European Journal of Orthodontics 29 (2007) 283–293 © The Author 2007.

007. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjm018 All rights reserved. For permissions, please email: [email protected].

Stepwise advancement versus maximum jumping with headgear

activator
Mang Chek Wey*, Margareta Bendeus*, Li Peng**, Urban Hägg*, A. Bakr M. Rabie*
and Wayne Robinson*
*Orthodontics, University of Hong Kong, Hong Kong, SAR and **Private Practice, Houston, Texas

SUMMARY The aim of this study was to compare the effects of stepwise mandibular advancement
versus maximum jumping and extended treatment versus early retention. The material was obtained
prospectively and consisted of lateral cephalograms taken at the start (T0), after initial (T1), and at the end
(T2) of treatment, from two groups of consecutively treated skeletal Class II patients who had undergone
therapy with headgear activators. The first headgear activator group, HGA-S (n = 24; mean age 11.9 ±
1.2 years), was treated for 13 months and had 4-mm mandibular advancement every 3 months. The
second headgear activator group, HGA-M (n = 31; mean age 11.2 ± 1.5 years), had maximum jumping,
6–8 mm interincisal opening, for a total of 15.4 months, and with reduced wear for the last 6.9 months.
The dropout over 12 months was 41 and 46 per cent, respectively. Pre-treatment growth changes were
obtained as a reference. An independent t-test was used to determine differences in baseline dentofacial
morphology between the groups, a paired t-test for intra-group comparisons, and an independent t-test
to evaluate differences between the groups.
The results, in both groups, showed enhanced mandibular prognathism during the initial phase (T0–T1),
followed by normal growth (T1–T2), and lower face height enhancement throughout treatment (T0–T2).

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For both groups, the mandibular plane and occlusal angle increased, possibly enhanced by ‘extrusion’ of
the lower molars. For both groups, maxillary forward growth was restrained only during the initial phase,
but the effect remained significant at T2 for the HGA-S group. In the HGA-M group, the lower incisors
were protruded, while in the HGA-S group, they were unaffected. The findings indicate that both modes
of mandibular jumping resulted in skeletal and dental effects. The length of active treatment seemed to
be decisive in maintaining the treatment effects; stepwise advancement had less dental effects.

Introduction
combination with headgear have shown that mandibular
There has been growing interest in the subject of orthopaedic stepwise advancement tended to result in larger
correction of Class II malocclusions in recent years (Graber enhancement of mandibular prognathism than maximum
et al., 1997; Meikle, 2005). Some studies have demonstrated jumping (Ömblus et al., 1997; Du et al., 2002), whereas a
no significant effect, while others have shown enhanced study using a removable functional appliance without
mandibular growth with functional appliance treatment headgear was unable to demonstrate any significant
(Pancherz, 1979; Jakobsson and Paulin, 1990; Ghafari et al., difference between the mode of mandibular jumping
1998; Illing et al., 1998; Keeling et al., 1998; Tulloch (Banks et al., 2004).
et al., 1998, Ruf et al., 2001; Basciftci et al., 2003; It has been reported that after enhancement of mandibular
Haralabakis et al., 2003; O’Brien et al., 2003a; Phan et al., prognathism in a shorter active period with functional
2006). The addition of high-pull headgear to the functional appliances, mandibular prognathism became ‘subnormal’
appliance possibly combines restraint and redirection of during the immediate post-treatment period (Pancherz and
maxillary growth with potentially more forward positioning Hansen, 1986). However, others have found a return to
of the mandible (van Beek, 1982; Dermaut et al., normal mandibular forward growth rate during extended
1992; Wieslander, 1993; Ömblus et al., 1997; Altenburger treatment (Hägg et al., 2002). An experimental study has
and Ingervall, 1998; Bendeus et al., 2002; Hägg et al., demonstrated that the enhancement of mandibular growth
2003). was maintained where the active treatment time was not too
Recent experimental studies demonstrated that condylar short (Chayanupatkul et al., 2003).
growth was enhanced with mandibular advancement, and The aim of this study was to compare the treatment effects
significantly more so with stepwise advancement than with of stepwise advancement versus maximum jumping of
maximum jumping (Rabie et al., 2003a,b). Two clinical the mandible, and extended treatment time versus early
studies using fixed or removable functional appliances in retention.
284 M. C. WEY ET AL.

Subjects and methods mechanism (n = 5), poor compliance (n = 9), self-discontinuation

from treatment (n = 2), and poor attendance (n = 1).
The material consisted of the lateral cephalograms from
two separate groups of consecutively treated patients with a
Headgear activator with maximum jumping and early
skeletal Class II malocclusion, obtained at the start (T0),
retention (HGA-M) group
after the initial phase (T1), and at the end of treatment (T2).
Inclusion criteria were age 8–16 years, overjet ≥6 mm, The HGA-M, with extraoral high-pull traction, had a
ANB ≥4 degrees, molars at least half unit Class II bilaterally, construction bite edge-to-edge with 6–8 mm interincisal
and no previous orthodontic treatment. For both groups, opening and an extraoral force of approximately 500 g at
ethical approval was obtained from the Ethics Committee, each side (van Beek, 1982; Figure 1B). The amount of
Faculty of Dentistry, University of Hong Kong. The subjects mandibular advancement varied from 9 to 15 mm (average
had been treated by postgraduate students under the 12 mm). The patients were instructed to wear the appliance
supervision of two designated supervisors. The length 10–14 hours per day during active treatment (T0–T1) and
of the treatment was predetermined to approximately compliance was evaluated from the patients’ written reports.
12 months in both groups. During retention (T1–T2), the headgear was removed and
the appliance was worn at night only. Forty-three (75 per
Headgear activator with stepwise advancement and cent) of 57 subjects completed the first stage of treatment
extended treatment (HGA-S) group (T0–T1), while 31 (11F and 20M; 54 per cent; mean age =
11.2 ± 1.5 years) completed the retention phase (T1–T2)
The appliance consisted of a high-pull headgear combined
after a total of 15.4 months, and were subsequently included
with a modified activator using a screw to advance (by the
in this study (Table 1). The dropout (n = 26; 46 per cent)
operator) the mandible 4 mm every 3 months (Figure 1A).
was due to poor compliance in the first 2 months of treatment
All subjects had the mandible advanced 8 mm during the
(n = 12), respiratory problems (n = 6), poor compliance
initial phase (T0–T1). Thereafter, the amount of mandibular
(n = 7), and emigration (n = 1).

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advancement was dependent on the size of the remaining
overjet at T1. The majority of the patients had a third
advancement and two subjects had a fourth advancement. Untreated growth data
The average mandibular advancement was 12 mm. The Growth changes were obtained from lateral cephalograms
interincisal opening was 3–4 mm. Extraoral force of of the HGA-M group 6 months prior to treatment.
approximately 350 g each side was used. The patients were
instructed to wear the appliance, with the headgear, 10–14
Method of analysis
hours per day during the whole treatment period and
compliance was evaluated from a written report. Thirty-four All radiographs were manually traced twice by one examiner
(83 per cent) of the 41 subjects completed the first stage of (MCW) with an interval of at least 2 weeks before being
treatment (T0–T1). Twenty-four patients (6F and 18M; 59 digitized and measured by CASSOS software (CASSOS
per cent; mean age = 11.9 ± 1.2 years) completed the later 2001, City University, Hong Kong) using the analysis of
phase of treatment (T0–T2) after 13.0 months, and were Björk (1947) and Pancherz (1982a, b; Figure 2). Data from
included in the analysis (Table 1; Figure 2). The dropout the two tracings of the same radiographs were then averaged.
(n = 17; 41 per cent) was due to failure (resulting in no As the treatment periods differed significantly between the
advancement of the mandible) of the appliance screw groups, interpolation was undertaken on the results to

Table 1 Age, duration of treatment, and adjusted treatment intervals for headgear activator with stepwise advancement group (HGA-S;
n = 24) and headgear activator with maximum jumping group (HGA-M; n = 31) at the start of treatment (T0), after the initial (T1), and
late phase of treatment (T2).

T0/(T0–T1) T1/(T1–T2) T2/(T0–T2)

HGA-S HGA-M HGA-S HGA-M HGA-S HGA-M

Mean SD Mean SD Diff Mean SD Mean SD Diff Mean SD Mean SD Diff

Age 11.9 1.16 11.2 1.49 0.7 12.6 1.21 11.9 1.48 0.7 13.2 1.24 12.4 1.48 0.8*
Duration 7.2 2.08 8.6 1.70 1.3* 5.8 1.05 6.9 1.98 1.0* 13.0 2.57 15.4 2.64 2.4**
Adjusted duration 6.0 6.0 6.0 6.0 12.0 12.0

SD, standard deviation.

*P < 0.05, **P < 0.01.
STEPWISE ADVANCEMENT 285

paired t-tests. Differences between the first and second

measurements were insignificant.

Results
Comparison of dentofacial morphology
At T0, the HGA-S group had a statistically significantly
more severe Class II jaw base relationship and deeper
overbite, but at T2 there was no difference in dentofacial
morphology between the two groups (Table 2).
There were no statistically significant gender differences
for normal growth and treatment changes in either group,
except for lower permanent first molar extrusion, which
was greater in males in the HGA-S group at T2. Data for
both genders were therefore pooled for analysis.
‘Growth changes’ over 6 months were significant for
linear measurement of mandibular forward growth (OLp-
Pg), lower incisor, and upper molar eruption (Table 3).

Treatment changes and effects in the HGA-S group

At the end of treatment (T0–T2), the statistically significant
treatment effects in the HGA-S group were a reduction of

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overjet and overbite, restraint of maxillary forward growth,
increase of mandibular prognathism and lower face height,
improvement of jaw base and molar relationship, retrusion
and intrusion of upper incisors, and extrusion of lower
molars (Tables 3 and 4; Figures 3 and 4). The mandibular
plane angle increased, while the maxillary and mandibular
occlusal plane angles decreased and increased, respectively.
Figure 1 Schematic cross-section of (A) headgear activator appliance Most of these effects were pronounced in both the initial
with screw mechanism for stepwise advancement and (B) headgear (T0–T1) and the late (T1–T2) phases of treatment, except for
activator appliance with maximum jumping (van Beek, 1982).
mandibular prognathism and retrusion of the upper incisors.
There were no differences in treatment effects between either
treatment phase except for a greater improvement in overjet
represent exactly the same length of compared periods, i.e. and molar relationship in the initial treatment phase.
6 and 12 months, respectively (Table 1). Growth changes
obtained from the untreated growth data were deducted
Treatment changes and effects in the HGA-M group
from treatment changes to obtain the net treatment effects.
At the end of treatment (T0–T2), the statistically significant
Statistical analysis effects in the HGA-M group were a reduction of overjet and
overbite, increased mandibular prognathism (OLp-Pg) and
Statistical analysis was carried out using the Statistical
lower face height, improvement of jaw base and molar
Package for Social Science (SPSS Inc., Chicago, Illinois,
relationship, protrusion of lower incisors and molars, and
USA) software. An independent t-test was used to determine
eruption of lower molars (Tables 3 and 4; Figures 3 and 4).
differences in baseline dentofacial morphology between
The mandibular plane and occlusal plane angles increased.
both groups. A paired t-test was used for intra-group
There were statistically significant effects in the initial (T0–
comparisons and differences between groups were evaluated
T1) treatment phase for these variables, and also for restraint
by an independent t-test.
of maxillary forward growth, retrusion of upper incisors and
molars, and intrusion of upper incisors. There were statistically
Method error
significant effects in the retention phase (T1–T2) for increase
Two weeks after the first measurement, 10 sets of radiographs of lower face height, forward movement and eruption of
were selected at random and retraced twice, redigitized, and upper incisors and molars, and eruption of lower molars.
remeasured. The combined method errors for landmark Most variables improved during T0–T1, while from T1–T2
identification and measurement were tested using two-tailed some effects rebounded, but mostly normal growth returned.
286 M. C. WEY ET AL.

effects continued in the HGA-S group, while some treatment

effects rebounded in the HGA-M group. The skeletal
contribution to the reduction of overjet at T2 was 70 per
cent in the HGA-S group and 59 per cent in the HGA-M
group (Figure 3). There was no significant difference in
treatment changes between the two groups for maxillary
and mandibular prognathism, jaw base relationship, and
lower face height (Figure 4A–D). The upper incisors were
more retruded during T0–T1 in the HGA-M group, but
rebounded and became more protruded at T2 than in the
HGA-S group (Figure 4E). The lower incisors became
protruded but only in the HGA-M group (Figure 4F).

Discussion
This was a prospective study based on two separate groups
of consecutive skeletal Class II patients treated with a
headgear activator, with two different modes of mandibular
jumping. The sampling criteria used were similar but the
Figure 2 Overjet (mm): Is-OLp minus Ii-OLp; Maxillary prognathism:
dentofacial morphology of the groups differed at the start of
A-OLp (mm) linear position of the maxillary base, SNA (°) angular treatment (T0) for jaw base relationship and overbite, which
measurement of maxillary position; Mandibular prognathism: Pg-OLp was more severe in the HGA-S group (Table 3). However,
(mm) linear position of the mandibular base, SNB (°) angular measurement
of mandibular position; Jaw base relationship: A-Pg (mm) jaw base
these differences were probably not clinically relevant, and

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relationship, A-OLp minus Pg-OLp, ANB (°) sagittal jaw relationship; consequently do not affect the validity of this study. The
Upper incisor: Is-A (mm) change in the position of the maxillary central dentofacial morphology of the patients was generally in
incisor, Is-OLp minus A-OLp; Lower incisor: Ii-Pg (mm) change in the
position of the mandibular central incisor, Ii-OLp minus Pg-OLp; Molar
agreement with that of Caucasian samples treated with the
changes: Ms-A (mm) change in the position of the maxillary permanent HGA-M appliance (Dermaut et al., 1992; Altenburger and
first molar, Ms-OLp minus A-OLp; Mi-Pg (mm) change in the position of Ingervall, 1998; Bendeus et al., 2002), except that the
the mandibular permanent first molar, Ms-OLp minus A-OLp; Ms-Mi
(mm) molar relationship, Ms-OLp minus Mi-OLp; Overbite (mm):
protrusion of the upper and lower incisors was more
distance from Ii perpendicular to OLs, Ii-OLs; Face height: Me-MxPl pronounced in the present Chinese subjects, which is a
(mm) lower face height; Incisor changes: Is-MxPl (mm) vertical position documented ethnic difference, also in Class II subjects (Lau
of the maxillary incisor; Ii-MPl (mm) vertical position of the mandibular
central incisor, distance from Ii perpendicular to MnPL; Molar changes:
and Hägg, 1999).
Msc-MxPl (mm) vertical position of the maxillary permanent first molar, Interpolations were made to represent intervals of exactly
distance from Msc perpendicular to MxPl; Mic-MPl (mm) vertical position 6 and 12 months, which enables a direct comparison to be
of the mandibular permanent first molar, distance from Mic perpendicular
to MnPl; Rotational changes: SN/MnPl (°) mandibular plane angle; SN/
made between the two groups and age with the results of
MxPl (°) maxillary plane angle; Occlusal planes: OLs/NSL (°) maxillary previous studies on functional appliances (Ömblus et al.,
occlusal plane angle; OLi/NSL (°) mandibular occlusal plane angle. 1997; Bendeus et al., 2002; Du et al., 2002; Hägg et al.,
2002, 2003), and a general comparison to be made with
Comparison of the treatment effects between the other studies on the headgear activator, where the patients
HGA-S and HGA-M groups were treated on average for 9–11 months (Dermaut et al.,
1992; Altenburger and Ingervall, 1998).
There were some statistically significant differences in the The findings suggest that during the actual period neither
treatment effects after therapy (T0–T2) between the HGA-S growth rate nor treatment response differed between the
and HGA-M groups (Table 4). The HGA-S group showed a genders, which might indicate that the majority of the
more pronounced reduction in overbite, improvement of patients were pre-pubertal when treated (Pancherz and
jaw base (ANB) and molar relationship, upper incisor Hägg, 1985). Since the growth reference data were obtained
intrusion, and less lower incisor protrusion. The upper prior to treatment, the average basic growth rate measured
occlusal plane closed and the mandibular plane angle might differ slightly to that observed during the respective
increased more in the HGA-S group. During T0–T1, there treatment periods, but probably to a negligible extent, since
was a greater improvement in jaw base relationship (ANB), the observation periods were short. Growth data obtained
less upper incisor retrusion and lower incisor protrusion, prior to treatment of the HGA-M group showed growth in
and the upper occlusal plane closed in the HGA-S group. respect of mandibular prognathism and face height, which
During the later treatment phase in the HGA-S group and is consistent with that observed in controls in some previous
the retention phase in the HGA-M group (T1–T2), there studies on functional appliances (Nelson et al., 1993;
were statistically significant differences since treatment Wieslander, 1993; O’Brien et al., 2003a). However, it
Table 2 Comparison of dentofacial morphology at the start (T0), after 6 months (T1), and after 12 months (T2) of treatment between the headgear activator with stepwise advancement
group (HGA-S; n = 24) and the headgear activator with maximum jumping group (HGA-M; n = 31).

Variables T0 T1 T2

HGA-S HGA-M HGA-S HGA-M HGA-S HGA-M

STEPWISE ADVANCEMENT

Mean SD Mean SD Difference Mean SD Mean SD Difference Mean SD Mean SD Difference

Sagittal
Overjet (mm) 11.0 2.53 10.2 2.32 0.8 7.7 1.84 5.8 2.00 1.9*** 5.2 3.38 5.6 2.93 −0.4
Maxillary prognathism
A-Olp (mm) 77.9 3.91 75.5 4.75 2.4 77.6 4.09 75.4 4.85 2.2 77.8 4.81 76.2 4.78 1.6
SNA (°) 80.8 2.86 79.4 4.34 1.4 80.0 3.27 78.8 4.18 1.3 79.4 4.18 78.9 4.11 0.5
Mandibular prognathism
Pg-Olp (mm) 78.6 5.20 78.2 5.03 0.5 80.7 5.04 79.9 5.36 0.8 82.6 5.35 81.6 4.87 1.0
SNB (°) 75.0 2.81 74.8 3.58 0.2 75.7 3.01 75.2 3.68 0.6 76.1 2.98 75.7 3.43 0.3
Jaw base relationship
A-Pg (mm) −0.8 3.19 −2.7 1.67 1.9* −3.1 2.92 −4.5 3.18 1.4 −4.8 3.69 −5.4 3.53 0.6
ANB (°) 5.8 1.46 4.6 2.65 1.2* 4.3 1.72 3.6 2.80 0.7 3.3 2.48 3.2 3.05 0.1
Upper Incisor
Is-A (mm) 14.8 2.13 15.4 2.44 −0.6 14.0 2.13 13.7 2.83 0.3 13.3 2.32 14.5 2.82 −1.2
Lower Incisor
Ii-Pg (mm) 3.1 3.22 2.5 2.90 0.5 3.1 3.35 3.3 2.85 −0.2 3.3 3.31 3.5 2.78 −0.2
Molar changes
Maxillary molar (mm) −21.3 2.21 −20.3 2.73 −1.0 −21.6 2.49 −21.2 2.83 −0.4 −21.7 2.37 −20.3 3.02 −1.5
Mandibular molar (mm) −24.7 3.44 −25.3 2.29 0.6 −24.4 3.44 −24.6 2.32 0.2 −24.1 3.63 −24.6 2.47 0.5
Molar relationship (mm) 2.6 1.36 2.3 1.52 0.4 −0.3 1.40 −1.0 2.19 0.7 −2.5 3.36 −1.2 2.50 −1.3
Vertical
Overbite (mm) 5.1 1.52 4.0 1.27 1.0** 3.5 1.74 2.3 1.15 1.2** 2.3 1.63 2.4 1.33 −0.1
Me-MxPl (mm) 63.1 4.14 63.2 4.41 −0.1 65.2 4.10 65.2 4.61 0.1 67.4 4.40 66.7 5.17 0.7
Incisor changes
Is-MxPl (mm) 30.4 2.52 29.9 2.80 0.5 29.9 2.69 29.4 2.77 0.4 29.5 2.83 30.6 2.95 −1.1
Ii-MPl (mm) 44.0 3.34 43.5 3.15 0.5 44.4 3.60 43.6 3.06 0.8 45.1 3.74 44.2 3.18 0.9
Molar changes
Msc-MxPl (mm) 23.2 2.20 22.9 2.23 0.4 23.7 2.28 23.1 2.23 0.6 24.3 2.54 23.8 2.37 0.4
Mic-MPl (mm) 32.3 2.57 32.5 2.34 0.2 33.1 2.75 33.3 2.31 −0.2 34.1 3.01 34.2 2.68 −0.1
Rotational changes
SN/MnPl (°) 33.9 6.22 34.8 4.75 −0.9 34.1 6.53 34.8 4.88 −0.7 34.3 6.60 34.9 4.65 −0.6
SN/MxPl (°) 9.9 2.00 10.5 3.49 −0.6 10.1 2.47 10.7 3.39 −0.6 10.6 2.41 10.4 3.45 0.2
Occlusal planes
OLs/NSL (°) 22.0 4.46 22.6 4.20 −0.5 21.3 4.50 22.5 3.92 −1.2 20.7 5.30 22.5 4.17 −1.8
OLi/NSL (°) 10.6 5.23 12.4 5.58 −1.9 11.3 4.88 14.0 5.19 −2.6 12.2 5.42 14.8 5.35 −2.7

SD, standard deviation.

*P < 0.05; **P < 0.01; ***P < 0.0001.
287

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 288

Table 3 Dentofacial growth and treatment changes during the initial (T0–T1), late (T1–T2), and both phases combined (T0–T2) in the headgear activator with stepwise advancement
group (HGA-S; n = 24) and headgear activator with maximum jumping group (HGA-M; n = 31).

Variables Growth changes HGA-S HGA-M

6 months
T0–T1 T1–T2 T0–T2 T0–T1 T1–T2 T0–T2

Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Sagittal
Overjet (mm) −0.2 1.43 −3.3*** 1.82 −2.3*** 2.17 −5.8*** 3.65 −4.3*** 2.34 −0.3 1.54 −4.6*** 3.14
Maxillary prognathism
A-OLp (mm) 0.8 1.11 −0.3 0.97 0.3 1.72 −0.1 2.50 0.0 0.85 0.7*** 1.01 0.7*** 0.99
SNA (°) 0.2 1.03 −0.8*** 0.95 −0.6 1.46 −1.4** 2.30 −0.6*** 0.88 0.2 0.67 −0.4** 0.85
Mandibular prognathism
Pg-OLp (mm) 1.0* 1.27 2.1*** 1.20 1.9*** 2.28 3.9*** 2.37 1.8*** 1.55 1.6*** 1.75 3.4*** 2.05
SNB (°) 0.2 0.70 0.7*** 0.73 0.3** 0.83 1.0*** 1.00 0.4** 0.65 0.6*** 0.74 0.9*** 0.99
Jaw base relationship
A-Pg (mm) −0.3 1.45 −2.3*** 1.30 −1.6** 2.66 −4.0*** 2.88 −1.8*** 1.67 −0.9** 1.49 −2.7*** 1.96
ANB (°) 0.0 0.99 −1.5*** 0.85 −0.9* 1.81 −2.5*** 2.30 −1.0*** 1.00 −0.4** 0.85 −1.4*** 1.18
Upper Incisor
Is-A (mm) −0.1 1.30 −0.9*** 1.08 −0.6* 1.41 −1.5*** 1.64 −1.7*** 1.16 0.8*** 0.83 −0.9** 1.50
Lower Incisor
Ii-Pg (mm) −0.1 0.65 0.1 1.05 0.1 1.48 0.2 1.46 0.8*** 1.09 0.2 1.03 1.0*** 1.33
Molar changes
Maxillary molar (mm) 0.2 1.10 −0.2 1.03 −0.1 1.52 −0.4 1.53 −0.8*** 1.03 0.9*** 0.77 0.0 1.38
Mandibular molar (mm) 0.1 0.59 0.4* 0.76 0.2 0.79 0.7* 1.23 0.7*** 0.72 0.1 0.79 0.7*** 0.87
Molar relationship (mm) −0.1 0.95 −2.9*** 1.48 −2.0*** 2.27 −5.1*** 3.56 −3.3*** 1.72 −0.1 1.22 −3.4*** 2.09
Vertical
Overbite (mm) 0.3 0.88 −1.6*** 1.14 −1.1** 1.66 −2.8*** 1.81 −1.7*** 1.18 0.1 0.89 −1.6*** 1.30
Me-MxPl (mm) 0.5 1.03 2.1*** 1.17 2.2*** 1.96 4.3*** 2.05 2.1*** 0.98 1.5*** 0.95 3.5*** 1.34
Incisor changes
Is-MxPl (mm) 0.3 0.63 −0.6** 0.96 −0.3* 0.77 −0.9** 1.24 −0.5** 0.88 1.2*** 0.93 0.7*** 0.93
Ii-MPl (mm) 0.4* 0.49 0.4** 0.71 0.7** 1.00 1.0*** 1.27 0.1 0.64 0.6*** 0.69 0.7*** 0.83
Molar changes
Msc-MxPl (mm) 0.5* 0.49 0.4** 0.67 0.7** 1.13 1.0*** 1.10 0.2 0.66 0.8*** 0.57 1.0*** 0.71
Mic-MPl (mm) 0.4 0.54 0.8*** 0.71 1.0*** 0.71 1.8*** 1.03 0.8*** 0.49 0.9*** 0.80 1.7*** 0.84
Rotational changes
SN/MnPl (°) −0.3 0.68 0.2 0.84 0.1 1.49 0.4 1.60 0.0 0.81 0.1 0.97 0.1 1.00
SN/MxPl (°) 0.1 0.75 0.2 1.25 0.6* 1.08 0.7 1.40 0.2 0.77 −0.2 0.73 0.0 0.91
Occlusal planes
OLs/NSL (°) 0.2 1.11 −0.7* 1.28 −0.6 1.53 −1.3** 2.11 0.0 0.99 −0.1 1.06 −0.1 1.40
OLi/NSL (°) −0.6 1.39 0.8 2.04 0.7 2.57 1.6* 2.87 1.5*** 1.74 0.9* 2.22 2.4*** 2.60

SD, standard deviation.

*P < 0.05; **P < 0.01; ***P < 0.001.
M. C. WEY ET AL.

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Table 4 Dentofacial treatment effects during the (initial T0–T1, late T1–T2, and combined T0–T2 phases) in the headgear activator with stepwise advancement group (HGA-S;
n = 24) and headgear activator with maximum jumping group (HGA-M; n = 31).

Variables HGA-S HGA-M HGA-S versus HGA-M

T0–T1 T1–T2 T0–T1 T0–T2 T0–T1 T1–T2 T0–T1 T0–T2 T0–T1 T1–T2 T0–T2
versus versus
STEPWISE ADVANCEMENT

T1–T2 T1–T2

Mean SD Mean SD Difference Mean SD Mean SD Mean SD Difference Mean SD Mean Mean Mean

Sagittal
Overjet (mm) −3.1*** 1.63 −2.1*** 1.79 −1.0* −5.4*** 2.63 −4.1*** 3.10 −0.1 2.22 −4.1*** −4.2*** 4.86 1.0 −2.0*** −1.2
Maxillary prognathism
A-OLp (mm) −1.0*** 1.06 −0.5 1.41 −0.1 −1.6* 1.84 −0.8* 1.68 0.0 1.36 −0.8* −0.8 2.59 −0.2 −0.5 −0.8
SNA (°) −1.0*** 1.01 −0.8* 1.24 −0.2 −1.9** 1.69 −0.8** 1.55 −0.1 1.32 −0.7** −0.9 2.57 −0.2 −0.7* −1.0
Mandibular prognathism
Pg-OLp (mm) 1.1** 1.25 0.8 1.78 −0.3 1.9** 1.83 0.7* 1.94 0.6 2.46 0.1 1.4* 3.66 0.4 0.2 0.5
SNB (°) 0.5** 0.70 0.1 0.76 −0.4 0.7* 0.82 0.2 0.96 0.4 1.23 −0.2 0.5 1.67 0.3 −0.3 0.2
Jaw base relationship
A-Pg (mm) −2.1*** 1.39 −1.4* 2.06 −0.7 −3.5*** 2.19 −1.5** 2.47 −0.7 2.19 0.8 −2.2** 4.02 −0.6 −0.7 −1.3
ANB (°) −1.5*** 1.56 −0.9* 1.41 −0.6 −2.6*** 1.71 −1.0** 1.68 −0.4 1.33 0.5** −1.4** 2.69 −0.5* −0.5 −1.2*
A,B on OP (mm) −1.5*** 0.93 −0.6 2.02 −0.9 −2.3* 2.59 −1.4** 2.82 −0.6 2.72 0.8 −2.0* 4.96 −0.1 0.0 −0.3
Upper Incisor
Is-A (mm) −0.8* 1.21 −0.5 1.35 −0.3 −1.4* 1.46 −1.7*** 1.98 0.9** 1.51 2.6*** −0.7 3.20 0.9** −1.4*** −0.7
Lower Incisor
Ii-Pg (mm) 0.2 0.86 0.2 1.09 0.0 0.5 1.08 0.9*** 1.35 0.3 1.17 0.6* 1.3*** 1.90 −0.7** −0.1 −0.8*
Molar changes
Maxillary molar (mm) −0.5 1.07 −0.4 1.30 0.1 −0.9 1.30 −1.1** 1.68 0.6* 1.41 1.7*** −0.5 2.83 0.6* −1.0*** −0.4
Mandibular molar (mm) −0.3 0.68 0.2 0.68 −0.1 0.5 0.93 0.6** 1.00 0.0 0.87 −0.6* 0.5* 1.43 −0.3 0.2 0.0
Molar relationship (mm) −2.8*** 1.22 −1.9*** 1.66 0.9* −4.9*** 2.45 −3.2*** 2.04 0.0 1.80 3.2*** −3.2*** 3.27 0.3 −1.9*** −1.7*
Vertical
Overbite (mm) −1.9*** 1.00 −1.4*** 1.28 −0.5 −3.4*** 1.36 −2.0*** 1.74 −0.2 1.13 −1.8*** −2.2*** 2.46 0.1 −1.2** −1.2**
Me-MxPl (mm) 1.6*** 1.10 1.7*** 1.51 −0.1 3.3*** 1.56 1.6*** 1.56 1.0*** 1.34 0.6* 2.5*** 2.59 0.0 0.7 0.8
Incisor changes
Is-MxPl (mm) −0.9*** 0.76 −0.6** 0.69 −0.3 −1.6*** 0.95 −0.8*** 1.19 0.9*** 1.09 −1.7*** 0.1 1.70 −0.1 −1.5*** −1.7***
Ii-MPl (mm) 0.0 0.60 0.3 0.75 −0.3 0.3 0.91 −0.3 0.95 0.2 0.84 0.9* −0.1 1.45 0.3 0.1 0.4
Molar changes
Msc-MxPl (mm) 0.0 0.55 0.2 0.83 0.2 0.1 0.81 −0.2 0.84 0.3* 0.76 0.6** 0.1 1.23 0.2 −0.1 0.1
Mic-MPl (mm) 0.4* 0.61 0.7*** 0.62 0.3 1.1*** 0.79 0.4** 0.75 0.5** 1.02 0.1 1.0** 1.49 0.0 0.2 0.2
Rotational changes
SN/MnPl (°) 0.5* 0.76 0.5 1.11 0.0 1.0* 1.20 0.3 1.07 0.4 1.29 −0.1 0.7* 1.88 0.2 0.1 0.3
SN/MxPl (°) 0.0 0.96 0.4 0.91 −0.4 0.4 1.06 0.1 1.25 −0.4 1.13 0.5* −0.3 2.04 −0.1 0.8** 0.7*
Occlusal planes
OLs/NSL (°) −0.9** 1.16 −0.8* 1.31 −0.1 −1.7** 1.62 −0.2 1.61 −0.3 1.62 −0.1 −0.5 2.86 −0.7* −0.5 −1.2**
OLi/NSL (°) 1.3** 1.65 1.3* 1.99 0.0 2.7*** 2.16 2.1*** 2.58 1.5* 3.06 0.6 3.6*** 4.74 −0.8 −0.2 −0.9

SD, standard deviation.

*P < 0.05; **P < 0.01; ***P < 0.001.
289

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290 M. C. WEY ET AL.

Figure 3 Maxillary and mandibular skeletal and dental treatment changes contributing to overjet correction (Pancherz, 1982a) for the total treatment
period (T0–T2). *P < 0.05, **P < 0.01, and ***P < 0.001.

should be noted that in other studies the controls showed and submitted written reports throughout the study, but still
practically no mandibular growth (Ömblus et al., 1997; it has to be borne in mind that orthodontic patients have been
Illing et al., 1998). stated to over report compliance (Brandão et al., 2006).
Metric cephalometric measurements are demonstrably The treatment effect on overjet was statistically significant
more accurate (Bookstein, 1997), but angular measurements with both devices after both 6 (T1) and 12 (T2) months of
are more commonly reported in the orthodontic literature, treatment (Table 4), which is consistent with previous

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and have therefore been included. studies of the HGA-M appliance (Dermaut et al., 1992;
In any functional appliance treatment, whether with fixed Altenburger and Ingervall, 1998; Bendeus et al., 2002).
or removable devices, there is a dropout rate. The dropout However, the overjet continued to decrease in the late phase
figure sometimes represents only patients who have left the in the HGA-S group only, and at the end of treatment (T2)
study (Tulloch et al., 1998) but it often includes, as in the there was no difference between the two groups (Figure
present research, non-compliant patients (Ömblus et al., 4G). Restraint on maxillary forward growth was found with
1997; Ghafari et al., 1998; Bendeus et al., 2002; O’Brien both devices after 6 months (T1) and while this disappeared,
et al., 2003a,b). The dropout rate in the initial treatment after 6 months of retention (T2) in the HGA-M group, it
phase of this study (T0–T1) was 17 per cent in the HGA-S became more pronounced in the HGA-S group after
group and 25 per cent in the HGA-M group. These figures extended treatment. In one study, there was no restraint of
are comparable with other investigations with similar maxillary growth after 6 months of treatment, whereas after
observation periods (Ömblus et al., 1997; Illing et al., 1998; a further 6 months of treatment there was an effect (Bendeus
Bendeus et al., 2002; Banks et al., 2004). However, the et al., 2002) similar to that reported after 9–11 months of
dropout rate at the end of the present study (T2) was over 40 treatment (Dermaut et al., 1992; Altenburger and Ingervall,
per cent in both samples. This was towards the higher end of 1998). In the present study, mandibular growth was
that reported in other studies on removable functional accelerated with both devices after 6 and 12 months of
appliances, which varied from 6 to 40 per cent (Nelson treatment, which is in agreement with all but one of the
et al., 1993; Ömblus et al., 1997; Altenburger and Ingervall, other studies, which indicated that mandibular growth was
1998; Illing et al., 1998; Keeling et al., 1998; Bendeus unaffected (Bendeus et al., 2002). However, the enhancement
et al., 2002). Dropout usually increases with time, but the of mandibular prognathism reached a statistically significant
age of the sample seems to be an important factor, as level only during T0–T1 similar to that reported for the
observed from a comparison between two recent studies on Herbst appliance (Hägg et al., 2002). The upper incisors
the Twin Block (TB; O’Brien et al., 2003a,b). In that were retruded with both devices during T0–T1, but relapsed
investigation, the younger sample had a dropout rate of 18 during T1–T2 in the HGA-M group. This was similar to the
per cent, whereas 3-year-old subjects had a dropout rate pattern observed by Bendeus et al. (2002) that there was no
almost twice as large. In the later study, it was also reported lasting effect after 12 months of treatment with HGA-M. At
that the dropout rate of patients treated with the fixed T2, the upper incisors were retruded in the HGA-S group,
functional Herbst appliance was approximately half that of which is in agreement with the observations made after 9
those treated with the TB appliance. There might be fewer and 11 months with the HGA-M appliance in two previous
dropouts in a patient sample treated by a single, ‘committed’, studies (Dermaut et al., 1992; Altenburger and Ingervall,
clinician than in a one treated by a larger number of clinicians. 1998). The mandibular incisors became protruded with the
The patients analysed in this study were definitely compliant HGA-M appliance in this study at T1 and T2, but no such
STEPWISE ADVANCEMENT 291

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Figure 4 Cumulative changes of (A) mandible, (B) maxilla, (C) jaw base, (D) lower face height, (E) maxillary incisors, (F) mandibular incisors, (G)
overjet, and (H) overbite. Growth changes 6 months and treatment changes 0–6 months (T0–T1) and 6–12 months (T1–T2) with the headgear activator
with stepwise advancement group (HGA-S; n = 24) and headgear activator with maximum jumping group (HGA-M; n = 31). *P < 0.05, **P < 0.01, and
***P < 0.001.
292 M. C. WEY ET AL.

effect was observed in the HGA-S group or with HGA-M in It has been claimed, from a survey of clinical studies, that
previous studies (Dermaut et al., 1992; Altenburger and increased mandibular growth during active treatment will be
Ingervall, 1998; Bendeus et al., 2002). This difference in followed by a period of subnormal growth, and that this
effect on the lower incisors might depend on the degree of ‘enhancement effect’ is merely temporary (Pancherz and
labial lower incisor capping rather than stepwise Michailidou, 2004). In many studies on functional
advancement. The skeletal changes contributing to the appliances, the active treatment period was comparatively
overjet reduction was larger with the HGA-S than the HGA- short, e.g. 5–7 months (Pancherz, 1979; Pancherz and
M, being 70 and 59 per cent, respectively, after treatment Hansen, 1986; Wieslander, 1993; Ömblus et al., 1997; Wong
(Figure 3). et al., 1997), i.e. a potentially unfavourable growth pattern
There was an increase of lower face height during both the was affected for a brief period but then returned to its original
initial and the late phases with both devices in this study, pattern (Pancherz and Fackel, 1990). In the present study,
whereas two previous reports found no effect on lower face the HGA-M treatment lasted for 8.6 months (T0–T1), and
height with high-pull headgear (Dermaut et al., 1992; Bendeus was followed by retention (T1–T2) using the same device at
et al., 2002). The increase in lower face height may be partly night only and without the headgear for nearly 6 months.
due to the lower molars having been extruded during treatment During the retention period, there were no further significant
with both devices and in both treatment phases, whereas in positive effects, and the skeletal changes did not differ from
one previous study (Bendeus et al., 2002) they were unaffected. those of normal growth, but relapse of dental effects and
The extrusion of the lower molars in the HGA-S group could increase in lower face height continued. With continued
be explained by the fact that this two-piece device did not treatment with the HGA-S, the effects achieved during the
prevent eruption, while in HGA-M group, there was no initial phase of treatment were maintained, and some further
occlusal stop at the lower first molars. The maxillary occlusal improvement occurred, which is in agreement with previous
plane angle closed in the HGA-S group only, due to continuous studies of extended treatment with the HGA-M and Herbst
intrusion of the upper incisors, but in the HGA-M group there appliance, respectively (Bendeus et al., 2002; Hägg et al.,

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was no net effect on intrusion of the upper incisor and no 2002). It has also been demonstrated that early removal of a
lasting effect on the maxillary occlusal plane. In both groups, functional appliance does not allow the new condylar bone
the mandibular occlusal plane angle increased due to extrusion to mature, and subsequently the treatment gain in bone is not
of the lower molars, whereas there was no significant effect fully maintained, whereas prolonged use of the functional
on the lower incisors in the vertical plane. Stepwise versus appliance results in permanent gain of the newly formed
maximum jumping of the mandible produced no significantly condylar bone (Chayanupatkul et al., 2003). Consequently,
different skeletal effect on mandibular prognathism compared the length of active treatment seems to be a crucial factor in
with maximum jumping. achieving more pronounced and lasting effects.
There were fewer dental effects in the HGA-S group,
which might be a reflection of the lower force transmitted to Conclusions
the dentition when the mandible was gradually advanced by
The findings indicate that stepwise mandibular advancement
8 mm (2 × 4 mm) over the first 6 months, compared with an
does not affect mandibular prognathism differently from
average jumping of the mandible of 12 mm in the HGA-M
maximum mandibular jumping. With both modes of
group at the start of treatment. A comparison of two groups
mandibular jumping, there is enhanced mandibular growth in
treated with the TB for 7 months (Banks et al., 2004) found
the initial phase only, and the effect is maintained in the late
no difference in sagittal maxillary and mandibular treatment
phase, indicating that extended treatment is of importance.
changes between stepwise advancement and maximum
There was a significant increase in lower face height with both
jumping of the mandible. This was in general agreement
devices but neither device prevented extrusion of the lower
with the findings of Illing et al. (1998) who compared the
molars. With stepwise advancement, the dental effects were
effects of stepwise versus maximum jumping using Bass
less pronounced, and there was no protrusion of the lower
versus Bionator and TB. A tendency to a greater increase in
incisors. The length of active treatment tended to be decisive
mandibular prognathism was observed with gradual
in maintaining and further enhancing the treatment effects.
advancement (3 × 2 mm) of the mandible with the Bass
appliance compared with maximum jumping with the Herbst
Address for correspondence
appliance after 6 months of treatment (Ömblus et al., 1997)
and with stepwise advancement (3 × 2 mm) with the Herbst Professor Urban Hägg
appliance (Hägg et al., 2002). In an experimental study, it Faculty of Dentistry
has been demonstrated that stepwise advancement of the The University of Hong Kong
mandible resulted in significantly more condylar bone 2/F Prince Philip Dental Hospital
formation (2 + 1.5 mm) than a similar amount of single 34 Hospital Road
advancement (3.5 mm), even though fixed appliances were Hong Kong SAR
used in both cases (Rabie et al., 2003b). E-mail:[email protected]
STEPWISE ADVANCEMENT 293

Acknowledgements Lau J W, Hägg U 1999 Cephalometric morphology of Chinese with Class

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European Journal of Orthodontics 27: 105–114
secretarial work.
Nelson C, Harkness M, Herbison P 1993 Mandibular changes during
functional appliance treatment. American Journal of Orthodontics and
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