Title	Effectiveness of a Fixed Functional Appliance When Compared to Headgear in Treating Class II Malocclusion
Clinical Question	For children with a class II malocclusion, is treatment with a fixed functional appliance more effective than headgear?
Clinical Bottom Line	Fixed functional appliances and headgear are successful in correcting Class II malocclusions in children. However, each appliance produces different skeletal and dento-alveolar effects. The components of the malocclusion, growth potential and compliance are some factors that would determine the choice of one over the other.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 19524823 Baccetti/2009 Bonded Herbst with fixed appliance (28 Female: 14/Male: 14 with a mean age of 13.0 years old) and Headgear with fixed appliances and Class II elastics (28 Female: 14/Male: 14 with a mean age of 13.0 years old) and a Control group of untreated malocclusions (28 Female: 14/Male: 14 with a mean age of 12.9 years old) selected from the University of Michigan Growth Study. The participants were chosen at their peak velocity in their craniofacial growth as assessed by the cervical vertebral maturation. Double blind controlled clinical trial Key results There was a 92.8% success rate in both treatment groups and both groups showed an increase in the mandibular length compared to the Class II control group. The bonded Herbst with fixed appliances (BH+FA) group had a significant increase in mandibular protrusion. Two pretreatment variables were significant (P <0.01) in predicting the post-treatment amount of mandibular soft-tissue improvement in the BH + FA group: a small Co-Go-Me angle and mandibular retrusion (pogonion to nasion perpendicular). The Headgear with fixed appliances (HG+FA) group showed more pronounced dentoalveolar changes (retrusion of maxillary incisors and mesial movement of mandibular molars). 17418708 Siqueria/2007 Cervical headgear (25 Female: 12/Male: 13 with a mean age of 12.40 years old) and Mandibular protraction appliance (25 Female: 12/Male: 13 with a mean age of 12.30 years old). All participants then followed with fixed appliances. The primary selection criteria for both groups was a Class II Division 1 malocclusion with at least an end-to-end bilateral Class II molar relationship, all maxillary and mandibular teeth up to the second molars, a convex facial profile, and increased overjet. Controlled Clinical Trial Key results Both appliances produced satisfactory results by reducing facial convexity and correcting the Class II malocclusion. The cervical headgear (CHG) group showed greater restriction of anterior displacement of the maxilla, improved skeletal class II relationship, decrease in facial convexity, extrusion and distalization of the maxillary first molars and extrusion of mandibular incisors. The mandibular protraction appliance (MPA) group showed a marked increase in maxillary length, mandibular protrusion, maxillary incisor retrusion, mesial displacement of mandibular first molars, and protrusion of the lower lip. In conclusion, the CHG corrected the Class II malocclusion primarily through greater restriction of the anterior displacement of the maxilla and distalization of the maxillary molars, whereas the MPA corrected the malocclusion through mesial displacement of the mandibular first molars, with consequent protrusion of the lower lip.
Evidence Search	(headgear[All Fields] AND fixed[All Fields] AND appliance[All Fields] AND class[All Fields] AND ii[All Fields] AND ("malocclusion"[MeSH Terms] OR "malocclusion"[All Fields])) AND ("2004/02/28"[PDat] : "2014/02/24"[PDat])
Comments on The Evidence	Both articles have adequate subject selection matched by age and malocclusion. The first article also compares treatment results with a matched control group of untreated subjects with Class II malocclusion. Lateral cephalograms before and after were analyzed and the results appropriately evaluated. The first article is a double-blind controlled clinical trial while the second one was not double-blinded. The authors of the first study allege that BH+FA had a beneficial effect on chin advancement; however, no attempt appears to have been made to ensure that the condyles were completed seated in the fossa during this evaluation.
Applicability	Class II malocclusions have several different etiologies, and phenotype manifestations thus warranting different treatment approaches. There is enough evidence to support the use of either appliance during the correction of a Class II malocclusion in a single-phase treatment. The choice of appliance should be based on the skeletal and dental components of the malocclusion, growth potential and patient’s compliance.
Specialty	(Orthodontics) (Pediatric Dentistry)
Keywords	Fixed functional appliances, Herbst appliances, Mandibular protraction appliance, class II malocclusion, Headgear, Cervical headgear, Headgear activator, orthodontics, pediatric dentistry
ID#	2688
Date of submission	04/03/2014
E-mail	surik@livemail.uthscsa.edu
Author	Komal Suri
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Maria Cervantes Mendez, DDS
Faculty mentor e-mail	CervantesMen@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available