FUNCTIONAL APPLIANCE PRINCIPLES,TYPES & FABRICATION

PRESENTER:-DR.A.B.OLATUNJI

OUTLINE

INTRODUCTION CLASSIFICATION PRINCIPLES COMMON TYPES. DESIGN & FABRICATION.(TWIN BLOCK) CONCLUSION REFRENCES

INTRODUCTION
Functional

appliances are those appliances which utilize the forces of the oro-facial muscles to move the jaw and the teeth. Functional appliances are devices which alter the patients functional environment in an attempt to influence and permanently change the surrounding hard tissue

INTRODUCTION (CONTD)
Most

of the appliances are intraoral device, consisting primarily of acrylic with wire components for retention and support. They are used to correct early class II malocclusions and some cases of class III malocclusion.

CLASSIFICATION

Classification by Profitt:1 Teeth borne passive appliance (myotonic appliance) e.g. Andresen activator, bionator etc. 2 Tooth borne active appliance (myodynamic) e.g. Modified bionator. 3 Tissue borne appliance e.g. Frankel, lip bumpers.

Active appliances reposition 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 Passive appliances act by repositioning the musculature associated with the mandible so that the jaw bone itself responds by growing to the new equilibrium position

PRINCIPLE
The appliances are constructed with the mandible postured and with the teeth out of occlusion. In Class II cases the mandible is held in a forward posture resulting in the generation of forces from the stretched facial muscles. This leads to altered bony development of the maxilla and mandible. In class II cases, enhancement of mandibular growth. This is achieved by:

PRINCIPLE

Elimination of soft tissue hindrance on skeletal growth e.g. Frankel Functional Regulator. Stretch of muscles and soft tissues attached to bone, causing periosteal stretch that promotes subperiosteal apposition of bone. Protrusion of the mandible, causing a stretch at the temporomandibular joint, leading to differentiation of the periosteum to secondary cartilage and subsequent bone formation and remodelling in the glenoid fossa and mandibular condyle.

CASE SELECTION

Considerations Regular attendance Age 10years to age of maximum pubertal growth Dental considerations Minimum dental irregularities and rotations Skeletal considerations Moderate to severe Class II malocclusions, few Class III
Social

COMMON TYPES
There are various types of functional appliance, the common ones include: ANDRESEN ACTIVATOR(MONOBLOC) THE BIONATOR THE FRANKEL FUNCTION REGULATOR TWIN BLOCK OF CLARK HERBST APPLIANCE.

ANDRESEN ACTIVATOR

A loose fitting appliance designed by Andresen and Haupl in 1936, to correct retrognathic mandible. Consist of a labial bow of 0.9mm hard stainless steel wire with horizontal middle section, two vertical loops and wire extensions through the canine-deciduous first molar embrasure into the acrylic body. The acrylic body is a block covering the teeth of both arches and the palate made to fit loosely advancing the mandible for class II correction.

ANDRESEN ACTIVATOR
In

most cases bite opening is by 23mm and advancement is by 4-5mm. In case the overjet is too large, forward positioning is done in 2-3 stages. Forward positioning of mandible by 78mm,vertical opening should be slight to moderate i.e. 2-4mm,and 4-6mm in forward positioning not more than 35mm.

INDICATIONS & CONTRAINDICATION.

INDICATIONS Class II division 1 malocclusion. Class II division 2 malocclusion. Class I open bite malocclusion. Class I deep bite malocclusion. Post-treatment retention. CONTRA-INDICATIONS Class I problems of crowded teeth, where there is disharmony between tooth size and jaw size. In cases of nasal stenosis.

ANDRESEN APPLIANCE
ADVANTAGES -Require little routine adjustments. DISADVANTAGES:-Requires good patient co-operation. -it is bulky and thus not comfortable. -Cannot produce precise detailing and finishing of occlusion.

ANDRESEN(SUPERIOR VIEW)

ANDRESEN (ANTERIOR VIEW)

ANDREASEN

TRIMMING OF ANDREASEN APPLIANCE

Protrusion of incisors, if the lingual surfaces of the teeth are loaded with acrylic, and passive labial bow placed. Retrusion of incisors, if the lingual surface is made free of acrylic, and active labial bow is placed. Intrusion of teeth, incisal area is loaded with acrylic, labial bow is placed below the greatest convexity at the incisal area Extrusion, the lingual surfaces are loaded above the area of greatest convexity in the maxilla and below the greatest convexity in the mandible. labial bow placed at the gingival 1/3

TRIMMING FOR PROTRUSION & RETRUSION

TRIMMING FOR EXTRUSION.

TRIMMING FOR INTRUSION

BIONATOR
The

bulkiness of the activator, and its limitation to night wear was a major deterrent in its use. This lead to the development of the bionator by Balters in 1960. Act on the principle that equilibrium between the tongue and the circumoral muscles is responsible for the shape of the dental arch

BIONATOR The standard appliance consist of a lower horse-shoe shaped acrylic lingual plate extending from the distal aspect of the last erupted molar to the corresponding point on the other side. For the upper arch it has only posterior extension that cover the molar and premolar regions. The anterior portion is open from canine to canine.

BIONATOR
Palatal

bar ,which is formed of 1.2mm hard stainless steel wire, it forms an oval posteriorly directed loop that orientate the tongue and mandible forwards to achieve a class 1 relationship. Labial bow made from 0.9mm hard stainless steel wire. It runs from canine to canine at the level of incisal third of the incisors.

BIONATOR

BIONATOR(ANTERIOR & LATERAL VIEW)

BIONATOR

INDICATIONS Bionator is indicated for treatment of class II division 1 malocclusion in the mixed dention,under the following conditions: Well aligned dental arches. Functional retrusion Mild to moderate skeletal discrepancy. CONTRA-INDICATIONS Class II relationship caused by maxillary prognathism. Labially tipped lower incisors.

BIONATOR
ADVANTAGES:-

-Appliance is less bulky -Can be worn full time.

DISADVANTAGE:-

-Disturbs oral function e.g. speaking, eating.

FRANKEL FUNCTION REGULATOR

Developed by Rolf Frankel (1980) Frankel believed that the active muscle and tissue mass.i.e the buccinator and the orbicularis oris complex have a major role in the development of skeletal and dentofacial deformities. Hence developed function regulators, to aid in the training, and reprogramming of orofacial muscular system.

FRANKEL FUNCTION REGULATOR

Consists

of shields which lie in the vestibule of the mouth labially and buccally The wire elements of 0.9mm hssw unite the labial and buccal shields. Designed to hold the lips and cheeks away from the teeth, disturbing muscle balance and producing tooth movement.

TYPES
There 1. 2. 3. 4.

are four variants:Type I or Function Regulator(FR) 1Class I and Mild Class II Type II or FR 2 Class II div 1 and 2 Type III or FR 3 Class III Type IV or FR 4 Anterior Open Bite and bimaxillary proclination.

PARTS OF THE FRANKEL REGULATOR

ACRYLIC

PART:Buccal shields, lip pads, lingual pads. WIRE PARTS:-Designed to connect the different parts and to stabilise the appliance. Palatal bow(1mm),labial bow(0.9mm),canine loop(0.8mm/0.9mm),lingual cross over wire, lower lingual spring(0.8mm)

FRANKEL FUNCTION REGULATOR

FRANKEL FUNCTION REGULATOR

CLINICAL MANAGEMENT

Use is extended progressively For the first 2 or 3 weeks, should be worn only in the evenings for about 2hours. When patient is confident in its management, night time wear is introduced Then should be worn full time, except for meals and sports. Frankel emphasized habitual lip seal. Within 3 months of commencement of treatment, progress should be obvious. When there is initial good progress ,but this declines, it is probably time to reactivate the appliance, by advancing the lower labial and lingual pads.

TWIN BLOCK OF CLARK

First described by William Clark in 1977. This system is currently one of the most popular functional appliances used. Recent evidence suggest that it is probably the most successful in the treatment of class II division 1 malocclusion.(Chadwick et al 1997) Consist of an upper and lower device with simple bite blocks that engage on occlusal inclined planes.

TWIN BLOCK
INDICATIONS -Excellent for treatment of severe class II div 1 malocclusion. -Class II div 2 malocclusion (provided the lower arch is well aligned and free of crowding) CONTRA-INDICATION. -Grossly increased overbite, because eruption of the posterior teeth is impeded.

ADVANTAGES.

Occlusal inclined planes gives greater freedom of movement in lateral and anterior excursion. Appearance is noticeably improved. Less bulky thus better patient compliance. Can be used in later stage of growth(late mixed dentition/early permanent dentition). Can be cemented in the mouth, without disrupting normal oral function, to improve patient compliance

TWIN BLOCK
The upper part of the appliance is similar to a conventional appliance with molar capping. The molar capping is limited to the posterior end of the arch with an inclined plane at the mesial end. this engages a similar incline on the lower appliance. A midline screw is incorporated to provide compensatory upper arch expansion as the anteroposterior jaw relationship is corrected.

TWIN BLOCK
The

appliance is retained posteriorly by Adams clasps. Anteriorly the retention is designed to reduce proclination of the lower labial segment, this may be in form of a labial bow,southend clasp or by acrylic incisal capping.

TWIN BLOCK(UPPER & LOWER)

TWIN BLOCK

DESIGN
The earliest design of twin-block consisted of: A midline screw to expand the upper arch. Occlusal bite block(at 90 degrees to occlusal plane) Clasps on upper molars and premolars(Adams clasp) However, in some cases with severe upper proclination,labial bow may be placed in the upper arch.

DESIGN
BASE PLATE:-Design is similar to upper and lower Hawley's plate. OCCLUSAL BITE BLOCKS WITH INCLINED PLANES:-the position of the inclined planes is determined by the lower block. -The inclined plane on the lower bite block is inclined from the mesial surface of the second premolar or second deciduous molar at 70 degress to the occlusal plane.

DESIGN

Mesially, the lower bite block extends up to the canine region with a flat occlusal plane. The upper inclined plane is angled from the mesial surface of the upper second premolar to the mesial surface of the first molar. The flat occlusal portion then passes distally over the remaining upper posterior teeth. The height of the bite block is determined by the vertical opening planned, but recommended to be beyond the freeway space.i.e.4-6mm

DESIGN

Initially, inclined planes were at 90 degrees to occlusal planes. However, adjustment was difficult for a lot of patients. Therefore, for convenience inclined planes were reduced to 45 degree, but since this caused equal vertical and horizontal movement, The angulation was further changed to 70 degrees, so that more horizontal vector of force would be produced. Nevertheless, the angulation can vary between 45-70 degrees

FABRICATION
IMPRESSIONS: Upper and lower impressions are taken to produce 2 pairs of models, study & working casts. -Areas where appliance components will contact soft tissue must be clearly delineated. -The impression must not stretch and excessively displace soft tissues in an area of contact with the appliance. BITE REGISTRATION:-The construction bite for a functional appliance for class II cases advances the mandible so that the condyles are out of the fossae and separates the joint by a predetermined amount.

FABRICATION

Bite registration can be taken by using interocclusal wax bite. Amount of sagittal & vertical advancement planned Horse-shoe shaped wax block is prepared.23mm more than vertical opening planned. Patient is asked to practice placement of mandible at the desired position using the mirror. Horse-shoe shaped wax block is placed on the occlusal surface of one of the cast (maxillary) and pressed in to form indentations on the wax.

FABRICATION

It is then removed and placed in the patients mouth and asked to bite in the proposed sagittal position. It is then tried on the cast, then checked again in the patients mouth An important aspect of the construction bite for twin block is to establish the correct vertical dimension, i.e. Should be open slightly beyond the clearance of the free way space to encourage the patient to close into the appliance rather than allow the mandible drop out of contact into rest position.

FABRICATION
The working casts are then articulated using the construction bite. Appropriate wires are bent to form the various wire components. Acrylic coverage marked on the casts, and the design carried out as described earlier. Finally finished in cold cure acrylic.

REACTIVATION OF TWIN BLOCK

This require addition of cold cure acrylic to the slope of the upper block at the chair side Alternatively, time consuming heat cure laboratory modification could be done. Light cure acrylic can also be used. Inconvenience of reactivation is a major drawback of the original design. To overcome this, a modification was described by Banks et al 1999 in the British orthodontic journal, by inserting a screw in the mesial surface of each block in the upper appliance.

STAGES OF TWIN BLOCK THERAPY

Twin block therapy is described in two stages:Active Phase. Support phase. ACTIVE PHASE:-We achieve the functional correction of mandibular position from skeletal retruded class II to class I. -In all functional therapy sagittal correction is achieved before vertical. This is done by trimming the upper block occlusodistally to encourage the lower molars to erupt and reduce the overbite

STAGES OF TWIN BOCK THERAPY

SUPPORT PHASE The aim of this phase is to maintain the corrected incisor relationship until the buccal segment occlusion is fully interdigitated To achieve this, an upper removable appliance is fitted with an anterior inclined plane to engage the lower incisors and canine. The lower block is left out at this stage. RETENTION:Treatment is followed by retention with the upper anterior inclined plane appliance. Wear is reduced to night time only, once the occlusion is fully established.

THE HERBST APPLIANCE

Described by Emil Herbst in1909 at the Berlin Dental Congress. Later popularised by Pancherz in 1979. It consist of a bilateral telescopic mechanism that maintains the mandible in a protruded position. It can be any of the following types:Banded Herbst appliance Cast Herbst appliance Acrylic splint Herbst appliance

VARIOUS FORMS

Banded Herbst:The system is fixed to the jaws by the use of bands on upper and lower molars. Cast Herbst Appliance:Attached to the jaws by cementing cast crown on upper and lower molars Acrylic splint Herbst Appliance:Attachment to the teeth the use of acrylic splint

HERBST APPLIANCE
INDICATIONS:-Dental and Skeletal class II malocclusion CONTRA-INDICATIONS:-Dental and Skeletal open bite. -Cases prone to root resorption ADVANTAGES:-The appliance is fixed, thus no issue of noncompliance. DISADVANTAGES:-Appliance is prone to breakage -Lateral movement is restricted.

BANDED HERBST APPLIANCE

CAST HERBST APPLIANCE

CONCLUSION
Management

of class II malocclusion cases posses a great challenge in orthodontic practice, a sound background knowledge of the principles of action, fabrication, clinical use i.e.timming & selection of patients, and management of these appliances is necessary in overcoming this challenge.

REFRENCES

Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. American Journal of Orthodontics and Dentofacial Orthopedics 2007;132:481-489. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA. Mandibular changes produced by functional appliances in Class II malocclusion: a systematic review. American Journal of Orthodontics and Dentofacial Orthopedics 2006;129:599.e1-599.e12 G.J. Carmicheal,P.A.Banks,S.M.Chadwick.A Modification to enable controlled progressive advancement of the Twin block appliance, British Orthodontic Journal 1999 vol 26,1999/9-13. Contemporary orthodontics, William Proffit,3rd Edition. Textbook of orthodontics, Samir Bishara. A textbook of orthodontics, W.J.B Houston,2nd edition.

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