Evaluation of Fixed Functional

Appliances in Treatment of class III

Malocclusion
Under supervision of:
Prof. Dr.Ahmed S. Salama
Professor and Head of Orthodontic Department,
Faculty of Dental Medicine for Girl
By: Marwa EL Shaarawy Al-Azhar University
Dr. Sara Elkabbany
Lecturer of orthodontic
Faculty of Dental Medicine for Girl
Al-Azhar University
 Content
 Introduction
 Prevalence
 Etiology
 Assessment of class III
 Treatment modalities
 Advantages and disadvantages of RFA
 Advantages, disadv. And indications of FFA
 Classification of FFA
 Concept of FFA
 Conclusion
 Introduction
 Class III malocclusion is one of the skeletal
malocclusion. Skeletal Class III malocclusion is a
challenging problem for orthodontists to manage due to its
multifactorial etiology.

 In skeletal class III malocclusion the mandible may be

prognathic, maxilla is retrognathic or combination of both.
Ngan P, Moon W. Evolution of Class III treatment in orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics.
2015 Jul 1;148(1):22-36.
Hartsfield JK, Morford LA, Otero LM, Fardo DW. Genetics and non-syndromic facial growth. Journal of pediatric genetics. 2013 Mar;2(01):009-20.
Prevalence:
Global prevalence 0%–26.7%
Asian countries, 15.80%
Chinese, 15.69%
Malaysian 16.59%
Japanese 14%
Koreans 9%–19%,
Taiwanese 1.65%
Indian children (0%–4.76%)
Silva RG, Kang DS. Prevalence of malocclusion among Latino adolescents. Am J Orthod Dentofacial Orthop. 2001;119(3): 313–315.
 African countries
4.59%
Americans 9.1%
Mexican 8.3%
Indians lowest prevalence 1.19%
Middle Eastern populations 10.18%
Iranians 15.2%
Turkish 10.30%
Egyptians 4% to 11.38%
Etiology
a. Genetic factors:

b. Environmental factors:

such as enlarged tonsils, difficulties in breathing,

hormonal disturbance, habits of protruding the
mandible, large size of the tongue, trauma, premature
loss of first molar.
1. Jaradat M. An Overview of Class III Malocclusion (Prevalence, Etiology and Management). JAMMR. 2018;25(7):1-13.
 Assessment of

Class III

malocclusion

Zere E, Chaudhari PK, Sharan J, Dhingra K, Tiwari N.

Developing Class III malocclusions: challenges and solutions.
Clinical, cosmetic and investigational dentistry. 2018;10:99.
Youssef MS. Growth treatment response vector (GTRV) analysis in Class III patients (Doctoral dissertation,
Marmara Universitesi (Turkey)).
 .

 Treatment options of skeletal Class III malocclusions

may include:

1. Growth modification in growing patient.

2. Camouflage treatment

3. Orthognathic surgery in non-growing patients

Vanlaecken R, Williams MO, Razmus T, Gunel E, Martin C, Ngan P. Class III correction using an inter-arch spring-loaded module. Progress in orthodontics. 2014
Dec;15(1):1-1.
Treatment options

Pattanaik S, Mohammad N, Parida S, Sahoo SN. Treatment Modalities for Skeletal

Class III Malocclusion: Early to Late Treatment.
 .

 Treatment options for growing patients with class III

malocclusion:
1. Removable functional appliance: 2- Fixed functional appliance:
a) Intra-oral a) Rigid

b) Extra-oral b) Flexible

c) Hybrid

Mandall N. Early class III protraction facemask treatment reduces the need for orthognathic surgery: amulti-centre, two-arm parallel randomized, controlled trial.
Journal of Orthodontics, 2016; (43): 164–175.
 .
 A functional appliance is a device that alters a patient's
functional environment in an attempt to influence and
permanently change the surrounding hard tissues.

Shahid F, Alam M.K, Irshad M, Rayan Alswilem R. and Kiran Ganji k. Forsus fatigue resistant device a fixed functional appliances: An update.
International Medical Journal. 2017 Feb 1;24(1):132-5.
 .
 Removable Functional Appliances:
 The options for correction of Class III malocclusion in growing patients
consist of two principal categories: intraoral appliances and extraoral
appliances:

 Removable functional appliance:

a) Intra-oral b) Extra-oral c) Combination
Advantages of RFA:
 Control vertical dimension
 Can be used in mixed dentition periods
 Less chair side adjustment
 Easy to be adjusted
 Patientcan maintain good oral hygiene and
mastication
 Less or no white spot lesion, decalcification and caries
 Damaged appliance can be removed by the patient
 Relativelycheap compared to fixed appliance and
orthognathic surgery
Disadvantages of RFA:
 Need patient cooperation
 Does not apply constant force.
 No precise tooth movement
 Need different phases of treatment
 May lead to fatigue
 Functional speech and respiratory disorders,
 They may affect esthetic.
 Patients may have pain and discomfort at various levels.
 May lead to oral mucosa pressure, soft tissue tension, oral
constriction, toothache, and pain
 2. Fixed Functional Appliance:

 Fixed functional appliances have been developed to eliminate

the disadvantages created by removable functional appliances.

 Fixed functional appliances (FFAs) were first introduced by

Emil Herbst in 1905 as Class II correctors for non-compliant
patients.
Advantages of FFA:

 Do not require the patient’s collaboration.

 Can be worn in association with fixed appliances.

 Continuous action.

 Short treatment duration.

 Can be used in late growth stage.

Disadvantages of FFA:
 Cause minor functional disturbance,

 Incisors flaring.

 Repeated breakage of the appliance especially in the

premolar area

 Plaque accumulation and enamel decalcification may occur.

 Tendency of posterior open bite.

 Mucosal ulceration.
Indication of FFA:
 1) The correction of skeletal anomaly in young developing
individuals.
a) In skeletal class II cases with retrognathic mandible.
b) In skeletal class III cases with retrognathic maxilla.
 2) Making use of the residual growth left in neglected post-
adolescent patients who have passed the maximal pubertal
growth and are too old for removable functional appliances.

 Verma N, Garg A, Sahu S, Choudhary AS, Baghel S. Fixed functional appliance-A Bird’s Eyeview.
 Indication of FFA:
 3) In adults patients –

 molars distallization

 -Used to enhance anchorage.

 -Used as mandibular anterior repositioning splint in patients

having Temporo-mandibular joint disorders.

 -Post-surgical stabilization of class II / class III

malocclusion.
Indication of FFA:

 4. Functional midline shifts can be corrected by using the

appliance unilaterally.
 Considerations for fixed functional
appliances
1. Age factor:

Fixed functional appliances have an important advantage that

they can be used in post adolescent patients in whom very less

growth is remaining.

Prateek, Shami and Sandhya. Fixed functional appliances: An overview. International Journal of Current Research. 2017; Vol. 9, Issue, 03:47407-47414.
 .
2. Growth considerations:

The prognosis of the fixed functional therapy is poor in patients

with hyperdivergent facial growth patterns i.e. in patients with a
large gonial angle and increased lower anterior facial height and
also in patients having an open bite.
3. Esthetic considerations: .
Fixed functional appliances yield excellent results in patients

with skeletal class II bases with retrognathic mandible who have

a positive VTO (visual treatment objective). On the contrary

fixed functional appliances are not recommended in patients

with a negative VTO because of unsatisfactory results.

 .
4. Compliance:

Being fixed type of appliances they have an advantage that

they do not demand patient compliance which is an

important factor in the success of removable type of

functional appliances.
 Concept and Biomechanics
 Most orthodontic appliances use intrinsic or stored force to
move teeth.

 This force is exerted from within the appliance its self and
dissipated against the teeth

and supporting structures.

 .
 FFA acts primarily because of its intrinsic force and
secondarily because of the extrinsic force delivered by the
muscles.

 FFA Could distract the mandible downward and backward.

 Possible adaptive mechanism in the condylar ramus area of

the mandible.

El-Sheikh M.M, Godfrey K, Manosudprasit M. and Wiwattanateepa N. An inverted forsus for class III treatment: A pilot typodont study. KDJ. 2003;(6) N0.
1 : 19-24
 .
 Classification Fixed Functional Appliance:

 A} Rigid Fixed Functional Appliances (RFFA)

1) The Herbst Appliance

2) The Mandibular Anterior Repositioning Appliance (MARA)

Prateek, Shami and Sandhya. Fixed functional appliances:

An overview. International Journal of Current Research.

2017; Vol. 9, Issue, 03:47407-47414.

C} Hybrid Fixed Functional Appliances (HFFA):
 Forsus Fatigue Resistant Device

 Osama Eissa O, ElShennawy M, Gaballah S, ElMehy GH. and El-Bialy D. Treatment of Class III malocclusion using miniscrew-anchored
inverted Forsus FRD:Controlled clinical trial. Angle Orthod. 2018.
  Forsus Fatigue Resistant Device in 2006.

 The FFRD is a three-piece, telescoping system, which incorporates a .

super-elastic nickel-titanium coil spring.

1. Shahid F, Alam M.K, Irshad M, Rayan Alswilem R. and Kiran Ganji k. Forsus fatigue resistant device a fixed functional appliances: An update. International Medical Journal.
2017 Feb 1;24(1):132-5.
El-Sheikh M.M, Godfrey K, Manosudprasit M. and Wiwattanateepa N. An inverted forsus for class III treatment: A pilot typodont study. KDJ. 2003;(6) N0. 1 : 19-24
 Conclusion
 1. Inverted FFRD can correct Class III malocclusion by moving the upper
dentition forward, to create positive overbite and overjet provides and
Class I canine and molar relationship.

 2. Posterior bilateral open bite developed mainly due to vertical intrusive

force on the lower posterior arch segment.
Osama Eissa O, ElShennawy M, Gaballah S, ElMehy GH. and El-Bialy D. Treatment of Class III malocclusion
using miniscrew-anchored inverted Forsus FRD:Controlled clinical trial. Angle Orthod. 2018.
 Conclusion
 The use of miniscrew-anchored inverted FRD could effectively increase
maxillary forward growth and result in counterclockwise rotation of the
occlusal plane.

 Clinically non significant proclination of the maxillary dentition was

observed.

 Distalization of the mandibular dentition together with intrusion of

mandibular molars and maxillary incisors were inevitable treatment
results.
 Conclusion
 Significant esthetic improvement of the facial profile, mainly due to
lower lip retrusion and upper lip protrusion, could be achieved.
B} Flexible Fixed Functional Appliances (FFFA)

The Jasper Jumper (modified J.J. in class III)

1. Kılıçoğlu H, Öğütlü N.Y. and Ceylan Alioğlu Uludağ C.A. Evaluation of Skeletal and Dental Effects of Modified Jasper Jumper Appliance and Delaire Face
Mask with Pancherz Analysis. Turkish J Orthod. 2017; 30: 6-14
 The appliance composed of two parts, the force module and the anchor units. .

 The force module is constructed of a SS coil or spring that is attached at both

ends to SS endcaps with holes for the anchoring unit.

 This module is surrounded by an opaque polyurethane covering for hygiene

and comfort.
Kılıçoğlu H, Öğütlü N.Y. and Ceylan Alioğlu Uludağ C.A. Evaluation of Skeletal and Dental Effects of Modified Jasper Jumper Appliance and Delaire
Face Mask with Pancherz Analysis. Turkish J Orthod. 2017; 30: 6-14
 Conclusion
 1. Treatment period of the Modified Jasper Jumper was shorter than
that of the face mask

 2. The maxillary base moved forward in both treatment groups, with

the distance being more in the face mask group.

 3. Maxillary incisor protrusion and forward movement was higher in

the Modified Jasper Jumper group than in the face mask group.

 4. In the Modified Jasper Jumper group, lower incisors were intruded,

while they were extruded in the face mask group.
 Conclusion
 5. In the Modified Jasper Jumper treatment group, overjet change was
calculated as 4.63 mm: 51.4% of this change was due to skeletal changes and
48.6% was due to dental changes. Further, 47.1% of skeletal changes were
due to 2.18 mm forward movement of A point and 4.3% were due to 0.20 mm
backward movement of B point.

 6. In the face mask treatment group, the overjet change was calculated as 5.17
mm: 70.6% of this change was due to skeletal changes and 29.4% was due to
dental changes. Further, 60.3% of skeletal changes were due to 3.12 mm
forward movement of A point and 10.3% were due to 0.53 mm backward
movement of B point.
McNamara JA, Franchi L, McClatchey LM, Kowalski SE, Cheeseman CC. Evaluation of adolescent and adult patients
treated with the Carriere Motion Class III appliance followed by fixed appliances. The Angle Orthodontist. 2021 Jan 12.
 Conclusion
 1. The Carriere Motion Class III appliance is an effective and efficient
adjunct to fixed appliances in the management of Class III
malocclusion in mature patients.

 2. Most of the treatment effects produced by the CM3 appliance were

dentoalveolar in nature, with minimal skeletal adaptations observed.
 Conclusion
 3. A counterclockwise rotation of the occlusal plane was evident, most
of which remained at the end of treatment.

 4. The CM3 treatment produced anterior movement of the maxillary

dentition relative to the mandible and posterior movement
(‘‘distalization’’) of the mandibular dentition relative to their bony
bases.
Conclusion of the use of FFA in class III
 Effective in the treatment of mild to moderate class III

 Their use is recommended in patients with deficient maxilla,

 The effect is mainly dento-alveolar effect in post pubertal,

 They can produce skeletal effect in young patients,

 Improvement of soft tissue profile.

 Maxillary and mandibular incisors angulation??