Growth Modification in

Class II, Open Bite/Deep

Bite, and Multidimensional
Problems
CHAPTER 14
PROFIT 6TH EDITION
PREPARED BY
DR.NIMRAH MUSHTAQ
Functional Appliances

• A functional appliance is one that changes the posture of the

mandible and causes the patient to hold it open and/or forward for
Class II correction or back or open for Class III correction.
• These appliances also can affect the maxilla and the teeth in both
arches.
• When the mandible is held forward, the elastic stretch of soft tissues
produces a reactive effect on appliances that hold it forward.
• If the appliance contacts the teeth, this reactive force produces an effect
like that of Class II elastics, moving the lower teeth forward and the
upper teeth back, and rotating the occlusal plane.
• If contact with the teeth is minimized, soft tissue elasticity can create a
restraining force on forward growth of the maxilla, so that a “headgear
effect” is observed .
• Any combination of these effects can be observed after functional
appliance treatment
• Skeletal changesby posturing the mandible to new positiontrue
stimulation of mandibular growth could be achieved
Move condyle out of the fossa, 1. Inc mandibular
mediated by reduced pressure length by growth
on the condylar tissue or by at condyle
altered muscle tension on the which may be
condyle accompanied by
2 repositioning the
1 articular fossa by
.
apposition of
bone on its
posterior wall
2. Headgear effect
restrain maxilla
& maxillary teeth
3. Holding mand
forward creates
force against the
lower teethant
movement of
4. Mandibular growthexpressed forward and/or inferiorly mand dentition
is most related to the eruption of the molars
• If molars erupt more than ramus grows in height(dashed
line),forward mandibular change will be negatedclass II
malocclusion will not improve
• The monobloc developed by RobinThe activator first functional
appliance to be widely accepted.
• Clockwise tipping of the occlusal planerotation of the maxilla,mand
or both
• Level curve of speepost freely erupt and incisor eruption blockage
Bionator

• The Bionator is tooth-borne and

induces mandibular
advancement with contact of
lingual flanges with the lingual
mucosa.
• It usually has a buccal wire and
can incorporate bite blocks
between the posterior teeth and
a tongue shield.
• The Bionator also incorporates a
major palatal connector to
stabilize the posterior segments,
but the appliance is limited in
bulk and relatively easy for the
patient to accommodate.
Activator

• The activator is also used to actively

advance the mandible and can
incorporate anterior and posterior
bite blocks and a labial bow
• The activator’s lingual shields
usually extend deeper along the
mandibular alveolus than other
functional appliances.
• and sometimes the appliance
incorporates a displacing spring so
that the patient has to close down
and advance the mandible to retain
the appliance in place
The Frankel-II appliance

• It actively advances the mandible

via contact of the lingual pad
behind the lower incisors with the
mucosa in that area and fosters
expansion of the arches with the
buccal shields.
• The lower lip pad also moves the
lower lip facially.
• The appliance is largely tissue-
borne and potentially causes more
soft tissue irritation than other
functional appliances, but a patient
can talk normally with it in place,
which makes full-time wear
feasible
• Because of the wire framework, it
is more susceptible to distortion
Headgear
• The other possible treatment for mandibular deficiency is to restrain
growth of the maxilla with extraoral force
• the mandible continue to grow more or less normally so that it
catches up with the maxilla
• functional appliances and headgear also differ in their effects on the
dentition.
• Removable functional appliances, especially those that rest against
the teeth (i.e., toothborne ones with a labial bow), often tip the
upper incisors lingually and the lower incisors facially.
• Headgear force against the maxillary molar teeth often tips them
distally.
• There also is a vertical effect on the posterior teeth, extrusive with
cervical headgear, possibly intrusive with high-pull headgear
Fixed Class II Correctors: Another
Class II Treatment Approach
• Fixed Class II correctors
• Herbst
• mandibular anterior repositioning appliance (MARA), and
• cemented Twin-Block and
• Forsus devices
• They are used in the mixed and early permanent dentitions.
• They require less patient cooperation
Herbst
• It forces the patient to maintain an advanced mandibular position and can
generate both skeletal and dental changes.
• the Herbst appliance is recommended for use in the early permanent dentition
because of rebound in the immediate posttreatment period.
• It produce maxillary posterior dental intrusion, it provides better results when
used in patients with normal or slightly long anterior face height.
• less patient compliance is an advantage
• breakage has long been recognized as a significant disadvantage
Herbst
• design currently uses crowns on
the upper first molars and lower
molars supported by lingual arch–
type connectors for stability.
• The mandible is forced anteriorly
in a passive manner by the
plunger and tube that is anchored
on the maxillary molars and
cantilevered off the lower molar.
• Spacers can be added to the
plunger to advance the mandible
farther
Mandibular anterior repositioning
appliance (MARA)
• more durable and less bulky alternative to the Herbst appliance
• they exert a protrusive effect on the mandibular dentition because
the appliance contacts the lower teeth.
• this type of dental change can be reduced with skeletal anchorage,
this supplemental anchorage does not affect the skeletal changes.
• the MARA appliance produce more maxillary restriction but less
mandibular advancement effect
mandibular anterior repositioning
appliance (MARA)
• It uses crowns on the molars
and has an elbow ,connected
by lingual arches, is durable and
stable.
• Patients find it less bulky than
the Herbst appliance
• To increase the advancement,
shims are added to the
horizontal portion of the elbow
and the elbow is tied back with
an elastomeric tie
Twin-Block
• It is retained on the teeth with
conventional clasps (but can be
cemented In place)
• The complementary inclines on
the upper and lower portions are
relatively steep, forcing the
patient to advance the mandible
in order to close.
• The plastic blocks also can be
used to control posterior eruption
The Forsus appliance

It has moderate bulk but is

flexible and adjustable .
• The appliance can be assembled
intraorally.
• It is adjusted by adding shims to
one or both sides for more rod
mandibular advancement.
Components of Removable and
Fixed Class II Functional Appliances
• Components to Advance the Mandible
• Components to advance the mandible are often classified as active or
passive.
• If the patient has to voluntarily move the mandible to avoid an
interference, the appliance is active.
• If it allows only a restricted path of movement or closure, it is
passive.
• active appliances includes:
• Activator
• Bionator
• Twin-Block, and
• MARA
passive appliances includes:
• Herbst and
• Forsus
Components to Advance the Mandible

• In Bionator or activator type appliance Flanges, either against the

mandibular alveolar mucosa below the mandibular molars or lingual
pads contacting the tissue behind the lower incisors, provide the
stimulus to posture the mandible to a new more anterior position
Components to Advance the Mandible
• The Frankel appliance uses lingual pads against the gingiva below the
lower incisors to stimulate forward posturing of the mandible. Ramps
supported by the teeth, as in the Twin-Block appliance are another
mechanism for posturing the mandible forward. So is the elbow in
the MARA appliance
Other Possible Components

• Vertical Control Components:

• Incisal and occlusal stops control
eruption of anterior and
posterior teeth, respectively.
• The acrylic caps the lower
incisors and serves as a stop
for the upper incisors, which
prohibits eruption of these
incisors.
• Incisal stops can extend to the
facial surface and control the
anteroposterior incisor position
• (F) A complete acrylic posterior
bite block impedes both
maxillary and mandibular
eruption (G) and is useful in
controlling the amount of
increase in anterior face heigh
• (C) Posterior stops can be
constructed of wire or acrylic
(D) and (E) This positioning of
the occlusal stops inhibits
maxillary eruption but allows
mandibular teeth to erupt
Stabilizing Components.

• Clasps
• They add retention, which is
needed to help maintain some
types of appliances with active
components such as springs and
expansion screws in position.
• The clasps also can serve as a
training device when patients
are learning to accommodate to
a functional appliance that
repositions their jaws.
Stabilizing Components

• labial bow on a functional

appliance is to help guide the
appliance into proper position,
not to tip the upper incisors
lingually.
Passive Components.

• Plastic buccal shields and lip pads,

both of which are incorporated into
the Frankel appliance
• A buccal shield holds the cheek
away from the dentition and
facilitates posterior dental
expansion and by disrupting the
tongue–cheek equilibrium.
• The lip pad holds the lower lip (or
upper lip with a Frankel FR-III
appliance) away from the teeth and
forces the lip to stretch to form a lip
seal. (D) The pad must be carefully
positioned at the base of the
vestibule to avoid soft tissue
irritation.
Active Expansion and Alignment
Components.
• Includes springs or expansion screws.
• Incorporating active elements into a functional removable appliance
has three problems:
• more tooth movement, the less skeletal change can be achieved .
• precise tooth positions cannot be achieved with springs or screws in
removable appliances.
• Finally, the tooth movement will be only tipping, which is less stable
and more susceptible to relapse
HEADGEAR
FACEBOW

OUTER
BOW

INNER
BOW
Combined vertical and
anteroposterior problems
SHORT FACE/ANTERIOR DEEP BITE:
• Skeletal vertical deficiency (short face) amost always in
conjunction with ant deep bite
• Mand deficiency(class II Div II)
• TREATMENT: 2 WAYS
1.Cervical headgear upper + lower molar extrude
2.Functional appliancepreferred

Fixed functional appliance are not good choice for short

faceintrude upper molars
LONG FACE /OPEN BITE:
• Maintain vertical position of max & mand posterior teeth
1. HIGH PULL HEADGEAR TO THE MAX 1ST MOLARS
Slow downdward growth of maxilla and stop eruption of these teeth(worn
consistency)
Most effective12 ounces/side
Doesn’t control eruption of lower molarlimits effectiveness
2.HIGH PULL HEADGEAR TO A MAX SPLINT
Place occlusal splint to which facebow is attachedallow vertical force to be
directed against all max posterior teeth,not just molar
Unfortunately, the maxillary splint still allows mandibular posterior teeth to
erupt, and if this occurs, there may be neither redirection of growth nor
favorable upward and forward rotation of the mandible.