For organization purposes :

Orthopedic GROWTH MODIFICATION

Appliances APPLIANCES:
Aimed at - Headgear
correcting - face mask
skeletal - Bionator
discrepancy not - palatal expansion (This pressure causes an
dental. Teeth increased amount of bone to grow between the
are just used as right and left halves of the jaw, which ultimately
results in an increased upper jawbone width)
a handle.
- twin block & Bionator
(Exception: Full time appliance)
- Herbst appliance - fixed alternative to the
*3 approaches
Twin Block or Bionator
in correcting
skeletal - bite plate
discrepancy:
- growth Indications:
modification - class 1 skeletal
- camouflage - class 2 skeletal
- orthognathic - skeletal deep bite
surgery - Skeletal open bite
- skeletal crossbite

*Force applied higher than orthodontic (400

g - 100 g) e.g. Hyrax appliance (140-200 g)
*Force duration: Part- timer 14-16 hrs..
 especially at night
Timing: In growing patients - mixed
dentition period before spurt (8-13 y in
girls - 10-15 y in boys)
ORTHOGNATHIC SURGERIES
Orthodontic FIXED ORTHODONTIC APPLIANCES
appliances
Aimed at
correcting dental
malocclusions
only and not
targeting any
skeletal issues.

*Force applied is
50-100 gm
lighter than the
orthopedic.
*Either
removable or
fixed.

REMOVAEBLE ORTHODONTIC
APPLIANCES
Functional appliances
using power of muscles to move arches and improving
tonicity of muscles . Arches mainly not teeth . So capping
on teeth and anchorage is applied.
ACTIVE:
- activator / Bionator /Anderson appliance (same as the
monoblock but has an palatal expander )
- monoblock
- Herbst
- Forsus
(Fixed appliances need pretreatment alignment before its
application)
- twin block
PASSIVE:
- frankel ( the only tissue- borne appliance)

🔵 Note :selective trimming is possible to move teeth in

the direction of the trimming.
e.g. mandible upward and mesial & maxilla downward and
distal.
Anchorage Intermaxillary / intramaxillary/ reciprocal / absolute
‫ ؟؟‬appliance ‫ لل‬anchorge ‫أعرف ازاي نوع ال‬
‫ هحرّ ك ايه ؟ وهثبّت ايه ؟‬.. ‫اسأل نفسك‬

1 phase treatment VS 2 phase treatment

‫ و حط‬Interceptive ‫ ابدأ ب‬- ‫ ؟‬growing patient .. ‫عندك وقت‬
habit or a skeletal ‫ تثبت الوضع على ما هو عليه و تصلح‬appliances
appliances actively ‫ بعدين حط‬.. rest ‫ بعدين‬.. ً‫ مثال‬discrepancy

So phase 1 ⏩ ⏩rest
correcting the dental malocclusion
phase 2
‫ ؟‬completely grown ‫معندكش وقت وجايلي متدهور‬
cooperation between orthodontic and ‫ هي خطوة واحدة بس‬-
.surgical therapy

HABIT BREAKERS / CORRECTIVE APPLIANCES

ABNORMAL SWALLOWING PATTERN THUMB SUCKING

* simple tongue thrust swallow: phases:

(tongue thrust during swallowing while 1. Birth - 3 y / normal/ no
teeth in contact) problem
- following an open bite create by a thumb 2. 4 - 7 y /abnormal / dental
sucking issues
- well circumscribed anterior open bite 3. +7 y /abnormal / dental &
- contraction of lips and all muscles skeletal issues
(masticatory & mentalis & mandibular
elevator muscles ) features:
So creating a muscular seal - upper and lower teeth tipping
- well circumscribed open bite
*Complex tongue thrust swallow: - developed abnormal
(tongue thrust during swallowing while swallowing
teeth are apart) - short & hypotonic upper lip
- Can be associated with one of the: mouth - thick lower lip so retruding
breathing , plus tonsillitis, pharyngitis or lower teeth
chronic naso- respiratory stress - V shaped maxilla & high vault
- diffuse open bite palate due to cheek pressure
- elevator muscles not contracted - finger has a callus ‫ودنة أو التهاب‬
However, mentalis ms & lips & masticatory or viral infection
muscles are contracted - developing a class 2 div.1
malocclusion
* Retained infantile swallowing pattern:
- very strong contraction of all muscles of Factors affecting damage:
face Position of finger , intensity
‫ ويظهر على وجهه االمتعاض‬grimace face (passive only finger or active
So inexpressive face in general as the with contracted facial muscles),
responsible nerve (facial n. 7 ) is duration and frequency
overwhelmed by holding the mandible all Management: thumb wrapping
the time with all the muscles thumb with gauze/ thumb
- tongue thrusting is between anterior and guard / nail liquid
posterior teeth

appliances: appliances:
- tongue guard - quad helix (the coils in it )
+ muscle exercises - tongue guard
-oral screen 🔵 note that always:
- tongue guard is a habit
breaker and therefore
PASSIVELY correcting open bite
and spacing. And that's applied
to the tongue guard used to
break any habit.
-tongue spares and spikes are
available modalities for tongue
guard but both traumatic.

LIP SUCKING TONGUE PACIFIER

features: SUCKING should be
- proclined upper incisors (residual stopped by
- retroclined lower incisors characteristic age of 2
- open bite of retained
appliances: oral screen + lip bumper infantile
swallowing)

Causes:
- Macroglossia
(in cretism or
Mongolian)
- if was forced
to quit finger
sucking
- organic cause
(inflammation
or ulceration)

Appliances:
Tongue guard
MOUTH BREATHING FINGER OR
( person whose lips incompetent and the normal contact NAIL BITING
between soft palate and tongue to close mouth properly is Common +6 y
opened) - crowding
- rotation and
Causes: attrition in
- pathological : (high fever , large adenoids , tonsillitis , incisors
hypertrophic pharyngeal lymph nodes, deviated nasal especially
septum or hypertrophy of nasal turbinates) lower
- habitual mouth breathing -develops
bruxism
Features: Appliances:
- short upper lip tongue guard
- thick lower lip
- hyper active mentalis muscle
- hypoactive buccinator
- tongue dropped in the floor of mouth so wide mandible &
narrow maxilla
- & CHARACTERISTIC ADENOID FACE:
" V shaped maxilla
" Proclined upper incisors & retroclined lower incisors
" broad mandible
" posterior crossbite
" increased overjet
" deep bite
" gingiva and pdl diseases
Appliances: oral screen or myofunctional trainer

Appliances VS Cases:

🔵
NOTES TO BEGIN WITH:
2 appliances can have the same component but one of the appliances is
called active and one is passive . Depending on whether it's moving teeth or
not. e.g. appliances with a bite plane: can be a retainer (passive) or

🔵
extruding molars and protruding upper anteriors (active).

🔵
movement in ortho is done on both teeth & gingiva.
force in ortho is very gentle to allow other tissues to compensate for the

🔵
action so no adverse effects e.g. gingival recession.
Torquing a tooth = rotating the root only so as to correct the preferred
interincisal angle 135° . This is done with a fixed appliance.
🔵 posterior crossbite ❎ scissor bite; scissor bite is when the lower molar is
too in the occlusion so its facial surface touches the lingual surface of the
upper. Unlike the cross bite when the lower molar is too out and upper molar

🔵
is in.
Posterior or anterior cross bite is mandatory to correct to prevent :
developing a class 3 malocclusion , functional shift of mandible, midline shift

🔵
and asymmetry.
Retention for a one year but full time wearing or more than a one year =
prolonged retention and required for treated rotated tooth unless you applied
precision or over correction so just go for the standardized retention.
Reverse pull headgear (facemask) (12-14 hrs a day) (Extraoral) (in growing
patients)
Maxillary growth by pulling the jaw forward In cases of skeletal class 3
maxillary deficiency.

Headgear (12-14 hrs a day) (Extra oral) (in growing patients)

*For Class 2 malocclusion with maxillary excess mainly
* space regainer (by the distalization of molars)
*Same distallization of molars can be used in class 3 cases to retract the mandible
*guidance for proper eruption position e.g. impacted canine

What's the guidelines for a proper eruption position for impacted canines ??
- Extraction of the deciduous C
- Use of head gear to gain space or / and a screw for arch expansion.
Specific types of high gear :.
HIGH PULL:
*distalization of molars - correcting crowding and
* upward force on maxilla and upper teeth
*& intrusion of molars - treating deep bite.
*treating open bite In class 2 cases maxillary excess

🔵*note:
🔺 Open bite = increased lower facial height LFH = steep mandibular angle =
increased mandibular angle = hyper - divergence = high angle between
palatal and mandibular planes. and sometimes indicate a vertical pattern of
growth (unfavorable)
🔺 Deep bite = decreased lower facial height LFH = decreased mandibular
angle = hypo-divergence = Upper and lower occlusal are parallel

CERVICAL PULL:
*distalization of molars - correcting crowding
* downward force on maxilla and upper teeth
* & extrusion of molars- correcting deep bite in cases of class 2 maxillary
excess
*In cases of dental class 3 : as a molar distalizer and so retrusion of lower incisors

STRAIGHT PULL: In cases of Class 2 malocclusion with no vertical problems. It

prevents anterior or posterior migration of upper teeth.

*note: inner bow of head gear can be attached to the removable appliance or
to the metallic bands on molars (6s)

Chin cup (14-16hrs/day)

Oblique direction of force causes backward and downward rotation of the
mandible. In cases of class 3 with mandibular excess. 400 gm/side

Monoblock
Twin Block
Frankel II appliance
(Functional removable appliances)
*Guides mandible to occlude in more advanced position. In moderate Skeletal
class 2 cases with mandibular deficiency.
*Can cause arch expansion - passively as tongue has a higher effect while lips
are being kept away from teeth.
Mechanism: bone is formed along the mandible & bone deposited in the
condyle : so accelerated mandibular growth + an elongated condyle &
elongated mandible.

Twin Block class 3 reversed bite

Frankel appliance 3 with bow on maxilla
*maxillary growth in class 3 cases & the labial arch to hinder the mandibular
growth
*the lip pad in Frankel is to make maxilla free of lips so free to grow

Lip Bumper ( fixed removable appliance) (molar tube, wire bow and lip pad)
* space regainer by distalization of 6s
* procline incisors
* habit breaker for lip biting

Labial bow / labial arch (removable appliance)

-To retract upper incisors. e.g. class 2 division 2
-management of mild crowding

Labial arch with 2 Adam's clasps or loops used for retracting protruded anterior
upper teeth so treating anterior increased overjet

Utility arches
Mini screws / mini implants
(Fixed appliances)
Both for
*To treat anterior open bite by intrusion of molars
* To treat deep bite by intrusion of lower incisors e.g. Class 2 div. 2
Mini screw alone can also
*gain space to relief crowding

Mini screw and Intermaxillary class 3 elastics (from upper 6 to lower 3)

Called BAMP
 (bone anchored maxillary protraction)
*In case of non cooperative patients only
*Procline maxilla and retrude mandible. In class 3 skeletal mild cases in
growing patients

Fixed appliance with Intermaxillary class 2 elastics (from upper 3 to lower 6)

Extrusion of lower molars. In cases of deep bite in class 2 division 2

Bite plane / bite block

ANTERIOR BITE PLANE for eruption of posterior teeth
POSTERIOR BITE PLANE for eruption on anterior teeth. In case of treating
deep bite with a cross bite, very beneficial to add the posterior bite plane to
the appliance e.g. screw or cervical pull headgear or palatal springs
ANTERIOR PLATE WITH A COVERING ON INCISORS to procline incisors. Can
be used alone or as a component with another appliance e.g. screw

🔵note: in general, eruption of molars or any teeth is favorable only in

growing patients. As if done to a completely grown patient , relapse is highly
expected due to high and completely grown muscular tonicity and forces of
occlusion.

Herbst appliance
Forsus appliance
*Both fixed and both for correcting increased overjet.
So what's the difference ??
- Herbst showed more favorable skeletal effects than Forsus
- Herbst is a fixed coil attached to molar bands. While Forsus is coils and
attached to brackets and wires on molars and all teeth.

Appliances to correct crossbites

For one tooth
🟢
🟢
single palatal spring
labial arch
🔵note:
-palatal spring (to protrude incisors) and labial arch (to stop the protrusion at
the desired limit) combination can be used.
-Disadvantages of palatal springs include being non retentive, very flexible in

🟢
protrusion
2 Adam's clasps
For multiple teeth
🟢
🟢
2D expansion screw with anterior plate if anterior teeth
Jack screw 2 D screw for expanding the arch through molars only - only 2

🟢
molar per arch included
3D expansion screw with anterior plate e.g. schwarz appliance if
anterior and posterior teeth
*Both are used for arch expansion

🔵
* Both are used to distalize molars (providing space = space regainer)
notes :
-expansile screws called wedging appliances.
-screws can be used alone or associated with another appliance (e.g. anterior
bite plate to procline incisors) or surgery (e.g. SAPRE surgically assisted rapid
maxillary expansion to correct severe class 3 cases in both adult and growing
patients)
- screw advantages include easy activation by the patient. And disadvantages
include being bulky.
- retention to maintain lateral expansion requires maintaining the arch form of
the cemented wires (from canine to canine or from molar to molar), also not
to over extend it.
- retention for expanded anterior lower arch requires maintaining an average
Incisal inclination.

🟢Elastics from lingual upper to buccal lower

🟢multiple palatal springs multiple upper teeth * and -management of
🟢Anterior bite block correct anterior crossbite by raising bite (then flaring
mild crowding

🟢Cross elastics to treat posterior crossbites

of upper anteriors is done)
🟢Fixed appliance with crossbite elastics from palatal surface of upper to
🟢Tongue blade
buccal of lower teeth

🟢HYRAX ( hygiene rapid expansion) Screw (removable /5-10 hrs/day/

activation 2 times/day, force: 140-200 gm)
rapid maxillary expansion (skeletal expansion- rapid) to treat bilateral
crossbite , mode of action :
heavy and rapid force to get skeletal and dental effect.

Fixed appliance for alignment and leveling 2x4

(4 anteriors and 2 molars : 2X4)
*ALONE To correct class 3 dental case
*FOLLOWED BY ORTHOGNATHIC SURGERY for decompensation (removal of
the camouflage features - proclined upper incisors & retroclined lower
incisors)

W arch (fixed appliance)

-Treating moderate crowding by arch expansion
-treating unilateral crossbite (modified w arch)

Quad helix (fixed appliance)

*correct unilateral (modified quad helix ) and bilateral posterior crossbite by
maxillary expansion

Box elastics
Vertical Intermaxillary elastics
Extrusion of upper and lower teeth in cases of mild to moderate open bite for
completely grown patients

Appliances for space maintaining or/ and regaining

🟢Lingual arch (passive / bilateral)

🟢Nance appliance (trans-palatal bar/ upper only) (passive / unilateral)
🟢
*Space maintainers
*If activated lingual arch (active / bilateral): space regainer
🟢 *If fixed lingual arch with acrylic teeth or fixed partial denture space
maintainer (functional in chewing and talking /anteriorly) it's functional
(restoring mastication) besides the space maintaining
*Modification of lingual arch with spurs to maintain the space distal to

🟢
lateral incisors.
Band loop (non functional / unilateral)
🟢 Distal shoe/ Eruption guiding / traumatic invasion (passive /unilateral/ distal
to first molar)
🔵
🟢
note: contraindicated for medically compromised patients as it's traumatic.
Fixed brackets with coil spring or tube with coil spring (compressed coil)
(active/ as a space regainer
🟢 Expansion screw (active /unilateral or bilateral) as a space regainer as it's

🟢
molar distalizer
Lip Bumper (active / anteriorly) as a space regainer by distalization of 6s

Appliances for retention:

-Hawley or Essix vacuum removable retainers after class 3 treatment for
maxilla and mandible
-modifications of Hawley (wrap around - soldered bow - soldered clasps - the
speciality wrap)
- last passivated removable appliance can also be a retainer
- last passivated fixed appliance can be a retainer
‫ تم استخدامه للعالج يقدر يكون‬appliance ‫ بس احفظها أنه آخر‬passivated ‫( مش عارفة أوصل لمعنى‬
)retainer ‫كمان‬
-previously mentioned orthopedic appliances used for treatment can be
retainers:
(Myofunctional appliances like twin block.. etc - chin cap - all headgear types)
-fixed wire to teeth from behind for indefinite time / retention for life /
permanent retention
And who would need a permanent retention ?
- Compromised treatment (anytype of orthognathic surgeries other than
maxillary or mandibular advancement or angioplasty)
- Late teen crowding
- Generalised spacing