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Annali di Stomatologia | 2026; 17(2): 487-493 ISSN 1971-1441 | DOI: 10.59987/ads/2026.2.487-493 Articles |
Three-dimensional skeletal, dentoalveolar, and temporomandibular changes after twin block therapy in growing patients with Class II malocclusion due to mandibular retrusion: influence of treatment timing
Article History
Received: May 3, 2026
Accepted: June 23, 2026
Published: June 30, 2026
Abstract
Class II malocclusion due to mandibular retrusion is one of the most common dentoskeletal discrepancies in growing patients and a major indication for functional orthopedic therapy. This retrospective cohort study with an untreated control comparison evaluated the three-dimensional skeletal, dentoalveolar, and temporomandibular joint (TMJ) effects of Twin Block therapy and assessed whether treatment timing influenced the magnitude of change. Fifty-four subjects were analyzed: 18 treated in the pre-pubertal stage (ETG), 18 treated in the pubertal stage (LTG), and 18 untreated controls (CG) with comparable baseline Class II characteristics. Treated patients underwent cone-beam computed tomography (CBCT) before treatment (T1) and at the end of functional therapy (T2); control data were obtained from matched radiographic records. Three-dimensional skeletal, dentoalveolar, and TMJ variables were measured using dedicated software; repeatability was assessed with the intraclass correlation coefficient. Both treated groups showed significant mandibular advancement compared with controls, with larger changes in the pubertal group. SNB increased by 1.2° in ETG and 2.3° in LTG, ANB decreased by 1.1° and 2.0° respectively, and Co- Gn increased by 1.9 mm in ETG versus 3.5 mm in LTG. Overjet decreased by 3.8 mm in ETG and 4.1 mm in LTG. Condylar displacement was mainly antero-inferior, without radiologic signs of TMJ degeneration. Twin Block therapy was effective in correcting Class II mandibular retrusion, but the greatest orthopedic response was observed when treatment was performed during the pubertal growth phase.
Keywords: Class II Malocclusion, mandibular advancement device, orthodontic appliances, removable orthodontic appliance, temporomandibular joint, CBCT Cone-Beam Computer Tomography, craniofacial growth.
Introduction
Class II malocclusion accounts for a substantial proportion of orthodontic problems in children and adolescents and is frequently associated with mandibular retrusion rather than isolated maxillary protrusion [1–2]. Its clinical relevance extends beyond sagittal occlusal discrepancy, because increased overjet, convex facial profile, lip incompetence, altered tongue posture, oral habits, and soft-tissue imbalance may affect function, esthetics, psychosocial well-being, and trauma risk [1,3–7]. Functional appliances are commonly used during growth to posture the mandible forward and to promote skeletal, dentoalveolar, muscular, and neuromuscular adaptation [8–15].
Treatment timing remains a central issue in dentofacial orthopedics. Cervical vertebral maturation (CVM) and other biologic indicators have been proposed to identify the individual growth phase and to optimize the timing of mandibular growth modification [16]. Although functional appliances can improve Class II relationships, the magnitude of true skeletal change is generally moderate and is often associated with dentoalveolar compensation [10–11,13]. Timing studies on Twin Block and other functional appliances suggest that the most favorable orthopedic response is obtained during or near the pubertal growth spurt [8,13,15]. Earlier treatment may still be appropriate in selected patients, especially when the objective includes reduction of overjet-related trauma risk or management of oral habits and functional risk factors [6–7,17–19].
Three-dimensional imaging has expanded the diagnostic perspective from conventional two-dimensional cephalometry to direct assessment of mandibular morphology, condylar position, joint spaces, and TMJ adaptation [20–21]. In growing patients, however, CBCT must be justified by a clear clinical indication, supported by documented ethics committee approval, and performed with dose optimization in accordance with accepted radiation-protection principles (ALARA/ALADA).
The present study evaluated the three-dimensional skeletal, dentoalveolar, and TMJ effects of Twin Block therapy in growing patients with Class II malocclusion due to mandibular retrusion and compared outcomes between pre-pubertal and pubertal subjects. The null hypothesis was that treatment timing would not influence the magnitude of three-dimensional skeletal response.
Materials and Methods
This retrospective cohort study with an untreated control comparison included 54 growing subjects with skeletal Class II malocclusion due to mandibular retrusion. Thirty-six patients who had received Twin Block therapy were identified from clinical records and allocated according to skeletal maturity into an early treatment group (ETG; CVM stages 1–2; n = 18) and a late treatment group (LTG; CVM stages 3–4; n = 18) [16]. An untreated control group (CG; n = 18) with comparable baseline Class II characteristics was selected from a radiographic reference database and had T1–T2 records over a comparable observation interval. The clinical setting was Bloom Dental Clinic, Tirana, Albania.
Inclusion criteria were age 8–14 years, ANB >4°, overjet >5 mm, bilateral Class II molar and canine relationship, mandibular retrusion clinically improvable in a forward postural position, and no previous orthodontic or surgical treatment. Exclusion criteria were craniofacial syndromes, marked mandibular asymmetry (>3 mm), severe oral habits likely to interfere with treatment, poor compliance, and inadequate image quality [3,17,22–24].
All treated subjects received a removable Twin Block appliance composed of upper and lower acrylic plates with inclined planes set at approximately 70° to the occlusal plane [8,9]. The construction bite advanced the mandible by approximately 5–6 mm from the resting position, depending on individual clinical tolerance. Patients wore the appliance full-time except during meals and oral hygiene, and it was reviewed every 4 weeks. Functional treatment was considered complete when a stable Class I molar and canine relationship and normalized overjet were achieved.
CBCT examinations in treated groups were obtained at baseline (T1) and at the end of functional therapy (T2) only when clinically indicated. Acquisition parameters were: field of view 17 × 13 cm, voxel size 0.3 mm, exposure time 8–12 s, tube voltage 80–90 kV, tube current 8–10 mA. DICOM datasets were processed, and cephalometric measurements were performed using WebCeph (semi-automatic web-based cephalometric software; AssembleCircle Co., Seoul, South Korea) [25]. Skeletal landmarks identified on the WebCeph platform included Sella (S), Nasion (N), A-point, B-point, Condylion (Co), Gonion (Go), Gnathion (Gn), and Pogonion (Pg). Dentoalveolar measurements included overjet, overbite, and upper and lower incisor inclination. TMJ variables included condylar position and anterior, superior, and posterior joint spaces [20–21]. Representative baseline records are shown in Figures 1 and 2.
The primary outcomes were changes in mandibular sagittal projection and effective mandibular length (SNB, ANB, and Co-Gn). Secondary outcomes were changes in overjet, incisor inclination, vertical mandibular rotation, TMJ position, and posterior joint space. Normality was assessed with the Shapiro-Wilk test. Intragroup differences (T1–T2) were analyzed with paired t-tests; intergroup comparisons used one-way ANOVA with Tukey post-hoc testing (p < 0.05). Twenty percent of radiographic records were remeasured after 2 weeks to assess reproducibility by the intraclass correlation coefficient (ICC). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants and, for minor participants, from parents or legal guardians.
Results
All treated subjects completed the functional phase, and all control subjects had complete T1–T2 records. Mean age was 9.4 ± 0.8 years in ETG, 12.8 ± 1.1 years in LTG, and 11.7 ± 1.2 years in CG. Mean treatment duration was 13.2 ± 1.5 months (ETG) and 12.9 ± 1.3 months (LTG). Measurement repeatability was high for all variables (ICC >0.92). Sample characteristics are summarized in Table 1.
| Group | n | Mean age (years) | CVM stage | Mean treatment duration (months) |
|---|---|---|---|---|
| ETG (pre-pubertal) | 18 | 9.4 ± 0.8 | 1–2 | 13.2 ± 1.5 |
| LTG (pubertal) | 18 | 12.8 ± 1.1 | 3–4 | 12.9 ± 1.3 |
| CG (control) | 18 | 11.7 ± 1.2 | 2–3 | — |
ETG, early treatment group; LTG, late treatment group; CG, control group; CVM, cervical vertebral maturation.
Both treated groups showed significant sagittal mandibular improvement compared with controls. The LTG demonstrated larger skeletal changes than the ETG. SNB increased by 1.2 ± 0.5° in ETG and 2.3 ± 0.6° in LTG versus 0.3 ± 0.2° in controls (p < 0.001). ANB decreased by 1.1 ± 0.4° in ETG and 2.0 ± 0.5° in LTG versus 0.2 ± 0.2° in controls (p < 0.001). Effective mandibular length (Co-Gn) increased by 1.9 ± 0.8 mm in ETG and 3.5 ± 1.0 mm in LTG versus 0.7 ± 0.5 mm in controls (p < 0.001). Mild clockwise mandibular rotation was recorded in ETG (+0.9° SN-GoGn), whereas rotation was negligible in LTG (+0.2°). Pogonion advancement was greater in LTG than ETG (3.0 mm vs 1.6 mm). Main skeletal changes are reported in Table 2.
| Variable | ETG (ΔT2 T1) | LTG (ΔT2 T1) | CG (ΔT2 T1) | p value |
|---|---|---|---|---|
| SNB (°) | +1.2 ± 0.5 | +2.3 ± 0.6 | +0.3 ± 0.2 | <0.001 |
| ANB (°) | −1.1 ± 0.4 | −2.0 ± 0.5 | −0.2 ± 0.2 | <0.001 |
| Co-Gn (mm) | +1.9 ± 0.8 | +3.5 ± 1.0 | +0.7 ± 0.5 | <0.001 |
| SN-GoGn (°) | +0.9 | +0.2 | +0.0 | NS |
Values are mean ± standard deviation unless otherwise indicated. For SN-GoGn, mean only; SD not available. ETG, early treatment group; LTG, late treatment group; CG, control group; NS, not significant.
Dentoalveolar correction occurred in both treated groups. Overjet decreased by 3.8 ± 0.9 mm in ETG and 4.1 ± 0.8 mm in LTG, whereas controls showed minimal spontaneous change (−0.3 ± 0.2 mm; p < 0.001). Upper incisors retroclined by 5.2 ± 2.4° in ETG and 4.6 ± 2.1° in LTG; lower incisors proclined by 3.8 ± 1.9° and 2.5 ± 1.6°, respectively. The dentoalveolar component appeared more pronounced in ETG, whereas LTG showed a more favorable skeletal-to-dental correction ratio. All treated patients achieved Class I molar and canine relationships, with an average sagittal correction of approximately 4 mm. Dentoalveolar and TMJ changes are shown in Table 3.
| Variable | ETG (ΔT2 T1) | LTG (ΔT2 T1) | CG (ΔT2 T1) | p value |
|---|---|---|---|---|
| Overjet (mm) | −3.8 ± 0.9 | −4.1 ± 0.8 | −0.3 ± 0.2 | <0.001 |
| U1/NA (°) | −5.2 ± 2.4 | −4.6 ± 2.1 | 0.0 ± 0.5 | <0.001 |
| L1/NB (°) | +3.8 ± 1.9 | +2.5 ± 1.6 | +0.3 ± 0.4 | <0.01 |
| Posterior joint space (mm) | +0.5 | +0.8 | +0.1 | <0.05 |
Values are mean ± standard deviation unless otherwise indicated. For posterior joint space, mean only; SD not available. ETG, early treatment group; LTG, late treatment group; CG, control group; TMJ, temporomandibular joint.
CBCT assessment demonstrated mainly antero-inferior condylar displacement in both treated groups, greater in LTG (+2.1 mm) than in ETG (+1.3 mm). Posterior joint space increased, and anterior joint space decreased, consistent with condylar adaptation to the advanced mandibular position [20,21]. No radiologic signs of degenerative TMJ change were reported during the observation period. Clinically, both treated groups showed a more balanced facial profile and improved lip competence, with a more evident reduction in facial convexity in LTG. Representative post-treatment records are shown in Figures 3 and 4.
Discussion
The present study supports the view that Twin Block therapy can produce clinically meaningful correction of Class II malocclusion through a combination of skeletal and dentoalveolar effects [8–11]. The main finding was the greater three-dimensional skeletal response in pubertal patients, who showed larger increases in SNB and Co-Gn and a greater reduction in ANB than pre-pubertal patients. These results are consistent with timing studies indicating that the optimal orthopedic window for functional treatment occurs during or near the pubertal growth spurt [8,13,15].
The observed mandibular effects are consistent with previous evidence showing that functional appliances can enhance mandibular projection within biologically limited ranges [10,11,13]. In the present study, ETG showed greater upper incisor retroclination and lower incisor proclination relative to skeletal gain, supporting the interpretation of a stronger dentoalveolar contribution in pre-pubertal treatment [12,14,26].
The three-dimensional findings strengthen the interpretation of a real, although moderate, skeletal response. Compared with conventional lateral cephalometry, CBCT permits more direct assessment of mandibular structures, condylar position, and joint spaces [20–21]. The antero-inferior condylar displacement and increased posterior joint space observed in the present sample are consistent with CBCT studies reporting adaptive condylar changes after functional appliance therapy [20,21]. Importantly, no radiologic signs of degenerative TMJ remodeling were observed, suggesting that the adaptation was physiologic within the evaluated period [21,27–28].
From a clinical perspective, the results support an individualized approach to treatment timing. Early treatment may be justified in selected children with marked overjet, psychosocial concerns, oral habits, mouth breathing, functional imbalance, or elevated incisal-trauma risk [6–7,17–19,29]. Assessment of tongue function, oral habits, respiratory pattern, and myofunctional disorders may contribute to more comprehensive patient selection and follow-up [5,12,14,18–19,22,24,30]. When the primary objective is to maximize mandibular skeletal correction, therapy during the pubertal growth phase appears more favorable [8,13,15].
This study has limitations. First, the sample size was modest, limiting generalizability. Second, the report was limited to T1–T2 changes without long-term post-treatment stability data. Third, group allocation was based on skeletal maturity, and the untreated controls were historical rather than randomized, which may introduce selection bias. Future studies should include longer follow-up, larger multicenter samples, blinded outcome assessment, and integrated analyses of soft tissues, airway function, and patient-centered outcomes [19,29–30].
Conclusions
Twin Block therapy was effective in correcting Class II malocclusion associated with mandibular retrusion in growing patients. Both pre-pubertal and pubertal treatment produced significant improvements in overjet, sagittal jaw relationship, and facial profile. Nevertheless, pubertal treatment showed a greater three-dimensional skeletal response, including larger increases in SNB and Co-Gn and more favorable condylar adaptation. In contrast, pre-pubertal treatment showed a relatively stronger dentoalveolar component. CBCT analysis documented physiologic TMJ adaptation without evidence of pathologic remodeling during the observation period. When clinically feasible, treatment during the pubertal growth phase appears to offer the greatest orthopedic benefit. At the same time, a comprehensive functional and preventive perspective remains important in patient selection, follow-up, and interdisciplinary management.
Author Contributions
Conceptualization, S. Saccomanno; Methodology, J. Jubani; Validation, F. Russo; Formal Analysis, E. Guercio Monaco; Investigation, M. Palermiti; Data Curation, G. Marzo; Writing – Original Draft Preparation, J. Jubani; Writing – Review and Editing, G. Marzo; Supervision, S. Saccomanno. All authors have read and agreed to the submitted version of the manuscript.
Acknowledgements
The authors wish to thank Dr. Yllka Abazi for her valuable contribution of clinical cases to this research.
Funding
The authors declare that no external funding was received for this study.
Informed Consent Statement
Written informed consent was obtained from all subjects involved in the study and from parents or legal guardians for minor participants.
Data Availability Statement
The data presented in this study are available from the corresponding author upon reasonable request, subject to ethical and privacy restrictions.
Conflicts of Interest
The authors declare no conflict of interest.
References
- 1. Lombardo, G., Vena, F., Negri, P., Pagano, S., Barilotti, C., Paglia, L., et al. Worldwide Prevalence of Malocclusion in the Different Stages of Dentition: A Systematic Review and Meta-Analysis. Eur. J. Paediatr. Dent. 2020, 21, 115–122. https://doi.org/10.23804/ejpd.2020.21.02.05
- 2. McNamara, J.A. Jr. Components of Class II Malocclusion in Children 8–10 Years of Age. Angle Orthod. 1981, 51, 177–202. https://doi.org/10.1043/0003-3219(1981)051<0177:COCIMI>2.0.CO;2
- 3. Saccomanno, S., Deli, R., Dicintio, G., De Corso, E., Paludetti, G., Grippaudo, C. Retrospective Epidemiological Study of Mandibular Rotational Types in Patients with Orthodontical Malocclusion. Acta Otorhinolaryngol. Ital. 2018, 38, 160–165. https://doi.org/10.14639/0392-100X-1682 https://doi.org/10.14639/0392-100X-1682
- 4. Tulloch, J.F.C., Phillips, C., Proffit, W.R. Benefit of Early Class II Treatment: Progress Report of a Two-Phase Randomized Clinical Trial. Am. J. Orthod. Dentofacial Orthop. 1998, 113, 62–72. https://doi.org/10.1016/S0889-5406(98)70277-X https://doi.org/10.1016/S0889-5406(98)70277-X
- 5. Franchi, L., Baccetti, T., McNamara, J.A. Jr. Mandibular Growth as Related to Cervical Vertebral Maturation and Body Height. Am. J. Orthod. Dentofacial Orthop. 2000, 118, 335–340. https://doi.org/10.1067/mod.2000.107009 https://doi.org/10.1067/mod.2000.107009
- 6. Thiruvenkatachari, B., Harrison, J., Worthington, H., O’Brien, K. Early Orthodontic Treatment for Class II Malocclusion Reduces the Chance of Incisal Trauma: Results of a Cochrane Systematic Review. Am. J. Orthod. Dentofacial Orthop. 2015, 148, 47–59. https://doi.org/10.1016/j.ajodo.2015.01.030 https://doi.org/10.1016/j.ajodo.2015.01.030
- 7. Batista, K.B., Thiruvenkatachari, B., Harrison, J.E., O’Brien, K.D. Orthodontic Treatment for Prominent Upper Front Teeth (Class II Malocclusion) in Children and Adolescents. Cochrane Database Syst. Rev. 2018, 3, CD003452. https://doi.org/10.1002/14651858.CD003452.pub4 https://doi.org/10.1002/14651858.CD003452.pub4
- 8. Baccetti, T., Franchi, L., Toth, L.R., McNamara, J.A. Jr. Treatment Timing for Twin-Block Therapy. Am. J. Orthod. Dentofacial Orthop. 2000, 118, 159–170. https://doi.org/10.1067/mod.2000.105571 https://doi.org/10.1067/mod.2000.105571
- 9. Clark, W.J. Twin Block Functional Therapy: Applications in Dentofacial Orthopedics, 2nd ed.; Mosby-Wolfe: London, UK, 2002. ISBN 072342120X, 9780723421207
- 10. O’Brien, K., Wright, J., Conboy, F., Sanjie, Y., Mandall, N., Chadwick, S., et al. Effectiveness of Treatment for Class II Malocclusion with the Herbst or Twin-Block Appliances: A Randomized, Controlled Trial. Am. J. Orthod. Dentofacial Orthop. 2003, 124, 128–137. https://doi.org/10.1016/S0889-5406(03)00345-7 https://doi.org/10.1016/S0889-5406(03)00345-7
- 11. O’Brien, K., Wright, J., Conboy, F., Appelbe, P., Davies, L., Connolly, I., et al. Early Treatment for Class II Division 1 Malocclusion with the Twin-Block Appliance: A Multi-Center, Randomized, Controlled Trial. Am. J. Orthod. Dentofacial Orthop. 2009, 135, 573–579. https://doi.org/10.1016/j.ajodo.2007.10.042 https://doi.org/10.1016/j.ajodo.2007.10.042
- 12. Tulloch, J.F.C., Proffit, W.R., Phillips, C. Outcomes in a Two-Phase Randomized Clinical Trial of Early Class II Treatment. Am. J. Orthod. Dentofacial Orthop. 2004, 125, 657–667. https://doi.org/10.1016/j.ajodo.2004.02.008 https://doi.org/10.1016/j.ajodo.2004.02.008
- 13. Perinetti, G., Primozic, J., Franchi, L., Contardo, L. Treatment Effects of Removable Functional Appliances in Pre-Pubertal and Pubertal Class II Patients: A Systematic Review and Meta-Analysis of Controlled Studies. PLoS ONE 2015, 10, e0141198. https://doi.org/10.1371/journal.pone.0141198 https://doi.org/10.1371/journal.pone.0141198
- 14. Siara-Olds, N.J., Pangrazio-Kulbersh, V., Berger, J., Bayirli, B. Long-Term Dentoskeletal Changes with the Bionator, Herbst, Twin Block, and MARA Functional Appliances. Angle Orthod. 2010, 80, 18–29. https://doi.org/10.2319/020109-11.1 https://doi.org/10.2319/020109-11.1
- 15. Pavoni, C., Lombardo, E.C., Lione, R., Faltin, K. Jr., McNamara, J.A. Jr., Franchi, L. Treatment Timing for Functional Jaw Orthopaedics Followed by Fixed Appliances: A Controlled Long-Term Study. Eur. J. Orthod. 2018, 40, 430–436. https://doi.org/10.1093/ejo/cjx078 https://doi.org/10.1093/ejo/cjx078
- 16. Baccetti, T., Franchi, L., McNamara, J.A. Jr. An Improved Version of the Cervical Vertebral Maturation Method for the Assessment of Mandibular Growth. Angle Orthod. 2002, 72, 316–323. https://doi.org/10.1043/0003-3219(2002)072<0316:AIVOTC>2.0.CO;2
- 17. Paolantonio, E.G., Ludovici, N., Saccomanno, S., La Torre, G., Grippaudo, C. Association between Oral Habits, Mouth Breathing and Malocclusion in Italian Preschoolers. Eur. J. Paediatr. Dent. 2019, 20, 204–208. https://doi.org/10.23804/ejpd.2019.20.03.07
- 18. Saccomanno, S., Di Tullio, A., D’Alatri, L., Grippaudo, C. Proposal for a Myofunctional Therapy Protocol in Case of Altered Lingual Frenulum: A Pilot Study. Eur. J. Paediatr. Dent. 2019, 20, 67–72. https://doi.org/10.23804/ejpd.2019.20.01.13
- 19. Saccomanno, S., Saran, S., De Luca, M., Fioretti, P., Gallusi, G. Prevention of Malocclusion and the Importance of Early Diagnosis in the Italian Young Population. Eur. J. Paediatr. Dent. 2022, 23, 178–182. https://doi.org/10.23804/ejpd.2022.23.03.02
- 20. Yildirim, E., Karacay, S., Erkan, M. Condylar Response to Functional Therapy with Twin-Block as Shown by Cone-Beam Computed Tomography. Angle Orthod. 2014, 84, 1018–1025. https://doi.org/10.2319/112713-869.1 https://doi.org/10.2319/112713-869.1
- 21. Kyburz, K.S., Eliades, T., Papageorgiou, S.N. What Effect Does Functional Appliance Treatment Have on the Temporomandibular Joint? A Systematic Review with Meta-Analysis. Prog. Orthod. 2019, 20, 32. https://doi.org/10.1186/s40510-019-0286-9 https://doi.org/10.1186/s40510-019-0286-9
- 22. Baysal, A., Uysal, T. Soft Tissue Effects of Twin Block and Herbst Appliances in Patients with Class II Division 1 Mandibular Retrognathy. Eur. J. Orthod. 2013, 35, 71–81. https://doi.org/10.1093/ejo/cjq187 https://doi.org/10.1093/ejo/cjq187
- 23. Ruf, S., Pancherz, H. Temporomandibular Joint Remodeling in Adolescents and Young Adults during Herbst Treatment: A Prospective Longitudinal Magnetic Resonance Imaging and Cephalometric Study. Eur. J. Orthod. 1999, 21, 375–388. https://doi.org/10.1093/ejo/21.4.375
- 24. Elfeky, H.Y., Fayed, M.M.S., Alhammadi, M.S., Soliman, S.A.Z., El Boghdadi, D.M. Three-Dimensional Skeletal, Dentoalveolar and Temporomandibular Joint Changes Produced by Twin Block Functional Appliance. J. Orofac. Orthop. 2018, 79, 245–258. https://doi.org/10.1007/s00056-018-0137-1 https://doi.org/10.1007/s00056-018-0137-1
- 25. Yassir, Y.A., Salman, A.R., Nabbat, S.A. The Accuracy and Reliability of WebCeph for Cephalometric Analysis. J. Taibah Univ. Med. Sci. 2022, 17, 57–66. https://doi.org/10.1016/j.jtumed.2021.08.010 https://doi.org/10.1016/j.jtumed.2021.08.010
- 26. Saccomanno, S., Antonini, G., D’Alatri, L., D’Angelantonio, M., Fiorita, A., Deli, R. Case Report of Patients Treated with an Orthodontic and Myofunctional Protocol. Eur. J. Paediatr. Dent. 2014, 15 (2 Suppl), 184–186. PMID: 25101498.
- 27. Saccomanno, S., Laganà, D., Mastrapasqua, R., Giancaspro, S., Manenti, R.J., Saran, S. The Relationship between TMJ Symptoms and Orthodontic Treatments: A Survey on 236 Orthodontic Patients. J. Biol. Regul. Homeost. Agents 2021, 35 (Suppl. 1), 197–204. https://doi.org/10.23812/21-3supp1-22 https://doi.org/10.23812/21-3supp1-22
- 28. Saccomanno, S., Bernabei, M., Scoppa, F., Pirino, A., Mastrapasqua, R., Visco, M.A. Coronavirus Lockdown as a Major Life Stressor: Does It Affect TMD Symptoms? Int. J. Environ. Res. Public Health 2020, 17, 8907. https://doi.org/10.3390/ijerph17238907 https://doi.org/10.3390/ijerph17238907
- 29. Pancherz, H. The Mechanism of Class II Correction in Herbst Appliance Treatment: A Cephalometric Investigation. Am. J. Orthod. 1982, 82, 104–113. https://doi.org/10.1016/0002-9416(82)90489-4 https://doi.org/10.1016/0002-9416(82)90489-4
- 30. Saccomanno, S., Quinzi, V., Adamo, D., Coceani Paskay, L., Fontanella, R., Serenelli, M., Marzo, G., Memè, L. Orthodontics and Myofunctional Therapy: A Critical Review of the Best Complementary Treatments of Orofacial Dysfunctions (Part 1). Eur. J. Paediatr. Dent. 2026, 27, 78–83. https://doi.org/10.23804/ejpd.2026.27.01.03