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


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

  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Contents       Introduction 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 , 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
  4. 4.         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
  5. 5.           The Twin force bite corrector Alpern class II closers Mandibular Corrector The Mandibular Anterior Repositioning Appliance(MARA) Functional Mandibular Advancer The Biopedic appliance The Klapper Superspring II appliance Forsus Fatigue resistant Device CONCLUSION REFERENCES
  6. 6. INTRODUCTION   Functional appliances are considered to be primarily orthopedic tools to influence the facial skeleton of the growing child in the condylar and sutural areas. A functional appliance by definition is an appliance that produces all or part of its effect by altering the position of the mandible.
  7. 7.   These appliances also exert orthodontic effects on the dentoalveolar area. The uniqueness lies in their mode of force application. Functional orthopedic treatment seeks to correct malocclusions and harmonize the shape of the dental arch and oro-facial functions.
  8. 8. Removable functional appliances have been there over the years and clinically accepted. But they have some disadvantages: •normally very large in size, •have unstable fixation, •cause discomfort, •lack tactile sensibility, •exert pressure on the mucosa, reduce space for the tongue, cause difficulties in deglutition and speech often affect aesthetic appearance. •the alteration in the mandibular posture creates added difficulties.
  9. 9.       Fixed functional appliances have some advantages over removable systems: They are designed to be used 24 hour a day They are smaller in size permitting better adaptation to functions Reduce the need for patient compliance As they are fixed on the upper &lower arches, transmit force directly to the teeth through support system Thus fixed functional appliances came into existence. They are also known as non compliance class II correctors.
  10. 10. Classification  According to the forces produced: • Appliances producing pushing forces • Appliances producing pulling forces
  11. 11. Appliances producing Pushing forces: • These appliances deliver a pushing force vector forcing the attachment points of the appliance away from one another.
  12. 12. Rigid: 1. Herbst Appliance and its modifications. 2. Mandibular protraction appliance 3. Ritto appliance 4. Biopedic appliance 5. Mandibular anterior repositioning appliance 6. Functional Mandibular Advancer
  13. 13. Flexible: • • • • • • • • Jasper Jumper Scandee tubular jumper Flex developer Amoric torsion coils Churro Jumper Adjustable Bite Corrector Klapper Super Spring II Forsus nitinol flat spring
  14. 14. Hybrid : • • • • Eureka spring Forsus fatigue resistant device Twin force bite corrector Sabbagh universal spring
  15. 15. Appliances Producing Pulling Force  These appliances act as a substitute for elastic and create a pulling force vector between the points of attachment: • SAIF (Severable Adjustable intermaxillary Force) spring. • Alpern class II closers. • The caliberated force module.
  16. 16. HERBST APPLIANCE Norris M. Langford JR. The Herbst Appliance. JCO, Vol 1981, Aug, 558-561.. Larry W. White. Current Herbst Appliance Therapy. JCO, Vol. 1994 May, 296-309.
  17. 17. History   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.) Hans Pancherz :History, Background, and Development of the Herbst Appliance, Semin Orthod 2003,March page3-11
  18. 18.   Herbst presented his appliance (original banded design) for the first time at the 5th international Dental Congress in Berlin in 1909. 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.
  19. 19. 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.
  20. 20.  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.
  21. 21.  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.
  22. 22. 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.
  23. 23.  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)
  24. 24. 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 (MP3FG) had the greatest amount of condylar growth.
  25. 25.  Ruf, Pancherz March 2003, the ideal period for the herbst appliance treatment is in the 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. Sabine Ruf, Hans Pancherz: When is the ideal period for Herbst therapy-Early or Late? Semin Orthod 2003,March, 47-56
  26. 26.  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).
  27. 27.  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).
  28. 28. 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).
  29. 29.  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.
  30. 30.  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.
  31. 31.  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.
  32. 32. Anchorage forms of the Herbst appliance
  33. 33. 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.
  34. 34.  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.
  35. 35. 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.
  36. 36. 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.
  37. 37. 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 1.
  38. 38. 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.
  39. 39.       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.
  40. 40. 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.
  41. 41.  Since 1995, cast chrome-cobalt 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.
  42. 42.  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.
  43. 43. 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.
  44. 44. 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.
  45. 45. The cast splint herbst      The bands are replaced by splints, cast from cobaltchromium alloy are 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
  46. 46. The bonded Herbst appliance (1982)  The bonded Herbst appliance eventually evolved into the acrylic splint Herbst appliance  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 Raymond P. Howe. The Bonded Herbst Appliance. JCO, Vol. 1982 Oct. 663-667.
  47. 47.  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
  48. 48. Cantileverd Herbst appliance  This was a design given by Larry W. White, 1994.  Buccal cantilever wire is made by doubling .045" wire and soldering the two strands together. Larry.W. White :Current Herbst Appliance Therapy:JCO 1997,May(296 - 309) 
  49. 49.  Advantage : • This design is particularly useful when mandibular bicuspids are absent or the primary molars cannot withstand functional forces.
  50. 50. 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. Philip Goodman, Paul Mckenna. Modified Herbst Appliance for the Mixed Dentition. JCO, Vol. 1985 Nov. 811-814.
  51. 51. 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.  The deciduous first and second molars are free to exfoliate through the framework
  52. 52. 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. Tarek Zreik. A Fixed-Removable Herbst Appliance. JCO. Vol. 1994 Apr. 246-248.
  53. 53.   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.
  54. 54. Edgewise Herbst Appliance This design was given by Terry Dischinger, 1995
  55. 55.  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.
  56. 56. Herbst with Mandibular Advancement Locking Unit (MALU) 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.
  57. 57. 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.
  58. 58. 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 cantilever-type Herbst. Instead of a screw attachment, it has a balljoint connector, and it needs no retaining springs. Robert A. Miller. The Flip-Lock Herbst Appliance. JCO, Vol. 1996, Oct, 552-558.
  59. 59.  The first generation was made from a dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint attachment
  60. 60.  In the second generation, the plastic was replaced with metal
  61. 61.   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
  62. 62. End of rod is crimped onto mandibular ball. Advantages : Less irritation Reduces the number of moving parts that can lead to breakage or failure
  64. 64. SAGITTAL CHANGES Skeletal: I. • 1. Restrains maxillary growth and decrease of SNA angle. • 2. Increases mandibular length This finding is in agreement with several bite jumping experiments in growing monkeys and rats.
  65. 65.   2. 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.  Kurt Popowich, Brian Nebbe, Paul W. Major. Effect of Herbst treatment on temporomandibular joint morphology : A systematic literature review. AJO,Vol.123, No.4, 2003 Apr. 388-394.
  66. 66. Animal studies  Peterson and Mc Namara :  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. Peterson and McNamara (semin orthodontics 2003)
  67. 67.  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.  • Significant bone resorption on the posterior surface of the postglenoid spine was noted.
  68. 68.  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.
  69. 69. CLINICAL STUDIES:  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. 
  70. 70.  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.
  71. 71. Ruf and Pancherz : 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 et al (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. Sabine Ruf:Short and Longterm effects of the Herbst appliance onTemporomandibular joint function,Semin Orthod 2003 March page 74-86.
  72. 72. 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.
  73. 73. 1. Mandibular teeth are moved anteriorly  Proclination of lower anteriors. Mandibular incisors proclined on an average of 6.6° during 6 months
  74. 74. 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. 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
  75. 75. 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.
  76. 76.  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. Arch perimeter changes are, however, of a temporary nature because settling of the teeth during the immediate post treatment period. 
  77. 77. 6. Arch width  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.
  78. 78. b) Vertical changes   Dental Skeletal
  79. 79.  Dental: In Class II malocclusions with deep bites, overbite may be reduced significantly by Herbst therapy, 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.
  80. 80.  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 .
  81. 81. 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. Skeletal alterations will be minimal. More of dentoalveolar changes. Increase risk of developing dual bite. 1. 2. 3.
  82. 82.  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.
  83. 83.    For mandibular fracture (particularly ramus) patients after surgery For prevention of bruxism For diseases of the TMJ
  84. 84. 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
  85. 85.  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.
  86. 86. 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.
  87. 87.  Attachment to the main arch wire :  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” ).
  88. 88.  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.
  89. 89. 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.
  90. 90. 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.
  91. 91. 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 facebow 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.
  92. 92. 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.
  93. 93. 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.
  94. 94. 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.
  95. 95.  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.    
  96. 96. 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.
  97. 97.  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.
  98. 98. 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. Raiph M. Clements, Alex Jacobson. The MARS appliance. AJO-DO, Vol. 1982 Dec. 445-455.
  99. 99. • • 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.
  100. 100. • 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.
  101. 101.  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.
  102. 102. Mandibular Protraction appliances :   This appliance was developed by Carlos Martin Coelho Filho 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. Carlos Martins Coelho Filho. Mandibular Protraction Appliances for Class II Treatment. JCO, 1995, May; 319-336.
  103. 103.    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.
  104. 104. 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)
  105. 105. MPA No. 2 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. Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin. Orthod. 1997; 31: 92 – 102.
  106. 106.  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
  107. 107. MPA-3    CARLOS M. COELHO FILHO 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. Carlos M. Coelho Filho. The Mandibular Protraction Appliance No.3. JCO, Volume 1998, June; 379-384.
  108. 108. 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.
  109. 109. MPA IV      The latest version, the MPA IV, is made up of the following parts: • “T” tube • Upper molar locking pin • Mandibular rod •Mandibular archwire Carlos M. Coelho Filho. Mandibular Protraction Appliance IV. JCO, Vol. 35, Jan. 2001, 1824.
  110. 110. 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.
  111. 111. Adjustable Bite corrector (ABC)  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. Richard P. West. The Adjustable Bite Corrector. JCO, Vol. 1995 Oct. 650-657.
  112. 112. 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
  113. 113.   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.
  114. 114. The Eureka Spring     Introduced by John DeVincenzo 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. John Devincenzo. The Eureka Spring : A New Interarch Force Delivery System. JCO, Vol. 1997, Jul, 454-467.
  115. 115. 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 140g-170g at the points of attachment as compared to 220-280g 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.
  116. 116. The churro jumper 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. Castañon R., Valdes M., White L.W. Clinical use of the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 – 45.
  117. 117.  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
  118. 118. 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.
  119. 119. THE AMORIC TORSION COILS • This appliance is made up of two springs, one of which slides inside the other. • They are intermaxillary springs without covering and have a simplified application system of rings on the ends. • These rings are fixed to the upper and lower arches with double ligatures. • The force exerted by the appliance is variable in accordance with the fixing points on the arch
  120. 120. The universal bite jumper  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. Xavier Calvez. The Universal Bite Jumper. JCO. Vol. 1998, Aug. 493-500.
  121. 121.  Its like a Herbst but is smaller in size and more versatile  An active coil spring can be added if necessary It is fitted in the patient’s mouth and cut to the appropriate length for the desired mandibular advancement. Activations are made by crimping 2-4 mm splint bushings onto the rods. UBJs with nickel titanium coil springs do not need to be reactivated.  
  122. 122. 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.
  123. 123. 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.  They consist of two springs one inside the other with soldered loops on each end.
  124. 124.  Various attachments can be placed through these loops to secure the springs to deliver either class II or class III 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.
  125. 125. The Ritto Appliance  The Ritto Appliance can be described as a miniaturized telescopic device with simplified intraoral application and activation
  126. 126.  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.
  127. 127. The Magnetic Telescopic Device  Ritto A.K.  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.
  128. 128. 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.
  129. 129. 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.
  130. 130. 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.
  131. 131. The Mandibular Anterior Repositioning Appliance(MARA) Is probably the most recent fixed functional appliance to become commercially available In the essence, it is an ingenious way to encourage patients to keep their mandibles thrust forward to avoid intentionally created, buccally placed occlusal interference’s. 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.
  132. 132.  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.    
  133. 133.   A study was done by Pangrazio-Kulbersh et al(AJO 2003) which showed that the MARA produced measurable treatment effects on the skeletal and dental elements of the craniofacial complex. 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
  134. 134. Functional Mandibular Advancer     Kinzinger,Ostheimer, Diederich 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. Kinzinger, Deidrich: Bite jumping with the functional mandibular Advancer, JCO December 2005 page 696-700
  135. 135.  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 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.
  136. 136. Advancement in therapeutic positions Maximum protrusion of mandible after 3 months
  137. 137. 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.
  138. 138.  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.
  139. 139. 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. Lewis Klapper. The SUPER spring II : A New Appliance for Non-Complaint Class II Patients. JCO, 1999, 33, No.1, 50-54.
  140. 140. 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. William Vogt:The Forsus Fatigue Resistant Device, JCO 2006 June page 368-376
  141. 141.  The push rod has a built in stop that compresses the spring when the patients mouth closes. The force 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.
  142. 142.  Another device from the same company is the FORSUS NITINOL FLAT SPRING which presents a Nitinol flat wire instead of the coil.  The appliance’s flat surface is more esthetically acceptable and it offers more comfort.  The Forsus Nitinol Flat Spring is slim, flat and made of SuperElastic Nitinol. Nitinol is always at work, delivering consistent forces. Force levels remain constant from the initial setup to the time of removal. The result is faster, more efficient treatment.
  143. 143. `  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. 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.
  144. 144.  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.
  145. 145.  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 successfully with the Fatigue resistant device in 6months after which it was used as an anchorage unit for the retraction of the maxillary anterior segment.
  146. 146. 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.
  147. 147. References:       Orthodontic treatment of the class II noncompliant patient – Moscos A. Papadopoulos Dentofacial Orthopedics With Functional Appliances – Graber , Rakosi , Petrovic. Orthodontics And Dentofacial Orthopedics – Mc Namara , Brudon , Kokich. Contemporary Orthodontics – Proffit , Fields , Sarver. Orthodontics , Current Principles And Techniques – Graber , Vanarsdall , Vig Larry.W. White :Current Herbst Appliance Therapy:JCO 1997,May(296 - 309)
  148. 148. 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 Kinzinger, Deidrich: Bite jumping with the functional mandibular Advancer, JCO December 2005 page 696-700 Hans Pancherz :History, Background, and Development of the Herbst Appliance, Semin Orthod 2003,March page3-11 Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin. Orthod. 1997; 31: 92 – 102.
  149. 149. William Vogt:The Forsus Fatigue Resistant Device, JCO 2006 June page 368-376 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. Sabine Ruf:Short and Longterm effects of the Herbst appliance onTemporomandibular joint function,Semin Orthod 2003 March page 74-86. Castañon R., Valdes M., White L.W. Clinical use of the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 – 45. Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod. 1996; 30: 552 – 58.
  150. 150. Sabine Ruf, Hans Pancherz: When is the ideal period for Herbst therapy-Early or Late? Semin Orthod 2003,March,page 47-56 Carlos Martins Coelho Filho. Mandibular Protraction Appliances for Class II Treatment. JCO, 1995, May; 319-336. Carlos M. Coelho Filho. The Mandibular Protraction Appliance No.3. JCO, Volume 1998, June; 379-384. Carlos M. Coelho Filho. Mandibular Protraction Appliance IV. JCO, Vol. 35, Jan. 2001, 18-24. ET JE Sanden, Hans Pancherz, Ken Hansen. Complications during Herbst Appliance Treatment. JCO, Vol. 38, March, 2004, No.3, 130-133.
  151. 151. Kurt Popowich, Brian Nebbe, Paul W. Major. Effect of Herbst treatment on temporomandibular joint morphology : A systematic literature review. AJO,Vol.123, No.4, 2003 Apr. 388-394. Larry W. White. Current Herbst Appliance Therapy. JCO, Vol. 1994 May, 296-309. Lewis Klapper. The SUPER spring II : A New Appliance for Non-Complaint Class II Patients. JCO, 1999, 33, No.1, 50-54. Norris M. Langford JR. The Herbst Appliance. JCO, Vol 1981, Aug, 558-561.. Philip Goodman, Paul Mckenna. Modified Herbst Appliance for the Mixed Dentition. JCO, Vol. 1985 Nov. 811-814.
  152. 152. John Devincenzo. The Eureka Spring : A New Interarch Force Delivery System. JCO, Vol. 1997, Jul, 454-467. Raymond P. Howe. The Bonded Herbst Appliance. JCO, Vol. 1982 Oct. 663-667. Raiph M. Clements, Alex Jacobson. The MARS appliance. Report of a case. AJO-DO, Vol. 1982 Dec. 445-455. Richard P. West. The Adjustable Bite Corrector. JCO, Vol. 1995 Oct. 650-657. Robert A. Miller. The Flip-Lock Herbst Appliance. JCO, Vol. 1996, Oct, 552-558. Tarek Zreik. A Fixed-Removable Herbst Appliance. JCO. Vol. 1994 Apr. 246-248. Xavier Calvez. The Universal Bite Jumper. JCO. Vol. 1998, Aug. 493-500.
  153. 153. Thank you Leader in continuing dental education