Maxillary Protraction Guide

Maxillary Protraction
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


This is the most common treatment protocol in
the treatment of Class III malocclusion with a deficient
midface.(True class III malocclusion)
Class III malocclusion:

5% Caucasian population (Foster, Mayberg 1973)
14%Chinese and Japanese (Irie, Nakmura 1975)




a large mandible
a deficient midface
combination

Oppenheim (1944) was the first to suggest the possibility of
Counterbalancing mandibular protrusion by bringing the
maxilla
forward.
Haas (1970 ) maxilla moves forward and downward as a result
of palatal expansion.
Delaire (1978) developed the orthopedic facemark to stimulate
maxillary development. It was initially used to correct
clockwise rotation of the maxilla and later as a method to treat
maxillary retrusion.
Petit 1983 modified the basic concept of Delaire by increasing
the amount of force generated by the appliance and decreasing
the total treatment time.

Petit Facemask:
1983
Forehead and chin pads
Midline framework made of
0.25 inch stainless steel with
acorn nuts in the ends
Cross bar attached by setscrews
on the midline framework
made of 0.075 inch stainless steel
Elastic force generated was
from distal of Maxillary molars to
the crossbar
Disadvantage: easily dislodged
by a restless sleeper

The treatment for patients with skeletal
maxillary retrusion is anterior movement of the maxilla
using protraction headgear, ideally in combination with
rapid maxillary expansion.(McNamara 1987).
This has been reported to be most beneficial
before the age of 8 years, before the posterior maxillary
sutures have closed.
Palatal expansion affects not only the
intermaxillary suture, but all of the circummaxillary
articulations.
“In a sense, palatal expansion "disarticulates" the
maxilla and initiates cellular response in the sutures,
allowing a more positive reaction to protraction forces.
It also initiates a downward and forward movement of
the retruded maxilla.

Another advantage of
maxillary expansion is the
correction of the posterior
crossbite that often accompanies a
Class III malocclusion because of
deficient transverse maxillary
growth and the abnormal
anteroposterior relationship of
maxilla to mandible.
In addition, a palatal
expansion appliance splints the
maxillary dentition during
protraction and helps transmit
force from the teeth to the maxilla,
thus limiting unwanted tooth
movement. (Franchi, Baccetti
1998)


Elastics running between the intra oral anchorage
system and the extra-oral appliance produce the necessary
force for maxillary traction.
The commercial design is relatively simple consisting
of a framework, or single midline rod, to which is connected
a forehead pad and a chin pad.
Heavy elastics are the attached to a midline cross bow
in the deciduous canine region. This causes maximum
displacement of the maxilla with a minimal rotational effect.
Maxillary protraction generally requires 300-600
grams of force per side, depending on the age of the patient.


The Role of maxillary protraction :
1.Eliminate a centric relation – Centric occlusion
discrepancy.
2.Protract the maxilla
3.Advance the maxillary dentition
4.Tip the lower incisors lingually
5.Encourage vertical mandibular development
Direction of Force:
Protraction forces applied parallel to the occlusal plane,
at the level of the maxillary arch, have been shown to
produce anterior rotation and a forward movement of the
maxilla.
Ishii et al (1987) applied force from the molar and
premolar levels and observed more forward translation of the
maxilla in the first molar region in addition to a forward and
upward rotation.

Staggers, Legan The orthodontist must first decide, in
cases of maxillary deficiency, whether to protract
with a clockwise moment on the maxilla, a
counterclockwise moment, or no moment.
If the patient has normal overbite and normal
vertical proportions, protraction without any moment
is indicated.
If the patient has an anterior open bite in
addition to the maxillary deficiency, a clockwise
moment should be used.
If the patient has a deep bite, a
counterclockwise moment should be chosen.


To evaluate the direction of the moment on the maxilla,
the line of force for zero moment (LFO) must be determined.
The LFO is the line of force passing from the point of elastic
attachment on the headgear through the maxillary center of
resistance.(zygomatic buttress) Contassi ,Legan1982
A force placed along the LFO produces no moment on
the maxilla.
Since the maxillary center of resistance is located
approximately at the zygomatic buttress, the outer bow must be
bent above the occlusal plane to attach the elastics along the
LFO and thus produce no moment.
When a clockwise moment is needed, the point of elastic
attachment to the outer bow must be above the LFO.
when counterclockwise rotation of the maxilla is
desired, the point of attachment must be below the LFO.

Treatment Effects of Protraction Headgear / Face
Mask Therapy:
Skeletal Effects :
•
Much of the information about the skeletal effects of
protraction forces derives from animal studies.
•
Maxillary forward movement and sutural remodeling have
been the main treatment effects noted by several investigators in
nonhuman primates. (Dellniger, 1973; Nanda, Hictory 1984)
• Kambara; 1977 found changes at the circummaxillary
sutures and at the maxillary tuberosity attributable to
posteroanterior traction, including the opening of the sutures,
stretching of sutural connective tissue fibres, new bone
deposition along the stretched fibres and apparent tissue
homeostasis that maintained the sutural width.

Nanda, Hickory; 1984, showed how the histologic modifications in
the zygomatico maxillary suture after maxillary protraction varied
according to the orientation of the force system applied.
The effects of maxillary protraction that are seen on the
lateral cephalogram include forward and downward movement of
the maxillary bone and dentition, lingual inclination of the
mandibular teeth and downward and backward rotation of the
mandible.
In a study of 129 treated subjects with protraction headgear
and RME and 21 untreated controls, Sung & Baik 1998 showed that
mean changes of maxillary length in protraction group ranged from
1.2 mm to 1.5 mm compared with 0.5 mm to 0.9 mm in the
untreated group which was statistically significant.
Thus maxillary length increased more in the protraction
group. This may be caused by more bone apposition occurring in the
posterior portion of maxilla, indicating an orthopedic effect of
maxillary protraction.

Ucuncu, Ucem and Yuksel (2000) showed a significant amount
of maxillary forward movement represented by an increase in
SNA angle; with the maxillary protraction appliance.
The significant increase in Co-A and decrease in the
maxillo mandibular difference [(Co-Gn) – (Co-A)] and molar
relationship showed that class III correction was achieved with
maxillary protraction appliance.
Goyene, Ersoy; (2004) in a study of 30 subjects showed
significant changes in SNA, NV-A, SV-ANS, SV-PNS, and PP
measurements, which indicated that maxilla moved anteriorly in
response to the maxillary protraction therapy.
Dental changes: related to orthopaedic protraction forces
to the maxilla include maxillary incisor protrusion, mandibular
incisor retrusion, achievement of normal overjet and overbite,
and decrease in the interincisal angle.

TIMING OF TREATMENT :
According to McNamara, 1994, the optimal time to begin
class III treatment is in the early mixed dentition, coincident
with the eruption of the upper permanent incisors.
Some authors advise that for optimal orthopaedic results,
treatment be initiated before the patient is 9 years old. (Kim,
Viona, Graber 1999).
Others suggest that maxillary protraction and chincup
therapy is effective throughout puberty and that orthopaedic
effects on the dentofacial structures may even be possible in
young girls as late as during acceleration phase of the pubertal
growth spurt. (Takada et al 1993).
The juvenile growth spurt that exists in some individuals
can act as an accelerating factor in general and skeletal growth.
(Ritucci, Nanda, 1986).

During the pubertal growth, maxillofacial growth
proceeds actively even though the increase in sutural
complexity of the palatomaxillary area after the junevile
period can resist maxillary protraction force. Thus in order
to get the maximum orthopedic effect with minimum
forward sliding of the dental arch on the maxillary base, the
growth period must be considered as an important variable
that can affect treatment results.
Baccetti, 1998 showed that treatment of class III
malocclusion with bonded maxillary expander and face
mask in the early mixed dentition results in a more
favourable craniofacial changes than treatment in late mixed
dentition.
Significant advancements of anterior and posterior
nasal spines, and of point A, and maxillary dentition were
recorded in the early treatment group.

Andrew Kapust, 1999 : in his study on different age groups
showed that younger age groups (4 to 7 and 7 to 10 years)
appeared to have responded better to treatment, however the 10
to 14 age group did demonstrate significant treatment effects
indicating that orthopedic change does occur in older children.
Franchi,Baccetti, 2004:Early treatment(early mixed or late
deciduous dentition) produces significant favourable
postpubertal modifications in both maxillary and mandibular
structures, whereas late treatment( late mixed dentition) induces
only a restriction of mandibular growth.


Protraction Alone Versus Protraction with Rapid Maxillary
Expansion :
Hata, Itoh, Nagakawa 1987 Numerous authors have reported on
the anterior constriction of the maxilla when it is protracted and
they emphasize the necessity of physically expanding the maxilla
before protraction.
Tanne Sakuda, 1991Palatal expansion alone has also been shown
to facilitate correction of a class III malocclusion by causing a
downward and forward displacement of the maxilla.
(McNamara 1993)Palatal expansion has been noted not only to
affect the intermaxillary suture, but also all of the circum
maxillary articulation’s.
It has also been suggested that the palatal expansion
‘disarticulates’ the maxilla, initiating a cellular response which
then allows a more positive reaction to protraction forces. (Turley
1988).

In a study on rhesus monkeys, rapid maxillary expansion
produced 0.5 to 1.0 mm of opening of the spheno occipital
synchondrosis, which led the authors to consider that this too
might be a factor. (Gardner, Kronman, 1971).
In a study on 60 patients; Baik (1995) found significantly
greater forward movement of the maxilla when protraction was
used in conjunction with rapid maxillary expansion (2.0 mm with
RME and 0.9 mm without RME).
A study, involving a meta analysis on 440 articles relating to
class III malocclusion, confirmed that maxillary protraction, in
combination with an initial period of expansion, provides more
significant skeletal effects than protraction alone. (Kin, Viana,
Graber 1999)

Vaugn, Mason, Moon, Turley AJO September 2005 Effects of
maxillary protraction with or with out rapid palatal expansion:
A prospective, randomized clinical trial
Forty-six children, Class III malocclusion aged 5 to 10 years
were randomly assigned to 1 of 3 groups:
(A) facemask with palatal expansion,
(B) facemask without palatal expansion. and
(C) observation for 12 months. (control)
Results
Group A-B= No statistical significance
GroupA-C= 3.69mm
GroupB-C=4.35mm


Conclusion:
The study demonstrated that facemask therapy with or
without palatal expansion produced equivalent changes
in the dentofacial complex that combined to improve the
Class III malocclusion (4mm)
These results suggest that indication for palatal
expansion should be based on clinical criteria other than
assisting the ClassIII correction


Other Appliance Designs
1.The protraction headgear
developed by Hickham (1991) uses
the top of the head and chin as
support. The headband and chin cap
are connected with the arms parallel
to the mandibular bases on both
sides.
The appliance does not interfere
with sleep, is somewhat more
esthetic than other protraction
devices, and has unilateral
capabilities (which may require an
extra cushion under one of the long
arms ).
The chief disadvantage is that it
must be carefully adjusted to fit

2. Nanda 1980 reported that
use of a modified protraction
headgear which was a
combination of headgear with
U- bend made on the inner bow
to passively fit into the molar
tube along with the facemesk.
It produced a more
controlled movement acting
along the center of resistance of
the maxilla producing a more
orthopaedic effect. The head
gear can also be used to correct
the axial inclination or mesial
displacement of the posterior
teeth.

3. Suborbital Protraction Appliance
A recent development by Grummons, has been
redesigned to increase the rigidity of the main frame and
make the device easier to adjust .
The zygomatic anchorage areas support the
appliance well, and the reciprocal force of the elastics to
the teeth is felt at the back of the head.
Although they are more sensitive, the two
zygomatic areas offer more surface contact than the chin
or other points and thus permit the application of similar
force magnitudes. There is no force on the TMJ, and the
appliance is easy to adjust and to wear during sleep.
disadvantage : esthetic objection to midfacial support.

4.Lever-Hook Edgewise Arch
for Midfacial Protraction
HECTOR L. VESCO 1999
Appliance Design
The arch is activated by two lever hooks
between the maxillary central and lateral incisors
These hooks apply a labial root torque to
counteract the labial pull of the facemask on the
crowns of the maxillary incisors, turning the
anterior segment into an anchorage unit. This
ensures that the response to protraction is
essentially skeletal.


Lever hook edge wise


Labial shields attached to the
lever hooks make the appliance
more comfortable and act as an
upper lip bumper. The protraction
force of the facemask prevents this
bumper from moving the maxillary
teeth distally.
Combined with the upward
force expressed by the posterior
segments of the archwire, the
anterior traction also helps avoid
undesirable counterclockwise
maxillary rotation.
This originally custom-made
arch is now commercially
manufactured as the Vesco arch

Facemask protraction can be started at the
same time the arch is inserted, or at the next visit.
The mask should be worn about 14 hours per day
(five hours after school and nine at night), using
two 3⁄8", 6oz elastics per side for an .016" × .022"
arch or three elastics per side for an .018" × .025"
arch.
Advantages of facemask therapy with the
Vesco arch
• Achieves effective and rapid skeletal protraction
of the maxilla and midface without proclination
of the maxillary dentition or counterclockwise
maxillary rotation.
• Controls incisor torque and molar tip automatically
when elastics are hooked to the arch.

• Uses the maxillary anterior protraction force to
prevent overextrusion of the molars.
• Produces a functional effect through its labial
shields.
• Can be used with .018" or .022" brackets of
any prescription.
• Can align dental midlines or open space for
cuspids.
• Can be used with a palatal expander.
• Combines maxillary protraction with fixed
orthodontic therapy in one overall phase of treatment.
• Can be used in the mixed dentition or the permanent
dentition, as long as growth remains


A Mini Maxillary protractor For Class III Correction:
Altug, Arslan JCO 2005
Apliance design
Consists of 4 parts
1. Maxillary expander – An acrylic
splint expansion appliance is
constructed with full coverage of
maxillary teeth. Hooks are
embedded in the premolar and
molar regions on both buccal
sides. Expander is activated
0.25mm per day.
2. Mandibular plate – An acrylic
plate covering the entire
mandibular arch.
.

3. Chin cup – A hook is
attached on the each side of
acrylic chin cup for
application of cervical forces.
4. Lower face bow – A 0.051
inch bow is used to connect
the chin cup to the mandibular
plate. A horizontal bar is
added 1.5 – 2 inches in front
of the lip for the attachment of
protraction elastics to the
hooks of maxillary expander.


Protraction force of 300-400 gm per side with a anteriorinferior force sector of 20-30˚ to occlusal plane is applied with
the elastics. Patient is instructed to wear the protractor 18 hrs
per day.
Advantage:
1. Does not require expensive lab work.
2. Eliminates the facial mask, improving patient co-operation.
3. Has a beneficial effect on soft tissue profile.
4. Relatively short treatment time – takes about 4 months to
establish proper overjet.


The Functional orthopedic magnetic appliance (FOMA) III
Vardimon et al (AJO-DO 1990)
developed an intraoral intermaxillary
appliance for the treatment of Class
lll malocclusions that exhibit
midface sagittal deficiency with or
without mandibular excess.
The functional orthopedic
magnetic appliance (FOMA) III
consists of upper and lower acrylic
plates with a permanent magnet
incorporated into each plate.
The upper magnet is linked to a
retraction screw and is retracted
periodically (e.g., monthly) to
stimulate maxillary advancement
and mandibular retardation

The upper plate of a FOMA III consists of a 0.031-inch
stainless steel arch wire forming the metal substructure (a). The
arch wire bypasses the premolar-canine segment to permit
eruption and crosses the occlusal plane at the M1-M2
embrasure. The upper magnetic housing (b) is linked to a
retraction screw (c). The magnetic unit (b + c) is positioned
along the midpalatal line

The attractive mode
neodymium magnets used in
this study produced a
horizontal force of 98 gm and
a vertical force of 371 gm.
The ratio of horizontal to
vertical force vectors is
dictated by inclination of
magnetic interface in the
sagittal plane. The more
perpendicular the magnetic
interface is to the occlusal
plane (sin 90° = 1), the greater
is the horizontal force vector
(Fh = attractive force ´ sin a).

Six female Macaca -fascicularis monkeys were treated with
FOMA IIIs.
After 4 months of treatment, the following results were
found:
The growth pattern of the cranial base (saddle angle) was not
altered.
Midfacial protraction did occur along a recumbent
hyperbolic curve with a horizontal maxillary displacement and
an anterosuperior premaxillary rotation.
Cumulative protraction of the maxillary complex was
initiated at the pterygomaxillary fissure with an additional
contribution provided by other circummaxillary sutures
(zygomaticomaxillary s., transverse s., premaxillary s.)
Inhibition of mandibular length was minimal, but a tendency
toward a vertical condylar growth pattern was observed

The interaction between sutural and condylar growth sites
appeared biphasic, characterized by an immediate and rapid
excitation of the circummaxillary sutures followed by a delayed
and slow suppression of the condylar cartilage.
A later radiographic and histologic study by Vardimon et al
(AJODO 1994), again on monkeys, revealed the following data:
Maxilla:
1.The target area of the protractive force was found to be
localized in the pterygomaxillary fissure.
2.Three dimensionally, the separation of the sutures at the PMF
was found to diminish in inferosuperior and lateromedial
directions.
Mandible:
The fact that no pathologic change was found in the condylar
cartilage encourages a long-term use of the FOMA III appliance,
initiating treatment at an www.indiandentalacademy.com
early skeletal age

Darendeliler et al (JCO 1993) reported a
case of a 7.5 years old female with Class
III dental malocclusion and bilateral
cross bite who was treated with a
combined MAD III(300g) and MED
(500g)appliance.
Upper and lower buccally placed
magnets were used for correction of A-P
discrepancy.
The upper and lower magnets in the
repelling configuration had a tendency to
move toward a fully centered contact,
thus creating a forward force against the
maxilla and a backward force against the
mandible.
When combined with an MED, the MAD
III offers an alternative in the early
correction of Class III malocclusions.

Three months of expansion produced a dental widening of
6.0mm anteriorly and 6.6mm posteriorly, and a skeletal widening of
.7mm anteriorly and 1.7mm posteriorly. The bonded upper plate
was then removed and replaced with a removable plate carrying
only the two buccal magnets.
The patient wore the MAD III for another 11 months, until a
cusp-to-cusp deciduous molar and canine relationship was obtained.
Eleven months after removal of appliances, the patient showed
a Class I dental relationship, with adequate overjet and overbite and
no crossbite


The Two – Piece
Corrector
Gerald EganHouse 1997
It is a removable acrylic
appliance that simultaneously
applies an anterior force to the
maxilla and an equal posterior
force to the mandible. The flat,
sliding surfaces of the two
pieces create almost no friction
as the dentition is disoccluded
during movement, but provide
both lateral and anteroposterior
stability.

A good bite registration in
centric relation is required for the
construction of the appliance. The
closer the bite registration is to 4-6
mm thick, the more accurate the
appliance will be.
The maxillary acrylic should
cover the entire palate and part of
the crowns of all maxillary teeth.
Full palatal coverage will allow the
correction to be applied skeletally as
well as dentally.
The mandibular acrylic should
extend as for inferiorly as possible
on the lingual and buccal aspects of
the teeth.

Because elastics provide the force between the two
parts of the appliance, placement of the hooks for elastic
attachment is critical to proper performance.
Maxillary arch: One hook on each side is placed on
the distobuccal of the maxillary first molar, two more
are located in the maxillary first bicuspid canine area,
Mandibular arch and a fourth is placed between the
mandibular canine and lateral incisor.
The shorter elastic on each side is always 1/8” 6oz
and is initially attached from the mandibular hook to the
more anterior hook in the maxillary first bicuspid –
canine area.

As the treatment progresses, it is moved to the
more posterior hook. This elastic provides class III
correcting force in addition to an inferior – superior
force that keeps the two parts from separating.
The longer elastic on each side, stretched from
the mandibular hook to the molar hook can be ¼”, 60z;
¼” 8oz; or 3/16” 60z, depending on the comfort level
of the patient and the amount of class III correction
needed.
The appliance should be worn about 12 hours /
day, in conjunction with a sof. Pad headcap and chin
cup.
This appliance is effective in class III case that
are not severe enough to require orthognathic surgery
(with ANB angles of more than – 2°).

Double Plate Appliance :AJO 2004
Ucem, Ucuncu, Yuksei

The double-plate appliance
was designed as intraorally
opposed angulated acrylic blocks.
The system was supplied with class
III elastics that were accepted to be
effective in class III treatment.
Demirel 1999, reported an
improvement in the soft tissue
profile due to the posterior rotation
of the mandible and the anterior
displacement of the maxilla during
double plate appliance therapy.

Ucem et al (Dec, 2004, AJO DO) compared the effects of
double plate appliance and face mask group, with a
control group.
They reported significant changes in the molar
relationship, incisor overjet, ANB angle,
maxillomandibular differential, and Holdaway angle in
both treatment groups compared with the control group.
Significant increases in the SNA angle and Co-A
point showed that maxillary growth was achieved in both
treatment groups.
Neither SNB angle nor the Co-Gn dimension
showed a significant difference between the treatment and
control group, hence it was concluded that main effect of
the appliance was advancement of the maxilla.

The Horse Shoe Appliance
Yang 1997
The horse shoe appliance was developed by Dr. Schwarz,
and is used to correct sagittal relationships by elastic force in
patients with class III malocclusion.
It has the advantages of good patient cooperation, ease of
construction, and effective modification.
Appliance design :
. Usually, a ball ended interdental clasp is used. But other
clasps, ie Adams clasp or circumferential clasp are also used.
Wire hooks are used for elastics. In the upper appliance,
a hook is positioned on the distal surface of the last molar and
in the lower appliance, a hook is positioned on the labial
surface of the cuspid.


It restricts the increment of anterior facial height by
minimizing the downward and backward rotation of the
mandible using elastic force (5oz, ¼” for each side) instead
of muscle force.
Also, the horseshoe appliance can be modified so
that it can be used for labial movement of anterior teeth with
maxillary expansion by adding a screw and anterior hook in
a plate for tongue elevation and a palatal bead or roll for
tongue exercises.


A 9year 8 month korean boy had
anterior cross bite with SNA angle=
75 degrees and was treated with the
horseshoe appliance .
After 2 months the maxiilary
growth was enhanced with SNA
angle=77.5 degees
Advantage:The horse shoe
appliance prevents the extrusion and
movement of teeth individually by
covering the entire occlusal surface
of the upper and lower dentition
with acrylic resin.

TANDEN TRACTION BOW APPLIANCE
Chun, Jeorg, Row, Yang, 1999
The Tanden Traction Bow Appliance is a more esthetic
and comfortable intraoral device.
It is removable, making it easy for the patient to maintain
oral hygiene, and allowing treatment to be suspended or
restarted whenever the clinician deems necessary, without
bonding or debonding.
In the clinical trials of Tanden Traction Bow Appliance,
(TTBA) structural superimposition according to Bjork
(1966); showed antero inferior movement of the maxilla,
posteroinferior repositioning of the mandible, and
protraction of the maxillary dentition. Therefore TTBA had
a similar treatment effect to that of an expander – facemask
combination.

Appliance design :
The TTBA comprises an upper splint, a lower
splint, and a traction bow. Its design allows the patient to
open the mouth freely.
The upper splint which can serve the same function as a
rapid maxillary expander, it covers the palatal and the
occlusal surfaces of the maxillary teeth.
Portion of the buccal surfaces are also covered, providing
adequate retention to overcome the maxillary protraction
force of as such as 400-500 g/side.
During active treatment, the labial bow is embedded in
the acrylic; it is uncovered and used to retain the incisors
when TTBA is reassembled as a monobloc retainer.

The lower splint covers the buccal and lingual surfaces of
the mandibular teeth to reinforce retention. Because the patient
wears the TTBA while sleeping, retention is critical.
The traction bow is a modification of a conventional
headgear outer facebow. A safety hook is soldered to the
adjusting U-loop to present disconnection of the appliance.
The position of the elastic hooks on the upper splint and the
tubes on the lower splint determine the direction of force. The
maxillary hooks should be placed distal to the deciduous or
permanent canines, so that the elastic force passes through the
center of resistance of the maxilla at about 20° to the occlusal
plane


The mandibular tubes should be located as
posteriorly as possible.
In the deciduous and mixed dentition, the
applied force should be 300-500g for orthopedic
effect, in the early permanent dentition it should be
150-300g for orthodontic effect, avoiding induce
stresses on TMJ.
The patient is asked to wear TTBA 12-14 hours
/ day for orthopedic effect and more than 14 hours a
day for orthodontic effect.
After the crossbite is overcorrected, the two
splints are fused into a monobloc and used as a
retainer.

Intentional Ankylosis:
Replantation of teeth after dental avulsion usually causes
ankylosis.Andreason, 1988
Intentional extraction and subsequent replantation of teeth
have also consistently caused ankylosis in experimental
animals.Hammer, Reed, Pierce 1970
Studies have shown that ankylosed teeth can provide stable
anchorage for transverse orthopedic movement of the maxilla.
Kokick, Ozawa, Omnell.
Filho,Ozawa,Okada, Carvalho,Silva JCO 2000
have developed a new treatment protocol for Class III
malocclusion with maxillary deficiency, involving extraction and
replantation of the upper deciduous canines to cause ankylosis
for temporary static anchorage prior to rapid maxillary expansion
and protraction. This method reinforces maxillary protraction

Advantages:
• Replanted deciduous canines are autogenous implants that
will undergo root resorption without the need to be extracted after
maxillary protraction is completed.
• Replanted teeth provide rigid and static anchorage, allowing the
maximum orthopediceffect with little dental compensation.
• The cost is low, and risk to the patient is mini-mal,
compared to osseointegrated titanium
implants.
• The procedure is well accepted by patients and
parents.
With deciduous teeth, intentional ankylosis
simply encourages the genetically programmed
process known as replacement resorption.
Permanent teeth are not suitable because they cannot
be removed after the procedure.

Distraction osteogenesis to advance the
maxilla:
Distraction osteogenesis has been used to
simulate LeFort I Maxillary advancement and anterior
segmental repositioning.
Molene and Monasterio (1993) ; distracted the
entire maxilla in 36 patients with cleft lip and palate.
Distraction forces were placed on the maxilla
by reverse pull headgear and an intraoral orthopedic
appliance to advance the maxilla 8 to 12 mm


Intraoral Orthopaedic Appliance

Figueroa and Polloy (1999) evaluated the cephalometric
changes on 14 patients with cleft palate who were treated
with rigid external distraction technique.
A complete LeFort I osteotomy was performed,
including pterygomaxillary and septal dysfunction, with
mobilization.
A cranially fixed rigid external distraction device was
placed after surgery. Distraction was performed by turning
the activating screw at a rate of 1 mm / day.
The avg predistraction ANB was -1.2° and post
distraction was 7.3° with an increase of 8.6°. The average
horizontal advancement of A point after distraction was
2.3 mm.

Rigid External Device

Compared with the amount of forward
maxillary movement that can be obtained from
maxillary protraction with a face mask (avg. 2-4
mm), distraction osteogenesis, once perfected, has
far greater impact in treating patients with more
severe class III maxillary deficiencies.


Implants Used as rigid anchorage with facemask therapy:
Smalley et al 1988 first studied the use of titanium implants
as a rigid anchorage for maxillofacial protraction in an animal
model.In this study branemark implants with stood 600g force
perside across the zygomaticomaxillary suture in Maca nemestrina
monkeys and resulted in an anterior displacement of 8mm.
Singer et al applied 400g of force to implants placed in the
zygomatic process of the maxilla of a 12 year old cleft-palate
patient with maxillary retrusion.This produced a 4mm forward and
downward displacement of the maxilla,a 3mm increase in the SN
plane, clockwise rotation of the mandible and an improved facial
profile.
Encar, Giray,pehlivanoglu, Iplikcioglu AJO may 2003
reported the treatment of a 10 year old girl with Class III skeletal
relationship with maxillary hypoplasia and severe oligodontia.

The maxillary arch was in
complete crossbite relationship with
the mandibular arch.The treatment
plan was to displace the maxillary
complex with titanium implant and
the remaining teeth along with petit
facemask since there was lack of
available teeth.
A palatal bar,soldered to the
molar and incisor bands was
extended distally on the right side to
the edentulous are, and a helix was
formed at the end of the bar through
which the titanium lag screw was
inserted in the bony alveolus.

The 2 incisor bands were also
combined with a labial bar and the two
ends of the labial bar were bent into a
hook to which the facemesk`s elastic
traction could be applied.
A petit facemask was fitted and
800g force was applied from each
hook of the appliance. The forces were
directed at 30 degrees to the occlusal
plane.The patient was instructed to
wear the appliance for 16hrs/day.
At the end of treatment, the
ANB angle increased by +2 degrees
ANS region displaced 3mm
anteriorly .

Pretreatment

Postreatment

Dental Onplants – Absolute Anchorage for Maxillary
Protraction :
One of the limitations in maxillary protraction with tooth borne
anchorage devices such as expansion appliance and palatal arches is
the loss of dental anchorage, especially with prolonged maxillary
protraction.
These undesirable effects include the loss of arch length, forward
movement of maxillary molars and proclination of maxillary incisors.
These dental changes can be minimized or even eliminated with
the use of a device called maxillary onplants. (Block, Hoffman, 1995).
The onplant comes as a disk, textured and coated with
hydroxyapatite on one side and with an internal thread on the other
side. The onplant can be placed on the palatal bone. After
osseointegration is complete, forces can be applied to the teeth from
the onplant palatal anchorage. Apart from providing a stationary
orthopedic anchorage, this device can be used in patients with multiple
missing teeth.

Ngan,Guan,Gong, Wei AJO October 2005

A 7.7-mm hexagonal onplant
(Nobel Biocare,Gotenberg,Sweden)
was surgically placed on the flat
part of the palatal bone near the
maxillary molar region..
The onplant was placed as
close to the midline as possible but
not on the midsagittal maxillary
suture, so as not to disturb lateral
growth with the surgical operation.
A transpalatal arch was
attached to the onplant and
soldered to a silver cast splint,
which was connected to all the
maxillary teeth

Maxillary protraction was started
four months after placement of the
onplant. A Petit facemask (Ormco Corporation,Glendora, Calif) was fitted with
elastics that delivered approximately
400g of force on each side.
The force was directed from the
canine area, 30degrees from the occlusal
plane, to counteract the anticlockwise
rotation of the palatal plane.
Patient was instructed to wear the
facemask for 12 hours per day. Traction
was continued for 12 months until
sufficient clinical movement of the
maxilla had been achieved to improve
the midface esthetics.

The application of an anteriorly directed force from a
facemask to an osseointegrated onplant placed in the palatal
bone resulted in a significant improvement in midface es-thetics.
This was noted by an increase in fullness of the
infraorbital region and the correction of the skeletal discrepancy
between the maxillary and mandibular jaw relationship (ANB
from -2.2degrees to 3.7degrees, Wits from -6.1mm to -1.0 mm).
To verify whether the onplant was stable during
application of orthopedic force, superimposition was also performed on the lingual contour of the maxilla along ANS-PNS to
detect any movement of the onplant.
The results showed no movement of the onplant during
both the six-month and 12-month period of protraction

The onplant was then used as an internal reference
point to measure spatial movement of the maxilla, which
was found to have been displaced 2.9 mm horizontally and
2.9 mm ver-tically during the 12-month period of
protraction.
This movement is more than the average horizontal
movement of two mm reported by other investigators using
tooth-borne appliances as anchorage for a facemask alone
or in combination with expansion techniques.


Advantage of Onplant Vs Implant
Elimination of dental changes such as extrusion and
mesial movements of upper molars by using onplant as
anchorage may be helpful in improving the stability of facemask
treatment.
onplant can be placed anywhere on the anterior part of
the hard palate. In contrast, placement of implants in this area
creates a potential risk of damage to the roots of adjacent teeth
because of the length of the implant fixtures available.
Placement of an implant on the anterior part of the hard palate
would not only have a risk of root damage of anterior teeth but
also the risk of penetration of the nasal floor.


REFERENCES.
1.He Hong, Peter Ngan, Han Guang, Liu Gong Qi,
Stephen H.Y. Wei, Use of Onplants as Stable Anchorage for
Facemask Treatment:A Case Report, AJO DO October 2005 page
402- 409
2.Jiang, lin, Changrong ji, Two stage treatment of skeletal Class III
malocclusion during the early permanent dentition: A case report,
AJO October Number 4,page 521-527
3. Vaughn, Mason, Moon, Turley:The effect of maxillary protraction
therapy with or without rapid palatal expansion:
A prospective,randomized clinical trial, AJO DO Sept 2005 page299309
4. Altug, Arslan,A mini maxillary protractor for Class III
correction:JCO sept 2005 page 522-524

Contents:
Intoduction
Rationale, Treatment effects, Direction of force,
Timing of Maxillary protraction
Facemask alone Vs Facemask with RME
Other Facemask designs
Magnets FOMA III
MAD III MED
Tandem Tractionbow appliance, Two piece Corrector,
Double plate, Horse shoe appliance
Intentional Ankylosis
Implants
Onplants
References

5. Franchi, Baccetti, McNamara:Postpubertal assessment of
treatment timing for maxillary expansion and protraction therapy
followed by fixed appliances:AJO November 2004 vol 126
number 5 page 555-568.
6. C de Moura Fuly, A G de Oliveira, W Ursi, Correction of
Class III malocclusion with a Jasper Jumper, JCO 2000; 24: 41–
46
7. Y S Chun, S G Jeong, J Row, S J Yang :A new appliance for
orthopedic correction of class III malocclusion , JCO 1999; 23:
705–711.
8. T Alcan, A Keles, N Erverdi: The effects of a modified
protraction headgear on maxilla,AJO DO, 2000; 117: 27–38.

9. Darendeliler, M.A.; Chiarini, M.; and Joho, J.P.: Case
Report: Early Class III treatment with magnetic appliances,
J. Clin. Orthod. 27:563-569, 1993.
10 Ravindra Nanda, Biomechanical and Clinical
considerations of a modified protraction headgear:AJO
August 1980 page 125-139.
11.John H Hickam,Maxillary Protraction Therapy: Diagnosis
and Treatment JCO 1991 page 103-113
12.. Vcen et al : Comparison of double-plate appliance and
facemask therapy in treating class III malocclusion. AJO
DO 2004; 126 ; 672-9.


13. Simonsen, R.: The effect of face mask therapy, Am. J.
Orthod.82:439, 1982.
14. Kambara, T.: Dentofacial changes produced by
extraoral forward force in the Macaca irus, Am. J.
Orthod. 1977,71:249-279.
15. Cozza,Marino, Mucedero,An Orthopaedic approach to
the treatment of Class III malocclusion in the early
mixed. Eur. Journ of orthod. 2004; 26 ; 191-199.
16.Ngan, Hagg Merwin, Wei: Treatment response to
maxillary expansion. EJO 1996 vol18 page 151-168


17. Keles, Tokmak,Ervedi,Nanda,Effect of varying the
force direction on maxillary Orthopaedic
Protrtaction, Angle Orthodontist 2002, Vol 72,No 5,
2002.
18. Staggers,Germane,Legan:Clinical considerations in
the use of Protraction headgear,JCO 1992,Vol 26,
No 2 page 87-91.
19. Kokich VG, Shapiro PA, Oswald R, KoskinenMoffett L, ClarrenSK: Ankylosed teeth as abutments
for maxillary protraction: a case report. Am J
Orthod. 1985;88:303–307.
20. Graber, Vanarsdall: Orthodontic current principles
techniques, 4th edition,2005 page 1053- 1112

21. Da Silva Filho OG, Ozawa TO, Okada CH, Okada
HY, Carvalho RM. Intentional ankylosis of deciduous
canines to reinforce maxillary protraction. J Clin Orthod.
2003;37:315–320.
22. Singer SL, Henry PJ, Rosenberg I. Osseointegrated
implants as an adjunct to facemask therapy: a case report.
Angle Orthod.2000;70:253–262.
23.Gallanger, Miranda, Buschang:Maxillary protraction
treatment and posttreatment effects.AJO DO
1998;113:612-9
24.Encar, Giray, Pehlivanoglu, Iplicioglu:Facemask
therapy in a patient with maxillary hypoplasia and severe
Oligodontia, AJO DO, May 2003 page 571-577

25. Franchi Baccetti : Splint therapy for skeletal class III
malocclusion in the primary dentition. J. Clin Pediatr. Dent.
1998; 22 (2), 93-98
26. Eganhouse : Two piece corrector for class III skeletal and
dental malocclusion. Journ of clinic orthod 1997; vol. 31 (4);
246.
27. Yang: Treatment of Class III malocclusion with the horse
shoe appliance: a case report in growing patients. Journ of
clinic orthod 1997; vol. 22 (1); 1-8.
28. Vesco: Lever hook edgewise arch for Midfacial
Protraction.JCO 1999 page 161-166


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