h

reaction of maxillofacial complex during protraction

Kong-Geun Lee, DDS, MSD, PhD, a Young-Kyu Ryu, DDS, MSD, PhD, b
Young-Chel Park, DDS, MSD, PhD, c and David J. Rudolph, DIDS, MSD, PhD a

Nashville, Tenn., Seoul, South Korea, and Los Angeles, Calif.

Most extraoral appliances used for protracting small or retropositioned maxilla do not allow for
variazions in the point of force appiication or in its direction. This variation may be necessary to
control vertical, anteroposterior, as well as transverse effects. The purpose of this study was to
investigate the initial reaction of the maxillofacial complex according to force magnitude, force
direction, and point of force application. For this purpose, an antenna-type modified protraction
headgear was tested with double exposure holographic interferometry on a dry human skull with
well-aligned upper teeth. Fringe patterns of each protraction condition were compared and
analyzed. In most cases, upward rotation of the anterior portion of the maxilla changed to
translation, or to downward rotation, as force direction was changed from parallel to the occlusat
plane to 20 downward to the occlusal plane. Furthermore, 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, which represents the center
of resistance of the maxilla. In most cases, with all force variables tested, a protraction of the
maxilla with palatal expansion was more effective in producing translation of the maxilla than was
protraction without palatal expansion. By varying force magnitude, force direction and point of force
application with maxillary protraction, the amount of maxillary rotation and translation might be
controlled. (Am J Orthod Dentofac Qrthop 1997;111:623-32.)

S k e l e t a l Class III malocclusion is characterized by either a large mandible, a small maxilla, a

retropositioned maxilla, or any combination of the
three. Recent studies 13 have noted that 42/{) to 60%
of Class III malocclusions are due to maxillary
deficiency or retrusion, in combination wilh a normal or mildly prognathic mandible. The treatment
of children with developing skeletal Class III realocclusions is difficult by orthodontic means alone;
therefore protraction of the maxilla may be indicated to correct the Class III skeletal problem. The
optimum application of such forces, however, has
not yet been determined.
Class III patients with maxillary deficiency may
present accompanying problems such as transverse
Based on a thesis by Kong-Geun Lee submitted to the Department of
Orthodontics, College of Dentistry, Yonsei University, Korea, in partial
fulfillment of the requirements for the degree of PhD.
~Resident, Orthodontic Center, Vanderbilt University, Nashville, Tenn.
bProfessor, Department of Orthodontics, College of Dentistry, Yonsei
University, Seoul, Korea.
CProfessor and Chairman, Department of Orthodontics, College of Dentistry, Yonsei University, Seoul, Korea.
JAssistant Professor, Section of Orthodontics, School of Dentist~, UCLA,
Los Angeles, Calif.
Reprint requests to: Dr. Kong-Geun Lee, Vanderbilt University, Orthodontic Center, The Village at Vanderbilt, 1500 21st Ave. S., Suite 3400,
Nashville, TN 37212.
Copyright 1997 by the American Association of Orthodontists.
0889-5406/97/$5.00 + 0 8/1/73161

and vertical deficiency. In these cases, there is a

need to control the movements of the maxilla during
protraction, on a case by case basis. If no maxillary"
rotation is desired, a more effective movement of
the maxilla may be achieved if the center of resistance of the maxilla can be found and the protraction force can be applied through this center of
resistance. Several experimental studies have been
performed to find the center of rotation and the
center of resistance of the maxilla to protract the
maxilla effectively. Burstone and Koenig4 have
suggested that, to obtain optimal stresses in the
periodontium, a clear understanding of force
magnitude, direction, duration, and point of force
application is needed. Christiansen and Burstone 5
further add that these objectives can be achieved
only by a clear understanding of the configuration
and center of resistance of the teeth to be moved.
Nanda 6 reported that, because facial sutures and
periodontal tissues behave in a similar manner in
response to applied force, these principles can also
be applied to the desired movement of craniofacial
bones. Nanda 68 also showed that with change in
moment and direction of force, the center of rotation of the maxilla can be altered and the force
variables can play an important role in the attainment of a desired directional change of midfacial
bones. It is important to have a clear understanding
623

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American Journal of Orthodontics and Dentofacial Orthopedics

June 1997

Fig, 1. Antenna-type modified protraction headgear.

Fig. 2. Fixation of skull to solid metal framework.

of force variables to attain desirable results. However, there have been few attempts to find the
response of the maxilla to complex combinations of
force variables, and no studies have completely
investigated maxillary protraction accompanied by
maxillary expansion.
The photographic technique of holography can
be used for recording and reconstructing images in
such a way that the three dimensional aspect of the
object can be retained and recorded as a hologram.
In this study, holographic interferometry is used to
determine any m o v e m e n t in three dimensions and
to measure small bone displacements. Because the
initial bone displacement is small with this technique, laser holography was used to accurately measure the m o v e m e n t and to avoid errors found in
previous studies of this nature. 9'1
The purpose of this study was (1) to find the
center of resistance of the maxilla; (2) to compare
the response of the maxillary complex according to
the various force systems such as magnitude, direction, and application point of force; and (3) to study
the effects of the palatal expansion on the maxillary
complex during protraction.

including the magnitude, point of application, and direction of force on the maxilla. An antenna, instead of an
outer bow, was soldered to an inner bow that was totally
reinforced by means of casting, with 2.7 mm in diameter
porcelain casting metal. Six hooks were soldered at different levels of the antenna at intervals of 5 mm to support
a nylon wire and to administer various points of force
application. Two vertical bars were attached to the base of
the metal framework to enable its use in different directions by raising or lowering the face mask simulator. The
U-shaped loops were made at the end of the inner bow to
enable insertion from the distal side of the maxillary first
molar headgear tube.
A Biderman-type Hyrax screw was set on the first
premolar band and the first molar band. In addition, a
0.018 0.022-inch stainless steel wire was soldered between the bands on each side, so that the protraction force
was transmitted more effectively to the entire maxillary
component.
The skull was fixed with nuts and bolts to a heavy
metal support by three intermediate modeling compound
shields and epoxy cement. Modeling compound shields
covered the frontal bone, occipital bone, and both parietal
bones (Fig. 2). When fixating the skull, the occlusal plane
was kept parallel to the base of the support. The fixed dry
skull with heavy metal framework was put on an optical
bench that was buffered against minor vibration by rubber
tubes. The equipment such as the laser, shutter, beam
splitter, beam expander, attenuator, and mirror were set
and fixed with a magnetic base on the optical bench (Fig.
3). Before conducting the experiments, the stabilization
was checked by double exposure of holography.

MATERIALS AND METHODS

Materials

A dry adult human skull (without the mandible), with

well-aligned upper permanent dentition, was used as the
experimental model. A modified protraction antenna
headgear was made, according to Dermaut's method 9
(Fig. 1). The effects of force variables was investigated,

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American Journal of Orthodontics and Dentofacial Orthopedics

Volume 111, No. 6

625

Fig. 3. Holographic set up.

Methods

The experimental holographic setup is illustrated (Fig.

4). The highly coherent and monochromatic light from the
laser source was split into two beams with a beam splitter.
One of the beams was directed by mirrors, expanded with
a spatial filter (microscope objective and a pinhole assembly), and was used to illuminate the object to be recorded.
This beam, referred to as the object beam, provided
information about the instantaneous condition of the
object surface. The second beam, known as tl:~e reference
beam, was not modulated by any intervening object. If
both of these beams impinge on a surface, they produce a
set of fringes, on the surface, as a result of their mutual
interference. The fringe pattern gives information about
the axis of rotation and the direction of bone deformation.
In this study, holographic interferometry was used to
measure initial bone displacements. Two images (one
before and the other after deformation of the skull) were
superimposed, which resulted in the formation of a fringe
pattern.
A 20 mW He-Ne laser (NEL GLG 5700; ~ = 0.6328
~m) was used. The intensity magnification of the reference beam and object beam was 4:1. This He-Ne laser was
exposed on the holographic plate (Agfa Gevaert, 8E 75).
The holographic plate consisted of a highly sensitized
emulsiol~ that coated a glass plate.
A double exposure technique was used. First, the laser
was exposed on the fixed skull for 15 seconds and the
protraction force was applied for 5 minutes. Tb,e laser was
exposed for another 15 seconds to the same holographic
plate. Frontal and lateral double exposures were taken.
Before the next exposure, the skull was left for a period of
5 minutes after removal of the force to allow conversion
from a strain state to a rest state.
After developing and fixing, the plates were bleached
in a solution composed of ferric nitrate and potassium
bromide, and dried. The completed holographic set of
plates consisted of 36 frontal views and 36 lateral views.

Fig. 4. Schematic drawing of holographic set up. a:

Laser. b: Beam splitter, c: Beam expander, d: Holographic plate, e: Spatial filter, ob: Object beam. rb:
Reference beam.

The fringes recorded on these plates by the double

exposure holographic technique were reconstructed with
the reference beam and photographs that were taken with
an autoexposure camera.
Six points of force applications, two directions of
force, and three different amounts of force were tested
(Fig. 5). The points of force applications were 15, 10, and
5 mm above the occlusal plane, occlusal plane level, as
well as 5 and 10 mm below the occlusal plane. The
direction of protraction force was parallel to the sagittal
plane and was parallel and 20 below to occlusal plane on
the lateral view. The magnitudes of applied force were
300, 500, and 500 gm with a 45 turn to the maxillary
jackscrew.
RESULTS
Frontal View

T h e response of the maxillary complex, when

protracted parallel to the occlusal plane.
1. T h e basic structure of the fringe pattern on
the maxilla is c o m p o s e d of horizontally par-

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American Journal of Orthodontics and Dentq[acial Orthopedics

June 1997

ponent of rotation than in the maxilla (Fig.

6, A and B).
The response of the maxillary complex when
protracted 20 downward to the occlusal plane:

Fig. 5. Point of application and direction.

allel bands. This indicates that the main

movement is a forward and upward rotation
of the anterior maxilla around an axis parallel
to the direction of the fringes (Fig. 6, A and

B).
2. In general, within one bony unit of the skull,
the fringe pattern is regular (Fig. 6, A and B).
However, the fringe pattern showed interruption of continuity at the sutures. Thus the
sutures seemed to behave as adjustment areas
in the skulls.
3. There was a slight "A" shape in the area of
the teeth, the alveolar process, and the maxilla (Fig. 6, A). This indicates that protraction
of the maxilla induces the constriction of the
anterior part of the plate. However, when
protracting with palatal expansion, the "A"
shape changed into a "V" shape (Fig. 6, B).
This indicates that expansion of the palate
compensated for the constriction of the palate.
4. When protraction was increased, more
fringes appeared(Fig. 6, A and B). This indicates more rotation of the maxilla.
5. At a higher point of force application, less
fringes (Fig. 6, A and B) were formed. This
indicates that with a higher point of force
application, less upward rotation of the anterior maxilla occurs.
6. The direction of the fringes on the zygomatic bone differed from the pattern on the
maxilla. Approximately a 45 difference in
angulation of the fringes on the zygomatic
bone were produced by a more lateral corn-

1. At the point of 500 gm force application, 15

mm above the occlusal plane accompanied
with palatal expansion, typical circular fringe
patterns appeared. The centers of each of
these circular patterns may be referenced
from two axes: Through the crista gali perpendicular, a line drawn through the most
inferior points of the zygomaticomaxillary sutures bilaterally. Thus the centers of each of
the fringe patterns can be further described as
located laterally at approximately 63% of the
distance from the crista gali axis to the inferior border of the zygomaticomaxillary suture
bilaterally, and approximately 13% of the
distance from the zygomaticomaxillary axis to
the inferior border of the orbit (Fig. 7, B1).
This indicates that a true translation .of the
maxilla occurred. The same application point,
without expansion, also showed a circular
fringe (Fig. 7, A1). However, the circular
fringe was not as distinct as with expansion.
This indicates that expansion of the palate is
more effective in inducing a true translation
of the maxilla, during the maxillary protraction.
2. The number of fringes decreased significantly
compared with protraction parallel to the
occlusal plane (Figs. 8 and 9). This means that
an upward rotation of the anterior portion of
the maxilla changes to translational, or downward, rotation as the force direction changes
from parallel to the occlusal plane to
20 downward.
3. Protraction when the point of force application was 10 mm above the occlusal plane
shows a downward rotation of the anterior
portion of the maxilla (Fig. 7,A2, A3, B2, B3).
This rotation increased as the point of force
application was lowered.
4. At the points above the occlusal plane, the
direction of the fringes on the zygomatic bone
showed reversal or vertical angulation compared with that of parallel protraction (Figs.
6, A,B and 7, A,B).
Lateral View

The fringe pattern showed a A shape on the

zygomatic arch from the zygomaticotemporal su-

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 111, No. 6

L e e et al.

1}27

Fig. 6. Response of maxillary complex when protracted parallel to occlusal plane with 500
gm. (Frontal view) AI: 15 mm above to occlusal plane. A2: Occlusal plane. A 3 : 1 0 mm
below to occlusal plane. BI: 15 mm above to occlusal plane + expansion. B2: Occlusal
plane + expansion. B3:10 mm below to occlusal plane + expansion. (Lateral view) C1:15
mm above to occlusal plane. 02: Occlusal plane. C3:10 mm below to occlusal plane.

ture, in two opposite directions. This indicates that

the suture was acting as a hinge axis (Figs. 6, C, and
7, C).
In the area of the zygomaticotemporal suture,
both bones (zygomatic process of the temporal bone

and temporal process of the zygomatic bone) were

sheared relative to each other (Figs. 6, C, and 7, C).
Without expansion, the fringes ran horizontally
on the maxilla. This indicates that the protraction
force was transmitted to the maxilla as one unit in

628 Lee et al.

American Journal of Orthodontics and Dentofacial Orihopedics

June 1997

Fig. 7. Response of maxillary complex when protracted 20 downward to occlusal plane

with 500 gm. (Frontal view) AI: 15 mm above to occlusal plane. A2: Occlusal plane. A3:10
mm below to occlusal plane. BI: 15 mm above to occlusal plane + expansion. B2:
Occlusal plane + expansion. B3:10 mm below to occlusal plane + expansion. (Lateral
view) C1:15 mm above to occlusal plane + expansion. 02: Occlusal plane + expansion.
0 3 : 1 0 mm below to occlusal plane + expansion.

one direction. However, during anterior rotation with

expansion, the fringe pattern changed to a more
vertical pattern. Furthermore, it divided in different
ways from the first premolar area to the inferior area

of the zygoma and also to the pterygomaxillary fissure

area (Figs. 6, C, and 7, C). This indicates that the
protraction force probably was transmitted two ways,
as primary and secondary stress areas.

L e e el al.

American Journal ~?fOrthodontics and Dentofacial Orthopedics

Volume 111, No, 6

629

20
No.
of
fringes
10

u15

ul0

u5

b5

bl0

Point of force application

Fig. 8. Number of fringes: parallel to occlusal plane.

30

300gin
500gin
500grn + Exp.

20
No.
of
fringes

10

u15

ul0

u5

b5

bl0

Point of force application

Fig. 9. Number of fringes: 20 downward to occlusal ;)lane.

DISCUSSION

Kragt w'l~ has reported the similarity in initial

responses of dry skull and human skull to orthopedic force by means of a holography study. Although
some differences of biomechanical behavior between this type of model and the patient may be
expected, a sulficient degree of similarity exists to
use it as a simulation tool.
With holographic interferometry, parallel horizontal bands on the maxilla would indicate that the

main movement with protraction headgear is a

forward with upward, or downward, rotation of the
anterior portion of the maxilla around an axis
parallel to the direction of the fringes. Ichikawa and
associates 1~ reported similar outcomes when a protraction force was applied parallel to the occlusal
plane. However, the fringe pattern in this study was
not made up of purely straight horizontal bands.
Furthermore, the distances between bands often
differed, thus indicating that a protraction of the

630

L e e et al.

maxilla results in unequal amounts of rotational

forces in different areas. This may be due to effects
of sutures and variations in bone shape and density.
Dermaut 13 reported the same result in his holographic investigation during retraction with Class II
elastics on a dry skull.
The A-shaped fringe pattern on the maxilla
during protraction in this study indicates a compressional movement of the anterior palatal constriction
accompanied by a forward translation and upward
rotation of the anterior maxilla. This fringe pattern
supports the results of Ichikawa; t2 Hata, 14 and
Itoh. 15
It is very interesting to compare these results
with Dermaut's experiment. ~3 He reported a slight
V-shaped fringe at the same area during retraction
with Class II elastics on a dry skull. He concluded
that this phenomenon leads to the backward tipping
of teeth and, to some extent, movement in a lateral
direction, depending on the localization of the axis
of rotation. The fringe pattern changed from a A to
a V shape when protracting with palatal expansion.
This indicates that palatal expansion compensates
for palatal constriction that results from maxillary
protraction. Hata 14 suggested that intraoral expansion devices be used whenever maxillary protraction
appliances are used, based on his study that showed
palatal constriction during protraction. There have
been no clear demonstrations to prove this theory.
Proffit.6 reported that the maxilla may move forward
in response to transverse widening alone, but the
average change is only 0.5 mm and posterior movement is as likely as anterior moment. However, the
clinical importance of expansion during protraction
may not be in its forward response only, but also in
its compensating effect on maxillary constriction.
The net effect is a change in the direction of bone
bending from constriction to expansion.
MikP v and Hirato ~s reported that the location of
the center of resistance in the midface of the human
skull is between the first and second upper premolars anteroposteriorly, and between the lower margin of orbitale and the distal apex of the first molar
vertically in the sagittal plane. However, the above
results were theoretically deduced with mechanical
tests on a simulated human skull. Hata and associates t4 reported that protraction 5 mm above the
palatal plane produces a relatively straight forward
movement of maxilla, but they were unable to find
the force system that could induce a true translation
of the maxilla.
When 500 gm force was applied 15 mm above
and 20 downward to the occlusal plane and was

American Journal of Orthodontics and Dentofacial Orthopedics

June 1997

accompanied with expansion, typical circular fringe

patterns appeared in the frontal view. The centers of
each of these circular patterns may be referenced
from two axes: Through the crista gali perpendicular, a line drawn through the most inferior points of
the zygomaticomaxillary sutures bilaterally. Thus
the centers of each of the fringe patterns can be
further described as located laterally at approximately 63% of the distance from the crista gali axis
to the inferior border of the zygomaticomaxillary
suture bilaterally, and approximately 13% of the
distance from the zygomaticomaxillary axis to the
inferior border of the orbit. In the lateral view, three
different fringe patterns appeared. The center of the
neutral area of these patterns is located on a line
passing through the distal contact of the maxillary
first molar perpendicular to the functional occlusal
plane, and 50% of the distance from the functional
occlusal plane to the inferior border of the orbit.
This point is coincident with the line of action of the
500 gm protraction force (Fig. 7, C1). The frontal
and lateral fringe patterns indicates the center of the
maxilla.
The same application without expansion also
showed a circular fringe. However, this circular
fringe pattern was not as distinct as with palatal
expansion. This indicates that during maxillary protraction, expansion of the palate is a more effective
method to induce pure translation of the maxilla.
Itoh and associates 1~ reported that the best usage
of protraction appliances should include a combination force of a forward and downward vector to
protract the maxilla and to minimize the upward
rotation of the anterior portion of the midface. Proffit16 reported that most children with a maxillary
deficiency are deficient vertically as well as anteroposteriorly. This implies that a slight downward direction
of an elastic traction is usually desirable between the
intraoral attachment and the face mask frame.
When a 20 downward pull from occlusal plane
was applied, the number of fringes decreased significantly in comparison to protraction parallel to the
occlusal plane. This means that upward rotation of
the anterior portion of the maxilla changed to
translation or downward rotation as force direction
changed from parallel to the occlusal plane to
20 downward. This phenomenon was similar to the
findings of Itoh and associates. 15 They reported that
a 20 downward pull from molar and premolar areas, decreased the rotation of the palatal plane.
The fringe pattern showed a A on the zygomatic
arch from the zygomaticotemporal suture in two
opposite directions on the lateral view. This reveals

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American Journal of Orthodontics and Dentofacial Orthopedics

Volume H1, No. 6

that the suture was acting as a hinge axis. There

was a difference in the lateral movement on both
sides of the suture, meaning that the suture
functioned as a hinge axis. Bishara and associates 19 reported that it is important for the clinician to remember that the main resistance to a
midpalatal suture opening is probably not in the
suture itself but in the surrounding structures,
particularly the sphenoid and zygomatic bones. In
the area of the zygomaticotemporal suture, both
bones (zygomatic process of the temporal bone
and the temporal process of the zygomatic bone)
had sheared relative to each other. This is in
agreement with the findings of I ~ a g t and associates, 11 who found a comparable movement in the
zygomatic area after having applied headgear
forces on a macerated skull.
On the lateral view, the fringe pattern showed a
horizontal direction on the maxilla. This may indicate that the protraction force is transrnitted to the
maxilla as one unit, in one direction. However,
during the protraction with expansion, the fringe
pattern changed vertically and divided in different
ways from the first premolar area, to the inferior
area of the zygoma, and to the pterygomaxillary
fissure. This indicates that the protraction force
probably transmitted in two ways, as primary and
secondary stress areas.
The following suggestions were developed
from this study so that an effective forward displacement of the maxilla through the, center of
resistance could be obtained clinically. For pure
translation, an optimum force system includes a
500 gm force applied at a point 15 mm above the
occlusal plane, directed 20 downward from the
occlusal plane with palatal expansion. ]-'his type of
force application is especially desirable if the face
height is normal and a rotation of the maxilla is
contraindicated.
Conversely, in deep overbite cases in which an
opening of the bite is necessary, a forward pull with
a concomitant upward rotation of the anterior part
of the maxilla will aid in file treatment of these
malocclusions. This was seen when 500 gm of force
was applied at every point of application when the
force was directed parallel to the occlusal plane with
palatal expansion. The lower the point of application, the greater the magnitude of the resultant
upward rotation.
Furthermore, in open bite, maxillary vertical
deficiency, or short lower face height cases, a
downward rotation of the anterior part of the maxilla
is desirable. This can be achieved in this study with a

63"~

500 gm force applied at or below the occlusal plane

directed 20 downward to the occlusal plane with
palatal expansion. Downward displacement of the
maxilla increases face height and rotates the mandible
downward and backward. This contributes to the correction of a skeletal Class III relationship.
Therefore the vertical control of the maxilla can
effectively be obtained by the type of force variables
applied to the midface. Each patient needs to be
evaluated to determine the desired maxillary movement. In addition, dental movements should also be
taken into account.
CONCLUSION

Laser holography was used on a human dry sknll to find

the force system that could induce true translation through
the center of resistance of the maxilla during protraction.
The response of the maxillarycomplex was analyzed by using
various force systems, such as the force magnitude, the
direction of force, and the application point of force. The
effects of palatal expansion on the maxillary complex were
also studied during protraction. The following conclusions
Were reached: When the point of force application was 15
mm above and directed 20 dowaawardto the ocdusal plane
with a force of 500 gm, along with palatal expansion, true
translation through the center of resistance of the maxilla
occurred. By varying the force system, the amount and
direction of maxillary rotation might be controlled. During
maxillaryprotraction, the expansion of the palate performed
a compensating action for the maxillary constriction tendency and was effective in inducing pure translation of the
maxilla.
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June 1997

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Bound volumes of the .American Journal of Orthodontics and Dentofacial

Orthopedics are available to subscribers (only) for the 1997 issues from the
Publisher, at a cost of $79.00 ($93.30 Canada and $90.00 international) for Vol.
111 (January-June) and VoL 112 (July-December). Shipping charges are
included. Each bound volume contains a subject and author index and all
advertising is removed. Copies are shipped within 60 days after publication of
the last issue of the volume. The binding is durable buckram with the journal
name, volume number, and year stamped in gold on the spine. Payment must
accompany all orders. Contact Mosby-Year Book, Subscription Services,
11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; telephone
(314)453-4351 or (800)325-4177.
Subscriptions must be in force to qualify. Bound volumes are not available
in place of a regular Journal subscription.