made by different
persons and in highly different ways, we were inevi-
tably restricted to using only those measurements
common to several investigations and were forced to
abandon those that were reported in a different form. It
is obvious that most of the articles meeting those
criteria were describing the orthopedic effect of acti-
vator therapy. Although Buschang, 89'96 Bishara, 97 and
Carter 95 claim that mandibular growth is clearly gender
related, obvious differences in response to orthopedic
therapy in girls and boys were not clearly established
in the publications, except for the studies of Luder 2°'22
and Jacobson 48 who did suggest some difference in
response between girls and boys. Most of the studies
on activator treatment (73%) used mixed samples.
Control groups were used in 75% of the studies. A
majority of these control groups consisted of patients
with a Class II, Division 1 malocclusion.
In the majority of studies, samples of approxi-
mately 30 patients were used, although there was a
large variation in the number of patients used in the
different studies. In half of the reported studies, the
initial ANB angle (before treatment) was given
(~ = 5.6 °, s = 0.8°), indicating that most samples were
composed of patients with skeletal Class II malocclu-
sions, as would be expected. The group of studies
describing the orthopedic effect of headgear activators
and Herbst appliances was small (see Table II).
Twenty-two studies on headgear therapy were re-
ported, with a composition more or less comparable to
the activator group (see Table II). Table III is a
compilation of the number of articles indicating a
significant (S) or nonsignificant (NS) difference be-
tween changes induced during therapy (combination of
growth and therapy) and changes observed in a control
group of growing children.
Significant changes in the SNA and SNB angles
(between the experimental and the control group) were
found in approximately 60% of the studies (SNA 67%,
SNB 46%) reporting the activator effect. In the head-
gear group, all studies reported significant changes in
the SNA angle between both groups. It should be
emphasized, however, that the number of studies was
very limited for this group. Changes in the ANB angle
were evaluated as "significantly different" in 86% of
the activator studies and in 75% of the headgear
studies.
Inhibition of maxillary growth as a result of acti-
vator or Herbst therapy was found in 33% of the
studies, whereas headgear therapy caused this effect in
all the reported studies. In contrast, the effect on
mandibular growth (expressed as a significant change
in mandibular length) was noted in 68% of the activa-
tor/I-Ierbst group and in 33% of the headgear group. In
Table IV, the mean changes and distribution of the
reported cephalometric parameters, due to normal
growth in boys between 11 and 12 years of age, 9s are
listed in column 1. We calculated the annual changes
for the different appliances from the consulted articles.
They are also presented in Table IV. The first question
arising is whether a mean change smaller than 1° or
1 mm is clinically significant. Although all calculated
values are listed in Table IV, only those with a thera-
peutic effect exceeding 1° or 1 mm will be discussed.
In the headgear group, as well as in the Herbst group,
the SNA angle was found to decrease more than 1° as
a therapeutic effect. It never exceeded 1.5 °, as can be
seen in Table IV (1.2 ° and 1.5°).
Because of the Herbst treatment, an increase in the
American Journal o f Orthodontics and Dentofacial Orthopedics Aelbers and Dermaut 517
Volume 110, No. 5

Table IV. Calculated values for annual changes (X, s) of all the reported articles
Riolo 11-12 yrs. AC HAC He + HGHe CHG + HPHG

Y s ,~ s TE Y~ s TE Y s TE Y, s TE

ASNA (°) +0.4 4.4 -0.3 0.3 -0.7 +0.6 0.3 -1.0 -0.8 0.5 -1.2 -i,1 0.7 -1.5
ASNB (°) +0.8 3.7 +0.7 0.7 -0.1 +1.1 0.6 +0.3 +2.1 0.4 +1.3 +0.4 0.9 -1.2
AANB (o) +0.4 5.8 -0.7 0.8 -0.3 -1.4 1.0 -1.0 -3.9 2.3 -3.5 -0.9 0.4 +0.5
APPL (°) 0.0 4.2 +0.2 0.3 +0.2 +0.3 0.2 +0.3 -0.9 1.0 +0.9 +0.5 0.8 +0.5
A maxillary length (mm) +0.7 3.9 +0.6 0.8 +0.1 +0.5 0.4 -0.2 +0.4 1.5 -0.3 -0.1 0,6 +0.8
h mandibular length (ram) +2.3 5,5 +2.8 1.3 +0.5 +3.3 2.0 +1.0 +6.3 1.3 +4.0 +t.6 1.0 -0,7

Mandibular length: Ar-Gn.

Maxillary length: PNS-ANS.
2, Mean value; s, standard deviation; TE, therapeutic effect,

SNB angle of 1.3 ° was calculated, whereas headgear
treatment alone actually decreased this angle (1.2°).
Both effects resulted in a decrease of the ANB angle of
3.5 ° in the Herbst group. An elongation of the man-
dible, because of the treatment, was calculated for
He-HGHe group (~ = 4 mm).
Changes in the cant of the palatal plane were
negligible. Depending on the calculated values, the
change in the cant of the palatal plane varied between
0.2 ° and 0.9 °. The calculated error for this parameter
however was 0.7 ° (see Table I).
Changes in maxillary length never exceeded 1 mm.
Four authors did suggest a remodeling of the glenoid
fossa as a result of activator treatment 29"37 and Herbst
therapy. 16'32 Clear radiologic evidence of this phenom-
enon does not exist so far. However, in animal experi-
ments, some remodeling of the fossa has been shown
histologically. 9'99'1°°The orthopedic effects observed in
animal studies will be discussed in part II of this
review.
DISCUSSION
Headgears, activators, and Herbst appliances have
proven to be valuable tools in orthodontic treatment.
Sagittal discrepancies between mandible and maxilla
can be corrected adequately. It remains questionable,
however, whether the results of this kind of therapy
can be attributed to skeletal effects rather than to
dentoalveolar compensation. Even long ago, Bj6rk 1°1
had many doubts about the orthopedic effect of acti-
vator therapy. He reported that mandibular prog-
nathism increases to a certain extent during activator
treatment, but stated that the increase might well be
within the range of normal growth. An extensive list of
articles has been published the last 40 years. In part I
of this review, we made an attempt to evaluate only the
Class II orthopedic effect of activators, Herbst appli-
ances, and headgears, according to the publications.
On average, there was a statistically significant change
for most of the cephalometric parameters used (Table
III). It should be emphasized, however, that the value
of this significance has to be interpreted with caution
because the mean values are rather small.
As has been pointed out previously (see Findings),
values not exceeding l° or 1 mm as a therapeutic effect
have little clinical significance. Mean changes of SNA
1.2 ° and 1.5 ° were found in the Herbst and headgear
groups, indicating that the apical base of the maxilla
could be restrained in its forward .growth to some
extent. It should be emphasized that dental changes in
the frontal area of the maxilla may cause some change
in the position of point A.
As previously mentioned, Baumrind and Frantz v7
claim that in any single clinical case one cannot be
sure that an observed difference for any parameter is
biologic rather than measurement error unless it ex-
ceeds 2 standard deviations (registered by testing the
error of the method). Statistically, this principle cannot
be transferred to average values. However, to test the
clinical significance of average changes, the error of
the method for the tested parameter gives some indi-
cation. We therefore accepted 2 s (which corresponds
to a significance level of 95%) as a criteria. When this
principle is applied to the error of the method we tested
(Table I), on average only few changes were found to
be biologically demonstrable. Therefore only those
values meeting these criteria have been printed in bold
type. Whatever criteria being accepted, Table IV shows
only small changes as therapeutic effect (maximum
1.5 ° ) besides the ones based on the criteria mentioned
previously. In the He-HGHe group, a mean change in
SNB of 1.3 ° was calculated. The Herbst appliance
seems to stimulate mandibular growth to some extent.
This effect is also reflected in a mean change of
ANB = 3.5 ° and an increase in mandibular length of
4 ram.
Most articles about Herbst appliance therapy have
been published by Pancherz. 21'23'46'52 Pancherz mea-
518 Aelbers and Dermaut
sured mandibular length as the distance between
condylion and gnathion on cephalograms taken with
open mouth. According to this review, only Herbst
therapy was able to change mandibular growth to a
clinically significant extent. In part II of this review,
the long-term effect of these changes will be evaluated.
Clear radiologic evidence of "fossa-remodeling" could
not be established so far. However, histologic changes
of the glenoid fossa in animal studies seem to support
this hypothesis. 9'99't°° In part II of this study, we will
return to this phenomenon.
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