ORIGINAL ARTICLE

Three-dimensional assessment of
mandibular and glenoid fossa changes
after bone-anchored Class III
intermaxillary traction
Hugo De Clerck,a Tung Nguyen,b Leonardo Koerich de Paula,c and Lucia Cevidanesd
Chapel Hill, NC, Brussels, Belgium, Rio de Janeiro, Brazil, and Ann Arbor, Mich

Introduction: Conventional treatment for young Class III patients involves extraoral devices designed to either
protract the maxilla or restrain mandibular growth. The use of skeletal anchorage offers a promising alternative to
obtain orthopedic results with fewer dental compensations. Our aim was to evaluate 3-dimensional changes in
the mandibles and the glenoid fossae of Class III patients treated with bone-anchored maxillary protraction.
Methods: Twenty-five consecutive skeletal Class III patients between the ages of 9 and 13 years (mean age,
11.10 6 1.1 year) were treated with Class III intermaxillary elastics and bilateral miniplates (2 in the infrazygo-
matic crests of the maxilla and 2 in the anterior mandible). The patients had cone-beam computed tomography
images taken before initial loading and at the end of active treatment. Three-dimensional models were generated
from these images, registered on the anterior cranial base, and analyzed by using color maps. Results: Poste-
rior displacement of the mandible at the end of treatment was observed in all subjects (posterior ramus: mean,
2.74 6 1.36 mm; condyles: mean, 2.07 6 1.16 mm; chin: mean,
0.13 6 2.89 mm). Remodeling of the glenoid
fossa at the anterior eminence (mean, 1.38 6 1.03 mm) and bone resorption at the posterior wall (mean,
1.34
6 0.6 mm) were observed in most patients. Conclusions: This new treatment approach offers a promising al-
ternative to restrain mandibular growth for Class III patients with a component of mandibular prognathism or to
compensate for maxillary deficiency in patients with hypoplasia of the midface. Future studies with long-term
follow-up and comparisons with facemask and chincup therapies are needed to better understand the
treatment effects. (Am J Orthod Dentofacial Orthop 2012;142:25-31)

C
lass III malocclusion is most commonly associated Whereas extraoral traction with a facemask applies
with hypoplasia of maxillary growth. However, anteriorly directed forces to the maxilla to mechanically
hyperplasia of the mandible also can result in disrupt the sutures and to stimulate maxillary forward
a mesiocclusion. Even when maxillary deficiency is the growth, reaction forces tend to push the chin posteri-
main etiology of the Class III malocclusion, a mandibular orly.1-4 These reaction forces result in clockwise
retraction effect can aid in the correction of the maxillo- rotation of the mandible and increased vertical
mandibular discrepancy. dimensions2,3,5 and are also observed in chincup
therapy.6,7 Little is known about eventual
modifications in the temporomandibular joint with
a
Adjunct professor, Department of Orthodontics, School of Dentistry, University facemask therapy. Modeling of the glenoid fossa has
of North Carolina, Chapel Hill; private practice, Brussels, Belgium.
b
Assistant professor, Department of Orthodontics, University of North Carolina,
been reported in magnetic resonance imaging studies
Chapel Hill. with the Herbst appliance8 and in histologic studies on
rhesus monkeys treated with chincup therapy.9 However,
c
Graduate student, Department of Orthodontics and Pediatric Dentistry, Federal
University of Rio de Janeiro, Rio de Janeiro, Brazil.
d
Assistant professor, Department of Orthodontics and Pediatric Dentistry, Uni-
there are no reported human studies of modeling of the
versity of Michigan, Ann Arbor. glenoid fossa after Class III extraoral traction. Further-
The authors report no commercial, proprietary, or financial interest in the prod- more, 2-dimensional cephalometric analysis does not
ucts or companies described in this article.
Reprint requests to: Hugo De Clerck, Kerkstraat 120, 1150 Brussels, Belgium;
allow clear visualization of changes in the glenoid fossa
e-mail, hugo.declerck@skynet.be. or asymmetric effects on both sides.
Submitted, November 2011; revised and accepted, January 2012. In contrast to facemask therapy, bone-anchored
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
maxillary protraction applies continuous anteriorly
doi:10.1016/j.ajodo.2012.01.017 directed forces to the maxilla and continuous retraction
25
26 De Clerck et al

forces to the mandible.10,11 Moreover, better compliance

can be expected from patients for intraoral elastic
traction rather than an extraoral device. Previous
studies have evaluated the effects of this protocol on
maxillary displacement and modeling by using
superimpositions of cone-beam computed tomography
(CBCT) images before and after orthopedic traction reg-
istered on the anterior cranial base.12-14 In this study, we
focused on the mandibular and glenoid fossa changes in
3 dimensions after bone-supported continuous Class III
intermaxillary traction.
MATERIAL AND METHODS Fig 1. Elastics are fixed for 24 hours a day between the
extensions of the maxillary and mandibular miniplates.
The prospective sample consisted of 25 consecutively
treated patients (13 girls, 12 boys) with a dentoskeletal in the incisor region until correction of the anterior cross-
Class III malocclusion. All patients were treated by 1 op- bite was obtained.
erator (H.D.C.) with the bone-anchored maxillary pro- The CBCT scans were taken at T1 and T2 with an iCat
traction technique. Institutional review board approval machine (Imaging Sciences International, Hatfield, Pa)
was obtained before the study. with a 16 3 22-cm field of view. Virtual 3-dimensional
At the initial observation (T1), all patients had a Class surface models were constructed from the CBCT images
III malocclusion in the mixed or permanent dentition with a voxel dimension of 0.5 3 0.5 3 0.5 mm. Construc-
characterized by a Wits appraisal of
1 mm or less tion of 3-dimensional surface models of the anatomic
(mean,
4.8 6 2.8 mm), an anterior crossbite or incisor structures of interest and the 3-dimensional graphic
end-to-end relationship, and a Class III molar relation- renderings were done by using software (ITK-SNAP;
ship. The skeletal characteristics of this sample at T1 open-source software, www.itksnap.org).
have been previously described in detail.15 All patients The T1 and T2 images were registered by using the an-
were of white ancestry, with a prepubertal stage of skel- terior cranial fossa as the reference. A fully automated
etal maturity according to the cervical vertebral matura- voxel-wise rigid registration method was performed with
tion method (CS 1 to CS 3).16 Twenty-one of the 25 software (IMAGINE, open-source software, http://www.ia.
patients were still prepubertal at the end of treatment unc.edu/dev/download/imagine/index.htm). This method,
(T2) (CS 1 to CS 3), whereas 4 patients were at CS 4. developed by Cevidanes et al,17 masks anatomic structures
The subjects' mean ages were 11.9 6 1.8 years at T1 altered by treatment or growth to prevent observer-
and 13.1 6 1.7 years at T2. The mean duration of the dependent reliance on subjectively defined anatomic
treatment was 1.2 6 0.1 years. landmarks. In this study, the 3-dimensional models at
The bone-anchored maxillary protraction orthopedic T1 and T2 were registered on anterior cranial fossa struc-
protocol consisted of the following. Each patient had tures, specifically the endocranial surfaces of the cribriform
miniplates placed on the left and right infrazygomatic plate region of the ethmoid bone and the frontal bone.
crests of the maxillary buttress and between the lower These regions were chosen because of their early
left and right lateral incisors and canines (Fig 1). Small completion of growth. The software compares the images
mucoperiosteal flaps were elevated, and modified mini- by using the intensity of the gray scale for each voxel of
plates (Tita-Link; Bollard, Brussels, Belgium) were se- the 2 images.
cured to the bone by 2 screws in the mandible or 3 After the registration step, all reoriented virtual models
screws in the maxilla screw diameter, 2.3 mm; length, 5 were superimposed to quantitatively evaluate the greatest
mm).10 The extensions of the plates perforated the at- surface displacement by using the CranioMaxilloFacial
tached gingiva near the mucogingival junction. Three (CMF) application software (developed at the M. E. M€ uller
weeks after surgery, the miniplates were loaded. Class Institute for Surgical Technology and Biomechanics,
III elastics applied an initial force of 150 g on each side, University of Bern, Bern, Switzerland, under the funding
and increased to 200 g after 1 month of traction and of the Computer Aided and Image Guided Medical
to 250 g after 3 months. The patients were asked to re- Interventions network, http://co-me.ch). The CMF tool
place the elastics at least once a day and wear them 24 calculates thousands of color-coded point-to-point
hours per day. In 14 patients, after 2 to 3 months of in- comparisons (surface distances in millimeters) between
termaxillary traction, a removable biteplate was inserted the 3-dimensional models, so that the differences be-
in the maxillary arch to eliminate occlusal interference tween 2 surfaces at any location can be quantified.

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De Clerck et al 27

For quantitative assessment of the changes between

the 3-dimensional surface models, the isoline tool allows
the user to define a surface-distance value to be ex-
pressed as a contour line (isoline) that corresponds to re-
gions having a surface distance equal to or greater than
the defined value. The isoline tool was used to quantita-
tively measure the greatest displacements between
points in the 3-dimensional surface models for the right
and left anterior and posterior surfaces of the condyles,
the right and left anterior and posterior surfaces of the
glenoid fossae walls, the chin, the right and left posterior
surfaces of the rami, and the soft-tissue chin (Fig 2).
The greatest displacements between T1 and T2 were
computed at each anatomic region of interest. The error
of the method as determined in previous studies showed
excellent reliability.12 Descriptive statistics was used to
describe the percentiles, means, standard deviations, Fig 2. Three-dimensional skeletal color map of the su-
and ranges. Pearson correlation coefficients were used perimposition of the mandible registered on the anterior
to assess the associations between changes at each ana- cranial base. The image of the isolines on the posterior
tomic region. The level of significance was set at 0.05. border of the mandible shows regions with a displacement
equal to or greater than a preset value. The red color of
the posterior border of the ramus corresponds to a poste-
RESULTS rior displacement of 4 mm.
Table I summarizes the descriptive statistics for
changes in the mandibular condyle, glenoid fossa, ra-
mus, and chin observed from T1 to T2 for the 25 consec- displacement of the right condyle, glenoid fossa, and ra-
utive patients treated with bone-anchored maxillary mus were highly correlated to the displacements of the
protraction. same anatomic regions on the left side. There also was
Throughout a year of treatment, the chin on average a high correlation between the posterior displacement
maintained its relative anteroposterior position (mean of the condyles and the amount of bone apposition at
change,
0.13 6 2.89 mm). The range of response the anterior eminence and resorption at the posterior
was highly variable, from 4.42 mm of anterior displace- wall of the glenoid fossa. Poor or no correlation was
ment to as much as
5.85 mm of posterior displace- found between the displacement of the posterior border
ment. On average, distal displacement of the posterior of the ramus and the displacement of the condyles or
ramus was observed (mean right ramus displacement, glenoid fossa modeling. However, the anteroposterior
2.73 6 1.36 mm; mean left ramus displacement, 2.76 displacement of the hard-tissue chin was correlated
6 1.36 mm) (Fig 3). The condyles moved posteriorly with the displacement of the posterior border of the ra-
(mean right condyle posterior surface changes, 2.03 6 mus and strongly correlated with the displacement of the
1.21 mm; mean left condyle posterior surface changes, soft-tissue chin.
2.12 6 1.06 mm). The posterior eminence of the glenoid
fossae showed resorption of the posterior wall (mean DISCUSSION
right posterior wall changes,
1.39 6 0.75 mm; mean Bone-anchored maxillary protraction treatment re-
left posterior wall changes,
1.30 6 0.46 mm). There sulted in the maintenance of the anteroposterior posi-
was apposition of bone at the anterior eminences of tion of the chin (
0.13 mm). Our 2-dimensional study
the fossae, with mean changes of 1.30 6 1.03 mm comparing bone-anchored maxillary protraction with
and 1.47 6 1.03 mm, respectively, at the right and left untreated Class III controls showed a similar mean value
anterior articular eminences (Fig 4). The soft-tissue for mandibular restraint, whereas the untreated Class III
chin (mean displacement,
0.03 6 3.0 mm) showed subjects had 2.2 mm of anterior displacement of the chin
similar positional changes compared with the hard- during the same time span.11 This contributed to 40% of
tissue chin (
0.13 6 2.89 mm). the overall improvement in the maxillomandibular dis-
Table II shows the correlations between changes at crepancy as expressed by the Wits appraisal. The large
the condyles, glenoid fossae, posterior surface of the variability of change in the anteroposterior position of
rami, and hard- and soft-tissue chins. The amounts of the chin can be explained by a combination of 4 separate

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28 De Clerck et al

Table I. Mean values, standard deviations, and ranges of surface distance changes in millimeters at each anatomic
region in the superimposition of T1 and T2, registered on the cranial base
Condyle Glenoid fossa Ramus Chin

R ant L ant R post L post R ant L ant R post L post R L Hard Soft
Mean
2.21
2.28 2.03 2.12 1.30 1.47
1.39
1.30 2.73 2.76
0.13
0.03
SD 0.98 0.82 1.21 1.06 1.03 1.03 0.75 0.46 1.36 1.36 2.89 3.00
Range (minimum and maximum)
1.06
0.52 0.32 0.51
1.18
1.06 0.10
0.45 0.18 0.69
5.85
5.01

4.12
3.63 4.52 4.50 2.79 3.22
3.40
2.15 6.45 5.54 4.42 5.05
R, Right; L, left; ant, anterior; post, posterior.

Fig 4. Three-dimensional skeletal color map of the su-

perimposition of the glenoid fossa at T1 over the image
at T2 registered on the anterior cranial base with a scale
of
3 to 13 mm shows bone apposition at the anterior
Fig 3. Three-dimensional skeletal semitransparency su- eminence (red) and resorption of the posterior wall
perimposition registered on the anterior cranial base. The (blue). The green color corresponds to surfaces without
3-dimensional image in red is from the CBCT image at T1, displacement.
and the transparent overlay is from the CBCT image at T2
of the bone-anchored maxillary protraction protocol. The
condyles moved posteriorly. and the untreated controls could not be explained by
the restricted growth of the mandible. In another study
factors that occur simultaneously to determine the indi- on the effects of chincup therapy, the increase of the
vidual mandibular pattern of growth and response to length of the mandible was almost the same as in the
treatment: (1) the amount and direction of condylar control group.20
growth, (2) bone remodeling in the articular fossa, (3) The superimposition and semitransparent overlays in
clockwise or counterclockwise rotation of the mandible this study indicate that bone-anchored maxillary pro-
(matrix rotation),18 and (4) the amount of closure or traction growth and treatment response result in bone
opening of the gonial angle (intramatrix rotation).18 apposition at the anterior eminence of the temporoman-
As reported in a previous 2-dimensional study, an in- dibular joint; this correlates well with the posterior dis-
crease in mandibular length of about 3 mm per year can placement of the anterior surface of the condyle, and
be expected in an untreated Class III population of the the bone resorption of the posterior wall of the articular
same age as the sample in our study.19 Our 2- eminence correlates well with the posterior displacement
dimensional comparison of bone-anchored maxillary of the posterior surface of the condyle. The high correla-
protraction and untreated controls showed no signifi- tion between modeling at the anterior and posterior em-
cant differences in the changes of mandibular body inences of the glenoid fossa and the displacement of the
length and ramus height; ie, the amounts of mandibular opposed surfaces of the condyle indicate that the ante-
growth observed in the bone-anchored maxillary pro- roposterior displacement of the chin was not due to a po-
traction and the untreated samples were similar.11 The sitional shift of the mandible between T1 and T2, after
2.7-mm difference in the forward projection of the correction of the anterior crossbite. The posterior dis-
chin between the bone-anchored maxillary protraction placement of the condyles occurred while maintaining

July 2012  Vol 142  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
De Clerck et al 29

Table II. Pearson correlation coefficients for growth and treatment response changes between all anatomic regions of
interest
Condyle Glenoid fossa Ramus Chin

R ant L ant R post L post R ant L ant R post L post R L Hard Soft
Condyle
R ant 0.75k
0.81k
0.62k
0.66k
0.55k 0.60k 0.48k
0.65k
0.43k 0.32 0.11
L ant §
0.46k
0.64k
0.69k
0.70k 0.39 0.35
0.46k
0.47k 0.34 0.14
R post § * 0.76k 0.43k 0.40k
0.62k
0.66k 0.53k 0.29
0.13 0.07
L post z z § 0.49k 0.52k
0.33
0.49k 0.37 0.38
0.11 0.11
Glenoid fossa
R ant z z * * 0.90k
0.26
0.26 0.21 0.09 0.13 0.27
L ant y § * y §
0.23
0.28 0.22 0.14 0.17 0.26
R post y NS z NS NS NS 0.68k
0.61k
0.44k 0.09 0.01
L post * NS z * NS NS z
0.46k
0.41k 0.01
0.05
Ramus
R z * y NS NS NS y * 0.81k
0.54
0.65k
L * * NS NS NS NS * * §
0.59
0.43k
Chin
Hard NS NS NS NS NS NS NS NS y y 0.79
Soft NS NS NS NS NS NS NS NS * § §
The top diagonal area of the table shows r values, and the bottom diagonal area shows P values.
R, Right; L, left; ant, anterior; post, posterior; NS, Not significant (P $0.5).
*P \0.5; yP \0.01; zP \0.001; §P \0.0001; kstatistically significant.

Fig 5. A, Three-dimensional skeletal color map and B, semitransparency superimposition registered

on the anterior cranial base shows a slight asymmetric displacement of the chin to the patient's right
side after unilateral elastic traction for about 5 months; C, asymmetric movement of the condyles cor-
responds to asymmetric modeling of the left and right glenoid fossae.

condylar width. Superimposition of the 2 CBCT images apposition and resorption in the left and right glenoid
of growing patients, registered on the anterior cranial fossae. However, this surface modeling is the result of
base, makes it possible to visualize the regions of a combination of normal growth and the effect of the

American Journal of Orthodontics and Dentofacial Orthopedics July 2012  Vol 142  Issue 1
30 De Clerck et al

orthopedic traction. Only when the CBCT images of un-

treated Class III subjects are available will the impact of
bone-anchored maxillary protraction on the overall
modification of the fossae be known. Although the mod-
eling processes in the temporomandibular joint might
contribute to posterior displacement (relocation) of the
whole mandible, the magnitude of these changes mea-
sured in this study was too small to explain entirely
the restriction of the forward projection of the chin.
Moreover, no correlation was found between chin dis-
placement and condylar changes or fossa modeling. An-
other interesting illustration of the relationship between
condylar changes and glenoid fossa remodeling is in the
correction of a Class III malocclusion with mandibular
asymmetry with unilateral elastic traction (Fig 5).
Posterior rotation of the mandible also results in pos-
terior displacement of the chin. In our 2-dimensional
study, such a clockwise rotation was observed in the un- Fig 6. Three-dimensional skeletal semitransparency su-
treated Class III sample; however, the mean mandibular perimposition registered on the anterior cranial base. The
plane angle in the bone-anchored maxillary protraction green volume is before treatment, and the transparent
group slightly decreased, indicating a mean counter- overlay is after treatment, illustrating a slight swing-back
clockwise rotation.11 In another 2-dimensional study of the ramus and closure of the gonial angle with a small
comparing the outcome of the bone-anchored maxillary reduction of the mandibular plane angle. This results in
protraction protocol with a matched facemask group, restriction of the forward projection of the chin.
the mandibular line showed a significantly different ro-
tation in relation to both the cranial base and the nasal for protraction of the midface, this study additionally
line, with a slight mandibular counterclockwise rotation demonstrates that compensatory effects on mandibular
with bone-anchored maxillary protraction compared growth considerably contribute to correcting the skeletal
with clockwise rotation with the facemask.15 In the 3- discrepancy and improving the facial profile. Three-
dimensional overlay of our sample, parallel lowering dimensional imaging makes it possible to better
without rotation of the mandibular border was com- understand the morphologic changes and facilitates
monly observed. assessment of the long-term results in the future.
In this study, the posterior borders of the left and
right mandibular rami were displaced over a mean dis- CONCLUSIONS
tance of about 2.7 mm. Anteroposterior changes in the
Previous studies have shown that bone-anchored
position of the chin were correlated with the ramus dis-
maxillary protraction stimulates forward displacement
placement. The posterior displacement of the posterior
and modeling of the maxillary and zygoma bones as 1
surface of the ramus was greater than the displacement
unit. This study also shows that mandibular shape rather
of the condyles, which could be visualized on the semi-
than mandibular size is affected by continuous inter-
transparency overlays as a slight swing-back of the ra-
maxillary traction. Moreover, 3-dimensional imaging
mus (Fig 6). Posterior displacement of the gonial
makes it possible to visualize the modeling processes
landmarks was also confirmed by the thin-plate spline
in the glenoid fossae and condyles. Based on the find-
analysis of our sample.21 This displacement without
ings of this study, the following can be concluded.
clockwise rotation of the mandible must result in a re-
duction of the gonial angle. This was confirmed by a de- 1. Restriction of forward displacement of the chin can
crease of 4.1 of the gonial angle compared with the be obtained by a combination of a slight swing-back
control group in our 2-dimensional study.11 Similar of the ramus and closure of the gonial angle.
changes in mandibular shape have been also reported 2. There was no posterior rotation of the mandible or
in animal experiments22 and in a sample of growing chil- no temporary positional shift.
dren with mandibular prognathism treated by chincup 3. There was a high correlation between modeling of
therapy.23 the anterior and posterior eminences of the glenoid
Although previous studies have shown that the fossae and displacement of the opposing condylar
treatment protocol applied in this study is indicated surfaces.

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De Clerck et al 31

4. There was interindividual variability in treatment tively treated Class III patients. Am J Orthod Dentofacial Orthop
outcomes. 2010;138:577-81.
12. Cevidanes LH, Heymann G, Cornelis MA, DeClerck HJ, Tulloch JF.
Superimposition of 3-dimensional cone-beam computed tomog-
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