Maxillary Protraction / orthodontic courses by Indian dental academy

Maxillary ProtractionMaxillary Protraction INDIAN DENTAL ACADEMY

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This is the most common treatment protocol in This is the most common treatment protocol in the treatment of Class III malocclusion with a deficient the treatment of Class III malocclusion with a deficient midface.(True class III malocclusion)midface.(True class III malocclusion)

Class III malocclusion:Class III malocclusion:

5% 5% Caucasian population (Foster, Mayberg 1973)Caucasian population (Foster, Mayberg 1973)

14%14%Chinese and Japanese (Irie, Nakmura 1975)Chinese and Japanese (Irie, Nakmura 1975)

a large mandiblea large mandible a deficient midfacea deficient midface combinationcombination


Oppenheim (1944)Oppenheim (1944) was the first to suggest the possibility of was the first to suggest the possibility of Counterbalancing mandibular protrusion by bringing the Counterbalancing mandibular protrusion by bringing the maxilla maxilla forward.forward.

Haas (1970 )Haas (1970 ) maxilla moves forward and downward as a result maxilla moves forward and downward as a result of palatal expansion.of palatal expansion.

Delaire (1978) Delaire (1978) developed the orthopedic facemark to stimulate developed the orthopedic facemark to stimulate maxillary development. It was initially used to correct maxillary development. It was initially used to correct clockwise rotation of the maxilla and later as a method to treat clockwise rotation of the maxilla and later as a method to treat maxillary retrusion.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.


Petit Facemask:1983

Forehead and chin padsMidline framework made of

0.25 inch stainless steel with acorn nuts in the ends

Cross bar attached by setscrews on the midline framework made of 0.075 inch stainless steel

Elastic force generated was from distal of Maxillary molars to the crossbar

Disadvantage: easily dislodged by a restless sleeper


The treatment for patients with skeletal maxillary retrusion is anterior movement of the maxilla using protraction headgear, ideally in combination with rapid maxillary expansion.(McNamara 1987). This has been reported to be most beneficial before the age of 8 years, before the posterior maxillary sutures have closed.

Palatal expansion affects not only the intermaxillary suture, but all of the circummaxillary articulations. “In a sense, palatal expansion "disarticulates" the maxilla and initiates cellular response in the sutures, allowing a more positive reaction to protraction forces. It also initiates a downward and forward movement of the retruded maxilla.


Another advantage of maxillary expansion is the correction of the posterior crossbite that often accompanies a Class III malocclusion because of deficient transverse maxillary growth and the abnormal anteroposterior relationship of maxilla to mandible.

In addition, a palatal expansion appliance splints the maxillary dentition during protraction and helps transmit force from the teeth to the maxilla, thus limiting unwanted tooth movement. (Franchi, Baccetti 1998)


Elastics running between the intra oral anchorage system and the extra-oral appliance produce the necessary force for maxillary traction.

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.

Heavy elastics are the attached to a midline cross bow in the deciduous canine region. This causes maximum displacement of the maxilla with a minimal rotational effect.

Maxillary protraction generally requires 300-600 grams of force per side, depending on the age of the patient.


The Role of maxillary protraction :

1.Eliminate a centric relation – Centric occlusion discrepancy.2.Protract the maxilla 3.Advance the maxillary dentition4.Tip the lower incisors lingually5.Encourage vertical mandibular development

Direction of Force: 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. Ishii et al (1987) applied force from the molar and premolar levels and observed more forward translation of the maxilla in the first molar region in addition to a forward and upward rotation.


Staggers, Legan The orthodontist must first decide, in cases of maxillary deficiency, 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.


To evaluate the direction of the moment on the maxilla, the line of force for zero moment (LFO) must be determined. The LFO is the line of force passing from the point of elastic attachment on the headgear through the maxillary center of resistance.(zygomatic buttress) Contassi ,Legan1982

A force placed along the LFO produces no moment on the maxilla.

Since the maxillary center of resistance is located approximately at the zygomatic buttress, the outer bow must be bent above the occlusal plane to attach the elastics along the LFO and thus produce no moment.

When a clockwise moment is needed, the point of elastic attachment to the outer bow must be above the LFO.

when counterclockwise rotation of the maxilla is desired, the point of attachment must be below the LFO.


Treatment Effects of Protraction Headgear / Face Mask Therapy: Skeletal Effects :• Much of the information about the skeletal effects of protraction forces derives from animal studies.• Maxillary forward movement and sutural remodeling have been the main treatment effects noted by several investigators in nonhuman primates. (Dellniger, 1973; Nanda, Hictory 1984)• Kambara; 1977 found changes at the circummaxillary sutures and at the maxillary tuberosity attributable to posteroanterior traction, including the opening of the sutures, stretching of sutural connective tissue fibres, new bone deposition along the stretched fibres and apparent tissue homeostasis that maintained the sutural width.


Nanda, Hickory; 1984, showed how the histologic modifications in the zygomatico maxillary suture after maxillary protraction varied according to the orientation of the force system applied. The effects of maxillary protraction that are seen on the lateral cephalogram include forward and downward movement of the maxillary bone and dentition, lingual inclination of the mandibular teeth and downward and backward rotation of the mandible. In a study of 129 treated subjects with protraction headgear and RME and 21 untreated controls, Sung & Baik 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 which was statistically significant.

Thus maxillary length increased more in the protraction group. This may be caused by more bone apposition occurring in the posterior portion of maxilla, indicating an orthopedic effect of maxillary protraction.


Ucuncu, Ucem and Yuksel (2000) showed a significant amount of maxillary forward movement represented by an increase in SNA angle; with the maxillary protraction appliance.

The significant increase in Co-A and decrease in the maxillo mandibular difference [(Co-Gn) – (Co-A)] and molar relationship showed that class III correction was achieved with maxillary protraction appliance. Goyene, Ersoy; (2004) in a study of 30 subjects showed significant changes in SNA, NV-A, SV-ANS, SV-PNS, and PP measurements, which indicated that maxilla moved anteriorly in response to the maxillary protraction therapy. Dental changes: related to orthopaedic protraction forces to the maxilla include maxillary incisor protrusion, mandibular incisor retrusion, achievement of normal overjet and overbite, and decrease in the interincisal angle.


TIMING OF TREATMENT : According to McNamara, 1994, the optimal time to begin class III treatment is in the early mixed dentition, coincident with the eruption of the upper permanent incisors. Some authors advise that for optimal orthopaedic results, treatment be initiated before the patient is 9 years old. (Kim, Viona, Graber 1999). Others suggest that maxillary protraction and chincup therapy is effective throughout puberty and that orthopaedic effects on the dentofacial structures may even be possible in young girls as late as during acceleration phase of the pubertal growth spurt. (Takada et al 1993). The juvenile growth spurt that exists in some individuals can act as an accelerating factor in general and skeletal growth. (Ritucci, Nanda, 1986).


During the pubertal growth, maxillofacial growth proceeds actively even though the increase in sutural complexity of the palatomaxillary area after the junevile period can resist maxillary protraction force. Thus in order to get the maximum orthopedic effect with minimum forward sliding of the dental arch on the maxillary base, the growth period must be considered as an important variable that can affect treatment results. Baccetti, 1998 showed that treatment of class III malocclusion with bonded maxillary expander and face mask in the early mixed dentition results in a more favourable craniofacial changes than treatment in late mixed dentition.

Significant advancements of anterior and posterior nasal spines, and of point A, and maxillary dentition were recorded in the early treatment group.


Andrew Kapust, 1999 : in his study on different age groups showed that younger age groups (4 to 7 and 7 to 10 years) appeared to have responded better to treatment, however the 10 to 14 age group did demonstrate significant treatment effects indicating that orthopedic change does occur in older children.

Franchi,Baccetti, 2004:Early treatment(early mixed or late deciduous dentition) produces significant favourable postpubertal modifications in both maxillary and mandibular structures, whereas late treatment( late mixed dentition) induces only a restriction of mandibular growth.


Protraction Alone Versus Protraction with Rapid Maxillary Expansion : Hata, Itoh, Nagakawa 1987 Numerous authors have reported on the anterior constriction of the maxilla when it is protracted and they emphasize the necessity of physically expanding the maxilla before protraction.

Tanne Sakuda, 1991Palatal expansion alone has also been shown to facilitate correction of a class III malocclusion by causing a downward and forward displacement of the maxilla.

(McNamara 1993)Palatal expansion has been noted not only to affect the intermaxillary suture, but also all of the circum maxillary articulation’s. It has also been suggested that the palatal expansion ‘disarticulates’ the maxilla, initiating a cellular response which then allows a more positive reaction to protraction forces. (Turley 1988). www.indiandentalacademy.com

In a study on rhesus monkeys, rapid maxillary expansion produced 0.5 to 1.0 mm of opening of the spheno occipital synchondrosis, which led the authors to consider that this too might be a factor. (Gardner, Kronman, 1971).

In a study on 60 patients; Baik (1995) found significantly greater forward movement of the maxilla when protraction was used in conjunction with rapid maxillary expansion (2.0 mm with RME and 0.9 mm without RME).

A study, involving a meta analysis on 440 articles relating to class III malocclusion, confirmed that maxillary protraction, in combination with an initial period of expansion, provides more significant skeletal effects than protraction alone. (Kin, Viana, Graber 1999)


Vaugn, Mason, Moon, Turley AJO September 2005 Effects of maxillary protraction with or with out rapid palatal expansion: A prospective, randomized clinical trial Forty-six children, Class III malocclusion aged 5 to 10 years were randomly assigned to 1 of 3 groups: (A) facemask with palatal expansion, (B) facemask without palatal expansion. and(C) observation for 12 months. (control). (control)

Results Group A-B= No statistical significance GroupA-C= 3.69mm GroupB-C=4.35mm


Conclusion: The study demonstrated that facemask therapy with or without palatal expansion produced equivalent changes in the dentofacial complex that combined to improve the Class III malocclusion (4mm) These results suggest that indication for palatal expansion should be based on clinical criteria other than assisting the ClassIII correction


1.The 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. The appliance does not interfere with sleep, is somewhat more esthetic than other protraction devices, and has unilateral capabilities (which may require an extra cushion under one of the long arms ). The chief disadvantage is that it must be carefully adjusted to fit comfortably behind the ears.

Other Appliance Designs


2. Nanda 1980 reported that use of a modified protraction headgear which was a combination of headgear with U- bend made on the inner bow to passively fit into the molar tube along with the facemesk.

It produced a more controlled movement acting along the center of resistance of the maxilla producing a more orthopaedic effect. The head gear can also be used to correct the axial inclination or mesial displacement of the posterior teeth.


3. Suborbital Protraction Appliance

A recent development by Grummons, has been redesigned 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.

Although they are more sensitive, the two zygomatic areas offer more surface contact than the chin or other points and thus permit the application of similar force magnitudes. There is no force on the TMJ, and the appliance is easy to adjust and to wear during sleep.

disadvantage : esthetic objection to midfacial support.www.indiandentalacademy.com

4.Lever-Hook Edgewise Archfor Midfacial ProtractionHECTOR L. VESCO 1999Appliance Design

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.


Lever hook edge wise


Labial shields attached to the lever hooks make the appliance more comfortable and act as an upper lip bumper. The protraction force of the facemask prevents this bumper from moving the maxillary teeth distally.

Combined with the upward force expressed by the posterior segments of the archwire, the anterior traction also helps avoid undesirable counterclockwise maxillary rotation.

This originally custom-made arch is now commercially manufactured as the Vesco arch


Facemask protraction can be started at thesame time the arch is inserted, or at the next visit.The mask should be worn about 14 hours per day(five hours after school and nine at night), usingtwo 3⁄8", 6oz elastics per side for an .016" × .022"arch or three elastics per side for an .018" × .025"arch. Advantages of facemask therapy with theVesco arch• Achieves effective and rapid skeletal protractionof the maxilla and midface without proclinationof the maxillary dentition or counterclockwisemaxillary rotation.• Controls incisor torque and molar tip automaticallywhen elastics are hooked to the arch.


• Uses the maxillary anterior protraction force toprevent overextrusion of the molars.• Produces a functional effect through its labialshields.• Can be used with .018" or .022" brackets ofany prescription.• Can align dental midlines or open space forcuspids.• Can be used with a palatal expander.• Combines maxillary protraction with fixedorthodontic therapy in one overall phase of treatment.• Can be used in the mixed dentition or the permanentdentition, as long as growth remains


A Mini Maxillary protractor For Class III Correction: Altug, Arslan JCO 2005

Apliance designConsists of 4 parts 1. Maxillary expander – An acrylic

splint expansion appliance is constructed with full coverage of maxillary teeth. Hooks are embedded in the premolar and molar regions on both buccal sides. Expander is activated 0.25mm per day.

2. Mandibular plate – An acrylic plate covering the entire mandibular arch.

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3. Chin cup – A hook is attached on the each side of acrylic chin cup for application of cervical forces.

4. 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.


Protraction force of 300-400 gm per side with a anterior-inferior force sector of 20-30˚ to occlusal plane is applied with the elastics. Patient is instructed to wear the protractor 18 hrs per day.

Advantage:1. Does not require expensive lab work.2. Eliminates the facial mask, improving patient co-operation.3. Has a beneficial effect on soft tissue profile.4. Relatively short treatment time – takes about 4 months to establish proper overjet.


Vardimon et al (AJO-DO 1990)Vardimon et al (AJO-DO 1990) developed an intraoral intermaxillary developed an intraoral intermaxillary appliance for the treatment of Class appliance for the treatment of Class lll malocclusions that exhibit lll malocclusions that exhibit midface sagittal deficiency with or midface sagittal deficiency with or without mandibular excess. without mandibular excess. The functional orthopedic The functional orthopedic magnetic appliance magnetic appliance (FOMA) III(FOMA) III consists of upper and lower acrylic consists of upper and lower acrylic plates with a permanent magnet plates with a permanent magnet incorporated into each plate. incorporated into each plate. The upper magnet is linked to a The upper magnet is linked to a retraction screw and is retracted retraction screw and is retracted periodically (e.g., monthly) to periodically (e.g., monthly) to stimulate maxillary advancement stimulate maxillary advancement and mandibular retardationand mandibular retardation

The Functional orthopedic magnetic appliance (FOMA) IIIThe Functional orthopedic magnetic appliance (FOMA) III


The upper plate of a FOMA III consists of a 0.031-inch The upper plate of a FOMA III consists of a 0.031-inch stainless steel arch wire forming the metal substructure (a). The stainless steel arch wire forming the metal substructure (a). The arch wire bypasses the premolar-canine segment to permit arch wire bypasses the premolar-canine segment to permit eruption and crosses the occlusal plane at the M1-M2 eruption and crosses the occlusal plane at the M1-M2 embrasure. The upper magnetic housing (b) is linked to a embrasure. The upper magnetic housing (b) is linked to a retraction screw (c). The magnetic unit (b + c) is positioned retraction screw (c). The magnetic unit (b + c) is positioned along the midpalatal linealong the midpalatal line


The attractive mode The attractive mode neodymium magnets used in neodymium magnets used in this study produced a this study produced a horizontal force of 98 gm and horizontal force of 98 gm and a vertical force of 371 gm.a vertical force of 371 gm.

The ratio of horizontal to The ratio of horizontal to vertical force vectors is vertical force vectors is dictated by inclination of dictated by inclination of magnetic interface in the magnetic interface in the sagittal plane. The more sagittal plane. The more perpendicular the magnetic perpendicular the magnetic interface is to the occlusal interface is to the occlusal plane (sin 90° = 1), the greater plane (sin 90° = 1), the greater is the horizontal force vector is the horizontal force vector (Fh = attractive force ´ sin a).(Fh = attractive force ´ sin a).


Six female Macaca -fascicularis monkeys were treated with Six female Macaca -fascicularis monkeys were treated with FOMA IIIs.FOMA IIIs.

After 4 months of treatment, the following results were After 4 months of treatment, the following results were found:found:

The growth pattern of the cranial base (saddle angle) was not The growth pattern of the cranial base (saddle angle) was not altered.altered.

Midfacial protraction did occur along a recumbent Midfacial protraction did occur along a recumbent hyperbolic curve with a horizontal maxillary displacement and hyperbolic curve with a horizontal maxillary displacement and an anterosuperior premaxillary rotation.an anterosuperior premaxillary rotation.

Cumulative protraction of the maxillary complex was Cumulative protraction of the maxillary complex was initiated at the pterygomaxillary fissure with an additional initiated at the pterygomaxillary fissure with an additional contribution provided by other circummaxillary sutures contribution provided by other circummaxillary sutures (zygomaticomaxillary s., transverse s., premaxillary s.)(zygomaticomaxillary s., transverse s., premaxillary s.)

Inhibition of mandibular length was minimal, but a tendency Inhibition of mandibular length was minimal, but a tendency toward a vertical condylar growth pattern was observedtoward a vertical condylar growth pattern was observed


The interaction between sutural and condylar growth sites The interaction between sutural and condylar growth sites appeared biphasic, characterized by an immediate and rapid appeared biphasic, characterized by an immediate and rapid excitation of the circummaxillary sutures followed by a delayed excitation of the circummaxillary sutures followed by a delayed and slow suppression of the condylar cartilage.and slow suppression of the condylar cartilage. A later radiographic and histologic study by Vardimon et al A later radiographic and histologic study by Vardimon et al (AJODO 1994), again on monkeys, revealed the following data:(AJODO 1994), again on monkeys, revealed the following data:

Maxilla:Maxilla: 1.The target area of the protractive force was found to be 1.The target area of the protractive force was found to be localized in the pterygomaxillary fissure. localized in the pterygomaxillary fissure. 2.Three dimensionally, the separation of the sutures at the PMF 2.Three dimensionally, the separation of the sutures at the PMF was found to diminish in inferosuperior and lateromedial was found to diminish in inferosuperior and lateromedial directions.directions.Mandible:Mandible:The fact that no pathologic change was found in the condylar The fact that no pathologic change was found in the condylar cartilage encourages a long-term use of the FOMA III appliance, cartilage encourages a long-term use of the FOMA III appliance, initiating treatment at an early skeletal ageinitiating treatment at an early skeletal agewww.indiandentalacademy.com

Darendeliler et al (JCO 1993)Darendeliler et al (JCO 1993) reported a reported a case of a 7.5 years old female with Class case of a 7.5 years old female with Class III dental malocclusion and bilateral III dental malocclusion and bilateral cross bite who was treated with a cross bite who was treated with a combined combined MAD IIIMAD III(300g)(300g) and MED and MED (500g)appliance.(500g)appliance. Upper and lower buccally placed Upper and lower buccally placed magnets were used for correction of A-P magnets were used for correction of A-P discrepancy. discrepancy. The upper and lower magnets in the The upper and lower magnets in the repelling configuration had a tendency to repelling configuration had a tendency to move toward a fully centered contact, move toward a fully centered contact, thus creating a forward force against the thus creating a forward force against the maxilla and a backward force against the maxilla and a backward force against the mandible. mandible. When combined with an When combined with an MEDMED, the , the MAD MAD IIIIII offers an alternative in the early offers an alternative in the early correction of Class III malocclusions.correction of Class III malocclusions.www.indiandentalacademy.com

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. The bonded upper plate was then removed and replaced with a removable plate carrying only the two buccal magnets. The patient wore the MAD III for another 11 months, until a cusp-to-cusp deciduous molar and canine relationship was obtained. Eleven months after removal of appliances, the patient showed a Class I dental relationship, with adequate overjet and overbite and no crossbite


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.


A good bite registration in centric relation is required for the construction of the appliance. The closer the bite registration is to 4-6 mm thick, the more accurate the appliance will be. The maxillary acrylic should cover the entire palate and part of the crowns of all maxillary teeth. Full palatal coverage will allow the correction to be applied skeletally as well as dentally. The mandibular acrylic should extend as for inferiorly as possible on the lingual and buccal aspects of the teeth.


Because elastics provide the force between the two parts of the appliance, placement of the hooks for elastic attachment is critical to proper performance.

Maxillary arch: One hook on each side is placed on the distobuccal of the maxillary first molar, two more are located in the maxillary first bicuspid canine area,

Mandibular arch and a fourth is placed between the mandibular canine and lateral incisor. The shorter elastic on each side is always 1/8” 6oz and 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.

The longer elastic on each side, stretched from the mandibular hook to the molar hook can be ¼”, 60z; ¼” 8oz; or 3/16” 60z, depending on the comfort level of the patient and the amount of class III correction needed.

The appliance should be worn about 12 hours / day, in conjunction with a sof. Pad headcap and chin cup.

This appliance is effective in class III case that are not severe enough to require orthognathic surgery (with ANB angles of more than – 2).


Double Plate Appliance :AJO 2004 Ucem, Ucuncu, Yuksei

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 (Dec, 2004, AJO DO) 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.

Significant increases in the SNA angle and Co-A point showed that maxillary growth was achieved in both treatment groups.

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 Horse Shoe Appliance Yang 1997

The horse shoe appliance was developed by Dr. Schwarz, and is used to correct sagittal relationships by elastic force in patients with class III malocclusion.

It has the advantages of good patient cooperation, ease of construction, and effective modification. Appliance design :. Usually, a ball ended interdental clasp is used. But other clasps, ie Adams clasp or circumferential clasp are also used. Wire hooks are used for elastics. In the upper appliance, a hook is positioned on the distal surface of the last molar and in the lower appliance, a hook is positioned on the labial surface of the cuspid.


It restricts the increment of anterior facial height by minimizing the downward and backward rotation of the mandible using elastic force (5oz, ¼” for each side) instead of muscle force. Also, the horseshoe appliance can be modified so that it can be used for labial movement of anterior teeth with maxillary expansion by adding a screw and anterior hook in a plate for tongue elevation and a palatal bead or roll for tongue exercises.


A 9year 8 month korean boy had anterior cross bite with SNA angle= 75 degrees and was treated with the horseshoe appliance . After 2 months the maxiilary growth was enhanced with SNA angle=77.5 degees

Advantage:The horse shoe appliance prevents the extrusion and movement of teeth individually by covering the entire occlusal surface of the upper and lower dentition with acrylic resin.


TANDEN TRACTION BOW APPLIANCEChun, Jeorg, Row, Yang, 1999

The Tanden Traction Bow Appliance is a more esthetic and comfortable intraoral device.

It is removable, making it easy for the patient to maintain oral hygiene, and allowing treatment to be suspended or restarted whenever the clinician deems necessary, without bonding or debonding.

In the clinical trials of Tanden Traction Bow Appliance, (TTBA) structural superimposition according to Bjork (1966); showed antero inferior movement of the maxilla, posteroinferior repositioning of the mandible, and protraction of the maxillary dentition. Therefore TTBA had a similar treatment effect to that of an expander – facemask combination. www.indiandentalacademy.com

Appliance design :The TTBA comprises an upper splint, a lower

splint, and a traction bow. Its design allows the patient to open the mouth freely.

The upper splint which can serve the same function as a rapid maxillary expander, it covers the palatal and the occlusal surfaces of the maxillary teeth.

Portion of the buccal surfaces are also covered, providing adequate retention to overcome the maxillary protraction force of as such as 400-500 g/side.

During active treatment, the labial bow is embedded in the acrylic; it is uncovered and used to retain the incisors when TTBA is reassembled as a monobloc retainer.


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 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


The mandibular tubes should be located as posteriorly as possible.

In the deciduous and mixed dentition, the applied force should be 300-500g for orthopedic effect, in the early permanent dentition it should be 150-300g for orthodontic effect, avoiding induce stresses on TMJ.

The patient is asked to wear TTBA 12-14 hours / day for orthopedic effect and more than 14 hours a day for orthodontic effect.

After the crossbite is overcorrected, the two splints are fused into a monobloc and used as a retainer.


Intentional Ankylosis:

Replantation of teeth after dental avulsion usually causes ankylosis.Andreason, 1988 Intentional extraction and subsequent replantation of teeth have also consistently caused ankylosis in experimentalanimals.Hammer, Reed, Pierce 1970 Studies have shown that ankylosed teeth can provide stable anchorage for transverse orthopedic movement of the maxilla. Kokick, Ozawa, Omnell. Filho,Ozawa,Okada, Carvalho,Silva JCO 2000 have developed a new treatment protocol for Class III malocclusion with maxillary deficiency, involving extraction and replantation of the upper deciduous canines to cause ankylosisfor temporary static anchorage prior to rapid maxillary expansion and protraction. This method reinforces maxillary protraction


Advantages:• Replanted deciduous canines are autogenous implants that will undergo root resorption without the need to be extracted aftermaxillary protraction is completed.• Replanted teeth provide rigid and static anchorage, allowing the maximum orthopediceffect with little dental compensation. • The cost is low, and risk to the patient is mini-mal,compared to osseointegrated titaniumimplants.• The procedure is well accepted by patients andparents. With deciduous teeth, intentional ankylosissimply encourages the genetically programmedprocess known as replacement resorption. Permanent teeth are not suitable because they cannotbe removed after the procedure.


Distraction osteogenesis to advance the maxilla:

Distraction osteogenesis has been used to simulate LeFort I Maxillary advancement and anterior segmental repositioning.

Molene and Monasterio (1993) ; distracted the entire maxilla in 36 patients with cleft lip and palate.

Distraction forces were placed on the maxilla by reverse pull headgear and an intraoral orthopedic appliance to advance the maxilla 8 to 12 mm


Intraoral Orthopaedic Appliancewww.indiandentalacademy.com

Figueroa and Polloy (1999) evaluated the cephalometric changes on 14 patients with cleft palate who were treated with rigid external distraction technique.

A complete LeFort I osteotomy was performed, including pterygomaxillary and septal dysfunction, with mobilization.

A cranially fixed rigid external distraction device was placed after surgery. Distraction was performed by turning the activating screw at a rate of 1 mm / day.

The avg predistraction ANB was -1.2 and post distraction was 7.3 with an increase of 8.6. The average horizontal advancement of A point after distraction was 2.3 mm.


Rigid External Devicewww.indiandentalacademy.com

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 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 perside across the zygomaticomaxillary suture in Maca nemestrina monkeys and resulted in an anterior displacement of 8mm. Singer et al applied 400g of force to 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. Encar, Giray,pehlivanoglu, Iplikcioglu AJO may 2003 reported the treatment of a 10 year old girl with Class III skeletal relationship with maxillary hypoplasia and severe oligodontia.


The maxillary arch was in complete crossbite relationship with the mandibular arch.The treatment plan was to displace the maxillary

complex with titanium implant and the remaining teeth along with petit facemask since there was lack of available teeth.

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


The 2 incisor bands were also combined with a labial bar and the two ends of the labial bar were bent into a hook to which the facemesk`s elastic traction could be applied.

A petit facemask was fitted and 800g force was applied from each hook of the appliance. The forces were directed at 30 degrees to the occlusal plane.The patient was instructed to wear the appliance for 16hrs/day.

At the end of treatment, the ANB angle increased by +2 degreesANS region displaced 3mm anteriorly .


Pretreatment Postreatment


Dental Onplants – Absolute Anchorage for Maxillary Protraction :

One of the limitations in maxillary protraction with tooth borne anchorage devices such as expansion appliance and palatal arches is the loss of dental anchorage, especially with prolonged maxillary protraction. These undesirable effects include the loss of arch length, forward movement of maxillary molars and proclination of maxillary incisors. These dental changes can be minimized or even eliminated with the use of a device called maxillary onplants. (Block, Hoffman, 1995). The onplant comes as a disk, textured and coated with hydroxyapatite on one side and with an internal thread on the other side. 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. Apart from providing a stationary orthopedic anchorage, this device can be used in patients with multiple missing teeth.


A 7.7-mm hexagonal onplant (Nobel Biocare,Gotenberg,Sweden) was surgically placed on the flat part of the palatal bone near the maxillary molar region..

The onplant was placed as close to the midline as possible but not on the midsagittal maxillary suture, so as not to disturb lateral growth with the surgical operation.

A transpalatal arch was attached to the onplant and soldered to a silver cast splint, which was connected to all the maxillary teeth

Ngan,Guan,Gong, Wei AJO October 2005


Maxillary protraction was started four months after placement of the onplant. A Petit facemask (Ormco Cor-poration,Glendora, Calif) 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, to counteract the anticlockwise rotation of the palatal plane.

Patient was instructed to wear the facemask for 12 hours per day. Traction was continued for 12 months until sufficient clinical movement of the maxilla had been achieved to improve the midface esthetics.


The application of an anteriorly directed force from afacemask to an osseointegrated onplant placed in the palatalbone resulted in a significant improvement in midface es-thetics.

This was noted by an increase in fullness of the infraorbital region and the correction of the skeletal discrepancy between the maxillary and mandibular jaw relationship (ANB from -2.2degrees to 3.7degrees, Wits from -6.1mm to -1.0 mm).

To verify whether the onplant was stable during application of orthopedic force, superimposition was also performed on the lingual contour of the maxilla along ANS-PNS to detect any movement of the onplant.

The results showed no movement of the onplant duringboth the six-month and 12-month period of protraction


The onplant was then used as an internal reference point to measure spatial movement of the maxilla, which was found to have been displaced 2.9 mm horizontally and 2.9 mm ver-tically during the 12-month period of protraction.

This movement is more than the average horizontal movement of two mm reported by other investigators using tooth-borne appliances as anchorage for a facemask alone or in combination with expansion techniques.


Advantage of Onplant Vs Implant Elimination of dental changes such as extrusion and

mesial movements of upper molars by using onplant as anchorage may be helpful in improving the stability of facemask treatment.

onplant can be placed anywhere on the anterior part of the hard palate. In contrast, placement of implants in this area creates a potential risk of damage to the roots of adjacent teeth because of the length of the implant fixtures available. Placement of an implant on the anterior part of the hard palate would not only have a risk of root damage of anterior teeth but also the risk of penetration of the nasal floor.


REFERENCES.

1.He Hong, Peter Ngan, Han Guang, Liu Gong Qi,Stephen H.Y. Wei, Use of Onplants as Stable Anchorage for Facemask Treatment:A Case Report, AJO DO October 2005 page 402- 409

2.Jiang, lin, Changrong ji, Two stage treatment of skeletal Class III malocclusion during the early permanent dentition: A case report, AJO October Number 4,page 521-527

3. Vaughn, Mason, Moon, Turley:The effect of maxillary protraction therapy with or without rapid palatal expansion: A prospective,randomized clinical trial, AJO DO Sept 2005 page299-309

4. Altug, Arslan,A mini maxillary protractor for Class III correction:JCO sept 2005 page 522-524


Contents:Intoduction

Rationale, Treatment effects, Direction of force, Timing of Maxillary protraction

Facemask alone Vs Facemask with RME

Other Facemask designsMagnets FOMA III MAD III MEDTandem Tractionbow appliance, Two piece Corrector,Double plate, Horse shoe applianceIntentional AnkylosisImplantsOnplantsReferences


5. Franchi, Baccetti, McNamara:Postpubertal assessment of treatment timing for maxillary expansion and protraction therapy followed by fixed appliances:AJO November 2004 vol 126 number 5 page 555-568.

6. C de Moura Fuly, A G de Oliveira, W Ursi, Correction of Class III malocclusion with a Jasper Jumper, JCO 2000; 24: 41–46

7. Y S Chun, S G Jeong, J Row, S J Yang :A new appliance for orthopedic correction of class III malocclusion , JCO 1999; 23: 705–711.

8. T Alcan, A Keles, N Erverdi: The effects of a modified protraction headgear on maxilla,AJO DO, 2000; 117: 27–38.


9. Darendeliler, M.A.; Chiarini, M.; and Joho, J.P.: Case Report: Early Class III treatment with magnetic appliances, J. Clin. Orthod. 27:563-569, 1993.

10 Ravindra Nanda, Biomechanical and Clinical considerations of a modified protraction headgear:AJO August 1980 page 125-139.

11.John H Hickam,Maxillary Protraction Therapy: Diagnosis and Treatment JCO 1991 page 103-113

12.. Vcen et al : Comparison of double-plate appliance and facemask therapy in treating class III malocclusion. AJO DO 2004; 126 ; 672-9.


13. Simonsen, R.: The effect of face mask therapy, Am. J. Orthod.82:439, 1982.

14. Kambara, T.: Dentofacial changes produced by extraoral forward force in the Macaca irus, Am. J. Orthod. 1977,71:249-279.

15. Cozza,Marino, Mucedero,An Orthopaedic approach to the treatment of Class III malocclusion in the early mixed. Eur. Journ of orthod. 2004; 26 ; 191-199.

16.Ngan, Hagg Merwin, Wei: Treatment response to maxillary expansion. EJO 1996 vol18 page 151-168


17. Keles, Tokmak,Ervedi,Nanda,Effect of varying the force direction on maxillary Orthopaedic Protrtaction, Angle Orthodontist 2002, Vol 72,No 5, 2002.

18. Staggers,Germane,Legan:Clinical considerations in the use of Protraction headgear,JCO 1992,Vol 26, No 2 page 87-91.

19. Kokich VG, Shapiro PA, Oswald R, Koskinen-Moffett L, ClarrenSK: Ankylosed teeth as abutments for maxillary protraction: a case report. Am J Orthod. 1985;88:303–307.

20. Graber, Vanarsdall: Orthodontic current principles techniques, 4th edition,2005 page 1053- 1112


21. Da Silva Filho OG, Ozawa TO, Okada CH, Okada HY, Carvalho RM. Intentional ankylosis of deciduous canines to reinforce maxillary protraction. J Clin Orthod. 2003;37:315–320.

22. Singer SL, Henry PJ, Rosenberg I. Osseointegrated implants as an adjunct to facemask therapy: a case report. Angle Orthod.2000;70:253–262.

23.Gallanger, Miranda, Buschang:Maxillary protraction treatment and posttreatment effects.AJO DO 1998;113:612-9

24.Encar, Giray, Pehlivanoglu, Iplicioglu:Facemask therapy in a patient with maxillary hypoplasia and severe Oligodontia, AJO DO, May 2003 page 571-577


25. Franchi Baccetti : Splint therapy for skeletal class III malocclusion in the primary dentition. J. Clin Pediatr. Dent. 1998; 22 (2), 93-98

26. Eganhouse : Two piece corrector for class III skeletal and dental malocclusion. Journ of clinic orthod 1997; vol. 31 (4); 246.

27. Yang: Treatment of Class III malocclusion with the horse shoe appliance: a case report in growing patients. Journ of clinic orthod 1997; vol. 22 (1); 1-8.

28. Vesco: Lever hook edgewise arch for Midfacial Protraction.JCO 1999 page 161-166


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