IP Indian Journal of Orthodontics and Dentofacial Research

Print ISSN: 2581-9356

Online ISSN: 2581-9364


IP Indian Journal of Orthodontics and Dentofacial Research (IJODR) open access, peer-reviewed quarterly journal publishing since 2015 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better more...

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Pooja U, Aravind, Alle, Lokesh NK, and Trivedi: Management of maxillary deficiency in a growing child with facemask therapy and RME- A case report


The etiology of class III malocclusion is multifactorial, involving both genetic and environmental factors.1 it is very critical to make a decision as the timing of early treatment is crucial for a successful outcome. Some studies have reported that early treatment should be carried out in patients to enhance the orthopedic effect.2, 3 moreover, an early benefit in terms of esthetics implies improved self-esteem, considering the psychological factor of the child. Facemask is one of the most commonly used interceptive tools to intercept developing skeletal class III malocclusion due to deficient maxilla.4

Case History

A 9 years old male patient reported with the chief complaint of decreased visibility of upper front teeth. Extraoral examination showed a deficient mid face, and a concave lateral profile (Figure 1) and intraoral examination shows maxillary and mandibular anteriors in crossbite relation with 2 mm of reverse overjet and 4 mm of overbite along with ankyloglossia. (Figure 2) cephalometric examination revealed true skeletal class III malocclusion with retrognathic maxilla and average mandible. (Figure 3)

Treatment Objectives

Stage 1: To correct reverse overjet and to improve the facial profile with a bonded protraction plate with hyrax expansion screw followed by facemask therapy.

Bonded protraction plate using clear acrylic was made incorporating 0.9 mm hyrax expansion screw and hooks between canine and first deciduous molar for engaging elastics from facemask, protraction plate was cemented using luting glass ionomer cement. Hyrax screw was activated as two turns per day for seven days. (Figure 4)

Following expansion protocol, patient was asked to wear the petit type of facemask daily for 14 hours engaging 5/16" elastics from the horizontal crossbar of facemask exerting heavy forces on the craniofacial segment of about 16 oz for about 14 h daily. (Figure 5)

The patient was monitored every 2 weeks for initial 2 months, followed by every 1 month. After 1 month of facemak therapy an edge-to-edge bite was observed. Correction of reverse overjet and improved facial profile was achieved in 5 months, after that patient was asked to continue the use of facemask and protraction plate for desired overcorrection of maxillary protraction for another 4 months. (Figure 6, Figure 7) cephalometric changes achieved are listed in Table 1. (Figure 8)

Stage 2 treatment was started with fixed orthodontic treatment after removal of the protraction plate with hyrax. MBT 0.022 slot brackets were used and alignment started with 0.016 NiTi archwire. This guided the eruption of premolars and in settling the occlusion with ideal overjet, overbite, class I molar, and canine relation bilaterally. (figure 7) Tongue tie was released with soft tissue diode laser (0.8w, 980nm). (Figure 8)

Retention protocol followed was upper wraparound retainer and lower canine to canine bonded lingual retainers. Periodic follow up was instructed and they were also informed that unpredictable mandibular growth could create the need for a new intervention and potential orthognathic surgery during adulthood.

Table 1

Pre and post-treatment cephalometric values





SNA (˚)




SNB (˚)




ANB (˚)




N perpendicular to A (mm)




U1 to SN (˚)




IMPA (˚)




SN to MP (˚)




FH to MP (˚)




Figure 1

Pretreatment: Extra oral photographs

Figure 2

Pretreatment: Intra oral photographs

Figure 3

Pretreatment: lateral cephalogram

Figure 4

A: Hyrax expander in place B: Hyrax expander after one week of activation

Figure 5

Petit type facemask in place

Figure 6

Intra oral photographs after nine month of facemask therapy

Figure 7

Post- facemask therapy: Extra oral photographs

Figure 8

Post-facemask therapy: Lateral cephalogram

Figure 9

Fixed orthodontic treatment

Figure 10

Surgical correction of tongue tie

A: Extent of tongue before surgery; B: Laser assisted lingual frenectomy; C: Extent of tongue after surgery



We have chosen facemask with RME therapy for achieving maxillary skeletal protraction. Haas 5 has mentioned in his article that rapid palatal expansion alone can advance the maxilla. A follow-up study by wertz et al. 6 found that maxillary advancement due to rapid palatal expansion treatment is limited and unpredictable. So combining RME with facemask therapy was beneficial in correcting maxillary deficiency in growing children 7 and an effective result was obtained in our study. As anchorage was taken from the forehead and chin face mask therapy not only advances maxilla but also prevents forward growth of mandible during the treatment period.

SNA angle has increased from 770 to 800 and ANB angle from 60 to 20 without much proclination of upper anteriors. A 30 increase in mandibular plane angle was observed this would be the result of downward and forward movement of maxilla.

The release of tongue tie will improve the tongue movement and skeletal class III tendency in the future. 8 Early diagnosis of malocclusion and its treatment is essential for the psychological development of a child and also to avoid complicated treatment procedures in future.


Facemask with RME is an effective treatment option for the management of skeletal class III malocclusion due to maxillary deficiency in an early age group. However, further follow-up of the patient is required as the mandible still continues to grow as he an adolescent.

Source of Funding

No financial support was received for the work within this manuscript.

Conflicts of Interest

There are no conflicts of interest.



R Duggal VP Mathur H Parkash AK Jena Class - III malocclusion: Genetics or environment? A twins studyJ Indian Soc Pedod Prev Dent 2005231273010.4103/0970-4388.16023


P M Campbell The dilemma of Class III treatment. Early or late?Angle Orthod198353317591


T Baccetti A retrospective comparison of functional appliance treatment of Class III malocclusions in the deciduous and mixed dentitionsEur J Orthod 19982033091710.1093/ejo/20.3.309


S Watkinson JE Harrison S Furness HV Worthington Orthodontic treatment for prominent lower front teeth (Class III malocclusion) in childrenCochrane Database Syst Rev 20139345110.1002/14651858.cd003451.pub2


A J Haas Rapid expansion of maxillary dental arch and nasal cavity by opening the midpalatal sutureAngle Orthod1961317390


RM Wertz M Dreskin Midpalatal suture opening: A normative studyAm J Orthod 19777143678110.1016/0002-9416(77)90241-x


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SJ Jang BK Cha P Ngan DS Choi SK Lee I Jang Relationship between the lingual frenulum and craniofacial morphology in adultsAm J Orthod Dentofac Orthop20111394e361710.1016/j.ajodo.2009.07.017


© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Article type

Case Report

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Authors Details

Pooja U, Naveen Aravind, Rajkumar S Alle, Lokesh NK, Mayank Trivedi

Article History

Received : 31-03-2021

Accepted : 14-05-2021

Available online : 12-07-2021

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