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Annali di Stomatologia | 2026; 17(2): 502-506 ISSN 1971-1441 | DOI: 10.59987/ads/2026.2.502-506 Articles |
Modified Teuscher-type activator combined with high-pull headgear for Class II Division 1 correction: a retrospective controlled study
Article History
Received: May 18, 2026
Accepted: June 24, 2026
Published: June 30, 2026
Abstract
Objective
To evaluate skeletal and dentoalveolar changes induced by a modified Teuscher-type activator combined with high-pull headgear in growing patients with Class II Division 1 malocclusion due to mandibular retrusion.
Methods
This retrospective controlled observational study included 72 growing subjects with skeletal Class II malocclusion. Thirty-six consecutive patients (TG; 20 females, 16 males; mean age 10.8 ± 1.1 years) were treated with a modified Teuscher-type activator combined with high-pull headgear. Thirty-six untreated subjects (CG; 19 females, 17 males; mean age 10.9 ± 1.0 years) were selected from the Bolton-Brush Growth Study database and matched for age, sex, and baseline malocclusion severity. Lateral cephalograms were obtained at baseline (T0) and after treatment/observation (T1). Skeletal and dentoalveolar changes were compared within and between groups.
Results
The treated group showed significant improvements in sagittal skeletal relationships compared with controls, with reductions in ANB angle and Wits appraisal (p < 0.001). Mandibular advancement was significantly greater in TG, with increased SNB and Co-Gn (p < 0.01), while maxillary sagittal progression was restrained (p < 0.05). Overjet and molar relationship improved significantly in TG (p < 0.001). Vertical skeletal control was also observed.
Conclusion
The modified Teuscher-type activator combined with high-pull headgear is an effective interceptive approach for Class II Division 1 malocclusion, producing favorable skeletal and dentoalveolar changes during growth.
Keywords: Teuscher-type activator; high-pull headgear; Class II Division 1 malocclusion; mandibular retrusion; cephalometry; functional appliances; growth modification.
1. Introduction
Class II malocclusion is one of the most prevalent dentoskeletal discrepancies in growing patients, with reported prevalence ranging from 15% to 20% in European populations [1–3]. In most cases, this condition is primarily characterized by mandibular retrusion rather than true maxillary protrusion, although different skeletal patterns may coexist.
From a clinical standpoint, Class II Division 1 malocclusion is associated with increased overjet, Class II molar relationship, and sagittal skeletal discrepancy between the maxilla and mandible. In addition, vertical growth pattern and transverse discrepancies often contribute to the severity and complexity of the malocclusion [4–6].
The rationale for interceptive orthodontic treatment in growing patients is the potential to modify craniofacial growth. The therapeutic objective is not limited to dentoalveolar compensation; it also aims to achieve skeletal correction by controlling maxillary growth, promoting mandibular advancement, and managing vertical development [7–9].
Extraoral orthopedic forces have been widely used to influence maxillary growth. High-pull headgear, when applied near the maxilla’s center of resistance, may reduce forward and downward displacement [6,9]. However, its isolated use may be insufficient in cases characterized by mandibular retrusion.
Functional appliances, on the other hand, are designed to stimulate mandibular growth and reposition the mandible anteriorly. Nevertheless, their effects are often attributed to dentoalveolar compensation rather than to true skeletal modification [7].
To overcome these limitations, combined orthopedic-functional appliances have been developed. Among them, the Teuscher-type activator combined with high-pull headgear represents a biomechanically sophisticated approach that integrates maxillary restraint with mandibular advancement [10].
The combination of these effects allows simultaneous control of sagittal and vertical discrepancies, potentially enhancing treatment efficiency during growth. Therefore, the present study aimed to evaluate the skeletal and dentoalveolar effects of a modified Teuscher-type activator combined with high-pull headgear in growing Class II Division 1 patients, compared with an untreated matched control group.
2. Objective of the study
This study aimed to evaluate skeletal and dentoalveolar changes induced by a modified Teuscher-type activator combined with high-pull headgear in growing Class II Division 1 patients.
The primary objective was to compare treatment-induced changes in 36 treated subjects (TG) and 36 untreated matched controls (CG), focusing on sagittal skeletal correction, mandibular adaptation, dentoalveolar changes, and vertical skeletal control.
3. Materials and methods
3.1 Study design and population
This retrospective controlled observational study included 72 growing subjects with skeletal Class II Division 1 malocclusion. The treated group (TG) comprised 36 consecutive patients who received a modified Teuscher-type activator combined with high-pull headgear (Figure 1). The control group (CG) consisted of 36 untreated subjects selected from the Bolton-Brush Growth Study and matched for age, sex, and baseline malocclusion severity.
The study was performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational studies and in accordance with the Declaration of Helsinki, with pertinent national and international regulatory requirements. The Institutional Review Board approved the study. All participants/their parents provided written informed consent and were free to withdraw from the study at any time.
3.2 Inclusion and exclusion criteria
Inclusion criteria were: age between 9 and 12 years; late mixed or early permanent dentition; skeletal Class II due to mandibular retrusion; overjet ≥ 5 mm; ANB ≥ 4°; Wits ≥ 2 mm.
Exclusion criteria were: syndromes or craniofacial anomalies; previous orthodontic treatment; systemic diseases affecting growth.
3.3 Treatment protocol
Patients were treated with a modified Teuscher-type activator combined with high-pull headgear. The extraoral force ranged from 400 to 500 g per side and was applied for 12–14 hours per day.
The appliance design included full acrylic coverage for anchorage, expansion screw, torque springs for incisor control, and highpull traction directed near the maxillary center of resistance.
3.4 Cephalometric analysis
Standardized lateral cephalograms were taken at T0 and T1. The following parameters were analyzed: SNA, SNB, ANB, Wits, SN-GoGn, FMA, LAFH, Co-Gn, U1-SN, IMPA, overjet, and molar relationship. Intra-examiner reliability was assessed using Dahlberg’s formula and intraclass correlation coefficient (ICC).
3.5 Statistical analysis
Data normality was assessed using the Shapiro-Wilk test. Paired t-tests were used for within-group comparisons, and independent t-tests for between-group comparisons. The significance level was set at p < 0.05.
4. Results
4.1 Baseline comparison
No statistically significant differences were found between TG and CG at T0, confirming adequate matching.
4.2 Dentoalveolar changes
The treated group showed significant improvement in overjet and molar relationship compared with controls (p < 0.001). Maxillary incisors showed controlled retroclination, while mandibular incisors exhibited limited proclination.
4.3 Skeletal changes
A significant reduction in ANB and Wits appraisal was observed in TG (p < 0.001). Maxillary sagittal growth was restrained, while mandibular advancement was significantly greater in TG (p < 0.01).
4.4 Vertical changes
Vertical control was evident in TG, with reduced increase in lower anterior facial height and less clockwise mandibular rotation compared with CG.
See Table 1 for selected cephalometric details.
| Variable | TG T0 Mean ± SD | TG T1 Mean ± SD | TG Δ | CG T0 Mean ± SD | CG T1 Mean ± SD | CG Δ | p-value |
|---|---|---|---|---|---|---|---|
| SNA (°) | 83.6 ± 2.1 | 82.9 ± 2.0 | −0.7 ± 0.8 | 83.4 ± 2.0 | 83.8 ± 2.1 | +0.4 ± 0.7 | 0.012 |
| SNB (°) | 77.1 ± 2.0 | 79.0 ± 2.1 | +1.9 ± 1.0 | 77.3 ± 2.1 | 77.8 ± 2.0 | +0.5 ± 0.8 | <0.001 |
| ANB (°) | 6.5 ± 1.2 | 3.9 ± 1.1 | −2.6 ± 1.1 | 6.1 ± 1.1 | 6.0 ± 1.2 | −0.1 ± 0.6 | <0.001 |
| Wits (mm) | 4.8 ± 1.4 | 1.7 ± 1.2 | −3.1 ± 1.3 | 4.6 ± 1.3 | 4.4 ± 1.2 | −0.2 ± 0.7 | <0.001 |
Data are expressed as mean ± standard deviation. Δ = T1 – T0. p-values refer to between-group comparisons of treatment changes (independent- sample t-test).
5. Discussion
The present study demonstrated that the modified Teuscher-type activator combined with high-pull headgear produces significant skeletal and dentoalveolar improvements in growing Class II Division 1 patients.
One of the main findings was the significant reduction in ANB and Wits values, indicating effective sagittal correction. This result is consistent with previous studies on orthopedic-functional and functional approaches for Class II correction [10–13].
The restraint of maxillary forward growth observed in the treated group supports the effectiveness of high-pull headgear when properly directed. However, it is important to note that the effect is not a true posterior displacement of the maxilla, but rather a modulation of its forward growth.
At the same time, mandibular advancement was significantly greater in the treated group. This finding suggests that the appliance’s functional component plays a crucial role in promoting favorable mandibular adaptation during growth.
From a dentoalveolar perspective, the significant reduction in overjet and improvement in molar relationship confirm the clinical effectiveness of the appliance. Importantly, lower incisor proclination remained limited, indicating good torque control.
Another relevant aspect is vertical control. The combination of activator and high-pull headgear appears to reduce clockwise mandibular rotation, making this approach particularly suitable for patients with mild vertical tendency.
The effectiveness of mandibular advancement appliances in treating growing patients with Class II malocclusion has been extensively investigated in the orthodontic literature. Systematic reviews and meta-analyses have demonstrated that functional appliances can produce significant improvements in sagittal skeletal relationships, primarily by enhancing mandibular growth and dentoalveolar adaptation [7,12–13,17]. Cozza et al. reported that functional appliances are associated with a measurable increase in mandibular length, although the magnitude of skeletal effects varies among studies and appliance designs [7]. Similar findings were confirmed by Koretsi et al. and Santamaría-Villegas et al., who concluded that removable functional appliances contribute to Class II correction through a combination of skeletal and dentoalveolar changes, with mandibular advancement representing the most clinically relevant skeletal outcome [13,17]. Evidence on Herbst and Twin Block appliances also supports their effectiveness in reducing Class II discrepancies, while highlighting differences in appliance design, compliance, and treatment efficiency [18–20]. Furthermore, meta-analytic evidence suggests that combining functional therapy with orthopedic approaches may enhance sagittal correction by simultaneously addressing maxillary growth restraint and mandibular advancement [12]. Collectively, the available evidence supports the use of mandibular advancement appliances as an interceptive treatment strategy for growing Class II patients, particularly when treatment is initiated during periods of active craniofacial growth [4,7,13,17].
Assessment of skeletal maturation is a key component in planning orthodontic therapy for growing individuals, as it helps determine the most appropriate timing for orthopedic and dentofacial interventions. Evidence from the literature supports the reliability of commonly adopted methods, including cervical vertebral maturation and hand-wrist radiographic analysis, despite some differences in their application and interpretation [4,14].
Additionally, dental indicators, such as those derived from tooth calcification stages and the Demirjian method, may provide supplementary information on dental development. However, their variability limits their use as stand-alone indicators of skeletal maturity [15]. The stage of skeletal maturation directly impacts treatment planning; for example, the maturation of the midpalatal suture can influence the indications for and expected response to maxillary expansion procedures [16].
However, we should report some study limitations. Firstly, the retrospective design may introduce selection bias; moreover, patient compliance represents a critical variable that cannot be fully controlled. Despite these limitations, the results support the use of this appliance as an effective interceptive strategy in growing Class II patients.
Conclusion
The modified Teuscher-type activator combined with high-pull headgear represents an effective interceptive treatment modality for Class II Division 1 malocclusion in growing patients.
Its effects are expressed through sagittal skeletal improvement, controlled maxillary growth, enhanced mandibular adaptation, dentoalveolar correction, and vertical control.
This combined orthopedic-functional approach may help simplify treatment and reduce the need for more complex interventions in the permanent dentition.
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