Orthodontic treatment without surgery

by John Utama
In my 30 years of practice I have done numerous dental courses , the
growth guidance appliance is arguably the most significant appliance I
have used. As explained in my first blog Are braces necessary?, the
upper arch (maxilla bone) is one of the most important bones in the body.
Its shape and size determine the viability of the airway and the occlusion
(bite), which in turn it can potentially give rise to serious conditions such
as OSA (Obstructive Sleep Apnoea), sleep breathing disorders, TMJ Pain
disorders and cosmetics issues.
The good news is that it is never too late to treat patients with
underdeveloped maxillae. In most cases it is generally acceptable that
orthodontic treatment without extracting any teeth is the way to go, like
most things, there are always exceptions. Many people are now aware that
expansion of the dental arches is widely practised by dentists and
orthodontists. There are numerous dental expanders and generally they all
work well. But most do not expand anteroposteriorly (maxillary
advancement ), which is most important to resolve some or all of the
issues described above. Maxillary advancement will create more space for
the tongue and will facilitate improvements in airway, TMJ pain and
aesthetics. Note that in regards to aesthetics, the appliance will do more
than straightening teeth, it will also improve the persons profile.
In severe cases, orthognathic surgery by Maxillofacial surgeons, may be
required to advance the jaws forward.
Fortunately the FAGGA appliance provides a more conservative option as
shown in the photos below.


The picture on the left above shows the photo prior to commencement of
treatment. The picture on the right shows the picture after the completion
of the FAGGA appliance. Note the improvement of the patients profile
and posture. Usually the maxillary advancement takes 4-6 months.


The picture on the left above shows the photo prior to commencement of
treatment, note the lower jaw shifts to the left. The picture on the right
shows the picture after the completion of the FAGGA appliance. Note
improvement of the lower jaw, which is more symmetrical after treatment.
This is how we do it
There are two different types of anterior growth guidance appliances, the
fixed and removable. The fixed appliance (FAGGA) is designed for adults
and the removable (RAGGA) is designed for children.

FAGGA (Fixed Anterior Growth Guidance Appliance)

The fixed appliance cannot be taken out, the patient comes in for simple
adjustments every 4-6 weeks. The upper arch expands anteriorly (to the
front) by approximately 1 mm a month as can be seen by the pictures
below. Note the spaces created between the upper canines and the first
premolars behind.
Once the desired spaces are achieved, the appliance is removed and a
lingual wire (FRLA) is inserted inside the mouth to avoid relapse, ie we
want to make sure that the teeth do not collapse back to the original
position.


Initial photo


29/9/14 FAGGA insertion


1/12/14 2 months after FAGGA insertion


3/1/15 3 months after FAGGA insertion

We will then place braces on both upper and lower teeth. The braces with
the help of elastic bands will move the back teeth forward to close the
gaps, while maintaining the position of the front teeth. This procedure will
also enhance the chance of all wisdom teeth erupting in the correct
position, without the need for extractions.
In the meantime the lower braces will straighten the lower teeth. Once all
the gaps are closed, the upper and lower teeth are coordinated to ensure
optimal aesthetics and function.


8/2/15 4 months after FAGGA insertion


4/4/15 Premolar teeth are being pulled forward


17/6/15 Now its the molars turn to be pulled forward


23/12/15 All spaces are now closed and the braces are off!

The end result is an expanded upper jaw both towards the front and the
sides. The jaw will be able to accommodate all permanent teeth (may
include wisdom teeth if the conditions are right) to erupt in the correct
position, the lower jaw is able to occlude into the ideal bite in harmony
with the TMJ joints and the facial muscles. The ensuing enlarged space in
the mouth allows the tongue to position itself correctly against the roof of

the mouth, opening up good airways at the back of the throat and inside
the nose.
Fees for both FAGGA and braces vary from $7500.00 to $10,000.00
depending on the complexity of the case. Please note that the fees are
generally higher than the fees for regular braces (usually $5500.00 to
$7500.00). The FAGGA appliance improves the airway, profile and the
TMJ joints, it does more than just straightening teeth. Payment plans are
available.
RAGGA (Removable Anterior Growth Guidance Appliance)
The removable appliance is for designed for children to accommodate the
orofacial growth (usually under 10 years old). The appliance is turned
(activated) twice a week by the patients themselves, or for the very young
ones, by their parents. It is to be worn 24/7 including eating. The
appliance does a similar function as the FAGGA in the growing mouth, it
expands the upper jaw in all dimensions, to lay down the foundation and to
accommodate the eruption of the incoming permanent teeth. When the
permanent teeth are ready to erupt down there will be adequate amount of
space. In most cases, braces are still required to complete the final
alignment and the coordination of the upper and lower teeth. However, due
to the presence of the already prepared spaces, the treatment time for the
braces may only take 6 to 9 months.


RAGGA on a model


RAGGA 6 months after activation (note amount of spaces created)
Before the treatment commences we also assess the airway and determine
if there is an airway obstruction, we may then refer patients to the ENT
surgeon. If there is a sign of obstruction due to mucus build up in the nasal
cavities, we may send the patient to an allergist. If there is a dysfunctional
habit, such as tongue thrusting we may send the patient to a myologist.
Fees for RAGGA is $3000.00-$3500.00 (first phase). When all the baby
teeth have come out, the braces will usually be required to straighten the
teeth, the fee is $3000.00 to $3500.00 (second phase).
Do you need the growth guidance appliance?
We will need to take your records such as xrays/photos and study models.
These records usually cost $300.00 and are claimable if you have a Health
Fund.
From the records we will assess the position of the upper jaw and your
profile from the photos. If the records determine that the patient is midface
deficient, then the growth guidance appliance will be recommended. If
there is only mild or no midface deficiency, only braces or no treatment is
required.


Lat Ceph xray analysis. Courtesy of Josh Jefferson
Risks of FAGGA and braces
The FAGGA is worn for 4-6 months. When the desired expansion is
achieved, fixed braces and FRLA (inside wire) will be inserted for
approximately 9-15 months.
Risks associated with the FAGGA:
-Gingival recession.
-Nonvitality (teeth may die)
-Speech impediment during the course of treatment
-Ulceration of tongue, lips and cheeks.
-Root resorption (roots become shorter)
-Part(s) of appliance may debond

Risks of braces:
-Gingival recession.
-Nonvitality (teeth may die)
-Speech impediment during the course of treatment

-Ulceration of tongue, lips and cheeks.

-Root resorption (roots become shorter)
-Brackets debonding (coming off)

John Utama BDS MBA

Robina Town Dental
Dentists @Capri
Gold Coast Australia
www.thewholedentist.com



johnutama@me.com