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Contents
Introduction Classification Advantages Appliances In Detail. Herbst Appliance. Modification Of Herbst Appliance. Jasper Jumper . The MARS device. The Mandibular Protraction Devices. The Amoric Torsion Coils. The Scandee Tubular Jumper. The Cantilevered Bite Jumper The IST device.
The Adjustable bite corrector. The Churro Jumper . The Eureka Spring. The SAIF spring. The Universal Bite Jumper. The Ritto Spring. The Magnetic Telescopic Device. The Twin Force Bite Corrector. Alpern Class II Closers.
The Horizontal Anterior Positioning Appliance. The Mandibular Anterior Repositioning appliance. The Biopedic Appliance. The Klapper Superspring II. The FORSUS Fatigue Resistance Device. Hybrid Appliance. Conclusion
Introduction
Definition :
A functional appliance by definition is one that changes the posture of the mandible, holding it open or open and forward, stretches the soft tissues and changes the tone of the muscles, creating pressures which are transmitted to the dental and skeletal structures, moving teeth and modifying growth.
85 years . The first of which was given by Emil Herbst however these were not well accepted at that time till later when these were reintroduced by Hans Pancherz.
large in size have unstable fixation cause discomfort lack tactile sensibility exert pressure on the mucous (encouraging gingivitis), reduce space for the tongue cause difficulties in deglutition and speech affect aesthetic appearance.
added difficulties. These adverse effects make the adaptation and acceptance of these appliances more difficult.
[Ref : Attitudes to orthodontic treatment. Oliver and Knappman British Journal of Orthodontics 1985; 12:17988. Ngan P., Kess B., Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am. J. Orthod. Dent. Orthop. 1989; 96:47-53.]
"non-compliance Class II correctors" This gives a false idea about the co-operation necessary during treatment. In reality, when we compare them to removable appliances, we can clearly recognize fixed appliances as non-compliance devices. However, for treatment to be successful, good cooperation is always necessary, especially if skeletal modifications instead of dentoalveolar compensation are desired.
Advantages
Fixed functional systems have some advantages over
removable systems. 1. They are designed to be used 24 hours a day, which means that there is a continuous stimulus for mandibular growth. 2. They are smaller in size permitting better adaptation to functions such as a mastication, swallowing, speech and breathing. 3. Fixed functional appliances are usually described as noncompliance Class II devices, which are able to treat Class II malocclusions successfully, while reducing the need for patient co-operation and overall treatment time. It is possible to treat this type of malocclusion with minimal effort.
4. Short treatment time due to the above 6-8 mths. 5. Just as the name implies, what distinguishes them
from removable appliances is that it is impossible for the patient to remove them. What we have therefore, is an appliance that allows greater control by the orthodontist. 6. Leads to the development of a New Morphogenetic pattern. 7. Has other actions also such as molar distalizing effect, correction of midlines, headgear effect etc.
Disadvantages
The main disadvantage that may be encountered is
dental movement that takes place during treatment. In certain FFAs components have an increased tendency to fracture. The size of different components may have to be altered as the patient may outgrow it or the desired effect may be achieved. The above factors add to the cost.
According To Type Of Forces Produced : Appliances Producing Pushing Force Appliances Producing Pulling Force.
These appliances deliver a pushing force vector forcing the attachment points of the appliance away from one another . e.g Herbst App.
These appliances create a pulling force vector between the points of attachment. e.G The SAIF Spring.
The type of the force exercised by this is continuous and elastic in nature . These Fracture /Get fatigued easily. FFFAs are not recommended in mixed dentition, especially late mixed dentition to avoid unwanted dental movements.
Types
RFFA with Pushing Forces: 1. Herbst Appliance and its modifications. 2. Mandibular advancement repositioning splint. 3. Mandibular protraction appliance. 4. Eureka Spring. 5. Universal Bite Jumper. 6. Biopedic. 7. Mandibular anterior repositioning appliance . 8. Functional Mandibular Advancer.
FFFA with Pushing Forces 1.
2.
Jasper Jumper.
The Bite Fixer .
3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13.
14. 15.
Churro Jumper. The Amoric Torsion Coils. Adjustable Bite Corrector. Universal Bite Jumper. Klapper Super Spring II. Forsus. The Scandee Tubular Bite Jumper.
The Magnetic Telescopic Device. The Mandibular Protraction Appliance. The BioPedic Appliance The Mandibular Anterior Repositioning Appliance
The IST Appliance The Ritto Appliance
mentioned as follows and can act singularly or in combinationthese theories are common to both fixed and removable myofunctional appliances.. They are: 1. Dentalveolar changes. 2. Redirection Of Condylar growth. 3. Deflection Of Ramal Form. 4. Horizontal Expression Of Mandibular Growth.
Adaptive changes in glenoid fossa location Leading to anterior repositioning of the mandible.
6.
[Ref : The Influence Of Functional Appliance Therapy On Glenoid Fossa Remodelling. DG Woodside,a Metaxas, G Altuna AJODO 1987 ; Vol 82 : Pg 181 -198 ]
Herbst Appliance
Introduced in the 5th International Dental Congress in
Berlin in the year 1909 by Emil Herbst. Called it the Fixed Bite Jumping Device or Scharnier or Joint.
In 1934 he published 3 articles in the journal
Zahnarztliche Rundschau on his experiences with the appliance. In the same journal his work was criticised by Martin Schwarz in 2 articles.
an overload of the anchorage teeth with periodontal damage as a consequence. This claim has, however, been disproved in a recent thesis of Pietz(2000).
his time. His contributions were many 90% of what is known today. His main contribution to modern orthodontics was, however, the development of the Okklusionsscharnier or Retentionsscharnier (Herbst appliance)
Herbst Appliance
Hans Pancherz (Semin Orthod 2003;9:3-11.) has beautifully described the history development and background of this appliance with useful clinical information and a background on Dr. Emil Herbst.
Bionator, And Frankel 1. It is Fixed to the teeth. 2. Patient compliance not at all required for correct functioning. 3. Works 24 hrs a day. 4. Treatment time is shortened.
the treatment of skeletal Class II malocclusions. It can be compared with an artificial joint working between the maxilla and mandible. A bilateral telescope mechanism keeps the mandible in an anterior-forced position during all mandibular functions such as speech, chewing, biting, and swallowing.
attached to orthodontic bands, crowns, or splints. The tube is positioned in the maxillary first molar region and the plunger in the mandibular first premolar region. The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible.
Originally the telescopes were curved . Made Of German Silver / Gold. Gold if worn more
than 6 months Bands or Crowns /Caps were used on Abutment teeth. Originally placed upside down with plunger on maxillary molar. No opening at the back.
The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible.
mucosa.
If plunger disengages from the tube on mouth
opening, it may get stuck in the tube opening on subsequent mouth closure and damage the appliance.
Several anchorage systems have been developed to control unwanted tooth movements
first molars and mandibular first premolars (sometimes canines). The crowns/caps were joined by wires that run along the palatal surfaces of the upper teeth and the lingual surfaces of the lower teeth.
If second permanent molars have not erupted then Herbst advised to anchor the appliance more firmly by placing bands on the canines, which were soldered to the palatal arch wire as were the upper molars.
Alternative to bands on the upper canines, a thin gold wire was placed on the labial surfaces of the
appliance in the early mixed dentition, Herbst had the following solution:
In the maxilla, the
permanent central incisors were used for anchorage instead of the cuspids.
In the mandible, crowns
were placed on the first permanent molars and bands on the 4 permanent incisors.
anchorage teeth instead of incisors. Buccal mucosa at the corner of the mouth is prone to ulceration when mandibular canine is used as an abutment tooth for the plunger.
Herbst and others realized the necessity of incorporating as many teeth as possible for anchorage to avoid unwanted side effects. Schwarz( 1934): Most teeth in the maxilla and mandible were interconnected by labial as well as lingual arch wires this was called Block anchorage.
1979 Onwards
Pancherz originally used a banded type of Herbst
appliance.Individually made stainless steel bands of a thick material (0.15- 0.18mm) were used.
1. 2. 3. 4.
Simple anchorage system Increased anchorage system Total anchorage system Cantilever Herbst
on 1st permanent molars and first premolars. Joined on each side by sectional arch wires.
Mandible- Premolars are
Disadvantages:
Space opening distal to maxillary canines Excessive intrusion of 1st permanent molars.
more teeth.
permanent molars.
Since 1995, cast chrome-cobalt splints are used routinely.
In the early 1980s, Howe and McNamara developed the acrylic splint Herbst appliance which is used both.as a fixed (bonded to the teeth) and removable appliance. recommended.
indicated in the early mixed dentition before the eruption of the mandibular permanent canines and first premolars.
The lower part has heavy metal extension arms that are
terminates in the premolar region in which the telescoping axles are soldered. Have occlusal rests incorporated.
appliance), the vertical force vector of the telescopes acting as lever arms will result in uncontrolled mesial tipping and extrusion (extraction) of the molar teeth.
But the anchorage control of the mandibular molars with
the cantilevers (even when using occlusal rests on the deciduous molars) is questionable.
treatment could prevent anterior movement of the mandibular incisors and molars. ( Pancherz and Hansen1988) Lower anchorage is a problem difficult to master in Herbst treatment. Some factors associated with anchor loss can be :
Severity of A-P interarch discrepancy Amount of bite jumping at the start of treatment.
Treatment Effects
Sagittal Skeletal Dental
Vertical Skeletal Dental
Sagittal Changes
1.Restrains maxillary growth and decrease of SNA angle.
2. Increases mandibular length
(Pancherz 1979, 1981, 1982). This finding is in agreement with several bite jumping experiments in growing monkeys (Stockli and Willert 1971, McNamara 1972, 1973, 1975) and rats (Petrovic and Stutzman 1969).
1) Condylar remodeling. (2)Glenoid fossa remodeling; (3) Condylar position changes within the fossa.
Animal Studies
Peterson and McNamara (semin orthodontics
2003) :
Evaluated histologically the TMJ, glenoid fossa, and
the posterior border of the mandible in juvenile Rhesus monkeys whose mandibles had been positioned forward with a Herbst appliance
Condyle remodelling :
Especially in the Posterosuperior region of the condyle. Glenoid Fossa Remodelling : Significant deposition of new bone on the anterior surface of the postglenoid spine occurred, indicating an anterior repositioning of the glenoid fossa. Similar to (Breitner 1930,33).
Significant bone resorption on the posterior surface of
Significant bony apposition on the posterior border of the mandibular ramus was evident during early experimental periods. No gross or microscopic pathological changes were noted in TMJ of the juvenile Rhesus monkey.
Clinical Studies
Have provided radiographic evidence of TMJ growth
Paulsen et al (1995) :
Analysed TMJ changes in a single case of Herbst treatment in
late puberty using CT scanning and OPG. Three months after insertion of the appliance CT-scanning and OPGs of the TMJ revealed new bone formation as a double contour in the articular fossa and on the posterior part of the condylar process as a result of adaptive bone remodeling.
Analysed three possible adaptive TMJ growth processes contributing to increase in mandibular prognathism accomplished by Herbst treatment : Condylar remodeling Glenoid fossa remodeling Condyle fossa relationship changes. Aidar, Abrahao ,Yamashita , Dominguez (AJO 2006) assesed the TMJ disc position with MRI after 12 month period of herbst appliance therapy in 20 ClassII div1 patients. They found mild changes in position of the disc with slight tendency towards retrusion due to mandibular advancement which returned to normal after appliance removal. These changes were in the normal phsiological limits as evaluated in short term.
Dental Changes
Basically a result of anchorage loss in the two dental arches.
Mandibular teeth are moved anteriorly. Proclination of lower anteriors. Mandibular incisors proclined on an average of 6.6 during 6 months (Pancherz, 1985). In 24 class II subjects treated with the Herbst appliance (Hansen et al, 1997), the proclination during treatment was 11. 2. Lower Incisor Proclination and recession.
1.
Large amount of lower incisor proclination during Herbst treatment could be thought to cause break down of the labial gingival attachment & create gingival recessions
The effect of the Herbst appliance on maxillary molar teeth is essentially comparable with that of a high pull headgear (Pancherz, AnechusPancherz, 1993). The teeth are both distalized and intruded. Normally, the dental changes occurring during Herbst appliance treatment would not be desirable. Distal tooth movements in maxillary buccal segments could however, be desirable in cases with anterior crowding
relation in most of the cases. However treatment is more effective in the molar than in the canine region
Arch Perimeter
Because of the distalizing forces of the telescope mechanism of the Herbst appliance on the upper 1st molars and the anteriorly directed forces on the lower front teeth, the maxillary and mandibular arch perimeters increase during treatment. (Hansen et al, 1995) Arch perimeter changes are, however, of a
temporary nature because settling of the teeth during the immediate post treatment period.
Arch Width
Hansen et al (1995) : During treatment the maxillary and mandibular dental arches expand laterally in both canine and molar areas. The expansion is more marked in the maxilla than in the mandible.
Vertical Changes
Dental
Skeletal Increase in lower anterior facial height (LAFH) due to over eruption of lower posterior teeth.
Increase in gonial angle this may be due to a more sagittaly directed growth of the condyle or it may result from resorptive bone changes in the gonion region, probably as a consequence of an altered muscle function during bite jumping
(Pancherz & Littman, 1989)
Stimulation of mandibular growth. Inhibition of maxillary growth (a less important change) Distal movement of upper dentition Mesial movement of lower dentition (proclination of the incisors
because. Skeletal alterations will be minimal. More of dentoalveolar changes. Increase risk of developing dual bite.
Postadolescent patients:
Who have passed the maximum pubertal growth spurt and
have still some growth potential left, treatment with the Herbst appliance is indicated as it can be finished within 6 to 8 months.
the proper use of removable appliances difficult or impossible but doesnt interfere with herbst. without any assistance from the patient.
Uncooperative patients: It is fixed to the teeth Patients who do not respond to removable appliances.
Treatment Timing
Most favorable time to treat the patients with the Herbst appliance is at the peak of pubertal growth spurt Pancherz, Hagg, 1985.
Pancherz & Hagg (1988): Indicated that the patients
treated at the initial closure of the middle phalanx of the third finger (MP3-FG) had the greatest amount of condylar growth. Because mandibular growth stimulation using the herbst appliance is also possible in post adolescent young adult subjects, a new concept of Class II therapy is proposed in which the Herbst appliance is used as an alternative to orthognathic surgery in Class II subjects.
Perfect end result cannot be obtained exclusively with Herbst. Class II cases cannot be treated to a perfect end result with the Herbst appliance exclusively. Many cases will require a subsequent dental-alignment treatment phase with a multibracket appliance.
Thus, treatment of a Class II, Division 1 malocclusion will usually occur in two steps STEP 1. ORTHOPEDIC PHASE. The sagittal jaw base relationship is normalized and the Class II malocclusion is transferred to a Class I malocclusion by means of the Herbst appliance.
STEP 2. ORTHODONTIC PHASE. Tooth
irregularities and arch discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).
treatment approach
anterior maxillary teeth by means of a multibracket orthodontic appliance. jaw base relationships and transformation of the Class II malocclusion into a Class I malocclusion by means of the Herbst appliance.
arch-discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth).
growth direction of the mandible. (A favorable growth pattern both facilitates treatment and counteracts post treatment relapse.) Normal or reduced lower facial height.
l
Dental morphology:
Class II dental arch relationship with increased overjet
and normal or increased overbite (open bite cases not suitable for Herbst appliance). Maxillary and mandibular teeth well aligned and the two dental arches fitting each other in normal sagittal position
Maturation:
Treatment during pubertal growth spurt.
Type I
Type I is characterized by a fixing system to the crowns
or bands through the use of screws. This is the most common form. It is necessary to weld the axles to the bands or crowns and then fix the tubes and plungers with the screws
Type II
Type II has a fixing system that fits directly onto the
archwires through the use of screws. This method of application has the disadvantage of causing constant fractures in the archwires. The lack of flexibility together with the difficulty in lateral movements and the stress placed on the archwires through activation causes fractures, especially in the lower arch
Type IV
Type IV has a fixation system with a ball attachment, which allows greater flexibility and freedom of mandibular movement.
A disadvantage in relation to other similar appliances is the fact that it needs brakes to stabilize the joint. These brakes are small and
Class II malocclusions
who have narrow maxillary arches, Herbst appliance with 1. A quad helix lingual arch wire or 2. Rapid palatal expansion device to the upper premolar and molar bands or to the splint.
Appliance Developed By Pancherz. The bands are replaced by splints, cast from cobaltchromium alloy and cemented to the teeth with GIC. The upper and lower front teeth are incorporated into the anchorage through the addition of sectional arch wires. The cast splint appliance ensures a precise fit on the teeth is strong and hygienic saves chair time Causes very few clinical problems
Modifications
the substitution of stainless steel crowns for bands. the elimination of the stabilizing bar.
The Bonded H
the acrylic splint Herbst appliance (McNamara, 1988; McNamara and Howe 1988).
The acrylic splint Herbst appliance is composed of a wire framework over which has been adapted, 2.5-3.0 mm thick splint Bioacryl, using a thermal pressure machine
for the stainless steel bands of the earlier appliance, the Herbst mechanism can be attached to both maxillary and mandibular arches using bonding procedures
available maxillary teeth with exception of the central and lateral incisors
The occlusal thickness of the
maxillary splint is kept to a minimum, so that the cusps of the posterior teeth perforate the splint
These perforated
openings permit the placement of the nylon tip of a posterior bandremoving plier against the cusps.
II)
III)
IV)
Repeated breakage and loosening of the appliance occurs, especially in the lower bicuspid band area. Rapid intrusion of the mandibular first bicuspids which though temporary, partially deactivates the appliance. As the bicuspids are depressed, the lingual arch is also depressed, resulting in impingement on the lingual gingiva. Possibility of incisal tooth fracture.
period of interceptive orthopedic treatment in the very early mixed dentition may be indicated to correct skeletal deviation and establish a normal relationship between maxilla and mandible.
This design is
particularly useful when mandibular bicuspids are absent or the primary molars cannot withstand functional forces.
optimal treatment timing, but the patients bicuspids are not erupted enough to receive either bands or crown.
crowns are fitted on the upper first permanent molars and bands on the lower first molars and incisors.
with much mandibular advancement, have the patient retrude the mandible until the discomfort disappears. The telescopic part of the appliance can be advanced again in six to eight weeks using washers or metal sleeves.
and hygienic. The Herbst mechanism is attached to stainless steel crowns on the maxillary first permanent molars and to the lower arch through a removable acrylic splint. Double buccal tubes on the stainless steel crowns can hold utility, sectional, or continuous archwires
Advantages of the EMBDEN Herbst It requires minimal cooperation. It promotes patient acceptance because it is not visible and it produces an immediate improvement in the profile. It allows more cases to be treated without extractions. It is easy to construct, fit, adjust, and clean. Materials are inexpensive, and breakage is minimal after a modest amount of laboratory experience is gained. The lower splint increases anchorage, thus providing more of a skeletal correction, and restricts forward movement of the lower incisors
malocclusions rapidly and without the need for patient cooperation. It allows orthodontic tooth movements during orthopedic correction and a smooth transition from Herbst treatment into the edgewise finishing appliance. The new appliance is more clinically efficient than previous models and is easily incorporated into an edgewise practice.
In the upper arch of the edgewise-Herbst MALU appliance, only the first molars are banded, with .051" headgear tubes. A palatal arch can be used in cases of overexpansion.
In the lower arch, the first molars are banded, and the anterior segment is bonded from cuspid to cuspid with .022" brackets. The bicuspids may be left unbracketed to help in settling the occlusion and locking in the mandible. The mandible can be progressively advanced using 1-5mm spacers.
Advantages:
1. Its cost is considerably lower because it requires no laboratory construction. 2. Its simplicity makes it useful even for nongrowing patients in whom only dental movement and mandibular repositioning are
required.
3. It can also be used in growing patients who have not cooperated with removable appliances
or headgear.
Lock Herbst appliance, reduces the number of moving parts that can lead to breakage or failure. It is easy to use and more comfortable for the patient than the conventional cantilevertype Herbst. Instead of a screw attachment, it has a ball-joint connector, and it needs no retaining springs.
The first generation was made from a dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint attachment
to be more efficient than the previous models, both in terms of application as well as its resistance to fracture
greater freedom of mandibular movement than is possible with the original bite jumping mechanism of Herbst. Dr. James Jasper in 1987
Force Module : The force module, analogous to the tube and plunger of the Herbst bite
jumping mechanism and is flexible. The force module is constructed of stainless steel coil of spring attached at both ends to stainless steel end caps in which holes have been drilled in the flanges to accommodate the anchoring unit. This module is surrounded by an opaque poly urethane covering for hygiene and comfort.
Principle of action :
When the force module is straight, it remains passive. As the teeth come into
occlusion the spring of the force module is curved axially producing a range of forces from 1 to 16 ounces.
advancement, the spring mechanism is curved or activated 4 mm relative to its resting length, thus storing about 8 ounces (250g) of potential for force delivery.
If less force is desired (eg force levels that produce
yield more force from the module but only builds excessive internal stress.
Anchor units :
A number of methods are available to anchor the force modules to either the permanent or mixed dentitions.
is used to correct a class II malocclusion, the force module is attached Posteriorly to the maxillary arch by a ball pin placed through the distal attachment of the force module.
canines and a small Lexan ball is slipped over the archwire to provide an anterior stop. The mandibular archwire is threaded through the hole in the anterior end cap and then ligated in place. The first and second bicuspid brackets are removed to allow the patient greater freedom of movement.
erupt above the occlusal plane as the anterior teeth are intruded.
When only the lower 1st
bicuspid bracket used to be removed as originally suggested by Dr. Jasper, Jaw opening used to be limited as the lower portion of the jumper tends to bind at the 2nd bicuspid.
distal tieback, all the force is transferred to the anterior teeth, which tends to tip them forward depress them and open space.
Removing the Jumper for an occlusal check
is time consuming.
In an extraction case, it is difficult to close
spaces because the jumper must be attached to the arch before closing loops.
attachment out of an 0.017 x 0.025 stainless steel wire, soldered to a rocky mountain lock, then bent so as to pass distal to the lower first molar. The lock is attached between the bicuspid and cuspid
An alternative is to place the lock distal to the molar bracket with the wire bent
distal to the cuspid. The approach uses a free sliding quick connect (figure). The wire runs parallel to the main archwire, allowing the jumper to clear the bicuspid brackets.
Advantages The attachment can be made in the office laboratory, and placement can be delegated to an assistant. The jaws can open fully. Force is directed distal to the molar; if the archwire breaks there is no effect on the anterior teeth. The jumper does not interfere with space closure or leveling procedures. A broken jumper is easy to replace. No auxiliary tubes are needed on the mandibular molars.
Disadvantages : Laboratory time is required to solder and bend the attachment. The rocky mountain lock assembly is an additional expense.
rigges which are 0.016 x 0.022 (0.018 slot) or 0.018 x 0.025 (0.022 slot) auxiliary sectional wires.
The sectional arch is looped
over the main archwires anteriorly between the first premolar and canine.
Posteriorly into the lower first
molar band.
adequate clearance from the alveolus and gingiva to avoid tissue impingement.
Advantages : Has all of the previous said advantages plus The clinician may leave the premolar bands in
The maxillary attachment is as the original attachment. The mandibular attachment includes an archwire that extends from the brackets on the lower incisors, posteriorly to the first permanent molars, by passing the region of the deciduous canines and molars.
In a mixed dentition patient the use of a transpalatal arch and fixed lower lingual arch is mandatory to control potential unfavorable side effects.
Jasper
Leveling and anchorage preparation Period of jasper jumper use (6-9 months) Period of finishing (12 months)
modules.
The archwires should be tied or cinched back posteriorly to increase anchorage, including
In addition, the clinician can place posterior tip-back bends in the mandibular archwire to enhance anchorage.
in the arch wire. Alternatively lower incisor brackets with 5 degrees of lingual crown torque incorporated into the slot also can be used to prepare anchorage.
passive, the mandibular arch wire is disengaged and the brackets on the 1st and 2nd premolars are removed bilaterally.
placed in the archwire distal to the lower canine bracket, and 3 mm Lexan beads are slipped over the ends of the arch wire and moved forward to rest against the bayonet bends bilaterally.
between mesial aspect of facebow tube and distal aspect of Lexan ball. In this example, distance from ball to face-bow tube is 20 mm. Thus 32 mm module should be selected.
The lower arch wire in threaded through the hole in the anterior end cap of the force module, ligated in place and the ends of arch wire are cinched or tied back firmly. Then the ball pin is inserted through the face bow tube on the maxillary first molar band from distal to mesial and cinched forward. In-patients with high mandibular plane angle the pin is cinched to achieve approximately 2mm of module deflection (150g / side). In patients with low or normal mandibular plane angle, the ball pin is cinched forward to achieve 4 mm of module deflection (300g force/ side).
closing movements slowly at first and told to avoid excessive wide opening during eating and yawning.
If molar distalization is desired. The jumper is placed so that only 2-4 ounces of force is produced by the module. In growing patients in whom orthopedic repositioning of the mandible is desired, higher forces (6 - 8 ounces) are used continuously.
Ball pin protrudes 2-3mm distally, allowing free movement. B. Ball pin too close to molar tube, which can cause breakage of ball pin or Jumper. C. Correct placement. Anterior force is delivered distal to lower molar bracket, while depressing force is delivered to archwire between cuspid and bicuspid.
Types of forces
produced :
Bilateral directions of
force generated by the modules include sagittal, intrusive and expansion forces.
dentition.
along the buccal surfaces of the maxillary teeth produces maxillary arch expansion. Modules curving outwards Vestibular shielding effect
Expansion forces can be minimized or
eliminated through the use of a transpalatal arch or a heavy arch wire that has been narrowed and to which buccal root torque has been applied.
Treatment effects :
Maxillary adaptations : i) Headgear effect :
One treatment effect produced most easily is
distalization of the upper posterior segment or the headgear effect. For this the maxillary arch wire must not be cinched or tied back, but remain straight and extend past the buccal tubes. Involves light forces (2-4 ounces) Minimal changes in the mandibular dentition. This effect can be produced in actively growing as well as adult patients.
six anterior teeth can be retracted in both extraction and non-extraction patients with a NiTi coil or an intramaxillary elastic, with the posterior maxillary dentition supported by the force module.
Cuspid retraction mechanics: As Jumper pushes ball pin distally, molar anchorage is maintained and cuspid is retracted along archwire.
Dental Asymmetries
The force module system also can be
used in-patients who have sagittal dental asymmetries. In a patient with a class II subdivision type of malocclusion the maxillary archwire orthopedic effects may also be achieved. Asymmetric orthopedic effects may also be achieved
Mandibular Adaptations :
In producing mandibular advancement
Jaspers theory of twos suggests that class II correction with Jasper jumper therapy can be equally proportioned between 5 components.
1. 20% due to maxillary basal restraint 2. 20% due to backward maxillary dent alveolar movement 3. 20% due to forward mandibular dentoalveolar movement 4. 20% due to condylar growth stimulation 5. 20% due to downward / forward glenoid fossa remodeling
Orthod 2005 studied 15 subjects (class II) treated with jasper jumper and compared them with15 untreated(class II) subjects. They were late adolescent patients.
Results: Class II discrepancies were mainly corrected by dentoalveolar changes and this could be an alternative method to orthognathic surgery in borderline class II cases.
MARS Appliance
(Mandibular advancing repositioning splint).
The teeth in the respective arches should be aligned, with correct axial inclinations, prior to attachment of the appliance. The MARS appliance should be attached only to the heaviest rectangular arch wires that can be accommodated by the brackets and tubes. The heavy arch wire prevents breakage at the point of attachment as well as excessive intrusion in the region of the mandibular canines. The mandibular arch wires should be securely tied back to the terminal molar before attachment of the MARS appliance.
Failure to do this will usually result in flaring of the lower incisors, even with the heavy rectangular arch wire, since the untied arch wire will slide forward through the tubes and brackets of the posterior teeth. Previously closed mandibular extraction spaces are likely to reopen if this precaution is not taken.
I position, the right and left strut lengths are measured. Tube attached most mesially on the last molar incorporated and most distally to mandibular canines.
middle of the interbracket space distal to the lower canine to the middle of the interbracket space mesial to the maxillary terminal molar.
by subtracting a calculated and standardized measurement of 7.4mm from the strut length.
cut so that 2mm extends out of the back of the upper member
is the PIED (Protrusive incisial edge distance) PIED is the horizontal distance measured at the midline between the maxillary and mandibular incisial edges with the mandible in its maximum strained protruded position.
The MARS appliance should be locked into position with the mandible 2 to 3 mm posterior to the maximum PIED measurement. In the event a patient encounters muscular discomfort as a result of protruding the mandible too far forwards the appliance is adjusted and locked in a less protrusive position. At subsequent appointment the PIED should be measured and recorded. The authors have observed that the PIED will increase from 0.5 to 2 mm between 3 to 4 week appointment intervals. When the PIED ceases to increase between appointments, the MARS appliance is then adjusted so that a super class I occlusal relationship is obtained.
1) Replacement of the struts with longer upper members of cylinders. 2)Placement of spacers 2 to 3 mm in length on the lower members or pistons.
Unlike the Herbst appliance, the MARS appliance : Requires neither soldering nor extensive lab procedures. Has minimal incidence of breakage Does not depress the canines, open spaces in the premolar area or flare mandibular incisors (provided the mandibular rectangular archwire is tied back to the terminal molars) Is easily removed.
mm
Need to customize the appliance for each patient.
This appliance was developed by Carlos Martin Coelho Filho (JCO 1995). His inability to purchase some of the newer class II corrective appliances in northern Brazil led him to develop these group of appliance that reposition the mandible forward.
with exaggerated overjets and Class II subdivision patients where only one side needs correction. Their advantages include ease of fabrication, low cost, infrequent breakage, patient comfort, and rapid installation.
But they are not claimed to be superior but are only
by bending a small loop at a right angle to the end of an .032" stainless steel wire. The length of the appliance is then determined by protruding the mandible into a position with proper overjet, overbite, and midline correction and measuring the distance from the mesial of the maxillary tube to the stop on the mandibular archwire.
Another small right-angle circle is then bent in an opposite direction into the other end of the .032" stainless steel wire. The angulation of these circle bends can vary to allow free sliding along the mandibular archwire. One appliance circle is placed over the maxillary archwire against the molar tube, and the other circle against the mandibular archwire stop. Both circles are then closed completely with a plier.
MPA No. 2
MPA No. 2 is made with right-
angle circles in two pieces of .032" stainless steel wire. Coil of .024" stainless steel wire is slipped over one wire. Travel of each wire is limited by wire coil.
Maxillary archwire has occlusally directed circles against molar tubes; mandibular archwire has occlusal circles 2-3mm distal to each cuspid.
Advantages :
Easily fabricated at chair side, with
comfortable.
MPA-3
CARLOS M. COELHO FILHO,(JCO
2001)
first two MPA designs have been overcome with the development of the MPA No. 3.
This version eliminates much of
the archwire stress and permits a greater range of jaw motion while keeping the mandible in a protruded position.
Appliance construction
The parts needed for the
construction of the MPA No. 3 are: internal diameter each about 27 mm long. stainless steel wire, each about 13 mm, long, with a loop bent into one end at an angle of about 130 to the horizontal. stainless steel each about 27 mm long.
MPA No. 3 reversed for Class III treatment, with open-coil spring between appliance tube and rod loop.
MPA IV
The latest version, the
MPA IV,** is much easier to construct and install, and much more comfortable for the patient. The MPA IV is made up of the following parts:
Piece of .040" stainless steel wire is inserted into longer tube to prevent deformation while bending molar locking pin with finger pressure.
Molar locking tube is then cut and annealed to make it easy to bend during installation.
This fourth version seems to be as efficient as its antecedents, but is much more practical to construct, easy to manipulate, and comfortable for the patient.
0.01 8 stainless steel, and will stretch to about 25% beyond its original length without permanent deformation.
The ABC can be used on either side of the mouth with a simple 180 rotation of the lower end cap to change it orientation.
Functions similar to the Herbst and Jasper Jumper but also incorporates several useful features like a) Universal right and left b) Adjustable length and force
forward into an improved profile with ideal overbite / overjet the point of the gauge is placed into the mesial opening of the headgear tube. The size is then read at point about 3mm below the contact between lower cuspid and first premolar using the correct appliance size ensuring optimum force delivery.
the coil spring or nickel titanium wire is replace with a new one from the kit.
maximum anchorage at the upper molars while bringing the lower posterior teeth forward form the pull at the jig attachment.
spring is an open wound coil spring encased in plunger assembly The ram is made from a special work hardened stainless steel that has been precision machined with 3 different radii. At the attachment end the ram has either a closed or an open ring clamp that attaches directly to the archwire.
The essential aspects include spring module A, molar attachment tube B, push rod C, free distance D, molar attachment wire E, free distance F.
A triple telescoping action permits the mouth to open as wide as 60 mm before the plunger becomes disengaged.
The cylinder assembly is connected to a molar tube with a an 0.032 wire that has been annealed at the anterior end. An 0.036 solid ball at the posterior end acts as
The Eureka spring comes in only 2 sizes one for extraction and one for non-extraction cases and left and the right sides are interchangeable.
Advantages
It has esthetic acceptability because of its small size and
at the points of attachment as compared to 220-280g of Jasper Jumper. Ability to produce rapid movement : this is in spite of its low force levels because the Eureka spring continues to work even when the mouth is opened as much as 20 mm as when sleeping or when the mandible is thrust forward as far as 10 mm, in an attempt to minimize the force.
Ease of installation
Low cost : similar in cost to the jasper jumper but less expensive than the fixed Herbst appliance.
It also has a vertical intrusive component at the maxillary molars and mandibular although this is minimal due to direct archwire attachment, rather than via auxiliary wire.
Construction :
The Churro Jumper requires a
series of 15-20 symmetrical and closely placed circles, formed in a wire size of .028" to .032".
Since the Churro Jumper
requires reciprocal anchorage, Generally, the largest possible edgewise archwire is the best to use. This will usually be an .018" X .025" archwire, or .0175"X .025". Any wire smaller than these invites breakage.
the mandibular archwire, at least the first premolar brackets should be omitted. It is usually advantageous to place a buccal offset in the wire just distal to the canine bracket so that the jumper also has buccal clearance, which permits unrestricted sliding along the wire
The length of the jumper is determined by the distance from the distal of the mandibular canine bracket to the mesial of the headgear tube on the maxillary molar band, plus 1012mm. This measurement is transferred to the Churro Jumper, with the coil closer to the canine bracket than to the headgear tube.
Mode of action :
In its passive form, the churro is not flexed However when the pin is pulled forward enough to cause the jumper to bow outward the cheek, the appliance begins to exert a distal and intrusive force against the maxillary molar and a forward and intrusive force against the
The bilateral class II churro jumper is most suitable for patients who need mandibular incisors advancement. Not a very good choice for class II bimaxillary proclination cases.
By reversing the attachments, the churro jumper can also be used to treat class III malocclusions.
Advantages :
Provides a constant, indefatigable force. Can be used either unilaterally or bilaterally. Can be used in class II or class III cases. Helps maintain anchorage. Very inexpensive. Can be constructed from commonly available materials universal in size. When broken, it is easily replaced. Staff members can quickly learn how to replace an appliance.
Disadvantages :
Restricts the mouth opening to 30-40 mm Archwire breakage is seen if larger wires not used. Patients with a low tolerance for discomfort will often break the appliance. Patients who incessantly move their mouths while
chewing, talking and nervous tics will fare poorly. Its maximum effectiveness depends on a permanent dentition to retain its effect. It must be manufactured in the office.
can be used in all phases of treatment, in the mixed or permanent dentition and with removable or fixed appliances.
This jumper also uses a
In the mandibular arch, the sliding rod ends in a 90 hook that is fixed to the archwire.
The UBJ tubes are welded to the maxillary molar bands or crowns. . The UBJs are adjusted while mandibular movements are checked. Depending on the case, the brackets can be bonded during the
same visit or a few weeks later. The advantage of this configuration is the possibility of immediate orthopedic action without waiting for dental alignment.
link the maxillary molar areas and the mandibular first premolar areas. They are attached to 1.2mm ball clasps, which are constructed on the working cast and then incorporated into the thermoformed splints.
splint from the middle rear area of the palate to the lingual surface of the mandibular incisor.
The UBJ is attached to two transverse axles, which allow opening and lateral
movements.
prevents the tip of the tongue from contacting the lower lip. appliance, given a little time to adjust. Cheek impingement is eliminated and it is the authors experience that the tongue is not irritated with this design.
Adjustments :
Reactivation are made every 6 to 8 weeks by crimping 2 to 4 mm splint bushings on to the rods. Midline or asymmetrical problems can easily be treated by adjusting one side or other of the appliance.
Advantages
It is simple, sturdy, and inexpensive. Inventory requirements are minimal--the UBJ can be used on either side of the mouth, and there is only one size, since it is cut to the desired length for each case.
It can be used at any stage of treatment --in the early mixed dentition to obtain an immediate mandibular advancement before any dental alignment, or in the permanent dentition for fixed functional treatment.
It can be used in Class II or Class III cases. Its low profile results in considerably less buccal irritation than with similar appliances. Patient comfort and acceptance are excellent. It can easily be attached to removable splints for maximum anchorage. It produces good results without the need for patient cooperation
First interarch force system developed by Armstrong In the later 1960s and early 1970s he introduced the Pace Spring, later termed multicoil spring and finally called Saif spring.
These were first marketed by North West orthodontics, later by Unitek, and currently by Pacific coast manufacturing.
They consist of two springs one inside the other with soldered loops on each end.
to secure the springs to deliver either class II or class III force. outside diameter of 3 mm, and deliver 200 to 400 gms of force.
Breakage is a constant problem. Bit bulky, not very hygienic and there is some limitation
to mandibular opening
Fixation accessories
out by placing a steel ball pin from the distal into the .045 headgear tube on the upper molar band, through the appliance eyelet and then bending it back on the mesial end.
The appliance is fixed onto a prepared lower arch and is activated by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance.
plungers with a semi-circular section and with NdFeB magnets placed in such a manner that a repelling force is exerted.
MALU system.
linking a magnetic field to the functional appliance. Its main disadvantages are its thickness, the laboratory work necessary to prepare it and the covering of the magnets.
in form and constitution because it has two internal coil springs. It consists of two joint telescopic systems. At the superior level it is fixed with a ball pin that is fitted into the buccal tube of a molar band. The placement in the lower arch is slightly different; it involves a fitting-in system that is later fixed with a screw to the inferior arch. Normally it is placed distal to the lower cuspid.
Drawbacks:
The major drawback of this appliance is the
difficulty to control the force. May create discomfort and impingement problems. Is recommended only for permanent dentition.
Class II correction and as a substitute for elastics. It consists of a small telescopic appliance with an interior coil spring and two hooks for fixing It functions in the same way as elastics and, similarly, is fixed to the lower molar and to the upper cuspid. It is available in three different sizes. Its telescopic action enables a comfortable opening of the mouth.
bilateral piston and plunger telescopic mechanism to reposition the mandible anteriorly and is directly attached to archwires of a multibanded fixed appliance.
to the archwires distal to the lower cuspid brackets and mesial to the tubes on the terminal upper molars.
intraorally with the patients mandible advanced 3-4 mm. The entire procedure can be completed at chair side in 30 minutes. The mandible can be advanced in small increments of 2-4 mm at 4 week intervals until the incisors are in an edge to edge relationship. Midline corrections are made by advancing the appliance more on one side. A correction of 3-4 mm can be achieved within 6 months, an overjet of 7 to 8 mm may require 12-14 months.
anterior contact while allowing for posterior eruption. Unfortunately, the lack of posterior support has been shown to have a loading effect on the TMJ.
Dr. William B. Farrar recognized
the need for posterior support and modified the original Sved appliance to incorporate two posterior acrylic pads along with an anterior ramp.
Components of HAP appliance: A. Anterior reverse ramp. B. Sagittal screws. C. Expansion arms. D. Coffin spring. E. Locking mechanism.
Locking mechanism
Coffin spring
provides upper and lower posterior occlusal support. A posterior pad can be added to the HAP, but adjustments become more difficult and the possibility of breakage increases. The vertical dimension can be increased if necessary. The bite-opening effect allows for passive or active eruption of the posterior occlusion to help level the curve of Spee.
Disadvantages
Temporary stainless steel crowns needed on all first molars.
Some increase in anterior facial height results from the placement of these crows.
Fabrication only available at one commercial
laboratory. The posterior and buccal location of the guide planes may cause loosening of the stainless steel crowns or breakage of the mandibular protruding horizontal bar.
resembles the Mandibular anterior repositioning appliance, but differs in its mode of action and intraoral activation. It relies on the principle of inclined planes that are placed in the buccal corridor spaces that will not hinder swallowing or articulation. The protrusion guide pins are fitted to the upper portion of the apliance at a 60 degree angle to horizontal, ensuring active, forward mandibular guidance during even partial jaw closure.
is done simply by moving the guide pins to a more forward threaded support sleeve. This gradual activation allows patients particularly adults to adjust to the appliance.
Kinzinger, Diederich JCO 2005
reports the use of FMA in a 16 year old male with Class II div2 and for just 3 months the patient was able to protrude the mandible significantly forward from the therapeutic position.
The Biopedic
Designed and introduced by Jay
Collins in 1997 (GAC International) soldered to maxillary and mandibular molar crowns.
edgewise tube and a large 0.070 inch molar tube. Large rods pass through these tubes. mesial of the molar tube and is fixed at the distal by a screw clamp. By moving the rod mesially the appliance is activated.
This short maxillary rod is inserted screw at the mesial of the maxillary first molar.
The two rods are connected by a rigid shaft and have pivotal region at their ends.
Although, it appears that there would be limitation of mandibular opening, it is not so. The design works more in harmony with the arc of mandibular opening.
Advantages
Can be used concurrently with banded treatment.
Esthetic benefit
Capability of adjusting the amount of protrusive activation. Disadvantages Potential for more breakage and loose crowns Greater cost. Need for crowns on molars
1997, for correction of class II malocclusions. On first glance, it resembles a Jasper Jumper with a substitution of a cable for the coil spring. In 1998 the cable was wrapped with a coil and the Klapper superspring II was the result. Only two sizes are required (left and right sides are not interchangeable) and breakage is less frequent. However it differs significantly from the Jasper Jumper at the molar attachment.
The SUPERspring II is a flexible spring element that attaches between the maxillary molar and the mandibular canine. It is designed to rest in the vestibule, making it impervious to occlusal damage and allowing for good hygiene. Only minor adjustments are needed for patient comfort, without any impingement on soft tissues.
Disadvantages
Requirement of a special molar tube Lack of adaptability to correct class III conditions Limitation to maximal opening Potential injury to the patient if breakage occurs and the rigid molar attachment forces the broken portion into the soft tissues.
push rod inserts into the telescopic cylinder and a hook on the mesial end is crimped directly to the archwire near the canine or premolar brackets.
stop that compresses the spring when the patients mouth closes. The spring is then transferred to the maxillary molars using the mandibular arch as the anchorage unit. eyelet of the telescoping spring and is threaded through the molar headgear tube from distal to mesial and cinhed,leaving 2mm slack.
over the mandibular arch wire and crimped shut.
Advantages: It does not require time-consuming and expensive lab work or the use of stainless steel
crowns. It produces consistent treatment results in a predictable amount of time, without depending on patient cooperation. It can deliver an orthopedic effect to both jaws or more of a dentoalveolar effect. It can be activated more on one side than on the other, so it excels at correcting midline deviations.
William Wogt JCO June 2006 reports a case where a 12 year old male with class II division 1 and moderate overjet of 7mm was corrected with the Fatigue resistant device in 6months after which it was used as an anchorage unit for the retraction of the maxillary anterior segment.
Conclusion :
Fixed functional appliances form an useful
addition to the clinicians orthodontic armamentarium. But many of these appliances need further studies to substantiate the claims made by their respective originators. With this in mind, clinicians must take great care in selecting the right patient and also pay attention to every detail in the manipulation, to attain successful results with these appliances.
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