CASE REPORT

Treatment of Class II malocclusion with

mandibular skeletal anchorage
Ezgi Cakir,a Siddik Malkoç,a and Mustafa Kirtayb
Malatya, Turkey

Introduction: The aim of this case report was to present the dentofacial changes obtained with bone anchorage
in a Class II patient with moderate to severe crowding. Methods: A boy, aged 14.5 years, with a dolichofacial
type, convex profile, and skeletal and dental Class II relationships was examined. After evaluation, functional
treatment with bone anchorage and 4 first premolar extractions was decided as the treatment approach. Mini-
plates were placed on the buccal shelves of the mandibular third molars. The hook of the anchor was revealed
from the first molar level. After surgery, the 4 first premolars were extracted to retract the protrusive mandibular
incisors. The maxillary and mandibular first molars were banded, and a lip bumper was inserted to apply elastics
and to help distalize the maxillary first molars. Orthodontic forces of 300 to 500 g were applied immediately after
placement, originating from the miniscrews to the hooks of the appliance to advance the mandible. Results:
After 20 months of treatment, the patient had a dental and skeletal Class I relationship, the mandible was
advanced, the maxilla was restrained, and overjet was decreased. Conclusions: The combination of a bone
anchor, Class II elastics, and an inner bow is a promising alternative to functional treatment, along with extrac-
tions, in Class II patients. (Am J Orthod Dentofacial Orthop 2017;151:1169-77)

C
lass II malocclusion, a common orthodontic prob-
lem, occurs in approximately one third of the
population.1-3 Class II correction techniques
include a variety of extraction protocols, palatal
expansion mechanisms, extraoral traction, and
functional appliances.4 The selection of appliance varies
according to the clinician's priorities, type of anomaly,
and patient's growth pattern.5,6
Mandibular retrusion is the most common feature of
Class II malocclusion.4 The objective of early Class II
malocclusion treatment is to correct a skeletal dispro-
portion by altering the pattern of mandibular growth.7
Removable or fixed functional appliances could be
used to advance the mandible. The efficiency of fixed
functional appliances has been analyzed in previous
studies. However, some disadvantages of fixed func-
tional appliances, such as distal and intrusive move-
ments of maxillary molars, mesial movement of
mandibular molars, retrusion of maxillary incisors, and
protrusion of mandibular incisors, have been reported.6,8
Alternatively, Class II elastics can cause similar side
effects.9 The use of skeletal anchorage systems to elim-
inate these side effects and accelerate orthodontic treat-
ment has become widespread.
Shortening the duration of orthodontic treatment
has become a trend in recent years. Patients who receive
treatment in more than 1 phase are occupied for a
considerably longer time in active treatment.10 The
duration of both functional and premolar extraction
treatment is prolonged. Is it possible to combine the 2
phases and shorten the treatment time?
The aim of this case report was to present the treat-
ment of a patient with a skeletal Class II malocclusion
with mandibular retrusion and moderate crowding, us-
ing Class II elastics with miniplate anchorage. Treatment
duration would be shortened by combining the 2 phases.

From the Faculty of Dentistry, In€on€

u University, Malatya, Turkey. DIAGNOSIS AND ETIOLOGY
a
Department of Orthodontics.
b
Department of Oral and Maxillofacial Surgery. A boy, aged 14.5 years, was referred to the Depart-
All authors have completed and submitted the ICMJE Form for Disclosure of ment of Orthodontics of In€ on€u University in Malatya,
Potential Conflicts of Interest, and none were reported. Turkey, for orthodontic treatment. His chief complaint
Address correspondence to: Siddik Malkoç, In€on€ u Universitesi, Dishekimligi
Fak€ultesi, Ortodonti AD, Malatya 44280, T€ urkiye; e-mail, siddikmalkoc@ was maxillary anterior crowding. The pretreatment clin-
yahoo.com. ical examination showed that he had a Class II Division 1
Submitted, December 2015; revised and accepted, May 2016. malocclusion associated with mandibular retrusion and
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved. an increased overjet. His facial photographs showed a
http://dx.doi.org/10.1016/j.ajodo.2016.05.017 symmetric face, a slightly convex profile with an
1169
1170
Fig 1. Pretreatment facial and intraoral photographs.
increased nasolabial angle, and a proportionally short
lower anterior facial height (Fig 1). No temporomandib-
ular disorder signs or symptoms were observed in the
questionnaire or the clinical examination.
Cephalometric analysis showed that he had a skeletal
Class II malocclusion (ANB, 17.4 ; Wits
appraisal, 16.6 mm) with bimaxillary retrognathism
relative to the frontal cranial base (SNA, 78.2 ; SNB,
70.9 ). The patient had a normal skeletal pattern
(SNGoGn, 37.9 ). The inclination of the maxillary inci-
sors was decreased (1-SN, 94.4 ), the mandibular inci-
sors were proclined (IMPA, 106.6 ; 1-NB, 8.4 mm),
and the interincisal angle was 118.6 (Table).
The intraoral examination showed Class II canine and
molar relationships and scissorsbites of the
second molars on both sides. The mandibular dental
midline almost coincided with the facial midline. The
maxillary midline deviated by 1.5 mm to the left relative
to the facial midline (Fig 1). Dental cast analysis showed
June 2017  Vol 151  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Cakir, Malkoç, and Kirtay
that arch length discrepancies were 4.5 mm in the
maxilla and 1.6 mm in the mandible. Overjet was
5.6 mm, and overbite was 3.2 mm (Fig 2).
The panoramic radiographic findings showed that all
third molars were impacted. The mandibular first molar
on the right side and the maxillary central incisor on the
left side were largely restored. The mandibular first
molar on the left side was restored with a poor root-
canal filling. Skeletal maturation of the patient was
found to be stage 5 according to the hand-wrist method
(Fig 3).11,12
TREATMENT OBJECTIVES
The main treatment objectives were to (1) correct the
mandibular retrusion using bone-anchored miniplates,
(2) resolve the maxillary and mandibular crowding, (3)
obtain optimal inclination of the patient's anterior teeth
and normal overjet and overbite, (4) establish Class I
Cakir, Malkoç, and Kirtay 1171

Another proposed treatment option involved a com-

Table. Pretreatment and posttreatment cephalo-
bination of comprehensive orthodontic treatment and
metric measurements
orthognathic surgery, but this approach was considered
Initial Final too aggressive and invasive for this patient.
Measurement value value Norm SD Therefore, we planned 4 premolar extractions after
SNA ( ) 78.2 76.6 82.0 2 the functional treatment. Extractions were necessary
SNB ( ) 70.9 71.9 80.0 2
ANB ( ) 7.4 4.7 2 1.5
to correct the inclination of the lower incisors and
Wits appraisal (mm) 6.6 4.2 1.0 1.0 the maxillary crowding. The functional treatment
SN-GoGn ( ) 37.9 37.7 32.0 5.2 was necessary to contribute to the patient's profile.
FMA (MP-FH) ( ) 29.2 29.2 24.5 4.5 However, this approach has a long treatment duration
U1-SN ( ) 94.4 89.5 102.6 5.5 and requires patient cooperation. The skeletal matura-
U1-palatal plane ( ) 99.1 95.6 110.0 5.0
U1-NA ( ) 16.2 13.0 22.8 5.7
tion stage was determined based on his hand-wrist
U1-NA (mm) 3.0 1.0 4.3 2.7 radiograph according to the methods of Bjork.11,12
IMPA ( ) 106.6 93.6 90.0 4.5 Skeletal maturation was stage 5.
L1-NB ( ) 37.8 26.2 26.2 4.0 After these evaluations, an all-in-1 treatment plan
L1-NB (mm) 8.4 4.5 4.0 1.8 was considered for achieving the treatment objectives.
Interincisal angle (U1-L1) ( ) 118.6 136.1 130.0 6.0
Lower lip to E-plane (mm) 0.9 2.4 2.0 2.0
Functional treatment with bone anchorage and 4 first
Upper lip to E-plane (mm) 2.5 5.5 4.8 2.0 premolar extractions was selected as the treatment
Holdaway ratio (%) 0.2 0.7 1.0 0.5 approach.
Maxillary length (Co-A) (mm) 86.1 88.5 90.0 5.0
Mandibular length (Co-Gn) 107.6 112.9 118.4 4.0 TREATMENT PROGRESS
(mm)
Mandibular body length 71.3 74.4 72.2 4.4 The treatment goals were explained to the patient
(Go-Gn) (mm) and his family, and informed consent was obtained.
Overbite (mm) 3.7 1.5 3.1 1.0 Endodontic retreatment of the mandibular first molar
Overjet (mm) 5.1 1.7 2.5 2.5
on the left side was completed, and then the patient
was referred to an oral surgeon for the placement of
canine and molar relationships with a functional occlu- miniplates. Under local anesthesia, a full-thickness mu-
sion, and (5) eliminate the scissorsbites of the coperiosteal flap was elevated, and cortical bone was
second molars. exposed over the buccal shelves of the mandible
(Fig 4, A). The buccal shelves of the mandibular second
TREATMENT ALTERNATIVES and third molars were selected as safe anatomic regions.
Several procedures have been suggested to correct a Three-hole miniplates were adjusted to fit the contour of
skeletal Class II malocclusion with mandibular retrusion. the surface of the exposed cortical bone (Fig 4, B). The
The first alternative was nonextraction treatment, which miniplate consisted of 2 components: the arm (hook)
could be performed using cervical headgear, intermaxil- and the body. The arm component was revealed intraor-
lary Class II elastics, and removable or fixed functional ally from the first molar level and was positioned outside
appliances. Our patient was in adolescence, and func- the dentition so that it did not interfere with tooth
tional treatment could be applied; however, functional movement.15 The wound was sutured and allowed to
appliances would have increased the mandibular incisor heal for 2 weeks before application of orthodontic force
inclination. (Fig 5, A-C). After the surgery, the patient was instructed
The second and third options were to extract 2 or 4 to clean the exposed loop and maintain good oral hy-
first premolars to correct the crowding. Camouflage giene.16 The maxillary and mandibular first molars
treatment with extraction of maxillary first premolars were banded, and the 4 first premolars were extracted
would eliminate the overjet and correct the maxillary to retract the protrusive mandibular incisors and to cor-
anterior crowding. There were Class II canine and molar rect maxillary crowding. A lip bumper was placed, and
relationships before treatment; therefore, maximum elastics were applied to improve the anchorage of the
anchorage would be required for protection for a Class maxillary first molars. Celikoglu and Candirli17 used in-
I molar relationship.13 However, there was a greater ner bows on the maxilla in their case report. We chose
need for anchorage since distalization of posterior and an inner bow similar to that used in their study because
anterior maxillary dental segments was needed to obtain of the poor appearance of the lip bumper.
a Class I canine and molar relationship as a result of the The application of orthodontic forces was started
treatment.14 2 weeks after miniplate placement. A force of 300 to

American Journal of Orthodontics and Dentofacial Orthopedics June 2017  Vol 151  Issue 6
1172 Cakir, Malkoç, and Kirtay

Fig 2. Pretreatmet dental casts.

Fig 3. Pretreatment extraoral and intraoral radiographs and tracing.

500 g was loaded with a Class II elastic from the lip 0.022-in preadjusted edgewise appliances were placed
bumper to the miniplates (Fig 5, D-F). The patient on the maxillary and mandibular teeth. Initial alignment
learned to use his lip bumper and Class II elastics, and and leveling were achieved with 0.0014-, 0.0016-, and

June 2017  Vol 151  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Cakir, Malkoç, and Kirtay 1173

Fig 4. A, Elevating a full-thickness mucoperiosteal flap; B, placing miniplates on the buccal shelves of
the mandibular second and third molars.

Fig 5. A-C, The application of orthodontic forces was started 2 weeks after miniplate placement; D-F, a
force of 300 to 500 g was loaded with a Class II elastic from the lip bumper to the miniplates.

0.018-in nickel-titanium archwires, and then the ca- TREATMENT RESULTS

nines were distalized during functional treatment using
a lace back. After distalization, 0.016 3 0.022-in stain-
less steel closing loops were used for the maxillary and
mandibular arches to retract both incisors and close
the extraction spaces along with Class II elastics. Correc-
tion of the second molar scissorsbite malocclusion began
with intermaxillary cross elastics. The mandibular first
molar on the right side was infected during the treat-
ment and restored with a root-canal filling. The mandib-
ular third molars and the miniplates were removed in the
same operation.
Finishing and detailing began with 0.017 3 0.025-
in stainless steel wires to obtain suitable interdigita-
tion in both arches. The total active treatment period
was 20 months. After removal of the appliance, maxil-
lary and mandibular lingual bonded retainers were
placed.
After 20 months of treatment, an acceptable occlu-
sion and a satisfactory facial profile were obtained.
The posttreatment facial photographs showed a
balanced and harmonious face. Protraction of the
mandible significantly improved the patient's facial pro-
file, and the dental midlines were almost coincident with
the facial midline. The teeth were well aligned and had
good interdigitation. Normal overjet (1.7 mm) and over-
bite (1.5 mm) and Class I canine and molar relationships
on both sides were achieved (Fig 6).
In comparison with the dental casts obtained before
treatment, the overerupted mandibular incisors were
significantly retruded, and the excessive curve of Spee
was also flattened (Fig 7).
The final panoramic radiograph and periapical radio-
graphs showed acceptable root paralleling with no

American Journal of Orthodontics and Dentofacial Orthopedics June 2017  Vol 151  Issue 6
1174 Cakir, Malkoç, and Kirtay

Fig 6. Posttreatment facial and intraoral photographs.

Fig 7. Postreatmet dental casts.

June 2017  Vol 151  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Cakir, Malkoç, and Kirtay
Fig 8. Posttreatment lateral, PA radiography was removed. Periapical, and panoramic radiographs
and tracing.
significant root resorption and marginal bone loss (Fig 8).
The lateral cephalogram and superimposition showed
retraction of the maxillary and mandibular incisors (Fig
9). In the pretreatment and posttreatment stages, there
were no changes in the SNGoGN and FMA angles and
no increase in facial height. Maxillary growth was slightly
restrained, while mandibular growth was slightly acceler-
ated (SNA, 76.6 ; SNB, 71.9 ). The cephalometric analysis
showed a decrease of the ANB angle of 4.7 (ANB, 14.7 ;
Wits appraisal, 14.2 mm). This decrease consisted of a
decrease of the SNA angle and an increase of the SNB
angle from pretreatment to posttreatment. The other
cephalometric change was the positions of the incisors.
The inclinations of the maxillary incisors and mandibular
incisors were decreased (1-SN, 89.5 ; IMPA, 93.6 ; 1-NB,
4.5 mm), and the interincisal angle was 136.1 . Other
cephalometric values were in normal ranges (Table).
American Journal of Orthodontics and Dentofacial Orthopedics
1175
Favorable growth of the mandible was observed on the
superimposition (Fig 9, C). Overjet and overbite were
improved.
DISCUSSION
The patient was dolichofacial, with a convex profile,
Class II skeletal and dental relationships with increased
overjet (5.6 mm), and mandibular incisor inclination
(IMPA, 106.6 ). Functional treatment with bone
anchorage and 4 first premolar extractions was selected
as the treatment approach for this patient to combine
correction of the Class II relationship and the position
of the mandibular incisors. This combination was chosen
to shorten the duration of treatment.
Longer orthodontic treatment duration is required
for extraction patients compared with nonextraction
June 2017  Vol 151  Issue 6
1176
Fig 9. A, Structural superimposed tracing of pretreatment (black line) and posttreatment (red line)
lateral cephalometric radiographs; B, maxillary and C, mandibular structural superimpositions showing
molar extrusion and incisor retraction.
patients.18,19 Class II nonextraction treatment involves
distalization of the maxillary molars into a Class I
relationship. For this purpose, conventional extraoral
appliances (headgear) are frequently used.20,21 These
appliances depend heavily on patient cooperation, a
major disadvantage that can offset the efficacy in
tooth movement.21 Our patient rejected headgear
because of social and esthetic concerns, and headgear
would also have provided only dental camouflage. Addi-
tionally, prescribing headgear would have resulted in a
longer orthodontic treatment.10
To retract the anterior teeth, the bilateral premolars
are commonly extracted to correct the dentoalveolar pro-
trusion.22 This patient had mandibular retrusion with
increased mandibular incisor inclination rather than
maxillary protrusion. Therefore, we planned 4 first pre-
molar extractions to correct the angle of the mandibular
incisors, the midline shift, and the maxillary crowding.
Premolar extractions and maximum anchorage are pre-
requisites for anchorage control, which is a challenge in
a patient with a skeletal Class II malocclusion.23 In
anchorage reinforcement, several auxiliaries, such as
headgear, lingual arch, transpalatal arch, holding arch,
and Class II elastics could be used.23 In addition, treat-
ment with 4 premolar extractions takes longer than treat-
ment with 2 premolar extractions or nonextraction
treatment.18,19 However, functional treatment was
necessary to improve the soft tissue profile of our patient.
Beckwith et al10 found that active treatment takes
significantly longer in patients treated in more than 1
phase. Although early treatment with either headgear
or functional appliance therapy could reduce the severity
June 2017  Vol 151  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Cakir, Malkoç, and Kirtay
of a Class II skeletal pattern, early treatment takes more
time.7 Other complications of functional treatment are
dental side effects and relapse. Functional treatment
leads to mesial migration of the mandibular teeth and
retroclination of the maxillary incisors.24 According to
Pancherz,25 the reason for Class II functional relapse is
unstable Class I cuspal interdigitation. If the occlusion
is not stable after functional treatment, premolar extrac-
tions might increase the risk of mandibular relapse dur-
ing phase 2 treatment. Skeletal anchorage systems were
applied to eliminate these side effects and to accelerate
the treatment.
In Class II patients, miniplates are often used to
retract the anterior teeth after extraction of the bilateral
premolars to correct dentoalveolar protrusion.22 Suga-
wara et al26 and Nur et al21 used miniplates for distal
movement of the mandibular and maxillary molars. In
addition, miniplates might also be used for functional
treatment. Celiko glu et al6 advanced the mandible to
eliminate mandibular incisor protrusion using a
miniplate-anchored Forsus Fatigue Resistant Device.
The buccal shelf is our preferred insertion region because
this eliminates the risk of tooth or root damage. In the
case report by Nur et al, the authors used intramaxillary
elastics from the hooks to the miniplates. We used inter-
maxillary elastics from the hooks of the lip bumper to the
miniplates. Conventionally, the effects of Class II elastics
are primarily dentoalveolar.27 Class II elastics retract the
maxillary anterior teeth and mesialize the mandibular
posterior teeth. They have similar long-term adverse ef-
fects as fixed functional appliances.27 We used Class II
elastics from the miniplates to the hooks of the appliance
Cakir, Malkoç, and Kirtay
to advance the mandible. Otherwise, this appliance
design can provide maxillary molar movement control
during distalization using a transpalatal bar and inner
bow. The canines were distalized during functional
treatment using a lace back. Therefore, it was possible
to shorten the duration of treatment and perform a com-
bination of the 2 phases simultaneously.
CONCLUSIONS
The combination of a bone anchor, Class II elastics,
and an inner bow is a promising alternative to functional
treatment, along with extraction, in Class II patients.
This approach, which reduces treatment duration,
should be considered as an alternative to functional
treatment.
REFERENCES
1. McLain JB, Proffit WR. Oral health status in the United States:
prevalence of malocclusion. J Dent Educ 1985;49:386-96.
2. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr.
Mandibular changes produced by functional appliances in Class
II malocclusion: a systematic review. Am J Orthod Dentofacial Or-
thop 2006;129:599.e1-12.
3. Gelgor IE, Karaman AI, Ercan E. Prevalence of malocclusion among
adolescents in central Anatolia. Eur J Dent 2007;1:125-31.
4. McNamara JA Jr. Components of a Class II malocclusion in chil-
dren 8-10 years of age. Angle Orthod 1981;51:177-202.
5. Gottfried PF, Schmuth GP. Milestones in the development and
practical applications of functional appliances. Am J Orthod
1983;84:48-53.
6. Celikoglu M, Unal T, Bayram M, Candirli C. Treatment of a skeletal
Class II malocclusion using fixed functional appliance with mini-
plate anchorage. Eur J Dent 2014;8:276-80.
7. Tulloch JF, Phillips C, Koch G, Proffit WR. The effect of early
intervention on skeletal pattern in Class II malocclusion: a ran-
domized clinical trial. Am J Orthod Dentofacial Orthop 1997;
111:391-400.
8. Nelson B, Hansen K, H€agg U. Class II correction in patients treated
with Class II elastics and with fixed functional appliances: a
comparative study. Am J Orthod Dentofacial Orthop 2000;118:
142-9.
9. Ellen EK, Schneider BJ, Sellke T. A comparative study of anchorage
in bioprogressive versus standard edgewise treatment in Class II
correction with intermaxillary elastic force. Am J Orthod Dentofa-
cial Orthop 1998;114:430-6.
10. Beckwith FR, Ackerman RJ, Cobb CM, Tira DE. An evaluation of
factors affecting duration of orthodontic treatment. Am J Orthod
Dentofacial Orthop 1999;115:439-47.
11. Uysal T, Ramoglu SI, Basciftci FA, Sari Z. Chronologic age and
skeletal maturation of the cervical vertebrae and hand-wrist: is
American Journal of Orthodontics and Dentofacial Orthopedics
1177
there a relationship? Am J Orthod Dentofacial Orthop 2006;
130:622-8.
12. Grave KC, Brown T. Skeletal ossification and the adolescent growth
spurt. Am J Orthod 1976;69:611-9.
13. Bengi AO, Karacay S, Akin E, Olmez H, Okçu KM, Mermut S. Use of
zygomatic anchors during rapid canine distalization: a preliminary
case report. Angle Orthod 2006;76:137-47.
14. Janson G, Brambilla AC, Henriques JFC, Freitas MR, Neves LS.
Class II treatment success rate in 2- and 4-premolar extrac-
tion protocols. Am J Orthod Dentofacial Orthop 2004;125:
472-9.
15. Sugawara J, Nishimura M. Minibone plates: the skeletal anchorage
system. Semin Orthod 2005;11:47-56.
16. Chen CH, Hsieh CH, Tseng YC, Huang IY, Shen YS, Chen CM. The
use of miniplate osteosynthesis for skeletal anchorage. Plast Re-
constr Surg 2007;120:232-7.
17. Celikoglu M, Candirli C. Unilateral maxillary molar distalization us-
ing zygoma-gear appliance. J Orthod Res 2014;2:109-12.
18. Mavreas D, Athanasiou AE. Factors affecting the duration of or-
thodontic treatment: a systematic review. Eur J Orthod 2008;30:
386-95.
19. Akinci H, Uysal T. Comparison of orthodontic treatment outcomes
in nonextraction, 2 maxillary premolar extraction and 4 premolar
extraction protocols with the American Board of Orthodontics
objective grading system. Am J Orthod Dentofacial Orthop 2014;
145:595-602.
20. Cangialosi TJ, Meistrall ME Jr, Leung MA, Ko JY. A cephalometric
appraisal of edgewise Class II nonextraction treatment with
extraoral force. Am J Orthod Dentofacial Orthop 1988;93:
315-24.
21. Nur M, Bayram M, Pampu A. Zygoma-gear appliance for intraoral
upper molar distalization. Korean J Orthod 2010;40:195-206.
22. Yao CC, Lai EH, Chang JZ, Chen I, Chen YJ. Comparison of treat-
ment outcomes between skeletal anchorage and extraoral
anchorage in adults with maxillary dentoalveolar protrusion. Am
J Orthod Dentofacial Orthop 2008;134:615-24.
23. Kuroda S, Yamada K, Deguchi T. Class II malocclusion treated with
miniscrew anchorage: comparison with traditional orthodontic
mechanics outcomes. Am J Orthod Dentofacial Orthop 2009;
135:302-9.
24. McNamara JA Jr, Bookstein FL, Shaughnessy TG. Skeletal and
dental changes following functional regulator therapy on Class II
patients. Am J Orthod 1985;88:91-110.
25. Pancherz H. The nature of Class II relapse after Herbst appliance
treatment: a cephalometric long-term investigation. Am J Orthod
Dentofacial Orthop 1991;100:220-33.
26. Sugawara J, Daimaruya T, Umemori M, Nagasaka H, Takahashi I,
Kawamura H, et al. Distal movement of mandibular molars in adult
patients with the skeletal anchorage system. Am J Orthod Dento-
facial Orthop 2004;125:130-8.
27. Janson G, Sathler R, Fernandes TM, Branco NC, Freitas MR.
Correction of Class II malocclusion with Class II elastics: a sys-
tematic review. Am J Orthod Dentofacial Orthop 2013;143:
383-92.
June 2017  Vol 151  Issue 6