Extraoral appliances

Faculty of Dentistry
Mansoura Egypt
Dr Maher Fouda
Professor of orthodontics

Reverse - pull headgear or face
mask
• It is used to apply an anteriorly
directed force , via elastics , on
the maxillary teeth and maxilla .It
is useful in the management of
Class III Malocclusions
particularly those associated with
a cleft lip and palate and in cases
of hypodontia where forward
movement of the buccal segment
teeth to close space is desirable
and there is concern that the
reciprocal effect on the anterior
teeth would create a reverse
overjet
• This is an example of when
anchorage needs to be lost
rather than enhanced and the
face mask can achieve this .

• In mixed dentition
stage , the face mask
is attached to hooks
opposite the laterals .
The hooks are
soldered to labial
arch which is
soldered to first molar
bands . The labial
arch is at the level of
the gingival third . A
palatal arch is also
adapted to the teeth
and is soldered to the
molar bands from the
palatal aspects of the
teeth .

• Patients with maxillary
deficiency can be treated by
expansion and advancement
of the maxilla in an attempt
to reduce the maxillary
deficiency . The appliance of
choice is the protraction
headgear with the aid of an
expansion appliance .This
Delaire face mask in the late
1960 was popularized and
the exraoral anchorage
regions were the chin and
the forehead.
Face mask

Multi-adjustable Face mask
• The appliance
depends completely
on patient co–
operation. The brow
and chin cup are
uncomfortable to
wear, particularly in
warm weather when
excessive sweating
underneath can lead
to a skin rash.

Ergonomic forehead rest
High impact molded plastic for a
smooth aesthetic appearance.
Replaceable medical-grade foam
cushion. Fully adjustable with
hexagon wrench.
Vertical main frame
Formed from the highest quality
corrosion resistant stainless
steel. Flat surface prevents
rotation of parts.
Forehead rest with dual free-
flow air vents
Allows air to flow under foam
padding for maximum patient
comfort.
Chin cup with streamlined
design
Smaller area for more even
pressure distribution for different
facial structures.
Horizontal crossbar
Multi-adjustable for precise angle of
force delivery. Multiple elastic stops
eliminate slippage. Molded plastic
with metal reinforced center for
strength.
Ergonomic chin cup
High impact molded plastic for a
smooth aesthetic appearance.
Replaceable medical-grade foam
cushion. Fully adjustable with
hexagon wrench.
Chin cup with free-flow air vent
Allows air to flow under foam
padding for maximum patient
comfort.
Chin cup with improved ergonomic
design. 20% smaller than previous
design. Less pressure applied to
tissue area of lower incisors.
Chin cup with full range of
motion option
The set-screw gives the option for a
fixed position or for full range of
motion. Glides smoothly along the
mainframe without side-to-side
rotation.
Allows the patient to open and close
their mouth comfortably with a full
range of movement.
Small light-weight end caps
Smooth aesthetic appearance.

Free-flow air vent
New forehead rest
design features dual air
vents for maximum
comfort and air
circulation.
Free-flow air vent
New chin cup design
features air vents for
maximum comfort and
air circulation.
Motion option
New sliding design
allows for a dynamic
range of motion without
side to side rotation.

Face mask
• Cotton linnings may help
overcome this or
alternatively, perforations
in these areas can be
introduced .Traction is
usually by elastics and if
these chafe at the angle of
the mouth significant
discomfort can arise.
Furthermore, saliva
passing down the elastics
can exacerbate this
problem .

Face mask
• Elastics attached to hooks
on the facemask are used
to apply traction either to
a removable appliance or
fixed appliance. Such
traction also keeps the
facemask in place on the
chin and forehead. The
elastics should be
attached to the middle of
the frame to prevent them
chafing at the angle of the
mouth .

Face mask
• The face mask exerts a
forward force on the
maxilla via elastics that
attached to a maxillary
appliance. To resist
tooth movements as
much as possible, the
maxillary teeth should
be splinted together as
one unit. The maxillary
appliance can be
banded, bonded or
removable .

Reverse pull Face mask
• The maxillary appliance to
which face mask is
attached must have hooks
for attachments to the face
mask that are located in the
canine premolar area above
the occlusal plane . This
places the force vector near
the center of resistance of
the maxilla and limits
maxillary rotation .The
design of the maxillary
appliance varies from a
simple palatal arch to rapid
maxillary (RME) appliance .

Face mask
Maxillary protraction
can be attempted in
young children who
have maxillary skeletal
deficiencies. The face
mask is attached with
elastic bands to a
maxillary splint. This
arrangement uses the
front of the face as a
point of anchorage in
order to place a forward
force on the maxilla.

Face mask (Delaire face mask) (Protraction
headgear)
• It is used in conjunction with removable bonded expansion
appliance attached to the upper arch. It is attached to a hook
mesial to the cuspid in also the mixed dentition. Clinically, the
maxilla can be advanced 2 to 4 mm over 8 – 12 months.
• Mandibular rotation, labial tipping of maxillary incisors , lingual
tipping of mandibular incisors, mesial movement of the
maxillary molars and changes in ANB differences toward a
more positive values are also caused by face mask.

Reverse-pull headgear
• It may be effective in
the primary and early
mixed dentitions .
• It is able to induce more
favorable craniofacial
adaptations in the early
mixed dentition than in
the late mixed dentition.
• On the other hand it is a
viable option for older
children before the
onset of puberty .

Genio-molar-anchor ( G.M.A ) Activator
• Force direction should be either
horizontal and parallel to the
occlusal plane or downward and
forward .
• Application of horizontal forces
may result in a downward rotation
of the posterior palatal plane and
open bite .
• A downward force 30 – 40 degrees
to the occlusal plane was
advocated to decrease posterior
palatal plane rotation. Protraction
from the upper first molar area has
been shown to produce
counterclockwise rotation of the
maxilla therefore protraction
should be made from the upper
canine area .

Face mask
• Rapid maxillary
expansion to expand
the maxilla before
protraction is needed
to disarticulate the
maxilla and inititate
cellular response in
the circum maxillary
sutures, allowing a
more positive
reaction to
protraction forces .

Face mask
• Extraoral elastics are the
means of force .
• Elastics should have high
elasticity and fatigue
resistance .
• The tensile forces stated
are created when the rings
are stretched to three times
their inner diameter .
• Tensile force ranges from
light (227 mg) to strong one
(455 gm) or strong (8 ounce
-224 gm) and exra strong
(14 oz – 392 gm ).

High pull Face bow
• Face bow can be slots into tubes soldered onto
bridge of a removable appliance crib, tubes which
are welded to a molar band of fixed appliance, or
tubes which are incorporated in a functional
appliance .

• Force vectors
above or below the
molar center of
resistance will result
in root or crown
distal tipping
respectively , while
force vector passing
through the center
of resistance will
cause bodily
movement of the
molar .
High pull Face bow

High pull Face bow
• High pull face bow can be attached to
maxillary intrusion splint. The splint
incorporates acrylic coverage of all the teeth
in the upper arch .

• Extrusion of the incisors to close an anterior open bite is
inadvisable, as the condition will relapse once the appliances
are removed. Treatment should aim to try and intrude the
molars, or at least control their vertical development.
Intrusion of the molars can be attempted with high – pull face
bow and / or by using buccal capping on a removable
appliance.
• The face bow is usually attached to the splint in the premolar
region through the center of resistance of the maxilla .
High pull Face bow

• Forces produced by the
high pull face bow
include a distally
directed component in
addition to an intrusive
component .
• This type of face bow is
commonly used in class
II skeletal problems with
excessive face height to
maintain the vertical
position of the maxilla
and inhibit eruption of
maxillary posterior teeth.
High pull Face bow

High pull Face bow
• Van Beek appliance incorporates high pull
face bow and buccal capping. It also
incorporates incisor cappings. It is indicated
in the treatment of anterior open bite.

• For bodily movement the
outer bow must be positioned
so that the resultant force is
through the center of
resistance .
• Bodily movement can be
attained with a medium
length outer bow in
combination with either a
headcap or necks trap I,e.a
combination of a head cap
and a neck strap attached to
a shorter and higher outer
bow than that used for crown
tipping is optimal for bodily
movement of the molars .
combi fashion releasable headgear

High pull fashion releasable headgear

vertical pull fashion releasable headgear

Face bow safety
• Severe ocular injuries including blindness have
occurred owing to accidents with headgear . These
have occurred with face bows in conjunction with
elastic force , where the face bow has been pulled out
of the mouth and recoiled back into the face or eyes .
The spring can easily be built into the face bow. If an
excessive force is applied, the components come
apart thus preventing recoil of the face bow .

Face bow safety
• Rigid safety strap, if correctly fitted, helps to
prevent the face bow from being dislodged. If
the face bow dislodged during the night,
patients should be advised to discontinue its
use and to return for adjustment .

Face bow safety
• Face bows with the
ends recurved to form
a guard over the sharp
end of the intra oral
bow are now available.
Patients should
warned of the dangers
and instructed that
face bow should not be
worn during any
horseplay .

Interlandi Face bow
• It may be considered for both
skeletal and dental correction.
Vertical and anteroposterior
maxillary development can be
restrained by face bow use,
providing it is worn for an
adequate period of time. More
commonly face bow is used
to control tooth position, e.g.
for anchorage support in the
upper arch distalization of
upper molars to correct class
II overjet reduction; or
intrusion of upper buccal
segments and/or incisors .

Interlandi face bow
• The combination of
upper molar intrusion
and maxillary growth
restraint helps to correct
a class II skeletal
discrepancy.
• Skeletal change with
face bow wear is minor
and face bow must be
worn over a long period
of time (years) to see
worthwhile.

Interlandi face bow
• The component parts
are a headcap, face
bow, elastics and
safety strap.
• The amount and
duration of force
application depends
on the purpose for
which face bow is
being worn.

Interlandi face bow
• For anchorage
management, 250 g
force applied per side
with wear of 8-10 hours
per day is sufficient .
• To achieve tooth
movement or growth
modification, a force of
500 g per side forb12-
14 hours per day is
required.

Interlandi face bow
• Injury while wearing face
bow is rare and has been
reported. It includes a
penetrating eye injury
from a face bow which
resulted in blindness.
Therefore face bow
should be worn with a
safety strap stapled to
headcap, snap away
headgear and safety
locking facebows.

Low pull face bow
Cervical pull face bow
exerts force below the
level of occlusal plane will
tend to extrude the upper
molar teeth and thus
cause an increase in the
vertical dimension of the
lower face. While this
may be an advantage in a
patient with a deep
overbite and reduced
lower facial height, it is
contraindicated in a
patient with open bite and
increased lower face
height .

Spring – Gear with adjustable levels of force

Cervical fashion releasable headgear

Cervical fashion releasable headgear
Nine-year-old
patient with space
loss due to an
ectopically erupted
maxillary permanent
first molar. Space
regaining was
accomplished by the
use of extraoral
cervical headgear.
(A) Side view of
headgear in use. (B
and C) pretreatment
and (D and E) post-
treatment study
models.

High pull headgear
• Intrusion of the upper
incisors can be
attempted by
applying headgear to
the upper labial
section of the arch-
wire during fixed
appliance treatments
but to avoid root
resorption a force of
less than 200 g is
advisable .

High pull headgear
Headgears used by Kingesly 1880.

(A and B) High-pull headgear used in combination with the modified
activator. Notice the direction of the outer arms. (B and C) intraoral view of
the Teuscher appliance showing the position of the buccal tubes placed in
the acrylic between the upper and lower second primary molars or
bicuspids. The torquing springs used for control of the incisors are placed
in contact with the most gingival portion of the incisors.
The Teuscher appliance

High pull headgear
• AJ – hook headgear
can be used for
retraction of canines
or incisors. It is most
effective in maximum
anchorage cases.
Retracting protruding
maxillary anterior
teeth.

Horizontal pull (low pull) headgear
• Care is required with
J – hooks as the hook
can be dislodged and
cause serious injury.
It is preferable to
bend the hook round
so that it forms a
circle and is attached
onto a hook soldered
to the removable
appliance or
archwires .

Uses of the face bow
(1) Reinforcement of
anchorage :
• Satisfactory reinforcement
of anchorage may require
the addition of teeth from
the opposite dental arch
to the anchor unit.
Reinforcement may also
include forces derived
from structures outside
the mouth .

Reinforcement of anchorage
• For example, to close a
mandibular premolar extraction
site , it would be possible to
stabilize all the teeth in the
maxillary arch so that they
could only move bodily as a
group, and then to run an
elastic from the upper posterior
to the lower anterior, thus
pitting forward movement of the
entire upper arch against distal
movement of the lower anterior
segment. This addition of the
entire upper arch would greatly
alter the balance between
retraction of the lower anteriors
and forward slippage of the
lower posteriors.

• This anchorage could be
reinforced by having the
patient wear a face bow
to the upper molars
placing backward force
against the upper arch .
The reaction force from
the face bow is
dissipated against the
bones of the cranial
vault, thus adding the
resistance of these
structures to the
anchorage unit . `

• The only problem with
reinforcement outside
the dental arch is that
springs within an arch
provide constant forces
, whereas elastics from
one arch to the other
tend to be intermittent.
Although this time
factor can significantly
decrease the value of
cross–arch and
extraoral
reinforcement, both
can be quite useful
clinically .

Correction of end to end molar relation
by face bow
• To change an end to end
molar relationship to Class I by
moving the upper molars
distally , either by tipping both
molars distally or by bodily
movement , extraoral force via
a face bow to the molars is the
most effective method . The
force is directed to the teeth
that need to be moved , and
reciprocal forces are not
distributed on the other teeth
that are in the correct positions
• The force should be constant
and light to provide effective
tooth movement because it is
concentrated against only 2
teeth .

by face bow
• The more the child wears
the headgear, the better;
14 to 16 hours per day is
minimal. Approximately
100 gm of force per side
is appropriate. The teeth
should move at the rate
of 1 mm / month, so a
cooperative child would
need to wear the
appliance for 3 months to
obtain the 3 mm of
correction .

by face bow
• If the outer bow of the
face bow is positioned
so that the resultant
force vector passes
occlusal to the center
of resistance, which is
near the midpoint of
the root, the molar
crown will tip distally .

by face bow
• Distal crown tipping will
occur if the face bow is
attached to a neckstrap
with either a medium
length , straight or long ,
low outer bow . Distal
tipping also would occur
with a medium length,
straight outer bow
attached to a headcap
as long as the resultant
force vector passes
occlusal to the center of
resistance .

by face bow
• For bodily movement
the outer bow must be
positioned so that the
resultant force is
through the center of
resistance .
• Bodily movement can
be attained with a
medium length outer
bow in combination
with either a headcap
or neckstrap .
High pull face bow

by face bow
• To move the molar
roots distally, the
outer bow should be
short and high so
the resultant force is
above the center of
resistance. This is
achieved most
conveniently with a
headcap for force
application.

Class III malocclusion with
mandibular excess
The most common types of headgear are shown here. (A) Cervical headgear
pulls from the back of the neck to a facebow that inserts into a tube on the
upper molar band. This type of headgear puts a distal and extrusive force on
the maxilla. (B) High-pull headgear pulls from the top of the back of the head
and places a backward and upward force on the maxilla. (C) Combination
headgear is both a cervical and high-pull headgear together and can be
adjusted to vary the direction of force on the maxilla.

Class III malocclusion with mandibular
excess
• Children who have
Class III malocclusion
because of excessive
growth of the mandible
are extremely difficult to
treat . The treatment of
choice would appear to
be a restraining device
(e.g., chin cup / chin
cap) to inhibit the growth
of the mandible , at least
preventing it from
projecting forward .

Class III with mandibular excess
• Functional appliances also
have been advocated for
mandibular excess
patients .
• Inhibiting mandibular
growth has proven to be
almost impossible so with
both types of appliances,
the major effect is
downward and backward
rotation of the mandible,
which decreases
anteroposterior projection
of the chin by making the
face longer .

Class III malocclusion with mandibular
excess
• There is some evidence
that a chin cup is more
effective in young
children under age 7
than the same treatment
used later.
• Unfortunately despite
efforts to modify
excessive mandibular
growth, many of these
children ultimately need
surgery, and the chin
cup treatment is
essentially camouflage.

High pull Chin cup
• Chin cup is used to inhibit
or control forward growth
of the mandible in skeletal
Class III patients. Patients
with mandibular excess
can usually be recognized
in the primary dentition
despite the fact that the
mandible appears
retrognathic in the early
years of most children .

High pull Chin cup
• Evidence exists that
treatment to reduce
mandibular protrusion is
more successful when it is
started in the primary or
early mixed dentition. Chin
cup does accomplish a
change in the direction of
mandibular growth, rotating
the chin down and back. In
addition, lingual tipping of
the lower incisors occurs as
a result of the pressure of
the appliance on the lower
lip and dentition.

High pull Chin cup
• A hard chin cup can
be custom fitted from
plastic , using an
impression of the
chin; a commercial
metal or plastic cup
can be used if it fits
well enough or a soft
cup can be made
from a football helmet
chin strap .
Chin-cup appliance in place.

High pull Chin cup
Chincaps used by Angle 1898 and used in the present day.

• The more the chin cup
migrates up towards the
lower lip during appliance
wear the more lingual
movement of the lower
incisors will be produced.
Although a wide variety
of chin cup designs are
available commercially,
these appliances can be
divided into two general
types: the occipital pull
chin cup and the vertical
pull chin cup.
High pull Chin cup

The occipital pull chin cup
• The occipital pull chin
cup is indicated for use
in patients with mild to
moderate mandibular
prognathism. This
treatment is useful
particularly in patients
with short lower anterior
facial height, because
chin cup treatment can
cause an increase in
this dimension.

• If the pull of the chin
cup is directed below
the condyle, a
downward and
backward rotation of the
mandible can take
place. If opening of the
mandibular angle is not
desired, forces should
be directed through the
condyle to help restrict
mandibular growth .

• This treatment is appropriate
with normal or reduced lower
anterior face height but is
contraindicated for a child
who has excessive lower
face height.
• More Asian than white
children can benefit from
chin cup because of their
shorter face heights.
• Unfortunately, the majority of
white children with excessive
mandibular growth have
normal or excessive face
heights , so that only small
amounts of mandibular
rotation are possible without
producing a long – face
deformity

Chin straps attached to high-pull caps have been used in an attempt to
restrict forward growth of the mandible-prostrusive patients. Some distal
tipping of the lower incisors and downward and backward rotation of the
mandible is usually noted, but the amount of mandibular growth is seldom
affected.

Soft-gear chin cup headcaps
• Both the occipital – pull and
vertical pull chin cup create
pressure on the
tempromandibular joint
region Several patients
complain of temporary
soreness of the TMJ during
the retention period Chin cup
affects the growth of not only
the mandible but also the
cranial base structures as
well . Chin cup does not
induce posterior
displacement of the glenoid
fossa .

• The use of Hickham
– type head cap
allows for variable
vectors of force to
be produced on the
lower jaw. There is
a need for the
extended use of the
chin cup over the
growth period .

The vertical pull chin cup
• Used in patients with
excessive facial height ,
when an increase in the
lower facial height is not
desired. It can result in a
decrease in the
mandibular plane angle
and the gonial angle and
an increase in the
posterior facial height .It is
very difficult to create a
true vertical pull on the
mandible because of the
problem of anchoring the
appliance cranially .

Chin cup
• A hard chin cup can be custom
fitted from plastic , using an
impression of the chin a
commercial metal or plastic cup
can be used if it fits well enough ;
or a soft cup can be made from a
football helmet chin strap Any of
these can irritate the soft tissue of
the chin and may require a
protective liner or talcum powder
for comfort . The more the chin
cup or strap migrates up toward
the lower lip during appliance
wear , the more lingual
movement of the lower incisors
will be produced . Soft cups may
produce more tooth movement in
this manner than hard ones .

Chin cup
• The headcap that includes
the spring mechanism can
be the same one used for
high pull headgear
• It is adjusted in the same
manner as the headgear to
direct a force of
approximately 16 to 24
ounces per side through the
head of the condyle or a
somewhat lighter force below
the condyle .
• Once it is accepted that
mandibular rotation is the
major treatment effect ,
lighter force oriented to
produce greater rotation
makes more sense .

Extraoral appliances

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