INTERNATIONAL jouRNAI of

ORTHOCONTICS

&
ederation of Orthodontic Associations
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 INTERNATIONAL jouRNAI of
ORTHOCONTICS Official Publscation of the
Federation of Oribodantic Associahions

VOLUME 29 NO 12 SPRING SUMMER 1993

OFFICERS
PRESIDENT
Dr Milton Bloch TABLE OF CONTENTS
§ Dramand Ct.
Huntington, NY 31748
1536) 673 7071 PAGE TITLE

PRESIDENT ELECT 2 President s Message

Dr Maunce Atkin
£6 West 94th Street
New York, NY {025
3 Is it Possible to Modulate the Growth of the Huntan
(212) 666-2204 Mandible with a Functional Apphance?
A Petrovic J Stutzmann NR J Lavergne and
VICE PRESIDENT R Shaye
TREASURER
Dr Reabert Weber 9 Anthology of Orthodontic Treatment
200 Monroe Street Universal Dynamics Minneapolis MN
Sheboygan Fails Wi 53085
(14) 467-4646
25 News and Notes of the Components
EDITOR
Br Davul Watson
27 Continuing Education
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ASSOCIATE EDITOR
Jean G Furnyama, D.D.S. Cover Photo Courtesy of — AOA, Inc
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 President's
Message

Milton Bloch, OD §

We dentists all agree that experience is valuable, yet there are dental] plans that reward
an experienced practitioner with less remittance if they are mn general practice than a speciahst
who provides the same service, even tf they are in general practice than a specialist who
provides the same service, even if the specialist 1s a neophyte. Some 28% of dental practi
tioners are general practitioners One wonders why a fee difference would be accepted so
readily by the organized profession I would be curious to know whether or not the rank and
file dentist welcomes this difference [f not, then we have a job to convince those who ad
minister the dental plan that experience is valuable and that fees for the same work should
be equal, whether it be for crowns, periodontal work, orthodontic work, root canal therapy
or any other dental work

Milton Bloch
President
Federation of Orthodontic Associations
 Is it Possible to Modulate the Growth of the
Human Mandible with a Functional Appliance?
DA Li JE MOGUCE MODULIRATI RAST Address fur cnrrespandencr
HUMANE MANDIBULE SA FUNKCION4LNIM Dr Rebert Shays
Office of Research
APARATIMA? ] SU School of Lreniestry
LEUU Florida Ave
A PETROVIC,J STUTZMANN, NR J LAVERGNE New Qrteans LA THLEY
and R SHAYE
Stasbourg France New Orleans US A
For instance, appropriate pressure in organ culture on
the growing condylar cartdage orminaling from
Summary
children and from laboratory animals trai mouse
A significant increase in overall mandibular length guinea pig rabhit squirrel monkey! systematically in
can be achieved with a functional appliance However duces the following vartations in the cell division com
this only appears possible in children with a high ussue partment (Petrovic 1982 1984 Petrovic and Stutz
level growth potential and responsiveness as defined mann P87!
by the mandibular subperiosteal ossification rate and —evtosolic (Na! devreases eytoselie iCal and 1H!
alveolar bone turnover rate inereases intracellular water content increases 1n
tracellular pH decreases
The problem of whether the growth of the human the number of cell divisons decreases
mandidie can be modulated hy orthopedic or functional Such variations were NOT detected when primary
appliances remains controversial It would be impossi cartilages lepiphyseal growth plate of long bones
ble in this short presentation to review past investiga metatarsa] and metacarpal cartilages etc ‘originating
tions Only our recent experimental and clinica] studies from children and from the same Jaboratory animals
wil be reported were exposed in culture to SIMILAR pressure These
Extensive research studies in rat (Petrovic and research investigations show how the biologie features
Charlier, }S67 Charlier et a] , 1969 Petravic et al 1975, of mandibular tissucs aceount for the HETFROGF NEI
Petrovie et al. 1981 Petrovie 1982,Petrovie, 1984) and Ty in the responsiveness of children lo apphance
in monkey (Stockh and Willert 1971 McNamara 1977 therapy These studies clearly demonstrate that
Komposch and Hockenjos, 1977 Graber, 1977, Carlson brologialls there Js no reasan ta state that the human
etal 1978, McNamara etal 1982, Graber 1983! have mandible should react differently from the anima) man
demonslrated beyond reasonable doubt that APPRO dible to similar appliances
PRIATE functional or orthopedic appliances may Our studies also show how a new classification of
stimulate or restrain the growth rate and growth facial growth rotations is a useful toal i detecting, EN
amount of the condylar cartilage and of the posterior DIREC PLY the responsiveness level ofa growing child
border of the ramus to vanous appliances 'Laveryne Petrov 1985
Are these experimental findings applicable to Petrovic et al 1986) According to this biologic and
humans? cephalometric elassification there are 6 growth
FIRST it ts well known that the responsiveness categorics and ]1 rotational types (Fig 2andda 3b del
of different children to functional appliances is very the results of long tern mvestigations with ap
variable Our biologic concept of mandibular tissue level propriate functional applianee show that a moderati in
growth potential and responsiveness tu orthopedic and crease in overall mandibular langth may be achieved
functional appliances, as based on investigations on inratiPetrovie tal 1981) and in monkey (McNamara
human mandibular tissues is an attempt to account for 19K6},
interindividual differences that the chnician is facing And in humans?
in his daily practice (Petravie and Stutzmann 1986! The answer usa difficult one No research approach
Comparative studies on the human ramus subperiostea! is faultiess We are using the following procedure (Fig
ossification rate, on the alveolar bone turnover rate and 1! In 9 le 12 vear-nld boys with a skeleta)] Class I] 4
its orlthodentically induced variations, and on the cephalographs were made at about 6-month intervals
clinical effectiveness of the LSU-activater Fraenkel ap The children were classified according to the grewlh
phanee Begg technique and Edgewise show that ¢ategory and to the rotational type (Lavergne Petrovic
hiological features of mandibular tissues and especial] 1985 Petrovic et cat 1986)"
ly the jevel of the tissue growth potential and respon The supplementary lengthening of the distance
siveness are essential for clinica! responsiveness between cond) lion and pogamon observed in boys IFig
(Petrovic and Stutzmann, 1984, 1986) 3a Jb 3chtreated with the 1 SU activator (Shave et
SECOND our research investigations at the al 1979 Shaye etal i979 Shaye, 1983) was compared
tissue ell and moteeular level have established in to the supplementary lengthening observed in non
organ culture, that the responsiveness of various treated hoysiFig 2) Le tothe lengthening duc te puber
human growth cartilages to appropriate biomechanical ta] physiological yariations the control group Js later
factors does NOT differ significatively from the COR treated with Edgewise) The difference between the 2
RESPONDING anima! growth cartilages (Petrovic groups is considered as Induced by the LSE activator
1982, Petrovic, 1984, Petrovic and Stutzmann 1986) The Lol activator group and the contro] group were

a
 prepubertal and pubertal accede atron
sheiera grow +

. setae
Gerke’ PP? Pat a zahor ovberial growth peak
aratsial tye
comes
(ork ser geere V4 avemeey ied oremolee 2nd wale

610% oute| Cio & eve! @ la #2 mane |

cepheiggrapa 41 ang ard 4th

(God) 4Cp (Cp2}

controls | contrat period 0 | comrot period ‘| control pend 2| | Edgeuine

4 Fh ac tivacoe | efervence oarioa| irvical | subsequent | ‘wal Ireaimanr gered

frestemrent timing WreatTen period lirearment pennies
{Rp) iIFp) (STp) iF Tpt

Fig 1 Timing of the 4 cephalographs and $1 t Tapming 4 Kefalograma . tretiranja

of the LSU acktvater treatment LSU aktivatorom

Fig 2 Mandsbular lengthening in 9 to 12 SI 2 Izdutenje mandibule kod neleéenih

yearold nontreated boys matched detaka 9 do 12 gOdina HYota upp
by chnica] features and skeletal redeno sa klinitkim izgtedima i ske
age with LSU-activator treated boys letnun dobom detaka ftretranih
(Median value for each rotanonal LSU aktlvatorom (srednja yrednost
type) za svaki rotacion) hip).

Contro] pertad (CeO tentrok ga loa [all tentrol pertad (Cpt)

COrrerponding mb corresecnging te torrerpomelag co
Raferenca perbag (2pP otritig? Srpatmant parted (ite) Sebseavent Trestegat sartpe ‘Spl
f 16 O months ¢ 1p & wonthe @ mpnths ta EE atecey
Lingtheaang Caagthaaing Cpl cp deagthineng Cet feo
¢ 353 a 04) oo 0 O6 = oa Qltoe
10 2B =a 0 4Pd 1d te — 6 pel ie $2 = rl

ota we oi} oft = 0 4t oO iL

le re © tel $0 43 0 4$3 le #) = Fal

St = 0 tt = O41) = 7:10 053 =

10 je ~o af 1O 78 ~ 8 OFF Ct
OL? we 092 = 71h= 1 iT Oo 7o
WP do = 0 Add lo ?@~—F €l cap ft
OD 6d ae 526 ° Sh me L 4¢ 1:07 a=
Ie BB = oO FST qi ohm 1 4nd kere 8 a4!

tim Lo) me DES oF 135, - iy =

10 48
= 6 t8l Li 33 = 3 940 Lb be =~ t FOl
 LSU-activator-induced supplemen sl Ya Suplementamo izdudenj3¢ Nudske
tary lengthening of the human mandijule anducirane LSU aktiva
mandible in 9 to 12 year-old gro toram uy detaka Zivotnng doaba 3
wing boys {Median value for cach do 12 godina (srednia vrednust za
rotational type) svaki cotaqon tiph

heFucance paciod [Ae lattlal Treatment pectod ciip] Sesbsequear = sateent periad |
at & te 0 moveny O te & month, & raatay co 12 mpainy
Tomgteanany Lemgibeacag Cp me Ltngtheacep Sip ta
0) > 0 a! oe 1 0?= > 19 am
I@ Fe wo 449 Id 7a d tel ic te rhe
0 45=m Los ee toe w=
10 tk ~¢ wl ' st ana Ir as ide

oO bS == 1 3h = L th am 1
to dr Oats trav a ati 1158 ams
2 46 om 1 td = 2?) L és
I¢ ed) @ 2tt Ir at tudl del
> 10 1 36 + 214 a iv
fo pe oil it %4 ite Fyoo4a
0 79 am 3 tl =v 436 om t
eo 43 Opel ia up att 24ae bk gar

Ge Growth category
RtRotational type
The lengthening was measuted between condylion and pogumon
The supplementary tengthening during ihe iuttal and the subsequeit treatment p
nod was catculated by companson wath Lhe reference period
The vertical relation was normal

Fig 3b LSU-activator-induced supplemen SI Jb Suplementarn> aztnzenje Wudske

tary lengthening of the human mandibule inducirano LSU aktiva
mandible (9 to 32 yeat-old gro torgm u detaka Zivoinog doba 9
wing boys). do 12 godtna

Ge Rt (lTp = Rel {Cp} pa) $lo Rel vfr2 CeO

P20) i+ O a7 om) (¢ 0.08 om} (4 0 7) =]

(+ 11d ae) - [* 0 28 mm] (+ t 19 cml

(+1265 ml 4+ 0 37 wm) L mi

(+ 2:30 mm) (+ 0 36 mee) | 6S om)

AlD (+ 2 56 mm} {= 0 $8 om} 3 24 =m)

AlN {* 2 83 mt i+ 0 #5 ont 37? eed

Growth category
Rotational type.
Control period corresponding to the Reference penod iRp)
Control period corresponding ta the Trutial Treatment period (1Tp'
Control period corresponding to the Subsequent Treatment penod
Supplementary lengthening.
 LSU-aCTIVATOR~}NDUCED SUPPLEMENTARY LENGTHENING OF
THE HUMAN MANDIBLE (9 TO 12 YEAR-OLD GROWING BOYS)

Therapeutically induced lengthensng

6c Rt of the mandible one year after
the onset of the treatment

P2D (+ 0.39 mm} + (+ 0,41 mm) = + 0,80 oom

A2D {+ 0.86 mm) + (+ 0.68 mm} = + 1,54 mm
R2D (+ 0.79 mm) + (+ 0.72 mm) = + 1,52 mm
RIN {+ 0.95 mm} + (+ 0.96 mm) » + 1,90 mm

AlD = (+ 2.08 mm} + (+ 2.22 mm) = + 4,30 mm

AIN {+ 1.98 mm) + (+ 2,60 mm) = + 4,58 mm

Fig 3c CSC attivatoranduced supplemen Si 34 Suptementatno szduzenje = fyudsxe

tary lengthcning of the huma mandible ynducatane (St! aktiaalo
mandsbie (@ tu 12 year-tld growing roam wu de¢aka 41. tnog debs # d
boy S} 12 xodins

tdentificatlon of the pesitional rotation group

PATIENT 17 year old boy

-measured SNB 725 = (retrognathic mandible}

oma

-measuted SNA 785 = (orthognathic maxilla)

measured ML/NSL 340
oi

measured NUNSL 9.0

expected MU/NSL = 192 - 2 (measured SNB)

192 - 2 (725) = 192 - 145 = 470

~expecied NU/NSL = (measured ML/NSL)}/2 7

= 34/2 7 = 10.0

expected MU/NSL- measured MLINSL = 470 34.0 = 13.0

Anterlar Inciinalion of the mandible

T2 = expected NUNSL measured NU/NLS = 100-90 = 10

Neutral inclination of the maxilla

T3 = mnasured ANB
= ANB = SNA - SNB = 785-725
= 6
Distal basal interjaw relationship

ROTATION GROUP = AIDN

Clinical effectwenass of one year

LSU-Activator treatment + + +
 IDENTIFICATION OF THE POSITIONAL GROWTH ROTATION GROUP

(according to POTROVIC, STUTZMANS, LAVERGNE, 1996

ML : Mandibutar jine the Ilne tangent to lower borde: of mandible through gnathiac

NSL . Nasion-sella tine, the Ene through N and S T, ~ Expected MLANSL - Maagured ML/NSL
NL : Nasal fing, the ime through ANS and PNS Tv, - Expected NL/NSL - Measured NU/NSL
{ANS anterior nasal spine, PNS + posierio: nasal spine)
3 < Massured ANE
MLSNSL + Angle between mandibular line anc nasion-sella bine
Expected ML/NSL - 192 - 2(Measured SNB)
NL/NSL : Angie between nasal line and nasion~- sella tme
Expacied NL/NSL . (Measured ML/NSLV2 7?

7, «tp AI MOR
vias Tlest
Al HOG
ae Ty Mas-T,
ses — At DOS
a Tm42 OR

Tae t AD Ley
pore eT, 64 me AL Ww
Tee ot DEI AION
> 7, A? Ow

Tyels+—
AS 1008
I au3-T,2? Al NOD
2 a+T 66 =—~at O08
¢ i,———~ a7 fon

Th.)
—- A Lie
21. Tene AL NOG
a07,—
2 oon

Tso Fi my

e277, Rz OW

Tas R3 wba
Te: oe > mwT.32-—R1nog
2«T, Az ODE

t9,7, Fz 006
ta Ty t33———
#1 NOG
aT; aT eI Pl MOG
T 496 ie PS moe

4,°,——~— FP? ow

ee T, ttePE ON
Tend Ce w ta Ts — ee PLM
Test —— Po oN

34 T, ——~
F2 ODE
te Ty 52 eee Fl Oe
Ty +9 be Tys tam Pt Om
Taek ae FP MOS
 matched by statura] growth increment skeletal age, to MeNamara J A Hinton, J Hoffman D, i, 12982. Histologe
some extent by tooth emergence and especially by the analysis of tempore mandibular joint adaptation to protrusive func
lengthening of the mandible during the reference tron in young adult rhesus monkeys Am J Orthod., 82 243-298
period (Rp! ys the control period (Cpo} Petrovic A 11982) — Postnatal growth of bone perspective of cur
It appears that the actual supplementary lengthen renttrends new approaches, andinnovatwns Ipp 297 331b In Fae
ing of the mandible induced by the LSU activator {S11 tars and Mechanisms Influencing Bone Growth Progress in Clinical
and Sl2t depends mainly on the tssue-level growth and Biological Research, val t01 (Mixon A D and Sarnat, B.G eds.|,
category (Fig 3a 3b, 3cl Only in the growth category Liss A 659 p
No d {rotational types AlD and AlNhis the actual one Petrovic A 11984. — An experimental and cybernetic approach to
vear lengthening clinically really significant (4.30 mm the mechanism of action of functional appliances on the mandibular
and 458 mm after a one year treatment! However the growth Ipp 213-2681 In Malocelusion and the Periodontium Cranio
tesult in growth category No 2 (rotational type A2D) Facia] Growth Series center for Human Growth and Development
University of Michgian. Ann Arbor IMichigam, US.4 268 p
is not negligible
The reported clinical findings are to be compared Petrovic A Charher J P 41967), — La synchondrose speno oc
with previously published biological findings isee Fig cipitale de seune rat en culture d'organes: mise en evidence d'un
74 and Table 77 in Petrovic et al., 1985) pate ntieh de crosssance independant ( It Acad Se Serie 0), 265,
1511 1313.
In vonelusion the results of this clinical investigation
seem (a Indicate that a significant inerease in overall Petrovic 4 Stutzmann, J 11984) — Petencil de crecimiento dei
mandibular length 1s achievable with a functional ap nivel tigular mandibular ratacton de creesmientv ¥ respuesta a
pliance especially in growth category No 5 In other aprates Functronales Orthedencia, d8 Nu db 26-34
words a methodologically rigorous evaluation of the
Petrovie A Stuszmann J VISABI, — The ennce pd of the mandibplar
modus operandi of a functional appliance has to take ussue level growth potential and the responsiveness toa funetiwnal
uty account the bilogaice HETEROGENEITY of the appliance Ipp 5974) In Orthodontics State af the Art Essence of
human mandibular tissues The reported resuits fit with the Science iGraber Leo Wo oed. Maahy Se Louis (U'8.4 1, 425 p
our previous investigations (Petrovic and Stutzmann
Petrovic A Stutzmann J i987!, — Recences acquisitions biologi
1986} furnishing evidence that there ts, ina given grow ques sur fa morphogenese de ia maadibule pp. t7-26). Le menton
ins, individual a remarkable paralelism between the (Quvrage publis sous ln dicecuon de J Lesagnars Masson l'ans
variations in the subperistea!l ossification rate, the
yarlations in the ¢ondylar cartilage growth rate, the Petrovie A Laviegne Jo Stutzmann, J 1) Rh) Tissue level
grawth and responsiveness poteatial growth rutatton ond treatment
varialions in the alveolar done Lurnover rate and the decisina Ipp §81 223) In Scvence and Chiical Judgement tn Orthoden
variations in the chnical effectiveness of a functional tics (Eds P P Vigand K S Eobbens), Monograph 19,¢ raniefacial
appliance Growth Series, Center for Human Growth and Development Univer
sity of Michigan Ann Arbor {hhichigan. 249 p
References
Petrovic A Stutzmann J Gasaon N O8L5 -— The final lengih
Chartier Joi’ Petrovie A. Herrmann Stutzmann J (1969) — EF of the mandible ts it genetically predelermined? Ipp, (05-126) In
fects of mandibulor hs perperopulaicn on che prechondeobiastir zone Cranio Facial Biology (Carlson D 8 ed.|, Monograph tO. Cranio facial
of young tal condyle Am J Orth 35, “174 Krowth Sermes Center for Human Growth and Development Univer
sity of Michigan 4on Arbor (Mirhigan [ SAO
(arlscn, OS McNamara J A Jaui DH OiSTs! — Hastological
analssis of the growLh of the mandibular condyle m the rhesus Petrovic A. Stutzmanon J Lavergne J ists! - Effect of func
monk Am 7 Anat LBt wd cat Lional appliances on Lhe mandchular vandss#r vartudage (pp $B 521
In Physiologic Prinerples of Functional Apphanees (Graber T M
Crater LL. WougT* OC hincop therapy for mandibular prognathism ed.l Slosby St Lavy tl SAL 86g
Am J Orthod J977 72 2441
Petrovic A Stutzmann J Oudet ¢ 11975) — Control processes
Grader T W igaal Bavlution af the concepts undervling in pestantal growth of condylar cartcage ad Che mandadle (pp fd 571
rranifacisl groweh regolacions [fu Clinical alteration of the grow In Jeterminants of mandibular form and growth (McNamara, J A
ing face (MeNamurs J A Jz ed! Motingraph 14 Cramefacial Jr editor Monograph 4 Cramofacial growth series Center far
Growih Series (Ribbens K A snd Howe R ¥ editors! Center for Human Growth and Development Ann Arbor dMichigan U S.4 1275
Hirman ( rowth ind Development Ann Arbor IMichigan US A!
P
Konprach Jt Horkenjas € 11477 Pee Rerktionsfabigke des Shaye R 419831 JC 0 cotervews Dr Robert Shape on func
temporamandibulaeen Koorpels Fortsehr Kiclerorthopadte 1977 tional apphances J Cim Orthod, 17 330
th, 12t it

Shaye KH Schwannyer B., Holfman Tn us79i, | Acivator construe

laxeragn fo tetrnvir A 14> Pathogenesis and treacment tion sampuafied J Cian Orthod 13, 773
dobre piudlizalion of dentofucial malrelatiens as related te the pat
tern of occlusal relauiehshap
pp 399.4021 In Nurmal and Abnormal Stockli P Wo Willers HG G97)! — Tisbuc reactions
in the tem
Bone daraaih Hasse and Choical Research, [Bixnon 4 FP and Sar poromandibular joint cesulting from unterwr displacement of the
mat BO eds A Lass New bark
mandibuile in the mankey Am J Orthod 60 142155

Mc'amara J A Jr 11975 Fo acutsunal adapitahalty of the tein

poramandittubar point Dent Clin Serth 4m 1% 489 497) Authors ane A more detasled expiration of the methodological
aspects of this studs is presenled in Petrrvsss A Stutatiann J
McNamara J oA L877! — Anexperimental study of increased ver Lavergne J 11/990! — Mechanisms of cranipfacia, growth and modus
Lica’ dimension in thi yrewing face Am J Orthod 7 342 395 operand. of functional appliances A cell level and cy bernetic approach
to orthodontic decision making (pp 14 ~$1]n Cramafacist Growth
McNamara J A ISH6! — Un ihe pxpssibuisties of stimulating man Theary and Orthodontic Treatment (Ed ('srison 1! Craniofactal
dibular growth tpp 75 47! En Orchadenics State of the 4rt Essence Growth Serves 23. Center for Human Growth and Development
of the Stavnce (Graber baw ed) Mosby St Louis 10 SA 421 p Lmsersity of Michigan San Arbor
All ariicles in this anthology originally or previously appeared in Dynamic fdeas, (he monthly news
leiter of Universal Dynamics, Inc ,7301 Zane Ave No, Minneapolis MN 55443

LOWER CROWDING
Lower crowding is one of Ihe most difficult problerns tions May Dé in ordar is a mesial buccal posrtion of the
faced by the practitioner We are faced with an arch canines, in relation {othe talerals with the mesial
of the
which is very much Jess malleable than the mala, we camne rotated buccally In many cases Second molar
do not have Ihe option of sulural expansion, and we extractions have allowed (he mandibular teeth to akgn
have notonty dillerant butoHan contiicling and contra spontaneausly with no further mterventiaon Second
diclory advice regarding trealment of incisor crowding motar extractions are aiso very usetul in space tegain
in tho mandible ‘(ng Brocedures and we will dévelop this further when
we CISCUSS appliance INerapy in Ine jower arch
One of the most commaniy recommended metheds lor
dealing with lower crowding 1s senal extraction This Pernaps the mosl controversial extractions in the lower
method ts of queshonable vaiue if premolar extractions arch are extractions of lower mcisors yet many cases
are not planned Another method, which is phiosophr In WHICN 2 fOwer incisor Nas been removed Show excel
cally similar is slicing of the mesial third of the fent atltgament and stability of the result The pradlem
deciduous cuspids to allow more space for the erupting woth this lype of treatment is thal 1o obtain [he very best
lateral incisors resuit the encisor should be ramoved as early as poss!
ble preterably defore the age of tan The possibility of
in an article in the January 1980 Journal of Chrarc Ortho securing a correction weth all of the incisors in the arch
dontics Dr K Paul Lee calls both of these techniques
acts a8 4 great deterrent to extractions at this age Inci
Into Question and presents an interesting hypothesis Sor extractions are certamnly possible and often quite
on the role played by the deciduous cuspidsin the devel
successiul in an older patent bul the anatumicas
opment of the mandible Dr Lee shows seven cases of response 1s natutafly much better in the very young
Incisars, In all seven cases the incisar alignment im
proved dramatically with no treatment in the lower arch Naturally many practitioners are reluctant to extractan
Or Lee did nole that on all of these cases the talerals incisor from a patient who Is stilt & growing individual
erupted lingual to thelr final position in the arch He did and who may Sil develop enough space to allow tha
nol feel thal balerals which stupted labially would have sooth to tamalin in the arch
an equally favorable prognosis
In an older patient the exteaction of an Incrsor is, while
Many patients do not Improve without treatment how not universally accepted much Jess controversial In
ever and soma seam to bacoma steadlly mora ctowded many cases it is the only Sofutron which will fit that
How can we then decide which patients wil nead early patient
treatment and which will not?
We will now consider the other biological option reliet
If the latarals have erupted bablally, we face a situation of pressure Some patients exhibit maxitiary malocclu
which bs unlikely lo improve through natural fotcas 1 sions which by thelrnatura teairict the normaldavalop
croasbites or excessively closed bites have severely ment of the mandible, and thus act as a causative factor
restricied the development of ihe mandible we face a In Mandibular crowding
situation wherein (realment for the lower arch may be
necessary If early |oss Of deciduous teeth has contribu Vary deap dites will oftan restrict the growth of the man
ted to the crowding, we face ihe necessity of regaining dible in a Saggital direction and the iower incisors will
the lost apace be quife crowded in these cases Class fl Division 2
cases will often exdibit crowding and lingualinclination
Lower Crowding— ol tha iowerincisors Maxillary arches which aré very re:
sincied ether in jength or widin wall often trap the
Space and Stability lower arch and festncl iis development

(in all of these instances corracton of {he maxillary

When we consider shortage of space in Ihe lower atcn
wa find savaral solutions available Some ara biological
and some ara machanical thal is, depandanton active
forces In [he appliance itself
The biological solutions fall into two broad categories,
extraction and reilet of deleterious pressures from [he
upper arch Wea will first consider extractions
Extraction philosophies fall into threa main categories
premolar extractions, sacond molar extractions tower
Incisor extractions Premolar extractions virtually re
quire the use of fixed appliances particularly in the
lower arch, Even wiih fixed appliances residual space
problems often remain afer treatment
Second molar extractions are ofien useful eliher as a
mathod of gaining space, or !n conjunction with certain
appliances. One of tha signs that second motar extrac
problem offen allows spontaneous correction of the
lower We beliave two factors account forthis The first
factor is the tongue, which Is forced by [he pressure of
an upper appliance to a lower position un the mouth
where it exerts pressure in all dweactons (hus creating
more space The second factor is Inat ihe appliances
aré uSualiy conslructed with an occlusal bile plane
which in tne case of lingually trited lower postanors,
wil] contact only the buccal cusps This contact willaci
to lilt the lower posteriors buccally bringing them toa
more upright position More space for the teath will than
be available on the same arch
Opening Up
We wilk degin our examination of applance therapy in
the lower arch
 We will arbitranly pass over lwo appliances wich
used Dy many practilioneis to gam space in (he lower
arch, the Jackson and the Crozal Goth of Inese require
a fatramount of adjustment tokeeptihnem in fune dur
ing tealment and both should really be learned in
courses designed to teach Ihem
Before we examine Ihe applances available we should
look at the growth patlern of the mandible While we are
constantly reminded of (he growth faking place al ihe
socalled growihsiles of (he mandible the condyles
fis Seldom mentioned that (he mandible grows three ds
mensionally ASupefimposition of aninfant s mandible
over the mandible of an adult will Show that the mandi
ble has undergone a process of overall remodeling be
coming not anly longer although this ss Fts primary di
techon of growth, but aiso wider thicker and deeper
We commonly accept tha! the pressure of a funclionai
applrance against the alveolar bone underlying {he
lower incisors Wil! Cause apposition of the hngual bone
and depositton of new bone on (he labial plate
should keep this in mind when wé examine ihe apphan
ces lor the lower arch
The most commonly used active appliance in the tower
archis stidine Schwarz plate This simple acirve plate is
very effective in ihe uprighting of lingually tilled lower
posterior teeth and 1s uselul in cases of moderate inci
Sof crowding The amount of stable lateral expansion
which can be expected in ihe mandible is lbmitad,
{hough we do not know precisely the extent of these 41
mitations lt bas been gecerally accepied that the infer
Canine width cannot be increased and while thts has
been questioned fecently no hard evidence bas been
presented to show Stability of greater dxpansion
A relatrvely unknown appliance which has shown some
good results (we hear reports of greal resulls, but have
nol had the opportunity to examine the evidence} is the
bow screw appliance Drawing 4 shows the special
Drawings by Jodi Baker
Screw USed In thks appliance This appliance has the
Capacity to work both saggrially andlaterally Again the
problem will be sladulity if the intercanine width is in
creased
With the advent of the Saggital apphance many at
tempts were made lo dupiicate the action of that apple
ance in Ine lower arch Unfortunately they were doom
ed lc failure The differences in {he formation of the ar
ches and the inherent structural flaws in the appliance
led to constanl breakage problems and very jiltle was
are every accomplished We soughl and found a better
way
To accompiish the same leatmen| odjeclives we
designed the applrance (drawing Brio distaiise the first
molars leaving ihe canines and premolars free to drift
inta place Over the last eighteen months (his appliance
has shown some good tesults bul st must not be viewed
We aS a panacea for lower crowding it well function quite
wall in cases of space loss dye Io early loss of decidu
ous teeth of jo distalise first molars {oHowing extrac
tion of second moiars If (he screws are aclivated aller
halely the apphance has shown some success In dis
talsing both first and second molars bul care musi be
taken to avord titing of the molars
If the crowding of the lower incisors Is slight proximal
al sinpping of the incisors may provide enough space The
teeth can inen be aligned with a Barrer apphance also
called Spring retainer or spring positioner Tha stup
ping should be done using the keystone techoique to
enhance the stability of the result
Onward and Upward
To thus point! we have examined the biological and me
chanical means to relieve lower crowding We wit! now
turn our altention to the effects of functional (raatment
an lower arch crowding
While there are a large number of functional appliances
of very different appearance they are all rooted in thé
same basic principles We are concerned here with
those specific principles which have a pronounced ef
fect on the lower arch
Numerous authors have noled the effect which func
tional appliances have on the lower incisors, Wilh the
mandible forced imta a protrusive position, a process af
lingual ¢esorplon and labial deposition takes place
The ladial plate is actually remadelied and the incisors
move juSually uptight) to a new pasilion in the (now
longer arch
This ts neither a grass norasudden movement Theinci
sors May only move one ariwo millimeters labially and
this movement will take place over a period of several
months Itis a significant Jactor in the uncrowding of the
jower arch since the leelh are eventyaily posilioned in
bone which was not even present al the initiation of
treatment Another lactor which is of critical impor
tance in the lower arch is the verlicai growth which 1s
aliciled by a functional apphance We may have a l#a
dency to regard this growlh as purely vertical but be
Cause of the inclined planes which afe usually present
 this growth ts usually oblique with a large buccal com ages the patient lo eat wiih {he appliance and ever to
ponent as wall as the vertical growth of the teeth and ali ealsmallér more frequent meals He fells {he patient to
of the associated structures, down to the basal bone It remove ihe appliance only to clean it n order io get
1S Certanly true [nat the lower arch 1s less maHeabie than ready for mare eating
the upper but substantive changes do take place
When presenting a Bionalor Or Hickman tells the pa
Itis often clarmed that lower posterior teeth are only up: trent that itis a talking appliance He encourages them
righted and that lower arch width rs an Immutable tac to talk incessantly with the applrance im place and to
tor incapable of change once the permanent dentilion orte nfo the appliance when speaking This accom
erupts This claim is based on the concept that growth plishes two ends the patieni has a grealer degree of
ends {or Is at least greally diminished} aller pubarty muscle aciivation and also learns very quickty 1¢ speak
Strang evidence exists to contradict this Iheory well with fhe appliance in the mouth

One of the common resulls (indeed one of the objec
tives} of functional treatment 1s the levelling of exager
ated curves of Spee Uniess one beheves thal teeth can
be intruded several millimeters, while still mamtaining
their apparent crown height which the author does not
it becomes Obvious that some measure of growth
yeolar growth, has laken place Itis also obvious, aftera
flew minutes work with a caliper that the teeth are in
somawhal wider relationship than before treatment
Summary and Conclusions
Thes article concludes our four part look at the probtem
of tower crowding We have examined brolagical me
chanical? and functional soiutions for this problem. In
the younger patiant it is oftan possible to finish treat
ment with 4 virlualiy perfect lower arch In the patant
who begins treatment with adull dentition ifs usuaily
possible to effect a greal improvemen! but the parfect
result most often eludes us
It might be woll for us to consider a certain degree of
lower arch crowding to be the norma! condrtion of the
adult human and to make higher priorities of such es
sential Objectives as good functional occlusion proper
vertical, and stable jaw retalionship
Admiltedly, most patients would preter to have perfect
anteriors, even at the expense of those treatment objec
tives which you know lo be essential but they will prob
ably be willing lo accept improvement in the lower arch,
lf ihe upper arch is perfected and if they see the very
beneficral changes which occur in the face during func
tional traatment
This may not entirety account forthe good results which
Dr Hickman sees in hs palients bulitis one ofthe mast
inventive and onginal psychological techniques we
have encountered Our thanks fo you Dr Aickman of
Westfield NJ for sharing it with us
al
Practical Tips
Todetect pressure pomts Onan activator pari ihe area
winch contacts the jinguals of the teeth with a thin film
of chloropercha (guttapercha dissolved in chloroform]
Return the appliance to the patient and on the next wsit
all contacts wilt be easily visible Our thanks to Dr
Robert Berman of Kingston Pennsylvania
The saggital appliance is offen constructed without a
labial bow when cuspid books are included in the app
ance Tms will sometimes leave the upper antertors in
less than ideal alignment One way to gel around his
probiem is io bend the cuspid hooks to hold elastics
which can be stretched across the anteniors This well
allow you to align them quickty and éasrly and save the
cost of a separate appliance Our thanks to Dr Keith
Whatcott of Provo, Uiah for tis most useful idea
Many doclors are still encountenng difficulty in getting
the bifes pust right Folded sheal wax presenis Some
problems both in the office and tn the laboratory An
gasy allernailve
is touse preformed denture bite blocks,
available from mos! dental supply companies Try to
avoid those with a very Soft texture as they will allow
distortions aller being ¢emoved from the mouth

We reahze that some of the statements made

sertes of articles may not dé acceptable to some ot our
in this
Lower Incisor Crowding—
readers Our opinions come from two sources exten
Sive reading of the literature avallable and observation
One Solution
of and discussions concerning changes which have
jaken place in the mandibles of hundreds tif not
thousands} of patients We have been forced to certain
conclusions, even [nough they may notbe proven ina
screatific sense. {
We welcome your comments on this Serres pro orcon
and we will publish your comments if you So desire We would lika to begra this article by expressing Our
gfatitude to Dr Harry G Barrer whose kind attentian
Psytreatment made it possible te write and to the Journal of Ctemcat
Orthodontics whose prompt attention and permission
In & recent Conversation with Dr George Hickman of to use these drawings is grafefully ackncwledgad
Wesllield New Jersey [commented on the fact that his
Many of you have used SIripping to reliavea minor crowd:
patienls Seemed to wear therr appliances more relogi
Ing at the end of treatment Judging by what we have
ously than in many practices Or Hickman explained st
heard resulls have been varied Many of you have used
this way
spring retainers (also called spring positioners, Barrer
When presenting a Saggttat apphance Dr Hickman appllances and those funoy litle things that fit over the
teils the patient that il is aneating appliance Me encour lower antenors}, again with varied results
 In order that this method be as clearly explained as
possible we contacted Dr Barrer to inquire about his
keystone stripping technique This technique, coupled
with the spring retainer is reported 10 minimize relapse
of lower incisors
In the same way thal you make use of natural forces in
functional treatment you should seek to simulate
natural forces in stripping techmiquas If you create flat,
juxtaposed mirror image surfaces preferably counter
rotated you will Nave broad adjacent planes which wal
result in the forces of displacement (drawing 1}.
The keystone lechnique is best done aller the spring re
talner is ready for insertion, The stripping can be done
with yourusval equipment but the power strippers offer
distinct advantages
The objective of each cut is to place the interproximal
plane at an angie opposite Io the force of rélromove-
ment Thus Ifatoothis rotated meslo-lablaily you want
to establish angles which will give a force in a mesial
lingual direction It 13 important to cut both adjacant
4B Keystomng qyls For clochwese rotated lett central, pai cuts a-a and c-c For tounter
clockwise rolated right central, par cuts b band dd
mesial surfaces post-correction
C Keystone cuts c-c and &e produce
CD Relationship of iniarprowimal planes aller keystoning procedure
Timing of Treatment—
Some Considerations
The proper lime to initiate Functional orthodontic treal
mantis a mattar of some controversy asistheeffectiva
ness of early interceplive orthodontic treatment Before
wé Can Seriously consider the question we must deline
whalwemeanby earlytraatment Forihe purposes of
this article we will define early ireatmenl as treatment
occuring Defore the pubertal growth spurt
leelh at the same time al the same angle, and without
raunding off the angles of the cut surtace.
When the stripping is completed the spring ratainar ig
inserted It ig meant to he worn at all times, excep! when
eating With good cooperation the lealh may be reposi
tloned In less than lwo months Severe problems may
require several spring retainers to complete
A month after the desired arch form has been attained
the patient may begin nighttime onty wear of the applt
ance After a further thrae months the appliance may
become a souvenir
It ls Important to keep In mind that this technique is nol
Sultable for gross malallgnment of lower Incisora It la
difficult 10 galn more than 4mm of Inierproximal space
through stripping
Anyone interested in more detall about ihis technique
should contact the JCO for reprints. The original arilcie
was in the August 1975 Issue
Illustrations courtesy of the Journal of Clinica! Orthodentics 1828
Pearl Street Boulder Colaredo BOG? (303}443-1720
For mesiorotatian oi centreis tlatten
a labialty directed resistance force
inlerceptive orthodontic traatment is intended to cor
réect dental and/or skeletal conditions which will inhibit
normal growth patterns The trend in biology is to
develop and grow toward normalily In effect, this
means thal early correction provides a favorable
cilmate far narmal development From abiologic stand
point skelelal or dental abnormalities should be cor
rected as Soon as they ara identified *
The desire to interevene must ba balanced against Ihe
possible lengihening of overall treatment tima and tem
pered by the psychological makeup of the child Coop
 eration may be a problem with chitdren younger than clusions should be corrected as soon as they are iden
sevan years but aach child should be assessed tified Practically speaking however this noble objec
individually bye ts neither desrrable nor prudent bacause of various
mitigating cucumstances The traatment! of each pa
Some problems should be treated very early, as early as
lent shouid be planned and lallored fo suil {he needs of
reasonable cooperation can be assured. Crossbites, the Individual |
which at the outset may have involved onty teeth and
their supporling alveolar processes, broaden their AEFERENCES
sphere ol inftuance loincilude basal porons of the max 1 Jacobson, Alex Ameéri¢en Journal of Dehogonhcs Volume 76
ilfa and mandible and can extend 1c remote areas al Number 5
2 Frankel, Rolf Removabée Orthodontic Apphances
fecling the growth and configurations of the condyles 3 3P Pieter and D Grobety Adsracs of tne 541m Congress of the
of the mandible * Both anterior and posterior cross- European Orthodonttc Socrety
bites are easily corrected al an early age, and can be cor 4 WJIB Houslon Absivacis of ihe 351% Congress af the European
rected In the deciduous dentition Orthodontic Soctety

GETTING
When considering the psyctiological siale of very
young children the psychological effect of the maloc-
clusion, ang ils relation to the child’s teetings must be
axamined Early lraatment is psychologically advan-
lageous to chikdren whose
lered by peergroupteasing
Classil Division t cases may
tures of the upper incisors,
sell-image has been shat
'Earlyconectionol severa
also prevent frequent frac INVOLVED
This article ss written as an aid for those of you who are
It would seem that the advantages of early treatmenl of Just getting invoived in removable functional treatment
danta! malocclusions would vastly oulweight the disad- We will try lo answer Some of the questions which are
vantages, and that crossbites at least should be most commonly asked at thal stage of involvament
lrealed very early
Tha mast common question (often unaskedg) is probably
When wea consider functional treatment, the prodtem ol ‘Will I gai into trouble doing this? The best answer to
timing Is more Complicated Many clinicians prefer to that queshon ts Nothing you can't handle
initiate lraatment as close te the pubarial growth spurt
as possible since this 19 generally though! io lesson The besl way to avoid probiems ts lo know which cases
overall treatment time Others disagree. “Optimum time Can be treated most easily with funclianal or removable
to glart the treatment is when the child ts about 7% apphances and which will be most difficult (of sven
years old or when the lower lateral incisors have impossible).
erupted “2 Some clinicians feelthal orthopedic ap- Classil Division 1 cases are ideally sulted to ramovable
pllances are 30 powertul Ihat thelr action largely ex- functional treatmant Since they witl be the most com
ceeds whatever the growI!h contribution might ba’ mon type of malocclusion to enter your otfice (his
Some difficully also exists in predicting the onsei of the works out very aicely Class Il Division 2 cases are also
pubertal growlh spurt so that in many cases il is most Suitable lor this type of freatment
more appropriate Io time treatment to the silage of den £xamine Ciass | crowded cases very critically They can
tal development rather than to allempt to make use of go either way and oflen require second molar semoval
the pubertal growth spurt 4 to treat oul with any success
Wailing lor ihe pubertal growth spurl is difficult to Excess, generalized spacing or microdontia cannol be
understand alnce Ine opportunities of taking acvan-
lrealed successfully withoul tixed appiiances Func
tage of growth are Jost particularly in those patienis tonal apphances wil always create more space :n the
with severe craniofacial skeletal disharmones 'Andit dental arches, Insome cases {hos can ba overcome par
may also be Inappropriate for the following reasons ticularty tn the very young palient bul most cases with
1 It postpones the beginning of treatment to a period
generalized spacing are not lrealable with removable
where the adaptability of ihe issues is decreasing very
appliances
rapidly
2. Il places the patent in an age where he has to face Never allempl to teeat Class Il) opanbite Cases
Many psychological problams conflicting with ade-
If & broad Sense, you now have an idea ol which cases
quale cooperation.
are most likely tobe lrealed successiully The next thing
3. It complicates the therapeutical approach since
toconsider is the treatment plan If you use a sequential
the permanent! teeth have erupted and cannot be guided
treatment plan you will avoid many problems in treat
into place. Very often, especially with boys the second
ment obtain a bettarresult and in many cases actually
molars are fully grown and hamper any distal maverment shorien treatmenitime It's very simple and logical and
of the first molars,
has shown itself lo be clinically successiu!l There are
4. It definitaly compromises long term stability
tour condilions of malocctusion and they should be
because he tissuas do not get a chance 10 adapt tham treated in this Sequence
selves to Ihe new environment?
Crossbiles, crowding jaw relationship and rotations If
At Universal Dynamics we have fabricated apphances
you follow this sequence everytmng will fall nto place
for patients from three years lo sixty years in age. Obv:
ously no cerlain pcint in ime is perfect for every pa- it has been said that this type of lrealmant is 75%
lant “Ideally and from a biologic standpaint, maloc- psychological and 25% phystologica! Tne mollvated
 patient! the cooperative patient the patient that partic! The advent of aclivators ol greatly reduced bulk allowed
pates tafher {han endures 1s Ine successful patient day as weil as night wear and necessitaled a change in
The practhtioner has little adjustment to do with a lunc the construction bite The longer period of wear mean{
tional appliance We have heard many stones of pa that more sustained muscie aclivily Could De eliciled
tenis who disappeared fram a practice only to turn and the patients desire to maintain some normality of
up Six Months later still weacing their funchional appil appearance also meant that gross protrusion of the
ance Invanably they have made astounding progress mandible was nol desirable
Obviously they leit invalyed in {her (reatment Equally
Ballers brought the mandibie to an edge lo edge bite {at
obvious 1hé practitioner mus! Dave had a large role in
least on {he Jaterals) and felt thal exaggerated fonward
these feelings So as you gel involved get the pafent
movement of the mandible must be avoided in the con
involved
struction bite for ihe original Bionator Schmulth m the
Las! bul hopefully not least we offer whatever help we Kybernator which was a modification ol Balters appl
cangwe Donot be afraid iocall us Ourknowledge has ante utilized the construction bile of Andresen
come largely from the dentisis whom we serve and we
In the United Stales in the jast few years the construc
are most willing to share 11 with (he profession We hoid
bon bites for the apen activators have undergone some
only in trust
changes Fora short iime the Swiss idea of mandibular
siretch had some following even though it was oaver
really Intended for an apphance worn day and night but
ACTIVATORS: recently the more usual bil recommended is edge to
The Starting Point edge with 2 to 3mm of incisal opening Itis generally ac
cepled thal displacement of the mandible more than
4mm beyond intercuspal position is nol fuaclional jaw
Much of your success In activalor {reatment is depend
orihopedics in the traditional sense
enton your first act, taking Ihe construction bite We are
reterring here to ihe entwe family of activator applian The type of appliance used will thus have a detinije ef
ces from 1he original monobloc to the latest specialized fect on the position of the mandible in the construction
designs And (hereis and has been from the beginning bile With the LSU activator as taught by Dr Robert
much controversy surrounding ths simpie piece of wax Shaye the recommended brite is the most protrusive
possible with a marked caudal displacement The An
The controversy stems from a tundamental desagree
dreseniGrossman monobloc as taughl by Dr Anihony
ment over the muscle response elicrted by the appil
Rice: utilizes a construction bile wherem the horizontal
ance Andresen felt the functional pattern could be
and vertical displacement of the mandible tagether
changed by ekciting incteased activity in the proteac
agual 10mm,1ie 4mm ol forward movement and 6mm
tors and elevators and stretching ol the retractors The
of interocciusal opening between the first pramolars
applance should thus be loose in the mouth to trigger
With the open activators Such as the Bionator and the
the orofacial Muscles to brte Wintoplace The appliance
Univator the bite rs usually end joend with 2 to3mm oft
was tO be worn at aight
incisal opening
Later authors disagreed Jeeling {hat the apphance did
We are back finally to where we started Your choice of
not elicit any mcreased activily of he mandibular mus
applance and your belief concerning the moda of ac
culature during sleep They believed the activator ob
{ron Of the apphance will delermine your construction
tained its results by disturbing Ihe equiktbrium between
bite And your construction bite will determine your
the forces acting on the mandible inrest position was
treatment for one year and your patient's appearance
not the activator in mavernent iney feli bul the ac
for the rest of his lite
tiyvalor al rest

Thus a fundamenial controversy was born Andresen re: it Broke While |

commended aconstruction bite with the mandible 3mm
distal 10 «ts most protrusive position with the mteroc Was Eating Spaghetti
clusal opening toa maximum of 4mm preferably within Repalrs are a real nuisance both for you and for us
the patients normal freeway space Others, notadly
While we are always working to avoid them by the mos!
Harvold have advoacted a much greater caudal
stringent qualilty contro! and constant evaluation of
displacement
materials and methods, accidents will happen The
Harvold placed the mandible 3mm distal to the most most important consideration in repairing an appliance
protrusive position but used extreme separation of the is lime and this is particularly important with active ap
Jaws openrng & to 10mm beyond the freeway space He plrances, since relapse can occur suddenly and dramat
and other proponents of this concep! (Woodside used ically This Can be overcome
vertical Separation of 12 to 15mm), feel that the myolatic
When the patient must he without anactve appliance rt
reflex and attempts {o increase the trequency of
is very simple to make a lemporary retainer with cold
masticatary movements should be ignored They feel
cure acrylic Simply apply separating medium or a thin
that passive lension in the stretched labial and oral
musculature will deliver (he needed force ta the activa
sheet of foil to a current model mix your acrylic and
tor Therefore the greater tha amount of stretch the spread i1 on the model about three millimeters (hick
move fofce which will be daliverad to the apphance
While crude this will serve for a few days while the ap
plrance 1s being repaired
Some authors aiso feel that the greater vertical Opening
wil maintain the appliance in the mouth ehminating Save ihat current model and send it along wilh the appi
the problem of sleeping ejection of the apphance ance Having acurrant modai will allow the technician
 to repair the apphance with consideration for tha answer this question exactly if 1s still possible {o esti
changes which have taken place during treatment Malte the number of apphances needed for any one pa
NEVER take the impression with ihe appiiance tn place lient by examining the specuc factors involved tn {he
as this will maka ihe model virluaily useless The mode} case
will not be accurate enough to allow us lo delermine if
the apphance Is fitting properiy Some ol these factors are degree and extent of
crowding degree of overbile and overjet fendency to
Another poor choice is the original modal Appliances open bite severrty of rotations jaw relatronship soft
do not simply break fornoreason Changes taking place tissue problems These ara some of the factors which
during lrealment will alter Ihe amounl and direction of must be considered
the forces acting on the apptiance Repairing the appli
ance to the original madet puts everything back to the Some patients may be {reated successtully with one ap
same situation that exrsted ai the beginning of treat pllance Class Il Division 1 patients with no crowding tn
ment and does not allow adaplion of the apphance to either arch are the mos Irkely candidate for ihis honor
Ihe changes which have occured In the mouth The They are alas. quite rare
same factors which caused it to break once will be hkely Class II Onision 2 patients with retruded central inci
to cause If to break gain sors often progress very rapidly after the mcisors are
We know that repairs 13. a subject which none oF us likes brought ta a normal angle The mandible very often
to think about Bul since they willbe necessary despite spontaneously adopts a Class | position leaving verti
allof our best efforts, we will make very attempl lo make cal development as the only real problem in the case
the rapa perfectly If you help us to do this, we will be Maxillary extractions Shoufd be avoided in Quysian 2
more sure of success cases as they will anly complicate treatment
Class | crowding cases can be vary satisfying or very
INSTANT RETAINER frustraling Many patiants have been completely cor
rected with second molar extractions and no further
freaiment If third motars are not present the Ciass |
crowded case can be very difficult If the case is vary
crowded no type of treatment should ba ruled out asa
fixed apphance approach might give a good resuliina
tasé which would be very difficult to treat with
removable appliances

Usually apatient treated with removable functional ap

pllances will vequire three appliances In extreme cases
a patient might need tour appliances tor active treat
ment ath one lasi finishing appliance for final place
ment of individual leeth If you find yoursell jumping
from one appliance to another and back again itis time
to focus on the planned sequence of treatment Sequen
tal treatment can save you much time and aggravation

An achive apphance usually mcorporales an expansion

screw with 24 lo 27% turns, With a va turn made very
four days, the appliance should have a uselul litle of
three to four months tf you have apatent whohashada
Saggilal appliance for six of ten months obviously
something Is amiss

A functlonal appliance has an average uselul life of pine

months, This can be shorter or slightly fonger depend
ing on the needs of Ihe indwidual patient
Nonetheless all appilances havea usefulliie span and
keeping therm in use beyond this life span can only pro:
Jong Irealment and erode patient cooperation

Orawings by Jodi Baker

Will This Patient

Ever Be Finished?
We are often asked how many appliances should he re
quired to bring tha average patient to a successful con
clusion with ramovadle treatment While it Is difficult to
 Ihey are very differant In appearance We can group Ihe
Menodloc activator and the LSU Activator togather
since their differences are of less magnitude than their
simularities
These appliances are yery useful in cases which are ad
versely allected by respiratory difficullias as lang as
the nasai passages are nol completely blocked They
will force a mouth breather to breathe through the nose
They are also much harder loinvoluntanly eject fram the
mouth, For patients whose work or personal feelings
practude daytime wear of an apphance these are very
good appliances

WHICH ONE?
Wa have skipped over some appliances such as all of
the tunctiona! Bio Blacks and all of Ine aclivators in
tended for Class Il treatment To communicate ade-
qualely the factors affecting Class IIl treatment would
require More space than we have (like a book) and the
The aumber of functional appliances available to the
whole philosophy of the Bio Biock system would be an
profession has increased anormously in the iast lew
issue In itself
years This proliferation of appliances has had the ef
tect of creating some confusion We hope In this articie We hope thal Ihis nas bean of Some value ta you but we
to give you some basis forachoice among the many ap are suze questions willremain Please call of write and
plances available we will do our best to provide more detailed answers
We generally make (he choice after examining several
factors such as overbite overjel crowding age of pa
tient coaperaton which can be expacied elc lt must
MEANS TO AN END
Many casés sequire movement of individual teeth. With
be remembered thaf all functional appliances will work
ramovable appliances, tha maans available are limited
In a Simulaz Manner wilh a different emphasis in one
tospringserscrews Both have certain advantages and
aspect of their action
disadvantages and we thought an examination ofthese
The most orderly way to proceed will ba to list each ap: wauld be useful
pllance with those characteristics which would indicate
Until very recently springs were the obvious choice All
tS USe In a Specific case
ot the screws avallable were much loo large to effect the
The Bionator wall give horizontal repositioning very movement of individual lesth Ascent technological ad
quickly and is also very Useful in casas where some vances have changed the situation dramatically New
residual crowding remains [tis intended to be worn vir screws which have become available on the last few
tually twenty tour hours perday ff 1he circumstances of years combine small size with good strength and allow
the patient's Jile will not allow this the apphance will a choice mm many cases, Some of the factors which af
noi effect its changes as quickly bul wail sfill work fect thal choice are the space available, the amount of
movement required, and the type of appliance to which
The Orthopedic Corrector | 1S very much like the
the device will be filled
Bionatot but has more flexibility in dealing with vary
deficient mandibles and with mandibular crowding The spting has obvious space advantages Even the
smatlest of screws will fake Up more space than a
The Orthopedic Corrector |S like the | but with occlusal
spring The spring aiso has the advantage ol baing very
acrylic to close an open dite adaptable and nol needing acrytic at Ihe point of aclion
Tha Univator | ts also somewhat simuilat to the Bionalor This allows springs to be placed on the buccal surfaces
bul 4s infanded Io promole more rapid alveolar growth of teeth, or to conlaci tesih in areas where acrylic would
with a concomilant change tn vertical be detrimental to the overall devslopment. In some
cases it is necessary to add a supporting wire for the
The Univator Il ts fike the | byt with 2 capacity to relieve spring but the overall effect is a Jessening of bulk At
moderate crowding in the upper anteriors It is not a
this point you may be wondering why we would ever use
replacement for ihe Sagittal appliance a screw Bul Screws have advantages of theirown
The Urivator lV ts intended to treat overjats of more than The adjustment and maintenance of Springs can be dli
10 milhmeters with associated procumbency of the up
ficulland tnexact The direction of force may be difficull
per anieriors
lo determine with springs, The screw has none of these
drawbacks The palient can adjusl ihe screw and this
The Univator ¥ is intended to ciose open bites, and in
saves the chair time which would be necessary for fre
corporates elements to retain the tongue
quent adjustment of springs The screw ts posttiva and
All of the above mentioned appliances are open acilvai exact inits movement and the direction of torce can be
ors allowing speech during wear All of them are intend pracisely datermined
ed to be warn fuil time
The screw 18 also much more useful when a tooth must
There are also aciilvators which are iniended and de- be moved a tong distance {over 2mm), since various
signed to be worn only at night They are made lo methods can be incorporaled lo prevent tipping The
bring the mandible lo a more protrussive position and amount of force generated by the screw 1s very lighl, and
 —

this helps nol only to keap the tooth upright but alsa to
mirumize ihe ask of damage to the tooth root and Ihe
Sufrouding supportive Issue structures
We have drawn Iwe conclusions from our expenence
with springs and screws The first 1S {0 use a screw i.
Slead of aspring whenever possible We fee! (hat lhead
vantages of Ihe screw are overwhelming in Ihose cases
in which the condition of Ihe patent allows us achoica

The second ts to keep springs as simple as possible

when they must be used This makes them more post
tive and much easier lo adjust This will save you lime
and we all know whal (me's

Yes, Orville, But Will

It Stay Up?
Recently we received a phone call from a doctor who
was faving some difficully with the retention of ns ap
pliances He had been using clasps of an unusual pat
tern and they were not working at alf well While this Orawings by Arta Mullaney
was an solated incident, itdid paint up the need for ade
quate retention of appliances, Let us examime some of
the malthods mast commonly used and some which are
less common

The Adams Clasp (drawing 4} s surely the mos! widely The bat clasp is vary widely used Uniorlunately sf as
used and one of the most efficient retentive devices uSually used wrongly (drawing 0) This method forces
available While usually frttad lo the first permanent astortion of the clasp to remove the apphance tram 1%a
molar in cases of dire necessily it can be filied to other mouth, and has no intrinsic ability 16 maintain its GOSt
teeth 11 will seldom work well when fitted to the sacond froning and thesefore its selention When the ball clasp
permanent molar of to antenor teeth it is easy to is fitted properly (drawing E}ithasaqrealarlengthalong
fabricale but difficult to fabricate well Prefabricated which forces can act and wil mainiain its shape and
Adams Ciasps are lernble, and should not be used ex positioning much better When trtted properly thes is a
cept in an emergency good secondary clasp which is Usually filled between
the premolars
An interesting and useful modification of the Adams
Clasp ts the double Adams {drawing A 1}, Its cal ed the We havé now examined the mast cammonly used
double Adams because Il extends io engage Iwo teeth clasps There areothers The arrowhead claspidrawing
ié. the distal of the first permanent molar and the Fiis extremely retentive and willmotinhibit the eruption
mesial of Ihe second deciduous molar While this clasp of the clasped léeth Among its drawbacks are the ne
iS Not new it has nol seen extensive use in this country cessity for Special (very expensive) pliers forrls fabnca
It 1S a good clasp giwing maximum relention in mixed tion the necessity of feethin approximal contact doris
deniition cases. It 1s also simpte and easy to adjust al functioning and extreme drfficulfy in maintaining and
though the bridge musi never be bent adjuSting ihe clasp iisel!

Another clasp which ss used extensively is the halt The Larry Dunn Clasp is unusual in that itis a tingual
clasp also called the C clasp (drawing B) While this clasp [drawing G) I1 1s nol widely used although your
clasp can give adequale telention, i118 More subject to editaris nat aware
of any teal problems
with ihe clasp It
distortion than the Adams Clasp and 15 best used aS a might be more difficult dor ine patient to remove and re
secondary retentive device, This is the mosl effective Seat Ine appliance bat this might be considered an ad
clasp which can be filled lo the second permanent vantage as weld as a drawback
molar While there are other clasps, probably more inan we
A seldom used denvalion of the halt clasp 15 the doubie know we bave now covered all of Ihe ciasps which you
half clasp which ls usually used between the premolars are likely to encounter We well now consider some al
{drawing C} Even though if is essentially two hall the factors which contribute io the success or faslure of
clasps, dis nol called a whole clasp Tims ctasp gies our retentive efforts
good retantion but the necessity ol soldering one arm One of the most serious problems :nselentronss the pa
Ol ihe clasp sottens the wire increasing the possibihty ten! with only partially erupled teeth Since all clasps
of distortion 1o some dagrea rely on the contours ol the teeth tor effective refention a
looth which has not erupted past ihe height ai cantour
cannot be effectively clasped A solution to this prob
lem 4s 10 DONG a Dfackel to of build an undercut of cam
posite onthe buccal surface of [he tooth and then use
a hall clasp to lock over the Dbrackel of undercut This
will give excellent relentton tn ihese cases
 Anolhet quile common problem 1s mrssing teeth, both The double Adams clasp 15 adjusted in the same man
in younger children who are tn the mixed deniitton and ner and bending the bridge will be even more quickly
in older patienis who may have lost one or several per disastrous
Manent teeih While it +s possible to generanze aboul
The bail clasp 1s also easily adjusted by use of the same
these patients {since any tooth might be gone) it is
Universal pier Simply grasp the free end close to Ihe
uSually possible {o find some method of ellective
balf and rotate if into cantact with the embrasure itis
retention
important 10 use only the tip of the pher to hald the
Ofcourse tnedesign of the clasp is not the mast critical clasp so thal any necessary cure ip the wire wil not be
factor sn the success of faiture of retentian The skill of lost idrawing C}
the mndividual technician in filling the clasp wilt deter
The half clasp 15 most easily adjusted by stmpie finger
mine that
pressure (6 Dring it inte beller contact, bui the double
We will continue our consideration of ratantian and al half clasp will sometimes require adjustment with a
lendant problems when we examine adjustments roundiconcave plier (drawing Dy
Should you for some reasons have an appliance with
arrowhead clasps you have probably come to the con
clusion that it is almost impossible to keep tt in adjust
ment You are absolutely right
Finally we come to the Larry Dunn clasp which never
needs adjustment and ts, in fact impossible to adjus!

Can You Adjust

That, Wilbur?
In the previous article we showed the most commonly
used clasps for removable appliances In thts articla we
wil! atlampt to show Ihe bes! tachniques for maintain
ing their ratentron tn the mouth But firsl a word about
loss of relention
The most common reason for loss of retention 1s inad
verlent abuse by the patient The bridges of the Adams
clasp, which is the most common Clasp, are so easy to
use aS ameans of removing the appliance and you can
say nothing which will persuade the average patient not
lfousethem Asaresull overa period oftime the patient
wul slowly pull the retentive feet of (he apliance away
from the tooth untifittalls onte his longue He willthen
blame you

You can foil him by using a Universal plier lo bend (ne

feel back into contact with Ihe tooth (drawing A) of by
benging the enfite clasp mio beilet contact (drawing
Al) The most common method of adjustment on
Adams clasps 1s also the most useless (drawing B}
Bending the bridge of Ihe clasp will move the feel to a
fully Duccal position on the tooth, and they will no
Jonger have an undercut to engage The clasp will
become dependent on friction to retatn the appilance
and will quickly fad The appliance will fall onto the
longue “he paltrent will blame you
 There Are No Lucky Breaks
In This Business
Early Indications
Among the questions which we heat mast frequently
Constant Improvements in materials and lechniques are ihose questions related to the very young patient
have reduced appliance breakage to an all time low Recently pubiished articles give some indigation ol
However the total e/imination of breakage may notieal julure problems We will recap these findings brietly
ly be possible
The great majority in Oivisian 2 cases are characterized
in some isolated cases there is ar appliance failure due bya highiipling thatis the lowers fipis high on the upper
to arch dimension eruptive height of the teeth, an un teeth in normal relaxed closure Since ihis is very easy
detected distortion in the impressron ora less than per todetect even with vecy young children itcanheanear
fect bite registration All of these problems are magni ly clue to 4 developing probierr
fied when posterior occlusal acrylic 1s used There ex
4 number of developing problems can be spotted qurta
ists a Certain potential for technician error which can
lead to a less than ideal fil of the appliance or an
early by Observing Me child in the more relaxed atmo
sphere of the waiting room A chile will modify his be
overzealous trimming of the acrylic leaving a thin area
havior when you aré actually working wilh him Breath
inthe appliance whichis unable to withstand the rregors
ing habits head and jaw posture hand ane sijithabiis
of the movements it was designed for Humans being as
ail wil be more easily discovered when ine child 1s
they are, this will probably continue to be a tactor
relaxed
despite all of our best efforts
Gfthese breathing habits jaw posture ancasg thabiis
Misuse of the appliance by the patient [howeves unin
‘wall give you ihe Clearest indication af a oudding prob
tenlional) is still the greatest single reason fo, Dreak
age Few appliances breakin the mouth most breakage
lem Breathing habits are wellknown g$ good indivato s
of future difficulties andl snowld be watctien ulvsely
occurs when the applianceis oufsida the enviranmentit
Drgst habits (thumb or f rger are especially destrurtive
was designed for for example inthe pocket
and can be difficull ic overcome Habilual jaw posture
Many instances of Dreakage occur when the apphance 1§ less wellunderslocd Gul may be a factor in jaw rela
is out of adjustment Clasps may become toosa caus lronship worlty of closer scrutiny since soft "issues ex
ing the appliance to ride up of down during speech or ertso murh influence on the develope i ot ‘he dental
eating Auxiliary springs are often overadjusted which arcnes
prevents proper sealing of the apphance thus subject
Another otten Gverlouked ing ator of future probleris
ing the appliance to stresses which Wi cannot be design
is Ihe amount oi wear iothe decmdusus mola s The ne
edto withstand These two factors account for much of clusal sevel cf the Ewil thus canthbule to 4 deep over
the breakage in active appliances
bite with all Gis concomilant aifficueties
Functional applrances must be worn to prevent break
One of ine advantages of eary detechonis al Pabi'ual
age tf the applianceis out of the mauth
too often orfor
patterns may be oroken up before they have had too
2 long period of time asmall amount of relapse wrll oc
much effect |’ a child 5 parent's are aware that a chica
cur The appliance will not fit properly when reinseried
may be doing kamself great harm by leaning his c7cek
and the potantia! for breakage will bea deamaticarly «n
on his fisy while watching lelevision |Melr intervention
creased The appliance wilt of course be in danger any
May prevent the devesopment of a crossbite
teme 1145 oul of Ihe moulh since {his 1S where most
breakage jakes place Early delectloo will allow you to plan treatment miore ef
fectively and ‘a treatmaoare semply sine sone problems
4 properly filled and adjusted appliance well not normal
may bé elrminated with the ehminahion uf ine habits
ly break Only when the appliance does not fil properly
wich are acting to Gause them
15 Oul Of adjustment of out of the mouth will tt break

229§
If you are now asking yourself whal you can do 1c pre
vent breakage here are some thoughts Aefer ta the art
cle on clasp adjustment on page 10 Never adjust a
spang more than twice the diameter of the wire Be sure
that your models are an accurale representation of the
patients mouth Send along a construction bile for all
functional appliances Try ine bite on {he mouels and
then back inihepatien! smouin belore sending i1 {othe
lab
Where Do We Go
Watch closely a patient who 15 losing his deciduaus From Here?
teeth Anacclusal bite plane whicn loses the suppart of
an underlying deciduous molar and is then subjected to Over the last several years we have made greal progress
IN appliance design and applicatror ye we still see
ihe pressure of the opposite molar as it eafoliates will
cases which stubbornly Jefuse to treal out as we would
be very hkely to break Succeeding teeth will nat fil the
hope We began to notice a pattern in ihese cases and
appliance as |] was originally constructed erupting pre
have concluded inat one of the reasons ‘or these = fatl
molars will unseat an appliance and make it subject 10
ures 15 thal we Nave spent ico lrttie ime evolving alogi
breakage
cal sequence of treatment and have placed 160 much
emphasts On appliances
 So here itis Treat all crossbites then crowding then
jaw relationship and finally rotations We wilt
elaborate
Crossbrtes— antenoror posterior unilateral or bilateral
lf the case is to be finished in Class | examrme the
modals in Class {1 chacking the buccal relationship, In
many cases a period of the dreaded lateral
axpansion wilisignificantty reduce treatment time and
save Much aggravation
Crowding—Here we are concerned mostly wrth the up
perarch butextreme crowding in the lower arch may re
Quite treatment or extractions also Again Ihe eiimina
tion of severe crowding at this stage will make all follow
ing trealment much easier
Jaw Relationship—aow that crossbiles have been eiim
inated and crowding reduced to minimal functional ap-
pllances will be able lo advance the mandible
establish the verlical which 1's their real purpose
Nord plate which will allow us to maintain the buccal
relationship on the side which is not in crossbite
We know thal correction of the crossbite will alleviate
the crowding of the upper right lateral incisor but we do
not know the fullextent of the changes which may take
place The correction of crossbites often is much more
beneficial to the patient than we are able to predict,
since the crossbite is so defrimental lo normal function
Itss Important in consideration of crosshites toexamine
the casts ina Class! relafionship, and to remember that
we are as concerned wilh functional as with dental
crosshites Excessive lingual inclination of the lowar
teath or restriction of the lowerarch may disguise a very
real crossbile, which should be treated in the first stage
of treatment
and

Rotation— The patrent should now be oul of appliances

and any remaining 7otations can be treated with fixed
apphances, positioners or some other method,
Treating each ot these probiems in the proper sequence
can yeduce treaiment time enhance patient! accep
tance and produce the best possible resull itis impor
tant not to move Io the next stage hefore completing the
correction of Ihe current stage Obviously in some
cases the correction of one problam will have a strong
bearing on another problem 1€ acrossbile correction
will alleviate Crowding lo some degree and sometimes
improves verlicat andlor jaw position Im some cases
two Stages may be frealed al once bul lls crucial to the
success of treatment to treat in sequence and tocom
plete each stage before moving to the nex!
Consideration of the sequence will also halp in treat
ment planning tor time and for apphance cosis We wul
begin a senes of articles Showing a hypothetical case
and the ways in which sequential treatment can cortect
it We will also show the appliance designs for each
stage We will welcome your comments on this series of
articles

We began the treatment! of Fred Malocciusso our hy

The Case of pothelical palent wilh a Nord crossbite appliance It
15 NOW nine months iater and Fred is now len years
Fred Malocclusso three months old Hers stillaClassil Division | case
but the crosshbite 1s more than completely corrected
Where do we go from here? promised a series in Its wise to overcorrect crossbiles to allow for some
which we would follow a hypothetical case through the degree of relapse
sequence of treaiment showing the progress of the AS we examine Fred we find thal the position of the
casé and the applrances most appropriate to each Stage right maxiary lateral mcisor while $ill nol good has
of lrealment We have given the hypothelical patient an nonetheless improved The overbite has also improved
appropraie name but it must be borne in mind that this
but the ovayet ramains a problem
is notan actual case itis rather an intellectual exercise
lg examine a philosophy of treatment Rather than be The mandibular second parraanent molars are begin
Ing 4 Case from one office it rs a case from all your of ning to have aninfiuence and are erupting early acom
fices and we thank you for Sharing your experiénces plication of treatment, io be sure bul one which we
which have made this seres possible should ignore for the present
AS yOU @xamine the accompanying drawing you will Taking all factors into account we will continue treat
note Fred is a Chass |} Division 1 case nine years six ment with a sagilal appliance to reheve the crowding in
months of age with deep overbita moderate crowding the upper anteriors and inswre enovgh space for the up
moderate ovenet (5mm) and unilateral posterior cross percuspids We will use both anterior and posterior bite
bite Our sequential {reaiment plan requires comection planes, ulslizing selective grinding of the posterior brte
of crossbrtes as ihe lirst Step Our applance will be a planes {fo increase the vertical dimension
 The Case of
Fred Malocclusso
You will notice that both appliances designed for Fred
have utilized double Adams clasps to gain maximum re
tention in the early mixed dentition

We will probably see a slight increase in the apparent

overjpt while Fred is wearing the sagiflal apphance
This ts nothing to worry aboul Since we can only treat
Class ll Division | cases with very little crowding with
functional appliances, all efforts al these early stages
must ba diracted to the creation of [hase preconditions
for Successful tunctional trealment
At this time, we can feel confident m projacting the
future Course Of treatment Within six months Fred sup
per arch will improve to the extent that we can than
mave fo a functional appliance We wilt have accom
plished the correction of our first two Slages in Sequen It aS Important to the successfui conclusion of Fred s
tial traatment crossbites and crowding We will be Case thal the good results gamed with the saqiiial appli
ready lo tackle the third stage jaw relationship, ance are not los{ The Bionator (or Univator or Bio
Block) musi have a wise (or wires) lingual to ihe upper in
Another sx months has passed Fradis now ten years crsors to prevent relapse of imat result! After the screw
rune months old His upper arch form is dramatically
im bas been activated fora month inis wire mous! be cul ai
proved and the right maxillary lateral mncisor is in good the midline Iitis notcut the appliance wil) be subject
position Please nole the small spaces distal to the lat ed to great stress and will very likely Dieak
erals These are one of (he Signs that sagittal treatment
has reached a successful conclusion We have had Had ihe chosce of functhianal apphance falien on one uf
some increase In vertical Dut ine overyet bas become ihe tradittonal activators which is worn only al night it
slightly more pranounced Fred is now a nice Class !| would be necessary to fil Fred with a retainer 1G wear
Division 1 during the day 10 riaintain the sagittal result
The choice of apphance now becomes more compl: Tha small drawing shows the tacisar resationship for the
cated We know that we want a functional appliance construction bite Note that itss end ic end with about
bul we have anumber of appliances tochoose from, and two millimeters of incisal opening
each will have advantages and disadvantages We have We now enter the third silage af Sequential treatment
decided lo use one of [he open activaiors, and of these
Crossbites nave been corrected crowding bas been re
we have chosen the Bionaior feeling that this apphance lreeved we witl Now turn to jaw relatronshrp Fred nas
will give us the most rapid horizontal reposriiocing of come along very Mcely and we can see the end of his
the mandible
treatment His sequential treatment

Fred has now worn his Bionator tarthfully for nine

months (hypothetical patients are socooperativel Heis
now eleven and a half years old His permanent teeth
have all erupted and his habitual closure +s as Shown
Atthisume wewiltpulFrediatoarest penou and allow
all changes to take Dlace
We ofcourse are all conditioned never to say the word
relapse pretending thatno posttreatment change
will occur with functional treatment tn fact we donot
foresee any change great enough to become 3 problem
But we will have some ¢nanges and it is infinitely
preferable to have those changes lake pace during
falher “an after treahnent The drawing shows the
position whichis natmal and almost ideal for the end of
treatnent wiih the first functiona! appliance Fake 3
break Fred!

Rest and
Reactivation
Sometimes it § best tadea nothing This siatement may
seem io be contradictory when apphed to your patients
bul itis nonetheless true The value ot periods of restis
 ollen overlooked As @ highly-skilled professional you the active phase is compleled the clasps may be cut
may faet you must he involved in [realmant until the pa- away and ground smooth flush to the acrylic
tant is finished
Univator Ilk—We recommend this appliance be used
However ireaiment lime may even be shortened by ony in patients mne or younger and only in cases with
allowing the natural forces of the mouth to came Into actual Class Ill molar relationships
play withoul any apphances Functional treatmant may
follow several active appilances As the moulh finds
Uniwvator|¥—Nochanges Eventhough lis themostdil
ficult to explain of the whole series, Il seems to have
new tunctional patterns normal” occlusion may no
been the best conceived
longerexist and can only be discovered by allowing the
patient to sellle into his new position, Univator ¥— We wil |rmil the occlusal coverage to the
molars since this seems to effec! a more rapid closure
Tha most interesting facel of these periods ot rest is
thal patents often continue to improve Spaces close
of the open bite This concep! of John Mew's has wide
impkcations for Functional treatment
the alignment of individual leeth improves and some
patients even complete their repos:tiaming Into Class f!

Some practitioners wil ask How can! charge a fee
when | am not doing anything?” Yet you have given ti
nancially and tn time to acquire the educallon and clini
cal skills which have brought the patient Io the point
where he can improve while ina rest period Your know
ledge determines the timing and exlent of the rest
perlod and you must make the decision on the futura
treatment af the patient
Another problem occurs when an appliance is used for
foo Jong a pariod of time Functional applrances are de-
pendenl on muscle stress for their actrvation Numer
aus Sludies have shown that muscles adapt fairly rapid
ly to new functional pallerns Thus the apphance loses
Calcium Supplements
In Our July #980 issue when discussing adult treatment
we mentioned the necessily of the body having calcium
available to bulld new bone We have since heard that a
specific supplement Oscal is formulated in a way that
allows the body to make maximum use of Ihe calcium.
Our thanks to Dr Al Baumann of St, Paul, Minnesota, for
bringing [his lo our atlention We have since found that
Oscal Is suggested for more rapid haaling of bone frac
fures in older people Since both conditions require the
formation of naw bone the same supplement should
work well

How Old Is Old?

much of its effect tn fhe first three months of use, In
many cases this makes no differance since the repos:
tioning of the mandible has been completed hy one ap
phance In some cases however a reactivation of ihe
muscles may be necessary If you have had a functional
Many practitioners are underslandably reluctant to at
apphance tn the mouth for six months o¢ jonger Il may tampi orthopedic correction in older patienis Many
be of no use and the palient s lreatment time is belng others report greal success and satisfaction in treating
extended fornolhing Maybe the patient would be better patients who are theoretically too old for functional
off resting
lreatment let use examine the evidence as it Is
available today

Univator Update {lis commonly accepted that functional jaw orlhoped

Ics achleves its resuits by stimulating and directing
condylar growin Numerous animal studies most nota-
bly those of McNamara and Petrovic. have shown that
Chrucal experence by a larga number of doctors has In condylar growth can, and will occur as a response Lo In
dicated that the following changes In design and use duced changes in mandibular position in a growing of
are necessary to the successful functioning of the Unt ganism No study to ourknowledge has shown condy
vator Series of appliancas Thase changes will become lar growth In an organism which has stopped growing
standard as of October 15 Should you object to any of
How are we to reconcile these divergent opinions? We
Ihese changes please notify us and we will fabricate
aré told by thosa who have done the pioneenng re
your appliances in the way that works best m your of
search on mandibular growth thal it will only occur tn
fice
the young growing patient Yet we have reports of greal
Unvator !|— To maintain the position of the apphance in success from doctors across Ihe continent, m the
Ihe mouth, it is necessary to construct the appliance t -atment
ol palients ranging fram thirly ta sixty years In
with alablal bow Because of our feeling ihat the Univat age. There musi be factors which account for this
or’s strongest porntis ihe stimulalton of vertical growIn divergence
the labial bow will be made with the buccal shields asin
We know that dento-alveolar change can take place at
legral components
any age Wecan [hereby induce danto-alveolar changes
Univator W—We most strongly recommend that this ap which will altar the positions of the condyles in the
phance not be used to replace the Sagittal appliance In fossae We know that we can alter the muscle patterns
cases Of severe upper anterlor crowding In cases of ef thea orofacial complex since this is one of the
shght to moderate crowding good results can be ob mechanisms by which we elicit change in the mandibu
tamed The apphance will be constructed wilh clasps to lar position of younger patients We can then, through
the first motars loenhance the stability of the apphance orthopedic treatment give an older patient an allered
during ihe actvation of the sagitlal component Once oral environment
=

The question now becomes one of stabilily Will tne necessary in adull Ireatment Could this be one reason
older patient maintain the new position? Is anew dento- why some adull patents treal out very well while others
alveolar relationship wilh retrained musculature seam to make only ihe most minor progress? We quite
enough? Will the temporomandibular joint function honestly do not know but we do teel 1) merits further
without trauma inits new position? study

To find answers to thease and other questions we turned Adult treatment 15 controversial Some cases seem to
to Ihree doctors who have treated themselves with func work Out much better than athers Al inis time we can
tional apphances. Atl of them finished treatment! some nol make a definite statement about ine growth poten
Ime ago We fell they would have some very special in jial in the mandible of the adult huinan We know ot
sights into adult functional treatment Several Studies in progress which should give us qreatec
Insight nto ihis aspect of adull {reatment when they are
We first spoke with Dr J L His trealmenthas resuttadin completed
2mm of vertical growth and 2mm of mandibular repos!
tioning He feels his result 15 definitely holding I Our position ts not one of advocacy It would be very
feels great nice to de abie to treat the adult patient arthopedx ally
with some certainty of Success More research will be
Or JL ts currently working with a number of adult pa done and case Studies of adult Ireatment will be
tients, and Qroughl up some rather interesting paints
drought to ihe attention of the professian Tae question
regarding adult treatment He feels two of the graatest
ol growth will be answered and prohah!y very soun
problems in adult treatment to be the lack of a detinite
contro} for the construction bite and a lack of nutri In the meantime you must make your own decision TF
tional control He feels if is nacassary to have 2 com lhe resull is aesinetc functional and permaaent is
plete blood chemistry done forthe adults in his practice ihat enougn?
Nutritional problems can affact lrealment in many
Ed nate The fotlowing article us from the Bio Block
ways but two areas are of Specral concern Any tenden
News We would like to express out gratitude tar Jorn
cy lo osleoporosis must be correcled Obviously bone
VWew forpermission toreprntithere We feittha this ar
musi be formed to have any success and this will only
ticle would be of greaf interest Doth fo those using the
be possible if the pafient has an adequate amount of
Bio Block system of appliances and to almost everyone
free catclum Dr JL has had some success with
invalved it removable funcional treatment Anyone
calcium lactate supplements
with am interest in pursamng tts system of veatment
Dr JL also noted thal hypoglycemic patients have ex can contact our offtce for mare unformahon
lrame dilliculty in adjusting lo a functional apphance
when the mandible is posiloned forward of its ideal
position Making Bite Planes Effective
In his opinion, adult trealmant is feasible and can be
We all expenente occasional non resulis wiih out
successful but more research is necessary and thepa
bile planes and are tempted ta assume taat they work
tient must be trealed in his entirety for a successful
wih Some patents andnatwithoiners While ihismay
result,
be stating ihe obvious iheré must presumably be a
We nax! spoke with Dr G.S who has been out of appli reason to account for the varaiion in response
ances lor six months and reports excellent slabidlily He
The Tropic Premis on which the Bio Blork systern is
feals hts repositioning is complete and he 1s now free
based stales 4 delicale Troprc mechanism overlays
from popping in his lamporomandibular joints He
Ibe genetic ¢ antralof facral growth in order to guide ine
also has had joint x-rays laken The radioiogist who ex
leeth and aws lo a Satisfactory occlusion = It furiher
amined the x-rays noted unexplainable growthina the
assumes thal the maxitla titts so as to balance the an
fossae
terior contact pressures against ihe posterior
Dr GS has Ireated many adult patients successtully
Those individuais that doub! this and assume that ine
and feels that orthopedic treatment will work tom artionis by infrusion of the antenor teeth and eruption
sevenonup He sees no problem with stability in ms
of the posteriors May convince themselves by grinding
patients Again he notes that nutritional supplementa
oné tooth free of a bite plane aflerifhas worked = rl wilt
410n 1S Necessary for Mos! adull patients and feels that
only erupt slightly showing that most of the eilect is
you must Ireal the whole patient
boney «iting
We then contacted Dr ¥ W He has been out of ireat
Ifihisis correct whyden tbite pianes arways work ? The
ment for a ysar and feels his correction 1s stabla He
answer is that ites the esting posture that activates the
opened his bite Smm and says if was just what |
tropic mechanrsm and notihe closed bile position un
needed He has since begun treating many adult pa
less {he two are synonymous In the rest pasitian the
llents and says they are progressing very well
tongue will frequenity lre between the posterror teeth
Dr VW began treating periodontal! probrems with outrs batanceng oul (he anterior ape posterior pressures even
tional Supplemants yaars ago, and reports excellent when the bite pfane 1s quete hign
resullS he continues to use them for those pa
This is especially true with the Class !l Division 2 cases,
tiants who need them in conjunction with functional
where bite opening ts most required and where the ote
treatment
plane often appears least effective Tne Tropic Premus
One signiticant factor is evident here AM of these doc would of cOurse Suggest the longue was a factac in
tors feel thal nutvittonal supplementalron 1s frequently Causing the mitial deep bite
 en

Rapid correction of mos! deep biles can be acheved

with the spht palafal bows on the slage t or 2 appli
ances The bite plane needs to be placed over Ihe iower
;cISOrs and Canines, but free of the palalal bows or up:
perieeih The bows which nead to be 1n 0 9mm wue to
provide the strength are {hen adjusted 10 depress the
upperimncisors The Jabial bow will need to be incontact
wilh those teeth if itis wished to prevent tham belng pro-
ciined This, of course lifts the appliance off the palate
and causes tlo bounce whenever the lower jaw ts C1OS
od (See ilustratian)
This initiates a functional response and the patient
willintermttently chew on the bile plane making I! boin
more aclive 20d more rapid It you don't beheve 1his just
try I in addition the anleror edge of the bite plane ss
chamlerad off 2mm antenor to the rest position of the
lower mcisors the patient wilt tend io posture forward
and so it works aS an activalor
This is really reverting to the Idea of the imelined bile
plane except that the slope is steeper and posifroned
precisely 2mm forward Itts particularly affective in the
Class I2 cases where mandibular growth tends to be
rapid once (he anterior teeth have been moved forward,
aspeciaily if some semrrapid expansion has been used

The bite opening depends on the type olcase but needs

lo be greater with the 1/2 cases (3 lo 4mm} than with
ihe 1/1 cases {2 to 3 mim) bul can be increased pro
gressrvely

Drawings by Jodi Bakar

Reprinted utth permission of Universal

Dynamics Minneapohs, MN
 News From The A.S.S.0.
The Amertcan Society for the Study of Orthodon Convention Center We will present UPDATE IN
ties continues in ils aim and purpose to present tnter ORTHODONTICS 1991 On the Panel will be Imorn
esting and valuable information for the Genera] prac ing sesston' Doctor Mohsen Momtahente Asst Prof
tilioner and the Specialist We are fortunate in having Oral Maxillofacial Surgery af Columbia [ oiversity
educators from the universities and teaching hospitals Asst Clinical Prat of Orel Maxulofacial surgery Eins
come attd share their knowledge with our members and tern Meateal College former Dhrectar of 1MJ Choi
guests at our screntifie meetings Montefiore Hospital Center Dr Bernard Weissfeld
The first meeting for 1991 was on Wednesday Constultant in Dentistry Catholic Medieal Center
February 27, 1991 and the speaker was Leo Taft DDS Diplomaie, Oral Surgery State of New York and
ABO FACD a Professor and Director of the Advanced received an Honorary Doctorate from St Johas Univer
Study of Orthodontics for Foreign Students at New sity for work with Cleft Palate children The AFTFR
York University College of Dentistry and a former NOON SESSION wil present a combined jecture by
President of the Dental] Society of the State of New Dr Alan Jay Sosnay Asst Choical Professor New York
York Dr Taft discussed CURRENT CONCEPTS IN Laversity College of Dentistry Postwraduale Depart
THE STRAIGHT WIRE/EDGEWISE THERAPY and mento” Jrthedentrcs and Dr Jeffrey K Lemler Asst
presented cases for carly treatment of Class TH Divi Prof New York University College ot Dentistry
sion I without the use of headgear and treatment of Department of Postgraduate Periodontics
extraction cases utilizing the Straight Wire/Edgewise Phe subjects for the morning session ure Myths
Apphance aud kacts of Orthodgnath Surgery contemporary aud
The second meeting will be held on Wednesday vet peedictable Orthognathis Reasons for ( teft Palate
May 15 199] and the featured speaker will be Dr Therapy and Treatment In the afternoon a combined
Samuel P Siegel Clinicat Assistant Professor tn the leclure Orthodentic lreitment of Periodontatly
Pediatric Dentistry Department at New York Umyer Involved Melacclusians Requrrements for evardination
sity College of Dentistry He will discuss and illustrate of Care tod Prognosis All dentists auxcicines and
‘EARLY TREATMENT OF DEVELOPING MALOG fuests are invited
CLUSIONS and will deal with Orthodantic treatment For any information ASSO Secretary 5012
in the mixed dentition stage of development Dr Siege! 2044h Street Oaklind Gardens New York f]db4
graduated from Tufts University College of Dentistry {78-224 GRGM
was a dental resident at the Guggenheim Childrens In
stitute and is a member of the American Association
of Orthodontists and has many articles on the subject
published
On April 21, 1991 a Sunday, the AS.S O is present
ing an ALL DAY SEMINAR on MOLLIN ORTHO)
DONTICS and the Climeian willbe Dr Alvin D Jacobs
This is a ONE DAY seminar which will be a valuable
survey for those dentists who wish to improve their
patient care with using the Mallin Technique and for
those with a knowledge of MOLLIN it will be a worth
while review The morning Session wilt be devoted to
AAOGP News
a step-by-slep description of the MOLLIN treatment The Amertean Academy of Orthodonties for the
The Afternoon Session will be a hands-on Laboratory General Practitioner has been very busy revently In
to gain familiarity with the MOLLIN Appliance and its January thes had Dr Ronald J) Holzhauer speak at
management The MOLLIN Technique is known world their Vid Winter Seminar on Diagnosis and [reatment
wide and ts used with excellent results Its outstanding Pianning He spoke on the Skeletal denial and prefite
advantages are the virtual ehmination of premolar criteria and mutations of the dentition anchorage van
extraction and arch expansion, mimmal banding siderations in treatment planning non extraction and
improved esthetics and hygiene efficient distalhextion extraction mechanies and current retention techniques
of pasterior teeth and low cost It will be presenied This seminar was well attended and a very informative
on Sunday April 21 1991 at the Queens District Den day
tal Society The tuition ts $125 for members and $150 The Academy currently, has 4 course in Campre
for non members and includes continental breakfast, hensive Orthodontics for the General Practitioner
luncheon and continuous coffee Credit of $25 will be Pedodontists and a course in Advanced Orthedentic
given to new members applying for membeship Com Apphance Treatment going in Chicago IL These
plete details willbe sent Write or call ASSO 3012 courses are 4 and 3 day courses respectively Dr Merle
204th Street, Oakland Gardens NY 11364 Bean wu be the lecturer on Functional Apphances at
{718.224.8898} the May session and (his session can be taken
4.5.5 0 has again been invited to present an ALL separately
DAY PROGRAM for the GREATER New York Dental The Academy will not offer ans courses dunmng ihe
Meeting held annually in New York City at the Javits summer
 Dr. Ogata to Speak on Neuromuscular
Factors in Orthodontics
The American Academy of Orthodanties for the
General Practitioner will hold its Summer Sermnar and
Annual Meeting in Wisonsin Dells on June 13-L6th
The guest speaker will be Dr Yoshitaka Ogata He
will talk on Neuromuscular Factors in Orthodonties
Dr Ogata has a Master of Science in Orthodontics
from the University of Missouri School of Dentistry and
has studied under Dr Strang and Dr Tweed
Dr Ogata is a diplomate of the American Board
of Orthodontics He is an active member
orthodontic examining boards, orthodontic organiza
tions and served as Chief of Orthodontic Services at
Childrens Orthopedic Hospital, University of
Washington He has been in private orthodontic prac
tice since 1961 in Seattle, Washington
The program will demonstrate how modern elec
tronic occlusal diagnosis dramatically simplifies occiusal
and orthodontic diagnosis which allows you Lo treat
with ease & confidence The two pivotal guestions
‘where dol begin and when am] finished” can he
answered quantitatively with new electronic
modalities Modern diagnostic and treatment modahties
take awav the unnecessary complex:ty
associated with the management of the acelusion For
the first the ability to integrate a precise occlusal
seheme inte the requirements of the entire
stomatognatie system is made possible by space age
technology
Non members are weleome lo attend and bring
their familes activitres will he offered for wives and
chidren
on several
Twin Wire Orthodontics Offered
Drs Brickbauer, Watson and Hecher will present
a course in Twin Wire Orthodontics on October 30
through November 8, 1991
Thrs is a comprehensive hands on course design
ed ta teach the original baste apphances and auxtharies
which are used in the Johnson Twin Arch Technique
The various procedures will be demonstrated and then
each participating dentist will repeat them on his typo-
dont under supervision
Actual use of the appliance in clinical practice will
be shown, various types of practica] cases will be
so often demonstrated and discussed including diagnosis and
treatment planning
Use of Springs elastics and expansion apphances
will be shown and ClassI TI and IH treatment will be
included

More of Murphy's Laws

*Leakproof seals — will *Evervone has a scheme for getting rich that will not
work
*Interchangeahle parts — wont
*All warranties expire upon payment of invoice
"lf you re feeling good dont worry youll get over it
elf you try to please everybody nobody will hke it
*Lou will always find something in the last place you
look *A short eul is the longest distance hetweent two
points
*No matter how jong or hard you shop for an item, alter
you ve bought it it will be on sale somewhere cheaper *You will remember that you forgot to take out the
trash when the garbage truck is two doors away
*In order to get a loan you must first prove you don t
need it ©The race is not always to the swift nor the battle ta
the strung but that’s the way to bet.
*Any tal dropped while repairing a car will roll
underneath to the exact center *There s never time to do it right, but there's always
time to do it over
*The repairman will never have seen a model quite like
yours hefore
*The light at the end of Lhe Lunnel 1s the headlamp of
eWhen a broken applance is demonstrated for the an oneaming train
repairman it will work perfectly
*Never play leapfrog with a unicorn
*Fverybody shauld believe in something I believe I 1
have another drink *A Smith & Wesson beats four aces

*Buiid 3 system that even a foal ean use and only a fool elf everything seems te be gong well, you abviously
will use it don’t know what's going on

2B
 1991 Continuing Education

ADVANCED STRAIGHT WIRE APPLIED ORTHODONTICS

This ¢ ourse was orginally presenled in
This program is designed for the dentist that has response to requests fram Ihase who had
knowledge tn the Straight Wire Orthodontic
panicipated in d technique workshop aad
technique who desired further knowledge in eliology
It will cover Session | diagnosis and other academic aspecis of
orthodonte treatment
Pechatrig Cahodantics
Bete Opentng Appliances
Fixed Functionals/Sagritals Included 14 the 3 day leciure and laborat iry
Modular Orthodontics (Wilson) curriculum are fhe following subiects Etiology
Advanced Utuity Aron
MyofunctionalTongue Thrust
@ mdlocclusion Diagnestic records Basic
Surgery «n Orthodonkcs cephdiometncs Mycluncional aspects of
Arch DevelopmentAirway malocclusian = recognition anc treatmert|
Reverse Face Mask Eary treatment Prevention and interceptian
Full Functonal Occlusion
Prope: TMJ Funcetron Cervical traction and headgea: therapy
Adult Case Fimshing Disia Drner therapy, and Ecenomics and
Relamners/Reiention fnatient commusicatians
Midline Carrection
Mini-Bionator
Equitibratian Leciures will be augmented with slides anc
Logic I'* Articutator demonstration models A Questian ant
TranscranialsTCD
Answer period will oe includect
Oniho Problem Cases
Missing Teeth'Prosthetcs
Hybrid Functionals
Molar Extractions
Early Recognition of Pediatric TMD
Transcranals & Tamograms
Sassoun Diagnosis in TMS TWIN WIRE COMBINATION
Bidlimshars'Verticalizers
TMD Treatment Planning This course 18 designed te ar truant
the newcomes with the ac sual use ul
Ihe Jahnson Twin Wire Appliance in
clinical practice Vanous tynes at
SASSOUN! PLUS CEPHALOMETRICS practical cases will be demonsirated
Dr Richard Beistle will give hands-on instruction tor and discussed including diaanosis
the most exacting orthodontic/orthopedic diagnostic and treatrent planning
sysiem available today Dr Bersile has revolutionized
the science of orthodontic diagnosis and trealment Practical use of the Tawen Wire Aprlainee
planning with his development of the Sassoun: Plus whl also include Class | Hl arc Ill
Cephalometric Evatuation reatment treatment of extrachon ¢ does
including atynical extractions impac led
This course features cuspids sequence of treatment etc
Cephalometric Diagnosis
Sassounr Plus Training The use of springs efastics and
Landmarks and Paints expansion apphances will be shawn
Planes and Arcs The problems of refentian ancf types of
Archid Construction retainers wall be sfudied
Archial Diagnosis
Analysis This 1s an Extensive Hands On Course
 AMERICAN ACADEMY OF ORTHODONTICS
FOR THE GENERAL PRACTITIONER
A Campecngeat “KOOP, fhe

Fei ya a Py op de ares

39S NORTH Ver S TREE

MILWALIKEE WISCONS % 53072
414/464 7870

1991
CONTINUING EDUCATION CALENDAR
SUMMER SEMNAR &
ANNUAL MEETING June 14 1b 1941
STRAIGHT WIRE October 1819 1991
Dr Jay Gerber — Sessice 1 of 5
TWIN WIRE COMBINATION Onloner 10
Ury Bicxtaue Hecher & Walsan Novemger @ 199
A $7500
NM $875 CO
TWIN WIRE 5 mobe 30 —
Cr Borkbaser & Hecher November S 1991
MM $800 00
Nh $525 00
TWIN WIRE t November 62 1991
Dr Dawid Watson 44 $250 00
NM $375 00
SASSOCUM PLUS CEPHALOMETRICS To be Announced
Cr Read T Restle NM $225 00
NM $245 00

APPLIED ORTHODONTICS Cecember G8 1991

Or Dawa H Walson 4A £350 00
NM $375 00
Moe Member Ni oo Nice Mears

AEGISTRATIGN FORM {Detach and Mail)

aur

OCIA SS

v STLTF
Please enter my requstration lor tne folowing course(s)

Mail registraon blat® and check for ane half the registratior tee 1o
American Academy of Orthodontics jor the General Practitioner
3953 North 76th Street Aiitwaukee Wisconsin 53222
vsa and Master Cha ge accepted {indicale number & expitati n dale;

REGISTRATION FORM (Detach and Mall)

IES

© OTF
Please ener hy regist ator ‘gr the iollcawag
¢ Gu Sets.

Mai -egis) ator blank and check for one hal! he regisiratvon fee 10
American Academy of Orthodontics for the General Practitioner
3953 North 76th Streei ~Mihwaukee Wisconsin 53222
Visa and Maste Charge accepted [ nd-cate number & expirasor dale)
 this
publication
is available

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