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The use of functional IN BRIEF

• Describes the different types of

appliances in contemporary functional appliance.

PRACTICE
• Explains the different ways in which
functional appliances work.

orthodontic practice • Explores the evidence behind claims that


functional appliances affect skeletal
growth.
• Outlines how functional appliances are
A. T. DiBiase,*1 M. T. Cobourne2 and R. T. Lee3 used in orthodontic practice and their
limitations.

Functional appliances have been used for over 100 years in orthodontics to correct Class II malocclusion. During this time
numerous different systems have been developed often accompanied by claims of modification and enhancement of
growth. Recent clinical evidence has questioned whether they really have a lasting influence on facial growth, their skeletal
effects appearing to be short term. However, despite these findings, the clinical effectiveness of these appliances is ac-
knowledged and they can be very useful in the correction of sagittal arch discrepancies. This article will discuss the clinical
use of functional appliances, the underlying evidence for their use and their limitations.

INTRODUCTION studies, using unreliable and over-compli-


The term functional appliance refers to cated cephalometric analyses, with all the
a large and diverse family of orthodon- inherent bias associated with these types of
tic appliances designed mainly to correct study.1 More recently, the results of several
Class II malocclusion. They were developed large prospective clinical trials have pro-
primarily in Europe but have been adopted vided the best evidence of what these appli-
by orthodontists in many countries. They all ances can do and equally importantly, what
work by posturing the lower jaw forward, they do not do.
the stretched musculature and soft tissues The development and use of functional
creating a force, which is transmitted to the appliances was pioneered in Europe early in
dentition. In addition, the soft tissue enve- the twentieth century, at the same time that Fig. 1 Modified Andresen activator. The
original design did not have lower incisor
lope surrounding the teeth is changed. This fixed appliances were being developed in
capping or Adams cribs, which have both been
results in tooth movement, establishment the USA. A simple monobloc appliance was added for retention
of a new occlusal relationship and reduc- described by Pierre Robin in 19022 for use in
tion of the overjet. The efficiency of these mandibular retrognathia and functional jaw designs have been described usually bearing
appliances in the correction of sagittal dis- expansion, it was the precursor of the appli- the name of their inventor and incorporat-
crepancies in growing patients has intrigued ance used for the treatment of Class II maloc- ing components reflecting their philosophy.
orthodontists for many years, particularly clusions described by Viggo Andresen while Functional appliances all have a postural
the question of whether they significantly working at the dental school in Oslo. The story effect on the mandible, although how this is
affect skeletal growth. There has been a lot of goes that following fixed appliance therapy achieved and the auxiliary components they
mystery and misinformation associated with on his daughter he fitted her with a modi- incorporate vary between different systems.
their use, often supported by quasi-scientific fied upper Hawley type retainer with a lower
theories of growth. Many of the claims made lingual flange that guided the mandible for- Removable functional appliances
in association with these appliances are in ward into an ideal inter-arch relationship. The
Activators
the form of case reports, or retrospective appliance was fitted as a retainer during her
three month summer holidays to be worn at The original Andresen-Häupl activator was
1
Consultant Orthodontist, Maxillofacial Unit, William night, and it corrected her Class II relationship. constructed from a single block (or mono-
Harvey Hospital, Kennington Road, Willesborough, Ash- Andresen refined the technique and appliance, bloc) of Vulcanite, which was later replaced
ford, Kent, TN24 0LZ; 2Professor of Orthodontics, King’s
College London, Hon Consultant in Orthodontics, Guy’s
with the assistance of Karl Häupl, and coined by acrylic (Fig. 1). The postural element of
and St Thomas NHS Foundation Trust, King’s College the phrase ‘functional jaw orthopedics’ to the appliance is achieved by a lingual exten-
London Dental Institute, London, SE1 9RT; 3Consultant/ encapsulate their philosophy of how the appli- sion of the bloc in the lower arch. It was
Honourary Professor, Centre for Oral Growth and Devel-
opment, Barts and The London School of Medicine and
ances worked. A detailed history on functional deliberately made loose to encourage activa-
Dentistry, Queen Mary University of London, New Road, appliances and the personalities involved has tion of the protractor and elevator muscles
London, E1 1BB been published by Levrini and Favero.3 to keep it in place. Apart from this postural
*Correspondence to: Andrew DiBiase
Tel: 01233 633331; Email: andrewdibiase@nhs.net effect it is designed to be a passive appli-
TYPES OF FUNCTIONAL ance, although guided eruption of the buc-
Refereed Paper APPLIANCES cal dentition can be achieved by facets cut
Accepted 12 November 2014
DOI: 10.1038/sj.bdj.2015.44 Functional appliances can either be remov- into the bloc. Numerous variations of the
© British Dental Journal 2015; 218: 123-128 able or fixed. Numerous different types and activator have been developed. Increased

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PRACTICE

vertical opening of the appliance has been


described by Herren, Harvold and Woodside.
An increase in vertical opening beyond the
freeway space supposedly activates the vis-
coelastic pull of the tissues, similar to the
stretch reflex, as opposed to just relying on
activation of the muscles. Other activators
are designed for use with headgear to restrain
maxillary growth, such as the Teuscher appli- Fig. 2 Teuscher-type activator with torquing
spurs and headgear tubes
ance (Fig.  2). This appliance incorporates
spurs on the upper incisors to prevent lingual Fig. 5 A modified functional regulator (FR 2)
appliance with lower incisor capping
tipping of the teeth while high-pull headgear
is applied. Another variation of the activator
is the Bionator developed by Wilhelm Balters,
who reduced the bulk of the appliance mak-
ing it easier to wear (Fig. 3). Others such as
the Bass or Dynamax appliances remove
direct contact with the lower incisors to try
and prevent their proclination. Posturing of
the mandible forwards is achieved by lingual Fig. 3 Modified Balters Bionator with lower
incisor capping
spurs or springs that sit in the mandibular
lingual sulcus (Fig. 4).
The most significant modifications of the Fig. 6 A Twin Block appliance
activator appliance are the function regula-
tors developed by Rolf Fränkel in the for-
mer German Democratic Republic.4 These
appliances are deliberately designed to have
minimal tooth contact and consist of a metal
framework with buccal shields and anterior
lip pads designed to relieve cheek and lip
pressure and disrupt any abnormal perioral Fig. 4 The Dynamax appliance. Mandibular
protrusion is achieved by lingual springs or
muscular activity (Fig.  5). Fränkel devel-
spurs that rest behind shoulders on a lower
oped these appliances to be worn full time fixed lingual arch
combined with oral exercises and, of all the
Fig. 7 A Herbst appliance
functional appliances, the function regulator
is probably the one that lives up to best to However, it disappeared into obscurity until
the description of functional. it was rediscovered and popularised by Hans
Pancherz in the late 1970s.6 Since then, it
Twin blocks has grown in popularity and is now one of
All the activator variations described above are the most widely used and researched func-
essentially one-piece appliances. This means tional appliances in the world. It consists
that they cannot be worn during eating. To of separate superstructures cemented to the
overcome this, William Clark developed the mandibular and maxillary dentition, and
Twin Block appliance5 (Fig. 6), which consists constructed from either orthodontic bands
of upper and lower removable appliances with or cobalt chromium cap splints connected by
bite blocks composed of bite ramps set at telescopic pistons that provide the protrusive
Fig. 8 FORSUS® spring
about 70 degrees. When occluding, the lower force to the mandible (Fig. 7).
block bites in front of the upper to posture the Such is the prevalence of Class II maloc-
mandible forwards. Generally, the Twin Block clusion in developed countries and the desire HOW DO FUNCTIONAL
appliance is robust and well tolerated, and has for a predictable and compliance-free way of APPLIANCES WORK?
become very popular in the UK. correction that numerous variations of the There is no doubt that a functional appli-
fixed Class II corrector based on the Herbst ance in a growing patient can be very effec-
Fixed functional appliances principle have been described. They usually tive in reducing even a very large overjet.
A major problem with any removable func- have exciting and promising names but most However, controversy remains about how
tional appliance is compliance, because they are introduced without being properly clini- they actually achieve this. Proponents of
do not work unless they are worn for the cally tested. A few persist and prove to be their use believe they have a direct and
required number of hours each day. This can clinically useful. An example of this is the lasting effect on the facial growth, particu-
be overcome by the use of a fixed functional FORSUS® spring from 3M. This is similar in larly of the mandible. Evidence for this has
appliance. The most well-known and popu- design to the Herbst, but attaches directly to proved elusive and they appear to work by
lar fixed functional appliance is the Herbst the molar bands of a fixed appliance and the a combination of altering the soft tissue
appliance. This was first described by Emil lower arch. It consists of a piston and nickel envelope that surrounds the teeth, disrupt-
Herbst in 1905, which makes it almost as titanium spring that produces a protrusive ing the occlusion and by creating an inter-
old as the speciality of orthodontics itself. force on the lower dental arch (Fig. 8). maxillary force.

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PRACTICE

Changing the soft activity of the muscles of mastication, par- opposed to correcting an underlying existing
tissue environment ticularly the lateral pterygoid, the fibres of skeletal discrepancy. These appliances also
The teeth sit in a zone of soft tissue balance which run directly into the condylar car- invariably impose on the animal a treatment
between the lips and the cheeks on one side tilage.7 Use of electromyography (EMG) regime that would be difficult for a human
and the tongue on the other. Certain func- showed hyperactivity of this muscle on patient to tolerate. Finally, the physiology
tional appliance systems, such as the function protrusion of the mandible and the con- and anatomy is different, particularly of
regulators developed by Rolf Fränkel, incor- clusion was that this would result in bony rodents, and therefore the direct application
porate buccal and labial shields or pads that remodelling and growth at the condyle and of any results to humans needs to be done
displace the lips and cheeks away from the glenoid fossa. However, while EMG studies with caution.
teeth. This allows the dental arches, especially have given equivocal or even contradictory Other evidence for the effects of func-
the upper, to expand as the force of the soft results,8 there is no doubt the postural ele- tional appliances on growth has come from
tissues is removed. However, there is no evi- ment of the appliance imparts considerable clinical studies, primarily using cephalo-
dence that this type of expansion is any more force between the maxillary and mandibu- metric radiography. Early studies tended
stable than other more active forms of expan- lar dentitions. This results in distal tipping to be retrospective case series reporting
sion, especially across the lower inter-canine and movement of the maxillary teeth and on the effects of the appliances. As such,
width, which is particularly prone to relapse. mesial movement of the mandibular teeth, they were susceptible to bias and tended to
Posturing the mandible forward will also which aids Class II correction. This can over-emphasise the positive effects of treat-
change the position of the lower lip. With be facilitated by introducing faceting into ment.1 They did not report on success rates
an increased overjet, the lower lip often rests the acylic of the appliance to guide erup- and often compared patients treated with
behind the upper incisors, proclining them tion of the buccal dentition. Clinically, the functional appliances with untreated sub-
and retroclining the lowers. This is often dentoalvolar effects are most apparent with jects from unrelated historic growth stud-
referred to as a lip trap. By posturing the proclination of the mandibular and retro- ies. Measurements tended to be taken from
lower jaw forward, the lower lip moves in clination of the maxillary incisors. These lateral cephalograms taken immediately fol-
front of the upper incisors, freeing the lower dental changes are most apparent with fixed lowing functional appliance treatment, using
incisors to procline and applying a force to functional appliances, where rapid tipping of unreliable and convenient cephalometric
the upper incisors, which retroclines them. the teeth and changes in the occlusal plane points to measure skeletal change and not
Following treatment, it is important that this are consistently seen due to the full-time taking account normal expected growth. It
relationship is maintained, with the lower lip directional forces. is, therefore, unsurprising that many of these
resting in front of the upper incisors creating investigations reported that functional appli-
an anterior oral seal, because if the upper DO FUNCTIONAL APPLIANCES ances could significantly increase mandibu-
lip drops back behind them the overjet will GROW JAWS? lar length.12
increase. It has been known since the nineteenth cen- Over the last decade, three large ran-
tury that bone will remodel and adapt to domised clinical trials have been undertaken,
Class II effect mechanical loading. This is further supported two in the USA and one in the UK. These have
Orthodontists routinely pitch one jaw against by cultural practices, such as foot bind- shown that initially there is a significant
the other when they use inter-maxillary elas- ing and the of use neck rings, which show increase in mandibular length, which can be
tics to help correct antero-posterior problems that environmental factors can change and measured cephalometrically in patients who
and provide anchorage support. Functional mould the skeleton. However, these types are treated with a functional appliance, com-
appliances produce a very similar effect of forces are provided from birth when the pared with controls.13–15 However, as these
through the muscles and soft tissues sur- greatest amount of growth is occurring. patients were followed through adolescence,
rounding the teeth. Many of the activator- Therefore, while functional appliances might these favourable growth changes were lost
type appliances were specifically designed be expected to have some effect on growth and ultimately, patients treated with func-
to be loose in the mouth, activating the of the facial skeleton, this is likely to be a tional appliances and those treated with
elevator and protractor muscles of the jaws relatively short-term influence during wear other types of appliances were essentially
to keep the appliance in place. The forces of the appliance. However, this has proved the same.16–18 Critics of these studies have
generated were transmitted to the jaws and to be an attractive and enticing proposition suggested that they do not represent ‘real
teeth. As these forces are intermittent, this for both clinicians and patients, even though world’ orthodontics, often carried out in uni-
force would be reduced at night and there- the evidence that functional appliances can versity departments by students less expe-
fore some of the appliances were designed significantly influence jaw growth is limited. rienced with the appliances. However, the
to open the bite vertically to a much greater Animal studies in rodents and primates UK-based study was carried out in hospital
extent than Andresen’s orginal activator. The have shown if the mandible is postured departments by experienced consultants and
theory was that this then enlisted the elastic forward, cellular changes do occur at the it came to the same conclusions. Functional
properties of the muscles and connective tis- condyle and glenoid fossa, particularly in appliances did not result in a significant
sues or ‘viscoelastic forces’, which would be juveniles and growing animals.9–11 These long-term increase in mandibular length as
maintained even if muscle activity fell off. changes consist of an increase in mitotic measured cephalometrically. It can be argued
The appliance was also more likely to stay activity of the prechondroblastic cell layer that the measurements used do not take into
in place at night. As such, appliances such in the condyle and bony remodelling of the account the growth rotations of the mandi-
as the Harvold or Woodside activators open anterior border of the glenoid fossa. However, ble that occur and have been described by
the bite much further than the freeway space rodents and primates grow and mature the implant studies of Björk and therefore
and similar changes would be expected from faster than humans which has the effect of under estimate mandibular growth.19 There is
the Twin Block appliance. magnifying these changes. Moreover, these also the wide variation and unpredictability
Early research focused on how the pos- experiments generally consist of converting in response to the appliances, with a percent-
tural component of these appliances affected a normal occlusion into a malocclusion, as age of patients’ jaw relationships improving

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PRACTICE

on their own without treatment which makes use of functional appliances by referring Functional bite
interpretation to a mean difficult. However, the patient at the appropriate time. An Having decided to correct an increased over-
combined, these clinical trials have provided increased overjet and Class II division 1 jet with a functional appliance, an important
data for well over 300 patients which makes type of malocclusion may well present in question is whether this should be done in
it difficult to ignore their findings. the primary dentition but more markedly in one treatment episode, or through progres-
In terms of the effects of different types the early mixed dentition, with eruption of sive forward posturing of the mandible. An
of appliances, a series of controlled clinical the permanent incisors. The temptation is overjet of up to 10 mm can theoretically be
trials in the UK have compared Twin Block therefore to start treatment at this stage with corrected with a single advancement, but
appliances with other types of functional a functional appliance to rapidly reduce the posturing beyond this is more difficult to
appliances, including Bionators, miniblocks, overjet. However, starting treatment in the tolerate, so in these circumstances an appli-
Bass and Dynamax appliances, by systemati- pre-adolescent period, while usually effec- ance will need to be reactivated or a second
cally matching samples by age and gender tive, will often necessitate an extended appliance used once some overjet reduction
and targeting treatment at early puberty. The period of retention to allow the permanent has been achieved. Activator appliances
outcome was a consistently greater increase dentition to establish itself before a second can be reactivated by sectioning them and
in mandibular length with the Twin Block, course of treatment with fixed appliances advancing the lingual flanges; Twin Blocks
with much of this length being expressed as to detail the occlusion. There is evidence by the addition of acrylic to the block and
an increase in the vertical dimension. The that the outcome following early treatment Herbst or other fixed functional appliances
overall increased length was clinically sig- is not any different from that obtained by added rings or crimpable shims to the
nificant vertically, especially with a longer from one course of treatment carried out male component of the telescope or piston.
treatment period, but limited to additional in adolescence.16–18,25 Indeed, the effect of Some clinicians, however, advocate instead
forward movement of the chin of around these appliances appears to be better in of reducing the overjet in one go, it should
3 mm over a 15 month period,20–23 However, children entering their adolescent growth be reduced gradually by reactivating the
while the results of this series of studies are spurt.26 So generally, while treatment is appliance. They claim this will improve tol-
promising only the short-term effects of the often started in the mixed dentition in the erance and wear of the appliance while opti-
appliances are presented. In the long term USA, in the UK, treatment with functional mising the effects on growth. In reality, the
it is unlikely that the average size of any appliances is more routinely started in the effects of either correction with maximum
growth changes will be clinically important late mixed or early permanent dentition. protrusion or by gradual advancement seem
or significant, echoing the results of the This allows immediate transition into fixed to be very similar.28
long-term randomised clinical trials. appliances following the functional phase
So, if functional appliances do not increase of treatment, reducing the overall treatment Clinical management
mandibular protrusion by any great extent, time and burden on the patient (Fig.  9). Following the fitting of an appliance the
how do they produce such dramatic and usu- Therefore, in most patients, referral for an patient is usually seen a few weeks later.
ally lasting Class II correction? Much of the orthodontic assessment should be made in Progress is monitored by a measuring the
affect is dentoalveolar, tipping the maxillary the late mixed so treatment will coincide overjet, which should reduce if the patient
teeth distally and the mandibular dentition with the peak in adolescent growth and be is wearing the appliance as instructed. It is
mesially. They also disclude the mandible as efficient as possible. In girls, however, essential to make sure that the patient is not
from the maxilla or ‘jump the bite’ while puberty can occur before this period and habitually posturing the mandible forward
restricting maxillary growth. This estab- therefore if there are signs they are entering and the degree the patient does this from the
lishes a new occlusal relationship while the their adolescent growth spurt they should occlusal position should be checked, referred
patient is actively growing. The mandible be referred earlier. Failure to refer at the to as the reversed overjet.29 The buccal segment
will always grow more than the maxilla dur- correct time can result in a lost oppor- relationship should also change from a Class II
ing normal growth, but in untreated Class II tunity for the patient to have even fairly to a Class I or even to a Class III relationship.
cases this extra growth does not usually severe skeletal discrepancies corrected Other indications that the appliance is being
manifest itself as Class II correction, because simply with functional appliances, neces- worn include a return of speech to normal and
the Class II occlusal cuspal relationship is sitating the use of orthognathic surgery evidence of general wear and tear associated
maintained and the jaws grow forward for correction, which carries greater risk with the appliance. A Twin Block appliance
together. However, if a new Class I occlusal and cost. will produce a lateral open bite within a few
relationship is established and maintained There is some evidence that early treat- weeks of full-time wear. Indications that the
while the patient is growing, the natural ment may reduce the incidence of dentoal- appliance is not being worn are no reduction
greater growth of the mandible compared veolar trauma.25 Also an increased overjet in the overjet or correction of buccal segment
to the midface allows the condyles to grow can have psychosocial implications, mak- relationship, no improvement in speech and
back into the glenoid fossae, while restrict- ing a child more susceptible to being bullied repeated breakages as the appliance is being
ing forward movement of the maxilla.24 This and early treatment does appear to result removed too frequently.
is why a similar effect can be achieved with in a temporary, but probably important, The reduction in overjet can occur rapidly,
the use of headgear or Class II elastics, as improvement in self-esteem.27 Therefore, in within a few months with appliances such
utilised with Begg or Tip Edge mechanics. certain individuals who are either deemed as the Twin Block. However, it is unwise to
to be at greater risk of trauma or are par- discontinue use of the appliance as soon
CLINICAL USE OF ticularly concerned about the appearance as the overjet is reduced. Initially, a lot of
FUNCTIONAL APPLIANCES of their teeth and being teased or bullied, the change is postural so if the appliance is
Timing of treatment treatment may be started earlier on the stopped too early the overjet will increase as
understanding that overall treatment time the condyle will drop back into the glenoid
The general dental practitioner plays a very will either be extended or a further course fossa. Therefore, the postured position of the
important role in facilitating the successful may be required. mandible needs to be maintained while hard

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PRACTICE

Fig. 9 Treatment of Class II division 1 malocclusion with functional and fixed appliances. Upper
left panel shows the presenting malocclusion in late mixed dentition. Upper right panel shows
the occlusion following 9 months treatment with a Twin Block functional appliance: note the
lateral open bites. Lower left panel show fixed appliances being used to settle and detail the
occlusion. Lower right panel shows final occlusion following removal of appliances

tissue adaptation and growth of the condyle LIMITATIONS OF Fig. 10 Treatment of a Class II divison 2-type
consolidates the new position of the man- FUNCTIONAL APPLIANCES malocclusion with a Twin Block appliance and
a sectional fixed appliance to decompensate
dible. The longer the functional appliance There is no doubt that functional appli- the upper labial segment
can be maintained, the more stable the result ances can produce spectacular results in a
appears to be. In an ideal world the postured relatively short period of time; however, this
position of the mandible would be main- is not always the case. Much of the early be compounded by the use of a functional
tained until the end of adolescent growth research undertaken in relation to these appliance, as it will tend to increase the
although this is rarely practical, particularly appliances was retrospective and therefore lower face. This makes them ideal in patients
if fixed appliances are planned, because it susceptible to bias, often over-reporting the with average or reduced lower face heights
would extend treatment time unrealisti- successful outcomes. From prospective stud- but not patients with increased lower face
cally. Some clinicians reduce the wear of ies we get a more realistic picture of what height. In addition an increased lower face
the appliance to night-time only to allow happens. height at the end of treatment is unlikely to
some occlusal settling. However, the problem The main problem with removable func- be helpful in developing an anterior oral lip
with this approach is that any newly formed tional appliances is compliance. These are seal and lip competence, which is important
bone at the condyle or glenoid fossa will be often difficult appliances to wear as they can for stability of overjet reduction. Therefore,
immature, highly vascular and susceptible affect speech and oral function and therefore these types of cases tend be more prone to
to resorption until it fully calcifies, which is not all patients tolerate them. From prospec- relapse.
only possible if it is not loaded. It takes time tive studies failure rates have been reported Finally, it should be remembered that
for this bone to mature, meaning if the appli- of up to 34% for Twin Blocks.30 This is pri- much of the effect of functional appli-
ance is withdrawn too early or only worn marily due to non-compliance. Fixed func- ances is dentoalveolar, with proclination
part time any bony remodelling or change tional appliances theoretically remove the of the lower incisors and retroclination
may well be lost. This is supported by some problem of cooperation but are more prone of the uppers occurring almost uniformly.
clinical evidence that shows by extending to breakage and are more expensive, which Proclining the lower incisors is inherently
the time period that functional appliances means that compared to other parts of the unstable and tends to relapse. Therefore, the
are worn, the changes produced appear to world they are not as popular in the UK. use of functional appliances is not ideal in
be more stable.23 The amount of tooth movement by tipping patients who present with proclined lower
A period of fixed appliance treatment is is also more marked and the shorter course incisors. However, they can be used in Class
usually needed after functional appliance of treatment more prone to relapse, as any II division 2 malocclusions if the upper labial
therapy as many cases also present with increased bony development needs time to segment is proclined or decompensated,
crowding. The corrected occlusion will also be established. either before or during the functional phase
need consolidating and detailing. This is par- A certain percentage of patients will not of treatment (Fig. 10).
ticularly notable with Twin Block appliances, grow well and therefore not respond well
as these do not allow free eruption of the buc- to treatment with functional appliances. CONCLUSIONS
cal dentition and leave lateral open bites at These tend to be the high angle cases with Despite the lack of evidence that functional
the end of the functional phase of treatment. reduced overbites or anterior open bites who appliances have any clinically significant
Establishing a good Class I buccal segment exhibit a predominantly vertical rather than lasting effect on mandibular growth, they are
relationship will aid in stability (Fig. 9). horizontal facial growth pattern. This can very effective appliances for the treatment

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PRACTICE

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