Is maxillary protraction the earlier the better? A retrospective study on early orthodontic treatment of Class III malocclusion with maxillary deficiency

To investigate the optimal timing of maxillary protraction in children with Class III malocclusion to aid comprehension of this still non-consensual topic. In all, the data of 97 children with Class III malocclusion treated by using the Delaire facemask with maxillary expansion were collected retrospectively and divided into three groups according to their dentition stages; those subjects in the mixed dentition group were further divided into three subgroups. All patients were regrouped by the cervical vertebral maturation index (CVMI) and observed closely by cephalograms at the beginning of treatment (T0) and after facemask removal (T1). Comparisons between subgroups, within groups, and the final evaluation of the increment of maxillary length were performed by different statistical methods. Similar favorable maxillary traction effects were achieved in all stages. Intragroup comparisons showed changes without significance in aspect ratio during the mixed dentition stage, while there was a significant decrease during the deciduous and permanent dentition stages. The largest increment of maxillary length was obtained when the maxillary protraction began at Cervical Stage (CS)2. However, no significant difference was found in all skeletal measurements among the three groups (deciduous, mixed and permanent dentition stages) and the three subgroups with mixed dentition. The univariable linear regression analysis also showed that CVMI and dentition stage at T1 did not have a significant impact on the increment of maxillary length. In our center, Class III malocclusion patients treated with the Delaire facemask achieved similar skeletal changes in short term, when they began the treatment at different dentition stages or CVMI stages. Starting the maxillary protraction at CS2 was likely a reliable choice for those who desired more maxillary advancement.

Treatment timing; Class III malocclusion; Orthodontic treatment; Maxillary protraction

[1] Zhou X, Zhang C, Yao S, Fan L, Ma L, Pan Y. Genetic architecture of non‐syndromic skeletal class III malocclusion. Oral Diseases. 2023; 29: 2423–2437.

[2] Londono J, Ghasemi S, Moghaddasi N, Baninajarian H, Fahimipour A, Hashemi S, et al. Prevalence of malocclusion in Turkish children and adolescents: a systematic review and meta‐analysis. Clinical and Experimental Dental Research. 2023; 9: 689–700.

[3] Ngan P, Moon W. Evolution of Class III treatment in orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics. 2015; 148: 22–36.

[4] Papadopoulou AK, Koletsi D, Masucci C, Giuntini V, Franchi L, Darendeliler MA. A retrospective long-term comparison of early RME-facemask versus late Hybrid-Hyrax, alt-RAMEC and miniscrew-supported intraoral elastics in growing Class III patients. International Orthodontics. 2022; 20: 100603.

[5] Umalkar SS, Jadhav VV, Paul P, Reche A. Modern anchorage systems in orthodontics. Cureus. 2022; 14: e31476.

[6] Lee HJ, Jeong H, Park JH, Choi DS, Jang I, Cha BK. A comparison of maxillary posterior changes following facemask therapy: skeletal anchorage versus tooth-borne anchorage. To be published in Orthodontics & Craniofacial Research. 2023. [Preprint]

[7] Si M, Hao Z, Fan H, Zhang H, Yuan R, Feng Z. Maxillary protraction: a bibliometric analysis. International Dental Journal. 2023; 73: 873–880.

[8] Baccetti T, McGill JS, Franchi L, McNamara JA, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. American Journal of Orthodontics and Dentofacial Orthopedics. 1998; 113: 333–343.

[9] Maino GB, Cremonini F, Maino G, Paoletto E, De Maio M, Spedicato GA, et al. Long-term skeletal and dentoalveolar effects of hybrid rapid maxillary expansion and facemask treatment in growing skeletal Class III patients: a retrospective follow-up study. Progress in Orthodontics. 2022; 23: 44.

[10] Arqub SA, Al-Zubi K, Iverson MG, Ioannidou E, Uribe F. The biological sex lens on early orthopaedic treatment duration and outcomes in Class III orthodontic patients: a systematic review. European Journal of Orthodontics. 2022; 44: 311–324.

[11] Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects of face mask/expansion therapy in Class III children: a comparison of three age groups. American Journal of Orthodontics and Dentofacial Orthopedics. 1998; 113: 204–212.

[12] 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. American Journal of Orthodontics and Dentofacial Orthopedics. 2000; 117: 669–680.

[13] Kajiyama K, Murakami T, Suzuki A. Comparison of orthodontic and orthopedic effects of a modified maxillary protractor between deciduous and early mixed dentitions. American Journal of Orthodontics and Dentofacial Orthopedics. 2004; 126: 23–32.

[14] Baik HS. Clinical results of the maxillary protraction in Korean children. American Journal of Orthodontics and Dentofacial Orthopedics. 1995; 108: 583–592.

[15] Wang J, Wang Y, Yang Y, Zhang L, Hong Z, Ji W, et al. Clinical effects of maxillary protraction in different stages of dentition in skeletal class III children: a systematic review and meta-analysis. Orthodontics & Craniofacial Research. 2022; 25: 549–561.

[16] Merwin D, Ngan P, Hagg U, Yiu C, Wei SHY. Timing for effective application of anteriorly directed orthopedic force to the maxilla. American Journal of Orthodontics and Dentofacial Orthopedics. 1997; 112: 292–299.

[17] Franchi L, Baccetti T, McNamara JA. Mandibular growth as related to cervical vertebral maturation and body height. American Journal of Orthodontics and Dentofacial Orthopedics. 2000; 118: 335–340.

[18] Krishnamoorthy VV, Parameswaran R, Vijayalakshmi D, Khan N, Nandakumar A. Assessment of skeletal maturation in concordance to statural height and body weight in 12-year-old children—a cross-sectional study. Journal of Clinical and Diagnostic Research. 2016;10: ZC51–ZC55.

[19] Nucci L, Costanzo C, Carfora M, d’Apuzzo F, Franchi L, Perillo L. Dentoskeletal effects of early class III treatment protocol based on timing of intervention in children. Progress in Orthodontics. 2021; 22: 49.

[20] Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Seminars in Orthodontics. 2005; 11: 119–129.

[21] Arpalahti A, Saarnio-Syrjäläinen A, Laaksonen S, Arponen H. Early orthodontic treatment in a Finnish public health centre: a retrospective cross-sectional study. Acta Odontologica Scandinavica. 2023; 81: 396–401.

[22] Rutili V, Quiroga Souki B, Nieri M, Farnese Morais Carlos AL, Pavoni C, Cozza P, et al. Long-term assessment of treatment timing for rapid maxillary expansion and facemask therapy followed by fixed appliances: a multicenter retro-prospective study. Journal of Clinical Medicine. 2023; 12: 6930.

[23] Lee DY, Kim ES, Lim YK, Ahn SJ. Skeletal changes of maxillary protraction without rapid maxillary expansion. The Angle Orthodontist. 2010; 80: 504–510.

[24] Kamath A, Sudhakar S, Kannan G, Rai K, Athul S. Bone-anchored maxillary protraction (BAMP): a review. Journal of Orthodontic Science. 2022; 11: 8.

[25] Zere E, Chaudhari PK, Sharan J, Dhingra K, Tiwari N. Developing Class III malocclusions: challenges and solutions. Clinical, Cosmetic and Investigational Dentistry. 2018; 10: 99–116.

[26] Woon SC, Thiruvenkatachari B. Early orthodontic treatment for Class III malocclusion: a systematic review and meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics. 2017; 151: 28–52.

[27] Jiang J, Lin J, Ji C. Two-stage treatment of skeletal Class III malocclusion during the early permanent dentition. American Journal of Orthodontics and Dentofacial Orthopedics. 2005; 128: 520–527.

[28] Alhoraibi L, Alvetro L, Al-Jewair T. Long-term effects of the Forsus device in Class II division I patients treated at pre-peak, peak, and post-peak growth periods: a retrospective study. International Orthodontics. 2020; 18: 451–460.

[29] Zhang W, Qu HC, Yu M, Zhang Y. The Effects of maxillary protraction with or without rapid maxillary expansion and age factors in treating Class III malocclusion: a meta-analysis. PLOS ONE. 2015; 10: e0130096.

[30] Yüksel S, Uçem TT, Keykubat A. Early and late facemask therapy. The European Journal of Orthodontics. 2001; 23: 559–568.

[31] Hu X, Cheung GSP, Zhang Y, Sun R, Dong F. Reliability and reproducibility of CBCT assessment of mandibular changes before and after treatment for Class III growing patients—an easy and quick way for evaluation. BMC Pediatrics. 2023; 23: 602.

[32] Lee N, Kim S, Park JH, Son D, Choi T. Comparison of treatment effects between two types of facemasks in early Class III patients. Clinical and Experimental Dental Research. 2023; 9: 212–218.

[33] Quinzi V, Salvati SE, Pisaneschi A, Palermiti M, Marzo G. Class III malocclusions in deciduous or early mixed dentition: an early orthopaedic treatment. European Journal of Paediatric Dentistry. 2023; 24: 42–44.

[34] Çifter M, Ekmen O, Gümrü Çelikel A, Tağrikulu B, Erbay E. Does the face mask increase the impact of rapid maxillary expansion on sagittal airway dimensions? European Oral Research. 2023; 57: 28–35.

[35] Kale B, Buyukcavus MH. Determining the short-term effects of different maxillary protraction methods on pharyngeal airway dimensions. Orthodontics & Craniofacial Research. 2021; 24: 543–552.

[36] Yilmaz BS, Seker ED, Yilmaz HN, Kucukkeles N. Do we pay for maxillary protraction? Evaluation of the effects of Alt-RAMEC protocol and face mask treatment on root development. Clinical Oral Investigations. 2022; 26: 3203–3211.