Clin Oral Invest

DOI 10.1007/s00784-015-1408-5

ORIGINAL ARTICLE

Comparison of the soft and hard tissue effects of two different

protraction mechanisms in class III patients: a randomized
clinical trial
Mevlut Celikoglu & Ibrahim Yavuz & Tuba Unal &
Husamettin Oktay & Abdulvahit Erdem

Received: 18 March 2014 / Accepted: 21 January 2015

# Springer-Verlag Berlin Heidelberg 2015

Abstract
Objective The objective of the present study is to test the null
hypotheses that there were no significant differences for hard and
soft tissue changes induced by mini maxillary protractor (MMP)
and face mask and rapid maxillary expansion (FM/RME).
Materials and methods Thirty-two patients who met the
criteria were randomly divided into two groups: 16 patients
(males/females 7/9) in the MMP group and 16 patients (males/
females 6/10) in the FM/RME group. The patients in both
groups were instructed to wear the appliances for at least
20 h per day until a 2-mm positive overjet was achieved.
Hard and soft tissue profile changes observed by MMP and
FM/RME were compared using paired and Students t tests.
Results Class III malocclusion and negative overjet were
improved by means of skeletal changes in conjunction with
upper incisor proclination and lower incisor retroclination in
both groups. Maxilla and surrounding soft tissues (SNA,
Ls-E, and Ls-PMV) were significantly moved anteriorly
M. Celikoglu (*)
Department of Orthodontics, Faculty of Dentistry, Akdeniz
University, Antalya, Turkey
e-mail: mevlutcelikoglu@hotmail.com
I. Yavuz
Department of Orthodontics, Faculty of Dentistry, Erciyes
University, Kayseri, Turkey
T. Unal
Department of Orthodontics, Faculty of Dentistry, Karadeniz
Technical University, Trabzon, Turkey
H. Oktay
Department of Orthodontics, Faculty of Dentistry, Istanbul Medipol
University, Istanbul, Turkey
A. Erdem
Department of Orthodontics, Faculty of Dentistry, Ataturk
University, Erzurum, Turkey
with less rotation of the palatal plane in the MMP group.
Mandibular incisors were found to be more retrusive in the
FM/RME group (p=0.024).
Conclusion Both groups showed similar effects except more
anterior movement of the maxilla and surrounding soft tissues
with less rotation of the palatal plane and retrusion of lower
incisors in the MMP group.
Clinical relevance This is the first study to compare the soft
and hard tissue changes induced by MMP appliance with a
conventional FM /RME.
Keywords Class III . Face mask . Maxillary protraction .
Maxillary deficiency
Introduction
Class III malocclusions are considered to be among the most
challenging orthodontic problems in orthodontics. The preva-
lence of this malocclusion was found to be approximately 1
5 % in Caucasian populations and as high as 15 % in Asian
populations [1, 2].
A class III malocclusion can exhibit a variety of skeletal
and dental components including maxillary retrognathism,
mandibular prognathism, retrusive maxillary dentition, protru-
sive mandibular dentition, and a combination of those com-
ponents [3, 4]. Two thirds of the skeletal class III malocclu-
sions were found to be due to either maxillary retrognathism
or a combination of maxillary retrognathism and mandibular
prognathism [3]. Therefore, face mask (FM) therapy has been
considered as a treatment option in growing class III subjects.
Since the application of FM therapy, treatment effects of this
appliance were investigated by several authors and reported as
follows: acceleration of forward growth of the maxilla with
counterclockwise rotation, forward movement of the

maxillary dentition, backward movement of the mandible
with a clockwise rotation, and backward movement of the
mandibular dentition [48]. Based on the studies [4, 6] that
compared the effects of maxillary protraction with the natural
growth of untreated control groups, orthopedic interventions
were confirmed to be effective.
Several investigators [911] have attempted to design dif-
ferent modifications of maxillary protraction appliances to
treat class III malocclusions. Among those, Altug and
Arslan [10] reported the mini maxillary protractor (MMP)
which was found to be effective to correct the class III maloc-
clusion. In addition, the authors stated that it was smaller than
the conventional FM and thus had minimal aesthetic disad-
vantages for growing subjects.
Facial profile of the skeletal class III deformities is usually
the main concern of these patients. The primary objective of
class III malocclusion treatment should be focused on soft
tissue profile and appearance rather than occlusion, as op-
posed to other malocclusion groups [12, 13]. Soft tissue re-
sponse to FM therapy has been investigated in previous stud-
ies [4, 14, 15].
To date, soft tissue effects of MMP have been limited in the
literature [16]. Moreover, the hard tissue changes induced by
this appliance have not been compared with a conventional
FM with or without rapid maxillary expansion (RME).
Therefore, this study aimed to test the null hypotheses that
there were no significant differences for hard tissue and con-
comitant soft tissue profile changes induced by MMP and face
mask and rapid maxillary expansion (FM/RME).
Material and methods
Ethical approval from the local ethic committee and informed
consent from the parents of the children were obtained. The
sample size for the present study was calculated based on a
significance level of 0.05 and a power of 90 % to detect a
clinically meaningful difference of 1 mm (0.84 mm) for the
distance from point A to vertical plane (PMV) between the
MMP and FM/RME groups. The power analysis showed that
16 patients in each group were required.
In order to obtain 32 patients that matched the specific
criteria to comprise the study sample, a single researcher
(MC) examined the initial data of 40 patients who needed
maxillary protraction. Inclusion criteria were as follows: (1)
skeletal class III malocclusion (ANB angle <0) and negative
overjet, (2) vertically normal growth pattern (SNGoMe=
32 5), (3) late mixed or early permanent dentition, (4) no
signs of functional class III malocclusion determined after
clinical examination, (5) no history of temporomandibular
disorders, and (6) no systemic diseases or congenital deformi-
ties; and (7) no previous orthodontic treatment. Thirty-four
patients who met the above criteria were randomly divided
Clin Oral Invest
into two groups using a random number table. One patient
in each group discontinued the treatment, and finally, 32 pa-
tients were analyzed. The flow diagram of the MMP and FM/
RME groups is shown in Fig. 1. Group I (MMP group)
consisted of 16 patients (7 males and 9 females; mean age
11.510.66 years) treated using the MMP appliance, and
group II (FM/RME group) consisted of 16 patients (6 males
and 10 females; mean age 12.000.89 years) treated using the
FM/RME appliance.
MMP appliance consisted of four parts as stated in the
literature [10, 1618] (Fig. 2).
In the FM/RME group, a four-banded RME appliance
(Hyrax type) was used for expansion and Petit-type FM for
the maxillary protraction. In both groups, the screw was acti-
vated twice a day, even in the absence of a posterior cross bite.
For the patients with posterior cross bite (three patients in the
MMP group and four in the FM/RME group), the activation of
the screw was continued until the cross bite was overcorrected
and for the patients without cross bite (13 patients in the MMP
group and 12 in the FM/RME group) until the suture was
opened (determined by means of occlusal film). A maxillary
protraction force of 400500 g per side with an anteroinferior
force vector of approximately 30 to the occlusal plane was
applied from the hooks placed in the canine region on the
buccal sides of the expanders in both groups. The patients in
both groups were instructed to wear the appliances for at least
20 h per day until a 2-mm positive overjet was achieved. All
patients included in the study were treated at the Department
of Orthodontics, Faculty of Dentistry, Ataturk University.
Cephalometric films were taken in a standard position by
the same cephalostat (Siemens Nanodor 2, Siemens AG,
Munich, Germany) by an experienced technician just before
(within 2 weeks prior to protraction therapy) and after (within
a week after protraction was completed) protraction therapy in
both groups. The subjects were requested to keep their teeth in
centric occlusion during the exposure, and special attention
was given to ensure that the lips were at rest. Eleven linear
and 14 angular measurements were performed to evaluate
skeletal, dental, and soft tissue changes. The landmarks and
measurements used in the present study are shown in Fig. 3.
After calibration was done, all radiographs were traced by one
researcher (TU) with a random queue of the cephalometric
films without knowing the group of the patient so that the
researcher was blinded.
Statistical analyses
Mean and standard deviation values were calculated for all
measurements. The normality test of Shapiro-Wilk and
Levenes variance homogeneity test were performed on the
data, and the data were found to be normally distributed.
Therefore, intragroup comparisons were performed by means
of paired t test, and intergroup comparisons were analyzed by
Clin Oral Invest
Fig. 1 Flow diagram of the
MMP and FM/RME groups
means of Students t test. Distribution of the genders and the
patients with posterior cross bite were tested using the Pearson
chi-square test. All statistical analyses were performed using
the SPSS software package program (SPSS for Windows 98,
version 10.0, SPSS Inc, Chicago, Ill). The significance level
was set at p<0.05 for all tests.
To determine the errors associated with digitizing and mea-
surements, 20 radiographs were selected randomly. All proce-
dures such as landmark identification, tracing, and measure-
ments were repeated 3 weeks later by the same researcher.
Intraclass correlation coefficients were performed to assess
the reliability of the measurements as described by Houston
[19]. The coefficients of reliability for all measurements were
above 0.93. In addition, the difference between the two read-
ings made by the same investigator was tested to estimate the
systemic error by means of paired t test and the results of
paired t test showed that there were no significant differences
between the first and second examinations, confirming that all
measurements were free from systemic errors (p>0.05).
Results
The chronological ages, observation periods, gender, and pa-
tients with posterior cross bite distribution of the MMP and
FM/RME groups are shown in Table 1. The patients wore the
MMP and FM/RME for 8.132.00 and 8.312.06 months,
respectively (p>0.05). The results of the Students t test and
Pearsons chi-square test showed no statistically significant
differences between groups regarding those parameters and
thus showing that both groups were well matched prior to
the study (p>0.05).

Fig. 2 Intra and extra-oral photograph of the MMP appliance
The comparisons of the initial linear and angular measure-
ments between the MMP and FM/RME groups are shown in
Table 2. No statistically significant differences were observed
between the groups (p>0.05).
In the MMP and FM/RME groups, maxilla moved forward
(SNA, 2.34 and 1.50, respectively) (p=0.000) and the
mandible displaced backward and downward (SNB,
1.24 and 1.33) (p < 0.001). The combined move-
ment of the maxilla and the mandible indicated a sig-
nificant improvement in the intermaxillary sagittal rela-
tionship (ANB, 3.59 and 2.84; convexity, 6.25 and
5.53, respectively) (p<0.001). Significant increases in the
vertical measurement (SN-GoGn, 1.73) (p=0.012) were ob-
served in the FM/RME group, while it was not found to be
statistically significant for the MMP group (0.80) (p>0.05).
Approximately 1 of difference for SN-GoGn between the
groups was found to be insignificant (p>0.05). Statistical
comparison of the groups regarding the skeletal measurements
showed that the increase in SNA in the MMP group was found
to be significant (p=0.016). In addition, the FM/RME group
showed a significant decrease in the SN/PP angle (1.68),
while it was found to be insignificant for the MMP group
(0.42) (p>0.05). The comparison between the groups re-
garding SN/PP angle was significant (p=0.035).
Clin Oral Invest
In the MMP and FM/RME groups, overjet improved (5.40
and 5.34 mm, respectively; p < 0.001) and overbite
(0.79 mm; p=0.008 and 1.41 mm; p>0.05, respectively)
decreased. The maxillary incisors were tipped labially (3.29
and 2.39, respectively) (p<0.001), and the mandibular inci-
sors tipped lingually (3.88 and 5.73, respectively)
(p<0.001). The mandibular incisor angle (IMPA) decreased
more in the FM/RME group when compared to the MMP
group (p=0.024).
Most of the soft tissue measurements were significantly
affected with maxillary protraction in both FM/RME and
MMP groups. Upper lip (p<0.001) and sulcus superior
(p=0.001 and p<0.001, respectively) moved anteriorly
relative to the vertical line. The distance between the upper
lip and E plane decreased (p=0.001 and p<0.001, respective-
ly). Lower lip (p>0.05), sulcus inferior (p=0.002 and p>0.05,
respectively), and soft tissue pogonion (p=0.027 and p>0.05,
respectively) moved posteriorly. Facial angle (p=0.001 and
p=0.001, respectively), Z-Ls (p<0.001), and Z-Li (p=0.011
and p>0.05, respectively) measurements decreased with pro-
traction in both FM/RME and MMP groups. When comparing
the groups regarding the soft tissue measurements, significant
differences were found for upper lip to vertical line (MMP
group 3.52 mm, FM/RME group 2.21 mm) (p=0.015) and
for the distance between upper lip and E plane (MMP group
2.60 mm, FM/RME group 1.38 mm) (p<0.05) (p=0.031)
(Table 3).
Discussion
Several investigators [4, 6, 8, 15] showed that the FM with or
without RME was an effective treatment option for the cor-
rection of class III malocclusion and they proved the effective-
ness of this approach. However, the appliance has a long ver-
tical bar in front of the face, and thus, it has aesthetic disad-
vantages [17]. MMP, firstly described by Altug and Arslan
[10], was presented to be an effective maxillary protractor to
correct maxillary deficiency [18]. In addition, the authors re-
ported that the MMP was smaller, lacked of the long vertical
bar of conventional FM, and had minimal disadvantages in
growing patients [17]. However, there was limited informa-
tion about the soft tissue effects of this appliance [16] and
the comparison of its effects with a conventional FM/
RME was neglected in the literature. The present study
was performed to evaluate the soft and hard tissue effects
of MMP and compare the results with a well-matched
FM/RME group.
The results of the maxillary protraction could be affected
by the patients original and skeletal and dental characteristics
as well as the growth of the maxilla and the mandible [20].
Therefore, it is important to compare the patients based on age
and dentoskeletal pattern. In our study, the groups showed no
Clin Oral Invest

Fig. 3 a Skeletal measurements

used in this study: (1) SNA (), (2)
SNB (), (3) ANB (), (4)
convexity (), (5) SN/GoGn (),
and (6) SN/PP (). b
Dentoalveolar measurements
used in this study: (1) U1-SN (),
(2) U1-NA (), (3) U1-NA (mm),
(4) IMPA (), (5) L1-NB (), (6)
L1-NB (mm), (7) overjet (mm),
and (8) overbite (mm). c Soft
tissue measurements used in this
study:(1) Ls-E (mm), (2) Li-E
(mm), (3) nasolabial (), (4)
Ls-PMV (mm), (5) Li-PMV
(mm), (6) Pog (s)-PMV (mm), (7)
Ss-PMV (mm), and (8) Si-PMV
(mm), (9) facial angle (), (10)
Z-Ls (), (11) Z-Li (), (12)
A-PMV (mm), and (13) B-PMV
(mm)

statistically significant differences regarding the chronological of class III malocclusions even in the absence of maxillary
age, cephalometric characteristics prior to protraction, and ob- constriction [18, 25, 26]. In the present study, maxillary ex-
servation periods. In addition, gender distributions of both pansion was mainly performed for disarticulating the maxil-
groups were similar. lary sutures regardless of posterior cross bite diagnosis in both
Previous studies [2124] reported that RME could disartic- groups.
ulate the circum-maxillary suture system, initiate cellular re- Both protraction therapies protruded the maxilla and
sponse in the sutures, and enhance the protraction effect of the inhibited forward growth of the mandible. Comparison of
maxillary protraction. Thus, RME has been advocated as a the skeletal measurements between the groups showed that
routine part of maxillary protraction therapy in the correction the increase in SNA (2.34) and the decrease in SN/PP
(0.42) were greater in the MMP group when compared with
the FM/RME group (1.50 and 1.68) (p<0.05). An acrylic
Table 1 Comparison of the groups regarding initial chronological age,
observation period, and male/female cap splint type expansion appliance used in the MMP group
prevented occlusal interferences, thus maximized the skeletal
MMP group RME/FM group Test effects of maxillary protraction, as stated by Altug and Arslan
Mean and SD Mean and SD
[18]. However, this difference for SNA (approximately 0.8)
Chronological age (years) 11.510.66 12.000.89 NS might be clinically insignificant. In the present study, a pro-
Observation period (months) 8.132.00 8.312.06 NS traction force of 400500 g per side with an anteroinferior
Male/female 7/9 6/10 NSa force vector of approximately 30 to the occlusal plane was
Presence of posterior cross bite 3 4 NSa applied. Protraction forces at the level of the occlusal plane
inevitably produce upward and forward rotation of the maxil-
MMP mini maxillary protraction, FM face mask la, and it has been shown that significant rotation of the palatal
a
Result of Pearson chi-square test plane and extrusion of the posterior teeth occur with maxillary
 Clin Oral Invest

Table 2 The results of the Students t test comparing the initial We believe that the significant decrease in overbite in the
measurements between the RME/facemask and MMP groups
FM/RME group (1.41 mm, p=0.008) was due to the extru-
Measurements RME/FM group MMP group p value sion of the posterior teeth and the rotation of the maxilla.
However, the acrylic cap splint type expansion appliance cov-
Mean SD Mean SD ering the posterior teeth used in the MMP group prevented the
Skeletal measurements
extrusion of the posterior teeth; thus, overbite decreased insig-
nificantly (0.79 mm, p>0.05). Conversely, the difference for
SNA () 78.33 3.41 76.71 2.12 0.137
overbite changes between the groups was found to be insig-
SNB () 81.96 4.25 79.30 2.59 0.064
nificant, due to the high standard deviations of the overbite
ANB () 3.63 2.42 2.58 1.45 0.172
changes in both groups, especially in the MMP group.
Convexity () 8.67 4.57 6.44 3.14 0.141
Both groups showed a significant amount of lingual incli-
SN/GoGn () 35.56 3.75 34.11 5.37 0.418
nation of the lower incisors (p<0.001). It was postulated that
SN/PP () 9.19 2.84 10.68 2.62 0.161
this change was due to the pressure exerted by the chin cup
A-PMV (mm) 40.82 3.40 41.18 3.10 0.583
and soft tissues [27, 28]. The comparison of the groups
B-PMV (mm) 51.46 3.69 51.50 4.81 0.117
showed that the MMP group showed less inclination of the
Dentoalveolar measurements
lower incisors (p=0.024). This difference between the groups
U1-SN () 107.09 5.04 104.92 6.31 0.331
might be due to the mandibular plate used in the MMP group.
U1-NA () 28.76 5.59 28.14 5.82 0.776
However, no mandibular plate was used in the FM/RME
U1-NA (mm) 4.76 1.83 3.76 1.92 0.173
group. Altug and Arslan [18] and Celikoglu and Oktay [16]
IMPA () 83.69 6.56 86.12 4.12 0.244
also showed less inclination of the mandibular incisors with
L1-NB () 17.47 3.80 20.01 4.75 0.137
the use of a mandibular plate in the mandible. Previous studies
L1-NB (mm) 1.93 1.40 2.50 1.20 0.254 [9, 11, 31, 32] using no mandibular plate with FM showed that
Overjet (mm) 1.18 1.60 1.78 1.42 0.359 mandibular incisors were significantly retruded.
Overbite (mm) 1.77 2.08 2.35 1.68 0.406 Merwin et al. [33] and Cha et al. [34] reported that skeletal
Soft tissue measurements contribution to overjet correction was approximately 63 %. In
Ls-E (mm) 5.29 0.95 5.06 1.58 0.649 the present study, overjet correction in the MMP group
Li-E (mm) 3.07 1.02 2.44 1.19 0.145 (5.40 mm) was achieved by 63.3 % skeletal (A-PMV;
Nasolabial () 98.33 12.80 106.24 14.83 0.146 2.16 mm and B-PMV; 1.26 mm, a total of 3.42 mm) and
Ls-PMV (mm) 60.47 4.93 60.20 4.36 0.879 36.7 % dental changes. In the FM/RME group, overjet correc-
Li-PMV (mm) 61.89 4.43 63.19 7.33 0.583 tion (5.34 mm) was achieved by 59.2 % skeletal (A-PMV;
Pog (s)-PMV (mm) 65.05 4.53 63.72 6.04 0.520 2.06 mm and B-PMV; 1.10 mm, a total of 3.16 mm) and
Ss-PMV (mm) 60.30 4.51 59.94 3.95 0.902 40.8 % dental changes (Fig. 4). According to Celikoglu
Si-PMV (mm) 56.55 4.31 56.75 4.93 0.843 and Oktay [16], overjet correction of 5.0 mm by MMP
Facial angle () 172.15 4.19 172.28 4.30 0.875 therapy was achieved, and approximately, 66 % of this
Z-Ls () 87.34 7.19 85.79 5.35 0.519 change was skeletal. In addition, maxillary skeletal con-
Z-Li () 86.46 7.01 82.25 4.91 0.075 tribution to overjet correction was higher than mandib-
ular skeletal contribution in both MMP and FM/RME
NS not significant
groups and this finding was in agreement with previous
studies [4, 16, 32, 35].
protraction [4, 14, 2729]. In agreement with these studies, Anterior movement of upper lip and posterior movement of
SN/PP decreased in both groups, although the decrease in the the lower lip and soft tissue pogonion contributed to profile
MMP group was less (1.68 and 0.42; p = 0.035). improvement in both groups. It has been indicated that the
Celikoglu and Oktay [16] using the same appliance for skeletal and dental changes underlying the soft tissue lead to
maxillary protraction found similar amounts of palatal profile changes [4, 27, 28, 35]. Celikoglu and Oktay [16] also
plane rotation (0.60), and this difference was statisti- reported significant forward movement of the upper lip
cally not significant when compared to untreated class I (2.1 mm) and insignificant backward movement of the lower
subjects. The acrylic cap splint type expansion appliance lip (0.6 mm) in their study. The comparison between the
covering the posterior teeth used in the MMP group groups showed that Ls-E (2.60 mm) and Ls-PMV
might have affected this finding. The findings of Sarver (3.52 mm) measurements were more affected in the MMP
and Johnston [30] as less rotation of the palatal plane in the group (FM/RME; 1.38 and 2.21 mm, respectively)
bonded RME group than in the banded RME group also (p<0.05). These soft issue differences between the groups
supported our findings. might be due to the maxillary skeletal and dental effects
Clin Oral Invest

Table 3 Intragroup and

intergroup comparisons analyzed Measurements RME+FM group P1 MMP group P2 P3
by means of paired t test and
Students t test, respectively Mean SD Mean SD

Skeletal measurements
SNA () 1.50 1.06 0.000 2.34 0.62 0.000 0.016
SNB () 1.33 0.53 0.000 1.24 0.91 0.000 0.754
ANB () 2.84 1.08 0.000 3.59 1.07 0.000 0.079
Convexity () 5.53 3.23 0.000 6.25 3.03 0.000 0.548
SN/GoGn () 1.73 1.34 0.012 0.80 1.62 0.347 0.215
SN/PP () 1.68 1.83 0.006 0.42 1.11 0.166 0.035
A-PMV (mm) 2.06 0.98 0.000 2.16 1.04 0.000 0.612
B-PMV (mm) 1.10 2.01 0.000 1.27 1.90 0.015 0.421
Dentoalveolar measurements
U1-SN () 2.39 1.57 0.000 3.29 1.50 0.000 0.134
U1-NA () 0.34 2.39 0.612 1.24 1.75 0.016 0.266
U1-NA (mm) 0.20 1.31 0.580 0.84 1.23 0.019 0.051
IMPA () 5.73 1.67 0.000 3.88 2.28 0.000 0.024
L1-NB () 5.16 1.47 0.000 2.78 1.12 0.101 0.183
L1-NB (mm) 1.64 0.72 0.000 1.00 1.12 0.004 0.092
Overjet (mm) 5.34 1.91 0.000 5.40 2.28 0.000 0.944
Overbite (mm) 1.41 1.59 0.008 0.79 2.33 0.312 0.459
Soft tissue measurements
Ls-E (mm) 1.38 1.20 0.001 2.60 1.55 0.000 0.031
Li-E (mm) 0.96 1.40 0.029 0.40 1.31 0.257 0.278
Nasolabial () 1.03 8.50 0.668 3.38 10.13 0.217 0.227
Ls-PMV (mm) 2.21 1.49 0.000 3.52 1.14 0.000 0.015
Li-PMV (mm) 0.60 2.08 0.314 0.43 3.84 0.669 0.885
Pog (s)-PMV (mm) 1.81 2.60 0.027 0.61 2.80 0.411 0.253
NS not significant, P1 and P2
Ss-PMV (mm) 1.98 1.79 0.001 0.94 1.51 0.000 0.320
results of paired t test evaluating
the changes in each group, P3 Si-PMV (mm) 2.29 1.85 0.002 2.92 2.08 0.102 0.176
results of Students t test Facial angle () 4.49 1.75 0.000 4.65 4.23 0.001 0.877
comparing the groups Z-Ls () 7.21 4.05 0.000 6.68 5.39 0.000 0.775
Bold entries show statistically Z-Li () 3.10 3.73 0.011 1.46 4.14 0.192 0.286
significant differences

Fig. 4 Skeletal and dental changes contributing to overjet correction in
both groups
underlying the soft tissue. Since the maxilla and the maxillary
incisors moved more anteriorly in the MMP group than in the
FM/RME group, the upper lip was probably more affected in
the MMP group.
However, this study had some limitations, such as
including a small number of patients, although it was
determined by power analysis and the lack of untreated
class III or class I malocclusion as control groups.
Further studies including more patients are needed to ex-
amine the long-term stability of the MMP. Conversely, as
stated previously by Celikoglu and Oktay [16], the MMP
appliance might be used in class III subjects who do
not wish to use FM due to its appearance, since both
appliances were similarly effective for the treatment of
patients with class III malocclusions.

Conclusion
& Class III malocclusion and negative overjet were im-
proved by means of skeletal changes in conjunction with
upper incisor proclination and lower incisor retroclination
in both MMP and FM/RME groups.
& The maxilla and surrounding soft tissue measurements
(SNA, Ls-E, and Ls-PMV) were significantly moved
more anteriorly with less rotation of the palatal plane
(SN/PP) in the MMP group as compared to FM/RME.
Conflict of interest The authors declare that they have no conflict of
interest.
Author contribution Mevlut Celikoglu treated the patients, planned
the study, and documented the article. Ibrahim Yavuz treated the patients,
performed the statistical analyses, and revised article. Tuba Unal collected
the data, performed the measurements, and prepared the figures and ta-
bles. Husamettin Oktay planned and edited the article and helped for
revision. Abdulvahit Erdem edited the article and helped for revision.
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