ORIGINAL ARTICLE

Effect of microimplant assisted rapid

palatal expansion on bone-anchored
maxillary protraction: A finite element
analysis
Sugitha Suresh, Shobha Sundareswaran, and Sreehari Sathyanadhan
Calicut, Kerala, India

Introduction: This study aimed to evaluate the craniofacial effects of microimplant assisted rapid palatal expan-
sion (MARPE) on bone-anchored maxillary protraction (BAMP) through a finite element analysis. Methods: A 3-
dimensional finite element model of the skull with associated sutures was created from the computed
tomography image of a 12-year-old male patient. Two protraction protocols: BAMP without MARPE (protocol
1) and BAMP with MARPE (protocol 2), were analyzed using Ansys software (Ansys, Canonsburg, Pa).
Stress distribution in the sutures and displacement pattern of craniofacial structures were analyzed in the 2
protocols using finite element analysis. Results: Both protocols produced changes in craniofacial structures
in all the 3 planes. Displacement of the maxilla was more pronounced in protocol 2 in all directions with mild
clockwise rotation. Protocol 1 displayed a translatory movement of the maxilla without any rotation and mild
constriction in the anterior region. In protocol 2, an expansion of the maxilla, which increased in the superoinferior
direction, was also observed. Von Mises stress in circummaxillary sutures was significantly more in protocol 2,
indicating an increased displacement of craniomaxillary structures. Conclusions: The use of MARPE during
BAMP enhanced maxillary protraction and reduced the counterclockwise rotation tendency of the maxilla.
Hence, it may be inferred that incorporation of MARPE during BAMP protocol may prove beneficial in the treat-
ment of patients with skeletal Class III malocclusion with open bite tendency or hyperdivergent growth pattern.
(Am J Orthod Dentofacial Orthop 2021;-:---)

F
or several years, the cornerstone of early skeletal
Class III malocclusion treatment has been the or-
thopedic face mask (FM), anchored from the
maxillary teeth with or without rapid maxillary expan-
sion (RME).1 The objective of this treatment modality
is to enhance the growth at the sutures by applying addi-
tional force to separate them.2 However, along with the
forward displacement of the maxilla, this therapy results
in certain unwanted side effects such as extrusion and
mesialization of the maxillary molars, proclination of
maxillary incisors, retroclination of mandibular incisors,
clockwise rotation of the mandible, and increased
From the Department of Orthodontics, Government Dental College, Calicut, Ker-
ala, India.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Shobha Sundareswaran, Department of Orthodon-
tics & Dentofacial Orthopaedics, Government Dental College, Medical College
Post, Calicut 673008, Kerala, India; e-mail, drshobhakumar@gmail.com.
Submitted, June 2019; revised, February 2020; accepted, April 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.04.040
vertical dimension of the face.3 The use of titanium min-
iplates as anchorage for applying bone-borne orthope-
dic forces has revolutionized Class III treatment by
enhancing midfacial growth without the attendant
side effects of FM therapy. This is accomplished by
applying reverse-pull forces from maxillary implants
instead of maxillary teeth.
Transverse maxillary deficiency with unilateral or
bilateral posterior crossbite is a common finding in pa-
tients with Class III malocclusion, which needs to be cor-
rected.1 Maxillary protraction therapy is thus very often
accompanied by palatal expansion.4 Moreover, the
palatal expansion also disarticulates the sutures and ini-
tiates a cellular response which enhances maxillary pro-
traction.4 However, being a tooth-borne appliance, this
could lead to buccal tipping and dehiscence of maxillary
posterior teeth.5 In recent years, the incorporation of mi-
croimplants for expansion has helped in alleviating un-
desirable dental side effects, resulting in significantly
better outcomes. Such microimplant assisted rapid
palatal expanders (MARPE), when combined with FM,

1
2 Suresh, Sundareswaran, and Sathyanadhan

reported further enhancement in the forward movement

of the maxilla in a short period.6 The skeletal expansion
results in effective disarticulation of the circummaxillary
sutures, which is postulated to be a key factor in efficient
and effective maxillary protraction.6
Another method of intercepting developing skeletal
Class III malocclusion is to apply bilateral Class III elastic
traction from implants placed in the maxillary infrazygo-
matic region to implants placed in the mandible, mesial
to the canines. This method, called bone-anchored
maxillary protraction (BAMP), is a protocol reported to
produce significantly larger maxillary advancement
than conventional RME and FM therapy displaying bet-
ter vertical control without adverse effects on the denti-
tion.7,8 However, clinical outcomes of incorporating
MARPE into BAMP have not been studied so far. It is
possible that skeletal expansion will enhance the positive
outcomes of BAMP protocol as well.
The finite element model (FEM) analysis is a noninva-
sive method of analyzing clinical situations virtually and
assessing the displacement and stress distribution
pattern in different clinical protocols.9 This study aimed
to evaluate the stress distribution and displacement
pattern when transverse forces are applied using MARPE
during BAMP protocol and also compare the skeletal and
dentofacial effects of BAMP with and without MARPE.
The null-hypothesis generated is that there would be
no change in the displacement and stress distribution
pattern in craniofacial structures and sutures after
BAMP with or without MARPE.
MATERIAL AND METHODS
A FEM was constructed from the spiral computed
tomographic images of the skull of a 12-year-old
growing person obtained from the Department of Radi-
ology, Government Medical College. The scan parame-
ters are tube voltage 120 kV, 360 mA, matrix size of
512 3 512, and a slice thickness of 0.3 mm and voxel
0.463 3 0.463 3 0.300. The scan data were saved as
digital imaging and communications in medicine (DI-
COM) files. The raw DICOM data from the computerized
tomography (CT) scan were imported into Mimics soft-
ware (version 8.11, Materialise Interactive Medical Im-
age Control System; Materialise, Leuven, Belgium), in
which the DICOM images of the scan were further pro-
cessed to extract maxilla, mandible, teeth, periodontal
ligament, and other soft tissues and then converting
it into stereolithographic file format. The data in ster-
eolithographic files were exported to Rapidform soft-
ware to convert it into a geometric model (lines and
surfaces) in Initial Graphics Exchange Specification
format.
Fig 1. FEM of the skull showing the meshing condition.
The expander, miniscrews, and miniplates were
modeled as computer-aided design geometry using
computer-aided 3-dimensional interactive application
software (Dassault Systemes, Paris, France) and posi-
tioned according to the situation in the live patient by
using the CT images as positioning aids. The material
properties were assigned into the geometric models ac-
cording to the information provided by the manufac-
turer. The combined geometric model is further
imported into Hypermesh software (version 13.0, Altair
Hypermesh; Altair Engineering, Inc, Detroit, Mich) to
convert into FEMs. The geometric models undergo a
process called meshing, in which these models are
divided into a finite number of elements. These elements
are connected at a finite number of points called nodes.
The meshing condition is shown in Figure 1. In this
study, 10 node solid tetrahedral elements were used.
Two FEMs were established in this study: one showing
maxillary protraction using BAMP without MARPE and
the other with MARPE. Both models contained
465,091 elements and 101,247 nodes each.
The mechanical properties of the structures such as
bone, teeth, and miniscrews in this model were obtained
from experimental data from previous studies10 (Table I).
These mechanical properties were found to be isotropic
and linear elastic. The thickness of the cortical bone
was modeled according to Farnsworth et al11; the thick-
ness of the periodontal ligament was 0.2 mm,12 and the
sutures were 0.5 mm.13
Nodes along with the foramen magnum and center
of the forehead were fully constrained by all degrees of
freedom with zero rotation and zero displacements.

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Suresh, Sundareswaran, and Sathyanadhan
Table I. Young’s modulus and Poisson’s ratio for ma-
terials of the models
Young’s modulus
Material (N/mm2) Poissons’s ratio
Cortical bone 1.34 3 104 0.30
Cancellous bone 0.78 3 104 0.30
Miniplate 10.3 3 104 0.33
Miniscrew 10.3 3 104 0.33
Suture 68.65 0.40
Tooth 2.07 3 104 0.30
Periodontal ligament 0.68 0.49
Two FEM models were created to simulate the 2 pro-
tocols (Fig 2). Protocol 1 simulates BAMP in which 2
miniplates are placed in the infrazygomatic crest in the
maxilla and 2 in the mandible between the canine and
lateral incisor on either side. Fixation was done using ti-
tanium screws (2 for each maxillary implant and 3 for
mandibular). The length of the screw was 5 mm and
diameter 2.3 mm. Elastics were engaged from the mini-
plates in the infrazygomatic crest to that in the mandible
using 250 g of protraction force. In protocol 2, maxillary
skeletal expansion was also incorporated along with
BAMP. This was done using MARPE, which is a bone-
borne palatal expander having 4 microscrews. The mi-
croscrews were inserted into the palate 3 mm lateral to
the midpalatine suture. These microscrews were
attached to the expansion screw, and the arms of the
expansion screw were designed to be soldered to the
bands of the first molars and first premolars. Here, along
with 250 g of protraction force, 800 g of palatal expan-
sion force per side was applied bilaterally. Forces were
directed transversely at the site of insertion of micro-
screws at the apex of the palate, 3 mm lateral to midpa-
latal suture.
The analysis was done using Ansys software (version
12.1; Ansys, Canonsburg, Pa), in which the nodal and
element solutions were plotted for both protocols. Stress
distribution and displacement of selected landmarks in
the maxillofacial bone were analyzed. Displacements of
various craniofacial structures were evaluated along
the x-, y-, and z-coordinates. The x-coordinate indicates
transverse direction, y-coordinate indicates anteropos-
terior direction, and z-coordinate shows vertical direc-
tion. Positive values in the x-axis indicate movements
to the right side, and negative values show movements
to the left. In the y-axis, positive values show backward
movement, and negative values indicate forward move-
ment. In the z-axis, upward movements are indicated by
positive values, and negative values show the downward
movement of the maxillary complex. The landmarks to
American Journal of Orthodontics and Dentofacial Orthopedics
3
assess the displacement pattern of maxillofacial bones
are given in Table II.
RESULTS
A comparison of the displacement pattern in x, y, and
z-planes is shown in Figure 3, and the amount of
displacement of the selected landmarks in both the pro-
traction protocols is shown in Table III. Protocol 1 in the
sagittal plane shows that all points in the nasomaxillary
complex moved forward except the superior point of the
nasal bone, superior border of the frontomaxillary pro-
cess, and the superior end of zygomaticofrontal process.
The ANS moved anteriorly and inferiorly by 0.31 mm and
0.21 mm, respectively. The PNS also moved anteriorly
and inferiorly by 0.32 mm and 0.21 mm, respectively,
indicating the absence of rotation of the maxilla. A
very mild constriction of the anterior maxilla in the
transverse plane is observed. The zygomatic bone moved
anteriorly, laterally, and inferiorly. The lateral walls of
the nasal cavity showed significant expansion. The infe-
rior border of the nasal bone moved anteriorly, with the
superior end showing a posterior movement. Point A and
the tip of the central incisor moved anteriorly by
0.32 mm and 0.32 mm, respectively.
The sagittal plane in protocol 2 showed that the for-
ward displacement of all the points in the nasomaxillary
complex is more than that obtained in protocol 1. The
maxilla showed more anterior movement, with ANS
moving anteriorly and inferiorly by 0.60 mm and
0.29 mm, respectively. PNS also moved anteriorly and
inferiorly by 0.60 mm and 0.28 mm, respectively, indi-
cating a clockwise rotation of the maxilla. The amount
of expansion shown by the maxilla was seen to be
more than that in protocol 1. The expansion increased
in a superoinferior direction with more expansion inferi-
orly. With the expansion, the zygomatic bone moved
anteriorly, laterally, and superiorly and the amount of
displacement was more than that in protocol 1. The
lateral wall of the nasal cavity showed more lateral
movements. In contrast to protocol 1, the superior and
inferior ends of nasal bone moved anteriorly. Point A
and the tip of the central incisor moved anteriorly to
the same extent.
The stress distribution in each suture is shown in
Table IV and Figures 4 and 5. In protocol 1, very mild
stress values were observed in the circummaxillary su-
tures. The von Mises stress was found to be highest in
the zygomaticomaxillary suture (1.13 MPa). A gradual
reduction in stress was observed in other sutures, namely
zygomaticotemporal, frontonasal, zygomaticofrontal,
pterygomaxillary, and midpalatine sutures (0.13 MPa)
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4 Suresh, Sundareswaran, and Sathyanadhan

Fig 2. Three-dimensional FEMs of the craniomaxillary complex simulating protocol 1 (A and C) and
protocol 2 (B and D).

The von Mises stress and maximum principal stress

Table II. Maxillofacial landmarks used as reference
values were higher for protocol 2. The von Mises stress
points for the assessment of displacement
was the highest in the zygomaticomaxillary suture
Area of examination Selected landmarks (4.3 MPa), followed by zygomaticotemporal, pterygo-
Maxilla Frontal process of the maxilla maxillary, zygomaticofrontal, frontonasal, and least in
Nasion midpalatine sutures (0.26 MPa). On analyzing the prin-
Inferior part of nasal bone
cipal stress, the zygomaticomaxillary suture showed ten-
ANS
PNS sile stress medially and compressive stress laterally,
Point A which is similar to the stress pattern seen in protocol
Frontal process of the zygoma 1. However, the magnitude was increased. The principal
Maxillary process of zygoma stress shown by zygomaticotemporal suture is tensile,
Temporal process of the zygoma
and that seen in zygomaticofrontal suture is predomi-
Maxillary central incisor tip
Maxillary dentition Maxillary first molar’s palatal nantly compressive. Stresses in pterygomaxillary, fronto-
cusp tip in the occlusal plane nasal, and frontomaxillary sutures were predominantly
tensile. Midpalatal suture showed tensile stress
throughout the suture, with the amount of stress
in descending order. When evaluating the principal
decreasing from anterior to a posterior direction indi-
stresses, tensile stress was observed medially and
cating more expansion in the anterior maxillary region.
compressive stress laterally in the zygomaticomaxillary
suture. While the zygomaticotemporal suture showed
DISCUSSION
tensile stress, the zygomaticofrontal suture mainly
showed compressive stress. Pterygomaxillary suture Among the prevailing treatment modalities for skel-
showed both compressive and tensile stresses with pre- etal Class III malocclusion with maxillary deficiency,
dominance for tensile stress. The stresses in frontonasal skeletal anchorage has gained increasing importance in
and frontomaxillary sutures were predominantly tensile. maxillary protraction and expansion. The present study

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Suresh, Sundareswaran, and Sathyanadhan
Fig 3. Three-Dimensional FEM of the craniomaxillary complex showing displacement (in mm) after
protocol 1 (A-C) and protocol 2 (D-F). A and D, x-axis; B and E, y-axis; C and F, z-axis.
focused on the comparison with the craniomaxilllary ef-
fects of BAMP with and without implant-supported
maxillary expansion by a FEM analysis, as it is a nonin-
vasive, viable method to study force distribution,
stress and strain in craniofacial skeleton during force
application.
Assessing the stress distribution in the craniofacial
skeleton is an important factor in understanding bone
remodeling. Many methods (laser holography, strain
gauges, and photoelastic techniques) have been intro-
duced to estimate the stress distribution in living tis-
sues.14,15 However, they were not effective for
quantifying the stress in an internal area of living struc-
ture, in which the FEM analysis was found to be useful.16
In this study, the stress distribution and displacement
pattern in all the 3 planes in the craniofacial structures
American Journal of Orthodontics and Dentofacial Orthopedics
5
during maxillary protraction by 2 methods are
compared.
When assessing the changes in the sagittal plane,
both protraction protocols were seen to be effective in
advancing the maxillary complex as indicated by the for-
ward displacement of Point A, ANS, and PNS. The cur-
rent study showed that MARPE produced a definite
enhancement and increased displacement of the whole
nasomaxillary complex in all 3 planes when used along
with BAMP. The stress pattern in the craniomaxillary
complex corresponds with the displacement pattern.
Previous studies have reported that disruption of cir-
cummaxillary sutures by rapid maxillary expansion en-
hances the protraction effects on the maxilla using
FM.17,18 However, there are many clinical studies that
do not support the favorable influence of rapid maxillary
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6 Suresh, Sundareswaran, and Sathyanadhan

Table III. Displacement of selected nodes in protocol 1 and protocol 2 simulations (mm)
Protocol 1 Protocol 2

Landmarks x y z x y z
Frontal process of maxilla 0.017 0.037 0.110 0.044 0.151 0.151
Nasal bone 0.030 0.061 0.082 0.033 0.273 0.085
ANS 0.002 0.312 0.218 0.003 0.609 0.296
Point A 0.001 0.322 0.229 0.003 0.608 0.312
PNS 0.003 0.323 0.216 0.004 0.601 0.286
Frontal process of zygoma 0.004 0.006 0.058 0.016 0.044 0.081
Maxillary process of zygoma 0.024 0.157 0.065 0.031 0.036 0.058
Temporal process of zygoma 0.043 0.057 0.063 0.085 0.118 0.078
Maxillary central incisor tip 0.007 0.329 0.232 0.013 0.608 0.314
Maxillary first molar tip 0.005 0.326 0.233 0.017 0.604 0.284

2
Table IV. The stress distribution in sutures for protocol 1and protocol 2 simulations (N/mm )
Protocol 1 Protocol 2

Sutures von Mises stress Maximum principal stress von Mises stress Maximum principal stress
Midpalatal suture 0.13 0.258 0.262 0.771
Zygomatico maxillary suture 1.137 1.496 4.389 6.709
Zygomatico temporal suture 0.936 2.579 4.116 11.928
Fronto nasal suture 0.829 0.221 1.563 0.424
Pterygomaxillary suture 0.224 0.362 2.245 3.711
Zygomatico frontal suture 0.572 1.025 2.073 3.287
Fronto-maxillary suture 0.261 0.231 0.678 0.526

expansion on maxillary protraction.19,20 Finite element
studies on RME with FM have reported more forward
movement of nasomaxillary complex during maxillary
protraction by facemask with rapid maxillary expan-
sion.21,22 Our findings correlate with these studies with
respect to the positive influence of expansion on pro-
traction. Literature is scant regarding the effects of
expansion on BAMP.
Sutures play a role in the growth of the craniofacial
region. The exogenous forces applied to the maxilla
are transmitted to the distant structures in the craniofa-
cial region by the sutures as mechanical stress and are
measured as sutural strains. Sutural strains vary with
changes in the vector of the orthopedic forces.23 Previ-
ous studies reported significant changes in the circum-
maxillary sutural system after maxillary
protraction.24-26 Jackson et al,27 in an animal study,
found that after maxillary protraction, skeletal remodel-
ing occurred in circummaxillary sutures, and the amount
of remodeling was found to be proportional to the orien-
tation and distance of the suture from the applied force.
The varying location and direction of protraction force
also result in changes in sutural expansion. In our study,
the von Mises stress in all the circummaxillary sutures
was more in expansion protocol than without expansion.
It indicates that more bone remodeling occurs in the
sutures with expansion. This explains the increased
displacement of the nasomaxillary complex obtained af-
ter protraction along with MARPE.
When analyzing the changes in the vertical plane, the
maxilla moved anteroinferiorly with a translatory motion
during protocol 1. There was no counterclockwise rota-
tion of the maxilla, as seen with FM protraction. This
suggests the center of resistance of maxilla to be at
the key ridge as observed by Billiet et al.28 When the
expansion was included with BAMP, a clockwise rotation
was noted in protocol 2. Generally, maxillary protraction
is not preferred in patients with Class III malocclusion
with maxillary deficiency and open bite because of the
counterclockwise rotation tendency of the maxilla. The
clinical significance of this study is that BAMP along
with MARPE gives favorable outcomes in such patients
with skeletal Class III malocclusion with open bite ten-
dency or hyperdivergent growth pattern. However, liter-
ature is scant regarding the effect of MARPE on BAMP
for early treatment of skeletal Class III malocclusion.
Hence, it was not possible to compare our findings
with previous studies.
In the transverse plane, medial movement of certain
nodes in the anterior maxillary region was observed in
protocol 1. This indicates anterior maxillary constriction
by maxillary protraction. Anterior maxillary constriction

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Suresh, Sundareswaran, and Sathyanadhan 7

Fig 4. Three-dimensional FEM of the craniofacial sutures showing stress distribution (N/mm2) after
protocol 1: (A) midpalatal suture, (B) zygomaticomaxillary suture, (C) zygomaticotemporal suture,
(D) frontonasal suture, (E) pterygomaxillary suture, (F) zygomaticofrontal suture, and (G) frontomaxil-
lary suture.

during maxillary protraction with FM has been reported
in previous studies, which suggests a need for maxillary
expansion during protraction.19,29 Incorporation of
MARPE resulted in a triangular pattern of expansion an-
teroposteriorly and superoinferiorly, with the apex of the
triangle pointing superiorly and posteriorly. This indi-
cates the increased resistance to palatal expansion
from the pterygomaxillary process. Park et al30 has also
reported a triangular pattern of expansion with MARPE
in the coronal plane. They observed a parallel expansion
in the axial plane as well.
The maxillary incisors in this study showed less pro-
clination in protocol 2. Retroclination of maxillary inci-
sors after RME has been reported by Wertz,31 and it was
said to be because of the dissipation of the gained arch
length, which was supposed to be due to the change in
muscular tension and interseptal fiber reaction. San-
glu and Hazar32 proposed that the maxillary inci-
dikçio
sors proclined after RME, which is contradictory to our
results.
In the present study, the sutures associated with
maximum von Mises stress were zygomaticomaxillary
and zygomaticotemporal sutures in both expansion
and nonexpansion patients. However, the stress values
in sutures were much higher when expansion was incor-
porated. This suggests the increased disarticulation of
the craniofacial bones in protocol 2. Gautam et al33 re-
ported that the overall stresses after maxillary protrac-
tion with maxillary expansion were significantly higher
than protraction with FM alone. Our findings support
this. Regarding the principal stress (first principal stress),
the presence of both compressive and tensile stress in
some sutures indicated the complex movements of
craniofacial structures. In both protocols (protocol 1
and protocol 2), the predominant tensile stress shown
by the frontonasal and frontomaxillary sutures indicated
translatory movement and clockwise rotation of the
maxilla, respectively.
This study used the CT image of the skull of a 12-
year-old male patient as his age is obviously closer to

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8 Suresh, Sundareswaran, and Sathyanadhan

Fig 5. Three-dimensional FEM of the craniofacial sutures showing stress distribution (N/mm2) after
protocol 2: (A) midpalatal suture, (B) zygomaticomaxillary suture, (C) zygomaticotemporal suture,
(D) frontonasal suture, (E) pterygomaxillary suture, (F) zygomaticofrontal suture, and (G) frontomaxil-
lary suture.

the optimal timing for early treatment modalities. The
FEMs here closely simulated the osseous and sutural
anatomy. This is important because if CT images of older
patients are used, the resultant changes of osseous and
sutural anatomy will affect the final results. Although
we are assigning the already established material proper-
ties to all the models, the above age factor is a definite
advantage in the present CT model used, making the
findings more accurate.
In many of the previous studies, the nasomaxillary
complex was modeled to be continuous, homogenous,
and isotropic without suture grids. This would result in
an error while analyzing the stress distribution in su-
tures. However, separate sutural grids were created,
and hence the stress distribution in sutures may be
more accurate, enabling these findings to be used as
guidelines in clinical situations.
The anatomy and material properties of the skull
differ from one person to the other. Thus, it will be
difficult to create a perfect model with all ideal prop-
erties. The material properties assigned to the tissues
in this study are linear elastic and isotropic. However,
in reality, bone is a more anisotropic structure. In
addition, bone growth cannot be simulated in finite
element study; only the influence of internal stress
on bone growth can be determined. The study was
undertaken by considering the mandible as fixed to
the skull through condyles. Hence, changes in the
craniofacial complex alone were assessed, excluding
the mandible.
CONCLUSIONS
This study evaluated and compared the effects pro-
duced by MARPE on the stress distribution and displace-
ment pattern during BAMP. The findings are as follows:
1. BAMP is seen to be effective in advancing the naso-
maxillary complex. The incorporation of MARPE
into this protocol produced further enhancement
and increased maxillary advancement.
2. MARPE had a significant role in producing more
clockwise rotation of the maxilla during BAMP.

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Suresh, Sundareswaran, and Sathyanadhan
3. MARPE exhibited a triangular pattern of expansion
of the midface with the apex of the triangle pointing
posteriorly and superiorly.
4. The stress distribution in sutures was more favorable
for maxillary advancement after MARPE. The
amount of von Mises stress was higher, with the
highest magnitude in zygomaticomaxillary and zy-
gomaticotemporal sutures.
5. The predominant tensile stresses observed in fron-
tonasal and frontomaxillary sutures in both proto-
cols indicate translation and clockwise rotation of
the maxilla.
AUTHOR CREDIT STATEMENT
Shobha Sundareswaran contributed to conceptuali-
zation, supervision, methodology, original and draft
preparation, and editing; Sugitha Suresh contributed
to carrying out the study, literature search, and draft
preparation; Sreehari Sathyanadhan contributed to liter-
ature search, methodology, and draft preparation.
ACKNOWLEDGMENTS
The authors express their sincere gratitude to Mr Ru-
pesh Kumar, Mechanical Engineer, Bangalore, for help-
ing them with the technical part of the study, and in
doing so, the finite element analysis, as well as support-
ing them throughout the study.
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