Title

Early Facemask Protraction in Class III Children Reduces the Later Need for Orthognathic Surgery; Short-term Skeletal Gains are Clear, but Long-term Cephalometric Changes Diminish

Clinical Question

In children with skeletal Class III malocclusion, does early orthopedic treatment with a protraction facemask, compared with no early treatment or delayed intervention, improve skeletal/occlusal outcomes and reduce the future need for orthognathic surgery?

Clinical Bottom Line

For 7- to 9-year old children with Class III malocclusion, early treatment with a protraction facemask makes it less likely they’ll need jaw (orthognathic) surgery as teenagers or young adults. About 36% of those treated needed surgery at six-year follow-up, compared to 66% who did not have early treatment (OR 3.34, 95% CI 1.21-9.24; p=0.027). Short-term x-ray (cephalometric) measurements show meaningful jaw movement with treatment (approximately +2° SNA, -1.5° SNB, +3.7° ANB). However, studies that followed children for three years or longer found that these jaw movement gains usually do not last-differences fade over time and are not significant after about three years. The best results occur in children who are young, whose jaws are still growing, and who can wear the appliance as directed (about 14 hours per day). Families should understand that the main goal is improving the odds of a healthy bite and possibly avoiding surgery, rather than hoping for a permanent jaw correction.

Best Evidence

PubMed ID	Author / Year	Patient Group	Study type (level of evidence)
27564126	Mandall 2016	73 UK children, 7-9 y, randomized to facemask (n=35) vs control (n=38); per-protocol n=65; 6-year follow-up.	Randomized Controlled Trial
Key results	36% facemask patients needed surgery vs 66% of controls (p = 0.027; OR 3.34, 95% CI 1.21-9.24). No long-term skeletal cephalometric difference, but positive overjet was maintained in 68% of treated patients. Results indicate a clinically important reduction in surgery risk even though skeletal changes relapsed radiographically.
24725349	Cordasco 2014	3 RCTs, n=155 (92 treated, 63 controls) growing Class III patients	Systematic review of randomized trials
Key results	Short-term cephalometric effects showed ANB +3.66° (95% CI 2.58-4.74), SNA +2.10° (1.14-3.06), SNB -1.54° (-2.13 to -0.95). All differences were statistically significant and clinically relevant, representing a forward movement of the maxilla and posterior rotation of the mandible within the typical 2°-4° change considered orthodontically meaningful. However, no long-term follow-up data were included.
28024779	Woon 2017	15 studies (9 RCTs, 6 CCTs), children ages 7-12.	Meta-Analysis
Key results	Short-term pooled results showed reverse overjet mean difference +2.5 mm (95% CI 1.21-3.79; p = 0.0001) and ANB +3.90° (95% CI 3.54-4.25; p < 0.0001). These represent clinically significant improvements in maxillary position and occlusion. The authors noted moderate evidence quality and highlighted the absence of long-term data and the heterogeneity due to varied protocols and appliance designs.
27564126	Lee 2021	17 studies (4 RCTs + 13 cohorts) of growing Class III; long-term outcome.	Meta-Analysis
Key results	In the short-term, SNA increased after facemask +2.29° (95% CI 1.48-3.09; p < 0.001) and after FM + RME +1.73° (0.84–2.62; p < 0.001). ≥3 years follow-up: SNA difference not significant (MD 0.28°, 95% CI -0.57 to 1.13). Meta-regression confirmed the skeletal effect declines over time. Confidence intervals narrow in short-term studies but broaden with duration, indicating less predictable long-term stability.

Evidence Search

("Malocclusion, Angle Class III"[Mesh] OR "Class III" OR "reverse overjet") AND ("Protraction Headgear" OR facemask OR "reverse headgear" OR "maxillary protraction" OR "protraction facemask") AND (child OR adolescent OR pediatric OR growing) AND (randomized controlled trial OR controlled clinical trial OR randomized OR randomly OR trial) Filtered for: meta-analyses and/or systematic reviews published in 2010 or after

Comments on
The Evidence

Mandall 2016: Strongly designed randomized trial with six-year follow-up. The main outcome (surgery need) was judged objectively, and both groups could get limited orthodontic care later, which avoided denying care but may influence results. Only included white Caucasian patients-results might not apply to all ethnicities. Cordasco 2014: Focused only on RCTs, so provides high internal validity. Found consistent short-term skeletal improvements but did not assess long-term changes. Woon 2017: Included both RCTs and controlled clinical trials, increasing sample size. Showed short-term improvements but long-term benefits were unclear due to high/unclear risk of bias and less data. Lee 2021: Analyzed longer-term outcomes, showing that any skeletal jaw position gains disappeared after about three years. The main outcome was SNA angle, and evidence quality was rated moderate. Focused on SNA as a long-term measure.

Applicability

Best candidates are children ages 7-9 with midface retrusion (maxillary deficiency), anterior crossbite and good compliance. The studies collectively demonstrate clinically meaningful short-term skeletal improvements of roughly 2-4° ANB and 2-3 mm negative overjet correction, translating to visibly improved profile and occlusal relationships. However, while CIs across all meta-analyses in the short term indicate consistent benefit, CIs in long-term data (specifically: Lee 2021 MD 0.28°, 95% CI -0.57-1.13) show that the skeletal benefit becomes uncertain and clinically negligible over time. Short-term orthopedic benefits are both statistically and clinically significant but tend to revert within approximately 3 years, suggesting that early facemask therapy is valuable for guiding favorable growth and delaying surgery, rather than permanently eliminating its need. Limitations: Treatment requires an expander (RME) and facemask, and consistent wear. Some discomfort or skin irritation may occur. Without retention appliances, relapse is possible—individual dentists may use retention, but this could change results compared with published studies. Most research is on Caucasian children, so results may differ elsewhere (e.g., Asian populations, where Class III is more common).

Specialty

(Orthodontics)

Keywords

Headgear, facemask, class III

ID#

3595

Date of submission

10/24/2025

E-mail

dubavsov@livemail.uthscsa.edu

Author

Igor Dubavsov, DDS

Co-author(s)

Co-author(s) e-mail

Faculty mentor

Sandra Andari, DDS, MS

Faculty mentor e-mail

andari@uthscsa.edu

Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)

None available

Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs)

None available