Dr. Martin B. Epstein

is anassociate clinical professor ofpostgraduate orthodontics atNew York University, where hereceived his dental and ortho-dontic degrees and was electedto Omicron Kappa Upsilon.Dr. Epstein conducts lecturesand seminars internationally andoffers courses in DifferentialSlot-Size Treatment. He hascourses scheduled in Europeand South America for theupcoming year. He maintainshis clinical orthodontic practicesin New York City and StatenIsland. In his leisure time heenjoys kayaking and golf.

Dr. Garri Tsibel

received hisB.S. in physiological sciencefrom the University of CaliforniaLos Angeles and D.D.S. fromthe New York University Collegeof Dentistry where he was elect-ed to Omicron Kappa Upsilonand was awarded the Robert J.DiTolla memorial award forexcellence in clinical dentistry.He is currently a first-year ortho-dontic resident at New YorkUniversity and hopes to teachand publish more articles in thefuture. Dr. Tsibel enjoys reading,running, and spending time withfriends and family.

Dr. Joshua Z. Epstein

receivedhis D.M.D. from the Universityof Medicine and Dentistry ofNew Jersey, where he wasalso elected to Omicron KappaUpsilon. Upon completing theorthodontic program at NewYork University, he receivedthe Theodore L. Jerrold awardfor orthodontic excellence.Dr. Epstein is in private practicewith Drs. Elkin, Kessler,Morgenstern, and Sargiss inNew Jersey (Brace Place).

Class III malocclusions continue to be the mostchallenging to accurately diagnose and clinically manage.Unfortunately,with adults,orthognathicsurgery and dental camouflage remain our only viabletreatment options.However,a variety oftreatmentalternatives exists for patients in the developing stagesofa Class III malocclusion.In the past much ofthetherapy has focused on restriction ofmandibulargrowth with chin cups and functional appliances.Thisis based on the traditional thought that developingClass III malocclusions were the result ofa prognathicmandible.Recently,however,there has been a growingawareness that the majority ofpatients with a develop-ing Class III skeletal pattern exhibit a maxillary deficiency with a normal or only slightly prognathicmandible.

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Therefore,considerable attention has lately been given to early treatment using maxillary protrac-tion therapy.In this article we will demonstrate why using facemask therapy in conjunction with maxillary expansion has been shown in clinical reports to be asuccessful and predictable treatment option.In addi-tion,we will discuss which patients are best suited forthis type oftherapy as well as our treatment protocol.Correction using facemasks with palatal expansionoccurs by a combination ofskeletal and dental changesin both sagittal and vertical dimensions.

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Thesechanges occur as a result offorward movement ofthemaxilla,backward and downward rotation ofthemandible and proclination ofthe maxillary incisors.

A wide variety ofclinical results using this treatmentcan be found in the literature,with more recentinvestigators reporting average maxillary advancementof3.3 mm,with some patients ranging from 5 to 8 mm,and average SNA change of2.35°,with some patientsshowing 4°to 5°change.

Moreover,anterior maxillary tooth movement and mandibular clockwise rotationeach accounted for 25% oftotal correction.

Otherdentofacial changes contributing to Class IIIcorrection shown to occur with facemask and palatalexpansion treatment are downward movement andcounterclockwise rotation ofthe maxilla,increasedconvexity in the midface with forward displacement of

Management

of the

Developing Class IIIMalocclusion

WITH FACEMASK THERAPY AND PALATAL EXPANSION

Martin B. Epstein, DDSJoshua Z. Epstein, DMDGarri Tsibel, DDSNew York, New York

orbitale and key ridge,increase in maxillary depthand lower facial height,anterior movement of maxillary molars and incisors,decrease in SNB,aswell as inferior movement ofB-point,pogonion andmenton.

Soft-tissue changes contributing to increasedconvexity ofthe profile are anterior movement of pronasale,subnasale,and labrale superius,as well asinferior movement ofthe soft-tissue chin.

Whencomparing the contribution oforthopedic and ortho-dontic effects with facemask and palatal expansiontherapy,nearly all investigators attribute the majority ofClass III correction to orthopedic movement,withmost ofthe change taking place in the maxilla.

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Accurate Diagnosis Is Key

The skeletal and dental changes in anteroposteriorand vertical dimension that occur with this treatmentare well suited for patients that present with deepoverbite,sagittal and vertical maxillary deficiency,and normal to mildly prognathic mandibles.In theliterature,developing Class III patients ranging from4 to 14 years ofage treated with facemask and palatalexpansion therapy have been examined.Someinvestigators have not found statistically significantdifferences in skeletal response between various agegroups.

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However,several clinical reports have shownsuperior treatment outcomes in younger children withearly mixed dentition.

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These children were shownto have an enhanced potential for orthopedic correctionwith significantly greater increase in SNA angle andadvancement ofthe maxilla,increased molar and overjet correction,and less mandibular clockwise rotation.

Furthermore,the treatment results were obtained fasterand with fewer hours ofdaily appliance wear.

In prac-tice,we have found that patients in the mixed dentition,typically age seven or eight (depending on dentaldevelopment),with the permanent incisors and firstmolars in the maxillary arch fully erupted respondmost favorably (Figures 1a-g).Regardless ofwhether ornot a patient has an initial transverse discrepancy,bothfacemask and palatal expansion therapy are used.Opening the palatal suture complex allows the maxillato be advanced more easily by the facemask and serve asan anchor for the orthopedic forces.While success is possible in patients younger thanage seven,cooperation typically is diminished becausethese appliances are more difficult for very youngpatients to manage.Prior to that age we continue toobserve their development and sometimes initiate treat-ment with a removable appliance in the maxillary archto correct dental anterior crossbites.Some studies indi-cate that older developing children demonstrate someorthopedic changes and beneficial dental correction.Our usual protocol is to treat patients in the late mixeddentition,while growth is still possible,to help avoid theneed for surgery.

Treatment Time

Ideal treatment time varies markedly in clinical reports.A range of6 to 18 months ofactive treatment time hasbeen reported.

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Following the completion offacemasktherapy,patients tend to continue growth patternssimilar to untreated Class III controls,characterizedmainly by deficient maxillary growth.

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Mandibulargrowth in these patients,however,is similar to Class Icontrols.

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As a result,overcorrection ofmaxillary protraction during treatment is a key to long-termstability,because deficient posttreatment maxillary growth in these patients is to be expected.With over-correction,most patients demonstrate sufficient stability and do not require additional facemask therapy in thesecond stage oftreatment.However,there are somepatients who require continued maxillary protractioneven during Phase II treatment.

In a study where at theend ofa four-year observation period and after halfof the patients completed their pubertal growth spurt,75%

Figures 1a-g. Patientsin the mixed dentitionwho exhibit maxillarydeficiency (identified bya deficient soft-tissuedrape of the upper lipand a flat profile) as theprime skeletal compo-nent of the developingClass III malocclusion areexcellent candidates forthis treatment protocol.A mild to moderatemandibular excess mayalso be present.

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ofpatients maintained positive overjet or an end-to-endincisal relationship.Patients who reverted to a negativeoverjet after treatment were shown to have excesshorizontal mandibular growth.

Appliance Design – Facemask

The key to successful treatment using facemask andpalatal expansion therapy is patient compliance.Many maxillary protraction appliances are uncomfortable towear and difficult for patients to adjust.This leads to lessthan ideal results because the patient cannot easily adhere to the at-home management ofthe appliance.We have found that Ormco’s Adjustable DynamicProtraction Facemask offers a significantly moremanageable approach.Compared with other facemaskdesigns,the AD Protraction Facemask is more comfort-able,especially for very young children.The foreheadrest and chin cup are much smaller and adapt moreaccurately to the patient’s anatomy (Figures 2a-d).Theentire appliance is also fully adjustable.With comfort and ease ofappliance use being vitalto treatment success,the most significant benefit to thisunique design is the dynamic range ofmovement itallows the patient (Figures 3a-b).The patients’ability to comfortably open and close their mouths withoutrestriction contributes greatly to patient compliance,which translates into extra hours ofappliance wear andgives the clinician efficient adjustment visits.

Appliance Design – Palatal Expansion

Conventional palatal expansion appliance designs pro-vide palatal expansion and sutural opening with closely adapted labial arms that extend to the canine region asan attachment for elastic traction.Our experience withthis design has been that the labial extensions can easily become dislodged or distorted due to the orthopedicelastic forces.In addition,as the maxillary dentition isbrought forward,there is a possibility ofimpactingmaxillary permanent canines that may initially be ina compromised position.Considering these factors,we use a new design thathas been modified to maintain the arch circumferenceand provide a more reliable connection ofthe labialextensions (Figures 4a-b).Also,the labial extensionsare now soldered into the headgear tube for increasedrigidity.It is important to attach the extensions in away that ensures unimpeded access to the workingbuccal tube.When there is a significant vertical com-ponent to the malocclusion (evidenced by a hyper-divergent growth pattern and high mandibular planeangle),we use a bonded variety ofexpander to aid incontrolling the vertical dimension.As mentioned,palatal expansion is advocated asan integral part ofthis treatment modality even in theabsence ofan initial transverse discrepancy.When thepalatal vault is narrow,we benefit by correction oftheposterior crossbite.In all patients,we gain an increasein arch length (maxillary crowding is common in thesepatients),loosening and activation ofcircummaxillary sutures,and initiation ofdownward and forward move-ment ofthe maxillary complex.

Treatment Protocol

Maxillary expansion is initiated two weeks prior tostarting facemask therapy.It is important to allow timefor the patient to acclimate to the expansion applianceprior to beginning facemask treatment.One turnevery fourth day is our typical protocol.The goal is toactivate the maxillary complex for protraction withoutsignificantly altering the transverse dimension.At thestart offacemask therapy,we evaluate the amount of expansion accomplished thus far and decide how much

Figures 2a-b. Compared with other designs, the ADProtraction Facemask is more comfortable for patients towear, especially very young children. The forehead rest andchin cup are smaller and have a more accurate adaptation tothe patient’s anatomy.Figure 2c. The sturdy metal supports of the AD ProtractionFacemask provide superior elastic traction.Figure 2d. An important design element of the AD ProtractionFacemask for the clinician is the ability to adjust the angle offorce delivery.

2a2c 2d2b

FEATURES OF THEAD PROTRACTIONFACEMASK:

•Accurate forehead andchin adaptation•Precision construction ofadjustment screws•Rigid metal supports forreliable elastic traction•Two-position reversiblechin cup•Dynamic, full range ofmovement•Adjustable angle of forcedelivery•Flat surface mainframeprevents rotation ofauxiliary parts