Recent advancements in fixed functional appliances /certified fixed orthodontic courses by Indian dental academy


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Recent advancements in fixed functional appliances /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Recent advancements in fixed functional appliances A Functional appliance by definition is one that changes the posture of the mandible, holding it open or open and forward. Pressures created by the stretch of the muscles and soft tissues are transmitted to the dental and skeletal structures ,moving teeth and modifying growth
  4. 4. • Removable functional appliances are normally very large in size, have unstable fixation, cause discomfort, lack tactile sensibility, exert pressure on the mucous (encouraging gingivitis), reduce space for the tongue, cause difficulties in deglutition and speech and very often affect aesthetic appearance. The alteration in the mandibular posture creates added difficulties. These adverse effects make the adaptation and acceptance of these appliances more difficult.
  5. 5. • Fixed functional systems have some advantages over removable systems. They are designed to be used 24 hours a day, which means that there is a continuous stimulus for mandibular growth. • They are smaller in size permitting better adaptation to functions such as a mastication, swallowing, speech and breathing. • Fixed functional appliances are usually described as non-compliance Class II devices, which are able to treat Class II malocclusions successfully, while reducing the need for patient co-operation and overall treatment time. It is possible to treat this type of malocclusion with minimal effort.
  6. 6. • Fixed functional appliances are normally known as "non-compliance Class II correctors" giving a false idea about the co-operation necessary during treatment. In reality, when we compare them to removable appliances, we can clearly recognize fixed appliances as non-compliance devices. However, for treatment to be successful, good co-operation is always necessary, especially if skeletal modifications instead of dento alveolar compensation are desired.
  7. 7. Functional-appliance therapy can achieve correction of Class II malocclusion through the following factors: • Dentoalveolar changes • Restriction of forward growth of the mid face • Stimulation of mandibular growth beyond that which would normally occur in growing children, • Redirection of condylar growth from an upward and forward–directed growth to a posterior direction • Deflection of ramal form, • Horizontal expression of mandibular growth from downward and forward to horizontal. • Changes in neuromuscular anatomy and function that would induce bone remodeling, • Adaptive changes in glenoid fossa location to a more anterior and vertical position.
  8. 8. Mode of action of functional appliance Regardless of various functional appliances, the following casual chain is involved • Functional appliance • Increased contractile activity of LPM • Intensification of the repetitive activity of the retrodiscal pad (bilaminar zone)
  9. 9. Increase in growth stimulating factors • Enhancement of local mediators • Reduction of local regulators (factors having negative feed back effects on cell multiplication rate Change in condylar trabecular orientation • Additional growth of the condylar cartilage • Additional sub periosteal ossification of the posterior border of the mandible • Supplementary lengthening of the mandible
  10. 10. One step versus stepwise advancement using fixed functional appliances • Rabie et al’s work on experimental rats showed that during the first advancement ,bone formation in the condyle and the glenoid fossa was less than that of the 1 step advancement .In response to the second advancement ,new bone formation in the condyle and the glenoid fossa was significantly greater when compared with single advancement with a maximum increase of 50% and 100% respectively. Moreover the higher level of bone formation in the stepwise advancement is maintained
  11. 11. • The results of the present study also indicate that the stepwise advancement produces a much more prominent effect on the growth of the glenoid fossa when compared with the condyle. The amount of increase in bone formation in the glenoid fossa in response to stepwise advancement when compared with single advancement was 2 times more than that expressed in the condyle.
  12. 12. • An explanation of these results could relate to the age of the animals used as reported by Woodside and coworkers they showed that in older primates there was a more pronounced response in the glenoid fossa than the condyle in mandibular advancement, whereas in the younger primates there was a more pronounced response in the condyle. Additional explanation of the enhanced response of the glenoid fossa was found to be caused by the amount of the blood vessels recruited in the glenoid fossa in response to advancement."
  13. 13. • Recently, Rabie et al reported that mechanical strain caused by forward mandibular positioning stimulated the cells of the chondroid layer in the glenoid fossa to secrete vascular endothelial growth factor (VEGF), which was 220% more than its levels during natural growth." VEGF enhances the invasion of new blood vessels and the perivascular connective tissues surrounding these new blood vessels are repository sites of mesenchymal cells. These cells could in turn replenish the population size of osteoprogenitor mesenchymal cells.
  14. 14. • VEGF also stimulates the vascular endothelial cells to secrete growth factors and cytokines that influence the differentiation of mesenchymal cells to enter the osteogenic pathway and engage in bone synthesis."' • On the other hand, the amount of VEGF expressed in the condyle in response to mandibular advancement was only 48% more than natural growth. Therefore, it is conceivable that the significant difference in the response between the glenoid fossa and the condyle is because of the ability of both tissues to vascularize to a different degree in response to advancement
  15. 15. The ideal period for therapy • With respect to the maximum mandibular growth stimulation and long term stability of the treatment, the ideal period is in the permanent dentition at or just after the pubertal peak of growth corresponding to the skeletal maturity stages FG to H of the MP3 (implying to the pre capping and pre union stages of the epiphysis and metaphysis)
  16. 16. Fixed functional appliances can be classified as either • Flexible (Flexible Fixed Functional Appliance - FFFA) • Rigid (Rigid Fixed Functional Appliance RFFA). • Hybrid appliances
  17. 17. • Flexible fixed functional appliances (FFFA) can be described as an inter-maxillary torsion coils, or fixed springs. Elasticity and flexibility are the main characteristics of flexible appliances. They allow great freedom of movement of the mandible. Lateral movements can be carried out with ease.
  18. 18. • Draw backs are the propensity with which fractures can occur both in the appliance itself (mainly in areas that have more acute angles) and in the support system (mainly in the lower arch). The appliance tend to produce fatigue in the springs. Another drawback is the tendency of the patient to chew on the appliance, possibly contributing to breakage or damage. While it is not possible for the patient to completely open his mouth, depending on the way the system is fixed onto the lower arch, good opening can be achieved. • opening the mouths too widely could result in breakage. Also, they are not very aesthetic appliances. When the curvature of the spring is accentuated, some protuberances can appear in the cheeks.
  19. 19. • These appliances are expensive, therefore, a system that allows the replacement of some of its components can reduce the cost of treatment. This leads to another disadvantage: the inventory of material that must be kept. Almost all are sold in kits of various sizes which contain components for both the left and right side. It is not always possible to treat a patient with only one size making it necessary to replace it with a larger size. Once again, this increases cost.
  20. 20. • The type of the force exercised by FFFAs is continuous and elastic in nature. The amount of force is variable in accordance with the skeletal pattern of the patient, the type of movement desired and the size of the cusps. Normally, in brachyfacial cases, due to their strong musculature, it is necessary to use more force (greater activation) than in Dolichofacial cases. The height of the dental cusps is a factor to bear in mind when treating with FFFAs. If the patient has high cusps with good intercuspation, it will be necessary to exert greater activation on the spring. If the large size of the cusps is linked to a brachyfacial skeletal pattern with strong musculature, we can predict a difficult clinical scenario and the appliance will be prone to fracture.
  21. 21. • If an advance of the mandible is required as when treating a retro mandibular case, the force exerted has to be greater than that used when only dental movement is desired to distalize the upper molar and procline the lower incisors. If the goal of the treatment is to achieve dentoalveolar movements, the appliance should be activated minimally by placing a slight bow in the force module. To maximize the dentoalveolar movements in the upper arch and minimize any loss of anchorage in the lower, the upper arch wire is not tied back.
  22. 22. • FFFA produces a "headgear" effect on the maxillary dentition due to the intrusive force applied to the maxillary posterior segments and produces an anterior intrusive force on the lower dentition. It can be used to obtain maximum anchorage, holding upper molars back as the upper incisors are retracted
  23. 23. • Due to the intrusive force on the upper molars, a posterior open bite is common as well as posterior expansion due to the deflected force module. Another unwanted common movement is the tendency for the lower molar to rotate mesio buccally, causing a mild posterior cross bite especially when the second molars have not been banded. Some buccal expansion in the upper and lower arches is to be expected, and placing bands on the second molars will aid final alignment. Placing a transpalatal or lingual arch during the force activation stage will help control unwanted buccal expansion of both arches. Loss of occlusion adds to instability, especially in the transverse dimension.
  24. 24. • The most unwanted dental movement is Proclination of lower incisors. To avoid this effect, good anchorage preparation should be carried out. However, in a brachyfacial pattern with strong musculature this movement would be expected. To increase anchorage to avoid unwanted dental movements, various additional systems can be used, such as a transpalatal bar, lingual arches or lower incisor brackets with lingual torque. • It is advantageous to start the treatment in adolescent patients when the majority of permanent teeth have erupted and 12-year molars can be banded. FFFAs are not recommended in mixed dentition, especially late mixed dentition to avoid unwanted dental movements
  25. 25. • Proper anchorage preparation is critical to achieving successful results. It is necessary to align and level arches before placing the final wire and activating the force module. A .017" x .025" or .018" x .025 stainless steel arch wire should be placed before inserting the FFFA. By fully engaging the brackets in both arches, especially the lower, anchorage is maintained during the activation of the force module, preventing unwanted mesial movement of the lower incisors and distal movement of the uppers. When proclining the lower incisors is desired as in Class II division 2 it may be advantageous to use a .016" x .022" stainless steel arch wire as a final wire.
  26. 26. • All FFFAs allow the patient to close in centric relation. • When the patient closes in centric relation, the contour of the bow should be significantly increased. By slightly over activating the appliance in centric relation, the patient will automatically position the mandible forward. This is a natural response to decrease the force module and alleviate discomfort. The upper arch wire should be cinched to increase anchorage and minimize dentoalveolar movements.
  27. 27. JASPER JUMPER • It is the most successful and widely used inter arch force delivery system. • This inter arch appliance uses a push force than a pull force. • It is made up of a covered spring and is marketed in a kit of different sizes with both left and right sides
  28. 28. INDICATIONS: Dental class II malocclusion Skeletal class II with maxillary excess as opposed to mandibular deficiency Deep bite with retroclined mandibular incisors CONTRA INDICATIONS: • Cases predisposed to root resorption • Dental and skeletal open bites • Vertical growth with high mandibular plane angle and excess lower facial height • Minimum buccal vestibular space
  29. 29. Advantages of jasper jumper are its ease of insertion and activation and generation of the intrusive forces on molars and incisors where as disadvantages include large inventory five sizes of left and right , breakage and a lack of force when the mouth is held open slightly. It is more prone for breakage when used to correct class III corrections
  30. 30. Cope in his study of comparison of Churro jumper and jasper jumper found that the Jasper Jumper consistently: • Displaced the maxilla posteriorly. • Failed to stimulate mandibular growth, but did rotate the mandible backward. • Tipped the maxillary molars posteriorly and intruded them. • Significantly tipped the maxillary incisors posteriorly and extruded them. • Significantly tipped, extruded, and moved the mandibular molars bodily in an anterior direction. • Significantly tipped the mandibular incisors anteriorly and intruded them.
  31. 31. THE AMORIC TORSION COILS • This appliance is made up of two springs, one of which slides inside the other . They are inter maxillary 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. • They are marketed in one size only and are bilateral. The force exerted by the appliance is variable in accordance with the fixing points on the arch
  32. 32. ADJUSTABLE BITE CORRECTOR (ABC) • This is an appliance which is assembled by the orthodontist as it is composed of various pieces – caps, closed coil springs, nickel titanium wire • It can be used on either side of the mouth with a simple 180º rotation of the lower end cap to change its orientation. This reduces the inventory by as much as one half. In the center lumen of the spring we find a nickel titanium wire which is responsible for the "push" force generated. Repairs and replacements are rapid and easily carried out with this kit. The cost of repair is minor
  33. 33. SCANDEE TUBULAR JUMPER • This is a coated inter maxillary torsion spring sold in a kit which includes the spring, the covering, the connectors, the ball pins and the glue . There is no distinction between left and right. • The covering can be of different colors making it more attractive for patients. The orthodontist constructs the appliance, cutting the spring to the length seen fit. When a fracture occurs, it is only necessary to replace individual components. It has the drawback of being thick after the covering is applied.
  34. 34. Klapper SUPER Spring II This is a flexible spring element which is attached between the maxillary molar and the mandibular canine. The length of the element causes it to rest in the vestibule when activated. This facilitates hygiene and avoids occlusal surfaces. The ends (fixing points) are different: The open helical loop of the spring is twisted like a J-hook onto the mandibular arch wire. On the maxillary end it is attached to the standard headgear tube (Super Spring I) or to a special oval tube and secured with a stainless steel ligature (Super Spring II). This new version prevents any lateral movement of the spring in the vestibule.
  35. 35. • Only two prefabricated sizes are available (with left and right versions of each). The length of the spring can be increased or decreased by simply bending the attachment wires. • The horizontal configuration of the attachment wire at the maxillary molar tube permits distalization with good radicular control.
  36. 36. • The SUPER spring II can be used in the entire range of Class II cases, from vertical facial patterns with shallow overbites to brachyfacial patterns with deep overbites. • It can be used with fully bracketed appliances and it makes an ideal auxiliary for a variety of mechanical systems. • The unique, unitary force couple applied by the spring against the maxillary molar allows a number of different applications. In the late mixed dentition, while the mandibular arch is fully bonded for anchorage, the maxillary molars can be distalized without bonding the adjacent teeth
  37. 37. • Other Class II auxiliaries tend to distalize only the maxillary molar crown, leaving the root in a mesial position that must be corrected later in treatment. The SUPER spring II moves both crown and root with a moderate, continuous force, and the adjacent teeth then follow the molar distally. • The SUPER spring II has proven to be excellent for TMD patients who require orthodontic treatment after splint therapy.
  38. 38. BITE FIXER • This is a new inter maxillary spring coil. The spring is attached and crimped to the end fitting to prevent breakage between the spring and the end fitting. Polyurethane tubing is inside the spring to prevent it from becoming a food trap . • The Bite Fixer is supplied in a kit with various sizes for both left and right
  39. 39. CHURRO JUMPER • This is an inexpensive alternative force system for the antero posterior correction of Class II and Class III malocclusions • So far, this is the only flexible functional appliance which can be made up by the orthodontist in his lab. The costs are reduced and the time spent is minimal.
  40. 40. The mesial and distal end of the jumper are circles. The distal circle is attached to the maxillary molars by a pin and the mesial end is placed over the mandibular arch wire against the canine bracket. However, when the pin is pulled forward enough to cause the jumper to bow outward toward the cheek, the appliance begins to exert a distal and intrusive force against the maxillary molar and a forward and intrusive force against the mandibular incisors as it attempts to straighten When used as a Class II corrector, the Churro exerts a posterior force on the maxillary arch and an anterior force on the mandibular arch, much like the Jasper Jumper.
  41. 41. The Churro Jumper as a Class III Force • The Churro Jumper, unlike many other Class II appliances, can be adapted to provide a well – designed force for correction of Class III malocclusions. • In the Class III version, the terminal circles are placed against the mesial of the mandibular molar tube and the distal of the maxillary canine bracket. • Ordinarily, the distance between the maxillary canine and first premolar brackets is enough to allow the jumper to open adequately and slide easily. If there is any restriction, however, the premolar bracket can be removed.
  42. 42. • Although the anterior (maxillary) circle can extend in a straight line from the shaft of the jumper, it is preferable to add a vertical bend that converts the Churro Jumper's force into a Class I vector, which produces less vertical thrust, incisor flaring, and anterior bite opening. This vertical bend also allows the Churro to lie unobtrusively in the mandibular vestibule, making it less noticeable and bothersome for the patient. • The Churro Jumper can improve the effectiveness of orthodontic therapy in Class III patients who refuse to wear Class III elastics
  43. 43. • The Churro Jumper has several disadvantages that sometimes limit its usefulness: • The restriction of mouth opening to 30-40mm is intolerable for some patients. • Arch wire breakage is common if larger wires are not used. • Patients with a low tolerance for discomfort will often break the appliance (as well as the spirit of the orthodontist). • Patients who incessantly move their mouths with chewing, talking, and nervous tics will fare poorly with it. • Its maximum effectiveness depends on a permanent dentition to retain its effect. • Presently, it must be manufactured in the office
  44. 44. Nevertheless, the Churro Jumper has considerable advantages: • It provides a constant, indefatigable force that cannot be removed from the mouth. • It can be used either unilaterally or bilaterally. • It can be used to correct Class II or Class III malocclusions. • It helps maintain anchorage, since it prevents the maxillary molars and mandibular incisors from moving into extraction sites. • The cost of construction for materials and labor is less. • It can be made as needed, from materials already present in most orthodontic offices, and does not require an expensive inventory. • It is universal in size and can be adapted to fit any malocclusion. • When broken, it is easily and inexpensively removed and replaced
  45. 45. Rigid Fixed Functional Appliances - RFFA • These appliances have two distinct differences in relation to FFFAs: • RFFAs do not easily fracture but neither do they have elasticity or flexibility. • After fitting and activation they do not allow the patient to close in centric relation. This means that the mandible is in a forward position 24 hours a day creating greater stimulus for mandibular growth than with FFFAs.
  46. 46. • Main indication is for the treatment of Class II malocclusions. Basically, correction consists of advancing the mandible to a forced anterior position to stimulate growth and harmonize skeletal defects. The majority of these appliances do not adapt to the treatment of Class III cases.
  47. 47. TREATMENT EFFECTS OF HERBST SAGITTAL CHANGES: The Herbst appliance restrains maxillary growth and stimulates mandibular growth Sagittal condylar growth increases where as vertical condylar growth is relatively unaffected Bone remodeling process in the lower mandibular border change the morphology of the mandible Experimental evidence indicate that articular fossa is repositioned anteriorly
  48. 48. DENTAL CHANGES • • • • The mandibular teeth are moved anteriorly Mandibular incisors are proclined Maxillary teeth are moved posteriorly Maxillary teeth are distalized as well as intruded
  49. 49. VERTICAL CHANGES • Deep over bite may be reduced significantly • Overbite reduction is mainly by intrusion of lower incisors and enhanced eruption of lower molars • Maxillary and mandibular occlusal planes tip down
  50. 50. Histological changes MRI studies of RUF and PANCHERZ showed that • Increased proliferation of the condylar cartilage was noted. These adaptations occurred primarily in the posterior and posterio superior regions of the condyle • Significant deposition of the new bone on the anterior surface of the postglenoid spine occurred, indicating an anterior repositioning of glenoid fossa
  51. 51. • Significant bone resorption on the posterior surface of the postglenoid spine was noted • 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 the temporo mandibular joints.
  52. 52. • Variations on the Herbst appliance and similar systems, utilizing ball attachments have appeared on the market in an attempt to: • improve patient comfort and acceptance • cause fewer clinical problems compared to screw or pin attachments • reduce the frequency of emergency appointments • allow good lateral mandibular movements • allow easy application in splints for correction in mixed dentition
  53. 53. TYPE II HERBST • Type II has a fixing system that fits directly onto the arch wires through the use of screws. This method of application has the disadvantage of causing constant fractures in the arch wires. The lack of flexibility together with the difficulty in lateral movements and the stress placed on the arch wires through activation causes fractures, especially in the lower arch.
  54. 54. TYPE IV HERBST • 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. The brakes are small and sometime difficult to fit. When a fracture occurs or a brake is lost, the appliance becomes loose .
  55. 55. THE CANTILEVER BITE JUMPER Most recently, the use of a cantilever has been proposed . The biggest difference resides in the fact that the Herbst style appliance is fitted directly to the lower molar bands through a cantilever arm. This system means that crowns have to be fitted to the upper and lower molars. The cantilever secured to the mandibular stainless steel crowns has a disadvantage in that the thickness of the screw mechanism can impinge on the patient’s cheek. The parts are available in kit form with pre-welded screw mechanisms and cantilever arms on crowns of seven different sizes.
  56. 56. MALU HERBST APPLAINCE • The MALU – Mandibular Advancement Locking Unit is a recently developed attachment device for the Herbst . It consists of two tubes, two plungers, two upper "Mobee" hinges with ball pins and two lower key hinges with brass pins. • The major advantages are the lower cost, no laboratory needed, flexibility and the possibility of using combined with edgewise therapy
  57. 57. • Each upper Mobee hinge is inserted into the hole at the end of the MALU tube and secured to the first molar headgear tube with ball pin. Each lower key hinge is inserted into the hole at the end of the plunger and locked to the base arch, distal to the cuspid, with the brass pin.
  58. 58. FLIP LOCK HERBST APPLAINCE • The Flip-Lock Herbst appliance offers several advantages over conventional Herbst designs: • Improved patient comfort and acceptance • Fewer clinical problems compared to screw or pin attachments • Less chair time for reactivation • Less frequent emergency appointments
  59. 59. FIRST GENERATION • 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. SECOND GENERATION FLIP LOCK • In the second generation, the plastic was replaced with metal. However, fracture problems persisted.
  61. 61. THIRD GENERATION FLIP LOCK • The third generation is made of a horseshoe 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 (Miller R., 1996)
  62. 62. THE VENTRAL TELESCOPE • This was the first telescopic RFFA that appeared as a single unit; i.e. upon reaching maximum opening it does not come apart . • This appliance is available in two sizes and fixing is achieved through ball attachments. It is particularly easy to activate. The operation is simple and is carried out by unscrewing the tube thus allowing an activation of around 3 mm.
  63. 63. • Its disadvantages lie in the fact that it is quite thick and suffers from fractures to the brake which stabilizes the joint. As with the other appliances where fixing is achieved through ball attachments, great accuracy is necessary with regard to inclination and the welding of components.
  64. 64. THE MAGNETIC TELESCOPIC DEVICE • 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.
  65. 65. THE MANDIBULAR PROTRACTION APPLIANCE (MPA) • This is an RFFA which was developed to be quickly made up by the orthodontist in the laboratory Its advantages include ease of manufacture, low cost, infrequent breakage, patient comfort and rapid fitting. • Another advantage it offers is that it can be made up at any time. This is helpful when there has been a failure in the supply of other commercially available appliances or if the orthodontist practices in an area where it is difficult to quickly obtain certain other alternatives. • The designer of the MPA developed three different types
  66. 66. MPA I • MPA I – each side of the appliance is made by bending a small loop at a right angle to the end of an .032" SS wire. The length of the appliance is then determined by protruding the mandible and another small right-angle circle is then bent in an opposite direction. The appliance slides distally along the mandibular arch wire and mesially along the maxillary arch wire. Bicuspid brackets must be debonded. • Limited mouth opening is the major disadvantage.
  67. 67. MPA II • MPA II – this is made by making rightangles circles in two pieces of .032" SS wire. A small piece of slipped coil is slipped over one of the wires. One end of each wire is then inserted through the loop in the other wire. This version allows the mouth to open wider than the first version.
  68. 68. MPAIII • MPA III – This version eliminates much of the arch wire stress that occurs with the MPA I and II. It permits a greater range of jaw movement while keeping the mandible in a protruded position. It is adaptable to either Class II or Class III mal occlusions. It resembles the Herbst by also incorporating a telescoping mechanism but is smaller in size. It requires more time to be built and a good electronic welder that does not darken or weaken the wire.
  69. 69. THE UNIVERSAL BITE JUMPER(UBJ) • This is like a Herbst but is smaller in size and more versatile – it can be used in all phases of treatment in mixed or permanent dentition, Class II or III malocclusions. An active coil spring can be added if necessary • No laboratory preparation is required. 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
  70. 70. The UBJ offers the following 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. • 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.
  71. 71. THE BIOPEDIC APPLIANCE • This is a bite jumping appliance which is engaged on the maxillary and mandibular molars, using a cantilever like system. It is then attached to a BioPedic buccal tube • Activation is achieved by sliding the appliance along the buccal tube and fixing the screw. It is universally sized for left and right sides. Two pivots on the ends allow the appliance to be rotated when the patient opens his mouth.
  72. 72. The Mandibular Anterior Repositioning Appliance (MARA) • This was created by Douglas Toll of Germany in 1991. It consisted of cams on the molars which guided the patient to bite into Class I • The first molars have to be covered with stainless steel crowns and the appliance must be laboratory manufactured. • The patient can pull back his mandible to a Class II relation but will be unable to achieve intercuspidation. This means that the lower molars will make direct contact with the metal, giving an unpleasant sensation. Furthermore, should the orthodontist opt for bands instead of crowns, fractures will often occur.
  73. 73. • The appliance design allows for use in conjunction with braces. It can be used for Class II treatment and for TMJ problems. • this is an appliance of simple characteristics which allows good hygiene during the correction stage. With a small modification to the original design using only wire and composite, a very interesting appliance can be created for finishing treatment of a Class II malocclusion treated with a functional appliance.
  74. 74. INDICATIONS: • Skeletal class II with mandibular deficiency CONTRA INDICATIONS: • Dolichofacial growth pattern • Cases predisposed to root resorption • Dental and skeletal open bites • Vertical growth with high mandibular plane angle and excessive lower facial height
  75. 75. RITTO APPLIANCE • The Ritto appliance is a rigid fixed functional appliance that can be described as a miniaturized telescopic device. The Ritto Appliance is a onepiece device with telescopic action. It comes in a single format, which allows it to be used on both sides. This design means that stock can be kept at minimum levels.
  76. 76. THE RITTO APPLAINCE • The Ritto Appliance can be described as a miniaturized telescopic device with simplified intra oral application and activation The construction of this appliance is based on the mechanism and function used in the Ventral Telescope adapted for use in conjunction with a fixed appliance
  77. 77. • They cause less breakage of arch wires and appliances and thus fewer emergency appointments • - Inventory requirements are minimal – The appliance can be used on either side of the mouth and there is only one size • - They can be used at any stage of treatment – mixed or permanent • - Their low profile results in considerably less buccal irritation • - They produce good results without the need for patient cooperation.
  78. 78. • In functional treatment with a rigid fixed functional appliance (RFFA), it is necessary to prepare the patient for 1 to 2 months before fitting the appliance to stimulate musculature and avoid having the patient exert too much force on the support systems, causing appliance breakage or unwanted dental movement. For this reason, the use of a mini-stimulator for mandibular advancement is advised. This is a thermoformed splint of 0.7 mm in thickness, for the upper incisors only and incorporating an acrylic bite block for the lower incisors. The bite block is constructed with the mandible in a forward position.
  79. 79. • For the first 15 days or 1 month, the patient should wear the splint for as long as possible and maintain the lower incisors fitted into the Bite block. In the following weeks, the patient should practice swallowing exercises with the lips in contact and with lower incisors against the bite block. • Only after this stage should therapy be started with the Ritto Appliance, now that the musculature has been stimulated and the patient has memorized the forward position of the mandible. Delocking of the occlusion is also achieved. • It is possible to fit the Ritto appliance in conjunction with the mini stimulator for the first few weeks
  80. 80. • Another important factor that contributes to comfort and rapid patient adaptation is the establishment of posterior contact after the advancement of the mandible. This also creates a posterior proprioceptive sense. It is not always necessary to have perfect coordination of the arches before starting functional treatment. Sometimes, even with a pronounced Curve of Spee, therapy can be started as long as some artificial contacts are constructed with composites on the molars . The extrusion of the premolars can be beneficial in the correction of a vertical problem.
  81. 81. • The main differences when compared to the Ventral Telescope appliance are: • The appliance does not come apart (no disengagement after achieving maximum extension). • The smaller size facilitates adaptation and it does not affect aesthetic appearance or speech. • It comes in a single format which allows it to be used on both sides and is available in only one size. • The Ritto Appliance is simple to use, comfortable, cost effective, breakage resistant and requires no patient cooperation
  82. 82. • It is even possible to carry out the treatment of Class II retromandibular cases in mixed or permanent dentition using only conventional bands on the upper molars and two tubes on the lower molars and brackets on the lower incisors. • 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 .
  83. 83. • The appliance is fixed onto a prepared the lower arch. The thickness and type of arch is chosen, its length is adjusted, locks are fitted and the Ritto appliance is then inserted. Activation is achieved by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance .
  84. 84. • The most common question raised on this appliance is on the effect produced on the lower incisors, given that the lower anchorage system is minimal. In a comparative study between the Ritto Appliance and the Herbst appliance, no statistically significant differences were found in the position of the lower incisors . In a scanogram analysis of the lower incisors, no indication of radicular resorption was found during treatment with the appliance.
  85. 85. SABBAGH UNIVERSAL SPRING Is the ideal solution for treating patients with: • Insufficient cooperation • Late cases with little remaining growth • Illnesses of the upper respiratory tract system, such as asthma • Patients who are allergic to plastics • The Sabbagh Universal Spring can be universally used as a substitute for activator, Herbst , headgear, elastics, as well as for the treatment of temporo mandibular dysfunction.
  86. 86. • The appropriate size can be adjusted by turning the inner telescope tube, as well as inserting activation springs (tension or compression springs). Compared to other similar appliances, the Sabbagh Universal Spring has many possibilities for activation, such as turning the inner telescope tube, or inserting the activation springs (tension or compression springs) Therefore, in most cases only one Sabbagh Universal Spring set is required for the entire treatment.
  87. 87. HYBRID APPLAINCES • There are also new appliances that can been classified as hybrid appliances because they represent the combination of a Rigid fixed functional appliance (RFFA) with Flexible fixed functional appliance (FFFA). They could be described as rigid appliances with coil spring-type systems.
  88. 88. • The objective of these appliances is to move the teeth by applying 24-hour elastic continuous force that would replace the traditional use of elastics and extra-oral force. Their common feature the use of coiled springs to produce this force. The force generated varies between 150 and 200 gm. Other advantages include reduction in the need for patient cooperation and the ease of placement
  89. 89. • The primary objective of the hybrid appliances is not to reposition the mandible anteriorly. If such was the case, it would be illogical to reposition a mandible and at the same time to keep exerting mesial inferior and distal superior force. Rigid fixed functional appliances offer the best choice to obtain this goal, as is well documented in the literature. With RFFAs, once the appliance has been activated the patient cannot close in centric relation during the therapy stage.
  90. 90. • In order to obtain the best possible results with a goal of skeletal movement, the authors propose a philosophy of using muscular pre-stimulation before the placement of the fixed appliance. This is in conjunction with a treatment plan based on an individualized pattern model. A general inconvenience with rigid fixed functional appliances is the fact that the fixed appliance needs to be placed as a whole, to establish the necessary anchorage. Also, control of the vestibular movement of the lower incisors is important. In such cases it is sometimes necessary to resort to other anchorage appliances. As such, it can be rather difficult to use these appliances in mixed dentition.
  91. 91. THE CALIBRATED FORCE MODULE • It was a fixed appliance designed to substitute Class II elastics and it was developed in 1988 by the CorMar Inc. Available in three sizes, it was applied to the inferior arch close to the molars and fixed by a screw, and mesial or distal to upper cuspids, and also fixed to the arch. Its coil spring produced a force between 150 and 200 gm .
  92. 92. • The same company proposed a Herbst appliance with an exterior coil spring, attached to the inferior tube. That system generated tooth movement by employing gentle and continuous force 24 hours a day .
  93. 93. EUREKA SPRING • This appliance appeared on the market in 1996 and it was developed by DeVicenzo and Steve Prins . It is a three part telescopic appliance fixed to the upper arch at the level of the molar band and to the lower arch distal to the cuspid. The appliance has an open coil spring that is placed inside of a part of the system.
  94. 94. • Interestingly the authors caution in the manual that the appliance does not create any orthopedic effect, but underline that the correction is totally dentoalveolar. • The placement system is relatively simple, and the patient can open his or her mouth widely without any difficulties due to the telescopic effect of the appliance. It is available in two sizes: 20 and 23 mm long. The appliance is universal and it can be applied both to the right as well as to the left side .
  95. 95. 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.
  96. 96. • Generally this type of fixing allows for rapid placement and removal of the appliance. It is available in two sizes and accompanied by a screwdriver to fix the screw in the lower arch. • Such as in the previous appliance its application vary between Class II and Class III treatment, and it may be also used as an anchorage system.
  97. 97. • Due to its original configuration, these appliances are suitable for cases where there is a need to carry out correction that requires predominantly dentoalveolar movement. In order to avoid protrusion of the lower incisors it is recommended to use stronger steel wires or to resort to other accessories. • The major drawback of this appliance is the difficulty to control the force. If we want less force, we should bend the mesial part of the ball pin in order to have more wire distal to the tube. This situation, however, may create discomfort and impingement problems
  98. 98. • The other disadvantage lies in the fact that the lower the lower dentition needs to be already aligned as it is recommended to use 016"x.022, or 017"x.025" stainless steel wires that guarantee necessary anchorage. In this way the device is in principle recommended for permanent dentition. • For Class III correction it is necessary to put a lip bumper tube (LBT) on the lower molar band.
  99. 99. • Recently the third modernized version of the appliance has been presented under the name "Twin Force Bite Corrector – Double Lock" . It is reduced in size and both the lower and upper placement is based on the system of lock-on screws. This new version facilitates the use of the appliance for Class III correction and it allows for a slightly better control of the force although it still falls short of the full control.
  100. 100. FORSUS • FATIGUE RESISTANT DEVICE • This is an innovative three telescopic appliance with a coil spring in its exterior part. This feature makes it resemble some flexible functional appliances (AFF). • In comparison with AFF its great advantage lies in coil spring resistance to breaking. The coil spring is applied by its sliding on a rigid surface avoiding in this way angulations at the fixing points. • It is sold in kits that include different length sizes for left and right
  101. 101. • In the original presentation the appliance is placed in the mandible on the round-segmented arch that is included in the kit. The appliance slides along the arch and facilitates opening of the mouth and lateral movements. The resulting force concentrates more on the anterior and inferior sectors. • In this way there is no interference with continuous arches used during the treatment, which offers wide application independently of the method applied. • The appliance may be fixed in various ways according to the needs of the patient
  102. 102. • The device gives the power to control the amount of force, whether through various available sizes, or through the direct attachment to the lower arch and the use of a stop for activation. Thus the appliance may be used in cases of mixed dentition and it allows for dental asymmetry correction when higher force on both sides is needed. • The device allows patient to open and move their jaw freely.
  103. 103. ALPERN CLASS II CLOSERS • This appliance is slightly different from the preceding ones and it is also 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.
  104. 104. The qualities that functional appliances should present can be summarized as follows: • - Patient comfort and acceptance are excellent • - They promote better compliance • - They offer an extensive range of motion • - They are simple and inexpensive • - They are easier to fit • - They are adaptable to either Class II or III • - They can used for mandibular
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