Fixed Functional Appliances - A Classification

Functional orthopedic treatment seeks to correct malocclusions and harmonize

the shape of the dental arch and oro-facial functions.

Removable functional appliances are normally very large in size, have unstable
fixation, cause discomfort, lack tactile sensibility, exert pressure on the mucous
(encouraging gingivitis), reduce space for the tongue, cause difficulties in
deglutition and speech and very often affect aesthetic appearance. The alteration
in the mandibular posture creates added difficulties. These adverse effects make
the adaptation and acceptance of these appliances more difficult 1,2 (Oliver and
Knappman, 1985; Ngan et al., 1989).

Fixed functional appliances first appeared in 1900 when Emil Herbst 3 (Herbst E.,
1910) presented his system at the Berlin International Dental Congress. Since
then and up to the seventies, very little was published on this appliance. It was at
that time that Hans Pancherz4 (Pancherz H., 1979) brought the subject back into
discussion with the publication of several articles on the Herbst.

It was only in the eighties that several systems derived from Herbst’s work
started to appear.

A number of fixed appliances have gained popularity in recent years to help

achieve better results in non-compliant patients.

Fixed functional appliances are normally known as "non-compliance Class II

correctors" giving a false idea about the co-operation necessary during
treatment. In reality, when we compare them to removable appliances, we can
clearly recognize fixed appliances as non-compliance devices. However, for
treatment to be successful, good co-operation is always necessary, especially if
skeletal modifications instead of dentoalveolar compensation are desired.

The aim of this article is to update the classification of fixed functional appliances,
published in 2000 in "The Functional Orthodontist". Their clinical applications will
be listed and a description of how they work will be given. The advantages that
some have over others will also be discussed.

CLASSIFICATION

Fixed functional systems have some advantages over removable systems. They
are designed to be used 24 hours a day, which means that there is a continuous
stimulus for mandibular growth.
They are smaller in size permitting better adaptation to functions such as a
mastication, swallowing, speech and breathing.

Fixed functional appliances are usually described as non-compliance Class II

devices, which are able to treat Class II malocclusions successfully, while
reducing the need for patient co-operation and overall treatment time. It is
possible to treat this type of malocclusion with minimal effort.

Just as the name implies, what distinguishes them from removable appliances is
that it is impossible for the patient to remove them. What we have therefore, is an
appliance that allows greater control by the orthodontist.

These appliances are fixed on the upper and lower arches. Since the application
of force is transmitted directly to the teeth through a support system, the main
disadvantage that may be encountered is dental movement that takes place
during treatment which may not be the most suitable for the type of malocclusion
in question. In an attempt to avoid this unwanted dental movement and as a way
of finding an appliance that allows easy adaptation by the patient, various fixed
functional appliances have appeared in recent years.

Fixed functional appliances can be classified as either flexible (Flexible Fixed

Functional Appliance - FFFA) or rigid (Rigid Fixed Functional Appliance - RFFA).

Flexible Fixed Functional Appliances

Flexible fixed functional appliances (FFFA) can be described as an inter-

maxillary torsion coils, or fixed springs. Elasticity and flexibility are the main
characteristics of flexible appliances. They allow great freedom of movement of
the mandible. Lateral movements can be carried out with ease. The major
drawbacks with these appliances are the propensity with which fractures can
occur both in the appliance itself (mainly in areas that have more acute angles)
and in the support system (mainly in the lower arch). If on one hand flexibility is
an advantage, on the other hand it does tend to produce fatigue in the springs.
Another drawback is the tendency of the patient to chew on the appliance,
possibly contributing to breakage or damage. While it is not possible for the
patient to completely open his mouth, depending on the way the system is fixed
onto the lower arch, good opening can be achieved.

It is important to tell patients to avoid opening their mouths too widely because
this could result in breakage. Also, they are not very aesthetic appliances. When
the curvature of the spring is accentuated, some protuberances can appear in
the cheeks.

Several appliances have come on to the market since the eighties featuring
variations on the covering and type of springs, method of fixation and
replaceability of fractured components. The covering used on the springs makes
the appliance more comfortable and hygienic as food does not accumulate inside
the spring. A disadvantage is that the covering can degrade quite quickly,
especially if the patient bites on the appliance. The ability to replace components
is important, as fractures are an unavoidable reality. These appliances are
expensive, therefore, a system that allows the replacement of some of its
components can reduce the cost of treatment. This leads to another
disadvantage: the inventory of material that must be kept. Almost all are sold in
kits of various sizes which contain components for both the left and right side. It
is not always possible to treat a patient with only one size making it necessary to
replace it with a larger size. Once again, this increases costs.

FFFAs can be used in the treatment of Class I, II division 1 and 2 and III
malocclusions. The intention when they first appeared was for the treatment of
Class II, both in malocclusions characterized by a mandibular deficiency as well
as in cases where a dental problem predominated. Later on, their application
extended to Class I problems especially when treatment including extraction was
foreseen. The appliance was used as an anchorage reinforcement or even for
molar distalization. The appliance is also used in a reverse type for treatment of
Class III malocclusions, as well as in cases of midline discrepancy.

The type of the force exercised by FFFAs is continuous and elastic in nature. The
amount of force is variable in accordance with the skeletal pattern of the patient,
the type of movement desired and the size of the cusps. Normally, in brachyfacial
cases, due to their strong musculature, it is necessary to use more force (greater
activation) than in dolicofacial cases. The height of the dental cusps is a factor to
bear in mind when treating with FFFAs. If the patient has high cusps with good
intercuspation, it will be necessary to exert greater activation on the spring. If the
large size of the cusps is linked to a brachyfacial skeletal pattern with strong
musculature, we can predict a difficult clinical scenario and the appliance will be
prone to fracture.

If an advance of the mandible is required as when treating a retromandibular

case, the force exerted has to be greater than that used when only dental
movement is desired to distalize the upper molar and procline the lower incisors.
If the goal of the treatment is to achieve dentoalveolar movements, the appliance
should be activated minimally by placing a slight bow in the force module. To
maximize the dentoalveolar movements in the upper arch and minimize any loss
of anchorage in the lower, the upper archwire is not tied back.

FFFA produces a "headgear" effect on the maxillary dentition due to the intrusive
force applied to the maxillary posterior segments and produces an anterior
intrusive force on the lower dentition. It can be used to obtain maximum
anchorage, holding upper molars back as the upper incisors are retracted.

Due to the intrusive force on the upper molars, a posterior open bite is common
as well as posterior expansion due to the deflected force module. Another
unwanted common movement is the tendency for the lower molar to rotate
mesiobuccally, causing a mild posterior crossbite especially when the second
molars have not been banded. Some buccal expansion in the upper and lower
arches is to be expected, and placing bands on the second molars will aid final
alignment. Placing a transpalatal or lingual arch during the force activation stage
will help control unwanted buccal expansion of both arches. Loss of occlusion
adds to instability, especially in the transverse dimension.

The most unwanted dental movement is proclination of lower incisors. To avoid

this effect, good anchorage preparation should be carried out. However, in a
brachyfacial pattern with strong musculature this movement would be expected.
To increase anchorage to avoid unwanted dental movements, various additional
systems can be used, such as a transpalatal bar, lingual arches or lower incisor
brackets with lingual torque.

It is advantageous to start the treatment in adolescent patients when the majority

of permanent teeth have erupted and 12-year molars can be banded. FFFAs are
not recommended in mixed dentition, especially late mixed dentition to avoid
unwanted dental movements.

Proper anchorage preparation is critical to achieving successful results. It is

necessary to align and level arches before placing the final wire and activating
the force module. A .017" x .025" or .018" x .025 stainless steel archwire should
be placed before inserting the FFFA. By fully engaging the brackets in both
arches, especially the lower, anchorage is maintained during the activation of the
force module, preventing unwanted mesial movement of the lower incisors and
distal movement of the uppers. When proclining the lower incisors is desired as
in in Class II division 2 it may be advantageous to use a .016" x .022" stainless
steel archwire as a final wire.

All FFFAs allow the patient to close in centric relation.

When the patient closes in centric relation, the contour of the bow should be
significantly increased. By slightly overactivating the appliance in centric relation,
the patient will automatically position the mandible forward. This is a natural
response to decrease the force module and alleviate discomfort. The upper
archwire should be cinched to increase anchorage and minimize dentoalveolar
movements.

Despite the clinical references available in published work about skeletal effects
produced by a bite-jumping mechanism with a FFFA, no current scientific
research would be found. Very few articles were published and these only report
clinical cases. This is in contract to the data available for the RFFA 14-23.

Found in this group were:

1 - The Jasper Jumper 16,17 (Jaspar J., 1987) (American Orthodontics, 1714
Cambridge Avenue Sheboygan, WI 53082-1048, USA).

This was the first FFFA to appear (Fig.1a and 1b).

Fig 1a

Fig 1b

It is made up of a covered spring and is marketed in a kit of different sizes with

both left and right sides. It is accompanied by a quite thorough instruction
manual. It is also an appliance which is more comfortable for the patient because
of its covering. Potential disadvantages are: the large inventory that must be
kept, the coating material may degrade and fractures can occur with some
frequency.

 
The majority of articles published on FFFAs are about the Jasper Jumper.
However, they are few in number, are comprised of mainly clinical cases, and
rarely refer to the skeletal and dental changes seen in treatment groups or
comparative studies.

2 - The Amoric Torsion Coils23 (Amoric M., 1994)

This appliance is made up of two springs, one of which slides inside the other
(Fig.2). They are intermaxillary springs without covering and have a simplified
application system of rings on the ends. These rings are fixed to the upper and
lower arches with double ligatures.

Fig 2

They are marketed in one size only and are bilateral. A large stock of material is
therefore, not necessary. The force exerted by the appliance is variable in
accordance with the fixing points on the arch.

3 – The Adjustable Bite Corrector14 (Richard P. West, 1995) (Orthoplus, Inc.,

1275 Fourth St., Suite 381, Santa Rosa, CA 95404)

This is an appliance which is assembled by the orthodontist as it is composed of

various pieces – caps, closed coil springs, nickel titanium wire (Fig.3).
 Fig 3

It can be used on either side of the mouth with a simple 180º rotation of the lower
end cap to change its orientation. This reduces the inventory by as much as one
half. In the center lumen of the spring we find a nickel titanium wire which is
responsible for the "push" force generated. Repairs and replacements are rapid
and easily carried out with this kit. The cost of repair is minor.

4 - The Scandee Tubular Jumper (Saga Dental AS, 2201 Kongsvinger, Norway).

This is a coated intermaxillary torsion spring sold in a kit which includes the
spring, the covering, the connectors, the ballpins and the glue (Figs.4a and 4b).
There is no distinction between left and right.

Fig 4a
 Fig 4b

The covering can be of different colors making it more attractive for patients. The
orthodontist constructs the appliance, cutting the spring to the length seen fit.
When a fracture occurs, it is only necessary to replace individual components. It
has the drawback of being thick after the covering is applied.

5 – The Klapper Super Spring15 (Lewis Klapper, 1999) (Trademark of

Orthodesign, 744 Falls Circle, Lake Forest, IL 60045).

This is a flexible spring element which is attached between the maxillary molar
and the mandibular canine (Fig.5). The length of the element causes it to rest in
the vestibule when activated. This facilitates hygiene and avoids oclusal
surfaces.

Fig 5

The ends (fixing points) are different:

The open helical loop of the spring is twisted like a J-hook onto the mandibular
archwire. On the maxillary end it is attached to the standard headgear tube
(Super Spring I) or to a special oval tube and secured with a stainless steel
ligature (Super Spring II). This new version prevents any lateral movement of the
spring in the vestibule.
Only two prefabricated sizes are available (with left and right versions of each).
The length of the spring can be increased or decreased by simply bending the
attachment wires.

The horizontal configuration of the attachment wire at the maxillary molar tube
permits distalization with good radicular control.

6 – The Bite Fixer (Ormco 1717 West Collins Avenue, Orange, CA 92867)

This is a new intermaxillary spring coil. The spring is attached and crimped to the
end fitting to prevent breakage between the spring and the end fitting.
Polyurethane tubing is inside the spring to prevent it from becoming a food trap
(Figs.6a and 6b).

Fig 6a

Fig 6b

The Bite Fixer is supplied in a kit with various sizes for both left and right.
7 – The Churro Jumper21 (Castañon R. et al., 1998)

This is an inexpensive alternative force system for the anteroposterior correction

of Class II and Class III malocclusions (Fig.7).

Fig 7

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
archwire 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.

Rigid Fixed functional appliances - RFFA

These appliances have two distinct differences in relation to FFFAs:

 RFFAs 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.

Their appearance dates from the beginning of the century and their main
indication is for the treatment of Classes II malocclusions. Basically, correction
consists of advancing the mandible to a forced anterior position to stimulate
growth and harmonize skeletal defects. The majority of these appliances do not
adapt to the treatment of Class III cases.

The working of RFFAs is based on a telescopic mechanism which encourages

forward repositioning of the lower jaw as the patient closes into occlusion.
Numerous published articles can be found that describe their method of
application, function and expected results over the short and long term. The
skeletal effects produced with this type of appliance are greater than with FFFAs
and are well described24-39.

Only at the end of the eighties did different designs for RFFAs appear.
Alternatives were also developed for fixation which sought to allow greater
freedom of mandibular movement and also to avoid unwanted dental movement,
especially that related to intrusion and vestibular inclination of the lower incisors.

Variations on the Herbst appliance and similar systems, utilizing ball attachments
have appeared on the market in an attempt to:

 improve patient comfort and acceptance

 cause fewer clinical problems compared to screw or pin attachments
 reduce the frequency of emergency appointments
 allow good lateral mandibular movements
 allow easy application in splints for correction in mixed dentition

To ensure a perfect fit into the ball attachments, great accuracy is required when
welding attachments. Nor is it possible to have lower brackets or fixed appliance
at the same time, unless other systems are resorted to such as a cantilever or
mini-tubes which require greater laboratory time.

1 - The Herbst Appliance3,4 (Herbst E., 1910; Pancherz H., 1979) (Dentaurum,
Inc, 10 Pheasant Run, Newtown, PA 18940).

The Herbst appliance was first described by Emil Herbst in 1905 at the Berlin
Dental Congress. After that very little was written on this appliance until the end
of the seventies when Hans Pancherz brought it back into discussion with the
publication of a series of articles4, 38, 39.

The Herbst appliance consists of two tubes, two plungers, axles and screws. The
original device is a banded Herbst design. The Herbst appliance has undergone
some changes in its original design but since the seventies has maintained its
general shape with only a few modifications taking place with regard to methods
of application (Type I, II and IV).

Type I is characterized by a fixing system to the crowns or bands through the use
of screws. This is the most common form. It is necessary to weld the axles to the
bands or crowns and then fix the tubes and plungers with the screws (Fig.8).
 Fig 8

Type II has a fixing system that fits directly onto the archwires through the use of
screws. This method of application has the disadvantage of causing constant
fractures in the archwires. The lack of flexibility together with the difficulty in
lateral movements and the stress placed on the archwires through activation
causes fractures, especially in the lower arch (Fig.9).

Fig 9

Type IV has a fixation system with a ball attachment, which allows greater
flexibility and freedom of mandibular movement. A disadvantage in relation to
other similar appliances is the fact that it needs brakes to stabilize the joint. The
brakes are small and sometime difficult to fit. When a fracture occurs or a brake
is lost, the appliance comes loose (Fig.10).

Fig 10
Evolution:

The first articles published describe a banded Herbst design that involved the
fitting of bands on the upper molars and first premolars with the bands connected
by a lingual wire. In the mandible, bands were placed on the lower first
premolars, and connected by a lower lingual arch. Later on, the banded version
of the appliance was modified to incorporate additional anchorage units:

 Bands were placed on all first premolars and all first molars and both
buccal and lingual wires connected the premolars and molar bands.
 The use of stainless steel crowns instead of bands has been advocated.
 The ball attachment appeared as an alternative to screws.

2- The Cantilevered Bite Jumper (Ormco 1717 West Collins Avenue, Orange, CA
92867)

More recently, the use of a cantilever has been proposed (Fig.11). The biggest
difference resides in the fact that the Herbst style appliance is fitted directly to the
lower molar bands through a cantilever arm. This system means that crowns
have to be fitted to the upper and lower molars. The cantilever secured to the
mandibular stainless steel crowns has a disadvantage in that the thickness of the
screw mechanism can impinge on the patient’s cheek. The parts are available in
kit form with pre-welded screw mechanisms and cantilever arms on crowns of
seven different sizes.

Fig 11

3- MALU Herbst Appliance (Saga Dental Supply A/S, postboks 216, Kongsviner,
Norway)
The MALU – Mandibular Advancement Locking Unit is a recently developed
attachment device for the Herbst (Fig.12). It consists of two tubes, two plungers,
two upper "Mobee" hinges with ball pins and two lower key hinges with brass
pins.

Fig 12

The major advantages are the lower cost, no laboratory needed, flexibility and
the possibility of using combined with edgewise therapy 24,35.

Each upper Mobee hinge is inserted into the hole at the end of the MALU tube
and secured to the first molar headgear tube with ball pin. Each lower key hinge
is inserted into the hole at the end of the plunger and locked to the base arch,
distal to the cuspid, with the brass pin.

4 – Flip-Lock Herbst Appliance (TP Orthodontics, Inc., 100 Center Plaza,

LaPorte, IN 46350).

This is the third generation of ball-joint Herbst appliances available from this
company. The first generation was made from a dense polysulfone plastic but
breakage occurred because of the forces generated within the ball-joint
attachment (Fig.13).

Fig 13

In the second generation, the plastic was replaced with metal (Fig.14). However,
fracture problems persisted.
 Fig 14

The third generation is made of a horse-shoe ball joint (Fig.15). This system has
proved to be more efficient than the previous models, both in terms of application
as well as its resistance to fracture40 (Miller R., 1996).

Fig 15

One of the advantages of this appliance over other similar appliances with a ball
joint, is that it is thinner and smaller which means greater patient comfort.

5 – The Ventral Telescope (Professional Positioners, Inc., 2525 Three Mile Road,
Racine Wisconsin 53404 – 1328).

This was the first telescopic RFFA that appeared as a single unit; i.e. upon
reaching maximum opening it does not come apart (Figs.16 a, b, and c).

16 a,b,c

This appliance is available in two sizes and fixing is achieved through ball
attachments. It is particularly easy to activate. The operation is simple and is
carried out by unscrewing the tube thus allowing an activation of around 3 mm.

Its disadvantages lie in the fact that it is quite thick and suffers from fractures to
the brake which stabilizes the joint. As with the other appliances where fixing is
achieved through ball attachments, great accuracy is necessary with regard to
inclination and the welding of components.

6 - The Magnetic Telescopic Device41 (Ritto A.K., 1997 and author of this article)

This consists of two tubes and two plungers with a semi-circular section and with
NdFeB magnets placed in such a manner that a repelling force is exerted
(Fig.17). Fitting is achieved by using the MALU system.

Fig 17

This appliance has the advantage of linking a magnetic field to the functional
appliance. Its main disadvantages are its thickness, the laboratory work
necessary to prepare it and the covering of the magnets.

7– The Mandibular Protraction Appliance7-9 (MPA) (Filho C., 1995, 1997, 1998)

This is an RFFA which was developed to be quickly made up by the orthodontist

in the laboratory (Fig.18).

Fig 18

Its advantages include ease of manufacture, low cost, infrequent breakage,

patient comfort and rapid fitting.

Another advantage it offers is that it can be made up at any time. This is helpful
when there has been a failure in the supply of other commercially available
appliances or if the orthodontist practices in an area where it is difficult to quickly
obtain certain other alternatives.

The designer of the MPA developed three different types:

MPA I – each side of the appliance is made by bending a small loop at a right
angle to the end of an .032" SS wire. The length of the appliance is then
determined by protruding the mandible and another small right-angle circle is
then bent in an opposite direction. The appliance slides distally along the
mandibular archwire and mesially along the maxillary archwire. Bicuspid brackets
must be debonded.

Limited mouth opening is the major disadvantage.

MPA II – this is made by making right-angles circles in two pieces of .032" SS

wire. A small piece of slipped coil is slipped over one of the wires. One end of
each wire is then inserted through the loop in the other wire. This version allows
the mouth to open wider than the first version.

MPA III – This version eliminates much of the archwire stress that occurs with the
MPA I and II. It permits a greater range of jaw movement while keeping the
mandible in a protruded position. It is adaptable to either Class II or Class III
malocclusions.nIt resembles the Herbst by also incorporating a telescoping
mechanism but is smaller in size. It requires more time to be built and a good
electronic welder that does not darken or weaken the wire.

8– The Universal Bite Jumper5 (UBJ) (Calvez X., 1998).

This is like a Herbst but is smaller in size and more versatile – it can be used in
all phases of treatment in mixed or permanent dentition, Class II or III
malocclusions. An active coil spring can be added if necessary (Fig.19).

Fig 19

No laboratory preparation is required. It is fitted in the patient’s mouth and cut to

the appropriate length for the desired mandibular advancement.
Activations are made by crimping 2-4 mm splint bushings onto the rods. UBJs
with nickel titanium coil springs do not need to be reactivated.

9– The BioPedic Appliance (GAC International, Inc., 185 Oval Drive, Central
Islip, NY 11722 – 1402).

This is a bite jumping appliance which is engaged on the maxillary and

mandibular molars, using a cantilever like system. It is then attached to a
BioPedic buccal tube (Fig.20).

Fig 20

Activation is achieved by sliding the appliance along the buccal tube and fixing
the screw. It is universally sized for left and right sides.Two pivots on the ends
allow the appliance to be rotated when the patient opens his mouth.

10 – The Mandibular Anterior Repositioning Appliance 6 (MARA) (AOA, 13931

Spring Street, PO Box 725, Sturtevant, WI 53177).

This was created by Douglas Toll of Germany in 1991. It consisted of cams on

the molars which guided the patient to bite into Class I (Fig.21).
 Fig 21

The first molars have to be covered with stainless steel crowns and the appliance
must be laboratory manufactured.

The patient can pull back his mandible to a Class II relation but will be unable to
achieve intercuspidation. This means that the lower molars will make direct
contact with the metal, giving an unpleasant sensation. Furthermore, should the
orthodontist opt for bands instead of crowns, fractures will often occur. The
appliance design allows for use in conjunction with braces. It can be used for
Class II treatment and for TMJ problems.

In our opinion, this is an appliance of simple characteristics which allows good

hygiene during the correction stage. With a small modification to the original
design using only wire and composite, a very interesting appliance can be
created for finishing treatment of a Class II malocclusion treated with a functional
appliance.

11 – The IST – Appliance (Sheu Dental, 58613 Iserlohn, Germany).

The Intraoral Snoring-Therapy Appliance is a new device designed by Hinz in

order to treat patients who suffers from breathing problems during sleep, e.g.
obstructive sleep apnea (Fig.22 a and b). According to the inventor, the IST
appliance suppresses snoring by moving the lower jaw forward reducing the
obstruction in the pharyngeal area.
 Fig 22 a

Fig 22 b

The device offers two very important advantages:

 The telescope is threaded so the orthodontist can change the protrusion

on each side individually up to 8mm.
 An end stop in the guiding sleeve prevents the telescope from
disengaging.

The appliance is available in two different lengths.

12 – The Ritto Appliance10-13 (Ritto A.K., 1998 and author of this article) (Please
see www.oc-j.com/ritto/ritto.htm)

The Ritto Appliance can be described as a miniaturized telescopic device with

simplified intraoral application and activation (Fig.23 a and b).
 Fig 23 a

Fig 23 b

The construction of this appliance is based on the mechanism and function used
in the Ventral Telescope adapted for use in conjunction with a fixed appliance.

The main differences when compared to the Ventral Telescope appliance are:

 The appliance does not come apart (no disengagement after achieving
maximum extension).
 The smaller size facilitates adaptation and it does not affect aesthetic
appearance or speech.
 It comes in a single format which allows it to be used on both sides and is
available in only one size.

The Ritto Appliance is simple to use, comfortable, cost effective, breakage

resistant and requires no patient cooperation.

The fact that the appliance does not disengage creates enormous advantages. It
eliminates the time lost in measuring length before fitting, as in other appliances.
This feature makes it possible to fit the appliance in approximately 5 minutes and
remove it in about half that time.

It is even possible to carry out the treatment of Class II retromandibular cases in

mixed or permanent dentition using only conventional bands on the upper molars
and two tubes on the lower molars and brackets on the lower incisors.

Fixation accessories consist of a steel ball pin and a lock (Fig.24). Upper fixation
is carried out by placing a steel ball pin from the distal into the .045 headgear
tube on the upper molar band, through the appliance eyelet and then bending it
back as shown in (Fig.25).

Fig 24 Fig 25

The appliance is fixed onto a prepared the lower arch. The thickness and type of
arch is chosen, its length is adjusted, locks are fitted and the Ritto appliance is
then inserted (Fig.26).

Fig 26 a Fig 26 b

Activation is achieved by sliding the lock along the lower arch in the distal
direction and then fixing it against the Ritto Appliance (Fig.27).
 Fig 27a Fig 27b

The most common question raised after the presentation of this appliance is on
the effect produced on the lower incisors, given that the lower anchorage system
is minimal. In a comparative study between the Ritto Appliance and the Herbst
appliance, no statistically significant differences were found in the position of the
lower incisors (II to A/pog; II to Pancherz plan). In a scanogram analysis of the
lower incisors, no indication of radicular resorption was found during treatment
with the appliance.

According to the authors, these results are due to the fact the protocol with
regard to patient selection was closely followed as were the 3 keys for the
success of treatment25.

Many orthodontists may have experienced the frustration of continual breakage

which discourages the use of fixed functional appliances (FFAs).

In functional treatment with a rigid fixed functional appliance (RFFA), it is

necessary to prepare the patient for 1 to 2 months before fitting the appliance to
stimulate musculature and avoid having the patient exert too much force on the
support systems, causing appliance breakage or unwanted dental movement.
For this reason, the use of a mini-stimulator for mandibular advancement is
advised. This is a thermoformed splint of 0.7 mm in thickness, for the upper
incisors only and incorporating an acrylic bite block for the lower incisors. The
bite block is constructed with the mandible in a forward position (Fig.28).

 
 Fig 28 a Fig 28 b Fig 28 c

For the first 15 days or 1 month, the patient should wear the splint for as long as
possible and maintain the lower incisors fitted into the Bite block. In the following
weeks, the patient should practice swallowing exercises with the lips in contact
and with lower incisors against the bite block.

Only after this stage should therapy be started with the Ritto Appliance, now that
the musculature has been stimulated and the patient has memorized the forward
position of the mandible. Delocking of the occlusion is also achieved.

It is possible to fit the Ritto appliance in conjunction with the mini stimulator for
the first few weeks (Fig. 29).

Fig 29

Another important factor that contributes to comfort and rapid patient adaptation
is the establishment of posterior contact after the advancement of the mandible.
This also creates a posterior proprioceptive sense. It is not always necessary to
have perfect coordination of the arches before starting functional treatment.
Sometimes, even with a pronounced Curve of Spee, therapy can be started as
long as some artificial contacts are constructed with composites on the molars
(Figs.30 a, b, c, d, e, f). The extrusion of the premolars can be beneficial in the
correction of a vertical problem.
 Fig 30 a Fig 30 b

Fig 30 c Fig 30 d

Fig 30 e Fig 30 f

Hybrid Appliances

There are also new appliances that can been classified as hybrid appliances
because they represent the combination of a rigid fixed functional appliance
(RFFA) with flexible fixed functional appliance (FFFA). They could be described
as rigid appliances with coilspring-type systems.
The objective of these appliances is to move the teeth by applying 24-hour
elastic continuous force that would replace the traditional use of elastics and
extra-oral force. Their common feature the use of coiled springs to produce this
force. The force generated varies between 150 and 200 gm. Other advantages
include reduction in the need for patient cooperation and the ease of placement.

We should be aware that the primary objective of the hybrid appliances is not to
reposition the mandible anteriorly. If such was the case, it would be illogical to
reposition a mandible and at the same time to keep exerting mesial inferior and
distal superior force. Rigid fixed functional appliances offer the best choice to
obtain this goal, as is well documented in the literature. With RFFAs, once the
appliance has been activated the patient cannot close in centric relation during
the therapy stage.

In order to obtain the best possible results with a goal of skeletal movement, the
author proposes a philosophy of using muscular pre-stimulation before the
placement of the fixed appliance. This is in conjunction with a treatment plan
based on an individualized pattern model. (The subject of the individualized
pattern model will be presented in a subsequent article in this journal.)

A general inconvenience with rigid fixed functional appliances is the fact that the
fixed appliance needs to be placed as a whole, to establish the necessary
anchorage. Also, control of the vestibular movement of the lower incisors is
important. In such cases it is sometimes necessary to resort to other anchorage
appliances. As such, it can be rather difficult to use these appliances in mixed
dentition.

THE CALIBRATED FORCE MODULE

It was a fixed appliance designed to substitute Class II elastics and it was

developed in 1988 by the CorMar Inc. Available in three sizes, it was applied to
the inferior arch close to the molars and fixed by a screw, and mesial or distal to
upper cuspids, and also fixed to the arch. Its coil spring produced a force
between 150 and 200 gm (Fig.31).
 Fig 31

The same company proposed a Herbst appliance with an exterior coil spring,
attached to the inferior tube. That system generated tooth movement by
employing gentle and continuous force 24 hours a day (Fig.32).

Fig 32

EUREKA SPRINGTM

This appliance appeared on the market in 1996 and it was developed by

DeVicenzo and Steve Prins. It is a three part telescopic appliance fixed to the
upper arch at the level of the molar band and to the lower arch distal to the
cuspid. A detailed user’s manual with all the indications and instructions for its
use accompanies the appliance.
The appliance has an open coil spring that is placed inside of a part of the
system.

Interestingly the authors caution in the manual that the appliance does not create
any orthopedic effect, but underline that the correction is totally dentoalveolar.

The placement system is relatively simple, and the patient can open his or her
mouth widely without any difficulties due to the telescopic effect of the appliance.
It is available in two sizes: 20 and 23 mm long. The appliance is universal and it
can be applied both to the right as well as to the left side (Fig.33).

Fig 33

Eureka Spring is a trademark of Eureka Spring, San Louis Obispo, California

93401

THE TWIN FORCE BITE CORRECTORTM

This appliance differs from others in form and constitution because it has two
internal coil springs. It consists of two joint telescopic systems. At the superior
level it is fixed with a ball pin that is fitted into the buccal tube of a molar band.
The placement in the lower arch is slightly different; it involves a fitting-in system
that is later fixed with a screw to the inferior arch. Normally it is placed distal to
the lower cuspid.

Generally this type of fixing allows for rapid placement and removal of the
appliance. It is available in two sizes and accompanied by a screwdriver to fix the
screw in the lower arch.

Such as in the previous appliance its application vary between Class II and Class
III treatment, and it may be also used as an anchorage system.

In our opinion, due to its original configuration, these appliances are suitable for
cases where there is a need to carry out correction that requires predominantly
dentoalveolar movement. In order to avoid protrusion of the lower incisors it is
recommended to use stronger steel wires or to resort to other accessories.
The major drawback of this appliance is the difficulty to control the force. If we
want less force, we should bend the mesial part of the ball pin in order to have
more wire distal to the tube. This situation, however, may create discomfort and
impingement problems (Fig.34, 35).

Fig 34

Fig 35

The other disadvantage lies in the fact that the lower the lower dentition needs to
be already aligned as it is recommended to use 016"x.022, or 017"x.025"
stainless steel wires that guarantee necessary anchorage. In this way the device
is in principle recommended for permanent dentition.

For Class III correction it is necessary to put a lip bumper tube (LBT) on the lower
molar band.

Recently the third modernized version of the appliance has been presented
under the name "Twin Force Bite Corrector – Double Lock" (Fig.36). It is reduced
in size and both the lower and upper placement is based on the system of lock-
on screws. This new version facilitates the use of the appliance for Class III
correction and it allows for a slightly better control of the force although it still falls
short of the full control.

THE TWIN FORCE BITE CORRECTOR is a trademark of Ortho Organizers Inc.,

1619s Rancho Santa Fe Rd. San Marcos CA92069.

 
FORSUSTM – FATIGUE RESISTANT DEVICE

This is an innovative three telescopic appliance with a coil spring in its exterior
part. This feature makes it resemble some flexible functional appliances (AFF).

In comparison with AFF its great advantage lies in coil spring resistance to
breaking. The coil spring is applied by its sliding on a rigid surface avoiding in this
way angulations at the fixing points.

It is sold in kits that include different length sizes for left and right side (Fig.37).

Fig 37

In the original presentation the appliance is placed in the mandible on the round-
segmented arch that is included in the kit. The appliance slides along the arch
and facilitates opening of the mouth and lateral movements. The resulting force
concentrates more on the anterior and inferior sectors.

In this way there is no interference with continuous arches used during the
treatment, which offers wide application independently of the method applied.

The appliance may be fixed in various ways according to the needs of the patient
(Fig38, 39).
 Fig 38

Fig 39

The device gives you the power to control the amount of force, whether through
various available sizes, or through the direct attachment to the lower arch and
the use of a stop for activation. Thus the appliance may be used in cases of
mixed dentition and it allows for dental asymmetry correction when higher force
on both sides is needed.

The device allows your patient to open and move their jaw freely.

Another device from the same company is the FORSUS TM NITINOL FLAT
SPRING which presents a Nitinol flat wire instead of the coil (Fig.40,41).

Fig 40
 Fig 41

The appliance’s flat surface is more esthetically acceptable and it offers more
comfort.

It is available in various sizes for different patients or to get more activation.

Forsus Nitinol Flat Spring requires no laboratory setup, making chairside

installation quick and easy. The Forsus Nitinol Flat Springs, available in three
different bypass designs, accommodate a variety of molar attachments making it
compatible with your current appliance system. This flexibility eliminates your
need for specialty molar attachments and reduces your inventory of bands and
tubes.

The Forsus Nitinol Flat Spring is slim, flat and made of Super-Elastic Nitinol.
Nitinol is always at work, delivering consistent forces. Force levels remain
constant from the initial setup to the time of removal. The result is faster, more
efficient treatment.

FORSUS is a trademark of 3M Unitek Corporation, 2724 South Peck Road,

Monrovia, CA 91016.

ALPERN CLASS II CLOSERS

This appliance is slightly different from the preceding ones and it is also the most
recent. It is predominantly applied in Class II correction and as a substitute for
elastics. It consists of a small telescopic appliance with an interior coil spring and
two hooks for fixing (Fig. 42).

Fig 42

It functions in the same way as elastics and, similarly, is fixed to the lower molar
and to the upper cuspid. It is available in three different sizes. Its telescopic
action enables a comfortable opening of the mouth.

GAC International, Inc., 185 Oval Drive, Islandia, NY 11749

DISCUSSION

Relying on published articles to date, we can state that FFFAs as well as Hybrid
appliances produce greater dental movement during treatment than RFFAs. This
is due to the type of force they produce. They also allow the patient to close in
centric relation during the therapy stage. In our opinion, these appliances are
suitable for cases where there is a need to carry out correction that requires
predominantly dento-alveolar movement.

When RFFAs initially appeared, they were intended for the correction of Class II
retrusive mandibles. They are considered to be excellent functional appliances
and are considered as non-invasive orthopedic appliances similar to rapid
maxillary expanders. Their method of activation is quite different from that of
FFFAs given that the patient cannot close in centric relation during treatment.
The mandible is in a forward position for 24 hours a day and the type of force
exerted by the appliance is a postural variable force. Their main indication is
Class II skeletal cases, where it is necessary to advance the mandible to
stimulate growth and harmonize skeletal defects.

Dental movement with both appliances is always achievable. If in some cases we

can take advantage of this benefit, in others we have to try and impede more
common dental movements, especially movement related to the labial version of
the lower incisors.

For many years now various methods have been suggested to increase
anchorage with a view toward avoiding unwanted dental movements. Lingual
arches, the thickness of the arch wires, the introduction of torque in the arch
wires and the use of lower incisor brackets with lingual torque are some
examples.

The evolution of support systems is, in our opinion, a backward step in the
scientific and technological progress that is foreseen for the next century. Initially,
appliances were supported on bands, then came the use of rigid bands,
connections welded to the bands, the introduction of crowns on the upper molars
and then on the crowns on all molars and sometimes on the lower pre-molars.
The introduction of the cantilever increased further still the thickness of the wires
that were being used as means of support.

In our 11 years of experience with the Ritto Appliance, we have come to the
conclusion that the "devolution" of the other systems is not the functional
philosophy for the next century. In addition to considerable time lost in the
laboratory and the associated cost, it also means an increase in treatment time
and discomfort for the patient. Too much time is spent fitting crowns, cementing,
waiting in the lab, removing the appliance for repairs and refitting and
recementing bands for finishing. This is a highly uncomfortable experience for the
patient.

We have found with the Ritto appliance that to avoid breakage problems and
unwanted dental movements, and to be successful with the treatment, it is
extremely important to prepare the patient and stimulate the musculature with the
mini splint before fitting the RFFAs. This can be achieved in 6 weeks.

The qualities that functional appliances should present can be summarized as

follows:

- Patient comfort and acceptance are excellent

- They promote better compliance

- They offer an extensive range of motion

- They are simple and inexpensive

- They are easier to fit

- They are adaptable to either Class II or III

- They can be used for mandibular positioning or dentoalveolar movement

- They cause less breakage of archwires and appliances and thus fewer
emergency appointments
- Inventory requirements are minimal – The appliance can be used on either side
of the mouth and there is only one size

- They can be used at any stage of treatment – mixed or permanent

- Their low profile results in considerably less buccal irritation

- They produce good results without the need for patient cooperation.

*The author has financial interest in the Ritto Appliance.

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