Reverse Face Mask Therapy

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Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA
296
Rapid Palatal Expansion Device
Function
1. Open the palatal suture.
2. Expand the maxillary dental arch.
Instruments Used
1. Bird beak plier
2. Heavy wire cutter
3. 3-prong plier
4. Soldering unit
Materials Used
1. Hyrax expansion screw
2. Molar and bicuspid bands
3. Large electrodes (solder)
4. Flux
5. .032 round wire
Force System Used
1. Force due to turning of rapid palatal expan-
sion screw.
When Placed
At the beginning of treatment when you have a crossbite present due to the constriction of the upper arch
or simply when there is a need to expand the upper arch. Best used when you have an ANB difference
of 3-4 or less. Best treatment results are on patients under 18 years of age.
After use, the expansion device will cause bite opening. A large diastema will appear during expansion;
this is a positive sign that palatal separation is occurring. Patients should be checked quite frequently
while they are turning the appliance. You should get approximately 1mm expansion every 2 days. After
turning is complete, ligate the palatal screw with .012 ligature wire and leave in place for 3-6 months.
Procedure
1. Size bands for the first molars and premolars in the mouth.
2. Take an alginate impression with the bands in the proper position on the teeth. Remove the
bands and place them in the impression. Sticky wax the bands in the alginate impression and
pour in plaster.
3. The palatal expansion screw has 4 extensions of wire. You should adapt these four extensions
to contact the lingual of all four bands. It will be helpful to place clay in the palate area or the
model to support the screw while you adapt the extensions. * Now cut two pieces of .032 wire
to run from lingual of the premolar to molar. This seems to stabilize the appliance more and also
provides more of a segmental movement rather than individual teeth. Solder expansion screw
and .032 wire to the bands, cut off excess wire and trim.
* Most expansion screws have an identifying mark that should always be placed toward the
anteriors. If there is not mark present, make sure the screw is placed so that the key is inserted in
the front and turned to the posterior.
4. After cementation, activate the appliance by turning the screw 3-4 times until it becomes very
difficult to turn. This will be enough initial activation. Check in two days and give the parent
instructions for turning.
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Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA
Instructions for Wearing your Hyrax
1. Your appliance has been cemented permanently. It is not to be removed for any
reason.
2. Take extra time in brushing your teeth regularly so that your new appliance will not
trap food around your teeth and cause decay.
3. You have been instructed as to how to turn your expansion device with the key given
you. Be sure you do this once in the morning and once at night. Always record the
turns in your calendar and be sure to bring it with you for your appointment.
4. Keep dental floss tied to the end of the key, so there will be no danger of dropping it.
5. If you should have any problems, call our office.
6. After you have completed the turns, you will need to wear the appliance to hold the
position of your teeth. Be sure to return for your monthly check-ups to make sure the
appliance is cemented securely.
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Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA
298
Reverse Pull Headgear for Early Correction
of Class III Malocclusion
University of Oklahoma School of Dentistry
Introduction
The developing Class III malocclusion is one of the most challenging problems in orthodontics. Until recently, most
practitioners believed that Class III malocclusions were primarily caused by overgrowth of the mandible. Difficulty
in controlling growth of mandible has been recognized . Hence, most believed in waiting for the majority of growth
to be completed and then correcting such a condition by means of orthodontics in combination with surgery.
However, recent studies suggested that a majority of Class III malocclusions have maxillary retrusion or deficiency
as all or at least part of the structural
etiology.
2
From these studies, it be-
came obvious that management of a
large number of Class III malocclu-
sions should include maxillary pro-
traction as a major objective.
Several investigators have demon-
strated dramatic skeletal changes that
can be obtained in animals with con-
tinuous protraction forces to the max-
illa.
3,4
Not only is Point A affected
through forward incisor movement,
but the entire maxilla is said to be
displaced anteriorly, with significant
effects as far posteriorly as the zygo-
maticotemporal suture. Maxillary
protraction methods have included
chin cup and spurs
5
, combined head
cap and chin cup
6
, pull down facial
mask
7
, football helmet
8
, and facial
mask with forehead and chin sup-
port.
9-11
Reverse pull headgear - Facial
Mask:
The facial mask with forehead and
chin support has become popular dur-
ing recent years for early maxillary
protraction due to the simplicity of
the appliance and better patient ac-
ceptance. This treatment modality
was developed as early as the 1900's,
and more recently was modified by
Delaire from France and others like
Petit
9
, McNamara
10
, and Turley
11
in
the U.S.
The main objective of the facial mask
tiated for 10-15 days, either to correct
crossbites or to loosen sutures.
The same expansion appliance can
then be used as an intraoral splint to
attach the facial mask to transfer the
protraction forces to the maxilla.
The facial mask is adjusted for the
patient face. Recently, making a cus-
tom mask for the individual patient
has been recommended for improved
comfort.
11
Anterior and downward forces in the
range of 400-600gms are applied by
means of elastics from the intraoral
hooks on the expansion appliance and
the hooks on the facial mask. For
maximum and rapid correction, a 24-
hour per day wear is recommended.
If patient complies, the treatment time
will range from 2-6 months. Part time
(14 hours a day)wear of the facial
mask may also give acceptable re-
sults. However, the treatment time in
such a case will be longer.
10,11
is to cause forward movement of the
entire maxilla to improve the spatial
relationship between the maxilla and
the mandible in Class III malocclu-
sions. If done early, this improve-
ment in the oro-facial environment
may cause redirection of maxillo-man-
dibular growth and hopefully their
normal relationship in the future.
Palatal expansion:
A large number of Class III patients
require maxillary expansion due to
presence of posterior crossbites.
11
Palatal expansion, if needed, is done
before protraction forces are com-
menced on the maxilla. In addition,
this expansion procedure aids in loos-
ening the sutures by which the max-
illa articulates with nine other bones
of the craniofacial complex. In a
sense, palatal expansion disarticu-
lates the maxilla and initiates cellu-
lar response in the sutures, allowing a
more positive reaction to protraction
forces.
10,11
Due to this reason, it has
been suggested that a palatal expander
of some kind should be used before
protraction, even if a patient does not
have crossbite, to help in loosening
the sutural system.
Treatment:
Treatment is commenced as early as
the problem of maxillary deficiency
is recognized. However, primary and
mixed dentition stage are preferred.
First, expansion of the maxilla is ini-
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Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA
Reverse Pull Headgear for Early Correction
of Class III Malocclusion (cont.)
References:
1. Graber T.M.: Current Orthodontic Concepts and Techniques, W.B. Saunders Co.,
Philadelphia, 1972.
2. Guyer E.C., Ellis E.E., McNamara J.A., Behrents R.G.: Components of Class III
Malocclusions in Juveniles and Adolescents. Angle Orthodontics 56: 7-30, 1986.
3. Jackson GW, Kokick VG, Shapiro PA: Experimental Response to Anteriorly Directed
Force in Young Macaca Nemestrina, Am J Ortho 75: 319-333, 1979.
4. Nanda R: Protraction of Maxilla in Shesers Monkeys by Controlled Extraoral Forces Am
J Ortho 74: 121-131, 1978.
5. Irie M, Nakamusa S: Orthopedic Approach to Severe Skeletal Class III Malocclusion Am
J Ortho 67: 377-392, 1975.
6. Kettle MA, Burnapp DR: Occipito-mental Anchorage in the Orthodontic Treatment of
Dental Defermities Due to Cleft-lip and Palate. Br Dent J 99: 11-14, 1955.
7. Cooke MS, Wreakes G: The Face Mask: A New Form of Reverse Headgear, Br J Ortho
4: 163-168, 1977.
8. Nelson FO: A New Extraoral Orthodontic Appliance, Int J Ortho 6:24-27, 1968.
9. Petit H: Adaptations Following Accelerated Facial Mask Therapy. In: Clinical Alteration
of the Growing Face. (Eds) JA McNamara et al. Monograph 14, Craniofacial
Growth Series, Center for Human Growth and Development, University of Michigan,
Ann Arbor, 1983.
10. McNamara JA: An Orthopedic Approach to the Treatment of Class III Malocclusion in
Young Patients, J Clin Ortho 21: 598-608, 1987.
11. Turley P.K.: Orthopedic Correction of Class III Malocclusion with Palatal Expansion and
Custom Protraction Headgear, J Clin Ortho 22: 314-325, 1988.
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300
Reverse Face Mark (RFM)
Instructions and Criteria for Use
Indications: Class III Skeletal Treatment Time: 6-9 months average (varies greatly)
Ideal Age: 5-8 years old
Mask therapy can provide effective treatment for midface insufficiency and mandibular prognathism.
Elastics with combined force levels from 1-3 pounds couple the face mask to an intraoral appliance to
elicit forward movement of the maxilla.
There are several options for the intraoral maxil-
lary appliance depending on the dental classifica-
tion and the amount of crowding, age of the
patient, and also the stage of orthodontic treatment
at which face mask therapy is initiated. Given
these criteria, the patient should be prepared for
face mask therapy with one of the below listed
options for the maxillary arch.
1. Banded and cemented rapid palatal expan-
sion device (RPE)
This option is indicated
when the patient is in the
permanent dentition and the
entire maxillary arch is
constricted and in crossbite
with the lower. It will be
necessary to split the palate
prior to the use of the RFM.
When you have completed
active treatment with the
RPE, this will be used for
the RFM. Elastics will be
worn from the first molar
hooks and first premolar bands to the
mouthbow.
2. Bonded RPE with acrylic coverage
This appliance is indicated in the primary or
mixed dentition when the maxillary arch is in
crossbite and constricted and it is necessary to
expand and develop the maxillary arch. With-
out the presence of the permanent premolars,
the bonded acrylic RPE will work for the
expansion. You should instruct the lab that
fabricates this appliance to add hooks to the
acrylic in the molar and cuspid area so that it
can be used for the RFM after expansion has
been completed.
3. Banded and cemented RFM appliance
This appliance can be used in the primary,
mixed or permanent dentition. Band either the
second primary molar or the first permanent
molar. This appliance simply has a labial and
a lingual wire encompassing the entire maxil-
lary arch that is soldered to the molar bands
labial and lingual. Hooks are soldered in the
cuspid area to the labial wire and molar hooks
are used to attach the elastics for the RFM.
This appliance can be used when expansion of
the maxillary arch is not necessary. There
should be no crowding or constriction
of the maxilla when using this appli-
ance. It may be necessary to place
some composite in the posterior to
open the bite and allow the maxilla to
come forward.
4. Fully bracketed and banded
maxillary arch
This can be in the mixed dentition in
which all primary teeth should be
bracketed as well as in the permanent
dentition. The arch should be pro-
gressed in treatment up to a minimum
of .016 X .022 stainless steel archwire. The
arch will need to be ligated together from
molar to molar with steel ligature wire using
the figure eight technique. Use the hooks on
the molars and the power arms on the cuspid
bracket for elastics to the mouthbow of the
RFM.
The Adaptable Class III Mask by Dr. Henri Petit is
the mask that is recommended. It is available
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Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA
***** Ordering Information:
Johns Dental Lab (800) 457-0504
Space Maintainers of the Midwest Lab (800) 325-8921
from most commercial laboratories. Space
Maintainers of the Midwest Lab and Johns
Dental Lab are familiar with our use and applica-
tion of this mask and the different maxillary
intraoral appliances used in conjunction.
1. The first adjustment you will need to make to
the mask is to position the forehead rest and
chin cup to fit the face. An allen wrench is
provided to loosen and move these two parts
vertically up and down to adapt to the
individuals face. The forehead pad is posi-
tioned just above the patients eyebrows and
the chin cup is centered over the patients chin.
2. Adjust the position of the mouthbow using the
allen wrench so that it is below the occlusal
plane of the upper arch and there is a down-
ward and forward pull from the elastics.
3. Place one 8 oz. elastic on each side from the
cuspid hook to the mouthbow. Have the
patient wear the appliance 24 hours per day
with this one elastic per side for two weeks.
At the beginning of the third week, have the
patient add one more 8 oz. elastic per side
from the molar hook to the mouthbow. Con-
tinue these two elastics per side for two weeks.
After one month, add another 8 oz. elastic per
side to the cuspid area hook. Your intentions
are to progress up to a 24 hour per day wearing
schedule with three 8 oz. elastics per side. The
schedule for this varies from patient to patient
depending on the individuals tolerance level
and cooperation.
4. Continue wearing the RFM until you have
corrected the Class III malocclusion to a Class
II. Always over correct past ideal anticipating
rebound toward the Class III.
Adapt forehead rest and chin
cup to fit the patients face.
Adjust mouthbow so that there
is a downward and forward
pull
Adjusting the Face Mask