List of contents Page No.

Research Title: Functional and

orthopedic appliances

Name of student: Murtada Najah Mohammed

Nawar Sabah
Haider Ali
Ali Hameed
Grade: 5

Supervision by
Dr. Hadil
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Chapter two Review of literature

1.1 Introduction: 1

 There are essentially three alternatives for treating any skeletal

malocclusions: growth modification, dental camouflage and
orthognathic surgery.
 While the growth modification could be possible in growing patients,
only the latter two options can be used in adults. Basically there are
three types of orthodontic appliances that can be used for modifying
the growth of maxilla and/or mandible; orthopedic appliances,
functional appliances and inter-arch elastic traction.
 The appliances that produce skeletal changes by applying orthopedic
forces are known as "orthopedic appliances", these employ heavy
forces, adequate anchorage is gained by extraoral means using
occipital, parietal, frontal cranial bones and cervical vertebrae

.1.2 HISTORY: 2

 1879-Norman Kingsley-Forward positioning of mandible in

orthodontics-Bite plane/Bite- jumping appliance (vulcanite).
Drawback-tendency to relapse even with bite guide.
 1883- Wilhelm Roux-first to study the influences of natural forces
and functional stimulation on form-foundation of both general
orthopedic and functional dental orthopedic principles (Wolff’s Law).
 1902-Pierre Robin-first practitioner to use functional jaw orthopedics
to treat a malocclusion-Monoblock in children with glossoptosis
syndrome.

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Chapter two Review of literature

 1909-Viggo Andresen (Denmark) -modified bite jumping appliance-

inspired from Benno Lisher’s theory.
 1938-Karl Häupl (Germany)-saw the potential of Roux’s hypothesis
and explained how functional appliances work through the activity of
the orofacial muscles.
 Andresen-Häupl association= ACTIVATOR
Biomechanical Orthodontics= Functional Jaw
Orthopedics = Norwegian System.
 1936-collaborated on a textbook = (Function orthodontics).
 1906-Alfred P. Rogers- Father Of Myofunctional therapy- the first to
implicate the facial muscles for the growth, development, and form
of the stomatognathic system.
 1905- Emil Herbst = Herbst appliance


 1949-Hans Peter Bimler-during WWII-incorporated elastic force to

orthopedic appliance= elastischer Gebissformer
(Elastic bite former) /adapter = Bimler appliance.
 1938 -developed, the “roentgenphotogramm,” by superimposing a
photograph on a head plate, to show the relationship between the
skull, the teeth, and the soft tissues.
 1957- Rolf Fränkel-Function Regulator.
 1977- Dr.William J. Clarks-Twin Block
 1989- Magnetic Appliances-Blechman et al. Prof.Rolf Frankel
Dr.William J. Clark

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Chapter two Review of literature

1.3 BASIS FOR FUNCTIONALAPPLIANCE:3

 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 and to overcome this
limitation, functional appliances came into being. 3
 These appliances are considered to be primarily orthopedic tools
to influence the facial skeleton of the growing child. 3
 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.3
 “The three M’s-Muscles, Malformation and Malocclusion”-By
Graber, 1963-described effects of function & malfunction. 4
 The Functional Matrix Hypothesis by Melvin Moss
 Identification of certain cartilages (e.g. Condylar cartilage) as
secondary cartilages.4
 Servosystem (or Cybernetic) Theory,1980, by Petrovic & associates
 Growth Relativity Theory (Vodouris & associates)4

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Chapter two Review of literature

1.4 CLASSIFICATION of Myofunctional appliance:5

1- Classification by Tom Graber

When functional appliances were removable:

a- Group I-Teeth supported E.g.: catlan’s appliance, inclined planes,

etc.
b- Group II-Teeth/Tissue supported- E.g.: activator, bionator, etc.
c- Group III-Vestibular positioned appliances with isolated support
from tooth/tissue E.g. :Frankel’s appliance, lip bumpers, vestibular
screen5

2- With advent of fixed functional appliances:

a- Removable Functional E.g. : Activator, Bionator, Frankel’s

b- Removable & Fixed-available in both removable & fixed type E.g. :
Twin Block, Herbst
c- Semi Fixed-Some components fixed, some detachable E.g.: Den
Holtz, Bass Appliance
d- Fixed E.g.: Herbst, Jasper Jumper, Churro Jumper, Saif springs,
Mandibular Anterior Repositioning Appliance (MARA), etc.6

3- With concept of hybridization by Peter Vig: 5

a- Classical Functional Appliance E.g.: Activator, Frankel’s appliance

b- Hybrid Appliances E.g.: propulsor, double oral screen, hybrid
bionators, etc.

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Chapter two Review of literature

4- Classification by Profitt:2 2

a- Teeth borne passive-myotonic appliances E.g.: Activator, Bionator

b- Teeth borne active-myodynamic appliances e.g.; Bimler’s
appliance, elastic open activator, Stockfish appliance
c- Tissue borne passive e.g.: Oral screen, lip bumpers
d- Tissue borne active e.g.: Frankel’s appliances
e- Functional orthopedic magnetic appliances(FOMA)2

1.5 Forces of Myofunctional appliance:4

 Mostly use tensile forces-cause stress & strain-alter

stomatognathic muscle balance.
 Both external (primary) & internal (secondary) forces observed in
each force application. • External Forces-occlusal & muscle forces
from tongue, lips & cheeks. 6
 Internal Forces-reac ons of ssues to 10 force
 They strain the contiguous tissues lead to formation of
osteogenetic guiding structure (deformation & bracing of the
alveolar process). 7
 This is important for 20 tissue for remodeling, displacement and all
other alterations that can be achieved by therapy.
 Differences in force application : -duration of force is interrupted
but there are exceptions like Hamilton & Clark it is full-time-wear
appliances & bonded Herbst & Jasper Jumper7
 Magnitude of force is small and if it induced strain is too great,
difficulty in wearing the appliances.

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Chapter two Review of literature

1.6 TREATMENT PRINCIPLES 8

Depending on the type of force applied there are 2 treatment principles:

I. Force Application

II. Force Elimination

 In force application8

Compressive stress & strain act on the structures involved resulting in a

10 altera on in form with 20 adaptation in function.

 In force elimination8

Abnormal & restrictive environmental influences are eliminated,

allowing optimal development. Function is rehabilitated & followed by
20 adaptation in form.

1.7 Indica ons 9

1- Use of Myofunctional appliance alone: -

a- Cases with mild skeletal discrepancy

b- proclined upper incisors
c- no dental crowding

2- Use of FA in combination with fixed appliance: -

a- Used most commonly to improve the anteroposterior
relationship before starting the fixed appliance treatment.
b- Extremely useful in class II cases
c- reduce the amount of a comprehensive fixed therapy
required
d- reduce need for orthognathic surgery

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Chapter two Review of literature

3- Interceptive treatment
a- Early intervention indicated when one wishes to utilize their
growth enhancing effect.
b- Extremely effective in reducing the relative prominence of the
proclined upper incisors, which are particularly susceptible to
Dentoalveolar trauma.

1.8 Ac on of func onal appliances10

 Skeletal, Dentoalveolar & soft tissue effects of FA’s reviewed by

Dare & Nixon (1999).
 Functional appliances can bring about the following changes:
a- Orthopedic Changes
b- Dentoalveolar changes
c- Muscular & Soft Tissue changes

Orthopedic Changes 11

1- Capable of accelerating the growth in the condylar region.

2- Can bring about remodeling of the glenoid fossa.
3- Can be designed to have a restrictive influence on the growth of
jaws.
4- Can change the direction of growth in jaws.

Dentoalveolar changes11

1- Can bring about changes in sagittal, transverse & vertical

directions.
2- Inhibition of downward & forward eruption of the maxillary teeth.
3- Retroclination of the upper incisors.
4- Proclination of the lower incisor.
5- Lower labial segment intrusion.
6- Levelling of the curve of Spee & tipping of the occlusal plane.

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Chapter two Review of literature

Muscular & Soft Tissue changes12

1- Improve the tonicity of the orofacial musculature

2- Removal of the lip trap & improved lip competence.
3- Removal of adaptive tongue activity.
4- Lowering of the rest position of mandible.
5- Removal of soft tissue pressures from the cheeks & lips.

1.9 Case selec on:14

1- Age: only in growing patient. Optimum age for FA therapy is between

10 years & pubertal growth phase

2- Social Considerations:

3- Dental Considerations: ideal case is when one devoid of gross local

irregularities

4- Skeletal Considerations: Moderate to severe Class II malocclusion

cases are ideal and in case of Mild Class III malocclusion with a reverse
overjet & an average overbite

1.10 Visual treatment objec ve15

 An impression diagnostic test undertaken before making a

decision to use a functional appliance.
 Enables us to visualize how the patient’s profile would be after FA
therapy.
 Performed by asking the patient to bring the mandible forward.
 An improvement in profile lead to positive indication.
 Profile worsens lead to negative and use of other Rx modalities
considered.
 Photographs taken with forward mandibular posture.

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Chapter two Review of literature

1.11 Maximizing the success of func onal appliances treatment:1,2,3

1- mild/moderate skeletal problems

2- Patient and family cooperation

3- Patient actively growing Growth spurt for boys (12-14) and for girls
(11-13)

 The difference between growth acceleration in response to a

functional appliance and true growth stimulation can be
represented using a growth chart

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Chapter two Review of literature

1.12 Common appliance in use

1.12.1 Vestibular screen 1

 Introduced by Newell in 1912.

 Takes the form of a curved shield of acrylic placed in the labial
vestibule.
 Works on the principle of both force application &
elimination.
 Vestibular screen does not contact teeth as compared to oral
screen.

 Indications: 2,3
a- To intercept mouth breathing, thumb sucking, tongue
trusting, lip biting & cheek biting.
b- Mild disto-occlusions.
c- To perform muscle exercises to help in correction of
hypotonic lip & cheek muscles.
d- Mild anterior Proclination.

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Chapter two Review of literature

 Modifications:

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Chapter two Review of literature

1.12.2 LIP BUMPER2

 “Combined removal-fixed appliance”.

 Used in both maxilla & mandible to shield the lips away from the
teeth.
 Maxillary appliance called Denholtz appliance.

 Uses: -
a- In lip sucking patients.
b- Hyperactive mentalis activity.
c- to augment anchorage
d- Distalization of first molars

1.12.3 Ac vator4

 Indications: In actively growing individuals with favorable

growth patterns.
a- Class II div I mo.
b- Class II div II mo.
c- class III
d- class I open bite
e- class I deep bite
f- As a preliminary T/t before major fixed appliance therapy to
improve skeletal jaw relations.
g- For post treatment retention
h- Children with lack of vertical development in lower facial
height.

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Chapter two Review of literature

 Contraindications: -15
1- Correction of class I cases with crowded teeth caused by
disharmony b/w tooth size & jaw size.
2- In children with excess lower facial height.
3- In children whose lower incisors are severely procumbent.
4- In children with nasal stenosis caused by structural problems
w/in the nose or chronic untreated allergy.
5- In non-growing individuals.

 Advantages: -16
1- uses existing growth of the jaws
2- minimal oral hygiene problems
3- intervals b/w appointments is long
4- appoints are short, minimal adjustments required
5- hence, more economical

 Disadvantages: -17
1- Requires very good patient cooperation
2- Cannot produce a precise detailing & finishing of occlusion.
3- May produce moderate mandibular rotation (hence
contraindicated in excess lower facial height cases)

 Mode of action :-9

According To Andresen & Häupl:

a- Induce musculoskeletal adaptation by introducing a new

pattern of mandibular closure.
b- Stretching of elevator muscles of mastication and
Contraction of myotactic reflex set up

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Chapter two Review of literature

c- kinetic energy which causes: -

1- Prevention of growth of maxillary Dentoalveolar process
2- Movement of maxillary. Dentoalveolar process distally
3- Reciprocal forward growth of mandible.
d- A condylar adaptation by backward & upward growth occurs.

 Modifications :-

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Chapter two Review of literature

 Were Time :-
1- 1st week / 2-3 hrs. A day during day time
2- 2nd week onwards / 3 hrs. During day & while sleeping.

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Chapter two Review of literature

1.12.4 Frankel’s function regulator:- 6

 Main effects:
1- Serves as a template against which craniofacial muscles
function. Framework of the appliance provide an artificial
balancing of environment.
2- removes the muscle forces in the labial & buccal areas
thereby providing an environment which enables skeletal
growth.
 Types:
1- FR I
a- Class I & Class II Div I
b- FR 1a-Class I with minor to moderate crowding.
c- FR 1b-Class II div I where overjet does not exceed 5mm FR
1c-Class II div I ;overjet >7mm

2- FR II
a- Class II div I & II

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Chapter two Review of literature

3- FR III-Class III
4- FR IV-open bite & bimaxilliary protrusion
5- FR V
a- Incorporate head gear. Indicated in long face patients having
high mandibular plane angle& vertical maxillary excess. FR III

1.12.5 BIONATOR4

 Developed by Balters in 1950’s.

 Modified activator is less bulky & more elastic
 Have 3 types:-
a- Standard type for class II div I having narrow dental arches
b- Class III Appliance
c- Open bite appliance

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Chapter two Review of literature

1.12.6 Twin block appliance 4

• The Twin Block appliance is a removable, orthodontic functional

appliance that is used to help correct jaw alignment, particularly an
underdeveloped lower jaw.

 Developed by Dr.William J. Clarks, 1977.

 Effectively combines inclined planes with intermaxillary & extraoral
traction.

• The removable twin block is a tissue-born functional appliance that is

worn fulltime.

 It helps in the advancement of the mandible.

 It is a two-piece appliance composed of an upper and lower bite
block.
 Orthopedic traction can be added in cases of severe skeletal
discrepancies. This includes the use of a Concord Facebow (or
headgear) at nigh me. Upper & lower bite blocks interlock at 70 0
angle.

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Chapter two Review of literature

• The fixed twin block is similar to the removable twin block, but can be
used in non- compliant patients. It is similar in design to the Herbst
appliance, however the telescopic tubes of the Herbst appliance are
replaced with two bite blocks.

• Advantages: -

1- Very good patient acceptance.

2- Bite planes offer greater freedom of movement & lateral
excursion.
3- Less interference with normal function.
4- significant changes in pa ent’s appearance within 2-3 months.

1.12.7 Herbst appliance 19

 Fixed functional appliance developed by Emil Herbst in early 1900’s.

 Indications: -
a- Correction of class II MO due to retrognathic mandible.
b- can be used as anterior repositioning splint in patients having TMJ
disorders.

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Chapter two Review of literature

 Specific indications :- 5
a- Post-adolescent pa ents: T/t completed w/in 6-8 months,
hence possible to use the residual growth in these patients.
b- Mouth breathers
c- Uncooperative patients

 It have 2 types:
1- Banded Herbst
2- Bonded Herbst

 Advantages:
1- Continuous action -T/t duration is short
2- less patient cooperation needed
3- Can be used in patients who are at the end of their growth
4- Can be used in patients with mouth breathing habit.

 Disadvantages: -
1- Cause minor functional disturbances.
2- Increased risk of development of dual bit, with TMJ dysfunction
symptoms as a possible consequence.
3- Repeated breakage & loosening of appliance occurs, especially in
lower premolar area.
4- Plaque accumulation & enamel decalcification can occur
5- Tendency for posterior open bite.

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Chapter two Review of literature

1.12.8 Jasper jumper7

 A relatively new flexible, fixed, tooth borne FA.

 Introduced by J.J.Jasper ,1980
 Actions similar to Herbst appliance but lack rigidity.
 Basically indicated in skeletal class II mo with max. Excess &
mandibular deficiency.

 Advantages: -
1- Produce continuous force
2- does not require patient compliance
3- allows greater degree of mandibular freedom than Herbst
appliance
4- Oral hygiene is easier to manage.

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Chapter two Review of literature

1.12.9 EUREKA SPRING4

 Developed by De-Vincenzo in 1996

 One of the first inter arch appliances to utilize the
compressive forces.
 Advantages:-
a- Good patient acceptance
b- Can be used for Class Il and Class ill correction as well as in
conjunction with extraoral force.
c- Possibility of alteration in the amount and direction of force
during treatment.
d- Components are available separately
e- Significantly less expensive than other appliances.

 Disadvantages:-
a- Technique sensitive insertion procedure
b- Frequent breakages of interval spring
c- Less force levels than force us and twin force corrector.
d- Tissue irritation.

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Chapter two Review of literature

1.12.10 The Klapper super spring12

 Introduced by Lewis Klapper in 1997.

 Fixed appliances 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 from mesial and requires
special molar tube for engagement.

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Chapter two Review of literature

1.12.11 Head gear1,2

 Most commonly used extra oral orthopedic appliance Used during

the growth period to intercept or correct certain skeletal
malocclusions as well as to distalize the maxillary dentition or
maxilla itself.
 Also form one of the important adjuncts to control or gain
anchorage.
 They derive anchorage from the cervical or the cranial regions.
 The major 3 components
1- Face bow
2- The force element
3- The head cap or cervical strap

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Chapter two Review of literature

1.12.12 Face mask3,1

 Headgears are generally used for the purpose of reinforcement

of anchorage or for maxillary Distalization . However, when an
anterior protractory force is required , a protraction headgear is
used . Facial mask therapy has gained popularity.
 The principal of pulling force on the maxillary structures with
reciprocal pushing force on the forehead or mandible through
facial anchorage is simple and mechanically sound enough to be
used as a therapeutic procedure for treatment of prognathic
syndromes, maxillary retrusions , clefts and mandibular
prognathism Hickham (1972) claims he was the first to use
reverse headgear. However this modality was made popular by
Delaire around the same time.
 A reverse pull headgear basically consists of a rigid extraoral
framework , which takes Anchorage from chin or forehead or
both for the anterior traction of the maxilla using extraoral
Elas cs that generate large amount of force up to 1 kg or more
 Indications:4,1
1- In a growing patient having a prognathic mandible and a
retrusive maxilla . It aids in pulling the Maxillary structures
forward and pushing mandibular structures backward
2- It can be used for bending the condylar neck for stimulating
temporo-mandibular joint adaptation to posterior
displacement of chin
3- It can also be used for selective rearrangement of the palatal
shelves in cleft patients
4- It can be used in correction of postsurgical relapse
osteotomies(or uncontrolled postsurgical Adaptations)
5- It can also be used to treat certain accessory problems
associated with nose morphology such as lateral deviations.

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Chapter two Review of literature

Face Mask

1.13 When to treat with functional appliance

 The best time to start functional appliance therapy is the late

mixed dentition.

 Advantage of the pubertal growth spurt should be taken.

 Girls & boys along with early matures should be assessed

individually.

1.14 limita ons & complica ons 5

1- Discomfort, as both upper & lower teeth are joined together

2- Depends on patient’s compliance

3- Can be used only if a favorable horizontal growth pattern is present in

cases of Class II correction.

4- It has to be removed during mastication, particularly when strongest

forces are applied.

5- May interfere with speech.

6- Treatment duration is often long

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Chapter two Review of literature

2.0 Conclusion

 The global demand for orthodontics without braces

continues to grow. It's an option that many parents and
patients would prefer.

 Myofunctional orthodontics offers a viable alternative to

traditional orthodontic methods.

 A functional appliance is an appliance that produces all or

part of its effect by altering the position of the
mandible/maxilla.

 These appliances utilize the muscle action of the patient to

produce orthodontic or orthopedic forces to restore facial
balance.

 The question that must be addressed in diagnosis is: “does

the patient require orthodontic treatment or functional
orthopedic treatment or a combination of both and to what
degree? Whether the patient requires functional appliance
alone or need a orthognathic surgery or to what extend FA
can reduce need for surgery?”

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Chapter two Review of literature

 “The study of orthodontia is indissolubly connected with

that of art as related to the human face. The mouth is a
most potent factor in making the beauty and character of
the face and the form & beauty of the mouth largely
depends on the occlusal relations of the teeth. Our duties as
orthodontists force upon us great responsibilities and there
is nothing which the student of orthodontia should be more
keenly interested than in art generally, and especially in its
relation to the human face, for each of his efforts, whether
he realizes it or not makes for beauty or ugliness, for
harmony or in harmony, for perfection or deformity of the
face. Hence it should be one of his life studies. ”
E.H.Angle,190

3.0 References

1- Dentofacial Orthopedics with Functional Appliances by Thomas M.

Graber, Thomas Rakosi & Alexandre G.Petrovic;2/e,2009

2- Orthodontics Diagnosis & Management of Malocclusion &

Dentofacial Deformi es by Om Prakash Kharbanda;2/e,2013

3- Orthodontics Principles & Practice by Basavaraj Subhashchandra

Phulari;1/e,2011

4- Textbook Of Orthodon cs By Gurkeerat Singh;2/e,2007

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Chapter two Review of literature

5- Textbook Of Pedodon cs by Shobha Tandon;2/e,2008

6- Orthodontics –The Art & Science by S.I.Bhalajhi;3/e,2003

7- Contemporary Orthodon cs by William R.Proffit;4/e,2007

8- Norman Wahl, Special Ar cle, “Orthodon cs in 3 millennia.

Chapter 9: Func onal appliances to midcentury”;(Am J Orthod
Dent facial Orthop 2006;129:829-33)

9- Various Internet Sources

10- Contemporary Applications of Orthodontic Implants,

Miniscrew Implantsand Mini Plates 2015, Pages 249-251

11- Contemporary Esthetic Dentistry 2012, Pages 685-718

12- Contemporary Applications of Orthodontic Implants,

Miniscrew Implantsand Mini Plates 2015, Pages 6-21

13- Esthetics and Biomechanics in Orthodontics (Second

Edition) 2015, Pages 133-146

14- Skeletal Anchorage in Orthodontic Treatment of Class II

Malocclusion Contemporary Applications of Orthodontic Implants,
Miniscrew Implantsand Mini Plates 2015, Pages 129-133

15- Current Therapy in Orthodontics 2010, Pages 103-114

16- Orthodontic Treatment of the Class II Noncompliant Patient

2006, Pages 35-57

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Chapter two Review of literature

17- Graber TM Rakosi T Petrovic AG. Dentofacial orthopedics

with func onal appliances. 2nd edi on. Mosby–Year Book, St.
Louis1997
18- Linder-Aronson S Woodside DG Lundström A. Mandibular
growth direc on following adenoidectomy. Am J Orthod. 1986;
89: 273-284
19- Harvold EP. Some biologic aspects of orthodontic treatment
in the transi onal den on. Am J Orthod. 1963; 49: 1-14
20- Harvold EP Vargervik K. Morphogenetic response to
ac vator treatment. Am J Orthod. 1971; 60: 478-490
21- Harvold EP. Bone remodeling and orthodontics. Eur J
Orthod. 1985; 7: 217-230
22- Thurow RC. Edgewise orthodontics.nCV Mosby, St.
Louis1966
23- Woodside DG. The activator. in: Removable orthodontic
appliances. Saunders, mPhiladelphia1977: 269-336
24- Wambera IC. A study of the incisal apices line inclination in
various malocclusions (thesis). Department of Orthodontics,
University of Toronto, Toronto1972
25- Teuscher U. Direction of force application for Class II,
Division 1 treatment with the ac vator-headgear combination.
Studieweek. 1980; : 193-203
26- The principle of the Andresen method of orthodontic
treatment: a discussion based on cephalometric x-ray analysis of
treated cases. Am J Orthod. 1951; 37: 437-458

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