Comparison of soft-tissue profiles after treatment with headgear or Herbst appliance

Introduction: Herbst and headgear appliances are considered effective for correcting Class II malocclusions in growing patients, although their skeletal and dental effects differ. In the literature, there is no comparison between profile esthetic outcomes with the Herbst and headgear. The purpose of this study was to provide that comparison. Methods: Lateral cephalometric radiographs of 48 matched pairs of growing Class II Division 1 patients treated with either the Herbst appliance or headgear (both combined with fixed appliances) were used to generate pretreatment and posttreatment standardized silhouettes. The silhouettes were randomly arranged and judged by laypeople and orthodontic residents using a 7-point Likert scale. Statistical analyses including nonparametric procedures and intraclass correlation were used to compare initial, final, and change profile esthetic scores for the 2 groups of subjects and agreement between evaluators.Results: Both groups of subjects had significant profile improvements with treatment (P <.05), and there were no statistically significant differences between the groups in average final profile scores. Overall, there was strong agreement between the evaluations of laypersons and orthodontic residents. Conclusions: Class II Division 1 growing patients treated with either Herbst appliance or headgear (both combined with fixed appliances) will benefit from significantly improved profiles that are equally attractive. Orthodontic treatment with either Herbst appliance or headgears can be effective in correcting Class II malocclusions, although their skeletal and dental effects differ. A number of authors have described the dentoalveolar and skeletal changes induced by the Herbst appliance. The dentoalveolar effects consist of distalization of the maxillary molars and forward movement of the mandibular dentition. 1 The main skeletal changemandibular stimulationis acceleration of a patients inherent mandibular growth rather than increased growth beyond what would occur without treatment.2, 3, 4 Pancherz and Anehus-Pancherz5 described the short-term and long-term effects of the Herbst appliance on the maxillary complex of 45 patients followed for 6.4 years after treatment. They noted significant high-pull headgear type changes on the maxillary complex, but the effect was temporary without additional retention. The treatment effects of headgears are well documented. High-pull headgears reduce forward and downward maxillary growth. The result of both effects is improvement of the apical base discrepancy in Class II patients. Dentally, high-pull headgears tend to distalize and intrude or reduce the eruption of the maxillary molars. Cervical-pull headgears, on the other hand, tend to restrict forward maxillary growth, rotate the anterior palatal plane downward, and distalize the maxillary molars. Recent evidence indicates that the mandibular plane is maintained with cervical-pull headgear.6, 7, 8

Hgg et al9 studied patients treated with a high-pull headgear Herbst appliance followed by headgear activator for retention compared with those treated with the Herbst followed by retention with the Andresen activator. When the appliances were combined with high-pull headgear, 70% of the overjet correction was via skeletal change compared with a skeletal component of correction of less than 30% with the Herbst alone. They concluded that adding headgear to the Herbst resulted in an increased orthopedic effect on the maxilla and greater improvement in skeletal relationships. In summary, Class II correction appears to be effective with either the Herbst appliance or headgear. Headgears are reported to contribute to the correction by both restricting forward maxillary growth and distalizing the maxillary molars. The Herbst appliance is reported to have significant headgear effects in terms of restricting the maxilla. However, these effects appear to be transient, and Class II correction with these appliances appears to include significant dentoalveolar components. Because Class II correction appears to be achievable with either appliance, a follow-up question is whether there is a difference in the esthetic outcomes. Dongieux and Sassouni10 studied frontal and profile esthetics with variations in mandibular position. They found that the soft-tissue profile view was the most reliable in assessing esthetics related to anteroposterior and vertical changes in the position of the mandible. The literature provides ample soft-tissue measures for evaluating various aspects of facial esthetics. However, because of the complexity of the human face and the subjectivity of facial beauty, a simple set of measures of lines or angles cannot quantify facial beauty. Some authors have used silhouettes effectively to study profile esthetics to neutralize the bias of variables such as coloring and complexion; the influence of these features was confirmed by Spyropoulos and Halazonetis.11 Previous investigators compared profile silhouettes after treatment with various modalities of Class II correction. Barrer and Ghafari12 compared profile silhouettes of patients treated without extractions and with either Frnkel, Begg light-wire, straight-wire edgewise, or Tweed edgewise appliances. They found that the posttreatment profiles were strongly preferred, with no difference between treatment modalities. ONeill et al13 reported on the profile attractiveness of children with Class II Division 1 malocclusion after treatment with the Frnkel appliance (n = 13) or the Harvold activator (n = 12) compared with a control group (n = 17). Initial and final profile silhouettes were judged by panels of art students, dental students, and parents of orthodontic patients. They found no significant differences in the changes in profile attractiveness of treated subjects compared with control subjects because profile attractiveness improved in most subjects in each group, including the control subjects; however, relatively small sample sizes might have affected statistical power. In contrast, Quinto et al14found soft-tissue differences between subjects treated with the Twin-block appliance and Class II control subjects. However, their measurements were made immediately after 12 months of Twinblock treatment and did not allow for posttreatment changes.

Shelly et al15 studied the treatment outcomes of 34 patients who had mandibular advancement. Laypersons and orthodontic residents evaluated randomized pretreatment and posttreatment profile silhouettes to quantify changes in profile esthetics. They found that, for patients with an initial ANB angle 6, there was consistent improvement in profile esthetics after treatment. However, for patients with an initial ANB <6, profile improvement was seen about half the time, but poorer esthetics were equally likely. Mergen et al16 studied the profile silhouettes of 100 patients treated with headgear and fixed appliances. The subjects were divided into 4 groups based on the severity of the skeletal anteroposterior and vertical statuses. Lay and orthodontic resident judges evaluated randomized pretreatment and posttreatment profile silhouettes. They found that, as initial skeletal discrepancies worsened, pretreatment profiles were judged less attractive. With treatment, all groups showed overall profile improvement, and all groups were judged equally attractive. Groups with greater initial skeletal discrepancies had the most profile improvement. The literature suggests that the profile view is the most reliable in assessing esthetics related to anteroposterior and vertical changes in the position of the mandible. Furthermore, profile silhouettes of patients have been successfully used to compare esthetic changes with or without extractions; with the Frnkel, Harvold, Begg, straight-wire, or Tweed edgewise appliances; with mandibular advancement surgery; and with headgears. There is no comparison in the literature between profile esthetic outcomes with the Herbst compared with headgear appliances. The purpose of this study was to evaluate profile outcomes of growing patients treated with Herbst or headgear combined with fixed orthodontic appliances. We had 5 specific goals: to determine (1) which treatment resulted in a more esthetic posttreatment soft-tissue profile, (2) whether there was a perceived improvement in the soft-tissue profile from pretreatment to posttreatment for the 2 treatment modalities, (3) whether the amount of soft-tissue profile improvement from pretreatment to posttreatment was similar between the 2 treatments, (4) whether there were differences in average initial profile scores between the Herbst and the headgear patients, and (5) whether there were differences in the appraisals of laypeople and orthodontic residents. Material and methods Two groups of 48 growing Class II Division 1 caucasian subjects were individually matched retrospectively for sex, age, and ANB and SN-MP angles (Table I, Table II). The sagittal maxillary skeletal relationship of each subject was deemed normal as defined by the measurement FH:NA to ensure that the skeletal discrepancy was due to mandibular skeletal retrusion.17,18 Inclusion criteria required girls younger than 12 years 0 months and boys younger than 14 years 0 months. Table I. Initial ANB and SN:MP angles: ranges and means () ANB range ANB mean

ANB range

ANB mean

Headgear

4-10

5.47

Herbst

4-10

5.53

Table II. Sex distribution and initial age Female (n) Initial mean age (y)

Headgear

12

10.93

Herbst

12

10.93

The first group of subjects was treated in the graduate orthodontic clinic at the University of Iowa with headgear (mixed headgear types) and fixed appliances. Extractions were based on treatment need for correction of crowding and not for Class II correction. When extractions were required, 2 maxillary and 2 mandibular premolars were removed. Extractions were indicated in 27% of the sample. All subjects completed treatment with Class I occlusion. The second group of subjects was treated in a private practice with a banded Herbst appliance and fixed appliances. The Herbst appliance was placed after the complete eruption of all 4 first premolars. Upon placement, the mandible was advanced approximately 3 to 4 mm, an additional 2 to 3 mm after 3 months of treatment, and again after 6 months as needed. In general, Class I occlusion was achieved after the second advancement. The Herbst appliance remained in place 12 to 15 months. The need for extractions was determined after treatment with the Herbst appliance. If extractions were deemed necessary, either 2 maxillary premolars or 2 maxillary and 2 mandibular premolars were extracted. Extractions were indicated in less than 10% of the subjects. Silhouettes were produced from the soft-tissue profile tracings of the pretreatment and posttreatment lateral cephalometric radiographs of all subjects. The tracings were scanned into Adobe Photoshop (version 7.0; Adobe Systems, San Jose, Calif) by using ScanMaker (9800XL; Microtek USA, Carson, Calif) set to gray scale and resolution of 300 dpi and saved as JPEG images. Each line tracing was arranged with the Frankfort horizontal parallel to the horizontal aspect of the computer monitor. The profile tracings were then filled in with solid black against a white background. The silhouettes were transferred to Windows PowerPoint

(Microsoft, Redmond, Wash), where they were standardized for size and showed each profile from soft-tissue glabella to slightly below the throat point. All silhouettes were randomly sorted for presentation to the evaluators. Each silhouette was labeled chronologically in the lower right corner. The silhouettes were also labeled with identification numbers according to test group pretreatment or posttreatmentin black text superimposed over the black silhouettes, making the labels invisible during projection. These identification labels could be viewed by clicking and moving the silhouettes. The presentation and judging of profiles was done according to the method of Mergan et al.16 Five introductory silhouettes (Fig 1) were shown to familiarize the evaluators with the range of esthetics in the sample and the rating procedure. The introductory silhouettes were shown at decreasing intervals of 30, 20, 15, 12, and 10 seconds. The actual 192 silhouettes were shown at intervals of 10 seconds. The presentation lasted for 32 minutes. The evaluators consisted of 2 groups, each comprising 10 people. The first group consisted of 10 laypersons, 6 men and 4 women, who had no direct patient contact and whose ages were 19 to 55 years. The second group consisted of 10 orthodontic residents, 6 men and 4 women, whose ages were 26 to 31 years. The evaluators were asked to score each profile using a Likert scale consisting of 7 points ranging from 1 (very unattractive) to 7 (very attractive).19

Introductory silhouettes to familiarize the evaluators with the range of esthetics in the sample. Statistical analysis The nonparametric Wilcoxon rank sum test was used to compare the mean difference for initial rating scores between the Herbst and headgear treatment groups. The same test was also used to compare final mean rating scores and changes of mean rating scores (final minus initial) between the groups. The nonparametric Wilcoxon signed rank test was used to compare the mean difference in rating scores between resident and lay raters; in addition, the intraclass correlation coefficient was used to determine the level of agreement between the 2 groups of evaluators. SAS software (version 9.1; SAS, Cary, NC) was used for the statistical analysis, and all tests had a .05 level of statistical significance. Means of average initial, final, and change esthetic scores are shown in Table III. The first goal of the study was to determine which treatment resulted in a more esthetic posttreatment soft-tissue profile. The data provided no evidence of significant differences in average final profile scores between the Herbst and headgear groups (P = .9357). Treatment with Herbst or headgear produced equally attractive soft-tissue profiles with mean average scores of 3.60 and 3.55, respectively. The second goal was to determine whether there was a perceived

improvement in the soft-tissue profile from pretreatment to posttreatment for the 2 modalities. Data analysis showed that, for both treatment groups, the final scores were significantly higher than the initial scores (P <.05 in each instance). The third goal was to determine whether the amount of soft-tissue profile improvement from pretreatment to posttreatment was similar between the Herbst and the headgear. Statistical analysis showed no difference in average change profile scores between the 2 groups (P = .0870). The mean change scores were 0.51 in the Herbst group and 0.86 in the headgear group. This represents changes of 17% and 32% for the Herbst and headgear groups, respectively. Fig 2, Fig 3 show 2 subjects whose profiles represent the approximate mean improvement for their group. The fourth goal was to determine whether there were differences in average initial profile scores between the Herbst and the headgear patients. The data analysis showed that the overall average initial scores for the Herbst group (mean, 3.09) were significantly higher (more esthetic) than those for the headgear group (mean, 2.69) (P = .034), despite careful matching of subjects for initial skeletal conformation, age, and sex. Finally, we sought to determine whether there were differences between the appraisals of laypeople and trained professionals. There was evidence that the initial scores of the lay raters were greater than those of the orthodontic residents in each treatment group (P = .0035 for the Herbst group; P <.0001 for the headgear group). However, when final profile scores were considered, there was no significant difference in the scores of the evaluator groups (P >.05 in each instance). Furthermore, intraclass correlation coefficients of 0.81 to 0.93 showed strong agreement for initial, final, and change scores for both Herbst and headgear subjects from the 2 groups of evaluators. Table III. Mean average (SD) esthetic scores Group All raters Lay raters

Headgear

Final

3.55 (1.41)

3.59 (1.33)

Initial

2.69 (1.33)

2.85 (1.32)

Change

0.86 (1.57)

0.74 (1.51)

% change

32

26

Group

All raters

Lay raters

Herbst

Final

3.60 (1.22) 3.09 (1.32)

3.61 (1.16) 3.19 (1.29)

Initial

Change

0.51 (1.40)

0.42 (1.41)

% change

17

13

Significantly different from the initial score for that treatment group, P <.05. Significantly different from corresponding initial headgear scores, P <.05.

Initial (left) and final (right) silhouettes for a headgear subject demonstrating approximate mean improvement for the headgear group: initial score, 2.65; final score, 3.6; change score, 0.95 (for all raters combined).

Initial (left) and final (right) silhouettes for a Herbst subject demonstrating approximate mean improvement for the Herbst group: initial score, 4.1; final score, 4.75; change score, 0.65 (for all raters combined). Discussion Our principal finding was that, despite differences in the mechanism of action of the 2 appliances, growing patients, treated with either Herbst or headgear (combined with fixed appliances) have significant profile improvement after treatment; both groups benefited from improved profiles that were equally attractive.

Ninety-six growing subjects with Class II Division 1 malocclusion were included in this study; 48 subjects treated with the Herbst appliance and 48 treated with headgear (both combined with fixed appliances) were closely matched for sex, age, and skeletal conformation. Pretreatment and posttreatment silhouette profiles, used to eliminate subjective distractions, were scored by lay and professional evaluators. Because the mechanism for correction of the dentition differs between the Herbst and headgear appliances, we were surprised to find that the final profile esthetic results were similar for both groups and that both groups had significant improvements. It was also unexpected that the initial profile scores for the 2 groups were significantly different. This was particularly surprising because the groups were matched carefully for underlying skeletal discrepancies, age, and sex. One might assume that similar underlying skeletal discrepancies would result in similar softtissue profiles; perhaps, however, these initial differences were the result of treatment selection biases. For example, many headgear subjects were treated with high-pull headgear, and they might have initially had greater frequencies of lip incompetence and obtuse lip-chin-throat angle, 2 features that impact profile scores negatively. Another surprising finding was that, on average, all scores were below average on the 1-to-7 Likert scale. However, after further investigation, we found that our mean scores were similar to those of previous investigators who used the same 7-point Likert scale.15, 16 Our mean improvement scores of 0.86 (headgear) and 0.51 (Herbst) compared favorably with 0.54 (Mergen et al16) and 0.40 (Shelly et al15) for Class II patients. One limitation of our study was the lack of an untreated Class II control group. ONeill et al13 compared profile improvement of subjects treated with either the Frnkel appliance or the Harvold activator with an untreated control group. Those authors found improvement in about two thirds to three fourths of treated subjects compared with improvement in approximately two thirds of untreated subjects, with no statistical difference between treated and untreated subjects. Their study, however, had small sample sizes (17 untreated controls, 13 subjects treated with a Frnkel, and 12 treated with an activator). Their small sample sizes could have been problematic and might have affected their outcome. We plan a future comparison with larger samples of treated and control subjects. A few subjects in each of our groups had extractions. One question that might be of concern is whether this affected their profile esthetics. However, studies document the negligible soft-tissue profile effects of extractions using sound treatment decisions for Class II treatment.20, 21 Our final goal was to compare the evaluations of laypeople and orthodontic residents. For the pretreatment silhouettes, the laypeople were less critical than the orthodontic residents, but overall there was strong agreement between the 2 groups of evaluators. These results are similar to those of Mergen et al, 16 who found overall good agreement between evaluators, but the initial profile silhouettes were judged less critically by laypeople. Kerr and ODonnell22 also found lay judges (art students and parents) to be more generous in evaluating profiles than

orthodontists. In general, though, investigators have found agreement about facial attractiveness among lay and professional judges.23, 24 Conclusions Our purpose in this study was to evaluate pretreatment and posttreatment profile silhouettes of 48 matched pairs of growing Class II Division 1 subjects who were treated with either the Herbst appliance or headgear (both combined with fixed appliances). Standardized profile silhouettes of the subjects were randomly arranged and projected for judging by laypeople and orthodontic residents using a 7-point Likert scale. Statistical analysis including nonparametric procedures and intraclass correlation coefficients demonstrated the following. 1.Both headgear and Herbst treatment groups had significant profile improvements with treatment.

2.Both headgear and Herbst treatment groups finished with similarly attractive profiles.

3.Despite close matching of the groups, the headgear subjects had lower initial scores and experienced greater percentage changes.

4.There was strong agreement between the evaluations of laypersons and orthodontic residents.