Alyssa Luck

Everything You Need to Know about AGGA (Anterior Growth Guidance Appliance)

· · 16 Comments

Note 2/5/2021: I badly need to update this page (especially since my website transition resulted in all the pictures being lost…ugh), but much of this information should still be useful/relevant!

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.

Table of Contents

What is AGGA?

Who came up with AGGA?

What is involved in AGGA treatment, and how long does it take?

How does AGGA work?

Is it legit?

Are there any dangers or downsides to AGGA?

How much does AGGA cost?

Where do practitioners learn how to use AGGA?

How can I find a practitioner who uses AGGA?

Before and Afters

Where can I learn more about AGGA?

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).

The AGGA. Source: springfieldsmiledoctor.com

(*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. Ronnie did a great job documenting his AGGA experience as well, so if you want more pics, you can look at all his posts I’ve linked at the very bottom of this page.

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
Here’s Ronnie’s final photo before having the AGGA removed, so you can see what the gaps look like.

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.

–Dr. Leonard Kundel

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.

–Dr. Randi Green

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.

–Dr. Paul Peterson

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.

  1. How and why does gentle pressure on the nasopalatine nerve cause “a rapid bone-depositing effort throughout the entire craniofacial region.”
  2. 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.
  3. 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

Update 2/5/21: My before/after!

Below are some of the more noteworthy before and after pictures I’ve come across.

One of Dr. Kundel’s patients. More photos on his website here. Very impressive results.
Another of Dr. Kundel’s patients. More photos on his website here. Again, impressive results.
The famous Ronnie of ronaldead.com! More photos here. His improvement in neck posture is most noticeable, but according to him, it’s the forward growth from AGGA that made the posture change possible.
One of Dr. Green’s patients. More photos on her website here, and her full patient story here. The lighting change is a tad suspicious with this one. Also, in the after picture, she’s facing slightly more to the right (you can see the bridge of her nose, where you can’t see it in the before photo).
Another one of Dr. Green’s patients. More photos on her website here. Again with the lighting change, but I still think this is a significant result.
Another Dr. Green patient! More photos here, and his full patient story here. (This is actually Dr. Green’s husband, and I talked to him on the phone when I inquired about a phone consultation with her! Super nice guy, and VERY enthusiastic about AGGA.)
From Dr. David Frey’s website.

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/videos about AGGA from Ronnie’s website and YouTube channel. Note that Ronnie went from being a huge AGGA proponent (older posts lower on the list) to being staunchly against it (first few links).

From practitioner websites:

Forums/groups:

  • 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:

Random articles:

Below are all of Ronnie’s other AGGA-related posts in chronological order (because while he no longer endorses that people use it, he’s done by far the best job documenting his experience that I’ve seen, so quite helpful for anyone who wants to know what to expect!)

Reader Interactions

Comments

  1. Hi, this Daniel, Dr. Green AGGA treatment patient, and practice manager for the Smile Doctor. Thank you for your kind words! We hope that through publishing Dr. Green’s amazing non-surgical AGGA cases that more people will realize the functional reasons why this treatment makes so much sense for so many reasons.

    My photos are indeed depicted above, and the changes from treatment have been life-changing.

    I am working on posting my x-rays among many photos during treatment and have posted an x-ray image mid-treatment with measurements to show bone remodeling. This proof exists on my blog chronicling treatment with AGGA here > https://www.springfieldsmiledoctor.com/blog/2018/4/30/facial-growth-orthodontics-with-daniel

    Scroll down to the November entry, and you’ll see the first x-ray image. My facial aesthetics including chin and neck have seen drastic improvements and now allow for my tongue to fully seat in the palate with the growth and remodeling that I received. I am also seeking a tongue tie release likely soon to aid in a positive treatment outcome for my case. More to come here for sure.

    I also just took a new 3D Image two weeks ago that is processing for measurement etc. One can most definitely see even more bone remodeling than in November. I have many x-rays and models from previous rounds of treatment that are being worked up into digestible content about my journey with AGGA and Controlled Arch Braces. I am currently three weeks into CAB and starting to close the gaps created behind my canines. My final photos from AGGA removal day will be posting soon.

    Your teeth while in AGGA, specifically the anterior teeth in the upper arch, are bonded together to move as one unit when new bone is remodeling in the maxilla. In my case, the light soreness lasted a day or two at most after the appliance was adjusted. Ask a qualified physiologic dentist like Dr. Green or any of the doctors you mentioned above that are nearest you for more specific answers in your consult or exam as to why the soreness occurs. They would be more than happy to answer your questions.

    As for Dr. Green’s two other patients depicted above — the lighting change is due to using two completely different camera setups. We try our best to keep consistent lighting in all photos, but when you change camera gear, the results can vary with the flash and lighting. That being said, we’re not professional photographers, but we do try our best to depict proper lighting to show off Dr. Green’s amazing results. We will continue to show before, during and after photos of consenting AGGA patients that are so willing to share their incredible successes. More cases will be publishing to the Smile Doctor site very soon!

    Per your comments, I urge those seeking answers about facial growth and development with physiologic orthodontics, facial growth orthodontics, epigenetic orthodontics that involve a growth appliance like AGGA to find care and answers with a qualified doctor that will answer all of your questions about treatment.

    I am glad you’re chronicling your journey. Did you start treatment with Dr. Suh in NC? Keep us posted!

    Reply

    • Hey Daniel! Thanks so much for your comment – I really appreciate how invested you are in sharing information about AGGA and your experience. That kind of transparency is very reassuring for patients/potential patients who are struggling with this kind of stuff. And I look forward to seeing more cases (and x-rays) published on Dr. Green’s site! I hope you guys don’t mind that I have a few of her photos on this page – I made sure to have the photos link back to her site, and provide written source credit, but I’m happy to take them down if you’d prefer me to.

      I have started treatment with Dr. Suh! I just had my spacers and bite pads placed, and will have my AGGA placed in a couple weeks. Thanks again for the referral 🙂 And I will certainly keep this blog updated with my progress as I go along!

      Reply

      • Alyssa, thank you! I set out to share my experience like a few others before me so the rest of us can know what to expect with facial growth and development and look forward to your updates.

        How treatment could work for most of us in adulthood should not be a mystery and for me has had so many positive benefits that go so far beyond straight teeth. The status quo will only change if we emphasize sharing the information, which by the way, you have done a great job of amassing seemingly everything relevant that exists on this page.

        I will continue publishing my case results as they become available and others that consent in Dr. Green’s care. Thank you for the source credits and links to Dr. Green’s website. The lack of permission or credit is one of the reasons we had to get more aggressive by watermarking images as others are not so caring and thoughtful as you.

        I am excited to see your posts soon! The first few days with spacers can be trying, but it gets better from there for most. I am happy you found someone qualified like Dr. Suh to help you on your journey.

        Reply

        • The status quo will only change if we emphasize sharing the information, which by the way, you have done a great job of amassing seemingly everything relevant that exists on this page.

          Thank you! I still have some more sections I want to add, and will hopefully get to soon. I think resources like Dr. Green’s website are fantastic, and obviously getting direct, personalized information from a qualified professional is ideal, but considering how many times I (and I’m sure many others) have been burned by qualified professionals, I think there’s also a very real need for objective third-party sources of information where people can read differing perspectives and come to their own conclusions. So my goal is to be that source, where I can. I don’t want to make people needlessly skeptical, but unfortunately blindly trusting practitioners can turn out badly.

          And no kidding about the spacers! Although honestly, it’s not them so much as the bite pads. Really not a fan of those! But judging by your experience, it will all be very worth it in the end.

          Reply

  2. Thank you so much for this valuable page! I’ve been suffering with TMD for at least a year. I went to a specialist who recommended a full mouth restoration at the cost of $45,000! Yikes! I asked what option B was and she suggested AGGA. Not sure it will work, but definitely a less costly option. Thanks again Alyssa!

    Reply

    • $45k, yikes!! That’s insane. So sorry I’m just now seeing your comment – life has been a bit crazy for me. So glad you found this page helpful though! Please update us if you decide to go with AGGA 🙂

      Reply

  3. This is good information! Such a brilliant website that you have here. I’m looking at getting the Fagga soon, so I’m basically scouring the internet as part of the due diligence process.

    Thank you for your efforts Alyssa.

    Reply

  4. Thanks much Slick! Scouring the internet as part of due diligence…oh yeah. I’ve been there! Honestly that’s why I wanted to create pages like this, so that everyone wouldn’t have to constantly reinvent the wheel when trying to find relevant info.

    If you find anything good that I don’t have listed here, definitely let me know so I can add it! I’m afraid I’ve fallen a bit behind in keeping this page updated.

    Reply

  5. Awesome site. Will read this through entirely. Great resources, I wish this was around when I was looking into it. I would have saved a ton of time.

    Reply

  6. Thank you for the great info you’ve gathered so far Alyssa! One suggestion I have is to check whatever box opens a new window/tab when one clicks on a link rather than opening by diverting from your page as it becomes hard to get back to your post. Keep up the good work!

    Reply

  7. Thanks for collecting all of this information in one place – this is super helpful for me right now, as I start to consider something like a DOME, AGGA, or Vivos DNA later this year (just trying to get my lower jaw back into normal resting position first via a bite splint made by my TMJ doc). I will absolutely be coming back to read your updates as AGGA continues along for you, and wish you expectation-exceeding success!!

    Your concerns are exactly the same as mine – I don’t want to suddenly be “fixed” and super happy about it only to find out 10 years later I actually ended up impairing the resilience of my teeth overall and they all start falling out one by one. Very scary – so the fact that you have focused so much on that, and yet chose to go with AGGA anyway, is very encouraging.

    That “pushing teeth” problem is one of the reasons that Vivos DNA is now lower on my list. It seemed so promising at first in terms of lateral and forward expansion plus overall ease of use (only wearing the appliance 12 hours a day), but now I am just reading too much about the long-term uncertainty involved when pressure is applied behind the teeth.

    You had mentioned in another post something about how you were going to get some lateral expansion, but concerned about the FRLA’s being tooth-borne. Did you ever look into something like a DOME procedure? That’s also on my list as well – that’s bone-borne, and gets up to 10mm of lateral expansion about 30 days after you start. But then you end up with this giant 1cm gap between your upper incisors … which is not pretty at all, and takes about 10 months to close up with braces. But, it definitely doesn’t really push the teeth at all (it does anchor to a molar on each side, but I think the expansionary forces are almost entirely on the bone) so there are ways to get lateral expansion without putting pressure on the teeth.

    What other procedures did you consider, but then decide not to go through with?

    Reply

    • Hey Toomer, sure thing! Glad it’s helpful, although I’m sure it would be immeasurably more so if I ever got a chance to update it and flesh it out more. But alas, life has had a way of preventing that lately!

      I haven’t even heard of a DOME procedure until now! I’m intrigued – do you have any good resources to learn about it that you could share with me? I’m woefully out of the loop these days. Lateral expansion has never been my top priority, but now that I have a taste of extra tongue room in the front, I’d be interested to see what I could achieve laterally as well.

      As far as other procedures I considered and then decided against – I can’t think of any at the moment that I haven’t already mentioned on here somewhere! Based on some of the comments I’ve been getting (including yours), it seems like this space has grown and advanced significantly since I was initially looking into options a year or two ago.

      Reply

    • Hi April! I posted an update video a couple weeks ago – you can always see my latest updates by going to either the home page of this website or to my YouTube channel. I’m 5 months into CAB, so not finished quite yet!

      Reply

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