Early class III orthopaedic treatment, with protraction facemask, in patients under 10 years of age, is skeletally and dentally effective in the short term and does not result in TMJ dysfunction. Seventy per cent of patients had successful treatment, defined as achieving a positive overjet. However, early treatment does not seem to confer a clinically significant psychosocial benefit.

Objective: To evaluate whether patients who had received early class III protraction facemask treatment were less likely to need orthognathic surgery compared with untreated controls. This paper is a 6-year follow-up of a previous clinical trial. Design: Multi-centre 2-arm parallel randomized controlled trial. Setting: Eight United Kingdom hospital orthodontic departments. Participants: Seventy three 7- to 9–year-old children. Method: Patients were randomly allocated, stratified for gender, into an early class III protraction facemask group (PFG) (n = 35) and a control/no treatment group (CG) (n = 38). The primary outcome, need for orthognathic surgery was assessed by panel consensus. Secondary outcomes were changed in skeletal pattern, overjet, Peer Assessment Rating (PAR), self-esteem and the oral aesthetic impact of malocclusion. The data were compared between baseline (DC1) and 6-year follow-up (DC4). A per-protocol analysis was carried out with n = 32 in the CG and n = 33 in the PFG. Results: Thirty six percent of the PFG needed orthognathic surgery, compared with 66% of the CG (P = 0.027). The odds of needing surgery was 3.5 times more likely when protraction facemask treatment was not used (odds ratio = 3.34 95% CI 1.21–9.24). The PFG exhibited a clockwise rotation and the CG an anti-clockwise rotation in the maxilla (regression coefficient 8.24 (SE 0.75); 95% CI 6.73–9.75; P < 0.001) and the mandible (regression coefficient 6.72 (SE 0.73); 95% CI 5.27–8.18; P < 0.001). Sixty eight per cent of the PFG maintained a positive overjet at 6-year follow-up. There were no statistically significant differences between the PFG and CG for skeletal/occlusal improvement, self-esteem or oral aesthetic impact. Conclusions: Early class III protraction facemask treatment reduces the need for orthognathic surgery. However, this effect cannot be explained by the maintenance of skeletal cephalometric change.

The favourable effect of early class III protraction facemask treatment undertaken in patients under 10 years of age, is maintained at 3-year follow-up in terms of ANB, overjet and % PAR improvement. The direct protraction treatment effect at SNA is still favourable although not statistically significantly better than the CG. Seventy per cent of patients in PFG had maintained a positive overjet which we have defined as ongoing treatment success. Early protraction facemask treatment does not seem to influence self-esteem or reduce the patient's personal impact of their malocclusion at 3-year follow-up.

The capacity for dentofacial orthopaedics to modify the growth of the jaws and face in the management of Class II malocclusion has been the subject of much debate over the past century. It is only recently, following the publication of randomized controlled trials, that answers based on high level evidence can be provided. This article aims to review the recent literature in order to provide some clarification on the important issues relating to Class II growth modification, including: immediate treatment effects, long term stability of skeletal changes, the effects of differing orthopaedic appliances and the importance of treatment timing.

This paper describes the clinical orthodontic treatment of two cases treated by the recipient of the 2010 Membership in Orthodontics William Houston Gold Medal of the Royal College of Surgeons of Edinburgh. The first case describes a three-phase treatment approach to correct a class II division 2 malocclusion on a non-extraction basis. The second case describes the treatment of a class III malocclusion with a notable unilateral crossbite using a quad-helix, a single premolar extraction and upper and lower pre-adjusted fixed appliances.