European Journal of Orthodontics, 2019, 1–6

doi:10.1093/ejo/cjz003

Original article

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Soft tissue facial profile in Class III malocclusion:
long-term post-pubertal effects produced by the
Face Mask Protocol
Chiara Pavoni1,2, Francesca Gazzani1, , Lorenzo Franchi3,4,
Saveria Loberto1, Roberta Lione1,2 and Paola Cozza1,2
1
Department of Clinical Sciences and Translational Medicine, University of Rome ‘Tor Vergata’, 2Department of
Dentistry, UNSBC, Tirana, Rome, 3Department of Surgery and Translational Medicine, University of Florence, Italy,
and 4Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI,
USA

Correspondence to: Chiara Pavoni, Department of Clinical Sciences and Translational Medicine University of Rome ‘Tor
Vergata Viale’, Oxford 81 00133, Rome, Italy. E-mail: dott.chiarapavoni@gmail.com

Summary
Objectives:  The objective of this study was to analyze soft tissue changes produced by rapid
maxillary expansion and facial mask therapy in growing Class III patients.
Materials:  The treated group consisted of 32 Caucasian patients (15 females and 17 males) with
dentoskeletal Class  III malocclusion treated with the Face Mask Protocol (FMP, rapid maxillary
expander, facial mask, and removable lower bite-block). All patients were evaluated before
treatment (T1; mean age, 8.4  years), at the end of active treatment (T2; mean age, 10.7  years),
and at a post-pubertal follow-up observation (T3; mean age, 15.8 years). The treated group was
compared with a matched control group of 20 untreated subjects (10 females and 10 males) with
dentoskeletal Class III malocclusion. Statistical comparisons between two groups were performed
with the independent samples t-test (P < 0.05).
Results:  Significant improvements were found during the long-term T1–T3 interval for profile facial
angle (–5.8°), nasolabial angle (–4.4°), mandibular sulcus (–10.3°), upper lip protrusion (+0.7 mm),
and lower lip protrusion (–1.1 mm) in the treated group. No significant post-pubertal effects were
found in terms of lower face percentage between two groups.
Limitations:  This study has a retrospective design and it used a historical control sample.
Conclusion:  The FMP induced positive effects on soft tissue facial profile with a good long-term
post-pubertal stability.

Introduction with Class III disharmonies, and the changes consist of a combined

effect of the protocol on both maxillary and mandibular components.
Treatment of patients with Class III malocclusion is considered one
Optimal timing for the orthopaedic approach to Class III malocclu-
the most challenging ones in orthodontics. Traditional strategies for
sion is related to early treatment, at a prepubertal phase of devel-
orthopaedic correction of Class  III malocclusions include chin-cup
opment (4). Class III patients who missed the opportunity for early
treatment and the protraction facemask protocol, either with or with-
growth modification have to go through their teenage years with a
out rapid maxillary expansion (RME) (1,2). RME and facial mask
socially and functionally undesired malocclusion, which is shown to
therapy is the most common orthopaedic treatment protocol for skel-
be the least favoured of all profiles in teenagers (5). Therefore, early
etal Class III malocclusion (3). The literature includes many articles
treatment could at least provide such patients with a higher quality of
on dentoskeletal effects of this type of therapy in growing subjects

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
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2 European Journal of Orthodontics, 2019
life throughout the years they are most vulnerable by their facial aes-
thetics (6). Several studies (7–11) reported soft tissue response to treat-
ment of Class III malocclusions. These studies showed that favourable
short-term soft tissue changes can be achieved after early orthopaedic
treatment with the facial mask. Arman et  al. (11,12) examined the
dentofacial changes in Class III patients treated with fixed appliances
subsequent to RME and facemask therapy. The post-treatment period
after orthopaedic Class  III treatment was less than 2  years and the
control sample consisted of Class  I  untreated subjects. The purpose
of this retrospective observational study, therefore, was to evaluate
the long-term post-pubertal soft tissue changes produced by the Face
Mask Protocol (FMP) in growing Class  III patients with respect to
untreated Class III controls.
Materials and methods
Subjects
Sample size determination was calculated on the basis of an effect
size of 0.9 for the primary outcome variable Profile facial angle,
an alpha level of 0.05, and a power of 0.80. The minimum sam-
ple size was 20 patients per group (SigmaStat 3.5, Systat Software,
Point Richmond, California, USA). The treated group comprised
32 patients with dentoskeletal Class III malocclusion treated con-
secutively with the FMP at the Department of Orthodontics of the
University of Rome ‘Tor Vergata’ from January 2006 to December
2009. At the initial observation (T1), all patients had Class III mal-
occlusion in mixed dentition with a Wits appraisal (13) of –2 mm
or less, anterior crossbite or incisor end-to-end relationship, and
Class  III molar relationship. All patients were of Caucasian ori-
gin, with a pre-pubertal stage of skeletal maturity according to
the cervical vertebral maturation method (CS 1–CS 3)  (14). No
permanent teeth were congenitally missing or extracted before or
during treatment. No discrepancy between centric occlusion and
centric relation (indicating pseudo-Class III malocclusion). Subjects
with facial asymmetry or with cleft lip and/or palate or craniofa-
cial syndromes were excluded. Lateral cephalograms were taken
at T1 (before treatment) and the end of active treatment with the
FMP (T2). After active therapy, they were recalled every 3 months
to assess the stability of treatment outcomes. The treated group
was re-evaluated at a follow-up observation (T3) with a third
set of lateral cephalograms at an average time after T2 of about
5 years (about 7 years after T1). All subjects reached post-pubertal
skeletal maturity at T3 (CS 4, CS 5, or CS 6)  and presented per-
manent dentition when fixed appliance therapy could be used to
refine the occlusion. In general, fixed appliance therapy was pro-
posed to all patients. However, only 26 patients (81.2 per cent)
agreed to receive fixed appliances. During fixed appliance therapy,
Table 1.  Demographics of the treated and control groupsa. f, female; m, male; SD, standard deviation
Treated group (n = 32, 15 f, 17 m)
Variables Mean SD
Age T1, y 8.4 1.2
Age T2, y 10.7 1.3
Age T3, y 15.8 2.5
T2–T1, y 2.2 1.0
T3–T2, y 5.2 2.1
T3–T1, y 7.4 2.0
Descriptive statistics and statistical comparisons at T1, T2, and T3 (independent-samples t-tests). NS, not significant.
a
T1 indicates before treatment; T2 immediately after removal of the functional appliances; T3 follow-up observation.
a short phase of intermaxillary Class  III elastics was performed
when appropriate. The stages of cervical vertebral maturation were
determined by an operator (LF) trained in this method. This study
was approved by the ethics committee of the University of Rome
‘Tor Vergata’ (protocol number 168/17), and informed consent was
obtained from parents. A historical control group of 20 untreated
subjects with dentoskeletal Class  III malocclusion was selected
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from a collection of lateral cephalometric longitudinal series (15)
to comprise the control group. The inclusion criteria of the con-
trol group were the same as the treated sample. The control group
matched the treated group as to skeletal maturation at the various
times; chronologic age at T1, T2, and T3; and durations of obser-
vation intervals (Table 1).
Treatment protocol
The three components of the FMP used in this study were a max-
illary expander, a facial mask with heavy elastics and a lower
removable bite-block (2) (Figures 1 and 2). Treatment started with
the placement of a banded maxillary expander soldered to bands
placed on the maxillary first permanent molars (Leone A2620;
Leone Orthodontic Products, Sesto Fiorentino, Florence, Italy)
with two vestibular hooks in the maxillary canine region to attach
the elastics. The patients’ parents were instructed to activate the
expander once or twice daily until overcorrection of the transverse
width was achieved (palatal cusps of the maxillary posterior teeth
approximating the buccal cusps of the mandibular posterior teeth).
In patients not requiring expansion, the expansion screw was not
activated. Maxillary protraction efficacy in correcting sagittal mal-
occlusion does not improve when additional expansion is carried
out (16,17). At the end of the expansion phase, the patients received
a facial mask (Dynamic Facemask; Leone Orthodontic Products)
with pads fitted to the chin and forehead for support. Elastics were
attached from soldered hooks on the expander to the support bar
of the facial mask in a downward and forward direction, producing
orthopaedic force levels up to 400–500 g per side. Inclination of the
extraoral elastics was about 30° to the occlusal plane to counteract
the counterclockwise rotation of the maxilla (18,19). Patients were
instructed to wear the facial mask for a minimum of 14 hours per
day. During facial mask treatment, a lower removable bite-block
(with 3 mm-thick posterior splints) was used on all treated patients,
with the aim to facilitate correction of occlusal relationships in the
presence of anterior or posterior crossbite (20). The patients were
instructed to wear the bite-block 24 hours a day. Mean treatment
duration was 1.7 +/– 0.8 years. All patients were treated at least to a
positive overjet before discontinuing treatment; most patients were
overcorrected toward a Class II occlusal relationship. No retention
appliance was worn after FMP.
Control group (n = 20, 10 f, 10 m)
Mean SD P
8.7 1.0 NS
10.8 1.3 NS
16.1 1.3 NS
2.1 0.8 NS
5.3 1.9 NS
7.4 1.4 NS
C. Pavoni et al. 3

Cephalometric analysis Results

A customized digitization regimen and cephalometric analysis pro-
vided by Viewbox (version 3.0; dHAL Software, Kifissia, Greece)
were used for all cephalograms examined in this study. The cus-
tomized cephalometric analysis, containing measurements from the
analysis of Bergman (21) generated six variables, three angular and
three linear. Table 2 summarizes the cephalometric measurements
No significant between-group differences were found either for chrono-
logic age at T1, for the observation intervals or for gender distribution.
The intraobserver reproducibility evaluated with the ICCs indicated a
high level of intraobserver agreement (ICCs varied between 0.941 for
upper lip protrusion and 0.998 for the nasolabial angle). As for the

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used for the study. Magnification was standardized to an 8 per cent
enlargement for all radiographs in both treated and control samples.
Statistical analysis, intraobserver reproducibility,
and method error
The primary aim of the study was to evaluate the soft tissue changes
produced by the FMP in growing Class III patients. Therefore, sta-
tistical between-group comparisons (treated group versus control
group) were calculated for the craniofacial starting forms at T1
and for the T1–T3 changes. In the presence of normally distrib-
uted data (Kolmogorv–Smirnov test), statistical between-group
comparisons were performed with independent samples t-tests.
If data were not normally distributed, statistical between-group
comparisons were carried out with the Mann–Whitney test. As
secondary statistical analysis, between-group comparisons for the
T1–T2 and T2–T3 changes were performed. Fifteen lateral cepha-
lograms, selected randomly from the patients in the study, were
traced and measured at 2 times within 2 weeks by the same opera-
tor (CP). The measurements at both times for each patient were
analyzed with the intraclass correlation coefficient (ICC). Linear
measurement errors were calculated with the method of moments’
estimator (22).
linear measurement errors they varied from 0.3 mm for the lower lip
protrusion and 0.5° for the profile facial angle.
No significant between-group differences were found in any of
the variables at T1 (Table 3). The statistical comparisons of the
T1–T3 changes between the treated and control groups (Table 4)
showed several significant modifications produced by the FMP.
Significant decreases in the treated group were found for profile
facial angle (–5.8°), nasolabial angle (–4.4°), mandibular sulcus
(–10.3°), and lower lip protrusion (–1.1  mm), whereas upper lip
protrusion exhibited a significant increase (+0.7 mm). During the
short-term T1–T2 interval (Table 5), profile facial angle (–4.4°),
nasolabial angle (–4.6°), mandibular sulcus (–5.8°), and lower lip
protrusion (–0.8  mm) showed significant decreases in the treated
group with respect to untreated controls whereas the upper lip
protrusion increased significantly by +1.7  mm. Only two cepha-
lometric variables showed significant changes during the T2–T3
period with a decrease in upper lip protrusion of –1.0 mm and a
decrease of –4.5° in mandibular sulcus in the treated group versus
the control sample (Table 6).
As for the dentoskeletal changes that occurred during the T1–
T3 interval, the treated group showed a significant improvement in
the sagittal skeletal relationships (ANB +3.1° and Wits +3.6  mm).
This favourable change was associated with a significant control in

Figure 1.  Intraoral frontal view of Face Mask Protocol. Figure 2.  Intraoral occlusal view of lower bite block

Table 2.  Soft tissue and skeletal cephalometric variables and their definition

Variables Definition

ANB Angle formed by connecting A point, N point, and B point

SNA
SNB
SN to GoGn
Profile facial angle (deg)
Nasolabial angle (deg)
Lower face %
Upper lip protrusion (mm)
Mandibular sulcus (deg)
Lower lip protrusion (mm)
Angle formed by connecting S point, N point, and A point
Angle formed by connecting S point, N point, and B point
Angle formed between the Sella-Nasion plane and the Gonion-Gnathion mandibula plane
Angle formed by connecting soft tissue glabella, subnasale, and soft tissue pogonion
Angle formed by the intersection of upper lip anterior and columella at subnasale
Lower third of the face from subnasale to soft tissue menton, measured vertically and expressed as a percentage
of the midface and lower face height, measured from soft tissue glabella vertically to soft tissue menton
Perpendicular distance between upper lip anterior and the subnasale-pogonion line
Angle formed by the lower lip anterior, soft tissue B point, and soft tissue pogonion when the lips are in repose
Perpendicular distance between lower lip anterior and the subnasale-pogonion line
4 European Journal of Orthodontics, 2019

Table 3.  Descriptive statistics and statistical comparisons (independent-samples t-tests) of the starting forms (cephalometric values at T1).
SD, standard deviations; Diff., differences; CI, confidence interval; Inc., incisor; Pal., palatal; Mand., mandibular

Treated group Control group 95% CI of the difference

Variables Mean SD Mean SD Diff. P value Lower Upper

Age (y) 8.4 1.2 8.7 1.0 –0.3 0.383 –0.9 0.4

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Profile facial angle (deg) 143.5 4.9 144.3 3.4 –0.8 0.548 –3.3 1.8
Nasolabial angle (deg) 127.6 7.0 127.8 7.0 –0.2 0.909 –4.2 3.8
Lower face % 54.1 2.6 53.3 2.1 0.8 0.290 –0.7 2.1
Upper lip protrusion (mm) 2.3 1.4 3.1 1.4 –0.8 0.053 –1.6 0.0
Mandibular sulcus (deg) 140.5 5.6 141.8 3.8 –1.3 0.361 –4.2 1.6
SNA (deg) 80.1 1.4 80.7 2.0 –0.6 0.281 –1.6 0.5
SNB (deg) 81.8 1.1 81.1 1.3 0.7 0.064 0.0 1.4
ANB (deg) –1.7 1.6 –0.5 2.2 –1.2 0.041 –2.4 –0.1
Wits (mm) –3.9 2.1 –3.3 2.3 –0.6 0.340 –1.9 0.7
SN to GoGn (deg) 35.3 3.4 36.4 2.3 –1.1 0.181 –2.7 0.5
Upper Inc. to Pal. Pl. (deg) 114.1 4.2 113.5 5.5 0.6 0.698 –2.4 3.5
Lower Inc. to Mand. Pl. (deg) 89.9 6.4 88.3 4.8 1.6 0.307 –1.5 4.7

Table 4.  Descriptive statistics and statistical comparisons (independent-samples t-tests) of the T3–T1 changes. SD, standard deviations;
Diff., differences; CI, confidence interval; Inc., incisor; Pal., palatal; Mand., mandibular

Treated group Control group 95% CI of the difference

Variables Mean SD Mean SD Diff. P value Lower Upper

Age (y) 7.4 2.0 7.4 1.4 0.0 0.934 –1.0 1.1
Profile facial angle (deg) –3.9 4.2 1.9 3.9 –5.8 0.000 –8.2 –3.5
Nasolabial angle (deg) –2.4 6.7 2.0 8.2 –4.4 0.043 –8.5 –0.1
Lower face % 0.3 2.1 0.4 2.6 –0.1 0.928 –1.4 1.3
Upper lip protrusion (mm) 0.5 1.3 –0.2 1.2 0.7 0.044 0.0 1.4
Mandibular sulcus (deg) –7.9 5.7 2.4 3.5 –10.3 0.000 –13.1 –7.4
Lower lip protrusion (mm) 0.0 1.5 1.1 1.2 –1.1 0.007 –2.0 –0.3
SNA (deg) 1.7 1.7 1.3 1.8 0.4 0.449 –0.6 1.4
SNB (deg) –0.3 1.5 2.7 1.2 –3.0 0.000 –3.7 –2.1
ANB (deg) 1.8 1.7 –1.3 2.1 3.1 0.000 2.0 4.3
Wits (mm) 2.1 1.1 –1.5 1.1 3.6 0.000 2.9 4.2
SN to GoGn (deg) –0.3 2.7 1.1 2.5 –1.4 0.070 –2.8 0.1
Upper Inc. to Pal. Pl. (deg) 2.7 4.2 5.5 4.8 –2.8 0.042 –5.4 –0.1
Lower Inc. to Mand. Pl. (deg) –2.3 5.9 –0.8 3.8 –1.5 0.279 –4.2 1.2

mandibular sagittal position (SNB –3.0°). No significant maxillary
advancement (SNA +0.4°) or change in vertical skeletal relationships
(SN to GoGn –1.4°) in the treated group was recorded. The upper
incisors exhibited a significant protrusion in the control group (–2.8°).
Discussion
A balanced soft tissue facial profile has been considered an important
factor to achieve during orthodontic treatment, especially in Class III
growing patients (7–10). The aim of this study was to analyze-long-
term post-pubertal soft tissue changes produced by the FMP in
growing Class III patients with respect to an untreated Class III sam-
ple by means of Bergman soft tissue analysis (21,23). Class III profile
is frequently reported as the main chief complaint by patients. Thus,
an important objective of early orthopaedic treatment includes facial
profile correction, which can lead to an improvement in psychosocial
well-being and appearance of patient, especially during their ado-
lescent years (8). Cephalometric analysis most commonly relies on
skeletal and dental measurements, with less emphasis on soft tissue
facial measurements. Several authors (24–27) extensively inves-
tigated the dentoskeletal effects of RME and facial mask therapy
and their stability after short- and long-term observations. However,
studies (7–10) on soft tissue effects of maxillary protraction therapy
are limited and they evaluated only short-term changes. The nov-
elty of the current investigation, therefore, is the analysis of the
long-term post-pubertal soft tissue changes produced by the FMP
in growing Class III patients with respect to an untreated Class III
sample. Significant improvements in facial profile were recorded in
the treated group during the T1–T3 long-term interval (Table 4).
In particular, the profile facial angle showed a significant reduction
(–5.8°) in the treated group. This result can be related to the long-
term improvement of the intermaxillary sagittal skeletal relationship
associated with a significant reduction in mandibular protrusion that
has been described by several authors (24–29). Upper lip protrusion
was significantly greater in the treated group than in the controls
though it was not clinically relevant (+0.7 mm). This favourable out-
come was most probably related to the significant decrease in the
profile facial angle in the treated group. A  significant reduction of
C. Pavoni et al. 5

Table 5.  Descriptive statistics and statistical comparisons (independent-samples t-tests) of the T2–T1 changes. SD, standard deviations;
Diff., differences; CI, confidence interval; Inc., incisor; Pal., palatal; Mand., mandibular

Treated group Control group 95% CI of the difference

Variables Mean SD Mean SD Diff. P value Lower Upper

Age (y) 2.2 1.0 2.1 0.8 0.1 0.543 –0.4 0.7

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Profile facial angle (deg) –3.6 4.3 0.8 2.1 –4.4 0.000 –6.4 –2.2
Nasolabial angle (deg) –4.3 6.7 0.3 8.5 –4.6 0.033 –8.9 –0.4
Lower face % 0.6 2.0 1.0 2.1 –0.4 0.538 –1.5 0.8
Upper lip protrusion (mm) 1.7 1.7 0.0 1.4 1.7 0.001 0.8 2.6
Mandibular sulcus (deg) –4.4 4.0 1.4 3.4 –5.8 0.000 –8.0 –3.7
Lower lip protrusion (mm) 0.0 1.4 0.8 1.4 –0.8 0.036 –1.6 –0.1
SNA (deg) 1.9 1.6 0.3 2.4 1.6 0.013 0.4 2.9
SNB (deg) –0.9 0.9 1.3 0.9 –2.2 0.000 –2.7 –1.7
ANB (deg) 2.8 1.9 –1.1 2.3 3.9 0.000 2.6 5.0
Wits (mm) 1.9 1.0 –0.6 0.4 2.5 0.000 2.1 2.9
SN to GoGn (deg) –0.4 1.9 0.1 1.7 –0.5 0.376 –1.5 0.6
Upper Inc. to Pal. Pl. (deg) 0.5 4.2 3.7 3.9 –3.2 0.008 –5.5 –0.9
Lower Inc. to Mand. Pl. (deg) –0.8 3.8 –0.7 2.6 –0.1 0.856 –1.9 1.6

Table 6.  Descriptive statistics and statistical comparisons (independent-samples t-tests) of the T3–T2 changes. SD, standard deviations;
Diff., differences; CI, confidence interval; Inc., incisor; Pal., palatal; Mand., mandibular

Treated group Control group 95% CI of the difference

Variables Mean SD Mean SD Diff. P value Lower Upper

Age (y) 5.2 2.1 5.3 1.9 –0.1 0.839 –1.3 1.0
Profile facial angle (deg) –0.4 3.9 1.2 2.5 –1.6 0.123 –3.5 0.4
Nasolabial angle (deg) 2.0 6.5 1.7 9.8 0.3 0.890 –4.2 4.8
Lower face % –0.3 2.4 –0.6 2.2 0.3 0.654 –1.0 1.6
Upper lip protrusion (mm) –1.2 1.4 –0.2 1.2 –1.0 0.013 –1.7 –0.2
Mandibular sulcus (deg) –3.5 4.5 1.0 2.0 –4.5 0.000 –6.6 –2.3
Lower lip protrusion (mm) 0.1 1.5 0.3 1.1 –0.2 0.449 –1.1 0.5
SNA (deg) –0.3 2.0 1.2 1.5 –1.5 0.005 –2.4 –0.4
SNB (deg) 0.7 1.6 1.4 1.0 –0.7 0.051 –1.5 0.0
ANB (deg) –0.8 2.6 –0.3 1.5 –0.5 0.400 –1.6 0.7
Wits (mm) 0.1 0.0 –0.9 0.7 1.0 0.000 0.7 1.3
SN to GoGn (deg) 0.3 1.8 1.0 1.7 –0.7 0.130 –1.7 0.2
Upper Inc. to Pal. Pl. (deg) 2.2 0.4 1.7 2.9 0.5 0.375 –0.8 2.0
Lower Inc. to Mand. Pl. (deg) –1.5 5.7 –0.2 3.9 –1.3 0.325 –4.0 1.3

the nasolabial angle in the treated group with respect to the con-
trol group (–4.4°) was reported also by Arman et  al. (11,12) and
Moshelkosha et  al. (8) who confirmed that a forward movement
of upper lip and nose occurred during maxillary protraction. The
Class III concave profile became more balanced, with the upper lip
area becoming more marked. In this study, also the position of lower
lip changed significantly. The treated group showed a significant con-
trol of lower lip protrusion when compared with the control group
in the long-term observation (–1.1  mm). This effect could have
occurred as a result of the improvement in the sagittal position of
the mandible that has been described also in other studies (24,25).
The treated group exhibited a significant decrease of the mandibular
sulcus contour angle in the T1–T3 intervals (–10.3°) probably as a
result of adaptation of the soft tissue to the changes in mandibular
sagittal position. In a recent longitudinal study, Bergman (23) ana-
lyzed cephalometric profile traits between the ages of 6 and 18 years
to assess soft tissue changes that occurred over time. In agreement
with our results, the author concluded that the mandibular sulcus
contour angle showed a tendency to decrease in size with growth.
Regarding the lower face percentage, no significant differences were
found between treated and control group (–0.1 per cent) due to a
good control of vertical skeletal relationships during orthopaedic
treatment. The use of bite blocks during the treatment combined
with the correct downward inclination of the extraoral elastics of
the facial mask might have accounted for the lack of an increase in
the vertical skeletal relationships in the treated group (SN to GoGn
–1.4°).
Interestingly enough, all the favourable profile changes were
produced mainly during the active phase with the FMP (Table 5),
and they remained stable during the post-treatment period (Table
6). Several statistically significant profile changes could be observed
immediately after the FMP (T1–T2 interval, Table 5) in terms of
improvement of facial profile (profile facial angle –4.4°, nasolabial
angle –4.6°, upper lip protrusion +1.7 mm, mandibular sulcus –5.8°,
6 European Journal of Orthodontics, 2019
and lower lip protrusion –0.8  mm). Some changes, however, were
not statistically different during T2–T3 interval between treated and
control group (Table 6). In particular, the profile facial angle (–1.6°),
13. Jacobson, A. (1976) Application of the “Wits” appraisal. American Jour-
the nasolabial angle (0.3°), and the lower lip protrusion (–0.2 mm)
showed a similar trend in the two groups.
The results of the current investigation, though interesting, need
to be corroborated by similar studies conducted on larger samples
of treated and control subjects at the end of growth, possibly with a
randomized controlled trial design.
Conclusion
The FMP induced positive effects on soft tissue facial profile with
a good stability when re-evaluated at a post-pubertal stage. In par-
ticular, the treated group showed a significant improvement of the
Class  III concave profile that was associated with favourable soft-
tissue changes at the lower third of the face.
Conflict of Interest
The authors certify that they have no affiliations with or involvement in any
organization or entity with any financial interest or non-financial interest in
the subject matter or materials discussed in this article.
References
1. Auconi, P., Scazzocchio, M., Cozza, P., McNamara, J.A., Jr and Franchi, L.
(2015) Prediction of Class  III treatment outcomes through orthodontic
data mining. European Journal of Orthodontics, 37, 257–267.
2. Pavoni,  C., Mucedero,  M., Baccetti,  T., Franchi,  L., Polimeni,  A. and
Cozza,  P. (2009) The effects of facial mask/bite block therapy with or
without rapid palatal expansion. Progress in Orthodontics, 10, 20–28.
3. Toffol,  L.D., Pavoni,  C., Baccetti,  T., Franchi,  L. and Cozza,  P. (2008)
Orthopedic treatment outcomes in Class  III malocclusion. A  systematic
review. The Angle Orthodontist, 78, 561–573.
4. Franchi, L., Baccetti, T. and McNamara, J.A. (2004) Postpubertal assess-
ment of treatment timing for maxillary expansion and protraction therapy
followed by fixed appliances. American Journal of Orthodontics and
Dentofacial Orthopedics, 126, 555–568.
5. Sunnak,  R., Johal,  A. and Fleming,  P.S. (2015) Is orthodontics prior to
11  years of age evidence-based? A  systematic review and meta-analysis.
Journal of Dentistry, 43, 477–486.
6. Liu, Z., McGrath, C. and Hägg, U. (2009) The impact of malocclusion/
orthodontic treatment need on the quality of life. A systematic review. The
Angle Orthodontist, 79, 585–591.
7. Kiliçoglu  H, Kirliç  Y. (1998) Profile changes in patients with class  III
malocclusions after Delaire mask therapy. American Journal of Orthodon-
tics and Dentofacial Orthopedics, 113: 453–462.
8. Moshkelgosha, V., Raoof, A., Sardarian, A. and Salehi, P. (2017) Photo-
grammetric comparison of facial soft tissue profile before and after pro-
traction facemask therapy in Class III children (6–11 years old). Journal of
Dentistry (Shiraz, Iran), 18, 7–16.
9. Kilic,  N., Catal,  G., Kiki,  A. and Oktay,  H. (2010) Soft tissue profile
changes following maxillary protraction in Class  III subjects. European
Journal of Orthodontics, 32, 419–424.
10. Ngan, P., Hägg, U., Yiu, C., Merwin, D. and Wei, S.H. (1996) Soft tissue
and dentoskeletal profile changes associated with maxillary expansion and
protraction headgear treatment. American Journal of Orthodontics and
Dentofacial Orthopedics, 109, 38–49.
11. Arman, A., Toygar, T.U. and Abuhijleh, E. (2004) Profile changes associ-
ated with different orthopedic treatment approaches in Class III malocclu-
sions. The Angle Orthodontist, 74, 733–740.
12. Arman, A., Ufuk Toygar, T. and Abuhijleh, E. (2006) Evaluation of maxil-
lary protraction and fixed appliance therapy in Class  III patients. Euro-
pean Journal of Orthodontics, 28, 383–392.
nal of Orthodontics, 70, 179–189.
14. Baccetti T., Franchi L, McNamara J.A., Jr. (2005) The cervical vertebral
maturation (CVM) method for the assessment of optimal treatment timing
Downloaded from https://academic.oup.com/ejo/advance-article-abstract/doi/10.1093/ejo/cjz003/5379693 by Goldsmiths College user on 14 March 2019
in dentofacial orthopedics. Seminars in Orthodontics, 11, 119–129.
15. Alexander, A.E., McNamara, J.A., Jr, Franchi, L. and Baccetti, T. (2009)
Semilongitudinal cephalometric study of craniofacial growth in untreated
Class III malocclusion. American Journal of Orthodontics and Dentofacial
Orthopedics, 135, 700.e1–14; discussion 700.
16. Foersch, M., Jacobs, C., Wriedt, S., Hechtner, M. and Wehrbein, H. (2015)
Effectiveness of maxillary protraction using facemask with or without
maxillary expansion: a systematic review and meta-analysis. Clinical Oral
Investigations, 19, 1181–1192.
17. Zhang, W., Qu, H.C., Yu, M. and Zhang, Y. (2015) The effects of maxil-
lary protraction with or without rapid maxillary expansion and age fac-
tors in treating Class  III malocclusion: a meta-analysis. PLoS One, 10,
e0130096.
18. Tanne, K., Hiraga, J. and Sakuda, M. (1989) Effects of directions of maxil-
lary protraction forces on biomechanical changes in craniofacial complex.
European Journal of Orthodontics, 11, 382–391.
19. Pavoni,  C., Masucci,  C., Cerroni,  S., Franchi,  L. and Cozza,  P. (2015)
Short-term effects produced by rapid maxillary expansion and facemask
therapy in Class III patients with different vertical skeletal relationships.
The Angle Orthodontist, 85, 927–933.
20. Cozza P, Baccetti T, Mucedero M, Pavoni C, Franchi L. (2010) Treatment
and posttreatment effects of a facial mask combined with a bite-block
appliance in Class  III malocclusion. American Journal of Orthodontics
and Dentofacial Orthopedics, 138, 300–310.
21. Bergman,  R.T., Waschak,  J., Borzabadi-Farahani,  A. and Murphy,  N.C.
(2014) Longitudinal study of cephalometric soft tissue profile traits
between the ages of 6 and 18 years. The Angle Orthodontist, 84, 48–55.
22. Springate, S.D. (2012) The effect of sample size and bias on the reliability
of estimates of error: a comparative study of Dahlberg’s formula. Euro-
pean Journal of Orthodontics, 34, 158–163.
23. Bergman, R.T. (1999) Cephalometric soft tissue facial analysis. American
Journal of Orthodontics and Dentofacial Orthopedics, 116, 373–389.
24. Franchi, L., Pavoni, C., Cerroni, S. and Cozza, P. (2014) Thin-plate spline
analysis of mandibular morphological changes induced by early class III
treatment: a long-term evaluation. European Journal of Orthodontics, 36,
425–430.
25. Masucci, C., Franchi, L., Defraia, E., Mucedero, M., Cozza, P. and Bac-
cetti, T. (2011) Stability of rapid maxillary expansion and facemask ther-
apy: a long-term controlled study. American Journal of Orthodontics and
Dentofacial Orthopedics, 140, 493–500.
26. Westwood,  P.V., McNamara,  J.A., Jr, Baccetti,  T., Franchi,  L. and
Sarver,  D.M. (2003) Long-term effects of Class  III treatment with rapid
maxillary expansion and facemask therapy followed by fixed appliances.
American Journal of Orthodontics and Dentofacial Orthopedics, 123,
306–320.
27. Pangrazio-Kulbersh V, Berger JL, Janisse FN, Bayirli B. (2007) Long-term
stability of Class  III treatment: rapid palatal expansion and protraction
facemask vs LeFort I maxillary advancement osteotomy. American Journal
of Orthodontics and Dentofacial Orthopedics, 131, 7.e9–719.
28. Baccetti,  T., Franchi,  L. and McNamara,  J.A., Jr. (2000) Treatment and
posttreatment craniofacial changes after rapid maxillary expansion and
facemask therapy. American Journal of Orthodontics and Dentofacial
Orthopedics, 118, 404–413.
29. Jamilian,  A., Cannavale,  R., Piancino,  M.G., Eslami,  S. and Perillo,  L.
(2016) Methodological quality and outcome of systematic reviews report-
ing on orthopaedic treatment for class III malocclusion: overview of sys-
tematic reviews. Journal of Orthodontics, 43, 102–120.