Myofunctional appliances in orthodontic

prepared by BILAL A.M.FALAHI

Prof. Maher A. Prof. Maher A. FoudaFouda

Prepared by:- Bilal A.M.Prepared by:- Bilal A.M.Faculty of dentistry-Faculty of dentistry-

Mansoura university - Mansoura university - EgyptEgypt

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removable or fixed orthodontic appliances which use forces generated by Stretching of muscles, facial and/or periodontium to

alter skeletal and dental relationships

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Conventional orthodontic appliances use mechanical Force to alter the position of tooth/ teeth into a more favorable

position. However, the scope of these fixed appliances is Greatly limited by certain morphological conditions which are

caused due to aberrations in the developmental process or the neuromuscular capsule surrounding the orofacial skeleton. To over come this limitation, functional appliances came into being. These appliances are considered to be primarily orthopedic tools to influence the facial skeleton of the growing child. The uniqueness of these appliances lies in the fact that instead of applying active forces,they transmit, eliminate and guide the natural forces (e.g. muscle activity, growth,

Tooth eruption) to eliminate the morphological aberrations and try to create conditions for the harmonious

development of the stomatognathic system.

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1

2

3

Group A-Teeth supported appliances, e.g.catlans appliance, inclined planes, etc.

Group B-Teeth/tissue supported, e.g.activator, bionator, etc.

I. Classification put forth by Tom Graber when functional appliances were removable:

Group C-Vestibular positioned appliances with isolated support from tooth/tissue, e.g.Frankel appliance, lip bumpers.

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Fixed functional appliances, e.g. Herbst, Jasper jumper, Churro jumper,adjustablecorrector,Eureka spring, mandibular anteriorrepositioning appliance,

(MARA), Klappersuper spring, Sabbagh universal spring (SUS).

Removable functionals, e.g. activator, bionator,frankel, etc.e

Semi-fixed functional appliances, e.g. DenHoltz, Bass appliances, etc.

II. With advent of fixed functional appliances, a new classification evolved:


Maximizing the success of functional appliances treatment

mild/moderate skeletal problems

Patient and family cooporation

Patient actively growingGrowth spurt for boys(12-14)

for girls(11-13)


The difference between growth acceleration in response to a functional appliance and true growth stimulationcan be represented using a growth chart


Functional appliances used in treatment of

CII malocclusion

prepared by BILAL A.M.FALAHIRemovable appliances


Removable appliancesACTIVATORActivator is a loose fitting appliance which was designed by Andreason and Haupl to correct retrognathic mandible.

INDICATIONSActively growing individual with favorable Growth pattern are good candidates for the activator therapy. Various types of activators have been devised for the treatment of various conditions like:• Class II division 1 malocclusion• Class II division 2 malocclusion• Class Ill malocclusion• Class I open bite malocclusion• Class I deep bite malocclusion• For post-treatment retention• Children with decreased facial height

the activator, was independently developed by Viggo Andresen121 inDenmark in 1908


Removable appliances

CONTRAINDICATIONS• Cannot be used in correction of

Class I problems of crowded teeth where there is disharmony between tooth size and jaw size

• Cannot be used in children with excess lower facial

Height.• Cannot be given in cases with

lower proclination• in case of nasal stenosis• In non-growing individuals

ACTIVATOR



HamiltonExpansionActivator

A multi-purpose functional appliance used to correct a Class II malocclusion. The mandible is advanced and the maxillary arch is expanded by the use of expansion screws. The lower posterior area is void of acrylic to allow for eruption. The appliance is primarily used for night time wear in conjunction with the Hamilton holding appliance which is worn in the day time



It is an intermaxillary wax record used to relate the mandible to the maxilla. This is done to improve the skeletal inter-jaw relationship. In most cases bite opening is by 2-3 mm and advancement is by 4-5 mm.

ACTIVATORCONSTRUCTION BITE



ADVANTAGES• Uses existing growth• Minimal oral hygiene

problems.• Appointments usually shortDISADVANTAGES• Requires good patient co-

operation• Cannot produce precise

detailing and finishing ofocclusion

ACTIVATOR



General considerations for construction bite1. In case the overjet is too large, forward positioning

is done in 2-3 stages2. In case of forward positioning of the mandible by7-8 mm, the vertical opening should be slight tomoderate i.e. 2-4 mm.3. If the forward positioning is not more than 3-5 mmthen the vertical opening can be 4-6 mm• Lower construction bite with marked mandibular

forward positioning This kind of construction bite is characterized by marked forward positioning of the mandible with minimum vertical opening. As a rule of the thumb the anterior advancement should not exceed more than70% of the most protrusive position, and vertically it should be within the limits of inter occlusal clearance.

ACTIVATOR


ACTIVATOR


ACTIVATORMANAGEMENT OF THE APPLIANCEThe patient is demonstrated to place and remove the appliance in mouth. The appliance is to be worn 2 to 3hours during the day for the first week. During the second week the patient sleeps with the appliance in mouth and wears it for 1-3 hours each day.The appliance is checked during the third week to evaluate the trimming.the patient is wearing the appliance without any difficulty and following the instructions, checkupappointments are scheduled every 6 weeks.


ACTIVATOR



Herman van BeekHeadgear ActivatorEffective in Class I, Division 1 open or deep bite cases. Upperanteriors are covered with acrylic for torque control. Loweranteriors are free to move lingually while acrylic prevents labialcrown tipping.


Teuscher ActivatorUsed in conjunction with headgear to maintain upper molar position.

Upper torquing springs are also featured in this appliance. Thisactivator may be worn with fixed appliances. If desired, lower lippads can be added


Bruner Headgear ActivatorWire over upper incisors provides more open space anteriorly.

Screw provides only upper expansion. Relief on lower occlusalplane allows eruption in lower

posterior area .


Bass Appliance


Removable appliancesThe bulkiness of the activator and its

limitation to night-time wear was a major deterrent in its greater use by clinicians to obtain maximum potential functional growth guidance. The appliance was too bulky for day-time wear. Moreover, during sleep, the function is minimized or virtually nonexistent.

This led to the development of the BIONATOR, a less bulky appliance. Its lower portion is narrow, and its upper component has only lateral extensions, with a crosspalatal stabilizing bar. The palate is free for proprioceptive contact with the tongue and the buccinator wire loops hold away the potentially deforming muscles. The appliance developed by BALTERS in 1960, can be worn all the time, except during meals.

BIONATOR

in 1960



According to Balters, "the equilibrium between the tongue and the circum oral muscles is responsible for the shape of the dental arches and that the functional space for the tongue is essential for the normal development of the orofacial system" e.g. posterior displacement of the tongue could cause Class 11 malocclusion. Taking into consideration the dominant role of the tongue, Balters designed an appliance, which could take advantage of tongue posture.

BIONATOR

PHILOSOPHY OF BIONATOR


Removable appliancesThus he constructed an appliance

whereby the mandible was positioned anteriorly, with the incisors in an edge to edge position. This forward positioning brought the dorsum of the tongue in contact with the soft palate and helped accomplish lip closure. Thus the principle of bionator is not to activate the muscles but to modulate muscle activity, thereby enhancing the normal development of the inherent growth pattern and eliminate abnormal and potentially deforming environmental factors.



BIONATOR TYPESThree basic constructions are

common in bionator• Standard appliance.• Open-bite appliance.• Class III or reverse bionator.

BIONATOR


Removable appliancesBIONATORBionator IClass II correction, opens bite (in case of deep bite). Individual posterior teeth can be erupted independently. Midline expansion screw opens contact points between posterior teeth for easier posterior eruption.



Bionator in mouth for CII with deep bite



Function regulator appliances were developed by Rolf Frankel (Germany). Frankel believed that the active muscle and tissue mass i.e., the buccinator mechanism and the orbicularis oris complex have a major role in the development of skeletal and dentofacial deformities.

Hence he developed function regulators as orthopedic exercise devices, to aid in the maturation,

training and reprogramming of the orofacial neuromuscular system.

FRANKEL FUNCTION REGULATORwas developed by Rolf Frankel in Germany and was introduced in 1966



1.. Vestibular area of operation- Shields of the appliance extend

to the vestibule and this prevents the abnormal muscle function.

2. Sagittal correction via tooth borne maxillary anchorage

- Appliance is fixed on the upper arch by grooves mesial to the 1st permanent molar and distal to the canine in the mixed dentition period.

- Presence of the lingual pad acts as proprioceptive stimulus and helps in the

forward posturing of the mandible.

FRANKEL PHILOSOPHY



3. Differential eruption guidance- Frankel is placed on the upper teeth.- Mandibular posterior teeth are free to erupt and

their unrestricted upward and forwardmovement contributes to both vertical as wellas horizontal correction of the malocclusion.4. Periosteal pull by buccal shields and lip pad- Presence of buccal shields and lip pads exert

the periosteal pull which helps in bone formation and lateral expansion of the maxillary apical base.

5. Minimal maxillary basal effect- Downward and forward growth of maxillaseems to be restricted, even though lateralmaxillary expansion is seen.

FRANKEL PHILOSOPHY



1. FRl-used for Class I and Class II, Division 1.

FRla -used for Class I, moderate crowding and deep bite. FRlB-used for Class II Division 1 overjet less than7mm.

FRlc-used for Class II Division 1 overjet more than7mm.

2. FR Il-used for Class II Division 2 and Division 1

3. FR Ill-used for Class III 4. FR IV-used for cases with

open bite and bimaxillary protrusion.

5. FR V-FR with headgear.

TYPES OF FUNCTION REGULATORS



Fränkel ICorrects overcrowding in

Class I cases and reduces the overbite and overjet in Class II, Division 1 cases. External muscle pressure is eliminated by the vestibular shields. Promotes transverse arch

development dentally and skeletally.

FRANKEL



Fränkel IIPromotes transverse and

vertical development of maxillary and mandibular arches, corrects Class II, Division 2 cases and

opens bite. Used after the maxillary incisors have been slightly

proclinated by an upper removable appliance

FRANKEL


Removable appliancesFRANKELII

MODE OF ACTION OF FR1. Increase in transverse sagittal direction- by use of buccal shields and lip pads2. Increase in vertical direction- by allowing the lower molar to erupt freely because appliance is fixed to the upper arch3. Muscle adaptation- The form and extension of the buccal shields and lip pads along with the prescribed excercises corrects the abnormal peri-oral muscle activity



ORAL EXERCISES WITH FRANKEL- Frankel-full time wear appliance.- Lips to be closed at all times or keep

a paper between the lips- Swallowing, speaking, etc. with the

appliance in mouth, itself serves as an exercise.



TREATMENT TIMINGThe best therapeutic effect of the

Frankel appliance is achieved during the late mixed and transitional dentition period, when both the soft and hard tissues are undergoing their greatest transitional changes.

Treatment for Class III and open bite cases should usually start sooner than for Class Il problems.



advantages over other functional appliances :-

1. The functional mechanism is very similar to that of the natural dentition.

2. The occlusal inclined planes give greater freedom of movement in lateral and anterior excursion and cause less interference with normal function.

3. Appearance is noticeably improved.

.4. Less bulk, therefore, better patient compliance.

TWIN-BLOCKThe twin block appliance was developed by Clark in 1977



5., Can be used in later stages of growth (late mixed dentition /early permanent dentition)

6. The appliance can be cemented in mouth, without disrupting the normal oral functions, to improve patient compliance.

7. Absence of lip pads and buccal shields, allow patient a much better comfort, however,

modifications containing lip pads can be incorporated as and when required.

TWIN-BLOCK



Case selection for clinical use of twin-block should,display the following criteria:

1. Angle's Class II Division 1malocclusion with good arch form.

2. A lower arch that is uncrowded or decrowded and aligned.

3. An upper arch that is aligned or can be easily aligned.

4. An overjet of 10-12mm and a deep overbite.

5. A full unit distal occlusion in the buccal segments.

6. On examination of models in occlusion with the lower model ad vanced to correct the increased overjet, the distal occlusion is also corrected and it can be seen that a potentially good occlusion of the

buccal teeth will result.

CASE SELECTION FOR TWIN-BLOCK APPLIANCE

TWIN-BLOCK



7. On clinical examination the profile should be

noticeably improved when the patient advances the mandible voluntarily to correct the over jet

8. To achieve a favorable skeletal change, during treatment, patient should be actively growing. Amore rapid growth response may be observed when the treatment coincides with the potential growth spurt.

TWIN-BLOCK



initially, inclined planes were at 90° to occlusal plane.However, adjustment to this sort of inclined plane was difficult for a lot of patients.Therefore, for patient convenience inclined planes were reduced to 45° but since, this angulation caused equal vertical and horizontal movement, the angulation was further changed to 70°, so that more horizontal vector of force would beproduced. Nevertheless, the inclined plane angulation can vary between 45° and 70° depending upon the patient

comfort levels.

ANGULATION OF THE INCLINED PLANESTWIN-BLOCK



Active phaseAverage time of treatment 6-9 months to achieve full

reduction of overjet to a normal incisors relationship and to correct the distal occlusion.

Support phaseThree to six months for molars to erupt into occlusion

and premolars to erupt after trimming the blocks.The objective is to support the corrected mandibular

translation while buccal teeth settle into occlusion .

RetentionNine months , reducing appliance wear when the

position is stabilized.An average estimate of treatment time is 18 months,

including retention.

Stages of Treatment


Fixed Appliances

Successful of orthodontic treatment often relies heavily on the patient’s cooperation in the wearing of removable appliances, elastics or headgear .eliminating the need to use these places the treatment result more under the control of orthodontist.

This lead to development of fixed appliances (non compliance)

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Fixed Appliances

Herbest appliances

JASPER JUMPERTHE MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE

(MARA)

EUREKA SPRINGTHE KLAPPER SUPER SPRING

fixed appliancesfixed appliances used to treat CIIused to treat CII

malocclusionmalocclusion

SABBAGH UNIVERSAL SPRING


fixed appliances

The maxillary and mandibular arches are splinted with frameworks that usually are cemented or bonded but can be removable, and connected with a pin-and-tube device that holds the mandible forward. Occasionally a modification of this appliance is superimposed on traditional fixed appliances Jaw position is controlled by a pin and tube apparatus that runs between the arches.

Herbst appliances


fixed appliancesIndications1- dental CII 2- skeletal CII due to mandibular

deficiency3- deep bite with retroclind

mandibular incisors.Contra indication1-Open bite2-vertical growth with high

maxillomandibular plan angle.Disadvantages• Appliance is prone to breakage.• Lateral movement is restricted

Herbst appliances

In 1905 Emil Herbst in Germany


fixed appliances

The Jasper Jumper (American Orthodontics)

consists of a heavy coil spring encased in vinyl coating .The flexible springs are attached to the maxillary 1st molar posteriorly and distal to the mandibular canine,either directly onto the lower arch wire or by means of an out-rigger.

JASPER JUMPER


fixed appliances

Indications• Dental Class II malocclusion• Deep bite with retroclined

mandibular incisors.Contraindications• Dental and skeletal open bites.• Minimum buccal vestibular space.• Vertical growth pattern with

increased lower facialheight.• Cases prone to root resorption

JASPER JUMPER


fixed appliances

Advantages- Ease of insertion and activation- Generation of intrusive forces

on molars andincisors.Disadvantages- Frequent breakages- Compromised oral hygiene- Externally perceivable bulge in

the cheeks

JASPER JUMPER


fixed appliances

The MARA consists of cams made from 0.060 square wire attached to tubes (0.062 square) on upper first molar bands or stainless steel crown. A lower first molar crown has a 0.059 arm projecting perpendicular to its buccal surface, which engages the cam of the upper molar The appliance is adjusted so that when patient closes the mouth, the cam on upper molar guides and repositions the mandible into a Class I relationship.

Its main disadvantage is that temporary stainless steel crowns are needed on all first molars.

THE MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE

(MARA)


fixed appliances

IndicationSkeletal Class II with

mandibular deficiency.ContraindicationsCases prone to root

resorptionDental and skeletal open bite

Vertical growth pattern.

THE MANDIBULAR ANTERIOR REPOSITIONING APPLIANCE

(MARA)


fixed appliances

. One of the first inter arch appliances to utilize the compressive forces.

Advantages- Good patient acceptance- Can be used for Class Il and Class ill correction aswell as in conjunction with extraoral force.- Possibility of alteration in the amount and directionof force during treatment.- Components are available separately- Significantly less expensive than other appliances.DisadvantagesTechnique sensitive insertion procedure- Frequent breakages of interval spring- Less force levels than fors us and twin forcecorrector.- Tissue irritation.

EUREKA SPRING

Developed by De-vincenzo in 1996


fixed appliances

Introduced by Lewis Klapper in 1997. Resembles jasper jumper except that instead of coil spring, cable is used. In 1998, the cable was wrapped with a coil and Klappcr super spring IT came into being.

Advantages- More vertical force vector,

therefore useful for intrusion.Disadvantages- Unlike, jasper Jumper it enters

the molar tube frommesial and requires special

molar tube for engagement.

THE KLAPPER SUPER SPRINGIntroduced by Lewis Klapper in 1997.


The Churro Jumper (Castañon R. et al., 1998)

This is an inexpensive alternative force system for the anteroposterior correction of Class II and Class III malocclusions. The mesial and distal end of the jumper are circles. The distal circle is attached to the maxillary molars by a pin and the mesial end is placed over the mandibular arch wire against the canine bracket. So far, this is the only flexible functional appliance which can be made up by the orthodontist in his lab. The costs are reduced and the time spent is minimal .


FORSUS FATIGUE RESISTANT DEVICE

The appliance consists of: •Spring module

•L bail pin •Push rod installation. The push rods are

availablein following sizes 25, 29, 32 and 35 mm which areavailable for right and left side.

•The L pin with the spring module is attached toupper first molar after selecting the appropriate push rod.

Its loop is attached to archwire between the cuspid and first bicuspid and the other end is inserted into the compressed spring module.

Advantages •Unequal push rods can be used for midline

correction •Spring can be reactivated by placing crimp split

ring bushings on push rod •Relative ease of installation and removal.



fixed appliances

It is the latest inter arch compressive spring to be introduced and has a number of unique features as:

• - Slotted screw for partial adjustment of distal aspect of the plunger assembly (upto 4 mm) The second coil spring inserted at the time of placement which in combination with the internal spring permits a greater active extension of force than any other appliance.

• Available in one standard link.• No difference in appliance for the right

and left sides. Lateral mandibular movement possible.

• - More resistant to fatigue fracture



fixed appliancesThe SUS is acombination between the Herbst appliance (as a

telescope) and theJasper Jumper (as a spring)aiming to increase the efficacy of the treatment

and to minimize theirdisadvantages. BenefitsReduces- Extraction and surgery cases.-Heavy forces to the teeth and TMJ-Patient cooperation-Treatment time-Chair-time-Breakage-Discomfort- Soft tissue impingement



fixed appliances

Indication:•Class II, late growth cases(rapid class II correction )•Non-compliant class II patients•TMD therapy


Dentoalveolar changes:-- distal movement of the upper molars- mesial movement of the lower molars- retrusion of the upper incisors- protrusion of the lower incisors- rotation of the occlusion plane in clockwise direction






fixed appliances

Disadvantages- Unsuitability for Class Ill treatment- Limitations in patients with maximum opening ofless than 48 mm.- Increased force levels- Considerably greater cost



Functional appliances used in treatment of CIII malocclusion


CIII functional appliances

Class III or Reverse BionatorThis type of appliance is used to

encourage the development of maxilla. The bite is taken in most

possible retruded position, to allow labial movement of the maxillary incisors and reciprocally a slight

restrictive effect on the lower arch. The bite is opened about 2 mm only in the interincisal region.The palatal bar configuration rW1Sforward instead

of posteriorly, with the loop extending as far as thedeciduous 1st molar or premolar.


CIII functional appliances

Fränkel IIICorrects Class III malocclusions

Lip pads are in the maxillary arch- Labial bow resting against mandibular teeth.Protrusion bow is on the upper teeth and is madeof 0.8 mm wire for forward movement of maxillaryincisiors if desired.- The occlusal rest is on the mandibularmolar unlikein FR!! where it is on the maxillary molar


Functional appliances used in treatment of open bite


Open bite functional appliances

FRIV- Used for open bite and bimaxillary

protrusion- Has no canine loops- Has no protrusion bow- Four occlusal rests present i.e, on

deciduous 1st molar and permanent 1st molar on each side to prevent eruption of posterior teeth.

- Palatal bar resembles FR III i.e. it does not contact the teeth

- The buccal shield in FR IV should be wafer thin to enable lip closure and exercise without which the appliance will be a failure.

Frankel (FR-4)Frankel (FR-4)



These are thought to be effective where the open bite is at least partly due to faulty postural activity of the orofacial musculature. The FR-4 works by allowing vertical eruption of upper and lower incisors and retraction of the maxillary incisors, and some authors have reported a change in mandibular rotation from a downward and backward direction to upwards and forwards.

Frankel (FR-4)Frankel (FR-4)


Open bite functional appliancesClark’s Twin-BlockClark’s Twin-Block



A modified activator is used treatment of open bite cases. The intermaxillary acrylic of the lateral occlusal zones is replaced by elastic rubber tubes. By stimulating orthopaedic gymnastics (chewing gum effect), the elastic activator intrudes upper and lower posterior teeth. A noticeable counterclockwise rotation of the mandible was accomplished by a decrease of the gonial angle.

Elastic ActivatorElastic Activator

British Journal of Orthodontics/Vol. 26/1999/89–92


Open bite functional appliancesElastic ActivatorElastic Activator



Bionator IIClass II correction, open

bite. Labial bar prevents anteriors from tipping labially. Includes midline expansion screw for arch development when necessary. Adams clasps can be used on the upper or lower.



Fränkel IIPromotes transverse and vertical

development of maxillaryand mandibular arches, corrects

Class II, Division 2 cases andopens bite. Used after the

maxillary incisors have been slightly

proclinated by an upper removable appliance



The Rapid Molar IntruderThe Rapid Molar Intrusion Appliance

(RMI)is a modification of the Jasper

Jumper .The Jasper Jumper is an auxiliary capable of producing rapid change in occlusal relationships. It is a flexible fixed appliance that delivers a light, continuous force. It can be used to move single teeth, units of teeth or an entire arch. It can deliver functional,bite-jumping forces, headgear-like forces, elastic-like forces.



Initial clinical experiences with the RMI device are promising, but a more structured research project is needed to demonstrate the long-term stability of the results. This noncompliance device for molar intrusion opens new horizons in the complex treatment of vertical excess. A follow-up study and future research will contribute valuable information about stability. In addition, significant new methods for retaining treated open bites that have undergone intrusion of posterior teeth might also be developed in future investigations.


Open bite functional appliancesThe Rapid Molar Intruder


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Myofunctional appliances in orthodontic

Health & Medicine