ORIGINAL ARTICLE

Evaluation of soft-tissue changes in

young adults treated with the Forsus
fatigue-resistant device
Burçin Akan and _Ilknur Veli
Izmir, Turkey

Introduction: This study aimed to evaluate the effects of the Forsus fatigue-resistant device (FRD) EZ2
appliance (3M Unitek, Monrovia, Calif) on facial soft tissues by using images obtained from cephalometric
radiographs and 3-dimensional (3D) facial scanning system. Methods: A total of 20 patients treated with the For-
sus FRD EZ2 appliance were included in this study. The cervical vertebral maturation index was used to deter-
mine growth and development stages, and the subjects were investigated at cervical vertebral maturation stages
5 and 6 (ie, postpeak period). Three-dimensional facial scanning images were obtained with 3dMD Face (3dMD
Ltd, Atlanta, Ga). Cephalometric radiographic images were taken before placement of the appliance (T0),
immediately after removal (T1), and at the 6-month (T2) follow-up after the removal of the appliance. For
comparison of the data, one-way repeated-measures analysis of variance and paired t test were used at
P \ 0.05. Results: Statistically significant changes were found in the Wits value, IMPA, L1P-NB (
), L1-NB
(mm), L1P-APog, U1P-L1P, overjet, overbite, Ls-E, and labiomental angle in T0-T1. In T0-T2, statistically
significant changes in the Wits, IMPA, L1P-NB (
), overjet, overbite and Ls-E values were observed.
Conclusions: The results revealed that the correction of malocclusion with Forsus FRD EZ2 appliance in pa-
tients at the postpeak period was mainly dentoalveolar. The soft tissues were affected to a limited extent.
Three-dimensional facial scanning demonstrated similar accuracy and precision to traditional cephalometry,
being a repeatable and accurate tool for linear and surface measurements. (Am J Orthod Dentofacial Orthop
2020;157:481-489)

S
keletal Class II malocclusion is one of the most correct the skeletal imbalance and profile disharmony
common anomalies and constitutes 12%-49% in individuals with Class II malocclusion.5
of orthodontic malocclusions.1,2 In Class II maloc- Functional appliances are divided into removable and
clusions, the disruption of harmony between the struc- fixed groups, with many different designs within each
tures forming the craniofacial system manifests itself group.6 These two types of functional appliances have
in unconformity in jaw relationships in the sagittal some advantages over each other. Because of their size
plane, and is caused by genetic and/or environmental and poor stability in the mouth, patient adaptation
factors.3 Upper jaw protrusion, lower jaw retrusion, or with removable functional appliances is difficult.7
a combination of both can be seen with this malocclu- Thus, fixed functional appliances have been developed
sion in which lower jaw retardation has generally been to eliminate the disadvantages created by removable
reported.4 Functional appliances are one of the treat- functional appliances.
ment alternatives for these malocclusions and can Several systematic reviews have focused on the
treatment effects of removable functional appliances,8,9
fixed functional appliances,10,11 or both.12 A debate as
to whether fixed functional appliances can stimulate
Department of Orthodontics, Faculty of Dentistry, Izmir Katip Celebi University,
Izmir, Turkey. mandibular growth and result in long-term skeletal
All authors have completed and submitted the ICMJE Form for Disclosure of Po- changes remains.
tential Conflicts of Interest, and none were reported. Perinetti et al11 assessed the skeletal and dentoalveo-
Address correspondence to: Burçin Akan, Department of Orthodontics, Faculty of
Dentistry, Izmir Katip Celebi University, Izmir 35640, Turkey; e-mail, burcin. lar effects of fixed functional appliances, alone or in
yksel@gmail.com. combination with comprehensive treatment, on pubertal
Submitted, December 2018; revised and accepted, May 2019. and postpubertal patients with a Class II malocclusion.
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved. The authors reported that dentoalveolar effects were
https://doi.org/10.1016/j.ajodo.2019.05.014 generally seen regardless of the treatment timing.
481
482 Akan and Veli

Mesial movement of the mandibular dentition,13 mesial Several articles using Forsus FRD have been previ-
movement5 or tipping14 of lower first molars, and procli- ously published. In these studies, 2-dimensional evalua-
nation of lower incisors5,14 were observed in the mandible, tions of dental, skeletal, and soft-tissue changes after
whereas distal movement of the maxillary dentition,13 the use of appliance were made. However, to our knowl-
distal tipping of upper first molars,14 and/or retroclination edge, no articles using 3D evaluations were found in the
of upper incisors5,14 were reported in the maxilla. These literature.
authors also pointed out the improvement of the profile, Traditional orthodontic records include patient
mainly due to soft-tissue pogonion and B-point photographs, lateral cephalometric and panoramic ra-
advancement.11 diographs, and dental models. However, with the devel-
Ishaq et al15 concluded that fixed functional appli- oping technology, the deficiencies of these methods are
ances appear to have no significant positional or emerging. Thus, extraoral photographs can be limited to
dimensional skeletal effects on the mandible in reflect real 3D images.
growing subjects with Class II malocclusion. They also Currently, stereophotogrammetry, which is a 3D
pointed out that a slightly greater skeletal dimensional facial scanning system, has become commonly used
effect was observed in the pubertal period than in the with growing popularity among plastic surgeons, ortho-
postpubertal period, although this difference was not dontists, and maxillofacial surgeons. This system has
statistically significant. become a valuable recording tool for diagnostic records
Forsus fatigue-resistant device (FRD; 3M Unitek, because it allows the face to be assessed on all 3 planes
Monrovia, Calif), which requires minimum patient of space.
cooperation, is a fixed functional appliance developed The purpose of this retrospective clinical archive
in recent years and preferred by some orthodontists study was to evaluate the soft-tissue effects of Forsus
because of its ease of application. FRD appliance by using cephalometric radiographs
Franchi et al16 assessed the dental, skeletal, and soft- and images obtained from 3D facial scanning system
tissue effects of Forsus FRD in growing patients with in patients with skeletal and dental Class II anomalies
Class II malocclusion using lateral cephalograms. The characterized by mandibular retrognathia in postpeak
authors concluded that the Forsus FRD was effective in period.
correcting Class II malocclusion with a combination of
skeletal (mainly maxillary) and dentoalveolar (mainly
mandibular) modifications. In addition, the authors MATERIAL AND METHODS
reported that soft-tissue measurements showed a signif- A power analysis using G*Power software (version
icantly greater backward movement of the soft tissue A 3.1.3; Franz Faul University, Kiel, Germany) determined
point in the Forsus FRD group. that a sample size of 16 subjects per group would pro-
Gunay et al17 used lateral cephalograms to evaluate vide a power of 97% to detect significant differences
the short-term dentoalveolar and soft-tissue changes with an 0.45 effect size and a value of 0.05 (critical
in late adolescent patients treated with the Forsus c2 5 3.3403; noncentrality parameter l 5 19.44).
FRD. The authors reported that the Forsus FRD slightly The records of T0 and T1 for 20 patients were
improved the profile, and the soft tissue reflected the completely available. The records of the T2 period were
majority of the dentoalveolar changes (ie, the backward reviewed and evaluated for 16 patients because of 4 pa-
movement of the upper lip following the retrusion of tients' records not being available. Thus, for 2 periods,
maxillary incisors and no longer position of the lower a total of 20 patients (10 boys, 10 girls) were included.
lip behind the maxillary incisors). As a routine protocol in our clinic, dental models, facial
Flores-Mir et al18 evaluated facial soft-tissue and intraoral photographs, and a set of 2D radiographs
changes after the use of fixed functional appliances including cephalometric and panoramic radiographs
in patients with Class II Division 1 malocclusion are obtained from patients for orthodontic diagnosis
through a systematic review of the literature. The au- and treatment planning.
thors reported that although fixed functional appli- The selection criteria were as follows: (1) no history
ances produce some statistically significant changes of previous orthodontic treatment; (2) cervical verte-
in the soft-tissue profile, the magnitude of the changes bral maturation (CVM) stage 5 or 6 as determined
may not be perceived as clinically significant. They also by cephalometric radiographs19; (3) skeletal Class II
pointed out that 3-dimensional (3D) quantification of relationship (ANB . 4
)20; (4) normal position of
the soft-tissue changes was required to understand the maxilla to the cranial base; (5) mandibular retro-
the soft-tissue changes obtained with the use of fixed gnathy (SNB \ 78
)20; (6) Class II molar and canine
functional appliances. relationship; (7) normal or diminished vertical growth;

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Akan and Veli 483

Fig 1. The Forsus FRD EZ2.

(8) lower incisor position should be upright on basal

bone or suitable for uprighting; (9) minimal crowding
in dental arches (# 4 mm); and (10) body mass index
is within normal limits.
All patients included in the study remained in similar
body mass index values during the study period.
Maxillary and mandibular arches were bonded with
0.022 3 0.028-in MBT prescribed appliances. Leveling
and aligning stages started with 0.016-inch nickel-
titanium (Ni-Ti) and continued with 0.016 3 0.022-in
Ni-Ti, 0.019 3 0.025-in Ni-Ti, and 0.019 3 0.025-in
stainless steel (SS) archwires, respectively. Once leveling
and aligning were achieved, the Forsus FRD EZ2 with
suitable rod length were mounted on 0.019 3 0.025-in
SS archwires bilaterally at both maxillary and mandibular
arches (Fig 1). A transpalatal arch was placed and the SS
archwire was cinched back in the lower arch at the stage
of appliance insertion. The lower parts of the Forsus FRD
were placed distal to the mandibular canine teeth.
To evaluate the effects of Forsus appliance, the re-
cords were taken before the insertion of the appliance
(T0), immediately after appliance removal (T1), and at Fig 2. The landmarks on the frontal view of the 3dMD
6 months follow-up (T2). The Forsus appliance was image.
removed when the Class I or super Class I molar and
canine relationship is achieved, and anterior teeth are optimized patient dose. The landmarks are shown in
mostly in a t^ete-a-t^ete position. In these 3 different Figures 2-4; definitions are available in Supplementary
time intervals, efficacy of the treatment on soft tissues Tables I and II.
was evaluated with lateral cephalometric radiography The positions and rotations on the 3D face image
and 3D facial images, respectively. were controlled and regulated in the coordinate system
3D facial images were obtained by using the 3dMD as suggested by Plooji et al21 for analysis. In order to su-
Face system (3dMD Ltd, Atlanta, Ga). All records were perimpose the 3D facial images, the registration protocol
obtained at the same posture and position. Patients was performed on the forehead, upper nasal dorsum,
were positioned on an adjustable chair and instructed and zygoma, which was reported by Maal et al22 as the
to look into his or her eyes in a mirror placed between most stable regions over time.
the cameras with eyes open and facial musculature The root mean square (RMS) value, which is specified
relaxed.21 All images were saved as TSB files and manip- in the software manually and determines how consistent
ulated using 3dMD Vultus software (3dMD, Atlanta, Ga). the registration process is, was recorded for each individ-
Skeletal and dental changes were evaluated using ual, and the superimpositions with the RMS value below
lateral cephalometric radiographs. All radiographs were 1 were re-evaluated. The RMS value has been applied so
taken with the same device (Orthopantomograph that it reaches the smallest possible value as in the study
OP300; Instrumentarium Dental, Tuusula, Finland) in of Taylor et al.23 Positive values in the measurements
10 seconds with an exposure time of 2.3 seconds and indicate that the anatomical point moves anteriorly after

American Journal of Orthodontics and Dentofacial Orthopedics April 2020  Vol 157  Issue 4
484 Akan and Veli

Fig 3. The landmarks on the lateral view of the 3dMD

image. Fig 4. The landmarks on lateral cephalometric radio-
graph.

treatment on the anteroposterior plane, and negative in SAS proc mixed procedure. For P \ 0.05, the results
values indicate that the anatomical point moves back- were considered statistically significant.
ward (posteriorly) in the anteroposterior plane.
Both the changes in the color histogram and the RESULTS
millimetric changes between the 2 images were exam- The same author repeated the measurements 1 week
ined. The color histogram provides a visual assessment after the first measurements on 20 3D images and 20
of the difference between the 2 superimposed images. cephalograms randomly selected from 10 patients. In-
When the result is positive, the second image topog- traclass correlation coefficients ranged from 0.9 to
raphy is more apparent and when the result is negative, 1.00. No significant errors were found when repeated
it is the opposite. The differences are represented along a measurements were evaluated with paired t tests.
color spectrum with values associated with each color. The cephalometric changes obtained with the Forsus
When comparing 2 images, the overpositive change is FRD were shown in Table I. The changes in the Wits
represented by the red code and the overnegative change value were statistically significant between T0-T1 and
is represented by the blue code (Fig 5). T0-T2. Although there was no statistically significant
change in the upper incisors, changes observed between
Statistical analysis
T0-T1 and T0-T2 periods in IMPA, L1-NB (
), L1-NB
Data were analyzed using the SAS 9.3 Software (SAS (mm), and L1P-APog values, which express the antero-
Institute, Cary, NC). The Shapiro-Wilks test was used to posterior position and inclination of the lower incisors,
determine whether the data containing the cephalo- were statistically significant. Also, the increase in L6P-
metric and 3D facial image recordings in 3 different MD value, which indicates the vertical position of the
periods comply with the normal distribution. Parametric lower incisors, was statistically significant (P \ 0.05).
tests were used to compare the data after normal distri- Although the OB and OJ values decreased significantly
bution of the data was determined (P . 0.05), and between T0-T1, they increased between T1 and T2
descriptive statistics were shown as mean 6 standard (P \ 0.001).
deviation. These values were tested using a one-way The soft-tissue changes obtained with the Forsus
analysis of variance. Comparisons of the obtained re- FRD were shown in Table II. The results showed no sta-
cords at different time intervals and binary comparisons tistically significant differences between all periods
were made with Bonferroni correction with a paired t test (P . 0.05).

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Akan and Veli 485

Fig 5. Superposition of 3dMD images in 2 different periods.

DISCUSSION determined by the CVM index using the lateral cepha-

This study aimed to determine the soft-tissue effects lometric radiographs of the patients included in the
of Forsus FRD appliance in patients with skeletal and study.19,29
dental Class II anomalies characterized by mandibular The first records were taken immediately before the
retrognathia in the postpeak period. insertion of the appliance, and the second records were
Clinical studies with fixed functional appliances have taken immediately after the appliance removal. In similar
reported no gender discrimination.24-26 Jones et al27 investigations by other researchers, lateral cephalometric
individually evaluated the efficacy of the Forsus device radiographs were taken just before the application
and intermaxillary elastics in female and male patients and immediately after appliance removal.14-30 In our
and found no gender differences in treatment efficacy. study, the third records were taken 6 months after the
In our study, the patients were restricted to postpu- appliance removal (T2). In this way, the continuity of
bertal growth period. In this way, the compounding fac- the effects resulting from appliance use was examined.
tor of growth was eliminated from treatment effects. The mean treatment duration of patients included in
According to Hassel and Farman,19 an insignificant our study was 5.11 6 1.6 months. Weiland and Ban-
amount of growth was expected in CVM stage 5 and tleon31 and Blackwood32 reported that fixed functional
growth is completed in CVM stage 6. Because the active appliances provided sufficient efficacy over 6 months.
growth of the craniofacial skeleton is mostly complete in In this study, the 3dMD Face system was used as 3D
CVM stages 5 and 6, a control group was not included digital photogrammetry. In our practice, scanning time
in the current study. Franchi et al16 similarly reported with 3dMD Face imaging system is 1.5 milliseconds
that the amount of craniofacial growth occurring after so that the distortions caused by motion are avoided
postpubertal stages (ie, CS5 or CS6) was very limited in and more accurate measurements can be made. Clinical
subjects with Class II malocclusion. More importantly, reproducibility was reported at 98.5%, while the sensi-
growth differences between Class II malocclusion tivity is \ 0.2 millimeters.33 Baysal et al34 reported
and normal occlusion subjects after late puberty are that 3dMD Face system and soft-tissue points have
insignificant.28 high reproducibility and reliability in both intergroup
Because patients with different growth and devel- and intragroup comparisons.
opment potentials can negatively affect the outcome Heinig and G€ oz35 reported an increased SNB angle in
of our research, bone age was taken into consideration. patients treated with the Forsus appliance. In a thesis
In order to reduce the number of radiographs taken project by G€ unay,36 Forsus appliances applied in the
from patients and thus exposure to radiation, hand- postpeak period did not change the ANB angle, indi-
wrist radiographs were not taken, and bone age was cating that this appliance had no skeletal effects.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020  Vol 157  Issue 4
486 Akan and Veli

Table I. Comparison of cephalometric changes

T0 (n 5 20) T1 (n 5 20) T2 (n 5 16)

Parameter Mean SD Mean SD Mean SD P T0-T1 T1-T2 T0-T2

Skeletal
SNA 79.265 3.440 78.645 3.554 78.218 3.316 0.524 NS NS NS
SNB 75.255 3.542 75.005 3.325 74.793 3.241 0.746 NS NS NS
ANB 4.010 1.865 3.640 1.877 3.425 1.445 0.545 NS NS NS
Wits 2.245 2.573 0.19 1.763 0.318 1.531 \0.0001 *** NS ***
A-Na perp –1.760 3.530 2.465 3.379 2.431 3.587 0.277 NS NS NS
Pog-Na perp –7.945 5.839 8.655 5.469 8.243 6.915 0.613 NS NS NS
FH-NA 88.260 3.467 87.685 3.155 87.743 3.585 0.418 NS NS NS
N-CF-A 59.935 3.104 60.085 3.475 60.112 2.840 0.577 NS NS NS
Sgn-FH 60.415 3.669 60.760 3.205 60.343 4.221 0.614 NS NS NS
SN/Go-Gn 32.790 5.140 32.960 5.660 33.275 5.649 0.835 NS NS NS
PFH/AFH 63.280 4.525 62.960 5.528 62.731 4.371 0.726 NS NS NS
FMA 23.760 5.361 23.905 5.414 23.775 5.699 0.912 NS NS NS
SN-PP 10.285 3.194 10.405 3.616 10.425 3.161 0.403 NS NS NS
PP-MP 25.350 4.904 25.430 6.116 25.743 4.991 0.361 NS NS NS
NA-APog 5.215 5.164 4.855 4.798 4.375 4.252 0.537 NS NS NS
Sum total 395.645 5.083 396.015 5.580 396.125 5.409 0.759 NS NS NS
S-Go 72.115 7.134 72.575 7.028 72.668 6.320 0.788 NS NS NS
ANS-Me 62.570 5.847 63.685 6.081 63.587 5.335 0.139 NS NS NS
CoA 83.155 4.444 83.870 4.598 83.681 4.501 0.485 NS NS NS
Co-gn 107.505 7.009 108.835 7.633 108.631 6.610 0.236 NS NS NS
Mx-Md 24.350 4.105 25.385 4.208 24.956 4.111 0.102 NS NS NS
Dental
U1-SN 103.505 4.845 101.705 5.589 102.668 5.942 0.087 NS NS NS
U1-PP 113.810 5.414 112.185 5.823 112.768 6.497 0.23 NS NS NS
U1-NA 24.240 4.564 23.075 5.335 24.450 5.348 0.297 NS NS NS
U1-NA 4.870 1.769 4.010 1.937 4.087 1.796 0.063 NS NS NS
U1-MxOP 55.825 3.420 55.575 3.026 54.731 3.801 0.332 NS NS NS
L1-MdOP 66.025 4.286 64.645 4.054 64.568 3.731 0.065 NS NS NS
IMPA 92.430 5.318 97.965 4.811 96.800 5.343 \0.0001 *** NS **
L1-NB 23.335 5.156 28.475 4.438 27.937 4.340 \0.0001 *** NS ***
L1-NB 4.685 1.918 6.260 1.556 5.712 1.641 \0.0001 *** NS **
L1-APog 1.165 2.165 3.045 1.681 2.531 1.499 \0.0001 *** NS ***
U1-L1 128.430 6.221 124.665 5.441 124.375 5.949 0.002 ** NS *
U1-PP 26.790 3.095 27.455 3.247 27.487 3.241 0.319 NS NS NS
U6-PP 20.615 2.443 20.130 2.324 20.062 2.713 0.539 NS NS NS
L1-MP 34.510 3.252 33.790 2.877 34.006 3.149 0.306 NS NS NS
L6-MP 25.245 3.216 26.395 2.818 26.062 2.795 0.02 * NS NS
OB 2.570 0.91 0.99 0.869 1.468 0.755 \0.0001 *** NS ***
OJ 5.830 1.588 2.905 0.843 3.112 0.755 \0.0001 *** NS ***
Soft tissue
Nasal projection 13.955 2.072 14.635 2.266 14.668 2.251 0.071 NS NS NS
A0 –2.655 1.504 –2.595 2.002 –2.825 1.682 0.896 NS NS NS
B0 –13.735 3.364 –12.600 3.703 –12.737 3.227 0.063 NS NS NS
Pog‫׳‬ –12.115 3.968 –11.265 4.060 –10.987 3.413 0.065 NS NS NS
ULA 0.3 2.178 –0.02 2.340 –0.206 2.220 0.512 NS NS NS
LLA –4.245 2.808 –3.245 3.171 –3.793 2.998 0.072 NS NS NS
Soft-tissue 125.715 3.427 125.895 3.661 125.893 3.051 0.508 NS NS NS
convexity
Nasofrontal angle 137.255 9.374 135.490 8.424 134.393 8.392 0.317 NS NS NS
Nasolabial angle 113.710 10.303 114.025 11.038 110.681 12.914 0.101 NS NS NS
LCTA 106.060 7.737 106.520 7.447 109.943 5.812 0.149 NS NS NS
Nasomental angle 123.945 4.525 123.365 3.661 121.806 4.371 0.153 NS NS NS
Labiomental angle 111.795 12.005 121.900 14.110 116.737 10.401 0.0008 *** NS NS

*P \ 0.05; **P \ 0.01; ***P \ 0.001.

NS, Not significant; SD, standard deviation.

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Akan and Veli 487

Table II. Comparison of the soft-tissue changes by 3dMD

T0 (n 5 20) T1 (n 5 20) T2(n 5 16)

Mean SD Mean SD Mean SD P

Upper lip length 22.025 2.204 21.853 3.043 22.700 2.707 0.125
Upper lip vermilion length 7.644 1.334 7.552 1.655 7.539 1.516 0.761
Lower lip length 43.583 3.465 43.300 3.962 43.198 3.267 0.8
Lower lip vermilion length 9.183 1.268 9.245 1.772 9.038 1.611 0.645
Anterior face height 113.400 7.328 113.559 8.805 116.404 6.552 0.064
Lower anterior face height 65.352 4.692 64.989 6.296 65.620 4.343 0.652
N-Me/Sn-me 1.737 0.062 1.752 0.09 1.775 0.071 0.106
Ls-Sto/Sto-Li 0.836 0.119 0.834 0.207 0.843 0.15 0.662
Sn-Sto/Sto-Me 0.508 0.054 0.505 0.057 0.526 0.665 0.205
Nasofrontal angle 152.346 6.147 152.155 6.954 152.023 6.577 0.199
Nasolabial angle 115.284 11.193 116.161 9.828 117.417 11.425 0.095
Labiomental angle 120.011 12.486 124.708 19.217 127.639 14.129 0.067
Soft-tissue convexity angle 154.804 5.127 154.977 4.180 153.594 4.416 0.64
Nasomental angle 138.723 4.907 138.348 4.460 137.976 4.484 0.862
Upper lip angle 106.752 5.282 108.022 4.712 107.043 4.642 0.233
Lower lip angle 122.114 6.507 122.822 6.604 120.373 5.775 0.061
Interlabial angle 141.913 14.849 136.458 15.492 132.865 16.541 0.071

*P \ 0.05; **P \ 0.01; ***P \ 0.001.

NS, Not significant; SD, standard deviation.

Similarly, no significant difference was found in the We used IMPA
, L1P-NB
, L1-NB (mm), L1P-APog
sagittal position of the lower jaw in our study. and L1P-MdOD
measurements to evaluate the posi-
As an alternative to the ANB angle, Wits analysis, tion and inclination of the lower incisors. In our study,
which was developed to make measurements indepen- there was a significant increase in mandibular dental
dently from the cranial base, was used in the evaluation measurements except for L1P-MdOD
. Similarly,
of the relationship between cranium and mandibula. many published articles have reported lower incisor
Saraçoglu37 reported a significant decrease in the young protrusion and proclination after fixed functional
adult group treated with Forsus FRD. In our study, the appliance treatment.27,31,35-37 In addition, with
Wits value was statistically significant between T0-T1 increasing age, dental effects are observed more
and T0-T2 and showed a statistically insignificant because of a reduction in skeletal response to forces
decrease between T1-T2. stimulating forward mandibular movement and
When cephalometric vertical values were examined, neuromuscular adaptation.
an increase between T0 and T1 periods was observed, In our study, linear dental relationship measurements
although this was not statistically significant. Sara- such as overbite and overjet showed significant differ-
glu37 examined the effects of Forsus FRD appliances
ço ences in both parameters. There was also a statistically
on patients with skeletal Class II malocclusion and dental significant decrease in an overjet amount (2.9 mm be-
Class II Division l anomalies accompanied by a mandib- tween T0-T1 periods and 2.7 mm between T0-T2 pe-
ular deficiency in peak and postpeak periods and riods). However, there was no significant increase
reported no significant vertical dimension changes in between T1-T2 periods.
young adults. In our study, OJ increased to a small amount between
U1P-PD
, U1P-SN
, U1P-NA
, U1-NA (mm), and T1-T2 periods was observed. A combination of upper
U1P-MxOD
angles were used in our study in order to incisor retrusion and lower incisor protrusion was effec-
evaluate the upper incisor inclinations. Although there tive in reducing the overjet amount. Similar changes
is a reduction in the inclination values, this was not sta- were also observed in the amount of overbite, which in-
tistically significant. In contrast to our study, Sarı38 dicates the vertical relationship of the maxillary and
found a significant decrease in the U1P-NA angle and mandibular incisors. Heining and G€ oz35 reported a
U1-NA distance on patients treated with jasper Jumper reduction of overjet by 4.6 mm by retrusion of maxillary
appliance compared with the control group. In the study incisors and protrusion of mandibular incisors and
of Nalbantgil,14 a statistically significant reduction in reduction of overbite by 1.2 mm by intrusion and pro-
the treatment group was reported. trusion of mandibular incisors.

American Journal of Orthodontics and Dentofacial Orthopedics April 2020  Vol 157  Issue 4
488 Akan and Veli

According to the soft-tissue analysis, no significant 7. Graber TM, Neumann B. Removable orthodontic appliances.
change was observed in any of the 17 soft-tissue param- Philadelphia: WB Saunders; 1977.
8. Chen JY, Will LA, Niederman R. Analysis of efficacy of functional
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appliances on mandibular growth. Am J Orthod Dentofacial
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changes in Ls, Li, Pog, Gn, Me, A and B between T0-T1 9. Koretsi V, Zymperdikas VF, Papageorgiou SN, Papadopoulos MA.
and T1-T2 periods was found. These results are because Treatment effects of removable functional appliances in patients
the Forsus FRD EZ2 appliance did not cause significant with Class II malocclusion: a systematic review and meta-analysis.
Eur J Orthod 2015;37:418-34.
soft-tissue changes on postpeak individuals, regardless
10. Flores-Mir C, Ayeh A, Goswani A, Charkhandeh S. Skeletal and
of the device used. Because the individuals in our study dental changes in Class II Division 1 malocclusions treated with
were in the postpeak development period, there was no splint-type Herbst appliances. A systematic review. Angle Orthod
growth in the mandible, so no change in the jaw projec- 2007;77:376-81.
tion occurred. According to this finding, it can be 11. Perinetti G, Primozie J, Furlani G, Franchi L, Contardo L. Treat-
ment effects of fixed functional appliances alone or in combina-
concluded that there is no skeletal effect of the Forsus
tion with multibracket appliances: a systematic review and
FRD appliance applied in the postpeak period and soft- meta-analysis. Angle Orthod 2015;85:480-92.
tissue changes are affected by dental changes only. 12. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA. Mandib-
Furthermore, findings from Covell et al39 and Cope ular changes produced by functional appliances in Class II maloc-
et al30 were similar to the results obtained in our research. clusion: a systematic review. Am J Orthod Dentofacial Orthop
2006;129:599.e1-12: discussion e1.
13. Pancherz H. The mechanism of Class II correction in Herbst appli-
CONCLUSIONS ance treatment. A cephalometric investigation. Am J Orthod 1982;
82:104-13.
(1) The FRD appliance has no statistically significant 14. Nalbantgil D, Arun T, Sayinsu K, Fulya I. Skeletal, dental and soft-
skeletal effects on the maxilla and mandible on tissue changes induced by the Jasper Jumper appliance in late
sagittal and vertical planes. adolescence. Angle Orthod 2005;75:426-36.
15. Ishaq RA, AlHammadi MS, Fayed MM, El-Ezz AA, Mostafa Y. Fixed
(2) Changes in maxilla and mandible are found to be
functional appliances with multibracket appliances have no skel-
dentoalveolar only. etal effect on the mandible: a systematic review and meta-analysis.
(3) Mandibular incisors were protruded and pro- Am J Orthod Dentofacial Orthop 2016;149:612-24.
clined. 16. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T.
(4) Overjet and overbite were reduced. Effectiveness of comprehensive fixed appliance treatment used
with the Forsus Fatigue Resistant Device in Class II patients. Angle
(5) There was only a limited impact on the soft-tissue
Orthod 2011;81:678-83.
profile. 17. Gunay EA, Arun T, Nalbantgil D. Evaluation of the immediate
dentofacial changes in late adolescent patients treated with the
SUPPLEMENTARY DATA Forsus(Ô) FRD. Eur J Dent 2011;5:423-32.
18. Flores-Mir C, Major MP, Major PW. Soft-tissue changes with fixed
Supplementary data associated with this article can functional appliances in Class II Division 1. Angle Orthod 2006;76:
be found, in the online version, at https://doi.org/10. 712-20.
1016/j.ajodo.2019.05.014. 19. Hassel B, Farman AG. Skeletal maturation evaluation using cervical
vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66.
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6. Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with treatment of Class II malocclusion with the Herren activator,
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26. Patel HP, Moseley HC, Noar JH. Cephalometric determinants of malocclusion by 3dmD system. Ankara: XIVth International
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ukkeleş N, Acar A, Biren S, Arun T. Comparisons between cer- Forsus appliance used in late adolescence [thesis]. Istanbul,
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30. Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO. Quan- 37. Saraço
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31. Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with 38. Sarı Z, Goyenc Y, Doruk C, Usumez S. Comparative evaluation of
the Jasper Jumper appliance–a preliminary report. Am J Orthod a new removable Jasper Jumper functional appliance vs an
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Orthod 1991;25:755-60. 39. Covell DA, Trammell DW, Boero RP, West R. A cephalometric study
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American Journal of Orthodontics and Dentofacial Orthopedics April 2020  Vol 157  Issue 4
489.e1 Akan and Veli

Supplementary Table I. Definition of measurements Supplementary Table I. Continued

used in cephalometric analysis
Parameter Unit Definition


Parameter Unit Definition ANB angle The relative position of the
Vertical cephalometric maxilla to the mandible
measurements Wits appraisal mm The method entails

drawing perpendiculars
SN/Go-Gn angle Angle formed by lines S-N
and Go-Gn from points A and B on

the maxilla and
Palatal-mandibular Angle formed by lines
plane angle ANS-PNS and Go-Gn mandible, respectively,
(PP-MP) onto the occlusal plane



Y-axis (sgn-FH) Measures the angle Convexity angle Angle between NA and
between sella-gnathion (NA-APog) pogonion-A (PogA)
and Frankfort Mx-Md Difference between Co-Gn
horizontal and CoA lengths

Dental measurements
FMA (Go-Gn/FH) Angle formed by the


mandibular plane and U1/SN Angle formed by the long
Frankfort horizontal axis of the maxillary

incisor with line S-N
SN-PP Angle formed by


intersecting the palatal U1/PP Angle formed by the long
plane with the SN line axis of the maxillary

incisor with line P-P
Sum of inner angles The sum of N-S-Art, S-Art-


Go, and Art-Go-Me U1/NA Angle formed between the
S-Go mm Distance between sella and U1 long axis and NA
gonion plane
ANS-Me mm Distance between points U1-NA mm Distance between the tip of
Ans and Me the upper incisor and a
Jarabak ratio Ratio obtained by the line from nasion to
formula: posterior facial point A


height/anterior facial U1-MxOP Angle formed by the long
height 3 100 axis of the maxillary
Maxillary height Angle between N-CF and incisor with the occlusal
(N-CF-A) CF-A plane
Maxillary skeletal U1-PP mm Vertical distance from
measurements upper incisor to palatal

plane
SNA Angle formed by the
intersection of SN and a U6-PP mm Vertical distance from the
line joining nasion and U6 occlusal surface to
point A PP


A-Na Perp mm Distance between point A IMPA Angle formed by the long
and vertical line axis of the mandibular
measured perpendicular incisors and mandibular
from nasion to plane


Frankfort horizontal L1/NB Angle formed by the long
Effective maxillary mm Measured from condylion axis of the maxillary
length (Co-A) to point A incisor with line NB

L1-NB mm Vertical distance from
Maxillary depth Angle between NA and
(FH-NA) Frankfort horizontal lower incisor to NB


Mandibular skeletal L1-MdOP Angle formed by the long
measurements axis of the mandibular

incisor with the occlusal
SNB Angle between SN and NB
Pog-Na Perp mm Distance between Pg and plane
distance vertical line measured L1-MP mm Vertical distance from
perpendicular from lower incisor to
nasion to Frankfort mandibular plane
horizontal L6-MP mm Vertical distance from the
Effective mandibular mm Measured from condylion L6 occlusal surface to
length (Co-Gn) to gnathion MP


Maxillo-mandibular Interincisal angle Angle formed by the long
relation (U1P/L1P) axes of the maxillary
measurements and mandibular incisors

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Akan and Veli 489.e2

Supplementary Table I. Continued Supplementary Table II. Definition of measurements

used in 3dMD analysis
Parameter Unit Definition
Overjet mm Horizontal distance Parameter Definition
between the maxillary Linear measurements
and mandibular incisors Upper lip length Distance between stomion
Overbite mm Vertical overlap of the and subnasale
maxillary central Upper lip vermilion length Distance between stomion
incisors over the and labiale superius
mandibular incisors Lower lip length Distance between stomion
Soft-tissue and soft-tissue menton
measurements Lower lip vermilion length Distance between stomion

and labiale inferius
Nasolabial angle Angle formed by a line
(Prn-Sn-Ls) tangent to the upper lip Anterior face height Distance between soft tissue N
and a line tangent to the and soft tissue Me
columella Lower anterior face height Distance between subnasale
Upper lip to mm Distance between the most and soft tissue Me
E plane anterior point on the Proportional measurements
curve of the upper lip N-Me/Sn-me Ratio of the anterior face
and esthetic plane height to the lower face
Lower lip to mm Distance between the most height
E plane anterior point on the Ls-Sto/Sto-Li Ratio of the upper lip
curve of the lower lip vermilion length to the
and esthetic plane lower lip vermilion length
Nasal projection mm Distance between the tip of Sn-Sto/Sto-Me Ratio of the upper lip length
the nose and subnasale to the lower lip length
Upper lip mm Distance from the most Angular measurements
protrusion (ULA) anterior point on the Nasofrontal angle (G-N-Prn) Angle formed by soft-tissue
upper lip to subnasale- glabella, nasion, and
pogonion pronasale
Lower lip protrusion mm Distance from the most Nasolabial angle (C-Sn-Ls) Angle formed by soft-tissue
(LLA) anterior point on the columella, subnasale, and
lower lip to subnasale- labiale superius
pogonion Labiomental angle (Li-B-Pog) Angle formed by labiale
Soft tissue A mm Distance from soft tissue inferius, soft tissue B, and
point (A0 ) A point to TVL Pog
Soft tissue B mm Distance from soft tissue Soft-tissue convexity Angle formed by soft-tissue
point (B0 ) B point to TVL angle (N-Sn-Pog) nasion, subnasale, and
Soft-tissue pogonion mm Distance from soft-tissue soft-tissue Pog
(Pog‫)׳‬ Pog point to TVL Nasomental angle Angle formed by soft-tissue

(N-Prn-Pog) nasion, pronasale, and
Soft-tissue convexity Angle is formed by soft-
tissue nasion, subnasale, soft-tissue Pog
and soft-tissue Upper lip angle (Chr-Ls-Chl) Angle formed by right
pogonion cheilion, labiale superius,

and left cheilion
LCTA Formed by labiale inferius,
soft-tissue pogonion, Lower lip angle (Chr-Li-Chl) Angle formed by right
and cervical points cheilion, labiale inferius,
and left cheilion
Interlabial angle (Ls-Sto-Li) Angle formed by labiale
superius, stomion, and
labiale inferius

American Journal of Orthodontics and Dentofacial Orthopedics April 2020  Vol 157  Issue 4