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FIXED FUNCTIONAL APPLIANCES

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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Contents
Classification
Herbst appliance
Type 1, II, IV
Modifications of Herbst appliance
Cast splint herbst, Herbst with ...
Mandibular Protraction appliances :
MPA 1,MPA 2, MPA 3 ,
MPA4
Adjustable Bite corrector (ABC)
The Eureka Spring
The churro...
THE TWIN FORCE BITE CORRECTOR
ALPERN CLASS II CLOSERS
Mandibular Corrector
The Horizontal Anterior Positioning (HAP)
appli...
Classification
According to the forces produced:
Appliances producing pushing forces
Appliances producing pulling forces...
Appliances producing
Pushing forces:
 These

appliances
deliver a pushing
force vector
forcing the
attachment points
of t...
Rigid:
 1.

Herbst Appliance and its modifications.
 2. Mandibular advancement repositioning
splint
 3. Mandibular prot...
Flexible:
 Jasper

Jumper
 Churro Jumper
 Adjustable Bite Corrector
 Universal Bite Jumper
 Klapper Super Spring II
...
Appliances Producing Pulling
Force
These appliances create a
pulling force vector
between the points of
attachment:
 SAIF...
Herbst Appliance
History, Background and Development
Design
Anchorage forms of the Herbst Appliance
Construction
Effects o...
History, Background
and Development
Developed by Emil Herbst (1872 – 1940) in
1900s.He lived in Bremen, Germany.
He called...
Herbst presented his appliance (original
banded design) for the first time at the 5th
international Dental Congress in Ber...
However after 1934, very little was published
about the Herbst appliance, and the treatment
method was more or less forgot...
Basic Design of Herbst
The Herbst appliance is basically a fixed
bitejumping device for the treatment of
skeletal Class II...
The tube is positioned in
the maxillary first molar
region and the plunger in
the mandibular first
premolar region.
The te...
Each telescope consists of a tube, a plunger,
2 pivots (axle), and two locking screws that
prevent the telescoping parts f...
Length of the plunger should be kept
at a maximum to prevent it from
disengaging from the tube.
A large interpivot distanc...
Original Herbst
Appliance
Originally Herbst had the
telescope mechanism
placed upside down (with
plunger attached to the
m...
The telescoping parts of
the Herbst appliance
were curved conforming
to Curve of spee and
were made of German
Silver or go...
Anchorage forms of the
Herbst appliance
Deserves special attention.
Because of anchorage loss, maxillary and
mandibular to...
Anchorage forms used from

1909 to 1934:

The standard anchorage
system used by Herbst:
Crowns or caps were
placed on the ...
If second permanent molars
have not erupted then Herbst
advised to anchor the
appliance more firmly by
placing bands on th...
Early mixed dentition
anchorage system:
When using the Herbst
appliance in the early mixed
dentition, Herbst had the
follo...
Late mixed dentition anchorage
system
Canines are used as
anchorage teeth instead of
incisors.
Buccal mucosa at the
corner...
Herbst and others realized the
necessity of incorporating as many
teeth as possible for anchorage to
avoid unwanted side e...
Anchorage forms used from 1979
onward:
Pancherz originally used a banded type of Herbst
appliance.Individually made stainl...
Simple anchorage system
Maxilla- Bands are
placed on 1st permanent
molars and first
premolars. Joined on
each side by sect...





Disadvantages:
Space opening distal to maxillary canines
Excessive intrusion of 1st permanent molars.
Buccal tipp...
2. Increased anchorage
system
 Maxillary and mandibular

front teeth were
incorporated in the
anchorage system by labial
...
Since 1995, cast chromecobalt splints are used
routinely.
The splints cover all buccal
teeth in the maxillary and
mandibul...
In the early 1980s, Howe and
McNamara developed the
acrylic splint Herbst appliance
which is used both.as a fixed
(bonded ...
The so-called cantilever Herbst
appliance design is mainly
indicated in the early mixed
dentition before the eruption of
t...
Support wires attached to the cantilever arms,
working as occlusal rests on the first or second
deciduous molars are impor...
None of the anchorage systems used in
Herbst treatment could prevent anterior
movement of the mandibular incisors and
mola...
TRETMENT EFFECTS

SAGITTAL



VERTICAL

DENTAL
SKELETAL

DENTAL
SKELETAL

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SAGITTAL CHANGES

I. Skeletal:
 1.Restrains

maxillary growth and decrease
of SNA angle.

 2.

Increases mandibular leng...
2a. Evidence of temporomandibular
growth adaptations in Herbst treatment:
Three adaptive processes in the TMJ are
thought ...
Animal studies
Peterson and McNamara (semin
orthodontics 2003) :
Evaluated histologically the TMJ, glenoid
fossa, and the ...
The following adaptations were observed:Condyle remodelling :
 Increased proliferation of condylar cartilage was
noted. I...
Significant bony apposition on the
posterior border of the mandibular ramus
was evident during early experimental
periods....
CLINICAL STUDIES:
Have provided radiographic evidence of
TMJ growth adaptation in Herbst
treatment.

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Paulsen et al (1995) :
Analysed TMJ changes in a single case of
Herbst treatment in late puberty using CT
scanning and OPG...
Roentgenograms of the
mandibular joints (N =
33). A, Before treatment.
B, After active treatment.
C, After the retention
p...
Ruf and Pancherz (1998, 1999):
Analysed three possible adaptive TMJ growth
processes contributing to increase in mandibula...
II. Dental:
Dental changes seen during Herbst appliance
treatment are basically a result of anchorage
loss in the two dent...
1. Mandibular teeth are moved
anteriorly
Proclination of lower anteriors. Mandibular
incisors proclined on an average of 6...
Lower Incisor Proclination & general
recession:Large amount of lower incisor proclination during
Herbst treatment could be...
No inter relation was found between the
amount of incisor proclination and
development of gingival recession. The
conclusi...
2. Maxillary molars are moved
distally.
The effect of the Herbst appliance on maxillary
molar teeth is essentially compara...
3) Mesial movements of lower molars
4) Sagittal dental arch relationship:
Overjet is reduced in all patients during treatm...
Herbst appliance corrects or overcorrects both
molar & canine sagittal relation in most of the
cases. However treatment is...
5. Arch perimeter:
Because of the distalizing forces of the
telescope mechanism of the Herbst appliance
on the upper 1st m...
6. Arch width

Hansen et al (1995) :
During treatment the maxillary and mandibular
dental arches expand laterally in both ...
b) Vertical changes
Dental
Skeletal

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Dental:
In Class II malocclusions with deep bites, overbite
may be reduced significantly by Herbst therapy
(Pancherz, 1982...
Skeletal:
Increase in lower anterior facial height (LAFH)
due to over eruption of lower posterior teeth.

Increase in goni...
Arji George, V. Surendra Shetty, SN Rao &
Ashima Valiathan:JIOS 1993 studied the
effect of Herbst on certain Orofacial mus...
Results:
1.A change in muscle activity in Class II patients with
respect to control.
Significantly reduced muscle activity...
The following changes contribute to Herbst
appliance correction of class II malocclusion.
 Stimulation

of mandibular gro...
INDICATIONS FOR
TREATMENT
Pancherz (AJO Jan 1985); indicated
that Herbst appliance should be used
only in growing individu...
Postadolescent patients:
 Who have passed the maximum pubertal
growth spurt and have still some growth
potential left, tr...
For mandibular fracture (particularly
ramus) patients after surgery
For prevention of bruxism
For diseases of the TMJ

www...
TIMING OF TREATMENT
Most favorable time to treat
the patients with the Herbst
appliance is at the peak of
pubertal growth ...
Ruf, Pancherz March 2003, the ideal period
for the herbst appliance treatment is in t he
permanent dentition or just after...
Perfect end result cannot be obtained exclusively
with Herbst.
Class II cases cannot be treated to a perfect end result
wi...
A Class II, Division 2 malocclusion may
require a three-step treatment approach
STEP 1. ORTHODONTIC PHASE. Alignment
of th...
So the ideal patient for treatment with the
Herbst appliance has the following
characteristics:
Skeletal morphology.
• Ret...
Dental morphology:
 Class II dental arch relationship with
increased overjet and normal or increased
overbite (open bite ...
Types of Herbst Appliance
The original design since the seventies
has maintained its general shape with
only a few modific...
Type I is characterized
by a fixing system to
the crowns or bands
through the use of
screws. This is the
most common form....
Type II has a fixing system
that fits directly onto the
archwires through the use of
screws. This method of
application ha...
Type IV has a fixation system
with a ball attachment, which
allows greater flexibility and
freedom of mandibular
movement....
MODIFICATIONS OF THE HERBST
APPLIANCE
 In

patients with class II
malocclusions who have
narrow maxillary arches,
expansi...
The cast splint herbst
The bands are replaced by splints, cast
from cobalt-chromium alloy and
cemented to the teeth with G...
Herbst with stainless steel
crowns
Norris M. Langford,
1982 JCO) suggested
using stainless steel
crowns on the upper first...
MODIFICATIONS:
the

substitution of stainless steel
crowns for bands.

the

elimination of the stabilizing
bar.

www.ind...
The bonded Herbst appliance
(1982)
The bonded Herbst appliance
eventually evolved into the acrylic splint
Herbst appliance...
By substituting an acrylic
splint for the stainless
steel bands of the earlier
appliance, the Herbst
mechanism can be
atta...
The maxillary splint
covers all available
maxillary teeth with
exception of the
central and lateral
incisors
The occlusal ...
These perforated
openings permit the
placement of the nylon
tip of a posterior bandremoving plier against
the cusps.

www....
Disadvantage of Banded Herbst:
I)

II)

III)

IV)

Repeated breakage and loosening of the
appliance occurs, especially in ...
Headgear – Herbst appliance : Weislander (1984)
Wesilander suggested the use of special
headgear – Herbst appliance in the...
He concluded that a
short period of
interceptive orthopedic
treatment in the very
early mixed dentition
may be indicated t...
Cantileverd Herbst
appliance
This was a design given
by Larry W. White, 1994.
Cantilever Herbst design.
Buccal cantilever ...
Advantage :
 This

design is
particularly useful
when mandibular
bicuspids are
absent or the
primary molars
cannot withst...
Modified Herbst appliance for the
mixed dentition
Introduced by Philip Goodman and Paul
Mc Kenna, 1985
They stated the mid...
The deciduous first and
second molars are free to
exfoliate through the
framework
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If the patient is uncomfortable
with much mandibular
advancement, have the patient
retrude the mandible until the
discomfo...
The EMDEN Herbst – a fixed removable
Herbst appliance. Tarek Zreik 1994
Introduced by Tarek Zreik, 1994 to
overcome breaka...
The Herbst mechanism is
attached to stainless steel
crowns on the maxillary
first permanent molars and
to the lower arch t...
Advantages of the EMBDEN Herbst
• It requires minimal cooperation.
• It promotes patient acceptance because it is not
visi...
Edgewise Herbst
Appliance
This design was given by Terry Dischinger, 1995

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The Edgewise Herbst Appliance
corrects Class II malocclusions rapidly
and without the need for patient
cooperation. It all...
Herbst with Mandibular
Advancement Locking Unit
Components (MALU)
 2 tubes
 2 plungers,
 2 upper “Mobee”
hinges with ba...
In the upper arch of
the edgewise-Herbst
MALU appliance,
only the first molars
are banded, with .
051" headgear tubes.
A p...
In the lower arch, the first
molars are banded, and the
anterior segment is bonded from
cuspid to cuspid with .022"
bracke...
Advantages:
1. Its cost is considerably lower because it

requires no laboratory construction.
2. Its simplicity makes it ...
Flip-Lock Herbst
Appliance
A new design, the FlipLock Herbst appliance,
reduces the number of
moving parts that can
lead t...
The first generation
was made from a
dense polysulfone
plastic but breakage
occurred because of
the forces generated
withi...
In the second
generation, the
plastic was replaced
with metal

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The third generation is
made of a horse-shoe
ball joint .
This system has
proved to be more
efficient than the
previous mo...
End of rod is crimped
onto mandibular ball.
Advantages :
Less irritation
reduces the number
of moving parts that
can lead ...
The Jasper Jumper :
This interarch flexible force module
allows patient greater freedom of
mandibular movement than is pos...
Force Module :
The force module, analogous to
the tube and plunger of the Herbst
bite – jumping mechanism and is
flexible....
The modules are
available in seven
lengths ranging from
26 to 38 mm in 2
mm increments.
They are designed
for use on eithe...
Principle of action :
When the force
module is straight, it
remains passive. As
the teeth come into
occlusion the spring
o...
If properly installed to produce mandibular
advancement, the spring mechanism is curved or
activated 4 mm relative to its ...
Anchor units :
A number of
methods are
available to anchor
the force modules to
either the
permanent or mixed
dentitions.
...
Attachment to the main
arch wire :
Dr. Jasper `s method.

When the jumper mechanism
is used to correct a class II
malocclu...
Bayonet bends are placed
distal to the mandibular
canines and a small Lexan
ball is slipped over the
archwire to provide a...
Disadvantages :Unattached bicuspids tend to
erupt above the occlusal
plane as the anterior teeth
are intruded.
When only t...
Replacement of a broken jumper required
removal of the entire archwire.
If an arch breaks or comes untied at the
distal ti...
2. Dr. Cope’s Method :
Dr. Don cope makes
an attachment out of
an 0.017 x 0.025”
stainless steel wire,
soldered to a rocky...
An alternative is to
place the lock distal
to the molar bracket
with the wire bent
distal to the cuspid.
The approach uses...
Advantages :
The attachment can be made in the office
laboratory, and placement can be delegated to
an assistant.
The jaws...
Disadvantages :
Laboratory time is required to solder
and bend the attachment.
The rocky mountain lock assembly is
an addi...
2) Attachment auxiliary
archwire :
Incorporates the use of “out
rigges” which are 0.016 x
0.022” (0.018” slot) or 0.018
x ...
The sectional archwire must have
adequate clearance from the alveolus
and gingiva to avoid tissue
impingement.
Advantages ...
Attachment in the Mixed
dentition
The maxillary attachment is as
the original attachment.
The mandibular attachment
includ...
Divided into 3 phases as
advocated by Dr. Jasper
Leveling and anchorage
preparation
 Period of jasper jumper use (6-9
mon...
Leveling and anchorage
preparation
Alignment of the maxillary and mandibular
anterior teeth during the initial phases of
o...
Anterior lingual crown torque can be
placed in the arch wire. Alternatively lower
incisor brackets with 5 degrees of lingu...
Preparation of the arches :
After the full sized arch wires have become
passive, the mandibular arch wire is
disengaged an...
Selection and
installation of the
modules

Determination of proper
length of force module.
Twelve millimeters are
added to...
The lower arch wire in threaded through the hole
in the anterior end cap of the force module,
ligated in place and the end...
The patients are coached to practice
opening and closing movements slowly at
first and told to avoid excessive wide
openin...
Activation of the module for
orthodontic and orthopedic
effect :
If molar distalization is desired. The jumper
is placed s...
Reactivation of the
module :

If the class II molar relationship is not corrected
completely by the initial activation, th...
Ball pin protrudes 2-3mm distally, allowing free movement. B. Ball
pin too close to molar tube, which can cause breakage o...
Activation of the force module can also
be made by crimpable stops (1 –
2mm) placed mesial to the lexan
beads.
It is more ...
Types of forces
produced :
Bilateral directions of
force generated by the
modules include
sagittal, intrusive and
expansio...
Buccal force → due to intrusive force acting
along the buccal surfaces of the maxillary
teeth → produces maxillary arch ex...
Treatment effects :
Maxillary adaptations :
i) Headgear effect :
One treatment effect produced most easily is
distalizatio...
Retraction of anterior
teeth
Upper canines alone or all the
six anterior teeth can be
retracted in both extraction and
non...
Maxillary anterior
teeth are retracted as
a unit by attaching
ligature to
appropriate archwire
tiebacks.

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Dental Asymmetries
The force module system also can be
used in-patients who have sagittal
dental asymmetries.
In a patient...
Mandibular
Adaptations :
In producing mandibular advancement
the movement of maxillary posterior
dentition must be cinched...
Jasper’s theory of two’s” suggests that class II
correction with Jasper jumper therapy can be
equally proportioned between...
Jay Bowman JIOS 2001 reported the use of
jasper jumper in a 13year old female with
class II division1 malocclusion and mod...
Nalbantgil D, Arun T, Sayinsu K, Fulya I
Angle Orthod 2005 studied 15 subjects (class
II) treated with jasper jumper and c...
MARS Appliance
(Mandibular advancing
repositioning splint).
This appliance was
introduced by Ralph M
Clements and Alex
Jac...
. Piston fitted to
the cylinder of a
MARS
appliance.

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• Allignment must be complete.
•

The teeth in the respective arches
should be aligned, with correct axial
inclinations, p...
Failure to do this will usually result in
flaring of the lower incisors, even with
the heavy rectangular arch wire, since
...
Determining length
of assembly
With the patients protruding the mandible into
a class I position, the right and left strut...
The upper member or hollow tube length is
determined by subtracting a calculated and
standardized measurement of 7.4mm fro...
The MARS appliance should be locked into
position with the mandible 2 to 3 mm posterior to the
maximum PIED measurement. I...


Two methods to lengthen the appliance
 1)

Replacement of the struts with longer upper
members of cylinders.
 2)Place...
Disadvantages :
Need for a fixed multi-banded appliance
limits its use in mixed dentition cases.
Disarticulates the poster...
Mandibular Protraction
appliances :
This appliance was
developed by Carlos
Martin Coelho Filho (JCO
1995).
His inability t...
They have proven effective in treating Class
I patients with exaggerated overjets and
Class II subdivision patients where ...
Each side of the appliance is
made by bending a small loop at
a right angle to the end of an .
032" stainless steel wire.
...
Another small right-angle
circle is then bent in an opposite
direction into the other end of
the .032" stainless steel wir...
Functioning of the appliance
MPA -1
Appliance slides distally along
mandibular archwire and
mesially along maxillary
archw...
MPA No. 2
MPA No. 2 is made
with right-angle circles
in two pieces of .032"
stainless steel wire.
Coil of .024" stainless
...
Improper relationship of
wires is prevented by coil.
Maxillary archwire has
occlusally directed circles
against molar tube...
Advantages :
Easily fabricated at chair side, with
ordinary inexpensive wires.
Do not require any special bands ,
crowns o...
MPA-3
CARLOS M. COELHO FILHO,(JCO
2001)

Many of the limitations of the
first two MPA designs have
been overcome with the
...
Appliance
construction
The parts needed for the
construction of the MPA No. 3
are:
Two maxillary tubes of 0.045”
internal ...
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Annealed pin bent mesial to the
molar tube

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MPA No. 3 reversed for
Class III treatment, with
open-coil spring
between appliance tube
and rod loop.

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Advantages of MPA n.o 3
over the previous
models :
More comfortable for the patient
Offers greater range of motion
Equally...
MPA IV
The latest version, the
MPA IV,** is much
easier to construct and
install, and much more
comfortable for the
patien...
Piece of .040" stainless steel
wire is inserted into longer
tube to prevent
deformation while bending
molar locking pin wi...
Mandibular rod
inserted into “T”
tube.

This fourth version seems to
be as efficient as its
antecedents, but is much more
...
Adjustable Bite corrector
(ABC) (JCO 1995)
Introduced by Richard P. West
The appliance essentially
consists of:
A stretcha...
The ABC can be used on
either side of the mouth
with a simple 180° rotation
of the lower end cap to
change it orientation....
After the patient has
postured forward into an
improved profile with ideal
overbite / overjet the point of
the gauge is pl...
Nickel titanium wire
is replaced and end
caps unscrewed to
add appliance length.

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Repairs and emergencies :
 Wire

fractures are infrequent with the ABC.
 Repair is easy, where the end caps are
unscrewe...
The ABC can be used for upper molar
anchorage control during retraction of
anterior teeth for space closure.
The class II ...
The Eureka Spring (JCO
1997)

Introduced by John De Vincenzo
The main component of the
Eureka spring is an open wound
coil...
The essential aspects
include spring
module A, molar
attachment tube B,
push rod C, free
distance D, molar
attachment wire...
A triple telescoping action permits the mouth
to open as wide as 60 mm before the plunger
becomes disengaged.
The cylinder...
Advantages

It has esthetic acceptability because of its small size
and lack of protuberances into the buccal vestibule, a...
Low cost : similar in cost to the jasper jumper
but less expensive than the fixed Herbst
appliance.
Minimal inventory requ...
The churro jumper (JCO
1998)

Introduced by Ridhardo Castanon,
Mario S Valdes and Larry White.

The Churro Jumper furnishe...
Construction :
The Churro Jumper requires a
series of 15-20 symmetrical
and closely placed circles,
formed in a wire size ...
Churro needs space to
slide on the mandibular
archwire, at least the
first premolar brackets
should be omitted. It is
usua...
The length of the jumper is
determined by the distance
from the distal of the
mandibular canine bracket to
the mesial of t...
Mode of action :
In its passive form, the
churro is not flexed
However when the pin is
pulled forward enough to
cause the ...
Unilateral / Bilateral use :
This jumper can be used unilaterally in cases
of class II subdivision malocclusions.
The bila...
Advantages :
Provides a constant, indefatigable force.
Can be used either unilaterally or
bilaterally.
Can be used in clas...
Disadvantages :
Restricts the mouth opening to 30-40 mm
Archwire breakage is seen if larger wires not
used.
Patients with ...
The universal bite jumper
(JCO 2001)
Introduced by Xavier Calvez
This is a fixed functional
which can be used in all
phase...
Fixed appliance configuration

In the mandibular arch, the sliding rod ends in a 90° hook that is
fixed to the archwire.

...
UBJ ATTACHED TO
AUXILLARY WIRE

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Lower cantilever configuration

The UBJ tubes are welded to the maxillary molar bands or
crowns. .
The UBJs are adjusted w...
Removable splint mounting

When used with removable acrylic splints, two lateral
UBJs link the maxillary molar areas and t...
Single median UBJ
A single median UBJ can
be used to link the
removable splint from the
middle rear area of the
palate to ...
The median UBJ provides muscular
therapy as it prevents the tip of the
tongue from contacting the lower lip.
Most children...
Adjustments :
Reactivation are made
every 6 to 8 weeks by
crimping 2 to 4 mm splint
bushings on to the rods.
Midline or
as...
Advantages
It is simple, sturdy, and inexpensive.
Inventory requirements are minimal--the UBJ
can be used on either side o...
It can be used in Class II or Class III cases.
Its low profile results in considerably less
buccal irritation than with si...
The saif Spring
(Severable Adjustable inter maxillary force)
First interarch force system developed by
Armstrong
In the la...
Various attachments can be placed through these
loops to secure the springs to deliver either class II or
class III force....
The Ritto Appliance
The Ritto Appliance
can be described as
a miniaturized
telescopic device
with simplified
intraoral app...
Fixation accessories
consist of a steel ball
pin and a lock.
Upper fixation is carried
out by placing a steel
ball pin fro...
The appliance is
fixed onto a
prepared lower arch
and is activated by
sliding the lock
along the lower arch
in the distal ...
The Magnetic Telescopic Device
Ritto A.K. in 1997
This consists of two tubes and two
plungers with a semi-circular
section...
THE TWIN FORCE BITE
CORRECTOR
This appliance differs from
others in form and constitution
because it has two internal coil...
Drawbacks:
The major drawback of
this appliance is the
difficulty to control the
force.
May create discomfort
and impingem...
ALPERN CLASS II CLOSERS
It is one of the most recent.
It is predominantly applied in
Class II correction and as a
substitu...
Mandibular Corrector (JCO
1985)
Introduced by Marston Jones
It is a fixed functional that uses
bilateral piston and plunge...
 The

length of the repositioning arms are
determined intraorally with the patient’s
mandible advanced 3-4 mm.
 The enti...
The Horizontal Anterior
Positioning (HAP) appliance

Most of the appliances have
anterior contact while allowing
for poste...
Components of HAP appliance: A. Anterior
reverse ramp. B. Sagittal screws. C.
Expansion arms. D. Coffin spring. E. Locking...
A lower "dipod, which
provides upper and lower
posterior occlusal support.
A posterior pad can be
added to the HAP, but
ad...
The Mandibular Anterior
Repositioning Appliance(MARA)
These interference’s are produced when a
horizontally adjustable ver...
Advantages over Herbst
Better esthetics
Problem with disengagement do not occur
Breakage from lateral mandibular movements...
Disadvantages
Temporary stainless steel crowns needed on
all first molars.
Some increase in anterior facial height
results...
Pangrazio-Kulbersh V, Berger JL, Chermak DS,
Kaczynski R, Simon ES, Haerian A,Ajo 2003,. The aim of
this study was to inve...
The results of the study showed that the MARA
produced measurable treatment effects on the
skeletal and dental elements of...
Functional Mandibular Advancer
Kinzinger,Ostheimer, Diederich,2002
It has a propulsive mechanism that
resembles the Mandib...
Reactivation in the sagittal plane
is done simply by moving the
guide pins to a more forward
threaded support sleeve. This...
Advancement in
therapeutic positions

Maximum protrusion of
mandible after 3 months

www.indiandentalacademy.com
The Biopedic
Designed and introduced by Jay
Collins in 1997 (GAC International)
It consists of buccal attachments
soldered...
This short maxillary rod is inserted screw at
the mesial of the maxillary first molar.
The two rods are connected by a rig...
Advantages
Can be used concurrently with banded
treatment.
Esthetic benefit
Capability of adjusting the amount of protrusi...
The Klapper Superspring II

Introduced by Lewis Klapper in
1997, for correction of class II
malocclusions.
On first glance...
The SUPERspring II is a
flexible spring element that
attaches between the
maxillary molar and the
mandibular canine. It is...
Disadvantages
Requirement of a special molar tube
Lack of adaptability to correct class III
conditions
Limitation to maxim...
Forsus Fatigue resistant
Device

This is an interarch push
spring which produces
about 200g of force when
fully compressed...
The push rod has a built in
stop that compresses the
spring when the patients
mouth closes. The spring is
then transferred...
Advantages:
It does not require time-consuming and
expensive lab work or the use of stainless
steel crowns.
It produces co...
Heinig N, Goz G 2001 reported the use of
`

Forsus spring over a period of 4 months to treat 13
patients with an average a...
The occlusal plane was rotated by 4.2 degrees in
clockwise direction as a result of intruding the lower
incisors and the u...
William Wogt JCO June 2006 reports a case
where a 12 year old male with class II division
1 and moderate overjet of 7mm wa...
Conclusion :
Fixed functional appliances form an useful
addition to the clinician’s orthodontic
armamentarium. But many of...
References:
1.

Larry.W. White :Current Herbst Appliance
Therapy:JCO 1997,May(296 - 309)

2.

Arji George, V. Surendra She...
4.

5.

Kinzinger, Oestheimer, Deidrich:
Development of a new fixed functional
appliance for treatment of skeletal class I...
6. Kinzinger, Deidrich: Bite jumping with the

functional mandibular Advancer, JCO
December 2005 page 696-700

7. Carlos M...
9. Sabine Ruf, Hans Pancherz: When is the ideal period

for Herbst therapy-Early or Late? Semin Orthod
2003,March,page 47-...
12. Miller R.A. The Flip-lock Herbst Appliance.

J. Clin. Orthod. 1996; 30: 552 – 58.

13. Jasper J.J., McNamara J. The co...
15. Heinig N, Goz G: Clinical application and

effects of the Forsus spring. A study of a new
Herbst hybrid, J Orofac Orth...
18. Erdogan E. Asymmetric Application of the

Jasper Jumper in the correction of midline
discrepancies. J. Clin. Orthod. 1...
21. Castañon R., Valdes M., White L.W.

Clinical use of the Churro Jumper. J.
Clin. Orthod. 1998; 32: 731 – 45.
22. Blackw...
24. Pangrazio-Kulbersh V, Berger JL, Chermak

DS, Kaczynski R, Simon ES, Haerian
A:Treatment effects of the mandibular
ant...
27. Hans Pancherz :History, Background, and

Development of the Herbst Appliance, Semin
Orthod 2003,March page3-11
28. Fil...
30. Mandeep sood, k.Sadashiva Shetty:

Functional therapy- Is it worth the effort?
JIOS1994 October page 128-136.

31. Aid...
Thank you
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Fixed functional appliances1 / /certified fixed orthodontic courses by Indian dental academy

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

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

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