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Lec. 2
Functional appliances
Impressions and Working Bite for functional appliance:
The next step in the use of a removable functional appliance is to make
impressions of the upper and lower arches and register the desired mandibular
position, the "working bite." The impression technique depends on the appliance
components that will be used. Good reproduction of the teeth and an accurate
representation of the area where the lingual pads or flanges will be placed are
mandatory. If buccal shields or lip pads are to be used, it is important not to
overextend the impressions so that tissue is displaced, because this makes it
difficult or impossible to accurately locate the appliance components in the
vestibule.
For the working bite, multiple layers of a wax hard enough to maintain its
integrity after cooling to room temperature are needed. The patient's
preliminary record casts can be used to trim the wax to a size that will register
all posterior teeth, while not covering the anterior teeth or contacting the
retromolar areas. With the anterior teeth exposed, the position of the mandible
easily can be judged while the bite is being taken.
The working bite is obtained by advancing the mandible forward to move
the condyles out of the fossa. Unless an asymmetry is to be corrected, the
mandible should be advanced symmetrically so that the pretreatment midline
relationships do not change appreciably. We recommend a 4 to 6 mm
advancement, but always one that is comfortable for the patient and does not
move the incisors past an edge-to-edge incisor relationship. From a scientific
perspective it appears that quite large, modest or relatively small advancements
all can produce growth modification, and that there is little difference between
the results.
The practical reason for recommending this modest advancement is better
patient comfort, facial esthetics and patient compliance than with large
advancements.
When the mandible is advanced, the bite also must be opened. There must
be enough space for the laboratory technician to place wire and plastic between
the teeth to connect major components of the appliance and construct occlusal
and incisor stops. The minimal posterior opening to achieve the vertical space is
about 3 to 4 mm. Interocclusal stops or facets to guide eruption, as in most
activators and bionators, usually require 4 to 5 mm of posterior separation to
be effective. If eruption of upper and lower posterior teeth is to be limited, as
in a child with excessive vertical face height, the working bite should be taken
with the patient open 2 to 3 mm past the resting vertical dimension (i.e., 5
to 6 mm total opening in the molar region), so that the soft tissue stretch
against the bite blocks will produce a continuous force opposing eruption.
In preparation for obtaining the working bite, the wax is softened in hot
water, while the child is directed to practice the working bite position. Some
children can easily reproduce working bites after only a few practice tries, but
others need more opportunities and perhaps some help. It is possible to aid
these patients by constructing an index to guide them. This is most easily
accomplished by using a stack of tongue blades with notches carved into the top
and bottom blade. This guide will stop the bite closure at the predetermined
jaw separation and determine the anteroposterior mandibular position at the
same time.
To produce the working bite: First, firmly seat the softened wax on the
maxillary arch so all teeth are indexed. Next, have the child position the
mandible forward to the correct position and close to the desired position,
paying careful attention to reproducing the previous midline relationship. If a
vertical stop made of tongue blades is used, it must remain in the proper
orientation (parallel to the true horizontal). When the correct bite has been
obtained, the wax should be cooled and removed from the mouth.
The working bite for a Herbst appliance is similar to the one for a
removable functional appliance, typically with 4 to 6 mm advancement.
 Impressions for the twin block appliance require little extensions past the
teeth, because the appliance, again, is tooth-borne. The working bite is taken
with advancement and opening in the same manner as for the bionator or
activator.

Clinical Management of Cl II Functional Appliances:

1) Removable Functional appliances:

The best technique for delivery is to adjust the appliance and work with
the child to master insertion and removal before any discussion with the parent.
This enables the child to be the full focus of attention.
With any functional appliance, a break-in period is helpful. Having the child
wear the appliance only a short time per day to begin with and increasing this
time gradually over the first few weeks is a useful method of introduction.
Most growth occurs during the evening hours when growth hormone is
being secreted; active eruption of teeth occurs during the same time period,
typically between 8 pm and midnight or 1 am. To take practical advantage of
this time period, it is suggested that children wear functional appliances from
after the evening meal until they awake in the morning, which should be
approximately 12 hours per day. Waiting until bed time to insert the appliance
misses part of the period of active growth.
A good appointment schedule is to schedule the child at 1 and 2 weeks
after insertion for inspection of the tissues and the appliance. If a sore spot
develops, the child should be encouraged to wear the appliance a few hours each
day for 2 days before the appointment, so the source of the problem can be
determined accurately. Usually smoothing the plastic components can be
accomplished quickly.
Because the initial mandibular advancement is limited to a modest 4 to 6
mm and many children require more anteroposterior correction, a new appliance
may be needed after 6 to 12 months of wear and a favorable response.

2) Fixed Functional Appliances:

Discussion should focus on care of the appliance and acceptable mandibular
movements. Soft tissue irritation is not a major problem with the Herbst or
twin block, but the teeth may be more sensitive than with removable functional
appliances. Patients should be instructed that the appliance is meant to remind
them to posture the mandible forward, not to force the mandible forward with
heavy pressure on the teeth.
Avoiding hard and sticky foods, large mouthfuls and exaggerated mandibular
movements can greatly reduce the need for repair of the fixed functional
appliances. The Herbst appliance must be carefully inspected for breakage at each
visit. After a positive treatment response is noted, changes in the pin and tube
length can be made during treatment to increase the amount of advancement
simply by adding washer-type sleeves to the pin to restrict insertion of the pin
into the tube. The twin block appliance can have plastic resin added to the
inclines to increase the advancement. Plastic also can be removed adjacent to the
teeth to allow drift, and especially on the occlusal surfaces to encourage
eruption when that is desirable.
If the patient is still in the mixed dentition, it is important to use a
removable functional appliance of the activator or bionator type as a retainer.
This should be worn approximately 12 hours per day until the patient is ready
for the second phase of fixed appliance treatment.

Clinical Management of Facemask Treatment:

Generally, it is better to defer maxillary protraction until the permanent
first molars have erupted and can be incorporated into the anchorage unit. Many
clinicians use protraction with a facemask following or simultaneously with palatal
expansion, because some evidence suggests that the expansion makes antero-
posterior skeletal change more likely. There is other evidence that the expansion
is optional.
The facemask obtains anchorage from the forehead and chin. The forward
force on the maxilla is generated via elastics that attach to a maxillary
appliance. To resist tooth movement as much as possible, the maxillary teeth
should be splinted together as a single unit. The maxillary appliance can be
banded, bonded, or removable. A removable plastic splint that covers the occlusal
surfaces of the teeth often is satisfactory. Multiple clasps combined with plastic
that extends over the incisal edges usually provide adequate retention.
 The appliance must have hooks for attachment to the face mask that are
located in the canine-primary molar area above the occlusal plane. This places the
force vector nearer the center of resistance of the maxilla and limits maxillary
rotation.
Approximately 350-450 grams of force per side is applied for 12-14 hours
per day. Most children with maxillary deficiency are deficient vertically as well as
anteroposteriorly, which means that a slight downward direction of elastic
traction between the intraoral attachment and the facemask frame often is
desirable. Moving the maxilla down as well as forward rotates the mandible
downward and backward, which contributes to correction of a skeletal Class III
relationship. A downward pull would be contraindicated if lower face height were
already large.

Clinical Management of Chin Cup Appliances:

A hard or soft chin cup can be used but both can irritate the soft tissue
of the chin. The more the chin cup or strap migrates up toward the lower lip
during appliance wear, the more lingual movement of the lower incisors will be
produced. Soft cups may produce more tooth movement in this manner than
hard ones.
The headcap that includes the spring mechanism can be the same one used
for high-pull headgear. It is adjusted in the same manner as the headgear to
direct a force of approximately 16 ounces (450-500 gm) per side through the
head of the condyle or a somewhat lighter force below the condyle.

Clinical Management of Class III Functional Appliances:

The working bite itself is significantly different: the mandible is rotated
open on its hinge axis but is not advanced. This type of bite is easier for the
dentist to direct because light force can be placed on each side of the mandible
to guide the mandible and retrude it. How far the mandible is rotated open
depends on the type of appliance and the need to interpose bite blocks and
occlusal stops between the teeth to limit eruption.
Appliance adjustments and instructions are similar to those for Class II
appliances.
 Modifying true mandibular prognathism is a difficult task regardless of the
chosen method. The limited success of early intervention is a reality that must
be recognized. For a child with severe prognathism, no treatment until
orthognathic surgery can be done at the end of the growth period may be the
best treatment.

Best wishes