The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019
RESEARCH ARTICLE

Effects of Mandibular Protraction Appliance and Jasper Jumper in Class II Malocclusion Treatment



Rafael P. Henriques1, José F. C. Henriques2, Guilherme Janson2, Marcos R. de Freitas2, Karina M. S. Freitas2, 3, *, Manoela F. Francisconi1, Fernanda P. H. Fontes1
1 Department of Orthodontics, FACOP, Piratininga, São Paulo, Brazil
2 Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru, São Paulo,Brazil
3 Department of Orthodontics, Uninga University Center, Maringa, Parana, Brazil

Abstract

Objective:

This study aimed to compare the effects of Mandibular Protraction Appliance (MPA) and Jasper Jumper (JJ), associated with fixed orthodontic appliances for Class II malocclusion treatment.

Materials and Methods:

Sample comprised of 71 subjects, divided into 3 groups: Group 1: 24 patients, mean initial age 12.36 years, treated with MPA for 2.74 years; Group 2: 25 patients, mean initial age 12.72 years, treated with JJ for 2.15 years; Control Group: 22 subjects, mean age of 12.67 years, with untreated Class II malocclusion, followed for 2.12 years. Initial and final variables and treatment changes were compared between groups by ANOVA and Tukey tests.

Results:

JJ group presented greater restriction of growth and maxillary retrusion and MPA showed a greater increase of mandibular effective length. MPA and JJ groups showed improvement of maxillomandibular relationship. Maxillary incisors showed greater retrusion and retroclination in MPA group. MPA presented greater proclination of mandibular incisors and JJ showed greater protrusion. MPA and JJ groups presented a decrease in overbite and overjet.

Conclusion:

MPA showed a significant increase in mandibular effective length and great dentoalveolar compensation. JJ showed significant restriction of maxillary anterior displacement and also important dentoalveolar compensations. JJ must be indicated mainly in cases with maxillary protrusion, and MPA, especially in cases with mandibular deficiency.

Keywords: Cephalometrics, Class II malocclusion, Functional appliances, Maxillary incisors, Jasper Jumper (JJ), Maxillomandibular relationship.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 53
Last Page: 60
Publisher Id: TODENTJ-13-53
DOI: 10.2174/1874210601913010053

Article History:

Received Date: 20/11/2018
Revision Received Date: 2/01/2019
Acceptance Date: 24/1/2019
Electronic publication date: 28/02/2019
Collection year: 2019

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© 2019 Henriques et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Orthodontics, Bauru Dental School, University of São Paulo, Alameda Octávio Pinheiro Brisolla 9-75, Bauru - SP - Brazil - 17012-901/; Department of Orthodontics, Uninga University Center, Maringa, Parana, Brazil; Tel: 551432358333; E-mail: kmsf@uol.com.br





1. INTRODUCTION AND STATEMENT OF THE PROBLEM

The current tendency for nonextraction treatment of Class II malocclusion is the use of appliances that do not need patient compliance, including fixed functional orthopedic appliances [1Jasper JJ. The Jasper Jumper: A fixed functional appliance 1987., 2Coelho Filho CM. The mandibular protraction appliance IV. Rev Dent Press Ortodon Ortop Facial 2002; 7: 49-60.]. Herbst appliance and its variations are the most used and investigated in the last years. Its main effects in Class II treatment are: Restriction of the anterior displacement of the maxilla, significant mandibular protrusion, distalization of maxillary molars, extrusion and retrusion of maxillary incisors, anterior movement of mandibular teeth in alveolar bone, intrusion of mandibular incisors, besides a significant improvement in maxillomandibular relationship [3Pancherz H. Dentofacial orthopedics or orthognathic surgery: Is it a matter of age? Am J Orthod Dentofacial Orthop 2000; 117(5): 571-4.
[http://dx.doi.org/10.1016/S0889-5406(00)70203-4] [PMID: 10799 118]
, 4Pancherz H. Treatment of class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation. Am J Orthod 1979; 76(4): 423-42.
[http://dx.doi.org/10.1016/0002-9416(79)90227-6] [PMID: 291343]
]. However, the Herbst appliance has a relatively high cost.

The Jasper Jumper appliance, more recently developed, had similar effects to the Herbst appliance, at a lower cost [1Jasper JJ. The Jasper Jumper: A fixed functional appliance 1987.]. In 1995, Coelho Filho [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
] developed the Mandibular Protraction Appliance, that consists of a simple mechanism that maintains continuous mandibular advancement and is constructed by the clinicians at a low cost. Some studies have demonstrated the efficacy of this appliance in correcting Class II malocclusion [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
-10Pontes LF, Maia FA, Almeida MR, Flores-Mir C, Normando D. Mandibular protraction appliance effects in class II malocclusion in children, adolescents and young adults. Braz Dent J 2017; 28(2): 225-33.
[http://dx.doi.org/10.1590/0103-6440201701032] [PMID: 28492754]
].

The Mandibular Protraction Appliance (MPA) and Jasper Jumper (JJ) are indicated for skeletal Class II malocclusion, mainly due to mandibular retrusion, and their main difference is rigidity. The effects of the MPA have not been compared with other fixed functional appliance, especially the JJ, to demonstrate the different effects in the correction of Class II malocclusions. Therefore, the objective of this study was to cephalometrically compare the dentoskeletal and soft-tissue changes after treatment of Class II malocclusions with MPA and JJ, associated with fixed appliances. The null hypothesis tested was: There are no differences between the effects of the MPA and JJ appliances in the Class II treatment.

2. MATERIALS AND METHODS

2.1. Materials

The present study was approved by the Ethics Committee in Human Research of the Bauru Dental School, University of São Paulo, Bauru, SP, Brazil. All patients signed informed consent.

The sample comprised of 71 subjects, divided into three groups. The primary selection criteria for the groups were a Class II Division 1 malocclusion with at least a bilateral half-cusp Class II molar relationship, all maxillary and mandibular teeth up to the second molars, a convex facial profile, and an accentuated overjet.

Group 1 comprised 24 patients (12 male; 12 female), at a mean age of 12.36 years (S.D =1.75), treated with MPA at a private clinic, for 2.74 years (S.D = 0.70).

Patients from group 1 used the MPA in conjunction with fixed appliances (Fig. 1). The MPA is an intraoral fixed functional appliance developed by Coelho Filho [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
] in 1995, that induces continuous mandibular protrusion to correct Class II malocclusions. It requires stainless steel rectangular archwires in both arches. The length of the appliance is determined by the distance from the mesial aspect of the maxillary tube to the stop on the mandibular archwire. Previous use of fixed orthodontic appliances is indispensable. Before placement of the MPA, 0.022 x 0.028-in fixed appliances were placed, and leveling progressed up to rectangular 0.021 x 0.025-in stainless steel archwires. Then the MPA was placed to correct the Class II anteroposterior discrepancy. The rectangular arches must have enough extension distal to the molar tubes for the bend-down tieback and to support elastic chains [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
]. The mandible was advanced to an edge-to-edge incisor position.

Group 2 consisted of 25 patients (13 male; 12 female), at a mean age of 12.72 years (S.D = 1.20), treated with JJ [11Jasper JJ, McNamara JA Jr. The correction of interarch malocclusions using a fixed force module. Am J Orthod Dentofacial Orthop 1995; 108(6): 641-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70010-2] [PMID: 7503042]
] for 2.15 years (S.D = 0.29). These patients were treated in the orthodontic graduate clinic at Bauru Dental School, University of São Paulo, Bauru, SP, Brazil.

Fig. (1)
Mandibular Protraction Appliance (MPA).


Patients from group 2 used the JJ appliance in conjunction with fixed appliances (Fig. 2). Before placement of the JJ, 0.022 x 0.028 in fixed appliances were placed, and leveling progressed up to rectangular 0.019 x 0.025 in stainless steel archwires. The Jasper Jumper (JJ) is a functional appliance for mandibular protraction (American Orthodontics, Sheboygan, USA). The mandibular arch was tied back to the first or second molars. In the maxillary arch, the jumper was attached to the headgear tube of the first molars as prescribed by the manufacturer with a ball-pin attachment. In the mandibular arch, the jumper was attached into the rectangular 0.019 x 0.025 in stainless steel archwire with a ball-pin attachment over the mandibular canine bracket from the distal side. JJ was selected according to the manufacturer’s instructions (American Orthodontics, Sheboygan, USA). The patients were seen every 4 weeks, and the appliances were activated every 8 weeks.

Fig. (2)
Jasper Jumper appliance.


In both groups, functional appliances were removed when a Class I or overcorrected Class I canine and molar relationship was achieved. Finishing of the occlusion was obtained with fixed appliances. Retainers consisted of Hawley plates in the maxillary arches and bonded canine-to-canine lingual arches in the mandibular arches.

The Control Group comprised 22 subjects (12 male; 10 female), at a mean age of 12.67 years (S.D = 0.75), with untreated Class II malocclusion, observed for a mean period of 2.12 years (S.D = 1.63). These subjects were obtained from the files of Bauru Dental School, University of São Paulo, Bauru, SP, Brazil.

2.2. Methods

Two lateral cephalograms of each subject were used. Lateral cephalograms were manually traced, landmarks were digitized by a single investigator (RPH) and measurements were obtained with Dentofacial Planner 7.02 (Dentofacial Planner Software, Toronto, Ontario, Canada), which corrected the radiographic magnification (6 and 9.8%).

Variables included maxillary skeletal component, mandibular skeletal component, maxillomandibular relationship, vertical component, maxillary dentoalveolar component, mandibular dentoalveolar component and dental relationships. The mandibular effective length was considered the measurement of the variable Co-Gn in millimeters.

2.3. Error Study

After a month interval from the first measurement, thirty randomly selected cephalograms were retraced and re-measured by the same examiner (RPH). Casual errors were calculated according to Dahlberg’s formula [12Dahlberg G. Statistical methods for medical and biological students. New York: Interscience. BMJ 1940; 2(4158): 358-9.
[http://dx.doi.org/10.1136/bmj.2.4158.358-b]
], and the systematic errors were evaluated with dependent t tests [13Houston WJB. The analysis of errors in orthodontic measurements. Am J Orthod 1983; 83(5): 382-90.
[http://dx.doi.org/10.1016/0002-9416(83)90322-6] [PMID: 6573846]
], for P <.05.

2.4. Statistical Analysis

Intergroup compatibility of sex distribution and severity of malocclusion were performed by Chi square tests. Intergroup compatibility of ages and treatment/observation time were performed by ANOVA test.

Initial variables and treatment changes were compared between the groups by ANOVA and Tukey tests.

All statistical analyses were performed with Statistica software (Statistica for Windows, Release 7.0, Copyright Statsoft Inc., 2005). Results were considered significant for P < 0.05.

3. RESULTS

The casual errors varied from 0.25 mm (Molar Relationship) to 0.94 mm (6-GoMe) and from 0.41º (ANB) to 1.47º (1.NB). Only two angular variables (IMPA and 1.NB) presented statistically significant systematic errors.

The three groups were compatible regarding the initial and final ages and time of evaluation (Table 1), sex distribution (Table 2) and initial severity of Class II molar relationship (Table 3).

Table 1
Compatibility of ages and time of evaluation between the 3 groups (ANOVA).


Table 2
Distribution of gender between the 3 groups (Chi square test).


Table 3
Compatibility of severity of malocclusion between the 3 groups (Chi square test).


At pretreatment stage, MPA group presented significantly greater maxillary protrusion, a smaller mandibular effective length and a more protruded mandible, when compared to the other groups (Table 4). The control group presented slighter anteroposterior discrepancy (ANB, Wits) when compared to the experimental groups (Table 4). The MPA group had more buccally tipped maxillary incisors and greater overjet, in relation to the other groups (Table 4). The control group presented a significantly smaller Class II molar relationship (Table 4).

The JJ group presented greater restriction of growth and anterior displacement of the maxilla and greater maxillary retrusion and the MPA group showed a significantly greater increase of mandibular effective length (Table 5). Both experimental groups showed significant improvement in maxillomandibular relationship in relation to the control group (Table 5). The maxillary incisors presented greater retrusion and palatal inclination in the MPA than the other groups (Table 5). The MPA group presented greater labial inclination and the JJ group showed greater protrusion of the mandibular incisors than the control group (Table 5). The MPA and JJ groups presented a decrease in overbite and overjet relative to the control, and the MPA group had greater overjet decrease also in relation to the JJ group (Table 5).

4. DISCUSSION

4.1. Pretreatment Comparison

MPA group showed a more protrusive maxilla in relation to the JJ and control groups. The mandible presented a smaller effective length in MPA group, when compared to JJ and control groups. This could be because subjects in MPA group were younger in the pretreatment stage than the other groups' individuals, in spite of not statistically significant.

Table 4
Intergroup comparison of pretreatment stage (ANOVA and Tukey tests).


Table 5
Intergroup comparison of treatment/observation changes (ANOVA and Tukey tests).


JJ group showed a more retruded mandible when related to MPA group. This could be explained because JJ is the group with more vertical growth pattern, despite without a significant difference.

MPA group presented the worst maxillomandibular relationship followed by the JJ group and then the control group. This was expected since the control group presented a smaller Class II molar relationship severity. However, despite these limitations, other studies have also used control groups with milder Class II characteristics than the experimental group [14Janson G, Caffer DdeC, Henriques JF, de Freitas MR, Neves LS. Stability of Class II, division 1 treatment with the headgear-activator combination followed by the edgewise appliance. Angle Orthod 2004; 74(5): 594-604.
[PMID: 15529492]
-17Lima KJRS. Comparison od dentoskeletal changes promoted by the Jasper Jumper and Activator appliances combined to extraoral anchorage followed by fixed appliances, in treatment of the Class division 1 [thesis] 2007.].

MPA group presented more buccally tipped maxillary incisors as compared to the other groups. MPA group showed a greater overjet in relation to the JJ and control groups and the MPA and JJ presented more severe Class II molar relationship when compared to the control group.

4.2. Treatment Changes Comparison

Both treated groups presented a restriction of the forward displacement of the maxilla, however with a significant difference only between JJ and control groups.

JJ group presented a smaller increase of the effective length of the maxilla during treatment when compared to the other groups. This means that the JJ promoted a greater restriction of the maxillary growth in relation to MPA and the normal growth in untreated subjects. MPA was not effective in producing a significant restriction of the forward displacement of the maxilla, since there was not a statistically significant difference with the control group.

The effect of restricting the anterior growth and displacement of the maxilla was already observed in some studies evaluating cases treated with the JJ [11Jasper JJ, McNamara JA Jr. The correction of interarch malocclusions using a fixed force module. Am J Orthod Dentofacial Orthop 1995; 108(6): 641-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70010-2] [PMID: 7503042]
, 16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-23Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998; 20(3): 271-81.
[http://dx.doi.org/10.1093/ejo/20.3.271] [PMID: 9699405]
].

The lack of significant difference in the maxillary skeletal component between the groups MPA and control was already observed by other authors [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006.].

Some studies described the decrease of SNA angle and the backward relocation of the A point with the use of JJ appliance as the “headgear effect”, with distalization and intrusion forces in the maxillary posterior region [18Küçükkeleş N, Ilhan I, Orgun IA. Treatment efficiency in skeletal Class II patients treated with the jasper jumper. Angle Orthod 2007; 77(3): 449-56.
[http://dx.doi.org/10.2319/0003-3219(2007)077[0449:TEISCI]2.0.CO;2] [PMID: 17465652]
, 19Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO III. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994; 64(2): 113-22.
[PMID: 8010519]
, 22Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
]. However, since MPA has the same mechanism of Class II correction as JJ, this effect was also expected in MPA group, but this was not observed. Therefore, the uprighting effect of both appliances on the maxillary incisors led to forward relocation of A-point because of appositional changes at that alveolar area. Since the MPA group had more palatal tipping of the maxillary incisors [9Furquim BD, Janson G, Cope LCC, Freitas KMS, Henriques JFC. Comparative effects of the Mandibular Protraction Appliance in adolescents and adults. Dental Press J Orthod 2018; 23(3): 63-72.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567]
], this could have camouflaged the restrictive effect of the MPA on the maxilla. Other researchers also reported A-point relocation related to the incisor inclination [22Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
, 25McNamara JA Jr. A method of cephalometric evaluation. Am J Orthod 1984; 86(6): 449-69.
[http://dx.doi.org/10.1016/S0002-9416(84)90352-X] [PMID: 6594 933]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
].

MPA group demonstrated a significantly greater increase in mandibular effective length when compared to JJ and control groups. This corroborates other studies, however, they also found a significant mandibular protrusion [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
-8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006.].

It is noticed that there was no significant mandibular protrusion neither a significant increase in mandibular effective length with the use of JJ. This is in agreement with previous studies [16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007., 17Lima KJRS. Comparison od dentoskeletal changes promoted by the Jasper Jumper and Activator appliances combined to extraoral anchorage followed by fixed appliances, in treatment of the Class division 1 [thesis] 2007., 19Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO III. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994; 64(2): 113-22.
[PMID: 8010519]
-21Covell DA Jr, Trammell DW, Boero RP, West R. A cephalometric study of class II Division 1 malocclusions treated with the Jasper Jumper appliance. Angle Orthod 1999; 69(4): 311-20.
[PMID: 10456598]
, 27de Oliveira JN Jr, Rodrigues de Almeida R, Rodrigues de Almeida M, de Oliveira JN. Dentoskeletal changes induced by the Jasper jumper and cervical headgear appliances followed by fixed orthodontic treatment. Am J Orthod Dentofacial Orthop 2007; 132(1): 54-62.
[http://dx.doi.org/10.1016/j.ajodo.2005.07.028] [PMID: 17628251]
]. However, some authors reported mandibular protrusion with the use of the JJ [11Jasper JJ, McNamara JA Jr. The correction of interarch malocclusions using a fixed force module. Am J Orthod Dentofacial Orthop 1995; 108(6): 641-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70010-2] [PMID: 7503042]
, 23Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998; 20(3): 271-81.
[http://dx.doi.org/10.1093/ejo/20.3.271] [PMID: 9699405]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
, 28Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
].

Another factor that can explain this difference, despite the similar pretreatment age of the groups, is that the MPA group presented a significantly smaller mandibular effective length in this stage than the other groups. Possibly these subjects still were at the beginning of the craniofacial growth spurt.

The two experimental groups treated with MPA and JJ showed a significant improvement of the maxillomandibular relationship when compared to the control group, also reported in the literature [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 9Furquim BD, Janson G, Cope LCC, Freitas KMS, Henriques JFC. Comparative effects of the Mandibular Protraction Appliance in adolescents and adults. Dental Press J Orthod 2018; 23(3): 63-72.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567]
, 16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-18Küçükkeleş N, Ilhan I, Orgun IA. Treatment efficiency in skeletal Class II patients treated with the jasper jumper. Angle Orthod 2007; 77(3): 449-56.
[http://dx.doi.org/10.2319/0003-3219(2007)077[0449:TEISCI]2.0.CO;2] [PMID: 17465652]
, 20Nalbantgil D, Arun T, Sayinsu K, Fulya I. Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence. Angle Orthod 2005; 75(3): 426-36.
[PMID: 15898385]
-23Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998; 20(3): 271-81.
[http://dx.doi.org/10.1093/ejo/20.3.271] [PMID: 9699405]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
-29Küçükkeles N, Orgun IA. Correction of Class II malocclusions with a Jasper Jumper in growing patients. Eur J Orthod 1995; 17: 445.]. This improvement of the maxillomandibular relationship results mainly of the restriction of the forward displacement of the maxilla in the JJ group and the increase of the mandibular effective length in the MPA group and the mandibular normal growth in the JJ group.

The vertical component remained practically unchanged in all groups evaluated, indicating that treatment with MPA and JJ did not influence the craniofacial growth pattern. Some authors reported an increase of the vertical measurements, with a tendency of clockwise mandibular rotation in patients treated with the JJ appliance [16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-19Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO III. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994; 64(2): 113-22.
[PMID: 8010519]
, 22Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
], while others did not verify significant vertical changes [20Nalbantgil D, Arun T, Sayinsu K, Fulya I. Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence. Angle Orthod 2005; 75(3): 426-36.
[PMID: 15898385]
, 27de Oliveira JN Jr, Rodrigues de Almeida R, Rodrigues de Almeida M, de Oliveira JN. Dentoskeletal changes induced by the Jasper jumper and cervical headgear appliances followed by fixed orthodontic treatment. Am J Orthod Dentofacial Orthop 2007; 132(1): 54-62.
[http://dx.doi.org/10.1016/j.ajodo.2005.07.028] [PMID: 17628251]
].

MPA group presented a greater palatal tipping and a greater retraction of the maxillary incisors when compared to the JJ and control groups. This is probably because, at the beginning of treatment, the maxillary incisors in the MPA group were significantly more labially tipped, and consequently, during treatment, a greater retrusion was needed in order to correct the overjet. This palatal tipping corroborates some previous findings about MPA [5Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod 1995; 29(5): 319-36.
[PMID: 8617856]
, 8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006., 30Coelho Filho CM. Clinical use of the mandibular projection appliance. Rev Dent Press Ortodon Ortop Facial 1998; 3: 69-130.].

Some studies found a significant retrusion of the maxillary incisors in cases treated with the JJ [16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-19Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO III. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994; 64(2): 113-22.
[PMID: 8010519]
, 22Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
, 28Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
]. The lack of significant retrusion of JJ group in the present study may be due to the greater maxillary retrusion observed during treatment [16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.].

MPA group presented greater labial tipping of the mandibular incisors with treatment, when compared to the control group, already mentioned in the literature [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006.]. In JJ group, this side effect probably was minimized by the lingual crown torque applied to the mandibular anterior teeth [11Jasper JJ, McNamara JA Jr. The correction of interarch malocclusions using a fixed force module. Am J Orthod Dentofacial Orthop 1995; 108(6): 641-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70010-2] [PMID: 7503042]
, 16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007., 17Lima KJRS. Comparison od dentoskeletal changes promoted by the Jasper Jumper and Activator appliances combined to extraoral anchorage followed by fixed appliances, in treatment of the Class division 1 [thesis] 2007.].

JJ group presented greater protrusion of the mandibular incisors in relation to the control group, corroborating previous studies [16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-19Cope JB, Buschang PH, Cope DD, Parker J, Blackwood HO III. Quantitative evaluation of craniofacial changes with Jasper Jumper therapy. Angle Orthod 1994; 64(2): 113-22.
[PMID: 8010519]
, 21Covell DA Jr, Trammell DW, Boero RP, West R. A cephalometric study of class II Division 1 malocclusions treated with the Jasper Jumper appliance. Angle Orthod 1999; 69(4): 311-20.
[PMID: 10456598]
-23Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998; 20(3): 271-81.
[http://dx.doi.org/10.1093/ejo/20.3.271] [PMID: 9699405]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
-28Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
]. However, this significant protrusion was also reported by studies evaluating MPA [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006.].

Both experimental groups presented significant decreases of the overjet and overbite and significant improvement in molar relationship with treatment, in relation to the control group. However, MPA group showed a greater decrease of overjet also significant when compared to JJ group.

The greater decrease of the overjet in MPA group in relation to JJ group can be explained by the pretreatment increased overjet presented by MPA group. This way, the overjet correction needed to be greater in MPA group.

The correction of overjet was several times previously reported in the literature [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
, 16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007.-24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006., 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
, 28Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
].

In MPA group, the overjet correction was due to the increase in mandibular effective length, the palatal tipping of the maxillary incisors and the protrusion and proclination of the mandibular incisors. In JJ group, the overjet correction was mainly due to the restriction of the forward displacement of the maxilla and the protrusion of mandibular incisors, associated with the normal mandibular growth.

The labial inclination of mandibular incisors in MPA group and the protrusion of these teeth in JJ group may have contributed to the relative “Intrusion Effect” of these teeth and correction of the overbite [20Nalbantgil D, Arun T, Sayinsu K, Fulya I. Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence. Angle Orthod 2005; 75(3): 426-36.
[PMID: 15898385]
, 26Weiland FJ, Bantleon HP. Treatment of Class II malocclusions with the Jasper Jumper appliance--a preliminary report. Am J Orthod Dentofacial Orthop 1995; 108(4): 341-50.
[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
, 28Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
].

In general, MPA and JJ associated with fixed appliances corrected the Class II malocclusion, and this was due to some skeletal and mainly dentoalveolar changes [8Siqueira DF, de Almeira RR, Janson G, Brandao AG, Coelho Filho CM. Dentoskeletal and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 2017; 131(447): 21-30.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567] [http://dx.doi.org/10.1016/j.ajodo.2006.04.029]
-10Pontes LF, Maia FA, Almeida MR, Flores-Mir C, Normando D. Mandibular protraction appliance effects in class II malocclusion in children, adolescents and young adults. Braz Dent J 2017; 28(2): 225-33.
[http://dx.doi.org/10.1590/0103-6440201701032] [PMID: 28492754]
, 18Küçükkeleş N, Ilhan I, Orgun IA. Treatment efficiency in skeletal Class II patients treated with the jasper jumper. Angle Orthod 2007; 77(3): 449-56.
[http://dx.doi.org/10.2319/0003-3219(2007)077[0449:TEISCI]2.0.CO;2] [PMID: 17465652]
-22Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
, 24Brandão AG. Comparative cephalometric study of changes promoted by the mandibular protraction appliance and pendulum, associated to fixed appliances, in treatment of the Class II division 1 malocclusion [thesis] 2006., 27de Oliveira JN Jr, Rodrigues de Almeida R, Rodrigues de Almeida M, de Oliveira JN. Dentoskeletal changes induced by the Jasper jumper and cervical headgear appliances followed by fixed orthodontic treatment. Am J Orthod Dentofacial Orthop 2007; 132(1): 54-62.
[http://dx.doi.org/10.1016/j.ajodo.2005.07.028] [PMID: 17628251]
]. This way, both appliances can be used in growing patients as well as in adults, that do not present growth potential [9Furquim BD, Janson G, Cope LCC, Freitas KMS, Henriques JFC. Comparative effects of the Mandibular Protraction Appliance in adolescents and adults. Dental Press J Orthod 2018; 23(3): 63-72.
[http://dx.doi.org/10.1590/2177-6709.23.3.063-072.oar] [PMID: 3008 8567]
, 10Pontes LF, Maia FA, Almeida MR, Flores-Mir C, Normando D. Mandibular protraction appliance effects in class II malocclusion in children, adolescents and young adults. Braz Dent J 2017; 28(2): 225-33.
[http://dx.doi.org/10.1590/0103-6440201701032] [PMID: 28492754]
, 16Neves LS. Comparative study of treatment effects of the Class II division 1 malocclusion with the Jasper Jumper and Bionator, associated to fixed appliances [thesis] 2007., 18Küçükkeleş N, Ilhan I, Orgun IA. Treatment efficiency in skeletal Class II patients treated with the jasper jumper. Angle Orthod 2007; 77(3): 449-56.
[http://dx.doi.org/10.2319/0003-3219(2007)077[0449:TEISCI]2.0.CO;2] [PMID: 17465652]
].

However, these skeletal and dentoalveolar changes presented important differences between the two appliances, that must be remembered when planning an orthodontic treatment.

In MPA group, there was a significant increase in mandibular effective length and great dentoalveolar compensation, including palatal inclination and retrusion of the maxillary incisors and buccal inclination of mandibular incisors.

In JJ group, there was a significant restriction of the anterior displacement of the maxilla, and also important dentoalveolar compensations, as protrusion of mandibular incisors.

This way, JJ must be indicated mainly in cases with a maxillary protrusion, and MPA, especially in cases with mandibular deficiency.

Thus, the most important of the orthodontic treatment is the detailed planning and the correct determination of the treatment protocol. Further researches are needed in order to evaluate the long-term stability of treatment with MPA and JJ associated to fixed appliances.

Functional appliances can also be used in patients with juvenile idiopathic arthritis, to reduce the asymmetry of mandibular growth and TMJ disorder [31Isola G, Ramaglia L, Cordasco G, Lucchese A, Fiorillo L, Matarese G. The effect of a functional appliance in the management of temporomandibular joint disorders in patients with juvenile idiopathic arthritis. Minerva Stomatol 2017; 66(1): 1-8.
[PMID: 27716739]
]. Functional appliance can reduce the pain during jaw movement, maximal mouth opening, TMJ sounds and crepitations and TMJ click [31Isola G, Ramaglia L, Cordasco G, Lucchese A, Fiorillo L, Matarese G. The effect of a functional appliance in the management of temporomandibular joint disorders in patients with juvenile idiopathic arthritis. Minerva Stomatol 2017; 66(1): 1-8.
[PMID: 27716739]
].

CONCLUSION

The JJ group presented a greater restriction of growth and anterior displacement of the maxilla and greater maxillary retrusion and the MPA group showed a significantly greater increase of mandibular effective length. Both experimental groups showed significant improvement in maxillomandibular relationship. Maxillary incisors presented greater retrusion and palatal inclination in MPA group. Regarding mandibular incisors, the MPA group presented greater labial inclination and the JJ group showed greater protrusion. The MPA and JJ groups presented a decrease in overbite and over jet.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The present study was approved by the Ethics Committee in Human Research of the Bauru Dental School, University of São Paulo, Bauru, SP, Brazil.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

Written informed consent has been obtained from all patients.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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[PMID: 15898385]
[21] Covell DA Jr, Trammell DW, Boero RP, West R. A cephalometric study of class II Division 1 malocclusions treated with the Jasper Jumper appliance. Angle Orthod 1999; 69(4): 311-20.
[PMID: 10456598]
[22] Karacay S, Akin E, Olmez H, Gurton AU, Sagdic D. Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod 2006; 76(4): 666-72.
[PMID: 16808575]
[23] Stucki N, Ingervall B. The use of the Jasper Jumper for the correction of Class II malocclusion in the young permanent dentition. Eur J Orthod 1998; 20(3): 271-81.
[http://dx.doi.org/10.1093/ejo/20.3.271] [PMID: 9699405]
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[http://dx.doi.org/10.1016/S0889-5406(95)70031-5] [PMID: 7572845]
[27] de Oliveira JN Jr, Rodrigues de Almeida R, Rodrigues de Almeida M, de Oliveira JN. Dentoskeletal changes induced by the Jasper jumper and cervical headgear appliances followed by fixed orthodontic treatment. Am J Orthod Dentofacial Orthop 2007; 132(1): 54-62.
[http://dx.doi.org/10.1016/j.ajodo.2005.07.028] [PMID: 17628251]
[28] Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial effects of treatment of Class II malocclusion with the Herren activator, activator-headgear combination, and Jasper Jumper. Am J Orthod Dentofacial Orthop 1997; 112(1): 19-27.
[http://dx.doi.org/10.1016/S0889-5406(97)70269-5] [PMID: 9228837]
[29] Küçükkeles N, Orgun IA. Correction of Class II malocclusions with a Jasper Jumper in growing patients. Eur J Orthod 1995; 17: 445.
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[31] Isola G, Ramaglia L, Cordasco G, Lucchese A, Fiorillo L, Matarese G. The effect of a functional appliance in the management of temporomandibular joint disorders in patients with juvenile idiopathic arthritis. Minerva Stomatol 2017; 66(1): 1-8.
[PMID: 27716739]

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