Home | About Us | Editorial Board | Current Issue | Archives | Search | Instructions | Subscription | Feedback | e-Alerts | Login 
Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
 Users Online: 764  
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size

  Table of Contents    
Year : 2011  |  Volume : 29  |  Issue : 3  |  Page : 273-277

Correction of skeletal Class III in a growing male patient by reverse pull facemask

1 Department of Orthodontics, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
2 Division of Orthodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication10-Oct-2011

Correspondence Address:
P Kapoor
Jamia Millia Islamia, New Delhi
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.85841

Rights and Permissions



The following case report describes the management of a 6-year-old male patient in early mixed dentition with a mesial step molar relation, an anterior reverse overjet, and skeletal Class III due to a slightly deficient maxilla. The treatment plan included protraction of the maxilla by a reverse pull Petit type facemask for 10 months followed by 15 months of active retention by a Frankel III appliance.

Keywords: Class III, maxillary deficiency, reverse pull facemask

How to cite this article:
Kapoor P, Kharbanda O P. Correction of skeletal Class III in a growing male patient by reverse pull facemask. J Indian Soc Pedod Prev Dent 2011;29:273-7

How to cite this URL:
Kapoor P, Kharbanda O P. Correction of skeletal Class III in a growing male patient by reverse pull facemask. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2023 Feb 4];29:273-7. Available from: http://www.jisppd.com/text.asp?2011/29/3/273/85841

   Introduction Top

Individuals with Class III malocclusion may have combinations of skeletal and dentoalveolar components. These characteristics could be summarized as follows: Skeletal components with underdeveloped maxilla, overdeveloped mandible or a combination of both, dentoalveolar components with proclined maxillary incisors, and retroclined mandibular incisors, to achieve dentoalveolar compensation. [1] Early treatment of Class III malocclusion has been advocated for many years, and the goal is focused on providing a more favorable environment for normal growth and on improving the psychosocial development of the child. [2] Early orthopedic treatment, using a facemask or chin cup therapy, improves the skeletal relationships, which in turn minimize excessive dental compensation such as overclosure of the mandible and retroclination of the mandibular incisors. Also correction of the anterior crossbite often helps in eliminating centric occlusion/centric relation (CO/CR) discrepancies, and avoids adverse growth potential. Most importantly, in mild and moderate Class III patients, early orthodontic or orthopedic treatment may eliminate the necessity for orthognathic surgery treatment. Studies have shown that treatment with facemask and/or a chin cap improves the lip posture and facial appearance. [3],[4]

Turpin [5] recommended that early treatment should be considered for young patients who present with positive factors such as convergent facial type, anteroposterior functional shift, symmetrical condyle growth, mild skeletal disharmony, some remaining growth, good cooperation, no familial prognathism, and good facial esthetics.

   Case Report Top

A 6-year-old growing male patient in acceleration stage of CVMI, came to the Orthodontic clinic with chief complaints of lower front teeth overlapping the upper teeth.

Extraoral examination revealed an apparently symmetrical mesoprosopic face with a straight but pleasant profile and apparently slightly deficient maxilla [Figure 1].
Figure 1: Pretreatment extraoral photographs revealed an apparently symmetrical mesoprosopic face with a straight but pleasant profile and slightly deficient maxilla

Click here to view

Intraoral examination revealed the presence of mixed dentition of teeth with the presence of permanent first molars on all four sides and 11, 21, 31, 41 in upper and lower arches. Mandibular deciduous second molars showed a mesial step relation to the maxillary deciduous second molars, and 11, 21, 52, 62 in crossbite relation to 31, 41, 72, 73, 82, 83 [Figure 2].
Figure 2: Pretreatment intraoral photographs revealed presence of early mixed dentition of teeth with crossbite of anteriors.

Click here to view

The panorex findings revealed the presence of early mixed dentition with erupted permanent first molars, and permanent lateral incisors, canines, and first and second premolars in an erupting stage.

The cephalometric findings revealed the patient in acceleration stage of CVMI - an average grower, with a tendency toward skeletal Class III skeletal bases, a normal mandibular plane angle, and proclined lower incisors. The length of the mandible was normal while the length of maxilla was short.

Treatment objectives

  • Protraction of maxilla
  • Attaining positive overjet
  • Correction of Class III skeletal relationship
  • Retention till the growth was complete

Treatment plan

Step 1: Maxillary protraction with bonded occlusal splint and Petit facemask

Step 2: Retention with Frankel III

Treatment done

Stage 1

Splint construction

The occlusal splint was constructed with a wire framework, extending around the maxillary arch from the first molar on one side to the first molar on the other side. The acrylic component of the plate was approximately 2 mm thick, covering the teeth from the deciduous canines to the first permanent molars, leaving a 1 mm clearance at the gingival margins on the buccal and palatal aspects. Hooks were positioned between the deciduous canines and the first molars, as superior as the patient's comfort allowed [Figure 3]
Figure 3: Occlusal splint with a wire framework extending around maxillary arch from first molar on one side to first molar on the other side. The acrylic component of the plate approximately 2 mm thick covering teeth from deciduous canines to first permanent molars. Hooks are positioned between deciduous canines and first molars

Click here to view

Facemask wear

The patient was given instructions regarding wear of the Petit facemask [6] (GAC Int. Inc., 355 Knickbocker Avenue, Bohemia, NY) on an average of 10 - 12 hours a day, with forces applied in the range of 300 g per side. The approximate time taken for protraction of the maxilla and for a positive overjet to appear was 10 months [Figure 4].
Figure 4: Petit facemask wear with elastics having a force of 300 gms per side and 15° to the occlusal plane

Click here to view

Stage 2 (10 months post protraction)

Intraoral examination revealed establishment of the positive overjet [Figure 5] and the cephalometric findings indicated a forward protaction of the maxilla as well as proclination of the maxillary incisors besides attaining a positive overjet of teeth.
Figure 5: 10 months post protraction intraoral photographs reveal a positive overjet although still no occlusion is settled in posteriors as the splint is debonded

Click here to view

Stage 3

Retention with Frankel III [Figure 6]. The intraoral photographs revealed establishment of the positive overjet and settling of occlusion [Figure 7]. The extraoral examination and radiographic findings indicated protraction of the maxilla and improvement of the profile.
Figure 6: Retention with Frankel III

Click here to view
Figure 7: Postretention (1 year) extraoral,intraoral photographs and radiographs reveal positive overjet and settling of occlusion with improvement in profile

Click here to view

   Discussion Top

A Petit type reverse pull facemask was used in the present case, in a growing child, to correct Class III malocclusion due to maxillary deficiency. The history of the reverse pull facemask dated back to Germany, more than 100 years ago. The individual most responsible for reviving an interest in this technique was Delaire. [7] Petit [6] modified the facemask of Delaire by increasing the amount of force generated by the appliance and decreasing the overall treatment time. McNamara [8] described a version of the petit facial mask that attached to a maxillary splint, which was bonded to the posterior dentition. The splint was fitted with hooks to attach elastics to the facemask, and an expansion screw was incorporated in the appliance. Mid facial orthopedic expansion could produce a slight anterior movement of Point A and a slight inferior and anterior movement of the maxilla.

The protocol followed for protraction as regards the direction and amount of force has been supported by these studies. Maxillary protraction usually requires 300 to 600 g of force per side, 12 hours a day, depending on the age of the patient. [9],[10] The facemask projects a downward and forward pull on the maxilla with protraction elastics attached near the maxillary canines, with a downward and forward pull of 15° from the occlusal plane.

The treatment was done at a very young age in early mixed dentition to enhance forward displacement of the maxilla by sutural growth. It has been shown by Melsen in her histological findings that the midpalatal suture was broad and smooth during the 'infantile' stage (8 to 10 years of age) and became more squamous and overlapping in the 'juvenile' stage (10 to 13 years). Also, the circummaxillary sutures were smooth and broad before age eight and became more heavily interdigitated around puberty. [11],[12]

Another important factor was retention of the positive overjet once achieved, for which Frankel III was given as a retention device for approximately a year-and-a-half. This was supported by a prospective clinical trial, where protraction facemask treatment starting in the mixed dentition was found to be stable two years after the removal of the appliances, due to the overcorrection and the use of a functional appliance as a retainer for one year. [10] The patient, however, still has to be recalled for follow-up till the growth of the mandible is complete as there are variations in the rate, growth direction, and rotation of the maxilla from child to adulthood.

Another modification that could have been done was to provide for rapid maxillary expansion in the occlusal splint, mostly advocated to loosen the circummaxillary sutures. A number of studies [13],l[14],[15],[16],[17],[18] have described the general treatment effects of rapid maxillary expansion and facemask therapy (RME/FM) during a single phase of treatment, with a combination of skeletal and dentoalveolar modifications noted in both the maxilla and the mandible. This combined therapy produces more favorable outcomes in patients treated in the deciduous or early mixed dentition than in late mixed dentition with respect to untreated Class III controls. [19],[20],[21] To date, however, few studies have evaluated craniofacial modifications after orthopedic correction. [22],[23],[24]

   Conclusion Top

The present case study shows the correction of skeletal Class III in a six-year-old male, in acceleration stage CVMI, with protraction facemask therapy and retention of a positive overjet with a Frankel III for another year-and-a-half.

   References Top

1.Ngan P, Hu AM, Fields HW. Treatment of Class III problems begins with differential diagnosis of anterior crossbites. Pediatr Dent 1997;19:386-95.  Back to cited text no. 1
2.Joondeph DR: Early orthodontic treatment. Am J Orthod Dentofacial Orthop 1993;104:199-200.   Back to cited text no. 2
3.Ngan P, Hägg U, Yiu C, Merwin D, Wei SH. Soft tissue and dentoskeletal profile changes associated with maxillary expansion and protraction headgear treatment. Am J Orthod Dentofacial Orthop 1996;109:38-49.   Back to cited text no. 3
4.Rokosi T, Schilli W. Class III anomalies: A coordinated approach to skeletal, dental, and soft tissue problems. J Oral Surg 1981;39:860-70.   Back to cited text no. 4
5.Turpin DL. Early Class III treatment. Presentation at 81st annual session. San Francisco: American Association of Orthodontists; 1981.  Back to cited text no. 5
6.Petit HP. Adaptation following accelerated facial mask therapy. In: McNamara JA Jr, Ribbens KA, Howe RP, editors. Clinical Alteration of the Growing Face. Monograph 14, Craniofacial Growth Series. Ann Arbor, Mich: Center for Human Growth and Development, University of Michigan; 1983.   Back to cited text no. 6
7.Delaire J. La croissance maxillaire. Trans Eur Orthod Soc 1971;81-102.  Back to cited text no. 7
8.McNamara JA Jr. An orthopedic approach to the treatment of Class III malocclusion in young patients. J Clin Orthod 1987;21:598-608.  Back to cited text no. 8
9.Ngan P, Wei SH, Hagg U, Yiu CK, Merwin D, Stickel B. Effects of headgear on Class III malocclusion. Quintessence Int 1992;23:197-207.  Back to cited text no. 9
10.Ngan P, Yiu C, Hu A, Hägg U, Wei SH, Gunel E. Cephalometric and occlusal changes following maxillary expansion and protraction. Eur J Orthod 1998;20:237-54.  Back to cited text no. 10
11.Melsen B, Melsen F. The postnatal development of the palatomaxillary region studied on human autopsy material. Am J Orthod 1982;82:329-42.  Back to cited text no. 11
12.Melsen B. Palatal growth studied on human autopsy material: A histologic microradiographic study. Am J Orthod 1975;68:42-54.   Back to cited text no. 12
13.Ngan P, Hagg U, Yiu C, Wei H. Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction. Sem Orthod 1997;3:255-64.  Back to cited text no. 13
14.Williams MD, Sarver DM, Sadowsky PL, Bradley E. Combined rapid maxillary expansion and protraction facemask in the treatment of Class III malocclusion in growing children: A prospective study. Sem Orthod 1997;3:265-74.  Back to cited text no. 14
15.Nartallo-Turley PE, Turley PK. Cephalometric effects of combined palatal expansion and facemask therapy on Class III malocclusion. Angle Orthod 1998;68:217-24.  Back to cited text no. 15
16.Macdonald KE, Kapust AJ, Turley PK. Cephalometric changes after correction of Class III malocclusion with maxillary expansion/ facemask therapy. Am J Orthod Dentofacial Orthop 1999;116:13-24.  Back to cited text no. 16
17.Saadia M, Torres E. Sagittal changes after maxillary protraction with expansion in Class III patients in the primary, mixed, and late mixed dentitions: A longitudinal retrospective study. Am J Orthod Dentofacial Orthop 2000;117:669-80.  Back to cited text no. 17
18.Yuksel S, Ucem TT, Keykubat A. Early and late facemask therapy. Eur J Orthod 2001;23:559-68.  Back to cited text no. 18
19.Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 1998;113:333-43.   Back to cited text no. 19
20.Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face mask/expansion therapy in Class III children: A comparison of three age groups. Am J Orthod Dentofacial Orthop 1998;113:204-12.  Back to cited text no. 20
21.Baccetti T, Franchi L, McNamara JA Jr. Treatment and posttreatment craniofacial changes after rapid maxillary expansion and facemask therapy. Am J Orthod Dentofacial Orthop 2000;118:404-13.  Back to cited text no. 21
22.Shanker S, Ngan P, Wade D, Yiu C, Ha¨gg U, Wei SHY . Cephalometric A point changes during and after maxillary protraction and expansion. Am J Orthod Dentofacial Orthop 1996;110:423-30.  Back to cited text no. 22
23.Gallagher RW, Miranda F, Buschang PH. Maxillary protraction: Treatment and posttreatment effects. Am J Orthod Dentofacial Orthop 1998;113: 612-9.  Back to cited text no. 23
24.McGill JS, McNamara JA Jr. Treatment and post-treatment effects of rapid maxillary expansion and facial mask therapy. In: McNamara JA Jr, editor. Growth modification: What works, what doesn't and why, monograph no. 36. Craniofacial growth series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1999.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (11,485 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

   Case Report
    Article Figures

 Article Access Statistics
    PDF Downloaded759    
    Comments [Add]    

Recommend this journal

Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer | Privacy Notice
  2005 - Journal of Indian Society of Pedodontics and Preventive Dentistry | Published by Wolters Kluwer - Medknow 
Online since 1st May '05