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M--Effect of Orthodontic Facemask as a Treatment for Children in Growth and Development Period: A Systematic Review

Harun Achmad1, Nurul Faizah2

1Lecturer department of Pediatric Dentistry, Faculty of Dentistry, Hasanuddin University, Indonesia

2Clinical Dental Student, Faculty of Dentistry, Hasanuddin University, Indonesia Hasanuddin University, Indonesia

E-mail Correspondence: [email protected] ABSTRACT

Background:Different mixed dentition in treatment strategies, orthodontic facemask give the most satisfactory results in the shortest period of time. The orthodontic facemask is the general appliances of choice for the majority of class III patients who experience early and late mixed dental phases especially with maxillary retrognathism.Aim: To review an article on the effect of orthodonyic facemask treatment on a child's growth and developmental period.Methods:Data was collected by searching the literature on article search sites, namely Google search and Pubmed published from 2013-2020, the search was carried out in January 2021. The search for data was carried out systematically using the keywords Facemask Orthodontics, Growth and Development, Children.Results:After eliminating duplicate articles, the titles and abstracts of each article were analyzed across 78 articles resulting in an exclusion of 84 articles. The full-text articles in the remaining 47 articles were re-analyzed and excluded 37 articles and produced 10 articles which were then entered into the analysis.Conclusion:Based on collected systematic review articles, with the excellent patient cooperation to treatment Class III malocclusion cases, orthodontic facemasks are the most appropriate and effective treatment during childrengrowth and development.

Keywords:Orthodontic Facemask, Growth and Development, Children

INTRODUCTION

In the era of globalization, the demand for and services for orthodontic care for children continues to increase from time to time. Originally, demand and services focused more on orthodontic curative action against malpositions of fixed teeth, but nowadays more demand and

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orthodontic science in children, especially in the field of preventive and interceptic orthodontics, has been in line with the government's program in the field of dental and oral health services in a tiered and integrated manner; however, the implementation in the field is still a complex problem.4,5From the limitations and scope of orthodontics, it means that in the field of Pediatric Dentistry and Pediatric Dental Dentists have a considerable share and responsibility in developing the field of pediatric orthodontics, both in clinical and theoretical aspects.6,7

Of the different mixed dentitionin treatment strategies, orthodontic facemasks provide the most satisfactory results in the shortest period of time. The orthodontic facemask is the tool of choice for most of the class III patients who have mixed early and late dentition phases especially with maxillary retrognathism.8Class III malocclusion is usually growth-related and becomes more severe when growth is over. This is the main reason for the difficulty to manage in developing Class III cases.9It is imperative to take advantage of the patient's growth potential and facemask therapy during the maxillary growth period plays an important role in the successful correction of maxillary deficiency.10Therefore, the authors are interested in making a systematic review article on the effects of orthodontic facemask treatment on child’s growth and development.

METHODS Data source

The data was collected by searching the literature on article search sites, namely google search and Pubmed which were published from 2013 to 2020, the search was carried out in January 2021. The search for data was carried out systematically using the keywords facemask orthodontics, growth and development, children.

KriteriaPenelitian

A. Inclusion criteria

1. Articles published from 2013-2020 2. Articles in English

3. Published scientific articles available online

4. An article that examines orthodontic facemask treatment during children’s growth and

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B. Exclusion criteria

1. Articles that cannot be accessed for free.

2. Articles that do not discuss the use of orthodontic facemasks during children’s growth and development.

Data collection

The data that will be used in this research are secondary data. The data is obtained from articles that are searched for in the article database which will then be reviewed according to the research criteria set by the researcher.

Research Procedures

1. Literature search was conducted on the online database google search and PubMed. In addition, a search for the list of references to articles that fall into the inclusion criteria was also carried out to find out whether there were other related studies that were relevant to this research.

2. Determination of the keywords carried out in the literature search, namely orthodontic facemasks, growth and development, children.

3. Eliminate duplicated literature.

4. Articles are filtered on the basis of title, abstract, and keywords.

5. Read complete or partial articles that have not been eliminated to determine whether the article meets the eligibility criteria.

6. Data collection was done manually by creating a research matrix containing: author's name, year, title, and conclusion.

7. Processing the data that has been obtained

The literature search was carried out on the online database, Pubmed, using keywords, namely orthodontic facemasks, growth and development, children.

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Figure 1.A diagram showing the selection of articles for review

The literature search was carried out on the online database, Pubmed, using keywords, namely orthodontic facemasks, growth and development, children.

RESULTS

Table 1.The Effect of Orthodontic Facemask Treatment on Children’s Growth and Development

No. Authors Years Titles Methods Conclusion

Excluded articles: (N=37)

- Article not on topic (n=37)

Excluded articles: N=37

- - Systematic review articles (12)

Articles found in an online database (N=84) using keywords, namely orthodontic facemasks, growth and development,

children

The number of articles after the duplicated articles are removed

(N= 47)

Total journals obtained for synthesis (N=10) The complete journal article

text is assessed for its eligibility (N=10) Ident

ificat ion

Eligi bility

Inclu ded Scre enin g

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1. Manuel Nienkemper,

Benedict Wilmes, Alexander Pauls, Dieter Drescher11

2013 Maxillary protraction using

a hybrid hyrax-facemask

combination

Treatment of 16 children (mean age 9.5 ± 1.3 years) was investigated clinically and by means of pre- and post-treatment

cephalograms.Changes in sagittal and vertical, and dental

and skeletal values were evaluated andtested for

statistically significant differences.

The hybrid hyrax- facemask combination seems to be effective for

orthopaedic treatment ingrowing class III patients. Unwanted maxillary dental movements can be avoided due to stable

skeletal anchorage.

2. Gregory W.

Jackson, Neal D.

Kravitz12

2014 Expansion/Facem ask Treatment of an AdultClass III Malocclusion

A 19-year-1-month-old Caucasian female presented with achief complaint of “I do not like

my underbite.” Her medical history was noncontributory. She

had a symmetrical, mesofacial face and a concave soft tissue profile. Herupper lip was slightly

retruded. She presented with maxillaryhypoplasia and flat malar eminences. She had a permanentdentition with class III

malocclusion in both molars andcanines.The maxillary arch

was tapered withmoderate crowding and the mandibular arch was ovoid withmoderate

crowding.

This case demonstrates that, given excellent patient cooperation,it is possible to treat an adult class III malocclusion

with

maxillary expansion and a protraction facemask.

3. Dr.

SaibaliniPani, Dr.

SnigdhaPattanaik , Dr. Subhrajeet Narayan Sahoo13

2017 Reverse Pull Headgear

For treating skeletal Class III malocclusion with a retrusivemaxilla and a hypodivergent growth pattern.presenting initially with

some degree of anterior mandibular

shift and a moderate overbite have an improved treatment prognosis.Correcting the anterior

crossbite usually results in a downward and backward

rotation of the mandible thatdiminishes its prognathism.

In many of the mild to moderate and some rather severe ClassIII

problems facemask therapy produces a pronounced occlusal

change within a relatively short period.

When used withcaution this type of treatment has proven extremely

rewarding in a wide variety of Class III conditions.

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4. Aby Abraham, Elbe Peter, Koshi

Philip, Mukundan V, Jinu George, R.

Sreevatsan14

2013 Early

management of class III malocclusion with

bonded maxillary expansion and facemask therapy

- A case report

A 10 year old girl came with the chief complaint of anterior cross bite to Orthodontic department.

Patient had no relevant medical and dental history. On extraoral examination, the facial profile was concave, anterior divergent

face and acute nasolabial angle

Patient was treated for a period of six months with rapid maxillary

expansion and facemask. Significant

improvements were obtained in facial profile and anterior cross bite correction

was achieved.

5. Dennyson Brito Holder da Silva, Ariane Salgado

Gonzaga15

2020 Importance of orthodontic intervention of the

Class III malocclusion in mixed dentition

Upon extraoralexamination, the patient's face

revealed typical characteristics of Class III malocclusion, with a deficiency of the middle

third of the face, without zygomatic projection, showing the sclera in the lower part of the iris

and active lip sealing.

In frontal view, there was a slight facial asymmetry with mandibular deviation to the

right, while

in lateral view it showed a concave profile, with a chin-neck line apparently adequate to the face size.

The intervention and supervision of skeletal

Class III performed in patients before the growth spurt,

associated with the interception of

deleterious oral habits and effective and efficient orthodontic

mechanics are decisive factors for the

success of orthodontic treatment of this malocclusion.

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6. SemaYüksel, Tuba TortopÜçem,

Alaaddin Keykubat16

2013 Early and late facemask therapy

The materialconsisted of lateral cephalometric radiographs of 34

subjects with Class III malocclusionstreated with a Delaire type facemask. Two groups of 17 patients each were

formed: an early(six girls, 11 boys) and a late treatment group

(eight girls, nine boys). At the beginning of

treatment, the mean ages were 9 years 8 months for the early treatment group and 12 years6

months for the late treatment group. The average treatment

time was 7 months for bothgroups. A control group consisting of 17 children with a

mean age of 9 years 5 months wasformed that matched only the

early treatment group according to age, and sagittal dentaland

skeletal relationships. To differentiate the orthodontic and

total effects of the Delairetype facemask, superimpositions were

made.

In both age groups, significant forward movementof the maxilla

was observed at the end oftreatment.Evaluation of the superimpositions showedthat in both age

groups there was a significantforward movement of the upper

incisor and molars.

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7. Sourabh Agrawal, Roopak

D. Naik, Anand K Patil, Harshavardhan

Kidiyoor17

2015 Customized petit type facemask for

class III correction

Under these conditions custom made petit facemask for increased patient compliance,

ease of adjustment and cost effectiveness is a viable

alternative.

In this era of customization where

even orthodontic brackets are customised

and treatment modalities like Invisalign are gaining

popularity, the orthodontist has to

strive for efficient appliance with perfect

adaptation. Custom made appliances using

3-D printing utilizing data from cone beam computer tomography may be the answer. The

current idea of customization of facemask for patient

comfort is a good beginning in this

direction.

8. Cordasco G, Matarese G, Rustico L, Fastuca S, Caprioglio A,

Lindauer SJ, Nucera R18

2014 Efficacy of orthopedic treatment with

protraction facemask on

skeletal Class III malocclusion: a systematic review and meta‐analysis

Inclusion criteria – randomized controlled trials (RCTs) of orthodontic treatments to correct

Class IIImalocclusions in children and

adolescentsDatabases searched – CENTRAL, MEDLINE, and EMBASEDates searched – 1966

to January 2013 as appropriateOther sources of evidence – hand searching of

reference listsLanguage restrictions – none.

Population – patients with skeletal Class III

malocclusion Intervention – orthopedic protraction

facemask treatment Comparison – untreated

patients with skeletal Class III Outcome – the following cephalometric

angles: ANB, SNA, SNB, SN‐mandibular

plane and SN‐palatal plane

were evaluated.

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9. Bhatnagar A19 2020 Correction of Class III Malocclusion in a Growing Child: A

Case Report

A 8 year old healthy female patient reported with the chief complaint of forward placement of lower front teeth as compared to upper front teeth with large

lower jaw. On extra oral examination, patient’s facial profile was concave, anterior divergent face and obtuse nasolabial angle. Lower lip was

positioned ahead of the upper lip.

The case focuses on early management of class III malocclusion, thus providing normal

skeletal, dental development along with

psychological development, in later ages. Combination of maxillary expansion

with the use of protraction appliance will increase the amount

of skeletal effect.

10. Simon

Watkinson20

2014 Orthodontic Treatment for Prominent Lower Front Teeth (Class

III Incisors) in Children: A

Cochrane Systematic

Review

The following databases were searched up to 7th January 2013:

Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, EMBASE via OVID.

Selection criteria: All randomised controlled trials of orthodontic treatments to correct

Class III incisors. Trials were eligible for inclusion in the review if they recruited children

and/or adolescents (aged 16 or less) receiving orthodontic treatment to correct Class III incisors. Trials including patients

with a cleft lip and/or palate or other cranio-facial deformity/syndrome were excluded as were trials that had recruited less than 80% children or adolescents or patients who had previously received surgical

orthognathic treatment. Active interventions included:

orthodontic braces, chin cups, facemasks, reverse headgear, bone-anchored appliances or any

There is some evidence that the use of a facemask, to correct prominent lower front

teeth in children, is effective when compared to no treatment on a short term basis. However, in view of the general poor quality of the included

trials, these results should be interpreted with caution. Further randomised controlled trials, with long follow-

up, are required.

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DISCUSSION

In recent years, facemask therapy with and without associated palatal expansion has become a common technique used to correct hypoplastic maxillary class III malocclusion.21Maxillary expansion has been recommended as a routine part of Class III treatment due to maxillary deficiency, however, the critical evaluation of expansion with respect to maxillary protraction has been limited.

Therefore, the aim of this study was to examine the bone, tooth and soft tissue effects of facemask therapy with and without associated maxillary expansion. The results of this study indicated that facemask therapy with and without RME caused significant bone and dentoalveolar changes in adolescent Class III patients.22,23

Fixed device therapy after facemask use is required in this case to treat occlusion. The ideal age for facemask therapy is generally for the initial case of mixed teeth. But if the patient also presents with late mixed teeth, the ideal treatment for class III due to maxillary deficiency is a facemask of RME.25,26If facemask therapy is used at the start of mixed teeth, considerable time may elapse before the final phase of fixed appliance treatment can begin. Several stages of orthodontic intervention may be required, and therefore this patient should be monitored until all major facial growths have been completed (Figure 2 and Table 1).14

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- A case report. International Dental Journal of Students Research;4(4):202-206.14 Table 1.Optimal time to start facemask therapy

Source:Abraham A, Peter E, Philip K, Mukundan V, George J, Sreevatsan R. Early management of class III malocclusion with bonded maxillary expansion and facemask therapy - A case report. International Dental Journal of Students Research;4(4):202-206.14

According toNienkemper et al11that significant skeletal repair of the sagittal plane can be achieved, as demonstrated by changes in SNA and WITS assessments. A meta-analysis of the treatment effects achieved with conventional and facemask RME showed an increase in SNA of 1,4°.11,24The results of the current investigation indicated a higher effectiveness associated with the maxillary anterior case.27,28,29,30

The decision for maxillary protraction is evidenced by the literature that Class III facemask treatment is the most preferred choice for retrognatic maxillary correction.31,32,33,34

The study showed significant favorable results in correction of dental variables, such as positive changes in the Wits analysis index and correction of patient overjet.35,36,37,38,39,40

These previously reported characteristics corroborate the outcome of this clinical case culminating in an increase in the Wits analysis value from -4 mm before treatment to +1 mm after treatment, and adequate overjet and overbite. In addition, differences in chin size between men and women as well as between different population groups make the adjustment of prefabricated face masks for different populations difficult. The custom-made facemask presented here are perfect for the patient at a very economical

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patient have been described by Migliaccioet al.46andKamatchi et al.47with protraction of the maxilla and chin, and Suresh48 andBuwembo49 andusing palatal expansion with facemask. Various soft tissue changes are combined to enhance the class III profile of the patient. The profile becomes more convex due to the forward movement of the upper lip and the retraction of the lower lip, the soft tissue pogonion moves backward and the menton moves downward as described byWinnier et al.50,51,52,53,54,55

CONCLUSION

Based on collected systematic review articles, with the excellent patient cooperation in treatment of Class III malocclusion cases, orthodontic facemasks are the most appropriate and effective treatment during children’s growth and development.

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