Fixed Appliance Management of Class II Malocclusion SUS2 Corrector

Fixed Appliance
Management of Class II
Malocclusion
SUS2 Corrector
©Dr Sylvain Chamberland 
©sylvainchamberland.com

Xbow appliance
•Sample of 69 consecutive cl II patients compared to  
30 historical cl II controls. Retrospective study.
•Xbow 4,5 months; T2 ceph : 6,5 months post Xbow removal
•Therefore, T2 measurement include relapse of most side effect
✦ Skeletal change:
✓ Diminution of Mx protrusion, without md advancement
✓ Increase vertical dimension compare to untreated control
Flores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental eﬀects of the Xbow appliance as measured on lateral
cephalograms. AJODO; 2009;136(6):822-832.
Flores-Mir, AJODO 2009

Xbow appliance
✦ Dental change
✓ Overjet
‣ Correction by increase incisor proclination (IMPA ➚ 4,7° ± 4,1°)
‣ No mx incisor movement
✓ Molar relationship
‣ U6 distalize 0,9 ± 1,2 mm
‣ L6 mesialize 1,1 ± 1,3 mm
Flores-Mir C, Barnett G, Higgins DW, Heo G, and Major PW. Short-term skeletal and dental eﬀects of the Xbow appliance as measured on lateral
cephalograms. AJODO; 2009;136(6):822-832.
Flores-Mir, AJODO 2009

Xbow vs Forsus
•Sample of 38 consecutive xbow appliance tx compared to  
36 Forsus appliance tx. Retrospective study.
•T1 ceph at baseline. T2 ceph at the end of tx
•Both appliance generate the same amount of incisors inclination
•The older the patient, the more OJ and upper incisors inclination remain
•The longer the tx time, the more the lower incisors procline
•Total tx time for both appliance is about the same
Flores-Mir et al AO 2013
Miller, Robert A, Long Tieu, and Carlos Flores-Mir. "Incisor Inclination Changes Produced by Two Compliance-free Class II Correction Protocols for
the Treatment of Mild to Moderate Class II Malocclusions." Angle orthodontist 83, no. 3 (2013): doi:10.2319/062712-528.1.

Xbow appliance
•Sample of 25 consecutive cl II patients. Mean age 11,1 ± 1,1 y.
•Prospective study
•CBCT at T0 and after debonding Xbow (T1). Tx time 6,0 m (5,0-8,0)
•Skeletal effect
✦ Mild SNA decrease (0,67± 1,35°)
Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed
Tomography." Angle Orthod 2014; 84, no. 4: doi:10.2319/072213-533.1
Erbas, A0 2014

Xbow appliance
•Dental effect
✦ U1: Palatal tipping (-3,58± 3,56°)+ extrusion (1,72 ± 1,87 mm)
✦ U6: No signiﬁcant distal tipping or intrusion. Mesial mvt inhibited
✦ L1: Labial tipping (10,87± 4,91°)
✦ L6: Mesial mvt (2,07 ± 1,24 mm) + extrusion (1,52± 1,08 mm)
Erbas, Banu, and Ilken Kocadereli. "Upper Airway Changes After Xbow Appliance Therapy Evaluated with Cone Beam Computed
Tomography." Angle Orthod 2014; 84, no. 4:: doi:10.2319/072213-533.1
p< .001
p< .001
p< .001
Erbas, A0 2014

•♀, 12 a. 5 m.
•End of Xbow
•Lower incisor proclination is
obvious (+21°)
La.Sha 0807
La.Sha 0308

•Xbow undesirable side effect
relapsed
•Incisor proclination return to
normal
✦ Sometimes, we pray for relapse
La.Sha 0308. 5 month of Xbow

•Tx time 23 months
•Outcome
✦ 82 weeks into retention
La.Sha 22-03-11

Forsus vs Cl II elastic
•Sample of 30 consecutive patients, 23 treated with Forsus (13,4 y), 7 with cl II
elastics (14,3 y). Prospective.
•Ceph T0 after alignment, ceph T1 at removal of Forsus. Tx time 6 m.
•No difference in skeletal effect Mx or Md
•Dental effect
✦ Forsus:
✓ 1/FH retroclined. /1-MP proclined
✓ Signiﬁcant increase of occlusal plane to FH
Dubois A, Rompré P, Rodrigue C, Remise C, Comparaison des eﬀets sur la croissance des maxillaires de l’utilisation du Forsus versus
celle des élastiques de classe II, Thèse de maîtrise
Dubois, Master thesis U. MTL.

Forsus effectiveness
•Retrospective study, 32 consecutive patients (12,7± 1,2 y) matched to 27 historical
untreated controls (12,8 ± 1,3 y)
•Ceph T0 prior tx and Ceph T1 at completion of ortho therapy. Tx time 2,4 ± 0,4 y
✦ Mean duration of FRD active phase: 5,2 ± 1,3 m
✦ Successful cl II correction in 87,5% of the patients
✦ Greater skeletal effect on maxillary structures by restraining sagittal advancement
of the mx (SNA ➘ 1,6 ±1,4°)
✦ Effect on the mandible is mainly dentoalveolar: large amount of mesial mvt of L1
(6,1° ± 6,3°) and L6 (2,4 ± 1,6 mm), extrusion of L6 (3,6 ± 1,5 mm)
Franchi L, Lisa Alvetro, Veronica Giuntini, Caterina Masucci, Eﬁsio Defraia, and Tiziano Baccetti. "Eﬀectiveness of Comprehensive Fixed Appliance Treatment Used wi
Forsus Fatigue Resistant Device in Class II Patients." Angle orthodontist 2011; 81, no. 4: doi:10.2319/102710-629.1
Franchi, A0 2011

•Follow-up at 2,3 ± 1,1 y post comprehensive tx. 36 consecutive patients/
20 historical untreated controls. Retrospective study.
✦ Mean FRD duration 4,8 ± 2,4 m
✦ Outcome (retrospective study)
✓ T1-T2: Baseline to end of ortho
✓ T2-T3: End of ortho to end of retention
✓ T1-T3: Baseline to end of retention
Cacciatore, Giorgio, Luis Tomas Huanca Ghislanzoni, Lisa Alvetro, Veronica Giuntini, and Lorenzo Franchi. "Treatment and Posttreatment Eﬀects
Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist (2014):doi:10.2319/112613-867.1
Cacciatore, A0 2014

•Follow-up
✦ T1-T2 FRD vs untreated controls
✓ Significant skeletal effect on Mx (SNA ➘ 1,7 °)
✓ No significant effect on Md
✓ Significant improve of dental relationship
‣ OJ -5,1mm; OB -3,1 mm; molar relationship +3,5 mm
‣ U1 retruded 1,6 mm, L1 proclined 5,6°/ 1,5 mm.  
L6 extruded 1.3 mm. U6: no vertical change
Induced by the Forsus Appliance A Controlled Clinical Study." Angle orthodontist 2014 doi:10.2319/112613-867.1
Cacciatore, A0 2014

•Follow-up
✓ Significant greater increase in sagittal position of Mx (SNA ➚
1,4°)
✓ Significantly increase of both OJ (1,3 mm) and OB (1,5 mm)
✓ Significant intrusion of U1 (-1,2 mm)
Cacciatore, A0 2014

•Follow-up
✓ No significant sagittal or vertical skeletal change
✓ Significant reduction of OJ (-3,8 mm), OB (-1,5 mm)
✓ Significant improvement of molar relationship (+ 3,7 mm)
✓ Significant retrusion of U1 (-1,1 mm)
✓ Significant intrusion of L1 (-1,2 mm)
✓ Success rate of overall correction: 83,3%
Cacciatore, A0 2014

Fatigue Resistant Device
•29 subjects, prospective study, 15 prior growth peak; 14 post growth peak.
•Tx time 9 months. Ceph + MRI study
✦ Palatal tipping + extrusion of mx incisors
✦ Protrusion + intrusion + labial tipping (5,5° - 6°) of md incisors
✦ Distal tipping of Mx molars
✦ Mesial movement + mesial tipping of Md molars
✦ No change in disk position
Aras, Ada, Saracoglu, Gezer, and Aras. "Comparison of Treatments with the Forsus Fatigue Resistant Device in Relation to skeletal maturity: A
cephalometric and magnetic resonance imaging study. AJODO 2011; 140: 616-25: doi:10.1016/j.ajodo.2010.12.018.
Aras, AJODO 2011

•Class II div 1
•Constricted maxilla
•Tx time: 99 weeks
Gu.Ma. 0707
Gu.Ma. 0708
Gu.Ma.250811; 2 years out of ortho

•Side effects relapsed

Twin Force Bite Corrector
•Sample of 23 patients before Pubertal Growth Spurt compared to 18
patients post PGS. Retrospective study.
•Skeletal change
✦ Mx restriction SNA ➘ 1,22°
•Dental change
✦ IMPA increased 4,4° to 5,5°
Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with
Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1
Chhibber, A0 2013

Twin Force Bite Corrector
•At end of ortho
✦ No difference between skeletal and dental parameters of both
groups
✦ Signiﬁcant longer tx time for the youngest group (3,67 y vs 2,75 y)
✦ Tx efﬁciency is greater for the post pubertal group
Chhibber, Aditya, Madhur Upadhyay, Flavio Uribe, and Ravindra Nanda. "Mechanism of Class II Correction in Prepubertal and Postpubertal Patients with
Twin Force Bite Corrector." Angle Orthod. 2013; 83, n718-727: doi:10.2319/090412-709.1
Chhibber, A0 2013

SaAl180111
SaAl271009. male; 13y 10 m
SaAl151112, 16y 11 m

•Tx plan: exo 4s/5s
•Cl II correction device helped to maintain
anchorage while retracting U1 and
protracting L6

SUS2 vs Forsus FRD
•Sample: 20 SUS2
, 20 Forsus, 19 controls. All post pubertal (~15 y±1 y)
•Both appliances. Tx time 5 m ± 1 m. Prospective study.
✦ Dentoalveolar effect
✓ 1/: retrusion + extrusion
✓ /1: protrusion + intrusion
✦ No signiﬁcant skeletal effect on Mx and Md. No vertical change
✦ Soft tissue proﬁle improvement is limited
Oztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal
Spring. European journal of dentistry. 2012 Turkey;6(3):302-10
Oztoprak, Eur. J. Dent. 2012

SUS2 vs Forsus FRD
•However:
✦ Lower incisors proclination more prominent with Forsus FRD
✓ SUS2
: ∆IMPA= 5,78° ± 3,91°
✓ Forsus: ∆IMPA = 10,8° ± 3,07°
✦ N-A-Pg: better reduction in facial convexity with SUS2
✓ SUS2
: -2,13°± 2,85°
✓ Forsus: + 0,65° ± 3.04°
p < .001
p < .05
Oztoprak MO, Nalbantgil D, Uyanlar A, and Arun T. A cephalometric comparative study of class II correction with Sabbagh Universal
Spring. European journal of dentistry. 2012 Turkey;6(3):302-10
Oztoprak, Eur. J. Dent. 2012

Study Design
Experimental groups Observation Time Point
Sample size (>25) Untreated Controls T0 Baseline T1 Prior Cl II device T2 Post Cl II device T3 End of Ortho
T4 Follow-up
Flores-Mir AJODO
2009 R
✔ 69 ✔ 30 ✔ 6 m. post Xbow
Miller AO 2013 R ✔ 38/36 ✔ ✔
Erbas AO 2014 P ✔ 25 ✔ ✔
Dubois et al P ✔ 23 / 7 ✔ ✔
Franchi AO 2011 R ✔ 32 ✔ 27 ✔ ✔
Cacciatore AO In
press R
✔ 36 ✔ 20 ✔ ✔ ✔
Aras AJODO 2011 P ✔ 15 / 14 ✔ ✔
Chhibber AO 2013
R
✔ 23 / 18 ✔ ✔
Oztoprak EJD 2012
R
✔ 20 / 20 ✔ 19 ✔ ✔

Poor Study Design
•Study about Cl II correction device are not at the level of RCT.
•Evidences are below that level of conﬁdence
•Even meta-analysis should be interprete with caution
Giuseppe Perinetti, Jasmina Primožič, Giovanna Furlani, Lorenzo Franchi, and Luca Contardo (2014) Treatment effects of
ﬁxed functional appliances alone or in combination with multibracket appliances: A systematic review and meta-analysis.
The Angle Orthodontist In-Press.

SUS2 Telescope Element
Telescope rod with ring
Position for turbo
spring or spacer
Arch adaptor
Fixing screw
Middle telescope tube
Inner spring 2,4 N
Guide Tube
Hexagon socket
screw
Eye

Inner Spring
•At maximum activation
✦ Spring path of 6 mm
✦ 2,4 N at full compression
•Deactivation with hexagon screw
✦ Spring path 2,1 mm
✦ 1,0 N at full compression
Spring span
Front stop
Back stop
Spring span

Turbo Spring
•Place on the telescope element
✦ Force of 3,0 N
•Spacer of 1 or 2 mm
✦ If required for reactivation,
although seldom necessary

SPEED™ Convertible Tube
• For class II correction devices!
•Repeatably convertible
•Facilitate insertion and removal
of cinched back SS wire

SPEED™ Convertible Tube
•Tips for bonding
✦ Adapt meshpad on the model
✦ Microetch enamel
✦ Use light bond adhesive or 2 paste system
✓ Extra care should be taken to ensure sufﬁcient curing time

Tips for bonding
•Etch enamel 15s
•Wash, rince & dry
•Apply Assure sealant on the tooth & light cure
•Apply Assure sealant on the bracket base & light cure
•Wipe the bracket base into Assure paste
•Place on the tooth & light cure

•Large mesh pad needs slight adjustment to obtain best ﬁt on the
buccal surface
•Good adaptation of the mesh pad is warrant of good bond strength
✦ Left side is not as nicely bonded than the right side

SPEED™ 
Convertible Tube
•Cinching a 20 x 25 SS wire in the
gum and without debonding the
tube is challenging
•Convertible tube permits easy
cinching outside the mouth
•Insertion and removal of the SS
wire takes seconds and done
without fear of debonding

•Buccal offset of the L pin at 3-4 mm distal to the tube
✦ Longer extension may impinge over the bracket of the 7s
✦ The L ball-pin is bent gingivally or occlusally at the mesial
✓ After some trial and errors, I prefer occlusal bend of the L
pin

L Pin
•Inserted distally on the eye of the telescope
•Inserted distally into the head gear tube
•Buccal offset 3-4 mm long
•The pin is bent gingivally or occlusally at the mesial of the tube
✦ With bonded convertible head gear tube, I prefer to bend occlusally
•Distal buccal offset and mesial occlusal bend are at 90° each other

•SUS2 telescope is used without the outer turbo spring for the ﬁrst 6
weeks
AlLa110814

•SUS2 telescope is used without the outer turbo spring for the ﬁrst 6
weeks
•Turbo spring is added to maintain forward activation
AlLa110814
LaShMa080813
This is not the same case as above

•L pin bent occlusally
•SPEED™ convertible tube on lower molars for easier insertion

•Arch adaptor tightly screwed onto the arch wire distal to the offset
•Buccal offset of the archwire distal to the lower canines

•Class II div 1
•Deep overbite
LaShMa160712

•Class II skeletal relationship
✦ ANB 7°, ABOP = 4 mm
•Bimax protrusion
12y 0m

Tx plan
•Comprehensive tx + SUS2 cl II corrector device
•Alternative tx plan
✦ Comprehensive + Extractions 4s/5s

At 44 weeks
•SUS2 corrector engaged in june 2013 at 36 weeks
✦ .020 X .025 SS wire U & L
•Turbo spring added in august at 44 weeks
LaShMa080813

At 52 weeks
•E links from the molars to the canines
LaShMa021013

At 62 weeks
•SUS2 for 26 weeks
LaShMa121213

•Tx time = 105 weeks
•Class I relationship achieved
•White spot lesion: !!! poor oral hygiene despite several warning
MaLaSh270814

•/1 AP relationship
nicely controlled
•/1 intrusion obtained
•/6 eruption occurred

•Class II div 1
•Deep curve of Spee. deep overbite
EmEho121212

•Severe class II skeletal relationship
✦ ANB 6,4°; ABOP = 7.5 mm
•Hypodivergent
13y 6m

Tx plan
•Comprenhensive tx, RPE + Fixed cl II correctors
✦ Increase vertical dimension
•Alternate tx plan
✦ Comprehensive tx+ Orthognathic surgery (BSSO)

At 32 weeks
•SUS2 were engaged at 26 weeks
•32 weeks
✦ E links 6-3 to distallize the canines
EmEho190913

At 43 weeks
•SUS2 removal (breakage occurred)
•17 weeks of SUS2 cl II correctors
•17x25 TMA mushroom loop
EmEho021213

!
•At 71 weeks
✦ Rebond 16, 26. Mx: 20x20 niti. Cl II elastic nightime
•At 81 weeks
✦ Mx: 21x25TMA, CE
EmEho180614
EmEho170714EmEho260814

•Vertical dimension improved
•/1 proclined 19°
✦ Not only because of SUS2
but also to arch leveling
•1/ retroclined 11°
15y 1m
ANB = 5,6° ABOP = 4,3 mm

•Some condylar growth
and molar eruption +
mesialisation helped to
achieve cl II correction

•Improved facial proﬁle
13y 6m 15y 1m

•Class II div 1
•Severe ALD, impacted 37
•Heavily restored 16, 46
•Md dental asymmetry
KiLe250311

•Hyperdivergent
•Convexe proﬁle
•Mild skeletal cl II (ANB = 6°; ABOP = 4 mm)
11y 8m

Tx plan
•Extraction of 16, 24, 46, 38
•SUS2 corrector
•Alternate tx plan
✦ Likely 14, 24, 35, 44

•SUS2 engaged at 30 weeks (march 2012)
•E links to distalize the canines + protract 47
KiLe040612 43 w
KiLe230412 37 w

•20 weeks of SUS2 corrector
•#47 protracted
•Arch symmetry achieved
KiLe160712 50 w
KiLe160712 50 w Bond #37

•Dentoalveolar protrusion
•Lower lip procumbency
•Unpleasant smile
12y 10m

•Class I canine relationship achieved
KiLe160913 110 w

post SUS20712
•Lip incompetency
•Strain of the mentalis muscle
14y 0m

End of Ortho
KiLe091213 122W

•Functional genioplasty to
✦ Obtain lip competency
✦ Improve proﬁle + smile display
14y 2m

11y 8m 12y 10m 14y 2m
Initial Post SUS2 Pre genio Final
14y 0m
Chamberland S, Profﬁt WR, Chamberland P-E, Genioplasty in growing patients,
Angle Orthod, in press

•Cl II div 1
•Accentuated curve of Spee Mx + Md
ElLa210812

14y
•Vertical maxillary excess
•Gummy smile
•Lip incompetency at repose
14y 5 m

Mini screw
•Mx:
✦ Palatal side (one on the left failed)
✓ Replace by one paramedian
•Md: Buccal
✦ The one on the left is too low and became  
submerged
ElLa221112

•Intrusion of mx posterior teeth help achieve some cl II correction
•Posterior open bite
•Deep overbite
ElLa070313

•Posterior intrusion helped to improved AP relationship
14y 11 m

•Md forward rotation
•Upper molar intrusion
•Limited eruption of lower
molars

•SUS2 corrector
•E links were maintained for a few weeks
ElLa100613

•Classe I relationship achieved
ElLa190814

•Facial proﬁle improve
•Lip strain persist
✦ A functional genioplasty is indicated
16y 5 m

•Limited mx dentoalvolar
growth
•Favourable md growth
•L6 extrusion
•L1 proclination +
intrusion

•Lip competency
•Smile display
16y 5 m14y 5 m

•Anchorage for molar protraction
✦ Congenitally missing 35, 45
BiAu 190814
BiAu060513

Molar protraction + Cl II correction
device
•Classe II div 2
•Internal root resorption of #46
•Tx plan
✦ RPE, Cl II correction device. Exo 46. Protraction 47.
MaHe220611

Molar protraction + Cl II correction
device
•Class I relationship + molar protraction achieved in 96 weeks
MaHe220611 MaHe031012
MaHe040613

•Class II div 2, deep overbite
•Hopeless 14, 36, 46
•Impacted 13
FrRo211111 16 y 2 m

•Tx plan
✦ Would usually not need extraction in the md arch
✦ How about exo 4s/6s + SUS2

•SUS2 were engaged ~ 1 years after tx was initiated because the above
mentioned reasons
•SUS2 was used 36 weeks
FrRo041113
FrRo270114
The patient delayed extraction of U4 some 3 months and L6 some 9 months

• Reassessment of bracket position
• Lower 7s protracted (3 mm to go for 47)
FrRo260814
Patient didn’t show for 4 months
(april to august)

•/1- maintained AP
•1/ torque improved
•Lip support maintained

•L7s protracted
•/1s maintained AP

Does the approach really matter?
•Most studies showed
✦ Some restriction of Mx forward growth
✦ No significant increase of Md growth
✦ Significant dentoalveolar change at end of ortho
✦ Class II correction is maintained at 2 y follow-up (83%)
✦ No significant skeletal change at 2 y follow up.

Side effect
•Incisor proclination occurred in spite of arch wire cinchback and -6° torque
embed in the brackets (19x25 into .22 slot)
•Wire-slot interplay should be reduce
✦ 20x25 or 21x25 SS wire + cinchback
•TADs + Cl II correction device reduce lower incisors proclination
✦ /1 change 3,61° ± 5,07° vs 9,29° ± 3,81°
•Extraction + cl II correction device: good marriage when space is necessary
along cl II correction
Cacciatore G, et al AO in press
Aslan B, et al AO 2014;84;76-87

Cost
•SUS2 : 135$ buy 3 get 1 (101$). One size ﬁts all
•Forsus: 260$, need large inventory for all different sizes.
✦ Must buy > 15000$ annually to get 50% discount…
•TFBC: 239$ buy 4 get 1 (210$) ( 2 lenght sizes + double lock or anchor
wire)
•XBow: 220$ + 260$ =480$
•Esprit corrector : ~ 169$
101/260 = 39%

Cost
•If most appliances do about the same
•Why should we pay >twice (257%) the price to get a Cl II corrector
device?

Key points
•SUS2
✦ Easy to install and remove.
✦ Less expensive.
✦ Minimal breakage if any
•U6 SPEED™ convertible tube’s headgear tube
•L6 & L7 SPEED™ convertible tube
Repeatably convertible
Much easier to cinchback

Fixed Appliance Management of Class II Malocclusion SUS2 Corrector

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Fixed Appliance Management of Class II Malocclusion SUS2 Corrector