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A. Base Plate 1. Supporting others component : claps, Screw Expansion etc. 2. Continue Strength/force of the resulting from claps to anchorages 3. To prevent unwanted moving teeth 4. To protect the spring or claps on palatal / lingual side 5. To hold and continue biting force
Stability of plate 1. Plate width was made as wide as possible, depend on treatment needs 2. The plate should be able to adapt with oral mucosa 3. The plate around moving teeth must be free
Functional Appliance Primarily orthopedic tools to influence the facial skeleton of the growing child Transmit, Eliminates, and guide the natural forces Muscle activity, growth, tooth eruption Try To create conditions for the harmonious development of the stomatognathic system
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 orthopedic appliances can modify the rate and amount of condylar 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 fossa Voudauris 1988 Fossa is altered and brought forward by mandibular advancement Ruf et al- AJO 1999 The increase in mandibular prognathism to be a result of condylar and glenoid fossa remodeling Rabie et al AJO 2002 Forward mandibular positioning causes significant increases in vascularization and new bone formation 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 rats Functional advancements at different ages and occlusions Stable Results Treatment continues until growth stops Continued growth possible with locked-in occlusion Unstable Results Continued 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 type Note- Most efficient in permanent dentition(Profit, Pancherz AJO 2002) Late stage of mixed dentition,1-2 years before the pubertal growth occur
Is not To Activate the Muscle but to Modulate Muscle Activity, Enhanceing the Normal Development of the Growth Patterns Eliminate Abnormal Environmental Factors
Dento-alveolar changes
Antero-posterior: Anterior movement of lower teeth, posterior movement of upper teeth. Vertical: lower posterior teeth erupt.
Cephlomatric superimposition
Cephlogram superimposition
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 both skeletal and dental effects in the growing dentofacial complex. January 2003 AJODO by Laecken et al Retroactive study suggests that both skeletal and dental changes contribute to Class II treatment with the Herbst appliance with fossa remodeling
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
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 the tendency of lower incisors procline reducing overbite
principles
Muscles stretched-producing forces-retracting mandible-transmitted to maxilla through labial bow-restraining the maxillary growth
Trimming
1.vertical control For dolichofacial patients:intrude molars, extrude incisors For branchfacial patients: intrude incisors, extrude molars
2.sagittal control
3.transverse movement
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