Dentofacial effects of two facemask therapies for maxillary protraction Miniscrew implants versus rapid maxillary expanders

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Original Article
Dentofacial effects of two facemask therapies for maxillary protraction
Miniscrew implants versus rapid maxillary expanders
Yuan Shu Gea; Jin Liub; Lin Chenc; Jian Li Hand; Xin Guoa
ABSTRACT
Objective: To compare the dentofacial effects of maxillary protraction with two facemask therapies
in growing Class III patients: facemask in association with miniscrew implants (MSI/FM) and
facemask with rapid maxillary expanders (RME/FM).
Materials and Methods: Forty-three Chinese patients with Class III malocclusion and maxillary
deficiency were randomly assigned to a MSI/FM sample of 20 patients and a RME/FM sample of
23 subjects. The changes in dentofacial cephalometric variables from the beginning (T1) to the end
of treatment (T2) were compared with t-test for paired samples in both groups and for independent
samples between the two groups.
Results: No significant cephalometric differences were observed between the two groups in active
treatment effects except for maxillary dental variables. However, significant favorable changes in
both maxillary and mandibular skeletal components were noted in two groups after treatment.
Sagittal measurements showed the maxilla was advanced, mandibular projection was reduced,
and the relative sagittal intermaxillary discrepancy improved. Patients experienced additional
unfavorable outcomes of clockwise rotation of the mandible as well as retroclination of the lower
incisors. The soft tissue profile was improved remarkably in both groups. Proclination of the
maxillary incisors and mesialization of the maxillary dentition were significantly different between
the two groups. The increases in U1-SN, U1-VR, and U6-VR were 6.41u, 2.78 mm, and 1.24 mm
less in the MSI/FM group than in the RME/FM group, respectively.
Conclusions: Compared with the RME/FM therapy, the MSI/FM protocol using a smaller
magnitude of protraction force improves skeletal relationships and soft tissue profile and reduces
the undesired dentoalveolar effects. (Angle Orthod. 2012;82:1083–1091.)
KEY WORDS: Class III malocclusion; Maxillary protraction; Miniscrew implants
INTRODUCTION
Protraction of the maxilla with facemask is a common
treatment for Class III malocclusion with maxillary
deficiency, especially at early ages. However, a
conventional force system that uses dental anchorage
has some inherent challenges. Indirect application of
force limits the potential for orthopedic change and
inevitably causes undesired tooth movements such as
mesial movement and extrusion of the maxillary molars
and proclination of the maxillary incisors.1–3
Orthopedic anchorage for maxillary protraction is a
new area of research and has been used increasingly
over recent years.4–12 Miniplates6–10 have been report-
ed successful for maxillary protraction in Class III
patients. In 1997, Kanomi13 first mentioned a tempo-
rarily placed miniscrew for orthodontic anchorage. The
following years brought more refined screw designs.
Miniscrews have now become established orthodontic
anchorage aids.11,12,14,15 Compared with other skeletal
anchorage systems, miniscrew implants have the
advantages of operational convenience, comfort, and
inexpensiveness. Additionally, immediate loading and
long-term stabilization are possible using miniscrew
implants as rigid anchors.
a Associate Professor, Department of Orthodontics, Shen-
Zhen Children’s Hospital, ShenZhen, China.
b Professor and Head, Department of Orthodontics, ShenZhen
Children’s Hospital, ShenZhen, China.
c Postgraduate Resident, Department of Stomatology, the
Third Affiliated Hospital, Sun Yat-Sen University, GuangZhou,
China.
d Assistant Professor, Department of Orthodontics, ShenZhen
Children’s Hospital, ShenZhen, China.
Corresponding author: Dr Yuan Shu Ge, Department of
Orthodontics, ShenZhen Children’s Hospital, 7019 YiTian Road,
FuTian District, ShenZhen City, GuangDong, China, 518026
(e-mail: frankge18@hotmail.com)
Accepted: March 2012. Submitted: January 2012.
Published Online: May 28, 2012
G 2012 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/012912-76.1 1083 Angle Orthodontist, Vol 82, No 6, 2012
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The purpose of this study was to evaluate the effects
of maxillary protraction using miniscrew implants with
facemask (MSI/FM). Specifically, we compared the
active treatment effects of skeletal, dentoalveolar, and
soft tissue structures in the MSI/FM group with
changes in a matched control group treated by using
rapid maxillary expanders in conjunction with face-
mask (RME/FM).
MATERIALS AND METHODS
Subjects
The original sample of 49 Chinese patients (26
female and 23 male) with a prepubertal stage of
skeletal maturity according to the cervical vertebral
maturation method (CS1–CS3) was recruited. The
patients met the following criteria: skeletal and dental
Class III malocclusion with maxillary deficiency (ANB
, 20u; Wits appraisal , 22 mm), reverse incisor
relationship and positive overbite, no significant
skeletal asymmetry, and no systemic diseases or
congenital deformities. This study was reviewed and
approved by the Ethics Committee of ShenZhen
Children’s Hospital. After informed consent, the pa-
tients were randomly assigned to the MSI/FM group
(25 patients, 14 female and 11 male) or the RME/FM
group (24 patients, 12 female and 12 male). During
treatment, four subjects of the initial MSI/FM group
were excluded because of the mobility of miniscrews,
and one subject of each group was excluded because
of poor cooperation. At the end of treatment, the MSI/
FM group had 20 subjects (11 female and 9 male;
mean age at T1, 10 years 4 months; mean treatment
duration, 11 months), and the RME/FM group had 23
subjects (12 female and 11 male; mean age at T1,
10 years 6 months; mean treatment duration, 1 year
1 month). The patient details are presented in Table 1.
MSI/FM Protocol
The miniscrew was 2 mm in diameter and 14 mm in
length (ShenGang, ZhangHua, Taiwan). The implant
site was the zygomatic buttress of the maxilla. The
miniscrews were inserted under local anesthesia. A 4-
mm vertical incision was made with a surgical blade at
the mucogingival junction above the maxillary first
molar. A mucoperiosteal flap was elevated to expose
the zygomatic process of the maxilla. A 1.5-mm spiral
drill was used to drill a pilot hole under irrigation with
normal saline solution. The miniscrew was then driven
into the pilot hole with a screwdriver at an angle of 55u to
70u to the maxillary occlusal plane as suggested by Loiu
et al.16 and Lin.17 The head of the miniscrews remained
outside the mucogingival junction so that elastics could
be attached. The miniscrews were left for 2 weeks to
allow adequate wound healing before loading.
A Petit facemask was subsequently fitted with the
application of 200 g to 250 g force to the miniscrews on
each side at a 30u angle downward to the occlusal
plane. The patients were instructed to wear the
facemasks for at least 14 hours per day (Figure 1).
RME/FM Protocol
Treatment began with the placement of a bonded
maxillary expander (Hyrax, Leone, Florence, Italy).
Patients were instructed to activate the expander twice
a day with a quarter turn (0.5 mm/d) until the desired
transverse width was achieved. The patients were
given facemask and RME simultaneously. Elastics
were attached from the hooks of the expander to the
Petit facemask in a downward and forward vector,
producing orthopedic forces of 400 g to 500 g per side.
All patients were treated to a positive dental overjet
before discontinuing treatment. Standardized lateral
cephalograms of each patient were taken at the
beginning (T1) and end of treatment (T2). All radio-
graphs were taken with the same cephalometer.
Cephalometric Analysis
The radiographs were scanned into the digital format
at 600 dpi and then processed by one investigator (Dr
Ge) using Dental Studio NX software (NemoCeph-Csoftware, Nemotec, Madrid, Spain). The customized
cephalometric analysis containing measurements from
the analyses of Jacobson, McNamara, Ricketts, Wits,
and Steiner generated 24 variables for each tracing.
To examine the movement of the maxillary dentition
relative to the maxilla, a maxillary horizontal reference
plane (HR) was drawn along the ANS-PNS line, and a
vertical line passing through PNS and perpendicular to
the HR was the maxillary vertical reference plane (VR)
(Figure 2).
Table 1. Number, Age at Start (T1) and End (T2) of Treatment, and Duration of Treatment of the Patients
Groupa
N (Female/Male) Age
Duration of Treatment (T1–T2)Initial Sample Present Sample T1 T2
MSI/FM 25 (14/11) 20 (11/9) 10 y, 4 mo 11 y, 3 mo 11 mo
RME/FM 24 (12/12) 23 (12/11) 10 y, 6 mo 11 y, 7 mo 1 y, 1 mo
a MSI/FM indicates miniscrew implants with facemask; RME/FM, rapid maxillary expander with facemask.
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To evaluate tracing and measurement errors, 40
lateral cephalograms of 20 patients were randomly
selected and remeasured by the same investigator
1 month later. The estimate of random errors was
made using the Dahlberg formula. No systematic
errors were found. The mean errors for angular and
linear measurements were from 0.4u to 1.4u and from
0.1 to 1.2 mm, respectively.
Statistical Analysis
Descriptive statistics were calculated for all mea-
surements at T1 and T2 by using the Statistical
Package for Social Science (version 13.0, SPSS,
Chicago, Ill). Paired samples t-tests were used to
determine the statistical significance of cephalometrics
between T1 and T2 for each group. T1–T2 changes in
both groups and the differences of the changes
between two groups were assessed with independent
sample t-tests. Statistical significance was tested at P
, .05, P , .01, and P , .001.
RESULTS
The analysis of the dentofacial characteristics at T1
(Table 2) revealed that there were no statistically
significant differences between the two groups for the
analyzed parameters. The homogeneity of the two
groups allowed for comparisons without annualizing
the data.
There were no significant differences for T1–T2
changes (Table 3) between groups MSI/FM and
RME/FM in any skeletal measured cephalometric
variable. The changes between T1 and T2 (Tables 4
and 5), however, revealed significant treatment
effects in both groups. Co-A showed average improve-
ments of 4.93 mm in the MSI/FM group and 5.04 mm
in the RME/FM group; and A-N perp increased
3.37 mm and 2.53 mm, respectively. Significant
restraining effects on mandibular growth were record-
ed in two groups, both at B-point and Pog-point. The
combined movement of the maxilla and the mandible
produced highly significant intermaxillary skeletal
improvements, with increases in the Wits appraisal of
4.83 mm and 5.33 mm, and an average increase in the
convexity of 3.80 mm and 3.62 mm in the MSI/FM and
RME/FM group, respectively. Significant clockwise
rotation of the mandibular plane and increase in the
anterior facial height were found after treatment in
both groups.
Of the dentoalveolar measurements, overjet im-
proved significantly—6.19 mm and 5.79 mm in the
MSI/FM and the RME/FM group, respectively. A
significant retroclination was recorded for the mandib-
ular incisors in both the MSI/FM and RME/FM groups,
but no significant difference was found between the
two groups. However, significant differences in the
changes of maxillary dentoalveolar parameters be-
tween the two groups were detected. The measure-
ments associated with the position of the maxillary
Figure 2. Maxillary dentoalveolar measurements used in the study.
(1) U1-VR, mm. (2) U1-HR, mm. (3) U6-VR, mm. (4) U6-HR, mm.
Figure 1. (A) Intraoral view of the miniscrews. (B) Cephalometric view of the miniscrews.
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dentition relative to the maxilla showed significant
forward movements of the maxillary dentition in both
groups, whereas this movement was more evident in
the RME/FM group. The maxillary incisors showed
significant proclination (U1-SN) in the RME/FM group,
whereas this was not seen in the MSI/FM group
(Tables 4 and 5). The increases in U1-SN, U1-VR, and
U6-VR were 6.41u, 2.78 mm, and 1.24 mm less in the
MSI/FM group than in RME/FM group, respective-
ly.These three variables were the only significant
differences between the two groups (Table 3).
Soft tissue variables showed significant improve-
ments. UL to E-plane increased 1.98 mm and 1.08 mm
in the MSI/FM vs the RME/FM group; soft tissue
convexity increased 7.41u and 7.14u, respectively
(Tables 4 and 5), whereas no significant difference
was seen between groups (Table 3).
DISCUSSION
Anatomically, the zygomatic buttress of the maxilla is a
pillar of cortical bone running along the zygomatic
process of the maxilla and zygoma. It has two cortical
plates—the buccal cortical plate and the sinus floor. This
anatomic advantage allows for bicortical fixation and
possibly contributes to better primary stability of the
miniscrew. Miniscrews achieve their retention purely
mechanically,18 so a thicker bone allows greater minis-
crew biting depth, more osseous contact and subse-
quently better primary stability of the miniscrew. Accord-
ing to Misch19 and Misch and Kircos,20 bone density of the
zygomatic buttress is greater than that of the maxillary
alveolar ridge. The zygomatic buttress is chosen as an
insertion site for orthodontic skeletal anchorage because
of its absence of adjacent tooth structure, ease of
Table 2. Comparison of Cephalometric Measurements Between the MSI/FM Group and the RME/FM Group at T1a
MSI/FM (n 5 20) RME/FM (n 5 23)
Diff t SigMean SD Mean SD
Maxillary measurements
SNA angle, degree 78.27 3.33 77.43 2.44 0.83 0.61 NS
Maxillary length (Co-A), mm 72.04 3.45 73.40 5.33 21.36 20.22 NS
Maxillary skeletal (A-N perp), mm 210.73 5.46 210.20 2.92 20.53 20.26 NS
Mandibular measurements
SNB angle, degree 81.88 2.59 81.93 1.55 20.06 20.06 NS
Mandibular length (Co-Gn), mm 104.09 5.43 105.11 5.64 21.02 20.39 NS
Mandibular skeletal (Pog-N perp), mm 214.67 9.76 211.57 6.75 23.10 20.78 NS
Gonial angle, degree 125.09 5.14 128.72 5.74 23.63 21.42 NS
Maxillomandibular measurements
ANB angle, degree 23.60 1.45 23.83 2.48 0.23 0.94 NS
Wits appraisal, mm 28.16 3.94 210.41 2.96 2.26 1.37 NS
Maxillary/mandibular differential, mm 31.43 3.38 31.72 4.60 20.29 20.15 NS
Convexity (A-N-Pog), mm 23.07 1.66 23.90 3.20 0.83 0.69 NS
Dental measurements
U1-SN, degree 102.23 7.03 102.53 5.88 20.30 20.10 NS
U1-NA, mm 4.40 2.45 5.44 2.78 21.04 20.85 NS
IMPA, degree 82.11 3.77 80.60 3.39 1.51 0.89 NS
L1-NB, mm 3.50 1.04 3.49 1.88 0.01 0.02 NS
Overbite, mm 3.53 1.44 4.29 1.57 20.76 21.06 NS
Overjet, mm 23.19 1.74 22.81 0.83 20.38 20.59 NS
U1-VR, mm 43.84 3.78 44.57 3.88 20.72 20.40 NS
U1-HR, mm 24.17 2.31 24.89 2.09 20.71 20.68 NS
U6-VR, mm 16.84 1.86 16.13 2.76 0.71 0.64 NS
U6-HR, mm 19.66 2.04 19.52 1.96 0.13 0.14 NS
Vertical measurements
Palatal plane angle (PP-SN), degree 10.94 2.22 11.49 2.56 20.54 20.48 NS
Mandibular plane angle (SN-MP), degree 33.42 3.33 34.24 3.45 20.82 20.52 NS
Anterior facial height (N-Gn), mm 107.60 4.53 106.88 7.62 0.72 0.25 NS
Posterior facial height (S-Go), mm 69.37 2.67 67.41 5.29 1.96 1.00 NS
Soft tissue measurements
UL to E-plane, mm 0.48 1.87 0.90 1.98 20.42 20.47 NS
LL to E-plane, mm 5.01 1.93 4.36 2.65 0.66 0.60 NS
Soft-tissue convexity, degree 180.63 3.01 183.78 6.70 23.16 21.29 NS
a MSI/FM indicates miniscrew implants with facemask; RME/FM, rapid maxillary expander with facemask; Diff, difference; Sig, significant; and
NS, not significant.1086 GE, LIU, CHEN, HAN, GUO
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surgical access, and subsequent ability to apply elastic
traction in addition to its thicker bone.
The zygomatic buttress has been used successfully
to place skeletal anchorage for maxillary protraction,
anterior retraction, maxillary retraction, distal move-
ment of the whole maxillary dentition, and intrusion of
the maxillary posterior teeth.4,16,17,21–23 In this study, six
miniscrews of four subjects in the MSI/FM group were
mobile and these four patients were excluded from the
sample. An additional four loose miniscrews were
replaced and afterwards remained stable throughout
the treatment. Forty-two of all 48 implants survived
until the planned orthopedic correction was completed.
The success rate of the miniscrews was 87.5%. This
coincides with results of available literatures, which
reported the mean success rate of miniscrews was
87.9% 6 7.6% ranging from 61.2% to 100%.15,24,25
Using miniscrews inserted in the maxillary zygomatic
buttress as skeletal orthopedic anchorage, one may
have concerns about the maintenance of stable
miniscrews throughout treatment; the underlying con-
cern was that excessive force applied to any tempo-
rary skeletal anchors can result in clinical failure, even
though most of the literature does not support this
idea.25–27 To date, no conclusive evidence exists
whether the amount of loading is a decisive factor
affecting the success rate of screw implants used as
orthodontic anchorage. This study showed that minis-
crews inserted in the maxillary zygomatic buttress are
a stable anchorage for maxillary protraction. The
success rate of miniscrews in this study suggests that
the MSI/FM protocol may offer a treatment alternative
Table 3. Comparison of Treatment Changes (T1–T2) Between the MSI/FM Group and the RME/FM Groupa
MSI/FM (n 5 20) RME/FM (n 5 23)
Diff t SigMean SD Mean SD
Maxillary measurements
SNA angle, degree 22.58 1.59 22.62 2.66 0.04 0.43 NS
Maxillary length (Co-A), mm 24.93 2.12 25.04 3.44 0.11 0.56 NS
Maxillary skeletal (A-N perp), mm 23.37 3.87 22.53 1.58 20.83 20.60 NS
Mandibular measurements
SNB angle, degree 1.80 0.80 1.79 1.25 0.01 0.02 NS
Mandibular length (Co-Gn), mm 22.81 1.72 23.84 4.00 1.03 0.71 NS
Mandibular skeletal (Pog-N perp), mm 0.77 5.21 2.03 4.67 21.27 20.54 NS
Gonial angle, degree 21.67 3.64 0.44 3.47 22.11 21.26 NS
Maxillomandibular measurements
ANB angle, degree 24.37 1.73 24.42 1.73 0.06 0.07 NS
Wits appraisal, mm 24.83 3.01 25.33 2.90 0.50 0.36 NS
Maxillary/mandibular differential, mm 1.94 1.34 1.21 1.73 0.73 1.01 NS
Convexity (A-N-Pog), mm 23.80 1.89 23.62 1.82 20.18 20.20 NS
Dental measurements
U1-SN, degree 21.88 3.51 28.29 3.27 6.41 4.09 **
U1-NA, mm 0.50 1.45 20.07 1.92 0.57 0.71 NS
IMPA, degree 5.57 3.63 4.01 2.23 1.56 1.10 NS
L1-NB, mm 1.60 1.32 1.02 1.02 0.58 1.04 NS
Overbite, mm 2.03 1.65 2.90 2.26 20.87 20.93 NS
Overjet, mm 26.19 1.75 25.79 1.13 20.40 20.58 NS
U1-VR, mm 21.20 1.55 23.98 2.77 2.78 2.62 **
U1-HR, mm 20.13 2.38 20.04 1.73 20.09 20.91 NS
U6-VR, mm 21.42 0.79 22.67 1.18 1.24 2.00 *
U6-HR, mm 21.11 1.79 22.10 1.16 0.99 1.38 NS
Vertical measurements
Palatal plane angle (PP-SN), degree 1.06 1.69 20.92 2.16 1.98 2.16 NS
Mandibular plane angle (SN-MP), degree 21.84 1.52 21.98 1.16 0.13 0.21 NS
Anterior facial height (N-Gn), mm 23.92 1.93 26.38 3.53 2.45 1.83 NS
Posterior facial height (S-Go), mm 21.24 1.57 23.14 3.29 1.90 1.57 NS
Soft-tissue measurements
UL to E-plane, mm 21.98 1.12 21.23 1.08 20.74 21.43 NS
LL to E-plane, mm 1.20 1.35 1.60 1.78 20.40 20.54 NS
Soft tissue convexity, degree 7.41 4.87 7.14 4.62 20.18 20.09 NS
a MSI/FM indicates miniscrew implants with facemask; RME/FM, rapid maxillary expander with facemask; Diff, difference; Sig, significant; and
NS, not significant.
* P , .05; ** P , .01; *** P , .001.
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to standard facemask therapy for Class III patients with
maxillary deficiency.
Application of 500 g to 1500 g of the total force is
recommended for the protraction of the maxilla. In this
study, forces used in the RME/FM group were about
800 g to 1000 g. In the MSI/FM group, however,
miniscrew implants were used as rigid skeletal anchors
to directly transfer forces to the sutural sides of the
maxilla by bypassing the periodontal ligament area, so
relatively low loading forces of 200 g to a maximum of
250 g per side were applied, and seemed adequate to
achieve clinical improvements. The results showed
that both groups produced similar changes in maxillary
advancement and the relative sagittal intermaxillary
discrepancy improvement with a smaller magnitude of
force in the MSI/FM group, suggesting that the forces
from the miniscrews were dispersed directly to the
circummaxillary sutures by bypassing the periodontal
ligament area of the dentition.
The response of the craniofacial complex to active
orthopedic treatment with MSI/FM and RME/FM
therapies was observed and compared. Significant
favorable changes in both maxillary and mandibular
skeletal components were noted. The treatment
effects produced by the MSI/FM therapy were similar
to those produced by the RME/FM therapy. When
compared with those reported by other investigators,
the cephalometric data of the present study showed
encouraging results. In patients treated with facemask
and various bone-borne anchors, maxillary advance-
ment ranged from 2.0 mm to 4.8 mm.4–9 Singer et al.4
reported maxillary advancement of 4 mm by using
osseointegrated implants as an adjunct to facemask
therapy. Enacar et al.5 demonstrated that the entire
Table 4. Comparison of Cephalometric Measurements of the MSI/FM Group Between T1 and T2a
T1 T2
Diff t SigMean SD Mean SD
Maxillary measurements
SNA angle, degree 78.27 3.33 80.84 2.64 22.58 24.87 **
Maxillary length (Co-A), mm 72.04 3.45 76.97 3.78 24.93 25.64 ***
Maxillary skeletal (A-N perp), mm 210.73 5.46 27.37 5.27 23.37 22.61 NS
Mandibular measurements
SNB angle, degree 81.88 2.59 80.08 2.56 1.80 6.74 ***
Mandibular length (Co-Gn), mm 104.09 5.43 106.90 5.31 22.81 24.89 **
Mandibular skeletal (Pog-N perp), mm 214.67 9.76 215.43 9.05 0.77 0.44 NS
Gonial angle, degree 125.09 5.14 126.76 5.18 21.67 21.37 NS
Maxillomandibular measurements
ANB angle, degree 23.60 1.45 0.77 1.59 24.37 27.58 ***
Wits appraisal, mm 28.16 3.94 23.32 3.59 24.83 24.82 **
Maxillary/mandibular differential, mm 31.43 3.38 29.49 3.85 1.94 4.35 *
Convexity (A-N-Pog), mm 23.07 1.66 0.73 1.86 23.80 26.03 ***
Dental measurements
U1-SN, degree 102.23 7.03 104.11 8.23 21.88 21.61 NS
U1-NA, mm 4.40 2.45 3.90 2.35 0.50 1.03 NS
IMPA, degree 82.11 3.77 76.54 6.65 5.57 4.61 *
L1-NB, mm 3.50 1.04 1.90 1.84 1.60 3.64 *
Overbite, mm 3.53 1.44 1.50 0.78 2.03 3.70 *
Overjet, mm 23.19 1.74 3.00 1.60 26.19 210.60 ***
U1-VR, mm 43.84 3.78 45.04 4.07 21.20 22.32 *
U1-HR, mm 24.18 2.31 24.31 2.12 20.13 20.17 NS
U6-VR, mm 16.84 1.86 18.27 1.75 21.42 24.37 **
U6-HR, mm 19.66 2.04 20.77 0.72 21.11 21.86 NS
Vertical measurements
Palatal plane angle (PP-SN), degree 10.94 2.22 9.89 2.34 1.06 1.88 NS
Mandibular plane angle (SN-MP), degree 33.42 3.33 35.27 3.69 21.84 23.64 *
Anterior facial height (N-Gn), mm 107.60 4.53 111.52 4.20 23.92 26.08 ***
Posterior facial height (S-Go), mm 69.37 2.67 70.61 2.79 21.24 22.38 NS
Soft tissue measurements
UL to E-plane, mm 0.48 1.87 2.46 2.20 21.98 25.03 **
LL to E-plane, mm 5.01 1.93 3.81 2.09 1.20 2.67 NS
Soft tissue convexity, degree 180.63 3.01 173.22 3.85 7.41 4.56 **
a MSI/FM indicates miniscrew implants with facemask; Diff, difference; Sig, significant; and NS, not significant.
*P , .05; ** P , .01; *** P , .001.
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maxillary complex was affected positively by 4 mm of
advancement. Kircelli et al.6 showed that 4.8-mm A-
point advancement was achieved with skeletally
anchored facemask therapy. Our results in the MSI/
FM group parallel these studies.
Two studies8,9 have shown that the facemasks in
conjunction with bone-borne anchorage devices result
in greater maxillary advancement than those with
tooth-borne anchorage devices, but this was not found
in our study. The probable reason might have been
due to magnitude of protraction force. Forces of 400 g
or at least 400 g per side were applied in both bone-
borne device group and tooth-borne device group of
those two studies. But in our study, the protraction
forces were 200 g to 250 g per side in the MSI/FM
group and 400 g to 500 g per side in the RME/FM
group. Whether higher force levels would result in
greater or more rapid orthopedic changes needs to be
elucidated in carefully controlled studies.
The incisors relationship improved significantly in
both groups as in previous studies.28,29 It has been well
documented that facemask treatment results in an
increase in maxillary incisor angulation and a decrease
in mandibular incisor angulation.1–3 A significant
amount of lingual inclination of the mandibular incisors
that was also noted previously was observed in both
groups. However, the MSI/FM group did not show the
significant proclination of maxillary incisors that was
present in the RME/FM group. Compared with the
RME/FM group, smaller changes were noted in the
amount of mesialization of maxillary incisors and
molars in the MSI/FM group. The MSI/FM protocol
actually eliminated the proclination of the maxillary
incisors and reduced the movement of the maxillary
Table 5. Comparison of Cephalometric Measurements of the RME/FM Group Between T1 and T2a
T1 T2
Diff t SigMean SD Mean SD
Maxillary measurements
SNA angle, degree 77.43 2.44 80.06 1.41 22.62 22.96 *
Maxillary length (Co-A), mm 73.40 5.33 78.44 5.10 25.04 24.41 **
Maxillary skeletal (A-N perp), mm 210.20 2.92 27.67 3.84 22.53 24.81 **
Mandibular measurements
SNB angle, degree 81.93 1.55 80.14 1.87 1.79 4.28 *
Mandibular length (Co-Gn), mm 105.11 5.64 108.96 8.51 23.84 22.89 NS
Mandibular skeletal (Pog-N perp), mm 211.57 6.75 213.60 6.89 2.03 1.31 NS
Gonial angle, degree 128.72 5.74 128.28 4.48 0.44 0.38 NS
Maxillomandibular measurements
ANB angle, degree 23.83 2.48 0.59 1.90 24.42 27.66 ***
Wits appraisal, mm 210.41 2.96 25.08 1.88 25.33 25.51 ***
Maxillary/mandibular differential, mm 31.72 4.60 30.51 5.02 1.21 2.10 NS
Convexity (A-N-Pog), mm 23.90 3.20 20.28 2.80 23.62 25.96 ***
Dental measurements
U1-SN, degree 102.53 5.88 110.82 4.21 28.29 27.59 ***
U1-NA, mm 5.44 2.78 5.51 1.88 20.07 20.10 NS
IMPA, degree 80.60 3.39 76.58 3.73 4.02 5.43 ***
L1-NB, mm 3.49 1.88 2.47 1.54 1.02 3.02 *
Overbite, mm 4.29 1.57 1.39 1.28 2.90 3.85 *
Overjet, mm 22.81 0.83 2.98 1.00 25.79 215.33 ***
U1-VR, mm 44.57 3.88 48.54 4.45 23.98 24.31 **
U1-HR, mm 24.89 2.09 24.93 2.33 20.04 20.08 NS
U6-VR, mm 16.13 2.76 18.80 3.58 22.67 26.03 ***
U6-HR, mm 19.52 1.96 21.62 2.17 22.10 25.44 **
Vertical measurements
Palatal plane angle (SN-PP), degree 11.49 2.56 12.41 2.39 20.92 21.28 NS
Mandibular plane angle (SN-MP), degree 34.24 3.45 36.22 3.50 21.98 25.14 ***
Anterior facial height (N-Gn), mm 106.88 7.62 113.26 10.67 26.38 25.42 ***
Posterior facial height (S-Go), mm 67.41 5.29 70.56 7.46 23.14 22.87 NS
Soft tissue measurements
UL to E-plane, mm 0.90 1.98 2.13 1.80 21.23 23.41 *
LL to E-plane, mm 4.36 2.65 2.76 2.52 1.60 2.69 NS
Soft tissue convexity, degree 183.78 6.70 176.64 6.16 7.14 4.64 **
a RME/FM, rapid maxillary expander with facemask; Diff, difference; Sig, significant; and NS, not significant.
* P , .05; ** P , .01; *** P , .001.
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dentition usually observed in conventional facemask
therapy. The possible explanation of these significant
differences in the changes of maxillary dentoalveolar
parameters between the two groups could be that the
MSI/FM protocol was strictly skeletal. This is an
advantage to the MSI/FM treatment, since chance of
later relapse would be minimized.
The soft tissue profile reflected the favorable
changes noted for the skeletal and dental components
of the craniofacial complex. The upper lip had a more
anterior position in relation to the E-plane. The
improvements in soft tissue convexity agree with the
data reported by Macdonald et al.29
Clinicians should be aware of some possible
drawbacks of the MSI/FM protocol such as loosening
of miniscrews, soft tissue irritation, and infection due to
poor oral hygiene. However, this treatment approach
offers an alternative to growing Class III patients with
maxillary deficiency.
CONCLUSIONS
N Miniscrews can be used as a reliable means of rigid
anchorage for maxillary protraction. The zygomatic
buttress of the maxilla is a substantial region where
skeletal anchorage can be placed.
N Compared with the RME/FM protocol, the MSI/FM
therapy produces a similar maxillary advancement
and mandibular restraining in Class III patients with
maxillary deficiency using a smaller magnitude of
protraction force.
N The MSI/FM protocol improves skeletal relationships
and soft tissue profile and eliminates the undesired
proclination of the maxillary incisors and reduces the
mesialization of the maxillary dentition, which are
present in the RME/FM therapy.
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 /ENU (Settings for the Rampage workflow.)
 >>
>> setdistillerparams
<<
 /HWResolution [2400 2400]
 /PageSize [612.000 792.000]
>> setpagedevice