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Functional ApplianceFunctional ApplianceMejMej (B) Dr Akbar S (B) Dr Akbar S HussinHussinBDS (Malaya), Grad Dip BDS (Malaya), Grad Dip ClinClin Dent (Adelaide)Dent (Adelaide)D D ClinClin Dent (Dent (Orthodontics)(AdelaideOrthodontics)(Adelaide), ), MOrthMOrth RCS (Edinburgh)RCS (Edinburgh)
Functional ApplianceFunctional Appliance
A variety of fixed or removable A variety of fixed or removable appliancesappliancesDesigned to ‘reposition’ the mandibleDesigned to ‘reposition’ the mandibleLeading to muscle stretching Leading to muscle stretching Forces transmitted to dentition and Forces transmitted to dentition and basal bonebasal bone
Functional ApplianceFunctional Appliance
Muscular forces generated by altering Muscular forces generated by altering the the mandibularmandibular position position sagitallysagitally & & verticallyverticallyResulting in orthodontic & Resulting in orthodontic & orthopaedicorthopaedicchangeschangesMost effective skeletal Most effective skeletal ClCl II II txtx((retrognathiaretrognathia))Most effective during active growthMost effective during active growth
Bishara, 1989
Functional ApplianceFunctional Appliance
Growth modification involving Growth modification involving functional appliances have the functional appliances have the objectives of acting as a therapeutic objectives of acting as a therapeutic biomechanical interference to cause biomechanical interference to cause clinically significant morphological clinically significant morphological alterations in a growing child’s alterations in a growing child’s dentition and craniofacial skeletondentition and craniofacial skeleton
Vig & Vig, 1986
The The First First Functional Functional ApplianceAppliance
BreastfeedingBreastfeeding
Places beneficial Places beneficial orthopaedicorthopaedic forces on forces on the jawsthe jawsHelps to develop airways (pacifier Helps to develop airways (pacifier suckling deforms airways)suckling deforms airways)Cultivates positive down & forward Cultivates positive down & forward growing forces required by both upper growing forces required by both upper & lower jaws& lower jaws
Page, 2001
BreastfeedingBreastfeeding
Suckling forces generally act to form Suckling forces generally act to form wide dental archeswide dental archesSuckling also promotes good swallow Suckling also promotes good swallow muscle tone which assists proper jaw muscle tone which assists proper jaw and airway developmentand airway development
Page, 2001
Functional AppliancesFunctional Appliances
AndreasenAndreasen ActivatorActivatorBionatorBionatorFrankleFrankle Functional Regulator FR2Functional Regulator FR2HarvoldHarvold ActivatorActivatorTeuscherTeuscher ApplianceApplianceClark Twin BlocksClark Twin BlocksHerbstHerbst ApplianceAppliance
Frankel appliance
Clark Twin Blocks
Herbst Appliance
Timing of TxTiming of Tx
Effective during active growthEffective during active growthThe faster the growth, the faster the The faster the growth, the faster the response, the shorter the response, the shorter the txtx timetimeMost common time for Most common time for txtx –– pubertal pubertal growth spurtgrowth spurtEarly Early txtx -- 99--10 yrs10 yrsDefinitive Definitive txtx -- 1212--13yrs13yrs
Early Early txtx
To intercept a developing problemTo intercept a developing problem–– Improve aestheticsImprove aesthetics–– Decreased trauma risk to anterior teethDecreased trauma risk to anterior teeth–– Early correction of deleterious habitEarly correction of deleterious habit–– Improve eventual prognosisImprove eventual prognosis–– Decrease length of definitive Decrease length of definitive txtx
Twelftree, 1998
Early Early txtx
Ideal Ideal txtx time time –– when four upper when four upper incisors have eruptedincisors have eruptedMost common Most common –– correction of large OJ correction of large OJ caused by caused by retrognathicretrognathic mandiblemandibleTx Tx -- Reposition mandible forwardReposition mandible forwardTx discontinued once correction Tx discontinued once correction achievedachievedSome relapse will occurSome relapse will occur
Definitive Definitive txtx
During pubertal growth spurtDuring pubertal growth spurtUsually all permanent teeth have Usually all permanent teeth have eruptederuptedCorrection of maxCorrection of max--mandmand discrepancy discrepancy usually followed by fixed appliance usually followed by fixed appliance txtxFunctional appliance may also be used Functional appliance may also be used during fixed appliance during fixed appliance txtx
Effects of TxEffects of Tx
SkeletalSkeletal–– CondylarCondylar growthgrowth
Increased Increased condylarcondylar remodellingremodellingIncreased Increased glenoidglenoid fossafossa remodellingremodelling
–– Increased lower face heightIncreased lower face height
Ruf et al., 2002
Effects of TxEffects of Tx
DentoalveolarDentoalveolar–– RetroclinationRetroclination of upper incisorsof upper incisors–– ProclinationProclination of lower incisorsof lower incisors–– MesialMesial eruption of lower posterior teeth eruption of lower posterior teeth
Mode of Action of Mode of Action of Functional AppliancesFunctional Appliances
DentoalveolarDentoalveolar changeschangesRestriction of forward growth of maxillaRestriction of forward growth of maxillaStimulation of Stimulation of mandibularmandibular growth beyond growth beyond what is normally seen in growing childrenwhat is normally seen in growing childrenRedirection of Redirection of condylarcondylar growth from upward growth from upward and forward directed growth to posterior and forward directed growth to posterior direction direction
Mode of Action of Mode of Action of Functional AppliancesFunctional Appliances
Changes in neuromuscular anatomy Changes in neuromuscular anatomy and function that would induce bone and function that would induce bone remodellingremodellingAdaptive changes to Adaptive changes to glenoidglenoid fossafossalocation to a more anterior and vertical location to a more anterior and vertical directiondirection
DentoDento--Alveolar EffectsAlveolar Effects
DentoDento--alveolar changes alveolar changes –– 6060--70%70%–– Inhibition of downward and forward Inhibition of downward and forward
eruption of maxillary teetheruption of maxillary teeth–– RetroclinationRetroclination upper incisorsupper incisors–– ProclinationProclination of lower incisorsof lower incisors
OrthopaedicOrthopaedic EffectsEffects
OrthopaedicOrthopaedic changes changes –– 3030--40% 40% –– CondylarCondylar growthgrowth
Increased Increased condylarcondylar remodellingremodellingIncreased Increased glenoidglenoid fossafossa remodellingremodelling
–– Increased lower facial heightIncreased lower facial height
Clark Twin BlocksClark Twin Blocks
Consists of separate upper & lower Consists of separate upper & lower appliances appliances More comfortable & aestheticMore comfortable & aestheticPt able to eat & speak without Pt able to eat & speak without restriction of tongue, lip & mandible restriction of tongue, lip & mandible movements movements Pt able to cooperate to wear appliance Pt able to cooperate to wear appliance 24hrs 24hrs
Fricker, 1998
Clark Twin Blocks
Clark Twin BlocksClark Twin Blocks
Constructed to a protrusive biteConstructed to a protrusive biteWith appliances in mouth, pt not able With appliances in mouth, pt not able to occlude in former distal positionto occlude in former distal positionMandible forced to adopt protrusive Mandible forced to adopt protrusive bitebite
Clark Twin BlocksClark Twin Blocks
Block ~ 5Block ~ 5--6mm thick between molars 6mm thick between molars (mouth open beyond freeway space) (mouth open beyond freeway space) so that pt cannot return to former so that pt cannot return to former distal occlusiondistal occlusion
Orthodontics and DentofacialOrthopaedics:
A Comprehensive Textbook
CTB designCTB design
BaseplateBaseplate–– Upper Upper –– up to 6sup to 6s–– Lower Lower –– up to ½ cusps of 5sup to ½ cusps of 5s
Expansion screwExpansion screw–– Necessary only when compensatory Necessary only when compensatory
expansion needed to accommodate lower expansion needed to accommodate lower arch as the mandible translates forwardarch as the mandible translates forward
CTB designCTB design
RetentionRetention–– Upper Upper
Adams clasps at upper 6s, 4sAdams clasps at upper 6s, 4s
–– Lower Lower Adams clasps at lower 4sAdams clasps at lower 4sBall clasps at lower anterior teethBall clasps at lower anterior teeth
CTB designCTB design
Occlusal blocks Occlusal blocks –– Upper Upper
From 6s up to From 6s up to mesialmesial of 5sof 5s
–– Lower Lower From midFrom mid--cusp of lower 5s to cusp of lower 5s to mesialmesial of lower 4of lower 4
–– Occlusal inclined plane Occlusal inclined plane –– 7070oo
Orthodontics and DentofacialOrthopaedics:
A Comprehensive Textbook
Orthodontics and DentofacialOrthopaedics:
A Comprehensive Textbook
Appliances for Cl II div 2
Bite RegistrationBite Registration
Boxing wax
Wooden spatula
Hot water
Pt bites with incisors edge to edge.
~ 6mm separation of molars
Fold wax lengthwise twice to 1/3 size
Do not flatten
Turn folded wax lengthwise and fold once with spatula in between
Crimp lower edge against spatula
Do not flatten
Pt bites with incisor edge to edge
Stages of TxStages of Tx
11stst stagestage–– To correct To correct anteroposterioranteroposterior relationship from relationship from
skeletal skeletal ClCl II to II to ClCl I I
22ndnd stagestage–– Settling of posterior teeth into occlusion from Settling of posterior teeth into occlusion from ClCl
II molar relationship to II molar relationship to ClCl II–– Upper bite blocks trimmed to allow eruption of Upper bite blocks trimmed to allow eruption of
lower posterior teethlower posterior teeth–– Lower bite blocks trimmed to level Lower bite blocks trimmed to level occlusalocclusal plane plane
Orthodontics and DentofacialOrthopaedics:
A Comprehensive Textbook
Stages of TxStages of Tx
In deep bite cases, trim blocksIn deep bite cases, trim blocksIn reduced or open bite cases, do not In reduced or open bite cases, do not trim blockstrim blocks
Tx ProtocolTx Protocol
FullFull--time wear for first 6 monthstime wear for first 6 months–– Worn at all times including eating and Worn at all times including eating and
sleepingsleeping–– Removed only for brushing of teethRemoved only for brushing of teeth–– Not to be worn during sporting activitiesNot to be worn during sporting activitiesNightNight--time wear for next 6time wear for next 6--9 months9 monthsFinishing may be undertaken with Finishing may be undertaken with fixed appliancesfixed appliances
Before
After
Pre CTB
Post CTB
Advantages of CTB TxAdvantages of CTB Tx
Comfortable Comfortable –– pt able to eat, speakpt able to eat, speakAesthetic Aesthetic –– appliance not obviousappliance not obviousMandible able to move freelyMandible able to move freelyCompliance Compliance –– can be removable or can be removable or temporarily cementedtemporarily cementedImproved facial appearanceImproved facial appearanceNormal speechNormal speech
Advantages of CTB TxAdvantages of CTB Tx
Easy to manage clinicallyEasy to manage clinicallyNot easily breakableNot easily breakableAllows independent arch developmentAllows independent arch developmentImprovement of vertical heightImprovement of vertical heightAllows for asymmetrical correctionAllows for asymmetrical correctionRapid & efficient correction of skeletal Rapid & efficient correction of skeletal discrepancy & malocclusion discrepancy & malocclusion
Advantages of CTB TxAdvantages of CTB Tx
Tx can be undertaken from childhood Tx can be undertaken from childhood to early adulthoodto early adulthoodMay be integrated with fixed May be integrated with fixed appliancesappliancesTx of TMJ dysfunction Tx of TMJ dysfunction –– splint allows splint allows displaced disc to be recaptureddisplaced disc to be recapturedTx of sleep Tx of sleep apnoeaapnoea –– increases airway increases airway spacespace
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