fixed fntl appliance

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Guide By

Dr. Chandralekha B Dr. Nilofer

Prof. & HOD PG Student

Dr. Roopa Tubaki

Sr. Lecturer

Vydehi Institute Of Dental Sciences



Contents Introduction Classification Advantages

Appliances In Detail. Herbst Appliance. Modification Of Herbst Appliance. Jasper Jumper . The MARS device.

The Mandibular Protraction Devices. The Amoric Torsion Coils. The Scandee Tubular Jumper. The Cantilevered Bite Jumper The IST device.



The Adjustable bite corrector.

The Churro Jumper . The Eureka Spring.

The SAIF spring.

The Universal Bite Jumper.

The Ritto Spring.

The Magnetic Telescopic Device.

The Twin Force Bite Corrector.

Alpern Class II Closers.



The Mandibular Correctors.

The Horizontal Anterior Positioning Appliance.

The Mandibular Anterior Repositioningappliance.

The Biopedic Appliance.

The Klapper Superspring II.

The FORSUS Fatigue Resistance Device.

Hybrid Appliance.

Conclusion



Introduction Definition :

A functional appliance by definition is one that

changes the posture of the mandible, holding it openor open and forward, stretches the soft tissues andchanges the tone of the muscles, creating pressures which are transmitted to the dental and skeletal

structures, moving teeth and modifying growth.



Functional Appliances have been in existence for over85 years .

The first of which was given by Emil Herbst … howeverthese were not well accepted at that time till later when these were reintroduced by Hans Pancherz.



Removable functional appliances are normally very

large in sizehave unstable fixation

cause discomfort

lack tactile sensibility exert pressure on the mucous (encouraging gingivitis),reduce space for the tongue

cause difficulties in deglutition and speech

affect aesthetic appearance.



The alteration in the mandibular posture createsadded difficulties. These adverse effects make theadaptation and acceptance of these appliances moredifficult.

[Ref : Attitudes to orthodontic treatment. Oliver and Knappman British Journal of Orthodontics 1985; 12:179-88.

Ngan P., Kess B., Wilson S. Perception of discomfort by patients undergoing orthodontic treatment. Am. J.Orthod. Dent. Orthop. 1989; 96:47-53.]



Fixed functional appliances are normally known as"non-compliance Class II correctors"

This gives a false idea about the co-operation necessary during treatment. In reality, when we compare them toremovable appliances, we can clearly recognize fixedappliances as non-compliance devices.

However, for treatment to be successful, good co-operation is always necessary, especially if skeletalmodifications instead of dentoalveolar compensationare desired.



Advantages… Fixed functional systems have some advantages over

removable systems.1. They are designed to be used 24 hours a day, which

means that there is a continuous stimulus for mandibulargrowth.

2. They are smaller in size permitting better adaptationto functions such as a mastication, swallowing, speechand breathing.

3. Fixed functional appliances are usually described as non-compliance Class II devices, which are able to treat ClassII malocclusions successfully, while reducing the need forpatient co-operation and overall treatment time. It ispossible to treat this type of malocclusion with minimaleffort.



4. Short treatment time due to the above 6-8 mths.

5. Just as the name implies, what distinguishes themfrom removable appliances is that it is impossible for

the patient to remove them. What we have therefore,is an appliance that allows greater control by theorthodontist.

6. Leads to the development of a “New Morphogenetic

pattern”. 7. Has other actions also such as molar distalizing

effect, correction of midlines, headgear effect etc.



Disadvantages The main disadvantage that may be encountered is

dental movement that takes place during treatment.

In certain FFA’s components have an increasedtendency to fracture.

The size of different components may have to bealtered as the patient may outgrow it or the desired

effect may be achieved. The above factors add to the cost.



I According To Type Of Forces Produced :

Appliances Producing Pushing Force Appliances Producing Pulling Force.

These appliances deliver a pushing force vector forcing the attachment points of the appliance away from one another .

e.g Herbst App.

These appliances create a pulling force vector between the points of

attachment.e.G The SAIF Spring.



II Depending Upon flexibility : Rigid Fixed Functional Appliance { RFFA}.

RFFAs do not easily fracture but neither do they have elasticity orflexibility.

After fitting and activation they do not allow the patient to close incentric relation. This means that the mandible is in a forward position24 hours a day creating greater stimulus for mandibular growth than

with FFFAs.

Used in Class II Div 1 & 2, And in Class III

Flexible Fixed Functional Appliance { FFFA }The type of the force exercised by this is continuous and

elastic in nature .These Fracture /Get fatigued easily.

FFFAs are not recommended in mixed dentition, especially late mixeddentition to avoid unwanted dental movements.



Types RFFA with Pushing Forces:1. Herbst Appliance and its modifications.2. Mandibular advancement repositioning

splint.3. Mandibular protraction appliance.4. Eureka Spring.5. Universal Bite Jumper.6. Biopedic.7. Mandibular anterior repositioning

appliance .8. Functional Mandibular Advancer.

FFFA with Pushing Forces1. Jasper Jumper.

2. The Bite Fixer .

3. Churro Jumper.

4. The Amoric Torsion Coils.

5. Adjustable Bite Corrector.

6. Universal Bite Jumper.

7. Klapper Super Spring II.

8. Forsus.

9. The Scandee Tubular Bite Jumper.

10. The Magnetic Telescopic Device.

11. The Mandibular Protraction Appliance.

12. The BioPedic Appliance

13. The Mandibular AnteriorRepositioning Appliance

14. The IST – Appliance

15. The Ritto Appliance



In spite of considerable research and debate, the precise

mode of action of functional appliances remains obscure.

Many theories seem to be propounded which arementioned as follows and can act singularly or in

combination…these theories are common to both fixed andremovable myofunctional appliances..

They are:

1. Dentalveolar changes.

2. Redirection Of Condylar growth.

3. Deflection Of Ramal Form.

4. Horizontal Expression Of Mandibular Growth.



5. Changes in neuromuscular anatomy and function.

6. Adaptive changes in glenoid fossa locationLeading to anterior repositioning of the mandible.

[ Ref : The Influence Of Functional Appliance Therapy OnGlenoid Fossa Remodelling. DG Woodside,a Metaxas,G Altuna AJODO 1987 ; Vol 82 : Pg 181 -198 ]



Herbst Appliance Introduced in the 5th International Dental Congress in

Berlin in the year 1909 by Emil Herbst.

Called it the “ Fixed Bite Jumping Device” or“Scharnier” or “Joint”.

In 1934 he published 3 articles in the journal

Zahnarztliche Rundschau on his experiences with theappliance.

In the same journal his work was criticised by MartinSchwarz in 2 articles.



According to Schwarz, the Herbst appliance could result inan overload of the anchorage teeth with periodontaldamage as a consequence. This claim has, however, beendisproved in a recent thesis of Pietz(2000).

However it was to be found that Herbst was much ahead of his time. His contributions were many 90% of what is known today. His main contribution to modern orthodontics was,

however, the development of the Okklusionsscharnier or

Retentionsscharnier (Herbst appliance)

[ Ref : “ History, Background, and Development of theHerbst Appliance” Hans Pancherz Semin Orthod 2003;9:3-11.]



The Original Herbst Appliance



In 1977 Hans Pancherz reinstated clinical trials.

Reintroduced by in 1979.

In his article “History, Background, and Development of the Herbst Appliance”

Hans Pancherz (Semin Orthod 2003;9:3-11.) hasbeautifully described the history development and

background of this appliance with useful clinicalinformation and a background on Dr. Emil Herbst.



Advantages of The Herbst Appliance over Activator,Bionator, And Frankel…

1. It is Fixed to the teeth.

2. Patient compliance not at all required for correctfunctioning.

3. Works 24 hrs a day.

4. Treatment time is shortened.



The Basic Design Of Herbst The Herbst appliance is a fixed bite-jumping device for

the treatment of skeletal Class II malocclusions.

It can be compared with an artificial joint workingbetween the maxilla and mandible.

A bilateral telescope mechanism keeps the mandiblein an anterior-forced position during all mandibular

functions such as speech, chewing, biting, andswallowing.



The telescope mechanism (tube and plunger) isattached to orthodontic bands, crowns, or splints.

The tube is positioned in the maxillary first molarregion and the plunger in the mandibular firstpremolar region.

The telescopes allow mandibular opening and closing

movements and when constructed properly lateral jawmovements are also possible.



Originally the telescopes were curved .

Made Of German Silver / Gold. Gold if worn morethan 6 months

Bands or Crowns /Caps were used on Abutment teeth.

Originally placed upside down with plunger onmaxillary molar.

No opening at the back.



The telescopes allowmandibular opening andclosing movements and

when constructed properly lateral jaw movements arealso possible.



Each telescope consists of a tube, a plunger, 2pivots (axle), and two locking screws that prevent

the telescoping parts from slipping past the pivots.



Length of the plunger should be kept at a maximum to

prevent it from disengaging from the tube.

A large interpivot distance prevents the plunger fromslipping out of the tube when the mouth is opened

wide. A plunger too far behind the tube can injure the buccal

mucosa.

If plunger disengages from the tube on mouthopening, it may get stuck in the tube opening onsubsequent mouth closure and damage the appliance.



Anchorage Forms Of The Herbst.. Deserves special attention.

Because of anchorage loss, maxillary and

mandibular tooth movements cannot be avoided. Several anchorage systems have been developed to

control unwanted tooth movements



From 1909 - 1934 The standard anchorage system used by Herbst:

Crowns or caps were placed on the maxillary permanentfirst molars and mandibular first premolars (sometimescanines).

The crowns/caps were joined by wires that run along thepalatal surfaces of the upper teeth and the lingual surfacesof the lower teeth.



If second permanent molars have not erupted then Herbst advised to anchor the appliance more

firmly by placing bands on the canines, which weresoldered to the palatal arch wire as were the uppermolars.

Alternative to bands on the upper canines, a thingold wire was placed on the labial surfaces of theupper incisors and soldered to the palatal arch

wire.



When using the Herbstappliance in the early mixeddentition, Herbst had thefollowing solution:

In the maxilla, thepermanent central incisors

were used for anchorageinstead of the cuspids.

In the mandible, crowns were placed on the first

permanent molars andbands on the 4 permanentincisors.



Late mixed dentition anchorage Canines are used as

anchorage teeth instead of incisors.

Buccal mucosa at thecorner of the mouth is proneto ulceration whenmandibular canine is used as

an abutment tooth for theplunger.



Herbst and others realized the necessity of incorporating as many teeth as possible foranchorage to avoid unwanted side effects.

Schwarz( 1934): Most teeth in the maxilla andmandible were interconnected by labial as well aslingual arch wires this was called Block anchorage.



1979 Onwards… Pancherz originally used a banded type of Herbst

appliance.Individually made stainless steel bands of

a thick material (0.15- 0.18mm) were used. 1. Simple anchorage system

2. Increased anchorage system

3. Total anchorage system

4. Cantilever Herbst



Maxilla- Bands are placedon 1st permanent molarsand first premolars. Joined

on each side by sectionalarch wires.

Mandible- Premolars are

banded and connected with a lingual sectionalarch.



Disadvantages:

Space opening distal to maxillary canines

Excessive intrusion of 1st

permanent molars. Buccal tipping of 1st premolars

Large proclination of lower anteriors

• Thus, anchorage had to be increased by incorporatingmore teeth.



Increased anchorage system Maxillary and mandibular front teeth were

incorporated in the anchorage system by labialsectional arch wires.

Mandibular lingual arch wire extended to 1st

permanent molars. Since 1995, cast chrome-cobalt splints are used routinely.



The splints cover all buccal teeth in the maxillary and

mandibular arches and also the mandibular canines.

Chair time is short and the appliance is strong, hygienic,and causes few clinical problems.



In the early 1980s, Howe and McNamara developed theacrylic splint Herbst appliance which is used both.as a fixed(bonded to the teeth) and removable appliance.

However, use of the Herbst as a removable device is notrecommended.



The Cantilever Herbst appliance design is mainly indicated in the early mixed dentition before the eruptionof the mandibular permanent canines and first premolars.

The lower part has heavy metal extension arms that aresoldered to the permanent first molar crowns.

The arms extend anteriorly, lateral to the dentition and

terminates in the premolar region in which the telescopingaxles are soldered.

Have occlusal rests incorporated.



Support wires attached to the cantilever arms, working as

occlusal rests on the first or second deciduous molars areimportant.

Without these rests (as seen in earlier designs of thisappliance), the vertical force vector of the telescopes acting

as lever arms will result in uncontrolled mesial tipping andextrusion (extraction) of the molar teeth.

But the anchorage control of the mandibular molars withthe cantilevers (even when using occlusal rests on thedeciduous molars) is questionable.



None of the anchorage systems used in Herbsttreatment could prevent anterior movement of themandibular incisors and molars. ( Pancherz andHansen1988)

Lower anchorage is a problem difficult to master inHerbst treatment. Some factors associated with anchorloss can be :

Severity of A-P interarch discrepancy

Amount of bite jumping at the start of treatment.



Treatment EffectsSagittal

Skeletal

Dental

Vertical

Skeletal

Dental



Sagittal Changes… 1.Restrains maxillary growth and decrease of SNA angle.

2. Increases mandibular length

(Pancherz 1979, 1981, 1982). This finding is in agreement with several bite jumping experiments in growingmonkeys (Stockli and Willert 1971, McNamara 1972,1973, 1975) and rats (Petrovic and Stutzman 1969).



Evidence of temporomandibular growthadaptations in Herbst treatment:

Three adaptive processes in the TMJ are thought tocontribute to the changes of mandibular position.

1) Condylar remodeling. (2)Glenoid fossa remodeling;

(3) Condylar position changes within the fossa.



Animal Studies Peterson and McNamara (semin orthodontics

2003) :

Evaluated histologically the TMJ, glenoid fossa, andthe posterior border of the mandible in juvenileRhesus monkeys whose mandibles had beenpositioned forward with a Herbst appliance



Condyle remodelling :

Especially in the Posterosuperior region of the condyle.

Glenoid Fossa Remodelling :

Significant deposition of new bone on the anteriorsurface of the postglenoid spine occurred, indicating ananterior repositioning of the glenoid fossa. Similar to(Breitner 1930,33).

Significant bone resorption on the posterior surface of the postglenoid spine was noted



Significant bony apposition on the posterior border

of the mandibular ramus was evident during early experimental periods.

No gross or microscopic pathological changes were

noted in TMJ of the juvenile Rhesus monkey.



Clinical Studies Have provided radiographic evidence of TMJ growthadaptation in Herbst treatment.

Paulsen et al (1995) :

Analysed TMJ changes in a single case of Herbst treatment inlate puberty using CT scanning and OPG.

Three months after insertion of the appliance CT-scanning andOPGs of the TMJ revealed new bone formation as a doublecontour in the articular fossa and on the posterior part of thecondylar process as a result of adaptive bone remodeling.



Ruf and Pancherz (1998, 1999):

Analysed three possible adaptive TMJ growth processescontributing to increase in mandibular prognathismaccomplished by Herbst treatment :

Condylar remodelingGlenoid fossa remodeling

Condyle fossa relationship changes. Aidar, Abrahao ,Yamashita , Dominguez (AJO 2006)

assesed the TMJ disc position with MRI after 12 monthperiod of herbst appliance therapy in 20 ClassII div1patients. They found mild changes in position of thedisc with slight tendency towards retrusion due tomandibular advancement which returned to normalafter appliance removal. These changes were in thenormal phsiological limits as evaluated in short term.



Dental Changes Basically a result of anchorage loss in the two dental arches.

1. Mandibular teeth are moved anteriorly.

Proclination of lower anteriors. Mandibular incisors

proclined on an average of 6.6 during 6 months(Pancherz, 1985). In 24 class II subjects treated with theHerbst appliance (Hansen et al, 1997), the proclinationduring treatment was 11.

2. Lower Incisor Proclination and recession.

Large amount of lower incisor proclination duringHerbst treatment could be thought to causebreak down of the labial gingival attachment &create gingival recessions



Maxillary Molars are driven distally…

The effect of the Herbst appliance on maxillary molar teeth is essentially comparable with that of ahigh pull headgear (Pancherz, Anechus-Pancherz, 1993). The teeth are both distalized and

intruded.

Normally, the dental changes occurring duringHerbst appliance treatment would not be

desirable. Distal tooth movements in maxillary buccal segments could however, be desirable incases with anterior crowding



Mesial Movement Of Lower Molars.

Sagittal Dental Arch Relationship…

Overjet is reduced in all patients during treatment by increase in mandibular length and mesial movement(proclination) of the mandibular incisors.

Class II molar correction by increase in mandibular length,distal movement of maxillary molars and mesial movementof the mandibular molars.

Herbst appliance corrects or overcorrects both molar & canine sagittalrelation in most of the cases. However treatment is more effective inthe molar than in the canine region



Arch Perimeter…

Because of the distalizing forces of the telescopemechanism of the Herbst appliance on the upper1st molars and the anteriorly directed forces on thelower front teeth, the maxillary and mandibular

arch perimeters increase during treatment.(Hansen et al, 1995)

Arch perimeter changes are, however, of atemporary nature because settling of the teethduring the immediate post treatment period.



Arch Width… Hansen et al (1995) : During treatment the maxillary and mandibular

dental arches expand laterally in both canine andmolar areas. The expansion is more marked in themaxilla than in the mandible.



Vertical Changes Dental

In Class II malocclusions with deep bites, overbitemay be reduced significantly by Herbst therapy (Pancherz, 1982, 1985) an average of 3.0mm (55%)during 6 months of treatment.

Overbite reduction is primarily accomplished by

intrusion of lower incisors and enhanced eruptionof lower molars.



Part of the registered changes in the vertical position of themandibular incisors results from proclination of theseteeth.

Because of vertical dental changes, maxillary andmandibular occlusal planes tip down.



Skeletal

Increase in lower anterior facial height (LAFH) due to overeruption of lower posterior teeth.

Increase in gonial angle – this may be due to a

more sagittaly directed growth of the condyle or itmay result from resorptive bone changes in thegonion region, probably as a consequence of analtered muscle function during bite jumping(Pancherz & Littman, 1989)



The following changes contribute to Herbstappliance correction of class II malocclusion.

Stimulation of mandibular growth.

Inhibition of maxillary growth (a less important change)

Distal movement of upper dentition

Mesial movement of lower dentition (proclination of the

incisors



Indications For Treatment Growing individuals ( Pancherz Ajo Do 1985).

Should not be used in non growing subjectsbecause.

1. Skeletal alterations will be minimal.2. More of dentoalveolar changes.

3. Increase risk of developing dual bite.



Postadolescent patients: Who have passed the maximum pubertal growth spurt and

have still some growth potential left, treatment with theHerbst appliance is indicated as it can be finished within 6 to

8 months. Mouth breathers: Nasal airway obstructions can make

the proper use of removable appliances difficult orimpossible but doesn’t interfere with herbst.

Uncooperative patients: It is fixed to the teeth without any assistance from the patient.

Patients who do not respond to removable appliances.



For mandibular fracture (particularly ramus) patientsafter surgery

For prevention of bruxism

For diseases of the TMJ



Treatment Timing Most favorable time to treat the patients with the Herbstappliance is at the peak of pubertal growth spurtPancherz, Hagg, 1985.

Pancherz & Hagg (1988): Indicated that the patientstreated at the initial closure of the middle phalanx of thethird finger (MP3-FG) had the greatest amount of condylargrowth.

Because mandibular growth stimulation using the herbst

appliance is also possible in post adolescent young adultsubjects, a new concept of Class II therapy is proposed in which the Herbst appliance is used as an alternative toorthognathic surgery in Class II subjects.



Perfect end result cannot be obtained exclusively with Herbst.

Class II cases cannot be treated to a perfect end

result with the Herbst appliance exclusively. Many cases will require a subsequent dental-alignmenttreatment phase with a multibracket appliance.



Thus, treatment of a Class II, Division 1 malocclusion will usually occur in two steps

STEP 1. ORTHOPEDIC PHASE. The sagittal jaw

base relationship is normalized and the Class IImalocclusion is transferred to a Class Imalocclusion by means of the Herbst appliance.

STEP 2. ORTHODONTIC PHASE. Toothirregularities and arch discrepancy problems aretreated with a multibracket appliance (with or

without extractions of teeth).



A Class II, Division 2 malocclusion may require a three-steptreatment approach

STEP 1. ORTHODONTIC PHASE. Alignment of theanterior maxillary teeth by means of a multibracketorthodontic appliance.

STEP 2. ORTHOPEDIC PHASE. Normalization of sagittal

jaw base relationships and transformation of the Class IImalocclusion into a Class I malocclusion by means of theHerbst appliance.

STEP 3. ORTHODONTIC PHASE. Tooth irregularities andarch-discrepancy problems are treated with a multibracket

appliance (with or without extractions of teeth).



So the ideal patient for treatment with the Herbstappliance has the following characteristics:

Skeletal morphology.

• Retrognathic mandible.

• Small mandibular plane angle indicating an anterior

growth direction of the mandible. (A favorable growthpattern both facilitates treatment and counteracts posttreatment relapse.)

• Normal or reduced lower facial height.



l Dental morphology:

Class II dental arch relationship with increased overjetand normal or increased overbite (open bite cases not

suitable for Herbst appliance). Maxillary and mandibular teeth well aligned and the

two dental arches fitting each other in normal sagittalposition

Maturation: Treatment during pubertal growth spurt.



Types Of Herbst Appliance Original Design Maintained With A Few

Modifications….

Type I

Type II

Type III

Type IV



Type I Type I is characterized by a fixing system to the crownsor bands through the use of screws. This is the mostcommon form. It is necessary to weld the axles to the

bands or crowns and then fix the tubes and plungers with the screws



Type II Type II has a fixing system that fits directly onto the

archwires through the use of screws. This method of application has the disadvantage of causing constantfractures in the archwires. The lack of flexibility

together with the difficulty in lateral movements andthe stress placed on the archwires through activationcauses fractures, especially in the lower arch



Type IV Type IV has a fixation system with a ballattachment, which allows greater flexibility andfreedom of mandibular movement.

A disadvantage in relation to other similarappliances is the fact that it needs brakes tostabilize the joint. These brakes are small and

sometime difficult to fit.



Class II malocclusions who have narrowmaxillary arches, Herbst

appliance with1. A quad helix lingualarch wire or

2. Rapid palatal

expansion device to theupper premolar andmolar bands or to thesplint.



Herbst With Stainless Steel CrownsNorris M. Langford

(1982 ) suggested using stainless

steel crowns on the upper firstmolar and the lower firstpremolar and canine for theHerbst appliance which aresuperior to banding, in that they

are resistant to breakage andbecoming loose.



Modifications

the substitution of stainless steel crowns forbands.

the elimination of the stabilizing bar.



The Bonded H



The Bonded Herbst Appliance The bonded Herbst appliance eventually evolved intothe acrylic splint Herbst appliance (McNamara, 1988;McNamara and Howe 1988).

The acrylic splint Herbst appliance is composed of a wire framework over which has been adapted, 2.5-3.0mm thick splint Bioacryl, using a thermal pressuremachine



By substituting an acrylic splintfor the stainless steel bands of the earlier appliance, the Herbst

mechanism can be attached toboth maxillary and mandibulararches using bondingprocedures



The maxillary splint covers allavailable maxillary teeth withexception of the central andlateral incisors

The occlusal thickness of themaxillary splint is kept to aminimum, so that the cusps of the posterior teeth perforatethe splint



These perforatedopenings permit theplacement of the nylon

tip of a posterior band-removing plier againstthe cusps.



Disadvantage of Banded Herbst:

I) Repeated breakage and loosening of theappliance occurs, especially in the lower

bicuspid band area.II) Rapid intrusion of the mandibular first

bicuspids which though temporary, partially deactivates the appliance.

III) As the bicuspids are depressed, the lingualarch is also depressed, resulting inimpingement on the lingual gingiva.

IV) Possibility of incisal tooth fracture.



Headgear Herbst Appliance Weislander 1984.

Suggested the use of headgear – Herbst appliance in thetreatment of large sagittal discrepancies between the

maxilla and mandible in early mixed dentition. The Herbst appliance consisted of a cast of vitallium

bonded to the lower arch and with bands on the upper firstpermanent molars.

The upper bands were united with a palatal bar andconnected to the lower splint with the Herbst telescopicarms.



He concluded that a shortperiod of interceptiveorthopedic treatment in

the very early mixeddentition may beindicated to correctskeletal deviation andestablish a normal

relationship betweenmaxilla and mandible.



Cantilevered Herbst Appliance Larry W White 1994.

Buccal cantilever wire is made by doubling .045" wire and

soldering the two strands together.



This design isparticularly useful whenmandibular bicuspids

are absent or theprimary molars cannot withstand functionalforces.

Modified Herbst Appliance For



Modified Herbst Appliance For

Mixed Dentition. Introduced by Philip Goodman and Paul Mc Kenna, 1985

They stated the middle phalanx development may, indicateoptimal treatment timing, but the patient’s bicuspids arenot erupted enough to receive either bands or crown.

Also they encountered a modification where stainless steelcrowns are fitted on the upper first permanent molars andbands on the lower first molars and incisors.



The deciduous first and second molars are free to exfoliate

through the framework



If the patient is uncomfortable with much mandibularadvancement, have the patient

retrude the mandible until thediscomfort disappears. Thetelescopic part of the appliancecan be advanced again in six toeight weeks using washers or

metal sleeves.



The Emden Herbst Appliance Introduced by Tarek Zreik, 1994 to overcome breakage

problems, he had with the Herbst appliance.

This modification makes the Herbst more durable, simpleand hygienic.

The Herbst mechanism is attached to stainless steel crowns on the maxillary first permanent molars and to the lower

arch through a removable acrylic splint. Double buccal tubes on the stainless steel crowns can hold

utility, sectional, or continuous archwires



• Advantages of the EMBDEN Herbst

It requires minimal cooperation.

• It promotes patient acceptance because it is not visible and

it produces an immediate improvement in the profile.• It allows more cases to be treated without extractions.

• It is easy to construct, fit, adjust, and clean.

• Materials are inexpensive, and breakage is minimal after a

modest amount of laboratory experience is gained.• The lower splint increases anchorage, thus providing more

of a skeletal correction, and restricts forward movement of the lower incisors



The Edgewise Herbst Appliance



The Edgewise Herbst Appliance corrects Class IImalocclusions rapidly and without the need for patientcooperation. It allows orthodontic tooth movements

during orthopedic correction and a smooth transitionfrom Herbst treatment into the edgewise finishingappliance. The new appliance is more clinically efficient than previous models and is easily

incorporated into an edgewise practice.

Herbst With Mandibular



Herbst With Mandibular

Advancement Locking Unit Components

2 tubes

2 plungers,

2 upper “Mobee” hinges with ball pins

2 lower key hinges with brass pins



In the upper arch of

the edgewise-HerbstMALU appliance,only the first molarsare banded, with

.051" headgeartubes.

A palatal arch canbe used in cases of overexpansion.

I h l h h fi



In the lower arch, the firstmolars are banded, and the

anterior segment is bonded from cuspid to cuspid with .022"brackets. The bicuspids may beleft unbracketed to help insettling the occlusion andlocking in the mandible.

The mandible can be

progressively advanced using1-5mm spacers.

Advantages:



Advantages:

1. Its cost is considerably lower because it requires

no laboratory construction.

2.Its simplicity makes it useful even for non-growing patients in whom only dental

movement and mandibular repositioning arerequired.

3.It can also be used in growing patients whohave not cooperated with removable appliancesor headgear.

Fli L k H b t A li



Flip-Lock Herbst Appliance

A new design, the Flip-Lock Herbst appliance,reduces the number of moving parts that canlead to breakage or

failure. It is easy to useand more comfortable forthe patient than theconventional cantilever-type Herbst. Instead of ascrew attachment, it has aball-joint connector, andit needs no retainingsprings.



The first generation was made from adense polysulfone

plastic but breakageoccurred because of the forces generated

within the ball-jointattachment



In the secondgeneration, the

plastic was replaced with metal



The third generation ismade of a horse-shoeball joint .

This system has provedto be more efficientthan the previousmodels, both in terms of

application as well as itsresistance to fracture



End of rod is crimpedonto mandibular ball.

Advantages :Less irritation

reduces the numberof moving parts

that can lead tobreakage or failure



The Jasper Jumper :

This interarch flexible force module allows patientgreater freedom of mandibular movement than ispossible with the original bite jumping mechanism of

Herbst. Dr. James Jasper in 1987



Force Module : The force module, analogous to the

tube and plunger of the Herbst bite– jumping mechanism and isflexible.

The force module is constructed of stainless steel coil of springattached at both ends to stainlesssteel end caps in which holes havebeen drilled in the flanges toaccommodate the anchoring unit.

This module is surrounded by anopaque poly urethane covering forhygiene and comfort.



The modules areavailable in sevenlengths ranging from

26 to 38 mm in 2 mmincrements.

They are designed for

use on either side of the dental arch.



Principle of action :

When the forcemodule is straight, itremains passive. As

the teeth come intoocclusion the springof the force module iscurved axially

producing a range of forces from 1 to 16ounces.

If l i ll d d dib l



If properly installed to produce mandibularadvancement, the spring mechanism is curved or

activated 4 mm relative to its resting length, thusstoring about 8 ounces (250g) of potential for forcedelivery.

If less force is desired (eg force levels that producetooth movement alone), the jumper is not activatedfully.

Increasing the activation beyond 4 mm does not yield more force from the module but only buildsexcessive internal stress.



Anchor units :

A number of methods are availableto anchor the forcemodules to either thepermanent or mixed

dentitions.

Attachment to the main



Attachment to the mainarch wire :

Dr. Jasper `s method. When the jumper mechanism

is used to correct a class IImalocclusion, the forcemodule is attached

Posteriorly to the maxillary arch by a ball pin placedthrough the distalattachment of the forcemodule.

The module is anchoredanteriorly to the lower arch wire(0.018”x 0.025” or 0.0x0.025” ).



Bayonet bends are placed

distal to the mandibularcanines and a small Lexanball is slipped over thearchwire to provide ananterior stop.

The mandibular archwire isthreaded through the holein the anterior end cap andthen ligated in place.

The first and second

bicuspid brackets areremoved to allow thepatient greater freedom of movement.

Disadvantages :-



Unattached bicuspids tend toerupt above the occlusal planeas the anterior teeth areintruded.

When only the lower 1stbicuspid bracket used to beremoved as originally suggested by Dr. Jasper, Jaw

opening used to be limited asthe lower portion of the jumper tends to bind at the2nd bicuspid.

Replacement of a broken jumper required



removal of the entire archwire.

If an arch breaks or comes untied at thedistal tieback, all the force is transferred tothe anterior teeth, which tends to tip themforward depress them and open space.

Removing the Jumper for an occlusal checkis time consuming.

In an extraction case, it is difficult to close

spaces because the jumper must be attachedto the arch before closing loops.

2. Dr. Cope’s Method :



Dr. Don cope makes anattachment out of an0.017 x 0.025” stainlesssteel wire, soldered to arocky mountain lock,

then bent so as to passdistal to the lower firstmolar. The lock isattached between thebicuspid and cuspid

An alternative is tol h l k d l



place the lock distalto the molar bracket

with the wire bentdistal to the cuspid.The approach uses afree sliding quick

connect (figure). The wire runs parallel tothe main archwire,allowing the jumperto clear the bicuspid

brackets.

Advantages



The attachment can be made in the officelaboratory , and placement can be delegated to anassistant.

The jaws can open fully . Force is directed distal to the molar; if the

archwire breaks there is no effect on the anterior

teeth. The jumper does not interfere with space closure

or leveling procedures. A broken jumper is easy to replace.

No auxiliary tubes are needed on the mandibularmolars.



Disadvantages :

Laboratory time is required to solder and

bend the attachment.The rocky mountain lock assembly is an

additional expense.

2) A h ili h i



2) Attachment auxiliary archwire :

Incorporates the use of “outrigges” which are 0.016 x0.022” (0.018” slot) or 0.018 x0.025” (0.022” slot) auxiliary sectional wires.

The sectional arch is loopedover the main archwires

anteriorly between the first

premolar and canine. Posteriorly into the lower first

molar band.

The sectional archwire must haveadequate clearance from the alveolus



adequate clearance from the alveolusand gingiva to avoid tissueimpingement.

Advantages :

Has all of the previous said advantages plus

The clinician may leave the premolar bands inplace

Materials are in expensive.

Attachment in the Mixed dentition



The maxillary attachment is asthe original attachment.

The mandibular attachment includes an archwire that extendsfrom the brackets on the lower

incisors, posteriorly to the firstpermanent molars, by passing theregion of the deciduous caninesand molars.

In a mixed dentition patient theuse of a transpalatal arch and fixed

lower lingual arch is mandatory tocontrol potential unfavorable sideeffects.

Divided into 3 phases as advocated by Dr.Jasper



Jasper

Leveling and anchorage preparation Period of jasper jumper use (6-9 months)

Period of finishing (12 months)

Leveling and anchorage preparation



Leveling and anchorage preparation Alignment of the maxillary and mandibular

anterior teeth during the initial phases of orthodontic treatment must be completed.Full-sized (or nearly full-sized) archwiresshould be inserted into the brackets in both

arches before the placement of the forcemodules.

The archwires should be tied or cinched backposteriorly to increase anchorage, including

second molars whenever possible. In addition, the clinician can place posterior

tip-back bends in the mandibular archwire toenhance anchorage.

Anterior lingual crown torque can be placed



gin the arch wire. Alternatively lower incisor

brackets with 5 degrees of lingual crowntorque incorporated into the slot also can beused to prepare anchorage.

Preparation of the arches :



After the full sized arch wires have becomepassive, the mandibular arch wire isdisengaged and the brackets on the 1st and2nd premolars are removed bilaterally.

Unless on triggers are used, bayonet bends areplaced in the archwire distal to the lowercanine bracket, and 3 mm Lexan beads areslipped over the ends of the arch wire and

moved forward to rest against the bayonetbends bilaterally .

Selection and installation of the



modules

Determination of properlength of force module. Twelvemillimeters are added tomeasurement of distancebetween mesial aspect of face-bow tube and distal aspect of Lexan ball. In this example,distance from ball to face-bow

tube is 20 mm. Thus 32 mmmodule should be selected.

The lower arch wire in threaded through the holein the anterior end cap of the force module, ligated



p gin place and the ends of arch wire are cinched or

tied back firmly. Then the ball pin is inserted through the face bow

tube on the maxillary first molar band from distalto mesial and cinched forward.

In-patients with high mandibular plane angle thepin is cinched to achieve approximately 2mm of module deflection (150g / side).

In patients with low or normal mandibular planeangle, the ball pin is cinched forward to achieve 4mm of module deflection (300g force/ side).

The patients are coached to practice opening and



p p p gclosing movements slowly at first and told to avoid

excessive wide opening during eating and yawning.

Activation of the module for orthodontic and

orthopedic effect :



orthopedic effect :

If molar distalization is desired. The jumperis placed so that only 2-4 ounces of force is

produced by the module. In growing patients in whom orthopedic

repositioning of the mandible is desired, higher

forces (6 - 8 ounces) are used continuously.

Reactivation of the module :



If the class II molar relationship is not corrected

completely by the initial activation, the modulesshould be reactivated 2 – 3 months later.

The pin extending through the face bow is pulled

anteriorly 1-2 mm on each side to reactivate themodule.

2-4 mm of the pin should extend distally when the

pins are activated maximally (so that the jumperdoes not blind against the distal aspect of the facebow tube.)



Ball pin protrudes 2-3mm distally, allowing free movement. B. Ball pin too close to molar

tube, which can cause breakage of ball pin or Jumper. C. Correct placement. Anteriorforce is delivered distal to lower molar bracket, while depressing force is delivered toarchwire between cuspid and bicuspid.

Activation of the force module can also



be made by crimpable stops (1 – 2mm)

placed mesial to the lexan beads.

It is more accurate

Easier to perform Avoids unintentional restriction of ball

pin / molar tube relationship

Types of forcesproduced :



Bilateral directions of force generated by themodules includesagittal, intrusive andexpansion forces.

Force module curves tobuccal, producingshielding effect on

dentition.

Buccal force due to intrusive force acting



along the buccal surfaces of the maxillary teeth

produces maxillary arch expansion. Modules curving outwards Vestibular

shielding effect

Expansion forces can be minimized oreliminated through the use of a transpalatalarch or a heavy arch wire that has beennarrowed and to which buccal root torque hasbeen applied.

Treatment effects :



Maxillary adaptations :

i) Headgear effect : One treatment effect produced most easily is

distalization of the upper posterior segment or theheadgear effect.

For this the maxillary arch wire must not be cinched ortied back, but remain straight and extend past thebuccal tubes.

Involves light forces (2-4 ounces)

Minimal changes in the mandibular dentition.

This effect can be produced in actively growing as wellas adult patients.

Retraction of anterior teeth



Retraction of anterior teeth

Upper canines alone or all thesix anterior teeth can beretracted in both extraction andnon-extraction patients with aNiTi coil or an intramaxillary elastic, with the posterior

maxillary dentition supported by the force module.

Cuspid retraction mechanics: As Jumper pushes ball pindistally, molar anchorage ismaintained and cuspid isretracted along archwire.

M ill t i t th



Maxillary anterior teeth areretracted as a unit by attaching ligature toappropriate archwiretiebacks.

Dental Asymmetries



The force module system also can beused in-patients who have sagittaldental asymmetries.

In a patient with a class II subdivisiontype of malocclusion the maxillary archwire orthopedic effects may also beachieved.

Asymmetric orthopedic effects may alsobe achieved

Mandibular Adaptations :



In producing mandibular advancementthe movement of maxillary posteriordentition must be cinched or tied back.

Also a transpalatal arch must be placed,to obtain intra arch anchorage.

Level of force generated is higher (6 to 8ounces ) than for headgear effect.

Jasper’s theory of two’s” suggests that class IIcorrection with Jasper jumper therapy can be



correction with Jasper jumper therapy can beequally proportioned between 5 components.

1. 20% due to maxillary basal restraint

2. 20% due to backward maxillary dent alveolar

movement 3. 20% due to forward mandibular dentoalveolar

movement

4. 20% due to condylar growth stimulation

5. 20% due to downward / forward glenoid fossaremodeling

Nalbantgil D, Arun T, Sayinsu K, Fulya I Angle( )



Orthod 2005 studied 15 subjects (class II) treated

with jasper jumper and compared them with15untreated(class II) subjects. They were lateadolescent patients.

Results: Class II discrepancies were mainly corrected by dentoalveolar changes and thiscould be an alternative method to orthognathicsurgery in borderline class II cases.

MARS Appliance

(M dib l d i



(Mandibular advancing

repositioning splint). This appliance was introduced

by Ralph M Clements and Alex Jacobson.1982

The MARS appliance iscomposed of a pair of telescopic struts, the ends of

which are attached to theupper and lower archwires of amulti-banded fixed applianceby means of locking device.



The Piston fitted tothe cylinder of aMARS appliance.

• Alignment must be complete.



• The teeth in the respective arches

should be aligned, with correct axialinclinations, prior to attachment of the appliance.

• The MARS appliance should beattached only to the heaviest

rectangular arch wires that can beaccommodated by the brackets andtubes. The heavy arch wire preventsbreakage at the point of attachmentas well as excessive intrusion in theregion of the mandibular canines.

• The mandibular arch wires shouldbe securely tied back to the terminalmolar before attachment of theMARS appliance.

Failure to do this will usually result in flaring of the



y glower incisors, even with the heavy rectangular

arch wire, since the untied arch wire will slideforward through the tubes and brackets of theposterior teeth. Previously closed mandibularextraction spaces are likely to reopen if this

precaution is not taken.

Determining length of



assembly… With the patients protruding the mandible into a class

I position, the right and left strut lengths aremeasured.

Tube attached most mesially on the last molarincorporated and most distally to mandibular canines.

The MARS strut length is that distance from themiddle of the interbracket space distal to the lowercanine to the middle of the interbracket space mesialto the maxillary terminal molar.

The upper member or hollow tube length is determinedby subtracting a calculated and standardized



by subtracting a calculated and standardizedmeasurement of 7.4mm from the strut length.

The free end of the lower member or the plunger is thencut so that 2mm extends out of the back of the uppermember

One reference measurement needed for this applianceis the PIED (Protrusive incisial edge distance) PIED isthe horizontal distance measured at the midlinebetween the maxillary and mandibular incisial edges

with the mandible in its maximum strained protruded

position.

The MARS appliance should be locked into positionwith the mandible 2 to 3 mm posterior to the maximum



with the mandible 2 to 3 mm posterior to the maximumPIED measurement. In the event a patient encountersmuscular discomfort as a result of protruding themandible too far forwards the appliance is adjusted andlocked in a less protrusive position.

At subsequent appointment the PIED should bemeasured and recorded. The authors have observedthat the PIED will increase from 0.5 to 2 mm between 3to 4 week appointment intervals. When the PIEDceases to increase between appointments, the MARS

appliance is then adjusted so that a super class Iocclusal relationship is obtained.

Two methods to lengthen the appliance

) R l f h i h l b f



1) Replacement of the struts with longer upper members of cylinders.

2)Placement of spacers 2 to 3 mm in length on the lowermembers or pistons.

Unlike the Herbst appliance, the MARSappliance :

Requires neither soldering nor extensive labprocedures.

Has minimal incidence of breakage Does not depress the canines, open spaces in the

premolar area or flare mandibular incisors(provided the mandibular rectangular archwire istied back to the terminal molars)

Is easily removed.

Disadvantages :



Need for a fixed multi-banded appliance limits itsuse in mixed dentition cases.

Disarticulates at the posterior segments from 1 to 3mm

Need to customize the appliance for each patient.

dib l i li



Mandibular Protraction appliances : This appliance was

developed by Carlos MartinCoelho Filho (JCO 1995).

His inability to purchase

some of the newer class IIcorrective appliances innorthern Brazil led him todevelop these group of appliance that reposition

the mandible forward.



They have proven effective in treating Class I patients with exaggerated overjets and Class II subdivisionpatients where only one side needs correction.

Their advantages include ease of fabrication, low cost,

infrequent breakage, patient comfort, and rapidinstallation.

But they are not claimed to be superior but are only

treatment alternatives to Class II therapies.

Each side of the appliance is madeby bending a small loop at a right



by bending a small loop at a rightangle to the end of an .032"

stainless steel wire.

The length of the appliance isthen determined by protrudingthe mandible into a position with

proper overjet, overbite, andmidline correction and measuringthe distance from the mesial of themaxillary tube to the stop on themandibular archwire.

Another small right-anglecircle is then bent in an



opposite direction into the

other end of the .032" stainlesssteel wire. The angulation of these circle bends can vary toallow free sliding along the

mandibular archwire.One appliance circle is

placed over the maxillary archwire against the molar

tube, and the other circleagainst the mandibulararchwire stop. Both circles arethen closed completely with aplier.

Functioning of the appliance MPA -1



Appliance slides distally along mandibular archwireand mesially along maxillary archwire upon opening.

But frequent dislodgmentof molar bands led Filho todevelop the 2nd protractionappliance. (MPA n.o 2)

MPA No. 2

MPA No 2 is made ith right



MPA No. 2 is made with right-

angle circles in two pieces of .032" stainless steel wire.

Coil of .024" stainless steel wire is slipped over one wire.

Travel of each wire is limitedby wire coil.

Improper relationship of wires is prevented by coil



wires is prevented by coil.

Maxillary archwire hasocclusally directed circlesagainst molar tubes;

mandibular archwire hasocclusal circles 2-3mmdistal to each cuspid.

Advantages : Easily fabricated at chair side, with

ordinary inexpensive wires



ordinary inexpensive wires.

Do not require any special bands ,crowns or wire attachments.

No impression or wax biteregistrations are needed.

Easily inserted adjusted,removed andcan be made and installed in about 30minutes.

Much smaller and thus more

comfortable. Permit a greater range of motion and

are less restrictive of movement

MPA-3 CARLOS M COELHO FILHO (JCO



CARLOS M. COELHO FILHO,(JCO2001)

Many of the limitations of thefirst two MPA designs have beenovercome with the developmentof the MPA No. 3.

This version eliminates much of the archwire stress and permits agreater range of jaw motion whilekeeping the mandible in a

protruded position.

Appliance construction The parts needed for the



The parts needed for theconstruction of the MPA No. 3 are:

Two maxillary tubes of 0.045”internal diameter each about 27mm long.

Two maxillary loops of 0.040”stainless steel wire, each about 13mm, long, with a loop bent intoone end at an angle of about 130 tothe horizontal.

Two mandibular rods of 0.036”stainless steel each about 27 mm

long.



Annealed pin bent mesial to the molartube



MPA No. 3 reversedfor Class III treatment, with open-coil springbetween appliance

tubeand rod loop.

Advantages of MPA n.o 3 over the

previous models :



previous models :

More comfortable for the patient

Offers greater range of motion

Equally simple and inexpensive but easier to

place Adaptable to either class II or class III cases

Can be used for mandibular positioning ordento alveolar movement

Causes less breakage.

MPA IV The latest version the



The latest version, the

MPA IV,** is much easierto construct and install,and much morecomfortable for thepatient. The MPA IV ismade up of the following

parts:

• “T” tube • Upper molar locking

pin • Mandibular rod •Mandibular archwire

Piece of .040" stainless steel wireis inserted into longer tube toprevent deformation whilebending molar locking pin with



finger pressure.

Molar locking tube is then cutand annealed to make it easy tobend during installation.

Mandibular rodinserted into “T”tube



tube.

This fourth version seems tobe as efficient as its

antecedents, but is muchmore practical to construct,easy to manipulate, andcomfortable for the patient.

Adjustable Bite corrector (ABC) (JCO 1995)

Introduced by Richard P West



Introduced by Richard P. West

The appliance essentially consistsof:

A stretchable closed coil springand internally threaded end cap

nickel titanium wire in the centrelumen of the spring.

The closed coil spring is made of

0.01 8” stainless steel, and willstretch to about 25% beyond itsoriginal length withoutpermanent deformation.

The ABC can be used oneither side of the mouthwith a simple 180



with a simple 180

rotation of the lower endcap to change itorientation.

Functions similar to theHerbst and Jasper Jumperbut also incorporatesseveral useful features

likea) Universal right and leftb) Adjustable length andforce

After the patient has posturedforward into an improved

fil ith id l bit /



profile with ideal overbite /

overjet the point of the gauge isplaced into the mesial openingof the headgear tube.

The size is then read at pointabout 3mm below the contactbetween lower cuspid and firstpremolar using the correctappliance size ensuringoptimum force delivery.



Nickel titanium wire isreplaced and end capsunscrewed to add appliance

length.

Repairs and emergencies :



Wire fractures are infrequent with the ABC. Repair is easy, where the end caps are unscrewed and

the coil spring or nickel titanium wire is replace witha new one from the kit.



The ABC can be used for upper molar anchoragecontrol during retraction of anterior teeth for spaceclosure.

The class II “push” force of the ABC creates full timemaximum anchorage at the upper molars whilebringing the lower posterior teeth forward form thepull at the jig attachment.

The Eureka Spring (JCO 1997)

Introduced by John De Vincenzo



The main component of the Eurekaspring is an open wound coil springencased in plunger assembly

The ram is made from a special work hardened stainless steel thathas been precision machined with3 different radii.

At the attachment end the ram has

either a closed or an open ringclamp that attaches directly to thearchwire.

The essentialaspects include

i d l A



spring module A,

molar attachmenttube B, push rod C,free distance D,molar attachment

wire E, free distanceF.

A triple telescoping action permits the mouthto open as wide as 60 mm before the plungerbecomes disengaged.



g g

The cylinder assembly is connected to a molartube with a an 0.032” wire that has beenannealed at the anterior end.

An 0.036” solid ball at the posterior end acts as

a universal joint, permitting lateral and verticalmovements of the cylinder.

The Eureka spring comes in only 2 sizes one forextraction and one for non-extraction cases and

left and the right sides are interchangeable.

Advantages It has esthetic acceptability because of its small size and

lack of protuberances into the buccal vestibule, as it isl bl



palmost invisible.

Resistance to breakage: produces forces of only 140g-170gat the points of attachment as compared to 220-280g of

Jasper Jumper. Ability to produce rapid movement : this is in spite of its

low force levels because the Eureka spring continues to work even when the mouth is opened as much as 20 mmas when sleeping or when the mandible is thrust forwardas far as 10 mm, in an attempt to minimize the force.

Ease of installation

No auxiliary archwires or extra impressions for laboratory fabrication are needed.

Low cost : similar in cost to the jasper jumper butless expensive than the fixed Herbst appliance.



Minimal inventory requirement

Optimal direction of force

Delivers a push force against mandibular anterior

and maxillary posterior teeth. It also has a vertical intrusive component at the

maxillary molars and mandibular although this isminimal due to direct archwire attachment,

rather than via auxiliary wire.

The churro jumper (JCO 1998)

Introduced by Ridhardo Castanon, Mario SValdes and Larry White



Valdes and Larry White.

The Churro Jumper furnishes orthodontists with an effective and inexpensive alternativeforce system for the anteroposterior correctionof class II and class III malocclusions.

It was developed as an improvement of the

MPA of Coelho. Although the churro jumper was conceived asan improvement to the MPA, it functions merelike a Jasper Jumper.

Construction :

The Churro Jumper requires aseries of 15-20 symmetrical and



5 y

closely placed circles, formed ina wire size of .028" to .032".

Since the Churro Jumperrequires reciprocal anchorage,Generally, the largest possibleedgewise archwire is the best touse. This will usually be an .018"

X .025" archwire, or .0175"X .025". Any wire smaller thanthese invites breakage.

Churro needs space to slide onthe mandibular archwire, atleast the first premolar bracketsshould be omitted. It is usually



advantageous to place a buccaloffset in the wire just distal tothe canine bracket so that the jumper also has buccalclearance, which permits

unrestricted sliding along the wire

The length of the jumper isdetermined by the distance from thedistal of the mandibular canine bracket

h i l f h h d b



to the mesial of the headgear tube on

the maxillary molar band, plus 10-12mm. This measurement is transferredto the Churro Jumper, with the coilcloser to the canine bracket than to theheadgear tube.

Mode of action :

In its passive form, thechurro is not flexed



However when the pin ispulled forward enough tocause the jumper to bowoutward the cheek, the

appliance begins to exert adistal and intrusive forceagainst the maxillary molar and a forward andintrusive force against the

incisors as it attempts tostraighten.

Unilateral / Bilateral use :

This jumper can be used unilaterally in cases of class II subdivision malocclusions



class II subdivision malocclusions.

The bilateral class II churro jumper is mostsuitable for patients who need mandibularincisors advancement. Not a very good choice

for class II bimaxillary proclination cases. By reversing the attachments, the churro

jumper can also be used to treat class IIImalocclusions.

Advantages :

Provides a constant, indefatigable force.



Can be used either unilaterally or bilaterally. Can be used in class II or class III cases.

Helps maintain anchorage.

Very inexpensive.

Can be constructed from commonly available materials universal in size.

When broken, it is easily replaced.

Staff members can quickly learn how toreplace an appliance.

Disadvantages :

Restricts the mouth opening to 30-40 mm



p g 3 4

Archwire breakage is seen if larger wires not used. Patients with a low tolerance for discomfort will

often break the appliance. Patients who incessantly move their mouths while

chewing, talking and nervous tics will fare poorly. Its maximum effectiveness depends on a

permanent dentition to retain its effect. It must be manufactured in the office.

The universal bite jumper (JCO 2001)

I d d b X i C l



Introduced by Xavier Calvez

This is a fixed functional whichcan be used in all phases of treatment, in the mixed orpermanent dentition and with

removable or fixed appliances.

This jumper also uses atelescoping mechanism, canalso have an active coil spring if

necessary.

Fixed appliance configuration



In the mandibular arch, the sliding rod ends in a 90° hook that is fixed to thearchwire.

UBJ ATTACHED TO AUXILLARY WIRE



Lower cantilever configuration



The UBJ tubes are welded to the maxillary molar bands or crowns. .

The UBJs are adjusted while mandibular movements are checked.

Depending on the case, the brackets can be bonded during thesame visit or a few weeks later.

The advantage of this configuration is the possibility of immediate

orthopedic action without waiting for dental alignment.

Removable splint mounting



When used with removable acrylic splints, two lateral UBJs

link the maxillary molar areas and the mandibular firstpremolar areas. They are attached to 1.2mm ball clasps,

which are constructed on the working cast and thenincorporated into the thermoformed splints.

Single median UBJ

A single median UBJ can be



g J

used to link the removablesplint from the middle reararea of the palate to thelingual surface of themandibular incisor.

The UBJ is attached to twotransverse axles, whichallow opening and lateral

movements.

The median UBJ provides muscular therapy as itprevents the tip of the tongue from contacting the



prevents the tip of the tongue from contacting the

lower lip. Most children are able to speak well with this

appliance, given a little time to adjust. Cheekimpingement is eliminated and it is the author’s

experience that the tongue is not irritated with thisdesign.

Adjustments :

Reactivation are made



Reactivation are made

every 6 to 8 weeks by crimping 2 to 4 mmsplint bushings on tothe rods.

Midline orasymmetrical problems

can easily be treated by adjusting one side orother of the appliance.

Advantages

It is simple, sturdy, and inexpensive.



Inventory requirements are minimal--the UBJcan be used on either side of the mouth, andthere is only one size, since it is cut to thedesired length for each case.

It can be used at any stage of treatment --in theearly mixed dentition to obtain an immediatemandibular advancement before any dental

alignment, or in the permanent dentition forfixed functional treatment.

It can be used in Class II or Class III cases.



Its low profile results in considerably lessbuccal irritation than with similar appliances.

Patient comfort and acceptance are excellent.

It can easily be attached to removable splintsfor maximum anchorage.

It produces good results without the need forpatient cooperation

The saif Spring

(Severable Adjustable inter maxillary force)



First interarch force system developed by Armstrong In the later 1960’s and early 1970’s he introduced

the Pace Spring, later termed multicoil spring andfinally called Saif spring.

These were first marketed by North Westorthodontics, later by Unitek, and currently by Pacific coast manufacturing.

They consist of two springs one inside the other with soldered loops on each end.

Various attachments can be placed through these loopsto secure the springs to deliver either class II or class IIIforce



force.

They are available in 7 mm and 10 mm lengths, have anoutside diameter of 3 mm, and deliver 200 to 400 gmsof force.

Breakage is a constant problem. Bit bulky, not very hygienic and there is some limitation

to mandibular opening

However large forces are generated by these springs which may account for the surprisingly rapid correctionobserved.

The Ritto Appliance



The Ritto Appliancecan be described as aminiaturized

telescopic device withsimplified intraoralapplication andactivation

Fixation accessoriesconsist of a steel ball pinand a lock.



Upper fixation is carriedout by placing a steel ballpin from the distal intothe .045 headgear tube

on the upper molar band,through the applianceeyelet and then bendingit back on the mesial

end.

The appliance is fixedonto a prepared lowerarch and is activated



by sliding the lockalong the lower archin the distal directionand then fixing it

against the Ritto Appliance.

The Magnetic Telescopic Device

Ritto A.K. in 1997

This consists of two tubes and two



This consists of two tubes and twoplungers with a semi-circularsection and with NdFeB magnetsplaced in such a manner that arepelling force is exerted.

Fitting is achieved by using theMALU system.

This appliance has the advantage of linking a magnetic field to thefunctional appliance. Its main

disadvantages are its thickness, thelaboratory work necessary toprepare it and the covering of themagnets.

THE TWIN FORCE BITE CORRECTOR This appliance differs from others



in form and constitution becauseit has two internal coil springs. Itconsists of two joint telescopicsystems. At the superior level it isfixed with a ball pin that is fittedinto the buccal tube of a molarband.

The placement in the lower arch isslightly different; it involves a

fitting-in system that is later fixed with a screw to the inferior arch.Normally it is placed distal to thelower cuspid.

Drawbacks:

The major drawback of this appliance is the



this appliance is thedifficulty to control theforce.

May create discomfort

and impingementproblems.

Is recommended only forpermanent dentition.

ALPERN CLASS II CLOSERS It is one of the most recent.

It is predominantly applied in



Class II correction and as asubstitute for elastics.

It consists of a small telescopicappliance with an interior coilspring and two hooks for fixing

It functions in the same way aselastics and, similarly, is fixed tothe lower molar and to the uppercuspid.

It is available in three differentsizes. Its telescopic action enablesa comfortable opening of themouth.

Mandibular Corrector (JCO 1985)

Introduced by Marston Jones

It is a fixed functional that uses



It is a fixed functional that usesbilateral piston and plungertelescopic mechanism toreposition the mandibleanteriorly and is directly

attached to archwires of amultibanded fixed appliance.

Connectors holding therepositioning arms are attached

to the archwires distal to thelower cuspid brackets and mesialto the tubes on the terminalupper molars.

The length of the repositioning arms are determinedintraorally with the patient’s mandible advanced 3-4 mm.

The entire procedure can be completed at chair side in 30minutes.



The mandible can be advanced in small increments of 2-4mm at 4 week intervals until the incisors are in an edge toedge relationship.

Midline corrections are made by advancing the appliancemore on one side.

A correction of 3-4 mm can be achieved within 6 months,an overjet of 7 to 8 mm may require 12-14 months.

The Horizontal Anterior Positioning (HAP)appliance

Most of the appliances have



anterior contact while allowing forposterior eruption. Unfortunately,the lack of posterior support hasbeen shown to have a loadingeffect on the TMJ.

Dr. William B. Farrar recognizedthe need for posterior support andmodified the original Svedappliance to incorporate twoposterior acrylic pads along withan anterior ramp.

Components of HAP appliance: A. Anterior reverse ramp. B.

Sagittal screws. C. Expansion arms. D. Coffin spring. E. Locking

mechanism.



Anterior reverse ramp

Sagittal screws

Expansion arms

Locking mechanism

Coffin spring

A lower "dipod, whichprovides upper and lowerposterior occlusal support.



A posterior pad can beadded to the HAP, butadjustments become moredifficult and the possibility of breakage increases.

The vertical dimension canbe increased if necessary. Thebite-opening effect allows forpassive or active eruption of

the posterior occlusion tohelp level the curve of Spee.

The Mandibular Anterior Repositioning

Appliance(MARA)

These interference’s are produced when a



p

horizontally adjustable vertical barattached to the buccal surface of amaxillary first molar stainless steel crown,hits a buccally protruding horizontal bar

extending from the lower first molarstainless steel crown.

Additional activations can be made by placing one or more shims at the mesialaspect of the horizontal bar. Advancing the mandible forward in

precise increments can be achieved by insertion of selected shims of varying

Advantages over Herbst

Better esthetics



Problem with disengagement do not occur Breakage from lateral mandibular movements

should be less.

Can be used concurrently with full edgewise

orthodontic appliance. This

Eliminates the need for a 2 phase treatment.

Can maintain the achieved orthopedic results, since the

appliance can continue in a non activated manner.

Disadvantages

Temporary stainless steel crowns needed on allfirst molars.



st o a s.

Some increase in anterior facial height resultsfrom the placement of these crows.

Fabrication only available at one commercial

laboratory. The posterior and buccal location of the guide

planes may cause loosening of the stainlesssteel crowns or breakage of the mandibularprotruding horizontal bar.

Functional Mandibular Advancer Kinzinger,Ostheimer, Diederich,2002

It has a propulsive mechanism thatresembles the Mandibular anterior



resembles the Mandibular anteriorrepositioning appliance, but differs inits mode of action and intraoralactivation.

It relies on the principle of inclined

planes that are placed in the buccalcorridor spaces that will not hinderswallowing or articulation.

The protrusion guide pins are fitted to

the upper portion of the apliance at a60 degree angle to horizontal, ensuringactive, forward mandibular guidanceduring even partial jaw closure.

Reactivation in the sagittal planeis done simply by moving theguide pins to a more forwardthreaded support sleeve. This



gradual activation allows patientsparticularly adults to adjust to theappliance.

Kinzinger, Diederich JCO 2005 reports the use of FMA in a 16 yearold male with Class II div2 and for just 3 months the patient was able

to protrude the mandiblesignificantly forward from thetherapeutic position.



Advancement in

therapeutic positionsMaximum protrusionof mandible after 3months

The Biopedic

Designed and introduced by Jay Collins in 1997 (GAC International)



It consists of buccal attachmentssoldered to maxillary andmandibular molar crowns.

The attachments contain a standard

edgewise tube and a large 0.070 inchmolar tube. Large rods pass throughthese tubes.

The mandibular rod inserts from the

mesial of the molar tube and is fixedat the distal by a screw clamp. By moving the rod mesially theappliance is activated.

This short maxillary rod is inserted screw atthe mesial of the maxillary first molar.



The two rods are connected by a rigid shaftand have pivotal region at their ends.

Although, it appears that there would belimitation of mandibular opening, it is not so.The design works more in harmony with thearc of mandibular opening.

Advantages

Can be used concurrently with bandedtreatment.



Esthetic benefit

Capability of adjusting the amount of protrusiveactivation.

Disadvantages

Potential for more breakage and loose crowns

Greater cost.

Need for crowns on molars

The Klapper Superspring II Introduced by Lewis Klapper in

1997, for correction of class IImalocclusions.



On first glance, it resembles a Jasper Jumper with a substitution of a cablefor the coil spring. In 1998 the cable was wrapped with a coil and the

Klapper superspring II was theresult.

Only two sizes are required (left andright sides are not interchangeable)and breakage is less frequent.

However it differs significantly fromthe Jasper Jumper at the molarattachment.

The SUPERspring II is aflexible spring element thatattaches between themaxillary molar and the



ymandibular canine. It isdesigned to rest in the

vestibule, making itimpervious to occlusal

damage and allowing forgood hygiene. Only minoradjustments are needed forpatient comfort, without any impingement on soft tissues.

Disadvantages

Requirement of a special molar tube



Lack of adaptability to correct class III conditions Limitation to maximal opening

Potential injury to the patient if breakage occurs andthe rigid molar attachment forces the broken portion

into the soft tissues.

Forsus Fatigue resistant Device This is an interarch push

spring which produces



p g pabout 200g of force whenfully compressed.

The distal end of the FRD`s

push rod inserts into thetelescopic cylinder and ahook on the mesial end iscrimped directly to thearchwire near the canine or

premolar brackets.

The push rod has a built instop that compresses thespring when the patientsmouth closes. The spring isthen transferred to the



maxillary molars using themandibular arch as theanchorage unit.

The L-pin is inserted in the

eyelet of the telescopingspring and is threadedthrough the molar headgeartube from distal to mesial andcinhed,leaving 2mm slack.

The mesial hook is loopedover the mandibular arch wireand crimped shut.

Advantages: It does not require time-consuming and

expensive lab work or the use of stainless steel



crowns. It produces consistent treatment results in a

predictable amount of time, without dependingon

patient cooperation. It can deliver an orthopedic effect to both jaws

or more of a dentoalveolar effect. It can be activated more on one side than on the

other, so it excels at correcting midlinedeviations.

William Wogt JCO June 2006 reports a case where a 12 year old male with class II division 1and moderate overjet of 7mm was corrected



with the Fatigue resistant device in 6monthsafter which it was used as an anchorage unit forthe retraction of the maxillary anteriorsegment.

Conclusion :

Fixed functional appliances form an useful



addition to the clinician’s orthodonticarmamentarium. But many of these appliancesneed further studies to substantiate the claimsmade by their respective originators. With this

in mind, clinicians must take great care inselecting the right patient and also pay attention to every detail in the manipulation, toattain successful results with these appliances.

erences:1. Larry.W. White :Current Herbst Appliance

Therapy:JCO 1997,May(296 - 309)



2. Arji George, V. Surendra Shetty, SN Rao & Ashima Valiathan: Effect of Herbst appliance on

Orofacial musclature. Journal of IndianOrthodontic Society. 1993; 4(3): 93-99.

3. S.Jay Bowman: Jasper Jumper in Class II

correction. A case report. JIOS 2001;34:101-105.

4. Kinzinger, Oestheimer, Deidrich:

Development of a new fixed functional



appliance for treatment of skeletal class IImalocclusion.J. Orofac Orthop 2002 63:384-399

5. Ken Hansen: Treatment and posttreatmenteffects of the herbst appliance on the dentalarches and arch relationships. Semin Orthod2003 March,page 67-73



9. Sabine Ruf, Hans Pancherz: When is the ideal period forHerbst therapy-Early or Late? Semin Orthod



2003,March,page 47-56

10. Mc Namara, Brudon, Kokich, Orthodontics andDentofacial Orthopaedics, 2001 page 285,333

11. Cope J.B., Buschang P., Cope D.D., Parker J., BlackwoodH.O. Quantitative evolution of craniofacial changes with

Jasper Jumper Therapy. Angle Othod. 1994; 64 (2): 113 – 122.

12. Miller R.A. The Flip-lock Herbst Appliance. J. Clin. Orthod. 1996; 30: 552 – 58.



13. Jasper J.J., McNamara J. The correction of interarch malocclusions using a fixed forcemodule. Am. J. Orthod. Dentofac. Orthop.1995; 108: 641-50.

14. Pancherz H. Treatment of Class IImalocclusions by jumping the bite with theHerbst appliance. A cephalometric

investigation. Am. J. Orthod. 1979; 76: 423-442

15. Heinig N, Goz G: Clinical application andeffects of the Forsus spring. A study of a newHerbst hybrid, J Orofac Orthop. 2001



Nov;62(6):436-50.

16. Pancherz H. The mechanism of Class IIcorrection in Herbst appliance treatment. Am.

J. Orthod. 1982; 87: 1-20.

17. Pancherz H. The Herbst appliance – Itsbiological effects and clinical use. Am. J.

Orthod. 1985; 87: 1-20.

18. Erdogan E. Asymmetric Application of the Jasper

Jumper in the correction of midline discrepancies. J.Clin. Orthod. 1998; 32: 170 – 80.

b f h d ff f h b



19. Sabine Ruf:Short and Longterm effects of the Herbstappliance onTemporomandibular jointfunction,Semin Orthod 2003 March page 74-86.

20. Cash R.G. Case Report: adult nonextraction treatment

with a Jasper Jumper. J. Clin. Orthod. 1991; 25: 43-7..

21. Castañon R., Valdes M., White L.W. Clinical useof the Churro Jumper. J. Clin. Orthod. 1998; 32:



731 – 45.

22. Blackwood H.O. Clinical Management with the Jasper Jumper. J. Clin. Orthod. 1991; 25: 755-60

23. Haegglund P. The Swedish-Style IntegratedHerbst Appliance. J. Clin. Orthod. 1997; 31: 378 – 390.

24. Pangrazio-Kulbersh V, Berger JL, Chermak DS,Kaczynski R, Simon ES, Haerian A:Treatment

ff f h d b l



effects of the mandibular anteriorrepositioning appliance on patients with ClassII malocclusion. Am J Orthod DentofacialOrthop. 2003 Mar;123(3):286-95

25. Calvez X. The universal bite jumper. J. ClinicalOrthod. 1998; 32: 493-499.

26. Filho C.M. Mandibular Protraction Appliancesfor Class II Treatment. J. Clin. Orthod. 1995;29: 319 – 336.

27. Hans Pancherz :History, Background, andDevelopment of the Herbst Appliance, Semin

O h d M h



Orthod 2003,March page3-11

28. Filho C.M. Clinical Applications of theMandibular Protraction Appliance. J. Clin.

Orthod. 1997; 31: 92 – 102.29. Filho C.M. The Mandibular Protraction

Appliance III. J. Clin. Orthod. 1998; 32: 379-384

30. Mandeep sood, k.Sadashiva Shetty:

Functional therapy- Is it worth the effort? JIOS1994 October page 128-136.



31. Aidar LA, Abrahao M,Yamashita HK,Dominguez GC:Herbst appliance therapy andtemporomandibular joint disc position- A prospective longitudinal magnetic resonanceimaging study. Am J Orthod DentofacialOrthop. 2006 Apr;129(4):486-96.

fixed fntl appliance

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