recent advancements in Fixed functional appliances /certified fixed orthodontic courses by Indian dental academy

Recent advancements in
fixed functional
appliances

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A Functional appliance by
definition is one that changes the
posture of the mandible, holding
it open or open and forward.
Pressures created by the stretch
of the muscles and soft tissues
are transmitted to the dental
and skeletal structures ,moving
teeth and modifying growth

CLASSIFICATION
Functional appliances can be classified as
REMOVABLE FUNCTIONAL APPLIANCES
FIXED FUNCTIONAL APPLIANCES


Removable functional appliances are normally
very large in size, have unstable fixation, cause
discomfort, lack tactile sensibility, exert pressure
on the mucous (encouraging gingivitis), reduce
space for the tongue, cause difficulties in
deglutition and speech and very often affect
aesthetic appearance. The alteration in the
mandibular posture creates added difficulties.
These adverse effects make the adaptation and
acceptance of these appliances more difficult.


Fixed functional systems have some advantages
over removable systems. They are designed to be
used 24 hours a day, which means that there is a
continuous stimulus for mandibular growth.
They are smaller in size permitting better
adaptation to functions such as a mastication,
swallowing, speech and breathing.
Fixed functional appliances are usually described
as non-compliance Class II devices, which are
able to treat Class II malocclusions successfully,
while reducing the need for patient co-operation
and overall treatment time. It is possible to treat
this type of malocclusion with minimal effort.

Fixed functional appliances are normally known
as "non-compliance Class II correctors" giving a
false idea about the co-operation necessary
during treatment. In reality, when we compare
them to removable appliances, we can clearly
recognize fixed appliances as non-compliance
devices. However, for treatment to be
successful, good co-operation is always
necessary, especially if skeletal modifications
instead of dento alveolar compensation are
desired.


Functional-appliance therapy can achieve correction
of Class II malocclusion through the following
factors:
Dentoalveolar changes
Restriction of forward growth of the mid face
Stimulation of mandibular growth beyond that which
would normally occur in growing children,
Redirection of condylar growth from an upward and
forward–directed growth to a 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.

Mode of action of functional
appliance
Regardless of various functional appliances, the
following casual chain is involved
Functional appliance
Increased contractile activity of 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
Change in condylar trabecular orientation
Additional growth of the condylar cartilage
Additional sub periosteal ossification of the
posterior border of the mandible
Supplementary lengthening of the mandible

One step versus stepwise advancement
using fixed functional appliances
Rabie et al’s work on experimental rats showed
that during the first advancement ,bone formation
in the condyle and the glenoid fossa was less than
that of the 1 step advancement .In response to the
second advancement ,new bone formation in the
condyle and the glenoid fossa was significantly
greater when compared with single advancement
with a maximum increase of 50% and 100%
respectively. Moreover the higher level of bone
formation in the stepwise advancement is
maintained

The results of the present study also
indicate that the stepwise advancement
produces a much more prominent effect on
the growth of the glenoid fossa when
compared with the condyle. The amount of
increase in bone formation in the glenoid
fossa in response to stepwise advancement
when compared with single advancement
was 2 times more than that expressed in the
condyle.

An explanation of these results could relate
to the age of the animals used as reported
by Woodside and coworkers they showed
that in older primates there was a more
pronounced response in the glenoid fossa
than the condyle in mandibular
advancement, whereas in the younger
primates there was a more pronounced
response in the condyle. Additional
explanation of the enhanced response of the
glenoid fossa was found to be caused by the
amount of the blood vessels recruited in the
glenoid fossa in response to advancement."

Recently, Rabie et al reported that
mechanical strain caused by forward
mandibular positioning stimulated the cells of
the chondroid layer in the glenoid fossa to
secrete vascular endothelial growth factor
(VEGF), which was 220% more than its
levels during natural growth." VEGF
enhances the invasion of new blood vessels
and the perivascular connective tissues
surrounding these new blood vessels are
repository sites of mesenchymal cells. These
cells could in turn replenish the population
size of osteoprogenitor mesenchymal cells.

VEGF also stimulates the vascular endothelial cells
to secrete growth factors and cytokines that
influence the differentiation of mesenchymal cells
to enter the osteogenic pathway and engage in
bone synthesis."'
On the other hand, the amount of VEGF
expressed in the condyle in response to mandibular
advancement was only 48% more than natural
growth. Therefore, it is conceivable that the
significant difference in the response between the
glenoid fossa and the condyle is because of the
ability of both tissues to vascularize to a different
degree in response to advancement

The ideal period for therapy
With respect to the maximum mandibular
growth stimulation and long term stability
of the treatment, the ideal period is in the
permanent dentition at or just after the
pubertal peak of growth corresponding to
the skeletal maturity stages FG to H of the
MP3 (implying to the pre capping and pre
union stages of the epiphysis and
metaphysis)

Fixed functional appliances can be classified
as either
Flexible (Flexible Fixed Functional
Appliance - FFFA)
Rigid (Rigid Fixed Functional Appliance RFFA).
Hybrid appliances


Flexible fixed functional appliances (FFFA)
can be described as an inter-maxillary
torsion coils, or fixed springs. Elasticity
and flexibility are the main characteristics
of flexible appliances. They allow great
freedom of movement of the mandible.
Lateral movements can be carried out with
ease.


Draw backs are the propensity with which fractures
can occur both in the appliance itself (mainly in
areas that have more acute angles) and in the
support system (mainly in the lower arch). The
appliance tend to produce fatigue in the springs.
Another drawback is the tendency of the patient to
chew on the appliance, possibly contributing to
breakage or damage. While it is not possible for the
patient to completely open his mouth, depending on
the way the system is fixed onto the lower arch, good
opening can be achieved.
opening the mouths too widely could result in
breakage. Also, they are not very aesthetic
appliances. When the curvature of the spring is
accentuated, some protuberances can appear in the
cheeks.

These appliances are expensive, therefore, a
system that allows the replacement of some of
its components can reduce the cost of
treatment. This leads to another disadvantage:
the inventory of material that must be kept.
Almost all are sold in kits of various sizes
which contain components for both the left
and right side. It is not always possible to treat
a patient with only one size making it
necessary to replace it with a larger size.
Once again, this increases cost.

The type of the force exercised by FFFAs is
continuous and elastic in nature. The amount of
force is variable in accordance with the skeletal
pattern of the patient, the type of movement desired
and the size of the cusps. Normally, in brachyfacial
cases, due to their strong musculature, it is
necessary to use more force (greater activation) than
in Dolichofacial cases. The height of the dental cusps
is a factor to bear in mind when treating with FFFAs.
If the patient has high cusps with good
intercuspation, it will be necessary to exert greater
activation on the spring. If the large size of the cusps
is linked to a brachyfacial skeletal pattern with strong
musculature, we can predict a difficult clinical
scenario and the appliance will be prone to fracture.

If an advance of the mandible is required as
when treating a retro mandibular case, the
force exerted has to be greater than that used
when only dental movement is desired to
distalize the upper molar and procline the
lower incisors. If the goal of the treatment is to
achieve dentoalveolar movements, the
appliance should be activated minimally by
placing a slight bow in the force module. To
maximize the dentoalveolar movements in the
upper arch and minimize any loss of
anchorage in the lower, the upper arch wire is
not tied back.

FFFA produces a "headgear" effect on the
maxillary dentition due to the intrusive force
applied to the maxillary posterior segments
and produces an anterior intrusive force on
the lower dentition. It can be used to obtain
maximum anchorage, holding upper molars
back as the upper incisors are retracted


Due to the intrusive force on the upper molars, a
posterior open bite is common as well as posterior
expansion due to the deflected force module.
Another unwanted common movement is the
tendency for the lower molar to rotate mesio
buccally, causing a mild posterior cross bite
especially when the second molars have not been
banded. Some buccal expansion in the upper and
lower arches is to be expected, and placing bands
on the second molars will aid final alignment.
Placing a transpalatal or lingual arch during the
force activation stage will help control unwanted
buccal expansion of both arches. Loss of occlusion
adds to instability, especially in the transverse
dimension.

The most unwanted dental movement is Proclination
of lower incisors. To avoid this effect, good
anchorage preparation should be carried out.
However, in a brachyfacial pattern with strong
musculature this movement would be expected. To
increase anchorage to avoid unwanted dental
movements, various additional systems can be used,
such as a transpalatal bar, lingual arches or lower
incisor brackets with lingual torque.
It is advantageous to start the treatment in
adolescent patients when the majority of permanent
teeth have erupted and 12-year molars can be
banded. FFFAs are not recommended in mixed
dentition, especially late mixed dentition to avoid
unwanted dental movements

Proper anchorage preparation is critical to
achieving successful results. It is necessary to align
and level arches before placing the final wire and
activating the force module. A .017" x .025" or .018"
x .025 stainless steel arch wire should be placed
before inserting the FFFA. By fully engaging the
brackets in both arches, especially the lower,
anchorage is maintained during the activation of the
force module, preventing unwanted mesial
movement of the lower incisors and distal
movement of the uppers. When proclining the lower
incisors is desired as in Class II division 2 it may be
advantageous to use a .016" x .022" stainless steel
arch wire as a final wire.

All FFFAs allow the patient to close in centric
relation.
When the patient closes in centric relation,
the contour of the bow should be significantly
increased. By slightly over activating the
appliance in centric relation, the patient will
automatically position the mandible forward.
This is a natural response to decrease the
force module and alleviate discomfort. The
upper arch wire should be cinched to
increase anchorage and minimize
dentoalveolar movements.

JASPER JUMPER
It is the most successful and widely used
inter arch force delivery system.
This inter arch appliance uses a push
force than a pull force.
It is made up of a covered spring and is
marketed in a kit of different sizes with
both left and right sides


INDICATIONS:
Dental class II malocclusion
Skeletal class II with maxillary excess as opposed to
mandibular deficiency
Deep bite with retroclined mandibular incisors
CONTRA INDICATIONS:
Cases predisposed to root resorption
Dental and skeletal open bites
Vertical growth with high mandibular plane angle and
excess lower facial height
Minimum buccal vestibular space


Advantages of jasper jumper are its ease
of insertion and activation and generation
of the intrusive forces on molars and
incisors where as disadvantages include
large inventory five sizes of left and right ,
breakage and a lack of force when the
mouth is held open slightly. It is more
prone for breakage when used to correct
class III corrections


Cope in his study of comparison of Churro jumper
and jasper jumper found that the Jasper Jumper
consistently:
Displaced the maxilla posteriorly.
Failed to stimulate mandibular growth, but did
rotate the mandible backward.
Tipped the maxillary molars posteriorly and
intruded them.
Significantly tipped the maxillary incisors
posteriorly and extruded them.
Significantly tipped, extruded, and moved the
mandibular molars bodily in an anterior direction.
Significantly tipped the mandibular incisors
anteriorly and intruded them.

JASPER JUMPER


THE AMORIC TORSION COILS
This appliance is made up of two springs, one of
which slides inside the other . They are inter
maxillary springs without covering and have a
simplified application system of rings on the
ends. These rings are fixed to the upper and
lower arches with double ligatures.
They are marketed in one size only and are
bilateral. The force exerted by the appliance is
variable in accordance with the fixing points on
the arch

AMORIC TORSION COILS


ADJUSTABLE BITE CORRECTOR
(ABC)
This is an appliance which is assembled by the
orthodontist as it is composed of various pieces –
caps, closed coil springs, nickel titanium wire
It can be used on either side of the mouth with a
simple 180º rotation of the lower end cap to
change its orientation. This reduces the inventory
by as much as one half. In the center lumen of
the spring we find a nickel titanium wire which is
responsible for the "push" force generated.
Repairs and replacements are rapid and easily
carried out with this kit. The cost of repair is minor

ADJUSTABLE BITE CORRECTOR


SCANDEE TUBULAR JUMPER
This is a coated inter maxillary torsion spring sold
in a kit which includes the spring, the covering,
the connectors, the ball pins and the glue . There
is no distinction between left and right.
The covering can be of different colors making it
more attractive for patients. The orthodontist
constructs the appliance, cutting the spring to the
length seen fit. When a fracture occurs, it is only
necessary to replace individual components. It
has the drawback of being thick after the covering
is applied.

SCANDEE TUBULAR JUMPER


Klapper SUPER Spring II
This is a flexible spring element which is attached
between the maxillary molar and the mandibular
canine. The length of the element causes it to rest in
the vestibule when activated. This facilitates hygiene
and avoids occlusal surfaces. The ends (fixing points)
are different: The open helical loop of the spring is
twisted like a J-hook onto the mandibular arch wire.
On the maxillary end it is attached to the standard
headgear tube (Super Spring I) or to a special oval
tube and secured with a stainless steel ligature (Super
Spring II). This new version prevents any lateral
movement of the spring in the vestibule.

Only two prefabricated sizes are available
(with left and right versions of each). The
length of the spring can be increased or
decreased by simply bending the
attachment wires.
The horizontal configuration of the
attachment wire at the maxillary molar
tube permits distalization with good
radicular control.

The SUPER spring II can be used in the entire
range of Class II cases, from vertical facial
patterns with shallow overbites to brachyfacial
patterns with deep overbites.
It can be used with fully bracketed appliances
and it makes an ideal auxiliary for a variety of
mechanical systems.
The unique, unitary force couple applied by the
spring against the maxillary molar allows a
number of different applications. In the late mixed
dentition, while the mandibular arch is fully
bonded for anchorage, the maxillary molars can
be distalized without bonding the adjacent teeth

Other Class II auxiliaries tend to distalize
only the maxillary molar crown, leaving the
root in a mesial position that must be
corrected later in treatment. The SUPER
spring II moves both crown and root with a
moderate, continuous force, and the
adjacent teeth then follow the molar
distally.
The SUPER spring II has proven to be
excellent for TMD patients who require
orthodontic treatment after splint therapy.

Klapper SUPER spring II


BITE FIXER
This is a new inter maxillary spring coil.
The spring is attached and crimped to the
end fitting to prevent breakage between
the spring and the end fitting.
Polyurethane tubing is inside the spring to
prevent it from becoming a food trap .
The Bite Fixer is supplied in a kit with
various sizes for both left and right

BITE FIXER


CHURRO JUMPER
This is an inexpensive alternative force
system for the antero posterior correction
of Class II and Class III malocclusions
So far, this is the only flexible functional
appliance which can be made up by the
orthodontist in his lab. The costs are
reduced and the time spent is minimal.

The mesial and distal end of the jumper are circles.
The distal circle is attached to the maxillary molars
by a pin and the mesial end is placed over the
mandibular arch wire against the canine bracket.
However, when the pin is pulled forward enough to
cause the jumper to bow outward toward the cheek,
the appliance begins to exert a distal and intrusive
force against the maxillary molar and a forward and
intrusive force against the mandibular incisors as it
attempts to straighten When used as a Class II
corrector, the Churro exerts a posterior force on the
maxillary arch and an anterior force on the
mandibular arch, much like the Jasper Jumper.

The Churro Jumper as a Class III
Force
The Churro Jumper, unlike many other Class II
appliances, can be adapted to provide a well –
designed force for correction of Class III
malocclusions.
In the Class III version, the terminal circles are
placed against the mesial of the mandibular
molar tube and the distal of the maxillary canine
bracket.
Ordinarily, the distance between the maxillary
canine and first premolar brackets is enough to
allow the jumper to open adequately and slide
easily. If there is any restriction, however, the
premolar bracket can be removed.

Although the anterior (maxillary) circle can
extend in a straight line from the shaft of the
jumper, it is preferable to add a vertical bend
that converts the Churro Jumper's force into a
Class I vector, which produces less vertical
thrust, incisor flaring, and anterior bite
opening.
This vertical bend also allows the Churro to lie
unobtrusively in the mandibular vestibule,
making it less noticeable and bothersome for
the patient.
The Churro Jumper can improve the
effectiveness of orthodontic therapy in Class
III patients who refuse to wear Class III
elastics

CHURRO JUMPER FOR
CLASS III


The Churro Jumper has several disadvantages
that sometimes limit its usefulness:
The restriction of mouth opening to 30-40mm is
intolerable for some patients.
Arch wire breakage is common if larger wires
are not used.
Patients with a low tolerance for discomfort will
often break the appliance (as well as the spirit of
the orthodontist).
Patients who incessantly move their mouths
with chewing, talking, and nervous tics will fare
poorly with it.
Its maximum effectiveness depends on a
permanent dentition to retain its effect.
Presently, it must be manufactured in the office

Nevertheless, the Churro Jumper has considerable
advantages:
It provides a constant, indefatigable force that cannot be
removed from the mouth.
It can be used either unilaterally or bilaterally.
It can be used to correct Class II or Class III
malocclusions.
It helps maintain anchorage, since it prevents the
maxillary molars and mandibular incisors from moving into
extraction sites.
The cost of construction for materials and labor is less.
It can be made as needed, from materials already present
in most orthodontic offices, and does not require an
expensive inventory.
It is universal in size and can be adapted to fit any
malocclusion.
When broken, it is easily and inexpensively removed and
replaced

CHURRO JUMPER


Rigid Fixed Functional
Appliances - RFFA
These appliances have two distinct differences
in relation to FFFAs:
RFFAs do not easily fracture but neither do they
have elasticity or flexibility.
After fitting and activation they do not allow the
patient to close in centric relation. This means
that the mandible is in a forward position 24
hours a day creating greater stimulus for
mandibular growth than with FFFAs.

Main indication is for the treatment of Class II
malocclusions. Basically, correction consists
of advancing the mandible to a forced anterior
position to stimulate growth and harmonize
skeletal defects. The majority of these
appliances do not adapt to the treatment of
Class III cases.


TREATMENT EFFECTS OF
HERBST
SAGITTAL CHANGES:
The Herbst appliance restrains maxillary growth and
stimulates mandibular growth
Sagittal condylar growth increases where as vertical
condylar growth is relatively unaffected
Bone remodeling process in the lower mandibular
border change the morphology of the mandible
Experimental evidence indicate that articular fossa is
repositioned anteriorly

DENTAL CHANGES
The mandibular teeth are moved anteriorly
Mandibular incisors are proclined
Maxillary teeth are moved posteriorly
Maxillary teeth are distalized as well as
intruded


VERTICAL CHANGES
Deep over bite may be reduced
significantly
Overbite reduction is mainly by intrusion of
lower incisors and enhanced eruption of
lower molars
Maxillary and mandibular occlusal planes
tip down


Histological changes
MRI studies of RUF and PANCHERZ
showed that
Increased proliferation of the condylar
cartilage was noted. These adaptations
occurred primarily in the posterior and
posterio superior regions of the condyle
Significant deposition of the new bone on
the anterior surface of the postglenoid spine
occurred, indicating an anterior repositioning
of glenoid fossa

Significant bone resorption on the posterior
surface of the postglenoid spine was noted
Significant bony apposition on the posterior
border of the mandibular ramus was evident
during early experimental periods
No gross or microscopic pathological
changes were noted in the temporo
mandibular joints.


Variations on the Herbst appliance and similar
systems, utilizing ball attachments have
appeared on the market in an attempt to:
improve patient comfort and acceptance
cause fewer clinical problems compared to
screw or pin attachments
reduce the frequency of emergency
appointments
allow good lateral mandibular movements
allow easy application in splints for correction in
mixed dentition

TYPE I HERBST


TYPE II HERBST
Type II has a fixing system that fits directly
onto the arch wires through the use of
screws. This method of application has the
disadvantage of causing constant
fractures in the arch wires. The lack of
flexibility together with the difficulty in
lateral movements and the stress placed
on the arch wires through activation
causes fractures, especially in the lower
arch.

TYPE II HERBST


TYPE IV HERBST
Type IV has a fixation system with a ball
attachment, which allows greater flexibility
and freedom of mandibular movement. A
disadvantage in relation to other similar
appliances is the fact that it needs brakes
to stabilize the joint. The brakes are small
and sometime difficult to fit. When a
fracture occurs or a brake is lost, the
appliance becomes loose .

TYPE IV HERBST


THE CANTILEVER BITE JUMPER
Most recently, the use of a cantilever has been
proposed . The biggest difference resides in the
fact that the Herbst style appliance is fitted directly
to the lower molar bands through a cantilever arm.
This system means that crowns have to be fitted to
the upper and lower molars. The cantilever secured
to the mandibular stainless steel crowns has a
disadvantage in that the thickness of the screw
mechanism can impinge on the patient’s cheek.
The parts are available in kit form with pre-welded
screw mechanisms and cantilever arms on crowns
of seven different sizes.

CANTI LEVER BITE JUMPER


MALU HERBST APPLAINCE
The MALU – Mandibular Advancement
Locking Unit is a recently developed
attachment device for the Herbst . It
consists of two tubes, two plungers, two
upper "Mobee" hinges with ball pins and
two lower key hinges with brass pins.
The major advantages are the lower cost,
no laboratory needed, flexibility and the
possibility of using combined with
edgewise therapy

Each upper Mobee hinge is inserted
into the hole at the end of the MALU
tube and secured to the first molar
headgear tube with ball pin. Each lower
key hinge is inserted into the hole at
the end of the plunger and locked to
the base arch, distal to the cuspid, with
the brass pin.


MALU HERBST


FLIP LOCK HERBST APPLAINCE
The Flip-Lock Herbst appliance offers
several advantages over conventional
Herbst designs:
• Improved patient comfort and acceptance
• Fewer clinical problems compared to
screw or pin attachments
• Less chair time for reactivation
• Less frequent emergency appointments

FIRST GENERATION
The first generation was made from a
dense polysulfone plastic but breakage
occurred because of the forces generated
within the ball-joint attachment .


FIRST GENERATION FLIP L0CK


SECOND GENERATION FLIP
LOCK
In the second generation, the plastic was
replaced with metal. However, fracture
problems persisted.


THIRD GENERATION FLIP LOCK
The third generation is made of a horseshoe ball joint. This system has proved to
be more efficient than the previous
models, both in terms of application as
well as its resistance to fracture (Miller R.,
1996)


FLIP LOCK THIRD GENERATION


THE VENTRAL TELESCOPE
This was the first telescopic RFFA that
appeared as a single unit; i.e. upon
reaching maximum opening it does not
come apart .
This appliance is available in two sizes and
fixing is achieved through ball
attachments. It is particularly easy to
activate. The operation is simple and is
carried out by unscrewing the tube thus
allowing an activation of around 3 mm.

Its disadvantages lie in the fact that it is
quite thick and suffers from fractures to
the brake which stabilizes the joint. As with
the other appliances where fixing is
achieved through ball attachments, great
accuracy is necessary with regard to
inclination and the welding of components .


VENTRAL TELESCOPE


THE MAGNETIC TELESCOPIC
DEVICE
This 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 . Fitting is achieved by using the MALU
system
This appliance has the advantage of linking a
magnetic field to the functional appliance. Its
main disadvantages are its thickness, the
laboratory work necessary to prepare it and the
covering of the magnets.

MAGNETIC TELESCOPIC
DEVICE


THE MANDIBULAR
PROTRACTION APPLIANCE
(MPA)
This is an RFFA which was developed to be quickly
made up by the orthodontist in the laboratory
Its advantages include ease of manufacture, low cost,
infrequent breakage, patient comfort and rapid fitting.
Another advantage it offers is that it can be made up
at any time. This is helpful when there has been a
failure in the supply of other commercially available
appliances or if the orthodontist practices in an area
where it is difficult to quickly obtain certain other
alternatives.
The designer of the MPA developed three different
types

MPA I
MPA I – each side of the appliance is made by
bending a small loop at a right angle to the end of an
.032" SS wire. The length of the appliance is then
determined by protruding the mandible and another
small right-angle circle is then bent in an opposite
direction. The appliance slides distally along the
mandibular arch wire and mesially along the
maxillary arch wire. Bicuspid brackets must be
debonded.
Limited mouth opening is the major disadvantage.

MPA II
MPA II – this is made by making rightangles circles in two pieces of .032" SS
wire. A 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. This version allows the
mouth to open wider than the first version.


MPAIII
MPA III – This version eliminates much of the
arch wire stress that occurs with the MPA I
and II. It permits a greater range of jaw
movement while keeping the mandible in a
protruded position. It is adaptable to either
Class II or Class III mal occlusions. It
resembles the Herbst by also 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.

MANDIBULAR PROTRACTION
APPLIANCE


THE UNIVERSAL BITE
JUMPER(UBJ)
This is like a Herbst but is smaller in size and more
versatile – it can be used in all phases of treatment
in mixed or permanent dentition, Class II or III
malocclusions. An active coil spring can be added if
necessary
No laboratory preparation is required. It is fitted in
the patient’s mouth and cut to the appropriate
length for the desired mandibular advancement.
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

The UBJ offers the following advantages:
It is simple, sturdy, and inexpensive.
Inventory requirements are minimal--the UBJ can be used on
either side of the mouth, and there is only one size, since it is
cut to the desired length for each case.
It can be used at any stage of treatment --in the early mixed
dentition to obtain an immediate mandibular advancement
before any dental alignment, or in the permanent dentition for
fixed functional treatment.
It can be used in Class II or Class III cases.
Its low profile results in considerably less buccal irritation
than with similar appliances.
Patient comfort and acceptance are excellent.
It can easily be attached to removable splints for maximum
anchorage.
It produces good results without the need for patient
cooperation.

UNIVERSAL BITE JUMPER


THE BIOPEDIC APPLIANCE
This is a bite jumping appliance which is
engaged on the maxillary and mandibular
molars, using a cantilever like system. It is then
attached to a BioPedic buccal tube
Activation is achieved by sliding the appliance
along the buccal tube and fixing the screw. It is
universally sized for left and right sides. Two
pivots on the ends allow the appliance to be
rotated when the patient opens his mouth.

BIOPEDIC APPLAINCE


The Mandibular Anterior
Repositioning Appliance (MARA)
This was created by Douglas Toll of Germany in 1991.
It consisted of cams on the molars which guided the
patient to bite into Class I
The first molars have to be covered with stainless
steel crowns and the appliance must be laboratory
manufactured.
The patient can pull back his mandible to a Class II
relation but will be unable to achieve intercuspidation.
This means that the lower molars will make direct
contact with the metal, giving an unpleasant
sensation. Furthermore, should the orthodontist opt for
bands instead of crowns, fractures will often occur.

The appliance design allows for use in
conjunction with braces. It can be used for
Class II treatment and for TMJ problems.
this is an appliance of simple
characteristics which allows good hygiene
during the correction stage. With a small
modification to the original design using
only wire and composite, a very interesting
appliance can be created for finishing
treatment of a Class II malocclusion
treated with a functional appliance.

INDICATIONS:
Skeletal class II with mandibular
deficiency
CONTRA INDICATIONS:
Dolichofacial growth pattern
Cases predisposed to root resorption
Dental and skeletal open bites
Vertical growth with high mandibular plane
angle and excessive lower facial height

MARA


RITTO APPLIANCE
The Ritto appliance is a rigid fixed
functional appliance that can be
described as a miniaturized telescopic
device. The Ritto Appliance is a onepiece device with telescopic action. It
comes in a single format, which allows
it to be used on both sides. This design
means that stock can be kept at
minimum levels.

THE RITTO APPLAINCE
The Ritto Appliance can be described as a
miniaturized telescopic device with simplified
intra oral application and activation The
construction of this appliance is based on the
mechanism and function used in the Ventral
Telescope adapted for use in conjunction with a
fixed appliance

They cause less breakage of arch wires 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
- They can be used at any stage of treatment –
mixed or permanent
- Their low profile results in considerably less
buccal irritation
- They produce good results without the need for
patient cooperation.

In functional treatment with a rigid fixed
functional appliance (RFFA), it is necessary to
prepare the patient for 1 to 2 months before
fitting the appliance to stimulate musculature
and avoid having the patient exert too much
force on the support systems, causing appliance
breakage or unwanted dental movement. For
this reason, the use of a mini-stimulator for
mandibular advancement is advised. This is a
thermoformed splint of 0.7 mm in thickness, for
the upper incisors only and incorporating an
acrylic bite block for the lower incisors. The bite
block is constructed with the mandible in a
forward position.

For the first 15 days or 1 month, the patient
should wear the splint for as long as possible
and maintain the lower incisors fitted into the
Bite block. In the following weeks, the patient
should practice swallowing exercises with the
lips in contact and with lower incisors against the
bite block.
Only after this stage should therapy be started
with the Ritto Appliance, now that the
musculature has been stimulated and the patient
has memorized the forward position of the
mandible. Delocking of the occlusion is also
achieved.
It is possible to fit the Ritto appliance in
conjunction with the mini stimulator for the first
few weeks

Another important factor that contributes to comfort
and rapid patient adaptation is the establishment of
posterior contact after the advancement of the
mandible. This also creates a posterior
proprioceptive sense. It is not always necessary to
have perfect coordination of the arches before
starting functional treatment. Sometimes, even with a
pronounced Curve of Spee, therapy can be started
as long as some artificial contacts are constructed
with composites on the molars . The extrusion of the
premolars can be beneficial in the correction of a
vertical problem.

MINI STIMULATOR


RITTO APPLAINCE


RITTO APPLIANCE


APPLAINCE FIXED TO
ARCH WIRE


The main differences when compared to the
Ventral Telescope appliance are:
The appliance does not come apart (no
disengagement after achieving maximum
extension).
The smaller size facilitates adaptation and it does
not affect aesthetic appearance or speech.
It comes in a single format which allows it to be
used on both sides and is available in only one
size.
The Ritto Appliance is simple to use, comfortable,
cost effective, breakage resistant and requires no
patient cooperation

It is even possible to carry out the treatment
of Class II retromandibular cases in mixed or
permanent dentition using only conventional
bands on the upper molars and two tubes on
the lower molars and brackets on the lower
incisors.
Fixation accessories consist of a steel ball
pin and a lock . Upper fixation is carried out
by placing a steel ball pin from the distal into
the .045 headgear tube on the upper molar
band, through the appliance eyelet and then
bending it back .

The appliance is fixed onto a prepared the
lower arch. The thickness and type of arch
is chosen, its length is adjusted, locks are
fitted and the Ritto appliance is then
inserted. Activation is achieved by sliding
the lock along the lower arch in the distal
direction and then fixing it against the Ritto
Appliance .


The most common question raised on this
appliance is on the effect produced on the
lower incisors, given that the lower anchorage
system is minimal. In a comparative study
between the Ritto Appliance and the Herbst
appliance, no statistically significant
differences were found in the position of the
lower incisors . In a scanogram analysis of the
lower incisors, no indication of radicular
resorption was found during treatment with the
appliance.

SABBAGH UNIVERSAL SPRING
Is the ideal solution for treating patients with :
Insufficient cooperation
Late cases with little remaining growth
Illnesses of the upper respiratory tract system,
such as asthma
Patients who are allergic to plastics
The Sabbagh Universal Spring can be
universally used as a substitute for activator,
Herbst , headgear, elastics, as well as for the
treatment of temporo mandibular dysfunction.

SABBAGH UNIVERSAL
SPRING


The appropriate size can be adjusted by turning
the inner telescope tube, as well as inserting
activation springs (tension or compression
springs). Compared to other similar appliances,
the Sabbagh Universal Spring has many
possibilities for activation, such as turning the
inner telescope tube, or inserting the activation
springs (tension or compression springs)
Therefore, in most cases only one Sabbagh
Universal Spring set is required for the entire
treatment.


HYBRID APPLAINCES
There are also new appliances that can
been classified as hybrid appliances
because they represent the combination of a
Rigid fixed functional appliance (RFFA) with
Flexible fixed functional appliance (FFFA).
They could be described as rigid appliances
with coil spring-type systems.


The objective of these appliances is to move
the teeth by applying 24-hour elastic
continuous force that would replace the
traditional use of elastics and extra-oral
force. Their common feature the use of
coiled springs to produce this force. The
force generated varies between 150 and 200
gm. Other advantages include reduction in
the need for patient cooperation and the
ease of placement

The primary objective of the hybrid
appliances is not to reposition the mandible
anteriorly. If such was the case, it would be
illogical to reposition a mandible and at the
same time to keep exerting mesial inferior
and distal superior force. Rigid fixed
functional appliances offer the best choice to
obtain this goal, as is well documented in the
literature. With RFFAs, once the appliance
has been activated the patient cannot close
in centric relation during the therapy stage.

In order to obtain the best possible results with a
goal of skeletal movement, the authors propose a
philosophy of using muscular pre-stimulation before
the placement of the fixed appliance. This is in
conjunction with a treatment plan based on an
individualized pattern model. A general
inconvenience with rigid fixed functional appliances
is the fact that the fixed appliance needs to be
placed as a whole, to establish the necessary
anchorage. Also, control of the vestibular movement
of the lower incisors is important. In such cases it is
sometimes necessary to resort to other anchorage
appliances. As such, it can be rather difficult to use
these appliances in mixed dentition.

THE CALIBRATED FORCE
MODULE
It was a fixed appliance designed to substitute
Class II elastics and it was developed in 1988
by the CorMar Inc. Available in three sizes, it
was applied to the inferior arch close to the
molars and fixed by a screw, and mesial or
distal to upper cuspids, and also fixed to the
arch. Its coil spring produced a force between
150 and 200 gm .

CALIBERATED FORCE
MODULE


The same company proposed a Herbst
appliance with an exterior coil spring,
attached to the inferior tube. That system
generated tooth movement by employing
gentle and continuous force 24 hours a
day .


HERBST WITH FORCE
MODULE


EUREKA SPRING
This appliance appeared on the market in
1996 and it was developed by DeVicenzo
and Steve Prins . It is a 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. The
appliance has an open coil spring that is
placed inside of a part of the system.

Interestingly the authors caution in the
manual that the appliance does not create
any orthopedic effect, but underline that the
correction is totally dentoalveolar.
The placement system is relatively simple,
and the patient can open his or her mouth
widely without any difficulties due to the
telescopic effect of the appliance. It is
available in two sizes: 20 and 23 mm long.
The appliance is universal and it can be
applied both to the right as well as to the
left side .

EUREKA SPRING


THE TWIN FORCE BITE
CORRECTOR
This appliance differs from others in form and
constitution because it has two internal coil
springs. It consists of two joint telescopic
systems. At the superior level it is fixed with a
ball pin that is fitted into the buccal tube of a
molar band. The placement in the lower arch
is slightly different; it involves a fitting-in
system that is later fixed with a screw to the
inferior arch. Normally it is placed distal to the
lower cuspid.

Generally this type of fixing allows for rapid
placement and removal of the appliance. It is
available in two sizes and accompanied by a
screwdriver to fix the screw in the lower arch.
Such as in the previous appliance its
application vary between Class II and Class
III treatment, and it may be also used as an
anchorage system.


Due to its original configuration, these
appliances are suitable for cases where there
is a need to carry out correction that requires
predominantly dentoalveolar movement. In
order to avoid protrusion of the lower incisors
it is recommended to use stronger steel wires
or to resort to other accessories.
The major drawback of this appliance is the
difficulty to control the force. If we want less
force, we should bend the mesial part of the
ball pin in order to have more wire distal to the
tube. This situation, however, may create
discomfort and impingement problems

The other disadvantage lies in the fact that the
lower the lower dentition needs to be already
aligned as it is recommended to use
016"x.022, or 017"x.025" stainless steel wires
that guarantee necessary anchorage. In this
way the device is in principle recommended
for permanent dentition.
For Class III correction it is necessary to put a
lip bumper tube (LBT) on the lower molar
band.

Recently the third modernized version of the
appliance has been presented under the
name "Twin Force Bite Corrector – Double
Lock" . It is reduced in size and both the
lower and upper placement is based on the
system of lock-on screws. This new version
facilitates the use of the appliance for Class
III correction and it allows for a slightly better
control of the force although it still falls short
of the full control.

TWIN FORCE BITE
CORRECTOR


FORSUS
FATIGUE RESISTANT DEVICE
This is an innovative three telescopic appliance with
a coil spring in its exterior part. This feature makes
it resemble some flexible functional appliances
(AFF).
In comparison with AFF its great advantage lies in
coil spring resistance to breaking. The coil spring is
applied by its sliding on a rigid surface avoiding in
this way angulations at the fixing points.
It is sold in kits that include different length sizes for
left and right side

In the original presentation the appliance is placed in
the mandible on the round-segmented arch that is
included in the kit. The appliance slides along the arch
and facilitates opening of the mouth and lateral
movements. The resulting force concentrates more on
the anterior and inferior sectors.
In this way there is no interference with continuous
arches used during the treatment, which offers wide
application independently of the method applied.
The appliance may be fixed in various ways according
to the needs of the patient

The device gives the power to control the
amount of force, whether through various
available sizes, or through the direct
attachment to the lower arch and the use of
a stop for activation. Thus the appliance may
be used in cases of mixed dentition and it
allows for dental asymmetry correction when
higher force on both sides is needed.
The device allows patient to open and move
their jaw freely.

FORSUS


ALPERN CLASS II CLOSERS
This appliance is slightly different from the
preceding ones and it is also the most recent. It
is predominantly applied in Class II correction
and as a substitute for elastics. It consists of a
small telescopic appliance with an interior coil
spring and two hooks for fixing .
It functions in the same way as elastics and,
similarly, is fixed to the lower molar and to the
upper cuspid. It is available in three different
sizes. Its telescopic action enables a
comfortable opening of the mouth.

ALPERN CLASS II CLOSURES


The qualities that functional appliances
should present can be summarized as
follows:
- Patient comfort and acceptance are
excellent
- They promote better compliance
- They offer an extensive range of motion
- They are simple and inexpensive
- They are easier to fit
- They are adaptable to either Class II or III
- They can be used for mandibular

Thank you
Leader in continuing dental education


recent advancements in Fixed functional appliances /certified fixed orthodontic courses by Indian dental academy

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