Fixed functional appliances/dental courses

FIXED FUNCTIONAL APPLIANCES
(PART 1)
www.indiandentalacademy.com

CONTENTS
 Introduction
 Fixed Functional Appliances – An Overview
 Disadvantages Of Removable Appliances
 Advantages Of Fixed Functional Appliances
Over Removable Appliances
 Classification Of Fixed Functional Appliances
 Flexible Fixed Functional Appliances
 Rigid Fixed Functional Appliances
 Hybrid Appliances

 Indications
 Contraindications
 Advantages
 Disadvantages
 A New Concept For Class II Therapy
 Timing Of Treatment – Ideal Treatment Period For
Maximal Mandibular Growth Stimulation.
 Skeletal Changes Associated With The Herbst Appliance
Based On Skeletal Maturation
 Mode Of Action
 Biomechanical Effects Of Fixed Functional Appliances On
Craniofacial Structures
 Herbst Appliance Therapy And Temporomandibular Joint
Disc Position
 Temporomandibular Joint Adaptations Associated With
Herbst Appliance Treatment.
 Effectiveness Of Treatment For Class Ii Malocclusion
With The Herbst Or Twin Block Appliance

INTRODUCTION

FIXED FUNCTIONAL APPLIANCES – AN OVERVIEW1

CLASSIFICATION OF FIXED FUNCTIONAL
APPLIANCES2

 Rigid Fixed functionals – ( ‘Herbst’ like)
 Flexible fixed functionals – (‘Jasper’ like)
 Hybrid appliances

RIGID FIXED FUNCTIONALS
 Herbst and its modifications
 The Mandibular Anterior Repositioning splint (MARS)
 The Ventral Telescope
 The Magnetic telescopic device
 The Mandibular Protraction Appliance (MPA I – IV)
 The Biopedic appliance
 The Mandibular anterior repositioning appliance
(MARA)
 The Intra-oral Snoring Therapy Appliance (IST)
 The Ritto Appliance
 The Universal Bite Jumper

FLEXIBLE FUNCTIONAL APPLIANCES
 The Jasper Jumper
 Amoric Torsion Coils
 The Adjustable Bite Corrector,
 The Scandee Tubular Jumper,
 The Klapper Super Spring
 The Bite Fixer (Ormco)
 The Churro Jumper

HYBRID APPLIANCE
 The Calibrated Force Module
 The Twin Force Bite Corrector
 Eureka Spring
 Forsus – Fatigue Resistant Device
 The Sabbagh Universal Spring

I) APPLIANCE PRODUCING PUSHING FORCE.
A) RIGID
 Herbst appliance
 MARS appliance [mandibular anterior
repositioning splint]
 MPA [Mandibular protraction appliance]
 Universal – bite jumper

B) FLEXIBLE
 Jasper jumper
 Adjustable bite corrector
 Churro jumper
 Klapper super spring II

II) Appliance producing pulling force.
 SAIF spring [Several adjustable
intermaxillary force spring].

FLEXIBLE FIXED FUNCTIONAL APPLIANCES1
 What are they
 Supplied as
 Variations
 Advantages
Elasticity & Flexibility
Covering
Headgear effect

 Disadvantages:
Elasticity & Flexibility
Covering
 Indications
Aesthetics
Inventory
Expensive
 Type of force
 Amount of force

 Side effects
 Anchorage control

VARIOUS FLEXIBLE FIXED FUNCTIONAL
APPLIANCES

 Scandee tubular jumper

 Klapper super spring

 Bite fixer

 Churro jumper

RIGID FIXED FUNCTIONAL APPLIANCES – RFFA1
Rigid Fixed functional appliances – RFFA1
 They do not easily fracture but neither do
they have elasticity or flexibility.
 After fitting and activation they do not allow
the patient to close in centric relation. This
means that the mandible is in a forward
position 24 hours a day creating greater
stimulus for mandibular growth than with
FFFAs.

 Indication
 Telescopic mechanism

 Herbst appliance – prototype

MAGNETIC TELESCOPIC DEVICE

MANDIBULAR PROTRACTION APPLIANCE (MPA)
(FILHO‘S APPLIANCE)

THE UNIVERSAL BITE JUMPER (UBJ)

THE MANDIBULAR ANTERIOR REPOSITIONING
APPLIANCE (MARA)

BIOPEDIC APPLIANCE

RITTO APPLAINCE

HYBRID APPLIANCES1
 What are they.
CALIBRATED FORCE MODULE

EUREKA SPRING

TWIN FORCE BITE CORRECTOR

FORSUS

INDICATIONS
 The fixed functional appliances are indicated in
correction of skeletal Class II malocclusions due
to retrognathic mandible.(including div1 & div
2).
 Post adolescent patients
Possible to use residual growth left in these
patients as treatment completed in 6-8 months.
 Mouth breathers
 Uncooperative patients
 Patients who do not respond to removable
functional appliances.

CONTRAINDICATIONS
 Contraindicated in non-growing patients.
 Hyperdivergent facial pattern.
 A patient with negative VTO
Use of functional appliances results in less
than satisfactory results and is therefore not
recommended.

ADVANTAGES
 Used in uncooperative patient. i.e. patients
compliance not required.
 Action is continuous for 24 hours of the day.
 Achieve the results in around 6-8 months.
 Advantageous in mouth breathers.
 Does not interfere with speech or mastication.
 Used successfully in post adolescent patients in
whom very little growth is remaining to work
with.
 Procedures such as rapid maxillary expansion,
fixed appliance or head gear can be given with
appliance in place.

DISADVANTAGES
 Though treatment result can achieved within 6-8
months, retention of the result has to be
maintained using removable functional
appliance.
 Risk of development of dual bite.
 Masticatory efficiency may be reduced.
 High incidence of breakage and loosening of the
appliance.
 May restrict lateral mandibular movements.
 Plaque accumulation and enamel decalcification
may occur, especially in the splint type of
appliance.

TIMING OF TREATMENT

THE IDEAL TREATMENT PERIOD FOR MAXIMAL
MANDIBULAR GROWTH STIMULATION
 Subjects treated at peak or 1 to 2 years after
peak exhibited the largest sagittal condylar
growth and thus the largest mandibular
length increase.
 Correspondingly, the greatest amount of
sagittal condylar growth was found in
subjects treated at the skeletal maturity stage
MP3-FG, which occurs close to the peak
growth period .

 Showed a steady increase in sagittal
condylar growth stimulation from the prepeak
to the peak growth period, followed by a
steady decline in the postpeak period.
 This pattern was most obvious in boys,
whereas in girls no marked differences in
skeletal mandibular treatment effects were
found when comparing different growth
periods.

 It is believed that Class II correction by
orthopaedic means is not possible after the
age of 13.5 years in girls and 15 years in
boys because 97% of the growth is
completed at these ages.
 However,in using the Herbst appliance, it is
possible to reactivate and stimulate condylar
growth even in subjects at the end of growth.

 The IDEAL PERIOD for the Herbst appliance
is in the permanent dentition at or just after
the pubertal peak of growth corresponding to
the skeletal maturity stages FG to H of the
middle phalanx of the third finger.

SKELETAL CHANGES ASSOCIATED WITH THE
HERBST APPLIANCE BASED ON SKELETAL
MATURATION
Objective:
 To evaluate skeletal changes when the
Herbst appliance is used in patients during
the high-velocity and the decelerating-
velocity periods of adolescent growth.
 To chart differences(if any) in the amounts
of skeletal and dental changes with the
Herbst appliance in relation to the maturation
stage of development.

METHOD
 In group 1 (n =19), the subjects were in the
high-velocity period of adolescent growth
when treatment with Herbst appliances was
started;
 In group 2 (n = 21), they were in the
decelerating period of adolescent growth.
Cephalograms were evaluated at pretreatment
and posttreatment.

RESULTS AND CONCLUSIONS
 Although there were small differences
between the 2 groups, these were not
statistically significant. The Herbst appliance
was equally effective when used at the high-
velocity and the decelerating-velocity periods
of adolescent growth.

A NEW CONCEPT FOR CLASS II THERAPY
 The current and widely accepted concept of
skeletal Class II treatment is
(1) growth modification(with functional
appliances and/or headgear)in prepeak and
peak patients,
(2) camouflage orthodontics (extractions of
teeth and fixed appliances) in postpeak
patients, and
(3)orthognathic surgery in adults

 The new concept of Class II treatment proposes
the following:
(1) growth modification in children and
adolescents as well as in postadolescents and
young adults (up to the age of 25 years),
(2) camouflage orthodontics, and
(3)orthognathic surgery in older adults.
 Growth modification in children should be
performed with removable functional appliances
and/or headgear.
 In adolescents, postadolescents and young
adults the Herbst appliance should be used.

MODE OF ACTION
 Mandibular growth induction.
 Maxillary growth restriction
 Dentoalveolar changes
 Glenoid fossa relocation
 Changes in neuromuscular anatomy and
function.

Functional appliance

Increased contractile activity of LPM

Intensification of retrodiscal pad activity

Increase in growth stimulating factors

Additional growth of condylar cartilage and subperiosteal
ossification of posterior border of ramus.

Supplementary lengthening of mandible

BIOMECHANICAL EFFECTS OF FIXED FUNCTIONAL APPLIANCES
ON CRANIOFACIAL STRUCTURES
 Objective: To evaluate displacement and
stress distribution on craniofacial structures
associated with fixed functional therapy.
 Materials and Methods: A finite element
model of the human skull was constructed
from computed tomography images.

Results:
 The entire mandible moved anteroinferiorly
 The pterygoid plate was displaced in a posterosuperior direction.
 The anteroinferior displacement of the mandibular dentition was
most pronounced in the incisor region.
 The maxillary dentition was displaced posterosuperiorly.
 The entire dentition experienced tensile stress except for the
maxillary posterior teeth.
 Tensile stress was also demonstrated at point A, the pterygoid
plates, and the mandible, and minimal compressive stress was
demonstrated at anterior nasal spine.
 Maximum tensile stress and von Mises stresses occurred in the
condylar neck and head.

Conclusion: Fixed functional therapy causes a
posterosuperior displacement of the maxillary
dentition and pterygoid plate and thus can
contribute to the correction of Class II
malocclusion.
The displacement was more pronounced in the
dentoalveolar region as compared to the
skeletal displacement.
All dentoalveolar structures experienced tensile
stress, except for anterior nasal spine and the
maxillary posterior teeth

HERBST APPLIANCE THERAPY AND TEMPORO MANDIBULAR JOINT DISC
POSITION:A PROSPECTIVE LONGITUDINAL MAGNETIC RESONANCE IMAGING
STUDY
 The objective of this study was to verify changes in
the position of the temporo mandibular joint (TMJ)
disc by means of magnetic resonance images (MRIs)
in adolescent patients treated with the Herbst
appliance.
 Method: Twenty Class II Division 1 patients treated
with Herbst appliances were selected for the study.
MRIs were analyzed at 3 stages: immediately before
Herbst treatment (T1), 8 to 10 weeks after appliance
placement (T2), and at the end of the 12-month
Herbst treatment, immediately after appliance
removal (T3).

 Results: Class I or overcorrected Class I
dental-arch relationships were observed after
Herbst therapy.
The qualitative evaluation showed that each
patient had the disc within normal limits at T1. At
T2, a slight tendency toward disc retrusion
because of mandibular advancement was
observed, but,
at T3, the disc returned to normal, similar to T1
values

MRIs of treated TMJs in closed mouth position.
Top row, right; Bottom row, left. Articular disc
is in superior normal position at T1 and T3, with
retrusive tendency at T2.

EFFECTIVENESS OF TREATMENT FOR CLASS II
MALOCCLUSION WITH THE HERBST OR TWIN-BLOCK APPLIANCES: A
RANDOMIZED, CONTROLLED TRIAL
 A total of 215 patients were enrolled in the
study:
110(62 girls and 48 boys) were allocated to
receive treatment with the Twin-block, and
105 (55 girls and 50 boys) to the Herbst
group.
The patient inclusion criteria for this
investigation were overjet 7 mm, second
premolars erupted, and no craniofacial
syndrome.

CONCLUSIONS
1. Patient cooperation with the Herbst appliance is
better than that with the Twin-block.
2. Phase I treatment is more rapid with the Herbst
appliance, but overall duration of treatment is similar
to that with the Twin-block.
3. The Herbst appliance is prone to debonding and
component breakage.
4. There are no differences in the dental and skeletal
effects of treatment between the 2 appliances, but
there was a marked sex effect: girls responded to
treatment better than boys.

REFERENCES
1. AKorrodi Ritto. Fixed FunctionalAppliances -A
Classification. Orthodontic Cyber Journal .2001;4:1-
38.
2. Poppadipolus. The Orthodontic Treatment Of Class II
Non-Compliant Patient,2nd ed.Elsevier;2001:145-
160.
3. Graber,Petrovic,Rakosi.Dentofacial Orthopaedics
With FunctionalAppliances,2nd edtion. Mosby;
1997:360-365.
4. P.F Mcsherry.Class II Correction- Reducing Patient
Compliance.Journal Of Orthodontics.2000;27:219-
225.
5. Sabine RufAnd Hans Pancherz.When Is The Ideal
Period For Herbst Therapy-Early Or Late?. Semin

REFERENCES
 J. Godinho And L. Fishman.Skeletal Changes Associated With
The Herbst Appliance Based On Skeletal Maturation. Am J
Orthod Dentofacial Orthop.2007;132:128-136.
 Carlos Flores-Mir.Skeletal And Dental Changes In Class
IIDivision 1 Malocclusions Treated With Splint-Type Herbst
Appliances-A Systematic Review.Angle
Orthodontist.2007;77:34-42.
 Luís Antônio De Arruda Aidar.Herbst Appliance Therapy And
Temporomandibular Joint Disc Position-A Prospective
Longitudinal Magnetic Resonance Imaging Study.Am J Orthod
Dentofacial Orthop. 2006;129:486-96.
 John E. Peterson, Jr, And James A. Mcnamara, Jr. Temporo
Mandibular Joint Adaptations Associated With Herbst Appliance
Treatment In Juvenile Rhesus Monkeys (Macaca Mulatta).
Semin Orthod. 2003;9:12-25.
 Abbie T. Schaefer, DDS, MS,A James A. Mcnamara.A
Cephalometric Comparison Of Treatment With The Twin-Block
And Stainless Steel Crown Herbst Appliances Followed By
Fixed Appliance Therapy.Am J Orthod Dentofacial
Orthop.2004;126:7-15.

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