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

Perception of facial esthetics and cephalometric correlations in Class II patients: a comparison between two-phase and one-phase treatments

An effective orthodontic treatment should not only aim for satisfactory occlusal outcomes but also consider its impact on facial esthetics. The study aims to evaluate and compare the perception of profile esthetics of skeletal Class II patients treated with two orthodontic modalities: (1) Two-phase approach involving functional appliances followed by fixed appliances with premolar extractions, or (2) One-phase approach using fixed appliances with premolar extractions. Additionally, the study aims to evaluate the correlation between the perceived esthetics and the corresponding cephalometric measurements. The study included 40 skeletal Class II adolescents who underwent either two-phase (n = 20, mean age = 12.38 ± 1.18) or one-phase (n = 20, mean age = 12.53 ± 0.79) orthodontic treatments. Eighty profile silhouettes (pre- and post-treatment) were assessed by 64 raters, including 23 orthodontists, 21 general dental practitioners, and 20 laypersons. The raters used a visual analog scale (VAS) to access profiles, upper and lower lips, and chin esthetics. At pre-treatment, all three groups of raters gave significantly lower scores to the profile silhouettes of the two-phase group compared to the one-phase group (P < 0.01); however, after treatment, they rated the two-phase group significantly higher (P ≤ 0.001). The two-phase group exhibited greater improvements in profile and upper and lower lip esthetics as perceived by all raters (P ≤ 0.001). Furthermore, cephalometric results revealed greater reductions in SNA, ANB, Wits appraisal, and G'-Sn-Pog' in the two-phase group compared to the one-phase group (P < 0.05). Five cephalometric parameters (SNB, SNPog, overjet, overbite, and UL-SnPog') demonstrated significant correlations with VAS scores given by orthodontists (P < 0.05). In conclusion, the two-phase group showed greater subjective and objective improvements in facial esthetics than the one-phase group. Additionally, the anteroposterior mandibular position and upper lip protrusion may be the primary cephalometric parameters correlated with subjective facial profile perceptions.

The effect of orthodontic treatment on facial attractiveness: a systematic review and meta-analysis

BACKGROUND

Facial and smile attractiveness are significant motivating factor for patients to seek orthodontic treatment. Although there is a general belief that orthodontic treatment improves facial appearance, this has yet not been systematically evaluated.

OBJECTIVE

The objective of this study was to assess the current evidence on the effect of orthodontic treatment on facial attractiveness.

SEARCH METHODS

Systematic and unrestricted search of nine databases were performed up to January 2022.

SELECTION CRITERIA

Studies evaluating facial attractiveness before and after orthodontic treatment.

DATA COLLECTION AND ANALYSIS

Extracted data included study design and setting, sample size and demographics, malocclusion type, treatment modality, and method for outcome assessment. Risk of bias was assessed with the ROBINS-I tool for non-randomized studies and with RoB-2 for randomized controlled trials (RCTs). Random-effects meta-analyses of mean differences and their 95% confidence intervals (CIs) were performed.

RESULTS

Twenty studies were included in data synthesis; three randomized controlled clinical trials and 17 non-randomized clinical studies of retrospective or prospective design. One of the RCTs was found to have low risk of bias, one presented some concerns and the third showed a high risk of bias. All non-randomized studies showed either unclear or high risk of bias. Data syntheses showed that orthodontic treatment improved facial attractiveness ratings by 9% when compared with untreated controls (MD: 9.05/95% CI: 4.71; 13.39). A combination of orthodontics and orthognathic surgery also showed a positive effect of 5.5% (MD: 5.51/95% CI: 1.55; 9.47) when compared with orthodontic treatment alone. There was no difference in effect between extraction and non-extraction treatments (MD: -0.89/ 95% CI: -8.72; 6.94) or between different types of Class II correctors (MD: 2.21/95% CI: -16.51; 20.93).

LIMITATIONS

With the exception of two RCTs, included studies were of unclear or low quality.

CONCLUSIONS

Orthodontic treatment has a clinically weak effect on facial attractiveness when compared to no treatment. The same is true when a combined orthodontic/surgical treatment is compared to orthodontics alone.

REGISTRATION

PROSPERO #: CRD42020169904.

Effect of Class II functional treatment on facial attractiveness, as perceived by professionals and laypeople

The literature offers different perspectives for and against two-phase treatment of skeletal Class II malocclusion. Facial attractiveness is an important aspect to take into account, given that children with skeletal Class II are often bullied by their peers and have low self-esteem and a lower social perception. The aim of the present study was to evaluate the aesthetic perception of facial profiles by a large number of observers, before and after treatment with a functional appliance, compared to untreated controls. The pre- and post-treatment cephalograms of 20 Class II subjects treated with Sander’s bite-jumping appliance and 20 untreated historical controls were collected and transformed into black and white silhouettes depicting only the lower third of the face. An online questionnaire comprising the silhouettes of the two groups, three “calibration” profiles and an “ideal” profile was submitted to dentists, orthodontists, undergraduates and laypeople, asking them to rate the profile’s attractiveness using a Visual Analogue Scale (VAS). The effect of treatment, and observers’ age, expertise and gender were analysed. The calibration images and the ideal profiles were used to evaluate the coherence of each observer’s judgement. The protocol was approved by the local Ethics Committee. Nine-hundred and ten questionnaires were collected. Treated subjects showed a larger improvement of facial attractiveness compared to controls. A significant effect of gender on the observer’s ratings was observed. Some observers showed incoherent judgement, which had a significant effect on the regression model. In conclusion, early treatment with functional appliances seems to improve patients’ facial aesthetics. This improvement is perceived equally by dental professionals and laypeople.

Changes in the craniofacial structures and esthetic perceptions of soft-tissue profile alterations after distalization and Herbst appliance treatment

INTRODUCTION

The purpose of this prospective clinical trial is to evaluate the changes of soft tissues and designate the esthetic perceptions of children with Class II malocclusion after Herbst appliance therapy and maxillary molar distalization using stereophotogrammetry.

METHODS

Thirty patients were allocated either to Herbst (6 boys and 9 girls; mean age = 11.60 ± 0.82 years) or distalization (4 boys and 11 girls; mean age = 11.46 ± 1.30 years) groups. Dentoskeletal and soft-tissue treatment changes were examined objectively by cephalometric analysis and stereophotogrammetry, respectively. Pre- and posttreatment profile views were evaluated subjectively by orthodontists and laypeople using the 7-point Likert scale. Intra- and intergroup comparisons for the repeated measurements were performed with 2-way variance analysis. Bonferroni test was used for multiple comparisons (P ≤0.05).

RESULTS

Greater skeletal changes were observed in the Herbst group than in the distalization group. Maxillary incisor retrusion and mandibular incisor protrusion were observed in the distalization and Herbst groups, respectively. Stereophotogrammetric measurements showed that mandibular body length and lower and anterior facial height increased in both treatment groups. Convexity angle (P = 0.020) and labiomental angle (P = 0.033) were greater in the Herbst group than the distalization group.

CONCLUSIONS

The skeletal contribution to correction of maxillomandibular discrepancy was greater in the Herbst group than the distalization group. Significant profile improvements were recorded for both groups with treatment. After both treatments, orthodontists were found to have higher rates of detection in the profiles than laypeople. The esthetic contribution of treatments to the facial profile was found similar in both groups.

Soft-tissue changes after Class II malocclusion treatment using the Sander bite-jumping appliance: a retrospective study

BACKGROUND

The soft tissue profile outcome after functional treatment of Class II malocclusion is important for a patient's aesthetic and psychosocial results. The soft tissue effects of the Sander bite-jumping appliance (BJA), which is the device that produces the greatest mandibular advancement according to a systematic review, have never been investigated. The aim of the present study was to assess the soft tissue effects of the BJA in comparison to matched untreated controls.

METHODS

A total of 19 patients treated with BJA during puberty were retrospectively recruited, and 15 untreated controls were retrieved from a previous growth study to match the treated group. Lateral cephalograms were used to evaluate the pre- and post-treatment differences in the ANB angle, the inclination of the upper and lower incisors, facial convexity, the nasolabial angle and the sagittal position of the skeletal and soft tissue at points A and B. Independent t-tests or Mann-Whitney U tests were used to detect differences between the two groups.

RESULTS

Statistically significant differences were found for the ANB angle, the inclination of the upper incisors and facial convexity.

CONCLUSIONS

Functional treatment of Class II patients with the Sander BJA during puberty was effective at improving the profile and reducing the facial convexity angle in the short term.

Comparison of surgical and non-surgical orthodontic treatment approaches on occlusal and cephalometric outcomes in patients with Class II Division I malocclusions

BACKGROUND

This study aimed to examine end-of-treatment outcomes of severe Class II Division I malocclusion patients treated with surgical or non-surgical approaches. This study tests the hypotheses that occlusal outcomes (ABO-OGS) and cephalometric outcomes differ between these groups.

METHODS

A total of 60 patients were included: 20 of which underwent surgical correction and 40 of which did not. Cast grading of initial and final study models was performed and information was gathered from pre- to post-treatment cephalometric radiographs. The end-of-treatment ABO-OGS and cephalometric outcomes were compared to Mann-Whitney U tests and multivariable linear regression models.

RESULTS

Following adjustment for multiple confounders (age, gender, complexity of case, and skeletal patterns), the final deband score (ABO-OGS) was similar for both groups (23.8 for surgical group versus 22.5 for non-surgical group). Those treated surgically had a significantly larger reduction in ANB angle, 3.4° reduction versus 1.5° reduction in the non-surgical group (p = 0.002). The surgical group also showed increased maxillary incisor proclination (p = 0.001) compared to the non-surgical group. This might be attributed to retroclination of maxillary incisors during treatment selection in the non-surgical group-namely, extraction of premolars to mask the discrepancy.

CONCLUSIONS

Those treated surgically had a significantly larger reduction in ANB angle and increased maxillary incisor proclination compared to those treated non-surgically with no significant changes in occlusal outcomes.

Soft tissue effects of three different Class II/1-camouflage treatment strategies

OBJECTIVE

Aim of this retrospective study was to compare soft tissue effects of Class II treatments with the forsus fatigue resistant device (FRD), the pendulum appliance, and the extraction of two maxillary premolars, all of which were combined with pre-adjusted fixed appliances.

PATIENTS AND METHODS

The sample of 54 patients with Class II malocclusions was divided in three groups: group I patients (mean age = 15.91 years) were treated with the FRD concurrently used with fixed appliances; group II patients (mean age = 16.08 years) were treated with the pendulum appliance combined with a Nance and headgear followed by fixed appliances; and group III patients (mean age = 19.04 years) were treated with the extraction of two maxillary premolars with miniscrew anchorage. Soft tissue and dentoskeletal parameters were measured on pretreatment (T1) and posttreatment (T2) lateral cephalograms. The changes from T1 to T2 were compared between the groups using Kruskal-Wallis test, and treatment differences were evaluated with the Wilcoxon test at p < 0.05.

RESULT

Soft tissue measurement changes related to the upper and lower lips were significantly greater in group II than in group III (p < 0.05). Upper incisor measurement changes were significantly different between groups II and III. Lower incisor measurement changes were significantly different between groups I and III and groups II and III (p < 0.05).

CONCLUSIONS

Pendulum and extraction treatment groups showed significant differences in relation with the upper and lower lip positional changes, which were significantly greater in the pendulum group. Treatment time with the extraction treatment was statistically shorter than with the nonextraction protocols.

Comparison of two scales for evaluation of smile and dental attractiveness

OBJECTIVE:

To compare the visual analogue scale (VAS) and the simplified Q-sort method used to investigate the highest level of agreement among dentists, orthodontists and laypeople when assessing smile and dental attractiveness.

MATERIAL AND METHODS:

An album containing 258 photos of 86 individuals with their lips at rest, a slight and broad smile, was assessed by 25 dentists (general clinicians and various specialties), 23 orthodontists and 27 laypeople with regard to smile and dental attractiveness. To this end, both VAS and simplified Q-sort method were used. Agreements were calculated by intraclass correlation coefficient (ICC).

RESULTS:

For the single measurement between the VAS method and the simplified Q-sort method, all simplified Q-sort rates were higher in all groups. The simplified Q-sort method results ranged between 0.42 and 0.49 while those of the VAS method varied between 0.37 and 0.42. The simplified Q-sort method also presented higher mean measurement values (0.95 and 0.96) in comparison to VAS (0.94 and 0.95).

CONCLUSIONS:

Both scales may be considered reliable for evaluating smile and dental attractiveness; however, the simplified Q-Sort method presented slightly higher values than the VAS method.

Class II, Division 1 Angle malocclusion with severe proclination of maxillary incisors

Protrusion of maxillary incisors is a common complaint among patients seeking orthodontic treatment. This report addresses the correction of Class II Angle malocclusion with excessively bucally proclined maxillary incisors, in an adolescent female patient, through the use of extraoral and fixed appliances. This case was presented to the Brazilian Board of Orthodontics and Dentofacial Orthopedics (BBO) as part of the requirements for obtaining the title of certified by the BBO.

Facial-profile attractiveness changes in adult patients treated with the Herbst appliance

AIM

The goal of this study was to compare facial profile attractiveness changes of adult patients treated with the Herbst appliance assessed by orthodontists and laypeople.

MATERIALS AND METHODS

The patient sample comprised 28 adult Herbst patients. Facial profile photographs of the patients were randomly divided into two evaluation sets (before T0, after treatment T1). Ten members of the Angle Society of Europe (orthodontists) and 10 dental students in their third semester (laymen) rated both sets of photographs using Visual Analog Scales (VAS) with an interval of 1 day between the ratings.

RESULTS

On average, both orthodontists and students found an improvement in facial profile attractiveness through Herbst appliance treatment (VAS T1-T0 = 0.3 ± 1.9 cm). However, the interindividual perception of profile attractiveness varied greatly in the two rater groups. For both time periods (T0, T1), lower VAS ratings were given by students than by orthodontists.

CONCLUSION

Herbst therapy in adult patients generally improves facial profile attractiveness. Students rated facial profiles more critically than orthodontists.

Finishing effectiveness of different archwires using SmartClip™ self-ligating brackets: a clinical study

OBJECTIVES

The aim of this clinical prospective trial was to evaluate finishing effectiveness of stainless steel (SS) archwires versus titanium molybdenum alloy (TMA) archwires using SmartClip™ self-ligating brackets.

SUBJECTS AND METHODS

Thirty-two patients were divided in two groups: a group of 21 (G1-SS) and a group of 12 (G2-TMA). The protocol consisted of two different finishing archwires coupled with self-ligating brackets: .019 × .025" SS archwires for G1-SS and .019 × .025" TMA archwires for G2-TMA. Lateral cephalometric radiographs obtained at the beginning (T1) and end (T2) of treatment were used to assess the changes in incisor inclination, and measurements of irregularity index (LII), interdental widths, arch length (AL) and arch depth (AD) were made on dental casts to investigate changes associated with crowding correction.

RESULTS

No significant differences from T1 to T2 were found for incisors proclination and AL changes. Statistically significant differences were found for LII (higher decrease in G1-SS), maxillary AD (higher increase in G1-SS) and three interdental maxillary widths (higher in G1-SS).

CONCLUSION

The statistically significant differences found were few and clinically negligible. Self-ligating brackets system coupled with .019 × .025" archwires showed good finishing effectiveness, but no clinically significant differences were found between SS and TMA.

Comparison of oral-health-related quality of life during treatment with headgear and functional appliances

BACKGROUND

Functional and headgear are two well-known approaches in the treatment of skeletal class II malocclusion in preadolescent children. Assessment of psycho-social impacts of wearing devices during the treatment period is central to enhancing the quality of healthcare services.

AIM

This study aimed to compare oral-health-related quality of life in two groups consisting of children wearing headgear or functional appliances. We also compared these groups with a non-malocclusion group.

DESIGN

The study population consisted of 187, 11- to 14-year-old children in three groups of functional (n = 67), headgear (n = 67) and non-malocclusion (n = 53). Children were asked to complete the translated version of the short form of the Child Perceptions Questionnaire. Total scores and subscale scores of the three clinical groups were compared through ANOVA.

RESULTS

There was no significant difference in mean total scale score and subscale scores between functional and headgear groups (P > 0.05). Significant differences were found in both mean total and subscale scores between the malocclusion and non-malocclusion groups (P < 0.001) except oral symptoms subscale (P > 0.05).

CONCLUSIONS

The results of this study reveal that functional and headgear appliances do not differ in terms of impact on daily life during the treatment. Moreover, both groups have poorer OHQoL compared to malocclusion group.

Effect of maxillary anteroposterior position on profile esthetics in headgear-treated patients

INTRODUCTION

Headgears have been used to treat Class II malocclusions for over a century. The purpose of this retrospective study was to investigate the profile esthetic changes resulting from headgear use in growing Class II patients with protrusive, normal, and retrusive maxillae.

METHODS

Profile silhouettes were created from pretreatment and posttreatment lateral cephalometric tracings of growing Class II patients treated with headgear followed by conventional fixed appliances. Ten patients had an initially protrusive maxilla (FH:NA, >92°), 10 had an initially normally positioned maxilla (FH:NA, 88°-92°), and 10 had an initially retrusive maxilla (FH:NA, <88°). A panel of 20 laypersons judged the profile esthetics of the randomly sorted silhouettes. Descriptive statistics, correlation analysis, and anlaysis of variance (ANOVA) with post-hoc Tukey-Kramer tests were used to ascertain differences between groups and the effects of treatment.

RESULTS

A significant moderate correlation was found between initial ANB magnitude and the improvement in profile esthetic score with treatment (r = 0.49, P <0.01). No significant correlations were found between the initial anteroposterior position of the maxilla (FH:NA) and the initial, final, or change in profile esthetic scores. There were average improvements with headgear treatment in profile esthetics for all groups.

CONCLUSIONS

In Class II growing patients with protrusive, normally positioned, or retrusive maxillae, headgear treatment used with fixed orthodontic appliances is effective in improving facial profile esthetics: the greater the initial ANB angle, the greater the profile esthetic improvement with treatment.

[Aesthetic repercussions of the class II treatment on the profile: comparative study Distal Activ Concept (DAC)/Extra-Oral Force (EOF)]

In the past orthodontists frequently used extra-oral force to slow down skeletal growth in their treatment of Class II malocclusions; more modern practice relies less on applying distal force to the maxilla than on stimulating forward growth of the mandible. Does this change in therapeutic design have any repercussions in facial esthetics? To evaluate the impact of treatment on the appearance of the profile, we conducted a study with 64 patients in the adolescent dentition stage with a Class II, division 1 malocclusions. None had teeth extracted or preliminary orthodontic treatment. We divided them into two sections; we treated the first group of 33 patients with the Distal Active Concept (DAC), which encourages forward movement and growth of the mandible, and we treated the second group of 31 patients with Extra-Oral Force (EOF) in combination with a full-banded appliance. Comparing the results with cephalometric profile analyses, we found that the soft tissue contour of the lower part of the face showed considerably more sagittal development in the children treated by DAC than those treated by EOF.