ORIGINAL ARTICLE

Orthodontic treatment changes of chin position

in Class II Division 1 patients
Mark B. LaHaye,a Peter H. Buschang,b R. G. Wick Alexander,b,c and Jim C. Boleyb,d
Thibodoux, La, and Dallas, Tex
Introduction: Because most patients with skeletal Class II malocclusions also have mandibular deficiencies,
treatment plans should include improvement in chin projection. On that basis, the purposes of this study
were to (1) determine how Class II treatment affects anteroposterior (AP) chin position in growing subjects
and (2) ascertain the most important determinants of AP chin position. Methods: Pretreatment and
posttreatment lateral cephalograms of 67 treated patients (25 extraction headgear and Class II elastics, 23
nonextraction headgear, and 19 Herbst) were collected, traced, and digitized. The average pretreatment age
was 12.2 years (range, 9-14 years), and the average treatment duration was 30.2 months (range, 17-65
months). Cephalometric changes were compared with 29 matched untreated Class II controls. Mandibular
superimpositions were used to evaluate condylar growth and true mandibular rotation. Results: All 3
treatment methods produced normal dental relationships and restricted or inhibited AP maxillary growth, with
no significant improvement of AP chin position. Differences between changes in vertical position of the
maxilla, maxillary and mandibular molars, and condylar growth could not reliably predict changes in chin
position. Analyses demonstrated that true mandibular rotation was the primary determinant of AP chin
position. Stepwise multiple regression showed that, combined with true mandibular rotation, condylar growth
and movements of the glenoid fossa accounted for 81% of the variation in AP changes of pogonion.
Conclusions: Contemporary treatments do not adequately address mandibular deficiencies. Future treatments must incorporate true mandibular rotation into Class II skeletal correction. (Am J Orthod Dentofacial
Orthop 2006;130:732-41)

hroughout the history of orthodontics, clinicians

have been faced with the challenge of correcting skeletal Class II malocclusions. It has been
reported that approximately 15% to 30% of American
children have Class II malocclusions, comprising about
20% to 30% of all orthodontic patients.1 They typically
have retrusive chin positions,2-7 and the skeletal Class
II pattern is generally not self-correcting.3,8-10
Three commonly used methods of Class II correction have been (1) extraction therapy with headgear and
Class II elastics (Ext HG), (2) nonextraction headgear
treatment (NE HG), and (3) functional appliances, such
as the Herbst. Headgear treatment, both extraction and
nonextraction, causes orthopedic changes in the maxilla
in addition to orthodontic tooth movement.11-18 Headgear treatment predictably achieves normal dental Class
I molar and canine relationships, proper overbite and
a

Private practice, Thibodoux, La.

Faculty, Baylor College of Dentistry, Dallas, Tex.
c
Private practice, Arlington, Tex.
d
Private practice, Richardson, Tex.
Reprint requests to: Peter H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246; e-mail,
PHBuschang@bcd.tamhsc.edu.
Submitted, November 2004; revised and accepted, February 2005.
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.02.028
b

732

overjet, and significant anteroposterior (AP) improvements. Treatment does not, however, generally cause
significant improvements in the AP relationship of the
chin.14,16,19-22 Some studies even reported unfavorable
backward rotation of the mandible after headgear therapy.14,15,17,18,23-25
Herbst treatment, which can also produce acceptable dental results, has been shown to cause an overall
increase in mandibular length as well as headgear
effects on the maxilla.26-29 Initial improvements in
mandibular growth might diminish during fixed appliance treatment.2,28 Studies have also shown either no
change or a slight increase in the mandibular plane
angle with Herbst treatment.26,29-31 This suggests that
Herbst treatment produces results similar to headgear
treatment, although no well-controlled comparisons of
treatment effects on chin position are available.
The inability of contemporary treatment approaches
to adequately address the chin is important for profile
considerations. People frequently seek orthodontic
treatment because of facial disharmony32; straighter
profiles and more prominent chins are preferred esthetically over retruded chin positions.33,34 Correction of
Class II Division 1 malocclusions requires maintenance
of normal AP maxillary growth and greater than normal
AP mandibular growth. Headgear and functional appli-

LaHaye et al 733

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 6

ance approaches that restrain maxillary growth while

allowing mandibular growth to catch up produce
straighter profiles, but less than desired facial angles.
Possible mechanisms for improving AP chin position include (1) increase in mandibular size, (2) repositioning of the glenoid fossa, and (3) counterclockwise
or forward rotation of the mandible. Implant and
histological studies show that the anterior aspect of the
chin is extremely stable.35-37 Schudy38 proposed that
the growth of the condyles must exceed the sum of the
vertical growth of the corpus of the maxilla and vertical
growth of the maxillary and mandibular processes if an
improvement in chin position is to occur. Apparently
supporting this hypothesis, Sinclair and Little39 attributed anterior repositioning of the chin to greater condylar growth than maxillary growth.
Alternatively, true mandibular rotation might play a
more fundamental or primary role in determining AP
chin position. Buschang and Santos-Pinto40 developed
mathematical models showing that the AP position of
pogonion in growing children and adolescents, both
treated and untreated, is most closely associated with
true rotation of the mandible, as defined by Solow and
Houston,41 followed by AP condylar growth and the
AP position of the glenoid fossa, respectively.40 These
findings were later validated by Thompson et al.42
Because of the lack of studies comparing matched
samples, the purposes of this study were to evaluate
maxillary and, particularly, mandibular changes associated with 3 commonly accepted forms of Class II
treatment. Our aims were to (1) determine how various
treatments affect chin position, (2) test the validity of
Schudys pogonion formula38 concerning the determinants of chin position, and (3) validate the mathematical model regarding determinants of chin position.
MATERIAL AND METHODS

The treated sample (n 67) consisted of 3 groups

of consecutively treated patients from the records of 3
private-practice orthodontists, each using a different
method of Class II correction. To be considered for this
study, the treated patients had to meet the following
selection criteria: 1. Class II Division 1 malocclusion:
half-step Class II molar and canine relationship; 2. Class II
skeletal relationships; 3. approximately equal numbers of
boys and girls; 4. growing white children (9-14 years);
5. complete records including acceptable pretreatment
and posttreatment cephalograms, pretreatment dental
models, and intraoral photographs; 6. mandibular deficiency, defined as smaller than average pretreatment
SNB angle according to age- and sex-specific norms43;
7. vertical growth tendencies, defined as greater than
average pretreatment mandibular plane angle (SN-

GoGn) based on age- and sex-specific norms43; and 8.

successfully treated by dental criteria: Class I molar and
canine relationship, adequate overbite (2-4 mm) and
overjet (1-3 mm).
The Ext HG group included 25 patients (12 boys,
13 girls) treated with 4 premolar extractions in a typical
Tweed edgewise manner with extensive use of tip-back
bends, anchorage preparation, and Class II elastics.
Various types of headgear (high-pull J hook, combipull, high-pull bow Hickam) were used. The mean
duration of treatment was 34.2 10.5 months. Their
mean pretreatment age was 12.1 2 years.
The NE HG sample consisted of 23 patients (11
boys, 12 girls) who were treated with the Alexander
straightwire appliance in conjunction with cervical
pull headgear and nonextraction therapy. These patients
were instructed to wear the headgear a minimum of 14
hours per day. The average duration of treatment was
25.2 10 months. Their mean pretreatment age was
12.7 2 years.
The Herbst group consisted of 19 patients (9 boys,
10 girls) treated with stainless steel crown Herbst
appliances for an average of 12.7 7 months, followed
by fixed edgewise appliances. The total mean treatment
time was 31.3 10 months. Their mean pretreatment
age was 11.7 3 years.
The untreated control group included children who
were followed longitudinally at the Human Growth and
Research Center at the University of Montreal. They
were from 3 school districts in Montreal representing
various socioeconomic strata of the larger population.44
The sample consisted of 29 untreated Class II Division
1 white subjects (14 boys, 15 girls) who were matched
to the treated sample for age, sex, ANB angle, and
SN-GoGn angle. The initial observation was at 12.4
1.5 years of age, and they were followed for 2.2 0.6
years.
Cephalometric methods

The analyses describe growth and modeling of 12

skeletal landmarks (Fig 1), identified using standard
definitions.43 All cephalograms were hand traced and
digitized by 1 investigator using Dentofacial Planner
(Dentofacial Software, Toronto, Ontario, Canada). The
linear measurements were adjusted to eliminate magnification.
Traditional measurements were used to determine
AP changes in the maxilla and the mandible (SNA,
SNB, ANB, and SN-Pg angles) and changes in the
mandibular plane angle (SN-GoGn). To evaluate condylar growth, true rotation (ie, rotation of the mandible
independent of the modeling changes, also called total
rotation36) and mandibular molar movement in the

734 LaHaye et al

American Journal of Orthodontics and Dentofacial Orthopedics

December 2006

Fig 1. Cephalometric landmarks, anterior and posterior reference points, and reference line.

mandible, mandibular superimpositions were performed by using natural reference structures.36 The
radiographic tracings were oriented based on the
following structures: (1) anterior contour of the chin,
(2) inner contour of the cortical plate at the lower
border of the symphysis, (3) distinct trabecular
structures in the symphysis, (4) contour of the
mandibular canal, and (5) third-molar tooth germ
before root formation. Anterior and posterior stable
reference landmarks were marked on the pretreatment (T1) tracing (Fig 1). The posttreatment (T2)
tracing was superimposed on the mandible as described above, and the reference structures were
transferred to the second, superimposed, tracing.
The horizontal and vertical movements of selected
landmarks were described based on rectangular coordinates (X,Y). A horizontal reference line (RL), was
oriented based on the T1 sella-nasion plane minus 7,
registering on T1 sella (Fig 2). For example, the AP
change in pogonion was measured parallel to RL, and
the vertical change was measured perpendicular to RL.
Horizontally, an anterior change was recorded as positive, and a posterior change was recorded as negative.
Vertically, a superior change was recorded as positive,
and an inferior change was recorded as negative (Fig
2). True rotation was determined as the angular change
between the T1 and T2 mandibular reference lines,

Fig 2. AP and vertical cephalometric landmark positions measured parallel and perpendicular to SN-7.

drawn through the posterior reference point (PRP) and

the anterior reference point (ARP), relative to RL.
Replicate analyses showed no significant systematic
errors. Random method errors ranged from 0.07 to 1.2,
with menton horizontal showing the greatest error.

LaHaye et al 735

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 6

Table I.

Pretreatment skeletal relationships of Herbst, nonextraction headgear, extraction headgear, and untreated
control groups
Herbst (n 19)

NE HG (n 23)

Ext HG (n 25)

Controls
(n 28)

Group
differences

Measurement

Mean

SD

Mean

SD

Mean

SD

Mean

SD

P value

SNA ()
SNB ()
ANB ()
SN-Pg
SN-GoGn ()
Age (y)

82.0
76.2
5.8
77.4
34.2
11.7

3.5
3.2
1.3
3.2
3.9
1.9

80.8
74.9
5.9
76.0
34.6
12.7

2.4
2.3
1.1
1.9
2.5
1.1

82.6
76.2
6.4
76.8
35.9
12.1

2.9
2.7
1.3
2.6
2.8
1.0

81.6
76.1
5.5
76.5
36.2
12.4

2.0
2.1
1.2
2.2
3.0
0.7

.129
.231
.062
.305
.082
.057

Table II. Annualized angular ( per year) treatment changes in Herbst, NE HG, and Ext HG, and changes for untreated
controls
Herbst

NE HG

Ext HG

Controls

Group differences

Measurement

Mean

SD

Mean

SD

Mean

SD

Mean

SD

P value

Post hoc

ANB ()
SNA ()
SNB ()
SN-Pg
SN-GoGn ()
True rotation

0.7*
0.7*
0.0
0.0
0.3
0.1

0.5
1.1
1.0
0.9
0.9
0.9

1.2*
1.0*
0.2
0.3*
0.3
0.7*

0.6
0.7
0.7
0.8
1.2
1.3

1.4*
1.3*
0.2
0.4*
0.2
0.5*

0.6
0.8
0.6
0.6
0.8
0.9

0.0
0.3
0.3*
0.0
0.1
0.2

1.1
1.0
0.7
0.8
1.2
1.8

.000
.003
.055
.144
.355
.321

1,2,3,4
2
NS
NS
NS
NS

*Significant changes between T1 and T2 (P .05).

Significant group differences based on Scheff test P .05: 1, Controls and Herbst; 2, Controls and Ext HG; 3, Controls and NE HG; 4, Ext HG
and Herbst.
NS, No significant group differences at .05 level.

Statistical methods

To account for group differences in duration between T1 and T2, the changes were annualized. In other
words, all changes given in the text and in Tables II and
III were standardized to represent changes per year
rather than changes over the entire treatment. The
distributions of all variables were normal based on the
skewness and kurtosis statistics. Analyses of variance
(ANOVA) were used to evaluate group differences.
Scheff tests were performed for post-hoc analysis of
group differences.
Stepwise linear regression was performed to determine the independent variables that were most closely
associated with the AP movements of pogonion (dependent variable). The linear regression equation takes
the form of:
Y 1X 1 2X 2 kX k
where, , 1, 2, . . . , and k are constants and X1,
X2, . . . , and Xk are independent variables combined
linearly to explain variation in the dependent variable (Y). To evaluate Schudys pogonion formula,38
the first regression included vertical maxillary

growth, vertical growth of the maxillary and mandibular first molars, and condylar growth as the
independent variables. The second regression evaluated the relative contributions of condylar growth,
fossa displacement, and true mandibular rotation on
the AP position of pogonion.
RESULTS

Mean pretreatment values showed that all 4 groups

included skeletal Class II subjects with ANB angles
ranging from 5.5 to 6.4 (Table I). The SNA and SNB
angles indicate normal positions of the maxilla and
mandibular retrusion, respectively. Based on the SNGoGn angle, the mandibular plane of all groups was
slightly greater than normal, indicating vertical growth
tendencies. There were no significant pretreatment
differences among the 4 groups.
The SNA and ANB angles were the only measurements showing significant treatment effects (Table II).
They decreased in all treated groups and remained
unchanged in the untreated control sample. In contrast
to the treated groups, which showed no changes, the
untreated controls showed a small (0.3) but statisti-

736 LaHaye et al

American Journal of Orthodontics and Dentofacial Orthopedics

December 2006

Table III.

Annualized horizontal and vertical treatment changes (mm per year) in Herbst, NE HG, and Ext HG
headgear, and changes for untreated controls
Herbst
Measurement
Horizontal
Pg
Me
Fossa
Point A
U6
Co sup
L6 sup
Vertical
Pg
Me
Fossa
A point
U6
Co sup
L6 sup

NE HG

Ext HG

Controls

Group differences

Mean

SD

Mean

SD

Mean

SD

Mean

SD

P value

Post hoc

0.7*
0.7*
0.0
0.1
0.3
0.7*
1.2*

1.0
1.2
1.3
0.6
0.9
0.7
0.9

1.4*
1.5*
0.1
0.1
0.2
0.3
1.1*

1.7
1.6
0.9
0.9
1.3
1.4
0.8

1.2*
1.2*
0.6*
0.6
0.6*
0.9*
1.7*

1.2
1.3
1.1
1.0
1.0
0.7
1.1

0.5*
0.5*
0.4*
0.7*
1.0*
0.5*
0.6*

0.7
0.9
0.9
0.5
0.6
1.2
0.4

.027
.029
.227
.000
.069
.292
.003

NS
NS
NS
1,4,5
NS
NS
1

2.3*
2.3*
0.2
1.2*
0.8*
2.6*
0.9*

1.0
1.0
1.5
0.9
0.9
1.3
0.7

4.4*
4.7*
0.9*
3.0*
2.5*
4.4*
1.5*

1.5
1.5
1.1
1.0
1.2
1.8
0.9

2.7*
2.9*
0.8*
0.6*
1.5*
2.7*
0.7*

1.4
1.3
2.0
1.0
0.9
1.3
0.6

2.2*
2.3*
0.1*
1.0*
1.5*
2.2*
0.8*

1.0
1.0
0.6
0.6
0.7
1.3
0.5

. 000
. 000
.018
.000
.000
.000
.001

2,3,4
2,3,4
NS
2,3,4
2,3,4
2,3,4
2,3,4

*Significant changes at. 05 level.

Significant group differences based on Scheff test P .05: 1, Controls and Herbst; 2, Controls and Ext HG; 3, Controls and NE HG; 4, Ext HG
and Herbst; 5, Ext HG and Herbst.
NS, No significant group differences at .05 level.
See Fig 1 for definitions.

cally significant decrease in SNB angle. Although

SN-Pg increased during treatment in the NE HG and
Ext HG groups, the changes were too small to produce
statistically significant group differences. Similarly, the
mandible rotated forward in the NE HG and Ext HG
groups, but the effect was not sufficient to produce
group differences. There were no significant changes in
SN-GoGn angle.
Treatment restricted maxillary growth but had no
significant effect on the mandible in AP measurements.
Point A remained stationary in the Herbst and NE HG
groups, moved posteriorly in the Ext HG group, and
moved anteriorly in the control group (Table III).
Significant retraction of Point A was found in the Ext
HG group when compared with all other groups.
Pogonion and menton showed significant anterior
movements in all groups. The glenoid fossa showed
slight posterior movements in the Ext HG and control
groups. The maxillary molar showed significant forward movement in the Ext HG and control groups.
Mandibular superimpositions showed posterior growth
of condylion for all groups except the NE HG group,
which had no significant AP changes. The mandibular
molar moved forward in all 4 groups, with greater
forward movements in the Ext HG group than in the
controls.
With the exception of the glenoid fossa, there were
significant vertical changes for all measurements in all

groups; the changes for the NE HG group were greater

than the changes of the other 3 groups (Table III). With
the exception of condylion and the mandibular molar, the
other measurements showed inferior movements ranging
between 0.1 and 4.7 mm per year. Condylion grew
superiorly 2.2 to 4.4 mm per year, and the mandibular
molar erupted 0.7 to 1.5 mm per year.
The first regression analysis, evaluating Schudys
pogonion formula,38 showed that vertical condylar
growth was most closely associated with the AP movements of pogonion. The regression indicated 0.385 mm
of anterior movement of pogonion for every 1 mm of
superior condylar growth. No other variables entered
the regression. Superior condylar growth alone explained 25% (R .50) of the variation in the AP
movements of pogonion; it produced estimates of AP
change of pogonion that were within 1.1 mm
approximately 68% of the time.
The second regression analysis (Table IV) showed
that true rotation was most closely associated (R .66)
with AP movement of pogonion. As shown in Figure 3,
the first step of the regression predicted 0.694 mm of
anterior movements of pogonion for every 1 of true
forward rotation. For example, assuming 2 for true
forward rotation, 2.076 mm of anterior movement of
pogonion would be predicted (.688 [2 * .694]).
Horizontal condylar growth, horizontal fossa remodeling, vertical fossa remodeling, and vertical condylar

LaHaye et al 737

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 6

Table IV.

Stepwise linear regression analyses of effects of true rotation, horizontal condylar growth, horizontal fossa
displacement, and vertical condylar growth on AP movements of pogonion
Step

Constant
()

1
2
3
4
5

0.688
0.364
0.224
0.164
0.233

Variable 1
True
True
True
True
True

rotation
rotation
rotation
rotation
rotation

Variable
2

Variable
3

Variable
4

Variable
5

SEE

0.694
0.851
1.072
0.972
0.834

Co H
Co H
Co H
Co H

0.459
0.778
0.783
0.738

Fo H
Fo H
Fo H

0.482
0.671
0.644

Fo V
Fo V

0.348
0.365

Co V

0.157

0.657
0.741
0.804
0.882
0.900

.000
.000
.000
.000
.000

0.93
0.83
0.74
0.59
0.55

PgH (mm)

SEE, Standard error of estimate; Co H, Horizontal condylar growth; Fo H, horizontal fossa displacement; Co V, vertical condylar growth.

-4

-3

-2

-1

6
5
4
3
2
1
0
-1 0
-2
-3

Y=.688-(X*-.694)
R=.657; R2=.432

True Rotation (deg)

Fig 3. Linear regression relating horizontal movement of pogonion (Y) with true mandibular rotation
(X).

growth were the second, third, fourth, and fifth variables to enter the regression, respectively. They produced a multiple regression of 0.90, which accounted
for 81% of the variation in AP chin movement. The
standard error of the estimate indicated that these 5
variables predicted the AP movements of pogonion
within 0.55 mm approximately 68% of the time.
DISCUSSION

The 3 treatment approaches produced Class I dental

relationships and reduced the maxillomandibular discrepancies by restricting or inhibiting maxillary
growth. Although the mandible came forward during
treatment, it did not come forward any more than
expected in the untreated Class II subjects, who maintained their original ANB angles. In other words, the
anterior growth of the maxilla was compromised to
coordinate with a mandible that was moving forward
but remained retruded.
In comparison with previous studies, the Ext HG
group showed greater correction of the maxillomandibular relationship because of a larger reduction of
SNA angle and perhaps less detrimental effects on SNB
angle. SNA and ANB angle decreases were approxi-

mately twice as large as changes previously reported

for extraction treatment over comparable treatment
periods.16,19,21,22,45,46 Most studies also reported decreases in SNB angles,16,19,21,22 but the results show that
Ext HG treatment can maintain or slightly improve the
SNB angle. This suggests that the Ext HG maintained
better control of the mandible by preventing worsening of
the mandibular position. Despite the belief that mesial
molar movement during space closure allows for a greater
positive mandibular response,16,46-49 the results showed
no significant response compared with the controls and,
more importantly, no improvement in mandibular position. Although the AP corrections were greater than
previously reported, the underlying problem of chin deficiency was clearly not addressed. At best, Ext HG
treatment maintains the mandibular plane angle and AP
mandibular position.
Nonextraction headgear treatment also produced greater
reductions in SNA and ANB angles than previously reported
for comparable treatments.12,14-16,19,21,45,46,50,51 The
SNB and mandibular plane angles were relatively
maintained; this is consistent with previously reported changes ranging from 2.3 to 2.2 for the
mandibular plane angle and 0.37 to 0.83 for SNB

738 LaHaye et al

angle.12-16,19-21,46,50-52 These results confirm that NE

HG treatment, when used with proper mechanics,
does not cause undesirable mandibular rotation.12,14,53 The mandibular plane angle was held
relatively constant throughout treatment. As with Ext
HG treatment, the NE HG results show that AP
correction was produced primarily by restricting or
inhibiting maxillary growth and preventing undesirable changes in mandibular position.
The AP correction in the Herbst group was less than
previously reported due to the lack of mandibular
changes. The amount of SNA angle reduction compared
favorably with amounts previously reported.2,26,29,53 ANB
angle changes, however, were less29,53 because no change
occurred in the SNB angle. Previous studies reported SNB
angle increases of 0.2 to 1.4.2,26,29,53 This suggests that
initial improvements from the Herbst appliance might not
routinely be maintained over the course of fixed treatment,2,28 particularly for patients with vertical tendencies.
Herbst treatment achieved Class I dental correction primarily by maxillary growth restriction, with no significant
increase in condylar growth or mandibular length, as
reported by others.27,54,55
Schudys pogonion formula38 was not supported by
the results. Of the variables that comprised the formula,
only vertical condylar growth entered into the regression equation, explaining 25% of the variability in the
AP movement of pogonion. This suggests that vertical
growth of the maxilla and vertical development of the
maxillary and mandibular dentoalveolar processes do
not add additional information for predicting changes in
AP chin position. For example, the difference between
condylar and maxillary vertical changes was almost
twice as great in the NE HG group as in the Ext HG
group, but there were little or no differences in anterior
movement of pogonion or mandibular rotation. Although significant amounts of vertical maxillary and
condylar growth occur during facial development, it
appears they might play a more secondary role in AP
positional changes of the mandible. Because this study
does not support the notion that vertical growth of the
maxilla as well as vertical maxillary and mandibular
dentoalveolar growth are primary determinants of AP
chin position, investigators should be cautious when
making inferences about the determinants of forward
mandibular movement.
The most important determinant of anterior chin
movements during growth and treatment was true
rotation. Buschang and Santos-Pinto40 originally produced mathematical models showing that mandibular
rotation was the most important determinant of horizontal movements of the chin in untreated children and
adolescents. Thompson et al42 reported a correlation of

American Journal of Orthodontics and Dentofacial Orthopedics

December 2006

0.69 between the horizontal movements of pogonion

and true rotation; this closely approximates our results
(R 0.64). As shown in Figure 3, the greater the
counterclockwise or forward true rotation of the mandible, the greater the anterior movement of pogonion.
Conversely, if the mandible rotates backwards, indicated by a positive value of true rotation, pogonion
shows unfavorable posterior movement. The cases
described by Bjrk and Skieller56 showed that anterior
movements of the chin were strongly related with true
rotation of the mandible. This suggests that compensatory changes in condylar and dentoalveolar development can occur secondarily to mandibular rotation, a
notion that is supported by morphologic studies evaluating patients with airway restrictions57-59 and muscular deficiencies.60-64
The multivariate models showed that accurate predictions of chin movements require additional information beyond true rotation. As previously shown,40,42 the
multiple regressions showed that true rotation, when
combined with horizontal and vertical changes in the
glenoid fossa and condyle, also accounted for approximately 90% of the variation of AP chin position.
Together, these studies suggest that an optimal skeletal
Class II correction will result from a treatment approach that provides the greatest amount of forward
mandibular rotation, which effectively allows for anterior movement of the chin point while controlling
undesirable inferior movement of the chin.
If the rotation of the mandible plays the primary
role, with or without treatment, then it becomes clear
that true rotation must be addressed when attempting to
produce greater anterior chin projection. By focusing
Class II correction on methods that control eruption and
intrude teeth, greater amounts of true mandibular rotation and greater improvements in chin projection might
be expected. Studies showed that chewing exercises,
performed from approximately 4 weeks to 2 years, can
produce 2 to 2.5 of mandibular plane closure.65,66
Posterior bite blocks have also been shown to intrude
posterior teeth and decrease mandibular plane angles.67-71 Vertical chincups, with or without headgear,
can redirect condylar growth, increase posterior facial
height, and reduce the mandibular plane angle.72-74
Removable molar intrusion appliances have also been
proposed to intrude maxillary molars and allow favorable forward rotation.75 These methods produce favorable results, but most depend on excellent patient
cooperation.
In the future, implants could provide orthodontists a
predictable, compliancefree method of inhibiting or
reducing dentoalveolar development and thus closing
the mandibular plane, rotating the mandible forward,

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 6

and improving the profile. Although no clinical studies

have been performed, animal studies and case reports
show that mini-implants, miniscrews, and titanium
miniplates can intrude molars from 0.5 mm per month
to 5 mm over the course of treatment, often closing the
mandibular plane.75-78 Unlike removable appliances,
implants do not require compliance, and they provide
absolute anchorage, which eliminates the side effects
produced by reciprocal forces and minimizes the
amount of force needed. The future offers great promise for a compliance-free, predictable method of producing true forward mandibular rotation and improvements in chin projection.
CONCLUSIONS

In this study evaluating the effect of extraction

headgear and Class II elastics, nonextraction headgear,
and Herbst treatment, we made the following conclusions.
1. Methods commonly used to correct Class II skeletal
malocclusions produce no significant improvements in AP chin position. Skeletal Class II correction in growing adolescents results primarily from
maxillary growth restriction or inhibition.
2. AP changes in chin position cannot be accurately
predicted by Schudys pogonion formula38 (ie,
based on condylar growth, vertical growth of the
maxilla, and vertical maxillary and mandibular
dentoalveolar growth).
3. Validating previously established mathematical
models, approximately 80% of the variability in AP
movement of the chin can be explained by true
rotation, AP and vertical condylar growth, and AP
movement or drift of the glenoid fossa. True mandibular rotation is the most important determinant
of AP changes of chin position.

REFERENCES
1. Proffit WR, Fields HW, Moray LJ. Prevalence of malocclusion
and orthodontic treatment need in the United States: estimates
from the NHANES-III survey. Int J Adult Orthod Orthognath
Surg 1998;13:97-106.
2. Burkhardt DR, McNamara JA, Baccetti T. Maxillary molar
distalization or mandibular enhancement: a cephalometric comparison of comprehensive orthodontic treatment including the
pendulum and the Herbst appliances. Am J Orthod Dentofacial
Orthop 2003;123:108-16.
3. Baccetti T, Franchi L, McNamara J, Tollaro I. Early dentofacial
features of Class II malocclusion: a longitudinal study from the
deciduous through mixed dentition. Am J Orthod Dentofacial
Orthop 1997;111:502-9.
4. McNamara JA. Components of Class II malocclusion in children
8-10 years of age. Angle Orthod 1981;51:177-201.

LaHaye et al 739

5. Craig CE. The skeletal patterns characteristic of Class I and Class

II, Division 1 malocclusions in norma lateralis. Angle Orthod
1951;21:44-56.
6. Drelich RC. A cephalometric study of untreated Class II Division
1 malocclusion. Angle Orthod 1948;18:70-5.
7. Renfroe EW. A study of the facial patterns associated with Class
I, Class II Division 1, and Class II Division 2 malocclusions.
Angle Orthod 1948;18:12-5.
8. Chung CH, Wong WW. Craniofacial growth in untreated skeletal
Class II subjects: a longitudinal study. Am J Orthod Dentofacial
Orthop 2002;122:619-26.
9. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in
dentofacial structures in untreated Class II Division 1 and normal
subjects: a longitudinal study. Angle Orthod 1997;67:55-66.
10. Lulla P, Gianelly AA. The mandibular plane and mandibular
rotation. Am J Orthod 1976;70:567-71.
11. Elms T. Long-term stability of Class II Division 1 nonextraction
cervical facebow therapy: II. cephalometric analysis. Am J
Orthod Dentofacial Orthop 1996;109:386-92.
12. Cook AH, Sellke TA, BeGole EA. Control of the vertical
dimension in Class II correction using a cervical headgear and
lower utility arch in growing patients. Part 1. Am J Orthod
Dentofacial Orthop 1994;106:376-88.
13. Firouz M, Zernik J, Nanda R. Dental and orthopedic effects of
high-pull headgear in treatment of Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop 1992;102:197-205.
14. Boecler PR, Riolo ML, Keeling SD, TenHave TR. Skeletal
changes associated with extraoral appliance therapy: an evaluation of 200 consecutively treated cases. Angle Orthod 1989;59:
263-9.
15. Baumrind S, Korn EL, Isaacson RJ, West EE, Molthen R.
Quantitative analysis of the orthodontic and orthopedic effects of
maxillary traction. Am J Orthod 1983;84:384-98.
16. Brown P. A cephalometric evaluation of high-pull molar headgear and face bow neck strap therapy. Am J Orthod 1978;74:
621-32.
17. Melsen B. Effects of cervical anchorage during and after treatment: an implant study. Am J Orthod 1978;73:526-40.
18. Ricketts RM. The influence of orthodontic treatment on facial
growth and development. Angle Orthod 1960;30:103-30.
19. Bishara SE. Mandibular changes in persons with untreated and
treated Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop 1998;113:661-73.
20. McLaughlin RP, Bennet JC. The extraction-nonextraction dilemma as it relates to TMD. Angle Orthod 1995;65:175-86.
21. Luppanapornlarp S, Johnston LE. The effects of premolar
extraction: a longterm comparison of outcomes of clear-cut
extraction and nonextraction Class II patients. Angle Orthod
1993;63:257-72.
22. Paquette D, Beattie JR, Johnston LE. A long-term comparison of
nonextraction and premolar extraction edgewise therapy in borderline Class II patients. Am J Orthod Dentofacial Orthop
1992;102:1-14.
23. Gandini MR, Gandini LG, Martins JC, Del Santo M. Effects of
cervical headgear and edgewise appliances on growing patients.
Am J Orthod Dentofacial Orthop 2001;119:531-9.
24. Weislander L, Buck DI. Physiologic recovery after cervical
retraction therapy. Am J Orthod 1974;66:294-301.
25. Schudy F. The rotation of the mandible resulting from growth:
its implications in orthodontic treatment. Angle Orthod 1965;
35:36-50.

740 LaHaye et al

26. Croft RS, Buschang PH, English JD, Meyer R. A cephalometric

and tomographic evaluation of Herbst treatment in the mixed
dentition. Am J Orthod Dentofacial Orthop 1999;116:435-43.
27. Franchi L, Baccetti T, McNamara JA Jr. Treatment and posttreatment effects of acrylic splint Herbst appliance therapy. Am J
Orthod Dentofacial Orthop 1999;115:429-38.
28. Pancherz H. The effects, limitations, and long-term dentofacial
adaptations to treatment with the Herbst appliance. Semin Orthod
1997;3:232-43.
29. Valant JR, Sinclair PM. Treatment effects of Herbst appliance.
Am J Orthod Dentofacial Orthop 1989;95:138-47.
30. Mills JR. The effect of functional appliances on the skeletal
pattern. Br J Orthod 1991;18:267-4.
31. Pancherz H. The Herbst applianceits biologic effects ad
clinical use. Am J Orthod 1985;87:1-20.
32. Herzberg BL. Facial esthetics in relation to orthodontic treatment. Angle Orthod 1952;22:3-22.
33. Czarnecki ST, Nanda RS, Currier GF. Perceptions of a balanced
facial profile. Am J Orthod Dentofacial Orthop 1993;104:180-7.
34. Spyropoulos MN, Halazonetis DJ. Significance of the soft tissue
profile on facial esthetics. Am J Orthod Dentofacial Orthop
2001;119:464-71.
35. Enlow DH, Harris DB. A study of the postnatal growth of the
human mandible. Am J Orthod 1964;50:25-50.
36. Bjrk A, Skieller V. Normal and abnormal growth of the
mandible. A synthesis of longitudinal cephalometric implant
studies over a period of 25 years. Eur J Orthod 1983;5:1-46.
37. Baumrind S, Ben-Bassat Y, Korn EL, Bravo LA, Curry S. 1.
Osseous changes relative to superimpositions on metallic implants. Am J Orthod Dentofacial Orthop 1992;102:134-42.
38. Schudy F. Vertical growth versus anteroposterior growth as
related to function and treatment. Angle Orthod 1964;34:75-93.
39. Sinclair PM, Little RM. Dentofacial maturation of untreated
normals. Am J Orthod 1985;88:146-56.
40. Buschang PH, Santos-Pinto A. Multivariate models for AP
movements of the bony chin [abstract]. J Dent Res 1997;76:31.
41. Solow B, Houston WJB. Mandibular rotations: concepts and
terminology. Eur J Orthod 1988;10:177-9.
42. Thompson, MA, Buschang RG, Ceen RF, English JD, Harper
RP. The determinates of antero-posterior movement of mandibular structures [thesis]. Waco: Baylor University; 1997.
43. Riolo ML, Moyers RE, McNamara JA, Hunter JS. An atlas of
craniofacial growth. Monograph no. 2. Craniofacial Growth
Series. Ann Arbor: Center for Human Growth and Development;
University of Michigan; 1974.
44. Demirjian A, Brault Dubuc M, Jenicek M tude comparitive de
la croissance de lenfent canadie dorige francais Montral. Can
J Public Health 1971;62:111-9.
45. Zierhut EC, Joondeph DR, rtun J, Little RM. Long-term profile
changes associated with successfully treated extraction and
nonextraction Class II Division 1 malocclusions. Angle Orthod
2000;70:208-19.
46. Bishara SE, Cummins DM, Jakobsen JR, Zaher AR. Dentofacial
and soft tissue changes in Class II Division 1 cases treated with
and without extractions. Am J Orthod Dentofacial Orthop 1995;
107:28-37.
47. Klontz HA. Facial balance and harmony: an attainable objective
for the patient with a high mandibular plane angle. Am J Orthod
Dentofacial Orthop 1998;114:176-88.
48. Pearson LE. Vertical control in treatment of patients having
backward-rotational growth tendencies. Angle Orthod 1978;48:
132-40.

American Journal of Orthodontics and Dentofacial Orthopedics

December 2006

49. Kuhn R. Control of anterior vertical dimension and proper

selection of extraoral anchorage. Angle Orthod 1968;38:340-50.
50. Haralabakis NB, Halazonetis DJ, Sifakakis IB. Activator versus
cervical headgear: superimpositional cephalometric comparison.
Am J Orthod Dentofacial Orthop 2003;123:296-305.
51. Kim KR, Muhl ZF. Changes in mandibular growth direction
during and after cervical headgear treatment. Am J Orthod
Dentofacial Orthop 2001;119:522-30.
52. Hubbard GW, Nanda RS, Currier GF. A cephalometric evaluation of nonextraction cervical headgear treatment in Class II
malocclusions. Angle Orthod 1994;64:359-70.
53. Schiavoni R, Grenga V, Macri V. Treatment of Class II high
angle malocclusions with Herbst appliance: a cephalometric
investigation. Am J Orthod Dentofacial Orthop 1992;102:393409.
54. McNamara JA, Carlson DA. Quantative analysis of temporomandibular joint adaptations to protrusive function. Am J Orthod
1979;75:593-611.
55. Stockli P, Willert H. Tissue reactions in the temporomandibular
joint resulting from anterior displacement of the mandible in the
monkey. Am J Orthod 1971;60:142-55.
56. Bjrk A, Skieller V. Facial development and tooth eruption.
An implant study at the age of puberty. Am J Orthod
1972;62:339-83.
57. Harvold ED, Tomer BS, Vargervik K, Chierici G. Primate
experiments on oral respiration. Am J Orthod 1981;79:359-72.
58. LinderAronson S, Woodside DG, Lundstrom A. Mandibular
growth direction following adenoidectomy. Am J Orthod 1986;
89:273-84.
59. Yamada T, Tanne K, Miyamoto K, Yamauchi K. Influences of
nasal respiratory obstruction on craniofacial growth in young
mucaca fuscata monkeys. Am J Orthod Dentofacial Orthop
1997;111:38-43.
60. Bakke M, Tuxen A, Vilmann P, Jensen BR, Vilmann A, Toft M.
Ultrasound image of human masseter muscle related to bite force
electromyography, facial morphology and occlusal factors.
Scand J Dent Res 1992;100:164-71.
61. Ingervall B, Helkimo E. Masticatory muscle force and facial
morphology in man. Arch Oral Biol 1978;23:203-6.
62. Kiliaridis S, Kalebo P. Masseter muscle thickness measured by
ultrasonography and its relation to facial morphology. J Dent Res
1991;70:1262-5.
63. Proffit WR, Fields HW, Nixon WL. Occlusal forces in normal
and longfaced adults. J Dent Res 1983;62:566-70.
64. Van Spronsen PH, Weijs WA, Prahl-Anderson B, Valk J, Van
Ginkel F. Relationhips between jaw muscle crosssections and
normal craniofacial morphology, studied with magnetic resonance imaging. Eur J Orthod 1991;13:351-61.
65. Ingervall B, Bitsanis E. A pilot study of the effect of masticatory
muscle training on facial growth in long-face children. Eur
J Orthod 1987;9:15-23.
66. Spyropoulos MN. An early approach for the interception of
skeletal open bites: a preliminary report. J Pedod 1985;9:200-9.
67. Sergl HG, Farmand M. Experiments with unilateral bite planes in
rabbits. Angle Orthod 1973;45:108-14.
68. Altuna G, Woodside DG. Response of the midface to treatment
with increased vertical occlusal forces. Treatment and posttreatment effects of monkeys. Angle Orthod 1985;55:251-63.
69. Woods MG, Nanda RS. Intrusion of posterior teeth with magnetsan experiment in growing baboons. Angle Orthod 1988;
58:136-50.
70. Rowe TK, Carlson DS. The effect of bite opening appliances on
the rotational mandibular growth and remodeling in the rhesus

LaHaye et al 741

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 6

71.

72.
73.
74.

monkey (mucaca mulatta). Am J Orthod Dentofacial Orthop

1990;98:544-9.
Melsen B, McNamara JA, Hoenie DC. The effect of bite blocks
with and without repelling magnets studied histomorphologically
in the rhesus monkey (mucaca mulatta). Am J Orthod Dentofacial Orthop 1995;108:500-9.
Buschang PH, Sankey W, English JD. Early treatment of hyperdivergent open bite malocclusions. Semin Orthod 2002;8:130-40.
Pearson LE. Treatment of a severe openbite excessive vertical pattern
with an eclectic non-surgical approach. Angle Orthod 1991;61:71-6.
Majourau A, Nanda R. Biomechanical basis of vertical dimension control during rapid palatal expansion therapy. Am J Orthod
Dentofacial Orthop 1996;106:322-8.

75. Gurton AU, Akin E, Keracay S. Initial intrusion of the molars in

the treatment of anterior open bite malocclusions in growing
patients. Angle Orthod 2004;74:454-64.
76. Park YC, Lee SY, Kim DH, Jee SH. Intrusion of posterior teeth
using miniscrew implants. Am J Orthod Dentofacial Orthop
2003;1223:690-4.
77. Kuroda S, Katayama A, Takano-Yamamoto T. Severe anterior
open bite case treated using titanium screw anchorage. Angle
Orthod 2004;74:558-67.
78. Yao CJ, Wu CB, Wu HY, Kok SH, Chang HF, Chen YJ.
Intrusion of the overerupted upper left first and second molars by
mini-implants with partialfixed orthodontic appliances: a case
report. Angle Orthod 2004;74:550-7.

Editors of the International Journal of Orthodontia (1915-1918),

International Journal of Orthodontia & Oral Surgery (1919-1921),
International Journal of Orthodontia, Oral Surgery and Radiography (1922-1932),
International Journal of Orthodontia and Dentistry of Children (1933-1935),
International Journal of Orthodontics and Oral Surgery (1936-1937), American
Journal of Orthodontics and Oral Surgery (1938-1947), American Journal of
Orthodontics (1948-1986), and American Journal of Orthodontics and Dentofacial
Orthopedics (1986-present)
1915
1931
1968
1978
1985
2000

to
to
to
to
to
to

1932 Martin Dewey

1968 H. C. Pollock
1978 B. F. Dewel
1985 Wayne G. Watson
2000 Thomas M. Graber
present David L. Turpin