Fixed functional appliances1 / /certified fixed orthodontic courses by Indian dental academy


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Fixed functional appliances1 / /certified fixed orthodontic courses by Indian dental academy

  1. 1. FIXED FUNCTIONAL APPLIANCES INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Contents Classification Herbst appliance Type 1, II, IV Modifications of Herbst appliance Cast splint herbst, Herbst with stainless steel crown, The bonded Herbst appliance, The Acrylic splint Herbst appliance , Headgear – Herbst appliance, Cantileverd Herbst appliance, Modified Herbst appliance for the mixed dentition, The EMDEN Herbst, Edgewise Herbst Appliance, Mandibular Advancement Locking Unit (MALU), Flip-Lock Herbst Appliance Jasper Jumper MARS Appliance
  3. 3. Mandibular Protraction appliances : MPA 1,MPA 2, MPA 3 , MPA4 Adjustable Bite corrector (ABC) The Eureka Spring The churro jumper The universal bite jumper The saif Spring Ritto Appliance The Magnetic Telescopic Device
  4. 4. THE TWIN FORCE BITE CORRECTOR ALPERN CLASS II CLOSERS Mandibular Corrector The Horizontal Anterior Positioning (HAP) appliance The Mandibular Anterior Repositioning Appliance(MARA) Functional Mandibular Advancer The Biopedic appliance The Klapper Superspring II appliance Forsus Fatigue resistant Device
  5. 5. Classification According to the forces produced: Appliances producing pushing forces Appliances producing pulling forces
  6. 6. Appliances producing Pushing forces:  These appliances deliver a pushing force vector forcing the attachment points of the appliance away from one another
  7. 7. Rigid:  1. Herbst Appliance and its modifications.  2. Mandibular advancement repositioning splint  3. Mandibular protraction appliance  4. Eureka Spring  5. Universal Bite Jumper  6. Biopedic  7. Mandibular anterior repositioning appliance  8. Functional Mandibular Advancer
  8. 8. Flexible:  Jasper Jumper  Churro Jumper  Adjustable Bite Corrector  Universal Bite Jumper  Klapper Super Spring II  Forsus
  9. 9. Appliances Producing Pulling Force These appliances create a pulling force vector between the points of attachment:  SAIF (Severable Adjustable intermaxillary Force) spring
  10. 10. Herbst Appliance History, Background and Development Design Anchorage forms of the Herbst Appliance Construction Effects on Dentofacial Complex Effects on facial profile Effects on masticatory system Mandibular anchorage problems Indications Timing Retention
  11. 11. History, Background and Development Developed by Emil Herbst (1872 – 1940) in 1900s.He lived in Bremen, Germany. He called his appliance “Okklusionsscharnier” or “Retentionsscharnier” (Sharnier = Joint and Retention was added since the upper part of the appliance served as a retainer for an expanded maxillary dental arch.)
  12. 12. Herbst presented his appliance (original banded design) for the first time at the 5th international Dental Congress in Berlin in 1909. In 1934 Martin Schwarz from Vienna criticized that the Herbst appliance could result in an overload of the anchorage teeth with periodontal damage as a consequence. This claim was recently disapproved by Pietz in his Thesis(2000)
  13. 13. However after 1934, very little was published about the Herbst appliance, and the treatment method was more or less forgotten until it was rediscovered by Pancherz in the late 1970s.
  14. 14. Basic Design of Herbst The Herbst appliance is basically a fixed bitejumping device for the treatment of skeletal Class II malocclusions. A bilateral telescope mechanism keeps the mandible in an anterior-forced position during all mandibular functions such as speech, chewing, biting, and swallowing. The telescope mechanism (tube and plunger) is attached to "orthodontic bands, crowns, or splints.
  15. 15. The tube is positioned in the maxillary first molar region and the plunger in the mandibular first premolar region. The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible.
  16. 16. Each telescope consists of a tube, a plunger, 2 pivots (axle), and two locking screws that prevent the telescoping parts from slipping past the pivots.
  17. 17. Length of the plunger should be kept at a maximum to prevent it from disengaging from the tube. A large interpivot distance prevents the plunger from slipping out of the tube when the mouth is opened wide. A plunger too far behind the tube can injure the buccal mucosa. If plunger disengages from the tube on mouth opening , it may get stuck in the tube opening on subsequent mouth closure and damage the appliance.
  18. 18. Original Herbst Appliance Originally Herbst had the telescope mechanism placed upside down (with plunger attached to the maxillary molar crown and the tube on the mandibular canine crown). Tube had no open end , thus not allowing the plunger to extend behind the tube.
  19. 19. The telescoping parts of the Herbst appliance were curved conforming to Curve of spee and were made of German Silver or gold( worn more than 6 months)
  20. 20. Anchorage forms of the Herbst appliance Deserves special attention. Because of anchorage loss, maxillary and mandibular tooth movements cannot be avoided. Several anchorage systems have been developed to control unwanted tooth movements.
  21. 21. Anchorage forms used from 1909 to 1934: The standard anchorage system used by Herbst: Crowns or caps were placed on the maxillary permanent first molars and mandibular first premolars (sometimes canines). The crowns/caps were joined by wires that run along the palatal surfaces of the upper teeth and the lingual surfaces of the lower teeth.
  22. 22. If second permanent molars have not erupted then Herbst advised to anchor the appliance more firmly by placing bands on the canines, which were soldered to the palatal arch wire as were the upper molars. Alternative to bands on the upper canines, a thin gold wire was placed on the labial surfaces of the upper incisors and soldered to the palatal arch wire.
  23. 23. Early mixed dentition anchorage system: When using the Herbst appliance in the early mixed dentition, Herbst had the following solution: In the maxilla, the permanent central incisors were used for anchorage instead of the cuspids. In the mandible, crowns were placed on the first permanent molars and bands on the 4 permanent incisors.
  24. 24. Late mixed dentition anchorage system Canines are used as anchorage teeth instead of incisors. Buccal mucosa at the corner of the mouth is prone to ulceration when mandibular canine is used as an abutment tooth for the plunger.
  25. 25. Herbst and others realized the necessity of incorporating as many teeth as possible for anchorage to avoid unwanted side effects. Schwarz( 1934): Most teeth in the maxilla and mandible were interconnected by labial as well as lingual arch wires( Block anchorage)
  26. 26. Anchorage forms used from 1979 onward: Pancherz originally used a banded type of Herbst appliance.Individually made stainless steel bands of a thick material (0.15- 0.18mm) were used. Simple anchorage system 2. Increased anchorage system 3. Total anchorage system 4. Cantilever Herbst 1.
  27. 27. Simple anchorage system Maxilla- Bands are placed on 1st permanent molars and first premolars. Joined on each side by sectional arch wires. Mandible- Premolars are banded and connected with a lingual sectional arch.
  28. 28.     Disadvantages: Space opening distal to maxillary canines Excessive intrusion of 1st permanent molars. Buccal tipping of 1st premolars Large proclination of lower anteriors • Thus, anchorage had to be increased by incorporating more teeth.
  29. 29. 2. Increased anchorage system  Maxillary and mandibular front teeth were incorporated in the anchorage system by labial sectional arch wires.  Mandibular lingual arch wire extended to 1st permanent molars.
  30. 30. Since 1995, cast chromecobalt splints are used routinely. The splints cover all buccal teeth in the maxillary and mandibular arches and also the mandibular canines. Chair time is short and the appliance is strong, hygienic, and causes few clinical problems.
  31. 31. In the early 1980s, Howe and McNamara developed the acrylic splint Herbst appliance which is used a fixed (bonded to the teeth) and removable appliance. However, use of the Herbst as a removable device is not recommended because the main advantage of a fixed Herbst appliance is that it works 24 hours a day without the dependence on patient cooperation.
  32. 32. The so-called cantilever Herbst appliance design is mainly indicated in the early mixed dentition before the eruption of the mandibular permanent canines and first premolars. The lower part has heavy metal extension arms that are soldered to the permanent first molar crowns. The arms extend anteriorly, lateral to the dentition and terminates in the premolar region in which the telescoping axles
  33. 33. Support wires attached to the cantilever arms, working as occlusal rests on the first or second deciduous molars are important. Without these rests (as seen in earlier designs of this appliance), the vertical force vector of the telescopes acting as lever arms will result in uncontrolled mesial tipping and extrusion (extraction) of the molar teeth. But the anchorage control of the mandibular molars with the cantilevers (even when using occlusal rests on the deciduous molars) is questionable.
  34. 34. None of the anchorage systems used in Herbst treatment could prevent anterior movement of the mandibular incisors and molars. ( Pancherz and Hansen1988) Lower anchorage is a problem difficult to master in Herbst treatment. Some factors associated with anchor loss can be :   Severity of A-P interarch discrepancy Amount of bite jumping at the start of treatment.
  36. 36. SAGITTAL CHANGES I. Skeletal:  1.Restrains maxillary growth and decrease of SNA angle.  2. Increases mandibular length (Pancherz 1979, 1981, 1982). This finding is in agreement with several bite jumping experiments in growing monkeys (Stockle and Willert 1971, McNamara 1972, 1973, 1975) and rats (Petrovic and Stutzman 1969).
  37. 37. 2a. Evidence of temporomandibular growth adaptations in Herbst treatment: Three adaptive processes in the TMJ are thought to contribute to the changes of mandibular position. 1) Condylar remodeling. (2)Glenoid fossa remodeling; (3) Condylar position changes within the fossa.
  38. 38. Animal studies Peterson and McNamara (semin orthodontics 2003) : Evaluated histologically the TMJ, glenoid fossa, and the posterior border of the mandible in juvenile Rhesus monkeys whose mandibles had been positioned forward with a Herbst appliance.
  39. 39. The following adaptations were observed:Condyle remodelling :  Increased proliferation of condylar cartilage was noted. It occurred primarily in the posterior and posterosuperior regions of the condyle. Glenoid fossa remodelling :  Significant deposition of new bone on the anterior surface of the postglenoid spine occurred, indicating an anterior repositioning of the glenoid fossa. Similar to (Breitner 1930,33).  Significant bone resorption on the posterior surface of the postglenoid spine was noted.
  40. 40. 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 TMJ of the juvenile Rhesus monkey.
  41. 41. CLINICAL STUDIES: Have provided radiographic evidence of TMJ growth adaptation in Herbst treatment.
  42. 42. Paulsen et al (1995) : Analysed TMJ changes in a single case of Herbst treatment in late puberty using CT scanning and OPG. Three months after insertion of the appliance CT-scanning and OPGs of the TMJ revealed new bone formation as a double contour in the articular fossa and on the posterior part of the condylar process as a result of adaptive bone remodeling.
  43. 43. Roentgenograms of the mandibular joints (N = 33). A, Before treatment. B, After active treatment. C, After the retention period. A double contour of the fossa outline was found on roentgenograms. The double contour disappeared in all cases during the retention period.
  44. 44. Ruf and Pancherz (1998, 1999): Analysed three possible adaptive TMJ growth processes contributing to increase in mandibular prognathism accomplished by Herbst treatment : Condylar remodeling Glenoid fossa remodeling Condyle fossa relationship changes. Aidar, Abrahao ,Yamashita , Dominguez (AJO 2006) assesed the TMJ disc position with MRI after 12 month period of herbst appliance therapy in 20 ClassII div1 patients. They found mild changes in position of the disc with slight tendency towards retrusion due to mandibular advancement which returned to normal after appliance removal. These changes were in the normal phsiological limits as evaluated in short term.
  45. 45. II. Dental: Dental changes seen during Herbst appliance treatment are basically a result of anchorage loss in the two dental arches. The telescope mechanism produces a posterior directed force on the upper teeth and an anterior directed force on the lower teeth, resulting in distal tooth movements in the maxillary buccal segments and mesial tooth movements in the mandible.
  46. 46. 1. Mandibular teeth are moved anteriorly Proclination of lower anteriors. Mandibular incisors proclined on an average of 6.6° during 6 months (Pancherz, 1985). In 24 class II subjects treated with the Herbst appliance (Hansen et al, 1997), the proclination during treatment was 11°.
  47. 47. Lower Incisor Proclination & general recession:Large amount of lower incisor proclination during Herbst treatment could be thought to cause break down of the labial gingival attachment & create gingival recessions. Ruf and Pancherz (1998): Assessed the effect of orthodontic proclination of lower incisors in children and adolesctents. The subjects were treated with Herbst appliance. Herbst treatment resulted in varying degrees of lower incisor proclination (mean=8.9°, range=0.5°19.5°).
  48. 48. No inter relation was found between the amount of incisor proclination and development of gingival recession. The conclusion of this study was that in children and adolescents a temporary orthodontic proclination of lower incisors seems not to result in gingival recession.
  49. 49. 2. Maxillary molars are moved distally. The effect of the Herbst appliance on maxillary molar teeth is essentially comparable with that of a high pull headgear (Pancherz, AnechusPancherz, 1993). The teeth are both distalized and intruded. Normally, the dental changes occurring during Herbst appliance treatment would not be desirable. Distal tooth movements in maxillary buccal segments could however, be desirable in cases with anterior crowding
  50. 50. 3) Mesial movements of lower molars 4) Sagittal dental arch relationship: Overjet is reduced in all patients during treatment by increase in mandibular length and mesial movement (proclination) of the mandibular incisors.  Class II molar correction by increase in mandibular length, distal movement of maxillary molars and mesial movement of the mandibular molars. 
  51. 51. Herbst appliance corrects or overcorrects both molar & canine sagittal relation in most of the cases. However treatment is more effective in the molar than in the canine region. This is probably due to the maxillary anchorage system, the molar connected to the first premolar, is pushed distally by the telescope mechanism (Pancherz and Hansen 1986). The canine, on the other hand, is not directly engaged in the anchorage system.
  52. 52. 5. Arch perimeter: Because of the distalizing forces of the telescope mechanism of the Herbst appliance on the upper 1st molars and the anteriorly directed forces on the lower front teeth, the maxillary and mandibular arch perimeters increase during treatment. (Hansen et al, 1995) Arch perimeter changes are, however, of a temporary nature because settling of the teeth during the immediate post treatment period.
  53. 53. 6. Arch width Hansen et al (1995) : During treatment the maxillary and mandibular dental arches expand laterally in both canine and molar areas. The expansion is more marked in the maxilla than in the mandible.
  54. 54. b) Vertical changes Dental Skeletal
  55. 55. Dental: In Class II malocclusions with deep bites, overbite may be reduced significantly by Herbst therapy (Pancherz, 1982, 1985) an average of 3.0mm (55%) during 6 months of treatment. Overbite reduction is primarily accomplished by intrusion of lower incisors and enhanced eruption of lower molars. Part of the registered changes in the vertical position of the mandibular incisors results from proclination of these teeth. Because of vertical dental changes, maxillary and mandibular occlusal planes tip down.
  56. 56. Skeletal: Increase in lower anterior facial height (LAFH) due to over eruption of lower posterior teeth. Increase in gonial angle – this may be due to a more sagittaly directed growth of the condyle or it may result from resorptive bone changes in the gonion region, probably as a consequence of an altered muscle function during bite jumping (Pancherz & Littman, 1989)
  57. 57. Arji George, V. Surendra Shetty, SN Rao & Ashima Valiathan:JIOS 1993 studied the effect of Herbst on certain Orofacial muscles along with the muscles of mastication. Experimental Gp: 6 patients with Class II div 1 malocclusion. Control Gp: 4 individuals with normal occlusion and acceptable facial balance. EMG activity of the 5 muscles of mastication where analyzed at rest, clench, mouth open, swallowing before and after treatment with the Herbst appliance.
  58. 58. Results: 1.A change in muscle activity in Class II patients with respect to control. Significantly reduced muscle activity of posterior temporalis, Mentalis and posterior masseter. Significantly increased muscle activity of the anterior belly of digastric. 2. A difference in activity before and after treatment. Increase in activity of anterior and posterior temporalis, Mentalis. Decrease in activity of the anterior belly of Digastric. 3. An improvement in muscle activity toward those of the control group.
  59. 59. The following changes contribute to Herbst appliance correction of class II malocclusion.  Stimulation of mandibular growth.  Inhibition of maxillary growth (a less important change)  Distal movement of upper dentition  Mesial movement of lower dentition (proclination of the incisors)
  60. 60. INDICATIONS FOR TREATMENT Pancherz (AJO Jan 1985); indicated that Herbst appliance should be used only in growing individuals. Should not be used in non growing subjects because. 1. Skeletal alterations will be minimal. 2. More of dentoalveolar changes. 3. Increase risk of developing dual bite.
  61. 61. Postadolescent patients:  Who have passed the maximum pubertal growth spurt and have still some growth potential left, treatment with the Herbst appliance is indicated as it can be finished within 6 to 8 months. Mouth breathers: Nasal airway obstructions can make the proper use of removable appliances difficult or impossible but doesn’t interfere with herbst. Uncooperative patients: It is fixed to the teeth without any assistance from the patient. Patients who do not respond to removable appliances.
  62. 62. For mandibular fracture (particularly ramus) patients after surgery For prevention of bruxism For diseases of the TMJ
  63. 63. TIMING OF TREATMENT Most favorable time to treat the patients with the Herbst appliance is at the peak of pubertal growth spurt (Pancherz, Hagg, 1985). Pancherz & Hagg (1988): Indicated that the patients treated at the initial closure of the middle phalanx of the third finger (MP3-FG) had the greatest amount of condylar growth.
  64. 64. Ruf, Pancherz March 2003, the ideal period for the herbst appliance treatment is in t he permanent dentition or just after the pubertal peak of growth corresponding to the skeletal maturity stages FG to H of the middle phalanx (implying the precapping to preunion stages of epiphysis and diaphysis) Because mandibular growth stimulation using the herbst appliance is also possible in post adolescent young adult subjects, a new concept of Class II therapy is proposed in which the Herbst appliance is used as an alternative to orthognathic surgery in Class II subjects.
  65. 65. Perfect end result cannot be obtained exclusively with Herbst. Class II cases cannot be treated to a perfect end result with the Herbst appliance exclusively. Many cases will require a subsequent dental-alignment treatment phase with a multibracket appliance. Thus, treatment of a Class II, Division 1 malocclusion will usually occur in two steps STEP 1. ORTHOPEDIC PHASE. The sagittal jaw base relationship is normalized and the Class II malocclusion is transferred to a Class I malocclusion by means of the Herbst appliance. STEP 2. ORTHODONTIC PHASE. Tooth irregularities and arch discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).
  66. 66. A Class II, Division 2 malocclusion may require a three-step treatment approach STEP 1. ORTHODONTIC PHASE. Alignment of the anterior maxillary teeth by means of a multibracket orthodontic appliance. STEP 2. ORTHOPEDIC PHASE. Normalization of sagittal jaw base relationships and transformation of the Class II malocclusion into a Class I malocclusion by means of the Herbst appliance. STEP 3. ORTHODONTIC PHASE. Tooth irregularities and arch-discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).
  67. 67. So the ideal patient for treatment with the Herbst appliance has the following characteristics: Skeletal morphology. • Retrognathic mandible. • Small mandibular plane angle indicating an anterior growth direction of the mandible. (A favorable growth pattern both facilitates treatment and counteracts post treatment relapse.) • Normal or reduced lower facial height.
  68. 68. Dental morphology:  Class II dental arch relationship with increased overjet and normal or increased overbite (open bite cases not suitable for Herbst appliance).  Maxillary and mandibular teeth well aligned and the two dental arches fitting each other in normal sagittal position Maturation:  Treatment during pubertal growth spurt.
  69. 69. Types of Herbst Appliance The original design since the seventies has maintained its general shape with only a few modifications taking place with regard to methods of application (Type I, II and IV).
  70. 70. Type I is characterized by a fixing system to the crowns or bands through the use of screws. This is the most common form. It is necessary to weld the axles to the bands or crowns and then fix the tubes and plungers with the screws.
  71. 71. Type II has a fixing system that fits directly onto the archwires through the use of screws. This method of application has the disadvantage of causing constant fractures in the archwires due to lack of flexibility together with the difficulty in lateral movements and the stress placed on the archwires through activation.
  72. 72. 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. These brakes are small and sometime difficult to fit.
  73. 73. MODIFICATIONS OF THE HERBST APPLIANCE  In patients with class II malocclusions who have narrow maxillary arches, expansion can be performed using the Herbst appliance by soldering a quad helix lingual arch wire or a rapid palatal expansion device to the upper premolar and molar bands or to the splint.
  74. 74. The cast splint herbst The bands are replaced by splints, cast from cobalt-chromium alloy and cemented to the teeth with GIC. The upper and lower front teeth are incorporated into the anchorage through the addition of sectional arch wires. The cast splint appliance ensures a precise fit on the teeth is strong and hygienic saves chair time Causes very few clinical problems
  75. 75. Herbst with stainless steel crowns Norris M. Langford, 1982 JCO) suggested using stainless steel crowns on the upper first molar and the lower first premolar and canine for the Herbst appliance which are superior to banding, in that they are resistant to breakage and becoming loose.
  76. 76. MODIFICATIONS: the substitution of stainless steel crowns for bands. the elimination of the stabilizing bar.
  77. 77. The bonded Herbst appliance (1982) The bonded Herbst appliance eventually evolved into the acrylic splint Herbst appliance (McNamara, 1988; McNamara and Howe 1988). The acrylic splint Herbst appliance is composed of a wire framework over which has been adapted, 2.5-3.0 mm thick splint Bioacryl, using a thermal pressure machine
  78. 78. By substituting an acrylic splint for the stainless steel bands of the earlier appliance, the Herbst mechanism can be attached to both maxillary and mandibular arches using bonding procedures
  79. 79. The maxillary splint covers all available maxillary teeth with exception of the central and lateral incisors The occlusal thickness of the maxillary splint is kept to a minimum, so that the cusps of the posterior teeth perforate the splint
  80. 80. These perforated openings permit the placement of the nylon tip of a posterior bandremoving plier against the cusps.
  81. 81. Disadvantage of Banded Herbst: I) II) III) IV) Repeated breakage and loosening of the appliance occurs, especially in the lower bicuspid band area. Rapid intrusion if the mandibular first bicuspids which though temporary, partially deactivates the appliance. As the bicuspids are depressed, the lingual arch is also depressed, resulting in impingement on the lingual gingiva. Possibility of incisal tooth fracture.
  82. 82. Headgear – Herbst appliance : Weislander (1984) Wesilander suggested the use of special headgear – Herbst appliance in the treatment of large sagittal discrepancies between the maxilla and mandible in early mixed dentition. The Herbst appliance consisted of a cast of vitallium bonded to the lower arch and with bands on the upper first permanent molars. The upper bands were united with a palatal bar and connected to the lower splint with the Herbst telescopic arms.
  83. 83. He concluded that a short period of interceptive orthopedic treatment in the very early mixed dentition may be indicated to correct skeletal deviation and establish a normal relationship between maxilla and mandible.
  84. 84. Cantileverd Herbst appliance This was a design given by Larry W. White, 1994. Cantilever Herbst design. Buccal cantilever wire is made by doubling .045" wire and soldering the two strands together.
  85. 85. Advantage :  This design is particularly useful when mandibular bicuspids are absent or the primary molars cannot withstand functional forces.
  86. 86. Modified Herbst appliance for the mixed dentition Introduced by Philip Goodman and Paul Mc Kenna, 1985 They stated the middle phalynx development may, indicate optimal treatment timing, but the patient’s bicuspids are not erupted enough to receive either bands or crown. Also they encountered a modification where stainless steel crowns are fitted on the upper first permanent molars and bands on the lower first molars and incisors.
  87. 87. The deciduous first and second molars are free to exfoliate through the framework
  88. 88. If the patient is uncomfortable with much mandibular advancement, have the patient retrude the mandible until the discomfort disappears. The telescopic part of the appliance can be advanced again in six to eight weeks using washers or metal sleeves.
  89. 89. The EMDEN Herbst – a fixed removable Herbst appliance. Tarek Zreik 1994 Introduced by Tarek Zreik, 1994 to overcome breakage problems, he had with the Herbst appliance. This modification makes the Herbst more durable, simple and hygienic.
  90. 90. The Herbst mechanism is attached to stainless steel crowns on the maxillary first permanent molars and to the lower arch through a removable acrylic splint. Double buccal tubes on the stainless steel crowns can hold utility, sectional, or continuous archwires.
  91. 91. Advantages of the EMBDEN Herbst • It requires minimal cooperation. • It promotes patient acceptance because it is not visible and it produces an immediate improvement in the profile. • It allows more cases to be treated without extractions. • It is easy to construct, fit, adjust, and clean. • Materials are inexpensive, and breakage is minimal after a modest amount of laboratory experience is gained. • The lower splint increases anchorage, thus providing more of a skeletal correction, and restricts forward movement of the lower incisors.
  92. 92. Edgewise Herbst Appliance This design was given by Terry Dischinger, 1995
  93. 93. The Edgewise Herbst Appliance corrects Class II malocclusions rapidly and without the need for patient cooperation. It allows orthodontic tooth movements during orthopedic correction and a smooth transition from Herbst treatment into the edgewise finishing appliance. The new appliance is more clinically efficient than previous models and is easily incorporated into an edgewise practice.
  94. 94. Herbst with Mandibular Advancement Locking Unit Components (MALU)  2 tubes  2 plungers,  2 upper “Mobee” hinges with ball pins  2 lower key hinges with brass pins
  95. 95. In the upper arch of the edgewise-Herbst MALU appliance, only the first molars are banded, with . 051" headgear tubes. A palatal arch can be used in cases of overexpansion.
  96. 96. In the lower arch, the first molars are banded, and the anterior segment is bonded from cuspid to cuspid with .022" brackets. The bicuspids may be left unbracketed to help in settling the occlusion and locking in the mandible. The mandible can be progressively advanced using 1-5mm spacers.
  97. 97. Advantages: 1. Its cost is considerably lower because it requires no laboratory construction. 2. Its simplicity makes it useful even for non- growing patients in whom only dental movement and mandibular repositioning are required. 3. It can also be used in growing patients who have not cooperated with removable appliances or headgear.
  98. 98. Flip-Lock Herbst Appliance A new design, the FlipLock Herbst appliance, reduces the number of moving parts that can lead to breakage or failure. It is easy to use and more comfortable for the patient than the conventional cantilevertype Herbst. Instead of a screw attachment, it has a ball-joint connector, and it needs no retaining springs.
  99. 99. The first generation was made from a dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint attachment
  100. 100. In the second generation, the plastic was replaced with metal
  101. 101. The third generation is made of a horse-shoe 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
  102. 102. End of rod is crimped onto mandibular ball. Advantages : Less irritation reduces the number of moving parts that can lead to breakage or failure
  103. 103. The Jasper Jumper : This interarch flexible force module allows patient greater freedom of mandibular movement than is possible with the original bite jumping mechanism of Herbst. Dr. James Jasper in 1987
  104. 104. Force Module : The force module, analogous to the tube and plunger of the Herbst bite – jumping mechanism and is flexible. The force module is constructed of stainless steel coil of spring attached at both ends to stainless steel end caps in which holes have been drilled in the flanges to accommodate the anchoring unit. This module is surrounded by an opaque poly urethane covering for hygiene and comfort.
  105. 105. The modules are available in seven lengths ranging from 26 to 38 mm in 2 mm increments. They are designed for use on either side of the dental arch.
  106. 106. Principle of action : When the force module is straight, it remains passive. As the teeth come into occlusion the spring of the force module is curved axially producing a range of forces from 1 to 16 ounces.
  107. 107. If properly installed to produce mandibular advancement, the spring mechanism is curved or activated 4 mm relative to its resting length, thus storing about 8 ounces (250g) of potential for force delivery. If less force is desired (eg force levels that produce tooth movement alone), the jumper is not activated fully. Increasing the activation beyond 4 mm does not yield more force from the module but only builds excessive internal stress.
  108. 108. Anchor units : A number of methods are available to anchor the force modules to either the permanent or mixed dentitions.
  109. 109. Attachment to the main arch wire : Dr. Jasper `s method. When the jumper mechanism is used to correct a class II malocclusion, the force module is attached Posteriorly to the maxillary arch by a ball pin placed through the distal attachment of the force module. The module is anchored anteriorly to the lower arch wire (0.018”x 0.025” or 0.0x0.025” ).
  110. 110. Bayonet bends are placed distal to the mandibular canines and a small Lexan ball is slipped over the archwire to provide an anterior stop. The mandibular archwire is threaded through the hole in the anterior end cap and then ligated in place. The first and second bicuspid brackets are removed to allow the patient greater freedom of movement.
  111. 111. Disadvantages :Unattached bicuspids tend to erupt above the occlusal plane as the anterior teeth are intruded. When only the lower 1st bicuspid bracket used to be removed as originally suggested by Dr. Jasper, Jaw opening used to be limited as the lower portion of the jumper tends to bind at the 2nd bicuspid.
  112. 112. Replacement of a broken jumper required removal of the entire archwire. If an arch breaks or comes untied at the distal tieback, all the force is transferred to the anterior teeth, which tends to tip them forward depress them and open space. Removing the Jumper for an occlusal check is time consuming. In an extraction case, it is difficult to close spaces because the jumper must be attached to the arch before closing loops.
  113. 113. 2. Dr. Cope’s Method : Dr. Don cope makes an attachment out of an 0.017 x 0.025” stainless steel wire, soldered to a rocky mountain lock, then bent so as to pass distal to the lower first molar. The lock is attached between the bicuspid and cuspid
  114. 114. An alternative is to place the lock distal to the molar bracket with the wire bent distal to the cuspid. The approach uses a free sliding quick connect (figure). The wire runs parallel to the main archwire, allowing the jumper to clear the bicuspid brackets.
  115. 115. Advantages : The attachment can be made in the office laboratory, and placement can be delegated to an assistant. The jaws can open fully. Force is directed distal to the molar; if the archwire breaks there is no effect on the anterior teeth. The jumper does not interfere with space closure or leveling procedures. A broken jumper is easy to replace. No auxiliary tubes are needed on the mandibular molars.
  116. 116. Disadvantages : Laboratory time is required to solder and bend the attachment. The rocky mountain lock assembly is an additional expense.
  117. 117. 2) Attachment auxiliary archwire : Incorporates the use of “out rigges” which are 0.016 x 0.022” (0.018” slot) or 0.018 x 0.025” (0.022” slot) auxiliary sectional wires. The sectional arch is looped over the main archwires anteriorly between the first premolar and canine. Posteriorly into the lower first molar band.
  118. 118. The sectional archwire must have adequate clearance from the alveolus and gingiva to avoid tissue impingement. Advantages : Has all of the previous said advantages plus The clinician may leave the premolar bands in place Materials are in expensive.
  119. 119. Attachment in the Mixed dentition The maxillary attachment is as the original attachment. The mandibular attachment includes an archwire that extends from the brackets on the lower incisors, posteriorly to the first permanent molars, by passing the region of the deciduous canines and molars. In a mixed dentition patient the use of a transpalatal arch and fixed lower lingual arch is mandatory to control potential unfavorable side effects.
  120. 120. Divided into 3 phases as advocated by Dr. Jasper Leveling and anchorage preparation  Period of jasper jumper use (6-9 months)  Period of finishing (12 months) 
  121. 121. Leveling and anchorage preparation Alignment of the maxillary and mandibular anterior teeth during the initial phases of orthodontic treatment must be completed. Full-sized (or nearly full-sized) archwires should be inserted into the brackets in both arches before the placement of the force modules. The archwires should be tied or cinched back posteriorly to increase anchorage, including second molars whenever possible. In addition, the clinician can place posterior tip-back bends in the mandibular archwire to enhance anchorage.
  122. 122. Anterior lingual crown torque can be placed in the arch wire. Alternatively lower incisor brackets with 5 degrees of lingual crown torque incorporated into the slot also can be used to prepare anchorage.
  123. 123. Preparation of the arches : After the full sized arch wires have become passive, the mandibular arch wire is disengaged and the brackets on the 1st and 2nd premolars are removed bilaterally. Unless on triggers are used, bayonet bends are placed in the archwire distal to the lower canine bracket, and 3 mm Lexan beads are slipped over the ends of the arch wire and moved forward to rest against the bayonet bends bilaterally.
  124. 124. Selection and installation of the modules Determination of proper length of force module. Twelve millimeters are added to measurement of distance between mesial aspect of face-bow tube and distal aspect of Lexan ball. In this example, distance from ball to face-bow tube is 20 mm. Thus 32 mm module should be selected.
  125. 125. The lower arch wire in threaded through the hole in the anterior end cap of the force module, ligated in place and the ends of arch wire are cinched or tied back firmly. Then the ball pin is inserted through the face bow tube on the maxillary first molar band from distal to mesial and cinched forward. In-patients with high mandibular plane angle the pin is cinched to achieve approximately 2mm of module deflection (150g / side). In patients with low or normal mandibular plane angle, the ball pin is cinched forward to achieve 4 mm of module deflection (300g force/ side).
  126. 126. The patients are coached to practice opening and closing movements slowly at first and told to avoid excessive wide opening during eating and yawning.
  127. 127. Activation of the module for orthodontic and orthopedic effect : If molar distalization is desired. The jumper is placed so that only 2-4 ounces of force is produced by the module. In growing patients in whom orthopedic repositioning of the mandible is desired, higher forces (6 - 8 ounces) are used continuously.
  128. 128. Reactivation of the module : If the class II molar relationship is not corrected completely by the initial activation, the modules should be reactivated 2 – 3 months later. The pin extending through the face bow is pulled anteriorly 1-2 mm on each side to reactivate the module. 2-4 mm of the pin should extend distally when the pins are activated maximally (so that the jumper does not blind against the distal aspect of the face bow tube.)
  129. 129. Ball pin protrudes 2-3mm distally, allowing free movement. B. Ball pin too close to molar tube, which can cause breakage of ball pin or Jumper. C. Correct placement. Anterior force is delivered distal to lower molar bracket, while depressing force is delivered to archwire between cuspid and bicuspid.
  130. 130. Activation of the force module can also be made by crimpable stops (1 – 2mm) placed mesial to the lexan beads. It is more accurate Easier to perform Avoids unintentional restriction of ball pin / molar tube relationship
  131. 131. Types of forces produced : Bilateral directions of force generated by the modules include sagittal, intrusive and expansion forces. Force module curves to buccal, producing shielding effect on dentition.
  132. 132. Buccal force → due to intrusive force acting along the buccal surfaces of the maxillary teeth → produces maxillary arch expansion. Modules curving outwards → Vestibular shielding effect Expansion forces can be minimized or eliminated through the use of a transpalatal arch or a heavy arch wire that has been narrowed and to which buccal root torque has been applied.
  133. 133. Treatment effects : Maxillary adaptations : i) Headgear effect : One treatment effect produced most easily is distalization of the upper posterior segment or the headgear effect.  For this the maxillary arch wire must not be cinched or tied back, but remain straight and extend past the buccal tubes.  Involves light forces (2-4 ounces)  Minimal changes in the mandibular dentition.  This effect can be produced in actively growing as well as adult patients. 
  134. 134. Retraction of anterior teeth Upper canines alone or all the six anterior teeth can be retracted in both extraction and non-extraction patients with a NiTi coil or an intramaxillary elastic, with the posterior maxillary dentition supported by the force module. Cuspid retraction mechanics: As Jumper pushes ball pin distally, molar anchorage is maintained and cuspid is retracted along archwire.
  135. 135. Maxillary anterior teeth are retracted as a unit by attaching ligature to appropriate archwire tiebacks.
  136. 136. Dental Asymmetries The force module system also can be used in-patients who have sagittal dental asymmetries. In a patient with a class II subdivision type of malocclusion the maxillary archwire orthopedic effects may also be achieved. Asymmetric orthopedic effects may also be achieved
  137. 137. Mandibular Adaptations : In producing mandibular advancement the movement of maxillary posterior dentition must be cinched or tied back. Also a transpalatal arch must be placed, to obtain intra arch anchorage. Level of force generated is higher (6 to 8 ounces ) than for headgear effect.
  138. 138. Jasper’s theory of two’s” suggests that class II correction with Jasper jumper therapy can be equally proportioned between 5 components. 1. 20% due to maxillary basal restraint 2. 20% due to backward maxillary dent alveolar movement 3. 20% due to forward mandibular dentoalveolar movement 4. 20% due to condylar growth stimulation 5. 20% due to downward / forward glenoid fossa remodeling
  139. 139. Jay Bowman JIOS 2001 reported the use of jasper jumper in a 13year old female with class II division1 malocclusion and moderate overjet, after 5 months an anterior end on relation was noted. They concluded that lingual tipping of maxillary incisors along with mandibular growth assisted to correct the overjet. There was labial tipping of 91 to 98 degrees so lingual crown torque on mandibular incisor was advised to prevent this adverse reponse with jasper jumper.
  140. 140. Nalbantgil D, Arun T, Sayinsu K, Fulya I Angle Orthod 2005 studied 15 subjects (class II) treated with jasper jumper and compared them with15 untreated(class II) subjects. They were late adolescent patients. Results: Class II discrepancies were mainly corrected by dentoalveolar changes and this could be an alternative method to orthognathic surgery in borderline class II cases.
  141. 141. MARS Appliance (Mandibular advancing repositioning splint). This appliance was introduced by Ralph M Clements and Alex Jacobson.1982 The MARS appliance is composed of a pair of telescopic struts, the ends of which are attached to the upper and lower archwires of a multi-banded fixed appliance by means of locking device.
  142. 142. . Piston fitted to the cylinder of a MARS appliance.
  143. 143. • Allignment must be complete. • The teeth in the respective arches should be aligned, with correct axial inclinations, prior to attachment of the appliance. • The MARS appliance should be attached only to the heaviest rectangular arch wires that can be accommodated by the brackets and tubes. The heavy arch wire prevents breakage at the point of attachment as well as excessive intrusion in the region of the mandibular canines. • The mandibular arch wires should be securely tied back to the terminal molar before attachment of the MARS appliance.
  144. 144. Failure to do this will usually result in flaring of the lower incisors, even with the heavy rectangular arch wire, since the untied arch wire will slide forward through the tubes and brackets of the posterior teeth. Previously closed mandibular extraction spaces are likely to reopen if this precaution is not taken.
  145. 145. Determining length of assembly With the patients protruding the mandible into a class I position, the right and left strut lengths are measured. The MARS strut length is that distance from the middle of the interbracket space distal to the lower canine to the middle of the interbracket space mesial to the maxillary terminal molar.
  146. 146. The upper member or hollow tube length is determined by subtracting a calculated and standardized measurement of 7.4mm from the strut length. The free end of the lower member or the plunger is then cut so that 2mm extends out of the back of the upper member One reference measurement needed for this appliance is the PIED (Protrusive incisial edge distance) PIED is the horizontal distance measured at the midline between the maxillary and mandibular incisial edges with the mandible in its maximum strained protruded position.
  147. 147. The MARS appliance should be locked into position with the mandible 2 to 3 mm posterior to the maximum PIED measurement. In the event a patient encounters muscular discomfort as a result of protruding the mandible too far forwards the appliance is adjusted and locked in a less protrusive position. At subsequent appointment the Pied should be measured and recorded. The authors have observed that the PIED will increase from 0.5 to 2 mm between 3 to 4 week appointment intervals. When the PIED ceases to increase between appointments, the MARS appliance is then adjusted so that a super class I occlusal relationship is obtained.
  148. 148.  Two methods to lengthen the appliance  1) Replacement of the struts with longer upper members of cylinders.  2)Placement of spacers 2 to 3 mm in length on the lower members or pistons. Unlike the Herbert appliance, the MARS appliance : Requires neither soldering nor extensive lab procedures. Has minimal incidence of breakage Does not depress the canines, open spaces in the premolar area or flare mandibular incisors (provided the mandibular rectangular archwire is tied back to the terminal molars) Is easily removed.
  149. 149. Disadvantages : Need for a fixed multi-banded appliance limits its use in mixed dentition cases. Disarticulates the posterior segments from 1 to 3 mm Needs to customize the appliance for each patient.
  150. 150. Mandibular Protraction appliances : This appliance was developed by Carlos Martin Coelho Filho (JCO 1995). His inability to purchase some of the newer class II corrective appliances in northern Brazil led him to develop these group of appliance that reposition the mandible forward.
  151. 151. They have proven effective in treating Class I patients with exaggerated overjets and Class II subdivision patients where only one side needs correction. Their advantages include ease of fabrication, low cost, infrequent breakage, patient comfort, and rapid installation. But they are not claimed to be superior but are only treatment alternatives to Class II therapies.
  152. 152. Each side of the appliance is made by bending a small loop at a right angle to the end of an . 032" stainless steel wire. The length of the appliance is then determined by protruding the mandible into a position with proper overjet, overbite, and midline correction and measuring the distance from the mesial of the maxillary tube to the stop on the mandibular archwire.
  153. 153. Another small right-angle circle is then bent in an opposite direction into the other end of the .032" stainless steel wire. The angulation of these circle bends can vary to allow free sliding along the mandibular archwire. One appliance circle is placed over the maxillary archwire against the molar tube, and the other circle against the mandibular archwire stop. Both circles are then closed completely with a plier.
  154. 154. Functioning of the appliance MPA -1 Appliance slides distally along mandibular archwire and mesially along maxillary archwire upon opening. But frequent dislodgment of molar bands led Filho to develop the 2nd protraction appliance. (MPA n.o 2)
  155. 155. MPA No. 2 MPA No. 2 is made with right-angle circles in two pieces of .032" stainless steel wire. Coil of .024" stainless steel wire is slipped over one wire. Travel of each wire is limited by wire coil.
  156. 156. Improper relationship of wires is prevented by coil. Maxillary archwire has occlusally directed circles against molar tubes; mandibular archwire has occlusal circles 2-3mm distal to each cuspid. 
  157. 157. Advantages : Easily fabricated at chair side, with ordinary inexpensive wires. Do not require any special bands , crowns or wire attachments. No impression or wax bite registrations are needed. Easily inserted adjusted,removed and can be made and installed in about 30 minutes. Much smaller and thus more comfortable. Permit a greater range of motion and are less restrictive of movement
  158. 158. MPA-3 CARLOS M. COELHO FILHO,(JCO 2001) Many of the limitations of the first two MPA designs have been overcome with the development of the MPA No. 3. This version eliminates much of the archwire stress and permits a greater range of jaw motion while keeping the mandible in a protruded position.
  159. 159. Appliance construction The parts needed for the construction of the MPA No. 3 are: Two maxillary tubes of 0.045” internal diameter each about 27 mm long. Two maxillary loops of 0.040” stainless steel wire, each about 13 mm, long, with a loop bent into one end at an angle of about 130 to the horizontal. Two mandibular rods of 0.036” stainless steel each about 27 mm long.
  160. 160.
  161. 161.
  162. 162. Annealed pin bent mesial to the molar tube
  163. 163. MPA No. 3 reversed for Class III treatment, with open-coil spring between appliance tube and rod loop.
  164. 164. Advantages of MPA n.o 3 over the previous models : More comfortable for the patient Offers greater range of motion Equally simple and inexpensive but easier to place Adaptable to either class II or class III cases Can be used for mandibular positioning or dento alveolar movement Causes less breakage.
  165. 165. MPA IV The latest version, the MPA IV,** is much easier to construct and install, and much more comfortable for the patient. The MPA IV is made up of the following parts: • “T” tube • Upper molar locking pin • Mandibular rod •Mandibular archwire
  166. 166. Piece of .040" stainless steel wire is inserted into longer tube to prevent deformation while bending molar locking pin with finger pressure. Molar locking tube is then cut and annealed to make it easy to bend during installation.
  167. 167. Mandibular rod inserted into “T” tube. This fourth version seems to be as efficient as its antecedents, but is much more practical to construct, easy to manipulate, and comfortable for the patient.
  168. 168. Adjustable Bite corrector (ABC) (JCO 1995) Introduced by Richard P. West The appliance essentially consists of: A stretchable closed coil spring and internally threaded end cap nickel titanium wire in the centre lumen of the spring. The closed coil spring is made of 0.01 8” stainless steel, and will stretch to about 25% beyond its original length without permanent deformation.
  169. 169. The ABC can be used on either side of the mouth with a simple 180° rotation of the lower end cap to change it orientation. Functions similar to the Herbst and Jasper Jumper but also incorporates several useful features like a) Universal right and left b) Adjustable length and force
  170. 170. After the patient has postured forward into an improved profile with ideal overbite / overjet the point of the gauge is placed into the mesial opening of the headgear tube. The size is then read at point about 3mm below the contact between lower cuspid and first premolar using the correct appliance size ensuring optimum force delivery.
  171. 171. Nickel titanium wire is replaced and end caps unscrewed to add appliance length.
  172. 172. Repairs and emergencies :  Wire fractures are infrequent with the ABC.  Repair is easy, where the end caps are unscrewed and the coil spring or nickel titanium wire is replace with a new one from the kit.
  173. 173. The ABC can be used for upper molar anchorage control during retraction of anterior teeth for space closure. The class II “push” force of the ABC creates full time maximum anchorage at the upper molars while bringing the lower posterior teeth forward form the pull at the jig attachment.
  174. 174. The Eureka Spring (JCO 1997) Introduced by John De Vincenzo The main component of the Eureka spring is an open wound coil spring encased in plunger assembly The ram is made from a special work hardened stainless steel that has been precision machined with 3 different radii. At the attachment end the ram has either a closed or an open ring clamp that attaches directly to the archwire.
  175. 175. The essential aspects include spring module A, molar attachment tube B, push rod C, free distance D, molar attachment wire E, free distance F.
  176. 176. A triple telescoping action permits the mouth to open as wide as 60 mm before the plunger becomes disengaged. The cylinder assembly is connected to a molar tube with a an 0.032” wire that has been annealed at the anterior end. An 0.036” solid ball at the posterior end acts as a universal joint, permitting lateral and vertical movements of the cylinder. The Eureka spring comes in only 2 sizes one for extraction and one for non-extraction cases and left and the right sides are interchangeable.
  177. 177. Advantages It has esthetic acceptability because of its small size and lack of protuberances into the buccal vestibule, as it is almost invisible. Resistance to breakage: produces forces of only 140g170g at the points of attachment as compared to 220280g of Jasper Jumper. Ability to produce rapid movement : this is in spite of its low force levels because the Eureka spring continues to work even when the mouth is opened as much as 20 mm as when sleeping or when the mandible is thrust forward as far as 10 mm, in an attempt to minimize the force. Ease of installation No auxiliary archwires or extra impressions for laboratory fabrication are needed.
  178. 178. Low cost : similar in cost to the jasper jumper but less expensive than the fixed Herbst appliance. Minimal inventory requirement Optimal direction of force Delivers a push force against mandibular anterior and maxillary posterior teeth. It also has a vertical intrusive component at the maxillary molars and mandibular although this is minimal due to direct archwire attachment, rather than via auxiliary wire.
  179. 179. The churro jumper (JCO 1998) Introduced by Ridhardo Castanon, Mario S Valdes and Larry White. The Churro Jumper furnishes orthodontists with an effective and inexpensive alternative force system for the anteroposterior correction of class II and class III malocclusions. It was developed as an improvement of the MPA of Coelho. Although the churro jumper was conceived as an improvement to the MPA, it functions mere like a Jasper Jumper.
  180. 180. Construction : The Churro Jumper requires a series of 15-20 symmetrical and closely placed circles, formed in a wire size of .028" to .032". Since the Churro Jumper requires reciprocal anchorage, Generally, the largest possible edgewise archwire is the best to use. This will usually be an .018" X .025" archwire, or . 0175"X .025". Any wire smaller than these invites breakage.
  181. 181. Churro needs space to slide on the mandibular archwire, at least the first premolar brackets should be omitted. It is usually advantageous to place a buccal offset in the wire just distal to the canine bracket so that the jumper also has buccal clearance, which permits unrestricted sliding along the wire
  182. 182. The length of the jumper is determined by the distance from the distal of the mandibular canine bracket to the mesial of the headgear tube on the maxillary molar band, plus 10-12mm. This measurement is transferred to the Churro Jumper, with the coil closer to the canine bracket than to the headgear tube.
  183. 183. Mode of action : In its passive form, the churro is not flexed However when the pin is pulled forward enough to cause the jumper to bow outward the cheek, the appliance begins to exert a distal and intrusive force against the maxillary molar and a forward and intrusive force against the incisors as it attempts to straighten.
  184. 184. Unilateral / Bilateral use : This jumper can be used unilaterally in cases of class II subdivision malocclusions. The bilateral class II churro jumper is most suitable for patients who need mandibular incisors advancement. Not a very good choice for class II bimaxillary proclination cases. By reversing the attachments, the churro jumper can also be used to treat class III malocclusions.
  185. 185. Advantages : Provides a constant, indefatigable force. Can be used either unilaterally or bilaterally. Can be used in class II or class III cases. Helps maintain anchorage. Very inexpensive. Can be constructed from commonly available materials universal in size. When broken, it is easily replaced. Staff members can quickly learn how to replace an appliance.
  186. 186. Disadvantages : Restricts the mouth opening to 30-40 mm Archwire breakage is seen if larger wires not used. Patients with a low tolerance for discomfort will often break the appliance. Patients who incessantly move their mouths while chewing, talking and nervous tics will fare poorly. Its maximum effectiveness depends on a permanent dentition to retain its effect. It must be manufactured in the office.
  187. 187. The universal bite jumper (JCO 2001) Introduced by Xavier Calvez This is a fixed functional which can be used in all phases of treatment, in the mixed or permanent dentition and with removable or fixed appliances. This jumper also uses a telescoping mechanism, can also have an active coil spring if necessary.
  188. 188. Fixed appliance configuration In the mandibular arch, the sliding rod ends in a 90° hook that is fixed to the archwire.
  190. 190. Lower cantilever configuration The UBJ tubes are welded to the maxillary molar bands or crowns. . The UBJs are adjusted while mandibular movements are checked. Depending on the case, the brackets can be bonded during the same visit or a few weeks later. The advantage of this configuration is the possibility of immediate orthopedic action without waiting for dental alignment.
  191. 191. Removable splint mounting When used with removable acrylic splints, two lateral UBJs link the maxillary molar areas and the mandibular first premolar areas. They are attached to 1.2mm ball clasps, which are constructed on the working cast and then incorporated into the thermoformed splints.
  192. 192. Single median UBJ A single median UBJ can be used to link the removable splint from the middle rear area of the palate to the lingual surface of the mandibular incisor. The UBJ is attached to two transverse axles, which allow opening and lateral movements.
  193. 193. The median UBJ provides muscular therapy as it prevents the tip of the tongue from contacting the lower lip. Most children are able to speak well with this appliance, given a little time to adjust. Cheek impingement is eliminated and it is the author’s experience that the tongue is not irritated with this design.
  194. 194. Adjustments : Reactivation are made every 6 to 8 weeks by crimping 2 to 4 mm splint bushings on to the rods. Midline or asymmetrical problems can easily be treated by adjusting one side or other of the appliance.
  195. 195. 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.
  196. 196. 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
  197. 197. The saif Spring (Severable Adjustable inter maxillary force) First interarch force system developed by Armstrong In the later 1960’s and early 1970’s he introduced the Pace Spring, later termed multicoil spring and finally called Saif spring. These were first marketed by North West orthodontics, later by Unitek, and currently by Pacific coast manufacturing. They consist of two springs one inside the other with soldered loops on each end.
  198. 198. Various attachments can be placed through these loops to secure the springs to deliver either class II or class III force. They are available in 7 mm and 10 mm lengths, have an outside diameter of 3 mm, and deliver 200 to 400 gms of force. Breakage is a constant problem. Bit bulky, not very hygienic and there is some limitation to mandibular opening However large forces are generated by these springs which may account for the surprisingly rapid correction observed.
  199. 199. The Ritto Appliance The Ritto Appliance can be described as a miniaturized telescopic device with simplified intraoral application and activation
  200. 200. 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 on the mesial end.
  201. 201. The appliance is fixed onto a prepared lower arch and is activated by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance.
  202. 202. The Magnetic Telescopic Device Ritto A.K. in 1997 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.
  203. 203. 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.
  204. 204. Drawbacks: The major drawback of this appliance is the difficulty to control the force. May create discomfort and impingement problems. Is recommended only for permanent dentition.
  205. 205. ALPERN CLASS II CLOSERS It is one of 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.
  206. 206. Mandibular Corrector (JCO 1985) Introduced by Marston Jones It is a fixed functional that uses bilateral piston and plunger telescopic mechanism to reposition the mandible anteriorly and is directly attached to archwires of a multibanded fixed appliance. Connectors holding the repositioning arms are attached to the archwires distal to the lower cuspid brackets and mesial to the tubes on the terminal upper molars.
  207. 207.  The length of the repositioning arms are determined intraorally with the patient’s mandible advanced 3-4 mm.  The entire procedure can be completed at chair side in 30 minutes.  The mandible can be advanced in small increments of 2-4 mm at 4 week intervals until the incisors are in an edge to edge relationship.  Midline corrections are made by advancing the appliance more on one side.  A correction of 3-4 mm can be achieved within 6 months, an overjet of 7 to 8 mm may require 12-14 months.
  208. 208. The Horizontal Anterior Positioning (HAP) appliance Most of the appliances have anterior contact while allowing for posterior eruption. Unfortunately, the lack of posterior support has been shown to have a loading effect on the TMJ. Dr. William B. Farrar recognized the need for posterior support and modified the original Sved appliance to incorporate two posterior acrylic pads along with an anterior ramp.
  209. 209. Components of HAP appliance: A. Anterior reverse ramp. B. Sagittal screws. C. Expansion arms. D. Coffin spring. E. Locking mechanism. Anterior reverse ramp Expansion arms Sagittal screws Locking mechanism Coffin spring
  210. 210. A lower "dipod, which provides upper and lower posterior occlusal support. A posterior pad can be added to the HAP, but adjustments become more difficult and the possibility of breakage increases. The vertical dimension can be increased if necessary. The bite-opening effect allows for passive or active eruption of the posterior occlusion to help level the curve of Spee.
  211. 211. The Mandibular Anterior Repositioning Appliance(MARA) These interference’s are produced when a horizontally adjustable vertical bar attached to the buccal surface of a maxillary first molar stainless steel crown, hits a buccally protruding horizontal bar extending from the lower first molar stainless steel crown. Additional activations can be made by placing one or more shims at the mesial aspect of the horizontal bar. Advancing the mandible forward in precise increments can be achieved by insertion of selected shims of varying length.
  212. 212. Advantages over Herbst Better esthetics Problem with disengagement do not occur Breakage from lateral mandibular movements should be less. Can be used concurrently with full edgewise orthodontic appliance. This Eliminates the need for a 2 phase treatment.  Can maintain the achieved orthopedic results, since the appliance can continue in a non activated manner. 
  213. 213. Disadvantages Temporary stainless steel crowns needed on all first molars. Some increase in anterior facial height results from the placement of these crows. Fabrication only available at one commercial laboratory. The posterior and buccal location of the guide planes may cause loosening of the stainless steel crowns or breakage of the mandibular protruding horizontal bar.
  214. 214. Pangrazio-Kulbersh V, Berger JL, Chermak DS, Kaczynski R, Simon ES, Haerian A,Ajo 2003,. The aim of this study was to investigate the MARA's dental and skeletal effects on anterior, posterior, and vertical changes in 30 Class II patients. The treatment group consisted of 12 boys with an average age of 11.2 years and 18 girls with an average age of 11.3 years. A pretreatment cephalometric radiograph was taken 2 weeks before treatment, and a posttreatment cephalometric radiograph was taken 6 weeks after removal of the MARA, with an average treatment time of 10.7 months. The mean and standard deviation were calculated for each cephalometric variable, and Student t tests were performed to determine the statistical significance of the changes.
  215. 215. The results of the study showed that the MARA produced measurable treatment effects on the skeletal and dental elements of the craniofacial complex. These effects included a considerable distalization of the maxillary molar, a measurable forward movement of the mandibular molar and incisor, a significant increase in mandibular length, and an increase in posterior face height. The effects of the MARA treatment were then compared with those of the Herbst and Frankel appliances. The treatment results of the MARA were very similar to those produced by the Herbst appliance but with less headgear effect on the maxilla and less mandibular incisor proclination than observed in the Herbst treatment group
  216. 216. Functional Mandibular Advancer Kinzinger,Ostheimer, Diederich,2002 It has a propulsive mechanism that resembles the Mandibular anterior repositioning appliance, but differs in its mode of action and intraoral activation. It relies on the principle of inclined planes that are placed in the buccal corridor spaces that will not hinder swallowing or articulation. The protrusion guide pins are fitted to the upper portion of the apliance at a 60 degree angle to horizontal, ensuring active, forward mandibular guidance during even partial jaw closure.
  217. 217. Reactivation in the sagittal plane is done simply by moving the guide pins to a more forward threaded support sleeve. This gradual activation allows patients particularly adults to adjust to the appliance. Kinzinger, Diederich JCO 2005 reports the use of FMA in a 16 year old male with Class II div2 and for just 3 months the patient was able to protrude the mandible significantly forward from the therapeutic position.
  218. 218. Advancement in therapeutic positions Maximum protrusion of mandible after 3 months
  219. 219. The Biopedic Designed and introduced by Jay Collins in 1997 (GAC International) It consists of buccal attachments soldered to maxillary and mandibular molar crowns. The attachments contain a standard edgewise tube and a large 0.070 inch molar tube. Large rods pass through these tubes. The mandibular rod inserts from the mesial of the molar tube and is fixed at the distal by a screw clamp. By moving the rod mesially the appliance is activated.
  220. 220. This short maxillary rod is inserted screw at the mesial of the maxillary first molar. The two rods are connected by a rigid shaft and have pivotal region at their ends. Although, it appears that there would be limitation of mandibular opening, it is not so. The design works more in harmony with the arc of mandibular opening.
  221. 221. Advantages Can be used concurrently with banded treatment. Esthetic benefit Capability of adjusting the amount of protrusive activation. Disadvantages Potential for more breakage and loose crowns Greater cost. Need for crowns on molars
  222. 222. The Klapper Superspring II Introduced by Lewis Klapper in 1997, for correction of class II malocclusions. On first glance, it resembles a Jasper Jumper with a substitution of a cable for the coil spring. In 1998 the cable was wrapped with a coil and the Klapper superspring II was the result. Only two sizes are required (left and right sides are not interchangeable) and breakage is less frequent. However it differs significantly from the Jasper Jumper at the molar attachment.
  223. 223. The SUPERspring II is a flexible spring element that attaches between the maxillary molar and the mandibular canine. It is designed to rest in the vestibule, making it impervious to occlusal damage and allowing for good hygiene. Only minor adjustments are needed for patient comfort, without any impingement on soft tissues.
  224. 224. Disadvantages Requirement of a special molar tube Lack of adaptability to correct class III conditions Limitation to maximal opening Potential injury to the patient if breakage occurs and the rigid molar attachment forces the broken portion into the soft tissues.
  225. 225. Forsus Fatigue resistant Device This is an interarch push spring which produces about 200g of force when fully compressed. The distal end of the FRD`s push rod inserts into the telescopic cylinder and a hook on the mesial end is crimped directly to the archwire near the canine or premolar brackets.
  226. 226. The push rod has a built in stop that compresses the spring when the patients mouth closes. The spring is then transferred to the maxillary molars using the mandibular arch as the anchorage unit. The L-pin is inserted in the eyelet of the telescoping spring and is threaded through the molar headgear tube from distal to mesial and cinhed,leaving 2mm slack. The mesial hook is looped over the mandibular arch wire and crimped shut.
  227. 227. Advantages: It does not require time-consuming and expensive lab work or the use of stainless steel crowns. It produces consistent treatment results in a predictable amount of time, without depending on patient cooperation. It can deliver an orthopedic effect to both jaws or more of a dentoalveolar effect. It can be activated more on one side than on the other, so it excels at correcting midline deviations.
  228. 228. Heinig N, Goz G 2001 reported the use of ` Forsus spring over a period of 4 months to treat 13 patients with an average age of 14.2 years with Class II malocclusion. RESULTS: lateral cephalograms showed that dental effects accounted for 66% of the sagittal correction. The sagittal occlusal relations were improved by approximately 3/4 of a cusp width to the mesial on both the right and left side as a result of distal movement of the upper molars and mesial movement of the lower molars. Retrusion of the upper and protrusion of the lower incisors reduced the overjet by 4.6 mm. Intrusion and protrusion of the lower incisors reduced the overbite by 1.2 mm.
  229. 229. The occlusal plane was rotated by 4.2 degrees in clockwise direction as a result of intruding the lower incisors and the upper molars. The maxillary and mandibular arches were expanded at the front and rear during treatment. Evaluation of a questionnaire filled in by the patients after 2 months of treatment showed that approximately half of them had experienced difficulties in brushing their teeth. The main problem, however, was the restriction experienced in the ability to yawn. Overall, two thirds of the adolescents found the Forsus spring better than the appliance previously used to correct their Class II malocclusion, such as headgear, activator or Class II elastics. CONCLUSION: The Forsus spring has stood the test in clinical application. It is a good supplement to the Class II appliance systems already available.
  230. 230. William Wogt JCO June 2006 reports a case where a 12 year old male with class II division 1 and moderate overjet of 7mm was corrected with the Fatigue resistant device in 6months after which it was used as an anchorage unit for the retraction of the maxillary anterior segment.
  231. 231. Conclusion : Fixed functional appliances form an useful addition to the clinician’s orthodontic armamentarium. But many of these appliances need further studies to substantiate the claims made by their respective originators. With this in mind, clinicians must take great care in selecting the right patient and also pay attention to every detail in the manipulation, to attain successful results with these appliances.
  232. 232. References: 1. Larry.W. White :Current Herbst Appliance Therapy:JCO 1997,May(296 - 309) 2. Arji George, V. Surendra Shetty, SN Rao & Ashima Valiathan: Effect of Herbst appliance on Orofacial musclature. Journal of Indian Orthodontic Society. 1993; 4(3): 93-99. 3. S.Jay Bowman: Jasper Jumper in Class II correction. A case report. JIOS 2001;34:101105.
  233. 233. 4. 5. Kinzinger, Oestheimer, Deidrich: Development of a new fixed functional appliance for treatment of skeletal class II malocclusion.J. Orofac Orthop 2002 63:384-399 Ken Hansen: Treatment and posttreatment effects of the herbst appliance on the dental arches and arch relationships. Semin Orthod 2003 March,page 67-73
  234. 234. 6. Kinzinger, Deidrich: Bite jumping with the functional mandibular Advancer, JCO December 2005 page 696-700 7. Carlos Martins Coelho Filho,Mandibular Protraction Appliances for Class II Treatment Volume 1995 May(319 - 336) 8. Klapper L, The Super spring II: A new appliance for non-compliant class II patients. J. Clin. Orthod. 1999; 33: 50-54.
  235. 235. 9. Sabine Ruf, Hans Pancherz: When is the ideal period for Herbst therapy-Early or Late? Semin Orthod 2003,March,page 47-56 10. Mc Namara, Brudon, Kokich, Orthodontics and Dentofacial Orthopaedics, 2001 page 285,333 11. Cope J.B., Buschang P., Cope D.D., Parker J., Blackwood H.O. Quantitative evolution of craniofacial changes with Jasper Jumper Therapy. Angle Othod. 1994; 64 (2): 113 – 122.
  236. 236. 12. Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod. 1996; 30: 552 – 58. 13. Jasper J.J., McNamara J. The correction of interarch malocclusions using a fixed force module. Am. J. Orthod. Dentofac. Orthop. 1995; 108: 641-50. 14. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation. Am. J. Orthod. 1979; 76: 423-442
  237. 237. 15. Heinig N, Goz G: Clinical application and effects of the Forsus spring. A study of a new Herbst hybrid, J Orofac Orthop. 2001 Nov;62(6):436-50. 16. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. Am. J. Orthod. 1982; 87: 1-20. 17. Pancherz H. The Herbst appliance – Its biological effects and clinical use. Am. J. Orthod. 1985; 87: 1-20.
  238. 238. 18. Erdogan E. Asymmetric Application of the Jasper Jumper in the correction of midline discrepancies. J. Clin. Orthod. 1998; 32: 170 – 80. 19. Sabine Ruf:Short and Longterm effects of the Herbst appliance onTemporomandibular joint function,Semin Orthod 2003 March page 74-86. 20. Cash R.G. Case Report: adult nonextraction treatment with a Jasper Jumper. J. Clin. Orthod. 1991; 25: 43-7..
  239. 239. 21. Castañon R., Valdes M., White L.W. Clinical use of the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 – 45. 22. Blackwood H.O. Clinical Management with the Jasper Jumper. J. Clin. Orthod. 1991; 25: 755-60 23. Haegglund P. The Swedish-Style Integrated Herbst Appliance. J. Clin. Orthod. 1997; 31: 378 – 390.
  240. 240. 24. Pangrazio-Kulbersh V, Berger JL, Chermak DS, Kaczynski R, Simon ES, Haerian A:Treatment effects of the mandibular anterior repositioning appliance on patients with Class II malocclusion. Am J Orthod Dentofacial Orthop. 2003 Mar;123(3):286-95 25. Calvez X. The universal bite jumper. J. Clinical Orthod. 1998; 32: 493-499. 26. Filho C.M. Mandibular Protraction Appliances for Class II Treatment. J. Clin. Orthod. 1995; 29: 319 – 336.
  241. 241. 27. Hans Pancherz :History, Background, and Development of the Herbst Appliance, Semin Orthod 2003,March page3-11 28. Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin. Orthod. 1997; 31: 92 – 102. 29. Filho C.M. The Mandibular Protraction Appliance III. J. Clin. Orthod. 1998; 32: 379384
  242. 242. 30. Mandeep sood, k.Sadashiva Shetty: Functional therapy- Is it worth the effort? JIOS1994 October page 128-136. 31. Aidar LA, Abrahao M,Yamashita HK, Dominguez GC:Herbst appliance therapy and temporomandibular joint disc position- A prospective longitudinal magnetic resonance imaging study. Am J Orthod Dentofacial Orthop. 2006 Apr;129(4):486-96. 32. William Vogt:The Forsus Fatigue Resistant Device, JCO 2006 June page 368-376
  243. 243. Thank you Leader in continuing dental education