ORIGINAL ARTICLE

Three-dimensional Evaluation of the

Carriere Motion 3D Appliance in the
treatment of Class II malocclusion
Elizabeth V. Biggs,a,b Erika Benavides,c James A. McNamara, Jr,a Lucia H. S. Cevidanes,a Flavio Copello,d,e
Ronald R. Lints,f Joel P. Lints,f and Antonio C. O. Ruellasa,d
Ann Arbor, Novi, and Traverse City, Mich, Rio de Janeiro, Brazil, and Baltimore, Md

Introduction: This study aimed to quantify the outcomes of adolescent patients with Class II malocclusion
treated with the Carriere Motion 3D Appliance (CMA) combined with full fixed appliances. Methods: Cone-
beam computed tomography scans of 22 patients were available before orthodontic treatment (T1), at removal
of the CMA (T2), and posttreatment (T3). The average age of the patients was 13.5 6 1.6 years at T1, 14.1 6 0.2
years at T2, and 15.6 6 0.5 years at T3. The 3-dimensional image analysis procedures were performed using
ITK-SNAP (version 3.6.0; www.itksnap.org, Hatfield, Pa) and SlicerCMF (version 4.11.0; http://www.slicer.org,
Cambridge, Mass); skeletal and dentoalveolar changes relative to cranial base, maxillary, and mandibular
regional superimpositions were evaluated. Results: Changes were analyzed with 1 sample t tests using the
mean differences during the CMA phase (T1 to T2) and total treatment time (T1 to T3). Significant skeletal
changes included a slight reduction of ANB from T1 to T3, mandibular growth (Co-Gn increment of 1.2 mm
and 3.3 mm from T1 to T2 and T1 to T3, respectively), inferior displacement of point A, and anterior and inferior
displacement of point B. The mandibular plane did not change significantly during treatment. During the CMA
treatment, posterior tipping and distal rotation of the maxillary molars, tip back and inferior displacement of
the maxillary canines, significant mesial rotation, and superior displacement of the mandibular molars were
observed. These movements rebounded during the full fixed appliance phase except for the molar and canine
vertical displacements. Clinically significant dental changes during treatment included a reduction in overjet and
overbite, Class II correction of the molar and canine relationship, and proclination of the mandibular incisors.
Conclusions: The CMA is an effective treatment modality for Class II correction in growing patients because
of a combination of mesial movement of the mandibular molar, distal rotation of the maxillary molar, and anterior
displacement of the mandible. (Am J Orthod Dentofacial Orthop 2023;164:824-36)

C
orrecting Class II malocclusion is a common goal population.1-4 Many options are available when
during routine orthodontic treatment, with these selecting a treatment modality, and the decision
patients comprising 20%-25% of the worldwide should be individualized on the basis of all aspects of
the patient. The Carriere Motion 3D Class II Correction
Appliance (CMA) is an appliance5 developed by Dr Luis
a
Department of Orthodontics and Pediatric Dentistry, School of Dentistry, Uni- Carriere of Barcelona, Spain, in 2004. Potential benefits
versity of Michigan, Ann Arbor, Mich.
b of using this appliance include obtaining the sagittal
Private practice, Novi, Mich.
c
Department of Periodontics and Oral Medicine, School of Dentistry, University correction first in patients presenting with Class II mal-
of Michigan, Ann Arbor, Mich. occlusions, a more esthetic treatment option with no ap-
d
Department of Orthodontics, School of Dentistry, Federal University of Rio de
pliances obstructing the incisors, and the ability to use
Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
e
Department of Orthodontics and Pediatric Dentistry, School of Dentistry, Uni- full fixed appliances or clear aligners following the use
versity of Maryland, Baltimore, Md. of the CMA.5-9
f
Private practice, Traverse City, Mich.
Although recent research6-9 has shown it to be an
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported. effective treatment option, some aspects of this
Address correspondence to: Antonio C.O. Ruellas, Department of Orthodontics appliance’s mechanism of action have not been
and Pediatric Dentistry, School of Dentistry, University of Michigan, 1011 North
investigated thoroughly. A technological advancement
University Ave, Ann Arbor, MI 48109-1078; e-mail, aruellas@umich.edu.
Submitted, November 2021; revised and accepted, May 2023. incorporated into this study is the use of digital dental
0889-5406/$36.00 models and cone-beam computed tomography (CBCT)
Ó 2023 by the American Association of Orthodontists. All rights reserved.
3-dimensional (3D) superimpositions relative to the
https://doi.org/10.1016/j.ajodo.2023.05.031

824
Biggs et al
cranial base, as well as regional maxilla and mandible for
comprehensive and precise quantification of skeletal and
dental changes10-16 compared with previous studies on
this treatment modality using conventional 2-
dimensional (2D)5,6,8,17 or 3D cephalometry.7,9 Recent
studies have been published on this topic evaluating
the effects of this device using 3D radiographic examina-
tions10,17 and superimposition of 3D models combined
with cephalometric x-rays.11 So far, no record of a study
has evaluated dental effects in digital dental models
through superimposition combined with 3D image su-
perimposition from CBCT scans. Therefore, this study
also aims to investigate such measures, including maxil-
lary and mandibular molar rotation, to evaluate the skel-
etal and dental effects of the CMA.
Specifically, the results of this study may allow clini-
cians to make informed decisions on which patients will
be best suited for using the CMA appliance in treating
Class II malocclusion in adolescent patients.
MATERIAL AND METHODS
This study obtained the Institutional Review Board
approval at the University of Michigan and received
notice of determination of “Not Regulated” status
(HUM00168734). A single treating clinician’s office pro-
vided blinded records of 28 patients. A different single
clinician observer analyzed all datasets. Six patients
were excluded from the sample for $1 of the following
reasons: missing intraoral scan data from $ 1-time
point; duration of treatment with the CMA appliance
(Henry Schein Orthodontics, Carlsbad, Calif) exceeded
12 months; technical issues with CBCT scan data, mak-
ing analysis of treatment impossible. The research sam-
ple consisted of 22 growing patients with Class II
malocclusion treated consecutively with the CMA and
full fixed orthodontic appliances. All patients presented
cervical vertebra maturation stage 3 or 4 at baseline. The
sample of 22 CBCT scans and 22 stereolithography in-
traoral scans (IOS) was taken at an initial time point
(T1), an intermediate time point coinciding with the
removal of the CMA (T2), and an immediate posttreat-
ment time point (T3). Thus, 66 CBCT scans and 66 ster-
eolithography files were available for study.
The sample size of 22 patients was based on an a of
0.05, using the measured difference (mean and standard
deviation) in the rotation of the maxillary first molar
from T1 to T2 shown in Table I allows for an estimated
power of 0.89 in this study.
All patients were treated at the office of Dr Ronald R.
Lints in Traverse City, Michigan. These blinded data are
now stored at the Dental and Craniofacial Bionetwork
for Image Analysis, The University of Michigan School
American Journal of Orthodontics and Dentofacial Orthopedics
825
of Dentistry. The following inclusion criteria were
used: bilateral Class II dental relationship (Division 1 or
2); SN-GoGn measurements \35
; no orthodontic or
orthopedic treatment before the initial timepoint;
growing patients; comprehensive, nonsurgical, nonex-
traction treatment was completed with a CMA appliance
used in the initial phase of treatment; no obvious cranio-
facial asymmetries; and no crossbites present at the
initial time point.
The CMA consisted of rigid stainless-steel or acrylic
bars bonded to the maxillary canines and first molars
bilaterally. Elastics were worn in a Class II pattern,
from hooks on the maxillary canine to attachments on
the mandibular first or second molar.5 An invisible
retainer or mandibular lingual holding arch anchors
the mandibular dentition. The elastics protocol for the
CMA appliance was: Force 1 elastics protocol (Henry
Schein Orthodontics) that generated about 375 g of
force12 that were used during the first month, then Force
2 elastics that generated about 540 g of force after that.5
The average age of the patients at the initial time
point was 13.5 6 1.6 years at T1, 14.1 6 0.2 years at
T2, and 15.6 6 0.5 years at T3. The average treatment
time with CMA (from T1 to T2) was 7.3 6 2.4 months
of age, and the total time until the completion of fixed
appliances treatment (from T1 to T3) was 26 6 6.8
months. One patient was in the late mixed dentition at
T1 but was in the permanent dentition at T2. All other
patients were in permanent dentition at the beginning
of treatment. The sample consisted of 7 adolescent
males and 15 adolescent females. During the analysis
of treatment outcomes, sex, race, and ethnicity were
not considered separately.
CBCT scans were taken for diagnostic and clinical
purposes for all subjects, using an iCat unit (Imaging Sci-
ences International, Hatfield, Pa), with a 8.9-second
scan time, 120 kVp, 5 mA, a field of view of 23 3 17
cm, and a voxel size of 0.3 mm3. The CBCT data were
analyzed by a 3D cranial base, maxillary and mandibular
superimpositions. The 3D image analysis procedures
were performed using open-source software ITK-SNAP
(version 3.6.0, www.itksnap.org, Hatfield, Pa) and Sli-
cerCMF (version 4.11.0; http://www.slicer.org, Cam-
bridge, Mass). Original deidentified digital imaging and
communications in medicine files were analyzed
through the following previously validated steps:
1. Head orientation of T1: 3D planes were used as a
reference to standardize and reproduce the head
orientation across all patients accurately13 as fol-
lows: (1) Frankfort horizontal plane (FHP) to match
the axial plane, and (2) midsagittal plane to match
the sagittal plane. After matching these planes, the
December 2023  Vol 164  Issue 6
826 Biggs et al

Table I. Maxillary dentoalveolar measurements from T1 to T2 and T1 to T3

T1 to T2 T1 to T3

Variables Mean 6 SD P value 95% CI Mean 6 SD P value 95% CI

U6 rotation 5.1 64.2 \0.001* 6.4 to 3.8 3.5 6 5.5 \0.001* 5.2 to 1.8
U6 movement AP, mm 0.9 6 1.0 \0.001* 1.2 to 0.6 0.4 6 1.1 0.009* 0.1-0.8
U6 movement SI, mm 0.0 6 0.6 0.634 0.2 to 0.2 0.7 6 1.0 \0.001* 0.4-1.0
U6 angulation 2.8 6 3.8 \0.001* 3.9 to 1.6 0.9 6 3.7 0.117 0.2 to 2.0
U3 movement AP, mm 1.4 6 1.2 \0.001* 1.8 to 1.0 0.1 6 1.3 0.397 0.2 to 0.5
U3 movement SI, mm 1.5 6 0.8 \0.001* 1.3-1.8 1.1 6 1.3 \0.001* 0.8-1.5
U3 angulation 4.8 6 3.8 \0.001* 6.0 to 3.7 0.2 6 4.1 0.77 1.1 to 1.4
U1 inclination 2.1 6 2.1 \0.001* 1.1-3.0 7.2 6 6.5 \0.001* 4.2-10.0
Note. Registration was performed using the maxilla as a reference. Positive values indicate mesial rotation, mesial movement, extrusion, and pro-
clination. Negative values indicate distal rotation, distal movement, intrusion, and retroclination. Data were analyzed with 1-way t tests.
SD, standard deviation; CI, confidence interval; SI, superoinferior; AP, anteroposterior; 3D, Euclidean distance.
*Statistically significant at P \0.01.

scan was moved to have the FHP pass through
point A.
2. Use manual cranial base approximations to
approximate T2 to T1 and T3 to T1.
3. Construction of segmentations (3D volumetric la-
bel maps) was performed for the oriented T1,
approximated to T2 and T3 scans. Separate cranial
base, maxilla, and mandible segmentations were
created for each time point.
4. Place landmarks (prelabeling)14 on the segmenta-
tions of each time point (Table II).
5. Voxel-based registrations were performed for T2 
T1 and T3  T1 superimpositions using 3 refer-
ences: the cranial base registration (surface of
the anterior cranial base),15 maxillary registration
(maxillary region of reference),14 and mandibular
registration (mandibular body region of refer-
ence).16
6. Generation of 3D surface models (visualization
toolkit files) using the 3D Slicer software model
maker tool.
7. Approximation and registration of IOS digital
models (DM) over the analogous maxilla and
mandible visualization toolkit models.18 For
approximation, landmarks were placed on the first
molar, the first premolar, and the canine on the
right and left sides of CBCT and digital models.
Then for registration, landmarks were placed in
the middle of the buccal surface of all teeth on
the CBCT model and the approximated DM.
8. Quantitative skeletal and dental change assess-
ments were made using Q3DC in 3D Slicer. Skeletal
and root apices landmarks were labeled in Slicer
over previously prelabeled landmarks. Dental land-
marks were placed on registered IOS digital model
files. Then, differences between T2 and T1 and T3
and T1 were measured for cranial base, maxillary
and mandibular registrations.
9. Generate semitransparent overlays for visualiza-
tion and qualitative assessment.
10. Repeat landmark placement and measurements in
3D Slicer for 20% of the sample to measure intra-
rater repeatability.
Statistical analysis
The intraclass correlation coefficient was used to test
the intrarater repeatability using a 2-way mixed-effects
model. Treatment effects were evaluated using a
1-sample t test focused on the changes occurring
between T1 and T2 and T1 and T3 time points. Statisti-
cal significance was defined using a P value of 0.05.
SPSS software (version 16.0; SPSS Inc, Chicago, Ill)
was used for the statistical analysis.
RESULTS
For the intrarater reliability, a value of 0.97 was
calculated on the basis of the 95% confidence interval
of the intraclass correlation coefficient estimate, indi-
cating excellent reliability.19
Using the models generated and superimposed in the
3D slicer software, measurements were completed and
organized on the basis of whether the models were regis-
tered using the cranial base, maxilla, or mandible.
Although many of the measured variables showed statis-
tical significance, some differences were not clinically
relevant. The difference between dental movements on
the right and left sides was statistically insignificant, so
they were combined and reported as 1 number.
Skeletal changes during treatment were measured on
the basis of models registered using the cranial base
(Tables III-VI). A statistically significant skeletal change

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Biggs et al
Table II. Definition of landmarks
Landmark Definition
Cranial base
Sella (S) 3D center of sella turcica
Nasion (N) The most anterior and central
point of the frontonasal suture
Maxilla
A-point (A) The point of maximum concavity
near the midline of the anterior
maxilla
Anterior nasal spine (ANS) Most anterior point of the anterior
nasal spine, centered at the
midline transversely
Posterior nasal spine (PNS) Most posterior point of the
posterior nasal spine, centered
at the midline transversely
Tip mesiobuccal cusp Most occlusal point of the
maxillary first molar mesiobuccal cusp of the
(tmUR6/tmUL6) maxillary right and left first
molarsy
Tip distobuccal cusp maxillary Most occlusal point of the
first molar (tdUR6/tdUL6) distobuccal cusp of the
maxillary right and left first
molarsy
Apex mesiobuccal root Most apical point of the
maxillary first molar (aUL6/ mesiobuccal root of the
aUR6) maxillary right and left first
molars
Tip cusp maxillary canines Most occlusal point at the cusp of
(tUR3/tUL3) the maxillary right and left
caninesy
Apex root maxillary canines Most apical point of the root of
(aUR3/aUL3) the maxillary right and left
canines
Incisal edge maxillary incisor The middle of the incisal edge of
(tU1) the most proclined maxillary
central incisor. If similar
proclination, the maxillary right
central incisor was usedy
Apex root Maxillary Incisor The most apical point of the root
(aU1) of the most proclined maxillary
incisor. If similar proclination,
the maxillary right central
incisor was used
Mandible
B-Point (B) The point of maximum concavity
near the midline of the anterior
mandible
Pogonion (Pog) The most anterior point at the
midline of the mandibular
symphysis
Gonion (Go) Two points are placed (right and
left) on the curvature of the
angle of the mandible. Located
by bisecting the angle formed
by the posterior ramus and the
inferior border of the mandible.
Midpoint is taken between the
right and left sides
American Journal of Orthodontics and Dentofacial Orthopedics
827
Table II. Continued
Landmark Definition
Menton (Me) Most inferior point on the
mandibular symphysis along
the midline transversely
Gnathion (Gn) The most anteroinferior midline
point on the mandibular
symphysis located midway
between pogonion and menton
Condylion (Co) Two points are placed (right and
left) on the most superior point
of the condyle. Midpoint is
taken between the right and
left sides
Tip mesiobuccal cusp Most occlusal point of the
mandibular molar (tLR6/ mesiobuccal cusp of the
tLL6 or tLR7/tLL7) mandibular first or second
molar (whichever molar was
used for attachment of Class II
elastics)y
Tip distobuccal cusp Most occlusal point of the
mandibular molar (tLR6/ distobuccal cusp of the
tLL6 or tLR7/tLL7) mandibular first or second
molar (whichever molar was
used for attachment of Class II
elastics)y
Apex mesial root mandibular Most apical point of the mesial
molar (aLR6/aLL6 or aLR7/ root of the mandibular first or
aLL7) second molar (whichever molar
was used for attachment of
Class II elastics)
Buccal groove of the Center of the buccal groove on the
mandibular first molar mandibular first molary
(bgLR6/bgLL6)
Distal contact point of the The most distal point on the distal
mandibular cusp (dCpLR3/ surface of the mandibular cusp
dCpLL3) (distal interproximal contact
point)y
Incisal edge mandibular The middle of the incisal edge of
incisor (tL1) the most proclined mandibular
central incisor. If similar
proclination, the mandibular
right central incisor was usedy
Apex root mandibular incisor The most apical point of the root
(aL1) of the most proclined
mandibular central incisor. If
similar proclination, the
mandibular right central incisor
was used
y
Landmarks that were placed on the surface of IOS models.
in the sagittal dimension from T1 to T3 was shown by a
reduction in ANB of 0.6
. An increase in the lower
anterior facial height also occurred during treatment,
as evidenced by an increase in the superior-inferior
(SI) and 3D measurements of ANS-Me from T1 to T2
(SI, 1.3 mm; 3D, 1.2 mm) and T1 to T3 (SI, 2.5 mm;
December 2023  Vol 164  Issue 6
828
Table III. Descriptive statistics for skeletal angular
measurements
Variables T1 T2 T3
SNA 82.0 6 4.3 81.8 6 4.3 81.7 6 4.4
SNB 78.3 6 4.2 78.1 6 4.0 78.3 6 4.3
ANB 4.1 6 1.5 3.9 6 1.5 3.5 6 1.4
SNGoGn 27.9 6 3.3 28 6 3.1 27.9 6 3.4
Note. Values are presented as mean 6 standard deviation. Registra-
tion was performed using the cranial base as a reference.
3D, 2.3 mm). Mandibular growth also occurred
throughout treatment, with Co-Gn increasing from T1
to T2 (1.2 mm) and T1 to T3 (3.3 mm). Point A had sta-
tistically significant changes inferiorly (T1 to T2, 0.7
mm; T1 to T3, 1.7 mm) and 3D (T1 to T2: 0.9 mm, T1
to T3: 1.8 mm).
Point B and pogonion were both displaced anteriorly
and inferiorly throughout treatment. Point B moved
inferiorly 2.0 mm from T1 to T2 and 2.7 mm from T1
to T3. Point B did not move significantly forward during
the initial phase of treatment but moved 0.8 mm anteri-
orly from T1 to T3. Similarly, pogonion was displaced 1.8
mm inferiorly during CMA treatment, resulting in a total
of 3.7 mm from T1 to T3. Pogonion did not have a sig-
nificant sagittal change in the initial phase but moved
anteriorly 1.1 mm from T1 to T3. SNA, SNB, and
SNGoGn had no statistically significant changes during
the study period.
The models registered relative to the cranial base also
evaluated dental changes and occlusal relationships
(Tables IV and V). There was a statistically significant
reduction in overjet during the initial (T1 to T2, 0.9
mm) and final phase (T1 to T3, 1.4 mm) of treatment.
Overbite was also significantly reduced with the Carriere
appliance (T1 to T2, 1.7 mm). Further reduction in
overbite occurred during treatment with full fixed appli-
ances, with an overall reduction of 2.5 mm. Class II
correction in the molar relationship improved by 2.7
mm during the initial phase of treatment, but this
change was reduced to 1.6 mm of Class II correction
by the end of fixed appliance treatment. Similarly, the
canine relationship had 3.0 mm of Class II correction
from T1 to T2 but only 2.3 mm from T1 to T3.
The analyses of the maxillary dentoalveolar move-
ments were performed using models registered regionally
on the maxilla (Table I). The maxillary first molar showed
statistically significant distal rotation during treatment,
with the most obvious change occurring during the
CMA phase of treatment (5.1
). Some of this distal rota-
tion was lost during the full fixed appliance (FFA) phase of
treatment, making the overall average reduced slightly
(3.5
).
December 2023  Vol 164  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Biggs et al
The maxillary first molar also was distalized (0.9
mm), tipped back (2.8
) during CMA treatment, and
displaced slightly vertically (0.7 mm to occlusal direc-
tion) during treatment with full fixed appliances. The
maxillary canine displayed significant distalization
(1.4 mm) and tip back (4.8
) from T1 to T2; these
changes rebounded from T2 to T3, however, and were
no longer significant at the final time point (AP: T1
to T3, 0.1 mm; angulation: T1 to T3, 0.2
). The maxil-
lary canine tip was displaced vertically during treatment
with the CMA (1.5 mm to occlusal direction);
this change was largely maintained throughout treat-
ment. The maxillary central incisor was proclined
slightly during the initial phase (2.1
) and more sub-
stantially proclined during the final phase of treatment
(T1 to T3, 7.2
).
Finally, the models were registered regionally on the
mandible to evaluate mandibular dentoalveolar changes
(Table VII). During treatment with the CMA from T1 to
T2, the mandibular molar to which the Class II elastic
was attached was rotated mesially significantly (8.3
),
but this rotation was reversed during the second phase
of treatment. The mandibular molar also moved mesially
(1.1 mm) and occlusally (0.6 mm) from T1 to T2. The
sagittal movement was maintained, whereas the molar
continued to move occlusally during treatment with
full fixed appliances (T1 to T3, 1.4 mm). There were no
significant angulation changes to the mandibular molar
during treatment. The mandibular incisor was proclined
3.7
on average from T1 to T2 and was proclined
approximately 8
overall from T1 to T3.
DISCUSSION
This is the first study to use both digital dental
models and CBCT scans, as well as cranial base and
regional superimpositions, to comprehensively quantify
the skeletal and dental effects of the CMA in growing pa-
tients with Class II malocclusions (Fig 1). Treatment
changes that occurred from T1 to T2 were a combination
of CMA use and growth during this timeframe. Changes
seen from T1 to T3 represent overall changes after treat-
ment with the CMA and full fixed appliances.
Treatment changes seen during this study were
compared with previous studies focused on the CMA
or other Class II correctors and the changes seen in un-
treated, growing patients with a Class II malocclusion.
However, it should be noted that most previous studies
that focused on the dentoalveolar and skeletal effects
of Class II correction appliances, including the CMA,
used 2D imaging. In these investigations, millimetric
and angular changes cannot be compared directly to
those derived from 3D imaging.
Biggs et al 829

Table IV. Skeletal angular measurements at T1, T2, and T3

T1 to T2 T1 to T3

Variables Mean 6 SD P value 95% CI Mean 6 SD P value 95% CI

SNA 0.3 6 0.8 0.159 0.6 to 0.1 0.4 6 0.8 0.051 0.8 to 0.0
SNB 0.3 6 1.3 0.305 0.8 to 0.3 0.0 6 1.5 0.925 0.7 to 0.6
ANB 0.3 6 0.6 0.072 0.5 to 0.0 0.6 6 0.6 \0.001* 0.9 to 0.3
SNGoGn 0.1 6 0.9 0.671 0.3 to 0.5 0.0 6 1.0 0.834 0.5 to 0.4
Note. Data analyzed with 1-sample t test results. Registration was performed using the cranial base as a reference.
SD, standard deviation; CI, confidence interval.
*Statistically significant at P \0.01.

Our sample had an average of 3.3 mm increase in the

Table V. Descriptive statistics for skeletal and occlusal
relationship
Variables T1 T2 T3
ANS-Me SI, mm 55.5 6 4.2 56.8 6 4.2 58.0 6 4.3
ANS-Me 3D, mm 56.9 6 4.1 58.1 6 4.0 59.2 6 4.2
Co-Gn 3D, mm 103.3 6 7.1 104.6 6 7.1 106.6 6 6.7
Overjet AP, mm 3.7 6 1.4 2.8 6 1.3 2.3 6 0.5
Open bite SI, mm 4.8 6 1.0 3.1 6 1.4 2.3 6 0.5
Molar relationship AP, mm 2.5 6 1.4 0.5 6 1.2 0.9 6 0.8
Canine relationship AP, mm 5.3 6 1.4 2.3 6 1.7 3.0 6 0.8
Note. Values are presented as mean 6 standard deviation. Registra-
tion was performed using the cranial base as a reference.
Molar relationship, the anteroposterior distance from the tip of the
mesiobuccal cusp of the U6 to the buccal groove of the L6; Canine
relationship, the anteroposterior distance, in mm, from the tip of the
U3 to the most distal point on the distal surface of L3; SI, superoin-
ferior; AP, anteroposterior; 3D, Euclidean distance.
Based on the measurements using the cranial base as
a reference, there was largely no sagittal change seen in
the maxillomandibular relationship (ANB angle) during
the initial phase of treatment with the CMA (T1 to T2)
in this sample. Similar results have been published by
Fouda et al,17 Luca et al,10 and Schimd-Herrmann
et al,11 respectively (change, 0.24
6 0.92
on ANB17;
0.8
of ANB reduction10; 0.71
of ANB reduction11).
However, there was a significant difference in the ANB
angle from the initial time point to treatment comple-
tion (T1 to T3). This change is likely because of mandib-
ular growth (mandibular length increment) seen
throughout treatment (Fig 2).
These findings differ in some respects from some pre-
vious studies on the CMA. Kim-Berman et al6 reported
restriction of maxillary growth at point A during the
CMA phase of treatment and reported a reduction in
the SNA angle and the ANB angle from T1 to T3. How-
ever, a more recent 3D study of the CMA by Wilson et al7
found no significant changes in SNA or SNB but did
report a slight reduction in ANB during the CMA phase
of treatment.
mandibular length (Co-Gn) during treatment (T1 to T3).
Previous 2D cephalometric analysis6 found that the in-
crease in the untreated controls for Co-Gn was approx-
imately 4.3 mm, whereas the group treated with the
CMA had increases of 5.1 mm on average. They did
not find the differences between the treated group and
the control group to be statistically significant.6 Both
measurements were greater than what was found in
the current sample.
The discrepancy in the magnitude of these changes
may lie in the differences between 3D and 2D measure-
ments. The growth of the mandible in the CMA sample is
likely responsible for the anterior and inferior displace-
ment of Point B and pogonion. In the vertical dimension,
an increase in the lower anterior face height occurred
during both phases of treatment; however, there was
no significant change in the mandibular plane angle.
These findings reinforce the trends seen in 2D
studies.6 Kim-Berman et al6 found that the increase in
lower anterior face height with the CMA was almost
double that found in untreated controls but less than
that in patients treated with full fixed appliances and
Class II elastics.20,21 Equivalent increases have been
observed using a Herbst or Forsus appliance.22-24
Alternatively, Yin et al8 found the increase in the vertical
dimension to be greater with the CMA than when Class II
elastics or the Forsus appliance was used.
Our more clinically important finding in the sagittal
dimension was the anterior displacement of the
mandible because of Co-Gn increment (1.2 6 1.0 mm
from T1 to T2; 3.3 6 1.3 mm from T1 to T3), particularly
from T2 to T3 (FFA phase). ANB angle decreased 0.3
6
0.6
from T1 to T2 and 0.6
6 0.6
from T1 to T3. Our
results for CMA can be compared with other Class II
correction treatment modalities. Similar results with
minimal skeletal effects in the sagittal dimension have
been demonstrated for Class II elastics (mandibular
growth exceeded maxillary growth by 1.1 mm)20 and
the pendulum appliance (ANB reduction of 0.3
6

American Journal of Orthodontics and Dentofacial Orthopedics December 2023  Vol 164  Issue 6
830 Biggs et al

Table VI. Skeletal and occlusal relationship measurements from T1 to T2 and T1 to T3

T1 to T2 T1 to T3

Variables Mean 6 SD P value 95% CI Mean 6 SD P value 95% CI

ANS-Me SI, mm 1.3 6 0.9 \0.001* 0.9-1.7 2.5 6 1.3 \0.001* 2.0-3.1
ANS-Me 3D, mm 1.2 6 1.0 \0.001* 0.8-1.6 2.3 6 1.3 \0.001* 1.7-2.9
Co-Gn 3D, mm 1.2 6 1.0 \0.001* 0.8-1.7 3.3 6 1.3 \0.001* 2.7-3.8
OJ AP, mm 0.9 6 0.7 \0.001* 1.2 to 0.6 1.4 6 1.1 \0.001* 1.9 to 0.9
OB SI, mm 1.7 6 0.8 \0.001* 2.0 to 1.3 2.5 61.1 \0.001* 3.0 to 2.0
Molar relationship, AP, mm 2.9 6 1.8 \0.001* 3.5 to 2.4 1.6 6 1.3 \0.001* 2.0 to 1.2
Canine relationship, AP, mm 3.0 6 1.9 \0.001* 3.6 to 2.4 2.3 6 1.9 \0.001* 3.6 to 2.4
A-A AP, mm 0.0 6 0.3 0.473 0.1 to 0.2 0.2 6 0.5 0.03 0.1-0.4
A-A SI, mm 0.7 6 0.7 \0.001* 0.4-1.0 1.7 6 0.8 \0.001* 1.3-2.1
A-A 3D, mm 0.9 6 0.6 \0.001* 0.6-1.2 1.8 6 0.8 \0.001* 1.5-2.2
B-B AP, mm 0.3 6 0.5 0.009* 0.1-0.6 0.8 6 0.7 \0.001* 0.5-1.1
B-B SI, mm 2.0 6 1.1 \0.001* 1.5-2.4 2.7 6 1.4 \0.001* 2.1-3.3
B-B 3D, mm 2.3 6 1.0 \0.001* 1.9-2.7 3.0 6 1.3 \0.001* 2.5-3.6
Pog-Pog AP, mm 0.3 6 0.6 0.025 0.0-0.6 1.1 6 0.8 \0.001* 0.8-1.5
Pog-Pog SI, mm 1.8 6 1.4 \0.001* 1.2-2.4 3.7 6 1.8 \0.001* 2.9-4.5
Pog-Pog 3D, mm 2.2 6 1.3 \0.001* 1.6-2.7 4.0 6 1.7 \0.001* 3.3-4.8
Note. Registration was performed using the cranial base as a reference. Positive values indicate inferior and distoclusion. Negative values indicate
superior and mesioclusion. Data were analyzed with 1-way t tests.
SD, standard deviation; CI, confidence interval; Molar relationship, the anteroposterior distance from the tip of the mesiobuccal cusp of the U6 to
the buccal groove of the L6; Canine relationship, the anteroposterior distance, in mm, from the tip of the U3 to the most distal point on the distal
surface of L3; SI, superoinferior; AP, anteroposterior; 3D, Euclidean distance.
*Statistically significant at P \0.01.

Table VII. Mandibular dentoalveolar measurements from T1 to T2 and T1 to T3

T1 to T2 T1 to T3

Variables Mean 6 SD P value 95% CI Mean 6 SD P value 95% CI

Mandibular molar rotation 8.3 6 5.5 \0.001* 6.6-10 0.5 6 5.9 0.568 2.3 to 1.3
Mandibular molar movement AP, mm 1.1 6 0.9 \0.001* 0.8-1.4 1.2 6 1.0 \0.001* 0.9-1.5
Mandibular molar movement SI, mm 0.6 6 0.6 \0.001* 0.4-0.7 1.4 6 0.9 \0.001* 1.1-1.7
Mandibular molar angulation 1.5 6 3.3 0.005* 0.5-2.5 0.1 6 3.5 0.885 1.1 to 1.0
L1 inclination 3.7 6 2.1 \0.001* 2.8-4.7 8.1 6 5.9 \0.001* 5.5-10.7

Note. Registration was performed using the mandible as a reference. Positive values indicate mesial rotation, mesial movement, extrusion, mesial
crown tip, and proclination. Negative values indicate distal rotation, distal movement, intrusion, distal crown tip, and retroclination. Data were
analyzed with 1-way t tests.
SD, standard deviation; CI, confidence interval; SI, superoinferior; AP, anteroposterior; 3D, Euclidean distance.
*Statistically significant at P \0.01.

0.9
).22 The Forsus fatigue-resistant device showed a
minimal skeletal change in some studies25 (ANB reduc-
tion of 0.9
, mandibular length increment of 1.3
mm24; ANB reduction of 0.8
, mandibular length incre-
ment of 1.4 mm26; ANB reduction of 1.4
, mandibular
length increment of 1.9 mm27), whereas others studies
reported a significant mandibular skeletal change28,29
(ANB reduction of 1.8
, mandibular length increment
of 1.1 mm28; mandibular length increment of 1.62
mm29). Three-dimensional evaluation of the Herbst
appliance also showed mild maxillary restriction and
anterior mandible positioning (A-point moved posteri-
orly 1.22 mm and B-point moved anteriorly 2.62
mm).21 Two-dimensional evaluations showed restriction
of the maxilla with anterior positioning and growth of
the mandible30-32 when using mandibular anterior
repositioning appliance (mandibular length increment
of 1.78 mm30; mandibular length increment of 0.94
mm31) and Twin-block appliance (mandibular length
increment of 1.47 mm31).
When evaluating overall differences in the molar and
canine relationship, the CMA proved to be an effective

December 2023  Vol 164  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Biggs et al
Fig 1. DM produced from IOS show examples of the molar and canine occlusal relationship present at
T1, T2, and T3.
Fig 2. Cranial base superimposition: changes in the sagittal maxillomandibular relationship: A, T1 to
T2; B, T1 to T3. White, T1; blue, T2; red, T3.
Class II corrector during the first phase of treatment in the
current sample (Figs 1 and 2; Tables IV-VI). However, some
of this correction was lost during the second treatment
phase. The 2D study of the CMA also found a similar
decrease in the amount of Class II correction during the
second phase of treatment, but it was postulated that
some of this relapse may have been intentional because
of overcorrection of the Class II relationship with the
CMA.6 Indeed, some of the patients in our sample were
corrected past Class I occlusion into a Class III tendency,
which rebounded during treatment with fixed appliances.
In our sample, maxillary molar and canine distal movement
relapse were likely allowed because of the larger mandib-
ular growth from T2 to T3, avoiding a Class III molar
relationship at T3. In addition, the rebound would result
in the proper mesial, distal inclination of the maxillary
molar and canine at the end of treatment.
Overbite and overjet significantly decreased because
of treatment with the CMA in our sample and displayed
further reductions during the FFA phase. Previous
studies of the CMA using CBCT imaging reported an
average of 2 mm of reduction in overbite and overjet.7-9
American Journal of Orthodontics and Dentofacial Orthopedics
831
The changes observed in 2D studies reported results of a
similar magnitude.6,8 These changes are important for
function and esthetics on completion of treatment for
patients with Class II malocclusions.
The regional maxillary registration provided insight
into dentoalveolar changes occurring in the maxilla dur-
ing treatment for the current CMA sample (Table I).
Figure 3 shows the changes to the maxillary molar and
canine during the CMA phase of treatment. Although
statistically significant, the amount of distalization of
the maxillary first molars from T1 to T2 was modest at
0.9 mm, and the change was no longer statistically sig-
nificant by the time treatment with fixed appliances was
completed.
When the CMA was first introduced, it was thought to
act through distalization of the maxillary dentition, but
it has since been found that this is not the main mech-
anism at play, and the results of this study confirm this
observation. Throughout the subjects, there also was
distal tipping of the maxillary first molar that reverted
by the end of treatment. Janakiraman et al33 reported
in 2016 that tip-back mechanics are not an effective
December 2023  Vol 164  Issue 6
832
Fig 3. Lateral view of maxillary regional superimposition
(T1 to T2) with overlaid IOS DM displaying dentoalveolar
changes from T1 to T2 with landmarks defining the apices
and cusp tips of the maxillary molar and canine. The incli-
nation changes and vertical displacement for the maxil-
lary molar and canine also are shown. White model
(T1), red; Blue model (T2), black.
method for distalization of the maxillary molars, so the
rebound seen in the CMA subjects is not surprising.
The maxillary molar had no significant change in the
vertical dimension during the CMA phase of treatment,
but it moved occlusally during treatment with fixed ap-
pliances. This could be due to the normal alveolar
growth, in that the mandibular plane did not change.
One of the merits of using 3D imaging in the evalu-
ation of the CMA is that it allows for the evaluation of
the molar rotation and positional changes of the canine,
which is not possible with standard 2D imaging. More
recently, it has been postulated that distal rotation about
the palatal cusp of the maxillary first molars is one of the
major means of action of the CMA.5,9,34,35 In this sam-
ple, we found an average of 5.1
of distal rotation of
the maxillary molar from T1 to T2, with a slight rebound
to 3.5
by T3. Rotational changes during the CMA phase
are illustrated in Figure 4 and Table I. Areepong et al9
found approximately 3.6
of distal rotation during the
phase of treatment with the CMA. So the amount of
rotational change found in this sample was even more
significant than that found in their sample,9 probably
because the molar relationship was overcorrection in
our sample. Importantly, the slight relapse in the distal
rotation of maxillary molars occurred after the active
CMA phase in this study while the patients were still in
orthodontic treatment. Future investigation of relapse
after treatment and long-term stability are still required.
December 2023  Vol 164  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Biggs et al
Derotation of the molars is needed for proper Class I
intercuspation and Class I premolar articulation because
the maxillary first molar is trapezoidal and occupies
differing amounts of arch length depending on the
orientation. Braun et al36 reported that, although maxil-
lary molar derotation alone is insufficient for complete
correction of a Class II malocclusion, in combination
with other factors such as growth, derotation can
contribute to an idealized Class I occlusion.
This sample, treated with the CMA, experienced
mandibular growth and molar derotation during treat-
ment. In combination, these 2 treatment effects likely
contributed greatly to the Class II correction in these pa-
tients. McDonald et al37 studied the effect of molar rota-
tion on arch length using straight-pull headgear for Class
II correction. The derotation of the maxillary molar
contributed about 1 mm per side of arch length on
average. Molar rotation is only part of the process in pa-
tients requiring a larger Class II correction. However, in
patients with a mild Class II discrepancy, molar derotation
help improve the occlusion toward a Class I molar rela-
tionship.37
The maxillary canine is the attachment point in the
maxilla for the Class II elastics used in conjunction with
the CMA. Therefore, many of the effects seen can be ex-
plained by the vectors exerted on these teeth by the inter-
maxillary elastics pattern. Significant distalization,
vertical displacement, and distal tipping resulted from
treatment with the CMA (Table I). The changes in angu-
lation to the maxillary canine from T1 to T2 are illus-
trated in Figure 3. The vertical change was the only
aspect maintained after the second phase of treatment.
Previous studies7,9 using 3D evaluation of the CMA
also showed distalization, extrusion, and distal tipping
of the maxillary canines, but because these studies did
not include a third-time point after the completion of
comprehensive orthodontic treatment, it was not re-
ported whether these changes were maintained.
The superimposition of the models registered using
the mandible as a reference shows the mandibular
growth reported earlier (Fig 5) and some dental effects
on the mandibular molars. The mandibular molar was
used to engage the elastic. In some patients, the
mandibular first molar was used, and the mandibular
second molar was used in others. The mandibular molar
displayed an average of 8.3
of mesial rotation during
the initial phase of treatment with the CMA. This rota-
tion (Fig 6; Table VII) was clinically significant and had
to be corrected during the FFA phase of treatment. Pre-
vious studies have not described the amount of rota-
tional change seen in the mandibular molar in any
cone beams. Wearing the retainer obviously does not
prevent all undesired dentoalveolar effects in the
Biggs et al
Fig 4. Occlusal view of maxillary regional superimposition (T1 to T2) with overlaid IOS DM illustrating
rotational changes in the maxillary molar from T1 to T2. White model (T1), red; Blue model (T2), black.
mandibular arch. On the basis of these findings,
we recommend bonding the hook on the mandibular
molar as mesial as possible to minimize the tendency
of rotation.
The regional examination of the mandibular molar
also showed statistically and clinically relevant mesial,
mesial tipping, and vertical movement (Fig 5; Table
VII). The anteroposterior change in the mandibular
molar was maintained during the second phase of treat-
ment, whereas the amount of vertical movement
increased further, and the mesial tipping was reversed.
Areepong et al9 and Wilson et al7 similarly reported me-
sialization, mesial tipping, and vertical displacement of
the mandibular molar using the CMA, although a second
phase of treatment was not included in their studies. The
mesial movement of the molar partially contributed to
the overall Class II correction seen in this sample of
CMA patients and appears to be more resistant to relapse
than the changes seen in the maxillary molar.
Because the anteroposterior changes in both the
maxillary molar and canine observed in the CMA phase
of treatment in this study largely rebounded by the
end of treatment, the correction in the Class II occlusal
relationship after treatment resulted from mandibular
dentoalveolar movements (mesial movement of mandib-
ular molar), maxillary molar derotation, as well as for-
ward displacement because of growth of the mandible
rather than distalization of the maxillary dentition. Jan-
son et al20 analyzed the outcome of the Class II maloc-
clusions treated with Class II elastics and found similar
mechanisms for Class II correction. They reported mini-
mal movement in the maxillary molars, mesialization of
the mandibular molars, and forward displacement of the
mandible, with dental changes comprising 63% of the
correction seen at the molar.
American Journal of Orthodontics and Dentofacial Orthopedics
833
When the occlusal movement of the teeth has been
found in this sample during treatment, these changes
are reported simply as vertical movement in a specific di-
rection rather than extrusion. Because 3D measurements
for an untreated control group are unavailable, we
cannot separate normal alveolar growth from extrusion
or intrusion movements because of treatment. Because
the mandibular plane did not change in this sample, ver-
tical movements in the mandibular molars are more
likely because of normal growth changes. For the maxil-
lary canine (from T1 to T2), the occlusal movement is
more likely to be extrusion because of treatment because
the vertical movement of the maxillary canine is of a
greater magnitude than that of the maxillary molar. In
addition, heavy Class II elastics exert extrusive forces
on the maxillary canine without any vertical anchorage
in the maxillary arch.
The effects of treatment with the CMA on the
mandibular incisors were evaluated in the mandibular
regional superimposition. The initial phase of treatment
resulted in 3.7
of incisor proclination (Figs 5 and 6;
Table VII), and an average of 8.1
of mandibular incisor
proclination occurred by the end of treatment. Similar to
the rotation of the mandibular molar, the invisible
retainer used for anchorage in the CMA phase of treat-
ment controls as much proclination in the mandibular
incisor as possible. However, some changes still occurred
because of the force exerted by the Class II elastics. Kim-
Berman et al6 reported even more significant flaring of
the mandibular incisors during the CMA phase of treat-
ment (an average of 6.6
), but this proclination was
reduced to 3.5
by the end of Phase II. Wilson et al7
and Areepong et al9 found mandibular incisor proclina-
tion similar to ours. The amount of flaring of the
mandibular incisors found in this study was also similar
December 2023  Vol 164  Issue 6
834 Biggs et al

Fig 5. Mandibular regional superimposition (lateral view) with overlaid IOS DM illustrating dentoalveolar
changes and condylar growth from T1 to T2: A, Condylar growth and inclination changes for the
mandibular molar and incisors; B, Condylar growth. White model (T1), red; Blue model (T2), black;
Amount of condylar growth, yellow.

Fig 6. Superimposed mandibular IOS DM (T1 to T2) based on the mandibular regional registration
(occlusal view). Rotational changes to the mandibular molar from T1 to T2 and incisor proclination
are shown as a result of CMA treatment. White model (T1), red; Blue model (T2), black.

to that produced by Class II treatment with the Forsus
appliance, as reported by Miller et al.38 The literature
shows that functional appliances cause flaring of the
mandibular incisors to varying degrees,31 including the
Herbst (5.2
6 6.4
),22 Forsus (6.1
6 6.3
),23 Twin-
block (3.3
6 3.4
),26 and mandibular anterior reposi-
tioning appliance (4.9
6 9.5
)30 appliances. Schmid-
Herrmann et al,11 evaluating 3D DM superimposition
during CMA treatment, found 2.94
6 2.52
) of
mandibular incisor protrusion. Fouda et al17 showed
that using miniscrews as anchorage associated with
CMA appliances led to decreased mandibular incisors
anterior movement.
A recent study by Matsumoto et al39 used CBCT im-
aging to examine the changes in the alveolar bone re-
sulting from the advancement and proclination of the
mandibular incisors. The mentioned study reported
minimal or no bone loss for mandibular incisor changes
below a threshold of 3.0
of proclination. Conversely,
changes in the incisor inclination at or .8.0
increased
the probability of developing bony dehiscences and a
50% probability of vertical bone loss.39 Although the
magnitude of mandibular incisor flaring with the CMA
in our sample does not quite reach this threshold, the
findings imply that mechanics during the remainder of
orthodontic treatment must be controlled carefully to
limit further proclination of the mandibular incisors.
There are some potential limitations to this clinical
investigation. First and foremost, the success of correc-
tion with the CMA depends on patient compliance with
wearing the elastics as prescribed. Previous studies have
shown compliance with removable orthodontic appli-
ances to be consistently suboptimal, and actual wear-
time is often significantly less than self-reported.40-42

December 2023  Vol 164  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Biggs et al
The subjects from this study are likely not exempt from
this pattern of behavior, and clinical outcomes may vary
depending on their degree of compliance.
Furthermore, no established normative values for 3D
measurements and no untreated control group are avail-
able for comparison because of ethical concerns with
unnecessary radiation exposure of untreated patients.
Therefore, although we can compare the treatment ef-
fects measured in this study to other studies that used
3D imaging technologies, these comparisons should be
made with caution.
As previously described, no untreated control group
was analyzed in 3-dimensions for direct comparison.
Although it is possible to speculate on which effects
were solely or partially because of treatment with this
appliance, firm conclusions cannot be made on this sub-
ject without normative values.
CONCLUSIONS
The CMA combined with full fixed appliances is an
effective treatment option for Class II correction in
adolescent patients with Class II malocclusions. During
the CMA phase, maxillary first molars displayed distal
movement, distal rotation, and tip back; maxillary ca-
nines showed tip back and vertical displacement. All
changes during treatment with the CMA rebounded by
the end of treatment, except for the molar and canine
vertical displacement that remained significant at T3.
Correction in the Class II occlusal relationship after treat-
ment resulted from mandibular dentoalveolar move-
ments (mesial movement of the mandibular molar),
maxillary molar derotation, and forward displacement
of the mandible during growth rather than distalization
of the maxillary dentition.
AUTHOR CREDIT STATEMENT
Elizabeth V. Biggs contributed to conceptualization,
methodology, formal analysis, investigation, original
draft preparation, manuscript review and editing, and
visualization; Erika Benavides contributed to manuscript
review and editing; James A. McNamara Jr. contributed
to manuscript review and editing; Lucia H. S. Cevidanes
contributed to conceptualization, methodology, manu-
script review and editing, and supervision; Flavio Copello
contributed to manuscript review and editing and visu-
alization; Ronald R. Lints contributed to resources,
manuscript review and editing; Joel P. Lints contributed
to resources and manuscript review and editing; and An-
tonio C. O. Ruellas contributed to conceptualization,
methodology, original draft preparation, manuscript re-
view and editing, and supervision.
American Journal of Orthodontics and Dentofacial Orthopedics
835
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2023.05.031.
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