Comparison of Skeletal and Dentoalveolar Effects of The Forsus and Advansync in Treatment of Class II Malocclusions

COMPARISON OF SKELETAL AND DENTOALVEOLAR EFFECTS OF THE
FORSUS AND ADVANSYNC IN TREATMENT
OF CLASS II MALOCCLUSIONS
Bryce E. Gabler, D.M.D.
An Abstract Presented to the Graduate Faculty of

Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2013
Abstract
Objective: To compare the skeletal and dentoalveolar effects produced by the Forsus
and the AdvanSync appliances in the treatment of growing patients with Class II
malocclusion. Materials and Methods: A retrospective study that included 40 Forsus
patients with a mean start age of 12y4m ± 7m and 40 AdvanSync patients with a mean
start age of 12y4m ± 1y11m. Lateral cephalograms were taken at pretreatment (T1),
post-functional appliance removal (T2), and fixed orthodontic treatment completion (T3).
An independent t-test was used to compare differences between the two groups at each
time point. A paired t-test was used to compare differences within each group from one
time point to another. Results: While there were no skeletal differences between groups
at T2, both appliances significantly restricted maxillary growth. There were significant
dentoalveolar differences between groups found at T2 in the U1-SN, the maxillary
incisors horizontal, the maxillary molar horizontal and vertical, and the mandibular
incisor apex measurements. The Forsus significantly extruded maxillary molars. The
AdvanSync significantly distalized maxillary molars, and significantly distalized and
retroclined maxillary incisors. Both appliances significantly moved forward and intruded
the mandibular molars and incisors, and significantly proclined the mandibular incisors.
Conclusion: The Forsus and the AdvanSync were both effective in the treatment of
Class II malocclusions, inducing some skeletal but mostly dentoalveolar changes.
1
COMPARISON OF SKELETAL AND DENTOALVEOLAR EFFECTS OF THE
FORSUS AND ADVANSYNC IN TREATMENT
OF CLASS II MALOCCLUSIONS
Bryce E. Gabler, D.M.D.
A Thesis Presented to the Graduate Faculty of

Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2013
COMMITTEE IN CHARGE OF CANDIDACY:
Professor Eustaquio A. Araujo,
Chairperson and Advisor
Professor Rolf G. Behrents
Associate Clinical Professor Donald R. Oliver
i
DEDICATION
I dedicate this project to my loving and supportive family.
ii
ACKNOWLEDGEMENTS
I would like to thank the following individuals for their contributions to my
research project:
Dr. Eustaqio Araujo. Thank you for your guidance and persistence in pointing me
in the right direction during my thesis preparation and for showing me endless ways to
treat patients.
Dr. Rolf Behrents. Thank you for your vast knowledge of cephalometrics and
tracings that greatly contributed to my thesis and for allowing me to obtain an orthodontic
education at Saint Louis University.
Dr. Donald Oliver. Thank you for your attention to detail during my thesis
preparation and revisions. Your impeccable attention to detail is something to truly be
admired.
Dr. Lisa Alvetro and her staff, thank you for providing me with the Forsus sample
and quick responses to my emails.
Dr. Terry Dischinger, thank you for providing me with the AdvanSync sample
and taking care of me while I collected data at your office.
Dr. Heidi Israel. Thank you for your assistance with the statistical analysis for
this thesis.
iii
TABLE OF CONTENTS
List of Tables .......................................................................................................................v
List of Figures ................................................................................................................... vii
CHAPTER 1: INTRODUCTION ........................................................................................1
CHAPTER 2: REVIEW OF THE LITERATURE

The Class II Problem Defined..................................................................................3
Prevalence of Class II Malocclusions ......................................................................3
Etiology of Class II Malocclusions ..........................................................................5
Patterns of Mandibular Growth ...............................................................................6
Class II Correction ...................................................................................................7
Role of Compliance .................................................................................................8
Compliance-Free Inter-arch Appliances ..................................................................9
Herbst ...........................................................................................................9
Mandibular Anterior Repositioning Appliance .........................................12
Forsus .........................................................................................................14
AdvanSync .................................................................................................19
Summary and Statement of Thesis ........................................................................22
Literature Cited ......................................................................................................23
CHAPTER 3: JOURNAL ARTICLE

Abstract ..................................................................................................................25
Introduction ............................................................................................................26
Materials and Methods ...........................................................................................28
Sample........................................................................................................28
Cephalometric Analysis .............................................................................30
Statistical Methods .....................................................................................35
Results ....................................................................................................................35
Discussion ..............................................................................................................41
Skeletal Effects ..........................................................................................45
Maxillary Dentoalveolar Effects ................................................................45
Mandibular Dentoalveolar Effects .............................................................46
Overall Effects ...........................................................................................47
Conclusions ............................................................................................................48
Literature cited .......................................................................................................49
Appendix ............................................................................................................................50
Vita Auctoris ......................................................................................................................57
iv
LIST OF TABLES
Table 3.1: Age and gender distribution of study sample ............................................28
Table 3.2: Median duration of treatment periods........................................................29
Table 3.3: Landmarks and definitions ........................................................................31
Table 3.4: T1 and T2 angular cephalometric comparison

of Forsus and AdvanSync ..........................................................................36
Table 3.5: T1 and T2 linear horizontal cephalometric comparison

Table 3.6: T1 and T2 linear vertical cephalometric comparison

Table 3.7: T2-T1 angular cephalometric measurements of Forsus.............................39
Table 3.8: T2-T1 linear horizontal cephalometric measurements of Forsus ..............39
Table 3.9: T2-T1 linear vertical cephalometric measurements of Forsus ..................39
Table 3.10: T2-T1 angular cephalometric measurements of AdvanSync.....................40
Table 3.11: T2-T1 linear horizontal cephalometric measurements of AdvanSync ......40
Table 3.12: T2-T1 linear vertical cephalometric measurements of AdvanSync ..........40
Table 3.13: Comparison of the angular effects of the Forsus

reported in the literature from T2-T1 .........................................................43
Table 3.14: Comparison of the linear horizontal effects of the Forsus

Table 3.15: Comparison of the linear vertical effects of the Forsus

Table 3.16: Comparison of the angular effects of the AdvanSync

Table 3.17: Comparison of the linear horizontal effects of the AdvanSync

Table 3.18: Comparison of the linear vertical effects of the AdvanSync

v
Table A.1: T1, T2, T3 angular cephalometric comparison
Table A.2: T1, T2, T3 linear horizontal cephalometric comparison

Table A.3: T1, T2, T3 linear vertical cephalometric comparison

of Forsus and AdvanSync .........................................................................52
Table A.4: T3-T2 angular cephalometric measurements of Forsus .............................53
Table A.5: T3-T2 linear horizontal cephalometric measurements of Forsus ..............53
Table A.6: T3-T2 linear vertical cephalometric measurements of Forsus...................53
Table A.7: T3-T2 angular cephalometric measurements of AdvanSync .....................54
Table A.8: T3-T2 linear horizontal cephalometric measurements of AdvanSync ......54
Table A.9: T3-T2 linear vertical cephalometric measurements of AdvanSync...........54
Table A.10: T3-T1 angular cephalometric measurements of Forsus .............................55
Table A.11: T3-T1 linear horizontal cephalometric measurements of Forsus ..............55
Table A.12: T3-T1 linear vertical cephalometric measurements of Forsus...................55
Table A.13: T3-T1 angular cephalometric measurements of AdvanSync .....................56
Table A.14: T3-T1 linear horizontal cephalometric measurements of AdvanSync ......56
Table A.15: T3-T1 linear vertical cephalometric measurements of AdvanSync...........56
vi
LIST OF FIGURES
Figure 3.1: Reference plane ..........................................................................................32
Figure 3.2: Landmarks on reference plane ...................................................................32
Figure 3.3: Angular measurements on reference plane ................................................33
Figure 3.4: Linear horizontal measurements on reference plane ..................................33
Figure 3.5: Linear vertical measurements on reference plane ......................................34
vii
CHAPTER 1: INTRODUCTION
Class II malocclusions represent a disproportionate relationship between the
upper and lower teeth, where the lower teeth are located further posteriorly than the upper
either due to skeletal factors, dental factors, or a combination of both. This is a common
malocclusion that frequently presents in orthodontics with a wide array of treatment
options. The latest trend in treating this particular malocclusion has derived from new
techniques designed to make treatment more predictable, reduce treatment time, and
reduce the need for patient cooperation.
There are many ways to treat Class II malocclusions including: removable and
fixed functional appliances, elastics, extractions, headgear, implant and non-implant
supported distalizers, and even surgery. Suppliers and orthodontists have been creating
more and more fixed Class II correcting appliances so as to limit reliance on patient
compliance that, if lacking, can lead to longer treatment times and less than ideal
treatment outcomes. In most cases these appliances can remove the fear of surgery and
maintain the parent’s desire to not see their children lose teeth due to Class II correction.
There are many different compliance-free inter-arch appliances including the: Herbst,
Mandibular Anterior Repositioning Appliance (MARA), Forsus, and AdvanSync. Each
appliance has advantages and disadvantages. Some allow treatment correction at an
earlier age, others allow concurrent treatment with comprehensive fixed therapy. There
also may be some side effects from these appliances most notably lower incisor flaring.
From those listed appliances, the two newest are the Forsus and AdvanSync, which both
allow concurrent treatment and both are thought to have similar side effects.
1
Many research articles have been published on the skeletal and dental effects of
the Forsus, but only one on the AdvanSync. The purpose of this study is to directly
compare and contrast the skeletal and dentoalveolar effects of the Forsus and AdvanSync
in treatment of Class II malocclusions. This study will analyze and compare various
angular and linear measurements investigating possible side effects and benefits of each
appliance.
2
CHAPTER 2: REVIEW OF THE LITERATURE
The Class II Problem Defined
In 1890s the “father of modern orthodontics,” Edward H. Angle, developed a
classification system for malocclusions that orthodontists still use today.1 Angle
subdivided major types of malocclusions along with giving us the definition of normal
occlusion. The upper first molars were deemed his “key to occlusion,” and in an ideal
situation the mesiobuccal cusp should occlude with the lower first molar’s buccal groove,
along a smoothly curving line giving you a normal occlusal relationship. Angle
described three classes of malocclusion, one being a Class II malocclusion. In a Class II
malocclusion the lower molar is distally positioned relative to the upper molar. Later,
cephalometric radiology came into widespread use after World War II, and was evident
that not only malposed teeth, but jaw relationships played a role in Class II
malocclusions.1
Prevalence of Class II Malocclusions
Class II malocclusion is a common occurrence within the general population and
even more so in orthodontic offices. From 1966 to 1970, the Division of Heath
Examination Statistics conducted a survey, which collected information about the health
of the United States population ages 12 to 17 years old.2 The study included the
occlusion of approximately 7,500 adolescents that was statistically designed to provide
estimates of approximately 22.7 million. Dentists examined several variables including
buccal segment relation and overjet. For the buccal segment relation they described
Class II malocclusion as “distoclusion,” and defined it as a condition where the lower
3
molars inter-digitate behind the normal position with the upper molars. Cusp-to-cusp
deviation also qualified as distoclusion. Combining unilateral and bilateral, they found
that 32% of the adolescents examined had Class II malocclusion. A significantly larger
amount of Class II malocclusion was present in white youth compared to black youth. In
this study, overjet was regarded as severe if greater than 5 mm, and was observed in 15%
of the population.2
From 1988 to 1991, the third National Health and Nutrition Examination Survey
(NHANES III) studied the prevalence of malocclusion and orthodontic treatment need in
the United States.3 They examined approximately 7,000 individuals statistically designed
to provide estimates of approximately 150 million persons of various ages among white,
black, and Mexican-Americans. Instead of molar relationships this study measured
overjet as an indicator for Class II malocclusion. Both the Division of Health
Examination Statistics from 1966 to 1970 and the NHANES III observed Class II
malocclusions, defined by overjet greater than 5 mm, to be 15% of the population.2, 3
However, in this study the prevalence of overjet greater than 4 mm was greater in blacks
at 16.5% than whites at 14.2%. Severe Class II malocclusion, deemed overjet greater
than 10 mm, was found in 4% of the population with greater prevalence in blacks and
Mexican-Americans at 0.4% each, than whites at 0.3%. The number of people who had
overjet of 3-4 mm representing Class II malocclusion was almost the same as those with
ideal 1-2 mm of overjet, with about 40%. Due most likely to late mandibular growth,
research also showed that overjet of 5 mm or more decreased with age, starting at over
20% at ages 8 to 11 years old and declining to 13% for adults. This study found that
4
Class II malocclusion is the most prevalent jaw discrepancy occurring in the United
States.3
Etiology of Class II Malocclusions
It was not long after cephalometric x-rays were invented that clinicians knew
there was more to a Class II malocclusion than just the dental component. In 1981,
McNamara set out to examine the different skeletal and dental patterns of Class II
malocclusions in order to allow a more tailored treatment option for each pattern.4 He
focused his study on several criteria including: maxillary skeletal position, maxillary
dental position, mandibular skeletal position, mandibular dental position, and the vertical
configuration. In studying children ages 8 to 10 years old, McNamara found the most
commonly occurring factor in Class II malocclusions is retrusion of the mandible, which
was found in 60% of the cases. The maxillary skeletal component, despite being quite
variable, was found on average to be normally positioned. If the maxilla was abnormally
positioned it was found to be in a position of retrusion more often than protrusion. He
also noted excessive vertical development was a frequent characteristic in Class II
malocclusions and may be due to altered respiratory functions. In the case of dental
positions, he noted the maxillary dental protrusion to be less than previous studies
reported and that lower incisors were usually well-positioned relative to the A-Po line.
McNamara identified 77 different combinations of morphological characteristics of Class
II malocclusions demonstrating just how complex Class II malocclusions can be.4
The 1998 longitudinal study by Buschang and Martins evaluated anterior-
posterior (AP) and vertical skeletal growth of 49 females and 50 males.5 In this study
they analyzed the same individuals over two separate time periods, childhood and
5
adolescence. There were two sets of cephalograms evaluated each over a four year
period, the adolescent period was defined as three years prior to and one year after peak
velocity. This adolescent period represented females 9 to 13 years of age and males 11 to
15 years of age. They used a one year overlap between the adolescent period to form the
other set, the childhood period, which represented females 6 to 10 years of age and males
8 to 12 years of age. They found that while AP relationships improved slightly during
childhood, they worsened in adulthood. Buschang and Martins noted for adulthood
individuals who became more retrognathic, they had twice as much mandibular growth
potential during childhood than they did in adulthood. This suggests the best time to
stimulate or restrict AP mandibular growth is during childhood. The results
demonstrated that changes in AP relationships were primarily due to horizontal
mandibular growth rather than changes in the maxilla. They also mentioned that their
finding supports studies suggesting Class II malocclusions are most often due to
retrognathic mandibles.4, 5 As for the vertical component, only a moderate relationship
was found between AP and vertical changes. Vertical growth changes were significantly
greatest during adolescence. In 30% of children, vertical and horizontal relationships
worsened, leading to a greater risk of malocclusion. In contrast, 34% to 37% of children
showed improvements in AP and limited vertical changes, indicating a Class I pattern.5
Patterns of Mandibular Growth
In a 1997 study by Bishara et al., the investigators compared the longitudinal
growth of Class II division 1 subjects against normal Class I subjects.6 They analyzed
and compared the cephalograms of 30 untreated Class II division 1 malocclusions to 35
6
untreated normal Class I subjects. They compared the subjects at three stages matching
both groups for age at each stage. This includes stage I, after complete primary dentition
but before any permanent teeth erupted; stage II, once first molars completely erupted
into occlusion; and stage III, at the completion of eruption of all permanent teeth
excluding third molars. This study found very few differences between the two groups.
Comparison of growth direction was found to be very similar for cranial base, maxillary,
mandibular, dental, and soft tissue except for upper lip protrusion which increased in
Class II division 1 subjects. As for growth magnitude, several significant differences
were noted for the Class II group. Overall, changes in maxillary and mandibular lengths
were larger in the Class I group and greater skeletal and soft tissue convexities were
found in the Class II group. Mandibular length (Ar-Pog), was found to be significantly
shorter in Stage I for the Class II group, but by Stage III, it was not significantly different
than the Class I group. This suggests the possibility of “catch up” growth in the mandible
of Class II division I subjects at the later stages of development. The results suggested
the two groups had similar growth trends, but the overall magnitude of growth differed in
a few aspects.6
Class II Correction
It is important to have an understanding of craniofacial growth and development
when trying to correct a Class II malocclusion. There is a “cephalocaudial gradient of
growth” postnatal that is important to note.1 This refers to an axis of increased growth
from the head to the feet. Just as the maxilla is more superior to the mandible, the
maxilla grows first creating a relatively deficient mandible. Even with skeletal growth
7
and forward dental shifting, if more than three to four mm of correction is needed, it is
unlikely to occur naturally.1 Therefore, since the start of orthodontics in the early 1900s,
practitioners have been trying to find the best method in correcting Class II
malocclusions. There have been many approaches to treating Class II malocclusions,
some that start early others waiting for growth. Multiple techniques act intra-orally,
either fixed or removable, to correct the Class II relationship by skeletal and or dental
changes. More and more practitioners are trying compliance-free appliances, in belief
that relying heavily on patient compliance is too unpredictable and unlikely to achieve
consistent and timely results.
Role of Compliance
Compliance in orthodontics can be a risky endeavor to expect of patients. Sahm
et al., placed a micro-electronic device in Bionators of 53 adolescent patients ages 9 to14
years old, with the instruction to wear them 15 hours a day over a three to six month
period and informed them that they were being recorded.7 The electronic device reported
patients wore their removable appliance on averaged only 7.65 hours per day, or just 51%
of the requested time.7 In another study using headgear, Brandao et al., placed recorders
on the appliances.8 The study included 21 patients, ages 10 to 19 years old, who were
instructed to wear their headgear 14 hours a day and report their duration of use. They
measured two separate time periods, the first period the patients did not know they were
being recorded, and the second period where they were told they were being recorded.
Patients reported wearing their appliance 13.6 hours a day, however, only 5.6 hours were
recorded in the first time period, and 6.7 hours in the second time period. Patients were
8
only compliant 56.7% in the first period and only 62.7% once they knew they were being
recorded.8 Given the apparent unreliability of patients to be compliant, there could be an
advantage in using fixed Class II malocclusion appliances that reduce the need for patient
compliance.
Compliance-Free Inter-arch Appliances
Fixed functional appliances are attached to the maxilla and mandible and used to
posture the mandible forward in attempt to correct the Class II malocclusion. Some of
these appliances include: Herbst, MARA, Forsus, and AdvanSync.
Herbst
The Herbst appliance was invented by Emil Herbst, and introduced in Berlin at
the International Dental Congress in 1905.9, 10 Not many years after its introduction, the
appliance was all but forgotten, until it was later reintroduced in a journal article, by Hans
Pancherz in 1979 that quickly popularized the appliance.10 It is a fixed intra-arch
appliance that is attached by bands/crowns to the maxillary first molars and mandibular
first premolars. Connected by a telescope mechanism, it creates an artificial joint
between the two jaws that continuously protrudes the mandible.9-12 The telescope
mechanism is made up of a tube attached to the molar, and a plunger attached to the
premolar. Both are screwed into bands/crowns that allow them to freely rotate around
their point of attachment. Slight lateral movements can be performed due to the loose fit
of the plunger inside of the tube.9-12 The Herbst appliance normally has a lower lingual
holding arch and a palatal expander can be used too, if needed.10
9
In Pancherz’s 1979 study, he divided 20 boys with Class II division 1
malocclusions equally into two groups.9 The treatment group received the Herbst
appliance, and the control group received no treatment. All boys had a bilateral full-cusp
distal molar relationship. Cephalograms were taken before and after treatment, which
lasted for only six months. The results showed overjet and overbite was reduced by
3.8 mm and 2.5 mm respectively for the Herbst group, no change noted in the control.
The ANB was significantly reduced, due to a reduction in the SNA by 0.7°. The SNB
increased by 1.2° in the Herbst group, whose changes were significantly larger than the
controls. Both lower and anterior facial heights increased, 1.8 mm and 0.8 mm
respectively for the Herbst group, 0.7 mm and 0.8 mm for the control. The IMPA
increased 5.4°, while profile convexity decreased non-significantly in the Herbst group,
compared to no change in the control. The mandibular length (Co-Pg) increased 3.2 mm
in the Herbst group, and only 1.0 mm in the control. Pancherz reported the Herbst to
have affected the mandibular length due to condylar growth stimulation, and also had a
restraining effect on the maxilla.9
In 1982, Pancherz ran the same study that included 22 Class II division 1 subjects
and 20 controls to quantitatively evaluate the sagittal skeletal and dental changes of the
Herbst appliance.11 Overall, treatment effect was 6.7 mm of molar correction, 43%
skeletally and 57% dentally. The mandibular length increased 2.2 mm and moved
forward 2.5 mm, while the maxilla distalized 0.4 mm. The mandibular molars and
incisors moved forward 1.0 mm and 1.8 mm respectively, while the maxillary molars and
incisors distalized 2.8 mm and 0.5 mm respectively.11
10
In a 1997 prospective study, Pancherz looked at the long term effects of the
Herbst appliance.12 He had been advocating using the Herbst to achieve an end-to-end
incisal relationship before discontinuing its use, because he knew there was some relapse.
In this study, he wanted to find out if anything else was unstable too. During the first six
months post-treatment, it was found that 90% of the occlusal changes occurred, and for
the most part were dental. Approximately 30% of the overjet and 25% of molar
relationships returned from their overcorrected state. Only minor unfavorable changes in
jaw relationship and relapse occurred in this period. Five years post-treatment, a Class I
dental relationship was maintained by stable cuspal inter-digitation, whereas relapse
occurred if an unstable occlusion was present, especially if any lip-tongue habits were
present. In these stable dental cases, it was found that while the dental arch remained
normalized, the jaw relationship was only improved not normalized. Therefore, long-
term, the dental effects from the Herbst appliance tend to compensate for the unfavorable
jaw relationship. As for mandibular growth, seven years post-treatment, only minimal
long-term effects remained. After treatment, mandibular length gain was smaller than
what was found in control subjects, the only lasting effect was a larger mandibular height
increase and opening of the β-angle (Co-Gn to MP). For the maxillary dental complex,
while a distalization and intrusion of molars occurred during treatment, seven years post-
retention, no changes were found against control subjects. The occlusal plane, which
tipped downward during treatment, tipped upward post-treatment to normal values.12
The Herbst appliance has several advantages: it is a fixed appliance that cannot
be removed by the patient therefore no compliance needed, works 24 hours a day, and
has a treatment time of approximately six to eight months.9-12 The Herbst appliance is
11
best used on Class II malocclusion at or just after puberty allowing for the greatest effect
on mandibular growth. “Late” Herbst treatment may be beneficial too, however, only
dental effects can be expected. “Early” treatment is not recommended, as stable cuspal
inter-digitation post-treatment is required but not possible that early.12 Some
disadvantages are cost, breakage, and inability to concurrently use full braces.13
Mandibular Anterior Repositioning Appliance
The Mandibular Anterior Repositioning Appliance (MARA) was first introduced
commercially in 1998.13 It was developed and tested by Douglas Toll and James Eckhart.
The MARA is designed to encourage patients to keep their mandible postured forward in
order to avoid intentionally created occlusal interferences by stainless steel bands placed
on the upper and lower first molars. The lower band has a buccally protruding horizontal
bar attached to it, called the “arm,” that when the patient bites down interferes with the
upper band’s vertical bar, called the “elbow,” forcing the patient to advance their lower
jaw in order to avoid the contact. The clinician can increase the amount needed to
advance, by placing a one to two mm shims on the “elbow,” which advances the elbow
forward, and requires greater advancement of the lower jaw.13 The MARA normally has
a lower lingual holding arch and a palatal expander can be used too, if needed.14, 15
In a 2003 study by Pangrazio-Kulbersh et al., 30 Class II patients were treated an
average of 10.7 months with the MARA .14 The study analyzed 12 boys, average age of
11.2 years old, and 18 girls, average age of 11.3 years old. A control group of 21 Class II
subjects were taken from the Michigan Growth Study. Two cephalograms were taken,
the first was taken two weeks before the start of treatment, and the second was taken six
12
weeks after completion of treatment. Overall, treatment effect was 5.8 mm of molar
correction, 47% skeletally and 53% dentally. The maxilla showed no restraining effect,
but the maxillary molars did distalize 2.4 mm. There was skeletal change in the
mandible, with a mandibular length increase of 2.7 mm and the chin point moved forward
2.0 mm. The mandibular molars and incisors moved forward 0.7 mm and 1.0 mm
respectively, while the IMPA increased 3.9°. Anterior and posterior facial height
increased 1.5 mm and 2.7 mm respectively. Vertically, there was no change in either
maxillary or mandibular molars.14
Several years later in 2011, Ghislanzoni et al. looked at the post-treatment effects
of the MARA in 23 consecutively treated Class II subject with an average start age of
10.2 years old.15 The control group was 17 Class II subjects from the Michigan and
Denver Child Growth Studies. Cephalograms were taken at three time points:
pretreatment (T1), post-MARA (T2), and at least one year after post-MARA (T3). A
lower lingual arch was used in conjunction with the MARA, as well as full fixed
appliances at the start or only after a few months of active treatment. The MARA was
used on average for 1.2 years. From T1-T3 a restriction of the maxilla was noted with a
decrease in SNA of 1.2°, along with a mandibular first molar extrusion of 1.6 mm, both
of which are in contrast to Pangrazio-Kulbersh’s previous findings.14, 15 Also,
mandibular length increased 2.0 mm, and the IMPA increased, but did relapse from 5.8°
in T1-T2 to 3.7° in T1-T3.15 Lower anterior facial height increased 1.8 mm. There was a
decrease in: ANB (1.8°), Wits (1.8 mm), overjet (3.3 mm), and overbite (1.4 mm).15
In a 2012 study by Pangrazio et al. the treatment effects of the MARA were
evaluated in 30 consecutively treated Class II adolescents.16 The MARA group was
13
composed of 12 boys, average age 11.9 years old, and 18 girls, average age 10.8 years
old. The control group was composed of 21 subjects from the Michigan Growth Study.
Cephalograms were taken at a maximum of five months prior to MARA treatment (T1),
post-MARA (T2), and at least two years after MARA removal and after completion of
fixed appliance therapy (T3). From T3-T1 only two measurements were found to be
significant. The overjet decreased 1.93 mm, and the occlusal plane steepened 2.88°. The
maxilla did show a non-significant restraining effect reflected in SNA that decreased
2.43°. The maxillary molars distalized 2.96 mm along with an intrusion of 0.78 mm. A
skeletal change in the mandible was noticed in that the mandibular length increased
1.84 mm and the chin point moved forward 4.47 mm. The mandibular molars moved
forward 2.12 mm, while the IMPA increased 2.81°. There was a non-significant decrease
in both the ANB (0.22°), and the Wits (0.34 mm).16
The MARA has several advantages over the Herbst: it allows concurrent full
fixed treatment, it does not connect the upper and lower arches together allowing full
range of motion, and it is more esthetic.13 Among the disadvantages to the Herbst are: it
is only active when patient closes down, requires full coverage crowns, and may result in
pronounced mobility of the mandibular first molars.13
Forsus
The Forsus Fatigue Resistant Device (FRD) was developed by William Vogt as a
semi-ridged fixed inter-arch Class II corrector.17, 18 The appliance is comprised of three
parts: a push rod with a built-in stop, a telescoping spring cylinder, and a L-pin or EZ-
module.18 An eyelet on one end of the cylinder is attached to the maxillary first molar
14
headgear tube by either an L-pin or EZ-module, and on the other end the straight end of
the rod is inserted into the cylinder with the hook end of the rod crimped onto the
mandibular arch wire either distal to the first premolar or canine. The cylinder is
comprised of an inner and outer sliding tube surrounded by a nickel-titanium open-coil
spring. When the patient bites down the push rod’s stop presses against the spring, and if
fully compressed exerts a designed 200 grams of force. Usually, the springs are not fully
compressed, making force levels comparable to inter-arch elastics. The rods come in five
different sizes, and one to two mm crimpable stops can be added onto the rod as more
activation is needed. If the midlines are off, different rod lengths can be used per side to
help correct, or additional stops can be placed on the deviated side. The idea behind the
Forsus, is to transfer the force generated from the compression of the spring to the
maxillary molars using the mandibular arch as anchorage.18
The Forsus appliance first started in 2001 as the Forsus Nitinol Flat Spring
(NFS).17 A pair of nickel-titanium spring bars with a transparent coating were attached to
the maxillary first molar bands and the mandibular archwire in similar fashion as the
Forsus FRD. However, in the mandible the spring was always distal to the canine as the
first premolar bracket had to be removed due to how the spring attached to the wire. The
Forsus NFS was evaluated in 2001, by Heinig and Goz who treated 13 Class II patients
(average age of 14.2 years old) for four months. Cephalograms were taken before the
Forsus was placed and after the Forsus removal. Patients already had teeth leveled and
aligned, and were in final archwires when the Forsus were placed for four months.
Results showed a 66% AP correction due to dentoalveolar effects. Skeletally, the maxilla
moved forward 0.3 mm, and the mandibular length increased 1.2 mm. The maxillary
15
molars distalized 1.1 mm, while the mandibular molars moved forward 1.7 mm. The
maxillary incisors distalized 1.7 mm and retroclined 5.3°, while the mandibular incisors
moved forward 1.8 mm and proclined 9.6°. The overjet was reduced by 4.7 mm, the
overbite by 1.2 mm, and the molar relationship improved 3.9 mm. The occlusal plane
was rotated clockwise 4.2° and thus bite opening was observed.17
In a 2008 study by Jones et al., the Forsus FRD was used to compare the
treatment result of Forsus against Class II elastics in Class II patients.19 Both groups had
34 Class II subjects, with an average age of 12.6 years old in the Forsus group, and
12.2 years old in the elastics group. Cephalograms were taken at pretreatment and at the
end of comprehensive treatment. They were analyzed using the pitchfork analysis and a
vertical cephalometric analysis. Between the two groups, the only significant difference
was the mandibular molar forward movement and total molar correction, which were
significantly greater in the Forsus group. The Forsus group had 1.1 mm more forward
movement of the mandibular molars and 0.8 mm greater molar correction than the elastic
group. The maxilla moved forward 1.7 mm, while the mandible moved forward 4.4 mm.
Both the maxillary molar and mandibular molar were found to have moved forward
1.2 mm and 1.8 mm, respectively. The maxillary incisors moved forward 0.7 mm and
proclined 3.7°, while mandibular incisors moved forward 1.2 mm and proclined 6.3°.
Total molar and incisor change were both 3.2 mm. Both groups showed maxillary and
mandibular molar extrusion, but less in the Forsus group. The general trend was forward
movement of the maxilla, mandible, and dentition for both the Forsus and elastic groups.
However, the mandibular skeletal and dental movements were greater than their
counterparts in the maxilla resulting in the Class II correction.19
16
In a 2011 study by Franchi et al., the treatment effects of the Forsus FRD were
evaluated in 32 Class II patients against a sample of 27 untreated Class II patients.20 The
Forsus group had an average age of 12.7 years old, and the untreated group, which came
from the Michigan Growth Study and Denver Child Growth Study, had an average age of
12.8 years old. Cephalograms were taken before and after comprehensive treatment,
which lasted 2.4 years on average. The results showed significant differences in the
majority of measured variables. The maxilla had a restraining effect of 1.2 mm for Pt A
to Nasion perpendicular and -2.1° for SNA, a change that was not found in the two prior
studies mentioned.17, 19, 20 The mandibular length increased 1.8 mm. The maxillary
molars distalized 0.4 mm, while the mandibular molars moved forward 1.6 mm. The
maxillary molars stayed the same vertically, while the mandibular molars extruded 2.2
mm. The maxillary incisors distalized 1.5 mm and retroclined 0.3°, while the mandibular
incisors moved forward 2.5 mm and proclined 5.2°. The maxillary incisors extruded 1.0
mm while the mandibular incisors intruded 2.0 mm. The overjet was reduced by 5.5 mm,
the overbite by 2.4 mm, and molar relationship improved 3.4 mm. Overall, the maxillary
restraining effect and the forward movement of the mandibular dentition was found to be
significant, whereas the mandibular skeletal change was not considered significant due to
a lack of significant effect in both the bony and soft tissue of the chin.20
Later in 2011, Aras et al. published a study comparing the dentoskeletal changes
along with the temporal mandibular joint (TMJ) relationship in Class II subjects treated
with the Forsus FRD at peak and end of pubertal growth.21 Peak of puberty group had 15
subjects with an average age of 14 years old, and near end puberty group had 14 subjects
with an average age of 15.1 years old. Cephalometric analysis along with magnetic
17
resonance imaging (MRI) was done before placement and after placement of the Forsus,
which on average was nine months. There were many significant intra-group changes
found, but not many inter-group changes. The peak pubertal group had significant
differences over the end of pubertal group, in both the mandibular length increase with
1.3 mm and mandibular molar forward movement of 1.1 mm. In both groups, MRI
analysis revealed, on average, an unaffected TMJ. It was concluded that the use of the
Forsus is not a risk factor for development of TMJ dysfunction when there are no signs or
symptoms before use. Overall, increases in mandibular dimensions and advancements
were small in the peak puberty group, whereas the end of pubertal group had no
significant changes, and dental changes were practically the same in both groups.21
The Forsus FRD has several advantages: it allows concurrent full fixed treatment,
requires no lab time as appliance are pre-fabricated, works 24 hours a day, can correct
midline deviations, and is compliance-free. In a study done by Bowman et al., patient
experience with the Forsus FRD was evaluated through a survey given to 70 patients.22
In order to take the survey, patients had to have had the Forsus in place for at least two
months, and still have it in place at the time of the survey. Patient ages ranged from 12 to
18 years old and averaged 14.5 years old. The study found cheek irritation as the most
bothersome side effect. Almost 90% of patients reported growing accustomed to the
appliance within four weeks, and 66.1% in two weeks. Out of the 70 patients, 51 had
reported wearing Class II rubber bands prior to Forsus, and while answers varied, about
50% reported Forsus to be at least easier than rubber bands. In 25 subjects (37.3%), an
extra trip to the orthodontist was required due to breakage.22 In a case study by Ross et
18
al. it was reported in their department that out of the 17 cases involving Forsus, there had
been recorded eight lost split crimps, one broken ‘L’ pin, and one broken molar band.23
Another disadvantage of Forsus, is that it requires anchorage preparation to
minimize unwanted movement before using the appliance.23 The case must be leveled
and aligned along with at least a 0.016 X 0.022-inch stainless steel (SS) in a 0.0180-inch
slot, or a 0.019 x 0.025-inch wire in a 0.022-inch slot. The archwires should both be tied
back or cinched back, with the lower canines stainless steel tied into the archwire.23 Two
more disadvantages are cost, and if the patient opens greater than 60 mm, the rod most
likely will come out of the cylinder and disengage, requiring the patient to once again
open wide enough to put the rod back inside the cylinder.13 It is however, the least likely
inter-arch compression spring to break.13
AdvanSync
The AdvanSync appliance was first introduced commercially in 2009.24 Also,
known as “Molar to Molar appliance,” it was developed and tested by Terry Dischinger.24
This appliance is designed to simultaneously advance the mandible while correcting
malocclusion.25 It is a fixed intra-arch appliance, where telescoping rods are attached by
screws, to specially designed molar bands, that are placed on maxillary and mandibular
first molars. Connected by a telescope mechanism, it creates an artificial joint between
the two jaws that continuously protrudes the mandible. The bands have dual screw
housing allowing greater range of activation and one to two mm spacers can be crimped
onto the rods to increase activation as well.25 This appliance, like the Forsus, can correct
19
the midline if off, by screwing the arm into the other band housing unit or by adding
spacers on the deviated side.
In a 2012 retrospective study by Al-Jewair et al., skeletal and dentoalveolar
effects were compared between the MARA and the AdvanSync appliances in Class II
patients.24 The MARA group had 40 subjects, 22 males, 18 females, and an average age
of 11.6 years old. The AdvanSync group had 30 subjects, 13 males, 17 females, and an
average age of 12.3 years old. The control group had 24 subjects, 13 males, 11 females,
and an average age of 11.9 years old. The control consisted of untreated Class II
individuals from the Michigan Growth Study. Results were measured by cephalograms
taken at three time points: pretreatment (T1), post-functional appliance treatment (T2),
and fixed orthodontic treatment completion (T3). Both MARA and AdvanSync groups
had fixed treatment concurrently. The appliances were activated two to four mm every
three months, over 12 months for the MARA and six to 12 months for the AdvanSync,
until slight dental overcorrection was achieved with the MARA and moderate
overcorrection with the AdvanSync.24
Results for T2-T1 showed that both appliances significantly increased the
mandibular length, ramus height, and anterior/posterior facial height.24 The mandibular
length increased 1.9 mm for the MARA and 1.4 mm for the AdvanSync. The
AdvanSync group had a significant restriction of maxillary growth with a SNA of -2.0°,
which was 1.1° more than the MARA group. The mandibular molars moved forward in
the MARA and the AdvanSync groups, by 2.3 mm and 2.1 mm respectively. The IMPA
was increased in both groups by about 5.4°. Skeletal changes for the MARA in T3-T2
20
were not significantly different, however, the AdvanSync produced a continued restraint
on maxillary growth.24
The net changes from T3-T1 revealed significant mandibular growth in the
MARA group with an increase of 2.7 mm, the AdvanSync however, was equal to the
control group.24 Significant maxillary restraint was shown in the AdvanSync group with
a SNA (-3.7°), but not for the MARA (-1.5°). Both appliances significantly increased the
IMPA by about 5.2°. Both appliances significantly decreased the overbite by 2.8 mm and
2.6 mm, and the overjet by 2.7 mm and 3.0 mm for the MARA and the AdvanSync
respectively. Overall, dentoalveolar changes were similar in both groups. Treatment
time was noticeably less in the AdvanSync group by about one year.24
The AdvanSync appliance has the same advantages as the Forsus appliance in
that it allows concurrent full fixed treatment, it requires no lab time as appliance are pre-
fabricated, it works 24 hours a day, it can correct midline deviations, and it is
compliance-free. AdvanSync, unlike Forsus can be placed at the start of treatment, since
it does not require leveling or being in a heavy wire to use. Being connected only to the
molars, the AdvanSync arms are 50% shorter than the traditional Herbst appliance, and
significantly shorter than the Forsus appliance.25 Shorter arms may reduce cheek
irritation, are less noticeable, and therefore may be more esthetic. A smaller appliance
may enhance oral hygiene and affect speech less.25 Unlike the MARA, a lower lingual
holding arch is not required but it may be placed if desired. Disadvantages to the
AdvanSync appliance are price, breakage, and requirement for a moderate overcorrection
as relapse is expected.
21
Summary and Statement of Thesis
Over the last several years, non-extraction treatment plans as well as non-
compliance therapies have become more and more popular. Since the return of the
Herbst appliance in the 1970s by Pancherz, the market has been flooded with various
Class II compliance-free appliances. The purpose of this study is to compare and contrast
two of the more recent appliances, the Forsus and AdvanSync. Multiple studies have
investigated the effects of the Forsus appliance, only one has been performed on the
AdvanSync. Differences in skeletal and dentoalveolar effects will be evaluated using
lateral cephalograms at three time points: pretreatment, post-functional appliance
removal, and fixed orthodontic treatment completion.
22
Literature Cited
1. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St. Louis:
Mosby; 2007.
2. Kelly JE, Harvey CR. An assessment of the occlusion of the teeth of youths 12-17
years. Vital Health Stat 11. 1977;1-65.
3. Proffit WR, Fields HW, Jr., Moray LJ. Prevalence of malocclusion and orthodontic
treatment need in the United States: estimates from the NHANES III survey. Int J
Adult Orthodon Orthognath Surg. 1998;13:97-106.
4. McNamara JA, Jr. Components of Class II malocclusion in children 8-10 years of age.
Angle Orthod. 1981;51:177-202.
5. Buschang PH, Martins J. Childhood and adolescent changes of skeletal relationships.

Angle Orthod. 1998;68:199-206; discussion 7-8.
6. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in dentofacial structures in

untreated Class II division 1 and normal subjects: a longitudinal study. Angle
Orthod. 1997;67:55-66.
7. Sahm G, Bartsch A, Witt E. Micro-electronic monitoring of functional appliance wear.

Eur J Orthod. 1990;12:297-301.
8. Brandao M, Pinho HS, Urias D. Clinical and quantitative assessment of headgear

compliance: a pilot study. Am J Orthod Dentofacial Orthop. 2006;129:239-44.
9. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst
appliance. A cephalometric investigation. Am J Orthod. 1979;76:423-42.
10. Pancherz H. The Herbst appliance--its biologic effects and clinical use. Am J Orthod.
1985;87:1-20.
11. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. A

cephalometric investigation. Am J Orthod. 1982;82:104-13.
12. Pancherz H. The effects, limitations, and long-term dentofacial adaptations to

treatment with the Herbst appliance. Semin Orthod. 1997;3:232-43.
13. Graber T, Vanarsdall R, Vig K. Orthodontics: Current Principles & Techniques. 4th
ed. St. Louis: Mosby; 2005.
14. Pangrazio-Kulbersh V, Berger JL, Chermak DS, Kaczynski R, Simon ES, Haerian A.
Treatment effects of the mandibular anterior repositioning appliance on patients
with Class II malocclusion. Am J Orthod Dentofacial Orthop. 2003;123:286-95.
23
15. Ghislanzoni LT, Toll DE, Defraia E, Baccetti T, Franchi L. Treatment and
posttreatment outcomes induced by the Mandibular Advancement Repositioning
Appliance; a controlled clinical study. Angle Orthod. 2011;81:684-91.
16. Pangrazio MN, Pangrazio-Kulbersh V, Berger JL, Bayirli B, Movahhedian A.

Treatment effects of the mandibular anterior repositioning appliance in patients
with Class II skeletal malocclusions. Angle Orthod. 2012;82:971-7.
17. Heinig N, Goz G. Clinical application and effects of the Forsus spring. A study of a
new Herbst hybrid. J Orofac Orthop. 2001;62:436-50.
18. Vogt W. The Forsus Fatigue Resistant Device. J Clin Orthod. 2006;40:368-77; quiz
58.
19. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction patients treated
with the Forsus Fatigue Resistant Device versus intermaxillary elastics. Angle
Orthod. 2008;78:332-8.
20. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T. Effectiveness of

comprehensive fixed appliance treatment used with the Forsus Fatigue Resistant
Device in Class II patients. Angle Orthod. 2011;81:678-83.
21. Aras A, Ada E, Saracoglu H, Gezer NS, Aras I. Comparison of treatments with the
Forsus Fatigue Resistant Device in relation to skeletal maturity: a cephalometric
and magnetic resonance imaging study. Am J Orthod Dentofacial Orthop.
2011;140:616-25.
22. Bowman AC, Saltaji H, Flores-Mir C, Preston B, Tabbaa S. Patient experiences with
the Forsus Fatigue Resistant Device. Angle Orthod. 2013;83:437-46.
23. Ross AP, Gaffey BJ, Quick AN. Breakages using a unilateral fixed functional
appliance: a case report using The Forsus Fatigue Resistant Device. J Orthod.
2007;34:2-5.
24. Al-Jewair TS, Preston CB, Moll EM, Dischinger T. A comparison of the MARA and
the AdvanSync functional appliances in the treatment of Class II malocclusion.
Angle Orthod. 2012;82:907-14.
25. Ormco. Class II correction in Class I time. Orange, CA: Ormco; 2012.
24
CHAPTER 3: JOURNAL ARTICLE
Abstract
Objective: To compare the skeletal and dentoalveolar effects produced by the Forsus
and the AdvanSync appliances in the treatment of growing patients with Class II
malocclusion. Materials and Methods: A retrospective study that included 40 Forsus
patients with a mean start age of 12y4m ± 7m and 40 AdvanSync patients with a mean
start age of 12y4m ± 1y11m. Lateral cephalograms were taken at pretreatment (T1),
post-functional appliance removal (T2), and fixed orthodontic treatment completion (T3).
An independent t-test was used to compare differences between the two groups at each
time point. A paired t-test was used to compare differences within each group from one
time point to another. Results: While there were no skeletal differences between groups
at T2, both appliances significantly restricted maxillary growth. There were significant
dentoalveolar differences between groups found at T2 in the U1-SN, the maxillary
incisors horizontal, the maxillary molar horizontal and vertical, and the mandibular
incisor apex measurements. The Forsus significantly extruded maxillary molars. The
AdvanSync significantly distalized maxillary molars, and significantly distalized and
retroclined maxillary incisors. Both appliances significantly moved forward and intruded
the mandibular molars and incisors, and significantly proclined the mandibular incisors.
Conclusion: The Forsus and the AdvanSync were both effective in the treatment of
Class II malocclusions, inducing some skeletal but mostly dentoalveolar changes.
25
Introduction
Angle first described Class II malocclusions in the 1890s. Since then, numerous
treatment options and appliances have been created in an effort to correct Class II
malocclusion.1 Within the general population, Class II malocclusion is a common
occurrence with a prevalence of about 15%.2, 3 In a study done by McNamara, 77
different combinations of morphological characteristics of Class II malocclusions were
identified.4 While Class II malocclusion types can be diverse it was found that 60% are
due to a retrusive mandible.4 Buschang and Martins noted for Class II malocclusions,
adulthood individuals who became more retrognathic, had twice as much mandibular
growth potential during childhood than they did in adulthood.5 This suggests that the
best time to stimulate or restrict anterior-posterior mandibular growth is during
childhood.5 Looking at mandibular growth, a study compared longitudinal growth of
Class II malocclusions to Class I subjects and found that over time, the direction of
growth in skeletal and dental components were very similar.6 However, in the Class II
group mandibular length was significantly shorter in the earlier stages but not
significantly different later. This suggests the possibility of “catch up” growth in the
mandible of Class II individuals at the later stages of development.6 If timed correctly
and along with favorable skeletal growth, functional Class II appliances can aid in the
correction of Class II malocclusions.
In attempt to make treatment more predictable, reduce treatment time, and reduce
the need for patient cooperation, compliance-free appliances have become more and more
popular. A study done using electronic devices to record the amount of time patients
actually wore their Bionators showed only 51% of requested use.7 Another study using
26
headgears equipped with recorders reported 56.7% compliance with the amount of time
they were asked to wear it, and after patients were informed they were being measured
there was only 62.7% compliance.8 With this in mind, compliance-free appliances
appear very beneficial. The Forsus and the AdvanSync appliance are two of the more
recent appliances that are compliance-free and allow for concurrent treatment with fixed
appliances. The Forsus appliance attaches to the maxillary molar band and the
mandibular archwire, while the AdvanSync appliance also attaches to the maxillary molar
band but in the lower arch it attaches to the mandibular molar band. While each
appliance functions a little differently both are thought to have similar effects.
The Forsus appliance has been evaluated in correcting Class II malocclusions
amongst adolescents in a few studies.9-11 From these studies significant forward
movement of mandibular molar and incisor were observed as well as significant
mandibular incisor proclination. 9-11 The effects of the AdvanSync on Class II
malocclusion have only been published once.12 That study also found significant forward
movement of mandibular molar and incisor proclination.12
The purpose of this study is to compare and contrast two of the more recent
compliance-free Class II malocclusion appliances, the Forsus and the AdvanSync.
Multiple studies have investigated the effects of the Forsus appliance, while only one has
been done on AdvanSync, and none comparing the two. Differences in skeletal and
dentoalveolar effects will be evaluated using lateral cephalograms at three time points:
pretreatment, post-functional appliance removal, and fixed orthodontic treatment
completion.
27
Materials and Methods
Sample
A retrospective study was conducted using lateral cephalograms of adolescent
patients who received treatment for their Class II malocclusion using either the Forsus or
the AdvanSync appliances. The sample was divided from two private practices. Forty
(20 males, 20 females) Forsus patient records were obtained from cases treated by Lisa
Alvetro, and 40 (20 males, 20 females) AdvanSync patient records were obtained from
Terry Dischinger. Lateral cephalograms were taken at pretreatment (T1), post-functional
appliance removal (T2), and fixed orthodontic treatment completion (T3). Inclusion
criteria were adolescent males and females with Class II malocclusion consisting of
molars in at least end-to-end relationship, no missing teeth, and a non-extraction
treatment plan. The mean starting age for the Forsus sample was 12y4m ± 6m, and the
AdvanSync sample had a mean starting age of 12y4m ± 1y11m, as shown in Table 3.1.
Table 3.1: Age and gender distribution of study sample
T1 T2 T3
Group Females:Males Mean Age ± SD Mean Age ± SD Mean Age ± SD
(Range) (Range) (Range)
Forsus 20:20 12y4m ± 7m 13y11m ± 8m 14y8m ± 8m
(10y7m-13y3m) (12y2m-15y2m) (13y1m-15y11m)
AdvanSync 20:20 12y4m ± 1y11m 13y3m ± 1y11m 14y7m ± 2y
(8y3m-15y11m) (8y9m-16y7m) (9y7m-18y2m)
28
In the Forsus sample, subjects were fully bonded, leveled and aligned, and a
0.019 x 0.025-inch Beta Titanium archwire was placed in the mandible and cinched
before the Forsus could be placed. The Forsus on the mandibular wire was attached
between the first pre-molar and second pre-molar. It took almost one year from the start
of treatment until the Forsus could be placed. The Forsus appliance was used for a mean
duration of 6.5 months, as seen in Table 3.2, to achieve Class I correction. After the
appliance was removed, fixed orthodontic treatment continued until an adequate
occlusion and finish was achieved, the overall treatment was a mean duration of two
years.
Table 3.2: Median duration of treatment periods
Group Class II Appliance Overall

Forsus 6.5m 24m
AdvanSync 11.2m 24m
In the AdvanSync sample, subjects either had their AdvanSync placed at the time
of bonding both arches second pre-molar to second pre-molar, or one month prior. After
the patients were fully bonded, the maxillary arch was figure-eight-laced first molar to
first molar and 0.014 CuNiTi archwires were placed in both upper and lower arches, with
the lower archwire annealed and bent up. Wire dimensions increase over treatment time
from 0.014 CuNiTi to 0.014 x 0.025 CuNiTi to eventually either a 0.019 x 0.025 TMA or
NiTi in the upper arch and a 0.016 x 0.025 SS in the lower. The AdvanSync appliance
was used until a moderate overcorrection was achieved for a mean duration of 11.2
months. After the appliance was removed, fixed orthodontic treatment continued until
29
an adequate occlusion and finish was achieved, the overall treatment was a mean duration
of two years.
Cephalometric Analysis
For each cephalogram, 13 anatomical landmarks were located as defined in Table
3.3. These landmarks were marked for both groups at both time points, and then
digitized using Dentofacial Planner version 7.0. Within Dentofacial Planner, two
reference planes were constructed in order to create an x-y coordinate grid. A horizontal
line was created parallel to the sella-nasion line minus seven degrees (SN-7), and a
vertical line was created perpendicular to SN-7 passing through sella. The reference
planes are shown in Figure 3.1 and the landmarks are shown in Figure 3.2. All
measurements were made by the software and were broken up into three categories:
angular, linear horizontal and linear vertical as shown in Figures 3.3, 3.4, and 3.5
respectively.
30
Table 3.3: Landmarks and definitions
Abbreviation Landmarks Definition

A A point The most posterior point of the maxilla in
the concavity between the anterior nasal
spine and prosthion
B B point The most posterior point of the mandible in
the concavity between infradentale and
pogonion
Gn Gnathion The most anterior and inferior midline
point on the external contour of the
symphysis of the mandible
Go Gonion The most inferior, posterior, and lateral
point on the mandible
L1 Lower Incisor The highest point on the incisal edge of the
crown of the most anterior mandibular
central incisor
L1a Lower Incisor Apex The root tip of the mandibular central
incisor
L6 Lower Molar The posterior contact point of the
mandibular first molar
N Nasion The most anterior point of the frontonasal
suture
Pg Pogonion The most prominent or anterior point on
the symphysis of the mandible in the
median plane
S Sella The center of the pituitary fossa
U1 Upper Incisor The highest point on the incisal edge of the
crown of the most anterior maxillary
central incisor
U1a Upper Incisor Apex The root tip of the maxillary central incisor
U6 Upper Molar The posterior contact point of the maxillary
first molar
31
Figure 3.1 Reference plane
Figure 3.2 Landmarks on reference plane
32
Figure 3.3 Angular measurements on reference plane
Figure 3.4 Linear horizontal measurements on reference plane
33
Figure 3.5 Linear vertical measurements on reference plane
The magnification
agnification of the cephalograms was corrected based on equalizing
equaliz the
distances from sella-nasion

nasion (S
(S-N) using T1 as the base value for T2 and T3.
T3 The
following equation was used to calcula

calculate
te the percentage of magnification:
magnification
Percentage of magnification at T2 = (S-N at T1) – (S-N at T2)

(S-N at T2)
Percentage of magnification at T3 = (S-N at T1) – (S-N at T3)

(S-N at T3)
The T2 and T3 measurements

ements were multiplied by this magnification factor for each
individual patient at all linear measurements.
34
Statistical Methods
Data were analyzed using SPSS (Statistical Package for Social Sciences) version
20.0 for windows. An independent t-test was used to compare differences among the two
groups at each time point. A paired t-test was used to compare differences within each
group from one time point to another. Differences were considered statistically
significant at p < .05.
The Cronbach’s Alpha test was performed to evaluate intra-examiner reliability.
From the study sample, 10% were re-traced in each group. The intra-class correlation
coefficients of the measurements ranged from 0.89-0.99.
Results
The Forsus and the AdvanSync groups were very similar in all variables at T1,
except for only one significant difference between the groups. The AdvanSync group
had an increased IMPA value to start with (P = .030). Tables 3.4, 3.5, and 3.6 illustrate
the different angular, linear horizontal, and linear vertical differences between the Forsus
and the AdvanSync groups at T1 and T2. While there were no skeletal differences
between groups at T2, there were significant dentoalveolar differences found in the U1-
SN, the maxillary incisors horizontal, the maxillary molar horizontal and vertical, and the
mandibular incisor apex measurements. Due to the Forsus group and the AdvanSync
group having been treated by different protocols under different offices after T2, the T3
differences will not be discussed, however full results can be found in the appendix under
Tables A.1, A.2, and A.3 respectively.
35
Table 3.4: T1 and T2 angular cephalometric comparison of Forsus and AdvanSync
Forsus AdvanSync
Mean SD Mean SD Significance
SNA° T1 80.50 2.91 80.80 4.01 .703 NS
T2 79.79 3.01 79.05 3.97 .355 NS
SNB° T1 75.21 2.58 75.39 4.02 .805 NS
T2 76.08 3.00 75.36 3.64 .337 NS
ANB° T1 5.31 1.81 5.39 2.19 .864 NS
T2 3.71 1.83 3.69 2.53 .972 NS
U1-SN° T1 101.73 10.49 101.28 10.78 .850 NS
T2 104.24 7.67 96.47 7.74 .001 **
IMPA° T1 99.66 7.52 103.18 6.68 .030 *
T2 107.17 7.94 110.19 8.18 .098 NS
T1: Pretreatment
T2: Post-functional appliance removal
NS: Not Significant, SD: Standard Deviation
* P .05; **P .001
Table 3.5: T1 and T2 linear horizontal cephalometric comparison of Forsus and

AdvanSync
Forsus AdvanSync
U6 T1 33.96 5.04 34.26 6.31 .810 NS
T2 34.31 5.27 31.49 5.91 .027 *
U1 T1 81.22 6.49 81.16 9.31 .972 NS
T2 80.65 7.85 76.76 7.50 .026 *
U1a T1 72.20 6.79 72.58 6.65 .800 NS
T2 70.46 6.10 70.66 6.84 .888 NS
L6 T1 30.93 4.86 31.38 6.40 .723 NS
T2 34.64 5.70 33.83 6.08 .539 NS
L1 T1 74.39 6.91 75.06 8.01 .690 NS
T2 77.40 7.46 76.32 7.31 .513 NS
L1a T1 61.08 6.99 60.75 8.34 .850 NS
T2 62.16 7.65 58.45 7.90 .036 *
Pg T1 67.64 7.64 67.73 9.62 .961 NS
T2 69.20 8.36 66.98 9.10 .259 NS
T1: Pretreatment
* P .05; **P .001
36
Table 3.6: T1 and T2 linear vertical cephalometric comparison of Forsus and
AdvanSync
Forsus AdvanSync
U6 T1 67.74 5.82 66.45 6.52 .353 NS
T2 69.49 5.92 65.9 7.44 .019 *
U1 T1 83.22 7.58 80.61 6.67 .106 NS
T2 84.88 7.29 82.11 7.97 .109 NS
U1a T1 56.53 4.94 55.12 5.48 .232 NS
T2 58.74 5.36 56.72 6.64 .138 NS
L6 T1 75.03 5.97 73.93 6.55 .434 NS
T2 77.27 6.46 76.53 7.60 .637 NS
L1 T1 75.81 6.77 75.93 6.81 .937 NS
T2 81.24 7.42 81.53 7.38 .858 NS
L1a T1 97.96 7.93 96.29 7.67 .342 NS
T2 100.61 8.25 100.81 8.79 .919 NS
Pg T1 113.38 10.06 112.36 9.36 .640 NS
T2 116.93 11.15 115.99 10.03 .695 NS
T1: Pretreatment
* P .05; **P .001
37
The differences within each group between T2-T1 resulted in most angular, linear
horizontal and vertical measurements having significant changes. The results of T2-T1
can be found in Tables 3.7-3.12. The results of T3-T1 and T2-T3 can be found in the
appendix under A.4-A.15. The skeletal differences observed in the Forsus group were a
restriction in maxillary growth, forward advancement of the mandible, and a forward and
downward advancement of the chin. Dentoalveolar effects of the Forsus came from
forward advancement of the mandibular molars, mandibular incisors, mandibular incisor
apex and proclination of the mandibular incisors. Extrusion of the maxillary dentition
and intrusion of the mandibular dentition were measured in all variables. The skeletal
differences in the AdvanSync group were a restriction in maxillary growth and downward
advancement of the chin. Dentoalveolar effects came from distalization of the maxillary
molars, incisors, and incisor apex. The maxillary incisors were also retroclined. The
mandibular molar moved forward, as it was intruded. The mandibular incisors were
proclined and intruded, while the incisor apex was distalized and intruded.
38
Table 3.7: T2-T1 angular cephalometric measurements of Forsus
Forsus
T2-T1 Mean SD Significance
SNA° -0.71 1.47 .004 *
SNB° 0.87 1.31 .001 **
ANB° -1.60 1.45 .001 **
U1-SN° 2.51 12.49 .211 NS
IMPA° 7.51 6.15 .001 **
T1: Pretreatment, T2: Post-functional appliance removal
* P .05; **P .001
Table 3.8: T2-T1 linear horizontal cephalometric measurements of Forsus
Forsus
U6 0.35 2.31 .337 NS
U1 -0.58 4.84 .455 NS
U1a -1.74 2.56 .001 **
L6 3.72 3.17 .001 **
L1 3.01 3.13 .001 **
L1a 1.08 2.97 .027 *
Pg 1.56 2.97 .002 *
* P .05; **P .001
Table 3.9: T2-T1 linear vertical cephalometric measurements of Forsus
Forsus
U6 1.75 2.18 .001 **
U1 1.67 1.88 .001 **
U1a 2.21 2.38 .001 **
L6 2.25 1.98 .001 **
L1 5.43 2.71 .001 **
L1a 2.65 2.95 .001 **
Pg 3.54 2.98 .001 **
* P .05; **P .001
(-) sign indicates intrusion for maxilla, extrusion for mandible
39
Table 3.10: T2-T1 angular cephalometric measurements of AdvanSync
AdvanSync
SNA° -1.75 2.54 .001 **
SNB° -0.04 2.59 .932 NS
ANB° -1.69 1.56 .001 **
U1-SN° -4.81 10.37 .006 *
IMPA° 7.01 7.71 .001 **
* P .05; **P .001
Table 3.11: T2-T1 linear horizontal cephalometric measurements of AdvanSync
AdvanSync
U6 -2.77 4.23 .001 **
U1 -4.40 5.68 .001 **
U1a -1.92 3.07 .001 **
L6 2.45 4.76 .002 *
L1 1.26 4.22 .067 NS
L1a -2.30 5.68 .014 *
Pg -0.75 5.38 .381 NS
* P .05; **P .001
Table 3.12: T2-T1 linear vertical cephalometric measurements of AdvanSync
AdvanSync
U6 -0.55 4.08 .398 NS
U1 1.51 5.60 .096 NS
U1a 1.60 5.24 .061 NS
L6 2.60 3.78 .001 **
L1 5.60 5.21 .001 **
L1a 4.51 5.41 .001 **
Pg 3.63 5.27 .001 **
* P .05; **P .001
40
Discussion
There have been several prior studies that evaluated the Forsus appliance in
correcting Class II malocclusions amongst adolescents. Results by Jones, Franchi, and
Aras, were all similar to this study, and are shown in Table 3.13-3.15. 9-11 There has only
been one published study on the effects of the AdvanSync on Class II malocclusion.12
Results by Al-Jewair were also similar to this study, and are shown in Table 3.16-3.18.
In this retrospective study, longitudinal cephalometric data was used to analyze
and compare the skeletal and dentoalveolar treatment effects of the Forsus and the
AdvanSync in treatment of adolescent Class II malocclusion patients. The results
showed that at the end of the functional appliance period, few differences between the
two appliances were found, all of which were dentoalveolar. This study adds to the
literature on the AdvanSync and provides a comparison of the Forsus to it. Comparisons
of the effects found from the Forsus and the AdvanSync in this study to those found in
existing literature can be seen in Table 3.13-3.18. The discussion hereafter will be
divided into four sections: skeletal effects, maxillary dentoalveolar effects, mandibular
dentoalveolar effects, and overall effects.
In comparing Forsus to AdvanSync, the standard deviation of AdvanSync was
much greater in most variables, while Forsus had smaller standard deviation values. This
in turn makes it more difficult to come up with significant differences between the two,
and may account for only finding a few differences between the two groups. In the
Forsus group, after T1 records were taken, almost one year of leveling and aligning
occurred before the appliance was inserted. It is important to note this may have affected
some of the values measured as one year of growth and fixed orthodontic treatment
41
occurred in addition to the duration of the Forsus from T1 to T2. Since a control group
was not used, growth was not accounted for and therefore some of the significant changes
observed may not be truly significant once growth is adjusted for.
42
Table 3.13: Comparison of the angular effects of the Forsus reported in the literature
from T2-T1
Author(s) SNA SNB ANB U1 L1

(°) (°) (°) (°) (°)
9
Jones et al. N/A N/A N/A 3.7* 6.3**
Franchi et al.10 -1.6** 0.3 -1.9** -1.2 6.1**
11
Aras et al. -0.68 0.50* -1.18* -3.81* 5.45*
Present study -0.71* 0.87** -1.60** 2.51 7.51**
* P .05; **P .001
(-) sign indicates decrease or retroinclination
Table 3.14: Comparison of the linear horizontal effects of the Forsus reported in the
literature from T2-T1
Author(s) U6 U1 L6 L1 Pg
(mm) (mm) (mm) (mm) (mm)
Jones et al.9 1.2** 0.7 1.8** 1.2** N/A
10
Franchi et al. 1.0 -1.1** 2.4** 2.3** 2.2
Aras et al.11 -1.68* -1.81* 3.09* 3.22* 1.31*
Present study 0.35 -0.58 3.72** 3.01** 1.56*
* P .05; **P .001
(-) sign indicates distalization
Table 3.15: Comparison of the linear vertical effects of the Forsus reported in the
Jones et al.9 1.5** 0.5 -3.3** 5.9** N/A
Franchi et al.10 1.6 1.6* -3.6** 0.5** N/A
11
Aras et al. -0.59 1.45* -1.32* 1.43* N/A
Present study 1.75** 1.67** 2.25** 5.43** 3.54**
* P .05; **P .001
43
Table 3.16: Comparison of the angular effects of the AdvanSync reported in the
Author(s) SNA SNB ANB U1 L1

(°) (°) (°) (°) (°)
Al-Jewair et al.12 -1.6** 0.3 -1.9** -8.4* 5.3**
Present study -1.75** -0.04 -1.69** -4.81* 7.01**
* P .05; **P .001
(-) sign indicates decrease or retroinclination
Table 3.17: Comparison of the linear horizontal effects of the AdvanSync reported in the
Al-Jewair et al.12 -0.5 -1.8 2.8** 1.1 -0.3
Present study -2.77** -4.40** 2.45* 1.26 -0.75
* P .05; **P .001
(-) sign indicates distalization
Table 3.18: Comparison of the linear vertical effects of the AdvanSync reported in the
Al-Jewair et al.12 0.1 0.3 2.4 0.2 N/A
Present study -0.55 1.51 2.60** 5.60** 3.63**
* P .05; **P .001
44
Skeletal Effects
All skeletal effects between the two groups were found to be not significant, but
there were significant findings within the groups. In both the Forsus and the AdvanSync
the maxilla was significantly restricted, which was also found in prior studies.10-12 Both
pogonion and the SNB significantly advanced forward in the Forsus group which was
found in prior.9-11 The ANB significantly decreased in both groups, which was in
agreement with prior studies as well.
Maxillary Dentoalveolar Effects
There were several significant maxillary dentoalveolar differences between the
Forsus and the AdvanSync groups. Compared to the Forsus group, the AdvanSync group
had significant retroinclination and distalization of the maxillary incisors, and the molars
were significantly distalized compared to the Forsus group. In the Forsus group the
molars were significantly extruded compared to the AdvanSync group. Within the
groups, the Forsus group had significant maxillary incisor extrusion which agrees with
prior studies.9-12 The AdvanSync group had significant retroinclination and distalization
of the maxillary incisors which agrees with the prior study.12 The AdvanSync group also
had significant distalization of the maxillary molars, which while non-significant in the
other study, it was found to move distally as well.12 The Forsus group had significant
maxillary molar extrusion which agrees with two prior studies9, 10 but not one.11
45
Mandibular Dentoalveolar Effects
There was only one significant difference between the Forsus and the AdvanSync
group at T2 in the mandibular dentoalveolar. The significant difference was the
horizontal movement of the mandibular incisor root. The Forsus group significantly
moved forward where the AdvanSync group significantly moved distally. This
measurement cannot be found in prior studies. It is important to note that the only
significant difference between the Forsus and the AdvanSync group to start treatment was
the IMPA value. The Forsus group started out on average more upright than the
AdvanSync group. Within the two groups, both significantly proclined the mandibular
incisors, which was also found in prior studies as a side effect for both.9-12 The Forsus
significantly moved the mandibular incisors forward, which agree with prior studies. 9-11
Both groups significantly intruded the mandibular incisor, which agrees with prior
studies.9-12 It is important to note that some of the intrusion observed for the mandibular
incisors is relative intrusion due to significant proclination. Both groups significantly
moved forward the mandibular molars, which was also found in prior studies. 9-12 The
AdvanSync group in agreement with the other study12 found significant intrusion. This
study found the mandibular molars to significantly intrude in the Forsus group, where the
others9-11 found extrusion. This may be explained in how the molars were measured at
the posterior contact point against an x-axis, whereas other studies measured the molar
cusp tip against the mandibular plane. 9-11
46
Overall Effects
The overall skeletal effect of the Forsus appliance was a significant restraint of
the maxilla with a significant mandibular advancement. The Forsus group experienced
significant proclination and extrusion of the maxillary incisors along with significant
maxillary molar extrusion. In the mandible, the Forsus group displayed significant
proclination of incisors as well as intrusion and movement forward. The mandibular
molars were significantly moved forward and also intruded. While skeletal effects were
small, Class II correction came mainly from mandibular dentoalveolar correction.
The overall skeletal effect of the AdvanSync appliance was a significant restraint
of the maxilla. The AdvanSync group experienced significant retroinclination and
distalization of the maxillary incisors along with significant distalization of the maxillary
molars. In the mandible, the AdvanSync group displayed significant proclination of the
incisors as well as intrusion. The mandibular molars were significantly moved forward
and intruded. While skeletal effects were minimal, Class II correction came from both
maxillary and mandibular dentoalveolar correction.
47
Conclusions
1) The Forsus and the AdvanSync are both efficient compliance-free appliances for
Class II correction.
2) Skeletal effects were minimal, with both the Forsus and the AdvanSync having
significant but small maxillary restraint (SNA -0.71°, -1.75° respectively).
3) The Forsus demonstrated mostly mandibular dentoalveolar Class II correction,
while the AdvanSync showed mostly a combination of maxillary and mandibular
dentoalveolar Class II correction.
4) The Forsus significantly extruded maxillary molars (1.75 mm).
5) The AdvanSync significantly distalized the maxillary molars (-2.77 mm).
6) The AdvanSync significantly retroclined the maxillary incisors (-4.81°).
7) The AdvanSync significantly distalized the maxillary incisors (-4.40 mm).
8) Both the Forsus and the AdvanSync significantly moved forward and intruded the
mandibular molars and incisors.
9) Both the Forsus and the AdvanSync significantly proclined mandibular incisors
(7.51°, 7.01° respectively).
48
Literature Cited
1. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St. Louis:
Mosby; 2007.
2. Kelly JE, Harvey CR. An assessment of the occlusion of the teeth of youths 12-17
years. Vital Health Stat 11. 1977;1-65.
3. Proffit WR, Fields HW, Jr., Moray LJ. Prevalence of malocclusion and orthodontic
treatment need in the United States: estimates from the NHANES III survey. Int J
Adult Orthodon Orthognath Surg. 1998;13:97-106.
4. McNamara JA, Jr. Components of Class II malocclusion in children 8-10 years of age.
Angle Orthod. 1981;51:177-202.
5. Buschang PH, Martins J. Childhood and adolescent changes of skeletal relationships.

Angle Orthod. 1998;68:199-206; discussion 7-8.
6. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in dentofacial structures in

untreated Class II division 1 and normal subjects: a longitudinal study. Angle
Orthod. 1997;67:55-66.
7. Sahm G, Bartsch A, Witt E. Micro-electronic monitoring of functional appliance wear.

Eur J Orthod. 1990;12:297-301.
8. Brandao M, Pinho HS, Urias D. Clinical and quantitative assessment of headgear

compliance: a pilot study. Am J Orthod Dentofacial Orthop. 2006;129:239-44.
9. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction patients treated
with the Forsus Fatigue Resistant Device versus intermaxillary elastics. Angle
Orthod. 2008;78:332-8.
10. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T. Effectiveness of

comprehensive fixed appliance treatment used with the Forsus Fatigue Resistant
Device in Class II patients. Angle Orthod. 2011;81:678-83.
11. Aras A, Ada E, Saracoglu H, Gezer NS, Aras I. Comparison of treatments with the
Forsus Fatigue Resistant Device in relation to skeletal maturity: a cephalometric
and magnetic resonance imaging study. Am J Orthod Dentofacial Orthop.
2011;140:616-25.
12. Al-Jewair TS, Preston CB, Moll EM, Dischinger T. A comparison of the MARA and
the AdvanSync functional appliances in the treatment of Class II malocclusion.
Angle Orthod. 2012;82:907-14.
49
APPENDIX
Table A.1: T1, T2, T3 angular cephalometric comparison of Forsus and AdvanSync
Forsus AdvanSync
SNA° T1 80.50 2.91 80.80 4.01 .703 NS
T2 79.79 3.01 79.05 3.97 .355 NS
T3 79.68 3.28 77.28 3.79 .003 *
SNB° T1 75.21 2.58 75.39 4.02 .805 NS
T2 76.08 3.00 75.36 3.64 .337 NS
T3 76.52 2.74 74.70 3.39 .010 *
ANB° T1 5.31 1.81 5.39 2.19 .864 NS
T2 3.71 1.83 3.69 2.53 .972 NS
T3 3.17 2.08 2.58 2.80 .286 NS
U1-SN° T1 101.73 10.49 101.28 10.78 .850 NS
T2 104.24 7.67 96.47 7.74 .001 **
T3 105.70 7.40 104.41 8.14 .462 NS
IMPA° T1 99.66 7.52 103.18 6.68 .030 *
T2 107.17 7.94 110.19 8.18 .098 NS
T3 107.94 8.50 109.31 8.32 .468 NS
T1: Pretreatment
T3: Fixed orthodontic treatment completion
* P .05; **P .001
50
Table A.2: T1, T2, T3 linear horizontal cephalometric comparison of Forsus and
AdvanSync
Forsus AdvanSync
U6 T1 33.96 5.04 34.26 6.31 .810 NS
T2 34.31 5.27 31.49 5.91 .027 *
T3 35.52 5.15 32.96 6.68 .059 NS
U1 T1 81.22 6.49 81.16 9.31 .972 NS
T2 80.65 7.85 76.76 7.50 .026 *
T3 81.47 7.15 77.86 9.15 .053 NS
U1a T1 72.20 6.79 72.58 6.65 .800 NS
T2 70.46 6.10 70.66 6.84 .888 NS
T3 70.45 6.67 68.32 7.44 .180 NS
L6 T1 30.93 4.86 31.38 6.40 .723 NS
T2 34.64 5.70 33.83 6.08 .539 NS
T3 35.92 5.58 33.41 7.27 .087 NS
L1 T1 74.39 6.91 75.06 8.01 .690 NS
T2 77.40 7.46 76.32 7.31 .513 NS
T3 78.34 6.90 74.51 9.11 .037 *
L1a T1 61.08 6.99 60.75 8.34 .850 NS
T2 62.16 7.65 58.45 7.90 .036 *
T3 62.85 6.89 58.12 8.85 .009 *
Pg T1 67.64 7.64 67.73 9.62 .961 NS
T2 69.20 8.36 66.98 9.10 .259 NS
T3 70.21 7.97 66.37 10.20 .065 NS
T1: Pretreatment
* P .05; **P .001
51
Table A.3: T1, T2, T3 linear vertical cephalometric comparison of Forsus and
AdvanSync
Forsus AdvanSync
U6 T1 67.74 5.82 66.45 6.52 .353 NS
T2 69.49 5.92 65.9 7.44 .019 *
T3 70.31 5.79 69.32 7.52 .514 NS
U1 T1 83.22 7.58 80.61 6.67 .106 NS
T2 84.88 7.29 82.11 7.97 .109 NS
T3 84.67 7.44 82.44 7.96 .199 NS
U1a T1 56.53 4.94 55.12 5.48 .232 NS
T2 58.74 5.36 56.72 6.64 .138 NS
T3 58.50 5.60 58.03 6.43 .726 NS
L6 T1 75.03 5.97 73.93 6.55 .434 NS
T2 77.27 6.46 76.53 7.60 .637 NS
T3 78.17 6.12 76.80 7.76 .385 NS
L1 T1 75.81 6.77 75.93 6.81 .937 NS
T2 81.24 7.42 81.53 7.38 .858 NS
T3 81.51 7.47 80.43 7.61 .522 NS
L1a T1 97.96 7.93 96.29 7.67 .342 NS
T2 100.61 8.25 100.81 8.79 .919 NS
T3 100.92 8.35 99.39 9.07 .434 NS
Pg T1 113.38 10.06 112.36 9.36 .640 NS
T2 116.93 11.15 115.99 10.03 .695 NS
T3 117.59 11.11 115.47 11.04 .393 NS
T1: Pretreatment
* P .05; **P .001
52
Table A.4: T3-T2 angular cephalometric measurements of Forsus
Forsus
SNA° -0.11 1.86 .722 NS
SNB° 0.44 1.11 .016 *
ANB° -0.54 1.62 .042 *
U1-SN° 1.46 5.60 .108 NS
IMPA° 0.77 4.02 .232 NS
* P .05; **P .001
Table A.5: T3-T2 linear horizontal cephalometric measurements of Forsus
Forsus
U6 1.21 1.99 .001 **
U1 0.82 1.98 .013 *
U1a 0.00 2.57 .994 NS
L6 1.27 2.27 .001 **
L1 0.93 2.01 .006 *
L1a 0.69 2.39 .077 NS
Pg 1.01 2.47 .013 *
* P .05; **P .001
Table A.6: T3-T2 linear vertical cephalometric measurements of Forsus
Forsus
U6 0.82 1.80 .007 *
U1 -0.21 1.55 .393 NS
U1a -0.24 2.22 .505 NS
L6 0.90 1.54 .001 **
L1 0.28 1.89 .361 NS
L1a 0.31 1.98 .323 NS
Pg 0.66 2.10 .052 NS
NS: Not Significant, SD: Standard Deviation, * P .05; **P .001
53
Table A.7: T3-T2 angular cephalometric measurements of AdvanSync
AdvanSync
SNA° -1.77 3.26 .001 **
SNB° -0.66 2.73 .135 NS
ANB° -1.11 1.79 .001 **
U1-SN° 7.94 7.00 .001 **
IMPA° -0.88 7.23 .448 NS
* P .05; **P .001
Table A.8: T3-T2 linear horizontal cephalometric measurements of AdvanSync
AdvanSync
U6 1.47 4.50 .046 *
U1 1.10 4.97 .171 NS
U1a -2.34 4.05 .001 **
L6 -0.42 4.26 .534 NS
L1 -1.81 4.98 .027 *
L1a -0.32 5.15 .692 NS
Pg -0.60 5.96 .525 NS
* P .05; **P .001
Table A.9: T3-T2 linear vertical cephalometric measurements of AdvanSync
AdvanSync
U6 3.42 4.00 .001 **
U1 0.32 4.30 .635 NS
U1a 1.31 4.23 .057 NS
L6 0.28 3.73 .643 NS
L1 -1.11 4.17 .102 NS
L1a -1.41 4.97 .080 NS
Pg -0.53 6.36 .602 NS
54
Table A.10: T3-T1 angular cephalometric measurements of Forsus
Forsus
SNA° -0.82 2.13 .020 *
SNB° 1.31 1.06 .001 **
ANB° -2.14 2.08 .001 **
U1-SN° 3.97 13.13 .063 NS
IMPA° 8.28 6.95 .001 **
T1: Pretreatment
* P .05; **P .001
Table A.11: T3-T1 linear horizontal cephalometric measurements of Forsus
Forsus
U6 1.56 2.20 .001 **
U1 0.24 4.30 .726 NS
U1a -1.74 3.22 .001 **
L6 4.99 2.60 .001 **
L1 3.95 2.48 .001 **
L1a 1.77 2.90 .001 **
Pg 2.57 2.54 .001 **
T1: Pretreatment
* P .05; **P .001
Table A.12: T3-T1 linear vertical cephalometric measurements of Forsus
Forus
U6 2.57 2.12 .001 **
U1 1.46 2.27 .001 **
U1a 1.98 2.51 .001 **
L6 3.14 2.18 .001 **
L1 5.70 3.14 .001 **
L1a 2.96 3.36 .001 **
Pg 4.21 3.23 .001 **
T1: Pretreatment
55
Table A.13: T3-T1 angular cephalometric measurements of AdvanSync
AdvanSync
SNA° -3.52 3.42 .001 **
SNB° -0.70 2.94 .143 NS
ANB° -2.81 2.01 .001 **
U1-SN° 3.13 8.61 .027 *
IMPA° 6.13 6.39 .001 **
T1: Pretreatment
* P .05; **P .001
Table A.14: T3-T1 linear horizontal cephalometric measurements of AdvanSync
AdvanSync
U6 -1.30 4.52 .077 NS
U1 -3.30 5.58 .001 **
U1a -4.26 4.20 .001 **
L6 2.03 5.31 .020 *
L1 -0.55 4.94 .482 NS
L1a -2.63 6.24 .011 *
Pg -1.36 6.34 .184 NS
T1: Pretreatment
* P .05; **P .001
Table A.15: T3-T1 linear vertical cephalometric measurements of AdvanSync
AdvanSync
U6 2.87 4.83 .001 **
U1 1.83 5.80 .052 NS
U1a 2.91 5.26 .001 **
L6 2.88 4.78 .001 **
L1 4.50 6.14 .001 **
L1a 3.10 6.40 .004 *
Pg 3.10 6.88 .602 NS
T1: Pretreatment
56
VITA AUCTORIS
Bryce Gabler was born on April 14, 1985 in Pennsylvania. He attended Lebanon
Valley College where he received his Bachelor of Science degree in Biology in 2007.
Bryce attended Temple Dental School where he received his DMD in 2011. He began
his orthodontic training at Saint Louis University in 2011. He plans to complete his
Masters of Science in Dentistry degree in December 2013. Upon graduation, he plans to
move to Pennsylvania to begin his orthodontic career.
57

Comparison of Skeletal and Dentoalveolar Effects of The Forsus and Advansync in Treatment of Class II Malocclusions

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Comparison of Skeletal and Dentoalveolar Effects of The Forsus and Advansync in Treatment of Class II Malocclusions

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COMPARISON OF SKELETAL AND DENTOALVEOLAR EFFECTS OF THE

FORSUS AND ADVANSYNC IN TREATMENT

Bryce E. Gabler, D.M.D.

An Abstract Presented to the Graduate Faculty of

malocclusion. Materials and Methods: A retrospective study that included 40 Forsus

dentoalveolar differences between groups found at T2 in the U1-SN, the maxillary

AdvanSync significantly distalized maxillary molars, and significantly distalized and

Class II malocclusions, inducing some skeletal but mostly dentoalveolar changes.

FORSUS AND ADVANSYNC IN TREATMENT

Bryce E. Gabler, D.M.D.

A Thesis Presented to the Graduate Faculty of

Professor Eustaquio A. Araujo,

Chairperson and Advisor

Professor Rolf G. Behrents

Associate Clinical Professor Donald R. Oliver

I dedicate this project to my loving and supportive family.

I would like to thank the following individuals for their contributions to my

education at Saint Louis University.

preparation and revisions. Your impeccable attention to detail is something to truly be

and quick responses to my emails.

and taking care of me while I collected data at your office.

List of Tables .......................................................................................................................v

List of Figures ................................................................................................................... vii

CHAPTER 1: INTRODUCTION ........................................................................................1

CHAPTER 2: REVIEW OF THE LITERATURE

CHAPTER 3: JOURNAL ARTICLE

Table 3.1: Age and gender distribution of study sample ............................................28

Table 3.2: Median duration of treatment periods........................................................29

Table 3.3: Landmarks and definitions ........................................................................31

Table 3.4: T1 and T2 angular cephalometric comparison

Table 3.5: T1 and T2 linear horizontal cephalometric comparison

Table 3.6: T1 and T2 linear vertical cephalometric comparison

Table 3.7: T2-T1 angular cephalometric measurements of Forsus.............................39

Table 3.8: T2-T1 linear horizontal cephalometric measurements of Forsus ..............39

Table 3.9: T2-T1 linear vertical cephalometric measurements of Forsus ..................39

Table 3.10: T2-T1 angular cephalometric measurements of AdvanSync.....................40

Table 3.11: T2-T1 linear horizontal cephalometric measurements of AdvanSync ......40

Table 3.12: T2-T1 linear vertical cephalometric measurements of AdvanSync ..........40

Table 3.13: Comparison of the angular effects of the Forsus

Table 3.14: Comparison of the linear horizontal effects of the Forsus

Table 3.15: Comparison of the linear vertical effects of the Forsus

Table 3.16: Comparison of the angular effects of the AdvanSync

Table 3.17: Comparison of the linear horizontal effects of the AdvanSync

Table 3.18: Comparison of the linear vertical effects of the AdvanSync

Table A.2: T1, T2, T3 linear horizontal cephalometric comparison

Table A.3: T1, T2, T3 linear vertical cephalometric comparison

Table A.4: T3-T2 angular cephalometric measurements of Forsus .............................53

Table A.5: T3-T2 linear horizontal cephalometric measurements of Forsus ..............53

Table A.6: T3-T2 linear vertical cephalometric measurements of Forsus...................53

Table A.7: T3-T2 angular cephalometric measurements of AdvanSync .....................54

Table A.8: T3-T2 linear horizontal cephalometric measurements of AdvanSync ......54

Table A.9: T3-T2 linear vertical cephalometric measurements of AdvanSync...........54

Table A.10: T3-T1 angular cephalometric measurements of Forsus .............................55

Table A.11: T3-T1 linear horizontal cephalometric measurements of Forsus ..............55

Table A.12: T3-T1 linear vertical cephalometric measurements of Forsus...................55

Table A.13: T3-T1 angular cephalometric measurements of AdvanSync .....................56

Table A.14: T3-T1 linear horizontal cephalometric measurements of AdvanSync ......56

Table A.15: T3-T1 linear vertical cephalometric measurements of AdvanSync...........56

Figure 3.1: Reference plane ..........................................................................................32

Figure 3.2: Landmarks on reference plane ...................................................................32

Figure 3.3: Angular measurements on reference plane ................................................33

Figure 3.4: Linear horizontal measurements on reference plane ..................................33

Figure 3.5: Linear vertical measurements on reference plane ......................................34