Tabellion and Lisson Head & Face Medicine (2024) 20:60 Head & Face Medicine

https://doi.org/10.1186/s13005-024-00462-w

RESEARCH Open Access

Dentofacial and skeletal effects of two

orthodontic maxillary protraction protocols:
bone anchors versus facemask
Maike Tabellion1* and Jörg Alexander Lisson1

Abstract
Background Maxillary retrognathia and/or mandibular prognathia are resulting in class III malocclusion. Regarding
orthodontic class III malocclusion treatment, the literature reports several treatment approaches. This comparative
clinical study investigated two maxillary protraction protocols including bone anchors and Delaire type facemask.
Methods Cephalometric radiographs of n = 31 patients were used for data acquisition. The patients were divided
into two groups according to their treatment protocol: bone anchored protraction (n = 12, 8 female, 4 male; mean
age 11.00 ± 1.76 years; average application: 13.50 ± 5.87 months) and facemask protraction (n = 19, 11 female, 8 male;
mean age 6.74 ± 1.15 years; average application: 9.95 ± 4.17 months). The evaluation included established procedures
for measurements of the maxilla, mandibula, incisor inclination and soft tissue. Statistics included Shapiro-Wilk- and
T-Tests for the radiographs. The level of significance was set at p < 0.05.
Results The cephalometric analysis showed differences among the two groups. SNA angle showed significant
improvements during protraction with bone anchors (2.30 ± 1.18°) with increase in the Wits appraisal of
2.01 ± 2.65 mm. SNA angle improved also during protraction with facemask (1.22 ± 2.28°) with increase in the Wits
appraisal of 1.85 ± 4.09 mm. Proclination of maxillary incisors was larger in patients with facemask (3.35 ± 6.18°) and
ML-SN angle increased more (1.05 ± 1.51°) than in patients with bone anchors. Loosening rate of bone anchors was
14.58%.
Conclusions Both treatment protocols led to correction of a class III malocclusion. However, this study was obtained
immediately after protraction treatment and longitudinal observations after growth spurt will be needed to verify the
treatment effects over a longer period. The use of skeletal anchorage for maxillary protraction reduces unwanted side
effects and increases skeletal effects needed for class III correction.
Keywords Maxillary retrognathia, Mandibular prognathia, Maxillary protraction, Bone anchors, Facemask

*Correspondence:
Maike Tabellion
[email protected]
1
Department of Orthodontics (G56), Saarland University, Kirrberger
Strasse 100, 66424 Homburg, Saar, Germany

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Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 2 of 14

Introduction maxilla in anterior and lateral regions. Growth of the

Class III malocclusion comprises a variety of skeletal and maxilla takes place at its articular and posterior margins
dentoalveolar anomalies coming along with maxillary thrusting in a downward and forward direction [2, 12, 14,
retrognathia or eugnathia combined with mandibular 16]. Since the growth pattern is unpredictable, it is dif-
prognathia or eugnathia [8, 11, 14]. Each patient pres- ficult to forecast which patient with class III malocclu-
ents an individual class III malocclusion with different sion can be treated successfully by orthopedic appliances
response to treatment approaches. The quality of maxil- alone or whether orthognathic surgery is required [21].
lary protraction treatment depends on the method that To our knowledge, the literature lacks studies that evalu-
is used. Extraoral maxillary protraction using a facemask ate especially the effects of the bone anchored maxillary
has been the possibility to advance the maxilla improv- protraction protocol. It was introduced by De Clerk et
ing growth during deciduous or early mixed dentition al. [11] and comprises four titanium miniplates attached
for ages. Successful advancement of the maxilla has been to the infrazygomatic crests and between the canine and
shown [2, 7]. However, unwanted side effects of face- lateral incisor of the mandibula on both sides. The litera-
mask protraction have arisen [2, 4, 11]. Studies of class ture reports several treatment approaches regarding class
III treatment effects using the facemask described in III malocclusion treatment with bone anchorage, such as
fact skeletal maxillary protraction, but also proclination hybrid hyrax in the maxilla and mentoplates in the man-
of maxillary incisors, set back of the chin with increas- dible or orthodontic mini-implants instead of titanium
ing lower face height due to clockwise rotation of the miniplates [20]. This study adds value to the current lit-
mandibula, extrusion of upper molars and retroclination erature by means of comparing different treatment meth-
of mandibular incisors depending on age of the patient, odologies for maxillary protraction particularly regarding
force, direction and duration of maxillary protraction bone anchorage using titanium miniplates in upper and
[26]. Infrequent use because of extraoral anchorage and lower jaws.
therefore less integration to daily routine of the patients
led to different treatment outcome [21, 31]. To minimize Aims of the study
the unwanted side effects and for better integration to Since many orthopedic treatment protocols regarding
daily routine, skeletal anchorage has been developed as a class III malocclusion coexist, this study investigated
new treatment method. Patients have been treated with two maxillary protraction protocols with and without
bone anchors attached to maxillary bone in the molar skeletal anchorage in growing patients. The purpose was
region and mandibular bone in the incisor region com- to evaluate skeletal, dentolaveolar and soft-tissue treat-
bined with class III elastics engaged to the bone anchors ment effects in patients with bone anchors, compared
[7]. This approach was first introduced by De Clerk et to patients with a tooth-borne facemask. Feasible com-
al. [10]. Unwanted skeletal and dental effects have been plications in conjunction with bone anchors should be
reduced and a low failure rate has been described. Stim- considered.
ulation and modification of maxillary growth must be
done at an early age. Otherwise, if the patient is advanced Methods
in age and growth is completed, orthognathic surgery is Patients
the only possibility to change maxillary and/or mandibu- The patients were divided into two groups depending on
lar position [21]. Orthopedic treatment may reduce the treatment protocol (bone anchors and facemask) with
necessity of orthognathic surgery or at least decrease the respect to age and compared to each other. Cephalomet-
extent of that treatment [7]. Correcting the sagittal devel- ric radiographs of 31 non-syndromic patients (12 bone
opment of the maxilla by postero-anterior traction can anchors, 19 facemask) at the age of 11.00 ± 1.76 years
only be done because of its forward displacement, com- (bone anchors) and 6.74 ± 1.15 years (facemask) were
pensatory reaction of the sutures, apposition-resorption identified and analyzed. All patients were exclusively
processes and development in the anterior and lateral diagnosed for orthodontic treatment at Saarland Univer-
regions. Especially sutures articulating with the fron- sity Hospital. The treated sample of patients with bone
tal, zygomatic, ethmoid and palatal bones effect maxil- anchors was collected prospectively over a period of four
lary growth. It is believed, that during facial growth, the years now, since bone anchored maxillary protraction
cartilaginous nasal septum is the primary force in pac- treatment was first introduced in our clinic at the end of
ing morphogenesis of the maxilla and the surrounding 2019. The treated sample of patients with facemask was
bones. Activity of the suture and expansion of cartilagi- collected mainly prospectively between 2019 and 2024,
nous nasal septum ceases after about seven years of age. but partially retrospectively between 2014 and 2018 to
After that apposition processes over all surfaces are the increase the number of participants.
prevalent growth mechanism [16]. Furthermore, tongue
pressure against the palatal vault leads to growth of the
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 3 of 14

Inclusion/Exclusion criteria oral and maxillofacial surgery clinic at Saarland Univer-

The presence of maxillary retrognathia (SNA angle < 79°) sity Hospital (Figs. 1 and 2). The surgery was performed
and/or mandibular prognathia (SNB angle > 81°) and by two surgeons specialized in orthognathic surgery.
Wits appraisal of ≤ 0.0 mm were the inclusion criteria for Three weeks after the surgery, maxillomandibular class
both groups. The limit for SNA angle for maxillary eug- III elastics were engaged between the upper and lower
nathia was set at 79° to 83°. The limit for SNB angle for bone anchor on each side. The initial force was 100 g
mandibular eugnathia was set at 77° to 81° [17]. Exclu- per side. The elastics had to be changed by the patients
sion criteria included comorbid syndromes and genetic at least once a day and they had to wear those 22 h per
disorders. day. A removable bite plate was placed in the lower jaw to
As a precondition, diagnostic data including digital eliminate occlusal interference. The force of the elastics
cephalometric radiographs had to be present. Data were was increased to 250 g per side after two months. Trans-
extracted from before the beginning of orthodontic treat- verse expansion of the maxilla was not performed, since
ment and at the end of maxillary protraction treatment. all patients presented congruent dental arches includ-
ing the transverse dimension. Active treatment time was
Control group 13.50 ± 5.87 months. After that, the patients were asked
The patients with bone anchors (n = 12) were compared to wear the elastics only during the night for retention
to patients with facemask (n = 19). purposes for another six months.
Since treatment with bone anchors was first introduced
in our clinic in 2019 with two to four patients per year Treatment protocol of patients with conventional facemask
agreeing with this treatment, sample size determination A hyrax expander was inserted at the beginning of the
was only partially possible. Against this background, we treatment and if necessary, rapid maxillary expansion was
collected n = 20 patients in the bone anchors group for performed by activation of the screw twice a day until the
our investigation. Since our surgeons changed the bone needed transverse dimension was achieved. Elastics were
anchor system at the beginning of 2024, the sample size attached from hooks of the hyrax expander to the cross-
matching the inclusion criteria until then was n = 12. N = 8 bar of the facemask (Fig. 3) and direction of elastic trac-
patients were excluded from the study, since n = 3 patients tion was forward and downward without interference of
showed poor compliance and ended the treatment ahead the lip. The force of the elastics was 350 g per side at the
of time and n = 5 did not want to undergo the surgical beginning and 500 g per side after two months. Patients
procedure and declined the treatment. Between 2019 and were asked to wear the facemask 16 h per day. Removable
2024 we did not have the same number of patients with bite plates were not needed. Active treatment time was
facemask, therefore, we investigated existing diagnostic 9.95 ± 4.17 months. After that, the patients were asked
data of patients with facemask treatment back until 2014. to wear the elastics only during the night for retention
Out of n = 20 patients with facemask, n = 19 patients met purposes for the remaining early orthodontic treatment
inclusion criteria, n = 1 patient was excluded. Both groups time.
did not receive prior orthodontic treatment. None of the
patients showed agenesis of permanent incisors. Cephalometric measurement
A total of 62 cephalometric radiographs of patients with
Treatment protocol of patients with bone anchors maxillary retrognathia and/or mandibular prognathia
Four titanium miniplates (PSM Medical GmbH, Gun- from one orthodontic clinic were available. A subdivision
ningen, Germany) were attached to the infrazygomatic by gender was not performed. The cephalometric radio-
crests and between the canine and lateral incisor of the graphs were measured by a single examiner using the
mandibula on both sides under general anesthesia at the

Fig. 1 Pretreatment intraoral photographs after placement of bone anchors in upper and lower jaw on both sides
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 4 of 14

Fig. 2 Panoramic radiograph with inserted bone anchors in upper and lower jaw on both sides

Landmarks and measuring technique

The parameters for evaluation of the cephalometric
radiographs were based on landmarks defined and used
by and Schwarz [28] and Segner and Hasund [29] for
calculating distances and angles (Table 1) in all groups
(Fig. 4). The following landmarks were used for cephalo-
metric analysis: Point NormA (NormA), NormB (Norm
B), Nasion (N), Sella (S), Basion (Ba), Articulare (ar),
Gonion (Go), Menton (Me), Point A (A), Point B (B),
anterior nasal spine (Spa), posterior nasal spine (Spp),
disto-buccal cuspid of the first lower molar (hPOcP),
apical point of the upper incisor (Ap1o), incisal point of
the upper incisor (Is1o), apical point of the lower inci-
sor (Ap1u), incisal point of the lower incisor (Is1u), most
anterior point of the soft tissue of the nose (Ns) with its
septum (CoTg), Subnasale (Sn), most anterior point of
the upper lip (Ls), most anterior point of the lower lip
(Li) and most anterior point of the soft tissue of the chin
(Pog´).
The angles SNA, SNB, ANB, NL-SN, ML-SN, ML-NL,
MeGoAr and Wits appraisal were used to evaluate the
sagittal and vertical position of maxilla and mandibula
and the growth pattern. The angles U1-NL and L1-ML
Fig. 3 Conventional facemask and hyrax expander with hooks
were used to evaluate the inclination of upper and lower
incisors. The nasolabial angle and the distances ULE and
software OnyxCeph® 3TM (Image Instruments GmbH, LLE were used to evaluate the soft tissue of the nose,
Chemnitz, Germany). upper and lower lip. The angle OP-ML was used to evalu-
ate the inclination of the occlusal plane.
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 5 of 14

Table 1 Cephalometric measurements and landmarks Statistical method, error of the method
Measurements Statistical analysis was performed with the SPSS software
Distances (mm) version 28 (IBM, Armonk, NY, USA). Statistics included
Wits distance between the deepest point on Shapiro-Wilk- and T-Tests for the cephalometric radio-
the curvature of the anterior surface of the
maxilla (Point A, (A)) and the deepest point
graphs. Paired samples T-Test was used for intragroup
on the curvature of the anterior surface of the differences. Independent samples T-Test was used for
mandibula (Point B, (B)) at occlusal plane level intergroup differences. The level of significance was
(distance between Point hPOcP and half of set at p < 0.05. The significance level was defined as fol-
the distance of Point Is1o and Point Is1u) lows: p ≥ 0.05 not significant, p < 0.05 significant, p < 0.01
ULE distance between the most anterior point of highly significant and p < 0.001 most highly significant.
the upper lip (Point Ls, (Ls)) and the distance
(esthetic line, (E)) between the most anterior
The effect size was tested using Cohen´s criteria (for d):
point of the soft tissue of the chin (Point Pog’, 0.2 = small effect size and low correlation, 0.5 = moderate
(Pog’)) and the most anterior point of the soft effect size and correlation, 0.8 = large effect size and high
tissue of the nose (Point Ns, (Ns)) correlation. For testing the interrater-reliability the eval-
LLE distance between the most anterior point uation process was repeated on 25% of each group two
of the lower lip (LL, (Li)) and the distance months after the first investigation to evaluate the impact
(esthetic line, (E)) between the most anterior
point of the soft tissue of the chin (Point Pog’,
of landmarking errors, which involved removing and
(Pog’)) and the most anterior point of the soft replacing the markings. The differences were statistically
tissue of the nose (Point Ns, (Ns)) analyzed using Dahlberg´s error of the method (MF) with
Angles (°) the formula MF=√(∑d2/2n), where d is the difference
SNA angle between the cranial base (SN) and the between two measurement results and n is the number
deepest point on the curvature of the ante- of duplicate measurements [9]. The MF for angular and
rior surface of the maxilla (Point A, (A))
linear measurements in the present study was < 1 for all
SNB angle between the cranial base (SN) and the
measurements. Intrarater-reliability was not tested, since
deepest point on the curvature of the ante-
rior surface of the mandibula (Point B, (B)) a single examiner conducted the investigation and the
ANB angle between the deepest point on the cur- degree of subjectivity existing despite time-shift should
vature of the anterior surface of the maxilla be minimized.
(Point A, (A)), the deepest point of the naso-
frontal suture (Nasion, (N)) and the deepest Results
point on the curvature of the anterior surface
Cephalometric measurements
of the mandibula (Point B, (B))
NL-SN angle between the distance Spa-Spp (nasal
Bone anchor (Table 2)
line, (NL)) and the cranial base (SN) Angles (Fig. 5) The changes between t0 and t1 showed
ML-SN angle between the mandibular plane (ML) active treatment effects. SNA angle showed a significant
and the cranial base (SN) increase of 2.30 ± 1.18° (t0: 80.13 ± 3.93°; t1: 82.43 ± 3.93°;
ML-NL angle between the mandibular plane (ML) p = < 0.001; d = 1.179). The maxilla moved forward. SNB
and the distance Spa-Spp (nasal line, (NL)) angle showed an increase of 0.71 ± 1.28° (t0: 81.63 ± 4.05°;
MeGoAr gonial angle: angle between the most inferior t1: 82.34 ± 4.38°; p = 0.081). The mandibula moved for-
point of the mandibular symphysis (Menton,
ward. According to the changes of the maxilla and
(Me)), the most inferior posterior point of
the mandibular angle (Gonion, (Go)) and the mandibula, ANB angle showed a significant increase
intersection of the dorsal contour of the con- of 1.58 ± 1.32° (t0: -1.51 ± 1.40°; t1: 0.08 ± 1.56°; p = 0.002;
dylar head and the contour of the posterior d = 1.324). NL-SN angle showed an increase of 0.90 ± 2.24°
cranial base (Articulare, (Ar)) (t0: 6.58 ± 2.97°; t1: 7.48 ± 2.37°; p = 0.192). The maxilla
U1-NL angle between the distance Ap1o-Is1o (longi- rotated clockwise. ML-SN angle showed a decrease of
tudinal axis of the upper central incisor, (U1))
-1.01 ± 2.84° (t0: 32.02 ± 4.26°; t1: 31.01 ± 5.67°; p = 0.244).
and the distance Spa-Spp (nasal line, (NL))
L1-ML angle between the distance Ap1u-Is1u (lon-
The mandibula rotated counterclockwise. ML-NL angle
gitudinal axis of the lower central incisor, (L1)) showed a decrease of -2.10 ± 3.73° (t0: 25.46 ± 3.13°; t1:
and the mandibular plane (ML) 23.36 ± 4.83°; p = 0.077) because of the rotation of the max-
Nasolabial angle between the distance Ls-Sn and the illa and mandibula. MeGoAr angle showed an increase of
distance Sn-CoTg 0.41 ± 4.00° (t0: 125.08 ± 4.46°; t1: 125.49 ± 6.36°; p = 0.730).
OP-ML angle between the occlusal plane (OP) and The difference was almost indistinguishable. U1-NL angle
the mandibular plane (ML) showed an increase of 1.69 ± 5.62° (t0: 112.12 ± 6.91°; t1:
113.81 ± 8.98°; p = 0.320). A proclination was recorded for
the maxillary incisors. L1-ML angle showed an increase of
2.03 ± 4.81° (t0: 85.29 ± 6.85°; t1: 87.89 ± 7.95°; p = 0.171). A
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 6 of 14

Fig. 4 Overview of the landmarks used on the cephalometric radiographs and the linear and angular parameters calculated from them according to
Schwarz and Segner and Hasund

proclination was recorded for the mandibular incisors as -4.25 ± 2.67 mm; t1: -4.83 ± 2.95 mm; p = 0.349). The differ-
well. Nasolabial angle showed an increase of 4.92 ± 17.59° ence was almost indistinguishable.
(t0: 99.25 ± 15.24°; t1: 104.17 ± 10.18°; p = 0.354). The upper The distance LLE showed a significant decrease of
lip moved forward due to maxillary and upper incisor -1.42 ± 2.02 mm (t0: -1.75 ± 2.34 mm; t1: -3.17 ± 2.98;
changes. OP-ML angle showed an increase of 1.00 ± 3.05° p = 0.033; d = 2.021). The lower lip moved backward.
(t0: 16.00 ± 4.00°; t1: 17.00 ± 4.02°; p = 0.140).
Facemask (Table 3)
Angles (Fig. 7) In this group the changes between t0 and
Distances (Fig. 6) Wits appraisal showed a signifi- t1 showed active treatment effects, too. SNA angle showed
cant increase of 2.01 ± 2.65 mm (t0: -5.43 ± 1.70 mm; t1: a significant increase of 1.22 ± 2.28° (t0: 80.30 ± 3.40°; t1:
-3.43 ± 2.31 mm; p = 0.032; d = 2.442) because of skeletal 81.52 ± 3.49°; p = 0.031; d = 2.280). The maxilla moved
and dental changes of the maxilla and the mandibula. The forward. SNB angle showed a significant decrease of
distance ULE showed a decrease of -0.58 ± 2.07 mm (t0: -0.81 ± 1.35° (t0: 80.12 ± 2.58°; t1: 79.31 ± 2.56°; p = 0.017;
d = 1.348). The mandibula moved backward. Accord-
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 7 of 14

Table 2 Bone anchors (n = 12) – cephalometric measurements: 26.06 ± 4.04°; t1: 27.74 ± 3.97°; p = < 0.001; d = 1.766) as
angles [°] and distances [mm]. t0: pretreatment visit; t1: a result of the rotation of the maxilla and mandibula.
posttreatment visit, M Mean, SD standard deviation, aPaired MeGoAr angle showed an increase of 0.40 ± 2.80° (t0:
samples T-test within group between t0-t1
128.13 ± 5.77°; t1: 128.53 ± 6.61°; p = 0.542). The differ-
Angles
ence was almost indistinguishable. U1-NL angle showed
T t0 t1 Δ
a significant increase of 3.35 ± 6.18° (t0: 104.01 ± 8.33°; t1:
M ± SD M ± SD M ± SD P valuea
107.35 ± 4.77°; p = 0.030; d = 6.184). A proclination was
SNA 80.13 ± 3.93 82.43 ± 3.93 2.30 ± 1.18 < 0.001
recorded for the maxillary incisors. L1-ML angle showed
SNB 81.63 ± 4.05 82.34 ± 4.38 0.71 ± 1.28 0.081
ANB − 1.51 ± 1.40 0.08 ± 1.56 1.58 ± 1.32 0.002
a significant decrease of -4.73 ± 5.28° (t0: 88.06 ± 8.27°; t1:
NL-SN 6.58 ± 2.97 7.48 ± 2.37 0.90 ± 2.24 0.192
83.33 ± 7.47°; p = 0.001; d = 5.281). A retroclination was
ML-SN 32.02 ± 4.26 31.01 ± 5.67 –1.01 ± 2.84 0.244
recorded for the mandibular incisors. Nasolabial angle
ML-NL 25.46 ± 3.13 23.36 ± 4.83 –2.10 ± 3.73 0.077 showed a decrease of -2.58 ± 9.47° (t0: 108.63 ± 10.09°; t1:
MeGoAr 125.08 ± 4.46 125.49 ± 6.36 0.41 ± 4.00 0.73 106.05 ± 10.97°; p = 0.251). The upper lip moved backward.
U1-NL 112.12 ± 6.91 113.81 ± 8.98 1.69 ± 5.62 0.32 OP-ML angle showed a significant increase of 2.63 ± 2.43°
L1-ML 85.29 ± 6.85 87.89 ± 7.95 2.03 ± 4.81 0.171 (t0: 14.11 ± 4.03°; t1: 16.74 ± 4.17°; p = < 0.001; d = 2.432).
Nasolabial 99.25 ± 15.24 104.17 ± 10.18 4.92 ± 17.59 0.354
OP-ML 16.00 ± 4.00 17.00 ± 4.02 1.00 ± 3.05 0.14
Distances Distances (Fig. 8) Wits appraisal showed a signifi-
T t0 t1 Δ cant increase of 1.85 ± 4.09 mm (t0: -3.83 ± 3.22 mm; t1:
M ± SD M ± SD M ± SD P -1.98 ± 2.23 mm; p = < 0.001; d = 1.705) because of skel-
valuea etal and dental changes of the maxilla and the mandib-
Wits − 5.43 ± 1.70 –3.43 ± 2.31 2.01 ± 2.65 0.032 ula. The distance ULE showed a significant increase of
ULE − 4.25 ± 2.67 –4.83 ± 2.95 − 0.58 ± 2.07 0.349 0.95 ± 1.90 mm (t0: -2.26 ± 2.54 mm; t1: -1.32 ± 2.00 mm;
LLE − 1.75 ± 2.34 –3.17 ± 2.98 –1.42 ± 2.02 0.033 p = 0.043; d = 1.900). The difference was almost indistin-
guishable.
ing to the changes of the maxilla and mandibula, ANB The distance LLE showed an increase of 0.42 ± 1.39 mm
angle showed a significant increase of 2.04 ± 1.55° (t0: (t0: 0.05 ± 2.57 mm; t1: 0.47 ± 2.63; p = 0.202). The differ-
0.16 ± 2.20°; t1: 2.20 ± 2.56°; p = < 0.001; d = 1.547). NL-SN ence was almost indistinguishable, too.
angle showed a decrease of -0.64 ± 1.88° (t0: 6.88 ± 3.07°;
t1: 6.25 ± 3.16°; p = 0.156). The maxilla rotated counter- Bone anchors versus conventional facemask – pretreatment
clockwise. ML-SN angle showed a significant increase results (Table 4)
of 1.05 ± 1.51° (t0: 32.93 ± 4.04°; t1: 33.98 ± 4.02°; p = 0.007; Angles SNA angle was smaller in patients with bone
d = 1.514). The mandibula rotated clockwise. ML-NL anchors (BAP) than in patients with facemask (FP) (BAP:
angle showed a significant increase of 1.68 ± 1.77° (t0: 80.13 ± 3.93°; FP: 80.30 ± 3.40°; Δ: -0.17; p = 0.896). SNB

Fig. 5 Bone anchors (n = 12) – cephalometric measurements: angles [°]. t0: pretreatment visit; t1: posttreatment visit
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 8 of 14

Fig. 6 Bone anchors (n = 12) – cephalometric measurements: distances [mm]. t0: pretreatment visit; t1: posttreatment visit

Table 3 Conventional facemask (n = 19) – cephalometric in patients with bone anchors (BAP) than in patients
measurements: angles [°] and distances [mm]. t0: pretreatment with facemask (FP) (BAP: 32.02 ± 4.26°; FP: 32.93 ± 4.04°;
visit; t1: posttreatment visit, M Mean, SD standard deviation, Δ: -0.91; p = 0.552). ML-NL angle was smaller in patients
a
Paired samples T-test within group between t0-t1 with bone anchors (BAP) than in patients with face-
Angles mask (FP) (BAP: 25.46 ± 3.13°; FP: 26.06 ± 4.04°; Δ: -0.60;
T t0 t1 Δ p = 0.665. MeGoAr angle was smaller in patients with
M ± SD M ± SD M ± SD P valuea bone anchors (BAP) than in patients with facemask (FP)
SNA 80.30 ± 3.40 81.52 ± 3.49 1.22 ± 2.28 0.031 (BAP: 125.08 ± 4.46°; FP: 128.13 ± 5.77°; Δ: -3.05; p = 0.131).
SNB 80.12 ± 2.58 79.31 ± 2.56 –0.81 ± 1.35 0.017
U1-NL angle was significantly larger in patients with
ANB 0.16 ± 2.20 2.20 ± 2.56 2.04 ± 1.55 < 0.001
bone anchors (BAP) than in patients with facemask (FP)
NL-SN 6.88 ± 3.07 6.25 ± 3.16 –0.64 ± 1.88 0.156
(BAP: 112.12 ± 6.91°; FP: 104.01 ± 8.33°; Δ: +8.11; p = 0.009;
ML-SN 32.93 ± 4.04 33.98 ± 4.02 1.05 ± 1.51 0.007
d = 7.761). L1-ML angle was smaller in patients with bone
ML-NL 26.06 ± 4.04 27.74 ± 3.97 1.68 ± 1.77 < 0.001
anchors (BAP) than in patients with facemask (FP) (BAP:
MeGoAr 128.13 ± 5.77 128.53 ± 6.61 0.40 ± 2.80 0.542
85.29 ± 6.85°; FP: 88.06 ± 8.27°; Δ: -2.77; p = 0.449). Nasola-
U1-NL 104.01 ± 8.33 107.35 ± 4.77 3.35 ± 6.18 0.03
bial angle was significantly smaller in patients with bone
L1-ML 88.06 ± 8.27 83.33 ± 7.47 –4.73 ± 5.28 0.001
anchors (BAP) than in patients with facemask (FP) (BAP:
Nasolabial 108.63 ± 10.09 106.05 ± 10.97 –2.58 ± 9.47 0.251
99.25 ± 15.24°; FP: 108.63 ± 10.09°; Δ: -9.38; p = 0.048;
OP-ML 14.11 ± 4.03 16.74 ± 4.17 2.63 ± 2.43 < 0.001
Distances
d = 12.299).
T t0 t1 Δ
M ± SD M ± SD M ± SD P valuea
OP-ML angle was larger in patients with bone anchors
Wits −3.83 ± 3.22 –1.98 ± 2.23 1.85 ± 4.09 < 0.001 (BAP) than in patients with facemask (FP) (BAP:
ULE −2.26 ± 2.54 –1.32 ± 2.00 0.95 ± 1.90 0.043 16.00 ± 4.00°; FP: 14.11 ± 4.03°; Δ: +1.89; p = 0.105).
LLE 0.05 ± 2.57 0.47 ± 2.63 0.42 ± 1.39 0.202
Distances Wits was smaller in patients with bone
anchors (BAP) than in patients with facemask (FP) (BAP:
angle was larger in patients with bone anchors (BAP) -5.43 ± 1.70 mm; FP: -3.83 ± 3.22 mm; Δ: -1.60; p = 0.227).
than in patients with facemask (FP) (BAP: 81.63 ± 4.05°; The distance ULE was significantly smaller in patients
FP: 80.12 ± 2.58°; Δ: +1.51; p = 0.212). ANB angle was sig- with bone anchors (BAP) than in patients with facemask
nificantly smaller in patients with bone anchors (BAP) (FP) (BAP: -4.25 ± 2.67; FP: -2.26 ± 2.54 mm; Δ: -1.99;
than in patients with facemask (FP) (BAP: -1.51 ± 1.40°; p = 0.046; d = 2.486). The distance LLE was smaller in
FP: 0.16 ± 2.20°; Δ: -1.67; p = 0.026; d = 1.936). NL-SN patients with bone anchors (BAP) than in patients with
angle was smaller in patients with bone anchors (BAP) facemask (FP) (BAP: -1.75 ± 2.34; FP: 0.05 ± 2.57 mm; Δ:
than in patients with facemask (FP) (BAP: 6.58 ± 2.97°; FP: -1.80; p = 0.059).
6.88 ± 3.07°; Δ: -0.30; p = 0.790). ML-SN angle was smaller
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 9 of 14

Fig. 7 Conventional facemask (n = 19) – cephalometric measurements: angles [°]. t0: pretreatment visit; t1: posttreatment visit

Fig. 8 Conventional facemask (n = 19) – cephalometric measurements: distances [mm]. t0: pretreatment visit; t1: posttreatment visit

Bone anchors versus conventional facemask – posttreatment anchors (BAP) than in patients with facemask (FP)
results (Table 5) (BAP: 7.48 ± 2.37°; FP: 6.25 ± 3.16°; Δ: +1.23; p = 0.255).
Angles In both groups the changes at t1 showed active ML-SN angle was significantly smaller in patients with
treatment results. SNA angle was larger in patients with bone anchors (BAP) than in patients with facemask (FP)
bone anchors (BAP) than in patients with facemask (FP) (BAP: 31.01 ± 5.67°; FP: 33.98 ± 4.02°; Δ: -2.98; p = 0.049;
(BAP: 82.43 ± 3.93°; FP: 81.52 ± 3.49°; Δ: +0.91; p = 0.508). d = 4.714). ML-NL angle was significantly smaller in
SNB angle was significantly larger in patients with bone patients with bone anchors (BAP) than in patients with
anchors (BAP) than in patients with facemask (FP) facemask (FP) (BAP: 23.36 ± 4.83°; FP: 27.74 ± 3.97°; Δ:
(BAP: 82.34 ± 4.38°; FP: 79.31 ± 2.56°; Δ: +3.03; p = 0.021; -4.38; p = 0.010; d = 4.314). MeGoAr angle was smaller in
d = 3.372). ANB angle was significantly smaller in patients patients with bone anchors (BAP) than in patients with
with bone anchors (BAP) than in patients with facemask facemask (FP) (BAP: 125.49 ± 6.36°; FP: 128.53 ± 6.61°; Δ:
(FP) (BAP: 0.08 ± 1.56°; FP: 2.20 ± 2.56°; Δ: -2.12; p = 0.015; -3.04; p = 0.217). U1-NL angle was significantly larger in
d = 2.237). NL-SN angle was larger in patients with bone patients with bone anchors (BAP) than in patients with
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 10 of 14

Table 4 Bone anchors (n = 12) versus conventional facemask facemask (FP) (BAP: 113.81 ± 8.98°; FP: 107.35 ± 4.77°;
(n = 19) – cephalometric measurements: angles [°] and distances Δ: +6.46; p = 0.014; d = 6.685). L1-ML angle was larger in
[mm]. t0: pretreatment visit, M Mean, SD standard deviation, patients with bone anchors (BAP) than in patients with
a
Independent samples T-test between groups at t0
facemask (FP) (BAP: 87.89 ± 7.95°; FP: 83.33 ± 7.47°; Δ:
Angles
+4.56; p = 0.117). Nasolabial angle was smaller in patients
Bone anchors Facemask
with bone anchors (BAP) than in patients with facemask
M ± SD M ± SD Δ P valuea
(FP) (BAP: 104.17 ± 10.18°; FP: 106.05 ± 10.97°; Δ: -1.88;
SNA 80.13 ± 3.93 80.30 ± 3.40 −0.17 0.896
p = 0.635). OP-ML angle was larger in patients with bone
SNB 81.63 ± 4.05 80.12 ± 2.58 + 1.51 0.212
ANB −1.51 ± 1.40 0.16 ± 2.20 –1.67 0.026
anchors (BAP) than in patients with facemask (FP) (BAP:
NL-SN 6.58 ± 2.97 6.88 ± 3.07 –0.30 0.79
17.00 ± 4.02°; FP: 16.74 ± 4.17°; Δ: +0.26; p = 0.432).
ML-SN 32.02 ± 4.26 32.93 ± 4.04 –0.91 0.552
ML-NL 25.46 ± 3.13 26.06 ± 4.04 –0.60 0.665
MeGoAr 125.08 ± 4.46 128.13 ± 5.77 –3.05 0.131 Distances Wits was smaller in patients with bone
U1-NL 112.12 ± 6.91 104.01 ± 8.33 + 8.11 0.009 anchors (BAP) than in patients with facemask (FP) (BAP:
L1-ML 85.29 ± 6.85 88.06 ± 8.27 –2.77 0.449 -3.43 ± 2.31 mm; FP: -1.98 ± 2.23 mm; Δ: -1.45; p = 0.060).
Nasolabial 99.25 ± 15.24 108.63 ± 10.09 –9.38 0.048 The distance ULE was significantly smaller in patients
OP-ML 16.00 ± 4.00 14.11 ± 4.03 + 1.89 0.105 with bone anchors (BAP) than in patients with facemask
Distances (FP) (BAP: -4.83 ± 2.95; FP: -1.32 ± 2.00 mm; Δ: -3.51;
Bone anchors Facemask p = < 0.001; d = 2.405). The distance LLE was signifi-
M ± SD M ± SD Δ P valuea cantly smaller in patients with bone anchors (BAP) than
Wits −5.43 ± 1.70 –3.83 ± 3.22 –1.60 0.227 in patients with facemask (FP) (BAP: -3.17 ± 2.98; FP:
ULE −4.25 ± 2.67 –2.26 ± 2.54 –1.99 0.046 0.47 ± 2.63 mm; Δ: -3.64; p = 0.001; d = 2.769).
LLE −1.75 ± 2.34 0.05 ± 2.57 –1.80 0.059
Bone anchors complications
Table 5 Bone anchors (n = 12) versus conventional facemask Local infection with granulation of the mucosa was seen
(n = 19) – cephalometric measurements: angles [°] and distances in five patients in the upper jaw on both sides and in one
[mm]. t1: posttreatment visit, M Mean, SD standard deviation, patient in the lower jaw on both sides. In eight patients
a
Independent samples T-test between groups at t1 all miniplates remained stable throughout protraction.
Angles Loosening rate was 14.58% with two patients on both
Bone anchors Facemask sides, one patient on the left side and two patients on the
M ± SD M ± SD Δ P valuea right side of the upper jaw. In four patients with loosen-
SNA 82.43 ± 3.93 81.52 ± 3.49 + 0.91 0.508 ing of the bone anchors, the bone anchors were removed
SNB 82.34 ± 4.38 79.31 ± 2.56 + 3.03 0.021 and replaced three months after removal. In one patient
ANB 0.08 ± 1.56 2.20 ± 2.56 –2.12 0.015 with loosening of the bone anchor on the left side, loos-
NL-SN 7.48 ± 2.37 6.25 ± 3.16 + 1.23 0.255 ening was low and elastic wear was still possible after
ML-SN 31.01 ± 5.67 33.98 ± 4.02 –2.98 0.049 consultation with the surgeons. Loosening was recog-
ML-NL 23.36 ± 4.83 27.74 ± 3.97 –4.38 0.01
nized in four patients after three months of elastic wear
MeGoAr 125.49 ± 6.36 128.53 ± 6.61 –3.04 0.217
and in one patient after four months of elastic wear.
U1-NL 113.81 ± 8.98 107.35 ± 4.77 + 6.46 0.014
L1-ML 87.89 ± 7.95 83.33 ± 7.47 + 4.56 0.117
Discussion
Nasolabial 104.17 ± 10.18 106.05 ± 10.97 –1.88 0.635
Bhatia and Leighton [3] described natural growth of the
OP-ML 17.00 ± 4.02 16.74 ± 4.17 + 0.26 0.432
maxilla at the age of ten to twelve years by an increase of
Distances
SNA angle of 0.5° and natural growth of the mandibula at
Bone anchors Facemask
that age by an increase of SNB angle of 0.6°. Modifying
M ± SD M ± SD Δ P valuea
facial growth using orthopedic forces has been of special
Wits − 3.43 ± 2.31 –1.98 ± 2.23 –1.45 0.06
ULE − 4.83 ± 2.95 –1.32 ± 2.00 -3.51 < 0.001
interest in orthodontists for ages, since maxillary pro-
LLE − 3.17 ± 2.98 0.47 ± 2.63 –3.64 0.001
traction was pioneered by Delaire in the 1970s [14]. For-
ward movement of the maxilla by 1–2 mm, a 3° increase
in SNA, 1.02° decrease in SNB and a reduction in ANB of
-2.43° were described with wide variations [5, 8, 10, 14,
18]. Improved dental arch relationships mostly because
of dentoalveolar compensation were the results of maxil-
lary protraction with facemask [11]. In literature, the
ideal treatment timing for orthopedic treatment of class
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 11 of 14

III malocclusion with maxillary retrognathia was at the face contour and normal occlusion after the treatment.
age of five to eight years during deciduous and early There was no relapse described after a six months follow-
mixed dentition [14, 23]. Six months after maxillary pro- up. Kircelli and Pektas [21] used miniplates on the lateral
traction, the maxilla showed forward movement, but also nasal wall of the maxilla in six patients at the mean age of
proclination of upper incisors and extrusion of maxillary 11.8 ± 1.1 years and attached them to a facemask for
molars resulting in increased lower face height and the 10.8 ± 2.4 months. The infraorbital region moved
mandibula rotating in posterior direction. Correction of 3.3 ± 1.1 mm forward. Point A moved 4.8 ± 2.0 mm for-
the class III malocclusion was due to forward movement ward. The results remained stable over the 15.2 ± 0.9
of the maxilla, but also clockwise rotation of the mandib- months follow-up period. They concluded that skeletal
ula. Therefore, correction of the overjet was because of anchorage combined with a facemask leads to remark-
dental and skeletal changes [19, 23]. Unwanted dental able advancement of the midface and soft-tissue profile
and skeletal side effects, such as proclination of upper in the late mixed-dentition period. Bone anchors and
incisors and clockwise rotation of the mandibula, were class III elastics without additional corticotomy or oste-
also seen in patients with facemask of our study. Success otomy was pioneered by De Clerck et al. in the 2000s
and failure of class III malocclusion treatment depends [11]. Extraoral facemask was no longer needed with this
on the potential of growth and treatment is requiring a approach and elastics can be worn all over the day. In this
long-term period, making patient´s motivation difficult study, De Clerck et al. described the treatment of three
in the long run [23, 30]. Therefore, knowing the ideal tim- female patients with maxillary deficiency and a concave
ing for facemask therapy to obtain better treatment soft tissue profile at the age of ten to eleven years. Ante-
results is indispensable. Takada et al. [30] described the rior crossbite was corrected in all three patients after
maximum peak of maxillary growth between ten to treatment and the soft tissue profile improved. The ceph-
twelve years of age for girls and twelve to thirteen years alometric radiographs showed an improvement of ANB,
for boys. This claim is contentious. Other than that, Alex- Wits appraisal and facial convexity. Upper incisor inclina-
ander et al. suggested that the maximum peak of maxil- tion remained stable during treatment, lower incisors
lary growth occurs during the prepubertal period [1]. were proclined afterwards. The class III correction was
Orthopedic class III malocclusion treatment shows the stable from the end of treatment to a 11- and 38-months
best results when the facemask is applied before the follow-up. In a later study, De Clerck et al. [13] treated
pubertal growth spurt, because the suture´s adaptability twenty-five Class III patients at the mean age of
and response to maxillary protraction decreases with age 11.10 ± 1.1 years with bone anchors and Class III elastics
[11, 24, 30]. Dibbets and van der Weele [15] investigated and took cone-beam computed tomography images
the treatment with the facemask and its forces regarding before elastic wear and after treatment. They reported a
temporomandibular joint dysfunction. They reported no posterior displacement of the mandibula after the treat-
causal relationship of facemask treatment with temporo- ment in all patients. The displacement of the posterior
mandibular joint dysfunction even with a 500 g force on ramus was 2.74 ± 1.36 mm, of the condyles,
each side. In our study, neither patients with bone 2.07 ± 1.16 mm and of the chin − 0.13 ± 2.89 mm. Even
anchors nor patients with facemask showed symptoms of remodeling of the mandibular fossa at its anterior emi-
temporomandibular joint disfunction before or after nence was 1.38 ± 1.03 mm and resorption of bone of the
treatment. To reduce unwanted side effects of facemask posterior region was − 1.34 ± 0.06 mm. Cevidanes et al.
therapy, titanium bone anchors were used some years [4] compared 21 patients with bone anchors at the mean
later for maxillary protraction being well tolerated by the age of 11 years 10 months ± 1 year 10 months and 34
patients [6, 10, 11]. Maxillary protraction was performed patients with facemask at the mean age of 8 years 3
using a rigid external distractor, a facemask after Le Fort I months ± 1 year 10 months after one year of treatment.
corticotomy in patients with a cleft or a combination of Maxillary advancement and midfacial length were about
skeletal anchorage in the upper jaw and facemask [10]. 2.5–3.0 mm larger in patients with bone-anchors. There
Liu et al. [22] described a technique using bone anchored were no differences between sagittal growth and position
hooks combined with facemask and additional sutural of the mandibula between the two groups. Maxilloman-
distraction for correction in four patients at the age of six dibular divergency was decreased of about 3° in patients
to twelve years or Le Fort III osteotomy in four patients with bone anchors, slight counterclockwise rotation of
older than twelve years with and without cleft lip and pal- the mandibula was noted in patients with bone anchors
ate. No complications concerning surgery process or and clockwise rotation of the mandibula was seen in
loosening of the bone-born hooks for distraction patients with facemask. Patients with bone anchors did
occurred. The midface advancement was 8 mm in not show the same amount of lingual inclination of lower
patients with sutural distraction and 10 mm in patients incisors as patients with facemask did. Nguyen et al. [26]
with Le Fort III osteotomy with remarkable changes in reported their results of twenty-five Class III patients at
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 12 of 14

the mean age of 11.10 ± 1.1 years treated with bone higher than in our facemask group, since we did not use
anchors and Class III elastics. Cone-beam computed mini-implants. Ngan et al. [25] compared 20 class III
tomography images before elastic wear and after treat- patients (mean age 9.8 ± 1.6 years) with tooth-borne rapid
ment showed a mean forward displacement of the max- palatal expansion appliance and facemask and 20 class III
illa of 3.7 mm and of the zygomas of 4.3 mm, but also patients (mean age 9.6 ± 1.2 years) with bone-anchored
incisors came forward 3.7 mm. De Clerck and Swennen rapid palatal expansion appliance and facemask. The
[10] described the success rate of miniplates concerning tooth-borne facemask group showed more proclination
stability with 97% in twenty-five patients with mean age of maxillary incisors (2.12 mm), the bone-anchored face-
12.0 ± 1.2 years, but during elastic use five miniplates out mask group showed less downward movement of Point A
of hundred showed signs of mobility. Two miniplates (-0.4 mm) than the tooth-borne facemask group (1.2 mm)
were stable again, after the patients stopped using elastics and less opening of the mandibular plane in the bone-
for two months. The other three miniplates were anchored facemask group (-0.25°) than in the tooth-
removed and replaced after three months of healing. borne facemask group (2.76°). The results of the
Contrary to expectations Cornelis et al. [7] concluded in tooth-borne facemask group were comparable to the
their systematic review of 28 full-text articles concerning results of our study. Regarding failure rate, the hybrid-
bone-anchored maxillary protraction that the level of hyrax with palatal mini-screws could be an alternative to
evidence available for supporting maxillary protraction the bone anchors used in our study. However, treatment
effect using bone anchors was low. They remarked identi- with mini-screws is not covered by the statutory health
cal samples in publications reporting results that tended insurance (GKV) applying to our patients. Since most of
to suggest positive results using bone anchors for class III those were dependent on treatment modalities covered
malocclusion treatment. They even questioned clinical by the statutory health insurance, they decided on bone
significance concerning the differences in sagittal correc- anchors as described in our study.
tion between bone anchors and facemask and recom- The observed failure of the bone anchors was mainly
mended long-term follow-up results. In a newer study due to poor oral or hand hygiene, which led to infections
Kamel et al. [20] reported their results of seventeen Class and subsequent loosening of the bone anchors. There-
III patients during late mixed or early permanent denti- from, better hygiene could lower the failure rate.
tion treated with a hybrid hyrax expander and class III Early treatment of class III patients, as shown in our
elastics to a bone-supported bar in the mandibula for study at the age of 6.74 ± 1.15 years for facemask patients,
about one year compared to thirteen patients without aimed to effect maxillary growth at sutures articulating
treatment. SNA angle showed an increase in the treated with the frontal, zygomatic, ethmoid and palatal bones.
group of 4.64 ± 0.95° and in the control group of Later treatment of class III patients, as shown in our
0.42 ± 0.21°. SNB angle showed a decrease in the treated study at the age of 11.00 ± 1.76 years for bone anchor
group of -0.25 ± 0.47° and in the control group an increase patients, aimed to effect apposition processes over all
of 1.03 ± 0.59°. ANB angle showed an increase in the surfaces, as this is the predominant growth mechanism
treated group of 4.90 ± 1.31° and a decrease in the control after the end of suture activity at around seven years of
group of -0.61 ± 0.55°. Wits appraisal showed an increase age [16].
in the treated group of 5.27 ± 1.07° and in the control In both groups, changes at t1 showed active treatment
group of 0.28 ± 0.45°. The lower face height increased in outcomes of the facemask or bone anchors, including
the treated group and the mandibula showed a clockwise possible growth effects that may occur between six and
rotation with closure of gonial angle. Maxillary and man- eleven years of age. Nonetheless, the maxilla moved
dibular incisors showed proclination in the treated group. more forward in patients with bone anchors (2.30 ± 1.18°)
Mesialization and extrusion of upper molars were seen in than in patients with facemask (1.22 ± 2.28°). Contrary
the treated group. Nienkemper et al. [27] reported their to expectations, the mandibula moved more forward
results of 16 growing class III children (mean age 9.5 ± 1.6 in patients with bone anchors (0.71 ± 1.28°) than in
years) treated with a hybrid hyrax-facemask combination patients with facemask (-0.81 ± 1.35°) as well. Accord-
using pre- and posttreatment cephalograms compared ingly, the ANB angle was smaller in patients with bone
with a control group of 16 untreated Class III subjects. anchors (0.08 ± 1.56°) than in patients with facemask
The mean treatment duration was 5.8 ± 1.6 months. The (2.20 ± 2.56°) after treatment. A clockwise rotation of
results showed significant improvement in SNA (2.4°), the maxilla was more expressed in patients with bone
SNB (-1.7°) and Wits appraisal (4.5 mm). Comparison of anchors (0.90 ± 2.24°) than in patients with facemask
the treatment and the control group showed a larger (-0.64 ± 1.88°). The clockwise rotation of jaws increases
gonial angle in the control group. All mini-implants in the ANB angle as well. Clockwise rotation of the mandib-
the treatment group remained stable during treatment. ula was less in patients with bone anchors (-1.01 ± 2.48°)
Compared to the results of our study, these values were than in patients with facemask (1.05 ± 1.51°). Divergency
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 13 of 14

of the maxilla and the mandible was less in patients with growing patients with a skeletal class III for whom treat-
bone anchors (-2.10 ± 3.73°) than in patients with face- ment is indicated should not be left untreated for ethical
mask (1.68 ± 1.77°). Mandibular angle change was almost reasons.
the same in patients with bone anchors (0.41 ± 4.00°) Finally, certain clinical aspects of the two treatment
and in patients with facemask (0.40 ± 2.80°) resulting approaches of our study must be considered. The extra-
in a horizontal growth pattern in patients with bone oral facemask is more bulky and less tolerated than intra-
anchors and in a vertical growth pattern in patients with oral bone anchors and class III elastics. The amount of
facemask. Forward movement of upper incisors was facemask use per day is smaller than for bone anchors.
less in patients with bone anchors (1.69 ± 5.62°) than in Two surgical procedures are required for the bone
patients with facemask (3.35 ± 6.18°). Forward move- anchors, that is, the insertion and removal of the mini-
ment of lower incisors was greater in patients with bone plates. After protraction of the upper jaw, however, the
anchors (2.03 ± 4.81°) than in patients with facemask bone anchors can be used for anchoring or distalisa-
(-4.73 ± 5.28°), since the chin cap part of the facemask tion during subsequent orthodontic treatment. In addi-
influences the lower incisor inclination in terms of back- tion, bone anchors are a useful treatment approach for
ward movement of the incisors. Movement of the inci- patients whose facemask therapy had not been success-
sors influences the anterior region of the upper and lower ful, and as an attempt to avoid or at least to decrease
jaw and influences ANB angle as well. Nasolabial angle the amount of later orthognathic surgery, especially in
got larger in patients with bone anchors (4.92 ± 17.59°) patients that have been too old for facemask treatment.
than in patients with facemask (-2.58 ± 9.47°), mainly
because the patients with bone anchors presented greater Conclusions
initial proclination of the upper incisors already prior Bone anchors and facemask therapy improves the rela-
to treatment. The change of the occlusal plane incli- tionship of the maxilla and mandibula in class III mal-
nation was only significant in patients with facemask occlusion patients and leads to favorable outcomes.
(2.63 ± 2.43°), whereas it was almost indistinguishable Skeletal and soft tissue changes were remarkable for the
in patients with bone anchors (1.00 ± 3.05°). Wits was short term for both groups. Unwanted side effects were
smaller but improved more during treatment in patients reduced using bone anchors. Nevertheless, even with
with bone anchors (2.01 ± 2.65 mm) than in patients with bone anchors complications could not be avoided. How-
facemask (1.85 ± 4.09 mm), depending on the changes of ever, bone anchors are capable of being integrated easily
the maxilla and the mandibula and incisor inclination of into everyday life, because elastics could be worn even
both jaws. at school. Nonetheless, larger patient numbers are nec-
The forward movement of the upper lip was less in essary for a final assessment, especially regarding long-
patients with bone anchors (-0.58 ± 2.07 mm) than in term stability and possible later need for orthognathic
patients with facemask (0.95 ± 1.90 mm), depending on surgery.
the movement of the maxilla and upper incisors. Back-
Author contributions
ward movement of the lower lip was less in patients with Concept: M. T. and J. A. L. Execution and data collection: M. T. Preparation of
bone anchors (-1.42 ± 2.02 mm) than in patients with Figures and Tables: M. T. Data analysis: M. T. Manuscript writing: M. T. Revision
facemask (0.42 ± 1.39 mm), depending on the movement and approval of manuscript: J. A. L.The final manuscript has been approved by
all authors.
of the mandibula and lower incisors.
All patients with a facemask presented a change of Funding
the deciduous to the permanent upper and lower inci- This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
sors during treatment. This change influenced upper and Open Access funding enabled and organized by Projekt DEAL.
lower incisor inclination as well. Due to the age discrep-
ancy of patients with facemask and with bone anchors, Data availability
No datasets were generated or analysed during the current study.
a clear comparison of the two maxillary protraction pro-
tocols is limited, but nevertheless of significant clinical
Declarations
interest, since patients requiring treatment for a skeletal
class III are referred to the orthodontist at different ages. Ethical approval
The ideal control for both groups of our study would This article does not contain any studies with human participants or animals
performed by any of the authors. Ethical approval for this study was granted
consist of untreated growing class III patients with cor- by the Ethical Committee of Ärztekammer des Saarlandes, Saarbrücken,
responding age. However, the ALARA principle pro- Germany (Decision Number: 240/21). The need for approval was waved.
hibits X-rays in patients without appropriate treatment.
Informed consent
Our study comprised cephalometric radiographs in For this type of study, formal consent is not required. Consent to publish a
patients with immediate treatment need. Apart from this, pretreatment intraoral photograph was obtained from the participant and the
parents.
Tabellion and Lisson Head & Face Medicine (2024) 20:60 Page 14 of 14

Competing interests 16. Enlow DH, Bang S. Growth and remodeling of the human maxilla. Am J
The authors declare no competing interests. Orthod. 1965;51:446–64. https://doi.org/10.1016/0002-9416(65)90242-3.
17. Franke R. (2007) Kephalometrische Charakterisierung eines kieferorthopä-
Received: 18 July 2024 / Accepted: 6 October 2024 dischen Patientenkollektivs anhand multivariat-statistischer Analysen. Dis-
sertation, Greifswald.
18. Hata S, Itoh T, Nakagawa M, Kamogashira K, Ichikawa K, Matsumoto M,
Chaconas SJ. Biomechanical effects of maxillary protraction on the cranio-
facial complex. Am J Orthod Dentofac Orthop. 1987;91:305–11. https://doi.
References org/10.1016/0889-5406(87)90171-5.
1. Alexander AE, McNamara JA Jr, Franchi L, Baccetti T. Semilongitudinal 19. Ishii H, Morita S, Takeuchi Y, Nakamura S. Treatment effect of combined
cephalometric study of craniofacial growth in untreated class III malocclu- maxillary protraction and chincap appliance in severe skeletal class
sion. Am J Orthod Dentofac Orthop. 2009;135. https://doi.org/10.1016/j. III cases. Am J Orthod Dentofac Orthop. 1987;92:304–12. https://doi.
ajodo.2008.06.025. :700.e1-14. org/10.1016/0889-5406(87)90331-3.
2. Baccetti T, Franchi L, McNamara JA Jr. Treatment and posttreatment 20. Kamel AM, Tarraf NE, Fouda AM, Hafez AM, El-Bialy A, Wilmes B. Dentofacial
craniofacial changes after rapid maxillary expansion and facemask therapy. effects of miniscrew-anchored maxillary protraction on prepubertal children
Am J Orthod Dentofac Orthop. 2000;118:404–13. https://doi.org/10.1067/ with maxillary deficiency: a randomized controlled trial. Prog Orthod.
mod.2000.109840. 2023;24:22. https://doi.org/10.1186/s40510-023-00473-4.
3. Bhatia SN, Leighton BC. A Manual of Facial Growth. A computer analysis of 21. Kircelli BH, Pektas ZO. Midfacial protraction with skeletally anchored face
Longitudinal Cephalometric Growth Data. New York: Oxford University Press; mask therapy: a novel approach and preliminary results. Am J Orthod Dento-
1993. fac Orthop. 2008;133:440–9. https://doi.org/10.1016/j.ajodo.2007.06.011.
4. Cevidanes L, Baccetti T, Franchi L, McNamara JA Jr, De Clerck H. Comparison 22. Liu C, Hou M, Liang L, Huang X, Zhang T, Zhang H, Ma X, Song R. Sutural
of two protocols for maxillary protraction: bone anchors versus face mask distraction osteogenesis (SDO) versus osteotomy distraction osteogenesis
with rapid maxillary expansion. Angle Orthod. 2010;799–806. https://doi. (ODO) for midfacial advancement: a new technique and primary clini-
org/10.2319/111709-651.1. cal report. J Craniofac Surg. 2005;16:537–48. https://doi.org/10.1097/01.
5. Chong YH, Ive JC, Artun J. Changes following the use of protraction headgear scs.0000159083.21931.c5.
for early correction of Class III malocclusion. Angle Orthod. 1996;66:351–62. 23. Merwin D, Ngan P, Hagg U, Yiu C, Wei SH. Timing for effective application of
https://doi.org/10.1043/0003-3219(1996)066<0351:CFTUOP>2.3.CO;2. anteriorly directed orthopedic force to the maxilla. Am J Orthod Dentofac
6. Cornelis MA, Scheffler NR, Nyssen-Behets C, De Clerck HJ, Tulloch JF. Patients’ Orthop. 1997;112:292–9. https://doi.org/10.1016/S0889-5406(97)70259-2.
and orthodontists’ perceptions of miniplates used for temporary skeletal 24. Mitani H. Occlusal and craniofacial growth changes during puberty. Am J
anchorage: a prospective study. Am J Orthod Dentofac Orthop. 2008;133:18– Orthod. 1977;72:76–84. https://doi.org/10.1016/0002-9416(77)90126-9.
24. https://doi.org/10.1016/j.ajodo.2006.09.049. 25. Ngan P, Wilmes B, Drescher D, Martin C, Weaver B, Gunel E. Comparison of
7. Cornelis MA, Tepedino M, Riis NV, Niu X, Cattaneo PM. Treatment effect of two maxillary protraction protocols: tooth-borne versus bone-anchored
bone-anchored maxillary protraction in growing patients compared to protraction facemask treatment. Prog Orthod. 2015;16:26. https://doi.
controls: a systematic review with meta-analysis. Eur J Orthod. 2021;43:51–68. org/10.1186/s40510-015-0096-7.
https://doi.org/10.1093/ejo/cjaa016. 26. Nguyen T, Cevidanes L, Cornelis MA, Heymann G, de Paula LK, De Clerck
8. Cozzani G. Extraoral traction and class III treatment. Am J Orthod. H. Three-dimensional assessment of maxillary changes associated with
1981;80:638–50. https://doi.org/10.1016/0002-9416(81)90266-9. bone anchored maxillary protraction. Am J Orthod Dentofac Orthop.
9. Dahlberg G. Statistical methods for Medical and Biological students. New 2011;140:790–8. https://doi.org/10.1016/j.ajodo.2011.04.025.
York: Intersience; 1940. 27. Nienkemper M, Wilmes B, Franchi L, Drescher D. Effectiveness of maxillary
10. De Clerck EE, Swennen GR. Success rate of miniplate anchorage for bone protraction using a hybrid hyrax-facemask combination: a controlled clinical
anchored maxillary protraction. Angle Orthod. 2011;81:1010–3. https://doi. study. Angle Orthod. 2015;85:764–70. https://doi.org/10.2319/071614-497.1.
org/10.2319/012311-47.1. 28. Schwarz AM. Roentgenostatics. A practical evaluation of the X-ray headplate.
11. De Clerck HJ, Cornelis MA, Cevidanes LH, Heymann GC, Tulloch CJ. Orthope- Am J Orthod. 1961;47:561–85.
dic traction of the maxilla with miniplates: a new perspective for treatment 29. Segner D, Hasund A. Individualisierte Kephalometrie. Hamburg: Dietmar
of midface deficiency. J Oral Maxillofac Surg. 2009;67:2123–39. https://doi. Segner. Verlag und Vertrieb; 1998.
org/10.1016/j.joms.2009.03.007. 30. Takada K, Petdachai S, Sakuda M. Changes in dentofacial morphology in
12. De Clerck H, Cevidanes L, Baccetti T. Dentofacial effects of bone-anchored skeletal class III children treated by a modified maxillary protraction head-
maxillary protraction: a controlled study of consecutively treated Class gear and a chin cup: a longitudinal cephalometric appraisal. Eur J Orthod.
III patients. Am J Orthod Dentofac Orthop. 2010;138:577–81. https://doi. 1993;15:211–21. https://doi.org/10.1093/ejo/15.3.211.
org/10.1016/j.ajodo.2009.10.037. 31. Yepes E, Quintero P, Rueda ZV, Pedroza A. Optimal force for maxillary protrac-
13. De Clerck H, Nguyen T, de Paula LK, Cevidanes L. Three-dimensional assess- tion facemask therapy in the early treatment of class III malocclusion. Eur J
ment of mandibular and glenoid fossa changes after bone-anchored class Orthod. 2014;36:586–94. https://doi.org/10.1093/ejo/cjt091.
III intermaxillary traction. Am J Orthod Dentofac Orthop. 2012;142:25–31.
https://doi.org/10.1016/j.ajodo.2012.01.017.
14. Delaire J. Maxillary development revisited: relevance to the orthopaedic Publisher’s note
treatment of Class III malocclusions. Eur J Orthod. 1997;19:289–311. https:// Springer Nature remains neutral with regard to jurisdictional claims in
doi.org/10.1093/ejo/19.3.289. published maps and institutional affiliations.
15. Dibbets JM, van der Weele LT. Extraction, orthodontic treatment, and cra-
niomandibular dysfunction. Am J Orthod Dentofac Orthop. 1991;99:210–9.
https://doi.org/10.1016/0889-5406(91)70003-F.