R.

Rama Putranto

Removable Appliances A. Base Plate

B. Component Retentive C. Component Active/Force anchorage

A. Base Plate 1. Supporting others component : claps, Screw Expansion etc. 2. Continue Strength/force of the resulting from claps to anchorages 3. To prevent unwanted moving teeth 4. To protect the spring or claps on palatal / lingual side 5. To hold and continue biting force

 Stability of plate 1. Plate width was made as wide as possible, depend on treatment needs 2. The plate should be able to adapt with oral mucosa 3. The plate around moving teeth must be free

 Functional Appliance Primarily orthopedic tools to influence the facial skeleton of the growing child Transmit, Eliminates, and guide the natural forces Muscle activity, growth, tooth eruption Try To create conditions for the harmonious development of the stomatognathic system

 Early Class II Malocclusion Class III Malocclusion

CLASSIFICATION OF FUNCTIONAL APPLIANCE Teeth Supported Appliances Ex/ Inclined plane, guiding plane, etc Teeth/Tissue supported : Activators, Bionator , etc Vestibular positioned appliances with isolated support from teeth/tissue :Frankle Appliance, Lip bumpers

 Removable Appliance : Activators , Bionators, Frankle , etc Semi-fixed Appliance : Bass Appliances Fixed Appliances: Herbst, Jasper Jumper, etc

Study by McNamara with primates 1975 Masticatory muscles and appropriate orthopedic appliances can modify the rate and amount of condylar growth LPM activity may induce condylar deposition

Growth Spurt Beginning of puberty or menstruation Evaluated by age, tooth eruption, height, ossification of hand/wrist bones on x-ray

Role of glenoid fossa Voudauris 1988 Fossa is altered and brought forward by mandibular advancement Ruf et al- AJO 1999 The increase in mandibular prognathism to be a result of condylar and glenoid fossa remodeling Rabie et al AJO 2002 Forward mandibular positioning causes significant increases in vascularization and new bone formation in the glenoid fossa

Factors influencing mandibular growth Cranium positioning Condylar cartilage Muscles (LPM ?) TMJ disc STH (Somatomedin) --> cell growth and division Other factors

Study with rats Functional advancements at different ages and occlusions Stable Results Treatment continues until growth stops Continued growth possible with locked-in occlusion Unstable Results Continued growth with imprecise occlusion

Optimum Timing
Increase of STH (Somatomedin) Increase of sex hormone High growth rate 8-10 years for removable type 11-13 years fixed type Note- Most efficient in permanent dentition(Profit, Pancherz AJO 2002) Late stage of mixed dentition,1-2 years before the pubertal growth occur

Female: 9~10 year old

Male: 11~12 year old

Effects of functional appliances

Is not To Activate the Muscle but to Modulate Muscle Activity, Enhanceing the Normal Development of the Growth Patterns Eliminate Abnormal Environmental Factors

Dento-alveolar changes
Antero-posterior: Anterior movement of lower teeth, posterior movement of upper teeth. Vertical: lower posterior teeth erupt.

Modification of Maxillary growth??

Restrain the forward growth of maxilla Catch up growth occurs after treatment

Cephlomatric superimposition

Changes in mandibular growth

Stimulate mandible growth Improve the growth direction of mandible

Cephlogram superimposition

Changes in glenoid fossae

Remolding of the glenoid fossa more anteriorly

Indications for functional appliances

The patient must still be growing,preferably approaching a phase of rapid growth. The pattern and direction of facial growth should be favorable. The profile improved immediately as the patient move mandible forward. The patient must be well motivated. Dentition are well aligned

INDIKASI
Well aligned dental arches Posterior positioned mandible Non severe skeletal discrepancy Lingual tipping of mandibular incisors Proper patient selection

KONTRAINDIKASI
Class ll skeletal by maxillary prognathism Vertically directed grower Labial tipping of lower incisors Crowding

Activator facts Original design worn at night Large one piece of acrylic Teeth could be redirected during eruption Large vertical opening construction bite Could not speak or eat when worn Advances mandibular jaw

July 2003 EJO by Basciftci et al the activator appliance can produce both skeletal and dental effects in the growing dentofacial complex. January 2003 AJODO by Laecken et al Retroactive study suggests that both skeletal and dental changes contribute to Class II treatment with the Herbst appliance with fossa remodeling

bionator

Prototype of less bulky activator Worn day and night Allows more tongue action Mandibular advancement Speaking possible, yet difficult

Herbst

Fixed to teeth Patient compliance not required Works 24 hours Less airway blockage Most popular type at present time in U.S.

Frankel

 The large part of Frankel appliance is confined to the oral vestibule The buccal shields and lip pads hold the buccal and labial soft tissue away from the teeth,eliminating restrictive influence

The manner in which the anteroposterior correction is different

Twin block

Removeble Separate upper/lower plates Patient compliance required Less airway blockage Improved speech Most popular removable type at present

BITE REGISTRATION
1.Anteroposterior dimension: for most patients: 4~6mm (edge to edge if no uncomfortable) 2.Vertical opening: 3~4mm in incisor region

A horseshoe-shaped wax bite rim is prepared Guiding the mandible into planned position Forming the wax bite Check and hardened

construction
Base plane Lip bow:transmit forces to upper incisors Lower incisors capping: minimize the tendency of lower incisors procline reducing overbite

principles

Muscles stretched-producing forces-retracting mandible-transmitted to maxilla through labial bow-restraining the maxillary growth

Rules for construction bite

In a forward positioning of the mandible of 7-8mm,the vertical opening must be slightly to moderated(2-4mm) If the forward positioning is no more than 3-5mm,the vertical opening should be 46mm The Activator can correct lower midline shift or deviation

Trimming
1.vertical control For dolichofacial patients:intrude molars, extrude incisors For branchfacial patients: intrude incisors, extrude molars

Acrylic contact Intrusion of the molars

Acrylic contour for extrusion of the molars

Intrusion of the incisors

2.sagittal control

Retrusion of the incisors

Mesial movement of molars

Distal movement of molars

3.transverse movement

Anterior bite plane

management
The bite plane should be length enough to ensure the lower incisors bite on the bite plane. Add to the height of the bite-plane during treatment

Buccal capping
Eliminating occlusion interference Dental incisors cross-bite Unilateral posterior teeth crossbite

Bilateral block

Unilateral block