F EATURE: Maxillary protrusion

4

A pplic ation of functional orthodontic
a ppli ances to tre atment of“mandibular retrusion syndrome”—Effective use of the TRAINER System™—
Akira KANAO 1), Masanori MASHIKO 2), Kosho KANAO 3)
1) Department of Behavioral Pediatric Dentistry, Okayama University Graduate School of Medicine,
Dentistry and Pharmaceutical Sciences2),3) Kanao Dental Clinic

Introduction
There have recently been an increasing
number of parents complaining of their children’s health-related problems other thancaries, such as decline in exercise ability,
open-mouth posture, slow eating, allergy andmisaligned teeth. Indeed, studies have shown
increases in the number of children with difficulty masticating hard chewy food or inability
to swallow correctly 1,2). The decline in oral
function is attributed to dietary changes
among children in the modern Japanese society including the eating of soft foods at homeand elsewhere3,4). It has also been shown thatthe perioral muscles in growing children influence body posture, respiration, mastication,
deglutition, speech and morphology of thejaws and teeth5,6).
When it is difficult to breathe through thenose due to, for example, tonsillitis or allergic
rhinitis, habitual mouth-breathing is inevitable.
Mouth breathing has been shown to adversely
affect the morphology of the dental arch andjaw bones7). It causes dryness of oral and pharyngeal mucosa. Dry mucosa is more sensitiveand susceptible to inflammation. Inflamedmucosa is more vulnerable to bacterial infection, which in turn aggravates the inflammatory condition. The pharynx gets swollen when

inflamed, making the airway narrower. Airway
constriction increases breathing difficulty,
which induces mouth breathing further. Pharyngeal inflammation caused by mouth breathing spreads to the tonsils. The tonsils have an
immunoprotective function, but become asource of infection once infected8). Infected
tonsils cause further narrowing of the upperand lower airways. Mouth breathing habit thus
has negative impact, particularly on the morphology of the jaws and dental arches ingrowing children. The morphology of the jaws
and dental arches then begins to control function, perpetuating a downward or negative
spiral of vicious circle.
Pediatric dentists are in a better position to
discover this downward spiral through thedental health checkup system they haveestablished and promoted, which will givethem a chance not only to help children withdental problems but to collaborate withotorhinolaryngologists, pediatricians and otherspecialists.

Maxillary protrusion
In our previous paper, we reported on“mandibular retrusion syndrome” in mandibular protrusion cases9). Maxillary protrusion can
be classified into three main skeletal types; 1)

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FEATURE: Maxillary protrusion

overdeveloped maxilla, 2) underdeveloped
mandible, 3) combination of the two.
Nezu, et al. 10,11) showed in their studies
assessing anteroposterior relationship of themaxilla and mandible relative to Nasion-perpendicular (McNamara Line) that a great
majority or 73% of Japanese Class II malocclusions were associated with manidbular
retrusion while true maxillary protrusion(overdeveloped maxilla) accounted for only
7%. In our view, etiologies of maxillary protrusion due to mandibular retrusion include
myofunctional habits during infancy and earlychildhood, e.g., thumb/finger sucking, pacifier
use and the way babies are breast-fed.
This case in the primary dentition had alarge overjet causing lip incompetence (Fig.
1). Without good lip seal, he had to build negative intraoral pressure for swallowing by curling the lower lip under the upper anterior
teeth. Lip incompetence leads to further

Fig. 1 Maxillary protrusion aggravated by myofunctional habitsdeformation of the jaws and dental arches,making lip closure even more difficult. He also
exhibited marked mentalis and buccinatorsstrain during swallowing. The inward force
exerted by the buccinators causes constriction of the upper and lower dental arches intoa V shape and pressure from the strained
mentalis muscle pushes the mandible down
and back. This clockwise rotation of themandible can be a cause of airway constriction, giving rise to the above-mentioned nega-

Fig. 2 Before Phase I treatment with Bionator (age 10Y8M)

46

4) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

Fig. 3 After Phase I treatment with 1 year and 1 month of Bionator (age 11Y9M)

Fig. 4 Before Phase I(age 10Y8M)

Fig. 5 End of Phase I treatment(age 11Y9M)

tive spiral.
In our clinic, we have been using appliancesthat are optimal for Phase I treatment of maxillary protrusion, such as bite plane, Bionator
and Twin Bock, and found these appliances
very effective. Fig. 2 to 8 shows a case treatedwith Bionator.

Fig. 6 Changes after 1 year and1 month of treatment

This patient had an overjet of +6mm andoverbite of +6mm with ANB of 10.3º and FMAof 21.9º. He was diagnosed as having a Class I
division 1 malocclusion with a normal maxilla
and a retrusive mandible. Bionator was used
to stimulate forward mandibular growth inPhase I. The patient’s good complianceJAPANESE JOURNAL OF CLINICAL DENTISTRY FOR CHILDREN 2009 APRIL (Vol.14 No.4)

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FEATURE: Maxillary protrusion

Coffin’s wire
labial bow
plate

lingal bow

expansion screw

Fig. 9 Bionator used

Fig. 7 Maxillary and mandibular changes
Fig. 8 Cephalometric changes
A case treatedwith Bionator

Before Phase I After Phase I
treatment
treatmentage 10Y8M
age 11Y9M

SNA

88.0º

90.0º

SNB

77.7º

80.6º

ANB

10.3º

9.4º

Mand.Plane

21.9º

25.7º

U-1 to FH plane

108.0º103.9ºL-1 to Mand. Plane

106.9º104.6ºFacial axis

88.5º

89.7º

A’-ptm’

51.6mm

54.3mmGn-Cd

107.5mm

113.5mmPog’-Go73.5mm

77.1mm

Gd-Go

54.2mm

53.8mmallowed for full effect of the appliance. There
was adequate improvement in anterior coupling to an overjet of +2mm and overbite of+2mm at the end of Phase I treatment.
Cephalometric analysis demonstrated a tendency for improvement in ANB (9.4º) andFMA (25.7º).
Bionator is a functional appliance developedby Balter12) in the 1950’s. It is a mono-block48

appliance with the upper and lower parts integrated into one unit, comprising resin, wires
and an expansion screw. It is mainly used fortreatment of maxillary protrusion. A construction bite is taken with the mandible brought
forward to an edge-to-edge position. The
appliance has the effects of increasing theintraoral volume and facilitating lip seal.
In our clinic, Bionators were previously
used in children at Hellman’s dental age IIC to
IIIB. The appliance had to be frequently
adjusted by grinding or adding resin due tosuch problems as mobility of exfoliating primary teeth and ectopic eruption of successive
permanent teeth. This increased chairtime
and the appliance adjustment was sometimes
very difficult to make. In our search for optimal appliances by trial and error, we wereintroduced to the TRAINER System™ in
2000. The TRAINER System™ lineup includes
the T4K™ (TRAINER for Kids), T4A™
(TRAINER for Alignment), T4B ™ (TRAINER
for Braces) and T4CII™ (TRAINER for Class
II). The T4K™ is further divided into two
types, soft and harder. Although we were initially puzzled by the wide range of appliances
available in the product lineup, applianceselection is simple and straightforward. The

4) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

T4K™ is the appliance of choice when thesecond molars are still unerupted. The T4A™
or T4CII™ is selected thereafter. The T4B™,
which is designed to be used with braces,
tends to increase patient susceptibility tostomatitis. The T4B™ can be used as a retainer to maintain mandibular position after insufficient Phase I treatment.
When we first incorporated the TRAINER
System™ into our practice, we used it for bite
opening prior to multi-bracket appliance therapy. We later observed added benefits of thesystem in eliminating minor crowding andimproving Class II relationship in many cases.
Some parents were satisfied with the improvements obtained with the TRAINER System™
and declined further treatment, giving us
mixed feelings. In fact, the number of patientstreated with multi-bracket appliances in ourclinic decreased after the introduction of the
TRAINER System™. The next section will
describe the effectiveness of the T4K™ in
Phase I treatment.

Features and objectivesof the TRAINER System™
The TRAINER System™ appliances were
designed and developed as a functional appliance system through repeated refinements
over a period of 10 years to arrive at the current stable design. These appliances weredevised to improve muscle function. They
were approved as orthodontic appliances by
the Japanese regulatory authority in 2008
(Fig. 10).
The TRAINER System™ appliances look similar to a positioner. The latter is fabricated on
setup models and allows some tooth movement. The positioner is more like a bite block
made of elastic resin and designed to settle
teeth and occlusion to predetermined, setup
positions. In contrast, the TRAINER System™

Fig. 10 Soft type made of silicone (left), harder
type made of polyurethane (right)

appliances are designed not only to improveform but to harmonize form and function.

Structure of the TRAINER
System™ appliance
The TRAINER System™ appliance is a flexible appliance made of non-thermoplastic silicone (soft) or polyurethane (harder) (Fig.
11). It is used to improve oral function. Treatment is initiated with the soft type, followedby the harder type. The appliance has two
main effects, one to guide hard tissues, i.e.
jaws and dental arches, and the other to guide
soft tissues, i.e. perioral muscles.
<Hard-tissue guidance system>
The TRAINER System™ appliance brings
the mandible forward using the upper anterior
teeth as an anchorage source. It also has anarch-expansion effect on a constricted arch,creating room for tooth alignment. Thus, mild
crowding may be eliminated with proper useof the appliance.

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FEATURE: Maxillary protrusion

1. Tooth channels
Accommodates teeth
2. Labial bows
Applies light force to misaligned teeth
3. Tongue tag
Maintains the tip of the tongue in correct
position
4. Tongue guard
Prevents tongue thrust and promotes
nasal breathing
5. Lip bumper
Controls mentalis strain
Materials: Soft type (silicone) and harder type (polyurethane) areavailable.

Fig. 11 Structure of T4KTM<Soft-tissue guidance system>
Patients with maxillary protrusion andmandibular retrusion often show mentalis
strain. The TRAINER System™ appliance
positions the mandible forward as a hard-tissue guidance system, facilitating lip seal andnasal breathing. This effect is unique tomono-block appliances. The appliance also
promotes proper functioning of the perioral
muscles that are involved in abnormal swallowing with the lower lip caught behind theupper anterior teeth or tongue-thrust swallowing. This helps to widen the lower airway.

Target ages and usesof the TRAINER System™
The objective of orthodontic treatment is toachieve maximum effect with minimum necessary treatment. Functional appliances including the TRAINER System™ should be usedduring active growth. There are large genderand individual variations in the timing ofgrowth peak. Scammon’s growth curves indicate that maxillary growth is similar to neural50

growth and mandibular growth to general
growth. This means that treatment timing
varies greatly depending on the type of malocclusion (Fig. 12).
The instruction manual of the TRAINER
System™ recommends the age ranges inwhich each appliance can be used effectively;
2 to 5 years for INFANT TRAINER™, 6 to 12
years for the T4K™ and over 12 years for the
T4A™. Because of individual variations ingrowth, age limits vary from one patient toanother. Our patients are instructed to wear
the TRAINER appliance for around 2 hours
during the day and at night during sleep
depending on the child’s age.
In our office, the use of the T4K™ is initiated when the child is at Hellman’s dental age
IIC or older rather than at a given calendar
age. Therapy with the T4K™ should be started with 30 minutes to 1 hour of daytime wearof the soft type. When the patient is accustomed to the soft-type appliance after one
month of use, wear time is increased from 1
hour to 1.5 and then to 2 hours. Nighttime4) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

maxillary growth peak
Optimization of “phase I treatment”
Mandibular growth peakTiming for use of functional appliancesFig. 12 Optimal timing for Phase I treatment

wear is finally added. Patient information isgathered before treatment using the assessment chart introduced in our previous article.
At every monthly visit, the patient is asked
how much time he wore it during the previous
one month.

Case presentation<Case 1 S.N. > (Fig. 13-20)
Diagnosis: An 8-year-old girl presented withprotruded anterior teeth. Facial photographs
showed a retrusive mandible, a protrusive
maxilla, an everted lower lip and mentalis
strain. Intraorally, E/E terminal plane was of
distal step type bilaterally. The upper anterior
teeth were protrusive with an overjet of+6mm and overbite of +3mm. Cephalometricanalysis showed retrusion of B-point, ANB of
6.8º and FMA of 31.0º. Based on these initialrecords, she was diagnosed as having a ClassII division 1 malocclusion.
—End of Phase I treatment: 2 years and
10 months of treatment time

At the end of Phase I treatment with the
T4K™, both the patient and parents felt thatthe face no longer looked protrusive. Her
post-treatment facial photographs show
improvements in mandibular retrusion, upper
lip protrusion, lower lip curl and metalis
strain. Intraorally, the molar relationshipremained Class I on the left side and Class II
on the right side. Both overjet and overbite
were reduced to +2mm. Cephalometrically,
ANB was improved to 5.1º with a slightly
increased but favorable FMA of 33.2º. Comparison of pre- and post-treatment models
showed an increase of 3mm in upper interpremolar width.

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FEATURE: Maxillary protrusion

Fig. 13 Before Phase I treatment with T4KTM (age 8Y0M)

Fig. 14 After Phase I treatment with 2 years and 10 months of T4KTM (age 10Y10M)

52

4) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

Fig. 15 Before Phase I(age 8Y0M)

Fig. 16 After Phase I(age 10Y10M)

Fig. 17 Changes after 2 years
and 10 months of treatment

Fig. 19 Cephalometric changes
Case 1

Fig. 18 Maxillary and mandibularchangesFig. 20 Changes in upper and lower dental arches

Before Phase I After Phase I
treatment
treatmentage 8Y0M
age 10Y10M

SNA

78.3º

77.9º

SNB

71.5º

72.8º

ANB

6.8º

5.1º

Mand.Plane

31.1º

34.6º

U-1 to FH plane

119.8º106.8ºL-1 to Mand. Plane

105.3º94.4ºFacial axis

84.6º

81.0º

A’-ptm’

45.4mm

47.4mmGn-Cd

106.0mm

115.2mmPog’-Go67.7mm

72.9mm

Gd-Go

50.9mm

57.0mm<Case 2 M.Y. > (Fig. 21-28)
Diagnosis: The patient was a half-Japanese
half-Caucasian girl aged 7 years 8 months
with chief complaints of deep bite and lack oflower incisor display. Facially, a low-angle
tendency was noted. Molar relationship was
Class II on both sides. The upper anterior
teeth were protrusive with an overbite of+6mm and overbite of +5mm. Cephalometricanalysis showed retruded B-point, ANB of 6.2ºJAPANESE JOURNAL OF CLINICAL DENTISTRY FOR CHILDREN 2009 APRIL (Vol.14 No.4)

53

FEATURE: Maxillary protrusion

Fig. 21 Before Phase I treatment with T4KTM (age 7Y8M)

Fig. 22 After Phase I treatment with 1 year and 1 month of T4KTM (age 8Y9M)

544) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

Fig. 23 Before Phase I(age 7Y8M)

Fig. 24 After Phase I(age 8Y9M)

Fig. 25 Changes after 1 year
and 1 month of treatment

Fig. 27 Cephalometric changes
Case 2

Fig. 26 Maxillary and mandibularchanges

Before Phase I After Phase I
treatment
treatmentage 7Y8M
age 8Y9M

SNA

84.0º

83.0º

SNB

77.8º

78.7º

ANB

6.2º

4.3º

Mand.Plane

22.5º

19.9º

U-1 to FH plane

100.6º

99.5º

L-1 to Mand. Plane

95.0º

93.8º

Facial axis

92.1º

90.9º

A’-ptm’

52.1mm

52.7mmGn-Cd

106.7mm

113.3mmPog’-Go71.8mm

77.8mm

Gd-Go

54.8mm

53.9mmFig. 28 Changes in upper and lower dental arches

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FEATURE: Maxillary protrusion

and FRMA of 22.5º. Thus, the case was diagnosed as Class II division 1.
—End of Phase I treatment: 1 year and 1
month of treatment time
At the end of Phase I treatment with the
T4K™, the patient and parents were happy
with good tooth alignment. Retrognathic
appearance was improved as the upper lip
protrusion, lower lip curl and mentalis strain
were eliminated. Molar relationship was corrected to Class I. The overjet and overbite
were reduced to +1.5mm and +2mm, respectively. ANB and FMA were improved to 4.3º
and 19.9º, respectively. There was an increaseof 3mm in upper inter-premolar width whenpre- and post-treatment models were compared.
<Case 3 W.K.> (Fig. 29-36)
Diagnosis: A 9-year-9-month girl came inwith protruded anterior teeth. Facially,

mandibular retrusion, upper lip protrusion,
lower lip curl and mentalis strain were noted.
Intraorally, molar relationship was Class II on
both sides. The upper anterior teeth appeared
protrusive with an overjet of +6mm and overbite of +4mm. Frenum surgery was necessary
to release tongue-tie. Cephalometric analysis
showed retruded B-point, ANB of 5.6º and
FMA of 20.1º. The patient was diagnosed ashaving a Class II division 1 malocclusion.
—End of Phase I: 1 year and 5 months oftreatment time
After Phase I treatment with the T4K™, thepatient and parents no longer felt that theteeth were protruded. Favorable facialchanges were observed with improvement ofmandibular retrusion and elimination of upper
lip protrusion, lower lip curl and mentalis
strain. Molar relationship was corrected toClass I on both sides. Both overjet and overbite were reduced to +1.0mm. Lingual frenec-

Fig. 29 Before Phase I treatment with T4KTM (age 9Y9M)

564) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

Fig. 30 After Phase I treatment with 1 year and 5 months of T4KTM (age 11Y2M)

Fig. 31 Before Phase I(age 9Y9M)

Fig. 32 After Phase I(age 11Y2M)

Fig. 33 Changes after 1 year and5 months of treatment

tomy was successfully performed 6 months
into treatment. There were favorable changes
in ANB and FMA to 4.4º and 21.3º, respectively. The lower inter-premolar width increased
4mm as measured on models.

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FEATURE: Maxillary protrusion

Fig. 34 Maxillary and mandibular changes
Fig. 35 Cephalometric changes
Case 3

Before Phase I After Phase I
treatment
treatmentage 9Y9M
age 11Y2M

SNA

90.8º

86.6º

SNB

85.2º

82.1º

ANB

5.6º

4.4º

Mand.Plane

20.1º

21.3º

U-1 to FH plane

104.4º103.6ºL-1 to Mand. Plane

103.4º98.7ºFacial axis

96.3º

88.1º

A’-ptm’

49.0mm

49.2mmGn-Cd

102.9mm

108.4mmPog’-Go73.5mm

76.0mm

Gd-Go

48.7mm

52.0mm<Case 4 W.E. > (Fig. 37-44)
Diagnosis: A 7-year-10-month-old girl presented with a deep bite. Facial examination
showed a retruded mandible, a protrusive
upper lip, an everted lower lip and mentalis
strain. Molar relationship was Class I on theleft and Class II on the right. The upper anterior teeth were protrusive with an overjet of+5mm and overbite of +4mm. Surgical revision of a high upper labial frenum was needed. Cephalometrically, ANB was 5.2º with
retruded B point. FMA was 35.0º. These data
led to the diagnosis of a Class II division 1
malocclusion.
—End of Phase I: 1 year and 5 months oftreatment time
The patient and parents felt that the teeth
became nice and straight at the end of treatment with the T4K™. Facially, upper lip protrusion, lower lip curl and mentalis strain
were eliminated with a reduction in retrusive
appearance of the mandible. The molar relationship was still Class I on the left and Class
II on the right. Both overjet and overbite weredecreased to +1.0mm. The frenum attachment was released and repositioned 6 months
into treatment and remains in good condition.
ANB was reduced to 4.7º and FMA to 33.8º.
Model analysis showed an increase of 4mm inupper inter-premolar width.

Discussion

Fig. 36 Changes in upper and lower dental arches

58

We were able to experience the effectiveness of the T4K™ through the cases we treated. The T4K™ is a prefabricated, single-sized
appliance. Its most prominent feature is theability to encourage proper use of the perioral
muscles. The T4K™ helps to establish a natural occlusal relationship for each individual
child and to form an unstrained pattern ofchewing. Morphologically, it creates an environment conducive to proper perioral soft tis-4) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

Fig. 37 Before Phase I treatment with T4KTM (age 7Y10M)

Fig. 38 After Phase I treatment with 1 year and 5 months of T4KTM (age 9Y3M)

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FEATURE: Maxillary protrusion

Fig. 39 Before Phase I(age 7Y10M)

Fig. 40 After Phase I(age 9Y3M)

Fig. 41 Changes after 1 year
and 5 months of treatment

Fig. 43 Cephalometric changes
Case 4

Before Phase I After Phase I
treatment
treatmentage 7Y10M
age 9Y3M

SNA

80.4º

79.8º

SNB

75.3º

75.0º

ANB

5.2º

4.7º

Mand.Plane

35.0º

33.8º

U-1 to FH plane

97.2º

96.3º

L-1 to Mand. Plane

88.5º

98.8º

Facial axis

71.8º

80.4º

A’-ptm’

43.7mm

45.5mm

Gn-Cd

101.6mm

107.8mmPog’-Go68.6mm

76.9mm

Gd-Go

51.2mm

49.4mmFig. 42 Maxillary and mandibularchangesFig. 44 Changes in upper and lower dental arches

604) Application of functional orthodontic appliances to treatment of “mandibular retrusion syndrome”

sue movement and natural posture of theperioral muscles.
Our experience suggests that the T4K™ is
as effective as Bionator or Twin Block, though
it may not be as easy to wear. Hellman Dental
age 3B, a period closer to mandibular growthpeak, may be the most desirable time forfunctional appliance therapy. The T4K™ canbe used effectively in Hellman Dental age 3B
as well, for it enables eruption guidance ofectopic canines and premolars into the dental
arch. This is difficult to accomplish with Bionator or Twin Block.
The T4K™ has an arch-expansion effect without an expansion screw. All cases presented
in this paper showed arch width increases in
the upper posterior area. The T4K™ applies
expansive force to a narrower dental arch
because of a difference in width between theappliance and the dental arch. In our experience, the T4K™ is also effective in developing
the lower dental arch. For patients withsevere arch deformities, prior treatment suchas orthodontic alignment of anterior teeth andarch expansion with an expander may beneeded before the use of the T4K™, as is thecase for Bionator and Twin Block.
In the treatment of “mandibular retrusion
syndrome”, the T4K™ works by guiding themandible forward using the upper anterior
teeth for anchorage. The upper tooth channelof the appliance is configured in such as way
as to torque the crowns palatally, decreasing
the labial inclination of the upper incisors.
Proclination of the lower incisors may occur
with the use of the appliance, though notobserved in the present cases.
The mechanism of action of the T4K™ on
the soft tissues is to encourage normal swallowing by bringing the anterior teeth into anedge-to-edge position and thereby facilitating
lip seal. This action is common to other func-

1. Light tooth contact
2. Lip seal
3. Stable tongue posture
4. Nasal breathing
Fig. 45 Requirements for proper oral function at
rest

tional appliances. In our view, proper oral
function simply consists of light tooth contact,
lip seal, stable tongue posture and nasal
breathing (Fig. 45), yet there aren’t many
children equipped with all these elements. We
even see many adults walking with the mouth
open.
The posture of the perioral muscles isacquired and becomes a habit through repeated swallowing and breathing in infancy andearly childhood 13). The optimal timing for
myofuncitonal intervention is a period of
active growth and development with highadaptive capacity 14). If the timing is missed,
the child would acquire compensatory habits,
which would require considerable efforts tocorrect later in life.
We regard morphological correction or normalization as a key to the establishment of
normal function when mouth breathing andother myofunctional habits persist. As we continue to observe our growing patients, it is ourhope to promote healthier growth throughPhase I treatment with this objective in mind
and by paying close attention to form andfunction.

SummaryThis paper introduced the mechanics of thethe TRAINER System™ and clinical cases
treated with the T4K™, demonstrating theeffectiveness of the appliance in guiding themandible forward and expanding the upperJAPANESE JOURNAL OF CLINICAL DENTISTRY FOR CHILDREN 2009 APRIL (Vol.14 No.4)

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FEATURE: Maxillary protrusion

and lower arches in maxillary protrusion caseswith “mandibular retrusion syndrome” often
seen among Japanese. When we first saw theappliance, we wondered if such a simple
appliance would have any effect. However,many “mandibular retrusion syndrome” cases
have been treated successfully with the T4K™
in our clinic. We would like to further increase
our clinical experience with the TRAINER
System™ and collect objective and scientific
data to validate the theory behind and thetreatment effect of the system. We also hopeto gain a better, more accurate understandingof growth peak, which is the key to the success of Phase I treatment to produce a greater
effect in a shorter period of time.
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