Protraction face mask /certified fixed orthodontic courses by Indian dental academy


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Protraction face mask /certified fixed orthodontic courses by Indian dental academy

  1. 1. PROTRACTION FACE MASK THERAPY INDIAN DENTAL ACADEMY Leader in continuing dental education 1
  2. 2. Review of literature  5 percent of the Caucasian population  higher in the Scandinavian and Japanese populations.  Primates have been used as models in the majority of the studies  Janzen and Bluher, Bare, and Johol on monkeys  Petrovic, Oudet, and Gasson on rats  Matsui on rabbits 2
  3. 3.  Kambara, Nanda, and Jackson, Kokich, and Shapiro reported that the maxilla of monkeys can be displaced anteriorly by using extraoral forces  Graber: the early attempts with the chin cup were not successful because of incomplete knowledge of mandibular and facial growth, its use on nongrowing patients, and an inadequate understanding of the forces generated by the chin cup. 3
  4. 4.  Armstrong: chin cups on 100 adolescent patients with mandibular prognathism Thilander treated sixty patients with chin cups for 1 to 6 years  Graber, Chung, and Aoba : chin cups for 12 to 14 hours each day with a force of 1.5 to 2 pounds on each side  Several clinical studies in the past have noted that treatment of patients in skeletal Class III should include protraction of the maxilla with or without chin cups 4
  5. 5.  Kettle and Burhapp reported an appliance for cleft lip and palate  Nelson :football-type helmet  Delaire, Verdon, and Floor have extensively used a facial mask to protract the maxilla  In 1944 Oppenheim believed that one could not control the growth or anterior displacement of mandible 5
  6. 6.  In 1960’s Delaire and others revived the interest in using the fm for max protraction. Petit later modified Delaire’s basic concept by increasing the amt of force generated by the appliance, thus decreasing overall treatment time.  In 1987 McNamara:use of a bonded expansion appliance with acrylic occ coverage for max protraction.  Turley : fabricating customized fm 6
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  10. 10. Diagnosis and Treatment Planning  Cephalometric values :often unreliable in a young child  Schulhof et al. : cephalometric indicators  appropriate to base treatment decisions on the patient’s facial profile, since an important objective of treatment is to optimize facial esthetics. 10
  11. 11. Facial Profile  Overall facial profile Evaluation  Chin position  Maxillary position 11
  12. 12.  Mandibular repositioning 12
  13. 13. Custom made pfm 13
  14. 14. Palatal Expansion  maxilla articulates with nine other bones  palatal expansion “disarticulates” the maxilla  correction of the posterior crossbite  splints the maxillary dentition 14
  15. 15. Maxillary Protraction  Not only is Point A affected through forward incisor movement, but the entire maxilla is displaced anteriorly, with significant effects as far posteriorly as the zygomaticotemporal suture 15
  16. 16. Patient Compliance  Patient compliance is the key to successful orthopedic correction  plaster cast for a broken arm  Positive reinforcement  At the appliance delivery appointment, the child is given a time card  Additional motivational techniques 16
  17. 17. Design and construction of the anchorage system  Metallic banded palatal exp appliance  Acrylic bonded palatal exp appliance 17
  18. 18.  Design of bonded maxillary occlusal splint used in permanent dentition  Wire extensions are placed on occlusal surfaces of upper second molars  to prevent extrusion during treatment. 18
  19. 19.  Design of bonded maxillary occlusal splint used in early mixed dentition.  First and second deciduous molars and first permanent molars are usually incorporated in the appliance.  Facial mask hooks usually lie mesial to upper first deciduous molar. 19
  20. 20. Skeletal effects of max protraction  Maxillary protraction does not always result in forward movement of max and showed that with the same line of force diff midfacial bones were displaced in diff direction depending on the moments of force generated at the sutures.  The cor of the max was found to be located at the distal contracts of the max first molars on half the dist form the functional occ plane to the inferior border of the orbit.  Protraction of the max below the cor produces counter clockwise rotation  Hata and colleagues also found that protraction forces at the level of max arch produced forward but counterclockwise rotation of the maxilla unless a heavy downward vector of force was applied. 20
  21. 21. Clinical response to max protraction  ant cross bites can be corrected with 3-4 months of max exp and protraction  forward max movement 31%, backward movement of mandible 21‘%, labial movement of max incisors 28%, and lingual movement of mand incisors20%.  Anchorage loss was observed  total facial height was increased by inferior movement of the max and downward and backward rotation of mandible 21
  22. 22. Variability in clinical response  Age  Design of anchorage system  Force level, direction, and point of application  Length of treatment time 22
  23. 23.  Treatment indication for fm therapy  Treatment timing for fm therapy 23
  24. 24. Retention  There are conflicting opinions about the stability of Class III orthopedic treatment.  Delaire says that “in successful cases, the facial skeleton is completely transformed. The therapeutic action has permitted, and in fact provoked, the establishment of a normal equilibrium, without possibility of relapse.”  In contrast, Cozzani cautions that “we cannot consider a Class III malocclusion fully resolved until facial growth has ended”.  In anticipation of some relapse, it is recommended for overcorrection of the overjet  Post treatment stability 24
  25. 25. Protraction of the maxillofacial complex - Mermigos, Full, and Andreasen  most difficult to treat as it is not limited to dental discrepancies but is more often related to an underlying skeletal problem. Cephalometric analysis may indicate that  1. SNA angle is significantly lower- greater degree of maxillary retrusion  2. Mandibular protrusion is greater  3. The mean ANB angle is negative  4. The gonial angle is more obtuse  5. The mandibular plane angle is steeper than normal  6. Lower anterior face height is significantly 25 greater
  26. 26. 1.A decrease in the mandibular plane angle.  2. A decrease in the gonial angle.  3. A decrease in the SNB angle.  4. A redirection in the downward vertical growth of the midface 26
  27. 27. Extra oral traction and Class III treatment - Cozzani There are three important diagnostic principles  First, it is particularly important to determine whether the mandible, on closure, is in centric relation or in a “convenient” anterior position  second principle is that the nature of the skeletal discrepancy must be defined  Third, a malocclusion reflects the interplay of many conditions that may be impossible to evaluate singularly. One important variable is the potential growth and development 27
  28. 28.  General treatment considerations  start treatment as early as possible, even as early as 4 years of age  Early treatment does not necessarily mean protracted treatment. It can be readily divided into two stages.  extractions may be contraindicated when orthodontic treatment must be combined with surgical treatment  Class III elastics because they can also extrude the mandibular incisors, and there is frequently excessive vertical dentoalveolar development in the incisor region. 28
  29. 29.  Summary  In summary, extraoral appliances are often useful in the treatment of Class III malocclusion.  In the examples cited, the Delaire appliance is effective in protracting the maxilla and/or maxillary dentition, particularly in younger patients.  Also, extraoral traction placed against the lower segment by means of facial wires can protract protrusive incisors while 29 preserving molar anchorage
  30. 30. An Orthopedic Approach to the Treatment of Class III Malocclusion in Young Patients - JAMES A. MCNAMARA Pre treatment Post treatment 30
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  32. 32.  Summary  This patient demonstrated both skeletal and dental adaptations during treatment. The maxilla and the upper dentition moved forward, while the mandible rotated downward and backward, with some lingual tipping of the lower incisor. In addition, there were favorable changes in the soft tissue contour. 32
  33. 33. Post treatment Pre treatment 33
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  35. 35.  Summary  This patient showed both dental and skeletal adaptation during the treatment period. The mandible rotated downward and backward, although no inhibition of mandibular growth was noted. The maxillary dentition moved downward and forward. Little change occurred in maxillary position. 35
  36. 36.  Conclusion  1. A forward and downward movement of the maxilla.  2. A forward and downward movement of the maxillary dentition.  3. A downward and backward redirection of mandibular growth.  4. A lingual tipping of the lower anterior teeth.  5. An inhibition of mandibular growth. 36
  37. 37. Orthopedic Correction of Class III Malocclusion: Retention and Phase II Therapy -PATRICK K. TURLEY 37
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  49. 49.  1. Use a rigid expansion appliance in the maxillary arch.  2. Ask for 24-hour facemask wear  3. Avoid camouflaging movements that limit the amount of orthopedic correction, contribute to future relapse, and make later surgery more difficult.  a. Avoid proclining the maxillary incisors to correct crowding or anterior crossbite. Resolution of a significant arch-length discrepancy may require molar distalization or even premolar extractions after the orthopedic phase has been completed.  b. Avoid Class III elastics as long as possible.  4. Overcorrect the anteroposterior occlusion to nearly an endto-end canine relationship.  5. Retain the overcorrected occlusion with night-time facemask wear for an additional three to six months, until there is positive overbite and good posterior interdigitation.  6. Monitor the occlusion while awaiting Phase II treatment.  7. Reinstate the facemask as needed before or during Phase 49 II
  50. 50. Cephalometric effects of face mask/expansion therapy in Class III children: A comparison of three age groups -Andrew  Pretreatment and posttreatment cephalometric radiographs from 63 subjects (4 to 13 years) who had a Class III malocclusion were analyzed.  Serial cephalometric tracings of 32 subjects with Class I occlusion made at 4, 6, 8, 10, 12, and 14 years were used as controls.  Landmarks were digitized on each tracing and treatment effects were measured by using cranial base and maxillary superimposition techniques 50
  51. 51.  CONCLUSION  combination of skeletal and dental changes that produce an improvement in the soft tissue profile.  The treated group (N = 63) demonstrated statistically significant hard and soft tissue movements affecting the entire dentofacial complex.  Skeletal change was primarily a result of anterior and vertical movement of the maxillae. Mandibular position was directed backward and downward but with a minimal increase in lower face height and mandibular inclination.  Dental changes also contributed to the correction, and soft tissue changes resulted in a more convex profile. The effect of age on treatment response appeared minimal when comparing the differences in angular and linear measurements alone.  This study demonstrated that, in this sample, face mask/expansion therapy produced changes in the dentofacial complex that combined to improve the Class III malocclusion.  Although these results suggest that early treatment may be most effective, face mask therapy can provide a viable option 51 for older children as well.
  52. 52. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy -Tiziano  The effectiveness of maxillary expansion and face-mask therapy in children with Class III malocclusion was studied in a sample of 46 subjects in mixed dentition and compared with a control sample of 32 subjects with untreated Class III malocclusion.  Treated and untreated samples were divided into early and late mixed-dentition groups to aid identification of the optimum timing of the orthopedic treatment 52
  53. 53.  CONCLUSIONS  1. Treatment of Class III malocclusion with maxillary expansion and a face mask in the early mixed dentition induced more favorable changes in the craniofacial skeleton compared with similar treatment started in the late mixed dentition. In particular, effective forward displacement of maxillary structures was achieved as an outcome of early treatment, whereas the latetreatment group showed no significant improvement in maxillary growth with respect to matched untreated controls.  2. Even though both early and late face-mask treatments reduced mandibular protrusion, significantly smaller increments in total mandibular length associated with more upward and forward direction of condylar growth were recorded only in the earlytreatment group.  3. Discriminant analysis revealed that both maxillary and mandibular modifications concurred in the overall treatment effects of maxillary expansion and face-mask 53 therapy
  54. 54. Biomechanical effects of maxillary protraction on craniofacial complex - Hata, Itoh, Nakagawa, Kamogashira, Ichikawa, Matsumoto  The deformational effects on the human skull resulting from maxillary protraction were examined by means of strain gauges and displacement transducers.  The protraction forces that were applied to this appliance were parallel to the occlusal plane at the following locations:  (1) the height of the maxillary arch,  (2) 5 mm above the palatal plane, and  (3) 10 mm above the Frankfort horizontal plane 54
  55. 55.  (1) protraction forces applied 10 mm above the Frankfort horizontal plane produced a posterior rotation of the maxilla with a forward movement of nasion  (2) protraction forces applied 5 mm above the palatal plane produced a combination of parallel forward movement and a very slight anterior rotation  (3) protraction forces applied at thelevel of the maxillary arch produced an anterior rotation and forward movement of the maxilla  (4) all three protraction forces caused the constriction of the anterior part of the palate. 55
  56. 56. Profile changes in patients with class III malocclusions after Delaire mask therapy -Hülya KiliçoJlu  16 girls (mean age: 8.65 years, SD: 1.4 years) with skeletal Class III relationships caused by maxillary retrognathism, was compared with an untreated control group of 10 girls (mean age: 9.29 years, SD: 1.4 years).  (1) After maxillary protraction, the maxilla was displaced anteriorly, whereas the mandible rotated posteriorly  (2) the maxillary incisors moved in the anterior direction, whereas the mandibular incisors moved posteriorly  (3) the mandibular plane angle and anterior lower and total face heights increased  (4) these changes were reflected in the profile, whereby the skeletal profile convexity increased and soft tissue facial angle and facial convexity decreased  (5) the Class III concave profile became more balanced, with 56 the upper lip area becoming more marked.
  57. 57.  CONCLUSIONS  1. The Delaire face mask treatment can provide orthopedic effects on dentofacial morphologic features of growing skeletal Class III female patients.  2. Treatment tended to reduce the concavity of the profile. This was characterized by a forward movement of the upper lip, backward repositioning of the pogonion soft, and slight inhibition of anterior migration of the lower lip.  3. The effect of the treatment was found to be more marked on the upper lip area. 57
  58. 58. References:  Text book of orthodontics – Bishara  Contemporary orthodontics – Profitt  Dentofacial orthopedics with functional appliances – Graber ,Petrovic ,Rakosi  Orthodontics - Bhalajhi 58
  59. 59.  AJO-DO Volume 1980 Aug (125 - 139): A modified protraction headgear - Nanda  AJO-DO Volume 1981 Dec (638 - 650): Extraoral traction and Class III treatment – Cozzani  AJO-DO Volume 1990 Jul (47 - 55): Protraction of the maxillofacial complex Mermigos, Full, and Andreasen  AJO-DO Volume 1988 May (388 - 394): Use of face mask in treatment of maxillary skeletal retrusion - Roberts and Subtelny 59
  60. 60.  AJO-DO Volume 1998 Mar (333 - 343): Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy – Tiziano  AJO-DO Volume 1987 Apr (305 - 311): Biomechanical effects of maxillary protraction on craniofacial complex Hata, Itoh, Nakagawa, Kamogashira, Ichikawa, Matsumoto  JCO Volume 1988 May(314 - 325): Orthopedic Correction of Class III Malocclusion with Palatal Expansion and Custom Protraction Headgear - PATRICK K. TURLEY, D  JCO Volume 1996 Jun(313 - 324): Orthopedic Correction of Class III Malocclusion: Retention and Phase II Therapy PATRICK K. TURLEY, DDS, MSD, M  JCO Volume 1987 Sep(598 - 608): An Orthopedic Approach to the Treatment of Class III Malocclusion in Young Patients - JAMES A. MCNAMARA, JR., DDS, P 60
  61. 61. Thank you 61