Original Article

Chin cup effects using two different force magnitudes in the management of
Class III malocclusions
Yasser L. Abdelnabya; Essam A. Nassarb

ABSTRACT
Objectives: To evaluate the dental and skeletal effects of chin cup using two different force
magnitudes in the management of Class III malocclusion cases.
Materials and Methods: Fifty growing patients (26 males and 24 females) with skeletal Class III
and mandibular prognathism were selected. The patients were divided into three groups. Patients
in group 1 (n 5 20) were treated with a chin cup and occlusal bite plane using 600 g of force per
side. Patients in group 2 (n 5 20) were subjected to the same treatment as in group 1 but using
300 g of force per side. In group 3 (n 5 10) no treatment was performed. For all patients, lateral
cephalograms were taken before treatment and after 1 year. Cephalograms were traced and
analyzed. The collected data were analyzed statistically using one-way analysis of variance and
the Tukey test.
Results: In the treatment groups, the SNB angle and ramus height decreased significantly. The
ANB angle, Wits appraisal, anterior facial height, mandibular plane angle, and retroclination of the
mandibular incisors were significantly increased in comparison to the control group. Utilization of
either force showed no significant differences, except that the reduction in the ramus height was
significantly greater with the use of higher force.
Conclusions: The use of a chin cup improved the maxillomandibular base relationship in growing
patients with Class III malocclusion but with little skeletal effect. The utilization of either force had
the same effects, except that the higher force had a more pronounced effect in reduction of ramus
height. (Angle Orthod. 2010;80:957–962.)
KEY WORDS: Class III; Chin cup; Force magnitude

INTRODUCTION The chin cup has been utilized for almost a century
for management of mandibular protrusion in growing
In clinical orthodontics, skeletal Class III malocclu-
patients.15 The rationale for a chin cup is to apply
sions are considered among the most difficult cases to
pressure on the temporomandibular joint to inhibit or
treat.1,2 Subjects with Class III may display maxillary
redirect condylar growth.14 The effects of the chin cup
retrusion, mandibular protrusion, or a combination of have been studied by many authors.10–14 Significant
the two. Several orthopedic appliances have been mandibular growth retardation and a decrease in the
developed for correction of such cases, including prechondroblastic layer of the condylar cartilage were
maxillary protraction appliances,1–4 functional applianc- reported in animal experimental studies using a chin
es,5–9 and the chin cup.1,10–14 cup.16,17 In addition, clinical studies in human patients
have reported that the chin cup had skeletal and dental
effects. Changes in mandibular growth, clockwise
a
Associate Professor, Department of Orthodontics, Faculty of rotation of the mandible, and lingual tipping of the
Dentistry, Mansoura University, Mansoura, Egypt. mandibular incisors were among the most common
b
Lecturer, Department of Orthodontics, Faculty of Dentistry, findings of these studies.10–14
Mansoura University, Mansoura, Egypt. Orthodontic or orthopedic force magnitudes are a
Corresponding author: Dr Yasser Lotfy Abdelnaby, Depart-
critical issue in clinical orthodontics. Optimal force is
ment of Orthodontics, Faculty of Dentistry, Mansoura University,
El Gomhoreyya St, PO Box 355116, Mansoura, Egypt the lowest force magnitude that could produce the
(e-mail: [email protected]) desired dental or skeletal effects. There has been
Accepted: March 2010. Submitted: February 2010. much debate regarding the force magnitude needed to
G 2010 by The EH Angle Education and Research Foundation, achieve adequate force levels at the condyle to affect
Inc. the mandibular growth. A relatively low force magni-

DOI: 10.2319/022210-110.1 957 Angle Orthodontist, Vol 80, No 5, 2010

958 ABDELNABY, NASSAR

Figure 2. Cephalometric linear measurements.

consisted of 20 patients (11 girls and 9 boys), and

Figure 1. Cephalometric points. group 3 consisted of 10 patients (5 boys and 5 girls).
The mean ages at the start of treatment were 9.6, 10.1,
tude of 150–200 g was utilized by Thilander.18 Higher and 9.2 years for groups 1, 2, and 3, respectively.
forces of 400 g were used by Tanne et al.19 Ritucci and Patients in groups 1 and 2 were treated with an
Nanda12 investigated the effect of a chin cup with 500 g occipital pull chin cup (Dentaurum, Ispringen, Ger-
orthopedic force. Gokalp and Kurt14 and Tuncer et al.15 many) and an acrylic occlusal bite plane with a
reported the use of 600 g. Stronger forces of 1000– thickness that just freed the occlusion anteriorly. The
1200 g were evaluated by Deguchi and Kitsugi.20 chin cup used was soft not acrylic. The force
In spite of a large number of studies regarding the magnitude exerted by the chin cup was 600 g per
chin cup, inadequate information is available compar- side in group 1 and 300 g per side in group 2. A force
ing the effects of different force magnitude. Katashiba gauge (Somfy tec, France) was utilized to determine
et al.21 found that the use of a chin cup with the lighter the applied force. The patients were instructed to wear
force, but with a longer wearing time, provided more the appliances for 14 hours each day. In group 3, the
skeletal correction than the use of heavier force for a patients did not receive any orthodontic or orthopedic
shorter time. On the other hand, it was reported that a treatment during the study period.
high force was needed to achieve skeletal effects with Lateral cephalogram films were taken for all patients
a chin cup.22 at two stages: before the start of treatment and after
The present study was conducted to evaluate the 1 year. All films were traced by one investigator.
dental and skeletal effects of a chin cup utilizing two Landmarks and measurements for cephalometric anal-
retraction orthopedic forces, 300 g and 600 g per side, ysis23 were done and are presented in Figures 1 to 3.
for the same wearing time, in the treatment of Class III Measurements obtained were corrected for standard
patients who were still growing. magnification. The cephalometric films were retraced
and the method error was determined with Dalhberg’s
MATERIALS AND METHODS formula; the error was less than 1 mm and 1 degree.
Fifty growing patients were selected for this study
(26 boys and 24 girls). They were selected according Statistical Analysis
to the following criteria: skeletal Class III pattern (ANB Means and standard deviations of the calculated
angle , 1 degree) and protrusive mandible (SNB measurements and the changes after treatment in
angle . 80 degrees). All patients had anterior cross-
each group were determined. The data were analyzed
bite. Hand-wrist radiographs were obtained for each
using one-way analysis of variance and Tukey test.
patient to assess skeletal maturation. All patients had
Significance for the statistical test was set at P , .05.
not passed the peak of pubertal growth spurt, as
shown by the epiphysis of the middle phalanx of the
RESULTS
third finger having capped its diaphysis. The patients
were randomly divided into three groups. Group 1 Clinically the anterior crossbite was corrected in all
consisted of 20 patients (10 boys and 10 girls), group 2 patients in the two treatment groups (Figures 4 and 5).

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EFFECTS OF CHIN CUP USING TWO DIFFERENT FORCES 959

tions were significantly decreased in comparison to the

control group. The ANB angle, Wits appraisal, SN-MP
angle, and anterior facial height were significantly
increased in the two treatment groups.
Regarding the differences in the changes in ceph-
alometric measurements between the two treatment
groups utilizing either force magnitude (600 vs 300 g
per side), no significant differences were found (P .
.05) except in ramus height (Ar-Go). The reduction in
ramus height was more pronounced with the utilization
of 600 g of force per side than the use of 300 g of force
per side (P , .05).

DISCUSSION
Figure 3. Cephalometric angular measurements.
The effect of the orthopedic appliances depends on
several factors, such as the applied force magnitude,
Means and standard deviations of the cephalometric wearing time of the appliance per day, and the duration
measurements of the three groups before treatment of treatment.21 The influence of using two orthopedic
are presented in Table 1. One-way analysis of force magnitudes (300 and 600 g per side) with a chin
variance indicated that there was a statistically cup was the scope of this study.
significant difference (P , .05) among the three The results of this investigation showed that the
groups in SNB angle, ANB angle, Wits appraisal, Ar- SNB angle was significantly decreased in the treat-
Go, SN-MP angle, N-Me, and 1-MP angle. ment groups in comparison with the untreated control
Means and standard deviations of the changes in group. Similar findings were found in previous chin cup
the cephalometric measurements and the results of studies.1,10–13,24 Such decreases in the SNB angle could
the Tukey test are presented in Table 2. In general, be attributed to either restraint in mandibular growth or
there were significant differences (P , .05) in the distal displacement and clockwise rotation of the
changes in cephalometric measurements between the mandible.1 With regard to changes in the mandibular
two treatment groups and the control group regarding corpus (Go-Me) among the investigated groups, no
mandibular position (SNB angle), the maxillomandib- significant changes were found in the treatment groups
ular relationship (ANB angle and Wits appraisal), in comparison to the control group. This finding was in
ramus height (Ar-Go), vertical measurements (N-Me agreement with those of Üçüncü et al.1 On the other
and SN-MP angle), and inclination of the mandibular hand, it differed from the findings of Mitani and
incisors (1-MP). In the treatment groups, the SNB Fukazawo.25 Growth of mandibular ramus height (Ar-
angle, ramus height, and mandibular incisor inclina- Go) was significantly decreased in the treatment

Figure 4. Pre and posttreatment intraoral photographs of patient utilized chin cup with 600 grams of force per side.

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960 ABDELNABY, NASSAR

Figure 5. Pre and posttreatment intraoral photographs of patient utilized chin cup with 300 grams of force per side.

groups in comparison with the untreated group. These those of other investigations.1,11,26 On the other hand,
results are compatible with those of other studies.11,12 they contrasted with those presented by other au-
Reduction of the ramus height could be attributed to thors.14 However, it was reported that the degree of
the use of the occipital-pull head cap, with the chin cup changes in the gonial angle seemed to be unpredict-
providing a posterosuperior orthopedic force; hence, able.27
pressure was exerted on the superior border of the In the present study, utilization of a chin cup had no
condyle that could affect vertical mandibular growth.1,22 significant effect on maxillary growth, as represented
However, they were in contrast to those of other by the SNA angle. This finding is in agreement with
investigators, who found an increase in ramus height, those reported in other studies.1,10–13,24 On the other
which was attributed to forward bending of the hand, a contrasting result was reported by another
condylar head.1,14,25 The mandibular length (Ar-Me) investigation,14 which found a significant increase in
showed no noticeable changes among the three the SNA angle with the use of a chin cup. The authors
groups in the present study. These results are in suggested that the correction of crossbite could
agreement with those of other investigations aiming to accelerate forward growth of the maxilla. However,
clarify the effects of the chin cup.14 The gonial angle the differing results could be a result of the longer
was decreased in the treatment groups; however, this treatment time (19 months) of the cited study vs the
reduction was not significant. These results matched treatment time in the present study (12 months).
One of the significant effects of chin cup use was the
improvement in the relationship of the maxillary and
Table 1. Means and Standard Deviations of the Cephalometric
Measurements of the Three Groups Before Treatment
mandibular bases. This was manifested by a signifi-
cant increase in the ANB angle and Wits appraisal in
Measurements Group 1a Group 2a Group 3a
the treatment groups in comparison with the control
SNA 81.30 6 0.47 81.20 6 0.41 80.70 6 0.48 group. The decrease in the SNB angle and clockwise
SNB 81.20 6 0.41 81.40 6 0.50 81.50 6 0.52
rotation of the mandible were responsible for the
ANB 0.1 6 0.71 20.20 6 0.41 20.80 6 0.63
Wits appraisal 27.30 6 2.15 26.90 6 2.73 26.50 6 2.63 improvement in the ANB angle and Wits appraisal.
Ar-Me 94.20 6 2.54 93.10 6 2.57 91.20 6 2.09 These findings are in agreement with those reported in
Ar-Go 37.60 6 3.64 37.20 6 2.46 36.50 6 2.17 previous studies.1,10–13,18
Go-Me 65.20 6 2.74 66.60 6 3.11 64.90 6 3.66 The anterior facial height (N-Me) and mandibular
Ar-Go-Me 129.70 6 2.55 127.20 6 3.66 127.30 6 4.57
plane angle (SN-MP) were significantly increased in
N-Me 113 6 3.94 116.90 6 3.07 114.80 6 3.64
SN-MP 34.80 6 1.28 35.60 6 0.94 34.90 6 1.19 the treatment groups in comparison with the control
1-MP 86.90 6 1.80 89.20 6 5.28 88.60 6 4.67 group. The backward and downward rotation of the
1-SN 99.70 6 6.20 100.90 6 5.37 99.70 6 5.41 mandible could be responsible for this result. This
a
Group 1: 600 g of force utilized with chin cup; group 2: 300 g of finding was in agreement with those presented in
force utilized with chin cup; group 3: no treatment (control). previous studies on the same topic.1

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EFFECTS OF CHIN CUP USING TWO DIFFERENT FORCES 961

Table 2. Means and Standard Deviations of the Changes in (10 hours per day), while wearing time was constant in
Cephalometric Measurements After Treatment in the Three Groups the present study (14 hours per day). Furthermore, it
and the Results of Tukey Testa was reported that wearing a chin cup for more than
Measurements Group 1a,b Group 2a,b Group 3a,b 9 hours and fewer than 15 hours per day could affect
SNA 0.3 6 0.47A 0.4 6 0.50A 0.2 6 0.42A the direction of chin growth, as alteration of the
SNB 22.20 6 0.41A 22.00 6 0.79A 20.30 6 0.48B direction was limited to the period that the force was
ANB 2.5 6 0.51A 2.40 6 0.50A 0.50 6 0.52B applied.27,29
Wits appraisal 4.60 6 1.23A 4.90 6 1.41A 20.20 6 0.42B
Ar-Me 1.26 6 0.65A 1.36 6 0.59A 1.70 6 0.48A
Ar-Go 20.95 6 0.67A 20.10 6 0.64B 1.30 6 0.48C CONCLUSIONS
Go-Me 0.80 6 1.00A 0.90 6 0.55A 1.20 6 0.91A
Ar-Go-Me 0.75 6 0.55A 0.65 6 0.64A 0.90 6 0.56A
N The use of a chin cup significantly improved the
N-Me 4.20 6 1.93A 4.70 6 2.05A 1.40 6 0.69B mandibular and maxillary relationship, but with only
SN-Mp 1.50 6 0.51A 1.40 6 0.50A 0.50 6 0.52B minor skeletal effects.
1-Mp 23.90 6 2.22A 22.80 6 1.10A 20.20 6 0.63B N The use of a chin cup significantly reduced the ramus
1-SN 1.20 6 1.36A 1.10 6 0.96A 0.20 6 0.78A height and increased the anterior facial height,
a
Group 1: 600 g of force utilized with chin cup; group 2: 300 g of mandibular plane angle, and retroclination of the
force utilized with chin cup; group 3: no treatment (control). mandibular incisors.
b
Means with the same superscripted letters in each row are not
N Utilization of either 300 or 600 g per side as the chin
significantly different at P , .05 according to the Tukey test.
cup retraction force had the same effect, except that
the latter had a more pronounced effect in the
In general, limited mandibular skeletal effects of the
reduction of ramus height.
chin cup were found in the present study, irrespective
of the use of the two different force magnitudes. This
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