Class III therapy using a face mask is a common approach for treatment of a deficient maxilla and reverse overbite. Usually, maxillary protraction is combined with transverse palatal expansion using intraoral appliances. The purpose of this study was to systematically review the effectiveness of face mask therapy in combination with concepts of palatal expansion and compression.
Material and methods
A systematic review and meta-analysis were performed to identify studies that address class III treatment using a face mask. The search was carried out using common electronic databases as well as hand search. Both screening and study eligibility analysis were performed with consideration of PRISMA and Cochrane Guidelines for systematic reviews. Several terms describing class III face mask treatment were searched. Particular attention was paid to new strategies of enhancing maxillary protraction.
The initial search identified 2048 studies. After a thorough selection process, a total of 22 articles met the inclusion criteria. After assessment of the individual quality scoring of each article, eight studies were provided for meta-analysis of the cephalometric parameters. The statistical analysis of treatment changes advocates a positive influence on sagittal maxillary development, which is not primarily influenced by transverse expansion. Dental side effects are more distinct when no expansion was carried out. For the concept of alternating activation/deactivation of the expansion appliance (alt-RAMEC), two articles of high methodological scoring were identified. They indicate an enhancement of face mask treatment.
The findings are consistent with results of previous literature studies regarding the efficiency of class III face mask treatment. A further need for more randomized controlled studies was identified especially with regard to the new concept of alternating maxillary expansion and compression, which showed a positive influence on the maxillary protraction based on two studies.
Class III therapy using extraoral face mask anchorage is effective for maxillary protraction. The recently discussed new protocols potentially improve this treatment.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Chen L, Chen R, Yang Y, Ji G, Shen G (2012) The effects of maxillary protraction and its long-term stability—a clinical trial in Chinese adolescents. Eur J Orthod 34(1):88–95. doi:10.1093/ejo/cjq185
Jager A, Braumann B, Kim C, Wahner S (2001) Skeletal and dental effects of maxillary protraction in patients with angle class III malocclusion. A meta-analysis. J Orofac Orthop 62(4):275–284
Keles A, Tokmak EC, Erverdi N, Nanda R (2002) Effect of varying the force direction on maxillary orthopedic protraction. Angle Orthod 72(5):387–396. doi:10.1043/0003-3219(2002)072<0387:EOVTFD>2.0.CO;2
Frankel R (1970) Maxillary retrusion in class 3 and treatment with the function corrector 3. Rep Congr Eur Orthod Soc:249–259
Frankel R (1971) Tooth eruption and alveolar process under the orthodontic effect of functional appliances. Fortschr Kieferorthop 32(2):217–228
Sakamoto T, Iwase I, Uka A, Nakamura S (1984) A roentgenocephalometric study of skeletal changes during and after chin cup treatment. Am J Orthod 85(4):341–350
Thilander B (1965) Chin-cap treatment for angle class 3 malocclusion. Rep Congr Eur Orthod Soc 41:311–327
McNamara JR, Brudon WL (1993) Orthodontic and orthopedic treatment in the mixed dentition. Mich, Ann Arbor
Delaire J (1971) Manufacture of the “orthopedic mask”. Rev Stomatol Chir Maxillofac 72(5):579–582
Petit H (1983) Introduction to the biomechanical study of the facial mask and its accessories. Orthod Fr 54(2):353–365
McNamara JA Jr (1987) An orthopedic approach to the treatment of class III malocclusion in young patients. J Clin Orthod 21(9):598–608
Nanda R (1980) Biomechanical and clinical considerations of a modified protraction headgear. Am J Orthod 78(2):125–139
Hardy D, Cubas M, Orellana M (2012) Prevalence of angle class III malocclusion: a systematic review and meta-analysis. Open J Epidemiol 2012(2):75–82
Williams S, Andersen CE (1986) The morphology of the potential class III skeletal pattern in the growing child. Am J Orthod 89(4):302–311
Jacobson A, Evans WG, Preston CB, Sadowsky PL (1974) Mandibular prognathism. Am J Orthod 66(2):140–171
Williams MD, Sarver DM, Sadowsky PL, Bradley E (1997) Combined rapid maxillary expansion and protraction facemask in the treatment of class III malocclusions in growing children: a prospective long-term study. Semin Orthod 3(4):265–274
Ellis E 3rd, McNamara JA Jr (1984) Components of adult class III malocclusion. J Oral Maxillofac Surg 42(5):295–305
Guyer EC, Ellis EE 3rd, McNamara JA Jr, Behrents RG (1986) Components of class III malocclusion in juveniles and adolescents. Angle Orthod 56(1):7–30. doi:10.1043/0003-3219(1986)056<0007:COCIMI>2.0.CO;2
Cohen PA (1992) Meta-analysis: application to clinical dentistry and dental education. J Dent Educ 56(3):172–175
Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA (1999) The effectiveness of protraction face mask therapy: a meta-analysis. Am J Orthod Dentofacial Orthop 115(6):675–685
Toffol LD, Pavoni C, Baccetti T, Franchi L, Cozza P (2008) Orthopedic treatment outcomes in class III malocclusion. A systematic review. Angle Orthod 78(3):561–573. doi:10.2319/030207-108.1
Cordasco G, Matarese G, Rustico L, Fastuca S, Caprioglio A, Lindauer SJ, Nucera R (2014) Efficacy of orthopedic treatment with protraction facemask on skeletal class III malocclusion: a systematic review and meta-analysis. Orthod Craniofac Res 17(3):133–143. doi:10.1111/ocr.12040
Akkaya S, Lorenzon S, Ucem TT (1999) A comparison of sagittal and vertical effects between bonded rapid and slow maxillary expansion procedures. Eur J Orthod 21(2):175–180
Wertz RA (1970) Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod 58(1):41–66
Pangrazio-Kulbersh V, Berger J, Kersten G (1998) Effects of protraction mechanics on the midface. Am J Orthod Dentofacial Orthop 114(5):484–491
Cozza P, Giancotti A, Petrosino A (2001) Rapid palatal expansion in mixed dentition using a modified expander: a cephalometric investigation. J Orthod 28(2):129–134
Sarver DM, Johnston MW (1989) Skeletal changes in vertical and anterior displacement of the maxilla with bonded rapid palatal expansion appliances. Am J Orthod Dentofacial Orthop 95(6):462–466
Liou EJ, Tsai WC (2005) A new protocol for maxillary protraction in cleft patients: repetitive weekly protocol of alternate rapid maxillary expansions and constrictions. Cleft Palate Craniofac J 42(2):121–127. doi:10.1597/03-107.1
Liou EJ (2005) Effective maxillary orthopedic protraction for growing class III patients: a clinical application simulates distraction osteogenesis. Prog Orthod 6(2):154–171
PRISMA (2009) Reporting guideline for systematic reviews and meta-analyses
Higgins J. GS (2009) Cochrane handbook for systematic reviews of interventions version 5.0.2
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700
Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr (2006) Mandibular changes produced by functional appliances in class II malocclusion: a systematic review. Am J Orthod Dentofacial Orthop 129(5):599 e591–512. doi:10.1016/j.ajodo.2005.11.010, discussion e591-596
Chen Y, Kyung HM, Zhao WT, Yu WJ (2009) Critical factors for the success of orthodontic mini-implants: a systematic review. Am J Orthod Dentofacial Orthop 135(3):284–291. doi:10.1016/j.ajodo.2007.08.017
Grec RH, Janson G, Branco NC, Moura-Grec PG, Patel MP, Castanha Henriques JF (2013) Intraoral distalizer effects with conventional and skeletal anchorage: a meta-analysis. Am J Orthod Dentofacial Orthop 143(5):602–615. doi:10.1016/j.ajodo.2012.11.024
Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I (1998) Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop 113(3):333–343
Chong YH, Ive JC, Artun J (1996) Changes following the use of protraction headgear for early correction of class III malocclusion. Angle Orthod 66(5):351–362. doi:10.1043/0003-3219(1996)066<0351:CFTUOP>2.3.CO;2
da Silva Filho OG, Magro AC, Capelozza Filho L (1998) Early treatment of the class III malocclusion with rapid maxillary expansion and maxillary protraction. Am J Orthod Dentofacial Orthop 113(2):196–203
Gallagher RW, Miranda F, Buschang PH (1998) Maxillary protraction: treatment and posttreatment effects. Am J Orthod Dentofacial Orthop 113(6):612–619
Isci D, Turk T, Elekdag-Turk S (2010) Activation-deactivation rapid palatal expansion and reverse headgear in class III cases. Eur J Orthod 32(6):706–715. doi:10.1093/ejo/cjq006
Kapust AJ, Sinclair PM, Turley PK (1998) Cephalometric effects of face mask/expansion therapy in class III children: a comparison of three age groups. Am J Orthod Dentofacial Orthop 113(2):204–212
Kurt G, Uysal T, Yagci A (2010) Soft and hard tissue profile changes after rapid maxillary expansion and face mask therapy. World J Orthod 11(4):e10–e18
Lee DY, Kim ES, Lim YK, Ahn SJ (2010) Skeletal changes of maxillary protraction without rapid maxillary expansion. Angle Orthod 80(4):504–510. doi:10.2319/091609-521.1
Macdonald KE, Kapust AJ, Turley PK (1999) Cephalometric changes after the correction of class III malocclusion with maxillary expansion/facemask therapy. Am J Orthod Dentofacial Orthop 116(1):13–24
Mandall N, Cousley R, DiBiase A, Dyer F, Littlewood S, Mattick R, Nute S, Doherty B, Stivaros N, McDowall R, Shargill I, Worthington H (2010) Is early class III protraction facemask treatment effective? A multicentre, randomized, controlled trial: 15-month follow-up. J Orthod 37:149–161
Masucci C, Franchi L, Defraia E, Mucedero M, Cozza P, Baccetti T (2011) Stability of rapid maxillary expansion and facemask therapy: a long-term controlled study. Am J Orthod Dentofacial Orthop 140(4):493–500. doi:10.1016/j.ajodo.2010.09.031
Ngan P, Hagg U, Yiu C, Merwin D, Wei SH (1996) Soft tissue and dentoskeletal profile changes associated with maxillary expansion and protraction headgear treatment. Am J Orthod Dentofacial Orthop 109(1):38–49
Ngan P, Hagg U, Yiu C, Merwin D, Wei SH (1996) Treatment response to maxillary expansion and protraction. Eur J Orthod 18(2):151–168
Saadia M, Torres E (2000) Sagittal changes after maxillary protraction with expansion in class III patients in the primary, mixed, and late mixed dentitions: a longitudinal retrospective study. Am J Orthod Dentofacial Orthop 117(6):669–680
Shanker S, Ngan P, Wade D, Beck M, Yiu C, Hagg U, Wei SH (1996) Cephalometric a point changes during and after maxillary protraction and expansion. Am J Orthod Dentofacial Orthop 110(4):423–430
Tortop T, Keykubat A, Yuksel S (2007) Facemask therapy with and without expansion. Am J Orthod Dentofacial Orthop 132(4):467–474. doi:10.1016/j.ajodo.2006.09.047
Vaughn GA, Mason B, Moon HB, Turley PK (2005) The effects of maxillary protraction therapy with or without rapid palatal expansion: a prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 128(3):299–309. doi:10.1016/j.ajodo.2005.04.030
Westwood PV, McNamara JA Jr, Baccetti T, Franchi L, Sarver DM (2003) Long-term effects of class III treatment with rapid maxillary expansion and facemask therapy followed by fixed appliances. Am J Orthod Dentofacial Orthop 123(3):306–320. doi:10.1067/mod.2003.44
Yavuz I, Halicioglu, K., Ceylan, I., Dagsuyu, I., Erdem, A. (2012) The effects of face mask therapy with and without rapid maxillary expansion in adolescent patients. Aust Orthod J:63–71
Masucci C, Franchi L, Giuntini V, Defraia E (2014) Short-term effects of a modified Alt-RAMEC protocol for early treatment of class III malocclusion: a controlled study. Orthod Craniofac Res 17(4):259–269. doi:10.1111/ocr.12051
Haas AJ (1970) Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod 57(3):219–255
Levrini L, Filippi V (1999) A fan-shaped maxillary expander. J Clin Orthod 33(11):642–643
Suzuki A, Takahama Y (1989) A jointed fan-type expander: a newly designed expansion appliance for the upper dental arch of patients with cleft lip and/or palate. Cleft Palate J 26(3):239–241, discussion 241
Huang C, Wang Y, Huang C, Liou E (2008) Maxillary displacement after rapid maxillary expansions: an animal study. J Taiwan Assoc Orthod 20(2):19–31
Tsai WC, Huang C, Lin C, Liou E (2008) Dentofacial changes of combined double-hinged maxillary expansion and protraction facemask therapy. J Taiwan Assoc Orthod 20(2):5–18
Smalley WM, Shapiro PA, Hohl TH, Kokich VG, Branemark PI (1988) Osseointegrated titanium implants for maxillofacial protraction in monkeys. Am J Orthod Dentofacial Orthop 94(4):285–295
Jackson GW, Kokich VG, Shapiro PA (1979) Experimental and postexperimental response to anteriorly directed extraoral force in young Macaca nemestrina. Am J Orthod 75(3):318–333
Cevidanes L, Baccetti T, Franchi L, McNamara JA Jr, De Clerck H (2010) Comparison of two protocols for maxillary protraction: bone anchors versus face mask with rapid maxillary expansion. Angle Orthod 80(5):799–806. doi:10.2319/111709-651.1
De Clerck H, Cevidanes L, Baccetti T (2010) Dentofacial effects of bone-anchored maxillary protraction: a controlled study of consecutively treated class III patients. Am J Orthod Dentofacial Orthop 138(5):577–581. doi:10.1016/j.ajodo.2009.10.037
Nienkemper M, Wilmes B, Pauls A, Drescher D (2013) Maxillary protraction using a hybrid hyrax-facemask combination. Prog Orthod 14:5. doi:10.1186/2196-1042-14-5
Wilmes B, Ngan P, Liou EJ, Franchi L, Drescher D (2014) Early class III facemask treatment with the hybrid hyrax and Alt-RAMEC protocol. J Clin Orthod 48(2):84–93
The manuscript does not contain clinical studies or patient data.
Conflict of interest
The authors declare that they have no competing interests.
Moritz Foersch and Collin Jacobs contributed equally to this work.
Rights and permissions
About this article
Cite this article
Foersch, M., Jacobs, C., Wriedt, S. et al. Effectiveness of maxillary protraction using facemask with or without maxillary expansion: a systematic review and meta-analysis. Clin Oral Invest 19, 1181–1192 (2015). https://doi.org/10.1007/s00784-015-1478-4
- Class III treatment
- Systematic review