10.

5005/jp-journals-10021-1092

CASE REPORT (IBO)

Ashok Surana

IBO Case Report: Management of Skeletal

Class III Malocclusion with Combined Rapid
Maxillary Expansion: Facemask Therapy and
5-Year Follow-up
Ashok Surana
ABSTRACT
This case report describes the management of skeletal Class III malocclusion with maxillary deficiency in an adolescent girl, using combined
rapid maxillary expansion-facemask approach, followed by comprehensive fixed appliance mechanotherapy. Excellent long-term stability is
demonstrated up to 5 years post-treatment.
Keywords: Class III malocclusion, Maxillary deficiency, Rapid maxillary expansion, Facemask, Overcorrection, Stability.
How to cite this article: Surana A. IBO Case Report: Management of Skeletal Class III Malocclusion with Combined Rapid Maxillary Expansion:
Facemask Therapy and 5-Year Follow-up. J Ind Orthod Soc 2012;46(4):216-222.

INTRODUCTION
Class III malocclusion is associated with a deviation in the
sagittal relationship of the maxilla and the mandible,
characterized by a deficiency and/or a backward position of
the maxilla, or by prognathism and/or forward position of the
mandible.1 Prevalence of this malocclusion in the white
Caucasion population has been reported to be 1 to 5%.2-4 In
the Asian populations, prevalence ranges from 9 to 19%.5-7
Prevalence in the Indian population is reported to be about
3.4%.8
Several factors including genetics, ethnicity, environmental factors and habitual posture have been implicated in
the etiology of this malocclusion.9-14
Early strategies for the management of Class III
malocclusion focused on aggressively restraining the growth
of the mandible, and it was only from the late 1960s that the
awareness of maxillary deficiency as a key component of
Class III malocclusion entered the orthodontic consciousness.
Animal and human studies in the 1970s and 1980s showed that
the maxilla can be repositioned anteriorly by dissociation from
the circum-maxillary sutures using protraction forces.15-21
Delaire 22 reintroduced facemask therapy for maxillary

Professor and Head

Department of Orthodontics, Guru Nanak Institute of Dental Sciences
and Research, Panihati, Kolkata, West Bengal, India
Corresponding Author: Ashok Surana, Department of Orthodontics
Guru Nanak Institute of Dental Sciences and Research, 157/F Nilgunj Road
Panihati, Kolkata, West Bengal, India, e-mail: life_line_dental@yahoo.co.in

Received on: 8/10/11

Accepted after Revision: 4/4/12

216

protraction in 1976, more than a century after it was first

described in Germany.
Petit23 modified the facemask of Delaire by increasing
the amount of force generated by the appliance and decreasing
the overall treatment time. McNamara24 suggested that rapid
maxillary expansion (RME) may enhance the protraction
effect of the facemask by disrupting the maxillary suture
system, and described a version of the Petit facemask,
attaching to a rapid maxillary expander bonded to the posterior
dentition.
In the last two decades, RME-facemask combination has
become the standard protocol in the management of growing
patients with maxillary deficiency25,26 with long-term studies
showing successful outcomes in 70 to 80% of patients.27-29
Turley 30 described RME-facemask combination as a
predictable and effective approach to managing treatment that
was once considered difficult.
This case report describes the use of the above procedure
for the management of Class III malocclusion with maxillary
deficiency in an adolescent girl and long-term stability is
demonstrated up to 5 years post-treatment.
DIAGNOSIS AND ETIOLOGY
A 13-year-old female patient reported with a chief complaint
of large lower jaw and negative overjet. She gave a history of
having previously received chin cap therapy from a dentist.
No relevant familial history was reported.
On extraoral examination (Fig. 1), the patient showed a
concave profile with slight deficiency in maxillary projection,
and lower lip positioned ahead of the upper. The nasolabial
angle was obtuse and lower facial height appeared to be
reduced, conferring a premature aged appearance. The smile
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JIOS
IBO Case Report: Management of Skeletal Class III Malocclusion with Combined Rapid Maxillary Expansion: Facemask Therapy

Fig. 1: Pretreatment extraoral views

Fig. 2: Pretreatment intraoral views

Fig. 3: Pretreatment OPG and lateral cephalogram

appeared unesthetic, with the upper incisors partially masked

by the lower incisors, and presence of wide buccal corridors.
Intraoral examination (Fig. 2) revealed crowding in the
maxillary anterior region, with 11, 12, 21 and 22 in crossbite
relationship. There was a bilateral posterior crossbite of 15,
16, 25 and 26. Molar relationship was Class III bilaterally,
while canine relationship was Class III on the right side and
Class I on the left side respectively. The lower dental midline
was shifted 1.5 mm to the left of the facial midline. No
significant mandibular deviation on closure or clicking of the
temporomandibular joint (TMJ) was observed.
A standard OPG and lateral cephalogram of the patient were
obtained (Fig. 3). Developing third molars were observed in
all the four quadrants. Cephalometric analysis (Table 1)
indicated a Class III sagittal relationship (ANB = 2, AO-BO
= 6.5 mm) and normodivergent skeletal pattern (FMA = 25,
SN-GoGn = 29.5).
In addition, the upper incisors were retroclined (U1-NA =
18, 4 mm) and the lower incisors proclined (L1-NB = 26.5,
6 mm). The upper lip was retropositioned and the lower lip
was positioned forward with respect to Ricketts E-Line (ULE Line = 6.5 mm, LL-E line = 1.5 mm).
Model analysis revealed space discrepancy of 9 and
1 mm in the maxillary and mandibular arches respectively.
Boltons analysis was suggestive of a relative mandibular tooth
material excess (overall ratio = 92.6, anterior ratio = 82).
Based on the patients hard and soft tissue relationships, a
diagnosis of skeletal Class III malocclusion with relative
maxillary deficiency was reached.

b. Correction of anterior and posterior crossbite relationships.

c. Achievement of well-aligned maxillary and mandibular
arches with Class I molar and canine relationship.
d. Correction of the dental midline discrepancy.
e. Reduction of buccal corridors.

TREATMENT OBJECTIVES
The treatment objectives for this patient were as follows:
a. Improvement of the soft tissue profile.

TREATMENT PLAN
Since the patient had a deficient midface, it was decided to
attempt transverse expansion and protraction of the maxillary
arch. This would be followed by finishing and detailing using
a fixed appliances. In anticipation of late, excessive mandibular
growth, the patient was advised of the possible need for jaw
surgery in the future.
TREATMENT PROGRESS
A banded Hyrax Expander (Leone, Italy) with an expansion
range of 13 mm was cemented on the first molars and first
premolars, with hooks incorporated above the first premolars
(Fig. 4). The patient was instructed to turn the screw one time
per day, until correction of posterior crossbite was achieved.
Following expansion, the screw was sealed and the patient
instructed to wear a Petit-type maxillary protraction facemask
daily for as many hours as possible except when she was
attending school. The direction of pull was forward and
downward, directed approximately at 30 to the maxillary
occlusal plane.
Beginning with a force level of 150 gm on each side, it
was increased to 300 gm on each side from the second week.
After 1 month of wear, force imparted was increased to and
maintained at 450 gm on each side.
After 9 months of facemask wear, a positive overjet was
achieved, following which facemask wear was discontinued,

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217

Ashok Surana

Fig. 4: Post-RMEfacemask intraoral views

the expansion assembly removed, and a transpalatal arch

cemented on the maxillary first molars.
Detailing of the occlusion in both arches was carried out
with fixed preadjusted edgewise appliances (0.022" in slots,
Roth prescription). Leveling and alignment began with 0.016"in HANT wires and progressed up to 0.017" 0.025"-in
stainless steel wires. At this stage 3/16" Class III elastics were
worn to help maintain the overjet correction. Vertical finishing
elastics and 0.016"-in nickel-titanium wires were used to settle
the occlusion. Total duration of active treatment was 19
months.
Following appliance removal, a fixed-spiral-wire (FSW)
retainer was bonded to the lingual surfaces of maxillary
incisors, and a lingual bar bonded to the mandibular canines.
In addition, Hawleys retainers were fabricated and the patient
instructed to wear full-time for 6 months, followed by
nighttime wear for 1 year.
TREATMENT RESULTS
There was a noticeable improvement in lip-nose-chin
relationships and a full smile with appreciably reduced buccal
corridors (Fig. 5). Correction of anterior and posterior
crossbite was achieved, resulting in a well-aligned dentition
with normal overjet and overbite. Molar and canine
relationships were corrected to Class I on the right side and
overcorrected to end-on on the left side (Fig. 6).
There was significant improvement in the maxillomandibular relationship, evidenced by changes in the ANB
angle and Wits appraisal. Slight downward and backward
rotation of the mandible occurred, shown by changes in FMA,
SN-MP and Jarabak ratio. Proclination of the maxillary

Fig. 5: Posttreatment extraoral views

incisors and retroclination of the mandibular incisors

occurred, contributing to the clinical improvement (Table 1).
The soft tissues responded favorably resulting in a
noticeably pleasant profile (Fig. 7).
LONG-TERM CHANGES
Five years post-treatment, the patient exhibited excellent
frontal and profile esthetics (Fig. 8). Canine and molar
relationships are Class I, overjet and overbite were ideal,
crossbite correction and anterior alignment are maintained,
with intact fixed retainers in both arches (Fig. 9). The current
OPG shows impacted third molars which will require
extraction (Fig. 10).
Cephalometric superimpositions (Figs 11 to 13) showed
that during treatment proclination of the maxillary incisors and
retroclination of lower incisors occurred, along with some
extrusion of maxillary molars and backward rotation of the
mandible. During the post-treatment phase, some proclination
of mandibular incisors occurred along with compensatory
proclination of the maxillary incisors which maintained the

Fig. 6: Posttreatment intraoral views

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IBO Case Report: Management of Skeletal Class III Malocclusion with Combined Rapid Maxillary Expansion: Facemask Therapy
Table 1: Comparison of cephalometric values
Parameters

Before treatment

Posttreatment

Five years posttreatment

Maxilla
SNA ()
N perpendicularPt. A (mm)
Midfacial length, Co-Pt. A (mm)
Angle of convexity ()

80
3
94
3

83
1
96
7

82
0
95
5

Mandible
SNB ()
N perpendicularPog (mm)
Effective mand. length, Co-Gn (mm)
Facial angle ()

82
3.5
124
89

81
4.5
124
85

80
1
124
87

Maxilla-mandible
AO-BO (mm)
ANB ()
Maxillomandibular difference (mm)

6.5
2
30

1
2
28

2
2
29

Vertical
FMA ()
SN-MP ()
Y-axis ()
Facial axis ()
Jarabak ratio (%)

25
29.5
62
6
68.75

29
32
65
7
66.1

29
32
62
6
64.2

Maxillary incisor
U1-NA ()
U1-NA (mm)
U1-APog (mm)
U1-SN ()
U1-PP ()

18
4
2
97
110.5

21
4
4
105
112

30.5
10
10
111.5
122

Mandibular incisor
L1-NB ()
L1-NB (mm)
IMPA ()
L1- APog (mm)

26.5
6
92
6.5

15
4
81
1

25
7
88
5

Soft tissues
Nasolabial angle ()
UL- E line (mm)
LL- E line (mm)
H - angle ()

104
6
1.5
12.5

95
3
0
18

83
2
0
16

Others
Interincisal angle ()
Saddle angle, N-S-Ar ()
Articular angle, S-Ar-Go ()
Gonial angle, Ar-Go-Me ()
Sum of cranial angles ()
Overjet
Overbite

137
127
142
122
391
2 mm
4 mm

139
126
145
121
392
2 mm
2 mm

124
128
144
123
395
2 mm
2 mm

Fig. 7: Posttreatment OPG and lateral cephalogram

clinical correction. Soft tissue fullness increased during

treatment and thereafter in the retention phase.
Overall, the patient exhibits excellent long-term stability
following combined RME-facemask and fixed orthodontic
treatment.

DISCUSSION
The use of facemask therapy for the management of midface
deficient Class III malocclusions has conventionally been
recommended in the deciduous and mixed dentitions.31-34 Little

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Ashok Surana

Fig. 8: Five years posttreatment extraoral views

maxillary protraction is expected when it is used in the

permanent dentition.35 However, clinical correction of the
malocclusion has been shown to occur by a combination of
skeletal and dental movements in both the anteroposterior and
vertical planes of space.36 Also, the orthopedic approach has
a significantly lower cost and risk potential associated with,
making it an attractive alternative to orthognathic surgery,
though the esthetic results and occlusal stability with the latter
may be superior.37
Also, following growth modification therapy, there is a
clear reestablishment of the Class III craniofacial pattern,
necessitating overcorrection to prevent clinical relapse.30,34
Recent case reports38,39 have demonstrated successful
management of Class III malocclusion in adolescent patients
using the RME-facemask protocol.
In this patient, posterior crossbite was corrected through
RME and a positive overjet was achieved following facemask
therapy. Throughout active treatment, there was no increase
in effective mandibular length, while effective maxillary
length increased by 2 mm (Table 1). In addition, favorable
dentoalveolar changes as well as slight downward and backward
rotation of the mandible occurred, which aided in the favorable
occlusal result. These are usual side effects of Class III
mechanotherapy.40,41 Backward rotation of the mandible also
makes it appear less prognathic and contributes to
improvement of the facial profile.42

Fig. 10: Five years posttreatment OPG and lateral cephalogram

Fig. 11: Overall cephalometric superimpositions

Fig. 9: Five years posttreatment intraoral views

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IBO Case Report: Management of Skeletal Class III Malocclusion with Combined Rapid Maxillary Expansion: Facemask Therapy

Fig. 12: Maxillary superimpositions

Fig. 13: Mandibular superimpositions

At 5 years post-treatment occlusion has settled further and

soft tissue esthetics are improved. The overcorrection
achieved at finishing possibly aided in long-term maintenance
of the treatment results, in accordance with the
recommendations of Turley30 and Baccetti et al.34
CONCLUSION
This case report demonstrates that Class III malocclusion with
maxillary deficiency can be successfully managed in the
permanent dentition, using RME-facemask protocol followed
by fixed orthodontic treatment. Careful case selection,
excellent patient cooperation and deliberate overcorrection
could ensure a treatment result that is stable, functional and
esthetic in the long-term.
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