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INTRODUCTION
Treatment of Class III malocclusion is still demanding in orthodontics. However, etiological studies have
shown that 40% to 60% of Class III skeletal malocclusions are due to maxillary deficiency or retrusion,
which is possible to treat if the patient is still growing
and cooperative.14 Face mask (FM) therapy has been
proposed and is the most frequently used treatment
protocol for this anomaly.
Animal and human studies511 show that it is possible
to advance a maxilla in a growing subject over a
certain period of time. Clinical studies show that rapid
palatal expansion has often been performed as part of
the treatment protocol. This approach proposes to
stimulate sutural activity of the neighboring sutures of
a
Professor and Department Chair, Department of Orthodontics, School of Dentistry, University of Marmara, Istanbul,
Turkey.
b
Assistant Professor, Department of Orthodontics, School of
Dentistry, University of Marmara, Istanbul, Turkey.
c
Professor, University of Istanbul, Department of Plastic and
Reconstructive Surgery, Istanbul, Turkey.
Corresponding author: Dr Nazan Kuc u kkeles, Marmara
niversitesi, Dis Hekimligi Fakultesi, Ortodonti AD, Tesvikiye
U
mah. Buyukciftlik sok. No:6 k.3, 34365 Nisantas, Sisli, Istanbul,
Turkey
(e-mail: nazles@tnn.net)
42
DOI: 10.2319/042210-220.1
43
Skeletal age
Distraction, d
Retention, d
13 y, 10 mo 6 2 y, 1 mo
6 (37.5)
10 (62.5)
5.6 6 2.82
65.2 6 24.2
87.38 6 27.07
Total, d
a
149.67 6 14.18
RME + FM
12 y, 9 mo 6 1 y, 10 mo
10 (55.6)
8 (44.4)
4.17 6 3.05
270.33 6 123.49
P
.102
.292
.175
.001
C
KKELES
LU, KOLDAS
KU
U
, NEVZATOG
44
Table 2. Dental and Skeletal Changes in Sagittal Direction. Mean
and Standard Deviation (SD) Values Before and After Treatment in
Each Groupa
SNA, u
SNB, u
ANB, u
FH-NA, u
Nper-A
R2-A
R2-ANS
R2-PNS
R2-UI
SN-UI, u
R2-UM
R2-B
IMPA, u
R2-LI
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Surgery + FM
RME + FM
75.44 6 4.92
78.91 6 3.62
.0001
78.84 6 3.56
77.22 6 3.07
.002
22.91 6 2.52
1.66 6 2.35
.0001
83.25 6 6
87 6 4.45
.0001
26.84 6 5.2
23.38 6 4.76
.0001
61 6 4.77
65.06 6 4.45
.0001
65.72 6 4.73
70.34 6 4.03
.0001
18.13 6 3.66
21.06 6 4.61
.001
62.03 6 6.73
67.13 6 5.89
.0001
98 6 11.78
99.38 6 11.66
.282
34.75 6 5.1
40.72 6 6.34
.0001
62.41 6 6.32
59.66 6 6.32
.001
80.25 6 5.99
78.41 6 6.87
.129
65.41 6 4.87
63.28 6 4.94
.007
78.78 6 3.28
80.42 6 3.18
.001
79.44 6 3.66
78.33 6 3.68
.001
2.89 6 1.84
2.31 6 1.59
.0001
86.75 6 3.21
88.47 6 3.25
.0001
23.83 6 2.97
21.67 6 3.45
.0001
65.53 6 4.31
67.53 6 5.03
.0001
70.5 6 4.91
72.58 6 5.77
.0001
20.72 6 2.89
22.03 6 3.06
.003
66.86 6 5.4
70.56 6 6.03
.0001
100.39 6 5.91
102.25 6 5.3
.05
37.97 6 5.71
41.81 6 6.55
.0001
65 6 7.12
62.69 6 7.37
.0001
83.11 6 4.85
82.19 6 6.47
.583
68.56 6 6.56
66.72 6 5.79
.044
.025
.204
.632
.348
.011
.348
.039
.275
.043
.236
.007
.142
.007
.204
.028
.473
.027
.104
.453
.352
.094
.627
.272
.209
.134
.108
.126
.073
45
Figure 2. (a, b) Intraoral appliance design in the surgery group. (c) LeFort I osteotomy performed in the surgery group. (d) Face mask (FM)
application after osteotomy.
DISCUSSION
Maxillary retrognathism is usually present with
midface retrusion, so the most favorable approach is
to advance the maxilla, either with a FM or with
surgery, depending on the patients age. However,
surgery cannot be performed before growth is completed, which means that young adolescents must live
with their Class III profiles as well as the potential
psychological problems and lack of self esteem that
sometimes occur in these adolescents. On the other
hand, the cost of orthognathic surgery is high, and
some patients need grafting after down-fracture, which
46
C
KKELES
LU, KOLDAS
KU
U
, NEVZATOG
Figure 3. (ad) Progress of a case from surgery-assisted face mask (FM) group. (e) Superimposition of pretreatment and posttreatment
cephalometric films of the patient following debonding of the intraoral device.
47
N-CF-A, u
SN-PP, u
SN-UOP, u
SN-MP, u
R1-A
R1-ANS
R1-PNS
N-ANS
ANS-Me
ANS-Me/N-Me
R1-UI
R1-UM
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Surgery + FM
RME + FM
63.56 6 3.49
62.44 6 3.12
.064
10.16 6 4.93
8.44 6 3.81
.059
20.5 6 5.38
17.06 6 6.93
.011
36.03 6 4.34
38.44 6 4.08
.001
50.53 6 2.94
52.19 6 3.04
.031
45.28 6 2.44
46.09 6 2.2
.216
43.31 6 3.42
45.47 6 3.73
.001
54.38 6 2.52
54.94 6 2.76
.416
64.63 6 7.56
68.97 6 7.46
.0001
.541 6 .030
.554 6 .023
.012
71.28 6 5.35
74.13 6 5.34
.0001
64.78 6 5.34
68.94 6 5.67
.0001
61.89 6 2.6
61.56 6 3.31
.394
9.83 6 3.2
8.64 6 3.18
.057
20.94 6 3.73
19.5 6 4.13
.038
35.92 6 4.23
37.53 6 4.58
.0001
52 6 2.96
52.81 6 3.05
.033
45.81 6 3.22
46.56 6 2.88
.015
43.64 6 3.54
45.67 6 3.54
.0001
54.75 6 3.52
55.67 6 3.25
.002
63.89 6 4.09
67.5 6 4.41
.0001
.538 6 .023
.548 6 .019
.0001
72.75 6 3.53
74.89 6 3.13
.0001
65.67 6 3.77
68.36 6 3.89
.0001
.12
.431
R2-A9
R2-Ls
.82
.868
R1-A9
.779
.216
R1-LS
.938
.548
R2-Li
.157
.559
NLA, u
.6
.607
a
.787
.875
.726
.489
.722
.484
.773
.420
.347
.61
.577
.729
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Before
After
P
Surgery + FM
RME + FM
75.91 6 6
81.16 6 5.6
.0001
77.91 6 6.89
82.34 6 6.83
.0001
53.81 6 3.34
54.81 6 4.11
.159
64.44 6 4.7
66.69 6 5.38
.007
80.84 6 5.52
80.97 6 5.28
.903
99.59 6 24.12
111.25 6 18.71
.015
81 6 6.14
83.06 6 6.5
.0001
82.81 6 5.99
85.17 6 6.23
.0001
53.86 6 3.41
55.47 6 3.18
.001
64.03 6 4.06
66.36 6 3.32
.0001
83.25 6 7.43
82.75 6 6.76
.399
110.11 6 12.39
109.75 6 11.53
.755
.02
.371
.034
.216
.967
.602
.787
.831
.297
.403
.114
.778
23.47
1.63
24.56
23.75
23.47
24.06
24.63
22.94
25.09
21.38
25.97
2.75
1.84
2.13
1.13
1.72
3.44
22.41
21.66
2.81
22.16
2.56
24.34
2.013
22.84
24.16
25.25
24.44
21
22.25
2.13
211.66
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
2.96*
1.69*
2.06*
3.13*
2.77*
3.07*
3.57*
3.03*
3.36*
4.92
3.45*
2.59*
4.59
2.73*
2.25
3.36
4.72*
2.48*
2.78*
2.52
2.16*
2.69
2.84*
.018*
2.2*
2.51*
3.31*
3.22*
2.7
2.9*
4.02
16.92*
RME + FM
21.64
1.11
23.19
21.72
22.17
21.3
22.08
21.31
23.69
21.86
23.83
2.31
.92
1.83
.33
1.19
1.44
21.61
2.81
2.75
22.03
2.92
23.61
2.010
22.14
22.69
22.06
22.36
21.61
22.33
.5
.36
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
1.82*
1.17*
1.16*
1.14*
1.63*
2.14*
1.62*
1.58*
1.86*
3.74*
2.91*
1.72*
6.94
3.58*
1.62
2.48
2.73*
1.51*
1.48*
1.18*
1.28*
1.03*
1.73*
.010*
1.63*
1.47*
1.3*
1.74*
1.68*
1.82*
2.45
4.84
P
.063
.36
.034
.034
.086
.069
.025
.122
.466
.458
.17
.626
.959
.998
.164
.702
.267
.347
.486
.664
.754
.197
.378
.330
.331
.077
.002
.011
.533
.665
.755
.028
C
KKELES
LU, KOLDAS
KU
U
, NEVZATOG
48
patients. Molina et al.25 reported 43 cases, all of which
involved treatment with this method; these patients
were corrected from a Class III skeletal relationship to
a Class I relationship, and the maxilla was advanced 5
to 9 mm. Moline et al. reported that there was new
bone formation at the pterygomaxillary suture and that
pretreatment apnea was decreased.
We believe that 5 to 9 mm of maxillary advancement is enough for the correction of many Class III
cases. This approach could be an effective and rapid
solution and also an alternative to some surgery
treatments, which led us to design this study and to
compare this technique with the conventional RME +
FM therapy. We found 4 mm of maxillary advancement with the surgically assisted approach in
5 months, compared to 1.3 mm with RME + FM
therapy in 9 months, which supports the findings of
Molina et al. Therefore, our findings show that
maxillary protraction is significantly more rapid and
that the amount of improvement was significantly
larger compared to treatment with RME-assisted FM.
The skeletal Class III relationship was changed to a
Class I relationship in both groups, but considering
that the surgical group had more severe pretreatment
discrepancies, the results were more dramatic in this
group. The amount of movement of the ANS point
was 4.63 mm for the surgery group and 2.08 mm for
the RME group, and these values were significantly
different (Table 5). The upper lip and lip sulcus also
moved forward more dramatically and significantly in
the surgical group compared to the RME group.
Hence, forward movement of the upper lip sulcus and
nasolabial angle presented large increases (11u) in
the surgical group, which shows that the nose tip was
elevated in a fashion similar to that associated with
maxillary advancement surgery.
The upper incisors moved forward significantly in the
surgery group, while there was no significant change in
the RME group. This may be explained by the more
rapid movement (5 months) in the surgery group, while
the mesial force vector on the upper incisors lasted for
a longer time (9 months) in the RME group. However,
this difference was not statistically significant, which is
probably due to the small sample size. Surgically
assisted maxillary protraction seems more rapid and
effective compared to the conventional method, but
considering long-term mandibular growth, selection of
the patients should be done carefully to avoid relapse.
The LeFort 1 osteotomy will be safer if it is
accomplished after full eruption of the permanent
teeth, which means we should wait until the patient is
12 or 13 years of age. It may be safer to exclude the
hereditary factor by diagnosing patients carefully and
waiting longer in suspicious cases to be certain that
growth has been completed. We support using the
Angle Orthodontist, Vol 81, No 1, 2011
RME-assisted approach in growing patients, preferably those who are less than 10 years of age.
CONCLUSIONS
N Significant skeletal and soft tissue changes were
obtained by both RME and surgically assisted FM
therapy.
N Surgery-assisted treatment was more rapid and
effective compared to the RME + FM approach.
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