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

PROTRACTION FACE
MASK THERAPY
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


1

Review of literature
 5 percent of the Caucasian population
 higher in the Scandinavian and Japanese
populations.
 Primates have been used as models in
the majority of the studies
 Janzen and Bluher, Bare, and Johol on
monkeys
 Petrovic, Oudet, and Gasson on rats
 Matsui on rabbits

2

 Kambara, Nanda, and Jackson, Kokich, and
Shapiro reported that the maxilla of monkeys
can be displaced anteriorly by using extraoral
forces
 Graber: the early attempts with the chin cup
were not successful because of incomplete
knowledge of mandibular and facial growth, its
use on nongrowing patients, and an
inadequate understanding of the forces
generated by the chin cup.

3

 Armstrong: chin cups on 100 adolescent
patients with mandibular prognathism
Thilander treated sixty patients with chin cups
for 1 to 6 years
 Graber, Chung, and Aoba : chin cups for 12 to
14 hours each day with a force of 1.5 to 2
pounds on each side
 Several clinical studies in the past have noted
that treatment of patients in skeletal Class III
should include protraction of the maxilla with or
without chin cups

4

 Kettle and Burhapp reported an appliance for
cleft lip and palate
 Nelson :football-type helmet
 Delaire, Verdon, and Floor have extensively
used a facial mask to protract the maxilla
 In 1944 Oppenheim believed that one could
not control the growth or anterior
displacement of mandible

5

 In 1960’s Delaire and others revived the
interest in using the fm for max protraction.
Petit later modified Delaire’s basic concept by
increasing the amt of force generated by the
appliance, thus decreasing overall treatment
time.
 In 1987 McNamara:use of a bonded expansion
appliance with acrylic occ coverage for max
protraction.
 Turley : fabricating customized fm

6

PROTRACTION FACE
MASK


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9

Diagnosis and
Treatment Planning
 Cephalometric values :often unreliable in
a young child
 Schulhof et al. : cephalometric indicators
 appropriate to base treatment decisions
on the patient’s facial profile, since an
important objective of treatment is to
optimize facial esthetics.

10

Facial Profile
 Overall facial profile
Evaluation
 Chin position
 Maxillary position


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 Mandibular repositioning


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Custom made pfm


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Palatal Expansion
 maxilla articulates with nine other bones
 palatal expansion “disarticulates” the
maxilla
 correction of the posterior crossbite
 splints the maxillary dentition


14

Maxillary Protraction
 Not only is Point A affected through
forward incisor movement, but the entire
maxilla is displaced anteriorly, with
significant effects as far posteriorly as the
zygomaticotemporal suture


15

Patient Compliance
 Patient compliance is the key to
successful orthopedic correction
 plaster cast for a broken arm
 Positive reinforcement
 At the appliance delivery appointment,
the child is given a time card
 Additional motivational techniques

16

Design and
construction of the
anchorage system
 Metallic banded palatal exp appliance
 Acrylic bonded palatal exp appliance


17

 Design of bonded maxillary occlusal
splint used in permanent dentition
 Wire extensions are placed on occlusal
surfaces of upper second molars
 to prevent extrusion during treatment.

18

 Design of bonded maxillary occlusal splint
used in early mixed dentition.
 First and second deciduous molars and first
permanent molars are usually incorporated in
the appliance.
 Facial mask hooks usually lie mesial to upper
first deciduous molar.

19

Skeletal effects of
max protraction
 Maxillary protraction does not always result in forward
movement of max and showed that with the same line of force
diff midfacial bones were displaced in diff direction depending
on the moments of force generated at the sutures.
 The cor of the max was found to be located at the distal
contracts of the max first molars on half the dist form the
functional occ plane to the inferior border of the orbit.
 Protraction of the max below the cor produces counter
clockwise rotation
 Hata and colleagues also found that protraction forces at the
level of max arch produced forward but counterclockwise
rotation of the maxilla unless a heavy downward vector of force
was applied.
20

Clinical response to
max protraction
 ant cross bites can be corrected with 3-4
months of max exp and protraction
 forward max movement 31%, backward
movement of mandible 21‘%, labial movement
of max incisors 28%, and lingual movement of
mand incisors20%.
 Anchorage loss was observed
 total facial height was increased by inferior
movement of the max and downward and
backward rotation of mandible

21

Variability in clinical
response
 Age
 Design of anchorage system
 Force level, direction, and point of
application
 Length of treatment time


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 Treatment indication for fm therapy
 Treatment timing for fm therapy


23

Retention
 There are conflicting opinions about the
stability of Class III orthopedic treatment.
 Delaire says that “in successful cases, the
facial skeleton is completely transformed. The
therapeutic action has permitted, and in fact
provoked, the establishment of a normal
equilibrium, without possibility of relapse.”
 In contrast, Cozzani cautions that “we cannot
consider a Class III malocclusion fully resolved
until facial growth has ended”.
 In anticipation of some relapse, it is
recommended for overcorrection of the overjet
 Post treatment stability

24

Protraction of the maxillofacial
complex - Mermigos, Full, and
Andreasen

 most difficult to treat as it is not limited to
dental discrepancies but is more often related
to an underlying skeletal problem.
Cephalometric analysis may indicate that
 1. SNA angle is significantly lower- greater
degree of maxillary retrusion
 2. Mandibular protrusion is greater
 3. The mean ANB angle is negative
 4. The gonial angle is more obtuse
 5. The mandibular plane angle is steeper than
normal
 6. Lower anterior face height is significantly
25
greater

1.A decrease in the mandibular plane
angle.
 2. A decrease in the gonial angle.
 3. A decrease in the SNB angle.
 4. A redirection in the downward vertical
growth of the midface


26

Extra oral traction and Class III
treatment - Cozzani
There are three important diagnostic principles
 First, it is particularly important to determine
whether the mandible, on closure, is in centric
relation or in a “convenient” anterior position
 second principle is that the nature of the
skeletal discrepancy must be defined
 Third, a malocclusion reflects the interplay of
many conditions that may be impossible to
evaluate singularly. One important variable is
the potential growth and development

27

 General treatment considerations
 start treatment as early as possible, even as
early as 4 years of age
 Early treatment does not necessarily mean
protracted treatment. It can be readily divided
into two stages.
 extractions may be contraindicated when
orthodontic treatment must be combined with
surgical treatment
 Class III elastics because they can also
extrude the mandibular incisors, and there is
frequently excessive vertical dentoalveolar
development in the incisor region.

28

 Summary
 In summary, extraoral appliances are
often useful in the treatment of Class III
malocclusion.
 In the examples cited, the Delaire
appliance is effective in protracting the
maxilla and/or maxillary dentition,
particularly in younger patients.
 Also, extraoral traction placed against the
lower segment by means of facial wires
can protract protrusive incisors while
29
preserving molar anchorage

An Orthopedic Approach to the
Treatment of Class III
Malocclusion in Young Patients
- JAMES A.
MCNAMARA

Pre treatment

Post treatment


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31

 Summary
 This patient demonstrated both skeletal
and dental adaptations during treatment.
The maxilla and the upper dentition
moved forward, while the mandible
rotated downward and backward, with
some lingual tipping of the lower incisor.
In addition, there were favorable changes
in the soft tissue contour.

32

Post treatment

Pre treatment


33


34

 Summary
 This patient showed both dental and
skeletal adaptation during the treatment
period. The mandible rotated downward
and backward, although no inhibition of
mandibular growth was noted. The
maxillary dentition moved downward and
forward. Little change occurred in
maxillary position.

35

 Conclusion
 1. A forward and downward movement of the
maxilla.
 2. A forward and downward movement of the
maxillary dentition.
 3. A downward and backward redirection of
mandibular growth.
 4. A lingual tipping of the lower anterior teeth.
 5. An inhibition of mandibular growth.

36

Orthopedic Correction of Class
III Malocclusion: Retention and
Phase II Therapy -PATRICK K.
TURLEY


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40


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44


45


46


47


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 1. Use a rigid expansion appliance in the maxillary arch.
 2. Ask for 24-hour facemask wear
 3. Avoid camouflaging movements that limit the amount of
orthopedic correction, contribute to future relapse, and make
later surgery more difficult.
 a. Avoid proclining the maxillary incisors to correct crowding
or anterior crossbite. Resolution of a significant arch-length
discrepancy may require molar distalization or even premolar
extractions after the orthopedic phase has been completed.
 b. Avoid Class III elastics as long as possible.
 4. Overcorrect the anteroposterior occlusion to nearly an endto-end canine relationship.
 5. Retain the overcorrected occlusion with night-time
facemask wear for an additional three to six months, until there
is positive overbite and good posterior interdigitation.
 6. Monitor the occlusion while awaiting Phase II treatment.
 7. Reinstate the facemask as needed before or during Phase
49
II

Cephalometric effects of face
mask/expansion therapy in
Class III children: A comparison
of three age groups -Andrew
 Pretreatment and posttreatment cephalometric
radiographs from 63 subjects (4 to 13 years)
who had a Class III malocclusion were
analyzed.
 Serial cephalometric tracings of 32 subjects
with Class I occlusion made at 4, 6, 8, 10, 12,
and 14 years were used as controls.
 Landmarks were digitized on each tracing and
treatment effects were measured by using
cranial base and maxillary superimposition
techniques

50

 CONCLUSION
 combination of skeletal and dental changes that produce an
improvement in the soft tissue profile.
 The treated group (N = 63) demonstrated statistically
significant hard and soft tissue movements affecting the
entire dentofacial complex.
 Skeletal change was primarily a result of anterior and vertical
movement of the maxillae. Mandibular position was directed
backward and downward but with a minimal increase in lower
face height and mandibular inclination.
 Dental changes also contributed to the correction, and soft
tissue changes resulted in a more convex profile. The effect
of age on treatment response appeared minimal when
comparing the differences in angular and linear
measurements alone.
 This study demonstrated that, in this sample, face
mask/expansion therapy produced changes in the dentofacial
complex that combined to improve the Class III malocclusion.
 Although these results suggest that early treatment may be
most effective, face mask therapy can provide a viable option
51
for older children as well.

Skeletal effects of early
treatment of Class III
malocclusion with maxillary
expansion and face-mask
therapy -Tiziano
 The effectiveness of maxillary expansion and
face-mask therapy in children with Class III
malocclusion was studied in a sample of 46
subjects in mixed dentition and compared with
a control sample of 32 subjects with untreated
Class III malocclusion.
 Treated and untreated samples were divided
into early and late mixed-dentition groups to
aid identification of the optimum timing of the
orthopedic treatment

52

 CONCLUSIONS
 1. Treatment of Class III malocclusion with maxillary
expansion and a face mask in the early mixed dentition
induced more favorable changes in the craniofacial
skeleton compared with similar treatment started in the
late mixed dentition. In particular, effective forward
displacement of maxillary structures was achieved as
an outcome of early treatment, whereas the latetreatment group showed no significant improvement in
maxillary growth with respect to matched untreated
controls.
 2. Even though both early and late face-mask
treatments reduced mandibular protrusion, significantly
smaller increments in total mandibular length
associated with more upward and forward direction of
condylar growth were recorded only in the earlytreatment group.
 3. Discriminant analysis revealed that both maxillary
and mandibular modifications concurred in the overall
treatment effects of maxillary expansion and face-mask
53
therapy

Biomechanical effects of
maxillary protraction on
craniofacial complex - Hata,
Itoh, Nakagawa, Kamogashira,
Ichikawa, Matsumoto
 The deformational effects on the human skull
resulting from maxillary protraction were
examined by means of strain gauges and
displacement transducers.
 The protraction forces that were applied to this
appliance were parallel to the occlusal plane at
the following locations:
 (1) the height of the maxillary arch,
 (2) 5 mm above the palatal plane, and
 (3) 10 mm above the Frankfort horizontal plane

54

 (1) protraction forces applied 10 mm above the
Frankfort horizontal plane produced a posterior
rotation of the maxilla with a forward movement
of nasion
 (2) protraction forces applied 5 mm above the
palatal plane produced a combination of
parallel forward movement and a very slight
anterior rotation
 (3) protraction forces applied at thelevel of the
maxillary arch produced an anterior rotation
and forward movement of the maxilla
 (4) all three protraction forces caused the
constriction of the anterior part of the palate. 55

Profile changes in patients with
class III malocclusions after
Delaire mask therapy -Hülya
KiliçoJlu

 16 girls (mean age: 8.65 years, SD: 1.4 years) with skeletal
Class III relationships caused by maxillary retrognathism, was
compared with an untreated control group of 10 girls (mean
age: 9.29 years, SD: 1.4 years).
 (1) After maxillary protraction, the maxilla was displaced
anteriorly, whereas the mandible rotated posteriorly
 (2) the maxillary incisors moved in the anterior direction,
whereas the mandibular incisors moved posteriorly
 (3) the mandibular plane angle and anterior lower and total face
heights increased
 (4) these changes were reflected in the profile, whereby the
skeletal profile convexity increased and soft tissue facial angle
and facial convexity decreased
 (5) the Class III concave profile became more balanced, with
56
the upper lip area becoming more marked.

 CONCLUSIONS
 1. The Delaire face mask treatment can provide
orthopedic effects on dentofacial morphologic
features of growing skeletal Class III female
patients.
 2. Treatment tended to reduce the concavity of the
profile. This was characterized by a forward
movement of the upper lip, backward repositioning
of the pogonion soft, and slight inhibition of anterior
migration of the lower lip.
 3. The effect of the treatment was found to be more
marked on the upper lip area.

57

References:
 Text book of orthodontics – Bishara
 Contemporary orthodontics – Profitt
 Dentofacial orthopedics with functional
appliances – Graber ,Petrovic ,Rakosi
 Orthodontics - Bhalajhi


58

 AJO-DO Volume 1980 Aug (125 - 139):
A modified protraction headgear - Nanda
 AJO-DO Volume 1981 Dec (638 - 650):
Extraoral traction and Class III treatment
– Cozzani
 AJO-DO Volume 1990 Jul (47 - 55):
Protraction of the maxillofacial complex Mermigos, Full, and Andreasen
 AJO-DO Volume 1988 May (388 - 394):
Use of face mask in treatment of
maxillary skeletal retrusion - Roberts and
Subtelny

59

 AJO-DO Volume 1998 Mar (333 - 343): Skeletal effects of
early treatment of Class III malocclusion with maxillary
expansion and face-mask therapy – Tiziano
 AJO-DO Volume 1987 Apr (305 - 311): Biomechanical
effects of maxillary protraction on craniofacial complex Hata, Itoh, Nakagawa, Kamogashira, Ichikawa, Matsumoto
 JCO Volume 1988 May(314 - 325): Orthopedic Correction
of Class III Malocclusion with Palatal Expansion and
Custom Protraction Headgear - PATRICK K. TURLEY, D
 JCO Volume 1996 Jun(313 - 324): Orthopedic Correction
of Class III Malocclusion: Retention and Phase II Therapy
PATRICK K. TURLEY, DDS, MSD, M
 JCO Volume 1987 Sep(598 - 608): An Orthopedic
Approach to the Treatment of Class III Malocclusion in
Young Patients - JAMES A. MCNAMARA, JR., DDS, P

60

Thank you


61

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

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