FRANKEL APPLIANCE(also called: Functional regulators / Functional corrector / Vestibular appliances / Oral gymnastics)

Introduced by Dr. Rolf Frankel of Germany Treatment is not directed toward the teeth or

skeletal tissues, but to the functional disorders responsible for dentoskeletal malformation

Primary aim: to identify a faulty postural performance of the orofacial musculature and correct it by functional appliance

Tissue-borne functional appliance

FRANKEL PHILOSOPHY1. Vestibular area of operation

- shields extend to vestibuleto prevent abnormal muscle function2. Sagittal correction via tooth borne Mx anchorage

- appliance is fixed on the upper arch by grooves mesial to the 1st permanent molar and distal to the canine in the mixed dentition period

- presence of lingual pad acts as proprioceptive stimulus and helps in the forward posturing of the Mn.3. Differential eruption guidance

- FR is placed on the Mx. teeth- Mn. posterior teeth are free to erupt (their

unrestricted upward & forward movement contributes to vertical & horizontal correction of malocclusion)4. Periosteal pull by buccal shields and lip pad

- helps in bone formation and lateral expansion of the Mx. apical base5. Minimal maxillary basal defect

- downward & forward growth of maxilla seems to be restricted, even though lateral Mx. expansion is seen

Myodynamic (rely in muscle movements or dynamic properties)

Maxillary restraining effect Decrowding during eruption

Vestibular screens are extended into the vestibular sulcus so tension is created in the soft tissuescauses outward bending of the thin buccal plate, facilitating outward drifting of teeth

Differential eruption – prevent Mx molars from downward and forward movement

Differential eruptions of lower molars contribute to establishment of correct sagittal relationship by 1-2mm

Periosteal matrix stimulation Buccal shields and lips are extended into

the vestibule causing tensionelicits periosteal pull and bone deposition

MODE OF ACTION OF FR1. Increase transverse sagittal direction

- by use of buccal shields and lip pads2. Increase in vertical direction

- by allowing the Mn. molar to erupt freely3. Muscle adaptation

- the form and extension of the buccal shields and lip pads along with the prescribed exercises corrects the abnormal perioral muscle activity

The Functional Matrix and Frankel Appliance

OO : Orbicularis OrisB: BuccinatorPMR: Pterygomandibular rapheSPC: Superior pharyngis constrictorLP: Labial PadVS: Vestibular shield

FR provides a larger functional matrix than the teeth.

The buccinator mechanism will grow and adapt to whichever functional matrix (soft-tissue capsule) is present in the mouth.

This adaptation occurs primarily during growth.

After growth is complete, very little, if any, change can be expected

ORAL EXERCISES WITH FR Frankel – worn full time Lips to be closed at all times or to keep a paper

between the lips Swallowing, speaking, etc. w/ the appliance in

mouth, itself serves as an exercise

TYPESFR I : used for correction of Class I and Class II div.1 malocclusion

FR I a : In class I malocclusion w/ minor crowding In delayed development of the basal bone and

dental structureFR I b:

In class II div. 1 malocclusion w/ deep bite and overjet <7mmFR I c:

In severe class II div.1 w/ overjet >7mmFR II : used for correction of class II div.1 and div.2 malocclusion

FR III : used for treatment of class III due to maxillary deficiency

FR IV : used for treatment of open bite and bimaxillary protrusionFR V: incorporate headgear, and is used in high angle cases

INDICATIONS OF FRGenerally,

AGE GROUP OF 8-10 YEARS (MIXED DENTITION PERIOD)WITH GROWTH SPURTS.

SKELTAL CL II MALOCCLUSION WITH PROGNATHIC MAXILLA AND RETROGNATHIC MANDIBLE.

FUNCTIONAL CL II MALOCCLUSION. IN A HORIZONTAL OR NETURAL GROWTH

VECTOR CASE. CL III MALOCCLUSIOS. BIMAXILLARY PROTRUSION AND OPEN BITE

PROBLEMS. FUNCTIONAL RETRUSION , DEEP OVER BITE ,

AND EXCESSIVE INTEROCCLUSAL PROBLEMS WITH A NORMALLY POSITIONED MAXILLAE

FR I Class I

Early tx : discrepancy bet. tooth size & arch size in px w/ normal overbiteLate tx : Mild crowding in the presence of adequate apical base

Class II div. 1Early tx : Mn. retrusion w/ normal overbiteLate tx : 1. Mn. retrusion w/ normal overbite, overjet >7mm2. Mn. retrusion w/ crowding3. Mn. retrusion w/ open bite

FR II Class I

Early tx : deep bite assoc. w/ arch size deficiencyLate tx : deep bite w/o irregularities

Class II div. 1 & 2Early tx : Mn. retrusion w/ deep bite & excessive overjet. Pre-tx mechanotherapy to correct Mx. incisors is requiredLate tx :1. Mn. retrusion w/ deep bite & excessive overjet w/o arch irregularities. Pre-tx mechanotherapy to correct incisors is required2. Mn. retrusion w/ arch irregularities. Pre-tx mechanism to correct crowding by extraction is required

FR III Class III

Early & late tx of Mx. retrusionOpen bite assoc. w/ class III

FR IV Early tx of skeletal open bite and bimaxillary

protrusionFR V

High angle cases Vertical growth pattern

CONTRAINDICATIONS OF FR Class I malocclusion with severe crowding Thumb sucking habit Severe dentoalveolar problems in permanent

dentition Uncooperative patients

ADVANTAGES: 1. enables elimination of abnormal muscle fxn aiding in normal development2. Tx can be initiated at early age 3. Less chair side time is spent4. The frequency of the patients visit is less5. They do not interfere with oral hygiene status6. Duration of tx is comparatively less. They deal with skeletal as well as dentoalveolar problems.

DISADVANTAGES: 1. bulky and the cooperation of the patient is essential. 2.They cannot be used in adult patients were the growth has ceased. 3. Cannot be used to bring about individual tooth movement and in cases of crowding. 4. Fixed appliance therapy may be required at the termination of treatment for final detailing of the treatment.

PARTS OF THE APPLIANCEAcrylic part Wire partsBuccal shields Palatal bowLip pads Labial bowLower lingual pads Canine extensions

Upper lingual wire (FR II)Lingual crossover wireLip padsLower lingual springs

Buccal shieldsExtend deep into the sulci in the apical region of Mx. 1st PM and tuberosity region

Areas where expansion of dental arch and alveolar process is required, the shields stand away from the lateral aspects of teeth and alveolus

In Mx. teeth & alveolus the gap bet. the shield & teeth surface is 2x wax thickness

In Mn., only 1 wax layer Thickness: about 2.5mm

Functions:1. Physiotherapy : by expanding the circumoral capsule in transverse direction soft tissues adapt new form2. Forced training : of the muscles of the cheek to adapt to fxnal performance3. Correction of spatial disorder : by stimulation of periosteal matrices

Labial pads / pelots

Rhomboid-shaped, fit the labial surface of Mn. frontal alveolar process

Teardrop-shaped in x-section (permits free seating of the lip pads in the vestibule

5mm distance from upper edges of lip pad to the gingival margin

Distal edge of lip pad should not overlap the canine root protuberance

Functions:1. Physiotherapy: supports the lower lip, smoothens the mentolabial sulcus, improves lip posture.

2. Forced training: main fxn is to prevent hyperactive mentalis from raising the lower lip

Lingual shield

Below the gingival margin of Mn. teeth Extends up to distal of 2nd PM Positioned by the 2 connecting wires to the

buccal shieldFunctions:1. Forced training: in Mn. retrusion, it keeps the mandible in advanced position. Whenever the mandible tries to slide back to its original position, it elicits a pressure sensation on the lingual aspect of the alveolar process stimulate protractors of the mandible

Vestibular wires Connects labial pad and buccal shields Made from 0.9mm wire Serves as skeleton for lower lip pads

Maxillary Labial bow Made from 0.9mm wire and usually lies in the

middle of the labial surfaces of the maxillary incisors

Runs gingivally at 90° bet. lateral incisor & canine

Forms a gentle curve distally at the height of middle canine root and re-embedded in the buccal shield

Palatal bow

Provides some extra wire length to facilitate a lateral expansion adjustment

Crosses the occlusal surface in the embrasure Mesial to 1st molar

Canine Loop Wraps around the lingual surface of canines Embedded in the buccal shield at occlusal plane

level Rises sharply to the gingival margin Fits in the embrasure

FR I 2 buccal shields 2 labial pads 1 lingual pad Wire parts

FR II Buccal shields Lip pads Lower lingual pad

Palatal bow, labial bow, canine extensions, upper lingual wire, lingual cross over wire, support wire for lip pads, lower lingual springs

Separators : recommended 1 week before taking impressionBetween Mx. canine & 1st deciduous molarSlicing mechanism allows immediate seating of appliance

FR III

FR IV

Same vestibular config. as FR I & II w/o canine

loops and protrusion bows 4 occlusal rests on Mx. 1st molars, and 1st

deciduous molars to prevent tipping of the appliance

MOA: spontaneous change of growth of mandible from downward & backward to upward & forward direction correction of skeletal anterior open bite

FR V For long face syndrome w/ high Mn. plane angle

and vertical Mx. excess

Addition of posterior acrylic bite blocks (arrest molar eruption

Also has headgear tubes that accept face bow for an occipital pull headgear

TREATMENT OBJECTIVES 1. INCREASE IN INTRA ORAL SPACE

achieved primarily through buccal shields and lip pads which eliminate the harmful mechanical forces on the pressure sensitive membraneous structures.

2. VERTICAL SPACE INCREASE possible because the construction bite is taken,

so that the bite is opened in the posterior segments as the mandible is held forward

3. MANDIBULAR PROTACTION The position of the mandible is changed

through the gradual training of the protractor

and retractor muscles followed by condylar adaptation.

4. MUSCLE FUNCTION ADAPTATION Development of new patterns of motor

function, improvement of muscle tones and establishment of proper oral seal.

The pads and shields massage the soft tissues improving blood circulation .

Wearing time worn all the time except for the meals so the

treatment should be started slowly For the first 2 weeks the appliance should be

worn for 2 to 4 hours during the day During the next 3 weeks the time is extended to

4 to 6 hours usually takes 2 months before the appliance is

worn at night The appliance and treatment progress should

be checked at 4 weeks interval An initial end to end molar relationship is

corrected in 6 months

TIMING OF TREATMENT Best therapeutic effect is achieved during late

mixed and transitional dentition period(both soft & hard tissues are undergoing their greatest transitional changes) about 8-10 y/o

Tx of Class III & open bite cases should usually start sooner than for Class II problems

INSTRUCTIONS FOR THE PATIENT > A little discomfort is to be expected initially > Salivation may be increased but it should not be a problem> Outline the duration of wear expected> Instruction on appliance care and oral hygiene maintenance> Demonstrate the lip seal exercise> Ask the patient to speak a few words and reassure that speech would normalize> Wearing time should be correctly followed

References:Premkumar, S. Orthodontics: Prep Manual for Undergraduates. Elsevier, 2008: Page 371-378

Singh, G. Textbook of Orthodontics, 2nd Ed. Jaypee Brothers, 2007: Page 523-529