Original Article

The Effects of Early Preorthodontic Trainer Treatment on

Class II, Division 1 Patients

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Serdar Usumez, DDS, PhDa; Tancan Uysal, DDS, PhDb; Zafer Sari, DDS, PhDa;
Faruk Ayhan Basciftci, DDS, MSa; Ali Ihya Karaman, DDS, MS, PhDc;
Enis Guray, DDS, PhDd

Abstract: The aim of this study was to clarify the dentoskeletal treatment effects induced by a preor-
thodontic trainer appliance treatment on Class II, division 1 cases. Twenty patients (10 girls and 10 boys,
mean age 9.6 6 1.3 years) with a Class II, division 1 malocclusion were treated with preorthodontic trainer
appliances (Myofunctional Research Co., Queensland, Australia). The patients were instructed to use the
trainer every day for one hour and overnight while they slept. A control group of 20 patients (mean age
10.2 6 0.8 years) with untreated Class II, division 1 malocclusions was used to eliminate possible growth
effects. Lateral cephalograms were taken at the start and end of treatment. Final cephalograms were taken
13.1 6 1.8 months after trainer application, compared with a mean of 11.2 6 2.4 months later for the
control group. The mean and standard deviations for cephalometric measurements were analyzed by paired-
samples t-test and independent-samples t-tests. At the end of the study period, the trainer group subjects
showed significant changes including anterior rotation and sagittal growth of the mandible, increased SNB
and facial height, reduced ANB, increased lower incisor proclination, retroclination of upper incisors, and
overjet reduction. However, only total facial height increase, lower incisor proclination, and overjet reduc-
tion were significantly higher when compared with the changes observed in the control group. This study
demonstrates that the preorthodontic trainer application induces basically dentoalveolar changes that result
in significant reduction of overjet and can be used with appropriate patient selection. (Angle Orthod 2004;
74:605–609.)
Key Words: Myofunctional treatment; Preorthodontic trainer; Class II, division 1

INTRODUCTION Excessive dental protrusion and excessive overjet are

characteristics of these cases, particularly in connection
Much attention has been paid to the problem of control-
with thumb or lip sucking and tongue thrusting.8 McNa-
ling dentofacial growth interferences caused by abnormal
mara9 claimed that the most frequent skeletal problem in
lip and tongue function in the mixed dentition period. Var-
Class II malocclusions in preadolescents is mandibular ret-
ious appliances have been presented for the treatment of
rognathia. This suggests that an appliance with the dem-
this problem.1–7 The main purpose of these appliances has
onstrated ability to stimulate significant mandibular growth
been to eliminate oral dysfunction, establish muscular bal-
would be an important part of the clinician’s armamentar-
ance, and correct or diminish maxillary incisor protrusion.8
ium. Animal studies have shown that appliances that posi-
tion the mandible anteriorly can stimulate significant man-
a
Assistant Professor, Department of Orthodontics, School of Den- dibular growth, primarily by an enhanced remodeling re-
tistry, Selcuk University, Konya, Turkey. sponse at the condyle.10–13
b
Research Assistant, Department of Orthodontics, School of Den-
tistry, Selcuk University, Konya, Turkey.
Myofunctional appliances have been used for many
c
Associate Professor and Head, Department of Orthodontics, years. There is a definite place for these appliances in or-
School of Dentistry, Selcuk University, Konya, Turkey. thodontics today because they are simple and economical,
d
Associate Professor, Department of Orthodontics, School of Den- but the cases need to be carefully selected, and the operator
tistry, Selcuk University, Konya, Turkey. needs to be well trained in their use.
Corresponding author: Tancan Uysal, DDS, Orthodontics, Selcuk
Universitesi Dis Hekimligi Fakultesi, Ortodonti A. D., Konya 42079, Class II, division 1 malocclusions may be treated effec-
Turkey tively in actively growing patients with any type of func-
(e-mail: [email protected]). tional appliance.13,14 The principal aims of dentofacial or-
Accepted: October 2003. Submitted: September 2003. thopedic treatment of skeletal Class II, division 1 maloc-
q 2004 by The EH Angle Education and Research Foundation, Inc. clusions with an activator are to correct the dental arch

605 Angle Orthodontist, Vol 74, No 5, 2004

606 USUMEZ, UYSAL, SARI, BASCIFTCI, KARAMAN, GURAY

TABLE 1. Intra- and Intergroup Values and Their Comparisons for the Control and Test Groups. Skeletal and Dental Measurements of the
Pre- and Posttreatment and Pre- and Postcontrol Lateral Cephalograms

Trainer Group (n 5 20)

Pretreatment, Posttreatment,
P-Value
0 mo 13.1 6 1.8 mo Difference
Paired-Samples
Mean SD Mean SD Mean SD t-Test

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1 SNA (8) 79.51 2.81 79.64 3.34 0.13 1.02 NSa
2 SNB (8) 73.80 1.83 75.12 2.55 1.31 1.35 .001**
3 ANB (8) 5.71 1.58 4.52 2.03 21.19 1.18 .001**
4 Sn-GoGn (8) 35.81 5.32 34.28 5.44 21.50 1.76 .003**
5 FH-MP (8) 26.97 4.93 25.44 5.54 21.53 2.35 .020*
6 PP-MP (8) 27.56 5.99 26.41 6.12 21.16 2.28 NS
7 Gn-Go-Ar (8) 127.50 6.45 127.18 6.67 20.31 3.11 NS
8 Ar-S-N (8) 124.19 6.19 124.41 6.52 0.22 3.65 NS
9 Me-Go-S (8) 115.06 5.50 114.00 6.16 21.06 5.99 NS
10 OP-SN (8) 21.25 3.40 20.00 4.35 21.25 2.11 .032*
11 MaxP Angle (8) 4.62 2.33 4.09 1.88 20.53 2.08 NS
12 Ramus height (mm) 57.06 4.31 58.06 2.86 1.00 3.22 NS
13 Corpus length (mm) 64.69 4.39 65.69 4.11 1.00 2.39 NS
14 N-Me (mm) 111.69 5.24 114.37 5.10 2.69 2.06 .000***
15 S-Go (mm) 70.78 4.73 72.75 4.95 1.97 2.15 .002**
16 Go-Ar (mm) 42.25 3.86 43.12 3.34 0.91 2.22 NS
17 Go-Me (mm) 63.75 5.67 65.31 4.80 1.56 3.39 NS
18 Co-Gn (mm) 103.69 5.91 106.56 5.25 2.88 4.53 .023*
19 Co-A (mm) 85.69 5.02 86.88 4.15 1.19 3.85 NS
20 Go-PC (mm) 50.56 5.54 50.81 5.54 0.25 4.06 NS
21 U1-NA (mm) 3.78 2.18 3.31 2.85 20.50 1.76 NS
22 U1-NA (8) 24.56 6.97 22.62 6.38 21.97 6.05 NS
23 U1-SN (8) 104.00 6.81 100.38 6.56 23.63 5.19 .014*
24 L1-NB (mm) 5.04 2.23 6.06 2.38 0.99 1.64 .025*
25 L1-NB (8) 27.69 4.24 30.44 5.33 2.75 3.89 .013*
26 IMPA (8) 95.94 6.25 99.56 7.34 3.63 3.86 .002**
27 Interincisal angle 122.81 9.12 123.13 7.83 0.31 6.37 NS
28 Overjet (mm) 6.83 1.65 3.16 1.67 23.75 1.60 .000***
29 Overbite (mm) 2.12 2.73 1.94 2.12 20.22 1.76 NS
a
NS, not significant.
* P , .05.
** P , .01.
*** P , .001.

relationship and to improve the patient’s facial profile by by changes in tongue position. Linder-Aronson et al19
promoting favorable mandibular growth changes.13,15 claimed that a child passing from oral to nasal breathing
Bergersen16 stated that excessive overjet ideally should increases the horizontal growth of the mandible and nor-
be corrected before full eruption of the permanent incisors malizes incisor position.
so that the lingual surfaces of the upper incisors will pro- To initiate Class II orthopedic therapy at an earlier age
vide stops to prevent increases in overbite. However, two and to correct functional problems of soft tissues such as
mm of overjet should remain after correction to ensure that lingual malposition, the centripetal thrust of the lips and
continued mandibular growth does not lead to progna- cheeks, oral respiration, and bruxism need to be part of the
thism.16 goal. With this aim, our attention was drawn to the preor-
Tulloch et al17 identified 50 studies conducted between thodontic trainer (Figure 1), a functional device usable in
1980 and 1987 that reported the treatment of young patients children from the age of four to 10 years. Quadrelli et
with Class II malocclusion. Because of the various inherent al20–22 recommended this appliance to correct the interpo-
limitations of the different investigations, they were unable sition of lips between dental arches, atypical swallowing,
to determine whether orthodontic treatment significantly in- and the centripetal thrust of cheeks upon the dental arches;
fluenced the growth potential of Class II patients. to discourage oral respiration; to avoid bruxism; and to fa-
Woodside et al18 indicated that mandibular growth is vor the action of the external pterygoid and thus encourage
achieved by changes in the mode of breathing and that pas- the active push of the mandible.
sive maxillary expansion plus bite opening was achieved The trainer and similar appliances are claimed to en-

Angle Orthodontist, Vol 74, No 5, 2004

EFFECT OF PREORTHODONTIC TRAINER APPLIANCE 607

TABLE 1. Extended

Control Group (n 5 20)

P-Value
First Observation, Second Observation,
Independent-
0 mo 11.2 6 2.4 mo Difference
Paired-Samples Samples
Mean SD Mean SD Mean SD t-Test t-Test

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80.46 3.06 80.35 3.11 20.11 1.70 NS NS
74.58 3.08 74.99 3.36 0.41 1.64 NS NS
5.86 1.40 5.36 1.51 20.50 1.24 NS NS
35.63 5.85 35.29 6.09 20.34 1.90 NS NS
26.44 5.04 26.25 5.73 20.20 3.19 NS NS
28.63 5.81 28.06 5.87 20.57 2.40 NS NS
124.34 5.80 124.62 6.60 0.29 2.12 NS NS
128.36 4.23 127.84 4.84 20.52 2.65 NS NS
108.62 5.76 108.92 5.82 0.31 1.32 NS NS
16.98 4.76 16.49 4.77 20.49 1.57 NS NS
22.20 2.73 21.83 2.87 0.38 2.88 NS NS
60.76 5.24 61.51 4.88 0.75 2.54 NS NS
65.14 3.78 65.57 3.33 0.43 0.99 NS NS
117.15 7.41 117.67 7.39 0.50 0.31 .004** .000***
75.64 5.07 76.68 4.91 1.04 0.63 .000*** NS
45.62 2.94 46.52 3.15 0.90 1.59 .020* NS
67.86 4.16 68.74 3.92 0.88 1.57 .022* NS
109.55 6.15 111.01 6.27 1.47 2.60 .021* NS
85.02 3.70 85.47 4.21 0.45 2.48 NS NS
50.26 3.43 50.80 3.55 0.54 1.69 NS NS
5.70 2.25 5.90 2.47 0.20 1.40 NS NS
22.65 7.41 24.00 7.53 1.35 3.87 NS NS
78.00 7.20 7.10 6.73 20.90 3.09 NS NS
5.15 1.90 5.00 1.97 20.15 1.56 NS .040*
24.70 5.50 24.40 5.74 20.30 3.74 NS .023*
94.65 5.71 94.20 6.51 20.45 4.36 NS .006**
126.75 9.29 126.25 8.10 20.50 5.41 NS NS
8.47 3.52 8.33 3.12 20.13 0.78 NS .000***
3.05 2.00 3.11 2.07 0.06 0.39 NS NS

courage transverse bone growth by acting as a ‘‘shield’’ for mm. None of the children in the test or control group had
the cheeks and bringing about muscular relaxation and pro- a thumb-sucking habit. All were Caucasian, and their ages
tection of the teeth and articulations from bruxism, by vir- ranged from 8.3 to 10.9 years (9.6 6 1.3 years). All were
tue of the ‘‘bite effect.’’23,24 The trainer is claimed to correct treated exclusively with the preorthodontic trainer appliance
a skeletal Class II by an active mandibular force. By dis- (Myofunctional Research Co., Queensland, Australia). The
tancing the lower lips from the dental alveolar arch, the patients were instructed to use the trainer every day for one
trainer is claimed to prevent a malposition of the tongue hour and overnight while they slept.
and lower lip during swallowing, thus solving the associ- The remaining samples formed the untreated control
ated dental open bite. It is also reported to promote nasal group to eliminate possible growth effects. This group con-
respiration.25 sisted of 10 boys and 10 girls, with similar Class II, division
Therefore, this study cephalometrically evaluates the 1 malocclusions (ANB . 48, and an overjet greater than
overall changes that occur during treatment with a preor- five mm). All were Caucasian with ages ranging from 9.6
thodontic trainer appliance and compares these changes to 11.0 years (10.2 6 0.8 years). The subjects in the control
with an untreated Class II, division 1 control group. group were informed about orthodontic treatment but re-
fused treatment.
MATERIALS AND METHODS Lateral cephalograms were taken at the start and end of
treatment. Final cephalograms were taken after 13.1 6 1.8
The study included 40 children with skeletal Class II, months of trainer application and 11.2 6 2.4 months of
division 1 malocclusions. Ten male and 10 female patients, growth in the control group. The radiographs were traced
treated between 2000 and 2002, were selected as the treat- and measured by two investigators (Dr Usumez and Dr
ment group. The ANB angles of all patients were greater Uysal). The landmarks were located according to the defi-
than four degrees, and their overjets were greater than 4.5 nition provided by Basçiftçi et al.13

Angle Orthodontist, Vol 74, No 5, 2004

608 USUMEZ, UYSAL, SARI, BASCIFTCI, KARAMAN, GURAY

control group using the Student’s t-test for unpaired sam-

ples. The mean difference of the study group was larger
than that of the control group for only facial height, N-Me
(mm), (P . .001).
Pre- and posttreatment dental differences
Preorthodontic trainer group. In group I, treatment re-

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sulted in decreases in U1-SN (deg) (23.63 6 5.19) (P .
.05) and overjet (mm) (23.75 6 1.60) (P . .001). The
means increased with treatment for L1-NB (mm) (0.99 6
1.64), L1-NB (deg) (2.75 6 3.89) (P . .05), and IMPA
(3.63 6 3.86) (P . .01).
Control group. No statistically significant differences
were observed between the first and second measurements
of the control group.
FIGURE 1. The preorthodontic trainer appliance. Intergroup comparisons. The mean differences were sig-
nificantly decreased more in the study group than in the
control group for U1-SN (deg) and L1-NB (P . .05),
All statistical analyses were performed using the SPSS IMPA (P . .01), and overjet (mm) (P . .001) (Table 1).
software package (SPSS for Windows, version 10.0.1,
SPSS Inc, Chicago, Ill). The mean differences between the DISCUSSION
pretreatment and posttreatment measurements and the first
and second observation period measurements for the con- This study of a sample of 40 children with Class II, division
trol group were evaluated using the paired t-test. Student’s 1 malocclusion was designed to study the effect of treatment
t-test was applied for comparison of the groups. with the preorthodontic trainer appliance. The observed
Two weeks after the first measurements, 30 radiographs changes during treatment reflect the combined effects of treat-
were selected at random and retraced. A paired-samples t- ment and individual growth. Ideally, a matched or at least
test was applied to the first and second measurements. It comparable control group should be included for identifying
was found that the difference between the first and second the changes due to growth.13,14,27–29 Therefore, a control group
measurements of the 30 radiographs was insignificant. Cor- consisting of longitudinal growth data for untreated Class II,
relation analysis applied to the same measurements showed division 1 malocclusion subjects was used in this investigation
that the highest r value was 0.99 for the interincisal angle to eliminate possible differences in growth pattern.
and the lowest r value 0.91 for FH-MP.26 It was decided to initiate Class II orthopedic therapy at an
earlier age to correct functional problems in the soft tissues
RESULTS such as lingual malposition, the centripetal thrust of lips and
cheeks, oral respiration, and bruxism. A functional device, the
The data from skeletal and dental measurements of the
preorthodontic trainer appliance (Figure 1), was used in this
pre- and posttreatment and pre- and postcontrol lateral
study for this purpose. Quadrelli et al20–22 indicated that the
cephalograms are summarized in Table 1.
trainer appliance can be used for children four to 10 years old
and recommended it to correct the interposition of lips be-
Pre- and posttreatment skeletal differences
tween dental arches, atypical swallowing, and centripetal
Preorthodontic trainer group. In group I, treatment was thrust of cheeks upon the dental arches; to discourage oral
associated with increases in the mean values for N-Me respiration; to avoid bruxism; and to favor the action of the
(2.69 6 2.06) (P . .001), SNB (1.31 6 1.35), S-Go (1.97 external pterygoids and thus encourage the active push of the
6 2.15) (P . .01), and Co-Gn (2.88 6 4.53) (P . .05). mandible.
In group I, treatment also was associated with decreases in For patients with a Class II malocclusion, the preorthodon-
ANB (21.19 6 1.18), SN-GoGn (21.50 6 1.76) (P . tic trainer appliance is constructed with the mandible in a
.01), FH-MP (21.53 6 2.35), and OP-SN (21.25 6 2.11) lightly protruded position, similar to the therapeutic position
(P . .05) (Table 1). used in activator treatment. For oral screen treatment, Graber30
Control group. In the control group, the means increased indicated that the construction bite cannot be as protrusive as
for S-Go (1.04 6 0.63) (P . .001), N-Me (0.50 6 0.31) that with an activator, and a screen is of value mainly in cases
(P . .01), Go-Ar (0.90 6 1.59), Go-Me (0.88 6 1.57), of mild Class II malocclusions. Similarly, we thought that
and Go-Me (1.47 6 2.60) (P . .05) (Table 1). myofunctional appliances might be a reliable alternative for
Intergroup comparisons. The mean differences in the sagittal activation of the mandible in the early mixed dentition
study group were compared with the mean differences in period. A review of the literature presents no information on

Angle Orthodontist, Vol 74, No 5, 2004

EFFECT OF PREORTHODONTIC TRAINER APPLIANCE 609

whether the preorthodontic trainer appliance can actually im- 12. McNamara JA. Neuromuscular and skeletal adaptations to altered
prove a Class II skeletal relationship. Although the use of function in the orofacial region. Am J Orthod. 1973;64:578–606.
13. Basciftci FA, Uysal T, Büyükerkmen A, Sarı Z. The effects of
myofunctional appliances such as the oral screen in the pri- activator treatment on the craniofacial structure of Class II divi-
mary and mixed dentitions are mentioned in the literature,8,31 sion 1 patients. Eur J Orthod. 2003;25:87–93.
only one study has been published concerning the specific 14. Sari Z, Göyenç Y, Doruk EC, Usumez S. Comparative evaluation
alterations induced by these procedures in the early occlusal of a new removable jasper jumper functional appliance versus an
developmental stages.22 One study has been published con- activator—headgear combination. Angle Orthod. 2003;73:286–
293.

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cerning the trainer appliances combined with the straight wire 15. Andresen V, Haupl K. Funktionsorthopädie.Die Grundlagen des
system.32 Norwegischen Systems. Leipzig, Germany: Johann Ambrosium
At the end of the study period, the myofunctional trainer Barth; 1945.
group subjects showed anterior rotation and sagittal growth of 16. Bergersen EO. Preventive eruption guidance in the 5 to 7 year
the mandible, increases in SNB, facial height, and lower in- old. J Clin Orthod. 1995;29:382–395.
17. Tulloch JF, Medland W, Tuncay OC. Methods use to evaluate
cisor proclination, reductions of ANB and overjet, and retro- growth modification in class II malocclusion [review]. Am J Or-
clination of upper incisors. However, only total facial height thod Dentofacial Orthop. 1990;98:340–347.
increase, lower incisor proclination, and overjet reduction 18. Woodside DG, Linder-Aronson S, Lundström A, McWilliam J.
were statistically significantly different when compared with Mandibular and maxillary growth after changed mode of breath-
the changes in the control group. This implies that the skeletal ing. Am J Orthod Dentofacial Orthop. 1991;100:1–18.
19. Linder-Aronson S, Woodside DG, Hellsing E, Emerson W. Nor-
changes were not significant enough to be distinguished from malization of incisor position after adenoidectomy. Am J Orthod
normal growth, and the reduction of overjet was mainly re- Dentofacial Orthop. 1993;103:412–427.
lated to the lower incisor proclination. These results are in 20. Quadrelli C, Ghiglione V, Marchetti C. Relationships between
accordance with the works of Tallgren et al8 and Owman-Moll posture, dysfunctions of the soft tissues of the stomatognatic ap-
and Ingerval,31 who reported similar changes with the use of paratus, respiration and occlusion in early treatment of skeletal
Class II. Paper presented at: Congress ‘‘Occlusion and Posture;
another type of myofunctional appliance (oral shields). New Trends and New Problems’’; June 2001; Milan, Italy.
21. Quadrelli C, Ghiglione V, Gheorghiu M. Relationships between
CONCLUSIONS posture, dysfunction of soft tissues of the stomatognatic appara-
tus, respiration and occlusion in the early treatment of skeletal
At the end of the study period, in the trainer group, only Class II. Paper presented at: XVI National Congress Sido; Oc-
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overjet reduction were significantly higher compared with the 22. Quadrelli C, Gheorgiu M, Marchetti C, Ghiglione V. Approccio
changes observed in the control group. This study demon- miofunzionale precoce nelle II Classi scheletriche. Mondo Ortod.
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24. Gibbs SL, Hunt NP. Functional appliances and arch width. Br J
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Angle Orthodontist, Vol 74, No 5, 2004