Functional Appliances

Introduction and History

• Functional appliances are mostly used in

orthodontics to redirect the growth of the mandible
to a more protrusive position.
• The change in pressures created by stretching the
muscles and soft tissues is used to modify growth in
a desired direction.
 Introduction and History

• Andresen in Norway developed the activator in 1920

which became the first functional appliance to be
widely accepted.
• Functional appliances were introduced into
American orthodontics in the 1960’s. Their use
became widespread in North America in the 1970’s.
• Nowadays the most commonly used functional
appliances are the bionator and the activator
 Where are functional
appliances mainly used?
 Cl II division 1

• Proclined upper incisors

• Micrognathic or retrusive mandible
• Deep bite
• Lower face height reduced patients
 Indications

• Mainly typical Class II division 1

presenting with large
dentoalveolar compensations
and a favorable growth pattern
Mandibular plane
Y axis
What is a favorable growth pattern?
What is a favorable growth pattern?
• Functional matrix of Moss
• Facial bone are responsive to functional needs .

Concept of functional appliance therapy

 The functional matrix theory of Moss
• Bone growth specially in the orofacial complex is dependent upon
the needs of the neuro muscular system.
• The neuro muscular system is itself dependent of the functional
needs of the patient
Maxillary growth
Can we grow a mandible?
• Yes and no!

• McNamarra studies have shown that monkeys

subjected to mandibular protractors 24 hours a day
had longer mandibles than controls
However..

• In human, the difference between the groups is

smaller .
• Usually, the mandible is longer by about 1.5 mm
after treatment than controls.
So…

• This difference does not explain the correction from

Class II to Class 1 witnessed in clinical situations.
Genetics

• Functional appliances
have no “effect” on true
(genetic) micrognathic
mandibles
Different types of functional
appliances
 The Bionator

• An example of a passive tooth-borne appliance

• One of the most commonly used functional
appliances because of its simplicity, sturdiness, ease of
fabrication, ability to be modified and patient acceptance
• Palatal coverage may be eliminated to decrease
bulkiness
Bionator

• Mandibular protractor.
• Reposition the mandible in a more forward position
• Increase mandibular length?
• Allow for full mandibular growth expression?
 The Frankel Appliance

•The only fully tissue-borne functional appliance

•Modifies growth by displacing soft tissues and
disrupting the equilibrium forces between the
cheek muscles and the tongue
•Requires more rigid design, fit, proper use and
case selections as compared to the passive
tooth-borne appliances for optimal results
• If you alter the functional envelope, a different
response from the growth sites of the orofacial
bones is to be expected.
• The use of a Frankl, a true functional appliance,
should help express maximum response from the
growth sites.
Mode of action

• Mandibular repositioning
• Periosteal pull
• Lip bumper effect
• Suture stimulation?
• Tongue pressure
 Indications for FA Therapy

• FAs are mostly used to treat dental and skeletal

Class II, div I malocclusions
• They are particularly effective in treating cases with
mandibular deficiency
• Other indications for use of FAs may include
prevention and correction of oral habits (thumb/lip
sucking), mouth breathing and other oral functional
aberrations
Timing of Use

• Functional Appliance Therapy should coincide with periods of active

growth
• Therapy should begin in middle to late mixed dentition
• Therapy may be started earlier if patient is compliant
• The success rate of FAs is very limited in non-growing persons
Common Skeletal and Dental Effects of
Functional Appliances

• Redirection of mandibular growth into a more protrusive

position
• Restriction of maxillary growth
• Proclination of lower incisors
• Lingual tipping of upper incisors
• Upper and lower molar extrusion
• Mainly dentoalveolar effects and a small increase of
mandibular length.
Twin Block ( 9 months)
Results
 Contraindications/
Special considerations
• FAs tend to open the bite and increase anterior
lower face height (ALFH) and are not recommended
in patients with minimum overbite and long ALFH
• FAs are also contraindicated in patients with
existing proclined lower incisors
• FAs can create a dual bite therefore FA therapy
requires careful evaluation and regular monitoring
 Special Considerations
At times, pretreatment with fixed appliances may be
needed in cases with crowded and irregular incisors to
prepare for proper working bite registration and
functional appliance position
• Most often, a final phase fixed appliance therapy is
indicated following FA therapy to establish optimal
functional occlusion
• Outcomes of treatment are totally dependent on
patient compliance (with the usual removable FAs)
 Fabrication of functional appliance

• Requires 2 appointments
• First Appointment:
• 1) Take accurate alginate impressions of both
arches with good reproduction of teeth and soft
tissues. Pour with yellow stone.
• The impressions should not be overextended This
will make it difficult to accurately locate the
appliance components into the vestibule
 Fabrication

• First Appointment:
• 2) A “working wax bite” is taken
- wax is softened and firmly seated on upper teeth
- slowly guide the mandible forward, to the desired
position (4-6mm of advancement recommended) and
record the bite
-vertically, the bite should be opened in the posterior
region (amount of clearance depends on appliance type
and patient’s existing overbite)
- examine the bite record for maintenance of previous
midline relationship and absence of dental and soft tissue
interferences
 Instructions to Lab

•Please fabricate... Specify type of

functional appliance
For most mandibular deficient cases, a bionator or activator-
type is the most readily accepted appliance

•Specify to include components of

appliance most effective in solving
patient’s problems
If transverse expansion of the arches is desired, write “attach
buccal shields to bionator/activator”, etc.
 Appliance Delivery
• Inspect appliance and smooth out acrylic as needed
• Check appliance fit on working cast first
• Try appliance in patient’s mouth and make appropriate
adjustments
• Master insertion and removal techniques with patient
• Give instructions to both the patient and parents
• Include oral hygiene instructions
 Instructions to the Patient
In courtesy of Dr. Shildkraut and Dr. Giambattistini
It is very important to follow the instructions below for the best
treatment outcomes.
• You may start by wearing the appliance for 5-6 hours per day at
home for the first week to get used to the appliance.
• You may find your speech affected for a few days. Once your tongue
has adjusted, you will be able to talk normally.
• By the second week, the appliance should be worn all day.
• From the 3rd week on, the appliance must always be in your mouth,
day and night, except when eating or brushing your teeth.
 Instructions to the Patient
In courtesy of Dr. Shildkraut and Dr. Giambattistini
• When you remove your appliance, always place it in its
box so as not to lose it or break it
• It is very important to keep your mouth as well as your
appliance clean at all times. To clean your appliance, use
a toothbrush and rinse it under water. Never clean it
under boiling water because you will distort the
appliance.
• You will be seen by us every 5-7 weeks for follow-up.
However, if at any point the appliance becomes loose or
irritating, do not hesitate to call us so we can see you
the soonest possible to make the proper adjustments.
• You will wear the appliance for a total of 1.5-2.0 years.
Adjustment and Recall Schedule
• Follow-up 2 weeks after appliance delivery for inspection of
soft tissues and appliance fit and condition
• Smooth out acrylic, trim back buccal shields and adjust lip pad as needed
• Ideally see patient every 5-7 weeks to motivate patient,
observe changes and assure for minimal dental side-effects
• Re-evaluation in 8-10 months with new records to assess
efficiency of therapy
• Final evaluation in 1.5-2.0 years
• Once FA therapy is completed, finalize treatment with fixed
appliance
 References
• Bishara, SE. Ziaja RR. Functional appliances: a review. American Journal of Orthodontics &
Dentofacial Orthopedics. 95(3):250-8, 1989 Mar.

• Caprioglio, Damaso. Aurelio Levrini. Interceptive Orthodontics. Bologna: Edizioni

Martina Bologna s.r.l., 2002. Chapter 5.

• Carels, C. van der Linden FP. Concepts on functional appliances' mode of action.
American Journal of Orthodontics & Dentofacial Orthopedics. 92(2):162-8, 1987 Aug.

• Collett, AR. Current concepts on functional appliances and mandibular growth stimulation.
Australian Dental Journal. 45(3):173-8, 2000 Sep.

• Frankel, R. Concerning recent articles on Frankel appliance therapy. American Journal of

Orthodontics. 1984;85:441-4.

• Graber, Thomas M. Orthodontics Current Principles and Techniques. Third Edition.

St Louis: Mosby, Inc., 2000. Chapter 10.
 References
• Macey-Dare, LV. Nixon F. Functional appliances: mode of action and clinical use.
Dental Update. 26(6):240-4, 246, 1999 Jul-Aug.

• Proffit, William R. Contemporary Orthodontics. Third Edition. St Louis: Mosby, Inc.,

2000. Chapters 11 and 15.

• Rudzki-Janson I. and Noachtar R. Functional appliance therapy with the Bionator.

Seminars in Orthodontics. 4(1):33-45, 1998 Mar.

• Schmuth, GP. Milestones in the development and practical application of functional

appliances. American Journal of Orthodontics. 84(1):48-53, 1983 Jul.

• Stratford, NM. Orthodontic treatment using functional appliances. Journal of the Irish
Dental Association. 43(4):110-6, 1997.

• Woodside, DG. Do functional appliances have an orthopedic effect? American Journal of

Orthodontics & Dentofacial Orthopedics. 113(1):11-4, 1998 Jan.

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