Case Report

Long-term surgical versus functional Class II correction:

A comparison of identical twins
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Aditya Chhibbera; Madhur Upadhyayb; Flavio Uribec; Ravindra Nandad

ABSTRACT
The purpose of this twin case comparison was to assess the short- and long-term effects of
nonsurgical treatment vs orthognathic surgical treatment for Class II correction. Two identical
twins (age 13 years 3 months) were treated for Class II correction where one patient was treated
nonsurgically using a fixed functional appliance, while the other was treated using orthognathic
mandibular advancement surgery. The patients were recalled and evaluated 5 years in retention.
Comparing changes in the short and long term, surgical treatment led to superior skeletal results
compared to the nonsurgical twin. However, the soft tissue profile was remarkably similar for both
The Angle Orthodontist 2015.85:142-156.

patients suggesting that soft tissue profile changes may not necessarily follow similar changes in
the bony skeletal structures. (Angle Orthod. 2015;85:142–156.)
KEY WORDS: Long term; Class II; Fixed functional; Surgical

INTRODUCTION more heritable than other structures.1,2 Even though

it is reported that both Class II and Class III
Morphogenesis and development of the face is one
malocclusion have strong familial tendency,3,4 it is
of the most complex processes in an individual’s
difficult to estimate the influence of environmental
development. Facial appearance has a strong
factors in modifying craniofacial growth because
genetic component with monozygotic or dizygotic
heritability studies of occlusion are typically based
twins appearing more similar than unrelated individ-
on twins and siblings who did not receive orthodontic
uals.1 The size, shape, and position of craniofacial
treatment. While some5 suggest that malocclusion is
structures are a combination of being genetically
a trait that can be greatly influenced by environmen-
determined and influenced by external environmental
tal factors, others believe that the cause is more
factors. Certain craniofacial characteristics such as
multifactorial.1
facial height and mandibular position appear to be
Based on the growth status treatment, options for
a
Assistant Professor, Division of Orthodontics, Section of
Class II correction commonly include use of functional/
Growth & Development, Columbia University College of Dental fixed functional appliances (FFA), headgear, camou-
Medicine, New York, NY. flage by extractions of premolars, or surgical correction
b
Assistant Professor, Division of Orthodontics, Department of of the underlying skeletal discrepancy when growth has
Craniofacial Sciences, University of Connecticut Health Center,
completed.6 The use of functional/FFAs to enhance
Farmington, Conn.
c
Associate Professor, Division of Orthodontics, Department of mandibular growth has been questionable.7 Class II
Craniofacial Sciences, University of Connecticut Health Center, correction with such devices is usually a combination of
Farmington, Conn. skeletal and dental changes, including restraining
d
Professor and Head, Division of Orthodontics, Department of maxillary growth, mild mandibular growth, proclination
Craniofacial Sciences, University of Connecticut Health Center,
Farmington, Conn.
of mandibular and retroclination of maxillary incisors
Corresponding author: Dr Aditya Chhibber, Division of often called ‘‘side effects’’ of using such appliances.8
Orthodontics, Section of Growth & Development, Columbia Orthognathic surgery, on the other hand, is aimed at
University College of Dental Medicine, 630 West 168th Street, correction of the underlying skeletal discrepancy with-
P&S Box 20, VC9-218, New York, NY 10032 out the ‘‘side effects’’ associated with FFAs. In
(e-mail: adityachhibber14@gmail.com)
(e-mail: ac3674@columbia.edu) comparing the outcome of orthognathic surgery in
adults to functional appliances in growing children, no
Accepted: March 2014. Submitted: January 2014.
Published Online: May 20, 2014
significant differences have been observed by some
G 2015 by The EH Angle Education and Research Foundation, studies,9,10 while others have reported conversely
Inc. claiming surgery to lead to greater skeletal correction.11

Angle Orthodontist, Vol 85, No 1, 2015 142 DOI: 10.2319/011314-46.1

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The Angle Orthodontist 2015.85:142-156.
Figure 1. Patient 1 (nonsurgical) pretreatment records.
Treatment options for adolescents are particularly
difficult due to uncertainty regarding the magnitude of
remaining mandibular growth,12,13 and therefore may
be treated by either camouflage/growth modification or
orthognathic surgery. Twin studies in general would be
advantageous in such situations because they would
help understand the contribution of genetics as
opposed to the effect of the environment (functional
143
appliance or surgery). It is unclear if the long-term
outcome with either method would be different. The
key question is ‘‘Are there esthetic differences when
Class II correction is achieved with surgical interven-
tion in comparison to camouflage using a fixed
functional appliance, both in the short and long term?’’
This twin case report allowed us to elucidate some
answers.
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The Angle Orthodontist 2015.85:142-156.
Figure 2. Patient 2 (surgical) pretreatment records.
CASE REPORT
Diagnosis
The patients who were identical twins 13 years
3 months at the start of treatment (Figures 1 and 2)
reported to our division at the University of Connecti-
cut Health Center with a chief complaint of an
Angle Orthodontist, Vol 85, No 1, 2015
CHHIBBER, UPADHYAY, URIBE, NANDA
increased overjet. Both sisters were assessed to be
at cervical vertebral maturation stage III. 14 Not
surprisingly, both twins had similar skeletal discrep-
ancies (Figure 3), with skeletal Class II relation due to
a retrognathic mandible and average to vertical
growth pattern.15 Even though the patients were
identical twins, they had slightly different dental
 LONG-TERM SURGICAL VS FUNCTIONAL CLASS II 145
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The Angle Orthodontist 2015.85:142-156.

Figure 3. The twins superimposed on each other at pretreatment. Their skeletal profiles were almost identical.

representations. It has been reported that variation in
occlusal relationships has little or no genetic associ-
ation.16 Patient 1 had a congenitally missing mandib-
ular right second premolar, while patient 2 had
bilaterally missing mandibular second premolars with
retained deciduous second molars and transposed
mandibular right canine. The overjet was more
pronounced in patient 2 due to slightly more proclined
maxillary incisors.
Treatment Objectives
The primary treatment objective for both patients
was to correct the underlying skeletal discrepancy.

Figure 4. Prefunctional appliance photographs for patient 1.

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The Angle Orthodontist 2015.85:142-156.
Figure 5. Patient 1 posttreatment records.
Therefore, orthognathic surgical treatment was initially
the treatment of choice presented to both patients. While
patient 1 declined the surgical option due to apprehension
of the surgical procedure, patient 2 agreed to it. Informed
consent was obtained from the parents for both patients,
explaining the differences in the treatment approach and
expected differences in outcome.
Patient 1 was thus treated nonsurgically with a FFA.
The treatment objectives for patient 1 were: attempt to
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CHHIBBER, UPADHYAY, URIBE, NANDA
maximize the differential jaw growth by nonsurgical
correction of the malocclusion, control the vertical
dimension and space maintenance for the missing
mandibular premolar for subsequent implant replace-
ment, retention, and follow up.
Patient 2 was treated with orthognathic surgery for
Class II correction. For patient 2, the treatment
objectives were: to surgically correct the underlying
skeletal discrepancy, correct the vertical dimension by
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Figure 6. Presurgical photographs for patient 2.
surgically impacting the maxilla, space maintenance for
the missing mandibular second premolars and subse-
quent implant placement, retention, and follow up.
Based on the unfavorable position of the transposed
mandibular right canine, it was decided not to attempt to
correct the transposition and mesially move the
mandibular right first premolar into the canine region.
Treatment Alternatives
As an alternative treatment plan, extraction of
maxillary premolars was considered for both patients.
This would camouflage the underlying skeletal dis-
crepancy by reducing the overjet primarily by maxillary
anterior teeth retraction. However, this approach could
potentially worsen the soft tissue profile.
Treatment Progress
For patient 1, initial leveling and alignment was
achieved with a 0.016-inch nickel–titanium archwire.
The archwires were gradually built up to maxillary 0.019
3 0.025-inch stainless steel and mandibular 0.021 3
0.025-inch stainless steel. A closed coil spring was
placed to maintain the space for the missing mandibular
right second premolar. To minimize the mandibular
incisor proclination during the fixed functional appliance
phase, mandibular incisor brackets with 26u torque
were used. The Twin Force Bite Corrector (TFBC)
appliance17–19 was used for 10 months for Class II
correction (Figure 4). The patient was in a super Class I
molar relation with anterior edge-to-edge incisal
147
relationship to compensate for mild relapse after
removal of the TFBC appliance. Class II elastics were
used to maintain the corrections that were achieved.
Finishing and detailing were done, and the patient was
debonded after 30 months of active treatment at the age
of 16 years (Figure 5).
Patient 2 had bilateral missing mandibular second
premolars. There was severe loss of arch length on the
mandibular right side due to mesial migration of the
entire posterior segment into the canine space. Since
the erupting canine was transposed with the first
premolar in an unfavorable manner (Figure 2), it was
decided not to correct the transposition. On the left side,
space was maintained for subsequent implant place-
ment for the missing mandibular second premolar. Thus,
the occlusion was planned to be finished in a Class III
molar relation on the right and Class I on the left side.
After the alignment phase, mandibular anterior teeth
were retracted into the edentulous space of the
missing second premolars to maximize the mandibular
surgical advancement (Figure 6). After assessing
completion of growth by serial lateral cephalograms,
surgery was planned when the patient was age
18 years and 2 months. To correct the vertical
maxillary excess and excessive gingival display,
LeFort I maxillary impaction along with mandibular
advancement using bilateral sagittal split osteotomy
technique was performed. The patient was subse-
quently debonded at the age of 18 years and 8 months
after an active treatment time of 5 years and 2 months
(Figure 7). Similar observations of an increased
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Figure 7. Patient 2 posttreatment records.
treatment time in surgical cases compared to nonsur-
gical cases have been reported.20
Treatment Results
Overall, cephalometric superimpositions were done
using the Björk and Skieller method.21 For regional
superimpositions, the maxilla was superimposed along
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CHHIBBER, UPADHYAY, URIBE, NANDA
the palatal cortex by registering on the bony internal
details and superior and inferior surfaces of the hard
palate. The mandible was superimposed posteriorly
over the outline of the mandibular canal and anteriorly
over the anterior contour of the chin and internal bony
structures of the symphysis.
In patient 1, the TFBC appliance phase superimpo-
sitions (Figure 8) revealed that overjet correction was
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Figure 8. Overall and regional superimpositions depicting fixed functional appliance (FFA) outcome: before FFA (solid black), after FFA (dashed grey).
due to proclination of mandibular incisors, and molar
correction was a combination of differential jaw growth
and mesial movement of mandibular molars. The
patient was recalled 5 years in retention and showed
stable correction of the treatment results (Figure 9).
Overall and regional superimpositions at pretreatment,
posttreatment, and retention (Figure 10) depicted me-
sial movement of the molars along with incisor
proclination for both arches. During the retention phase,
there was mild relapse of the mandibular incisor
proclination leading to an increase in overjet with stable
results for molar correction that were achieved.
For patient 2, the surgical phase superimpositions
(Figure 11) showed the maxilla was impacted 4–5 mm
posteriorly and 2–3 mm anteriorly. The mandible was
advanced by 4–5 mm. The patient was recalled 4 years
in retention and showed slight improvement of the
occlusal relationship (Figure 12). Overall and regional
superimpositions at pretreatment, posttreatment, and
retention time points (Figure 13) showed that the
overjet and molar correction was essentially due to
the surgical advancement of the mandible. In the
retention phase, the skeletal corrections achieved were
remarkably stable with mild relapse of the mandibular
incisor inclination, which led to slight increase in overjet.
Comparison of Treatment Progress, Results, and
Long-term Retention
The cephalometric and clinical comparison of the twin
sisters took place at three time points: pretreatment,
149
posttreatment, and long-term retention (Figures 3, 14,
and 15; Table 1).
1. At the initial examination (13 years 3 months). Even
though the skeletal A and B points were slightly
backwardly positioned in patient 2 compared to
patient 1, the underlying skeletal discrepancy asso-
ciated with mandibular retrognathia and vertically
maxillary excess was similar in both. The overjet was
slightly more pronounced in patient 2 due to
proclined maxillary incisors (Figure 3). Dentally there
were minor differences, with patient 1 having her
mandibular second premolar missing, while patient 2
had bilateral missing second premolars with a
transposed mandibular right canine.
2. At the posttreatment level (age 16 years, 5 months
for patient 1 and 18 years, 8 months for patient 2).
The overall skeletal outcome was superior for
patient 2. She showed greater skeletal Class II
correction with good vertical control, while her twin
had dental compensations. However, the esthetic
outcome was similar in both patients (Figure 14).
3. At the retention level (22 years and 9 months).
Interestingly, even though the skeletal outcome of
patient 2 remained superior, the soft tissue profile was
still remarkably similar even though they underwent
different procedures for Class II correction (Figure 15).
DISCUSSION
When comparing different treatment options, their
efficacy is determined based on achievement of good
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Figure 9. Five years retention evaluation for patient 1 (nonsurgical twin).
occlusion, acceptable skeletal, dentofacial esthetics,
and long-term stability.14 The risks and cost/benefit
ratio of treatment approaches must be understood
when a treatment decision is being made for an
individual patient. The advantage of using twins for
such comparisons is that the difference in outcome
can be assumed to be epigenetic and thus directly the
result of the intervention provided, ie, surgery or FFA.
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Because the treatment approaches were so drastically
different, different outcomes would be expected in both
of the twins, and were observed at the end of
treatment.
It may be argued that in the surgical patient the
occlusion was not established perfectly on the right
side; however, the transposition between the canine
and the first premolar along with the missing second
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Figure 10. Nonsurgical case overall and regional superimpositions: pretreatment (solid black), post treatment (dashed grey), and retention
(dashed black).

premolar made space management complicated, and
further surgical advancement of the mandible on the
right side to achieve a Class III molar relation might
have shifted the skeletal midline to the patient’s left
side and created facial asymmetry. In addition, it could
also be argued that the mandibular anterior teeth were
not retracted enough in the surgical case to create a
greater overjet to advance the mandible. However,
presurgically the occlusion was set to a Class II
relation bilaterally, and any further retraction was not

Figure 11. Overall and regional superimpositions depicting surgery outcome: before surgery (solid black), after surgery (dashed grey).

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Figure 12. Four-year retention evaluation for patient 2 (surgical twin).
possible without consideration of interproximal reduc-
tion of lower anterior teeth or extraction of additional
teeth. It has been reported that often in surgical cases
there is not adequate decompensation of the dentition
for greater surgical correction.22,23 Additionally, since
the surgical plan entailed maxillary impaction, it was
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CHHIBBER, UPADHYAY, URIBE, NANDA
thought that the maxillary impaction would cause an
autorotation of the mandible allowing greater mandib-
ular advancement.
Studies comparing surgery to camouflage for Class
II correction have indicated that that surgical skeletal
correction generally results in better esthetic outcome
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Figure 13. Surgical case overall and regional superimpositions: pretreatment (solid black), posttreatment (dashed grey), and retention
(dashed black).
compared to camouflage,20 while others comparing
surgery to growth modification have reported that the
soft tissue profile outcome was similar with either
method.24 Moreover, Ibitayo et al.10 compared the
outcome of growing hyperdivergent Class II patients
treated with functional appliances to adults with
Figure 14. The twins superimposed on each other after treatment.
153
surgical maxillary impaction and mandibular advance-
ment and found similar dentoskeletal outcomes with
either method hypothesizing that residual growth
played an important contributing factor in normalization
of the malocclusion in the growing functional group. In
comparative studies of mandibular advancement
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Figure 15. The twins superimposed on each other at retention.
surgery to camouflage by extractions or fixed func-
tional appliances,25,26 it has been reported that while
the skeletal profile outcome showed greatest improve-
ment with mandibular advancement surgery, no
significant differences was observed for soft tissue
profile improvement, suggesting that soft-tissue re-
modeling does not follow changes in skeletal struc-
tures in a predictable manner similar to observations
made by Park and Burstone.27 Here with the twins,
even though the vertical control and skeletal correction
was better in the surgical case compared to the
nonsurgical twin, the long-term profile outcome were
remarkably similar.
The benefits of superior skeletal outcome with
orthognathic surgery should be outweighed against
the risks/complications and costs associated. The
most common short-term complications include pain,
swelling, and intraoperative or postoperative bleeding.
The most common long-term complication is postop-
erative neurosensory loss of the inferior alveolar nerve
with up to 35% for subjective reporting and 33% for
objective testing.28 Other long-term complications such
as neurosensory abnormality, nonunion, mal union,
postoperative malocclusion, and relapse have also
been reported.29 Orthodontic treatment with functional
appliances involves frequent short visits to a clinician
for a long duration. While the orthodontic armamen-
tarium is relatively inexpensive compared to those
used in a surgical setup, the frequent visits over a long
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CHHIBBER, UPADHYAY, URIBE, NANDA
time period could possibly increase the overall
treatment cost to the patient. Kumar et al.30 compared
the cost of orthodontics to orthognathic surgery and
reported that the overall cost of orthodontics was
relatively inexpensive and accounted for only 25% of
overall treatment cost. Venugoplan et al.31 using the
nationwide inpatient sample database for the year
2008 analyzed 10,345 orthognathic surgical proce-
dures in the United States and reported that the mean
charge per hospitalization was $47,348, and the total
hospitalization charge for the entire United States was
approximately $466.8 million. However, they did not
have a breakdown on the type of surgery related to the
cost associated. Nevertheless, it may therefore seem
justifiable to question the cost, affordability, need,
want, and effects of orthognathic surgery compared to
other nonsurgical methods in patients with residual
mandibular growth.
CONCLUSIONS
Two identical twins were treated with two different
treatment methods for Class II correction. In the long
term, even though the skeletal outcome with orthog-
nathic surgery was superior compared to her nonsur-
gical twin, the soft tissue profiles were remarkably
similar. The increased treatment time and cost may
call to question the use of such surgical intervention
compared to other nonsurgical methods if done prior to
the completion of growth.
 LONG-TERM SURGICAL VS FUNCTIONAL CLASS II 155

Table 1. Cephalometric Values for Patients 1 and 2

Patient 1 Patient 2
Fixed Functional Appliance Surgical
Pretreatment Posttreatment Retention Pretreatment Posttreatment Retention
Maxillary skeletal
SNA (u) 81 81 82 80 79 79
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ANS-PNS (mm) 61 58 61 59 54 54
Co-A (mm) 90 93 94 90 90 90
Mandibular skeletal
SNB (u) 74 76 77 73 78 78
Go-Gn (mm) 64 69 70 65 66 66
Co-Gn (mm) 105 112 114 106 115 115
Maxilla-mandible
ANB (u) 7 5 5 7 1 1
PP-SN (u) 8.5 7 6.5 7 4 4.5
Co-Gn-Co-A (mm) 15 19 20 16 15 15
Overjet (mm) 8 2.5 3.5 10 3 4.5
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Vertical skeletal
SN-GoGn (u) 37 36.5 33 36 37 35
UFH (N-ANS) (mm) 54 56 56 56 49 49
LFH (ANS-Me) (mm) 72 76 77 73 76 76
Occ-Sh (u) 20.5 20.5 18 19 16 14
Maxillary dentoalveolar
U1-SN (u) 109 106 110 113 113 111
U6-palatal plane (mm) 18 20 21 20 22 23
U6-sella vertical (mm) 43 47 49 42 48 49
U1-sella vertical (mm) 78 79 80.5 76.5 80 79.5
U1-palatal plane (mm) 22 27 28 24.5 30 29.5
Mandibular dentoalveolar
L1-APog (mm) 1 5 4 1 5.5 4.5
IMPA (u) 92 102 102 93 97 90
L6-mandibular plane (mm) 32 36.5 37 31 36 37
L1-sella vertical (mm) 68 74 76 65 75 74
L1-mandibular plane (mm) 41 43 45 45 47 48.5
L6-sella vertical (mm) 43 47 49.5 39 49 51
Soft tissue
G-Sn-Pg (u) 157 160 159 157 162 165
Nasolabial angle (u) 114 112 110 104 104 103
E line-Ls (mm) 21 25 26 22 25 27
E line-Li (mm) 1 0 22 22 3 4.5

ACKNOWLEDGMENTS
We thank Drs Erin Kazmierski, Jill Danaher, Allen Yaghoub-
zadeh, and Shyam Desai for their contribution to the treatment of
these two patients.
REFERENCES
1. King L, Harris EF, Tolley EA. Heritability of cephalometric
and occlusal variables as assessed from siblings with overt
malocclusions. Am J Orthod Dentofacial Orthop. 1993;104:
121–131.
2. Johannsdottir B, Thorarinsson F, Thordarson A, Magnusson
TE. Heritability of craniofacial characteristics between
parents and offspring estimated from lateral cephalograms.
Am J Orthod Dentofacial Orthop. 2005;127:200–207.
3. Nakasima A, Ichinose M, Nakata S, Takahama Y. Hereditary
factors in the craniofacial morphology of Angle’s Class II and
Class III malocclusions. Am J Orthod. 1982;82:150–156.
4. Harris JE, Kowalski CJ. All in the family: use of familial
information in orthodontic diagnosis, case assessment and
treatment planning. Am J Orthod. 1976;69:493–509.
5. Kawala B, Antoszewska J, Necka A. Genetics or environ-
ment? A twin-method study of malocclusions. World J
Orthod. 2007;8:405–410.
6. Spalding PM. Treatment of Class II malocclusions. In:
Bishara SE, ed. Textbook of Orthodontics. 1st ed. Philade-
phia, PA: WB Saunders; 2001:324–374.
7. Chhibber A, Upadhyay M, Uribe F, Nanda R. Mechanism of
Class II correction in prepubertal and postpubertal patients with
Twin Force Bite Corrector. Angle Orthod. 2013;83:718–727.
8. Bishara SE, Ziaja RR. Functional appliances: a review.
Am J Orthod Dentofacial Orthop. 1989;95:250–258.
9. Berger JL, Pangrazio-Kulbersh V, George C, Kaczynski R.
Long-term comparison of treatment outcome and stability of
Class II patients treated with functional appliances versus
bilateral sagittal split ramus osteotomy. Am J Orthod Den-
tofacial Orthop. 2005;127:451–464.

Angle Orthodontist, Vol 85, No 1, 2015

 156
10. Ibitayo AO, Pangrazio-Kulbersh V, Berger J, Bayirli B.
Dentoskeletal effects of functional appliances vs bimaxillary
surgery in hyperdivergent Class II patients. Angle Orthod.
2011;81:304–311.
11. Lohrmann B, Schwestka-Polly R, Nägerl H, Ihlow D, Kubein-
Meesenburg D. The influence of functional orthodontics and
mandibular sagittal split advancement osteotomy on dental
and skeletal variables—a comparative cephalometric study.
Downloaded from www.angle.org by UNIVERSITY OF PITTSBURGH on 05/13/19. For personal use only.
Eur J Orthod. 2006;28:553–560.
12. Nanda RS, Meng H, Kapila S, Goorhuis J. Growth changes
in the soft tissue facial profile. Angle Orthod. 1990;60:
177–190.
13. Bishara SE. Facial and dental changes in adolescents and
their clinical implications. Angle Orthod. 2000;70:471–483.
14. Franchi L, Baccetti T, McNamara JA Jr. Mandibular growth
as related to cervical vertebral maturation and body height.
Am J Orthod Dentofacial Orthop. 2000;118:335–340.
15. Arnett GW, Bergman RT. Facial keys to orthodontic
diagnosis and treatment planning—part II. Am J Orthod
Dentofacial Orthop. 1993;103:395–411.
16. Harris E, Johnson MG. Heritability of craniometric and
The Angle Orthodontist 2015.85:142-156.
occlusal variables: a longitudinal sib analysis. Am J Orthod
Dentofacial Orthop. 1991;99:258–268.
17. Chhibber A, Upadhyay M, Uribe F, Nanda R. Long-term
stability of Class II correction with the Twin Force Bite
Corrector. J Clin Orthod. 2010;44:363–376.
18. Campbell E. A Prospective Clinical Analysis of a Push-Type
Fixed Intermaxillary Class II Correction Appliance [thesis].
Farmington, Conn: University of Connecticut; 2003.
19. Guimaraes CH Jr, Henriques JF, Janson G, et al. Prospec-
tive study of dentoskeletal changes in Class II division
malocclusion treatment with twin force bite corrector. Angle
Orthod. 2013;83:319–326.
20. Proffit WR, Phillips C, Douvartzidis N. A comparison of
outcomes of orthodontic and surgical-orthodontic treatment
of Class II malocclusion in adults. Am J Orthod Dentofacial
Orthop. 1992;101:556–565.
Angle Orthodontist, Vol 85, No 1, 2015
CHHIBBER, UPADHYAY, URIBE, NANDA
21. Björk A, Skieller V. Facial development and tooth eruption:
an implant study at the age of puberty. Am J Orthod. 1972;
62:339–383.
22. Potts B, Shanker S, Fields HW, Vig KW, Beck FM. Dental
and skeletal changes associated with Class II surgical-
orthodontic treatment. Am J Orthod Dentofacial Orthop.
2009;135:566.e1–7.
23. Burden D, Johnston C, Kennedy D, Harradine N, Stevenson
M. A cephalometric study of Class II malocclusion treated
with mandibular surgery. Am J Orthod Dentofacial Orthop.
2007;131:7.e1–8.
24. Shell TL, Woods MG. Perception of facial esthetics: a
comparison of similar class ii cases treated with attempted
growth modification or later orthognathic surgery. Angle
Orthod. 2003;73:365–373.
25. Cassidy DW Jr, Herbosa EG, Rotskoff KS, Johnston LE Jr.
A comparison of surgery and orthodontics in ‘‘borderline’’
adults with Class II, division 1 malocclusions. Am J Orthod
Dentofacial Orthop. 1993;104:455–470.
26. Kinzinger G, Frye L, Diedrich P. Class II treatment in adults:
comparing camouflage orthodontics, dentofacial orthope-
dics and orthognathic surgery—a cephalometric study to
evaluate various therapeutic effects [in English, German].
J Orofac Orthop. 2009;70:63–91.
27. Park YC, Burstone CJ. Soft-tissue profile—fallacies of hard-
tissue standards in treatment planning. Am J Orthod Den-
tofacial Orthop. 1986;90:52–62.
28. Bays RA, Bouloux GF. Complications of orthognathic
surgery. Oral Maxillofac Surg Clin North Am. 2003;15:
229–242.
29. Tucker MR. Orthognathic surgery versus orthodontic cam-
ouflage in the treatment of mandibular deficiency. J Oral
Maxillofac Surg. 1995;53:572–578.
30. Kumar S, Williams AC, Sandy JR. Orthognathic treatment:
how much does it cost? Eur J Orthod. 2006;28:520–528.
31. Venugoplan SR, Nanda V, Turkistani K, Desai S, Allareddy
V. Discharge patterns of orthognathic surgeries in the United
States. J Oral Maxillofac Surg. 2012;70:e77–86.