Functional Appliances Research Articles

Association between orthodontic treatment and upper airway changes in children assessed with cone-beam computed tomography (CBCT): A systematic review.

Some orthodontic devices used in children share similar design principles to appliances used to treat obstructive sleep apnoea in adults. As well as treating malocclusion, orthodontic appliances used in children may therefore also have effects on the upper airway. A review of the literature to assess the effects of orthodontic treatment on the upper airway dimensions in children assessed on CBCT. Following registration of the protocol (PROSPERO CRD42023439056), a systematic electronic search of published studies was performed using several databases (PubMed; Scopus, Web of Science and Science Direct) in accordance with the PRISMA guidelines. Inclusion criteria were as follows: age under 18 years, orthodontic treatment with any appliance, a control group who received no treatment or a non-active alternative treatment and airway measurement using CBCT. RoB-2 and ROBINS-I tools were used to assess risk of bias and quality of the evidence. In total, 341 studies were identified following the initial search. Title and abstract screening resulted in 45 studies for further full-text analysis. On completion of the screening process, a total of 23 studies met the inclusion criteria. Study interventions included functional appliances (10 studies), rapid maxillary expansion (RME) (9 studies), reverse-pull headgear (1 study) and 4 premolar dental extractions (3 studies). The included studies had moderate to high risk of bias, and the quality of evidence was low. The scientific evidence shows that functional appliances are associated with significant improvements in both upper airway volume and constriction when used in children however, the effects on the nasal cavity are limited. RME was associated with a significant increase in nasal cavity and nasopharyngeal dimensions, but not the upper pharyngeal airway. Neither reverse-pull headgear nor dental extractions were associated with any change in airway dimensions; however, the evidence is limited. Functional appliances may reduce the severity of obstructive sleep apnoea (OSA) in children.

Autism spectrum disorder and compliance with a removable orthodontic functional appliance: A case report

Autism spectrum disorder and compliance with a removable orthodontic functional appliance: A case report

Assessment of the impact of fixed functional appliances on airway in patients receiving orthodontic treatment: A systematic review

Assessment of the impact of fixed functional appliances on airway in patients receiving orthodontic treatment: A systematic review

Assessing the efficacy of fixed functional appliances in orthodontic patients: A systematic review

Assessing the efficacy of fixed functional appliances in orthodontic patients: A systematic review

Discrepancy index, treatment complexity index and objective Grading system: correlation between parameters, indices and implications for treatment

Abstract Objectives An assessment of orthodontic treatment duration and results allows for measurable outcomes, goal-setting, and the establishment of patient management standards. It is important information that can be utilised for educational purposes in an orthodontic postgraduate program. The aim of this study was to determine correlations of the parameters within and between the Objective Grading System (OGS), Discrepancy Index (DI) and Treatment Complexity Index (TCI) and identify those factors associated with treatment outcomes and duration. Materials and methods This retrospective cohort study involved a consecutive sampling of 242 pre- and post-treatment patient records from the postgraduate orthodontic clinic between 2013 and 2017. The cases were assessed using the DI, OGS, and TCI pre-treatment. Treatment outcomes were assessed using the OGS. Spearman’s Rank Correlation Coefficients were computed within and between the indices. Multiple and logistic regressions were used to evaluate associations between treatment outcomes and duration, respectively. Results Within DI, significant correlations (p < 0.05) were observed between overjet-overbite, overjet-occlusal relationship, overjet-crowding, overbite-anterior open bite, overbite-crowding, anterior open bite-lateral open bite, anterior open bite-crowding, lingual posterior cross bite-crowding. Within pre-OGS, significant correlations (p < 0.05) were observed between alignment-marginal ridge, alignment-occlusal relationship, alignment-root angulation, overjet-interproximal contact, marginal ridge-buccolingual inclination, marginal ridge-overjet, marginal ridge-occlusal contact, marginal ridge-occlusal relationship, overjet-occlusal contact, overjet-occlusal relationship, overjet-root angulation, occlusal relationship-root angulation, interproximal contact-root angulation. Within TCI, functional appliance correlated with orthognathic surgery (p < 0.001), rapid palatal expansion (RPE) (p = 0.005) and multidisciplinary collaboration (p = 0.001). Pre-OGS correlated with DI (p < 0.001) and TCI (p = 0.026). Cephalometric (p = 0.002) and other conditions (p = 0.031) were associated with treatment outcomes. RPE was associated with extended treatment duration (p = 0.014). Conclusions DI, OGS, and TCI exhibited weak correlations within and between indices. Cephalometric values, clinical conditions, and RPE use should be carefully considered during treatment planning.

Powerscope Efficiency for Class II Malocclusion Correction: Case Reports

Abstract In day-to-day clinical practice, orthodontists face great challenges in the management of mild-to-moderate Class II malocclusion. Myofunctional appliances are usually used for Class II malocclusion correction having a mandibular deficiency in the growing phase. The fixed functional appliances evolved due to noncompliance of myofunctional and excellent results were achieved due to less patient cooperation in such cases. PowerScope, also called “noncompliance Class II correctors,” is the one innovation for such cases. Its one-size-fits-all design; offers the advantage of easy chairside installation, shortens the duration of treatment, gives predictable results, and is used in noncompliant patients. These case reports showed how PowerScope is efficient for correcting Class II division 1 malocclusion having a mandibular deficiency. Successful and stable results were achieved with improvement in mandible advancement, esthetic appearance, and facial profile.

Evaluation of the Changes in Condylion-Gonion-Menton Angle and Dentoalveolar Heights After Treatment of Skeletal Class II Division I Malocclusions with Removable Functional Appliances

Objectives: Condylion-Gonion-Menton (CoGoMe) angle and dentoalveolar heights are important parameters that provide information about maxillomandibular growth and development. This study aimed to examine the changes in the CoGoMe angle and dentoalveolar heights after functional treatment and to analyze whether they are related to each other. Materials and Methods: A total of 60 patients, 38 females (mean age 11.7 ± 0.6) and 22 males (mean age 12.6 ± 0.5), with skeletal class II division I malocclusion caused by mandibular retrognathia in the peak period were included. Linear measurements of skeletal angular and dentoalveolar heights were made on lateral cephalograms taken pre- (T0) and post-functional treatment (T1). Paired sample t test, Wilcoxon test and Spearman’s rho correlation coefficient were used for statistical analyses. Statistical significance was accepted as p

The Role of Orthodontics in the Management of Maxillofacial Fractures in Children: A Review on Contemporary Approaches.

Maxillofacial fractures present complex challenges requiring effective orthodontic management to restore function and aesthetics. This review explores various orthodontic techniques, including fixed braces, maxillomandibular fixation (MMF), functional orthodontic therapy (FOT), and acrylic splints, emphasizing their roles in stabilizing fractures and promoting healing. The management of condylar fractures is discussed, highlighting the benefits of early intervention with functional appliances to facilitate condylar remodeling in children and adolescents. Additionally, the review covers splinting methods for dental and dentoalveolar fractures and the use of open reduction internal fixation (ORIF) for maxillary fractures. It addresses the complications and challenges of fracture management, the need for a multidisciplinary approach, and the limitations of current studies. Future directions include the use of advanced technologies such as virtual surgical planning (VSP) and 3D printing to enhance treatment precision and outcomes. This review provides a comprehensive overview of orthodontic strategies for maxillofacial fractures, offering insights into clinical applications and future advancements.

Temporomandibular joint rehabilitative approaches for children and adolescents affected by juvenile idiopathic arthritis: A systematic review.

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, and temporomandibular joints (TMJs) are involved in 39%-78% of patients. The aim of this systematic review was to assess the effectiveness of conservative approaches in improving TMJ arthritis in children and adolescents affected by JIA. PubMed, Scopus, and Web of Science were systematically searched from the inception until February 25, 2024, to identify observational studies presenting participants with a diagnosis of JIA affecting the TMJ, rehabilitative approaches for TMJ arthritis as interventions, and clinical or radiological assessment of TMJ arthritis as outcome. Of 478 papers suitable for title/abstract screening, 13 studies were included. The studies evaluated the effectiveness of intra-articular (IA) corticosteroid (CS) injections, IA infliximab injections, arthrocentesis alone or in combination with IACS injections, occlusal splint, functional appliance, and physiotherapy. The effectiveness of IACS injections was shown in eight studies. IA infliximab injections did not appear to significantly improve TMJ arthritis. Results of this systematic review suggested that conservative treatments, especially IACS injections, might be effective in improving TMJ arthritis in patients affected by JIA. Further studies with a higher level of evidence and more representative samples should be conducted.

Orthodontic and orthopedic management of dentofacial deformity from juvenile idiopathic arthritis: a systematic literature review

Summary Background An update on the knowledge regarding the orthopedic/orthodontic role in treating JIA-related dentofacial deformities is relevant. Objectives This systematic review aimed to assess the level of evidence regarding the management of dentofacial deformity from juvenile idiopathic arthritis (JIA) with orthodontics and/or dentofacial orthopedics. Search methods The following databases were searched without time or language restrictions up to 31 January 2024 (Medline, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and Latin American and Caribbean Health Sciences Literature). Selection criteria Inclusion criteria were studies dealing with JIA subjects receiving treatment with orthodontic and/or dentofacial orthopedic functional appliances. Data collection and analysis After the removal of duplicate studies, data extraction, and risk of bias assessment according to ROBINS-I guidelines were conducted. Data extraction was conducted by two independent authors. Results The electronic database search identified 397 eligible articles after the removal of duplicates. Following the application of the pre-defined inclusion and exclusion criteria, 11 articles were left for inclusion. Two trials were associated with a severe risk of bias, four trials were at moderate risk of bias, and the other five presented a low risk of bias. Various research groups employed and documented the effects of different types of appliances and methodologies. The study heterogeneity did not allow for meta-analyses. In addition, a lack of uniformity in treatment objectives was observed across the included studies. After treatment with dentofacial orthopedics skeletal improvement was demonstrated in 10 studies, and a decrease in orofacial signs and symptoms was reported in 7 studies. Conclusions Across the available literature, there is minor evidence to suggest that dentofacial orthopedics may be beneficial in the management of dentofacial deformities from JIA. There is little evidence to suggest that it can reduce orofacial signs and symptoms in patients with JIA. Based on current evidence, it is not possible to outline clinical recommendations for specific aspects of orthopedic management in growing subjects with JIA-related dentofacial deformity. Registration PROSPERO (CRD42023390746).

Development of a questionnaire for patient perception to functional appliances

ObjectiveTo developed and evaluate the validity, reliability, and Arabic translation of a questionnaire for preadolescent perception to removable functional appliances.Subjects and methodsA new questionnaire was drafted based on previously used questionnaires. Twelve orthodontic experts were selected within content and face validity panel and twenty preadolescents wearing functional appliances were participated in the face validation of the questionnaire. Two rounds of content validity were performed with the same experts. The final form of the validated questionnaire was translated from English to Arabic language. The content validity index (CVI) was used for content validity and the Cronbach’s alpha test was used to assess the internal consistency reliability of the questionnaire.ResultsDuring the first round of content validity, 50 items were relevant to the underlying construct (Item-CVI ≥ 0.78), while four items were considered not valid (Item-CVI < 0.78) and the average scale-CVI was 0.93. In terms of face validation by experts, the percentage of agreement was adequate (96.4%). The questionnaire was modified by removing the non-valid items, adding/modifying items, and merging some categories. For second round of content validity, all items were found to be valid (I-CVI ≥ 0.78) and the overall questionnaire had adequate content validity (Scale-CVI/Ave = 0.94). The translated valid questionnaire also achieved a perfect agreement (100%) for face validity by patients. The internal consistency was appropriate (≥ 0.7).ConclusionsA new valid, reliable, and translated questionnaire (English and Arabic versions) that cover the majority of aspects of patients’ perception during treatment with removable functional appliances has been developed.

Determinated area (DA) treatment goal when treating malocclusions with jaw functional orthopedics (JFO): Contribution to scientific evidence

One of the goals of malocclusion treatment with Jaw Functional Orthopedics (JFO) is to obtain touch of the inferior incisors against the superior incisors in Determinate Area (DA). It is postulated that this touch would bring better stimuli and consequently faster results. Surface electromyographic study of the muscles was performed in Masseter, Temporal and suprahyoid muscles bilaterally from 159 patients undergoing malocclusion treatment with functional orthopedic appliances (FOA). To record muscle electric activity were used a conditioning signal module from Lynx Electronics Ltda with 8 channels, model EMG1000; software AqDAnalysis 4,18 from Lynx Electronics Ltda.; Software Lynx BioInspector 1,8r; passive surface electrodes (Ag/AgCl) from Noraxon Dual Electrodes (USA); dischargeable reference electrodes Kendall Meditrace (Ag/AgCl) – Canada. Frequency calibration was 2000 Hz, with 2048 sample by channel and time 1,024 seconds, and filters regulation was 20 Hz and 1000 Hz. The results found prove that there is a better electromyographic activity (bilaterally balanced) of the studied muscles when there is touch on DA. Conclusion. Touch in DA improves the neuromuscular response of patients treated with JFO. sEMG is a trustable tool to analyze masticatory muscles function for Diagnosis, Treatment and evaluation post treatment/gained objective.

Growth Evaluation After Costochondral Graft Combined With Functional Appliance in Children With Temporomandibular Joint Ankylosis.

The treatment of temporomandibular joint (TMJ) ankylosis in children is a great challenge for surgeons. Costochondral graft (CCG) is a common method of reconstructing the TMJ in children. However, the growth pattern of CCG is unpredictable. In this study, we introduced a surgical-orthodontic approach and evaluated the growth results of the mandible and maxilla in children with TMJ ankylosis through 3-dimensional computed tomography measurements. A prospective cohort study was conducted on child patients diagnosed as having TMJ ankylosis between September 1, 2018 and June 1, 2020. Computer-aided virtual mandibular position guided the CCG, and removable functional appliance was used after surgery. The maximal incisal opening (MIO), the maxilla height, and the length of mandibular ramus were determined. Paired t test was performed to analyze the differences among various stages. Six patients (3 females, 3 males; aged 6-9y) were included in this study. MIO was 12.4mm before surgery and improved to 36.8mm after 42.8 months' follow-up. Mandible length increased by 5.1mm in the affected side and by 5.3mm in the unaffected side, without significant difference. The affected maxilla height increased by 6.7mm, which was more than 5.0mm in the unaffected side. In conclusion, continued growth of mandible and maxilla can be achieved through CCG combined with functional appliance treatment for children TMJ ankylosis.

Advansync in management of class II malocclusion: A systematic review

Class II malocclusions are of interest to practising orthodontists since they constitute a significant percentage of the cases they treat. In individuals with Class II malocclusions, there is an anteroposterior discrepancy between the maxillary and mandibular dentitions, which is usually accompanied by a skeletal discrepancy. In such malocclusions, a functional appliance (myofunctional or fixed functional) is chosen as a treatment method depending on the severity and need of the particular case. This systematic review aims to evaluate the dental-alveolar, skeletal and soft tissue changes with the use of Advansync™ (A Class II corrector/ fixed functional appliance) in the treatment of Class II malocclusion. A literature search was done on Pubmed, EbscoHost , Google Scholar, Science Direct. This was conducted by two reviewers independently and any conflicts in results were managed through discussion. A Risk of Bias was done for the final articles included in the study. A total of 3,099 records were identified while searching through the database based on Mesh terms and search strategies. Based on the inclusion and exclusion criteria’s the total articles which were eligible for the systematic review were six. As the study was specific in terms of age and gender there was a high risk of selection bias but low risk of reporting bias.Out of the 6 studies, 5 had a low risk of bias and based on their cumulative findings, the effectiveness of Advansync is similar to those of other Class II correctors. The advantage of Advansync over other correctors is that the appliance saves treatment time and can be incorporated from the second month of treatment thereby shortening the duration of treatment.Fixed Class II correctors are used widely in Orthodontics. The selection of the appropriate appliance for the patient is the need of the hour. Thus, this systematic review gives us an insight on the use of Advansync in Class II correction.

Evaluation of the Co-Go-Me angle as a predictor in Class II patients treated with Herbst appliance and skeletal anchorage: a retrospective cohort study.

A condylion-gonion-menton (Co-Go-Me) angle threshold of 125.5° has been introduced as a predictive parameter of cephalometric mandibular response in the orthopedic treatment of growing Class II patients with functional appliances, despite some contradictions in the literature. Considering the lack of studies evaluating the role of skeletal anchorage, this study aims to reassess the threshold of 125.5° in the Co-Go-Me angle as a useful predictor in growing skeletal Class II patients treated with acrylic splint Herbst appliance and two mini-screws in the lower arch (STM2). Thirty-five consecutively treated patients (20 males, 15 females; mean age, 11.37 years) with mandibular retrusion were classified into two groups according to their Co-Go-Me baseline values (Group 1, <125.5°; Group 2, >125.5°). The STM2 protocol involved the use of the MTH Herbst appliance with an acrylic splint in the lower arch and two interradicular mini-screws as anchorage reinforcement. Cephalometric analysis was performed by the same operator for each patient at baseline (T0) and at the end of the Herbst phase (T1). The effects of time and group on the variables were assessed by a repeated-measures analysis of variance. The primary research outcome was the difference between the groups in terms of mandibular responsiveness to treatment referred to as the relative difference (T1-T0) in Co_Gn. The mean duration of the treatment was 9.5 months. No statistically significant differences between groups were detected at baseline, except from the expected SN/GoMe° (p < 0.001) and Co-Go mm (p = 0.028). No statistically significant changes between groups, which were caused by the treatment, were found considering the mandibular sagittal and vertical skeletal parameters. Similarly, no statistically significant differences were found in the dental changes between the high-angle and low-angle patients, apart from the upper molar sagittal position (p = 0.013). The 125.5° threshold in the Co-Go-Me value was not a reliable predictive parameter for the mandibular response in growing patients treated with the MTH Herbst appliance and lower skeletal anchorage. Due to its effective control in the sagittal and vertical planes, the STM2 technique might be an appropriate protocol to use in treating skeletal Class II patients, regardless of the growth pattern.

Effects of Removable Functional Appliances on the Dentoalveolar Unit in Growing Patients.

Background and Objectives: The objective of this retrospective controlled study is to compare class II growing patients who underwent treatment with two different functional appliances: the Fraenkel regulator (FR-2), utilized as the control group, and the elastodontic device "Cranium Occluded Postural Multifunctional Harmonizers" (AMCOP), utilized as the test group. Materials and Methods: The study sample consisted of 52 patients with class II division I malocclusion (30 males, 22 females, mean age 8.6 ± 1.4 years) who were treated with the two different types of appliances: Group 1 (n = 27, mean age 8 [7.00, 9.00] years, 12 females, 15 males) received treatment with AMCOP, while Group 2 (n = 25, mean age 9.2 years [8.20, 10.00], 10 females, 15 males) received treatment with FR-2. The mean treatment duration for Group 1 was 28.00 [21.50, 38.00] months, while for Group 2 it was 23.70 [17.80, 27.40] months. Cephalometric analyses were performed on lateral cephalograms taken before treatment (T1) and after treatment (T2). Results: Significant intragroup differences were observed over time in Group 1 for 1^/PP. Similarly, significant intragroup differences were observed over time in Group 2 for SNB, ANB, and IMPA. Conclusions: Both treatment modalities resulted in the correction of class II malocclusion with dentoalveolar compensation, although the treatment duration with AMCOP tended to be longer on average.

3D Printer-Assisted Layered Fabrication of a Novel Appliance for Oral Myofunctional Therapy and Functional Evaluation of Its Effects on Orofacial Muscles During Wear.

Aim Balanced function of the orofacial muscles is important for normal occlusion and dentition; however, patients with malocclusion often present with myofunctional disorder (MFD). Myofunctional therapy (MFT) has received much attention as a method for reducing MFD. Moreover, prefabricated functional appliances (PFAs) have been developed as a method to eliminate abnormal muscle pressure and guide the tongue into the correct position. However, PFAs have disadvantages, such as poor intraoral retention, limited usage time due to discomfort and poor patient compliance, and changes in the axis of the mandibular anterior teeth.Therefore, this study aimed to develop a new custom-made splint-type orthodontic appliance with CAD/CAM technology. Moreover, we evaluated the characteristics of the appliance and conducted functional tests to determine the effects of the appliance on the orofacial muscles and the discomfort associated with its use. Materials and methods Twenty-five volunteers (nine females and 16 males; mean age 28.4 ± 3.4 years) with normal swallowing function were included in the study. Lip-closing strength (LCS), electromyogramduring swallowing, oxygen saturation, and pulse rate were measured and compared when the appliance was not worn and when it was worn. In addition, tongue habits were evaluated, and the maximum tongue pressure was measured when the appliance was not worn. The subjects were asked to answer a questionnaire using a numerical rating scale (NRS) regarding discomfort when wearing the appliance. The evaluation items were swallowing difficulty, speaking difficulty, and breathlessness, which were rated on an 11-point scale ranging from 0 to 10. Statistical tests were conducted using IBM SPSS version 28.0.1 (IBM, Armonk, NY, USA) with the Shapiro-Wilk and Levene's test, followed by the Wilcoxon signed rank sum test. The significance level was set at α = 0.05. The measurement error for each measurement item was evaluated using an intraclass correlation coefficient. Results A new custom-made splint-type orthodontic appliance was fabricated for each subject. The fit and retention of the appliance in the mouth were good when fitted, and a comparison of the functional test measurements of 25 subjects with and without the appliance showed that the LCS decreased significantly (p<0.05) before and after wearing the appliance. However, no statistically significant differences were found for the other items. The Mann-Whitney U test regarding the effects of sex, previous orthodontic treatment, or MFT, and oral habits did not statistically significantly influence the effects of wearing the device. In the NRS results, "difficulty swallowing" was observed in half of the subjects, "difficulty breathing" was rarely observed, and "difficulty speaking" was observed in all subjects. Conclusions A novel custom-made splint-type orthodontic appliance was designed and fabricated using digital workflow and 3D printing technology. This appliance was designed to correct oral habits and was made from a new material classified as a class II medical appliance according to the international harmonized classification.

Non - extraction treatment of class ii division 2 malocclusion with forsus fatigue-resistant device – 2 case report

Class II malocclusion is one of the most frequent problems encountered in orthodontic. The most common characteristic of Class II malocclusion is mandibular retrognathia rather than maxillary protrusion according to McNamara. Non-growing patients with Class II mandibular retrusion are mostly treated with fixed functional appliances. This article represents two case reports of Class II division 2 malocclusion cases treated with Forsus Fatigue Resistant Appliance after initial levelling and alignment. Forsus Fatigue Resistant appliance in particular when used in conjunction with full bonded fixed appliance facilitate the correction of Class II Div 2 malocclusion by skeletal and dental changes.

Effects of two-phase treatment with functional appliances versus one-phase treatment with pre-molar extraction in Class II div 1 monozygotic twins: A case study

The aim of the study was to compare the skeletal, dental, or soft-tissue outcomes of a one-phase camouflage treatment with pre-molar extraction versus a two-phase treatment with combined twin-block high-pull headgear followed by fixed orthodontic treatment in monozygotic twins. 12-year-old male monozygotic twins presented to the dental clinic with complaints about their anterior teeth. Cephalometric analysis of the patients revealed skeletal Class II malocclusion and a long facial type. Extraoral examination of the patients revealed incompetence of lip seal and a convex profile. In Patient 1, the use of a high pull headgear combined with a twin block to correct skeletal anteroposterior and vertical malocclusions with growth modification and then fixed orthodontic treatment was planned. Patient 2 did not comply with the treatment, complaining that the use of the device could cause esthetic problems and difficulties in use. Therefore, camouflage treatment with extraction of four pre-molars was planned as another treatment option for Class II patients in Patient 2. With the camouflage treatment, the patient continued to grow normally. The combined treatment with twin block and a high pull occipital headgear resulted in inhibition of maxillary growth and a reduction in the severity of the skeletal Class II malocclusion, but the mandibular changes were similar in both patients at the end of treatment. Despite the different treatment modalities, both twins achieved a Class I canine-molar relationship and ideal overjet and overbite. Patients can close their lips with improved soft-tissue profiles. The criteria for the choice of treatment depend entirely on the requirements of the patient.

Navigating the Gray Area: Managing Borderline Cases in Orthodontics

Borderline cases in orthodontics present unique challenges to orthodontists, as they often require tailored treatment approaches to achieve optimal outcomes. Firstly, borderline cases encompass a spectrum of orthodontic issues, including mild to moderate malocclusions, skeletal discrepancies, and asymmetries. Treatment planning for these cases involves a complete assessment of the patient's skeletal and dental characteristics, as well as individual treatment goals and preferences. Orthodontists must employ a combination of traditional fixed appliances, such as braces or clear aligners, and adjunctive techniques such as functional appliances, temporary anchorage devices (TADs), or orthognathic surgery when indicated.