CLINICIAN’S CORNER Midfacial protraction with skeletally anchored face mask therapy: A novel approach and preliminary results Beyza Hancıoglu Kircelli a and Zafer Özgür Pektas b Ankara, Turkey Introduction: The purpose of this pilot study was to investigate the effects of facemask treatment with a rigid skeletal anchor. Methods: Miniplates were placed on the lateral nasal wall of the maxilla in 6 subjects (mean age, 11.8  1.1 years). No dental tissue was incorporated into the anchorage system. Lateral cephalograms of each patient were evaluated at the beginning of treatment (T1), at the end of active treatment (T2), and at the end of follow-up (T3). Results: In the horizontal plane, mean A-point movement was 4.8  2.0 mm in a mean of 10.8  2.4 months. The infraorbital region showed significant anterior movement (mean, 3.3  1.1 mm) at T2. At T3, advancement of the maxilla and the infraorbital region was well maintained (mean follow-up time, 15.2  0.9 months). Miniplate stability was excellent in all patients throughout treatment. Conclusions: Remarkable advancement in the middle face and consequent fullness in the soft-tissue profile can be achieved by using skeletal anchorage in conjunction with facemask therapy in the late mixed-dentition period. (Am J Orthod Dentofacial Orthop 2008;133:440-9) P rotraction of the maxilla with a facemask is a common treatment for Class III malocclusion with maxillary retrusion, especially at early ages. In the context of facemask therapy, the objective is to augment growth at the sutural sides by adding additional force to the natural force, separating the sutures more than would otherwise occur. 1 Although many types of facemasks have been introduced, 2-7 conventional mechanotherapy always in- cludes an intraoral appliance on the maxillary teeth with elastics stretched between the intraoral and ex- traoral parts. However, a conventional force system that uses dental anchorage has some inherent challenges. Application of 500 to 1500 g of total force is recom- mended for protraction of the maxilla. 8 However, it is impossible to directly transfer the total orthopedic force to the sutural sides, because some of the force is dissipated to the periodontal ligament area. Furthermore, tooth move- ment is undesirable when growth modification is at- tempted; it detracts from the skeletal change. 1 Unfortunately, however, tooth movement is inevitable when force is applied via the dentition. The usual effects of conventional facemask therapy on the dentition include extrusion and mesial movement of the maxillary molars, proclination of the maxillary incisors, and retroclination of the mandibular incisors. 9-16 Obviously, the major goal of orthopedic treatment is to correct the jaw discrepancy by achieving true skeletal alteration rather than just moving teeth to camouflage the problem. Additionally, a patient with an unsatisfactory clinical outcome will be a potential candidate for later orthog- nathic surgery. 12 This unfortunately requires decompen- sation and reversal of the previous treatment in exchange for extra time and money and the risk of root resorption. These concerns show that the periodontal ligament area of the dentition should be bypassed with facemask therapy in patients who require true skeletal correction. Therefore, it would be reasonable to take advantage of rigid skeletal anchorage for transferring orthopedic forces directly to the circummaxillary sutures. A few attempts have been made. Kokich et al 17 applied extraoral protraction forces to deliberately anky- losed deciduous canines. Singer et al 18 used osseointe- grated implants in the zygomatic buttress to obtain direct attachment to the maxilla. Enacar et al 19 attached the protractive forces to a titanium lag screw placed in the processus pterygoideus and to the remainder of the ante- rior teeth. Hong et al 20 used an onplant on the palatal bone as anchorage for facemask treatment. Current miniplates, commonly used for rigid fixa- tion of the bony segments in maxillofacial surgery, have been shown to be a reliable means of rigid anchorage for From the Faculty of Dentistry, Baskent University, Ankara, Turkey. a Assistant professor, Department of Orthodontics. b Assistant professor, Department of Oral and Maxillofacial Surgery. Reprint requests to: Beyza Hancıog ˘lu Kircelli, Bas ¸kent Universitesi, Adana Uygulama ve Aras ¸tirma Merkezi, Kazim Karabekir mah. 59 sok. No: 91 01120 Yuregir, Adana, Turkey; e-mail, beyzakircelli@yahoo.com. Submitted, January 2007; revised and accepted, June 2007. 0889-5406/$34.00 Copyright © 2008 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.06.011 440