CONTINUING EDUCATION ARTICLE

A comparative study of anchorage in bioprogressive versus

standard edgewise treatment in Class II correction with
intermaxillary elastic force

Elizabeth K. Ellen, DMD,a Bernard J. Schneider, DDS, MS,b

and Terry Sellke, DDS, MSc
Chicago, Ill.

The primary purpose of this study was to evaluate the effectiveness of cortical anchorage, by comparing
two groups of patients with Class II malocclusions that were treated successfully with Class II elastics. One
group of 30 previously treated patients had a utility arch used to set up cortical anchorage in the lower arch
before Class II elastic wear; the second group was treated with standard edgewise mechanics where
anchorage preparation consisted of full appliances, a well-aligned mandibular arch, and a rectangular arch
wire. The groups were selected according to age, sex, and the amount of Class II elastic usage.
Pretreatment and posttreatment cephalometric radiographs were used to generate 32 variables. A Student’s
t test was used to evaluate treatment change between the groups and revealed that there were no
statistically significant differences. Lower molar teeth extruded and moved mesially equally in both groups.
Although cortical anchorage did not retard lower molar movement, it was no less effective in controlling
molar movement with a partial appliance than the fully banded standard edgewise appliance.
(Am J Orthod Dentofacial Orthop 1998;113:430-6)

T he use of intermaxillary elastics has been a
standard procedure in the correction of a Class II, Divi-
sion 1 malocclusion since the early days of orthodontic
treatment. It is well documented in the literature that
although intermaxillary elastics are effective in correct-
ing the anteroposterior relationship of the dentition,
undesirable side effects can occur. Most authors men-
tion adverse results from the vertical vector of force that
is inherent with the use of Class II elastics.1-9 This ver-
tical force extrudes the maxillary incisors and mandibu-
lar molars and can lead to rotation of the occlusal plane
as well as a resultant opening rotation of the
mandible.2,7,9,10 The horizontal vector of force has been
shown to cause the mandibular first molars to rotate or
tip mesially, procline the mandibular anterior teeth, and
displace the entire lower dental arch anteriorly.2,7,9,11,12
In addition, the effect on the maxillary incisors may
adversely affect the smile line of the patient leading to
excessive gingival tissue showing, and the lower incisor
may become more proclined and protrusive.4,13
From the Department of Orthodontics, College of Dentistry, University of Illi-
nois at Chicago.
aFormer resident; presently in private practice, Wayne, NJ
bProfessor.
cAssociate Professor.
Reprint requests to: Dr Bernard J. Schneider, College of Dentistry, Department
of Orthodontics, 801 S. Paulina Street, Chicago, IL 60612.
Copyright © 1998 by the American Association of Orthodontists.
0889-5406/98/$5.00 + 0 8/1/87103
430
In an attempt to eliminate or minimize these unde-
sirable effects of Class II elastics, the Bioprogressive
technique advocates placing appropriate bends in the
mandibular arch wire to set up the mandibular molar in
a position of close proximity to the buccal cortical bone
of the mandible. To establish this so-called “cortical
anchorage,” the lower first molar is rotated distolin-
gually, tipped distally, expanded, and torqued (buccal
root torque) so that the roots come to lie beneath the
adjacent buccal cortical bone. This is an area that
exhibits a greater bone density because of the external
oblique line of the mandible. By placing the roots of
the lower first molar adjacent to the more dense corti-
cal bone, anchorage is believed to be enhanced, there-
by minimizing movement of the molar teeth.4,14,15
In reviewing the literature, it was found that there
are no studies specifically documenting the effective-
ness of cortical anchorage. The purpose of this study is
to evaluate treatment changes, both skeletal and dental,
in cases treated with Class II elastics, with either a util-
ity arch to set up cortical anchorage or standard edge-
wise full-arch mechanics.
MATERIAL AND METHODS
A total of 56 previously treated orthodontic patients
were selected, 30 from the private practice of a faculty
member of the University of Illinois Orthodontic
Department and 26 from the files of the University of
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, Number 4
Fig 1. Cephalometric points traced and digitized for this
study. The points are: sella (1), nasion (2), anterior nasal
spine (3), point A (4), maxillary incisor root apex (5),
maxillary first molar mesial buccal root apex (6), posteri-
or nasal spine (7), maxillary first molar mesial buccal
cusp tip (8), maxillary first molar greatest mesial contour
(9), mandibular first molar mesial buccal cusp tip (10),
mandibular first molar greatest mesial contour (11),
mandibular first molar mesial buccal root apex (12),
mandibular incisor root apex (13), mandibular incisor
incisal tip (14), maxillary incisor incisal tip (15), point B
(16), pogonion (17), menton (18), gonion (19), anterior
fiducial point (20), posterior fiducial point (21). Points 1
through 19 were used to generate cephalometric angu-
lar measurements including the angulation of the upper
and lower teeth.
Illinois Orthodontic Department. The criterion for selec-
tion was the existence of a Class II malocclusion, where
Class II elastics were used to correct the malocclusion.
Patients were not included if headgear was used during
treatment or if teeth were extracted. All cases were treat-
ed to a Class I molar and canine relationship. The
patients were selected so that age, sex, and the amount of
elastic use (in months) are approximately the same in
each group. One group had a utility arch used to set up
cortical anchorage in the lower arch before Class II elas-
tic use (cortical anchorage group, CAG) and the second
group was treated with standard edgewise mechanics
where anchorage preparation consisted of full appli-
ances, a well-aligned mandibular arch, and placement of
a rectangular “ideal” arch (standard edgewise group,
SEG). Characteristics of the samples are listed in Table
I. No adults were included in either sample.
Ellen, Schneider, and Sellke 431
Fig 2. Cartesian coordinate system measurements.
Vertical measurements include X axis to maxillary
incisor crown tip, mandibular incisor crown tip, maxillary
molar mesiobuccal cusp tip, mandibular molar
mesiobuccal cusp tip, points A, B and pogonion. Hori-
zontal measurements include Y axis to maxillary incisor
crown tip, mandibular incisor crown tip, maxillary molar
greatest mesial contour, mandibular molar greatest
mesial contour, mandibular molar mesiobuccal root tip,
points A, B, and pogonion.
DATA COLLECTION
Each patient had two lateral cephalometric radi-
ographs taken, one before treatment and another at the
end of treatment. Radiographs were traced and 19 land-
marks identified and digitized (Fig 1), using the Oli
System (Orthodontic Logic Systems, Kansas City,
Mo). Fiducial points 20 and 21 were used to produce a
reference line for tooth movement measurement. Bilat-
eral structures were bisected and then considered mid-
sagittal points. The enlargement factor for both groups
was determined to be so close that an enlargement fac-
tor of 8.0% was used for both the CAG and the SEG,
which resulted in reducing the coordinate data by
0.9259.
Cephalometric Measurements
Angular measurements were used to describe
changes in the position of the jaws in relation to the
cranial base as well as the inclination of teeth. Linear
measurements of the spatial position of various points
were determined by the construction of a Cartesian
432 Ellen, Schneider, and Sellke American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

Table I. Treatment group characteristics

Mean Age Mean Range Mean treatment Mean Elastic Use (months)
Group N (yr/mo) (yr/mo) Time (yr/mo) Full time Part time

F: 16
CAG 11.01 9.05-13.07 2.02 8.3 2.7
M: 14
F: 16
SEG 12.07 10.03-14.05 2.03 8.8 2.6
M: 10

Table II. Pretreatment cephalometric values (A)

CAG SEG

Mean SD Mean SD P value

Angular measurements (degrees)

SNA 80.87 3.94 82.27 3.07 0.2081
SNB 77.47 3.69 77.06 2.62 0.0868
ANB 3.40 2.03 5.23 1.14 0.0001*
Palatal Plane -0.14 3.42 -0.29 3.02 0.5252
Occlusal Plane 9.41 4.43 9.73 3.11 0.0762
Mandible Plane 25.28 5.66 25.51 5.90 0.8254
Facial Plane 86.05 3.76 85.37 2.77 0.1249
U1 Angle 113.92 9.00 109.52 10.89 0.3226
U6 Angle 80.44 5.21 81.01 5.13 0.9496
L1 Angle 93.36 5.71 93.25 5.34 0.7370
L6 Angle 79.91 4.86 82.74 5.77 0.3710
Linear measurements (mm)
Vertical
U6 Height 63.21 3.03 63.72 4.08 0.1251
U1 Height 69.84 4.25 69.83 4.76 0.5542
L6 Height 62.50 3.04 63.23 4.02 0.1500
L1 Height 65.02 4.12 65.48 5.11 0.2614
Point A Height 48.08 3.37 48.00 3.62 0.7069
Point B Height 82.76 4.60 83.71 6.08 0.1501
Pogonion Height 96.83 5.74 97.78 6.84 0.3634
Horizontal
U1 AP 74.52 7.16 72.98 6.90 0.8602
U6 AP 43.74 4.85 42.88 4.78 0.9484
L1 AP 68.67 6.53 66.88 6.00 0.6700
L6 crown AP 41.36 5.33 40.46 5.44 0.9100
L6 root AP 33.68 6.64 32.49 6.18 0.7191
Point A AP 70.20 5.12 69.97 5.09 0.9786
Point B AP 63.46 7.06 61.00 5.72 0.2880
Pogonion AP 64.64 7.94 61.99 6.36 0.2634

*P < .0018 (alpha level with Bonferroni correction factor).

SD, Standard deviation.

coordinate system (Fig 2). The X axis of the Cartesian
coordinate was a line drawn 7° from the SN line on the
pretreatment (A) cephalometric radiograph that was
then transferred to the posttreatment (B) cephalometric
radiograph. The Y axis was generated by the computer
by dropping a line from Sella perpendicular to the X
axis.
Mandibular superimposition
The mandibular dental changes, both linear and
angular, were determined by using Björk’s structural
method of superimposition, as modified by Dibbets.16
The mandibular superimposition was used to eliminate
displacement so that the spatial position of the lower
teeth, specifically the mandibular molar, could be
American Journal of Orthodontics and Dentofacial Orthopedics Ellen, Schneider, and Sellke 433
Volume 114, Number 4

Table III. Treatment changes within each group

CAG SEG

Mean SD P value Mean SD P value

Angular measurements
SNA -1.33 1.70 0.0002* -1.70 1.73 0.0001*
SNB -0.02 1.26 0.9425 -0.06 1.51 0.8371
ANB -1.30 1.50 0.0001* -1.66 1.51 0.0001*
Palatal Plane 0.58 1.57 0.0497 0.76 1.45 0.0131
Occlusal Plane 0.63 2.92 0.2466 1.80 2.61 0.0017*
Mandible Plane 0.31 2.05 0.4197 0.22 2.04 0.5944
Facial Plane 0.38 1.27 0.1118 0.14 1.45 0.6221
U1 Angle 2.09 8.30 0.1785 1.40 11.74 0.5486
U6 Angle -1.71 5.61 0.1063 -0.68 5.40 0.5261
L1 Angle 6.47 5.76 0.0001* 7.90 6.23 0.0001*
L6 Angle -0.36 4.77 0.6822 -0.75 5.62 0.5050
Linear measurements
Vertical
U6 Height 2.89 3.74 0.0002* 3.00 2.10 0.0001*
U1 Height 2.28 3.70 0.0002* 3.69 2.04 0.0001*
L6 Height 4.05 3.79 0.0001* 4.04 2.44 0.0001*
L1 Height 6.00 4.04 0.0001* 7.29 2.72 0.0001*
Point A Height 2.54 2.48 0.0001* 3.26 1.99 0.0001*
Point B Height 4.75 5.24 0.0001* 6.68 3.40 0.0001*
Pogonion Height 6.20 5.55 0.0001* 6.18 3.69 0.0001*
Horizontal
U1 AP -0.50 2.55 0.9153 0.17 3.75 0.8197
U6 AP 0.17 2.29 0.6925 0.00 2.31 0.9933
L1 AP 3.20 2.68 0.0001* 4.00 3.29 0.0001*
L6 crown AP 4.39 2.56 0.0001* 4.08 2.68 0.0001*
L6 root AP 4.76 2.80 0.0001* 4.47 3.32 0.0001*
Point A AP -0.02 2.25 0.9679 0.02 2.07 0.9627
Point B AP 1.06 2.53 0.0288 1.12 3.26 0.0934
Pogonion AP 1.77 3.00 0.0031 1.64 3.29 0.0176

*P < .0018 (alpha level with Bonferroni correction factor).

SD, Standard deviation.

determined to compare the anchorage response in each
of the treatment groups (Fig 3). Once again, a coordi-
nate system was constructed. Fiduciary points (nos. 20
and 21) were transferred from the initial to the final
cephalometric tracing. The line connecting these points
formed the x-axis. The y-axis was perpendicular from
the posterior fiduciary point (no. 21).
Statistics
The statistical analyses were based on the compari-
son of the CAG and SEG groups at the pretreatment and
posttreatment stages. Means and standard deviations
were calculated for all variables in both groups. A
paired t test was used to test the treatment changes with-
in groups, while the Student t test was used to test the
variables for significant differences between the groups.
To control for Type I error that may result in multiple
univariate tests such as these, the Bonferoni correction
factor was used. This correction factor is derived by
dividing the chosen alpha level of 0.05 by the number of
variables observed. The corrected alpha level was used
to decide if a particular variable was significantly dif-
ferent once the t test statistic had been performed.
Method Error
Ten cephalometric radiographs were randomly
selected, retraced and digitized. Differences between
the original and the retraced cephalometric radiographs
were statistically analyzed using a matched paired t
test. The results of the analysis indicated that there
were no statistically significant differences between
the original and repeat measurements at the 0.05 level.
RESULTS
Statistical analysis was undertaken to determine if any
significant differences existed between the CAG and the
SEG at the pretreatment stage (Table II). Only one vari-
able differed between the two groups at the pretreatment
stage. The ANB angle was larger in the SEG suggesting
that this group had a larger denture base discrepancy.
434 Ellen, Schneider, and Sellke American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

Table IV. Comparison of the CAG and SEG treatment changes

CAG SEG

Mean SD Mean SD P value

Angular measurements
SNA -1.33 1.70 -1.70 1.73 0.9190
SNB -0.02 1.26 -0.06 1.51 0.3360
ANB -1.30 1.50 -1.66 1.51 0.9810
Palatal Plane 0.58 1.57 -1.66 1.51 0.7005
Occlusal Plane 0.63 2.92 0.76 1.45 0.5736
Mandible Plane 0.31 2.05 1.80 2.61 0.9759
Facial Plane 0.38 1.27 0.14 1.45 0.4785
U1 Angle 2.09 8.30 1.40 11.74 0.0740
U6 Angle -1.71 5.61 -0.68 5.40 0.8538
L1 Angle 6.47 5.76 7.90 6.23 0.6786
L6 Angle -0.36 4.77 -0.75 5.62 0.3900
Linear measurements
Vertical
U6 Height 2.89 3.74 3.00 2.10 0.8914
U1 Height 2.28 3.70 3.69 2.04 0.0784
L6 Height 4.05 3.79 4.04 2.44 0.9891
L1 Height 6.00 4.04 7.29 2.72 0.1620
Point A Height 2.54 2.48 3.26 1.99 0.2607
Point B Height 4.75 5.24 6.68 3.40 0.1029
Pogonion Height 6.20 5.55 6.18 3.69 0.9874
Horizontal
U1 AP -0.50 2.55 0.17 3.75 0.8023
U6 AP 0.17 2.29 0.00 2.31 0.9565
L1 AP 3.20 2.68 4.00 3.29 0.2899
L6 crown AP 4.39 2.56 4.08 2.68 0.8110
L6 root AP 4.76 2.80 4.47 3.32 0.3745
Point A AP -0.02 2.25 0.02 2.07 0.6836
Point B AP 1.06 2.53 1.12 3.26 0.1899
Pogonion AP 1.77 3.00 1.64 3.29 0.6243

*P < .0018 (alpha level with Bonferroni correction factor).

SD, Standard deviation.

Table V. Comparison of CAG and SEG treatment changes for mandibular tooth movements
CAG SEG

Mean SD Mean SD P value

Vertical measurements
L6 Height -2.14 1.48 -2.63 1.39 0.7682
L1 Height 0.41 1.99 0.95 2.03 0.9137
Horizontal measurements
L6 AP 3.68 1.26 3.23 1.82 0.0573
L1 AP 2.43 1.73 3.07 1.96 0.5082
Angular measurements
L6 Angle 1.20 4.16 0.16 5.76 0.0917
L1 Angle 8.06 5.76 8.79 5.71 0.9712

*P < .0018 (alpha level with Bonferroni correction factor).

Treatment Changes changes are listed in Tables III through V. Changes that
The treatment changes were derived from calculat- result from orthodontic treatment were similar in each
ing the difference between the posttreatment and the group; these consisted of a decrease in the SNA and
pretreatment measurements. Details of treatment ANB angle, an increase in labial inclination of the
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 114, Number 4
lower incisor, and an increase in all vertical measure-
ments related to the X axis of the Cartesian coordinate
system. Horizontal movement related to the Y axis
revealed forward movement of the lower incisors,
lower molar crown, and root. When treatment changes
of the CAG were compared with those experienced by
the SEG, there were no statistically significant differ-
ences observed. Even measurements made when
mandibular superimposition was done to eliminate dis-
placement, revealed no differences in the inclination or
vertical and horizontal movement of the lower molar
teeth were observed.
DISCUSSION
It was apparent that significant changes did occur
within each group at the end of orthodontic treatment
(Table III). These changes included a reduction of
facial convexity and the Class II skeletal base discrep-
ancy. This was probably due to treatment and growth
changes. In addition, there was an increase in lower
incisor inclination, a vertical increase in facial height
and upper and lower dentition, and horizontal forward
movement of the lower dentition. The SEG did show a
tip (downward) of the occlusal plane that did not occur
in the CAG. This difference could have been due to the
emphasis placed in the Bioprogressive technique of
intruding maxillary incisors with a partial appliance,
as opposed to a leveling approach of a full appliance.
When the CAG was compared with the SEG, no sig-
nificant difference existed between groups in any of
the variables measured, including the occlusal plane
(Table IV).
Treatment did influence mandibular tooth move-
ment within each group. Both groups displayed an
increase in the vertical height of the molars, molars and
incisors moved forward, and the lower incisors
increased their labial inclination (Table V). Mandibular
superimposition was done to eliminate displacement. It
is conceivable that mandibular displacement between
the two groups differed and that this would mask a dif-
ference in tooth movement. When mandibular tooth
movements between the two groups were compared,
once again no statistical differences were found (Table
V). It has been claimed that cortical anchorage will
enhance molar stability while class II elastics are being
worn. The current study however shows that the lower
molars moved mesially and occlusally equal amounts
in both groups.
The side effects associated and reported in the lit-
erature, namely, lower teeth moving mesially, in-
creased labial inclination of lower incisors, and lower
molars moving occlusally, all occurred in both groups
studied.2,7,11,17
Ellen, Schneider, and Sellke 435
Fig 3. Mandibular superimposition measurements.
Measurements included vertical distances measured
from the X axis to the mandibular molar (1), and incisor
(2) teeth. Angulation of these teeth were also measured
to the X axis (3, 4). Horizontal distances were measured
from the Y axis to the mandibular incisor (5) and the
molar (6,7).
Although cortical anchorage did not resist the side
effects of Class II elastics more effectively than stan-
dard edgewise anchorage preparation, it should be
kept in mind that it was no worse. Bien2 concluded
that anchorage is enhanced by increasing the number
of teeth into the anchorage unit, thereby increasing the
root area resisting displacement. The results of this
study demonstrated that cortical anchorage, incorpo-
rating only a partial appliance, provided anchorage
equal to a fully banded lower arch. This certainly has
clinical applications in cases where Class II elastic
wear is being contemplated, and the entire lower arch
is not available for appliances. It is important to
remember that the measurements taken at the end of
treatment do not represent the position of the teeth
immediately after a Class I molar relationship was
achieved using Class II elastics. It is possible that fin-
ishing details addressed after Class II elastics were
discontinued changed the direct effects due to Class II
elastic use.
CONCLUSIONS
The results of this study support the following con-
clusions:
1. There were no skeletal or dental measurements that
behaved differently between the two groups studied
even though anchorage preparation was different.
2. In both groups, the SNA and ANB angles decreased
significantly; however, within the SEG, the occlusal
plane was observed to have tipped down, whereas with-
in the CAG, significant tipping was not observed.
3. Molar anchorage was neither enhanced nor compro-
mised by establishing cortical anchorage.
436 Ellen, Schneider, and Sellke American Journal of Orthodontics and Dentofacial Orthopedics
October 1998

This study suggests that Class II elastics can be
worn with a partial appliance, with a utility arch and
cortical anchorage bends, and be equally as effective as
a fully bonded lower arch in correcting Class II maloc-
clusions.
We thank Dr Cyril Sadowsky, BDS, MS, for his
help in the preparation of this article.
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