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CASE REPOrT

Correction of skeletal Class III in a growing male patient by reverse pull facemask
Abstract
The following case report describes the management of a 6-year-old male patient in early mixed dentition with a mesial step molar relation, an anterior reverse overjet, and skeletal Class III due to a slightly deficient maxilla. The treatment plan included protraction of the maxilla by a reverse pull Petit type facemask for 10 months followed by 15 months of active retention by a Frankel III appliance.

Kapoor P, Kharbanda OP1

Department of Orthodontics, Faculty of Dentistry, Jamia Millia Islamia, 1Division of Orthodontics, Center for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India Correspondence: Dr. Priyanka Kapoor, Jamia Millia Islamia, New Delhi, India. E-mail: drkapoorpriya@gmail.com

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Key words
Class III, maxillary deficiency, reverse pull facemask

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Website: www.jisppd.com DOI: 10.4103/0970-4388.85841 PMID: **********

Introduction
Individuals with Class III malocclusion may have combinations of skeletal and dentoalveolar components. These characteristics could be summarized as follows: Skeletal components with underdeveloped maxilla, overdeveloped mandible or a combination of both, dentoalveolar components with proclined maxillary incisors, and retroclined mandibular incisors, to achieve dentoalveolar compensation.[1] Early treatment of Class III malocclusion has been advocated for many years, and the goal is focused on providing a more favorable environment for normal growth and on improving the psychosocial development of the child. [2] Early orthopedic treatment, using a facemask or chin cup therapy, improves the skeletal relationships, which in turn minimize excessive dental compensation such as overclosure of the mandible and retroclination of the mandibular incisors. Also correction of the anterior crossbite often helps in eliminating centric occlusion/centric relation (CO/CR) discrepancies, and avoids adverse growth potential. Most importantly, in mild and moderate Class III patients, early orthodontic or orthopedic treatment may eliminate the necessity for orthognathic surgery treatment. Studies have shown that treatment with facemask and/or a chin

cap improves the lip posture and facial appearance.[3,4] Turpin[5] recommended that early treatment should be considered for young patients who present with positive factors such as convergent facial type, anteroposterior functional shift, symmetrical condyle growth, mild skeletal disharmony, some remaining growth, good cooperation, no familial prognathism, and good facial esthetics.

Case Report
A 6-year-old growing male patient in acceleration stage of CVMI, came to the Orthodontic clinic with chief complaints of lower front teeth overlapping the upper teeth. Extraoral examination revealed an apparently symmetrical mesoprosopic face with a straight but pleasant profile and apparently slightly deficient maxilla [Figure 1]. Intraoral examination revealed the presence of mixed
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Kapoor and Kharbanda: Correction of skeletal Class III by reverse pull facemask

dentition of teeth with the presence of permanent first molars on all four sides and 11, 21, 31, 41 in upper and lower arches. Mandibular deciduous second molars showed a mesial step relation to the maxillary deciduous second molars, and 11, 21, 52, 62 in crossbite relation to 31, 41, 72, 73, 82, 83 [Figure 2]. The panorex findings revealed the presence of early mixed dentition with erupted permanent first molars, and permanent lateral incisors, canines, and first and second premolars in an erupting stage. The cephalometric findings revealed the patient in acceleration stage of CVMI an average grower, with a tendency toward skeletal Class III skeletal bases, a normal mandibular plane angle, and proclined lower incisors. The length of the mandible was normal while the length of maxilla was short.

Figure 1: Pretreatment extraoral photographs revealed an apparently symmetrical mesoprosopic face with a straight but pleasant profile and slightly deficient maxilla

Treatment objectives
Protraction of maxilla Attaining positive overjet Correction of Class III skeletal relationship Retention till the growth was complete

Treatment plan
Step 1: Maxillary protraction with bonded occlusal splint and Petit facemask Step 2: Retention with Frankel III
Figure 2: Pretreatment intraoral photographs revealed presence of early mixed dentition of teeth with crossbite of anteriors.

Treatment done Stage 1

Splint construction The occlusal splint was constructed with a wire framework, extending around the maxillary arch from the first molar on one side to the first molar on the other side. The acrylic component of the plate was approximately 2 mm thick, covering the teeth from the deciduous canines to the first permanent molars, leaving a 1 mm clearance at the gingival margins on the buccal and palatal aspects. Hooks were positioned between the deciduous canines and the first molars, as superior as the patients comfort allowed [Figure 3] Facemask wear The patient was given instructions regarding wear of the Petit facemask[6] (GAC Int. Inc., 355 Knickbocker Avenue, Bohemia, NY) on an average of 10 12 hours a day, with forces applied in the range of 300 g per side. The approximate time taken for protraction of the maxilla and for a positive overjet to appear was 10 months [Figure 4].
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Figure 3: Occlusal splint with a wire framework extending around maxillary arch from first molar on one side to first molar on the other side. The acrylic component of the plate approximately 2 mm thick covering teeth from deciduous canines to first permanent molars. Hooks are positioned between deciduous canines and first molars

Stage 2 (10 months post protraction)

Intraoral examination revealed establishment of the positive overjet [Figure 5] and the cephalometric findings indicated a forward protaction of the maxilla

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Kapoor and Kharbanda: Correction of skeletal Class III by reverse pull facemask

Figure 4: Petit facemask wear with elastics having a force of 300 gms per side and 15 to the occlusal plane

Figure 5: 10 months post protraction intraoral photographs reveal a positive overjet although still no occlusion is settled in posteriors as the splint is debonded

Figure 6: Retention with Frankel III

as well as proclination of the maxillary incisors besides attaining a positive overjet of teeth.

Figure 7: Postretention (1 year) extraoral,intraoral photographs and radiographs reveal positive overjet and settling of occlusion with improvement in profile

Stage 3
Retention with Frankel III [Figure 6]. The intraoral photographs revealed establishment of the positive overjet and settling of occlusion [Figure 7]. The extraoral examination and radiographic findings indicated protraction of the maxilla and improvement of the profile.

dentition. The splint was fitted with hooks to attach elastics to the facemask, and an expansion screw was incorporated in the appliance. Mid facial orthopedic expansion could produce a slight anterior movement of Point A and a slight inferior and anterior movement of the maxilla. The protocol followed for protraction as regards the direction and amount of force has been supported by these studies. Maxillary protraction usually requires 300 to 600 g of force per side, 12 hours a day, depending on the age of the patient.[9,10] The facemask projects a downward and forward pull on the maxilla with protraction elastics attached near the maxillary canines, with a downward and forward pull of 15 from the occlusal plane. The treatment was done at a very young age in early mixed dentition to enhance forward displacement of the maxilla by sutural growth. It has been shown by Melsen in her histological findings that the midpalatal
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Discussion
A Petit type reverse pull facemask was used in the present case, in a growing child, to correct Class III malocclusion due to maxillary deficiency. The history of the reverse pull facemask dated back to Germany, more than 100 years ago. The individual most responsible for reviving an interest in this technique was Delaire.[7] Petit[6] modified the facemask of Delaire by increasing the amount of force generated by the appliance and decreasing the overall treatment time. McNamara[8] described a version of the petit facial mask that attached to a maxillary splint, which was bonded to the posterior

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Kapoor and Kharbanda: Correction of skeletal Class III by reverse pull facemask

suture was broad and smooth during the infantile stage (8 to 10 years of age) and became more squamous and overlapping in the juvenile stage (10 to 13 years). Also, the circummaxillary sutures were smooth and broad before age eight and became more heavily interdigitated around puberty.[11,12] Another important factor was retention of the positive overjet once achieved, for which Frankel III was given as a retention device for approximately a year-and-ahalf. This was supported by a prospective clinical trial, where protraction facemask treatment starting in the mixed dentition was found to be stable two years after the removal of the appliances, due to the overcorrection and the use of a functional appliance as a retainer for one year.[10] The patient, however, still has to be recalled for follow-up till the growth of the mandible is complete as there are variations in the rate, growth direction, and rotation of the maxilla from child to adulthood. Another modification that could have been done was to provide for rapid maxillary expansion in the occlusal splint, mostly advocated to loosen the circummaxillary sutures. A number of studies[13-18] have described the general treatment effects of rapid maxillary expansion and facemask therapy (RME/FM) during a single phase of treatment, with a combination of skeletal and dentoalveolar modifications noted in both the maxilla and the mandible. This combined therapy produces more favorable outcomes in patients treated in the deciduous or early mixed dentition than in late mixed dentition with respect to untreated Class III controls.[19-21] To date, however, few studies have evaluated craniofacial modifications after orthopedic [22-24] correction.

Conclusion
The present case study shows the correction of skeletal Class III in a six-year-old male, in acceleration stage CVMI, with protraction facemask therapy and retention of a positive overjet with a Frankel III for another year-and-a-half.

References
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Kapoor and Kharbanda: Correction of skeletal Class III by reverse pull facemask

Cephalometric A point changes during and after maxillary protraction and expansion. Am J Orthod Dentofacial Orthop 1996;110:423-30. 23. Gallagher RW, Miranda F, Buschang PH. Maxillary protraction: Treatment and posttreatment effects. Am J Orthod Dentofacial Orthop 1998;113: 612-9. 24. McGill JS, McNamara JA Jr. Treatment and post-treatment effects of rapid maxillary expansion and facial mask therapy. In: McNamara JA Jr, editor. Growth modification: What works,

what doesnt and why, monograph no. 36. Craniofacial growth series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1999.
How to cite this article: Kapoor P, Kharbanda OP. Correction of skeletal Class III in a growing male patient by reverse pull facemask. J Indian Soc Pedod Prev Dent 2011;29:273-7. Source of Support: Nil, Conflict of Interest: None declared.

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