Journal of Orthodontics

ISSN: 1465-3125 (Print) 1465-3133 (Online) Journal homepage: http://www.tandfonline.com/loi/yjor20

An active, skeletally anchored transpalatal

appliance for derotation, distalization and vertical
control of maxillary first molars

Jan Hourfar, Björn Ludwig & Georgios Kanavakis

To cite this article: Jan Hourfar, Björn Ludwig & Georgios Kanavakis (2014) An active, skeletally
anchored transpalatal appliance for derotation, distalization and vertical control of maxillary first
molars, Journal of Orthodontics, 41:sup1, s24-s32, DOI: 10.1179/1465313314Y.0000000102

To link to this article: http://dx.doi.org/10.1179/1465313314Y.0000000102

Published online: 16 Dec 2014.

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 MINI-IMPLANT SUPPLEMENT Journal of Orthodontics, Vol. 41, 2014, S24–S32

An active, skeletally anchored transpalatal

appliance for derotation, distalization and
vertical control of maxillary first molars
Jan Hourfar1, Björn Ludwig2 and Georgios Kanavakis3
1
Private Practice, Reinheim, Germany; Department of Orthodontics, University of Heidelberg, Germany 2Private practice Traben-Trarbach,
Germany; Department of Orthodontics, University of Homburg/Saar, Germany 3Department of Orthodontics and Dentofacial Orthopedics,
Tufts University School of Dental Medicine, Boston, MA, USA

Objective: The objective of this investigation was to evaluate treatment outcomes of the skeletally anchored ‘Frog’
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appliance. Design: A single-centre, retrospective study was performed. Setting: Private orthodontic practice.
Participants: Patients who had undergone comprehensive orthodontic treatment with the skeletally anchored
‘Frog’ appliance. Methods: 43 participants (20 males and 23 females) who had received treatment with the
skeletally anchored ‘Frog’ appliance where included. In order to explore dentoalveolar and skeletal treatment
outcomes, pre- (T1) and post- (T2) treatment measurements were performed on patients’ plaster models and
cephalometric images. Comparisons between T1 and T2 were made by means of a Student’s t-test. All statistical
analyses were conducted at the 0.05 level of statistical significance. Results: Study model analysis revealed a
statistically significant derotation of maxillary molars (mDT22T159.5u, P,0.001) as well as an increase in transverse
arch dimensions at the end of treatment (mDT2–T152.2 mm, P,0.001). Cephalometric changes included bodily
distalization of maxillary molars (mD(T2–T1)521.9 mm, P,0.001), as well as noticeable angular displacement (mDT2–T15
4.1u, P50.004). No significant anchorage loss was observed, as displayed by the limited change in maxillary incisor
position (mD(T1–T2)50.2 mm, P50.45). In addition, excellent vertical control of the maxillary molars was achieved, with
no change in the mandibular plane (ML/NSL) angle (mDT2–T150.3u, P50.38). Conclusions: The skeletal ‘Frog’ is effective
in derotating and distalizing maxillary molars without anchorage loss and with excellent vertical control.
Key words: Class II correction, molar derotation, molar distalization, skeletal anchorage, vertical control

Received 28 March 2014; accepted 18 May 2014

Introduction have been proposed for molar derotation and distaliza-

A Class II (Angle) molar relationship occurs in
approximately 20% of the population (Proffit et al.,
1998) and can result from an underlying skeletal
discrepancy, a dental malocclusion or a combination
of both (Thiruvenkatachari et al., 2013). In the presence
of maxillary tooth size-arch length discrepancies, these
can be resolved with extractions (de Almeida-Pedrin
et al., 2009; Livas et al., 2011), maxillary expansion
(Lagravere et al., 2005; Vargo et al., 2007) or molar
derotation and distalization (Papadopoulos et al., 2010;
Grec et al., 2013).
The traditional method of applying an extra-oral,
distalizing force on maxillary molars through the use of
headgear, provides good treatment results (King et al.,
1990; Haas, 2000; Siqueira et al., 2007); however, it
requires optimal patient compliance (Egolf et al. 1990).
Instead, numerous intraoral appliances and techniques
tion (Ghosh and Nanda, 1996; Gianelly, 1998;
Mandurino and Balducci, 2001; Ngantung et al., 2001;
Chiu et al., 2005; Angelieri et al., 2006). All intra-oral
distalizing appliances utilize the lower dentition (Muse
et al., 1993, Gianelly, 1998), the anterior palate
(Ngantung et al., 2001; Chiu et al., 2005) or the
maxillary anterior teeth (Ghosh and Nanda, 1996;
Angelieri et al., 2006) as anchorage to produce their
effect on the maxillary molars. Therefore, their use
commonly results in significant proclination of max-
illary or mandibular incisors, respectively.
In order to prevent loss of anchorage, various
‘distalizing’ techniques using mini-implants or bone-
plates have been proposed (Kircelli et al., 2006;
Sugawara et al., 2006; Fudalej and Antoszewska, 2011;
Grec et al., 2013; Kaya et al., 2013). Compared to tooth-
borne appliances, bone-borne ‘distalizers’ not only

Address for correspondence: G. Kanavakis, Department of

Orthodontics and Dentofacial Orthopedics, Tufts University,
School of Dental Medicine, 1 Kneeland Street, DHS#1145,
Boston, MA 02111, USA
Email: georgios.kanavakis@tufts.edu
# 2014 British Orthodontic Society DOI 10.1179/1465313314Y.0000000102
 JO September 2014 Mini-implant Supplement
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Figure 1 Sample definition
minimize anchorage loss (Grec et al., 2013), but also
deliver better treatment results by providing greater
amounts of distalization (Fudalej and Antoszewska,
2011). Ludwig et al. (2011b) proposed the ‘Skeletal Frog
– appliance’. The device is anchored on two palatal
mini-implants, is very hygienic and easy to activate.
However, its clinical effectiveness has yet not been
demonstrated. Therefore the purpose of this study was
to quantify treatment results with the ‘skeletal Frog –
appliance’. It was hypothesized that the method is
effective in molar derotation and distalization and also
provides good vertical control.
Materials and methods
Study population
All patients’ records of a single orthodontic practice in
Traben-Trarbach, Germany were reviewed. In order to
be included in the study, patients had to fulfill the
following criteria:
1. Complete initial (T1) and final (T2) orthodontic
records including study models and cephalometric
X-rays.
2. No previous history of orthodontic treatment.
3. Complete permanent dentition. No tooth agenesis
or loss of permanent teeth.
4. Mild to moderate maxillary crowding, enough to
‘block out’ at least one of the permanent canines.
Clinical outcomes of the skeletal ‘Frog’ appliance S25
5. At least a half cusp Class II molar relationship at
the beginning of treatment.
6. No or minimal mandibular crowding which could
be resolved with mild interproximal reduction.
7. Comprehensive treatment had to be completed
without premolar extractions, with the use of a
skeletally anchored ‘Frog appliance’ (Ludwig et al.,
2011b), in order to achieve a Class I molar
relationship.
The search generated a total of 91 patients who were
treated with a skeletally supported ‘Frog’ appliance.
Application of the inclusion criteria resulted in a sample
of 43 patients (20 males and 23 females). Average age at
T1 was 11.6 years (m511.6; SD¡1.64) and 13.5 years at
T2 (m513.5; SD¡1.69) (Figure 1).
Clinical procedures
All patients underwent comprehensive, non-extraction
orthodontic treatment with pre-torqued and pre-angu-
lated fixed appliances (slot dimension: 0.022060.0280).
For the insertion of the skeletally anchored ‘Frog’
distalizer, two 8 mm long and 1.6 mm in diameter mini-
implants (Ortho Easy; Forestadent, Pforzheim, Germany)
were placed in the paramedian area of the anterior palate
(Ludwig et al., 2011a).
Construction and activation of the skeletal ‘Frog’
appliance
Constructively, the appliance combines features of a
classic trans-palatal arch and a distalization device,
similar to a skeletally supported Pendulum-appliance
(Escobar et al., 2007; Polat-Ozsoy et al., 2008)
(Figure 2). Detailed steps for appliance fabrication have
been presented elsewhere (Ludwig et al., 2011b).
For optimal treatment results, the appliance was
activated before insertion with two compensating bends;
a 15–20u uprighting bend (Figure 3a) and a 5–10u toe in
bend (Figure 3b). After the initial activation, the
distalizing screw was turned five full turns every 4–
6 weeks in order to re-activate the compensating bends.
This process is a minor modification from the
activation steps described previously by Ludwig et al.
(2011b).
Measurements on plaster models
Transverse changes in maxillary arch dimensions were
evaluated by measuring the intermolar distance at the level
of the first and second maxillary molars. The distances
between the mesio-buccal and disto-buccal cusps as well as
the central fossae of the first and second molars were
measured with a digital caliper (Mitutoyo Digimatic
 S26 Hourfar et al. Mini-implant Supplement
Figure 2 The skeletal ‘Frog’ appliance
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Caliper CD-10CX; Mitutoyo America Corporation,
Aurora, IL, USA), at T1 and T2 (Figure 4A).
Measurements for molar rotation were performed on
digital photographs of the study models. In order to
acquire the photographs under standardized conditions,
all models were aligned on a grid at a preset distance
from a digital camera that was mounted on a tripod.
The amount of molar rotation was measured by the
angles between the straight line transversing the
mesiobuccal and distobuccal cusp tips of the first and
second molars, and the raphe-median line (Figure 4B).
This methodology has been described previously by
Kinzinger et al. (Kinzinger et al.).
Cephalometric measurements (Table 1)
Tracings were printed in colour (HP Color Laser Jet
CP1215; Hewlett Packard, Palo Alto, CA, USA) and all
cephalometric measurements were performed manually
to a quarter millimetre. Pre- (T1) and post– (T2)
treatment cephalometric X-rays were traced, analysed
and superimposed according to the methodology
described by Bjork (Bjork and Skieller, 1977), in one
sitting by a single operator (JH). Cephalometric
measurements were used to quantify skeletal and dental
changes in both sagittal and vertical dimensions. A
Figure 3 (a) 15–20u uprighting bend; (b) 5–10u toe in bend; (c) reactivation (4–5 turns every 4–6 weeks)
JO September 2014
schematic of all performed cephalometric measurements
is displayed in Figure 5.
Statistical analysis
In order to test intra-examiner reliability, the same
operator repeated all measurements on 20 randomly
selected cases, 3 months after initial measurements had
been performed. Measurements error was calculated via
the Dahlberg formula. Measurement error was calcu-
lated via the Dahlberg formula (Dahlberg, 1940)
(ME5!Sd2/2n) and ranged between 0.17 and 0.38. The
Kolmogorov–Smirnov test revealed a normal distribu-
tion of the data; therefore, the comparison between
measurements at T1 and T2 was performed by means of
a paired Student’s t-test. All statistical analyses were
conducted at the 0.05 level of statistical significance.
Results
Study model analysis
At the end of comprehensive orthodontic treatment
(T2), there was a statistically significant increase of
approximately 2 mm in the transverse dimension, as
measured by the distance between the central fossae of
the first (mDT22T152.2 mm, P,0.001) and second
maxillary molars (mDT22T151.7, P50.011) (Table 2).
 JO September 2014 Mini-implant Supplement Clinical outcomes of the skeletal ‘Frog’ appliance S27

Figure 4 Model analysis. (A) linear measurements; (B) angular measurements (RML: median raphae line; mb: mesio-
buccal; db: disto-buccal; cf: central fossa; M1: maxillary first molar; M2: maxillary second molar)
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Figure 5 (A) Linear and angular cephalometric measurements; (B) superimpositions according to Björk

Table 1 Definitions of cephalometric measurements.

Measurement Type Definition

SNA Angular — Skeletal Angle between the anterior cranial base (S–N) and Point A
NL/NSL Angular — Skeletal Angle between the anterior cranial base (S–N) and the palatal plane (ANS–PNS)
ML/NSL Angular — Skeletal Angle between the mandibular plane (ML) and the anterior cranial base (S–N)
m1/ANS–PNS Angular — Dental Angle between the long axis of the maxillary first molar and the
palatal plane (ANS–PNS)
i/ANS–PNS Angular — Dental Angle between the long axis of the maxillary central incisor and
the palatal plane (ANS–PNS)
m1-CEJ/ANS–PNS Linear — Dental Vertical distance between the cement–enamel junction of the first
maxillary molar and the palatal plane
i-CEJ/ANS–PNS Linear — Dental Distance between the cement–enamel junction of the maxillary central
incisor and the palatal plane
m1-CEJpost/m1-CEJpre Linear — Dental Sagittal distance between the maxillary first molar on the superimposition,
measured parallel to the palatal plane (ANS-PNS)
i-CEJpost/i-CEJpre Linear — Dental Sagittal distance between the maxillary central incisor on the superimposition,
measured parallel to the palatal plane (ANS–PNS)
 S28 Hourfar et al. Mini-implant Supplement JO September 2014

Table 2 Treatment changes in transverse dimension.

T1 T2 DT2–T1

Intermolar distance (mm) (n543) m SD m SD m SD P-value

Central fossa (cf) First molar 45.3 2.6 47.5 2.3 2.2 2.1 ,0.001
Second molar 50.4 2.4 52.6 3.1 1.7 1.7 0.01
Mesio-buccal cusp (mb) First molar 49.1 2.9 52.0 2.6 2.9 2.0 ,0.001
Second molar 54.9 2.7 57.3 3.9 2.1 1.4 ,0.001
Disto-buccal cusp (db) First molar 52.1 3.0 53.2 2.7 1.1 2.6 0.007
Second molar 56.1 2.5 57.7 3.3 1.2 1.2 0.015
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Table 3 Molar derotation

T1 T2 DT1–T2

Molar rotation (n543) m SD m SD m SD P-value

Tooth #16 15.2 8.9 5.8 5.7 9.5 8.5 ,0.001

Tooth #26 15.9 7.3 6.9 6.6 8.9 8.3 ,0.001
Tooth #17 20.1 4.5 23.5 7.0 0.7 5.9 0.74*
Tooth #27 5.2 7.1 20.1 8.9 2.1 6.0 0.33*

*Not statistically significant.

In addition, the results revealed a statistically sig-
nificant derotation of the maxillary first molars. As
displayed in Table 3, treatment with the skeletal ‘Frog’
appliance resulted in an average derotation of the first
maxillary molar of 9.5u (mDT2–T159.5u, P,0.001). The
second maxillary molars, as expected, did not exhibit
any rotational changes.
Cephalometric measurements
Treatment changes in cephalometric values are dis-
played in Tables 4 and 5. The skeletal ‘Frog’ appliance
had minimal skeletal effects and most of its effects were
dento-alveolar.
In addition to the previously mentioned molar
derotation, there was a statistically significant bodily
distalization of the first maxillary molar [mD(T2–T1)5
21.9 mm, P,0.001] (Figure 5B and Table 5). However,
the maxillary molars, on average, also exhibited a
tipping movement of 4.1u [mDT2–T154.1u, P50.004]
(Table 4).
Anchorage was controlled efficiently during treatment
by means of the two palatal mini-implants that support

Table 4 Pre- and post-treatment cephalometric measurements.

T1 T2 DT2–T1

Measurement (n543) m SD m SD m SD P-value

SNA (u) 80.0 3.4 80.7 3.4 0.7 2.7 0.09*

NL/NSL (u) 7.2 4.1 6.9 4.1 20.3 3.6 0.59*
ML/NSL (u) 34.0 3.9 34.3 3.8 0.3 2.5 0.38*
m1/ANS–PNS (u) 79.6 4.8 75.5 5.1 24.1 5.7 0.004
i/ANS–PNS (u) 107.4 6.6 111.5 5.3 4.2 5.9 0.004
m1-CEJ/ANS–PNS (mm) 13.7 3.0 14.6 2.9 1.0 1.3 ,0.001
i-CEJ/ANS–PNS (mm) 17.0 2.6 17.6 2.6 0.6 1.2 0.002

*Not statistically significant.

 JO September 2014 Mini-implant Supplement
Table 5 Sagittal dental changes from superimpositions according to Björk.
Measurement (n543)
Molar displacement m1-CEJpost/m1-CEJpre
Incisor displacement i-CEJpost/i-CEJpre
*Not statistically significant.
the appliance. This was exhibited by the negligible linear
sagittal change in incisor position [mD(T1–T2)50.2 mm,
P50.45] (Table 5), although there was also an angular
change of approximately 4 degrees (mDT2–T154.2u,
P50.004) (Table 4).
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Vertically, the skeletal ‘Frog’ appliance produced
extrusion of the maxillary molars (mDT2–T151 mm,
P,0.001) as well as the maxillary incisors (mDT2–T15
0.6 mm, P50.002). However, it was so minimal that
there was no skeletal impact on the vertical dimension.
This is evident by the slim change in the ML/NSL angle
(mDT2–T150.3u, P50.38).
In order to explore the presence of potential vertical
side effects from using the skeletal ‘Frog’ appliance in
hyperdivergent patients, the same cephalometric ana-
lyses were repeated again on subjects that were
diagnosed as hyperdivergent (ML/NSL§36u) before
treatment. These results are displayed in Table 6. It
appears that in hyperdivergent subjects, although
significant distalization was obtained, the appliance
did not cause significant extrusion of the maxillary
molars (mDT2–T150.8 mm, P50.08), or the maxillary
incisors (mDT2–T150.2 mm, P50.52). Furthermore, the
mandibular plane angle was reduced after treatment in
these subjects (mDT2–T1521.3u, P50.016).
Discussion
This exploratory clinical study was performed in order
to quantify treatment effects of the skeletally anchored
‘Frog’ appliance (Ludwig et al., 2011b). According to
Table 6 Dental and skeletal vertical changes in hyperdivergent (ML/NSL§36) subjects.
Measurement (n512)
ML/NSL (u)
m1-CEJ/ANS–PNS (mm)
i-CEJ/ANS–PNS (mm)
Molar displacement m1-CEJpost/m1-CEJpre
*Not statistically significant.
Clinical outcomes of the skeletal ‘Frog’ appliance S29
D(T2–T1)
m SD P-value
21.9 1.4 ,0.001
0.2 1.4 0.45*
the results, the appliance managed to create an average
derotation of approximately 9u, measured as an angle
introduced by Henry in 1956 (Henry, 1956) (Figure 2).
Dahlquist et al. (1996) reported that the average value of
this angle in subjects with normal occlusion is approxi-
mately 11u. In the present study, at the end of treatment,
rotational average values were 5.8u for the right
maxillary molar and 6.9u for the left. Hence, the skeletal
‘Frog’ appliance managed to overcorrect rotated
molars. These results are directly comparable to the
ones reported by Kinzinger et al. (2004) who followed
the exact same methodology to study dentoalveolar
effects of the classic pendulum appliance. In their study,
molar derotation was also successful, but ranged
between 1.83 and 6.75u. A noticeable advantage of
utilizing a skeletally anchored appliance to create molar
derotation, is the ability to prevent mesial molar
displacement. This effect is usually observed when using
a traditional trans-palatal arch (Dahlquist et al., 1996;
Ingervall et al., 1996).
Furthermore, the skeletal ‘Frog’ appliance produced
noticeable distalization of the maxillary molars. Average
bodily posterior displacement was 1.9 mm, accompa-
nied by an average of 4.1u of distal tipping. Collective
results from previous research have been analysed by
Grec et al. (2013) and have demonstrated that tooth-
borne molar distalizers manage to produce distal
movements from 1.17 to 6.1 mm. Distal tipping ranges
between 0.89 and 18.5u. Skeletally anchored dista-
lizers, however, appear to produce more noticeable
distalization, ranging from 3.9 to 6.4 mm, with less
D(T2-T1)
m SD P-value
21.3 1.6 0.015
0.8 1.4 0.08*
0.2 1.2 0.52*
21.7 1.2 ,0.001
 S30 Hourfar et al. Mini-implant Supplement JO September 2014
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Figure 6 (a) Insertion of skeletal ‘Frog’; (b) post-treatment; (c) pre- (black) and post- (red) treatment sagittal tooth
positions; (d) molar derotation and distalization on digital models

average distal tipping (3–12.2u). Compared to the above,
results of the present study are less significant. However,
this is associated with the fact that our sample population
did not present a need for excessive distalization. A Class
I molar relationship was achieved primarily by derotation
and minimal distalization of the maxillary molars. The
effectiveness of the skeletal ‘Frog’ appliance in ortho-
dontic patients with serious distalization needs could be
the objective of future clinical studies.
A clinical example for the overall treatment effects of
the skeletal ‘Frog’ appliance is displayed in Figures 6
and 7. Molar derotation and distalization was sufficient
to resolve moderate maxillary crowding (Figure 6),
achieving a Class I molar relationship at the end of
comprehensive orthodontic treatment (Figure 7).
An important outcome of the present investigation
was the successful anchorage control during treatment
(Table 5). As indicated by the insignificant average
change of 0.2 mm in sagittal maxillary incisor position,
the skeletal ‘Frog’ appliance did not result in an adverse
linear protrusion of the maxillary incisors. Effective
anchorage control is also achieved by other skeletally
anchored molar distalizers (Kircelli et al., 2006; Escobar
et al., 2007; Öncag et al., 2007; Polat-Ozsoy et al., 2008).
These previous studies have demonstrated a linear
(retrusion) and angular (retroclination) distal displace-
ment of the maxillary incisors at the end of distalization
(Escobar et al., 2007; Öncag et al., 2007; Polat-Ozsoy
et al., 2008). Unfortunately, no direct comparisons can
be made to our results, because our post-treatment
measurements were done at the end of comprehensive
orthodontic treatment and represent the final position of
the maxillary incisors after torque expression from the
final orthodontic archwire (O’Higgins et al., 1999)

Figure 7 Final occlusion at the end of comprehensive orthodontic treatment with the skeletal ‘Frog’ appliance
 JO September 2014 Mini-implant Supplement
(0.021 inch60.025 inch stainless steel). Possibly, this
caused anchorage control, as measured in the present
investigation, to appear less efficient than with other
skeletally anchored appliances.
In regard to changes in the vertical dimension, the
skeletally anchored ‘Frog’ resulted in extrusion of
incisors (m50.6 mm, P50.002) as well as molars
(m51 mm, P,0.001). There is variability in previously
reported vertical effects of other mini-implant supported
distalizers. While some studies have demonstrated
extrusion of posterior teeth during distalization
(Escobar et al., 2007), others have exhibited limited
intrusion effects (Kinzinger et al., 2009; Oberti et al.,
2009). Unfortunately, due to lack of standardization in
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study methodology, results are not directly comparable.
In addition, it needs to be noticed that results of the
present study do not only depict the action of the
appliance, but also the comprehensive orthodontic
treatment. Interestingly, molar extrusion did not cause
a significant skeletal vertical change. At the end of
comprehensive treatment, there was an insignificant
average increase of 0.3u in mandibular plane angle (ML/
NSL; P50.38). Furthermore, contrary to what would be
expected, when subjects with a hyperdivergent skeletal
pattern (ML/NSL§36u) were analysed separately, a
decrease in mandibular plane angle was presented at the
end of treatment (Table 6). It appears that the skeletal
‘Frog’ appliance is effective in maintaining excellent
vertical control while derotating and distalizing max-
illary molars. Results from previous studies vary
significantly, and while some distalizing appliances
appear to provide adequate vertical control (Taner
et al., 2003; Öncag et al., 2007; Kinzinger et al., 2009;
Oberti et al., 2009; Patel et al., 2009; Sar et al., 2012),
others create a noticeable increase in mandibular plane
angle (Angelieri et al., 2006; Kircelli et al., 2006; Escobar
et al., 2007; Polat-Ozsoy et al., 2008; Papadopoulos
et al., 2010).
Moreover, there is great variety in designs of skeletally
anchored molar distalizers. It has been reported that
appliances including palatal coverage of the mini-
implants with an acrylic plate (Kircelli et al., 2006;
Escobar et al., 2007; Polat-Ozsoy et al., 2008; Oberti
et al., 2009) are less hygienic, usually create tissue
irritation and in some cases the acrylic plate can be
buried in to the palatal tissues despite the presence of the
mini-implants. On the contrary, the skeletal ‘Frog’
appliance does not contact the palatal tissues and
therefore allows for adequate oral hygiene and
improved patient comfort (Proffit et al., 1998; Ludwig
et al., 2011b).
The present study evaluated orthodontic treatment
outcomes with a skeletally anchored ‘Frog’ appliance.
Clinical outcomes of the skeletal ‘Frog’ appliance S31
Although the appliance appeared to be effective in
derotating and distalizing maxillary molars while
providing good vertical control, there were a few
limitations. The sample population did not require
significant distalization and most of the correction was
achieved by derotation. Also, measurements were
performed at the beginning and at the end of
comprehensive treatment. Although mechanotherapy
was identical in all cases, the overall effect of the
‘Frog’ appliance might have been influenced by the
tooth movement during the final stages of treatment.
Conclusions
1. The skeletal ‘Frog’ is an effective appliance in cases
where maxillary molars need to be derotated and
distalized.
2. The appliance provides excellent vertical control and
can therefore be used safely in patients with
hyperdivergent skeletal patterns.
Disclaimer statements
Contributors None.
Funding None.
Conflicts of interest The authors state that there are no
financial, commercial or other conflicts of interest
regarding the submitted manuscript.
Ethics approval None.
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