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Orthodontic Treatment
of the Class II Noncompliant Patient
CURRENT PRINCIPLES AND TECHNIQUES

Edited by

Moschos A. Papadopoulos DDS Dr Med Dent

Associate Professor
Department of Orthodontics
School of Dentistry
Aristotle University of Thessaloniki
Thessaloniki, Greece

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2006
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© 2006, Elsevier Limited. All rights reserved.

The right of Moschos A. Papadopoulos to be identified as editor of this

work has been asserted by him in accordance with the Copyright, Designs
and Patents Act 1988.

No part of this publication may be reproduced, stored in a retrieval system, or

transmitted in any form or by any means, electronic, mechanical,
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First published 2006

ISBN-13: 978-0-7234-3391-0
ISBN-10: 0-7234-3391-7

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

Note
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our knowledge, changes in practice,
treatment and drug therapy may become necessary or appropriate. Readers
are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered, to
verify the recommended dose or formula, the method and duration of
administration, and contraindications. It is the responsibility of the
practitioner, relying on their own experience and knowledge of the patient, to
make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions. To the fullest
extent of the law, neither the Publisher nor the Editor assumes any liability for
any injury and/or damage to persons or property arising out or related to any
use of the material contained in this book.
The Publisher

The
publisher’s
policy is to use
paper manufactured
from sustainable forests

Printed in China
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Preface

During orthodontic treatment, cooperation or compliance of the orthodontics, and Chapter 2 provides a classification of the non-
patients is a major factor for a successful treatment outcome. In compliance appliances used for the treatment of Class II
order to achieve successful treatment results, patients are expected to malocclusion. In Section II, Chapter 3 presents an overview of the
follow the recommended regimens suggested by their orthodontists. various currently available noncompliance intermaxillary appliances
Unfortunately, lack of patient compliance is one of the major used in Class II orthodontic treatment, while Chapters 4–14 discuss
problems in orthodontic treatment and often the clinicians have to in detail the current principles and the clinical management of these
deal with this issue almost daily. Orthodontic treatment in patients appliances, including the Herbst appliance, the Cantilever Bite
with limited compliance can, among other things, result in a longer Jumper (CBJ), the Ritto Appliance, the Mandibular Protraction
treatment time, destruction of the teeth and periodontium, Appliance, the Mandibular Anterior Repositioning Appliance
extraction of additional teeth, frustration for the patient and addi- (MARA), the Jasper Jumper, the Flex Developer, the Eureka Spring,
tional stress for the orthodontist and staff. This is the reason why a the Twin Force Bite Corrector, and the Sabbagh Universal Spring
lot of effort has been directed over the years to developing (SUS). In Section III, Chapter 15 presents an overview of the various
noncompliance techniques. intramaxillary distalization appliances utilized for the management
Noncompliance approaches are a very important option for the of Class II malocclusion, while Chapters 16–23 discuss thoroughly
orthodontic treatment of patients with Class II malocclusion who the current principles and the clinical management of these
present with minimal or no cooperation, especially when nonextraction appliances, such as the Pendulum appliance, the Penguin Pendulum,
treatment protocols have to be utilized. Conventional orthodontic the Distal Jet, the Keles Slider, the Jones Jig and modifications,
procedures usually require patient cooperation, which very often is a magnets, the First Class Appliance and the Keles TPA. Section IV
significant problem to overcome in order to achieve successful focuses on the intramaxillary appliances with absolute anchorage:
treatment outcomes. During the last decades a great variety of Chapter 24 presents an overview of these appliances, Chapter 25
noncompliance appliances and techniques have been proposed in describes the use of implants as absolute anchorage for Class II
order to correct Class II malocclusion, either by advancing the correction, and Chapter 26 provides information concerning the use
mandible to a more forward position or by distalizing the maxillary of onplants for maxillary molar distalization. The final chapter,
molars into a Class I relationship. Chapter 27 (Section IV), provides the reader with all currently available
The aim of this book is to cover the subject of noncompliance evidence concerning the clinical efficacy of the noncompliance
Class II orthodontic treatment in a comprehensive and critical way, appliances used for Class II correction.
presenting the principles and techniques of the most important Effort was made by the editor to invite orthodontists who are
currently available noncompliance appliances used for the treatment of expert in each specific subject to contribute chapters to this book.
Class II malocclusion, while focusing on their clinical management Almost all the authors have either developed or introduced
and effectiveness. sophisticated appliances, or they have been actively involved in their
The book is divided into five sections, starting from the problem clinical evaluation.
of compliance (Section I), describing several intermaxillary appliances It is the hope of the editor that this book will provide all the
(Section II), intramaxillary distalization appliances (Section III), and background needed for the better understanding and more efficient
intramaxillary appliances with absolute anchorage (Section IV), and use of the currently available noncompliance appliances and that
closing with the evidence-based knowledge on the efficacy of these students, faculty, and practitioners will find this book useful for the
appliances (Section V). clinical management of noncompliant patients presenting with Class
In detail, the book contains information regarding the following II malocclusion.
subjects, chapter by chapter. In Section I, Chapter 1 introduces the Moschos A. Papadopoulos
reader to the main aspects of the noncompliance treatment in Thessaloniki, Greece
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List of contributors

Claudio Arcuri, MD, DDS John P. DeVincenzo, DDS, MS Joe H. Mayes, DDS, MSD
Associate Professor, Fatebenefratelli Hospital, Adjunct Associate Professor, Department of Clinical Assistant Professor, Department of
Department of Oral Pathology, Orthodontics, Orthodontics,
University of Rome “Tor Vergata”, School of Dentistry, Loma Linda University, Baylor College of Dentistry and
Rome, Italy Loma Linda, CA, USA Consultant to the Craniofacial Virtual Reality
Lab,
Lars Bondemark, DDS, Odont Dr James E. Eckhart, DDS University of California (USC) and
Associate Professor, Head of the Department Private Practice, Torrance, CA, USA Private Practice, Lubbock, TX, USA
of Orthodontics,
Faculty of Odontology, Carlos Martins Coelho Filho, DDS, MSD
Alfred Peter Muchitsch, MD, DDS
Malmö University, Malmö, Sweden Former Professor of Orthodontics,
Assistant Professor, Clinical Department of
Federal University of Maranhão and
Steven Jay Bowman, DDS Orthodontics,
Private Practice, São Luis, Maranhão, Brazil
Adjunct Professor, Department of School of Dentistry, Medical University of Graz,
Orthodontics, Arturo Fortini, MD, DDS Graz, Austria
University of Saint Louis, St Louis, MO, USA Private Practice, Florence, Italy
Ravindra Nanda, BDS, M Dent Sc, PhD
Friedrich K. Byloff, DDS, MD, Dip Orth Lorenzo Franchi, DDS, PhD Professor and Head, Department of
Private Practice, Graz, Austria
Research Associate, Department of Orthodontics,
†
Aldo Carano, Dr Odont, MS, Spec Orthod Orthodontics, Oral Surgery, Pediatric Dentistry and AEGD,
Adjunct Professor, Department of University of Florence, Florence, Italy and School of Dental Medicine, University of
Orthodontics, Thomas M. Graber Visiting Scholar, Connecticut,
University of Ferrara, Ferrara, Italy and Department of Orthodontics and Pediatric Farmington, CT, USA
Adjunct Professor, Department of Dentistry,
Orthodontics, School of Dentistry, University of Michigan, Hans Ulrik Paulsen, DDS, Odont Dr
University of Saint Louis, St Louis, MO, USA Ann Arbor, MI, USA Visiting Professor, Karolinska Institutet,
Stockholm, Sweden and
Fabio Oliveira Coelho, DDS Aldo Giancotti, DDS, MS Former Associate Professor, Department of
Graduate Student of Orthodontics, Uniararas Assistant Professor, Fatebenefratelli Hospital, Orthodontics,
University and Department of Orthodontics, University of Aarhus, Aarhus and
MS candidate, São Paulo, São Luis, Maranhão, University of Rome “Tor Vergata”, Department of Orthodontics, Copenhagen
Brazil Rome, Italy Municipal Dental Health Service, Copenhagen,
M. Ali Darendeliler, BDS, Dip Orth, Cert Orth, PhD Denmark
James J. Jasper, DDS
Professor and Chair, Discipline of Orthodontics, Private Practice, Santa Barbara, CA, USA
Faculty of Dentistry, Sydney Dental Hospital, António Korrodi Ritto, DDS, PhD
University of Sydney, Ahmet Keles, DDS, DMSc Private Practice, Leiria, Portugal
Sydney, Australia Associate Research Investigator,
The Forsyth Institute, Boston, MA, USA and Jeff Rothenberg, DDS
†
= deceased Private Practice, Istanbul, Turkey Private Practice, Miami, FL, USA
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Aladin Sabbagh, DDS Flavio Uribe, DSS, MDS Heinz Winsauer, DDS
Private Practice, Nuremberg, Germany Assistant Professor, Division of Orthodontics, Private Practice, Bregenz, Austria
School of Dental Medicine, University of
Gang Shen, BDS, MDS, PhD Connecticut, Andrej Zentner, BDS, PhD, Dr habil, FDS RCS
Associate Professor, Discipline of Orthodontics, Farmington, CT, USA Professor and Chairman, Department of
Faculty of Dentistry, Sydney Dental Hospital, Orthodontics and Social Dentistry, Academic
University of Sydney, Frank J. Weiland, DMD, PhD Center for Dentistry Amsterdam (ACTA),
Sydney, Australia Former Associate Professor, Department of Amsterdam, The Netherlands
Orthodontics,
University Dental School, Graz and
Private Practice, Graz, Austria
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Acknowledgments

The editor is most grateful to all colleagues involved in the American Journal of Orthodontics and Dentofacial Orthopedics,
preparation of the chapters included in this book for their valuable Clinical Orthodontics and Research, European Journal of
contributions, and especially to Dr A. Carano, who recently passed Orthodontics, Hellenic Orthodontic Review, Journal of Orofacial
away. He was a very decent person and a great scientist who, Orthopedics, The Angle Orthodontist and World Journal of Orthodontics
although seriously ill, succeeded in contributing a chapter are acknowledged for granting permission to use in Chapters 4, 10, 19,
concerning his innovation, the Distal Jet appliance. The editor 20, 22, 23 and 26, certain texts, figures, and diagrams which were
wishes also to express his sincere appreciation to his mentor, previously published by their journals, as well as Mr I. Gkiaouris for
Professor T. Rakosi, for his inspiration and guidance during the very his assistance during the preparation of the literature reviews used
first years of his postgraduate studies in orthodontics, and to for Chapters 3, 15, and 27. Finally, Mr M. Parkinson, Senior
Professor A. E. Athanasiou for his friendship and his continuing Commissioning Editor, Ms H. Kenner, Development Editor, and
support over the years. Dr A. Mavropoulos, Dr A. Karamouzos, and Ms J. Dingwall, Project Manager, are also acknowledged for their
Professor S. Kiliaridis are also acknowledged for their significant excellent cooperation during the preparation and publication
contribution in the preparation of the two published papers procedures of this book, as well as Elsevier Health Sciences for the
concerning the sectional jig assembly. Further, the journals high quality of the published work.

Dedication

To my family for their love,

understanding and their full
support over the years
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Contents

Section I
CLASS II ORTHODONTIC TREATMENT AND COMPLIANCE
1. The problem of compliance in orthodontics 3
Andrej Zentner
2. Classification of the noncompliance appliances used for
Class II correction 9
Moschos A. Papadopoulos

Section II
INTERMAXILLARY APPLIANCES USED FOR THE MANAGEMENT OF
CLASS II NONCOMPLIANT PATIENTS
3. Overview of the intermaxillary noncompliance appliances 21
Moschos A. Papadopoulos
4. The Herbst appliance 35
Hans Ulrik Paulsen, Moschos A. Papadopoulos
5. The Cantilever Bite Jumper (CBJ) 59
Joe H. Mayes
6. The Ritto Appliance® — an easy way to treat Class II malocclusions 69
António Korrodi Ritto
7. The Mandibular Protraction Appliance in the treatment
of noncompliant Class II patients 93
Carlos Martins Coelho Filho, Fabio Oliveira Coelho
8. The Mandibular Anterior Repositioning Appliance (MARA™) 107
James E. Eckhart
9. Energy management: the philosophy behind fixed
intermaxillary mechanics 121
James J. Jasper
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10. The Jasper Jumper™ 125

Frank J. Weiland
11. The Flex Developer 145
Heinz Winsauer, Alfred Peter Muchitsch
12. The Eureka Spring™: a compact, versatile, and cost-effective
Class II corrector 163
John P. DeVincenzo
13. The Twin Force Bite Corrector in the correction of Class II
malocclusion in adolescent patients 181
Flavio Uribe, Jeff Rothenberg, Ravindra Nanda
14. The Sabbagh Universal Spring (SUS) 203
Aladin Sabbagh

Section III
INTRAMAXILLARY DISTALIZATION APPLIANCES USED FOR THE
MANAGEMENT OF CLASS II NONCOMPLIANT PATIENTS
15. Overview of the intramaxillary noncompliance distalization
appliances 219
Moschos A. Papadopoulos
16. The Pendulum Appliance 231
M. Ali Darendeliler, Gang Shen, Friedrich K. Byloff
17. The Penguin Pendulum 241
Joe H. Mayes
18. Noncompliance Class II treatment with the Distal Jet™ 249
Aldo Carano, Steven Jay Bowman
19. The Keles Slider Appliance for bilateral and unilateral
maxillary molar distalization 273
Ahmet Keles
20. The Jones Jig™ and modifications 283
Moschos A. Papadopoulos
21. The use of magnets for maxillary molar distalization 297
Lars Bondemark
22. The First Class Appliance 309
Arturo Fortini, Lorenzo Franchi
23. An effective and precise method for rapid molar derotation:
Keles TPA 331
Ahmet Keles
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Contents ■ xiii

Section IV
INTRAMAXILLARY APPLIANCES WITH ABSOLUTE ANCHORAGE USED
FOR THE MANAGEMENT OF CLASS II MALOCCLUSION
24. Overview of the intramaxillary noncompliance
appliances with absolute anchorage 341
Moschos A. Papadopoulos
25. The use of implants as absolute anchorage for Class II correction 345
Aldo Giancotti, Claudio Arcuri
26. The use of onplants for maxillary molar distalization 359
Lars Bondemark

Section V
CLINICAL EFFICACY OF THE NONCOMPLIANCE APPLIANCES
27. Clinical efficacy of the noncompliance appliances used for
Class II orthodontic correction 367
Moschos A. Papadopoulos

Index 389