Original Article

A comparison of the MARA and the AdvanSync functional appliances in the

treatment of Class II malocclusion
Thikriat S. Al-Jewaira; Charles B. Prestonb; Eva-Maria Molla; Terry Dischingerc

ABSTRACT
Objectives: To determine the skeletal and dentoalveolar effects produced by the MARA and the

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AdvanSync functional appliances in the treatment of growing patients with Class II malocclusion.
Materials and Methods: A retrospective study was conducted using lateral cephalograms of
patients consecutively treated with MARA (n 5 40) and AdvanSync (n 5 30) during their skeletal
growth spurt as evaluated by the improved cervical vertebral maturation method. A comparison
was made with 24 untreated Class II control subjects obtained from the University of Michigan
growth study and matched with the experimental groups for skeletal age, sex, and craniofacial
morphology. Cephalograms were taken at three time points: (T1) pretreatment, (T2) postfunctional
appliance treatment, and (T3) fixed orthodontic treatment completion. Treatment changes were
evaluated between the time points using 35 variables. Data were analyzed using one-way analysis
of variance and Scheffe’s post hoc test.
Results: At the postfunctional appliances’ phase (T2–T1), both appliances showed significant
increases in total mandibular length, ramus height, and anterior/posterior facial height. The
AdvanSync resulted in significant restriction of maxillary growth, 1u more than MARA. This effect
continued during the fixed orthodontic treatment stage (T3–T2). The net changes (T3–T1) revealed
significant mandibular growth enhancement with MARA (+2.7mm) and significant headgear effect
with AdvanSync. Both appliances caused 5u flaring in mandibular incisors as well as significant
decreases in overjet and overbite. The treatment time for AdvanSync was 1 year less than MARA.
Conclusion: The MARA and the AdvanSync resulted in normalization of the Class II malocclusion.
The AdvanSync showed more headgear effect but less mandibular length enhancement than
MARA did. Both appliances showed similar dentoalveolar changes. (Angle Orthod. 2012;82:907–
914.)
KEY WORDS: Fixed functional appliance; Cephalometry; Class II malocclusion

INTRODUCTION repositioning appliance (MARA)1 (AOA, Sturtevant,

Of the fixed functional appliances available to the
orthodontist today for the correction of Class II
dentoskeletal malocclusion are the mandibular anterior
a
Orthodontic Specialty Resident, Department of Orthodontics,
School of Dental Medicine, State University of New York at
Buffalo, New York.
b
Professor and Chairman, Department of Orthodontics,
School of Dental Medicine, State University of New York at
Buffalo, New York.
c
Private practice, Lake Oswego, Oregon.
Corresponding author: Thikriat S. Al-Jewair, Department of
Orthodontics, School of Dental Medicine, 140 Squire Hall, State
University of New York at Buffalo, Buffalo, New York
(e-mail: taljewair@gmail.com)
Accepted: November 2011. Submitted: September 2011.
Published Online: January 3, 2012
G 2012 by The EH Angle Education and Research Foundation,
Inc.
Wis) and the AdvanSync2 (also known as Molar to
Molar appliance; Ormco Co, Glendora, Calif), in
addition to others. Both the MARA and the AdvanSync
are fixed tooth-born functional appliances consisting of
crowns cemented on maxillary and mandibular per-
manent first molars, a position where orthopedic forces
are applied. They have the advantage of allowing
concurrent treatment with preadjusted edgewise ap-
pliances and therefore efficient normalization of the
occlusion.
The efficacy of the MARA in correcting Class II
malocclusions has been evaluated in a few studies.3–7
A recent study3 of 23 consecutively treated MARA
patients concluded that the appliance resulted in
significant elongation of the mandible and headgear
effect of the maxilla compared with untreated controls.
The study did not report sex differences nor did it
compare its effects with other functional appliances.

DOI: 10.2319/090411-569.1 907 Angle Orthodontist, Vol 82, No 5, 2012

908
Table 1. Age and Treatment/Observation Times of the Experimental and Control Groups
Mean (6SD) Ages, years
Group T1 T2
MARA (n 5 40) 11.6 6 1.9 13.0 6 1.6
AdvanSync (n 5 30) 12.3 6 1.3 13.4 6 1.2
Control (n 5 24) 11.9 6 1.9 13.1 6 1.9
Pangrazio-Kulbersh et al.5 compared the treatment
effects of the MARA with untreated controls and with
banded Herbst and Frankel appliances’ effects report-
ed in previous studies. They found similar effects of the
MARA to the Herbst but with less headgear effect on
the maxilla and less mandibular incisor flaring. It also
produced greater dentoalveolar changes than the
Frankel II appliance. Their study, however, lacked a
concurrent comparative treatment group to MARA.
The effects of the AdvanSync are still not known.
No published studies were found comparing the
MARA and the AdvanSync appliances. The aim of this
retrospective cephalometric study is to evaluate the
skeletal and dentoalveolar changes produced by the
MARA and the AdvanSync during active treatment with
the appliances and during follow-up including edge-
wise fixed orthodontic treatment.
MATERIALS AND METHODS
A retrospective study was conducted using lateral
cephalograms in habitual occlusion of adolescent
patients who received treatment for their Class II
skeletal malocclusions using the MARA or the Ad-
vanSync functional appliances. Measurements on
cephalograms were made at three time points: (T1)
pretreatment, (T2) at functional appliance treatment
completion, and (T3) at fixed orthodontic treatment
completion. Approval for this study was obtained from
the Health Sciences Institutional Research Board of
the University at Buffalo.
The inclusion criteria were: white healthy boys and girls
presenting with Class II malocclusion with the molars in at
least an end-to-end relationship, presenting during the
peak growth spurt as indicated by the improved version of
the cervical vertebral maturation (CVM) method,8 retro-
gnathic mandible (SNB #77u), ANB angle $4u, normal
Frankfort to Mandibular plane angle (FMAu 5 25 6 5u),
overjet ,10 mm, no missing teeth, a nonextraction
treatment approach, crowns cemented on permanent
maxillary and mandibular first molars, and the appliance
maintained for at least 6 months.
The treatment groups included consecutively treated
Class II malocclusion division 1 patients obtained from
two orthodontists. Forty (22 males, 18 females) MARA
patient records obtained from the cases treated by the
developer of the appliance, Dr Douglas Toll, and 30
(13 males, 17 females) AdvanSync obtained from one
Angle Orthodontist, Vol 82, No 5, 2012
AL-JEWAIR, PRESTON, MOLL, DISCHINGER
Mean (6SD) Treatment/Observation Time, years
T3 T2–T1 T3–T2 T3–T1
15.0 6 1.5 1.5 6 0.9 1.8 6 1.5 3.3 6 1.9
14.7 6 1.4 1.2 6 0.5 1.2 6 0.6 2.3 6 0.7
14.4 6 1.9 1.3 6 0.6 1.6 6 0.7 3.0 6 1.0
author (Dr Dischinger) were included. Results were
compared with 24 (13 males, 11 females) untreated
control individuals obtained from the University of
Michigan Growth Study Center and matched with the
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treatment groups for skeletal age, sex, and craniofacial
morphology. Mean ages and treatment/observation
durations for each group are listed in Table 1.
The MARA (AOA, Sturtevant, Wis) and the
AdvanSync (Ormco Co, Glendora, Calif) were de-
signed to allow simultaneous fixed orthodontic
appliance treatment (0.0220 3 0.0280 slot edgewise
bracket system in the included samples fully bonded
at T1) with the brackets on the mandibular incisors
having a built-in labial root torque. Both functional
appliances include stainless-steel crowns with single
archwire tubes on permanent first molars. The
MARA’s upper crowns are also attached to 0.0620
square tubes to accommodate 0.0600 upper elbows
and lower crowns with soldered lower protruding
arms. The crowns are attached to lower lingual
holding arches (2–3 mm lingual to mandibular
incisors) to prevent mesiolingual rotation of the
molars. This side effect can also be prevented by
bonding lower anterior brackets. The AdvanSync did
not include lower lingual holding arches, and the
maxillary and mandibular crowns of this appliance
are connected by telescoping rods.
The treatment protocols used by the MARA and the
AdvanSync developers include stepwise activation as
judged by the severity of the overjet.9,10 The appliances
are activated 2 to 4 mm every 3 months over a 12-
month (for MARA) and 6- to 12-month (for AdvanSync)
duration until slight dental overcorrection is achieved
with the MARA and moderate overcorrection with the
AdvanSync. The occlusion with the AdvanSync is
overcorrected to an anterior crossbite and a Class III
canine relationship with the maxillary canine in an end-
to-end relationship with the mandibular first premolar
or in a full-tooth relationship in the more severe cases.
Once the appliances are removed, edgewise fixed
orthodontic treatment is continued to achieve correct
anterior torque and occlusion and adequate finish.
Cephalometric Analysis
The lateral cephalograms representing the treat-
ment groups were scanned with an Epson Expression
1680 Pro (Epson USA, Long Beach, Calif) and with the
EFFECTS OF FUNCTIONAL APPLIANCES
use of Adobe Photoshop 6.0; the scanning resolution
was set at 300 dpi and color depth at 16-bit grayscale.
All cephalograms were then imported into commercial
software (Dolphin Digital Imaging system version 11,
Chatsworth, Calif), where they were digitally traced
using a customized digitization set that included 58
landmarks and four fiducial markers. Thirty-five variables
were produced per x-ray and were chosen from different
cephalometric analyses.11–14 Magnifications of x-rays
were 8% for the MARA group, 6% and 10% for the
AdvanSync group (two different x-ray machines), and
12.9% for the untreated controls. For standardization
purposes, the magnification was corrected to 8% for all
cephalograms.
The tracings and measurements were carried out by
one author and validated by another. Any disagree-
ment was resolved by retracing after discussion.
Linear measurements were made to the nearest
0.5 mm and angular measurements to the nearest
0.5u. Superimpositions were conducted manually. The
overall craniofacial treatment changes were evaluated
by superimposing on the S-N line, registered at Sella.
Regional superimpositions in the maxilla were made
along the palatal plane and registering on the internal
structures of the maxilla above the incisors and the
surfaces of the hard palate.12,13 The mandibular
regional superimposition was made on the inner
contour of the posterior symphysis, the outline of the
inferior mandibular canal, and the germ of the third
molar prior to root development (if present).12,13
Superimpositions to evaluate sagittal and vertical
dentoalveolar changes were conducted using the
method described earlier by McNamara.12 All of the
registrations were repeated twice to ensure accuracy.
Method Error
To determine accuracy of the method, 15 randomly
chosen cephalograms were retraced, remeasured, and
superimposed 2 weeks apart by one investigator using
the same landmarks and variables included in this study.
Measurements were calculated using the intraclass
correlation coefficient, and they showed high reliability
(between .86 and .98) and were all within 1 mm/1u of the
original. The average error did not exceed 0.3 mm/0.30u.
Study Analysis
Data were analyzed using SPSS (SPSS version 16
for Windows, Chicago, Ill). Descriptive statistics were
conducted initially, and means and standard deviations
were calculated. Data were normally distributed; there-
fore, parametric tests were conducted. A one-way
analysis of variance was used to compare differences
among the three groups at baseline and to evaluate the
909
changes at each time point. Scheffe’s post hoc analysis
was used for multiple comparisons. Statistical tests
were interpreted at the 5% significance level.
RESULTS
When the initial records of the three groups were
compared (T1), the dentoskeletal characteristics of the
three groups were generally similar except for four
measurements. The MARA group had increased
maxillary protrusion (Co-Pt A; P , .001), mandibular
corpus length (Go-Gn; P 5 .002), and Wits appraisal
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(P 5 .004) compared with controls. Both the MARA and
the AdvanSync groups showed more distally positioned
mandibular molars (P , .001) than the controls.
Table 2 illustrates the T2–T1 differences between
groups. The AdvanSync restricted maxillary growth
‘‘headgear effect’’ as indicated by SNAu (22u). Both
treatment groups showed significant increases in the
total lengths of the mandible (Co-Gn), the ramus
height (Co-Go), and the anterior and posterior facial
heights. The dentoalveolar measurements revealed
significant retroclination of the maxillary incisors relative
to Frankfort horizontal in the AdvanSync group in
addition to nonsignificant eruption and distalization of
maxillary molars. The mandibular incisors proclined 5u,
and the mandibular molars moved forward (+2 mm) with
MARA and AdvanSync (P , .001) over controls.
The treatment effects at follow-up (T3–T2) are present-
ed in Table 3. The AdvanSync in comparison to controls
showed a continued significant restraining in maxillary
growth, less increase in ramus height (Co-Go; P , .001),
and more relapse in the Wits appraisal and maxillary
molars’ horizontal position. All interdental measurements
were statistically significant for the same group.
The net treatment changes (T3–T1) showed a signif-
icant headgear effect in the AdvanSync group (Table 4).
The mandibular growth enhancement (Co-Gn) was
significant with MARA (+2.7 mm) and not significant with
AdvanSync over controls. Figure 1 depicts the changes in
the total mandibular length (Co-Gn) between the three
time points. Both treatment modalities resulted in reduc-
tion in the ANBu and the angle of convexity and an
increase in the anterior and posterior facial height over
controls. The anterior/posterior facial height of the Advan-
Sync group was less than MARA. The mandibular molars
erupted and drifted forward more than 3 mm in both
groups. Interdentally, significant decreases in overjet and
overbite were observed. Sex differences between the
groups were analyzed at the three time points, but the
small samples did not allow reliable subanalyses.
DISCUSSION
This is a retrospective cephalometric study of the
dentoskeletal treatment effects of the MARA and the
Angle Orthodontist, Vol 82, No 5, 2012
910 AL-JEWAIR, PRESTON, MOLL, DISCHINGER

Table 2. Differences Among Treatment and Control Groups at T2–T1a

D T2–T1
MARA AdvanSync Control Significance Difference of D
Variable Mean 6 SD Mean 6 SD Mean 6 SD M-C A-C M-C A-C
Cranial Base
Ba-S-N, u 21.9 6 3.9 0.6 6 3.1 20.3 6 1.8 .119 .601 21.6 0.9
Maxillary skeletal
SNA, u 20.5 6 1.5 21.6 6 2.4 0.4 6 1.7 .192 .001* 20.9 22.0
Co-Pt A, mm 1.8 6 0.6 1.0 6 0.7 1.6 6 0.7 .941 .628 0.2 20.6
Pt A-Na Perp, mm 21.6 6 3.0 21.6 6 2.4 20.4 6 2.6 .195 .237 21.2 21.2
Mandibular skeletal

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SNB, u 1.5 6 1.6 0.3 6 1.6 0.2 6 0.9 .008* .987 1.3 0.1
Co-Gn, mm 4.5 6 3.6 4.0 6 2.4 2.6 6 2.0 .015* .002* 1.9 1.4
Pg-Na Perp, mm 0.5 6 4.8 20.3 6 4.5 0.3 6 2.5 .976 .890 0.2 20.6
Go-Gn, mm 3.3 6 2.5 0.9 6 4.7 1.6 6 1.1 .648 .439 1.7 20.7
Co-Go, mm 4.4 6 1.8 3.4 6 3.1 1.9 6 2.8 ,.001* .038* 2.5 1.5
Intermaxillary
ANB, u 22.1 6 1.6 21.9 6 1.5 0.1 6 1.4 , 001* ,.001* 22.2 22.0
Wits appraisal 21.6 6 4.1 26.6 6 3.4 0.4 6 2.3 .088 ,.001* 22.0 27.0
(Co-A)–(Co-Gn) 2.7 6 4.2 4.0 6 2.3 1.0 6 22.1 ,.001* ,.001* 1.7 3.0
Vertical skeletal
Na-Me, mm 7.1 6 4.7 5.2 6 4.2 3.1 6 2.7 ,.001* ,.001* 4.0 2.1
S-Go, mm 5.8 6 3.1 4.7 6 2.3 2.3 6 2.2 ,.001* ,.001* 3.5 2.4
ANS-Me, mm 0.0 6 8.0 0.6 6 1.1 0.1 6 2.3 .902 .252 20.1 0.5
FH-mandibular plane, u 0.6 6 2.7 1.0 6 2.7 1.8 6 1.5 .364 .672 21.2 20.8
SN- occlusal plane, u 0.5 6 2.9 3.8 6 3.3 20.4 6 2.3 .540 ,.001* 0.9 3.4
MP-occlusal plane, u 20.7 6 2.7 22.8 6 3.2 0.7 6 1.9 .148 ,.001* 21.4 23.5
Facial-axis , u 0.4 6 1.5 20.2 6 1.7 20.2 6 1.6 .340 .981 0.6 0.0
Angle of convexity, u 23.4 6 3.3 23.7 6 3.4 20.1 6 2.6 ,.001* ,.001* 23.3 23.6
Maxillary dentoalveolar
U1-FH, u 2.3 6 9.4 28.4 6 4.7 20.4 6 2.2 .418 .002* 2.7 28.0
U1-vertical 0.2 6 2.1 0.3 6 1.7 0.4 6 0.6 .923 .995 20.2 20.1
U1-horizontal 2.3 6 9.0 21.8 6 3.1 0.2 6 0.6 .449 .457 2.1 22.0
U6-vertical 0.9 6 2.0 0.1 6 1.5 0.6 6 0.7 .781 .488 0.3 20.5
U6-horizontal 0.7 6 2.8 20.5 6 2.7 0.8 6 1.0 .992 .162 20.1 21.3
Mandibular dentoalveolar
IMPA, u 5.4 6 5.9 5.3 6 3.6 0.0 6 3.5 ,.001* ,.001* 5.4 5.3
L1 to Pt A-Pg, mm 3.1 6 2.3 2.6 6 1.5 0.1 6 0.8 ,.001* ,.001* 3.0 2.5
L1-vertical 0.0 6 5.2 0.2 6 1.9 0.6 6 0.7 .803 .902 20.6 20.4
L1-horizontal 1.7 6 6.3 1.1 6 2.4 0.3 6 0.5 .220 .497 1.4 0.8
L6-vertical 2.2 6 5.3 2.4 6 1.7 0.6 6 0.8 .234 .224 1.6 1.8
L6-horizontal 3.0 6 2.5 2.8 6 2.2 0.7 6 0.8 ,.001* ,.001* 2.3 2.1
Interdental
Overbite, mm 22.8 6 2.6 23.6 6 2.1 0.2 6 1.4 ,.001* ,.001* 23.0 23.8
Overjet, mm 22.7 6 3.0 26.5 6 2.7 20.3 6 0.7 .003* ,.001* 22.4 26.2
U1-L1, u 28.4 6 10.5 2.1 6 2.3 0.6 6 4.6 ,.001* .824 29.0 1.5
Molar AP relationship, mm 3.4 6 2.1 6.6 6 2.9 0.4 6 1.3 ,.001* ,.001* 3.0 6.2
a
Horizontal changes: backward movements are labeled (2), forward movements are labeled (+). Vertical changes: superior movements are
labeled (2), inferior movements are labeled (+). Dimensional changes: decreases are labeled (2), increases are labeled (+).
* P , .05.

AdvanSync functional appliances with edgewise fixed
orthodontic treatment in Class II skeletal malocclusion
correction of patients treated during their growth
spurt. The results showed that the differences
between the two treatment modalities are modest
with few exceptions.
At the completion of functional appliances treatment
(T2–T1), the MARA and the AdvanSync showed
significant skeletal increases in total mandibular
lengths (+1.9 mm and +1.4 mm, respectively). Similar
effects were reported in previous studies of the MARA
over untreated controls.3,5 In addition, the AdvanSync

Angle Orthodontist, Vol 82, No 5, 2012

EFFECTS OF FUNCTIONAL APPLIANCES 911

Table 3. Differences Among Treatment and Control Groups at T3–T2

D T3–T2
MARA AdvanSync Control Significance Difference of D
Variable Mean 6 SD Mean 6 SD Mean 6 SD M-C A-C M-C A-C
Cranial base
Ba-S-N, u 21.0 6 1.8 0.2 6 2.5 0.5 6 1.5 .890 .996 21.5 20.3
Maxillary skeletal
SNA, u 20.6 6 1.8 21.6 6 1.9 0.0 6 1.4 .543 .012* 20.6 21.6
Co-Pt A, mm 1.4 6 2.2 0.8 6 2.5 1.9 6 2.2 .653 .206 20.5 21.1
Pt A-Na Perp, mm 20.6 6 2.6 21.7 6 2.7 0.2 6 2.1 .519 .032* 20.8 21.9
Mandibular skeletal

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SNB, u 0.2 6 1.5 20.9 6 1.4 0.5 6 1.2 .716 .001* 20.3 21.4
Co-Gn, mm 3.6 6 3.6 1.4 6 2.1 2.8 6 2.1 .504 .467 0.8 21.4
Pg-Na Perp, mm 0.0 6 5.1 21.4 6 2.4 1.2 6 3.7 .641 .140 21.2 22.6
Go-Gn, mm 2.3 6 1.8 3.0 6 6.8 1.1 6 5.5 .864 .726 1.2 1.9
Co-Go, mm 3.4 6 9.2 0.7 6 2.2 1.7 6 3.0 .401 ,.001* 1.7 21.0
Inter-maxillary
ANB, u 20.3 6 1.6 20.7 6 1.2 20.5 6 1.0 .872 .755 0.2 20.2
Wits appraisal 0.0 6 3.6 5.1 6 2.7 20.3 6 3.6 .945 ,.001* 20.3 5.4
(Co-A)–(Co-Gn) 2.2 6 1.6 0.6 6 2.2 0.9 6 2.3 .489 .928 1.3 20.3
Vertical skeletal
Na-Me, mm 3.8 6 1.9 1.2 6 2.9 1.9 6 2.7 .839 .975 1.9 20.7
S-Go, mm 3.6 6 4.9 0.6 6 3.8 1.9 6 2.1 .708 .859 1.7 21.3
ANS-Me, mm 20.2 6 1.0 20.5 6 1.0 0.1 6 2.1 .904 .837 20.3 20.6
FH-mandibular plane, u 21.1 6 3.0 21.1 6 2.1 20.8 6 2.1 .925 .932 20.3 20.3
SN-occlusal plane, u 20.2 6 2.6 22.0 6 3.7 0.3 6 2.1 .812 .021* 20.5 22.3
MP-occlusal plane, u 20.9 6 2.9 1.0 6 3.6 20.8 6 2.7 .999 .117 20.1 1.8
Facial-axis, u 0.0 6 2.2 0.3 6 2.0 0.6 6 1.2 .513 .825 20.6 20.3
Angle of convexity, u 21.5 6 2.7 21.9 6 3.2 20.9 6 2.3 .774 .457 20.6 21.0
Maxillary dentoalveolar
U1-FH, u 21.2 6 5.2 7.3 6 5.8 0.0 6 2.5 .714 ,.001* 21.2 7.3
U1-vertical 0.5 6 2.2 0.5 6 1.3 0.4 6 0.8 .949 .967 0.1 0.1
U1-horizontal 0.3 6 9.2 1.9 6 2.4 0.1 6 0.8 .993 .547 0.2 1.8
U6-vertical 1.1 6 2.2 1.6 6 0.5 0.6 6 1.2 .573 .122 0.5 1.0
U6-horizontal 0.9 6 3.3 3.0 6 2.9 0.2 6 1.4 .617 .003* 0.7 2.8
Mandibular dentoalveolar
IMPA, u 20.1 6 5.0 0.1 6 3.8 0.1 6 3.0 .985 1 20.2 0.0
L1 to Pt A-Pg, mm 20.3 6 1.9 20.9 6 1.4 0.0 6 0.7 .770 .123 20.3 20.9
L1-vertical 1.5 6 5.2 0.6 6 1.8 0.4 6 0.9 .474 .987 1.1 0.2
L1-horizontal 20.6 6 5.6 0.3 6 1.9 0.2 6 0.5 .916 .997 20.8 0.1
L6-vertical 1.5 6 4.6 1.2 6 1.8 0.7 6 1.1 .628 .861 0.8 0.5
L6-horizontal 0.6 6 2.5 0.6 6 3.8 0.4 6 0.7 .493 .376 0.2 0.2
Interdental
Overbite, mm 0.2 6 1.6 1.2 6 1.4 0.0 6 1.6 .932 .028* 0.2 1.2
Overjet, mm 20.4 6 1.8 3.1 6 1.8 20.1 6 1.0 .824 ,.001* 20.3 3.2
U1-L1, u 2.3 6 7.6 26.3 6 7.2 0.7 6 3.6 .645 .001* 1.6 27.0
Molar AP relationship, mm 0.2 6 1.7 23.0 6 2.3 0.4 6 1.5 .440 ,.001* 20.2 23.4
* P , .05.

showed significant restriction in maxillary growth.
These findings confirm a short-term orthopedic effect
on the maxilla and the mandible of this appliance. This
is similar to the short-term effects documented in
multiple studies of the Herbst appliance.15–17 Van-
Laecken et al.16 in a cephalometric study of 52
consecutively treated patients with the edgewise
Herbst appliance found that after 8 months of Herbst
treatment, the mandible moved forward 1.7 mm and
the maxilla underwent temporary growth restriction of
1.4 mm in addition to other dentoalveolar effects. The
MARA in our study did not show a significant headgear
effect despite the significant larger maxillary length at
starting form. Results of previous studies are incon-
sistent with respect to this measurement.3,5,6 This could
be attributed to the different methodologies used in

Angle Orthodontist, Vol 82, No 5, 2012

912 AL-JEWAIR, PRESTON, MOLL, DISCHINGER

Table 4. Differences Among Treatment and Control Groups at T3–T1

D T3–T1
MARA AdvanSync Control Significance Difference of D
Variable Mean 6 SD Mean 6 SD Mean 6 SD M-C A-C M-C A-C
Cranial Base
Ba-S-N, u 23.0 6 3.3 0.8 6 3.6 0.2 6 1.2 .587 .985 23.2 0.6
Maxillary skeletal
SNA, u 21.1 6 2.3 23.3 6 2.9 0.4 6 1.7 .068 ,.001* 21.5 23.7
Co-Pt A, mm 3.2 6 2.9 1.8 6 3.1 3.5 6 2.0 .910 .101 20.3 21.7
Pt A-Na Perp, mm 22.2 6 2.3 23.3 6 3.3 20.2 6 2.2 .004* ,.001* 22.0 23.1
Mandibular skeletal

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SNB, u 1.8 6 2.2 20.6 6 1.9 0.7 6 1.2 .108 .022* 1.1 21.3
Co-Gn, mm 8.1 6 7.1 5.4 6 3.5 5.4 6 1.7 .006* .785 2.7 0.0
Pg-Na Perp, mm 0.6 6 6.3 21.7 6 4.2 1.5 6 3.6 .807 .095 20.9 23.2
Go-Gn, mm 5.6 6 2.3 3.9 6 5.0 2.7 6 1.1 .401 .959 2.9 1.2
Co-Go, mm 7.8 6 9.8 4.1 6 2.8 3.6 6 4.8 .186 .939 4.2 0.5
Intermaxillary
ANB, u 22.4 6 1.6 22.6 6 1.9 20.4 6 1.5 ,.001* ,.001* 22.0 22.2
Wits appraisal 21.6 6 3.6 21.5 6 3.1 0.1 6 3.3 .151 .174 21.7 21.6
(Co-A)–(Co-Gn) 4.9 6 3.3 4.7 6 2.5 1.9 6 1.9 .006* .084 3.0 2.8
Vertical skeletal
Na-Me, mm 10.9 6 4.3 6.4 6 4.7 5.0 6 2.6 ,.001* .001* 5.9 1.4
S-Go, mm 9.4 6 2.3 5.3 6 4.6 4.2 6 1.9 .011* ,.001* 5.2 1.1
ANS-Me, mm 20.2 6 1.9 0.1 6 0.2 0.2 6 1.7 .503 .972 20.4 20.1
FH-mandibular plane, u 20.4 6 3.0 0.0 6 2.4 21.0 6 1.9 .228 .493 0.6 21.0
SN-occlusal plane, u 0.3 6 3.4 1.8 6 3.5 20.1 6 2.6 .914 .121 0.4 1.9
MP-occlusal plane, u 21.6 6 3.5 21.9 6 3.0 20.1 6 2.8 .233 .125 21.5 21.8
Facial-axis, u 0.4 6 2.3 0.1 6 2.1 0.4 6 1.7 .950 .520 0.0 20.3
Angle of convexity, u 24.9 6 3.5 25.6 6 4.6 21.0 6 2.8 .001* ,.001* 23.9 24.6
Maxillary dentoalveolar
U1-FH, u 1.1 6 9.1 21.2 6 3.4 20.4 6 3.2 .716 .930 1.5 20.8
U1-vertical 0.7 6 2.8 0.8 6 1.9 0.8 6 0.9 .997 .993 20.1 0.0
U1-horizontal 2.6 6 9.1 0.1 6 2.3 0.3 6 0.7 .377 .989 2.3 20.2
U6-vertical 2.0 6 2.7 1.7 6 1.8 1.2 6 1.1 .362 .679 0.8 0.5
U6-horizontal 1.6 6 3.2 2.5 6 2.6 1.0 6 1.1 .656 .139 0.6 1.5
Mandibular dentoalveolar
IMPA, u 5.3 6 6.3 5.4 6 6.1 0.1 6 4.8 .001* .001* 5.2 5.3
L1 to Pt A-Pg, mm 2.8 6 2.2 1.7 6 1.5 0.1 6 0.9 ,.001* .005* 2.7 1.6
L1-vertical 1.5 6 5.5 0.8 6 1.6 1.0 6 1.1 .874 .961 0.5 20.2
L1-horizontal 1.1 6 3.7 1.4 6 1.6 0.6 6 0.6 .003* .016* 0.5 0.8
L6-vertical 3.7 6 3.4 3.6 6 1.7 1.3 6 1.1 .002* .007* 2.4 2.3
L6-horizontal 3.6 6 2.5 3.4 6 2.7 1.1 6 0.8 ,.001* ,.001* 2.5 2.3
Interdental
Overbite, mm 22.6 6 2.3 22.4 6 2.0 0.2 6 1.2 ,.001* .001* 22.8 22.6
Overjet, mm 23.1 6 3.0 23.4 6 2.0 20.4 6 1.0 ,.001* ,.001* 22.7 23.0
U1-L1, u 26.1 6 10.5 24.2 6 7.1 1.3 6 6.1 .009* .091 27.4 25.5
Molar AP relationship, mm 3.6 6 1.9 3.6 6 2.3 0.8 6 1.4 ,.001* ,.001* 2.8 2.8
* P , .05.

the studies, and many did not consider skeletal age at
case inclusion. Although the mandibular body in-
creased in length with MARA, it underwent a slight
decrease in the AdvanSync group when compared
with controls.
The mandibular molars in both treatment groups at
the end of T2–T1 moved forward (+2 mm) more than
controls, and the findings were significant. Pangrrazio-
Kulbresh et al.5 in an earlier study evaluated pretreat-
ment and posttreatment changes in 30 Class II
patients treated with MARA and compared them to
21 untreated controls and found that the mandibular
molars moved forward a mean distance of 1.2 mm
versus 0.5 mm in controls, which accounted for some
of the Class II correction. The difference in the forward
drift between our study and the previous study can be

Angle Orthodontist, Vol 82, No 5, 2012

EFFECTS OF FUNCTIONAL APPLIANCES
Figure 1. Changes in total mandibular lengths (Co-Gn) in millimeters between T1, T2, and T3.
explained by the increased distal position of the
mandibular molars at the starting forms for both
treatment groups. The AdvanSync also showed
significant clockwise rotation of the functional occlusal
plane. This can be explained by the significant
proclination of the mandibular incisors. The mandibular
incisor to the mandibular plane angle in both applianc-
es showed an increase of 5u over controls. This finding
is in agreement with many earlier studies17–19 that
evaluated the dentoalveolar effects of functional
appliances and is greater with tooth-born appliances
than tissue-born ones such as the Frankel appliance.19
The skeletal changes during follow-up (T3–T2) were
not significantly different from controls for the MARA
group. The patients started treatment during the
skeletal growth spurt, and during this follow-up phase,
they might have passed the growth spurt. This can
explain the stability of the changes during the follow-up
phase. The AdvanSync, on the other hand, showed a
continued restraining effect on maxillary growth. The
mandibular growth enhancement, however, did not
remain significant. This finding was reported in studies
of the effects of the Twin block appliance on patients
treated during the peak growth spurt in which the
mandibular elongation does not differ from controls
after active treatment with the appliance.20 It is also
similar to studies of other appliances such as the
Herbst appliance when evaluated during the active
treatment phase and during the fixed orthodontic
treatment phase.21 In addition, the rebound in the
overcorrected Wits appraisal measurements and
overjet was significant in the AdvanSync group. This
is expected since the treatment protocol includes
913
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greater overcorrection at the end of the functional
appliance phase (T2–T1) than with the MARA.
The net changes at the completion of fixed
orthodontic treatment (T3–T1) revealed different or-
thopedic effects of the two treatment modalities. A
significant restriction in maxillary growth was evident
with AdvanSync. The MARA induced a larger mandib-
ular growth enhancement than AdvanSync and con-
trols. This confirms a mandibular growth modification
effect of this appliance. This could also be related to
the significantly larger mandibular length of MARA
group at starting forms. It has to be noted that the
effects of the condyle/fossa were not evaluated in this
study.
Previous studies of the Herbst appliance have
documented significant intrusion of maxillary first
molars.16 Our study found slight eruption of maxillary
molars with the use of both treatment modalities, but
the finding was not significant.
To our knowledge, this is the first study to report on
the treatment effects of the AdvanSync appliance. It
should be noted that ethical principles precluded
the use of a concurrent control group; therefore, a
historical control sample was used that might or might
not be similar to the experimental group in the growth
pattern. This study assumed that the growth pattern of
the controls was linear and matched the experimental
groups. The clinical effects in this cephalometric study
cannot be completely explained by the growth modi-
fication effects of the examined appliances. Other
factors using different methods of evaluation such as
tomographic studies of the temporomandibular joints
should be investigated. This warrants the need for
Angle Orthodontist, Vol 82, No 5, 2012
914
longitudinal follow-up comparative studies of patients
who received treatment with the appliances after
treatment completion and growth cessation.
CONCLUSIONS
N Both the MARA and AdvanSync affect the skeletal
and dentoalveolar craniofacial complex and are
effective in normalizing the Class II malocclusion to
Class I in patients treated during the skeletal growth
spurt.
N The MARA produced a significant elongation in the
total length of the mandible.
N The AdvanSync resulted in significant headgear
effect when compared with MARA and controls and
maintained the Class I relationship at T3–T1.
N Both appliances resulted in similar dentoalveolar
findings.
ACKNOWLEDGMENTS
We would like to express our appreciation to Douglas E. Toll
for providing the MARA sample for this study and Robert
Dunford for his help during the statistical analysis of the data. We
also thank James A. McNamara Jr. the curator of the Michigan
Growth Study for his help.
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