Dept.

of Orthodontics

Seminar on Orthodontic Appliances

Presented by G. Calamus Emerald Internee

ORTHOPEDIC APPLIANCES
INTRODUCTION In Orthodontic practice, forces employed is basically of 2typesa. Orthodontic force b. Orthopedic force Orthodontic forces are those that are applied to the teeth by means of wires and other active components of a removable or fixed appliance. The forces produced by these appliances are light and range from 50-100gms.

Orthopedic forces are those that affect the deeper craniofacial structures. These are heavy forces of over 400gms that bring about a change in the skeletal tissue. Thus orthopedic appliances utilize the teeth as handles to transmit the forces to the adjacent skeletal structures.

BASIS FOR ORTHOPEDIC APPLIANCES

In order to produce skeletal changes, consideration should be given to the amount of force applied and the duration of the force. Amount of the force: Heavy force of over 400gms totally compress the periodontal ligament on the pressure side and cause hyalinization which prevents tooth movement. These heavy forces are conducted to the skeletal structures to produce an orthopedic effect. Duration of the force: Intermittent forces ranging from12-14 hrs a day are believed to bring about minimum tooth movement and maximum skeletal change. The most extra oral orthopedic appliances are worn 12-14hrs a day. Increase in the duration of wear results in increase in the dental effects.

METHOD OF APPLICATION OF ORTHOPEDIC FORCE

Orthopedic force can be applied with help of extra oral apparatus, which include, a) Head gear b) Face vow c) J hooks d) Chin cap

Head gear: Head gear is used in orthodontics to modify growth of the maxilla, to distalize and protract maxillary teeth, or to reinforce anchorage. They are the most commonly used extra oral orthopedic appliances. When head gear is used for skeletal modifications, heavier forces are recommended. Such heavier forces bring about actions on the sutures of the maxilla, changing the magnitude and direction of their growth.

Mode of action and goals of treatment with head gears

A head gear intended for use in growth modifications is designed to deliver an adequate extra oral orthopedic force to compress the maxillary sutures, modifying the pattern of bone opposition at these sites. Although posterior and superior extra oral orthopedic forces primarily are intended to inhibit anterior and inferior development of the maxilla, they also inhibit mesial and occlusal eruption of the maxillary posterior teeth.

The goal of treatment is for this restriction of maxillary growth to occur while the mandible continues to grow forward and adequate amount to catch up with maxilla.

These forces need to be of sufficient magnitude, applied in an appropriate direction, and delivered for an adequate length of time during a period of active mandibular growth for these to be a positive treatment prognosis.
Although the head gear can be an effective appliance in the treatment of variety of class2 problems, the most ideal indication for use of extra oral force in the correction of skeletal classII Malocclusion is with antero posterior excess.

Another indication for treatment with head gear accompanying the maxillary excess would be normal mandibular skeletal and dental morphology because the extra oral force would minimally influence these features. Finally, the ideal circumstance for use of head gear must be one where there is continued active mandibular growth, primarily displacing the mandible in a forward rather than downward direction.
The head gear face bow assembly has 3 main components. 1) Face bow 2) Force element 3) Head cap or cervical cap

FACE BOW

The face bow is a metallic component that helps in transmitting the extra oral forces onto the posterior teeth. The face bow consists of outer bow, inner bow and the junction. The outer bow is for extra oral attachment which is soldered to an inner bow that is attached intra orally to the maxillary first permanent molar bands. The outer bow is made of 1.5mm stiff round wire and is contoured to fit round the face. The outer bow can be short medium or long.

Short outer bow- is lesser in length than inner bow. Medium outer bow- length is equal to inner bow. Long outer bow- is longer than inner bow.

The distal end of the outer bow is curved to form a hook that gives attachment to the force element. The inner bow is made of 1.25mm round stainless steel wire and contoured around the dental arch and molars. The inner bow is inserted into the buccal tubes fixed on the maxillary first molars. Stops are placed on the inner bow-mesial to the molar tubes to prevent the inner bow from sliding too far through the tubes. The junction is the rigid joint between the inner and outer bow. It can be simple soldered, wire wrapped soldered or welded joint. The junction is placed at the midline of the bows. When asymmetric forces are needed, the joint can be shifted from the midline.

Face bows are also available commercially. They can be obtained asa) Standard face bows with/without cuspid hooks and protective caps for the ends of the outer bow. The outer bow length is variable. Here the stopper loops can bent into the inner bow or stopper screws can be used.

b) Face bow with stop loops: They are available with/without cuspid hooks and with protective caps to the outer bow ends. Outer bow is of medium length. Force is applied from the head gear or the neck band via the elastics to the outer bow and is transmitted to the teeth and jaws.

J hooks

It is alternative method of applying an extra oral force by engaging J hooks to the removable appliance. This is not suitable for retracting the buckle segment as it attach din the region of the incisors. This is an excellent method of reinforcing the anchorage.

J hooks can be engaged to the helix incorporated in the modified labial bow or onto the soldered hooks of the labial bow or to that of fixed appliances in the region of incisors.
The type of force used is directed upwards so that the appliance does not get displaced. J hooks and occipital pull head gear can be used with removable and fixed appliances since the direction of the pull is upward and distally directed.

Along with the vertical pull head gear they can be used to intrude the upper anterior segment. The force used is approximately about to 200-400gms per side. The ends of the j hooks should be bent and provided with protective caps. They should be firmly engaged to the intra oral appliance so that it does not slip out and cause any injury due to elastic pull either to the patient or to the children who are playing along with them. Force Element:

It is that part of the assembly which provided the force to bring about the desired effect. This may comprise of springs, elastics and other stretchable materials. The force element connects the face bow to the head cap or neck strap.

The Head cap or Cervical strap

The appliance takes anchorage from the rigid bones of the skull or from the back of the neck by means of a head cap or neck strap or a combination of the two. The selection of this depends upon the individual patient needs. Selection of the Head gear: There are three major decisions to be made in the selection of the head gear1) Head gear anchorage location must be chosen to provide a correct vertical component of force to the skeletal and dental structures. A high pull head cap will place a superior and dental force on the teeth and maxilla.

A cervical neck strap will place an inferior and distal force on the teeth and skeletal structures. When the head cap and neck strap are combined, the force direction can be varied by altering the proportion of total force provided by each component. The choice of head gear configuration should be based on the original facial pattern: the more the excessive vertical growth is present, the higher direction of the pull and vice versa.

2) The second decision is how the head gear is attached to the dentition. The usual arrangement is a face bow to tubes on the permanent first molars.

Alternatively a removable appliance can be fitted to the maxillary teeth and the face bow attached to this appliance. This appliance can take the form of a maxillary splint or a functional appliance.

This particular approach is particularly indicated for children with vertically excessive growth.

3) Finally a decision must be made as to whether bodily movement or tipping of the teeth or maxilla is desired.

Since the center of the resistance for a molar is estimated to be in the middle root region, force vectors above this point results in a distal root movement.

Forces through the center of resistance of the molar causes bodily movement and vectors below this point should cause distal crown tipping. The length and position of the outer head gear bow relative to the center of resistance along with the form of anchorage determine the molar movement.

Effect of head gear to the maxilla:

The direction of force must be compatible with vertical relationships observed in the patient. A distal inferior direction of head gear force will restrict forward maxillary growth but will allow or accentuate downward growth.

If the mandible is rotated downward and backward, this will nullify most of the forward mandibular growth that reduce the classic relationship. On the other hand, distal and superior head gear force will limit vertical maxillary development and should not be used on a patient who has short face in conjunction with a classic jaw relationship.

Biomechanics and principles in the use of head gear

Head gears have the ability to move the dentition of the maxilla in all three planes of space. The following factors should be considered when planning the use head gears. 1) Center of resistance of the dentition:

A decision should be made as to whether bodily movement or tipping of the teeth is required. The center of resistance for a molar is usually at the middle root region. Forces applied through the center of resistance of the molars result in their bodily movement. If force is applied below the center of resistance, it causes a distal crown tipping while if it is above the center of resistance it causes distal root tipping.

2) Center of resistance of maxilla:

The center of resistance of maxilla as a whole should also be considered when planning head gears. It is believed to exist at the postero superior aspect of zygomatico maxillary suture. Under clinical conditions the center of resistance of the dental arch as a whole should be considered. This is located between the roots of the premolars. Forces passing through the center of resistance of the maxilla produce translation of the maxilla in a distal direction while forces passing above or below this point cause rotation of the maxilla. The point of origin of the Force: Head gears derive anchorage from the occipital region of the cranium or the cervical region.

Occipital head gears produce a superior and distal force on the teeth and the maxilla, while cervical head gears produce an inferior and distal force on the teeth and maxilla. Thus an appropriate point of origin should be selected based on what type of tooth and maxillary movement would be beneficial for a given patient. Point of attachment of Force :

The point of attachment refers to the hook present on the distal end of the outer bow to which the force element is attached. It is possible to alter the direction of the force to the maxilla and the maxillary dentition by altering the point of attachment. This can be done by varying the angle between the inner and outer bow.

Types of Head gears

Based on site of anchorage head, gears can be of 3 types1) Cervical head gears 2) Occipital head gears 3) Combination head gears Cervical head gears:

These head gears obtain anchorage fro the nape of the neck (fig). Cervical head gears cause extrusion of the maxillary molars leading to an increase in the lower facial height.
They also move the maxillary definition and the maxilla in a distal direction. These head gears are generally indicated in low mandibular angle cases, as an increase in lower facial height would be beneficial in such patients.

It is important to consider the relation of line force to the center of resistance of the maxilla and upper dental arch.
If the line of force passes through the center of resistance of the maxilla, no rotation of the maxilla occurs. However when the line of force passes below the center of resistance of the maxilla we can expect a clockwise rotation of the maxilla. Similar considerations apply to the dental arch.

Occipital head gears:

These head gears derive anchorage from the back of the head (fig). This type of head gear produces a distal and superiorly directed force on the maxillary teeth and the maxilla. Combination of head gears: In this type of head gear, occipital and cervical anchorages are combined (fig). When forces exerted by both are equal, a distal and slightly upward force is exerted on the maxillary dentition and the maxilla. By varying the proportions of the total force derived from the head cap and the neck strap, the resultant force direction can be altered.

USES OF HEAD GEARS

Orthopedic effect: Forces applied onto maxilla can be used to restrict its downward and forward growth. The distal force in such a case should be applied through the center of resistance of the maxilla.

It has been suggested that forces in the range 350-450gms on each side for a minimum of 12-14 hrs/day are required. Orthopedic effects from extra oral forces are best tapped in the pre-adolescent years. Anchorage augmentation: Extra-oral forces are used to reinforce anchorage when those obtained from intra-oral sources are insufficient. The head gear should be worn for approximately 10 hrs/day for this purpose and force values of 300gms/side are usually

In the maxilla, anchorage reinforcement is achieved by restricting the mesial movement of molars.
Distalization of molars:

Distal movement of upper molars maybe required for correction of molar relation or to gain space for correction of crowding or retraction of anteriors.

Extra-oral forces can be effectively used for this purpose when worn for a minimum 14hrs/day. Unilateral distalization of molars can be achieved using extra-oral force by varying the length of the outer bow.
The larger force is applied on the side of the longer bow. Asymmetric head gears used for the above purpose are general cervical or combination type.

Molar rotation: In order to derotate a molar, the molar has to be banded with buccal tube placed distally and then subsequently repositioned.

Correction is achieved by adjustment of the inner bow so that it produces a rotational force on the molar. As soon as the correction is achieved, the face bow should be readjusted to apply a direct distal force.

Space maintenance: A most effective method of maintaining arch length is by the use of extra-oral forces. The mesial movement of molars is prevented and the face bow does not interfere with erupting teeth.

In this situation, daily wear of approximately 8 hrs is sufficient.

FACE MASK

Head gears are used generally for the purpose of reinforcement of anchorage or for maxillary distalization. However, when an anterior protractory force is required, a protraction head gear is used. Facial mask therapy has gained popularity in the last decade. The principle of pulling force on the maxillary structures with reciprocal pushing force on the forehead or the mandible through facial anchorage is simple and mechanically sound enough to be used as a therapeutic procedure for treatment of prognathic syndromes, maxillary retrusions, clefts and mandibular prognathism.

Hickam (1972) claims he was the first to use reverse head gear. However this modality was made popular by Delaire around the same time. A reverse pull head gear basically consists of a rigid extra oral framework which takes anchorage from the chin or the forehead or both for the anterior traction of the maxilla using extra oral elastics which generate large amounts of force upto 1kg or more.
Indications:

1. It can be used in a growing patient having a prognathic mandible and a retrusive maxilla. It aids in pulling the maxillary structures forward and pushing the mandibular structures backward.

2). It can be used for the bending the condylar neck for stimulating temporo-mandibular joint adaptations to posterior displacement of the chin. 3). It can be used for selective rearrangement of the palatal shelves in the cleft patients. 4). It can be used in correction of post surgical relapse after osteotomes. 5). It can be used to treat certain accessory problems associated with nose morphology such as lateral deviations.

Sites of Anchorage

Anchorage for the purpose of maxillary retraction can be obtained from forehead, chin or from forehead & chin. Anchorage from chin: In this type of protraction head gear which is commonly used in Britain, chin cup with posts are employed.

As the anchorage is employed solely from the chin, the force is transmitted to the condylar cartilage and thereby has a disadvantage of altering the growth of the mandible. Anchorage from skull: Certain forms of reverse pull head gears obtain anchorage only from the forehead. The disadvantages include patient discomfort while sleeping, cost and time required in fabrication and fixing. Anchorage from chin and forehead: This face mask makes use of anchorage from both the forehead and the chin. Anchorage is spread over a large area. Thus no excessive force is exerted onto the growth cartilage. However, the disadvantages with this appliance are difficulty in speech and compromise in aesthetics and comfort due to its size.

Biomechanical considerations

Amount of force: The amount of force required to bring about skeletal changes is about 1 pound per side. Direction of force: Most authors recommend a 15-20 degree downward pull to the occlusal plane to produce a pure forward translatory portion of the maxilla.

If the line of force is parallel to the occlusal plane, a forward translation as well an upward rotation takes place. Duration of force: The time taken to achieve desired results is proportional to the amount of force utilized. Low forces take 13months to produce desired results. However very high force values like 1600-3000 gms reduces treatment time to 4-21 days.

Frequency of use: Most authors recommend 12-14 hrs of wear a day.

Parts of a reverse pull head gear

The reverse pull head gear consists of the following parts

Chin cup: Most protraction head gears obtain anchorage from the chin as well as the forehead. The chin cup is used to take anchorage from the chin area. It is usually connected to the rest of the face mask assembly by means of metal rods.

The chin cup can be ready made or can be fabricated from an impression of the patient's genial region.
Forehead cap: The forehead support of cap or strap is used to derive anchorage from the forehead.

Elastics:

Elastic force is used to apply a forward traction on the upper arch. Vertical posts of the chin cup are used to attach the elastics onto the molar tubes or hooks soldered on the arch wire. This sort of traction is purely for tooth movement. Intra-oral appliance:

The most common type of protraction device is a multi banded appliance with rigid wire. Traction hooks are placed whether in the molar premolar region.

Mc Namara advocates a banded R.M.E along with the protraction device which more or less resembles the banded herbst appliance.

Metal frame:

The main component of a face mask assembly is the metal frame. It connects the various components such as chin cup and forehead cap. It also has provision to receive elastics from intra oral appliance. The design of the metal frame differs based on the type of face mask.

Types of Reverse pull head gear

1) Protraction head gear by Hickham:

Developed in the early 60s, this appliance uses the chin and the top of the head for anchorage. The force distribution is as follows-12% head, 85%chin. It consists of two short arms in front of the mouth to engage maxillary protraction elastics. It also has a chin cup from which originates two long arms. The two long arms run parallel to the lower border of the mandible and go vertically up from the angle of the mandible and end behind the ears. An elastic strap is attached to the end to of the long arms to encircle the head. Advantages: Better aesthetics and comfort than others with the option of unilateral force applicability.

2)Face mask of Delaire:

This was popularized by Delaire in the 60s and uses the chin and forehead for support. The appliance is made up of a rigid wire framework which is squarish and kept away from the face. It has a forehead cap and chin cup with a wire running in front of the mouth used for elastic attachments. 3) Tubinger model:

This is modified type of Delaire facemask. It consists of a chin cup from which originates two rods that run in the midline and is shaped to avoid interference of nose. The superior ends of the two rods house a forehead cap from which the elastic encircle the head.

4) Petit type of face mask: It is a modified type of Delaire face mask. It consists of a chin cup and forehead cap with a single rod running in the midline from the forehead cap to the chin cup.

A cross bar at the level of the mouth is used to engage elastics.

CHIN CUP

The chin cup or the chin cap is an extra oral orthopedic device that covers the chin and is connected to head gear. It is used to restrict the forward and downward growth of the mandible. The chin cup face bow assembly consists of a chin cup, head cap and an adjustable elastic strap that connect the chin cup with the head cap.

Types of chin cups: 1) Occipital pull chin cup 2) Vertical pull chin cup Occipital pull chin cup: This type of chin cup derives anchorage from the occipital region of the head. It is used in classIII malocclusions associated with mild to moderate mandibular prognathism. They are successful in patients who can bring their incisors close to an edge to edge position at centric relation. They are also indicated in patients with slightly protrusive lower incisors as they invariably produce lingual tipping of the lower incisors.

Vertical pull chin cup: This type of chin cup derives anchorage from the partial region of the head.

It is indicated in patients with steep mandibular plane angle and excessive anterior facial height. These patients usually exhibit an anterior open bite.
Fabrication:

They are fabricated individually or prefabricated commercially. Fabrication of a chin cup requires an impression to be taken of the chin area. The caste is poured and the chin cup is fabricated using self cure acrylic resins.

Force magnitude and duration of wear: At the time of appliance delivery a force of 150-300gms/side is used.
Over the next two months the force is gradually increased to 450-700gms/side.

The patient is asked to wear the appliance for 12-14 hrs/day to achieved the desired results.

Thank You