Original Article

Comparison between two bone anchored force systems for correction of

skeletal Class II malocclusion in growing patients: a randomized controlled
clinical trial, part 1: short-term skeletal changes
Yasmine M. Mahmouda; Sherief H. Abdel-Haffiezb; Eiman S. Marzoukc;
Adham A. El Ashwahd; Hanan A. Ismaile

ABSTRACT
Objectives: To compare the treatment effects of pushing or pulling force mechanics applied to

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bimaxillary miniplates with those of deferred treatment control patients to evaluate mandibular
skeletal growth changes in growing patients with skeletal Class II malocclusion due to mandibular
deficiency.
Materials and Methods: Thirty-nine patients (24 males, 15 females; mean age ¼ 11.59 6
0.56 years) were equally and randomly assigned to one of three groups: Group A, skeletally
anchored fixed-functional appliance (pushing mechanics); Group B, skeletally anchored Class II
spring (pulling mechanics); and Group C, deferred treatment skeletal Class II control patients.
Pretreatment and posttreatment cone-beam computed tomography scans were used for assess-
ment of measurements (time interval: 11.52 6 0.32, 11.53 6 0.31, and 9.63 6 0.22 months for
groups A, B, and C, respectively).
Results: Relative to the control group, both intervention groups showed significant increases in
effective mandibular length (Co-Gn), with mean differences of 5.08 6 2.25 mm in Group A, and
3.83 6 2.79 mm in Group B. A significant improvement in the sagittal relationship was observed
in both groups, with reductions in ANB angle by 4.31° in Group A, and 5.5° in Group B. The man-
dibular plane angle was increased significantly in Group B by 1.83 6 0.72°.
Conclusion: Mandibular growth was enhanced using either pushing or pulling skeletally
anchored force mechanics. The use of pulling force mechanics, specifically, was associated with
increases in lower facial height. (Angle Orthod. 2025;00:000–000.)
KEY WORDS: Developing Class II malocclusion; Miniplates; Fixed functional appliance; Class II
springs; Skeletal anchorage

INTRODUCTION among different samples in the Egyptian population.2,3

Conventional functional appliances have been used for
Skeletal Class II malocclusion is a common diagno- decades to treat mandibular deficiency in growing
sis in patients pursuing orthodontic intervention.1 It was patients, despite the contentious evidence regarding
found that skeletal Class II malocclusion due to man- their efficiency.4 Authors of recent systematic reviews
dibular deficiency represented approximately 20–27% have revealed that functional tooth-borne appliances

a
PhD Resident, Department of Orthodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
b
Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
c
Professor, Department of Orthodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
d
Professor, Department of Oral Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt.
e
Professor, Department of Orthodontics, Faculty of Dentistry, Alexandria University; and Professor, Department of Orthodontics,
Faculty of Dentistry, Pharos University, Alexandria, Egypt.
Corresponding author: Dr Yasmine M. Mahmoud, Department of Orthodontics, Faculty of Dentistry, Alexandria University,
Champollion St., P. O. Box: 21521, Azarita, Alexandria, Egypt
(e-mail: [email protected])
Accepted: June 19, 2025. Submitted: November 13, 2024.
Published Online: July 28, 2025
Ó 2025 by The EH Angle Education and Research Foundation, Inc.

DOI: 10.2319/111324-934.1 1 Angle Orthodontist, Vol 00, No 00, 2025

2 MAHMOUD, ABDEL-HAFFIEZ, MARZOUK, EL ASHWAH, ISMAIL

Table 1. Eligibility Criteria

Inclusion Criteria Exclusion Criteria
Chronological age 11–13 y History of previous orthodontic treatment
Cervical maturational stage 3 or 4 (circumpubertal growth stage) Previous craniofacial surgeries
Skeletal Class II malocclusion due to mandibular deficiency (SNB  76°) Chronic diseases, syndromes, growth problems that may affect bone
Horizontal growth pattern (MP/SN  39°) Temporomandibular disorders
Angle Class II division 1 malocclusion (overjet  5 mm) Parafunctional habits (for example, thumb sucking, tongue thrusting
mouth breathing, nail biting, bruxism)

were not able to achieve pure skeletal changes.5,6 bimaxillary skeletal anchorage was used and found
Different trials have been conducted using miniplate significant skeletal effects mainly due to mandibular
anchorage for orthopedic correction of skeletal Class protrusion. However, the conclusion was that low con-
II malocclusion, and researchers reported skeletal fidence in results exists and that a high-quality clinical
increases in mandibular length of 3.03 6 0.81 mm trial was still needed.14 In the current study, we aimed
within 8.45 6 1.15 months.7–13

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at assessing the effect of two different force systems
However, authors of most previous studies used along with bimaxillary skeletal anchorage on the treat-
bone-borne anchorage in a single jaw and authors of ment of growing skeletal Class II subjects in compari-
only a few studies examined the use of bimaxillary son with the natural growth changes observed in a
skeletal anchorage in conjunction with either intermax- deferred treatment Class II control group. The null
illary elastics or fixed functional appliances.11–13 hypothesis of this study was that the use of direct
Authors of a recent systematic review aimed at evalu- bimaxillary miniplate anchorage with two different
ating the available evidence from studies in which force systems would not yield statistically significant

Enrollment Assessed for eligibility ( = 60)

Excluded ( = 21)
i Not meeting inclusion criteria ( = 21)
i Declined to participate ( = 0)
i Other reasons ( = 0)

Randomized ( = 39)

Allocation
Group A Group B Group C
Allocated to intervention ( = 13) Allocated to intervention ( = 13) Allocated to control ( = 13)
i Received allocated i Received allocated i Received allocated
intervention ( = 13) intervention ( = 13) intervention ( = 13)
i Did not receive allocated i Did not receive allocated i Did not receive allocated
intervention ( = 0) intervention ( = 0) intervention ( = 0)

Follow-Up
Lost to follow-up ( = 0) Lost to follow-up ( = 0) Lost to follow-up ( = 0)

Discontinued intervention Discontinued intervention Discontinued intervention

( = 0) (miniplate mobility) ( = 1) ( = 0)

Analysis
Analysed ( = 13) Analysed ( = 12) Analysed ( = 13)
i Excluded from analysis i Excluded from analysis i Excluded from analysis
( = 0) ( = 0) ( = 0)

Figure 1. Consolidated Standards of Reporting Trials (CONSORT) diagram of the participants flow chart.

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SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 3

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Figure 2. Miniplate adaptation over the three-dimensional (3D)
printed skull models. (A) and (B) Over the zygomatic buttress and
mandibular symphysis in Group A; (C) and (D) over the nasal but-
tress and the external oblique ridge in Group B.

skeletal mandibular growth effects in comparison with Figure 3. Surgical fixation of the miniplates in (A) and (B) pushing
natural mandibular growth. (Group A) and (C) and (D) pulling (Group B) groups.

Sample Size Calculation

MATERIALS AND METHODS
Sample size was estimated assuming a 5% a error
Trial Design and 80% study power based on studies by Al-Dumaini
This study was a three-parallel-arm randomized et al.,13 ElKordy et al.,7 and Eissa et al.,16 who
controlled clinical trial and was reported in compliance reported changes in mandibular length of 3.0 6
with the Consolidated Standards of Reporting Trials 0.42 mm using pulling mechanics, 1.27 6 1.01 mm
(CONSORT) statement.15 This trial was registered at using pushing mechanics, and 2.63 6 2.7 mm in
ClinicalTrials.gov with identifier NCT04884022. untreated cases, respectively. Using an analysis of
variance (ANOVA) with a pooled SD ¼ 1.37, the
required sample size was determined to be 12
Ethical Approval patients per group, subsequently augmented to 13
patients to account for potential attrition. The sample
The study was conducted after obtaining ethical size was based on Rosner’s method17 and calculated
approval from the Institutional Review Board at the Fac- by G*Power 3.0.10 (http://www.gpower.hhu.de).
ulty of Dentistry, Alexandria University (IRB:00010556–
IORG:0008839 and Manuscript Ethics Committee 0219-
02/2021). Prior to commencement, all guardians of the
patients were apprised of the purpose of the study and
associated risks and benefits, and signed informed con-
sent was obtained.

Participants, Eligibility Criteria, and Settings

Patients were recruited from the outpatient clinic of
the Department of Orthodontics, Faculty of Dentistry,
Alexandria University, and were examined, consider-
ing the eligibility criteria listed in Table 1. A total of 60
individuals was assessed for eligibility, and participant
flow during the trial is described in the CONSORT flow Figure 4. (A) Direct loading of SARA appliance, (B) CS coil spring
chart (Figure 1). to the miniplates (C) with 250g force measured using force gauge.

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4 MAHMOUD, ABDEL-HAFFIEZ, MARZOUK, EL ASHWAH, ISMAIL

Table 2. Anatomical Landmarks and Reference Planes

Symbol Name Definition
Anatomical Landmarks
S Sella The center of Sella turcica
N Nasion The most anterior point of the nasofrontal suture
Po Porion The most superior and outer point of the external auditory meatus
Or Orbitale The lowest point on the inferior margin of the orbit
A point Subspinal The deepest point in the concavity of the anterior maxilla between the ANS and alveolar crest
B point Supramental The innermost point on the contour of the mandible between the incisor and alveolar bone
Co Condylion The most superoposterior point on the curvature of the condylar head
ANS Anterior nasal spine The apex of the spina nasalis anterior
PNS Posterior nasal spine The most posterior point on the contour of the palate in the midsagittal plane
Me Menton The deepest point of the mandibular symphysis
Pog Pogonion The most prominent point on the chin
Gn Gnathion The midpoint between Me and Pog
Go Gonion The lowest point of the bony contour of the angle of the mandible

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Reference planes
FHP Frankfort horizontal plane Defined by 3 landmarks: right orbitale, left orbitale, and porion
MSP Midsagittal plane Plane through Sella and nasion perpendicular to HRP
SN Sella-nasion plane Plane joining nasion and Sella perpendicular to MSP
OP Occlusal plane Plane joining the maxillary incisal edge with first molar mesial cusp tip
PP Palatal plane Plane joining anterior nasal spine and posterior nasal spine perpendicular to the MSP
MP Mandibular plane Plane joining gnathion and left and right gonion
VR Vertical plane Plane through Sella perpendicular to Sella-nasion plane

Table 3. Angular and Linear Skeletal Measurements

Lin’s CCCa
Variable Description Intra Inter
Angular
measurements (°)
SNA Angle between the lines Sella-nasion and nasion–A point, which describes the anteroposterior position 0.958 0.979
of maxillary base relative to the anterior cranial base
SNB Angle between the lines Sella-nasion and nasion–B point, which describes the anteroposterior position 0.965 0.965
of mandibular base relative to the anterior cranial base
ANB Angle between the lines A point–nasion and nasion–B point, which describes the anteroposterior 0.925 0.916
position of maxillary base to the mandibular base
NA-Pog Angle between nasion–A point and A point–pogonion, which describes the angle of convexity 0.976 0.904
SN-PP Angle between Sella-nasion and ANS-PNS, which describes the palatal plane angle 0.981 0.978
SN-MP Angle between Sella-nasion and Go-Gn, which describes the mandibular plane angle 0.951 0.978
Gonial angle The angle between the points Co, Go, and Me, which determines the direction of growth of the lower 0.952 0.919
half of the face
SN-OP Angle between Sella-nasion and occlusal plane, which describes the occlusal plane angle 0.911 0.813
Linear measurements
(mm)
Co-A The linear distance between condylion and A point, which determines the effective maxillary length 0.967 0.930
Co-Gn The linear distance between condylion and gnathion, which determines the effective mandibular length 0.981 0.978
A-VR The linear distance between the A point and vertical plane, which determines the A-P maxillary position 0.931 0.932
B-VR The linear distance between the B point and vertical plane, which determines the A-P mandibular position 0.980 0.976
Wits appraisal Distance between A point perpendicular OP and B point perpendicular OP, which determines the posi- 0.944 0.961
tion of the maxillary base relative to the mandibular base
Pog-VR The linear distance between the Pog and vertical plane, which determines the A-P position of mandibular chin 0.915 0.909
Go-Pog The linear distance between the Go and Pog points, which determines the mandibular body length 0.930 0.970
Co-Go The linear distance between the Co and Go points, which determines the mandibular ramus length 0.961 0.963
AFH The linear distance between ANS and Me points, which determines the anterior lower facial height 0.970 0.906
PFH The linear distance between S and Go points, which determines the posterior facial height 0.944 0.966
A-FH The linear distance between the A point and FH plane, which determines the maxillary vertical position 0.961 0.961
B-FH The linear distance between the B point and FH plane, which determines the mandibular vertical position 0.927 0.933
Pog-FH The linear distance between the Pog and FH plane, which determines the mandibular chin vertical position 0.978 0.975
A-SN The linear distance between the A point and SN plane, which determines the maxillary vertical position 0.964 0.963
B-SN The linear distance between the B point and SN plane, which determines the mandibular vertical position 0.944 0.968
Pog-SN The linear distance between the Pog and SN plane, which determines the mandibular chin vertical position 0.902 0.967
a
CCC indicates concordance correlation coefficient.

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SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 5

Table 4. Comparison of Mean Age and Sex Distribution Among the Study Groups at T1
Age (y) Gender
a
95% CI Male, Female,
N Mean 6 SD for Mean P Value No. (%) No. (%) P Value
Group A 13 12.08 6 0.76 11.62, 12.54 .159 8 (61.5) 5 (38.5) .843
Group B 12 12.00 6 0.85 11.46, 12.54 7 (53.8) 5 (38.5)
Group C 13 11.46 6 0.97 10.88, 12.05 9 (69.2) 4 (30.8)
a
CI indicates confidence interval.

Randomization and Patient Allocation zygomatic buttress, perforating the attached gingiva
at the maxillary molar region (Figure 3A, B).
Eligible participants were equally and randomly
In Group B, two L-shaped miniplates were fixed in the
assigned to either one of the intervention groups (Group
external oblique ridge, perforating the attached gingiva
A treated by pushing force mechanics or Group B
at the mandibular molar region, and two straight mini-
treated by pulling force mechanics) or the deferred treat-
plates were fixed in the nasal buttress, perforating the

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ment control Group C, using a random sequence table
attached gingiva at the canine region (Figure 3C, D). In
(https://www.random.org). Randomization was made in
both groups, each miniplate was fixed by three titanium
blocks to ensure an equal allocation ratio. Each patient
miniscrews (2 3 10 mm), the last hole of the miniplate
was assigned a number from consecutively numbered
was opened to allow attachment of the appliance, and
opaque sealed envelopes. The patients were, thereafter,
the miniplates were loaded directly with force from the
assigned to one of the groups using a randomization
appliance 3 weeks after placement.7,8,13
table based on the numbers.18
Orthopedic Treatment
Blinding
In Group A, 250 g of pushing force was applied using
The operator obtaining the outcome data from con-
a fixed functional appliance (Sabbagh Advanced Repo-
cealed cone-beam computed tomographies (CBCTs)
sitioning Appliance (SARA); Forestadent, Pforzheim,
was blinded, as was the statistician who analyzed the
Germany), measured using a force gauge (Figure 4).
data, which were labeled with randomized numbers.
The proper pushrod of the SARA appliance was
Due to the nature of the study, the participants and the
adjusted using split crimps (3 mm in length), and the
main operator could not be blinded.
molar tube part was removed (Figure 4A). In Group B,
the same amount of pulling force was applied using a
Intervention Procedure
Class II Spring (CS Class II correction device coil spring
Routine orthodontic records and CBCTs were taken [CS]; DynaFlex, Lake Saint Louis, Missouri, USA;
at baseline (T1). CBCT scanning was performed in Figure 4B). Follow-up appointments were scheduled
maximum intercuspation using a field of view of 14.5 3 every 4 weeks to check miniplate stability and to adjust
13 cm at 85 kVp, 15 mAs, 0.25 mm voxel dimension, the applied force. The appliances were removed after
with a SCANORA 3D device (Soredex, Milwaukee, Wis- 9 months, while the miniplates were kept for an addi-
consin, USA). Also, a three-dimensional (3D) printed tional month before surgical removal to confirm correction
skull model was obtained for each patient in the inter- of the skeletal relationship. A second set of orthodontic
vention groups for adaptation of the miniplates to the records and CBCT was taken after removal of the mini-
underlying bone in a standardized location prior to the plates and after ending the 9-month observation period of
surgical procedure. Segmentation was done using Blue- the control group (T2).7
sky Bio software (Grayslake, Ill), then printed with Fused
Deposition Modeling (Figure 2). Outcome Assessment and Evaluation
Analysis was done directly on the CBCT using InVivo-
Surgical Procedure
Dental Application version 5.3.1 (Anatomage Inc, Santa
For each patient in the intervention groups, four tita-
nium miniplates (STEMA, Neuhausen ob Eck, Ger- Table 5. Cervical Vertebral Maturation Stages of the Subjects in
many) were inserted in two surgical procedures under the Three Study Groups at T1; x 2 Test
local anesthesia by the same surgeon. In Group A, Stage 3 Stage 4 Total P Value
two Y-shaped miniplates were fixed from one end in Group A 9 (69.2%) 4 (30.8%) 13 (100.0%) .605
the mandibular symphysis, leaving the other end per- Group B 7 (58.3%) 5 (41.7%) 12 (100.0%)
forating the attached gingiva at the canine-premolar Group C 10 (76.9%) 3 (23.1%) 13 (100.0%)
Total 26 (68.4%) 12 (31.6%) 38 (100.0%)
region, and two straight miniplates were fixed in the

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6 MAHMOUD, ABDEL-HAFFIEZ, MARZOUK, EL ASHWAH, ISMAIL

Table 6. Comparison of Baseline Characteristics of the Skeletal Variables Among the Study Groups; One-Way ANOVAa
Baseline data N Mean 6 SD 95% CI for Mean P Value
SNA (°) .055
Group A 13 80.54 6 1.66 79.53, 81.54
Group B 12 81.75 6 0.87 81.20, 82.30
Group C 13 80.38 6 1.71 79.35, 81.42
SNB (°) .503
Group A 13 73.77 6 1.24 73.02, 74.52
Group B 12 74.08 6 0.79 73.58, 74.59
Group C 13 73.54 6 1.33 72.73, 74.34
ANB (°) .115
Group A 13 6.62 6 1.61 5.64, 7.59
Group B 12 7.83 6 0.94 7.24, 8.43
Group C 13 6.85 6 1.77 5.78, 7.92
SNMP (°) .207
Group A 13 34.85 6 2.08 33.59, 36.10

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Group B 12 33.42 6 2.15 32.05, 34.78
Group C 13 34.69 6 2.21 33.35, 36.03
SNPP (°) .308
Group A 13 9.77 6 1.36 8.95, 10.59
Group B 12 9.08 6 0.67 8.66, 9.51
Group C 13 9.69 6 1.38 8.86, 10.52
SNOP (°) .434
Group A 13 20.38 6 1.39 19.55, 21.22
Group B 12 21.08 6 2.35 19.59, 22.58
Group C 13 20.23 6 1.30 19.44, 21.02
PLMP (°) .510
Group A 13 25.69 6 1.44 24.82, 26.56
Group B 12 24.92 6 2.47 23.35, 26.48
Group C 13 25.62 6 1.39 24.78, 26.45
NAPog (°) .503
Group A 13 11.85 6 2.12 10.57, 13.12
Group B 12 11.08 6 1.83 9.92, 12.25
Group C 13 12.00 6 2.20 10.67, 13.33
Yaxis (°) .790
Group A 13 61.00 6 1.22 60.26, 61.74
Group B 12 60.75 6 1.29 59.93, 61.57
Group C 13 61.08 6 1.19 60.36, 61.79
Gonial Angle (°) .882
Group A 13 116.69 6 1.97 115.50, 117.89
Group B 12 116.75 6 2.22 115.34, 118.16
Group C 13 117.08 6 2.10 115.81, 118.35
COGN (mm) .186
Group A 13 98.46 6 2.22 97.12, 99.80
Group B 12 100.17 6 3.13 98.18, 102.15
Group C 13 98.54 6 2.22 97.20, 99.88
GOPog (mm) .335
Group A 13 66.38 6 1.80 65.29, 67.48
Group B 12 67.08 6 1.68 66.02, 68.15
Group C 13 66.00 6 1.96 64.82, 67.18
CoGo (mm) .538
Group A 13 48.77 6 1.30 47.98, 49.56
Group B 12 49.50 6 2.71 47.78, 51.22
Group C 13 48.77 6 1.30 47.98, 49.56
COA (mm) .431
Group A 13 79.00 6 1.68 77.98, 80.02
Group B 12 79.83 6 2.66 78.15, 81.52
Group C 13 78.85 6 1.57 77.90, 79.80
Wits (mm) .476
Group A 13 3.85 6 1.63 2.86, 4.83
Group B 12 4.42 6 1.51 3.46, 5.37
Group C 13 4.46 6 1.05 3.83, 5.10

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SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 7

Table 6. Continued
Baseline data N Mean 6 SD 95% CI for Mean P Value
PFH (mm) .580
Group A 13 66.15 6 3.18 64.23, 68.08
Group B 12 67.25 6 2.49 65.67, 68.83
Group C 13 66.15 6 3.18 64.23, 68.08
AFH (mm) .646
Group A 13 56.92 6 1.61 55.95, 57.89
Group B 12 57.67 6 2.90 55.82, 59.51
Group C 13 57.08 6 1.50 56.17, 57.98
AVR (mm) .931
Group A 13 54.23 6 1.92 53.07, 55.39
Group B 12 53.92 6 2.61 52.26, 55.57
Group C 13 54.15 6 1.91 53.00, 55.31
BVR (mm) .951
Group A 13 37.00 6 2.48 35.50, 38.50

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Group B 12 37.33 6 3.96 34.82, 39.85
Group C 13 37.00 6 2.48 35.50, 38.50
PogVR (mm) .867
Group A 13 37.31 6 3.50 35.19, 39.42
Group B 12 36.50 6 4.70 33.51, 39.49
Group C 13 36.69 6 3.68 34.47, 38.92
ASN (mm) .416
Group A 13 50.08 6 6.81 45.96, 54.19
Group B 12 53.08 6 6.07 49.23, 56.94
Group C 13 49.85 6 7.08 45.57, 54.13
BSN (mm) .668
Group A 13 85.23 6 2.68 83.61, 86.85
Group B 12 86.08 6 3.09 84.12, 88.05
Group C 13 85.15 6 2.73 83.50, 86.81
PogSN (mm) .501
Group A 13 95.31 6 3.12 93.42, 97.19
Group B 12 96.75 6 3.57 94.48, 99.02
Group C 13 95.62 6 2.84 93.90, 97.33
a
ANOVA indicates analysis of variance; CI, confidence interval.

Clara, California, USA), after importing the DICOM files remeasuring 30% of the variables with a 2-week inter-
into the software. The landmarks and reference planes val. Lin’s CCC ranged from 0.813 to 0.981, indicating
are described in Table 2. Angular and linear measure- an accepted to excellent agreement within and
ments are described in Table 3. between examiners.

Statistical Analysis RESULTS

The data were analyzed using SPSS version 26 Baseline Data
(SPSS, Chicago, Ill). The Shapiro-Wilk test was The demographic characteristics for all groups are
employed to assess normality, revealing that the data presented in Table 4. Baseline measurements were
followed a normal distribution. Variables are presented reported and compared among the three groups using
using mean and standard deviation values. Paired t-test one-way ANOVA (Tables 5 and 6). No significant dif-
was used for intragroup comparisons between T1 and ference was found among the groups at baseline. For
T2. Intergroup changes between T1 and T2 were ana- all variables, independent-samples t-tests were used
lyzed using one-way ANOVA, followed by the least to confirm that no sex-based differences existed (Sup-
square difference (LSD) test. The significance level was plementary Table 1).
established at a P-value of  .05.
Patient Flow and Dropout
Measurement Error
One patient in the pulling group did not complete
In this study, Lin’s concordance correlation coeffi- the intervention due to repeated mobility of the man-
cient (CCC) was used to determine the intraexaminer dibular miniplates and inability to fix them for the third
and interexaminer reliability of measurements after time. Thus, a total of 38 subjects was analyzed.

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Figure 5. Photos of patient from the pushing group (A) pretreat-
ment and (B) posttreatment. Figure 6. Photos of patient from the pulling group (A) pretreatment
and (B) posttreatment.
Clinical examples of patient progress are presented in
Figures 5 and 6. decreased significantly in Group A (4.31 6 1.44°) and
Group B (7.5 6 0.9°). Among the three study groups,
Sagittal Skeletal Changes a statistically significant difference was observed for
several sagittal measures (Table 8). Also, a significant
The intragroup sagittal skeletal changes between
decrease was found in the Wits appraisal in Group A
T1 and T2 are summarized in Table 7, while Table 8
(4.31 6 1.44 mm) and Group B (7.5 6 0.9 mm).
demonstrates comparisons among the three study
groups. A significant increase in Co-Gn was recorded
Vertical Skeletal Changes
of 5.08 6 2.25 mm for Group A, 3.83 6 2.79 mm for
Group B, and 0.23 6 0.6 mm for Group C. The differ- The vertical skeletal changes within study groups from
ence between groups A and B was not significant, T1 to T2 are presented in Table 9. Comparison of
while the difference between Group C and both inter- changes among the groups are shown in Table 10. All
vention groups was significant. The linear measure- the vertical measurements in groups A and C showed
ment Go-Pog increased significantly in Group A changes that were not statistically significant. However,
(4.08 6 1.85 mm) and Group B (1.83 6 0.94 mm). In in Group B, a statistically significant increase of 1.83 6
addition, a significant increase was found in groups A 0.72° occurred in the mandibular plane angle, 3.25 6
and B of the two linear measurements B-VR (5.62 6 1.71° in the palatal plane angle, 2.42 6 1.16° in the
2.93 mm and 5.83 6 2.95 mm) and Pog-VR (3.85 6 occlusal plane, and 3.00 6 1.04° in the Y-axis angle. The
0.9 mm and 4.17 6 0.83 mm) between T1 and T2, distances between SN plane and A, B, and Pog points
respectively. No significant difference was found in significantly increased by 3.25, 4.42, and 7 mm, respec-
these measures between the two intervention groups. tively. Also, the ramus length increased significantly by
Groups A and B demonstrated a significant increase 4.75 6 0.87 mm. For PFH, a 6.83 6 1.34 mm increase
in the SNB angle (4.38 6 0.65° and 4.17 6 0.58° for was found, while AFH increased by 1.5 6 1.17 mm.
groups A and B, respectively). A statistically significant
Harms
decrease in the SNA angle occurred in Group B only
(1.33 6 0.98°). A significant decrease in ANB between Miniplate mobility occurred in 14 of 156 miniplates
T1 and T2 was seen in Group A (4.31 6 0.75°) and (8.97%), and each of these was considered a mini-
Group B (5.5 6 0.67°). Similarly, the NA-Pog angle plate failure. The surgical procedure was repeated to

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SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 9

Table 7. Mean Values of Sagittal Skeletal Measures at the Beginning (Pre) and End (Post) in the Study Groups; Paired t-Test
Group A Group B Group C
Mean 6 SD P Value Mean 6 SD P Value Mean 6 SD P Value
SNA (°) .337 .001** .19
T1 80.54 6 1.66 81.75 6 0.87 80.38 6 1.71
T2 80.62 6 1.45 80.42 6 1.00 80.62 6 1.80
T2  T1 0.08 6 0.28 1.33 6 0.98 0.24 6 0.60
SNB (°) ,.001** , .001** .082
T1 73.77 6 1.24 74.08 6 0.79 73.54 6 1.33
T2 78.15 6 1.07 78.25 6 0.87 73.77 6 1.48
T2  T1 4.38 6 0.65 4.17 6 0.58 0.23 6 0.44
ANB (°) ,.001** , .001** .337
T1 6.62 6 1.61 7.83 6 0.94 6.85 6 1.77 .337
T2 2.31 6 1.25 2.33 6 1.07 6.92 6 1.85
T2  T1 4.31 6 0.75 5.5 6 0.67 0.07 6 0.28
NAPog (°) ,.001** , .001** .137

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T1 11.85 6 2.12 11.08 6 1.83 12 6 2.20
T2 7.54 6 3.04 3.58 6 2.11 12.38 6 1.76
T2  T1 4.31 6 1.44 7.5 6 0.9 0.38 6 0.87
COGN (°) ,.001** .001** .19
T1 98.46 6 2.22 100.17 6 3.13 98.54 6 2.22
T2 103.54 6 3.43 104 6 4.94 98.77 6 2.24
T2  T1 5.08 6 2.25 3.83 6 2.79 0.23 6 0.60
GOPog (°) ,.001** , .001** .082
T1 66.38 6 1.80 67.08 6 1.68 66 6 1.96
T2 70.46 6 1.90 68.92 6 1.16 66.23 6 2.05
T2  T1 4.08 6 1.85 1.84 6 0.94 0.23 6 0.44
COA (°) .219 .039 .165
T1 79 6 1.68 79.83 6 2.66 78.85 6 1.57
T2 79.31 6 1.70 80.17 6 2.92 79 6 1.63
T2  T1 0.31 6 0.85 0.34 6 0.49 0.15 6 0.38
Wits (°) ,.001** , .001** .337
T1 3.85 6 1.63 4.42 6 1.51 4.46 6 1.05
T2 1 6 0.82 1.33 6 0.89 4.54 6 0.97
T2  T1 2.85 6 0.99 3.09 6 1.44 0.08 6 0.28
AVR (°) .111 .266 .165
T1 54.23 6 1.92 53.92 6 2.61 54.15 6 1.91
T2 54.69 6 2.21 53.58 6 2.54 54.31 6 1.89
T2  T1 0.46 6 0.97 0.34 6 0.98 0.16 6 0.38
BVR (°) ,.001** , .001** .337
T1 37.00 6 2.48 37.33 6 3.96 37 6 2.48
T2 41.69 6 2.87 41.75 6 3.86 37.08 6 2.47
T2  T1 4.69 6 0.95 4.42 6 0.90 0.08 6 0.28
PogVR (°) ,.001** , .001** .165
T1 37.31 6 3.50 36.5 6 4.70 36.69 6 3.68
T2 41.15 6 3.36 40.67 6 4.70 36.85 6 3.83
T2  T1 3.84 6 0.90 4.17 6 0.83 0.16 6 0.38
* P , 0.017 (due to Bonferroni correction); ** P , 0.001.

fix the mobile miniplates using new miniscrews. Clini- therapeutic challenge in orthodontics, and authors of
cal termination of 1 patient from the study was decided bimaxillary skeletal anchorage studies who used either
due to excessive miniplate mobility after refixing them. pushing or pulling forces reported protrusive mandibular
Repeated CS coil spring breakage in Group B was changes.14 However, no previous authors have com-
reported in 6 of 26 springs with a 23.07% failure rate, pared the impact of altering the direction of orthopedic
while only 1 SARA appliance failed in Group A (3.8%). forces (pushing vs pulling) with bimaxillary skeletally
anchored appliances on the correction of growing skele-
tal Class II subjects. In the present study, we compare
DISCUSSION
the skeletal changes induced by using bimaxillary skele-
The actual skeletal correction of Class II malocclusion tal anchorage in conjunction with two different mechani-
due to mandibular deficiency presents a prevalent cal methods (pushing vs pulling).

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10 MAHMOUD, ABDEL-HAFFIEZ, MARZOUK, EL ASHWAH, ISMAIL

Table 8. Comparison of the Mean Differences (T2  T1) in the Sagittal Skeletal Measures Among the Study Groups; One-Way ANOVA and
LSD Testa
P Value
Mean 6 SD 95% CI for Mean P Value A-B A-C B-C
SNA (°) , .001** ,.001** .564 ,.001**
Group A 0.08 6 0.28 0.09, 0.24
Group B 1.33 6 0.98 1.96, 0.71
Group C 0.23 6 0.60 0.13, 0.59
SNB (°) , .001** .339 , .001** ,.001**
Group A 4.38 6 0.65 3.99, 4.78
Group B 4.17 6 0.58 3.80, 4.53
Group C 0.23 6 0.44 0.03, 0.50
ANB (°) , .001** ,.001** , .001** ,.001**
Group A 4.31 6 0.75 4.76, 3.85
Group B 5.50 6 0.67 5.93, 5.07
Group C 0.08 6 0.28 0.09, 0.24

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NAPog (°) , .001** ,.001** , .001** ,.001**
Group A 4.31 6 1.44 5.18, 3.44
Group B 7.50 6 0.90 8.07, 6.93
Group C 0.38 6 0.87 0.14, 0.91
CoGn (°) , .001** .144 , .001** ,.001**
Group A 5.08 6 2.25 3.72, 6.43
Group B 3.83 6 2.79 2.06, 5.61
Group C 0.23 6 0.60 0.13, 0.59
GoPog (°) , .001** ,.001** , .001** .003*
Group A 4.08 6 1.85 2.96, 5.19
Group B 1.83 6 0.94 1.24, 2.43
Group C 0.23 6 0.44 0.03, 0.50
COA (°) .728 .917 .526 .469
Group A 0.31 6 0.85 0.21, 0.82
Group B 0.33 6 0.49 0.02, 0.65
Group C 0.15 6 0.38 0.07, 0.38
Wits (°) , .001** .560 , .001** ,.001**
Group A 2.85 6 0.99 3.44, 2.25
Group B 3.08 6 1.44 4.00, 2.17
Group C 0.08 6 0.28 0.09, 0.24
AVR (°) .065 .021 .346 .147
Group A 0.46 6 0.97 0.12, 1.05
Group B 0.33 6 0.98 0.96, 0.29
Group C 0.15 6 0.38 0.07, 0.38
BVR (°) , .001** .376 , .001** ,.001**
Group A 4.69 6 0.95 4.12, 5.26
Group B 4.42 6 0.90 3.84, 4.99
Group C 0.08 6 0.28 0.09, 0.24
PogVR (°) , .001** .285 , .001** ,.001**
Group A 3.85 6 0.90 3.30, 4.39
Group B 4.17 6 0.83 3.64, 4.70
Group C 0.15 6 0.38 0.07, 0.38
* P , .017 (due to Bonferroni correction); ** P , .001.
a
ANOVA indicates analysis of variance; CI, confidence interval; LSD, least significant difference.

It has been strongly recommended to include treatment and reduce the effect of normal growth.7–9
untreated Class II controls in studies to examine the In this study, for a comparable investigation of the
effectiveness of treatment modalities relative to natu- effect of the appliances, force maintenance, and com-
ral growth changes. A deferred treatment control pliance avoidance, it was decided to use CS coil
group was recruited as part of the current study due to springs instead of intermaxillary elastics in the pulling
a shortage of contemporary growth studies and the group.21
absence of historical control data in the population CBCTs were needed in this study for surgical plan-
participating in this study.7,16,19,20 ning for miniplate placement and to take advantage of
The treatment intervention period was 9 months to the better visualization and accuracy with less or equiv-
allow analysis of the small changes induced by active alent radiation dose of one CBCT to the sum of

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SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 11

Table 9. Mean Vertical Skeletal Measures at T1 and T2 in the Groups; Paired t-Test
Group A Group B Group C
Mean 6 SD P Value Mean 6 SD P Value Mean 6 SD P Value
SNMP (°) .190 ,.001** .082
T1 34.85 6 2.08 33.42 6 2.15 34.69 6 2.21
T2 35.08 6 2.10 35.25 6 2.05 34.92 6 2.22
T2  T1 0.23 6 0.60 1.83 6 0.72 0.23 6 0.44
SNPP (°) .273 ,.001** .337
T1 9.77 6 1.36 9.08 6 0.67 9.69 6 1.38
T2 10.00 6 1.63 12.33 6 1.61 9.85 6 1.28
T2  T1 0.23 6 0.73 3.25 6 1.71 0.16 6 0.55
SNOP (°) .337 ,.001** .337
T1 20.38 6 1.39 21.08 6 2.35 20.23 6 1.30
T2 19.92 6 1.32 23.5 6 2.20 20.31 6 1.25
T2  T1 0.46 6 1.66 2.42 6 1.16 0.08 6 0.28
PLMP (°) .068 .089 .165

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T1 25.69 6 1.44 24.92 6 2.47 25.62 6 1.39
T2 26.23 6 1.36 24.33 6 2.23 25.77 6 1.42
T2  T1 0.54 6 0.97 0.59 6 1.08 0.15 6 0.38
Yaxis (°) .337 ,.001** .337
T1 61.00 6 1.22 60.75 6 1.29 61.08 6 1.19
T2 60.92 6 1.12 63.75 6 1.48 61.23 6 1.17
T2  T1 0.08 6 0.28 3.00 6 1.04 0.15 6 0.55
Gonial Angle (°) .190 .144 .190
T1 116.69 6 1.97 116.75 6 2.22 117.08 6 2.10
T2 116.92 6 2.22 117.67 6 3.52 117.31 6 1.97
T2  T1 0.23 6 0.60 0.92 6 2.02 0.23 6 0.60
CoGo (mm) .096 ,.001** .337
T1 48.77 6 1.30 49.5 6 2.71 48.77 6 1.30
T2 49.54 6 2.37 54.25 6 2.70 48.85 6 1.28
T2  T1 0.77 6 1.54 4.75 6 0.87 0.08 6 0.28
PFH (mm) .104 ,.001** .082
T1 66.15 6 3.18 67.25 6 2.49 66.15 6 3.18
T2 66.77 6 3.30 74.08 6 2.71 66.38 6 3.12
T2  T1 0.62 6 1.26 6.83 6 1.34 0.23 6 0.44
AFH (mm) .096 .001** .165
T1 56.92 6 1.61 57.67 6 2.90 57.08 6 1.50
T2 57.69 6 2.02 59.17 6 3.21 58.62 6 3.57
T2  T1 0.77 6 1.54 1.50 6 1.17 1.54 6 3.76
ASN (mm) .054 ,.001** .190
T1 50.08 6 6.81 53.08 6 6.07 49.85 6 7.08
T2 50.46 6 6.54 56.33 6 5.84 50.08 6 6.99
T2  T1 0.38 6 0.65 3.25 6 0.97 0.23 6 0.60
BSN (mm) .053 ,.001** .337
T1 85.23 6 2.68 86.08 6 3.09 85.15 6 2.73
T2 85.69 6 2.75 90.50 6 4.03 85.23 6 2.74
T2  T1 0.46 6 0.78 4.42 6 1.68 0.08 6 0.28
PogSN (mm) .053 ,.001** .190
T1 95.31 6 3.12 96.75 6 3.57 95.62 6 2.84
T2 95.77 6 3.06 103.75 6 3.86 95.85 6 2.64
T2  T1 0.46 6 0.78 7.00 6 1.95 0.23 6 0.60
* P , .017 (due to Bonferroni correction); ** P , .00.

panoramic and lateral cephalometric x-rays together.22 forces to the bone. In Group A, mandibular length
The success rate of the miniplates was 91.03%, which increased by 5.08 6 2.25 mm, in agreement with pre-
was similar to that previously reported, ranging vious studies in which similar pushing mechanics was
between 86.7 and 97%.7–9,23 used with miniplate anchorage.7,9,11 This was mainly
Significant improvement in the intermaxillary antero- due to increase in the mandibular body length by
posterior relationship was observed in both interven- 4.08 mm, in agreement with Kochar et al.,11 who
tion groups due to an increase in effective mandibular showed Go-Pog increased by 3.29 mm. However,
length in response to direct transfer of orthopedic using pulling mechanics in Group B increased the

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12 MAHMOUD, ABDEL-HAFFIEZ, MARZOUK, EL ASHWAH, ISMAIL

Table 10. Comparison of Mean Changes (T2  T1) in the Vertical Skeletal Measures Among the Study Groups; One-Way ANOVA and LSD
Testa
P Value
Mean 6 SD 95% CI for Mean P Value A-B A-C B-C
SNMP (°) , .001** ,.001** 1 ,.001**
Group A 0.23 6 0.60 0.13, 0.59
Group B 1.83 6 0.72 1.38, 2.29
Group C 0.23 6 0.44 0.03, 0.50
SNPP (°) , .001** ,.001** .859 ,.001**
Group A 0.23 6 0.73 0.21, 0.67
Group B 3.25 6 1.71 2.16, 4.34
Group C 0.15 6 0.55 0.18, 0.49
SNOP (°) , .001** ,.001** .254 ,.001**
Group A 0.46 6 1.66 1.47, 0.54
Group B 2.42 6 1.16 1.68, 3.16
Group C 0.08 6 0.28 0.09, 0.24

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PLMP (°) .009* .002* .262 .039
Group A 0.54 6 0.97 0.05, 1.12
Group B 0.58 6 1.08 1.27, 0.11
Group C 0.15 6 0.38 0.07, 0.38
Yaxis (°) , .001** ,.001** .399 ,.001**
Group A 0.08 6 0.28 0.24, 0.09
Group B 3.00 6 1.04 2.34, 3.66
Group C 0.15 6 0.55 0.18, 0.49
Gonial Angle (°) .295 .175 1 .175
Group A 0.23 6 0.60 0.13, 0.59
Group B 0.92 6 2.02 0.37, 2.20
Group C 0.23 6 0.60 0.13, 0.59
CoGo (mm) , .001** ,.001** .097 ,.001**
Group A 0.77 6 1.54 0.16, 1.70
Group B 4.75 6 0.87 4.20, 5.30
Group C 0.08 6 0.28 0.09, 0.24
PFH (mm) , .001** ,.001** .371 ,.001**
Group A 0.62 6 1.26 0.15, 1.38
Group B 6.83 6 1.34 5.98, 7.68
Group C 0.23 6 0.44 0.03, 0.50
AFH (mm) .675 .464 .431 .969
Group A 0.77 6 1.54 0.16, 1.70
Group B 1.50 6 1.17 0.76, 2.24
Group C 1.54 6 3.76 0.73, 3.81
ASN (mm) , .001** ,.001** .604 ,.001**
Group A 0.38 6 0.65 0.01, 0.78
Group B 3.25 6 0.97 2.64, 3.86
Group C 0.23 6 0.60 0.13, 0.59
BSN (mm) , .001** ,.001** .360 ,.001**
Group A 0.46 6 0.78 0.01, 0.93
Group B 4.42 6 1.68 3.35, 5.48
Group C 0.08 6 0.28 0.09, 0.24
PogSN (mm) , .001** ,.001** .637 ,.001**
Group A 0.46 6 0.78 0.01, 0.93
Group B 7.00 6 1.95 5.76, 8.24
Group C 0.23 6 0.60 0.13, 0.59
* P , .017 (due to Bonferroni correction); ** P , .001.
a
ANOVA indicates analysis of variance; CI, confidence interval; and LSD, least significant difference.

mandibular length by 3.83 6 2.79 mm, in agreement applied relative to the condyles. Additionally, mandibu-
with previous studies,12,13 but this increase was lar position improved significantly (SNB increased by
mainly due to an increase in ramal length of 4.75 mm, 4.38 6 0.65° and 4.17 6 0.58° for groups A and B,
in agreement with a previous study.13 The disparity in respectively), in agreement with previous, similar stud-
growth patterns between the two groups may be attri- ies in which bimaxillary miniplate anchorage was
buted to the differing orientations of the force vectors used.11,13

Angle Orthodontist, Vol 00, No 00, 2025

SKELETAL CHANGES WITH TWO BONE ANCHORED SYSTEMS 13

of these mechanics should be limited to horizontally

growing patients.

SUPPLEMENTAL DATA
Supplemental Tables 1 is available online.
Supplementary Table 1. Measures at T1 and T2
by sex for each group; independent-samples t-test.
Figure 7. A schematic diagram showing the miniplates and appli-
ance settings in the (A) pushing and (B) pulling groups, with the dis- REFERENCES
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