Fixed functional appliance /certified fixed orthodontic courses by Indian dental academy

Fixed
Functional
Appliances
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INTRODUCTION


A skeletal Class II - fault with the maxilla

A skeletal Class II - fault with the mandible

Correction of Class II malocclusion – An
Enigma
• Dilemma regarding –
•
•
•
•

Age to initiate ?
Modality of correction
What to expect ??
How to retain ??


Contributors to Class II malocclusion
• Maxillary prognathism – 30%
• Mandibular retrusion - 70%
----Mc’Namara (1981)
Mastorakos study( 1984) --- slight disagreement with
Mc’Namara’s values


Earlier dictum in Growth modulation
• Start treatment early for Class II correction ; hold
the correction for a longer period.
• Distinct European and American strategies
• Complete second phase of treatment with fixed
appliances


Problems with two-phase treatment
• Excessively long duration of treatment
• Burn-out of patient co-operation
• No additional benefits to majority of patients
compared to those undergoing a single phase of
treatment
• Less cost-effective


Timing of Class II correction
Based on RCT’s done in US and UK, Proffit states
• “ Early treatment for most Class II children is
no more effective and considerably less efficient
than later one-stage treatment during
adolescence” - AJODO 2006


Wrong assumptions made..
• Class II correction in mixed dentition does not
work well
• Start Class II correction only in permanent
dentition
• What about cases with severe proclination??
• What about psychological benefits to those
Class II children who are bullied due to their
protruding teeth?

The present view
• Two-phase treatment may make the
treatment
unnecessarily
prolonged
;
economics and co-operation levels difficult to
justify
• Therefore a single phase of treatment gaining
widespread acceptance.

CONSIDER A PROTOCOL BASED ON:
• Growth status of the patient,
• State of dentition,
• Nature of dental malocclusion (irregularities)
needing pre-functional corrections,
• Whether the patient will need any extractions,
• Amount of incisor exposure.

Growth status of the patient
• Optimum timing for growth modulation of
Class II (irrespective of treatment modality) is
the active growth period coinciding with the
pubertal growth spurt
– Sassouni 1972
– Pearson 1978
– Pancherz 1985
– Malmgren 1987
– Baccetti 2000 etc

• Mandibular growth is slightly behind the
skeletal growth (Fishman and others).
• Hence, the ideal timing for growth modulation
would be during or slightly after the peak of
the growth spurt.


Assessment of the Peak of Growth Spurt
• Earlier method was the hand and wrist
radiograph (or MP3)

2 ½ years

6 ½ years
11 years

19 years

Cervical Vertebral analysis of Franchi,
Bacetti and Mc’Namara


• The one phase treatment cases could be
classified, based on their growth status, into:
a. Early (CVM I – Growth spurt peak will occur
after more than 1 year),
b. Appropriate (CVM II– peak will occur within
few months),
c. Late (CVM III – spurt has already occurred,
or beyond).


Parameters to judge prognosis


Weigh the following
• Predisposition to trauma
• Psychological assessment

•Problem areas – Skeletal, dental or both?
•Any transverse /vertical problems?


Cases ideal for early intervention
• Patients with severe deficit of mandibular
growth.
• Cases with severe proclination/ psychological
insult
• Cases with excessively narrow maxilla
• Class II intervention by way of habit correction

Is amalgamation of fixed appliances
and functionals acceptable?
“Concurrent usage of fixed appliances and
functional therapy does not spell a biologic
compromise; instead it may offer a
mechanical advantage”
–T.M Graber


Shifting paradigms in Class II
treatment
Concept of Telescoping treatment
Coupling two modalities of treatment to
extract maximum benefit of both in a
shorter time.
Also aim at minimising side effects of each

other

Telescoping treatment
for Class II malocclusions
• Combining

benefits

of

mandibular

advancement while minimising side effects on
dentition.
• Help in augmenting sagittal and transverse
corrections
• Minimise overall treatment time

Add-ons’when combining Fixed Functional
appliances with fixed mechanotherapy

Aid intra-arch corrections

• obtaining unilateral lower midline shift,
• upper molar distalization

• anchorage conservation

Shifting paradigms in Class II treatment
Previous concept of Class II management
Extractions

Functional

Surgical

Childhood
Mild Class II

Adulthood
Severe ClassII


Shifting paradigms in Class II treatment
Proposed concept of Class II management by Pancherz

Herbst
Functional

Extractions

Surgical

Childhood
Mild Class II

Adulthood
Severe ClassII


THE METHOD OF OPERATION OF
FUNCTIONAL APPLIANCES
functional appliance
Increased contractile activity of the LPM
Intensification of the repetitive activity of the retrodiscal pad
(Bilaminar zone)
Increase in growth stimulating factors
Enhancement of local mediators

Reduction of local regulators
(factors having negative feed back
effects on cell multiplication rate)
Changes in condylar trabecular orientation
Additional growth of condylar cartilage
Additional sub-periosteal ossification of the
Posterior border of the mandible
Supplementary lengthening of the mandible
THE METHOD OF OPERATION OF
FUNCTIONAL APPLIANCES


Advantages of fixed functional appliances
over removable functional appliances
• less dependent on the patient co-operation
• works 24 hrs a day, so there is continuous
stimulus for mandibular growth

• Treatment time is short (approx 6 – 8 months)
• Direction of force is more constant

• smaller in size permitting better adaptation

CORRECTION OF CL II MALOCCLUSION
• Dento alveolar changes
• Restriction of forward growth of the mid face
• Stimulations of mandibular growth beyond that
which would normally occur in growing children.
• Redirection of condylar growth –
upward & forward directed growth to posterior
direction

• Deflection of ramal form
• Horizontal expression of mandibular growth
from downward and forward to horizontal.
• Changes in neuromuscular anatomy and
function that would induce bone remodeling.
• Adaptive changes in glenoid fossa location to a
more anterior and vertical position.

Classification of Fixed Functional
Appliances
• According to Antonio Korrodi Ritto
– Rigid Inter-maxillary Appliances (RIMA)
– Flexible Inter-maxillary Appliances (FIMA)

– Hybrid Appliances (Combination of RIMA & FIMA)


Classification of Non-compliance
Inter-maxillary Appliances
According to Moschos A Papadopoulous
– Rigid Inter-maxillary Appliances (RIMA)
– Flexible Inter-maxillary Appliances (FIMA)
– Hybrid Appliances (Combination of RIMA & FIMA)
– Appliances acting as substitutes for elastics


Rigid Inter-maxillary Appliances
(RIMA)
Herbst like appliances


• Emil Herbst, 1905 @ the Berlin Dental
Congress
• 1970,Hans Pancherz brought it back into
discussion with the publication of a series of
articles


Herbst Appliance
• a passive tube and plunger system with the
exact length of the tube determining the
amount of anterior mandibular displacement

• tube - attached to a maxillary posterior unit
• plunger is fixed anteriorly to the mandibular

dentition - slides through the tube during
opening and closing movements

Herbst appliance


Herbst Appliance


Modifications of Herbst
Appliance


Goodman’s Modified Herbst Appliance
• SS crowns on maxillary molars
• TPA 0.045” round wire connecting the crowns
• Frameworks for upper ans lower arches - 14
gauge half round wire
• Maxillary pivots soldered to most distal part of
the crown
• Mandibular pivot soldered to wire framework


Upper Stainless Crowns and Lower
Acrylic
• Larry White
• Lower part removed for oral hygiene
• Zeirk – Enden Herbst
– double buccal tubes on maxillary molars

• Magnusson System – Valant & Sinclair
– Molars connected with TPA


Upper Stainless Crowns and Lower
Acrylic


Mandibular Advancement Locking Unit
• 1996, Raffaele Shiavoni
• 2 tubes, two plungers, two upper “Mobee”
hinges with ball pins and two lower key hinges
with brass pins
• upper “Mobee” hinge
– inserted into hole at the end of the MALU tube
– secured to the first molar headgear tube with ball pin.

• lower key hinge
– inserted into the hole at the end of the plunger and
locked to the base arch, distal to the cuspid with brass
pins.

MALU


Magnetic Telescopic Device
• Ritto A.K. 1997
• consists of two tubes and two plungers with a
semi-circular section and with NdFeB magnets
placed in such a manner that a repelling force
is exerted

• Fitted using the MALU system

Magnetic Telescopic Device


Flip- Lock Herbst Appliance
• Robert A Miller
• They have 3 Generations
– Generation 1- dense polysulfone plastic but breakage

occurred because of the forces generated within the
ball-joint
– Generation 2 -plastic was replaced with metal
– Generation 3 - horse-shoe ball joint

Flip- Lock Herbst Appliance


Hanks Telescoping Herbst Appliance
• One piece design
• Two tubes, a ball & socket joint and a rod
attachment to mandibular premolars or
cantilever arm
• American Orthodontics


Hanks Telescoping Herbst Appliance


Ventral Telescope
•
•
•
•

First telescopic single unit appliance
Available in two sizes
Fixing is achieved through ball attachments
Easy to activate

Disadvantages
• Quite thick
• Ball attachments - great accuracy is necessary
with regard to inclination and welding of
components

Ventral Telescope


Universal Bite Jumper (UBJ)
• Calvez X, 1998
• like a Herbst but is smaller in size and more
versatile
• active coil spring can be added if necessary
• Activations are made by crimping 2-4 mm
splint bushings onto the rods
• UBJs with nickel titanium coil springs do not
need to be reactivated

UBJ


IST ( Intraoral Snoring Therapy)
Appliance
• Hinz
• treat patients - breathing problems during sleep,
e.g. OSA
• “suppresses snoring by moving the lower jaw
forward reducing the obstruction in the
pharyngeal area”
• The telescope is threaded so the orthodontist can
change the protrusion on each side individually
up to 8mm.
• An end stop in the guiding sleeve prevents the
telescope from disengaging.

IST Appliance


Acrylic Splint with Hinge System
• 1988, James A. Mc Namara


Cantilever Bite jumper
• Appliance fitted directly to the lower molar
bands through a cantilever arm
• crowns have to be fitted to the upper and
lower molars
• parts are available in kit form with pre-welded
screw mechanisms and cantilever arms on
crowns of seven different sizes


Cantilever Bite jumper


Mandibular Advancing
Repositioning Splint (MARS)
• 1982, Ralphm Clements, Alex Jacobson
• Composed of a pair of telescoping struts.
• Each strut is composed of two separate parts.
– Plunger
– Hollow tube


Other Rigid Inter-maxillary
Appliances


Biopedic Appliance
• Designed by Jay Collins and manufactured
and sold by GAC, was introduced in 1997.


Biopedic Appliance
• buccal attachments soldered to maxillary and
mandibular molar crowns. The attachments contain
a standard edgewise tube and a large 0.070-inch
molar tube. Large rods pass through these tubes.
• The mandibular rod inserts from the mesial of the
molar tube and is fixed at the distal by a screw
clamp.


Biopedic Appliance
• Appliance activation - moving the rod mesially
• The short maxillary rod is inserted from the
distal and fixed by a similar screw at the
mesial of the maxillary first molar.
• The two rods are connected by a rigid shaft
and have pivotal regions at their ends.


Ritto Appliance
• Ritto A.K., 1998
• miniaturized telescopic device
• appliance does not come apart - no
disengagement after achieving maximum
extension


Ritto Appliance


Mandibular Protraction Appliance
• 1995 Coelho Filho


MPA I
• bending a small loop at a right angle to the
end of an .032" SS wire
• length - determined by protruding the
mandible
• another small right-angle circle is then bent in
an opposite direction
• The appliance slides distally along the
mandibular archwire and mesially along the
maxillary archwire
• Bicuspid brackets must be debonded.

MPA I


MPA II
• right-angles circles in two pieces of .032" SS
wire
• small piece of slipped coil is slipped over one
of the wires
• One end of each wire is then inserted through
the loop in the other wire
• allows the mouth to open wider than MPA I


MPA III
• Eliminates archwire stress that occurs with the
MPA I and II
• greater range of jaw movement while keeping
the mandible in a protruded position
• resembles the Herbst - incorporating a
telescoping mechanism but is smaller in size.
• It requires more time to be built and a good
electronic welder that does not darken or
weaken the wire.

MPA III


Mandibular Anterior
Repositioning Appliance
Douglas Toll of Germany in 1991
first molars - covered with stainless steel crowns
the appliance must be laboratory manufactured.

In a large .062 square tube on the upper molar, an adjustable
.060 square ‘elbow’ hangs vertically.
lower molar has a .059 round wire arm projecting buccally
from mesial.
To cause more mandibular advancement, shims are placed
on the elbow.

MARA


Flexible Inter-maxillary Appliance
Jasper jumper like appliance


Jasper Jumper
• Dr. James Jasper (1987)
• covered spring
• marketed in a kit of different sizes with both
left and right sides


Jasper Jumper


Gentle Jumper


Scandee Tubular Jumper
• coated intermaxillary torsion spring sold in a
kit which includes the spring, the covering, the
connectors, the ballpins and the glue
• no distinction between left and right
• constructs the appliance, cutting the spring to
the length seen fit


Scandee Tubular Jumper


Amoric Torsion Coils
• two springs, one of which slides inside the
other
• inter maxillary springs without covering
• simplified application system of rings on the
ends.
• rings are fixed to the upper and lower arches
with double ligatures
• marketed in one size only and are bilateral.
• force exerted -variable - accordance with the
fixing points on the arch

Amoric Torsion Coils


Adjustable Bite Corrector (ABC)
• 1995, Richard P West - a variation of the Jasper
Jumper
• swivel adjustments at its ends, thereby

eliminating the need for left and right models and
thus reducing inventory by half.
• The push force generated from a nickel titanium
wire in the center lumen of the spring

ABC


ABC
• The length of the ABC can be increased as
much as 4 mm by simply turning the ends of
the spring

• permits the clinician to alter the applied force
by merely rotating the end(s) of the spring


Bite Fixer
• In 1998 Ormco introduced the Bite Fixer, which
is claimed to be an improved Jasper Jumper
because breakage is reduced
• spring is attached and crimped to the end
fitting to prevent breakage between the spring
and the end fitting
• Polyurethane tubing inside – prevent being
food trap

Bite Fixer


Klapper SUPERspring II
• 1997 Lewis Klapper - Klapper Superspring for the
correction of Class II malocclusions. On first glance
• it resembles a Jasper Jumper with the substitution of a
cable for the coil spring.
• In 1998 the cable was wrapped with a coil and the
Klapper Superspring II was the result

Klapper SUPERspring II


Klapper Spring


Churro Jumper
• inexpensive alternative force system for the
anteroposterior correction of Class II and Class
III malocclusions
• mesial and distal end of the jumper are circles
• distal circle is attached to the maxillary
molars by a pin and the mesial end is placed
over the mandibular archwire against the
canine bracket.

Churro Jumper


Churro jumper


Forsus Nitinol Flat Spring
• slim, flat and made of Super-Elastic Nitinol
• delivers consistent forces
• Force levels remain constant from the initial
setup to the time of removal

• The result is faster, more efficient treatment.

Forsus Nitinol Flat Spring


Hybrid Appliances
Combination of FIMA & RIMA


Eureka Spring
• 1996 , DeVicenzo & Steve Prins
• three part telescopic appliance fixed to the
upper arch at the level of the molar band and
to the lower arch distal to the cuspid
• open coil spring that is placed inside of a part
of the system
• appliance is universal and it can be applied
both to the right as well as to the left side

Eureka Spring


Sabbagh Universal Spring
• possesses a gentle, slowly accelerating force
• size can be adjusted by turning the inner
telescope tube & inserting activation springs
(tension or compression springs)


Sabbagh Universal Spring


ForsusTM Fatigue Resistant Device
• telescopic appliance with a coil spring in its
exterior part
• coil spring is applied by its sliding on a rigid
surface avoiding in this way angulations at the
fixing points


Forsus FRD


Twin Force Bite Corrector
• two internal coil springs
• two joint telescopic systems
• superior level - ball pin fitted into the buccal
tube of a molar band
• fitting-in system fixed with a screw to the
inferior arch - distal to the lower cuspid


Twin force Bite Corrector


Twin force Bite Corrector

Quick-connect Twin Force Bite Corrector
Classic Twin Force Bite Corrector

Appliances acting as
substitutes for Elastics


Appliances acting as
substitutes for Elastics
• Calibrated Force module
• Alpern Class !! Closers

• Saif Springs


Calibrated Force Module
• 1988 – Cormar Inc.
• Avaialable in 3 sizes
• Attached to to the lower archwire diatal of
mandibular molars and fixed by a screw and to
the upper archwire distal or mesial to
maxillary canines
• Forces 150-200gms - Spring coils


Calibrated Force Module


Alpern Class II Closers
• Alpern Sentalloy Interarch coil Springs (GAC )
• Small telescopic device with Sentalloy coil
springs and two hooks for fixing
• Available in four sizes
• Force 250 gms
• Fixed to the mandibular molar and to canine
bracket


Alpern Class II Closers


Saif Spring
• Armstrong late 1960s and early 1970s introduced
the Pace Spring, later termed Multicoil Spring
• Saif Springs (Severable Adjustable Intermaxillary
Force) Pacafic Coast Manufacturing Inc.
• Spring inside a spring with welded loops on each
side generate high forces.
• Set up like Class II or Class III elastics

Conclusion


Conclusion
• qualities that functional appliances should
have:
– Patient comfort and acceptance are excellent
– promote better compliance
– offer an extensive range of motion
– simple and inexpensive
– Easy to fit
– adaptable to either Class II or III

Conclusion
– be used for mandibular positioning or dentoalveolar
movement
– cause less breakage of archwires and appliances and
thus fewer emergency appointments
– Inventory requirements are minimal . The appliance
can be used on either side of the mouth and there is
only one size
– used at any stage of treatment mixed or permanent
– low profile results - considerably less buccal irritation
– produce good results without the need for patient
cooperation

References
• Olivier R.G., Knappman J.M. Attitudes to orthodontic
treatment. British Journal of Orthodontics 1985; 12:179-88.
• Ngan P., Kess B., Wilson S., Perception of discomfort by
patients undergoing orthodontic treatment. Am. J. Orthod.
Dent. Orthop. 1989; 96:47-53.
• Herbst E. Atlas und Grundriss der Zahnärztlichen Orthopädie.
Munich, Germany, J.F. Lehmann Verlag, 1910.
• Pancherz H. Treatment of Class II malocclusions by jumping
the bite with the Herbst appliance. A cephalometric
investigation. Am. J. Orthod. 1979; 76: 423-442.
• Calvez X. The universal bite jumper. J. Clinical Orthod. 1998;
32: 493-499.
• Eckart E. Introducing the MARA. Clinical Impressions 1998; 7:
2-5.

References
Filho C.M. Mandibular Protraction Appliances for Class II
Treatment. J. Clin. Orthod. 1995; 29: 319 ? 336.
Filho C.M. Clinical Applications of the Mandibular Protraction
Appliance. J. Clin. Orthod. 1997; 31: 92 ? 102.
Filho C.M. The Mandibular Protraction Appliance III. J. Clin.
Orthod. 1998; 32: 379-384.
Ritto A.K. Fixed Functional Appliances ? Trends for the next
century. The Functional Orthodontist 1999; 16 (2) 122 ? 135.
West R.P. The adjustable bite corrector. J. Clinical Orthod. 1995;
29: 650-57.


References
• Klapper L. The SUPERspring II: A new appliance for noncompliant class II patients. J. Clin. Orthod. 1999; 33: 50-54.
• Jasper J.J. The Jasper Jumper ? a fixed functional appliance.
Sheboygan, wisconsin: American Orthodontics, 1987.
• Jasper J.J., McNamara J. The correction of interarch
malocclusions using a fixed force module. Am. J. Orthod.
Dentofac. Orthop. 1995; 108: 641-50.
• Erdogan E., Erdogan E. Asymmetric Application of the Jasper
Jumper in the correction of midline discrepancies. J. Clin.
Orthod. 1998; 32: 170 ? 80.
• Cope J.B., Buschang P., Cope D.D., Parker J., Blackwood H.O.
Quantitative evolution of craniofacial changes with Jasper
Jumper Therapy. Angle Othod. 1994; 64 (2): 113 ? 122.

References
• Cash R.G. Case Report: adult nonextraction treatment with a
Jasper Jumper. J. Clin. Orthod. 1991; 25: 43-7.
• Castañon R., Valdes M., White L.W. Clinical use of the Churro
Jumper. J. Clin. Orthod. 1998; 32: 731 ? 45.
• Blackwood H.O. Clinical Management with the Jasper Jumper.
J. Clin. Orthod. 1991; 25: 755-60.
• Amoric M. Les Ressorts intermaxillaires en torsion. Rev.
Orthop. Dento Facial 1994; 28: 115 ? 117.
• Shiavoni R., Bonapace C., Grenga V. Modified Edgewise-Herbst
Appliance. J. Clin. Orthod. 1996; 30: 681 ? 87.


References
• Ricketts R. M. The keystone triad II. Growth, treatment and clinical
significance. Am. J. Orthod. 1964; 50: 728-50.
• Petrovic A.G., Stutzmann J., Outdet C., Control processes in the
postnatal growth of the mandibular condylar cartilage in:
McNamara J.A.ed Determinants of mandihular form and growth.
Monograph 4. Craniofocial Growth Series. Ann Arbor: Center of
Human Growth and Development University of Michigan,
1975:101-53.
• Nashed R.R., Reynolds I.R. A cephalometric investigation of overjet
changes in fifty severe Class II division 1 malocclusions. Br. J.
Orthod. 1989; 16: 31-37.
• Mills J.R.E. The effect of functional appliances on the skeletal
pattern. Br. J. Orthod. 1982; 18: 267-75.
• McNamara J.A., Carlson D.S. Quantitative analysis of
temporomandibular Joint adaptations to protrusive function Am J
Orthod 1979; 76: 593-611.

References
• McNamara J.A. Components of Class II malocclusion in children 810 years of age. Angle Orthod 1981; 51: 177-202.
• Illing H.M., Morris D.O., Lee R.T. A prospective evaluation of Bass,
Bionator and Twin Block appliances. Part I ? the hard tissues. Europ.
J. Orthod. 1998; 20: 501-516.
• Hilgers J.J. Hyperefficient Orthodontic treatment using tandem
mechanics. Semin. Orthod. 1998; 4: 17-25.
• Heather M. L., Morris D. O., Lee R.T. A prospective evaluation of
Bass, Bionator and Twin Block appliances. Part I- the hard tissues.
Eurp. J. Orthod. 1998; 20: 501-516.
• Harvold E., Vargervik K. Morphogenetic response to activator
treatment. Am. J. Orthod. 1971; 60: 478-90.
• Haegglund P. The Swedish-Style Integrated Herbst Appliance. J. Clin.
Orthod. 1997; 31: 378 ? 390.


References
• Dischinger T. Edgewise Herbst Appliance. J. Clin. Orthod. 1995;
29: 738 ? 742.
• Burke G., Major P., Glover K., Prasad N. Correlations between
condylar characteristics and facial morphology in Class II
preadolescent patients. Am. J. Orthod. Dentof. Orthop. 1998;
114: 328-36.
• Pancherz H. The mechanism of Class II correction in Herbst
appliance treatment. Am. J. Orthod. 1982; 87: 1-20.
• Pancherz H. The Herbst appliance ? its biological effects and
clinical use. Am. J. Orthod. 1985; 87: 1-20.
• Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod.
1996; 30: 552

Fixed functional appliance /certified fixed orthodontic courses by Indian dental academy

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