ORIGINAL ARTICLE

Stability of Class II malocclusion

treatment with Class II elastics
Guilherme Janson,a Ana Liesel Guggiari Niederberger,a Gabriela Janson,a Marcelo Vinicius Valerio,a
Waleska Caldas,a and Fabr
ıcio Pinelli Valarellib
Bauru, S~ao Paulo, and Maring
a, Paran
a, Brazil

Introduction: The objective of this study was to compare the long-term cephalometric stability after successful
therapy of nonextraction Class II malocclusion with elastics and with headgear. Methods: The sample
comprised 43 patients with Class II malocclusion and was divided into 2 groups. The elastic group (EG) con-
sisted of 20 patients treated with fixed appliances associated with Class II elastics, and the headgear group
(HG) consisted of 23 patients treated with fixed appliances and extraoral headgear. Pretreatment, posttreatment,
and long-term posttreatment lateral radiographs were evaluated; t tests were used to compare the long-term
posttreatment changes between the groups. Results: The groups were matched regarding initial age, time of
long-term posttreatment evaluation, initial malocclusion severity, quality of treatment result, and all
pretreatment cephalometric variables. Intergroup comparisons of long-term posttreatment changes showed
that the HG group presented significantly greater mandibular protrusion, occlusal plane angle decrease, and
maxillary molar mesialization. However, long-term posttreatment stability was similar in overjet, overbite, and
molar relationships. Conclusions: Nonextraction Class II malocclusion treatment with elastics or extraoral
headgear have similar long-term posttreatment stability. (Am J Orthod Dentofacial Orthop 2023;163:609-17)

I
t is well known that, in orthodontics, seeking a suc-
cessful finishing of active treatment is not enough,
but optimization of the results in the long-term is
the main issue. There are several treatment options to
effectively correct a Class II malocclusion. Studies
confirm that Class II correction stability does not depend
on the treatment protocol and that the occlusal results
present good stability in the long term.1-6
Elastics have been an option to correct Class II maloc-
clusion since the late 1800s,7-10 and normal occlusion
a
Department of Orthodontics, Bauru Dental School, University of S~ao Paulo,
Bauru, S~ao Paulo, Brazil.
b
Department of Orthodontics, Ing
a University Center Uning
a, Maring
a, Paran
a,
Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This work was supported by the National Program of Foreign Postgraduate
Scholarship (BECAL), Ministry of Education, Republic of Paraguay, and the Co-
ordination for the Improvement of Higher Education Personnel, CAPES (financial
code 001), Brazil.
This retrospective study was approved by the Ethics in Research Committee of
Bauru Dental School, University of S~ao Paulo (CAAE 65047717.7.0000.5417).
Address correspondence to: Marcelo Vinicius Valerio, Department of Orthodon-
tics, Bauru Dental School, University of S~ao Paulo, Alameda Oct
avio Pinheiro Bri-
solla 9-75, Bauru, S~ao Paulo 17012-901, Brazil; e-mail, drmarcelovalerio@
gmail.com.
Submitted, May 2021; revised and accepted, October 2021.
0889-5406/$36.00
Ó 2023.
https://doi.org/10.1016/j.ajodo.2021.10.017
can usually be obtained with intermaxillary forces,
with primarily dentoalveolar effects.11-14
The elastics produce palatal tipping and retrusion of
the maxillary incisors, mesialization, and protrusion of
mandibular molars and incisors, respectively, and slight
distalization of the maxillary molars.7,11-15 Class II
elastics are usually used from 1 point in the maxillary
canine area to a point on the mandibular molar area.
The unfavorable collateral effect is the clockwise
rotation of the occlusal and mandibular planes, with
extrusion of the maxillary incisors and mandibular
molars.9,13,16
Comprehensive long-term posttreatment follow-up
studies of Class II malocclusion correction with elastics
are scarce.3,17 Fidler et al3 published an article that
showed good long-term stability of Class II malocclusion
correction, but in this study, Class II elastics were used
only occasionally. Nelson et al17 evaluated the follow-
up changes of treatment with elastics associated with
the Begg technique and with the Herbst appliance and
found that the unfavorable effects of the elastics did
not persist in the long term. The long-term effects of
Class II malocclusion treatment with elastics are gener-
ally similar to fixed functional appliances.12,17
Despite these studies showing that the long-term ef-
fects of Class II elastics in Class II malocclusions are
mostly favorable, there is still widespread speculation
that the extensive reciprocating distomesial movements
609
610
of the maxillary and mandibular teeth to a normal occlu-
sion produced by intermaxillary elastics are responsible
for relapse after treatment,12,18,19 suggesting that the
prognosis with this mechanics is unfavorable. Therefore,
the purpose of this study was to evaluate the long-term
cephalometric stability after successful treatment of
nonextraction Class II malocclusion with Class II elastics.
MATERIAL AND METHODS
Ethical approval was obtained from the Ethics in
Research Committee of Bauru Dental School, University
of S~ao Paulo (CAAE 65047717.7.0000.5417), and all
subjects signed informed consent.
The sample size calculation showed that to detect a
mean difference of 1.5 mm in the overjet changes between
both groups with a standard deviation of 1.1, a test power
of 80%, and a significance level of 5%, 12 patients would
be needed in each group.17 To increase test power, even
more,20 all the patients the fit the selection criteria were
included. Thus, the final test power was 96%.21
A sample of 43 patients was retrospectively selected
from the files of the Orthodontic Department at Bauru
Dental School, University of S~ao Paulo, according to
the following criteria: (1) Class II, Division 1 malocclu-
sion with a minimum of half Class II molar relationship
(when the maxillary molar is positioned mesially to its
described position in normal occlusion the equivalent
of approximately half the width of a premolar),22,23
treated nonextraction (excluding third molars), (2)
good occlusal finishing (established by the cast-
radiograph evaluation [CRE]24), and (3) availability of
lateral cephalometric and panoramic radiographs, and
dental casts at 3 stages (pretreatment [T1], posttreat-
ment [T2], and long-term posttreatment [T3]). The
occlusal relationships and cephalometric characteristics
at T3 were not considered in the sample selection.
The sample was divided into 2 groups according to the
treatment protocol to correct the Class II malocclusion.
The elastic group (EG) consisted of 20 Class II malocclu-
sion patients (11 males, 9 females) treated with Class II
elastics to correct the anteroposterior discrepancy.
The mechanics consisted of standard fixed edgewise
or Roth preadjusted appliances with 0.022 3 0.028-in
slots and a usual wire sequence characterized by an
initial 0.015-in twist-flex or a 0.014-in Nitinol, 0.016,
0.018, 0.020 and 0.019 3 0.025 or 0.018 3 0.025-in
stainless steel archwires. Deep overbites were corrected
by reversed and accentuated curve of Spee. Class II ante-
roposterior discrepancy was corrected with Class II elas-
tics on both sides for at least 6 months, for 15-18 h/d,
with 200 g of force, measured with a tension gauge.
The elastics were used more on 1 side than the other
when necessary.
May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Janson et al
The headgear group (HG) consisted of 23 Class II Di-
vision 1 malocclusion patients (13 male; 10 female),
matched regarding initial age and sex and followed dur-
ing a comparable period to the EG long-term posttreat-
ment period (T2
T3). The patients were treated only
with the cervical traction headgear to correct the Class
II relationship associated with fixed appliances.
From .4000 patient records of the Orthodontic
Department files, 2050 patients treated without extrac-
tions were initially selected. From these records, all pa-
tients with Class I and III malocclusions were excluded,
reducing the records to 663. Thus, patients with Class
II malocclusion treated with intraoral distalizing appli-
ances, fixed or removable functional appliances, minis-
crews, a combination of different protocols to aid
molar anteroposterior discrepancy correction, or who
have undergone replanning were also eliminated. The
remaining records included 30 patients who were treated
with cervical headgear and 241 patients who were
treated with Class II intermaxillary elastics. Then, after
applying the restricted selection criteria, 25 and 20 pa-
tients remained in HG and EG, respectively, to be
matched regarding several pretreatment characteristics.
The need for at least a half Class II molar initial discrep-
ancy and long-term follow-up were the main reasons for
the reduced number of patients in the elastic group.
The retention protocol in both groups included a
maxillary Hawley retainer worn full time during the first
6 months and as night-time wear for the subsequent 6
months. In the mandibular arch, a canine-to-canine
bonded retainer was installed and recommended to be
used for 3 years. At the long-term posttreatment stage,
16 (80%) patients of the EG and 13 (56.5%) patients of
the HG group still wore fixed canine-to-canine retainers.
Lateral cephalometric headfilms of all patients were
obtained in centric occlusion with passive lip posture
and digitized with Microtek ScanMaker (model i800; Mi-
croteck International, Inc, Carson, Calif), traced, and
analyzed with Dolphin Imaging software (version 11.5;
Dolphin Imaging and Management Solutions, Chats-
worth, Calif), which corrected the image magnification
factors. Several angular and linear variables were ob-
tained from the lateral cephalograms to analyze the skel-
etal and dental changes during the long-term
posttreatment period (Table I and Fig). The lateral ceph-
alograms were blindly traced by a previously calibrated
examiner (A.L.G.N.) at the 3 stages.
To evaluate the initial malocclusion severity of the
groups, the peer assessment rating (PAR) index25 was
calculated by 1 examiner on the pretreatment dental
study casts of each patient. Initial dental cast analysis
was carried out using the US-weighted PAR Index.26
The scores were weighted for the separate components
Janson et al 611

Table I. Skeletal and dentoalveolar cephalometric variables

Variables Definitions
Skeletal cephalometric variables
Maxillary component
SNA ( ) SN to NA angle
Mandibular component
SNB ( ) SN to NB angle
Maxillomandibular relationship
ANB ( ) NA to NB angle
Wits (mm) Distance between perpendicular projections of Points A and B on the functional occlusal plane
Vertical component
FMA ( ) Frankfort mandibular plane angle
SNGoGn ( ) SN to GoGn angle
SN.OP ( ) Angle between SN plane and the occlusal plane of Downs
PP.OP ( ) Angle between the palatal plane and Occlusal plane of Downs
LAFH (mm) Distance from ANS to menton
Dental cephalometric variables
Maxillary dentoalveolar component
Mx1.PP ( ) Maxillary incisor long axis to palatal plane angle
Mx1-PP (mm) Perpendicular distance between incisal edge of maxillary incisor and palatal plane
Mx1-APerp (mm) Distance between the most anterior point of maxillary incisor crown and a line perpendicular to
palatal plane, tangent to A point. Reading is negative if the incisal edge is posterior to A point
Mx6-APerp (mm) Distance between the mesiobuccal cusp tip of the maxillary first molar and a line perpendicular
to the palatal plane, tangent to A point. Reading is positive if the mesiobuccal cusp tip is
posterior to A point
Mx6-PP (mm) Perpendicular distance between the mesiobuccal cusp tip of the maxillary first molar and palatal
plane
Mandibular dentoalveolar component
Md1-PgPerp (mm) Distance between the most anterior point of the mandibular incisor crown and a perpendicular
to the mandibular plane, tangent to Pg. Reading is negative if the incisal edge is posterior to
Pg
Md1-MP (mm) Perpendicular distance between incisal edge of mandibular incisor and mandibular plane
Md6-PgPerp (mm) Distance between the mesiobuccal cusp tip of the mandibular first molar and a line
perpendicular to the mandibular plane, tangent to Pg. Reading is positive if the mesiobuccal
cusp tip is posterior to PgPerp
Md6-MP (mm) Perpendicular distance between the mesiobuccal cusp tip of the mandibular first molar and
mandibular plane
IMPA (L1-MP) ( ) Mandibular incisor long axis to mandibular plane angle
Dental relationships
Overjet (mm) Distance between incisal edges of maxillary and mandibular central incisors, parallel to the
functional occlusal plane
Overbite (mm) Distance between incisal edges of maxillary and mandibular central incisors, perpendicular to
Frankfort plane
Molar relationship (mm) Distance between mesial points of maxillary and mandibular first molars, parallel to Frankfort
plane

and summed to obtain a total score (PAR Index),
expressing the malocclusion severity.
The treatment results were evaluated on the basis of
the CRE developed by the American Board of Orthodon-
tics.24 This system for scoring dental casts and pano-
ramic radiographs contains 8 criteria: alignment,
marginal ridges, buccolingual inclination, occlusal
relationships, occlusal contacts, overjet, interproximal
contacts, and root angulation. The scores were blindly
assigned by a previously calibrated examiner (A.L.G.N.).
After a 30-day interval, a random sample of 14 lateral
cephalometric, panoramic radiographs, and dental casts
were selected and remeasured by the same examiner
(A.L.G.N.). The random errorsP were calculated according
to Dahlberg’s formula (Se2 5 d2/2n),27 in which Se2 is
the error variance and d is the difference between 2 de-
terminations of the same variable. The systematic errors
were evaluated with dependent t tests at P \0.05.28
Statistical analyses
The normal distribution of the variables was verified
with Kolmogorov-Smirnov tests. All variables showed
normal distributions. Therefore, group comparability
regarding initial, final, and long-term posttreatment

American Journal of Orthodontics and Dentofacial Orthopedics May 2023  Vol 163  Issue 5
612
Fig. Unusual cephalometric variables. 1, Mx1.PP; 2,
Mx1-APerp; 3, Mx1-PP; 4, Mx6-APerp; 5, Mx6-PP; 6,
Md1-PgPerp, 7, Md1-MP; 8, Md6-PgPerp; 9, Md6-MP.
ages, treatment time, long-term posttreatment time,
initial malocclusion severity (PAR Index), and the quality
of treatment results in both groups were compared with
t tests. Intergroup sex, the severity of Class II malocclu-
sion relationship, and the presence of canine-to-canine
retainer distributions at T3 were compared with chi-
square tests. Intergroup initial cephalometric character-
istics were also compared with t tests.
T tests were used to compare the intergroup treat-
ment changes (T2
T1) and the long-term posttreat-
ment changes (T3
T2). The results were considered
significant at P \0.05. The statistical analyses were per-
formed with Statistica software (version 6.0, Statsoft,
Tulsa, Okla.).
RESULTS
Random errors of the initial PAR and CRE ranged
from 0.24 (canine relationship) to 1.05 mm (CRE) and
were within acceptable levels.29 No statistically signifi-
cant systematic errors were detected. Among the 21
cephalometric variables, the random errors ranged
from 0.71 mm (overbite) to 1.20 mm (Overjet and
LAFH) for linear variables and from 0.07 (SNA) to
1.20 (FMA and SnGoGn) for angular variables and
were within acceptable levels.30 Only 2 cephalometric
May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Janson et al
variables presented significant systematic errors: SNA
and SN-GoGn.
The groups were comparable regarding initial age,
time of long-term posttreatment evaluation, initial
PAR Index, quality of treatment result (CRE), sex, the
severity of Class II molar relationship, and presence of
canine-to-canine retainer distributions at T3 (Table II).
However, patients of the EG presented significantly
greater posttreatment and long-term posttreatment
ages and treatment time. All pretreatment cephalometric
variables were similar in the groups (Table III).
During treatment, the HG group presented signifi-
cantly greater maxillary anterior displacement restriction
and increased lower anterior face height and maxillary
molar dentoalveolar height. Mandibular incisor behavior
was significantly different in the groups because they
were protruded in the EG and retruded in the HG. The
HG also had significantly greater mandibular incisor ver-
tical development. Mandibular molar behavior was also
significantly different in the groups because they mesial-
ized in the EG and distalized in the HG (Table IV).
During the posttreatment period, the HG group pre-
sented significantly greater mandibular protrusion,
occlusal plane angle decrease, and maxillary molar me-
sialization (Table V).
To avoid the influence of the different intergroup
treatment times in the results, subgroups with matching
treatment times were also compared with t tests. The re-
sults were similar to those of the original groups, except
that there was no intergroup difference in the occlusal
plane changes (Tables VI and VII).
DISCUSSION
Elastics, for Class II malocclusion correction, have
been widely used; nevertheless, there remains some
conviction that the extensive reciprocating sagittal
movements of the teeth with elastics could lead to un-
stable treatment results in the long term.12,18,19 There-
fore, in this study, patients with Class II Division 1
malocclusion, treated with and without Class II elastics,
were evaluated after a long-term posttreatment period.
To evaluate the stability of Class II malocclusion
treatment with elastics, we compared the long-term
posttreatment results with patients treated with extrao-
ral headgear associated with fixed appliances, which has
been traditionally used for a long time; its effects are
widely described in the literature.15,31,32
Selection criteria for the sample were rigidly applied
to attain a homogenous sample. The groups were statis-
tically comparable regarding initial age, sex distribution,
long-term posttreatment period, and the presence of
canine-to-canine retainer at T3. However, the final
Janson et al 613

Table II. Initial intergroup data comparison Table III. Initial intergroup cephalometric data com-
parison
Variables EG (n 5 20) HG (n 5 23) P value
Age (y) P
T1 14.14 6 5.62 12.14 6 1.21 0.209y Variable EG (n 5 20) HG (n 5 23) value
T2 17.26 6 5.50 14.61 6 1.25 0.030*,y Maxillary component
T3 24.36 6 6.19 19.88 6 2.72 0.003*,y SNA ( ) 80.67 6 4.27 81.68 6 4.20 0.441
Treatment time (y) 3.12 6 1.12 2.47 6 0.83 0.036*,y Mandibular component
Time of long-term 6.94 6 4.90 5.27 6 2.40 0.153y SNB ( ) 76.54 6 3.54 77.33 6 3.42 0.456
posttreatment Maxillomandibular
evaluation (y) relationship
Initial PAR 33.15 6 9.21 33.0 6 10.35 0.960y ANB ( ) 4.12 6 2.71 4.33 6 3.02 0.813
CRE T2 (quality of 19.75 6 5.92 20.39 6 8.63 0.781y Wits (mm) 2.11 6 3.28 2.34 6 2.88 0.804
treatment result) Vertical component
Sex 0.920z FMA ( ) 26.80 6 5.78 26.89 6 5.08 0.956
Males 11 13 SNGoGn ( ) 34.06 6 5.65 33.10 6 6.09 0.599
Female 9 10 SN.OP ( ) 16.89 6 4.40 15.68 6 4.88 0.422
Severity of Molar 0.852z PP.OP ( ) 9.04 6 4.73 7.41 6 4.32 0.245
discrepancy LAFH (mm) 62.15 6 5.59 61.84 6 6.31 0.868
Complete Class II 9 11 Maxillary dentoalveolar
Half Class II 11 12 component
Canine-to-canine 1.632z Mx1.PP ( ) 112.84 6 8.23 113.97 6 8.25 0.654
retainer at T3 Mx1-PP (mm) 26.74 6 2.37 26.80 6 3.00 0.943
Still wearing 15 13 Mx1-APerp (mm) 4.74 6 3.01 4.90 6 3.41 0.868
Not wearing 5 10 Mx6-APerp (mm) 25.62 6 2.67 27.05 6 2.84 0.098
Mx6-PP (mm) 21.22 6 2.19 20.49 6 2.61 0.329
Note. Values are mean 6 standard deviation. Mandibular dentoalveolar
*Statistically significant at P \0.05; yt test; zchi-square test. component
Md1-PgPerp (mm) 8.28 6 3.21 8.33 6 2.31 0.952
IMPA (L1.MP) ( ) 94.06 6 5.81 94.78 6 5.48 0.677
age, the age at the long-term posttreatment evaluation, Md1-MP (mm) 38.71 6 3.75 38.33 6 3.58 0.736
and the treatment time were greater in the EG (Table II). Md6-PgPerp (mm) 27.86 6 3.14 27.30 6 3.04 0.559
Md6-MP (mm) 32.66 6 2.62 33.83 6 2.77 0.165
The initial malocclusion severity, evaluated with the Dental relationships
PAR Index, the Class II molar relationship discrepancy, Overjet (mm) 4.95 6 2.11 5.83 6 2.52 0.227
and all pretreatment cephalometric variables were com- Overbite (mm) 3.01 6 1.73 2.88 6 1.88 0.819
parable between the groups (Tables II and III). To ensure Molar relationship (mm) 1.95 6 1.80 2.37 6 1.84 0.456
that the changes in the long-term were only consequent Note. Values are mean 6 standard deviation. Data were analyzed us-
to the different treatment protocols, good quality ing t test.
occlusal results at posttreatment (CRE) were determinant
to include patients in each group. In addition, elimi-
nating the possibility of slightly worse occlusal results
of 1 specific group has influenced its stability. Thus, in (Table IV). This heavier force will produce greater maxil-
the intergroup comparison,33 groups were matched lary anterior displacement restriction.36,37
regarding the occlusal outcomes. The greater lower anterior face height increase in the
In both groups, the long-term posttreatment time HG group was probably consequent to the greater maxil-
was .5 years after orthodontic appliance removal. The lary molar extrusion, which is an expected effect of the
mean time of posttreatment evaluation was 6.94 6 headgear (Table IV).4
4.90 years in the EG and 5.27 6 2.40 years in the HG. Class II elastics are usually responsible for the unfa-
Accordingly, stability after orthodontic treatment in vorable collateral effect of clockwise rotation of the
both mechanics could be evaluated with high reliability mandibular and occlusal planes, consequent to the
because half of the total relapse occurs in the first 2 years extrusion of the maxillary incisors and mandibular mo-
after orthodontic appliance removal and achieves good lars.9,13,16 In this study, there was a slight counterclock-
stability after 5 years of posttreatment.31,34 wise rotation of the mandibular and occlusal planes,
During treatment, maxillary forward growth was which were not significantly different from the slight
more efficiently restricted in the HG, which is expected clockwise rotations in the HG (Table IV). Similar results
because the headgear applies heavier forces on the were also observed in a previous study.38 Compensation
anchorage molars and, consequently, on the maxilla35 by reversed and accentuated curves of Spee archwires

American Journal of Orthodontics and Dentofacial Orthopedics May 2023  Vol 163  Issue 5
614 Janson et al

Table IV. Intergroup comparisons of treatment Table V. Intergroup comparisons of long-term post-
changes (T2
T1) treatment changes (T3
T2)
P P
Variable EG (n 5 20) HG (n 5 23) value Variable EG (n 5 20) HG (n 5 23) value
Maxillary component Maxillary component
SNA ( ) 0.32 6 2.88
1.34 6 2.32 0.043* SNA ( ) 0.09 6 2.04 0.27 6 2.26 0.792
Mandibular component Mandibular component
SNB ( ) 1.43 6 1.67 0.60 6 1.90 0.137 SNB ( )
0.31 6 1.12 0.67 6 1.63 0.030*
Maxillomandibular Maxillomandibular
relationship relationship
ANB ( )
1.11 6 2.77
1.93 6 2.23 0.291 ANB ( ) 0.42 6 1.61
0.40 6 2.20 0.181
Wits (mm)
1.73 6 2.85
2.47 6 2.80 0.390 Wits (mm) 0.46 6 2.23 0.28 6 2.45 0.807
Vertical component Vertical component
FMA ( )
1.09 6 3.41 0.30 6 3.44 0.191 FMA ( ) 0.56 6 3.08
0.73 6 2.97 0.171
SNGoGn ( )
1.81 6 2.97
0.35 6 3.08 0.124 SNGoGn ( )
0.42 6 2.55
0.58 6 2.08 0.814
SN.OP ( )
0.65 6 4.36 1.38 6 3.47 0.118 SN.OP ( )
0.19 6 2.33
1.94 6 2.26 0.022*
PP.OP ( )
1.44 6 3.97
0.73 6 3.83 0.554 PP.OP ( )
0.77 6 2.99
1.22 6 2.43 0.589
LAFH (mm) 1.26 6 4.08 4.29 6 2.89 0.007* LAFH (mm) 1.55 6 3.03 0.97 6 1.63 0.431
Maxillary dentoalveolar Maxillary dentoalveolar
component component
Mx1.PP ( ) 1.51 6 8.66 0.76 6 8.44 0.777 Mx1.PP ( ) 1.02 6 1.75 0.33 6 1.00 0.115
Mx1-PP (mm)
0.24 6 2.49 1.04 6 1.64 0.051 Mx1-PP (mm)
2.00 6 6.49 0.03 6 3.41 0.198
Mx1-APerp (mm) 0.20 6 3.28 0.29 6 3.27 0.931 Mx1-APerp (mm) 0.89 6 2.61
0.29 6 2.25 0.120
Mx6-APerp (mm) 1.51 6 2.81 0.85 6 3.54 0.511 Mx6-APerp (mm) 0.29 6 1.85
1.47 6 2.42 0.012*
Mx6-PP (mm) 0.89 6 1.98 2.47 6 1.31 0.003* Mx6-PP (mm) 0.54 6 1.07 0.87 6 1.15 0.331
Mandibular dentoalveolar Mandibular dentoalveolar
component component
Md1-PgPerp (mm) 1.11 6 2.76
0.56 6 1.86 0.024* Md1-PgPerp (mm) 0.30 6 1.49 0.75 6 1.30 0.294
IMPA (L1.MP) ( ) 3.50 6 5.41 1.91 6 4.67 0.308 IMPA (L1.MP) ( ) 0.10 6 1.59
1.53 6 3.63 0.071
Md1-MP (mm) 0.16 6 2.67 1.72 6 1.74 0.027* Md1-MP (mm) 1.35 6 1.76 0.91 6 1.26 0.346
Md6-PgPerp (mm)
1.60 6 2.12 0.90 6 4.16 0.020* Md6-PgPerp (mm)
0.35 6 1.58
0.22 6 1.16 0.770
Md6-MP (mm) 1.91 6 2.07 2.77 6 1.92 0.166 Md6-MP (mm) 1.39 6 1.99 0.47 6 1.40 0.085
Dental relationships Dental relationships
Overjet (mm)
2.17 6 2.18
2.87 6 2.55 0.337 Overjet (mm)
0.08 6 1.12
0.19 6 0.82 0.719
Overbite (mm)
1.76 6 1.73
1.56 6 1.77 0.718 Overbite (mm) 0.74 6 0.78 0.41 6 1.16 0.286
Molar relationship (mm)
2.24 6 1.87
3.05 6 2.05 0.187 Molar relationship (mm) 0.15 6 1.00 0.03 6 0.91 0.696

Note. Values are mean 6 standard deviation. Data were analyzed us- Note. Values are mean 6 standard deviation. Data were analyzed us-
ing t test. ing t test.
*Statistically significant at P \0.05. *Statistically significant at P \0.05.

in HG, there was mandibular protrusion. The greater

were used in almost all patients in the EG, which may
have controlled the vertical effects during treatment.
The EG demonstrated greater mandibular incisor
labial protrusion and mesial molar movement, which
are expected with Class II elastics mechanics.37 (Table
IV). However, the HG had greater mandibular incisor
extrusion.
Comparing the behavior of the groups during the
long-term posttreatment period, both showed similar
changes for most variables except for the anteroposterior
position of the mandible to the cranial base (SNB), of the
occlusal plane rotation in relation to the cranial base, and
of the maxillary molar anteroposterior changes, that were
significantly different between the groups (Table V). In
the EG, there was slight mandibular retrusion, whereas,
mandibular protrusion in the HG could result in greater
growth changes experienced by this group, which had a
significantly younger age at the end of treatment.39,40
However, these slightly different changes did not pro-
duce significantly different intergroup changes in the
apical base relationships, as in previous studies.4,17
The HG had a significantly greater counterclockwise
rotation than the EG only when the cranial base was
used as a parameter for occlusal plane rotation evalua-
tion (Table V). Nonetheless, both groups were similar
when the occlusal plane was evaluated in relation to
the palatal plane. It suggests that growth may have
slightly influenced the cranial base direction. Therefore,
it can be assumed that both groups presented similar
long-term posttreatment changes in occlusal plane

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Janson et al 615

Table VI. Intergroup data comparison in subgroups Table VII. Intergroup comparisons of long-term post-
with comparable treatment time treatment changes (T3
T2) including patients with
comparable treatment time
Variable EG (n 5 15) HG (n 5 15) P value
Age, (y) P
T1 14.73 6 6.09 12.40 6 1.40 0.158y Variable EG (n 5 15) HG (n 5 15) value
T2 17.85 6 6.29 15.06 6 1.19 0.102y Maxillary component
T3 25.37 6 6.31 20.14 6 2.57 0.006*,y SNA ( ) 0.26 6 2.25 0.42 6 2.43 0.853
Treatment time (y) 2.69 6 0.98 2.77 6 0.87 0.819y Mandibular component
Time of long-term 7.36 6 5.02 5.08 6 2.44 0.124y SNB ( )
0.35 6 1.06 1.09 6 1.50 0.005*
posttreatment Maxillomandibular
evaluation (y) relationship
Initial PAR 33.2 6 9.38 33.5 6 9.64 0.960y ANB ( ) 0.62 6 1.77
0.65 6 2.56 0.126
CRE T2 (Quality of 20.00 6 5.16 19.80 6 9.72 0.944y Wits (mm) 0.59 6 2.52
0.42 6 2.18 0.252
treatment result) Vertical component
Sex 1.000z FMA ( ) 0.37 6 1.87
1.42 6 3.13 0.067
Male 7 7 SNGoGn ( )
0.32 6 2.24
1.03 6 1.72 0.340
Female 8 8 SN.OP ( )
0.87 6 1.69
1.79 6 2.40 0.231
Severity of Molar discrepancy 0.715z PP.OP ( )
0.99 6 2.63
1.14 6 2.48 0.848
Complete Class II 7 7 LAFH (mm) 1.97 6 3.21 0.67 6 1.57 0.167
Half Class II 8 8 Maxillary dentoalveolar
Canine-to-canine retainer at 0.015*,z component
T3 Mx1.PP ( )
3.68 6 5.95
0.20 6 3.21 0.056
Still wearing 12 6 Mx1-PP (mm) 1.35 6 1.91 0.31 6 0.85 0.065
Not wearing 3 9 Mx1-APerp (mm) 1.14 6 2.85
0.56 6 2.52 0.094
Mx6-APerp (mm) 0.67 6 1.95
1.41 6 2.55 0.018*
Note. Values are mean 6 standard deviation. Mx6-PP (mm) 0.61 6 1.15 0.48 6 1.05 0.755
*Statistically significant at P \0.05; yt test; zChi-square test. Mandibular dentoalveolar
component
Md1-PgPerp (mm) 0.11 6 1.13 0.45 6 1.33 0.457
rotation. The numerically greater counterclockwise rota- IMPA (L1.MP) ( ) 0.13 6 1.41
1.01 6 3.70 0.272
tion of the HG was probably because, during treatment, Md1-MP (mm) 1.28 6 1.80 0.93 6 0.98 0.518
Md6-PgPerp (mm)
0.49 6 1.61
0.15 6 0.97 0.490
this group had a numerically greater clockwise rotation, Md6-MP (mm) 1.35 6 2.09 0.67 6 1.24 0.293
consequent to a significantly greater extrusion of the Dental relationships
maxillary molars (Table IV). Overjet (mm)
0.17 6 1.22
0.26 6 0.90 0.813
The maxillary molar showed greater mesialization dur- Overbite (mm) 0.75 6 0.63 0.58 6 1.10 0.616
ing the long-term posttreatment period in the HG, also Molar relationship (mm) 0.17 6 0.99 0.01 6 0.89 0.631
probably because of the younger posttreatment age of Note. Values are mean 6 standard deviation. Data were analyzed us-
this group, which allowed greater changes to occur.41-43 ing t test.
Despite the mandibular incisor labial protrusion being *Statistically significant at P \0.05.
significantly more pronounced, during treatment, in the
EG, this variable did not show greater relapse in the
long-term posttreatment period than the HG. intergroup difference in the occlusal plane changes
The intergroup mean treatment time difference was (Tables VI and VII).
0.65 years (7.8 months), which probably occurred Despite these differences in a few variables, there
because of the Class II elastics protocol used. Patients were no significant intergroup differences in overjet,
used elastics on both sides for 10.45 months on average overbite and molar relationships, which are the most
(15-18 h/d) with 0.019 3 0.025-in or 0.018 3 0.025-in important variables in Class II malocclusion treatment.
stainless steel archwires. Once the sagittal discrepancy Changes in these variables may be perceived by patients
was corrected, elastics continued to be used as active and may be the reason for posttreatment relapse com-
retention. This is recommended to attempt long-term plaints. Therefore, we can assume that Class II malocclu-
stability of Class II correction with these mechanics. sion treatment stability with Class II elastics is similar
Nevertheless, as treatment time could influence sta- to treatment with a headgear. The presence of posttreat-
bility, it was decided to compare the long-term post- ment intraarch retainers seems unlikely to have influ-
treatment changes, including only patients with enced the stability of the sagittal relationship but
comparable treatment times. The results were similar might be beneficial for maintaining the alignment
to those of the whole sample, except that there was no stability.31,44

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616
CONCLUSIONS
Overall, treatment of Class II malocclusions with in-
termaxillary elastics or headgear appliances had similar
long-term posttreatment stability in overjet, overbite,
and molar relationships.
AUTHOR CREDIT STATEMENT
Guilherme Janson contributed to project administra-
tion, supervision, and manuscript review and editing;
Ana Liesel Guggiari Niederberger contributed to concep-
tualization, original draft preparation, and formal anal-
ysis; Gabriela Janson contributed to manuscript review
and editing; Marcelo Vinicius Valerio contributed to
manuscript review and editing; Waleska Caldas contrib-
uted to formal analysis; and Fabr
ıcio Pinelli Valarelli
contributed to formal analysis.
ACKNOWLEDGEMENTS
The authors thank the National Program of Foreign
Postgraduate Scholarship (BECAL), Ministry of Educa-
tion, Republic of Paraguay, and the Coordination for
the Improvement of Higher Education Personnel,
CAPES (financial code 001), Brazil, for their financial
support.
REFERENCES
1. Janson G, Camardella LT, Araki JD, de Freitas MR, Pinzan A. Treat-
ment stability in patients with Class II malocclusion treated with 2
maxillary premolar extractions or without extractions. Am J Orthod
Dentofacial Orthop 2010;138:16-22.
2. Janson G, Leon-Salazar V, Leon-Salazar R, Janson M, de
Freitas MR. Long-term stability of Class II malocclusion treated
with 2- and 4-premolar extraction protocols. Am J Orthod Dento-
facial Orthop 2009;136: 154.e151-110; discussion 154-5.
3. Fidler BC, Artun J, Joondeph DR, Little RM. Long-term stability of
Angle Class II, Division 1 malocclusions with successful occlusal re-
sults at end of active treatment. Am J Orthod Dentofacial Orthop
1995;107:276-85.
4. Elms TN, Buschang PH, Alexander RG. Long-term stability of Class
II, Division 1, nonextraction cervical face-bow therapy: I. Model
analysis. Am J Orthod Dentofacial Orthop 1996;109:271-6.
5. Elms TN, Buschang PH, Alexander RG. Long-term stability of Class
II, Division 1, nonextraction cervical face-bow therapy: II. Cephalo-
metric analysis. Am J Orthod Dentofacial Orthop 1996;109:386-92.
6. Sadowsky C, Sakols EI. Long-term assessment of orthodontic
relapse. Am J Orthod 1982;82:456-63.
7. Reddy P, Kharbanda OP, Duggal R, Parkash H. Skeletal and dental
changes with nonextraction Begg mechanotherapy in patients
with Class II Division 1 malocclusion. Am J Orthod Dentofacial Or-
thop 2000;118:641-8.
8. Asbell MB. A brief history of orthodontics. Am J Orthod Dentofa-
cial Orthop 1990;98:206-13.
9. Bien SM. Analysis of the components of force used to effect distal
movement of teeth. Am J Orthod 1951;37:508-21.
May 2023  Vol 163  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Janson et al
10. Hanes RA. Bony profile changes resulting from cervical traction
compared with those resulting from intermaxillary elastics. Am J
Orthod 1959;45:353-64.
11. Nelson B, Hansen K, H€agg U. Overjet reduction and molar correc-
tion in fixed appliance treatment of Class II, Division 1, malocclu-
sions: sagittal and vertical components. Am J Orthod Dentofacial
Orthop 1999;115:13-23.
12. Janson G, Sathler R, Fernandes TM, Branco NC, Freitas MR.
Correction of Class II malocclusion with Class II elastics: a system-
atic review. Am J Orthod Dentofacial Orthop 2013;143:383-92.
13. Ellen EK, Schneider BJ, Sellke T. A comparative study of anchorage
in bioprogressive versus standard edgewise treatment in Class II
correction with intermaxillary elastic force. Am J Orthod Dentofa-
cial Orthop 1998;114:430-6.
14. Nelson B, Hansen K, H€agg U. Class II correction in patients treated
with Class II elastics and with fixed functional appliances: a
comparative study. Am J Orthod Dentofacial Orthop 2000;118:
142-9.
15. Edwards JG. Orthopedic effects with ”conventional” fixed ortho-
dontic appliances: a preliminary report. Am J Orthod 1983;84:
275-91.
16. Phillips J. Apical root resorption under orthodontic therapy. Angle
Orthod 1955;25:1-22.
17. Nelson B, H€agg U, Hansen K, Bendeus M. A long-term follow-up
study of Class II malocclusion correction after treatment with Class
II elastics or fixed functional appliances. Am J Orthod Dentofacial
Orthop 2007;132:499-503.
18. Case CS. Principles of retention in orthodontia. 1920. Am J Orthod
Dentofacial Orthop 2003;124:352-61.
19. Aras I, Pasaoglu A. Class II subdivision treatment with the Forsus
Fatigue Resistant Device vs intermaxillary elastics. Angle Orthod
2017;87:371-6.
20. Cohen J. Statistical power analysis for the behavioral sciences. Hill-
sdale, NJ: L Erlbaum Associates; 1988.
21. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible
statistical power analysis program for the social, behavioral, and
biomedical sciences. Behav Res Methods 2007;39:175-91.
22. Wheeler TT, McGorray SP, Dolce C, Taylor MG, King GJ. Effective-
ness of early treatment of Class II malocclusion. Am J Orthod Den-
tofacial Orthop 2002;121:9-17.
23. Andrews LF. The straight wire appliance. Syllabus of philosophy
and techniques. 2nd ed. San Diego: Larry F. Andrews Foundation
of Orthodontic Education and Research; 1975.
24. Casko JS, Vaden JL, Kokich VG, Damone J, James RD,
Cangialosi TJ, et al. Objective grading system for dental casts
and panoramic radiographs. American Board of Orthodontics.
Am J Orthod Dentofacial Orthop 1998;114:589-99.
25. Richmond S, Shaw WC, O’Brien KD, Buchanan IB, Jones R,
Stephens CD, et al. The development of the PAR Index (peer assess-
ment rating): reliability and validity. Eur J Orthod 1992;14:
125-39.
26. DeGuzman L, Bahiraei D, Vig KW, Vig PS, Weyant RJ, O’Brien K.
The validation of the peer assessment rating index for malocclu-
sion severity and treatment difficulty. Am J Orthod Dentofacial Or-
thop 1995;107:172-6.
27. Dahlberg G. Statistical methods for medical and biological stu-
dents. New York: Interscience; 1940.
28. Houston WJB. The analysis of errors in orthodontic measurements.
Am J Orthod 1983;83:382-90.
29. Mislik B, Konstantonis D, Katsadouris A, Eliades T. University clinic
and private practice treatment outcomes in Class I extraction and
nonextraction patients: A comparative study with the American
Janson et al
Board of Orthodontics Objective Grading System. Am J Orthod
Dentofacial Orthop 2016;149:253-8.
30. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T.
Effectiveness of comprehensive fixed appliance treatment used
with the Forsus fatigue resistant device in Class II patients. Angle
Orthod 2011;81:678-83.
31. Al Yami EA, Kuijpers-Jagtman AM, van, van ’t Hof MA. Stability of
orthodontic treatment outcome: follow-up until 10 years postre-
tention. Am J Orthod Dentofacial Orthop 1999;115:300-4.
32. Schiavon Gandini MRS, Gandini LG, da Rosa Martins JC, Del
Santo M. Effects of cervical headgear and edgewise appliances
on growing patients. Am J Orthod Dentofacial Orthop 2001;119:
531-8; discussion 538.
33. de Freitas KM, Janson G, de Freitas MR, Pinzan A, Henriques JF,
Pinzan-Vercelino CR. Influence of the quality of the finished oc-
clusion on postretention occlusal relapse. Am J Orthod Dentofacial
Orthop 2007;132:428.e9-14.
34. de Freitas KM, de Freitas MR, Janson G, Pinzan A, Henriques JF.
Retrospective analysis of orthodontic treatment outcomes and
its relation to postretention stability. J Appl Oral Sci 2006;14:
324-9.
35. Lima Filho RM, Lima AL, de Oliveira Ruellas AC. Longitudinal study
of anteroposterior and vertical maxillary changes in skeletal Class II
patients treated with Kloehn cervical headgear. Angle Orthod
2003;73:187-93.
36. Cozza P, De Toffol L, Colagrossi S. Dentoskeletal effects and facial
profile changes during activator therapy. Eur J Orthod 2004;26:
293-302.
American Journal of Orthodontics and Dentofacial Orthopedics
617
37. Lima KJ, Henriques JF, Janson G, Pereira SC, Neves LS,
Cançado RH. Dentoskeletal changes induced by the Jasper jumper
and the activator-headgear combination appliances followed by
fixed orthodontic treatment. Am J Orthod Dentofacial Orthop
2013;143:684-94.
38. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction
patients treated with the Forsus fatigue resistant device versus in-
termaxillary elastics. Angle Orthod 2008;78:332-8.
39. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Early dentofacial
features of Class II malocclusion: a longitudinal study from the de-
ciduous through the mixed dentition. Am J Orthod Dentofacial Or-
thop 1997;111:502-9.
40. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Longitudinal
growth changes in untreated subjects with Class II Division
1 malocclusion. Am J Orthod Dentofacial Orthop 2008;134:
125-37.
41. Vaden JL, Harris EF, Behrents RG. Adult versus adolescent Class II
correction: a comparison. Am J Orthod Dentofacial Orthop 1995;
107:651-61.
42. Martins DR, Janson GRP, Almeida RR, Pinzan A, Henriques JF,
Freitas MR. Atlas de crescimento craniofacial. S~ao Paulo: Santos;
1998.
43. Furquim BDA, Janson G, Cope LCC, Freitas KMS, Henriques JFC.
Comparative effects of the Mandibular Protraction Appliance in
adolescents and adults. Dental Press J Orthod 2018;23:63-72.
44. Bock NC, von Bremen J, Ruf S. Occlusal stability of adult Class II
Division 1 treatment with the Herbst appliance. Am J Orthod Den-
tofacial Orthop 2010;138:146-51.
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