Pacific Coast Society of Orthodontists Bulletin Summer 2020 - 41

Let's Talk About That

time. This patient should be ready for treatment
now.
2. Would you use a one-phase or two-phase
treatment? Generally, my Class II treatment
plans are a single phase of treatment, assuming
there are no other issues when screened at an
earlier age. For instance, I would take care of
transverse issues earlier in Phase I if there is any
functional shift present. However, absent any
functional shift, if the maxilla is narrow relative
to the mandible when the mandible is postured
forward, I would expand the maxilla just prior
to placing the MARA as part of a single phase of
comprehensive treatment rather than a separate
first phase. If the Class II presents at an early age
with a large component of maxillary dental or
skeletal protrusion, I use headgear in Phase I, with
tentative plans for a MARA in Phase II, depending
on growth.
3. Which appliance would you use? I use a MARA
appliance for most Class II cases in my practice
(Figure 1). Understanding that most Class II
patients present with a retrognathic mandibular
profile, I like to use functional appliances in an effort to posture the mandible forward to meet the
maxilla. Most patients, of course, have a mixture
of mandibular retrognathia and maxillary dental
and/or skeletal protrusion, so I like to use the
MARA for its headgear effect as well. It creates a
distal and intrusive force on the maxillary posterior dentition that offers a 24-hour/day high-pull

Figure 1. MARA appliance used by Dr. Jason Pair

Summer 2020    PCSO Bulletin	

headgear effect, and if the case has severe maxillary spacing, it offers wonderful anchorage from
which to retract incisors. Generally, when I place
the MARA, I will either not place brackets the
first day or bracket only the upper 4-4. Once the
patient is used to wearing the MARA and comfortable with the new functioning jaw position,
I will place the lower brackets. This, of course,
is different in a Class II, division 2 pattern, or in
a case with significantly misaligned maxillary
incisors, in which case I will bracket the maxillary
arch first to create overjet before delivering the
MARA appliance.
4. What are the benefits or advantages of using
your appliance over other approaches to Class
II treatment? When discussing the advantages
of MARA relative to other Class II approaches,
I can only speak to advantages over headgear
and Herbst, because they are appliances I have
used. Full disclosure: I do still use headgear in
the context of backing up anchorage for space
closure or in the rare case where I feel the Class
II is due primarily to maxillary protrusion or
dental protrusion. That being said, if I need some
headgear effect to hold the maxilla while also
posturing the mandible forward, MARA is the
ideal tool. The headgear effect is 24/7, rather
than intermittent as with normal headgear wear.
I had the experience of working with Herbst for
3+ years early in my career. Despite correcting
many full-cusp Class II cases, I always struggled
with controlling the lower incisor angulation. In
my experience, I have had much better control of
the mandibular incisor angulation during Class II
correction with MARA, but as with all modalities,
MARA is not always the answer, whether it be
with unfavorable growers due to genetics that
we just cannot manipulate or the outlier kid who
just can't wear the appliance without breaking
it and never progresses. Having said that, in my
humble opinion, the advantages far outweigh
the disadvantages.
5. How long does active treatment typically take?
I leave the MARA appliance in place for approxi-

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Pacific Coast Society of Orthodontists Bulletin Summer 2020

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