Last updated 4/8/2019
Hey folks! This is my first post in what will hopefully be a series about the various orthodontic appliances used for non-surgical palate expansion and facial growth in adults.
You should all know by now that I’m not a dentist or orthodontist, so unfortunately, I won’t have any groundbreaking contributions of knowledge. But at least I can put all the info in one place, right? I’ve linked all of my sources throughout this post, so you can go link-diving if you want to read other people’s words and learn more.
If you want info and experience from an actual AGGA patient, definitely check out Ronnie’s website. He was my first source of information on AGGA, and is the true AGGA MVP for documenting his journey so thoroughly.
Table of Contents
What is AGGA?
AGGA stands for Anterior Growth Guidance Appliance.* You might also see “FAGGA,” where the “F” specifies that it’s “Fixed,” or cemented to your teeth. There’s also a removable version of AGGA, but that one is mainly used in children, so this page will deal with the fixed version of AGGA.
Anyway, the AGGA is an orthodontic appliance that is intended to prompt forward growth of the premaxilla/maxilla and create space in the upper dental arch. It’s mostly wire, with a small acrylic oval that presses lightly on the upper palate behind the front teeth.
This oval may look inconsequential, but it’s actually the important part of the appliance (more on that in the “How does AGGA work?” section).
(*Fun fact: AGGA also stands for the Australian Glass and Glazing Association. Who knew.)
Who came up with AGGA?
The ControlledArch Treatment System, which encompasses both AGGA and the Controlled Arch braces used in conjunction with it, was developed by Dr. Steve Galella, DDS.
Dr. Galella has a background in facial trauma surgery, and after developing the ControlledArch System, is now known as an authority on facial beauty and facial growth modification. He is the Clinical Director of the Facial Beauty Institute, co-founder of OrthoMatrix Corp, and speaks and trains other dentists all over the world. (Source 1, 2, 3)
What is involved in AGGA treatment, and how long does it take?
Dr. Kundel (Ronnie’s dentist) has a good outline of this on his website. The below is an abbreviated compilation of that information plus various other tidbits I’ve read from other practitioner websites and patient experiences.
Phase 1: The Growth Phase (usually about 1 year)
- The AGGA is cemented to your upper teeth
- Acrylic “bite plates” are stuck to your lower molars
- This is done to make the surface of your molars flat so that instead of securely biting together, your lower jaw is free to slide around
- This allows the jaw muscles to relax and find their natural resting position
- Supposedly this also prompts the jaw to remodel forward; this makes sense if the jaw was initially being held back by an underdeveloped maxilla, which is probably the case in many (most?) AGGA patients. I don’t quite understand how this helps in patients who already had an overbite
- The appliance is adjusted monthly so that the acrylic oval continues to press on the soft palate as the palate expands forwards
- Gaps are created behind the canines
After the desired amount of forward growth has been achieved…
Phase 2: Controlled Arch Braces (usually about 1 year; less if implants are chosen)
- The AGGA is removed
- Full braces are placed on all upper and lower teeth
- Metal arch wires (the “controlled arches” are cemented to the backs of the upper and lower teeth along the gums
- This is what makes these braces different from regular braces!
- These arch wires supposedly are stiff enough to provide a gentle widening stimulus as well, so some lateral palate expansion may be achieved during this phase
- Back teeth are pulled forward to fill the newly created gaps, OR implants are placed in the gaps
- The braces are tweaked to achieve proper occlusion and alignment of the upper and lower teeth
Optional: Myofunctional Therapy
Many practitioners recommend undergoing myofunctional therapy concurrently with AGGA treatment. This involves exercises to improve oral posture and develop good habits, such as nasal breathing, lip seal, proper tongue posture, and proper swallowing technique.
How does AGGA work?
The closest I’ve found to a specific physiological explanation for how AGGA works is that the small acrylic oval presses on the nasopalatine nerve*, which somehow elicits a growth response throughout the entire midface.
In the words of several dentists who use AGGA (emphasis mine):
AGGA does not push teeth. In fact, you can barely feel it (I am an AGGA patient myself, so I know).
What AGGA does is stimulate a very particular spot on the upper palate which triggers the body’s own built-in bone-building response.
In particular, AGGA presses gently atop a nerve located in the incisive foramen on the roof of the mouth, and by doing so sets in motion a rapid bone-depositing effort throughout the entire craniofacial region.
The fixed (adults) or removable (children) AGGA growth appliances puts light pressure on the nasopalatine nerve that runs right through your palate. The growth appliance stimulates remodeling and development in the entire midface of the patient.
Remodeling and bone development occurs behind the canines, but you’ll also see a lot of facial changes for our AGGA patients.
Jaw development orthodontics actually works with the physiology of the body. The anterior growth guided appliance or AGGA puts light pressure over a nerve in the palate, and by doing so, it activates growth centers in the body to turn on and stimulate bone remodeling, not just in the top jaw but in the entire mid-face region.
It acts through a repeated stimulus to the nasopalatine nerve, a branch of the trigeminal nerve. This stimulus is delivered by the tongue pressing on the special pad overlying this nerve. Each press from the tongue delivers a message to brain. The tool, which is the rest of the appliance, produces a micro-trauma that the body then responds to by going into repair mode and laying down new bone, just as it would to any trauma such as a fracture or increased load.
Unfortunately, I have yet to find a good explanation for how or why stimulating this nerve would cause bone growth in the midface.
I mean, intuitively it makes some sense – the appliance is essentially providing the stimulus on the palate that a properly functioning tongue would provide. If the tongue indeed is primarily responsible for the support and growth of the maxilla (which is a topic for another day), then an appliance that provides that stimulus 24/7 would be expected to affect the growth of the maxilla.
(*Side note: for a truly glorious jumble of jargon, I highly recommend reading about the gross anatomy of said nerve on this page.)
Is it legit?
Hard to say. On the one hand, it’s hard to argue with success, and there are quite a few AGGA success stories published online (some of which I share below). The enthusiastic support and confidence of doctors like Dr. Kundel and Dr. Green (and their patients) is also encouraging. Plus, I’d like to think that LVI wouldn’t continue propagating this treatment method if it didn’t work.
On the other hand, the question of how exactly AGGA works is still somewhat shrouded in mystery. Explanations range from almost-but-not-quite scientific precision (like the quotes I shared above) to vague hand-waving.
This could be a simple communication issue, where the detailed mechanisms simply haven’t been written up and been made available to the public.
Or, it could be that it does work, but we just don’t fully understand how yet.
OR, it could be that it doesn’t actually work, it’s not legit, and everyone who uses it is simply pushing their teeth and compromising the integrity of their roots and gums. Some forum users over at The Great Work seem to think this is the case (see here and here).
My personal opinion (as of this writing in March 2019) is that AGGA is the most promising of the palate expanders/growth appliances, the success stories are compelling, and I certainly want to believe that it works exactly as advertised. However, I think there are several important questions that haven’t been answered.
- How and why does gentle pressure on the nasopalatine nerve cause “a rapid bone-depositing effort throughout the entire craniofacial region.”
- If the AGGA truly doesn’t push teeth, and works solely based on this nerve pressure, why do people report that their front teeth are sore in the days following an adjustment? Sore teeth clearly signal to me that the wire behind the six front teeth is exerting pressure.
- The before and after pictures are great, but where are all of the before and after x-rays and CBCT scans? I want to see proof (and lots of it!) that the AGGA doesn’t result in bone loss in front of the roots of the front teeth.
Are there any dangers or downsides to AGGA?
As alluded to above, the major potential dangers to using AGGA are the same as with any palate expander/growth appliance used in adults: that rather than getting true bone growth, you’ll compromise the integrity of your roots and gums by pushing teeth too far outside the palate bone or tipping teeth in their sockets.
I found one dentist’s office that actually lists the risks to AGGA treatment on their website (although note that braces and other conventionally accepted orthodontic treatments also carry these same risks):
- 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
How much does AGGA cost?
I think this depends heavily on your location, but like anything in orthodontia, it ain’t cheap. I know it can be super helpful to have a general idea of cost, so I’ll do my best to round up any details about the cost of AGGA that I find scattered around the internet.
Update 2/2/20: My treatment (AGGA + CAB) is costing me $15k. Ultimately it will be more, since I’ll probably end up getting implants, but I’m trying not to think about that right now…
This dentist usually charges from $7,500 to $10,000, depending on the case. They’re located in Gold Coast, Australia.
Here, Ronnie shares that he’s paying $15,000, which includes the cost of AGGA + the Controlled Arch braces. This is with Dr. Kundel in NYC.
A user on Reddit shares here that she consulted with Dr. Randi Green in Springfield, MO, and the estimated total treatment cost was $9,600. This would include AGGA, braces, and myofunctional therapy.
A commenter on the above post shares that his total treatment cost is $8,100, but he doesn’t share where he’s located.
Another Reddit user here shares that their total cost will be $10,000.
Where do practitioners learn how to use AGGA?
Dr. Galella teaches several online courses about the ControlledArch System, and also holds in-person workshops at various locations.
Practitioners can also train at LVI (the Las Vegas Institute for Advanced Dental Studies), which is an ADA-certified provider of continuing education for dental professionals focused on physiologic-based dentistry. They teach classes on AGGA and the ControlledArch Treatment System, among many other topics. The AGGA/Controlled Arch courses are taught by Dr. David Buck and Dr. Timothy Gross.
How can I find a practitioner who uses AGGA?
The best way is probably to search the doctor listings on LVI Global. Note that LVI offers many types of classes, so practitioners listed who don’t have the “Ortho” badge probably don’t use AGGA.
This link should bring up all the practitioners who have specifically taken the ortho trainings. For some reason, the site won’t let you filter by both badge and location, so I’d recommend just zooming in on the map and clicking on the red locations markers to see their names.
Pro-tip: if you find a practitioner on the LVI site, but they don’t have any mention of AGGA or facial growth orthodontics on the website for their practice, do not despair! Contact them anyway and ask if it’s a service they provide. I found Dr. Edmond Suh in Wake Forest, NC using the LVI map, and his practice website has absolutely no mention of AGGA or anything like it, but I contacted them and found out that he routinely uses it in his practice. He also is one of the instructors at LVI!
Before and Afters
Below are some of the more noteworthy before and after pictures I’ve come across.
Where can I learn more about AGGA?
The best resource I’ve found for information on AGGA is Ronald Ead’s website, so I’ve linked all his AGGA-related posts below. I’ve also found some good information on the websites of a few AGGA practitioners, which I’ve referenced throughout this post and have listed below as well.
Aside from that, information is pretty scattered around the internet, and not always of great quality. But as I find sources (even sub-par ones), I’ll add them to the list below! Definitely let me know in the comments if you know of a source I don’t have listed yet.
My experience with AGGA:
Top posts about AGGA from Ronnie’s website (I’ve linked all his others further down on the page):
- My Failed (First) Attempt at Adult Palatal Expansion
- The Best Adult Palate Expander in Existence
- AGGA: 23 Questions Answered
- AGGA: The Mystery Deepens
- 26 Week AGGA X-Rays
- 34 Weeks with AGGA, Mysterious Results
- 36 Weeks with AGGA: Unprecedented Growth
- 44 Weeks with AGGA: Last Photos Before Braces
From practitioner websites:
- Frequently Asked Questions about AGGA (Dr. Kundel)
- Facial Growth Orthodontics (Dr. Randi Green)
- Explanation of how AGGA works (Dr. David Buck)
- Facial Growth Guidance (Dr. Heng Lim)
- Anterior Growth Guidance Appliance (Dr. Ronald Konig)
- There’s regular discussion of AGGA on the TMJ/TMD/CMD/OSA Physiologic Discussion Group (whew) on Facebook.
- Note that this group is affiliated with LVI, so you probably won’t see much AGGA skepticism or potential downsides.
- However, you will see responses from actual practitioners using AGGA (including Randi Green, David Buck, Timothy Gross, and LVI founder Bill Dickerson). So that’s pretty neat.
- People occasionally discuss AGGA on r/orthotropics on Reddit.
Threads from The Great Work forum:
- Fixed Anterior Growth Guidance Appliance (FAGGA) – Holy Grail? Gonial angle change, maxilla movement forwards and palate widening. Without surgery.
- Thoughts on FAGGA appliance?
- AGGA Dos and Don’ts – Optimizing Your Forward Growth
- Born Beautiful (essay by Dr. Anne-Maree Cole on the LVI website)
- Probably Possible (essay by Dr. Anne-Maree Cole on the LVI website)
- Berks dentist specializes in correcting jaw problems (article in Reading Eagle about Dr. David Schwartz and AGGA)
Below are all of Ronnie’s other AGGA-related posts in chronological order:
- 2 Weeks with Adult Palate Expander
- 4 Weeks with Adult Palate Expander
- 6 Weeks with Adult Palate Expander
- 8 Weeks with Adult Palate Expander
- 10 Weeks with Adult Palate Expander
- 12 Weeks with Adult Palate Expander
- 14 Weeks with Adult Palate Expander
- 16 Weeks with Adult Palate Expander
- 18 Weeks with Adult Palate Expander
- 20 Weeks with Adult Palate Expander
- 22 Weeks with AGGA
- 25 Weeks with AGGA
- 38 Weeks with AGGA
- 40 Weeks with AGGA: Fastest Growth Yet
- VIDEO: How to Brush and Floss with AGGA
- 42 Weeks with AGGA: Rapid Growth Continues
- VIDEO: Last Night with AGGA
- VIDEO: Controlled Arch Braces Week 1 Update
- 2 Weeks with Controlled Arch Braces
- VIDEO: Week 2 With Controlled Arch Braces
- Video: Week 3 Controlled Arch: Nasal Constriction
- VIDEO: Myofunctional Tongue Posture Advice for AGGA Patients
- 4 Weeks with Controlled Arch
- 6 Weeks with Controlled Arch
- VIDEO: Do Controlled Arch Braces Fix AGGA Incisor Flaring?
- 8 Weeks with Controlled Arch
- VIDEO: 10 Week Controlled Arch Update
- 12 Weeks with Controlled Arch
- VIDEO: How AGGA Changed my Life in 2018
- VIDEO: Science Behind AGGA – Dr. Bromage Lecture Summary