Med Oral Patol Oral Cir Bucal. 2012 Jul 1;17 (4):e689-96.

Cranial base and maxillary changes with frankel’s regulator

Journal section: Clinical and Experimental Dentistry doi:10.4317/medoral.17631

Publication Types: Research http://dx.doi.org/doi:10.4317/medoral.17631

Cranial base and maxillary changes in patients treated

with Frankel’s functional regulator (1b)

Juan-Jose Alió-Sanz 1, Carmen Iglesias-Conde 2, Jose Lorenzo-Pernía 3, Alejandro Iglesias-Linares 4, Asun-

ción Mendoza-Mendoza 5, Enrique Solano-Reina 6

1
DDS, MS, PhD. Professor of orthodontics, Complutense University of Madrid, Spain
2
DDS, PhD.Private practice, Orense, Spain
3
DDS , PhD.Associate professor, Department of orthodontics, Complutense University of Madrid
4
DDS , MSc, PhD.Lecturer Masters Programme in Orthodontics and Dentofacial Orthopaedics School of Dentistry. University
of Seville
5
DDS , MSc, PhD.Professor of paedriatic dentistry, University of Seville. Spain
6
DDS , MSc, PhD.Chairman of orthodontics, University of Seville. Spain

Correspondence:
University of Seville, Spain
41009 Seville (Spain)
aiglesiaslinares@gmail.com Alió-Sanz JJ, Iglesias-Conde C, Lorenzo-Pernía J, Iglesias-Linares A,
Mendoza-Mendoza A, Solano-Reina E����������������������������������
. ��������������������������������
Cranial base and maxillary chan-
ges in patients treated with Frankel’s functional regulator (1b). Med Oral
Patol Oral Cir Bucal. 2012 Jul 1;17 (4):e689-96.
Received: 29/03/2011 http://www.medicinaoral.com/medoralfree01/v17i4/medoralv17i4p689.pdf
Accepted: 16/09/2011
Article Number: 17631 http://www.medicinaoral.com/
© Medicina Oral S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: medicina@medicinaoral.com
Indexed in:
Science Citation Index Expanded
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Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emcare
Indice Médico Español

Abstract
Objectives: The purpose of this study was to assess cranial base and maxillary growth in patients with Class II-
type I malocclusions when treated with Frankel’s functional regulator (FR-1b).
Study Design: The treatment group was made up of 43 patients that were divided into two groups: prepubescent (n:
28), and pubescent (n: 15). The control group included 40 patients who did not receive any kind of treatment and
were likewise divided into a prepubescent group (n: 19), and a pubescent group (n: 21). A computerized cephalo-
metric study was carried out and superimpositions were done in order to assess the antero-posterior, vertical and
rotational movement of the maxilla. Results: The results indicate that anterior cranial length is not affected by the
regulator but the cranial deflection of the treatment group was diminished. Although a slight counterclockwise
rotation effect on the upper jaw was observed due to treatment, no growth restriction of the maxilla in a vertical or
antero-posterior direction was observed compared to other non-treated Class II-type I malocclusion patients.
Conclusion: The functional regulator does not have any effect on anterior cranial length, but it does affect the
angulation of the cranial base. According to our results, the appliance has demonstrated a flattening effect of the
cranial base (p<0.05) in the treated sample. The functional regulator induces counterclockwise rotation rather
than vertical or sagittal changes in the maxilla.

Key words: Orthodontics, frankel regulator, class II treatment, cephalometry, superimposition.

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Introduction Material and Methods

Class II-type 1 malocclusion is a common clinical pro- In order to assess any potential change in skeletal struc-
blem in orthodontics, with approximately 15%-30% of tures of the maxilla and the cranial base due to FR
North American children and 20%-30% of all orthodon- treatment, a retrospective cephalometric study was per-
tic patients having this type of dentoskeletal imbalance formed in Class II-type I malocclusion patients.
(1) and represents approximately 50% of all orthodontic Sample
treatment in a European representative sample (2). Of A total of 83 Caucasian individuals were selected con-
the various treatment strategies for Class II treatment, secutively for four years for inclusion in the study be-
muscular and presumable skeletal regulation through cause they came to the Department of Orthodontics of
Frankel’s 1b appliance has been for decades one of the the Complutense University of Madrid for dental scree-
most widely used treatments for Class II malocclusions ning. Of the total number of patients, only 43 patients
in prepuberal children. Despite this protocol being (18 boys/25 girls) met the following inclusion-exclusion
so widespread, there is relatively little information in criteria for being included in the treated sample (FR-
the literature about the dentoskeletal changes of this group): 1) Class II-type I malocclusion; 2) No craniofa-
2-phase nonextraction Class II therapy in adolescents cial abnormalities; 3) Subspinal to nasion to supramen-
or young adults in relation to other skeletal structures ton (ANB) angle or convexity equal to or greater than
besides those changes that take place in the mandibular 5º; 4) Non-dolichofacial growth pattern; 5) No hypodon-
bone (3,4). tia or dental inclusions or extractions; 6) No previous
The aim of this cephalometric study was to evaluate the maxillofacial surgery; 7) Treatment with a functional
role of upper jaw skeletal modifications on the outcomes regulator type-Ib exclusively; 8) Treatment period bet-
of this type of nonextraction Class II therapy as well ween the ages of 8-14 years old; 9) Caucasian origins.
as other potential effects on the cranial base between The control sample (Ct-group) included 40 patients (22
groups. boys/18 girls) with identical inclusion-exclusion crite-
Whether the functional regulator (FR) induces a sti- ria but who have not undergone any kind of orthodontic
mulatory effect on lower jaw growth in Class II type I treatment. These patients refused orthodontic treatment
patients (5-8) or whether it just forces a reaccommoda- but were admitted to take part in the growth study per-
ting anterior positional change (9) has not yet been fully formed by the Department of Orthodontics of the Com-
clarified. Most short-term and long-term studies done plutense University of Madrid. FR and Ct-groups were
to date have found an increase in anterior mandibular both divided in two additional subgroups, prepubescent
growth in patients treated with a FR compared to pa- (8-11 years old; n:28; 12 boys-16 girls) and pubescent
tients in control groups (6,7). Along these lines, some (12-14 years old; n:15; 6 boys - 9 girls) in order to com-
authors (10) observed a statistically significant increase pare different growth stages. FR group: prepubescent
in mandibular length due to FR treatment. Neverthe- (n:28; 12 boys-16 girls) and pubescent (n:15; 6 boys -
less, an elegant study carried out by McNamara et al. 9 girls). Ct-group: prepubescent (n:19; 10 boys-9 girls)
(11) has questioned whether Class II corrective results and pubescent (n:21; 12 boys - 9 girls).
were just the expression of an anterior positional change Functional regulator appliance
rather than an effect of increased mandibular length. The FR was constructed according Frankel’s design
On the other hand, the upper jaw is another skeletal struc- (5,23,24). The construction bite was obtained using a
ture potentially modified in FR Class II treatments. Stu- direct functional chew-in technique in neutrocclusion
dies on normal craniofacial growth showed a downwards with 2-4mm wax height. The average treatment period
and forwards maxillary growth pattern with substantial was 1year and 6months. Instructions were given to use
interindividual variation (12,13). Findings on FR effects the appliance for 1hour/day for the first 15days, 3hours/
on the maxilla are often contradictory. Many studies de- day for the next 15days, then in addition to the three
fended the idea that anterior maxillary growth is restric- hours during the day to wear the appliance at night for
ted during treatment, (14-17) while others have noticed one month, and finally to use the appliance all day and
a downwards redirection of upper jaw growth inducing night.
a clockwise slope in the palatal plane (7,16,18,19). Still Cephalometric records
other authors have found no effects on the upper jaw due Lateral x-rays were obtained with a Siemens-Palomex-OY
to FR Class II treatment (11, 20-22). x-ray machine, and cephalometric tracings were done with
Whether the FR induces a stimulatory effect on cranial the NemotecDental-Studio (v.2.0.0.1) orthodontic soft-
base growth on Class II-type I patients or whether it ware with reference to the landmarks shown in (Fig. 1).
causes changes in the cranial base slope in growing pa- The lines and angles described in (Fig. 2) were traced
tients has not yet been determined. for the comparative measurements. All cephalometric
measurements were performed by two independent re-
searchers following same criteria (25).

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Reliability of the method

All the cephalometries were traced by two experimen-
ted researchers (J.A.S. and C.I.C.) belonging to the
general research project on growth carried out in the
Master’s Program in Orthodontics at the Universidad
Complutense of Madrid. These researchers calibrate
their measurements annually to avoid any error in the
cephalometric tracings. In order to estimate the intra-
examiner variation for the radiological evaluation all
the radiographs were evaluated twice by the same expe-
rienced examiner (J.A.S.). In order to estimate the inter-
examiner variation all the radiographs were evaluated
by a second experienced examiner (C.I.C.).
Once both researchers have performed the tracings,
they were compared to each other thereby obtaining one
of three distinct possibilities:
1) Type I Concordance: total coincidence of the tra-
cings.
2) Type II Concordance: difference in some parame-
ter among the tracings that are less than the following
values: Anterior cranial length(CC-N): Less than 1mm;
Fig. 1. Cephalometric measurements used in this study. Cranial deflection(N-Ba/Po-Or): Less than 1º; SNA an-
N(nasion), S(sella turcica), Ba(basion), Cf(pterygomaxillary),
Po(porion), Or(suborbital), A(point A), ANS(anterior nasal spine), gle: Less than 30; Maxillary depth(Po-Or/N-A): Less
PNS(posterior nasal spine), Co(condylion). than 30; Distance from point A to the nasion perpen-

Fig. 2. Superimposition of the maxilla. Ba-N plane at Nasion point.

Anterior cranial length(CC-N): distance between CC and nasion.; Cranial deflection(N-Ba/Po-Or): angle formed between the basion-na-
sion plane and the Frankfurt plane; SNA angle: angle formed by the sella turcica-nasion(S-N) and nasion-point A(N-A) planes; Maxillary
depth(Po-Or/N-A): angle formed by the Frankfurt plane and the N-A plane; Distance from point A to the nasion perpendicular to Frankfurt
(A-FHp): distance between point A and a line perpendicular to the Frankfurt plane (Po-Or) that descend from the nasion(N); Effective maxil-
lary length(Co-A): distance from the highest and most posterior part of the condylion(Co) to the maximum concavity of the anterior maxillary
outline(point A); Maxillary height: angle formed by the nasion-Cf and Cf-point A planes, where Cf is defined as the intersection of the pterygoid
plane(PtV) and the Frankfurt plane; Slope of the palatal plane(Po-Or/ANS-PNS): angle formed by the Frankfurt plane and palatal plane; A: the
maximum concavity of the anterior maxillary outline(point A); ANS: anterior nasal spine; PNS: posterior nasal spine; Pp: palatal plane.

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dicular to Frankfurt (A-FHp): Less than 1mm; Effecti- ned between groups according to age either. However,
ve maxillary length(Co-A): Less than 3mm; Maxillary significant differences (p<0.05) were found in the pre-
height: Less than 1mm; Slope of the palatal plane(Po- pubescent group in relation to cranial deflection (Ba-N/
Or/ANS-PNS): Less than 10. FH) between the FR and Ct-groups. Surprisingly, the
3) Type III Concordance: Greater difference than des- treatment group showed a flatter cranial base than the
cribed above. control group, while no such tendency was observed for
In Type II concordance the arithmetic mean is esta- the pubescent group. Despite no significant differences
blished between the two parameter values that do not being found in the angular variable, both genders dis-
coincide. When the difference is greater (Type III played obvious significant differences in anterior cra-
concordance) the tracings are done again and are refe- nial length measurements (Table 1).
renced against the three concordance possibilities men- Maxilla
tioned above. The causal error was determined using While the slope of the palatal plane showed significant
Dahlberg’s formula (S.E.=√‾d²/2n) and the systematic differences in the prepubescent group of the FR-group
error using a t test for a P<0.05. compared to that of the Ct-group, none of the other selec-
Statistical Analysis ted measurements of the upper jaw showed significant
Two-way analysis of variance (ANOVA) with interac- differences between groups (Table 2). Interestingly, the
tion and the Student’s t-test for independent samples treatment group ended up having a more parallel palatal
(p<0.05) were then obtained to determine whether there plane in relation to the Frankfurt plane compared to the
was any interaction between age and the treatment, if Ct-group, which showed a notable clockwise rotation of
age affects the treatment and if the treatment has any the palatal plane. Remarkably, no such differences were
effect or not on the variable. The Student t-test was used noted for the pubescent group.
to compare the FR-group and Ct-group in the prepubes- According to sex, none of the variables showed diffe-
cent and pubescent subgroups after verifiying random- rences within each group. ���������������������������
Nevertheless, expected sig-
ness, using the Student´s t test for independent samples nificant differences were only found between the boys
(the Wald-Wollowitz runs test at p>0.05 for all variables and girls, in the Ct-group as well as in the FR-group, in
in both groups) and for normality (the Shapiro-Wilk relation to the effective maxillary length measurements
test for normality at p>0.05 for all variables in both (Co-A) (Table 3).
groups). Changes were seen in the sagittal, vertical and rotatio-
nal planes in the maxillary superimpositions. Sagittally,
Results measurements related to the point A position showed
Cranial Base significant differences between the FR-group and the
No significant differences were found between the Ct-group (Table 4). The point A position was farther
Ct-group and the FR-group in anterior cranial length back in the prepubescent stage of the FR-group. Howe-
(Table 1). Similarly, no significant differences were obtai- ver, these differences returned to normal in the pubes-

Table 1. Cephalometric measurements of the cranial base according to age and sex.

VARIABLE GROUP

PPB(8-11y) PB(12-14y) TOTAL(8-14y) FEMALE MALE

CC-N Initial Fr 58.81+2.57 60.21+2.80 59.80+2.81 **58.55+2.73 **60.39+2.41
Initial Ct 58.15+3.27 60.51+2.25 59.30+2.71 **57.97+2.45 **60.60 +2.99
Final FR 58.91+2.59 60.25+3.00 59.98+2.89 **58.59+2.77 **60.44 +2.41
Final Ct 58.21+3.29 6.59+2.33 59.39+2.77 **58.03+2.53 **60.66+2.95
Ba-N/FH Initial Fr 27.30+2.61 27.81+2.50 27.45+2,94 26.75+2.93 28.38+2.75
Initial Ct 27.56+1.85 28.85+1.75 27.24+1.80 29.45+1.86 28.87+1.77
Final FR 27.32+2.67 27.74+3.58 27.50+2.96** 6.83+2.95 28.44+2.80
Final Ct 31.36+1.91** 28.91+1.77** 31.06+1.84** 29.50+1.88 28.93+1.79
CC-N: anterior cranial base ; BaN/FH : cranial deflection; PPB: prepubescent; PB: pubescent; y: years; Ct: control group; FR: Fran-
kel group; **: P<0.01.

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Table 2. Cephalometric measurements of the maxilla.

VARIABLE GROUP

PPB (8-11y) PB (12-14y) TOTAL (8-14y)

SNA initial FR 79.41 +3.65 79.53 +2.85 79.51 +3.03

initial Ct 79.69 +3.60 78.67 +2.73 79.25 +3.21

final FR 79.45 +3.59 79.48 +2.77 79.47 +3.09

final Ct 79.71 +3.54 78.69 +2.67 79.19 +3.15

N-A/FH initial FR 90.09 +2.29 90.42 +3.25 89.43 +2.94

initial Ct 90.58 +2.74 27.56 +2.74 90.58 +2.65

final FR 90.03 +2.22 89.05 +3.31 89.35 +3.02

final FR 90.62 +2.68 90.47 +2.70 90.47 +2.72

A-FH initial FR 0.23 +2.42 -0.99 +3.35 -0.58 +3.09

initial Ct 0.68 +2.74 0.48 +2.75 0.48 +2.83

final FR 0.21 +2.45 -0.96 +3.41 -0.53 +3.14

final Ct 0.65 +2.70 0.45 +2.69 0.52 +2.68

Co-A initial FR 91.36 +4.63 88.14 +4.81 89.26 +4.97

initial Ct 89.36 +4..01 86.74 +3.99 88.07 +4.19

final FR 91.36 +4.62 88.10 +4.85 89.24 +4.93

final Ct 89.32 +4.02 86.79 +4.02 88.13 +4.15

N-CfA initial FR 58.46 +3.01 57.77 +2.89 58.01 +2.88

initial Ct 58.71 +2.98 58.94 +2.70 58.82 +2.83

final FR 58.41 +3.00 57.74 +2.85 57.97 +2.91

final Ct 58.68 +3.00 58.89 +2.76 58.78 +2.87

ANS-PNS/FH initial FR -2.60 +3.42 -0.75 +3.84 -1.40 +3.76

initial Ct -1.58 +3.09 -2.90 +2.57 -2.19 +2.91

final FR -2.97 +3.39 -2.94* +3.81 -2.96* +3.74

final Ct -2.99 +3.11 -1.39* +2.56 -2.18* +2.89

PPB: prepubescent; PB: pubescent; y: years; Ct: control group; FR: Frankel group; SNA :Sella Trucica-Nasion
- A point angle; N-A/FH: maxillary depth; A-FH : distance from the A point to perpendicular from the Nasion
in relation to the Frankfurt plane; Co-A : effective maxillary length; N-Cf-A : maxillary height ; ANS-PNS/
FH : palatal plane slope ; *: p<0.05.

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Table 3. Comparison of cephalometric measurements of the maxilla according to sex.

VARIABLE GROUP
TREATMENT CONTROL
FEMALES MALES FEMALES MALES
SNA INITIAL 79.77 +3.05 79.01 +3.10 78.40 +3.46 79.88 +2.84
FINAL 79.82 +3.13 79.10 +3.03 78.37 +3.48 79.92 +0.87
N-A/FH INITIAL 88.99 +2.33 90.00 +3.69 90.71 +3.02 90.43 +2.40
FINAL 88.93 +2.34 89.97 +3.67 90.68 +3.06 90.38 +2.36
A-FH INITIAL -0.99 +2.45 -1.87 +3.81 0.80 +3.12 0.42 +2.50
FINAL -0.97 +2.49 -1.90 +3.85 0.74 +3.14 0.38 +2.59
Co-A INITIAL 87.98 +5.05 91.00 +4.36 86.31 +4.01 89.56 +3.77
FINAL 88.03 +5.07 89.97* +4.37 86.39 +4.07 89.52* +3.78
N-CfA INITIAL 58.04 +3.24 57.81 +2.51 59.16 +2.53 58.50 +3.10
FINAL 58.11 +3.18 57.87 +2.53 59.11 +2.57 58.54 +3.09
ANS-PNS/FH INITIAL -0.62 +3.87 -2.56 +3.40 -2.06 +2.50 -2.33 +3.19
FINAL -0.58 +3.84 -2.53 +3.36 -2.02 +2.57 -2.35 +3.24
SNA :Sella Trucica-Nasion - A point angle; N-A/FH: maxillary depth; A-FH : distance from the A point to perpendicular from the
Nasion in relation to the Frankfurt plane; Co-A : effective maxillary length; N-Cf-A : maxillary height ; ANS-PNS/FH : palatal
plane slope ; *: p<0.05.

Table 4. Superimpositions of the Maxilla-Sagital plane, Maxilla-Vertical plane< Maxilla-Rotational plane. Comparison of superimposi-
tions of the maxilla according to sex.
VARIABLE GROUP
PPB (8-11y) PB (12-14y) TOTAL(8-14y) FEMALES MALES

Point A Frankel -2.51** +0.63 0.10* +1.57 -1.20* +1.08 0.27 +0.94 -0.34 +1.28

Control 0.22** +0.30 0.22* +0.31 0.23* +0.30 0.30 +0.39 0.17 +0.19

ANS Frankel 1.52 +1.29 1.64 +2.15 1.56 +1.62 1.25 +1.72 1.99 +1.39

Control 1.07 +0.42 1.05 +0.82 1.06 +0.65 0.86 +0.56 1.23 +0.69

PNS Frankel 1.02 +1.31 1.39 +1.69 1.15 +1.45 0.96 +1.50 1.41 +1.38

Control 1.09 +0.50 1.16 +0.74 1.13 +0.63 0.98 +0.69 1.25 +0.56

ANS-PNS/FH Frankel 1.44*- +0.90 -1.41* +1.65 -1.43* +1.20 -0.17 +1.12 -0.79 +1.25

Control 0.15* +0.86 0.05* +0.62 0.10* +0.74 0.07 +0.78 0.12 +0.72
PPB: prepubescent; PB: pubescent; y: years; ANS: anterior nasal spine; PNS: posterior nasal spine;ANS-PNS/FH: palatal plane slope §. t
Student test; $: two-way ANOVA analysis;*: p<0.05.

cent stage. Regarding the vertical measurements, our pubescent groups (Table 4). Notably, these differences
study of the ANS and PNS did not show any significant reflected a counterclockwise rotation of the palatal pla-
differences between the two groups (Table 4). Rotatio- ne in the FR-group while no sex variability was found
nal plane measurements displayed significant differen- for any of the variables analyzed (Table 4).
ces between the FR-group and the Ct-group, both in
the overall averages as well as in the prepubescent and

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Discussion a stretching of mandibular retrusive muscles causing

Effects of the FR on the cranial base upper jaw restriction. In addition, Owen (14) has sug-
The anterior cranial base length did not show any diffe- gested a shortening effect in mandible muscles during
rences among the groups studied, not even in the pre- patients’ sleep. The protrusive muscles, such as the late-
pubescent and pubescent groups, which leads us to state ral pterygoid, allow the retrusive muscles, like the pos-
that the anterior cranial base is definitely not affected terior temporal, to retrude the mandible to its normal
by treatment with a FR. According to Björk (26), the position at rest. According to this author’s hypothesis,
increase of cranial vault size is very small after the age this muscular pressure is transmitted to the upper jaw
of 10-12 years, while the facial and mandibular bones through the appliance and brings about an effect similar
continue growing until after the age of 20 years. to headgear. The muscular force generated produces a
As shown in our results, a flatter cranial base is obser- functional force vector which is the cause of the “head-
ved in the prepubescent FR-group. In that way, changes gear” effect on the maxilla (5). Nevertheless, this author
in the Ba-N or Po-Or planes would result in a flattening suggested that the slight maxillary retrusion observed
of the cranial base. Despite a natural change in Nasion could at least partially occur due to the notable degree
remodeling and growth also being capable of inducing of individual variability among the study subjects.
this result, it might be reasonable to suggest that this According to our results of the point A superimposi-
result may be due to the effect of the appliance. Some tions, a -1.20mm posterior displacement of the maxilla
authors (27) have described a 0.86mm displacement of is observed in the FR-group, compared to that of the
the Basion towards the back with a cranial base rotation Ct-group. As expected, the Ct-group showed anterior
of 0.44º (NSBa). These researchers suggested that the maxillary growth of 0.23mm throughout the period
effect observed in the cranial base is due to the posterior of the study. Remarkably, such restrictive effects on
movement of the Basion rather than an anterior move- upper jaw growth are just observed in the prepubescent
ment of the Nasion. Although significant differences on group.
displacement of up to 2.5mm were found among some The significant difference of 1.43mm anterior displace-
patients, according to some authors, this could be the ment found between the FR and Ct-groups in the supe-
result of a great variability in the position of the Ba- rimposition of point A might be explained by previous
sion rather than the effect of the appliance on the cranial studies (11,23). These authors believe this appliance has
base (27). little or no effect on upper jaw growth. According to
Effects of the FR on the maxilla these authors’ hypothesis, observed differences might
Sagittal Changes be caused by point A landmark variability. In that way,
The FR appliance resulted in little or null effect on the point A would be easily modified by the radicular posi-
upper jaw structure. Even though significant differences tion of the upper central incisors through a remodeling
are found related to the point A position in the different mechanism. Therefore, a change in the lingual slope of
projections between the FR-group compared to the Ct- the upper incisors can have a small but significant effect
group, no sagittal growth restriction can be attributed to on cephalometric maxillary measurements.
the appliance. The functional appliance does not restrict Another explanatory factor that may contribute to
antero-posterior maxillary growth. such observed differences is that suggested by Nielsen
The absence of restrictive effects on the maxilla is ex- (16). According to this author, the cephalometric point
tremely important since it readily points us to using the A would be affected by the clockwise rotation of the
functional appliance when the maxilla is retruded with upper jaw which in turn moves backwards at the end of
an open nasolabial angle (23). treatment.
Notable controversy exists regarding the effect of the Vertical changes
FR appliance on the maxilla. Thus, while many studies, The FR appliance used in this study did not produce
(10,21, 27-30) including ours, indicated that there is no any effect on the vertical displacement of the maxilla
appreciable antero-posterior effect on this structure, during treatment. The upper jaw grows vertically at the
others have found restrictive properties of the FR on same rate and in the same direction in both groups, as
upper jaw growth (14,15). shown by the anterior nasal spine (ANS) and posterior
Restricted upper jaw growth, or the “headgear effect”, nasal spine (PNS) superimpositions and even by the
found by other authors might result from appliance maxillary height measurement (N-Cf-A). None of these
design variations, such as a lack of interproximal re- measurements showed significant differences compa-
duction of the molars as indicated by McNamara et al. red to the Ct-group. Similarly, previous studies seem to
(11), or due to a one-stage construction bite, averaging support our results (11,16,29).
more than 5.9mm of mandibular advancement, as no- Rotational changes
ted by Falck et al. (19). These authors suggest that such In order to determine the presence or absence of maxi-
substantial mandibular advancement might produce llary rotation we used Ricketts’ measurement of the

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slope of the palatal plane (Po-Or/ANS-PNS) and the 7. Fränkel R. The treatment of Class II, Division 1 malocclusion with
distance between the initial and final positions of the functional correctors. Am J Orthod. 1969;55:265-75.
8. Rushforth CD, Gordon PH, Aird JC. Skeletal and dental changes
palatal plane. The prepubescent group showed signifi- following the use of the Frankel functional regulator. Br J Orthod.
cant differences in so far as a more parallel palatal pla- 1999;26:127-34.
ne to the Frankfort plane is observed in the FR-group 9. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster
compared to the Ct-group. In contrast, the Ct-group LL. Headgear versus function regulator in the early treatment of
Class II, division 1 malocclusion: a randomized clinical trial. Am J
experienced a slight clockwise rotation of the palatal Orthod Dentofacial Orthop. 1998;113:51-61.
plane. According to these results, the FR-group showed 10. Rodrigues de Almeida M, Castanha Henriques JF, Rodrigues de
a slight counterclockwise rotation in the initial and final Almeida R, Ursi W. Treatment effects produced by Fränkel applian-
palatal plane superimpositions. ce in patients with class II, division 1 malocclusion. Angle Orthod.
2002;72:418-25.
Though the FR may tend to parallelize the palatal plane 11. McNamara JA Jr, Bookstein FL, Shaughnessy TG. Skeletal and
in a counterclockwise direction, when we compare the dental changes following functional regulator therapy on class II pa-
initial and final superimpositions of this group we find tients. Am J Orthod. 1985;88:91-110.
that there is a clear counterclockwise rotation in this 12. Björk A. Sutural growth of the upper face studied by the implant
method. Acta Odontol Scand. 1966;24:109-27.
plane, while in the control group there is practically no 13.Björk A, Skieller V. Growth of the maxilla in three dimensions
rotation of the palatal plane when we consider the data as revealed radiographically by the implant method. Br J Orthod.
referring to total measurements. If we look at the data 1977;4:53-64.
regarding the prepubescent group, we see that in this 14. Owen AH 3rd. Morphologic changes in the sagittal dimension
using the Fränkel appliance. Am J Orthod. 1981;80:573-603.
group there is a clockwise rotation of the palatal pla- 15. Janson GR, Toruño JL, Martins DR, Henriques JF, de Freitas
ne. Contrary to the results obtained in this study, other MR. Class II treatment effects of the Fränkel appliance. Eur J Or-
authors have found that the palatal plane in the group thod. 2003;25:301-9.
treated with the functional appliance showed a clock- 16. Nielsen IL. Facial growth during treatment with the function re-
gulator appliance. Am J Orthod. 1984;85:401-10.
wise rotation (8,30). 17. Remmer KR, Mamandras AH, Hunter WS, Way DC. Cephalome-
tric changes associated with treatment using the activator, the Fränkel
appliance, and the fixed appliance. Am J Orthod. 1985;88:363-72.
Conclusions 18. Gianelly AA, Arena SA, Bernstein L. A comparison of Class II
As can be inferred from the study results we can con- treatment changes noted with the light wire, edgewise, and Fränkel
clude that: appliances. Am J Orthod. 1984;86:269-76.
1. According to our results, the FR appliance has de- 19. Falck F, Fränkel R. Clinical relevance of step-by-step mandibu-
lar advancement in the treatment of mandibular retrusion using the
monstrated a flattening effect of the cranial base(p<0.05) Fränkel appliance. Am J Orthod Dentofacial Orthop. 1989;96:333-
in the treated sample but it does not have any effect on 41.
anterior cranial length. 20. Fränkel R. Concerning recent articles on Fränkel appliance the-
2. The FR does not produce any growth restriction of rapy. Am J Orthod. 1984;85:441-7.
21. McNamara JA Jr, Howe RP, Dischinger TG. A comparison of the
the maxilla in an antero-posterior direction. Herbst and Fränkel appliances in the treatment of Class II malocclu-
3. The FR appliance does not modify normal vertical sion. Am J Orthod Dentofacial Orthop. 1990;98:134-44.
maxillary growth compared to other non-treated Class 22. Righellis EG. Treatment effects of Fränkel, activator and extrao-
II-type I malocclusion patients. ral traction appliances. Angle Orthod. 1983;53:107-21.
23. Mills JR. The effect of functional appliances on the skeletal pat-
4. A slight counterclockwise rotation effect on the upper tern. Br J Orthod. 1991;18:267-75.
jaw is observed due to FR treatment. 24. Kerr WJ, TenHave TR, McNamara JA Jr. A comparison of skel-
etal and dental changes produced by function regulators (FR-2 and
FR-3). Eur J Orthod. 1989;11:235-42.
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