THE FRANKEL FUNCTIONAL REGULATOR.pptx

FRANKEL APPLIANCE (ALL TYPES AND MODIFICATIONS)

1. 1 PRESENTED BY – Dr. Firdosh Rozy THE FRANKEL FUNCTIONAL REGULATOR

2. Introduction History Synonyms Philosophy Mode of action of FR Indications and Contraindications Advantages and Disadvantages Components Diagnosis Types modifications Treatment objectives Clinical handling Instructions Journal reviews Conclusions References CONTENTS :

3. INTRODUCTION : Functional appliances are defined as loose fitting or passive appliances which harness or eliminates the natural forces of the orofacial musculature that are transmitted to the teeth and alveolar bone through the medium of appliance.

4. The basis of functional treatment in general is a principal that a “ new pattern of function” dictated by the appliance, leads to corresponding “new morphologic pattern.”

5. The functional regulator is a removable orthodontic appliance developed by Prof. Rolf Frankel. This appliance is used during the mixed and early permanent dentition stages to effect changes in anteroposterior, transverse and vertical jaw relationship. The frankel appliance has 2 main treatment effects- First, It serves as a template against which the craniofacial muscles function . The 2 nd effect of frankel appliance is its influence on skeletal and dental development.

6. Dr. Rolf Frankel was an orthodontist from the obscure town of Zwickau , East Germany wrote of his functional appliance developments. His first contributions were in German attracted very little attention abroad. However, 2 events occurred to change the odds. HISTORY :

7. First, Rolf Frankel learned English . 2 nd a professor of orthodontics at the university of Chicago recognized the significant contributions being made by frankel, saw the results and documentations and invited him to US to present his philosophy & show his treated cases. Seminar were arranged there under the aegis of Dr. J ames McNamara, Dr. T.M. Graber at universities of Michigan & Detroit. The original introduction of Dr. Frankel had been arranged by Bedrick Neumann of Czechoslovakia, & subsequent team effort by Neumann & Graber produced Removable Orthodontic Appliances, which incorporated a chapter on the Frankel Regulator. Dr. CHARLES NORD was correct when he called the frankel method “ A Revolution in orthodontic appliances.

8. SYNONYMS : FRANKEL APPLIANCE VESTIBULAR APPLIANCE ORAL GYMNASTIC APPLIANCE FUNCTIONAL REGULATOR Frankel postulates that increase in crowding is the result of hypertonic muscles in the buccinator mechanism restricting the lateral growth of the teeth and their supporting tissues. One objective of the vestibular shield is to regulate the hypertonic muscles of the buccinator and the perioral muscles, thereby giving rise to the name… FUNCTIONAL REGULATOR.

9. THE PHILOSOPHY OF FRANKEL APPLIANCE

10. A major tenet of the frankel philosophy is that the dentition is heavily influenced by T he functional matrix The buccinator mechanism The orbicularis oris complex. 1. VESTIBULAR ARENA OF OPERATIONS : FR is largely confined to the oral vestibules, & hold away the buccal & labial musculature from the dentition in those areas in which pressure on the dentoalveolar structures has restricted the outward development of these structures during the critical transitional phase of dental development.

11. FMH of Melvin Moss : Buccal shields of frankel directly alter the soft tissue configuration, increasing the oral volume, that is the capsular matrix that allows the muscle to exercise and adapt and improve.

12. The 2 nd pillar of the FR philosophy is the method by which the sagittal correction is achieved. Frankel has designed the FR so that there is no tooth contact at all in the lower arch. The forward posturing of mandible is achieved by an acrylic pad that contacts the alveolar bone only behind the lower anterior segment. Appliance is fixed on the upper arch by grooves mesial to the 1st permanent molar and distal to the canine in the mixed dentition period. Presence of the lingual pad acts as a proprioceptive stimulator and helps in the forward posturing of the mandible. 2 . SAGGITAL CORRECTION VIA TOOTH BORNE MAXILLARY ANCHORAGE :

13. 3. DIFFERENTIAL ERUPTION GUIDANCE : By being free of the mandibular teeth, selective differential eruption of the lower posterior teeth is possible, which not only corrects vertical dimension deficiencies but also helps in the sagittal correction of class II malocclusions. 4 . MINIMAL MAXILLARY BASAL EFFECT : Little sagittal protrusive effect seen in maxilla with FR therapy, even though lateral Maxillary expansion in seen, in contrast to a significant forward change of the mandible.

14. 4 . BUCCAL SHIELDS, LIP PADS, & PERIOSTEAL PULL : Research by Enlow, Hoyt, & Moffet has shown that pull on periosteal tissue enhances growth beneath it. Frankel reasons that there will be an outward periosteal pull by maximal extension of the shields & pads into the depth of the buccal and labial vestibule to the point at which the depth of the sulcus is under tension.

15. Since the thin, bony shell beneath this area houses the erupting permanent teeth , an outward growth of membranous bone , plus relief of any restrictive tissue pressure , results in bodily transverse changes in the posterior segments and bone formation at the apical base contiguous to the lip pads. Both of these occurrences are desirable treatment objects that have been unattainable with conventional fixed or removable appliances.

16. MODE OF ACTION OF FR : Increase in transverse and sagittal direction - by use of buccal shields and lip pads . 2. Increase in vertical direction - by allowing the lower molar to erupt freely because appliance is fixed to the upper arch

17. 3. Muscle adaptation - Development of new patterns of motor function by buccal shields and lip pads of FR can be achieved by- a) massaging the soft tissues b) loosening the tight muscles c) Improving the blood circulation d) improving muscle tonicity e) Providing new functional matrix for perioral muscle to act upon it- ‘Ought-to-be matrix’

18. 4. Mandibular forward positioning- Position of mandible can be changed by gradual training of the protractor and retractor muscles followed by condylar adaptation.

19. Mixed dentition period with growth spurts. Skeletal class II malocclusion with prognathic maxilla and retrognathic mandible (Positive VTO) Functional class II malocclusion. In a horizontal or neutral growth vector case. Class III malocclusions. Bimaxillary protrusion and open bite problems. INDICATIONS :

20. Fr- VTO : The Fr- VTO is a simple, yet very important maneuver that is performed before making a decision to use the FR appliance. The patient is first asked to close the teeth in habitual occlusion and relax the lips. The profile view is carefully studied and can be photographed at this time to obtain an instant imprint. Then the patient is asked to posture the mandible forward into a correct sagittal relationship, reducing the overjet. A photograph of this profile can be taken again & can be compared with the teeth in occlusion. If this clinical maneuver improves the profile, the FR appliance is probably indicated.

21. CONTRAINDICATIONS : Class I malocclusion with severe crowding Thumb sucking habit. Severe dentoalveolar problems in permanent dentition. Uncooperative patients.

22. ADVANTAGES 1. It enables elimination of abnormal muscle function thereby aiding in normal development. 2. Treatment can be initiated at early age . 3. Less chair side time is spent. 4. The frequency of the patients visit is less. 6. T hey deal with skeletal as well as dent alveolar problems.

23. 1. The appliance is bulky and the cooperation of the patient is essential. 2. They cannot be used in adult patients were the growth has ceased. 3. Cannot be used to bring about individual tooth movement and in cases of crowding. 4. Fixed appliance therapy may be required at the termination of treatment for final detailing of the treatment. DISADVANTAGES :

24. COMPONENTS OF FRANKEL :

25. LOWER LINGUAL PAD : It lies lingually below the gingival margin of mandibular teeth and extends distally to the roots of lower second premolar. Operational Purpose: Forced Training: It is used to overcome poor postural performance of muscles suspending the mandible. ACRYLIC PART

26. BUCCAL SHIELDS : They should extend deep into the sulcus, particularly in the apical region of maxillary first premolar and maxillary tuberosity. The shield must be at an appropriate distance from the lateral aspect of the teeth and alveolus for expansion. The thickness of the shield should not exceed 2.5mm in order to make the wearing of the appliance comfortable

27. PURPOSE OF BUCCAL SHEILD To restrain the cheek musculature 2. The action of the tongue, acting from within the oral cavity brings about an expansion of the dental arches. 3. The shields -first premolar and maxillary tuberosity area- stretches the periosteum cause tension -deposition of bone along the lateral aspects of maxilla.

28. The vestibular shield creates tension at the depth of the mucobuccal fold in a lateral direction. This tension is directed at influencing the erupting permanent teeth to erupt further laterally than normal, thereby resulting in arch expansion. Notice that less influence is seen on fully erupted teeth, as shown by the open arrow.

29. LABIAL PADS : These pads are rhomboid in shape . In crossection they should be in tear drop shape. The upper edges of the lip pads should be at a distance of 5mm from gingival margin. The distal edge should not overlap the labial protuberance of canine root

30. Operational purpose: ◂ The lip pads when correctly positioned in depth of sulcus have a supporting effect on lower lip smoothing the mentolabial sulcus and improving lip posture. ◂ Thus the lower lip makes a normal contact with the upper lip which is important for establishment of competent lip seal.

31. Forced training: ◂ The main purpose of lip pads is to prevent hyperactive mentalis muscle. ◂ This inhibitory action is necessary in order to achieve a training effect on lip muscles which are designed to bring about physiological lip seal.

32. WIRE COMPONENTS : PALATAL BOW It originates in the central groove of maxillary first molar forming an occlusal rest that is parallel to the occlusal plane so as to allow expansion of molars laterally. The wire makes a loop in the buccal shield and recurve to cross in the interproximal groove between maxillary second premolar and first molar.

33. The wire then crosses the palate with a posterior curve that approximates between hard and soft palate. From there it recurves in a similar manner. It is constructed by 1mm gauge of wire. It is used for posterior appliance stability and intermaxillary anchorage.

34. 2. CANINE LOOP : Canine loop is embedded in the buccal shield at the level of the occlusal plane. It rises sharply to the gingival margin of maxillary first deciduous molar, and fits in the embrasure between the deciduous first molar and the canine to lock the appliance in place on the maxilla.

35. The loop wraps around the lingual surface of the canine and emerges labially in the canine-lateral incisor embrasure, curving distally over the canine cusp. The free end can be bend. In the mixed dentition stage the wire embedded in the acrylic can be adjusted to prevent interference with the proper eruption of the canine and first premolar. It is fabricated by 0.9mmgauge of wire. It helps in canine guidance and proper stabilization of the appliance.

36. 3. LABIAL BOWS : The labial wire turns gingivally at right angle between the maxillary lateral incisors and canine to form the canine loops.

37. 3. LOWER LABIAL WIRES : They are fabricated by 0.9mm diameter of wire. It supports the lip pads in proper position. The average distance between the labial wires embedded in the lip pads and gingival margin is 7mm.

38. Three wires are used for fabrication of labial wires. The central wire is bend in the shape of inverted “V” and must be high enough to prevent irritation of labial frenum. Lateral wire are positioned 0.75mm away from wax relief in order to ensure that they will be firmly embedded in the future buccal shield.

39. 4. LOWER LINGUAL WIRES : The central wire follows the contour of lingual apical base at approximately 1mm to 2mm from the mucosa and 3mm to 4mm below the lingual gingival margin of incisors, to allow the addition of the acrylic. It is fabricated by 0.8mm dia of wire.

40. Two lingual springs emerges from the lingual shield occlusally and are contoured to the lingual surface of the lower incisors right above the cingulum of the lower incisors. If they are to be used as “function activated” element they may be placed on the lingual surface of lower incisors superior to the cingulum. This should only be done in severely tipped lower incisors.

41. 5. LOWER LABIAL SUPPORT WIRES : The lingual contour of the wire is positioned 1mm away from the mucosa. It should run posteriorly , and the free ends, about 9mm to 10mm below the lingual gingival margin ,are then bend at right angle to secure a firm seat in the acrylic. It is important that the wire pass interocclusally without contacting upper and lower teeth.

42. They are then bend laterally to insert in buccal shield. The lateral end of the wire are parallel to the occlusal plane because they will be used as guides when lower anterior section of appliance is advanced to change mandibular position step by step. For this purpose the portion of the wire embedded in the acrylic should be straight so that it can slide through the acrylic of the shield.

43. Impression making Impressions should reproduce the whole alveolar process to the depth of the sulci , including maxillary tuberosities. Gauge to measure the correct depth of sulcus

44. TYPES OF FRANKEL APPLIANCE :

45. 1 lingual pad

46. FR 1 a

47. FR I b

48. Lower lingual springs Surface of the lower incisors right above the cingula . Lower labial wire It supports the Skelton for the lip pads .

49. Labial bow The bow originates in the buccal shield and lies in the middle of the labial surfaces of incisors , turning gingivally at right angles between maxillary lateral incisors and canines.

50. Canine loop The loop wraps around the lingual surface of the canines .It is embedded in the buccal shield at the occlusal plane level. It rises sharply to the gingival margin and fits in the embrasure.

51. FRI c The buccal shields are split horizontally and vertically into 2 parts – Anteroinferior portion contains the wires for lingual acrylic pressure pad or shield and for the lower lip pads. Vertical split is opened to the desired position by a 2 to 3 mm advancement and is then filled with acrylic. Used if overjet > 7mm

52. FR II FRANKEL’S REGULATOR ACRYLIC COMPONENT WIRE COMPONENT FR II 2 LOWER LIP PADS 2 BUCCAL SHIELDS LOWER LINGUAL ACRYLIC PAD a. palatal bow. b. labial bow. c. canine extensions. d. upper lingual wire. e. lingual cross over wire. f. support wire for lip pads. g. lower lingual springs.

53. CONSTRUCTION

54. 2. Impression Deep upto vestibules. The purpose of this mandibular manipulation is to relocate the jaw in the direction of treatment objectives. •This creates artificial functional forces and allows assessment of the appliance's mode of action. As discussed earlier. 3. Bite construction

55. 6. Work model mounting … mount the models on the straight line fixators .

56. 7. Wax relief:

57. 8. Wire formation

58. FR III

59. INDICATION :

60. The proposed method of action of the FR-3 appliance. The distracting forces of the upper lip are removed from the maxilla by the upper labial pads. The force of the upper lip is transmitted through the appliance to the mandible because of the close fit of the appliance to that arch (after Fränkel1). MODE OF ACTION

61. Construction bite The procedure of taking the construction bite is done by retruding the mandible as much as possible with the condyle in its most posterior position. The vertical opening is kept to a minimum to allow lip closure with minimal stress

62. Wax relief No wax is applied to the mandibular arch.

63. FR IV

64. • Correction of open bite and bimaxillary protrusion . • Exclusively confined to mixed dentition INDICATION : MODE OF ACTION : The downward and backward growth direction of the mandible was changed to a upward and forward direction by FR-4 therapy, allowing the skeletal anterior open bite to be successfully corrected through upward and forward mandibular rotation.

65. INDICATED : Long face syndrome having a high mandibular plane angle and vertical maxillary excess FR V Modification of Frankel by Albert H Owen (1985 –JCO)

66. FRANKEL’S REGULATOR ACRYLIC COMPONENT WIRE COMPONENT FR V 2 LOWER LIP PADS 2 BUCCAL SHIELDS LOWER LINGUAL ACRYLIC PAD ACRYLIC BITE BLOCK ADDITIONAL a. palatal bow. b. labial bow. c. upper lingual wire. d. lingual cross over wire. e. support wire for lip pads. f. lower labial wires

67. It also has head gear tubes that accept a face bow for an occipital pull headgear. Additional bite blocks – to arrest molar eruption.

68. MODIFICATIONS OF FRANKEL APPLIANCES : Capped FR appliance – OTTON et al, 1992 Modified FR for VME – OWEN 1985 Change in angulation of cross over wire – Chate , 1986 Hybrid appliance , FR –ACTIVATOR combination – 1986 KINGSTON modified buccal shields FR with continuous buccolabial shield and palatal acrylic support – Hynes 1986

69. Capped FR appliance – OTTON et al, 1992 Given by Raymond Otto in 1992 ◂ Indicated in deep bite cases ◂ Controls labial tipping of mandibular incisors Disadvantages ◂ Need of sufficient posterior separation ◂ Capping may impinge on maxillary incisors as treatment progresses ◂ Difficult to clean

70. 3. Change in angulation of cross over wire – Chate , 1986 Strictly horizontal advancement results in incisal movements of lower wire and shield. Difficulty in establishing normal lip function

71. 4. Hybrid appliance , FR –ACTIVATOR combination – 1986 Given by Dr. Peter Vig and Dr. Katherine Vig in 1986 •Hybrid appliances are specifically and individually tailored for every patient. •Problems of every patient is recognized and Instead of using a “named” appliance for the treatment of a class of malocclusion, various components of different functional appliances can be used to make a composite appliance.

72. 5. KINGSTON modified buccal shields

73. 6. FR with continuous buccolabial shield and palatal acrylic support – Hynes 1986 Palatal acrylic support and continuous buccolabial acrylic construction, which replaces conventional function regulator with separate buccal shields and lip pads. The appliance is not "locked" into the mesial embrasure of the maxillary first molars by a cross-palatal bar.

74. CLINICAL HANDLING OF THE FR : Stabilizing the appliance at the delivery is absolutely essential. Pre placement, all margins are checked for smoothness .  Check vertical dimension.  Over extension of the labial ,lingual, lip and buccal pads causes tissue irritation . So the extension should be correct.

75. Wearing time  For the first two weeks the appliance should be worn for 2 to 4 hours during the day.  During the next 3 weeks the time is extended to 4 to 6 hours.  It usually takes 2 months before the appliance is worn at night.  The appliance and treatment progress should be checked at 4 weeks interval.  An initial end to end molar relationship is corrected in 6 months.

76. INSTRUCTIONS FOR THE PATIENT:  A little discomfort is to be expected initially.  Salivation may be increased but it should not be a problem.  Instruction on appliance care and oral hygiene maintenance .  Demonstrate the lip seal exercise .  Ask the patient to speak a few words and reassure that speech would normalize.  Wearing time should be correctly followed.

77. JOURNAL REVIEWS

78. References • Dentofacial orthopedics with functional appliances . Graber,Rakosi , Petrovic Graber Neumann •McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental changes following functional regulator therapy on Class II patients. American journal of orthodontics. 1985 Aug 1;88(2):91-110 • Falck F, Fränkel R. Clinical relevance of step-by-step mandibular advancement in the treatment of mandibular retrusion using the Fränkel appliance. American Journal of Orthodontics and Dentofacial Orthopedics. 1989 Oct 1;96(4):333-41

79. McNamara JA, Howe RP, Dischinger TG. A comparison of the Herbst and Fränkel appliances in the treatment of Class II malocclusion. American Journal of Orthodontics and Dentofacial Orthopedics. 1990 Aug 1;98(2):134-44. •Hamilton SD, Sinclair PM, Hamilton RH. A cephalometric , tomographic , and dental cast evaluation of Fränkel therapy. American Journal of Orthodontics and Dentofacial Orthopedics. 1987 Nov 1;92(5):427- 34