Extraoral heavy forces from a facial mask directed forward and downward from the maxillary cuspid area have been shown to correct midfacial retrusion at an early age (Delaire et al. 1972, 1976; Tindlund 1987, 1989, 1994a, b; Tindlund and Rygh 1993a, b; Tindlund et al. 1993a, b, 1994). Protraction from the maxillary cuspid area produces an adequate horizontal and vertical force to increase midfacial vertical height as well as anteroposterior length. In some instances, it also can reduce an anterior open bite by lowering the palatal plane. For this reason, early correction of anterior and/or posterior crossbites during the deciduous and mixed dentition is highly recommended:

When considering a treatment plan for young children who travel long distances, it is important to consider patient comfort as well as treatment efficiency.

In cases of marked midfacial retrusion, interceptive orthopedics is started at 6 years and often lasts for 15 months with an average of six visits (two visits for a transverse expansion of about 10 mm during a 3-month period and an additional four visits for the use of protraction forces for 12 months).

A fixed palatal expansion appliance can be easily combined with the use of an extraoral facial mask (Figs. 23.1 and 23.2) (Rygh and Tindlund 1982) providing:

The creation and use of a modified quad-helix [Rocky Mountain: maxillary quad-helix. 0.38 (0.985 mm) Blue Elgiloy (Ricketts)] appliance (Rygh and Tindlund 1982) is shown in Fig. 23.3. Four preformed bands with brackets or tubes are placed on the second deciduous molars and deciduous cuspids and are soldered to the quad-helix spring. The first deciduous molars serve as additional anchorage. Permanent molars are banded only when the second deciduous molars are missing. Hooks for elastics are positioned mesiolingually to the cuspid bands. The elastics are attached to the protraction facial mask (Fig. 23.2c, d). The elastic forces are directed forward and downward from the anterior maxillary segment, resisting the normal counterclockwise rotational effect. The quad-helix appliances when used with brackets and tubes permit alignment of upper incisors after their eruption (Figs. 23.1 and 23.3j–l).

The modified quad-helix appliance is removed from the teeth and adjusted and activated at 6-week intervals (Fig. 23.2a, b). A resiprocal force of about 200 g on each side is optimal. The arch increases in width approximately 3 mm per month, irrespective of cleft type (Tindlund et al. 1993b). The cuspid segments often need more expansion than the molar area. Because there is a great tendency for relapse, overexpansion is necessary.

With transverse expansion of the maxillary arch, a downward clockwise rotation of the mandible occurs without any forward movement of the maxilla (Tindlund et al. 1993b). By comparing the use of fixed quad-helix appliances with removable expansion plates on noncleft patients, Hermanson et al. (1985) found that a fixed quad-helix appliance was more effective with fewer visits, less costly, and required shorter treatment time. Further, a removable plate would not readily resist the forward-downward traction to the cuspid area from a facial mask. As a rule, transverse expansion is completed before protraction is started.

The quad-helix appliance is formed to make passive contact with the incisors, by bends or by a soldered-on extension (Fig. 23.2a, b). In cases where no transverse expansion is needed, or if the quad-helix spring is inconvenient after the expansion period, a simple palatal arch is soldered to four bands on second deciduous molars and cuspids (Fig. 23.2e, f). The intraoral appliance is used as anchorage for the facial mask (Scheu: Great Lake Reversed Pull Face Crib, 2500.1 small) (Fig. 23.2c, d). No other mask fixation is needed other than the two intraoral elastics [Unitek: Latex ex-oral 1/4”LGT; Unitek/3M: “Fran” 8oz. 1/4” (404–736)] from hooks in the cuspid areas. The force used for facial protraction is about 350 g on each side, totaling 700 g. The facial mask is used mainly at night for 10–12 h. Sleeping disturbances have not been reported. Patient cooperation is excellent in almost all cases. Within a few days, the children manage to put on the mask themselves, and complaints about soreness are very rare. It is important that the elastics are attached to the anterior segment and inclined downward and forward about 15° to the occlusal plane. Several facial masks of various designs are now available. If the use of protraction forces is delayed until the permanent incisors are fully erupted, elastic forces from hooks placed on the arch wire between the lateral incisor and cuspid area may be utilized. In most cases, the incisors should be advanced bodily to obtain surface bone deposition at subnasal (A-point) by use of edgewise arch wires with labial root torque (Fig. 23.3l).

The results obtained by early orthopedics must be stabilized with a passive fixed palatal arch wire. The retainer remains until the anchor deciduous teeth are lost (Fig. 23.2e