Fixed functional appliances

FIXED FUNCTIONAL
APPLIANCES
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Fixed functional Appliances
Introduction
• Most orthodontists consider functional appliances to be primarily
orthopaedic tools that influence the facial skeleton of the growing child in the
condylar and sutural area.
• However, these appliances also exert on orthodontic effect on the dento-
alveolar area. The ability of removable functional appliances to produce
dental rotations and bodily movement is limited.
• Fixed appliance, on the other hand, have little skeletal effect. Many class II
cases therefore require a stage of treatment with fixed appliances
proceeding (or) following functional therapy.

• Removable functional appliances are normally large, have unstable fixation,
cause discomfort of the tongue, cause difficulties in deglutition and speech
and very often affect esthetic appearance.
• The mandibular posture crease added difficulties. These adverse effects
make the adaptation and acceptance of these appliance more difficult.
• Successful orthodontic treatment often relies heavily on patient co-operation
in the wearing of head gear elastics (or) removable appliance.
• Eliminating the need to use head gears, intermaxillary elastics, (or)
removable appliances places the treatment results more under the control of
the orthodontist.
• Thus fixed functional appliance came into existence. Fixed functional
appliances are normally known as Non-compliance class II correctors.

Historical Perspective
• Fixed functional appliance first appeared around 1905, when Emil Herbst
presented his appliance at Berlin international dental congress. After that
very little was published about the appliance. It was in 1979 that Hans
Pancherz brought the subject back into discussion by publishing several
articles.
• In 1982, Raph.M.Clements & Alex Jacobabson introduced the MARS
appliance – mandible advancing repositioning splint. It is a fixed functional
device that is attached to arch wires of a multibanded orthodontic appliance
designed to maintain class II mandibles in a protruded position.
• In 1987, A.O.Jasper and McNamara used a flexible force module that can
be incorporated in the fixed appliance.
• In 1989, Vardiman came up with the functional magnetic system. Here,
lingual midline magnets are embedded in the acrylic.
• In 1957, Armstrong developed the SAIF spring – severable adjustable
intermaxillary force, that produces a similar type of pulling force to class II
elastics. These are long Nickel Titanium closed coil springs.

• In 1993, Yokota introduced the MGA – mandibular growth advancer. This
appliance used a headgear and a functional appliance simultaneously. It
had on upper howley’s appliance and a lower hawley’s appliance fused intra
orally stepwise to form a splint.
• In 1995, Richard P.West developed the ABC – adjustable bite corrector.
The adjustable and constant force application is its major advantage.
• In 1996, Robert A.Miller came up with a new flip lock Herbst appliance that
had a ball end appliance.
• In 1997, Paul Haegglund and Staffan Sagerdal came up with a Swedish
type integrated Herbst appliance.
• In 1997, Carlos M. and Coetho Filho devised 4 types of MPAs – mandibular
protraction appliances. The MPAs were attached to the fixed appliance.
• In 1994, Amoric Torsion Coils came that were made up of 2 springs one of
which slides into the other

• In 1997, John Devincenzo & Steve Prins designed the Eureka spring that
had more desirable characteristics than any class II inter-arch force delivery
system.
• In 1998, Xavier calvez devised the UBJ – universal Bite Jumper that could
be used in both class II and class III malocclusions.
• In 1998, Racardo Castanon designed the Churro Jumper.
• Around 1995, Saga Dental, Norway introduced the Scandec Tubular Jumper
which had different colour coverings making it more attractive for patients.
• Then came klapper supper spring by Lewis Klapper. This is a flexible spring
element attached to maxillary molar and mandibular canine.
• The bite fixer, cantilevered bite jumper etc. were also introduced,
mandibular advancement locking unit (MALU), Ventral telescopic rigid fixed
functional appliance, fixed twin block was introduced by William J.Clark,
Biopedic appliance.
• Forsus fatigue resistance device was a three telescope appliance with a coil
spring. It was flat and made of super elastic nitinal. Nitinol is always at work
delivering consistent force.

• CLASSIFICATION :According to the forces produced.
• Appliances producing pushing forces: These appliances deliver a
pushing force vector, forcing the attachment points of the appliance away
from one another e.g.,
• Rigid. This appliances were designed to be firm. Though these
appliances appeared stronger they had the disadvantages of breakages.
Repairs from these breakages were time consuming.
• Herbst appliance and its modifications.
– Mandibular advancement repositioning splint (MARS)
– Mandibular protraction appliance (MPA)
– Eureka spring
– Universal bite jumper
– Mandibular corrector
– Biopedic
– Mandibular anterior repositioning appliance (MARA).
_ The ventral telescope
_ The magnetic telescopic device
_ The intraoral snoring therapy appliancewww.indiandentalacademy.com

Flexible
In order to overcome the problem of breakages the flexible fixed
functional appliances were designed.
Jasper Jumper
Churro jumper
Adjustable bite corrector
Klapper superspring corrector
Forsus.
The americ torsion coil
The bite fixer
The Scandee Tubular Jumper
II. Appliances producing a pulling force: These appliances created
pulling force vector between the points of attachment.
* SAIF (Severable adjustable intermaxillary force) spring
* Rick – A – Nator.

• APPLIANCES PRODUCING PULLING
FORCE

APPLIANCES PRODUCING PUSHING FORCE

• HERBST APPLIANCE
• The Herbst appliance was developed by Emil Herbst in the early 1900s.
Emil Herbst (1872-1940) was a German orthodontist who lived in Bremen,
Germany. He was a student of dentistry at the University of Leipzig where
he graduated in 1894.
• This device was on the of the early attempts to produce mechanically a
“jumping of the bite”, an idea that had been advocated earlier by Kingsley
(1880) among others. (Bite jumping is the production of a change in sagittal
intermaxillary jaw relationship by anterior displacement of mandible).
• Herbst presented his appliance (original banded design) for the first time at
the 5th International Dental Congress in Berlin in 1909 by the name
Okklusionsscharnier or Retentionsscharnier. Scharnier means joint, and the
word retention was added because the upper part of the appliance served
as retainer for an expanded maxillary dental arch by the incorporation of a
circumferential palatal platinum gold archwire.

HERBST DESIGN
TELESCOPING PARTS OF HERBST APPLIANCE

• APPLIANCE DESIGN:
• The Herbst appliance is a fixed bite jumping device for the treatment of
skeletal class II malocclusions.
• A bilateral telescopic mechanism attached to orthodontic bands keeps the
mandible in an anterior jumped position.
• Each telescope consists of a tube, a plunger, two pivots (axle), and two
locking screws that prevent the telescoping parts from slipping past the
pivots.
• Originally, the telescoping parts of the Herbst appliance were curved
conforming to curve of spee. The later designs were, however, as straight
as they are today.
• Until 1934, Herbst made the telescopes of German silver but recommended
gold in cases in which the appliance had to be worn for a longer period of
time (more than 6 months).
• The pivot for the tube is usually soldered to the maxillary first molar band,
and the pivot for the plunger is affixed to the mandibular first premolar band
• . The length of the tube determines the amount of bite jumping. Usually the
mandible is retained in an incisal end-to-end relationship.

• Originally Herbst was placing the telescope mechanism upside down with the
plunger attached to the maxillary molar crown and the tube on the
mandibular canine crown.
• Furthermore, the tube had no open end, thus not allowing the plunger to
extend behind the tube as was the case in later designs.
• The length of the plunger should be kept at a maximum to prevent it from
disengaging from the tube. A large interpivot distance prevents the plunger
from slipping out of the tube when the mouth is opened wide.
• Therefore the upper pivot should be placed distally on the molar band, and
the lower pivot should be placed mesially on the premolar band. If the
plunger is too long, however, it may protrude too far behind the tube and
injure the buccal mucossa distal to the maxillary permanent first molar.
• If the plunger disengages from the tube on mouth opening, it may get stuck
in the tube opening on subsequent mouth closure and damage the appliance
ie, break or loosen the bands.
• Besides opening movements small lateral movements of the mandible can
be performed with the Herbst appliance. This is possible because of loose fit
of the tube and plunger at their sites of attachment.

• Side Effects :
• Space opening distally to the maxillary canines.
• Excessive intrusion of 1st permanent molars
• Buccal tipping of the 1st premolars
• Instrusion of lower 1st premolars
• Proclination of lower anteriors.
• The Construction Bite :
• The patient is motivated and is allowed to practice to posture the mandible
forward with the midlines coinciding, in this new position the construction
bite is recorded. Wax bite is the blue print for the appliance.
• If acrylic splints are needed for anchorage, care should be taken that
sufficient vertical clearance is left for their construction.
• Goodman – Recommended the construction bite to be made in an edge to
edge position with facial midlines coinciding. This will usually leave large
space in the posterior segment.

• CONSTRUCTION OF HERBST APPLIANCE

EFFECTS OF HERBST APPLIANCE :
• The Herbst appliance is the effective modality in the treatment of class II
malocclusion.
• Normalization of occlusion is generally accomplished with 6 to 8 months of
treatment. Over corrected sagittal dental arch relationship and incomplete
cuspal interdigitation at the end of treatment are to be expected before
settling occurs.
• Improvement in sagittal and vertical occlusion relationships during
treatment is a result of both skeletal an dental changes (Pancherz, 1982).
Sagittal Changes
Skeletal
• Restrains maxillary growth and decrease of SNA angle. This many be
explained by growth processes in the cranial base displacing the nasion (N)
point more anteriorly, thus apparently decreasing the SNA angle.
• Increases mandibular length (Pancherz 1979,11 1981, 198213) which can
be attributed to condylar growth stimulation as an adaptive reaction to the
forward positioning of mandible.

Dental
• 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 segements and mesial tooth
movements in the mandible.
1. Arch Perimeter :
• The distalizing forces of the telescope mechanism of the Herbst appliance
on the upper 1st molars and anteriorly directed forces on the lower front
teeth, tend to increase arch perimeters in the maxillary and mandibular arch
during treatment (Hansen et al. 1995).
2. Arch Width :
• Hansen et al (1995) : During treatment the maxillary and mandibular dental
arches expand laterally in both canine and molar areas.
• In summary following changes contribute to Herbst appliance correction of
class II malocclusion.
• Stimulation of mandibular growth.
• Inhibition of maxillary growth (a less important change)
• Distal movement of upper dentition
• Mesial movement of lower dentition (proclination of the incisors)

VERTICAL CHANGES :
a) Skeletal :
• Increase in lower anterior facial height (LAFH) due to eruption of lower
posterior teeth.
• Increase in gonial angle.
b) Dental
• 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.
EARLY POST TREATMENT EFFECTS :
• Over corrected sagittal dental arch relationships and incomplete cuspal
interdigitation are generally seen after Herbst treatment. As active treatment
is short (6-8 months), the occlusion is unstable and adaptive occlusal
changes tend to occur.

Dental :
• 90% of the post treatment occlusal changes occur within
6 months after treatment are of dental origin. Upper teeth (especially the
molars) move anteriorly, the lower teeth move posteriorly and the incisors
become upright.
Skeletal :
• A catch up maxillary growth and minor reduction in mandibular growth are
apparent in subjects treated with the Herbst appliance in comparison with
untreated controls (Pancherz, 1981,13 Pancherz, Hansen, 1986).15
• Increase in lower anterior facial height seen during treatment is temporary.
LATE POST TREATMENT EFFECTS :
• When examining patients treated with the Herbst appliance 5 to 10 yrs after
treatment, several effects can be observed.
• Class I dental arch relationship is maintained by stable cuspal interdigitation
of upper and lower teeth.

Teeth locked in a stable forces to the mandible are more likely to
transfer maxillary growth forces to the mandbile (or vice versa) and thus
possibly act as restricting or stimulating factors on mandibular growth. Thus
a functionally stable occlusion after Herbst or any orthodontic therapy could
be more important for lasting treatment results than the post treatment
growth pattern (Pancherz, Fackel, 1990).
RELAPSE AFTER HERBST TREAMENT :
• Pancherz (1991)12 : Investigated nature of class II relapse after Herbst
treatment. Results reveals that relapse in overjet and sagittal molar
relationship resulted mainly from post treatment maxillary and mandibular
dental changes.
• In particular maxillary incisors and molars moved significantly to a more
anterior position in the relapse group than in stable group.
• IDEAL TREATMENT PERIOD FOR LONG TERM STABILITY:
• In order to favour occlusal stability after treatment and to reduce the time of
post treatment retention, Herbst therapy in the permanent dentition at or just
after peak height velocity is recommended.

EFFECTS OF FACIAL PROFILE :
• Pancherz, Anehus – Pancherz (1994) has evaluated short and long term
effects of the Herbst appliance on the soft tissue profile.
• Upper lip becomes retrusive, lower lip remains almost unchanged are the
treatment changes seen.
Post Treatment Effects :
• Reduction in the soft tissue profile convexity (excluding the nose) because
of normal jaw growth changes.
• Increase in the soft tissue profile including the nose convexity because of
normal nose growth.
• Retrusion of upper and lower lips in relation to the E line because of normal
nose and chin growth.
• Most favourable soft tissue profile changes are seen in subjects with
protrusive upper lips and retrussive chin and lower lips.

BENEFIT OF CLASS II PATIENTS FROM HERBST TREATMENT IN
TERMS OF IMPROVED TEMPORO MANDIBULAR JOINT FUNCTION:
Disc Position :
• A slight retrusion of the disc compared with pretreatment values is seen at
the end of treatment (Pancherz et al 1999;17 Ruf and Pancherz, 2000) can
be due to remodling process of condyle and fossa, remodeling of the disc
(Nagy and Daniel, 1992).
• Until further knowledge is available, the Herbst appliance must be
considered the only functional appliance able to improve the position of the
articular disc during treatment. With partial disc displacement, there is a
good prognosis for disc repositioning.
TIMING OF THE TREATMENT :
• Most favourable time to treat the patients with the Herbst appliance is at the
peak of pubertal growth spurt (Pancherz, Hagg, 1985).

SELECTION OF PATIENT FOR TREATMENT WITH HERBST
APPLIANCE:
• Skeletal morphology :
• Retrognathic mandible.
• Small mandibular plane angle.
• Dental Morphology :
• Class II dental arch relationship with increased overjet and normal or
increased overbite (Open bite cases not suitable for Herbst appliance).
• Maxillary and mandibular teeth well aligned.
• Maturation : Treatment during pubertal growth spurt.
• Multiphase treatment approach :
• Class II, division 1 malocclusion.

• Orthopedic phase
• Orthodontic phase
• Class II, division 2 malocclusion :
• Orthopedic phase
• REACTIVATION
• Reactivation is accomplished by : replacing the original tubes with longer
tubes and sliding short section of unused upper sleeve over each lower
plunger.
HERBST II WITH FIXED APPLIANCE

• HERBST APPLIANCE MODIFICATION :
• 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.
• The cast splint Herbst
• The bands are replaced by splints cast from cobalt-chromium alloy and
cemented to the teeth with GIC. The upper and lower front teeth are
incorporated into the anchorage through the addition of sectional arch wires.
• The cast splint appliance
– ensures a precise fit on the teeth
– is strong and hygienic
– saves chair time
– causes very few clinical problems.

LANGFORD’S STAINLESS STEEL CROWN DESIGN
HERBST WITH STAINLESS STEEL CROWNS
3) Herbst with stainless steel crowns
Norris M. Langford, (1982)37 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. He also suggested, making a small hole in the occlusal pit
of each crown to allow trapped air to escape and to provide even coverage of
cement around the tooth.

• 4) The bonded Herbst appliance
• Introduced by Raymond P Howe, (1982)40 to overcome some of the
limitations of the original banded appliance which were:
• Since the banded design is attached in the lower arch to first premolar
bands, the use of the appliance is limited to patients with erupted
mandibular first bicuspids. Although it is suggested that the mandibular
canine may be used in the anchor, when the first premolar has yet to erupt,
however, the buccal mucosa at the corner of the mouth is prone to
ulceration when the mandibular canine is used as an abutment tooth for the
plunger.
• Repeated breakage and loosening of the appliance occurs, especially in the
lower bicuspid band area.
• Rapid intrusion of the mandibular first bicuspids which though temporary,
partially deactivates the appliance.
• As the bicuspids are depressed, the lingual arch is also depressed, resulting
in impingement on the lingual gingiva.
• Possibility of incisal tooth fracture.

Design:
• Like the original design, this also includes paired telescoping elements. Also
these elements are attached to the maxillary arch as in the original appliance.
• However the paired telescoping elements, which had been attached to the lower
bicuspids bands are now attached to the entire lower dental arch by an acrylic
bite splint.
• The splint is constructed using a circumferential wire framework, which supports
the lower Herbst axles. The entire framework is embedded in an acrylic splint,
which extends from the last available molar tooth on one side, around the arch, to
the last molar tooth on the opposite side.
• The acrylic coverage begins at the free gingival margin on the buccal of the
posterior teeth and runs over the occlusal surface of the teeth, ending at the free
gingival margin on the lingual. In the anterior region, the splint is reduced from
the cervical, so that only the occlusal 1/3rd of the incisor and cuspid crowns is
covered with acrylic.
• The splint contains the lower pivots, which are positioned in the area of the
mandibular first bicuspids or deciduous first molars.
• The lower splint is bonded to all lower teeth including the Incisors, using a
conventional etching and bonding technique.

In 1983, Raymond P. Howe in his article on “Updating the bonded Herbst
appliance”, suggested using an acrylic splint for the maxillary arch as well.
The maxillary splint covers all available maxillary teeth with exception of the
central and lateral incisors. Acrylic coverage extends from the free gingival
margin on the buccal surfaces of the teeth over the occlusal, ending at the
free gingival margin on the lingual surfaces.
The occlusal thickness of the maxillary splint is kept to a minimum, so
that the cusps of the posterior teeth perforate the splint
• Advantages
• Allows attachment to the entire mandibular dental arch without the use of
orthodontic bands on the mandibular first bicuspid teeth - hence patients at
any stage of dental development can be fitted with the bonded Herbst.
• Intrusion of mandibular bicuspids is minimized.
• Tissue impingement of the lower lingual wire is prevented.
• Offers a degree of protection from incisal fracture.
• Incidence of failure of the appliance due to breakage is greatly reduced.

5) The Acrylic splint Herbst appliance:
• The bonded Herbst appliance eventually evolved into the acrylic splint
Herbst appliance (McNamara, 1988;23 McNamara and Howe 1988).
• Design:
• The acrylic splint Herbst appliance is composed of a wire framework over
which has been adapted, 2.5-3.0 mm thick splint Biocryl, using a thermal
pressure machine. If the maxillary splint is removable, the canine is
incorporated into the appliance. If the maxillary part of the appliance is to be
bonded in position, only the lingual surface of the maxillary canine is
incorporated into the arch. The maxillary splint covers the posterior dentition
but does not contact the upper incisors. The mandibular part of the
appliance always is removable. A splint covers the entire posterior dentition
as well as the lower anterior teeth. The mandibular part of the appliance
also covers the lingual surfaces of the anterior teeth and 1/3rd to 1/2 of the
labial surfaces of these teeth.
6) Headgear - Herbst appliance:
• Introduced by Weislander (1984)
• Wesilander suggested the use of special headgear - Herbst appliance in the
treatment of large sagittal discrepancies between the maxilla and mandible
in early mixed dentition.

• The Herbst appliance consisted of a cast of vitallium bonded to the lower arch
and with bands on the upper first permanent molars.
• The upper bands were united with a palatal bar and connected to the lower
splint with the Herbst telescopic arms.
• -A plate was constructed in the upper jaw as anchorage for a headgear worn
12-14 hrs/day A combination of high pull and low pull forces was used.
• Forces of 1500 gms to 2000 gm on each side were used.
• 7) Modified Herbst appliance for the mixed dentition:
• Introduced by Philip Goodman and Paul Mc Kenna, 1985
• 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 framework for both arches is made of 14 guage half round wire.
• The transpalatal bar made of 0.045" round wire, should be kept 1-1 1/2 mm
away from the palatal tissue.
• The maxillary pivots are soldered to the most distobuccal points of the crowns
and the mandibular pivots are soldered to the wire frame work, level with the
mesial aspects of the first deciduous molars.

• 8) Edgewise bioprogressive Herbst appliance
• This appliance introduced by Terry G. Dischinger, 1989, incorporates edgewise
brackets and bioprogressive mechanics in the Herbst design, to correct class II
malocclusion.
• The mandibular first permanent molars are banded. The maxillary arch is
completely bracketed, but usually only the incisors are bracketed in the mandible.
Stainless steel crown are placed on the upper first permanent molars and lower
1st bicuspids. An 0-040" lingual wire joins the mandibular crowns and bands. No
transpalatal bar is used in maxilla so that the first permanent molars can rotate as
the class II relationship is corrected by the Herbst mechanism.
DISCHINGER’S BIOPROGRESSIVE HERBST APPLIANCE DESIGN

• The Herbst rod and tube mechanism is attached to stainless steel crowns
on the maxillary first permanent molars and usually on the mandibular first
premolars. Double buccal tubes on the SS crowns serves as archwire slots
in the upper arch.In the mandible, an 0.022" x 0.026" slot on each stainless
steel crown accommodates the edgewise archwire.
• The maxillary arch wire sequence is the same as in any normal edgewise
case, the goal being to place an edgewise wire as quickly as possible to
maintain the torque on the maxillary incisors while the Class II malocclusion
corrected.
• Bioprogressive sectional mechanics are used in the lower arch until a utility
arch can be placed through the incisors brackets into the slots on the
stainless steel crowns.
• Dischinger stated that this appliance allows rapid correction of Class II
malocclusion without regard to patient cooperation. It allows orthodontic
tooth movements during orthopedic correction and permits a smooth
transition from Herbst treatment into fixed finishing appliances.

• 9) The EMDEN Herbst - a fixed removable Herbst appliance
• Introduced by Tarek Zreik, 1994,51 to overcome breakage problems, he
had with the Herbst appliance.
• In the Emden Herbst, 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.
• EMDEN HERBST – A FIXED REMOVABLE HERBST APPLIANCE

• MANDIBULAR SPLINT REMOVED FOR BRUSHING
• Double buccal tubes on the stainless steel crowns can hold utility, sectional
or continuous archwires.
• This modification makes the Herbst more durable, simple and hygienic.
• 10) Cantilevered Herbst appliance
• This was a design given by Larry W. White, 1994.33
• In this design, axles are soldered to the mesiobuccal surfaces of the
maxillary stainless steel crowns buccal tubes are also soldered to the
maxillary crowns, permitting simultaneous archwire placement in the
maxillary anterior region.
• In the mandible, stainless steel crowns on the 6 yrs molars are connected
with a lingual arch. The mandibular axles are soldered to buccal wires
extending from the molar crowns to the buccal embrasures between the
bicuspids. The buccal cantilever wire is made by doubling on 0.045" wire
and soldering between the two strands, which makes the wire almost
unbreakable.

•
CANTILEVER HERBST DESIGN
This design is particularly useful when mandibular bicuspids are absent or
the primary molars cannot withstand functional forces.
11). Edgewise Herbst Appliance
This design was given by Terry Dischinger, 1995.
This design is very similar to Dischinger’s edgewise bioprogressive Herbst
appliance, except that the appliance attachment to the mandibular arch is
different. In this the mandibular premolars are not crowned.
In most permanent dentition cases, the maxillary six anterior teeth are
bracketed and the bicuspids are not bracketed. The mandibular incisors are
bracketed with - 10° torque brackets to prevent tipping of the mandibular
incisors. In the mixed dentition only the incisors are bracketed.

• Stainless steel crowns are placed on the maxillary and mandibular
permanent first molars. Double buccal tubes on the molar crowns permit
use of an auxillary archwire to intrude the maxillary incisors.
• The maxillary arch is tied back to hooks on the molar tubes to prevent space
from opening between the upper molars and second bicuspids.
• In the mandibular arch, a 2mm half round Remanium cantilever is placed
between the first molar and the interproximal area between the first bicuspid
and cuspid. The axle is placed at the mesial end of the cantilever and an
0.022" x 0.028' archwire tube is placed above and below the axle.
• No TPA or lingual arch is used.
• A stop off the cantilever arm passes between the lower first and second
bicuspid and ends in the distal central fossa of the first bicuspid or the
mesial central fossa of the second primary molar. This prevents tipping of
the cantilever arm and impingement into the buccal mucosa.
12) MALU (Mandibular Advancement Locking Unit)
Stainless steel crowns are placed on the maxillary and mandibular
permanent first molars. Double buccal tubes on the molar crowns permit
use of an auxillary archwire to intrude the maxillary incisors.

• The maxillary arch is tied back to hooks on the molar tubes to prevent space
from opening between the upper molars and second bicuspids.
• In the mandibular arch, a 2mm half round Remanium cantilever is placed
between the first molar and the interproximal area between the first bicuspid
and cuspid. The axle is placed at the mesial end of the cantilever and an
0.022" x 0.028' archwire tube is placed above and below the axle.
• No TPA or lingual arch is used.
• A stop off the cantilever arm passes between the lower first and second
bicuspid and ends in the distal central fossa of the first bicuspid or the
mesial central fossa of the second primary molar. This prevents tipping of
the cantilever arm and impingement into the buccal mucosa
• The basic Herbst appliances mechanism can be attached in various ways
for treatment of class II malocclusion, depending on the patient’s age, the
treatment goals, and technical requirements.
• The mandibular advancement locking unit (MALU) a recently developed
attachment device, by Raffaele Schiavoni, Carlo Bonapace and Vittorio
Grenga, has several advantages over other Herbst appliances.
• - Low cost as no lab construction
• - Simplicity

HERBST WITH MALU ATTACHMENTS
Appliance Design
The MALU consists of two tubes, two plungers, two upper “Mobee” hinges with ball
pins and two lower key hinges with brass pins.
In the upper arch of the Edgewise Herbst MALU appliance only the first molars are
banded, with 0.051" headgear tubes. A palatal arch can be used in cases of over
expansion.
In the lower arch the first molars are banded and the anterior segment is bonded
from cuspid to cuspid with 0.022" brackets.
The bicuspids may be left unbracketed to help in settling the occlusion.
An 0.021" x 0.025" stainless steel archwire with slight labial root torque in the
anterior segment is bent back tightly at the distal ends.
Tip back bends mesial to the lower first molars are helpful in controlling the
incisors. www.indiandentalacademy.com

• 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 the 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.
• The length of the tube-plunger assembly is adjusted according to the
amount of mandibular protrusion, needed. The mandible can be
progressively advance using 1-5 mm spacers.
• 13. The Swedish Style Integrated Herbst Appliance
• Introduced by Paul Haegglund and Staffan Segerdal.38
• This is basically Herbst appliance integrated with an edgewise appliance.
• Forces form the Herbst appliance are distributed to the mandibular archwire
through a sliding auxilIary archwire of 0.9 to I mm (0.036") round stainless
steel.
• This auxiliary wire is attached to the main archwire posteriorly with 0.036"-
0.043" buccal tubes on the lower first molars, and anteriorly with elastomeric
module to surgical ball hooks or crimpable hooks, or with a posted archwire.

SWEDISH STYLE INTEGRATED HERBST APPLIANCE
FORCE OF HERBST APPLIANCE DISTRIBUTED TO MANDIBULAR
MAIN ARCHWIRE BY AUXILLARY ARCHWIRE

• COELHO DESIGN USING 1.5MM DIAMETER ROD ATTACHED
TO UPPER FIRST MOLAR AND SLIDING FREELY ALONG
AUXILLARY ARCHWIRE
DIFFERENT HOOKS USED TO ATTACH HERBST TUBES

• In cases, the first molar bands have only single tubes, the distal ends of the
auxiliary archwires are bent into “emergency hooks”. These hooks are then
attached to the main archwires mesial to the lower first molars, and locked
in place with elastomeric modules. However the sliding range is reduced.
• To connect the pistons to the auxiliary archwire the authors first used MALU
attachments with Cotter pin opening. Later they developed a modified piston
that can be connected to the auxiliary archwire at the anterior loop or distal
to it.
• The authors have also tried Coelho design of a 1.5 mm diameter rod
connected to the upper first molar and sliding freely along the auxiliary
archwire. For additional forward advancement, a coil or tube is added on the
auxiliary archwire distal to a stop in the canine region.
• The Herbst tubes are attached to headgear tubes or extra on the upper first
molar bands. The attachment is through hooks (made of 0.9- 1 mm, of
round stainless steel wire with ends annealed) or ball pins or wires with
stops in combination MALU attachments.

• HERBST APPLIANCE FOR BEGG’S TREATMENT
For Begg treatment, the Herbst appliance is combined with 0.022" x
0.016" ribbon archwires and T pins, or a round archwire with a torquing
auxiliary and passive uprighting springs or T pins.
The maxillary archwire should be constricted at its distal ends, to
counteract the expansion effect of the Herbst appliance.

• THE JASPER JUMPER
• The major drawback of the Herbst appliance is its lack of flexibility. This
restriction of lateral movements of the mandible lead to the introduction of the
Japser Jumper by Dr. James Jasper in 1987.
• The Jasper Jumper is a relatively new tooth borne functional appliance
capable of producing rapid change in occlusal and intermaxillary relationships.
It is a flexible fixed appliance that delivers light, continuous force that can
move teeth singly, in large groups or an entire arch to produce significant
dento-alveolar and profile changes.
• This appliance is flexible and can be attached between the maxillary and
mandibular arches to produce rapid interarch changes through the application
of either “Headgear” like forces, “activator” like forces or combination of both.

• Parts of the appliance:
• The system is composed of two parts the force module and the anchor
units.
• Force Module:
• The force module, analogous to the tube and plunger of the Herbst bite -
jumping mechanism, is flexible.
• The force module is constructed of stainless steel coil or 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 polyurethane covering for hygiene
and comfort.
• The modules are available in seven lengths ranging from 26 to 38 mm in 2
mm increments.
• They are designed for use on either side of the dental arch.
• When the force module is straight, it remains passive. As the teeth come
into occlusion the spring of the force module is curved axially as the
muscles of mastication elevate the mandible producing a range of forces
from 1 to 16 ounces.
• This kinetic energy is then captured when the force module is curved, and
the force is converted to potential energy to be used for a variety of clinical
effects.

• If properly installed to produce mandibular advancement, the spring
mechanism is curved or activated 4 mm relative to its resting length, thus
storing about 8 ounces (250g) of potential for force delivery.
• If less force is desired (e.g force levels that produce tooth movement alone),
the jumper is not activated fully.
• Increasing the activation beyond 4 mm does not yield more force from the
module but only builds excessive internal stress in the module. The
tendency to add more force for faster treatment result is to be avoided.
• Anchor units:
• A number of methods are available to anchor the force modules to either the
permanent or mixed dentitions.
• JASPER JUMPER

• 1) Attachment to the main arch wire:
• The most common method and the method originally designed by Dr.
Jasper.
• 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 then
extends anteriorly through the face bow tube on the upper first molar band.
• The ball pin is anchored in position by having the clinician place a return
bend in the ball pin at its mesial end.
• The module is anchored anteriorly to the lower arch wire (0.018"x 0.025" or
0.021" x 0.025").
• Bayonet bends are placed distal to the mandibular canines and small Lexan
bands are 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.

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.
• Replacement of a broken jumper required removal of the entire archwire.
• If an archwire breaks or becomes 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 are bent.
• Dr. Cope’s Method:
• Dr. Don Cope makes an attachment out of an 0.017" x 0.025" stainless
steel wire, soldered to a Rocky mountain lock, then bent so as to pass
distal to the lower first molar. The lock is attached between the bicuspid
and cuspid.

• An alternative is to place the lock distal to the molar bracket with the wire
bent distal do the cuspid. The approach uses a free sliding quick connect.
The wire runs parallel to the main archwire, allowing the jumper to clear the
bicuspid brackets.
• 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.
• Disadvantages :
• 1. Laboratory time is required to solder and bend the attachment.

USE OF FORCE MODULE IN MIXED DENTITION
In a mixed dentition patient the use of a transpalatal arch and fixed lower lingual
arch is mandatory to control potential unfavorable side effects.
Clinical Management :
Divided into 3 phases as advocated by Dr. Jasper
i) Levelling and anchorage preparation
ii) Period of Jasper jumper use (6-9 months)
iii) Period of finishing (12 months
3) Attachment in the Mixed dentition
The maxillary attachment is as previously described.
The mandibular attachment is through an archwire that extends from the
brackets on the lower incisors posteriorly to the first permanent molars
bypassing the region of the deciduous canines and molars.

MAXIMUM ANCHORAGE SETUP FOR FORCE MODULE
USE OF TPA COMBINED WITH FIXED APPLIANCES
USE OF LOWER LINGUAL ARCH COMBINED WITH
FIXED APPLIANCES

• Types of forces produces:
• Bilateral directions of force generated by the modules include sagittal,
intrusive and expansion forces.
• Sagittal forces
• - distalize the posterior anchor unit (maxillary Ist and 2nd molars).
• - Apply anterior force to mandible and mandibular dentition
• Intrusive forces
• - in the maxillary posterior and mandibular anterior regions.
• Buccal force
• - due to intrusive force acting along the buccal surfaces of the maxillary
teeth - produces maxillary arch expansion.
• Modules curving outwards - Vestibular shielding effect
• Expansion forces can minimized or eliminated through the use of a
transpalatal arch or a heavy arch wire that has been narrowed and to which
buccal root torque has been applied.
• .

• TREATMENT EFFECTS:
• Maxillary adaptations:
1) Head gear 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 extended 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
ii) 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.
• iii) Dental asymmetries
• The force module system also can be used in-patients who have sagittal
dental asymmetries.
• In a patient with a Class II subdivision type of malocclusion the maxillary
archwire can be tied back on the side of the existing Class I molar
relationship.
• Asymmetric orthopedic effects may also be achieved.

• Additional applications:
• Can be used to support anchorage for the retraction of maxillary anterior
teeth in patient with class I occlusions.
• In Class III malocclusion - reverse placement.
• Correction of anterior crossbites inpatients with pseudo class III
malocclusions.
• Post surgical stabilization of class II or class III malocclusions.
• V bend stopper (Gurukeerat Singh, JIOS 1998) used for the Jasper
jumper instead of the bayonet bend distal to the canine. Helps to separate
the anterior and posterior segments thus allowing: Placement of lingual
crown torque in the mandibular incisor area to prevent anterior tipping.
• Buccal root torque can be easily placed in the posterior segment when the
jumper is used to distalise the maxillary first molar or retract maxillary
incisors.

MARS APPLIANCE: (Mandibular advancing repositioning splint)
APPLIANCE DESIGN :
• The MARS appliance is a functional device attached to the archwires of a
multibanded orthodontic appliance designed to maintain Class II mandibles
in a protruded position.
• This appliance was introduced by Ralph M Clements and Alex Jacobson.
• 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.
• The purpose of the MARS appliance is to maintain the mandible in a
continuous protruded position during jaw closure as well as during all
opening and excursive movements.
• The MARS appliance effects a forward repositioning of the mandible by
using the principle of compressive struts rather than via tension, as with
Class II elastics, or via predominantly muscular repositioning as with
removable functional appliances.

Each strut is composed of two separate parts a piston or plunger and a cylinder
or hollow tube. These two components telescope together, forming an individual
strut. The free ends of the plunger and the hollow tube (struts) are attached to
the upper and lower archwires by means of a slot and set screw arrangement
which locks them securely into position on the archwire.
Two struts are required for each patient, one on the right side and one on the
left.
The original struts were made of headgear components. Presently the struts
made by Dentanrum is used along with the Rocky mountain lock (which have
set screws) for archwire attachment.
The hollow tube is attached by means of a slotted set screw attachment to the
upper archwire mesial to the most distal molar incorporated into the fixed
appliance.
The plunger is locked into position by means of a similar slotted set screw
attachment on the lower archwire distal to the lower canines.

• The locking mechanism, which is secured to the respective archwire, is
attached to the plunger and hollow tube by a loose fitting screw which allows
the struts to rotate about the point of attachment. The loose fit permits labial
movement of the mandible.
• All preliminary rotations, space closure and alignment procedures must
have been completed before attachment of the MARS appliance.
• The MARS appliance is always attached only to the heavy rectangular
archwires that fully engage the bracket slots.
• With the patients protruding the mandible into a Class I position, the right
and left strut lengths are measured.
• The MARS strut length is that distance from the middle of the interbracket
space distal to the lower canine to the middle of the interbracket space
mesial to the maxillary terminal molar.
• The upper member or hollow tube length is determined by subtracting a
calculated and standardized measurement of 7.4mm from the strut length.
The upper member is measured on the side opposite the attachment tab
and measurement is taken from the opening immediately beneath the tab.

The free end of the lower member or the plunger is then cut so that 2mm
extends out of the back of the upper member under the attachment tab.
One reference measurement needed for this appliance is the PIED (Protrusive
incisial edge distance). PIED is the horizontal distance, measured at the midline
between the maxillary and mandibular incisial edges with the mandible in its
maximum strained protruded position.
The MARS appliance should be locked into position with the mandible 2
to 3 mm posterior to the maximum PIED measurement. In the event a patient
encounters muscular discomfort as a result of protruding the mandible too far
forward the appliance is adjusted and locked in a less protrusive position.
At subsequent appointment the PIED should be measured and recorded. The
authors have observed that the PIED will increase from 0.5 to 2 mm between 3 to
4 week appointment intervals. When the PIED ceases to increase between
appointments, the MARS appliance is then adjusted so that a super Class I
occlusal relationship is obtained.

• Two methods to lengthen the appliance:
• 1. Replacement of the struts with longer upper members of cylinders.
• 2. Placement of spacers 2 to 3 mm in length on the lower members or pistons.
• To ensure a good, stable Class I occlusal relationship the MARS appliance should be
adjusted to a point at which the mandibular incisal edges are 2 to 3mm anterior to
their final desired (position) to allow for some relapse on removal.
• When no further increase in PIED can be detected at two subsequent appointments,
the MARS appliance is removed.
• Unlike the Herbst appliance. the MARS appliance:
• 1. Requires neither soldering nor extensive lab procedures.
• 2. Has minimal incidence of breakage
• 3. Does not depress the canines, open spaces in the premolar area or flare
mandibular incisors (provided the mandibular rectangular arch wire is tied back to the
terminal molars)
• Is easily attached and removed from the arch wire.
• Can be placed at an appropriate time during treatment.
• Disadvantages :
• Need for a fixed multi-banded appliance limits use in mixed dentition cases.
• Disarticulates the posterior segments form 1 to 3 mm
• Need for custom sizing of each appliance for each patient.

• MANDIBULAR PROTRACTION APPLIANCES:
• These appliances were 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.
• The are also effective in treating Class I patients with exaggerated
overjets and Class II subdivision patients where only one side needs
correction.
• Mandibular protraction appliance No.1 (MPA 1):
• Requires stainless steel edgewise arches in both arches.
• The mandibular archwire requires stops such as circles, crimpable
hooks, or loops distal to the cuspids to prevent direct contact between
the appliance and the bonded brackets.
MANDIBULAR PROTRACTION APPLIANCE NO.1
STOPS PLACED DISTAL TO CANINE

• Bonding the cuspids and planning a connecting lingual arch allows the
clinician to use the cuspid brackets as stops as well.
• The lower archwire should have enough lingual torque in the anterior region
to resist labial displacement of the lower incisors form the protrusive
pressure of the appliance.
• It should be tightly cinched back with a tip down distal to the mandibular
tube or with a tie back.
• The maxillary archwire does not need a stop, tieback or special torque
adjustment.
• Each side of the appliance is made by bending a small loop at a right angle
to the end of an 0.032" stainless steel archwire.
• The length of the appliance is then determined by protruding the mandible
into a position with proper overjet, overbite, and midline correction and
measuring the distance from the mesial of the maxillary tube to the stop on
the mandibular archwire.
• Another small right angle circle is then bent in an opposite direction into the
other end of the 0.032" stainless steel wire.
• The angulation of these circle bends can vary to allow free sliding along the
mandibular archwire. One appliance circle is placed over the maxillary
archwire against the molar tube and the other circle against the mandibular
archwire stop. Both circles are then closed completely with a plier.

Functioning of the appliance:
1. It slides distally along the mandibular archwire and mesially along the maxillary
archwire upon opening and returns to rest against the mandibular archwire stop
and the maxillary buccal tube on closing.
2. To allow sufficient clearance for sliding along the mandibular wire, bicuspid
brackets must be omitted and a buccal offset in the lower archwire is often
needed.
Filho noticed significant changes within four months with this appliance. With
careful patient selection and judicious use this first design works quite effectively.
Disadvantages:
Impossibility of bonding the lower bicuspids
The appliance’s limited mouth opening
Frequent dislodgment of molar bands led Filho to develop the 2nd protraction
appliance.

• Mandibular protraction appliance No.2 (MPA 2)
• The MPA No.2 is fabricated by making right angle circles in two pieces of
0.032" stainless steel wire.
• A small piece of rigid coil or stainless steel tubing is slipped over one of the
wires. The coils may be made form 0.024" stainless steel wire with tweed
loop bending plier. One end of each wire is inserted through the other wire’s
loop so that each wire passes through the other up to the limit of the wire
coil. The coil prevents the two wires form interfering with each other and
ensures their correct relationship.
• The maxillary edgewise arch is made with an ordinary amount of anterior
torque and with occlusally directed circles against the molar tubes.
• The mandibular edgewise archwire should have sufficient torque in the
anterior portion to resist labial incisor inclination and should have occlusally
directed circles placed 2-3 mm distal to each cuspid.

MANDIBULAR PROTRACTION APPLIANCE NO.2
The lower archwire should be firmly cinched back or tied back.
•The appropriate length of each arch wire assembly is determined by placing
the archwires in the mouth with the correct overjet, overbite, midline and
molar occlusion.
•The distance between the mesial surface of the maxillary molar tube and
the mandibular circle is then measured on each side.
• This distance is transferred to each wire assembly and attachment loops
are bent in the wire ends for the maxillary and mandibular archwire circles.
•The 2-3 mm distance between cuspid brackets and mandibular archwire
circles allows adjustment for asymmetries that may develop during
treatment.

• By simply sliding the archwire to one side or the other the midline can be
attained and more pressure put on one side of the mouth.
• Both MPA No, I and No.2 rely on a combination of condylar growth and
dentoalveolar adaptation to achieve a Class I posterior occlusion.
• 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 needed Easily inserted adjusted and
removed 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
• Easily adaptable for preserving maxillary molar and mandibular incisor
anchorage when minimal movement of these teeth is required.

Mandibular Protraction appliance No.3 (MPA No.3)
• The limitations of the first two MPA designs namely problems of breakage,
restricted opening and patient discomfort associated with MPA No.1 and the
difficulty of chair side construction of the MPA
• No.2, have been over come 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.
• MANDIBULAR PROTRACTION
APPLIANCE NO.3
MANDIBULAR PROTRACTION
APPLIANCE NO.3
(Showing maximum opening)

• Appliance construction:
• The parts needed for the construction of the MPA No.3 are
• Two maxillary tubes of 0.045" internal diameter each about 27 mm long.
Two maxillary loops of 0.040" stainless steel wire, each about 13 mm, long,
with a loop bent into one end at an angle of about 130 to the horizontal.
• Two mandibular rods of 0.036" stainless steel each about 27 mm long.
• Four pieces of band material Two short lengths of annealed 0.036" stainless
steel wire, each with a loop in one end, for attaching the appliance to the
maxillary molar headgear tube.
• Weld each maxillary tube to a maxillary loop. Weld two pieces of band
material around the combined wires, this will eliminate the use for soldering.
• Prepare a stainless steel edgewise mandibular archwire by bending an “0”
loop on each side distal to the cuspid winding the wire twice around a tweed
loop forming plier. (preferably 0.019 x 0.025" wire, 0.016 x 0.022" or 0.017 x
0.025" also acceptable).

Appliance placement:
• Place the mandibular archwire in the mouth so that enough wire extends
distal to the molar tube for a bend down tieback. The 2nd molars may be
included to increase anchorage. More working space available if a simple
2x6 bonded appliance is placed.
• The maxillary arch can be fully or partially bonded using any type and size
of archwire. Round or Edgewise, stainless steel or nickel titanium.
• Attach the maxillary tube to the distal end of the maxillary first molar
headgear tube by threading the short annealed stainless steel pin through
the loop of the MPA tube and then through the headgear tube.
• Bend the annealed pin down mesial to the headgear tube.
•Prepare each 0.036" mandibular rod by making a 90o bend at one end.
Place a small piece of tubing over the same end then crimp and weld it so it
stays fixed. Insert the longer leg of the mandibular rod through the “0” loop in
the archwire from the lingual. Manipulate the rod upward until it is nearly
perpendicular to the wire.

Ask the patient to position the mandible to correct any overbite, overjet and
midline deviation, ‘then the assembled maxillary tube to measure the
distance from the distal end of the headgear tube to the “0” loop on the
mandibular archwire. Mark and cut the tube at this point.
• The MPA No.3 almost unrestricted opening to atleast 50-55 mm. It can also
be used unilateralIy.
• Adaptations of the MPA No.3:
• 1. If the maxillary tube assembly is cut short of a fulIy protruded mandibular
position, a nickel titanium open coil spring (0.045" internal diameter) can be
placed over the mandibular rod between the maxillary tube and the end of
the rod. This design may reduce the orthopedic protrusion, but provides a
gently continuous Class II force. The force is small enough that the
mandibular rod can rest directly against the cuspid bracket without risk of
breakage. However there is a mesial rotation of the cuspid.
• 2. By reversing the direction of MPA No.3, it can be used to correct Class III
malocclusions and anterior cross bites.

• MANDIBULAR PROTRACTION APPLIANCE NO. III
FOR CLASS III PATIENTS
Advantages over 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
dentoalveolar movement
Causes less breakage.

• ADJUSTABLE BITE CORRECTOR (ABC) (Richard P. West)
• APPLIANCE DESIGN :
• The appliance essentially consists of :
• A stretchable closed coil spring and internally threaded end cap that allows
the parts to rotate freely like a nut on a bolt.
• The axial or “push force is generated by a length of a nickel titanium wire in
the centre lumen of the spring.
ADJUSTABLE BITE CORRECTOR
ADJUSTABLE BITE CORRECTOR FOR MIXED DENTITION

The closed coil spring is made of 0.018" stainless steel, and will stretch to
about 25% beyond its original length without permanent deformation. This
allows additional range of opening with no risk of breaking the appliance or
accidentally changing its length.
The ABC can be used on either side of the mouth with a simple 1800
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 :
As long as the ABC is opened at least one half turn prior to placement, the
device will always swivel away form the occlusion during function.
Failure to remember this point may cause a patient to have difficulty
closing mouth without biting on the spring.
This universal feature greatly reduces inventory

• b) Adjustable length and force:
• A special ABC measuring gauge makes size selection simple.
• After the patient has postured forward into an improved profile with ideal
overbite / overjet, then 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 ensures optimum force delivery.
• If the measurement is between sizes, remove one end cap and exchange
the nickel titanium wire for one of the proper length, cut from the extra wire
provided in the kit. Unscrew each end cap and adjust length of spring. The
ABC can be lengthened as much as 4 mm or 2½ turns at each end. Beyond
this there are changes of the spring pulling out of the end cap when the
patient opens wide.
• The adjustable feature can be used for treatment of asymmetrical problems
or midline shifts, for changing anchorage as treatment progress, or when
force needs to be varied.

• Mixed dentition treatment:
• In Class II patients requiring maxillary expansion, the ABC can be attached
to a bonded palatal expander, with headgear tubes embedded in the acrylic
or normal buccal attachments in the upper molar bands.
• When measuring for ABC size in such a case. move the lower point of
attachment distally to create a more vertical force. This will prevent the open
bite that often occurs during palatal expansion.
• Permanent dentition treatment:
• The ABC inhibits forward growth of the maxilla while encouraging maximum
functional effect and forward growth of the mandible.
• The simplest method of attaching the ABC to the lower molar is by a jig to a
lip bumper or auxiliary archwire tube in the molar bracket.
• A tieback or tie down loop in the jig will ensure that forces are not
concentrated at the lower anterior teeth if the distal bend in the archwire
should break off.
• All jig wires should be bent with gentle curves in both horizontal and vertical
planes. Sharp bends will cause binding and interference as the ABC slides
back and forth during function.
• Attachment to the upper molar is through the molar clip or eyelet pin.
• If the treatment goal is to distalise the upper molars, a section of active open
coil spring can be placed on the archwire between the molars, so the force
of the ABC at the first molar is transmitted to the 2nd molar as well.

• Anchorage :
• The ABC can be used for upper molar anchorage control during retraction of
anterior teeth for space closure.
• The Class II “push” force of the ABC creates full time maximum anchorage
at the upper molars while bringing the lower posterior teeth forward form the
pull at the jig attachment.
THE EUREKA SPRING
• Introduced by John De Vincenzo (1997).
• Components
• The main component of the Eureka spring is an open wound coil spring
encased in plunger assembly
• The ram is made form 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 opening clamp that
attaches directly to the archwire.
• The plunger has a tolerance of 0.002" within the cylinder. A triple
telescoping action permits the mouth to open as wide as 60 mm before the
plunger becomes disengaged.
• The cylinder assembly is connected to a molar tube with a an 0.032" wire
that has been annealed at the anterior end.
• An 0.036" solid ball at the posterior end acts as a universal joint, permitting
lateral and vertical movements of the cylinder.

EUREKA SPRING

The Eureka spring comes in only 2 sizes one for extraction and one for non-
extraction cases and left and the right sides are interchangeable.
Advantages :
1. Ability to function without the need for patient co - operation
2. Esthetic acceptability of the Eureka spring because of its small size and lack of
protuberances into the buccal vestibule, is almost invisible.
3. Resistance to breakage: produces forces of only 140g-170g at the points of
attachment as compared to 220-280g of Jasper Jumper.
It never functions in any mode other than straight compression which is evenly
distributed over the entire length of the spring.
The spring life is 3 to 6 months.
4. 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.
5. Functional acceptability to patients. Promoted by its miniaturization and worry
free operation, as well as its rapid movement.
6. Ease of installation - No auxiliary archwires or extra impressions for laboratory
fabrication are needed.
7. Low cost: similar in cost to the Jasper jumper but less expensive than the fixed
Herbst appliance.

• 8. Minimal inventory requirement
• 9. Optimal direction of force
• Delivers a push force against mandibular anterior and maxillary posterior
teeth.
• It also has a vertical intrusive component at the maxillary molars and
mandibular incisors although this is minimal due to direct archwire
attachment, rather than via an auxiliary wire.
• THE CHURRO JUMPER
• Introduced by Ricardo Castanon, Mario S Valdes and Larry Wh ite (1998).
• The Churro Jumper furnishes orthodontists with aneffective 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.
CHURRO JUMPER

• Mode of action:
• In its passive form, the Churro is not flexed
• However when the pin is pulled forward enough to cause the jumper to bow
outward 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 incisors as it attempts to straighten.
• Unilateral I Bilateral use:
• This jumper can be used unilaterally in cases of Class II subdivision
malocclusions.
• The bilateral Class II Churro jumper is most suitable for patients who need
mandibular incisors advancement. Not a very good choice for Class II
bimaxillary proclination cases.
• By reversing the attachments, the Churro jumper can also used to treat
class III malocclusions.
• Advantages :
• Provides a constant, indefatigable force.
• Can be used either unilaterally or bilaterally.
• Can be used in Class II or Class III cases.
• Helps maintain anchorage.
• Very inexpensive.
• Can be constructed from commonly available materials universal in size.
• When broken, easily replaced.
• Staff members can quickly learn how to replace an appliance.

• Disadvantages :
• Restriction of mouth opening to 30-40 mm
• Archwire breakage if larger wires not used.
• Patients with a low tolerance for discomfort will often break the appliance.
• Patients who incessantly move their mouths while chewing, taking and
nervous tics will fare poorly.
• Its maximum effectiveness depends on a permanent dentition to retain its
effect.
• It must be manufactured in the office.
• THE UNIVERSAL BITE JUMPER
• Introduced by Xavier Calvez (1998)
• This is a fixed functional appliance 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. It can be used in Class III cases if mounted in a
reverse configuration.
I) Fixed appliance configuration
In its normal configuration, the UBJ is attached to the maxillary headgear tube
with a ball pin which is bent so it can be tied with a ligature to the hook on the
molar band. A TPA or expander can be used to control palatal width.

• In the mandibular arch the sliding rod ends in a 90° hook that is fixed to the
archwire. The premolars should be left free, while 0.022" brackets are
banded from canine to canine.
• The 0.021" x 0.025" mandibular stainless steel archwire should have a stop
and a buccal offset to allow clearance for sliding, should be cinched back
tightly and also be attached to an auxiliary sliding arch wire which is fixed in
two places to the main arch.
UNIVERSAL BITE JUMPER ATTACHED TO FIXED APPLIANCE
No laboratory preparation is required. The UBJ is fitted in the patient’s
mouth and cut to the appropriate length for the desired mandibular
advancement. www.indiandentalacademy.com

UNIVERSAL BITE JUMPER ATTACHED TO AUXILLARY ARCHWIRE
UNIVERSAL BITE JUMPER ATTACHED TO LOWER CANTILEVER

• II. Lower cantilever configuration:
• In this design the loop on the rod is fixed to a lower cantilever, consisting of
a 2.4 mm x 1.4 mm oval Remanium wire, with a welded ball clasp, from the
mandibular molar crown to the interproximal area between mandibular 1 st
premolar and canine.
• An 0.048" welded lingual arch links the two mandibular molars and contacts
the lingual surface of the mandibular incisors. An 0.025" tube adjacent to the
cantilever allows positioning of the mandibular incisor realignment archwire.
• Thus advantage of this configuration is the possibility of immediate
orthopedic action without waiting for dental alignment.
• III. Removable splint mounting
• When used with removable acrylic splints, two lateral UBJ s link the
maxillary molar areas and the mandibular first premolar areas.
• They are attached to 1.2mm ball clasps, which are constructed on the
working cast and then incorporated into the thermoformed splints. The lower
loop of the UBJ should be oriented in an anteroposterior direction. A single
median UBJ can be used to link

LATERIAL UNIVERSAL BITE JUMPER ATTACHED
TO REMOVABLE SPLINTS
TWO LATERAL UNIVERSAL BITE JUMPER WITH NITI COIL SPRINGS
FOR CLASS III TREATMENT

• the removable splint from the middle rear area of the palate to the lingual
surface of the mandibular incisor. The UBJ is attached to two transverse
axles, which allow opening and lateral movements. The median UBJ
provides muscular therapy as it prevents the tip of the tongue from
contacting the lower lip.
• Most children are able to speak well with this appliance, given a little time to
adjust. Cheek impingement is eliminated and it is the author’s experience
that the tongue is not irritated with this design.
• Adjustments :
• The UBJ is generally set to obtain to 2/3rds of maximum mandibular
advancement.
• Reactivation are made every 6 to 8 weeks by crimping 2 to 4 mm splint
bushings on to the rods.
• Midline or asymmetrical problems can easily be treated by adjusting one
side or other of the appliance.

• Advantages:
• The UBJ offers the following advantages
• Simple, study and inexpensive
• Inventory requirements are minimal
• Can be used at any stage of treatment
• 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 good
• Can easily be attached to removable splints for maximum anchorage.
• MANDIBULAR CORRECTOR
• Introduced by Narston Jones (1985) It is a fixed functional appliance that
uses bilateral piston and plunger telescopic mechanism to reposition the
mandible anteriorly and is directly attached to archwires of a multi banded
fixed appliance.

It is used with nearly full sized edgewise archwires - 0.0175" x 0.025" in 0.018"
slot and 0.021" x 0.025" SS in 0.022" slot 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.
The length of the repositioning arms are determined intraorally with the patient’s
mandible advanced 3-4 mm. The entire procedure can be completed at chair
side in 30 minutes.
The mandible can be advanced in small increments of 2-4 mm at 4 week
intervals until the incisors are in an edge to edge relationship. Midline
corrections are made by advancing the appliance more on one side.
A correction of 3-4 mm can be achieved within 6 months, an overjet of 7 to 8
mm may require 12-14 months.
When an over treated Class I occlusion has been achieved, the appliance is
removed and short class II elastics are placed to bring the posterior teeth into
tight intercuspation.

• THE HORIZONTAL ANTERIOR POSITIONING
• Introduced by William E. Harrell (1988).
• The HAP appliance is a fixed functional appliance that both repositions the
mandible and permits expansion and / or movement during the TMJ stabilization
phase.
• The components of the appliance are:
• The anterior reverse ramp, which allows for sagittal movement of the anterior
teeth using sagittal screws, anterior repositioning to reduce anterior disc
dislocation; encouraging growth possibilities in Class II retrognathic children; and
torquing of maxillary anterior teeth with fixed appliances, when the anterior lip of
acrylic is removed.
• Expansion arms on the lingual of the cuspids and bicuspids, which allow
expansion and keep the incisors from dumping lingually during the use of buccal
seating elastics.
• The coffin spring, which connects the two sides of the appliance, adds
strength, and can be used for molar expansion or rotation.
• A locking mechanism, consisting of a soldered half round tube and lock wire,
that holds the appliance in place.
• A lower “dipod”, which provides upper and lower posterior occlusal support. A
posterior pad can be added to the HAP, but adjustments become more difficuIt
and the possibility of breakage increases.
•The vertical dimension can be increased if necessary. The bite opening effect
allows for passive or active eruption of the posterior occlusion to help level the
curve of spee. www.indiandentalacademy.com

HORIZONTAL ANTERIOR POSITIONING APPLIANCE
A)Sagittal screws
B)Anterior reverse ramp
C)Expansion arms
D)Coffin spring
E)Locking mechanism

• THE MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE (MARA)
• Is probably the most recent fixed functional appliance to become
commercially available
• It was introduced in 1998 by Ormco / A company after extensive
development and testing by Douglass Toll of Germany and James Eckhardt
of U.S.A.
• 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. Additional activations can be made by placing
one or more shims at the mesial aspect of the horizontal bar.
• Advancing the mandible forward In precise increments can be achieved by
insertion of selected shims of varying length.

MARA APPLIANCE
Advantages over Herbst
Better esthetics
Problem with disengagement do not occur
Breakage from lateral mandibular movements
sbould be less.
Can be used concurrently with. full edgewise
orthodontic appliance.
Therefore this
a) Eliminates the need for a 2 phase treatment.
b) Can maintain the achieved orthopedic results, since the appliance can
continue in a non activated manner.
Disadvantages
Temporary stainless steel crowns needed on all first molars.
Some increase in anterior facial height results from the placement of these
crowns.
Fabrication only available at one commercial laboratory.
The posterior and buccal location of the guide planes may cause loosening
of the stainless steel crowns or breakage of the mandibular protruding
horizontal bar.

THE BIOPEDIC
Designed and introduced by Jay Collins in 1997 (GAC)
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. This
short maxillary rod is inserted from the distal and fixed by similar screw at the mesial
of maxillary 1st molar. The two rods are connected by a rigid shaft and have pivotal
region at their ends.
BIOPEDIC

• Although, it appears that there would be limitation of mandibular opening, it
is not so. The anterior extension of the mandibular rod reaching only to the
region of the second premolar and the maxillary molar attachment beginning
at the distal of the molar crown work more in harmony with the arc of
mandibular opening.
• Advantages
• Can be used concurrently with banded treatment.
• Esthetic benefit
• Capability of adjusting the amount of protrusive activation.
• Disadvantages
• Potential for more breakage and loose crowns
• Greater cost.
• Need for crowns on molars

• THE SAIF SPRING (SEVERABLE ADJUSTABLE INTER MAXILLARY
FORCE)
• First interarch force system developed by Armstrong.
• In the later 1960’s and early 1970’s he introduced the Pace Spring, later
termed Multicoil spring and finally called Saif spring.
• These were first marketed by North West orthodontics, later by Unitek, and
currently by Pacific coast manufacturing.
• They consist of two springs one inside the other with soldered loops on each
end.
• Various attachments can be placed through these loops to secure the
springs to deliver either Class II or Class III force.
• They are available in 7 mm and 10 mm lengths, have an outside diameter of
3 mm, and deliver 200 to 400 gms of force.
• Breakage is a constant problem.
• Bit. bulky, not very hygienic and there is some limitation to mandibular
opening
• However large forces are generated by these springs which may account for
the surprisingly rapid correction observed.

• Introduced by Lewis Klapper in 1997,34 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.
The Klapper superspring II inserts from the mesial and is rigidly secured to the
molar by an oval attachment tube. The Klapper superspring creates a distal root tip
movement on the molar, this may be desirable in some patients.
Because the Klapper superspring inserts gingivally on the molar and cannot roll to
the buccal as readily as the Jasper Jumper, there may be a greater vertical
component to the force vector a pronounced curve of spee levels faster.
•THE KLAPPER SUPERSPRING II

• Disadvantages
• Requirement of a special molar tube
• Lack of adaptability to correct class III conditions
• Limitation to maximal opening
• Potential injury to the patient if breakage occurs and the rigid molar
attachment forces the broken portion into the soft tissues.
• Extended wear may cause excessive root distal tipping to the maxillary
molar and more intrusion at the molars and incisors than desired
• Palatal root torque may be excessive
• No statistical results of clinical trials are available to date.
• RICK-A-NATOR
• This appliance consistence of two maxillary first molar bands attached to
anterior bite plate via two 0.036" connector wires. This incisal ramp
encourages the mandible to come forward which corrects the Class II molar
relationship to a Class I and eliminates the overjet.

• Parts of Rick - A - Nator
• 1. Two molar bands with lingual attachments which could be
• a) Fixed (soldered)
• b) Mia attachment (mesial direction)
• c) Mershon attachment (vertical direction)
• 2. 0.036" connector wire from molar bands to incisal ramp.
• 3. Incisal ramp (clear acrylic)
• Tvpes of Rick - A- Nator
• When construction the Rick-A-Nator the clinical must decide whether the
appliance is to be fixed or fixed removable.
• a. Fixed attachment:
• The type has the 0.036" wires soldered directly to the lingual of the molar
bands. One important advantage of this type is that the patient cannot
remove the appliance and thus you are assured of 24 hours of wear time.
Also with the fixed type there is less breakage and the appliance is more
stable.

• b. Mia attachment:
• The female part of the Mia attachment is soldered to the lingual of the molar
band.
• The male part is soldered to the 0.036" connector wire and fits into the
female part form the mesial.
• After the molar bands are cemented, the appliance can easily be removed
by the patient or the clinician in a mesial direction.
• The disadvantage with the fixed types are that if the patient wants to remove
the appliance to eat or clean it, they cannot do so. Also, if the clinician wants
to remove the appliance to reline the acrylic, he first needs to remove the
cemented molar bands
• c. Mershon attachment
• The female part of the Mershon attachment is soldered to the lingual of the
molar band.
• The male part is soldered to the 0.036" connector wire and fits into the
female part from the vertical.
• This attachment enables the clinician to remove the appliance with relative
ease but makes it more difficult for the patient. The appliance is removed in
a vertical direction.

• FORSUS NITINOL FLAT SPRING
• Flat nickel titanium spring.
• Attaches to maxillary molar bands with an attached pin & loop assembly:
Link n loop.
• Other end of the spring connects to the mandibular arch Wire or an auxiliary
bypass arch. Produces 225-250 gram of force when it is compressed 5mm
for initial activation. Delivers a constant level of force from insertion to
removal
• FORSUS

• Advantages
• Doesn’t require time consuming & expensive lab work.
• Produces consistent treatment results in a predictable amount of time.
• It can deliver an orthopedic effect to both jaws or more of a dentoalveolar
effect.
• Can be activated on one or more side than on the other, so it excels at
correcting midline deviations.
• ACTIVE VERTICAL CORRECTOR
• The A VC consists 2 posterior occlusal splints, one for the upper & one for
the lower jaw.
• Samarium cobalt magnets are incorporated into the occlusal splints over the
occlusal region of the teeth to be intruded. One magnet per distal quadrant
is used

• The magnets in the upper splints are incorporated in a mode to repel the
magnets in the lower splints. Therefore the appliance is a combination of
acrylic posterior bite blocks & repelling magnetic forces
• To prevent unwanted crossbite development due to the shearing forces of
repelling magnets angled buccal flanges are added to the lower occlusal
splints to stabilize the appliance during lateral jaw movement.
• A heavy gauge stainless steel wire connects the occlusal splint of each
arch. The magnets are cylindrical in shape with a diameter of 10mm. The
magnets along with bite blocks measures 12mm in height.
• Because SmCo is a highly reactive rare earth material they are best kept
isolated from the oral environment.Hence, they are hermetically sealed in
stainless steel capsules.

• The magnet generates a force of 700 gm per unit at zero air gag in
repulsion.. If the anterior opend bite is of skeletal origin than dental origin, it
is preferred.
• Hence, patients in the growing age & in the mixed dentition period are
preferred to elicit maximum skeletal response.
• While registering the bite, 5-mm clearance is given at the posteriors, 1mm
more than the actual measurement of 4mm required by the magnet for
safety.
• When the posteriors are intruded auto rotation of the mandible takes place
& the mandible moves anteriorly to close the open-bite. The A VC can be
cemented or bonded. At the end of 12 weeks the appliance can be re-
moved & be used as a removable appliance.

• VENTRAL TELESCOPIC (PROFESSIONAL POSITIONERS)
• This was the first telescopic rigid fixed functional appliance that appeared as a single
unit.
Design :
It is available in 2 sizes and fixing is achieved through ball attachments the
operation is simple and is carried out by unscrewing the tube thus allowing an
activation of around 3mm.
Disadvantages :
It is quite thick and suffers from fractures to the brake which stabilizes the joint.
Accuracy is necessary with regard to inclination and the welding of
components.

THE RITTO APPLIANCE
The main advantages of this appliance are, it eliminates the time lost in
measuring length before fitting as in other appliances. This feature makes it
possible to fit the appliance in approximately 5 minutes and remove it in half
that time. It is simple to use, comfortable breakage resistance and requires no
patient cooperation.
Appliance Design :
It consists of steel ball pin and a lock. Upper fixation is carried out by placing a
steel ball pin from the distal into the .045 headgear
RITTO APPLIANCE
tube on the upper molar band, through the appliance eyelet and then bending
it back. 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. www.indiandentalacademy.com

Activation :
• Activation is achieved by sliding the lock along the lower arch in the distal
direction and then fixing it against the Ritto Appliance.
• 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.

TWIN FORCE BITE CORRECTOR (PUSH TYPE):
Concists ball and socket joint fasteners allowinng wide range of motion and
lateral jaw movements
DESIGN:
Two plunger/ tubes telescopic asssemblies on each side with NITI coil springs
delivering constant force (average compressive force 210 gm)
Attachment by Hexnuts to maxillary and mandibular arch
Mesial to maxillary first molar and distal to mandibular canine
On full compression mandible postured to edge to edge
Skeletal and dental changes
↓ANB
↓NAPg
↓AB (OP)
↓AB (FH)
↓ Overjet www.indiandentalacademy.com

CONCLUSION
So in conclusion, though fixed functional appliances have a track record
showing proven efficiency, a correct diagnosis of the problem area in the class
II malocclusion is paramount for successful treatment with fixed functional
appliance.
As Maslow said, If your only instrument is a hammer then every problem looks
like a nail. If your only orthodontic tool for correcting class II malocclusion is a
protractor then every class II seem like mandibular retrusion and clearly not
everyone is.
A complete understanding of possibility and limitations of the treatment will help
the clinicians to avoid failures and disillusionment.

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• John Devincenzo. The Eureka Spring : A New Interarch Force Delivery
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treatment. A prospective longitudinal magnetic resonance
imaging and cephalometric radiographic investigation. AJO-DO,
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