392 Section IV Treatment and Treatment Considerations

Figure 21-15 Circummaxillary sutures complex. A, Frontomaxillary suture. B, Nasomaxillary suture. C, Zygomatico-
maxillary suture. D, Zygomaticotemporal suture. E, Pterygopalatine suture. F, Intermaxillary suture. G, Ethmomaxillary
suture. H, Lacrimomaxillary suture.

labial movement of the maxillary incisors (28%), and

lingual movement of the mandibular incisors (20%)
(Figure 21-17). Molar relationship was corrected to a
Class I or Class II dental relationship by a combination
of skeletal movements and differential movement of
the maxillary and mandibular molars (Figure 21-18).
Anchorage loss was observed during maxillary pro-
traction with mesial movement of the maxillary
molars. Overbite was improved by eruption of the
maxillary and mandibular molars. The total facial
height was increased by inferior movement of the
maxilla and downward and backward rotation of the
mandible.
Patients with skeletal Class III malocclusion often
present with a concave facial profile, a retrusive naso-
Figure 21-16 Maxillary protraction below the center of resistance pro- maxillary area, and a prominent lower third of the face.
duces anticlockwise rotation of the maxilla (arrow). Protraction elastics The lower lip is often protruded relative to the upper
attached near the maxillary canine with a downward and forward pull of
30 degrees to the occlusal plane minimize bite opening. (From Ngan P et lip. Treatment with maxillary expansion and protrac-
al: Sernin Orthod 3:255-264, 1997.) tion can straighten the skeletal and soft tissue facial pro-
files and improve the posture of the lips (Figure 21-19).
It is important to note that the profile and occlusion of
Clinical Response to Maxillary Protraction Clinically, Class III patients usually become worse with no treat-
anterior crossbites can be corrected with 3 to 4 months ment because of deficient horizontal maxillary growth
of maxillary expansion and protraction depending on and excess mandibular growth. These changes often
the severity of the malocclusion. Improvement in over- lead to dental compensations and overclosure of the
bite and molar relationship can be expected with an mandible. Figure 21-20 compares the overjet changes in
additional 4 to 6 months of maxillary protraction. In a Class III patients with and without treatment. In
prospective clinical trial,77 overjet correction was patients treated with 8 months of maxillary protraction,
found to be the result of forward maxillary movement the maxilla came forward an average of 2.1 mm. In con-
(31%), backward movement of the mandible (21%), trol patients without treatment, the maxilla came for-
 Treatment of Class III Malocclusion in the Primary and Mixed Dentitions Chapter 21 393

Figure 21-17 Skeletal and dental contributions to overjet correction with maxillary expansion and protraction.

Figure 21-18 Skeletal and dental contributions to molar correction with maxillary expansion and protraction.

ward only 0.5 mm. On average, the mandible posi- direction and point of application, and treatment
tioned back 1.0 mm with treatment. With no treatment ti me (Table 21-2).25,79-89
the mandible came forward 1.7 mm. In addition, with-
out treatment, the incisors compensated to the skeletal Age of Patient Several studies have examined the
discrepancy by the proclination of the maxillary incisors effect of age on maxillary protraction therapy 78-82
and retroclination of the mandibular incisors. In gen- Although some studies 80,82 suggest that face mask/
eral, the direction of these changes is similar to those expansion therapy may be most effective in the pri-
occurring with treatment. mary and early mixed dentitions, other studies 78,79,81
also suggest that it is a viable option for older children
before the onset of puberty.
Variability in Clinical Response
Clinically, the maxilla can be advanced 2 to 4 mm Design of Anchorage System The design of
over an 8- to 12-month period of maxillary protrac- anchorage system for maxillary protraction varies from
tion. The amount of forward maxillary movement is palatal arches to rapid maxillary expansion (RME)
influenced by a number of factors including age of appliances (see Table 21-2). The need to expand the
the patient, the use of anchorage system (with or maxilla before protraction is not entirely clear. Most of
without an expansion appliance), the force level, the studies 77,79,83,85,87-89 utilize palatal expansion to "dis-
39 4 Section IV Treatment and Treatment Considerations

Figure 21-19 I mprovement of facial profile in eight patients treated with maxillary expansion and protraction.
Pretreatment facial profile (left). Posttreatment facial profile (right).
 Treatment of Class III Malocclusion in the Primary and Mixed Dentitions Chapter 21 395

Figure 21-20 Comparison of overjet changes in patients with Class III malocclusion with or without treatment.
A, Changes with treatment at the maxilla (A), maxillary incisors (Is), mandibular incisors (li), and pogonion (Pog)
with 8 months of maxillary protraction (effect of treatment). B, Changes with no treatment (control).

RME, Rapid maxillary expansion.

articulate" the maxilla and initiate cellular response in Force Level, Direction, and Point of Appli-
the circummaxillary sutures, allowing a more positive cation Orthopedic effects require greater forces than
reaction to protraction forces. Few studies have ade- do orthodontic movements. Successful maxillary pro-
quate control groups to determine whether it makes a traction has been reported using 300 to 500 g of force
difference if maxillary protraction was used in con- per side in the primary and mixed dentitions (see
j unction with RME. In a study by Baik, 79 60 patients Table 21-2). Most of these studies recommended wear-
treated with a protraction face mask were divided into ing the headgear for 10 to 12 hr/day.
two groups with or without RME. The author found Hata et al 76 suggested that an effective forward
significantly greater forward movement of the maxilla displacement of the maxilla can be obtained clini-
( +2.0 mm) when protraction was used in conjunction cally from a force applied 5 mm above the palatal
with RME compared with protraction without RME plane. In deep overbite cases in which an opening of
( +0.9 mm). Does it make a difference if protraction was the bite is desired, a forward pull from the level of
initiated during palatal expansion or after expansion? the maxillary arch with a concomitant anterior rota-
In the same study, greater forward movement of the tion of the maxilla aids in the treatment of these mal-
maxilla (+2.8 mm) was found when protraction was occlusions. In several clinical studies a 30- to 45-
initiated during maxillary expansion compared with degree forward and downward protraction force
protraction after expansion (+1.85 mm). applied at the canine region produced an acceptable
396 Section IV Treatment and Treatment Considerations

Figure 21-21 A 10-year, 10-month-old patient treated with protraction face mask for 12 months. A, Pretreatment
model and lateral cephalometric radiograph. B, Immediately posttreatment model and lateral cephalometric radio-
graph. C, Two years posttreatment model and lateral cephalometric radiograph. D, Four years posttreatment model
and lateral cephalometric radiograph.

clinical response with one degree of counterclock- and protraction has not been reported in the litera-
wise rotation of the palatal plane.77,87 ture. Increased treatment time may compromise
patient oral hygiene and cooperation.
Length of Treatment Time There is no consen-
sus on the length of treatment with protraction head- Posttreatment Stability Animal and human studies
gear. A review of the literature shows that treatment have shown that the effects on the maxilla remained
ti me varies from 3 to 16 months (see Table 21-2). Most stable for 1 to 2 years after treatment. In a few stud-
of the orthopedic changes are observed within the ies 77,84,86-91 in which patients were followed after maxil-
first 3 to 6 months after maxillary expansion. lary expansion and protraction were completed, it was
Prolonged use of protraction force results in den- found that, in general, the anterior position of the max-
toalveolar changes including mesial movement of illa was maintained posttreatment. It is interesting to
maxillary molars and proclination of maxillary note that during this growth period the maxilla and
incisors. The benefit of repeated maxillary expansion mandible reverted back to the original growth pattern
 Treatment of Class III Malocclusion in the Primary and Mixed Dentitions Chapter 21 397

Figure 21-21, cont'd E, Cephalometric tracings and superimposition of treatment changes. Note the positive
overjet after treatment. F, Cephalometric tracings and superimposition of posttreatment growth changes. Note the
overjet reverted back to an anterior crossbite because of excessive forward mandibular growth.

and, in some cases, Class III correction was lost because a Class III functional appliance for 1 year.77 The treat-
of excess mandibular growth. ment was found to be stable 2 years after the removal
Fewer studies followed the early treatment patients of the appliances. When these patients were followed
through the pubertal growth period. In a prospective for another 2 years, 15 of the original 20 patients main-
clinical trial, a group of Chinese patients were tained a positive overjet. In patients that relapsed back
overtreated to a Class I or II relationship with maxil- to a negative overjet, the mandible outgrew the max-
lary expansion and protraction and then retained with illa in the horizontal direction. Figure 21-21 illustrates
398 Section IV Treatment and Treatment Considerations

Figure 21-22 Treatment of a 6-year-old patient with a Class III malocclusion and a hyperdivergent growth pattern.
A and B, Pretreatment facial profile. C to E, Pretreatment intraoral photographs.

unfavorable growth changes in a patient 4 years after that diminishes its prognathism. The presence of an
treatment with maxillary expansion and protraction. adequate overbite helps maintain the immediate den-
The overjet reverted back to an anterior crossbite tal correction after treatment. For patients presenting
because of excessive forward mandibular growth. As a with a hyperdivergent growth pattern and a minimal
result, the authors recommend overcorrection of the overbite, a bonded acrylic palatal expansion appliance
overjet and molar relationships in anticipation of the to control vertical eruption of molars has been recom-
subsequent horizontal mandibular growth. It is also mended. However, a study comparing the use of
advisable to use a retention device such as a mandibu- banded or bonded expansion appliances as anchorage
lar retractor or a functional appliance following maxil- devices for maxillary expansion and protraction
lary protraction. showed little differences in the skeletal and dental
changes following the use of either appliance. 92
Treatment Indications for Face Mask Therapy The Specifically, vertical eruption of the posterior molars
face mask is most effective in the treatment of mild to and an increase in lower facial height were observed in
moderate skeletal Class III malocclusions with a retru- both groups. Figure 21-22 shows the treatment of a
sive maxilla and a hypodivergent growth pattern. 6-year-old patient presenting with a Class III malocclu-
Patients presenting initially with some degree of ante- sion and a hyperdivergent growth pattern. An upper
rior mandibular shift and a moderate overbite have a transpalatal arch and a lower lingual holding arch were
more favorable prognosis. In these cases correction of used as retentive devices. The patient wore a vertical
the anterior crossbite and the mandibular shift results chin cup appliance at night to control mandibular
in a downward and backward rotation of the mandible growth and vertical eruption of the posterior teeth.