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The effects of facial mask/bite block therapy with or without rapid palatal
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1 Maxillary protraction with or without RME

The effects of facial mask/bite block therapy

with or without rapid palatal expansion

Chiara Pavoni, DDS*, Manuela Mucedero, DDS, MS**, Tiziano Baccetti, DDS, PhD***,
Lorenzo Franchi, DDS, PhD***, Antonella Polimeni, MD, DDS****, Paola Cozza, MD, DDS, MS*****

* Private practice, Rome, Italy

** Research Fellow, Department of Orthodontics, The University of Rome ‘Tor Vergata’, Italy.
*** Assistant Professor, Department of Orthodontics, The University of Florence, Florence, Italy;
Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric Dentistry, School of
Dentistry, The University of Michigan, Ann Arbor.
**** Professor and Head of Department of Paediatrics Dentistry, Univerity of Rome "Sapienza", Italy
***** Professor and Head, Department of Orthodontics, The University of Rome “Tor Vergata”, Rome, Italy.
Correspondence to:
Lorenzo Franchi, DDS, PhD
Dipartimento di Odontostomatologia - Università degli Studi di Firenze
Via del Ponte di Mezzo, 46-48 - 50127, Firenze, Italy
Tel. 011 39 055 354265 - Fax: 011 39 055 321144
E-mail: lorenzo.franchi@unifi.it

Introduction: The aim of this study was to compare the effects of the
Facial Mask in combination with a mandibular bite block (FM/BB) or
with rapid maxillary expansion with a bonded device (RME/FM) in pa-
Introduction
tients with Class III malocclusions. Subjects and methods: The
FM/BB sample included 22 subjects, 12 girls and 10 boys. The ave-
A series of treatment approaches
rage age for the FM/BB group before treatment (T1) was 8.7 ± 1.2
can be found in the literature re-
years, the mean age after active treatment (T2) was 10.4 ± 1.3 years,
garding orthopedic treatment of
and the mean duration of treatment was 1.7 ± 0.8 years. The RME/FM
Class III malocclusions1. To control
sample comprised 17 subjects, 10 girls and 7 boys. The average
the sagittal discrepancy, the use of
ages were 7.8 ± 1.8 years at T1 and 9.3 ± 1.9 years at T2. The mean
the protraction facial mask (FM)
duration of observation was 1.5 ± 0.6 years. Lateral cephalograms we-
with2-5 or without6-10 rapid maxil-
re analyzed at T1 and T2. The T2 to T1 changes in the 2 groups we-
lary expansion (RME) for treating
re compared with an independent sample t-test (p<0.05). Results: The
Class III malocclusions has gained
comparison between the 2 treatment protocols for Class III malocclusion
popularity among clinicians during
showed that there were no significant differences for any measurements
the last 20 years. RME prior to ma-
in either the sagittal or the vertical planes from T1 to T2. Conclusions:
xillary protraction has been used
Facial masks in combination with different types of full-coverage occlusal
by several authors11-13 in patients
splints resulted in very similar dentoskeletal outcomes regardless of the
with Class III malocclusions to cor-
presence or absence of RME. Both the Bite Block appliance and the
rect posterior crossbites and to dis-
splinted RME aided in limiting the posterior rotation of the mandible.
rupt the maxillary sutural system
thus enhancing the orthopedic ef- C Pavoni, M Mucedero, T Baccetti, L Franchi, A Polimeni, P Cozza. The effects
fect of the FM. The benefits of RME of facial mask/bite block therapy with or without rapid palatal expansion. Prog
Orthod 2009;10(1):20-28.

20 PROGRESS in ORTHODONTICS 2009;10(1):20-28

2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 21

Maxillary protraction with or without RME 2

before maxillary protraction are in hyperdivergent subjects with clock- ra25 proposed a bonded maxillary
controversial. Baik14 reported sta- wise rotation of the mandible, since expander with acrylic splints as a “bi-
tistically significant differences bet- they reduce the extrusion of the po- te-block” device in combination with
ween groups with or without RME sterior teeth and allow the autorotation a facial mask for the treatment of
followed by FM with greater for- of the mandible with bite closure. The Class III malocclusions.
ward (1.0 mm) and downward favorable outcomes of BB therapy for The aim of this study was to com-
movement (0.5 mm) at A-point for the control of vertical mandibular pare the dentoskeletal effects of
the expansion group. On the con- growth have been observed both in the FM/BB protocol with those of
trary, a randomized clinical trial experimental animals and in human RME/FM as alternative treatment
by Vaughn et al.15 showed no sta- studies17-21. The control of the vertical protocols in growing patients with
tistically significant differences bet- skeletal relationships is an important Class III malocclusions.
ween groups treated with FM with aspect of orthopedic treatment of
or without RME in any measured Class III malocclusion with FM. It has
cephalometric variable. Similar re- been shown that avoiding backward Subjects and methods
sults were reported in a recent in- rotation of the mandible is crucial to
vestigation by Tortop et al.16. prevent relapse after early orthope- The treated group consisted of 39
Bite-blocks (BB) are generally used to dic Class III treatment22-24. As an ex- subjects (22 female, 17 male) with
produce beneficial therapeutic effects tension of these concepts McNama- Class III malocclusion who were
divided into 2 groups according to
the following treatment protocols:
1. The FM/BB group comprised
22 subjects (12 female, 10 ma-
Introduzione: obbiettivo del lavoro è stato quello di confrontare gli ef-
les) who were treated consecu-
fetti della maschera facciale associata a un bite block inferiore (FM/BB) o
tively with a FM combined with
a un espansore rapido incollato con splints occlusali (RME/FM) in soggetti
con malocclusione di III Classe. Soggetti e metodi: Il gruppo FM/BB a lower removable BB ap-
comprendeva 22 soggetti, 12 femmine e 10 maschi. L’età media del pliance at the Department of
gruppo FM/BB all’inizio del trattamento (T1) era di 8,7 ± 1,2 anni, al ter- Orthodontics of the University
mine della terapia attiva (T2) era di 10,4 ± 1,3 anni e la durata media of Rome “Tor Vergata”;
del trattamento era di 1,7 ± 0,8 anni. Il gruppo RME/FM consisteva di 2. The RME/FM group included
17 soggetti, 10 femmine e 7 maschi. L’età media a T1 era di 7,8 ± 1,8 17 subjects (10 female, 7 ma-
anni, a T2 era di 9,3 ± 1,9 e la durata media del trattamento era di les) who were treated consecu-
1,5 ± 0,6 anni. Le teleradiografie in proiezione latero-laterale sono state tively with a bonded acrylic
analizzate a T1 e a T2. I cambiamenti T1-T2 nei 2 gruppi sono stati con- splint rapid maxillary expander
frontati con il t-test per campioni indipendenti (p < 0,05). Risultati: Il con- followed by FM therapy at the
fronto tra i 2 protocolli per la terapia della malocclusione III Classe ha mo- Department of Orthodontics at
strato che non vi erano differenze statisticamente significative per nessuna the University of Florence.
delle variabili cefalometriche sul piano sagittale o verticale nell’intervallo Success of therapy at the end of
T1-T2. Conclusioni: La maschera facciale utilizzata in combinazione con the observation period was not a
2 diverse tipologie di splints occlusali produceva effetti dento-scheletrici mol- determinant factor for selection of
to simili indipendentemente dalla presenza dell’espansore rapido. Sia il bi- patients.
te block inferiore che l’espansore incollato con splints occlusali determi- At the time of initial observation (T1)
navano un controllo della rotazione posteriore della mandibola.
all patients had Class III malocclusion
Key words: Class III malocclusion, Facial Mask, Byte Block appliance, in the mixed dentition characterized
Rapid Maxillary Expansion. by Wits appraisal of -2 mm or less,

PROGRESS in ORTHODONTICS 2009;10(1):20-28 21

2 PIO09_20-33_Franchi 10-12-2009 9:34
3 Maxillary protraction with or without RME
anterior crossbite or incisor end-to-
end relationship, and Class III molar
relationship. All patients were of
Caucasian origin, and they presen-
ted with a prepubertal stage of ske-
letal maturity according to the cervi-
cal vertebral maturation method
(CS1 or CS2)26. No permanent
teeth were congenitally missing or
extracted before or during treatment.
Lateral cephalograms were taken
before treatment (T1) and at the end
of active treatment (T2). The avera-
ge age of the FM/BB group was
8.7 years ± 1.2 years at T1, and
it was 10.4 years ± 1.3 years at
T2. The mean age of the RME/FM
group was 7.8 years ± 1.8 years
at T1, and it was 9.3 years ± 1.9
years at T2. Mean duration of treat-
ment was 1.7 years ± 0.8 years in
the FM/BB group and 1.5 years ±
0.6 years in the RME/FM group
FM/BB protocol
The intraoral part of the upper ap-
pliance (intraoral anchorage ap-
pliance for postero-anterior elastics
connecting with the facial mask)
was constructed with a 1 mm stain-
less steel arch (buccal and lingual),
with two hooks in the maxillary ca-
nine region to attach the elastics
(Figs 1 and 2). The intraoral ap-
pliance was soldered to bands pla-
ced on the upper first permanent
molars. Maxillary protraction was in-
stituted using forward and down-
ward traction directed approxima-
tely 30 degrees to the occlusal pla-
ne. Extra-oral elastics were attached
from the hooks on the intraoral ap-
pliance to the adjustable crossbar of
22
Pagina 22
Fig. 1 The FM/BB protocol. The intraoral part consisted of a double arch solde-
red to bands on the upper first permanent molars, with hooks in the maxillary ca-
nine region and of a lower removable bite block appliance (lateral view).
FM, so that the elastics did not in- the maxilla. Elastics of increasing
terfere with the function of the lips. force were used during the first
Hooks were soldered in the frontal month of therapy until a heavy or-
part of the upper arch, between the thopedic force (600 g for each si-
lateral incisors and the deciduous de) was delivered during the follo-
canines, in order to obtain a direct wing treatment period. A Delaire
effect of forward displacement of FM (Fig. 3) was used to provide
Introduction: Le but de cette étude était de comparer les effets de la mas-
que faciae en combination avec un bite block mandibulaire (FM/BB) ou
avec une expansion maxillaire rapide avec un dispositif collé (RME/FM)
dans les patients présentant des malocclusions de la classe III. Sujets et
méthodes: L'échantillon de FM/BB a inclus 22 sujets, 12 filles et 10 gar-
çons. L'âge moyenne pour le groupe de FM/BB avant le traitement (T1)
était 8.7 1.2 ans, l'âge moyen après le traitement actif (T2) était l 10.4
1.3 ans, et la durée moyenne du traitement était 1.7 0.8 ans. L'échantil-
lon de RME/FM a comporté 17 sujets, 10 filles et 7 garçons. Les âges mo-
yens étaient de 7.8 l ± 1.8 ans au T1 et 9.3 1.9 ans au T2. La durée mo-
yenne de l'observation était de1.5 0.6 ans. Des cephalograms latéraux ont
été analysés au T1 et au T2. Le T1-T2 changements entre les deux grou-
pes ont été comparés avec un t-test (p<0.05). Résultats: La comparaison
entre les 2 protocoles de traitement pour la malocclusion de la classe III a
prouvé qu'il n'y avait aucune différence significative pour aucune mesure
dans les plans verticaux sagittaux ou du T1 au T2. Conclusions: Les mas-
ques faciaux en combination avec différents types de pleine couverture oc-
clusale ont eu comme conséquence les résultats dentoskelletiques très
semblables indépendamment de la présence ou de l'absence de RME. Le
deux appareils Bite Block appliance et splinted RME ont facilité le traitement
en limitant la rotation postérieure de la mâchoire inférieure.
Traduit par Maria Giacinta Paolone
PROGRESS in ORTHODONTICS 2009;10(1):20-28
2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 23

Maxillary protraction with or without RME 4

Fig. 2 The FM/BB protocol. Occlusal view of the double arch soldered to bands
on the upper first permanent molars.

Fig. 3 The FM/BB protocol. Delaire facial mask for the maxillary protraction.

the extraoral anchorage. The pa- During FM treatment a BB appliance tation. The BB appliance was con-
tients were instructed to wear the was used in all treated patients (Fig. structed in the form of a Schwarz pla-
FM at least 14 hours per day; co- 2), with the aim to counteract any ten- te for the lower arch with occlusal re-
operation was good for all of them. dency to clockwise mandibular ro- sin splints. When indicated additio-
nal components like a vestibular arch
and/or an expansion screw were
Introducción: El objetivo de este estudio fue comparar los efectos de la má-
added. The splints had the goal to
scara facial en combinación con un bloque de mordida mandibular (FM/BB)
combinado, con o sin un dispositivo de expansión rápida del maxilar control for molar eruption, limit inter-
(RME/FM), en pacientes con maloclusión de clase III. Argumento y mé- maxillary divergency, and prevent
todos: En la FM/BB, la muestra incluyó 22 sujetos, 12 niñas y 10 niños. clockwise mandibular rotation. The
La edad media del grupo FM/BB antes del tratamiento (T1) fue de 8,7 ± patients were instructed to wear the
1,2 años, la edad media después de un tratamiento activo (T2) fue de 10,4 BB 24 hours per day, also during
± 1,3 años, y la duración media del tratamiento fue de 1,7 ± 0,8 años. La meals; cooperation was good for
muestra RME/FM incluyó 17 sujetos, 10 niñas y 7 niños. El promedio de all of them.
edades fueron 7,8 ± 1,8 años en T1 y 9,3 ± 1,9 años en T2. La duración
media de la observación fue de 1,5 ± 0,6 años. Se realizo un análisis ce-
falometro en radiografía latero lateral T1 y T2. Los cambios T1 y T2 en los
RME/FM protocol
2 grupos fueron comparados con una muestra independiente prueba t (p
< 0,05). Resultados: La comparación entre los 2 protocolos de tratamiento
de la maloclusión clase III mostraron que no hubo diferencias significativas The treatment protocol in this group
en las medidas observadas. Ya sea desde el punto de vista sagital que ver- included the use of a bonded acry-
tical T1 a T2. Conclusiones: Las máscaras faciales en combinación con lic splint expander before maxil-
los diferentes tipos dispositivos oclusales utilizados dieron resultados dento lary protraction therapy13. Vesti-
esquelétales muy similares, independientemente de la presencia o ausencia bular hooks were present in the
de RME. Tanto el bloque de mordida y el aparato splinted RME, ayudan en RME appliance at the level of the
la limitación de la rotación posterior de la mandíbula. deciduous canines (Figs 4 and 5).
Traducido por Santiago Isaza Penco
Patients were instructed to activate

PROGRESS in ORTHODONTICS 2009;10(1):20-28 23

2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 24

5 Maxillary protraction with or without RME

Fig. 4 The RME/FM protocol. The intraoral part consisted of a bonded acrylic splint
rapid maxillary expander with hooks in the maxillary canine region (lateral view).

Fig. 6 The RME/FM protocol. Petit fa-

cial mask for the maxillary protraction.

mined in this study. The regimen con-

Fig. 5 The RME/FM protocol. Occlusal view of the bonded acrylic splint rapid ma-
xillary expander.
the screw of the expander once
or twice a day until the desired
transverse width was achieved (ie,
the palatal cusps of the maxillary
molar were in contact with the buc-
cal cusps of the mandibular molar).
When the required expansion was
achieved, protraction therapy with
FM (Petit’s design, Fig. 6) followed
immediately, with the same clinical
management as in the FM/BB
group. Cooperation was good for all
patients. No BB appliance was used
in this group during facial mask wear.
All patients in both groups were trea-
ted at least to a positive dental over-
jet before discontinuing treatment;
most patients were overcorrected to-
ward a Class II occlusal relationship.
Cephalometric analysis and
method error
A customized digitation and analysis
were used for all cephalograms exa-
tained measurements from the analy-
ses of Jacobson27, McNamara28,
Ricketts29, Steiner30 and Tweed31.
Before the cephalometric analysis,
the intraobserver measurement error
was evaluated. Fifteen lateral ce-
phalograms, selected from various
subjects in the study, were traced
and measured at 2 times within a
week by the same operator. The
measurements at both times for
each patient were analyzed with
the intraclass coefficient correlation,
which varied from 0.966 for the
SNB angle to 0.995 for the incli-
nation of the maxillary incisor to
the Frankfort horizontal line. These
values indicated a high level of in-
traobserver agreement. Linear mea-
surement errors averaged 0.3 mm
(SD 0.8 mm), and angular measu-
rements averaged 0.4° (SD 0.6°).
Each cephalogram was traced at

24 PROGRESS in ORTHODONTICS 2009;10(1):20-28

2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 25

Maxillary protraction with or without RME 6

Table 1. Comparison of Starting Forms (T1)

Cephalometric Measures FM/BB RME/FM Difference p-value

N=22 N=17
Mean SD Mean SD
Cranial Base
NSBa (°) 128.0 4.9 129.3 5.3 -1.3 0.422
Maxillary Skeletal
SNA (°) 81.5 3.5 78.8 3.3 2.7 0.022*
PtA to Nasion perp (mm) -0.5 2.9 -0.9 2.5 0.4 0.599
Co-Pt A (mm) 76.8 5.5 74.2 4.4 2.6 0.121
Mandibular Skeletal
SNB (°) 81.0 3.4 78.7 3.1 2.3 0.033*
Pog to Nasion perp (mm) -2.0 5.3 -1.9 4.0 -0.1 0.922
Co-Gn (mm) 101.6 6.0 98.5 7.0 3.1 0.144
Maxillary/Mandibular
ANB (°) 0.4 2.0 0.2 1.4 0.2 0.616
WITS (mm) -6.4 2.3 -5.0 2.7 -1.4 0.081
Max/Mand difference (mm) 24.8 2.7 24.3 3.5 0.5 0.600
Vertical Skeletal
FH to occlusal plane (°) 12.1 4.5 10.0 5.1 2.1 0.181
FH to palatal plane (°) -0.7 2.9 -0.9 3.4 0.2 0.843
MPA (°) 26.2 5.8 26.7 4.4 -0.5 0.785
Pal. pl. to mand. pl. (°) 26.9 6.1 27.6 3.9 -0.7 0.697
ANS to Me (mm) 57.3 4.7 56.7 4.3 0.6 0.652
Co-Go (mm) 46.5 4.9 44.4 4.0 2.1 0.157
Gonial Angle (°) 129.1 7.2 130.9 4.1 -1.8 0.374
Interdental
Overjet (mm) 0.6 2.0 -0.3 1.5 0.9 0.135
Overbite (mm) 0.4 1.1 0.1 1.1 0.3 0.539
Interincisal angle (°) 128.1 10.4 139.8 10.0 -11.7 0.001***
Molar relationship (mm) 2.9 1.2 3.6 1.7 -0.7 0.126
Maxillary Dentoalveolar
U1 to Pt A vert (mm) 3.7 2.2 1.7 1.7 2.0 0.004**
U1 to FH 116.4 9.1 109.1 6.6 7.3 0.009**
Mandibular Dentoalveolar
L1 to Pt A Pg (mm) 3.0 2.3 1.3 1.9 1.7 0.022*
L1 to MPA (°) 89.3 5.5 84.4 7.2 4.9 0.021*
Soft Tissue
UL to E plane (mm) -3.3 2.0 -3.6 2.0 0.3 0.660
LL to E plane (mm) -0.5 3.3 -1.4 2.8 0.9 0.387
Nasolabial angle (°) 128.9 10.7 135.1 15.1 -6.2 0.146
*p<0.05; **p<0.01; ***p<0.001;

the 2 time points, and 36 varia-
bles (24 linear and 12 angular)
were measured.
Statistical analysis
Descriptive statistics were calcula-
ted for all the cephalometric mea-
sures in the 2 groups at T1, and for
the T2-T1 changes Comparison of
craniofacial starting forms at T1 bet-
ween the 2 treated groups was per-
formed by means of Hotelling T2
test and independent sample t-test.
The T2-T1 changes were compared
with independent sample t-test. The
power of the study exceeded 0.80.
All statistical computations were
performed with a statistical soft-
ware (Statistical Package for the
Social Sciences, SPSS, Version
12.0, Chicago, USA).
Results
No significant differences were
found between the 2 appliance
groups for any examined cephalo-

PROGRESS in ORTHODONTICS 2009;10(1):20-28 25

2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 26

7 Maxillary protraction with or without RME

Table 1. Comparison of changes during treatment (T1 to T2)

Cephalometric Measures FM/BB RME/FM Difference p-value

N=22 N=17
Mean SD Mean SD
Cranial Base
NSBa (°) 0.1 2.3 -0.6 2.4 0.7 0.353
Maxillary Skeletal
SNA (°) 1.7 2.6 1.4 1.8 0.3 0.658
PtA to Nasion perp (mm) 1.7 3.1 1.0 1.9 0.7 0.414
Co-Pt A (mm) 4.4 3.3 3.2 2.8 1.2 0.256
Mandibular Skeletal
SNB (°) -0.7 2.3 -0.8 2.4 0.1 0.875
Pog to Nasion perp (mm) -0.7 6.2 -1.3 4.3 0.6 0.725
Co-Gn (mm) 4.1 4.1 4.4 3.3 -0.3 0.811
Maxillary/Mandibular
ANB (°) 2.3 1.6 2.1 2.4 0.2 0.748
WITS (mm) 2.2 3.0 0.5 4.3 1.7 0.151
Max/Mand difference (mm) -0.3 2.4 1.2 2.3 -1.5 0.068
Vertical Skeletal
FH to occlusal plane (°) -0.1 4.2 2.7 6.2 -2.8 0.098
FH to palatal plane (°) -1.4 3.3 -0.7 2.5 -0.7 0.445
MPA (°) 0.3 3.5 0.8 3.2 -0.5 0.653
Pal. pl. to mand. pl. (°) 1.7 2.1 1.5 2.9 0.2 0.762
ANS to Me (mm) 4.0 2.8 3.9 3.4 0.1 0.983
Co-Go (mm) 2.6 3.5 2.8 2.8 -0.2 0.832
Gonial Angle (°) -0.2 3.7 -2.0 1.9 1.8 0.078
Interdental
Overjet (mm) 3.0 2.2 3.9 2.5 -0.9 0.235
Overbite (mm) 1.5 1.7 0.6 1.2 0.9 0.054
Interincisal angle (°) 0.3 7.9 -4.2 8.4 4.5 0.093
Molar relationship (mm) -2.6 1.9 -2.5 2.3 -0.1 0.964
Maxillary Dentoalveolar
U1 to Pt A vert (mm) 0.9 1.9 1.9 1.4 -1.0 0.064
U1 to FH -0.7 5.9 2.4 6.3 -3.1 0.132
U1 horizontal (mm) 3.0 2.6 3.5 1.9 -0.5 0.539
U1 vertical (mm) 2.6 1.5 1.5 2.0 1.1 0.071
U6 horizontal (mm) 4.1 2.6 3.8 3.5 0.3 0.765
U6 vertical (mm) 1.8 1.4 0.7 1.7 1.1 0.052
Mandibular Dentoalveolar
L1 to Pt A Pg (mm) -1.3 1.5 -0.9 1.6 -0.4 0.423
L1 to MPA (°) 0.1 6.3 1.1 3.7 -1.0 0.565
L1 horizontal (mm) -0.6 2.5 -0.1 1.7 -0.5 0.449
L1 vertical (mm) 2.6 1.5 1.8 1.2 0.8 0.098
L6 horizontal (mm) 1.0 3.6 1.3 2.5 -0.3 0.725
L6 vertical (mm) 1.9 1.6 1.8 1.6 0.1 0.962
Soft Tissue
UL to E plane (mm) 0.7 1.4 0.7 2.2 0.0 0.999
LL to E plane (mm) -0.1 1.7 -0.4 2.7 0.3 0.649
Nasolabial angle (°) 1.2 10.2 -5.0 14.4 6.2 0.129

metric variable at T1 (Table 1). The were significantly larger in the FM/BB group. Hotelling’s T2 test
only exceptions were the sagittal FM/BB group and the position of on the starting forms, however, in-
maxillary and mandibular angular upper and lower incisors that were dicated that the FM/BB group did
measurements (SNA°, SNB°) that significantly more protruded in the not differ significantly (F=1.856;

26 PROGRESS in ORTHODONTICS 2009;10(1):20-28

2 PIO09_20-33_Franchi 10-12-2009 9:34 Pagina 27
p=0.115) from the RME/FM group
when considering the model of ce-
phalometric variables as a whole.
The comparison of the cephalome-
tric changes from T1 to T2 in the 2
groups revealed no significant dif-
ferences for any of the dentoskele-
tal measurements in either the sa-
gittal or the vertical planes (Table 2).
Discussion
Early treatment of Class III maloc-
clusions during the early mixed den-
tition period has been advocated
to reduce the amount of sagittal dis-
harmony before the completion of
active growth and the need for sur-
gical treatment in adulthood32. The
aim of the current investigation was
to compare the therapeutic chan-
ges of 2 treatment protocols for early
intervention in Class III patients.
The response of the craniofacial
complex to active orthopedic treat-
ment of Class III malocclusion with
the FM/BB and the RME/FM pro-
tocols consisted in similar dento-
skeletal modifications in both the
sagittal and vertical planes.
Both angular and linear sagittal
measurements of the maxilla sho-
wed an anteroposterior advance-
ment of the upper jaw during treat-
ment that ranged from 1.0 mm to
1.7 mm (or degrees), with an im-
provement in Co-PtA of 4.4 mm for
FM/BB therapy and 3.2 mm in
RME/FM. These findings are in
agreement with those reported in
the RCT by Vaughn et al15 who
suggested that expansion does not
aid in the correction of Class III
malocclusions with facemask the-
rapy. Similarly, a recent investiga-
PROGRESS in ORTHODONTICS 2009;10(1):20-28
Maxillary protraction with or without RME 8
tion by Tortop et al.16 compared 2
orthopedic protocols with the FM
(14 subjects were treated with FM
therapy and 14 patients with
FM/RME protocol) and indicated
that increases in Co-PtA or SNA
did not present significant differen-
ces between the treatment groups.
The amount of enhancement of
midfacial length during active treat-
ment was larger in the present study
when compared with previous re-
ports (Co-PtA: FM/BB 4.4 mm;
RME/FM 3.2 mm; Vaughn et al15
without expansion: 2.95 mm; with
expansion 2.98 mm; Tortop et
al16 without expansion 3.1 mm;
with expansion 2.1 mm). This fa-
vorable outcome could be ascri-
bed to the use of the occlusal splints
that facilitated the forward move-
ment of the upper arch, or to the
prolonged time of facial mask wear
in the present study (12-18 months
on average) with respect to other
clinical trials (about 7-12 months).
No significant differences between
the 2 treatment protocols were found
for the changes in the mandible. Ho-
wever, the changes in the mandibu-
lar variables in both treated groups
were generally favorable, with a si-
milar increase in the ANB angle
(FM/BB 2.3 degrees; RME/FM 2.1
degrees). These increases are smaller
than in previous reports15,16. Howe-
ver, it should be noted that in both the
investigations by Vaughn et al.15 and
by Tortop et al.16 a significant in-
crease in the vertical skeletal rela-
tionship of the mandible to the cranial
base took place as a consequence of
orthopedic treatment. The positional
posterior rotation of the mandible may
have contributed to the increased
ANB angle. The posterior mandibu-
lar rotation did not occur in either of
the 2 treatment groups analyzed in
the current study, most probably for
the bite-block effect exerted by either
the bonded RME or the lower BB
appliance. The increase in MPA was
smaller than 1 degree in both groups.
Even not to a statistically significant le-
vel, the RME/FM group showed a
larger amount of closure of the gonial
angle (2 degrees) than the FM/BB
group (0.2 degrees). This trend is in
agreement with the data by Tortop et
al.16. The counterclockwise rotation
of the palatal plane (FH to palatal
plane) that is regarded as an unfa-
vorable treatment outcome of maxil-
lary protraction in Class III malocclu-
sion12 was limited for both treatment
groups, in agreement with previous
observations of the literature15,16
when a downward inclination of the
extraoral elastics was comprised bet-
ween 15 and 30 degrees.
The most notable, even not statisti-
cally significant, differences bet-
ween the 2 treatment protocols per-
tain to the dentoalveolar level. The
FM/BB induced an average im-
provement of the overbite of 1.5
mm; the improvement produced by
the RME/FM was 0.6 mm. In the
FM/BB group this favorable chan-
ge was associated with a consi-
derable amount of palatal inclina-
tion of the maxillary incisors in re-
lation to the Frankfort plane (about
3.1° more than in the RME/FM
group) and with a greater increase
in the interincisal angle (4.5° more
than in the RME/FM group). It must
be emphasized, however, that the
initial amount of protrusion of upper
incisors was more severe in the
FM/BB group before therapy.
The mandibular dentoalveolar mea-
27
 2 PIO09_20-33_Franchi 10-12-2009 9:34
1 Maxillary protraction with or without RME
surements, as well as the soft tissue
measures, did not show any signi-
ficant difference between FM/BB
group and RME/FM group.
Conclusions
This comparison of 2 treatment pro-
tocols for prepubertal orthopedic
treatment of Class III malocclusion re-
vealed that FM/BB and RME/FM
did not show significant differences in
skeletal, dental, and soft tissue ef-
fects in the short term. The effects of
maxillary protraction were not in-
fluenced by the concurrent use of a
RME. When compared with previous
reports that did not include the use of
occlusal splints, the presence of “bi-
te-block” components prevented the
clockwise rotation of the mandible.
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