Facemask jc

JOURNAL CLUB
Facemask therapy with and
without expansion.
Tuba
Tortop, Alaadin Keykubat, Sema Yuksel
(AJODO 2007;132.no4)
www.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 AIM OF STUDYAIM OF STUDY
 MATERIAL AND METHODSMATERIAL AND METHODS
 RESULTSRESULTS
 DISCUSSIONDISCUSSION
 CONCLUSIONCONCLUSION
 REFERNCESREFERNCES

INTRODUCTIONINTRODUCTION
 Head gears are generally used for the purpose of
reinforcement of anchorage or for maxillary distalisation.
However, when an anterior protractory force is required, a
face mask is used.
Hickham claims he was the first to use. However, this
modality was made popular by Delaire around the same time.
A facemask basically consists of a rigid extra-oral framework
which takes anchorage from the chin or forehead or both for
the anterior traction of the maxilla using extra-oral elastics
which generate large amounts of force upto 1000pounds or
more. www.indiandentalacademy.com

Indications
 It can be used in a growing patient having a
prognathic mandible and a retrusive maxilla.
 It can also be used for selective rearrangement of
the palatal shelves in cleft patients.
 It can be used in correction of post surgical
relapse after osteotomy.
 It can be used to treat certain accessory problems
associated with nose morphology such as lateral
deviations.

 Sites of anchorage-
 Anchorage from skull (forehead)
 Anchorage from chin
 Anchorage from chin & forehead
Biomechanical considerations
Amount of force: The amount of force to bring about skeletal changes is
about 1 pound (450 gms) per side.
Direction of force: Most authors recommend 15-20 degree downward pull
to the occlusal plane to produce a pure forward Translatory motion of
the maxilla.
Duration of force- Low forces (250 gm/side) take 13 months to
produce desired results. However, very high force values like 1600-3000
gms reduced treatment time to 4 – 21 days.
Frequency of use: Most authors recommend 12-14 hrs of wear a day.www.indiandentalacademy.com

 Parts of a facemask
 Chin cup
 Forehead cap
 Intra-oral appliance
 Elastics
 Metal frame
Facemask of Delaire : This
was popularized by Delaire in
the 60's and also uses the chin
and forehead for support.

 Tubinger model:
 This is a modified type of Delaire face mask.
 It consists of a chin cup from which originates two
rods that run in the midline and is shaped to avoid
the interference of nose.
 The superior ends of the two rods house a forehead
cap from which elastics encircle the head. In
addition, a cross bar extends in front of the mouth
which can be used to engage elastics.

 Petit type of face mask :
 This is also a modified
form of Delaire face mask.
 It consists of a chin cup
and a forehead cap with a
single rod running in the
midline from forehead cap
to chin cup.
 A cross bar at the level of
the mouth is used to
engage elastics.
 The advantage of this
model is that the forehead
cap, chin cup and the cross
bar can be adjusted to suit
the patient.

 Class III skeletal patterns often exhibit a high incidence of
deficient transverse maxillary growth. In the treatment of
Class III malocclusions maxillary expansion is frequently
needed to increase the transverse width of the maxilla
Also, maxillary expansion alone has been believed to be
beneficial in the treatment of certain types of Class III
malocclusion.
Haas reported that rapid palatal expansion the maxilla might
move slightly forward and downward.
According to several authors, rapid maxillary expansion
disrupts the circummaxillary sutural system initiates cellular
response in the sutures, and enhances the protraction effect of
the mask. www.indiandentalacademy.com

 Baik ( AJO-DO 1995 )compared 47 patients treated with
facemasks and rapid palatal expansion with 13 patients treated
with facemasks and labiolingual appliances and found
significantly greater forward movement of Point A in the
expansion group.
 It was concluded that
1. After maxillary protraction, the maxilla and the maxillary
dentitions moved forward and downward, and the mandible and
the mandibular dentitions moved backward and downward.
2. The RPE group showed statistically significant changes in point
A, ANS, and maxillary molar compared with labiolingual
appliance group
3. Age showed no statistical significant differences.

 Kim et al (AJODO 1999) evaluated facemask therapy in a
meta-analysis study and reported that the results of
protraction with or without expansion were similar, but the
average duration of treatment was longer in the
nonexpansion group
No distinct differences were present between the palatal
expansion group and the nonexpansion group except for
upper incisor angulation, which showed greater
proclination in the nonexpansion group.
 To compare facemask treatment results between expansion
and nonexpansion groups and between treated groups and a
control group; all groups were matched by age and sagittal
skeletal relationship.
AIM OF THE STUDYAIM OF THE STUDY

MATERIALS AND METHODSMATERIALS AND METHODS
 The material of this study consisted of the lateral cephalograms
of 42 children with skeletal and dental Class III malocclusion due
to maxillary retrusion or a combination of maxillary retrusion
and mandibular protrusion
 Each patient had a negative ANB angle, a Class III molar
relationship and negative overjet
 Two treatment groups and a control group were formed with 14
subjects in each
 The groups were matched by sex, ANB angle and mandibular
plane angle

 The facemask plus expansion group consisted of 14
patients with maxillary bilateral posterior crossbite
accompanying the Class III malocclusion.
 Each subject was treated with a Delaire-type face mask and
a bonded rapid maxillary expansion appliance (hyrax)
 The bonded appliance had vestibular hooks at the canine
region for extraoral elastics.
 The hyrax screws were activated twice a day with a quarter
turn until the desired change in the transverse dimension
was achieved
 Facemasks were used either at the beginning of expansion
or at the end of the first week.
FACEMASK PLUS EXPANSION GROUPFACEMASK PLUS EXPANSION GROUP

 The facemask group consisted of 14 patients with no
posterior crossbite.
 Each subject was treated with a Delaire-type face mask and a
removable intraoral appliance.
 The removable intraoral appliance had 2 Adams clasps at the
molars, 2 ball clasps, a labial bow, and 2 hooks at the anterior
region for extraoral elastics.
 The total force of the face mask was 600 g, the angle between
the occlusal plane and the direction force applied by the
facemask was approximately 20°, and the patients were
instructed to wear the appliance 16 hours a day in both
treatment groups.
FACEMASK GROUPFACEMASK GROUP

 A retrospective control group of 14 children was
observed without treatment for 10 months.
 Lateral cephalometric radiographs were taken at the
beginning and the end of the observation period.
Retrospective control group
At the beginning and after Class I molar occlusion and a
minimum 2 mm overjet were obtained, lateral cephalometric
radiographs were taken.
The average treatment times were 8 months for the FMEXP
group and 7 months for the FM group.www.indiandentalacademy.com

 All radiographs were traced, digitized, and evaluated
 Ten linear and 13 angular measurements were evaluated
 To differentiate dental and skeletal, effects, total superimpositions
were made on sella-nasion line (SN) at sella

TOTAL SUPERIMPOSITIONTOTAL SUPERIMPOSITION
 For the total superimposition, the pretreatment
tracing SN plane was used as the horizontal
reference plane, and vertical perpendicular to SN
at point T was used as the vertical reference
 On total superimpositions, vertical and
horizontal movements of anterior nasal spine
and pogonion (Pg) were evaluated according to
reference grid formed in the first cephalogram

Local superimpositions were made
on palatal plane at ANS for
maxilla
For the maxillary superimposition,
the pretreatment tracing ANS-
posterior nasal spine (PNS) plane
was used as the horizontal
reference plan and vertical
perpendicular to ANS-PNS at
point T was used as the vertical
reference plane.
On local superimpositions vertical
and horizontal movements of
maxillary incisors and molars
were evaluated according to the
reference grid formed in the first
cephalogram.
Local superimpositionLocal superimposition

 All cephalometric radiographs were retraced and
redigitized and superimpositions and
measurements were repeated after 15days.
 Method error coefficients were calculated and
found to be within acceptable limits
 Statistical analysis was undertaken with
software

RESULTSRESULTS
FMEXP
 Comparison of the pretreatment values showed that maxillary
height was ,significantly greater in the FM group compared with
the FMEXP and the control groups (P <.05).
 The pretreatment facial axis value in the control group was
significantly greater than in the FM group (P <.05)
 Of the cephalometric measurements, CoA and CoGn showed
significant increases (P <.001 and P <.01, respectively) in the
FMEXP group.
 The significant increase in SNA angle (P <.05) and the significant
decrease in SNB angle (P <.01) resulted in a significant increase
in ANB angle (P <.001).

 Maxillary depth and the Wits appraisal increased significantly
during FMEXP therapy (P <.01).
 A significant decrease in facia! axis and an increase in SNGoGn
were observed
(P <.01).
 Molar relationship, overjet, and U6PTV also showed significant
increases in the FMEXP group (P <.01 and P <.001,
respectively)

Fm Group
In the FM group, significant increases in CoA and CoGn were found
(P <.01 and P <.05, respectively), and the maxillomandibu!ar
differential decreased significantly (P <.05).
SNA angle, ANB angle, and the Wits appraisal showed significant
increases
The decrease in gonial angle (GnGoAr) was statistically significant in
the PM group.
The SN dimension showed a significant increase in this group
The occlusal plane decreased significantly during FM therapy

CONTROL GROUP
 In the control group. CoA, CoGn, and
maxillomandibular differential increased
significantly without treatment
 There were significant increases in maxillary
depth and facial depth

 A significant increase in the SN dimension was observed
 Overbite and U6PTV showed significant increases during the
observation period
 On the superimpositions, ANSx showed significant increases in
both 'treatment groups
 The increase in Pgy was significant only in the FMEXP group

 The increases in CoA in the FMEXP and the
FM groups showed significant differences
compared with the control group
 The decrease in maxillomandibular difference in
the FMEXP and FM groups was significantly
different compared with the increase in the
control group

 A significant difference was observed in facial depth between the
treatment groups and the control group
 The increases in SNA angle in the FMEXP and the FM groups
showed significant differences compared with the control group
 There was a significant difference in SNB angle between the
FMEXP and the control groups
 Increases in ANB angle and Wits appraisal in the treatment
groups were significantly different compared with the control
group
 A significant difference was observed in maxillary height
between the FM and the control group

 Increases in molar relationship in the treatment groups
were significantly different compared with the control
group
 Also, the increase in molar relationship in the FM group
was significantly greater than in FMEXP group
 Increases in overjet in the treatment groups showed
significant difference compared with the control group
The superimpositions showed that changes in ANSx and
Pgx in the treatment groups were significantly different
compared with the control group

RESULTSRESULTS
fmexpfmexp FMFM CC
Comparison of the pretreatment
values showed that maxillary
height was ,significantly greater
in the FM group compared with
the FMEXP and the control
groups (P <.05).
The pretreatment facial axis value
in the control group was
significantly greater than in the
FM group (P <.05)
Of the cephalometric
measurements, CoA and CoGn
showed significant increases (P
<.001 and P <.01, respectively) in
the FMEXP group.
The significant increase in SNA
angle (P <.05) and the significant
decrease in SNB angle (P <.01)
resulted in a significant increase
in ANB angle (P <.001).
In the FM group, significant
increases in CoA and CoGn
were found (P <.01 and P
<.05, respectively), and the
maxillomandibu!ar differential
decreased significantly (P
<.05).
SNA angle, ANB angle, and
the Wits appraisal showed
significant increases
The decrease in gonial angle
(GnGoAr) was statistically
significant in the PM group.
The SN dimension showed a
significant increase in this
group
In the control group.
CoA, CoGn, and
maxillomandibular
differential increased
significantly without
treatment
There were
significant increases
in maxillary depth
and facial depth

DISCUSSIONDISCUSSION
 In this investigation, treatment changes were analyzed and compared
after orthopedic therapy of Class III malocclusion with the FMEXP
and the FM.
 To evaluate the changes during these treatments, a control group was
formed of children with untreated Class III malocclusion.
 Significant increases in CoA, SNA angle. And ANSx demonstrated
the forward movement of the maxilla in both treatment groups, and
this agreed with several facemask studies with or without expansion.
Several authors showed that the maxilla can displace in a forward and
downward direction during maxillary expansion.
Surgically assisted rapid palatal expansion induced a slight forward
movement of the maxilla
However da Silva et al reported downward and backward rotation of
the maxilla and concluded that anterior displacement of the maxilla with
significant changes in SNA angle should not be expected.www.indiandentalacademy.com

 Palatal expansion might disarticulate the maxilla and initiate
cellular response in the sutures, allowing a more positive reaction
to protraction forces.
 As a result of this belief, the use of bonded rapid palatal
expansion appliances before or at the beginning of the facemask
therapy have been recommended to facilitate maxillary
movement.
 Baik compared intraoral appliances during facemask therapy; 47
patients were treated with rapid palatal expansion and 13 patients
with labiolingual appliances.
 He found significantly greater forward movement of Point A in
the expansion group (2 mm) compared with the labiolingual
group (0.9 mm), but the angular change was similar in the
expansion and the non expansion groups.

 In this study, in the FMEXP group. expansion was used
primarily to correct the posterior crossbites rather than to
disarticulate the maxillary sutures.
 results indicated that increases in CoA and SNA angle had no
significant differences between the treatment.
 On the total superimposition the forward movements of ANS
were 3 mm in the FMEXP group and 2.3 mm in the F'vl group,
and no
 significant difference was determined between these groups.
 In a meta analysis study, it was concluded that the results of
protraction were similar for the expansion and the nonexpansion
groups.

 Increases in ANB angle and Wits appraisal and the
decrease in the maxillomandibular differential in both
treatment groups indicated successful treatment of the
sagittal skeletal relationship.
 In this study, molar relationship and overjet also
improved significantly in both treatment groups; similar
changes were reported in previous facemask studies.

Merwin et al reported maxillary molar extrusion with increased
lower facial height during facemask therapy with a banded
expansion appliance.
 Wertz suggested that the bite opening effect of the maxillary
splint might reduce the tendency toward extrusion of the
posterior teeth.
 In the FMEXP group, a 1.1 mm decrease in overbite and a 1.4
mm eruption of the maxilIary molars were observed; these
results were consistent with the findings of a previous maxillary
expansion and protraction study

 In a meta-analysis study, Kim et alIn a meta-analysis study, Kim
et al17 suggested that
 the use of an expansion appliance enhances the protraction
effect in terms of time with less dental effect.
 treatment times were similiar in the FMEXP and the FM groups
suggested that the use of an expansion appliance enhances the
protraction effect in terms of time with less dental effect.
 treatment times were similar in the FMEXP and the FM groups

CONCLUSIONCONCLUSION
 Both treatment procedures were effective in the dental
and skeletal therapy of patients with Class III
malocclusion
 The skeletal contribution to Class III treatment was
statisticalIy significant, but the dental contribution
showed no significance in the treatment groups.
 With the arylic splint of the bonded expansion
appliance, the eruption of the maxillary molar seemed
to be less compared with the removable intraoral
appliance.

REFERENCESREFERENCES
 Bacetti T, Lranchi L – treatment and posttreatment changes afterBacetti T, Lranchi L – treatment and posttreatment changes after
rapid maxillary expansion and facemask therapy. AJO-DOrapid maxillary expansion and facemask therapy. AJO-DO
2000;118:404-132000;118:404-13
 Baik HS – Clinical results of the maxillary protraction in KoreanBaik HS – Clinical results of the maxillary protraction in Korean
children. AJO-DO 1995;108:583-92children. AJO-DO 1995;108:583-92
 Full CA, Mermigos J – protraction of the maxillofacialFull CA, Mermigos J – protraction of the maxillofacial
complex.AJO-DO 1987;91.47-55complex.AJO-DO 1987;91.47-55
 Westwood PV, Bacetti T – longterm effects of class IIIWestwood PV, Bacetti T – longterm effects of class III
treatment with rapid maxillary expansion and facemask therapy –treatment with rapid maxillary expansion and facemask therapy –
AJO-DO 2003;123:306-10AJO-DO 2003;123:306-10
 Kim JH, Viana MAG – The effectiveness of protraction faceKim JH, Viana MAG – The effectiveness of protraction face
mask therapy: a meta analysis.AJO-DO 1999;115:675-80mask therapy: a meta analysis.AJO-DO 1999;115:675-80
 Williams MD, Sarver DM – combined rapid maxillary expansionWilliams MD, Sarver DM – combined rapid maxillary expansion
and protraction facemask in the treatment of class IIIand protraction facemask in the treatment of class III
malocclusions in growing children.Sem in orthod 1997;3:265-74malocclusions in growing children.Sem in orthod 1997;3:265-74

 Suza N, Suzuki MI – Effective treatment plan for maxillarySuza N, Suzuki MI – Effective treatment plan for maxillary
protraction.AJO-DO 2000;118.55-62protraction.AJO-DO 2000;118.55-62
 Mac Donald KE, Kapust AJ – Cephalometric changes afterMac Donald KE, Kapust AJ – Cephalometric changes after
correction of class III malocclusion with maxillarycorrection of class III malocclusion with maxillary
expansion and facemask therapy. AJO-DO 1999:116.13-24expansion and facemask therapy. AJO-DO 1999:116.13-24
 Nartallo-Turley PE, Turley PK – cephalometric effects ofNartallo-Turley PE, Turley PK – cephalometric effects of
combined palatal expansion and facemask therapy on classcombined palatal expansion and facemask therapy on class
III malocclusion A.O; 1998;68.217-24III malocclusion A.O; 1998;68.217-24
 Ngan PW, Hagg U – treatment response and long termNgan PW, Hagg U – treatment response and long term
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 Kapust AJ, Sinclair PM – cephalometric effects ofKapust AJ, Sinclair PM – cephalometric effects of
facemask/expansion therapy in class III children. AJO-DOfacemask/expansion therapy in class III children. AJO-DO
1998;113:204-121998;113:204-12
 Ucem TT, Ucune N – facemask therapy in treating class IIIUcem TT, Ucune N – facemask therapy in treating class III
malocclusions.AJO-DO 2004;126.672-79malocclusions.AJO-DO 2004;126.672-79www.indiandentalacademy.com

 Ngan P, Wade D- cephalometric A pointNgan P, Wade D- cephalometric A point
changes during and after maxillary protractionchanges during and after maxillary protraction
and expansion.AJO-DO 1996;110.423-28and expansion.AJO-DO 1996;110.423-28
 Proffit W.R., Fields H.W Jr.: ContemporaryProffit W.R., Fields H.W Jr.: Contemporary
orthodontics – Mosby 3rd Edition 2000orthodontics – Mosby 3rd Edition 2000
 Graber T.M., Vanarsdall R.L. Jr: Orthodontics –Graber T.M., Vanarsdall R.L. Jr: Orthodontics –
Current principles and Techniques. Mosby 1994Current principles and Techniques. Mosby 1994
2nd Edition.2nd Edition.

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