Bücco - Guide ortho
Home » Dental news » Protraction facemask

Protraction facemask

Definition

Protraction facemask, facemask, protraction mask, orthopaedic facemask, Delaire mask are many names designating the same appliance.

Delaire facemask

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.

Facemask in front view

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.

 

.

Evolution after 9 weeks of treatment

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.

.

 

Picture on the left: Evolution after 21 weeks of treatment with a facemask worn during the sleeping hours. Picture of the right: Results obtained at the end of the treatment when the fixed appliances were removed.

 

 

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.

 

Back to top.

Why do we need to treat Class III malocclusions at an early age?

Wear facet and risk of gingival recession

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.

Anterior (forward) functional shift

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.

Back to top.

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.

Back to top.

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.

Back to top.

Clinical cases

Class III, young mixed dentition.

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.

Class III, side view

Class III, initial lateral cephalometric view

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.

.

Back to top.

Treatment

Case #1

Hyrax as facemask

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.

.

.

Delaire mask, front and side views.

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.

.

Evolution at 32 weeks of treatment

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

Follow-up 6 weeks after the treatment

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.

Post treatment profile

Post treatment cephalometric view

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.

.

Back to top.

_______________________________________________________________________________________________________________________________________

Case #2

Class III, primary dentition. August 2001.

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.

Class III, side view.

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).

.

Evolution after 32 weeks of orthopaedic correction with a Delaire mask. April 2002.

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).

Evolution of the profile after orthopaedic treatment with a facemask

The profile shows a drastic change. The cephalometric X-ray confirms the skeletal correction and the dental overjet.

.

Evolution in August 2003, 15 months after the patient stopped wearing the facemask

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.

Evolution in February 2008

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).

Final occlusion after a treatment with fixed appliances

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.

Evolution 88 weeks after the fixed appliances were removed

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.

Profile comparison with the cephalometric view

The picture on the right indicates that the upper dentition is ahead of the lower dentition.

.

Evolution of the profile on a 10-year period

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.

.

Back to top.

.

Bibliography

 

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

Questions and comments

Leave a comment

  1. yemi says:

    very interesting results. was there a need to prop open the occlusion anteriorly, with maybe a posterior bite plane in any of the cases?

    1. No. It is not necessary to use open the bite while doing maxillary protraction. As the maxilla is pulled forward and down, relative extrusion occur posteriorly and correct the deepbite.

  2. Emily Christofidou says:

    Very interesting article.

  3. Medhat says:

    Hallo Dr. Chamberland, i hope you did enjoy your stay while lecturing in Belgium. Unfortunately i could not attend, hopefully next time.
    I have some questions regarding using the face mask:
    1- Does the commonly seen eversion of the upper anterior teeth (i.e. compensation class III) influence your decision using the face mask?
    As you start treatment from an already compensated situation, this will make the labioversion of the upper incisors worse after using the face mask.
    2- what about cases with impacted canines, do you combine the face mask with a protrusion utility arch. Or prefere afouding the risk of root resorption of the lateral incisors?
    Thank you,
    Best regards,

    1. Hi Dr Medhat,

      Yes I enjooyed very much my stay in Bruxelles.

      Question 1.

      Facemask therapy is recommended for young patient, ideally 5 to 7-8 years old, but also 8to 10 years old. At this age, there is usually few if any dental compensation or eversion of the upper incisors.  Therefore, i do not worry that much about increasing dental compensation when  protracting the maxilla at this young age.

      Dental compensation in a class III malocclusion will likely appear after the facemask therapy as the cl III growth pattern will continue to express from, let’s say, age 7 to 12 assuming the patient was treated at age 6. It is during the pubertal growth spurt that will will know for sure if our interceptive treatment will old and a positive overbite will be maintained.

      I have very limited experience of facemask therapy in adloescent patient. Often time, if they have a cl III relatioship at this age, i will let them grow and treate them surgically at 17-18.

      Question 2

      An impacted canine will likely be diagnose in a patient older than 12-13. I do not do facemask therapy at this age because of poor prognosis. However, Dr DeClerk who is from Belgium and who you likely know well, might use his Bone anchor system where he can pull the bone with cl III elastics and move the teeth in opposite direction. I can not say more. You should ask him.

      However, I may be treating a case that would fit some of your description. She is 11 years old. Constricted maxilla, posterior crossbite, blocked out maxillary canine, proclined lower incisors, retroclined lower incisors.

      Classe-III-masque-de-protraction-Chamberland-Orthodontiste-a-Quebec

      I did RPE , extracted #53 and she wear a protraction face mask since june 2014. The patient and her parents were told that she will likely need orthognathic surgery.

      I get some maxillary protraction but i still have no room for the canines. Of course, i will not put braces in the upper arch until i get enough overjet and class I molar relationship. Putting braces would move incisors into collision with impacted 13.

      She come back next week. I will take progress records. Wish me good luck. I will need it.

       

  4. Dr. M. Ashrafi says:

    How will face mask effect in open bite cases,
    will it worsen the vertical growth pattern patient ?
    Thanks

    1. Face mask therapy and open bite

      Hi Dr Ashrafi

      Sorry for the delay to answer your question. I need a moment to find the appropriate case.

      Vaughn et al (AJODO 2005) published a randomized clinical trial on the effects of maxillary protraction therapy with and without RPE. The conclusion say that PRM therapy produce equivalent changes with or without RPE. Correction results from a combination of skeletal and dental changes that produce an improvement in the skeletal, dental and soft tissue relationship. Skeletal change was a combination of anterior and vertical movement of maxilla and posterior and downward movement of the mandible,

      Therefore i agree with you that there might be a risk of worsening an openbite. But i have treated some case and it was not that bad.

      Here are 2 exemple.

      Case 1

      JeBeSe-classe-III-protraction-face-mask-Chamberland-orthodontiste-a-QuebecCeph-initial-fin-ph-1-masque-de-delaire-beSeJe-Chamberland-orthodontsite-a-Quebec
      As you can see, there was no overbite at the beginning, but at the end of phase 1, a positive overbite of 1 mm was obtain.

      Case 2

      MaAnFa-cl-III-openbite-masque-de-Delaire-Chamberland-Orthodontiste-a-Quebec
      MaAnFa-ceph-initial-fin-ph-1-Chamberland-Orthodontiste-a-Quebec
      This case show an openbite of 1-2 mm, a posterior crossbite and significant arch length discrepancy. Progress at 6 months show a positive overjet and overbite. Lower canine were extracted to allow uprighting of the lower incisors and alleviate crowding. Follow up at 28 month post phase 1 show an edge to edge incisor relationship. The your boy is now 12 years old and is getting into his pubertal growth spurt. Chances are that class III relationship might worsen. He is under observation. I will likely not recommand phase 2 treatment until the growth has ceased.
      The ceph show initial and end of phase 1 therapy.

       

      Gregory A. Vaughn, Brian Mason, Hong-Beom Moon, and Patrick K. Turley, The effects of maxillary protraction therapy with or without rapid palatal expansion: A prospective, randomized clinical trial, Am J Orthod Dentofacial Orthop 2005;128:299-309

       

  5. amine says:

    thanks Dr.Chamberland for this intresting demonstrations
    I have a question if you allow me.
    Can we apply facemask therapy simultaneously with Hyrax palatal expander when the expansion screw is activated?

    Thanks a lot Dr Chamberland i realy need to know.

      1. Dr Amine says:

        thank you doctor

  6. Hongjin says:

    Hello dr chamberland, nice article up there.
    I have a question dr, does the chin cup in this protraction mask limits the forward growth of mandible? Or helps in directing it downward, like the chin cup therapy.

    1. The chincup does not limit or reduce mandibular growth. However, the the maxilla is protracted forward and downard, therefore the chin move down as the there is some opening of the mandibular plane.

  7. L says:

    Hello doctor,

    Is protraction face mask therapy non surgical? And at what point in time is it too late to have this? For example, could a 17-year-old be treated and see successful results? If it is possible, is it much more difficult to adjust than adolescents?

    Thank you.

    1. Face mask therapy is a non surgical approach to class III malocclusion in very young patients of 5 to 8 years old.

      It is not effective in adult. I consider a 17-year old an adult because much of the growth is done. Best treatment for class III at taht age would likely be surgical.

      1. Livia says:

        Thank you for your response! I know that there may be another article for this, but I’m just going to ask under the already existing thread.
        Can I wear a palatal expander and expect successful results?
        I’m 17 and I have crowding in my teeth because I have a small mouth (maybe because I have an underdeveloped maxilla??).
        If I wanted braces, would I have to wear an expander first?
        Would it be effective for someone my age, and would it be more painful?
        Thank you.

        1. Skeletal expansion can be done non surgically  at your age if you have abone anchor skeletal expander. The fact that you have crowding does not mean that you have a narrow maxilla.  Extraction may be indicated instaed of maxillary expansion. I can’t tell without seeing you.

          It will not be that much painful at your age. I would not worry.

          Have a consultation with a certifed orthodontist to learn more.

          1. L says:

            Hello again

            Thank you for your response. Along with widening the mouth/ opening the suture, will a palatal expander help bring out a deficient maxilla? For example, to achieve midfacial balance. My midface is a bit sunken in. I’m not sure why yet, but if it’s because of an underdeveloped maxilla, will an expander help? Or are expanders only for braces? Would I need some sort of headgear? Sorry for the many questions and thank you for your help!

            1. At your age, 17 y, or any age, expansion alone will not bring the maxilla forward.

              The goal of maxillary expansion is to correct the maxillary transverse deficiency, not the AP deficiency. Other means will be necessary to correct the AP position of your maxilla and a face mask won’t help at 17 years old.

  8. Paula says:

    Hi my name is paula I’m 32 years old and I had braces at very young age until 16 due my upper jaw was protrude they took two teeth out so they can move the maxilla back, but my profile still looks a bit protrude can this mask help me to close the spaces where the teeth were there? Thank you

    1. CHances are that you have a retrognatic mandible and you may need a surgery to advance the mandible of the chin.

  9. dr Vuyani Dubula says:

    Is it safe to use a protraction face mask when the patient has no premolars

    1. It is safe to use a protraction facemask on primary molars. If the fisrt molar are erupted, an appliance anchor on 1st molar is used.

  10. Justin Gardner says:

    Dr Chamberlain,

    Our daughter just started with a protraction face mask (Ormco part#716-0002). She is very excited and willing to wear the mask but it WILL NOT stay on at night. Any advice on how to get it to stay in place at night? Or should we discuss a different style mask with our orthodontist.

    Thank you,
    The Gardners

    1. Usually the patients get use to it and can keep it at night. If she can, then I would recommend to wear it daytime for 12 hours.

  11. Jana Jacques says:

    Dr Chamberland my granddaughter has used this device for a few weeks now. She is developing a rash on her chin. Possibly from drooling while asleep. Any suggestions on how to prevent and treat this rash. Thank you Jana Jacques

    1. For the rash, I recommend to use miniserviette féminine (minifeminie pad) into the menton pad and the frontal pad. It is very soft and non allergic.

  12. Emily says:

    Dear Dr.Chamberland,

    Thanks for the great write up about the PFM therapy! May i asked if you have cases with upper fixed appliance used in combination with PFM therapy? I ll be grateful if you could share your case here.Thanks

    1. No. I don’t use PFM on upper fixed appliance (braces). It is via a tooth-borne expansion device or a hybrid bone-borne tooth-borne device.

  13. Sandalee Karunaratne says:

    Dr. Chamberland,

    My daughter who is 11 years old just started this therapy. Our Dr. has fixed the appliance which we have to expand and reverse as accordingly for several weeks before fixing the face mask. Within the 1 month the process started, the appliance got removed 3 times off the cement fixed to it. Our Dr. is now not sure to carry on the process as if it comes out when the face mask is on; it would hurt my daughter’s face. Now for the 4th time he has taken the impression to make a new one.
    What could the reason be. Even our Dr. said he had encountered such a case for the first time. Even if it is strongly cemented the appliance got removed. Value your advice on this.
    Thank you,
    Sandalee

    1. It is sad that the appliance come off her teeth. The teeth need to be ecthc, wash and dry before placing the device. If it get remove, it is either bad cimentation or bad appliance design. It is very rare that one of my appliace get removed although it could occur sometime.
      It is the best decision to make a new one and not recement the old one.

  14. Hong Li says:

    Hi Dr Chamberland,

    How/would you use the chin cup and face mask to treat combination case (11 yrs old boy with 2mm deficient max with 1mm negative overjet) to protract max and limit mandibular growth ?
    Since you mention earlier on that face mask doesn’t control mand growth.

    Thanks

    1. At this age we can use hybrid hyrax with 2 miniscrew. This would help protracting the maxilla. It is true that the Facemask does not limit mandibular growth. The goal os to bring the maxilla forward enough to achieve positive overjet + some extra.

      This case show the change in only 2 weeks. The expansion device was bonded, activation 1 swing per day. Wear of facemask 12 hours per days.

      At baseline, centric relation show edge to edge incisor relationship. At 14 days, a positive overjet is obtained. The patient is 9 years old.

  15. qing guo says:

    Thank you for the great article! I really enjoyed reading it.
    I have these questions:

    1. Would you consider NOT using the facemask in a vertical grower or high angle case – in case the mandible rotates too much after facemask and patient looks too long in the face? What can be done instead if you are concerned with vertical growth? Or at that age (7-8) it is still early therefore not to worry?

    2. Would you prefer bonded expander with occlusal coverage over a banded hyrex so the expansion is more orthopedic and less buccal tipping?

    Regards

    1. I would be hesitant to use a facemask in a vertical grower if there is an open bite. However, if one use an hybrid hyrax with miniscrew, forward movement of the maxilla will be easier. See the picture above.

      I don’t use bonded expander with occlusal rest. I only use banded expansion device.

  16. Hong Li says:

    In the case of mandibular excessive growth:

    Do you ever make use of chin cup?

    or just wait till 18 yrs old and surgery?

    Thank you

    1. No, I do not use a chin cup. It would be very impopular in my area. It will not stop mandibular growth anyway.
      Orthognathic surgery is easy, accessible and predictable. Moreover, our health care system cover the cost.

  17. Dian Amir says:

    Hi Dr. Chamberland

    My patient is a boy 8 yrs old, with maxillary retrognathi, crossbite anterior teeth and posterior teeth. His permanent first molar is not full erupted yet and dm2 has necrotic and mobile also. I’m planning to use PFM.
    What is your suggestion about type of RME and hook for PFM for this case? Should I wait until the maxillary permanent molar full erupt, so I can put the molar band on it.
    I’m looking forward hearing from you
    Thank you Doctor.

    1. I would wait to get the 1st molar in. i would not rely on deciduous molar that are necrotic and mobile. But yes i did PFM in youger patient on their deciduous second molar.
      I hope that help

Leave a Reply



Votre adresse de messagerie et votre téléphone ne seront pas publiés. Les champs obligatoires sont indiqués avec un astérisque (*).

 


Loading...