Maxillary Protraction Dr.M.M.varadharaja / orthodontic courses by Indian dental academy

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Maxillary Protraction

INDIAN DENTAL ACADEMY

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Contents • 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

– 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– 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.


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. Protract the maxilla 2. Advance the maxillary dentition3. Tip the lower incisors lingually4. Encourage vertical mandibular

development5. 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 2006Indicators 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.


• 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 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.


Positive factors Negative factorsConvergent 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

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


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 Archfor 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 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 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 U-loop 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 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 supported 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.


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, hydroxyapatite-coated 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 skeletalanchors

• 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.


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