R. Rama Putranto

Removable AppliancesA. Base Plate

B. Component RetentiveC. Component Active/Force anchorage

A. Base Plate1. Supporting others component : claps, Screw Expansion etc.2. Continue Strength/force of the resulting from claps to anchorages3. To prevent unwanted moving teeth4. To protect the spring or claps on palatal / lingual side5. To hold and continue biting force

• Stability of plate1. Plate width was made as wide as possible, depend on treatment needs2. The plate should be able to adapt with oral mucosa3. The plate around moving teeth must be free

• Functional AppliancePrimarily orthopedic tools to influence the facial skeleton of the growing childTransmit, Eliminates, and guide the natural forcesMuscle activity, growth, tooth eruptionTry To create conditions for the harmonious development of the stomatognathic system

• Early Class II Malocclusion• Class III Malocclusion

CLASSIFICATION OF FUNCTIONAL APPLIANCE• Teeth Supported Appliances Ex/ Inclined

plane, guiding plane, etc• Teeth/Tissue supported : Activators, Bionator ,

etc• Vestibular positioned appliances with isolated

support from teeth/tissue :Frankle Appliance, Lip bumpers

• Removable Appliance : Activators , Bionators, Frankle , etc

• Semi-fixed Appliance : Bass Appliances• Fixed Appliances: Herbst, Jasper Jumper, etc

Study by McNamara with primates 1975• Masticatory muscles and appropriate orthopedicappliances can modify the rate and amount ofcondylar growth• LPM activity may induce condylar deposition

Growth Spurt• Beginning of puberty or menstruation• Evaluated by age, tooth eruption, height, ossification of hand/wrist bones on x-ray

Role of glenoid fossaVoudauris 1988• Fossa is altered and brought forward bymandibular advancementRuf et al- AJO 1999• The increase in mandibular prognathism to be aresult of condylar and glenoid fossa remodelingRabie et al –AJO 2002• Forward mandibular positioning causes significantincreases in vascularization and new boneformation in the glenoid fossa

Factors influencing mandibular growth• Cranium positioning• Condylar cartilage• Muscles (LPM ?)• TMJ disc• STH (Somatomedin) --> cell growth and division• Other factors

Study with ratsFunctional advancements at different ages andocclusionsStable Results• Treatment continues until growth stops• Continued growth possible with locked-inocclusionUnstable ResultsContinued growth with imprecise occlusion

Optimum Timing• Increase of STH (Somatomedin)• Increase of sex hormone• High growth rate• 8-10 years for removable type• 11-13 years fixed typeNote- Most efficient in permanent dentition-(Profit, Pancherz AJO 2002)

• Late stage of mixed dentition,1-2 years before the pubertal growth occur

• Female: 9~10 year old

• Male: 11~12 year old

Effects of functional appliances

Is not To Activate the Muscle but to Modulate Muscle Activity,Enhanceing the Normal Development of the Growth PatternsEliminate Abnormal Environmental Factors

Dento-alveolar changes

• Antero-posterior: Anterior movement of lower teeth, posterior movement of upper teeth.

• Vertical: lower posterior teeth erupt.

Modification of Maxillary growth??

• Restrain the forward growth of maxilla

• Catch up growth occurs after treatment

Cephlomatric superimposition

Changes in mandibular growth

• Stimulate mandible growth

• Improve the growth direction of mandible

Cephlogram superimposition

Changes in glenoid fossae

• Remolding of the glenoid fossa more anteriorly

Indications for functional appliances

• The patient must still be growing,preferably approaching a phase of rapid growth.

• The pattern and direction of facial growth should be favorable.

• The profile improved immediately as the patient move mandible forward.

• The patient must be well motivated.• Dentition are well aligned

INDIKASI

• Well aligned dental arches• Posterior positioned mandible• Non severe skeletal discrepancy• Lingual tipping of mandibular incisors• Proper patient selection

KONTRAINDIKASI

• Class ll skeletal by maxillary prognathism• Vertically directed grower• Labial tipping of lower incisors• Crowding

Activator facts• Original design worn at night• Large one piece of acrylic• Teeth could be redirected during eruption• Large vertical opening construction bite• Could not speak or eat when worn• Advances mandibular jaw

July 2003 EJO by Basciftci et al– the activator appliance can produce bothskeletal and dental effects in the growingdentofacial complex.January 2003 AJODO by Laecken et al– Retroactive study suggests that both skeletaland dental changes contribute to Class IItreatment with the Herbst appliance with fossaremodeling

bionator

• Prototype of less bulky activator• Worn day and night• Allows more tongue action• Mandibular advancement• Speaking possible, yet difficult

Herbst

• Fixed to teeth• Patient compliance not required• Works 24 hours• Less airway blockage• Most popular type at present time in U.S.

Frankel

• The large part of Frankel appliance is confined to the oral vestibule

• The buccal shields and lip pads hold the buccal and labial soft tissue away from the teeth,eliminating restrictive influence

• The manner in which the anteroposterior correction is different

Twin block

• Removeble• Separate upper/lower plates• Patient compliance required• Less airway blockage• Improved speech• Most popular removable type at present

BITE REGISTRATION

• 1.Anteroposterior dimension: for most patients: 4~6mm (edge to edge if no uncomfortable)

• 2.Vertical opening: 3~4mm in incisor region

• A horseshoe-shaped wax bite rim is prepared• Guiding the mandible into planned position• Forming the wax bite• Check and hardened

construction

• Base plane• Lip bow:transmit forces

to upper incisors• Lower incisors

capping: minimize ⑴the tendency of lower incisors procline

reducing overbite⑵

principles

Muscles stretched-producing forces-retracting mandible-transmitted to maxilla through labial bow-restraining the maxillary growth

Rules for construction bite

• In a forward positioning of the mandible of 7-8mm,the vertical opening must be slightly to moderated(2-4mm)

• If the forward positioning is no more than 3-5mm,the vertical opening should be 4-6mm

• The Activator can correct lower midline shift or deviation

Trimming

1.vertical control• For dolichofacial patients:intrude molars,

extrude incisors• For branchfacial patients: intrude incisors,

extrude molars

Acrylic contact Intrusion of the molars

Acrylic contour for extrusion of the molars

Intrusion of the incisors

2.sagittal control

Retrusion of the incisors

Mesial movement of molars

Distal movement of molars

3.transverse movement

Anterior bite plane

management

• The bite plane should be length enough to ensure the lower incisors bite on the bite plane.

• Add to the height of the bite-plane during treatment

Buccal capping

• Eliminating occlusion interference • Dental incisors cross-bite• Unilateral posterior teeth crossbite

Bilateral block

Unilateral block