Short-term dentoskeletal changes following

Class II treatment using a fixed functional

appliance: the Austro Repositioner

M. Dolores Austro, Encarnación

González, M. Angustias Peñalver,
Domingo Pérez & José Antonio Alarcón

Journal of Orofacial Orthopedics /

Fortschritte der Kieferorthopädie
Official Journal of the German
Orthodontic Society / Offizielle
Zeitschrift der Deutschen Gesellschaft
für Kieferorthopädie

ISSN 1434-5293
Volume 79
Number 3

J Orofac Orthop (2018) 79:147-156

DOI 10.1007/s00056-018-0135-3

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 Author's personal copy
J Orofac Orthop (2018) 79:147–156
https://doi.org/10.1007/s00056-018-0135-3

ORIGINAL ARTICLE

Short-term dentoskeletal changes following Class II treatment using

a fixed functional appliance: the Austro Repositioner

A pilot study

M. Dolores Austro1 · Encarnación González2 · M. Angustias Peñalver2 · Domingo Pérez3 · José Antonio Alarcón4

Received: 6 May 2017 / Accepted: 20 February 2018 / Published online: 16 April 2018
© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Abstract
Objective Purpose of this prospective study was to evaluate the skeletal and dentoalveolar effects of a fixed functional
appliance, the Austro Repositioner, in dolicho- and brachyfacial skeletal Class II patients.
Material and methods In all, 20 dolicho- and 25 brachyfacial consecutive patients treated with the Austro Repositioner
were compared with untreated controls (20 dolicho- and 20 brachyfacial patients) with the same initial dentoskeletal
features. Lateral cephalograms were acquired before and 1.0±0.2 year after therapy.
Results Significant improvements in skeletal Class II relationships were observed in both groups. The ANB angle decreased
(3.56° in dolicho- and 3.13° in brachyfacial patients, P < 0.001) due to changes localized exclusively in the mandible, the
SNB angle increased to 3.20° in dolicho- and 3.02° in brachyfacial patients, and the total mandibular length (Co-Pg)
increased to 6.47 mm in dolicho- and 5.78 mm in brachyfacial patients (P < 0.001). A favorable guidance of vertical pattern
was also achieved in both groups, and no significant changes were observed in the upper and lower incisors in both groups.
Conclusions The Austro Repositioner was effective for short-term treatment of skeletal Class II malocclusion resulting
from the retrusion of the mandible in both dolicho- and brachyfacial patients.

Keywords Fixed functional appliance · Angle Class II · Mandibular retrusion · Brachyfacial facial pattern · Dolichofacial
facial pattern

 M. Dolores Austro
[email protected]

1
Department of Stomatology, Section of Pediatric Dentistry,
Faculty of Odontology, Hospital General Universitario
Morales Meseguer, University of Murcia, Avda. Marqués de
los Vélez, s/n, 30008 Murcia, Spain
2
Department of Stomatology, Section of Pediatric Dentistry,
Faculty of Odontology, University of Granada, Granada,
Spain
3
Department of Stomatology, Section of Statistics, Faculty of
Odontology, University of Murcia, Murcia, Spain
4
Department of Stomatology, Section of Orthodontics, Faculty
of Odontology, University of Granada, Granada, Spain

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148 M. D. Austro et al.

Dentoskelettale Veränderungen nach einjähriger Klasse-II-Behandlung mit einer festsitzenden

funktionellen Apparatur: der Austro-Repositioner
Eine Pilotstudie

Zusammenfassung
Ziel In der vorliegenden prospektiven Studie sollten die skelettalen und dentoalveolären Effekte einer festsitzenden funk-
tionellen Apparatur (Austro-Repositioner) bei Patienten mit skelettaler Angle Klasse-II und dolicho- bzw. brachyfazialem
Wachstumsmuster evaluiert werden.
Material und Methoden Insgesamt wurden 45 konsekutive Patienten (20 dolicho- und 25 brachyfazial) mit dem Aus-
tro-Repositioner behandelt und mit unbehandelten Kontrollpatienten (20 dolicho- und 20 brachyfazial) verglichen, die zu
Behandlungsbeginn die gleichen initialen dentoskelettalen Befunde aufwiesen. Vor der Behandlung sowie 1,0±0,4Jahr nach
Behandlungsbeginn wurden Fernröntgenseitenbilder angefertigt.
Ergebnisse Hinsichtlich der skelettalen Klasse-II-Relation ließen sich in beiden Gruppen statistisch signifikante Verbes-
serungen beobachten, wobei die Veränderungen ausschließlich den Unterkiefer betrafen: Verringerung des ANB-Winkels
(3,56° bei dolicho-, 3,13° bei brachyfazialen Patienten; p < 0,001), Vergrößerung des SNB-Winkels (3,20° bei dolicho- und
3,02° bei brachyfazialen Patienten) und Erhöhung der Unterkiefergesamtlänge (Co-Pg) auf 47 mm bei dolicho- und 5,78 mm
bei brachyfazialen Patienten (p < 0,001). In beiden Gruppen wurde das vertikale Wachstumsmuster günstig beeinflusst. Bei
der Stellung oberer wie unterer Inzisivi wurden keine statistisch signifikanten Änderungen beobachtet.
Schlussfolgerungen Sowohl Klasse II-Patienten mit dolicho- als auch mit brachyfazialem Wachstumstyp profitierten von
der einjährigen Behandlung mit dem Austro-Repositioner.

Schlüsselwörter Festsitzende funktionelle Apparatur · Angle Klasse-II · Unterkieferrücklage · Brachyfaziales

Wachstumsmuster · Dolichofaziales Wachstumsmuster

Introduction of appliances present disadvantages. Removable appliances

require patient compliance (which is often not achieved),
Class II malocclusion is one of the most prevalent orthodon- can be uncomfortable, may limit lateral mandibular move-
tic conditions worldwide, and this deformity is commonly ments, and may interfere with normal functions such as
treated using functional appliances [25, 32]. At the begin- speech and eating. On the other hand, fixed appliances re-
ning of the 20th century, extraoral forces were applied to quire additional chairside time and laboratory support, and
the maxilla with headgear for the correction of Class II may be more prone to breakage [21].
malocclusion; this therapeutic approach reflected the belief To overcome these drawbacks, a new fixed functional
which prevailed during that era that the majority of skeletal appliance has been developed. The Austro Repositioner is
Class II malocclusions are caused by the protrusion of the a fixed functional appliance bonded on the maxillary first
maxilla [31]. However, subsequent studies indicated that molars; its design is quite similar to that of the Nance [19]
the incidence of Class II division 1 malocclusion resulting and Ballester and Langlade [3] appliances, incorporating an
from the protrusion of the maxilla does not exceed 20% inclined planed that causes the anterior displacement of the
of the total cases of Class II malocclusion, and that the mandible.
majority of these cases are caused by significant mandibu- The purpose of this prospective study was to evaluate the
lar retrusion [16]; this finding prompted many researchers short-term skeletal and dentoalveolar effects of the Austro
to use functional appliances in an attempt to stimulate the Repositioner when used alone for a single phase of therapy
growth of the mandible [23]. in both dolicho- and brachyfacial patients in comparison
Class II functional appliances are indicated in the cor- with untreated controls with Class II malocculsions.
rection of mandibular deficiencies as they allow mandibular
postural changes by holding the mandible forward and/or
downward. The muscles and soft tissues are stretched, and Materials and methods
the resultant pressure is transmitted to the skeletal and den-
tal structures, potentially resulting in skeletal growth mod- This prospective clinical study was based on the records
ification and tooth movement [27]. of 45 consecutively treated patients from the private prac-
Many researchers have developed various types of re- tice of the first author (M.D.A.). The sample comprised
movable and fixed functional appliances over time [38]. 20 dolichofacial (FMA angle >28°; 11 boys and 9 girls,
The main issue in clinical practice is that both these types mean age 11.3 years) and 25 brachyfacial patients (FMA

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Short-term dentoskeletal changes following Class II treatment using a fixed functional appliance: the Austro Repositioner 149

Table 1 Comparison of starting forms between the treated and control groups
Tab. 1 Vergleich der Ausgangssituationen in den Behandlungs- und den Kontrollgruppen
Measurements Dolichofacial Dolichofacial P value Brachyfacial Brachyfacial con- P value
treated (n = 25) control (n = 20) treated (n = 20) trol (n = 20)
Mean SD Mean SD Mean SD Mean SD
SNA (°) 81.06 3.27 81.04 2.31 0.985 NS 82.11 3.59 82.57 1.79 0.582 NS
SNB (°) 74.78 3.20 74.90 2.13 0.890 NS 76.03 3.29 76.62 1.80 0.452 NS
ANB (°) 6.28 1.40 6.14 0.72 0.702 NS 6.08 1.26 5.97 0.52 0.686 NS
Pt A-Na perp 2.64 2.15 2.09 2.67 0.488 NS 2.30 2.67 1.97 1.29 0.581 NS
(mm)
Pg-Na perp –2.82 3.18 –2.78 4.75 0.975 NS –0.27 4.54 0.02 1.74 0.773 NS
(mm)
Co-Po (mm) 100.53 4.69 100.86 3.27 0.806 NS 101.54 6.81 101.27 4.70 0.876 NS
FMA (°) 28.73 1.94 28.32 1.23 0.437 NS 19.33 4.65 19.99 1.61 0.517 NS
LAFH (mm) 61.18 3.82 61.80 3.24 0.586 NS 57.00 6.05 57.92 3.99 0.545 NS
OB (mm) 2.14 4.66 2.88 0.86 0.508 NS 6.09 2.46 6.01 1.28 0.894 NS
OJ (mm) 6.41 2.18 6.62 1.14 0.717 NS 6.80 1.56 6.77 0.48 0.718 NS
U1 to SN (°) 98.17 5.56 96.77 4.48 0.146 NS 102.81 8.16 101.67 4.59 0.556 NS
L1 to GoMe 93.06 5.05 94.49 6.93 0.457 NS 95.95 5.98 96.78 3.62 0.570 NS
(°)
SD standard deviation

Hier steht eine Anzeige.

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Fig. 1 Austro Repositioner design Fig. 2 Anterior displacement of the mandible through the acrylic resin
Abb. 1 Austro-Repositioner, Design wedge, when closing the mouth
Abb. 2 Bei Mundschluss wird durch den Keil aus Akrylharz eine Vor-
verlagerung des Unterkiefers erreicht

angle <20°; 14 boys and 11 girls, mean age 11.7 years). Ver- known growth studies such as the Burlington and Michigan
tical facial patterns (dolicho- and brachyfacial) were distin- growth studies. The control group was matched as closely
guished following standard orthodontic criteria, FMA angle as possible to the treatment group for age, sex, and CVM
(FMA angle between 20° and 28° corresponds to mesofa- stage.
cial, FMA angle >28° to dolichofacial, and FMA angle <20° The Austro Repositioner is a fixed functional appliance
to brachyfacial pattern) [28, 30]. composed of two bands bonded on the maxillary first mo-
Inclusion criteria for enrollment in the study were as fol- lars: a 0.9 mm stainless bar attached to the bands and an
lows: skeletal Class II division 1 malocclusion (ANB angle acrylic resin wedge that covers part of the anterior palate,
>5°) resulting from the retrusion of the mandible (SNB around and in the middle of the bar. The acrylic resin wedge
angle <78°), overjet of 5 mm or greater, and growth inter- consists of an inclined plane, located in the area of the
val between cervical vertebral maturation (CVM) stages 3 palatal rugae; the thicker area of the acrylic wedge coin-
and 4 (i. e., pubertal growth spurt peak, according to the cides with the position of maximum mandibular retrusion,
CVM method) [1] at the beginning of treatment. and the thinner area coincides with the upper retroincisor
The following conditions were considered as further region (Fig. 1). This configuration causes the anterior dis-
exclusion criteria: congenitally missing or extracted per- placement of the mandible; thus, when the patient closes
manent teeth (except third molars), posterior crossbites the mouth, the lower incisors make contact with the thicker
or severe maxillary transverse deficiency, severe facial area of the inclined plane. To properly close the mouth, the
asymmetry determined by clinical or radiographical ex- mandible is forced to slide through the inclined plane to an
amination, congenital syndromes, previous orthopedic/ anterior position, which is marked by the bite registration
orthodontic treatment, and poor oral hygiene. (Fig. 2). The initial mandible advance is 4 mm.
Lateral cephalograms were acquired before (T1) and im- The acrylic resin wedge is designed differently depend-
mediately after functional appliance therapy (T2) in the ing on the vertical facial pattern. In dolichofacial cases,
treatment group. The time between T1 and T2 was approx- the acrylic resin wedge is not extended to the upper in-
imately 1.0±0.2 year. cisor lingual surface; thus, the patient can close the mouth
Informed consent was obtained from the parents of all completely and a good posterior interdigitation is achieved.
patients included in the study. This design prevents eruption of the posterior teeth and
The treated groups were compared with untreated con- thus maintains the posterior vertical dimension (Fig. 3). On
trol groups of 40 subjects (20 dolichofacial patients: 9 boys, the other hand, in brachyfacial patients, the acrylic resin
11 girls, mean age 11.5 years; and 20 brachyfacial patients: wedge is extended to the upper incisors, and in this anterior
11 boys, 9 girls, mean age 11.4 years) with the same ini- segment, the wedge is 1.0–1.5 mm thicker. Because of this
tial dentoskeletal Class II features as the treated subjects specific design, the lower incisors make contact with the
(Table 1). The control subjects were derived from the on- anterior area of the acrylic resin wedge and prevent the oc-
line Craniofacial Growth Legacy Collection (http://www. clusion of the posterior teeth, thus, promoting their eruption
aaoflegacycollection.org), which consists of several well- and improving the overbite (Fig. 4).

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Short-term dentoskeletal changes following Class II treatment using a fixed functional appliance: the Austro Repositioner 151

Fig. 3 Austro Repositioner configuration for dolichofacial patients. Fig. 4 Austro Repositioner configuration for brachyfacial patients.
The acrylic resin wedge is not extended to the upper incisor lingual The acrylic resin wedge is extended to the upper incisors
surface Abb. 4 Austro-Repositioner für brachyfaziale Patienten. Der Keil aus
Abb. 3 Austro-Repositioner für dolichofaziale Patienten. Der Keil aus Akrylharz reicht bis zu den oberen Inzisivi
Akrylharz reicht nicht bis zur Lingualfläche der oberen Inzisivi

For all subjects, standard lateral cephalometric radio- in the variables were determined using a two-sample t-test
graphs with the teeth in centric occlusion and with the to compare variable changes between the two groups.
head oriented horizontally with the Frankfort plane were All images were scored by a single, experienced observer
acquired using a cephalostat in accordance with standard (M.D.A.). To test for observer reliability, 30 randomly se-
cephalometric procedures. The same digital X-ray de- lected images were reassessed by the same observer and
vice (Planmeca PM-2002 EC Proline Dental Pan X-Ray scored by another independent expert (J.A.A.). Inter- and
Machine, Helsinki, Finland), technician, focus-median intrarater agreements were calculated using Cohen’s kappa
plane distances (150 cm), and film–median plane distances (κ) coefficient [37].
(10 cm) were used for all radiographs. A reference ruler
was placed on the cephalostat for the exact measurement
and standardization of the magnification factor (7.47%). Results
Several classic linear and angular measurements from the
analyses of Steiner [33], Ricketts [29], and McNamara The inter- and intrarater agreement coefficients were
[17] were measured using Dolphin Imaging 11.0 software κ = 0.90 and κ = 0.95, respectively. There were no sta-
(Chatsworth, CA, USA). tistically significant differences between the treatment and
control groups at T1 (Table 1).
Statistical analysis Changes in the dolichofacial treatment and control
groups from T2 to T1 are described and compared in
Sample size was established with two sample t-test, a study Tables 2 and 3. A significant improvement in the max-
power of 90%, a significant level of 0.05 and a detected illomandibular skeletal relationship was observed after
difference of 1.2°, based on a previous-pilot evaluation of Austro Repositioner treatment; the ANB angle decreased
20 cases (10 dolicho- and 10 brachyfacial patients). The significantly (3.56°) in the treated group compared to the
appropriate sample size was 20 subjects in each group. growth changes in the control group. These results can
A standard statistical software package (IBM SPSS be attributed to changes in the mandible, as no significant
Statistics 20, IBM Armonk, New York, NY, USA) was differences were observed in the maxillary cephalometric
used for statistical analysis. After confirmation of normal measurements (SNA angle and Pt A-Na perp), while the
distribution of the variables, the differences in the pretreat- SNB angle, Co-Po distance, and Pg-Na perp increased
ment variables between the two groups were determined significantly in the treated group as compared to those in
using a two-sample t-test; the effects of the treatment on the control group (P < 0.001). Mandibular skeletal changes
the variables were determined using a paired-sample t-test also caused a significant reduction of the overjet in the
to compare the pre- and posttreatment variables in each treated group (2.75 mm), as no significant changes were
group alone, and the effects of the appliance on the changes detected in the upper and lower incisor angulations. One of
the most interesting results referred to the vertical changes:

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Table 2 Descriptive values after treatment in both the treated and control groups
Tab. 2 Deskriptive Statistik nach Behandlung in den Behandlungs- und den Kontrollgruppen
Measurements Dolichofacial treated Dolichofacial control Brachyfacial treated Brachyfacial control
(n = 25) (n = 20) (n = 20) (n = 20)
Mean SD Mean SD Mean SD Mean SD
SNA (°) 80.70 2.74 81.00 2.13 82.00 3.60 82.74 1.77
SNB (°) 77.98 2.52 75.09 2.26 79.05 3.24 77.07 1.86
ANB (°) 2.72 1.38 5.91 0.63 2.95 1.27 5.67 0.57
Pt A-Na perp 3.27 1.54 2.28 2.35 1.87 2.20 2.01 1.28
(mm)
Pg-Na perp (mm) 0.89 3.68 –2.27 4.44 2.62 3.42 0.63 1.49
Co-Po (mm) 107.00 4.77 101.90 3.29 107.32 8.12 102.45 4.67
FMA (°) 23.42 2.18 28.74 1.20 22.64 2.22 20.26 1.52
LAFH (mm) 58.95 3.75 3.75 3.75 60.10 6.93 58.35 3.94
OB (mm) 2.46 1.35 2.81 0.75 3.20 1.12 5.97 1.30
OJ (mm) 3.66 0.69 6.70 1.00 4.15 1.32 6.70 0.42
U1 to SN (°) 97.94 5.75 95.04 4.41 102.89 7.26 101.88 5.05
L1 to GoMe (°) 93.34 4.98 95.18 6.78 95.76 5.74 97.03 3.93
SD standard deviation

Table 3 Comparison of changes during time of observation in dolichofacial- and control groups (T2–T1)
Tab. 3 Vergleich der Änderungen während der Beobachtungszeit (T2–T1) bei den dolichofazialen Patienten (Behandlungs- und Kontrollgruppe)
Measurements Dolichofacial treated (n = 25) Dolichofacial control (n = 20) Treated vs.
control
Mean differ- SD P value Mean differ- SD P value P value
ences ences
SNA (°) –0.36 1.17 0.200 NS –0.04 0.75 0.81 NS 0.308 NS
SNB (°) 3.20 1.63 0.000 S 0.19 0.39 0.04 S 0.000 S
ANB (°) –3.56 1.42 0.000 S –0.23 0.86 0.23 NS 0.000 S
Pt A-Na perp 0.22 1.30 0.501 NS 0.19 0.66 0.20 NS 0.920 NS
(mm)
Pg-Na perp 3.79 2.61 0.000 S 0.51 0.69 0.00 S 0.000 S
(mm)
Co-Po (mm) 6.47 4.51 0.000 S 1.04 0.57 0.000 S 0.000 S
FMA (°) –5.31 2.54 0.000 S 0.42 0.68 0.042 S 0.000 S
LAFH (mm) –2.23 5.27 0.041 S 0.42 0.60 0.004 S 0.028 S
OB (mm) 0.31 4.31 0.756 NS –0.06 0.47 0.551 NS 0.695 NS
OJ (mm) –2.75 2.11 0.000 S 0.08 0.54 0.501 NS 0.000 S
U1 to SN (°) –0.63 1.60 0.111 NS 0.27 0.55 0.035 S 0.020 S
L1 to GoMe (°) 0.28 1.80 0.501 NS 0.69 0.87 0.002 S 0.362 NS
SD standard deviation

in the treatment group, both the FMA angle and LAFH showing a reduction of 3.13° (P < 0.001). This skeletal
decreased significantly in the treatment group, while these Class II correction was exclusively due to mandibular
measurement values increased in the control group; this changes, as no statistically significant changes in the max-
finding reflects the potential of the Austro Repositioner illary base (SNA angle and Pt A-Na perp) were found.
for controlling the vertical facial pattern in dolichofacial In contrast, the SNB angle showed an increase of 3.02°
patients. in the treated group, compared with 0.46° in the controls
Tables 2 and 4 illustrate the cephalometric changes from (P < 0.001). There was a significant gain in the mandibular
T2 to T1 in the brachyfacial treated and control subjects. length as measured by the change in Co-Pg, with the treat-
The most relevant finding was the improvement in the ment group showing a 5.78 mm increase compared with
Skeletal Class II correction induced by the Austro Reposi- 1.19 mm increase in the controls (P < 0.001); Pg-Na perp
tioner. There was a statistically significant difference in the increased more in the treated group (P < 0.05). Vertical
ANB angle between the groups, with the treated subjects changes showed a significant increment in the FMA angle

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Short-term dentoskeletal changes following Class II treatment using a fixed functional appliance: the Austro Repositioner 153

Table 4 Comparison of changes during time of observation in brachyfacial-treated and control groups (T2–T1)
Tab. 4 Vergleich der Änderungen während der Beobachtungszeit (T2–T1) bei den brachyfazialen Patienten (Behandlungs- und Kontrollgruppe)
Measurements Brachyfacial treated (n = 20) Brachyfacial control (n = 20) Treated vs. control
Mean differ- SD P value Mean differ- SD P value P value
ences ences
SNA (°) –0.11 1.47 0.713 NS 0.18 0.68 0.260 NS 0.426 NS
SNB (°) 3.02 1.33 0.000 S 0.46 0.48 0.000 S 0.000 S
ANB (°) –3.13 1.58 0.000 S –0.30 0.51 0.019 S 0.000 S
Pt A-Na perp –0.43 2.76 0.441 NS 0.05 0.72 0.784 NS 0.456 NS
(mm)
Pg-Na perp 2.89 4.25 0.002 S 0.61 0.53 0.000 S 0.022 S
(mm)
Co-Po (mm) 5.78 4.68 0.000 S 1.19 0.42 0.000 S 0.000 S
FMA (°) 3.31 3.81 0.000 S 0.27 1.24 0.340 NS 0.001 S
LAFH (mm) 3.11 3.56 0.000 S 0.44 0.90 0.073 NS 0.002 S
OB (mm) –2.88 2.49 0.000 S –0.05 0.49 0.683 NS 0.000 S
OJ (mm) –2.65 1.44 0.000 S –0.06 0.59 0.626 NS 0.000 S
U1 to SN (°) 0.07 1.97 0.856 NS 0.20 1.62 0.579 NS 0.810 NS
L1 to GoMe (°) –0.19 2.17 0.662 NS 0.25 1.60 0.485 NS 0.446 NS
SD standard deviation

and in the LAFH in the treated group (P < 0.001); this length, and a reduced dental overjet, as well as a favorable
finding can be attributed to an opening of the mandibu- guidance of vertical pattern.
lar angle in the treated group as a consequence of the As no previous studies about the Austro Repositioner ex-
effects induced by the Austro Repositioner. The signifi- ist, a pilot study was designed to test for its efficacy in the
cant (P < 0.001) improvement of overjet (2.65 mm) induced treatment of Class II malocclusion due to mandibular retru-
by Austro Repositioner treatment could be due to skele- sion in both dolicho- and brachyfacial subjects. To estimate
tal effects, as no significant changes were observed in the appropriate sample size, a preliminary evaluation with
maxillary and mandibular incisor angulations. Finally, the 20 patients was carried out. Although the estimated sample
treated group showed a significant reduction of the overbite size was 20 subjects per group, a consecutive recruitment
(2.88 mm), while the control group showed no significant of the cases was carried out. Dolichofacial cases were more
changes. difficult to recruit, and when 20 patients were assigned to
this group, the number of recruited brachyfacial subjects
was 25. We decided not to eliminate these “extra” 5 pa-
Discussion tients in this group, and to take this difference into account
in the statistical analysis.
The present prospective clinical study was designed to eval- For ethical reasons, we could not recruit a group of
uate the potential skeletal and dental effects of a fixed func- Class II untreated patients, so, the control subjects were
tional appliance, the Austro Repositioner, in the correction derived from the online open access Craniofacial Growth
of Class II malocclusion due to mandibular retrognatism, Legacy Collection. The control group was matched to the
in comparison with untreated controls who presented very treatment group for age, sex, and CVM stage in order to
similar craniofacial characteristics at baseline. Because of make them comparable. Nevertheless, the use of histori-
the difference in growth, development, and treatment re- cal controls has a risk of biases, which must be taken into
sponses of Class II subjects, depending on the vertical fa- account when interpreting the results.
cial pattern, two groups of patients, namely dolicho- and Skeletal maturity determined by CVM method [1], in-
brachyfacial patients, were established. stead of chronological age, was chosen as inclusion criteria.
The results demonstrated that intervention with the Only subjects between CVM stages 3 and 4 (i. e., pubertal
Austro Repositioner appliance is effective for functional growth spurt peak) at the beginning of the treatment, were
mandibular retrognatism correction in both dolicho- and recruited.
brachyfacial patients. This new fixed functional appliance Total treatment duration was approximately 1 year, as
produced a statistically significant improvement in skele- the aim of this pilot study was to evaluate the short-term
tal Class II relationships, an increase in the mandibular effects of Austro Repositioner.

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154 M. D. Austro et al.

Skeletal correction was due to changes localized exclu- When comparing the present data and appliance to the
sively in the mandible. In both groups, the SNB angle literature, the Austro Repositioner presents a higher coef-
increased significantly after 1 year of treatment (3.20° in ficient of efficiency, as previously mentioned. The main
dolicho- and 3.02° in brachyfacial patients); this finding is differences where located in the mandible, which showed
very relevant, considering that few studies described a sig- a good response to the appliance, at least in the short term.
nificant increment in the SNB angle after functional ther- Several factors could contribute to these results, including
apy [7, 12, 18, 39]. In the systematic review of mandibu- that it is a fixed appliance (thus, its action extent is al-
lar changes produced by functional appliances in Class II most continuous), the timing chosen for its application, and
malocclusion by Cozza et al. [6], outcomes in terms of the soft, fairly physiological advancement of the mandible
changes in the mandibular position in relation to the cranial that could also exert a good muscular response. In addition,
base (SNB angle) were not clinically significant in any re- one of the main reasons that could explain the observed
viewed article, except that of Tümer and Gültan [36], who changes, in comparison with other appliances that stimu-
found a clinically and statistically significant supplemen- late mandibular growth, is the good control of the vertical
tary increase of 2.2° per year. In our study, the SNB angle growth pattern provided by the Austro Repositioner.
increased even more because of the mandibular growth in- Similar to other studies, compared to the Twin Block [2,
crement and vertical pattern control provided by the Austro 4, 5], Herbst [4], Sander bite jumping [15], and Sydney
Repositioner in both dolicho- and brachyfacial Class II pa- Magnoglide appliance [26], the Austro Repositioner had an
tients. irrelevant constraint on the maxillary growth.
In addition to improvement of the SNB angle, the total A considerable advantage of the appliance was the con-
mandibular length (measured by Co-Pg) also increased trol of the vertical growth pattern; this control was due to
significantly in both groups (6.47 mm in dolichofacials the different design in dolicho- and brachyfacial subjects.
and 5.78 mm in brachyfacials). Compared to the 1.04 In dolichofacial subjects, both FMA and LAFH decreased
and 1.19 mm growth observed in their respective control significantly, while in the comparative control group, these
groups, the extent of supplementary mandibular growth values increased significantly. These results reflect that the
induced by functional treatment was clinically significant clockwise rotation of the mandible, which is frequently
(>2.0 mm) [6] in both groups. In this sense, the outcome observed after functional treatments [11, 20, 34, 36] and
for the Austro Repositioner was superior to that of other should be minimized [35], can not only be avoided after
functional appliances such as the Herbst appliance [9, 22, Austro Repositioner treatment, but that this new appliance
39], Twin Block [2, 7, 20, 34], Fränkel Regulator type 2 can even induce a counterclockwise rotation of the lower
[18, 34], and functional magnetic systems [26]. According jaw. This phenomenon facilitated a sagittal increment of the
to Cozza et al. [6], the average coefficient of efficiency mandible and, thus, an improvement of the skeletal Class II
for functional jaw orthopedics was 0.16 mm per month, relationship in dolichofacial patients. The opposite was ob-
with an average active treatment duration of approximately served in brachyfacial patients, where FMA and LAFH in-
17 months. The Herbst appliance had the highest coeffi- creased significantly compared with the controls, and, as
cient of efficiency (0.28 mm per month), followed by the a consequence, the overbite also increased significantly and
Twin Block (0.23 mm per month). Both the bionator and improved in these patients.
the activator had intermediate scores of efficiency (0.17 No significant changes were observed in the angulations
and 0.12 mm per month, respectively). The Fränkel Regu- of the upper and lower incisors in the treated groups. These
lator type 2 appliance had the lowest efficiency (0.09 mm results imply that the significant improvement of the overjet
per month). In recent studies, the coefficient of efficiency achieved in both groups was due to skeletal changes and not
was higher: 0.33 mm with the crown Herbst [12], 0.36 mm due to dentoalveolar compensations, reinforcing the ortho-
with the Herbst [4], 0.43 mm with the functional magnetic pedic effect developed by the Austro Repositioner. These
Sydney Magnoglide [26], 0.44 mm with the Twin Block findings offer a great advantage in comparison with other
[4], and 0.48 mm with the Sander bite-jumping appliance functional appliances, where the retroclination of the upper
[15]. In our study, the coefficient of efficiency for an av- incisor [2, 4, 5, 11–13, 15] or the proclination of the lower
erage duration of active Austro Repositioner treatment of incisor was common [5, 8, 10–14, 22, 24].
12 months showed even higher scores: 0.54 mm per month The Austro Repositioner was shown to be an effec-
in dolichofacial patients and 0.48 mm per month in brachy- tive fixed functional appliance for the treatment of skeletal
facial patients. These good results reflect the potential of Class II malocclusion resulting from the retrusion of the
the Austro Repositioner for inducing favorable changes in mandible. Its conception and design maximize the mandible
the mandible of growing Class II patients with mandibular
retrusion.

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Short-term dentoskeletal changes following Class II treatment using a fixed functional appliance: the Austro Repositioner 155

growth response to functional mandibular protrusion. Its Compliance with ethical guidelines
mechanism of action in the sagittal plane depends on the
Conflict of interest M.D. Austro, E. González, M.A. Peñalver,
forced advancement of the mandible by an inclined guiding D. Pérez and J.A. Alarcón declare that they have no competing in-
plane, and in the vertical plane depends on the control of terests.
the extrusion of the posterior teeth. Some more advantages
Ethical standards All procedures performed in studies involving hu-
can be listed as follows: it is esthetic and comfortable; sore man participants were in accordance with the ethical standards of the
spots are minimal; and, while initially it may feel strange institutional and/or national research committee and with the 1964
to hold the jaw forward while eating, within a short time, Helsinki declaration and its later amendments or comparable ethical
standards. Informed consent was obtained from all individual partici-
chewing becomes more natural. According to the patient
pants included in the study.
experience, this appliance causes little discomfort and has
less effect on speech and eating, it does not limit mandibular
movements and it does not need patient cooperation. References
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