Chapter 15

ORTHOPEDIC FACIAL MASK

THERAPY
Of all the options available to
alocclusion, the onthopedic acialthe orthodontist in the treatment
of the early developing Cass
Cass l malocclusion dentiied in mask (Fig. 1) may provide the greatest opportunity to correct a
sk was developed by either the late deciduous or eardy
Delaire(1971, 1976, permanent
Delaire et al., 1972) and refined dentition. The laca
1984, 1991). As the craniofacial complex by Petit (1982_1985,
three planes of space may be produced byinthis juveniles is stil quite malleable, significant changes in
all
maxillary expansion. type of therapy, especially when combined with rapid

Figure 1. Frontal view of the Petit facial mask. Note that the elastics converge on and attach to the

crossbow immediately adjacent to the central suppori bar, The position of the upper and iower pads is

adjustable.

that can lead to the

ere is no question that a wide variety of skeletal and dental configurations exist among
o-workers(1986). others, have
hicalmanifestationola Clas malocclUsiap.gUyer ang had Class Il malocclusions, about 25% had
ted that in a sample of children age 5 to 15 years who An aduitionar
plemaxTlary skelelal retrusion and
about 20% Nad Simple mandibuBar prognathism. had an excessive
Moreover, 40% of the sample
had a combination ol these two relationships.
eranterior facialheighi.
appropriate to select a treatment modality that would fit
would seem
Cm a theoretical perspective, the
t
skeletal retrusion, a chin
rr o rranke in the case maxillary
of
needs of an individual (e.g.
pin the case of mandibuar prognatusm). However, the nalure of the treatment respanse produced
Ihis therapPY is initiated indicate the use of this
the facial mask (Fig. 2) anO ne age a which
problems n tuventes.
plianceina wide range niassi

283
 85

111

9
A
27
B

9:3 10-0

Figute 2.
Typical treatmeni
treatment, at age ine response observed with
C) years and orthopedic facial mask'
Superimpositon of the two three months. 8) After seven
the tiacings along the months of tuerapy. A) Prior to
changes in bc:h
hard tissue and basion-nasion line ortiupudic facial mask
soft tissue
facial contour.
at the
pterygomaxillary therapy.
fissure. Noe

C84
 TREATMENT EFFECTS
PAODUCED BY FACIAL
Even though the orthopedic MASK THERAPY
son,
Jackson, 1904 Sucliffe, 1914),
with the facial mask. Most surprisinnl navailable for over
WIfe.Q., Cooke and publish y lew studies h 100 years
ver 100.years
(Potpeschenigg.1875
-
(Potpeschenigg,-1875
andArcoria,
Vavarro and Arcoria, Wreakes,
191).
1991). i1977: 1977; McNamn with faclal mase lreatment. effects produced
nchorage Unitunit (e.g..
(e.g, bonded
It
appears McNamara,
S hat the the faria5,1987; Roberts
Roberts and Shll en anecdotal in
reatment effects (Eig 2bonded acrylic splint facial mask, and Subtelny,
expander) canespecially when cor ley.1988;
produce one or mote the following
Correction of
is observed inCO-CR discrepancy.
pseudo-Class This correction is
2
Ill
patients. jmmediate and usuail
Maxillary
maxilla is skeletal
observed.protractiop. Usually 1-2 mm of forward
movement of the
3.
Forward movement of the
4.
naxillary dentition.
Lingual tipping of the lower
anterior crossbite is being incisors Ihis tipping often occurs as
.
corrected. a pre-existing
Redirection of mandibular growth in a
which the patient more vertical
height, this changebegins treatment with a short or direction. instances in
In
obviousiy is neutral lower anterior
has a long
iower antericr facial advantageous. In instances in which facial
height at the patient
a

treatment effect may be undesirable. There arebeginning treatment, this

of
facial mask treatment leads to an inhibition of no clinical studies that show that
mandibular growMn.
COMPONENTS OF ORTHOrEDIC FACIAL MASK THERAPY
The therapeutic technique to be described involves the use of
expansion splint and heavy elastics. a
facial mask, a bonded maxillary
The Facial Mask
individual most
responsible for reviving interest in this orthopedic technique is Jean Delaire of
es, FTance (Delaire_1971, 1976; Delaire et al., 1972). Delaires approach involves.applying traction
emaxillary sutures while reciprocaily pushing on the mandible and the forehead through the
rage provided by the facial mask. This approach provides a repositioning of the bores of the
c i a l complex to a greater extent than that which could be carried out by traditional orthodontic
a This basic treatmen:' technique has been used by other clinicians, including Irie and
akamura (1975).
ajor
ges in facial mask design have been prompted by Henri Peit, formerly of Baylor Dental
as now of Paris, France (Peti 1982, 1983, 1984,
1991
Fen advocales the use of the facia
forces.are
DpiardLElavely shot period of time Howe¬r, %aiy LUNS trealment period very heavy
1 Craniofacial complex, The Petit facial mask oriqinaly was consiuuled on a patient-by-
d tone
1ent bas USing G25rQund lenaths of stainless stee, to wnicn paes IOr the lorehead and chin were
ach oaSIS, Decause several hours ere
euir I S iniial approach was not practical on a rOUune1acial mask was Simpiresin and made
the design of the
labl.
addcateeach-applianee-Later,
NY). This latter desian w
able o mmercialy (Great Lakes Orthodontic Products, Icnawanda, pan and forehead
avely sin
Os nple in that it containod a single
midiline roa connecteo
connectod to an
adjustable
to
chin
crossbow.
a pad

and
I n addition,'eastics
were

285
 orno dic Facial Mas
Mask

Figure 3. The lateral view

of the
elastics. The direction
ol
orthopedic facial mask. Note the
the elastics pull can be adjusted downward direction of
must not
interfere with the function by taising or
lowering the
adjustable ciossbar.
pull of the
of the lips. However,

A
Figure 4. The
oropedic tacial mask of Pelit.
B
A) Anterior oblique view. B)
Posterior oblique view.

286
 onthopedic Facial Mask

Figure 9.
Original design of the facial mask. The
Note that the current rectangular support bar (see
version of the
appliance (Figure 4) has shorter extensions ofarrows)
can be removed.
the facial mask shown
in this
figure.
thecrossbow than dces

The position
of the crossbar is
set screw. The final position
adjusted in the vertical dimenslon in a similar manner
of the chin pad is determined first by.placing the by loosening the
intraorally on the hooks of the maxillary splint. The elastics are appropriate elastic
the crossbar. The
vertical position of the crossbar then stretched anteriorly and are attached to
anteriorly from the appliance, crossing at the point of contact is adjusted so that the elastic
extends
of the upper and lower
impingement on
upper lower lip function should be
or lip. Any
not avoided.
cause irritation the corner of the mouth, a potential
to Care must be taken that the elastics do
yersion of the Petit facial mask. problem with the commerciaiy-avaitesle
Sequential Use of Elastics
At the time of the delivery of the facial mask, !he use of
elastics, Ormco Corporation, Glendura, California) bilateral 3/8', 8 oz. elastics (a.g., Tiger
for the
nat time, the force on the mask is increased by using 1/2', first
14
two weeks is recommended. After
0z. elastics (e.g., Whale elastics").
aXimum force is delivered through the use of 5/16" elastics (e.g., Walrus
02. of force. If a patient develops redness o
elastics") that are rated at
other problems with the sot tissue, the amount of
dstic force can be lessencd or the duration of appliance wear can be reduced Care should be taken
make sure that excess pressure is not applied !o the soft tissue. Such heavy pressure can lead to
ueing and irritation of the skin and to gingival problems intraorally.

aly. the patient is instructed to wear the facial mask onaLillLtima basis except during meals
i patients (5-9 years old) usually can follow this regimen, particulariy if the patient is told that ful
me wear will last only 4-6 inonths. n older patients. tuil-tme wear may not be possible. The
pplia should be worn at all times except when the patient isin schoolorpadipaag TCOntact
nce
Sports. Some patientsfind the facial mask idecally is worn during the summer rather than during the
 orthopeg rdcläl Mask

The current version ol the Petit

the forehead andch0regions. facial mask (Fig. 4) is
The pads made of two pads that
foam thatIS.non-absorbent, are made from acrylic and coniact the so l
framework made irom a round, easily cleaned and are lined with a sOL
replaceable. The An
The positions of the pads are contoured length of .25" stainless pads are conneclee.oy.eond
adjustable through the steel with acorn nuts on
midline framework also can be bent to conform loosening and tightening of a ea
(Fig. 3). better to Sel
the outline of the lace of the scre n
indiviouai pa
In the
center of the midline
the main trameworK by a setframework is a crossbar made from 0.075" stainless steelthat is
The ends of the crossbar are Screw. thus allowing the position of the crOSsbar to be secured o
contoured for patient safety (Fig.1) adjusted verticaly.
Bonded Maxillary Splint
The second component of this
appliance
system is the maxillary splint (Fig. 5).
maxillary expansionappliance-hatis-bended to the posterier-dentition This splintan acrylic and wire
to the bonded rapid maxillary expansion is similar
in design
appliance described elsewhere in this appliance and the maxillary portion of the acrylic splint
text. Herosi
In mixed dentilion paticnts, the splint usually covers the
permanent first molars. The hooks for the elastics arise atfirst and second deciduous molars and the
the anterior aspect of
regionof the upper first deciduous molar (Fig. G). In instances in which the appliance in tTE
present, the splint can be instructed so that the only a deciduous dentit:on is
canine as well as the deciduous molars are
included. In these instances, the hooks for theupper
elastic are fabricated adjacent to the
deciduous canines. maxillary

f a bonded maxillary splint is used in

patients in the late mixed or early permanent deniiion (Figs. 7
and 8). modification of e
appliance design often is necessary. ! permanent second )
erupted, it ts ecessaiy tu piace an occlusal rest against these teeth to motars are

teeth during appliance prevent supraerupiionof these

wear. The framework should not be extended to encompass theon
posteriorly because of the danger of opening the bite due to placement of the acrylic secund molars
the occlusal
Surfaces of the upper secomd mTotars.

Modifications also can be made in the position of the facial mask hooks. depending on the direction
force desired. If a downward force on the mailla is_decired, the tciai riask hooks are of
placed at
arying heigh's within the maxillary vestidule. f a more horizontal pulis desired, the haoks are placed
cent to the acrylic near theocclusal_suface. Thelimitingfactor with regard to the direction of pu
S he relative
positions of the upper and lower lip.

maxillarybeen
has
splint is made of airamcwork of 045 rOundstainlesssleelwire towhich an expansion
soldered. The hooks for elastic and ary occlusal rest are made from the same size
re. A sheet of 3 mm thick splint BiocryM is heated and adapted to tine framework and associated
AUsing a BiostarfM thermal pressure machine (Great Lakes Onhodontic Products, Tonawanda
T h e use of a splint BiocryM less than 3 mmi thick can lead to problems in occlusal decalcification
c u e of the abrasion of the appliance by the opposing aentilion and the subsequent contact of
j e fuids with the occlusal surfaces of the involved teeth. In cases of sevce bruxism, a lower
Sible retainer (see Chaper19)canbe uscd atnight toreducetie ocCUsalabrasion due to bruxiSm.
he n orthodoiilic resin and a "salt and
DoXtlary splint also can be fabricated using methyl methcrylala
ha application method. One of the advantages of using a cold Cure 2cryliC 1n the fabrication of
can be incorporated into the acrylic, a íeature that is
O10n c e is
that multiple colors and designs
O9great interest to young palienis.
 Orthopedic Facial Mask

igure 5. Occlusal view of the

patient. Note the bonded rapid palatal expansion appliance Used on
position of the facial mask hooks. a mixed dentition

Figure 6. Lateral view of a bonded maxillany expansion appliance used in a mixed dentition patient.
A
disadvantage of using cold cure
the applance, making mastication acrylic is that often aflat plane is created on the
initially diicult._The use of a BiostariM
approximation of the originalocciusal occlusal surface d
are generally easier to remove
does allow
confiquration In the Biocry, Splints made Irom for the genera
tends to be more than are splints made Biocraso
trom cold-cure acrylic,
flexible. because the Biocry

idfacial orthopedic expansion hes, in itself, shown to be beneficial

Class ll malocclusion. in the treatment of certain
Oppenheim (1944) was one of the first to discuss typeso
1970.1973) has demonstrated that rapid palatal this possiblty.
Haaso
ot Point Aand a slightly downward and expansion can produce a slightly forward Tio
foward
Shown tRIS phenomeoon_ in.non-human _primates.movement ofthe maxilla and Dellinger (19
Haas also. has shown that jncieasea lary
movement.can be enhanced by the use of Class | traction
palatal appliance (Haas. 1970)-
*****
from.a.chin cup 10.the, distal as
Within the contextof2cial mask therapy, the
naxillary Sutural system, presumable effect of such expansion is to druptthe
thus enhancing the effect ui the
adjustmeis occur more
readiy. The orthepedic facial mask by making
bite opening effect of the maxillary splint also may duce Ihe
tendencytoward extrusion of nosterior teelh which has been observed i o the
appliance (Wertz, 1970) the using banded desy
 onhopedic Facial Mask

Figure 7.
Occlusal view of
Note the oclusal rest
a
bonded rapid
extending to the
maxillary splint used in a
patient in the
second molars. permanent denlition.

Figure 8. Lateral
view of the same
appliance shown in Figure 7.

astic Traction
acial mask is
DOW ot thesecured to the face
facial mask by stretching elastics from
of elastics, (Fig. 1). Heavy
the hooks
on the
a
aluent ghter forces ultimately resulting in forces are
a 14 o. Ioice generaieduSually through maxillary splint to
adjusts to the may be u_ed during the the use of
appliand Deng_generated
break-in perie0, by 5/16" elastics
DuLIOrges shoUld be
a

(Peit,
increased as the
NICAL
MANAGEMENT OF THE FACIAL MASK
Cedures used in
umahat concerned bonding the
the bonded maxillary splint are the same
escrid below. The overall rapid maxillary as
tnose
he clinical management
orthodontic literalure (McNanmara,
expansion
ol this appliance.
se
described in detail
These
1987 treatment apprnach procedroe
res 'in
n
 Orthopedic Facial Mask

Impresslons
A standard aluminumtray can be used
splint. often is advisable qulte effectvely when making an
either to take two maxilary
impression ofso that Work models_are impresslon for the maxllan.
application the acrylic. The availabl. both
impresslons or double-pour a single
associated soli tissue. Thé workImpresslon should be for wire-bending and soldering and maxila
models then are checked tor proper toc
poured and trimmed. reproduction of the teeth and
Splint Fabrication and Delivery
The
wire framework is formed from
teeth. Hooks facing .045" round stainless steel
the hooks attachposteriorly are soldered
to the to tt.e framework inwire that is contoured to the
canine (Fig. 6). framework in the reglon of the upper firstthe desired position (Fig. 5).posterior
base wire. Then AHyrax-type expansion screw is deciduous molar or the Usually
a
model using_a Biostarsheet of splint BiocryM is placéd in the middle of the deciduous
extending to the gingival After cooling, thesoftened and formed over thepalate and soldered to the
procedure described in a margins of the involved appliance is trimmed and framework and the work
step-by-step teeth. The polished with the
At the time
fashion in
Chapter 8. splint is bonded into place uslngacrvi
of
appliance bonding, the
facial mask hooks
aa

excess are free from clinician, using dental floss, should

bonding excessive bonding
material
discovered on the day that within the hooks often agent. Since the check to make sure that the
is not bonding agent is
first attached todetected at the time of
CXcessive bonding the elastics are
material and also should not the
appliance. bonding transparent,
and
3Activation contact the
underlying
The
hooks should be only
free
is
of the Spin gingival tissue. of

The patient is
before bedime.instructed to turn
In the majoriky ofthe midline expainsion screw of
ndicated, some maxillary Class Ill individuals for the appliance O1Ice
until the desired expansion is whhom the use of per da, generaly
change is necessanychange in the transversebeneficial. In such instances, the an:orthopedic facial mask IS
dimension is maxillary
produce a disruption inthethemaxillary splint stil achieved. splint
In instances in which is expanded
sutural system thatis activated, usually once a day for
no
transverse
In
bordeline presumably facilitates the action of the
erght to ten days to
change in thecasesr vertical
the
placement andexpansion of the
and
facial mask.
relationship,
wear the
transverse dimenslon
tius other eliminating may
banded RMEappliance and the
produce associated
mask only after the need for facial the desired
school and during ma_k Wear entrcly, orchange in the occlusal
4 Delivery of the Facial nightime hours. allowing the patient to
Mask
The
facial mask usually is
Petit
facia mask (Fig. 4) is delivered two weeks after
of most
paticils. When
available in one placementof the
universal size and can splint.
The current version ot
and the delivering the facial ba
adjusted to fit the facial tne
the pads. positions of the
forehcad, mask, the appliance is
and chin pads are
adjusted
held against the conours
by loosening the set face of the palient
Some screws located in
versions of tho mask also include
original irntetion n!
practical purposes,
this
rectangular support
a
rectangular support vire for the chin
was to allow
do not see pad
u1ovement of the chin(Fig.
mask we
the for vertical n
sh0uld he re'noved need lor this
and
discarded. rectangular support, and thus this part pad.
ot the
ror a
tacia

290
 ert,

Figure 10. A removable maintenance plate with arrow clasps between

upper posterior teeth is worn
time after the facial mask is
removed. Other retention tul
appliances can also be used (see text)
school year, while other patients find the summer the most difficult time to wear ihe
of swimming, baseball, and other summer activities. appliance because
Patients must be instructed to maintain a
indications that the bonded splint
high level of oral hygiene and to report immediately any
might
become loosened in
The patient should be seen
any area.
every three to five weeks- ta check the condition of the splint and
changes. to'evaluate hard and soft tissue

DiscontinuationolFreatmet
One question that often arises.concerns the indications for the discontinuance of treatment. The facial
mask usually is worn until a positive overiet of 2-5 mm is achieved interincisally, Atthis time,
part time
or nlghttime wear is recommended for an additional three to six month period. The maillary spint IS
then removed, using a bracket-removing plier with a
sharp edge (e.g.. 349 anterior bracket removing
plier, ETM Corporation, Monrovia. A). Aremovable palatal stabilization_plate with arrow clasps
berween the first and second deciduOuS molarsis worn fl time (Fig. 10). In cases oi prolound
neuromuscuiar imbáiances the FR-3appliance of Fränkel (Fränkel, 1976; Fränkel and Frankel, T99
MCNamaa and Huge, 1985) can be worn as an active retainer. A chin cup can be worn as a retainer in
patients with residual mandibular prognathism.
The facial mask shoiild be discontinued immediately if the patient complains of any symplois O
temporomandibular (TM disorders. Although rare, signs and symptoms of TM disorderare obse
in palients wearing the facial mask, immediate discontinuance of the appliance usually resUiis
reversal of the symptomatologgy.

other Considerations ealy

in
time to intervene an
The question arises as to the ideal time at which to intervene. The optimal
incisors. Usually the
lower
ine
Class lll patient is at the time of initial eruption of the upper central
 have already eruplea, and by timing facial
incisors, a
positive vertical and horizontal mask therapy to coinckde wlth the
maintained. t
appears that the overlap of the eruptlon of
the uppe
the cverbite and maintenance
overjet correction. of an permanent
anterior occlusion
incisors
i can be achleved anc
is extremely important to susta
As with al types of
intercepled and treated.ornhodontic
Obviously,
treatment, not every Class Ill malocclusion
Gmore severe the malocclusion, the blder the patient at the can be
successu
the less is the likelihood of time of the onsel ol
a Sronq tamily hi_iory of
mandibular successful treatment without irealme***
stable Outcome. However, in many prognathism surgerY SO
or other Class lll
this type therapy produces a
of ot the mild IO moderate and some patients lessens the prognosIs Tor
When used with caution and pronounced occlusal change within rather severe Class
with the a
relatively short perlod orcases.
guarantees long-term stabilty, this appropriate disclalmers to the parents regarding the time
of
type of treatment has proven laCk o
variety of Class Ill conditions. extremely rewarding in a WOE

In
approximately 50% of those
patients in whom facial mask
a secord phase of
treatment often is therapy is initiated in the mixed
eruption ct the permanent teeth has necessary prior to the placement of fixed denttion.
placement ol a bonded or banded occurred. This type of intervention appliances after the
rapid simply may Invove
reintroduction of facial mask maxillary expansion appliance. It also may tne
given the patient or the
to therapy, either on a full-time require tne
or
part-time basis. No
because of the varied parents regarding the long-term outcome of this type guarantees of treatment
should be

environmental factors. etiologies of Class ll malocclusion that include both progran.

hereditary and

The orthopedic facial mask treatment described in

maintained using either a this chapter, especially if the treatment result is
means of actively maintenance plate,
a FR-3
appliance of Fränke, or a chin
this treatinent are intervening patient with ine developing Class ll malocclusion.cup. provkdes a
in the
uite dramatic, usually The results of
vertical overlap of the occurring within a four to six
upper and lower incisors Is achieved, theremonth period, and if a positive
maintaining the corrected result during the transition to is a reasonable
chance of
the permanent dentition.

ACKNOWLEDGMENTS
The senior author would like tothank Henri Petit for
crthopedic facial mask therapy. His introducing him to the concept of heavy force
must be recognized as
ideas, which are based in part on the
innovative apprcach to the treatment ofteachings
of Jean Delaire,
and
providing an
dental problems in the young Class lll patient. early-developing skeletal

REFERENCES C'TED
OKe, M,S. 3nd G. Wreakes. The face mask: a new form of reverse
168, 1977. headgear. Br. i Orhd.4:162-
re,J. Confection du masque orthupeuique. Rov. Stomat. Paris, 72:579-584, 1971.
elaire,
r,.articulation fronto-maxillaire. 8ases theoriques et principles generaux d'application le
dices extra-orales
976. postero-änterieures sur masque orthopedique. Rev. Stomat. Paris, 77:921-930,

uelaire.
tats P. Verson, J.P. Lumineau, A. Ghega-Negrea, J. Talmant, and M. 80isson.
Quelques
es tractions extra-orals a appui tronto-mentonnier dans de traitement orthopedique des
293