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Protraction Facial Mask

Samuel Berkowitz

23A.1 Protraction of the Maxilla

Using Orthopedics
Children with complete unilateral and bilateral cleft
of the lip and palate are usually at risk for poor facial
growth. They are prone to developing midfacial retrusion related to maxillary hypoplasia or growth retardation secondary to excessive palatal scarring. Usually, this results in an anterior dental crossbite or
severely rotated maxillary incisors which may occlude
in a tip-to-tip relationship with the mandibular incisors. Depending on the age of the patient and the
extent of midfacial maldevelopment, some of these
early problems can be corrected using midfacial orthopedic protraction forces which increase growth at
the circumaxillary sutures as they are repositioned
anteriorly (Fig. 23A.1). When all else fails, midfacial
surgery is available.
Some of the earlier work in this field, which encouraged a rethinking of the use of orthopedic forces
for the correction of midfacial retrusion, includes
Hass [1], Delaire [2], Delaire et al. [35, 9], Irie and
Nakamura [6], Ranta [7], Subtelny [8], Friede and
Lennartsson [10], Sarnas and Rune [11], Berkowitz
[12], Tindlund [13], Nanda [14], and Molstad and
Dahl [15]. More recently this area has been influenced
by the work of Tindlund et al. [618] and Buschang et
al. [19].
Earlier attempts by Kettle and Burnapp [20] in
which anteriorly directed extraoral forces were derived from chin caps were relatively unsuccessful.
Facial mask therapy seems to offer better control and
a wider range of force application.
In many cases, in the mixed dentition, palatal expansion using fixed orthodontic appliances was
applied simultaneously with protraction to correct a
bilateral crossbite and create a more favorable condition for midfacial growth and development.
Prior to the use of orthopedic forces, many standard orthodontic treatments designed to move the

Fig. 23A.1 a, b. Protraction of the maxillary complex using

orthopedic forces. The maxilla articulates with nine bones: two

of the cranium, the frontal and ethmoid, and seven of the face,
viz., the nasal zygomatic, lacrimal, inferior and nasal concha,
palatine, vomer and its fellow of the opposite side. Sometimes it
articulates with the orbital surface, and sometimes with the
lateral pterygoid plate of the sphenoid. Illustration showing
how protraction forces applied to the maxilla depend on the
disarticulation and growth at all the dependent sutures. (Courtesy of E. Genevoc)


S. Berkowitz

Fig. 23A.2. a Frontal and b lateral views of a Delaire-style pro-

traction facial mask. Padded chin and forehead rests distribute

reaction forces of 350400 gm per side equally to both areas.
Elastics are attached to hooks placed on the arch wire between
the cuspids and lateral incisor. c Intraoral view of edgewise rec-

dentition to correct a Class III malocclusion due to

midfacial retrusion in the absence of mandibular
prognathism failed. Orthodontic forces applied to the
teeth by Class III elastics would not displace the maxilla; at best they would flare the maxillary incisors
without creating an adequate incisor overbite and axial inclination. This treatment was found to be unsatisfactory and soon fell out of favor.
Since 1975 Berkowitz has been using a modified
protraction facial mask originally popularized by Delaire et al. [3] (Figs. 23A.223A.4). It has been very
successful in controlling the direction of protruding
forces without causing severe sore spots on the chin or
forehead. He has found that protraction forces do not
modify the direction of mandibular growth as Delaire
et al. [3] claimed, but by increasing midfacial height,
the mandible is repositioned downward and backward with growth to make the patients maxillary
retrusion appear less evident.

tangular arch with hooks for protraction elastics. d, e, f Delairestyle protraction facial mask used with a fixed labial-palatal
wire framework. Elastic forces of 350400 gm per side can still
be used with this intraoral framework

Protraction forces (350450 gm per side) must be

intermittent (the mask is worn only for 12 h per day),
and directed downward and forward from a hook located mesial to the maxillary cuspids. Pulling downward from the molars should be avoided because it
will tilt the palatal plane downward in the back by extruding the molars and thus opening the bite. When
the midfacial height is deficient, protraction forces
need to be modified to increase vertical as well as anterior growth. This is done by using more vertically
directed elastic forces.
Berkowitz has found 350450 gm of force per side
to be adequate in most instances, but there are rare instances when the elastic force needs to be reduced to
prevent sore spots at the chin point. Friede and
Lennartsson [10] have used protraction forces between 150 to 500 gm per side. Ire and Nakamura [6]
have used 400 gm per side, Roberts and Subtelny [21]
670 gm, Sarnas and Rune [11] 300800 gm, and Tind-

Chapter 23A

Protraction Facial Mask

Fig. 23A.3 ax. Case BB (WW-62). Maxillary protraction in a

UCLP. a Complete unilateral cleft lip and palate. b, c Lip and
nose after surgery. d Cuspid crossbite of the lateral cleft seg-

ment at 5 years of age due to mesioangular rotation of the

lund et al. [1618] 350 gm per side. Unfortunately,

when performed in the mixed dentition, treatment
time may extend into years because of the need to
keep pace with mandibular growth. If this is the case,
treatment should be divided into intermittent periods
not to exceed 6 months at a time with a break for
1 month between periods. Following this formula, the
patient will usually remain cooperative.
Although Berkowitz has been successful in using
strong elastic forces with labile-lingual appliances
during the deciduous dentition, he recommends

palatal segment. e Buccal occlusion after expansion using a

quad helix expander. f, g 6 years of age. Note relapse of cuspid
crossbite due to failure of using a palatal arch retainer. h Palatal
view showing good arch form

starting treatment at 78 years of age when all of the

maxillary incisors can be bracketed and a rectangular
edgewise arch with lingual root torque used as Subtelny [8] suggested. The torqued rectangular arch will
carry the incisor roots forward, moving skeletal landmark point A anteriorly, which prevents stripping of
the alveolar crest with subsequent incisor flaring. The
arch wire needs to be tied back so that it does not slide
anteriorly, tipping the incisor, rather than moving the
entire maxilla forward orthopedically.



S. Berkowitz

Fig. 23A.3 ax. (continued) i, j Facial photographs at 8 years.
k Orthodontic alignment of incisors prior to secondary alveolar bone graft. l Protraction facial mask with elastics. m, n Class

III elastics used to maintain tension at circumaxillary suture

during the time not wearing protraction forces. o Occlusion

after orthopedic-orthodontic forces. Lateral incisor space regained. p Removal retainer with lateral incisor pontic

Chapter 23A

Protraction Facial Mask

Fig. 23A.3 ax. (continued) q, r Fixed bridge at 18 years of age replacing missing lateral incisor and stabilizing maxillary arch form.
s, t, u 17 years prior to nose-lip revision. v, w, x Facial photos at 19 years, showing good facial symmetry after revision



S. Berkowitz

Fig. 23A.4. Case BB (WW-62) a Lateral cephalometric tracings

Tindlund et al. [1618] conclude that early transverse expansion of the maxilla together with protraction orthodontic treatment is an effective method for
normalizing maxillo-mandibular discrepancies in
cleft lip and palate patients. The average age at the
start of treatment was 6 years, 11 months, and the average duration of treatment was 13 months. Significant changes were achieved due to anterior movement
of the upper jaw and a more posterior positioning of
the lower jaw resulting from clockwise mandibular
Berkowitz also found that the combined use of
palatal expansion and protraction forces before the
pubertal growth spurt to be a more efficient means of
gaining orthopedic advancement than the use of protraction forces alone. He speculates that the expansion
forces possibly disarticulate the circumaxillary sutures, thus allowing the maxillary complex to be carried downward and forward more easily.
Delaire et al. [5] and Subtelny [8] have stated that
orthopedic forces applied to the entire maxillary com-

and superimposed polygons (Basion Horizontal Method) for

Case BB (WW-62) show an excellent facial growth pattern.
b The midfacial growth increment between 15 to 16-4, when the
protraction facial mast was used, increased midfacial protrusion to a greater degree than that which would have occurred

plex are more likely to be effective in younger children.

Berkowitzs clinical experience supports the recommendation by Abyholm et al. [22] and Bergland et
al. [23] (1) that a rigid fixation of the advanced maxilla should be maintained for at least 3 months after
bone grafting, and (2) the use of protraction forces.
This is necessary to help reduce the tendency to relapse created by the surrounding soft tissue of the lip,
muscles, and skin.
Many patients with a complete bilateral cleft lip
and palate have a protruding premaxilla until 10 years
of age or older, but after the postnatal mandibular
growth spurt, the maxillary incisor teeth may be in
crossbite. Protraction orthopedic forces with anterior
criss-cross elastics upright and reposition the premaxilla forward, perhaps by inducing bone growth at
the premaxillary-vomerine suture. Fixed retention is
always necessary to control the improved incisal overbiteoverjet relationship at least until secondary alveolar bone grafting is done.

Chapter 23A

1. Haas AJ. Palatal expansion: just the beginning of dentofacial orthopedics. Am J Orthod 1970; 57:219255.
2. Delaire J. Considerations sur la croissance faciale (en particulier du maxillaire superieur): deductions therapeutiques.
Rev Stomatol 1971; 72:5776.
3. Delaire J, Verdon P, Lumineau J-P, Chierga-Negrea A, Talmant J, Boisson M. Quelques resultats de tractions extraorales a appui fronto-mentonnier dans le traitement orthopedique des malformations maxillo-mandibulaires de
classe III et des sequelles osseuses des fentes labio-maxillaires. Rev Stomatol 1972; 73:633642.
4. Delaire J, Verdon P, Kenesi MC. Extraorale Zugkraften mit
Stirn-Kinn-Abstutzung zur Behandlung der Oberkieferdeformierungen als Folge von Lippen-Kiefer-Gaumenspalten.
Fortschr Kieferorthop 1973; 34:225237.
5. Delaire J,Verdon P, Flour J. Ziele und Ergebnisse extraoraler
Zuge in postero-anteriorer Richtung in Anwendung einer
orthopdischen Maske bei der Behandlung von Fallen der
Klasse III. Fortschr Kieferorthop 1976; 37:247262.
6. Irie M, Nakamura S. Orthopedic approach to severe skeletal
Class III malocclusion. Am J Orthod 1974; 67:375377.
7. Ranta R. Protraction of cleft maxilla. Eur J Orthod 1988;
8. Subtelny JD. Oral respiration: facial maldevelopment and
corrective dentofacial orthopedics. Angle Orthod 1980;
9. Delaire J, Verdon P, Flour J. Moglichkeiten und Grenzen extraoraler Krafte in postero-anteriorer Richtung unter Verwendung der orthopdischen Maske. Forttschr Kieferorthop 1978; 39:2740.
10. Friede H, Lennartsson B. Forward traction of the maxilla in
cleft lip and palate patients. Eur J Orthod 1981; 3:2139.
11. Sarnas K-V, Rune B. Extraoral traction to the maxilla with
face mask: a follow-up of 17 consecutively treated patients
with and without cleft lip and palate. Cleft Palate J 1987;
12. Berkowitz S. Some questions, a few answers in maxillamandibular surgery. Clin Plast Surg 1982; 9:603633.

Protraction Facial Mask

13. Tindlund RS. Orthopaedic protraction of the midface in the
deciduous dentition: results covering 3 years out of treatment. J Craniomaxillofac Surg 1989; 17(Suppl. 1):1719.
14. Nanda R. Differential response of midfacial sutures and
bones to anteriorly directed extraoral forces in monkeys. J
Dent Res 1978; 57:362.
15. Molstad K, Dahl E. Face mask therapy in children with cleft
lip and palate. Eur J Orthod 1987; 9:32113215.
16. Tindlund RS, Rygh P. Maxillary protraction: different effects on facial morphology in unilateral and bilateral cleft
lip and palate patients. Cleft Palate Crainofac J 1993;
17. Tindlund RS, Rygh P, Boe OE. Orthopedic protraction of the
upper jaw in cleft lip and palate patents during the deciduous and mixed dentition in comparison with normal
growth and development. Cleft Palate Craniofac J 1993a;
18. Tindlund RS, Rygh P, Boe OE. Intercanine widening and
sagittal effect of maxillary transverse expansion in patients
with cleft lip and palate during the deciduous and mixed
dentitions. Cleft Palate Craniofac J 1933b; 30:195207.
19. Buschang PH, Porter C, Genecov E, Genecov D. Face mask
therapy of preadolescents with unilateral cleft lip and
palate. Angle Orthod 1994; 64:145150.
20. Kettle MA, Burnapp DR. Occipito-mental anchorage in the
orthodontic treatment of dental deformities due to cleft lip
and palate. Br Dent J 1955; 989:1114.
21. Roberts CA, Subtelny JD. Use of the face mask in the treatment of maxillary skeletal retrusion. Am J Orthod Dentofacial Orthod 1988; 93:388394.
22. Abyholm FE, Bergland O, Semb G. Secondary bone grafting
of alveolar clefts: a surgical/orthodontic treatment enabling a non-prosthodontic rehabilitation in cleft lip and
palate patients. Scand J Reconstr Surg 1981; 15:127.
23. Bergland O, Semb G, Abydholm F, Borchgrevink H, Eskeland G. Secondary bone grafting and orthodontic treatment on patients with bilateral complete clefts of the lip
and palate. Ann Plast Surg 1986; 17:460471.