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Similar change in occlusal and palatal planes rotating counter clockwise with treatment are seen with protraction facemask treatment [15].
Loiu reported a 5.8-mm-forward movement of the maxilla in 3 months using a maxillary expansion and constriction protocol in conjunction with protraction facemask [25].
In a study with protraction facemask [10], A point was found to move forward by an average of 1.8 mm over a 6-month period.
The goal of combining the RPE with protraction facemask is to provide a more effective protraction of the maxilla by disarticulating the circummaxillary sutures [12, 13].
Baccetti also reported a rotation of the mandible and a 2.5-mm restriction in mandibular protrusion with protraction facemask [11, 17].
Further, tooth-borne expanders reported more anterior movement of the maxilla when protraction was combined with expansion and compared with protraction without expansion.
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This forward and downward displacement of the nasomaxillary complex with maxillary protraction with expansion more closely approximates the natural growth direction of the maxilla [10].
Alterations in these functions play a part in shoulder dysfunction manifested with scapular protraction in patients with scapular dyskinesis (loss of acromial upward rotation, excessive scapular internal rotation, and excessive scapular anterior tilt) that results in decrease of the subacromial space with consequent decrease in RC strength and alteration of RC activation sequencing patterns [16].
Recently, Ngan et al. had reported that in non-cleft class III individuals, the hybrid HYRAX bone-borne expansion device along with maxillary protraction yielded desirable sagittal skeletal change with minimal dental side effects [41].
Some benefits of the RPE in conjunction with maxillary protraction therapy in treating skeletal class III patients are correction of crossbites often associated with class III malocclusions, anchoring the maxillary dentition against forward movement and anterior constriction, and backward and downward rotation of the mandible [6, 24 27].
A tapered whisker would flick past the object with a protraction angle of ∼20°, while an untapered whisker would require a protraction angle larger than 60°.
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