Sagittal and vertical changes after treatment of Class II Division 1 malocclusion according to the Cetlin method


      This cephalometric study was designed to evaluate the dentoskeletal anteroposterior and vertical changes produced by Cetlin therapy (lower lip bumper, ACCO, cervical headgear) to correct Class II Division 1 malocclusion in the late mixed dentition. All measurements were made on 2 lateral headfilms, at pretreatment and at 1 year after beginning treatment. The selected sample (n = 110; 67 boys and 43 girls; mean age, 10 to 11 years) and the control group (n = 100; 48 boys, 52 girls; mean age, 10 to 11 years) matched for number, age, and malocclusion. The average observation interval was 13 months. The final measurements between intervals were averaged and tested for significance by analysis of variance. A one-factor (group) repeated measure model and a two-factor (group and facial type) repeated measure model were fitted to each variable separately and significance values were set at P ≤.05. The Class I molar relationship was achieved in all treated subjects primarily through distalization of upper first molars. A significant distal tipping was found in 70% of the treated cases. The results showed a significant forward growth limitation of the maxilla with the use of cervical headgear. No significant change of mandibular position was found in the treated group compared with the control group. Both bite opening and proclination of upper and lower front teeth occurred. Cetlin therapy is reliable and effective for space recovery and interceptive Class II Division 1 treatment. Additional therapy may be needed later. (Am J Orthod Dentofacial Orthop 2000;118:150-8)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Orthodontics and Dentofacial Orthopedics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kloehn SJ
        Guiding alveolar growth and eruption of teeth to reduce treatment time and produce a more balanced denture and face.
        Angle Orthod. 1947; 17: 10-33
        • Blueher WA
        Cephalometric analysis of treatment with cervical anchorage.
        Am J Orthod. 1959; 29: 45-53
        • Wieslander L
        The effect of orthodontic treatment on the concurrent development of the craniofacial complex.
        Am J Orthod. 1963; 49: 15-27
        • Ringenberg QM
        • Butts WC
        A controlled cephalometric evaluation of single-arch cervical traction therapy.
        Am J Orthod. 1970; 57: 179-185
        • Wieslander L
        The effect of force on craniofacial development.
        Am J Orthod. 1974; 65: 531-538
        • Baumrind S
        • Molten R
        • West EE
        • Miller DM
        Distal displacement of the maxilla and the upper first molar.
        Am J Orthod. 1979; 75: 630-640
        • Cangialosi TJ
        • Meistrel Jr, ME
        • Leung MA
        • Yang Ko J
        A cephalometric appraisal of Edgewise class II nonextraction treatment with extraoral force.
        Am J Orthod. 1988; 93: 315-324
        • Horn AJ
        Strategies de traitment de Classe II.
        Journal de l’Edgewise. 1982; 3: 27-29
        • Merrifield LL
        Differential diagnostic guidelines.
        J Tweed Found. 1978; 6: 10-15
        • Chaconas SJ
        • Caputo AA
        • Davis JC
        The effects of orthodontic forces on the craniofacial complex utilizing cervical headgear appliances.
        Am J Orthod. 1976; 69: 527-539
        • Cook AH
        • Sellke TA
        • BeGole EA
        Control of the vertical dimension in Class II correction using a cervical headgear and lower utility arch in growing patients, Part I.
        Am J Orthod Dentofacial Orthop. 1994; 106: 376-388
        • Klein PL
        An evaluation of cervical traction of the maxilla and the upper first permanent molar.
        Angle Orthod. 1957; 27: 61-68
        • Kloehn SJ
        Evaluation of cervical anchorage force in treatment.
        Angle Orthod. 1961; 31: 91-104
        • Melsen B
        Effects of cervical anchorage during and after treatment: an implant study.
        Am J Orthod. 1978; 73: 526-540
        • Watson WG
        A computerized appraisal of the high pull facebow.
        Am J Orthod. 1972; 62: 561-579
        • Wieslander L
        Early or late cervical traction therapy of Class II malocclusion in the mixed dentition.
        Am J Orthod. 1975; 67: 432-439
        • Firouz M
        • Zernik J
        • Nanda R
        Dental and orthopedics effects of high-pull headgear in treatment of Class II, Division 1 malocclusion.
        Am J Orthod. 1992; 102: 197-205
        • Burke M
        • Jacobson A
        Vertical changes in high angle Class II, Division 1 patients treated with cervical or occipital pull headgear.
        Am J Orthod. 1992; 102: 501-508
        • Hubbard GW
        • Nanda RS
        • Currier GF
        A cephalometric of nonextraction cervical headgear treatment in Class II malocclusion.
        Angle Orthod. 1994; 64: 359-370
        • Caldwell S
        • Hymas A
        • Timm T
        Maxillary traction splint: a cephalometric evaluation.
        Am J Orthod. 1984; 85: 376-384
        • De Beats J
        • Schatz JP
        • Joho JP
        Skeletal changes associated with plate-headgear therapy in the early mixed dentition.
        JCO. 1995; XXIX: 700-705
        • Joffe L
        • Jacobson A
        The maxillary orthopedic splint.
        Am J Orthod. 1979; 75: 54-69
        • Falk F
        • Fränkel R
        Clinical relevance of step by step mandibular advancement in the treatment of mandibular retrusion using the Fränkel appliance.
        Am J Orthod. 1989; 96: 333-341
        • Fränkel R
        The treatment of Class II, Division 1 malocclusion with functional corrector.
        Am J Orthod. 1996; 55: 265-275
        • Fränkel R
        The functional matrix and its practical importance in orthodontics.
        Trans Eur Orthod Soc. 1969; : 207-218
        • Fränkel R
        Biomechanical aspects of the form/function relationship in craniofacial morphogenesis: a clinician’s approach.
        in: Clinical alterations of the growing face. P.Mon 14, Craniofacial Growth Series. Center for Human Growth and Development, University of Michigan, Ann Arbor1983
        • Perillo L
        • Johnston LE
        • Ferro A
        Permanence of skeletal changes after function regulator (FR-2) treatment of patients with retrusive Class II malocclusion.
        Am J Orthod. 1996; 109: 132-139
        • Andresen V
        • Haupl K
        • Petrik L
        5th edition. Johann Ambrosius Barth, Muenchen1953
        • Pancherz H
        The mechanism of Class II correction in Herbst appliance treatment.
        Am J Orthod. 1982; 82: 104-113
        • Pancherz H
        • Littmann C
        Morphologie und Lage des Unterkiefers bei der Herbst-Behandlung. Eine kephalometrische Analyse der Veranderungen bis zum Wachstumsabschluss.
        Inf Orthod u Kieferorthop. 1989; 28: 493-513
        • Bass NM.
        Bass orthopedic appliance system.
        J Clin Orthod. 1987; 21 (312-320,384-394): 254-265
        • Teuscher U
        A growth-related concept for Class II treatment.
        Am J Orthod. 1978; 74: 258
        • Sander FG
        • Wichelhaus A
        Skelettale und dentale Veraenderungen bei der Anwendung der Vorschubdoppelplatte.
        Fortschr Kieferorthop. 1995; 56: 127-139
        • Bolmgren GA
        • Moshiri F
        Bionator treatment in Class II, Division 1.
        Angle Orthod. 1982; 56: 255-262
        • Mamandras AH
        • Allen LP
        Mandibular response to orthodontic treatment with the Bionator appliance.
        Am J Orthod Dentofacial Orthop. 1990; 97: 113-120
        • Charlier JP
        • Petrovic A
        • Herrmann-Stutzmann J
        Effect of hyperpropulsion on the prechondroblastic zone of young rat condyles.
        Am J Orthod. 1969; 55: 71-74
        • Petrovic A
        Mechanism and regulation of mandibular condylar growth.
        Acta Morph Neerl Scand. 1972; 10: 25-34
        • Petrovic AG
        Control of postnatal growth of secondary cartilages of the mandible by mechanism regulating occlusion. Cybernetic model.
        Trans Europ Orthodont Soc. 1974; 50: 69-75
        • Bjork A
        • Skieller V
        Facial development and tooth eruption.
        Am J Orthod. 1972; 62: 339-383
        • Uner O
        • Yucel–Eroglu E
        Effects of a modified maxillary orthopedic splint: a cephalometric evaluation.
        Eur J Orthod. 1996; 18: 269-286
        • Pearson LE
        Vertical control in treatment of patients having backward rotational growth tendencies.
        Angle Orthod. 1978; 48: 132-140
        • Woodside D
        • Linder-Aronson S
        Progressive increase in lower anterior face height and the use of posterior occlusal bite block in management.
        in: Orthodontics: state of the art, essence of the science. Mosby, St Louis1986
        • Dellinger EL
        A clinical assesment of the active vertical corrector: a nonsurgical alternative for skeletal open bite treatment.
        Am J Orthod. 1986; 89: 428-436
        • Case CS
        The advisability of extraction teeth in the correction of the irregularities.
        Dental Cadmos. 1905; 67: 105-112
        • Tweed CH
        Indications for extractions of the teeth in orthodontic procedures.
        Am J Orthod. 1944; 30: 421-428
        • Angle EH
        A treatment of the malocclusion of the teeth.
        7th edition. SS White Dental Mfg Co, Philadelphia1907
        • Brodie AG
        Gordon’s dental science and dental art.
        Lea & Febiger, Philadelphia1938 (cap 5)
        • Johnson EL
        Application of occipital anchorage.
        Am J Orthod. 1943; 29: 638-647
        • Miller LS
        Nonextraction treatment in growing patients, with emphasis on distal movement.
        Am J Orthod. 1961; 46: 737-757
        • Cetlin NM
        • Ten Hoeve A
        Nonextraction treatment.
        JCO. 1983; 17: 396-413
        • Bernardi FA
        A cephalometric analysis of the stability and type of movement of obtained Class II malocclusions treated with extraoral forces [Master’s Thesis].
        St Louis University, St Louis1956
        • Biggerstaff RH
        • Allen RC
        • Tuncay OC
        • Berkowits J
        A vertical cephalometric analysis of the human craniofacial complex.
        Am J Orthod Dentofacial Orthop. 1987; 92: 321-328
        • Bench RW
        • Gugino CF
        • Hilgers JJ
        Bioprogressive therapy, part IV.
        J Clin Orthod. 1978; 12: 48-69
        • Aru G
        • Colli S
        • Falconi A
        • Zappa G
        Il lip bumper in Ortodonzia.
        Mondo Ortodontico. 1985; 2: 25-32
        • Castaldo A
        • Vettese P
        Valutazione della potenzialità di espansione del lip bumper in pazienti trattati senza estrazioni.
        Ortognat It. 1992; 1: 479-490
        • Cetlin NM
        Terapia non estrattiva.
        Giornate Culturali, Varese19\20 Aprile 1996
        • Ferro A
        • Perillo L
        Valutazione a distanza di un anno dell’altezza dento-basale nei trattamenti con lip bumper.
        Arch Stomat. 1988; 29: 1117-1125
        • Nidoli G
        • Lazzati M
        • Macchi A
        • Carloni L
        • Raso M
        Il ruolo del lip bumper nella terapia ortodontica senza estrazioni: indagine clinico-statistica.
        Mondo Ortodontico. 1989; 14: 325-332
        • Osborn WS
        • Nanda RS
        • Currier GF
        Mandibular arch perimeter changes with lip bumper treatment.
        Am J Orthod Dentofacial Orthop. 1991; 99: 527-532
        • Ostinelli E
        • Calegari R
        • Norcini A
        • Palerma C
        Lip bumper: indicazioni cliniche, valutazioni statistiche.
        Ortognat It. 1993; 2: 777-784
        • Perillo L
        Le modificazioni del perimetro dell’arcata dentaria inferiori e dei suoi diametri trasversali con l’impiego del lip bumper.
        Ortognat It. 1992; 1: 16-22
        • Perillo L
        • Ferro F
        Il lip bumper (LB).
        Schede di Aggiornamento SIDO, 1994-5
        • Scaramella F
        • Siciliani G
        • Campo P
        Utilizzazione clinica del lip bumper.
        Min Ortognat. 1985; 3: 9-14
        • Ten Hoeve A
        Palatal bar and lip bumper in nonextraction treatment.
        JCO. 1985; 4: 15-34
        • Perillo L
        • Ratto A
        • Ferro A
        Studio delle modificazioni dentobasali verticali indotte dal lip bumper: contributo clinico.
        Mondo Ortod. 1991; 16: 141-144
        • Pancherz H
        La terapia delle II classi scheletriche con cerniera di Herbst.
        Sillabo SIDO, 1992
        • Hanes RA
        Bony profile changes resulting from cervical traction compared with those resulting from intermaxillary elastics.
        Am J Orthod Dentofacial Orthop. 1959; 45: 353-364
        • Mays RA
        A cephalometric comparison of two types of extraoral appliance used with the Edgewise mechanism.
        Am J Orthod. 1969; 55: 195-196
        • Merrifield LL
        • Cross JJ
        Directional forces.
        Am J Orthod. 1970; 57: 435-464
        • Poulton DR
        The influence of extraoral traction.
        Am J Orthod. 1967; 53: 8-18
        • Boatwright PL
        Single arch treatment with the Kloehn headgear: a cephalometric evaluation.
        ([Master’s Thesis}) St Louis University, St Louis1969
        • Cangialosi TJ
        • Meistrell ME
        • Leung MA
        A cephalometric appraisal of edgewise Class II nonextraction treatment with extraoral force.
        Am J Orthod Dentofacial Orthop. 1988; 93: 315-324
        • Sandusky WS
        Cephalometric evaluation of the effects of the Kloehn type of cervical traction used as an auxiliary with the edgewise mechanism following Tweed’s principles for correction of Class I Division I malocclusion.
        Am J Orthod. 1965; 51: 262-287
        • Ringenberg QM
        • Butts WC
        A controlled cephalometric evaluation of single-arch cervical traction therapy.
        Am J Orthod. 1970; 57: 179-185
        • Petrovic AG
        A cybernetic approach to craniofacial growth control mechanism.
        Nova Acta Leopoldina. 1986; 58: 27-67
        • Bergersen EO
        A cephalometric study of the clinical use of the mandibular lip bumper.
        Am J Orthod. 1972; 61: 578-602
        • Nevant CT
        • Buschang PH
        • Alexander RG
        • Steffen JM
        Lip bumper therapy for gaining arch length.
        Am J Orthod Dentofacial Orthop. 1991; 100: 330-336
        • Subtelny JD
        • Sakuda M
        Muscle function, oral malformation, and growth changes.
        Am J Orthod. 1966; 52: 495-517
        • Baumrind S
        • Korn EL
        • Isaacson RJ
        • West EE
        • Molthen R
        Quantitative analysis of the orthodontic and orthopedic effects of maxillary traction.
        Am J Orthod. 1983; 84: 384-398
        • Brown P
        A cephalometric evaluation of high pull molar headgear and face bow neck strap therapy.
        Am J Orthod. 1978; 74: 62132
        • Ricketts RM
        • Bench RW
        • Gugino F
        • Hilgers JJ
        • Schulhof RJ
        Bioprogressive therapy.
        Rocky Mountains Orthodontics, Denver (CO)1979
        • Blueher WA
        Cepahlometric analysis of treatment with cervical anchorage.
        Angle Orthod. 1959; 29: 45-53
        • Boecler PR
        • Riolo ML
        • Keeling SDE
        • Ten Haeve TR
        Skeletal changes associated with extraoral appliance therapy: an evaluation of 200 consecutively treated cases.
        Angle Orthod. 1994; 59: 263-269
        • Elms TN
        • Buschang MA
        • Alexander RG
        Long-term stability of Class II, Division 1, nonextraction cervical face-bow therapy: II. cephalometric analysis.
        Am J Orthod. 1996; 109: 386-392
        • Wieslander L
        • Buck DL
        Physiologic recovery after cervical traction therapy.
        Am J Orthod. 1974; 66: 294-301
        • Nance HN
        The limitation of orthodontic treatment. I, mixed dentition diagnosis and treatment. II, diagnosis and treatment in permanent dentition.
        Am J Orthod. 1947; 33: 117-223