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


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

  1. 1. Fixed Functional Appliances
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  4. 4. A skeletal Class II - fault with the maxilla
  5. 5. A skeletal Class II - fault with the mandible
  6. 6. A skeletal Class II - fault with the mandible
  7. 7. Correction of Class II malocclusion – An Enigma • Dilemma regarding – • • • • Age to initiate ? Modality of correction What to expect ?? How to retain ??
  8. 8. Contributors to Class II malocclusion • Maxillary prognathism – 30% • Mandibular retrusion - 70% ----Mc’Namara (1981) Mastorakos study( 1984) --- slight disagreement with Mc’Namara’s values
  9. 9. Earlier dictum in Growth modulation • Start treatment early for Class II correction ; hold the correction for a longer period. • Distinct European and American strategies • Complete second phase of treatment with fixed appliances
  10. 10. Problems with two-phase treatment • Excessively long duration of treatment • Burn-out of patient co-operation • No additional benefits to majority of patients compared to those undergoing a single phase of treatment • Less cost-effective
  11. 11. Timing of Class II correction Based on RCT’s done in US and UK, Proffit states • “ Early treatment for most Class II children is no more effective and considerably less efficient than later one-stage treatment during adolescence” - AJODO 2006
  12. 12. Wrong assumptions made.. • Class II correction in mixed dentition does not work well • Start Class II correction only in permanent dentition • What about cases with severe proclination?? • What about psychological benefits to those Class II children who are bullied due to their protruding teeth?
  13. 13. The present view • Two-phase treatment may make the treatment unnecessarily prolonged ; economics and co-operation levels difficult to justify • Therefore a single phase of treatment gaining widespread acceptance.
  14. 14. CONSIDER A PROTOCOL BASED ON: • Growth status of the patient, • State of dentition, • Nature of dental malocclusion (irregularities) needing pre-functional corrections, • Whether the patient will need any extractions, • Amount of incisor exposure.
  15. 15. Growth status of the patient • Optimum timing for growth modulation of Class II (irrespective of treatment modality) is the active growth period coinciding with the pubertal growth spurt – Sassouni 1972 – Pearson 1978 – Pancherz 1985 – Malmgren 1987 – Baccetti 2000 etc
  16. 16. • Mandibular growth is slightly behind the skeletal growth (Fishman and others). • Hence, the ideal timing for growth modulation would be during or slightly after the peak of the growth spurt.
  17. 17. Assessment of the Peak of Growth Spurt • Earlier method was the hand and wrist radiograph (or MP3) 2 ½ years 6 ½ years 11 years 19 years
  18. 18. Cervical Vertebral analysis of Franchi, Bacetti and Mc’Namara
  19. 19. • The one phase treatment cases could be classified, based on their growth status, into: a. Early (CVM I – Growth spurt peak will occur after more than 1 year), b. Appropriate (CVM II– peak will occur within few months), c. Late (CVM III – spurt has already occurred, or beyond).
  20. 20. Parameters to judge prognosis
  21. 21. Weigh the following • Predisposition to trauma • Psychological assessment •Problem areas – Skeletal, dental or both? •Any transverse /vertical problems?
  22. 22. Cases ideal for early intervention • Patients with severe deficit of mandibular growth. • Cases with severe proclination/ psychological insult • Cases with excessively narrow maxilla • Class II intervention by way of habit correction
  23. 23. Is amalgamation of fixed appliances and functionals acceptable? “Concurrent usage of fixed appliances and functional therapy does not spell a biologic compromise; instead it may offer a mechanical advantage” –T.M Graber
  24. 24. Shifting paradigms in Class II treatment Concept of Telescoping treatment Coupling two modalities of treatment to extract maximum benefit of both in a shorter time. Also aim at minimising side effects of each other
  25. 25. Telescoping treatment for Class II malocclusions • Combining benefits of mandibular advancement while minimising side effects on dentition. • Help in augmenting sagittal and transverse corrections • Minimise overall treatment time
  26. 26. Add-ons’when combining Fixed Functional appliances with fixed mechanotherapy Aid intra-arch corrections • obtaining unilateral lower midline shift, • upper molar distalization • anchorage conservation
  27. 27. Shifting paradigms in Class II treatment Previous concept of Class II management Extractions Functional Surgical Childhood Mild Class II Adulthood Severe ClassII
  28. 28. Shifting paradigms in Class II treatment Proposed concept of Class II management by Pancherz Herbst Functional Extractions Surgical Childhood Mild Class II Adulthood Severe ClassII
  29. 29. THE METHOD OF OPERATION OF FUNCTIONAL APPLIANCES functional appliance Increased contractile activity of the LPM Intensification of the repetitive activity of the retrodiscal pad (Bilaminar zone) Increase in growth stimulating factors Enhancement of local mediators
  30. 30. Reduction of local regulators (factors having negative feed back effects on cell multiplication rate) Changes in condylar trabecular orientation Additional growth of condylar cartilage Additional sub-periosteal ossification of the Posterior border of the mandible Supplementary lengthening of the mandible THE METHOD OF OPERATION OF FUNCTIONAL APPLIANCES
  31. 31. Advantages of fixed functional appliances over removable functional appliances • less dependent on the patient co-operation • works 24 hrs a day, so there is continuous stimulus for mandibular growth • Treatment time is short (approx 6 – 8 months) • Direction of force is more constant • smaller in size permitting better adaptation
  32. 32. CORRECTION OF CL II MALOCCLUSION • Dento alveolar changes • Restriction of forward growth of the mid face • Stimulations of mandibular growth beyond that which would normally occur in growing children. • Redirection of condylar growth – upward & forward directed growth to posterior direction
  33. 33. • 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.
  34. 34. Classification of Fixed Functional Appliances • According to Antonio Korrodi Ritto – Rigid Inter-maxillary Appliances (RIMA) – Flexible Inter-maxillary Appliances (FIMA) – Hybrid Appliances (Combination of RIMA & FIMA)
  35. 35. Classification of Non-compliance Inter-maxillary Appliances According to Moschos A Papadopoulous – Rigid Inter-maxillary Appliances (RIMA) – Flexible Inter-maxillary Appliances (FIMA) – Hybrid Appliances (Combination of RIMA & FIMA) – Appliances acting as substitutes for elastics
  36. 36. Rigid Inter-maxillary Appliances (RIMA) Herbst like appliances
  37. 37. • Emil Herbst, 1905 @ the Berlin Dental Congress • 1970,Hans Pancherz brought it back into discussion with the publication of a series of articles
  38. 38. Herbst Appliance • a passive tube and plunger system with the exact length of the tube determining the amount of anterior mandibular displacement • tube - attached to a maxillary posterior unit • plunger is fixed anteriorly to the mandibular dentition - slides through the tube during opening and closing movements
  39. 39. Herbst appliance
  40. 40. Herbst Appliance
  41. 41. Modifications of Herbst Appliance
  42. 42. Goodman’s Modified Herbst Appliance • SS crowns on maxillary molars • TPA 0.045” round wire connecting the crowns • Frameworks for upper ans lower arches - 14 gauge half round wire • Maxillary pivots soldered to most distal part of the crown • Mandibular pivot soldered to wire framework
  43. 43. Upper Stainless Crowns and Lower Acrylic • Larry White • Lower part removed for oral hygiene • Zeirk – Enden Herbst – double buccal tubes on maxillary molars • Magnusson System – Valant & Sinclair – Molars connected with TPA
  44. 44. Upper Stainless Crowns and Lower Acrylic
  45. 45. Mandibular Advancement Locking Unit • 1996, Raffaele Shiavoni • 2 tubes, two plungers, two upper “Mobee” hinges with ball pins and two lower key hinges with brass pins • upper “Mobee” hinge – inserted into hole at the end of the MALU tube – secured to the first molar headgear tube with ball pin. • lower key hinge – inserted into the hole at the end of the plunger and locked to the base arch, distal to the cuspid with brass pins.
  46. 46. MALU
  47. 47. Magnetic Telescopic Device • Ritto A.K. 1997 • 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 • Fitted using the MALU system
  48. 48. Magnetic Telescopic Device
  49. 49. Flip- Lock Herbst Appliance • Robert A Miller • They have 3 Generations – Generation 1- dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint – Generation 2 -plastic was replaced with metal – Generation 3 - horse-shoe ball joint
  50. 50. Flip- Lock Herbst Appliance
  51. 51. Hanks Telescoping Herbst Appliance • One piece design • Two tubes, a ball & socket joint and a rod attachment to mandibular premolars or cantilever arm • American Orthodontics
  52. 52. Hanks Telescoping Herbst Appliance
  53. 53. Ventral Telescope • • • • First telescopic single unit appliance Available in two sizes Fixing is achieved through ball attachments Easy to activate Disadvantages • Quite thick • Ball attachments - great accuracy is necessary with regard to inclination and welding of components
  54. 54. Ventral Telescope
  55. 55. Universal Bite Jumper (UBJ) • Calvez X, 1998 • like a Herbst but is smaller in size and more versatile • active coil spring can be added if necessary • 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
  56. 56. UBJ
  57. 57. IST ( Intraoral Snoring Therapy) Appliance • Hinz • treat patients - breathing problems during sleep, e.g. OSA • “suppresses snoring by moving the lower jaw forward reducing the obstruction in the pharyngeal area” • The telescope is threaded so the orthodontist can change the protrusion on each side individually up to 8mm. • An end stop in the guiding sleeve prevents the telescope from disengaging.
  58. 58. IST Appliance
  59. 59. Acrylic Splint with Hinge System • 1988, James A. Mc Namara
  60. 60. Cantilever Bite jumper • Appliance fitted directly to the lower molar bands through a cantilever arm • crowns have to be fitted to the upper and lower molars • parts are available in kit form with pre-welded screw mechanisms and cantilever arms on crowns of seven different sizes
  61. 61. Cantilever Bite jumper
  62. 62. Mandibular Advancing Repositioning Splint (MARS) • 1982, Ralphm Clements, Alex Jacobson • Composed of a pair of telescoping struts. • Each strut is composed of two separate parts. – Plunger – Hollow tube
  63. 63. Other Rigid Inter-maxillary Appliances
  64. 64. Biopedic Appliance • Designed by Jay Collins and manufactured and sold by GAC, was introduced in 1997.
  65. 65. Biopedic Appliance • 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.
  66. 66. Biopedic Appliance • Appliance activation - moving the rod mesially • The short maxillary rod is inserted from the distal and fixed by a similar screw at the mesial of the maxillary first molar. • The two rods are connected by a rigid shaft and have pivotal regions at their ends.
  67. 67. Ritto Appliance • Ritto A.K., 1998 • miniaturized telescopic device • appliance does not come apart - no disengagement after achieving maximum extension
  68. 68. Ritto Appliance
  69. 69. Mandibular Protraction Appliance • 1995 Coelho Filho
  70. 70. MPA I • bending a small loop at a right angle to the end of an .032" SS wire • length - determined by protruding the mandible • another small right-angle circle is then bent in an opposite direction • The appliance slides distally along the mandibular archwire and mesially along the maxillary archwire • Bicuspid brackets must be debonded.
  71. 71. MPA I
  72. 72. MPA II • right-angles circles in two pieces of .032" SS wire • 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 • allows the mouth to open wider than MPA I
  73. 73.
  74. 74. MPA III • Eliminates archwire stress that occurs with the MPA I and II • greater range of jaw movement while keeping the mandible in a protruded position • resembles the Herbst - 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.
  75. 75. MPA III
  76. 76. Fixed Functional Appliances
  77. 77. Mandibular Anterior Repositioning Appliance Douglas Toll of Germany in 1991 first molars - covered with stainless steel crowns the appliance must be laboratory manufactured. In a large .062 square tube on the upper molar, an adjustable .060 square ‘elbow’ hangs vertically. lower molar has a .059 round wire arm projecting buccally from mesial. To cause more mandibular advancement, shims are placed on the elbow.
  78. 78. MARA
  79. 79. Flexible Inter-maxillary Appliance Jasper jumper like appliance
  80. 80. Jasper Jumper • Dr. James Jasper (1987) • covered spring • marketed in a kit of different sizes with both left and right sides
  81. 81. Jasper Jumper
  82. 82. Jasper Jumper
  83. 83. Gentle Jumper
  84. 84. Scandee Tubular Jumper • coated intermaxillary torsion spring sold in a kit which includes the spring, the covering, the connectors, the ballpins and the glue • no distinction between left and right • constructs the appliance, cutting the spring to the length seen fit
  85. 85. Scandee Tubular Jumper
  86. 86. Amoric Torsion Coils • two springs, one of which slides inside the other • inter maxillary springs without covering • simplified application system of rings on the ends. • rings are fixed to the upper and lower arches with double ligatures • marketed in one size only and are bilateral. • force exerted -variable - accordance with the fixing points on the arch
  87. 87. Amoric Torsion Coils
  88. 88. Adjustable Bite Corrector (ABC) • 1995, Richard P West - a variation of the Jasper Jumper • swivel adjustments at its ends, thereby eliminating the need for left and right models and thus reducing inventory by half. • The push force generated from a nickel titanium wire in the center lumen of the spring
  89. 89. ABC
  90. 90. ABC • The length of the ABC can be increased as much as 4 mm by simply turning the ends of the spring • permits the clinician to alter the applied force by merely rotating the end(s) of the spring
  91. 91. Bite Fixer • In 1998 Ormco introduced the Bite Fixer, which is claimed to be an improved Jasper Jumper because breakage is reduced • spring is attached and crimped to the end fitting to prevent breakage between the spring and the end fitting • Polyurethane tubing inside – prevent being food trap
  92. 92. Bite Fixer
  93. 93. Klapper SUPERspring II • 1997 Lewis Klapper - Klapper Superspring for the correction of Class II malocclusions. On first glance • it resembles a Jasper Jumper with the 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
  94. 94. Klapper SUPERspring II
  95. 95. Klapper Spring
  96. 96. Churro Jumper • inexpensive alternative force system for the anteroposterior correction of Class II and Class III malocclusions • mesial and distal end of the jumper are circles • distal circle is attached to the maxillary molars by a pin and the mesial end is placed over the mandibular archwire against the canine bracket.
  97. 97. Churro Jumper
  98. 98. Churro jumper
  99. 99. Forsus Nitinol Flat Spring • slim, flat and made of Super-Elastic Nitinol • delivers consistent forces • Force levels remain constant from the initial setup to the time of removal • The result is faster, more efficient treatment.
  100. 100. Forsus Nitinol Flat Spring
  101. 101. Hybrid Appliances Combination of FIMA & RIMA
  102. 102. Eureka Spring • 1996 , DeVicenzo & Steve Prins • 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 • open coil spring that is placed inside of a part of the system • appliance is universal and it can be applied both to the right as well as to the left side
  103. 103. Eureka Spring
  104. 104. Sabbagh Universal Spring • possesses a gentle, slowly accelerating force • size can be adjusted by turning the inner telescope tube & inserting activation springs (tension or compression springs)
  105. 105. Sabbagh Universal Spring
  106. 106. ForsusTM Fatigue Resistant Device • telescopic appliance with a coil spring in its exterior part • coil spring is applied by its sliding on a rigid surface avoiding in this way angulations at the fixing points
  107. 107. Forsus FRD
  108. 108. Twin Force Bite Corrector • two internal coil springs • two joint telescopic systems • superior level - ball pin fitted into the buccal tube of a molar band • fitting-in system fixed with a screw to the inferior arch - distal to the lower cuspid
  109. 109. Twin force Bite Corrector
  110. 110. Twin force Bite Corrector Quick-connect Twin Force Bite Corrector Classic Twin Force Bite Corrector
  111. 111. Appliances acting as substitutes for Elastics
  112. 112. Appliances acting as substitutes for Elastics • Calibrated Force module • Alpern Class !! Closers • Saif Springs
  113. 113. Calibrated Force Module • 1988 – Cormar Inc. • Avaialable in 3 sizes • Attached to to the lower archwire diatal of mandibular molars and fixed by a screw and to the upper archwire distal or mesial to maxillary canines • Forces 150-200gms - Spring coils
  114. 114. Calibrated Force Module
  115. 115. Alpern Class II Closers • Alpern Sentalloy Interarch coil Springs (GAC ) • Small telescopic device with Sentalloy coil springs and two hooks for fixing • Available in four sizes • Force 250 gms • Fixed to the mandibular molar and to canine bracket
  116. 116. Alpern Class II Closers
  117. 117. Saif Spring • Armstrong late 1960s and early 1970s introduced the Pace Spring, later termed Multicoil Spring • Saif Springs (Severable Adjustable Intermaxillary Force) Pacafic Coast Manufacturing Inc. • Spring inside a spring with welded loops on each side generate high forces. • Set up like Class II or Class III elastics
  118. 118. Conclusion
  119. 119. Conclusion • qualities that functional appliances should have: – Patient comfort and acceptance are excellent – promote better compliance – offer an extensive range of motion – simple and inexpensive – Easy to fit – adaptable to either Class II or III
  120. 120. Conclusion – be used for mandibular positioning or dentoalveolar movement – cause less breakage of archwires 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 – used at any stage of treatment mixed or permanent – low profile results - considerably less buccal irritation – produce good results without the need for patient cooperation
  121. 121. References • Olivier R.G., Knappman J.M. Attitudes to orthodontic treatment. British Journal of Orthodontics 1985; 12:179-88. • Ngan P., Kess B., Wilson S., Perception of discomfort by patients undergoing orthodontic treatment. Am. J. Orthod. Dent. Orthop. 1989; 96:47-53. • Herbst E. Atlas und Grundriss der Zahnärztlichen Orthopädie. Munich, Germany, J.F. Lehmann Verlag, 1910. • Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation. Am. J. Orthod. 1979; 76: 423-442. • Calvez X. The universal bite jumper. J. Clinical Orthod. 1998; 32: 493-499. • Eckart E. Introducing the MARA. Clinical Impressions 1998; 7: 2-5.
  122. 122. References Filho C.M. Mandibular Protraction Appliances for Class II Treatment. J. Clin. Orthod. 1995; 29: 319 ? 336. Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin. Orthod. 1997; 31: 92 ? 102. Filho C.M. The Mandibular Protraction Appliance III. J. Clin. Orthod. 1998; 32: 379-384. Ritto A.K. Fixed Functional Appliances ? Trends for the next century. The Functional Orthodontist 1999; 16 (2) 122 ? 135. West R.P. The adjustable bite corrector. J. Clinical Orthod. 1995; 29: 650-57.
  123. 123. References • Klapper L. The SUPERspring II: A new appliance for noncompliant class II patients. J. Clin. Orthod. 1999; 33: 50-54. • Jasper J.J. The Jasper Jumper ? a fixed functional appliance. Sheboygan, wisconsin: American Orthodontics, 1987. • Jasper J.J., McNamara J. The correction of interarch malocclusions using a fixed force module. Am. J. Orthod. Dentofac. Orthop. 1995; 108: 641-50. • Erdogan E., Erdogan E. Asymmetric Application of the Jasper Jumper in the correction of midline discrepancies. J. Clin. Orthod. 1998; 32: 170 ? 80. • Cope J.B., Buschang P., Cope D.D., Parker J., Blackwood H.O. Quantitative evolution of craniofacial changes with Jasper Jumper Therapy. Angle Othod. 1994; 64 (2): 113 ? 122.
  124. 124. References • Cash R.G. Case Report: adult nonextraction treatment with a Jasper Jumper. J. Clin. Orthod. 1991; 25: 43-7. • Castañon R., Valdes M., White L.W. Clinical use of the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 ? 45. • Blackwood H.O. Clinical Management with the Jasper Jumper. J. Clin. Orthod. 1991; 25: 755-60. • Amoric M. Les Ressorts intermaxillaires en torsion. Rev. Orthop. Dento Facial 1994; 28: 115 ? 117. • Shiavoni R., Bonapace C., Grenga V. Modified Edgewise-Herbst Appliance. J. Clin. Orthod. 1996; 30: 681 ? 87.
  125. 125. References • Ricketts R. M. The keystone triad II. Growth, treatment and clinical significance. Am. J. Orthod. 1964; 50: 728-50. • Petrovic A.G., Stutzmann J., Outdet C., Control processes in the postnatal growth of the mandibular condylar cartilage in: McNamara J.A.ed Determinants of mandihular form and growth. Monograph 4. Craniofocial Growth Series. Ann Arbor: Center of Human Growth and Development University of Michigan, 1975:101-53. • Nashed R.R., Reynolds I.R. A cephalometric investigation of overjet changes in fifty severe Class II division 1 malocclusions. Br. J. Orthod. 1989; 16: 31-37. • Mills J.R.E. The effect of functional appliances on the skeletal pattern. Br. J. Orthod. 1982; 18: 267-75. • McNamara J.A., Carlson D.S. Quantitative analysis of temporomandibular Joint adaptations to protrusive function Am J Orthod 1979; 76: 593-611.
  126. 126. References • McNamara J.A. Components of Class II malocclusion in children 810 years of age. Angle Orthod 1981; 51: 177-202. • Illing H.M., Morris D.O., Lee R.T. A prospective evaluation of Bass, Bionator and Twin Block appliances. Part I ? the hard tissues. Europ. J. Orthod. 1998; 20: 501-516. • Hilgers J.J. Hyperefficient Orthodontic treatment using tandem mechanics. Semin. Orthod. 1998; 4: 17-25. • Heather M. L., Morris D. O., Lee R.T. A prospective evaluation of Bass, Bionator and Twin Block appliances. Part I- the hard tissues. Eurp. J. Orthod. 1998; 20: 501-516. • Harvold E., Vargervik K. Morphogenetic response to activator treatment. Am. J. Orthod. 1971; 60: 478-90. • Haegglund P. The Swedish-Style Integrated Herbst Appliance. J. Clin. Orthod. 1997; 31: 378 ? 390.
  127. 127. References • Dischinger T. Edgewise Herbst Appliance. J. Clin. Orthod. 1995; 29: 738 ? 742. • Burke G., Major P., Glover K., Prasad N. Correlations between condylar characteristics and facial morphology in Class II preadolescent patients. Am. J. Orthod. Dentof. Orthop. 1998; 114: 328-36. • Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. Am. J. Orthod. 1982; 87: 1-20. • Pancherz H. The Herbst appliance ? its biological effects and clinical use. Am. J. Orthod. 1985; 87: 1-20. • Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod. 1996; 30: 552
  128. 128.