Myofunctional Appliances

1. MYOFUNCTIONAL APPLIANCES Prepared By: Shi--- IV year Part I B.D.S K.M.C.T. Dental College Kozhikode,Kerala

2. CONTENTS INTRODUCTION -DEFINITION -HISTORY BASIS FOR FUNCTIONAL APPLIANCE CLASSIFICATION FORCES TREATMENT PRINCIPLES INDICATIONS ACTION OF FUNCTIONAL APPLLIANCES CASE SELECTION VISUAL TREATMENT OBJECTIVE COMMON APPLIANCES IN USE WHEN TO TREAT WITH FUNCTIONAL APPLIANCE? LIMITATIONS & COMPLICATIONS OF FAs CONCLUSION REFERENCES

3. DEFINITION “ A removable or fixed appliance which favorably changes the soft tissue environment” -Frankel,1974 “ A removable or fixed appliance which changes the position of mandible so as to transmit forces generated by the stretching of the muscles,fascia &/or periosteum,through the acrylic and wirework to the dentition and the underlying skeletal structures. -Mills,1991

4. “Loose fitting or passive appliance which harness natural forces of the oro -facial musculature that are transmitted to the teeth & alveolar bone through the medium of the appliance.”

5. HISTORY 1879-Norman Kingsley-Forward positioning of mandible in orthodontics-Bite plane/Bite-jumping appliance(vulcanite). Drawback-tendency to relapse even with bite guide. 1883- Wilhelm Roux-first to study the influences of natural forces and functional stimulation on form-foundation of both general orthopedic and functional dental orthopedic principles (Wolff’s Law).

6. Ottolengui -removable plate 1902-Pierre Robin-first practitioner to use functional jaw orthopedics to treat a malocclusion- Monoblock in children with glossoptosis syndrome.

7. 1909-Viggo Andresen(Denmark) -modified bite jumping appliance-inspired from Benno Lisher’s theory. Viggo Andresen Karl Häupl 1938-Karl Häupl (Germany)-saw the potential of Roux’s hypothesis and explained how functional appliances work through the activity of the orofacial muscles.

8. Andresen- Häupl association ACTIVATOR Biomechanical Orthodontics Functional Jaw Orthopedics N orwegian S ystem. 1936-collaborated on a textbook  Funktionskieferorthopädie (Function orthodontics). 1906-Alfred P. Rogers- Father Of Myofunctional therapy- the first to implicate the facial muscles for the growth, development,and form of the stomatognathic system.

9. The Original Herbst Appliance Prof. Emil Herbst 1905/09- Emil Herbst - okklussionsscharnier / Retentionsscharnier  Herbst appliance

10. 1949-Hans Peter Bimler -during WWII-incorporated elastic force to orthopedic appliance  elastischer Gebissformer (elastic bite former) /adapter  Bimler appliance. ~ 1938 -developed, the “ roentgenphotogramm ,” by superimposing a photograph on a head plate, to show the relationship between the skull, the teeth, and the soft tissues.

11. 1956-Martin Schwarz- Double Plates  combine the advantages of the activator and the active plate by constructing separate mandibular and maxillary acrylic plates that were designed to occlude with the mandible in a protrusive position. Double Plates 1950-Wilhem Balters -Modified activator by reducing bulk from palate & substituted with a coffin spring  Bionator Prof.Dr.Wilhem Balters Dr.Martin Schwarz

12. 1957-Rolf Fränkel -Function Regulator. 1977-Dr.William J. Clarks-Twin Block 1989 Magnetic Appliances- Blechman et al. Prof.Rolf Frankel Dr.William J. Clark

13. BASIS FOR FUNCTIONAL APPLIANCE “The three M’s- Muscles,Malformation and Malocclusion”-By Graber,1963-described effects of function & malfunction. The Functional Matrix Hypothesis by Melvin Moss Identification of certain cartilages( eg . Condylar cartilage) as secondary cartilages.

14. Servosystem (or Cybernetic) Theory,1980, by Petrovic & associates Growth Relativity Theory( Vodouris & associates)

15. CLASSIFICATION Classification by Tom Graber,when functional appliances were removable : ( i ) Group I-Teeth supported - Eg : catlan’s appliance,inclined planes.etc. (ii) Group II-Teeth/Tissue supported- Eg:activator,bionator,etc . (iii) Group III-Vestibular positioned appliances with isolated support from tooth/tissue- Eg:Frankel’s appliance,lip bumpers,vestibular screen

16. II. With advent of fixed functional appliances: ( i ) Removable Functionals-Eg : Activator, Bionator , Frankel’s (ii)Removable & Fixed-available in both removable & fixed type- Eg : Twin Block,Herbst (iii)Semi Fixed-Some components fixed,some detachable Eg : Den Holtz, Bass Appliance (iv) Fixed- Eg : Herbst,Jasper Jumper,Churro Jumper,Saif springs,Mandibular Anterior Repositioning Appliance(MARA),etc.

17. III. With concept of hybridization by Peter Vig : ( i ) Classical Functional Appliance- Eg : Activator,Frankel’s appliance (ii)Hybrid Appliances- Eg : propulsor,double oral screen,hybrid bionators,etc .

18. IV. Classification By Profitt ( i ) Teeth borne passive- myotonic appliances- Eg : Activator,Bionator (ii) Teeth borne active- myodynamic applainces-Eg ; Bimler’s appliance, elastic open activator,Stockfish appliance (iii)Tissue borne passive- Eg : Oral screen,lip bumpers (iv)Tissue borne active- Eg : Frankel’s appliances (v) Functional orthopedic magnetic appliances(FOMA)

19. FORCES Mostly use tensile forces-cause stress & strain-alter stomatognathic muscle balance. Both external(primary) & internal(secondary) forces observed in each force application. External Forces- occlusal & muscle forces from tongue,lips & cheeks. Internal Forces-reactions of tissues to 1 force

20. They strain the contiguous tissues  formation of osteogenetic guiding structure (deformation & bracing of the alv . process). This rxn important for 2 tissue  remodelling,displacement and all other alterations that can be achieved by therapy. Differences in force application : -duration of force is interrupted (exceptions-Hamilton & Clark full-time-wear appliances & bonded Herbst & Jasper Jumper) -Magnitude of force is small.If induced strain is too great,difficulty in wearing the appliances.

21. Treatment Principles Depending on the type of force applied,2 treatment principles can be differentiated: I. Force Application II. Force Elimination

22. In force application,compressive stress & strain act on the structures involved  resulting in a 1 alteration in form with 2 adaptation in function. In force elimination,abnormal & restrictive environmental influences are eliminated,allowing optimal development.Function is rehabilitated & followed by 2 adaptation in form.

23. INDICATIONS Use of FA alone: -cases with mild skeletal discrepancy - proclined upper incisors -no dental crowding Use of FA in combination with fixed appliance: -used most commonly to improve the anteroposterior relationship before starting the fixed appliance treatment .

24. -extremely useful in class II cases -reduce the amount of a comprehensive fixed therapy required -reduce need for orthognathic surgery Interceptive treatment -early intervention indicated when one wishes to utilize their growth enhancing effect. -extremely effective in reducing the relative prominence of the proclined upper incisors,which are particularly susceptible to dentoalveolar trauma.

25. ACTION OF FUNCTIONAL APPLAINCES Skeletal,dento -alveolar & soft tissue effects of FA’s reviewed by Dare & Nixon(1999). Functional appliances can bring about the following changes: ( i ) Orthopaedic Changes (ii) Dento-aveolar changes (iii) Muscular & Soft Tissue changes

26. Orthopaedic Changes: -Capable of accelerating the growth in the condylar region. -Can bring about remodeling of the glenoid fossa . -Can be designed to have a restrictive influence on the growth of jaws. -Can change the direction of growth in jaws.

27. Dento -alveolar Changes: -can bring about changes in sagittal,transverse & vertical directions. -Inhibition of downward & forward eruption of the maxillary teeth. - Retroclination of the upper incisors. - Proclination of the lower incisor. -Lower labial segment intrusion. - Levelling of the curve of Spee & tipping of the occlusal plane.

28. Muscular & Soft Tissues Changes: -improve the tonicity of the orofacial musculature. -Removal of the lip trap & improved lip competence. -Removal of adaptive tongue activity. -Lowering of the rest position of mandible. -Removal of soft tissue pressures from the cheeks & lips.

29. CASE SELECTION Age : only in growing patient. Opt. age for FA therapy  b/w 10 years & pubertal growth phase Social Considerations : Dental Considerations : ideal caseone devoid of gross local irregularities Skeletal Considerations : Moderate to sever Class II mo cases are ideal Mild Class III mo with a reverse overjet & an average overbite

30. VISUAL TREATMENT OBJECTIVE An imp. diagnostic test undertaken before making a decision to use a functional appliance. Enables us to visualize how the patient’s profile would be after FA therapy. Performed by asking the patient to bring the mandible forward. An improvement in profile  positive indication. Profile worsens negative -other R x modalities considered. Photographs taken with forward mandibular posture.

31. COMMON APPLIANCES IN USE

32. V ESTIBULAR S CREEN Introduced by Newell in 1912. Takes the form of a curved shield of acrylic placed in the labial vestibule. Works on the principle of both force application & elimination. Vestibular screen does not contact teeth as compared to oral screen.

33. Indications : -to intercept mouth breathing,thumb sucking,tongue trusting,lip biting & cheek biting. -mild disto -occlusions. -to perform muscle exercises to help in correction of hypotonic lip & cheek muscles. -mild anterior proclination . Modifications : HOTz MODIFICATION DOUBLE ORAL SCREEN (With additional tongue shield)

34. KRAUS’S MODIFICATION To reduce bulk & allow expansion when required Courtesy: The Orthodontic Cyber Journal

35. L IP B UMPER “combined removal-fixed appliance”. Used in both maxilla & mandible to shield the lips away from the teeth. Maxillary appliance  Denholtz appliance. Uses : -in lip sucking patients. -hyperactive mentalis activity. -to augment anchorage - distalization of first molars

36. A CTIVATOR Indicaitons : In actively growing individuals with favorable growth patterns. -class II div I mo -class II div II mo -class III -class I open bite -class I deep bite -as a preliminary T/t before major fixed appliance therapy to improve skeletal jaw relations. -for post treatment retention -children with lack of vertical development in lower facial height.

37. Contraindication s: -correction of class I cases with crowded teeth caused by disharmony b/w tooth size & jaw size. -in children with excess lower facial height. -in children whose lower incisors are severely procumbent. -in children with nasal stenosis caused by structural problems w/in the nose or chronic untreated allergy. -in non-growing individuals.

38. Advantages : -uses existing growth of the jaws -minimal oral hygiene problems -intervals b/w appointments is long -appoints are short,minimal adjustments required - hence,more economical

39. Disadvantages : -requires very good patient cooperation -cannot produce a precise detailing & finishing of occlusion. -may produce moderate mandibular rotation(hence contraindicated in excess lower facial height cases)

40. Mode Of Action : Acc. To Andresen & Haupl -induce musculoskeletal adaptation by introducing a new pattern of mandibular closure.  stretching of elevator muscles of masticationcontractionmyotactic reflex set up kinetic energy which causes: -prevention of growth of max. dento - alveolar process -movement of max. dento alveolar process distally -reciprocal forward growth of mandible. In addition, a condylar adaptation by backward & upward growth occurs.

41. Modifications: BOW ACTIVATOR By A.M.Schwarz Wunderer’s modificaiton for Class III

42. PROPULSOR by Muhlemann & Hotz REDUCED ACTIVATOR/KYBERNATOR By G.P.F.Schmuth Herren’s Modification

43. Type I - Distal Activator Type II - Prognathism Activator K A R V E T Z K Y M O D I F I C A T I O N

44. K A R V E T Z K Y M O D I F I C A T I O N Type III a Pan Activator Type III b Pan Activator

45. Wear Time : 1 st week 2-3 hrs a day during day time 2 nd week onwards 3 hrs during day & while sleeping.

46. F RANKEL’S F UNCTION R EGULATOR 2 main T/t effects: 1) serves as a template against which craniofacial muscles function. Framework of the appliance provide an artificial balancing of environment. 2) removes the muscle forces in the labial & buccal areas thereby providing an environment which enables skeletal growth.

47. Types: FR I -Class I & Class II Div I . FR 1a-Class I with minor to moderate crowding. FR 1b-Class II div I where overjet does not exceed 5mm FR 1c-Class II div I ; overjet >7mm

48. FR II - Class II div I & II

49. FR III -Class III FR IV -open bite & bimaxilliary protrusion FR V - incorporate head gear. Indicated in long face patients having high mandibular plane angle& vertical maxillary excess. FR III FR IV

50. B IONATOR Developed by Balters in 1950’s. Modified activator less bulky & more elastic 3 types- > Standard type-class II div I having narrow dental arches > Class III Appliance >Open bite appliance

51. Standard type Class III Appliance Open Bite Appliance

52. T WIN B LOCK A PPLIANCE The Twin Block appliance is a removable, orthodontic functional appliance that is used to help correct jaw alignment, particularly an underdeveloped lower jaw.  Developed by Dr.William J. Clarks , 1977. Effectively combines inclined planes with intermaxillary & extraoral traction.

53. The removable twin block is a tissue-born functional appliance that is worn fulltime. It helps in the advancement of the mandible. It is a two-piece appliance composed of an upper and lower bite block. Orthopedic traction can be added in cases of severe skeletal discrepancies. This includes the use of a Concord Facebow (or headgear) at nighttime. Upper & lower bite blocks interlock at 70 angle.

54. The fixed twin block is similar to the removable twin block, but can be used in non-compliant patients. It is similar in design to the Herbst appliance, however the telescopic tubes of the Herbst appliance are replaced with two bite blocks.

55. Advantages : -very good patient acceptance. -bite planes offer greater freedom of movement & lateral excursion. -less interference with normal function. -significant changes in patient’s appearance within 2-3 months.

56. H ERBST A PPLIANCE Fixed functional appliance developed by Emil Herbst in early 1900’s. Indications : -correction of class II MO due to retrognathic mandible. -can be used as anterior repositioning splint in patients having TMJ disorders.

57. Specific indications -Post adolescent patients: T/t completed w/in 6-8 months,hence possible to use the residual growth in these patients. -Mouth breathers -Uncooperative patients 2 types: -Banded Herbst -Bonded Herbst

58. Banded Herbst Appliance Bonded Herbst Appliance

59. Advantages : -continuous action -T/t duration is short -less pt cooperation needed -can be used in pts who are at the end of their growth -can be used in pts with mouth breathing habit.

60. Disadvantages : -cause minor functional disturbances. -increased risk of development of dual bit,with TMJ dysfunction symptoms as a possible consequence. -repeated breakage & loosening of appliance occurs,esp . in lower premolar area. -plaque accumulation & enamel decalcification can occur -tendency for posterior open bite.

61. J ASPER J UMPER A relatively new flexible,fixed ,tooth borne FA. Introduced by J.J.Jasper ,1980 Actions similar to Herbst appliance but lack rigidity. Basically indicated in skeletal class II mo with max. excess & mandibular deficiency.

62. Advantages : -produce continuous force -does not require patient compliance -allows greater degree of mandibular freedom than Herbst appliance -oral hygiene is easier to manage.

63. WHEN TO TREAT WITH FUNCTIONAL APPLIANCE ??? The best time to start functional appliance therapy is the late mixed dentition. Advantage of the pubertal growth spurt should be taken. Girls & boys along with early maturers should be assessed individually.

64. LIMITATIONS & COMPLICATIONS Discomfort, as both upper & lower teeth are joined together. Mainly depends on patient’s compliance Can be used only if a favorable horizontal growth pattern is present in cases of Class II correction. It has to be removed during masticaiton,particularly when strongest forces are applied. May interfere with speech. Treatment duration is often long

65. CONCLUSION The global demand for orthodontics without braces continues to grow.  It's an option that many parents and patients would prefer. Myofunctional orthodontics offers a viable alternative to traditional orthodontic methods. A functional appliance is an appliance that produces all or part of its effect by altering the position of the mandible/maxilla.

66. These appliances utilize the muscle action of the patient to produce orthodontic or orthopaedic forces to restore facial balance. The question that must be addressed in diagnosis is : “does the patient require orthodontic treatment or functional orthopedic treatment or a combination of both and to what degree? whether the patient requires functional appliance alone or need a orthognathic surgery or to what extend FA can reduce need for surgery?”

67. “ The study of orthodontia is indissolubly connected with that of art as related to the human face.The mouth is a most potent factor in making the beauty and character of the face and the form & beauty of the mouth largely depends on the occlusal relations of the teeth. Our duties as orthodontists force upon us great responsibilities and there is nothing which the student of orthodontia should be more keenly interested than in art generally,and especially in its relation to the human face,for each of his efforts,whether he realizes it or not makes for beauty or ugliness,for harmony or inharmony,for perfection or deformity of the face.Hence it should be one of his life studies. ” - E.H.Angle,1907

68. REFERENCES Dentofacial Orthopedics with Functional Appliances by Thomas M. Graber,Thomas Rakosi & Alexandre G.Petrovic;2/e,2009 Orthodontics Diagnosis & Management of Malocclusion & Dentofacial Deformities by Om Prakash Kharbanda;2/e,2013 Orthodontics Principles & Practice by Basavaraj Subhashchandra Phulari;1/e,2011 Textbook Of Orthodontics By Gurkeerat Singh;2/e,2007

69. Textbook Of Pedodontics by Shobha Tandon;2/e,2008 Orthodontics –The Art & Science by S.I.Bhalajhi;3/e,2003 Contemporary Orthodontics by William R.Proffit;4/e,2007 Norman Wahl,Special Article, “Orthodontics in 3 millennia. Chapter 9: Functional appliances to midcentury” ;(Am J Orthod Dentofacial Orthop 2006;129:829-33) Various Internet Sources