case_images: PMC6681608_01
case_images: Case 1. (a) 9-year and 10-month-old male patient with skeletal Class II malocclusion, increased overjet, and overbite before treatment. (b) Panoramic radiograph taken at first visit when the patients was 9 years old.
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case_images: fig2
case_images: Treatment began when the patient was 12 years and 6 months old (Figure 2(a)) when he had a full permanent dentition with a bilateral full-cusp Class II molar relationship and noteworthy increased overjet (11.9 mm) and overbite. Soft tissue profile and cephalometric analysis suggested that Class II malocclusion (ANB, 6.3 ; Wits appraisal, 10.5 mm) was mainly due to mandibular retrusion (SNB, 72.8 ; Pog to Nasion perp., -12.6 mm) (Figure 2(a); Table 1). A hypodivergent growth pattern (SN to GoGn, 28.5 ) was also seen with no major skeletal transverse maxillary deficiency (Figure 2(a); Table 1). A panoramic radiograph taken at 9 years revealed no significant anomalies (Figure 2(b)).
case_images: Case 1. (a) The series of the MPM recordings with corresponding ages and according to the timing of functional treatment (waiting before treatment, beginning of treatment, and end of treatment). (b) Intraoral views of the Twin-Block appliance. (c) Intraoral views of the removable Clark's retention appliance.
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case_images: fig3
case_images: The MPM staging was initially performed at 9 years and 10 months (stage 1) and again at 11 years and 1 month (stage 1) and 12 years and 6 months (stage 3) (Figure 3(a)). Twin-Block appliance carrying the TheraMon  Chip (MC Technology GmbH, Hargelsberg, Austria) for patient compliance recording and a lower acrylic labial bow with the aim of preventing mandibular incisor proclination (Figure 3(b)). This Twin-Block appliance had an expansion screw (Model A4805-14R, Leone Orthodontic Products, Sesto Fiorentino (FI), Italy) in the upper block. Mandibular advancement for the bite construction was maximum with almost an edge-to-edge incisor relationship (Figure 3(b)). Wearing was at night for 6 months (Figure 3(c)). At the end of the functional treatment, the patient achieved MPM stage 4 (Figure 3(a)) and had a Class I dentoskeletal relationship (overjet reduced to 4.1 mm with 7.8 mm of improvement) with an ANB angle of 2.2  and a Wits appraisal of 1.6 mm (4.1  and 8.9 mm of improvement as compared to the pretreatment measurements, respectively) (Figure 4;
case_images: Case 1. Patient after 14 months of functional treatment with Twin-Block when he was 13 years and 10 months old.
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case_images: fig4
case_images: After active functional treatment, the patient had a super Class I molar relationship along with a noteworthy lateral open bite on both sides as the side effect of the treatment; second molars were in contact (Figure 4). The panoramic radiograph revealed the presence of third molars in all quadrants and absence of any anomaly (Figure 4).
case_images: Case 1. (a) Patient after 18 months of follow-up (including 6 months of retention) when he was 15 years and 4 months old. (b) Superimposition of pretreatment (black), posttreatment (red), and follow-up (green) cephalometric tracings on stable structures of the anterior cranial base. (c) Regional superimposition of cephalometric tracings on the maxilla and mandible.
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case_images: fig5
case_images: At the end of functional treatment, superimposition on the anterior cranial base showed a notable forward displacement of the Pog and a slight clockwise rotation of the mandible (Figure 5(b)), with SN to GoGn increased by 1.5  (Table 1). Table 1). The regional maxillary superimposition demonstrated irrelevant first molar movements and a significant improvement of the incisor inclination over 10 , from 127.5  to 117.3  (Figure 5(c); Table 1). Finally, stable results were seen at the 18-month follow-up (including 6 months of retention appliance wearing) in terms of an occlusion and skeletal relationship (Figure 5; Table 1).
case_images: PMC6681608_02
case_images: Case 2. (a) 9-year and 8-month-old female patient with skeletal Class II malocclusion, increased overjet, and overbite before treatment. (b) Panoramic radiograph taken at first visit when the patients was 8 years 10 months old.
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case_images: fig6
case_images: Treatment began when the patient was 11 years and 2 months old (Figure 6(a)), when she had an almost complete permanent dentition with a bilateral half-cusp Class II molar relationship and increased overjet (9.9 mm) and overbite. Soft tissue profile and cephalometric analysis suggested that Class II malocclusion (ANB, 5.3 ; Wits appraisal, 4.2 mm) was due to mandibular retrusion (SNB, 75.4 ; Pog to Nasion perp., -6.5 mm) (Figure 6(a); Table 2). A normal vertical growth pattern (SN to GoGn, 30.1 ) was also seen with no major skeletal transverse maxillary deficiency (Figure 6(a); Table 2). A panoramic radiograph taken at 8 years 10 months revealed no significant anomalies (Figure 6(b)).
case_images: Case 2. (a) The series of the MPM recordings with corresponding ages and according to the timing of functional treatment (waiting before treatment, beginning of treatment, and end of treatment). (b) Intraoral views of the Bionator appliance. (c) The fixed appliance on the maxillary anterior teeth.
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case_images: fig7
case_images: The MPM staging was initially performed at 9 years and 8 months (stage 1) and again at 10 years and 6 months (stage 1) and 11 years and 2 months (stage 2) (Figure 7(a)). After this recording, functional treatment began by means of a Bionator appliance carrying the TheraMon  Chip (Figure 7(b)). Mandibular advancement for the bite construction was maximum with an edge-to-edge incisor relationship (Figure 7(b)). Since parents of the patients refused a full-fixed appliance treatment, a 3-month long fixed treatment limited to the maxillary anterior teeth in combination with posterior occlusal pads was performed (Figure 7(c)). At the end of the whole treatment that lasted 15 months, the patient achieved MPM stage 4 (Figure 7(a)) and had a Class I dentoskeletal relationship (overjet reduced to 4.9 mm with 5.0 mm of improvement) with an ANB angle of 3.3  and a Wits appraisal of -0.3 mm (2.0  and 4.5 mm of improvement as compared to the pretreatment measurements, respectively) (Figure 8;
case_images: Case 2. Patient after 12 months of functional treatment with the Bionator and 3 months of fixed appliance treatment when she was 12 years and 6 months old.
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case_images: fig8
case_images: Case 2. (a) Patient after 16 months of follow-up when she was 13 years and 10 months old. (b) Superimposition of pretreatment (black), posttreatment (red), and follow-up (green) cephalometric tracings on stable structures of the anterior cranial base. (c) Regional superimposition of cephalometric tracings on the maxilla and mandible.
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case_images: fig9
case_images: At the end of the whole treatment, superimposition on the anterior cranial base showed a forward displacement of the Pog and a slight clockwise rotation of the mandible (Figure 9(b)), with SN to GoGn increased by 1.7  (Table 2). Table 2). The regional maxillary superimposition demonstrated molar extrusion and a significant improvement of the incisor inclination by about 11 , from 124.5  to 115.6  (Figure 9(c); Table 2). Finally, stable results were seen at the 16-month follow-up in terms of an occlusal and skeletal relationship (Figure 9; Table 2).
case_images: PMC6681608_03
case_images: Case 3. 13-year-old male patient with skeletal Class II malocclusion, increased overjet, and overbite before treatment.
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case_images: fig10
case_images: A 13-year-old male (Figure 10) presented with a dentoskeletal Class II malocclusion, a bilateral half-cusp Class II molar relationship, and increased overjet and overbite, along with a scissor bite on the left side. As for the other cases, soft tissue profile and cephalometric analysis showed that Class II malocclusion (ANB, 7.1 ; Wits appraisal, 7.2 mm) was mainly due to mandibular retrusion (SNB, 75.6 ; Pog to Nasion perp., -8.6 mm) (Figure 10; Table 3). A normal vertical growth pattern (SN to GoGn, 32.2 ) was also seen with no major skeletal transverse maxillary deficiency (Figure 10; Table 3).
case_images: Case 3. (a) The MPM recordings with corresponding ages and according to the timing of functional treatment (beginning and end of treatment). (b) Occlusal views of the modified Twin-Block appliance. (c) Intraoral views of the modified Twin-Block appliance. (d) The full-fixed appliance.
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case_images: fig11
case_images: Twin-Block appliance carrying the TheraMon  Chip. This modified Twin-Block appliance had a lower acrylic labial bow (as that in Case 1) and a three-way screw (Model A0930-14, Leone Orthodontic Products) in the upper block allowing a simultaneous increase in the transverse dimension and prevention of upper incisor reclination (Figure 11(b)). Mandibular advancement for the bite construction was maximum with an edge-to-edge incisor relationship (Figure 11(c)). After 10 months of functional treatment with the Twin-Block, the patient had a super Class I molar relationship along with a bilateral open bite as the side effect of the treatment (Figure 11(b)). Twin-Block treatment (Figure 11(d)), the patient underwent a second phase of fixed orthodontic treatment with an MBT straight-wire multibracket appliance (Optimus, Effedental, Barbeano di Spilimbergo (PN), Italy) to refine the occlusion (Figure 11(e)). This treatment involved the use of intermaxillary elastics and lower incisor stripping to reduce their inclination to the mandibular plane. At the end of the full-fixed appliance treatment that lasted 18 months, the patient achieved an MPM stage 4 (Figure 11(a)) and had a Class I dentoskeletal relationship with an ANB angle of 3.9  and a Wits appraisal of 4.0 mm (3.2  and 3.2 mm of improvement as compared to the pretreatment measurements, respectively) (Figure 12;
case_images: Case 3. Patient after 10 months of functional treatment with modified Twin-Block and 18 months of full-fixed appliance treatment when he was 15 years and 6 months old.
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case_images: fig12
case_images: Case 3. (a) Patient after 21 months of follow-up when he was 17 years and 3 months old. (b) Superimposition of pretreatment (black), posttreatment (red), and follow-up (green) cephalometric tracings on stable structures of anterior cranial base. (c) Regional superimposition of cephalometric tracings on the maxilla and mandible.
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case_images: fig13
case_images: At the end of functional and full-fixed treatments, superimposition on the anterior cranial base showed a notable forward displacement of the Pog and counter-clockwise rotation of the mandible (Figure 13(b)), with SN to GoGn reduced by 6.7  (Table 3). Table 3). The regional maxillary superimposition demonstrated slight molar extrusion and an improvement of the incisor proclination by about 6  (Figure 13(c); Table 3). Finally, stable results were seen at the 21-month follow-up in terms of occlusion and skeletal relationship (Figure 13; Table 3).