CENTENNIAL SPECIAL ARTICLE

Growth modication of the face: A current

perspective with emphasis on Class III treatment
Hugo J. De Clercka and William R. Proftb
Chapel Hill, NC, and Brussels, Belgium

A summary of the current status of modication of jaw growth indicates the following. 1. Transverse expansion of
the maxilla is easy before adolescence, requires heavy forces to create microfractures during adolescence, and
can be accomplished only with partial or complete surgical osteotomy after adolescence. Transverse expansion
of the mandible or constriction of either jaw requires surgery. 2. Acceleration of mandibular growth in preadoles-
cent or adolescent patients can be achieved, but slower than normal growth afterward reduces or eliminates a
long-term increase in size of the mandible. Restraint of maxillary growth occurs with all types of appliances to
correct skeletal Class II problems. For short-face Class II patients, increasing the face height during preadoles-
cent or adolescent orthodontic treatment is possible, but it may make the Class II problem worse unless favor-
able anteroposterior growth occurs. For those with a long face, controlling excessive vertical growth during
adolescence is rarely successful. 3. Attempts to restrain mandibular growth in Class III patients with external
forces largely result in downward and backward rotation of the mandible. Moving the maxilla forward with
external force is possible before adolescence; moving it forward and simultaneously restricting forward mandib-
ular growth without rotating the jaw is possible during adolescence with intermaxillary traction to bone anchors.
The amount of skeletal change with this therapy often extends to the midface, and the short-term effects on both
jaws are greater than with previous approaches, but individual variations in the amount of maxillary vs mandib-
ular response occur, and it still is not possible to accurately predict the outcome for a patient. For all types of
growth modication, 3-dimensional imaging to distinguish skeletal changes and better biomarkers or genetic
identication of patient types to indicate likely treatment responses are needed. (Am J Orthod Dentofacial
Orthop 2015;148:37-46)

A
lthough growth modication has been
considered important from the beginning of
orthodontics, the concepts underlying its use
and the views of its clinical usefulness have varied
greatly over time. To orthodontists in the late 19th
and early 20th centuries, growth modication was
easy because it was assumed that growth was largely
controlled by environmental factors and was judged
as successful because the dental occlusion improved.
By midcentury, cephalometrics had shown that most
a
Adjunct professor, Department of Orthodontics, School of Dentistry, University
of North Carolina, Chapel Hill, NC; private practice, Brussels, Belgium.
b
Kenan distinguished professor, Department of Orthodontics, School of
Dentistry, University of North Carolina, Chapel Hill, NC.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conicts of Interest, and none were reported.
Address correspondence to: Hugo J. De Clerck, Kerkstraat 120, 1150 Brussels,
Belgium; e-mail, hugo.declerck@skynet.be.
Submitted, revised and accepted, April 2015.
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.04.017
of the changes produced by the treatment methods
of that time were tooth movement, not modied
growth. At that point, the American view was that it
was almost impossible to modify growth because of
tight genetic control, and that attempts to do so
were rarely indicated. Europeans remained more pos-
itive; in the United States, there was increasing accep-
tance of European functional appliances and
enthusiasm for growth modication in the last quarter
of the century. There is a somewhat less enthusiastic
view of it now, as better data for long-term outcomes
have become available, and genetic inuences once
again are being emphasized.
In this article, we had 2 goals: (1) to provide an
overview of growth modication possibilities and limi-
tations based on the best current data for the various
types of malocclusions, and (2) to discuss in more
detail Class III growth modication with elastics to
bone anchors, the most recent form of growth modi-
cation and, in terms of short-term changes, perhaps the
most successful.
37
38
TRANSVERSE GROWTH MODIFICATION
Transverse growth modication is largely done in the
context of maxillary expansion by opening the midpala-
tal suture. Ample clinical evidence now conrms that
opening the suture can be accomplished. In young chil-
dren, up to age 8 or 9 years, little force is needed. Up to
that age, a transpalatal lingual arch for dental expansion
also will open the midpalatal suture. A jackscrew device
is not needed, and rapid expansion is contraindicated
because of the possibility of injury to the nose, involving
displacement of the vomer bone.
By age 9 or 10, there is enough interdigitation of
bone spicules on the edges of the midpalatal suture
that opening the suture requires microfractures, and a
heavier force from a jackscrew device is necessary to
do this. The rate of opening the suture with a jackscrew
remains controversial. The original reason for rapid
expansion was that the suture would open too rapidly
for tooth movement to accompany it, and the amount
of skeletal vs dental change would be greater. This is
true in the short term but not in the medium or long
term: after rapid expansion, skeletal relapse is followed
by tooth movement, so that a few weeks after the jack-
screw is tied off and left in place as a retainer, the skeletal
and dental components of the expansion are about 50-
50. Approximately the same ratio is found when the
expansion is done slowly, at a rate of about 1 mm per
week.1 Slow expansion, therefore, can be considered
an equally effective and less traumatic way to expand
the maxilla. Additional transverse growth after adoles-
cent expansion almost never occurs.2
The suture opens in a V pattern both transversely
and vertically, with more expansion anteriorly and
some expansion all the way up to the orbits. Extremely
heavy force in late adolescence carries with it the risk
of an uncontrolled fracture that extends vertically and
can lead to a signicant injury.
Transverse expansion of the mandible is possible only
with distraction osteogenesis at the symphysis. The ma-
jor indication is lack of development of the mandibular
midline structures (Fig 1). Symphysis distraction as a
way to gain space for the alignment of crowded mandib-
ular incisors is now judged to have a poor ratio of benet
to cost and risk.
Excessive transverse growth is almost totally a prob-
lem in the mandible. Mandibular arch width is affected
by tongue size and posture; with a large tongue carried
low in the mouth, a posterior crossbite is likely to be
present with normal or even wide maxillary dimensions.
It may be the best clinical judgment to tolerate such a
crossbite rather than to attempt an extreme maxillary
expansion. Narrowing the mandibular arch in such a case
July 2015  Vol 148  Issue 1
De Clerck and Proft
Fig 1. Extreme mandibular deciency: A, sagittaly and
B, transversely, in a patient with congenitally missing
mandibular canines and 3 incisors, and a hypoplastic
tongue but normal facial soft tissues. This made him an
ideal candidate for mandibular distraction osteogenesis
in preparation for eventual surgical mandibular advance-
ment.
is almost impossible; surgical narrowing by removal of
bone at the symphysis is difcult and potentially unstable.
MODIFYING CLASS II GROWTH
Patients with a Class II growth pattern have some
combination of decient forward mandibular growth
and excessive maxillary growth that is more likely to be
downward than forward. The desired growth modica-
tion, of course, is stimulation of forward mandibular
growth and restraint of maxillary growth in both direc-
tions.
The orthodontic literature has hundreds of reports of
devices to modify growth in this way and much data for
outcomes of treatments. Functional appliances that
position the mandible forward are the mainstays of
treatment. Their short-term effects are summarized in
a recent meta-analysis, to which readers are referred
for further information.3 The conclusions relative to
growth modication are that (1) functional appliances
can accelerate the rate of forward mandibular growth
before and during adolescence, (2) there is an element
of restraint of maxillary growth in the response, and
(3) a signicant part of the correction of a Class II maloc-
clusion is due to dental rather than skeletal change.
Does acceleration of mandibular growth during
adolescence lead to a larger mandible at the end of the
growth period? The possibilities are shown in Figure 2;
the consistent conclusion is that the period of growth
acceleration is followed by diminished growth later, so
that if there is any increase in mandibular length in the
long term, it is quite small. Sometimes the change is
evaluated as statistically signicant; sometimes it is
not, but the data do not support the idea that the ortho-
dontist is growing mandibles.
American Journal of Orthodontics and Dentofacial Orthopedics
De Clerck and Proft
Fig 2. Diagrammatic representation of the difference be-
tween mandibular growth acceleration and true stimula-
tion of mandibular growth. Good evidence shows that
growth in the period after acceleration is slower than ex-
pected growth. The extent of some true stimulation in
the long term is small if not zero. (From Proft WR, Fields
HW Jr, Sarver DM. Contemporary orthodontics. 5th ed.
Philadelphia: Elsevier; 2013. With permission from
Elsevier).
Is extraoral force to the maxilla effective in restraining
its forward growth? The answer is yes, and the amount of
growth restraint is greater with headgear than with
functional appliances, but the outcomes of treatment
between functional appliances and headgear are remark-
ably similar. It appears that an improvement in the ante-
roposterior position of the maxilla relative to the
mandible greater than 5 mm is about as much as growth
modication can provide, and that such a favorable result
occurs in not more than two thirds to three quarters of
the patients treated during adolescence.4
The timing of Class II growth modication treatment
remains controversial despite multiple clinical trials with
the same conclusion: that 2-stage treatment beginning
before the adolescent growth spurt is not more effective
than 1-stage treatment during adolescence.5 The pri-
mary indication for preadolescent treatment, therefore,
is psychosocial problems caused by teasing and harass-
ment about protruding maxillary teeth, not a severe
malocclusion.
SHORT-FACE AND LONG-FACE GROWTH
MODIFICATION
Vertical deviations from acceptable facial proportions
are less frequent but not less important than anteropos-
terior deviations and can accompany Class II or Class III
growth patterns.
American Journal of Orthodontics and Dentofacial Orthopedics
39
The best description of short-face problems is that
the lower third of the face is short relative to the other
facial thirds; the graphic way to say it is that the chin
is too close to the nose. Patients with this problem usu-
ally have a relatively long ramus, an acute gonial angle,
and a low mandibular plane angle: the so-called skeletal
deepbite conguration. If they also are somewhat
mandibular decient, a Class II Division 2 malocclusion
may be present.
In those patients, one would want downward growth
of the mandible and would be willing to accept some
downward rotation of the mandible to increase anterior
face height. The problem is that rotating the mandible
down also moves the chin back, so improving the face
height may make the mandibular deciency worse.
The most successful approach to growth modica-
tion in these patients is an activator or bionator type
of appliance, with contact of the mandibular incisors
against the palatal portion of the appliance and the
acrylic trimmed to allow eruption of the mandibular pos-
terior teeth. It may be necessary to tip the maxillary in-
cisors facially rst to allow mandibular advancement.
A less desirable alternative is cervical headgear because
it elongates the maxillary posterior teeth and rotates
the occlusal plane down posteriorly. It is better to in-
crease both the occlusal plane and the mandibular plane
angles during treatment.
Does the deepbite impede forward mandibular
growth? Occasionally, there is a burst of forward growth
as face height is increased, but this is the exception
rather than the rule. On the other hand, lengthening
the face is a quite successful form of growth modica-
tion.6 For Class II deepbite patients, trauma to the
palatal soft tissues or gingivae facial to the mandibular
incisors is an indication for beginning treatment before
adolescence.
In contrast, modifying the long-face pattern of
growth and controlling downward and backward rota-
tion of the mandible is difcult and, at least until
now, has been almost impossible. In theory, it should
be possible to impede downward growth of the posterior
maxilla with high-pull headgear and impede eruption of
the posterior teeth in both arches. In fact, even the
combination of high-pull headgear with a functional
appliance with bite-blocks is not successful in produc-
ing the desired skeletal changes.7 It is possible that an
adaptation of the technique for intrusion of the maxil-
lary posterior teeth to correct open bites after adolescent
growth, or bone plates across the zygomaticomaxillary
suture, can be used to diminish the downward growth
of the maxilla that is a key component of long-face
development, but there are as yet no data to conrm
that.8
July 2015  Vol 148  Issue 1
40 De Clerck and Proft

For modication of vertical growth, the conclusions

are the following. Can you produce downward and back-
ward rotation of the mandible and increase the face
height when this is required? Yes. Can you produce up-
ward and forward rotation of the mandible, or even
maintain its vertical position, in a patient with a long-
face pattern? Unfortunately, no, at least not yet.

CLASS III GROWTH MODIFICATION

Class III problems are a combination of possible
causes: decient maxillary growth forward and down-
ward and excessive mandibular growth forward, or de-
cient growth downward. Decient vertical growth allows
upward and forward rotation of the mandible and exac-
erbates a Class III problem; downward and backward
rotation alleviates it, but only if excess face height
does not become a problem instead. At present, there
are 3 major treatment methods, which will be discussed
separately.

Chincup effects on the mandible

Attempts to restrain mandibular growth go back to
the beginning of orthodontics and almost always involve
a cup or cap on the chin that is attached to the back of
the head (Fig 3). Although this produces an upward and
backward force, almost always the result is downward
rotation of the mandible, with minimal restraint of
growth in length of the mandible. Some data suggest
that chincup restraint is more effective at an early age,
but catch-up growth after early treatment tends to
wipe out any improvement.
If a patient with a large mandible also has a short
face, chincup treatment would be more valuable. For
that reason, it is widely acknowledged that wearing a
chincup during mandibular growth is more effective in
patients of Asian than of European or African descent,
simply because shorter face height is more likely in Asian
Class III patients. In contrast, most Americans and Euro-
peans with a Class III problem caused by excessive
mandibular growth also have a long face; for them, chin-
cup therapy is not effective.
Facemask effects on the maxilla
Until the pioneering work of Delaire9 with facemask
treatment in young children, orthodontists thought
that bringing the maxilla forward was impossible; efforts
to do that resulted only in proclination of the maxillary
teeth. It now is well established that protraction of the
maxilla can be accomplished with facemask therapy,
that skeletal change is more likely in children at age
8 years or younger, and that the upper limit for a positive
result is about age 10.10 Above that age, the outcome
Fig 3. Chincup for mandibular restraint circa 1900 (gure
from Angle EH. Treatment of malocclusion of the teeth
and fractures of the maxillae. 7th ed. Philadelphia: SS
White Dental Mfg Co; 1907). Angle was convinced that
it would work if patients really cooperated but acknowl-
edged his disappointment with the usual results.
usually is only tooth movement and downward and
backward mandibular rotation.
Disarticulation of the maxillary sutures by rapid
palatal expansion or an alternating expansion-
constriction of the midpalatal suture before traction
often is included in the standard facemask protocol.
However, in a randomized prospective clinical trial,
the amount of protraction of the midface was not
affected by rapid palatal expansion.11 The only indica-
tion for rapid palatal expansion in facemask patients,
therefore, is a severe constriction of the maxilla, so
that a crossbite would not be corrected as the maxilla
moved forward.
Some investigators have tried using bone anchors on
the maxilla to decrease tooth movement in the hope that
this would allow treatment at later ages, but the
improvement in skeletal change was small and inconsis-
tent.12 For most patients at any age, downward and
backward rotation of the mandible is part of the
response, which again means that short-face patients
are most likely to respond well.
Below, magnitudes of change with facemask treat-
ment are compared with the changes obtained with
the third method, Class III elastics to bone anchors.

July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
De Clerck and Proft
Fig 4. A, Start of intermaxillary bone anchored elastic traction; B, a biteplate to unlock the occlusion;
C-E, distalization mechanics with the xed appliance; F, 4 years out of retention.
Class III elastics to bone plates
The use of skeletal anchorage in Class III orthopedics
has 2 advantages: (1) it can be used to minimize both
dentoalveolar changes and downward and backward
mandibular rotation, and (2) with continuous light force
from Class III elastics, there now is evidence that greater
skeletal changes can be created than have been seen pre-
viously, with effects on the maxilla, mandible, and
temporomandibular joint. Because this method is rela-
tively new and has not been as thoroughly examined
as the treatment procedures discussed above, it will be
reviewed here in more detail.
The technical aspects will be considered rst. Mini-
plates are inserted on the infrazygomatic crest and in
the mandibular canine region and connected by elastics
day and night. In the maxilla, an intraoral incision and
reection of a ap are needed to allow placement of
the bone anchor above the alveolar process and the
attachment that projects into the mouth to emerge at
the proper location. To prevent dehiscence of the soft
tissues, the lower part of the bone anchor should be con-
toured so that it is in close contact with the bone surface
before the ap is sutured.13
To reduce the risk of bacterial inltration, it is impor-
tant that the perforation of the soft tissues through
which the intraoral part of the bone anchor enters the
oral cavity is located at the upper extent of the attached
gingiva. Furthermore, the section of the extension perfo-
rating the soft tissues should be round to facilitate oral
hygiene and good adaptation of the soft tissues around
the bone anchor. In the mandible, the plates should be
American Journal of Orthodontics and Dentofacial Orthopedics
41
inserted after eruption of the canines to reduce the risk
of damaging these teeth during xation of the screws.
Repeatedly loading the intraoral part of the bone anchor
by tongue or nger pressure should be avoided because
it may lead to bone loss and increased mobility of the
screws. That is why early loading is advocated to
neutralize the adverse effects from discontinuous
muscular forces.
The success rate of miniplates is mostly related to
the surgical procedure and the thickness and quality
of the bone, which varies from one location to
another.14 Cone-beam computed tomography (CBCT)
images can be helpful to choose the best places for
insertion of the screws. Especially in young children,
both the thickness and the density of the bone in
the infrazygomatic crest may be insufcient for good
mechanical retention of the osteosynthesis screws.
For this reason, the best stability of the skeletal
anchorage is obtained in children at least 11 years
old. Higher density and thickness of the external
cortical bone in the mandible results in a lower failure
rate than in the maxilla. At any age, mandibular bone
is more dense than maxillary bone, so 3 screws are
needed to stabilize the maxillary bone plates, but
only 2 are needed in the mandible.
A typical sequence of treatment is shown in Figure 4.
If at the start of treatment there is a reverse crossbite of
the incisors, a biteplate should be used to unlock the oc-
clusion and to facilitate forward movement of the
maxilla. This biteplate is worn day and night, and also
during eating. At every monthly checkup (needed for
July 2015  Vol 148  Issue 1
42
patients treated in this way), interdigitations in the bite-
plate or occlusal interferences should be eliminated.
It has always been assumed that higher forces are
needed for moving bones than for moving teeth. How-
ever, better clinical results are obtained with light
bone-anchored intermaxillary traction than with heavy
extraoral force from a facemask. More important than
the amount of force seems to be the loading protocol:
continuous intraoral forces give a better outcome than
intermittent extraoral traction. This probably is due in
part to better compliance with wearing intraoral elastics
than an extraoral facemask, but as a general rule, heavy
force is not required for growth modication. This has
been conrmed by both human experience and animal
experiments.15
In a typical treatment, the timing is similar to Class II
growth modication: intermaxillary traction is main-
tained for 12 months and is followed by treatment
with a xed orthodontic appliance. Because of growth
changes in the maxilla and the mandible, a Class III or
Class I molar occlusion is often transformed into a Class
II relationship that will need to be corrected in the xed
appliance stage of treatment.
In these maxillary-decient patients, there often is
insufcient space for the eruption of the maxillary ca-
nines. Usually some additional space is already obtained
by the protraction of the maxilla, resulting in an increase
of arch length in the molar region. More space can be
created using maxillary miniplates combined with the
xed appliance as anchorage to distalize the maxillary
molars and premolars (Fig 4). This can improve smile es-
thetics and tooth exposure, especially in patients with a
hypoplastic midface, and reduce the need for premolar
extractions. An alternative would be headgear to support
the distalization, but bone-anchored distalization me-
chanics depend less on compliance than does headgear
traction, and because the miniplates are inserted below
the zygomaticomaxillary suture, this will not result in
compression of the sutures, minimizing what would be
an undesired orthopedic effect with headgear.
After debonding, some relapse of the Class III growth
can still occur. In that case, additional intermaxillary
elastics may be needed for some time to maintain the
nal occlusion. Therefore, the miniplates should be
removed only after stabilization of growth.
Next, we consider facial changes. Extra forward
growth of the zygomaticomaxillary complex and re-
straint of the forward displacement of the bony chin
can result in an important reduction of the soft tissue
concavity and improvement of the overall expression
of the face. The upper lip is most affected by the protrac-
tion; the tip of the nose usually is slightly moved upward
and forward, whereas the chin becomes less prominent.
July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
De Clerck and Proft
Exposure of the maxillary dentition typically improves.
All these changes take place over a long period.
Cranial base superimpositions of CBCT images allow
a much better understanding of the changes produced
by treatment of this type. When there is considerable
variability in the treatment outcomes, the percentage
of various types of change in a series of consecutive pa-
tients provides a better understanding than statistics
based on the normal distribution. Figure 5 is a frontal
view of soft tissue changes in 25 consecutive patients,
all treated by the rst author and analyzed by colleagues
at the University of North Carolina.16,17
As shown in Figure 5, in the majority of the patients,
the midface and the maxilla, not just the maxilla, were
moved forward. This included forward movement of
the infraorbital area, the zygomatic arches, and the
nose. The mean advancement of the zygomatic arch
was 3.7 6 1.7 mm; for the maxillary incisor, it was
4.3 6 1.7 mm. The large standard deviations suggest
high variability, and Figure 5 shows that there were mid-
face advancements of 4 to 5 mm in 8 of the 25 patients
(32%) and 2 to 3 mm in 12 patients (48%). The nasal tip
moved upward by 1 to 2 mm as well as forward in those
who had midface advancement. But there was essen-
tially no maxillary or midface advancement (0-1 mm)
in 20% of the patients.
There also was an effect on the mandible in almost
every patient, with 4 to 5 mm of distal movement of
the chin in 3 patients (12%) and 2 to 3 mm in 5 patients
(20%). Distal movement of the chin in monkeys who had
a continuous force against the chin was reported in early
animal experiments but had not been seen in humans
previously. This would be possible, of course, only if
there was remodeling or relocation of the condylar fossa
and distal movement of the condyles, and this was
observed in the CBCT superimpositions in most patients.
Although the patients were growing during the treat-
ment period, the chin moved forward in only 5 (20%),
so there was some degree of growth restraint in 80%,
and in many patients there was an increase in the length
of the mandible without forward movement of the chin.
These skeletal effects underlying the soft tissue changes
are discussed in more detail below.
There were effects on the maxilla and the midface.
The maxilla is connected by sutures to the surrounding
bones. Animal experiments have clearly shown by histol-
ogy that traction across the posterior sutures of the
maxilla leads to increased bone formation and forward
displacement of the maxilla.18 Resistance against
separation of sutures depends on the total surface of
the suture and the complexity of the interdigitations,
and that is why the zygomaticomaxillary suture has
a much higher resistance to separation than the
De Clerck and Proft 43

Fig 5. Cranial base superimpositions from before to after 1 year (11-13 months) of intermaxillary trac-
tion for 25 consecutive maxillary-decient Class III adolescents. Red shows forward movement relative
to the cranial base; blue shows backward movement relative to the cranial base. (From Nguyen et al,16
with permission from Elsevier).

zygomaticotemporal and the zygomaticofrontal sutures.
This explains why not only the maxilla and the teeth but
also the zygomatic bone often move forward as 1 unit.
For the same reason, much larger separations are
observed all along the transverse palatine suture than
at the level of the tight junction between the pyramidal
process of the palatine bone and the pterygoid plates of
the sphenoid bone. In contrast to the zygoma, the pala-
tine bone seems not to be affected much by the forward
traction.
The center of resistance of the maxilla has been hy-
pothetically dened as at the buttress.19 Since the line
of force connecting both bone anchors is at a clear dis-
tance below the buttress, counterclockwise rotation of
the maxilla was initially expected. During protraction,
however, only a small amount of rotation occurs. There-
fore, the center of resistance of the zygomaticomaxillary
complex must be located close to the line of force with
intraoral traction, and more backward and downward
than the theoretical center of resistance of the maxilla.
Thanks to the pure skeletal anchorage, almost no den-
toalveolar compensations are observed at the level of
the maxillary incisors.
Since mild transverse crossbites are spontaneously
eliminated during the orthopedic correction as the
maxilla is brought forward, rapid maxillary expansion
is indicated for intermaxillary traction patients only
with severe transverse discrepancies between the 2 jaws.
There are signicant differences between both the
timing and the outcome of facemask protraction and in-
termaxillary traction. It is well known that interdigitation
of sutures increases with age, so protraction of the mid-
face can be obtained more easily in young patients. For
this reason, treatment with a facemask has always been
advocated before the age of 9 years. However, other pa-
rameters such as skeletal maturation and staging of the

American Journal of Orthodontics and Dentofacial Orthopedics July 2015  Vol 148  Issue 1
44
interdigitation of sutures on CBCT images may better
predict the orthopedic outcome in the future.
Despite being older (because bone anchors are less
stable at earlier ages), patients treated with bone-
anchored orthopedics without rapid maxillary expansion
at a mean age of 12 years showed about twice as much
maxillary forward displacement compared with a group
treated about 4 years earlier with a facemask preceded
by rapid palatal expansion.20 However, there was high
variability in the amount of protraction observed with
both protocols. Downward and backward rotation of
the mandible occurred in many facemask patients; this
was not observed in the intermaxillary traction patients.
There are effects on the mandible and temporoman-
dibular joint. Because facemask treatment is more suc-
cessful than chincup therapy, the adaptability of the
sutures to external factors has been considered greater
than the adaptability of condylar cartilage, and Class
III orthopedics have been focused mostly on stimulation
of maxillary growth. However, the forces generated by
bone-anchored elastics also pull the chin backward
and upward. This is in contrast to the more horizontal
reaction forces of the facemask applied to the chin.
That is why no posterior rotation of the mandible and
no increase of the vertical dimension of the face are
commonly observed with intermaxillary traction. Clock-
wise rotation of the mandible results in increased facial
convexity and is often wrongly interpreted as a restraint
of mandibular growth.
The increases in length of the ramus and the body of
the mandible in patients treated with intermaxillary trac-
tion are not signicantly different from those of a con-
trol group. However, the distance between the condyle
and the chin (condylion-gnathion) increases signi-
cantly less in a treated group than in the controls. This
is explained by a reduction of the gonial angle in the
treated group, vs its slight increase in the control group.
One would think that a reduction of the gonial angle
would project the bony chin more forward, but in
contrast to the control group, the gonial landmarks
moved posteriorly in the treated group. This swing-
back movement of the ramus is an important cause of
restriction of forward projection of the chin. The combi-
nation of a slight closure of the gonial angle and the
swing-back of the ramus explains why, despite similar
lengthening of the ramus and the body of the mandible
in treated patients and untreated controls, the chin pro-
jection is restrained without an increase of the mandib-
ular plane angle. The shape rather than the size of the
mandible is affected by the elastic traction.
Superimposition on the cranial base of the CBCT im-
ages before and after bone-anchored elastic traction
also shows posterior displacement of the condyles in
July 2015  Vol 148  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
De Clerck and Proft
about half of our treated patients. A high correlation
was found between the amount of displacement of the
anterior and posterior surfaces of the condyles and the
amount of apposition at the anterior eminence and
resorption at the posterior wall of the glenoid fossa (un-
published data, in preparation). This reects a moderate
relocation of the articular fossa; this also has been
observed as a response to Herbst appliance treatment,
but in the opposite direction.21,22
It also is true that the direction of condylar growth
could be modied by the force application. Similar to
the method of superimposition on metal markers of
Bjork and Skieller,23 a method for superimposition on
stable internal structures in the chin has been developed
(unpublished data, in preparation), and soon this will
give us better insight into whether the direction of
condylar growth is related to and can be inuenced by
the direction of the elastic traction.
Although almost no dentoalveolar changes are
observed in the maxilla, in nearly all intermaxillary trac-
tion patients a spontaneous decompensation of the up-
right mandibular incisors occurs. Why this occurs is not
yet clear. It could be explained by increased pressure by
the tongue and perhaps by reduced muscular force from
the lower lip. This repositioning of the mandibular inci-
sors, however, commonly results in a spontaneous
reduction of incisor crowding.
In comparison with chincup treatment, bone-
anchored traction does not produce downward and
backward rotation of the mandible but does produce ef-
fects on the shape of the mandible that have not been
observed in chincup patients. Would 3D studies of chin-
cup patients show changes at the condyles or mandib-
ular shape in those who do have a positive response to
treatment? Perhaps, but it appears that intermaxillary
traction produces much more predictable and greater
changes.
There are also effects in patients with cleft lip and
palate. In addition to the total bone surface and inter-
digitation of sutures, stretching of the intraoral and ex-
traoral soft tissue envelopes may contribute to the limits
of protraction of the midface. The impact of the soft tis-
sues on the resistance to the forward traction of the
maxilla is not known yet. Is there a maximum amount
of stretching? How much does it inuence relapse, and
how could it eventually be modied by external factors?
In cleft patients, scar tissues from the surgical closure of
the lips and soft and hard palates further restrict the for-
ward movement. The location and the amount of these
scar tissues certainly affect the amount of protraction of
the midface. It has not yet been established whether in-
termaxillary traction can overcome the restriction in for-
ward growth of the maxilla that frequently results from
De Clerck and Proft
cleft lip and palate correction. Three-dimensional imag-
ing data now being collected and analyzed will clarify
this possible use of the method.
Regarding intraoral traction vs orthognathic surgery,
do the changes during intermaxillary traction make a
difference in the need for later surgical repositioning
of the maxilla or both jaws? Although good data for
long-term outcomes with intermaxillary traction are
not yet available, several advantages are possible even
if the treatment effects are partially lost as the original
growth pattern continues after treatment. Improvement
of facial esthetics in teenagers instead of postponing a
surgical approach until completion of growth may
have a favorable effect on self-esteem and psychosocial
development of these young people during puberty.
Treated patients can more easily adapt to these relatively
slow changes than to the sometimes drastic facial trans-
formation obtained immediately after orthognathic sur-
gery, and the magnitude of surgical change needed after
intermaxillary traction would be expected to be less than
in patients who had no growth modication. Since
growth modication with intermaxillary traction is
completed at an older age than facemask treatment,
posttreatment changes also should be less than after
facemask treatment. Because of the high variability
and the lack of objective criteria for prediction of the
outcome, however, patients and parents should always
be told that orthopedic treatment never can exclude a
surgical approach after growth.
CONCLUSIONS
More than a century of research has shown that in
contrast to tooth movement, growth modication of
the face is hard to obtain. Many attempts have been
made to change proportional relationships during skel-
etal growth and to limit unwanted dental compensa-
tions. It appears that for the large part, this occurs
only within limits of average change of a few millimeters.
Although larger changes are seen in some patients, it is
difcult to be sure that much of this is not a growth
change that would have occurred without treatment.
Recently in Class III growth, miniplate anchorage
combined with light forces from continuous intermaxil-
lary elastic traction has shown a better outcome than
tooth-supported appliances for maxillary protraction
or chincup restraint of the mandible, achieving greater
skeletal changes with less displacement of the dentition.
Three-dimensional imaging with accurate and repro-
ducible registrations on the anterior cranial base and
the mandibular symphysis make it possible now to study
much better the real effects on the growth of the jaws,
distinguishing this growth from dental and overall facial
American Journal of Orthodontics and Dentofacial Orthopedics
45
changes. There is no doubt that within certain limits, at
least in the short term, some modication of growth of
the different components of the midface can be ob-
tained with intermaxillary traction. In some cases, this
may be sufcient to avoid orthognathic surgery or at
least reduce the severity of the surgical correction
needed after completion of growth. Individual variations
in treatment outcomes, however, are high. For all types
of growth modication, better biomarkers are needed
to predict the outcome and to dene guidelines and
indications for an orthopedic approach in growing
children.
REFERENCES
1. Akkaya S, Lorenzon S, Ucem TT. Comparison of dental arch and
arch perimeter changes between bonded rapid and slow expansion
procedures. Eur J Orthod 1998;20:255-61.
2. McNamara JA Jr, Baccetti T, Franchi L, Erberger TA. Rapid maxillary
expansion followed by xed appliances: a long-term evaluation of
changes in arch dimensions. Angle Orthod 2003;73:344-53.
3. Vaid NR, Doshi VM, Vandekar MJ. Class II treatment with func-
tional appliances: a meta-analysis of short-term treatment effects.
Semin Orthod 2014;20:324-38.
4. Tulloch JFC, Phillips C, Koch G, Proft WR. The effect of early
intervention on skeletal pattern in Class II malocclusion: a ran-
domized clinical trial. Am J Orthod Dentofacial Orthop 1997;
111:391-400.
5. Thiruvenkatachari B, Harrison JE, Worthington HV, O'Brien KD.
Orthodontic treatment for prominent upper front teeth (Class II
malocclusion) in children. Cochrane Database Syst Rev 2013;
(11):CD003452.
6. Franchi L, Baccetti T. Prediction of individual mandibular changes
induced by functional jaw orthopedics followed by xed appli-
ances in Class II patients. Angle Orthod 2006;76:950-4.
7. Freeman CS, McNamara JA Jr, Baccetti T, Franchi L, Graff TW.
Treatment effects of the bionator and high-pull headgear combina-
tion followed by xed appliances in patients with increased vertical
dimensions. Am J Orthod Dentofacial Orthop 2007;131:184-95.
8. Schefer NR, Proft WR, Phillips C. Outcomes and stability in pa-
tients with anterior open bite and long anterior face height treated
with temporary anchorage devices and a maxillary intrusion splint.
Am J Orthod Dentofacial Orthop 2014;146:594-602.
9. Delaire J. Maxillary development revisited: relevance to the ortho-
paedic treatment of Class III malocclusions. Eur J Orthod 1997;19:
289-311.
10. Wells AW, Sarver DM, Proft WR. Long-term efcacy of reverse-
pull headgear therapy. Angle Orthod 2006;76:915-22.
11. Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxil-
lary protraction therapy with or without rapid palatal expansion: a
prospective, randomized clinical trial. Am J Orthod Dentofacial Or-
thop 2005;128:299-309.
12. Sar C, Arman-Ozcirpici C, Uckan S, Yazici AC. Comparative evalu-
ation of maxillary protraction with or without skeletal anchorage.
Am J Orthod Dentofacial Orthop 2011;139:636-49.
13. Cornelis MA, Schefer NR, Mahy P, Siciliano S, De Clerck HJ,
Tulloch JF. Modied miniplates for temporary skeletal anchorage
in orthodontics: placement and removal surgeries. J Oral Maxillo-
fac Surg 2008;66:1439-45.
14. De Clerck EE, Swennen GR. Success rate of miniplate anchorage for
bone anchored maxillary protraction. Angle Orthod 2011;81:1010-3.
July 2015  Vol 148  Issue 1
46 De Clerck and Proft

15. Liu SS, Kyung HM, Buschang PH. Continuous forces are more
effective than intermittent forces in expanding sutures. Eur J Or-
thod 2010;32:371-80.
16. Nguyen T, Cevidanes L, Cornelis MA, Heymann G, de Paula LK, De
Clerck H. Three-dimensional assessment of maxillary changes
associated with bone anchored maxillary protraction. Am J Orthod
Dentofacial Orthop 2011;140:790-8.
17. De Clerck H, Nguyen T, de Paula LK, Cevidanes L. Three-dimen-
sional assessment of mandibular and glenoid fossa changes after
bone-anchored Class III intermaxillary traction. Am J Orthod Den-
tofacial Orthop 2012;142:25-31.
18. Kambara T. Dentofacial changes produced by extraoral forward
force in the Macaca irus. Am J Orthod 1977;71:249-57.
19. Teuscher U. An appraisal of growth and reaction to extraoral
anchorage: simulation of orthodontic-orthopedic results. Am J Or-
thod 1986;89:113-21.
20. Hino CT, Cevidanes LH, Nguyen TT, De Clerck HJ, Franchi L,
McNamara JA Jr. Three-dimensional analysis of maxillary changes
associated with facemask and rapid maxillary expansion compared
with bone anchored maxillary protraction. Am J Orthod Dentofa-
cial Orthop 2013;144:705-14.
21. Ruf S, Pancherz H. Temporomandibular joint growth adaptation in
Herbst treatment: a prospective magnetic resonance imaging and
cephalometric roentgenographic study. Eur J Orthod 1998;20:
375-88.
22. LeCornu M, Cevidanes LH, Zhu H, Wu CD, Larson B, Nguyen T.
Three-dimensional treatment outcomes in Class II patients treated
with the Herbst appliance: a pilot study. Am J Orthod Dentofacial
Orthop 2013;144:818-30.
23. Bjork A, Skieller V. Growth of the maxilla in three dimensions as
revealed radiographically by the implant method. Br J Orthod
1977;4:53-64.

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