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Evaluating the treatment efficiency of Carriere Distalizer: a cephalometric and study model comparison of Class II appliances

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Evaluating the treatment efficiency of Carriere Distalizer: a cephalometric and study model comparison of Class II appliances

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Content 1

EVALUATING THE TREATMENT
EFFICIENCY OF CARRIERE DISTALIZER: A
CEPHALOMETRIC AND STUDY MODEL
COMPARISON OF CLASS II APPLIANCES

BY

EUGENE HAN

A Thesis Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA

In Partial Fulfillment of the Requirements for the Degree

MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)

Degree Conferral Date: May 2019

2

Table of Contents

I. Abstract 3
II. Introduction 4
III. Literature Review 5

A. Background of Class II 5
1. Prevalence in populations
2. Cephalometric Significance
3. Growth Potential and Treatment

B. Class II Skeletal Corrections 7
1. Headgear
2. Herbst
3. Twin Block
4. Forsus

C. Class II Dentoalveolar Corrections 10
1. Elastics
2. Extractions
3. Molar Distalizers
a. Pendulum
b. Distal Jet
c. Jones Jig
D. Other Class II Treatments 13
1. Skeletal Anchorage
2. Surgery

E. Carriere Distalizer

IV. Materials and Methods 16
A. Subjects
B. Data Collection
C. Statistical Analysis
V. Results 19
A. Baseline Information
B. Total Treatment Time and Time For Elastics/Appliance Use
C. Quantification of Class II Correction
D. Cephalometric Changes
VI. Discussion 21
VII. Conclusion 25
VIII. Figures and Tables 26
IX. References 43

3

I. Abstract
Introduction: The purpose of this study was to evaluate the treatment efficiency of Carriere
distalizer in comparison to Class II intermaxillary elastics and Forsus. Methods: Three groups of
patients treated with Class II intermaxillary elastics (n=18), Carriere Distalizer (n=18), and
Forsus appliance (n=18) were collected from three private orthodontic practices. Inclusion
criteria were as follows: (1) 10-14 years old of start age with permanent dentition; (2) no history
of previous orthodontic treatment; (3) complete pre- and post-treatment records; (4) dental Class
II division 1 (end-to-end or more); (5) no pre-treatment transverse discrepancy; (6) non-
extraction treatment plan; (7) Class I post-treatment occlusal relationship. The data consisted of
cephalometric and study model measurements from pre- and post-treatment records and
treatment time. Two-tail student t test was used to analyze the differences in cephalometric
changes and dental corrections between Carriere distalizer group and Class II elastics/Forsus
group. Results: All three groups of patients showed no differences in the age of treatment
initiation, pre-treatment cephalometric measurements and Discrepancy Index (DI). The time of
Class II correction for Carriere Distalizer was significantly shorter than that for Class II elastics;
there was no difference in the length of Class II correction between Carriere Distalizer and
Forsus groups. The amount of Class II correction (canine/molar relationship) was significantly
lower for Carriere Distalizer when compared with Forsus appliance. Carriere Distalizer, similarly
to Class II elastics, did not induce any statistically significant correction in skeletal component
(ANB and Wits appraisal). Conclusion: There is a lack of skeletal correction induced by
Carriere Distalizer in growing patients. Carriere Distalizer can be effectively applied to treatment
of mild to moderate Class II dental malocclusion over 6 months on average, although the total
treatment time may be prolonged.
4

II. Introduction

According to Angle’s classification of malocclusion in the 1890’s, there are three types of
malocclusion: Class I, Class II, Class III. Angle postulated that the upper first molars were the
key to occlusion, and that the position of the upper and lower molars would determine the
different types of malocclusions present in a patient (Proffit, 2013). Class I malocclusion shows
the mesiobuccal cusp of the upper molar occluding the buccal groove of the lower molar, with
incorrect line of occlusion. Class II malocclusion shows the upper molar mesially positioned
relative to the lower molar, while Class III malocclusion shows the lower molar distally
positioned relative to the lower molar. Class II malocclusion can be further specified into two
two divisions, depending on the position of the anterior teeth. Class II div 1 malocclusion is
characterized by proclined anterior teeth, while Class II div 2 malocclusion shows retroclined
anterior teeth. Occlusal relationships in the mixed dentition often times are analogous to those in
the permanent dentition and can sometimes predict the relationship of the permanent molars.

Treatment of Class II malocclusion is a common challenge that orthodontists encounter
on a daily basis. Class II division I malocclusion treatment, along with the dental problems that is
present, can be complicated by mandibular deficiency and/or maxillary excess (McNamara,
1981). Patients with Class II div 1 often exhibit convex facial profile, recessed chin, everted
lower lip, and short chin-to-neck length. These dental and soft tissue features can pose negative
influences on affected children both functionally and emotionally. Many different treatment
modalities exist for Class II malocclusion depending on whether the problem is skeletal or
dentoalveolar, and the age of the patient.
5

III. Literature Review

A. Background of Class II

1. Prevalence in Populations

The prevalence of Class II div 1 malocclusion varies from 8.6% to 33.7% in the US
population (da Silva Filho et al., 2008; Erickson and Graziano, 1966). Class II malocclusions in
Saudi Arabia are present in 31.8% of the population (Maspero et al., 2018). In Iranian
population, they are present in 21% (Eslamipour et al., 2018). In Chinese population, Class II
malocclusion prevalence was 7.97% (Shen et al., 2018). Omani adolescent population show 11%
Class II div 1 malocclusion and 1.8% Class II div 2 malocclusion (Al Jadidi et al., 2018).
Malocclusions, including Class II malocclusion, are likely to be partially genetically controlled
by a polygenic inheritance (Cakan et al., 2012). Overall, Class II div 1 malocclusion accounts for
20-30% of all orthodontic patients (Proffit, 2013; Proffit et al., 1998).

2. Cephalometric Significance

Class II malocclusion can be produced by many different combinations of skeletal and
dental components. It can be portrayed by protrusion of the maxillary dentition, while the
skeletal relationship is normal. There may be mandibular deficiency, which is the most common
single characteristic of Class II malocclusion (McNamara, 1981). Although rarer, the maxilla
may be excessive than the mandible. In order to accurately diagnose where the deficiencies exist,
6

it is essential to take a cephalometric radiograph. The main objective of cephalometric analysis is
to establish the anteroposterior and vertical relationship of the maxilla, mandible, and each
dentition.

3. Growth Potential and Treatment
Class II treatment need to be approached differently according to the different
combinations of skeletal and dental components. The age of the patients also need to be
considered. Specifically, for skeletally related Class II malocclusion, treatment differ according
to the growth potential of patients. Growing adolescent patients and non-growing adult patients
thus have different treatment modalities.

Growth curves for the maxilla and mandible on the Scammon’s curves show that the
maxilla typically grow earlier than the mandible. The maxilla and mandible grows by two basic
mechanisms: 1) passive displacement by growth in the cranial base and 2) active growth of the
maxillary and mandibular structures (Proffit, 2013). Growth is completed in the width, length
and height in sequence.

For the skeletal correction of Class II malocclusion with functional appliances, the aim is
to stimulate mandibular growth and to position the mandible forward; the appliances can be
either fixed or removable (Aras et al., 2011; Baccetti et al., 2000; Cacciatore et al., 2014a;
Celikoglu et al., 2016; Clark, 1982, 1988; Cozza et al., 2006; Karacay et al., 2006; Linjawi and
Abbassy, 2018). They stimulate the growth to accelerate the growth curve temporarily, but the
final size of the mandible remains relatively the same (Pancherz, 1985). Although there are some
7

that support early treatment of Class II malocclusions in patients before adolescence, studies
have shown that the effects of early treatment disappeared after comprehensive orthodontic
treatment during adolescence. (Konik et al., 1997; Tulloch et al., 2004). Adults that do not have
growth potential are inherently more limited in treatment options, but many other options still
exist. According to the most recent scientific evidence, the optimal time of applying functional
appliances is during or slightly after the onset of puberty peak in growth velocity (Baccetti et al.,
2000; Franchi et al., 2013; Konik et al., 1997; O'Brien et al., 2009).

B. Class II Skeletal Corrections
For adolescent patients with potential for growth, Class II skeletal corrections may be
considered.

1. Headgear

Headgear is one of the most common treatment with an emphasis on maxillary growth
restriction. The rationale of headgear is to hold the maxillary growth and to allow the mandibular
growth to catch up (Nucera et al., 2018). It is indicated in maxillary skeletal and dental
protrusion. The appliance is an extraoral traction device that attach to tubes on the maxillary first
molar bands (Graber, 2017). Patients with normal or decreased vertical facial dimensions can use
the cervical facebow, while high-pull facebow can be used with increased vertical facial
dimensions. Long term skeletal effects of headgear show restriction of horizontal maxillary
growth with continued horizontal mandibular growth (Bilbo et al., 2018; McNamara et al.,
1996). It may also help retract the maxillary and mandibular dentitions to a differing degree
8

(Graber, 2017). However, compliance with removable orthodontic appliances are suboptimal
(Al-Moghrabi et al., 2017), and headgear had the greatest discrepancy in requested wear time
and actual wear time (Shah, 2017).

2. Herbst

Herbst appliance is a fixed functional appliance that can also be removable. The original
design was developed by Herbst, while the banded design of the appliance was reintroduced by
Pancherz and refined by Rogers (Graber, 2017). Stainless steel crowns or bands are placed on the
upper first molars and lower first premolars. A lower lingual wire extends from the lower first
molar to first molar. The upper and lower bands are attached by bilateral telescopic arms. The
effects of the Herbst appliance is marked mandibular morphological changes and sagittal
condylar growth increase (Pancherz, 1997). It also results in redirection of maxillary growth,
mesial tooth movements in the mandible, and distal tooth movements in the maxilla (Pancherz,
1982). The treatment is equally effective in patients treated before and after the pubertal peak of
growth (Konik et al., 1997). Stable cuspal interdigitation after therapy is difficult to achieve, so
mixed dentition treatment is not recommended (Pancherz, 1997).

3. Twin Block
Twin Block appliance is a removable functional appliance that is composed of maxillary
and mandibular removable acrylic blocks, designed by Clark. The blocks interlock at a 45-degree
angle that guide the mandible forward; interpoximal clasps and labial bows help seat the blocks
to the teeth (Clark, 1988). Bite registration is recorded typically in edge-to-edge in order to
9

maximize the mandibular displacement. The bite blocks can be trimmed to facilitate the eruption
of the lower posterior teeth with a deep bite (Graber, 2017). Twin Block produces increase in
mandibular length as well as lower anterior facial height; it seems to be slightly more efficient in
correcting molar relationship and sagittal maxillomandibular skeletal difference compared to the
Herbst appliance (Schaefer et al., 2004). Similar to the headgear, because Twin Block is a
removable appliance, compliance can be problematic (Shah, 2017).

4. Forsus
Forsus appliance is a multi-piece device that is composed of a telescoping spring that
attaches at the upper first molar and a push rod linked to the lower archwire, distal to either the
canine or first premolar bracket (Cacciatore et al., 2014b). Similar to the Herbst appliance, the
Forsus appliance produces continuous orthopedic force to correct Class II malocclusion (Eissa et
al., 2017). The skeletal changes using a Forsus appliance occur in the maxillary region, where a
significant restraint of the maxilla was recorded; the appliance did not induce significant
mandibular changes (Cacciatore et al., 2014b). Although some patients experience discomfort
due to cheek irritation from the telescope spring, Forsus is relatively well accepted by patients
(Bowman et al., 2013).

10

C. Class II Dentoalveolar Corrections

Class II dentoalveolar corrections may be considered for those with minor Class II
malocclusion, if the facial appearance is acceptable. Though dentoalveolar corrections cannot
correct skeletal malocclusion, they can successfully camouflage the skeletal discrepancies.

1. Elastics

Non-extraction treatment with Class II elastics can be considered if forward movement of
the lower arch is acceptable (Proffit, 2013). Elastics can be used typically from the upper canines
to the lower molars. Changes from the elastics seem to be mostly dentoalveolar, with no
significant changes in the growth of the jaws (Combrink et al., 2006). Although very popular in
contemporary treatment due to its effectiveness, Class II elastics do have some unwanted effects.
The dentoalveolar effects include: 1) lingual tipping, retrusion, and extrusion of the maxillary
incisors 2) labial tipping and intrusion of the mandibular incisors and 3) mesialization and
extrusion of the mandibular molars (Janson et al., 2013). Because of the vertical force of the
elastics, it is important to monitor the rotation of the occlusal plane and not use heavy force
(Proffit, 2013).

2. Extractions

Retraction of the upper incisors into a premolar extraction site is another viable treatment.
Extractions can be done in the lower arch for a Class I dental finish, while without lower
11

extractions, a Class II molar relationship with Class I canine relationship can be achieved.
Premolar extractions for Class II correction can provide excellent occlusion and facial balance
(Luppanapornlarp and Johnston, 1993; Vaden et al., 2018). However, because Class II
malocclusion is primarily due to mandibular deficiency, retracting the maxillary segment may
not be the best suitable treatment for such patients (Proffit, 2013). Extraction treatment in
orthodontics should always be planned with consideration of the width and length of the face and
the general dental condition of the patient for a good long-term result (Al-Ani and Mageet, 2018)

3. Molar Distalizers

Upper molars can be distalized, which in turn could provide space where other maxillary
teeth can be retracted. There are many different types of molar distalizers, such as the Pendulum
appliance, Distal Jet, Jones Jig, and the Carriere Distalizer.

a. The Pendulum appliance consists of a large Nance button and is bonded to the occlusal
surfaces of the upper first and second molars; the distal aspect of the acrylic has springs
that push the molars when activated (Graber, 2017). The Pendulum appliance can
effectively move maxillary molars posteriorly, although distal tipping is observed
(Bussick and McNamara, 2000; Hilgers, 1992; Nissen, 2017).

b. The Distal Jet consists of a bilateral piston that is embedded in a palatal acrylic; the
apparatus is attached to the premolars and the pistons pus the molars distally when
activated (Kinzinger and Diedrich, 2008). The Distal Jet allows for more distal translation
12

of molars with less distal tipping (Bowman, 1998, 2016; Carano and Testa, 1996;
Kinzinger and Diedrich, 2008).

c. Jones Jig appliance consist of a mainframe wire that is inserted into the buccal tube of the
molar and a coil spring that slides onto the mainframe which is ligated to the bicuspid
bracket. The apparatus is commonly used in conjunction with a Nance from the
bicuspids. The Jones Jig appliance successfully distalizes molars, but also increases
anterior face height and extrudes first and second premolars (Patel et al., 2014).
Compared to the Pendulum appliance, the Jones Jig appliance took more time in
distalization time with similar results (Shetty et al., 2017).

13

D. Other Class II Treatments

1. Skeletal Anchorage

Skeletal anchorage can be utilized in Class II dentoalveolar corrections. Titanium screws
that range from various diameters (1-3 mm) and lengths (6-12mm) can be placed with high
success rates and minimal discomfort for orthodontic anchorage (Kuroda et al., 2007).
Temporary anchorage devices (TADs) offer an effective system where distalization can be
performed that eliminates conventional anchorage adverse effects like anchorage loss and distal
tipping of the molars (Levin et al., 2018; Mohamed et al., 2018; Oh et al., 2011). They can be
used in conjunction with the molar distalizers, in order to minimize adverse effects (Escobar et
al., 2007). In recent years, the maximum amount of orthodontic tooth movement has been
increasing, and en-masse distalization of the maxillary arch is becoming a treatment option for
Class II malocclusion patients (Choi et al., 2011; Kook et al., 2014; Tekale et al., 2015). Because
the success rates of TADs range from 80% to 96% and can provide anchorage without patient
compliance (Dalessandri et al., 2014), TADs may be a great adjunct to many Class II treatment
modalities.

14

2. Surgery

Surgery may be the only possible treatment for those patients whose orthodontic
problems are so severe that neither growth modification nor camouflage offer a solution (Proffit,
2013). Patients will typically go through presurgical orthodontics, orthognathic surgery, then
postsurgical orthodontics (Luther et al., 2003). If the Class II malocclusion has greater than
10mm overjet, distance from pogonion to nasion perpendicular more than 18 mm, mandibular
body length less than 70mm, or facial height greater than 125mm, surgery is a likely treatment
for the patient (Proffit et al., 1992). Because mandibular deficiency is one of the biggest causes
of Class II malocclusion, mandibular advancement is one of the most common surgeries. In 40%
of surgical Class II patients, however, successful surgical treatment was accomplished by also
vertically repositioning the maxilla (Proffit et al., 1992). Mandibular advancement is one of the
most stable surgeries with more than 90% chance of less than 2 mm of relapse (Bailey et al.,
2004), even though the long-term overjet increase for surgery patients are twice as likely
compared to camouflaged patients (Mihalik et al., 2003).

There have been some newer surgical approaches, although research is limited.
Presurgical orthodontic phase typically decompensates the teeth and creates a further
compromise in facial esthetics. There is a growing interest in surgery-first approach; surgery first
approach may improve esthetics at a much earlier stage in treatment and may reduce treatment
time due to regional acceleratory phenomenon post-surgery (Kochar et al., 2017). With the rise
of clear aligners in adult population, they are also being utilized in certain surgical cases instead
of conventional braces (Kankam et al., 2018).
15

E. Carriere Distalizer

Carriere Motion 3D Class II appliance or Carriere Distalizer (Henry Schein Inc., New
York, NY) has been marketed as a Class II corrector that functions to rotate and upright the
maxillary first molars while distalizing the posterior segments as a unit (Carriere, 2004). The
lower arch, either banded with a lower lingual holding arch or held together with a clear retainer,
serves as the main anchorage source for Class II correction (Fig 12). Depending on the span of
Carriere Distalizer, elastics can be worn from the upper canines or premolars to the lower
molars; these are similar to Class II intermaxillary elastics. Due to the fact that application of
Carriere Distalizer usually precedes the delivery of full edgewise appliance, adolescent patient`s
comfort and overall experience can be improved (Hamilton et al., 2013). Although Carriere
distalizer has been growing in popularity among clinical practitioners over the last decade, few
studies are available to evaluate the treatment efficiency of Carriere Distalizer for Class II
correction. The purpose of this study was to evaluate the treatment efficiency of Carriere
distalizer in comparison to Class II intermaxillary elastics and Forsus.

16

IV. Materials and Methods

A. Subjects
The study was approved by the ethics board committee of University of Southern California
(IRB approval ID: UP-18-00467). Treatment records of 78 patients, treated with bilateral Class II
intermaxillary elastics, Carriere Distalizer, and Forsus appliance (3M Unitek Corp., St. Paul,
MN) coupled with full edgewise appliances (MBT prescription 022” slot, Opal Orthodontics,
South Jordan, UT), were collected from three private orthodontic practices in southern
California. Patient compliance was not reported as an issue of concern by the case providers.
Orthodontic informed consent was obtained from all patients/parents. The inclusion criteria
were: (1) 10-14 years old of start age with permanent dentition; (2) no history of previous
orthodontic treatment; (3) complete pre- and post-treatment records (cephalometric x ray and
digital study models); (4) dental Class II division 1 (end-to-end or more); (5) no pre-treatment
transverse discrepancy; (6) non-extraction treatment plan; (7) Class I post-treatment occlusal
relationship. The 78 patients were allocated into the three corresponding groups: (1) Class II
intermaxillary elastics, (2) Carriere Distalizer, and (3) Forsus appliance.

A pilot study was conducted based on the records of 12 patients randomly selected from each
treatment group, for the purpose of obtaining an estimate of sample size. Among all the variables
tested, molar correction (Fig 13) generated the least clinically important difference (in absolute
value) between Carriere distalizer group and Class II elastics/Forsus group. As a result, sample
size calculation was performed using the between-group mean differences and standard deviation
(SD) of molar correction, with other assumptions as follows: continuous variable, normal
17

distribution, two independent samples-Carriere distalizer group and Class II elastics/Forsus
group, type I error rate of 0.05 and power of 0.8 (Pandis et al., 2011). The minimum required
sample size was 16. 18 subjects were finally assigned to each treatment group with within-group
genders being balanced.

B. Data collection
The baseline information of the 54 patients, including gender, age (pre-treatment), length of
treatment (months), and length of Class II correction (months), was recorded from Dolphin
management software (Patterson Dental Supply, Inc., Chatsworth, CA) (Table 1). The
Discrepancy Index (DI) of each patient was assessed using the ABO worksheet
(https://www.americanboardortho.com/media/1186/discrepancy-index-worksheet-for-print.pdf).
Pre- and post-treatment cephalometric x-rays were traced on Dolphin Imaging software
(Patterson Dental Supply, Inc., Chatsworth, CA). The main body of clinical variables of
cephalometric analysis was extracted from multiple other analysis to represent the skeletal and
dentoalveolar components in sagittal and vertical dimensions (Tables 2 and 3) (Burstone et al.,
1978; Havold, 1974; Jacobson, 1975; McNamara et al., 1985; Steiner, 1953; Tweed, 1969).
Changes in Cephalometric measurements were calculated as the differences between post- and
pre-treatment values (Table 4).

In order to evaluate the amount of Class II correction, pre-treatment molar and canine
relationships were first measured using digital study models on centric occlusion (CO) supported
by OrthoCAD software (Align Technology, Inc., San Jose, CA) (Fig 13). The reference surfaces
for molar relationship measurement were the buccal groove of mandibular first molar and the
18

mesiobuccal cusp of maxillary first molar; the reference surfaces for canine relationship were the
interproximal contact point between mandibular canine and first premolar, and the cusp of
maxillary canine. The distances (mm) between the two reference surfaces of molar and canine
were recorded separately for left and right sides in each subject. Although all the patients were
finished with Class I molar and canine relationship, the distances between reference surfaces
from post-treatment study models were measured again. The differences between pre- and post-
treatment measurements were then calculated to obtain the relative amount of Class II correction
of molar and canine (Table 4).

C. Statistical analysis
Data collection procedures were carried out by two researchers independently and repeated at an
interval of 6 weeks. For the dataset of each clinical variable evaluated, the assumption of
normality distribution was not violated (Shapiro-Wilk test, α=0.05) (IBM SPSS Statistics, IBM
corporation, NY). The intraclass coefficients (ICC) calculated for all the clinical variables
showed excellent inter-rater and intra-rater reliability of measurements-ICC>0.75 (data not
shown, IBM SPSS Statistics). Therefore, an average was taken from the multiple measurements
of each clinical variable. Finally, two-tail student`s t test was applied to detect the potential
differences in start age, DI, length of treatment, length of Class II correction, cephalometric
changes, and Class II correction-between Carriere distalizer group and Class II elastics/Forsus
group (α=0.05).

19

V. Results

A. Baseline information
The pre-treatment age of subjects in Carriere Distalizer group was 11.9 ± 1.0 (mean ± standard
deviation), while that of subjects in Class II elastics and Forsus groups were 12.6 ± 1.2 and 12.8
± 1.2, respectively (Table 1). The differences in the start age between Carriere Distalizer and
Class II elastics group, and between Carriere Distalizer and Forsus group were not statistically
significant. The ABO DI scores of the samples in three groups showed similar statistical
dispersions, which ranged from 6 to 26 (Table 1). The mean DI scores showed no statistical
differences between Carriere Distalizer group and Class II elastics/Forsus group. All other
clinical characteristics as measured by cephalometric analysis were also statistically comparable
between the treatment groups (Table 2).

B. Total treatment time and time for elastics/appliance use
Based on the subjects collected for the study, the length of treatment (total treatment time) with
Carriere Distalizer as the Class II corrector was 32.3 ± 8.4 months (Table 1). For Forsus group,
the length of treatment was 28.6 ± 5.3 months, which was not statistically different from that of
Carriere Distalizer group. The length of treatment with conventional Class II elastics was 23.9 ±
5.8 months-significantly shorter when compared with Carriere Distalizer group (P=0.002) (Table
1 and Fig 14). However, the length of Class II correction (time for elastics/appliance use) for
Carriere Distalizer (6.3 ± 2.2 months) was significantly shorter than that for Class II elastics
(10.3 ± 3.9 months) (P=0.005), while there was no statistical difference between Carriere
Distalizer and Forsus (7.2 ± 2.7 months) groups (Table 1 and Fig 14).
20

C. Quantification of Class II correction
The amount of Class II corrections as calculated from pre- and post-treatment study models is
presented in the main text as absolute values for a better understanding. Class II molar
relationship correction was significantly lower for Carriere Distalizer (3.7 ± 1.7 mm) when
compared to that of Forsus appliance (5.2 ± 2.3 mm) (P= 0.046, Table 4 and Fig 15A). The mean
difference in canine relationship correction was highly significant between Carriere Distalizer
(3.5 ± 1.7 mm) and Forsus groups (4.5 ± 2.2 mm) (P=0.009, Table 4 and Fig 15A). In contrast,
the Class II treatment mechanics involving Carriere distalizer and intermaxillary elastics showed
no statistically significant difference in correction of both molar and canine relationships (Table
4 and Fig 15B).

D. Cephalometric changes
Pre- and post-treatment cephalometric measurements are presented in Tables 2 and 3. For the
Carriere Distalizer group, pre- and post-treatment differences in ANB and Wits appraisal were
both statistically similar to those in Class II elastics group. However, Forsus group showed
significantly higher amount of changes in ANB and Wits than Carriere Distalizer group (ANB:
P=0.001; Wits: P=0.001) (Table 4 and Fig 16). Except for ANB and Wits, all the other
cephalometric variables showed no statistically significant differences in pre- and post-treatment
changes (Table 4, Fig 17, and Fig 18).

21

VI. Discussion

To evaluate the efficiency of using Carriere Distalizer to treat Class II division I non-extraction
patients, we compared the length of treatment, the length of Class II correction, the amount of
Class II correction and pre- and post- treatment differences in cephalometric measurements
between growing patients treated by Carriere Distalizer and conventional Class II intermaxillary
elastics or Forsus appliance. Patient data collected for the study showed no differences in
baseline information (Tables 1, 2).

In terms of treatment time, the potential difference in the length of treatment was not statistically
significant between Carriere Distalizer and Forsus groups (Fig 14A). According to the statistics
collected from the current patient samples, treatment with either of these two Class II correction
appliances requires an average of approximately 2.5 years (Table 1). By comparison, the average
length of treatment with intermaxillary elastics as the Class II correction mechanics was 5-6
months shorter than that with Carriere Distalizer (Fig 14A). Class II correction with Carriere
Distalizer usually precedes the delivery of full edgewise appliance. Unlike the conventional
Class II elastics supported by upper and lower edgewise appliance and full-size wires, the
intermaxillary elastics supported by Carriere Distalizer and lower lingual holding arch or clear
retainer may result in extra space distal to maxillary lateral incisors, extrusion of maxillary
canines, and worsening in arch length discrepancy in the mandibular arch (Fig 19). Additionally,
due to the existence of a ball-and-socket joint on top of the pad bonded to maxillary first molars,
part of the Class II correction induced by Carriere Distalizer is achieved by derotating the
maxillary first molars distally (Fig 20). Without an active retention device such as a transpalatal
22

arch, replase of derotated molars is unavoidable and needs to be re-corrected into the treatment
(Nanda, 2015; Proffit, 2013). Therefore, although sagittal discrepancy in the buccal segments
may not be a concern in the later stage of the treatment, these factors mentioned above could
potentially increase the complexity of the treatment after Carriere Distalizer is removed,
resulting in prolonged total treatment time.

The average length of Class II correction or appliance/elastics use for Carriere Distalizer group
was comparable to that of Forsus group (Fig 14B). An average of 6-7 months is required for
Carriere Distalizer to correct an end-to-end sagittal discrepancy (Table 1 and Table 2).
Considering the significantly higher amount of correction in molar and canine relationships and
the potential skeletal correction induced by Forsus, Class II correction with Carriere Distalizer in
growing patients is not as efficient as with Forsus appliance (Figs 14, 15). However, the
efficiency of Carriere Distalizer in correcting posterior sagittal discrepancy is still superior to
that of Class II intermaxillary elastics; for similar amount of Class II correction, Class II elastics
requires 4 months more on average compared to Carriere Distalizer (Table 1 and Fig 14B).

In our study, we calculated the differences in canine/molar relationship between pre- and post-
treatment digital study models, as the amount of Class II correction. Thus the measurements in
canine and molar relationship correction are combinations of both dentoalveolar and skeletal
correction generated by the utilization of Carriere Distalizer and the control
appliances/mechanics. With Carriere Distalizer, an average of 3.5-3.7mm of canine and molar
correction was obtained, which is similar to the amount of Class II correction with Class II
elastics (Table 4 and Fig 14). Forsus appliance was more effective than Carriere Distalizer in the
23

correction of sagittal discrepancy; the Class II correction achieved with Forsus appliance was an
average of 4.5-5.2mm, approximately 1mm more than that with Carriere Distalizer (Table 4). All
patients collected for the study were finished with Class I canine and molar relationship, which
are considered clinically acceptable treatment results. However, when the post-treatment study
models were measured using the methodology mentioned in the section of ‘Material and
Methods’, most cases did not show a zero distance between references surfaces defined for
canine/molar relationship. Therefore, although statistically significant differences were detected
in Class II correction between Carriere Distalizer and Forsus groups, the differences may not be
clinically significant.

In order to better understand the difference in Class II correction, comparison of cephalometric
changes reflecting skeletal components were performed between treatment groups. ANB and
Wits appraisal were the only clinical variables that showed statistical significance: pre- and post-
treatment changes in Carriere Distalizer group were significantly lower than those in Forsus
group but were not statistically different from those of Class II elastics group (Table 4 and Fig
16). Based on the scientific evidences currently available, the treatment effect of Class II elastics
is primarily dentoalveolar, while functional appliance like Forsus or Herbst appliance may
impact the growth of maxilla and mandible in growing patients in spite of the potential
controversies(Janson et al., 2013; Linjawi and Abbassy, 2018; Madurantakam, 2016). As a
result, the lower amount of correction associated with the application of Carriere Distalizer is
attributed to a lack of skeletal correction in the sagittal dimension; the correction of a mild-to-
moderate dental Class II can be realized with Carriere Distalizer. Finally, the potential between-
group differences in dental and vertical cephalometric changes were not statistically significant,
24

which indicates that desirable orthodontic dentoalveolar corrections can be equally achieved with
Carriere Distalizer followed by full edgewise appliance (Fig 6 and Fig 18).

Like most orthodontic appliances, the success of Carriere Distalizer hinges on patient
compliance with intermaxillary elastics and lower retainer wear when Carriere Distalizer is in
place. A series of other patient-related factors may also need to be evaluated before commencing
the treatment with Carriere Distalizer, such as vertical skeletal pattern, torque of lower incisors,
and inclination of occlusal plane. Our group treated a 14 years old male patient with Carriere
Distalizer coupled with a lower clear retainer for 8 months but failed to obtain any treatment
effects as expected from Carriere Distalizer (Fig 21). According to the superimposition of the
cephalometric radiographs taken before appliance delivery and immediately after appliance
removal, maxillary arch was barely distalized with anchorage loss in the lower arch (Table 5 and
Fig 21). While patient compliance was ruled out as the culprit because of anchorage loss in the
lower arch and the fit of lower clear retainer, a low-angle skeletal pattern (vertically) was
suspected as the major factor that resulted in the failure of treatment. Therefore, for the purpose
of achieving better clinical outcomes with Carriere Distalizer, a further investigation regarding
the potential failure factors of applying Carriere Distalizer to treat Class II patients is warranted.

25

VII. Conclusions
There is a lack of skeletal correction induced by Carriere Distalizer in growing patients. Carriere
Distalizer can be effectively applied to treatment of mild to moderate Class II dental
malocclusion over 6 months on average, although the total treatment time may be prolonged.

26

VIII. Figure and Tables
Figure Captions
Fig 1. (Aidar, 2016) - Headgear

Fig 2. (Batista et al., 2017) – Herbst

Fig 3. (Al-Anezi, 2011) – Twin Block

27

Fig 4. (Moro et al., 2018) - Forsus

Fig 5. (Valarelli et al., 2017) – Class II Elastics

Fig 6. (Lee et al., 2014) – Extraction Treatment

28

Fig 7. (Verma et al., 2013) – Pendulum appliance

Fig 8. (Cozzani et al., 2014) – Distal Jet

Fig 9. (Singh et al., 2017) – Jones Jig

29

Fig 10. (Lee et al., 2014)– palatal TADs

Fig 11. (Schwartz et al., 2016) – 2 Jaw Surgery for Class II

30

Fig 12. Carriere Distalizer and appliance used for the lower arch. Carriere Distalizer functions
to distalize the posterior segment as a unit (A1 and B1). The lower arch, either banded with a
lower lingual holding arch (A2) or held together with a clear retainer (B2), serves as the main
anchorage source for Class II correction. Depending on the span of Carriere Distalizer, elastics
can be worn from the upper canines or premolars to the lower molars.

31

Fig 13. Measurement of canine and molar relationship on digital study models. The reference
surfaces for canine relationship were the interproximal contact point between mandibular canine
and first premolar, and the cusp of maxillary canine (A1 and B1); the reference surfaces for
molar relationship measurement were the buccal groove of mandibular first molar and the
mesiobuccal cusp of maxillary first molar (A2 and B2); The distances (mm) between the two
reference surfaces of molar and canine were recorded separately for left and right sides in each
subject.

32

Fig 14. Length of treatment (total treatment time) and length of Class II correction (time for
elastics/appliance use). * P<0.05, ** P<0.01, *** P<0.001.

Fig 15. Quantification of Class II correction based on measurements from pre- and post-
treatment study models. * P<0.05, ** P<0.01, *** P<0.001.

33

Fig 16. Pre- and post-treatment differences in ANB and Wits appraisal. * P<0.05, ** P<0.01,
*** P<0.001.

Fig 17. Pre- and post-treatment changes in SN-GoGn and FMA. * P<0.05, ** P<0.01, ***
P<0.001.

34

Fig 18. Pre- and post-treatment changes in maxillary and mandibular dental measurements. *
P<0.05, ** P<0.01, *** P<0.001.

35

Fig 19. Potential side effects induced by Carriere Distalizer. (A1, B1, C1, D1, and E1) Pre-
treatment intraoral photos. (A2, B2, C2, D2, and E2) Intraoral photos taken after 4-months of
treatment with Carriere Distalizer. The intermaxillary elastics supported by Carriere Distalizer
and lower lingual holding arch or clear retainer may result in extra space distal to maxillary
lateral incisors (A2, C2, and D2), extrusion of maxillary canines (B2, C2, and D2), and
worsening in arch length discrepancy in the mandibular arch (E2-lower right buccal segment).

36

Fig 20. Relapse of derotated molar with Carriere Distalizer. (A1 and B1) Pre-treatment intraoral
photos. (A2 and B2) Progress photos after three months of treatment with Carriere Distalizer.
(A3 and B3) Progress photos one month after removal of Carriere Distalizer. The right molar
relationship was corrected to Class I with Carriere Distalizer (B2) and part of the correction was
achieved by derotating the upper right first molar (A2). However, there was replase of derotated
upper right first molar after Carriere Distalizer was removed (B3).

37

Fig 21. Pre-treatment and progress records of the failure case. (A1, B1, C1, D1 and E1) Pre-
treatment intraoral photos. (A2, B2, C2, D2, and E2) Progress intraoral photos after eight months
of treatment with Carriere Distalizer. (F) Superimposition of cephalometric tracings before and
after application of Carriere Distalizer.

38

Table 1.

Number of
subjects
(n)
Age
(years)
Length of
treatment
(months)
Length of
Class II
correction
(months)

Discrepancy
Index (DI)

Mean SD Mean SD Mean SD Mean Min Max
Class II
elastics
18 12.6 1.2 23.9** 5.8 10.3** 3.9 13 7 26
Carriere
Distalizer
18 11.9 1.0 32.3 8.4 6.3 2.2 12 6 22
Forsus

18 12.8 1.2 28.6 5.3 7.2 2.7 15 7 22
Table 1. Baseline information of subjects in each group. * P<0.05, ** P<0.01.

39

Table 2.

Pre-treatment Class II
elastics

Carriere
Distalizer
Forsus

Mean SD Mean SD Mean SD
Maxillary skeletal
SNA (°) 79.9 3.6 80.4 3.1 82.0 3.0
Co-ANS (mm) 92.1 7.0 89.5 6.9 94.1 9.0
Mandibular skeletal
SNB (°) 75.4 2.9 76.1 2.8 76.7 2.3
Co-Gn (mm) 116.2 8.1 117.5 10.2 119.3 11.0
Maxillary/mandibular
ANB (°) 4.5 2.2 4.2 2.0 5.3 2.4
Wits (mm) 3.2 1.9 2.6 2.3 4.5 2.8
Maxillary dental
U1-SN (°) 98.0 7.8 100.5 7.6 102.6 7.7
U1-NA (°) 18.1 9.0 20.1 6.3 20.7 8.7
U1-NA (mm) 2.4 3.2 3.5 2.4 2.9 4.0
Mandibular dental
IMPA (°) 95.1 8.3 94.0 7.9 95.3 6.9
L1-NB (°) 22.8 8.2 23.6 6.4 23.0 5.5
L1-NB (mm) 3.9 3.0 4.6 2.3 4.6 1.9
Interdental
Interincisal angle (°) 131.8 12.1 132.0 9.9 131.1 9.1
Overjet (mm) 5.1 1.3 4.8 0.8 6.3 2.6
Overbite (mm) 4.2 2.9 4.0 1.4 5.0 2.0
Vertical
Upper facial height (mm) 54.3 6.1 49.5 3.2 53.6 5.0
Lower facial height (mm) 64.1 6.8 58.5 5.2 69.0 6.8
FMA (°) 25.1 5.0 24.7 5.6 23.9 4.1
Sn-GoGn (°) 29.5 4.8 30.8 5.2 29.6 3.5
Canine relationship (mm) 4.3 1.2 3.4 1.8 5.2 2.5
Molar relationship (mm) 4.2 1.2 4.3 1.3 4.5 1.2
Table 2. Pre-treatment cephalometric measurements and canine/molar relationship.

40

Table 3.

Post-treatment Class II
elastics

Carriere Distalizer Forsus
Mean SD Mean SD Mean SD
Maxillary skeletal
SNA (°) 79.8 3.8 80.9 4.4 80.7 3.1
Co-ANS (mm) 93.7 4.3 90.8 5.6 95.9 8.0
Mandibular skeletal
SNB (°) 76.3 3.4 77.3 3.6 78.3 2.8
Co-Gn (mm) 121.3 5.6 124.2 7.0 126.8 12.2
Maxillary/mandibular
ANB (°) 3.5 1.7 3.7 2.2 2.4 2.1
Wits (mm) 1.7 1.3 1.2 1.2 0.3 2.8
Maxillary dental
U1-SN (°) 106.7 5.2 106.2 6.0 108.0 4.3
U1-NA (°) 26.9 5.0 25.3 4.8 27.2 5.4
U1-NA (mm) 4.4 1.5 6.5 2.9 5.5 2.1
Mandibular dental
IMPA (°) 101.6 5.5 98.7 7.6 99.8 6.0
L1-NB (°) 28.9 5.2 30.0 7.5 27.5 5.3
L1-NB (mm) 6.7 2.5 6.8 2.3 6.4 2.1
Interdental
Interincisal angle (°) 120.6 7.8 120.9 9.9 122.8 6.5
Overjet (mm) 2.9 0.7 2.8 0.5 3.0 1.0
Overbite (mm) 2.6 0.6 2.2 0.8 2.7 1.0
Vertical
Upper facial height (mm) 55.1 5.7 51.3 2.8 54.5 5.7
Lower facial height (mm) 68.6 4.8 64.8 4.0 72.6 6.7
FMA (°) 24.6 5.7 26.4 6.8 22.2 4.5
Sn-GoGn (°) 27.9 4.9 30.8 6.6 26.2 4.2
Canine relationship (mm) 0.8 1.0 0.6 0.8 0.8 0.9
Molar relationship (mm) -0.25 0.9 -0.8 1.0 -0.6 0.9
Table 3. Post-treatment cephalometric measurements and canine/molar relationship.

41

Table 4.

Post-Pre treatment Class II
elastics

Carriere
Distalizer
Forsus
Mean SD Mean SD Mean SD
Maxillary skeletal
SNA (°) -0.1 2.1 0.6 2.4 -1.2 2.5
Co-ANS (mm) 1.6 5.2 1.3 4.4 1.8 6.0
Mandibular skeletal
SNB (°) 0.95 1.5 1.2 1.9 1.6 1.5
Co-Gn (mm) 5.1 4.6 6.7 6.8 7.5 6.6
Maxillary/mandibular
ANB (°) -1.0 1.6 -0.5 1.5 -2.9*** 1.7
Wits (mm) -1.5 2.0 -0.5 2.3 -4.2*** 2.7
Maxillary dental
U1-SN (°) 8.7 10.2 5.7 7.7 5.4 8.6
U1-NA (°) 8.8 11.3 5.1 7.1 6.5 9.4
U1-NA (mm) 2.0 2.7 3.0 7.7 2.5 3.7
Mandibular dental
IMPA (°) 6.4 7.4 4.7 7.9 4.5 5.7
L1-NB (°) 6.1 6.5 6.4 6.4 4.5 5.9
L1-NB (mm) 2.8 1.4 2.2 1.9 1.8 1.8
Interdental
Interincisal angle (°) -11.2 15.6 -11.1 11.1 -8.3 11.2
Overjet (mm) -2.2 1.3 -2.0 0.9 -3.2 2.4
Overbite (mm) -2.6 2.8 -1.8 1.2 -3.2 2.2
Vertical
Upper facial height (mm) 0.85 2.2 1.9 4.0 0.9 3.3
Lower facial height (mm) 4.5 4.1 6.3 2.6 3.5 3.3
FMA (°) -0.48 3.8 1.7 4.8 -1.7 4.7
Sn-GoGn (°) -1.6 2.6 -0.1 4.1 -1.4 1.9
Canine correction (mm) -3.8 1.4 -3.7 1.7 -5.2** 2.3
Molar correction (mm) -3.5 1.5 -3.5 1.7 -4.5* 2.2
Table 4. Pre- and post-treatment changes in cephalometric measurements and canine/molar relationship
correction.

42

Table 5.

Before Carriere
Distalizer
After Carriere
Distalizer
Norms
Maxillary skeletal
SNA (°) 80.5 78.8 80.7
Co-ANS (mm) 89.9 88.7 95.2
Mandibular skeletal
SNB (°) 74.7 74.7 77.3
Co-Gn (mm) 116.2 113.7 120.6
Maxillary/mandibular
ANB (°) 5.8 4.5 3.4
Wits (mm) 7.4 6.1 -1.2
Maxillary dental
U1-SN (°) 103.4 106.8 102.6
U1-NA (°) 22.9 27.9 21.9
U1-NA (mm) 4.8 6.3 4.3
Mandibular dental
IMPA (°) 101.7 108.0 94.8
L1-NB (°) 27.0 29.8 25.1
L1-NB (mm) 6.1 7.1 4.9
Interdental
Interincisal angle (°) 124.3 118.2 129.6
Overjet (mm) 6.6 6.3 2.0
Overbite (mm) 5.4 4.2 2.0
Vertical
Upper facial height (mm) 53.8 54.1 58.2
Lower facial height (mm) 66.1 65.0 74.3
FMA (°) 19.6 19.8 27.7
Sn-GoGn (°) 27.4 26.4 32.9
Table 5. Cephalometric measurements of the failure case before and after applying Carriere Distalizer for Class II
correction.

43

XI. References

Aidar, L.A. (2016). Class II malocclusion associated with mandibular deficiency and maxillary and
mandibular crowding: follow-up evaluation eight years after treatment completion. Dental
Press J Orthod 21, 99-113.
Al-Anezi, S.A. (2011). Class II malocclusion treatment using combined Twin Block and fixed
orthodontic appliances - A case report. Saudi Dent J 23, 43-51.
Al-Ani, M.H., and Mageet, A.O. (2018). Extraction Planning in Orthodontics. J Contemp Dent
Pract 19, 619-623.
Al-Moghrabi, D., Salazar, F.C., Pandis, N., and Fleming, P.S. (2017). Compliance with removable
orthodontic appliances and adjuncts: A systematic review and meta-analysis. American journal
of orthodontics and dentofacial orthopedics : official publication of the American Association of
Orthodontists, its constituent societies, and the American Board of Orthodontics 152, 17-32.
Al Jadidi, L., Sabrish, S., Shivamurthy, P.G., and Senguttuvan, V. (2018). The prevalence of
malocclusion and orthodontic treatment need in Omani adolescent population. Journal of
orthodontic science 7, 21.
Aras, A., Ada, E., Saracoglu, H., Gezer, N.S., and Aras, I. (2011). Comparison of treatments with
the Forsus fatigue resistant device in relation to skeletal maturity: a cephalometric and
magnetic resonance imaging study. American journal of orthodontics and dentofacial
orthopedics : official publication of the American Association of Orthodontists, its constituent
societies, and the American Board of Orthodontics 140, 616-625.
Baccetti, T., Franchi, L., Toth, L.R., and McNamara, J.A., Jr. (2000). Treatment timing for Twin-
block therapy. American journal of orthodontics and dentofacial orthopedics : official
publication of the American Association of Orthodontists, its constituent societies, and the
American Board of Orthodontics 118, 159-170.
Bailey, L., Cevidanes, L.H., and Proffit, W.R. (2004). Stability and predictability of orthognathic
surgery. American journal of orthodontics and dentofacial orthopedics : official publication of
the American Association of Orthodontists, its constituent societies, and the American Board of
Orthodontics 126, 273-277.
Batista, K., Lima, T., Palomares, N., Carvalho, F.A., Quintao, C., Miguel, J.A.M., Lin, Y.L., Su, T.L.,
and O'Brien, K. (2017). Herbst appliance with skeletal anchorage versus dental anchorage in
adolescents with Class II malocclusion: study protocol for a randomised controlled trial. Trials
18, 564.
Bilbo, E.E., Marshall, S.D., Southard, K.A., Allareddy, V., Holton, N., Thames, A.M., Otsby, M.S.,
and Southard, T.E. (2018). Long-term skeletal effects of high-pull headgear followed by fixed
appliances for the treatment of Class II malocclusions. The Angle orthodontist 88, 530-537.
Bowman, A.C., Saltaji, H., Flores-Mir, C., Preston, B., and Tabbaa, S. (2013). Patient experiences
with the Forsus Fatigue Resistant Device. The Angle orthodontist 83, 437-446.
Bowman, S.J. (1998). Modifications of the distal jet. Journal of clinical orthodontics : JCO 32,
549-556.
Bowman, S.J. (2016). Upper-Molar Distalization and the Distal Jet. Journal of clinical
orthodontics : JCO 50, 159-169.
Burstone, C.J., James, R.B., Legan, H., Murphy, G.A., and Norton, L.A. (1978). Cephalometrics for
orthognathic surgery. Journal of oral surgery 36, 269-277.
44

Bussick, T.J., and McNamara, J.A., Jr. (2000). Dentoalveolar and skeletal changes associated
with the pendulum appliance. American journal of orthodontics and dentofacial orthopedics :
official publication of the American Association of Orthodontists, its constituent societies, and
the American Board of Orthodontics 117, 333-343.
Cacciatore, G., Alvetro, L., Defraia, E., Ghislanzoni, L.T., and Franchi, L. (2014a). Active-
treatment effects of the Forsus fatigue resistant device during comprehensive Class II
correction in growing patients. Korean journal of orthodontics 44, 136-142.
Cacciatore, G., Ghislanzoni, L.T., Alvetro, L., Giuntini, V., and Franchi, L. (2014b). Treatment and
posttreatment effects induced by the Forsus appliance: A controlled clinical study. The Angle
orthodontist 84, 1010-1017.
Cakan, D.G., Ulkur, F., and Taner, T.U. (2012). The genetic basis of facial skeletal characteristics
and its relation with orthodontics. Eur J Dent 6, 340-345.
Carano, A., and Testa, M. (1996). The distal jet for upper molar distalization. Journal of clinical
orthodontics : JCO 30, 374-380.
Carriere, L. (2004). A new Class II distalizer. Journal of clinical orthodontics : JCO 38, 224-231.
Celikoglu, M., Buyuk, S.K., Ekizer, A., and Unal, T. (2016). Treatment effects of skeletally
anchored Forsus FRD EZ and Herbst appliances: A retrospective clinical study. The Angle
orthodontist 86, 306-314.
Choi, Y.J., Lee, J.S., Cha, J.Y., and Park, Y.C. (2011). Total distalization of the maxillary arch in a
patient with skeletal Class II malocclusion. American journal of orthodontics and dentofacial
orthopedics : official publication of the American Association of Orthodontists, its constituent
societies, and the American Board of Orthodontics 139, 823-833.
Clark, W.J. (1982). The twin block traction technique. European journal of orthodontics 4, 129-
138.
Clark, W.J. (1988). The twin block technique. A functional orthopedic appliance system.
American journal of orthodontics and dentofacial orthopedics : official publication of the
American Association of Orthodontists, its constituent societies, and the American Board of
Orthodontics 93, 1-18.
Combrink, F.J., Harris, A.M., Steyn, C.L., and Hudson, A.P. (2006). Dentoskeletal and soft-tissue
changes in growing class II malocclusion patients during nonextraction orthodontic treatment.
SADJ 61, 344-350.
Cozza, P., Baccetti, T., Franchi, L., De Toffol, L., and McNamara, J.A., Jr. (2006). Mandibular
changes produced by functional appliances in Class II malocclusion: a systematic review.
American journal of orthodontics and dentofacial orthopedics : official publication of the
American Association of Orthodontists, its constituent societies, and the American Board of
Orthodontics 129, 599 e591-512; discussion e591-596.
Cozzani, M., Pasini, M., Zallio, F., Ritucci, R., Mutinelli, S., Mazzotta, L., Giuca, M.R., and Piras, V.
(2014). Comparison of maxillary molar distalization with an implant-supported distal jet and a
traditional tooth-supported distal jet appliance. Int J Dent 2014, 937059.
da Silva Filho, O.G., Ferrari Junior, F.M., and Okada Ozawa, T. (2008). Dental arch dimensions in
Class II division 1 malocclusions with mandibular deficiency. The Angle orthodontist 78, 466-
474.
45

Dalessandri, D., Salgarello, S., Dalessandri, M., Lazzaroni, E., Piancino, M., Paganelli, C.,
Maiorana, C., and Santoro, F. (2014). Determinants for success rates of temporary anchorage
devices in orthodontics: a meta-analysis (n > 50). European journal of orthodontics 36, 303-313.
Eissa, O., El-Shennawy, M., Gaballah, S., El-Meehy, G., and El Bialy, T. (2017). Treatment
outcomes of Class II malocclusion cases treated with miniscrew-anchored Forsus Fatigue
Resistant Device: A randomized controlled trial. The Angle orthodontist 87, 824-833.
Erickson, D.M., and Graziano, F.W. (1966). Prevalence of malocculsion in seventh grade children
in two North Carolina cities. Journal of the American Dental Association 73, 124-127.
Escobar, S.A., Tellez, P.A., Moncada, C.A., Villegas, C.A., Latorre, C.M., and Oberti, G. (2007).
Distalization of maxillary molars with the bone-supported pendulum: a clinical study. American
journal of orthodontics and dentofacial orthopedics : official publication of the American
Association of Orthodontists, its constituent societies, and the American Board of Orthodontics
131, 545-549.
Eslamipour, F., Afshari, Z., and Najimi, A. (2018). Prevalence of orthodontic treatment need in
permanent dentition of Iranian population: A systematic review and meta-analysis of
observational studies. Dent Res J (Isfahan) 15, 1-10.
Franchi, L., Pavoni, C., Faltin, K., Jr., McNamara, J.A., Jr., and Cozza, P. (2013). Long-term skeletal
and dental effects and treatment timing for functional appliances in Class II malocclusion. The
Angle orthodontist 83, 334-340.
Graber, V., Vanarsdall, Huang (2017). Orthodontics - Current Principles and Techniques, 6th edn
(Elsevier).
Hamilton, C.F., Saltaji, H., Preston, C.B., Flores-Mir, C., and Tabbaa, S. (2013). Adolescent
patients' experience with the Carriere distalizer appliance. European journal of paediatric
dentistry : official journal of European Academy of Paediatric Dentistry 14, 219-224.
Havold, E.P. (1974). The activator in interceptive orthodontics (St. Louis, MO: C. V. Mosby Co. ).
Hilgers, J.J. (1992). The pendulum appliance for Class II non-compliance therapy. Journal of
clinical orthodontics : JCO 26, 706-714.
Jacobson, A. (1975). The "Wits" appraisal of jaw disharmony. American journal of orthodontics
67, 125-138.
Janson, G., Sathler, R., Fernandes, T.M., Branco, N.C., and Freitas, M.R. (2013). Correction of
Class II malocclusion with Class II elastics: a systematic review. American journal of orthodontics
and dentofacial orthopedics : official publication of the American Association of Orthodontists,
its constituent societies, and the American Board of Orthodontics 143, 383-392.
Kankam, H.K.N., Gupta, H., Sawh-Martinez, R., and Steinbacher, D.M. (2018). Segmental
Multiple-Jaw Surgery without Orthodontia: Clear Aligners Alone. Plast Reconstr Surg 142, 181-
184.
Karacay, S., Akin, E., Olmez, H., Gurton, A.U., and Sagdic, D. (2006). Forsus Nitinol Flat Spring
and Jasper Jumper corrections of Class II division 1 malocclusions. The Angle orthodontist 76,
666-672.
Kinzinger, G.S., and Diedrich, P.R. (2008). Biomechanics of a Distal Jet appliance. Theoretical
considerations and in vitro analysis of force systems. The Angle orthodontist 78, 676-681.
Kochar, G.D., Chakranarayan, A., Londhe, S.M., Varghese, B., Jayan, B., Chopra, S.S., Mitra, R.,
and Verma, M. (2017). Management of Skeletal Class II Malocclusion by Surgery-First Approach.
J Craniofac Surg 28, e40-e43.
46

Konik, M., Pancherz, H., and Hansen, K. (1997). The mechanism of Class II correction in late
Herbst treatment. American journal of orthodontics and dentofacial orthopedics : official
publication of the American Association of Orthodontists, its constituent societies, and the
American Board of Orthodontics 112, 87-91.
Kook, Y.A., Bayome, M., Trang, V.T., Kim, H.J., Park, J.H., Kim, K.B., and Behrents, R.G. (2014).
Treatment effects of a modified palatal anchorage plate for distalization evaluated with cone-
beam computed tomography. American journal of orthodontics and dentofacial orthopedics :
official publication of the American Association of Orthodontists, its constituent societies, and
the American Board of Orthodontics 146, 47-54.
Kuroda, S., Sugawara, Y., Deguchi, T., Kyung, H.M., and Takano-Yamamoto, T. (2007). Clinical
use of miniscrew implants as orthodontic anchorage: success rates and postoperative
discomfort. American journal of orthodontics and dentofacial orthopedics : official publication
of the American Association of Orthodontists, its constituent societies, and the American Board
of Orthodontics 131, 9-15.
Lee, J., Miyazawa, K., Tabuchi, M., Sato, T., Kawaguchi, M., and Goto, S. (2014). Effectiveness of
en-masse retraction using midpalatal miniscrews and a modified transpalatal arch: Treatment
duration and dentoskeletal changes. Korean journal of orthodontics 44, 88-95.
Levin, L., Vasiliauskas, A., Armalaite, J., and Kubiliute, K. (2018). Comparison of skeletal
anchorage distalizers effect in maxillary buccal segment: A systematic review. Stomatologija 20,
66-72.
Linjawi, A.I., and Abbassy, M.A. (2018). Dentoskeletal effects of the forsus fatigue resistance
device in the treatment of class II malocclusion: A systematic review and meta-analysis. Journal
of orthodontic science 7, 5.
Luppanapornlarp, S., and Johnston, L.E., Jr. (1993). The effects of premolar-extraction: a long-
term comparison of outcomes in "clear-cut" extraction and nonextraction Class II patients. The
Angle orthodontist 63, 257-272.
Luther, F., Morris, D.O., and Hart, C. (2003). Orthodontic preparation for orthognathic surgery:
how long does it take and why? A retrospective study. Br J Oral Maxillofac Surg 41, 401-406.
Madurantakam, P. (2016). Fixed or removable function appliances for Class II malocclusions.
Evidence-based dentistry 17, 52-53.
Maspero, C., Galbiati, G., Giannini, L., Guenza, G., and Farronato, M. (2018). Class II division 1
malocclusions: comparisons between one- and two-step treatment. European journal of
paediatric dentistry : official journal of European Academy of Paediatric Dentistry 19, 295-299.
McNamara, J.A., Jr. (1981). Components of class II malocclusion in children 8-10 years of age.
The Angle orthodontist 51, 177-202.
McNamara, J.A., Jr., Bookstein, F.L., and Shaughnessy, T.G. (1985). Skeletal and dental changes
following functional regulator therapy on class II patients. American journal of orthodontics 88,
91-110.
McNamara, J.A., Jr., Peterson, J.E., Jr., and Alexander, R.G. (1996). Three-dimensional diagnosis
and management of Class II malocclusion in the mixed dentition. Semin Orthod 2, 114-137.
Mihalik, C.A., Proffit, W.R., and Phillips, C. (2003). Long-term follow-up of Class II adults treated
with orthodontic camouflage: a comparison with orthognathic surgery outcomes. American
journal of orthodontics and dentofacial orthopedics : official publication of the American
47

Association of Orthodontists, its constituent societies, and the American Board of Orthodontics
123, 266-278.
Mohamed, R.N., Basha, S., and Al-Thomali, Y. (2018). Maxillary molar distalization with
miniscrew-supported appliances in Class II malocclusion: A systematic review. The Angle
orthodontist 88, 494-502.
Moro, A., Borges, S.W., Spada, P.P., Morais, N.D., Correr, G.M., Chaves, C.M., Jr., and Cevidanes,
L.H.S. (2018). Twenty-year clinical experience with fixed functional appliances. Dental Press J
Orthod 23, 87-109.
Nanda, R. (2015). Esthetics and biomechanics in orthodontics, 2nd edition (St. Louis, MO:
Sanders Elsevier).
Nissen, S.H. (2017). The Pendulum Appliance for Class II Non-Compliance Therapy. Journal of
clinical orthodontics : JCO 51, 564-567.
Nucera, R., Militi, A., Lo Giudice, A., Longo, V., Fastuca, R., Caprioglio, A., Cordasco, G., and
Papadopoulos, M.A. (2018). Skeletal and Dental Effectiveness of Treatment of Class II
Malocclusion With Headgear: A Systematic Review and Meta-analysis. The journal of evidence-
based dental practice 18, 41-58.
O'Brien, K., Wright, J., Conboy, F., Appelbe, P., Davies, L., Connolly, I., Mitchell, L., Littlewood, S.,
Mandall, N., Lewis, D., et al. (2009). Early treatment for Class II Division 1 malocclusion with the
Twin-block appliance: a multi-center, randomized, controlled trial. American journal of
orthodontics and dentofacial orthopedics : official publication of the American Association of
Orthodontists, its constituent societies, and the American Board of Orthodontics 135, 573-579.
Oh, Y.H., Park, H.S., and Kwon, T.G. (2011). Treatment effects of microimplant-aided sliding
mechanics on distal retraction of posterior teeth. American journal of orthodontics and
dentofacial orthopedics : official publication of the American Association of Orthodontists, its
constituent societies, and the American Board of Orthodontics 139, 470-481.
Pancherz, H. (1982). The mechanism of Class II correction in Herbst appliance treatment. A
cephalometric investigation. American journal of orthodontics 82, 104-113.
Pancherz, H. (1985). The Herbst appliance--its biologic effects and clinical use. American journal
of orthodontics 87, 1-20.
Pancherz, H. (1997). The effects, limitations, and long-term dentofacial adaptations to
treatment with the Herbst appliance. Semin Orthod 3, 232-243.
Pandis, N., Polychronopoulou, A., and Eliades, T. (2011). Sample size estimation: an overview
with applications to orthodontic clinical trial designs. American journal of orthodontics and
dentofacial orthopedics : official publication of the American Association of Orthodontists, its
constituent societies, and the American Board of Orthodontics 140, e141-146.
Patel, M.P., Henriques, J.F., Freitas, K.M., and Grec, R.H. (2014). Cephalometric effects of the
Jones Jig appliance followed by fixed appliances in Class II malocclusion treatment. Dental Press
J Orthod 19, 44-51.
Proffit, W.F., H (2013). Contemporary orthodontics, 5th edition (St. Louis, MO: Mosby Elsevier).
Proffit, W.R., Fields, H.W., Jr., and Moray, L.J. (1998). Prevalence of malocclusion and
orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J
Adult Orthodon Orthognath Surg 13, 97-106.
48

Proffit, W.R., Phillips, C., Tulloch, J.F., and Medland, P.H. (1992). Surgical versus orthodontic
correction of skeletal Class II malocclusion in adolescents: effects and indications. Int J Adult
Orthodon Orthognath Surg 7, 209-220.
Schaefer, A.T., McNamara, J.A., Jr., Franchi, L., and Baccetti, T. (2004). A cephalometric
comparison of treatment with the Twin-block and stainless steel crown Herbst appliances
followed by fixed appliance therapy. American journal of orthodontics and dentofacial
orthopedics : official publication of the American Association of Orthodontists, its constituent
societies, and the American Board of Orthodontics 126, 7-15.
Schwartz, K., Rodrigo-Domingo, M., and Jensen, T. (2016). Skeletal Stability after Large
Mandibular Advancement (> 10 mm) with Bilateral Sagittal Split Osteotomy and Skeletal Elastic
Intermaxillary Fixation. J Oral Maxillofac Res 7, e5.
Shah, N. (2017). Compliance with removable orthodontic appliances. Evidence-based dentistry
18, 105-106.
Shen, L., He, F., Zhang, C., Jiang, H., and Wang, J. (2018). Prevalence of malocclusion in primary
dentition in mainland China, 1988-2017: a systematic review and meta-analysis. Sci Rep 8,
4716.
Shetty, S., Maurya, R., Raj, H.V.P., and Patil, A. (2017). Comparison of the Pendulum appliance
and the Jones Jig: A prospective comparative study. Eur J Dent 11, 323-329.
Singh, D.P., Arora, S., Yadav, S.K., and Kedia, N.B. (2017). Intraoral Approaches for Maxillary
Molar Distalization: Case Series. J Clin Diagn Res 11, ZR01-ZR04.
Steiner, C.C. (1953). Cephalometrics for you and me. American journal of orthodontics 39, 729-
755.
Tekale, P.D., Vakil, K.K., Vakil, J.K., and Gore, K.A. (2015). Distalization of maxillary arch and
correction of Class II with mini-implants: A report of two cases. Contemp Clin Dent 6, 226-232.
Tulloch, J.F., Proffit, W.R., and Phillips, C. (2004). Outcomes in a 2-phase randomized clinical
trial of early Class II treatment. American journal of orthodontics and dentofacial orthopedics :
official publication of the American Association of Orthodontists, its constituent societies, and
the American Board of Orthodontics 125, 657-667.
Tweed, C.H. (1969). The diagnostic facial triangle in the control of treatment objectives.
American journal of orthodontics 55, 651-657.
Vaden, J.L., Williams, R.A., and Goforth, R.L. (2018). Class II correction: Extraction or
nonextraction? American journal of orthodontics and dentofacial orthopedics : official
publication of the American Association of Orthodontists, its constituent societies, and the
American Board of Orthodontics 154, 860-876.
Valarelli, F.P., Carniel, R., Cotrin-Silva, P.P., Patel, M.P., Cancado, R.H., Freitas, K.M.S., and de
Freitas, M.R. (2017). Treatment of a Class II Malocclusion with Deep Overbite in an Adult
Patient Using Intermaxillary Elastics and Spee Curve Controlling with Reverse and Accentuated
Archwires. Contemp Clin Dent 8, 672-678.
Verma, S.K., Rastogi, K., Bhushan, R., and Sagar, M. (2013). Molar distalisation by pendulum
appliance. BMJ Case Rep 2013.

Abstract (if available)

Abstract Introduction: The purpose of this study was to evaluate the treatment efficiency of Carriere Distalizer in comparison to Class II intermaxillary elastics and Forsus. Methods: Three groups of patients treated with Class II intermaxillary elastics (n=18), Carriere Distalizer (n=18), and Forsus appliance (n=18) were collected from three private orthodontic practices. Inclusion criteria were as follows: (1) 10-14 years old of start age with permanent dentition

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Asset Metadata

Creator Han, Eugene (author)

Core Title Evaluating the treatment efficiency of Carriere Distalizer: a cephalometric and study model comparison of Class II appliances

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 02/19/2019

Defense Date 02/14/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Carriere Distalizer,Class II corrector,Class II elastics,Forsus,OAI-PMH Harvest,orthodontics

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Grauer, Dan (committee member), Paine, Michael (committee member), Sameshima, Glenn (committee member)

Creator Email eugeneh@usc.edu,eugenejhan@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-122824

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Legacy Identifier etd-HanEugene-7083.pdf

Dmrecord 122824

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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