CASE REPORT

Nonextraction treatment of a skeletal Class III

adolescent girl with expansion and facemask:
Long-term stability
Roy Sabri
Beirut, Lebanon
This article describes the combined use of maxillary expansion and a protraction facemask in the correction of a
skeletal Class III malocclusion after the patient's pubertal growth spurt. Treatment efcacy and the effects on
facial and smile esthetics are presented. The nonextraction option with an arch-size increase and stability issues
is discussed. (Am J Orthod Dentofacial Orthop 2015;147:252-63)

reatment of Class III malocclusions in growing

children is a clinical challenge for the orthodontist.
Growth is unpredictable and often unfavorable
with this skeletal pattern. Because of our limited ability
to inuence mandibular growth and the possibility of
separating maxillary sutural attachments, treatment
has shifted to the maxillary protraction paradigm. Moreover, maxillary retrusion was found to be the most
contributory factor to a skeletal Class III malocclusion.
The well-documented literature on greater orthopedic
effects in younger children has discouraged clinicians
from using facemasks after 10 years of age. This case
report illustrates the long-term positive response to
late facemask therapy and the stability of nonextraction
treatment with increases in the arch perimeters.

DIAGNOSIS AND ETIOLOGY

The patient was a girl, age 12 years 9 months, whose

chief complaint was an unpleasant smile and crowded
teeth. Her medical history was noncontributory. Her
dental history included routine dental evaluations and
restorations on the maxillary central incisors, rst molars, and left rst premolar. There were carious lesions
on the mesial aspects of the maxillary lateral incisors
and white decalcication spots at the upper third of
the central incisors. Her oral hygiene was poor, and she
Clinical associate, Medical Center, American University of Beirut; private practice,
Beirut, Lebanon.
The author has completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Roy Sabri, Independence St, Sodeco, Freij Bldg,
PO Box 16-6006, Beirut, Lebanon; e-mail, roysabri@dm.net.lb.
Submitted, December 2013; revised and accepted, January 2014.
0889-5406/$36.00
Copyright ! 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.01.027

252

had gingival inammation. The probable cause of her

malocclusion was a combination of genetic and developmental factors.
The patient had a straight prole with a tendency to
upper and lower lip retrusion. The nasolabial angle was
increased, and the throat length normal. From a frontal
view, the face was symmetrical and well balanced. Mild
paranasal hollowing was noticed. The lips were competent at rest, and the upper lip vermilion was thin. She had
a low lip line upon smiling, displaying half the clinical
crown height of the maxillary incisors along with the
mandibular teeth. The smile arc was nonconsonant,
with at maxillary incisal edges not running along the
lower lip curvature (Fig 1).
Intraorally, she had an Angle Class I molar relationship and an anterior edge-to-edge bite. There was anterior crowding, with the maxillary lateral incisors blocked
in, and the maxillary and mandibular canines blocked
out. The mandibular left canine had a thin band of
attached gingiva. The arch-length deciencies were
10.5 mm in the maxillary arch and 6.5 mm in the
mandibular arch. The transpalatal arch width at the rst
molars was 31.1 mm, which was smaller than the average
normal width of 35.4 mm.1 The maxillary left rst premolar and rst molar were in crossbite. The maxillary
dental midline was deviated slightly to the patient's right
in relation to the facial midline, whereas the mandibular
midline was deviated to the left, leading to a 3-mm
dental midline discrepancy (Figs 1 and 2).
The panoramic radiograph showed a full complement
of teeth, including developing third molars. The overall
bone level was within normal limits (Fig 3).
The cephalometric analysis showed a skeletal Class III
anteroposterior relationship evidenced by an ANB angle
of 0! and a Wits appraisal of "6 mm. The maxillary and

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Fig 1. Pretreatment facial and intraoral photographs (age 12 years 8 months).

mandibular incisors were upright, and the soft-tissue

analysis conrmed lip retrusion with an increased
value of the Holdaway line to the tip of the nose
(Fig 4, Table I). The skeletal age as assessed from the
lateral cephalometric radiograph was 12 years 8 months.
This was evaluated according to the method of Hassel
and Farman,2 combining the observations of the
hand-wrist changes (Fishman method3) and the changes
in the cervical vertebrae during skeletal maturation.

smile esthetics. Addressing the transverse maxillary

arch deciency would help achieve an optimal posterior
intercuspation.
TREATMENT ALTERNATIVES

Three treatment options were considered.

1.

TREATMENT OBJECTIVES

The main objective in treating this malocclusion was

to improve the smile, which was the patient's chief
complaint. The crowding and arch-length deciency
needed to be corrected and the uprighted maxillary
and mandibular incisors proclined to improve lip support. The skeletal Class III anteroposterior relationship
also had to be addressed to help correct the anterior
edge-to-edge bite and enhance the facial prole and

2.

American Journal of Orthodontics and Dentofacial Orthopedics

Extraction of 4 rst premolars to reposition the

blocked-out canines. The 2 main advantages of
this treatment option are the efciency to resolve
the severe arch-length deciency and the possible
long-term stability of tooth alignment. Nevertheless, a 4-premolar extraction treatment would not
address the upright incisors and the lip retrusion,
and might even worsen the prole.
Extraction of the maxillary rst premolars. This
would address the arch-length deciency that was
more severe in the maxillary arch, with a less adverse
effect on the prole than would extraction of 4 premolars. Class III elastics would help correct the

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Fig 2. Pretreatment dental casts.

However, this treatment plan relies on patient

cooperation and might have questionable longterm stability.
The nonextraction, RME, and facemask treatment
option was adopted because it would optimize facial
and smile esthetics. Cooperation and stability issues
were discussed with the patient and her parents.
TREATMENT PROGRESS

Fig 3. Pretreatment panoramic radiograph.

3.

anterior edge bite and nish in a Class II molar relationship. However, the facial and smile esthetics
would not be optimized.
Nonextraction with rapid maxillary expansion
(RME) and maxillary protraction facemask treatment. The arch-length deciency would be resolved
by transverse and anteroposterior arch expansion.
The combined orthopedic effects of RME and
the facemask would bring the maxilla downward
and forward. This would enhance both the prole
and the smile esthetics by increasing incisor display.

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A tissue-borne appliance with bands attached to the

rst premolars and rst molars was used for RME.4 The
appliance was activated by turning the screw once a day
for 30 days, resulting in approximately 7 mm of arch
widening at the level of the rst molars (Fig 5). Central
incisor separation and an occlusal radiograph
conrmed the midpalatal suture opening (Fig 6). The
screw was then locked with a double ligature tie, and
the facemask was initiated. The elastics were hooked
from the rst premolar brackets on the RME to the
horizontal outer bow of the facemask in a 30! downward and forward direction, delivering 450 g of force
per side for 12 to 14 hours per day (Fig 7, A). The facemask was worn for a total of 15 months. The RME was
kept for 7 months as a stabilizer and replaced by an
intraoral splint attached to the rst molar bands with
a palatal wire and a labial wire with soldered elastic

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Table I. Cephalometric summary

Before
After
5 years
Measurement
Norm treatment treatment posttreatment
Skeletal
SNA (! )
82
77
77
78
SNB (! )
80
77
77
77
2
0
0
1
ANB (! )
FH-NA (max
90
89
89
90
depth) (! )
FH-NP (facial
87
89
89
90
angle) (! )
Wits (mm)
1
"6
"1
"3
SN-MPA (! )
32
38
37
38
FMA (! )
25
26
26
26
Dental
U1-SN (! )
103
91
111
109
U1-NA (! )
22
15
34
31
U1-NA (mm)
4
2
10
10
L1-NB (! )
25
15
28
25
L1-NB (mm)
4
2
8
8
L1-MP (! )
87
80
94
90
L1-APo (mm)
1
2
8
8
U1-L1 (! )
131
150
113
124
Soft tissue
Facial contour
11
10
14
15
angle (! )
Holdaway line (mm)
Tip of nose
9
11
10
10
Subnasale
5
4
4
4
Upper lip
0
0
0
0
Lower lip
0
0
"1
"1
Supramentale
5
4
4
3
Pogonion
0
0
0
0
Max, Maxillary.

Fig 4. Pretreatment cephalometric radiograph and

tracing.

hooks (Fig 7, B and C). The mandibular arch was bonded

with edgewise brackets (0.022 3 0.028 in) 11 months
after RME was initiated, and the maxillary arch was
bonded 5 months later when the facemask was discontinued. A normal progression of archwires, starting with
0.014-in nickel-titanium alloy and working up to
0.018-in stainless steel, was used to level, align, and
coordinate the arches. Interarch posterior and anterior
elastics were also needed to achieve proper occlusal
interdigitation. Her cooperation was excellent, and the
appliances were removed at age 16 years 8 months,
3 years after the start of xed appliance treatment.
Retention consisted of a maxillary Hawley-type
removable appliance worn full time for 24 months, followed by 12 months of nighttime wear. The mandibular
retainer was a 0.0215-in twisted wire bonded onto the
lingual sides of the incisors and canines. The xed
mandibular retainer could be kept permanently to
enhance the long-term stability of the results.

The mandibular third molars were extracted 1 year

posttreatment and the maxillary third molars 2 years
later, after they had fully erupted. A gingival graft
was harvested from the palate and placed on the labial
aspect of the mandibular left canine at 30 months
posttreatment.
TREATMENT RESULTS

Favorable facial changes were observed with better

lip support and an improved nasolabial angle. The smile
was enhanced dramatically; a normal lip line displaying
the whole clinical crown height of the maxillary incisors
with the interdental papilla was observed with no more
mandibular tooth display. The smile arc was optimized
with the incisal edges and cusp tips of the maxillary teeth
running along the curvature of the lower lip. A rst
molar-to-rst molar transverse dental projection in a
posed smile was obtained (Fig 8). Intraorally, the severe
arch-length deciencies were eliminated in both arches
with proclination of the anterior teeth and transverse
maxillary arch expansion. The transpalatal rst molar

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Fig 5. Postexpansion intraoral photographs.

Fig 6. Radiograph showing postexpansion midpalatal

suture opening.

width was increased by 5.4 mm to an arch width of

36.5 mm (Table II). Excellent tooth alignment was
achieved with optimal overbite and overjet. The maxillary canines were seated in Class I, and the buccal occlusion was well interdigitated. The maxillary second molars
appeared higher because they were not banded due to
the open-bite tendency. Gingival recession on the
mandibular left canine was noticed before the graft
procedure. There were white decalcication spots mainly
at the gingival levels of the mandibular left premolars
and rst molar (Figs 8 and 9).
The posttreatment panoramic radiograph showed
good overall root parallelism. The supporting tissues
appeared healthy, and no apical blunting was noticed
despite the lengthy treatment time. The third molar
buds appeared at the crestal bone level and were mesially

February 2015 # Vol 147 # Issue 2

tipped on the left side (Fig 10); these molars were

extracted later. The posttreatment cephalometric radiograph and the superimposed tracings showed even
downward and forward facial growth. The improvement
of the skeletal Class III was conrmed by a 5-mm reduction of the Wits appraisal and the favorable prole
change by a 3! increase of the facial contour angle.
There was clear advancement of the upper and lower
lips, along with growth of the chin and nose. The maxillary and mandibular incisors were proclined labially.
As expected with facemask treatment, the maxillary rst
molars moved slightly downward and forward. There
was good vertical control with no change in the mandibular plane angle despite the use of mechanics (RME
and facemask) that have a tendency to open the bite
(Figs 11 and 12, Table I).
The posttreatment records taken 5 years after xed
appliance removal showed excellent stability of the
treatment results. The prole maintained a mild convexity and lip fullness. The remarkable enhancement in
smile esthetics was preserved; there were optimal lip
line, smile arc, and transverse tooth display without
black triangles (Fig 13). Intraorally, the long-term stability was exceptional 2 years after the removable maxillary
retainer was discontinued. Tooth alignment, optimal
overbite and overjet, well-interdigitated buccal occlusion, seated canines, and maxillary arch-width increases
were maintained. The maxillary second molars were still
out of occlusion and did not settle as would have been
expected. The grafted band of attached gingiva on the
mandibular left canine appeared stable with no gingival
recession (Figs 13 and 14, Table II). The panoramic
radiograph showed healthy supporting tissues and

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Fig 7. A, Frontal view of patient with facemask; B, occlusal view of intraoral wire splint; C, intraoral
frontal view of soldered elastic hooks.

extracted third molars (Fig 15). The cephalometric radiographs and superimposed tracings at posttreatment (age
16 years 8 months) and 5 years posttreatment (age
21 years 8 months) showed no changes in tooth
positions and soft-tissue prole. There was no facial
growth at 5 years posttreatment except for minor residual growth at the symphysis (Figs 16 and 17).
The nal occlusion may be considered short of ideal
according to the American Board of Orthodontics
norms.5 The maxillary second molars, which were not
banded to prevent bite opening, did not seat spontaneously and remained out of occlusion at 5 years posttreatment. Excursion movements do not reect
balancing interferences, which might lead to potential
myofacial discomfort. The proclination of the maxillary
incisors in compensation for the remaining skeletal
discrepancy also is short of ideal. However, given the
long-standing stability of the completely functional
occlusion, the risks and benets of any future intervention should be properly weighed. Alignment of the
second molars with segmental mechanics to control
the vertical and lingual seating can be achieved. However, it should be combined with selective grinding to
prevent occlusal disturbances and compromising of
an overbite that is already less than the optimal 30%
and that provides minimal anterior protective guidance,
and yet has favorable function and esthetics. If the
anterior occlusion becomes traumatic with fremitus of
the maxillary incisors, interproximal recontouring and
retroclination of the mandibular incisors would probably be the likely approaches to achieve a more

favorable overjet and overbite relationship, particularly

in the absence of a Bolton discrepancy.
DISCUSSION

Extractions in orthodontics have historically been

controversial.6 The frequency of extractions was at its
lowest in the 1900s with Angle7 and reached its peak
with Tweed8 in the 1950s for esthetic and stability
considerations. Today, there is increasing evidence
that extractions do not guarantee stability.9,10 Also,
the well-documented public preference for fuller and
more protrusive proles than our customary cephalometric standards has favored a return toward nonextraction treatment.11-14 The 2 most commonly cited
reasons for extraction today are crowding and prole
considerations.15 The treatment decision for this
patient was challenging because she had a nonextraction prole and an arch-length deciency that justied
extractions. To avoid compromising her facial esthetics,
she was treated without extractions by increasing the
arch perimeters anteroposteriorly and laterally. However, this enlargement method of treatment was found to
have the poorest stability results compared with serial
extractions, arch maintenance, and extractions in the
permanent dentition.16 The stability of this treatment
result was probably due to the lengthy stabilization
after RME (15 months) and the prolonged treatment
with the xed appliance (3 years), which allowed
enough time for muscle adaptation. Optimal tooth
interdigitation, prolonged retention, and the absence

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Fig 8. Posttreatment facial and intraoral photographs (age 16 years 8 months).

Table II. Arch-width measurements (mm)

Arch
Records date
3-3
4-4
5-5
6-6

Maxillary
T1
31.1
21.7
28.7
31.1

T2
24.6
27.5
33.2
36.5

Mandibular
T3
24.4
27.3
32.7
36.6

T1
20.7
23.3
28.6
35.0

T2
20.1
25.9
29.6
34.8

T3
20.1
25.1
29.0
34.6

T1, Pretreatment; T2, posttreatment; T3, 5 years posttreatment; 3,

canine; 4, rst premolar; 5, second premolar; 6, rst molar.

of late mandibular growth were also responsible for

long-term stability.17
RME has been shown to increase the perimeter of
the maxillary arch and can provide space to correct
moderate (3-4 mm) crowding.18,19 An average
increase in arch perimeter of 4.7 mm for an average
molar expansion of 6.5 mm has been reported.19,20
To correct the pretreatment maxillary arch-length

February 2015 # Vol 147 # Issue 2

deciency of 10.5 mm, 5 mm were gained from RME

and the remaining 5.5 mm from incisor proclination
(3 mm labially). RME can also be benecial in the
treatment of Class III malocclusions, particularly
borderline cases.21 An assessment of the maxilla after
RME with cone-beam computed tomography has
shown signicant displacement of the bones of the
circummaxillary suture in growing children with an
overall movement of the maxilla downward and forward.22 Similar effects with forward and downward
rotation of Point A, backward movement of Point B,
and clockwise rotation of the mandible have also
been found in animal studies.23
These effects with RME can also improve the softtissue prole by increasing its convexity.24 Inevitably,
there are side effects with RME such as an increase in
the vertical dimension, which did not affect this patient
with an open-bite tendency. In fact, in a study of the
long-term effects of RME, the authors found that the

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259

Fig 9. Posttreatment dental casts.

Fig 10. Posttreatment panoramic radiograph.

mandibular plane angle and the lower anterior facial

height increases were transitory.25
Many studies have documented the orthopedic
effect of maxillary protraction facemasks to bring
the maxilla forward and downward, often accompanied by downward and backward rotation of the
mandible and dental changes that are favorable for
correction of Class III malocclusions.26 It has also
been recognized from the beginning that facemask
treatment must start quite early relative to most other
orthodontic treatments. The original guideline by
Delaire,27 the initiator of facemask therapy, was to
start before the age of 8 years. Today, there is general
agreement that maxillary skeletal effects are most
likely in younger children, whereas mostly dental

Fig 11. Posttreatment cephalometric radiograph and

tracing.

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260

Fig 12. Superimposed pretreatment (solid lines) and posttreatment (dashed lines) cephalometric
tracings.

Fig 13. Five-year posttreatment facial and intraoral photographs (age 21 years 8 months)2 years
without the removable maxillary retainer.

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Fig 14. Five-year posttreatment dental casts.

Fig 15. Five-year posttreatment panoramic radiograph.

changes occur after 10 years of age.26-33 The

facemask was started for this patient at 12 years
11 months of age after her pubertal growth spurt.
The skeletal improvements achieved could not have
been possible with facemask treatment alone at this
age but were most likely the result of RME. The
facemask could have enhanced the orthopedic effect
of RME and vice versa.26 RME presumably can facilitate the orthopedic effect of the facemask by disrupting the circummaxillary sutural system.26,34 It could
be further speculated that this type of tissue-borne
acrylic RME provided better anchorage that favored
more skeletal effects and fewer dental changes.

Fig 16. Five-year posttreatment cephalometric radiograph.

The combined effect of RME and facemask treatment

was also instrumental in reestablishing the major components of a balanced smile for this patient, whose
main concern was her unpleasant smile.35 The downward displacement of the maxilla helped to optimize
the lip line and the amount of vertical tooth exposure.
The upper lip now reaches the gingival margin upon

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and vice versa. This combined effect has also remarkably

improved smile esthetics by optimizing anterior tooth
display and reducing lateral negative spaces. An additional challenge was met by the long-term stability of
the treatment results despite anteroposterior and lateral
arch expansion with nonextraction treatment dictated
by prole considerations.
REFERENCES

Fig 17. Superimposed posttreatment (solid lines) and

5-years posttreatment (dashed lines) cephalometric
tracings.

smiling, displaying the whole clinical crown height of the

maxillary incisors compared with a 50% display initially.
There was no more mandibular tooth display often associated with Class III malocclusions. RME and maxillary
protraction also helped ll the lateral negative spaces
or buccal corridors by bringing a wider portion of the
maxillary arch forward to ll the intercommissure space
with a rst molar-to-rst molar smile.36 The smile arc
was also changed from at to consonant, with the
edges of the maxillary anterior teeth running along the
curvature of the lower lip.37 Thus, this treatment was
successful in addressing the patient's chief complaint,
and the results had a positive psychological impact on
her personality and self-esteem.
CONCLUSIONS

The treatment results indicate that a maxillary protraction facemask can still be effective after the patient's
peak of pubertal growth spurt, despite the consensus in
the literature to start before age 8 years for maximum orthopedic effects. This nding suggests that individual
dentofacial characteristics may allow clinicians to push
the envelope of treatment beyond central tendencies
of treatment responses. Research may focus on the identication of such characteristics.
The successful expansion with midpalatal suture
opening enhanced the orthopedic effect of the facemask

February 2015 # Vol 147 # Issue 2

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American Journal of Orthodontics and Dentofacial Orthopedics

February 2015 # Vol 147 # Issue 2