Appliances in Pediatric Dentistry


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Appliances in Pediatric Dentistry

  2. 2.  Space maintainers  Habit breaking appliances  Removable appliances  Myofunctional appliances  Orthopaedic appliances  Conclusion  References
  4. 4. This term was coined by JC Brauer in 1941. It is defined as the process of maintaining a space in a given arch previously occupied by a tooth or a group of teeth Boucher: it is a fixed or removable appliance designed to preserve the space created by the premature loss of a primary tooth or a group of teeth
  5. 5. If a child loses a primary tooth early through decay or injury, the child's other teeth could shift and begin to fill the vacant space. When the child's permanent teeth emerge, there's not enough room for them. The result is crooked or crowded teeth and difficulties with chewing or speaking.
  6. 6. This is a ideal case where a space maintainer would have helped
  7. 7. 1. If the space shows signs of closing. 2. If the use of space maintainer will make the future orthodontics less complicated. 3. If the need for treatment of malocclusion at a later date is not indicated.
  8. 8. 4. When the space should be maintained for two year or more. 5. To avoid supra eruption of opposing tooth. 6. To improve the masticatory system and restore dental health.
  9. 9. 1. If the radiograph shows that the succedant tooth will erupt soon. 2. When the space left is greater than the needed for the permanent as indicated from radiographically. 3. If the space shows no signs of closing. 4. When the succedenous tooth is congenitally absent.
  10. 10. • It should maintain the entire space created by the tooth • It must restore function • Prevent supraeruption of opposing tooth • It should be simple in construction
  11. 11. • It should be strong enough to withstand occlusal forces • Should permit maintenance of oral hygiene • Must not restrict the growth of jaws • It should not exert undue forces of its own
  14. 14. Missing Tooth Treatment Treatment Unilateral loss of primary 1st molar Band / crown and loop Band/crown and loop Unilateral loss of primary 2nd molar No treatment until eruption of 1st permanent molar, later transpalatal arch Distal shoe until eruption of 1st permanent molars and permanent incisors, then lower lingual holding arch Bilateral loss of primary 1st molars Bilateral bands/crowns and loops. Bilateral bands/crowns and loop Bilateral loss of primary 2nd molars No treatment until eruption of 1st permanent molars, later Nance palatal arch. Bilateral distal shoes until eruption of 1st permanent molars and incisors, then lingual arch Multiple bilateral primary molars loss Saddle appliance until 1st permanent molars are erupted, later Nance. Saddle appliance until 1s permanent molars and incisors are erupted, later lingual arch.
  15. 15. Missing Tooth Treatment Treatment Unilateral loss of primary 1st molar No treatment unless leeway space is to be preserved No treatment unless leeway space is to be preserved Unilateral loss of primary 2nd molar Transpalatal Band and loop until eruption of permanent incisors, then lower lingual holding arch Bilateral loss of primary 1st molars No treatment unless leeway space is to be preserved No treatment unless leeway space is to be preserved Bilateral loss of primary 2nd molars Nance Bilateral bands and loops until eruption of permanent incisors, then lower lingual arch Multiple bilateral primary molars loss Nance Saddle appliance until eruption of permanent incisors, then lower lingual holding arch
  16. 16. Missing Tooth Treatment Treatment Unilateral loss of primary 1st molar No treatment unless leeway space is to be preserved No treatment unless leeway space is to be preserved Unilateral loss of primary 2nd molar Transpalatal Lower lingual holding arch Bilateral loss of primary 1st molars No treatment unless leeway space is to be preserved No treatment unless leeway space is to be preserved Bilateral loss of primary 2nd molars Nance Lower lingual holding arch Multiple bilateral primary molars loss Nance Lower lingual holding arch
  17. 17. They are unilateral, fixed, nonfunctional and passive Used when single tooth is missing in the posterior segment. Can also be given in bilateral posterior tooth loss
  18. 18. Indication: 1. Premature loss of one tooth. Contraindication: 1. Long span. 2. Space lost 3. Severe malocclusion. 4. Abutment tooth mobile
  19. 19. Advantages: 1. Simple and easy constructed. 2. Moderate chair time. 3. Give room for erupting permanent tooth. 4. Easy to clean. 5. Inexpensive. Disadvantages: 1. Not restore the function. 2. Not prevent the extrusion of opposing tooth. 3. Has to be replaced if the tooth anterior to space exfoliated.
  20. 20. Design It consists of a band fabricated from 0.005’’ steel band and a loop that extends from the band to the distal surface of the anterior abutment tooth. Loop is placed 1mm from the gingival surface. Construction Band two types- Preformed, Custom made
  21. 21. Custom made bands are made by taking the required amount of band material from the spool and pinching them to form the band. Fabricated using various pliers- Beak pliers, band adaptor and how’s plier. Band pinching Festooning Trimming Folded flap method
  22. 22. Band is adapted on to the tooth Impression of the arch Cast is obtained with the band secure on the tooth Loop is prepared with 0.9 mm hard round stainless steel wire. Loop soldered to the band Cemented to the tooth
  23. 23. Modifications Loop made only on one side Occlusal rest Occlusal stop Crown loop Reverse
  24. 24. Controversy: Recently a study has shown that space changes with regard to arch width or arch perimeter 6 months following premature loss of a primary maxillary first molar was minimal. The early space changes in the maxillary dental arch consist mainly of palatal migration of the maxillary incisors indicating that the mesial movement of permanent molars might not occur as a consequence of the tooth extraction. There was statistically significant 1 mm of space loss detected; however, it is not likely to be of enough clinical significance for the use of a space maintainer. If palatal movement seems to be needed, a palatal arch was suggested instead of band and loop space maintainer. JADA 2007 vol 138:362-8
  25. 25. Lingual arch space maintainer Bilateral, fixed or semifixed, nonfunctional passive Indications 1. Bilateral loss of primary first or second molars after the eruption of permanent mandibular incisors, 2. If there is multiple loss of primary teeth. 3. In late mixed dentition stage, may be used to hold leeway space to allow sufficient space for permanent canines & premolars to erupt or to preserve space for later alignment of crowded incisors.
  26. 26. Advantages: Used with uncooperative patient. Used in children with bad oral hygiene. Can maintain the space through period of mixed dentition. Preserve the integrity of the whole arch. There is no breakage problem or retention problem. It allows free individual movement of teeth while maintaining space. It is easily removed, adjusted and replaced. Disadvantages: Not restore masticatory function. Not prevent over eruption of opposing teeth.
  27. 27. Construction The wire should be made to contact the cingula of the mandibular incisors In the edentulous ridge region wire curved down to the lingual 1 mm away from the soft tissue Should maintain 3-4 mm contact with the lingual surface of the band Konstantinos et al (1998) have suggested that in the canine region 2 omega bends need to be given ???
  28. 28. Bilateral, fixed, passive and nonfunctional space maintainer Indicated when there is bilateral missing deciduous molars in the upper arch The first permanent molars are banded The arch wire extends from the palatal surface of one molar band to the other, anteriorly it extends upto the rugae area and is embedded in an acrylic button.
  29. 29. Can be made active- The acrylic button may irritate
  30. 30. Bilateral, fixed, passive and nonfunctional Used when there is unilateral loss deciduous molars The first permanent molars are banded The wire component extends from the palatal aspects of the bands to cross.. It prevents the mesiolingual rotation of the molars around.. It can be used in bilateral loss of posterior teeth !!! PEDIATRIC DENTISTRY V 29 / NO 3 MAY / JUNE 2007
  31. 31. Early version of distal shoe – Willet’s distal shoe Present version – Roche’s modified distal shoe appliance Unilateral, fixed, nonfunctional and passive An intraalveolar appliance INDICATION The distal shoe appliance is used to maintain the space of a primary second molar that has been lost before the eruption of the permanent first molar. The result of this mesial drift is loss of arch length and possible impaction of the second premolar
  32. 32. Contraindication: 1. Medically compromised pt. (because no complete epithelization around alveolare bone) lead to (subacute bact endocarditis). 2. Poor oral hygiene. 3. Long span. 4. Damaged abutment.
  33. 33. Construction • The crown/band is adapted on the first deciduous molar and impression is taken… • An IOPA is taken.. • On the cast position of the mesial surface of the first permanent molar is marked, then V shaped notch is made • Loop is fabricated
  34. 34. Loop is soldered to the crown, appliance is sterilized.. Extract the tooth just before cementation.. Appliance tried in patient’s mouth and IOPA taken to confirm… Final cementation.
  35. 35. REMOVABLE SPACE MAINTAINERS a. Non-functional types b. Functional types
  36. 36. It is like a removable partial denture, Not only Mesiodistal space but also the vertical space is maintained. Masticatory Function is restored in functional type Esthetics & speech improvement
  37. 37. removable unilateral space maintainers They are too small and present swallowing and choking dangers for children.
  38. 38. The esthetic and hygienic EZretainer maintains the mesiodistal dimension of an extraction space and can also be used to regain slightly closed spaces, according to Dr. Güray. The appliances are color-coded for each quadrant and are available in boxes of four.
  39. 39. Gajanan et al.concluded that ribbond space maintainer as well as repaired ribbond space maintainer are comparable to the conventional band and loop in terms of physical strength. McDonald and Avery suggested that the band and loop space maintainer should be removed once a year to inspect, clean and apply fluoride to the tooth. FRC loop space maintainer seems to eliminate these annual maintenance steps. Contemporary Clinical Dentistry | April 2012 | Vol 3 | Supplement 1
  40. 40. These space maintainers are available with stainless steel crowns or stainless steel bands with an assortment of attachments. There is no welding or soldering required and they are fully adjustable to different edentulous spans.
  41. 41. Newell in 1912 Principle Both on principle of force elimination and force application Indications Mostly to intercept mouth breathing; thumb sucking, tongue thrusting , lip biting and cheek biting Flaccid hypotonic upper lip Correction of mild anterior proclination
  42. 42. Mechanism of action When patient closes the lips or swallows All muscle forces transmitted to anterior teeth Retraction of the proclined teeth
  43. 43. Modifications Hotz modification
  44. 44. Kraus modification
  45. 45. Rehak modification Commercially available polyamide or thermoplastic appliance
  46. 46. Synonyms Lip plumper Principle Both on principle of force elimination and force application Indications Hyperactive mentalis Lip sucking habit
  47. 47. Mode of action- Lip bumper will prohibit lip from exerting excessive force on the mandibular incisors and reposition the lip away from the lingual aspect of the maxillary incisors Types Removable Fixed Denholtz modification
  48. 48. The Palatal Crib is designed to reduce the comfort of thumb sucking by placing a metal crib over the most anterior portion of the palate, preventing the thumb from resting along or contacting the palate.
  49. 49. The Blue Grass appliance is designed to prevent the patient from sucking their thumb or tongue thrusting. This fixed appliance uses a spinning roller to help break the patient's habit and allow the anterior teeth to return to their normal position
  50. 50. Modified blue grass appliance was used using 3 mm acrylic beads as recommended by Baker. It encourages neuromuscular stimulations by using multiple beads. Between 4–6-year-old children can be instructed to play with the beads with the tongue immediately after placement.
  51. 51. Since Teflon rollers are not in contact with palatal tissues, children can roll them with their tongues. Within few days, the tongue establishes new non-harmful habit of playing with roller. Hence, this appliance works through counter conditioning response to the original conditioned stimulus for thumb sucking. Case Reports in Dentistry Volume 2013, Article ID 537120
  52. 52. The Quad Helix appliance is designed to achieve arch development by providing a light, continuous force to both anterior and posterior segments. Fabricated as either fixed or removable (MIA), this appliance can also be used for molar rotation
  53. 53. Four helixes Anterior bridge Outer arms Expansion and rotation
  54. 54. PURPOSE About one third of people brux (grind or clench) their teeth. Many of these people do so subconsciously . The purpose of a night guard is to reduce the negative effects of bruxism. These negative effects can include: Mobile teeth Drifting teeth Recession or clefting of the gum tissue Wear of teeth “v” shaped erosions in the root surfaces Increased bone loss Muscle soreness or stiffness Joint clicking Joint soreness or stiffness
  55. 55. Called as three quarter clasp Construction This need 0.8 mm stainless steel wire, extends from the interproximal embrassure either mesially or distally and passes below the maximum bulge area and above the gingival margin buccally. Adjustment The clasp is adjusted by holding it at the contact point and bending it towards the tooth.
  56. 56. Drawbacks It cannot be used on deciduous teeth as there is no infra- bulge area. Only on posterior.. Cannot be used in partially erupted teeth Thick wire.. Create space..
  57. 57. Used on premolars and molars Construction 0.8 mm wire is used Take apiece of wire of 5 inches Begin to form the clasp from the buccal aspect……. Adjustment Clasp is adjusted by bending the clasp towards the tooth by holding it at the contact point.
  58. 58. Used for additional retention About 3 inches of 0.7 mm, stainless steel wire is used for forming the clasp. A small triangle is made…. The triangle should be perpendicular to the tooth surface… The free end of triangle should be placed distally to prevent injury to the cheek. Adjustment The clasp is adjusted by bending it towards the tooth at the contact point.
  59. 59. Introduced by C. P. Adams Modified arrowhead clasp or Liverpool Clasp or Universal Clasp 0.7 mm stainless steel wire is used Arrowheads should be positioned at … Arrowheads should have a point contact.. The bridge should be located at the middle third of the tooth The bridge should be 2 mm .. When viewed from the side the bridge… Advantages
  60. 60. Uses Used for retraction of anterior teeth Used for retention of teeth Used for reinforcement Used for the attachment of auxiliary springs Stainless steel wire 0.6 mm- Retraction 0.7 mm- Retention 0.8 to 1.0 mm- Reinforcement Contra-Indication Activation
  61. 61. Stainless steel wire of 0.6 mm- Retaction 0.7 mm- Retention Activation Advantage • Can be used to close space between canine and premolar. • Can control canines • Used for retention
  62. 62. Type a – the labial bow is split in the mid-line and the two halves do not overlap each other Activation – by closing the U loops Advantage – Uses- For minor correction of spaces, to flatten arch Type b – the two halves of the split labial bow cross each other at the midline and engage the distal aspect of the central incisor of the opposite side. Activation Advantage
  63. 63. 0.5 mm stainless steel wire Activation By placing a bend on the vertical limb of wire…. Advantage Can be used for correction of severe protrusion of teeth Light force is applied Range of action is longer
  64. 64. Classification Based on the direction of tooth movement brought about by the springs Based on the nature of the support required for the action 1. Self-supporting spring 2. Guided spring 3. Auxiliary spring
  65. 65. Formula F α Edr4 / l3 Factors to be considered Wire dimension Force applied Deflection Direction of the tooth movement
  66. 66. Description of the screw Pitch of the screw
  67. 67. Activation A key is provided by the manufacturer In adults one-quarter turn is opened once in a week In case of children, one-quarter turn is opened once in three days as the periodontal ligament is wider
  68. 68. Advantages • Can be used in many types of tooth movements… Intermittent forces.. Controlled force.. Activation is simple, can be done by patient or parent Useful in moving the teeth which are to be clasped Disadvantages Appliance is bulky Sometimes the screw tends to turn back Expensive
  69. 69. For clinical application, the expansion screw appliances are grouped as Group 1 – Expansion screw appliances used to widen the arch Group 2 – Expansion screw appliances used to move teeth in labial direction Group 3 – Expansion screw appliances used to move teeth in mesio-distal direction Group 4 – expansion screw appliances used to move individual teeth in buccal or labial direction Group 5 – Traction screws used for closure of extraction spaces
  70. 70. 1. Tooth borne passive appliances Tooth borne active appliances Tissue borne passive appliances 2. Myotonic appliances Myodynamic appliances 3. Removable functional appliances Fixed functional appliances 4. Group I, II and III appliances
  71. 71. Synonyms Catalan’s appliance Incisor capping appliance Principle Designed to have 450 angulation Forces the maxillary teeth in cross bite to tip labially
  72. 72. Indications Maxillary anterior teeth in cross bite Single tooth crossbite Palatally displaced maxillary incisors Segment of upper arch in cross bite Contraindications Cross bite due to true manibular prognathism NOTE- Inclined plane is of value in patients whose permanent molars have not erupted + loss of primary molars
  73. 73. Mode of action When appliance cemented contact established only at anterior region When patient swallows No contact posteriorly All forces transmitted to the region of contact Teeth guided to erupt in normal position
  74. 74. Duration of treatment 2-3 weeks, maximum Disadvantage Speech Dietary restriction Worn more than 6 weeks– anterior open bite Frequent re-cementation
  75. 75. Synonyms Biomechanic working retainer Andersen appliance Nocturnal airway patency appliance Norwegian appliance First removable functional appliance – Viggo Andersen
  76. 76. Indications Class II, Division 1 malocclusion Class II, Division 2 malocclusion Class III malocclusion Class I open bite malocclusion Class I deep bite malocclusion As a preliminary treatment before major fixed appliance therapy to improve skeletal jaw relations Children with lack of vertical development in lower facial height Activators As Retainers [JCO 1980 Aug(529 - 545)]
  77. 77. Contraindications Class I problems of crowded teeth caused by disharmony between tooth size and jaw size. In children with excess lower facial height and extreme vertical mandibular growth. whose lower incisors are severely procumbent. with nasal stenosis caused by structural problems within the nose or chronic untreated allergy. Limited application in non-growing individuals.
  78. 78. Two principles Force application —the source is usually muscular. Force elimination —the dentition is shielded from normal & abnormal functional and tissue pressures by pads, shields, and wire configurations Mode of action Myotactic reflex
  79. 79. Herren modified the activator in two ways : By over-compensating the ventral position of the mandible in the construction wax bite. By seating the appliance firmly against the maxillary dental arch by means of clasps (arrowhead, triangular or Jackson's).
  80. 80. Horizontally split activator maxillary portion and a mandibular portion connected together by an elastic bow. allows step wise sagittal advancement of the mandible by adjustment of the bow.
  81. 81. This is an activator modification that is mostly used in treatment of Class III malocclusion. Opening --Anterior screw
  82. 82. Professor G.P.F. Schmuth. Resembles a bionator with the acrylic portion of the activator reduced from the maxillary anterior area leaving a small flange of acrylic on the palatal slopes. The two halves may be connected by an omega shaped palatal wire similar to bionator.
  83. 83. • Developed - monobloc of Robin Consists of a bimaxillary block of acrylic made with the bite open and the mandible in a forward position. Extra oral force used Appliance worn only during nights
  84. 84. Mandibular portion resembles an activator Maxillary portion has acrylic covering only the palatal aspect of the buccal teeth Palate remains free of acrylic -- more convenient to wear the appliance for longer hours. TMJ dysfunction cases – best in mandibular positioning
  85. 85. A modification of the activator by H.P. Bimler. There are three main kinds of Bimler appliance: Type A for patients with Class II Division 1 malocclusions, Type B for those with Class II Division 2 and Type C for patients with a Class III malocclusion.
  86. 86. Developed by Balter Termed by Kantorowicz Advantages over activator Considerably less bulky than the activator. It lacks the part covering the anterior section of the palate, which is contiguous to the tongue. Children able to speak normally, though the appliance fits loosely in the mouth. The bionator can be worn day and night except at meals. An important feature -- its freedom of movement in the oral cavity.
  87. 87. Indications 1. In a class II, div. 1 malocclusion having - The dental arches are well aligned originally. - The skeletal discrepancy is not too severe. - A labial tipping of the upper incisors is evident. 2. Class III malocclusion 3. Open bite cases
  88. 88. Contraindications 1. The Class II relationship is caused by maxillary prognathism. 2. A vertical growth pattern is present. 3. Labial tipping of the lower incisors is evident.
  89. 89. Standard Appliance. Reversed bionator. Open-Bite Appliance.
  90. 90. William Clark – 1977 Goal –maximize the growth response to functional mandibular protrusion Principle Occlusal inclined plane Use of masticatory forces
  91. 91. Indication Class II Div 1 with a good arch form Lower arch uncrowded Upper arch aligned Overjet 10-12 mm and a deep bite VTO positive Patient actively growing– pubertal growth spurt
  92. 92. Standard appliance design Midline screw Occlusal bite blocks Clasps Maxilla – molars and premolars Mandible – premolars and incisors Labial bows
  95. 95. DESIGN: Acrylic + wire components Base of operation – VESTIBULE Buccal shields, lower lip pads – restrain musculature
  96. 96. Labial bow Palatal bow Upper lingual wire Canine loop
  97. 97. Labial support wire Lingual cross over wire Lower lingual springs
  98. 98. FR – Ia Class I malocclusion with mild to moderate crowding Class I deep bite cases FR – Ib Class II, division 1 malocclusion Overjet does not exceed 5mm FR – Ic Class II division 1 Overjet more than 7 mm
  99. 99. FR 2 Class II div 1 and 2 FR 3 Class III FR 4 Open bite and bimaxillary protrusion FR 5 • Incorporate headger
  100. 100. MECHANISM OF ACTION: 1. Establishing muscular equlibrium •Buccal & vestibular pads – relieve buccinator & orbicularis oris pressure • In rest & deglutition • Lingual shields - decrease outward thrust of tongue
  101. 101. 2. Enhanced & supplementary widening of upper jaw Shields – depth of vestibule ---- create tension ---- periosteal pull ---- apposition of bone Stimulate midpalatal suture growth (Stutzman – 1983)
  102. 102. 3. Mandibular protrusion: Normalizing musculature Not by construction bite Lip pads - proprioceptive signal for maintenance of mandibular protrusion
  103. 103. 4. Dental effects: • Anchored to maxilla positively --- Prevents downward & forward movement of maxillary molars • Lingual shields ---- decrease outward thrust of tongue ---- allows eruption in more vertical manner • Buccal shields --- bodily eruption
  104. 104. Indications Mandibular retrusion Prevention of Bruxism Diseases of TMJ Contraindication Non growing subject. Hyperdivergent facial pattern. Abnormal mid face. Negative V.T.O.
  105. 105. Diagnostic criteria for selection – Patients with convex profile ,class II skeletal & class II dental. Mainly with retrognathic mandible & orthognathic maxilla ( ANB – 50 ) Positive V.T.O All first molars & permanent lateral incisors should be fully erupted. Lower incisors should be upright or even slightly lingually positioned.
  106. 106. The appliance can be compared to an artificial joint working between the maxilla and the mandible. A bilateral telescope mechanism attached to orthodontic bands keeps the mandible mechanically in a continuous anterior jumped position
  107. 107. Each telescopic device consists of 1. A tube ( upper) 2. A plunger ( lower) 3. Two pivots 4. Two screws. Plunger Tube Pivots Screws
  108. 108. Bonded Herbst appliance. Banded Herbst appliance. Drawback Banded Herbst appliance- Breakage & loose bands Bonded Herbst appliance difficult to maintain hygiene, decalcification & decay are commonly seen . can create posterior openbite which needs correction later.
  109. 109. Jasper jumper - developed & patented by James.J Jasper in 1987 The term jasper jumper --- combining the surname of its inventor with the functional concept expounded by Kingsley in late 19th century (jumping the bite).
  110. 110. The Jasper Jumper has 3 particular features – It leaves standard oral functions such as mastication & phonetics unimpaired by virtue of its slenderness & flexibility. It maintains the sense of touch of opposing tooth. It cannot be removed readily from the mouth.
  111. 111. Indications for Jasper Jumper They are basically indicated in skeletal Class II maloccusion with maxillary excess and mandibular deficiency. Dental class II malocclusion. Deep bite with retroclined mandibular incisors.
  112. 112. Contraindications – Cases predisposed to root resorption. Dental & skeletal open bites. Vertical growth pattern. High mandibular plane angle & increased lower anterior face height.
  113. 113. The system is composed of two parts The Force Module and The Anchor Units.
  114. 114. It is an open coil, embedded in soft synthetic & is attached through special connecting pieces.
  115. 115. Other accessories supplied are – A ball stop – placed on a continuous or segmented orthodontic archwire, forming a ventral stop for the appliance.
  116. 116. A ball pin – with which the appliance is attached to the upper head gear tube.
  117. 117. Basis for orthopaedic appliances Forces applied to the teeth have the potential to radiate outwards and affect the nearby skeletal structures. For such skeletal changes to occur, the forces employed should be over 400 grams. Thus the orthopaedic appliances utilize the teeth as handles to transmit the forces to the adjacent structures.
  118. 118. Amount of force Duration of force
  119. 119. Uses Orthopaedic effect Anchorage augmentation Distalization of molars Molar rotation Space maintenence
  120. 120. Indications It can be used in a growing patient having a prognathic mandible and retrusive maxilla. It can be used for bending the condylar neck for stimulating Tmj. Selective rearrangement of the of the palatal shelves in cleft patients. Correction of postsurgical relapse after osteotomies.
  121. 121. A modified RPE appliance in conjunction with a facemask can be used in growing Class III patients to correct transverse and sagittal discrepancies. IJO VOL. 21 NO. 3 FALL 2010
  122. 122. Cephalometric analysis showed a forward and downward movement of the maxilla, backward and downward rotation of the mandible, proclination of the maxillary incisors, and slight retroclination of the madibular incisors. The mandibular plane angle remained stable The patient’s facial profile improved. The nasolabial angle became more acute and the upper lip and nose came forward in relation to the chin IJO VOL. 21 NO. 3 FALL 2010
  123. 123. In many studies, it was shown that cervical headgear significantly restrained maxillary forward growth. However, with cervical headgear, many experienced the undesirable backward rotation of the palatal plane, the opening of the mandibular plane and maxillary molar extrusion A maxillary splint design that provided a much larger base area than merely maxillary first molars for the high-pull headgear force application
  124. 124. Due to application of extra oral force to the maxilla with maxillary traction splint appliance there was restriction of downward and forward growth of the maxilla and maxillary dentition Retraction and intrusion of the maxillary incisors and retraction and inhibition of vertical development of the maxillary molars were significant. The mandibular plane angle showed a significant reduction in the treated group as compared to control group. Orthodontic Waves, March 2010
  125. 125. The Tandem Appliance comprises three separate components, one fixed and two removable. The upper section is a fixed Hyrax appliance with buccal arms soldered for attachment of protraction elastics. The lower section is similar to a removable retainer, with posterior occlusal coverage and buccal headgear tubes embedded in the lower first-molar regions
  126. 126. The Tandem Appliance provides a toothborne anchorage system that combines skeletal and dentoalveolar movement. The increased level of patient cooperation with the Tandem Appliance, combined with the ability to control the vertical dimension, protract the maxilla, and benefit from the Class III elastic dentoalveolar effect, makes this appliance extremely valuable in nonsurgical Class III treatment. JCO vol 14, issue 6, 2011
  127. 127. Catch them young Watch them grow