CLINICIANS CORNER

Extraoral appliances: A twenty-rst century update

Stanley Braun, DDS, MME, PE Indianapolis, Ind With the locations of the centers of resistance of the dentomaxillary complex having recently been dened, and with the newly acquired knowledge of the critical interplay between part-time extraoral and full-time intraoral force systems, the basic designs of all types of extraoral appliances are discussed in depth. Armed with this information, the clinician can improve the efciency of all extraoral appliances to obtain better dentomaxillary-complex growth control and negate or enhance appliance-induced intraoral force systems. (Am J Orthod Dentofacial Orthop 2004;125:624-9)

xtraoral appliances are a vital component of the clinicians treatment armamentarium. These appliances have 3 primary purposes: to achieve forecastable changes in the growth pattern of the dentomaxillary complex, to negate or enhance clinician-induced intratraoral force systems, and to provide a protractive force system to the surgically separated dentomaxillary complex.1 The normal growth pattern of the dentomaxillary complex has been described in relatively precise terms via the C-axis.2 The alterations in the C-axis associated with growth are described by 3 cephalometric dimensions: changes in C-axis length (sella-M point, in millimeters), alterations in the C-axis vector related to sella-nasion (, in degrees), and the palatal plane (ANS-PNS) related to the C-axis (, in degrees) (Fig 1). The 3 cephalometric dimensional changes related to normal dentomaxillary growth have been recorded for each sex and age. The previously imprecise description of the growth of the dentomaxillary complex as downward and forward or via partial vector components has been suitably replaced.3-13 For extraoral appliances to affect the growth of the dentomaxillary complex, the frontomaxillary sutures, the nasomaxillary sutures, the zygomaticomaxillary sutures, and the transverse palatine suture must be viable.14 When a suitable force system is applied to the dentomaxillary complex, the sutures will respond over time, as teeth do when a force system is applied relative
Clinical professor of Orthodontics, Vanderbilt University Medical Center, Nashville, Tenn. Reprint requests to: Dr Stanley Braun, 7940 Dean Rd, Indianapolis, IN 46240; e-mail, ortho.braun@juno.com. Submitted, June 2003; revised and accepted, September 2003. 0889-5406/$30.00 Copyright 2004 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2003.09.023

to their centers of resistance.15 The locations of the centers of resistance of the dentomaxillary complex have been previously identied16 (Fig 2). To properly design an extraoral force system for a patient, the clinician must know the locations of the centers of resistance of the dentomaxillary complex. They are easily determined from the patients sagittal cephalogram and subsequently transferred to the patient clinically. This is achieved by establishing the dimension Y/2 for the patient (noted in Fig 2) and locating it intraorally with an amalgam plugger or the equivalent. This instrument is favored because it has a thin handle and does not distort the facial tissues. When correctly located intraorally, its head can be easily palpated by the clinician. For example, if the dimension Y/2 for a patient is 15 mm, the clinician locates the amalgam plugger on a visualized line 15 mm perpendicular to the buccoclusal plane projected superiorly through the distal contact of the maxillary rst molar. This will place the head of the amalgam plugger up into the buccal vestibule. Holding the amalgam plugger head facing buccally in this position, the patient is instructed to close the teeth and relax the facial tissues and lips. The clinician can now palpate the amalgam plugger head and place a temporary mark of its location on the face (Fig 3). This is repeated on the opposite side of the arch, and the patient is viewed frontally. If the procedure is done correctly, both facial markings will be at the same level. If they are not, the procedure should be repeated until this is obtained. Having marked the centers of resistance of the dentomaxillary complex bilaterally, the clinician can then design the appropriate extraoral force system to properly relate to the centers of resistance.17 Figures 4 and 5 illustrate a protractive headgear and a cervical headgear, respectively; their lines of action are colinear with the centers of resistance. In both cases, one can

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Fig 1. Relationship of C-axis (S-M point) to S-N and palatal plane (ANS-PNS).

Fig 2. Q, center of resistance of dentomaxillary complex in sagittal view. FOP, functional occlusal plane; Or, orbitale. Line through Or is parallel to FOP.

condently expect the dentomaxillary complexs growth to be inuenced without tipping. The clinician should periodically evaluate the lines of action of the headgear after the appropriate tractive force is applied because the outer bows ex signicantly. The outer bow lengths and angles can be adjusted to achieve the desired line of action and point of application of the extraoral forces. In a recent study,18 a cervical headgear providing a mean clockwise moment of 166.9 N mm, and a total mean tractive force of 4.45 N (453.6 grams), worn 8 to 10 hours in 24 hours for .81-.84 years by 19 females and 15 males, had a clinically signicant effect in reducing the normal linear growth of the C-axis length and in altering the palatal plane angle relative to the C-axis vector. Alteration of the palatal plane is believed to have been caused by the signicant clockwise moment cited. Many types of extraoral appliances can be designed to achieve a desired effect on growth of the dentomaxillary complex. Figure 6 illustrates an occipital headgear designed to produce a reduction in growth along the C-axis without angular changes in the palatal plane or the C-axis vector relative to sella-nasion. Its line of action is colinear with the centers of resistance of the dentomaxillary complex and is parallel to the patients C-axis.

Negating (balancing) intraoral force systems

Obtaining patient compliance in wearing extraoral appliances in public is problematic. Compliance is more easily achieved with part-time wear, usually while sleeping, and, if necessary, also wearing the appliance a few hours before bedtime. Recognizing this, the clinician should be aware that the energy applied to the teeth by an intraoral appliance commonly occurs full time, but the energy applied by an extraoral appliance does not. If the clinician wishes to negate the effect of the intraoral appliance on the reactive or anchor teeth with a part-time extraoral force system, the energy applied by it must equal the energy applied to the teeth by the full-time intraoral force system.19,20 This is expressed mathematically as follows: extraoral energy applied intraoral energy applied energy impulse (force or moment) (time) [extraoral force or moment] (time) [intraoral force or moment] (time) This can be applied to a clinical case. Intrusive cantilevers, emanating from the posterior reactive teeth on each side of the arch, exert a 50-g intrusive force on each side of the 4-tooth incisor segment (Fig 7). An occipital headgear, worn 8 hours in 24 hours, will be used to negate the resulting reactive force system on the posterior teeth. To establish the magnitude of the occipital headgear force required per side:

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Fig 4. Extraoral protractive lines of force colinear with centers of resistance of dentomaxillary complex. Mark on cheek coincident with center of resistance of dentomaxillary complex.

Fig 3. A, Palpitating amalgam plugger located colinear with centers of resistance of dentomaxillary complex; B, temporary facial marking (arrowhead), corresponding to centers of resistance of dentomaxillary complex.

FY (8 hours) F sine 60 (8 hours) 50 (24) F 173 grams To establish the line of action (D) of the occipital headgear force relative to the center of resistance of the reactive posterior teeth: [headgear moment] (hours) [intraoral moment] (hours) 173 (D) [8] [50(30)] 24 D 26 mm Thus, an occipital headgear worn 8 hours per day exerting a force of 173 g per side, acting 60 to the buccal occlusal plane, with its line of action offset 26 mm perpendicular from the buccal segment center of resistance, will ensure stability of the reactive teeth. (Part-time extraoral force systems negating the effects

of full-time intraoral force systems are supported by considerable anecdotal and clinical evidence. The clinician is cautioned against extrapolating this calculation at its limit: for example, if a force of 462 g per side is used, then 3 hours of wear is required. The biology involved in tooth movement probably will not support this extreme. Additional research is necessary to quantify the physiologic limits of this energy calculation. However, the clinician can condently use this energy calculation if the part-time extraoral force range is 6 to 10 hours in 24 hours.) In another example, a part-time headgear can be used to maintain the stasis of the posterior reactive teeth during en masse bilateral translatory space closure of the anterior 6 teeth into the rst premolar extraction sites, bilaterally. A TMA T-loop (Ormco, Glendora, Calif), activated for this illustration only, produces the force system shown in Figure 8. The 10:1 moment-toforce ratio at the brackets (approximately equal to 2000 g mm: approximately equal to 200 g) will result in the equivalent linear forces at the centers of resistance shown in Figure 8.21-23 The extraoral distal force component, colinear with the dental centers of resistance necessary to maintain stasis of the posterior teeth, can be determined as follows: Extraoral appliance impulse energy intraoral appliance impulse energy FH (10 hours) 200 (24 hours) FH 480 g

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Fig 5. Cervical headgear lines of force colinear with centers of resistance of dentomaxillary complex. Q, dentomaxillary center of resistance.

Fig 6. Occipital headgear lines of force colinear with centers of resistance of dentomaxillary complex and C-axis. Q, dentomaxillary center of resistance.

Fig 7. Force system of occipital headgear designed to negate effects on reactive posterior teeth resulting from incisor intrusive cantilevers. Q, buccal segment center of resistance; o, incisor teeth center of resistance.

(In this example, it is assumed the patient will wear the extraoral appliance 10 hours in 24 hours.) The 480-g distal force, colinear with the center of resistance of the buccal teeth, is the required distal component of an extraoral appliance. If the appliance were a cervical one in which the neck strap makes an angle of 45 to the

buccal occlusal plane, then the neck strap force required would be 679 g (480g/cos 45). Similarly, if a high-pull headgear were used whose straps make an angle approximating 40 to the occlusal plane, the high-pull force would be 627 g (480g/cos 40). A straight distal pull headgear having its line of action

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Fig 8. Forces colinear with centers of resistance of anterior and posterior teeth resulting from TMA T-loop activated to produce 10:1 moment/force ratios at brackets.

Fig 9. Force systems resulting from extrusive cantilevers and cervical headgear to enhance eruption of posterior teeth while maintaining occlusal plane.

colinear with the 200-g intraoral protractive force would be 480 g/side to achieve stasis of the posterior teeth. If the extraoral appliance has an extrusive or an intrusive component, as it would in a cervical or high-pull headgear, the vertical components would be free to exert an extrusive or intrusive effect on the posterior teeth independent of anteroposterior stasis.
Enhancing intraoral force systems

If it is desired to erupt the maxillary buccal teeth to the level of the anterior teeth, intraoral extrusive cantilevers can be applied bilaterally, as in Figure 9. The anterior dental intrusive forces are colinear with the centers of resistance of the 6 anterior teeth, which are ligated onto a relatively rigid passive anterior wire segment. This will not result in any reactive movement of the anterior teeth.24 Because of the activation of the extrusive cantilevers bilaterally, each buccal segment will experience an extrusive force of 125 g and a moment relative to each center of resistance of 4375 g mm. A passive lingual arch is advisable to prevent the seg-

ments from altering arch form. A sleeping-time cervical headgear force system (Fig 9) is used to ensure that the buccal segments occlusal planes will not tip, but will erupt, maintaining the existing occlusal plane bilaterally. The headgear moment energy is designed to be equal to the moment energy resulting from the extrusive cantilevers as follows: [headgear moment] (8 hours) [intraoral cantilever moment] (24 hours) [F(D)] (8) 4375(24) M 13,125 g mm If headgear traction is 300 g per side, then D 13,125/300 43.8 mm Thus, a cervical headgear exerting a tractive force of 300 g per side and offset perpendicularly 43.8 mm from the centers of resistance of the buccal segments will provide eruption of each buccal segment without altering their occlusal planes. Each segment will experience a maximal total eruptive force of 385 g (125 g 300 sine 60). In a given patient, extraoral appliance wear might be needed to affect the growth of the dentomaxillary

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complex and to negate or enhance forces and moments produced by intraoral appliances. The headgear effects on both occur simultaneously. They are not independent except in the nongrowing patient. The headgear might thus need to be adjusted relative to the centers of resistance of the dentomaxillary complex for growth control and be periodically adjusted relative to the centers of resistance of the appropriate teeth to balance or enhance intraoral force systems. It would not be unusual to begin appropriate headgear therapy for growth control in a patient and, from time to time during intraoral appliance activity, to adjust it or introduce another appropriate headgear to provide the temporary force system needed relative to the centers of resistance of the reactive teeth. This article is dedicated to Dr Charles J. Burstone, the leader in establishing orthodontic therapy on a scientic basis.
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