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Table 4. (a) Comparison of C, FFA and OS with respect to pre, post and difference scores of FMA angle by One-Way ANOVA test; (b) Pair wise comparison of three groups (C, FFA and OS) with respect to pre, post and difference scores of FMA angle by Tukey’s Honest Significant (HSD) Difference test procedure.

4) Dentoalveolar changes: (Tables 5 and 6)

C group: U1 to SN angle indicated a reduction in proclination (mean diff. 12.9˚) showing a highly significant change (p = 0.0018) and a statistically significant change was also seen with respect to L1 to MP angle (mean diff. 2.9˚). It can be inferred that predominant amount of reduction in convexity was due to the intrusion and retraction of the upper anterior teeth and mild amount of lower incisor retraction had occurred.

FFA group: A highly significant change was seen with respect to reduction U1 to SN angle (mean diff. 13.6˚), which was achieved partly by retracing and closing spaces in the proclined upper anterior teeth and could also be accounted to occur due to the distalizing effect of Fixed Functional Appliances. Mesialization of lower incisors had occurred, but it was statistically insignificant.

OS group: There was no significant difference with the pre and post-treatment values, so it can be inferred that the reduction in facial convexity was achieved predominantly by surgically correcting the underlying skeletal defect by advancing the mandible.

5) Soft tissue changes: (Tables 7 and 8)

C group: Highly significant change (p = 0.0052) was seen in the Nasolabial angle (mean diff. −14.4˚), indicating that overall reduction in facial convexity was on account of retracting the upper incisors, which increased the nasolabial angle.

FFA group: An increase in the nasolabial angle (mean diff. −9.4˚) was observed which was statistically significant (p = 0.0062) and a highly significant (p = 0.0003) change was seen with respect to the mentolabial angle (mean diff. −24.4˚), which had increased post-treatment. These changes helped in the overall reduction of facial convexity.

OS group: Statistically significant change (p = 0.0179) was seen in the nasolabial angle (mean diff. −6.4˚) which was increased and the angle formed from the soft tissue N’-Pg’-FH angle (p = 0.0107) had also increased (mean diff. −2.3˚). It can be inferred that there was significant change in the Mentolabial angle following the surgical correction of the underlying skeletal structure and in the nasolabial angle it was achieved by dentoalveolar changes.

6) Inference drawn from the VAS on the perception of treatment outcome (Graphs 1-3).

It was observed that the laypersons appreciated the changes in all the three groups equally.

The orthodontists and mostly the oral surgeons were more critical in evaluating the cases and this could be attributed to their enhanced observational skills regarding minute details for which they have been trained.

Table 5. Comparison of C, FFA and OS with respect to pre, post and difference scores of U1 to SN angle by One-Way ANOVA test.

Table 6. Comparison of C, FFA & OS w.r.t pre, post & difference scores of L1 to MP angle by One-Way ANOVA test.

Table 7. Comparison of C, FFA and OS with respect to pre, post and difference scores of Nasolabial angle by One-Way ANOVA test.

Table 8. Comparison of C, FFA and OS with respect to pre, post and difference scores of Mentolabial angle by One-Way ANOVA test.

Graph 1. Comparison by VAS of Camouflage group.

Graph 2. Comparisons by VAS of Fixed Functional Appliance group.

Graph 3. Comparison by VAS of Orthognathic Surgery group.

4. DISCUSSION

There are several studies comparing either of the two treatment modalities in young adult Class II patients [14-16] but only one compares results of all the three treatment modalities [1].

Studies comparing camouflage orthodontic group (C group) vs orthognathic surgical group [14,16], showed that the patients perception of facial improvement, posttreatment in both groups were significantly positive. In our study similar results were obtained on using a VAS. Although, the cephalometric analysis showed a highly significant change on the sagittal skeletal aspect only in the OS group with ANB angle (mean diff. 3.9˚).

There was a study, which compared the treatment induced changes in orthognathic surgical group (OS group) vs. fixed functional appliance group in adults [15], and a few others who campared the effect of FFA group in adult patients [5,6,9,17]. The overall results revealed that fixed functional appliances can be used as an alternative in borderline Class II patients.

A) Comparison of treatment changes between treatment groups:

1) Comparison between skeletal changes in groups:

The comparison of skeletal parameters between treatment groups, which includes changes in the sagittal relations, the position of the two jaw bases and the vertical positions have been included. One-way ANOVA test showed that there were no statistically significant differences between the treatment groups to start with. When the pre and post-treatment outcomes were compared, there was a highly significant change seen with the treatment outcomes.

Following which pair wise comparison of the three groups (C, FFA and OS) with respect to the pre and post-treatment values were compared by Tukey’s Honest Significant Difference (HSD) test procedure, to compare each group against the other and to find out which among the three groups had significant changes when compared with each other.

In the sagittal plane, highly significant changes were seen in the OS group and the FFA group showed statistically significant changes. But there were no changes in the C group post treatment (Tables 1(a) and (b)).

In the vertical plane, when the pre and post-treatment relationship of the jaw bases was compared, it was shown that there were no changes in all the three categories. Since the growth pattern of the samples taken in this study, ranged from normodivergent to mild hyperdivergent growth pattern, there was no chances of worsening of profile due to the downward and backward rotation on the mandible (Tables 4(a) and (b)).

In the maxilla, all the parameters showed insignificant changes.

In the mandible, a highly significant difference existed in the OS group when compared with the FFA group, showing that there was a reduction in the overall facial convexity due to the advancement of the mandible, while an increase in the mandibular corpus length was also seen in the FFA group (Tables 2 and 3).

The dentoalveolar changes were observed in the upper incisors which was statistically significant in the C group in comparison with OS group, since dentoalveolar corrections were carried out in the C group and OS group correction was predominantly by surgical correction. In the lower incisor there was a significant difference present with the FFA group when compared with the C and OS group, this was because there was proclination of lower anteriors. However, the FFA group did not show a significant change when studied individually with respect to pre and post inclination of lower incisors (Tables 5 and 6).

Soft tissue changes had occurred in all the three groups, when compared with each other using the Tukey’s HSD test, indicating that the three groups differed statistically with regards to nasolabial angle in all the groups and with respect to mentolabial angle was statistically significant in the OS group suggesting that the change was more pronounced in the surgical group (Tables 7 and 8).

B) Inference drawn from the VAS on the perception of treatment outcome (Graphs 1-3):

The changes in profile in the C group, was appreciated well by the laypersons (mean 2.62), followed by the Orthodontists (mean 3.72). There was a statistically significant similarity in the opinion amongst the orthodontists and laypersons. While the oral surgeons (mean 4.14) rated the treatment changes that occurred as “average”.

The VAS scoring over the FFA group was perceived as “good” by the laypersons (mean 2.30) and by the orthodontists (mean 3.80). The Oral surgeons gave an “average” score.

Whereas, no significant changes were appreciated in the OS group in contrast to the other groups when evaluated by all the three categories of raters in assessing the improvement in facial profile post treatment by laypersons (mean diff. 2.14), orthodontists (mean diff. 3.44) and oral surgeons (mean diff. 4.90) which was similar to the scoring in the other groups.

From the above findings it can be inferred that the laypersons appreciated the changes in all the three groups equally.

The orthodontists and mostly the oral surgeons were more critical in evaluating the cases and this could be attributed to their enhanced observational skills regarding minute details for which they have been trained.

5. CLINICAL IMPLICATIONS & CONCLUSIONS

The aim of this study was to evaluate the effectiveness of each of the three treatment options (camouflage orthodontics, FFA and orthognathic surgery) on indiviuals from an Indian Population with a convex profile having boderline Class II malocclusion and derive their clinical implications.

• By camouflage orthodontics alone, reasonably favourable results were achieved. But care should be taken not to over-retract the upper anteriors, resulting in a unaesthetic appearance due to an increased Nasolabial angle.

• The size and position of the nose should also be taken into account, to determine the extent of retraction that can be achieved. Patients with a large or upturned nose could be a limitation to camouflage orthodontics in Class II patients.

• There is limited possibility of retraction of upper anteriors in camouflage group when the cortical plate is thin.

• FFA carries out the correction by a combination of skeletal and dental changes. But long term studies with respect to stability needs to be evaluated.

• FFA has a tendency to procline lower anteriors; hence it should be ensured that the teeth are not proclined to start with.

• Significant improvement was observed in the Orthognathic surgery group, but the cost factor and the fear of undergoing surgery normally holds back patients from opting for this treatment modality. Hence, FFA could be considered as an alternative in borderline Class II adults.

• When the preand post-treatment profile photographs were assessed by laypersons and Orthodontists on a VAS, they rated all the three treatment modalities as “good”, while, the Oral surgeons rated all the three groups as “average”.

6. ACKNOWLEDGEMENTS

The Authors are grateful to Dr. Dipesh D. Rao who helped them formulte the article.

REFERENCES

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