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MYOFUNCTION

AL
APPLIANCES
Prepared By:
Shi--IV year Part I B.D.S
K.M.C.T. Dental College
Kozhikode,Kerala

CONTENTS
INTRODUCTION
-DEFINITION
-HISTORY
BASIS FOR FUNCTIONAL APPLIANCE
CLASSIFICATION
FORCES
TREATMENT PRINCIPLES
INDICATIONS
ACTION OF FUNCTIONAL APPLLIANCES

CASE SELECTION
VISUAL TREATMENT OBJECTIVE
COMMON APPLIANCES IN USE
WHEN TO TREAT WITH FUNCTIONAL APPLIANCE?
LIMITATIONS & COMPLICATIONS OF FAs
CONCLUSION
REFERENCES

DEFINITION
A removable or fixed appliance which favorably
changes the soft tissue environment
-Frankel,1974
A removable or fixed appliance which changes the
position of mandible so as to transmit forces
generated by the stretching of the muscles,fascia
&/or periosteum,through the acrylic and wirework to
the dentition and the underlying skeletal structures.
-Mills,1991

Loose fitting or passive appliance which harness


natural forces of the oro-facial musculature
that are transmitted to the teeth & alveolar
bone through the medium of the appliance.

HISTORY
1879-Norman Kingsley-Forward positioning of
mandible in orthodontics-Bite plane/Bite-jumping
appliance(vulcanite).
Drawback-tendency to relapse even with bite
guide.

1883- Wilhelm Roux-first to study the


influences of natural forces and functional
stimulation on form-foundation of both
general orthopedic and functional dental
orthopedic principles (Wolffs Law).

Ottolengui-removable plate
1902-Pierre Robin-first practitioner to use
functional jaw orthopedics to treat a
malocclusion-Monoblockin children with
glossoptosis syndrome.

1909-Viggo Andresen(Denmark) -modified bite jumping


appliance-inspired from Benno Lishers theory.

Viggo Andresen

Karl Hupl

1938-Karl Hupl(Germany)-saw the potential of Rouxs


hypothesis and explained how functional appliances work
through the activity of the orofacial muscles.

Andresen-Hupl associationACTIVATOR
Biomechanical Orthodontics Functional Jaw
Orthopedics Norwegian System.
1936-collaborated on a textbook
Funktionskieferorthopdie (Function orthodontics).
1906-Alfred P. Rogers- Father Of Myofunctional therapythe first to implicate the facial muscles for the
growth, development,and form of the
stomatognathic system.

1905/09- Emil Herbst okklussionsscharnier /


Retentionsscharnier Herbst
appliance
Prof. Emil Herbst

The Original Herbst Appliance

1949-Hans Peter Bimler-during WWII-incorporated elastic


force to orthopedic appliance elastischer Gebissformer
(elastic bite former) /adapter Bimler appliance.
~1938 -developed, the
roentgenphotogramm, by
superimposing a photograph on a
head plate, to show the relationship
between the skull, the teeth, and the
soft tissues.

1950-Wilhem Balters-Modified activator by reducing bulk from


palate & substituted with a coffin spring Bionator
1956-Martin Schwarz- Double Plates
combine the advantages of the
activator and the active plate by
constructing separate mandibular and
maxillary acrylic plates that were
designed to occlude with the
mandible in a protrusive position.

Double
Plates

Prof.Dr.Wilhem Balters

Dr.Martin Schwarz

1957-Rolf Frnkel-Function Regulator.


1977-Dr.William J. Clarks-Twin Block
1989Magnetic Appliances-Blechman et al.

Prof.Rolf Frankel

Dr.William J. Clark

BASIS FOR FUNCTIONAL APPLIANCE


The three Ms-Muscles,Malformation and
Malocclusion-By Graber,1963-described effects
of function & malfunction.
The Functional Matrix Hypothesis by Melvin
Moss
Identification of certain cartilages(eg. Condylar
cartilage) as secondary cartilages.

Servosystem (or Cybernetic) Theory,1980, by


Petrovic & associates
Growth Relativity Theory(Vodouris &
associates)

CLASSIFICATION
I. Classification by Tom Graber,when functional
appliances were removable:
(i) Group I-Teeth supported -Eg: catlans appliance,inclined
planes.etc.
(ii) Group II-Teeth/Tissue supported-Eg:activator,bionator,etc.
(iii) Group III-Vestibular positioned appliances with isolated
support from tooth/tissue-Eg:Frankels appliance,lip
bumpers,vestibular screen

II. With advent of fixed functional appliances:


(i) Removable Functionals-Eg: Activator, Bionator, Frankels
(ii)Removable & Fixed-available in both removable & fixed
type-Eg: Twin Block,Herbst
(iii)Semi Fixed-Some components fixed,some detachable Eg:
Den Holtz, Bass Appliance
(iv) Fixed- Eg: Herbst,Jasper Jumper,Churro Jumper,Saif
springs,Mandibular Anterior Repositioning
Appliance(MARA),etc.

III. With concept of hybridization by Peter Vig:


(i) Classical Functional Appliance-Eg:
Activator,Frankels appliance
(ii)Hybrid Appliances-Eg: propulsor,double oral
screen,hybrid bionators,etc.

IV. Classification By Profitt


(i) Teeth borne passive-myotonic appliances-Eg:
Activator,Bionator
(ii) Teeth borne active-myodynamic applainces-Eg;
Bimlers appliance, elastic open activator,Stockfish
appliance
(iii)Tissue borne passive-Eg: Oral screen,lip bumpers
(iv)Tissue borne active-Eg: Frankels appliances
(v) Functional orthopedic magnetic
appliances(FOMA)

FORCES
Mostly use tensile forces-cause stress & strain-alter
stomatognathic muscle balance.
Both external(primary) & internal(secondary)
forces observed in each force application.
External Forces-occlusal & muscle forces from
tongue,lips & cheeks.
Internal Forces-reactions of tissues to 10force

They strain the contiguous tissues formation of


osteogenetic guiding structure (deformation & bracing of the
alv. process).
This rxn important for 20 tissue remodelling,displacement
and all other alterations that can be achieved by therapy.
Differences in force application :
-duration of force is interrupted (exceptions-Hamilton &
Clark full-time-wear appliances & bonded Herbst & Jasper
Jumper)
-Magnitude of force is small.If induced strain is too
great,difficulty in wearing the appliances.

TREATMENT PRINCIPLES
Depending on the type of force applied,2
treatment principles can be differentiated:
I. Force Application
II. Force Elimination

In force application,compressive stress & strain act on


the structures involved resulting in a 10alteration in
form with 20 adaptation in function.
In force elimination,abnormal & restrictive
environmental influences are eliminated,allowing
optimal development.Function is rehabilitated &
followed by 20 adaptation in form.

INDICATIONS
Use of FA alone:
-cases with mild skeletal discrepancy
-proclined upper incisors
-no dental crowding
Use of FA in combination with fixed appliance:
-used most commonly to improve the anteroposterior
relationship before starting the fixed appliance
treatment.

-extremely useful in class II cases


-reduce the amount of a comprehensive fixed therapy
required
-reduce need for orthognathic surgery

Interceptive treatment
-early intervention indicated when one wishes to
utilize their growth enhancing effect.
-extremely effective in reducing the relative
prominence of the proclined upper incisors,which are
particularly susceptible to dentoalveolar trauma.

ACTION OF FUNCTIONAL APPLAINCES


Skeletal,dento-alveolar & soft tissue
effects of FAs reviewed by Dare &
Nixon(1999).
Functional appliances can bring
about the following changes:
(i) Orthopaedic Changes
(ii) Dento-aveolar changes
(iii) Muscular & Soft Tissue changes

Orthopaedic Changes:
-Capable of accelerating the growth in the
condylar region.
-Can bring about remodeling of the glenoid
fossa.
-Can be designed to have a restrictive
influence on the growth of jaws.
-Can change the direction of growth in jaws.

Dento-alveolar Changes:
-can bring about changes in sagittal,transverse &
vertical directions.
-Inhibition of downward & forward eruption of the
maxillary teeth.
-Retroclination of the upper incisors.
-Proclination of the lower incisor.
-Lower labial segment intrusion.
-Levelling of the curve of Spee & tipping of the
occlusal plane.

Muscular & Soft Tissues Changes:


-improve the tonicity of the orofacial
musculature.
-Removal of the lip trap & improved lip
competence.
-Removal of adaptive tongue activity.
-Lowering of the rest position of mandible.
-Removal of soft tissue pressures from the cheeks
& lips.

CASE SELECTION
Age: only in growing patient. Opt. age for FA
therapy b/w 10 years & pubertal growth
phase
Social Considerations:
Dental Considerations: ideal caseone
devoid of gross local irregularities
Skeletal Considerations: Moderate to sever
Class II mo cases are ideal
Mild Class III mo with a reverse overjet & an
average overbite

VISUAL TREATMENT OBJECTIVE


An imp. diagnostic test undertaken before making a
decision to use a functional appliance.
Enables us to visualize how the patients profile would be
after FA therapy.
Performed by asking the patient to bring the mandible
forward.
An improvement in profile positive indication.
Profile worsensnegative-other Rx modalities
considered.
Photographs taken with forward mandibular posture.

COMMO
N
APPLIAN
CES IN

VESTIBULAR SCREEN
Introduced by Newell in 1912.
Takes the form of a curved shield of acrylic placed in the labial
vestibule.
Works on the principle of both force application & elimination.
Vestibular screen does not contact teeth as compared to oral
screen.

Indications:
-to intercept mouth breathing,thumb sucking,tongue trusting,lip
biting & cheek biting.
-mild disto-occlusions.
-to perform muscle exercises to help in correction of hypotonic
lip & cheek muscles.
-mild anterior proclination.
Modifications:

HOTz MODIFICATION

DOUBLE ORAL SCREEN


(With additional tongue shield)

KRAUSS
MODIFICATION

To reduce bulk &


allow expansion when
required
Courtesy: The Orthodontic
Cyber Journal

LIP BUMPER
combined removal-fixed appliance.
Used in both maxilla & mandible to shield
the lips away from the teeth.
Maxillary appliance Denholtz appliance.
Uses:
-in lip sucking patients.
-hyperactive mentalis activity.
-to augment anchorage
-distalization of first molars

ACTIVATOR
Indicaitons: In actively growing individuals with
favorable growth patterns.
-class II div I mo
-class II div II mo
-class III
-class I open bite
-class I deep bite
-as a preliminary T/t before major fixed appliance therapy
to improve skeletal jaw relations.
-for post treatment retention
-children with lack of vertical development in lower facial
height.

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

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

Disadvantages:
-requires very good patient cooperation
-cannot produce a precise detailing &
finishing of occlusion.
-may produce moderate mandibular
rotation(hence contraindicated in excess
lower facial height cases)

Mode Of Action: Acc. To Andresen & Haupl


-induce musculoskeletal adaptation by introducing a new
pattern of mandibular closure.
stretching of elevator muscles of
masticationcontractionmyotactic reflex set up kinetic
energy which causes:
-prevention of growth of max. dentoalveolar process
-movement of max. dento alveolar process
distally
-reciprocal forward growth of mandible.
In addition, a condylar adaptation by backward & upward
growth occurs.

Modifications:

BOW ACTIVATOR By A.M.Schwarz

Wunderers modificaiton for


Class III

PROPULSOR by Muhlemann & Hotz

Herrens Modification

REDUCED ACTIVATOR/KYBERNATOR By G.P.F.Schmuth

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Type I - Distal Activator

Type II - Prognathism Activator

K
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Type III a Pan Activator

Type III b Pan Activator

Wear Time:
1st week 2-3 hrs a day during day
time
2nd week onwards 3 hrs during day
& while sleeping.

FRANKELS FUNCTION REGULATOR


2 main T/t effects:
1) serves as a template against which craniofacial
muscles function. Framework of the appliance
provide an artificial balancing of environment.
2) removes the muscle forces in the labial & buccal
areas thereby providing an environment which
enables skeletal growth.

Types:
FR I-Class I & Class II Div I .
FR 1a-Class I with minor to moderate crowding.
FR 1b-Class II div I where overjet does not exceed 5mm
FR 1c-Class II div I ;overjet >7mm

FR II- Class II div I & II

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

FR III

FR IV

BIONATOR
Developed by Balters in 1950s.
Modified activator less bulky &
more elastic
3 types> Standard type-class II div I having
narrow dental arches
> Class III Appliance
>Open bite appliance

Standard type

Class III Appliance

Open Bite Appliance

TWIN BLOCK APPLIANCE


The Twin Block appliance is a removable,
orthodontic functional appliance that is
used to help correct jaw alignment,
particularly an underdeveloped lower jaw.
Developed by Dr.William J. Clarks , 1977.
Effectively combines inclined planes with
intermaxillary & extraoral traction.

The removable twin block is a tissue-born functional


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

The fixed twin block is similar to the


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

Advantages:
-very good patient acceptance.
-bite planes offer greater freedom of
movement & lateral excursion.
-less interference with normal
function.
-significant changes in patients
appearance within 2-3 months.

HERBST APPLIANCE
Fixed functional appliance developed
by Emil Herbst in early 1900s.
Indications:
-correction of class II MO due to
retrognathic mandible.
-can be used as anterior
repositioning splint in patients having
TMJ disorders.

Specific indications
-Post adolescent patients: T/t
completed w/in 6-8 months,hence
possible to use the residual growth in
these patients.
-Mouth breathers
-Uncooperative patients
2 types:
-Banded Herbst
-Bonded Herbst

Banded Herbst Appliance

Bonded Herbst Appliance

Advantages:
-continuous action
-T/t duration is short
-less pt cooperation needed
-can be used in pts who are at the
end of their growth
-can be used in pts with mouth
breathing habit.

Disadvantages:
-cause minor functional disturbances.
-increased risk of development of
dual bit,with TMJ dysfunction
symptoms as a possible
consequence.
-repeated breakage & loosening of
appliance occurs,esp. in lower
premolar area.
-plaque accumulation & enamel
decalcification can occur
-tendency for posterior open bite.

JASPER JUMPER
A relatively new flexible,fixed
,tooth borne FA.
Introduced by J.J.Jasper ,1980
Actions similar to Herbst
appliance but lack rigidity.
Basically indicated in skeletal
class II mo with max. excess &
mandibular deficiency.

Advantages:
-produce continuous force
-does not require patient compliance
-allows greater degree of mandibular
freedom than Herbst appliance
-oral hygiene is easier to manage.

WHEN TO TREAT WITH FUNCTIONAL


APPLIANCE ???
The best time to start functional
appliance therapy is the late mixed
dentition.
Advantage of the pubertal growth
spurt should be taken.
Girls & boys along with early
maturers should be assessed
individually.

LIMITATIONS & COMPLICATIONS


Discomfort, as both upper & lower teeth
are joined together.
Mainly depends on patients compliance
Can be used only if a favorable horizontal
growth pattern is present in cases of Class
II correction.
It has to be removed during
masticaiton,particularly when strongest
forces are applied.
May interfere with speech.
Treatment duration is often long

CONCLUSION
The global demand for orthodontics without braces
continues to grow. It's an option that many parents
and patients would prefer.
Myofunctional orthodontics offers a viable
alternative to traditional orthodontic methods.
A functional appliance is an appliance that produces
all or part of its effect by altering the position of the
mandible/maxilla.

These appliances utilize the muscle action of the patient to


produce orthodontic or orthopaedic forces to restore facial
balance.
The question that must be addressed in diagnosis is : does
the patient require orthodontic treatment or functional
orthopedic treatment or a combination of both and to what
degree?
whether the patient requires functional appliance alone or
need a orthognathic surgery or to what extend FA can reduce
need for surgery?

The study of orthodontia is indissolubly connected with


that of art as related to the human face.The mouth is a
most potent factor in making the beauty and character of
the face and the form & beauty of the mouth largely
depends on the occlusal relations of the teeth.
Our duties as orthodontists force upon us great
responsibilities and there is nothing which the student of
orthodontia should be more keenly interested than in art
generally,and especially in its relation to the human
face,for each of his efforts,whether he realizes it or not
makes for beauty or ugliness,for harmony or
inharmony,for perfection or deformity of the face.Hence it
should be one of his life studies. - E.H.Angle,1907

REFERENCES
1) Dentofacial Orthopedics with Functional Appliances by
Thomas M. Graber,Thomas Rakosi & Alexandre
G.Petrovic;2/e,2009
2) Orthodontics Diagnosis & Management of Malocclusion
& Dentofacial Deformities by Om Prakash
Kharbanda;2/e,2013
3) Orthodontics Principles & Practice by Basavaraj
Subhashchandra Phulari;1/e,2011
4) Textbook Of Orthodontics By Gurkeerat Singh;2/e,2007

5) Textbook Of Pedodontics by Shobha Tandon;2/e,2008


6) Orthodontics The Art & Science by S.I.Bhalajhi;3/e,2003
7) Contemporary Orthodontics by William R.Proffit;4/e,2007
8) Norman Wahl,Special Article, Orthodontics in 3
millennia. Chapter 9: Functional appliances to
midcentury;(Am J Orthod Dentofacial Orthop
2006;129:829-33)
9) Various Internet Sources