AGGA is NOT the Holy Grail of Adult Orthodontics

In this article I will explain why I no longer believe that AGGA is the “Holy Grail” of adult orthodontics.

In prior articles I have praised AGGA heavily. The present article provides my current, more nuanced view of AGGA.

AGGA only accomplishes forward maxillary expansion.

AGGA definitely does expand the maxilla forward in relation to the rest of the face.

This results in increased oral volume and can allow a trapped mandible to reposition itself in a new, forward position.

Thus, for patients with posterior displacement of the condyle of the mandible in the fossa of the temporomandibular joint, AGGA could be used to relieve TMD symptoms.

 

This image shows that the maxilla definitely expands forward with AGGA. Just watch the upper lip. The significant increase in oral volume can be felt by the AGGA patient.

 

Is this expansion bona fide growth or is it simply moving the front teeth through the alveolar bone? Below I will suggest that it is a little bit of both, which is why I am simply labelling whatever AGGA does as “forward expansion.”

Such forward maxillary expansion is great, even if it involves a safe amount of compromise to the gums. But patients must be aware that this seems to be all that AGGA is able to accomplish.

And in my case, forward maxillary expansion was not sufficient to address all of my orthodontic needs.

So where did AGGA come up short for me? Why is it definitely not the “Holy Grail?”

1. AGGA does not expand the mandible.

Since AGGA made my maxilla longer but did not make my mandible longer simultaneously, it got to the point that my maxilla was so much longer than my mandible that the only way my lower front teeth could meet my upper front teeth in proper occlusion was for my mandible to dislocate forward in the TMJ.

 

A view of my left TMJ, x-ray from 1/14/19. The mandibular condyle has descended down and forward on the articular eminence. The mandible is out of the fossa. This anterior displacement is better than posterior displacement (the mandibular condyle being too far back in the fossa), but it is far from ideal.

 

So yes, AGGA did expand my maxilla forward. But since this is all that it did, it resulted in an asymmetry between my maxilla and my mandible.

A “Holy Grail” orthodontic treatment must correct the size and position of every incorrectly-grown bone in the craniofacial complex–not just the maxilla in the forward direction.

Those of us with underdeveloped faces tend to have (at least) underdeveloped maxillas, mandibles, mid-faces, nasal passages, improper maxillary angulation, and perhaps more.

So it is simplistic thinking to believe that all of our underdevelopment can be corrected by an appliance that simply expands one bone (the maxilla) in one direction (forward).

2. AGGA does not widen the maxilla (lateral expansion).

Another glaring shortcoming of AGGA in my case was its inability to widen my maxilla. Again, this is what I mean when I say that all AGGA does is expand one bone in bone dimension – it didn’t even expand the maxilla laterally in my case.

 
Even after 16 weeks of treatment, the Controlled Arch system seemed to have no effect on maxillary widening.

Even after 16 weeks of treatment, the Controlled Arch system seemed to have no effect on maxillary widening.

 

The internet has come to believe that AGGA through some organic physiological process triggers bone growth 3 dimensionally throughout the entire craniofacial complex. I take my share of responsibility for the spread of this hyperbole.

The truth is, any “expansion” or “growth” or “remodeling” of anything other than the maxilla is negligible with AGGA.

When I say “negligible,” I mean “okay, maybe it is happening to some degree, but I can’t notice it and it sure as heck is nothing compared to the amount of forward maxillary expansion that is occurring.”

We were all under the impression that AGGA expands the maxilla forward and then “Controlled Arch Braces” come in and save the day with a potentially unlimited amount of widening.

Well, it turns out that Controlled Arch Braces are simply a tooth-borne appliance that push on teeth and (maybe) stretch the mid-palatal suture like a Schwartz appliance does.

But mostly Controlled Arch Braces just move teeth through the alveolar bone in order to create lateral expansion. In other words, the Controlled Arch is fundamentally just like any other palatal expander that has been around for decades–it pushes on teeth.

In fact mostly what the Controlled Arch does is uses the front teeth as anchors to drag the molars forward to close the AGGA gaps. It’s like digging your feet into the ground during tug of war.

 

The Controlled Arch leverages the combined root strength of the front teeth to drag the back teeth forward to close the AGGA gaps. This can be problematic for patients whose front teeth have already been compromised by aggressive AGGA expansion, since using the front teeth for anchorage places additional stress on them.

 

The Arch also prevents the front teeth from moving backwards to their original position as the molars are dragged forward.

The “Controlled Arch” is actually an orthodontic tool used for this purpose not just by AGGA providers. To other dentists it is known simply as a lingual arch.

3. AGGA has no effect on the volume of the nasal airway or mid-face

AGGA treatment has no significant impact on mandibular growth or maxillary widening, but can it make the nasal floor bigger or bring the mid-face forward to match the new, forward-position of the maxilla?

No.

I can’t emphasize this enough: my experience is that AGGA did not have a magical 3D-bone-growth effect on my entire craniofacial complex.

I believe it had zero or negligible effect on my nasal floor, and that my nasal passages are no wider now than they were before.

And it did little or nothing to bring my mid-face forward, so that after AGGA had done its work and made my maxilla longer, my mid-face appears sunken compared to my lower face.

To repeat, in my case the only thing AGGA did to any appreciable degree was to expand the maxilla in the forward direction.

4. AGGA does not change the angle of the maxilla.

Okay, this is a big one, and I’m only now starting to realize what a big deal the maxillary angle actually is.

Folks, it turns out that when our faces are underdeveloped, it is not just the size of the maxilla that is off. It turns out that the maxilla grows at the wrong angle too, and this hugely problematic.

An improperly angled maxilla is one that grows at a downward angle rather than an angle closer to parallel to the ground.

So imagine you are looking at a clock – the wrong angle for the maxilla would be if the the front of the maxilla slanted down toward 7 o’clock rather than went straight across to 9 o’clock.

 

The red line serves as the x-axis, at 0 degrees. It puts the downward angulation of my maxilla into perspective. This x-ray was taken after AGGA treatment, in January 2019, which means AGGA did not upright my maxilla into a more neutral (0 degree) position.

 

AGGA does nothing to upright the maxilla. All it does is elongate the maxilla in the improper angulation it is already positioned in.

Is the angle of the maxilla really a big deal? I’m starting to think it is the biggest deal of them all.

As I’ve meditated on this in recent months (since Dr. Zubad Newaz pointed out to me that my maxilla is slanted downwards even after AGGA) I’ve started to realize that maybe the TRUE cause of my forward-head posture is that my neck is kinking (chin coming forward) in an effort to make my downward-slanted maxilla parallel to the ground, just so that my teeth will touch.

In other words, no matter how much longer AGGA makes the maxilla, if the maxilla remains at this downward sloping angle, then optimum form and function will never be achieved.

5. AGGA can push teeth through alveolar bone

Again, we all have the impression that AGGA is this magical biocompatible device that simply stimulates the perfect sweet spot in the maxilla, mimicking the proper role of the tongue, and thus triggers some kind of biochemical bone deposition process hidden within our bodies by evolution.

Maybe, to some degree.

But AGGA also just pushes on teeth. Especially the front teeth. That’s probably why they hurt like hell after every adjustment.

And probably why when many of us have our braces removed, our front teeth feel like they just fielded a ground ball. And why we wouldn’t dare bite into an apple at that point.

And many have reported x-rays that show bone loss to the upper front teeth following AGGA.

And some have even reported mobility in the front teeth (AGGA made their front teeth loose).

Definitely be aware that this is an issue and monitor the state of your alveolar bone during treatment, especially after 4-5mm AGGA gaps.

Bone loss seems to be especially problematic for the upper front teeth.

AGGA providers may respond to this saying, “give it some time, the bone will grow back, it’s all part of the process.”

Really? Just like 3D growth was supposed to be part of the process? Just like Controlled Arch Braces were supposed to widen the maxilla?

I wouldn’t count on it, especially since the consensus among virtually all dentists is that alveolar bone, once gone, does NOT come back.

Conclusion

In conclusion, although I wanted to believe and actually did believe that AGGA was a miracle orthodontic device that could correct most adult facial underdevelopment and airway problems, I no longer believe this is the case.

I think AGGA is an effective device for creating forward maxillary expansion. But even in this respect, it is limited because too much forward expansion would seem to pose a threat to the alveolar bone of the front teeth.

Due to its shortcomings when it comes to mandibular expansion, maxillary lateral expansion, expansion of the nasal passages, expansion of the mid-face, and correcting of downward maxillary angulation, I would have to designate AGGA as a “one dimensional” appliance.

Who is AGGA good for?

AGGA may be an appropriate treatment for someone with compression in the TMJ whose mandible is set too far back in the joint and is compressing nerves and causing TMD symptoms.

AGGA could be good for expanding the maxilla forward a few millimeters and decompressing the TMJ as a result.

For some patients this is all they want and need–relief from TMD symptoms.

But for someone like me who is trying to reestablish genetically optimal structure throughout the entire craniofacial complex so that I can have a pain-free, elongated neck posture and eliminate most or all of my sleep disordered breathing issues–AGGA is not for such patients.

It is too one-dimensional. Forward maxillary expansion is a hell of a lot better than nothing, but for $5000-15000 and 2 years of your time you could do a lot better, and with no risk to your alveolar bone.

Alternatives to AGGA

Call me jaded, but after 3 failed rounds of orthodontics I am now starting to grow weary of orthodontic expanders and growth appliances.

I’m starting to think that surgery may have been my best option all along, since it is the only option which addresses every dimension of facial underdevelopment.

Surgery can bring the maxilla and mandible forward together, unlike AGGA which expands the maxilla but not the mandible.

Surgery can widen the maxilla. In this case I am referring to MSE (maxillary skeletal expander) which is generally part of the surgery treatment plan for providers like my own orthodontist Dr. Zubad Newaz and also for West Coast providers like Dr. Audrey Yoon and her accompanying oral surgeon Dr. Stanley Liu.

Basically the orthodontist expands you laterally with MSE, then puts you through braces to align the teeth and establish proper occlusion.

Following completion of orthodontics, surgery is performed to bring both jaws forward, and to rotate them into their proper angulation.

To my mind, this is the treatment protocol that leaves the fewest stones unturned and results in the most complete establishment of genetically optimal facial structure.

Am I saying go out and get oral surgery? No. I was wrong about AGGA and I could be wrong about this too.

What I am saying is…if you are looking to invest in some kind of facial reconstruction treatment, then you may want to hang tight for another year before committing to AGGA, surgery or anything else.

In one year from now I will be done with MSE and maybe even surgery and will be able to report back on how those treatment modalities worked out for me.

Be patient, let me be the guinea pig.

Ronald Ead89 Comments