Evaluation of Effects of Bimaxillary Anchored Fixed Functional Appliance on Temporomandibular Joint and Maxillomandibular Complex in Late Adolescents: An MRI Study

Abstract

Objective

To evaluate and assess changes in temporomandibular joint (TMJ), dental, skeletal and soft tissue changes following bimaxillary anchored fixed functional appliance (FFA) treatment of skeletal Class II malocclusion using Magnetic Resonance Imaging.

Methods

The prospective single-arm clinical trial included 15 patients (8 males, 7 females; mean age 15.71 + 1.81years) with Class II Division 1 malocclusion treated with bimaxillary anchored Forsus FRD. Four miniplates were placed bilaterally in maxilla and mandible. Then Forsus FRD L pin module was attached to miniplates without levelling of the arches. Pre-treatment (T1) and post-functional (T2) lateral cephalograms and MRI of TMJ were recorded. A total of 7 parameters were used to assess TMJ in all the 3 planes using MRI. Student’s t-test was carried out to compare pre- and post-treatment-induced changes.

Results

The mandible significantly moved forward (SNB, 3.71 + 0.91°; SND, 3.21 + 1.25°; Pg-OLp, 2.61 + 0.66 mm, p < 0.001) and there was distalizing effect on maxilla (SNA, –0.79 + 0.89°; A-OLp, –0.57 + 0.47mm, <0.001). Mean overjet correction of 4.43mm was achieved, of which 71.8% were skeletal changes. 65% of skeletal changes contributed to molar relationship correction. The forward positioning of mandible seems to be because of condylar and glenoid fossa remodelling, with condyle moving in anterior position within glenoid fossa (3.28 + 2.29) and articular disc moved posteriorly relative to condylar head (2.27 + 1.62°).

Conclusion

Significant skeletal changes and TMJ remodelling were observed with bimaxillary anchored FFA in correcting skeletal Class II malocclusion.

Keywords

Orthodontia Orthodontic orthodontic care orthodontic treatment

Introduction

Skeletal Class II malocclusion is often characterized by maxillary protrusion, mandibular retrusion, or their combination alongside abnormal dental relationships and soft tissue profile discrepancy.¹ Skeletal Class II due to a retrognathic mandible warrants correction through growth modification by removable or fixed functional appliances (FFAs) in growing individuals. Previous research by Koretsi et al.² and Zymperdikas et al.³ have determined that the correction obtained with these appliances is predominantly dentoalveolar and less skeletal, thus affecting the stability of the results.

With the expanded utilization of skeletal anchorage devices in orthodontics, miniscrews and miniplates have been used previously in conjunction with FFAs with different designs to control the unwanted effects.^4–6 However, these designs limited the use of miniplates only on mandibular symphysis and failed to provide substantial evidence to prove the superior skeletal effects attained.^{7, 8} A recent systematic review⁹ also concluded that FFA supported by bi-maxillary anchorage failed to control the proclination of mandibular incisors.

Therefore, it was hypothesized in the present study that anchorage support from both mandible and maxilla would lead to better anchorage control and greater skeletal effects. Since the orthopedic forces applied by functional appliances affect not only the dentition but also the position of mandibular condyle within the glenoid fossa, TMJ remodeling was investigated.

Furthermore, no MRI study has previously attempted to assess the TMJ adaptation following skeletally anchored FFA therapy. Therefore, this study was aimed to evaluate the preliminary changes in TMJ complex and also assess dental, skeletal, and soft tissue changes in the maxillomandibular complex brought about by treatment with bimaxillary anchored FFA.

Material and Methods

The study protocol was approved by the institutional Ethical Committee and is registered under the Clinical Trial Registry. Informed consent was obtained from parents of all subjects at the start of the study.

The prospective single-arm clinical trial was conducted in the Department of Orthodontics and Dentofacial Orthopedics.

Sample Selection

The sample size was calculated based on a significance level of 0.05 and a power of 80%. The power of the study determined that a sample of 13 subjects was required to detect a clinically significant increase in mandibular length with a standard deviation of 0.94 mm and an effect size of 0.7.⁵ A final sample of 15 subjects (8 males, 7 females; 15.71 ± 1.81years) was selected among the patients who reported to the department OPD.

The inclusion criteria were (a) skeletal Class II with SNB <78° and SNA = 80°–82°; (b) convex profile giving a positive clinical visual treatment objective (VTO); (c) CVMI stage 4 and 5 (assessed by CVM method using lateral cephalogram¹⁰); (d) horizontal or average growth pattern; (e) bilateral Class II/ end-on molar relation; (f) no previous orthodontic treatment; and (g) no clinical signs or symptoms of TMJ disorder. The exclusion criteria were (a) history of TMJ trauma; (b) signs of periodontal disease and (c) systemic disease affecting bone metabolism.

Appliance Design

Four “T”-shaped miniplates (S. K. Surgicals Pune, Maharashtra, India) were used as the anchorage plates in maxilla and mandible. For the insertion of Forsus-FRD (3 M Unitek, Monrovia, California, USA) appliance, a headgear tube (0.045 inch) was soldered on the head of S.S. screw (Figure 1a). This screw with the soldered headgear tube was tightened on the last hole of maxillary miniplate with a bolt, such that this screw should come at the level of middle third of the buccal surface of maxillary first molar once the miniplate is fixed on the zygomatic buttress (Figure 1b).

Figure 1.

(A) Screw with Soldered Headgear Tube. (B,C) Maxillary and Mandibular Miniplates. (D-F) Intra-oral Photographs with the Forsus FRD.

Methodology

A standardized lateral cephalogram in natural head position and MRI of TMJ with TMJ surface coil for simultaneous imaging of left and right joints were recorded for all the subjects before starting the treatment (T1). MRI scans were taken with patient’s head at right angle to the MRI table. All the surgical procedures were performed by a maxillofacial surgeon under local anesthesia. In the maxilla, two plates were fixed using three 2 × 6 mm screws on right and left zygomatic buttress. Two miniplates were fixed in the region of mandibular canine and premolar bilaterally with three screws (2 × 8 mm). During the surgical procedure, the patient was asked to bite in centric occlusion, and distance was measured from the distal of the headgear tube to distal of the mandibular canine, using the measurement gauge to determine the length of pushrod to be used. A mark was made with a surgical marker to locate the position of the mandibular miniplate during surgery. The miniplates were loaded after 3 weeks of the surgery. The Forsus FRD, L pin module was inserted in the headgear tube attached to the maxillary plate and the mesial hook of pushrod was placed inside the circular hole of the mandibular miniplate (Figure 1 d–f).

The leveling and alignment of the arches was not done before the functional phase, as the Forsus was directly attached to the miniplates. The subjects were observed at an interval of 4 weeks and the appliance was activated by using split crimps (1.5 mm of activation) if required.

The appliance was removed after overcorrected Class I molar and canine relationship was achieved. Standardized lateral cephalogram and MRI-TMJ were recorded (T2) following the pre-treatment protocol. The mean duration of the functional phase was 8.5 + 1.4 months. The same maxillofacial surgeon removed the miniplates under local anesthesia and teeth were bonded with 0.022-inch slot pre-adjusted fixed appliances.

Cephalometric Analysis

Standardized lateral cephalograms of all the subjects were evaluated using modified Pancherz analysis¹¹ to assess the skeletal and dental changes by superimposing the tracings (at T1 and T2) on the T-FMN line, with T point as the registration point. Apart from this, variables assessing soft-tissue, incisor inclination, and skeletal divergence were additionally added (Table 1).

Table 1.

Parameters Used to Evaluate Treatment Changes.

S. No.	Parameter	Description
Cephalometric Parameters
1	Overjet	The linear distance between points “is” and “ii.”
2	Molar relationship	The linear distance between points ms and mi (a positive value indicates a distal relationship; a negative value indicates a mesial relationship).
3	Position of maxillary base (mm)	The linear distance of A point from OLp.
4	Position of mandibular base (mm)	The linear distance of point Pog from OLp.
5	Position of condylar head (mm)	The linear distance of point Co from OLp.
6	Composite mandibular length (mm)	Total distance of point Pog from OLp and point Co from OLp.
7	Position of maxillary central incisor within maxilla (mm)	The linear distance of point “is” from A point.
8	Position of mandibular central incisor within mandible (mm)	The linear distance of point “ii” from Pog.
9	Position of maxillary first molar within maxilla (mm)	The linear distance between point ms and A point.
10	Position of mandibular first molar within mandible (mm)	The linear distance between point mi and point Pog.
11	Mandibular ramus length (mm)	The linear distance between Co and Go.
12	Mandibular body length (mm)	The linear distance between Go and Pog.
13	SNA (°)	The angle between the points S, N, and A.
14	SNB (°)	The angle between the points S, N, and B.
15	SND (°)	The angle between the points S, N, and D.
16	ANB (°)	The angle between three landmarks: A, N, B.
17	FMA (°)	The angle between FHP (Frankfort horizontal plane) and the mandibular plane.
18	IMPA (°)	The angle between long axis of lower incisor and the mandibular plane.
19	U1 to SN (°)	The angle between long axis of upper incisor and the Sella-Nasion (SN) plane.
20	Z angle (°)	The angle formed by intersection of true horizontal and a line connecting soft tissue Pog and the most protrusive lip point.
21	Upper lip to E line (mm)	The linear distance between most prominent point on upper lip and E line.
22	Lower lip to E line (mm)	The linear distance between most prominent point on lower lip and E line.
MRI Parameters
23	Joint Space Index (JSI)	JSI = [(P – A) / (P + A)] × 100, Where A is narrowest anterior interarticular joint space and P is the narrowest posterior interarticular joint space. The physiologic range for the condylar position, as described by Vargas-Pereira,²⁸ is an index value of 21.1 to (–32.5). A positive value indicates an anterior condylar displacement, a negative value indicates a posterior condylar displacement, and a zero value is referred to as “concentric.”
24	Eminence angle	One tangent is drawn to the most convex point of the articular eminence. The deepest point of the mandibular fossa is connected to the most convex point of the articular eminence. The angle formed by the intersection line (eminence and fossa) and the line tangent to the eminence is the articular eminence angle. Katsavrias has suggested that its value for adults should vary from 30° to 60°.²⁹
25	Glenoid Fossa angle	The angle between the tangents to the most prominent point on anterior and posterior slopes of the glenoid fossa.
26	Condylar width and height	Condyle is defined by a tangent to the posterior border of the condylar neck (Y-axis) and a line is drawn perpendicular to this condyle tangent through the broadest point of the condyle (X-axis). Condylar height is measured from the top of the condyle to the midpoint on the X-axis. Condylar width is measured as the distance between the anterior and posterior surface of the condylar head along the X-axis.
27	Sagittal disc position	The angle between 12 o’clock position and the posterior band of the articular disk. The normal range for this angle as described by Silverstein et al.³⁰ is 18.78 to –25.78 (Ideal value –3.58). A positive value indicates an anterior disc position, whereas a negative value indicates a posterior disc position.
28	Linear displacement of the condyle, glenoid fossa, articular eminence & post glenoid spine	The C-EAM is defined by the intersection of two lines, one along the maximum length, and other along the maximum width of EAM. A perpendicular is drawn from the transferred Frankfurt Horizontal plane (FHP), passing through the C-EAM. Thereafter, four points are marked, one at the most superior point in the glenoid fossa (C-GF), the other at the center of the condylar head (C-CH), the third point is marked on the most inferior point of the articular eminence (C-AE), and the fourth point is marked at the tip of post glenoid spine (PGS). The shortest distance of the C-CH, C-GF, C-AE, and PGS from the C-EAM is calculated.
29	Coronal Disc Position	The coronal disc position was evaluated by constructing a transverse coronal axis (a) of the condyle, which is the longest mediolateral distance of condyle. Then, line (b) is drawn perpendicular to “a” and tangential to the condylar head on both mesial and distal sides. Line (c) is drawn parallel to “b” and tangential to the most prominent points on the mesial and distal surface of the disc. Then, distance e’ is measured between “b” and “c” at the lateral aspect of the joint. The distance “f” is measured between “b” and “c” at the medial aspect of the joint. If e’ = f’, then disc is not displaced e’> f’, then disc is laterally displacede’ < f’, then disc is medially displaced.

MRI Evaluation

MRI scans of TMJ were recorded with an H Txt VOLMER 3 Tesla (GE, USA) scanner. The images were obtained in maximum intercuspation (closed mouth) and open mouth positions. The MRI protocol included T1 (TR560/TE12.1/FoV 160 × 160 mm) and T2 (TR3000/TE105.9/FoV 160 × 160 mm) weighted spin-echo sequences in coronal, sagittal, and axial planes of 3 mm slice thickness with no interslice gap. Both right and left TMJ were evaluated. All the measurements were done using RadiAnt DICOM viewer 2020.1 software and those sections were chosen that displayed the maximum width of the condyle. The parameters used to evaluate treatment changes are summarized in Table 1 (Figure 2).

Figure 2.

Skeletal and Dental Changes Assessed by Modified Pancherz Analysis.

Statistical Analysis

Data analysis was done using IBM SPSS Version 16.0. Quantitative data were expressed as means and standard deviations, while qualitative data were expressed as percentages. Normality of the data was checked by using the Shapiro–Wilk test. Change in the quantitative parameters was assessed for significance using the paired t-test. The analysis of coronal disc position was done using the chi-square test. A p value of <.05 was considered to be significant. All the measurements were repeated twice by the same observer and a second observer after an interval of 1 month, and correlation coefficient values of 0.88–0.92 for intra-rater and 0.91–0.95 for inter-rater reliability were calculated.

Results

Out of 15 subjects, one was excluded due to infection in right mandibular miniplate, accounting for a final sample size of 14 subjects (7 males and 7 females).

Cephalometric Evaluation

Treatment changes of cephalometric measurements, as assessed by paired t-test, are shown in Table 2. The maxillary measurements (SNA, –0.79 + 0.89°; A-OLp, –0.57 + 0.47 mm) exhibited a statistically significant backward movement of maxilla, whereas mandible (SNB, 3.71 + 0.91°; SND, 3.21 + 1.25°; Pg-OLp, 2.61 + 0.66 mm) significantly moved forward. Intermaxillary sagittal relationship improved significantly due to changes in both maxilla and mandible. Also, a significant increase was observed in FMA (0.57 + 0.65°). The angular measurements of upper and lower incisors did not show any significant change, while linear measurements showed a significant backward movement. Facial convexity improved was demonstrated by a change in Z angle (3.57 + 0.76°).

Table 2.

Cephalometric Changes After Bimaxillary Anchored FFA Therapy Assessed by Paired t-test (N = 14).

Variables	Pre-treatment (T1)Mean (SD)	Post-treatment (T2)Mean (SD)	Treatment Changes (T2–T1)Mean (SD)	p
Overjet (mm)	10.89 (2.08)	6.46 (2.37)	–4.43 (1.57)	<.001
Molar relationship (mm)	3.07 (1.00)	–1.82 (1.05)	–4.89 (0.66)	<.001
Maxillary base (mm)	67.0 (5.80)	66.43 (5.7)	–0.57 (0.47)	<.001
Mandibular base (mm)	67.57 (5.47)	70.18 (5.69)	2.61 (0.66)	<.001
Condylar head (mm)	11.89 (2.79)	11.43 (3.23)	–0.46 (1.05)	.121
Composite mandibular length (mm)	79.46 (5.21)	81.61 (5.78)	2.14 (1.13)	.002
Maxillary central incisor within maxilla (mm)	11.57 (2.93)	10.29 (2.82)	–1.28 (0.97)	<.001
Mandibular central incisor within mandible (mm)	1.71 (2.84)	1.68 (2.64)	–0.03 (1.31)	.92
Maxillary first molar within maxilla (mm)	–19.0 (3.17)	–19.68 (3.14)	–0.68 (0.37)	.001
Mandibular first molar within mandible (mm)	–21.71 (1.67)	–20.68 (1.77)	1.03 (0.97)	<.001
Mandibular ramus length (mm)	49.86 (5.42)	50.57(5.45)	0.71 (0.47)	<.001
Mandibular body length (mm)	64.93 (5.69)	65.57 (5.64)	0.64 (0.50)	<.001
SNA (°)	81.50 (1.40)	80.71 (1.86)	–0.79 (0.89)	.006
SNB (°)	74.29 (1.77)	78.00 (1.78)	3.71 (0.91)	<.001
SND (°)	72.21 (2.19)	75.43 (2.10)	3.21 (1.25)	<.001
ANB (°)	7.21 (1.37)	2.71 (1.68)	–4.50 (1.09)	<.001
FMA (°)	23.57 (4.72)	24.14 (5.00)	0.57 (0.65)	.006
IMPA (°)	98.64 (5.29)	97.93 (5.04)	–0.71 (2.13)	.231
U1 to SN (°)	117.43 (9.03)	116.50 (8.87)	–0.93 (1.86)	.084
Z angle (°)	64.64 (6.29)	68.21 (6.02)	3.57 (0.76)	<.001
Upper lip to E line (mm)	–0.57 (2.31)	–0.28 (2.19)	0.29 (0.83)	.218
Lower lip to E line (mm)	–1.07 (3.73)	–0.28 (2.39)	0.79 (1.72)	.110

Notes: N: Number of subjects; SD: Standard deviation.

p < .05, significant; p > .05, nonsignificant. Bold values are depicting statistically significant values.

The schematic diagram of maxillary and mandibular skeletal and dental changes assessed by modified Pancherz analysis is displayed in Figure 3. The mean overjet correction was 4.43 + 1.57 mm with a contribution of 71.8% skeletal changes and 28.2% dental changes. The molar relation changed from Class II to Class I, showing correction of 4.89 + 0.66 mm of which 65% was by skeletal changes and remaining 35% was by dental changes. The pre-treatment and post-functional photographs of the patient are depicted in Figure 4.

Figure 3.

Parameters Used for MRI Evaluation.

Figure 4.

Pre-treatment and Post-functional Photographs of a Patient.

MRI Evaluation

An initial comparison of right and left TMJs at T1 was done by independent t-test (Table 3). All the parameters showed statistically nonsignificant differences (p > .05) between both the joints except for position of glenoid fossa, articular eminence, condylar width and height in coronal section, and condylar height in the axial section (p < .05). Treatment changes in TMJ are shown in Table 4. All the joints showed a statistically significant increase in Joint Space Index (JSI) (3.28 + 2.29), indicating an anterior shift of the condylar position in the glenoid fossa. The significant decrease in posterior band angle (2.27 + 1.62°) indicated a backward movement of the articular disc. A significant forward displacement of the center of condyle, glenoid fossa, and the tip of post glenoid spine was observed. Eminence angle and glenoid fossa angle did not show any significant changes. The condylar height in all three sections exhibited a significant increase, whereas condylar width showed a significant increase in the coronal section of the right joint and axial section of right and left joints. After end of the functional phase T2, coronal disc position did not change relative to the condylar head (Table 5).

Table 3.

Comparison of Right and Left Temporomandibular Joints at Pre-treatment (T1) Assessed by Independent t-test (N = 14).

Variables	Pre-treatment (T1) Right Mean (SD)	Pre-treatment (T1) Left Mean (SD)	Difference of Right and Left Mean (SD)	p
Joint space index (%)	1.1 (3.89)	0.99 (3.93)	0.10 (0.69)	.59
Eminence angle (°)	42.27 (3.4)	42.25 (3.67)	0.01 (0.64)	.93
Glenoid fossa angle (°)	55.01 (5.84)	54.57 (6.34)	0.44 (1.19)	.19
Condylar sagittal width (mm)	10.97 (1.91)	10.95 (1.94)	0.02 (0.08)	.34
Condylar sagittal height (mm)	4.74 (0.81)	4.74 (0.81)	0.00 (0.0)	.34
Sagittal disc position (°)	3.20 (4.50)	3.24 (4.49)	–0.04 (0.16)	.34
Linear displacement of condyle (mm)	14.18 (1.64)	14.41 (1.52)	–0.23 (0.71)	.25
Linear displacement of glenoid fossa (mm)	15.10 (1.62)	15.63 (1.79)	–0.53 (0.53)	.00
Linear displacement of articular eminence (mm)	24.99 (2.51)	25.75 (2.69)	0.76 (0.36)	.00
Linear displacement of post glenoid spine (mm)	4.50(1.11)	4.48(1.13)	0.02 (0.16)	.74
Condylar coronal width (mm)	22.10 (1.9)	22.61 (2.04)	–0.51 (1.05)	.09
Condylar coronal height (mm)	6.98 (0.82)	7.34 (0.92)	–0.36 (0.65)	.06
Condylar axial width (mm)	17.27 (1.04)	17.60 (1.4)	–0.33 (0.98)	.23
Condylar axial height (mm)	3.06 (0.5)	3.44 (0.66)	–0.38 (0.59)	.03

Note: p < .05, significant; p > .05, nonsignificant. Bold values are depicting statistically significant values.

Table 4.

Treatment Changes in Temporomandibular Joint After Functional Therapy Assessed by Paired t-test (N = 14).

Variables	Pre-treatment (T1) Mean (SD)	Post-treatment (T2) Mean (SD)	Treatment Changes (T2–T1) Mean (SD)	p
	Joint Space Index (%)
Right	1.1 (3.89)	4.24 (3.6)	3.14 (2.16)	<.001
Left	0.99 (3.93)	4.41 (3.84)	3.42 (2.45)	<.001
Total	1.05 (3.77)	4.33 (3.59)	3.28 (2.29)	.002
	Eminence angle (°)
Right	42.27 (3.4)	42.4 (3.85)	0.13 (1.40)	.745
Left	42.25 (3.67)	42.22 (3.78)	–0.03 (1.55)	.946
Total	42.26 (3.42)	42.31 (3.68)	0.05 (1.45)	.959
	Glenoid Fossa angle (°)
Right	55.01 (5.84)	54.92 (5.13)	–0.09 (1.85)	.870
Left	54.57 (6.34)	54.62 (5.58)	0.06 (1.88)	.911
Total	54.79 (5.88)	54.78 (5.17)	–0.01 (1.84)	.992
	Condylar sagittal width (mm)
Right	10.97 (1.91)	11.37 (2.15)	0.40 (0.88)	.124
Left	10.95 (1.94)	11.47 (2.19)	0.52 (0.96)	.065
Total	10.96 (1.86)	11.42 (2.09)	0.46 (0.91)	.398
	Condylar sagittal height (mm)
Right	4.74 (0.81)	5.27 (1.01)	0.54 (0.58)	.005
Left	4.74 (0.81)	5.30 (0.97)	0.57 (0.58)	.003
Total	4.74 (0.78)	5.29 (0.96)	0.55 (0.57)	.025
	Sagittal disc position (°)
Right	3.20 (4.50)	0.93 (4.09)	–2.26 (1.67)	<.001
Left	3.24 (4.49)	0.97 (4.25)	–2.27 (1.63)	<.001
Total	3.22 (4.34)	0.95 (4.02)	–2.27 (1.62)	.049
	Linear displacement of Condyle (mm)
Right	14.18 (1.64)	15.44 (1.54)	1.26 (0.33)	<.001
Left	14.41 (1.52)	15.36 (1.40)	0.95 (0.42)	<.001
Total	14.30 (1.53)	15.41 (1.42)	1.11 (0.34)	.008
	Linear displacement of glenoid Fossa (mm)
Right	15.10 (1.62)	16.09 (1.68)	0.99 (0.37)	<.001
Left	15.63 (1.79)	16.47 (1.71)	0.84 (0.56)	<.001
Total	15.37 (1.67)	16.28 (1.65)	0.91 (0.47)	.049
	Linear displacement of articular eminence (mm)
Right	24.99 (2.51)	25.71 (2.70)	0.72 (0.33)	<.001
Left	25.75 (2.69)	26.54 (2.75)	0.79 (0.40)	<.001
Total	25.37 (2.54)	26.13 (2.66)	0.76 (0.36)	.290
	Linear displacement of post Glenoid spine (mm)
Right	4.50 (1.11)	5.30 (1.08)	0.80 (0.32)	<.001
Left	4.48 (1.13)	5.32 (1.10)	0.84 (0.34)	<.001
Total	4.49 (1.08)	5.31 (1.05)	0.82 (0.32)	<.001
Condylar coronal width (mm)
Right	22.10 (1.90)	22.68 (1.78)	0.58 (0.64)	.006
Left	22.61 (2.04)	22.85 (2.10)	0.24 (0.80)	.279
Total	22.36 (1.92)	22.77 (1.88)	0.41 (0.73)	.431
Condylar coronal height (mm)
Right	6.98 (0.82)	8.31 (1.02)	1.34 (0.68)	<.001
Left	7.34 (0.92)	8.35 (1.02)	0.04 (0.57)	<.001
Total	7.16 (0.87)	8.34 (0.99)	0.69 (0.90)	<.001
Condylar axial width (mm)
Right	17.27 (1.04)	17.73 (1.08)	0.46 (0.38)	<.001
Left	17.60 (1.40)	17.92 (1.23)	0.32 (0.60)	.064
Total	17.44 (1.21)	17.83 (1.12)	0.39 (0.49)	.225
Condylar axial height (mm)
Right	3.06 (0.5)	3.54 (0.58)	0.47 (0.44)	.002
Left	3.44 (0.66)	3.64 (0.67)	0.19 (0.42)	.109
Total	3.26 (0.60)	3.59 (0.61)	0.33 (0.45)	.047

Note: p < .05, significant; p > .05, nonsignificant. Bold values are depicting statistically significant values.

Table 5.

Treatment Changes in Coronal Disc Position After Functional Therapy Assessed by Chi-square Test (N = 14).

	Pre-treatment (%)	Post-treatment (%)	p
Right
Central	7 (50.0%)	7 (50.0%)	1.000
Lateral	6 (42.9%)	6 (42.9%)
Medial	1 (7.1%)	1 (7.1%)
Left
Central	8 (57.1%)	8 (57.1%)	1.000
Lateral	6 (42.9%)	6 (42.9%)
Medial	0	0

Note: p < .05, significant; p > .05, nonsignificant.

Discussion

The correction of skeletal Class II arising due to mandibular retrognathism has been researched extensively over the past decades. The treatment modality varies depending on the age of the patient at the commencement of treatment. The present study aimed at skeletal correction in late adolescents using skeletal anchorage with FFA to limit the dentoalveolar side effects. The design of the appliance fabricated included the application of anchor support from both the jaws unlike the previous studies,^{5, 6, 12} which had used anchorage only from mandible. As the mandibular repositioning involved adaptive remodeling of condyle and glenoid fossa, MRI was conducted to evaluate and report changes in TMJ, in contrast to the previous studies¹³ based on 2D cephalogram.

The commencement of fixed functional therapy without levelling and alignment of the arches was beneficial for the late adolescent subjects nearing the completion of growth. An untreated control group was not included, as it is unethical to leave patients without treatment during late adolescence when favorable treatment effects are expected. In the present study, the included subjects are already in late adolescence, when most of the active growth of craniofacial skeleton is completed. Consequently, it will be highly unethical to leave these subjects without treatment, as it will prevent us from utilizing their residual growth. The only choice of treatment remaining will be a surgical correction of retrognathic mandible, after their growth completion.

Modified Pancherz analysis was used to assess skeletal and dental changes. It is considered as the most suitable method of superimposition in comparison to Ricketts and Bjork method.¹⁴

Maxillomandibular Complex Changes

The analysis revealed greater skeletal effects with bimaxillary anchored Forsus. Overjet showed a significant reduction of 4.43 mm. In agreement with previous studies,^{5, 6, 13} the overjet correction was a combination of skeletal (71.8%) and dental changes (28.2%). The molar relationship changed from Class II to Class I relation with 65% of skeletal changes and 35% were dental changes. Unal et al.⁵ have reported overjet correction with 74% skeletal changes by using only mandibular anchorage. The present study also displayed significant improvement in mandibular position (SNB, 3.71°) and length (2.14 mm), which is similar to the results shown by Kochar et al.,¹³ who also used bimaxillary anchorage with FFA. There was a clockwise rotation of mandible, which can be explained by the transmission of downward and forward forces of the Forsus appliance, directly to the symphyseal region of the mandible. The appliance had a distalizing force on maxilla (SNA, –0.8°), which is in accordance with the previous study¹³ using bimaxillary anchorage.

Regarding maxillary and mandibular incisor positions, no significant change was found after the bimaxillary anchored Forsus therapy. This shows that this modality was able to overcome the biggest disadvantage of the functional appliances, that is, proclination of the lower incisors. Meta-analysis has shown an increase of 7.99° in lower incisor inclination after FFA.³ While previous studies^{5, 6, 12, 15} using single jaw anchorage reported retroclination of upper and lower incisors, Elkordy et al.¹⁶ stated that retroclination of the upper incisors creates a lock, restricting the forward growth of the mandible and also applies pressure on the lower incisors resulting in their retroclination. Since the present study uses bimaxillary anchorage, minimal forces were acting on the maxillary dentition due to which there was insignificant change in maxillary incisors inclination, and hence, no change was seen in the inclination of the lower incisors.

The soft-tissue facial profile improved after the Forsus therapy. There was no change in the position of upper and lower lips. This can be attributed to the control in the incisor position, which directly affects soft tissue. Conventional Forsus has resulted in protrusion of lower lips due to flaring of lower incisors.¹⁵

TMJ Changes

The pre-treatment MRIs of a majority of subjects had positive JSI values indicating that condyle was anteriorly positioned within the fossa. After functional therapy, the condylar head shifted more anteriorly within the glenoid fossa with an increase in JSI. The condylar height increased in all three planes after the functional therapy. The right joint showed a significant increase in width in the coronal and axial planes, whereas in the sagittal plane, there was no change in the width. Similar findings were observed by Arici et al.¹⁷ and Elfeky et al.,¹⁸ who reported a small increase in condylar dimensions and volume 7–9 months post-functional therapy. These changes are suggestive of condylar growth taking place in the postero-superior direction. On the contrary, Ruf and Pancherz¹⁹ concluded that the condyle gets displaced in a forward direction during treatment but returns to its original position post-functional therapy.

The linear displacement was measured to find out whether the condyle-glenoid fossa complex did actually shift anteriorly from its pre-treatment position. In the present study, it was observed that the center of the condylar head was displaced anteriorly by 1.11 mm along the FH plane.

The center of the glenoid fossa and post glenoid spine also moved anteriorly, indicating a forward remodeling of the glenoid fossa post FFA therapy. These findings are in agreement with those of Kyburz et al.²⁰ and Gandedkar et al.²¹ In contrast to these observations, Kinzinger et al.²² found no significant differences in the glenoid fossa–condyle relationship before and after treatment.

The contrasting findings can be explained because of the difference in the type of functional appliances used. Furthermore, it has been suggested that semi-rigid FFA (Forsus) should be used for better condylar repositioning post-functional therapy.²⁰

The pre-treatment position of the articular disc was slightly anterior, as indicated by posterior band angle of 3.22°. The disc was displaced in a posterior direction relative to the head of the condyle after FFA therapy. This posterior displacement of the disc is because of the pull from retrodiscal tissues as stated by Voudoris.²³ The position of the disc did not change with the functional therapy in the coronal section. These findings are similar to those of Kinzinger et al.²⁴ who reported that the disc shifted posteriorly after appliance insertion and moved to its original position after removal.

The eminence angle and glenoid fossa angle did not show any changes after the treatment, which is in accordance with previous studies.^{25, 26} However, the annual increase in the eminence inclination is only 1.25°/year²⁷; the functional duration of 8 months may not be sufficient to detect such minor changes.

The greater skeletal effects achieved in the present study can be attributed to the use of anchorage directly from both the jaws. With this modality, we can “jumpstart” with the functional phase, without waiting for levelling and alignment of the arches, and thus, harnessing the growth potential of the late adolescent subjects. Since this treatment modality was successful in correcting Class II in late adolescents and TMJ was capable of growth adaptation, hence, this method helps to evade orthognathic surgery, which remains the only choice of treatment in subjects who are at the end of their growth period.

The limitations of the study are that the findings are based on short-term observations and there was a need for two surgical procedures, for miniplate insertion and removal, making this method invasive in comparison to conventional functional therapy.

Conclusion

The forward positioning of mandible accomplished by the bimaxillary anchored FFA was a result of condylar and glenoid fossa remodeling.

The height of the condylar head increased significantly in all three planes and condylar width showed a significant increase in the axial and coronal planes.

The condyle shifted anteriorly within the glenoid fossa with forward displacement of both the center of the fossa and post glenoid spine.

The articular disc shifted posteriorly in the sagittal plane, whereas coronal disc position remained unchanged.

About 71.8% of overjet reduction and 65% of molar correction was due to skeletal changes, and inclination of lower incisors was maintained.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethical Approval and Informed Consent

The study protocol was approved by the institutional Ethical Committee and is registered under the Clinical Trial Registry (CTRI/2020/01/022858). Informed consent was obtained from parents of all subjects at the start of the study. Trial Registration: CTRI, CTRI/2020/01/022858, Registered 20 January 2020, http://ctri.nic.in/Clinicaltrials/rmaindet.php?trialid=39369&EncHid=70842.68512&modid=1&compid=19

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Scope

This study could not integrate functional and fixed phases, as MRI was required post-functional therapy. However, further studies can prove to be beneficial by combining both the phases, subsequently reducing the treatment duration. Additionally, future studies with long-term follow-ups and a larger sample size are required to determine the stability of the results achieved in the present study.

ORCID iD

Anshika Gandhi

References

McNamara

JA.

Components of Class II malocclusion in children 8–10 years of age. Angle Orthod . 1981;51(3):177–202.

Koretsi

, Zymperdikas

, Papageorgiou

, Papadopoulos

MA.

Treatment effects of removable functional appliances in patients with Class II malocclusion: A systematic review and meta-analysis. EORTHO . 2015;37(4):418–434. Doi:10.1093/ejo/cju07

Zymperdikas

, Koretsi

, Papageorgiou

, Papadopoulos

MA.

Treatment effects of fixed functional appliances in patients with Class II malocclusion: A systematic review and meta-analysis. EORTHO . 2016;38(2):113–126. Doi:10.1093/ejo/cjv03

Eissa

, El-Shennawy

, Gaballah

, El-Meehy

, El Bialy

Treatment outcomes of Class II malocclusion cases treated with miniscrew-anchored Forsus Fatigue Resistant Device: A randomized controlled trial. Angle Orthod . 2017;87(6):824–833. Doi:10.2319/032717-214

Unal

, Celikoglu

, Candirli

Evaluation of the effects of skeletal anchoraged Forsus FRD using miniplates inserted on mandibular symphysis: A new approach for the treatment of Class II malocclusion. Angle Orthod . 2015;85(3):413–419. Doi:10.2319/051314-345

Elkordy

, Abouelezz

, Fayed

MMS

, Aboulfotouh

, Mostafa

YA.

Evaluation of the miniplate-anchored Forsus Fatigue Resistant Device in skeletal Class II growing subjects: A randomized controlled trial. Angle Orthod . 2019;89(3):391–403. Doi:10.2319/062018-468

Elkordy

, Aboelnaga

, Fayed

MMS

, AboulFotouh

, Abouelezz

AM.

Can the use of skeletal anchors in conjunction with fixed functional appliances promote skeletal changes? A systematic review and meta-analysis. Eur J Orthod . 2016;38(5):532–545. Doi:10.1093/ejo/cjv08

Arvind

TRP

, Kumar Jain

Skeletally-anchored forsus fatigue resistant device for correction of Class II malocclusions: A systematic review and meta-analysis. Orthod Craniofac Res . August 8, 2020:ocr.12414. Doi:10.1111/ocr.1241

Alhammadi

, Qasem

AAA

, Yamani

AMS

, . Skeletal and dentoalveolar effects of Class II malocclusion treatment using bi-maxillary skeletal anchorage: A systematic review. BMC Oral Health . 2022;22:339. Doi:10.1186/s12903-022-02363

10.

Baccetti

, Franchi

, McNamara

JA.

The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod . 2005;11(3):119–129. Doi:10.1053/j.sodo.2005.04.00

11.

Pancherz

A cephalometric analysis of skeletal and dental changes contributing to Class II correction in activator treatment. Am J Orthod . 1984;85(2):125–134. Doi:10.1016/0002-9416(84)90004

12.

Celikoglu

, Buyuk

, Ekizer

, Unal

Treatment effects of skeletally anchored Forsus FRD EZ and Herbst appliances: A retrospective clinical study. Angle Orthod . 2016;86(2):306–314. Doi:10.2319/040315-225

13.

Kochar

, Londhe

, Shivpuri

, Chopra

, Mitra

, Verma

Management of skeletal Class II malocclusion using bimaxillary skeletal anchorage supported fixed functional appliances. J Orofac Orthop . 2021;82(1):42–53. Doi:10.1007/s00056-020-00239

14.

You

, Hägg

A comparison of three superimposition methods. Eur J Orthod . 1999;21(6):717–725. Doi:10.1093/ejo/21.6.71

15.

Turkkahraman

, Eliacik

, Findik

Effects of miniplate anchored and conventional Forsus Fatigue Resistant Devices in the treatment of Class II malocclusion. Angle Orthod . 2016;86(6):1026–1032. Doi:10.2319/122515-887

16.

Elkordy

, Abouelezz

, Salah Fayed

, Attia

, Rahman Ishaq

, Mostafa

YA.

Three-dimensional effects of the mini-implant–anchored Forsus Fatigue Resistant Device: A randomized controlled trial. Angle Orthod . 2016;86(2):292–305. Doi:10.2319/012515-55

17.

Arici

, Akan

, Yakubov

, Arici

Effects of fixed functional appliance treatment on the temporomandibular joint. Am J Orthod Dentofac Orthop . 2008;133(6):809–814. Doi:10.1016/j.ajodo.2006.07.03

18.

Elfeky

, Fayed

, Alhammadi

, Soliman

SAZ

, El Boghdadi

DM.

Three-dimensional skeletal, dentoalveolar and temporomandibular joint changes produced by twin block functional appliance. J Orofac Orthop . 2018;79(4):245–258. Doi:10.1007/s00056-018-0137

19.

Ruf

, Pancherz

Temporomandibular joint remodeling in adolescents and young adults during Herbst treatment: A prospective longitudinal magnetic resonance imaging and cephalometric radiographic investigation. Am J Orthod Dentofac Orthop . 1999;115(6):607–618. Doi:10.1016/S0889-5406(99)70285

20.

Kyburz

, Eliades

, Papageorgiou

SN.

What effect does functional appliance treatment have on the temporomandibular joint? A systematic review with meta-analysis. Prog Orthod . 2019;20(1):32. Doi:10.1186/s40510-019-0286

21.

Gandedkar

, Shrikantaiah

, Patil

, . Influence of conventional and skeletal anchorage system supported fixed functional appliance on maxillo-mandibular complex and temporomandibular joint: A preliminary comparative cone beam computed tomography study. Int Orthod . 2019;17(2):256–268. Doi:10.1016/j.ortho.2019.03.00

22.

Kinzinger

, Roth

, Gülden

, Bücker

, Diedrich

Effects of orthodontic treatment with fixed functional orthopaedic appliances on the disc-condyle relationship in the temporomandibular joint: A magnetic resonance imaging study (Part II). Dentomaxillofac Radiol . 2006;35(5):347–356. Doi:10.1259/dmfr/7097258

23.

Voudouris

, Kuftinec

MM.

Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: Growth relativity. Am J Orthod Dentofac Orthop . 2000;117(3):247–266. Doi:10.1016/S0889-5406(00)70231

24.

Kinzinger

, Gülden

, Roth

, Diedrich

Disc-condyle relationships during Class II treatment with the functional mandibular advancer (FMA). J Orofac Orthop . 2006;67(5):356–375. Doi:10.1007/s00056-006-0626

25.

Wadhawan

, Kumar

, Kharbanda

, Duggal

, Sharma

Temporomandibular joint adaptations following two-phase therapy: An MRI study. Orthod Craniofac Res . 2008;11(4):235–250. Doi:10.1111/j.1601-6343.2008.00436

26.

Chintakanon

, Sampson

, Wilkinson

, Townsend

A prospective study of Twin-block appliance therapy assessed by magnetic resonance imaging. Am J Orthod Dentofac Orthop . 2000;118(5):494–504. Doi:10.1067/mod.2000.10983

27.

Katsavrias

EG.

The effect of mandibular protrusive (activator) appliances on articular eminence morphology. Angle Orthod . 2003;73(6):7.

28.

Hansen

, Pancherz

, Petersson

Long-term effects of the Herbst appliance on the craniomandibular system with special reference to the TMJ. Eur J Orthod . 1990;12(3):244–253. Doi:10.1093/ejo/12.3.244

29.

Rabelo

, Sousa Melo

, Torres

MGG

, Campos

PSF

, Bento

, Melo

DP.

Condyle Excursion Angle, Articular Eminence Inclination, and Temporomandibular Joint Morphologic Relations With Disc Displacement. J Oral Maxillofac Surg . 2017;75(5):938.e1–938.e10. Doi:10.1016/j.joms.2017.01.019

30.

Silverstein

, Dunn

, Binder

, Maganzini

MRI assessment of the normal temporomandibular joint with the use of projective geometry. Oral Surg Oral Med Oral Pathol . 1994;77(5):523–530. Doi:10.1016/0030-4220(94)90236-4