Maxillary protraction /certified fixed orthodontic courses by Indian dental academy

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


Contents
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Introduction
Different appliances used in class III patients
Face mask therapy
Biomechanical considerations
Treatment effects of face mask
Rapid Maxillary Expansion
Treatment timing
Different designs of Protractor appliances
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Delaire mask
Petit facemask
Modified protraction headgear
Sub orbital protraction headgear

– Lever-Hook Edgewise Arch
– Mini Maxillary protractor
– The Functional orthopedic magnetic appliance
(FOMA) III
– Double plate appliance
– Two piece corrector
– Tandem Traction Bow Appliance

• Rigid Anchorage for face mask therapy
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Intentional ankylosis
Osseointegrated implants
Titanium lag screws
Onplants
Miniplates

• Conclusion
• References


Introduction
• The incidence of skeletal class III
malocclusion is rather small in the
population, but it is one of the most difficult
malocclusions to treat
• The prevalence of Class III malocclusion
in white population is approximately 5%
(Mills 1966, Jacobson 1974), rising to as
much as 48% of those seeking treatment
in the Japanese population

• The term prognathism referred to an
overdeveloped mandible and was frequently
misused to describe true Class III
malocclusion.
• Contemporary studies have found Class III to
be composed of pure mandibular protrusion
(19.1% to 45.2%), pure maxillary retrusion
(19.5% to 37.5%), or a combination of
mandibular protrusion and maxillary retrusion
(1.5% to 30%).

• According to Ellis and McNamara 1984
and Sue et al 1987, maxillary
retrognathism is present in 62% to 67% of
all class III patients
• According to Bell et al AJO 1981 maxillary
retrognathism was found in 30–40% and
Jacobson et al AJO 1974 reported that
the one-quarter of Class III malocclusions
demonstrated retruded maxilla

• Both anteroposterior and vertical maxillary
deficiency can contribute to a Class III
malocclusion, resulting in a prognathic
appearance of the jaws, dentition, and soft
tissue profile.
• For example, if the maxilla is positioned
posteriorly, the effect is direct.
• If the maxilla does not develop vertically,
the mandible rotates upward and forward
producing the appearance of a prognathic
mandible. www.indiandentalacademy.com

Appliances used in the correction
of Class III malocclusions
• Mandibular skeletal appliances (e.g., chin cap,
lower headgear) and mandibular dental
appliances (e.g., Lip bumper)
• Maxillary skeletal appliances (e.g., facial mask,
reverse headgear, rapid palatal expansion) and
maxillary tooth-borne appliance (e.g., Y plate)
• Intermaxillary skeletal appliances (e.g.,
Hickham chincap, functional regulator III) and
intermaxillary dental appliances (e.g., Class III
elastics)

Face mask therapy
• Face-mask therapy was first described more
than a century ago, and since the late 1960s
it has been used with increasing frequency
for the correction of Class III malocclusion.
• In 1944, Oppenheim reported that it is
impossible to move the mandible backward,
but that it is possible to bring the maxilla
forward to compensate for mandibular
overgrowth when treating Class III
malocclusions

• Delaire (1978) developed the orthopedic
facemask 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.

• The principle of maxillary protraction is to
apply tensile force on the circumaxillary
sutures and thereby stimulate bone
apposition in the suture areas; in doing so,
the maxillary teeth become the point of
force application, and the face (forehead,
chin, zygoma) or occipital area becomes
the anchorage source

• 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.
• Elastics running between the intra oral
anchorage system and the extra-oral
appliance produce the necessary force for
maxillary traction.
• Maxillary protraction generally requires
300-600 grams of force per side,
depending on the age of the patient.

Biomechanical consideration
Direction of force application
• 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.

• Staggers JCO 1992 - The orthodontist must
first decide, 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.

Hata AJO 1987


• Keles AO 2002 examined the effect of
varying the force direction on maxillary
protraction.
• In group 1, they applied the force
intraorally from the canine region with a
forward and downward direction at a 30°
angle to the occlusal plane.
• In group 2, the force was applied
extraorally 20 mm above the maxillary
occlusal plane.

• Group 1 the maxilla advanced
forward with a counter-clockwise
rotation.
• In group 2 anterior translation of
maxilla without rotation.
• The maxillary incisors were
proclined slightly in group 1, but
in contrast they were retroclined
and extruded in group 2, so this
method can be used effectively
on patients who present as class
III combined with an anterior
open bite.

The Role of maxillary
Protraction
1.
2.
3.
4.

Protract the maxilla
Advance the maxillary dentition
Tip the lower incisors lingually
Encourage vertical mandibular
development
5. Eliminate a centric relation – Centric
occlusion discrepancy

Treatment Effects of Protraction
Headgear / Face Mask Therapy
• Much of the information about the skeletal
effects of protraction forces still derives from
animal studies
• Kambara AJO 1977 found changes at the
circummaxillary sutures and at the maxillary
tuberosity, including the opening of sutures,
stretching of sutural connective-tissue fibers,
new bone deposition along the stretched
fibers, and apparent tissue homeostasis that
maintained the sutural width.

• Nanda and Hickory AO 1984 showed that
the forward movement and the anterior
displacement of the maxilla are because of
the remodeling of the circummaxillary
sutures, in particular the
zygomaticomaxillary, zygomaticotemporal,
and transverse palatine sutures, and
reported that the type of displacement was
related to the direction of force.

• Biomechanical studies on dry human
skulls have demonstrated further that the
application of an anteriorly directed force
results in forward movement of the
maxilla.
• These investigations also showed that the
direction of the force is critical in
controlling rotation of the upper jaw
(Tanne AO 1991, Itoh AJO 1985)

• Lee et al AJODO 1997 Using holographic
interferometry on a dry human skull they
showed a 500 gm force applied 15 mm
above and directed 20° below the occlusal
plane produced a translation of the
maxillary complex, indicated by a typical
circular fringe pattern on the holographic
plate

• Holberg AO 2007 examined the strain in the
sutures of the midface and the cranial base
with maxillary protraction therapy using a
finite elements model
• The measured strains were on average
about hundredfold lower than the Frost
thresholds (2000 strain). So it does not
seem probable that these strains suffice to
stimulate any additional bone growth.
• The good clinical efficacy of maxillary
protraction therapy is apparently based, for
the most part, on dental effects, while its
skeletal effects still remain doubtful.

Skeletal effects
• The orthopedic force of the face mask
stimulates cellular activity in
circummaxillary sutures and maxillary
tubercula, and this facilitates maxillary
forward displacement.
Effects on Maxilla
• Sung & Baik AJODO 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

• Maxillary length increase more in the
protraction group, could be caused by
more bone apposition occurring in the
posterior portion of maxilla, indicating an
orthopedic effect of maxillary protraction
• The significant increase in Co-A, NV-A,
SV-ANS, SV-PNS was found


Forward movement of Maxilla
• Many studies have confirmed a true
skeletal effect resulting from treatment
with face mask
• Increase in SNA angle, as much as
+3.71°, Increase in nasion to A-point, as
much as +3.30mm and increase in maxilla
to cranial base, 3.39 mm (Kapust AJODO
1998) and forward movement of ANS of
2mm have been reported

Vertical movement of maxilla
• Many authors have observed
counterclockwise rotation of the palatal plane
• But this could be affected by many factors,
including site of force application, direction of
elastic traction, and patients’ facial patterns
• Other vertical effects included a significant
change in the ANS-menton distance (+3.80
mm), which represented a 1.39% increase in
the lower face height

Effects on mandible
• Downward and backward movement of the
chin (SNB angle, -1.23°; nasion-Pog point,
-2.59 mm; B-point, -2.15 mm)
• Mandibular rotation might be due to a
combination of vertical maxillary
movement and eruption of the maxillary
molars, and a distal or retraction force on
the chin.

• About 67% of the improvement in the
intermaxillary relationship during treatment
was due to maxillary forward growth and the
remainder was due to the inhibition of
mandibular forward growth related to
mandibular backward rotation.
• Silva et al AJODO 1998 suggested that the
ratio of maxillary anterior displacement to
mandibular retroposition was almost 1:1,
• Decrease in the maxillo mandibular
difference [(Co-Gn) – (Co-A)] was also found

Effect of facemask on midface
• Nartallo-Turley AO 1998 showed
significant anterior movement of orbitale
(2.0 mm) and the key ridge (1.1 mm) in a
group of patients aged 3.9 to 10.8 years.
• Conversely, in patients with a mean age of
8.9 years, Kulbersh et al AJODO 1998
found no significant changes in the
position of orbitale because of maxillary
protraction.

Effect on upper airway
dimension
• Maxillary protraction
caused the upper
airway dimensions to
increase in patients
with a retrusive
maxilla. (Hiyama AO
2002 and Oktay AO
2008)

Airway width


Airway area

Soft tissue changes
• Various soft tissue changes combined to improve
the Class III profile.
• Forward movement of the upper lip and slight
inhibition of anterior migration of the lower lip,
coupled with soft tissue pogonion moving back and
menton moving down, contributed to the profile
becoming more convex.
• The effect of the treatment was found to be more
marked on the upper lip area. (Kilicoglu AJODO
1998)
• In addition, significant forward repositioning of
pronasale and subnasale.

Dental changes
• Orthodontic effects included forward and
downward movement of the maxillary
dentition
• Superimposition on the maxillae confirmed
that the maxillary molar moved forward and
the upper and lower incisors demonstrated
an incline plane effect where the upper
incisor moved forward and the lower incisor
moved back
• Achievement of normal overjet and overbite

Long term effects
• Over the long term, there was a slightly
greater increase in midfacial length (1.6 mm)
in the treatment group than in the controls
• The overall increase in mandibular length
was 2.4 mm less in the treated group than in
the controls
• The change in the Wits appraisal was
substantial between groups (6.1 mm), with an
improvement in the intermaxillary relationship
in the treated group (3.4 mm); it worsened
(2.7 mm) in the untreated controls

• During the posttreatment period that
includes the pubertal growth spurt,
craniofacial growth in RME/FM patients is
similar to that of untreated Class III
controls.
• Aggressive over-correction of the Class III
skeletal malocclusion, even toward a
Class II occlusal relationship, appears to
be advisable, with the establishment of
positive overbite and overjet relationships
essential to the long-term stability of the
treatment outcome. (Westwood AJODO
2003)

Wells, Sarver, Proffit AO 2006
Indicators of possible
failure
• Decreased posterior
vertical facial height
as indicated by the
vertical position of
both PNS and Go,
mandibular length,
and overbite.

Rapid maxillary expansion
• There is some evidence in the literature
that maxillary expansion alone can be
beneficial in the treatment of certain types
of Class III malocclusion, particularly
borderline malocclusions.
• Oppenheim was one of the first to observe
this phenomenon, and Haas (AJO 1970)
has reported that maxillary expansion can
produce a slightly forward movement of
the maxilla. www.indiandentalacademy.com

• The maxilla articulates with 9 other bones.
• 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.
• To disrupt the maxillary sutural system,
rapid palatal expansion for 8 to 10 days
has been recommended for patients with
no deficiency in the transverse dimension
(Baccetti AJODO 1998)

• Some perceived benefits that are
associated with rapid maxillary expansion
in conjunction with maxillary protraction
therapy in treating skeletal Class III
patients are
– Transverse expansion to correct crossbites
often associated with class III malocclusions,
– Increase in arch length
– Splinting of the maxillary dentition against
forward movement and anterior constriction
during protraction therapy, backward and
– Downward rotation of the mandible

• Baik AJODO 1995 compared 47 patients
treated with facemasks and rapid palatal
expansion with 13 patients treated with
facemasks and labiolingual removable
appliances and found significantly greater
forward movement of Point A in the
expansion group.
• Similar results were obtained in an Finite
Elelment Study by Pawan Gautham
(AJODO In Press)

• Lee AJODO 1997 with testing different
force variables, showed a protraction of
the maxilla with palatal expansion was
more effective in producing translation of
the maxilla than was protraction without
palatal expansion
• 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.

• Tortop AJODO 2007 showed both face
mask with and without expansion were
effective in the dental and skeletal therapy
of patients with Class III malocclusions.
• With the acrylic splint of the bonded
expansion appliance, the eruption of the
maxillary molar seemed to be less
compared with the removable intraoral
appliance

• Vaughn AJODO 2005 conducted a
controlled randomized clinical trial to
quantify the effects of maxillary protraction
with or without palatal expansion and
found no significant differences between
expansion and nonexpansion groups in
any measured variable.
• They also found no statistically significant
differences in overall treatment time or in
the time it took to achieve anterior
crossbite correction.

• These authors suggest that, in the
absence of objective reasons for
expansion such as maxillary width or
space deficiencies, expansion does not
aid the correction of Class III
malocclusions with facemask therapy.


Treatment timing
• In the assessment of overall efficiency for
face mask, an important variable is the
issue of optimal timing to start orthopedic
treatment in the growing patient.
• The Optimal time to intervene in a Class III
malocclusion seems to be when the
maxillary incisors erupt.


• Treating at such an early age is reported
to remove factors that inhibit growth and
development, such as an anterior
crossbite that limits normal alveolar bone
growth of the maxilla and thus allows a
more favorable environment for
dentofacial growth.
• Biologically, the circummaxillary sutures
are smooth and broad before age 8 and
become more heavily interdigitated around
puberty.

• Takada et al EJO 1993 have reported that
face mask treatment is most effective in
prepubertal patients (mean age, 7.8 years)
and pubertal patients (mean age, 10.3 years)
and becomes less effective after late puberty
• Baccetti et al and Kapust et al AJODO 1998
have recommended an even earlier age to
start the treatment, that is, the former have
reported that an effective outcome was
achieved in the group whose average age
was 6.9 years of age, and the latter in the
group ranging www.indiandentalacademy.com
from 4 to 7 years of age

• Other studies, however, have found that
patient age had little influence on
treatment effect.
• Merwin et al AJODO 1997 reported that
similar therapeutic responses were
obtained when maxillary protraction began
either before or after 8 years of age.
• Sung and Baik AJODO 1998 observed no
statistical skeletal differences among
treated patients aged 7 to 12 years

• In a controlled clinical trial, Franchi AJODO
2004 it was shown that significant maxillary
advancement could be achieved
orthopedically only by treating Class III
patients during the deciduous or early
mixed-dentition phases.
• Cha AO 2003 investigated the skeletal and
dentoalveolar changes contributing to overjet
and molar correction of 3 developmental
stages and found decreased maxillary
skeletal advancement (60%) with increased
dentoalveolar effect (40%) in subjects past
the pubertal growth peak.

Turpin AO 1983 guidelines to decide when
to intercept a Class III malocclusion.
Positive factors

Negative factors

Convergent facial type

Divergent facial type

AP functional shift

No AP shift

Symmetrical condylar growth

Asymmetrical growth

Young with growth remaining

Growth completed

Mild skeletal disharmony ANB <–2

Severe skeletal disharmony ANB >–2

Good cooperation expected

Poor cooperation expected

No familial prognatism

Familial pattern established

Good facial esthetics

Poor facial esthetics

Designs of maxillary protractor
appliances
• Delaire mask was
popularized to protract
the maxilla in 1978.
• In this appliance
design, extraoral
anchorage regions
were the chin and
forehead.

• The protraction
elastics were
attached between
the anterior hooks
(facing the distal
side of the lateral
incisors) soldered
on the intraoral arch,
with the hooks on
the prelabial arch of
the mask placed at
the level of the labial
commissural line.

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

Nanda 1980 - Modified
Protraction Headgear
• Combination of headgear
with U- bend made on the
inner bow to passively fit into
the molar tube from distal
• It produced a more
controlled movement acting
along the center of
resistance of the maxilla
producing a more
orthopaedic effect.

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.
• More esthetic than other
protraction devices, and has
unilateral capabilities
• The chief disadvantage is that
it must be carefully adjusted to
fit comfortably behind the ears.

• It is impossible to stabilize the force system
in reverse pull headgear, which takes
anchorage from the chin, because the
movement of the mandible does not allow to
apply a consistent force.
• Also another concern is the uncertain effect
of maxillary orthopedic forces on the TMJ
and on mandibular growth.
• Grummons claimed that reverse headgears
might have harmful effects on the TMJ.

Suborbital Protraction
Appliance by Grummons
• Redesigned face mask 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.
• The two zygomatic areas offer more surface
contact than the chin or other points and thus
permit the application of similar force magnitudes.
• Disadvantage : esthetic objection to midfacial
support

Alcan, Keles AJODO 2000


Lever-Hook Edgewise Arch
for Midfacial Protraction
Vesco 1999
• 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.

• Labial shields attached to the lever hooks
make the appliance more comfortable and
act as an upper lip bumper.
• Combined with the upward force
expressed by the posterior segments of
the archwire, the anterior traction also
helps avoid undesirable counterclockwise
maxillary rotation.


Advantages of facemask therapy with
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 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 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- Altug JCO
2005
Consists of 4 parts
• Maxillary expander
• Mandibular plate – An
acrylic plate covering the
entire mandibular arch.
• Chin cup – A hook is
attached on the each side of
acrylic chin cup for
application of www.indiandentalacademy.com
cervical forces

• 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.

The Functional orthopedic
magnetic appliance (FOMA) III
• Vardimon AJODO 1990 developed an
intraoral intermaxillary appliance for the
treatment of Class III malocclusions that
exhibit midface sagittal deficiency with or
without mandibular excess
• It consists of upper and lower acrylic
plates with a permanent magnet
incorporated into each plate.
• The upper magnet is linked to a retraction
screw

• The upper magnet is
retracted periodically
(e.g., monthly) to
stimulate maxillary
advancement and
mandibular retardation.


• 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

• Midfacial protraction did occur with a
horizontal maxillary displacement and an
anterosuperior premaxillary rotation.
• 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.

• Vardimon et al (AJODO 1994), revealed the
following data:
• Maxilla:
– The target area of the protractive force was found
to be localized in the pterygomaxillary fissure.
– Three dimensionally, the separation of the sutures
at the pterygomaxillary fissure 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,

Darendeliler et al (JCO 1993)
• Reported cases treated with a combined
Maxilary Advancing Device (MAD) III and
Maxillary Expansion Device (MED) 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.

• 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.
• Then patient wore the MAD
III for another 11 months,
until a cusp-to-cusp
deciduous molar and canine
relationship was obtained.

• Tuncer AO 2005 determined the effects of
a magnetic appliance in functional Class III
patients.
• The significant findings showed a posterior
rotation of the mandible (mean 2.1°),
increased overjet (4.8 mm), decreased
overbite (-3.7mm), protrusion of the upper
incisors (6.2°), retrusion in the lower
incisors (-0.6°), reduced SNB angle (21.8°)
• The results of this study indicate that the
primary effect of magnetic appliance was
the increase in the posterior rotation of the
mandible.

Double plate appliance
• 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 (AJODO 2004) 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.
•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 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.

• Because elastics provide the force between
the two parts of the appliance, placement of
the hooks for elastic attachment is critical to
proper performance.
• The elastic 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 www.indiandentalacademy.com
separating.

Tanden Traction Bow
Appliance- Chun 1999
• Appliance design
• Comprises an upper splint, a lower splint, and
a traction bow.
• The upper splint which can serve the same
function as a rapid maxillary expander,
• It covers the palatal and the occlusal surfaces
and portion of the buccal surfaces of the
maxillary teeth providing adequate retention to
overcome the maxillary protraction force of as
such as 400-500 g/side

• 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 Uloop 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 www.indiandentalacademy.com
direction of force.

• The mandibular tubes should
be located as posteriorly as
possible.
• 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
• After the crossbite is
overcorrected, the two splints
are fused into a monobloc
and used as a retainer.

Rigid anchorage for face mask
therapy
• The necessity to use teeth as anchorage
results in stimulation of the periodontal
membrane and dissipation of the
protraction force transmitted to the
circummaxillary sutures
• Clinical studies in humans have
consistently shown changes are a
combination of the movement of teeth and
orthopedic displacement of the maxilla

• The usual effects of conventional
facemask therapy on the dentition include
extrusion and mesial movement of the
maxillary molars, proclination of the
maxillary incisors, and retroclination of the
mandibular incisors
• These concerns show that the periodontal
ligament area of the dentition should be
bypassed with facemask therapy in
patients who require true skeletal
correction.

Intentional Ankylosis
• Intentional extraction and subsequent
replantation of teeth have also
consistently caused ankylosis in
experimental animals. Hammer 1970
• Filho JCO 2000 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.

Advantages
– Replanted deciduous canines are autogenous
implants that will undergo root resorption
without the need to be extracted after maxillary
protraction is completed.
– Risk to the patient is minimal, compared to
osseointegrated titanium implants.
– With deciduous teeth, intentional ankylosis
simply encourages the genetically programmed
process known as replacement resorption.

However, it limits the time available for
treatment because the anchored teeth
inevitably resorb as their permanent
successors erupt.

Distraction Osteogenesis To
Advance The Maxilla
• In cleft patients considerable advancement
of the dentomaxillary complex is often
required because of its hypoplastic
development
• Distraction, after a complete Le Fort I
osteotomy, has been found effective in
treating these patients
• In a Le Fort I osteotomy, the maxilla is
freed of all bony attachments, though it is
still supportedwww.indiandentalacademy.com
by the soft tissues

Biomechanical considerations in
distraction – Figueroa AJODO
1999
• Line of action and point of application of
any protractive force(s) used during
distraction osteogenesis must be
considered relative to its center of mass.
• This is in contrast to the nonsurgically
separated dentomaxillary complex, which
is a constrained body, and therefore the
application of protractive force(s) must be
considered relative to its center of
resistance.

• If linear protraction of the
osteotomized dentomaxillary
complex is desired parallel
to the functional occlusal
plane, the line of action of
the distraction force(s) would
pass through the center of
mass (in the sagittal view)
and be parallel to the
functional occlusal plane.

• The average predistraction ANB was -1.2
and post distraction was 7.3 with an
increase of 8.6 (Figueroa AJODO 1999)
• 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 AJODO 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/side across the
zygomaticomaxillary suture in Maca
nemestrina monkeys and resulted in an
anterior displacement of 8mm.

• Singer et al AO 2000 applied 400g of force
to Osseointegrated 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. www.indiandentalacademy.com

Titanium lag screw
• Encar AJODO 2003 reported the
treatment of a 10 year old girl with Class III
skeletal relationship with maxillary
hypoplasia and severe oligodontia.
• There is a tendency for the
Osseointegrated implant to submerge into
the alveolus because of the residual
dentoalveolar development in a growing
person, in whom usually maxillary
protraction is done

• A palatal bar,
soldered to the molar
and incisor bands
was extended distally
on the right side to
the edentulous area,
and a helix was
formed at the end of
the bar through which
the titanium lag screw
was inserted in the
bony alveolus.

• Three weeks
later, 800 g of
orthodontic force
was applied.
• Condylion-A,
from 68°
increased to 80 °
; ANB increased
from -3° to +2°
and ANS region
displaced 3mm
anteriorly

Onplants for rigid anchorage
• An onplant is a relatively flat, disk-shaped
fixture with a textured, hydroxyapatitecoated surface for integration with bone.
• 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.
• Hong et al AO 2005 report the use of an
onplant as absolute anchorage for
orthopedic facemask treatment

• A 7.7-mm hexagonal
onplant was surgically
placed on the flat part of the
palatal bone near the
maxillary molar region.
• A Petit facemask 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

• This was noted by
an increase in
fullness of the
infraorbital region
and the correction
of the skeletal
discrepancy
• ANB from 2.2degrees to
3.7degrees, Wits
from -6.1mm to 1.0 mm

Miniplates as rigid skeletal
anchors
• Kiricelli AJODO 2008 reported six
consecutively treated patients with
facemask therapy and miniplates.
• Miniplates were placed in the lateral nasal
wall of the maxilla, independent of the
dentition, and applied the orthopedic
forces directly to the intraoral extensions
of the miniplate.

• Lateral nasal wall of
the maxilla is the
most appropriate
location to achieve
fullness of the
nasobuccal folds,
the infraorbital
region, and,
consequently, the
soft-tissue profile.

• The mean anterior
movement of orbitale was
3.3 mm (range, 2.2-5.0
mm).
• Authors suggest that
application of orthopedic
forces directly to the
lateral nasal wall of the
maxilla with miniplate
anchorage might offer a
treatment choice to effect
maxillary retrusion at the
Le Fort II level.

Kircelli AJODO 2006


Conclusion
• Although our knowledge about Class III
treatment with facemask and maxillary
expansion has increased substantially in
recent years, much remains to be learned.
• Although earlier intervention might provide
a better orthopedic response, treatment in
the late mixed or early permanent dentition
can produce positive results.
• Both early and late orthodontic treatment
are associated with compromises that
should be anticipated by the practitioner.

References
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