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 efficacy 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)
T
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 influence mandibular growth and the possibility of
separating maxillary sutural attachments, treatment
has shifted to the maxillary protraction paradigm. More-
over, 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, first mo-
lars, and left first premolar. There were carious lesions
on the mesial aspects of the maxillary lateral incisors
and white decalcification 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 Conflicts 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 Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.01.027
252
had gingival inflammation. The probable cause of her
malocclusion was a combination of genetic and devel-
opmental factors.
The patient had a straight profile 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 compe-
tent 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 flat maxillary incisal edges not running along the
lower lip curvature (Fig 1).
Intraorally, she had an Angle Class I molar relation-
ship and an anterior edge-to-edge bite. There was ante-
rior 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 deficiencies were
10.5 mm in the maxillary arch and 6.5 mm in the
mandibular arch. The transpalatal arch width at the first
molars was 31.1 mm, which was smaller than the average
normal width of 35.4 mm.1 The maxillary left first pre-
molar and first 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
Sabri
Fig 1. Pretreatment facial and intraoral photographs (age 12 years 8 months).
mandibular incisors were upright, and the soft-tissue
analysis confirmed 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.
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 deficiency
needed to be corrected and the uprighted maxillary
and mandibular incisors proclined to improve lip sup-
port. The skeletal Class III anteroposterior relationship
also had to be addressed to help correct the anterior
edge-to-edge bite and enhance the facial profile and
American Journal of Orthodontics and Dentofacial Orthopedics
253
smile esthetics. Addressing the transverse maxillary
arch deficiency would help achieve an optimal posterior
intercuspation.
TREATMENT ALTERNATIVES
Three treatment options were considered.
1. Extraction of 4 first premolars to reposition the
blocked-out canines. The 2 main advantages of
this treatment option are the efficiency to resolve
the severe arch-length deficiency and the possible
long-term stability of tooth alignment. Neverthe-
less, a 4-premolar extraction treatment would not
address the upright incisors and the lip retrusion,
and might even worsen the profile.
2. Extraction of the maxillary first premolars. This
would address the arch-length deficiency that was
more severe in the maxillary arch, with a less adverse
effect on the profile than would extraction of 4 pre-
molars. Class III elastics would help correct the
February 2015  Vol 147  Issue 2
254
Fig 2. Pretreatment dental casts.
Fig 3. Pretreatment panoramic radiograph.
anterior edge bite and finish in a Class II molar rela-
tionship. However, the facial and smile esthetics
would not be optimized.
3. Nonextraction with rapid maxillary expansion
(RME) and maxillary protraction facemask treat-
ment. The arch-length deficiency 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 profile
and the smile esthetics by increasing incisor display.
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Sabri
However, this treatment plan relies on patient
cooperation and might have questionable long-
term 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
A tissue-borne appliance with bands attached to the
first premolars and first 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 first molars (Fig 5). Central
incisor separation and an occlusal radiograph
confirmed 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 first premolar brackets on the RME to the
horizontal outer bow of the facemask in a 30 down-
ward and forward direction, delivering 450 g of force
per side for 12 to 14 hours per day (Fig 7, A). The face-
mask 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 first molar bands with
a palatal wire and a labial wire with soldered elastic
Sabri 255

Table I. Cephalometric summary

Before After 5 years
Measurement Norm treatment treatment posttreatment
Skeletal
SNA ( ) 82 77 77 78
SNB ( ) 80 77 77 77
ANB ( ) 2 0 0 1
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 discon-
tinued. 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 fixed appliance treatment.
Retention consisted of a maxillary Hawley-type
removable appliance worn full time for 24 months, fol-
lowed 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 fixed
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 first
molar-to-first molar transverse dental projection in a
posed smile was obtained (Fig 8). Intraorally, the severe
arch-length deficiencies were eliminated in both arches
with proclination of the anterior teeth and transverse
maxillary arch expansion. The transpalatal first molar

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
256
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 maxil-
lary canines were seated in Class I, and the buccal occlu-
sion 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 decalcification spots mainly
at the gingival levels of the mandibular left premolars
and first 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
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tipped on the left side (Fig 10); these molars were
extracted later. The posttreatment cephalometric radio-
graph and the superimposed tracings showed even
downward and forward facial growth. The improvement
of the skeletal Class III was confirmed by a 5-mm reduc-
tion of the Wits appraisal and the favorable profile
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 maxil-
lary and mandibular incisors were proclined labially.
As expected with facemask treatment, the maxillary first
molars moved slightly downward and forward. There
was good vertical control with no change in the mandib-
ular 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 fixed
appliance removal showed excellent stability of the
treatment results. The profile maintained a mild convex-
ity 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 stabil-
ity was exceptional 2 years after the removable maxillary
retainer was discontinued. Tooth alignment, optimal
overbite and overjet, well-interdigitated buccal occlu-
sion, 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
Sabri
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 radio-
graphs 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 profile. There was no facial
growth at 5 years posttreatment except for minor resid-
ual growth at the symphysis (Figs 16 and 17).
The final 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 spontane-
ously and remained out of occlusion at 5 years post-
treatment. Excursion movements do not reflect
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 benefits of any future interven-
tion should be properly weighed. Alignment of the
second molars with segmental mechanics to control
the vertical and lingual seating can be achieved. How-
ever, 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 prob-
ably be the likely approaches to achieve a more
American Journal of Orthodontics and Dentofacial Orthopedics
257
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 profiles than our customary cephalo-
metric standards has favored a return toward nonex-
traction treatment.11-14 The 2 most commonly cited
reasons for extraction today are crowding and profile
considerations.15 The treatment decision for this
patient was challenging because she had a “nonextrac-
tion profile” and an arch-length deficiency that justified
extractions. To avoid compromising her facial esthetics,
she was treated without extractions by increasing the
arch perimeters anteroposteriorly and laterally. Howev-
er, 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 fixed appliance (3 years), which allowed
enough time for muscle adaptation. Optimal tooth
interdigitation, prolonged retention, and the absence
February 2015  Vol 147  Issue 2
258 Sabri

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

deficiency of 10.5 mm, 5 mm were gained from RME

Table II. Arch-width measurements (mm)
and the remaining 5.5 mm from incisor proclination
Arch Maxillary Mandibular (3 mm labially). RME can also be beneficial in the
Records date T1 T2 T3 T1 T2 T3
treatment of Class III malocclusions, particularly
3-3 31.1 24.6 24.4 20.7 20.1 20.1 borderline cases.21 An assessment of the maxilla after
4-4 21.7 27.5 27.3 23.3 25.9 25.1 RME with cone-beam computed tomography has
5-5 28.7 33.2 32.7 28.6 29.6 29.0 shown significant displacement of the bones of the
6-6 31.1 36.5 36.6 35.0 34.8 34.6 circummaxillary suture in growing children with an
T1, Pretreatment; T2, posttreatment; T3, 5 years posttreatment; 3, overall movement of the maxilla downward and for-
canine; 4, first premolar; 5, second premolar; 6, first molar. ward.22 Similar effects with forward and downward
rotation of Point A, backward movement of Point B,
of late mandibular growth were also responsible for and clockwise rotation of the mandible have also
long-term stability.17 been found in animal studies.23
RME has been shown to increase the perimeter of These effects with RME can also improve the soft-
the maxillary arch and can provide space to correct tissue profile by increasing its convexity.24 Inevitably,
moderate (3-4 mm) crowding.18,19 An average there are side effects with RME such as an increase in
increase in arch perimeter of 4.7 mm for an average the vertical dimension, which did not affect this patient
molar expansion of 6.5 mm has been reported.19,20 with an open-bite tendency. In fact, in a study of the
To correct the pretreatment maxillary arch-length long-term effects of RME, the authors found that the

February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Sabri 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 accompa-
nied 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 Fig 11. Posttreatment cephalometric radiograph and
likely in younger children, whereas mostly dental tracing.

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
260 Sabri

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.

February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Sabri 261

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 facili-
tate the orthopedic effect of the facemask by disrupt-
ing 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 radio-
graph.
The combined effect of RME and facemask treatment
was also instrumental in reestablishing the major com-
ponents of a balanced smile for this patient, whose
main concern was her unpleasant smile.35 The down-
ward 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

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
262
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 asso-
ciated with Class III malocclusions. RME and maxillary
protraction also helped fill the lateral negative spaces
or buccal corridors by bringing a wider portion of the
maxillary arch forward to fill the intercommissure space
with a first molar-to-first molar smile.36 The smile arc
was also changed from flat 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 pro-
traction 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 or-
thopedic effects. This finding 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 iden-
tification of such characteristics.
The successful expansion with midpalatal suture
opening enhanced the orthopedic effect of the facemask
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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 addi-
tional challenge was met by the long-term stability of
the treatment results despite anteroposterior and lateral
arch expansion with nonextraction treatment dictated
by profile considerations.
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