European Journal of Orthodontics 13 (1991) 212-222 © 1991 European Orthodontic Society

Class III malocclusion: a comparison of extraction

and non-extraction techniques
Joanna M. Battagel* and Harry S. Orton**
"Department of Child Dental Health, London Hospital Medical College, Dental School, London, and
"Princess Dental Wing, Kingston Hospital, Surrey, England

SUMMARY A retrospective cephalometric study was made of the hard tissue changes in a group of
90 Class III, Skeletal III children, diagnosed as suitable for treatment by orthodontic means alone.
Thirty-two were treated by a combination of upper incisor proclination and headgear to an intact
mandibular dentition (Group 1), while in 28 the overjet was corrected with mid-arch extractions
and Edgewise mechanics (Group 2). The remaining 30 children acted as controls (Group 3).
Children were initially examined as male and female subgroups, and where no significant
differences were seen data were pooled. In order to standardize the results, treatment/observation
effects were presented as average changes per year.
The three groups were essentially comparable pretreatment. Following overjet correction, the
lower incisors uprighted in both groups, with an improved relationship to the A-Po line: the upper
incisors were proclined in Group 1 only. Underlying skeletal changes were restricted to the

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mandible, which showed a downward and backward hinging, and an increase in lower face
height. The improved mandibular position was significantly greater in the non-extraction group
and was accompanied by an improvement in facial convexity. In addition, treatment could be
started earlier and was completed in a significantly shorter time (Table 1).
It would, therefore, appear that, in the short term at least, a non-extraction/headgear approach
has advantages over a standard mid-arch extraction/Edgewise technique.

Introduction 1987), and chin cup therapy (Graber, 1977;

The orthodontic treatment of Class III malocclu-
sion may frequently prove more difficult than
anticipated and further facial growth will be
often detrimental to long-term stability (Hopkin,
1963; Mills, 1982; Houston andTulley, 1986). In
the early permanent dentition, it is tempting to
correct the overjet by the extraction of lower
premolars and retraction of the lower labial
segment. However, such extractions may be
regretted later if incisor compensation has to be
reversed prior to orthognathic surgery (Creek-
more, 1978; Houston and Tulley, 1986; Evans,
1988).
Non-extraction therapy, using either inter-
maxillary anchorage or the chin retractor, was
described by Angle (1907) and the concept is
presently enjoying renewed popularity. Tech-
niques in current use include reverse headgears
(Nanda, 1980; Cozzani, 1981; Campbell, 1983),
the FR3 (Frankel, 1971; Kerr and Ten Have,
Sakamoto et al., 1984). Patient acceptance of
these devices tends to be less good than when
conventional appliances and extra-oral traction
are prescribed. The technique of using headgear
to an intact mandibular dentition is less well
known (Cozzani, 1981; Orton et al., 1983) and
would, therefore, seem to deserve further exam-
ination.
The aim of this study was to compare the
results of treatment in two groups of Class III,
Skeletal III children considered suitable for
orthodontic correction and to compare these
with the changes found in a similar group of
untreated children. Only the hard tissue changes
are reported in this paper.
Subjects
The material used in this study comprised the
before and after treatment lateral skull radio-
graphs of 60 children with a Class III incisor
CLASS III: WITH AND WITHOUT EXTRACTIONS
relationship on a Skeletal III dental base. The
British Standard definition was used in the
assessment of the incisor relationship (British
Standards Institution, 1983) and the skeletal
pattern was considered to be Class III where a
corrected ANB analysis showed a difference of
less than 1.5 degrees. The control group of 30
patients was subjected to the same selection
criteria and children were included if they had
two lateral skull radiographs taken at least 1 year
apart. All patients with a deep overbite and a
reverse overjet exhibited some degree of forward
mandibular displacement. They have not been
specifically identified in the analyses since there is
increasing evidence that little or no residual
anterior displacement occurs (Gravely, 1984;
Kerr and Ten Have, 1988a).
Treatment was carried out using one of two
different techniques. The first group (Group 1) of
32 patients (19 males and 13 females) was treated
non-extraction by a combination of upper inci-
sor proclination and headgear to an intact
mandibular dentition. The headgear was
attached to a removable appliance as described
by Orton et al. (1983) and no independent
movement of the lower labial segment was
attempted. The second group (Group 2) com-
prised 28 children (11 males and 17 females).
These were treated by the extraction of lower
premolars and standard Edgewise mechanics to
retract and align the lower labial segment, and
align the upper arch. A few patients had upper
extractions where this was necessary to relieve
crowding. The allocation of patients to either
treatment group depended largely on the degree
of lower arch irregularity. Most children with
mandibular crowding required extractions and
were, therefore, found in Group 2, but in a few
Group 1 children, very mild crowding was
accepted. The ages of the children and the time
taken to complete treatment or of observation
are shown in Table 1. Children in group 1
completed treatment in a significantly shorter
time as no control of residual extraction spaces
was required.
Methods
Pairs of lateral skull radiographs from each
patient were traced, orientated with the Frank-
fort plane horizontal, and sixteen skeletal and
dental landmarks identified. Points recorded
conformed to British standard definitions (Bri-
213
tish Standard Institution, 1983) except for gnath-
ion, for which the definition given by Riolo et al.
(1974) was used.
The tracings were digitized, re-orientated to
the Frankfort horizontal, and a vertical reference
line drawn through sella. All measurements were
corrected for X-ray magnification and converted
to life size. Twelve angular and eleven linear
measurements were made (Table 3).
Digitizing error was controlled by the program
at 0.1 mm, and the method error calculated by
retracing and redigitizing ten film pairs, and
applying Dahlberg's (1940) formula (Table 2).
The errors found were generally larger than
those quoted by other authors, as film pairs
rather than single films were tested. As expected,
they were almost entirely due to difficulties in
landmark identification at the tracing stage. The
Frankfort horizontal was particularly vulner-
able.
The data were examined using SPSS.
Measurements for each sex were examined separ-
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ately due to the different numbers of males and
females in each group. Where there were no
significant differences between the groups, data
were pooled. Means and standard deviations
were calculated for each variable and '/' tests
used to examine:
(1) differences between the sexes in each group
before treatment or observation (Table 3);
(2) differences due to treatment (or observation)
within each group for each sex (Table 4).
A one-way analysis of variance was employed to
test:
(1) the differences between the three groups
before treatment (or observation), with the
sexes separated where necessary (Table 3);
(2) the effects of treatment compared with nor-
mal growth of the control group, again
retaining separation of the sexes (Table 5).
Tukey's honestly significantly different (HSD)
test was applied to the analysis of variance to
indicate the exact intra-group differences.
Because of the variation in time between the two
X-rays of the control and treatment groups, all
differences observed between X-ray 2 and X-ray
1 have been expressed as change per year (Table
5).
214 J. M. BATTAGEL AND H. S. ORTON

Table 1 Ages of sample and time taken to complete treatment (in

years).

Non-extraction—E.O.T.

Whole group Males Females

(n= 19)

Group 1 Mean SD Mean SD Mean SD

Before 12.66 1.84 12.44 1.57 12.99 2.20

After 14.52 2.12 14.32 1.76 14.81 2.60
Treatment time 1.86 0.72 1.88 0.61 1.83 0.88

Lower premolar extraction

Whole group Males Females

(« = 28)

Group 2 Mean SD Mean SD Mean SD

Before 13.33 1.52 13.62 1.84 13.14 1.29

After 15.64 1.67 16.03 2.03 15.40 1.40
Treatment time 2.32 0.68 2.41 0.77 2.26 0.64

Untreated controls

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Whole group Males Females
(n = 30) (i=H)

Group 3 Mean SD Mean SD Mean SD

Before 12.38 2.07 11.38 1.80 12.96 2.03

After 15.34 2.56 14.62 2.82 15.76 2.38
Observation time 2.96 1.56 3.24 1.61 2.80 1.55

Significance of ages and treatment/observation times for groups as a

whole

Group 1 Group 1 Group 2

v. Group 2 v. Group 3 v. Group 3

Age before ns ns 0.05

Age after 0.05 0.001 0.05
Treatment/observation time 0.05 ns ns

Results The analysis of variance on the data before

The results are presented in Tables 3-5.
Before treatment
Only four variables showed significant differ-
ences between the sexes before treatment: overjet
in the non-extraction group; the inclination of
the upper incisors to the maxillary plane in the
non-extraction and control groups; the distance
between articulare and pogonion in the mid-arch
extraction group; and the MM angle in the
controls (Table 3).
treatment also showed only four significant
differences between measurements (Table 3).
Variables concerned were ANB, the Y axis, the
MM angle in females, and lower face height.
Changes within each group due to observation or
treatment
Control group (Table 1, and Table 4 columns
9-12). The average time between X-rays in this
group was approximately 3 years (Table 1),
slightly more (3.24 years) in the male and slightly
CLASS III: WITH AND WITHOUT EXTRACTIONS 215

Table 2 Error of the method for treatment/observa- 'B' point, pogonion, and the lower incisor to sella
tion change (n = 10) calculated by Dahlberg's formula. vertical. The significance of these findings will be
discussed later. Females showed a similar pattern
Measurement Error of change, but again differences were smaller.
Angular Extraction/Edgewise group (Table 1, and
SNA 0.90° Table 4 columns 5-8). Children in this group
SNB 0.65°
ANB 0.56° were older at the start of treatment, since therapy
SN pogonion 0.65° could begin only once premolars had been
NA pogonion 0.87° extracted (Table 1). The lower incisors were
BaSN 1.01° retroclined and also retracted significantly with
Kaxis 0.75° respect to A-Po. Most other linear measure-
FH to N. pog. 0.73°
MM angle 0.75° ments showed significant increases, in particular
Gonial angle 1.07° mandibular length and prominence, and lower
ljl to max. plane 1.67° face height. The females again showed fewer
TjT to mand. plane 1.25° changes. The lower incisor retraction paralleled
that of the males. Smaller, but significant in-
Linear
Overjet 0.63 m m creases in ANB, mandibular length, and lower
Overbite 0.52 m m face height were seen, but most linear skeletal
Tl to A-Po 0.44 m m measurements showed little change.
Art. to pog. 1.10 m m
'A' to sella vertical 1.62 m m Differences between groups due to treatment or
'B' to sella vertical 0.78 m m

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Pog. to sella vertical 0.94 m m
1|1 tip to sella vertical 2.13 m m
111 apex to sella vertical 1.66 m m
Iff tip to sella vertical 1.83 m m
Lower face height 0.63 m m
less (2.80 years) in the female subgroup. During
this period, significant changes in angular values
were few. Statistically significant differences at
the 1 per cent level or better occurred in the males
during the period of observation in all linear
skeletal measurements. Similar significant, but
smaller growth changes, were seen in the girls. In
both groups the largest changes were in the
distance articulare to pogonion.
Non-extraction/headgear group (Table 1, and
Table 4 columns 1-4). In this group, the ages of
the male and female subgroups corresponded
almost exactly (Table 1), with the males likely to
be at the beginning and the females at the end of
their pubertal growth spurts. In the males, nearly
all angular as well as linear measurements
showed significant alterations (Table 4). In par-
ticular angle ANB increased by 1.57 degrees,
rather than decreasing as expected due to normal
growth. Mandibular length did increase, but to a
very much smaller degree. Measurements which
did not change significantly, but would normally
increase with growth, included the distances of
observation ( Table 5)
In this section, the results of the analysis of
variance of the annualized treatment/observa-
tion data will be considered. The changes
reported may seem small in relation to the
method errors given in Table 2, but it must be
remembered that the former are changes per
year, whereas the latter were calculated for the
entire study period. To aid interpretation of the
results, the significance symbols should be
explained. Overall significant differences at the 5,
1, and 0.1 per cent levels are designated by small
Roman, Arabic, and capital Roman numerals,
respectively, with each group being represented
by its own number (Table 5, column 4). Where
Tukey's HSD test showed that one group dif-
fered from the other two, this group is placed
outside the brackets in the significance column.
Contrary to expectation the control group
(Group 3) did not show consistently significant
differences from the two treatment groups.
Instead, the group which showed most signifi-
cant changes and differed from the others in most
variables was Group 1, the non-extraction
group.
Control group. When the changes were exam-
ined on an annualized basis, the control children
showed increases in mandibular prominence,
length and lower face height, and a decrease in
the K-axis and MM angle. There were negligible
angular dental changes, but both upper and
Table 3 Before treatment/observation measurements, significance of difference between groups as a wholet, and between male and female
sub-groups.

Group 1 (non-extraction) Group 2 (extraction) Group 3 (control)

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M (n=19) Fdi-13:) Sig. M ( n = l 1) F(n=n;) Sig. M (;i=l 1) F(«=19) Sig.

Measurement Mean SD Mean SD MvF Mean SD Mean SD MvF Mean SD Mean SD MvF

Angular
SNA 78.02 3.37 78.89 3.16 77.08 3.65 77.33 3.80 79.14 4.80 79.57 4.32
SNB 79.86 4.20 80.65 3.46 78.33 2.84 78.77 3.94 79.44 3.60 80.44 4.25
ANB -1.69t 2.32 — 1.77| 1.64 -1.26 2.33 -1.45 2.23 0.14t . 1.78 -0.76f 2.05
SN pogonion 80.65 4.22 81.61 3.68 79.22 2.74 79.58 3.74 80.42 3.81 81.26 4.14
NA pogonion 174.19 4.83 173.51 3.35 174.85 4.56 174.69 4.24 175.88 3.02 175.14 3.64
BaSN 130.89 4.71 129.43 4.83 132.39 4.93 131.03 4.73 128.98 5.52 130.44 5.81
/axis 56.98t 3.53 55.42f 1.58 59.36f 3.96 58.25f 3.13 58.44 4.38 57.03 3.80
FH to N-pog. 90.36 2.63 91.06 1.83 89.27 3.15 89.90 3.25 89.21 3.20 90.60 3.58
MM angle 27.27 5.38 23.67t 4.69 30.36 5.83 29.49f 5.29 31.03 4.79 26.42 4.77 •
Gonial angle 132.02 4.78 130.15 4.87 135.13 2.87 132.77 5.52 133.56 3.55 131.83 4.58
1U to max. plane 108.51 6.27 116.25 8.54 *• 111.01 4.18 111.39 6.24 108.66 5.19 114.85 5.94 ••
1|1 to mand. plane 84.35 5.05 86.78 7.16 82.98 6.68 80.40 6.77 82.97 6.97 84.86 6.89

Linear
Overjet -0.94 1.08 0.36 1.44 ** 0.03 2.30 0.39 1.21 0.34 1.91 0.29 1.61
Overbite 2.76 2.08 1.74 1.50 1.96 1.62 1.51 1.44 2.27 1.85 1.09 1.32 •—i

T) to A-Po 3.69 1.37 3.09 1.77 3.49 2.77 2.86 2.47 2.71 1.90 3.02 2.19
Art. to Pog. 99.76 5.80 98.08 6.37 102.29 .5.28 98.08 5.26 • 98.33 4.80 97.82 5.94 2
A to sella vert. 61.80 3.41 62.42 2.91 61.19 4.08 59.94 3.97 62.22 5.42 61.66 4.09 w
B to sella vert. 63.09 5.08 64.14 3.68 61.28 6.77 60.57 6.04 61.16 6.10 62.23 5.43 -i
Pog. to sella vert. 64.52 5.94 65.83 4.41 62.67 6.83 61.91 6.39 62.62 6.90 63.69 6.22 H
J]i tip to S. vert. 64.47 4.10 66.90 3.93 65.05 5.34 64.29 5.52 65.73 6.33 65.69 6.00 om
Ml_ apex to S. vert. 56.78 3.22 57.69 2.76 56.31 3.82 55.65 4.12 57.46 4.27 56.58 4.36
Iff tip to S. vert. 66.47 3.72 66.83 3.55 65.19 5.65 63.53 4.99 65.07 4.86 65.41 5.55 p

Lower face height 58.85t 6.86 55.65J 3.17 62.58| 6.82 60.23t 4.58 61.26 5.49 58.42 6.05 Z
oX
*P<0.05; **P<0.0\.
t Indicates significant differences at the 0.05 level between groups before treatment, as shown by a one-way analysis of variance. For the MM angle, only
females showed a difference. For the other three measurements, the two sexes are combined.

ORTON
 o
r1

Table 4 Changes during treatment/observation and significant intra-group differences during this time.

Group 1 (non-extraction) Group 2 (extraction) Group 3 (control) H

X

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M («=19) F(n=13) M (n = 11) F(n=17) M (n = ID F(n=19)
z
Measurement Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD o
Angular H
SNA 0.26 0.94 0.25 .00 0.09 2.65 -0.01 1.34 0.28 .03 — 0.17 • .31 X
SNB -1.33** 1.61 -0.09 .38 0.13 2.12 -0.89* 1.44 0.56 .31 0.50 .52 o
c
ANB 1.57*** 1.62 0.37 .20 -0.01 2.83 0.88* 1.65 -0.76 .75 -0.83* .37 H
SN pogonion -0.80* 1.39 0.38 .48 0.84 1.82 -0.07 1.37 0.78 .46 0.60 .59 m
X
H
NA pogonion 1.78* 3.22 0.40 2.17 -0.77 5.44 0.41 2.87 -0.27 .45 -1.01 2.36 73
BaSN 0.69 2.45 0.88 .95 -0.14 2.15 0.52 3.69 -0.10 .79 0.41 .89 >
Y axis 1.03* 1.75 0.11 .40 0.00 2.61 0.68 1.48 -0.10 .50 -0.02 .03 a
FH to N. pog 0.00 1.75 0.49 .46 1.28 2.44 0.10 1.43 1.26 .98 0.61 .28 H
MM angle 3.32 9.75 0.22 .19 0.36 2.19 0.64 1.99 -1.15 2.17 -0.62 .68 o
Gonial angle -0.83 1.99 0.06 .70 -0.83 2.28 -0.36 1.78 -1.39 * 1.96 -0.46 .44
z
en

jU to max. plane 4.37* 6.89 2.24 ' ».75 1.50 5.50 -0.99 6.43 1.68 3.35 -0.70 3.27
TfT to mand. plane -4.74*** 4.15 -2.70** 2.38 -8.13** 8.35 -3.01* 5.46 0.05 3.00 -1.09 2.97

Linear
Overjet 2.53*** 1.82 1.19 2.00 1.59 2.49 1.51** 1.73 0.23 0.99 0.08 5.98
Overbite -0.81* 1.44 0.58 .02 -0.78 1.60 0.06 1.53 -0.24 0.63 -0.07 .04
T| to A-Po -2.45** 1.75 -0.63 .14 -2.43* 3.07 -2.01*** 1.91 -0.12 0.81 -0.02 .01
Art. to Pog. 3.21*** 2.70 2.28* 2.70 8.13*** 3.10 1.78*** 1.75 6.09 *** 3.61 4.06*** 3.95
'A" to sella vert. 1.54** 1.72 0.72 .40 2.77* 3.14 0.40 1.64 2.24 ** .56 0.45 .13
'B' to sella vert. -0.21 2.54 0.42 2.59 3.24* 4.29 -0.86 2.44 3.20 **' 3.19 1.41 .70
Pog. to S. vert. 0.72 2.60 1.26 2.92 4.86** 4.98 0.50 2.43 3.87 ' 3.77 1.74** 2.26
JJJ_ tip to S. vert. 3.22*** 2.95 2.09** 2.43 3.79* 4.81 0.17 2.92 2.98 * K 2.26 1.04* .63
JM apex to S. vert 1.72*** 1.88 0.95* 1.47 3.51** 2.93 0.49 1.79 2.22 1 1.75 0.99** .29
TfT tip to S. vert. -1.16 2.44 0.24 1.92 1.21 3.79 -1.64* 2.43 2.72 *• 2.43 0.93 .51
Lower face height 4.40*** 2.73 1.66** 1.83 7.42*** 3.68 2.62*** 2.56 3.49 •* 2.70 1.39** .95

*/ > <0.05; **/ 3 <0.01; ***P<0.001.

218 J. M. BATTAGEL AND H. S. ORTON

Table 5 Annualized changes (i.e. changes per year) and significance between
groups. Where there are no differences between males and females, data for both
sexes have been pooled. Where differences occur, changes are indicated for each
sex. Significant differences between the groups are indicated in the last column.
In the significance column each group is represented by its own numeral, the
type of numeral indicating the significance: i, ii, iii indicates groups differing at the
0.05 level; 1, 2, 3 indicates groups differing at the 0.01 level; I, II, III indicates
groups differing at the 0.001 level. The group shown outside the brackets differs
from the group or groups within.

Group 1 Group 2 Group 3

Measurement (non-extraction) (extraction) (control) Significance
Angular
SNA 0.08 ±0.77 -0.01+0.80 0.04 + 0.49
SNB -0.64+1.13 -0.20 + 0.67 0.21 ±0.63 I (III)
ANB 0.73 ±0.89 0.19 ±0.90 -0.26±0.56 I (II, III)
SN pogonion — 0.35+ 1.07 0.14±0.63 0.26 ±0.66 i Oii)
Na pogonion 0.82 + 0.31 — 0.16± 1.69 -0.24 + 0.88 i (iii)
BaSN 0.41 + 1.45 0.00+1.38 0.06 + 0.72
Kaxis 0.45 ±1.02 0.20±0.86 -0.04±0.56
FH to N. pog 0.01 ±1.01 0.24±0.85 0.31+0.73
MM angle 0.49+1.06 0.21+0.88 -0.25 + 0.81 i (iii)
Gonial angle 7 0.39+1.25 -0.24±0.93 -0.32±0.64

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jU to max. plane 2.47 + 3.98 -0.26±2.67 0.01 ±1.62 I (II, III)
TjT to mand.
plane -2.58 ±2.68 -2.04 + 3.15 -0.33 ±1.26 3(1,2)

Linear
Overjet 1.41 + 1.57 0.59 + 0.79 0.07 + 0.33 I (II, III)
Overbite -0.18±0.80 -0.11 ±0.69 0.00 ±0.31
Tl to A-Po -1.14+1.18 -0.85±0.95 -0.06 ±0.38 III (I, II)
Art. to Pog. 1.34+1.27 1.90+1.71 1.7O±1.38
'A' to sella vert. 0.62 ±0.80 0.52+1.11 0.41 ±0.57
'B' to sella vert.
male -0.22 ±1.54 1.42 ±1.90 1.01 + 1.28 i(ii)
female -0.17+1.48 -0.45 + 0.91 0.60 ±0.76 ii (iii)
Pog. to S. vert. 0.29 ±1.54 0.93 + 1.83 0.89± 1.21
XH tip to S. vert.
male 1.79+1.57 1.57 + 2.00 1.00 ±0.93
female 1.65±2.13 —0.06± 1.31 0.41+0.71 1 (2, 3)
ljl apex toS. vert. 0.80 ±0.90 0.72 ±1.26 0.52±0.57
TfT tip to S. vert.
male —0.83+ 1.61 0.67+1.63 0.89±0.93 1 (2, 3)
female -0.35+1.63 -0.72 ±1.09 0.32±0.59 2(3)
Lower face height
male 2.25+1.22 3.21 + 1.49 1.09 ±0.65 III (I, II)
female 1.30 ±1.46 I.22+I.I2 0.42±0.70 iii (i, ii)

lower incisors moved forwards with antero-
posterior facial growth; this being more marked
in the upper arch.
Treatment groups. Following treatment,
several of these changes were minimized or
reversed, particularly in the non-extraction
group. In these children a reduction in mandibu-
lar prominence was seen, as evidenced by a
decrease in SNB, SN pogonion, and the distance
of 'B' to sella vertical. The mandibular length
increased less (but not significantly), whereas the
MM angle and lower face height both showed
significant increases. This may have been due
partly to the effect of the posterior bite planes
used to disengage the occlusion during treat-
CLASS III: WITH AND WITHOUT EXTRACTIONS
ment. Facial convexity improved, and the upper
and lower incisors snowed approximately a 5
degree combined angular change, with the upper
teeth proclining and the lowers retroclining by
the same amount. The overjet showed a large
increase whilst the lower incisor was significantly
retracted with respect to A-Po.
In the extraction group, angular changes were
similar, but few reached the level of significance.
The antero-posterior dental changes were
smaller and perhaps because the children were
older, greater increases in mandibular length and
lower face height in males were apparent. Pogo-
nion, 'B' point, and the lower incisor in males
showed no restraint, growing forwards as much
or more than in the controls. Dentally, overjet
correction was less good and the upper incisors
were actually slightly retroclined. Despite the
fact that they were actively retracted, trie lower
incisors showed less uprighting and a poorer
relationship to A-Po than those in the non-
extraction group.
Discussion
The sample
Homogeneity. The composition of this sample
with regard to age and sex is not ideal. It would
have been desirable to have equal numbers of
male and female patients in all groups, for their
pubertal status to be equivalent, and for the
average ages at the beginning and end of treat-
ment/observation periods to be comparable.
However, patients were selected retrospectively
on the basis of their Class III skeletal and incisor
relationship at the time of thefirstX-ray, and no
more suitable pairs of films could be found. No
long-term height records were available and,
therefore, pubertal status could only be esti-
mated from the patient's age.
Control group. Radiographs for these children
were selected using the same criteria as for the
Class III treatment groups. Some had refused
treatment on social grounds, whereas others
were on a hospital waiting list awaiting the start
of therapy. It is likely, therefore, that this group
had slightly milder malocclusions on average
than the active groups. However, their growth
patterns should be more representative of this
type of malocclusion than those of children with
normal occlusions. When compared with Kerr
219
and Ten Have's (1988ft) normal control group,
however, differences in changes over the growth
interval are relatively few. ANB becomes more
negative, the gonial angle closes less, and the
lower incisors retrocline to a greater extent.
Comparison of results. Because of the discre-
pancies in ages and treatment times, it was
decided to annualize each measurement before
the groups were compared. This provides com-
parability, but also has several limitations: first,
it is artificial because the changes examined are
unlikely to be linear over the period chosen.
Secondly, all of the mean changes recorded will
be small and, in most instances, less than their
standard deviations. Thus, any statistically sig-
nificant results will tend to be an under-estimate
of the true situation.
An alternative method of analysis suggested
by Talass et al. (1987), where control group
measurements are subtracted from the treatment
group values before these are compared, was
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rejected for two reasons. First, the ages and sexes
of the children need to be exactly comparable
and, secondly, this would tend to obscure rather
than highlight the differences between treatment
and growth.
The effect of mandibular displacements
Anterior and/or lateral displacements of the
mandible were present in several of the children
studied irrespective of their group. This factor
has been ignored in the analyses, since there is
increasing evidence (Mills, 1966; Gravely, 1984;
Kerr and Ten Have, 1988a) that there is little or
no residual anterior displacement of the man-
dible, but simply a temporary avoidance activity
when the overjet is reversed and the overbite
deep. Even Slattery's (1988) selected group does
not show clear evidence of a true displacement.
Intra-group changes during treatment!observation
In any study undertaken on growing individuals,
the post-treatment effect will inevitably be a
product of treatment and growth. Where no
significant change in a measurement has been
recorded, this could be due to either the small
average growth change or a reversal of normal
growth by the treatment procedures. It is note-
worthy that in the treated groups, females show
fewer changes than males. Either treatment was
more effective in influencing change in girls,
perhaps due to better co-operation or because
220
they were mature, there was little growth. to
affect. The reality is likely to be a combination of
these effects, since active growth was apparent in
the linear dento-skeletal measurements for both
control subgroups (Table 4 columns 9-12).
Annualized changes: treatment effects
In general, the pattern of changes observed is in
line with those reported by other authors
(Graber, 1977; Wendell et al., 1985; Juixang et
al., 1985; Kerr and Ten Have, 19886). These
changes were confined to angular and linear
alterations in tooth position, together with a
favourable backward rotation of the mandible,
and increases in facial convexity and lower face
height.
When the three groups were compared, the
extraction/Edgewise children showed few signifi-
cant changes: this may have been a feature of
treatment selection, since individuals with pro-
nounced lower arch crowding were always allo-
cated to'this group. Nonetheless, the non-extrac-
tion/headgear group showed significantly more
improvement in dental and skeletal measure-
ments than the extraction group. In particular
the lower incisors, which were out of contact with
the passive appliance, were retroclined slightly
more than those in the extraction group which
had been deliberately moved lingually. The mean
incisor .retraction in the Edgewise/extraction
group is similar to that reported by Kerr and Ten
Have (1988*), and Slattery (1988), whilst the
behaviour of the non-extraction group compares
favourably with the 3.5 degree change reported
by Orton e/a/. (1983).
This brings into question the mode of action of
headgear to the intact mandibular dentition.
References to its use are scant. Cozzani (1981)
suggested that, apart from better control of
overbite and the vertical dimension (which were
not found in this study), it might exert some
influence over the potential growth and develop-
ment of the mandible. However, his paper is
purely descriptive. Orton et al. (1983) show a
downward and backward hinging of the man-
dible, which is not apparent in Kerr and Ten
Have's (1988ft) facial polygons depicting Fran-
kel, removable, and Edgewise therapy. Slattery
(1988), however, shows a similar treatment
change in his mandibular displacement group,
but here the method of treatment is not known.
A similar improvement in mandibular position
occurs following chin cup therapy (Graber, 1977;
J. M. BATTAGEL AND H. S. ORTON
Sakamoto et al., 1984; Mitani and Sakamoto,
1984), but this is accompanied by wider reaching
changes in Y axis, gonial angle and mandibular
length. Small improvements in Faxis and articu-
lare to pogonion were seen in the non-extraction/
headgear group, but these were not significant.
The degree of short-term skeletal improve-
ment in ANB was entirely due to alteration of'B'
point and compares favourably with changes
reported by Mills (1966) and Slattery (1988), but
unfavourably with Kerr and Ten Have's (1988ft),
Frankel and Edgewise groups.
Overjet correction in the non-extraction group
was assisted by proclination of the upper inci-
sors. However, because of the favourable lower
incisor response, this labial movement was about
half (4.59°) of the 9 or 10 degrees reported by
Mills (1966), Kerr and Ten Have (1988ft), and
Juixang et al. (1985) for upper removable
appliances alone. Since the degree of incisor
proclination is normally considered stable
(Mills, 1966; Slattery, 1988) and excessive procli-
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nation is deleterious in terms of overbite and
possible incisor mobility, this technique would
seem to have several advantages. In particular, it
widens the range of Class III malocclusions
which can be treated by orthodontics alone
without recourse to extractions.
Finally, facial profile, in terms of facial con-
vexity, was significantly better in the non-extrac-
tion/headgear group. The angle N-A-pogonion
is very close to 180° in Class III patients, and the
angle measured in this study was the outer or
right-hand angle (with the radiograph facing to
the right) rather than the inner angle normally
used. Thus, an improvement is indicated by an
increase, as pogonion moves dorsally. In both
other groups, pogonion moved forwards during
the period of observation. This improvement in
profile (mentioned earlier by Orton et al., 1983) is
also observed following Frankel therapy (Kerr
and Ten Have, 1987) and the use of chin caps
(Sakamoto et al., 1984), but does not appear to
have been reported following conventional
Edgewise treatment. It therefore seems possible
that the application of headgear to the intact
mandibular dentition may have both orthodon-
tic and orthopaedic effects. Preliminary findings
indicate that the latter are reversed post-treat-
ment where growth is still active, as are the
beneficial effects of other mandibular appliances.
Whilst the short-term advantages of this tech-
nique are considerable, a follow-up study of the
cases out of retention is clearly indicated.
CLASS III: WITH AND WITHOUT EXTRACTIONS
Limitations of study
Some of the limitations of this study have already
been mentioned. In any retrospective cephalo-
metric analysis it is difficult to find suitable
numbers of patients matched for treatment time,
sex, and age (or better still, pubertal status).
Control group patients will tend to have milder
malocclusions and have X-rays taken at less
frequent intervals. The results reported relate to
very mixed groups and separation of the sexes,
together with annualization of the observed
effects, only partially addresses this problem. In
addition the study only covers a relatively short
period of active treatment. An analysis of the
patients several years out of retention would be a
much more stringent test of the non-extraction/
headgear technique.
Conclusions
Successful orthodontic treatment of the Class
III, Skeletal III malocclusion is accompanied by
at least short-term dental and mandibular skele-
tal changes. These effects are greater when a non-
extraction approach, using headgear to an intact
mandibular dentition is used, rather than a
conventional extraction/Edgewise approach.
1. Lower incisors move lingually during the
application of headgear, on average by 4.6
degrees. This facilitates overjet correction.
2. There is a 1 degree per year improvement in
ANB, when compared with a Class III control
group. This is due to a reduction in SNB in
association with a downward and backward
repositioning of the mandible.
3. There is no improvement in the position of'A'
point.
4. The facial convexity increases as the chin
point moves posteriorly.
However, this approach must normally be
limited to those children whose lower arch
crowding is either absent or very mild.
Address for correspondence
Joanna M. Battagel
Department of Child Dental Health
London Hospital Medical College
Dental School
Stepney Way
London El 2AD
England
221
Acknowledgments
The authors would like to thank Mr A. M.
Ferman of The London Hospital Medical Col-
lege Biometrics Laboratory for designing the
software used in this study.
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