Functional appliances

Definition: removable or fixed orthodontic appliances which use forces generated by stretching of the muscles, fascia and/or periodontium to alter skeletal and dental relationship. Functional appliances are conceptually based on Moss functional matrix theory, which proposes that functional matrices, tissues like muscles and glands, influence skeletal units such as: jaw bones; and ultimately control their growth. Moss functional matrix theory: the origin, development and maintenance of all skeletal units are secondary, compensatory and mechanically obligatory responses to temporally and operationally prior demands of related functional matrices (Wikipedia). When we talk about functional appliances, we are concerned about correcting skeletal class II or class III ant-post relationships. Mainly well talk about class II functional appliances, because they are now rarely used for class III. Functional appliances may correct sagittal relationships (anterio-posterior dimension) by: Increasing the activity of certain muscles (in case of class II, muscles of the mandible). Elimination of the abnormal function of the perioral muscles (in case of class II division 1, we want to eliminate lower lip trap behind upper incisors, which is an etiological factor for class II division 1 malocclusion). Functional appliances come in variety of removable or fixed designs; theyre designed in a way to reposition the mandible which leads to muscles stretching and transmission of forces to dentition and basal bone.

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As we said in class II skeletal relationship, functional appliances are designed to stretch and reposition the mandible in forward position, so when the patient put the appliances, he/she is forced to achieve edge to edge relationship. Now force will be generated as a result of muscles stretching, these forces will go directly to the teeth and indirectly to the bone. Thats why the first response in functional appliances treatment is dento-alveolar response, so in case of class II division 1: therell be retroclination of uppers and proclination of lowers before any skeletal changes. Aims of functional appliances treatment: Correction of Over jet (horizontal) and Over bite (Vertical), in case of class II, sometimes the over jet is increased and the over bite is deep. Correction of buccal segment relationship, in case of skeletal class II, buccaly molar relationship will be class II. Change soft tissue environment, such as lip trap behind upper incisors. Types: Functional for class II malocclusion. Functional for class III malocclusion. Functional for vertical problems (anterior open bite, deep over bite in case of deep over bite we can use flat anterior bite plane). Categories: Tooth borne the force is transmitted to teeth directly and the appliances are retained by the teeth Can be passive: by repositioning the muscles associated with the mandible, so that the jaw bone itself responds by growing to the new equilibrium position, the appliances only stretch muscles and reposition it. Buccal shield: wire or acrylic between cheek and teeth, itll stretch the buccinator muscle so itll eliminate outside forces (equilibrium theory), thus expansion of the maxilla no bone expansion, but soft tissue; so it is passive.
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 Can be active: by repositioning the mandible so that the condyle is forced out of the glenoid fossa and this in turn is thought to stimulate the posterior superior growth of the condyle, so translation of mandible will take place in inferior anterior direction. Tissue borne mainly retained by tissues and the force comes from stretching the surrounding tissues (e.g.: frankel appliance) Fixed functional appliances if the patient is non-compliant and in an important stage of growth, and you need to utilize the growth Removable functional appliances can be inserted and removed by the patient As we said earlier, most of what well talk about is for class II, there are a lot of class III functional appliances but theyre rarely used. Class III can be corrected with growth modification appliances such as reverse headgear. Keep in mind that there are differences between headgear and functional appliances; you cant say that the headgear is a functional appliance it is a growth modification appliance, but functional appliances can be growth modification appliances. Now back for tooth borne functional appliances used for class II division 1 malocclusion (all of them have the same goal, to keep the mandible in an advanced position) Andresen appliance mono block, so its one piece attached to upper and lower at the same time Twin block two pieces, upper and lower and the contact between them on the beveled area Harvold Bionator contains a coffen spring and wire buccal shield Woodside Bass Teucher it contains headgear tube Hamilton
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Indications for class II functional appliances: Growing patient because they can be growth modification appliances Motivated patients very compliant patient that will keep the appliances in their mouths Un-crowded well aligned class II division 1 it cant make extrusion, intrusion, bodily movementetc., it only changes anterio-posterior skeletal relationships Mild to moderate class II skeletal relationship if the case is severe we can go for functional appliances, but we wont expect to have good results as in mild or moderate cases Normal to reduced MMPA and LFH, because it increases LFH Average to increased over bite, because it reduces the over bite Contraindications for class II functional appliances: Non-growing, or too young patients, because of relapse. Why does relapse occur? Because the growth pattern is genetically determined High angle MMPA, because functional appliances already increase it Backward mandibular rotation with increased LFH, because functional appliances already increase it Anterior Open Bite, because functional appliances decrease the over bite (we have special functional appliances for vertical problems) Proclined lower incisors, because the first thing that functional appliances do is proclination of lower incisors Removable functional appliances: Frankel appliance functional regulator Frankel I: class II division 1 malocclusion Frankel II: class II division 2 malocclusion Frankel III: class III malocclusion Frankel IV: anterior open bite

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Now frankel appliance is a soft tissue borne appliance, can be used for both class II and III malocclusion, it is good in mixed dentition and when soft tissue significantly contribute to malocclusion because it is soft tissue born, so the physiological shedding of primary teeth wont affect the retention and itll eliminate the soft tissues forces such as expressive lower lip and lip trap (buccal shield and lip pad) Lip pad: acrylic pad to move the lower lip labialy, so itll allow the mandible to grow forward. Components of frankel appliance: Buccal shield: to do periosteal stretching of the buccenator and its made of acryl Lip pads: in case of class II itll be in the lower lip while in case of class III itll be in the upper lip Lingual shields Wire component: 0.9 mm except the palatal arch 1mm with its occlusal rest which stabilizes the appliance against the upper arch

Frankel II has a wire in the upper arch to push the retroclined incisors for treatment of class II division 2 malocclusion. Both Frankel I and II has lip pad in the lower arch while Frankel III has lip pad in the upper arch
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 Andresen appliance Composed of one piece mono block Labial bow 0.8mm with tubing or 0.9mm in diameter Lower incisors capping lower incisors contained within acryl, and this part is the one that holds the mandible in forward position Posterior bite block Channels to guide tooth eruption Should be worn for at least 14 hours a day Indications of Andresen appliance: Class II division 1 Growing patient Well aligned arches Proclined upper incisors and retroclined lower incisors Normal or increased over bite

Indications always depend on the effects of class II functional appliances which are: retroclination of upper incisors, proclination of lower incisors, extrusion of posterior teeth, restriction of maxillary growth, enhancement of mandibular growth, reduction of over bite and increasing LFH.

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 Bionator appliance mono block Similar to Andresen appliance but has less acryl in the palate It contains coffen spring and wires that will act as buccal shield

Harvold appliance similar to Andresen but with more bite opening Twin block Two pieces, upper and lower Upper part composed of labial bow (0.7mm) and acrylic plate Lower part composed of labial bow (0.6mm) and adams clasps on lower first premolars Contain expansion screw Should be worn for 24 hours a day Twin block retain the mandible in forward position by posterior bite blocks of upper and lower. Actually we have beveled surfaces on the bite blocks, the patient cant close normally; he/she will be forced to advance the mandible forward so the beveled surfaces contact. With time the mandible growth will be stimulated and the protruded position will be achieved and we have to reduce from the upper bite block to enhance extrusion of lower posterior teeth.

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So the lateral open bite will be closed by over eruption. Why do we need an expansion screw in twin block? Now expansion of maxilla is important in class II malocclusion. The mandible is triangular in shape (wider posteriorly), so if we advance the mandible forward same part of the maxilla will bite with wider part of the mandible thus cross bite. So while advancing the mandible we expand the maxilla to eliminate cross bite. Twin blocks are constructed to a protrusive bite, so when the appliances in mouth the patient wont be able to occlude in former distal position and the mandible will be forced to adopt protrusive bite. The block is 5-6 mm thick posteriorly (mouth open beyond freeway space) so the patient cant return to former distal position. We ask the patient to advance the mandible to achieve edge to edge (over jet = 0), because therell be relapse, so we over correct. Bite construction: Anterio-posterioly: the mandible should be advanced to reach edge to edge or in some cases where the over jet is large, we ask the patient for maximum protrusion minus 2-3mm (to keep the patient in comfort) Vertically opening: anteriorly 2-3mm and posteriorly 4-6mm (which is the thickness of the posterior bite block) Transverse position: we need to correct the midline if the midline shift is of dental origin (due to premature loss of lower C for example) we cant correct it with bite registration, if it was due to skeletal cause we can correct with bite registration Bite registration: Boxing wax Tongue depressor to achieve the anterior separation which is 2-3mm, same thickness of tongue depressor Hot water so we can melt the wax Posteriorly we need separation of 4-6mm, so it has to be a thick wax block
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 Before taking the bite we need to train the patient to advance his mandible, so we can take the bite with protruded mandible Now the goal of the functional appliances is skeletal effect, but most of the corrections come from dento-alveolar movement (75%) while real skeletal changes are minimal (25%). If we have a case of 8mm over jet and we want to make it 2mm, we need 6mm movement; around 4mm will be a result of retroclination of upper incisors and proclination of lower incisors, while 2mm will be a result of restriction of maxillary growth and enhancement of mandibular growth. Wear time of functional appliances: 12-14 hours for (Andresen, harvold, headgear, bionater) Full time for (twin block, frankel) Timing of treatment: Optimum treatment time is during pubertal growth spurt not too early and not too late When eruption of permanent teeth allows, i.e.: late mixed dentition, Es can be present if C D E are present, when anyone exfoliate we need to replace the bite block Dento-alveolar effects of class II functional appliances: Retroclination of upper incisors Proclination of lower incisors Guided distal eruption of upper molars normal eruption direction of upper molars is occlusal and mesial Guided mesial eruption of lower molars normal eruption direction of lower molars is occlusal and mesial

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In case of class II malocclusion, the upper molars will be mesially to the lowers. Now in the guided eruption, we block the upper molar eruption and allow the lowers, so we will have mesially erupted lowers while we distalize the uppers, so we will have class I molar relationship. Skeletal effects of class II functional appliances: Enhancement of mandibular growth we hold the mandible in forward position Suppression of maxillary growth as a result of holding upper and lower teeth with an appliance we hold the mandible forward, and as a result there will be a reactionary force transmitted to the maxilla in a posterior direction thus restricting maxillary growth (newtons 3rd law: every movement has an opposite movement, equally in magnitude and opposite in direction) Fixed functional appliances in place of Adams clasps therell be bands and they are cemented on teeth Used for un cooperative patients Fixed to teeth 24 hours wear time Fracture easily and frequently Available in many forms and types, but all have the same effect

Done by: Khalid Mortaja

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