ORIGINAL ARTICLE Evaluation of the vertical holding appliance in treatment of high-angle patients

Marc DeBerardinis, DMD, MS,a Tony Stretesky, DDS,b Pramod Sinha, DDS, BDS, MS,c and Ram S. Nanda, DDS, MS, PhDd Oklahoma City, Okla Controlling the vertical dimension of high-angle patients without the benefit of compliance can be a challenging aspect of orthodontic treatment. This retrospective study examines the skeletal and dental effects of a modified transpalatal bar, dubbed the vertical holding appliance (VHA), which was used in an attempt to control the vertical dimension of high-angle patients. Two cephalometrically similar groups of high-angle patients (16 patients each) were compared to determine advantages from using the VHA. Group I (n = 16, pretreatment age 13.4 1.6 years) was treated with 4 premolar extractions in conjunction with the VHA cemented in place for 17.4 6.1 months. Group II (n = 16, pretreatment age 13.4 1.9 years), which was matched for age and pretreatment skeletal pattern, was treated with the Tweed technique and 4 premolar extractions. Lateral cephalometric radiographs were taken before the placement of the VHA, as well as at the end of treatment. The results showed that although y-axis increased significantly in group II (P < .05), it remained the same in group I. Within group I, the Frankfort mandibular plane angle and gonion gnathion/sella nasion angle decreased, whereas both of these values increased in group II. However, these changes were statistically insignificant. Lower anterior face height increased more in group II than in group I (P < .05). The percentage of lower anterior face height to total anterior face height decreased in group I, whereas it increased in group II. The difference between the 2 groups was determined to be significant (P < .01). Eruption of the maxillary first molar within group I was less than in group II. No significant differences were found between groups I and II for changes in overbite. (Am J Orthod Dentofacial Orthop 2000;117:700-5)

ertical dysplasia presents a unique problem for the orthodontist to diagnose as well as to treat effectively. Nanda1 found that the vertical pattern of development was established before the eruption of the permanent first molar and long before the adolescent growth spurt. Anterior vertical dimension is a key feature that is related to existing vertical growth patterns. Subjects with increased lower anterior face height (LAFH) constitute a group of clinically challenging patients in the treatment of malocclusions. Patients exhibiting an increased lower anterior vertical dimension usually have a mandible, which, for a variety of reasons, tends to rotate downward and backward during growth. The increased LAFH may be due to an increase in alveolar growth, dental extrusion, lack of ramus growth, or deficient vertical condylar growth.
From The University of Oklahoma, College of Dentistry, Department of Orthodontics. aFormer Graduate Student. bClinical Professor, Department of Orthodontics. cAssistant Professor, Department of Orthodontics. dProfessor and Chair, Department of Orthodontics. Reprint requests to: Ram S. Nanda, DDS, Ms, PhD, The University of Oklahoma, College of Dentistry, Department of Orthodontics, 1001 Stanton L. Young Blvd, Oklahoma City, OK 73190. Copyright 2000 by the American Association of Orthodontists. 0889-5406/2000/$12.00 + 0 8/1/105128 doi.10.1067/mod.2000.105128

Hereditary and environmental factors may also play a role in these types of vertical dysplasias. Regardless of the etiology of the increased anterior face height, the orthodontist is faced with the challenge of treating the whole face as well as the malocclusion. Patients with this type of vertical growth pattern may be more susceptible to dental extrusion and further bite opening during orthodontic mechanotherapy. Therefore, it would be beneficial to the clinician to have a method that caused restriction of further vertical growth or even intrusion of the posterior teeth, in an attempt to reduce LAFH and allow the mandible to rotate forward. Wilson2 reported on the clinical advantage of using a modified transpalatal arch dubbed as the vertical holding appliance (VHA) on a sample of 58 patients. She determined that the use of the VHA was beneficial in restraining the vertical development of maxillary molars. These results need verification because her sample included the use of conjunctive corrective procedures, and she did not have a control group for comparison of the reported benefits of VHA. This study examined the skeletal and dental effects of the VHA, which is essentially a transpalatal arch with an acrylic pad. The VHA uses tongue pressure to reduce the vertical dentoalveolar development of maxillary permanent first molars.

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The criteria for selection targeted those patients representing the typical high-angle, long-faced orthodontic patients. The control sample for comparison was treated with contemporary Tweed mechanics. The Tweed mechanics are designed with special emphasis in controlling the increase in LAFH and posterior rotation of the mandible. The technique uses high-pull headgear with second order arch wire mechanics.
MATERIAL AND METHODS

For this retrospective study, a sample of 32 patient records (22 female and 10 male) was selected. The sample was grouped as follows: Group I: VHA patients with 4 premolar extractions (n = 16; pretreatment age, 13.4 1.6 years; 5 male and 11 female patients) Group II: Patients with 4 premolar extractions who were treated with the contemporary Tweed technique, without the use of the VHA (n = 16; pretreatment age, 13.4 1.9 years; 5 male and 11 female patients) The patients in the 2 treatment groups were selected on the basis of their having a vertical skeletal or dentoalveolar problem. Acceptance into the sample was allowed if the patient met at least one of the following criteria: High Frankfort mandibular plane angle (FMA) (the patient must have an FMA of at least 30) High gonion gnathion/sella nasion (GoGn/SN) angle (the patient must have an angle of at least 40) Lack of overbite In addition, groups I and II were matched for age, extraction sequence, and pretreatment skeletal pattern. The VHA was cemented in place in group I for 17.4 6.1 months. All patients in groups I were treated with 0.018-in pretorqued, preangulated, edgewise appliances in both arches. Group II was treated with 0.022in standard edgewise brackets with the contemporary Tweed technique, which includes the use of a high-pull J-hook headgear connected to hooks on the maxillary arch wire distal to the maxillary central incisors. Pretreatment lateral cephalometric radiographs were taken before the placement of the VHA. Every patient also had a follow-up posttreatment radiograph. With the use of the Dentofacial Planner software program, the following cephalometric variables were used to evaluate skeletal and dental treatment changes: Skeletal 1. FMAThe angle formed by the mandibular plane (MP) and the Frankfort horizontal plane. 2. Y-axisThe angle formed by points sella-Gn and the Frankfort horizontal plane.

Fig 1. Palatal view of VHA cemented in place clinically.

3. SN-GoGnThe angle formed by the SN and GoGn. 4. LAFH 5. %LAFHPercent LAFH. Dental (mm) 1. OverbiteThe computer provided the precise measurement of lack of or the extent of incisor overlap. Lack of overlap (ie, open bite) was indicated by a negative sign, and positive overlap was indicated with a positive sign. 2. 6/to palatal planeMaxillary permanent first molar centroid perpendicular to palatal plane. 3. /6 to MPMandibular permanent first molar centroid perpendicular to the MP.
Design of the Vertical Holding Appliance

The VHA was fabricated with banded maxillary permanent first molars connected with a 0.040-in chrome cobalt wire with a dime-size acrylic button at the sagittal and vertical level of the gingival margin of the molar bands. Four helices were incorporated into the wire configuration for flexibility. The appliance was cemented in place (Fig 1).
Statistical Evaluation

The means of several key cephalometric skeletal measurements were statistically tested for group differences to determine if the 2 groups were matched for their craniofacial pattern. None of the differences among these measurements were found to be statistically significant at P < .05. Therefore, the groups were directly compared by using an unpaired t test to evaluate the effects of the VHA. All intragroup treatment changes were reevaluated with paired t tests.
RESULTS

Table I shows the changes in measurements within group I. It was noted that LAFH increased 1.53 mm

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Table I. Changes

in skeletal and dental measurements from cephalometric radiographs of group I patients treated
Pretreatment Posttreatment Mean SD Treatment change Mean P value

with the VHA

Variable Angular () SNA SNB ANB FMA OM angle Y-axis SN-palatal plane SN-GoGn Linear and ratio (mm or %) LAFH TAFH %LAFH %LPFH SN-palatal plane 6/to palatal plane Pog-NB

Mean

SD

78.87 74.23 4.64 30.39 76.21 62.25 8.24 42.19 72.89 123.1 59.17 57.47 48.58 20.07 1.11

2.69 2.68 1.63 4.03 7.09 2.28 3.27 4.16 5.36 6.53 1.84 2.48 2.51 2.86 1.04

77.48 74.31 3.18 30 74.68 62.27 8.98 41.61 74.43 126.94 58.58 58.89 49.83 20.89 2.03

3.36 2.85 2.06 3.94 6.39 2.2 3.7 4.64 6.05 7.65 2.19 2.44 3.17 2.76 1.29

1.39 0.09 1.47 0.39 1.53 0.02 0.74 0.58 1.53 3.84 0.59 1.43 1.26 0.82 0.93

.0003* .6708 .0001 .4374 .4665 .9582 .0528 .2773 .0343 .0002 .0749 .0041* .0008 .0649 .0006

*Significant difference: < .01 (N = 16). Significant difference: < .001 (N = 16). Significant difference: < .05 (N = 16). Significant difference: < .001 (N = 16).

in length (P < .05), and its percentage actually decreased by 0.59%. There were no significant changes in FMA, GoGn-SN, and y-axis measurements. It was also noted that the mandibular first molar erupted by 2.91 mm (P < .0001). Table II shows the mean vertical changes within group II. It was noted that LAFH increased by 3.39 mm (P < .0001), and its percentage of total anterior face height increased by 0.47% (P < .05). The FMA and GoGn-SN values remained the same; however, the yaxis increased significantly by 0.79 (P < .05). Overbite decreased by 1.49 mm (P < .05), and the 1.23-mm eruption of the maxillary first molar was found to be significant (P < .01). The mandibular first molar also erupted 2.68 mm (P < .0001). Table III shows the comparison of groups I and II. The unpaired t test revealed that the only significant vertical differences between these 2 groups involved LAFH. The mean LAFH increase in the VHA extraction group was significantly less than the increase in group II (P < .05). Similarly, the percentage of LAFH, which decreased by 0.59% in the VHA group, increased by 0.47% in group II (P < .01).
DISCUSSION

Preventing backward rotation of the mandible, anterior bite opening, and a subsequent increase of LAFH by limiting the amount of maxillary molar

extrusion is essential during orthodontic treatment of a patient with a high-angle growth pattern. It has been hypothesized that because of their weaker musculature, these types of patients are typically at an increased risk for biomechanically induced molar extrusion, which is a component of nearly all orthodontic mechanics.2 Several techniques to control vertical dimension have been advocated. One such technique that has been shown to be successful is the high-pull facebow headgear.3-6 However, the patient compliance needed for successful treatment has been a problem. In the search for noncompliant treatment modalities to combat this problem, it has been suggested that the transpalatal arch may play a role in preventing vertical descent of maxillary molars.7 Wise et al8 studied the effects of a normal transpalatal arch on vertical control of the maxillary first molar. They found that it restricted eruption of the molar by 0.20 mm per year (0.80-mm vs 1.00-mm eruption) compared with a matched control group. None of the patients underwent extraction, and the TPA was in place for a minimum of 5 months. Wise et al8 have shown a slight inhibition of normal eruption of the maxillary first molar with a conventional TPA and speculated that a TPA left significantly off the palate with an acrylic button may prove to be more effective in controlling upper molar eruption.

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Table II. Changes

in skeletal and dental measurements from cephalometric radiographs of group II patients treated with the Tweed technique
Pretreatment Variable Angular () SNA SNB ANB FMA OM angle Y-axis SN-palatal plane SN-GoGn Linear and ratio (mm or %) LAFH TAFH %LAFH %LPFH SN-palatal plane 6/to palatal plane Pog-NB Mean SD Posttreatment Mean SD Treatment change Mean P value

78.44 73.4 5.07 32.76 72.1 61.51 10.04 44.11 73.66 125.89 58.51 57.27 49.76 19.99 0.17

4.74 4.11 1.68 2.54 8.15 2.2 6.36 4.81 5.51 6.23 3.29 3.75 2.68 2.11 1.24

77.69 72.81 4.86 33.31 71.51 62.3 10.46 44.15 77.05 130.69 58.98 58.01 50.88 21.21 1.51

4.74 4.44 2.22 2.92 10.9 2.62 6.14 4.81 5.58 6.77 3.09 3.93 2.85 2.48 1.68

0.76 0.59 0.21 0.55 0.59 0.79 0.43 0.04 3.39 4.81 0.47 0.74 1.12 1.23 1.34

.0092 .0283 .5125 .1085 .863 .0108 .3023 .9159 .0001 .0001 .0291 .2921 .0005 .0027* .0001

*Significant difference: < .01 (N = 16). Significant difference: < .05 (N = 16). Significant difference: < .0001 (N = 16). Significant difference: < .01 (N = 16).

In pursuit of this, the present study examines the effectiveness of such an appliance. The aim was to see if tongue pressure on the appliance was capable of impeding the normal descent of the maxillary molar throughout orthodontic treatment. When conducting a retrospective clinical study, it is difficult to obtain a large sample that is well balanced. The 2 groups of 16 patients within the sample were matched for age, sex, extraction treatment, and skeletal pattern. For purposes of comparison of outcome of treatment, it was thought that evaluation of the present sample would be helpful in assessing the clinical benefits of using this appliance.
Effects on the Skeletal Bases

Group I showed a mean decrease in FMA and GoGn-SN of 0.39 and 0.58, respectively, and group II showed a mean increase of 0.55 and 0.04 for the same measurements. However, these changes were not statistically significant. The y-axis increased significantly within group II (P < .05). Although no statistically significant differences in FMA, GoGn/SN, and yaxis could be found between groups I and II, clinical significance may be seen from the data, which show that in group I, the mandible did not rotate downward and backward as it did in group II. Perhaps the most interesting finding in this study is the different amount of change in LAFH between

groups I and II. This is a key feature of the long face syndrome and is one of the difficult skeletal features to control in high-angle patients who are prone to backward mandibular rotation and linear increases in this dimension.1 When we compared groups I and II, a significant difference (P < .05) was noted in the increase of LAFH. The VHA extraction group increased 1.53 mm (P < .05), and the Tweed treatment extraction group increased 3.39 mm ( P < .0001). It appeared that the VHA was able to limit the increase in the LAFH. The percentage of LAFH to total anterior face height decreased in group I by 0.59%. However, this value increased in group II by 0.47%. Although these changes may seem small, their opposite vectors of change were large enough to show a significant difference between the 2 values (P < .01). This further supports the VHAs ability to control LAFH.
Effects on the Dentition

Vertical effects on the posterior teeth. Vertical effects on the posterior dentition were measured by the amount of eruption of the maxillary first permanent molar relative to the palatal plane. Within group I, the molar erupted 0.82 mm, and within group II, it erupted 1.23 mm. Whereas the pretreatment to posttreatment change in molar eruption was not statistically significant in group I, the eruption of the molar

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Table III. Group

1 VHA versus group II Tweed 2 sample t test results for mean treatment change
Group I treatment change Group II treatment change Mean SD Two sample t test P value

Variable Angular () SNA SNB ANB FMA OM angle Y-axis SN-palatal plane SN-GoGn Linear and ratio (mm or %) LAFH TAFH %LAFH %LPFH SN-palatal plane 6/to palatal plane Pog-NB *Significant difference: < .05 (N = 16). Significant difference: < .01 (N = 16).

Mean

SD

1.39 0.09 1.47 0.39 1.53 0.02 0.74 0.58 1.53 3.84 0.59 1.43 1.26 0.82 0.93

1.19 0.81 1.1 1.94 8.2 1.41 1.42 2.06 2.63 3.19 1.24 1.68 1.19 1.64 0.86

0.76 0.59 0.21 0.55 0.59 0.79 0.43 0.04 3.39 4.81 0.47 0.74 1.12 1.23 1.34

1.01 0.98 1.27 1.29 13.53 1.09 1.59 1.4 2.39 3.17 0.78 2.72 1.01 1.37 0.84

.116 .0402* .0056 .1182 .8141 .092 .5539 .3283 .0446* .3982 .0076 .4016 .7278 .4532 .1794

was statistically significant in group II (P < .01). Although the difference between the VHA and the Tweed groups appears to be small (0.41 mm), it has to be considered that 1 mm of vertical movement of the molars results in approximately 3 mm of rotation of the mandible as measured at gnathion.9 Therefore, the concomitant effects of the VHA on the anterior vertical dimension may be clinically significant. Regardless of the treatment modality used for maxillary molar restraint, it is questionable whether compensatory mandibular first molar eruption occurs as a result. A correlation analysis was performed to determine if there is a relationship between vertical maxillary molar movement and a compensatory vertical movement of the mandibular first permanent molar. No statistical relationship between the 2 variables was formed for either group. Vertical effects on the anterior teeth. During the treatment of high-angle patients, the amount of overbite is usually of paramount importance. There were no significant treatment differences between groups I and II for this measurement. Lack of overbite was only one of the possible criteria for patient selection. Patients were accepted into the sample if they met only one of the other 2 criteria, which were a high FMA and a high GoGn-SN angle. Group I had a mean pretreatment overbite of 2.28 mm, which was less than the mean overbite of 3.42 mm for group II. This must be considered when evaluating the intragroup treatment changes in overbite.

We noticed further bite opening in group II (1.49 mm), as compared with the extraction VHA group (0.82 mm). This, however, was not harmful because the mean pretreatment overbite within group II was larger than that of the VHA group. Groups I and II finished with overbites of 1.46 1.55 mm and 1.93 1.14 mm, respectively, which were acceptable posttreatment results.
CONCLUSION

Clinically, we have found that the VHA is useful in restricting and even helping to reduce the percentage of lower anterior vertical face height. When treating high-angle patients, the orthodontist must usually guard against further anterior bite opening during leveling and aligning procedures. An ideal treatment goal for a patient with an acceptable pretreatment overbite would be to at least maintain the same amount of overlap throughout treatment. Our results from the VHA group have shown that control of anterior vertical dimension was possible with this appliance. Group II, which used tip-back bends for the posterior teeth in conjunction with a high-pull anterior J-hook headgear, demonstrated more bite opening, as well as a significantly greater increase in LAFH.
REFERENCES 1. Nanda SK. Patterns of vertical growth in the face. Am J Orthod 1988;93:103-16. 2. Wilson MD. Vertical control of maxillary molar position with a

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palatal appliance [thesis]. Oklahoma City: Health Sciences Center, University of Oklahoma; 1996. 3. Pearson LE. Vertical control in treatment of patients having backward-rotational growth tendencies. Angle Orthod 1978; 48:132-40. 4. Yamaguchi K, Nanda, RS. The effects of extraction and nonextraction treatment on the mandibular position. Am J Orthod Dentofacial Orthop 1991;100:443-52. 5. OReilly M, Nanda S, Close J. Cervical and oblique headgear: a comparison of treatment effects. Am J Orthod Dentofacial Orthop 1993;103:504-8.

6. Burke M, Jacobson A. Vertical changes in high-angle class II division 1 patients treated with cervical or occipital pull headgear. Am J Orthod Dentofacial Orthop 1992;102:501-8. 7. 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. 8. Wise J, Magness WB, Powers J. Maxillary molar vertical control with the use of transpalatal arches. Am J Orthod Dentofacial Orthop 1994;106:403-8. 9. Kuhn R. Control of anterior vertical dimension and proper selection of extraoral anchorage. Angle Orthod 1968;38:340-9.

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