Skeletal, Dental and Soft-Tissue Changes Induced by the Jasper Jumper Appliance in Late Adolescence

Transcription

1 Originl Article Skeletl, Dentl nd Soft-Tissue Chnges Induced by the Jsper Jumper Applince in Lte Adolescence Didem Nlbntgil ;Tülin Arun b ; Korkmz Syinsu c ; Fuly Işık c Abstrct: The purpose of this study ws to evlute the skeletl, dentl, nd soft-tissue chnges in ltedolescent ptients treted with Jsper Jumpers pplied with sectionl rches. The study smple consisted of 0 subjects ( treted, untreted) with skeletl nd dentl Clss II mlocclusion. Our study ws crried out on lterl cephlometric films. Among these rdiogrms, were tken before the leveling stge in the tretment group. Hlf of the remining 0 were tken before plcement nd fter removl of the Jsper Jumper pplince in the tretment group nd the other hlf t the beginning nd six months fter in the control group. The ptient selection criteri were Clss II mlocclusion cused by retrognthic mndible, norml or low-ngle growth pttern, nd postpek growth period. The sttisticl ssessment of the dt suggests tht the sgittl growth potentil of the mxill ws inhibited. There were no significnt chnges in the verticl skeletl prmeters. The mndibulr incisors were protruded nd intruded, wheres the mxillry incisors were retruded nd extruded. The upper molrs tipped distlly s the lower molrs tipped mesilly. Becuse of these chnges, the occlusl plne rotted in the clockwise direction. Overbite nd overjet were reduced, nd the soft-tissue profile improved significntly. The results reveled tht, in lte-dolescent ptients, the Jsper Jumper corrected Clss II discrepncies mostly through dentolveolr chnges. It is suggested tht this tretment method could be n lterntive to orthognthic surgery in borderline Clss II cses. (Angle Orthod 00;:.) Key Words: Jsper Jumper; Functionl therpy; Skeletl Clss II mlocclusion; Dentofcil orthopedics; Fcil profile INTRODUCTION The Jsper Jumper (Americn Orthodontics, Sheboygn, Wis) is fixed functionl pplince which keeps the mndible in protruded position by pplying continuous, light forces. In correction of Clss II mlocclusions, it cts like hedger, ctivtor or combintion of both ccording to how it is ctivted. In ddition, it hs the dvntges of llowing the mndible lterl movements, good ptient coopertion, nd esy orl hygiene., Even though previous studies hve reveled the clinicl outcome of the pplince, there is still some debte bout Reserch ssistnt, Deprtment of Orthodontics, Fculty of Dentistry, Yeditepe University, Istnbul, Turkey. b rofessor, Deprtment of Orthodontics, Fculty of Dentistry, Yeditepe University, Istnbul, Turkey. c Assistnt rofessor, Deprtment of Orthodontics, Fculty of Dentistry, Yeditepe University, Istnbul, Turkey. Corresponding uthor: Tülin Arun, DDS, hd, Deprtment of Orthodontics, Fculty of Dentistry, Yeditepe University, Bgdt cd. No:, Göztepe, Istnbul 0, Turkey (e-mil: trun@yeditepe.edu.tr) Accepted: June 00. Submitted: Februry by The EH Angle Eduction nd Reserch Foundtion, Inc. how much correction is chieved by skeletl chnges vs dentolveolr chnges. In, Cope et l used Jsper Jumper in Clss II ptients nd evluted the crniofcil chnges. They reported tht the chnges were mostly dentolveolr rther thn skeletl. According to their results, the mxill underwent significnt posterior displcement, the mxillry incisors retroclined, wheres the mx- TABLE. Age Rnge nd Sex Distribution of Tretment nd Control Groups n Age (X) Min Mx Control group Girls Boys Totl Tretment group Girls Boys Totl n indictes the number of ptients; X, men ge before plcement of Jsper Jumper (yer);, stndrd devition; min, minimum ge before plcement of Jsper Jumper (yer); mx, mximum ge before plcement of Jsper Jumper (yer).

2 JASER JUMER ALICATION IN LATE ADOLESCENCE FIGURE. Lterl view of the sectionl rch. FIGURE. Angulr nd liner dentl mesures used in the study. SN indictes Sell-nsion plne; RL, horizontl reference line; RL, verticl reference line;, U/SN ngle;, IMA;, interincisl ngle;, SN/O ngle;, L-NB distnce;, overjet; nd, overbite. FIGURE. Angulr nd liner skeletl mesures used in the study. SN indictes Sell-nsion plne; RL, horizontl reference line; RL, verticl reference line;, SNA ngle;, SNB ngle;, ANB ngle;, SN/ ngle;, SN/M ngle;, g-nb distnce;, A-RL distnce;, A-RL distnce;, B-RL distnce;, Ar-g distnce;, SE distnce; nd, SL distnce. illry molrs tipped distlly. Also, clockwise rottion of the mndible ws evident nd the mndibulr incisors proclined significntly, wheres the mndibulr molrs tipped mesilly. Weilnd nd Bntleon studied consecutive growing ptients with Clss II, division mlocclusions treted with Jsper Jumper pplinces nd reported tht the correction of the mlocclusion ws chieved both by skeletl (0%) nd dentl (0%) chnges. As with these findings, Kucukkeles nd Orgun showed tht the pplince produced mostly dentolveolr chnges. In cse study by Mills nd McCulloch, the investigtors used modified Jsper Jumper on mixed dentition Clss II ptient. They reported tht the effects of the pplince were lrgely dentolveolr. Covell et l investigted the effects of tretment with the Jsper Jumper in growing Clss II ptients. They stted tht the pplince corrected Clss II discrepncies mostly through dentolveolr chnges nd, to limited extent, by restrint of forwrd mxillry growth.

3 NALBANTGIL, ARUN, SAYINSU, IŞIK FIGURE. Horizontl nd verticl mesurements of upper incisor nd first molr relted to reference lines. SN indictes Sell-nsion plne; RL, horizontl reference line; RL, verticl reference line;, Ut-RL distnce;, Ut-RL distnce;, U-RL distnce;, U-RL distnce;, Uc-RL distnce;, Uc-RL distnce;, U-RL distnce; nd, U-RL distnce. FIGURE. Horizontl nd verticl mesurements of lower incisor nd first molr relted to reference lines. SN indictes Sell-nsion plne; RL, horizontl reference line; RL, verticl reference line;, Lt-RL distnce;, Lt-RL distnce;, L-RL distnce;, L- RL distnce;, Lc-RL distnce;, Lc-RL distnce;, L-RL distnce; nd, L-RL distnce. Consequently, review of the literture shows tht functionl pplinces including the Jsper Jumper hve similr effects on dentolveolr nd skeletl structures. Among these chnges, the incresed inclintion of the lower incisors is usully considered n unfvorble effect of functionl therpy. In our study, to prevent or minimize this effect we pplied the Jsper Jumpers using sectionl rches. Considering these findings, this study ws done to evlute the skeletl, dentl, nd soft-tissue chnges in ltedolescent ptients treted with Jsper Jumpers pplied with sectionl rches. MATERIALS AND METHODS Tretment smple The study smple consisted of 0 subjects ( treted, untreted) with skeletl nd dentl Clss II mlocclusions. The ptient inclusion criteri were () skeletl nd dentl Clss II mlocclusion cused by retrognthic mndible, () norml or low-ngle growth pttern, nd () postpek growth period. The study method ws pproved by the Yeditepe University Ethicl Committee. Skeletl ge ws used for selecting the ptients, nd postpek growth period ws defined by hnd-wrist rdiogrphic stges. The men pretretment ge for the tretment group ws.0 0. yers nd. 0. yers for the control group. The ge rnge nd the sex distribution of tretment nd control groups re shown in Tble. Tretment methods In the tretment group, stndrd edgewise brckets nd bnds were plced with trnspltl rch in the upper rch to increse stbility. After leveling, inch nd inch stinless steel continuous rchwires were inserted nd cinched bck in the upper nd lower rches, respectively. In the lower rch, /0.0

4 JASER JUMER ALICATION IN LATE ADOLESCENCE FIGURE. The sgittl, verticl, nd oblique forces induced by the Jsper Jumper. C indictes the resistnce center of the upper dentolveolr rch; C, the resistnce center of the lower dentolveolr rch; F, the force pplied by the Jsper Jumper to the upper rch; F, the force pplied by the Jsper Jumper to the lower rch; M, the moment cused by F; M, the moment cused by F; F F; nd M M. FIGURE. Angulr nd liner soft-tissue mesures used in the study: SN indictes Sell-nsion plne; RL, horizontl reference line; RL, verticl reference line;, H ngle;, N-A-g ngle;, nsolbil ngle;, lbilis superior-rl distnce;, lbilis inferior- RL distnce;, A-lbilis superior distnce;, E line-lbilis superior distnce;, E line-lbilis inferior distnce; nd -b, lip strength. 0.0 inch cross tubes (order-no Denturum, Ispringen, Germny) were crimped distl to the cnine brckets. Jsper Jumper mechnics were pplied on inch stinless steel sectionl rches connected to the lower continuous rchwire by mens of / inch cross tubes. The nterior tip of the sectionl rch ws djusted to pss close to the deepest prt of the vestibulr sulcus, which coincided with pproximtely one crown length of extension from the enmelcement border of the cnine tooth. Becuse it ws impossible to pss through the center of resistnce of the lower dentolveolr rch, this wy provided the most prcticl wy to pss the force s ner s possible to the center of resistnce of the lower dentolveolr rch without cusing n excessive irrittion on the mucosl surfce of the vestibulr sulcus (Figure ). Jsper Jumpers were selected ccording to the mnufcturer s instructions nd connected to the lower rch through sectionl rches inserted between the uxiliry tubes of the lower molr bnds nd cross tubes. The ptients were seen every four weeks, nd the pplinces were ctivted every eight weeks. The pplince ws removed when Clss I or overcorrected Clss I cnine nd molr reltionship ws chieved. Cephlometric methods Our study ws crried out on lterl cephlometric films, of which were tken off the tretment group before the leveling stge. These preleveling cephlometric films were used for comprison of IMA vlues before leveling, t insertion, nd removl of the Jsper Jumper. Hlf of the remining 0 were tken before plcement nd fter removl of the Jsper Jumper pplince in the tretment group nd the other hlf t the beginning nd six months lter in the control group. The pretretment nd posttretment rdiogrms of ech ptient were trced on cette pper t the sme time by one exminer to minimize ny method error. Cephlometric lndmrks nd mesurements cn be seen in Figures. The reference lines used in this study were lso used in previous investigtions. Sttisticl methods The nonprmetric Wilcoxon signed rnk test ws used to ssess the differences in ech group. To evlute the

5 0 NALBANTGIL, ARUN, SAYINSU, IŞIK TABLE. 0 0 Chnges nd Comprisons of retretment nd osttretment Vlues Within the Control Group SNA ( ) SNB ( ) ANB ( ) SN/ ( ) SN/M ( ) SE (mm) SL (mm) g-nb (mm) Ar-g (mm) A-RL (mm) B-RL (mm) A-RL (mm) ANS-Me/N-Me (%) Jrbk rtio (%) Gonil rtio (%) S-Ar/Ar-Go (%) U/SN ( ) IMA ( ) Interincisl ngle ( ) SN/O ( ) L/NB (mm) Overjet (mm) Overbite (mm) H ngle ( ) Nsolbil ngle ( ) N-A-g ( ) A-lbilis superior (mm) E line-lbilis superior (mm) E line-lbilis inferior (mm) Lbilis superior-rl (mm) Lbilis inferior-rl (mm) Lip strength (mm) retretment Men D indictes the difference between pretretment nd posttretment..0,.0,.00. osttretment Men D Difference Wilcoxon differences between the groups the Mnn-Whitney U-test ws used. A confidence level greter thn % ws considered sttisticlly not significnt. To ssess the mgnitude of the method error, 0 rndomly selected cephlogrms were trced nd mesured gin by the sme exminer fter n intervl of 0 dys. ired t-tests nd correltion nlysis were used to evlute the findings. The method error did not exceed 0. mm nd 0. for the liner nd ngulr mesurements, respectively. RESULTS Skeletl chnges Sttisticl comprisons of pretretment nd posttretment vlues of the groups re shown in Tbles. Comprisons of the cephlometric mesurements reveled tht the pplince hd only limited skeletl effect on the mxill. In the control group, SNA show sttisticlly significnt increse (Tble ) wheres, no significnt chnge ws present in the tretment group (Tble ). When the two groups were compred, significnt decrese ws found s seen in Tble. As with this finding, significnt decrese ws found in the A-RL line. When mesurements of the mndible were evluted, no significnt chnge between two groups ws found (Tble ). However, the ANB ngle demonstrted significnt decrese when the two groups were compred (Tble ). When the skeletl verticl prmeters were evluted, the only significnt chnge ws found in the ANS-Me/N-Me rtio. Dentl chnges In the tretment group, the dentl chnges cused by Jsper Jumper were evident. The upper incisors were significntly retroclined s compred with the control group (Tble ). The mxillry incisl tip moved distlly. mm, wheres the incisor pex moved mesilly 0.0 mm. Likewise, significnt verticl movements of the upper incisors occurred (Tble ). On the other hnd, in the tretment group, the lower incisors showed significnt proclintion (Tbles nd ). The

6 JASER JUMER ALICATION IN LATE ADOLESCENCE TABLE. 0 0 Chnges nd Comprisons of retretment nd ostretment Vlues Within the Tretment Group SNA ( ) SNB ( ) ANB ( ) SN/ ( ) SN/M ( ) SE (mm) SL (mm) g-nb (mm) Ar-g (mm) A-RL (mm) B-RL (mm) A-RL (mm) ANS-Me/N-Me (%) Jrbk rtio (%) Gonil rtio (%) S-Ar/Ar-Go (%) U/SN ( ) IMA ( ) Interincisl ngle ( ) SN/O ( ) L/NB (mm) Overjet (mm) Overbite (mm) H ngle ( ) Nsolbil ngle ( ) N-A-g ( ) A-lbilis superior (mm) E line-lbilis superior (mm) E line-lbilis inferior (mm) Lbilis superior-rl (mm) Lbilis inferior-rl (mm) Lip strength (mm) retretment Men D indictes the difference between pretretment nd posttretment..0,.0,.00. osttretment Men D Difference Wilcoxon IMA incresed., wheres L-NB distnce incresed. mm (Tble ). The chnges reltive to reference lines lso support these findings. The mndibulr incisl tip moved forwrd. mm, wheres the incisor pex moved bckwrd insignificntly. The verticl chnges of the lower incisors displyed greter movement in the opposite direction to the mxillry incisors (Tble ). The upper molr showed significnt bckwrd movement with distl tipping nd intrusion, wheres the lower molr displyed significnt mesil tipping movement (Tble ). The dentolveolr effects tht occurred both in the upper nd lower jws produced clockwise rottion of the occlusl plne (Tble ). The decrese in overbite nd overjet supports the incisor inclintion vritions cused by the pplince (Tble ). Soft-tissue chnges Soft-tissue profiles improved significntly, reflecting the chnges tht took plce in the dentoskeletl structures. When the two groups were compred, significnt increse ws seen in the nsolbil ngle. Likewise, the sttisticlly significnt decrese in the lbilis superior-rl distnce nd lip strength lso showed the retrusion of the upper lip (Tble ). When the prmeters relted to the lower lip were evluted, the decrese in the E line-lbilis inferior distnce showed tht the lower lip moved forwrd s the lower incisors protruded. DISCUSSION This study evluted the skeletl, dentl, nd soft-tissue chnges in lte-dolescent ptients treted with Jsper Jumpers, pplied with sectionl rches. The study smple ws composed of lte-dolescent ptients who were t the end of their postpubertl growth period. This group ws chosen becuse it would benefit from the miniml residul growth nd hve miniml relpse due to growth nd posttretment dentoskeletl chnges. In the tretment group, the Jsper Jumper ws pplied using sectionl rches to prevent or minimize the lower

7 NALBANTGIL, ARUN, SAYINSU, IŞIK TABLE. 0 0 Comprison of Skeletl, Dentl, nd Soft-Tissue Chnges of the Control nd Tretment Groups Relted to Tretment SNA ( ) SNB ( ) ANB ( ) SN/ ( ) SN/M ( ) SE (mm) SL (mm) g-nb (mm) Ar-g (mm) A-RL (mm) B-RL (mm) A-RL (mm) ANS-Me/N-Me (%) Jrbk rtio (%) Gonil rtio (%) S-Ar/Ar-Go (%) U/SN ( ) IMA ( ) Interincisl ngle ( ) SN/O ( ) L/NB (mm) Overjet (mm) Overbite (mm) H ngle ( ) Nsolbil ngle ( ) N-A-g ( ) A-lbilis superior (mm) E line-lbilis superior (mm) E line-lbilis inferior (mm) Lbilis superior-rl (mm) Lbilis inferior-rl (mm) Lip strength (mm) Control Group D Test D indictes the difference between pretretment nd posttretment..0,.0,.00. Tretment Group D Test Mnn-Whitney U TABLE. Men Vlues of IMA Before Levelling (T), t Insertion (T), nd Removl (T) of Jsper Jumper T (Men) T (Men) T (Men) IMA ( ) incisor protrusion., Becuse the lower rch ws stbilized by cinching the rchwire behind the molr tubes, the center of resistnce of the lower dentolveolr rch ws locted between the roots of the premolrs. Sectionl rches were used to decrese the distnce to the center of resistnce to reduce the moment produced by this force. This wy, the force vector produced pssed s ner s possible to the center of resistnce of the mndibulr rch (Figure ). The results showed tht Clss II correction ws chieved mostly through dentolveolr chnges nd skeletl chnges plyed minor role (Figures nd ). The results reveled tht the pplince hd limited skeletl effect on the mxill. This restrint of forwrd mxillry growth ws the only skeletl chnge cused by the pplince. This finding is in ccordnce with the results of other investigtors who showed tht the pplince hd high-pull hedger effect on the mxill.,,,, Weilnd nd Bntleon, on the other hnd, found tht the Jsper Jumper hd limited effects on the mxill nd stted tht the chnge t point A is the result of the retrusion of the upper incisors. Unlike the mxill, we did not find ny significnt effect on mndibulr growth. Our results support the findings of Cope et l, Kucukkeles nd Orgun, nd Covell et l but contrdict Weilnd nd Bntleon. This contrdiction my be relted to severl fctors such s ge, vrince of the smple groups, nd different tretment mechnics. The ANS-Me/N-Me rtio ws the only verticl skeletl prmeter found to be significnt in our study. This decrese in the lower fcil height my be relted to the smple hving norml or low-ngle growth pttern.

8 JASER JUMER ALICATION IN LATE ADOLESCENCE TABLE. Cephlometric Mesurements nd Sttisticl Comprisons of Dentl Vlues Reltive to Reference Lines Within the Control Group Ut-RL (mm) Ut-RL (mm) U-RL (mm) U-RL (mm) Lt-RL (mm) Lt-RL (mm) L-RL (mm) L-RL (mm) Uc-RL (mm) Uc-RL (mm) U-RL (mm) U-RL (mm) Lc-RL (mm) Lc-RL (mm) L-RL (mm) L-RL (mm) Men retretment D indictes the difference between pretretment nd posttretment..0,.0,.00. Men osttretment D Difference Wilcoxon TABLE. Group Cephlometric Mesurements nd Sttisticl Comprisons of Dentl Vlues Reltive to Reference Lines Within the Tretment Ut-RL (mm) Ut-RL (mm) U-RL (mm) U-RL (mm) Lt-RL (mm) Lt-RL (mm) L-RL (mm) L-RL (mm) Uc-RL (mm) Uc-RL (mm) U-RL (mm) U-RL (mm) Lc-RL (mm) Lc-RL (mm) L-RL (mm) L-RL (mm) Men retretment D indictes the difference between pretretment nd posttretment..0,.0,.00. osttretment Men D Difference Wilcoxon The findings relted to the dentolveolr structures showed significnt tretment effects. Becuse the upper molrs nd incisors were blocked together, the upper incisors retroclined nd the molrs distlized considerbly s result of the high-pull effect of the pplince. This is in ccordnce with the findings of Mills nd McCulloch, Cope et l, Weilnd nd Bntleon, Kucukkeles nd Orgun, nd Covell et l. In our study, the use of the segmentl rches llowed the force vector to be shifted to more verticl direction. Consequently, this verticl force vector tipped nd intruded the upper molrs significntly. Therefore, we think tht Jsper Jumpers used with the segmentl rches cn be used in high-ngle cses. The incresed lower incisor inclintion is usully considered n unfvorble functionl therpy effect. To prevent or minimize this effect, we pplied the Jsper Jumpers using sectionl rches, but sttisticlly significnt protrusion still occurred t the lower incisors. This my be the result

9 NALBANTGIL, ARUN, SAYINSU, IŞIK TABLE. Comprison of Chnges in Dentl Vlues Reltive to Reference Lines of Control nd Tretment Groups Ut-RL (mm) Ut-RL (mm) U-RL (mm) U-RL (mm) Lt-RL (mm) Lt-RL (mm) L-RL (mm) L-RL (mm) Uc-RL (mm) Uc-RL (mm) U-RL (mm) U-RL (mm) Lc-RL (mm) Lc-RL (mm) L-RL (mm) L-RL (mm) Control Group D Test D indictes the difference between pretretment nd posttretment..0,.0,.00. Tretment Group D Test Mnn-Whitney U FIGURES. () (e) Fcil nd introrl photogrphs before tretment.

10 JASER JUMER ALICATION IN LATE ADOLESCENCE FIGURES. () (e) Fcil nd introrl photogrphs fter tretment. of the fct tht it ws impossible to pss through the center of resistnce of the lower dentolveolr rch without cusing n excessive irrittion in the vestibulr sulcus of the ptients. Our results re similr to those in the literture.,,,, The use of lower incisor brckets with negtive torque vlues or hving lingul crown torque t the lower nterior segment of the rchwire my be further options to prevent the protrusion of the lower incisors. Retrusion nd extrusion of the upper incisors nd distl tipping of upper molrs, nd protrusion nd intrusion of the lower incisors nd mesil tipping of the lower molrs ll point to clockwise rottion of the occlusl plne. Cope et l, Weilnd nd Bntleon, Kucukkeles nd Orgun, nd Covell et l, ll reported similr effects on the occlusl plne in their studies. In ddition, the chnges in overbite nd overjet re consistent with our previous dentolveolr findings. The correction of the overjet ws chieved by combintion of the retrusion of the upper incisors nd protrusion of the lower incisors. These tipping movements were lso effective t correcting the excessive overbite. revious Jsper Jumper nd Herbst studies lso hve shown significnt decreses in overbite nd overjet. The chnge of the ngultion of the incisors probbly is due to the nchorge loss during tretment. Becuse this tipping movement occurs round their pices, extrusion nd intrusion were observed t the upper nd lower incisors, respectively. These findings revel tht the chnges were mostly dentolveolr rther thn skeletl. The soft-tissue prmeters show tht the Jsper Jumper fvorbly improved the profile. As the upper incisors retruded, the upper lip moved bck nd the lower lip ws no longer cptured behind the upper incisors. Moreover, the proclined lower incisors supported the lower lip. Lip strength decresed fvorbly becuse of the upper incisor retrusion. revious studies show similr soft-tissue chnges., Most of the time, Clss II surgery is indicted for the ptients who hve very little growth left similr to the ptients in our study. De Clerck nd Timmermn reported tht there were no significnt differences between ptients treted with hedger-ctivtor nd the ones who

11 NALBANTGIL, ARUN, SAYINSU, IŞIK hd undergone mndibulr dvncement osteotomy. Likewise, Ruf nd ncherz suggested the use of functionl therpy in some of the borderline cses insted of orthognthic surgery. Also, Weilnd nd Droschl used Jsper Jumper in one of their cses who did not wnt surgery nd received very stisfctory results. Tking these into considertion this tretment method could be n lterntive to orthognthic surgery in some borderline Clss II cses. CONCLUSIONS This study demonstrted the skeletl, dentl, nd softtissue effects of the Jsper Jumper used in lte dolescence. The results reveled tht, the pplince corrected Clss II discrepncies mostly through dentolveolr chnges. Becuse the Jsper Jumper cn successfully correct the softtissue profile in lte-dolescent ptients, it is suggested tht this tretment method could be n lterntive to orthognthic surgery in borderline Clss II cses. However, further studies will be needed to evlute the long-term effects nd stbility of the pplince used in young dults. REFERENCES. Blckwood HO. Clinicl mngement of the Jsper Jumper. J Clin Orthod. ;: 0.. Mills CM, McCulloch KJ. Cse report: modified use of the Jsper Jumper pplince in skeletl Clss II mixed dentition cse requiring pltl expnsion. Angle Orthod. ;:.. Cope JB, Buschng H, Cope DD, rker J, Blckwood HO. Quntittive evlution of crniofcil chnges with Jsper Jumper therpy. Angle Orthod. ;:.. Weilnd FJ, Bntleon H. Tretment of Clss II mlocclusions with the Jsper Jumper pplince. A preliminry report. Am J Orthod Dentofcil Orthop. ;: 0.. Kucukkeles N, Orgun A. Correction of Clss II mlocclusions with Jsper Jumper in growing ptients. Eur J Orthod. ; :.. Covell DA, Trmmell DW, Boero R, West R. A cephlometric study of Clss II division mlocclusion treted with the Jsper Jumper pplince. Angle Orthod. ;: 0.. Firouz M, Zernik J, Nnd R. Dentl nd orthopedic effects of high pull hedger in tretment of Clss II division mlocclusion. Am J Orthod Dentofcil Orthop. ;: 0.. Rins MD, Nnd R. Soft tissue chnges ssocited with mxillry incisor retrction. Am J Orthod Dentofcil Orthop. ; :.. Tlss MF, Tlss L, Bker RC. Soft tissue profile chnges resulting from retrction of mxillry incisor. Am J Orthod Dentofcil Orthop. ;:.. Tomlk DJ, iecuch JF, Weinstein S. Morphologic nlysis of upper lip re following mxillry osteotomy vi the tunneling pproch. Am J Orthod Dentofcil Orthop. ;:.. Schwindling F. Jsper Jumper Color Atls. ed. Merzig, Germny: Edition Schwindling; :.. Jsper JJ, McNmr JA. The correction of interrch mlocclusion using fixed force module. Am J Orthod Dentofcil Orthop. ;: 0.. Weilnd FJ, Droschl H. Tretment of Clss II division mlocclusion with the Jsper Jumper: cse report. Am J Orthod Dentofcil Orthop. ;:.. Ruf S, ncherz H. Dentoskeletl effects nd fcil profile chnges in young dults treted with the Herbst pplince. Angle Orthod. ;:.. Konik M, ncherz H, Hnsen K. The mechnism of Clss II correction in lte Herbst tretment. Am J Orthod Dentofcil Orthop. ;:.. Woodside DG, Altun G, Hrvold E, Herbert M, Metxs A. rimte experiments in mlocclusion nd bone induction. Am J Orthod Dentofcil Orthop. ;:0.. ncherz H. The mechnism of Clss II correction in Herbst pplince tretment. Am J Orthod Dentofcil Orthop. ;:.. Schweitzer M, ncherz H. The incisor-lip reltionship in Herbst/ multibrcket pplince tretment of Clss II division mlocclusions. Angle Orthod. 00;:.. De Clerck H, Timmermn H. Effect of hedger ctivtor tretment nd of mndibulr dvncement osteotomy on profile convexity. Rev Belge Med Dent. ;:.