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The European Journal of Orthodontics Advance Access originally published online on June 13, 2006
The European Journal of Orthodontics 2006 28(5):496-502; doi:10.1093/ejo/cjl011
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© The Author 2006. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.

Orthodontic and orthopaedic changes associated with treatment in subjects with Class III malocclusions

Jalen Devecioglu Kama*, Törün Özer* and Sedat Baran**

* Department of Orthodontics, Faculty of Dentistry University of Dicle, Turkey
** Private Practice, Adana, Turkey

Address for correspondence Jalen Devecioglu Kama, Dicle Üniversitesi, Dis Hekimligi Fakültesi, Ortodonti Anabilim Dali, Diyarbakir 21280, Turkey. E-mail: jdk{at}dicle.edu.tr


   Introduction
Top
 Introduction
Subjects and methods
 Results
 Discussion
 Conclusions
 References
 
Skeletal Class III anomalies are associated with maxillary retrusion, mandibular protrusion, or both (Haas, 1970Go; Ishii et al., 1987Go). In subjects with maxillary deficiency where the mandible is not markedly affected, treatment may involve stimulation and guidance of maxillary growth by orthopaedic forces.

Maxillary deficiency generally involves all three planes of space and stimulation of maxillary development not only involves expansion of the mid-palatal suture but may also increase the vertical and antero-posterior dimension of the maxilla.

Maxillary deficiency may be treated by maxillary protraction after palatal expansion (Haas, 1970Go; Tindlund et al., 1993Go; Shanker et al., 1996Go). The aim of palatal expansion is to overcome the problem of maxillary constriction but the bones of the craniofacial skeleton that have sutures with the maxilla are also affected (Bishara and Staley, 1987Go; Ceylan, 1993Go). Palatal expansion is therefore carried out before facemask therapy to facilitate anterior movement of the maxilla (Shanker et al., 1996Go).

Recent publications have described the treatment effects of rapid palatal expansion (RPE) and facemask treatment. After this combined treatment, skeletal and dentoalveolar modifications were noted (Ngan et al., 1997Go; Williams et al., 1997Go; Nartallo-Turley and Turley, 1998Go; Macdonald et al., 1999Go; Saadia and Torres, 2000Go; Yüksel et al., 2001Go).

It has also been reported that treatment produces more favourable outcomes in those treated in the primary or early mixed dentition rather than in the late mixed dentition (Baccetti et al., 1998Go, 2000Go; Kapust et al., 1998Go). Other researchers report that the ideal timing for this combined treatment is in the late mixed dentition as patient co-operation is required and this may be lost if treatment starts too early (Merwin et al., 1997Go; Suda et al., 2000Go; Turley, 2002Go). The most important criterion for this kind of treatment is pubertal growth and this must be taken into consideration to ensure continuing circummaxillary sutural activity (Bowden, 1976Go; Fishman, 1982Go; Merwin et al., 1997Go; Suda et al., 2000Go; Turley, 2002Go).

However, chronological age is not a reliable growth indicator alone and RPE/facemask treatment should be planned according to skeletal age, which can be determined from hand-wrist or cervical vertebrae radiographs (Bowden, 1976Go; Fishman, 1982Go; Suda et al., 2000Go).

The Delaire type facemask, in which the frontal and mental regions can be used for extraoral anchorage, is an effective appliance for maxillary protraction (Haas, 1970Go; Ishii et al., 1987Go) and the effects of maxillary protraction on the dentofacial skeleton will alter according to the direction and degree of the applied force.

The aim of this study was to examine the craniofacial and dentoalveolar changes in Class III malocclusion subjects characterized by maxillary retrusion and narrowness, following RPE and facemask treatment.


   Subjects and methods
Top
 Introduction
 Subjects and methods
Results
 Discussion
 Conclusions
 References
 
Ethical approval for the study was granted by the local research committee of the Council of the Faculty of Dentistry, University of Dicle. Written parental informed consent was also obtained.

Thirty, Class III patients, who had been referred to the Department of Orthodontics at the University of Dicle, were recruited for this study. None had any other craniofacial anomaly and there was no history of previous orthodontic treatment. The control and treatment group each comprised 15 subjects: the treatment group eight girls and seven boys and the control group nine girls and six boys. In order to determine skeletal ages, hand-wrist radiographs were analysed according to the atlas of Greulich and Pyle (1959)Go.

The selection of the cases (treatment and control group) was made on the following criteria: an Angle Class III dental relationship with anterior cross-bite, and/or Skeletal Class III relationship with maxillary retrognathism, ANB angle less than -1 degree.

For both the treatment and control groups lateral cephalograms were taken before treatment. In the treatment group, a second lateral cephalogram was taken at the end of active treatment when the retainer was placed. For the control group, a second lateral cephalogram was obtained an average of 16 months after the first radiograph. The treatment and control groups were classified according to their skeletal ages. The ages of the subjects in both groups were similar and the chronological and skeletal age distributions over the treatment period are shown in Table 1.


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  		Table 1 Comparison of chronological and skeletal ages (years) in the treatment (n = 15) and control (n = 15) groups.

 
In the treatment group, the first and second premolars and the first molars were banded. After obtaining alginate impressions, a hyrax screw was soldered to the bands on the models in an antero-posterior direction. Following cementation, the patient was instructed to turn the screw twice a day, a one-quarter turn in both the morning and evening. After 1 week the screw was removed, a second alginate impression was taken, and the screw was soldered in a transverse direction as the conventional hyrax expander. The average treatment time was approximately 20 days. Following correction of the posterior crossbite, the screw was used for 3 months for retention.

At this stage, an impression of the patient's face was taken and a Delaire-type facemask adapted to the plaster mould (Enacar and Demirhanoglu, 1989Go). The patients were asked to wear a removable anterior inclined bite plane appliance in the mandible and fixed orthodontic appliances in the maxilla. Elastics, applying a force of 600 g, were directed 20 degrees inferior to the occlusal plane from the mesial surface of the upper canines. These elastics were worn for 16-18 hours a day. The mean treatment time for this phase was 6 months. All patients were treated to a positive dental overjet before stopping active treatment and most were overcorrected towards a Class II incisor relationship. Finally, a fixed appliance was placed in the lower arch (Figures 1 and 2) and this phase of fixed appliance treatment lasted approximately 15 months.


Figure 1
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  		Figure 1 Case no. 1. Study cast photographs (a) before and (b) after maxillary expansion and protrusion treatment.

 

Figure 2
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  		Figure 2 Intraoral photographs after (a) antero-posterior and (b) transversal expansion.

 
On the pre- and post-treament/observation radiographs, the FHp reference plane was constructed by drawing a vertical reference line from sella to Frankfort horizontal. The points and variables measured are shown in Figures 3 and 4 and an example of one of the superimpositions in Figure 5. All measurements were undertaken by one author (JDK).


Figure 3
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  		Figure 3 Reference point used in the cephalometric analysis. (S, sella; N, nasion; Or, orbitale; Po, porion; ANS, anterior nasal spine; PNS, posterior nasal spine; A, Down's point A; B, Down's point B; Gn, gnathion; Me, menton; Go, gonion; 6(Ms), mesial contact point of upper first molar; 6(Mi), mesial contact point of lower first molar.)

 

Figure 4
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  		Figure 4 Skeletal and dental measurements.

 

Figure 5
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  		Figure 5 Superimposition of a sample case on S-N reference plane on sella.

 
Statistical analysis was undertaken using version 6 of the Statistical Package for Social Sciences (SPSS, Chicago, Illinois, USA). Wilcoxon's test was used to evaluate the treatment effects and changes during the observation period in each group, and the differences between the groups were determined using a Mann-Whitney U-test.

To determine the accuracy of the method, all cephalograms were retraced after a period of 3 weeks and the variables were recalculated. The method error was within acceptable limits. The accuracy of the linear measurements ranged from 0.1 to 0.3 mm, with a standard deviation (SD) of approximately 0.7 mm, and the angular measurements varied by 0.1 degrees, SD: 0.5-0.7 degrees.


   Results
Top
 Introduction
 Subjects and methods
 Results
Discussion
 Conclusions
 References
 
At the beginning of the study, there were no significant differences between the skeletal and chronological ages in either group (Table 1).

The lateral cephalometric radiographs taken pre- and post-treatment showed the following.


Sagittal angular variables

In the treatment group, SNA (P < 0.05) and ANB (P < 0.001) increased and SNB decreased (P < 0.01). However, in the control group there was no statistically significant difference. Comparison of the two groups showed an increase in ANB in the treatment group (P < 0.001; Table 2).


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  		Table 2 Biometric evaluation of skeletal and dental variables in the treatment (n = 15) and control (n = 15) groups.

 

Sagittal linear measurements

The following sagittal linear measurements were increased in the treatment group: A{perp}FHp (P < 0.001), ANS-PNS (P < 0.01), and 6{perp}FHp (P < 0.05). In the control group Go-Gn was increased (P < 0.05; Table 2). A comparison between the treatment and control groups demonstrated that A{perp}FHp was increased in the treatment group (P < 0.001).


Vertical measurements

SN/Go-Gn and SN/ANS-PNS angles were significantly increased in the treatment group (P < 0.05; Table 2). Similarly, increases in vertical linear measurements were observed for anterior face height and A{perp}FH (P < 0.001); N-ANS and ANS-Me (P < 0.01); and posterior face height, 1-(ANS-PNS), 6-(ANS-PNS) (P < 0.05). In the control group, N-Me was also increased (P < 0.01). A comparison between the groups demonstrated that N-ANS, ANS-Me, and A{perp}FHp dimensions were increased in the treatment group (P < 0.05; Table 2).


   Discussion
Top
 Introduction
 Subjects and methods
 Results
 Discussion
Conclusions
 References
 
Skeletal Class III malocclusions are known to be the most difficult malocclusion types to treat among the many skeletal disorders (Enacar and Demirhanoglu, 1989Go). No consensus exists as to when these malocclusions should be treated, i.e. in the early stages or when the growth rate has reduced, and variation in genetic growth pattern is one of the most difficult issues (Sugawara et al., 1990Go). Early orthopaedic treatment success is dependent on growth of the facial skeleton and modification of growth (Shanker et al., 1996Go).

It has been suggested that to obtain optimum treatment results with maxillary protraction, it must be applied in the pre-pubertal period. The recommendation being that RPE is undertaken before maxillary protraction to eliminate the bioelastic stress of the sutural elements. As a result of this, the maxillary segments separate from each other orthodontically and this separation of the maxilla from the surrounding elements is helpful in maxillary protraction (Shanker et al., 1996Go). Turley (2002)Go suggested that palatal expansion should be a routine part of facemask treatment and proposed that, besides the lengthening of the arches and opening of the occlusion, the most important role of palatal expansion in facemask treatment is the disassociation of the sutures between the circummaxillary bones.

Subjects with deficient maxillary development or borderline skeletal Class III patients who do not require orthognathic surgery may be suitable for RPE (Haas, 1970Go; Gryson, 1977Go; Nanda, 1978Go; Sarver and Johnston, 1989Go). The effects of RPE are not only restricted to the maxilla; the maxilla is related to 10 other bones of the cranium and facial skeleton which could directly or indirectly be affected by RPE (Bishara and Staley, 1987Go; Sarver and Johnston, 1989Go; Ceylan, 1993Go).

In the treatment group in the present investigation, the angle between the maxilla and craniofacial base was increased whereas that between the mandible and craniofacial base was decreased. As a result of this, the relationship between the jaws was corrected in a sagittal direction. Sarver and Johnston (1989)Go and Silva Filho et al. (1991)Go reported that that the maxilla was displaced downward and forward after palatal expansion, as a result of which there was a downward and backward rotation of the mandible (Haas, 1970Go). Enacar and Demirhanoglu (1989)Go found that facemask treatment caused a mesial movement of the basal and alveolar regions, and that anterior rotation of the maxilla and posterior rotation of the mandible occurred. Kambara (1977)Go and Nanda (1978)Go observed anterior rotation and displacement of the maxillary complex when protraction forces were applied.

In the treatment group in the present study, A{perp}FHp showed an increase of 3.49 mm, indicating anterior movement of the maxilla. There was only a very small increase in the control group (0.07 mm), and thus a significant difference was noted between the groups. This finding was greater than that reported by other researchers (Ishii et al., 1987Go; Enacar and Demirhanoglu, 1989Go; Takada et al., 1993Go; Tindlund et al., 1993Go; Shanker et al., 1996Go). Similarly, ANS-PNS in the treated group increased by 1.91 mm but there was no change in the control group. Mandibular sagittal development was not significant in the treatment group but there was an increase of 1.97 mm in the control group. Although there was no statistical difference when the groups were compared, the lower rate of mandibular sagittal development in the treatment group may show some inhibition of mandibular growth.

Tindlund et al. (1993)Go found that palatal expansion and maxillary protraction resulted in a 1.3-mm forward movement of point A. Similarly, Ishii et al. (1987)Go and Takada et al. (1993)Go demonstrated that maxillary protraction increased maxillary length by 2.2-2.7 mm. Shanker et al. (1996)Go found that, after 6 months of protraction, there was a 2.4-mm forward movement of point A. This forward movement was achieved by 75 per cent skeletal movement and 25 per cent local remodelling.

In the present study, both groups showed an increase in the angle between the maxillary incisors and the cranial base. The increase in the control group may be due to the compensatory mechanisms occurring in Class III subjects (Graber et al., 1985Go). Kapust et al. (1998)Go also showed that the maxillary dentition moved forward and downward.

As a result of RPE and maxillary protraction, there was mesial movement of the first molars. Yüksel et al. (2001)Go reported upper molar displacement of 3.2 mm following facemask therapy in a late treatment group, and Pangrazio-Kulbersh et al. (1998)Go found a 2.4 mm significant mesialization of the upper molars. In the present study, 6{perp}FHp dimension increased by 1.46 mm in the control group but decreased by 1.03 mm in the treated group. This maxillary molar increase was associated with mesial movement of the upper molars, while the decrease in the lower molars appeared to be as a result of mandibular posterior rotation.

Hata et al. (1987)Go found that localization of the applied force result in variations in the craniofacial complex. Ishii et al. (1987)Go also studied the localization of protraction forces, with forces applied from the first premolars and first molars. They recommended that forces should be applied from an anterior point to achieve more parallel movement.

In this investigation, anterior and posterior face heights were increased in the treatment group. However, only the increase in ANS-Me (2.99 mm) was greater in the treatment group when compared with the control group. Ngan et al. (1996)Go in their investigation reported that lower face height increased on average by 2.9 mm.

As a result of a protraction force directed 20 degrees inferior to the occlusal plane, an increase of 2.17 degrees in SN/Go-Gn angle was observed. Additionally, following anterior and downward displacement of the maxilla, the mandible had a posterior rotation (Haas, 1970Go; Kambara, 1977Go). In addition, A{perp}FH dimension, which is a vertical movement of point A, increased by 2 mm. This is in agreement with the study by Shanker et al. (1996)Go, who found that point A moved downward by 0.3 mm.

Vertical dental findings showed that anterior and posterior dentoalveolar heights increased in the treatment group, but the differences between the groups were not significant. Merwin et al. (1997)Go found greater molar extrusion in an older age group with a bonded expansion appliance. Contrary to the present findings, in several maxillary protraction studies with or without expansion (Ishii et al., 1987Go; Takada et al., 1993Go; Kapust et al., 1998Go), it has been shown that eruption of maxillary posterior teeth results in a downward and backward rotation of the mandible.


   Conclusions
Top
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusions
References
 
This study demonstrated that RPE and facemask therapy produced favourable changes in the dentofacial complex in patients presenting with Class III malocclusions. Improvements in the skeletal and dental relationships aided correction of the Class III relationship. The treated group had significant hard tissue movements affecting the dentofacial complex. Skeletal change was a combination of anterior and vertical movement of the maxilla, and posterior and downward movement of the mandible. Dental changes also contributed to the correction. These results suggest that Class III malocclusion can be treated well with RPE and facemask treatment.


   References
Top
 Introduction
 Subjects and methods
 Results
 Discussion
 Conclusions
 References
 

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A. S. Kilinc, S. G. Arslan, J. D. Kama, T. Ozer, and O. Dari
Effects on the sagittal pharyngeal dimensions of protraction and rapid palatal expansion in Class III malocclusion subjects
Eur J Orthod, February 1, 2008; 30(1): 61 - 66.
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