The effects of Frankel's function regulator (FR-4)

therapy on the treatment of Angle Class I skeletal

anterior open bite malocclusion
Elif Erbay, DDS, MS," T~rkbz UOur, DDS, DDO, b and Mustafa Ulgen, DDS, Dr.med.dent. °
Istanbul, Turkey

The present study attempts to evaluate cephalometrically the effects of Fr&nkel's function regulator
(FR-4) appliance on the treatment of Angle Class I skeletal anterior open bite malocclusion. Forty
Turkish children (26 girls and 14 boys), with Angle Class I skeletal anterior open bite, were
randomly divided into two groups of 20 (13 girls and 7 boys). Patients who had not undergone
treatment served as the control group, whereas a second group was treated with lip-seal training
and the FR-4 appliance. Chronologic mean decimal age at initial period of the investigation was 8.7
years in the treated group, and 8.9 years in the control group. Treatment and observation periods
were 2 years. Investigation was carried out on lateral cephalograms taken before and after the
study period. The results indicate that a spontaneous downward and backward growth direction of
the mandible observed in the control group could be changed to a upward and forward direction
by FR-4 therapy. The skeletal anterior open bite was successfully corrected through upward and
forward mandibular rotation. (AM J ORTHOD DENTOFACORTHOP 1995;108:9-21.)

k . / n the basis of recent investigations, it is introduced, all publications related to orthodontic

apparent that skeletal anterior open bite malocclu- treatment of skeletal anterior open bite cases were
sion is generally more difficult to treat and results mostly presented as case reports. However, Frfinkel
harder to maintain than other malocclusions. Even and FrfinkeP -6 evaluated the changes biometrically
if there were no arch length discrepancies, orth- that occurred in the control and treated groups
odontic tradition generally applied in treatment of over the study period, to evaluate the effect of lip
skeletal anterior open bite is extraction of perma- seal training with the FR appliance in the treat-
nent premolars or molars. In contrast, Frfinkel 1"2 ment of skeletal anterior open bite.
successfully treated skeletal anterior open bite We attempted to make a new study on the same
cases with the function regulator appliance, gener- subject, as we had detected the following points
ally without extraction. Frfinkel 2'3 considered the lacking in Frfinkel and Frfinkel's study. 4-6
deficiency of an anterior oral seal, the incompetent • The authors did not classify the cases according
lip posture, is due to poor postural performance of to arch relationship in the sagittal plane and per-
the lip-valve musculature, and is the most impor- haps due to this fact did not identify which type of
tant factor in the cause of skeletal anterior open function regulator appliance or appliances were
bite malocclusion. Fr/inkel and FrfinkeP -6 suggest used.
that lip seal training with the function regulator • The latest lateral cephalometric radiographs of
appliance is an effective means of activating and the treated group were taken after a minimum of 4
improving muscle tone. This creates the anterior years out of retention.
oral seal and suspends the mandible in a proper • There is approximately 1 year between the mean
postural position. Consequently, functional, as well ages of the treated and control groups at initial stage
as morphologic aberrations, are improved. of the investigation and the observation period.
From our literature references, it is evident that • There was no information on whether a sexual
up to the date Frfinkel and Fr/inkel's s t u d y 4-6 w a s dimorphism existed.
• To evaluate the changes in skeletal pattern of the
From the Department of Orthodontics, Faculty of Dentistry, University of
skeletal anterior open bite that occurred during
Istanbul. treatment with a function regulator and lip-seal
aAssistant. training, Fr~inkel and FrfinkeP 6 have used only the
bChairman and Professor.
CProfessor.
cephalometric measurements in the vertical plane.
Copyright © 1995 by the American Association of Orthodontists. The aim of this study was to investigate cepha-
0889-5406/95/$3.00 + 0 8/1/47797 lometrically the effects, in the sagittal and vertical
10 Erbay, U~mr, and (7lgen American Journal of Orthodontics and Dentofacial Orthopedics
Julv 1995

Fig. 1. FR-4 on both maxillary and mandibular casts. Fig. 2. FR-4 on maxillary cast.

Table I. S a m p l e characteristic chronologic a n d skeletal m e a n decimal ages (year)

N Mean Ages S ~ Min. Max.

Treated group (girls) 13 Chronologic 8.7 0.5 0.1 7.9 9.3

Skeletal 7.7 0.8 0.2 6.8 8.8
Treated group (boys) 7 Chronologic 8.6 0.6 0.2 7.5 9.4
Skeletal 8.0 1.6 0.6 6.0 10.0
Control group (girls) 13 Chronologic 8.7 1.2 0.3 7.0 10.1
Skeletal 7.5 1.3 0.4 5.8 8.8
Control group (boys) 7 Chronologic 9.3 1.2 0.4 7.6 11.0
Skeletal 8.3 1.4 0.5 6.0 10.0
Treated group (pooled) 20 Chronologic 8.7 0.5 0.1 7.5 9.4
Skeletal 7.8 1.1 0.2 6.0 10.0
Control group (pooled) 20 Chronologic 8.9 1.2 0.3 7.0 11.0
Skeletal 7.8 1.3 0.3 5.8 10.0

Min. = Minimum.
Max. = Maximum.

planes, of F r ~ n k e l ' s f u n c t i o n r e g u l a t o r ( F R - 4 ) ap- deciduous or permanent teeth were extracted over the
p l i a n c e 5'~ a n d lip-seal t r a i n i n g for t r e a t m e n t of study period. These patients were randomly divided into
A n g l e Class I skeletal a n t e r i o r o p e n bite maloc- two groups which closely matched in age and sex. Pa-
clusion. tients who did not undergo treatment served as the
control group and a second group they were treated with
MATERIALS AND M E T H O D S lip-seal training and the FR-4 a p p l i a n c e s The FR-4
appliance has two buccal shields, two lower lip pads, a
Forty Turkish children with Angle Class I skeletal palatal bow, an upper labial wire, and four occlusal rests
anterior open bite malocclusion were included in this on the upper permanent first molars and upper decidu-
study. Subjects were selected from the patients referred ous first molars (Figs. 1 and 2).
for orthodontic treatment tO the Department of Orth- As seen in Table I, the treated and control groups
odontics at the Faculty of Dentistry, University of Istan- were comprised of 13 girls and 7 boys. Both groups were
bul. The criteria used for sample selection were (1) divided into subgroups according to sex.
Angle Class I molar relationship; (2) anterior open bite The chronologic and skeletal mean decimal ages for
of at least 1 mm when the incisal points of the upper and all groups at initial stage of the study are given in Table
lower central incisors were projected onto N-Me line; I. Skeletal age was established by means of the standard-
and (3) a steep mandibular plane angle (SN/GoMe ized hand-wrist radiograph that was scored with the
angle ->37°). standards of Greulich and Pyle.s Children in the treated
All cases were in the mixed dentition stage and no and control groups were followed up for 2 years. In the
American Journal of Orthodontics and Dentofacial Orthopedics Erbay, Ug~ur, a n d Dh, en 11
Volume 108, No. 1

Table II. The pretreatment and posttreatment mean values of cephalometric measurements in girls of the
treated group (N" 13) and comparison of differences according to the Wilcoxon test
Pretreatment Posttreatment Difference

Y~ S S S Wilcoxon test

Linear
1. N-Me 107.7 3.5 111.7 4.1 +4.0 1.7 **
2. N-ANS 45.6 1.6 49.0 1.7 +3.4 1.2 **
3. ANS-Me 62.0 3.0 62.7 3.7 + 0.7 1.6
4. S-Go 62.2 4.5 66.6 5.1 +4.4 1.3 **
5. S-At 28.2 2.3 30.3 2.0 +2.1 1.0 **
6. Ar-Go 36.9 3.1 39.4 3.6 +2.5 1.1 **
7. N-ANS/ANS-Me 0.7 0.0 0.8 0.1 +0.1 0.0 **
8. S-Go/N-Me x 100 57.8 3.7 59.6 4.0 +1.8 0.9 **
9. N-S 63.6 2.8 65.7 2.9 +2.1 0.7 **
10. Go-Me 60.5 2.4 64.2 2.8 +3.7 1.6 **
11. ANS-PNS 45.7 2.4 48.3 2.5 + 2.6 1.6 **
12. Overbite - 3.8 1.3 1.1 0.9 + 4.9 1.2 **
13. _6~ ANSPNS 18.6 1.3 19.7 1.8 + 1.1 0.8 **
14. 6~ GoMe 27.1 2.0 29.1 2.5 +2.0 1.0 **
15. 1 ~ ANSPNS 24.4 1.6 27.0 2.0 +2.6 1.2 **
16. ]~ GoMe 34.1 3.1 37.2 2.3 +3.1 2.6 **
Angular
17. SN/GoMe 43.0 4.4 40.6 4.3 -2.4 0.9 **
18. SN/ANSPNS 8.9 1.5 10.4 2.4 + 1.5 1.5 **
19. ANSPNS/GoMe 34.1 3.8 30.2 4.1 - 3.9 2.1 **
20. NSAR 124.0 6.2 123.9 6.2 - 0.1 2.8
21. SArGo 147.2 6.5 146.5 7.2 - 0.7 2.2
22. ArGoMe 133.1 5.5 130.3 5.3 - 2.8 1.2 **
23. { < 2 0 - < 2 1 - <22 404.3 4.6 400.6 4.6 -3.7 2.3 **
24. SN/U.occ.plane 19.5 3.6 23.4 4.0 +3.9 2.1 **
25. GoMe/L.occ.plane 16.2 2.9 18.4 5.1 +2.2 3.6 *
26. SNA 78.4 3.0 78.1 2.9 - 0.3 1.2
27. SNB 74.3 2.8 74.4 2.7 + 0.1 1.4
28. ANB 4.1 1.6 3.7 1.3 -0.4 0.6 *
29. I_./ANSPNS 114.0 4.2 108.8 4.0 - 5.2 3.5 **
30. ]-/GoMe 91.7 5.7 91.4 5.4 - 0.3 3.0

*p _< 0.05; **p _< 0.01.

U.occ.plane, Upper occlusal plane; L.occ.plane, lower occlusal plane

t r e a t e d group t h e p a t i e n t s w e r e instructed to use their to each child to hold b e t w e e n the lips during h o m e w o r k
appliances for an average of 18 hours p e r day with and while watching television. A d e q u a t e overbite was
lip-seal training. A s already e m p h a s i z e d by Frfinkel and successfully established in all patients of the t r e a t e d
Frfinkel, 4-6 the most difficult part of functional o r t h o p e - group.
dics with t h e F R - 4 is to obtain the child's c o o p e r a t i o n in
lip-seal training. Therefore, on the basis of Frfinkel's Cephalometric analysis
experience, p a r e n t s and children w e r e i n f o r m e d that the
m o s t i m p o r t a n t aim of functional o r t h o p e d i c s was to All lateral c e p h a l o m e t r i c radiographs w e r e traced by
correct the existing facial disfigurement resulting from a a single investigator. All c e p h a l o m e t r i c r e f e r e n c e points
deviant postural p e r f o r m a n c e of the facial muscles. Ac- used in the p r e s e n t study are shown in Fig. 3. F o u r t e e n
cordingly, an u n d e r s t a n d i n g was achieved of how t h e linear m e a s u r e m e n t s (Fig. 4), 13 angular m e a s u r e m e n t s
F R - 4 appliance w o r k e d as an exercise device and that (Fig. 5), and 2 ratios w e r e analyzed on each radiograph.
lip-seal training was indispensable for overcoming a p o o r
postural behavior o f the orofacial musculature. P a r e n t s Statistical analysis
and children w e r e i n f o r m e d that c o m p e t e n t lip seal could
only be established w h e n " k e e p i n g the lips s e a l e d " was Descriptive statistics w e r e calculated for p r e s t u d y
p e r f o r m e d continuously. T h e p a r e n t s w e r e involved in and poststudy values and changes over the study period,
supporting the child and r e m i n d i n g him or h e r of the which w e r e defined as the poststudy value minus the
n e e d to maintain lip seal, and a plastic spatula was given prestudy value for each patient in all groups.
12 Erbay, U~ur, and (Jlgen American Journal of Orthodontics and Dentofacial Orthopedics
July 1995

8
43

Fig. 5. Angular measurements.

...........................................

Fig. 3. Cephalometric reference points.

/

--7

11J . . . . Z___

!
Fig. 6. Initial skeletal patterns of treated (red line) and control
31 (black line) groups,

Statistical analysis was performed by nonparametric

methods. The significance of changes across time that
occurred in all groups was determined with the Wilcoxon
matched-pairs signed-ranks test. The significance of dif-
ferences between independent groups was also studied
Fig. 4. Linear measurements. by means of the Mann-Whitney U test.
American Journal of Orthodontics and Dentofacial Orthopedics Erbay, U~ur, and ~osrn"en 1
Volume 108, No. 1
3

Table III. The pretreatment and posttreatment mean values of cephalometric measurements in boys of the
treated group (N : 7) and comparison of differences according to the Wilcoxon test
Pretreatment Posttreatment Difference

X~ S X S D S Wilcoxon test

Linear
1. N-Me 112.2 5.5 115.9 5.7 +3.7 2.3 *
2. N-ANS 46.0 3.1 49.1 3.5 +3.1 1.2 *
3. ANS-Me 66.1 4.3 66.7 4.9 + 0.6 1.6
4. S-Go 652 2.1 70.0 2.1 +4.8 2.2 *
5. S-Ar 29.8 1.9 32.4 2.1 +2.6 1.5 *
6. Ar-Go 39.2 1.5 41.4 1.8 +2.2 0.9 *
7. N-ANS/ANS-Me 0.7 0.1 0.8 0.i +0.1 0.0 *
8. S-Go/N-Me x 100 58.1 1.4 60.4 2.2 +2.3 1.2 *
9. N-S 66.9 3.0 68.7 3.0 + 1.8 0.9 *
10. Go-Me 60.6 1.6 64.7 2.1 +4.1 0.9 *
11. ANS-PNS 47.6 1.3 51.1 2.4 +3.5 2.1 *
12. Overbite - 4.2 1.4 1.2 0.9 + 5.4 1.4 *
13.6 ~ ANSPNS 18.9 1.6 21.8 2.4 +2.9 1.6 *
14. 6~ GoMe 28.1 1.2 29.2 1.3 + 1.1 1.1 *
15. 1 ~ ANSPNS 25.5 3.1 28.4 3.3 +2.9 1.4 *
16. T * G o M e 36.5 1.8 39.3 1.4 +2.8 1.4 *
Angular
17. SN/GoMe 43.9 3.4 40.5 3.8 - 3.4 1.1 *
18. SN/ANSPNS 5.7 3.7 6.9 4.0 + 1.2 0.7 *
19. ANSPNS/GoMe 38.2 5.5 33.7 6.2 - 4.5 1.1 *
20. NSAr 124.9 6.1 122.1 5.2 -2.8 2.1 *
21. SArGo 143.4 7.4 144.6 6.6 + 1.2 2.3
22. ArGoMe 137.1 5.7 133.4 4.9 -3.6 2.2 *
23. {<20- <21- <22 405.4 3.8 400.2 3.6 -5.2 1.6 *
24. SN/U.occ.plane 17.9 2.0 18.5 4.1 + 0.6 3.5
25. GoMe/L.occ.plane 17.7 3.0 22.5 2.6 +4.8 4.2 *
26. SNA 77.9 2.0 78.5 1.4 +0.6 1.4
27. SNB 73.4 2.1 75.0 2.4 + 1.6 1.0 *
28. ANB 4.5 1.1 3.6 1.2 -0.9 0.9 *
29. I_/ANSPNS 109.1 5.5 107.2 8.8 - 1.9 5.9
30. 1/GoMe 91.4 5.8 91.1 4.3 - 0.3 3.1

*p -< 0.05.

RESULTS parameters, respectively, out of 30 measurements.

Descriptive statistics and findings of the Wil- As will be seen in Table VIII, the statistically
coxon test for both sexes in treated and control significant changes in the treated group were de-
groups are found in Tables II to V. tected in 24 parameters. A proportion of changes
Comparisons of sex showed that statistically sig- observed during the treatment period was a result
nificant differences were seen in three parameters of growth. With the intention of determining the
(13.6 ~ ANSPNS, 24. SN/Upper Occlusal Plane treatment-induced genuine alterations by elimina-
Angle, 27. SNB) between girls and boys in the tion of those spontaneous changes due to growth,
treated group (Table VI), whereas in two param- changes occurring in the treated group were com-
eters (24. SN/Upper Occlusal Plane Angle, 27. SNB) pared with those evoked spontaneously in the con-
between girls and boys in the control group (Table trol group (Table IX). Therefore only the changes
VII). in 16 parameters that occurred in the treated group
Separations of sex in the treated and control were determined to be essentially related to the
groups were eliminated to evaluate the whole ma- treatment by FR-4 and lip-seal training (Table X).
terial, because sexual dimorphism in control and The data in Table X show that most linear
treated groups amounted to only two and three incremental changes in facial, mandibular, and
14 Erbay, U~ur, and (Jlgen American Journalof Orthodontics and Dentofacial Orthopedics
July 1995

Table IV. The pretreatment and postobservation mean values of cephalometric measurements in girls of
the control group (N : 13) and comparison of differences according to the Wilcoxon test
Preobservation Postobservation Difference

2 s 2 s s Wilcoxon test

Linear
1. N-Me 107.8 4.7 114.5 4.3 +6.7 2.8 **
2. N-ANS 46.0 2.1 49.1 2.9 +3.1 1.8 **
3. ANS-Me 61.8 3.9 65.4 3.7 +3.6 1.7 **
4. S-Go 62.9 3.7 65.8 3.3 +2.9 1.3 **
5. S-Ar 28.3 2.0 30.7 2.1 +2.4 0.8 **
6. At-Go 37.9 3.1 39.5 3.3 +1.6 1.8 **
7. N-ANS/ANS-Me 0.8 0.1 0.8 0.1 0.0 0.0
8. S-Go/N-Me × 100 58.3 2.1 57.5 2.0 -0.8 1.2 *
9. N-S 62.8 2.1 64.8 2.4 +2.0 1.0 **
10. Go-Me 58.6 3.8 64.2 4.4 +5.6 1.3 **
11. ANS-PNS 46.1 1.9 48.5 2.0 +2.4 1.6 **
12. Overbite -3.2 1.5 -1.5 1.8 +1.7 2.1 *
13.6 ~ ANSPNS 18.2 2.2 21.4 1.6 +3.2 2.1 **
14. 6~ GoMe 26.9 2.1 28.5 2.6 +1.6 1.2 **
15.1 ~ ANSPNS 24.7 2.1 27.4 2.4 +2.7 1.4 **
16. T ~ GoMe 34.8 2.8 37.1 2.7 +2.3 1.1 **
Angular
17. SN/GoMe 43.8 2.1 44.5 2.8 +0.7 2.1
18. SN/ANSPNS 9.7 2.6 9.7 3.7 0.0 2.9
19. ANSPNS/GoMe 34.1 2.3 34.9 2.1 +0.8 1.3
20. NSAr 126.3 7.0 128.7 7.7 +2.4 2.6
21. SArGo 144.2 9.5 142.9 10.3 -1.3 3.2
22. ArGoMe 133.4 4.1 133.9 5.1 +0.5 2.2
2 3 . { < 2 0 - < 2 1 - <22 404.0 2.2 405.6 3.0 +1.6 2.3
24. SN/U.oec.plane 19.7 3.6 21.2 3.9 +1.5 3.1
25. GoMe/L.occ.plane 17.4 3.0 19.6 4.0 +2.2 2.9
26. SNA 77,7 4.3 77.4 4.9 -0.3 1.5
27. SNB 73.4 3.5 73.0 3,9 -0.4 1.4
28. ANB 4.3 1.8 4.4 1.9 +0.1 0.9
29. 1/ANSPNS 112.6 5.4 112.0 5.7 -0.6 4.5
30. 1/GoMe 91.1 3.3 92.2 4.3 +1.1 2.9

*p _< 0.05; **p -< 0.01.

maxillary dimensions in both groups were signifi- Measurement of lower anterior facial height
cant over the time period studied. (ANS-Me) indicated that significant growth incre-
The salient finding of this investigation was the ment occurred in the control group but remained
closing of the anterior open bite in the treated almost constant in the treated group during 'the
group. The mean overbite was improved from same period. The mean incremental linear value
-3.95 to 1.1 mm with a mean increase of 5.0 mm in for lower anterior facial height in the control group
the treated group (Table VIII). However, overbite (ANS-Me: 4.3 mm) was also significantly greater
remained negative with a mean increase of 1.4 mm than in the treated group (ANS-Me: 0.6 mm).
in the control group (Table IX). The comparison of mean changes found for
In the treated group, total anterior facial height total posterior facial height (S-Go) in both groups
(N-Me) and upper anterior facial height (N-ANS) showed a statistically significant difference. The
showed an incremental increase of 3.9 mm and 3.3 rate of growth in total posterior facial height in the
ram, respectively. However, the control group dem- treated group (S-Go: 4.5 mm) exceeded that of the
onstrated a significantly greater increase in total control group (S-Go: 3.6 ram).
anterior facial height (N-Me: 7.3 mm), but a similar Both the ratio of upper to lower anterior facial
change in upper anterior facial height (N-ANS: 3.1 height (N-ANS/ANS-Me) and the quotient deter-
mm) when compared with the treated group. mining the total anterior to posterior facial height
American Journal of Orthodontics and Dentofacial Orthopedics Erbay, U~mr, and Uloen 15
Volume 108, No. 1

Table V. The preobservation and postobservation mean values of cephalometric measurements in boys of
the control group (N" 7) and comparison of differences according to the Wilcoxon test
Preobservation Postobservation Difference

y, S X" s s Wilcoxon test

Linear
1. N-Me 114.7 3.7 123.2 5.1 +8.5 2.0 *
2. N-ANS 46.4 1.9 49.4 2.8 +3.0 1.4 *
3. ANS-Me 68.3 4.4 73.8 6.7 +5.5 2.8 *
4. S-Go 67.9 3.7 72.8 6.4 +4.9 3.7 *
5. S-Ar 31.7 2.7 34.3 2.3 +2.6 1.7 *
6. Ar-Go 40.1 3.6 43.1 5.8 +3.0 3.6
7. N-ANS/ANS-Me 0.7 0.1 0.7 0.1 0.0 0.0
8. S-Go/N-Me x 100 59.2 2.8 59.1 4.0 -0.1 2.2
9. N-S 65.9 2.5 68.5 3.2 +2.6 0.9 *
10. Go-Me 60.7 2.6 67.6 3.6 +6.9 1.8 *
11. ANS-PNS 48.5 1.4 51.5 2.0 +3.0 1.2 *
12. Overbite - 3.9 1.1 - 3.0 1.6 +0.9 0.9 *
13.6 ~ ANSPNS 21.3 2.4 24.6 3.3 +3.3 2.8 *
14. 6~ GoMe 29.9 1.4 31.9 1.9 +2.0 1.5 *
15. 1 ~ ANSPNS 27.5 3.4 29.4 3.0 +1.9 0.8 *
16. T ~ GoMe 37.7 1.6 40.6 2.6 +2.9 1.4 *
Angular
17. SN/GoMe 43.7 4.9 44.4 5.5 +0.7 1.6
18. SN/ANSPNS 7.8 3.7 7.7 3.2 0.1 1.4
19. ANSPNS/GoMe 35.9 4.9 36.7 5.0 +0.8 1.8
20. NSAr 126.0 2.4 126.4 3.5 +0.4 1.9
21. SArGo 141.2 3.8 141.2 4.6 0.0 2.5
22. A r G o M e 137.3 4.3 136.6 5.0 -0.7 2.5
23. { < 2 0 - <21 - <22 404.5 4.7 404.2 6.1 -0.3 3.1
24. SN/U.occ.plane 19.1 3.7 18.0 3.6 -1.1 0.8
25. GoMe/L.occ.plane 16.9 3.9 19.5 4.3 +2.6 3.4
26. SNA 77.8 3.4 78.4 3.4 +0.6 1.0
27. SNB 73.6 2.8 74.7 3.5 +1.1 2.1
28. ANB 4.2 2.1 3.7 3.0 -0.5 1.4
29. _I/ANSPNS 112.6 4.5 113.0 5.1 +0.4 5.0
30. T/GoMe 90.5 6.0 90.4 3.9 -0.1 3.9

*p _< 0.05.

ratio (S-Go/N-Me x 100) in the treated group increase of upper posterior dentoalveolar height in
showed a significant increase of 0.1 and 2.0, respec- the control group (6 ~ ANSPNS: 3.2 mm) was al-
tively, during the treatment period. In contrast, the most twice that of the treated group (6 ~ ANSPNS:
ratio of N-ANS/ANS-Me was unchanged and a 1.8 mm) for the same period.
significant decrease was observed in the quotient The data in Table X show that most angular
expressing the ratio S-Go/N-Me in the control changes in the treated group were statistically sig-
group over the time period studied. nificant compared with the changes of the control
The data in Table X show that differential group over the study period.
mandibular corpus growth was observed in both The SN/GoMe and ANSPNS/GoMe angles
groups for the same period. The amount of mean showed a significant decrease of 2.8 ° and 4.6 °,
mandibular corpus incremental growth (Go-Me) in respectively, whereas the SN/ANSPNS angle in-
the treated group was 3.8 mm, and this value was creased an average of 1.4° in the treated group.
approximately two thirds of the corresponding con- In contrast, the data of the control group showed
trol groups value (Go-Me: 6.0 mm). that the SN/GoMe and ANSPNS/GoMe angles
The upper posterior dentoalveolar height (6 increased, whereas the SN/ANSPNS angle de-
ANSPNS) increased significantly in both groups. creased slightly during the observation period.
However, it is of interest that the mean incremental In the treated group, the NSAr angle decreased
16 Erbay, U~ur, and (llgen American Journal of Orthodontics and Dentofacial Orthopedics
July 1995

Table VI. Comparison of differences between girls and boys in the treated group according to the
Mann-Whitney U test
Treated group girls (N : 13) Treated group boys (N : 7)

S Wileoxon test -D ] S Wilcoxon test Mann-Whitney U test

I
Linear
1. N - M e +4.0 1.7 ** +3.7 2.3 *
2. N - A N S +3.4 1.2 ** +3.1 1.2 *
3. A N S - M e +0.7 1.6 +0.6 1.6
4. S - G o +4.4 1.3 ** +4.8 2.2 *
5. S - A r +2.1 1.0 ** +2.6 1.5 *
6. A r - G o +2.5 1.1 ** +2.2 0.9 *
7. N - A N S / A N S - M e +0.1 0.0 ** +0.1 0.0 *
8. S - G o / N - M e × 100 +1.8 0.9 ** +2.3 1.2 *
9. N - S +2.1 0.7 ** +1.8 0.9 *
10. G o - M e +3.7 1.6 ** +4.1 0.9 *
11. A N S - P N S +2.6 1.6 ** +3.5 2.1 *
12. O v e r b i t e +4.9 1.2 ** +5.4 1.4 *
13.6 ~ ANSPNS + 1.1 0.8 ** +2.9 1.6 * ##
14. 6~ G o M e +2.0 1.0 ** +1.1 1.1 *
15. _1~ A N S P N S +2.6 1.2 ** +2.9 1.4 *
16. T ~ G o M e +3.1 2.6 ** +2.8 1.4 *
Angular
17. SN/GoMe -2.4 0.9 ** -3.4 1.1 *
18. SN/ANSPNS + 1.5 1.5 ** + 1.2 0.7 *
19. ANSPNS/GoMe - 3.9 2.1 ** - 4.5 1.1 *
20. NSAr -0.1 2.8 -2.8 2.1 *
21. SArGo -0.7 2.2 +1.2 2.3
22. ArGoMe -2.8 1.2 ** -3.6 2.2 *
23. {<20- <21- <22 -3.7 2.3 ** -5.2 1.6 *
24. SN/U.occ.plane + 3.9 2.1 ** + 0.6 3.5 #
25. GoMe/L.occ.plane + 2.2 3.6 * + 4.8 4.2 *
26. SNA -0.3 1.2 +0.6 1.4
27. SNB +0.1 1.4 +1.6 1.0 * #
28. ANB -0.4 0.6 * -0.9 0.9 *
29. _I/ANSPNS - 5.2 3.5 ** - 1.9 5,9
30. ]/GoMe -0.3 3.0 -0.3 3,1

*p < 0.05; **p -< 0.01; # p <- 0.05; # # p < 0.01.

an average of 1.0 °, whereas the average change in age of only 0.3 ° in the control group. However, in
the A r G o M e angle was a decrease of 3.1 °. Similarly, the treated group, the degree of retrusion of the
the treated group demonstrated a considerable upper incisors relative to palatal plane was 4.0 ° .
decrease of 4.2 ° in the sum of the saddle (NSAr), The improvement in axial inclination of the upper
joint (SArGo), and gonial (ArGoMe) angle. All incisors was found to be statistically significant in
these changes were significantly different from the the treated group.
changes determined in the control group.
The SN/Upper Occlusal Plane angle increased DISCUSSION
an average of 2.8 ° in the treated group, whereas the For better understanding of the findings of this
change in this measurement was an increase of only study, polygons were drawn by using mean values
0.6 ° in the control group. An increase of this angle obtained at initial and terminal stages of both
in the treated group was significantly greater than treated and control groups, and these polygons
in the control group. were superimposed at Sella along the SN line (Figs.
The angulation of the upper incisors to the 6, 7 and 8). The initial skeletal patterns of the
palatal plane (I_/ANSPNS) remained almost con- treated and control groups are seen to be analo-
stant during the study period, decreasing an aver- gous in Fig. 6. In Fig. 7, spontaneous changes due
American Journal of Orthodontics and Dentofacial Orthopedics Erbay, U~ur, a n d ~o6tr/"en
Volume 108,No. 1 17

Table VII. C o m p a r i s o n of differences b e t w e e n girls a n d boys in the control group according to the
M a n n - W h i t n e y U test

Control group girls (N : 13) Control group boys (N : 7)

-D S Wilcoxon test -D S Wilcoxon test Mann- Whitney U test

Linear
1. N-Me +6.7 2.8 ** +8.5 2.0 *
2. N-ANS +3.1 1.8 ** +3.0 1.4 *
3. ANS-Me +3.6 1.7 ** +5.5 2.8 *
4. S-Go +2.9 1.3 ** +4.9 3.7 *
5. S-Ar +2.4 0.8 ** +2.6 1.7 *
6. Ar-Go + 1.6 1.8 ** +3.0 3.6
7. N-ANS/ANS-Me 0.0 0.0 0.0 0.0
8. S-Go/N-Me x 100 -0.8 1.2 * -0.1 2.2
9. N-S +2.0 1.0 ** +2.6 0.9 *
10. Go-Me +5.6 1.3 ** +6.9 1.8 *
11. ANS-PNS +2.4 1.6 ** +3.0 1.2 *
12. Overbite + 1.7 2.1 * + 0.9 0.9 *
13.6 ~ ANSPNS +3.2 2.1 ** +3,3 2.8 *
14. 6~ GoMe +1,6 1.2 ** +2.0 1.5 *
15.11 ANSPNS + 2.7 1.4 ** + 1.9 0.8 *
16. ]-~ GoMe +2.3 1.1 ** +2.9 1.4 *
Angular
17. SN/GoMe +0.7 2,1 +0.7 1.6
18. SN/ANSPNS 0.0 2.9 -0.1 1.4
19. ANSPNS/GoMe + 0.8 1.3 + 0.8 1.8
20. NSAR +2.4 2.6 ** +0.4 1.9
21. SArGo - 1.3 3.2 0.0 2.5
22. ArGoMe +0.5 2.2 -0.7 2.5
2 3 . { < 2 0 - < 2 1 - <22 +1.6 2.3 * -0.3 3.1
24. SN/U.occ.plane + 1.5 3.1 - 1.1 0.8 *
25. GoMe/L.occ.plane + 2.2 2.9 * + 2.6 3.4
26. SNA - 0.3 1.5 + 0.6 1.0
27. SNB -0.4 1.4 +1.1 2.1
28. ANB +0.1 0.9 -0.5 1.4
29. I_JANSPNS - 0.6 4.5 + 0.4 5.0
30. ]/GoMe + 1.1 2.9 -0.1 3.9

*p _< 0.05; **p _< 0.01; #p _< 0.05.

to growth o b s e r v e d in the c o n t r o l g r o u p d u r i n g a F R - 4 appliance. It a p p e a r s most likely that this

2-year p e r i o d are seen. However, in Fig. 8, alter- r e d u c t i o n in m a n d i b u l a r p l a n e angles was the result
ations that arose d u r i n g a 2-year p e r i o d in the of differential increase b e t w e e n total posterior a n d
t r e a t e d g r o u p are observed. a n t e r i o r facial height (4.5 a n d 3.9 mm, respect-
U p w a r d a n d forward m a n d i b u l a r r o t a t i o n in the ively) over the study period. G r e a t e r posterior
t r e a t e d g r o u p was a most i m p o r t a n t finding in this vertical growth w o u l d result in a lowering of the
investigation ( T a b l e X, Figs. 7 a n d 8). T h e reduc- gonial region a n d s u b s e q u e n t u p w a r d a n d forward
tion in m a n d i b u l a r p l a n e angles (17. S N / G o M e , m a n d i b u l a r rotation. Theoretically, Frfinkel a n d
1 8 . A N S P N S / G o M e ) o c c u r r e d despite a concomi- Frfinkel 4-6 explained this r o t a t i o n m e c h a n i s m with
t a n t i n c r e a s e in total a n t e r i o r facial height. How- the possible effect of the f u n c t i o n r e g u l a t o r ' s buc-
ever, the rate of growth increase in total a n t e r i o r cal shields a n d lip seal exercises. T h e y hypothe-
facial height in the t r e a t e d g r o u p was diminished, sized that the posterior edges of the buccal shields
while the increase in total posterior facial height are deeply p o s i t i o n e d in the v e s t i b u l a r sulcus a n d
was stimulated. T h e overall d i m i n i s h m e n t in total provoke p r e s s u r e s e n s a t i o n in this area. This could
a n t e r i o r facial height growth was d u e to successful cause the inferior t r a n s l a t i o n of the posterior p a r t
i n h i b i t i o n of lower a n t e r i o r facial growth by the of the m a n d i b l e with a c o m p e n s a t o r y translative
18 Erbay, U~ur, and (Ylgen American Journal of Orthodontics and Dentofacial Orthopedics
July 1995

Table VIIh The pretreatment and posttreatment mean values of cephalometric measurements in the
treated group (N" 20 = 13 girls and 7 boys) and comparison of differences according to the
Wilcoxon test
Pretreatment Posttreatment Difference
2 s 2 s S Wilcoxon test

Linear
1. N-Me 109.3 4.7 113.2 5.0 +3.9 1.8 ***
2. N-ANS 45.8 2.2 49.1 2.4 +3.3 1.2 ***
3. ANS-Me 63.5 3.9 64.1 4.5 +0.6 1.6
4. S-Go 63.3 4.1 67.8 4.5 +4.5 1.6 ***
5. S-At 28.8 2.2 31.0 2.3 +2.2 1.2 ***
6. Ar-Go 37.7 2.8 40.1 3.2 +2.4 1.0 ***
7. N-ANS/ANS-Me 0.7 0.1 0.8 0.1 +0.1 0.0 ***
8. S-Go/N-Me x 100 57.9 3.1 59.9 3.4 +2.0 1.0 ***
9. N-S 64.7 3.2 66.8 3.2 +2.1 0.7 ***
10. Go-Me 60.6 2.1 64.4 2.5 +3.8 1.4 ***
11. ANS-PNS 46.4 2.2 49.3 2.8 +2,9 1.8 ***
12. Overbite -3.9 1.3 1.1 0.9 +5.0 1.3 ***
13.6 ~ ANSPNS 18.7 1.4 20.5 2.2 +1.8 1.4 ***
14. 6~ Go Me 27.5 1.8 29.2 2.1 +1.7 1.1 ***
15.1 ~ ANSPNS 24.8 2.2 27.5 2.6 +2.7 1.2 ***
16. T ~ Go Me 34.9 2.9 37.9 2.3 +3.0 2.3 ***
Angular
17. SN/GoMe 43.3 4.0 40.1 4.1 -2.8 1.1 ***
18. SN/ANSPNS 7.8 2.8 9.2 3.4 +1.4 1.3 ***
19. ANSPNS/GoMe 35.5 4.8 30.9 4,8 -4.6 2.6 ***
20. NSAr 124.3 6.0 123.3 5.8 - 1.0 2.8
21. SArGo 145.9 6.9 145.8 6.9 -0.1 2.4
22. ArGoMe 134.5 5.7 131.4 5.3 -3.1 1.6 ***
23. { < 20 - < 21 - < 22 404.7 4.2 400.5 4.2 4.2 2.2 ***
24. SN/U.occ.plane 19.0 3.2 21.7 4.6 +2.7 3.0 **
25. GoMe/L.occ.plane. 16.7 3.0 19.8 4.7 +3.1 3.9 **
26. SNA 78.3 2.6 78.3 2.5 0.0 1.3

27. SNB 74,0 2.6 74.6 2.5 +O.6 1.5

28. ANB 4,2 1.4 3.6 1.2 -0.6 0.7 **
29. !/ANSPNS 112,3 5.2 108.3 5.9 -4.0 4.6 **
30. l/GoMe 91.6 5.6 91.3 5.0 -0.3 2.9

**p _< 0.01; ***p _ 0.001.

growth at the condyles, leading to an increase in due to increased masticatory muscle strength, in-
ramus length. They suggested that, concomitant stead of increased mandibular condylar growth.
with the lowering of the posterior part of the Another noteworthy finding in this study was a
mandible, its anterior part could be raised with the reduction of the rate of mandibular corpus growth.
posterior edges of the FR as a rotational center. Mandibular corpus growth increment value in the
They concluded that such a forward rotation of the treated group was nearly two thirds that of the
mandible was brought about by the force of the control group. As suggested by Fr/inkel and
vertical muscle chain being strengthened by lip seal Frfinkel, 6 "no wax is applied to the frontal region of
exercises. This hypothesis is supported by the find- the mandibular cast because the lip pads are not
ings of Ingervall and Bitsanis. 9 They found consid- intended to stimulate alveolar basal development
erable anterior mandibular rotation in children by exerting tension on the connective tissue fibers
with long-face structure during muscle training in the depth of frontal vestibular sulcus." So it
with chewing gum. However, Ingervall and Bitsanis 9 seems reasonable to assume that this finding might
suggested the anterior mandibular rotation could be attributable to the effect of the FR-4 appliance.
be explained by reduced midfacial vertical growth Incremental increase in the upper posterior
American Journalof Orthodontics and Dentofacial Orthopedics Erbay, U~ur, and ~1"en
19
Volume 108, No. 1

Table IX. The preobservation and postobservation mean values of cephalometric measurements in the
control group (N : 20 = 13 girls and 7 boys) and comparison of differences according to the
Wilcoxon test
Preobservation Postobservation Difference

s 2 s ~ s Wilcoxon test

Linear
1. N-Me 110.2 5.4 117.5 6.2 +7.3 2.6 ***
2. N-ANS 46.2 2.0 49.2 2.8 +3.0 1.7 ***
3. ANS-Me 64.1 5.1 68.3 6.3 +4.2 2.3 ***
4. S-Go 64.6 4.4 68.2 5.6 +3.6 2.5 ***
5. S-Ar 29.5 2.8 32.0 2.7 + 2.5 1.2 ***
6. Ar-Go 38.7 3.4 40.8 4.5 +2.1 2.5 **
7. N-ANS/ANS-Me 0.7 0.1 0.7 0.1 0.0 0.0
8. S-Go/N-Me x 100 58.6 2.4 58.0 2.9 -0.6 1.6 *
9. N-S 63.9 2.7 66.2 3.2 +2.3 1.0 ***
10. Go-Me 59.3 3.5 65.3 4.4 +6.0 1.6 ***
11. ANS-PNS 46.9 2.1 49.5 2.4 +2.6 1.5 ***
12. Overbite -3.5 1.4 - 2.1 1.8 + 1.4 1.8 **
13.6 ~ ANSPNS 19.3 2.7 22.5 2.7 +3.2 2.3 ***
14. 6~ GoMe 28.0 2.3 29.7 2.7 + 1.7 1.3 ***
15. 1 ~ ANSPNS 25.7 2.9 28.1 2.7 +2.4 1.3 ***
16. ]~ GoMe 35.9 2.8 38.4 3.1 +2.5 1.2 ***
Angular
17. SN/GoMe 43.8 3.2 44.5 3.8 +0.7 1.9
18. SN/ANSPNS 9.0 3.1 9.0 3.6 0.0 2.4
19. ANSPNS/GoMe 34.7 3.4 35.5 3.4 + 0.8 1.5 *
20. NSAr 126.2 5.7 127.9 6.5 + 1.7 2.6 **
21. SArGo 143.2 8.0 142.3 8.6 -0.9 3.0
22. ArGoMe 134.8 4.5 134.9 5.1 + 0.1 2.3
23. { < 2 0 - < 2 1 - <22 404.2 3.2 405.1 4.3 +0.9 2.7
24. SN/U.occ.plane 19.5 3.5 20.1 4.0 + 0.6 2.8
25. GoMe/L.occ.plane 17.2 3.2 19.6 4.0 + 2.4 3.0 **
26. SNA 77.7 3.9 77.7 4.4 0.0 1.4
27. SNB 73.4 3.2 73.6 3.7 + 0.2 1.8
28. ANB 4.3 1.9 4.2 2.3 -0.1 1.1
29. _I/ANSPNS 112.7 5.0 112.4 5.5 - 0.3 4.6
30. T/GoMe 90.9 4.3 91.6 4.2 + 0.7 3.2

*p -< 0.05; **p -< 0.01; ***p -< 0.001.

dentoalveolar height in the treated group was posterior midfacial structures and the correction on
found to be almost half that in the control group. the mandibular steepness, therefore, apparently is
The occlusal rests of the FR-4 appliance on the not due to mechanical interruption of sutural or
upper first molars appear to restrict the rate of alveolar growth of the posterior portion of the
growth in upper posterior dentoalveolar structures. maxilla." However, their assumption is limited to
Several authors9-12 have stressed that the intrusion the on the tracing of a single case. 4-6
of the posterior teeth can cause autorotation of the The decrease in upper incisor angulation to the
mandible anteriorly. However, the inhibition of palatal plane in the treated group was remarkably
growth in upper posterior dentoalveolar height greater than that of the control group. The labial
found in this study is not in agreement with the bow of the FR-4 contacts the upper incisors when
opinion of Frfinkel and Frfinkel. 4-6 They suggest the lips are sealed. 6 Therefore the effect of lip seal
that "the FR appliance may not have had any training with the FR-4 appliance also becomes
intrusive effect on the maxillary molars or a depres- apparent by the improvement in axial inclination of
sive function on the vertical development of the the upper incisors.
20 Erbay, U~ur, and Ulgen American Journal of Orthodontics and Dentofacial Orthopedics
July 1995

!/
//
//
//

//
i~

//
//

\
./
Fig. 8. Alterations arising during 2-year treatment period in
Fig. 7. Spontaneous changes in control group during 2-year treated group (red line; initial skeletal pattern and black line;
observation period (red line; initial skeletal pattern and black terminal skeletal pattern).
line; terminal skeletal pattern).

Table X. Comparison of differences between the treated and control groups according to the
Mann-Whitney U test
Treated group (N : 20) Control (N : 20)

S Wilcoxon test D S Wilcoxon test Mann-Whitney U test

Linear
1. N - M e +3.9 1.8 *** +7.3 2.6 *** ###
2. N - A N S +3.3 1.2 *** +3.0 1.7 ***
3. A N S - M e +0.6 1.6 +4.2 2.3 *** ###
4. S - G o +4.5 1.6 *** +3.6 2.5 *** #
5. S - A r +2.2 1.2 *** +2.5 1.2 ***
6. A t - G o +2.4 1.0 *** +2.1 2.5 **
7. N - A N S / A N S - M e +0.1 0.0 *** 0.0 0.0 ###
8. S - G o / N - M e × 100 +2.0 1.0 *** -0.6 1.6 * ###
9. N-S +2.1 0.7 *** +2.3 1.0 ***
10. G o - M e +3.8 1.4 *** +6.0 1.6 *** ###
11. A N S - P N S +2.9 1.8 *** +2.6 1.5 ***
12. O v e r b i t e +5.0 1.3 *** +1.4 1.8 ** ###
13.6 ~ ANSPNS +1.8 1.4 *** +3.2 2.3 *** #
14. 6~ G o M e +1.7 1.1 *** +1.7 1.3 ***
15.1 ~ ANSPNS +2.7 1.2 *** +2.4 1.3 ***
16. ] ~ G o M e +3.0 2.2 *** +2.5 1.2 ***
Angular
17. SN/GoMe -2.8 1.1 *** +0.7 1.9 ###
18. SN/ANSPNS + 1.4 1.3 *** 0.0 2.4 #
19. ANSPNS/GoMe -4.6 2.6 *** +0.8 1.5 * ###
20. NSAr - 1.0 2.8 + 1.7 2.6 ** ##
21. SArGo -0.1 2.4 -0.9 3.0 ##
American Journal of Orthodontics and Dentofacial Orthopedics Erbay, Ug~ur, and ~,6D/-en
Volume 108, No. 1
21

Table X. Cont'd.

Treated group (N : 20) Control (N:20)

S Wilcoxon test S Wilcoxon test Mann-Whitney U test

Angular
22. ArGoMe -3.1 1.6 *** +0.1 2.3 ###
2 3 . { < 2 0 - < 2 1 - <22 -4.2 2.2 *** +0.9 2.7 ###
24. SN/U.occ.plane + 2.7 3.0 ** +0.6 2.8 ##
25. GoMe/L.occ.plane + 3.1 3.9 ** +2.4 3.0
26. SNA 0.0 1.3 0.0 1.4
27. SNB +0.6 1.5 +0.2 1.8
28. ANB -0.6 0.7 ** -0.1 1.1
29. 1/ANSPNS -4.0 4.6 ** -0.3 4.6 ##
30. 1/GoMe - 0.3 2.9 +0.7 3.2

*p _< 0.05; **p -< 0.01; ***p -< 0.001; #p < 0.05; # # p < 0.001.

SUMMARY AND CONCLUSIONS 5. Frfinkel R, Fr/inkel C. A functional approach to treatment

of skeletal open bite. AM J ORTHOD 1983;84:54-68.
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the FR-4 appliance had significant effects on the tion regulator. Basel: Karger, 1989:40-1, 46, 89, 186-208.
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Berlin: VEB Verlag Volk und Gesundheit, 1973:38-9, 86,
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102-3, 103-5.
It was concluded that as a result of treatment of 8. Greulich WW, Pyle SI. Radiographic atlas of skeletal devel-
these anomalies with the FR-4 appliance and lip- opment of the hand and wrist. Stanford, California: Stan-
seal training, the growth and development pattern ford Oxford University Press, 1970.
of the mandible was altered. The spontaneous 9. Ingervall B, Bitsanis E. A pilot study of the effect of
downward and backward growth direction of the masticatory muscle training on facial growth in long-face
children. Eur J Orthod 1987;9:15-23.
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was changed to a upward and forward direction by loaded posterior bite-block on the maxillo-facial morphol-
FR-4 therapy, allowing the skeletal anterior open ogy. Eur J Orthod 1992;14:54-60.
bite to be successfully corrected through upward 11. Kiliaridis S, Egermark I, Thilander B. Anterior open bite
and forward mandibular rotation. treatment with magnets. Eur J Orthod 1990;12:447-57.
12. Woodside DG, Linder-Aronson S. Progressive increase in
lower anterior face height and the use of posterior occlusal
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