ORIGINAL

ARTICLES

Hybrid appliances: A component approach to dentofacial orthopedics

Peter S. Vig, B.D.S., Ph.D., D. Orth., F.D.S.R.C.S.(Eng.), and Katherine W. L. Vlg, B.D.S., D. Orth., F.D.S.R.C.S.(Eng.)* Ann Arbor, Mich. The net treatment effect of orthodontic or orthopedic therapy may be considered as the algebraic sum of all dentoalveolar, skeletal, and neuromuscular changes over time. Cumulative effects resulting from growth and adaptation in response to therapeutic biomechanical interference may be manipulated to result in clinically significant morphologic alterations in the growing childs dentition and craniofacial skeleton. All of the currently used functional appliances can be regarded as assemblies of a small number of component parts. This article attempts to identify these salient components and their respective contributions to the total design and probable function of such appliances. The logical consequence of such an analysis is the derivation of principles upon which the design of hybrid appliances may be based. Hybrid appliances are specifically and individually tailored to exploit the natural processes of growth and development. Such an approach represents a departure from the practice of adopting a named appliance for the treatment of a class of malocclusion. Instead, a detailed analysis of skeletodental and soft-tissue features, together with the patients growth status and underlying cause of the malocclusion, are used to establish a set of treatment objectives. This in turn determines the selection of the components and their assemblies, resulting in appliance designs that uniquely match the needs of individual patients. (AM J ORTHOD
DENTOFAC ORTHOP 90: 273-285, 1988.)

Key words: Functional!appliances, mode of action, dentofacial orthopedics, growth modification

BACKGROUND:THEPROBLEM

Functional appliances have been widely used in Europe for more than 60 years. A large array of supeficially different appliances exists and still seems to be growing. Such appliances are frequently distinguished by eponyms that commemorate their designers. Some have evocative names that suggest a biologic or dynamic principle unleashed by the appliance. Examples of these are the Activator, Bionator, Kinetor, and the Function Regulator. These appliances today are appropriately regarded as biomechanical tools of dentofacial orthopedics. Originally, however, they were considered to have individual attributes that their proponents rationalized as systems or philosophies of treatment. Without exception, such rationalizations were based on selective clinical impressions of treatment effects, an absence of tested hypotheses concerning cause and effect, and although heuristically useful, they were more fanciful
From the University of Michigan. *Chairman and Fmfeasor, Depatment of Chthodontics, School of Dentistry; Reseamh Scientist, Center for Human Gnwth and Development. **Associate Fmfessor, Department of Orthodontics, School of Dentistry.

than factual. Unfortunately, this tendency still persists and is partly responsible for the considerable confusion surrounding this integral part of modem comprehensive orthodontics. Concepts such as functional correction are expressed in an appealing but scientifically naive manner. To state that normalizing function leads to normalizing growth and hence form is scientifically meaningless. It also implies an understanding of craniofacial biology, the causes of malocclusion, and the specific adaptive response to each named appliancean understanding that we simply do not have. Implicit in such verbiage is a notion that malocclusion is primarily the result of abnormal function without specifying what is abnormal, or for that matter, what function is. Tacit acceptance of such a metaphysical approach, with undefinable factors at its core, also envelops the subject in a mystique that resists scientific validation of competing hypotheses. Clearly, all appliances are capable of producing some change. The fact that some patients have orthodontically significant improvements following treatment in no way validates the theoretical principle or
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Flg. 1. Diagrammatic representation of a malocclusion in the coronal plane. The problems depicted are (1) transverse mandibular deficiency, (2) crossbite on patients left side, (3) lingual inclination of the lower molar, and (4) cant of the maxillary functional occlusal plane.

hypothetical mechanism postulated for the mode of action of the appliance. The preceding comments are made with a constructive intent. Despite the availability of excellent contemporary textbooks, 9 a growing clinical and research literature, and a multitude of continuing education courses, considerable confusion and a relatively poor general understanding of functional appliance therapy prevails. There are practical problems attributable to this state of confusion and the underlying causes of this state of affairs. Given a choice of numerous appliances with their associated theories, how does the clinician choose? All too often the answer is to be found in the clinicians acceptance of an appliance as being the best simply because a well-known author or lecturer says so. This confluence of the credibility of one clinicians clinical experience with anothers credulity frequently leads to fads, fanaticism, and ultimately frustration. If prolonged, repeated, and sufficiently widespread, such frustration can lead finally to a wholesale rejection of all functional appliances and dentofacial orthopedics. Should this occur, orthodontics would revert to a more limited scope of activity.
APPLIANCE COMPONENTS AND THEIR EXPECTED FUNCTIONS

components. Each component has a desired function and is generally incorporated for a specific purpose. In multibanded biomechanical systems, headgear and elastics are adjunctive components. The configuration of arch wires is also made up of identifiable components. For example, closing loops, tip-back bends, and other features are components of the biomechanical systems we use to induce dentoalveolar and skeletal adaptations. Within the fixed appliance schemes, there is scope for great diversity and the opportunity exists for making design modifications at each appointment for all patients. These variations enable the skilled and knowledgeable clinician to depart from a cookbook approach and to address individual problems in a specific way appropriate for any given clinical situation. The biomechanical principles are relatively well understood and form the basis of appliance selection, design, and manipulation. In other words, decision making is predicated on the (1) changes desired, (2) estimate of forces required, and (3) the materials used (that is, materials such as brackets and wires). Each set of arch wires or combination of components in this scheme is not treated as a different named appliance, nor is a different set of biologic principles invoked to explain the mode of action. Functional appliances are no different. All of the currently used appliances are made up in various combinations from three basic functional components. These components produce basal and dentoalveolar changes by acting on the following: 1. Eruption (biteplanes) 2. Linguofacial muscle balance (shields or screens) 3. Mandibular repositioning (construction or working bite) The details of these components vary qualitatively and quantitatively as does the configuration of the connecting elements and hence the overall appearance (and name) of the appliance.
Eruption: Biteplanes

Recognizing the limited data and verifiable facts, the purpose of this article is to simplify the concepts relating to the still empirical choice of treatment methods. All appliances are assemblies of a few simple

Biteplanes may be flat or inclined, and anterior or posterior, which contact single or multiple dental units; ahbough they are usually thought of as blocks of acrylic resin, they may in fact be made of wire or any other suitable material. Clinical experience supported by recent research3 indicates that relatively low forces, if applied either continuously or intermittently, are capable of impeding the eruption of teeth. Apically directed forces may therefore be expected to impede or arrest eruption; other forces may produce tipping or eruptive deflection from the starting axial inclination. A flat anterior biteplane of sufficient dimensions to

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Fig. 2. A, Components assembled to produce a hybrid appliance. Black arrows indicate the expected direction of tooth movements. White arrows show the unopposed muscle force directions. 8, An alternative design of a hybrid appliance that affects eruption and muscle equilibrium. C, Another set of functional components assembled to yield a hybrid appliance design. Although biomechanically different from A and B, this design also has the potential for correcting the component problems inherent in the malocclusion depicted in Fig. 1. D, A further variant of a hybrid appliance that may be used for the correction of the malocclusion in Fig. 1.

disocclude the posterior teeth may be expected to have several effects. The magnitude of treatment effects will be related to the amount of dentoalveolar vertical growth or adaptation that accompanies and compensates for the separation of the maxilla and mandible produced by growth. These effects may comprise some or all of the following: 1. Differential eruption of posterior teeth 2. Noneruption, relative or absolute intrusion of incisors 3. Incisor overbite reduction 4. Disocclusion with removal of intercuspation In the cybernetic model of mandibular growth regulation proposed by Petrovic4 interarch cuspal relationship is assigned the role of a comparator. Disoc-

elusion may thus also have at least a theoretical deregulating or promoting influence on mandibular growth. Based on his extensive studies of treatment effects produced by various functional appliances and different forms of multibanded therapy, Johnston postulates that disocclusion, a feature that is common to all functional appliances, may well be responsible for any additional increments of mandibular growth observed in the functional versus fixed cases. Unimpeded posterior tooth eruption may also result in a down and backward mandibular rotation that tends to increase anterior vertical lower facial height and reduces the prognathism of the mandible. A flat posterior biteplane would have the opposite effect in terms of the previously mentioned effects 1 through 3, while retaining the feature of disocclusion.

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Fig. 3. A, A hybrid appliance viewed from the superior or maxillary aspect. 8, The appliance in contact with the maxillary structures as viewed from the inferior aspect. Note the lingual and buccal shields and the wires that contact teeth whose vertical eruption they impede. The anterior portion of acrylic caps the lower incisors. C, Right buccal and incisal view of this hybrid appliance. The posterior biteplane and in&al capping contact those teeth whose vertical development is to be maintained. Teeth not in contact with the appliance can erupt further. This differential eruption may be used to level both arches. D, View showing the anterior aspect and the buccal shield on the patients left side. Note the wide space between the buccal shield and the dentoalveolar structures relieved of buccal muscle pressures.

Inclined planes may be designed to provide guide planes for the labiolingual mechanical eruptive displacement of incisors or the buccolingual deflection of erupting posterior teeth. A less obvious version of an inclined plane is to be found in the trimmed activator and other named appliances of this generic type. The trimmed activator used for correction of a Class II malocclusion will have facets that contact the mesiolingual aspect of the maxillary posterior teeth and the distolingual aspect of the mandibular buccal dentition. These facets arc also angulated in such a way as to promote the buccal movement of all posterior teeth as they erupt and as they move distally and mesially, respectively.

Other, less than obvious, biteplane-like components of functional appliances also exist. The capping or incisal coverage used in various versions of the activator is merely another eruption-impeding device. Nonacrylic versions of this appliance component include the wire elements in the Function Regulator (FR) 2. These may take the form of a palatal wire in contact with upper incisors, the springs resting on the cingulum area of the lower incisors, the wire from the buccal shield to the occlusal surface of upper first molars, and all of the other wires that engage interproximally between all of the maxillary teeth posterior to the canines. Hence, with this appliance only the lower posterior teeth are entirely

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unimpeded in their eruption; all of the other teeth are prevented or differentially restrained in their eruption relative to the mandibular buccal segments. The differential eruption control of anterior versus posterior teeth has aheady been discussed in relation to the control of overbite. Differential manipulation of upper versus lower posterior teeth is also possible as in the example of the FR2 cited previously. Other examples also exist in presently used appliances in which buccal teeth in one jaw are free to erupt while their antagonists are restrained. This is a feature of the Herbst appliance as well as the Harvold-Woodside activator. It should be remembered that as upper posterior teeth erupt, they migrate not only in a vertical but also in au anterior direction. Therefore, impeding or arresting the eruption of maxillary molars not only permits the relative increase of mandibular dentoalveolar height, but also results in a relatively greater mesial or anterior movement of the lower buccal segments, both through eruption and also by their forward translation, which is produced by normal mandibular growth. With the diminished or arrested eruption of the maxillary molars, this combination of effects can be expected to result in the improvement of a Class II molar relationship. Conversely, if the lower posterior teeth are restrained from erupting while the uppers do so unimpeded, the expected result would be an improvement in a Class III molar relationship.
Linguofaclal muscle balance: Shields or screens

appliance contacts the facial aspect of spaced, proclined maxillary incisors. The vestibular shields and lip pads (or @lots) of the Fr%nkel FR appliances are components that behave as parts of an oral shield, which they indeed resemble. Therefore, it is not necessary to postulate that periosteal stretching in the depths of the vestibule induces surface bone apposition, resulting in a wider dental base into which teeth migrate and thereby increasing arch width and perimeter. Under the untested periosteal stretching hypothesis, the peripheral extension of the vestibular shield assumes a critical role. On the other hand, viewing the shield simply as a means of keeping the buccal musculature away from the teeth, the vertical extension, and hence the type of impression, become less than critical. Incidentally, at least in experiments on long bones, the effect of increased periosteal tension seems,to be counterproductive for growth. Relief of periosteal tension appears to stimulate bone growth.s8
Mandibular reposltlonlng: working bite Construction or

Although certain elements still require experimental validation, there is little doubt that the growing dentoalveolar structures are plastic and responsive to linguofacial muscle pressures. The so-called equilibrium theory of tooth position6 predicts that over time tooth movement occurs in response to any perturbation of the homeostatic relationship between the radially directed forces of the tongue and the opposing, but smaller, forces exerted by the circumoral muscles of the lips and cheeks. Vestibular shields or oral screens and the smaller, and hence more localized, lip bumpers have been used in orthodontics for many years. Lip bumpers produce arch length increases at least in part, if not always entirely, by removing the effect of resting lip pressures from the labial surface on incisors. Consequently, the incisors procline under the influence of unopposed lingual muscle pressures. Depending on the design of an oral shield or screen, it is possible to obtain or retain expansion of the buccal segments by relieving the contact between the buccinator and the posterior teeth. Conversely, retraction of incisors will result if the shield induces stretching in the labial musculature and the transmission of increased lip pressure as the

The term functional appliance is an abbreviation of myofunctional appliance, which is what such devices were called in Britain during the 1950s and 60s. Presumably, the prefix myo was dropped in the United States to distinguish this form of treatment from the then popular myofunctional therapy, which was directed at muscle re-education or retraining to alter some so-called oral habits. All of the functional appliances are constructed to a construction or working bite registration. Such registrations of maxillomandibular relationships are based on the assumption that by displacing the mandible from its rest position, and thus stretching the muscles attached to it, reflex activity tends to restore the mandible to a postural position that was originally determined by the unstretched muscles. Hence, most construction bites are taken at a vertical dimension that is beyond the freeway space or interocclusal clearance. In addition to this increase in the vertical dimension, the construction bite may also displace the mandible in the sag&al and transverse planes. The spatial relationship between the jaws to which functional appliances are constructed is determined by the registration and may differ from the intercuspal position in three linear dimensions. Thus, the parameters or variables are defined as millimeters of displacement in the (a) vertical, (b) anteroposterior or sag&al, and (c) transverse or coronal planes. At present these variables are usually arbitrarily selected. Empirical formulas for the dimensions of the working bite are advocated by some clinicians. These

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Fig. 4. Pretreatment views. A, Incisor overbite and lingual crossbite resulting in a lack of buccal intercuspation, which is a characteristic of the so-called Brodie syndrome. B, Occlusal view of the lower arch. Note the lack of space for the unerupted second premolar%

range from (a) minimal opening and an edge-to-edge incisor forward displacement, (b) 4.0 mm open and 6.00 mm forward, (c) to an opening and forward displacement beyond a position of comfort for the patient to induce the maximum stretching of both contractile and connective tissues. Displacement of the mandible in the coronal or transverse plane requires an asymmetric working bite that is advocated only in some skeletal asymmetries with certain specific and known causes. Dental asymmetry, such as midline discrepancies, without an underlying skeletal asymmetry, should not be regarded as an indication for a transverse mandibular displacement in recording the construction bite. A feature of individual variation that is frequently overlooked is the pretreatment habitual posture of the mandible. Not all patients have a standard path of closure from rest to occlusion, which is ,up and forward, through an arc of constant or standard dimensions.

Patients are frequently encountered who have a considerably increased freeway space. This sometimes, but not invariably, occurs together with a decreased dentoalveolar height and deficiency in the dimensions of the midface or maxillary complex. Many deep bite cases have a retruded condylar position in habitual occlusion with an upward and backward path of closure from postural resting position. Others may exhibit a downward and forward mandibular posture with an increased interocclusal clearance and an upward and backward path of closure into occlusal position. Clearly, applying a standardized formula of 4.0 mm opeW6.0 mm forward to the bite registration in such patients may not produce significantly increased muscle stretching nor result in discernible neuromuscular or skeletodental adaptations. It is not the purpose of this article to discuss either the efficacy of functional appliances for mandibular growth stimulation or the mechanisms that have been

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Fig. 5. A, The hybrid appliance in situ maintains a downward and anterior displacement of the mandible relative to its habitual resting posture. This bite registration was at a vertical dimension greater than the patients freeway space. B, An anterior view of the appliance. This hybrid is a composite of a FR2 (lower part) and an indexed posterior biteplane. The biteplane is in contact only with the upper teeth. The lower posterior teeth are free to erupt and move both mesially and buccally.

postulated for this effect. The biomechanical relevance of mandibular displacement that is maintained by a functional appliance lies in the production and dissipation of forces that may by design be directed to the maxilla, mandible, and the dentition. These forces are applied through either wire or acrylic components. The points of application are at the sites of contact. These are either on the crowns of teeth or on the mucosal surfaces of the jaws. As with other mechanical systems, such forces have equal and opposite reactions and may be resolved into vectors that are mutually perpendicular. Therefore, functional appliances designed to correct a Class II malocclusion and constructed to a downward and forward jaw registration will be expected to yield forces

1. Distally-Applied to the maxilla and some of the maxillary teeth 2. Mesially-Applied to the mandible and some of the mandibular teeth 3. Apically-Applied to those teeth that are in occlusal contact with the appliances 4. Transversely-Depending on specific appliance design features In essence, this is analogous to the combined effects of Class II mechanics such as those used in fully banded techniques with Class II elastics with or without headgear. The major qualitative and quantitative differences between multibanded and functional appliances are that functional appliances 1. Disocclude the dentition

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Fig. 6. A, Left buccal occlusion and incisor relationship obtained after 10 months of treatment with the hybrid appliance. Note that the buccal crossbite relationship is improved and a fully banded appliance achieved final correction. B, View of the right side and incisors after 10 months of the phase I dentofacial orthopedics. C, This occlusal view of the mandibular arch shows the second premolars erupted.

2. Maintain a condylar position that is anterior and inferior to a centric jaw relation condyle to fossa relationship 3. Differentially affect the eruption of teeth within and between the opposing arches 4. Use forces that are no greater than those that may be produced by the patients own musculature
THE COMPONENT APPROACH APPLIED TO CLINICAL PROBLEMS: MATCHING PARTS OF THE APPLIANCE TO THE PARTS COMPRISING THE PROBLEM

This approach to problem solving and appliance design is consonant with, and may be regarded as a corollary to, the problem-oriented approach to orthodontic diagnosis and treatment planning. For illustrative purposes, a hypothetical case is considered. Fig. 1 is a diagrammatic representation of the transverse or coronal section through a plane mesial to the first molars. The clinical problem depicted has several obvious components. These are

1. Skeletal-Mandibular transverse deficiency relative to the width of the maxilla 2. Dental-Right buccal crossbite of the maxillary molar with a lingual inclination of the mandibular molar and some buccal tipping of the maxillary molar 3. Dentoalveolar-Supraeruption of the right buccal segment in the maxilla with a consequent cant of the upper functional occlusal plane The malocclusion depicted is in a growing child in whom further skeletal growth, dentoalveolar adaptation, and eruption may be expected to occur. For the purpose of this illustration, the sagittal or anteroposterior relationships need not concern us. The intent here is to demonstrate that appliance components can be identified to match and resolve the component parts of the clinical problem. Furthermore, the selection and assembly of these components represent an opportunity for creative problem solving, and through a rational process result in the creation of a hybrid appliance that is uniquely adapted to the specific clinical condition. Perhaps equally important, this il-

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Fig. 7. A, Initial radiograph shows the presence of all unerupted teeth including lower second premolars. B, A panoramic radiograph taken after completion of the phase I treatment.

lustration also demonstrates that four appliances with distinctly different shapes and designs are essentially homologous from a functional aspect (see Fig. 2, A through 0). The all acrylic design shown in Fig. 2, A, is based on the following components: 1. Biteplanes to arrest the vertical development of the patients right maxillary molar, while permitting further eruption of the left molar to the predetermined level. This corrects the cant of the occlusal plane in the maxilla. 2. The buccal shields protect the lower teeth from the pressures of the buccal musculature, while maintaining soft-tissue contact with the upper molars. These changes in muscle equilibrium may be expected to produce dentoalveolar adaptations that are favorable to the correction of the crossbite and the lateral discrepancy in jaw widths. The white arrows in Fig. 2, A, represent unopposed lingual muscle pressure on the lower teeth and unreciprocated buccal muscle forces on the upper teeth. The black arrows on the tooth crowns indicate the directions in which these

teeth will migrate during their subsequent eruption. The design of the acrylic contacting the palate is such that it contacts the left molar, which therefore cannot move in a palatal direction. However, on the right side, where there is a crossbite and a buccally inclined molar, the contact is relieved to permit the lingual movement of the maxillary right molar in response to the unopposed buccal muscle pressures. 3. Construction bite or increased vertical dimension is maintained by the contact of the appliance with the palate and the vestibular mucoperiosteal fold in the mandible where the inferior edges of the buccal shields touch if a Frankel type of appliance is used. This vertical opening is predetermined and obtained by the appropriate maxillomandibular wax bite registration. A vertical dimension greater than the freeway space serves two functions. It disoccludes the teeth and also applies an apically directed force that opposes eruption of the molar in contact with the biteplane. Fig. 2, B, shows an alternative configuration of

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Flg. 8. A, The pretreatment cephalogram shows a Class II skeletal relationship. B, The cephalogram taken after 10 months of dentofacial orthopedic treatment with the hybrid appliance. C, The skeletal and dental changes may be seen on the superimposed tracings.

components. This too is an all acrylic appliance and differs from the previous design in several ways. The flat biteplane in contact with the patients right molar serves the same function as in the previous appliance. The other molars are in contact with an inclined plane that will deflect these teeth buccally as they continue to erupt. The inclination of the plane determines the direction; the masticatory muscles that are stretched beyond their resting length by the construction bite provide the force. There are no buccal shields in this design, which resembles a Harvold-Woodside activator on the crossbite side and a classical Andresen activator on the opposing side. The vertical dimension of the functional appliance is once again determined by palatal contact with the appliance and in this case the inferior extension contacting the depth of the lingual vestibule. The perturbation of linguofacial muscle balance is

in this case produced by shielding both the maxillary and mandibular erupting teeth from the pressures that the tongue would normally exert. As the lingual forces excede those of the cheek, this modification may therefore be less effective in terms of promoting a buccal tipping or drifting of the lingually inclined lower right molar than the design in Fig. 2, A. Another set of components that may be manipulated to effect correction of our hypothetical malocclusion is illustrated in Fig. 2, C. This design consists of two buccal shields and is similar to the Frinkel appliances. The buccal shields maintain the desired degree of jaw separation and disclusion. They also permit the lingual muscle pressures to act unopposed. If buccal tooth movement is undesirable in any quadrant, it is necessary only to ensure that no space exists between the shield and the buccal surface of teeth and alveolar mucosa in such areas. On the patients right side, an occlusal contact exists

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between the right maxillary molar and the wire element embedded in the buccal shield. This wire is functionally analogous to an occlusal stop or biteplane, similar to those depicted in the design of Fig. 2, A. As there is no vertical stop on the patients left side, it is obvious that progress of subsequent eruption must be monitored in terms of the cant of the occlusal plane. The cant here is corrected by the differential eruption of the left and right maxillary buccal segments. When correction has been achieved, it is necessary to prevent the further eruption of the patients left maxillary molars. This is achieved simply by modifying the appliance to incorporate either a wire stop or an acrylic occlusal stop, which may be added to the buccal shield by using quicksetting acrylic. The final example of a hybrid appliance designed to correct this malocclusion is seen in Fig. 2, D. This assembly comprises components that have already been described in the previous illustrations. On the patients right side, this appliance is exactly the same as Fig. 2, A. However, on the other side, there is a buccal shield between the lower molars and the cheek, a lingual shield that thus completely relieves the lower left buccal segments from linguofacial muscle pressures, and a wire connector between these two shields. The wire connecting the shields serves as an occlusal stop that defines the limit of vertical eruptive movement of the upper left molar. The precise level at which this wire component is to be placed is determined by the degree of cant of the pretreatment functional occlusal plane of the maxillary teeth. These four designs demonstrate the salient features of the component approach to designing treatment for a specific clinical problem. To further clarify this concept and also to illustrate how this analytic approach may be useful in evaluating an appliance, the reader is referred to Fig. 3, A through D. Fig. 3, A, is a view from the superior (or maxillary) aspect and shows a hybrid appliance in isolation. At first sight this is a somewhat confusing picture. When placed on the upper model, as in Fig. 3, B, some familiar components can be more readily recognized. A lingual shield protects most of the dentition from the muscle pressures of the tongue. The lingual aspect of the maxillary left posterior teeth is not shielded. On one side only there is a buccal shield extending from the upper right canine to the molar. On this side the wires connecting lingual and buccal shields are in contact with teeth whose eruption is therefore being retarded. Fig. 3, C, shows the right buccal view. Those teeth in contact with the posterior biteplane and the incisor

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musculature. Wires contacting the cingula of both upper and lower incisors tend to prevent the eruption of all the anterior teeth. Thus, differential eruption reduces the overbite and levels the curve of Spee in the mandible. The appliance is constructed to a bite registration (Fig. 5, A), which is vertically greater than the freeway spacewith a mandibular forward posture in the bite registration. The functional or orthopedic phase of treatment with the hybrid appliance lasted approximately 10 months. After an initial habituation period of 4 to 6 weeks, the patient wore the appliance almost 24 hours per day for 8 to 9 months. The results of this phase of treatment are seen in Fig. 6, A through C, which showsthe occlusalchanges.Spontaneous eruption of the lower secondpremolars occurredtogether with reduction of overjet, overbite, and correction of the transverse discrepancy.The progresscephalogram (Fig. 8, B) and panoramic view (Fig. 7, B) show skeletal, soft-tissue, and dental changes. A superimposition of tracings comparing the start with the end of phase I is shown in Fig. 8, C. Superimposition on the best fit of the maxilla indicates little or no eruption of the maxillary teeth. Only a slight lingual tipping of the maxillary incisors has occurred. The mandibular superimposition shows very slight labial bodily movement of the incisorsand a similar slight distal movement of the lower first molars. The increase in arch length was not sufficient to accommodate the lower secondpremolars and the remainder of the space was created by a transverse expansion of the mandibular arch with a consequentincreasein arch perimeter. The overall superimposition on sella-nasion and the sphenoethmoidtriad indicate that mandibular growth and little or no maxillary growth have occurred during the short treatment period. This differential skeletalgrowth and mandibular change combined to produce a significant improvement that shortened the final phase of fully banded appliances considerably.

The component approach, which has been outlined, requires a careful identification of each part of the patients problem. This leads logically to define a set of appliance components that may effect dentoalveolar and skeletal change by manipulating the processesof eruption, growth, and adaptation. This attempt at the specific identification of the dentoalveolar, skeletal, and neuromuscular features that are the substrate of the functional appliance results in making a differential diagnosis of the malocclusion in terms of its clinically discernible etiologic features. Such an approach may lead to the design of a hybrid appliance made up of components in a unique way for correcting a multifactorial problem list. Alternatively, an existing named appliance may be chosen. Such a choice would be justified on the basis of the appliances components and of the problems to be resolved. This basis for selection is founded on biologic considerations; an esti-

mate of the probability of treatment outcomes may thus be rational, rather than entirely based on empiricism. From an educational perspective, the component approach provides a common basis for the comparison of all functional appliances. It highlights both similarities and differences covering the entire range of functional appliances. Such a unifying, and yet simple, concept enables both teacher and student to attempt a biomechanical analysis of the force systems inherent in various alternative designs. Like other orthodontic treatment, functional appliances apply forces to teeth or bones. However, a feature that is unique to functional appliances is that they are differentially changing muscle pressures that influence skeletodental adaptations during growth. To fully utilize this capability of functional appliances, it is clearly important to identify components and their probable use for attaining treatment goals. What may be the optimum assembly of components in one appliance may prove less than adequate in many others. Therefore, the clinician should be willing and able to make modifications in appliance design or, where indicated, select a composite of components to construct a hybrid appliance. Finally, the component analysis is also a necessary first step toward the systematic approach to the study of treatment efficacy and the effects produced by functional appliances. Despite considerable research and an extensive literature, it is difficult to obtain unequivocal data on the utility of any of the functional appliances. One of several reasons for this is the lack of precision in defining the biomechanical features of the appliances studied. For example, the term activator does not necessarily apply to the same appliance in Norway, Sweden, Switzerland,13 Toronto,14 or New Orleanst5 This is no more remarkable than the diversity of different biomechanical systems that go under the generic name of the edgewise appliance. The superficial similarities may well obscure important functional differences inherent in the qualitative or quantitative variations in the components. For example, LudeP has demonstrated that varying the horizontal/vertical values of the working bite dimensions produces different average treatment effects even with one version of an activator. Clinical research protocols for studies aimed at comparing the efficacy of alternative treatments need to have specified and predetermined end points for the defined treatment goals. When alternative appliances are the independent variables, it is advisable to consider as a priority the similarities and differences that may be expected to result in observed variations in treatment

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response. Such considerations are just as relevant to the experimental design as selecting appropriately matched controls and randomizing allocation of treatments. Analysis of functional appliances by components enables a more objective and biologically rational characterization of the appliances to be evaluated and can even promote the formulation of better defined or less ambiguous hypotheses. For example, a comparison of the bonded and banded versions of the Herbst appliances may appropriately start with a consideration of their respective functional components. The bonded appliance has a feature-namely, the occlusal coverage of the maxillary posterior teeth-that is not present in the banded version. This in effect is a biteplane and acts to disocclude posterior teeth. It may therefore be reasonable to test the following hypothesis: disocclusion of buccal segment interdigitation results in more rapid transition from a Class II to a Class I occlusion and is also accompanied by greater increments of mandibular growth per unit time. For those inclined to a decision analysis approach to clinical research, the component analysis of appliances may also be appealing. Given the prior probability of a specified treatment outcome, it should be possible to derive conditional probabilities and thus make probability revisions to compute the odds in favor of certain results. This probabilistic (or Bayesian) approach, currently favored in medical research, may be applicable to such orthodontic issues. Identification of the functional components and their presence or absence in a given pair of appliances may be a valid starting point for probability revision in such studies. Doing this would in fact test the comparative attributes of various appliances in terms of their components and their contribution to treatment efficacy. Implicit in the design and construction of all hybrid appliances is a laboratory that is attuned to an individualized approach to appliance design and construction. This discussion has touched on some potential advantages of the component approach. These apply equally to the orthodontic clinician, teacher, student, and research worker. We wish to express our thanks to Mr. Robert Garrnon, senior orthodontic technician at the Dental School at the University of North Carolina in Chapel Hill, for constructing the hybrid appliancesillustrated in this article and providing much of the inspiration and skill for the concept of hybrid appliances. Our thanks are also due to Dr. J. B. McLain, our former colleague at the University of North Carolina, for the

design of Figs. 1 and 2, A through D, and for his helpful suggestions and participation in discussionsleading to the preparation of this manuscript, and Dr. Bill Terry for the original referral of patient D.J. for an attempt at orthodontic correction before surgical intervention. We also acknowledge support from N.I.H.1N.I.D.R. Grants DE06881 and DE03610.
REFERENCES

I. Graber TM, Rakosi T, Petrovic AG: Dentofacial orthopedics with functional appliance. St. Louis, 1985, The C. V. Mosby Company. 2. Graber TM, Neumann V: Removable orthodontic appliances. Philadelphia, 1977, W. B. Saunders Co. 3. Steedle JR, Proftit WR: The pattern and control of eruptive tooth movements. AM J ORTHOD 56-66, 1985. 87: 4. Petrovic A: Control of postnatal growth of secondary cartilages of the mandible by mechanisms regulating occlusion. Cybernetic model. Trans Eur Orthod Sot SO: 69, 1974. 5. Johnston LE: A comparative analysis of Class II treatments. In Vig PS, Ribbens KA (editors): Science and clinical judgment in orthodontics, Monograph 19, Craniofacial Growth Series, Ann Arbor, 1986, Center for Human Growth and Development, University of Michigan, pp 103-148. 6. Proffit WR: Equilibrium theory revisited. Angle Orthod 48: 17% 186, 1978. 7. Crilly RG: Longitudinal overgrowth of chicken radius. J Anat 112: 11-18, 1972. 8. McLain JB, Vig PS: Transverse periosteal sectioning and femur growth in the rat. Anat Ret pp 207, 339-348, 1983. 9. Ackerman JL, Proffit WR: The characteristics of malocclusion: A modem approach to classification. AM J ORTHOD56: 443, 1969. 10. Archer SY, Vig PS: Effects of head position on intraoral pressures in Class I and Class II adults. AM J GRTHOD 311-318, 87:
1985.

11. Andresen V: The Norwegian eruption of functional gnatheorthopedics. Acta Gnathol 1: 5, 1936. 12. Ahlgren J: Early and late electromyographic response to treatment with activators. AM J ORTHOD 88-93, 1978. 74: 13. Stockli R, Teuscher UM: Combined activator-headgear orthopedics. In Graber TM, Swain BF (editors): Orthodontics: current principles and techniques. St. Louis, 1985, The C. V. Mosby Company. 14. Harvold EP: The activator in interceptive orthodontics. St. Louis, 1976, The C. V. Mosby Company. 15. Shaye R, Schwaninger B, Hoffman D: Activator construction simplified. J Clin Orthod 13: 773, 1979. 16. Luder HV: Effects of activator treatment-evidence for the occurrence of two different types of reaction. Eur J Orthod 5: 259,
1983. Reprint requests to:

Dr. Peter Vig School of Dentistry University of Michigan Ann Arbor, MI 48109-1078