Dr.

Rebin Ali
07/02/2015

Lec. 5

Functional Appliances
Definition
Functional appliances utilize, eliminate, or guide the forces of muscle
function, tooth eruption and growth to correct a malocclusion.

Theories on how functional appliances work

Functional appliances eliminate a sagittal jaw discrepancy by posturing
the mandible forward. This postural correction is fundamental to the
appliances mode of action and influences four principle regions:
1. Orofacial soft tissues 2.Muscles of mastication 3.Dentition and
occlusion 4. Jaw skeleton.
1. Orofacial soft tissues
The teeth sit between the tongue on one side and the lips and cheeks on
the other.
If the balance of these forces is altered, tooth movement can result.
2. Muscles of mastication
Forward posturing of the mandible results in stretch and an alteration in
activity of the muscles of mastication, particularly those involved in
elevation and retraction of the mandible. These forces will be transmitted
to the dentition via the appliance.
3. Dentition and occlusion

It would appear that changes caused by functional appliances are

principally due to dento-alveolar changes. This means there is distal
movement of the upper dentition and mesial movement of the lower
dentition, with tipping of the upper incisors palatally and the lower
incisors labially.
4. Jaw skeleton
Sutural growth can be significantly influenced by the application of
external force and there is some evidence that the class II force
component placed upon the maxilla by a conventional functional
appliance can apply some restraint upon forward maxillary growth,
particularly when combined with headgear.

Clinical effects of functional appliances

1. Orthopaedic Changes:
-Capable of accelerating the growth in the condylar region.
-Can bring about remodeling of the glenoid fossa.
- Restrain forward growth of maxilla.
-Can change the direction of growth in jaws.

Dento-alveolar Changes:
Retroclination of the upper incisors.
Proclination of the lower incisor.
Distal tipping of the maxillary dentition;
Mesial eruption of the mandibular buccal dentition;
Levelling of the curve of Spee & tipping of the occlusal plane.
Muscular & Soft Tissues Changes:

-improve the tonicity of the orofacial musculature.

-Removal of soft tissue pressures from the cheeks & lips.

Indications
1. Age: only in active growing patient.
2. Social Considerations: Patient positively interested in treatment.
3. Dental Considerations: ideal case one devoid of gross dental
irregularities
4. Skeletal Considerations:
Mild to moderate sagittal skeletal discrepancy (class II
and III)
Reduced, normal or moderately increased anterior face
height.
Timing of Treatment
Functional appliances should be used when the patient is growing. It has
been suggested that treatment should, if possible, coincide with the
pubertal growth spurt. Generally puberty starts in girls approximately
two years before boys and is shorter in duration. The mean PHV (peak
height velocity (PHV) as the peak in adolescent maxillary and
mandibular growth occurs at the same time) occurs at around 12 years
of age in girls and 14 in boys.
However, chronological age is a poor predictor as there is a huge range
of individual variability. standing height measurements, hand wrist
radiographs, cervical vertebral maturation status and secondary sex
characteristics have been advocated as tools to assess patients maturity
status and if the pubertal growth spurt has happened yet or is in

progress. In general, it is considered better to start functional appliance

therapy in the late mixed dentition or early permanent dentition, as
doing so will allow patients to progress to the second phase treatment
with a fixed appliance.
Impressions and bite
Detailed impressions in alginate should be taken of both dental arches
with adequate extension into the lingual and labial vestibules.
The bite recording should prescribe to the laboratory the exact position
of the postured mandible in all three dimensions anteroposteriorly,
vertically and transversely. The degree
of protrusion will depend on the size of the overjet and the comfort of the
patient. For patients with a large overjet, protruding the patients
mandible more than 75 per cent of their maximum protrusion can make
the appliance difficult to tolerate. It is relatively easy to reactivate some
functional appliances during treatment if further protrusion is required.
Vertically there should be approximately 2-mm of separation between
the incisors. The exceptions to this are for Harvold-type activators, which
are constructed to open the bite beyond the freeway space and for twin
blocks, which require at least 5-mm of vertical separation in the buccal
segments to allow for the inclined occlusal planes.

TYPES OF APPLIANCES
Activator (Monobloc)
The acrylic body of the Andresen activator covers part of the palate and
the lingual aspect of the mandibular alveolar ridge. A Hawley arch fits
anterior to the maxillary incisors and carries U-loops for adjustment. On

the palatal aspects of the maxillary incisors, the acrylic is relieved to

allow their retraction.
A main feature of the appliance is the faceting of the acrylic on palatal
and lingual aspects of the maxillary and mandibular posterior teeth,
respectively, designed to direct their eruption. On the palatal aspect of
the maxillary posterior teeth the facets are cut so as to allow occlusal,
distal and buccal movement of these teeth. This movement is achieved
by keeping the acrylic in contact with only the mesiopalatal surfaces of
the premolars and molars. On the lingual aspect of the mandibular
posterior teeth the facets only permit occlusal and mesial movement,
with the acrylic contacting the distolingual surface of these teeth.
This appliance seems to be like upper and lower base plate which are
attached with each other, hence the name monobloc. The appliance is
loose fitting and has no anchorage elements.

Bionators:
It is less bulky than activator. The bionator is a loose fitting appliance
and not anchored to the teeth by clasps.
The reduced bulk of the appliance and its ability to reposition the
mandible and modifies dental eruption have been important in its ready
acceptance by both the parents and dental surgeons.
The appliance resembles the activator with some exceptions. The labial
wire across maxillary incisors is modified to act as a screen, reducing the
pressure from the cheek musculature on the dental arches. The
appliance also has a transpalatal wire that helps in stabilizing it when the

tongue rests against the wire and adds more rigidity. The acrylic is
reduced to minimum.

Function Regulator Appliance (Frankel)

The Frankel appliance is the only completely tissue-borne appliance.
It is used for correction of Class I, Class II div. 1 and 2, Class III
malocclusion as well as open bites. The functional components of
appliance generate forces by altering posture of the mandible, changing
soft tissue pressure against the teeth or both.
It can be difficult to wear, is expensive to make and is troublesome to
repair. As a result it is now used less frequently.
The function regulator differs from other appliances in that it has no
contact with the lower teeth or alveolar process when the patient holds
the mandible in forward position. When the patient retracts the lower
jaw, a lower lingual pad comes into contact with lingual mucosa below
the level of marginal gingiva of mandibular anterior teeth.
The main purpose of the appliance is to train the lip and cheek
musculature to function normally and to relieve the pressure on the
dental arch maximally, thereby promoting transverse arch development.

Twin Block
This appliance consists of individual maxillary and mandibular plates
with ramps that guide the mandible forward when the patient closes
down. The appliance has the advantage of allowing nearly a full range of

mandibular movements, easy acclimation, reasonable speech and simple

modifiability.
The blocks need to be at least 5 mm high, which prevents the patient
from biting one block on top of the other. Instead the patient is
encouraged to posture the mandible forwards, so that the lower block
occludes in front of the upper block. The appliance can be worn full time,
including during eating in some cases, which means that rapid correction
is possible. It is also possible to modify the appliance to allow expansion
of the upper arch during the functional appliance phase. It is also easy
to reactivate the twin-block appliance. This means that during treatment
if further advancement of the mandible is required, it is possible to
modify the existing appliance rather than having to construct a new
appliance

Herbst Appliance
There is a section attached to the upper buccal segment teeth and a
section attached to the lower buccal segment teeth. These sections are
joined by a rigid arm that postures the mandible forwards. It is as
successful at reducing overjets as the twin-block appliance. It is however
slightly better tolerated than the bulkier twin-block appliance, with
patients finding it easier to eat and talk with it in place. The principle
disadvantages are the increased breakages and higher cost of the Herbst
appliance.