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Cephalometric analysis of dental and skeletal effects of Carriere Motion 3D

appliance for Class II malocclusion

Article  in  American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American
Board of Orthodontics · January 2022
DOI: 10.1016/j.ajodo.2020.12.024

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ORIGINAL ARTICLE

Cephalometric analysis of dental and

skeletal effects of Carriere Motion 3D
appliance for Class II malocclusion
Lombardo Luca,a Cervinara Francesca,a Guiducci Daniela,a Spedicato Giorgio Alfredo,b and Siciliani Giuseppea
Ferrara and Bologna, Italy

Introduction: The objective was to describe the dental and skeletal changes obtained using the Carriere Motion
Appliance (CMA), lateral cephalogram, and the corresponding cephalometric tracings. Methods: A sample of 29
patients with Class II malocclusion (mean age, 12.6 6 1.7 years) was retrospectively selected. All patients were
treated at a single center using a CMA as the primary sagittal correction device. Cephalometric tracings at the begin-
ning and end of treatment were compared. Each cephalometric tracing was performed 3 times by the same operator.
Results: Using the CMA, the 29 patients studied reached dental Class I in 4.4 6 0.98 months. All measurements
were subjected to statistical analysis, paired t test, and all displayed differences between T0 and T1 (P\0.05) except
for the SNA. At the end of treatment, the Wits and ANB values were reduced by 1.38 mm and 0.8 , respectively. Over-
bite and overjet were also reduced by 1.4 mm and 2 mm, respectively. The SNB, FMA, LAFH, and IMPA increased to
a lesser extent (ie, 0.7 , 0.4 , 1.5 mm, and 1.5 , respectively). Conclusions: The CMA is a rapid and efficient means
of correcting Class II malocclusion. Its effects are predominantly dentoalveolar, with minimal skeletal alteration of little
clinical significance. (Am J Orthod Dentofacial Orthop 2022;161:659-65)

C
lass II malocclusion was first described by Edward
Angle as a more distal position of the mandibular
dentition than the maxillary; there are 2 types, Di-
vision 1 and 2,1 and it is still today a topic of much study
and discussion that covers many aspects, including diag-
nosis, treatment plan and timing. Class II malocclusion is
the product of the combination of several dentoalveolar
and skeletal factors, among which the most common is
mandibular retrusion; these factors must be weighed
in the choice of treatment plan.2
There are many devices for the treatment of Class II
malocclusion; some influence skeletal growth, whereas
others have a prevalent dentoalveolar action. The former
group includes functional, fixed3 and removable4-6
a
Postgraduate School of Orthodontics, University of Ferrara, Ferrara, Italy.
b
Department of Statistical Sciences, University of Bologna, Bologna, Italy.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
The views and opinions expressed in this article are those of the authors’ and do
not necessarily reflect the position of the organizations of which they represent.
All patients in the study released their written consent to use the data and
intraoral and extraoral photographs. The University of Ferrara has accepted the
protocol.
Address correspondence to: Cervinara Francesca, Postgraduate School of
Orthodontics, University of Ferrara, Via Montebello, 31, Ferrara 44100, Italy;
e-mail, cervinarafrancesca@gmail.com.
Submitted, April 2020; revised and accepted, December 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.12.024
appliances, whereas the latter features fixed appliances
with intermaxillary elastics7 and molar distalization de-
vices,8-12 some of which are also combined with
temporary skeletal anchorage.13-16 Depending on the
type of discrepancy, extractions in 1 or both arches,17
or orthognathic surgery18 may also be indicated.
A recent introduction to the range of devices used for
Class II correction is the Carriere Motion Appliance
(CMA); this is a device consisting of an arm; a pad to
be cemented to either the canine or the first premolar,
equipped with a hook for applying an elastic; and
another pad to be cemented to the first molar. The latter
pad features a ball and socket-type structure that allows
derotation of the maxillary first molar while controlling
its inclination during the correction of the posterior
teeth as a single unit (Fig 1). In the mandibular arch, a
tube or button is cemented onto the mandibular first
or second molar to apply the elastic. Various methods
can be used to control the proclination of the mandib-
ular incisors, including lingual archwire, miniscrews,
or a thermoformed Essix-type retainer. The Essix also
has the added advantage of causing mandibular
disclusion.19
The CMA can be used in patients with unilateral or
bilateral Class II, Division 1 or 2, in both growing and
adult patients.19One of the main advantages of the de-
vice is that it can be used to correct Class II before

659
660
Fig 1. Carriere Motion Appliance in detail. A, CMA; B,
canine pad with elastic hook; C, lateral view of the molar
pad; and D, molar pad.
beginning treatment with fixed orthodontics or aligners,
at a favorable moment for patient compliance.20
We aimed to investigate the dental and skeletal
changes achieved using the CMA via lateral cephalo-
grams and cephalometric analysis.
MATERIAL AND METHODS
From the archive of the University of Ferrara Postgrad-
uate School of Orthodontics, the records of all patients
with Class II malocclusion treated using CMA from 2017
to 2019 were selected by a single operator (S.G.A.). The se-
lection took place according to the following inclusion
criteria: (1) Class II malocclusion classified from edge-to-
edge to full, (2) aged between 10 and 14 years, (3) hypo-
divergent or normodivergent skeletal pattern, and (4) the
availability of full pretreatment (T0) records (intraoral
and extraoral photographs, panoramic radiograph, lateral
cephalogram, digital models with 3 Shape TRIOS [3Shape,
Copenhagen, Denmark]) and posttreatment (T1 at CMA
removal) records (intraoral and extraoral photographs,
panoramic radiograph, lateral cephalogram, digital
models with 3 Shape TRIOS). The final sample was thus
composed of 29 consecutive patients (12 males and 17 fe-
males), with an average age of 12.62 6 1.77 years.
All patients were treated using the same protocol:
CMA; lower Essix; and 6¼ oz elastics, to be changed 3
times a day and removed only during meals; together
with the thermoformed retainer (Fig 2).
Each T0 and T1 lateral cephalogram was obtained
from the same machine and was analyzed by orienting
it so that the Frankfurt plane was parallel to the floor,
with the same magnification factor, and the cephalo-
metric measurements were performed 3 times by the
same operator and on 3 different computers using Dol-
phin Imaging Software (Dolphin Imaging and Manage-
ment Solutions, Chatsworth, Calif).
May 2022  Vol 161  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Luca et al
The cephalometric values analyzed are shown in
Table I.
Statistical analysis
A sample of 29 subjects was used to assess whether
some measures statistically differ between pretreatment
and posttreatment. Different outcomes were measured 3
times (including T0 and T1). A paired sample t test was
used to assess the difference between the pretreatment
and posttreatment.
R statistical software (version 2019; R Core Team,
Vienna, Austria) was used to perform the statistical anal-
ysis.21 Given the actual sample size, the desired power of
1 b 5 0:80 and a significance level of a 5 0:05, the
experiment would be able to detect an effect size equal
to dz 5 0:4733078 that lies between the small and mod-
erate thresholds (0.2-0.5) according to Sawiloski.22
The assessment of measurement error (in terms of
repeatability) was estimated using the intraclass correla-
tion (ICC) index.23 All outcomes’ ICC index is estimated
above 0.94, indicating excellent repeatability of the
experiment for all outcomes.24
RESULTS
A super Class I relationship was achieved in all patients,
and the average duration of CMA treatment was 4.4 6
0.94 months (with a minimum and maximum treatment
time of 3 and 6 months, respectively). All study values
were obtained from cephalometric tracings performed
digitally on T0 and T1 lateral cephalograms. Each tracing
was performed 3 times by the same operator using Dol-
phin software. The resulting measurements were reported
on an Excel sheet and then statistically analyzed.
Table II shows that all the cephalometric parameters
analyzed significantly changed with the exception of
the SNA angle, which showed no statistically significant
variation. In particular, there were statistically significant
sagittal mandibular alterations, with an average increase
in T1 values of 0.7 for SNB and 1.9 mm for Co-Gn.
Furthermore, intermaxillary sagittal measures vary
considerably in favor of Class recovery, specifically the
Wits and ANB, which decreased respectively by an
average of 1.38 mm and 0.8 (Fig 3). Furthermore, the
overjet and overbite decreased by 2 mm and 1.4 mm on
average (Fig 3). There was also a slight increase in the
IMPA (which increased on average by 1.5 ) (Fig 3), an
adverse effect of the use of elastics, although countered
by the Essix retainer.
For each outcome, the following information will be
reported: (1) descriptive statistics by time (Table II), (2)
bivariate plot (mean 6 standard deviation, split by
time), and (3) t test log results (Table II), In addition,
Luca et al
Fig 2. A and B, Intraoral photographs before CMA treatment; C and D, posttreatment intraoral photo-
graphs with CMA still in situ.
Table III reports on ICC measures of all outcomes for
repeatability analysis. (Table III).
DISCUSSION
At the end of the phase with CMA, a molar super Class
I relationship was achieved in all subjects. It has been re-
ported that correction of Class II malocclusion with elas-
tics required that elastic wear be used for 10.0 6 6.0
months.25 In our sample, the duration of CMA treatment
was 4.48 6 0.98 months, which was less than reported
by Kim-Berman et al,26 who reported a treatment time
of 5.1 6 2.8 months using force 1 (6¼ oz) and force 2
elastic (8 oz of 3/16 size) and by Yin et al,27 who reported
6.3 6 2.2 months, not specifying the force of the elas-
tics. Our results, with respect to the duration of CMA
treatment, were in line with what was found by Aree-
pong et al28 using 8 oz 3/16 elastics. Therefore, from
these results, it seems that 6¼ oz elastics was sufficient
to correct Class II malocclusion without increasing the
treatment time, at least in patients from this age group.
As regard the sagittal changes, the maxilla-
mandibular ratios were similar in both groups; however,
less than those found by Kim-Berman et al.26 In our
study, the ANB angle and Wits index values decreased
by 0.7 and 1.3 mm, respectively, while in the study by
Kim-Berman et al29 they decreased by 0.8 and
2.1mm.26 These results are in line with the ones shown
in a study by Giuntini et al,29 who found a decrease in
ANB angle (using the twin-block appliance) and the For-
sus Fatigue Resistant.29
Another parallel between our study and that con-
ducted by Kim-Berman et al26 concerns the upper jaw,
in particular, the values of the SNA angle and the dis-
tance Co-A; in our study, the values of the former did
American Journal of Orthodontics and Dentofacial Orthopedics
661
not vary statistically significantly while the latter
increased. In contrast, Kim-Berman et al26 reported
that SNA values increased, and the Co-A distance
increased less than in this study; however, this difference
could be due to the use of lighter elastics.26
Our analysis of vertical measurements revealed an in-
crease in the FMA, LAFH, and the angle of the occlusal
plane, as reported by Kir-Berman at al26 and Areepong
et al.28
However, what we found does seem to be in line with
the results obtained by Tomblyn at al30 or the findings
reported in the systematic review by Janson et al,7 which
stated that Class II elastics are associated with a reduc-
tion in the growth of the upper jaw, a more pronounced
lower jaw development, and an increase in both lower
facial height and occlusal plane angle, which rotated
clockwise. A similar rotation related to the use of the
twin-block appliance has been described as well by
Giuntini et at.29 Vertical changes, although minimal,
have also been reported by Taylor et al31 in a study on
Herbst and Pendulum appliances.31
Therefore, skeletal changes occur, and these increases
or decreases are statistically significant but not clinically
appreciable. This is likely due to the short duration of
elastics and the reduced force that they apply; an idea
consistent with a review by Janson et al.7 Similar claims
have been reported in systematic reviews of the literature
concerning fixed and removable functional appliances;
specifically, those by Zymperdikas et al32 and Koretsi
et al,33 each of which concluded that skeletal changes,
although statistically significant, were not clinically
relevant.
The most appreciable clinical and cephalometric
changes are dentoalveolar (ie, a reduction in overjet
and overbite). This is in line with both Kim-Berman’s
May 2022  Vol 161  Issue 5
662 Luca et al

Table I. Cephalometric measurements

Variables Definition
SNA The angle between the SN plane and NA line
SNB The angle between the SN plane and NB line
ANB The angle between NA and NB lines
FMA The angle between the mandibular plane and the Frankfurt plane
IMPA The angle between the mandibular plane and the axis of the inferior anterior incisor
U1-palatal plane (PP) The angle between the axis of the maxillary anterior incisor and the palatal plane (anterior and
posterior nasal spines)
Mandibular plane angle The angle between the mandibular plane (Gonion-Gnathion) and the Frankfurt plane
Occlusal plane angle The angle between the occlusal plane and the mandibular incisor
Wits AO-BO segment in which AO and BO indicate the projections of A and B points on the occlusal
plane
Overjet Distance between incisal point of maxillary incisor and incisal point of mandibular incisor taken
on a plane parallel to the palatal one
Overbite Distance between incisal point of maxillary incisor and incisal point of mandibular incisor taken
on a plane perpendicular to the palatal one
Midfacial length (Co-A) Distance between condilyon and point A
Mandibular length (Co-Gn) Distance between condylion and point B
Low anterior facial height LAFH (ANS-Me) Distance between anterior nasal spine and menton
PTV-6 Distance between the maxillary first molar and pterygovertical line
Mandibular plane-occlusal plane Distance between occlusal plane and mandibular plane

and Janson’s findings.7,26 Mandibular incisor proclina-
tion, from 3.3 to 6.2 has been described as related to
Class II treatment with different appliances.7,29,31,33,34
That being said, with respect to the Kim-Berman26 study
and the one by Areepong et al28 we found that the IMPA
angle increased to a lesser extent, perhaps because of our
use of lighter elastics.
We calculated an additional angle between the
maxillary incisors and the bispinal plane; this measure
increased in almost all patients; we found a proclination
of maxillary incisors of about 0.8 , slightly higher
than reported by Kim-Berman (0.3 ) with the same
appliance.26
This effect is different from the one usually described
by Class II mechanics: maxillary incisor retroclination has
been described as an effect of Class II elastics7 and other
Class II devices such as the Jasper Jumper35 (U1-Palatal
Plane decreased 9.38 ) and the twin-block and Forsus

Table II. Statistically significant differences in cephalometric measurements between T0 and T1

Variables T0 T1 t df P
SNA 80.40 6 4.718 80.42 6 4.759 0.16 28 0.9
SNB 76.30 6 3.814 77.05 6 3.838 3.9 28 \0.001
ANB 4.457 6 1.872 3.680 6 1.833 8.3 28 \0.001
Wits 2.947 6 1.959 1.564 6 1.395 5.3 28 \0.001
FMA 20.06 6 5.115 20.54 6 5.306 2 28 0.06
U1-palatal plane 110.4 6 8.085 111.2 6 8.184 4.2 28 0.0003
IMPA 99.85 6 6.320 101.40 6 6.013 6.4 28 \0.001
OVJ 5.601 6 1.869 3.631 6 1.686 6.7 20 \0.001
OVB 3.814 6 1.483 2.441 6 1.672 7.1 28 \0.001
Midfacial length 79.63 6 6.027 80.91 6 5.668 2.7 28 0.01
Mandibular lenght 100.3 6 7.795 102.7 6 7.939 4.6 28 \0.001
Mandibular plane angle 17.51 6 4.691 18.32 6 5.029 3.8 28 0.0008
LAFH 55.73 6 6.127 57.24 6 6.239 4.3 28 0.0002
Occlusal plane 65.86 6 6.288 67.61 6 6.385 8.5 28 \0.001
PTV-U6 14.85 6 3.024 14.25 6 3.219 1.7 28 0.1
Mandibular plane-occlusal plane 13.86 6 4.470 12.77 6 4.807 3.3 28 0.002
Note. Values are mean 6 standard deviation. All values between T0 and T1 are significantly different (P \0.05) (excluding SNA angle, P \0.90).
df, degrees of freedom.

May 2022  Vol 161  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Luca et al 663

Fig 3. Diagrams showing statistically significant reduction of overjet, overbite, and Witts index and in-
crease of IMPA and U1-PP.

appliances29 (maxillary incisor retroclination of 6.5 and A limitation of this study was that we had not consid-
6.3 , respectively). ered occlusal data, so the sample may not have been
The maxillary incisor proclination we obtained using homogeneous, meaning that we did not make a differ-
the CMA appliance was comparable to previous studies ence between full Class II and edge-to-edge Class II
on the Herbst appliance: malocclusion.
Taylor et al31 reported maxillary incisor proclina-
tion (0.8 ) using this appliance, whereas Burkhardt CONCLUSIONS
et al36 reported a proclination of about 1 . Maxillary Taking into consideration the sample of the study, 29
incisor proclination is described in these studies consecutive patients (12 males and 17 females), with an
together with a mandibular advancement reported average age of 12.62 years treated by the same operator,
as a 3.3 mm anterior displacement of the Pogonion we concluded that:
and 5.4 of incisor proclination in the study by Taylor
et al.31 In the study by Burkhardt maxillary incisor
proclination is described together with an increase Table III. ICC Index by outcomes
of SNB angle of 0.2 and a mandibular incisor procli-
nation of 5.2 .36 Variable ICC
Wits 0.973
In our sample, 6 oz elastics together with the lower SNA 0.966
Essix retainer demonstrated a similar effect to that Overbite 0.977
caused by the Herbst appliance31,36: more specifically, U1_palatal_plane 0.998
a proclination of the mandibular incisors (mean, 1.5 ) ANB 0.945
and a slight mandibular advancement (SNB increased IMPA 0.997
SNB 0.941
of about 0.7 ).
Mandibular plane-occlusal plane 0.996
These effects may explain the maxillary incisor procli- FMA 0.996
nation we found in our sample because 1 main differ- occlusal_plane angle 0.997
ence when using the CMA, with respect to the majority LAFH 0.997
of Class II devices, is that the maxillary incisors are Mandibular plane angle 0.996
Overjet 0.982
completely unbounded and their position may be Mandibular_length 0.993
affected by the pressure exerted by the mandibular inci- Midfacial_length 0.985
sors in patients with decreased overjet. PTV-6 0.993

American Journal of Orthodontics and Dentofacial Orthopedics May 2022  Vol 161  Issue 5
664
1. CMA is a mechanism through which molar super
Class I has been obtained.
2. The main effects are dentoalveolar rather than skel-
etal; skeletal changes are minimal and clinically
insignificant.
3. Six-ounce elastics provide as rapid Class II correc-
tion as 8 oz elastics while reducing unwanted effects
(stable SNA, smaller increase in IMPA, and occlusal
plane).
AUTHOR CREDIT STATEMENT
Lombardo Luca contributed to conception, study
design, data analysis, data interpretation, and manuscript
review and editing; Cervinara Francesca contributed to
data analysis, data interpretation, and original draft prepa-
ration; Guiducci Daniela contributed to original draft prep-
aration; Spedicato Giorgio Alfredo contributed to data
analysis, data interpretation, and Siciliani Giuseppe contrib-
uted to conception, study design, data analysis and inter-
pretation, and manuscript review and editing.
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