www.ajlobby.com Orthodontic Functional Appliances www.ajlobby.com www.ajlobby.com Orthodontic Functional Appliances Theory and Practice Dr Padhraig Fleming BDent Sc (Hons.), MSc, PhD, MOrth RCS, FDS (Orth.) RCS, FHEA Senior Clinical Lecturer/Hon Consultant Barts and The London School of Medicine and Dentistry Queen Mary University of London Institute of Dentistry Whitechapel London UK Professor Robert Lee BDS, MDS, FDS, MOrth RCS (Eng.) Hon Professor/Consultant Barts Health NHS Trust Barts and The London School of Medicine and Dentistry Institute of Dentistry Whitechapel London UK www.ajlobby.com This edition first published 2016 © 2016 by John Wiley & Sons, Ltd Registered Office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK 1606 Golden Aspen Drive, Suites 103 and 104, Ames, Iowa 50010, USA For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley‐blackwell The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988 All rights reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher Designations used by companies to distinguish their products are often claimed as trademarks All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book It is sold on the understanding that the publisher is not engaged in rendering professional services If professional advice or other expert assistance is required, the services of a competent professional should be sought The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions Readers should consult with a specialist where appropriate The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read No warranty may be created or extended by any promotional statements for this work Neither the publisher nor the author shall be liable for any damages arising herefrom Library of Congress Cataloging‐in‐Publication Data Names: Fleming, Padhraig S., author | Lee, Robert, 1947 July 26– , author Title: Orthodontic functional appliances: theory and practice / Dr Padhraig Fleming, Professor Robert Lee Description: Chichester, West Sussex; Ames, Iowa : John Wiley & Sons, Inc., 2016 | Includes bibliographical references and index Identifiers: LCCN 2016007082 | ISBN 9781118670576 (hb) | ISBN 9781118670545 (Adobe PDF) | ISBN 9781118670569 (epub) Subjects: MESH: Orthodontic Appliances, Functional | Malocclusion–therapy | Orthodontics, Corrective Classification: LCC RK521 | NLM WU 426 | DDC 617.6/43–dc23 LC record available at http://lccn.loc.gov/2016007082 A catalogue record for this book is available from the British Library Wiley also publishes its books in a variety of electronic formats Some content that appears in print may not be available in electronic books Set in 9.5/12pt Minion by SPi Global, Pondicherry, India 1 2016 www.ajlobby.com Contents List of contributors, vi Flexible fixed functional appliances, 93 Peter Miles Preface, vii Biological basis for functional appliance therapy, Development of functional appliances, 10 The role of genetics and environmental factors on the condyle in mandibular growth, 21 Peter A Mossey and Colin Larmour Functional appliance therapy: Indications and case selection, 28 Clinical use of the Twin Block appliance, 51 Transferring from functional to fixed appliances, 102 The use of functional appliances in the correction of Class III malocclusion, 119 Andrew DiBiase 10 Functional appliances: A focused review of the clinical evidence, 127 11 Cases, 135 Index, 160 Rigid fixed functional appliances, 70 Peter Miles v www.ajlobby.com List of contributors Dr Andrew DiBiase Dr Peter Miles Consultant Orthodontist East Kent Hospitals NHS University Foundation Trust Department of Orthodontics William Harvey Hospital Kent UK Senior Lecturer University of Queensland School of Dentistry Queensland Australia BDS, MSc, MOrth RCS, FDS (Orth.) RCS Dr Colin Larmour BDS, MSc, FDS RCPS, MOrth RCS, FDS (Orth.) Consultant Orthodontist University of Aberdeen Dental School and Hospital Aberdeen Royal Hospitals Aberdeen UK Mr Kieran McLaughlin MSc, Adv Dip Dent Tech BDSc, MDS, FCID Visiting Lecturer Seton Hill University Center for Orthodontics Pennsylvania USA Professor Peter A Mossey BDS, PhD, MOrth RCSEng, FDS RCSEd, FFD RCSI Professor of Orthodontics Division of Oral Health Sciences Dundee Dental Hospital and School Dundee UK Orthodontic Technician Barts Health NHS Trust Barts and The London School of Medicine and Dentistry Institute of Dentistry London UK vi www.ajlobby.com Preface Orthodontists are united in a quest to achieve functional, aesthetic and stable outcomes compatible with optimal health and stability of the dentition While the focus on aesthetics has intensified in recent years, the scope to alter facial growth, and in particular aesthetics, with orthodontic appliances has been disputed Functional appliance therapy offers the possibility of modifying growth, producing potentially more meaningful facial as well as inter‐arch change The skeletal and soft tissue variations in individuals are the main limiting factors in our ability to achieve the perfection we desire The use of functional appliances has been one of the more contentious areas within orthodontics for decades Paradoxically, these appliances have been relied on to produce skeletal change, dental change or a combination of both in pre‐adolescent, adolescent and indeed mature individuals for a century While users of these appliances have often harboured inconsistent objectives, the popularity of the appliances, while subject to regional variation, has been sustained and relatively consistent This book would not have been possible without the inspiration of early developers of functional appliance therapy and more recent innovators including the likes of William Clark, who have been integral in the refinement, simplification and popularity of functional appliances The authors have used functional appliances successfully both throughout our training and within our orthodontic practices in growing Class II patients Our aim within this textbook has been to highlight the rationale, indications and implications of this approach While a number of chapters are intended to have a clinical and practical focus, we hope to have maintained an evidence‐based underpinning throughout In particular, while we are aware of the limitations of much of the evidence pertaining to appliance therapy, irrespective of design, we emphasize best available e­vidence in the form of randomized studies Allied to the research focus, however, we attempt to supplement theoretical concepts with practical elements We are unapologetic in relation to our emphasis on the Twin Block, as this has proven a reliable, effective and user‐friendly appliance within our respective practices However, we endeavour to embody contemporary and universal approaches to functional treatment in an unbiased fashion, particularly by devoting chapters to both flexible and rigid fixed functional designs We therefore hope that a clinician without experience of either removable or fixed functional appliances will be capable of identifying appropriate patients, designing a suitable appliance and managing the care of a functional case effectively on the basis of this textbook To this end, we have documented a significant number of personally treated cases to augment the theory behind the biological basis and indications for functional treatment We would like to express our gratitude to a number of people who have influenced our lives and our professional careers In particular, we would like to pay tribute to our families, Caroline, Oliver, Sophie, Anne and Johnny Fleming, whose endless love and support are always appreciated We would also like to recognize Norma Lee and her children for their unlimited patience and understanding, and Dr Margaret Collins for encouraging and recommending this publication We are indebted to Dr Peter Miles, Dr Andrew DiBiase and Professor Peter Mossey for agreeing to write chapters within this book and for adding an extra dimension to our efforts Finally, we would like to acknowledge Mr Kieran McLaughln for his technical expertise and p­assion in fabricating and describing the technical aspects of a range of removable appliances Above all, we hope that you enjoy the book and that our efforts and approach have a bearing either on your treatment or on your expectations of treatment with functional appliances Dr Padhraig Fleming Professor Robert Lee vii www.ajlobby.com www.ajlobby.com 148   Orthodontic functional appliances GC Diagnosis A male patient (Figure 11.4) aged 12 years presented with a severe skeletal II profile due to micrognathia He had a history of a left condylar fracture in infancy, with resultant (a) underdevelopment of the left condyle and ascending ramus He had an associated mandibular asymmetry and a maxillary cant related to restricted vertical development of the left  maxilla The aesthetic impairment was compounded by functional issues, with a maximal inter‐incisal opening of 12 mm (a–d) (b) (c) (d) Figure 11.4  www.ajlobby.com Cases   149 Treatment Distraction osteogenesis was performed on the left mandibular ramus to improve the skeletal II deformity, while restoring height to the ascending ramus (e–j) Post‐surgically a hybrid activator was placed for a period of months to maintain Class II correction while allowing preferential vertical development of (e) (f) the left maxillary segment, promoting correction of the ­maxillary cant (k–o) Thereafter, fixed appliances were placed to improve the occlusion The maximal inter‐incisal mouth ­opening increased to 26 mm An advancement genioplasty may  be ­considered at skeletal maturity to improve the chin prominence further (p–t) (g) (h) (i) (j) (k) Figure 11.4  (Continued ) www.ajlobby.com 150   Orthodontic functional appliances (l) (n) (m) (o) Figure 11.4  (Continued ) www.ajlobby.com Cases   151 (p) (q) (r) (s) (t) Figure 11.4  (Continued ) www.ajlobby.com 152   Orthodontic functional appliances ML Diagnosis A female patient (Figure 11.5) aged 12 years presented with a skeletal II profile related to mandibular retrognathia and average vertical dimension in the late mixed dentition Lips were incompetent at rest with a lower lip trap (a) (b) The arches were generally well aligned, although there was an upper midline diastema with proclined maxillary incisors There was developmental absence of the lower right second premolar In occlusion, molar and canine relationships were Class II bilaterally with an increased overjet of 11 mm (a–i) (c) Figure 11.5  www.ajlobby.com (d) Cases   153 (e) (f) (g) (h) (i) Figure 11.5  (Continued ) Treatment A modified Twin Block appliance was worn on a full‐ time  basis for 12 months, resulting in full correction of the malocclusion and improvement in the skeletal pattern Thereafter, fixed appliances were placed to finish and detail the occlusion, with indefinite retention of the lower right ­second primary molar (j–y) www.ajlobby.com 154   Orthodontic functional appliances (j) (k) (l) (m) (n) (o) (p) (q) Figure 11.5  (Continued ) www.ajlobby.com Cases   155 (r) (s) (t) (u) (v) (w) (x) (y) Figure 11.5  (Continued ) www.ajlobby.com 156   Orthodontic functional appliances HF Diagnosis A female patient (Figure 11.6) aged 12 years presented with a mild skeletal III profile in the early permanent dentition There was a mild degree of both mandibular prognathism and ­maxillary retrusion She could achieve an edge‐to‐edge incisor (a) relationship, displacing anteriorly on closure into a frank reverse overjet The mandibular arch was spaced, while the upper arch was crowding, with space loss subsequent to premature loss of the maxillary right second primary molar There was a reversed overjet of mm in the displaced position (a–g) (b) (c) (d) (e) (f) (g) Figure 11.6  www.ajlobby.com Cases   157 Treatment A reverse Twin Block appliance was used for a period of 9  months to correct the incisor relationship, establishing a positive overjet and overbite with lateral open bites developing in the posterior regions bilaterally (h–m) Thereafter, fixed appliances were placed on a non‐extraction basis, with space re‐creation in the upper right side to facilitate eruption of the impacted second premolar Following treatment, facial harmony, dental aesthetics and good interdigitation were achieved (n–v) (h) (i) (j) Figure 11.6  (Continued ) www.ajlobby.com 158   Orthodontic functional appliances (k) (l) (m) (n) (o) Figure 11.6  (Continued ) www.ajlobby.com Cases   159 (p) (q) (r) (s) (t) (u) (v) Figure 11.6  (Continued ) www.ajlobby.com Index Page References in italics refer to Figures; those in bold refer to Tables achondroplasia, 23 acromegaly, 24 activator effect, 39, 40–42 activators, 70 see also under names development of, 10–12 Adam’s clasps, 52 AdvancSyncTM appliance, 89 age, 28–29 Andreasen activator, 3, 11, 12 Andresen‐Häupl appliance, 10, 12 animal experimentation, 3–5, antero‐posterior skeletal pattern, 30–31 BAMP see bone anchored maxillary protraction (BAMP) Bass appliance, 29 Bass Dynamax, 18 Bass Orthopaedic appliance, 18 Begg appliances, 28 vs Herbst, 90 Begg retainers, 114 Bimler appliance, 12 Bionator, 12, 13, 39, 89 bite jumping plane appliance, 10 bone anchored maxillary protraction (BAMP), 125 in Class III correction, 120 calcium ions (Ca++), role in condylar cartilage, 24 case‐control studies, 127, 127 case series and reports, 127 case studies, 135–160 cephalometry, 10 limitations of, 132 cervical vertebral maturation (CVM), 28–29, 29 chin caps, in Class III correction, 120 Clark Twin Block, 18 Class II correction consolidation, 103, 109–115, 111–115, 117 early use of Class II elastics, 13, 116 extraction pattern, 116 fixed appliance prescription, 116, 116 fixed functional appliance, 114 maintaining postured bite, 103, 111, 110–114 maintenance of removable functional appliance during early fixed phase, 111, 114, 114 part‐time functional appliance wear, 103, 111, 110–114 reinforced anchorage, 103, 109 upper removable appliance with inclined bite plane, 114 Class II correctors, 70 Class II effects, 102, 102 Class II elastics, 114, 116 Class III malocclusion, 119–125 aetiology, 119 case selection, 120 correction, 120 early treatment, 119 functional appliances for, 120–125 mechanisms, 120 Co‐Go‐Me angulation, 30 cohort studies, 127, 127 collagen, Type III, compliance, 35, 39, 132 Concorde facebow, 51 condylar growth during application of mechanical forces, 24 genetic control of, 22 condylar removal/injury, 22–23 condylar response to postural or mechanical changes, 23–24 condylar growth during application of mechanical forces, 24 effect of mandibular immobilization, 23–24 effects on glenoid fossa, 23 condylar transplantation experiments, 23 condyle functional/biochemical interface, 24 role in mandibular growth, 21–26 control group, use of, 128 controlled clinical trials, 127 cranial binding, 2, craniofacial morphology function and, craniofacial skeleton, growth of, 1–2 appositional and resorptive growth, 21 primary cartilaginous growth, 21 sutural growth, 21 cross‐sectional studies, 127 cyclic adenosine‐monophosphate (cAMP), in condylar cartilage, 24 Delta, 22 delta clasps, 52 Dynamax, 111, 115 ecological studies, 127 edge‐wise appliances, 10, 28 effectiveness of functional appliances, assessment, 129 endochondral ossification, environmental influences, 21, 23–25 effect of orthopaedic forces, 24 limitations of animal experiments, 24–25 ethical concerns, 128 Eureka Spring, 98 evidence‐based dentistry (EBD), 127 Orthodontic Functional Appliances: Theory and Practice, First Edition Padhraig Fleming and Robert Lee © 2016 John Wiley & Sons, Ltd Published 2016 by John Wiley & Sons, Ltd 160 www.ajlobby.com facial growth, 1–2 facial growth pattern, 29–30 cross‐sectional and longitudinal growth, 29 longitudinal method, 29 metric approach, 30 structural method, 30 fibroblast growth related factor (FGF8), finite element analysis, fixed appliances, transfer from functional appliances to, 102–117 cephalometric superimposition, 102, 107 Class II correction consolidation, 103, 109–115, 111–115, 117 early use of Class II elastics, 114, 116 extraction pattern, 116 fixed appliance prescription, 116, 116 fixed functional appliance, 114 maintaining postured bite, 103, 111–114 maintenance of removable functional appliance during early fixed phase, 111, 114, 114 part‐time functional appliance wear, 103, 111–114 reinforced anchorage, 103, 109 upper removable appliance with inclined bite plane, 114 planning, 102, 104–106 timing, 103, 109 fixed functional appliance (FFA), 18, 97–98, 98 see also flexible fixed functional appliances; rigid fixed functional appliances appliance efficiency, 99 comparison between, 89 effectiveness of removable vs., 132 molar correction in, 99 ulcer arising from, 99 fixed mandibular advancement appliances, 19 flexible fixed functional appliances, 93–99 see also Forsus FRD; Jasper Jumper follow‐up, long‐term, 128 Forsus FRD, 70, 93–95, 94, 99 Frankel appliance, 12, 14, 18, 135 Frankel appliance, 120 Fränkel functional regulator (FR3), 199–123, 121 construction and clinical management, 122, 123 effects of, 124 Frankfurt–mandibular plane angle (FMPA), 74 functional appliance long‐term effects, 131 research in context, 132 short‐term effects on skeletal pattern, 129, 129 functional matrix theory, 2, 21, 25 functional regulators, 12, 14–17, 18 Index   161 ginglymoarthroidal joint, glossoptosis syndrome, 10 growth variation, inter‐individual, 133 growth velocity charts, 28 haemorrhage, intracapsular, 22 hand–wrist radiographs, 28 Harvold appliance, 5, 6, 129, 131 Hawley retainers, 39, 114 headgear, 7, 10, 18, 51, 54, 55, 89, 93 activator effect and, 39 advantages of, 103 compliance, 35 vs Herbst appliances, 90 Herbst in combination with, 70, 72–74 mandibular shape and, 30 protraction, in Class III correction, 120, 125 headgear effect, 70, 72, 89, 94 headgear tubes, 39, 54, 93 Herbst appliance, 2–3, 5, 7, 18, 29, 30, 31, 39, 70, 70–72, 99, 131 vs activator, 89 vs Begg treatment, 90 class II correction, 72 in combination with headgear, 70, 72–74 vs fixed functional appliance, 25 vs headgear, 90 lower incisor changes, 73 proclination of lower labial segment in, 116 soft tissue effects, 74, 89 timing of treatment, 74, 74–77, 77–81, 81–85, 85–88 vs Twin Block, 89, 132 vertical effects, 73 Herren activator, 93 IGF‐1 (insulin‐like growth factor), 23 intention‐to‐treat (ITT) analysis, 132 intracapsular haemorrhage, 22 Jagged, 22 Jasper Jumper, 93, 99 Mandibular Anterior Repositioning Appliance (MARA), 70, 89, 99 mandibular condylar cartilage (MCC), 22 mandibular growth, 1–2, gene‐environmnent interaction, 25 maximal rate prediction, 28 modification, 25 overal control of, 25 relapse, 25 matrix‐metalloproteases (MMPs) MMP‐1, MMP‐13, maxillary growth, 1, maxillary incisor retroclination with functional appliances, 130, 130–131 maxillary restraint, median opening activators, 39, 46–48 meta‐analyses, high‐quality, 127 myotonic appliances, Sox9, 5, 22 Spee, 39 standing height measurements, 28 systematic reviews (SRs), 127 randomized controlled trials (RCTs), 127–129 bias in, 129 rapid maxillary expansion (RME), 125 removable functional appliance, effectiveness of, vs fixed, 132 reverse Twin Block appliance, 124 construction and management, 124, 124 effects, 125 rigid fixed functional appliances, 70–90, 92 see also Herbst; MARA rodents, experiments on, 4–5, Runx2, 5, 22 tantalum implants, Teuscher appliance, 7, 39, 55 TGF‐B1 (transforming growth factor beta‐1), 23 timing for therapy, optimal, 132 tissue‐borne appliance, 12 torquing spurs, 54–55 transverse skeletal abnormality, 31, 32–35 treatment duration, Twin Block appliance, 5, 7, 18, 30, 39, 51–70, 72, 99 advantages, 51 appliance design, 52, 54–55, 59–61 bite registration, 52, 57–58 breakages, 60 case selection, 51–52 dental features, 52, 53–55 general features, 51 skeletal features, 51 soft tissue features, 51 clinical use, 51–69 development, 51 early fixed phase, 111 fitting, 55, 58 follow‐up appointments, 58, 60, 63–67 vs Herbst, 89, 132 impressions, 52 lateral open bites following, 111 length of retention, 64 limitations, 51 modifications, 54–55 overjet and reversed overjet, 64, 67–68 post‐treatment retention, 68 proclination of lower labial segment in, 116 space planning for fixed therapy, 64 usage, 93 Twin Force appliance, 95, 98 Twist, 22 type I collagen, 22 Sella‐Nasion‐B point, 124 skeletal II discrepancy, 2–3, soft tissues, 31, 35 effects of appliances on, 131 van Beek appliance, 7, 39, 55 vascular endothelial growth factor (VEGF), vertical skeletal pattern, 30 visco‐elastic theory, 5–7 non‐randomized studies, 127–129 Norwegian system, 12 Notch1, 22 Notch3, 22 Notch4, 22 occlusal features, 31, 36–38 Osterix, 22 Overjet, 40–42, 44–45 Ovid MEDLINE®, 133 PAR (Peer Assessment Rating) score reduction, 74 part‐time functional appliance wear, 103, 111–114 advantages, 111–114 Peer Assessment Rating (PAR) score reduction, 74 primates, experiments on, 3–4 protraction headgear in Class III correction, 120, 125 www.ajlobby.com WILEY END USER LICENSE AGREEMENT Go to www.wiley.com/go/eula to access Wiley’s ebook EULA www.ajlobby.com ...www.ajlobby.com Orthodontic Functional Appliances www.ajlobby.com www.ajlobby.com Orthodontic Functional Appliances Theory and Practice Dr Padhraig Fleming BDent Sc (Hons.),... Andresen to explore the use of forward mandibular activation therapeutically Orthodontic Functional Appliances: Theory and Practice, First Edition Padhraig Fleming and Robert Lee © 2016 John Wiley &... continues to emphasize the major role of the functional matrix.7–11 Orthodontic Functional Appliances: Theory and Practice, First Edition Padhraig Fleming and Robert Lee © 2016 John Wiley & Sons,