Like many orthodontic practices, we continue to find thelives of our patients’ becoming busier and morecomplicated. They need excellent results in the most timeefficient and cost effective manner. Their parents also wanttreatment to be as convenient as possible for their children.Our solution to these challenges has been to incorporate theForsus™ Appliance into our initial treatment plan for manyof our patients.

There was a time in my practice when fixed Class IIcorrection appliances were incorporated into treatmentonly after more compliance-dependent methods failed.Now, as a part of the initial treatment plan, the Forsusappliance provides the compliance-free benefits of a fixeddevice in a design that is easy to install and reliable in avariety of applications. Treatment protocol for cases thatrequire Class II correction, maxillary distalization toincrease maxillary arch length, and extraction withmaxillary anchorage needs now include the Forsusappliance.

Every orthodontist realizes that their most valuable asset ischair time. Extended treatment time means increased use ofchair time. So there is a productivity aspect to this approachas well: the most efficient and cost effective method of usingForsus is to use it as a part of your initial treatment plan. Ifyou wait until a patient has demonstrated a lack ofcompliance prior to initiating the use of Forsus, you havealready wasted valuable chair and treatment time.

Forsus Correctors in Class II Correction with Patient Comfort in MindWe have found patient acceptance of the Forsus applianceat initial consultation excellent. Often the parents arerelieved to know that the appliance works automatically,independent of patient cooperation. They also appreciatethat, although the appliance is not indestructible, it is

extremely durable. As their orthodontist, I appreciate thepredictability of the appliance which allows me toaccurately gauge their treatment time.

In our office we have experienced an ease in patientacceptance due to an increase in patient comfort. Thisincrease in comfort can be attributed to what can bereferred to as a “first bicuspid hook up.” With thisattachment technique, the bulge or cheek irritation seennear the commissure of the lips is no longer an issue. Toinstall it this way we attach the push rods distal to themandibular first bicuspid. Clinically, this technique doesnot appear to have any significant effect on the horizontaland vertical components of force. The comparison belowshows the push rods distal to the mandibular first bicuspidand mandibular cuspid with the first bicuspid providing afavorable direction for Class II correction. (Fig. 1-2)

As part of our installation we have incorporated the use of anElastomeric Ligature with a Guard (3M Unitek# 406-429)turned on its side. It is placed facing distal on the firstbicuspid bracket and under the archwire to act as abumper. A mandibular .019 x .025 stainless steel archwireis then placed and cinched down distal to the molars. Thebicuspid is tied with a steel ligature after the mandibular

From “Plan B” to “Plan A”: Using Forsus™

Class II Correctors as a Regular Mode of Treatmentby Lisa Alvetro, DDS

After receiving her DDS summa cum laude from Ohio State University, Dr. Lisa Alvetro completed her orthodontic residency at CaseWestern Reserve University. She has had a successful practice in Sidney, Ohio, for 13 years where she strives to maintain current on thelatest orthodontic trends and developments in the field. The Forsus Class II Device plays an integral role in her practice’s objectives oftreatment efficiency and patient satisfaction as a regular mode of treatment. Dr. Alvetro is presently on the staff at Case Western ReserveUniversity teaching Practice Management.

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Figure 1: Rod placed distal to mandibular1st bicuspid using Forsus™ EZ Modules inthe maxillary arch

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Figure 2: Rod placed distal to mandibularcuspid using Forsus™ EZ Modules in themaxillary arch

Figure 7A-H: Pre-treatment

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archwire wire is in place. The guard acts as a stress breakerprotecting the bicuspid from the sliding rod and decreasesthe risk of bond failure of the bicuspid bracket. (Fig. 3-4)

When attaching the push rod distal to the first bicuspids,some modification of the rod may be necessary to achievethe correct amount of activation. This occurs most often inpatients with small mandibles or in patients who aresignificantly mandibular retrognathic. Rod modificationrequires removing the stop on the push rod using anabrasive wheel. This allows the Forsus spring to movecompletely down to the recurve in the rod. One must thentrim the push rod to size, so that it does not extend beyondthe end of the Forsus spring, when the spring is compressedand activated. (Fig. 5-6)

Aside from patient comfort, a clinical bonus of the “firstbicuspid hook up” appears to be an increase in the abilityto control mandibular incisor position. Flaring of theincisors may be reduced by the addition of the firstbicuspids into the anterior anchorage unit. This isparticularly helpful in mandibular retrognathic patientswhere you want to minimize mandibular incisor movementand maximize mandibular repositioning. In the followingcase the incisor angulation is maintained during Class IIcorrection. The patient wore Forsus springs bilaterallyplaced distal to the first bicuspids for 5 months out of a 24 month treatment to correct her malocclusion. (Fig. 7-12)

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Figure 3: Elastomeric ligature with Guard

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Figure 4: Push rod distal to 1st bicuspidwith Guard under archwire

Figure 5: Heatless Mizzy wheel used toremove stop

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Figure 6: Checking rod length after modification

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Figure 8A-H: Post-treatment

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8D 8E

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8B8A 8C

Figure 9-10:9: Pre-treatment; 10: Post-treatment

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Stop on rodremoved

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Forsus Correctors in Maxillary Molar Distalization to Increase Arch LengthWe have found the Forsus appliance to be an effective way toachieve molar distalization when an increase in arch length isneeded. Before, we may have considered extraction of themaxillary first bicuspids to create space for the eruptingcuspids. Or we may have needed to extract the maxillarysecond molars in order to distalize the maxillary buccalsegment. Now we can predictably distalize and create spaceeven when the second molars are fully erupted. Also, byleaving the Forsus appliance attached, we can easily hold thespace and distalized molar position.

Following distalization, our Forsus springs become ouranchorage when a reciprocal force is applied. Duringretraction of the buccal segments we no longer have tostruggle with relapse of the maxillary molar position andspace loss. We have eliminated the need to place transpalatalor nance holding arches to maintain molar position.

Our technique for distalizing molars uses the standardmandibular “first bicuspid” hook up but utilizes a smallerdimension maxillary archwire than typically used. Usually a.016 x .022 stainless steel or .016 stainless steel in a .022 slot isplaced as the archwire. We want the archwire to be passive inthe maxillary molars to allow as much distal movement, asquickly as possible. The maxillary molars are tied independentof the remaining dentition, allowing them to move distallyfrom the rest of the maxillary buccal segment. The maxillaryarchwire needs to be replaced at every other appointment toavoid backing off the end of the archwire. Once a slight overcorrection is achieved, the remaining buccal segment isretracted using NiTi coil springs attached at the molar to thebicuspid. The buccal segment can also be retracted by simplychaining the bicuspids back to the molars. The Forsusappliance remains in place until the first bicuspid is retractedto a Class I position. (Fig. 13-18)

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Figure 11: Pre-treatment cephalometric film

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Figure 12: Post-treatment cephalometric film

Figure 13A-H: Pre-treatment with blockedout, ectopically erupting maxillary rightand left cuspids

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Figure 14A-H: Post-treatment: Forsus™

Appliance for 7 months during treatment

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Figure 15: Pre-treatment with blocked out maxillary cuspid and Class II molar relationship

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Figure 22A-H: Forsus springs wereremoved after 4 months of wear.Mandibular extraction spaces are closed,maxillary molar over corrected, maxillarycuspids retracted and maxillary andmandibular incisors are in contact.

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22D 22E

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22B22A 22C

Forsus Correctors as Anchorage in Class II Extraction CasesA common clinical concern is extracting bicuspids in ClassII mandibular retrognathic patients. Often arch lengthdeficiencies or incisor protrusion indicate the need forextractions. One challenge is protracting the mandibularposterior segments into the extraction site without retractingthe mandibular incisors. Another is holding maxillary molarposition and not losing anchorage during space closure.Both of these events can significantly increase overjet andwork against correction of the malocclusion.

We have found the Forsus appliance an effective way to holdor distalize the maxillary molars while maintainingmandibular incisor position during space closure. Ourtreatment protocol requires a standard maxillary set up. In themandibular arch, the push rods are placed distal to the cuspidsinstead of the first bicuspids as in our “first bicuspid hook up.”The mandibular cuspid and 1st bicuspid are ligated togetherwith a steel ligature under a .019 x .022 stainless steel archwire.A NiTi closed coil spring with eyelets connects the molar to thebicuspid to slide the molars forward. (Fig. 19)

This patient was significantly mandibular retrognathic. Themandibular arch length deficiency combined with theincisor protrusion indicated that extractions would benecessary. After initial leveling and aligning, Forsusappliances were placed as described above. Four monthsafter Forsus placement the mandibular extraction spacewas closed and the buccal occlusion overcorrected due tomaxillary molar distalization. (Fig. 20-25)

Figure 16: Post maxillary distalization,cuspids erupted with slight overcorrection of buccal segments

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Figure 17: Pre-treatment with bilaterallyblocked out maxillary cuspids

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Figure 18: Post-treatment with maxillarycuspids in place

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Figure 19: Mandibular applianceconfiguration with NiTi closed coil spring in place to protract molars. Push rod will support incisor positionduring space closure.

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Figure 20A-H: Pre-treatment

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20B20A 20C

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Figure 21: Pre-treatment cephalometric film

After mandibular space closure, the Forsus appliance isremoved and treatment continues by placing the NiTiclosed coil springs in the maxillary arch to finish maxillary

space closure and establish molar occlusion. If additionalmaxillary anchorage is needed the Forsus appliance canremain in place during maxillary space closure. (Fig. 26)

In our office, as we treat more and more cases using theForsus appliance we are continually impressed by theamount of correction we can achieve with limited effort onour part and on the part of our patients. If you are notcurrently using Forsus correctors in your practice, it is wellworth the commitment to try this appliance. If youcurrently are using Forsus correctors, I challenge you to trynew ways of using it.

My point is this: to effectively evaluate and appreciate theForsus appliance, one must use it systematically. Decidewhat your criteria for use will be and then use it consistentlyon each patient who meets those criteria. Only then will yoube able to appreciate the effectiveness and efficiency of theForsus appliance. It is a powerful appliance that cansimplify your life and the lives of your patients.

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Figure 23: Progress cephalometric filmafter Forsus appliance removal

Figure 25: Mandibular extraction spacesclosed with incisor position held byForsus appliance push rod

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Figure 24: Pre-treatment mandibular occlusal

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Figure 26: Closing remaining maxillaryextraction space after Forsus appliance is removed. Over correction in molarrelation was obtained while closingmandibular extraction space andmaintaining mandibular incisor position.

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Reprinted from Orthodontic Perspectives Vol. XIV No. 2.© 2007 3M. All rights reserved.