Orthidontic fxn

Cases   141

(t) (u) (v) (w)
(x)

(y) (z)

(aa) (ab)

Figure 11.2  (Continued )

142   Orthodontic functional appliances

AS resulting in isolated retroclination of the maxillary central
incisors.
Diagnosis
A female patient (Figure 11.3) aged 12 years presented with a There was mild crowding of both dental arches, with procli-
skeletal II profile related to mandibular retrognathia and nation of the maxillary lateral incisors. In occlusion, molar and
decreased lower anterior facial height in the permanent den- canine relationships were Class II bilaterally. The overjet was
tition. There was a high resting position of the lower lip, 3 mm to the central incisors, with a maximal overjet of 9 mm to
the lateral incisors (a–h).

(a) (b) (c)
Figure 11.3 

Cases   143

(d)
(e) (f)

(g) (h)

Figure 11.3  (Continued )

144   Orthodontic functional appliances

Treatment open bites reduced. Thereafter, fixed appliances were placed to
A modified Twin Block appliance with ‘T’ springs to procline finish and detail the occlusion, although some relapse in the
the maxillary central incisors was worn on a full‐time basis for overbite arose following initial alignment; this was addressed
12 months, resulting in full correction of the buccal segment with continuous archwire mechanics, including counterforce
relationships and decrease in the overbite (i–r). Following NiTi archwires and use of Class II elastics during the fixed
tapering of appliance wear to a nights‐only basis, the lateral appliance phase (s–ak).

(i) (j)

(k) (l) (m)

(n)

(o) (p)

Figure 11.3  (Continued )

Cases   145

(q) (r)
(s)

(t) (u)

(v) (w)

Figure 11.3  (Continued )

146   Orthodontic functional appliances

(x)
(y) (z)

(aa) (ab)

Figure 11.3  (Continued )

Cases   147

(ac) (ad) (ae) (af)
(ag)

(ah) (ai)

(aj) (ak)

Figure 11.3  (Continued )

148   Orthodontic functional appliances

GC underdevelopment of the left condyle and ascending ramus.
He had an associated mandibular asymmetry and a maxil-
Diagnosis lary cant related to restricted vertical development of the
A male patient (Figure 11.4) aged 12 years presented with a left  maxilla. The aesthetic impairment was compounded
severe skeletal II profile due to micrognathia. He had a his- by functional issues, with a maximal inter‐incisal opening of
tory of a left condylar fracture in infancy, with resultant 12 mm (a–d).

(a) (b) (c)

(d)

Figure 11.4 

Cases   149

Treatment the left maxillary segment, promoting correction of the
Distraction osteogenesis was performed on the left mandibular m­ axillary cant (k–o). Thereafter, fixed appliances were placed
ramus to improve the skeletal II deformity, while restoring to improve the occlusion. The maximal inter‐incisal mouth
height to the ascending ramus (e–j). Post‐surgically a hybrid ­opening increased to 26 mm. An advancement genioplasty
activator was placed for a period of 6 months to maintain Class may  be c­onsidered at skeletal maturity to improve the chin
II correction while allowing preferential vertical development of prominence further (p–t).

(e) (f) (g)

(h) (i)

(j) (k)

Figure 11.4  (Continued )

150   Orthodontic functional appliances

(l) (m)

(n) (o)

Figure 11.4  (Continued )

Cases   151

(p) (q)

(r) (s)

(t)

Figure 11.4  (Continued )

152   Orthodontic functional appliances

ML The arches were generally well aligned, although there was
an upper midline diastema with proclined maxillary inci-
Diagnosis sors. There was developmental absence of the lower right
A female patient (Figure 11.5) aged 12 years presented with a second premolar. In occlusion, molar and canine relation-
skeletal II profile related to mandibular retrognathia and average ships were Class II bilaterally with an increased overjet of
vertical dimension in the late mixed dentition. Lips were incom- 11 mm (a–i).
petent at rest with a lower lip trap.

(a) (b) (c) (d)
Figure 11.5 

Cases   153

(e)
(f) (g)

(h) (i)

Figure 11.5  (Continued )

Treatment Thereafter, fixed appliances were placed to finish and detail
A modified Twin Block appliance was worn on a full‐ the occlusion, with indefinite retention of the lower right
time  basis for 12 months, resulting in full correction of the s­ econd primary molar (j–y).
malocclusion and improvement in the skeletal pattern.

154   Orthodontic functional appliances

(j) (k) (l)
(m)

(n) (o)

(p) (q)

Figure 11.5  (Continued )

Cases   155

(r) (s) (t)

(u)
(v) (w)

(x) (y)

Figure 11.5  (Continued )

156   Orthodontic functional appliances

HF relationship, displacing anteriorly on closure into a frank
reverse overjet.
Diagnosis
A female patient (Figure 11.6) aged 12 years presented with a The mandibular arch was spaced, while the upper arch was
mild skeletal III profile in the early permanent dentition. crowding, with space loss subsequent to premature loss of the
There was a mild degree of both mandibular prognathism and maxillary right second primary molar. There was a reversed
­maxillary retrusion. She could achieve an edge‐to‐edge incisor overjet of 3 mm in the displaced position (a–g).

(a) (b) (c)
(d) (e)

(f) (g)
Figure 11.6 

Cases   157

Treatment fixed appliances were placed on a non‐extraction basis, with
A reverse Twin Block appliance was used for a period of space re‐creation in the upper right side to facilitate eruption
9  months to correct the incisor relationship, establishing a of the impacted second premolar. Following treatment, facial
positive overjet and overbite with lateral open bites devel- harmony, dental aesthetics and good interdigitation were
oping in the posterior regions bilaterally (h–m). Thereafter, achieved (n–v).

(h) (i)

(j)

Figure 11.6  (Continued )

158   Orthodontic functional appliances

(k)

(l) (m)

(n) (o)

Figure 11.6  (Continued )

Cases   159

(p) (q) (r)

(s) (t)

(u) (v)

Figure 11.6  (Continued )

Index

Page References in italics refer to Figures; those in bold refer to Tables

achondroplasia, 23 Class III malocclusion, 119–125 facial growth, 1–2
acromegaly, 24 aetiology, 119 facial growth pattern, 29–30
activator effect, 39, 40–42 case selection, 120
activators, 70 see also under names correction, 120 cross‐sectional and longitudinal growth, 29
early treatment, 119 longitudinal method, 29
development of, 10–12 functional appliances for, 120–125 metric approach, 30
Adam’s clasps, 52 mechanisms, 120 structural method, 30
AdvancSyncTM appliance, 89 fibroblast growth related factor (FGF8), 5
age, 28–29 Co‐Go‐Me angulation, 30 finite element analysis, 3
Andreasen activator, 3, 11, 12 cohort studies, 127, 127 fixed appliances, transfer from functional appliances
Andresen‐Häupl appliance, 10, 12 collagen, Type III, 7
animal experimentation, 3–5, 7 compliance, 35, 39, 132 to, 102–117
antero‐posterior skeletal pattern, 30–31 Concorde facebow, 51 cephalometric superimposition, 102, 107
condylar growth Class II correction consolidation, 103, 109–115,
BAMP see bone anchored maxillary protraction
(BAMP) during application of mechanical forces, 24 111–115, 117
genetic control of, 22 early use of Class II elastics, 114, 116
Bass appliance, 29 condylar removal/injury, 22–23 extraction pattern, 116
Bass Dynamax, 18 condylar response to postural or mechanical fixed appliance prescription, 116, 116
Bass Orthopaedic appliance, 18 fixed functional appliance, 114
Begg appliances, 28 changes, 23–24 maintaining postured bite, 103, 111–114
condylar growth during application of mechanical maintenance of removable functional appliance
vs. Herbst, 90
Begg retainers, 114 forces, 24 during early fixed phase, 111, 114, 114
Bimler appliance, 12 effect of mandibular immobilization, 23–24 part‐time functional appliance wear, 103,
Bionator, 12, 13, 39, 89 effects on glenoid fossa, 23
bite jumping plane appliance, 10 condylar transplantation experiments, 23 111–114
bone anchored maxillary protraction (BAMP), 125 condyle reinforced anchorage, 103, 109
functional/biochemical interface, 24 upper removable appliance with inclined bite
in Class III correction, 120 role in mandibular growth, 21–26
control group, use of, 128 plane, 114
calcium ions (Ca++), role in condylar cartilage, 24 controlled clinical trials, 127 planning, 102, 104–106
case‐control studies, 127, 127 cranial binding, 2, 3 timing, 103, 109
case series and reports, 127 craniofacial morphology. function and, 2 fixed functional appliance (FFA), 18, 97–98, 98 see also
case studies, 135–160 craniofacial skeleton, growth of, 1–2
cephalometry, 10 appositional and resorptive growth, 21 flexible fixed functional appliances; rigid fixed
primary cartilaginous growth, 21 functional appliances
limitations of, 132 sutural growth, 21 appliance efficiency, 99
cervical vertebral maturation (CVM), 28–29, 29 cross‐sectional studies, 127 comparison between, 89
chin caps, in Class III correction, 120 cyclic adenosine‐monophosphate (cAMP), in condylar effectiveness of removable vs., 132
Clark Twin Block, 18 molar correction in, 99
Class II correction consolidation, 103, 109–115, cartilage, 24 ulcer arising from, 99
Delta, 22 fixed mandibular advancement appliances, 19
111–115, 117 delta clasps, 52 flexible fixed functional appliances, 93–99 see also
early use of Class II elastics, 13, 116 Dynamax, 111, 115 Forsus FRD; Jasper Jumper
extraction pattern, 116 ecological studies, 127 follow‐up, long‐term, 128
fixed appliance prescription, 116, 116 edge‐wise appliances, 10, 28 Forsus FRD, 70, 93–95, 94, 99
fixed functional appliance, 114 effectiveness of functional appliances, assessment, 129 Frankel appliance, 12, 14, 18, 135
maintaining postured bite, 103, 111, 110–114 endochondral ossification, 1 Frankel 3 appliance, 120
maintenance of removable functional appliance environmental influences, 21, 23–25 Fränkel functional regulator 3 (FR3), 199–123, 121
construction and clinical management, 122, 123
during early fixed phase, 111, 114, 114 effect of orthopaedic forces, 24 effects of, 124
part‐time functional appliance wear, 103, 111, limitations of animal experiments, 24–25 Frankfurt–mandibular plane angle (FMPA), 74
ethical concerns, 128 functional appliance
110–114 Eureka Spring, 98 long‐term effects, 131
reinforced anchorage, 103, 109 evidence‐based dentistry (EBD), 127 research in context, 132
upper removable appliance with inclined bite plane, 114 short‐term effects on skeletal pattern, 129, 129
Class II correctors, 70 functional matrix theory, 2, 21, 25
Class II effects, 102, 102 functional regulators, 12, 14–17, 18
Class II elastics, 114, 116

Orthodontic Functional Appliances: Theory and Practice, First Edition. Padhraig Fleming and Robert Lee.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

160

Index   161

ginglymoarthroidal joint, 1 overal control of, 25 Sox9, 5, 22
glossoptosis syndrome, 10 relapse, 25 Spee, 39
growth variation, inter‐individual, 133 matrix‐metalloproteases (MMPs) standing height measurements, 28
growth velocity charts, 28 MMP‐1, 5 systematic reviews (SRs), 127
haemorrhage, intracapsular, 22 MMP‐13, 5 tantalum implants, 1
hand–wrist radiographs, 28 maxillary growth, 1, 2 Teuscher appliance, 7, 39, 55
Harvold appliance, 5, 6, 129, 131 maxillary incisor retroclination with functional TGF‐B1 (transforming growth factor
Hawley retainers, 39, 114
headgear, 7, 10, 18, 51, 54, 55, 89, 93 appliances, 130, 130–131 beta‐1), 23
maxillary restraint, 7 timing for therapy, optimal, 132
activator effect and, 39 median opening activators, 39, 46–48 tissue‐borne appliance, 12
advantages of, 103 meta‐analyses, high‐quality, 127 torquing spurs, 54–55
compliance, 35 myotonic appliances, 5 transverse skeletal abnormality, 31, 32–35
vs. Herbst appliances, 90 non‐randomized studies, 127–129 treatment duration, 7
Herbst in combination with, 70, 72–74 Norwegian system, 12 Twin Block appliance, 5, 7, 18, 30, 39, 51–70,
mandibular shape and, 30 Notch1, 22
protraction, in Class III correction, 120, 125 Notch3, 22 72, 99
headgear effect, 70, 72, 89, 94 Notch4, 22 advantages, 51
headgear tubes, 39, 54, 93 occlusal features, 31, 36–38 appliance design, 52, 54–55, 59–61
Herbst appliance, 2–3, 5, 7, 18, 29, 30, 31, 39, 70, 70–72, Osterix, 22 bite registration, 52, 57–58
Overjet, 40–42, 44–45 breakages, 60
99, 131 Ovid MEDLINE®, 133 case selection, 51–52
vs. activator, 89 PAR (Peer Assessment Rating) score reduction, 74
vs. Begg treatment, 90 part‐time functional appliance wear, 103, 111–114 dental features, 52, 53–55
class II correction, 72 general features, 51
in combination with headgear, 70, 72–74 advantages, 111–114 skeletal features, 51
vs. fixed functional appliance, 25 Peer Assessment Rating (PAR) score reduction, 74 soft tissue features, 51
vs. headgear, 90 primates, experiments on, 3–4 clinical use, 51–69
lower incisor changes, 73 protraction headgear in Class III correction, development, 51
proclination of lower labial segment in, 116 early fixed phase, 111
soft tissue effects, 74, 89 120, 125 fitting, 55, 58
timing of treatment, 74, 74–77, 77–81, 81–85, 85–88 randomized controlled trials (RCTs), 127–129 follow‐up appointments, 58, 60, 63–67
vs. Twin Block, 89, 132 vs. Herbst, 89, 132
vertical effects, 73 bias in, 129 impressions, 52
Herren activator, 93 rapid maxillary expansion (RME), 125 lateral open bites following, 111
IGF‐1 (insulin‐like growth factor), 23 removable functional appliance, effectiveness of, vs. length of retention, 64
intention‐to‐treat (ITT) analysis, 132 limitations, 51
intracapsular haemorrhage, 22 fixed, 132 modifications, 54–55
Jagged, 22 reverse Twin Block appliance, 124 overjet and reversed overjet, 64, 67–68
Jasper Jumper, 93, 99 post‐treatment retention, 68
Mandibular Anterior Repositioning Appliance construction and management, 124, 124 proclination of lower labial segment in, 116
effects, 125 space planning for fixed therapy, 64
(MARA), 70, 89, 99 rigid fixed functional appliances, 70–90, 92 see also usage, 93
mandibular condylar cartilage (MCC), 22 Twin Force appliance, 95, 98
mandibular growth, 1–2, 2 Herbst; MARA Twist, 22
rodents, experiments on, 4–5, 5 type I collagen, 22
gene‐environmnent interaction, 25 Runx2, 5, 22 van Beek appliance, 7, 39, 55
maximal rate prediction, 28 Sella‐Nasion‐B point, 124 vascular endothelial growth factor (VEGF), 5
modification, 25 skeletal II discrepancy, 2–3, 3 vertical skeletal pattern, 30
soft tissues, 31, 35 visco‐elastic theory, 5–7

effects of appliances on, 131

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