Fixed Functional Appliances for Treatment of Class II

Malocclusions; Effects and Limitations

By

Amr Khairy El-morsy

B.D.S 2013G, Faculty of Oral and Dental Medicine,

Cairo University
MSc Student, Orthodontic Department, Faculty of Dental Medicine,
Al-Azhar University (Boys-Cairo)

Under supervision of

Dr. Farouk Ahmed Hussein

Professor & Chairman, Department of Orthodontics
Faculty of Dental Medicine Al-Azhar university
(Boys-Cairo)
Dr. Ramadan Yusuf Abu-Shahba
Associate Professor, Department of Orthodontics
Faculty of Dental Medicine Al-Azhar university
(Boys-Cairo)
Dr. Khaled Farouk Abdullah
Lecturer, Department of Orthodontics
Faculty of Dental Medicine Al-Azhar university
(Boys-Cairo)

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 Contents

o Definition of Class II Malocclusion

o Prevalence
o Etiology
o Features of Class II Division 1
o Moyers’ differential diagnosis
o Treatment modalities for Class II Malocclusion
o Timing of Class II treatment
o Fixed Functional Appliances (FFA)
A) Rigid
B) Flexible
C) Hybrid
o Effect of FFA
o Effect of Skeletally Anchored FFA
o References

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Definition of Class II malocclusion

In 1898 Angle defined Class II malocclusion as: The mandibular

dental arch and the body of the mandible are in distal relation to the
maxillary arch. The mesiobuccal cusp of the maxillary permanent first
molar occludes in the space between the mesiobuccal cusp of the
mandibular permanent first molar and the distal aspect of the buccal cusp
of the mandibular second premolar. The mesiolingual cusp of the
maxillary permanent first molar occludes mesial to the mesiolingual cusp
of the mandibular permanent first molar.

Prevalence

Class II malocclusion is one of the most frequently encountered

orthodontic issues as it occurs in about one-third of the population. In
2008, a systematic review was performed for the evaluation of prevalence
of malocclusion between different traits. It was found that; In permanent
dentition, the global distributions of Class I, Class II, and Class III
malocclusion were 74.7%. [31 - 97%], 19.56% [2 - 63%] and 5.93% [1 -
20%], respectively. In mixed dentition, the distributions of these
malocclusions were 73% [40 - 96%], 23% [2 - 58%] and 4% [0.7 - 13%].
Caucasians showed the highest prevalence of Class II in permanent

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dentition (23%) and mixed dentition (26%). Class III malocclusion in
mixed dentition was highly prevalent among Mongoloids.
A Survey Study was conducted to evaluate the prevalence of
malocclusion among the dental students of Fayoum University, Egypt,
and revealed 21% prevalence of Angle class II, with an equal distribution
in both genders.

Etiology

I- Prenatal factors:

- Hereditary: Majority of the class II cases are genetic in origin. The

mismatch between the size of the maxilla and mandible is due to the
fact that, the jaws are individually inherited from either of the parent's
genes.

- Congenital factors: Defects associated with malformation of the first

and second branchial arches can cause skeletal malformations as many
of the facial structures are derived from these two arches. These can be
caused by genetic, radiological, chemical, endocrine, infections and
mechanical factors

- Intrauterine fetal posture: Abnormal posture such as hands against the

chin region in the growing fetus is found to affect mandibular growth.

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 II- Natal factors:

In some difficult births, the use of forceps can damage

either or both the tempromandibular joints, a subsequent damage of
TMJ can cause ankylosis or impaired mandibular growth.

III- Postnatal Factors:

a. Any factor that affects the condylar growth; Traumatic injuries of

TMJ rhuematoid arthritis, long-term radiation therapy to the
craniofacial region etc.

b. Mesial drift of the maxillary molars due to premature loss of

deciduous molars, congenital absence of second primary
molar…etc.

c. Parafunctional habits; mouth breathing, abnormal swallowing

pattern, thumb sucking and tongue thrusting.

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➢ Features of Class II Malocclusion:

Features of Class II

Characterized by proclined upper incisors with a resultant increase in

overjet

a. Extraoral features: Convex profile, decreased nasolabial angle, short

hypotonic upper lip, incompetent lips, everted lower lips, deep
mentolabial sulcus, hyperactive mentalis muscle.

b. Skeletal features: skeletal class 2 can be caused be either mandibular

retrusion, Maxillary protrusion, or both. Also, can be caused due to
vertical maxillary excess and clockwise mandibular rotation.
Decreased posterior facial height, steep mandibular plane angle,
increased ANB angle, increased angle of convexity and an increased
overjet.,

c.Intraoral features: Class II molar and canine relation. Class II

molar relation may be associatedwith a Class II canine relation with
excessive overjet caused by spacing and protrusion of the maxillary
teeth as in skeletal cases. It is also possible to find a Class II molar
relationship associated with a Class I canine relationship and

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normal overjet caused by crowding or loss of maxillary teeth mesial
to the first molars.

- Proclination of upper anterior teeth: This feature differentiates

Division I from Division 2. With the resultant increased overjet.

- Deep overbite and excessive curve of Spee: Due to proclination of

upper anteriors, there is absence of centric stops, the lower anterior
teeth fail to make contact with the palatal surface of the upper
anteriors and became free to overerupt leading to an increased
anterior overbite and excessive curve of Spee.

- Proclination of lower incisors

- Narrow V-shaped palatal arch and deep palate.

- Lip trap: Pushing the upper incisors more forward and further
increases the overjet.

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❖ Moyers’ differential diagnosis of class II cases.

• Horizontal types
Moyers et al classified Class II patients into six horizontal
facial types (A, B, C, D, E, F): Type A has a normal skeletal profile
with maxillary dental protraction. Type B has a Class II skeletal
profile with a prognathic maxilla and normal mandible. Type C has
a severe Class II skeletal profile with retrognathic mandible and
maxilla, maxillary and mandibular dental protraction. Type D has a
retrognathic mandible with a normal or retruded maxilla and
maxillary dental protraction. Type E has a prognathic midface and
a normal mandible. Type F only has a retruded mandible with a
normal maxilla.

• Vertical Types

Vertical Type 1 The characteristic features of vertical Type 1 are a

mandibular plane steeper than normal, an even steeper functional
occlusal plane, and a palatal plane which is tipped somewhat
downward.
Vertical Type 2 is essentially a square face. The mandibular plane,
functional occlusal plane, and palatal plane are all flatter than
normal and are nearly parallel.

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Vertical Type 3 The characteristic feature of vertical Type 3 is a
palatal plane which is tipped upward anteriorly. During growth the
upper face height does not keep pace with the total face height,
resulting in a strong tendency to open-bite.
vertical Type 4 the mandibular plane, the functional occlusal plane,
and the palatal plane are all tipped markedly downward, leaving the
lip line unusually high on the alveolar process in the maxilla. The
gonial angle is obtuse.

Vertical Type 5 is most closely related to vertical Type 2, “the

square face syndrome” and is found only in horizontal Subgroups B
and E. In Type 5 the mandibular and functional occlusal planes are
normal. However, the palatal plane is tipped downward while the
gonial angle is the most squarish of all the types.

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 • Visual Treatment Objective (VTO): According to Ricketts, it
gives any individual prediction based on empirically obtained
mean growth rates and includes the expected influence of
orthodontic treatment.

• Sunday Bite: occurs in young (in my experience, 10-12 year old)

patients who realize they have an under-bite so they “correct it”
by posturing the mandible forward from Class II to Class I dental.

• The Fränkel maneuver: is a procedure by which the mandible

of Class II individuals is postured forward in dental Class I
relationship. The evaluation of the resulting facial profile
provides information concerning the components determiningthe
sagittal discrepancy.

➢ Treatment modalities:

A- Growing patient (Growth modification):

- Orthopedic treatment.

- Functional appliance Therapy.

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Growth modification using can be used before cessation of growth to
redirect remaining growth into favorable direction.

B- Adult patient:

- Dental (Orthodontic treatment).

- Skeletal:

- Mild-Moderate: Orthodontic camouflage (extraction, adult

orthopedic treatment, Distalization)

-Severe: Orthognathic surgery.

❖ Timing of class II treatment:

Treatment options for class II malocclusion are based on

whether the patients are growing or not. The best timing for class II
treatment has always been a topic of controversy for a long time.
Two common strategies have been followed by orthodontists to
correct class II malocclusion. The first one is done in two steps, one
in pre-adolescence and the other in adolescence years; the second
one is achieved in one step during adolescence.

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 ➢ Cervical vertebrae maturation index

• Cervical Stage 1

In CS 1, the inferior borders of vertebral bodies C2 to C4 are flat (or

sometimes slightly convex. The third and fourth cervical bodies are
trapezoidal in morphology, assuming the shape of a wedge of cheese ,with
the posterior border of the vertebral body taller than the anterior border
and the superior surface sloping downward and forward. This stage occurs
from approximately the time of eruption of the deciduous dentition until

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about 2 years before the peak in craniofacial skeletal growth. It should be
noted that in some young subjects, C3 and C4 are rectangular and short
vertically, reminiscent of the shape of an ice hockey puck in profile

• Cervical Stage 2

CS 2 is characterized by a visible notch along the inferior border of the

second cervical vertebra (odontoid process). The lower borders of the
third and fourth vertebral bodies remain flat. Both C3 and C4 retain a
trapezoidal shape (wedge of cheese). CS 2 can be considered the “get-
ready” stage because the peak interval of mandibular growth should begin
within a year after this stage is evident.

• Cervical Stage 3

CS 3 is characterized by visible notching of the inferior borders of C2 and

C3; the inferior border of C4 remains flat. Most of the C3 and C4 bodies
still retain a trapezoidal shape. In some instances, however, either C3 or
C4 has a more rectangular horizontal shape. It must be remembered that
the difference between stages is gradual, not abrupt, so that saying that
someone is a late CS 3 or an early CS 4 is appropriate, depending on the

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transitional morphology of the third and fourth vertebrae. At this stage,
maximum craniofacial growth velocity is anticipated.

• Cervical Stage 4

In CS 4, all three bodies have obvious concavities along their inferior

surfaces, so the more important factor now is the shape of C3 and C4. At
CS 4, both vertebral bodies have a rectangular horizontal rather than a
trapezoidal shape. It is easiest to remember this stage as the “bar of soap”
stage because the bodies of both C3 and C4 assume this well-known
shape. Alternatively, the familiar rectangular image of a credit card is
another way to visualize this stage. During CS 4, continued accelerated
craniofacial growth can be anticipated.

• Cervical Stage 5

CS 5 can be differentiated from CS 4 on the basis of the shapes of C3 and

C4, with these bodies becoming square. At least one of the bodies of C3
and C4 is square. If not square, the body of the other cervical vertebra is
rectangular horizontal. All three cervical bodies have notches, so the
presence of notching no longer is important in the differential diagnosis.
We have found it easy to remember this stage as the “marshmallow” stage
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, in that the shape of the vertebral bodies now resemble the soft, white,
puffy confection seen so commonly at summer campfires in the United
States and elsewhere. When this stage is reached, most substantial
craniofacial growth has been achieved.

• Cervical Stage 6

It has been our experience that the most difficult stage to determine is CS
6, requiring measurement of the length of the posterior and inferior
borders of C3 and C4. At CS 6, at least one of the third and fourth cervical
bodies has assumed a rectangular vertical morphology, with the length of
the posterior border being longer than the inferior border. If not
rectangular vertical, the body of the other cervical vertebra is squared. In
addition, the cortical bone appears better delineated in CS 6 than at CS 5.
It has been reported that 17% of females never reach CS 6.33 At this stage,
a patient can be evaluated for corrective jaw surgery or the placement of
endosseous implants in the esthetic region.

❖ Patient compliance

In cases where patients are non-compliant, a fixed functional appliance

could be an option. Compliance can play a crucial role in a successful
orthodontic treatment. Thus, there is a dilemma when working with poor
cooperators because not only are the treatment results unreliable and
unpredictable, but the treatment time is also longer Compliance-Free
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Appliances are attached to the maxilla and the mandible and are used
when a limited amount of compliance is required. In Class II correction,
they are used to posture the mandible forward; in effect bringing the lower
dentition forward and the upper dentition back.

Fixed Functional Appliances

Types
I- Rigid Fixed Functional Appliances.
II- Flexible Fixed Functional Appliances.
III- Hybrid Fixed Functional Appliances.

I. Rigid Fixed Functional Appliances

These appliances are not elastic nor flexible, so they are not
easily fractured. When using the appliance, the mandible will be in
a forward position 24 hours which won’t allow the patient to bite at
maximal intercuspation which offers more stimulus for growth that
results in mandibular protraction. Skeletal effects produced by
RFFA are greater than those produced by flexible ones.

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 A) The Herbst Appliance:

The Herbst appliance was created in 1905 by Emil Herbst at the

Berlin Dental Congress. After that, not a lot of studies were conducted for
the appliance, but in the late seventies, Hans Pancherz rediscovered the
appliance and published many articles.

The Herbst appliance consists of Two tubes, two plungers, axles, and
screws. It’s most common type is putting bands or crowns with the help
of the screws and joining the axles to the bands and finally fitting the tubes
and the plungers with the screws.

The Herbst appliance has multiple modifications such as; Cantilevered

Bite Jumper, MALU Herbst Appliance, Flip-Lock Herbst Appliance, The
Ventral Telescope, The Magnetic Telescope Device (Ritto A.K.), The
Mandibular Protraction Appliance, The Universal bite jumper, The
Biopedic Appliance, The Mandibular Anterior Repositioning Appliance,
The Ritto Appliance.

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B) The Mandibular Anterior Repositioning Appliance (MARA):

MARA was created by Douglas Toll of Germany in 1991. It

consisted of Stainless Steel crown covering the first molar and cams on
the molars to guide the patient to bite into a forward position to a Class I
occlusion. The appliance was less bulky and easily tolerated by the
patient. It’s used for Class II treatment and TMJ problems.

C)The Mandibular Protraction Appliance:

It was created by Dr.Coelho Filho in 1995. It’s advantages include
easy to fabricate in the laboratory, low cost, patient comfort, hard to get
fractured and easy fitting. MPA has 4 different types

MPA I: each side of the appliance needs a small loop at a right angle at
the end of 0.032” SS wire. The length of the appliance is determined by
how protruded the mandible is and another 90-degree angle is then bent
in the opposite direction. Its main disadvantage is that the mouth is open
less.

MPA II: It is created by making circles in two pieces of .032" SS wire

which is perpendicular to one another. A small piece of the slipped coil is

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slipped over one of the wires. This type allows the mouth to open more
than MPA I.

MPA III: This type allows a greater range of motion in both arches while
keeping the mandible in a protruded position. It resembles the Herbst
Appliance but smaller in size and need more time to build.

MPA IV: This type is easier to manipulate, comfortable, and practical. It

consists of a “T” tube, upper molar locking pin, mandibular rod, and
mandibular archwire.
D)The Cantilever Bite Jumper:
Introduced by Mayes in the mid-1980s. it’s a modification of a Herbst
appliance. The main difference is that it is fitted directly to the mandibular
molar bands through a cantilever arm. The crown in the maxillary and
mandibular molars should be fitted and the cantilever arm attached to the
SS crown, which might impinge the patient’s cheek.

E) The Ritto Appliance:

It was introduced by Dr. A Koroddi Ritto in 1998. It can be defined

as a small telescopic process with a simplified intra-oral application. Its
small size facilitates adaptation and doesn’t affect speech. It consists of a

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single piece device with telescopic action which allows it to be used on
both sides. The total length of the appliance when closed is 25mm and the
maximum opening is 33mm.

II- Flexible fixed functional appliances:

This appliance allows satisfactory free mandibular movement due
to its elasticity and flexibility. The amount of force delivered by the
appliance can be controlled by the clinician. Their major drawback is that
it is easy to get fractured and tend to produce fatigue of springs due to its
flexibility so the clinician should inform the patients to avoid opening
their mouths too widely.

A) Jasper Jumper:
It is the first flexible fixed functional appliance to appear.
Introduced by James Jasper in 1987 to overcome the rigidity problem of
the Herbst appliance. It consists of a covered spring and has different sizes
with the right and left sides. It can be attached between the upper and
lower arches to deliver both sagittal and intrusive forces that resemble
either head-gear or activator-like forces or combination of the two.

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 B)The Churro Jumper:
Introduced by Ricardo Castanon et.al. in 1998. In the class II
relation, each jumper attaches to the maxillary molars by a pin that passes
through a circle on the distal end of the jumper and then through the distal
end of the headgear tube. It is preserved by bending the pin down on the
mesial end of the tube. So far, this is the only flexible functional appliance
that can be manufactured in his lab.

C)The Adjustable Bite Corrector:

Introduced by Dr.richard west in 1995. It is similar to the Jasper
Jumper. It consists of a stretchable closed-coil spring and internally
threaded end-caps at both ends which increases the range of motion with
no risk of fracture. There is a nickel-titanium wire which is responsible
for the “push” force generated.

D)The Bite Fixer:

It’s an intermaxillary spring coil. The spring is crimped and attached
to the end fitting to avoid fracture between the spring and the end fitting.

III- Hybrid fixed functional appliances:

They can be described as a rigid appliance with spring systems. They
are a combination of both rigid and flexible appliances. It depends on
using open springs to produce force, force delivered by Hybrid appliances

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ranges from 150-260g. The objective of these appliances is to move teeth
by applying 24 hours a day which can replace the Class II elastics.

A) Forsus Fatigue Resistance device:

Introduced by William Vogt in 2006. It is a semi-rigid telescoping
system that contains a nickel-titanium coil spring and consists of a spring
that delivers a 220g of force, clip, and a push-rod which connects the
appliance to the mandible. The Forsus (FRD) can be used instead of Class
II elastics in mild cases and instead of Herbst appliances in severe cases.

A) Eurika Spring:
This appliance was developed by John Devincenza in 1997. Its main
advantage over the other appliances is its small non-bulky size which
won’t impinge in the patient’s cheek and it is aesthetically acceptable, not
easy to fracture, and good for non-compliant Class II patients.

A) Twin Force Bite Corrector Appliance:

Introduced by Jeff Rothenberg in 2004. The TFBC is a push-
type intermaxillary fixed functional appliance with ball and socket joint
that allows a large range of motion. It consists of two internal coil springs
and two joint telescoping systems. It’s placed with a ball pin which is
fitted into the buccal tube of a molar band, the placement of the lower arch
is slightly different, it requires a fitting-in system fixed with a screw distal

22
to the lower cuspid. It can be used for the treatment of Class II or Class
III malocclusion and can also be used as an anchorage system.

A) PowerScope Appliance:
PowerScope is kind of similar to the Herbst type II appliance. It
was invented by Dr. Andy Hayes by working with American orthodontics.
PowerScope particularize in patient comfort, simple insertion, and
installation, prolonged scale of motion, can be inserted in the clinic
without any laboratory procedures, and it has a universal size that fits all
situations which can be attached directly to the stainless steel archwires
which eliminate the need for bands on the upper molars.

The appliance allows an intermaxillary wire to wire installation using a

nut with a hexagonal screw. It provides a ball and socket joint to increase
patient comfort by maximizing lateral movement to the mandible. The
appliance has a telescopic system which is an 18mm telescoping
mechanism consisting of the inner shaft, push rod, middle and outer
tubing. There is a nickel-titanium (NiTi) spring located between the
middle and outer tubing that produces a constant force of 260g. there is a
Hex-Head screw at the upper and lower end of the telescopic system that
allows ample movement of the jaws.

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PowerScope has also some Accessories besides its main parts such as
Crimpable shims which is used to set the initial activation or if the
appliance needs to be reactivated during treatment. Driver magnets that
slide onto the driver to hold the appliance.

❖ Effect of fixed functional appliance

Biomechanical force produced by forward mandibular positioning solicit

cellular and molecular changes in mandibular condyles, however, the
effect of functional appliances on condylar growth remains a controversial
issue, and the mechanisms by which those changes are triggered are not
completely understood. Several studies have reported a positive response
of the condyle to mandibular advancement. Some researchers believe that
this positive response is actual growth of the mandible, while others
believe that functional appliances only accelerate growth of the mandible,
helping it to reach its final size earlier, but not producing a larger size

❖ Skeletal and dental changes of dentally anchored FFA appliances

The dentoskeletal effects of Herbst and Twin Block (TB) appliances in

treatment of Skeletal Class II malocclusion was compared. The study
included three groups; Herbst group, TB group and control group in

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Active therapy was finished when a normal or overcorrected overjet was
obtained in a retruded mandibular position. Pre-treatment and post-
treatment lateral cephalograms were traced and analyzed. In control
group, all sagittal and vertical skeletal measurements increased as a result
of continuing growth. However, skeletal discrepancy and overjet
remained unchanged. After functional appliance therapy, Skeletal class II
was corrected in both groups by slight decrease in SNA and increase in
SNB angles. Greater increases were recorded in TB group for all
mandibular skeletal measurements. Dentally, upper dental arch
distalization and lower incisor protrusion was found in both groups which
were more significant in Herbst group.

To evaluate the dentoskeletal changes in patients treated with tooth-borne

functional appliances, an 80 consecutively treated patients who were
equally divided into Bionator, Herbst, Twin Block, and mandibular
anterior repositioning appliance (MARA) groups, and control group
comprised 21 children with untreated skeletal Class II malocclusions. The
initial mean age for the Bionator group was 10 years 7 months, for the
acrylic Herbst group was 12 years 2 months, for the Twin Block group
was 10 years 11 months, and for the MARA group 11 years 1 month.
Lateral cephalograms were taken for the treated group at T1 (initial
records), T2 (completion of functional therapy), and T3 (completion of
fixed appliance therapy. The results of the study showed significant

25
increase in mandibular length in Twin Block, Herbst, and MARA patients
when compared to control group. Restriction of maxillary growth was
found in the Herbst appliance and MARA groups (T2–T1). SNB increased
more with the Twin Block and Herbst groups when compared with the
Bionator and MARA groups. The overbite, overjet. The Twin Block
group had significant flaring of the lower incisors at the end of treatment.

A study was done by Nalbantgil D, to evaluate the changes induced by

the Jasper Jumper appliance skeletally, dentally, and soft tissue, the results
demonstrated that the sagittal growth potential of the maxilla was
inhibited with no change in the vertical skeletal parameters. The
mandibular incisors were protruded and intruded while maxillary incisors
were protruded and retruded. Upper molars tipped distally whereas the
lower molars tipped mesially. The overjet was reduced and the soft-tissue
improved.

Chhibbar A, Nanda R. Dentoskeletal effects and efficiency of treatment

of the Twin Force Bite Corrector appliance were compared before and
after pubertal growth in Class II patients. according to their Cervical
Vertebrae Maturation Stage (CVMS). The first group where treatment
started before the pubertal growth spurt (CVMS I and II), while the second
group where the treatment started after the pubertal growth (CVMS III to
V). The study concluded that at the end of the treatment there was no

26
difference in dentoskeletal effects of the TFBC appliance in prepubertal
and postpubertal patients.

❖ Skeletal and dental changes of skeletally anchored FFA

With the great advances and widespread usage of mini-screws and

miniplates in conjugation with fixed functional appliances was greatly
increased, assuming that they decrease the side effects of fixed functional
appliances as lower anterior teeth proclination and increases the FFA
skeletal effects.

Miniscrews had been used with the Herbst appliance and FFRD in an
attempt to address more skeletal effect, other studies used the FFRD
appliance with miniplates to avoid any tooth borne anchorage.

The effects of modified Herbst appliance in association with TADs on the

lower incisor inclination was evaluated. Ten adolescent patients with
skeletal class II malocclusion were assigned into 2 groups; group I,
consisted of 5 cases treated with modified Herbst appliance and group II,
consisted of 5 cases treated with conventional cast Herbst appliance. The
changes in lower incisors inclination was assessed on lateral head films
and compared between the two studied groups. The result has shown that
lower incisor inclination increases only 1 in group I compared to 7 in

27
group II. So, it was concluded that the association of TADs with the
Herbst appliance can optimize treatment efficiency and skeletal response
by reducing the occurrence of excessive lower incisor proclination.

To evaluate the skeletal, dentoalveolar, and soft tissue effects of the

Forsus Fatigue Resistant Device (FRD) appliance with miniplate
anchorage for the treatment of skeletal Class II malocclusion, A
prospective clinical study included group of 17 patients with Class II
malocclusion due to mandibular retrusion.
After leveling of the maxillary arch, two miniplates were placed
bilaterally on the mandibular symphysis. Then, the Forsus FRD appliance
was adjusted to the miniplates without leveling the mandibular arch. The
changes were evaluated using the cephalometric lateral films. The
mandible significantly moved forward and caused a significant restraint
in the sagittal position of the maxilla. The overjet correction (- 5.11 mm)
was found to be mainly by skeletal changes (A-VRL, -1.16 mm and Pog-
VRL, 2.62 mm; approximately 74%) with significant increase in SNB
angle and decrease in ANB; the remaining changes were due to the
dentoalveolar contributions. The maxillary and mandibular incisors were
significantly retruded.

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Thus, concluded that this new approach was an effective method for
treating skeletal Class II malocclusion due to the mandibular retrusion via
a combination of skeletal and dentoalveolar changes.

Another study was preformed to evaluate the skeletal, dentoalveolar, and

soft tissue effects of the Forsus FRD appliance with miniplate anchorage
inserted in the mandibular symphyses and to compare the findings with a
well-matched control group treated with a Herbst appliance for the
correction of a skeletal Class II malocclusion due to mandibular retrusion.
The sample consisted of 32 Class II subjects divided into two groups.
Group I consisted of 16 patients, treated using the Forsus FRD EZ
appliance with miniplate anchorage inserted in the mandibular
symphyses. Group II consisted of 16 patients treated using the Herbst
appliance. The results showed that both appliances were effective in
correcting skeletal class II malocclusion and showed similar skeletal and
soft tissue changes. The maxillary incisor was statistically significantly
more retruded in the skeletally anchored Forsus FRD group. The
mandibular incisor was retruded in the skeletally anchored Forsus FRD
group, while it was protruded in the Herbst group. Although both
appliances were successful in correcting the skeletal Class II
malocclusion, the skeletally anchored Forsus FRD EZ appliance did so
without protruding the mandibular incisors.

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❖ Effect of functional appliances on condyle:

To evaluate the effect FFA on temporomandibular joint (TMJ) (the sum

of condylar modeling, glenoid fossa modeling, and condylar position
changes within the fossa), in patients with a Class II division 1
malocclusion, two groups of successfully treated subjects were evaluated,
group treated by Tip-Edge brackets and class II elastics (24) and another
group treated with Herbst (40). The Bolton Standards served as a control
group. Lateral head films obtained before treatment and after an
observation period of 2.6 years. The results showed that the Tip-Edge
group exhibited less favorable sagittal ‘‘effective’’ TMJ growth changes
necessary for skeletal Class II correction, while bite jumping with the
Herbst appliance has a favorable sagittal orthopedic effect on a short-time
basis.

The amount and direction of condylar growth, glenoid fossa displacement,

and ‘‘effective’’ temporomandibular joint (TMJ) changes (a summation
of condylar growth, glenoid fossa displacement, and condylar position
changes within the fossa) were analyzed in 35 Class II, Division 1
malocclusions (23 boys and 12 girls) treated with the Herbst appliance.
Lateral head films in habitual occlusion and with the mouth wide open
from before (T1) and after 7.5 months of Herbst treatment (T2) as well as
7.5 months (T3) and three years (T4) after treatment were evaluated. As a

30
control group, a sample of 12 untreated male Class II, Division 1
malocclusions was used during a 7.5-month time period corresponding to
the treatment period (T2-T1) of the Herbst cases. The results revealed that
during the treatment period (T2- T1) condylar growth was directed
posteriorly about twice the amount as in the control subjects, and the fossa
was displaced in an anterior inferior direction. The effective TMJ changes
showed a pattern similar to condylar growth but were more pronounced.
During the first posttreatment period (T3-T2), all TMJ changes reverted.
The glenoid fossa was displaced backward; the amount of condylar
growth and effective TMJ changes was reduced, and the changes were
more superiorly directed. During the second posttreatment period (T4-
T3), all TMJ changes were considered physiological. This concluded that
during Herbst treatment, the amount and direction of TMJ changes
(condylar growth, fossa displacement, and effective TMJ changes) were
only temporarily affected favorably by Herbst treatment.

To evaluate the condylar changes through cone-beam computed

tomography (CBCT) images in patients treated with Twin-Block
functional appliance, CBCT images of 30 patients were used. Mandible
was segmented and pretreatment and posttreatment (T0 and T1) condylar
volume was compared. Results showed a decrease in SNA and ANB and
an increase in SNB Additionally, mandibular length, and condylar volume

31
increased at both the left and right sides. However, increase at Co-A was
not statistically significant.

32
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