Seminars in Orthodontics 29 (2023) 194−203

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Seminars in Orthodontics
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The evolution of maxillary protraction techniques in the early management

of Class III malocclusion
Sarah Abu Arqub a,*, Niloufar Azami b, Dalya Al-Moghrabi c
a
Clinical Assistant Professor, Department of Orthodontics, University of Florida, Gainesville, Florida
b
Clinical Assistant Professor, Division of Orthodontics, Department of Craniofacial Sciences, University of Connecticut Health, Farmington, Connecticut
c
Assistant Professor, Department of Preventive Dental Sciences, College of Dentistry, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Appliances and techniques prescribed in the early management of Class III malocclusion have varied throughout
Early treatment the years. Earlier, tooth-anchored protraction facemask therapy was prescribed to correct the skeletal maxillary
Class III malocclusion deficiency associated with Class III malocclusion. More recently, bone-anchored mechanism for maxillary protrac-
Protraction
tion has been introduced and it has been used in conjunction with the conventional facemask or Class III elastics.
Tooth anchored
bone anchored
Proponents of orthopedic treatment highlight the importance of early treatment and improvement of the skeletal
discrepancy which, in turn, would minimize the severity of future dental compensation, establish proper occlusal
function, possibly eliminate the need for orthognathic surgery, and provide pleasing esthetics. Therefore, this arti-
cle revisits the various protraction protocols (tooth-borne) vs bone-anchored) used in the early management of
Class III patients. Its main focus is to describe the efficacy of timely intervention of the different protraction
techniques.

Introduction modalities are: tooth-borne and bone-anchored protraction facemask,

Early treatment of Class III malocclusion continues to pose a chal-
lenge for clinicians due to the highly unpredictable and variable clinical
outcomes and treatment duration. Many factors have been correlated to
the success of early treatment for Class III patients including: age,1 sex,2
compliance level,3 severity of malocclusion,4 timing of the interven-
tion,5 and the questionable long-term prognosis due to the limited abil-
ity to accurately predict growth.6
The early correction of the anterior cross bite associated with a func-
tional shift (pseudo Class III) has been long proven to be successfully
treated. Dental correction can be achieved in the mixed dentition stage
with a sectional fixed or a removable appliance.7 This treatment
approach is considered relatively stable in cases where growth is favor-
able.7 On the other hand, in the presence of a skeletal discrepancy,
growth modification of either jaw comes into play. Depending on the
diagnosed skeletal discrepancy (maxillary deficiency or mandibular
overgrowth), the appropriate orthopedic appliance is often selected.
Despite the multifactorial etiology related to hereditary and environ-
mental components of Class III malocclusion,8 evidence has shown that
approximately 50% of subjects with Class III malocclusion exhibit maxil-
lary deficiency with a normal or prognathic mandible.9 Therefore, max-
illary protraction treatment modalities were adopted in early treatment
of Class III malocclusion. Among the common protraction treatment
and bone-anchored maxillary protraction (BAMP) (Fig. 1).
Skeletal changes induced by various tooth-borne protraction proto-
cols are more favorable when treatment is implemented in the early
mixed dentition rather than in the late mixed dentition stage.10-12 This
is related to the fact that circum-maxillary sutures are still non-fused
during the juvenile years, and begin to fuse at later stages of develop-
ment.13 Bacceti et al. were the first to indicate the efficacy of a bonded
expander with a facemask in the early rather than in the late mixed
dentition stage.14 They indicated that disarticulation from the ptery-
goid process was feasible in the infantile and juvenile periods.14 How-
ever, in patients over 10 years old, the sutures become more
interdigitated and it becomes less likely to achieve the desired skeletal
outcomes with a protraction tooth-borne facemask.15 Therefore, max-
illary protraction with the use of bone anchors has been suggested as
an alternative to facemask therapy in the late mixed and/or permanent
dentition stage.16-19 De Clerck et al compared treatment effects of
bone-anchored maxillary protraction with miniplates in patients aged
11 years to a matched control group.20 They noticed significant poste-
rior relocation of the condyle and marked improvement in the jaw
relationship and midface deficiency in the treatment group.20 Yet, a
recent systematic review indicated that the available evidence to sup-
port the maxillary advancement effects after BAMP is limited and long
term data is needed.16 Therefore, this article revisits the various

* Corresponding author.
E-mail addresses: sabuarqub@ufl.edu (S. Abu Arqub), Azami@uchc.edu (N. Azami), dhalmoghrabi@pnu.edu.sa (D. Al-Moghrabi).

https://doi.org/10.1053/j.sodo.2023.05.004

1073-8746/© 2023 Elsevier Inc. All rights reserved.

S. Abu Arqub et al.
Fig. 1. The evolution of the maxillary protraction techniques. EO: extraoral; IO: intraoral; Mn: mandibular; Mx: maxillary; RPE: rapid palatal expander.
*Osseointegrated dental implants or onplants were previously used.
protraction protocols (tooth-borne vs bone-anchored) in the early
management of Class III patients, and focuses mainly on the efficacy of
the timely intervention of the different protraction techniques.
Growth prediction in class III patients
Mandibular growth prediction remains a challenge in early Class III
treatment.21 Ngan suggested the use of serial cephalograms taken a cou-
ple of years apart following facemask therapy to calculate the ratio
between the horizontal growth changes of the maxilla to that of the
mandible, to predict future mandibular growth.22 The rationale was
based on that a single radiograph can be used to predict growth with
only 70% of accuracy.22 Others relied on certain cephalometric variables
such as the position of the mandible, ramal length, and the gonial angle
to predict successful outcomes for early Class III orthopedic treatment.23
Shullhoff et al. compared some morphological characteristics (molar
relationship, cranial deflection, porion location, and ramus positions) of
Class III patients with the norm to predict the expected growth.24
Numerous studies related to identification of appropriate predictors for
Class III growth have been published.25-27 Yet, consensus is lacking with
regard to the reliability of these predictors.28
Despite the above-mentioned challenges encountered with early
interventions in Class III malocclusion and the frequent observed relapse
irrespective of treatment modality.26,27 Proponents of orthopedic treat-
ment stressed on the benefits of correcting the skeletal discrepancy at an
early stage. This helps minimize the dental compensation, aid in estab-
lishing proper occlusal function, further, avoid the need for future
orthognathic surgery and achieve pleasing esthetics.22
Protraction headgear − facemask
Facemask therapy of various designs 10-12 has been commonly used
as an early treatment modality for maxillary protraction in Class III mal-
occlusion. A downward and forward pull of 30° from the occlusal plane,
via elastics attached to an adjustable anterior wire, adjacent to the max-
illary canines is often recommended to lessen the tipping of the palatal
plane.29 The required force for protraction ranges between 300 to 600
grams/ side, and patients are instructed to wear the appliance for
12 hours/day, which requires high level of compliance.29 Compliance
with protraction facemask therapy is an issue. A systematic review found
a mean discrepancy of five hours/day between the required wear time of
extraoral appliances and the objectively measured values using micro-
electronic sensors.30 Furthermore, these appliances caused skin irrita-
tion in 43.5% of patients.31
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Seminars in Orthodontics 29 (2023) 194−203
Biomechanics and efficacy of facemask
From a biomechanical perspective, the center of resistance of the
maxillary arch was found to be located distal to the maxillary first
molars, bisecting the distance between the inferior border of the
orbit to the functional occlusal plane. If the line of force for protrac-
tion passes below the center of resistance, a counterclockwise rota-
tion for the maxilla will be produced, which can be unfavorable for
patients with open bite tendency.32 Moreover, several studies have
indicated that the maximum maxillary protraction can only be
achieved when facemask therapy is initiated in the early mixed or
primary dentition, close to the time of eruption of maxillary
incisors,21,22,33,34 after which the circum-maxillary sutures become
heavily interdigitated.33 Therefore, the closer Class III patients to
puberty, other treatment alternatives should be considered.
Maxillary expansion in conjunction with facemask therapy
Rapid palatal expansion (RPE) is commonly used in conjunction with
protraction facemask therapy to optimize skeletal correction. The
expander is often activated twice daily (0.25 mm/turn) for around one
week, and if the maxillary arch was severely constricted, activation can
be continued for 2 weeks.29 However, a recent systematic review found
minimal difference in maxillary skeletal correction between protraction
facemask therapy used with or without RPE.35 Furthermore, the evi-
dence is weak in support of the minor skeletal benefits associated with
using alternating rapid maxillary expansion and constriction (Alt-
RAMEC) when compared to RPE in conjunction with protraction face-
mask.36 However, the long-term stability of the former is unclear.
The efficacy of the tooth-borne protraction facemask therapy in con-
junction with a rapid maxillary expander (RPE) was mainly observed
short term.30,37 In a multicenter randomized controlled trial (RCT), the
use of protraction facemask therapy obviated the need for orthognathic
surgery in 64% of the patients compared to 34% in the control group.34
This was assessed based on the consensus of a panel of experts.34 Fur-
thermore, positive overjet was achieved following the use of protraction
facemask therapy in 70% of the patients at 15-months and 3-years fol-
low-up. This was sustained at 6-years follow-up.15,34,38 However, in the
same RCT, occlusal and skeletal improvements showed limited sustain-
ability at 6-year follow-up, with no significant differences between the
groups.34 In terms of patient-reported outcomes, there was no difference
in self-esteem and psychological outcomes in patients undergoing face-
mask therapy at 6-year follow-up.34 Therefore, it seems that the out-
comes achieved from facemask therapy are mainly dentoalveolar.
S. Abu Arqub et al.
Bone-anchored protraction facemask
The bone-anchored protraction facemask system has been intro-
duced to help achieve maximum skeletal effects, especially in older age
groups. The protocol for using the different modalities of bone-anchored
protraction facemask involves the application of heavy orthopedic forces
400-500 gm /side via extraoral elastics directed at 30°downwards and
anterior to the maxillary occlusal plane. Patients are required to wear
the appliance 14-16 hours daily. In some occasions, occlusal biteplates
might be used to eliminate any interferences in the incisor region.
Evolution of bone-anchored protraction facemask
Bone-anchored protraction facemask modalities have evolved from
relying on ankylosed teeth to the use of osseointegrated implants,
onplants and recently the use of miniplates and miniscrews. The idea of
bone-anchored protraction came into view in 1985 when Kokich et al.
applied an anterior protraction force to ankylosed primary maxillary
canines that acted as natural implants in a patient with Apert syn-
drome.39 After 12 months of treatment, the maxilla was protracted by
around 4mm, little mandibular growth was observed, and the ankylosed
teeth were stable.39 Due to the limitations associated with the resorption
of the anchor teeth, and the restricted time associated with the presence
of primary teeth to be used as anchors, the Branemark-type osseointe-
grated titanium implants placed in the zygomatic bone were examined
as anchor units for protraction in Macaca nemestrina monkeys40 8 mm
of maxillary advancement was observed after the application of 600 g/
side.40 This monkeys’ experimental model led researchers to investigate
the use of osseointegrated implants for protraction in humans. Singer et
al. illustrated the use of these osseointegrated implants as a method to
obtain an attachment for the protraction force in the maxilla.41 Their
implants were placed in the inferior aspect of the zygomatic process of
the maxilla, customized abutments were attached to the implants after 6
months of osseointegration. Orthodontic bands were fitted after another
2 months following osseointegration, to allow for soft tissue healing. A
Petit facemask was fitted afterwards and 400 gm of force was applied to
the abutments at an angle of 30° to the occlusal plane.41 Their results
showed that the maxilla was displaced 4 mm horizontally and vertically,
and significant improvement in the midface esthetics was noticed.41
It should be noted that placement of the implants in the alveolar
bone must be avoided in actively growing individuals due to the contin-
uous vertical alveolar development.41 Therefore, extra alveolar sites
such as the infrazygomatic region or anterior part of the palate are more
suitable for implant placement in growing subjects undergoing
protraction.41,42 Further, the use of palatal onplant was suggested as an
anchor for protraction with a facemask. Onplants use, eliminated the
possible risks of damaging the roots of adjacent teeth and penetration of
the nasal floor.43 Hong et al. illustrated the efficacy of maxillary protrac-
tion with onplants in a patient with significant maxillary hypoplasia.43
However the risks associated with the use of osseointegrated implants
and/or onplants include soft tissue irritation, failure of osseointegration,
in addition to the need of a waiting period prior to loading the implant/
onplant, which can delay treatment.44 In 2008, Kircelli and Pektas pro-
posed the use of facemask with miniplates placed in the nasal wall of the
maxilla, ahead of the center of resistance and anterior to the sutural
complex that joins the maxilla to the base of the skull.45 Six subjects
were treated in their report; their mean age was 11.8 years. The mean
achieved advancement of the maxilla at point “A” was 4.8 mm in an
average protraction duration of 10 months.45 Significant movement of
the infraorbital region was noticed. These effects were well maintained
during the follow up period of 15 months.45
Later, Zhou et al. proposed a different zone between the maxillary
lateral incisors and canines as a point for anchorage.46 In their case
report, miniplates were placed in that area in an 11.7-year-old patient
with skeletal Class III malocclusion, the patient was subjected to gradu-
ally progressing protraction forces. Initially 450 g per side was applied,
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Seminars in Orthodontics 29 (2023) 194−203
then gradually increased to 500-600 g one month after the start of trac-
tion. Wits appraisal was significantly reduced and minimal increase in
the maxillary incisal and mandibular plane angles was noticed.46 It was
not until 2011 when Cha et al. suggested the placement of the miniplates
for protraction in the maxillary zygomatic process.47 Their rationale was
based on the adequate quality of bone in that region, safe zone; away
from the roots of adjacent teeth and the proximity to the center of resis-
tance for the nasomaxillary complex allowing the vector for the protrac-
tion force to pass in close proximity to the center of resistance of the
nasomaxillary complex. Maxillary protraction started two weeks after
placement of the miniplates, with a force of 300cN per side, applied 12
to 14 hours per day.47 Despite the immediate loading for the miniplates
and their effectiveness in protraction, an invasive surgical procedure is
often required. Therefore, the hybrid Hyrax rapid palatal expander
(RPE) appliance was introduced, where 2 miniscrews are placed in the
palate, an expander is connected to these miniscrews and the first
molars. After expansion, the patient undergoes protraction therapy with
a conventional facemask.48
Advantages of bone-anchored protraction facemask
The extrusion of the maxillary posterior teeth and the downward
movement of the posterior maxilla with the use of the conventional
tooth-borne facemask often lead to downward and backward rotation of
the mandible.49 This can worsen the open bite tendency in hyperdiver-
gent patients, therefore, the tooth-borne facemask is not recommended
in high angle facial types.50-52 Attempts to eliminate this side effect by
changing the point of force application has failed.53,54 On the other
hand, the control of the mandibular rotation with the bone-anchored
protraction facemask has been reported.55,56 In a recent study that eval-
uated the effects of the bone-anchored facemask on the vertical skeletal
pattern, closure of the mandibular plane was reported in the high angle
group.57 The same study reported that bone-anchored facemask showed
greater changes than tooth-borne facemask in young subjects (CNM 3),
and was more successful at the later stages of development.57 Similarly
the Hybrid Hyrax bone-anchored RPE reduced the dentoalveolar side
effects associated with the conventional tooth-borne facemask.19 Despite
the above-mentioned advantages of the bone-anchored facemask ther-
apy, the associated autorotation of the mandible and the dentoalveolar
side effects are inevitable.58 Furthermore, outstanding compliance with
extra-oral appliance wear is essential for treatment success.30 To over-
come these limitations, bone-anchored maxillary protraction (BAMP)
with intermaxillary elastics has been introduced.17
Introduction of bone-anchored maxillary protraction (BAMP) with
intermaxillary elastics
Over the past decade, skeletally anchored maxillary protraction has
become the treatment of choice in patients with Class III malocclusion.59
Different protocols have been introduced that harness the orthopedic
effects of the appliance59 including bone-anchored facemask described
earlier. Another approach described by De Clerck et al.,17,18 is the bone-
anchored maxillary protraction (BAMP), which eliminates the use of an
extra-oral appliance and involves the use of four modified miniplates
(Bollard, Tita-Link, Brussels, Belgium) as anchorage; two are placed in
the infra-zygomatic crest of the maxillary buttress, and another two are
inserted between mandibular lateral incisors and canines, secured with
2-3 miniscrews paired with intermaxillary elastics.17,18 The intraoral
attachment arm of the plates passes through the mucogingival junction.
The loading is usually initiated about three weeks after surgery, and
150 g of force on each side is applied using elastics in the Class III direc-
tion. The patient is instructed to wear the elastics full time. The force is
increased up to 200 g after one month and to 250 g after three months.20
A removable bite plate could be used to eliminate any occlusal interfer-
ences and jump the bite during treatment.18 BAMP has been shown to
present significant orthopedic changes without using an extra-oral
S. Abu Arqub et al. Seminars in Orthodontics 29 (2023) 194−203

Fig. 2. Case 1. A 13-year-old patient presented with Class III malocclusion due to skeletal discrepancy, and slight mandibular asymmetry to the right. (A-C) extraoral
photos displaying the Class III malocclusion due to maxillary deficiency and mandibular prognathism. (D-H) Intraoral photos depicting the dental Class III malocclusion
with mandibular midline deviation to the left side, mild proclination of the upper incisors, and normal inclination of the lower incisors.

Fig. 3. Case 1. 6 months after maxillary and mandibular miniplate insertion and the use of Class III intermaxillary. (A-C) extraoral photographs illustrating the
improvement in the facial profile. (D-F) intraoral photographs illustrating edge-to-edge incisal relationship.

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S. Abu Arqub et al.
Fig. 4. Case 1. Posttreatment cephalometric superimposition indicating the significant forward movement of the maxilla without significant displacement of the chin.
appliance, therefore, it is less reliant on patients’ compliance.20 The min-
iplates have been shown to be well tolerated by patients, compared to
other dental procedures; patients considered miniplates better than
extractions and associated the placement procedure with minimal peri-
operative pain and discomfort.60 In addition, the intraoral attachments
of the miniplates can be used for anchorage purposes during orthodontic
treatment.60 This provides flexibility and versatility for implementing
different mechanics.60
|Reported advantages and drawbacks of BAMP
The reported success rate of miniplates varies between 93-100
percent, and the main reported reasons for failure were mobility,
cheek ulceration, fracture, and undesirable position of the mini
plates.59 The failure rate of the miniplates placed for BAMP in
young patients is usually higher than the ones used for anchorage
purposes in adult patients.61 The high failure rate may be explained
by the shallow alveolar height, the less available attached gingiva,
and the longer duration of utilizing mini-plates in younger Class III
patients, which can sometimes last until late adolescence. However,
the success rate of miniplates is still higher than miniscrews.61 Con-
sidering their minimal dental side effects, the use of BAMP is con-
sidered an effective alternative to traditional facemask for the early
orthopedic correction of Class III patients.61
However, the main drawback of miniplates is the need to wait until
late mixed dentition to initiate treatment. This is because mandibular
miniplate need to be placed after the eruption of the lower canines to
avoid root damage. Moreover, the increased interdigitation of the cir-
cum-maxillary sutures could affect the BAMP’s treatment outcomes neg-
atively.62 The surgical risks associated with the flap surgery required for
the insertion and removal of the miniplates, and their higher cost com-
pared to miniscrews are additional drawbacks.63
Efficacy of BAMP
Earlier studies evaluating the effects of BAMP treatment utilized 2-
dimensional (2D) data from lateral cephalometric analysis.59 A recent
meta-analysis evaluating the difference in Wits values between BAMP
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Seminars in Orthodontics 29 (2023) 194−203
group and a control group (no treatment) showed significant effects of
nearly 7 mm in the former group.60 However, it is worth mentioning
that only a modest effect size of 0.6 mm of Wits increase in the BAMP
group over the traditional facemask (active control) was shown in this
meta-analysis.60 Vertically, BAMP treatment resulted in a mild reduction
of about 2 degrees in the mandibular plane and palatal plane angles rela-
tive to the cranial base; the maintenance or slight reduction of the ante-
rior facial height associated with BAMP is an advantage in Class III
patients with vertical (hyperdivergent) growth pattern.60
Dentally, BAMP treatment resulted in a slight proclination of lower
incisors (nearly 1.3 degrees); considering the common retroclination
effect of conventional or bone-anchored protraction facemask treatment
on lower incisors, BAMP treatment shows better control of the lower
incisors’ position.58 Moreover, compared to conventional facemask,
BAMP produces less proclination of maxillary incisors.60
The use of clear aligners with BAMP
Fig. 2 illustrates the orthopedic treatment of a 13-year-old male
patient Class III malocclusion due to a combination of maxillary retro-
gnathism and mandibular prognathism, with mild mandibular asymme-
try to the left side. Intraorally, the patient had bilateral Class III molar
relationship, mandibular midline deviation to the left side, mild procli-
nation of his upper incisors, and normal inclination of the lower incisors.
BAMP treatment using Stryker TM Skeletal Anchorage System (Stryker
Corporation, MI, USA) was planned (2 maxillary and 2 mandibular mini-
plates were inserted and the use of Class III intermaxillary elastics was
initiated); the patient achieved edge-to-edge incisal relationship after
six months of treatment (Fig. 3). Later, 11 months after BAMP treatment,
a positive overjet was achieved and orthodontic treatment was initiated
using Invisalign TM clear aligners. The total treatment duration was 20
months. The miniplates were maintained until the patient reached late
adolescence. The cephalometric superimposition showed significant
maxillary advancement without significant forward displacement of the
chin (Fig. 4). The regional superimposition of the mandible revealed a
slight backward swing of the ramus with 4 degrees closure of the gonial
angle. The inclination of both maxillary and mandibular incisors was
maintained during the treatment (Figs. 4 and 5).
S. Abu Arqub et al. Seminars in Orthodontics 29 (2023) 194−203

Fig. 5. Case 1. Posttreatment outcomes following the use of BAMP and clear aligner treatment (total treatment duration: 20 months).

Fig. 6. Case 2. Initial photographs of an 11-year-old patient with cleft lip and palate whom had previous orthopedic treatment with facemask at age 9.
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S. Abu Arqub et al.
Fig. 7. Case 2. Progress extraoral and intraoral photographs taken on follow-up visits after debond. The patient was 18 years old illustrating balanced facial profile and
corrected malocclusion with positive overjet and overbite.
Orthopedic effects of BAMP
The more recent 3D imaging methods, along with surface registra-
tion on the anterior cranial base as a reference, provided more accurate
quantitative assessment regarding the treatment outcomes and the
nature of the orthopedic effects of BAMP.64 In a three-dimensional study
assessing the effects of BAMP, Nguyen et al.18 reported a mean of
3.7 mm (range of 1.45 to 8.5 mm) forward displacement of the maxilla
after one year of treatment. The treatment effect was evident in the mid-
face with an average of 3.60- and 3.76-mm advancement in the right
and left zygomas, respectively.18 As previously described by Heymann
et al.65 due to the proximity of the miniplates to the zygomaticomaxil-
lary sutures, the applied force would be closer to the zygomatic and
infraorbital areas, which results in more significant changes compared
to the conventional facemask treatment. The positive changes were also
evident in the soft tissues, although significant variation was noticed
between individuals.65 The upper lip was advanced 3.98 mm forward,
and the nose was displaced 3.82mm forward.65
In another study, Nguyen et al.66 quantified the surface changes of
the mandible in growing patients treated using BAMP. They described
that patients treated with BAMP exhibit a swing-back effect of the man-
dible due to a distal inclination of the ramus combined with the closure
of the gonial angle and a counterclockwise rotation of the mandible.
This effect restricted the forward displacement of the chin, which is
favorable in the orthopedic treatment of Class III patients with mandibu-
lar prognathism and vertical growth pattern.67
BAMP is associated with lesser compliance requirements compared
to the use of facemask, making it more convenient to continue the use of
intraoral elastics until late adolescence. However, miniplates should be
removed when the mandibular growth is ceased. The issue with leaving
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Seminars in Orthodontics 29 (2023) 194−203
the miniplates in situ long term, is the possibility of bone apposition
over the plates, hence, the difficulty of their removal.68
The use of BAMP in cleft lip and palate patients
Maxillary deficiency in transverse and anteroposterior dimensions in
patients with cleft lip and palate results from both inherited growth defi-
ciencies and the post-surgical scar tissue following surgical repair. The
maxillary growth impediment progressively increases until the end of
growth.69,70 Figs. 6 and 7 show BAMP treatment in an 11-year-old male
patient with cleft lip and palate. The patient had Class III malocclusion
with significant maxillary retrusion and vertically directed growth pattern.
The patient underwent early orthopedic treatment at the age of 9 using
protraction facemask. A positive overjet was achieved after one year of
treatment with limited improvement in the soft tissue profile, therefore,
BAMP treatment was offered. BAMP treatment involved placement of Bol-
lard miniplates (Tita-Link, Brussels, Belgium) followed by full-time intrao-
ral Cass III elastic wear for one year. The patient was then instructed to
continue elastic wear part-time until the age of 18. The final results
showed a more balanced soft tissue profile with improved maxillary and
malar projection (Fig. 7). BAMP treatment in this patient eliminated the
need for orthognathic surgery. However, it is important to note that
between 20% to 76.5% of patients with unilateral or bilateral cleft lip and
palate will eventually need orthognathic surgery.71
Randomized controlled trials (RCTs) that evaluated the effects of
various maxillary protraction protocols
Table 1 summarizes the various RCTs that have been conducted with
regard to early protraction protocols for Class III patients. Mandall et

Table 1
Summary of the randomized controlled trials that evaluated the effects of various maxillary protraction protocols.
Study Treatment groups
Mandall et al. 201015 FM with RPE (n= 35; mean age:
8.7±0.9 y)
Control (n= 38; mean age: 9±0.8 y)
Mandall et al. 201238 FM with RPE (n= 35; mean age:
8.7±0.9 y)
Control (n= 38; mean age: 9±0.8 y)
Mandall et al. 201634 FM with RPE (n= 35; mean age:
8.7±0.9 y)
Control (n= 38; mean age: 9±0.8 y)
Vaughn et al 200572 FM with RPE (n= 15; mean age:
7.4±0.5 y)
FM (n= 14; mean age: 8.1±0.5 y)
201
Control (n= 17; mean age: 6.6±0.5 y)
Liu et al 201573 FM with RPE (n= 21; mean age: 9.81±
1.72 y)
FM with alternating expansion (n=
22; mean age: 10.11± 1.44 y)
Seiryu et al 202074 FM (n= 20; mean age: 10±1 y)
FM with miniscrew(n= 19; mean age:
11±1 y)
Liang et al. 202175 Bone-anchored protraction FM (using
miniplates) with RPE (n= 20; mean
age: 10.75 ± 1.3 y)
FM with RPE (n= 21; mean age: 10.5 ±
1.1 y)
Miranda et al. 202176 Miniscrew anchored protraction (Mx
202277, 202378 and Mn miniscrews) with RPE
(n=20; mean age: 10.7±0.9y)
Miniscrew anchored protraction (Mn
miniscrews) with RPE (n= 15; mean
age: 11.5 ±1.2 y)
FM: facemask; Mn: mandibular; Mx: maxillary; PAR: Peer Assessment Rating; RPE: rapid palatal expansion; TMJ: temporomandibular joint; y: year(s).
Duration of the study/treatment
15 months
3 y follow-up
6 y follow-up
Treatment duration: 1.15-1.16 y
FM with RME group :11.19 ± 2.75
months
FM with alternating expansion:
10.95 ± 2.73 months
Average treatment duration: 1 y and
9 months
Treatment duration: 10.6-12.1
months
Average treatment duration:
11 months
S. Abu Arqub et al.
Outcomes assessed Summary of findings
Dentofacial changes (lateral cephalograms and study models) FM group:
- SNA: +1.4° forward, SNB: - 0.7° backward; ANB: +2.1 ° Improved.
- Overjet: + 4.4 mm, Improved
Occlusal changes (PAR index) FM group: 32.2% improvement in PAR
Self-esteem (Piers−Harris children’s self-concept scale) No improvement in self-esteem
Psychosocial impact of malocclusion with an oral aesthetic sub- Reduced impact of malocclusion for FM group
jective impact scores (OASIS) questionnaire
TMJ signs and symptoms No TMJ dysfunction in both groups
Dentofacial changes (lateral cephalograms and study models) FM group:
- SNA: +2.3° forward, SNB: +0.8° forward, ANB: + 1.5° improved
- Overjet: +3.6, improved
Occlusal changes (PAR index) FM group: 21% improvement in PAR
Self-esteem (Piers−Harris children’s self-concept scale) No significant improvement in self esteem
Psychosocial impact of malocclusion with an oral aesthetic sub- No significant difference in terms of impact of malocclusion between
jective impact scores (OASIS) questionnaire groups
TMJ signs and symptoms No TMJ dysfunction
Need for orthognathic surgery FM group: 36%
Control: 66%
Changes in skeletal pattern FM: clockwise rotation of maxilla and mandible
Control: anticlockwise rotation of maxilla and mandible
Changes in overjet FM: 68% positive overjet
Occlusal changes PAR No difference between groups
Self-esteem No difference between groups
Oral esthetic impact of malocclusion No difference between groups
Skeletal and dental cephalometric variables No significant differences between the FM groups in measured skeletal
and dental cephalometric variables
Significant treatment effects in FM groups compared to controls:
- 2 mm forward Mx movement
- Counterclockwise Mx rotation
- Mn clockwise rotation
- Post movement B point 1.5 mm
- Forward movement Mx dentition 1 mm
Mx forward movement FM with RPE: 3.04 mm
FM with alternating expansion: 2.11 mm
Changes in other cephalometric measurements Counterclockwise rotation palatal plane:
FM with RPE= 1.73°, FM with alternating expansion =0.83°
Downward and backward mandibular rotation smaller in FM with
alternating expansion group
Treatment duration FM with RPE average protraction time: 10.84 months
FM with alternating expansion average protraction time: 9.06
months
Dental and skeletal changes SNA, SN-ANS, ANB values were significantly increased in the FM with
miniscrew group compared with FM group (SNA, 1.18 SN-ANS, 1.38
ANB, 0.88)
Increase in proclination of Mx incisors in the FM group (U1-SN, 5.08°)
Seminars in Orthodontics 29 (2023) 194−203
Success rate of miniscrew use No mobility or looseness of miniscrew were reported
Dental and skeletal changes CBCT Bone-anchored protraction FM with RPE:
- Greater forward Mx movement
- Greater increase Mx length
- Less rotations in the palatal and Mn planes
- Less proclination of Mx incisors
- Less retroclination of Mn incisors
- Less extrusion of Mx molars
Overjet correction Group 1: 94.4%, group 2: 71.4%
Molar mesialization Group 2: greater mesial movement of molars
Skeletal sagittal changes - Similar skeletal sagittal and vertical changes between both groups
- Similar increase in Mx length
Upper airway space changes No differences between groups
Pain and discomfort Similar levels of pain and discomfort
S. Abu Arqub et al.
al.15,34,38 have illustrated the short and long term dentofacial changes
associated with the use of tooth-anchored protraction facemask. It seems
that some relapse was noticed following the initial dentofacial improve-
ment (3 years post-treatment).38 Yet, some favorable effects were main-
tained and the need for orthognathic surgery was reduced.34
The effects of protraction with or without expansion was experimented by
Vaughn et al.,72 whom illustrated the similar efficacy in terms of skeletal and
dental changes in both protraction protocols. Changing the expansion proto-
cols with protraction therapy has been studied by Liu et al, whom found a lim-
ited added benefit of more efficient protraction effects using the alternating
palatal expansion and constriction with a facemask.73 Seiryu et al investigated
the effects of palatal miniscrews with facemask therapy to facilitate the deliv-
ery of more consistent forces to the maxillary complex.74 They found that the
use of palatal miniscrews with facemask was associated with superior skeletal
correction and fewer dental side effects when compared to facemask alone as
a result.74 Furthermore, another RCT assessed the efficacy of utilizing custom-
ized miniplates for protraction, have shown positive effects on maxillary
advancement, less dental side effects and minimal mandibular and maxillary
plane rotations.75 Finally, the clinical trial by Miranda et al. aimed at compar-
ing the dentoskeletal efficacy between the miniscrew anchored protraction
hybrid Hyrax and the conventional Hyrax.76 Similar skeletal effects were
observed between both groups, and greater control of the mesial displace-
ment for the maxillary first molar was noticed in the Hybrid Hyrax group.76
With regard to effects on airway77 and pain levels78 no significant differences
were observed between the treatment groups.
Conclusion
This article highlights the various options for maxillary protraction
therapies implemented in the early intervention for Class III patients.
There is some evidence that supports the use of early protraction for
Class III patients using both conventional and bone-anchored techni-
ques. Their dentofacial and soft tissue effects have been proved short
term. Although the skeletal and soft tissue efficacy of protraction has
greatly improved with the use of miniplates as anchors, more random-
ized clinical trials are needed to evaluate the long-term stability of the
achieved outcomes.
Patient consent
Patient consent was obtained.
Funding
No funding or grant support.
Author contributions
All authors attest that they meet the current ICMJE criteria for
Authorship.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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