An occasionally irregular blog about orthodontics

Treatment of Class III Malocclusion

Treatment of Class III Malocclusion

Treatment of Class III Malocclusion: A new Cochrane Review


Well, I am now recovering from what is termed “minor” surgery. The first step in my process of seeking care was to have a really good look at the relevant Cochrane Reviews.   The reviews were useful but were not conclusive, as is unfortunately the case with many Cochrane reviews.  So I had an informed discussion with the consultant and went along with her recommendations!

However, we need to consider if an inconclusive review is of no value? I feel strongly, that regardless of the overall conclusions, all Cochrane reviews are useful in enabling us to help our patients to take their treatment decisions.   If we have no strong evidence for potential treatments, it is clear that we should inform our patients that this is the case and help them take treatment decisions.

I was, therefore, pleased to see the recent Cochrane review into the treatment of  Class III malocclusion.  You can access this here

This was carried out by a team based in Liverpool and Manchester.  I and Bill Shaw had advised on the initial stages of the review protocols and it was great to see this review published.  So well done Jayne and the team.

As with all Cochrane reviews, this was a very precise review and carried out to a very high standard. Having done several reviews, you have no choice to carry it out to their standards and these are a lot of work.

The aims of the review were to evaluate the treatment of Class III malocclusion in children and adolescents.  Inclusion criteria for papers were RCTs of studies of treatment for people under 16 years old.  The interventions were confined to orthodontics only, they did not evaluate orthognathic treatment.  They identified 440 potential papers for inclusion and this was reduced to papers reporting 7 studies that were included.  All the studies were carried out in children under 11, in University Hospital settings.

Class III Facemask

Class III Facemask


The treatments were provided with Facemasks or a variant of a chin cup.







They concluded that only one of the studies was of low risk of bias. This was the UK-based study by Nicky Mandall and her co-workers.

The outcomes that were reported were concerned with skeletal relationship and overjet. These, of course, are the traditional orthodontist derived measurements that may not have any meaning for our patients. Only the study by Nicky Mandall considered self-esteem and she reported that there was some change in self-esteem, for the treatment group when compared to control, following treatment but this had “washed out” after a couple of years follow-up.

They concluded that there was low quality evidence that the use of facemask therapy between the ages of six and ten years leads to a short-term improvement in reverse overjet and ANB.  There was insufficient evidence to describe any long-term benefits.

Overall comments

Does this paper change my practice?  This needs careful thought, I had always been very skeptical on the effectiveness of facemask therapy for Class III malocclusion and I have never carried out this treatment.  Yet this review suggests that it does have a treatment effect.  I looked at the review closely, particularly the Forest plots (which are a great way of presenting data).  These were very useful and showed that the use of facemask when compared to an untreated control there was a mean difference in ANB of 3.8.  This is clinically significant.

As a result, I am going to change my clinical practice and describe the results of this review to my patients and explain to them that in the short-term there is some evidence that facemask treatment is useful. However, I will also let them know that these are only short-term studies and that long-term results are not available.  They can then take an evidenced based decision.

It is perfectly possible that these results may mirror the results of the studies into the early treatment of Class II malocclusion which revealed that this was of minimal benefit. But more of that later as our Cochrane review into Class II treatment is due to be published any day.

One final comment that I would like to make on this review is that it did not include any research into methods of mid face protraction using bone anchors as described by Hugo DeClerc. This work looks really interesting and it would be great to see some trials carried out into this promising looking treatment method.

It was great to see another review providing useful treatment to help our patients take decisions.

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There Are 5 Comments

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  1. Anand Srinivasa says:

    Hi Kevin,

    Firstly thanks for the info on Cl 3 treatment in children aged between 7-10 years. Unlike you I have always been using Facemasks for treating skeletal Cl 3 cases demonstrating either a pure maxillary retrognathism or a combination of max retrognathism and mandibilar prognathism. With insufficient reliable data on the subject it was always really hard to sleep well at night knowing if you are doing the right thing by the patient. However achieving a positive overjet with relative improvement in facial profile always justified the means. The results of the study does make it a lot easier to explain to the patient that this form of treatment is evidence based to an extent

  2. Tony Kilcoyne says:

    Hi Kevin,
    The final comment you made about mid-face protraction using plates/elastics was very interesting too.

    Do you think this could perhaps be more easily/readily done using mini-screw implants straight through the mucosa alone, rather than plates?

    If so it would make application in young children easier and less traumatic clinically, including ease of removal too.

    Yours curiously,


  3. Raj says:

    Hi Kevin, Thank you for hosting a great Blog!
    I have heard that there is some thought about “mobilizing” the maxilla using Mini-implant Assisted Rapid Palatal Expanders (MARPE) and then using Protraction methods such as the Reverse HG , Class III Carriere, etc. MARPEs have been shown to create midface sutural expansion and reduce the “extrusive” effects of therapy. I have a few patients that I have started the MARPE with the hope of protracting the maxilla during growth.
    Is anyone aware of any studies or case reports with such a protocol?

  4. A worried mum says:

    Hi Kevin
    I am the parent of a child with maloclussion class 3. He is a young 11 year old. We have visited the orthodontist and he reports that his upper jaw does not have enough space and he will need teeth removed from his upper jaw and braces and then when he stops growing he will probable require surgery. I find this ridiculous that you would remove teeth due to a small jaw and then make the big Jaw smaller. In the growing jaw surely it would make sense to encourage growth of the smaller upper jaw. I have Googled as we mothers do, and wondered your thoughts on the upper jaw expander and whether you were aware of any trails or who I should contact for more information. My sons orthodontist does not want to see him for a year, and wants to wait. I am really not happy with this situation especially as all the research suggests underbite get worse naturally not better.
    Please help

    • Kevin O'Brien says:

      Hi, sorry for the delay in getting back to you. I think that you could ask your dentist to refer you to a local consultant orthodontist who works in a hospital for a second opinion. This service is readily available. You can discuss this with your dentist. I hope that this works out for you.

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