Protraction Facial Mask (Berkowitz)

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23A.1 Protraction of the MaxillaUsing Orthopedics

Children with complete unilateral and bilateral cleftof the lip and palate are usually at risk for poor facialgrowth. They are prone to developing midfacial retru-sion related to maxillary hypoplasia or growth retar-dation secondary to excessive palatal scarring. Usual-ly, this results in an anterior dental crossbite orseverely rotated maxillary incisors which may occludein a tip-to-tip relationship with the mandibular inci-sors. Depending on the age of the patient and theextent of midfacial maldevelopment, some of theseearly problems can be corrected using midfacial or-

thopedic protraction forces which increase growth atthe circumaxillary sutures as they are repositionedanteriorly (Fig.23A.1). When all else fails, midfacialsurgery is available.

Some of the earlier work in this field, which en-couraged a rethinking of the use of orthopedic forcesfor the correction of midfacial retrusion, includesHass [1], Delaire [2], Delaire et al. [3–5, 9], Irie andNakamura [6], Ranta [7], Subtelny [8], Friede andLennartsson [10], Sarnas and Rune [11], Berkowitz[12], Tindlund [13], Nanda [14], and Molstad andDahl [15]. More recently this area has been influenced

by the work of Tindlund et al. [6–18] and Buschang etal. [19].Earlier attempts by Kettle and Burnapp [20] in

which anteriorly directed extraoral forces were de-rived from chin caps were relatively unsuccessful.Facial mask therapy seems to offer better control anda wider range of force application.

In many cases, in the mixed dentition, palatal ex-pansion using fixed orthodontic appliances wasapplied simultaneously with protraction to correct abilateral crossbite and create a more favorable condi-tion for midfacial growth and development.

Prior to the use of orthopedic forces, many stan-dard orthodontic treatments designed to move the

Protraction Facial Mask Samuel Berkowitz

23A

Fig. 23A.1 a, b. Protraction of the maxillary complex usingorthopedic forces.The maxilla articulates with nine bones: twoof 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 itarticulates with the orbital surface, and sometimes with thelateral pterygoid plate of the sphenoid. Illustration showinghow protraction forces applied to the maxilla depend on thedisarticulation and growth at all the dependent sutures. (Cour-tesy of E. Genevoc)

a

b



dentition to correct a Class III malocclusion due tomidfacial retrusion in the absence of mandibularprognathism failed. Orthodontic forces applied to theteeth by Class III elastics would not displace the max-illa; at best they would flare the maxillary incisors

without creating an adequate incisor overbite and ax-ial inclination. This treatment was found to be unsat-isfactory and soon fell out of favor.

Since 1975 Berkowitz has been using a modifiedprotraction facial mask originally popularized by De-laire et al. [3] (Figs.23A.2–23A.4). It has been very successful in controlling the direction of protrudingforces without causing severe sore spots on the chin orforehead.He has found that protraction forces do notmodify the direction of mandibular growth as Delaireet al. [3] claimed, but by increasing midfacial height,the mandible is repositioned downward and back-

ward with growth to make the patient’s maxillary retrusion appear less evident.

Protraction forces (350–450 gm per side) must beintermittent (the mask is worn only for 12h perday),and directed downward and forward from a hook lo-cated mesial to the maxillary cuspids. Pulling down-ward from the molars should be avoided because it

will tilt the palatal plane downward in the back by ex-truding the molars and thus opening the bite. Whenthe midfacial height is deficient, protraction forcesneed to be modified to increase vertical as well as an-terior growth. This is done by using more vertically directed elastic forces.

Berkowitz has found 350–450 gm of force per sideto be adequate in most instances,but there are rare in-stances when the elastic force needs to be reduced toprevent sore spots at the chin point. Friede andLennartsson [10] have used protraction forces be-tween 150 to 500gm per side. Ire and Nakamura [6]

have used 400gm per side,Roberts and Subtelny [21]670 gm, Sarnas and Rune [11] 300–800gm, and Tind-

480 S. Berkowitz

Fig.23A.2. a Frontal and b lateral views of a Delaire-style pro-traction facial mask.Padded chin and forehead rests distributereaction forces of 350–400gm per side equally to both areas.Elastics are attached to hooks placed on the arch wire betweenthe cuspids and lateral incisor. c Intraoral view of edgewise rec-

tangular arch with hooks for protraction elastics. d , e , f Delaire-style protraction facial mask used with a fixed labial-palatalwire framework. Elastic forces of 350–400gm per side can stillbe used with this intraoral framework

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d

b c

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lund et al. [16–18] 350 gm per side. Unfortunately,when performed in the mixed dentition, treatmenttime may extend into years because of the need tokeep pace with mandibular growth. If this is the case,treatment should be divided into intermittent periodsnot to exceed 6months at a time with a break for1 month between periods. Following this formula, thepatient will usually remain cooperative.

Although Berkowitz has been successful in using

strong elastic forces with labile-lingual appliancesduring the deciduous dentition, he recommends

starting treatment at 7–8years of age when all of themaxillary incisors can be bracketed and a rectangularedgewise arch with lingual root torque used as Subtel-ny [8] suggested. The torqued rectangular arch willcarry the incisor roots forward, moving skeletal land-mark point “A” anteriorly, which prevents stripping of the alveolar crest with subsequent incisor flaring. Thearch wire needs to be tied back so that it does not slideanteriorly, tipping the incisor, rather than moving the

entire maxilla forward orthopedically.

Chapter 23A Protraction Facial Mask 481

Fig. 23A.3a–x. Case BB (WW-62). Maxillary protraction in aUCLP. a Complete unilateral cleft lip and palate. b , c Lip andnose after surgery. d Cuspid crossbite of the lateral cleft seg-

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

palatal segment. e Buccal occlusion after expansion using aquad helix expander. f , g 6 years of age. Note relapse of cuspidcrossbite due to failure of using a palatal arch retainer. h Palatal

view showing good arch form

a b

c

f g h

d e



482 S. Berkowitz

Fig. 23A.3a–x. (continued) i, j Facial photographs at 8 years.k Orthodontic alignment of incisors prior to secondary alveo-lar bone graft. l Protraction facial mask with elastics. m , n ClassIII elastics used to maintain tension at circumaxillary suture

during the time not wearing protraction forces. o Occlusionafter orthopedic-orthodontic forces. Lateral incisor space re-gained. p Removal retainer with lateral incisor pontic

i

l n

o p

m

j k




Fig. 23A.3a–x. (continued) q , r Fixed bridge at 18years 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 19years, showing good facial symmetry after revision

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s t

w

u

v x



Tindlund et al. [16–18] conclude that early trans-verse expansion of the maxilla together with protrac-tion orthodontic treatment is an effective method fornormalizing maxillo-mandibular discrepancies incleft lip and palate patients. The average age at thestart of treatment was 6years, 11 months, and the av-erage duration of treatment was 13 months. Signifi-

cant changes were achieved due to anterior movementof the upper jaw and a more posterior positioning of the lower jaw resulting from clockwise mandibularrotation.

Berkowitz also found that the combined use of palatal expansion and protraction forces before thepubertal growth spurt to be a more efficient means of gaining orthopedic advancement than the use of pro-traction forces alone.He speculates that the expansionforces possibly disarticulate the circumaxillary su-tures, thus allowing the maxillary complex to be car-ried downward and forward more easily.

Delaire et al. [5] and Subtelny [8] have stated thatorthopedic forces applied to the entire maxillary com-

plex are more likely to be effective in younger chil-dren.

Berkowitz’s clinical experience supports the rec-ommendation by Abyholm et al. [22] and Bergland etal. [23] (1) that a rigid fixation of the advanced maxil-la should be maintained for at least 3 months afterbone grafting, and (2) the use of protraction forces.

This is necessary to help reduce the tendency to re-lapse created by the surrounding soft tissue of the lip,muscles,and skin.

Many patients with a complete bilateral cleft lipand palate have a protruding premaxilla until 10yearsof age or older, but after the postnatal mandibulargrowth spurt, the maxillary incisor teeth may be incrossbite.Protraction orthopedic forces with anteriorcriss-cross elastics upright and reposition the pre-maxilla forward, perhaps by inducing bone growth atthe premaxillary-vomerine suture. Fixed retention isalways necessary to control the improved incisal over-

bite–overjet relationship at least until secondary alve-olar bone grafting is done.

484 S. Berkowitz

a

b

Fig. 23A.4. Case BB (WW-62) a Lateral cephalometric tracingsand superimposed polygons (Basion Horizontal Method) forCase BB (WW-62) show an excellent facial growth pattern.b The midfacial growth increment between 15 to 16-4,when theprotraction facial mast was used, increased midfacial protru-sion to a greater degree than that which would have occurrednormally



References

1. Haas AJ. Palatal expansion: just the beginning of dentofa-cial orthopedics.Am J Orthod 1970; 57:219–255.

2. Delaire J. Considerations sur la croissance faciale (en parti-culier du maxillaire superieur): deductions therapeutiques.

Rev Stomatol 1971; 72:57–76.3. Delaire J, Verdon P, Lumineau J-P, Chierga-Negrea A, Tal-mant J, Boisson M. Quelques resultats de tractions extra-orales a appui fronto-mentonnier dans le traitement ortho-pedique des malformations maxillo-mandibulaires declasse III et des sequelles osseuses des fentes labio-maxil-laires.Rev Stomatol 1972; 73:633–642.

4. Delaire J, Verdon P, Kenesi MC. Extraorale Zugkraften mitStirn-Kinn-Abstutzung zur Behandlung der Oberkieferde-formierungen als Folge von Lippen-Kiefer-Gaumenspalten.Fortschr Kieferorthop 1973; 34:225–237.

5. Delaire J,Verdon P, Flour J.Ziele und Ergebnisse extraoralerZuge in postero-anteriorer Richtung in Anwendung einerorthopädischen Maske bei der Behandlung von Fallen der

Klasse III.Fortschr Kieferorthop 1976; 37:247–262.6. Irie M, Nakamura S.Orthopedic approach to severe skeletalClass III malocclusion.Am J Orthod 1974; 67:375–377.

7. Ranta R. Protraction of cleft maxilla. Eur J Orthod 1988;10:215–222.

8. Subtelny JD. Oral respiration: facial maldevelopment andcorrective dentofacial orthopedics. Angle Orthod 1980;50:147–164.

9. Delaire J,Verdon P, Flour J.Moglichkeiten und Grenzen ex-traoraler Krafte in postero-anteriorer Richtung unter Ver-wendung der orthopädischen Maske. Forttschr Kiefer-orthop 1978; 39:27–40.

10. Friede H,Lennartsson B.Forward traction of the maxilla incleft lip and palate patients. Eur J Orthod 1981; 3:21–39.

11. Sarnas K-V, Rune B. Extraoral traction to the maxilla withface mask: a follow-up of 17 consecutively treated patientswith and without cleft lip and palate. Cleft Palate J 1987;24:95–103.

12. Berkowitz S. Some questions, a few answers in maxilla-mandibular surgery.Clin Plast Surg 1982; 9:603–633.

13. Tindlund RS.Orthopaedic protraction of the midface in thedeciduous dentition: results covering 3 years out of treat-ment. J Craniomaxillofac Surg 1989; 17(Suppl. 1):17–19.

14. Nanda R. Differential response of midfacial sutures andbones to anteriorly directed extraoral forces in monkeys. JDent Res 1978; 57:362.

15. Molstad K,Dahl E. Face mask therapy in children with cleft

lip and palate. Eur J Orthod 1987; 9:3211–3215.16. Tindlund RS, Rygh P. Maxillary protraction: different ef-fects on facial morphology in unilateral and bilateral cleftlip and palate patients. Cleft Palate Crainofac J 1993;30:208–221.

17. Tindlund RS, Rygh P,Boe OE.Orthopedic protraction of theupper jaw in cleft lip and palate patents during the decidu-ous and mixed dentition in comparison with normalgrowth and development. Cleft Palate Craniofac J 1993a;39:182–194.

18. Tindlund RS, Rygh P, Boe OE. Intercanine widening andsagittal effect of maxillary transverse expansion in patientswith cleft lip and palate during the deciduous and mixeddentitions.Cleft Palate Craniofac J 1933b; 30:195–207.

19. Buschang PH, Porter C, Genecov E, Genecov D. Face masktherapy of preadolescents with unilateral cleft lip andpalate.Angle Orthod 1994; 64:145–150.

20. Kettle MA, Burnapp DR.Occipito-mental anchorage in theorthodontic treatment of dental deformities due to cleft lipand palate. Br Dent J 1955; 989:11–14.

21. Roberts CA, Subtelny JD. Use of the face mask in the treat-ment of maxillary skeletal retrusion. Am J Orthod Dento-facial Orthod 1988; 93:388–394.

22. Abyholm FE,Bergland O,Semb G.Secondary bone graftingof alveolar clefts: a surgical/orthodontic treatment en-abling a non-prosthodontic rehabilitation in cleft lip andpalate patients. Scand J Reconstr Surg 1981; 15:127.

23. Bergland O, Semb G, Abydholm F, Borchgrevink H, Eske-land G. Secondary bone grafting and orthodontic treat-ment on patients with bilateral complete clefts of the lipand palate.Ann Plast Surg 1986; 17:460–471.


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Protraction Facial Mask (Berkowitz)