FUNCTIONAL APPLIANCES

Dr. Fahad Shukur Ali

PhD. orthodontics and dentofacial orthopedics
“Does orthodontic patients require only fixed orthodontic
treatment or they some times may need orthopedic
treatment or may need a removal appliance ?”
There are essentially three alternatives for treating any skeletal malocclusions:

1. growth modification,
2.dental camouflage,
3. and orthognathic surgery.

The first two options are used in growing patients, and the latter two can be used in adults.
These appliance are used for growth modification
procedure that are aimed in intercepting & treating jaw
discrepancies.
 Orthodontic force vs orthopedic force

There are two types of forces used in orthodontics. One

is “orthodontic force,”
which when applied brings about dental change; the
other is “orthopedic force,” that brings about skeletal
change.

Unlike orthodontic forces which are light forces (50–100

gm) bringing about tooth movement, orthopedic forces
are heavy forces, generally in the range of (300–500 gm)
(over 400 gm) per side, that bring about changes in the
magnitude and direction of bone growth.The appliances
that produce skeletal changes by applying orthopedic
forces are known as “orthopedic appliances.”
Rationale of orthopedic appliance
therapy
Orthopedic appliances generally use teeth as
“handles” to transmit forces to the underlying
skeletal structures.

The basis of orthopedic appliance therapy

resides in the use of intermittent forces of very
high magnitude. Such heavy forces when
directed to the basal bones via teeth, tend to
alter the magnitude and direction of the
growth of the jaws by modifying the pattern of
bone apposition at periosteal sutures and
growth sites. Immediate tooth movement does
not occur since hyalinized zones in periodontal
ligament caused by heavy forces prevent direct
frontal resorption of the socket wall.
 According to the mode of action orthodontic appliance are classified into:

A. Active appliances: is one that uses some

kind of force to move teeth into the desired
position for example removable, fixed,
orthopedic and myofunctional, combination,
space regainer, and clear aligner.

B. Passive Appliances: is one that holds the teeth

in place mostly after active treatment has been
completed, for examples retainers, habit breaker
and space maintainer.
According to the patient’s ability to remove of
the orthodontic appliance are classified into :-

A. Removable
appliances:

B. Fixed
appliances:
 Functional Orthodontic Appliances
These are appliances which engage both arches
and act principally by holding the mandible
away from its resting position, they transmit the
natural forces of the circum-oral musculature to
the teeth and/ or alveolar bone.
 Functional Orthodontic Appliances
can also be classified in to

Removable functional appliance fixed or simi fixed functional appliance

Activator
Forcus appliance
Bionator Herpst appliance
Jusper jumper
Twin block
Frankel appliances
These appliances generally
cause a change in the
surrounding soft tissue
envelope of the teeth
thereby leading to a more
harmonious relationship of
the jaws to each other and
to the other bones of the
facial skeleton, e.g. the
Frankel appliance. They can
be either
Functional appliance are different varieties
of appliances fabricated mainly to correct
skeletal class II by enhancing mandibular
growth and also altering the mandibular
position (forward and downward) .
• Patient and family cooperation
• Mild \ moderate skeletal problems
• Actively growing patient : boys (12 – 14y )
girls ( 11-13y )
Can functional appliance be used in
earlier than pubertal growth spurt?
If there is a psychosocial concerns relating to the
aesthetic

If there is a significant increased risk of trauma

due to the increased overjet

Habit braker
AGE OF THE PATIENT
It is advisable to start with
patients in the mixed dentition
period, to make most of the
active growth occurring during
prepubertal growth spurt.
Treatment may have to be
continued until the completion
of adolescent growth, so as to
prevent relapse caused by the
re-expression of patient’s
fundamental (essential) growth
pattern after the cessation of
orthopedic therapy.
Optimum timing of extraoral force application is considered to be during evening and night. This is because an increased
release of growth hormone and other growth-promoting endocrine factors

Orthopedic appliances are worn intermittently for only about 10–14 hours a day.
 Mode of action of functional appliances

These appliances correct or at least reduce the anteroposterior skeletal discrepancy in a

process known as growth modification or dentofacial orthopaedics by:
1. forcing the mandible to posture forward to reduce overjet
2. stretching the soft tissues (muscles of mastication)
3. force transmission from the muscle to the appliance to the teeth
4. encourage the back compensatory growth of mandible
5. increasing lower anterior facial height (LAFH)
6. restraining the maxillary growth
7. the resultant correction in overjet is attributed to 70% tooth movement and 30% skeletal changes
1 -Andresen activator (Monoblock appliance )

The activator was originally described by Andresen and Häuplthe early 1900s.
It was based upon the hypothesis of stimulating increased muscle activity in the mandibular elevator and retractor
muscles to act directly on the dentition through the appliance and stimulate the mandibular condyle to allow
remodelling and growth.

Function: It use for treatment of Skeletal Class II

due to mandibular deficiency

Dr.FaHaD
Mode of Action: Forward Positioning of the Dr.FaHaD
Mandible with lingual flanges (acrylic guide ) which will stretch 5 mm
the muscles, reposition and accelerate the mandibular Growth. Dr.FaHaD
Dr.FaHaD
 Dr.FaHaD

Dr.FaHaD

Dr.FaHaD

Dr.FaHaD
Dr.FaHaD
5 mm
Dr.FaHaD
Dental Changes Produced by
Activator

Incisor Changes

The activator helps in

successful overjet and
overbite reduction by
retroclination of upper incisors
and proclination of lower
incisors.
Vertical Molar Changes

The design of the activator permits removal of

occlusal acrylic above the lower molar and
premolars.
This facilitates upward and forward eruption of
the lower molars and makes the activator a
logical choice for low angle class II division 1,
where there is a need for the molars to be free
to erupt into the freeway space. Lower molar
eruption of this kind is assumed to be a
favorable factor in correcting the class II molar
relationship and reducing the deep incisor
overbite.
 Changes In Lower
Facial Height
The activator produces an
increase in lower facial height by
encouraging eruption of lower
molars when acrylic is trimmed
above the lower molars.
 2. Twin Block appliance

Function : It is used for treatment of Skeletal Class II due to

mandibular deficiency

Mode Of Action: It is made up of two components an upper and a lower plate which work
together to posture the lower jaw forward. This frees up the "locked-in lower jaw and
encourages it to grow to its fullest potential The upper plate may also have an expansion screw
to widen the upper arch to avoid developing a posterior crossbite when the lower jaw is
Advanced
Advantage of Twin-block

1. The appliance can be worn full time, including during eating

in some

2. It is also possible to modify the appliance to allow expansion

of the upper arch by incorporating expansion screw

3. An alternative modification to allow correction of Class II

division 2 malocclusions is by incorporating z-spring in the
upper part to proclinethe incisors and convert the case into
class II div1.

Disadvantage of Twin-block

residual posterior open bitesat the end of the functional

phase.
3-Herbst appliance
The Herbst appliance is a tooth born fixed functional appliance.

Components: There is a section attached (banded or bonded) to the upper buccal molar teeth
and another section attached to the lower premolar teeth. These sections are joined by a rigid
arm that postures the mandible forwards.

Advantage
As it is a fixed appliance, it removes some (but not all) patient`s compliance factors and better
tolerated than the other bulkier functional appliances

Disadvantage
• Increased breakages
• Higher cost
• Not easy repairable
4-Jasper jumper

It is a fixed tooth born functional appliance characterised by

more flexibility and less rigidity in comparison to Herbst
appliance.
Advantages
1)It produces 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.
5. Bionator

The bionator was originally designed to modify tongue behavior, using a heavy wire loop in the
palate. The lack of acrylic in the palate makes it easy to wear. A buccal extension of the labial bow
holds the cheeks out of contact with the buccal segment teeth, allowing some arch expansion.
6. Fränkel appliance

This appliance is also called Functional Regulator (FR), it is completely tissue-borne

appliance. Four types of Fränkelappliances:

Class II division 1(FR1),

Class II division 2(FR2),
Class III (FR3)
Anterior open bite malocclusions (FR4).

This appliance is rarely used in contemporary orthodontic treatment because of several

disadvantages such as difficulty in wearing and fabrication, and is troublesome to repair.
7. Lip bumper

Lip bumper is a combined removable-fixed functional appliance. Used in both

maxilla and mandible to hold the lips away from the teeth. Also used to hold
the lower molars back while allowing the lower front teeth to move forward.
This provides space for over crowded anterior teeth.

Uses:
•in patients exhibit lower lip sucking
•in patients with hyperactive mentalis
•to support anchorage
•distalization of molars
•as a space regainer
8-Oral screen
It is a curved shield of acrylic centered in the vestibule between the labial/buccal aspects of the teeth from
behind and lips and cheeks from the front
Types
•Active: It transfers the force of circumoral musculature to the most proclined teeth
•Passive: eliminate the force exerted by circumoral musculature allowing the teeth to move labially by action
of tongue

Advantages
1.Act as habit breaker in patients suffering from mouth breathing, tongue thrusting, lip and cheeks biting
2.Muscle trainer for hypotonic lip and cheek muscles
3.To retrocline mild proclined anterior teeth
Extra Oral Traction
(EOT) Appliances
1-Headgear

can be added to a fixed appliance, removable appliance or

a functional appliance, such as a Twin-block appliance,
usually with the aim of achieving orthopaedic changes.
 at the time of treatment planning, the direction of pull should be considered which is one of
Directions of pull the following three directions:

1-High-pull headgear (occipital) which helps to restrict the vertical

growth of maxilla and reduce overbite, so typically used in cases with
increased vertical proportions

2-Low-pull headgear (cervical) which is used to increase the vertical

dimension by having an extrusive effect on the molars in cases of
reduced vertical proportions

3-Straight-pull headgear which controls the anteroposterior and is

typically used in cases with average vertical proportions
Force magnitude and wearing time

The magnitude and duration of force vary according to the purpose.

These appliances usually best achieve by wearing at bedtime. The
minimum duration of wearing is shown in the table below:
Headgear Components

1. Face-bow (inner and outer bows)

2. Headcap or neck strap
3. Spring mechanism or strap: this element connects the face-bow to the headcap or neck
strap. It is supplied with safety release mechanism to protect the patient from injuries due to
excessive force or accidental pulling out and recoil by other children
 1. Force-delivering Unit
Face bow: it consists of an outer and an
inner bow. The length of the outer bow
can be adjusted to produce the desired
force vector/line of force. It is contoured
to fit around the face. The inner bow is
contoured to follow the shape of the
dental arch. The anterior portion of the
bow should be placed about 4–5 mm
away from the maxillary incisors fitting
comfortably between the lips at rest.
 2.Force generating- unit:
It connects the face
bow to the anchor unit.
It may be in the form of
springs, elastics, or other
stretchable material. The
force is delivered to the
teeth through the face
bow and then to the
underlying skeletal
structures via teeth.
 3. Anchor unit:
The extraoral attachments
that provide anchorage for
headgear can be:

a.Cervical attachment/neck
strap
b. Occipital attachment/head
cap
c. High pull headgear
d. Combination pull headgear
 Amount, Duration and Timing of Force

• Headgears should apply extraoral forces in the magnitude of 400–600 gm

per side, intermittently for a duration of 12 to 14 hours a day to bring
about the desired skeletal effects.
• Headgear treatment is usually given at 8.5 to 10.5 years in females and
9.5 to 11.5 years in males.
Excessive force greater than 1,000 gm will result in trauma to the teeth
periodontium, while a force of less than 300 gm may produce dental
changes rather than skeletal changes.
Disadvantages of EOT

Success with extra-oral traction is dependent on good

patient cooperation. Patients may often not wear the
headgear for the prescribed duration. This has led
nowadays to a reduction in the popularity and the use
of headgear within clinical orthodontic practice
2-Reverse/protraction
headgear (Delaireface mask)
Face mask consists of the following
parts:
a. Forehead cap
b. Chin cup
c. Metal framework
d. Slots for intraoral elastics.
Elastics are used to apply forward
pulling force on the upper arch,
which are stretched from the
intraoral attachment to the slots on
the anterior part of the framework,
which brings about downward and
forward pull of the maxilla. The
most commonly used types are
Delaire type and Petit type of face
mask.
 Timing and duration
There is an increasing body of evidence that orthopedic correction treatment is
more likely to be successful if it is carried out prior to the pubertal growth spurt,
with the optimal time to intervene at the time of the initial eruption of upper
central incisors. The facemask can be attached to transpalatal arches to rapid
maxillary expansion appliances. For successful maxillary protraction a force of
300–500 gm/side with 12-14 hours per day wear is required. The treatment
time varies from 3 to 16 months.
This appliance can achieve skeletal changes by
advancement of the maxilla and/or restrain or redirect
mandibular growth.
Dr.FaHaD
This can be achieved in patients, where a face-mask is
fitted and worn a minimum of 14 hours per day prior to
pubertal growth spurt (before maxilla stops growing).

Dr.FaHaD
A forward maxillary pull is applied with the help of heavy
elastics that are attached to hooks on the rigid framework.

Dr.FaHaD
3-Chin cap
Types of Chin Cup
Chin cups are available in the following types:
1. Occipital pull chin cup: indicated in
patients with:
i. A mild skeletal prognathism of the mandible.
ii. A decreased facial height.
iii.A well-aligned or protrusive, but not
retroclined mandibular incisors.

2. Vertical pull chin cup: indicated in

patient with open bite.

A force of 150–300 grams is used at the time

of the appliance delivery and over the next
two months, the force is gradually increased
to 450–700 grams per side. The patient is
asked to wear the chin cup appliance for 12–
16 hours/day to have the desired results.
An extraoral appliance that fitted by mean of a
head cap to occipital region and has
attachments for the placement and activation of
the chin cap. Used to restrain and redirect the
growth of the mandible as early as possible,
even in 4-5 years old.
One area of controversy is whether to provide
early treatment (in the early mixed dentition
when the patient is under 10 years old) or wait
until the late mixed dentition. Early treatment
usually involves two phases of treatment:

an initial phase with the functional appliance,

followed by a pause while the adult dentition
erupts,

and then a second phase of fixed appliances.

In contrast to this, if functional appliance

treatment is started in the late mixed dentition,
then by the end of the functional stage of
treatment the adult dentition is usually erupted
sufficiently to proceed straight onto the fixed
appliances.
Selection of ortho appliances depend on?
B .type of tooth movements
A .growth
C All of the above
D none of the above

Which is correct for principal of treatment of myofunctional appliance :-

A Force application and elimination
B Amount of force
C Direction of force
D Duration of force

Orthopedic appliance wear usually recommended for what time in a day

:-
A During morning & afternoon
B During evening & night
C Any time during day
D None of the answers
Which statement is correct for myofunctional appliance :-
A Forces are natural & Force transmit to the bone by muscle
B It is an active appliance
C Forces are natural
D Force transmit to the bone by muscle

Which is correct for principal of treatment of myofunctional appliance :-

A Force application and elimination
B Amount of force
C Direction of force
D Duration of force

the most Popular clasp in retention of removal orthodontic appliances:-

A Adam Clasp.
B Ring clasp
C combination clasp
D RPA
Component of removable appliance that resist un wanted tooth
movement:-
A Anchorage.
B fixed appliance
Cremoval appliance

The type of appliance depend on:-

A type of teeth movement
B age of the patient
C need of patient
D AIl of above

midline diastema during ugly ducking stage is a (nalocclusion can be

frequently by
removable Appliance
ATrue
B False
is a loose fitting monobloc appliance that advances the mandible With lingual
flange
A andreson activator
B twin Block
C herbst
D All of the above
E None of the above

Most commonly appliance used in UK

A passive Removal appliance
B functional appliance
C twin appliance
D All of the above
E None of the above

functional appliances are Most frequently used for correction of antero

_posterior jaw
relationship
A classI
B class lIl
C class Il
D None of the above
what are retentive components of Removable orthodontic appliance
A wires
B retentive tag
C clasps
D Bowse_spring
E screw

Disadvantages of herbs functional appliance

A expensive
B, easy breakage
C troublesome to repair
D All of the above

is a loose fitting monobloc appliance that advances the mandible With

lingual flange
A andreson activator
B twin Block
C herbst
D All of the above
E None of the above
myofunctional appliance can be only used in non growing patients
ATrue
B False

myofunctional appliance should be worn for about

A 12_14 hours/day
B10_12 hours/day
C24 hours/day
D8 hours/day
E None of the above

Twin Block appliance

A is the least comfortable
Bis the bulkiest appliance
C contains a screw that help in expansion
D an appliance that allow better movement of the mandible
E an appliance that contains cheek and lip pads
The component of the orthodontics appliance that resists the unwanted
tooth movement
C is the Anchorge D all of the above E a and B
A is the Hawley arch
B is the springs

The use of myofunctional appliance

A is indicated while the patient is adult
B can correct the teeth without the bone
C needs good patient compliance
D Band C
E none of the above

oral screen is tissue borne passive myofunctional appliance

A True,, tt
B False
Myofunctional appliance is contra indicated in
A forward rotation
B backward rotation
C average rotation D all of the above

Tooth movement in orthodontic based on the application

A biologic force
B physiologic force
C both A&B
Dnon

active component of removable appliance can be categorized as (except):

A spring
B Bows
C screWs
D Ball ended clasp