frankel’s functional regulator / orthodontic courses by indian dental academy

FRANKEL’S FUNCTIONAL REGULATOR

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INDIAN DENTAL ACADEMY

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FRANKEL’S FUNCTIONAL REGULATOR

IntroductionFrankel’s philosophyFabrication of the applianceAppliance delivery & Clinical handlingFR in class 2 and class 3Modification of FRStudies on FRComparison b/w FR and other functional appliances

Rolf frankel

Zwichau- Germany

1967 functional regulator

FRANKEL’S PHILOSOPHYMossFunctional performance of the muscular portions of the capsule influence the developing functional spaces

Functional spaces also influence by atmospheric pressure

FRANKEL’S PHILOSOPHY

Pressure on soft tissue

Muscular forces

Sub atmospheric pressure

Studies of Mobius During swallowing Vacuum in oral cavity


‘ SPACE FACTOR’ important aspect of epigenetic regulation


Functional space deficiency in transverse and vertical planes

Perioral muscles had restraining effect on dental archesInsertion of appliance –expands capsule and allows for new functional adaptation of musclesActivator – ‘ push from within’FR – ‘ought to be matrix’All activities of oral cavity – muscle training


FRANKEL’S PHILOSOPHYBuccal shields and lip pads exert periosteal pull exp not verified this effect Graber (1988) exp- on primates showed that this effect is temporary

FRANKEL’S PHILOSOPHY The mechanical effect of the appliance directed to the capsular matrix and not to teeth / alveolar process.

MOYERS‘altering the condition that determine the pattern of occlusal development rather than altering the occlusion directly.’

Classification of FRFR1Types a , b and cFR 2 FR3FR4MODIFICATIONS OF FR

FR 1

Acrylic componentsBuccal shield Lip pads Lingual shield

Buccal shields

ExtensionThickness 2.5mmExpansion of the capsule

Lip padsextension and Tear drop shape Smoothen sulksLip posture and seal seal

5 mm

Lip pads and buccal shields

Concomitant action in mandibular retrusion

Lingual shieldsextensionOver comes the poor posture of mandibular musclesDifferent action from activatorAction only in step advancement

Labial bow

Canine loop

Palatal bow

Cross over wire

Wire components of FR 1

Wire components of FR 1

Lower lingual wires

Cross over wires

Labial bowPalatal bow Canine loop

Labial bowPosition and extensionStabilizingConnecting‘Function activated’

Palatal bowExtensionOcclusal rest on maxillary molarStabilizing action Intermaxillary anchorage

Canine loop

ExtensionGuide eruption of canineIntermaxillary anchorage

Lower lingual wires

ExtensionPrevent lingual movement of incisorsFunction activated element in deep bite and retruded anteriors

Cross over wiresRun b/w 1st and 2nd premolarsNot to be lodged interdentally Cause movement of buccal segmentsNo training effect

FR1a and FR1 b

Lower lingual loops

Overjet 5mm

Lower lingual shield

Overjet 7mm

FR 1CStep by step opening in the anterior and vertical direction

Overjet > 7mm

FR 2Canine loop and labial bow

Upper lingual wire

Upper lingual wireRuns b/w canine and lateralStabilizing effectPrevents lingual tipping of anteriors in div 2 cases corrected in pre fr phase

Upper lingual wirePreferred in class2 div 2 with horizontal growth patternBite opening action similar anterior bite plane/activatorBite opening effect also due to buccal shields

FR 3

Lower labial wire

Upper lingual wire

Upper lip pads

Occlusal rests

Buccal shields in FR 3Stand away from maxilla but not from mandible

Lip pads in FR 3

Larger in sizeStands away from alveolar processExpansion of capsule and correction of postural imbalance

Palatal bow and occlusal rests

Palatal bow not lodged interdentally

Additional occlusal rest on lower molar in deep bite

Upper lingual wire and lower labial bow

Upper wire not touch the anteriors but can be activated to protrude incisors

Lower labial bow must touch the incisors

FR 4

4 occlusal rests

Palatal bow

Lower labial pads and buccal shields

upper labial bow

Construction of the FR appliance

Impression techniqueReproduce whole alveolar process and depth of the sulcusTray selectionAdequate base

construction biteDiffers from other functional appliancesAdvancement only by 2-3mm in first step

Preparation of the casts

Gauge to measure the correct depth of the sulcus

Properly carved working models

Preparation of the castsseating grooves:

Seating grooves are cut in the maxillary model in FR 1 and FR 2 in the permanent dentition

Preparation of the castsseating grooves

Seating grooves in maxillary model for permanent dentition

Notching in the deciduous dentition

Preparation of the casts

Sulcus trimming and position of lower lip pads

12 mm

Extension of lower lip pads

Preparation of the castswax relief:

Maximum thickness of wax padding under buccal shield

Wax padding under the buccal shield to allow for dentoalveolar expansion

Wire fabrication

Correct position of wires on the maxillary work model

Labial bow 0.9mm , canine loop 0.8mm and palatal bow 1mm

Wire fabricationPalatal bow

Canine loop

Wire fabrication

Correct position of lip pads and lingual shields and wiresLo-la 0.9mmLo –li 0.8mm

Wire fabrication

Correct position b/w wires and wax up -0 .75mm

Wire fabrication

Lingual wires 0.8mm

Extension arm of cross over wire 1mm

Single piece 3 separate pieces

Wire fabricationFuture splitting of buccal shield with use of metal sheet

Wire fabrication – FR 2

Palatal bow and upper lingual bow (0.9mm) in FR 2 seated inter proximally for locking

Bite registration - most comfortable retruded position

Wire fabrication - FR 3

Preparation of models- FR 3

Trimming of maxillary casts

Wax relief – FR 3

FR 3

CORRECT POSITION OF THE UPPER LIP PADS


Correct position of protrusion and palatal bow


Occlusal rest below palatal bow

Mandibular labial bow

Timing of treatment7-8 ½ yearsBest therapeutic effect when mandibular lateral incisors eruptClass2 div I with mandibular retrusion- males till a 15-16 yearsNot start during circum pubertal growth period /late mixed dentition.

Treatment phases with FRInitial phase

Active phase

Retention phase

Initial phaseAppliance delivery

CheckSmoothness of marginsLip pad –tear dropSeparation b/w teeth In mixed dentition make notches

Initial phaseAppliance delivery

Check appliance fitOverextension of shieldsPalpate face to to check for sharp edges

Initial phaseWearing the appliance

Success of treatment – lip sealEmphasis on lip exercisesDuration of wearIst week – 1-3 hrs in afternoon only2nd week – 4-6 hrs3 – 4 months – full time wear

Active phaseCheck after every 4 weeks

Mucosal irritationStability of applianceImpingement of cross over wires

Appliance adjustmentsCanine loop -occlusally Molar rests – gingivally

Active phaseAppliance adjustmentsLabial bows & lingual wires-retract /close spacesLingual wires – towards cingula

Further advancement in severe cases

Active phaseAfter 3 months of full time wearCheck

ExpansionOverjet Overbite molar relationship-(6-8 months)Leveling of curve of speeDecrease in mentalis activity

Retentive phaseDifferent from fixed appliances Labial and lingual wires can hold altered tooth positionsUsed as retainer in pts where the training effect not satisfactoryFixed treatment may be required

2 hrs in afternoon6 hrs in nightOnly night – i year

6 months

FR in treatment of class IIMandible displaced anteriorly- retractor muscle force –600gmsActivator-force transmitted to single teethBjork : rapid reaction in the dental system TMJ unaffectedMajor dental changes – Proclination of lower incisors

FR in treatment of class IIActivator treatment

before after

FR in treatment of class IIMode of action of activator in the treatment of mandibular retrusion

FR in treatment of class IISuspending muscles relax during sleepMandible drops inferiorly and backwardsProclination of lower anteriors2-3mm advancement initial afternoon wear

FR in treatment of class IIPost –sup elongation of condyleRemodeling at ramal-corpus junction- elongation of corpus

The adjustive function of the ramus

FR in the treatment of class 2

Mandibular retrusion to be overcome byExpanding the oral spaceSuspending muscles of mandible provide dynamic forceCorrect immature patterns b/w protractors and retractorsKeep mandible forward but not mechanically


Change in position brought by lingual shieldsInitial bite 2-3 mm Advancement in small steps for biologic reasons.


Step by step advancement by splitting the buccal shieldsSuspending muscles are not overstrainedActivator –extreme alteration of mandibular position –occlusal instability & TMDFR advancement in steps stability in post retention periods


Characterized by diminished volume of the superior part of the oro-facial capsuleRelated to structural and postural imbalance of musclesLingual volume not to be diminished


Expansion of upper oral space

Tongue space not diminished


Septo premaxillary ligament pull translates upper incisors bodilyFR3 promotes max basal bone development and translates maxilla forwardAppliance should not be locked in the maxilla by wires

FR in the treatment of skeletal open bites

Aimed at correcting the poor lip valve mechanism.Marked activity of temporalis and masseter when lips are closedAcc to Frankel tongue thrust is compensatory

Modifications of FR appliance


Modifications of FR appliance1. Capped frankel appliance-OTTON et al

19922. Modified functional regulator for VME -

Owen19853. Change in the angulation of cross over wire

–Chate 19864. Hybrid appliance –activator –FR

combination -19865. KINGSTON modified buccal shields6. Fr with continuous buccolabial shield and

palatal acrylic support – Haynes 1986

CAPPED FR controls tippingIndicated in deep bite cases

CAPPED FRDisadvantages- need of sufficient posterior separation- capping may impinge on U1 as treatment progresses- difficult to clean

Change in the angulation of cross over wire

Strictly horizontal advancement results in incisal movements of the lower wire and shields


Difficulty in establishing normal lip functions


In cases with step advancement FR to be constructed so that it be parallel to the downward and forward repositioning of the mandible

Modified FR for VME Posterior part of maxilla –important for vertical growth control ½ -1/3 mm posterior eruption increases AFH by 1mm.Molars intruded chin translated forward improving profile

Modified FR for VME

Modified FR for VME by adding posterior bite blocksAdded head gear tubes

Modified FR for VME25 pts av age 7 yrs 3 months,bite 3-4 mm assessed after 19 monthsU1 retractedNo proclination of L1Horizontal movement of the chinAFH decreasedGumminess of smile reduced

HYBRID FUNCTIONAL APPLIANCE (fr and activator

combination)Hybrid appliances are those that are specifically and individually tailored to exploit the natural process of growth and development

1. Bite planes2. Shields and screens3. Construction and working bite

HYBRID FUNCTIONAL APPLIANCE (fr and activator

combination)

FR with kingston modified buccaL SHIELDS

Modified Fr with continuous buccolabial shield and palatal acrylic support- haynes

ajo 1986To eliminate lip trapNo pressure on the gingival dentoalveolar tissues

Studies on Frankel‘s appliance


N.R.E Robertson AJO 198312 cases with FR2 and FR3 using cephs and conclude the principle changes were dentoalveolarMC NAMARA AJO 19843 adult patients with class 2 malocclusion with mandibular retrusion Length of mandible not increased but vertical dimensions increasedAdaptation minimal not sufficient to overcome malocclusion

FACIAL GROWTH DURING TREATMENT WITH FR APPLIANCE

Leth Nielsen AJO 1984

10 pts treated with FR showed maxilla retrognaticNo indication that mandibular growth was promotedChanges more in vertical planeNot necessarily improved the profile

Skeletal and dental changes following FR therapy on class II patients

MC NAMARA AJO 1985

100 pts treated for 24 months and compared with controlsNo change in maxillaIf considered pt A then slight retrusion of maxillaU6 forward movement reduced but not verticalL6 vertical movement

Skeletal and dental changes following FR therapy on class II patients

MC NAMARA AJO 1985

U1 tipped posteriorly some tipping of L1Downward movement of mandible noticed Some forward movement noticed in some pts

The effect of FR 4 in class 1 skeletal anterior open bite

ELIT ERBAY AJO 199520 treated and 20 controlsUseful in treatment Diminished AFH ,growth rate of AFH (3.9 mm)decreased ,& PFH increased (4.5 mm).

Caused forward and upward rotation of mandibleReduction in mandibular plane angles i.e Sn-GoMe,AnsPns-GoMe

Frankel-post vestibular shields caused inferior translation of mandible,growth at condyle increase in ramal length

Anterior part of mandible rotated upward because of the lip seal

Erbay’s study noted FR inhibited posteriors and improved the axial inclination of U1

Comparison of FR with other functional

appliances

FR Vs twin blocktoth/mc namara AJO 1999

4O PTS WITH TWIN BLOCK AND FR COMPARED TO CONTROLSResultsIncrease in mandibular length

Twin block – 3mm > controlsFR – 1.9MM

Vertical dimension & dentoalveolar changes TB > FRTB -mandibular skeletal & dentoalveolar changesFR – more skeletal and less dentoalveolar

FR Vs herbst appliancemc namara ,howe ajo 1990

45 herbst and 41 FR pts compared with controlsResults Both appliance – no effect on maxillaherbst – prevented vertical eruption and caused posterior movement of u6U1 lingual tipping- bothLower proclination L1 – herbst > FR mandibular length

Control - 2.1mm/yrHerbst - 4.8mmFR – 4.3mm

FR Vs fixed mechanotherapy

CREEKMORE,RADNEY AJO 1983FR compared to edgewise with headgearEdgewise had greater retractive force on maxillaRetraction of u1 > FR Retraction of L1Backward growth of condyle But 1.2mm < FRPog forward 1mm< FR

Fr therapy in cleft palate patients

keere,welch ajo 1981

9 pts treated with Fr for 6-18 monthsTo treat collapsed maxilla and cross biteResultsNot clinically useful in cleft patients

Frankel’s functional regulator


The occipital reference system

Orientation to the earth’s surface

The occipital reference system

Case 1Class2 Mandible retrudedNo lip seal+ VTOFR 1

8 yrs 4 months

1 1/2 year post retention

Case 1

Pre treatment After FR 1 ½ years post retention

Case 1bjork

Occipital reference system

Case 2

Class 2Mandibular retruded open bite no lip seal

8 yrs 5 months

22 yrs .9 years post retention

Case 2

Case 312 yrs

16 yrs

Case 3

Case 4Class 3Maxillary retrusion Mandibular prognatismNo lip seal Flaccid lips

6 yrs 5 months

7 yrs 3 months

Case 4

After FR 7 yrs post retention

Case 4

Case 5Class 3Incompetent lip valve retruded maxilla

5 years 7 months

Case 5

Case 6Class 2 div 1 skeletal open biteLips habitually parted hypotonic

9 yrs 10 months

20 yrs

Case 64 yrs 11 months

9 yrs

After FR

At 20 yrs

Case 7

Stability of transverse dimensions in post retention periods

Pre FR Post FR 7 years post retention

Case 7

Case 8

Pre FR

8 yrsPost FR 17 yrs

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