fixed functional appliances (part 1) / dental implant courses by indian dental academy
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FIXED FUNCTIONAL APPLIANCES(PART 1)
INDIAN DENTAL ACADEMYLEADER IN CONTINUING DENTAL EDUCATION
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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
www.indiandentalacademy.com 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
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INTRODUCTION
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FIXED FUNCTIONAL APPLIANCES – AN OVERVIEW1
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CLASSIFICATION OF FIXED FUNCTIONAL APPLIANCES2
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Rigid Fixed functionals – ( ‘Herbst’ like) Flexible fixed functionals – (‘Jasper’
like) Hybrid appliances
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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
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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
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HYBRID APPLIANCE
The Calibrated Force Module The Twin Force Bite Corrector Eureka Spring Forsus – Fatigue Resistant Device The Sabbagh Universal Spring
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I) APPLIANCE PRODUCING PUSHING FORCE.
A) RIGID Herbst appliance MARS appliance [mandibular anterior
repositioning splint] MPA [Mandibular protraction appliance] Universal – bite jumper
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B) FLEXIBLE Jasper jumper Adjustable bite corrector Churro jumper Klapper super spring II
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II) Appliance producing pulling force. SAIF spring [Several adjustable
intermaxillary force spring].
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FLEXIBLE FIXED FUNCTIONAL APPLIANCES1
What are they Supplied as Variations Advantages Elasticity & Flexibility CoveringHeadgear effect
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Disadvantages:Elasticity & FlexibilityCovering Indications AestheticsInventoryExpensive Type of force Amount of force
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Side effects Anchorage control
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VARIOUS FLEXIBLE FIXED FUNCTIONAL APPLIANCES
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Scandee tubular jumper
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Klapper super spring
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Bite fixer
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Churro jumper
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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.
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Indication Telescopic mechanism
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Herbst appliance – prototype
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MAGNETIC TELESCOPIC DEVICE
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MANDIBULAR PROTRACTION APPLIANCE (MPA) (FILHO‘S APPLIANCE)
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THE UNIVERSAL BITE JUMPER (UBJ)
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THE MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE (MARA)
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BIOPEDIC APPLIANCE
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RITTO APPLAINCE
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HYBRID APPLIANCES1
What are they.CALIBRATED FORCE MODULE
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TWIN FORCE BITE CORRECTOR
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FORSUS
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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.
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CONTRAINDICATIONS
Contraindicated in non-growing patients.
Hyperdivergent facial pattern. A patient with negative VTOUse of functional appliances results in
less than satisfactory results and is therefore not recommended.
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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.
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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.
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TIMING OF TREATMENT
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THE IDEAL TREATMENT PERIOD FOR MAXIMALMANDIBULAR 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 .
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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.
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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.
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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.
www.indiandentalacademy.comSKELETAL CHANGES ASSOCIATED WITH THE
HERBST APPLIANCE BASED ON SKELETALMATURATION
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.
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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.
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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.
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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
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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.
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MODE OF ACTION
Mandibular growth induction. Maxillary growth restriction Dentoalveolar changes Glenoid fossa relocation Changes in neuromuscular anatomy
and function.
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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
www.indiandentalacademy.comBIOMECHANICAL 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.
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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.
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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
www.indiandentalacademy.comHERBST 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).
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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
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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.
www.indiandentalacademy.comEFFECTIVENESS OF TREATMENT FOR CLASS IIMALOCCLUSION 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.
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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.
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REFERENCES
1. A Korrodi Ritto. Fixed Functional Appliances - 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 Functional Appliances,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 Ruf And Hans Pancherz.When Is The Ideal Period For Herbst Therapy-Early Or Late?. Semin Orthod. 2003;9:47-56.
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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.