functional aplliances 1

FUNCTIONAL APLLIANCESFUNCTIONAL APLLIANCES

INTRODUCTION The stomatognathic system consist of teeth,

the periodontal membrane ,basal bone,T.M.J,and the motivating and draping Neuromusculature.

BONE is plastic in nature and its form and function are related intimately. Changes in functional stress produces changes in internal bone architecture and external shape.

Bone is most responsive to external stimuli .

The term “Functional appliance” refers to variety of removable appliance designed to alter the arrangement of various muscle groups that influence the function and position of the mandible in order to transmit the forces to the dentition and the basal bone.

Intra-oral devices. Growth modification procedures used for

Correction of early class II and some class III.

SEE TO BELIEVESEE TO BELIEVE

FLATHEAD INDIAN PAPOOSE TIED TO BOARDS TO PRODUCE FLATHEAD-SHAPED SKULL (INTENTIONAL, PLANNED PRESSURE.

CHINESE FEET CRUELLY MUTILATED, THE INSTEP BROKEN TO KEEP THE FEET WITHIN A THREE-INCH MEASUREMENT (INTENTIONAL, PLANNED PRESSURE .

HERD OF HEREFORD CATTLE SHOWING HORNS WHICH ARE NOT PROPERLY SHAPED WHICH HAVE NOT BEEN TREATED WITH WEIGHTS TWO-YEAR-OLD HEREFORD BULL SHOWING PROPERLY SHAPED HORNS AFTER TREATMENT WITH WEIGHTS.

COWBOYS WHO RIDE HORSES DAY AFTER DAY BECOME BOWLEGGED (SPRUNG LEGS) BECAUSE OF THE PRESSURE EXERTED(UNINTENTION

AL) ON THEIR LEGS .

THUMB-SUCKING HABIT AND RESULT.

CHIN PROPPING HABIT AND RESULT.

THE PAST

NORMAN W.KINGSLEY

FIRST TO USE FORWARD POSITIONNG OF MANDIBLE.

“Jumping the bite” by vulcanite plate .

PIERRE ROBIN DESIGNED AN APPLIANCE WHICH WAS

LATER USED TO INFLUENCE MUSCULAR ACTIVITY BY A CHANGE IN SPATIAL RELATIONSHIP OF JAWS.

“MONOBLOC”

VIGGO ANDERSEN “ACTIVATOR”

DESIGNED AN INERT APPLIANCE THAT FITTED LOOSELY IN THE MOUTH AND BY ITS MOBILITY TRANSFERRED MUSCULAR STIMULI TO THE JAWS,TEETH AND SUPPORTING STRUCTURES.

ACTIVATOR

In 1908 Viggo Anderson developed a loose fitting Hawley,s type of appliance with vertical acrylic extensions to contact the lingual surfaces of lower teeth.

Idea was to transfer functioning stimuli to the jaws , teeth and supporting tissues.

“BIOMECHANIC WORKING RETAINER” Later teamed up with HAUPL and it was called

“Activator” because of the ability to activate muscles.

Also called as Norwegian appliance.

Labial bow -.9 mm usually in upper arch only.

Acrylic portion – cold cure / heat cure .

Jack screw /springs or other optional components.

COMPONENTS

INDICATIONS OF ACTIVATOR Class –II Div 1 Class –II Div 2 Class –III Class –I Open bite. Class –I Deep bite. Skeletal improvement young age {pre-

fixed appliance therapy} . Lack of vertical development .

CONTRAIDICATION

Class I Crowding.Excessive Vertical excess . Excessive proclined lower incisors .Nose stenosis /allergy/structural

problems who cannot breathe through nose.

Non growing pts.

CONSTRUCTION BITE Reposition the mandible in forward direction. Wax record used to relate the mandible to

maxilla in three dimension of space. Two types

a) Low vertical ,marked forward positioning .

b) High vertical ,slight forward positioning .

Modification of activator

PHILOSOPHY OF ACTIVATOR

ALFRED P.ROGERS “BIONATOR” RECOGNIZED THE IMPORTANCE OF THE

WHOLE OROFACIAL SYSTEM IN THE PROBLEMS OF ORTHODONTIC TREATMENT.

BIONATOR

FRANKEL

CLASSIFICATION

I. TOM GRABER 1) GROUP –1 : Teeth supported e.g catalan’s .2) GROUP-2 : Teeth/Tissue supported e.g Activator .3) GROUP-3 : Vestibular positioned . Frankel.

II. Removable / Semi-fixed. E.g BASS / Fixed

III. Peter vig{Hybridization}1) Classical e,g Activator .2) Hybrid e.g Bass alliance .

IV. PROFFIT 1) Teeth borne passive appliance ; Activator .2) Tooth borne active appliance; Kinetor .3) Tissue borne passive appliance; Oral screen .4) Tissue active passive appliance: Frankel .5) FOMA

V. MYOTONIC {muscle mass}/ MYODYNAMIC .{action}

CONCEPTS OF FUNCTIONAL JAW ORTHOPEDICS

THREE APPROACHES TO TREATMENT OF

SKELETAL MALOCCLUSION

GROWTH MODULATIONCAMOUFLAGESURGICAL CORRECTION

Clinical considerations & applications of growth and development

Growth is not continuous process but has variations regarding various organs, tissues and therefore time becomes very important factor whenever we are dealing with craniofacial growth and development.

Growth does not take place in a steady manner, there are certain periods where there is sudden increase in growth, which is called as Growth spurts.

GROWTH SPURTS

These growth spurts are sex-linked. The greatest increment of growth are actually at the 3 year age level. The second peak is from 6 to 7 years. The appearance of growth spurts are as follows:

The tendency for most of the boys is to have 2 or 3 peaks while most girls show only two peaks

MALE FEMALE

First Peak Second Peak

Third Peak

3 Years 7 to 9 Years14 to 15 Years

3 Years6 to 7 Years

11 to 12 Years

Treatment principles

Selective force application .Selective force elimination .Differential eruption of selected

teeth .

MODE OF ACTION DENTOALVEOLAR CHANGES . MIDFACE GROWTH RESTRICTION . MANDIBULAR GROWTH INDUCTION . CHANGES IN NEUROMUSCULAR

ENVIRONMENT & FUNCTION . ADAPTIVE CHANGES IN THE GLENOID

FOSSA LOCATION.

MODE OF ACTION

INCREASED CONTRACTILE ACTIVITYOF LPM. INTENSIFICATION OR RETRODISCAL PAD. INCREASE IN GROWTH STIMULATING FACTOR. ADDITIONAL GROWTH OF CONDYLAR CARTILAGE. ADDITIONAL SUB PERIOSTEAL OSSIFICATION. SUPPLEMENTARY LENGHTENING OF MANDIBLE.

EFFECTS OF FUNCTIONAL APPLIANCE IN TREATMENT OF CLASS II CASES .

TEMPORAL STIMULATION . HEADGEAR EFFECTS . CLASS II EFFECTS . DIFFERENTIAL ERUPTION OF TEETH.

Overall changes Increase or decrease in jaw size. Change in spatial relationship of the

jaws. Change in the direction of growth of

the jaws. Acceleration of the desirable growth.

DIAGNOSIS OF FUNCTIONALAPPLIANC

E THERAPY

PATIENT FOR FUNCTIONAL TREATMENTOF MANDIBULAR DEFICIENCY

PREPUBESCENT BY 2 TO 3 YEARS . MANDIBULAR DEFICIENCY REASON FOR CLASS II MALOCCLUSION . NORMAL OR SLIGHTLY EXCESSIVE MAXILLARY

DEVELOPMENT. NORMAL OR SLIGHTLY SHORT FACIAL HEIGHT NORMAL OR SLIGHTLY PROTRUSIVE MAXILLARY

INCISOR TEETH . NORMAL POSITIONED OR RETRUSIVE LOWER

INCISOR . EXCELLENT PATIENT CO – OPERATION.

IDEAL CASE FOR FUNCTIONAL ANALYSIS

RELATIVELY NORMAL MAXILLA . RETRUDEDMANDIBLE . HORIZONTAL MANDIBLUAR GROWTH

DIRECTION . MIMIMUM UPPER & LOWER INCISOR

CROWDING & PROCLINATION . GOOD V.T.O . POTENTIAL GROWTH REMAINING .

CASE EXAMINATION

VTO .RECORDS .MODELS.

V.T.O

CEPHALOMETRIC DIAGNOSIS

FACIAL SKELETON .SADDLE ANGLE .ARTICULAR ANGLE.GONIAL ANGLE .ANT. & POSTERIOR FACE HEIGHT RATIO

JAW BASES SNA , SNB, INCLINATION ANGLE, BASAL PLANE ANGLE, MANDIBULAR BASE.

DENTOALVEOLAR RELATIONSHIPSAXIAL INCLINATION OF INCISORS

THEORIES OF CONSTRUCTION BITE

CONSTUCTION BITE

CONSTUCTION BITE

Wax bite

Wax bite

SINGLE VS PROGRESSIVE SAGGITAL ADVANCEMENT

SINGLE STEP ADVANCEMENT

ADVANTAGES FULL EXPRESSION OF V.T.O . NO NEED FOR APPLIANCE REACTIVATION . INCREASED UTILIZATION OF MUSCLE STRETCH &

VISCO ELASTIC PROPERTIES OF TISSUES . MAINTAINS FORCE EVEN DURING SLEEP .

DISADVANTAGES PATIENT DISCOMFORT . POOR PATIENT COMPLIANCE. INCREASED CONTRIBUTION OF DENTOALVELOAR

STRUCTURES .

PROGRESSIVE ADVANCEMENT

ADVANTAGES MORE FAVOURABLE & PHYSIOLOGIC RESPONSE . REDUCED EFFECT ON INCISOR INCLINATION . COMPLIANCE BETTER. GREATER LIKELIHOOD OF MAINTAINING CORRECT

APPLIANCE POSITION DURING SLEEP.DISADVANTAGES FULL V.T.O CANNOT BE EXPRESSED . REQUIRES APPLIANCE REACTIVATION . PROLONGED TREATMENT TIME . VISCOELASTICITY OF TISSUES LESS RELIED UPON.

PROGRESSIVE ADVANCEMENT

INDICATIONS VERTICAL GROWING PATIENTS . ADULTS . PATIENT WITH TMJ DISFUNCTION .

MANDIBULAR ADVANCEMENT

CLARK – 10mm MAXIMUM . 70% OF MAXIMUM PROTRUSIVE RANGE

OF THE PATIENT. ALWAYS 3MM BEHIND MAXIMUM

PROTRUSIVE RANGE – PREVENT CLASP KNIFE REFLEX.

VERTICAL OPENING

MINIMAL VERTICAL OPENINGWITHIN THE FREEWAY SPACEREASON – LOOSELY FITTING APPLIANCES

INCREASES FREQUENCY OF REFLEX CONTRACTION IN THE MUSCLES OF MASTICATION

MYOTATIC REFLEX

VERTICAL OPENING

MODERATE VERTICAL OPENING 4 MM BEYOND THE REST POSITION OF

THE MANDIBLE . CONTRACTION PRODUCED ARE

ISOMETRIC RATHER THAN ISOTONIC. INCREASING FREEWAY DURING SLEEP .

VERTICAL OPENING

EXTREME VERTICAL OPENING (HARVOLD)

8 TO 10 MM BEYOND THE FREEWAY SPACE

VISCOELASTIC PROPERTIES ( PASSIVE TENSION)

INTRODUCTION TO CLARK’S TWIN BLOCK

INTRODUCTION TO CLARK’S TWIN BLOCK

SIMPLE, COMFORTABLE & ESTHETICALLY ACCEPTABLE

WORN 24 HRS A DAY . MOST VERSATILE .

INTRODUCTION TO CLARK’S TWIN BLOCK

SIMPLE BITE BLOCKS . GUIDING MECHANISM . MANDIBULAR DISPLACEMENT . FUNCTIONAL EQUILBRIUM ESTABLISHED

UNDER NEUROLOGICAL CONTROL IN RESPONSE TO REPETITIVE TACTILE STIMULUS .

PROPRIOCEPTIVE STIMULUS TO GROWTH . INFLUENCE ON RATE OF GROWTH

&TRABECULAR STRUCTURE OF SUPPORTING BONE .

REQUISITES FOR TWIN BLOCK APPLIANCES

CLASS II DIV I WITH NORMAL MAXILLA & RETROGNATHIC MANDIBLE

MINIMAL CROWDING PROPER ARCHFORM PROPER TORQUE OF MAXILLARY &

MANDIBLUAR INCISOR IDEAL AGE ( 2 TO 3 YRS BEFORE PUBERTAL

GROWTH SPURT) POSITIVE V.T.O. VERTICAL PROBLEM NOT EXCESSIVE NORMAL AIRWAY

DELTA CLASP ( CLARK) IMPROVED RETENTION . MINIMUM ADJUSTMENT . REDUCES METAL FATIGUE .

OCCLUSAL BITE BLOCKS 700 .

CLINICIANS CHOOSE THIS ANGULATION TO APPLY MORE A HORIZONTAL FORCE

DESIGN & CONSTRUCTION OF TWIN BLOCK

DESIGN & CONSTRUCTION OF TWIN BLOCK

TOOTH & TISSUE BORNE TYPE . THREE DIMENSIONAL CONTROL ON

ANCHORE TEETH . LIMITS TIPPING & DISPLACEMENT OF

INDIVIDUAL TEETH .

DESIGN & CONSTRUCTION OF TWIN BLOCK

ORIGINAL DESIGN ADAMS CLASP – UPPER MOLARS &

LOWER PREMOLARS MIDLINE SCREWS UPPER LABIAL BOW( OPTIONAL) OCCLUSAL BITE BLOCKS BALL CLASPS ON LOWER INCISORS PROVISION FOR EXTRA ORAL TRACTION

STAGES OF TWIN BLOCK

ACTIVE PHASE 7 – 9 MONTHS OPEN BITE IN BICUSPID AREA CLASS I SKELETAL RELATION CLASS I MOLAR RELATION

STAGES OF TWIN BLOCK

SUPPORT PHASE 6 – 9 MONTHS MAINTAIN THE MANDIBLE IN THE ADVANCED

POSITION . ALLOW ERUPTION OF BICUSPIDS . 4 – 6 MONTHS FOR BUCCAL TEETH TO ERUPT INTO

OCCLUSION & FOR FUNCTIONAL REORIENTATION OF TRABECULAR SYSTEM .

TWO APPLIANCES RECOMMENDED . DAY TIME APPLIANCE – REMOVABLE ORTHODONTIC

APPLIANCE WITH ADAMS CLASP ON THE FIRST PERMANENT MOLARS AND AN INCISAL RAMP .

RICK – A – NATOR APPLIANCE .

MANAGEMENT OF CLASS III MALOCCLUSION

REVERSE PULL FACIAL MASK ATTACHED TO UPPER BLOCK . ELASTIC FORCE SHOULD BE INCREASED

GRADUALLY . 4 TO 6 HRS DAILY WEAR ( HEAVY

FORCES) .

SOLUTION IN TREATING A NON CLASSICAL CASE

SKELETAL OPEN BITE / VERTICAL GROWERS

MANDIBULAR ADVANCEMENT – 4MM . LOWER MOLAR ERUPTION PREVENTED . VERTICAL OPENING CAN BE SLIGHTLY

INCREASED.

DENTAL OPEN BITE TONGUE CRIB . PREVENTS ERUPTION OF LOWER POSTERIOR

TEETH .

CONSTRICTED MAXILLARY ARCH SLIGHT – MIDLINE EXPANSION SCREW . SEVERE – HYRAX .

CONSTRICTED MANDIBULAR ARCH SLIGHT LINGUAL TORQUING – MIDLINE EXPANSION

SCREW .

CLASS II DIV 2 MIXED DENTITION – ANTERIOR SAGGITAL

APPLIANCE . PERMANENT DENTITION – HYRAX .

AIRWAY PROBLEMS ENT CONSULTATION .

FLARED MAXILLARY INCISOR LABIAL BOW. STRAIGHT WIRE APPLIANCE .

INADEQUATE ARCH LENGTH -MANDIBULAR

POSTERIOR SAGGITAL APPLIANCE . LIP BUMPER .

MANAGEMENT OF CLASS II DIV 2 MALOCCLUSION

LABIAL TIPPING OF UPPER INCISOR IS REQUIRED TO CORRECT THE DISATL OCCLUSION.

BITE REGISTRATION EDGE TO EDGE CONSTRUCTION .

ALL ABOUT TWIN BLOCK APPLIANCE WEAR – FULL TIME INCLUDING MEALS. APPLIANCE TAKEN OUT DURING SPORTS &

SWIMMING APPLIANCE HELPS TO STRAIGHTEN ONES TEETH

AS WELL AS HELPS YOUR JAWS TO GROW, HENCE OPTIMUM CO – OPERATION NEEDED.

SLIGHT DISCOMFORT INTIALLY PRESENTS IF PERSISTS CONTACT YOUR DOCTOR.

BLOCKS SHOULD BE IN CONTACT ALL THE TIME BREAKAGE OF APPLIANCE SHOULD BE

IMMEDIATLEY REPORTED . APPLIANCE REMOVED SHOULD BE STORED IN THE

WATER .

THANK YOU

CASE REPORTS

RAJANI KADAM

1O/F

MANJULA

13/F

CONCLUSSION IF ONE BELIEVES THAT THE FACIAL

STRUCTURES HAVE CHANGED THROUGH THE YEARS AS A PART OF EVOLUTIONARY PROCESS (CHANGE IN THE HABITS, ENVIRONMENT ETC.) THEN ONE CAN DEFINITELY EXPECT A CHANGE OF THESE FACIAL STRUCTURES THROUGH THESE FUNCTIONAL APPLIANCES WHICH PROVIDES OPTIMAL ENVIRONMENT FOR THE FACIAL STRUCTURES TO GROW AND AT THE SAME TIME ELIMINATING THE UNFAVORABLE ONES .

If

THANK YOU

Clinical Implication of growth spurts

A knowledge of growth spurts in essential for successful treatment planning in Orthodontics. This helps us to decide the timing of Orthodontic treatment, i.e., whether to start the treatment at the time of peak growth or after the active growth is completed.

These are obvious for Orthopaedic correction of Maxillo-Mandibular relationship.

Pubertal increments still offer the best time for a large number of cases, as far as predictability, growth direction, patient management and total treatment time are concerned.

Growth Prediction

The orthodontist would be able to forecast a child's adult appearance with or without treatment with accurate growth prediction.

Growth prediction is based on the observed growth pattern, using the static cephalogram taken at the initiation of treatment and averages from previous growth studies.

Prediction of craniofacial growth has been the "Holy Grail" of orthodontics.

Growth PredictionAccording to Hirschfeld and Moyers, six important considerations of growth prediction are:

Future size of a part of the face (the addition of length increments to a structure whose dimensions are already established).

Relationship of parts in order to predict the future facial pattern (for example, evaluating whether further growth will impede a situation, such as the maxilla being behind the mandible).

Timing of growth events (for example, deciding when to provide treatment to achieve specific treatment goals).

Vectorial characteristics of growth that are based primarily on the pattern recognized in the first evaluation.

Growth velocity. This is also important in the timing of treatment so that treatment efficacy is maximized per unit of treatment time.

The effect of orthodontic treatment on any of these prediction parameters. It is the goal of the clinician to base his or her treatment plan on the assessment of the previous five considerations and expect that the treatment plan will work to correct or improve the predicted growth pattern.

Methods for studying Physical Growth Hand Wrist X-rays

They are used to study biological or skeletal age of the person.

The hand wrist region is made up of numerous small bones. These bones show predictable & scheduled pattern of appearance, ossification & union from birth to maturity

Anatomy of Hand Wrist

The hand wrist region is made up of following 4 group of bones :

• Distal ends of long bones of forearm

• Carpals

• Metacarpals

• Phalanges

Hassle & Farman developed a system of skeletal maturation, determination using cervical vertebrae. The shapes of cervical vertebrae were found to be different at different levels of skeletal development

C3 & C4 (Wedge shaped) – Square shaped

The curvature of inferior vertebral borders were seen to appear sequentially from C2 to C3 to C4 as the skeleton matures

Cervical vertebrae maturity indicators (CVMI)