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Dentoskeletal effects and facial profile changes in Class III patient treated with protraction facemask appliance: a case report
Journal of the World Federation of Orthodontists 1 (2012) e73ee77
Contents lists available at SciVerse ScienceDirect
Journal of the World Federation of Orthodontists journal homepage: www.jwfo.org
Research
Dentoskeletal effects and facial profile changes in Class III patient treated with protraction facemask appliance: a case report Himawan Halim a, *, Anita Budihardja b a b
Department of Orthodontics, Indonesian Naval Dental Institute, Jakarta, Indonesia Private Practice
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 February 2012 Received in revised form 9 March 2012 Accepted 15 April 2012 Available online 18 June 2012
Introduction: Treatment of skeletal Class III malocclusion with an anterior crossbite is challenging due to unpredictable results and potentially unfavorable growth. Growth modification in growing patients is an alternative approach to orthognathic surgical correction. Objective: Case report of a patient with Class III malocclusion and anterior crossbite was treated with maxillary protraction facemask to illustrate that treatment has to be started during growth period and patient compliance is a determining factor. Treatment procedure: Treatment of anterior crossbite was completed in two phases. The first phase was to correct the skeletal discrepancy with rapid palatal expansion, miniscrews and protraction facemask. The second phase was to correct the dental alignment with fixed orthodontic appliance. Conclusions: Protraction facemask therapy started at growing age with good patient compliance is a good approach in treating anterior crossbite relating to skeletal problems in the mixed dentition period. Ó 2012 World Federation of Orthodontists.
Keywords: Anterior crossbite Dentofacial Protraction face mask
1. Introduction Class III malocclusion is easy to identify but often quite difficult to treat. This type of malocclusion can be recognized, not only by dental specialist but also by lay person. The appearance of dental anterior crossbite often stimulates the parent to seek orthodontic treatment for the child. According to Angle, a Class III molar relationship refers to a condition where the mesio buccal cusp of the upper first molar occludes between the mandibular first and second molar. Although this definition represents a typical Class III relationship, the lower molar can be mesial to the upper molar in a varying degree [1,2]. Class III malocclusion can involve maxillary skeletal retrusion, mandibular skeletal protrusion, or a combination of both. Patients with Class III malocclusion usually present with a Class III molar relationship, posterior crossbite, and/or anterior crossbite [3]. The upper arch is usually narrow and short, and the upper teeth are commonly crowded. The lower arch is broad and the mandibular teeth are often spaced. Dental compensation might include maxillary dentoalveolar protrusion and mandibular dentoalveolar retrusion. In addition to a prominent chin that causes a concave * Corresponding author: Indonesian Naval Dental Institute, Sumenep no.7, Jakarta 10310, Indonesia. E-mail address: [email protected] (H. Halim). 2212-4438/$ e see front matter Ó 2012 World Federation of Orthodontists. doi:10.1016/j.ejwf.2012.04.003
profile, a midface deficiency is often apparent as well as increased mandibular incisor display and a prominent lower lip [2,3]. A type of Class III malocclusion that refers to pseudo-Class III malocclusion or functional crossbite is characterized by the presence of occlusal prematurity in centric relation, which results in a habitual forward positioning of the mandible (faulty habitual occlusion). The shift may occur in an anterior and/or in a lateral direction. Patients can actually reach an incisor edge to edge relationship in central occlusion. These patients may exhibit a forward path of closure. This type of crossbite is often seen in children, typically because of interferences caused by lack of wear of their deciduous canines. Dental functional crossbite can later manifest as skeletal Class III malocclusion [1,2]. There are several possible etiologies that may cause Class III malocclusion. True skeletal Class III malocclusion is usually inherited and may have a very strong genetic basis. The Hapsburg jaw, the prognathic mandible of this European royal family is a well-known example. Other possible etiologies are congenital defects, trauma, and premature contact that lead to a functional crossbite [4]. With the limited ability to influence mandibular growth and the malleability of maxillary growth well established, treatment modalities to influence mild to moderate Class III alveolar base discrepancies have shifted to a maxillary protraction paradigm. Maxillary protraction is one of the main treatment modalities in Class III maxillary retrognathic preadolescent and adolescent patients [5e7].
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Fig. 1. Initial extra oral (AeC) and intra oral (DeF) photographs.
1.1. Treatment options for Class III malocclusion Treatment for Class III patients always depend on the age of the patient, whether they are still growing or not. When an adult patient is diagnosed with skeletal Class III malocclusion, treatment options are limited. Treatment options would involve comprehensives orthodontic therapy, either combined with extraction and/or orthognathic surgery. Orthognathic surgery designed to balance the skeletal components could involve a mandibular set back (for mandibular prognathism) and/or a Le Fort I procedure for maxillary skeletal retrusion. A surgically assisted rapid palatal expansion (RPE) is sometimes necessary [2,4,8]. There are several treatment modalities that can be considered in treating a young Class III patient in late deciduous or mixed dentition, which includes the following: inclined bite plane, exercising with tongue blades, enameloplasty of the deciduous canine, removable plate to expand the maxillary dental arch or to proclined the upper teeth, functional regulator III from Professor Fraenkel, chin cup, and facial protraction mask (with or without RPE). These treatment options have their own indication and benefits that need to be considered before used [2,4,8].
that the patients from 8 to 12 years old and those in a younger age group (5 to 8 years old) had similar therapeutic response. A protraction facemask is optimally worn on a full-time basis (about 20 hours a day, except during meals) for about 6 to 8 months, then it can be worn on a nighttime basis only for additional period of time. Young patients (5 to 9 years old) can usually follow this regimen. In older patients, full time wear may not be feasible. They should wear the appliance at all times except while attending school or participating in contact sports. Less than full time wear can result in longer treatment time [8]. Several authors have reported changes achieved by protraction facemask therapy [3,4,8]. The treatment effects are a combination
1.2. Facial protraction mask More recently, orthopedic treatment with facemask appliance has become an accepted procedure for treating Class III patients with maxillary retrognathism. Designed by Delaire in the late 1960s and then modified by Petit and others, facemasks have proven to have the greatest opportunity to correct Class III malocclusion, whether identified during the late deciduous or early mixed dentition. Significant changes in all three planes of space may be achieved, especially when combined with rapid maxillary expansion [8,9]. For optimal result, it is suggested that treatment should be initiated as soon as possible. According to McNamara and Brudon [8], the optimal time to begin an early Class III treatment is in the early mixed dentition coincident with the eruption of the upper permanent incisors. Hickham [10] advised that the treatment should be initiated before the patient is 8 years old. Proffit et al. [4] recommended that maxillary protraction initiated before the age of 9 would produce more skeletal changes and less dental movement. Takada et al. [11] reported that maxillary protraction and chin cup therapy were effective through puberty. Merwin et al. [12] reported
Fig. 2. Initial cephalometric (A) and panoramic (B) radiographs.
H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
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Fig. 3. Extra oral (AeC) and intra oral (DeF) photographs after facemask.
of skeletal and dental changes of the maxilla and mandible. The maxilla moves downward and forward with a slight upward movement in the anterior and downward movement in the posterior palatal plane. As a consequence, downward and backward rotation of the mandible improves the maxillo-mandibular skeletal relationship in the sagittal dimension but results in an increase lower anterior facial height. Upper incisor labial inclination increased and lower inclination decreased [6e8].
1.3. Rapid palatal/maxillary expansion Face mask therapy is often supplemented with maxillary expansion. Some benefits are associated with RPE in conjunction with face mask therapy, including transverse expansion to correct posterior crossbites, increasing arch length, splinting of the maxillary dentition against forward movement and anterior constriction during protraction therapy, and disruption of the circummaxillary sutural system that facilitates the orthopedic effects of the facemask. Maxillary expansion can produce a slightly forward movement of the maxilla [3,13]. A banded maxillary splint and bonded maxillary splint can be options for performing the palatal expansion; McNamara et al. [8] suggested acrylic bonded maxillary splint in the posterior dentition. In mixed dentition the splint usually covers the first and deciduous molars and the permanent first molar. If permanent second molars have erupted, it is necessary to place an occlusal rest against these teeth to prevent supra eruption of these teeth during appliance wear. The bite opening effect of the maxillary splint also may reduce the tendency toward extrusion of posterior teeth, which has been observed using the banded design of appliance. When a banded appliance is used, two teeth per side are banded, the first and second deciduous molar, or the first permanent molar and second deciduous molar, or the first permanent molar and premolar. The appliance is activated once or twice daily (0.25 mm per activation) [8].
Some clinicians have advocated maxillary expansion 1 week before starting facemask use, even without maxillary constriction or crowding. A clinical trial by Vaughn et al. [3] reported that early facemask therapy, with and without palatal expansion, is effective to correct skeletal Class III malocclusion. 1.4. Phase II orthodontic treatment Although it is important to decide when to start the phase I treatment, it is also important to decide when to begin the phase II orthodontic treatment. Phase II is usually completed with a fixed appliance. Starting treatment after the permanent second molars have erupted allows the practitioner to evaluate post treatment growth and to minimize the duration of the fixed appliance therapy [13]. Latent mandibular growth and condylar growth seem to be the main cause of posttreatment relapse. Therefore overcorrection is recommended because after facemask treatment, patients will resume growth similar to an untreated Class III patient. Some patients may be required to continue facemask therapy during the phase II treatment. 2. Objectives The objective of this case report is to describe a patient treated in our clinic using a combination of RPE, protraction facemask, and fixed orthodontic appliance. 3. Case report An 11-year-old boy came to our clinic with his parents and grandparents. The chief complaint was that his lower jaw was too far forward and he had crocked teeth in the upper jaw. Anamnesis showed that a genetic predisposition runs in the family with his father and grandmother also having the same type of facial profile. Extraoral examination revealed that the maxilla was retrognathic and the mandible was slightly prognathic. He had symmetric, mesofacial face and concave profile. Intraoral examination revealed
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H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
late mixed dentition phase, with unerupted teeth 15, 35, and 45. Tooth 25 was agenesis with 75 still in the place. He had crowding in the upper (5 mm) and lower jaws (2.5 mm), an anterior crossbite, and a deep bite. No posterior crossbite was found. Overjet was e2 mm and overbite was 3 mm. Molar relationship in both side was full Class III. Cephalometric analysis indicated a Class III malocclusion with retrognathic maxilla and prognathic mandible. Temporomandibular joint function was normal (Figs. 1 and 2). The treatment plan was divided into two phases. The first phase used a banded RPE with protraction facemask and then a 2 4 fixed appliance, which was continued through the second phase, and a full fixed orthodontic appliance also was added during the second phase of treatment. We started the treatment by placing orthodontic bands for RPE on teeth 16, 14, 24, and 26. The RPE is only activated once a day for 1 week because the patient did not have posterior crossbite and then the patient was told to wear face mask 16 hours a day. We had a little trouble with patient cooperation because the patient could not tolerate the RPE well and also had trouble with his oral hygiene. His parents asked us to remove the RPE as soon as possible because he had been complaining about it and relating that he was having problems at his new school. After 4 months we removed the RPE and replaced it with a 2 4 appliance in the upper and lower arches. A utility arch was used to intrude lower anterior teeth and nickel-titanium (Ni-Ti) wire was used to level and align the upper teeth. As a replacement for the RPE, mini-implants were used. A 1.6mm diameter, 8-mm length mini-implant was placed between teeth 13 and 14 and between 23 and 24 for the attachment of the extra oral elastics. Patient was told to wear the face mask 16 hours a day. Progress was seen and anterior crossbite was resolved. Patient was still asked to wear face mask 12 hours a day and a full fixed appliance already placed in both upper and lower arch. Treatment was continued to close the rest of the space in upper jaw, to align tooth 15 (Figs.3e6). 4. Discussion It is suggested to begin Class III treatment as soon as possible when the upper permanent incisors erupt. It has been demonstrated that treatment changes in younger patients were greater than those in older patients [4]. Better skeletal effect can be obtained in the primary and early mixed dentition. At later ages, tooth movement and/or mandible rotation are likely the major components of the response of the treatment. In addition to treatment timing, patient cooperation is an important factor in determining the success of the treatment. The treatment for this patient should have started sooner. The patient began treatment during late stage of mixed dentition and the cooperation was not as expected. After 2 years of treatment, a good result was achieved. His profile was improved. A better result would have been achieved if he came for treatment earlier. The application of protraction from a facemask resulted in significant improvement in facial aesthetics and maxillomandibular relationship. Sella nasion point-A angle increased, demonstrating anterior displacement of the maxilla. The point-A nasion point-B angle and Witt’s appraisal were also increased. The mandible was rotated downward and backward because the Frankfort mandibular plane angle was slightly increased. The dental measurement revealed upper incisors are proclined and the lower incisors are slightly uprighted. Undesirable movements, such as mesial movement and extrusion on maxillary molars and labial tipping of maxillary incisors, have been reported with the use of facemask. The
Fig. 4. Cephalometric (A) and panoramic (B) radiographs after facemask.
conventional protraction force is applied via elastic to teeth or other devices supported by teeth. Ankylosed deciduous canines could be used as absolute anchorage for facemask therapy. However, the inevitable resorption of anchor teeth as their permanent successors erupting limits the time available for treatment [14]. McNamara et al. [8] suggested using bonded or banded RPE as a unit so the given orthopedic force will be distributed through the skeletal structures instead of through dental movements. Since the osseous-integrated implant is known to behave like an ankylosed tooth, it has been used in both animal models and in human case reports as an alternative method of maxillary protraction [15]. Onplant [16], which was placed in the inferior border of the zygomatic buttress, and miniplate, which was placed in the maxillary anterior alveolar bone, were used as orthopedic anchorages [15,16]. The screw type mini-implants made of titanium have been added to the existing options for orthodontic therapy. They are commonly used for adjunctive tooth movement, en masse retraction, molar distalization or mesialization, molar extrusion or intrusion, and vertical control [16]. A mini-implant used as an RPE substitute, will apply the protraction force from the face mask. The procedures for insertion and removal are simple compared with onplant or miniplate. They can be inserted without predrilling or preparation of a flap.
H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
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Fig. 5. Extra oral (AeC) and intra oral (DeF) photographs after debonding.
5. Conclusions
References
Protraction facemask is an effective treatment option for skeletal Class III malocclusion. RPE, together with protraction face mask, could be used to eliminate posterior crossbite and achieve better results. Mini-implants are options that could be considered to be used together with protraction facemask. Treatment timing and patient cooperation are crucial factors determining treatment outcome. Treatment of patients with Class III malocclusion is better planned in two phases to take advantage of the early growth period.
[1] Daskaloganinakis J. Glossary of orthodontic terms, Vol 1. Berlin: Quintessence Publishing; 2000. [2] Bhalajhi SI. Orthodontics: the art and science. 3rd ed. New Delhi: Arya (Medi) Publishing House; 2006. [3] Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxillary protraction therapy with or without rapid palatinal expansion: A prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 2005;128:299e309. [4] Profitt WR, Fields Jr HW, Sarver DM. Contemporary orthodontics. 4th ed. St. Louis: Mosby Elsevier; 2007. [5] Keles A, Tokmak EC, Erverdi N, Nanda R. Effect of varying the force direction on maxillary orthopedic protraction. Angle Orthod 2002;72:387e96. [6] Gallagher RW, Miranda F, Buschang PH. Maxillary protraction: treatment and post treatment effects. Am J Orthod Dentofacial Orthop 1998;113: 612e9. [7] Kim JH, Viana MAG, Graber TM, Omerza FF, BeGole E. The effectiveness of protraction face mask therapy: a meta analysis. Am J Orthod Dentofacial Orthop 1999;115:675e85. [8] Mc Namara JA, Brudon WL. Orthodontics and dentofacial orthopedics. 1st ed. Ann Arbor, MI: Needham Press Inc; 2001. [9] Alcan T, Keles A, Erverdi N. The effects of a modified protraction headgear on maxilla. Am J Orthod Dentofacial Orthop 2000;117:27e38. [10] Hickham JH. Maxillary protraction therapy: diagnosis and treatment. J Clin Orthod 1991;25:102e13. [11] Takada K, Petdachai S, Sakuda M. Changes in dentofacial morphology in skeletal Class III children treated by a modified maxillary protraction head gear and a chin cup: longitudinal cephalometric appraisal. Eur J Orthod 1993; 15:211e21. [12] Merwin D, Ngan P, Hagg U, Yiu C, Wei S. Timing for effective application of anteriorly directed orthopedic force to the maxilla. Am J Orthod Dentofacial Orthop 1997;112:292e9. [13] Turley PK. Managing the developing Class III malocclusion with palatal expansion and facemask therapy. Am J Orthod Dentofacial Orthop 2002;122: 349e52. [14] Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L, Clarren SK. Ankylosed teeth as abutments for maxillary protraction: a case report. Am J Orthod 1985; 88:303e7. [15] Zhou YH, Ding PL, Lin Y, Qui LX. Facemask therapy with miniplate implants anchorage in a patient with maxillary hypoplasia. Chin Med J (Engl) 2007;120: 1372e5. [16] Lee JS, Kim JK, Park YC, Vanarsdall Jr RL. Application of orthodontics mini implants. 1st edition. Hanover Park, IL: Quintessence Publishing; 2007.
Fig. 6. Cephalometric (A) and panoramic (B) radiographs after debonding.
Contents lists available at SciVerse ScienceDirect
Journal of the World Federation of Orthodontists journal homepage: www.jwfo.org
Research
Dentoskeletal effects and facial profile changes in Class III patient treated with protraction facemask appliance: a case report Himawan Halim a, *, Anita Budihardja b a b
Department of Orthodontics, Indonesian Naval Dental Institute, Jakarta, Indonesia Private Practice
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 February 2012 Received in revised form 9 March 2012 Accepted 15 April 2012 Available online 18 June 2012
Introduction: Treatment of skeletal Class III malocclusion with an anterior crossbite is challenging due to unpredictable results and potentially unfavorable growth. Growth modification in growing patients is an alternative approach to orthognathic surgical correction. Objective: Case report of a patient with Class III malocclusion and anterior crossbite was treated with maxillary protraction facemask to illustrate that treatment has to be started during growth period and patient compliance is a determining factor. Treatment procedure: Treatment of anterior crossbite was completed in two phases. The first phase was to correct the skeletal discrepancy with rapid palatal expansion, miniscrews and protraction facemask. The second phase was to correct the dental alignment with fixed orthodontic appliance. Conclusions: Protraction facemask therapy started at growing age with good patient compliance is a good approach in treating anterior crossbite relating to skeletal problems in the mixed dentition period. Ó 2012 World Federation of Orthodontists.
Keywords: Anterior crossbite Dentofacial Protraction face mask
1. Introduction Class III malocclusion is easy to identify but often quite difficult to treat. This type of malocclusion can be recognized, not only by dental specialist but also by lay person. The appearance of dental anterior crossbite often stimulates the parent to seek orthodontic treatment for the child. According to Angle, a Class III molar relationship refers to a condition where the mesio buccal cusp of the upper first molar occludes between the mandibular first and second molar. Although this definition represents a typical Class III relationship, the lower molar can be mesial to the upper molar in a varying degree [1,2]. Class III malocclusion can involve maxillary skeletal retrusion, mandibular skeletal protrusion, or a combination of both. Patients with Class III malocclusion usually present with a Class III molar relationship, posterior crossbite, and/or anterior crossbite [3]. The upper arch is usually narrow and short, and the upper teeth are commonly crowded. The lower arch is broad and the mandibular teeth are often spaced. Dental compensation might include maxillary dentoalveolar protrusion and mandibular dentoalveolar retrusion. In addition to a prominent chin that causes a concave * Corresponding author: Indonesian Naval Dental Institute, Sumenep no.7, Jakarta 10310, Indonesia. E-mail address: [email protected] (H. Halim). 2212-4438/$ e see front matter Ó 2012 World Federation of Orthodontists. doi:10.1016/j.ejwf.2012.04.003
profile, a midface deficiency is often apparent as well as increased mandibular incisor display and a prominent lower lip [2,3]. A type of Class III malocclusion that refers to pseudo-Class III malocclusion or functional crossbite is characterized by the presence of occlusal prematurity in centric relation, which results in a habitual forward positioning of the mandible (faulty habitual occlusion). The shift may occur in an anterior and/or in a lateral direction. Patients can actually reach an incisor edge to edge relationship in central occlusion. These patients may exhibit a forward path of closure. This type of crossbite is often seen in children, typically because of interferences caused by lack of wear of their deciduous canines. Dental functional crossbite can later manifest as skeletal Class III malocclusion [1,2]. There are several possible etiologies that may cause Class III malocclusion. True skeletal Class III malocclusion is usually inherited and may have a very strong genetic basis. The Hapsburg jaw, the prognathic mandible of this European royal family is a well-known example. Other possible etiologies are congenital defects, trauma, and premature contact that lead to a functional crossbite [4]. With the limited ability to influence mandibular growth and the malleability of maxillary growth well established, treatment modalities to influence mild to moderate Class III alveolar base discrepancies have shifted to a maxillary protraction paradigm. Maxillary protraction is one of the main treatment modalities in Class III maxillary retrognathic preadolescent and adolescent patients [5e7].
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H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
Fig. 1. Initial extra oral (AeC) and intra oral (DeF) photographs.
1.1. Treatment options for Class III malocclusion Treatment for Class III patients always depend on the age of the patient, whether they are still growing or not. When an adult patient is diagnosed with skeletal Class III malocclusion, treatment options are limited. Treatment options would involve comprehensives orthodontic therapy, either combined with extraction and/or orthognathic surgery. Orthognathic surgery designed to balance the skeletal components could involve a mandibular set back (for mandibular prognathism) and/or a Le Fort I procedure for maxillary skeletal retrusion. A surgically assisted rapid palatal expansion (RPE) is sometimes necessary [2,4,8]. There are several treatment modalities that can be considered in treating a young Class III patient in late deciduous or mixed dentition, which includes the following: inclined bite plane, exercising with tongue blades, enameloplasty of the deciduous canine, removable plate to expand the maxillary dental arch or to proclined the upper teeth, functional regulator III from Professor Fraenkel, chin cup, and facial protraction mask (with or without RPE). These treatment options have their own indication and benefits that need to be considered before used [2,4,8].
that the patients from 8 to 12 years old and those in a younger age group (5 to 8 years old) had similar therapeutic response. A protraction facemask is optimally worn on a full-time basis (about 20 hours a day, except during meals) for about 6 to 8 months, then it can be worn on a nighttime basis only for additional period of time. Young patients (5 to 9 years old) can usually follow this regimen. In older patients, full time wear may not be feasible. They should wear the appliance at all times except while attending school or participating in contact sports. Less than full time wear can result in longer treatment time [8]. Several authors have reported changes achieved by protraction facemask therapy [3,4,8]. The treatment effects are a combination
1.2. Facial protraction mask More recently, orthopedic treatment with facemask appliance has become an accepted procedure for treating Class III patients with maxillary retrognathism. Designed by Delaire in the late 1960s and then modified by Petit and others, facemasks have proven to have the greatest opportunity to correct Class III malocclusion, whether identified during the late deciduous or early mixed dentition. Significant changes in all three planes of space may be achieved, especially when combined with rapid maxillary expansion [8,9]. For optimal result, it is suggested that treatment should be initiated as soon as possible. According to McNamara and Brudon [8], the optimal time to begin an early Class III treatment is in the early mixed dentition coincident with the eruption of the upper permanent incisors. Hickham [10] advised that the treatment should be initiated before the patient is 8 years old. Proffit et al. [4] recommended that maxillary protraction initiated before the age of 9 would produce more skeletal changes and less dental movement. Takada et al. [11] reported that maxillary protraction and chin cup therapy were effective through puberty. Merwin et al. [12] reported
Fig. 2. Initial cephalometric (A) and panoramic (B) radiographs.
H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
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Fig. 3. Extra oral (AeC) and intra oral (DeF) photographs after facemask.
of skeletal and dental changes of the maxilla and mandible. The maxilla moves downward and forward with a slight upward movement in the anterior and downward movement in the posterior palatal plane. As a consequence, downward and backward rotation of the mandible improves the maxillo-mandibular skeletal relationship in the sagittal dimension but results in an increase lower anterior facial height. Upper incisor labial inclination increased and lower inclination decreased [6e8].
1.3. Rapid palatal/maxillary expansion Face mask therapy is often supplemented with maxillary expansion. Some benefits are associated with RPE in conjunction with face mask therapy, including transverse expansion to correct posterior crossbites, increasing arch length, splinting of the maxillary dentition against forward movement and anterior constriction during protraction therapy, and disruption of the circummaxillary sutural system that facilitates the orthopedic effects of the facemask. Maxillary expansion can produce a slightly forward movement of the maxilla [3,13]. A banded maxillary splint and bonded maxillary splint can be options for performing the palatal expansion; McNamara et al. [8] suggested acrylic bonded maxillary splint in the posterior dentition. In mixed dentition the splint usually covers the first and deciduous molars and the permanent first molar. If permanent second molars have erupted, it is necessary to place an occlusal rest against these teeth to prevent supra eruption of these teeth during appliance wear. The bite opening effect of the maxillary splint also may reduce the tendency toward extrusion of posterior teeth, which has been observed using the banded design of appliance. When a banded appliance is used, two teeth per side are banded, the first and second deciduous molar, or the first permanent molar and second deciduous molar, or the first permanent molar and premolar. The appliance is activated once or twice daily (0.25 mm per activation) [8].
Some clinicians have advocated maxillary expansion 1 week before starting facemask use, even without maxillary constriction or crowding. A clinical trial by Vaughn et al. [3] reported that early facemask therapy, with and without palatal expansion, is effective to correct skeletal Class III malocclusion. 1.4. Phase II orthodontic treatment Although it is important to decide when to start the phase I treatment, it is also important to decide when to begin the phase II orthodontic treatment. Phase II is usually completed with a fixed appliance. Starting treatment after the permanent second molars have erupted allows the practitioner to evaluate post treatment growth and to minimize the duration of the fixed appliance therapy [13]. Latent mandibular growth and condylar growth seem to be the main cause of posttreatment relapse. Therefore overcorrection is recommended because after facemask treatment, patients will resume growth similar to an untreated Class III patient. Some patients may be required to continue facemask therapy during the phase II treatment. 2. Objectives The objective of this case report is to describe a patient treated in our clinic using a combination of RPE, protraction facemask, and fixed orthodontic appliance. 3. Case report An 11-year-old boy came to our clinic with his parents and grandparents. The chief complaint was that his lower jaw was too far forward and he had crocked teeth in the upper jaw. Anamnesis showed that a genetic predisposition runs in the family with his father and grandmother also having the same type of facial profile. Extraoral examination revealed that the maxilla was retrognathic and the mandible was slightly prognathic. He had symmetric, mesofacial face and concave profile. Intraoral examination revealed
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H. Halim, A. Budihardja / Journal of the World Federation of Orthodontists 1 (2012) e73ee77
late mixed dentition phase, with unerupted teeth 15, 35, and 45. Tooth 25 was agenesis with 75 still in the place. He had crowding in the upper (5 mm) and lower jaws (2.5 mm), an anterior crossbite, and a deep bite. No posterior crossbite was found. Overjet was e2 mm and overbite was 3 mm. Molar relationship in both side was full Class III. Cephalometric analysis indicated a Class III malocclusion with retrognathic maxilla and prognathic mandible. Temporomandibular joint function was normal (Figs. 1 and 2). The treatment plan was divided into two phases. The first phase used a banded RPE with protraction facemask and then a 2 4 fixed appliance, which was continued through the second phase, and a full fixed orthodontic appliance also was added during the second phase of treatment. We started the treatment by placing orthodontic bands for RPE on teeth 16, 14, 24, and 26. The RPE is only activated once a day for 1 week because the patient did not have posterior crossbite and then the patient was told to wear face mask 16 hours a day. We had a little trouble with patient cooperation because the patient could not tolerate the RPE well and also had trouble with his oral hygiene. His parents asked us to remove the RPE as soon as possible because he had been complaining about it and relating that he was having problems at his new school. After 4 months we removed the RPE and replaced it with a 2 4 appliance in the upper and lower arches. A utility arch was used to intrude lower anterior teeth and nickel-titanium (Ni-Ti) wire was used to level and align the upper teeth. As a replacement for the RPE, mini-implants were used. A 1.6mm diameter, 8-mm length mini-implant was placed between teeth 13 and 14 and between 23 and 24 for the attachment of the extra oral elastics. Patient was told to wear the face mask 16 hours a day. Progress was seen and anterior crossbite was resolved. Patient was still asked to wear face mask 12 hours a day and a full fixed appliance already placed in both upper and lower arch. Treatment was continued to close the rest of the space in upper jaw, to align tooth 15 (Figs.3e6). 4. Discussion It is suggested to begin Class III treatment as soon as possible when the upper permanent incisors erupt. It has been demonstrated that treatment changes in younger patients were greater than those in older patients [4]. Better skeletal effect can be obtained in the primary and early mixed dentition. At later ages, tooth movement and/or mandible rotation are likely the major components of the response of the treatment. In addition to treatment timing, patient cooperation is an important factor in determining the success of the treatment. The treatment for this patient should have started sooner. The patient began treatment during late stage of mixed dentition and the cooperation was not as expected. After 2 years of treatment, a good result was achieved. His profile was improved. A better result would have been achieved if he came for treatment earlier. The application of protraction from a facemask resulted in significant improvement in facial aesthetics and maxillomandibular relationship. Sella nasion point-A angle increased, demonstrating anterior displacement of the maxilla. The point-A nasion point-B angle and Witt’s appraisal were also increased. The mandible was rotated downward and backward because the Frankfort mandibular plane angle was slightly increased. The dental measurement revealed upper incisors are proclined and the lower incisors are slightly uprighted. Undesirable movements, such as mesial movement and extrusion on maxillary molars and labial tipping of maxillary incisors, have been reported with the use of facemask. The
Fig. 4. Cephalometric (A) and panoramic (B) radiographs after facemask.
conventional protraction force is applied via elastic to teeth or other devices supported by teeth. Ankylosed deciduous canines could be used as absolute anchorage for facemask therapy. However, the inevitable resorption of anchor teeth as their permanent successors erupting limits the time available for treatment [14]. McNamara et al. [8] suggested using bonded or banded RPE as a unit so the given orthopedic force will be distributed through the skeletal structures instead of through dental movements. Since the osseous-integrated implant is known to behave like an ankylosed tooth, it has been used in both animal models and in human case reports as an alternative method of maxillary protraction [15]. Onplant [16], which was placed in the inferior border of the zygomatic buttress, and miniplate, which was placed in the maxillary anterior alveolar bone, were used as orthopedic anchorages [15,16]. The screw type mini-implants made of titanium have been added to the existing options for orthodontic therapy. They are commonly used for adjunctive tooth movement, en masse retraction, molar distalization or mesialization, molar extrusion or intrusion, and vertical control [16]. A mini-implant used as an RPE substitute, will apply the protraction force from the face mask. The procedures for insertion and removal are simple compared with onplant or miniplate. They can be inserted without predrilling or preparation of a flap.
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Fig. 5. Extra oral (AeC) and intra oral (DeF) photographs after debonding.
5. Conclusions
References
Protraction facemask is an effective treatment option for skeletal Class III malocclusion. RPE, together with protraction face mask, could be used to eliminate posterior crossbite and achieve better results. Mini-implants are options that could be considered to be used together with protraction facemask. Treatment timing and patient cooperation are crucial factors determining treatment outcome. Treatment of patients with Class III malocclusion is better planned in two phases to take advantage of the early growth period.
[1] Daskaloganinakis J. Glossary of orthodontic terms, Vol 1. Berlin: Quintessence Publishing; 2000. [2] Bhalajhi SI. Orthodontics: the art and science. 3rd ed. New Delhi: Arya (Medi) Publishing House; 2006. [3] Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxillary protraction therapy with or without rapid palatinal expansion: A prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 2005;128:299e309. [4] Profitt WR, Fields Jr HW, Sarver DM. Contemporary orthodontics. 4th ed. St. Louis: Mosby Elsevier; 2007. [5] Keles A, Tokmak EC, Erverdi N, Nanda R. Effect of varying the force direction on maxillary orthopedic protraction. Angle Orthod 2002;72:387e96. [6] Gallagher RW, Miranda F, Buschang PH. Maxillary protraction: treatment and post treatment effects. Am J Orthod Dentofacial Orthop 1998;113: 612e9. [7] Kim JH, Viana MAG, Graber TM, Omerza FF, BeGole E. The effectiveness of protraction face mask therapy: a meta analysis. Am J Orthod Dentofacial Orthop 1999;115:675e85. [8] Mc Namara JA, Brudon WL. Orthodontics and dentofacial orthopedics. 1st ed. Ann Arbor, MI: Needham Press Inc; 2001. [9] Alcan T, Keles A, Erverdi N. The effects of a modified protraction headgear on maxilla. Am J Orthod Dentofacial Orthop 2000;117:27e38. [10] Hickham JH. Maxillary protraction therapy: diagnosis and treatment. J Clin Orthod 1991;25:102e13. [11] Takada K, Petdachai S, Sakuda M. Changes in dentofacial morphology in skeletal Class III children treated by a modified maxillary protraction head gear and a chin cup: longitudinal cephalometric appraisal. Eur J Orthod 1993; 15:211e21. [12] Merwin D, Ngan P, Hagg U, Yiu C, Wei S. Timing for effective application of anteriorly directed orthopedic force to the maxilla. Am J Orthod Dentofacial Orthop 1997;112:292e9. [13] Turley PK. Managing the developing Class III malocclusion with palatal expansion and facemask therapy. Am J Orthod Dentofacial Orthop 2002;122: 349e52. [14] Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L, Clarren SK. Ankylosed teeth as abutments for maxillary protraction: a case report. Am J Orthod 1985; 88:303e7. [15] Zhou YH, Ding PL, Lin Y, Qui LX. Facemask therapy with miniplate implants anchorage in a patient with maxillary hypoplasia. Chin Med J (Engl) 2007;120: 1372e5. [16] Lee JS, Kim JK, Park YC, Vanarsdall Jr RL. Application of orthodontics mini implants. 1st edition. Hanover Park, IL: Quintessence Publishing; 2007.
Fig. 6. Cephalometric (A) and panoramic (B) radiographs after debonding.