Applicability of the Forsus Fatigue Resistant Device
as a Class II Corrector in Young Adults
by Chetan V. Jayade, DDS
Dr. Chetan V. Jayade
received his BDS at
Karnataka University
in 1997, his MDS
at Rajiv Gandhi
University in 2001
and his MOrthRCS at Edinburgh in 2004. He
is currently on faculty at Panineeya Dental
College in Hyderabad, India. His Masters
dissertation won the National Award for
Best Thesis in 2001, and since then he has
had been published four times in Indian
journals and has three publications in
international journals. He presented a paper
about the Forsus Fatigue Resistant Device
at the World Federation of Orthodontists
Congress in Paris, 2005.
Fixed functional appliances (Class II correctors) are an integral part of an orthodontists
armamentarium, owing to their ability to correct Class II malocclusions without relying on
patient compliance. Although their use has traditionally been restricted only to growing
individuals, recent studies have documented successful use of compliance-free Class II
correctors in young adults as well. Data from various research groups in Europe indicates
that appliances such as Herbst and Functional mandibular advancers are also successful
in Class II correction in adult Class II patients1,2,3. Pancherz has rightly termed this as a
shifting paradigm in Class II treatment options. MRI data of adult patients undergoing fixed
functional treatment have demonstrated the possibility of condylar remodeling in adults
too4. This fact has surely opened new doors of exciting possibilities for Orthodontists.
For the past seven years, the Forsus Fatigue Resistant Device has been used in my
practice and by our residents in over a hundred Class II patients. In young adults also, we
have had predictable results, and in this paper I will also enlist suitable situations in which
Forsus corrector can be used effectively in adults. Modifications in usage and their rationale
will also be described.
Need for Class II Correctors in Young Adults
There are, in my opinion, four main indications of Class II correctors in young adults, namely:
Skeletal Correction in patients with mild skeletal Class II malocclusion. Borderline
Class II cases with deficient mandible (LANB 4-6 degrees) are suitable for this approach.
However, obvious surgical cases are a contra-indication to such treatments. It is also
important to consider that these individuals should not be seeking drastic changes in
their facial appearance.
Dental Class II malocclusion correction only. Obviously, the amount of skeletal correction
achievable in adults is much less than in adolescents (only 30-40% skeletal changes may
be expected). Therefore, the best results in young adults are those cases which have mainly
a dental component of Class II without an underlying skeletal discrepancy.
Correction of Class II subdivision malocclusion patients having a mandibular midline
shift. In these cases, by selective differential force selection on either side, subdivision
correction becomes more predictable, while addressing the lower midline.
Class II dental malocclusion requiring maxillary molar distalization. Again, in these
cases, selective molar distalization, on one side or bilaterally, is easily effected by minor
variations during appliance installation.
Forsus Fatigue Resistant Device as an Efficient
Class II Corrector
The Forsus fatigue resistant device satisfies all requisites of an ideal Class II corrector, namely,
is very simple to use, comfortable to the patient, corrects Class II malocclusions effectively
and the fact that all this is achieved without problems of breakage is an added bonus.
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 Among five brands of Class II correctors I have used on patients,
the Forsus Class II Corrector has proven to be most comfortable
to a patient, right from installation itself. The Forsus corrector,
not being as forceful as Herbst, allows gradual overpowering of
the patients oral musculature. On the day of insertion, the patient
does not experience any pain. Within a month, at the time of recall,
it is generally observed that a part of Class II correction would
be initiated. This, by itself, is a big motivational feature for me.
Whenever a patient is apprehensive about having a Forsus corrector
in the mouth, I introduce him to another who already has it in place.
The latters positive experience helps in encouraging the new
patient too.
Also, while doing such a modification, we have observed a
phenomenon of alveolar bone bending. This phenomenon was
documented by Schwindling5 in his book and we verified it in an
earlier research project6.
On a personal basis, I feel this phenomenon of alveolar bone
bending, if seen in many cases and remains stable over an extended
time period, may be of prime importance in achieving a good dento-
alveolar camouflage in skeletal Class II young adults. What it would
essentially mean is that instead of simply proclining lower anteriors
(which jeopardizes their periodontal integrity) while using a Class II
corrector, the entire alveolus gets bent and aids the overall correction
since active bone growth is complete in young adults.

Clinical Protocol Figure 1: Omega Loop

bent into mandibular
There are a few changes that I make before placement of Forsus archwire for push rod
corrector in a patient. These are essential to get an improved placement.

biomechanical vector as well as to minimize unwanted dental

effects, especially lower incisor proclination and buccal flaring of
upper molars.
1
The fixed appliance prescription of choice is the MBT Versatile+

Figure 2: Slight bending
Appliance System with 0.022" slot brackets. As is expected with of push rod after inward
fixed Class II correctors, due to applied force vectors, upper incisor bend is made.
torque loss and labial flaring of lower incisors is bound to happen.
MBT system brackets, with relatively high lingual root torque in
upper incisors and -6 degrees of labial root torque in lower incisors,
have better capabilities in resisting both these untoward effects.
2

In the upper arch, necessarily, second molars are banded. This

prevents a step from being created between the first and second
molars during the Forsus corrector phase. It is important that
Duration of Forsus Class II Corrector Usage
Most clinicians prefer to keep Forsus device only for 4-5 months
the wire sizes at the time of inserting the Forsus device should
in majority of patients. However, data of Rabie and co-workers has
be 1925 SS. In my use of the appliance, the upper archform is
defined the appropriate duration of fixed functional appliances as
constricted by 2 mm on either side and additionally supported by
being close to one year. This was derived by extrapolation from their
a Zachrisson type TPA to prevent buccal rolling of the molars. As
animal experiments7.
per the need of the case, additional lingual root torque in the upper
archwire and extra labial root torque in lower wire is added to Based on these lines, I prefer leaving the Forsus device for an
further prevent the above mentioned side effects. average time period of 7-8 months. Activation of the appliance is
done either at the L-pin end by pulling it mesially, or adding the
The lower wire is always cinched back. Upper wire may or may not
split crimps provided with the kit. After the appliance is in place
be cinched back based on the need for molar distalization. When
for 4-5 months, one might see the overjet reducing rapidly and the
one needs distalization, 2-3 mm of wire is left projecting from the
patient achieving an edge-to-edge relation. From this point onward,
tube intentionally to allow molars to freely slide under the influence
I deactivate the appliance by loosening at the L-pin and leave the
of the Forsus correctors (refer to Case 3).
Forsus device in place for at least a couple of months. This way, we
obviate the need for an additional retention appliance while stabilizing
Improved Biomechanical Vector the achieved result.
Instead of hooking the push rod directly on a plain archwire next
to a bracket, I make an omega loop in the 1925 SS wire (Figure
1) and then insert the push rod onto this hook. Before placement,
Case Reports
In this section, three cases are shown which correspond to the earlier
the pushrod is also given an inward bend to follow the curvature of
discussion. Treatment of two female patients SP (Case 1; Figures 3-7)
the lower arch and vestibule. This displaces the force vector closer
and RM (Case 2; Figures 8-10 ) of ages 16 and 17 with Class II div 1
to the Cres of the mandibular dentition (Figure 2). In turn, what is
and div 2 malocclusions respectively is depicted to illustrate benefits of
expected is more of a bodily movement of the lower dentoalveolar
the Forsus Fatigue Resistant Device in bilateral Class II correction. In
segment than mere steepening of the occlusal plane. Additionally,
both cases, initial leveling and aligning was done with NiTi wires. The
this modification helps prevent canine bracket breakage and makes
Forsus corrector was placed after placing 1925 SS wires. Activation
it less visible.
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of the push rod was needed only in SP since she had a large
overjet of 10 mm to begin with. Very little finishing is required after
Forsus Class II Corrector phase, and one can witness excellent
overjet reduction and good Class I buccal segment relationship.
Cephalometric superimpositions show minimal proclination of
lower incisors.
The third case, SK (Figures 11-13), a 24 year old male reported with
a large overjet, overbite and a unilateral half unit Class II relation
on the left side. He also had a compromised periodontal status.
Unilateral molar distalization was achieved on the left side during
the Forsus corrector phase by leaving the end of the upper wire
uncinched on the left side.

Case 1

4 5
3A 3B 3C
Figure 4: Case 1 pre-treatment. Figure 5: Case 1 pre-treatment.

6A 6B
3D 3E 3F
Figure 6: Case 1 during treatment.

3G 3H 3I 6C
Figure 3: Case 1 pre-treatment.

7A 7B 7C

7D 7E 7F

7G 7H 7I
Figure 7: Case 1 post-treatment. 15
 Case 2

8A 8B 8C

8D 8E 8F

Figure 8: Case 2 pre-treatment.

9A 9B 9C

9D 9E 9F

Figure 9: Case 2 post-treatment.

9G 9H

Figure 10: Case 2 post-cephalometric superimposition.

10
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Case 3
11A 11B
11C 11D
Figure 11: Case 3 pre-treatment.
12A 12B
Figure 12: Case 3 during treatment.
13A 13B
Figure 13: Case 3 post-treatment.
Conclusion
Most Orthodontists are skeptical about using a fixed functional
appliance after the end of pubertal growth spurt in their patients.
Instead of compromising on facial appearance by extracting only
upper first premolars (which leads to unaesthetic appearance
in some cases) or resorting to an invasive procedure such as an
orthognathic surgery for borderline skeletal malocclusions. The clinician
now has the ability to use the Forsus Fatigue Resistant Device to
correct Class II malocclusions in young adults in a predictable manner.
One has to be careful though, in ensuring limited side effects of
the Class II corrector by taking adequate precautions as mentioned
earlier. I see this application as a potentially practice-transforming
technique and recommend it to practitioners who havent used
Forsus correctors in young adults.
So, what are you waiting for? Go ahead and give the Forsus Fatigue
Resistant Device a try. I bet you will enjoy the experience. The
satisfaction on the patients face after treatment will surely be a
driving force for your future patients too.
11E
12C
13C
References
1. Ruf S, Pancherz H 1999a Dentoskeletal effects and facial profile changes in
young adults treated with the Herbst appliance. Angle Orthodontist 69:239-246
2. Ruf S, Pancherz H 2004 Orthognathic surgery and dentofacial orthopedics in
adult Class II div 1 treatment: mandibular sagittal split osteotomy versus Herbst
appliance. American Journal of Orthodontics and Dentofacial Orthopedics
126:140-152
3. Frye L, Diedrich PR, Kinzinger GS 2009 Class II treatment with fixed functional
orthodontic appliances before and after pubertal growth peak a cephalometric
study to evaluate differential therapeutic effects. Journal of Orofacial
Orthopedics. 70(6): 511-27.
4. Kinzinger GS, Gulden N, Diedrich P 2006 Disc-condyle relationships during Class
II treatment with the Functional Mandibular Advancer (FMA). Journal of Orofacial
Orthopedics. 67(5): 356-75
5. Schwindling MP 1997 Jasper Jumper Color Atlas: Class II correction without
compliance problems. Needham Press.
6. Taneja T, Jayade VP. Skeletal and Dental effects of Forsus FRD - A prospective
study Masters Dissertation submitted to the Rajiv Gandhi University of Health
Sciences 2005.
7. Rabie AB, Xiong H, Hagg U 2006 Forward mandibular positioning enhances
condylar adaptation in adult rats. European Journal of Orthodontics 26: 353-358.
Case photos provided by Dr. Chetan V. Jayade
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