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A comparison of the treatment effects

of the Forsus Fatigue Resistance Device
and the Twin Block appliance in patients
with class II malocclusions
This article was published in the following Dove Press journal:
Clinical, Cosmetic and Investigational Dentistry
2 August 2014
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Abdulfatah Hanoun 1 Objectives: We evaluated the skeletal and dentoalveolar effects of the Forsus Fatigue Resistance
Thikriat S Al-Jewair 1,2 Device (FRD) and the Twin Block appliance (TB) in comparison with nontreated controls in
Sawsan Tabbaa 1 the treatment of patients with class II division 1 malocclusion.
Mhd Amer Allaymouni 1 Materials and methods: This retrospective study included three groups: TB (n=37; mean
Charles B Preston 1 age, 11.2 years), FRD (n=30; mean age, 12.9 years), and controls (n=25; mean age, 12.6 years).
Lateral cephalograms were evaluated at T1 (pretreatment) and at T2 (postappliance removal/
1
Department of Orthodontics,
School of Dental Medicine, equivalent time frame in controls). Cephalometric changes were evaluated using the Clark
State University of New York at analysis, including 27 measurements.
Buffalo, NY, USA; 2College of Results: Sagittal correction of class II malocclusion appeared to be mainly achieved by
Dentistry, University of Dammam,
Saudi Arabia dentoalveolar changes in the FRD group. The TB was able to induce both skeletal and den-
toalveolar changes. A favorable influence on facial convexity was achieved by both groups.
Significant upper incisor retroclination occurred with the TB (−12.42°), whereas only −4° was
observed in the FRD group. The lower incisors proclined more in the FRD group than the TB
group. Incisor overjet reduction was 62% in the TB group versus 56% in the FRD group. Molar
relation was corrected in both functional groups, resulting in a class I relation, although no
change appeared in the control sample.
Conclusion: Both appliances were effective in correcting the class II malocclusion. Both the
FRD and the TB induced significant maxillary and mandibular dentoalveolar changes; skeletal
changes were induced by TB but not FRD therapy.
Keywords: orthodontics, cephalometry, class II malocclusion, functional appliances

Introduction
Class II malocclusions are of interest to practicing orthodontists because they ­constitute
a significant percentage of the cases they treat.1 Myriad treatment modalities for
class II malocclusions have been investigated and published.2 Some authors attempt
to correct the underlying skeletal imbalance through growth modification by either
extraoral traction or functional appliances, whereas others focus on dental camouflage
of the jaw discrepancy.
Correspondence: Thikriat S Al-Jewair The Twin Block (TB; Clark, 1982) appliance is one of the widely used removable
Department of Orthodontics, School
of Dental Medicine, State University of
functional appliances to correct class II dentoskeletal disharmony. It was found to be
New York at Buffalo, 3435 Main Street the preferred functional appliance in the United Kingdom; more than 75% of British
Buffalo, New York 14214, USA
Tel +1 716 713 4547
Orthodontic Society members claimed it is their first choice.3 One of the unique
Email [email protected] features of this appliance is that it is constructed in two separate parts: the upper and

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lower appliances. Forward mandibular posturing is achieved Materials and methods

by incorporating buccal blocks with interlocking inclined This is a retrospective comparative study of class II maloc-
planes of approximately 70°, with the lower blocks engaging clusion subjects treated with TB or FRD in comparison with
in front of the upper blocks.4–6 a matched sample of untreated class II controls.
The effects of the TB are well established in the A total of 92 patients were included: 30 in the FRD
literature.4,5,7,8 O’Brien et al8 investigated the changes in group (12 girls and 18 boys; mean ± SD of 12.9±1.1 years),
the anteroposterior relationship of the maxilla to the man- obtained from one private practice, and 37 in the TB group
dible and the overjet during treatment for growing patients (24 girls and 13 boys; 11.2±1.6 years), selected from the
(8–10 years). The mean overjet correction was 6.6 mm, private practice of the developer of the appliance, Dr Wil-
whereas the net effect of treatment in terms of overjet liam Clark (Scotland, United Kingdom). This TB sample was
correction when compared with the untreated group was previously used in other studies to investigate the TB therapy
6.9 mm. The skeletal contribution to the overjet correction effects;6 25 untreated class II subjects (12 girls and 13 boys;
was 27%; the remaining 73% was a result of dentoalveolar 11.9±1.9 years) obtained from the University of Michigan
changes. growth study and matched with the experimental groups for
The TB, however, is highly dependent on patient skeletal age (at the start or during the growth spurt), sex,
compliance. To overcome this limitation, a new generation and craniofacial morphology. This study was approved by
of fixed functional appliances has become popular. These the State University of New York at Buffalo Institutional
appliances are more streamlined than the removable types Review Board.
and do not interfere with speech. The Herbst appliance2 and The inclusion criteria were: Caucasian healthy boys and
its different modification was one of the early compliance- girls who were starting or within the period of their skeletal
free appliances. Recently, the idea of incorporating nickel- growth spurt, as indicated by the cervical vertebral maturation
titanium push coil springs as part of the appliances has method; class II division 1 malocclusion, with the canines and
received a lot of interest. These appliances include Saif molars in at least an end-to-end relationship; in the late mixed
Spring,9 Jasper-Jumper,9 Klapper spring,9 Eureka Spring or early permanent dentitions; normal growth pattern (Frank-
appliance,10 the Adjustable Bite Corrector,11 and Xbow.12 The fort to Mandibular plane angle =21°−35°); A point-Nasion-B
more advanced and recently popularized designs include the point angle $4.5°; retrognathic mandible (Sella-Nasion-B
Twin Force bite corrector13 and the Forsus Fatigue Resistant point angle #76°, Sella-Nasion-A point angle $80°); records
Device (FRD).14–16 of sufficient quality for accurate identification of landmarks
The FRD (3M Unitek Corp, Monrovia, CA, USA) is a on cephalograms; exclusive treatment with FRD or TB for at
semirigid telescoping system incorporating a superelastic least 6 months; having the appliance not removed prematurely
nickel-titanium coil spring that can be assembled chair-side because of breakage; and nonextraction treatment. Patients
and that can be used in conjunction with complete fixed with unfavorable growth patterns, craniofacial anomalies, in
orthodontic appliances. The FRD attaches at the maxillary the early mixed dentition, or who had an anterior open bite
first molar and onto the mandibular archwire, distal to either of more than 2 mm were all excluded.
the canine or the first premolar bracket. The TB sample received the original design and treatment
Many papers were published on the FRD, but only a few protocol suggested by Dr Clark.6 No brackets were bonded
were clinical studies15–19 reporting variable effects. Franchi during the TB therapy. The bite registration was taken by
et al16 found that the FRD protocol is effective in correcting advancing the mandible sagittally, with no deviation, by
class II malocclusion with a combination of skeletal and 7 mm, with 3–5 mm interocclusal clearance in the first
dentoalveolar modifications, although a recent cephalometric bicuspid region. The treatment continued until the molars
study20 of class II correction with the Sabbagh Universal achieved a solid Angle’s class I occlusion. Although the FRD
Spring and the FRD found that both appliances did not sample received the clip-on design, before FRD insertion,
induce significant skeletal effects. The correction was mainly the maxillary and mandibular arches were bonded with pre-
dentoalveolar, with more mandibular incisors proclination in adjusted edgewise appliances (0.022-inch bracket slot) until
the FRD than with the Sabbagh Universal Spring². the upper and lower 19×25-inch SS wires were reached. The
The objective of this study was to evaluate the mandibular archwire was cinched distal to the molars. For
­dentoskeletal changes with FRD and TB in class II patients the maxillary dentition, the archwire management varied
in comparison with untreated controls. according to the individual treatment goals in terms of upper

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Dovepress Forsus and Twin Block treatment effects

molar distalization. Then the FRD was attached distal to the Results
mandibular first bicuspids. The bracket torques were 17° and The results were obtained from an evaluation of 184 lateral
10° in the maxillary central and lateral incisors and −6° in cephalograms of 92 subjects. Each subject was evaluated at
the mandibular incisors. T1 and T2. The mean ages at T1 and treatment/observation
periods are presented in Table 1.
Cephalometric analysis The results of the reliability testing between the repeated
Two lateral cephalograms for each subject were used, pre- measurements revealed good agreement (r=0.83–0.99).
treatment, with the functional appliances (T1), immediately Dahlberg’s variance results showed that the random method
before the insertion of the FRD appliance in fully bonded error was within 1 mm/1°.
upper and lower arches, and before any treatment in the TB The sex distribution between the three groups did not
group, and with postfunctional appliance removal (T2). Clark show statistically significant differences. Although there were
cephalometric analysis was used, which includes 27 angular more men than women in the FRD group, this 20% difference
and linear measurements.6 Nine randomly selected radio- did not achieve statistical significance (P=0.36).
graphs were digitally retraced and remeasured 3 weeks apart Overall, the groups were comparable at baseline (T1)
by a single evaluator. An intraclass correlation coefficient was with the exception of; the incisor overjet, the posterior facial
used to evaluate intraobserver reliability, and the Dahlberg height, the mandibular length, and the ramus height, which
formula was used to calculate the random method error. showed significant differences between the treatment groups
One investigator who was blind to the type of group digi- and the untreated controls.
tally traced and analyzed the cephalograms of the FRD and
the controls, using the Dolphin system (Dolphin Digital Imag- Within-group comparisons
ing System, version 11; Chatsworth, CA, USA). Dr Clark, Significant skeletal changes were observed at T2 in all
using Quick Ceph™ (Quick Ceph ­Systems; San Diego three groups (Table 2). Posterior facial height increased by
CA, USA), traced the TB sample, and the intraexaminer 2.7±2 mm in the control group, 3.2±2.4 mm in the TB, and
­reliability was reported in a previous study.6 The magnifica- 1.6±1.4 mm in the FRD. The mean total mandibular length
tion for the radiographs was standardized at 8%. ­Craniofacial significantly increased by 3.13±2.7 mm in the controls,
superimpositions were made using S-N reference line and 6.3±3.9 mm in the TB, and 1.6±2.1 mm in the FRD. A ­similar
registered at Sella. Maxillary superimpositions were made finding was noted for the ramus height (mean increase of
along the palatal plane, registered at an A point-Nasion-B 2.3±1.8 mm in controls, 4.2±2.5 mm in TB, and 1.3±1.3 mm
point angle, whereas the mandibular superimpositions were in FRD).
made on the inner contour of the inferior symphysis, the The dentoalveolar changes were much more notable than
inferior mandibular canal, and the germ of the third molar, the skeletal changes. The upper incisors retroclined signifi-
if present. ­Maxillary and mandibular dentoalveolar changes cantly in the TB (12.4°±6.5°) and FRD (3.9°±4.5°) groups,
were evaluated using reference lines perpendicular on the with no significant change in the controls. The mandibular
palatal plane and mandibular plane, respectively. All super- incisors flared by 2.1°±5.7° in the TB and by 3.9°±4.6° in the
impositions were conducted manually. FRD groups, respectively. The mean decrease in the overjet was
62% in the TB and 56% in the FRD groups, respectively.
Data analyses
The data were analyzed using SPSS software (version 21; Table 1 Age and treatment/observation times of the experimental
IBM Corporation, Armonk, NY, USA). Descriptive statis- and control groups
tics were used to present the baseline data of each of the Group Mean age (years) Mean treatment/
three groups. The Levene test was used to check for the ± standard observation time
deviation (T1) (years) ± standard
homogeneity of variances at T1 of all three groups. Paired
deviation (T1–T2)
t-tests were used to compare pre- and posttreatment measure- Twin Block 11.2±1.6 1.3±0.6
ments in each group. Analysis of variance (ANOVA) was Forsus Fatigue 12.9±1.2 0.7±0.1
used to compare the mean changes between the three groups, Resistance Device
followed by Tukey HSD (honestly significant differences) for Control 12.6±0.9 1.3±0.7
Notes: T1: immediately before the insertion of the FRD appliance in fully bonded
determining homogeneous subsets whenever appropriate. upper and lower arches, and before any treatment in the TB group. T2: postfunctional
The significance level was set at 5%. appliance removal.

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Hanoun et al Dovepress

Table 2 Within-group comparisons of changes between T1 and T2

Variable Mean (T1–T2) SD (T1–T2) P-value*
CRT TB FRD CRT TB FRD CRT TB FRD
Cranial base, ° -0.44 -0.29 -0.35 0.67 1.47 0.53 0.00* 0.23 0.00*
Mandibular plane to Frankfort, ° 0.23 -0.58 0.94 1.52 2.58 0.88 0.45 0.18 0.00*
Craniomandibular, ° -0.21 -0.96 0.59 1.61 2.45 0.65 0.52 0.02* 0.00*
Facial plane, ° -0.72 -1.03 -0.88 1.28 1.73 0.89 0.01* 0.00* 0.00*
Facial axis, ° -0.12 -0.05 -0.85 1.21 2.23 0.82 0.64 0.89 0.00*
Condyle axis, ° 0.65 -0.01 0.16 1.85 3.00 1.39 0.09 0.98 0.54
Maxillary plane, ° 0.06 0.25 0.06 0.93 2.19 0.62 0.74 0.49 0.58
Occlusal plane to Frankfort, ° 0.57 -1.94 -1.50 2.47 4.86 1.68 0.26 0.02* 0.00*
Upper incisor, ° 0.05 12.42 3.91 2.36 6.50 4.05 0.91 0.00* 0.00*
Lower incisor, ° -0.61 -2.11 -3.91 3.36 5.70 4.55 0.37 0.03* 0.00*
Interincisor, ° 0.54 -8.26 0.00 4.13 8.25 5.57 0.52 0.00* 1.00
Convexity, mm 0.50 1.70 1.02 0.63 1.40 0.85 0.00* 0.00* 0.00*
MX position to Na/V, mm -0.12 0.80 0.50 1.17 1.89 1.39 0.61 0.01* 0.06
PG to Na/V, mm -0.94 -1.54 -1.63 1.79 3.28 2.92 0.01* 0.01* 0.00*
Anterior cranial base, ° -1.19 -1.91 -0.69 0.95 1.60 0.76 0.00* 0.00* 0.00*
Porion location (Porion-PTV), mm 0.56 0.38 0.46 0.89 1.89 0.82 0.00* 0.24 0.00*
Mx1 to A -| FH, mm -0.20 3.43 -1.47 1.11 2.09 2.88 0.38 0.00* 0.01*
Md 1 to A-Po, mm -0.22 -3.01 -1.97 1.34 1.84 1.06 0.43 0.00* 0.00*
Mx 6 to PTV, mm -1.46 0.06 0.79 1.14 2.64 1.15 0.00* 0.90 0.00*
Incisor overjet, mm 0.51 7.03 3.97 1.42 2.72 1.70 0.08 0.00* 0.00*
Incisor overbite, mm 0.22 1.34 0.81 1.86 2.54 1.33 0.57 0.00* 0.00*
Molar relation, mm 0.00 4.89 4.38 1.12 2.22 1.48 1.00 0.00* 0.00*
Posterior facial height, mm -2.71 -3.22 -1.57 2.02 2.37 1.39 0.00 0.00* 0.00*
Midfacial length, mm -1.33 -1.73 -0.18 1.60 3.30 1.90 0.00 0.00 0.61
Mandibular length, mm -3.13 -6.27 -1.62 2.67 3.91 2.10 0.00* 0.00* 0.00*
Mx/Md difference, mm -1.85 -4.56 -1.43 1.89 2.14 1.29 0.00* 0.00* 0.00*
Ramus height, mm -2.28 -4.19 -1.32 1.83 2.49 1.31 0.00* 0.00* 0.00*
Corpus length, mm -2.03 -1.61 -1.90 1.63 2.61 1.46 0.00* 0.00* 0.00*
Notes: *Dependent t-test; P-value ,0.05. T1: immediately before the insertion of the FRD appliance in fully bonded upper and lower arches, and before any treatment in
the TB group. T2: postfunctional appliance removal.
Abbreviations: MX position, A-point to Nasion vertical; Na/V, Nasion vertical; PG, landmark Pogonion; PTV, Pterygoid vertical, a line drawn perpendicular to the Frankfort
plane and through point Pterygoid; Mx1, Maxillary incisor tip to a perpendicular through A-point to Frankfort horizontal; A-I FH, Perpendicular through A-point to Frankfort
horizontal; Md1, Mandibular incisor tip to line A-point to Pogonion; A-Po, Line A-point to Pogonion; SD, standard deviation; CRT, control; TB, Twin Block; FRD, Forsus
Fatigue Resistance Device.

Between-group comparisons was significantly different between TB and FRD (P=0.04);

The mean change of the Frankfort to Mandibular plane however, neither of the two experimental groups was different
angle when compared by ANOVA was statistically different from the controls. There is insufficient evidence to support that
between the three groups (P,0.01). However, Tukey analysis either of the two appliances had a significant headgear effect.
showed no evidence that any of the two experimental groups The mean change of the lower incisor angle was signifi-
significantly differed from the controls (Table 3). cantly different between the three groups (ANOVA P=0.042).
There was no significant difference between the three Statistically significant lower incisors’ proclination has occurred
groups in many skeletal variables such as cranial base angle, in the FRD group when compared with the controls. However,
facial depth, facial-axis angle, condyle-axis angle, maxillary the difference between the FRD and the TB groups was not
plane angle, and mandibular corpus length. The net increases statistically significant, as confirmed by Tukey HSD test.
in the mandibular length (Basion-Pogonion) and Ramus height
in the FRD group did not differ significantly from the controls. Discussion
However in the TB group, the increases of both variables were This is a retrospective comparative study of two com-
two times larger than in FRD and controls (P,001). The monly used appliances. The TB and FRD groups showed
Maxillary position to Nasion/Vertical did not show a significant favorable reduction in skeletal convexity (1.7±1.4 mm
difference (P=0.08). Midfacial length (Condylion to A-point) and 1.02±0.85 mm, respectively). This reduction was in

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Dovepress Forsus and Twin Block treatment effects

Table 3 Between-group comparisons of changes between T1 differential length increased by 4.6±2.1 mm in the TB group
and T2 compared with the controls (1.8±1.9 mm). These findings
Variable F- P-value* Subsets for alpha confirm previous investigations21,23 that suggest a mandibular
statistic =0.05**
growth ­enhancement effect by this appliance. In contrast, the
1 2 3
amount of change in the FRD group was not significantly
Cranial base, ° 0.154 0.857 C, F, T
different from in the controls, which parallels the findings
Mandibular plane to 5.432 0.006 T, C C, F
Frankfort, ° of the late puberty FRD group in a previous study18 but is in
Craniomandibular, ° 6.071 0.003 T, C C, F disagreement with another.16 The differences between previ-
Facial plane, ° 0.379 0.686 T, F, C ous reports may not be easily explained because they could
Facial axis, ° 2.321 0.104 F, C, T
be associated with the treatment protocol and duration, wires,
Condyle axis, ° 0.643 0.528 T, F, C
Maxillary plane, ° 0.165 0.849 F, C, T and slot dimension; fixed appliance torque differences;16
Occlusal plane to 4.143 0.019 T, F F, C the age factor;18,20 and possible different neuromuscular
Frankfort, ° responses.24 There was a highly significant increase in the
Upper incisor, ° 52.983 ,0.001 C F T
corpus length of all three groups (Student’s t-test P,0.001)
Lower incisor, ° 3.276 0.042 F, T T, C
Interincisal, ° 19.051 ,0.001 T F, C but no significant difference between them (ANOVA P=0.70),
Convexity, mm 9.764 ,0.001 C, F T which suggests it was only a result of the growth effect.
MX position to Na/V, mm 2.629 0.078 C, F, T The upper incisors’ retroclination was statistically and
PG to Na/V, mm 0.478 0.622 F, T, C
clinically significant in both experimental groups (Student’s
Anterior cranial base, mm 8.613 ,0.001 T, C C, F
Porion location 0.130 0.878 T, F, C t-test P,0.001), with the highest change seen in the TB group.
(Porion-PTV), mm This finding is in contradiction with some previous studies25,26
Mx1 to A -| FH, mm 45.449 ,0.001 F, C T and is in agreement with many others.22,27,28 The considerable
Md 1 to A-Po, mm 26.328 ,0.001 T F C
upper incisors’ retroclination may be attributed to the appli-
Mx 6 to PTV, mm 9.852 ,0.001 C T, F
Incisor overjet, mm 70.947 ,0.001 C F T ance design, particularly when the labial bow is incorporated.22
Incisor overbite, mm 2.308 0.105 C, F, T It may also be attributed to the treatment period and treat-
Molar relation, mm 65.754 ,0.001 C F, T ment modality. In a previous study,23 semirapid maxillary
Posterior facial height, mm 5.721 0.005 T, C C, F
Midfacial length, mm 3.313 0.041 T, C C, F
expansion and alignment of the upper arch were performed
Mandibular length, mm 19.80 ,0.001 T C, F before TB therapy, which may have influenced the amount of
Mx/Md difference, mm 28.761 ,0.001 T C, F retroclination. Pretreatment dentoskeletal characteristics and
Ramus height, mm 18.122 ,0.001 T C, F the variation in appliance-wearing time among patients also
Corpus length, mm 0.348 0.707 C, F, T
have to be taken into consideration. In addition, variability
Notes: *Analysis of variance test, P-value ,0.05; **Tukey Honestly Significant
Differences, homogeneous subset results. T1: immediately before the insertion of the among clinicians adds an operator factor to the effect of this
Forsus Fatigue Resistance Device appliance in fully bonded upper and lower arches, appliance. The upper incisor retroclination in the FRD group
and before any treatment in the TB group. T2: postfunctional appliance removal.
Abbreviations: C, controls; F, Forsus Fatigue Resistance Device; T, Twin Block; was smaller than in the TB group. The presence of fixed
MX position, A-point to Nasion vertical; Na/V, Nasion vertical; PG, landmark brackets on the upper incisors may have limited the amount of
Pogonion; PTV, Pterygoid vertical, a line drawn perpendicular to the Frankfort plane
and through point Pterygoid; A-I FH, Perpendicular through A-point to Frankfort retroclination in this group. The 3.9° retroclination in the FRD
horizontal; Md1, Mandibular incisor tip to line A-point to Pogonion; A-Po, Line
A-point to Pogonion.
group was similar to previous findings,20 but it should be noted
that direct comparison is not possible because of the different
reference lines used in the Clark cephalometric analysis.
agreement with previous FRD16,18 and TB studies21,22 in which At T2, the lower incisors proclined by an average of 2.1°
the A point-Nasion-B point angle angle reduction was used and 3.9° in the TB and FRD groups, respectively, but the dif-
to represent the relative skeletal convexity correction. The ference between the groups was not statistically significant.
difference between the three groups in terms of convexity The lower incisors proclination in the TB group was less than
reduction was highly significant (ANOVA P,0.001). that reported in previous studies.21,22,25,28 Many factors that
There was a significant difference between the three groups were discussed as possible contributors for the difference in
in the total mandibular length and maxillary-mandibular the upper incisors’ retroclination are similarly applicable. In
(Mx-Md) differential lengths (ANOVA P,0.001). The total some studies, the acrylic of the lower part of the TB appliance
mandibular length increased in the TB group two times more was extended to cover the lower incisal edges. This acrylic
than in the controls (6.3±3.9 mm). Similarly, the Mx-Md extension aimed to limit the lower incisors tipping.27,28

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Hanoun et al Dovepress

The mean changes in the molar relationship in both groups Disclosure

differed significantly from the controls (4.4 and 4.9 mm in The authors report no conflicts of interest in this work.
the FRD and TB groups, respectively; ANOVA P,0.001).
The molar relationship correction was found to be a result References
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2009;136(6):822–832.
investigating the efficacy of orthodontic appliances. However,
13. Rothenberg J, Campbell ES, Nanda R. Class II correction with the Twin
it alone is not enough for a comprehensive understanding Force Bite Corrector. J Clin Orthod. 2004;38(4):232–240.
of the functional orthodontic treatment. An investigation of 14. Vogt W. The Forsus Fatigue Resistant Device. J Clin Orthod.
2006;40(6):368–377, quiz 358.
three-dimensional soft tissue changes and temporomandibular 15. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction
changes/remodeling during and after treatment completion in patients treated with the Forsus Fatigue Resistant Device versus
intermaxillary elastics. Angle Orthod. 2008;78(2):332–338.
prospective tomographic studies is recommended.
16. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T.
Effectiveness of comprehensive fixed appliance treatment used with
Conclusion the Forsus Fatigue Resistant Device in Class II patients. Angle Orthod.
2011;81(4):678–683.
The FRD and TB are effective in the treatment of patients 17. Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol
with class II malocclusion. Both appliances were able to Flat Spring and Jasper Jumper corrections of Class II division 1
malocclusions. Angle Orthod. 2006;76(4):666–672.
induce favorable changes in the sagittal relation, but the type 18. Aras A, Ada E, Saracoğlu H, Gezer NS, Aras I. Comparison of treat-
of change differed significantly between the groups. The TB ments with the Forsus fatigue resistant device in relation to skeletal
maturity: a cephalometric and magnetic resonance imaging study. Am
induced mandibular skeletal correction with much less influ-
J Orthod Dentofacial Orthop. 2011;140(5):616–625.
ence on the maxilla. The FRD induced dentoalveolar changes, 19. Gunay EA, Arun T, Nalbantgil D. Evaluation of the Immediate
and the contribution to the final overjet correction was a result ­Dentofacial Changes in Late Adolescent Patients Treated with the
Forsus(™) FRD. Eur J Dent. 2011;5(4):423–432.
of an equal combination of upper incisor retroclination and 20. Oztoprak MO, Nalbantgil D, Uyanlar A, Arun T. A cephalometric compar-
lower incisor proclination. ative study of class II correction with Sabbagh Universal Spring (SUS(2))
and Forsus FRD appliances. Eur J Dent. 2012;6(3):302–310.
21. Tümer N, Gültan AS. Comparison of the effects of monoblock and
Acknowledgment twin-block appliances on the skeletal and dentoalveolar structures. Am
J Orthod Dentofacial Orthop. 1999;116(4):460–468.
We thank Robert Dunford for his help with the statistical 22. Lund DI, Sandler PJ. The effects of Twin Blocks: a prospective controlled
analysis. study. Am J Orthod Dentofacial Orthop. 1998;113(1):104–110.

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23. Trenouth MJ. Cephalometric evaluation of the Twin-block ­appliance in 27. Sidlauskas A. Clinical effectiveness of the Twin block appliance in
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Resistant Device. J Clin Pediatr Dent. 2011;35(3):331–338. Medicina (Kaunas). 2005;41(5):392–400.
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correction of Class II malocclusions with the twin block appliance. Am
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