ORIGINAL ARTICLE

Comparative evaluation of maxillary protraction

with or without skeletal anchorage
rpc,b Sina Uckan,c and A. Canan Yazcd

la Sar,a Ayca Arman-Ozc
C
ag
Ankara, Turkey

Introduction: The aim of this prospective clinical study was to evaluate the skeletal, dentoalveolar, and softtissue effects of maxillary protraction with miniplates compared with conventional facemask therapy and an
untreated Class III control group. Methods: Forty-ve subjects who were in prepubertal or pubertal skeletal
growth periods were included in the study and divided into 3 groups of 15 patients each. All subjects had skeletal
and dental Class III malocclusions with maxillary deciency, vertically normal growth pattern, anterior crossbite,
Angle Class III molar relationship, normal or increased overbite, and retrusive nasomaxillary complex. Before
maxillary protraction, rapid maxillary expansion with a bonded appliance was performed in both treatment
groups. In the rst group (MP1FM), consisting of 5 girls ande 10 boys (mean age, 10.91 years), facemasks
were applied from 2 titanium miniplates surgically placed laterally to the apertura piriformis regions of the maxilla.
The second group (FM) of 7 girls and 8 boys (mean age, 10.31 years) received maxillary protraction therapy with
conventional facemasks applied from hooks of the rapid maxillary expansion appliance. The third group of 8 girls
and 7 boys (mean age, 10.05 years) was the untreated control group. Lateral cephalometric lms were obtained
at the beginning and end of treatment or observation in all groups and analyzed according to a structural superimposition method. Measurements were evaulated statistically with Wilcoxon and Kruskal-Wallis tests. Results:
Treatment periods were 6.78 and 9.45 months in the MP1FM and FM groups, respectively, and the observation
period in the control group was 7.59 months. The differences were signicant between the 3 groups (P \0.05)
and the MP1FM and FM groups (P \0.001). The maxilla moved forward for 2.3 mm in the MP1FM group and
1.83 mm in the FM group with maxillary protraction. The difference was signicant between 2 groups (P\0.001).
The protraction rates were 0.45 mm per month in the MP1FM group and 0.24 mm per month in the FM group
(P \0.001). The maxilla showed anterior rotation after facemask therapy in the FM group (P \0.01); there
was no signicant rotation in the MP1FM group. Posterior rotation of the mandible and increased facial height
were more evident in the FM group compared with the MP1FM group (P \0.01). Both the maxilla and the mandible moved forward signicantly in the control group. Protrusion and mesialization of the maxillary teeth in the
FM group were eliminated in the MP1FM group. The maxillomandibular relationships and the soft-tissue prole
were improved remarkably in both treatment groups. Conclusions: The undesired effects of conventional
facemask therapy were reduced or eliminated with miniplate anchorage, and efcient maxillary protraction
was achieved in a shorter treatment period. (Am J Orthod Dentofacial Orthop 2011;139:636-49)

lass III malocclusions are considered to be among

the most challenging orthodontic problems to treat.
The prevalence of Class III malocclusions is approximately 1% to 5% in white populations.1,2 However, in

From the University of Baskent, Ankara, Turkey.

a
Postgraduate resident, Department of Orthodontics, Faculty of Dentistry.
b
Associate professor, Department of Orthodontics, Faculty of Dentistry.
c
Professor, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry.
d
Assistant professor, Department of Biostatistics, Faculty of Medicine.
The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article.
rpc, Baskent Universitesi,

Reprint requests to: Ayca Arman-Ozc

Dis Hekimli
gi
Fak
ultesi, Ortodonti Anabilim Dal, 06490 Bahcelievler-Ankara, T
urkiye;
e-mail, ayca@baskent.edu.tr.
Submitted, April 2009; revised, May 2009; accepted, June 2009.
0889-5406/$36.00
Copyright 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.06.039

636

Asian populations, the incidence of this malocclusion is

as high as 14%.3-5 A Class III malocclusion might be due
to mandibular prognathism, maxillary retrognathism,
protrusive mandibular dentition, retrusive maxillary
dentition, and a combination of these components.6-10 It
has been reported that two thirds of skeletal Class III
malocclusions are due to either maxillary retrognathism
or a combination of maxillary retrognathism and
mandibular prognathism.6-10
Early treatment is commonly indicated to obtain
a more normal jaw relationship. A facemask is thought
to be an effective treatment approach for skeletal Class
III patients with maxillary deciency.The results of previous clinical studies have indicated that the application
of an orthopedic force with a protraction facemask to
the craniofacial complex during the early phase of

Sar et al

growth can contribute to the treatment of Class III malocclusion.11-15 The principle of maxillary protraction is
to apply an anteriorly directed force on the
circummaxillary sutures, which are still patent at an
early age and thereby stimulate bone apposition in the
suture areas.
A tooth-borne device bonded to the maxillary teeth is
the point of force application, and the forehead and the
chin are the anchorage sources for protraction in facemask theapy. The effects of maxillary protraction include
anterior movement of the maxilla and the maxillary
dentition, accompanied by counterclockwise rotation,
lingual inclination of the mandibular teeth, and clockwise rotation of the mandible, causing the chin to
move downward and backward. Lower anterior facial
height increases while overbite decreases.16-23 These
effects tend to turn a Class III malocclusion into
a Class I malocclusion and produce an orthognathic
prole in a short time. However, indirect application of
force limits the potential for orthopedic change and
inevitably causes undesirable tooth movements such as
mesial movement and extrusion of the maxillary
molars and labial tipping of the maxillary incisors.
There is a need for a stable anchorage to transfer the
force directly to the circummaxillary sutures, thus
eliminating the undesirable dental effects and obtaining
major skeletal effects. Orthopedic anchorage for maxillary
protraction is a new area of research, and investigations on
this subject are limited. Ankylosed tooth, osseointegrated
implants, titanium screws, and onplants have been used as
stable anchorage in previous case reports.24-27 Titanium
miniplates have been shown to provide absolute
anchorage when orthopedic forces were applied with
facemasks in some clinical studies.28-32
To date, however, there is a lack of knowledge on the
comparative effects of maxillary protraction with or
without skeletal anchorage. Since there is no study in
the literature, in this prospective study, we attempted
to evaluate the skeletal, dentoalveolar, and soft-tissue
effects of maxillary protraction with miniplates compared with conventional facemask therapy and an untreated Class III control group.
MATERIAL AND METHODS

Forty-ve subjects from the Department of Orthodontics, Faculty of Dentistry, University of Baskent in
Ankara, Turkey, were included in this study. All subjects
were between the PP2 5 and MP3cap developmental
stages at the beginning of the treatment or the control
period according to their hand-wrist radiographs.33
The patients were selected by the following inclusion criteria: (1) skeletal and dental Class III malocclusion with
maxillary deciency (ANB, \0
; Nperp-A, \1 mm;

637

Wits apprasial, \2 mm); (2) vertically normal growth

pattern (SNGoGn, \40
); (3) anterior crossbite and
Angle Class III molar relationship; and (4) normal or
increased overbite and retrusive nasomaxillary complex.
All subjects and parents were informed of the experimental protocols and signed an informed consent
form that was previously approved by the ethics committee of the University of Baskent. The selected patients
were divided into 3 groups of 15 patients each.
In the rst group (MP1FM) consisting of 5 girls and 10
boys (mean age, 10.91 years), facemasks were applied
from 2 titanium miniplates (OsteoMed, Addison, Tex)
surgically placed laterally to the apertura piriformis
regions of the maxilla. Subjects without anchorage teeth
for the application of facemask, depending on congenitalIy missing teeth or early removal of posterior deciduous
teeth, were given priority for inclusion in this group.
I-shaped titanium miniplates, used for xation in maxillofacial surgery, with 3 holes were placed by the same maxillofacial surgeon (S.U.) under local or general anesthesia.
A mucoperiosteal incision was made at the labial vestibule
between the maxillary lateral incisors and canines, and
a mucoperiosteal ap was elevated to expose the lateral
nasal wall of the maxilla on both sides. An appropriate cortical bone area was found to adapt the miniplates around
the apertura piriformis, and special care was taken not to
damage the erupting canines. Miniplates were then
shaped according to the anatomic structures and xed
in position with 2 monocortical miniscrews (diameter,
1.5 mm; length, 7 mm). The incisions were sutured with
3.0 polyglactin 910 exposing the third hole into the oral
cavity (Fig 1). After a 1-week period to allow soft-tissue
healing, protraction forces were applied with elastics
from the hooks of the miniplates to the facemasks (Fig 2).
The second group (FM) of 7 girls and 8 boys (mean
age, 10.31 years) received maxillary protraction therapy
with conventional facemasks applied from the hooks of
the rapid maxillary expansion (RME) appliance.
To distinguish the treatment changes from normal
growth changes, the third group of 8 girls and 7 boys
(mean age, 10.05 years) was the untreated Class III control group. The subjects of the control group matched
those in the treatment groups with regard to chronologic
age, skeletal development, and craniofacial morphology.
Before maxillary protraction, a bonded RME appliance
with hooks was applied in both treatment groups. The
midline expansion screw (1114/10, Lewa, Remchingen,
Germany) of the RME appliance was activated twice per
day for 7 days until the midpalatal suture was disturbed,
and expansion was continued with a semirapid protocol
(RME of 7 days, followed by slow maxillary expansion) in
patients with continuing maxillary transverse deciency
until the desired expansion was achieved.34 Immediately

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638

Fig 1. A, Mucoperiosteal incisions made at the labial vestibule of the maxilla on both sides; B and C,
adaptation and xation of miniplates to lateral nasal walls of the maxilla; D, sutures exposing the third
hole into the oral cavity before maxillary protraction.

after the maxillary sutural system was disrupted, the

patients were given Petit-type facemasks (716-0001,
Ormco, Glendora, Calif). The facemask protocol was the
same for both treatment groups. Elastics, directed 20
to
30
downward from the occlusal plane, delivered a force
of 400 g per side, as determined by a force gauge. The
patients were instructed to wear their facemasks at least
16 hours per day, and facemask therapy was continued until at least a 4-mm overjet was achieved. Later, all patients
had retention treatment with facemasks or chincaps, and
some were treated with xed appliances subsequently.
Lateral cephalometric lms were obtained at the start
of the maxillary protraction or the observation period
(T1) and at the end of the active treatment or the observation period (T2) in all groups and were hand-traced on
orthodontic tracing paper on a conventional light box by
using a 0.3-mm lead pencil and measured by the same
investigator (C.S.) under optimal conditions. For the
evaluation of the lateral cephalometric radiographs, in
addition to the conventional reference planes, horizontal
(HR) and vertical (VR) reference planes were constructed
for some linear and angular measurements. A horizontal
line constructed by subtracting 7
from the sella-nasion
line was used as the HR plane. A vertical line passing
through sella and perpendicular to the HR plane was
the VR plane (Figs 3-5). The lateral cephalometric
radiographs taken at T2 were superimposed on those
taken at T1, on stable cranial structures, by using the

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total structural superimpositioning method.35 These

reference structures were the contours of the anterior
wall of sella turcica, the anterior contours of the median
cranial fossa, the intersection of the anterior contour of
sella and tuberculum sella, the inner surface of the frontal bone, the contours of the cribriform plate, the contours of the bilateral fronto-ethmoidal crests, and the
contour of the median border of the cerebral surfaces
of the orbital roofs. The HR and VR planes were transferred from the T1 to the T2 radiographs. The sensitivity
values of the linear and angular radiographic measurements were 0.5 mm and 0.5
, respectively.
Maxillary regional superimpositions were used to
measure the movement of the maxillary dentition relative to the maxillary basal bone.36 The maxillae were
superimposed on the best t of the lingual curvature
of the palatal plate and internal bony structures. To examine the changes in the maxillary dentoalveolar structures, a maxillary HR line (HRmx) was drawn along the
ANS-PNS line, and a vertical line passing through PNS
and perpendicular to the HRmx was the maxillary VR
plane (VRmx) (Fig 6).
Mandibular regional superimpositions were made on
mandibular stable structures, according to the method
described by Bj
ork and Skieller.35 The 2 radiographs
were superimposed on the anterior contour of the
chin, the inner contour of the cortical plate at the lower
border of the symphysis, the trabecular structures inside

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639

Fig 2. A, Intraoral view of the miniplates placed laterally to the apertura piriformis; B, extraoral frontal
view of the application of a facemask via miniplates; C, prole view of the patient with a facemask.

the symphysis, the contour of the mandibular canal, and

the lower contour of a mineralized molar germ before
root development begins. To evaluate the changes,
a line passing through gonion and gnathion was used
as the mandibular HR plane (HRmp), and a vertical line
passing through gonion, perpendicular to the HRmp
served as the mandibular VR plane (VRmp). The degree
of mandibular rotation was assessed by measuring the
angle between the sella-nasion lines of the rst and second radiographs on the superimposed tracings (Fig 7).
Cephalometric landmarks, reference planes and lines,
and measurements are shown in Figures 3 through 7.
Statistical analysis

Statistical analysis was performed by using the Statistical Package for Social Sciences (version 13.0, SPSS,
Chicago, Ill). The normality of the distribution of the variables was checked by using the Shapiro-Wilks test and
the homogeneities of the group variances by the Levene

test. Since variables were not normally distributed and

some groups variances were not homogeneous, the
Wilcoxon test was used to analyze the changes during
the treatment or control periods, and the groups in
each period were compared with the Kruskal-Wallis
1-way analysis of variance (ANOVA) by ranks test, and
then multiple comparisons between pairs of groups
were carried out according to the Dunn test. The results
were expressed as means and standard deviations, medians, and minimum and maximum values. P \0.05
was considered to be statistically signicant.
Three weeks after the rst measurements, the
tracings and the measurements were repeated by the
same author on 30 lateral cephalograms of 15 randomly
selected patients. To assess the reliability of the measurements, the intraclass correlation coefcients (r)
were calculated for each variable in the T1 and T2 cephalograms. The intraclass correlation coefcients ranged
from 0.989 to 1.000. No signicant differences were

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640

Fig 3. Maxillary and maxillomandibular skeletal measurements used in the study: 1, SNA (
); 2, HR-ANS
(mm); 3, HR-PNS (mm); 4, HR.PP (
); 5, Cd-A (mm);
6, A-VR (mm); 7, Nperp-A (mm); 8, ANB (
); 9, (A-VR)(B-VR) (mm); 10, Wits (mm).

found between the rst and second measurements of

those randomly selected cephalograms.
RESULTS

Mobility was noted in 8 of the 30 miniplates at T2;

however, only 2 were replaced with additional surgeries
during the protraction therapy. The other 6 miniplates
showed minimal mobility and were rigid enough to
withstand the protraction forces, so they were used until
the end of the treatment. Since 2 of the 30 miniplates
needed to be replaced, the success rate was 93%.
Table I gives initial values of the 3 groups. There were
no signicant differences between the groups at T1. The
differences between the changes through T2 to T1 in the
MP1FM, FM, and control groups are shown in Table II.
The treatment durations were 6.78 and 9.45 months
in the MP1FM and FM groups, respectively, and the observation period in the control group was 7.59 months.
The difference was signicant among the 3 groups
(P \0.05).
The maxilla moved forward 2.83 mm in the MP1FM
group and 2.16 mm in the FM group with maxillary protraction. Protraction rate was estimated by dividing the
total amount of protraction (A-VR) into the treatment
duration. The difference in protraction rates between
the MP1FM and FM groups was statistically signicant

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(P\0.001) at 0.45 and 0.24 mm per month, respectively.

The forward movement of the maxilla (A-VR) was significant in the control group (P \0.05). The changes in
SNA, A-VR, Cd-A, and Nperp-A were statistically significant between the treatment groups (P \0.001); when
compared with the FM group, the MP1FM group
demonstrated signicantly greater changes. The maxilla
showed anterior rotation (HR.PP) after facemask therapy
in the FM group, but there was no signicant rotation in
the MP1FM group (P \0.001).
Regarding the mandibular skeletal measurements,
the mandible was positioned downward and backward
signicantly in both treatment groups (SNB, B-VR,
Nperp-Pg, and Pg-VR). The changes in SNB and
Pg-VR were statistically different between the MP1FM
and FM groups (SNB, P \0.05; Pg-VR, P \0.01) and
were more evident in the FM group. There was also
a signicant increase in the Cd-Gn measurement in the
control group (P\0.01), whereas no signicant changes
were seen in the treatment groups. Posterior rotation of
the mandible (SN.GoGn, HR.GoMe) was signicantly
greater in the FM group when compared with the
MP1FM group (SN.GoGn, P \0.001; HR.GoMe,
P \0.01). True rotation of the mandible was evaluated
with structural superimposition of the mandibles in all
groups. The mandible was rotated posteriorly in both
treatment groups according to this superimposition,
but the increase in the FM group was more pronounced
than in the MP1FM group (P \0.01).
Anterior and total facial heights (ANS-Me, N-Me) increased signicantly in the treatment groups, and the
changes were more evident in the FM group compared
with the MP1FM group (P \0.001).
The skeletal changes in both the maxilla and the
mandible led to a signicant improvement in the intermaxillary sagittal relationship (Wits, ANB, [A-VR][B-VR]) in both treatment groups, whereas no signicant
difference was seen between groups.
Overjet increased signicantly in the treatment
groups. The difference was statistically signicant between the treatment groups regarding maxillary incisor
position (U1i.PP, U1.HRmx) (P \0.001). The maxillary
incisors showed signicant protrusion (U1.HRmx, U1iHRmx) in the FM group (P \0.01), whereas signicant
retrusion was seen in the MP1FM group (P \0.05).
On the other hand, the maxillary molars demonstrated
signicant mesialization in the FM group (P \0.05),
and no signicant changes were seen in the MP1FM
group. The difference between the 2 groups was significant (P \0.001). In addition, the mandibular incisors
were retracted signicantly in both treatment groups
(P \0.01). The proclination of the maxillary incisors
was statistically signicant, whereas no signicant

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Fig 4. Mandibular skeletal measurements and facial

heights used in the study: 1, SNB (
); 2, Cd-Gn (mm);
3, B-VR (mm); 4, Pg-VR (mm); 5, Nperp-Pg (mm);
6, HR.GoMe (
); 7, SN.GoGn (
); 8, BaNa.PtGn (
);
9, S-Go (mm); 10, N-ANS (mm); 11, ANS-Me (mm);
12, N-Me (mm); 13, S-Go/N-Me.

change was observed in the position of the mandibular

incisors in the control group.
The soft-tissue prole and the sagittal lip relationship
were improved remarkably in both treatment groups. The
measurements associated with the soft-tissue A-point and
the position of the upper lip (A0 -VR, UL-VR, Sn-Me0 )
showed signicant forward movements in both treatment
groups (P \0.01), whereas this movement was more evident in the MP1FM group compared with the FM group
(P \0.001). The lower lip and the chin (LL-VR, Pg0 -VR)
moved backward signicantly in both treatment groups,
and no signicant difference was seen between those
groups. The control group demonstrated signicant forward movement of the upper lip, the lower lip, and the
chin after the changes of underlying skeletal structures.
DISCUSSION

Lately, the use of skeletal anchorage has been reported

not only for dentoalveolar movements such as distalization, mesialization, intrusion, and extrusion, but also for
orthopedic effects such as maxillary protraction in skeletal
Class III patients.24-32 Since the force is transmitted to the
maxilla indirectly in conventional maxillary protraction
therapies, undesired effects such as anterior rotation
of the maxilla, proclination of the maxillary incisors,

641

Fig 5. Soft-tissue and dentoalveolar measurements

used in the study: 1, A0 -VR (mm); 2, UL-VR (mm); 3, LLVR (mm); 4, B0 -VR (mm); 5, Pg0 -VR; 6, Sn-Me0 (mm);
7, N0 -Me0 (mm); 8, U1.PP (
); 9, L1.MP (
).

excessive forward movement, and extrusion of the

maxillary molars have been reported.16-23 These effects
camouage the malocclusion and conict with the main
goals of the skeletal Class III treatment. Hence, to
transfer the force directly to the circummaxillary sutures,
and thereby to increase the skeletal effects of the
maxilla and eliminate the dental movements, skeletal
anchorage can be used. In recent years, a few
researchers have shown that the maxilla can be
effectively protracted via ankylozed deciduous teeth,
osseointegrated implants, titanium screws, onplants,
and titanium miniplates.24-32
In this prospective, controlled clinical study, we
attempted to use facemasks with titanium miniplates
that were surgically placed laterally to the apertura
piriformis regions of the maxilla, thus to maximize the
skeletal effects, decrease the anterior rotation of the
maxilla by applying the force through the center of resistance, and eliminate the undesired dental effects. Also,
the treatment effects of maxillary protraction with
miniplate anchorage were evaluated comparatively
with conventional facemask therapy and an untreated
Class III control group.
In this study, all patients were at the prepubertal or
pubertal stage of growth, and their mean chronologic
ages were 10.91, 10.31, and 10.05 years in MP1FM,
FM, and control groups, respectively, at T1. Maxillary
protraction has been recommended by many authors

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642

Fig 6. Maxillary dentoalveolar measurements with local

superimpositions: 1, U1.HRmx (
); 2, U6-HRmx (mm);
3, U6-VRmx (mm); 4, U1i-HRmx (mm); 5, U1i-VRmx.

to be started at earlier ages to achieve more skeletal effects,11,14,16,37,38 whereas studies comparing the effects
of maxillary protraction applied in different skeletal
developmental stages reported similar skeletal
responses.39,40 Since this study was prospective, all
groups were homogeneous and similar with regard to
skeletal pattern, skeletal development, and chronologic
age before treatment. Only patients having
congenitally missing teeth and early loss of deciduous
posterior teeth in the mixed dentition stage were
included in the rst group.No signicant differences
were noted for any variables at T1.
RME with a bonded appliance was performed in both
treatment groups. RME has been advocated as a routine
part of facemask therapy in the correction of Class III
malocclusions even in the absence of maxillary constriction.41,42 RME expands a narrow maxilla, corrects
a posterior crossbite, increases arch length, and splints
the maxillary dentition during protraction therapy.
Additionaly, RME can disarticulate circummaxillary
sutures to facilitate the forward movement of the
maxilla via facemask therapy and lead to downward
and forward movement of A-point by approximately
1 mm.4143
In the MP1FM group, titanium miniplates were
preferred to be placed laterally to the apertura piriformis
region on both sides of the maxilla with 2 miniscrews.
Since the miniplates were xed with monocortical miniscrews, there was no need to wait for osseointegration.
This might be the major advantage of miniplate anchorage compared with osseointegrated implants and
onplants. In addition, they can be bent easily and withstand orthopedic forces. One main reason for choosing
a placement site laterally to the apertura piriformis regions of the maxilla was to apply protraction forces as
close as possible to the center of resistance (CR) of the

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Fig 7. Mandibular dentoalveolar measurements with

local superimpositions and true mandibular rotation:
1, L1i-VRmd (mm); 2, L1i-HRmd (mm); 3, L1.HRmd (
);
4, true mandibular rotation (
).

nasomaxillary complex. Because it is anterior to the circummaxillary sutures, the apertura piriformis was also
preferred for stimulating downward and forward
growth of the maxilla, which grows parallel to the force
vector.
The major complications for the MP1FM group were
mobility and inammation during protraction. Two of
the 30 miniplates were replaced during treatment because of their instability. The placement site was near
the apical region of the lateral incisors and erupting canines; thus, the possible reason for the mobility might
have been the quantity of cortical bone area in patients
with erupting canines. To prevent this complication, applying miniplates to the zygomatic buttress could be an
alternative in patients with erupting canines. The other
possible reasons for mobility might have been the application of an opposite force vector to the direction of
placement of the screws and the patients poor oral hygiene.
It was reported in many clinical studies that applying
the force vector between the lateral incisor and the
canine with a direction of 30
to 45
might help to decrease the amount of counterclockwise rotation of the
maxilla.4447 Despite modifying the location (molars,
premolars, canines) and the direction of the force
vector, anterior rotation of the maxilla could not be
prevented in conventional facemask applications. The
protraction forces applied from the level of the

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643

Table I. Mean values of measurements at T1 and comparison of groups with the Kruskal-Wallis and Dunn tests

Parameter
Chronologic age (y)
Maxillary skeletal parameters
SNA (
)
A-VR (mm)
Cd-A (mm)
NPerp-A (mm)
HR-ANS (mm)
HR-PNS (mm)
HR.PP (
)
Mandibular skeletal parameters
SNB (
)
B-VR (mm)
Cd-Gn (mm)
NPerp-Pg (mm)
Pg-VR (mm)
SN.GoGn (
)
HR.GoMe (
)
BaNa.PtGn (
)
Facial heights
S-Go (mm)
N-Me (mm)
ANS-Me (mm)
N-ANS (mm)
S-Go/N-Me
Maxillomandibular parameters
ANB (
)
(A-VR)-(B-VR) (mm)
Wits (mm)
Dentoalveolar parameters
Overjet (mm)

MP 1 FM

FM

Control

Mean 6 SD

Mean 6 SD

Mean 6 SD

Median (range)
10.91 6 1.22
11.30 (9.00-12.30)

Median (range)
10.31 6 1.52
10.50 (8.50-13.10)

Median (range)
10.05 6 1.14
10.08 (8.50-12.08)

P
NS

77.86 6 3.14
77.50 (73.00-82.50)
60.60 6 3.19
60.50 (55.00-66.50)
80.80 6 3.86
80.50 (72.50-87.50)
4.36 6 3.44
4.50 (11-1.50)
43.13 6 3.57
42.00 (38.50-50.50)
41.90 6 3.31
41.50 (36.00-49.00)
1.53 6 4.18
2.00 (10.00-6.50)

77.86 6 2.72
79.00 (71.50-81.00)
60.40 6 3.60
59.50 (52.00-66.00)
79.50 6 3.87
80.00 (72.50-86.50)
4.53 6 2.92
5.00 (10-0.50)
41.36 6 2.53
42.00 (37.00-45.00)
40.43 6 2.28
40.00 (37.00-45.00)
1.13 6 3.55
1.00 (6.00-8.00)

78.63 6 2.43
78.50 (75.00-82.50)
60.83 6 2.49
60.50 (57.00-65.00)
78.90 6 4.12
78.00 (70.50-84.00)
3.56 6 2.27
3.50 (7.00-0)
41.80 6 2.92
42.00 (36.00-46.00)
40.90 6 2.29
40.00 (38.50-45.50)
1.03 6 2.68
2.00 (4.00-5.00)

NS

81.13 6 3.45
80.50 (75.50-87.50)
62.93 6 5.39
63.00 (52.00-72.00)
111.96 6 5.64
114.00 (100.0-120.0)
0.53 6 6.50
1.50 (17.00-11.00)
63.90 6 6.21
63.00 (53.50-74.00)
31.33 6 4.78
32.00 (22.00-38.00)
26.80 6 4.68
28.00 (18.00-34.00)
91.33 6 4.17
91.50 (84.00-99.00)

81.26 6 2.36
82.00 (75.50-85.00)
62.50 6 4.48
63.50 (49.50-67.00)
107.76 6 5.30
108.00 (101.0-116.5)
1.90 6 3.48
2.00 (7.50-3.00)
63.23 6 5.59
65.00 (48.00-69.50)
30.63 6 4.98
30.00 (23.00-38.00)
26.00 6 4.98
26.00 (18.00-33.00)
91.86 6 4.84
92.00 (83.00-101.5)

82.14 6 2.78
82.00 (78.00-87.50)
63.86 6 4.18
63.00 (57.00-71.50)
108.30 6 6.30
107.50 (99.0-118.0)
0.63 6 5.09
0.50 (12.50-8.00)
64.30 6 4.88
65.00 (56.50-72.00)
31.23 6 4.59
31.00 (24.50-38.50)
26.46 6 4.73
26.00 (19.00-34.00)
91.40 6 4.26
93.00 (81.50-96.00)

NS

71.36 6 4.84
72.00 (64.00-80.00)
111.03 6 6.64
111.00 (100.0-122.5)
59.83 6 4.55
61.00 (52.00-69.00)
51.20 6 3.64
50.00 (46.50-59.50)
0.63 6 0.03
0.63 (0.56-0.71)

69.53 6 4.03
70.00 (62.50-76.50)
108.50 6 6.10
108.00 (100.0-118.5)
58.63 6 4.20
58.00 (52.00-65.00)
49.86 6 2.91
50.50 (45.00-54.00)
0.63 6 0.04
0.63 (0.54-0.70)

68.96 6 3.35
69.00 (63.00-74.50)
108.83 6 5.96
110.00 (99.0-117.0)
58.66 6 4.02
60.00 (53.00-67.00)
50.16 6 3.06
50.50 (44.00-54.00)
0.63 6 0.03
0.62 (0.56-0.70)

NS

3.26 6 2.17
3.5 (8.00- 1.00)
2.33 6 3.20
1.50 (7.00-3.00)
8.50 6 3.25
9.00 (13.00- 3.00)

3.40 6 2.35
2.50 (8.00-0.00)
2.10 6 3.02
1.50 (6.50-2.50)
7.36 6 2.08
8.00 (10.00- 2.50)

3.51 6 2.05
3.50 (7.00- 0.50)
3.03 6 3.33
3.50 (7.50-2.00)
8.83 6 3.09
8.00 (16.50- 5.50)

NS

3.06 6 1.42
3.50 (6.00- 1.00)

3.63 6 0.89
3.50 (5.00- 2.50)

3.63 6 1.80
3.00 (9.00- 2.00)

NS

American Journal of Orthodontics and Dentofacial Orthopedics

NS
NS
NS
NS
NS
NS

NS
NS
NS
NS
NS
NS
NS

NS
NS
NS
NS

NS
NS

May 2011  Vol 139  Issue 5

Sar et al

644

Table I. Continued

Parameter
Overbite (mm)
U1i-VRmx (mm)
U1i-HRmx (mm)
U1.HRmx (
)
U1.PP (
)
L1i-VRmd (mm)
L1.HR (
)
L1.MP (
)
U6-VRmx (mm)
U6-HRmx (mm)
Soft-tissue parameters
N0 -Me0 (mm)
Sn-Me0 (mm)
A0 -VR (mm)
B0 -VR (mm)
UL-VR (mm)
LL-VR (mm)
Pg0 -VR (mm)

MP 1 FM

FM

Control

Mean 6 SD

Mean 6 SD

Mean 6 SD

Median (range)
2.73 6 1.70
2.50 (0.00-5.50)
43.80 6 3.08
42.50 (40.00-51.00)
25.50 6 2.73
25.50 (20.00-31.00)
114.60 6 5.87
115.00 (105.0-126.0)
113.70 6 6.32
114.00 (104.0-125.0)
62.16 6 3.98
62.00 (54.50-68.50)
87.63 6 6.48
87.00 (76.00-101.00)
84.96 6 6.97
85.00 (72.00-100.00)
16.80 6 4.40
16.50 (11.00-24.50)
18.46 6 3.73
18.00 (11.00-23.00)

Median (range)
3.93 6 1.88
4.00 (0.50-7.00)
41.66 6 3.81
41.00 (34.50-50.00)
25.70 6 2.08
25.00 (23.00-29.50)
110.83 6 6.44
110.00 (102.0-126.0)
110.36 6 6.01
110.00 (102.0-124.5)
61.73 6 3.46
62.00 (53.00-67.00)
88.03 6 7.32
87.00 (78.00-103.50)
85.43 6 8.50
82.50 (74.00-103.50)
14.70 6 2.78
14.00 (10.50-20.00)
19.50 6 2.29
19.00 (16.00-24.00)

Median (range)
3.06 6 1.82
3.00 (0.00-7.00)
43.73 6 5.21
44.50 (31.00-51.00)
24.63 6 3.07
25.00 (17.50-29.00)
113.20 6 7.13
112.00 (102.50-128)
114.23 6 8.33
112.00 (101.0-128.0)
62.50 6 4.40
63.50 (54.00-68.50)
87.66 6 8.26
87.50 (73.00-100.00)
84.93 6 7.58
85.00 (73.00-97.00)
17.40 6 3.23
18.50 (10.00-22.00)
18.83 6 2.15
18.50 (15.50-23.00)

P
NS

118.46 6 7.50
119.00 (108.0-132.0)
63.46 6 5.65
64.00 (54.00-74.00)
75.93 6 3.90
77.00 (67.50-82.00)
73.70 6 5.74
73.00 (62.50-82.50)
78.60 6 4.87
78.50 (69.00-86.00)
80.20 6 5.57
80.00 (69.50-90.00)
75.66 6 6.62
75.00 (64.00-85.50)

115.40 6 5.73
114.00 (106.0-127.0)
61.86 6 3.58
61.00 (55.00-68.00)
75.26 6 3.46
74.50 (66.50-81.00)
72.66 6 5.05
74.00 (58.00-78.50)
77.90 6 3.89
78.00 (69.00-83.50)
79.56 6 4.47
80.00 (68.00-84.50)
74.76 6 6.42
76.50 (57.50-82.00)

116.80 6 6.80
116.00 (106.5-132.0)
63.00 6 4.75
63.00 (56.50-74.00)
76.06 6 3.05
74.50 (72.00-81.00)
74.86 6 4.47
73.50 (68.00-82.50)
78.93 6 3.76
78.50 (73.00-85.00)
80.90 6 4.13
80.50 (74.50-87.50)
76.76 6 5.58
79.00 (67.00-83.50)

NS

NS
NS
NS
NS
NS
NS
NS
NS
NS

NS
NS
NS
NS
NS
NS

NS, Not signicant.

maxillary arch, above the CR, caused anterior rotation

and forward movement of the maxilla. In our MP1FM
group, force was applied from the apertura piriformis
region with a 30
pull downward to the occlusal plane,
passing as close as possible to the CR; in the FM
group, the protraction force was applied 30

downward from the hooks of the RME appliance to the
occlusal plane, above the CR.
When treatment durations were evaluated, signicant differences were seen between the treatment
groups (P\0.001). In the MP1FM group, treatment duration was 6.7 months, whereas it was 9.4 months in FM
group. This difference might be due to different anchorage units used in the groups. In addition, the observation
period in the control group was 7.5 months.

May 2011  Vol 139  Issue 5

One major objective of this study was to evaluate the effects of facemask therapy with skeletal anchorage comparatively with tooth anchorage on the forward movement of the
maxilla. The Point-A advancement of the maxilla has been
reported in many previous studies by using conventional
intraoral anchorage devices. Many investigators including
Mermigos et al48 (SNA angle, 11.8
; A-point, 11.76
mm), Baik21 (SNA angle, 11.5
; A-point, 12 mm), Ngan
et al45 (SNA angle, 11.4
; A-point, 11.9 mm), Arman
et al17 (SNA angle, 11.83
; A-point, 12.11 mm), and
Nartallo-Turley and Turley49 (SNA angle, 12.35
,
A-point, 13.34 mm) demonstrated these ndings. In this
study, the forward movement of Point A was 2.16 mm,
and the increase in the SNA angle was 1.83
in the FM group.
Our results for this group agree with previous studies.

American Journal of Orthodontics and Dentofacial Orthopedics

Sar et al

645

Table II. Changes in the groups, with the signicance of changes in each group (Wilcoxon test) and comparison of

changes in the groups wth the Kruskal-Wallis and Dunn tests

Parameter
Treatment duration(y)
Protraction rate(mm/mo)
Maxillary skeletal parameters
SNA (
)
A-VR (mm)
Cd-A (mm)
NPerp-A (mm)
HR-ANS (mm)
HR-PNS (mm)
HR.PP (
)

MP 1 FM (1)

FM (2)

Control (3)

Mean 6 SD

Mean 6 SD

Mean 6 SD

Median (range)
0.56 6 0.16
0.50 (0.30-0.80)
0.45 6 0.20
0.41 (0.17-0.83)

P
z

2.53 6 1.24
2.00 (1.00-5.50)
2.83 6 0.93
3.00 (1.50-5.00)
3.26 6 1.82
3.00 (1.00-8.50)
2.53 6 1.31
2.00 (0.50-4.50)
0.66 6 1.24
0.50 (1.00-4.00)
1.50 6 0.65
1.50 (0.50-3.00)
0.91 6 1.82
1.00 (3.00-4.00)

Mandibular skeletal parameters

1.93 6 2.19
SNB (
)
2.50 (5.00-2.50)
B-VR (mm)
2.76 6 2.01
2.50 (5.50-0.50)
Cd-Gn (mm)
0.30 6 2.15
0.00 (5.00-3.00)
NPerp-Pg (mm)
2.80 6 2.67
3.00 (7.00-2.50)
Pg-VR (mm)
2.53 6 2.10
2.50 (6.00-2.00)
1.46 6 2.78
SN.GoGn (
)
2.00 (6.00-4.50)
1.86 6 2.10
HR.GoMe (
)
2.50 (3.00-5.00)
1.90 6 2.14
BaNa.PtGn (
)
2.50 (4.00-5.00)
1.83 6 2.19
Mandibular rotation (
)
3.00 (4.00-4.00)
Facial heights
S-Go (mm)
0.36 6 1.26
0.00 (1.50-3.00)
N-Me (mm)
2.73 6 2.76
3.50 (5.50-5.00)
ANS-Me (mm)
2.10 6 1.79
2.00 (2.00-5.00)
N-ANS (mm)
0.56 6 2.29
1.00 (3.50-4.00)
S-Go/N-Me
0.01 6 0.02
0.02 (0.05-0.03)
Maxillomandibular parameters
4.46 6 1.95
ANB (
)
4.00 (1.00-9.00)
(A-VR)-(B-VR) (mm)
5.66 6 2.24
5.50 (1.50-10.00)

y
y
y
*
y
NS

*
y
NS
y
y
*
y
*

NS
*
y
NS
*

y
y

Median (range)
0.78 6 0.26
0.80 (0.40-1.30)
0.24 6 0.18
0.20 (0.00-0.62)

P
z

1.83 6 1.33
2.00 (0.00-4.00)
2.16 6 1.38
2.00 (0.00-5.00)
1.80 6 1.70
1.50 (1.50-6.00)
1.76 6 1.36
1.50 (0.00-4.00)
1.00 6 0.98
1.00 (1.50-2.00)
2.24 6 1.19
2.00 (0.00-4.00)
1.63 6 1.51
1.00 (1.00-5.00)

2.30 6 1.23
2.50 (4.00-0.50)
3.03 6 1.92
3.50 (6.00-1.00)
0.43 6 2.15
0.50 (3.00-4.00)
2.90 6 3.97
2.50 (9.00-4.00)
3.36 6 2.51
3.50 (7.00-1.00)
3.06 6 2.07
3.00 (1.00-6.00)
2.76 6 1.98
2.50 (0.00-7.50)
3.13 6 2.48
3.00 (7.00-2.00)
2.80 6 2.23
3.00 (3.00-6.00)
1.23 6 1.98
1.00 (2.00-6.00)
4.63 6 1.96
4.00 (2.00-9.00)
3.96 6 1.74
4.00 (0.50-7.00)
0.70 6 1.29
0.50 (1.00-3.00)
0.01 6 0.01
0.01 (0.04-0.01)
4.20 6 1.96
5.00 (0.00-7.50)
5.06 6 2.16
5.00 (0.50-8.50)

American Journal of Orthodontics and Dentofacial Orthopedics

y
y
y
y
y
y
y
y
NS
*
y
y
y
y

*
y
y
NS
y
y
y

Median (range)
0.63 6 0.10
0.60 (0.50-0.80)
0.05 6 0.08
0.05 (0.08-0.27)

P
z

0.26 6 0.53
0.00 (1.00-1.00)
0.44 6 0.69
0.50 (0.50-2.00)
0.80 6 0.95
1.00 (0.50-3.50)
0.30 6 0.59
0.00 (1.00-1.50)
0.94 6 0.91
0.50 (0.50-2.50)
0.80 6 0.84
0.50 (0.00-2.50)
0.20 6 1.19
0.00 (2.50-1.50)
0.65 6 0.65
0.50 (0.00-2.00)
1.23 6 1.27
1.50 (1.00-3.50)
1.86 6 1.12
2.00 (0.50-4.50)
0.96 6 1.66
0.50 (2.00-5.00)
1.93 6 1.32
2.00 (0.00-4.50)
0.40 6 0.87
0.00 (2.00-1.00)
0.03 6 0.83
0.00 (1.00-2.00)
0.53 6 0.81
0.00 (0.00-2.50)
0.20 6 1.42
0.00 (3.00-2.00)
1.06 6 1.29
1.00 (1.00-3.50)
0.83 6 1.01
1.00 (1.50-3.00)
0.10 6 0.91
0.00 (2.00-1.50)
0.76 6 0.86
0.50 (0.50-2.50)
0.00 6 0.01
0.01 (0.05-0.03)
0.38 6 0.71
0.30 (1.50-0.50)
0.78 6 1.22
0.50 (3.50-1.20)

1-2

2-3

1-3

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

May 2011  Vol 139  Issue 5

Sar et al

646

Table II. Continued

Parameter
Wits (mm)
Dentoalveolar parameters
Overjet (mm)
Overbite (mm)
U1i-VRmx (mm)
U1i-HRmx (mm)
U1.HRmx (
)
U1.PP (
)
L1i-VRmd (mm)
L1.HRmd (
)
L1.MP (
)
U6-VRmx (mm)
U6-HRmx (mm)
Soft-tissue parameters
N0 -Me0 (mm)
Sn-Me0 (mm)
A0 -VR (mm)
B0 -VR (mm)
UL-VR (mm)
LL-VR (mm)
Pg0 -VR (mm)

MP 1 FM (1)

FM (2)

Control (3)

Mean 6 SD

Mean 6 SD

Mean 6 SD

Median (range)

Median (range)

Median (range)

5.43 6 1.69
5.00 (3.00-9.00)

6.56 6 2.88
7.00 (1.00-11.50)

0.53 6 1.14
0.50 (2.00-1.50)

7.66 6 1.61
8.00 (4.00-10.00)
0.33 6 2.17
0.50 (2.00-5.50)
0.30 6 1.37
0.00 (4.00-1.00)
0.66 6 0.97
0.50 (1.00-2.50)
2.36 6 3.54
1.50 (10.00-2.00)
0.83 6 3.95
1.00 (-12.00-4.00)
3.93 6 2.59
3.50 (10.00- 1.00)
7.16 6 3.12
7.00 (13.00-0.00)
7.83 6 3.51
7.00 (14.00- 2.00)
0.03 6 0.63
0.00 (1.50-1.00)
0.16 6 0.67
0.00 (1.00-1.50)

7.93 6 1.65
7.50 (5.00-11.50)
0.90 6 1.64
0.50 (5.00-1.50)
1.86 6 1.32
2.00 (1.00-4.00)
0.43 6 0.86
0.50 (1.00-2.00)
2.73 6 4.46
2.00 (6.00-11.00)
2.36 6 3.14
3.00 (3.50-8.00)
2.96 6 1.45
3.00 (6.00- 1.00)
7.06 6 3.86
7.50 (13.00-2.00)
5.40 6 4.03
4.50 (16.50-2.00)
1.93 6 2.35
2.50 (4.00-5.00)
0.60 6 1.12
0.50 (1.00-4.00)

0.33 6 0.72
0.50 (2.00-1.00)
0.26 6 0.62
0.00 (1.00-1.50)
0.53 6 0.85
0.00 (0.00-2.50)
0.33 6 0.44
0.00 (0.00-1.50)
0.90 6 1.15
0.50 (0.00-3.00)
0.80 6 1.85
0.00 (3.50-4.00)
0.13 6 0.63
0.00 (1.50-1.50)
0.43 6 1.51
0.00 (4.00-3.50)
0.83 6 1.43
0.50 (3.50-1.00)
0.20 6 0.64
0.00 (2.50-0.00)
0.00 6 0.00
0.00 (0.00-0.00)

1.66 6 3.79
2.00 (6.00-8.00)
2.43 6 2.08
2.00 (3.00-5.00)
3.36 6 1.20
3.50 (1.00-5.50)
2.86 6 1.88
2.50 (6.00-0.00)
3.43 6 1.76
3.00 (1.00-7.00)
1.33 6 2.12
1.00 (5.50-2.00)
2.66 6 2.34
2.00 (6.00-0.50)

NS
NS
*
*
NS
y
y
y
NS
NS

NS
y
y
y
y
*
y

3.86 6 2.59
4.00 (0.00-10.00)
3.86 6 2.23
4.00 (0.00-9.00)
2.66 6 2.17
2.00 (0.00-6.50)
2.90 6 3.29
2.50 (13.00-0.50)
2.63 6 2.74
2.00 (2.00-7.00)
1.16 6 2.41
1.00 (5.00-3.50)
2.53 6 2.23
3.00 (6.50-1.00)

NS
y
NS
*
*
y
y
y
*
*

y
y
y
y
y
NS
y

0.46 6 1.39
0.00 (2.00-4.00)
0.30 6 1.46
0.00 (2.00-3.00)
0.90 6 0.91
1.00 (1.00-2.50)
1.66 6 1.35
2.00 (0.50-4.00)
0.83 6 1.09
1.00 (1.00-3.00)
1.60 6 1.05
2.00 (0.00-3.50)
1.76 6 1.37
2.00 (0.50-4.00)

1-2

2-3

1-3

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

NS

*
*

NS

NS

NS

NS, Not signicant; *P \0.05; yP \0.01; zP \0.001.

As for maxillary protraction with skeletal anchorage

in the literature, few studies are available, and most
are case reports. Singer et al25 used a facemask with
osseointegrated implants placed in the zygomatic buttresses of the maxilla of a cleft-palate patient, and
4 mm of forward and downward movement of the maxilla was achieved in 8 months. Similarly, Enacar et al26
applied a titanium screw to the alveolus to provide anchorage in a patient with oligodontia and achieved
3 mm of anterior displacement in the ANS after 7 months

May 2011  Vol 139  Issue 5

of facemask therapy. Hong et al27 used an onplant

placed in the hard palate in an 11-year-old patient as
absolute anchorage and found 2.9 mm of maxillary
displacement after the 12-month period of protraction.
In their case reports, Kircelli et al29 and Zhou et al30
used titanium miniplates for maxillary protraction and
reported 8 mm of protraction in 12 months and
5.5 mm of protraction in 6 months, respectively. Liu
et al28 demonstrated a technique named sutural distraction osteogenesis and placed bone-borne traction

American Journal of Orthodontics and Dentofacial Orthopedics

Sar et al

hooks in bone holes, lateral to the apertura piriformis

regions of 4 growing patients. Protraction forces were
applied through the nostrils. Signicant midfacial
advancement was reported with this method.
In a recent study, which was evaluated statistically,
Kircelli and Pektas32 applied 6 miniplates to the lateral
nasal walls of the maxilla in growing patients. Then
facemasks were applied with miniplates. They found
4.8 mm of maxillary advancement after 10.8 months
of protraction therapy, and the protraction rate was
0.44 mm per month. In our study, the forward movement of Point A in the MP1FM group was 2.83 mm
in 6.7 months. When the difference of the treatment
durations between the MP1FM and FM groups was
considered, evaluating the protraction rate would be
more meaningful (0.45 mm per month in the MP1FM
group and 0.24 mm per month in the FM group). These
ndings support the observations of Kircelli and
Pektas.32 It can be interpreted that almost twice as
much protraction was found in MP1FM group when
compared with the FM group in the same duration.
Applying the force directly to the maxilla, instead of
indirect application via the maxillary teeth and their surrounding periodontia in the MP1FM group, might be
the reason for this difference.
These ndings in the FM group with regard to anterior rotation of the maxilla (HR.PP) show similarity with
the ndings of previous studies in the literature. Anterior
rotation of the maxilla was statistically signicant in the
FM group (P \0.01), whereas no signicant change was
seen in the MP1FM group. Applying the force vector as
close as possible to the CR in the MP1FM group might
be the reason for elimination of the rotation of the
maxilla when compared with the FM group.
Many authors have shown signicant downward and
backward rotation of the mandible with facemasks. In
this study, the posterior rotation of the mandible was
signicant in the MP1FM and the FM groups, whereas
the rotation in the FM group was more evident. The possible explanation of this result might be the signicant
anterior rotation of the maxilla seen in the FM group,
thus affecting the position of the mandible as well. In
addition, the longer treatment duration in the FM group
might be the other possible reason affecting the position
of the mandible. This might be due to the chincap effect
of the facemask therapy. Accordingly, lower and total facial heights increased signicantly in both treatment
groups, whereas greater changes were seen in the FM
group compared with the MP1FM group. The ndings
observed in the FM group have been reported in previous
studies.
Proclination of the maxillary incisors, mesialization
and extrusion of the maxillary molars, and retroclination

647

of the mandibular incisors, which are the main effects of

conventional facemask therapy with a tooth-borne
device on dentoalveolar structures, were reported in
many previous studies.22,39,40,45,50 In our study, the FM
group showed similar dentoalveolar ndings as
reported in previous studies. In the MP1FM group, the
maxillary incisors showed signicant retrusion, and the
maxillary molars did not show any movement contrary
to the facemask therapies with tooth-borne anchorage
devices. These ndings agree with the observations of
facemask therapies with skeletal anchorages. The
possible explanation of our ndings could be that the
anchorage unit used in facemask therapy determines
the movement of the maxillary teeth. The undesired
dental effects of conventional facemask therapies were
eliminated with miniplate anchorage. Also, the mandibular incisors showed signicant retrusion in both treatment groups from the chincap effect of the facemasks.
Improvements in the soft-tissue prole followed the
underlying skeletal components in both treatment
groups. Since the increase in lower facial height (ANSMe) was more evident in the FM group than in the
MP1FM group (P \0.001), the FM group demonstrated
signicantly greater changes regarding the soft-tissue
lower facial height (Sn-Me0 ) (P \0.001). In addition,
the probable reason for the more forward movement
of the upper lip in the MP1FM group might have
been due to the signicant forward movement of Point
A when compared with the FM group.
The undesired effects of conventional facemask therapy, such as anterior rotation of the maxilla, posterior
rotation of the mandible, and increase in facial height,
were reduced, and protrusion of the maxillary incisors,
and mesialization and extrusion of the maxillary molars
were eliminated by the skeletal anchorage. In addition,
more evident skeletal effects were obtained, and the
treatment duration was reduced signicantly in the
MP1FM group.
The potential application for this technique might be
for growing skeletal Class III patients lacking anchorage
teeth for the facemask because of congenitally missing
teeth or the absence of posterior deciduous teeth in the
mixed dentition stage. Also, patients with increased vertical growth patterns could be another possible application
of this method. Although there are many advantages of
maxillary protraction with skeletal anchorage, surgical operations when placing and removing miniplates are the
major disadvantages of this application. For this reason,
clinicians should be cautious in selecting patients. In addition, short-term facemask application after a LeFort I
osteotomy or a corticotomy could be advised for patients
at the postpubertal development period or for young
adults.

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Sar et al

648

Signicant relapse potential has been reported in

studies of the long-term effects of facemask therapies.
Consequently, cephalometric variables should be reevaluated in the long term.
CONCLUSIONS

This study was the rst to evaluate the treatment

effects of facemask therapy with skeletal anchorage
compared with conventional anchorage in a prospective,
controlled, clinical study design. We made the following
conclusions.
1.

2.

3.

4.

The maxilla was effectively protracted without signicant rotation in a shorter period of time in the
MP1FM group when compared with the FM group.
The mandible demonstrated signicantly greater
posterior rotation, and the increase in lower facial
height was more evident in the FM group.
The undesired dentoalveolar effects of conventional facemask therapies, such as mesialization
and proclination of the maxillary teeth and extrusion of the maxillary molars, were reduced or
eliminated with miniplate anchorage placed laterally to the apertura piriformis on both sides of the
maxilla.
Maxillary protraction via miniplate achorage might
be a promising early treatment approach in patients
with severe maxillary retrusion or a lack of anchorage teeth for a facemask. Future studies are needed
to examine the long-term stability of the changes
related to the maxilla and the mandible.

REFERENCES
1. Haynes S. The prevalence of malocclusion in English school children aged 11-12 years. Trans Eur Orthod Soc 1970;89-98.
2. Thilander B, Myberg N. The prevalence of malocclusion in Swedish
school children. Scand J Dent Res 1973;81:12-20.
3. Iwagaki H. Hereditary inuence of malocclusion. Am J Orthod Oral
Surg 1938;24:328-38.
4. Allwright WC, Burndred WH. A survey of handicapping dentofacial
anomalies among Chinese in Hong Kong. Int Dent J 1964;14:
505-19.
5. Irie M, Nakamura S. Orthopedic approach to severe skeletal Class III
malocclusion. Am J Orthod 1975;67:377-92.
6. Ellis EE, McNamara JA Jr. Components of adult Class III malocclusion. Am J Orthod 1984;85:277-90.
7. Nanda R. Biomechanical and clinical considerations of a modied
protraction headgear. Am J Orthod 1980;78:125-39.
8. Sanborn RT. Differences between the facial skeletal patterns of
Class III malocclusion and normal occlusion. Angle Orthod 1955;
25:208-22.
9. McNamara JA, Brudon WL. Orthodontic and orthopedic treatment
in the mixed dentition. Ann Arbor, Mich: Needham Press; 1993. p.
285-93.
10. Guyer EC, Ellis EE, McNamara JA Jr, Behrents RG. Components of
Class III malocclusion in juveniles and adolescents. Angle Orthod
1986;56:7-30.

May 2011  Vol 139  Issue 5

11. Kajiyama K, Murakami T, Suzuki A. Evaluation of the modied

maxillary protractor applied to Class III malocclusion with retruded
maxilla in early mixed dentition. Am J Orthod Dentofacial Orthop
2000;118:549-59.
12. Baccetti T, Franchi L, McNamara JA Jr. Treatment and posttreatment craniofacial changes after rapid maxillary expansion and
facemask therapy. Am J Orthod Dentofacial Orthop 2000;118:
404-13.
13. Chong YH, Ive JC, 
Artun J. Changes following the use of protraction headgear for early correction of Class III malocclusion. Angle
Orthod 1996;66:351-62.
14. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face
mask/expansion therapy in Class III children: a comparison of
three age groups. Am J Orthod Dentofacial Orthop 1998;113:
204-12.
15. Franchi L, Baccetti T, McNamara JA. Postpubertal assessment of
treatment timing for maxillary expansion and protraction therapy
followed by xed appliances. Am J Orthod Dentofacial Orthop
2004;126:555-68.
16. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal
effects of early treatment of Class III malocclusion with maxillary
expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 1998;113:333-43.
17. Arman A, Toygar TU, Abuhijleh E. Evaluation of maxillary protraction and xed appliance therapy in Class III patients. Eur J Orthod
2006;28:383-92.
18. Gallagher RW, Miranda F, Buschang PH. Maxillary protraction:
treatment and posttreatment effects. Am J Orthod Dentofacial
Orthop 1998;113:612-9.
19. Williams MD, Sarver DM, Sadowsky PL, Bradley E. Combined rapid
maxillary expansion and protraction facemask in the treatment of
Class III malocclusions in growing children: a prospective
long-term study. Semin Orthod 1997;3:265-74.
20. Da Silva Filho OG, Magro AC, Capelozza Filho L. Early treatment of
the Class III malocclusion with rapid maxillary expansion and maxillary protraction. Am J Orthod Dentofacial Orthop 1998;113:
196-203.
21. Baik HS. Clinical results of the maxillary protraction in Korean
children. Am J Orthod Dentofacial Orthop 1995;108:583-92.
22. Macdonald KE, Kapust AJ, Turley PK. Cephalometric changes after
the correction of Class III malocclusion with maxillary expansion/
facemask therapy. Am J Orthod Dentofacial Orthop 1999;116:
13-24.
23. Gu Y, Rabie AB, Hagg U. Treatment effects of simple xed appliance and reverse headgear in correction of anterior crossbites.
Am J Orthod Dentofacial Orthop 2000;117:691-9.
24. Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L, Clarren SK.
Ankylosed teeth as abutments for maxillary protraction: a case
report. J Orthod 1985;88:303-7.
25. Singer SL, Henry PJ, Rosenberg I. Osseointegrated implants as an
adjunct to facemask therapy: a case report. Angle Orthod 2000;70:
253-62.
26. Enacar A, Giray B, Pehlivano

glu M, _Iplikcio

glu H. Facemask therapy with rigid anchorage in a patient with maxillary hypoplasia
and severe oligodontia. Am J Orthod Dentofacial Orthop 2003;
123:571-7.
27. Hong H, Ngan P, Han G, Qi LG, Wei SH. Use of onplants as stable
anchorage for facemask treatment: a case report. Angle Orthod
2005;75:453-60.
28. Liu C, Hou M, Liang L, Huang X, Zhang T, Zhang H, et al. Sutural
distraction osteogenesis (SDO) versus osteotomy distraction osteogenesis (ODO) for midfacial advancement: a new technique and
primary clinical report. J Craniofac Surg 2005;4:537-48.

American Journal of Orthodontics and Dentofacial Orthopedics

Sar et al

Uckan S. Orthopedic protraction with

29. Kircelli BH, Pektas ZO
skeletal anchorage in a patient with maxillary hypoplasia and
hypodontia. Angle Orthod 2006;76:156-63.
30. Zhou YH, Ding P, Lin Y, Qui LX. Facemask therapy with miniplate
implant anchorage in a patient with maxillary hypoplasia. Chin
Med J 2007;15:1372-5.
31. Ding P, Zhou YH, Lin Y, Qui LX. Miniplate implant anchorage for
maxillary protraction in Class III malocclusion. Zhonghua Kou
Qiang Yi Xue Za Zhi 2007;5:263-7.
Pektas. Midfacial protraction with skeletally
32. Kircelli BH, ZO
anchored face mask therapy: a novel approach and preliminary results. Am J Orthod Dentofacial Orthop 2008;133:440-9.
33. Helm S, Siersbaek-Nielsen S, Skieller V, Bjork A. Skeletal maturation of the hand in relation to maximum pubertal growth in
body height. Tandlaegebladet 1971;75:1223-34.

34. _Iseri H, Ozsoy

S. Semirapid maxillary expansiona study of
long-term transverse effects in older adolescents and adults. Angle
Orthod 2004;74:71-8.
35. Bj
ork A, Skieller V. Normal and abnormal growth of the mandible.
A synthesis of longitudinal cephalometric implant studies over
a period of 25 years. Eur J Orthod 1983;5:1-46.
36. McNamara JA Jr. Inuence of respiratory pattern on craniofacial
development. Angle Orthod 1981;51:269-300.
37. Cozzani G. Extraoral traction and Class III treatment. Am J Orthod
1981;80:638-50.
38. Saadia M, Torres E. Sagittal changes after maxillary protraction
with expansion in Class III patients in the primary, mixed, and
late mixed dentitions: a longitudinal retrospective study. Am J
Orthod Dentofacial Orthop 2000;117:669-80.
39. Merwin D, Ngan P, Hagg U, Yiu C, Wei SH. Timing for effective application of anteriorly directed orthopedic force to the maxilla. Am
J Orthod Dentofacial Orthop 1997;112:292-9.

649

40. Sung SJ, Baik HS. Assessment of skeletal and dental changes by
maxillary protraction. Am J Orthod Dentofacial Orthop 1998;
114:492-502.
41. McNamara JA. An orthopedic approach to the treatment of Class III
malocclusion in young patients. J Clin Orthod 1987;21:598-608.
42. Turley PK. Orthopedic correction of Class III malocclusion with palatal expansion and custom protraction headgear. J Clin Orthod
1988;22:314-25.
43. Haas J. Rapid expansion of the maxillary dental arch and nasal cavity
by opening the mid-palatal suture. Angle Orthod 1961;31:73-90.
44. Itoh T, Chaconas SJ, Caputo AA, Matyas J. Photoelastic effects of
maxillary protraction on the craniofacial complex. Am J Orthod
1985;88:117-24.
45. Ngan P, Hagg U, Yiu C, Merwin D, Wei SH. Soft tissue and dentoskeletal prole changes associated with maxillary expansion and
protraction headgear treatment. Am J Orthod Dentofacial Orthop
1996;109:38-49.
46. Tanne K, Hiraga J, Sakguda M. Effects of directions of maxillary
protraction forces on biomechanical changes in craniofacial complex. Eur J Orthod 1989;11:382-91.
47. Lee KG, Ryu YK, Park YC, Rudolph DJ. A study of holographic interferometry on the initial reaction of maxillofacial complex during
protraction. Am J Orthod Dentofacial Orthop 1997;111:623-32.
48. Mermigos J, Full CA, Andreasen G. Protraction of the maxillofacial
complex. Am J Orthod Dentofacial Orthop 1990;98:47-55.
49. Nartallo-Turley PE, Turley PK. Cephalometric effects of combined
palatal expansion and facemask therapy on Class III malocclusion.
Angle Orthod 1998;68:217-24.
50. Westwood PV, McNamara JA, Baccetti T, Franchi L, Sarver DM.
Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by xed appliances. Am
J Orthod Dentofacial Orthop 2003;123:306-20.

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