## 2 The Use of Gamification in Therapy for Children
Standardised facemasks, which are only available in two sizes, fail to accommodate the diverse anatomical facial structures of young patients, often resulting in discomfort, skin irritation, and low adherence to treatment protocols. Furthermore, the generic medical appearance of the facemask can evoke feelings of embarrassment or self-consciousness in patients, further impeding compliance [20]. Patient cooperation is essential for the success of the treatment. Some attempts have been made to make the facemask more comfortable, but none of them has been impactful in terms of overall patient experience improvements [21]. Indeed, the literature shows that attempts to improve compliance with therapy primarily focus on the maximisation of the device's performance from an ergonomic perspective. Early attempts experimented with custom protraction headgear [22] by taking an impression of the patient's facial structure to create a precise anatomical model. This ensured the headgear could be customised to the individual's facial contours for a more ergonomic fit. An impression of the child's face was taken using alginate, a widely used material in dentistry for its ability to capture detailed and accurate impressions of anatomical structures. Alginate's quick-setting properties and ease of use make it ideal for creating a precise mould of the patient's facial structure, which was essential for designing the customised protraction headgear. [PERSON] et al. [23] proposed a chin-cup customisation method based on the removal of the felt sticker from the inside of a prefabricated chin cup, filling the chin cup with putty-consistency polyvinyl siloxane (PVS), ensuring the material extends beyond the cup's borders for better retention, and using the chin cup as an impression tray by pressing it against the chin and holding it briefly (hardening of the material is not necessary). With this solution, the impression material can adhere more securely, forming a customised chin cup tailored to the patient's anatomy, improving comfort and compliance. Other attempts to improve the ergonomics of the facemask were proposed by [PERSON] et al. [24], who used a silicone chin cup to prevent skin irritations due to the extended use of correction facemasks. Lastly, [PERSON] et al. [21] experimented with a modified facemask] by moulding the patient's face. All the procedures described above were obviously extremely unpleasant and challenging for both the patient and the clinician, and the proposed solutions were insufficient to address all the issues emerging from the use of facemasks related to a negative patient experience leading to poor compliance with therapy. Considering this, the _SuperPowerMe_ project was initiated as a multidisciplinary effort, combining expertise in orthodontics, product design, software development, and game design to develop child-oriented strategies to facilitate patients' acceptance and improved compliance with the therapy. The project aimed to develop a personalised facemask system that integrates gamification principles to increase patient engagement and compliance, while also allowing precise monitoring of treatment adherence through sensor technology. The goal of the project is to transform orthodontic therapy by implementing innovative solutions to improve the patient's experience and support the orthodontist with precise and accurate monitoring. Since the facemask was identified as the least favoured and least appealing option among ten intra-oral and extra-oral devices [20], the objective of the present study was to design and test solutions to improve the patient experience. To do so, a therapeutic ecosystem composed of a personalised facemask, a monitoring system, and a video game was developed. Personalised facemasks were manufactured and tested in an observational study involving ten patients. Thanks to the positive outcomes of the first study, the personalised facemasks were equipped with electronics to monitor the wear time and connected to a video game.