Enhanced Sutural Protraction: An Innovative Orthopedic Protocol for Midfacial Advancement in Growing Patients

Midfacial hypoplasia is a common condition in clinical practice. It is characteristic of various craniofacial syndromes but can also occur as an isolated form of dento-skeletal dysmorphosis. Managing this condition in growing patients is challenging. Surgical approaches have high relapse rates, whereas orthodontic treatments yield variable results in midface advancement and stability. This study evaluates the effectiveness of the Meazzini-Mazzoleni Enhanced Sutural Protraction (MMESP) protocol for correcting severe midfacial hypoplasia in growing patients. Ten patients, with or without associated malformations, were treated at 2 ERN CRANIO centers: Fondazione IRCCS San Gerardo dei Tintori and ASST Santi Paolo e Carlo-Ospedale San Paolo. Treatment began after assessing circum-maxillary suture maturation. A suture release phase was conducted using either palatal expansion or a modified Alt-RAMEC protocol. A rigid external distractor, anchored skeletally or dentally, was used to advance the midface without osteotomies. After correction, stabilization was achieved with temporary anchorage devices (TADs), intraoral elastics, or a protraction face mask. Lateral cephalograms and craniofacial CT scans at baseline, post-treatment, and 12-month follow-up quantified skeletal changes. Cephalometric superimpositions showed significant, stable midface advancement, averaging 15.68 mm at A point, achieving full correction. 3D CT models confirmed the movement followed the osteotomy trajectory of a Le Fort III procedure, with a cranio-caudal gradient and maximum effect at the maxillary alveolar bone. Tensile deformation with bone apposition was observed along circum-maxillary sutures. The MMESP protocol provides a safe, effective, and stable correction of severe midfacial hypoplasia in growing patients, delivering excellent outcomes.