THE KOREAN JOURNAL of

Case Report ORTHODONTICS

pISSN 2234-7518 • eISSN 2005-372X

http://dx.doi.org/10.4041/kjod.2014.44.5.268

Correction of Angle Class II division 1 malocclusion

with a mandibular protraction appliances and
multiloop edgewise archwire technique
Benedito Freitasa A Brazilian girl aged 14 years and 9 months presented with a chief complaint of
Heloiza Freitasb protrusive teeth. She had a convex facial profile, extreme overjet, deep bite, lack
Pedro César F dos Santosc of passive lip seal, acute nasolabial angle, and retrognathic mandible. Intraorally,
Guilherme Jansond she showed maxillary diastemas, slight mandibular incisor crowding, a small
maxillary arch, 13-mm overjet, and 4-mm overbite. After the diagnosis of severe
Angle Class II division 1 malocclusion, a mandibular protraction appliance was
placed to correct the Class II relationships and multiloop edgewise archwires
were used for finishing. Follow-up examinations revealed an improved facial
profile, normal overjet and overbite, and good intercuspation. The patient
was satisfied with her occlusion, smile, and facial appearance. The excellent
results suggest that orthodontic camouflage by using a mandibular protraction
appliance in combination with the multiloop edgewise archwire technique is
a
Discipline of Orthodontics, School an effective option for correcting Class II malocclusions in patients who refuse
of Dentistry, Federal University of orthognathic surgery.
Maranhão, São Luís-Maranhão, Brazil
b
[Korean J Orthod 2014;44(5):268-277]
Private Practice, São Luís-Maranhão,
Brazil
c Key words: Class II malocclusion, Mandibular advancement, Orthodontic
Discipline of Orthodontics, School of
Dentistry, Federal University of Ceará, treatment
Fortaleza, Brazil
d
Department of Orthodontics, Bauru
Dental School, University of São Paulo,
São Paulo, Brazil

Received September 21, 2013; Revised October 25, 2013; Accepted November 15, 2013.

Corresponding author: Benedito Freitas.

Professor, Discipline of Orthodontics, School of Dentistry, Federal University of Maranhão,
Avenida dos Portugueses, Campus Bacanga, São Luís-Maranhão, CEP: 65085-580, Brazil.
Tel +55-98-81331756, e-mail: [email protected]

The authors report no commercial, proprietary, or financial interest in the products or companies
described in this article.
© 2014 The Korean Association of Orthodontists.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

268
Freitas et al • Treatment of Class II malocclusion

INTRODUCTION origin and are mainly attributable to evolutionary changes

in craniofacial growth, dietary and social habits, and
According to Angle,1 a Class II malocclusion is charac­ ethnic admixture. Therefore, orthodontic treatment
terized by the distal occlusion of the mandibular first plan­­ning depends on several factors, including the na­
molar in relation to the maxillary first molar; in a Class ture of the malocclusion, patient characteristics, and
II division 1 malocclusion, the maxillary incisors addi­ family history.4 One treatment option is the combined
tionally exhibit proclination. This malocclusion is also use of a mandibular protraction appliance (MPA) and
characterized by an anteroposterior dental discrepancy, multiloop edgewise archwires (MEAWs). The MPA is
which may be associated with skeletal changes. The a fixed orthopedic appliance used for treating Class II
overjet may be excessive and the overbite is most likely malocclusions. Its advantages include ease of fabrication
deep. The retrognathic profile and excessive overjet by the dentist or assistant, easy placement, and the
result in abnormal contraction patterns of the facial possibility of concomitant use with other appliances,
muscles and tongue. Typically, the mentalis becomes thus reducing the total treatment time and increasing
hyperactive, to elevate the orbicularis oris and achieve post-treatment stability. 5 The MEAW technique was
lip sealing. 2 The marked overjet also increases the developed in 1967 to treat severe open bites and was
patient's susceptibility to dental trauma. Additionally, found to be extremely effective. Since then, it has been
the unaesthetic facial appearance often has psychosocial applied in various malocclusions, especially at the final
consequences.3 treatment stage, to achieve better intercuspation.6
Class II division 1 malocclusions have a multifactorial This paper reports a case of severe Angle Class II

Figure 1. Pretreatment facial and intraoral photographs.

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 Freitas et al • Treatment of Class II malocclusion

division 1 malocclusion in a female patient outside the The initial panoramic radiograph (Figure 2) revealed
maximum pubertal growth peak who was treated by the presence of well-positioned third molars and the
orthodontic camouflage using the MPA and MEAW absence of morphologic changes to the condyles. The
technique. initial lateral cephalogram showed a horizontal growth
pattern (FMA = 22°), well-positioned maxilla (SNA =
DIAGNOSIS AND ETIOLOGY 79°), retrognathic mandible (SNB = 76°), and marked
incisor proclination (1.NA = 44°) (Figure 2 and Table 2).
A Brazilian girl aged 14 years and 9 months presented
with a chief complaint of protrusive teeth. She had a TREATMENT OBJECTIVES
convex facial profile, deep bite, lack of passive lip seal,
acute nasolabial angle, retrognathic mandible, and The treatment objectives were to improve the facial
no midline deviation. No signs of temporomandibular aesthetics, balance the lip musculature, achieve stable
dysfunction such as clicks, cracks, and crepitation were occlusion, correct the maxillary dental protrusion and
noted. She also did not report systemic problems or canine relationship, reduce the overjet and overbite, and
a family history of the same malocclusion. Intraoral correct the mandibular incisor crowding.
examination revealed good oral hygiene, maxillary dia­
stemas, slight crowding of the mandibular incisors, a MPA fabrication
small maxillary arch, overjet of 13 mm, and overbite of The MPA consisted of three parts: the maxillary and
4 mm (Figure 1). mandibular parts and the bootstrap.
Her occlusion was assessed using the Dental Aesthetic To construct the maxillary portion, a short piece of
Index (DAI), as recommended by the World Health stainless steel tubing was joined transversely to one end
Organization.7 The assessment revealed a very severe of a telescopic stainless steel tube (outer diameter =
or disfiguring malocclusion, necessitating orthodontic 1.0 mm; inner diameter = 0.9 mm; length = 35 mm) by
treatment (Table 1). point welding (fusion welding held the tubes together
while silver soldering them with flux and a blowtorch).
After the tubing was cut flush with the telescopic tube,
Table 1. Dental Aesthetic Index (DAI) values before and a 0.9-mm-diameter stainless steel wire clip was inserted
after treatment and at the 3-years follow-up examination into the telescopic tube and maxillary first molar tube
Three-
Pre- Post-
Component Weight treatment year
treatment retention

MVT (n) 6 0 0 0
CIS 1 1 0 0
SIS 1 1 0 0
MD (mm) 3 1 0 0
LAIMx (mm) 1 0 0 0
LAIMd (mm) 1 1 0 1
AMxOJ (mm) 2 13 3 2.5
MdOJ (mm) 4 0 0 0
VAOB (mm) 4 0 0 0
APMR 3 0 0 0
DAI 45 19 19
MVT, Missing visible teeth (incisors, canines, and premolars
in the maxillary and mandibular dentitions); CIS, crowding
in the incisal segments (0 = no crowding; 1 = one segment
crowded; 2 = two segments crowded); SIS, spacing in the
incisal segments (0 = no spacing; 1 = one segment spaced;
2 = two segments spaced); MD, midline diastema; LAIMx,
largest anterior irregularity in the maxilla; LAIMd, largest
anterior irregularity in the mandible; AMxOJ, anterior
maxillary overjet; AMdOJ, anterior mandibular overjet;
VAOB, vertical anterior open bite; APMR, anteroposterior Figure 2. Pretreatment panoramic and cephalometric
molar relationship (0 = normal; 1 = half cusp; 2 = one cusp). radiographs and tracing.

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Freitas et al • Treatment of Class II malocclusion

Table 2. Cephalometric measurements

Measurement Norms Pretreatment Posttreatment Three-year retention
Maxilla
SNA (°) 82 79 82 82
Co-A (mm) 85 92 89 81
A-Nperp (mm) 1 −2 −1 0
Mandible
SNB (°) 80 76 80 79
Co-Gn (mm) 108 120 120 120
P-Nperp (mm) −2 −2 −3 +1.5
Growth pattern
FMA (°) 25 22 22 24
SN.Ocl (°) 14 1.5 7 8.5
SN.GoGn (°) 32 29 20 25
LFH (mm) 62 72 68 69
Facial axis (°) 90 93 93 89
ODI (°) 74.5 69 68 71
Jaw relation
ANB (°) 2 3 2 2
Wits (mm) 0 +4 +2.5 +2.5
APDI (o) 81.5 77 80 80.5
Upper teeth
1.NA (°) 22 44 25 22
1-NA (mm) 4 13 5 34
1.PP (°) 112.1 130 110 110
1-PP (mm) 33 38 31.5 33
6-PP (mm) 27.9 26 26 24
Lower teeth
1.NB (°) 25 25 26 26
1-NB (mm) 4 3 3.5 4.7
o
IMPA ( ) 92 91 101 100
1-GoMe (mm) 48.3 43 42 42
Soft tissue
Nasolabial angle (°) 110 80 90 91
Line E (mm) −2 −4 −3 −3.5
SNA, Sella-nasion-A point; Co-A, distance from condylion to A point; A-Nperp, distance from A point to nasion perpendicular
line; SNB, sella-nasion-B point; Co-Gn, distance from condylion to gnathion; P-Nperp, distance from pogonion to nasion
perpendicular line; FMA, Frankfurt-mandibular plane angle; FH, Frankfurt horizontal plane; SN.Ocl, sella-nasion-occlusal
plane angle; SN.GoGn, sella-nasion line to gonion-menton line angle; LFH, lower facial height; facial axis, basion-nasion line
to pterygoid-gnathion line angle; ODI, overbite depth indicator; ANB, A point-nasion-B point; Wits, distance from A point
to B point at the occlusal plane; APDI, anteroposterior dysplasia indicator; 1.NA, angle between the maxillary central incisor
axis and nasion-A point line; 1-NA, distance from the maxillary central incisor to nasion-A point line; 1.PP, angle between
the maxillary central incisor axis and the palatal plane; 1-PP, distance from the edge of the maxillary central incisor to the
palatal plane; 6-PP, distance from the occlusal surface of the maxillary first molar to the palatal plane; 1.NB, angle between
the mandibular central incisor and nasion-B point line; 1-NB, distance from the edge of the mandibular central incisor to
nasion-B point; IMPA, incisor axis-mandibular plane angle; 1-GoMe, distance from the mandibular central incisor edge to
the mandibular plane; Nasolabial angle, angle between the line drawn through the midpoint of the nasal aperture and the
line drawn perpendicular to the Frankfurt horizontal plane while intersecting subnasale; Line E, distance from the lower lip
connecting the tip of nose and soft tissue pogonion.

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 Freitas et al • Treatment of Class II malocclusion

on each side (Figure 3).

For the bootstrap, a piece of 0.9-mm-diameter stain­
less steel wire was bent at 90° on one end and inserted
into the maxillary telescopic tube to prevent subsequent
deformation of the tube. Then, the straight end of the
wire was inserted into the maxillary tubing, and the wire
was bent until it was parallel to the maxillary telescopic
tube. The wire was cut so that its total length was ap­
proximately twice the length of the maxillary first molar
tube. The wire was annealed to allow for easy ben­
ding around the maxillary first molar tube during its
placement and to prevent dislodgement of the appliance
(Figure 3).
The mandibular part was fabricated from a 0.9-mm-
diameter stainless steel rod and 0.019 × 0.025-inch
stainless steel archwire with a helix between the canine
and the first premolar on each side. The rod had a
U-shaped bend at one end; the bend was threaded
through each helix from the lingual side and turned
parallel to the archwire. During MPA placement, the
rods were inserted into the maxillary tubes, which were
shortened to match the helices when the mandible
Figure 3. The mandibular protraction appliances. A, Right protruded to the point where the optimal overbite,
side; B, left. overjet, and midline were achieved. The rods extended

Figure 4. Intraoral progress photographs showing the mandibular protraction appliance used in conjunction with Class II
elastics in the multiloop edgewise archwire technique.

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Freitas et al • Treatment of Class II malocclusion

less than a millimeter distally from the maxillary tubes edgewise brackets (0.022 × 0.025-inch slot, Roth
(Figure 3). prescription). Leveling was performed with 0.014-inch
nickel titanium (NiTi), 0.016-inch NiTi, 0.018-inch
TREATMENT ALTERNATIVES stain­less steel, 0.020-inch stainless steel, and 0.019 ×
0.025-inch stainless steel archwires. During leveling, in
Two treatment options were presented to the patient. ad­dition to the 0.016-inch NiTi archwire, a continuous
The first option was orthognathic surgery including ligature was tied from molar to molar to reduce the
mandibular advancement and genioplasty. The second maxillary diastemas and to prevent labial tipping of the
option was nonsurgical treatment by dentoalveolar mandibular incisors. Interproximal enamel reduction of
compensation without extraction (orthodontic camou­ 2 mm was performed on the mandibular lateral incisors
flage). to relieve the mandibular crowding. After the 0.020-
The patient rejected the first option, so nonsurgical inch stainless steel archwire was placed, the ligature
treatment comprising mandibular advancement with was replaced with an elastic chain. In the mandibular
the MPA and orthodontic finishing with the MEAW 0.019 × 0.025-inch stainless steel archwire, a helix was
technique (Figure 4) was planned. included between canines and premolars for placement
of the MPA.
TREATMENT PROGRESS The MPA was maintained for 10 months in total.
The initial mandibular advancement was 6 mm. After
Treatment was initiated by banding the maxillary 4 months, further advancement was performed to
and mandibular first molars and bonding pre-adjusted achieve an edge-to-edge relationship. The MPA was

Figure 5. Posttreatment facial and intraoral photographs.

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 Freitas et al • Treatment of Class II malocclusion

removed after an additional 6 months of use. Although thereafter (DAI = 19) (Table 1).
correction of the molar relationship was observed, The final lateral cephalogram demonstrated proper
a mild Class II malocclusion remained in the canine in­c lination of the maxillary incisors (Figure 6). The
and premolar regions. MEAWs (0.019 × 0.025-inch mandibular incisors were facially inclined and the upper
stainless steel archwires) were placed in the dental lip projection was reduced. The patient was satisfied
arches. Intermaxillary (5/16 inch) elastics were used with her dental and facial appearance. Dentoalveolar
from the first “L” loops on the maxillary lateral incisors stability was maintained even after 3 years (Figures 7, 8,
to the mandibular first molar tubes. The MEAWs were and 9).
maintained for 2 months to avoid possible relapse
of the Class II relationship (Figure 4). The patient DISCUSSION
showed excellent compliance during the treatment.
After 26 months of active treatment, the appliances Angle Class II malocclusions, commonly characterized
were removed and impressions were taken to fabricate by an anteroposterior dental discrepancy, are more
retainers. A modified Hawley plate and 3 by 3 fixed severe when combined with skeletal disharmony, which
retainer were used in the maxillary and mandibular may be caused by mandibular deficiency, maxillary
arches, respectively. protrusion, or a combination of both.8 Mandibular re­
trusion is the most common characteristic in children
RESULTS with Class II malocclusions9 and shows no tendency for
self-correction with growth. Furthermore, mandibular
The post-treatment photographs revealed an improved retrusion worsens during the pubertal growth spurt,10
facial profile (Figure 5). The intraoral photographs exhi­ and maintains the same standard after this period until
bited bilateral Class I molar and canine relationships and young adulthood.11 For patients with skeletal Class II
an occlusion with a normal overjet and overbite (Figures malocclusions who have completed growth, the fol­
5 and 6). Good intercuspation, proximal contacts, and lowing treatment options are possible: (1) orthodontic
root parallelism were achieved (Figure 6). The decreased camouflage, which may be combined with extraction,
DAI value suggested normal occlusion at the completion based on retraction of the facially inclined maxillary
of orthodontic treatment (DAI = 19) and 3 years inci­sors and facial inclination of the mandibular inci­
sors, to improve occlusion and facial aesthetics without
correcting the underlying skeletal problem; or (2) or­
tho­g ­n athic surgery to reposition the mandible or
maxilla, depending on the skeletal Class II problems
associated with mandibular deficiency and downward
and backward mandibular rotation caused by excessive
maxillary vertical growth. Another option would
have been orthodontic treatment with first premolar
extraction; however, given the horizontal growth pattern
of the patient, this alternative was not considered be­
cause it would impair deep bite correction and affect
fa­cial aesthetics.
Surgical treatment includes mandibular advancement,
superior maxillary repositioning, or a combination of
both. Mandibular deficiency is a problem existing in
nearly two thirds of surgical patients, and one third of
surgical patients require maxillary surgery alone (15%)
or in combination with mandibular surgery (20%). In
the present case, orthognathic surgery was considered
for anterior mandibular repositioning and genioplasty
after the growth period, but the patient did not accept
this option. Although surgical patients achieve an ideal
skeletal relationship, with the mandible positioned
anteriorly and the mandibular incisors in an ideal
rela­tionship with the basal bone, patients treated by
ortho­dontic camouflage usually present less problems
Figure 6. Posttreatment panoramic and cephalometric
than those who are surgically treated.12 Orthognathic
radiographs and tracing.

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Freitas et al • Treatment of Class II malocclusion

Figure 7. Three-years follow-up facial and intraoral photographs.

surgery may cause complete condylar resorption in 10% ever, extractions may have led to a marked facial con­
of surgical cases. 13 Patients treated with orthodontic cavity and worsened the facial profile.15 Furthermore,
camouflage also report less functional problems in the the normative index used showed a dramatic change in
temporomandibular joint than those treated by orthog­ the severity of malocclusion, with reduction to a level
nathic surgery. Finally, with regard to the cost-bene­ considered to require little or no orthodontic treatment
fit relationship for patients outside the growth period, after treatment without extraction.
similar results have been observed between the treat­ More recently, several approaches to orthopedic
ment options, although orthodontic camouflage may treat­m ent of Class II malocclusions in young adults
yield a slightly greater overjet one year after treatment.8 have been indicated with mandibular advancement
In the present case, both the overjet and the overbite applian­ces.5,16-25 Some studies have indicated associated
were in the normal range even at 3 years post-treatment problems, such as increased treatment time26 or partial
(Figure 9). loss of outcomes after use of Class II elastics. 27 The
Treatment with extraction of the two first premolars, present patient underwent orthodontic treatment after
which is often indicated in comparison to treatment her maximum growth peak. Orthodontic camouflage
without extraction, is reportedly the most effective with the MPA16 was used in addition to Class II elastics
protocol when assessed by a normative index.14 This in the MEAW technique within a relatively normal
protocol was considered for the present patient; how­ treatment time. However, one should also consider the

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 Freitas et al • Treatment of Class II malocclusion

Figure 10. Superimposition of the pretreatment (black

line) and post-treatment (gray line) tracings.

stages 5 and 6, when treatment was started (Figure

3). Some growth could still occur, but not enough to
Figure 8. Three-years follow-up panoramic and cepha­ correct the Class II malocclusion by mandibular growth
lometric radiographs and tracing. (Figure 10).

CONCLUSION
Orthodontic camouflage using the MPA and MEAW
technique is an effective option for correcting Class
II malocclusions in patients who refuse orthognathic
surgery. In the present case, this treatment significantly
improved the facial profile, achieved a satisfactory
occlusion and pleasant aesthetics, and ensured good
dentoalveolar stability even at 3 years after treatment
was completed.

REFERENCES
1. Angle EH. Classification of malocclusion. Dental
cosmos 1899;41:248-64.
2. Thüer U, Ingervall B. Pressure from the lips on the
teeth and malocclusion. Am J Orthod Dentofacial
Orthop 1986;90:234-42.
Figure 9. Superimposition of the post-treatment (solid 3. Jenny J, Cons NC. Comparing and contrasting
line) and three years follow-up (dotted line) tracings. two orthodontic indices, the Index of Orthodontic
Treatment need and the Dental Aesthetic Index. Am
J Orthod Dentofacial Orthop 1996;110:410-6.
greater success of treatment of a bilateral half cusp Class 4. Dolce C, Mansour DA, McGorray SP, Wheeler TT.
II malocclusion, as in the present case, than treatment Intrarater agreement about the etiology of Class II
with extraction resulting in a bilateral full cusp Class II malocclusion and treatment approach. Am J Orthod
malocclusion.15 According to Franchi et al.,28 the peak Dentofacial Orthop 2012;141:17-23.
in skeletal growth occurs between stages 3 and 4 of 5. Coelho Filho CM. Mandibular protraction appliances
cervical vertebral maturation in 93.5% of individuals. for Class II treatment. J Clin Orthod 1995;29:319-
The present patient was past her growth peak, between 36.

276 http://dx.doi.org/10.4041/kjod.2014.44.5.268 www.e-kjo.org

Freitas et al • Treatment of Class II malocclusion

6. Kim YH. Tratamiento de maloclusiones severas patients treated with a bionator during prepubertal
mediante la técnica de alambre Edgewise Multiloop and pubertal growth. In: McNamara JA Jr, Ribbens
(Multiloop Edgewise Arch-Wire, MEAW). Ortodoncia KA, Howe RP, editors. Clinical alteration of the
Clínica 2004;7:22-34. growing face. Monograph 14, Craniofacial Growth
7. WHO. Oral Health Surveys: Basic Methods. Geneva, Series. Ann Arbor: Center for Human Growth and
Switzerland: World Health Organization; 1997. Development, The University of Michigan; 1983.
8. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz 18. Janson G, Barros SEC, de Freitas MR, Henriques JFC,
DL, Laster LL. Headgear versus function regulator Pinzan A. Class II treatment efficiency in maxillary
in the early treatment of Class II, Division 1 maloc­ premolar extraction and nonextraction protocols.
clusion: a randomized clinical trial. Am J Orthod Am J Orthod Dentofacial Orthop 2007;132:490-8.
Dentofacial Orthop 1998;113:51-61. 19. Xu TM, Liu Y, Yang MZ, Huang W. Comparison
9. Wong L, Hägg U, Wong G. Correction of extreme of extraction versus nonextraction orthodontic
overjet in 2 phases. Am J Orthod Dentofacial Orthop treatment outcomes for borderline Chinese patients.
2006;130:540-8. Am J Orthod Dentofacial Orthop 2006;129:672-7.
10. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Lon­ 20. Coelho Filho CM. Mandibular protraction appliance
gi­tudinal growth changes in untreated subjects with IV. J Clin Orthod 2001;35:18-24.
Class II Division 1 malocclusion. Am J Orthod Den­ 21. Ruf S, Pancherz H. Dentoskeletal effects and facial
tofacial Orthop 2008;134:125-37. profile changes in young adults treated with the
11. Baccetti T, Stahl F, McNamara JA Jr. Dentofacial Herbst appliance. Angle Orthod 1999;69:239-46.
growth changes in subjects with untreated Class 22. Ruf S, Pancherz H. Temporomandibular joint
II malocclusion from late puberty through young remodeling in adolescents and young adults during
adult­hood. Am J Orthod Dentofacial Orthop 2009; Herbst treatment: A prospective longitudinal mag­
135:148-54. netic resonance imaging and cephalometric radio­
12. Mihalik CA, Proffit WR, Phillips C. Long-term follow- graphic investigation. Am J Orthod Dentofacial
up of Class II adults treated with orthodontic Orthop 1999;115:607-18.
camou­flage: a comparison with orthognathic sur­ 23. Kinzinger G, Diedrich P. Skeletal effects in class II
gery outcomes. Am J Orthod Dentofacial Orthop treatment with the functional mandibular advancer
2003;123:266-78. (FMA)? J Orofac Orthop 2005;66:469-90.
13. Ruf S, Pancherz H. Orthognathic surgery and den­to­ 24. Nalbantgil D, Arun T, Sayinsu K, Fulya I. Skeletal,
facial orthopedics in adult Class II Division 1 treat­ dental and soft-tissue changes induced by the
ment: mandibular sagittal split osteotomy ver­sus Jasper Jumper appliance in late adolescence. Angle
Herbst appliance. Am J Orthod Dentofacial Orthop Orthod 2005;75:426-36.
2004;126:140-52. 25. Ruf S, Pancherz H. Herbst/multibracket appliance
14. Bock NC, von Bremen J, Ruf S. Occlusal stability treatment of Class II division 1 malocclusions in early
of adult Class II Division 1 treatment with the and late adulthood. a prospective cephalometric
Herbst appliance. Am J Orthod Dentofacial Orthop study of consecutively treated subjects. Eur J Orthod
2010;138:146-51. 2006;28:352-60.
15. Janson G, Valarelli FP, Cançado RH, de Freitas 26. Popowich K, Nebbe B, Heo G, Glover KE, Major
MR, Pinzan A. Relationship between malocclusion PW. Predictors for Class II treatment duration. Am J
severity and treatment success rate in Class II non­ Orthod Dentofacial Orthop 2005;127:293-300.
extraction therapy. Am J Orthod Dentofacial Orthop 27. Herrera FS, Henriques JF, Janson G, Francisconi MF,
2009;135:274.e1-8. de Freitas KM. Cephalometric evaluation in different
16. Johnston LE Jr. A comparative analysis of Class II phases of Jasper jumper therapy. Am J Orthod
treatments. In: Vig PS, Ribbens KA, editors. Science Dentofacial Orthop 2011;140:e77-84.
and clinical judgment in orthodontics. Monograph 28. Franchi L, Baccetti T, McNamara JA Jr. Mandibular
19, Craniofacial Growth Series. Ann Arbor: Center growth as related to cervical vertebral maturation
for Human Growth and Development, The University and body height. Am J Orthod Dentofacial Orthop
of Michigan; 1986. 2000;118:335-40.
17. Janson I. Skeletal and dentoalveolar changes in

www.e-kjo.org http://dx.doi.org/10.4041/kjod.2014.44.5.268 277