Protraction facemask, facemask, protraction mask, orthopaedic facemask, Delaire mask are many names designating the same appliance.
The protraction facemask is an appliance commonly used in the interceptive treatment of Class III malocclusions where the maxilla (upper jaw) is anteroposteriorly (front-back) deficient. It is designed to apply forward and downward traction on the upper jaw.
A metal bar acts as a framework to maintain support to the forehead and chin. The supports, a forehead rest and a chin cup, are adjusted individually to match the height of the patient’s face.
An extraoral force is applied through two (2) 8-oz elastics attached to hooks mounted on a fixed intraoral appliance (the most often a palatal expander) toward an adjustable bar attached to the vertical framework.
The force is directed from the back toward the front and downward (posteroanterior and inferior).
The mask is worn during the evening and night for a duration of 8 to 12 hours. Wearing the facemask during the day is neither recommended nor necessary. You will see results with good diligence during the evening and night.
The forces induced by the elastics are heavy forces. It is necessary to let the skin of the forehead and chin rest and breathe during the day. For that matter, we recommend cutting and adjusting panty liners and applying them on the internal surface of the supports.
On these intraoral views, notice the anterior crossbite involving 3 incisors, the upper right primary canine and the upper right first primary molar. After only 9 weeks of treatment, the lateral incisor is the only one presenting a crossbite. Observe the position of the intraoral hooks aligned with the primary canines on each side. The elastics are attached to these hooks.
The above pictures indicate the evolution of the treatment of the young boy after 21 weeks of treatment. Notice the improvement of the relationship of the mandibular arch midline with the maxillary arch midline and the correction of the overjet. At 35 weeks, we proceeded with the removal of the fixed appliance and stopped using the facemask. The upper incisors present a normal overjet and overbite. The patient will be seen every 6 months to verify the evolution of the intermaxillary relationship until the permanent dentition appears. We will be able to evaluate at that moment if another phase of treatment will be necessary or not.
Why do we need to treat Class III malocclusions at an early age?
1- To prevent irreversible changes to hard tissues (bone, enamel) and soft tissues (gingiva, ligament).
An anterior crossbite can cause wear of enamel at the tip of the upper or lower incisors involved. The forward displacement of the lower incisor to accommodate the upper tooth in crossbite causes reduction of the gingiva or gingival recession. The gingival reduction of the inferior central incisors on the buccal side is very obvious on the picture on the opposite side.
2- To correct the skeletal discrepancy between the upper and lower jaw and thus contribute to a growth with a normal intermaxillary relationship.
This also minimizes dental compensations which would result from the persistence of the initial bad relationship. Early treatment allows for bigger orthopaedic changes over a shorter period of time.
3- To improve occlusal function.
Generally, a forward functional shift exists on the lower jaw from the first contact between teeth which are in crossbite up to where the teeth close together completely. This forward shift contributes to the lengthening of the lower jaw which already tends to be too long. The facemask moves the upper maxilla forward, corrects the shift and, by eliminating the skeletal discrepancy, contributes to a normal growth pattern.
4- To simplify the major treatment in phase 2 during teenage years.
Early treatments of this type of malocclusion can eliminate the necessity to have an orthognathic surgery later. Even if a surgery were to be necessary, an early treatment can make the future surgery less imposing.
5- To provide a better facial esthetics and thus improve or facilitate the child’s psychosocial development.
When should we not treat early?
Contraindications to early treatment:
• Several skeletal disharmonies.
• Mandibular deviation caused by a growth asymmetry between the left and right condyle.
Early treatment, but at what age must it start?
To answer this question, researchers had to group individuals by age brackets. I will spare you the numerous studies that exist on the subject. Uncontested leaders of therapies with facemasks are Dr Jean Delaire and Dr Pierre Verdon in France, Dr Peter Ngan from West Virginia University and Dr Patrick Turley from UCLA in California.
Three age brackets were identified:
• 4 to 7 years of age
• 7 to 10 years of age
• 10 to 14 years of age
The three groups have had significant skeletal changes.
The 4-7 years of age group shows more than twice as many maxillary advancement compared to the other two older groups. Skeletal changes are obtained more quickly and with less hours of wearing the facemask per day than the older groups.
The 7-10 years of age group shows more changes than the 10-14 years of age group.
The 10-14 years of age group shows that it is possible to get skeletal changes at that age, but they are less important than the groups treated younger.
Stability of treatments with facemask
Individuals who had an early treatment with a facemask show that the upper jaw is moved more forward by 2 mm in average when compared to a control group who has not received early treatment. Moreover, the control group of untreated Class III individuals shows aggravation of the maxillomandibular Class III relationship of 1 mm per year. The facemask does not standardize the growth pattern. It is recommended to overcorrect to avoid having the Class III growth getting worse and taking over what was gained.
Is it worth treating orthopaedically each patient with a Class III malocclusion?
The answer is yes. Therapy with a facemask corrects Class III malocclusions in 75% to 85% of Class III patients. The remaining 15% to 25%, those whose malocclusion comes back and who will need orthognathic surgery, will have a more stable surgical correction because the range of the correction will be smaller than in patients who had no treatment with an orthopaedic mask.
Benefit of palatal expansion at the same time the facemask is used
The anchor hooks on which the elastics are attached are generally fixed to a Hyrax or HAAS palatal expander. It is not proven that palatal expansion as such facilitates protraction of the maxilla. Thus, maxillary expansion is indicated only if there is a problem with the width of the maxilla on top of the length problem.
Here are the intraoral views of a 7-year-old young girl. The blue arrows indicate a forward shift of the lower jaw. The relationship of anterior teeth shows a reversed occlusion. The mandibular arch midline is shifted to the right (of the patient) and can be explained by the fact that the Class III shift (gap between the blue arrows) is greater on the left than on the right.
Analysis of the profile shows an upper lip being behind the lower lip, meaning that the lower lip appears more forward. The cephalometric X-ray confirms the skeletal Class III malocclusion including a shift where the upper maxilla is behind (more backward compared to) the mandible. The crossbite of the upper teeth with regard to the lower teeth is obvious.
A Hyrax palatal expander was bonded to the teeth. The expansion screw was not activated. There were no width problems to correct. Two soldered hooks on the Hyrax framework are positioned to be aligned with the canines.
The facemask was worn during the evening and night during the sleeping hours. The elastics ensure a forward and backward traction of the maxilla on which the Hyrax appliance is anchored.
The above intraoral pictures show the evolution after 32 weeks of treatment with a Delaire facemask. The anchor hooks for the elastics are aligned with the canines. The alignment of the blue arrows shows that the Class III shift was corrected if you compare with the initial intraoral views. The mandibular arch midline is better aligned.
Post treatment follow-up
The above pictures show the result 6 weeks after the fixed appliances were removed. The treatment with the facemask lasted only 39 weeks. Notice the perfect fit of the arch midlines and the Class I relationship of the canines. The forward functional shift is no longer present. The growth of the jaws will occur in optimal conditions.
The side view during the follow-up appointment 6 weeks after the appliances were removed shows the improvement of the relationship of the upper lip with regard to the lower lip.
The cephalometric X-ray taken when the appliances were removed shows the skeletal correction obtained. The little white arrow indicates that the upper lip is more forward than on the initial X-ray of this young patient.
Here is the dentition of a young girl of 6 years and 5 months of age who presents a Class III malocclusion. The upper teeth are behind the lower teeth (green arrows). The palate is too narrow and causes a right posterior crossbite (blue arrows). The mandibular arch midline deviates to the right of the patient, on the same side as the crossbite.
The profile shows that the upper lip is behind the lower lip and the cephalometric X-ray confirms the backward shift of the upper dentition (white arrow).
This series of pictures shows the evolution after 32 weeks of orthopaedic treatment with a facemask. Notice the improvement of the alignment of the arch midlines (red arrows) and the presence of a positive overjet (green arrow).
The profile shows a drastic change. The cephalometric X-ray confirms the skeletal correction and the dental overjet.
In August 2003, that is 15 months after the patient stopped wearing the facemask, the upper lateral incisors erupted and a lack of space was noted. A new phase of palatal expansion was performed from August 2003 to March 2004. The patient was seen again in June 2007. Irregularities had been noted. The upper right canine was erupting in crossbite.
The patient and her parents decided to begin the last phase of treatment with fixed appliances in both arches in February 2008. Note the crossbite of the upper right canine (blue arrow).
The treatment with fixed appliances (SPEED™ brackets) lasted for 82 weeks, that is from March 2008 to October 2009. The mandibular arch midline fits with the maxillary midline.
The above pictures represent the occlusion 88 weeks after the fixed appliances were removed. Notice the excellent stability of the case. The gingiva which presented some swelling at the papillae during the removal is now perfectly healthy because of an excellent oral hygiene.
The picture on the right indicates that the upper dentition is ahead of the lower dentition.
This series of pictures shows the evolution of the profile on a 10-year period.
2001: Before the protraction facemask.
2002: After the protraction facemask.
2008: Before the major treatment started.
2009: At the end of the major treatment (removal of the fixed appliances).
2011: 2 years after the fixed appliances were removed.
Ngan P. et al, Treatment response and long-term dentofacial adaptation to maxillary expansion and protraction, Semin Orthod 1997; 3:255-264
Ngan p., Early timely treatment of class III malocclusion, Semin Orthod 2005; 11:140-145
Turley P.K., Treatment of class III malocclusion with maxillary expansion and protraction, Semin Orthod 2007; 13:143-157
Baccetti T., Franchi L., The long-term perspective on orthodopedic treatment of class III malocclusion, Craniofacial growth series volume 44, page 105-15
Other chapters of the same book: Dr Turley page 117-133 and Dr Ngan page 135-145