Introduction to

Myofunctional appliance

Submitted to : Submitted by :
Dr. Kanistika Jha
Department of orthodontics Reema kandel
College of medical sciences Roll no 12
BDS 4th year , 8th batch
Contents :
• Introduction
• Lip bumper
• History
• Vestibular screen
• Treatment principle • Activator
• classification • Functional regulator of frankel
• Components of functional • Bionator
appliances • Twin block appliance
• Action of functional appliances • Herbst appliance
• Advantages • Jasper jumper
• Indications • Past KU question
• Contraindications • MCQ’s
Introduction
• 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, and/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 orofacial
musculature that are transmitted to the teeth and alveolar bone through the
medium of the appliance
The force component of the functional appliance are derived from the orofacial
musculature
These appliances transmit, eliminate, and guide the natural forces {e.g. muscle
activity, growth, tooth eruption} of musculature

They can bring about following changes :

• An increase or decreased in jaw size
• Change in spatial relationship of the jaw
• Change in direction of growth of the jaws
• Acceleration of desirable growth
History of myofunctional appliance
Name year contribution
Norman Kingsley 1879 bite jumping appliance

Pierre Robin 1902 Monoblock

Emil Herbst 1905 herbst appliance

Alfred P. Roger’s 1906 • father of myofunctional therapy

• First to implicate the facial muscles for the growth,
development and form of the stomatognathic system

Viggo 1909 modified bite jumping appliance[activator]

Andresen[Denmark]
Name year contribution

Wilhem Batler’s 1950 Bionator

Mertin schwarz 1956 double plats

Rolf Frankel 1957 function regulator

Dr. William J. Clarks 1977 Twin block

Vardimon 1989 magnetic appliance

 Treatment principle
Force application
• Compressive stress and
strain act on the structures
involved and results in a
primary alteration in form
with a secondary adaption in
function
Force elimination
• This involves the
elimination of abnormal and
restrictive environmental
influences on the dentition
thereby allowing optimal
development . Thus function
is rehabilitated with a
secondary change in form
Classification of
myofunctional appliance
Basic classification of functional appliance
Removable functional
appliances Fixed functional Semifixed
appliance functional
appliances
Can be removed and
inserted into oral cavity That are fitted on to That have certain
by pts at will the tooth by component fixed
orthodontist and
E.g. activator and its cannot be removed at E.g. denholtz, bass
modification, frankel will by pts
appliance
functional regulator, twin
block appliance, balter’s E.g. herbst appliance,
bionator etc jasper jumper ,
rigid/flexible/hybrid
FA
Classification by Proffit
Tooth borne passive
appliance
They have no intrinsic
force generating
components like springs
or screw . They depend Include modification
on soft tissue stretch and
muscular activity to
produce desired treatment
results
E.g. activator, bionator,
herbst appliance
Tooth borne active Tissue borne
appliances appliances
Mostly located in
of activator and vestibule and have
bionator that include little or no contact
expansion screws or with the dentition
other active E.g. functional
components like regulator of frankel
springs to provide
intrinsic force
Classification by Tom Graber

Group A Group B Group C

Teeth or tissue
Teeth supported supported Vestibular
appliances appliances positioned
appliances with
isolated support
E.g. Catalans, E.g. activator, from tooth
inclined planes bionator
E.g. oral screen,
frankel appliance,
lip bumpers
Classification based on transmission of force

Group I appliances Group II appliances Group III appliances

These appliance
That transmit the reposition the These also reposition
muscle force directly mandible and the the mandible but their
to the teeth for the resultant force is area of operation is a
purpose of correction transmitted to the vestibule, outside the
of the malocclusion teeth and other dental arch
structures
E.g. oral screen, E.g. frankel
inclined planes E.g. activator, appliance, vestibular
bionator screen
Classification into myotonic and
myodynamic appliances
Myodynamic appliances
Myotonic appliance

That depends on
That depends on the the muscle activity
muscle mass for for their action
their action
Components of functional appliances
1. Bite planes
2. Shields or screen
3. Construction bite
Bite planes
• Flat or inclined, anterior or posterior,
may contact single or multiple teeth ,
usually made up of acrylic resin
• relatively low force
[continuously/intermittently ] which are
apically directed, are expected to impede
or arrest eruption, other force may
produce tipping or eruptive deflection
Effects of bite planes:
• Differential eruption of
posterior teeth
• relative or absolute intrusion
of incisors
• Incisor overbite reduction
• Disocclusion may cause
additional increments of
mandibular growth
• Unimpeded posterior tooth
eruption may also result in a
downward and backward
mandibular rotation
Shields or screens
• There is little doubt that the growing
dentoalveolar structures are plastic
and responsive to linguofacial
muscle pressure
• Vestibular shields or oral screens and
lip pads have been used to shield the
muscles away thereby allowing
unrestricted growth of jaws and
dentoalveolar structures
• They are also used to transmit
muscle forces on to dentoalveolar
structures
Construction or working bite
• All of the functional appliance
are constructed to a
‘construction’ or ‘working’
bite registration

• Intermaxillary wax record

used to relate mandible to
maxilla in 3D space
Action of functional appliance

Orthopedic changes Dentoalveolar changes Muscular and soft

tissue change
• MFA are capable of • Palatal tipping of upper
accelerating growth in • Improve the tonicity of
incisors
condylar region the orofacial
• Labial tipping lower musculature
• Remodeling of glenoid anterior
fossa • Removal of the lip trap
• In transverse direction -
• Influence on the growth • Improved lip
expansion of dental arches
of the jaw competence
• In vertical direction –
• Can change the direction • Removal of adaptive
allow selective eruption of
of growth of the jaws teeth tongue activity
Advantages of functional appliance
• It enable elimination of abnormal muscle functions

• Treatment can be initiated at an early age

• Less chair side time is spent

• They do not interfere with oral hygiene maintenance

• Patient acceptance is good

Indications
• Growing Class II division 1 MO
• Growing Class II division 2 MO
• Growing Class III malocclusion
• Growing Class I, openbite malocclusion
• Growing Class I, deepbite malocclusion
• As a preliminary treatment before major fixed appliance
• For post treatment retention
• Children with lack of vertical development in lower facial height
Contraindications
• They cannot be used :
• in adult patients in whom growth has ceased

• to bring about individual tooth movements

• In minor local irregularities that may interfere with the functional therapy
Myofunctional
appliances
Vestibular screen
• Introduced by Newell in 1912
• Takes the form of a curved shield of acrylic
placed in labial vestibule

Principle
• Works on the principle of both force application and
elimination
• Can be either to apply the force of circumoral
musculature to certain teeth or to relieve those
forces from the teeth thereby allowing them to
move due to force exerted by the tongue
Indications
• Used mostly to intercept mouth breathing habits, thumb sucking habit, tongue
thrusting habit, lip biting habit, cheek biting habit.

• In case of mild disto-occlusion

• Can be Used to perform muscle exercises to help in correction of hypotonic lip and
cheek muscles

• Can be used to correct mild anterior proclination

Modification of vestibular screen
A. Hotz modification

B. Krau’s modification

C. Double oral screen

Lip bumper
• Other names:
• lip plumber
• combined removable-fixed appliance
• modified vestibular screen

• Can be used in maxilla and mandible both

• When specially used in maxilla it is called

Denholtz appliances
Indications of lip bumper
1. In patients exhibiting lower lip habits such as lip sucking :
• The lip bumper shields the lower lip away.

2. Used in patient with flattened or crowded lower anteriors

• To eliminate hyper-active mentalis activity

3. Distalization of first molar

4. Used to augment anchorage

5. Used as space regainers if the lower molar drifted mesially

Appliance design
• Appliances is made up 0.9mm
stainless wire extending from one
molar to opposite molar

• The lip bumper is inserted into round

molar tubes of 0.93mm diameter
soldered to bands on the first molar

• Anterior portions of wire from canine

to canine can be reinforced with
acrylic
 Frankel philosophy :
• Frankel believed that stability of
treatment outcome could be expected
to occur only if the structural and
functional deviations of the muscular
capsule can be correct
• The training of protractors of the
mandible is expected to influence a
more forward posture of the mandible
to be initiated in a very careful and
stepwise manner, without disturbing
the condyle–fossa relationship
• FR appliance offers an opportunity to
eliminate this restrictive effect
permitting normal displacement of the
teeth and the facial bones
Philosophy of myofunctional appliance
Activator :
• Activator induces musculoskeletal
adaptation by introducing a new pattern of
mandibular closure
• Results in stretching of muscles that result
in myotatic reflexes resulting in kinetic
energy production which causes:
1. Prevention of further forward growth of
maxillary Dento-alveolar process.
2. Movement of Maxillary Dento-alveolar
process distally
3. A reciprocal forward force on mandible
• a condylar adaptation by backward and
upward growth occurs
Clark’s philosophy
• Occlusal incline plane is a functional
mechanism of natural dentition
• When the mandible occludes in a
distal relationship to the maxilla, the
occlusal forces acting on mandibular
teeth in normal function have a distal
component of force that is
unfavourable to normal forward
mandibular development
• The forces of occlusion are used as a
functional mechanism to correct the
malocclusion
Philosophy of myofunctional appliance
Balter’s philosophy :
• Wilhelm Balters’ hypothesized that class II
MO are a result of a backward position of
the tongue
• A disturb equilibrium between tongue and
circumoral muscles lead to MO
• The principle of treatment with bionator is
not to activate the muscles but to modulate
muscle activity, thereby enhancing the normal
development of the inherent growth pattern,
eliminating abnormal and potentially
deforming environmental forces
Activator
Introduced by Norman Kingsley In 1879[vulcanite
palatal plate]
1909, Viggo Andresen developed a loose-fitting
appliance, which he first used in his daughter

 Other names : Vorbissplatte (by Hotz)

Biomechanical retainer
functional jaw orthopedics
Norwegian appliances
Monoblock (by Pierre Robin)
called activator due to its ability to activate muscle
forces
Mode of action of activator
• According to Andresen and Haupl, the Activator induces musculoskeletal
adaptation by introducing a new pattern of mandibular closure

• Appliance loosely fits into the mouth.

• Patient has to move mandible forward to engage appliance. This results in

stretching of elevator muscle of mastication , which starts contracting thereby
setting up a myotactic reflex
Mode of action of activator
• This generates Kinetic energy which causes :

A] Prevention of further forward growth of maxillary dento-alveolar process.

B] Movement of Maxillary Dento-alveolar process distally
C] A reciprocal forward force on mandible

• In addition to this myotactic reflex , a condylar adaptation by backward and

upward growth occurs
Construction Bite
• It is intermaxillary bite record [relate mandible to maxilla in 3D space]
• Anterior advancement of mandible and vertical positioning/bite opening
• Ant advancement 4-5 mm and bite opening 2-4 mm usually in most cases

General consideration
1. overjet too large – ant advancement in 2-3 phases
2. In case of 7-8mm forward positioning slight to moderate vertical opening[2-4mm]
3. If forward positioning is not more than 3-5mm than vertical opening can be 4-
6mm
• Low construction bite with marked mandibular forward positioning
• High construction bite with slight mandibular forward positioning
• Construction bite without mandibular forward positioning
• Construction bite with vertical opening and posterior positioning of mandible
Bite registration for activator appliance
• Upper and lower impressions with deep
flanges are taken on a horseshoe-shaped
wax roll [2-3mm thick] softened in a wax
bath.
• The activator bite is recorded ‘within the
freeway space’
• The sagittal forward positioning is 4–5 mm
• The bite with upper and lower models is
transferred to a hinge articulator
• A labial bow of 0.8/0.9 mm (20/21 gauge)
wire is constructed
• followed by wax-up ,routine dewax and
acrylisation
Component of activator
1. Labial Bow:
- The wire used is spring hardened 0.9 mm
stainless steel
- It consists of horizontal middle sections , 2
vertical loops extensions through canine and
deciduous first molar embrasure into the acrylic
body

2. Jack Screw (Optional) : Fitted to maxillary

arch

3. Acrylic Portion
Modification of activator
• The bow activator of A.M. Schwarz
• Wunderer’s modification
• The reduced activator or cybernator of
schmuth
• The propulsar
• Cutout or palate free activator
• Herren’s modifications of activator
Indications of activator
Growing Class II, div 1 malocclusion
Growing Class II, div 2 malocclusion
Growing Class III malocclusion
Growing Class I, open bite malocclusion
Growing Class I, deep bite malocclusion
As a preliminary treatment before major fixed appliance
For post treatment retention
Children with lack of vertical development in lower facial height
Contraindication
Contraindicated in cases with:
• In growing class I problems with crowded teeth

• In child with excess lower facial height and extreme vertical mandibular growth

• In children with severely procumbent lower incisors

• In children with nasal stenosis

Advantages
It uses existing growth of jaws
Minimal oral hygiene problems
Intervals between appointment are long
Appointments are usually short due to need for minimal adjustments
More economical

Disadvantages
Requires very good patient co-operation
Cannot produce the precise detailing and finishing of the occlusion
May produce moderate mandibular rotation
Case1 : treated with activator

Fig : Before treatment extra-oral view

Fig : Before treatment intra-oral view
Fig : bite construction
Fig : during treatment intra-oralview
Fig : After treatment Extra-oral view
Fig : After treatment intra-oral view
Function regulator
• Developed by Rolf Frankel(Germany) .
• Other name: Frankel Appliance
• Vestibular Appliance
• Oral Gymnast appliance.
• Tissue borne Passive appliance
Frankel philosophy
Frankel appliance is based on the following principle

A. Vestibular arena of operation :

A. dentition is influenced by perioral muscle function so appliance is designed to
hold away the muscle from dentition
B. Sagittal correction via tooth borne maxillary anchorage :
A. FA is anchorage firmly in maxillary arch .mandible positioned anteriorly by
means of acrylic pad [act as proprioceptive trigger]
C. differential eruption guidance
A. By allowing lower premolars to erupt freely because appliance i.e.fixed to upper
arch
D. Minimal maxillary basal effect
E. Periosteal pull by buccal shields and lip pad :
A. are extended to bring outward periosteal pull[aid in bone formation in apical base
Mode of action :
Increase in Transverse Sagittal space:
By use of Buccal shields and Lip pad

Increase in Vertical space :

 By allowing lower premolars to erupt freely because appliance i.e.fixed to upper
arch

Mandibular protraction :
-lingual pad guide the mandible to a more mesial position .Thus position of mandible
change by course of time by gradually training the protractor/retractor muscles and by
condylar adaptation
Muscle Adaptation : The Lip pads and Shield cause
periosteal muscle pull leading to the Bone formation .

- The pads and shields massage the soft tissues and improve
the tight muscles and improve muscle tone .

- The Lip pads prevents Hyperactivity of mentalis muscle ,

eliminates Lip Trap and helps in establishing proper lip seal.
Types of functional regulator
1] Functional Regulator 1 {FR 1} :
• It has 3 modification and they are :
a) FR1a
b) FR1b
c) FR1c

2] Functional Regulator 2 {FR 2}

3] Functional Regulator 3 {FR 3}
4] Functional Regulator 4 {FR 4}
5] Functional Regulator 5 {FR 5}
A]FR1a :

• The appliance consists of Acrylic

parts and Wire Components, and
they are:
1. Acrylic parts:
• 2 Vestibular Shields
• 2 Lip pads
2. Wire Components :
• Palatal Bow
• Labial Bow
• Labial Support wire
• Lingual Bow
• Canine Loops
Indication:
• Used in Class I malocclusions with mild to moderate crowding
• Also used for Class I Deep Bite cases

B]FR1b :
• Unlike in FR1a , lingual acrylic pads are present which help in forward positioning of
mandible and lower lingual springs are also added .
• Used to treat Class II, Division 1 where overjet has not exceed 5mm.

C]FR1c :
• Buccal shields are split horizontally and vertically into 2 parts
• Used to treat Class II, Division 1 where Overjet is greater than 7mm .
• Used when multiple stage advancement needed
Functional regulator 2 of frankel
• Most commonly used Appliance.
A. Acrylic components :
a) Buccal Shields
b) Lip Pads
c) Lower Lingual Pads
B. Wire Components :
a) Palatal Bow
b) Labial Bow
c) Canine Extensions
d) Upper lingual wire [lingual sb]
e) Lingual crossover wire
f) Support wire for Lip pads
g) Lower Lingual Springs
Indication:

• Used for growing Class II, Division 1 and Division 2

malocclusion

• children who are 7-year-old or younger are

considered good candidates for FR II therapy
Functional Regulator 3 of Frankel
• Indicated in growing Class III malocclusion characterized by maxillary skeletal
retrusion and not mandibular prognathism .
• It consists of 2 upper Lip pads, which are larger and more extended than of FR2.
( Appear Tear-drop shaped in sagittal section )

Purpose of Lip Pads:

• To eliminate the restrictive pressure of the upper lip on the under-developed maxilla
.
• To exert tension resulting to stimulate bone growth .

• To transmit upper lip forces to the mandible through labial arch for a retrusive
stimulus
Functional regulator 4 of Frankel
• It lacks canine loop and lingual
stablishing bow
• Consists of 4 occlusal rest on maxillary
molars to prevent tipping of the
appliance

• Used for the correction of the Open

Bites in growing individual
• and to a lesser extent bimaxillary
protrusion
• Almost exclusively confined to mixed
dentition
Functional regulator 5 of Frankel
• It incorporates Headgears .

• Indicated in patients with Long face Syndrome having a high

mandibular plane angle and vertical maxillary excess of growing
cases
Construction bite
• For minor sagittal problems – edge-to-edge insical relationship construction bite
• FR 3 – bite registration is taken with patient’s mandible in most comfortable
Retruded position

Wear time
1. 1st few weeks : 2-4 hours/day(daytime)
2. After 3rd weeks : 4-6 hours/day(daytime)
3. After 3rd visit(2 months) : Full time wear
 Bionator
Developed by Balter's during early 1950
Wilhelm Balters modified the activator by removing the bulk of palatal acrylic plate
and replaced it with a coffin spring
Less bulky and more elastic than activator
He designed an extended labial bow in the buccal region to isolate teeth and arches
from harmful effects of perioral muscles and thereby enhance the transverse growth of
the arches
There are three types of activator
1. open bite appliance
2. Standard appliance
3. Class III appliance
Balter's hypothesis:
• A/c to Class II malocclusion results from the backwards (dorsal) position of the
tongue that disturbs the cervical region and impedes respiratory function, causing
faulty swallowing patterns and mouth breathing.

• A/c to Balters, the equilibrium between the tongue and circumoral muscles is
responsible for the shape of the dental arches and proper intercuspation and that
providing the tongue with adequate functional space is of utmost importance.

• A class II malocclusion is due to lack of transverse development as a

consequence of weakness of the tongue in comparison with buccinator
mechanism while a class III malocclusion is caused due to forward position of
the tongue
• Bionator prevents external and internal muscle forces from exerting undesirable
and restrictive effects on the dentition and supporting structures.

• Balters believed that primarily the role of the tongue was the decisive factor.

• Therefore, one of the main objectives of treatment in class II division 1

malocclusions is to bring the tongue forward.

• The principle of treatment with bionator is not to activate the muscles but to
modulate muscle activity, thereby enhancing the normal development of the
inherent growth pattern, eliminating abnormal and potentially deforming
environmental forces.

• The labial bow which is extended to the buccal vestibules on both the sides is
expected to isolate dental arches from abnormal perioral pressure, and let the
tongue exert a moulding pressure. Coffin spring being the stimulus.
Standard appliances
• It has Acrylic and wire components
• Acrylic component
• It consists of a relatively slender
acrylic body fitted to lingual
aspect of mandibular arch and
part of maxillary arch
• Acrylic extends upto distal of
first permanent molars
• Maxillary plates covers only
molars and premolars with
anterior region remaining
uncovered
• The acrylic extends 2mm below
the gingival margin
B. Wire component: the wire components are palatal arch
and vestibular wire

I. Palatal Arch

Palatal arch is made up of 1.25mm/16gauge/0.045inch diameter

wire. It emerges opposite the middle of the 1st premolars and
follows the contour of the palate forming a curve that reaches
distal surface of 1st permanent molars [coffin spring]

The palatal arch is kept 1mm away from the mucosa

I. Vestibular wire

Made up of 0.9mm/19gauge/0.036inch stainless steel wire that emerges from

the contact point between the upper canines and premolars

It rises vertically and is bent at right angle to go distally along the middle of
the upper premolar crowns

Mesial to the molars, a rounded bend is made so that the wire runs at the level
of the lower papilla up to the mandibular canine , where it is bent to reach the
upper canines

The Vestibular wire is kept away from the surface of the incisors by the
thickness of a sheet of paper
Class III appliance
• This is used in mandibular
prognathism
• The acrylic parts are similar
to the standard appliance
• The palatal arch is placed in
the opposite direction so that
the rounded arch is placed
anteriorly
• The vestibular wire runs over
lower incisors instead of
terminating at the lower
canines
The open bite appliances
• Palatal arch and the
vestibular wire are same as
the standard appliance
• Maxillary acrylic portion is
modified so that even the
anterior area is covered
• Its purpose is to prevent the
tongue from thrusting
between the teeth as the
tongue is responsible in most
cases for the open bite
Bite registration for Bionator
• In most cases Bionator bite is recorded with
incisor edge-to-edge relationship

• The forward posturing of the mandible enlarges

the oral space, bringing the dorsum of the tongue
into contact with the soft palate and thus helps to
accomplish lip closure

• Balters considered that a high bite could impair

tongue function which could lead to tongue thrust
habit. In case the over-jet is too large, to allow an
edge-to-edge bite, a step-by-step protraction
procedure is followed

• If overjet is too much a stepwise advancement is

preferred
Advantages:

1. Reduced size
2. Can be worn both day and night
3. Action faster than activator
4. Constant wear so more rapid adjustment of musculature

Disadvantages:

1. Difficulty in managing it
2. Difficulty in stabilized the appliance during fabrication
3. Vulnerable to distortion – less support in alveolar and incisal region
Indication of Bionator
Indicated in growing patient with
1. Growing Class III MO
2. Open bite cases
3. In a growing class II div 1 MO having following features
• Well aligned dental arches
• Retruded mandible
• Not very severe skeletal discrepancy
• Labial tipping of upper incisors

Contraindication of Bionator
 Contraindicated in growing patients with:
1. Growing Class II MO - caused by maxillary prognathism
2. Vertical growth pattern
3. Labial tipping of mandibular incisors
Twin block appliance
Introduced by William Clark

It consists of an upper and

lower device with simple bite
blocks that engage on occlusal
inclined planes . Designed to
be worn 24 hours/day (Patient-
friendly).

The twin block is a smart

modification of Schwartz
double plate and the split
activation.
Clark’s philosophy
• Occlusal incline plane is a functional
mechanism of natural dentition

• When the mandible occludes in a distal

relationship to the maxilla, the occlusal
forces acting on mandibular teeth in
normal function have a distal
component of force that is unfavourable
to normal forward mandibular
development

• The forces of occlusion are used as a

functional mechanism to correct the
malocclusion
Components of standard twin blocks:
Consist of 2 separate removable appliance
 upper part has Labial bow
Modified arrow-head clasp
Jackscrew
Bite block

Lower part has Interdental ball end clasp

Delta clasp
Bite block
Bite registration
• Is done in the same way as for the activator
• In most cases an edge-to-edge bite is desirable
• If overjet is too much a stepwise advancement is preferred
Fundamental of bite recordings :
Extent of horizontal advancement:

• The maximum forward movement of the mandible up to 10 mm can be managed

with a single activation.
• However, if over-jet is very large such as 14 mm or more, the mandible is
advanced in a stepwise manner more often in two stages.

• If forward posturing of the mandible causes a cross-bite relation. mandibular

posturing should not be done until the maxillary arch is expanded to prevent
buccal-cross-bite.
Extent of Vertical opening
• bite is often recorded beyond the freeway space.
• If the forward positioning of the mandible is 10 mm or 7–8 mm, the vertical
opening must be slight to moderate, that is 2–4 mm so as not to overstretch the
muscles.
• If the forward positioning is not more than 3–5 mm, the vertical opening could be
more up to 4–6 mm.
• Greater vertical and less sagittal activation is recorded in vertical growth type
while normal/horizontal growers receive more horizontal activation.
Midline considerations:

• Midline changes due to skeletal reasons should be deeply looked and investigated
for any underlying pathology.

• Minor deviations of midline due to a skeletal lateral translation of the mandible

can be corrected during recording the bite.
Bite
registration
Angulation of inclined plane:
• During evolution of the appliance bite angulation of the blocks varied from 45–
90°

• Very first appliance was constructed with bite angulation 90 degree[posterior

cross bite in 30% cases]

• Bite block with 45 degree apply equal downward and forward component of
force to lower dentition

• Bite blocks with 70° angulation apply a more horizontal component of force
Treatment phases with twin block:
• Pre-functional phase

• Functional phase
Active phase[6-9mpnths]
Supportive phase[4-6months]
Retentive phase[9months]

• Follow-up.
Modification of twin blocks:
Twin block in deciduous dentition
• Design and construction using C clasp for retention on deciduous molars. In addition, a
functional retainer can be given during support phase
Twin block traction technique
• inadequate response to functional correction, addition of orthopaedic traction force can
be considered in the following conditions.
1. Severe max protrusion
2. Unfavourable growth pattern
3. Adult patient
Concorde face bow
is used to:
1. Apply inter-maxillary and
extraoral traction
2. Restrict maxillary growth
3. Encourage mandibular
growth.
Twin block in treatment of anterior open bite and
vertical growth pattern of growing individual
• thicker wax bite with an inter-
incisal clearance of 4 mm and a
lesser amount of the sagittal
advancement is used.
• Palatal spinner can be added to
control tongue thrust.
• Avoid over eruption of second
molar occlusal rest can be added
• Intraoral elastics should be used
should there be a tendency for an
anterior open bite.
Twin block appliance in growing class II div 2 MO
• Class II division 2 patients require progressive sagittal development. A combined
transverse and sagittal development is achieved with three way screw.
Twin block appliance in growing class III MO
Twin-block appliance for Class III malocclusion can be modified by reversing the
incline and recording the bite by holding the mandible as distal as possible.
• Reverse twin blocks
• Are designed to encourage maxillary
development
• Reverse occlusal inclined plane cut at a 70
degree angle drive the teeth forwards by force
of occlusion
• Restrict forward mandibular development
• Modifications : lip pads may be used to
support the upper lip clear of incisors
• Three-way expansion screw : opening of
which has reciprocal effects of driving upper
molars distally and advancing incisosrs
Fixed twin block
Avoid trimming the block
and only a progressive
activation is
recommended.
Advantages
1. Less Bulk, therefore Better patient compliance
2. Functional mechanism similar to that of natural dentition
3. Appearance is noticeably improved .
4. Can be used in later stages of growth ( late mixed dentition/ Early permanent
dentition )
5. Absence of Buccal shields and Lip pads allow patient a much better comfort.
6. Appliance can be cemented in mouth , without disrupting the normal oral
functions .
Indications :
(Case Selection For Twin-Block Appliance)
1. Growing Class II Malocclusion with good arch form
2. A lower arch that is uncrowded or, aligned or, decrowded .
3. An Upper arch that is aligned or, can be easily aligned
4. An Overjet of 10-12 mm and a Deep Overbite .
5. Full Unit Distal occlusion in Buccal segments
6. On Clinical examination , the profile should be noticeably improved when the
patient advances the mandible voluntarily to correct overjet
7. To achieve a favorable skeletal change during treatment , Patient should be
actively growing
Contraindication
1. Growing Class II Skeletal malocclusion by Maxillary prognathism

2. Vertically directed Grower

3. Vertically directed Grower

4. Labial Tipping of Lower Incisors

5. Crowding cases
Case 1 treated with twin block appliance

Fig : Before treatment [extra oral] view

Fig : Before treatment [intra-oral] view
Fig : Before treatment [lateral cephalometry] view
Fig : During treatment [intra-oral] view
Fig : During treatment [intra-oral] view
Fig : during and after treatment [extra oral] view
Fig : After treatment [intra-oral] view
Fig : After treatment [intra-oral] view
Herbst appliance
• Herbst is fixed functional appliance developed by Emil Herbst in early
1900’s

Types
1. Banded Herbst appliance
2. Bonded Herbst appliance
Jasper jumper
• It is a relatively new type of flexible, fixed, tooth borne functional appliance ,
introduced by – J.J. Jasper in 1980
• Its action is similar to herbst appliance but lack of rigidity
Reference
Contemporary Orthodontics , William R.Proffit 5 th
edition

Orthodontics, The Art and Science, Dr.S.I.Bhalajhi 7 th

edition

OP Kharbanda, Orthodontics ,diagnosis and management

of malocclusion and dentofacial deformities
KU Past Questions
1. Define functional appliances . Explain the effect of functional appliances
on various tissue system. Enumerate basic types and components of
frankel’s regulator

2. Classify myofunctional appliances and describe in berief about Bionator

3. Short notes :
1. Lab fabrication of standard Bionator
2. Twin block appliances
3. Chincup therapy
MCQ’S
1. In which of the following conditions oral screen should not be used
a. Nail biting
b. Tongue thrusting
c. Acute infections of tonsils and adenoids
d. Thumb sucking
2. Amount of pressure/force exerted by lip on maxillary incisors
e. 10-15gm/cm^3
f. 20-25gm/cm^3
g. 25-30gm/cm^3
h. 30-35gm/cm^3
3. Denholtz appliance is used for
a. Correction of open bite
b. Distalisation of molar
c. Correction of deep bite
d. Correction of anterior cross bite
4. Frankel appliance is
e. Myofunctional appliance
f. Removable appliance
g. Fixed appliance
h. None of above
5. The only tissue borne appliance is
i. Activator
j. Bionator
k. Twin block
l. Frankel
6. The 2 blocks in twin blocks appliance are angulated at
a. 45 degree
b. 70 degree
c. 65 degree
d. 80 degree

7. Jasper jumper is
e. Flexible fixed functional appliance
f. Rigid fixed functional appliance
g. Fixed functional appliance
h. None of above

8. Myofunctional appliance is given at which stage

i. Primary dentition
j. Mixed dentition
k. Permanent dentition
l. adulthood
9. Which of the following is fixed functional appliance
a. Bionator
b. Bow activator
c. Herbst appliance
d. A&B

10. Bionator was developed by

e. Balter’s
f. Neumann
g. Moyer’s
h. Bimler
THANK YOU