Dental and Orthopedic effects of High-Pull Headgear in Treatment of Class II Division I Malocclusion: A Case Report of Identical Twins

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1 Dental and Orthopedic effects of High-Pull Headgear in Treatment of Class II Division I Malocclusion: A Case Report of Identical Twins Ravi Jhamb 1, Neeral Barthunia 2, Sandeep Singh Bhatia 3, Jyoti Agrawal 4 1,4-PG student, Department of orthodontics & Dentofacial orthopeadics Daswani dental college and Research center, Kota, Rajasthan, India. 2-HOD, Departmentof orthodontics & Dentofacial orthopeadics Daswani dental college and Research center, Kota, Rajasthan, India. 3- Senior Lecturer, Department of orthodontics & Dentofacial orthopeadics Daswani dental college and Research center, Kota, Rajasthan, India. ABSTRACT Correspondence to: Dr. Ravi Jhamb, Department of orthodontics & Dentofacial orthopeadics Daswani dental college and Research center, Kota, Rajasthan. Contact Us: A prospective cephalometric study was done in two identical twin s to know the skeletal and dental effects of high pull headgear. Two identical twins aged 14 years were treated for mild class II correction with high pull headgear therapy along with maxillary splint. In both adolescence, the growth remaining was %. The patient wore the headgear for a 9 month period, on an average of 12 hours a day. The force of gm was applied to initiate distal movement of molars and maxillary orthopedic changes in the treated patients. The Furthure 2 nd phase of treatment is planned with fixed appliance orthodontic treatment. In this case report, the cephalometric analysis revealed that both patients have convex profile, class II skeletal pattern with vertical growth pattern and forwardly placed maxilla,and there is a difference in the inclination of upper incisors. This case report, supports the dental and orthopedic effects of high pull headgear in the correction of skeletal class II malocclusion. KEYWORDS: Skeletal Class II, Identical Twins, Immediate Post-Treatment Effects, Tissue And Soft Tissue Changes AASSSAAsasasss INTRODUCTION The Class II division first defined by Angle in 1899, has an incidence rate of 1.5% to 7%. 1 It s etiology generally believed to be genetic and familial occurrence has been documented in several studies of twins. 2-3 Facial appearance has a strong genetic component with monozygotic or dizygotic twins appearing more similar than unrelated individuals. 4 Some authors considered factors of twins such as a high lip line 5, hyperactive lip or mentalis muscles and masticatory bite forces 6 to be of main importance.others stress morphologic and growth factors, such as an upright incisor position, 7,8,9 small tooth size, increase columella angle of the upper incisors, thin incisors with small tubercula 10,11, decreased verticle jaw development and anterior rotation of the mandible. 12 The use of headgear therapy is very common in the treatment of Class II, Division 1 malocclusions with prognathic maxilla in growing age.extraoral maxillary traction appliances are used to improve the dental relationship between the maxilla and the mandible, as well as the skeletal relationship between the two jaws. The most widely used appliances for extraoral anchorage are the cervical face bow and high-pull headgear. With the high-pull headgear, it is possible to generate the force in the direction which is consistent with the treatment objectives of Class II, Division 1 malocclusion.forces produced by the high-pull headgear,like those produced by the cervical appliance, include a distally directed component. However, the high-pull headgear produces, in addition, an intrusive component instead of an extrusive one. Furthermore, with the high pull headgear, it is possible to change the direction of force in relation to the center of resistance of the dental units to which the force is being applied, to achieve better control of the resulting tooth movement. 13,14 Several clinical investigations have demonstrated that with the high-pull headgear it is possible to achieve significant distal movement of the dentition and to modify vertical changes in the maxillary molar position. There are still considerable variabilities,however, in the magnitude of force which is described as necessary to produce these orthopedic changes. 15,16,17 The objective of my case report is to investigate the dental and skeletal changes produced by a high-pull headgear with a well-defined force system. A pair of identical twins is presented. The boys have a marked similarity in facial appearance. Both boys have same age group of 14 years with incompetent lips, increased lower facial height and convex profile (Figure No.1, 2). A review of medical history showed nothing remarkable. Both boys have the same chief complain of forwardly placed teeth in the upper front region of the jaw. The clinical examination showed a complete permanent dentition. Occlusal analysis shows a class II div.1 malocclusion. The Panoramic radiograph showed How to cite this article: Jhamb R, Barthunia N, Bhatia SS, Agrawal J. Dental and Orthopedic effects of High-Pull Headgear in Treatment of Class II Division I Malocclusion: A Case Report of Identical Twins. Int J Oral Health Med Res 2017;4(5): International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 70

2 that alveolar bone and root formation in normal limits. Minor differences before treatment were one boy have overjet of 10mm and overbite of 3 mm and second boy have overjet of 7 mm and overbite of 4mm. Pre-treatment cephalometric evaluation revealed a skeletal class II relationship (Figure No.3, 4). Some values are showing that both boys have tendency towards the vertical growth pattern.the maxillary incisors are proclined and average mandibular incisors. The soft tissue profile showing both have protruted upper lips (Table no.1). Figure 3: Boy1 Pretreatment Panoramic And Cephalometric radiographs Figure 1: Boy 1 pretreatment facial and intraoral photographs Figure 4: Boy 2 pretreatment panoramic and cephalometric radiographs PARAMETERS AVERAGE BOY 1 (Pretreatment Value) BOY 2 (Pretreatment Value) ANB AO to BO 0-2mm AO ahead to BO by 4 mm AO ahead to BO by 6 mm MAX 18 mm 22 mm 21 mm PLACEMENT FMA BASAL PLANE ANGLE UI SN * 112* LI- MP S-LINE 2mm 7mm 4mm Table 1: Pretreatment cephalometric values (show class II skeletal pattern) Figure 2: Boy 2 pretreatment facial and intraoral photographs Treatment Objectives: To restrain the forward growth of maxilla. To prevent downward and backward rotation of mandible. Achieving class I skeletal base relationship. Achieving ideal overjet and overbite. International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 71

3 To achieve a stable, functional occlusion by establishing class I molar and canine relationship as well as pleasing smile and lip competence. Treatment Alternatives: In growing patients, several nonsurgical options are available for treating a high angle class II malocclusion which includes functional appliance, molar distalization appliance, selective removal of permanent teeth.extraction of maxillary teeth alone or in combination with mandibular teeth would create mainly a camouflage of the dental as well as skeletal disharmony. Intraoral distalization appliances have the advantage of reduced patient compliance. Side effects on the other maxillary teeth (premolar mesialization and incisor proclination) or mandibular teeth, breakage, the need for frequent reactivation, and the lack of favorable skeletal effects are all possible disadvantages of these appliances. 18 Treatment Plan: A comprehensive diagnosis, treatment objectives and treatment alternatives were presented to the patient and the parents. The following treatment plan was chosen: a. Placement of maxillary splint to restrict the forward growth of maxilla and Delivery of a high-pull headgear to achieve Class I molar relationships and alteration of growth. b. Further 2 nd phase of treatment is planned with fixed appliance orthodontic treatment. Chosen Mechanotherapy: Use of a high-pull headgear followed by fixed-appliance therapy produces favorable Dentoskeletal changes in growing subjects with highangle Class II malocclusion, although it is indicated in patients with high degree of cooperation. 19 High-pull headgear with maxillary splint was used for the twins. The outer bows were attached to the head straps of the headgear. The direction of the applied force was modified by changing the point at the level of buccal trifurcation of the maxillary first molars. It was clinically and radiographically determined that the headgear force was directed through that point as an approximation of the center of resistance of these teeth. The inner bow was made parallel to the occlusal plane, and the length of the outer bow was reduced so that it did not extend distally to the maxillary first molar. A force of 500 gm was used for each side, as measured by a force gauge. Thus the appliance generated a force including intrusive, as well as distally directed components. The headgear bow position and the lines of force are shown in Fig. 5. Results: Treatment with headgear produced an improvement of facial esthetics and a notable change in lip posture and balance.the total treatment duration with the high-pull headgear therapy was the 9-month course without any discomfort or complications. The headgear was worn by both boys an average of 12 hours a day. Dental and skeletal changes are achieved with the Figure 5: Maxillary Splint and photographic representation of position of outer bow of headgear, and point and line of force application in relation to center of resistance of maxillary first molar. (pics taken after growth modulation) Figure 6: Boy 1 post growth modulation facial and intraoral photographs headgear therapy.(figure no.6,7) The most significant changes were noted in the maxillary molars. After the 9- month period, the maxillary molars in both boys were distally displaced and an ideal class I molar relationship is achieved in both the boys. Remarkable changes were also seen in the incisor proclination, maxillary rotation, nasolabial angle as suggested by post- growth modulation cephalometric values (Figure no.8,table no.2). International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 72

4 Figure 7: Boy 2 post growth modulation facial and intraoral photographs Figure 8: Post treatment cephalometric radiographs of boy 1 and boy 2. DISCUSSION Armstrong 16 and Badell 20 suggest continuous headgear wear (24 hours per day) to achieve optimal orthodontic results. In the present study intermittent headgear wear, on a daily basis, can also create clinically significant correction of Class II molar relation in a short period of 9 months. Armstrong 16, Watson 17, Badell 20 and Graber 21 used force in excess of 400 gm and sometimes up to two or three times that amount, particularly if rapid orthopedics was desired. The results of the present study show that the forward growth of A point was significantly decreased by using about 500 gm of force and we also achieve class I skeletal base relationship as suggested by post- growth modulation cephalometric values. This finding also shows that orthopedic maxillary changes are possible with maxillary splint with headgear. Baumrindet al 22,23 Attribute the backward movement of A point to normal remodeling at the anterior maxillary surface. The present study shows a reduction in the horizontal growth of the maxilla in both the identical twins with the help of headgear. Weislander 24 using only 300 to 400 gm of force reported that the A point and the ANS moved distally2.0 mm in almost a 3-year period. Watson 17 showed that A point and ANS could move distally as much as 4.0 mm in less than 1 year using 600 to 1000 gm of force on each side. Baumrind et al 25,26 in their comparison of different types of headgear observed that in neither of the treatment groups, which were studied, did the body of the mandible grow as much as it did in the control group. The present study also demonstrates that there was a nonsignificant tendency for reduced mandibular growth and in both identical twins we use a force of 500 gm was used for each side, as measured by a force gauge.the direction of the applied force was the point at the level of buccal trifurcation of the maxillary first molars. The treatment with the high pull headgear with maxillary splint completed the 9-month course of treatment without any discomfort or complications. The headgear was worn by both boys an average of 12 hours a day. The most important clinical change observed in the current study was the distal displacement of the maxillary molars and a subsequent change in the direction of occlusal molar relationship from Class II to Class I (figure no.7,8).badel1 20 achieved a 2.3 mm ClassII occlusal correction with a combination headgear worn full time for an average of 4 months. Weislander 24 achieved almost 3.0 mm of dental movement with force levels, comparable to those used in our study, over a 2- to 3-year period. Watson 17 also found an average of 3.0 mm of distal maxillary molar movement over a period of 5 to 16 months. In the present study, similar dental results an average of 3.5mm was achieved in a relatively short period of 9 months. CONCLUSION An average of 500 gm of force is sufficient to translate the molars distally, and at the same time initiate maxillary changes that are normally associated with higher force levels. It is possible to translate the molars in the direction of the applied force, when the forces are passed through the center of resistance of the maxillary molars with high pull headgear. If the headgear is used for a short period of 9 months and the patient is cooperative, one can expect a significant dental improvement in the Class II molar relationship. An accurate cephalometric analysis allowed identification of the components of the skeletal deformity and, consequently, successful correction of the malocclusion. International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 73

5 Variables Averge Pretreatment (boy1) Postgrowth modulation(boy1) Pretreatment (boy2) Postgrowth modulation (boy2) SNA SNB ANB A ton perp.(mm) 0-1mm 4mm 2mm 3.5mm 1.5mm Ao tobo 0-2mm Ao is ahead to Bo by 4mm Ao is ahead to Bo by 2mm Ao is ahead to Bo by 6mm Ao is ahead to Bo by2mm NA-Pog N-FH-Pog Co-gn (mm) 120.6± mm 115mm 114mm 114mm Max placement 18±2mm 22mm 22mm 21mm 21mm FMA Sadddle Angle 123± Articular angle 143± Upper gonial angle Lower gonial angle Bjork sum 396± Basal plane angle Occ-pal. plane Maxillary rotation UI-SN UI-Nperp. 2-4mm 13mm 11mm 13mm 5mm UI-Apog. 25,4mm 55,13mm 48,11mm 42,12mm 40,9mm UI-Npog. 2mm 18mm 15mm 15mm 12mm Nasolabial angle 102 ± LI-MP LI-NB 25,4mm 25,8mm 24,7mm 29,7mm 29,6.5mm LI-Npog. 8mm 6mm 6mm 7mm 7mm REFERENCES 1. Ingervall B, seeman L,Thilander B.frequency of malocclusion and need of orthodontic treatment in 10 year old children in gothenburg.svensk tandalakare-tidskrift 1972; 65: Kloeppel W. Deckbiss bei Zwillingen. Fortschr Kieferorthop 1953; 14: Litt RA, Nielsen IL. Class II Division 2 malocclusion- to extract or not extract. Angle orthod 1984; 54: King L, Harris EF, Tolley EA. Heritability of cephalometric and occlusal variables as assessed from siblings with overt malocclusions. Am J Orthod Dentofacial Orthop. 1993; 104: Karlsen AT. Craniofacial craracteristics in children with Angle classii div.2 malocclusion combined with extreame deep bite. Angle orthod 1994; 64: Sassoni v. A classification of skeletal facial types. Am J Orthod Dentofacial Orthop. 1969; 55: Schware AM.Der Deckbiss (steilbiss) im fernotgenbild.fortschr Kiefer-rorthop 1956; 17:89-103, , Logan WR. Deckbiss- Aclinical evaluation.transeur Orthod Soc 1959: Hausser E.zur Atiologie and Genese des Decbisses fortschr Kieferorthop 1953; 14: Delevianis HP, Kuftinec MM.variations in morphology of the maxillary central incisors found in classii, division 2 malocclusions. Am J Orthod Dentofacial Orthop. 1980; 78: Bryant RM,SadowskyPL,HazelrigJB. Variability in three morphological features of permanent maxillary central incisors. Am J Orthod Dentofacial Orthop. 1984;86: Bjork A.Prediction of madibular Growth Rotation Am J Orthod Dentofacial Orthop1969; 55: Burstone CJ. The biomechanics of tooth movement. In: Draus BS, Riedel RA, eds. Vistas in orthodontics. Philadelphia: Lea& Febiger, 1962: Bowden DEJ. Theoretical considerations of headgear Table 2: Cephalometric Values pretreatment and after groth modulation therapy: a literature review. Br J Orthod 1978; 5: Silverstein A. Changes in the bony facial profile coincident with treatment of Class II, division I malocclusion. Angle Orthod1954; 24: Armstrong MM. Controlling the magnitude, direction, and duration of extraoral force. Am J Orthod 1971; 59: Watson WG. A computerized appraisal of the highpull facebow.am J ORTHOD 1972; 62: Sfondrini MF, Cacciafesta V, Sfondrini G. Upper molar distalization:a critical analysis. Orthod Craniofacial Res. 2002; 5: Brown P. A cephalometric evaluation of high-pull molar headgear and face-bow neck strap therapy. Am J Orthod Dentofacial Orthop. 1978; 74: Badell MC. An evaluation of extraoral combined highpull cervical traction to the maxilla. Am J Orthod Dentofacial Orthop. 1976; 69: Graber TM. Extra oral force--facts and fallacies. Am J Orthod Dentofacial Orthop. 1955; 41: Baumrind S, Mohhen R, West EE, Miller DM. Distal displacement of maxilla and the upper first molar. Am J Orthod Dentofacial Orthop 1979; 75: Baumrind S, Korn EL, Ben-Bassat Y, West EE. Quantitation of maxillary remodeling. A description of osseous changes relativeto superimposition on metallic implants. Am J Orthod Dentofacial Orthop 1987;92: Weislander L. The effect of force on the craniofacial development.am J Orthod Dentofacial Orthop 1974; 65: Baumrind S, Kom EL, Mohhen R, West EE. Changes in mandibular dimensions associated with the use of force to retract the maxilla. Am J Orthod Dentofacial Orthop 1981; 79: Baumrind S, Korn EL, Molthen R, West EE. Changes in facial dimensions associated with use of forces to retract the maxilla. Am J Orthod Dentofacial Orthop 1983; 84: Source of Support: Nil Conflict of Interest: Nil International Journal of Oral Health and Medical Research ISSN JANUARY-FEBRUARY 2018 VOL 4 ISSUE 5 74