Original Article

Comparison of facemask therapy effects using skeletal and tooth-borne

anchorage:
A longitudinal retrospective study
Hyeon-Jong Leea; Dong-Soon Choib; Insan Jangb; Bong-Kuen Chab

ABSTRACT
Objectives: To investigate long-term outcomes of dentoskeletal changes induced by facemask
therapy using skeletal anchorage in Class III patients and compare them to those of conventional
tooth-borne anchorage.
Materials and Methods: This retrospective study included 20 patients who received facemask
(FM) therapy with miniplates as anchorage for maxillary protraction (Miniplate/FM group, 10.6 6
1.1 years old [mean 6 SD]) and 23 patients who were treated with facemask with rapid maxillary
expander (RME/FM group, 10.0 6 1.5 years old [mean 6 SD]). Dentoskeletal changes were
evaluated using lateral cephalograms at pretreatment (T1), after facemask therapy (T2), and at the
post-pubertal stage (T3). Cephalometric changes were compared between groups and clinical
success rates at T3 were evaluated.
Results: SNA and A to N perpendicular to FH increased significantly more in the Miniplate/FM
group than in the RME/FM group when comparing short-term effects of facemask therapy (T1–T2).
ANB, Wits appraisal, Angle of convexity, mandibular plane angle, and overjet decreased
significantly more in the RME/FM group than in the Miniplate/FM group after facemask therapy
(T2–T3). A more favorable intermaxillary relationship was observed in the Miniplate/FM group than
in the RME/FM group in long-term observations (T1–T3). Clinical success rate at T3 was 95% in the
Miniplate/FM group and 85% in the RME/FM group.
Conclusions: Facemask therapy with skeletal anchorage showed a greater advancement of the
maxilla and more favorable stability for correction of Class III malocclusion in the long-term than
conventional facemask therapy with tooth-borne anchorage. (Angle Orthod. 2022;92:307–314.)
KEY WORDS: Class III malocclusion; Facemask; Skeletal anchorage; Miniplate; Rapid maxillary
expander

INTRODUCTION uncertain stability after pubertal growth.1 Despite the

difficulty in predicting growth, orthopedic therapy may
Early intervention for Class III malocclusion is one of offer a favorable growth environment and decrease the
the most challenging endeavors in orthodontics due to chances of later orthognathic surgery.
Rapid maxillary expansion (RME) and facemask
a
Postgraduate Student, Department of Orthodontics, College
therapy is a widely used treatment protocol for the
of Dentistry, Gangneung-Wonju National University, Gangneung,
South Korea. correction of Class III malocclusion with maxillary
b
Professor, Department of Orthodontics, College of Dentistry, deficiency. The short- and long-term effects of con-
Gangneung-Wonju National University, Gangneung, South ventional facemask therapy are well documented in
Korea.
Corresponding author: Dr Bong-Kuen Cha, Department of
earlier reports.1–11 A combination of the advancement
Orthodontics, College of Dentistry, Gangneung-Wonju National of the maxilla, clockwise rotation of the mandible, and
University, Jukheon-gil 7, Gangneung City, Gangwon Province mesial displacement of the maxillary dentition has
25457, South Korea been reported to contribute to the improvement of
(e-mail: [email protected])
Class III malocclusion after treatment.2–4 In long-term
Accepted: November 2021. Submitted: March 2021.
Published Online: December 29, 2021
observation, the treated group exhibited relatively
Ó 2022 by The EH Angle Education and Research Foundation, successful outcomes. However, favorable dentoskele-
Inc. tal relationships induced by early orthopedic treatment

DOI: 10.2319/032121-219.1 307 Angle Orthodontist, Vol 92, No 3, 2022

308 LEE, CHOI, JANG, CHA

Table 1. Descriptive Statistics for the Miniplate/FM Group and the RME/FM Groupa
Age (y) Interval (y)
T1 T2 T3 T1–T2 T2–T3 T1–T3
Groups n Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Miniplate/FM 20 10.6 1.1 11.7 1.2 18.4 1.8 1.1 0.4 6.5 1.6 7.7 1.6
RME/FM 23 10.0 1.5 11.1 1.5 18.8 1.8 1.0 0.3 7.5 2.7 8.8 2.7
a
FM indicates facemask; RME, rapid maxillary expansion; SD, standard deviation.

showed a tendency to be re-established with Class III craniofacial deformities, poor compliance, or cosmetic
characteristics during the pubertal growth period.1,5,7–11 surgery were excluded from the study.
Indirect force transmission through the maxillary The Miniplate/FM group consisted of 20 patients (14
dentition may limit skeletal changes and cause girls and 6 boys), and 23 patients (15 girls and 8 boys)
unwanted dental movement. Therefore, facemask with ages matching those of the Miniplate/FM group
therapy using skeletal anchorage with miniplates were included in the RME/FM group (Table 1). No
placed in the zygomatic buttress area was previously significant difference was found in age, time intervals of
introduced.12–15 In short-term observation, the skeletal T1, T2, and T3, and gender distribution between the
anchorage group showed more significant advance- groups (P . .05). Cervical vertebral maturity at T3 was
ment of the maxilla, prevention of mesial movement of stage 5 (Miniplate/FM; four patients, RME/FM; five
maxillary dentition, and control of vertical changes patients) or stage 6 (Miniplate/FM; 16 patients, RME/
compared to the conventional tooth-borne anchorage FM; 18 patients), indicating the end of circumpubertal
group after the first phase treatment with facemask growth. The long-term clinical success rates were
therapy.14 Other investigators proposed several mod- evaluated in patients who had received the second
ifications of skeletal anchorage for maxillary protrac- phase of orthodontic treatment using fixed appliances.
tion, such as miniplates on the lateral nasal walls of the An unsuccessful outcome was defined as an incisor
maxilla,16,17 bimaxillary miniplates for the application of edge-to-edge bite or a negative overjet with a Class III
protraction force by intraoral Class III elastics,18,19 or molar relationship at T3.
miniscrew-assisted RME.20
However, there have been no reports on the long- RME/FM Group
term effects of facemask therapy with skeletal anchor- Bonded or banded maxillary expanders with protrac-
age. The aims of this study were to investigate the tion hooks were applied to the maxillary teeth. The
long-term outcomes of dentoskeletal changes induced patients were instructed to activate the expanders once
by facemask therapy using miniplate anchorage in or twice a day until the desired transverse width was
Class III patients and to compare them to those of achieved. After expansion, a protraction force of 300 g
conventional tooth-borne anchorage. to 400 g per side was applied and the patients were
instructed to wear the facemask for at least 14 hours
MATERIALS AND METHODS per day. Protraction was continued until at least a
This study was approved by the ethics committee of positive overjet and a Class I or Class II molar
Gangneung-Wonju National University Dental Hospital relationship was achieved. The mean duration of
(IRB 2019-008). The sample was collected retrospec- facemask therapy in the RME/FM group was 9.0 6
tively from the records of patients who first visited the 0.3 months. After facemask therapy, two patients used
Department of Orthodontics, Gangneung-Wonju Na- a functional regulator-III or a chin cup for retention, and
tional University Dental Hospital, between 1998 and another two patients used removable acrylic plates in
2011. The inclusion criteria were: (1) patients who the maxilla for space preservation. After the pubertal
received facemask (FM) therapy with RME appliances growth spurt, the patients underwent a second phase
(RME/FM group) or miniplates as anchorage (Mini- of orthodontic treatment with fixed appliances for an
average of 2.3 years, except for three patients who
plate/FM group); (2) anterior crossbite or an edge-to-
were satisfied with their occlusion. After the second
edge incisor relationship with a Class III molar
phase of orthodontic treatment, the patients used
relationship, and Wits appraisal of -2.5 mm or less at
wraparound retainers or fixed retainers.
pretreatment (T1); and (3) lateral cephalograms avail-
able at T1, after facemask therapy (T2), and at the final
Miniplate/FM Group
observation (T3) at a post-pubertal stage according to
the cervical vertebral maturation method.21 Patients The surgical procedures for placing the miniplates
who had prior orthopedic or orthodontic treatment, were described previously.12–15 The end of the miniplate

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EFFECTS OF FACEMASK THERAPY WITH MINIPLATES 309

assess measuring errors. The method error was

calculated by Dahlberg’s formula. The mean error
was 0.5 mm for linear measurements, and 0.68 for
angular measurements.

Statistical Analysis
Because several measurements did not show a
normal distribution by Shapiro-Wilk test, nonparametric
tests were performed. The cephalometric measure-
ments were compared between the groups using the
Mann-Whitney U-test. The intragroup differences in T1-
T2, T2-T3, and T1-T3 were evaluated with the
Bonferroni-corrected Wilcoxon signed-rank test. The
statistical comparisons were performed using SPSS
software version 18.0 (SPSS, Inc., Chicago, IL, USA).
Figure 1. Intraoral photograph of elastics applied from miniplates to Post-hoc power analyses (b) were conducted for all
the facemask. variables that exhibited statistically significant differ-
ences (P , .05).
was exposed to the oral cavity between the maxillary
canine and the first premolar area and modified into a RESULTS
hook for elastics (Figure 1). The patients were
The dentoskeletal characteristics at T1 did not
instructed to wear the facemask for at least 14 hours
significantly differ between the groups, except for
per day with 300 to 400 g of force per side as in the
SNA, Wits appraisal, and L1 to MP, which were
RME/FM group. Space regaining or maxillary expan-
greater in the RME/FM group than in the Miniplate/
sion were performed with additional intraoral applianc-
FM group (Table 2). Table 3 presents the cephalomet-
es such as a pendulum, removable acrylic plate, or
ric measurements at T1, T2, and T3, and the intragroup
RME while wearing the facemask. Protraction was
differences of each group. SNA, ANB, A to N
continued until at least a positive overjet and a Class I
perpendicular FH, and the angle of convexity, Wits
or Class II molar relationship was achieved. The mean
appraisal, and mandibular plane angle (FMA) signifi-
duration of active protraction was 9.7 6 0.3 months.
cantly increased at T2 in both groups. However, during
The patients were instructed to wear the facemask at
the T2–T3 period, the angle of convexity decreased
night for retention and 14 patients showed favorable
significantly in both groups.
cooperation of wear. The mean duration of nightwear
In comparing the short-term outcomes of facemask
was 1.3 years and the total duration of protraction in
therapy (T1–T2) between the groups (Table 4), the
the Miniplate/FM group was 2.2 years. The patients
Miniplate/FM group showed a significantly greater
underwent a second phase of treatment for an average
increase in SNA (b ¼ 0.52) and A to N perpendicular
of 2.3 years, except for one patient who was satisfied
to FH (b ¼ 0.45) than the RME/FM group. There was no
with the first phase treatment outcome. After the
significant difference in changes in overjet and in the
second phase of treatment, the patients used wrap-
mean duration of protraction between the groups (P .
around retainers or fixed retainers.
.05).
Table 5 shows a comparison of the changes during
Cephalometric Analysis
the pubertal growth period after active facemask
Lateral cephalometric radiographs were taken in therapy (T2–T3) in both groups. Changes in SNA,
maximum intercuspal occlusion using the Cranex 3þ SNB, A to N perpendicular to FH, mandibular length,
(Soredex Orion Corporation, Helsinki, Finland) or the and the lower anterior facial height at T2-T3, did not
CX-90SP (Asahi Roentgen, Kyoto, Japan). The ceph- significantly differ between the groups. However, ANB
alograms were traced by one investigator on acetate (b ¼ 0.35), Wits appraisal (b ¼ 0.46), Angle of convexity
paper using a 0.5 mm pencil. Subsequently, the linear (b ¼ 0.47), FMA (b ¼ 0.61), and overjet (b ¼ 0.33)
and angular variables were measured using Quick decreased more in the RME/FM group than in the
Ceph Studio software (Quick Ceph Systems, San Miniplate/FM group.
Diego, CA, USA). The magnification factor of each As summarized in Table 6, the Miniplate/FM group
cephalogram was standardized at 8%. Fifteen lateral showed a significantly greater increase in SNA (b ¼
cephalograms were arbitrarily selected and remea- 0.47), ANB (b ¼ 0.46), Wits appraisal (b ¼ 0.55), A to N
sured by the same investigator at a 2-week interval to perpendicular FH (b ¼ 0.46), and Angle of convexity (b

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310 LEE, CHOI, JANG, CHA

Table 2. Comparison of Dentoskeletal Features at Pre-Treatment (T1) Between the Miniplate/FM Group and the RME/FM Groupa
Miniplate/FM (n ¼ 20) RME/FM (n ¼ 23)
Cephalometric Measurements Mean SD Mean SD P Value Sig
Cranial base
Saddle angle (8) 133.9 3.5 131.9 3.2 .075 NS
Maxillary skeletal
SNA (8) 77.4 2.5 79.2 3.4 .032 *
Midfacial length (Co-A) (mm) 79.2 4.6 79.3 4.0 .865 NS
A to N perpendicular FH (mm) -3.4 1.9 -3.2 3.7 .526 NS
SNO (8) 59.3 4.3 61.7 5.1 .056 NS
Mandibular skeletal
SNB (8) 79.3 3.1 80.1 3.6 .394 NS
Mandibular length (Co-Gn) (mm) 111.9 7.1 111.0 6.5 .865 NS
Gonial angle (8) 129.0 5.1 126.6 4.9 .100 NS
Maxillary/mandibular
ANB (8) -1.8 1.8 -0.9 1.8 .071 NS
Wits appraisal (mm) -9.5 2.8 -7.5 2.8 .027 *
Maxillo-mandibular differential (mm) 32.6 4.7 31.7 3.9 .635 NS
Angle of convexity (8) -4.2 3.7 -2.0 4.4 .119 NS
Vertical skeletal
Palatal plane angle (8) 0.5 2.6 1.6 3.0 .263 NS
FMA (8) 30.0 3.8 29.5 3.9 .635 NS
Lower anterior facial height (mm) 64.8 4.3 64.8 4.4 .981 NS
Dentoalveolar
U1 to FH (8) 112.3 6.3 111.9 7.6 .961 NS
L1 to MP (8) 81.5 4.5 85.6 5.8 .016 *
Overbite (mm) 2.0 2.3 2.0 2.6 .798 NS
Overjet (mm) -1.6 2.0 -1.6 1.6 .826 NS
* P , .05 (Mann-Whitney U-test).
a
FM indicates facemask; NS, Not significant; RME, rapid maxillary expansion; SD, standard deviation.

¼ 0.81) than the RME/FM group in the long-term Changes From Facemask Therapy (T1–T2)
observation (T1–T3). In contrast, no significant differ-
Significant advancement of the maxilla and clock-
ences were found in mandibular length, FMA, and
wise rotation of the mandible improved the intermax-
lower anterior facial height between the groups.
illary relationship after protraction therapy in both
Eighteen out of the 19 subjects in the Miniplate/FM
groups. The increase in SNA (þ3.18 vs þ2.18) and A
group maintained positive overjet, and only one patient
to N perpendicular FH (þ3.3 mm vs þ2.1 mm) was
showed an edge-to-edge incisal relationship at T3
greater in the Miniplate/FM group than in the RME/FM
(success rate: 95%). In the RME/FM group, 17 out of
group, which was probably related to the direct
the 20 patients maintained positive overjet, but two
transmission of the orthopedic force to the circum-
patients showed an edge-to-edge relationship and one
axillary sutures in the Miniplate/FM group. The results
patient showed an anterior crossbite at T3 (success
were consistent with those reported by investigators
rate: 85%).
using skeletal anchorage for facemask therapy.14,19,22,23
S ar et al.22 placed miniplates on a more anterior part of
DISCUSSION
the maxilla than in the current study. They also found
This was a longitudinal study of facemask therapy more maxillary advancement in the miniplate group
with skeletal anchorage in Class III children from 8 to than in the RME/FM group (SNA, þ2.538 vs þ1.838; A to
18 years of age, and the final observation was done at N perpendicular FH, þ2.53 mm vs þ1.76 mm) and the
or near the cessation of pubertal growth. By matching differences between the groups were less than in the
the mean age between the groups, which may affect current results. Cevidanes et al.,19 who used intraoral
the success of facemask therapy, an attempt was Class III elastics and bimaxillary application of mini-
made to remove bias due to age differences (Table 1). plates for maxillary protraction, found that the increase
The Miniplate/FM group showed more skeletal dis- in the midfacial length (Co-A, þ5.3 mm vs þ2.4 mm)
crepancy than the RME/FM group before facemask was greater in the miniplate group than in the
therapy (Table 2). However, it did not seem to affect conventional tooth-borne anchorage group. Hino et
the long-term treatment outcome, and the stability of al.23 also reported significant protraction of the maxilla
facemask therapy was even more favorable in the and zygomatic area when using intraoral Class III
Miniplate/FM group longitudinally. elastics to bone anchors.

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EFFECTS OF FACEMASK THERAPY WITH MINIPLATES 311

Table 3. Descriptive Statistics and Intragroup Differences of Each Group; Pre-Treatment (T1), After Facemask Therapy (T2), at the Final
Observation (T3)a
Miniplate/FM Group RME/FM Group
Intragroup Intragroup
T1 T2 T3 Difference T1 T2 T3 Difference
T1– T2– T1– T1– T2– T1–
Cephalometric Measurements Mean SD Mean SD Mean SD T2 T3 T3 Mean SD Mean SD Mean SD T2 T3 T3
Cranial base
Saddle angle (8) 133.9 3.5 134.1 3.6 133.4 3.7 NS * * 131.9 3.2 131.8 3.0 131.2 3.1 NS * *
Maxillary skeletal
SNA (8) 77.4 2.5 80.5 3.1 81.3 3.6 * * * 79.2 3.4 81.3 3.4 81.9 3.6 * NS *
Midfacial length (Co-A) (mm) 79.2 4.6 84.7 4.3 87.4 5.4 * * * 79.3 4.0 83.8 3.9 88.3 3.8 * * *
A to N perpendicular FH (mm) -3.4 1.9 -0.1 2.7 0.3 2.8 * NS * -3.2 3.7 -1.1 3.8 -0.8 4.2 * NS *
SNO (8) 59.3 4.3 61.8 4.9 61.7 4.9 * NS * 61.7 5.1 63.4 5.7 63.7 5.0 * NS *
Mandibular skeletal
SNB (8) 79.3 3.1 78.0 3.2 79.9 3.7 * * NS 80.1 3.6 78.4 3.5 81.4 4.5 * * NS
Mandibular length (Co-Gn) (mm) 111.9 7.1 115.5 6.8 124.7 6.4 * * * 111.0 6.5 114.1 6.7 127.0 7.1 * * *
Gonial angle (8) 129.0 5.1 127.4 5.0 126.0 6.0 * * * 126.6 4.9 125.6 4.9 123.1 6.4 * * *
Maxillary/mandibular
ANB (8) -1.8 1.8 2.5 2.0 1.4 1.8 * NS * -0.9 1.8 2.9 1.4 0.5 2.4 * * NS
Wits appraisal (mm) -9.5 2.8 -3.8 3.4 -3.8 2.2 * NS * -7.5 2.8 -2.3 2.4 -4.4 3.2 * * *
Maxillo-mandibular differential (mm) 32.6 4.7 30.8 5.4 37.3 5.2 * * * 31.7 3.9 30.3 4.3 38.7 4.9 * * *
Angle of convexity (8) -4.2 3.7 4.3 4.3 1.2 4.1 * * * -2.0 4.4 5.0 3.6 -1.1 5.7 * * NS
Vertical skeletal
Palatal plane angle (8) 0.5 2.6 -0.9 2.7 -0.9 2.7 * NS * 1.6 3.0 0.6 3.1 1.3 2.8 * * NS
FMA (8) 30.0 3.8 30.9 4.0 29.7 5.6 * NS NS 29.5 3.9 31.1 4.4 27.6 5.4 * * *
Lower anterior facial height (mm) 64.8 4.3 68.2 4.6 73.8 5.3 * * * 64.8 4.4 68.7 5.4 73.9 4.8 * * *
Dentoalveolar
U1 to FH (8) 112.3 6.3 114.4 5.9 119.6 6.9 NS * * 111.9 7.6 114.7 5.6 119.8 6.9 NS * *
L1 to MP (8) 81.5 4.5 80.6 7.2 85.5 7.1 NS * * 85.6 5.8 83.6 5.0 88.3 6.9 * * NS
Overbite (mm) 2.0 2.3 1.4 1.6 1.3 1.0 NS NS NS 2.0 2.6 1.8 1.9 0.7 1.0 NS NS NS
Overjet (mm) -1.6 2.0 4.1 2.1 3.2 1.3 * NS * -1.6 1.6 4.7 1.4 2.2 1.8 * * *
* P , .016 (Wilcoxon signed rank test with Bonferroni correction).
a
FM indicates facemask; NS, not significant; RME, rapid maxillary expansion; SD, standard deviation.

Previous studies14,20 showed less increase in lower excessive mandibular growth compared to the Class I
facial height in bone-anchored groups, which might control group.7,9 Direct comparisons with untreated
have been the result of more extrusion of the maxillary Class I or III controls could not be made in the present
molars during conventional tooth-anchored facemask study. However, anterior growth of the maxilla in the
therapy. However, in the present study, changes in the RME/FM group was similar with that reported previ-
vertical skeletal measurements at the short-term ously7,9 and the stability of the protracted maxilla in the
observation timepoint did not show significant differ- Miniplate/FM group was also well-maintained.
ences between the groups. Interestingly, the decrease of ANB, angle of convex-
ity, and FMA was less in the Miniplate/FM group
Changes After Active Protraction (T2–T3) compared to the RME/FM group, and the Wits
Definite forward displacement of the maxilla was not appraisal and overjet were well-maintained in the
determined after active protraction therapy (T2–T3), miniplate group during the post-protraction period
but mandibular growth was considerable with a (Table 5). This may be partly explained by the fact
significant increase in SNB and mandibular length in that a majority of the Miniplate/FM group used a
both groups. Macdonald et al.7 found that the Class III facemask for an extra year after active protraction
untreated group showed significantly less forward therapy at night for retention. The removal of RME
growth of the maxilla but greater forward movement appliances is usually recommended after the first
of the mandible compared to the Class I control group. phase treatment to prevent the possible risk of micro-
Turley9 reported that maxillary growth after RME/FM leakage and decalcification of teeth.24 In contrast,
therapy was similar to that of untreated Class III miniplates can remain without any special risk and,
children during the post-protraction observation period. thus, are used for further protraction. The decrease in
Changes at the post-protraction period were mainly FMA was more evident (-3.58) in the RME/FM group
caused by deficient maxillary growth and normal to than in the Miniplate/FM group (-1.28). Nightwear of the

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312 LEE, CHOI, JANG, CHA

Table 4. Comparison of Dentoskeletal Changes at T2–T1 Between the Miniplate/FM Group and the RME/FM Groupa
Miniplate/FM (n ¼ 20) RME/FM (n ¼ 23)
Cephalometric Measurements Mean SD Mean SD P Value Sig
Cranial base
Saddle angle (8) 0.2 0.6 -0.1 0.6 .059 NS
Maxillary skeletal
SNA (8) 3.1 1.6 2.1 1.0 .024 *
Midfacial length (Co-A) (mm) 5.5 2.8 4.5 1.6 .214 NS
A to N perpendicular FH (mm) 3.3 1.8 2.1 1.0 .008 *
SNO (8) 2.5 1.8 1.7 2.1 .064 NS
Mandibular skeletal
SNB (8) -1.3 0.9 -1.7 1.1 .218 NS
Mandibular length (Co-Gn) (mm) 3.6 3.1 3.1 1.4 .961 NS
Gonial angle (8) -1.6 1.5 -1.0 1.2 .295 NS
Maxillary/mandibular
ANB (8) 4.4 1.4 3.8 1.4 .223 NS
Wits appraisal (mm) 5.7 2.7 5.2 2.0 .429 NS
Maxillo-mandibular differential (mm) -1.9 2.1 -1.4 1.4 .278 NS
Angle of convexity (8) 8.5 3.1 7.0 2.8 .128 NS
Vertical skeletal
Palatal plane angle (8) -1.4 1.6 -1.0 1.1 .584 NS
FMA (8) 0.9 1.0 1.6 1.6 .079 NS
Lower anterior facial height (mm) 3.4 1.8 3.9 2.6 .380 NS
Dentoalveolar
U1 to FH (8) 2.1 5.6 2.8 5.6 .592 NS
L1 to MP (8) -0.9 5.5 -2.0 3.3 .289 NS
Overbite (mm) -0.6 2.0 -0.2 2.7 .752 NS
Overjet (mm) 5.7 2.4 6.3 1.7 .312 NS
* P , .05 (Mann-Whitney U-test).
a
FM indicates facemask; NS, not significant; RME, rapid maxillary expansion; SD, standard deviation.

Table 5. Comparison of Dentoskeletal Changes at T3–T2 Between the Miniplate/FM Group and the RME/FM Groupa
Miniplate/FM (n ¼ 20) RME/FM (n ¼ 23)
Cephalometric Measurements Mean SD Mean SD P Value Sig
Cranial base
Saddle angle (8) -0.7 0.8 -0.6 0.9 .660 NS
Maxillary skeletal
SNA (8) 0.8 1.2 0.6 1.3 .414 NS
Midfacial length (Co-A) (mm) 2.7 2.5 4.5 3.8 .210 NS
A to N perpendicular FH (mm) 0.4 1.3 0.3 1.4 .884 NS
SNO (8) -0.1 1.6 0.3 3.1 .990 NS
Mandibular skeletal
SNB (8) 1.9 1.7 3.0 2.6 .125 NS
Mandibular length (Co-Gn) (mm) 9.2 4.2 12.9 8.2 .268 NS
Gonial angle (8) -1.4 2.0 -2.5 3.2 .257 NS
Maxillary/mandibular
ANB (8) -1.1 1.6 -2.4 2.4 .019 *
Wits appraisal (mm) 0.0 3.0 -2.1 2.9 .022 *
Maxillo-mandibular differential (mm) 6.5 2.6 8.4 4.9 .312 NS
Angle of convexity (8) -3.1 3.4 -6.1 5.1 .027 *
Vertical skeletal
Palatal plane angle (8) 0.0 1.6 0.7 1.3 .157 NS
FMA (8) -1.2 2.3 -3.5 2.7 .011 *
Lower anterior facial height (mm) 5.6 3.6 5.2 3.4 .836 NS
Dentoalveolar
U1 to FH (8) 5.2 8.1 5.1 7.2 .752 NS
L1 to MP (8) 4.9 8.0 4.7 7.6 .913 NS
Overbite (mm) -0.1 1.4 -1.1 2.0 .079 NS
Overjet (mm) -0.9 1.5 -2.5 2.0 .012 *
* P , .05 (Mann-Whitney U-test).
a
FM indicates facemask; NS, not significant; RME, rapid maxillary expansion; SD, standard deviation.

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EFFECTS OF FACEMASK THERAPY WITH MINIPLATES 313

Table 6. Comparison of Dentoskeletal Changes at T3–T1 Between the Miniplate/FM Group and the RME/FM Groupa
Miniplate/FM (n ¼ 20) RME/FM (n ¼ 23)
Cephalometric Measurements Mean SD Mean SD P Value Sig
Cranial base
Saddle angle (8) -0.5 0.9 -0.7 0.9 .367 NS
Maxillary skeletal
SNA (8) 3.9 2.1 2.7 1.1 .022 *
Midfacial length (Co-A) (mm) 8.2 4.4 9.0 4.1 .465 NS
A to N perpendicular FH (mm) 3.7 2.1 2.4 1.4 .019 *
SNO (8) 2.4 1.7 2.0 3.1 .306 NS
Mandibular skeletal
SNB (8) 0.6 1.9 1.3 2.7 .247 NS
Mandibular length (Co-Gn) (mm) 12.8 6.0 16.0 8.1 .223 NS
Gonial angle (8) -3.0 2.0 -3.5 2.6 .487 NS
Maxillary/mandibular
ANB (8) 3.3 1.5 1.4 2.5 .004 *
Wits appraisal (mm) 5.7 2.8 3.1 2.8 .007 *
Maxillo-mandibular differential (mm) 4.6 3.0 7.0 4.6 .051 NS
Angle of convexity (8) 5.4 3.1 0.9 5.3 .022 *
Vertical skeletal
Palatal plane angle (8) -1.4 1.8 -0.3 1.6 .024 *
FMA (8) -0.3 2.6 -1.9 3.2 .061 NS
Lower anterior facial height (mm) 9.0 4.2 9.1 3.3 .626 NS
Dentoalveolar
U1 to FH (8) 7.3 9.0 7.9 8.9 .798 NS
L1 to MP (8) 4.0 4.8 2.7 8.2 .575 NS
Overbite (mm) -0.7 2.2 -1.3 2.6 .503 NS
Overjet (mm) 4.8 2.3 3.8 1.9 .137 NS
* P , .05 (Mann-Whitney U-test).
a
FM indicates facemask; NS, not significant; RME, rapid maxillary expansion; SD, standard deviation.

facemask for retention might have inhibited the clinical success rate after attaining post-pubertal
counterclockwise rotation of the mandible during skeletal maturity, and only one patient had an edge-
pubertal growth as a chin cup effect,6 and minimized to-edge incisor relationship. Based on these results,
the relapse tendency of the Class III intermaxillary facemask therapy with miniplates is expected to
relationship. achieve more predictable outcomes than conventional
therapy.
Overall Long-Term Changes (T1–T3) This retrospective study had several limitations,
The current results were in agreement with those including a small sample size and no objective
reported by Westwood et al.1 and Masucci et al.10 that evaluation of patient compliance. Several patients
the forward movement of the maxilla after RME/FM showed poor cooperation during the retention period.
therapy was relatively modest in long-term observa- Additionally, the retention protocol was different be-
tion, contrary to short-term observation. In the present tween groups because the RME/FM group could not
study, the Miniplate/FM group showed significantly keep wearing the facemask after RME removal. A
greater advancement of the maxilla and a more definite overcorrection with nightwear in the Miniplate/
favorable intermaxillary relationship compared to the FM group might have contributed to more favorable
RME/FM group at T1–T3 (Table 6). However, it long-term outcomes.
remains unclear whether Miniplate/FM therapy has a
long-term effect on growth modification of the mandi- CONCLUSIONS
ble, and further studies are needed.
Desirable dentoskeletal changes occurred in both
 The Miniplate/FM group showed superiority in max-
groups, allowing for a positive occlusal relationship at illary advancement compared to the RME/FM group
T3. Skeletal changes from facemask therapy helped to during the active treatment period, and maxillary
maintain an improved dental relationship for about 3 to growth during the post-protraction period was similar
4 years after the second phase of treatment. The in both groups.
clinical success rate of the RME/FM group (85%) in the  After facemask therapy, the intermaxillary relation-
current study was a little higher than in previous ship was better maintained in the Miniplate/FM group
reports.1,5,8,10,11 The Miniplate/FM group had a 95% compared to the RME/FM group.

Angle Orthodontist, Vol 92, No 3, 2022

314 LEE, CHOI, JANG, CHA

 After attaining post-pubertal skeletal maturity, the 12. Cha BK, Choi DS. Easy orthodontic treatments of growing
Miniplate/FM group showed more favorable dentos- children: orthopedic treatments of class III malocclusion
keletal changes and higher clinical success rates using skeletal anchorage. Kor J Dent Clin Orthod. 2006;5:
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