Rom J Morphol Embryol 2019, 60(2):605–615

RJME
ORIGINAL PAPER Romanian Journal of
Morphology & Embryology
http://www.rjme.ro/

Correction of Class III malocclusions through morphological

changes of the maxilla using the protraction face mask by
three different therapeutic approaches
LUMINIŢA LIGIA VAIDA1), ABEL EMANUEL MOCA1), BIANCA MARIA NEGRUŢIU1), ALEXANDRU IOSIF PRECUP1),
BOGDAN ANDREI BUMBU1), IOANA SCROBOTĂ1), SIMION BRAN2)
1)
Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea,
Romania
2)
Department of Oral Rehabilitation, “Iuliu Haţieganu” University of Medicine and Pharmacy,
Cluj-Napoca, Romania

Abstract
Face mask (FM) therapy used for maxillary protraction improves the facial profile in patients with Class III malocclusion. The aim of this
study was to compare the sagittal morphological changes of the maxilla through three different therapeutic approaches, respectively using
removable appliances (RA), rapid maxillary expansion (RME) and surgically assisted rapid maxillary expansion (SARME), each of them in
combination with the FM therapy in growing and non-growing patients. The sample, consisting of 42 orthodontic patients aged 7–21, was
divided into four groups, according to their age. The first group of patients, aged 6–9 (RA + FM group), received treatment with RA in
combination with FM, the second group of patients, aged 10–13 (RME + FM pubertal group), received treatment with RME in combination
with FM, the third group of patients, aged 14–16 (RME + FM postpubertal group), received treatment with RME and FM, and the fourth group
of patients, aged 17–21 (SARME + FM group), underwent SARME in combination with FM. To assess the sagittal skeletal changes of the
maxilla, the sella–nasion–A point (SNA) and A point–nasion–B point (ANB) angles were measured at the beginning and after the FM therapy.
The differences in the evolution of the SNA angle between the groups were statistically significant (p<0.001). Post-hoc analysis showed
that patients aged 6–9 had the highest evolution, statistically higher than patients aged 14–16 (p=0.007) or patients aged 17–21 (p<0.001).
The evolution of the SNA angle was significantly higher in patients aged 10–13, in comparison to patients aged 17–21 (p<0.001). The efficiency
of the FM therapy alone or associated with RME depends on patients’ growing period. In non-growing patients, the FM therapy is efficient
when associated with SARME.
Keywords: Class III malocclusion, face mask therapy, rapid maxillary expansion, surgically assisted.

 Introduction problems, poor self-esteem and other psychological variables

The global prevalence of Class III malocclusion
reported in the literature ranges from 0% to 26.7% for
different populations. Prevalence rates of 15.69–16.59%
were reported for the Southeast Asian countries (China
and Malaysia). For Japan, the prevalence rate was around
14%. In Caucasians, prevalence ranged from 3% to 5% [1].
Prevalence rates of 2% to 6% and ~5% have been found
in European and Latin populations, respectively [2].
Class III skeletal malocclusions imply not only
mandibular prognathism (mandibular skeletal excess), as
it was considered in the past, but very often a maxillary
deficiency [3–6]. Thus, Class III skeletal malocclusions
may consist of maxillary retrognathism, mandibular
prognathism, or a combination of both, along with several
dento-alveolar and soft tissue compensations expressed
in various morphological manners [7–9]. According to
Pattanaik & Mishra (2016), there are various combinations
for the occurrence of such malocclusions: mandibular
prognathism – 20%, maxillary retrusion – 25%, a combi-
nation of the two – 22%, remainder – no antero-posterior
skeletal imbalances [10].
Depending on the severity of facial aesthetics alterations,
Class III patients experience dento-maxillary functional
disturbances, periodontal problems [11], psychological
– stress, anxiety, coping, current thoughts related to
themselves with implications for the quality of life [12–14].
Considering these aspects, the treatment plan for Class III
malocclusions should address the skeletal regions that
have been altered and should be conducted in complete
dependency on the skeletal maturation, the timing of the
treatment, being therefore, of utmost importance [15].
Literature offers many therapeutic methods for Class III
malocclusion. Correction of the skeletal maxillary deficiency
may be obtained using various devices with an orthopedic
effect: face mask (FM)/orthopedic mask [8, 16], protraction
headgear/reverse headgear, chin cup, reverse twin-block,
skeletal anchorage systems [17]. All these orthopedic
appliances are effective in ameliorating the skeletal
maxillary deficiency in growing patients. However, many
studies show that the effects depend largely on the timing
of the treatment: the earlier the treatment is applied, the
more pronounced the orthopedic effects on the maxillary
growth are (orthopedic effect) and the dental changes
(orthodontic effect), often unwanted, are diminished
[18–21]. Disadvantages of early treatment are related to
the difficulty of collaboration with the patient and the
need for long-term follow-up of the patient, throughout
the entire growth period, to prevent relapse [8].

ISSN (print) 1220–0522 ISSN (online) 2066–8279

606 Luminiţa Ligia Vaida et al.
For non-growing patients, treatment options include
orthodontic camouflage in mild to moderate Class III
cases and orthognathic surgery (Le Fort I with maxillary
advancement) in moderate to severe cases [8].
Many authors have recommended the use of FMs in
combination with rapid maxillary expansion (RME) in pre-
adolescents and adolescents due to the fact that RME has
the effect of relaxing the maxillary and circummaxillary
suture system, which increases the orthopedic effect of
the FM [22].
The orthognathic surgical treatment is more effective
in correcting skeletal maxillary problems, but it implies
higher risks and greater costs [8]. Therefore, if the FM
treatment in young adults proves to be effective and
the maxillary skeletal correction can be achieved, the
disadvantages of orthodontic camouflage treatments and
orthognathic surgery can be overcome [8].
The aim of this study was to compare the sagittal
morphological changes of the maxilla, which can be
obtained through three different therapeutic approaches,
respectively using removable appliances (RA), RME and
surgically assisted rapid maxillary expansion (SARME),
each of them in combination with FM in growing and
non-growing patients. We have also aimed to analyze
the impact of the FM therapy on the evolution of
mandibular–maxillary skeletal relationships.
 Patients, Materials and Methods
The sample consisted of 42 orthodontic patients, aged
7 to 21, of whom 22 were female patients and 20 were
male patients, who were treated using FM in combination
with RA, RME or SARME. For this retrospective study,
we have used lateral cephalometric radiographs and profile
photostatic examination. Inclusion criteria were: values
for the A point–nasion–B point (ANB) angle less than 0°,
maxillary retrusion evidenced by the sella–nasion–A
point (SNA) angle (less than 80°, normal values being
80±2°), negative overjet, Class III molar relationship,
concave facial profile caused by the retrusion of the
upper lip, narrow maxilla. We excluded subjects with
severe craniofacial skeletal deformities (such as cleft lip
and/or palate, craniofacial syndromes). The study was
conducted in accordance with the World Medical
Association (WMA) Declaration of Helsinki – Ethical
Principles for Medical Research Involving Human Subjects,
approved by the Ethics Committee of the University of
Oradea, Romania. All patients included in the study gave
their consent. For the under-aged patients, a paternal
consent was obtained. All lateral cephalometric radiographs
were taken in the same cephalostat at the beginning of the
treatment (T1) and at the end of the observation period
(T2), after achieving a harmonious facial profile, with
a positive overjet and a Class I molar relationship.
Additionally, the bone age, respectively the skeletal
maturation and pubertal growth of these subjects were
determined using the simplified version of the cervical
vertebral maturation method, as described by Baccetti
et al. (2005), with the patients’ lateral cephalometric
radiographs [23]. Because all the patients from the study
also had a transverse maxillary growth deficiency, the
objectives of the treatment were to correct the sagittal
and transverse arch discrepancies by stimulating the
maxillary growth, to redirect the mandibular growth and
to obtain Class I molar and canine relationships with
correct overbite and overjet.
The sample was divided into four groups, according
to their chronological age and bone age. The first group
included 12 patients aged 6 to 9 (6 years old to 9 years
and 11 months old), the second group included 12 patients
(pubertal group) aged 10 to 13 (10 years old to 13 years
and 11 months old), the third group included 10 patients
(postpubertal group) aged 14 to 16 (14 years old to 16 years
and 11 months old), and the fourth group included 10
patients aged 17 to 21. The first group of patients (RA +
FM group) received treatment with RA in combination
with FM for 3–6 months, the second group of patients
(RME + FM pubertal group) received treatment with
RME in combination with FM for 3–8 months, the third
group of patients received treatment with RME and FM
for 3–8 months, and the fourth group of patients (SARME
+ FM group) underwent SARME in combination with
FM for 4–12 weeks.
All patients in the study received indications for
wearing FM as to correct the canine and molar occlusal
relationships, to obtain an overjet within normal range
and a harmonious facial profile with correction of the
lip relationship.
The RA that were used for the first group of patients
consisted of acrylic palatal plates provided with stainless
steel hooks to anchor the extra oral elastics to the FM.
RME was achieved using a Hyrax expander, including
bands that were compatible with the permanent maxillary
first molars and premolars. Additionally, two stainless steel
wire hooks were welded at the molar bands and extended
mesial to the maxillary canine to apply extraoral elastics
to the FM. After cementation, the Hyrax screw was
activated twice a day (0.25 mm per turn) until the desired
expansion in the transverse dimension was achieved (for
seven to 21 days). The treatment with FM was initiated
when the diastema appeared in each patient. The RME
appliance was not removed during the FM treatment.
For the fourth group of patients, we used the same
tooth borne RME device described above, but within the
SARME technique.
The elastic force used for the FM was 14 oz, and the
elastic (force vector) orientation was 30–45° below the
occlusal plane so as to produce a forward and clockwise
maxillary movement according to the initial overbite of
the incisors. The first three groups of patients wore the
FM for 12–14 hours a day, and the fourth group wore
the FM for 14–16 hours a day.
To asses the sagittal skeletal changes of the maxilla,
followed by the improvements of the facial profile, the
SNA and ANB angles were measured in T1 and remeasured
in T2 by the same two investigators. The cephalometric
analysis was performed using OnyxCeph [open software
license (OSL), version 62], a computerized decalcation
software.
All the data from the study was analyzed using IBM
Statistical Package for the Social Sciences (SPSS)
Statistics 20. Quantitative variables were tested for normal
distribution using the Shapiro–Wilk test and were written
as averages with standard deviations/mean ranks. Analysis
in paired groups with normal distribution of the variables
 Correction of Class III malocclusions through morphological changes of the maxilla using the protraction… 607
was made using paired samples t-tests. Analysis in paired before (SNA-T1) and after (SNA-T2) treatment were
groups with non-parametric distribution was made using statistically significant (p<0.001), proving a significant
related-samples Wilcoxon signed-rank test. Also, quantitative increase of the SNA angle after treatment (average value
independent variables with non-parametric distribution of increasement = 4.33±0.985°) for patients aged 6–9. An
were tested using Kruskal–Wallis H-test, and afterwards example of clinical case from this age group with the SNA
were used in the post-hoc analysis the Dunn–Bonferroni angle increasing, occlusal relationship and morphological
test. Non-parametric quantitative variables were correlated aspect of profile improvements is presented in Figure 2.
using Spearman’s rho correlations.

 Results
The evolution of the SNA angle post-treatment analyzed
for patients aged 6–9 is represented in Table 1 and Figure 1.
Table 1 – Evolution of the SNA angle post-treatment
analyzed for patients aged 6–9
Parameter Average ± SD p*
SNA-T1 (p=0.245**) 74.33±1.435
<0.001
SNA-T2 (p=0.146**) 78.67±1.073
SNA-T2 – SNA-T1 4.33±0.985 –
SNA: Sella–nasion–A point; T1: At the beginning of the treatment;
T2: At the end of the observation period; SD: Standard deviation;
*Paired samples t-test; **Shapiro–Wilk test.
Figure 1 – Evolution of the SNA angle post-treatment
Distribution was analyzed using the Shapiro–Wilk analyzed for patients aged 6–9. SNA: Sella–nasion–
test, and proved to be parametric (p>0.05). According to A point; T1: At the beginning of the treatment; T2:
the related-samples t-test, differences of the SNA angle At the end of the observation period.

Figure 2 – Group RA + FM patient, 8½ years old, photostatic

examination of frontal and profile view: (a) Before treatment;
(b) During FM treatment; (c) After seven months of FM therapy;
(d) Pre-treatment endo-oral view; (e) After seven months of FM
therapy endo-oral view; (f) Profile evolution during FM therapy.
RA: Removable appliance; FM: Face mask.
608 Luminiţa Ligia Vaida et al.

Table 2 and Figure 3 show the evolution of the SNA aspect of profile were improved is presented in Figure 4.
angle post-treatment analyzed for patients aged 10 to 13.
Table 2 – Evolution of the SNA angle post-treatment
analyzed for patients aged 10–13
Parameter Average ± SD p*
SNA-T1 (p=0.2**) 75.33±1.371
<0.001
SNA-T2 (p=0.259**) 79±1.348
SNA-T2 – SNA-T1 3.67±0.985 –
SNA: Sella–nasion–A point; T1: At the beginning of the treatment;
T2: At the end of the observation period; SD: Standard deviation;
*Paired samples t-test; **Shapiro–Wilk test.

Distribution was analyzed using the Shapiro–Wilk

test, and proved to be parametric (p>0.05). According to
the related-samples t-test, differences of the SNA angle
before and after treatment were statistically significant
(p<0.001) proving a significant increase of the SNA
angle after treatment (average value of increasement = Figure 3 – Evolution of the SNA angle post-treatment
3.67±0.985°) for patients aged 10 to 13. An example of analyzed for patients aged 10–13. SNA: Sella–nasion–
clinical case treated with RME + FM, where the SNA A point; T1: At the beginning of the treatment; T2:
angle increased, occlusal relationship and morphological At the end of the observation period.

Figure 4 – Patient treated with RME + FM, 13 years and 5 months old, photostatic examination: (a) Before treatment;
(b) During FM treatment; (c) After five months of FM therapy; (d) Pre-treatment endo-oral view; (e) After five months
of FM therapy endo-oral view; (f) Profile evolution during FM therapy; (g) Cephalometric analysis before and after
FM therapy. RME: Rapid maxillary expansion; FM: Face mask.
 Correction of Class III malocclusions through morphological changes of the maxilla using the protraction…
For patients aged 14 to 16, the evolution of the SNA
angle post-treatment is highlighted in Table 3 and Figure 5.
Distribution was analyzed using the Shapiro–Wilk test,
and proved to be non-parametric (p=0.033) for the final
measurement of the SNA angle. According to the Wilcoxon
test, differences of the SNA angle before and after treatment
were statistically significant (p=0.003) proving a signifi-
cant increase of the SNA angle after treatment (median
difference = +2°) for patients aged 14–16.
Table 3 – Evolution of the SNA angle post-treatment
analyzed for patients aged 14–16
Parameter Median p*
SNA-T1 (p=0.108**) 76
0.003
SNA-T2 (p=0.033**) 78
SNA-T2 – SNA-T1 2 –
SNA: Sella–nasion–A point; T1: At the beginning of the treatment;
T2: At the end of the observation period; *Related-samples Wilcoxon
signed-rank test; **Shapiro–Wilk test.
Figure 5 – Evolution of the SNA angle post-treatment
analyzed for patients aged 14–16. SNA: Sella–nasion–
A point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
Patients aged 17 to 21 have an alteration of the SNA angle
post-treatment, which is represented in Table 4 and Figure 6.
Figure 7 – Patient treated with SARME + FM, 19 years and 2 months old, photostatic examination: (a) Before treatment;
(b) After 10 weeks of FM therapy; (c) Pre-treatment endo-oral view.
609
Table 4 – Evolution of the SNA angle post-treatment
analyzed for patients aged 17–21
Parameter Average ± SD p*
SNA-T1 (p=0.067**) 77.13±0.835
<0.001
SNA-T2 (p=0.534**) 79±1.195
SNA-T2 – SNA-T1 1.88±0.641 –
SNA: Sella–nasion–A point; T1: At the beginning of the treatment;
T2: At the end of the observation period; SD: Standard deviation;
*Paired samples t-test; **Shapiro–Wilk test.
Figure 6 – Evolution of the SNA angle post-treatment
analyzed for patients aged 17–21. SNA: Sella–nasion–
A point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
Distribution was analyzed using the Shapiro–Wilk
test and proved to be non-parametric (p>0.05). According
to the related-samples t-test, differences of the SNA angle
before and after treatment were statistically significant
(p<0.001) proving a significant increase of the SNA angle
after treatment (average value of increasement = 1.88±
0.641°) for patients aged 17 to 21. An example of clinical
case from treated with FM + SARME, where the SNA
angle increased post-treatment, occlusal relationship
and morphological aspect of profile were improved is
presented in Figure 7.
610 Luminiţa Ligia Vaida et al.

Figure 7 (continued) – Patient treated with SARME + FM, 19 years and 2 months old, photostatic examination:
(d) After 10 weeks of FM therapy endo-oral view; (e) Cephalometric analysis before and after FM therapy; (f) Profile
evolution during FM therapy. SARME: Surgically assisted rapid maxillary expansion; FM: Face mask.

Any alteration of the ANB angle post-treatment for
patients aged 6 to 9 can be observed in Table 5 and
Figure 8. Distribution was analyzed using the Shapiro–
Wilk test, and proved to be parametric (p>0.05). According
to the related-samples t-test, differences of the ANB angle
before and after treatment were statistically significant
(p<0.001), proving a significant increase of the ANB angle
after treatment (average value of increasement = 5.17±
0.835°) for patients aged 6–9. The clinical significance of
the increased value of the ANB angle is represented by
the improvement of the morphological aspect of the facial
profile by rebalancing the dimensional relationships
between the maxilla and the mandible.
Table 5 – Evolution of the ANB angle post-treatment
analyzed for patients aged 6–9
Parameter Average ± SD p*
ANB-T1 (p=0.37**) -3.92±1.443
<0.001
ANB-T2 (p=0.099**) 1.25±0.866
ANB-T2 – ANB-T1 5.17±0.835 – signed-rank test; **Shapiro–Wilk test.
Patients aged 10 to 13 presented an improvement of the
ANB angle post-treatment, which is emphasized in Table 6
and Figure 9. Distribution was analyzed using the Shapiro–
Wilk test, and proved to be non-parametric (p=0.048) for
the final measurement of the ANB angle. According to the
Wilcoxon test, differences of the ANB angle before and
after treatment were statistically significant (p=0.002)
proving a significant increase of the ANB angle after
treatment (median difference = +4°) for patients aged
10–13.
Table 6 – Evolution of the ANB angle post-treatment
analyzed for patients aged 10–13
Parameter Median p*
ANB-T1 (p=0.598**) -3
0.002
ANB-T2 (p=0.048**) 1
ANB-T2 – ANB-T1 4 –
ANB: A point–nasion–B point; T1: At the beginning of the treatment;
T2: At the end of the observation period; *Related-samples Wilcoxon

ANB: A point–nasion–B point; T1: At the beginning of the treatment;

T2: At the end of the observation period; SD: Standard deviation;
*Paired samples t-test; **Shapiro–Wilk test.

Figure 9 – Evolution of the ANB angle post-treatment

Figure 8 – Evolution of the ANB angle post-treatment
analyzed for patients aged 6–9. ANB: A point–nasion–
B point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
analyzed for patients aged 10–13. ANB: A point–nasion–
B point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
Table 7 and Figure 10 underline the evolution of the
ANB angle post-treatment analyzed for patients aged 14 to
 Correction of Class III malocclusions through morphological changes of the maxilla using the protraction…
16. Distribution was analyzed using the Shapiro–Wilk test,
and proved to be non-parametric (p<0.001) for the final
measurement of the ANB angle. According to the Wilcoxon
test, differences of the ANB angle before and after treatment
were statistically significant (p=0.004) proving a signifi-
cant increase of the ANB angle after treatment (median
difference = +2°) for patients aged 14–16.
Table 7 – Evolution of the ANB angle post-treatment
analyzed for patients aged 14–16
Parameter Median p*
ANB-T1 (p=0.149**) -2
0.004
ANB-T2 (p<0.001**) 0
ANB-T2 – ANB-T1 2 –
ANB: A point–nasion–B point; T1: At the beginning of the treatment;
T2: At the end of the observation period; *Related-samples Wilcoxon
signed-rank test; **Shapiro–Wilk test.
611
of the ANB values before and after treatment in patients
according to their age. Distribution was analyzed using the
Shapiro–Wilk test, and proved to be non-parametric in
most of the age groups (p<0.05), also it appeared to be
asymmetrical according to the box-plot figure, as such
reporting of the results will be using the mean rank of the
ANB angle. According to the Kruskal–Wallis H-test, the
differences of the ANB angle evolution between the age
groups were statistically significant (p<0.001). Post-hoc
analysis showed that the highest evolution observed was at
patients aged 6–9 (mean rank ANB = 34.38°), statistically
higher than the evolution observed at patients aged 14–16
(mean rank ANB = 11.75°) (p<0.001) or at patients aged 17–
21 (mean rank ANB = 7.62°) (p<0.001). Also, the evolution
of the ANB angle was significantly higher at patients aged
10–13 (mean rank ANB = 26°) in comparison to patients
aged 14–16 (p=0.032) or patients aged 17–21 (p=0.004).
Table 8 – Evolution of the ANB angle post-treatment
analyzed for patients aged 17–21
Parameter Median p*
ANB-T1 (p=0.037**) -2
0.007
ANB-T2 (p<0.001**) 0
ANB-T2 – ANB-T1 2 –
ANB: A point–nasion–B point; T1: At the beginning of the treatment;
T2: At the end of the observation period; *Related-samples Wilcoxon
signed-rank test; **Shapiro–Wilk test.

Figure 10 – Evolution of the ANB angle post-treatment

analyzed for patients aged 14–16. ANB: A point–nasion–
B point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
Data from Table 8 and Figure 11 represent the
evolution of the ANB angle post-treatment analyzed for
patients aged 17 to 21. Distribution was analyzed using
the Shapiro–Wilk test, and proved to be non-parametric
(p<0.05). According to the Wilcoxon test, differences of
the ANB angle before and after treatment were statistically
significant (p=0.007) proving a significant increase of Figure 11 – Evolution of the ANB angle post-treatment
the ANB angle after treatment (median difference = +2°) analyzed for patients aged 17–21. ANB: A point–nasion–
for patients aged 17–21. B point; T1: At the beginning of the treatment; T2:
At the end of the observation period.
The comparison of the different values of the SNA angle
before and after treatment in patients according to their Table 9 – Comparison of the SNA values before and
age can be observed in Tables 9 and 10, and Figure 12. after treatment in patients according to their age
Distribution was analyzed using the Shapiro–Wilk test, Age groups Average rank – SNA p*
and proved to be non-parametric (p<0.05) in most of the 6–9 years (p=0.053**) 32.17
age groups, also it appeared to be asymmetrical according 10–13 years (p=0.035**) 26.54
to the box-plot figure, as such reporting of the results will <0.001
14–16 years (p<0.001**) 12.75
be using the mean rank of the SNA angle. According to 17–21 years (p=0.037**) 8.88
the Kruskal–Wallis H-test, the differences of the SNA
SNA: Sella–nasion–A point; *Related-samples Wilcoxon signed-rank
angle evolution between the age groups were statistically test; **Shapiro–Wilk test.
significant (p<0.001). Post-hoc analysis showed that the
Table 10 – Post-hoc comparison of the SNA values before
highest evolution observed was at patients aged 6–9 (mean
and after treatment in patients according to their age
rank SNA = 32.17°), statistically higher than the evolution
observed at patients aged 14–16 (mean rank SNA = 12.75°) 6–9 10–13 14–16 17–21
Age groups*
years years years years
(p=0.001) or at patients aged 17–21 (mean rank SNA =
6–9 years – 1 0.001 <0.001
8.88°) (p<0.001). Also, the evolution of the SNA angle
10–13 years 1 – 0.038 0.006
was significantly higher in patients aged 10–13 (mean
rank SNA = 26.54°) in comparison to patients aged 14–16 14–16 years 0.001 0.038 – 1
(p=0.038) or patients aged 17–21 (p=0.006). 17–21 years <0.001 0.006 1 –
Tables 11 and 12, and Figure 13 show the comparison SNA: Sella–nasion–A point; *Related-samples Wilcoxon signed-rank test.
612 Luminiţa Ligia Vaida et al.
Distribution was analyzed using the Shapiro–Wilk test,
and proved to be non-parametric (p<0.05). The association
between the SNA evolution and the ANB evolution in the
studied patients proved to be statistically significant and
highly correlated (p<0.001, R=0.791), data showing that
patients with high differences in the SNA angle after
treatment showed also high differences in the ANB angle
after treatment. These results explain that the values of
the ANB angle increased to normal values following the
wearing of FM as a result of a much greater increase of
the SNA angle compared to the SNB angle.
Table 13 – Correlation between SNA evolution and
ANB evolution
Correlation p*
SNA difference (p=0.001)** ×
<0.001, R=0.791
ANB difference (p=0.006**)
Figure 12 – Comparison of the SNA values before SNA: Sella–nasion–A point; ANB: A point–nasion–B point; *Spearman’s
and after treatment in patients according to their age. rho correlation coefficient; **Shapiro–Wilk test.
SNA: Sella–nasion–A point.
Table 11 – Comparison of the ANB values before
and after treatment in patients according to their age
Age groups Average rank – ANB p*
6–9 years (p=0.03**) 34.38
10–13 years (p=0.003**) 26
<0.001
14–16 years (p=0.172**) 11.75
17–21 years (p<0.001**) 7.62
ANB: A point–nasion–B point; *Related-samples Wilcoxon signed-
rank test; **Shapiro–Wilk test.
Table 12 – Post-hoc comparison of the ANB values
before and after treatment in patients according to
their age
6–9 10–13 14–16 17–21
Age groups*
years years years years
6–9 years – 0.512 <0.001 <0.001
10–13 years 0.512 – 0.032 0.004 Figure 14 – Correlation between SNA evolution and
14–16 years <0.001 0.032 – 1 ANB evolution. SNA: Sella–nasion–A point; ANB:
17–21 years <0.001 0.004 1 – A point–nasion–B point.
ANB: A point–nasion–B point; *Related-samples Wilcoxon signed-
rank test.  Discussions
The morphological changes that occurred on the maxilla
in treated patients consisted both in transversal resize
(using RME, SARME or RA screw activation) as well
as in sagittal elongation obtained by using FM therapy.
Similar to Gencer et al. (2015), our study showed that
FM therapy is the customary choice for most patients in
the late deciduous dentition or early mixed dentition with
Class III malocclusion due to sagittal maxillary deficiency
[24]. This study revealed that FM therapy has maximum
benefits on sagittal changes at the maxilla in patients aged
6 to 9 years (Table 1) and in patients aged 10 to 13 years
(Table 2), if, after the age of 10, FM therapy is associated
with other methods of stimulating the suture growth of
the maxilla. The study also revealed that the use of FM
therapy has good results after the age of 14 (Tables 3
and 4) when bone growth decreases significantly, if FM
Figure 13 – Comparison of the ANB values before therapy is associated with methods of stimulating suture
and after treatment in patients according to their age. growth such as RME or SARME.
ANB: A point–nasion–B point; T1: At the beginning Most authors claim that maxillary protraction is
of the treatment; T2: At the end of the observation
usually conjugated with maxillary expansion to achieve
period.
maxillary disarticulation and to initiate a cellular response,
The correlation between the evolution of the SNA and which allows a more positive reaction to protraction
the ANB angles is represented in Table 13 and Figure 14. forces [25–27]. It is important for the maxillary and
 Correction of Class III malocclusions through morphological changes of the maxilla using the protraction…
peri-maxillary sutures to be active and not synostosized
so that the mask wearing effect manifests on the skeletal
level. During active growth, in childhood, prepubertal and
pubertal period, most of the maxillary and peri-maxillary
sutures are active. Bacettti et al. (2005) described the six
stages, CS1–CS6 (cervical stage 1 to cervical stage 6),
of the maturation of the three cervical vertebrae – C2,
C3, C4. Thus, in our study patients from the first group,
aged 6 to 9 years, were in the CS1 and CS2 stages of
skeletal maturation that corresponded to the prepubertal
period. The patients from the second group, aged 10 to
13 years, were in the stages CS3–CS5 that corresponded
to pubertal period. The patients from the third group, aged
14 to 16 years, were in the stage CS6 that corresponded
to postpubertal period and the fourth group of patients,
aged 17 to 21 years, presented completed growth [23]. This
statement is supported in a previous study conducted by
us on our patients [28]. Some methods that can be used
for the investigation of the appearance of the suture are
the cone-beam computed tomography (CBCT) and the
micro-computed tomography (CT) [29]. The sagittal growth
of the maxilla following the FM in patients aged 6 to
9 years and 10 to 13 years is statistically significantly
higher than after the age of 14 years (Tables 9 and 10).
Even though statistically significant differences were not
obtained between patients aged 6 to 9 years and patients
aged 10 to 13 years, the beneficial effect of mask therapy
on the SNA angle was higher in patients aged 6 to 9 years,
according to the average rank (Table 9). In the group of
patients aged 6 to 9 years, we used palatal plates made
of Orthoplast or Orthoset acrylic resins [30] for the
dilatation of the maxilla in which we extended the acrylic
material of the base plate over the occlusal surfaces of
the lateral teeth (as acrylic blocks) to eliminate occlusal
contacts and to facilitate the growth and the advancement
of the maxilla during the use of FM.
A favorable therapeutic outcome in increasing the
values of the SNA angle was observed even in patients
with complete or almost complete growth, provided that
FM therapy be associated with the SARME technique.
No significant differences of SNA angle variations from
T1 to T2 were observed between the 14–16 years group
and 17–21 years group (Table 10).
This study proved that FM therapy has a favorable
effect on the variations in the mandibular–maxillary
relationship in all age groups studied (Tables 5–8), with
statistically significant improvements in the values of the
ANB angle at the end of the treatment and, respectively,
on the morphological aspect of the facial profile. No
significant differences related to ANB angle variations
were observed between the 6–9 years group and 10–13
years group or the 14–16 years group and 17–21 years
group (Table 12).
The statistically significant positive correlations between
the increase in the value of the SNA angle and the increase
in the value of the ANB angle (Table 13) during treatment
show that FM therapy contributes to the control of the
mandibular growth.
Many studies concluded that dental side effects in
patients treated with FM were more distinct when no
expansion was carried out [31, 32]. We consider that it is
of utmost importance to associate FM therapy with RME
or SARME in postpubertal and non-growing patients.
613
A study on the antero-posterior growth and development
pattern of the maxilla, by means of SNA, SNB and ANB
angles, performed on a Romanian population, showed that,
for the maxilla, 10% of the subjects presented normal
development, 43.33% presented a prognathic maxilla, and
46.66% presented an underdevelopment of the maxilla
[33].
The etiology of Class III malocclusion is multifactorial,
including genetic heredity, hormonal imbalances and
disturbances, such as gigantism or pituitary adenomas,
environmental factors, or often it may be a combination
of these factors [34, 35]. Many factors, such as resting
tongue habits and/or an atypical swallowing pattern,
history of prolonged sucking, mouth breathing, functional
mandibular shifts for respiratory needs, tongue size,
enlarged tonsils, trauma, premature loss of primary teeth
and muscle dysfunction, independently or in combination
with other environmental factors, are common causes of
Class III malocclusions [36, 37]. Most of the patients
included in our study presented muscle imbalances caused
by orofacial dysfunctions (such as tongue behavior) or oral
habits and the interrelation between maxillary constriction
and orofacial dysfunctions is well-known [38, 39]. Thus,
we indicated orofacial myofunctional therapy as an
adjunct to the Class III malocclusion therapy adapted to
the dysfunction of each patient. We consider that obtaining
an orofacial muscular balance facilitates the orthodontic
and orthopedic treatment, and similar to Mason & Franklin
(2009), we consider that, when the cause of the tongue
pattern or other oral habits is not treated, the forward
tongue posture and functions are more likely prone to
relapse, further altering the growth of the maxilla and
mandible [40].
Cha (2003) observed that the effects of maxillary
advancement after FM therapy between the prepubertal
growth peak group and the pubertal growth peak group
revealed no significant difference, unlike the postpubertal
growth peak group, which showed a decrease in maxillary
skeletal advancement [15]. Our findings are similar to
those results.
Vaughn et al. (2005) observed that in a group of
46 children, aged 5 to 10, diagnosed with retrognathic
maxilla, treated with FM in combination or not with
RME, the value of the ANB angle improved by 4° and
the forward displacement of the maxillary complex was
1.5 mm. These results were similar in expansion or non-
expansion patients [31].
In a study performed on a 12-year-old boy diagnosed
with maxillary retrognathia, the authors obtained a maxillary
advancement of 3° using FM and skeletal anchorage
(from initial SNA of 79° to final SNA of 82°) without
RME; in the same case report, the value of the ANB
angle increased by 1° after the FM therapy [41]. In another
study on a 9½-year-old female patient with Class III
malocclusion treated with FM + RME, authors obtained
a 3° increase of the SNA angle (from 79° to 82°) and a
significant change in the maxillo-mandibular relationship,
respectively a 6° improvement in the ANB angle (from
-4° to +2°) [42]. In another case report performed on
12-year-old Class III malocclusion patients treated with
protraction FM anchored on bonded expander to correct
the skeletal relation, the author obtained an increase of
614 Luminiţa Ligia Vaida et al.
the SNA angle by 4° (from 80° to 84°) and an increase
of the ANB angle by 6° (from -4° to +2°) [10]. A similar
increase in the value of the SNA angle (4°) was obtained
by other authors on an 11 years and 5 months old patient
with Class III malocclusion treated with FM [43].
In a study performed by Stocker et al. (2016) [44]
on a 9-year-old patient with Class III malocclusion, the
authors used FM in combination with a modified RME
and constriction protocol, introduced by Liou (2005)
[45]. The authors observed an increase by 4.8° in the
value of the SNA angle (from the initial 73° to 77.8°
post-treatment) [44].
The observed increase in the value of the SNA angle
in the above-mentioned studies was similar or a little bit
lower than the increased mean value of the SNA angle
recorded in our study for the age groups of 6–9 and 10–
13 years but using RME + FM therapy. The increase in
the value of the ANB angle during treatment reported
by the above-mentioned authors was similar or slightly
higher than the value reported by us.
In a study performed on 129 subjects with Class III
malocclusion, divided into six age groups from 7 to
12 years, the authors evaluated the effect of maxillary
protraction and the results showed no statistically signifi-
cant differences concerning the degree of skeletal change
among the groups taken into study [46]. Other authors
examined 30 patients divided into two groups, aged 5 to
8 and 9 to 12, treated with maxillary expansion and
FM and found that cephalometric changes were similar
between the two age groups, meaning that a similar
skeletal response may be found in both early and late
dentition patients [20].
Westwood et al. (2003) performed a long-term study
to compare the growth pattern between 34 prepubertal
patients treated with RME + FM therapy protocol and
the control group. The authors observed that during the
post treatment period, patients from the RME + FM group
and the patients from the control group of Class III
presented a similar growth with unchanged skeletal
relationship between the maxilla and the mandible in the
RME + FM group [47].
A limit of this research is related to the accuracy of the
cephalometric measurements. In orthodontics, a degree
of accuracy less than 2° is considered acceptable [48]. On
the other hand, some differences may be caused by the
difficulty of A-point identification on the lateral cephalo-
gram [49]. However, cephalometric analysis remains one
of the most popular and effective methods for diagnosing
and monitoring skeletal imbalances [50].
 Conclusions
The authors concluded that FM therapy produces
maxillary advancement with maximum efficiency in
patients in prepubertal and in pubertal period when
associated with RME therapy. In patients in postpubertal
period, RME + FM therapy produces a satisfactory
maxillary advancement and in non-growing patients or
in patients at the end of the growth period the FM therapy
may produce a slight maxillary advancement only when
this therapy is associated with SARME.
Conflict of interests
The authors declare that they have no conflict of
interests.
Authors’ contribution
Luminiţa Ligia Vaida and Bianca Maria Negruţiu
equally contributed to the manuscript.
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Corresponding authors
Abel Emanuel Moca, Teaching Assistant, DMD, PhD, Department of Dental Medicine, Faculty of Medicine and
Pharmacy, University of Oradea, 10 1 December Square, 410068 Oradea, Bihor County, Romania; Phone +40746–
662 967, e-mail: abelmoca@yahoo.com
Alexandru Iosif Precup, Teaching Assistant, DMD, PhD, Department of Dental Medicine, Faculty of Medicine and
Pharmacy, University of Oradea, 10 1 December Square, 410068 Oradea, Bihor County, Romania; Phone +40743–
143 120, e-mail: sanduprecup@yahoo.com
Received: March 16, 2019
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Accepted: October 7, 2019