Introduction

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.

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

Discussion

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.

Conclusion

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.