Orthopedic protraction of the maxilla part 1

Faculty of Dentistry
Mansoura Egypt
Dr Maher Fouda
Professor of orthodontics
Orthopedic protraction of
the maxilla in Class III cases
.

Patients with skeletal Class III malocclusion often present
with a concave facial profile, a retrusive nasomaxillary area,
and a prominent lower third of the face. The lower lip is
often protruded relative to the upper lip.

It is important to note that the profile and occlusion of Class
III patients usually becomes worse with no treatment because
the lack of horizontal maxillary growth and excess mandibular
growth often lead to compensated incisal changes and
overclosure of the mandible

Treatment with maxillary expansion and protraction with
face mask can straighten the skeletal and soft tissue facial
profiles and improve the posture of the lips.

Both anteroposterior and vertical maxillary deficiency can
contribute to Class III malocclusion. If the maxilla is small or
positioned posteriorly, the effect is direct. If it does not grow
vertically, the mandible rotates upward and forward,
producing an appearance of mandibular prognathism that
may be due more to the position of the mandible than its size
.
Class III malocclusion

ONE SHOULD FOLLOW
THE PHILOSOPHY OF…..
SELECTING AN
APPLIANCE FOR THE
PATIENT NOT A PATIENT
FOR APPLIANCE .

Delaire orthodontic face-mask or reverse pull
headgear.
Petit facemask
TYPES OF FACE MASKS

Delaire face mask Banded Haas expander
Face mask could be connected to a banded Haas rapid
palatal expander

Face mask could be connected to a bonded acrylic splint rapid
maxillary expander with hooks in the maxillary canine region

Face mask could be also connected to double
arch soldered to bands on the upper first
permanent molars.

Petit face mask connected to Coffin spring

In the primary dentition, it is advisable to use a cemented acrylic occlusal bite
block or a removable acrylic plate with occlusal coverage). In patients with the
mixed dentition and early permanent dentition, a removable acrylic plate should
be used, supported by bands with headgear tubes on the molars or a rigid
archwire with a palatal arch. Probably the best stabilization in patients with
maxillary first molars is provided by a fixed rapid palatal expansion (RPE) device .
A Hyrax type of nonbonded device, as bonded RPEs interfere with the primary
exfoliating teeth or teeth in the eruptive phase. Studies have also indicated that a
simultaneous sutural expansion with an RPE at the start of protraction headgear
treatment facilitates the anterior movement of the maxilla

Occlusal view of a
removable intraoral
stabilization appliance.
The acrylic plate has a
clasp that fits on a
molar tube of a
cemented band. This
plate must be worn
when the protraction
appliance is in use.
Occlusal view of a rapid
palatal expansion (RPE)
device used as a
stabilization appliance.
This is an ideal
stabilization device if
the first molars are
fully erupted
Occlusal view of a
bonded rapid palatal
expansion (RPE)
device. In mixed
dentition patients its
use may interfere
with the exfoliation
of primary teeth and
eruption of
permanent teeth.

To resist tooth movement as much as possible, the maxillary teeth
should be splinted together as a single unit. The maxillary appliance can
be banded, bonded, or removable .

removable intraoral appliance and heavy elastics . Adams' clasps and the covered
occlusal surface in the intraoral appliance provided retention for the elastics .
Adams' clasps were placed on the primary molars before eruption of the first
molar, and on the permanent first molar in the case of complete eruption of the
maxillary first molar. Hooks for the elastics were placed between the primary
canine and the primary first molar.
Combination of Facemask-Removable Appliance
Treatment could be carried out using a Delaire-type face
mask with

To prevent dislodgement, the appliances are
readjusted by putting acrylic in the area of both upper
buccal segments when required.

Treatment could be carried out using a petite-type
face
mask with upper removable appliance with
midpalatal expansion screw

The removable appliance resulted in the protrusion of upper incisors, forward
movement of the maxilla and distal movement of the upper molars. In the
vertical dimension, the anterior facial height increased and overbite
decreased. In this group overjet was increased .
Comparative Evaluation of a Combination of Facemask-Removable Appliance and Removable Appliance Alone for Antero-Posterior
Expansion in 8 - 10-Year-Old Cl III Children with Maxillary Deficiency
•Iranian Journal of Orthodontics: March 2018, 13 (1);
Anterior - Posterior Expansion Appliance: in
This Appliance, Z Hooks Distal
to Upper Canines Were Considered and 2
Screws Were Used in Y-Plate

A removable plastic splint that covers the occlusal surfaces
of the teeth often is satisfactory. Multiple clasps combined
with plastic that extends over the incisal edges usually
provide adequate retention. If necessary, the splint can be
bonded in place, but this causes hygiene problems and
should be avoided if possible for long-term use. It also is
possible to use a heavy wire splint that incorporates a
lingual arch (for arch expansion) cemented to the primary
and molars and whatever permanent teeth are available .

A maxillary removable splint is sometimes used to make the upper arch a single
unit for maxillary protraction. A, The splint incorporates hooks in the canine-
premolar region for attachment of elastics and should cover the anterior and
posterior teeth and occlusal surfaces for best retention (B). Note that the hooks
extend gingivally, so that the line of force comes closer to the center of resistance
of the maxilla. Multiple clasps also aid in retention. If necessary, the splint can be
bonded in place, but this causes hygiene problems and should be avoided if
possible for long-term use. C and D, A banded expander or wire splint also can be
used for delivery of protraction force. It consists of bands on primary and
permanent molars or just permanent molars connected by a palatal wire for
expansion and hooks on the facial for facemask attachments.

The effects of facemask and reverse chin cup on maxillary deficient patients
Journal of Orthodontics, Vol. 39, 2012, 95–101
The upper removable appliance could have two Adams clasps on the
permanent first molars, two C clasps on the primary canines, and two
C clasps on the permanent central incisors .
If necessary, the number of C clasps and Adams clasps could be increased
for anchorage reinforcement. Two hooks were mounted on the right and
left buccal segments..

Two orthodontic latex elastics (5/160, medium size)
connected the hooks of the upper removable appliance to
the horizontal crossbar of the face mask in order to
deliver approximately 500 g of force . The patients were
instructed to wear the appliance full-time except for
eating, contact sports and tooth brushing

Petit type of face mask : this is also a modified type of Delaire face
mask. It consist 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
Bonded expander
Face mask could be connected to a bonded rapid palatal expander

This rail-style facemask provides more comfort during sleeping and is
less difficult to adjust. It also can be adjusted to accommodate some
vertical mandibular movement. Both types can lead to skin irritation
caused by the plastic forehead and chin pads. These occasionally require
relining with an adhesive-backed fabric lining for an ideal fit or to
reduce soft tissue irritation.
Petit facemask Bonded expander

In case of cleft palate ;the expander is often combined
with maxillary protraction using a reverse-pull
headgear to address the maxillary deficiency and
allow for 3–4 mm of overjet if possible. Light elastics
(6.5 oz, 180 g) are used for 1–2 weeks followed by the
heavier elastics (14 oz, 400 g), which provides
orthopedic force.
Face mask could be connected to a 3 way palatal expander

If forward traction is applied at an early age, it is possible to produce
forward displacement of the jaw rather than just displacement of teeth
When facemask treatment is discontinued, there is usually a rebound of
mandibular growth similar to what occurred for this patient. Whether
surgery eventually will be required will be determined by mandibular growth
during and after adolescence .

The elastics of facemask of the protraction appliance are oriented in a
downward and forward direction at an angle of approximately 30° relative
to the occlusal plane. The protraction appliance has hooks in the oral
cavity. The oral appliance is of rapid palate expansion.
Face mask could be connected to upper removable appliance
with palatal screw

For most young children, a facemask is as acceptable as conventional headgear.
Contouring an adjustable facemask for a comfortable fit on the forehead is not
difficult for most children. There are a variety of designs . Approximately 350 to
450 gm of force per side is applied for 12 to 14 hours per day. Most children with
maxillary deficiency are deficient vertically, as well as anteroposteriorly, which
means that a slight downward direction of elastic traction between the intraoral
attachment and the facemask frame often is desirable, and some downward-
backward mandibular rotation improves the jaw relationship. A downward pull
would be contraindicated if lower face height was already large

The technique requires strict patient compliance as the facemask must
be worn 10–12 hours/day for at least 6 months. The effects of facemask
treatment include: forward maxillary movement, proclination of the
maxillary incisors, downwards and backwards mandibular rotation and
retroclination of the mandibular incisors.

Fully made of stainless steel and non toxic acrylic, it can
be dimensionally adjustable to fulfill each individual
requirement with vertical or horizontal adjustment. All
anchorage points are made with allen-screws.
Delaire face mask

The replaceable chin and forehead pads are made of natural leather
for better patient comfort. Face masks with zygomatic holds feature
an adjustable blue strap band. Universal Adjustable Face Masks can
be dimensionally adjusted to fulfill each individual requirement with
both a horizontal and vertical adjustment.

This Delaire-type facemask offers good stability when used for
maxillary protraction. It is rather bulky and can cause problems
with sleeping and wearing eyeglasses. With even modest facial
asymmetry, it can appear to be ill-fitted on the face. Note the
downward and forward direction of the pull of the elastics..
Face mask could be connected to a banded hyrex rapid
palatal expander
Banded hyrax expander

After Delairs demonstration that a facemask attached to a
maxillary splint could move the maxilla forward by inducing
growth at the maxillary sutures, but only if it was done at an
early age, this approach to maxillary deficiency became
popular in the late twentieth century .
Face mask could be connected to a double palatal and labial
arches

Clinical experience indicates that some children will prefer
one type over the other, and changing to the other type of
facemask can improve cooperation if the child complains .
Petit facemask

The facemask is most effective in the treatment of mild to
moderate skeletal Class III malocclusions with a retrusive maxilla
and a hypodivergent growth pattern.
Petit facemaskBonded hyrax expander
INDICATIONS

If there is maxillary retrusion with a deep overbite
and the patient is motivated, treatment can be
undertaken using a facemask .

Class III incisor relationships resulting from a
premature contact and subsequent mandibular shift
should also be treated early due to the association
between childhood crossbites and adult
temporomandibular joint dysfunction.

Frequently, the primary canines are the prematurely
contacting teeth requiring cuspal grinding or
extraction .

For most young children, a facemask is as well-accepted as
conventional headgear. Contouring an adjustable facemask for a
comfortable fit on the forehead is not difficult for most children.
There are a variety of designs that accommodate mandibular
movement and eyeglasses if necessary
Intraoral and extraoral photographs of mini maxillary
protractor

To avoid the instability of the expansion appliance during
attaching and removal of the elastics the hooks of the expander
are bonded to the neighbouring teeth by composite material .

For children with anteroposterior and vertical maxillary deficiency,
the preferred treatment is to move the maxilla into a more
anterior and inferior position, which also increases its size as bone
is added at the posterior and superior sutures.
Mode of action

Although the goal of facemask therapy is forward displacement of the
maxilla, both downward-backward rotation of the mandible, backward
displacement of the mandibular teeth, and forward displacement of the
maxillary teeth typically occur in response to this type of treatment .
Mode of action

When force is applied to the teeth for transmission to the sutures,
tooth movement in addition to skeletal change is inevitable.
Facemask treatment is most suited for children with minor-to-
moderate skeletal problems, so that the teeth are within several
millimeters of each other when they have the correct axial
inclination.
Mode of action

Often mandibular rotation and displacement of maxillary
teeth- not forward movement of the maxilla-are the
major components of the treatment result
The force vectors that minimize tilting of the palatal
plan

Moving the maxilla down as well as forward rotates the
mandible downward and backward, which contributes to
correction of a skeletal Class III relationship. A downward pull
would be contraindicated, however, if lower face height were
already large.

To facilitate Class III correction, the mesial and vertical
eruption of the maxillary molar can be emphasized so that
the occlusal plane rotates down posteriorly. This facilitates
normal interdigitation of the molars in a Class III patient.

The age of the patient is a critical variable. It is easier and more
effective to move the maxilla forward at younger ages. Although
some recent reports indicate that anteroposterior changes can be
produced up to the beginning of adolescence .

The chance of true skeletal change appears to decline
beyond age 8, and the chance of clinical success begins to
decline at age 10 to 11.

The French results suggested that successful forward repositioning of the
maxilla can be accomplished before age 8, but after that, orthodontic
tooth movement began to overwhelm skeletal change, and more recent
studies comparing untreated Class III children to those treated with
maxillary protrusion have confirmed greater skeletal change at earlier
ages.

Long-term follow-up suggests that for a good chance of
success, treatment should begin by age 10 at the latest.
The chance of successful forward movement is
essentially zero by the time sexual maturity is achieved.

Protraction face-mask is used to advance the maxilla. The forces
applied in this technique are in the region of 400 g per side and a
cooperative patient is necessary to achieve the 14 hours per day
wear required .
Petit facemask Banded hyrax expander

Rapid maxillary expansion in conjunction with
protraction face-mask therapy, however, more
recent work has suggested that this additional
appliance is not essential to success.

A protraction facemask is optimally worn on a full-time
basis (about 20 hours a day, except during meals) for
about 6 to 8 months, then it can be worn on a nighttime
basis only for additional period of time.
Dentoskeletal effects and facial profile changes in Class III patient
treated with protraction facemask appliance: a case report
Journal of the World Federation of Orthodontists 1
(2012) e73ee77

Young patients (5 to 9 years old) can usually follow this regimen. In
older patients, full time wear may not be feasible. They should wear
the appliance at all times except while attending school or
participating in contact sports. Less than full time wear can result in
longer treatment time.

As with transverse expansion, it is easier and more effective to
move the maxilla forward at younger ages, although recent
reports indicate that some a-p changes can be produced into
early adolescence. When force is applied to the teeth for
transmission to the sutures, tooth movement in addition to
skeletal change is inevitable .

Approximately 12 ounces of force per side is applied for 14
hours per day. Most children with maxillary deficiency are
deficient vertically as well as anteroposteriorly, which means
that a slight downward direction of elastic traction between
the intraoral attachment and the facemask frame usually is
desirable.

Generally, it is better to defer maxillary protraction until the
permanent first molars have erupted and can be incorporated into the
anchorage unit. Following palatal expansion or in conjunction with it, a
facemask that obtains anchorage from the forehead and chin is used
to exert a forward force on the maxilla via elastics that attach to a
maxillary appliance .
FACE MASK (REVERSE HEADGEAR)

Barrel Sagittal
The Barrel Sagittal is a fixed sagittal used to develop the
premaxilla. To activate, the patient turns both gears towards
the midline until the next hole is easily accessible.

Lingual mechanics and freedom to place brackets from
molar to molar make the Barrel Sagittal our most popular
sagittal appliance. Note: You must bond the occlusal rests in
order to achieve the anchorage to develop the premaxilla
Barrel Sagittal

Jet 3 Way (A)
The Jet Sagittal is a fixed sagittal used to develop the
premaxilla. A midline gear can be added to expand
transversely. The Jet Sagittal is popular with doctors who
have uncooperative patients. The doctor activates the
appliance by loosening the Jet screw and sliding it mesial to
compress the NiTi coil spring

Lingual mechanics and freedom to place brackets from
molar to molar make the Jet Sagittal a popular sagittal
appliance. Note: You must bond the occlusal rests in order
to achieve the anchorage to develop the premaxilla.

The protraction headgear force is applied via elastics to teeth or
other devices supported by teeth and/or the palate. The primary
aim is to transmit the force to the midface sutural interfaces. To
achieve this, it is important to stabilize the maxilla as one unit . In
the primary dentition, it is advisable to use a cemented acrylic
occlusal bite block or a removable acrylic plate with occlusal
coverage .

This patient was treated with a Petit face mask to move forward
the maxilla and to restrict the mandibular growth, in conjunction
with a intraoral bonded maxillary acrylic appliance with bite blocks
("McNamara Appliance") for RME . The expansion screw was
activated 2 turns every day for two weeks. Two metallic hooks
were positioned bilaterally between the primary canine and first
molar, to engage the elastics.

The face mask was placed after one week of RME. The appliance was
carefully adjusted to patient's forehead and chin, and extraoral 5/16
inch (13 oz) elastics were placed for one week (in the second week they
were subtituted by 14 oz elastics), 30° downward in relation to the
occlusal plane, to the face mask attachment framework. The orthopedic
force exerted by the elastics was 400 g per side, measured by a Dontrix
gauge. The patient was instructed to use the appliance for a minimum
of 12 to 14 hours daily, and the expansion screw was activated only
twice a day.

Modified Haas-type expander
When modified Haastype expander is used , it will follow a protocol
comprising one full turn on the first day and a half turn in the
subsequent days until overcorrection of the case. In order to facilitate
intraoral elastic placement, the hooks of the expander were positioned
between the canines and first molars, in a horizontal direction parallel
to the occlusal plane.

After screw fixation, a Petit face mask is placed with initial force of
350 grams , ultimately reaching 500 grams on each side. The
patients are instructed to wear the mask for at least 14 hours/day.
The mean treatment time with the face mask is 11 months ± 3
months (ranging from 6 to 18 months).

In cases in which there is no transverse narrowing of the maxilla, a
protocol for activating and deactivating the disjunctor screw is
recommended to dismantle the circummaxillary sutures. Activating
1mm / day for 1 week, and then deactivating 1mm / day during the
following week, this procedure can be repeated for 7-9 weeks by
disarticulating the maxilla in this way without producing excessive
enlargement, and facilitating maxillary complex movement.

On the other hand Vaughn GA. & cols. they report that
there are no differences in the use or not of this
combination in cases in which there is no transverse
narrowing in the maxilla.
Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxillary protraction therapy with or without rapid palatal expansion: A
prospective, randomized clinical trial. American Journal of Orthodontics and Dentofacial Orthopedics. 2005; 128 (3): 299-309.

If the maxilla is narrow, palatal expansion is quite compatible
with maxillary protraction and the expansion device is an
effective splint; there is no reason, however, to expand the
maxilla just to improve the protraction.
With the splint over the maxillary teeth and forward pull
from the facemask, the hooks on the splint should be
elevated. Even so, the line of force is likely to be below the
center of resistance of the maxilla, so some downward
rotation of the posterior maxilla and opening of the bite
anteriorly can be anticipated.

Whatever the method of attachment, the appliance must have
hooks for attachment to the face mask that are located in the
canine-primary molar area above the occlusal plane. This
places the force vector nearer the center of resistance of the
maxilla and limits maxillary rotation .
Cemented modified reverse twin
block with hooks

The face mask is still being worn only at nights as retention,
to restrain the mandible growth. The intraoral McNamara
appliance was substituted by a removable fan-shaped maxillar
expander with occlusal blocks, which was activated three
times a week, for a wider anterior expansion. The child will be
closed monitored until all major facial growth is stopped.

Generally, it is better to defer maxillary protraction until the permanent
first molars and incisors have erupted. The molars can be included in
the anchorage unit and the inclination of the incisors can be controlled
to affect the overjet. Many clinicians use protraction with a facemask
following or simultaneously with palatal expansion, but a randomized
clinical trial has shown that simultaneous palatal expansion makes no
difference in the amount of anteroposterior
skeletal change
A, Protraction elastics are attached to
the intraoral anchorage appliance near
the maxillary canines region with a
downward and forward pull of 30
degrees to the occlusal plane. B, The
force vectors that minimize tilting of
the palatal plan

The skeletal effects are larger in patients younger than 10
years of age, and may be enhanced when rapid maxillary
expansionis used concurrently. It is controversial whether this
form of treatment leads to any long-term growth
enhancement.

Backward displacement of the mandibular teeth and forward
displacement of the maxillary teeth also typically occur in response
to this type of treatment . As children come closer to adolescence,
mandibular rotation and displacement of maxillary teeth—not
forward movement of the maxilla—are the major components of the
treatment result.

• An inadequate overbiteto maintain the corrected incisor
position. • Unfavourable growth in the AP and vertical skeletal
dimension. Unfavourable AP growth can result in a relapse of
overjet correction whereas unfavourable vertical growth can
result in a reduction of overbite
Stability of Class III correction Relapse of
Class III correction may be related to:

If headgear force compressing the maxillary sutures can inhibit
forward growth of the maxilla, reverse (forward-pull) headgear
separating the sutures should stimulate growth. Until Delaire and
coworkers in France showed that forward positioning of the maxilla
could be achieved with reverse headgear, if treatment was begun at
an early age, reverse pull headgear was remarkably unsuccessful in
producing anything but movement of the upper teeth .

Even in young patients, two side effects of treatment are almost inevitable
when reverse headgear that attaches to the teeth is used (Figure 7-20):
forward movement of maxillary teeth relative to the maxilla and
downward and backward rotation of the mandible. For this reason, in
addition to being quite young, the ideal patients for treatment with this
method would have both: •Normally positioned or retrusive, but not
protrusive, maxillary teeth •Normal or short, but not long, anterior facial
vertical dimensions
Forward traction against the maxilla typically has three
effects: (1) some forward movement of the maxilla, the
amount depending to a large extent on the patient's age; (2)
forward movement of the maxillary teeth relative to the
maxilla; and (3) downward and backward rotation of the
mandible because of the reciprocal force placed against the
chin

An obvious way to decrease the amount of tooth movement in face
mask treatment would be to place the traction force to skeletal
anchors in the maxilla . As with all applications of skeletal anchorage,
only preliminary reports with this technique are available as yet, but
already it is clear that skeletal anchorage can be used to help bring the
maxilla forward.

Orthopedic protraction of the maxilla part 1

Orthopedic protraction of the maxilla part 1

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Orthopedic protraction of the maxilla part 1

Similar to Orthopedic protraction of the maxilla part 1 (20)

More from MaherFouda1

More from MaherFouda1 (20)

Recently uploaded

Recently uploaded (20)

Orthopedic protraction of the maxilla part 1