Article Type : Research Article
Authors : Katpale S, Shenava S, Mudaliar P, Mathew R, Singh S and Gaonkar P
Keywords : Class II malocclusion; Rigid appliances; Fixed functional appliances; Herbst appliance; Forsus; Mandibular protraction appliance; Advan Sync
Functional orthopaedic treatment aims to correct
malocclusion and harmonize the orofacial function. Correcting class II malocclusion
is difficult due to its complex and multifactorial aetiology. As several
removable and fixed appliances are available the orthodontist can choose the
appliance depending on patient’s needs. In this review article an attempt has
been made to review various available fixed functional appliances.
Functional Appliances: A removable or fixed appliance
which is designed to alter the posture of the mandible by stretching the
musculature and changing the neuromuscular environment to produce movement of
teeth and modification of growth [1]. Due to the bulk and
inconvenience [2], their intermittent wear which does not elicit
continuous muscle activity, Patient cooperation has long been recognized as an
important factor in the outcome of orthodontic treatment. Failure of patient
compliance to prescribed schedules of removable appliance wear will result
either in slow treatment response or no response. To reduce these inadequacies,
non-compliant appliances or fixed functional appliances were developed. An
unfavourable response to functional appliances treatment can be summarized as
due to excessive use, Poor or wrong diagnosis, Inadequate training, Poor
knowledge of growth, Improper bite registration, Poor design/fabrication, Poor
patient co-operation, Poor patient selection and Impatience of orthodontist.
These factors combined with need for unprecedented demand for harnessing growth
to its zenith led to the development of fixed functional appliances.
In the 19th century, Norman Kingsley
introduced bite plate for jumping the bite. He was the first to use the forward
positioning of the mandible in orthodontic therapy. In the 20th
century, Pierre Robin (1867-1950), described the construction and properties of
the monobloc. Cope JB showed that majority of class 2 corrections was due to
dental rather than skeletal change. Clockwise or backward rotations were
evident for the mandible. Weiland FJ and Bantleon gave a report of treatment of
class 2 malocclusion with jasper jumper. It concluded that correction was a
result of skeletal 40% and dental 60% changes.
Jasper JJ and McNamara gave an article describing in detail about
anchorage preparation, torque application methods of anchoring, activating, and
reactivating the modules. Carlos introduced the mandibular protraction
appliance (MPA) for class 2 treatment. West R.P devised the adjustable bite
corrector; it is a stretchable closed coil spring. Schiavaini et al described
an attachment for Herbst appliance called the Mandibular Advancement Locking
Unit (MALU). Korrodi Ritto invented the Magnetic Telescoping Device which
linked a magnetic field to the functional appliance. Klapper Lewis (1999)
introduced the Super spring II in non-complaint class II patient. Ritto
described a Miniaturized Telescopic Device, the Ritto appliance. Cozza et al
(2006) performed a systematic review of literature to evaluate the
effectiveness of functional appliances in enhancing mandibular growth in class
II subjects. Selmi Arici Huseyin Akan (2008) tested the hypothesis that
functional appliance treatment in a group of class II div I patients with
mandibular retrusion changes the condyle position in the glenoid fossa.
Herbst was a remarkable man, far ahead of his times.
Herbst appliance was developed by in 1900s. Herbst presented the original
banded design appliance for the first time at the 5th International Dental
Congress in Berlin in 1909. It is a fixed bite jumping device. After 1934 very
little was published about the Herbst appliance until it was rediscovered by
Hans Pancherz of Malmo, Sweden in the late 1970’s.
The Herbst appliance is basically a fixed bite jumping device used for correction of skeletal Class II malocclusions. A bilateral telescope mechanism forces the mandible in an anterior-forced position during all mandibular functions [4]. The telescope mechanism (tube and plunger) is attached to orthodontic bands, crowns, or splints. Herbst appliance (Figure 1) consists of 2 telescopic devices.
Figure 1: Herbst appliance.
Telescopic device consists of –
·
A tube
·
A plunger
·
2 pivots
·
2 screws
·
Pivot tube
soldered to the permanent maxillary 1st molar band.
·
Pivot (plunger) to
the mandibular 1st premolar band.
·
The screws prevent
the telescopic parts from slipping off the pivots. The length of the tube
determines the amount of advancement (bite jumping).
·
If the plunger is
too long, it may extend far behind the tube & injure the buccal mucosa
distal to upper 1st molar. To permit the lateral movements it may be necessary
to widen the pivot opening.
The standard anchorage system used by Herbst:
·
Crowns on the maxillary
permanent first molars and mandibular first premolars (sometimes canines).
·
Crowns joined by
wires that run along the palatal surfaces of the upper teeth and the lingual
surfaces of the lower teeth (Figure 2).
·
If upper second
permanent molars have not erupted the appliance is anchored firmly by placing
bands on the upper canines, which were soldered to the palatal arch wire as
were the upper molars.
· An alternative to bands on the upper canines is placing a thin gold wire on the labial surfaces of the upper incisors and soldered to the palatal arch wire.
Figure 2: Standard anchorage system used by Herbst.
Figure 3: The Cast Splint Herbst.
Figure 4: Herbst with stainless steel crowns.
Figure 5: Cantilevered Herbst appliance.
Figure 6: The EMDEN Herbst.
Figure 7: Edgewise bioprogressive Herbst appliance.
Figure 8: Flip-Lock herbst appliance.
Figure 9: Force module.
This appliance was introduced by Ralph M Clements and
Alex Jacobson in 1982 [13] and was a substitute for intermaxillary elastics
(Figure 10).
·
Piston
·
Cylinder
Locking devices
Figure 10: MARS appliance.
The MARS appliance is composed of a pair of telescopic
struts (piston & cylinder of 0.045” thickness), the ends of which are
attached to the upper and lower arch wires of a multi-banded fixed appliance by
means of locking device. The appliance is placed after levelling and alignment
is done. It is attached to the heaviest rectangular arch wires i.e. the wire
that can be accommodated by the brackets and tubes.
Disadvantages: Need for a fixed multi-banded appliance
limits its use in mixed dentition cases.
This appliance was developed by Carlos Martin & Coelho Filho in 1995 [14]. It was developed to be quickly made up by the orthodontist in the lab (Figure 11).
Figure 11: Mandibular protraction appliances.
MPA-
I
A small loop is bent on each side at a right angle to
the end of an 0.032” SS wire. Patient is asked to protrude the mandible into a
position with proper overjet, overbite to determine the length of the tube. The
distance from the mesial of the maxillary tube to the stop on the mandibular
arch wire is measured. Another small right-angle circle is then bent in an
opposite direction into the other end of the .032" stainless steel wire.
One appliance circle is placed over the maxillary arch wire against the molar
tube, and the other circle against the mandibular arch wire stop.
MPA-
II
The right angles circle is made of 0.032” SS wire. A
small piece of slipped coil is slipped over one of the wires. One end of each
wire is then inserted through the loop in the other end. This version allows
mouth to open wider than the previous version.
MPA-
III
Appliance length measured from mesial of maxillary
tube to mandibular arch wire stop with mandible in proper protruded position.
This helps to eliminates arch wire stress that was experienced with MPA I and
II. It permits a greater range of jaw motion while keeping the mandible in a
protruded position. The MPA IV is much easier to construct and install, more
comfortable. The MPA IV assembly consist of: “T” tubes, Upper molar locking
pin, Mandibular rod, Mandibular arch wire.
Introduced by Richard P. West [15]. The assembly consists of: A stretchable closed coil spring made of 0.018” stainless steel and internally threaded end cap Nickel titanium wire in the centre lumen of the spring (Figure 12). The closed coil spring 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 its orientation. This reduces the inventory. The NiTi wire is responsible for the push force.
Figure 12: Adjustable bite corrector.
The Eureka Spring
Introduced by John DeVincenzo and Steve Prins [16]. It is a three-part telescopic appliance fixed to the upper arch at the level of the molar band and to the lower arch distal to the cuspid (Figure 13). The main component of the Eureka spring is an open coil spring encased in plunger assembly [17].
Figure 13: Eureka spring.
The Churro Jumper
Introduced by Ridhardo Castanon, Mario S Valdes and Larry White [18]. It is an effective and inexpensive alternative force system for the anteroposterior. It was developed as an improvement of the MPA of Coelho. The distal circular end is attached to the maxillary molars by a pin and the mesial circular end is placed over the mandibular arch wire against the canine bracket (Figure 14).
Figure 14: Churro jumper
Till date, this is the only flexible functional
appliance which can be made up by the orthodontist making it cost effective.
The Ritto Appliance
The Ritto Appliance [19] (Figure 15) can be described as a miniaturized telescopic device with simplified intraoral application and activation. Its mechanism is of the ventral telescope without any disengagement. It comes in a single format which allows it to be used on both sides and is available in only one size. It is comfortable, easy to adapt, cost effective, esthetical and breakage resistant. Conventionally banding the upper and lower molars and placing brackets on the lower incisor makes it useful in mixed dentition. The appliance is fixed onto a prepared lower arch, its length is adjusted, locks are fitted, and the appliance is then inserted. It is activated by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance.
Figure 15: Ritto appliance.
Alpern Class II Closers
It consists of a small telescopic appliance with an interior coil spring and two hooks for fixing (Figure 16). It is fixed to the lower molar and to the upper cuspid like the elastics. Its telescopic action eases opening of the mouth.
Figure 16: Alpern class II closers.
The Mandibular Anterior Repositioning Appliance (MARA)
This was created by Douglas Toll of Germany in 1991.
It consists of shim on the molars, the elbow fits in the shim and guides the
patient to bite into Class I. If the patient pulls back his mandible to a Class
II relation, he will be unable to achieve intercuspation (Figure 17). This
means that the lower molars will make direct contact with the metal, giving an
unpleasant sensation. The appliance design allows for use in conjunction with
braces.
Figure 17: The Mandibular Anterior Repositioning Appliance (MARA).
Introduced by Lewis Klapper in 1997 [20]. It is a flexible spring element which rests in the vestibule when activated and is attached to the maxillary molar and the mandibular canine. The open helical loop of the spring is twisted like a J-hook onto the mandibular arch wire (Figure 18). On the maxillary end it is attached to the standard headgear tube (Super Spring I) or to a special oval tube and secured with a stainless-steel ligature (Super Spring II). This new version prevents any lateral movements of the spring in the vestibule. The horizontal configuration of the attachment wire at the maxillary molar tube permits distalization with good radicular control.
Figure 18: The Klapper Super Spring I & II.
Forsus-Fatigue Resistant Device
This is an innovative three telescopic appliance with
a coil spring in its exterior part [21]. It is available in different length
sizes for left and right side (Figure 19). In the original presentation, the
appliance is placed in the mandible on the round-segmented arch. The appliance
slides along the arch and helps opening of the mouth and lateral movements.
Since the resulting force concentrates more on the anterior and inferior
sectors. There is no interference with continuous arches used during the
treatment. The appliance may be fixed according to the needs of the patient.
The appliance may be used in mixed dentition cases and for dental asymmetry
correction. The device allows the patient free mouth opening. Similar device is
the forsus nitinol flat spring which presents a Nitinol flat wire instead of
the coil. The appliance’s flat surface is more esthetical and comfortable. It
is available in three different designs, with various molar attachments. The
Forsus Nitinol Flat Spring is slim, flat, and made of Super-Elastic Nitinol.
Force levels remain constant from the initial setup to the time of removal.
Figure 19: FORSUS.
It has a ready-to-use concept [22], eliminating the need for measuring, or assembly or appliance manipulation. It does not need gingival headgear tubes or special band assemblies and can be used with either banded or bonded tubes (Figure 20).
Figure 20: PowerScope.
Features
·
It has
one-size-fits which reduces inventory requirement [23]
·
It features a low
profile which gives aesthetic appearance. Its smooth and rounded-edge design
provides better patient comfort. Its telescopic system features will not disengage
during treatment, thus avoid unnecessary emergency visits. Ulceration is not
seen as the piston does not extend distally.
·
A NiTi internal
spring mechanism delivers 260 grams of force for continuous activation during
treatment. Painful pinching of the cheeks and food entrapment is avoided by
enclosed design [24]. The ball-and-socket joint helps lateral mandibular
movement for improved patient comfort and acceptance.
The AdvanSync combines two distinct treatment phases
i.e. mandibular advancement along with malocclusion correction. Therefore, it
helps in to achieve skeletal as well as dental corrections at the same time;
hence reduces treatment time [25].
AdvanSync is designed to advance the mandible to a Class I occlusion within six to nine months – while the patient has been bonded upper and lower 5 to 5 [26-30]. Since it is fixed it does not need patient compliance. Its compact design provides maximum comfort and range of movement. It is placed simultaneously with initial bonding, synchronizing Class II treatment with orthodontic therapy [31-35] (Figure 21).
Figure 21: AdvanSync.
·
The factors
affecting mandibular growth with functional appliances are more important and
should be considered, rather than concentrating on short term results.
Significant mandibular growth and long-term retention basis are still
debatable. Because of individual differences in growth rates and direction may
explain some of the discrepancies reported in clinical studies in human beings.
This may also be one of the reasons, in some reports there increased condylar
growth, whereas in other investigation it was of minor clinical value
·
Another area,
where we have still lack of knowledge is soft tissue changes and adaptations
after functional appliance therapy.
·
Future long-term
studies, clinical trials with control group, are required to know whether we
can grow mandibles and retain it for lifetime.