Early correction of Angles Class 3 malocclusion

Early correction of classEarly correction of class
IIIIII
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INTRODUCTIONINTRODUCTION
 Class III malocclusion is one of the most difficult anomalies toClass III malocclusion is one of the most difficult anomalies to
understand .The studies conducted to identify etiologicalunderstand .The studies conducted to identify etiological
features of class III malocclusion showed that the deformity isfeatures of class III malocclusion showed that the deformity is
not restricted to jaws but involves total craniofacial complex.not restricted to jaws but involves total craniofacial complex.
 Hence a thorough knowledge on the various components ofHence a thorough knowledge on the various components of
class III is essentialclass III is essential
 This seminar deals with the diagnosis and treatment planningThis seminar deals with the diagnosis and treatment planning
in early stagesin early stages

DEFINITIONDEFINITION
According to Angle, in class III malocclusion lowerAccording to Angle, in class III malocclusion lower
molar occluded mesial to their normal relationshipmolar occluded mesial to their normal relationship
the width of one premolar or even more in extremethe width of one premolar or even more in extreme
casescases
TweedTweed
pseudo classIII :- normally shaped mandibles andpseudo classIII :- normally shaped mandibles and
underdeveloped maxillaunderdeveloped maxilla
Skeletal class III :- large mandiblesSkeletal class III :- large mandibles
Moyers Acc to etiologyMoyers Acc to etiology
OsseousOsseous
Muscular or functionalMuscular or functional
DentalDental

IncidenceIncidence
 Varies among different ethnic groupVaries among different ethnic group
 Asian higher frequency due to large percentage with maxillaryAsian higher frequency due to large percentage with maxillary
deficiencydeficiency
 Japanese 4% - 13%Japanese 4% - 13%
 Chinese 4% - 14% , acc to Lin ,incidence of pseudo class IIIChinese 4% - 14% , acc to Lin ,incidence of pseudo class III
and true classIII 2.3% and 1.7% respectivelyand true classIII 2.3% and 1.7% respectively
 Caucasians 1% - 4%Caucasians 1% - 4%
 African Americans 5% - 8%African Americans 5% - 8%

EtiologyEtiology
 HeredityHeredity
 McGuiganMcGuigan described the most well-known exampledescribed the most well-known example
of inheritance, theof inheritance, the Hapsburg familyHapsburg family, having the, having the
distinct characteristics of a prognathic lower jaw. Ofdistinct characteristics of a prognathic lower jaw. Of
the 40 members of the family for whom records werethe 40 members of the family for whom records were
available, 33 showed prognathic mandibles.available, 33 showed prognathic mandibles.
 InIn 1970 Litton et al1970 Litton et al studied the families of 51studied the families of 51
individuals with Class III anomalies and concludedindividuals with Class III anomalies and concluded
that the dental Class III characteristics were related tothat the dental Class III characteristics were related to
genetic inheritance in offspring and siblingsgenetic inheritance in offspring and siblings
 EnvironmentalEnvironmental Acc toAcc to rakosi and schillirakosi and schilli
 HabitHabit :- Abnormal mandibular posture:- Abnormal mandibular posture
 Mouth breathingMouth breathing

Anteriorly positioned tongue {Local epigenetic factor}Anteriorly positioned tongue {Local epigenetic factor}
 There is a dispute regarding whether it is a primary etiologicThere is a dispute regarding whether it is a primary etiologic
factor or a compensatory phenomenon. It may also arise like afactor or a compensatory phenomenon. It may also arise like a
compulsive disorder in patients with mental disorders. Alsocompulsive disorder in patients with mental disorders. Also
patients with naso respiratory difficulties present with samepatients with naso respiratory difficulties present with same
tongue posture.tongue posture.
Abnormal Incisal guidance (Pseudo class III}Abnormal Incisal guidance (Pseudo class III}
Premature loss of deciduous molarsPremature loss of deciduous molars leading to autorotationleading to autorotation
of the mandible.of the mandible.
Lack of eruption in maxillary buccal segmentsLack of eruption in maxillary buccal segments leading toleading to
autorotation of the mandible.autorotation of the mandible.
Lack of maxillary vertical heightLack of maxillary vertical height

Components of class IIIComponents of class III
 Ellis and McNamaraEllis and McNamara have calculated 243 possiblehave calculated 243 possible
combinations of Class III malocclusioncombinations of Class III malocclusion
 (Position of the maxilla, the mandible, the maxillary alveolus,(Position of the maxilla, the mandible, the maxillary alveolus,
the mandibular alveolus, and the vertical development andthe mandibular alveolus, and the vertical development and
giving to each three possible values (plus, zero, and minus)giving to each three possible values (plus, zero, and minus)
 Guyer et alGuyer et al conducted a cephalometric study to identify theconducted a cephalometric study to identify the
various types of skeletal Class III patterns between 13- and 15-various types of skeletal Class III patterns between 13- and 15-
year-old children. (57% of the patients with either a normal oryear-old children. (57% of the patients with either a normal or
prognathic mandible showed a deficiency in the maxilla)prognathic mandible showed a deficiency in the maxilla)
 MasakiMasaki ( maxillary skeletal retrusion more in Asians )( maxillary skeletal retrusion more in Asians )
 Wu, Peng, and LinWu, Peng, and Lin ( skeletal Class III malocclusion with( skeletal Class III malocclusion with
maxillary retrusion to be as high as 75%. )maxillary retrusion to be as high as 75%. )

Class III with various combinations ofClass III with various combinations of
anteroposterior and vertical problemsanteroposterior and vertical problems
•The Asian patients with Class III malocclusion typically
had a more retrusive facial profile and a longer lower
anterior facial height.
•A backward rotation of the mandible was often observed
to accommodate the relatively smaller maxilla.

 CEPHALOMETRIC CLASSIFICATION OF CLASSCEPHALOMETRIC CLASSIFICATION OF CLASS
III MALOCCLUSIONIII MALOCCLUSION
 Class III Malocclusion caused by dento alveolarClass III Malocclusion caused by dento alveolar
malrelationshipmalrelationship
May or May not be associated with
forced bite.
No basal discrepancy.
Maxillary incisors tipped lingually.
Mandibular incisors tipped labially
Treated as early as possible in
growing patients since it can have
activator like functional effect
(particularly in forced bite category)
leading to basal discrepancy.
Most of the cases require only
correction of incisal malrelationship
which can be done at any age. It is
easy to treat.

VARIATIONS OF CLASS III

Class III Malocclusions with long mandibular baseClass III Malocclusions with long mandibular base
SNA normal, increased SNB.SNA normal, increased SNB.
Large gonial angle, small articular angle.Large gonial angle, small articular angle.
Anteriorly positioned mandibular base.Anteriorly positioned mandibular base.
Flattended anteriorly positioned tongue.Flattended anteriorly positioned tongue.
Posterior cross bite may also be seen.Posterior cross bite may also be seen.
Class III Malocclusion with under developed maxillaClass III Malocclusion with under developed maxilla
Decreased SNA, normal SNB
Maxilla small and retrognathic
Found in certain races like Asians
of Mongoloid origin and in cleft
palate patients.
Can be treated by growth
guidance during eruption of
permanent incisors if they are
upright by tipping them labially.

Class III Malocclusion with under developed maxilla &Class III Malocclusion with under developed maxilla &
long mandibular baselong mandibular base
 Divided into two based on ramus lengthDivided into two based on ramus length
Short ramusShort ramus
 Vertical growth patternVertical growth pattern
 Increased gonial angleIncreased gonial angle
 Open bite tendencyOpen bite tendency
 Crowding in the upper archCrowding in the upper arch
 Moderate cases can be treated by extractionModerate cases can be treated by extraction
 of all first premolarsof all first premolars
Long ramusLong ramus
 Horizontal growth patternHorizontal growth pattern
 Decreased gonial angleDecreased gonial angle
 Reversed overbiteReversed overbite
Class III Malocclusion with pseudo forced bite.
• Labial tipping of upper incisors
• Lingual tipping of lower incisors
• Anterior guidance from postural rest position to habitual occlusion

 (( Kwong and Lin )Pseudo Class III malocclusion is anKwong and Lin )Pseudo Class III malocclusion is an
intermediate form between Class I and skeletal Class IIIintermediate form between Class I and skeletal Class III
malocclusion.malocclusion.
 The only exception was the gonial angle, which was generallyThe only exception was the gonial angle, which was generally
more obtuse in the skeletal Class III sample.more obtuse in the skeletal Class III sample.
 Measurement of the gonial angle in the pseudo Class IIIMeasurement of the gonial angle in the pseudo Class III
sample was found to be rather similar to the Class I sample,sample was found to be rather similar to the Class I sample,
making this, measurement a key diagnostic feature in themaking this, measurement a key diagnostic feature in the
differential diagnosis between pseudo and skele-tal Class IIIdifferential diagnosis between pseudo and skele-tal Class III
malocclusions.malocclusions.

INDICATIONS AND CONTRAINDICATIONS FORINDICATIONS AND CONTRAINDICATIONS FOR
EARLY CLASS III TREATMENTEARLY CLASS III TREATMENT
 The objective of early Class III treatment is to create anThe objective of early Class III treatment is to create an
environment in which a more favorable dentofacialenvironment in which a more favorable dentofacial
development can occur.development can occur.
 The goals of early interceptive treatment may includeThe goals of early interceptive treatment may include
 (1) preventing progressive, irreversible, soft tissue, or bony(1) preventing progressive, irreversible, soft tissue, or bony
changes;changes;
 (2) improving skeletal discrepancies and providing a more(2) improving skeletal discrepancies and providing a more
favorable environment for future growth;favorable environment for future growth;
 (3) improving occlusal function;(3) improving occlusal function;
 (4) simplifying phase II comprehensive treatment and(4) simplifying phase II comprehensive treatment and
minimizing the need for orthognathic surgery; andminimizing the need for orthognathic surgery; and
 (5) providing more pleasing facial esthetics, thus improving(5) providing more pleasing facial esthetics, thus improving
the psychosocial development of a child.the psychosocial development of a child.

TurpinTurpin developed a list of positive and negative factors to aid indeveloped a list of positive and negative factors to aid in
deciding when to intercept a developing Class IIIdeciding when to intercept a developing Class III
malocclusion.malocclusion.
The positive factors includeThe positive factors include
 good facial esthetics,good facial esthetics,
 mild skeletal disharmony,mild skeletal disharmony,
 no familial prognathism,no familial prognathism,
 anteroposterior functional shift,anteroposterior functional shift,
 convergent facial type, symmetric condylar growth, andconvergent facial type, symmetric condylar growth, and
 growing patients with expected good cooperation.growing patients with expected good cooperation.

 The negative factors includeThe negative factors include
 poor facial esthetics,poor facial esthetics,
 severe skeletal disharmony,severe skeletal disharmony,
 familial pattern established,familial pattern established,
 no anteroposterior shift, divergent facial type,no anteroposterior shift, divergent facial type,
 asymmetric growth,asymmetric growth,
 growth complete, and expected poor cooperation.growth complete, and expected poor cooperation.
 The author recommends that early treatment should beThe author recommends that early treatment should be
considered for a patient that presents with characteristics listedconsidered for a patient that presents with characteristics listed
in the positive column.in the positive column.
 For individuals who present with characteristics in theFor individuals who present with characteristics in the
negative column, treatment can be delayed until growth isnegative column, treatment can be delayed until growth is
completed.completed.
 Patients should be aware of the fact that surgery may bePatients should be aware of the fact that surgery may be
necessary at a later date, even when an initial phase ofnecessary at a later date, even when an initial phase of
treatment may be successful.treatment may be successful.

DIFFERENTIATING A DENTAL CROSS BITE FROM
SKELETAL CROSS BITE
I. DENTAL ASSESMENT

PROFILE ASSESMENTPROFILE ASSESMENT
 Asses facial proportions,chin position,mid face position and verticalAsses facial proportions,chin position,mid face position and vertical
proportionproportion
• Check vertical proportion in CR CO
• The normal vertical proportion ratio of lower face to total
face height is 55%
• Reduced in patients with functional shift and overclosure

CEPHALOMETRIC ASSESMENTCEPHALOMETRIC ASSESMENT
To confirm the contributions of maxilla and mandible as wellTo confirm the contributions of maxilla and mandible as well
as the incisors to the class III skeletal and dental relationsas the incisors to the class III skeletal and dental relations
Class III,therefore can be categorized into dentoalveolar, skeletalClass III,therefore can be categorized into dentoalveolar, skeletal
and pseudo classIII malocclusion.and pseudo classIII malocclusion.

 Early correction of anterior cross biteEarly correction of anterior cross bite
Vadiakas and Viazis [ 1992 AJO]Vadiakas and Viazis [ 1992 AJO]
The appliances suggested for correction of anterior crossbites in theThe appliances suggested for correction of anterior crossbites in the
deciduous dentition can be differentiated in three categoriesdeciduous dentition can be differentiated in three categories
I. Those that deliver heavy-intermittent forces and includeI. Those that deliver heavy-intermittent forces and include::
1. Fixed or removable mandibular acrylic inclined bite plane1. Fixed or removable mandibular acrylic inclined bite plane
2. Reversed stainless steel crowns2. Reversed stainless steel crowns
3. Tongue blade3. Tongue blade
II. Those that deliver light-continuous forces and includeII. Those that deliver light-continuous forces and include::
1. Removable appliance with auxiliary springs1. Removable appliance with auxiliary springs
2. Removable plate with screw2. Removable plate with screw
3. Maxillary lingual arch -W arch3. Maxillary lingual arch -W arch
4. Fixed light arch wire4. Fixed light arch wire
III. Those that may correct skeletal problems in young patientsIII. Those that may correct skeletal problems in young patients
(maxillary deficiency and/or mandibular prognathism):(maxillary deficiency and/or mandibular prognathism):
1. Maxillary protraction devices1. Maxillary protraction devices
2. Chincup therapy2. Chincup therapy
3.functional appliances and others3.functional appliances and others

 TREATMENT OF PSEUDO CLASS IIITREATMENT OF PSEUDO CLASS III
MALOCCLUSIONMALOCCLUSION
 Patients with pseudo Class III malocclusion often present withPatients with pseudo Class III malocclusion often present with
anterior crossbites that are caused by a premature tooth contactanterior crossbites that are caused by a premature tooth contact
or improper positioning of the maxillary and mandibularor improper positioning of the maxillary and mandibular
incisors and the temporo-mandibular joint.incisors and the temporo-mandibular joint.
 Elimination of the CO-CR discrepancy may avoid abnormalElimination of the CO-CR discrepancy may avoid abnormal
wear and traumatic occlusal forces to the affected teeth, avoidwear and traumatic occlusal forces to the affected teeth, avoid
potential adverse growth influences in the maxilla and.potential adverse growth influences in the maxilla and.
mandible, improve maxillary lip posture and facialmandible, improve maxillary lip posture and facial
appearance, and avoid abnormal posterior occlusion, whichappearance, and avoid abnormal posterior occlusion, which
may develop as a result of habitual posturing of the mandiblemay develop as a result of habitual posturing of the mandible
to accommodate the abnormal anterior occlusal contacts.to accommodate the abnormal anterior occlusal contacts.

 Reverse stainless steel crownReverse stainless steel crown was used to correct a single toothwas used to correct a single tooth
in anterior crossbite.in anterior crossbite.
 An oversized permanent lateral incisor preformed crown form isAn oversized permanent lateral incisor preformed crown form is
trimmed and contoured at the gingival margin to fit snugly overtrimmed and contoured at the gingival margin to fit snugly over
the maxillary primary tooth or teeth in crossbite.the maxillary primary tooth or teeth in crossbite.
 The crown is cemented in reverse (i.e., facial to lingual) withThe crown is cemented in reverse (i.e., facial to lingual) with
polycarboxylate cement.polycarboxylate cement.
 One drawback of this method is the non esthetic appearance of theOne drawback of this method is the non esthetic appearance of the
stainless steel crowns.stainless steel crowns.
 With the advent of bonded resin composite, the stainless steelWith the advent of bonded resin composite, the stainless steel
crown can be replaced by bonded composite resin slopes forcrown can be replaced by bonded composite resin slopes for
anterior tooth crossbite correction.anterior tooth crossbite correction.

 A tongue bladeA tongue blade has also been used for the correction of ahas also been used for the correction of a
single tooth in anterior crossbite.single tooth in anterior crossbite.
 This method is unpredictable and its effect is dependent on theThis method is unpredictable and its effect is dependent on the
frequency of patient use and the patient's tolerance offrequency of patient use and the patient's tolerance of
discomfort.discomfort.
 This approach is best applied to teeth with some mobility orThis approach is best applied to teeth with some mobility or
when the maxillary incisors are erupting.when the maxillary incisors are erupting.
INCLINED PLANEINCLINED PLANE
 Correction of multiple teeth in anterior crossbite has beenCorrection of multiple teeth in anterior crossbite has been
accomplished by using a fixed or removable appliance with anaccomplished by using a fixed or removable appliance with an
inclined plane .inclined plane .
 This appliance can correct the malocclusion rapidly with littleThis appliance can correct the malocclusion rapidly with little
patient compliance when the inclined plane is cemented.patient compliance when the inclined plane is cemented.

On the other hand, this appliance has several disadvantagesOn the other hand, this appliance has several disadvantages
1. The force exerted on the ramp is unpredictable.1. The force exerted on the ramp is unpredictable.
2. Patients may experience speech difficulty during treatment.2. Patients may experience speech difficulty during treatment.
3. A potential for root damage exists because of the heavy3. A potential for root damage exists because of the heavy
irregular forces placed on the tooth.irregular forces placed on the tooth.

 REMOVABLE APPLIANCE WITH AUXILLARY SPRINGSREMOVABLE APPLIANCE WITH AUXILLARY SPRINGS
 The maxillary lingual arch with finger springs is recommendedThe maxillary lingual arch with finger springs is recommended
when patient cooperation is questionablewhen patient cooperation is questionable
 The appliance is fabricated using an indirect technique.The appliance is fabricated using an indirect technique.
 Bands are fitted on the maxillary second primary molars or theBands are fitted on the maxillary second primary molars or the
permanent first molars. An impression of the maxillary arch withpermanent first molars. An impression of the maxillary arch with
the bands is taken. Bands are transferred to the impression beforethe bands is taken. Bands are transferred to the impression before
pouring.pouring.
 A lingual arch is fabricated and soldered to the molar bands.A lingual arch is fabricated and soldered to the molar bands.
Finger springs with helices are soldered to the lingual arch.Finger springs with helices are soldered to the lingual arch.
 Anterior crossbite can usually be corrected in 2 to 3 weeks withAnterior crossbite can usually be corrected in 2 to 3 weeks with
little patient compliance.little patient compliance.

 In patients presenting with a deep over-bite, a mandibularIn patients presenting with a deep over-bite, a mandibular
Hawley appliance with an anterior labial bow can be used toHawley appliance with an anterior labial bow can be used to
prevent forward movement of the lower incisors during biteprevent forward movement of the lower incisors during bite
jumping.jumping.
 In most cases crossbite correction is maintained by theIn most cases crossbite correction is maintained by the
overbite, and no retention appliance is necessaryoverbite, and no retention appliance is necessary

W arch Vadiakas and Viazis[ 1992 AJO].W arch Vadiakas and Viazis[ 1992 AJO].
 The appliance (W-arch, extended in the anterior) deliversThe appliance (W-arch, extended in the anterior) delivers
relatively light-continuous forces, is fixed so notrelatively light-continuous forces, is fixed so not
dependent upon on patient compliance, and usuallydependent upon on patient compliance, and usually
requires only two to three activations (one every 3 weeks)requires only two to three activations (one every 3 weeks)
for correction of the crossbite.for correction of the crossbite.
 If a posterior crossbite is also present, correction can beIf a posterior crossbite is also present, correction can be
achieved simultaneously with the same appliance.achieved simultaneously with the same appliance.

W arch Vadiakas and Viazis[ 1992 AJO].
•Once positive overbite is achieved, relapse is rare,
therefore long retention time is not required.
•Adequate overbite depth to "hold" the correction is
necessary.
• The disadvantages include adjustment of bands and
taking an impression, as well as removal of the
appliance for reactivation and recementation

 Compomer BiteplaneCompomer Biteplane [JCO 2002 ] Croll&Helpin[JCO 2002 ] Croll&Helpin
 Bonded biteplanes are suitable for correction of crossbiteBonded biteplanes are suitable for correction of crossbite
related to simple tipping of teeth, but cannot be used in casesrelated to simple tipping of teeth, but cannot be used in cases
where crowding precludes their placement and effectiveness.where crowding precludes their placement and effectiveness.
 They are also generally contraindicated in patients withThey are also generally contraindicated in patients with
skeletal crossbite related to Class III malocclusion.skeletal crossbite related to Class III malocclusion.


Use of a self-etching adhesive facilitates the bonding
procedure in that no separate etching or rinsing step
is required, and the bond achieved is durable and
reliable.
If it is placed to achieve proper mechanical
advantage between the maxillary incisor and its
antagonist, the crossbite is usually corrected within
two weeks..
Although the treated teeth become slightly mobile
during the correction, they stabilize rapidly after the
biteplane is removed.

TREATMENT OF SKELETAL CLASS IIITREATMENT OF SKELETAL CLASS III
MALOCCLUSIONMALOCCLUSION
The Frankel III (FRIII) regulator is a functional
appliance designed to counteract the muscle forces
acting on the maxillary complex.
•According to Frankel, the vestibular shields in the
depths of the sulcus are placed away from the alveolar
buccal plates of the maxilla to stretch the periosteum and
allow for forward, development of the maxilla.
• The shields are fitted closely to the alveolar process of
the mandible to hold or redirect growth posteriorly.
•The effectiveness of each appliance is dependent on
patient cooperation and wearing them full time.

FRANKEL IIIFRANKEL III

 Treatment with an FR III and other types of functionalTreatment with an FR III and other types of functional
appliances is more successful in patients with a Class IIIappliances is more successful in patients with a Class III
malocclusion presenting with a functional shift on closure.malocclusion presenting with a functional shift on closure.
 In two separate studies the FRIII appliance appears to effectIn two separate studies the FRIII appliance appears to effect
occlusal changes (i.e., introducing dental compensations) byocclusal changes (i.e., introducing dental compensations) by
proclination of upper incisors and retroclination of lowerproclination of upper incisors and retroclination of lower
incisors.incisors.
 Treatment with an FRIII and other types of functionalTreatment with an FRIII and other types of functional
appliances is more successful in patients with a Class IIIappliances is more successful in patients with a Class III
malocclusion presenting with a functional shift on closure.malocclusion presenting with a functional shift on closure.
 In two separate studies the FRIII appliance appears to effectIn two separate studies the FRIII appliance appears to effect
occlusal changes (i.e., intro-ducing dental compensations) byocclusal changes (i.e., intro-ducing dental compensations) by
proclination of upper incisors and retroclination of lowerproclination of upper incisors and retroclination of lower
incisors.incisors.

 The mandible was repositioned downward and backward,The mandible was repositioned downward and backward,
decreasing the prognathism of the mandible and increasingdecreasing the prognathism of the mandible and increasing
the lower facial height. Changes in the position of thethe lower facial height. Changes in the position of the
maxilla were minimal.maxilla were minimal.
 The best response to FRIII treatment was noted in patientsThe best response to FRIII treatment was noted in patients
with Class III malocclusions with an increased overbite of 4with Class III malocclusions with an increased overbite of 4
to 5 mm in the early mixed dentition.to 5 mm in the early mixed dentition.
 The FRIII appliance can also be used as a retentive deviceThe FRIII appliance can also be used as a retentive device
following maxillary protraction treatment.following maxillary protraction treatment.

The BioFrankel-3The BioFrankel-3
Cozza,Marino and Muzedero [JCO2003]Cozza,Marino and Muzedero [JCO2003]
 The BioFrankel-3 is similar to the classic Balters bionatorThe BioFrankel-3 is similar to the classic Balters bionator
with the palatal omega loop reversed for Class IIIwith the palatal omega loop reversed for Class III
correction, except that it incorporates upper labial pads as incorrection, except that it incorporates upper labial pads as in
the FR-3appliancethe FR-3appliance
 The labial pads lie above the upper incisors and anterior toThe labial pads lie above the upper incisors and anterior to
the maxillary mucosa and are removable from the face bowthe maxillary mucosa and are removable from the face bow
tubes fixed in the acrylic.tubes fixed in the acrylic.
 These pads function to eliminate the restrictive pressure ofThese pads function to eliminate the restrictive pressure of
the upper lip on the underdeveloped maxilla, stimulatingthe upper lip on the underdeveloped maxilla, stimulating
bone apposition on the labial alveolar surfaces.bone apposition on the labial alveolar surfaces.
 The anterior labial arch rests against the lower anterior teethThe anterior labial arch rests against the lower anterior teeth
with minimal active pressure.with minimal active pressure.

 As in the FR-3 appliance, the labial arch induces tension of theAs in the FR-3 appliance, the labial arch induces tension of the
soft tissue in the vestibular fold, with the aim of expandingsoft tissue in the vestibular fold, with the aim of expanding
and remodeling the dentoalveolar arch and the apical base,and remodeling the dentoalveolar arch and the apical base,
eliminating pressure, and applying traction.eliminating pressure, and applying traction.
 The working bite should be taken in the most retruded positionThe working bite should be taken in the most retruded position
possible, allowing slight inter incisal clearance for correctionpossible, allowing slight inter incisal clearance for correction
of the anterior crossbite. To allow for tooth eruption, theof the anterior crossbite. To allow for tooth eruption, the
posterior acrylic is progressively relieved as the crossbiteposterior acrylic is progressively relieved as the crossbite
improves.improves.

 Class III activator :Class III activator :
 Rakosi (1979)Rakosi (1979) modified activator for use in CLASS IIImodified activator for use in CLASS III
treatment.treatment.
 The modifications consist four stop loops located mesial toThe modifications consist four stop loops located mesial to
first molars (prevent mesial tipping of molars and stabilize thefirst molars (prevent mesial tipping of molars and stabilize the
appliance)appliance)
 Lower labial low (Stabilize the appliance)Lower labial low (Stabilize the appliance)
 Upper labial pads (remove force of upper lip and createUpper labial pads (remove force of upper lip and create
periosteal pull)periosteal pull)
 Tongue crib.Tongue crib.

 Construction bite is taken with opening and posteriorConstruction bite is taken with opening and posterior
positioning of the mandible. Hence it is useful in two types ofpositioning of the mandible. Hence it is useful in two types of
malocclusions. They are class III malocclusions withmalocclusions. They are class III malocclusions with
functional protrusion and skeletal class III with normalfunctional protrusion and skeletal class III with normal
functional path.functional path.
 Satravahe et al (AJO 1999)Satravahe et al (AJO 1999)
 Activator treatment leads to increased SNA, FacialActivator treatment leads to increased SNA, Facial
convexity, facial axis etc.convexity, facial axis etc.
 In the post treatment , period the skeletal effect remainedIn the post treatment , period the skeletal effect remained
period but, the gonial angle showed a compensatory.period but, the gonial angle showed a compensatory.

Bionator III appliance :Bionator III appliance :
Levrini et al (1993Levrini et al (1993)) modified balter’s bionator for classmodified balter’s bionator for class
III .The new application hasIII .The new application has
1.Deeper and wider lingual wings.1.Deeper and wider lingual wings.
2.Acrylic vestibular lateral shields extending deeply to2.Acrylic vestibular lateral shields extending deeply to
upper formix.upper formix.
3.Upper labial buttons.3.Upper labial buttons.
4.Upper incisior inclined plane.4.Upper incisior inclined plane.

According to Garrattini et al (AJO 1998) bionator is
an effective appliance in mid facial deficiency
especially with hypo divergent growth pattern.
The control of mandibular growth is unpredictable with
this appliance. The dentoalveolar chances exceeded
the skeleral effects of bionator III.

Reverse bionator-BaltersReverse bionator-Balters
 It has the following differences from the standard bionatorIt has the following differences from the standard bionator
design.design.
1.Palatal bar configuration runs forward rather posteriorly.This1.Palatal bar configuration runs forward rather posteriorly.This
stimulates tongue to remain in a retracted position.It contactsstimulates tongue to remain in a retracted position.It contacts
the anterior palate encouraging maxillary growth.the anterior palate encouraging maxillary growth.
2.labial bow runs in front of lower incisors rather than upper2.labial bow runs in front of lower incisors rather than upper
incisors.The wire may be passive or exert light pressure.incisors.The wire may be passive or exert light pressure.
3.Bite is taken in the most retruded position with 2 mm inter3.Bite is taken in the most retruded position with 2 mm inter
incisal opening.incisal opening.
4.Lower acrylic portion is extended from canine to canine,4.Lower acrylic portion is extended from canine to canine,

 Removable mandibular retractor :Removable mandibular retractor :
It is an appliance used in early functional treatment of CLASSIt is an appliance used in early functional treatment of CLASS
III malocclusion. It leads toIII malocclusion. It leads to
1.Anterior morphogentic rotation of mandible as a result of1.Anterior morphogentic rotation of mandible as a result of
upward and forward direction of condylar growth, leading toupward and forward direction of condylar growth, leading to
reduced mandibular protrusion and total length.reduced mandibular protrusion and total length.
2. More vertical orientation of the ramus.2. More vertical orientation of the ramus.
3.Reduced gonial angle.3.Reduced gonial angle.
4.Maxillary skeletal and dentoalveolar protrusion.4.Maxillary skeletal and dentoalveolar protrusion.

Tollaro, Baccetti, and Franchi Nov 1995 AJO 1997 Dec
AJO Treatment with the functional appliance produced a
significantly increased growth of the maxilla, featuring a
more downward and forward displacement of the region of
point A and a significantly more upward and forward
direction of condylar growth, leading to a "shrinkage" of total
mandibular length. .
This skeletal mandibular change can be considered as a
biologic process to "dissipate" excess of mandibular growth
relative to the maxilla.

A Fixed Reverse Labial Bow for Moderate Class IIIA Fixed Reverse Labial Bow for Moderate Class III
Interceptive TreatmentInterceptive Treatment
CARANOS. JAY BOWMAN, MARCO VALLE[JCO2003]CARANOS. JAY BOWMAN, MARCO VALLE[JCO2003]
 A new approach to the management of mild-to-moderateA new approach to the management of mild-to-moderate
dental and skeletal Class III malocclusions in growingdental and skeletal Class III malocclusions in growing
patients, without relying on special patient co-operation.patients, without relying on special patient co-operation.
 It consists of an .045" stainless steel arch wire that isIt consists of an .045" stainless steel arch wire that is
inserted into the headgear tubes of the upper molar bands.inserted into the headgear tubes of the upper molar bands.
 The anterior part of the wire restricts the lower incisorsThe anterior part of the wire restricts the lower incisors
during closure of the mandible.during closure of the mandible.
 Each distal end has a clip fabricated from an .028" piece ofEach distal end has a clip fabricated from an .028" piece of
wire, 7mm long, ending in a distal ball end soldered to awire, 7mm long, ending in a distal ball end soldered to a
3mm tube (internal diameter 1.2mm).3mm tube (internal diameter 1.2mm).
 The clip prevents the ends of the wire from sliding out ofThe clip prevents the ends of the wire from sliding out of
the molar tubes.the molar tubes.

 Restriction of the lower arch and the mandible is only one of theRestriction of the lower arch and the mandible is only one of the
orthodontic effects required during interceptive treatment oforthodontic effects required during interceptive treatment of
moderate Class III malocclusions. Therefore, it is always used inmoderate Class III malocclusions. Therefore, it is always used in
conjunction with one or more other maxillary fixed appliances,conjunction with one or more other maxillary fixed appliances,
such as a rapid palatal expander a palatal arch for incisorsuch as a rapid palatal expander a palatal arch for incisor
advancement or a tongue crib.advancement or a tongue crib.


The lower arch can be left free or can be prepared
with a lingual arch for anchorage, depending on how
much lingual inclination of the lower incisors is
required during treatment.
The results are predictable and rapid, usually
occurring within two to four months. ANB generally
increases due to an increase in SNA, with no
downward and backward rotation of the mandible.
The lower incisor inclination decreases, while the
overbite and overjet are improved.

 Two-Piece Corrector for Class III Skeletal andTwo-Piece Corrector for Class III Skeletal and
Dental MalocclusionsDental Malocclusions
 GERALD R. EGANHOUSE [ JCO1997GERALD R. EGANHOUSE [ JCO1997]]
 The Two-Piece Corrector is designed to applyThe Two-Piece Corrector is designed to apply
biological forces that will counteract any Class IIIbiological forces that will counteract any Class III
developmental vectors, whether skeletal ordevelopmental vectors, whether skeletal or
dentoalveolar, and correct or minimize their effectsdentoalveolar, and correct or minimize their effects
on the patient.on the patient.
 It is a removable acrylic appliance thatIt is a removable acrylic appliance that
simultaneously applies an anterior force to thesimultaneously applies an anterior force to the
maxilla and an equal posterior force to the mandible.maxilla and an equal posterior force to the mandible.
 The flat, sliding surfaces of the two pieces createThe flat, sliding surfaces of the two pieces create
almost no friction as the dentition is disoccludedalmost no friction as the dentition is disoccluded
during movement, but provide both lateral andduring movement, but provide both lateral and
anteroposterior stability.anteroposterior stability.

 The Two-Piece Corrector has the following advantages:The Two-Piece Corrector has the following advantages:
 Requires little chair time.Requires little chair time.
 Relatively inexpensive.Relatively inexpensive.
 Does not require full-time wear (the head cap and chin cupDoes not require full-time wear (the head cap and chin cup
need only be worn at night).need only be worn at night).
 Easy for patients to adapt to.Easy for patients to adapt to.
 Provides efficient overcorrection of skeletal and dental ClassProvides efficient overcorrection of skeletal and dental Class
III malocclusions in properly selected cases.III malocclusions in properly selected cases.

splints, Class III elastics, and chincup (SEC III)splints, Class III elastics, and chincup (SEC III)
Ferro, Nucci, Ferro and Gallo[AJO2003]Ferro, Nucci, Ferro and Gallo[AJO2003]
 In the 1980s, Ferro proposed a new orthopedic approachIn the 1980s, Ferro proposed a new orthopedic approach
splints, elastics, and chincup for Class IIIsplints, elastics, and chincup for Class III (SEC III(SEC III) to correct) to correct
this skeletal malocclusion.this skeletal malocclusion.
In this approach,In this approach,
 2 removable splints with hooks for Class III elastics and a2 removable splints with hooks for Class III elastics and a
chincup were associatedchincup were associated
 The rationale was that 2 splints with a flat occlusal planeThe rationale was that 2 splints with a flat occlusal plane
would facilitate correcting the Class III relationship,would facilitate correcting the Class III relationship,
eliminating both intercuspation and aggravating factors, sucheliminating both intercuspation and aggravating factors, such
as anterior tongue thrust .as anterior tongue thrust .
 SEC III was shown to be successful at the end of the treatmentSEC III was shown to be successful at the end of the treatment
and post retention of still growing patients.and post retention of still growing patients.

splints, Class III elastics, and chincup

 The authors conducted a study on long term stability afterThe authors conducted a study on long term stability after
successful SEC ||| and concluded thatsuccessful SEC ||| and concluded that
 1. The SEC III appliance achieved a long-term Class III1. The SEC III appliance achieved a long-term Class III
occlusal correction in a high percentage (88.5%) ofocclusal correction in a high percentage (88.5%) of
successfully treated patients. Thus, SEC III treatment issuccessfully treated patients. Thus, SEC III treatment is
reliable at least at the end of the facial growth, as defined byreliable at least at the end of the facial growth, as defined by
age.age.
 2. At the end of treatment, the best predictors of relapse seem2. At the end of treatment, the best predictors of relapse seem
to be low Wits appraisal, ANB angle, and overbite, and largeto be low Wits appraisal, ANB angle, and overbite, and large
SNB. No backward mandib-ular rotation was observed.SNB. No backward mandib-ular rotation was observed.
 3. After treatment, forward mandibular rotation occurs.3. After treatment, forward mandibular rotation occurs.
 4. Mandibular forward rotation cannot be considered a4. Mandibular forward rotation cannot be considered a
rebound because during treatment no mandibular postrotationrebound because during treatment no mandibular postrotation
was seen.was seen.
 5. Relapse appears to be affected by increased growth of the5. Relapse appears to be affected by increased growth of the
mandibular ramusmandibular ramus

 Early Class III Treatment with Magnetic AppliancesEarly Class III Treatment with Magnetic Appliances
DARENDELILER, CHIARINI, JOHO [JCO1993]DARENDELILER, CHIARINI, JOHO [JCO1993]
Authors demonstrated the use of a Magnetic Expansion Device (MED) inAuthors demonstrated the use of a Magnetic Expansion Device (MED) in
conjunction with the MAD III appliance in other words, light maxillaryconjunction with the MAD III appliance in other words, light maxillary
expansion forces combined with a functional orthopedic device for earlyexpansion forces combined with a functional orthopedic device for early
treatment of a Class III malocclusiontreatment of a Class III malocclusion..
A MAD III appliance was
constructed from a bonded
upper plate and a removable
lower plate, each carrying two
buccal magnets
Two repelling samarium cobalt
magnets, each coated with
vacuum-molded plastic, were
also embedded in the acrylic of
the upper plate to form an MED

.
Pins and tubes were placed to guide the separation of
the palate. Only one of the repelling magnets could
slide on the pins for activation of the MED.
Self-polymerizing acrylic was added every three weeks
to re-establish contact between the magnets.
Since the MAD III is composed of two removable
plates and is therefore less bulky than a traditional
Class III activator, it allows normal function in speech,
swallowing, and chewing.
Thus, it stimulates the mandible to assume a gently
forced centric relation, allowing continuous growth
modification of both the mandible and the maxilla in an
anteroposterior direction

 With this appliance, the magnets can be located to orient theWith this appliance, the magnets can be located to orient the
intermaxillary forces either more anteriorly or moreintermaxillary forces either more anteriorly or more
posteriorly.posteriorly.
 The magnets can even be placed to repel in the anterior regionThe magnets can even be placed to repel in the anterior region
and attract in the posterior region, thus creating an openingand attract in the posterior region, thus creating an opening
rotation that could be used to correct a deep bite.rotation that could be used to correct a deep bite.
 When combined with an MED, the MAD III offers anWhen combined with an MED, the MAD III offers an
alternative in the early correction of Class III malocclusions.alternative in the early correction of Class III malocclusions.

 Modified quad helixModified quad helix ( Nute and Dibiase[1998 JCO]( Nute and Dibiase[1998 JCO]
 In adult patients, if the skeletal discrepancy is not severeIn adult patients, if the skeletal discrepancy is not severe
enough to require orthognathic surgery, dentoalveolarenough to require orthognathic surgery, dentoalveolar
correction can often be achieved with orthodontic treatment.correction can often be achieved with orthodontic treatment.
 Modified Quad Helix appliance proclines the maxillaryModified Quad Helix appliance proclines the maxillary
anterior segment to correct an anterior cross bite and facilitateanterior segment to correct an anterior cross bite and facilitate
bracket placement. It may also expands the maxilla to correctbracket placement. It may also expands the maxilla to correct
a posterior cross bite.a posterior cross bite.

The arms contacting the palatal surfaces of the
incisors were activated by advancing them 2-3mm.
Although the wire is large, the force was kept within
acceptable limits because it was distributed over a
number of teeth and because the arms added
flexibility.
The appliance was attached with glass ionomer
cement
The Quad Helix was removed every six to eight
weeks, reactivated, and recemented until the cross
bites were corrected and the maxillary incisors
could be bracketed

Chin Cup TherapyChin Cup Therapy
 Skeletal Class III malocclusion with a relatively normalSkeletal Class III malocclusion with a relatively normal
maxilla and a moderately protrusive mandible can be treatedmaxilla and a moderately protrusive mandible can be treated
with the use of a chin cup.with the use of a chin cup.
 This treatment modality is popular among the AsianThis treatment modality is popular among the Asian
populations because of its favorable effects on the sagittal andpopulations because of its favorable effects on the sagittal and
vertical dimensions.vertical dimensions.
 The objective of early treatment with the use of a chin cup isThe objective of early treatment with the use of a chin cup is
to provide growth inhibition or redirection and posteriorto provide growth inhibition or redirection and posterior
positioning of the mandible.positioning of the mandible.

Effects on Mandibular GrowthEffects on Mandibular Growth
 The orthopedic effects of a chin cup on the mandibleThe orthopedic effects of a chin cup on the mandible
includeinclude
(1) redirection of mandibular growth vertically,(1) redirection of mandibular growth vertically,
(2) backward repositioning (rotation) of the mandible,(2) backward repositioning (rotation) of the mandible,
andand
(3) remodeling of the mandible with closure of the gonial(3) remodeling of the mandible with closure of the gonial
angle.angle.
 However, chin cup therapy has been shown to produce aHowever, chin cup therapy has been shown to produce a
change in the mandible associated with a downward andchange in the mandible associated with a downward and
backward rotation and a decrease in the angle of thebackward rotation and a decrease in the angle of the
mandible.mandible.
 In addition, there is less incremental increase inIn addition, there is less incremental increase in
mandibular length together with posterior movement ofmandibular length together with posterior movement of
"B point" and pogonion."B point" and pogonion.

 Because of the backward mandibular rotation, control of theBecause of the backward mandibular rotation, control of the
vertical growth during chin cup treatment is difficult tovertical growth during chin cup treatment is difficult to
manage.manage.
 Effects on Maxillary GrowthEffects on Maxillary Growth
 Some studies have indicated that a chin cup appliance has noSome studies have indicated that a chin cup appliance has no
effect on the anteroposterior growth of the maxilla.effect on the anteroposterior growth of the maxilla.
 However, Uner, Yuksel, and Ucuncu showed that earlyHowever, Uner, Yuksel, and Ucuncu showed that early
correction of an anterior crossbite with a chin cup appliancecorrection of an anterior crossbite with a chin cup appliance
prevents retardation of anteroposterior maxillary growth.prevents retardation of anteroposterior maxillary growth.
 Sugawara et al compared the growth changes of patients afterSugawara et al compared the growth changes of patients after
chin cup treatment with control subjects and reported that, atchin cup treatment with control subjects and reported that, at
age 17, the midface is more deficient in patients of the controlage 17, the midface is more deficient in patients of the control
groups than in those of the treatment groups.groups than in those of the treatment groups.

 Force Magnitude and DirectionForce Magnitude and Direction
 Chin cups are divided into two types:Chin cups are divided into two types:
 the occipital-pull chin cupthe occipital-pull chin cup that is used for patients withthat is used for patients with
mandibular protrusion andmandibular protrusion and
 the vertical-pull chin cupthe vertical-pull chin cup that is used in patients presentingthat is used in patients presenting
with a steep mandibular plane angle and excessive anteriorwith a steep mandibular plane angle and excessive anterior
facial height.facial height.
 Most of the reported studies recommended an orthopedicMost of the reported studies recommended an orthopedic
force of 300 to 500 g per side.force of 300 to 500 g per side.
 Patients are instructed to wear the appliance 14 hr/day.Patients are instructed to wear the appliance 14 hr/day.
 The orthopedic force is usually directed either through theThe orthopedic force is usually directed either through the
condyle or below the condyle.condyle or below the condyle.
 Treatment Timing and Duration Patients with mandibularTreatment Timing and Duration Patients with mandibular
excess can usually be recognized in the primary dentitionexcess can usually be recognized in the primary dentition
despite the fact that the mandible appears retrognathic in thedespite the fact that the mandible appears retrognathic in the
early years for most children.early years for most children.

 Evidence exists that treatment to reduce mandibular protrusionEvidence exists that treatment to reduce mandibular protrusion
is more successful when it is started in the primary or earlyis more successful when it is started in the primary or early
mixed dentition.mixed dentition.
 The treatment time varies from 1 year to as long as 4 yearsThe treatment time varies from 1 year to as long as 4 years
depending on the severity of the original malocclusion.depending on the severity of the original malocclusion.
 Stability of TreatmentStability of Treatment
 The stability of chin cup treatment remains unclear. SeveralThe stability of chin cup treatment remains unclear. Several
investigators reported stability in horizontal maxillary andinvestigators reported stability in horizontal maxillary and
mandibular changes associated with chin cup treatment.mandibular changes associated with chin cup treatment.
 However, few studies reported a tendency to return to theHowever, few studies reported a tendency to return to the
original growth pattern after the chin cup is discontinued.original growth pattern after the chin cup is discontinued.

 Sugarwara et alSugarwara et al published a report on the longterm effects ofpublished a report on the longterm effects of
chin cup therapy on three groups of Japanese girls who startedchin cup therapy on three groups of Japanese girls who started
chin cup treatment at 7, 9, and 11 years with serial lateral headchin cup treatment at 7, 9, and 11 years with serial lateral head
filmsfilms
 The authors found that the skeletal profile was greatlyThe authors found that the skeletal profile was greatly
improved during the initial stages of chin cup therapy, butimproved during the initial stages of chin cup therapy, but
these changes were often not maintained.these changes were often not maintained.
 Patients who started treatment at an earlier age had a catchupPatients who started treatment at an earlier age had a catchup
mandibular displacement in a forward and downward directionmandibular displacement in a forward and downward direction
before growth was completed.before growth was completed.
 The authors concluded that chin cup therapy did notThe authors concluded that chin cup therapy did not
necessarily guarantee a positive correction of the skeletalnecessarily guarantee a positive correction of the skeletal
profile after completion of growth, which suggests the needprofile after completion of growth, which suggests the need
for the extended use of the chin cup over the growth period.for the extended use of the chin cup over the growth period.

 Chincap therapy is applicable when a growing patient has aChincap therapy is applicable when a growing patient has a
true skeletal Class III malocclusion and a large mandible;true skeletal Class III malocclusion and a large mandible;
lacks maxillary recession, an acute cranial base angle, a longlacks maxillary recession, an acute cranial base angle, a long
face syndrome, and symptoms of temporomandibularface syndrome, and symptoms of temporomandibular
disorders; and orthognathic surgery is not an option.disorders; and orthognathic surgery is not an option.
 Treatment must continue until growth has ceased to preventTreatment must continue until growth has ceased to prevent
redevelopment of the prognathic face after chincap therapy,redevelopment of the prognathic face after chincap therapy,
and some overcorrection might be warranted, although it is notand some overcorrection might be warranted, although it is not
necessarily required.necessarily required.
Hideo mittani AJO JUN 2002

 Effects on the Temporomandibular JointEffects on the Temporomandibular Joint
 There is some concern on the adverse effect of chin cupThere is some concern on the adverse effect of chin cup
appliance on the TMJ.appliance on the TMJ.
 In a study by Deguchi and Kitsugi,65 several patientsIn a study by Deguchi and Kitsugi,65 several patients
complained of temporary soreness of the TMJ during thecomplained of temporary soreness of the TMJ during the
retention period.retention period.
 Of 40 patients, 2 continued to have TMJ pain and some degreeOf 40 patients, 2 continued to have TMJ pain and some degree
of difficulty in opening the mouth after the end of activeof difficulty in opening the mouth after the end of active
treatment.treatment.
 Several studies indicated that the chin cup affects the growthSeveral studies indicated that the chin cup affects the growth
of not only the mandible, but also the cranial base structures asof not only the mandible, but also the cranial base structures as
well.well.
 However, a recent study failed to support the hypothesis that aHowever, a recent study failed to support the hypothesis that a
chin cup appliance induces the posterior displacement of thechin cup appliance induces the posterior displacement of the
glenoid fossa.glenoid fossa.

 Combined MPA and Chin cap therapyCombined MPA and Chin cap therapy
 Yoshida et al[1999AO]Yoshida et al[1999AO]
 During combined MPA and chincap treatment the maxillaDuring combined MPA and chincap treatment the maxilla
moved forwards with counter clock wise rotation and themoved forwards with counter clock wise rotation and the
mandible moved backward and downward with clockwisemandible moved backward and downward with clockwise
rotation and growth retardationrotation and growth retardation
 The gross effects of treatment on forward growth of maxillaThe gross effects of treatment on forward growth of maxilla
persisted in the post treatment period where as mandiblepersisted in the post treatment period where as mandible
showed rebound like growth.so together these appliances workshowed rebound like growth.so together these appliances work
in an effective manner .in an effective manner .

 Protraction Face Mask TherapyProtraction Face Mask Therapy
 Protraction face mask has been used in the treatment ofProtraction face mask has been used in the treatment of
patients with Class III malocclusion and a maxillarypatients with Class III malocclusion and a maxillary
deficiency.deficiency.
 In 1944 Oppenheim believed that one could not control theIn 1944 Oppenheim believed that one could not control the
growth or anterior displacement of the mandible and suggestedgrowth or anterior displacement of the mandible and suggested
moving the maxilla forward in an attempt to counterbalancemoving the maxilla forward in an attempt to counterbalance
mandibular protrusion.mandibular protrusion.
 In the 1960s Delaire and others revived the interest in using aIn the 1960s Delaire and others revived the interest in using a
face mask for maxillary protraction.face mask for maxillary protraction.
 Petit later modified Delaire's basic concept by increasing thePetit later modified Delaire's basic concept by increasing the
amount of force generated by the appliance, thus decreasingamount of force generated by the appliance, thus decreasing
the overall treatment time.the overall treatment time.
 In 1987 McNamara introduced the use of a bonded expansionIn 1987 McNamara introduced the use of a bonded expansion
appliance with acrylic occlusal coverage for maxillaryappliance with acrylic occlusal coverage for maxillary
protraction.protraction.
 Turley improved patient cooperation in wearing the applianceTurley improved patient cooperation in wearing the appliance
by fabricating customized face masks.by fabricating customized face masks.

 The protraction face mask is made of two pads that contact theThe protraction face mask is made of two pads that contact the
soft tissue in the forehead and chin region.soft tissue in the forehead and chin region.
 The pads are connected by a midline framework and areThe pads are connected by a midline framework and are
adjustable through the loosening and tightening of a set screw.adjustable through the loosening and tightening of a set screw.
 An adjustable anterior wire with hooks is also connected toAn adjustable anterior wire with hooks is also connected to
the midline framework to accommodate a downward andthe midline framework to accommodate a downward and
forward pull on the maxilla with elasticsforward pull on the maxilla with elastics
 To minimize the opening of the bite as the maxilla isTo minimize the opening of the bite as the maxilla is
repositioned, the protraction elastics are attached near therepositioned, the protraction elastics are attached near the
maxillary canines with a downward and forward pull of 30maxillary canines with a downward and forward pull of 30
degrees to the occlusal plane.degrees to the occlusal plane.
 Maxillary protraction generally requires 300 to 600 g of forceMaxillary protraction generally requires 300 to 600 g of force
per side, depending on the age of the patient. Tension of theper side, depending on the age of the patient. Tension of the
elastics can be estimated using a tension stress gauge.elastics can be estimated using a tension stress gauge.
 Patients are instructed to wear the face mask for 12 hours aPatients are instructed to wear the face mask for 12 hours a
day.day.

Design and Construction of the Anchorage SystemDesign and Construction of the Anchorage System
Metallic Banded Palatal Expansion ApplianceMetallic Banded Palatal Expansion Appliance
 In the mixed dentition the banded palatal expansion applianceIn the mixed dentition the banded palatal expansion appliance
is constructed by using bands fitted on the maxillary primaryis constructed by using bands fitted on the maxillary primary
second molars and permanent first molars).second molars and permanent first molars).
 In the primary dentition the bands are fitted on the primaryIn the primary dentition the bands are fitted on the primary
first and second molars. Taking a compound impression of thefirst and second molars. Taking a compound impression of the
bands and maxillary teeth is recommended to improve thebands and maxillary teeth is recommended to improve the
accuracy of transferring the bands to the impression. Theaccuracy of transferring the bands to the impression. The
impression is then poured up.impression is then poured up.

 Nanda introduced a modified protraction face bow design inNanda introduced a modified protraction face bow design in
order to deliver the protraction forces from a higher level andorder to deliver the protraction forces from a higher level and
was able to eliminate the counterclockwise rotation of thewas able to eliminate the counterclockwise rotation of the
maxilla.maxilla.
 Recently another design named the ModifiedRecently another design named the Modified
 Maxillary Protraction Headgear was introduced{Kajiyama etMaxillary Protraction Headgear was introduced{Kajiyama et
al2000 AJO}al2000 AJO}
 The investigators applied the force above the eyes at the levelThe investigators applied the force above the eyes at the level
of the frontal region with a specially designed face bow toof the frontal region with a specially designed face bow to
prevent a counterclockwise rotation of the maxilla.prevent a counterclockwise rotation of the maxilla.
 Their results showed that the appliance is effective to protractTheir results showed that the appliance is effective to protract
the maxilla with significant clockwise rotation.the maxilla with significant clockwise rotation.

 Molar bands are joined by soldering a heavy wireMolar bands are joined by soldering a heavy wire
(0.043inch) to the palatal plate, which had a Hyrax(0.043inch) to the palatal plate, which had a Hyrax
type screw in the midline.type screw in the midline.
 A 0.045inch wire is soldered bilaterally to the buccalA 0.045inch wire is soldered bilaterally to the buccal
aspects of the molar bands and extended anteriorly toaspects of the molar bands and extended anteriorly to
the canine area for protraction with elastics.the canine area for protraction with elastics.
 The appliance is activated twice daily (0.25 mm perThe appliance is activated twice daily (0.25 mm per
turn) by the patient or parent for 1 week.turn) by the patient or parent for 1 week.
 In patients with a more constricted maxilla, activationIn patients with a more constricted maxilla, activation
of the expansion screw is carried out for 2 weeks orof the expansion screw is carried out for 2 weeks or
more depending on the discrepancy.more depending on the discrepancy.

Acrylic Bonded Palatal Expansion ApplianceAcrylic Bonded Palatal Expansion Appliance
 The acrylic bonded palatal expansion appliance incorporatesThe acrylic bonded palatal expansion appliance incorporates
a Hyraxtype screw into a wire framework made from 0.040a Hyraxtype screw into a wire framework made from 0.040
inch stainless steel .The framework extends around the buccalinch stainless steel .The framework extends around the buccal
and lingual surfaces of the dentition.and lingual surfaces of the dentition.
 A separate 0.040inch stainless steel wire is bent to cross theA separate 0.040inch stainless steel wire is bent to cross the
occlusion between the primary first and second molars andocclusion between the primary first and second molars and
ends with a hook for protraction with elastics.ends with a hook for protraction with elastics.
 Acrylic is then added on all the occlusal surfaces of theAcrylic is then added on all the occlusal surfaces of the
primary molars and permanent first molars using a "salt andprimary molars and permanent first molars using a "salt and
pepper" application of methyl methacrylate monomer andpepper" application of methyl methacrylate monomer and
polymer.polymer.
 The appliance is bonded to the teeth using a chemicalcureThe appliance is bonded to the teeth using a chemicalcure
adhesive that is specially formulated for the bonding of largeadhesive that is specially formulated for the bonding of large
acrylic appliances.acrylic appliances.

 Benefits of palatal expansionBenefits of palatal expansion
 Palatal expansion has been advocated as a routine part of ClassPalatal expansion has been advocated as a routine part of Class
III correction with facemask therapy.III correction with facemask therapy.
 The benefits of palatal expansion might include expansion of aThe benefits of palatal expansion might include expansion of a
narrow maxilla and correction of posterior crossbite, increasenarrow maxilla and correction of posterior crossbite, increase
in arch length, bite opening, loosening or activation ofin arch length, bite opening, loosening or activation of
circummaxillary sutures, and initiating downward and forwardcircummaxillary sutures, and initiating downward and forward
movement of the maxillary complex.movement of the maxillary complex.
 Haas showed that maxillary expansion always moves theHaas showed that maxillary expansion always moves the
maxilla down and often moves it forward. These findings havemaxilla down and often moves it forward. These findings have
been supported by others.been supported by others.
 Clinicians have advocated maxillary expansion a week beforeClinicians have advocated maxillary expansion a week before
starting facemask use, even without maxillary constriction orstarting facemask use, even without maxillary constriction or
crowding. Critical evaluation of the benefits of expansion,crowding. Critical evaluation of the benefits of expansion,
however, have been limited.however, have been limited.

Skeletal Effects of Maxillary ProtractionSkeletal Effects of Maxillary Protraction
 Several circummaxillary sutures play an important role in theSeveral circummaxillary sutures play an important role in the
development of the nasomaxillary complex frontomaxillary,development of the nasomaxillary complex frontomaxillary,
nasomaxillary, zygomaticotemporal, zygomaticomaxillary,nasomaxillary, zygomaticotemporal, zygomaticomaxillary,
pterygopalatine, intermaxillary, ethmomaxillary, and thepterygopalatine, intermaxillary, ethmomaxillary, and the
lacrimomaxillary sutures.lacrimomaxillary sutures.
 Animal studies have shown that the maxillary complex can beAnimal studies have shown that the maxillary complex can be
displaced anteriorly with significant changes in thedisplaced anteriorly with significant changes in the
circummaxillary sutures and the maxillary tuberosity.circummaxillary sutures and the maxillary tuberosity.
 Maxillary protraction, however, does not always result inMaxillary protraction, however, does not always result in
forward movement of the maxilla.forward movement of the maxilla.
 Nanda showed that with the same line of force, differentNanda showed that with the same line of force, different
midfacial bones were displaced in different directionsmidfacial bones were displaced in different directions
depending on the moments of force generated at the sutures.depending on the moments of force generated at the sutures.

 Jackson, Kokich, and Shapiro found that anterior positioningJackson, Kokich, and Shapiro found that anterior positioning
of the maxillary complex was accompanied with a smallof the maxillary complex was accompanied with a small
amount of counterclockwise rotation during the treatmentamount of counterclockwise rotation during the treatment
period.period.
 The center of resistance of the maxilla was found to be locatedThe center of resistance of the maxilla was found to be located
at the distal contacts of the maxillary first molars one half theat the distal contacts of the maxillary first molars one half the
distance from the functional occlusal plane to the inferiordistance from the functional occlusal plane to the inferior
border of the orbit.border of the orbit.
 Protraction of the maxilla below the center of resistanceProtraction of the maxilla below the center of resistance
produces counterclockwise rotation of the maxilla.produces counterclockwise rotation of the maxilla.
 Using human skulls,Using human skulls, Hata and colleaguesHata and colleagues also found thatalso found that
protraction forces at the level of the maxillary arch producedprotraction forces at the level of the maxillary arch produced
forward but counterclockwise rotation of the maxilla unless aforward but counterclockwise rotation of the maxilla unless a
heavy downward vector of force was appliedheavy downward vector of force was applied

Clinical Response to Maxillary ProtractionClinical Response to Maxillary Protraction
 Clinically, anterior crossbites can be corrected with 3 to 4Clinically, anterior crossbites can be corrected with 3 to 4
months of maxillary expansion and protraction depending onmonths of maxillary expansion and protraction depending on
the severity of the malocclusion.the severity of the malocclusion.
 Improvement in overbite and molar relationship can beImprovement in overbite and molar relationship can be
expected with an additional 4 to 6 months of maxillaryexpected with an additional 4 to 6 months of maxillary
protraction.protraction.
 In a prospective clinical trial, overjet correction was found toIn a prospective clinical trial, overjet correction was found to
be the result of forward maxillary movement (31%), backwardbe the result of forward maxillary movement (31%), backward
movement of the mandible (21%), labial movement of themovement of the mandible (21%), labial movement of the
maxillary incisors (28%), and lingual movement of themaxillary incisors (28%), and lingual movement of the
mandibular incisors (20%).mandibular incisors (20%).
 Molar relationship was corrected to a Class I or Class IIMolar relationship was corrected to a Class I or Class II
dental relationship by a combination of skeletal movementsdental relationship by a combination of skeletal movements
and differential movement of the maxillary and mandibularand differential movement of the maxillary and mandibular
molars.molars.

 Anchorage loss was observed during maxillary proAnchorage loss was observed during maxillary pro
traction with mesial movement of the maxillarytraction with mesial movement of the maxillary
molars. Overbite was improved by eruption of themolars. Overbite was improved by eruption of the
maxillary and mandibular molars.maxillary and mandibular molars.
 The total facial height was increased by inferiorThe total facial height was increased by inferior
movement of the maxilla and downward andmovement of the maxilla and downward and
backward rotation of the mandible.backward rotation of the mandible.
 Patients with skeletal Class III malocclusion oftenPatients with skeletal Class III malocclusion often
present with a concave facial profile, a retrusive nasopresent with a concave facial profile, a retrusive naso
maxillary area, and a prominent lower third of themaxillary area, and a prominent lower third of the
face.The lower lip is often protruded relative to theface.The lower lip is often protruded relative to the
upper lip.upper lip.
 Treatment with maxillary expansion and protractionTreatment with maxillary expansion and protraction
can straighten the skeletal and soft tissue facial procan straighten the skeletal and soft tissue facial pro
files and improve the posture of the lipsfiles and improve the posture of the lips

Variability in Clinical ResponseVariability in Clinical Response
 Clinically, the maxilla can be advanced 2 to 4 mm over an 8Clinically, the maxilla can be advanced 2 to 4 mm over an 8
to 12month period of maxillary protraction.to 12month period of maxillary protraction.
 The amount of forward maxillary movement is influenced byThe amount of forward maxillary movement is influenced by
a number of factors including age of the patient, the use ofa number of factors including age of the patient, the use of
anchorage system (with or without an expansion appliance),anchorage system (with or without an expansion appliance),
the force level,direction and point of application, andthe force level,direction and point of application, and
treatment timetreatment time
 Age of PatientAge of Patient
 Several studies have examined the effect of age on maxillarySeveral studies have examined the effect of age on maxillary
protraction therapy .protraction therapy .
 Although some studies suggest that face mask/ expansionAlthough some studies suggest that face mask/ expansion
therapy may be most effective in the primary and early mixedtherapy may be most effective in the primary and early mixed
dentitions, other studies also suggest that it is a viable optiondentitions, other studies also suggest that it is a viable option
for older children before the onset of puberty.for older children before the onset of puberty.

 Design of Anchorage SystemDesign of Anchorage System
 The design of anchorage system for maxillary protractionThe design of anchorage system for maxillary protraction
varies from palatal arches to rapid maxillary expansion (RME)varies from palatal arches to rapid maxillary expansion (RME)
appliances).appliances).
 The need to expand the maxilla before protraction is notThe need to expand the maxilla before protraction is not
entirely clear. Most of the studies utilize palatal expansion toentirely clear. Most of the studies utilize palatal expansion to
"disarticulate" the maxilla and initiate cellular response in the"disarticulate" the maxilla and initiate cellular response in the
circummaxillary sutures, allowing a more positive reaction tocircummaxillary sutures, allowing a more positive reaction to
protraction forces.protraction forces.
 Few studies have adequate control groups to determineFew studies have adequate control groups to determine
whether it makes a difference if maxillary protraction waswhether it makes a difference if maxillary protraction was
used in conjunction with RME.used in conjunction with RME.
 In a study by Baik, 60 patients treated with a protraction faceIn a study by Baik, 60 patients treated with a protraction face
mask were divided into two groups with or without RME.mask were divided into two groups with or without RME.

 The author found significantly greater forward movement ofThe author found significantly greater forward movement of
the maxilla (+2.0 mm) when protraction was used inthe maxilla (+2.0 mm) when protraction was used in
conjunction with RME compared with protraction withoutconjunction with RME compared with protraction without
RME (+0.9 mm).RME (+0.9 mm).
 In the same study, greater forward movement of the maxillaIn the same study, greater forward movement of the maxilla
(+2.8 mm) was found when protraction was initiated during(+2.8 mm) was found when protraction was initiated during
maxillary expansion compared with protraction aftermaxillary expansion compared with protraction after
expansion ( + 1.85 mm).expansion ( + 1.85 mm).

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 Force Level, Direction, and Point of ApplicationForce Level, Direction, and Point of Application
 Orthopedic effects require greater forces than do orthodonticOrthopedic effects require greater forces than do orthodontic
movements.movements.
 Successful maxillary protraction has been reported using 300Successful maxillary protraction has been reported using 300
to 500 g of force per side in the primary and mixed dentitions .to 500 g of force per side in the primary and mixed dentitions .
 Most of these studies recommended wearing the headgear forMost of these studies recommended wearing the headgear for
10 to 12 hr/day.10 to 12 hr/day.
 Hata et alHata et al suggested that an effective forward displacement ofsuggested that an effective forward displacement of
the maxilla can be obtained clinically from a force applied 5the maxilla can be obtained clinically from a force applied 5
mm above the palatal plane.mm above the palatal plane.
 In deep overbite cases in which an opening of the bite isIn deep overbite cases in which an opening of the bite is
desired, a forward pull from the level of the maxillary archdesired, a forward pull from the level of the maxillary arch
with a concomitant anterior rotation of the maxilla aids in thewith a concomitant anterior rotation of the maxilla aids in the
treatment of these malocclusions.treatment of these malocclusions.

 In several clinical studies a 30 to 45degree forward andIn several clinical studies a 30 to 45degree forward and
downward protraction force applied at the canine regiondownward protraction force applied at the canine region
produced an acceptable clinical response with one degree ofproduced an acceptable clinical response with one degree of
counterclockwise rotation of the palatal plane.counterclockwise rotation of the palatal plane.
 Length of TreatmentLength of Treatment
 Time There is no consensus on the length of treatment withTime There is no consensus on the length of treatment with
protraction headgear.protraction headgear.
 A review of the literature shows that treatment time variesA review of the literature shows that treatment time varies
from 3 to 16 months).from 3 to 16 months).
 Most of the orthopedic changes are observed within the first 3Most of the orthopedic changes are observed within the first 3
to 6 months after maxillary expansion.to 6 months after maxillary expansion.


 Prolonged use of protraction force results in dentoalveolarProlonged use of protraction force results in dentoalveolar
changes including mesial movement of maxillary molars andchanges including mesial movement of maxillary molars and
proclination of maxillary incisors.proclination of maxillary incisors.
 The benefit of repeated maxillary expansion and protractionThe benefit of repeated maxillary expansion and protraction
has not been reported in the literature. Increased treatmenthas not been reported in the literature. Increased treatment
time may compromise patient oral hygiene and cooperationtime may compromise patient oral hygiene and cooperation

 Posttreatment StabilityPosttreatment Stability
 Animal and human studies have shown that the effects on theAnimal and human studies have shown that the effects on the
maxilla remained stable for 1 to 2 years after treatment.maxilla remained stable for 1 to 2 years after treatment.
 In a few studies in which patients were followed afterIn a few studies in which patients were followed after
maxillary expansion and protraction were completed, it wasmaxillary expansion and protraction were completed, it was
found that, in general, the anterior position of the maxilla wasfound that, in general, the anterior position of the maxilla was
maintained posttreatment.maintained posttreatment.
 It is interesting to note that during this growth period theIt is interesting to note that during this growth period the
maxilla and mandible reverted back to the original growthmaxilla and mandible reverted back to the original growth
pattern and, in some cases, Class III correction was lostpattern and, in some cases, Class III correction was lost
because of excess mandibular growth.because of excess mandibular growth.
 Fewer studies followed the early treatment patients throughFewer studies followed the early treatment patients through
the pubertal growth period.the pubertal growth period.
 In a prospective clinical trial, a group of Chinese patients wereIn a prospective clinical trial, a group of Chinese patients were
overtreated to a Class I or II relationship with maxillaryovertreated to a Class I or II relationship with maxillary
expansion and protraction and then retained with a Class IIIexpansion and protraction and then retained with a Class III
functional appliance for 1 year.functional appliance for 1 year.


 The treatment was found to be stable 2 years after the removalThe treatment was found to be stable 2 years after the removal
of the appliances. When these patients were followed forof the appliances. When these patients were followed for
another 2 years, 15 of the original 20 patients maintained aanother 2 years, 15 of the original 20 patients maintained a
positive overjet.positive overjet.
 In patients that relapsed back to a negative overjet, theIn patients that relapsed back to a negative overjet, the
mandible outgrew the maxilla in the horizontal direction.mandible outgrew the maxilla in the horizontal direction.
 The overjet reverted back to an anterior crossbite because ofThe overjet reverted back to an anterior crossbite because of
excessive forward mandibular growth.excessive forward mandibular growth.
 As a result, the authors recommend overcorrection of theAs a result, the authors recommend overcorrection of the
overjet and molar relationships in anticipation of theoverjet and molar relationships in anticipation of the
subsequent horizontal mandibular growth.subsequent horizontal mandibular growth.
 It is also advisable to use a retention device such as aIt is also advisable to use a retention device such as a
mandibular retractor or a functional appliance followingmandibular retractor or a functional appliance following
maxillary protraction.maxillary protraction.

 Treatment Indications for Face Mask TherapyTreatment Indications for Face Mask Therapy
 The face mask is most effective in the treatment of mild toThe face mask is most effective in the treatment of mild to
moderate skeletal Class III malocclusions with a retrusivemoderate skeletal Class III malocclusions with a retrusive
maxilla and a hypodivergent growth pattern.maxilla and a hypodivergent growth pattern.
 Patients presenting initially with some degree of anteriorPatients presenting initially with some degree of anterior
mandibular shift and a moderate overbite have a moremandibular shift and a moderate overbite have a more
favorable prognosis.favorable prognosis.
 In these cases correction of the anterior crossbite and theIn these cases correction of the anterior crossbite and the
mandibular shift results in a downward and backward rotationmandibular shift results in a downward and backward rotation
of the mandible that diminishes its prognathism.of the mandible that diminishes its prognathism.
 The presence of an adequate overbite helps maintain theThe presence of an adequate overbite helps maintain the
immediate dental correction after treatment.immediate dental correction after treatment.

 For patients presenting with a hyperdivergent growthFor patients presenting with a hyperdivergent growth
pattern and a minimal overbite, a bonded acrylicpattern and a minimal overbite, a bonded acrylic
palatal expansion appliance to control verticalpalatal expansion appliance to control vertical
eruption of molars has been recommended.eruption of molars has been recommended.
 However, a study comparing the use of banded orHowever, a study comparing the use of banded or
bonded expansion appliances as anchorage devicesbonded expansion appliances as anchorage devices
for maxillary expansion and protraction showed littlefor maxillary expansion and protraction showed little
differences in the skeletal and dental changesdifferences in the skeletal and dental changes
following the use of either appliance.following the use of either appliance.
 Specifically, vertical eruption of the posterior molarsSpecifically, vertical eruption of the posterior molars
and an increase in lower facial height were observedand an increase in lower facial height were observed
in both groups.in both groups.

 Treatment Timing for Face Mask TherapyTreatment Timing for Face Mask Therapy
 The optimal time to intervene in a patient with early Class IIIThe optimal time to intervene in a patient with early Class III
malocclusion is at the time of initial eruption of the uppermalocclusion is at the time of initial eruption of the upper
central incisors.central incisors.
 A positive overjet and overbite at the end of face maskA positive overjet and overbite at the end of face mask
treatment appears to maintain the anterior occlusion aftertreatment appears to maintain the anterior occlusion after
treatmenttreatment
 There is some evidence that better skeletal and dental responseThere is some evidence that better skeletal and dental response
can be obtained in the primary and early mixed dentition.can be obtained in the primary and early mixed dentition.
 The erupted maxillary first molars provides better anchorageThe erupted maxillary first molars provides better anchorage
for maxillary protraction.for maxillary protraction.
 More recent clinical studies indicate that maxillary protractionMore recent clinical studies indicate that maxillary protraction
is effective through puberty with diminishing skeletal responseis effective through puberty with diminishing skeletal response
as the sutures mature.as the sutures mature.

 Tandem traction bow applianceTandem traction bow appliance
 Chun ,Jeong, Row andYang [JCO1999] introduced aChun ,Jeong, Row andYang [JCO1999] introduced a
new appliance for treatment of growing Class III patients:new appliance for treatment of growing Class III patients:
 . The TTBA is more esthetic and comfortable than. The TTBA is more esthetic and comfortable than
conventional devices because it is worn intraorally.conventional devices because it is worn intraorally.
 It is removable, making it easy for the patient to maintain oralIt is removable, making it easy for the patient to maintain oral
hygiene, and allowing treatment to be suspended or restartedhygiene, and allowing treatment to be suspended or restarted
whenever the clinician deems necessary, without bonding orwhenever the clinician deems necessary, without bonding or
debonding.debonding.
 In clinical trials of the TTBA, structural superimpositionIn clinical trials of the TTBA, structural superimposition
according to Bjork showed anteroinferior movement of theaccording to Bjork showed anteroinferior movement of the
maxilla, posteroinferior repositioning of the mandible, andmaxilla, posteroinferior repositioning of the mandible, and
protraction of the maxillary dentition.protraction of the maxillary dentition.
 Therefore, we concluded that the TTBA has a similarTherefore, we concluded that the TTBA has a similar
treatment effect to that of an expanderfacemask combination.treatment effect to that of an expanderfacemask combination.

 Appliance ConstructionAppliance Construction
 The TTBA comprises an upper splint, a lower splint, and a traction bow .The TTBA comprises an upper splint, a lower splint, and a traction bow .
Its design allows the patient to open the mouth freely .Its design allows the patient to open the mouth freely .
 The upper splint, which can serve the same function as a rapid maxillaryThe upper splint, which can serve the same function as a rapid maxillary
expander, covers the palatal and occlusal surfaces of the maxillary teeth .expander, covers the palatal and occlusal surfaces of the maxillary teeth .
 A portion of the buccal surfaces are also covered, providing adequateA portion of the buccal surfaces are also covered, providing adequate
retention to overcome the maxillary protraction force of as much as 400retention to overcome the maxillary protraction force of as much as 400
500g per side.500g per side.
 The lower splint covers the buccal and lingual surfaces of the mandibularThe lower splint covers the buccal and lingual surfaces of the mandibular
teeth to reinforce retention . Because the patient wears the TTBA whileteeth to reinforce retention . Because the patient wears the TTBA while
sleeping, retention is critical, and reduction of interdental resin must besleeping, retention is critical, and reduction of interdental resin must be
avoided except in cases of severe undercuts.. The position of the elasticavoided except in cases of severe undercuts.. The position of the elastic
hooks on the upper splint and the tubes on the lower splint determine thehooks on the upper splint and the tubes on the lower splint determine the
direction of force.direction of force.

 Advantages :Advantages :
•• Promotes patient compliance, because it is more esthetic andPromotes patient compliance, because it is more esthetic and
comfortable than extraoralcomfortable than extraoral
 appliances. The TTBA is so small that it can be stored in aappliances. The TTBA is so small that it can be stored in a
removable appliance case. Nighttime wear is adequate for anremovable appliance case. Nighttime wear is adequate for an
orthopedic effect.orthopedic effect.
•• Promotes good oral hygiene, because it is removable.Promotes good oral hygiene, because it is removable.
•• Allows early treatment of any Class III malocclusion,due toAllows early treatment of any Class III malocclusion,due to
optimal retention in the deciduous,mixed, or early permanentoptimal retention in the deciduous,mixed, or early permanent
dentition.dentition.
•• Distributes the force of protraction to all maxillaryDistributes the force of protraction to all maxillary
 teeth.teeth.
Permits free mandibular movement, with its polished occlusalPermits free mandibular movement, with its polished occlusal
surface, so that a functional shift is easily corrected.surface, so that a functional shift is easily corrected.

 During active treatment, the labial bow is embedded in the acrylic; it isDuring active treatment, the labial bow is embedded in the acrylic; it is
uncovered and used to retain the incisors when the TTBA is reassembleduncovered and used to retain the incisors when the TTBA is reassembled
as a monoblock retainer.as a monoblock retainer.

 Maintains arch length, unlike extraoral maxillaryMaintains arch length, unlike extraoral maxillary
 protraction appliances that tend to produceprotraction appliances that tend to produce
 anterior crowding.anterior crowding.
 Requires no additional biteplate for correctionRequires no additional biteplate for correction
 of anterior crossbite.of anterior crossbite.
 Can be changed to a monoblock retainer at chairsideCan be changed to a monoblock retainer at chairside
for maintenance of crossbite correction.for maintenance of crossbite correction.
 Can be used in conjunction with fixed appliances ifCan be used in conjunction with fixed appliances if
necessarynecessary

 .Klempner[JCO2003] The Modified Tandem Appliance.Klempner[JCO2003] The Modified Tandem Appliance
 Designed for Class III patients with skeletal midfacialDesigned for Class III patients with skeletal midfacial
deficiencies. The MTA has three components, one fixed anddeficiencies. The MTA has three components, one fixed and
two removable.two removable.
 The upper fixed appliance can be a traditional maxillaryThe upper fixed appliance can be a traditional maxillary
expander, with or without palatal acrylic , a Quad Helix, or aexpander, with or without palatal acrylic , a Quad Helix, or a
Nance appliance. Soldered buccal arms are used for elasticNance appliance. Soldered buccal arms are used for elastic
traction.traction.
 Upper brackets can be added, depending on the patient’s ageUpper brackets can be added, depending on the patient’s age
and clinical situation.and clinical situation.
 The lower appliance comprises a removable acrylic retainerThe lower appliance comprises a removable acrylic retainer
with posterior occlusal coverage and buccal headgear tubeswith posterior occlusal coverage and buccal headgear tubes
embedded in the area of the lower first molarsembedded in the area of the lower first molars
 . An .045" headgear facebow with the outer bows bent out for. An .045" headgear facebow with the outer bows bent out for
elastic attachment is inserted into the lower tubes.elastic attachment is inserted into the lower tubes.

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