The treatment of Class II, Division I malocclusion with functional correctors

Rolf Friinkel, Dr. Med. Dent.* %wickau/Snchsen, German Democratic

Republic

he problems facing us in our special branch of health service are chiefly of a mechanical nature. According to Hotz, the adjustment of teeth basically involves a modification of that natural interplay of forces which is responsible for the shape of the dentoalveolar arches. For these processes to take a physiologic course, the quantity, direction, and duration of this interplay of forces must be modified in such a way that certain mechanical stimuli are active at the growth sites. This has been described by MOSS, Pauwels, Reitan, Blechschmidt, Graumann, and others. The perfected construction of modern appliances, both fixed and removable, enables us to bring about artificial changes in this interplay of forces. The usual method is to create additional mechanical forces and make them operate in such a way that normalization of the dentition results via an adaptation process. Today there can be no doubt that this part of our treatment no longer constitutes a problem. There is, however, another major problem for which a solution has not been found; this is the question of what happens when the appliance is removed and the artificial forces cease to operate. We have no assurance that the physiologic interplay of forces itself has been modified. Posttreatment examination reveals that our morphologic results will be stable only if they are in equilibrium with the biomechanical forces prevailing in the environment. We can hope that, under conditions of prolonged retention, there will be some spontaneous adaptation of the surrounding soft tissue, but WC are quite uncertain as to the degree of such adaptation, and it cannot be predicted. The simplest way to achieve an equilibrium between the dentition and this interplay of forces remains the extraction of one or more teeth. It should he remembered that extraction not only facilit,ates our mechanical therapy; a reduction in the number of teeth may also permit an adaptation of the jaw s
*Chief of the Orthodontic Department, German Democratic Republic. County Hospital Heinrich Braun, Zwickau,

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size and shape to the existence of an abnormal interplay of forces. III view of the great importance of this interplay of forces (or functional matrix, as Ness calls it), it would appear logical to cxxtend treatment to the functional matrix it,self when instituting measures for orthodontic tooth movement. This actually constitutes the theoretical background for treatment with functional correctors. In this article, I shall confine myself to certain problems oE ( lass IT, 1)ivision 3 cases which arise in connection with the use of skeletal vcMibular* screens. Fig. 1 illustrates the Frankel functional appliance t,hat is used in the t,rratment of Class II cases. The mandible is reposit,ioned in a forward direction to prodncc the so-called construction hitc, in which the incisors are ill an end-

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Fig. 2.

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to-end relation. The degree to which the buceal shields and the lip pads extend beyond the upper and lower arches corresponds to that of the nomal dentition. Fig. 2 illustrates an occlusal view of a Class II malocclusion. The remarkable degree of expansion of the dental arches and of the palatal vault was achieved in this case with the functional appliance in 1 year and 7 months. These casts illustrate not only that good morphologic results can be obtained with functional correctors, but also the manner in which these results are obtained. Basically, of course, this widening effect has been brought about bv artificially changing the interplay of forces. This was not done, however, by bringing additional mechanical forces, such as screws or springs, into operation. It was accomplished by eliminating the cheek pressure by the inhibitive action of the buccal shields and by intensifying the lingual forces in a lateral direction. One might argue that a result obtained in this way is just as prone to relapse as any other unless the interplay of forces itself has actually been changed. Our experience shows, however, that the vestibule, as a base of operations, affords new and interesting possibilities in achieving our objectives. The projecting buccal shields exert a direct mechanical effect on the cheeks in that they stretch with the passing of time. While the cheeks perform their motor functions (speaking, swallowing, and facial expression), the buccal shields art, in effect, as a correctional device. Concurrently, any dysfunction is inhibited. The pressures produced by t,he motor functions and the tone of the cheek muscles are also modified since they adjust to a new shape as determined by the buceal shields. Moreover, we aim at bringing about a new equilibrium between the mechanical forces of the tongue and the cheeks with the aid of oral-seal exercises and a reorient,ation of the tongue position against the palate. This therapeutic principle corresponds to that applied in general orthopedics. The first objective is to modify the soft-tissue structures by physiotherapy, and the second is to rccducatc motor functions and muscle tone by exercises.

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Fig. 3 shows anterior and lateral views of the plaster casts. The black arrows at the level of the root tips and at the alveololabial sulcus indicate the expansion of the deeper supporting structures. As the arrows show, a marked expansion of 5 mm. is also demonstrable in the alveolar proces, in the premolar region. A comparison was made of 150 upper plaster casts, of which half had been treated with palatal plates and the other half with functional correctors. The result,s confirm our view that stretching of the soft tissues in the alveololabial sulcus by means of the projecting buccal shields stimulates bone apposition in the apical base area. In this context, it is well to remember that the alveolar process owes its existence to the ontogenesis and topogenesis of the teeth. Moreover, the direction of a growing tooth can be altered by changing the mechanical conditions of its environment. According to Atkinson, a tooth will invariably grow in the direetion of least resistance. Baume investigations of extraction cases confirmed s these findings. If we take these factors into account, it would seem that the eruption stage of the permanent teeth is of particular interest. Our experience, especially in the treatment of Class II and Class III cases, has shown that the eruption path of the teeth and, hence, the development of the alveolar process may he favorably influenced by eliminating the pressure of cheeks and lips. We consider that functional correctors offer a new form of preventive t,heragy in the mixed dentition. The correction of abnormal sagittal relations in Class II cases is an orthodontic problem which has been discussed on repeated occasions. Many authors hold the view that, basically, this problem can be solved only by orthodontic traction against the maxilla. Other authors advocate a solution by means oi a mesial repositioning of the mandibular molars and premolars. This leaves one question unsolved: Are WC able also to correct the abnormal sagittal relations prevailing at the maxillary base? Graber points out that two thirds of the cases in the average orthodontic practice are due to abnormal maxillomandibular relat,ions, and this clearly illustrates the importance of the problem. There always have been major differences b&w-een European and American orthodontists concerning the question of whether or not mandibular growth can be stimulated. However that may be, the hope of achieving such growth with the aid of intermaxillary elastic bands has failed. Any correction in the position of the mandible implies a modification of the motor and tonic functions. The traction of elastic bands is unphysiologic. It provokes counteractions on the part of the muscles of mastication which involve the question of reciprocal innervation. Moving the teeth is all that these elastic bands can do. A bite shift with activators and double plates, and the resultant construction bite, requires the muscles to adopt a new permanent target of operation. Moreover, in Class I occlusion the mandible is not supported solely by the teeth hut also by the muscles. It this way, re-education of the muscles and stimulation of mandibular growth would seem to be a practical possibility. Fig. 4 illustrates a functional appliance placed on a lower plaster cast. It shows that bite shift with the functional corrector is not achieved by the func-

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tional corrector resting on the mandibular molars or premolars, or on the incisors, either, since the center part of the lingual arch has been annealed. Our experiments have shown that, for the first 3 months at least, the bite correction is mainly effected by the U-shaped loops. If the mandible tries to fall back into its habitual distal position, these U-shaped loops produce a reaction by making contact with the mucosa at the lingual surfaces of the alveolar process. For this reason, the appliance must not be worn longer than 1 or 2 hours daily during the initial treatment period. The fact that functional correctors do not rest on the lower posterior teeth provides a unique opportunity to determine how the correction of abnormal sagittal relations actually occurs. One fact has been established beyond doubt : There is no mesial movement of the lower molars and premolars. Fig. 5 shows the lateral cephalograms of a Class II, Division 1 malocclusion. The first roentgenogram was made at the beginning of treatment, when the

Fig. 4.

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patient was Sl/, years old. The second film was taken S/2 months later, and the last was taken after another 16 months. It is evident from the center film that the distoclusion has disappeared; at this time, the patient had been wearing a moditied type of functional corrector for a period of 6 months. Note also the changes visible in the orolabial zone. These are the result of the lip pads action and of oral-seal exercises. Fig. 6 shows a cephalometric tracing of the three films shown in Fig. 5, with the occipital cross serving as reference plane and the occipital base as a reference line. The occipital base is adjusted to the habitual head posture. For this purpose, small spots of barium paste are applied to the tip of the nose and near the tragus of the ear. The film, in turn, can be adjusted to a head photograph taken with the patient standing upright, relaxed, and without any fixation. The vertical of this coordinate system follows the same direction as the trunk of the body. This is an eminently suitable method for determining any positional changes of the marked points during observation and treatment. A forward movement of the mandible is clearly visible, while the position of the middle face and the maxilla has remained relatively stable by comparison. The possibility that this might be due to a pubertal growth spurt can definitely be excluded in this age range. Fig. 7 shows the facial photographs of the patient shown in Figs. 5 and 6. These photographs were taken before treatment began and after a treatment period of 234 years. In the upper photograph, note the marked mentolabial fold and the high position of the soft tissues of the chin which is caused by mentalis muscle activity. The lower photographs show the effect of the lower lip pads. The over-all profile correction is quite obvious. Fig. 8 illustrates the head film of the mother of the patient shown in Fig. 9. The head films of the daughter shown in Fig. 9 were selected from our longi-

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Fig. 7.

tudinal investigations of Class II cases in the age range from 5 to 8 years. The films illustrate the hereditary factor in Class II cases. The first film of the daughter (Fig. 9) was taken at the age of 6 ydars, 4 months. The second film was taken 6 months later. During the intervening period a skeletal screen with lateral bite blocks and U-shaped loops had been worn for no longer than 3 months. Obvious changes are raising of the bite, uprighting. of the incisors, and improvement of the distoclusion and of the soft-tissue profile in the lower face. The third film was taken 5 months later; it shows a marked, relapse. However, the improvement in the orolabial zone has remained comparatively stable. The lip line is not as high as it was before treatment. I should be mentioned in this context that after removal of the test appliance, the child was unable to occlude the molars for about. ll/! months. This is indicative of a

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neuromuscular re-education process. It should be added that in routine practice treatment is deferred until the first permanent molars have just erupted, since otherwise stable results cannot be obtained. Fig. 10 illustrates subsequent development in this patient. The first film shows unexpected results 15 months later. It illustrates a Class 1.1 relationship after eruption of the permanent upper incisors. We believe that this eruption path of the incisors is due to the correction of the orolabial zone and, more particularly, to the lowering of the lip line, which was achieved in the 3-month treatment period. The center film shows the rrsult obtained after 7 months of

Fig. 8.

Fig. 9.

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treatment with a modified functional corrector. Both the distoclusion and the pronounced overbite have disappeared. The third film was taken after another ii/s months had elapsed. It shows t,hat this time the result has remained stable. This also applies to the? improvement in the orolabial zone, especially in the lower-lip region. A graphic representation using the occipital cross system is extremely useful for measuring esactly how niuch the various marked points have moved in either an anterior and posterior direction or an upward and downward direction. 6Superimposed cephalometric tracings showed that the points articulare and spina nasalis posterior were remarkably stable. Sclla and nasion moved slowly upward and forward during the 31/h years of observation. Nasospinale and spina nasalis anterior moved straight forward to exactly the same extent. Pogonion and the antcgonial notch evident,ly moved downward during treatment. In order lo attain a clear idea of the changes effected in molar relations, the distal surface of the first permanent molars is taken as a reference point. The tracings also showed that the upper molars moved distally while the lower molars moved mesially. These changes cannot be explained by a physiologic mesial movement of the posterior teeth. It seems equally improbable that this effect might be due to a normal mandibular growth spurt. Moreover, we have been able to ascertain on numerous occasions that such relatively major changes take place solely during the period of treatment and never during the observation period. Since the appliance makes no contact whatever with the lower posterior teeth, the only explanation possible would seem to be that this result is due to the correction of impaired basal relations. It is impossible to go into all the problems involved in the treatment of Class II cases with functional correctors. However, in order to avoid any mis-

Fig. 10.

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understanding, I wish to point out quite clearly that this article is not intended to advocate a new appliance-one which would be particularly suit,able for improved orthodontic treatment of the permanent dentition. All my publications should be regarded as a contribution to the general problem of form and I unction, which is of paramount importance for our special field and, unfortunately, is far from being solved. We do know this much: Form and function arc interrelated in that there is mutual influence and reciprocal a&ion between the two. There is also general agreement that inheritance plays a major part with respect to form and function. However, we grossly oversimplify the problem by taking the easy way out and attributing our failures and relapses to an unfavorable hereditary disposition, that is, adverse skeletal growt>h or ~nuscular behavior. In the light of our present knowledge of inheritance, malocclusions and abnormal muscular behavior patterns which coincide with a family likeness can hardly be interpreted as inherited in the sense of a simple Mendelian transmission. Actually, both a genetic predetermination and a similarity of tonic and contractile muscle patterns are responsible for cases of striking famil) likeness. When we remember the passive nature of t,hc gnathic growth zones, we immediately see the importance of the type of musculomechanical influence that is produced by neural overstress anti emotional factors. During t,hc initial eruption period of the permanent dentition, the functional matrix plars a particularly important part. We all know that prior to their eruption, the permanent teeth are crowded together within the alveolar process. In the course of topogenesis, they spread and in this way induct the development of the alveolar bone in a sagittal and lateral direction. In their growth process, the teeth follow the line of least resista.nce. The experience so far gained with functional correctors indicates that by eliminating abnormal perioral pressure, these appliances enable us to effect significant changes in the eruption of the teeth and hence in the development of the alveolar process, probably right up to the apical base. The traction exerted on the buccal fold by the lateral shields also seems t,o play an important part in this process. According to Di Salvo, this period of transition from the deciduous to the permanent dentition is also characterized by constantly changing occlusal sensory stimulation. The change that occurs at this age in the angle between the maxillary and mandibular planes, as described by Zehle, is also part of this development. We therefore believe that the age range from 6 to 8 years is ideal for modifying muscular behavior patterns in the orofacial complex in order to change the position of the mandible. In this way we can guide mandibular development and prevent faulty apical basal relations. If it is true that osteogenesis in 6he gnathic growth zones is a compensatory event which is stimulated and controlled by mechanical environmental factors, then the logical conclusion is to study the mechanical facts. Our practical procedures, therefore, are based on the concept, that abnormal mechanical factors prevailing in the functional matrix, or in the interplay of forces, must be located and eliminated. Under no circumstances should this be delayed until the perma-

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nent teeth have erupted, because we are then faced with a fait accompli. The only measures deserving the name of orthopedic treatment are those taken during the first stage of development of t,he permanent dentition and its supporting bone structure. In this respect, the vestibule constitutes a new base of operation for the practical application of mechanical devices. Further investigations, of course, are necessary. These should aim particularly at establishing whether the results obtained in this period remain stable. In conclusion, thcrefore, let me quote Melvin Moss: We have not yet arrived at our goal but our direction is now clear.