FIXED FUNCTIONAL APPLIANCES GUIDE

FIXED
FUNCTIONAL
APPLIANCES

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Contents
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Introduction
Classification
Herbst appliance
Type 1, II, IV
Modifications of Herbst appliance
Cast splint herbst, Herbst with stainless steel crown,
The bonded Herbst appliance, The Acrylic splint Herbst
appliance , Cantileverd Herbst appliance, Modified Herbst
appliance for the mixed dentition, The EMDEN Herbst,
Edgewise Herbst Appliance, Mandibular Advancement
Locking Unit (MALU), Flip-Lock Herbst Appliance
Jasper Jumper
MARS Appliance

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Mandibular Protraction appliances :
MPA 1,MPA 2, MPA 3 , MPA4
Adjustable Bite corrector (ABC)
The Eureka Spring
The Churro jumper
The Universal bite jumper
The Saif Spring
Ritto Appliance
The Magnetic Telescopic Device

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The Twin force bite corrector
Alpern class II closers
Mandibular Corrector
The Mandibular Anterior Repositioning
Appliance(MARA)
Functional Mandibular Advancer
The Biopedic appliance
The Klapper Superspring II appliance
Forsus Fatigue resistant Device
CONCLUSION
REFERENCES

INTRODUCTION




Functional appliances are considered to be
primarily orthopedic tools to influence the facial
skeleton of the growing child in the condylar and
sutural areas.
A functional appliance by definition is an appliance
that produces all or part of its effect by altering the
position of the mandible.






These appliances also exert orthodontic
effects on the dentoalveolar area. The
uniqueness lies in their mode of force
application.
Functional orthopedic treatment seeks to
correct malocclusions and harmonize the
shape of the dental arch and oro-facial
functions.

Removable functional appliances have been there
over the years and clinically accepted.
But they have some disadvantages:
•normally very large in size,
•have unstable fixation,
•cause discomfort,
•lack tactile sensibility,
•exert pressure on the mucosa, reduce space for the
tongue, cause difficulties in deglutition and speech
often affect aesthetic appearance.
•the alteration in the mandibular posture creates
added difficulties.

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Fixed functional appliances have some advantages
over removable systems:
They are designed to be used 24 hour a day
They are smaller in size permitting better adaptation
to functions
Reduce the need for patient compliance
As they are fixed on the upper &lower arches,
transmit force directly to the teeth through support
system
Thus fixed functional appliances came into existence.
They are also known as non compliance class II
correctors.

Classification


According to the forces produced:
• Appliances producing pushing forces
• Appliances producing pulling forces


Appliances producing Pushing forces:
• These appliances
deliver a pushing
force vector
forcing the
attachment points
of the appliance
away from one
another.

Rigid:
1. Herbst Appliance and its modifications.
2. Mandibular protraction appliance
3. Ritto appliance
4. Biopedic appliance
5. Mandibular anterior repositioning appliance
6. Functional Mandibular Advancer


Flexible:
•
•
•
•
•
•
•
•

Jasper Jumper
Scandee tubular jumper
Flex developer
Amoric torsion coils
Churro Jumper
Adjustable Bite Corrector
Klapper Super Spring II
Forsus nitinol flat spring

Hybrid :
•
•
•
•

Eureka spring
Forsus fatigue resistant device
Twin force bite corrector
Sabbagh universal spring


Appliances Producing Pulling Force


These appliances act as a
substitute for elastic and create
a pulling force vector between
the points of attachment:
• SAIF (Severable Adjustable
intermaxillary Force) spring.
• Alpern class II closers.
• The caliberated force
module.


HERBST APPLIANCE

Norris M. Langford JR. The Herbst Appliance. JCO, Vol 1981, Aug, 558-561..
Larry W. White. Current Herbst Appliance Therapy. JCO, Vol. 1994 May, 296-309.

History




Developed by Emil Herbst (1872 – 1940) in
1900s.He lived in Bremen, Germany.
He called his appliance
“Okklusionsscharnier” or “Retentionsscharnier”
(Sharnier = Joint and Retention was added since the
upper part of the appliance served as a retainer for an
expanded maxillary dental arch.)

Hans Pancherz :History, Background, and Development of the Herbst Appliance, Semin
Orthod 2003,March page3-11





Herbst presented his appliance (original
banded design) for the first time at the 5th
international Dental Congress in Berlin in
1909.
However after 1934, very little was
published about the Herbst appliance, and
the treatment method was more or less
forgotten until it was rediscovered by
Pancherz in the late 1970s.


Basic Design of Herbst


The Herbst appliance is basically a fixed
bitejumping device for the treatment of skeletal
Class II malocclusions.



A bilateral telescope mechanism keeps the
mandible in an anterior-forced position during all
mandibular functions such as speech, chewing,
biting, and swallowing.



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



The tube is positioned in
the maxillary first molar
region and the plunger in
the mandibular first
premolar region.



The telescopes allow
mandibular opening and
closing movements and
when constructed properly
lateral jaw movements are
also possible.



Each telescope consists of a tube, a plunger,
2 pivots (axle), and two locking screws that
prevent the telescoping parts from slipping
past the pivots.


Original Herbst Appliance


Originally Herbst had the
telescope mechanism placed
upside down (with plunger
attached to the maxillary
molar crown and the tube on
the mandibular canine crown).



Tube had no open end , thus
not allowing the plunger to
extend behind the tube.



The telescoping parts of
the Herbst appliance were
curved conforming to
Curve of spee and were
made of German Silver or
gold( worn more than 6
months)


TIMING OF TREATMENT


Most favorable time to treat the
patients with the Herbst
appliance is at the peak of
pubertal growth spurt (Pancherz,
Hagg, 1985).



Pancherz & Hagg (1988):
Indicated that the patients treated
at the initial closure of the middle
phalanx of the third finger (MP3FG) had the greatest amount of
condylar growth.



Ruf, Pancherz March 2003, the ideal period for the
herbst appliance treatment is in the permanent
dentition or just after the pubertal peak of growth
corresponding to the skeletal maturity stages FG
to H of the middle phalanx (implying the
precapping to preunion stages of epiphysis and
diaphysis)



Because mandibular growth stimulation using
the herbst appliance is also possible in post
adolescent young adult subjects, a new concept of
Class II therapy is proposed in which the Herbst
appliance is used as an alternative to orthognathic
surgery in Class II subjects.

Sabine Ruf, Hans Pancherz: When is the ideal period for Herbst therapy-Early or Late?
Semin Orthod 2003,March,pagewww.indiandentalacademy.com
47-56



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-alignment treatment 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 II malocclusion is
transferred to a Class I malocclusion by means of the Herbst
appliance.



STEP 2. ORTHODONTIC PHASE. Tooth irregularities and arch
discrepancy problems are treated with a multibracket appliance
(with or without extractions of teeth).



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



STEP 1. ORTHODONTIC PHASE. Alignment of
the anterior maxillary teeth by means of a
multibracket orthodontic appliance.



STEP 2. ORTHOPEDIC PHASE. Normalization
of sagittal jaw base relationships and
transformation of the Class II malocclusion into a
Class I malocclusion by means of the Herbst
appliance.



STEP 3. ORTHODONTIC PHASE. Tooth
irregularities and arch-discrepancy problems are
treated with a multibracket appliance (with or
without extractions of teeth).

Types of Herbst Appliance


The original design since the seventies has
maintained its general shape with only a
few modifications taking place with regard
to methods of application (Type I, II and
IV).




Type I is characterized by
a fixing system to the
crowns or bands through
the use of screws. This is
the most common 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 has a fixing system
that fits directly onto the
archwires through the use
of screws. This method of
application has the
disadvantage of causing
constant fractures in the
archwires due to lack of
flexibility together with the
difficulty in lateral
movements and the stress
placed on the archwires
through activation.




Type IV has a fixation system
with a ball attachment, which
allows greater flexibility and
freedom of mandibular
movement.



A disadvantage in relation to
other similar appliances is the
fact that it needs brakes to
stabilize the joint. These brakes
are small and sometime difficult
to fit.


Anchorage forms of the Herbst
appliance


Anchorage forms used from 1909

to 1934:






The standard anchorage system
used by Herbst:
Crowns or caps were placed on
the maxillary permanent first
molars and mandibular first
premolars (sometimes canines).
The crowns/caps were joined by
wires that run along the palatal
surfaces of the upper teeth and
the lingual surfaces of 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 were soldered to the palatal
arch wire as were the upper
molars.



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

Early mixed dentition
anchorage system:


When using the Herbst appliance
in the early mixed dentition,
Herbst had the following
solution:



In the maxilla, the permanent
central incisors were used for
anchorage instead of the cuspids.



In the mandible, crowns were
placed on the first permanent
molars and bands on the 4
permanent incisors.


Late mixed dentition anchorage system




Canines are used as anchorage
teeth instead of incisors.
Buccal mucosa at the corner
of the mouth is prone to
ulceration when mandibular
canine is used as an abutment
tooth for the plunger.


Anchorage forms used from 1979
onward:


Pancherz originally used a banded type of Herbst
appliance.Individually made stainless steel bands of a thick
material (0.15- 0.18mm) were used.
Simple anchorage system
2. Increased anchorage system
3. Total anchorage system
1.


Simple anchorage system


Maxilla- Bands are placed
on 1st permanent molars
and first premolars. Joined
on each side by sectional
arch wires.



Mandible- Premolars are
banded and connected with
a lingual sectional arch.









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
incorporating more teeth.


2. Increased anchorage system


Maxillary and mandibular front
teeth were incorporated in the
anchorage system by labial
sectional 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 the acrylic
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 not
recommended because the main
advantage of a fixed Herbst
appliance is that it works 24
hours a day without the
dependence on patient
cooperation.

MODIFICATIONS OF THE HERBST
APPLIANCE
• In patients with class II
malocclusions who have
narrow maxillary arches,
expansion can be performed
using the Herbst appliance
by soldering a quad helix
lingual arch wire or a rapid
palatal expansion device to
the upper premolar and
molar bands or to the splint.

Herbst with stainless steel
crowns


Norris M. Langford,
(1982 JCO) suggested
using stainless steel crowns
on the upper first molar and
the lower first premolar and
canine for the Herbst
appliance which are
superior to banding, in that
they are resistant to
breakage and becoming
loose.

The cast splint herbst







The bands are replaced by splints, cast from cobaltchromium alloy are cemented to the teeth with GIC.
The upper and lower front teeth are incorporated
into the anchorage through the addition of sectional
arch wires. The cast splint appliance
ensures a precise fit on the teeth
is strong and hygienic
saves chair time
Causes very few clinical problems


The bonded Herbst appliance (1982)


The bonded Herbst appliance eventually
evolved into the acrylic splint Herbst
appliance



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

Raymond P. Howe. The Bonded Herbst Appliance. JCO, Vol. 1982 Oct. 663-667.



The maxillary splint
covers all available
maxillary teeth with
exception of the central
and lateral incisors



The occlusal thickness
of the maxillary splint is
kept to a minimum, so
that the cusps of the
posterior teeth perforate
the splint

Cantileverd Herbst appliance


This was a design given by
Larry W. White, 1994.



Buccal cantilever wire is
made by doubling .045" wire
and soldering the two strands
together.
Larry.W. White :Current Herbst Appliance Therapy:JCO 1997,May(296 - 309)






Advantage :
• This design is
particularly useful
when mandibular
bicuspids are absent or
the primary molars
cannot withstand
functional forces.


Modified Herbst appliance for the mixed
dentition


Introduced by Philip Goodman and Paul Mc
Kenna, 1985



They stated the middle phalynx development
may, indicate optimal treatment timing, but
the patient’s bicuspids are not erupted enough
to receive either bands or crown.

Philip Goodman, Paul Mckenna. Modified Herbst Appliance for the Mixed Dentition. JCO,
Vol. 1985 Nov. 811-814.

Also they encountered a
modification where stainless
steel crowns are fitted on the
upper first permanent molars
and bands on the lower first
molars and incisors.


The deciduous first and
second molars are free to
exfoliate through the
framework


The EMDEN Herbst – a fixed removable
Herbst appliance. Tarek Zreik 1994


Introduced by Tarek Zreik, 1994 to
overcome breakage problems, he had
with the Herbst appliance.



This modification makes the Herbst
more durable, simple and hygienic.

Tarek Zreik. A Fixed-Removable Herbst Appliance. JCO. Vol. 1994 Apr. 246-248.





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.


Edgewise Herbst Appliance
This design was given by Terry Dischinger, 1995




The Edgewise Herbst Appliance corrects
Class II malocclusions rapidly and without
the need for patient cooperation. It allows
orthodontic tooth movements during
orthopedic correction and a smooth
transition from Herbst treatment into the
edgewise finishing appliance. The new
appliance is more clinically efficient than
previous models and is easily incorporated
into an edgewise practice.


Herbst with Mandibular
Advancement Locking Unit (MALU)
In the upper arch of the
edgewise-Herbst MALU
appliance, only the first
molars are banded, with .
051" headgear tubes.
A palatal arch can be
used in cases of
overexpansion.

In the lower arch, the first
molars are banded, and the
anterior segment is bonded
from cuspid to cuspid with .
022" brackets. The bicuspids
may be left unbracketed to
help in settling the occlusion
and locking in the mandible.
The mandible can be
progressively advanced using
1-5mm spacers.

Flip-Lock Herbst Appliance


A new design, the FlipLock Herbst appliance,
reduces the number of
moving parts that can lead
to breakage or failure. It is
easy to use and more
comfortable for the patient
than the conventional
cantilever-type Herbst.
Instead of a screw
attachment, it has a balljoint connector, and it
needs no retaining springs.

Robert A. Miller. The Flip-Lock Herbst Appliance. JCO, Vol. 1996, Oct, 552-558.



The first generation was
made from a dense
polysulfone plastic but
breakage occurred
because of the forces
generated within the
ball-joint attachment




In the second
generation, the plastic
was replaced with
metal






The third generation is
made of a horse-shoe
ball joint .
This system has
proved to be more
efficient than the
previous models, both
in terms of application
as well as its resistance
to fracture

End of rod is crimped
onto mandibular ball.
Advantages :
Less irritation
Reduces the number
of moving parts that
can lead to breakage
or failure

TRETMENT EFFECTS



SAGITTAL

VERTICAL

• DENTAL
• SKELETAL

-DENTAL
-SKELETAL


SAGITTAL CHANGES
Skeletal:

I.

•

1. Restrains maxillary growth and decrease
of SNA angle.

•

2. Increases mandibular length
This finding is in agreement with several bite
jumping experiments in growing monkeys
and rats.





2. Evidence of temporomandibular
growth adaptations in Herbst
treatment:
Three adaptive processes in the TMJ are
thought to contribute to the changes of
mandibular position.
1) Condylar remodeling.
 (2)Glenoid fossa remodeling;
 (3) Condylar position changes within
the fossa.


Kurt Popowich, Brian Nebbe, Paul W. Major. Effect of Herbst treatment on
temporomandibular joint morphology : A systematic literature review. AJO,Vol.123, No.4,
2003 Apr. 388-394.

Animal studies


Peterson and Mc Namara :



Evaluated histologically the TMJ, glenoid fossa,
and the posterior border of the mandible in
juvenile Rhesus monkeys whose mandibles had
been positioned forward with a Herbst
appliance.

Peterson and McNamara (semin orthodontics 2003)



The following adaptations were observed:-



Condyle remodelling :
• Increased proliferation of condylar cartilage was
noted. It occurred primarily in the posterior and
posterosuperior regions of the condyle.
Glenoid fossa remodelling :
• Significant deposition of new bone on the anterior
surface of the postglenoid spine occurred, indicating
an anterior repositioning of the glenoid fossa.



• 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:


Paulsen et al (1995) :



Analysed TMJ changes in a single case of
Herbst treatment in late puberty using CT
scanning and OPG.
Three months after insertion of the
appliance CT-scanning and OPGs of the
TMJ revealed new bone formation as a
double contour in the articular fossa and on
the posterior part of the condylar process as
a result of adaptive bone remodeling.






Roentgenograms of the
mandibular joints (N = 33).
A, Before treatment. B,
After active treatment. C,
After the retention period.
A double contour of the
fossa outline was found on
roentgenograms. The
double contour disappeared
in all cases during the
retention period.


Ruf and Pancherz :
Analysed three possible adaptive TMJ growth processes
contributing to increase in mandibular prognathism
accomplished by Herbst treatment :
Condylar remodeling
Glenoid fossa remodeling
Condyle fossa relationship changes.




Aidar et al (AJO 2006) assesed the TMJ disc position with MRI
after 12 month period of herbst appliance therapy in 20 ClassII
div1 patients. They found mild changes in position of the disc
with slight tendency towards retrusion due to mandibular
advancement which returned to normal after appliance removal.
These changes were in the normal phsiological limits as
evaluated in short term.

Sabine Ruf:Short and Longterm effects of the Herbst appliance onTemporomandibular
joint function,Semin Orthod 2003 March page 74-86.

Dental:


Dental changes seen during Herbst appliance
treatment are basically a result of anchorage loss in
the two dental arches. The telescope mechanism
produces a posterior directed force on the upper teeth
and an anterior directed force on the lower teeth,
resulting in distal tooth movements in the maxillary
buccal segments and mesial tooth movements in the
mandible.


1. Mandibular teeth are moved
anteriorly


Proclination of lower anteriors. Mandibular
incisors proclined on an average of 6.6° during 6
months


2. Maxillary molars are moved distally .


The effect of the Herbst appliance on maxillary
molar teeth is essentially comparable with that of
a high pull headgear. The teeth are both
distalized and intruded.



Normally, the dental changes occurring during
Herbst appliance treatment would not be
desirable. Distal tooth movements in maxillary
buccal segments could however, be desirable in
cases with anterior crowding

3) Mesial movements of lower molars
4) 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 movement of the
mandibular molars.



5. Arch perimeter:



Because of the distalizing forces of the
telescope mechanism of the Herbst appliance
on the upper 1st molars and the anteriorly
directed forces on the lower front teeth, the
maxillary and mandibular arch perimeters
increase during treatment.
Arch perimeter changes are, however, of a
temporary nature because settling of the teeth
during the immediate post treatment period.




6. Arch width


During treatment the maxillary and
mandibular dental arches expand laterally in
both canine and molar areas. The
expansion is more marked in the maxilla
than in the mandible.


b) Vertical changes



Dental
Skeletal




Dental:

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

Overbite reduction is primarily accomplished by
intrusion of lower incisors and enhanced
eruption of lower molars.



Part of the registered changes in the vertical
position of the mandibular incisors results from
proclination of these teeth.



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



Skeletal:



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



Increase in gonial angle – this may be due to a more
sagittaly directed growth of the condyle or it may
result from resorptive bone changes in the gonion
region, probably as a consequence of an altered
muscle function during bite jumping .


INDICATIONS FOR TREATMENT


Pancherz (AJO Jan 1985); indicated
that Herbst appliance should be used
only in growing individuals.



Should not be used in non growing
subjects because.
Skeletal alterations will be minimal.
More of dentoalveolar changes.
Increase risk of developing dual bite.

1.
2.
3.




Postadolescent patients:
• Who have passed the maximum pubertal growth
spurt and have still some growth potential left,
treatment with the Herbst 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 or
impossible 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)
patients after surgery
For prevention of bruxism
For diseases of the TMJ


The Jasper Jumper :


This interarch flexible force module allows
patient greater freedom of mandibular
movement than is possible with the original
bite jumping mechanism of Herbst : Dr. James
Jasper




Force Module :



The force module, analogous to the
tube and plunger of the Herbst bite –
jumping mechanism and is flexible.



The force module is constructed of
stainless steel coil of spring attached
at both ends to stainless steel end
caps in which holes have been drilled
in the flanges to accommodate the
anchoring unit.



This module is surrounded by an
opaque poly urethane covering for
hygiene and comfort.

Principle of action :


When the force
module is straight, it
remains passive. As
the teeth come into
occlusion the spring
of the force module
is curved axially
producing a range of
forces from 1 to 16
ounces.




Attachment to the main
arch wire :



When the jumper mechanism is
used to correct a class II
malocclusion, the force module is
attached Posteriorly to the
maxillary arch by a ball pin
placed through the distal
attachment of the force module.



The module is anchored
anteriorly to the lower arch wire
(0.018”x 0.025” ).




Bayonet bends are placed
distal to the mandibular
canines and a small Lexan
ball is slipped over the
archwire to provide an
anterior stop.



The mandibular archwire is
threaded through the hole in
the anterior end cap and then
ligated in place.



The first and second bicuspid
brackets are removed to
allow the patient greater
freedom of movement.

2) Attachment auxiliary archwire :


Incorporates the use of “out
rigges” which are 0.016 x
0.022” (0.018” slot) or 0.018 x
0.025” (0.022” slot) auxiliary
sectional wires.



The sectional arch is looped
over the main archwires
anteriorly between the first
premolar and canine.





Posteriorly into the lower first
molar band.

Attachment in the Mixed dentition






The maxillary attachment is as
the original attachment.
The mandibular attachment
includes an archwire that extends
from the brackets on the lower
incisors, posteriorly to the first
permanent molars, by passing the
region of the deciduous canines
and molars.
In a mixed dentition patient the
use of a transpalatal arch and fixed
lower lingual arch is mandatory to
control potential unfavorable side
effects.

Selection and installation of the
modules


Determination of proper length
of force module. Twelve
millimeters are added to
measurement of distance
between mesial aspect of facebow tube and distal aspect of
Lexan ball. In this example,
distance from ball to face-bow
tube is 20 mm. Thus 32 mm
module should be selected.

Activation of the module for orthodontic
and orthopedic effect :


If molar distalization is desired. The jumper is
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.


Treatment effects :



Maxillary adaptations :
i) Headgear effect :
• One treatment effect produced most easily is distalization
of the upper posterior segment or the headgear effect.
• For this the maxillary arch wire must not be cinched or
tied back, but remain straight and extend past the buccal
tubes.
• Involves light forces (2-4 ounces)
• Minimal changes in the mandibular dentition.
• This effect can be produced in actively growing as well as
adult patients.


Retraction of anterior teeth


Upper canines alone or all the
six anterior teeth can be
retracted in both extraction and
non-extraction patients with a
NiTi coil or an intramaxillary
elastic, with the posterior
maxillary dentition supported
by the force module.



Cuspid retraction mechanics:
As Jumper pushes ball pin
distally, molar anchorage is
maintained and cuspid is
retracted along archwire.



Advantages :



The attachment can be made in the office
laboratory, and placement can be delegated to an
assistant.
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 mandibular
molars.









Disadvantages :

Unattached bicuspids tend to
erupt above the occlusal plane
as the anterior teeth are
intruded.



When only the lower 1st
bicuspid bracket used to be
removed as originally
suggested by Dr. Jasper, Jaw
opening used to be limited as
the lower portion of the jumper
tends to bind at the 2nd
bicuspid.



Replacement of a broken jumper required
removal of the entire archwire.



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



Removing the Jumper for an occlusal check is
time consuming.



In an extraction case, it is difficult to close
spaces because the jumper must be attached to
the arch before closing loops.


MARS Appliance






Mandibular advancing
repositioning splint.
This appliance was introduced
by Ralph M Clements and Alex
Jacobson.1982
The MARS appliance is
composed of a pair of telescopic
struts, the ends of which are
attached to the upper and lower
archwires of a multi-banded
fixed appliance by means of
locking device.

Raiph M. Clements, Alex Jacobson. The MARS appliance. AJO-DO, Vol. 1982 Dec. 445-455.

•
•

Allignment must be complete.
The teeth in the respective arches
should be aligned, with correct axial
inclinations, prior to attachment of the
appliance.

•

The MARS appliance should be
attached only to the heaviest
rectangular arch wires that can be
accommodated by the brackets and
tubes. The heavy arch wire prevents
breakage at the point of attachment as
well as excessive intrusion in the
region of the mandibular canines.

•

The mandibular arch wires should be
securely tied back to the terminal molar
before attachment of the MARS
appliance.

• Unlike the Herbert appliance, the
MARS appliance :







Requires neither soldering nor extensive lab
procedures.
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
is tied back to the terminal molars)
Is easily removed.



Disadvantages :



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



Disarticulates the posterior segments from 1
to 3 mm



Needs to customize the appliance for each
patient.


Mandibular Protraction
appliances :




This appliance was
developed by Carlos
Martin Coelho Filho
His inability to purchase
some of the newer class II
corrective appliances in
northern Brazil led him to
develop these group of
appliance that reposition
the mandible forward.

Carlos Martins Coelho Filho. Mandibular Protraction Appliances for Class II Treatment.
JCO, 1995, May; 319-336.







They have proven effective in treating Class I
patients with exaggerated overjets and Class II
subdivision patients where only one side needs
correction.
Their advantages include ease of fabrication,
low cost, infrequent breakage, patient comfort,
and rapid installation.
But they are not claimed to be superior but are
only treatment alternatives to Class II therapies.

Functioning of the appliance MPA -1

Appliance slides distally along
mandibular archwire and
mesially along maxillary
archwire upon opening.
But frequent dislodgment
of molar bands led Filho to
develop the 2nd protraction
appliance. (MPA n.o 2)


MPA No. 2
Improper relationship of
wires is prevented by coil.
Maxillary archwire has
occlusally directed circles
against molar tubes;
mandibular archwire has
occlusal circles 2-3mm distal
to each cuspid.
Filho C.M. Clinical Applications of the Mandibular Protraction Appliance. J. Clin. Orthod.
1997; 31: 92 – 102.



Advantages :



Easily fabricated at chair side, with ordinary
inexpensive wires.



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



No impression or wax bite registrations are
needed.



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



Much smaller and thus more comfortable.



Permit a greater range of motion and are less
restrictive of movement

MPA-3






CARLOS M. COELHO FILHO

Many of the limitations of
the first two MPA designs
have been overcome with
the development of the MPA
No. 3.
This version eliminates
much of the archwire stress
and permits a greater range
of jaw motion while keeping
the mandible in a protruded
position.

Carlos M. Coelho Filho. The Mandibular Protraction Appliance No.3. JCO, Volume 1998, June;
379-384.

Advantages of MPA n.o 3 over the
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 or dento
alveolar movement
Causes less breakage.

MPA IV








The latest version,
the MPA IV, is made
up of the following
parts:
• “T” tube
• Upper molar
locking pin
• Mandibular rod
•Mandibular archwire

Carlos M. Coelho Filho. Mandibular Protraction Appliance IV. JCO, Vol. 35, Jan. 2001, 1824.

This fourth version seems to
be as efficient as its
antecedents, but is much more
practical to construct, easy to
manipulate, and comfortable
for the patient.


Adjustable Bite corrector (ABC)


Introduced by Richard P. West



The appliance essentially consists of:



A stretchable closed coil spring and
internally threaded end cap



nickel titanium wire in the centre lumen
of the spring.



The closed coil spring is made of 0.01 8”
stainless steel, and will stretch to about
25% beyond its original length without
permanent deformation.
Richard P. West. The Adjustable Bite Corrector. JCO, Vol. 1995 Oct. 650-657.

The ABC can be used on
either side of the mouth
with a simple 180° rotation
of the lower end cap to
change it orientation.
Functions similar to the
Herbst and Jasper Jumper
but also incorporates
several useful features like
a) Universal right and left
b) Adjustable length and
force





After the patient has
postured forward into an
improved profile with ideal
overbite / overjet the point
of the gauge is placed into
the mesial opening of the
headgear tube.
The size is then read at
point about 3mm below the
contact between lower
cuspid and first premolar
using the correct appliance
size ensuring optimum
force delivery.

The Eureka Spring







Introduced by John DeVincenzo
The main component of the Eureka
spring is an open wound coil spring
encased in plunger assembly
The ram is made from a special work
hardened stainless steel that has been
precision machined with 3 different radii.
At the attachment end the ram has either a
closed or an open ring clamp that attaches
directly to the archwire.
John Devincenzo. The Eureka Spring : A New Interarch Force Delivery System. JCO, Vol.
1997, Jul, 454-467.

Advantages


It has esthetic acceptability because of its small size and lack
of protuberances into the buccal vestibule, as it is almost
invisible.



Resistance to breakage: produces forces of only 140g-170g at
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 mm as when
sleeping or when the mandible is thrust forward as 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.

The churro jumper
Introduced by Ridhardo Castanon, Mario S
Valdes and Larry White.
The Churro Jumper furnishes orthodontists
with an effective and inexpensive alternative
force system for the anteroposterior
correction of class II and class III
malocclusions.
It was developed as an improvement of the
MPA of Coelho.
Although the churro jumper was conceived
as an improvement to the MPA, it functions
mere like a Jasper Jumper.
Castañon R., Valdes M., White L.W. Clinical use of the Churro Jumper. J. Clin. Orthod.
1998; 32: 731 – 45.



Churro needs space to
slide on the mandibular
archwire, at least the first
premolar brackets should
be omitted. It is usually
advantageous to place a
buccal offset in the wire
just distal to the canine
bracket so that the jumper
also has buccal clearance,
which permits unrestricted
sliding along the wire


The length of the jumper is
determined by the distance
from the distal of the
mandibular canine bracket to
the mesial of the headgear tube
on the maxillary molar band,
plus 10-12mm. This
measurement is transferred to
the Churro Jumper, with the
coil closer to the canine bracket
than to the headgear tube.


THE AMORIC TORSION COILS
• This appliance is made up of two springs, one of which slides inside the
other.
• They are intermaxillary springs without covering and have a simplified
application system of rings on the ends.
• These rings are fixed to the upper and lower arches with double
ligatures.
• The force exerted by the appliance is variable in accordance with the
fixing points on the arch


The universal bite jumper


Introduced by Xavier Calvez



This is a fixed functional which
can be used in all phases of
treatment, in the mixed or
permanent dentition and with
removable or fixed appliances.



This jumper also uses a
telescoping mechanism, can also
have an active coil spring if
necessary.
Xavier Calvez. The Universal Bite Jumper.
JCO. Vol. 1998, Aug. 493-500.



Its like a Herbst but is smaller in
size and more versatile



An active coil spring can be
added if necessary
It is fitted in the patient’s mouth
and cut to the appropriate length
for the desired mandibular
advancement.
Activations are made by crimping
2-4 mm splint bushings onto the
rods. UBJs with nickel titanium
coil springs do not need to be
reactivated.






Advantages





It is simple, sturdy, and inexpensive.
Inventory requirements are minimal--the UBJ can
be used on either side of the mouth, and there is
only one size, since it is cut to the desired length
for each case.
It can be used at any stage of treatment --in the
early mixed dentition to obtain an immediate
mandibular advancement before any dental
alignment, or in the permanent dentition for fixed
functional treatment.

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 and finally
called Saif spring.



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



Various attachments can be placed through these
loops to secure the springs to deliver either class II
or class III 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 correction observed.

The Ritto Appliance



The Ritto Appliance can
be described as a
miniaturized telescopic
device with simplified
intraoral application and
activation




The appliance is fixed
onto a prepared lower
arch and is activated
by sliding the lock
along the lower arch in
the distal direction and
then fixing it against
the Ritto Appliance.


The Magnetic Telescopic Device


Ritto A.K.



This consists of two tubes and two
plungers with a semi-circular section
and with NdFeB magnets placed in
such a manner that a repelling force is
exerted.



Fitting is achieved by using the
MALU system.



This appliance has the advantage of
linking a magnetic field to the
functional appliance. Its main
disadvantages are its thickness, the
laboratory work necessary to prepare
it and the covering of the magnets.

THE TWIN FORCE BITE
CORRECTOR




This appliance differs from others in
form and constitution because it has
two internal coil springs. It consists
of two joint telescopic systems. At
the superior level it is fixed with a
ball pin that is fitted into the buccal
tube of a molar band.
The placement in the lower arch is
slightly different; it involves a
fitting-in system that is later fixed
with a screw to the inferior arch.
Normally it is placed distal to the
lower cuspid.

ALPERN CLASS II CLOSERS









It is one of the most recent.
It is predominantly applied in Class
II correction and as a substitute for
elastics.
It consists of a small telescopic
appliance with an interior coil spring
and two hooks for fixing
It functions in the same way as
elastics and, similarly, is fixed to the
lower molar and to the upper cuspid.
It is available in three different sizes.
Its telescopic action enables a
comfortable opening of the mouth.


Mandibular Corrector (JCO 1985)


Introduced by Marston Jones



It is a fixed functional that uses
bilateral piston and plunger
telescopic mechanism to reposition
the mandible anteriorly and is
directly attached to archwires of a
multibanded fixed appliance.



Connectors holding the
repositioning arms are attached to
the archwires distal to the lower
cuspid brackets and mesial to the
tubes on the terminal upper molars.

The Mandibular Anterior Repositioning
Appliance(MARA)
Is probably the most recent fixed functional
appliance to become commercially available
In the essence, it is an ingenious way to
encourage patients to keep their mandibles thrust
forward to avoid intentionally created, buccally
placed occlusal interference’s.
These interference’s are produced when a
horizontally adjustable vertical bar attached to
the buccal surface of a maxillary first molar
stainless steel crown, hits a buccally protruding
horizontal bar extending from the lower first
molar stainless steel crown.



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.












A study was done by Pangrazio-Kulbersh et
al(AJO 2003) which showed that the MARA
produced measurable treatment effects on the
skeletal and dental elements of the craniofacial
complex.
The effects of the MARA treatment were then
compared with those of the Herbst and Frankel
appliances. The treatment results of the MARA
were very similar to those produced by the Herbst
appliance but with less headgear effect on the
maxilla and less mandibular incisor proclination
than observed in the Herbst treatment group

Functional Mandibular Advancer







Kinzinger,Ostheimer, Diederich
It has a propulsive mechanism that
resembles the Mandibular anterior
repositioning appliance, but differs in its
mode of action and intraoral activation.
It relies on the principle of inclined planes
that are placed in the buccal corridor spaces
that will not hinder swallowing or
articulation.
The protrusion guide pins are fitted to the
upper portion of the apliance at a 60 degree
angle to horizontal, ensuring active, forward
mandibular guidance during even partial jaw
closure.
Kinzinger, Deidrich: Bite jumping with the functional mandibular Advancer, JCO December
2005 page 696-700



Reactivation in the sagittal plane is
done simply by moving the guide
pins to a more forward threaded
support sleeve. This gradual
activation allows patients
particularly adults to adjust to the
appliance.



Kinzinger, Diederich reports the use
of FMA in a 16 year old male with
Class II div2 and for just 3 months
the patient was able to protrude the
mandible significantly forward from
the therapeutic position.

Advancement in
therapeutic positions

Maximum protrusion of
mandible after 3 months

The Biopedic


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



It consists of buccal attachments
soldered to maxillary and mandibular
molar crowns.



The attachments contain a standard
edgewise tube and a large 0.070 inch
molar tube. Large rods pass through
these tubes.



The mandibular rod inserts from the
mesial of the molar tube and is fixed at
the distal by a screw clamp. By
moving the rod mesially the appliance
is activated.



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



Although, it appears that there would be
limitation of mandibular opening, it is not so.
The design works more in harmony with the arc
of mandibular opening.


The Klapper Superspring II








Introduced by Lewis Klapper in 1997,
for correction of class II malocclusions.
On first glance, it resembles a Jasper
Jumper with a substitution of a cable for
the coil spring. In 1998 the cable was
wrapped with a coil and the Klapper
superspring II was the result.
Only two sizes are required (left and
right sides are not interchangeable) and
breakage is less frequent.
However it differs significantly from
the Jasper Jumper at the molar
attachment.

Lewis Klapper. The SUPER spring II : A New Appliance
for Non-Complaint Class II Patients. JCO, 1999, 33, No.1,
50-54.

Forsus : Fatigue resistant Device


This is an interarch push
spring which produces about
200g of force when fully
compressed.



The distal end of the FRD`s
push rod inserts into the
telescopic cylinder and a
hook on the mesial end is
crimped directly to the
archwire near the canine or
premolar brackets.
William Vogt:The Forsus Fatigue Resistant Device, JCO 2006 June page 368-376



The push rod has a built in stop
that compresses the spring
when the patients mouth
closes. The force is then
transferred to the maxillary
molars using the mandibular
arch as the anchorage unit.



The L-pin is inserted in the
eyelet of the telescoping spring
and is threaded through the
molar headgear tube from
distal to mesial and
cinhed,leaving 2mm slack.



The mesial hook is looped over
the mandibular arch wire and
crimped shut.

 Another device from the same company

is the FORSUS NITINOL FLAT
SPRING which presents a Nitinol flat wire
instead of the coil.
 The appliance’s flat surface is more

esthetically acceptable and it offers more
comfort.
 The Forsus Nitinol Flat Spring

is slim, flat and made of SuperElastic Nitinol. Nitinol is always at
work, delivering consistent forces.
Force levels remain constant from
the initial setup to the time of
removal. The result is faster, more
efficient treatment.

`



Heinig N, Goz G 2001 reported the use of Forsus spring over a
period of 4 months to treat 13 patients with an average age of
14.2 years with Class II malocclusion.



RESULTS: lateral cephalograms showed that dental effects
accounted for 66% of the sagittal correction. The sagittal
occlusal relations were improved by approximately 3/4 of a cusp
width to the mesial on both the right and left side as a result of
distal movement of the upper molars and mesial movement of the
lower molars. Retrusion of the upper and protrusion of the lower
incisors reduced the overjet by 4.6 mm. Intrusion and protrusion
of the lower incisors reduced the overbite by 1.2 mm.

Heinig N, Goz G: Clinical application and effects of the Forsus spring. A study of a new
Herbst hybrid, J Orofac Orthop. 2001 Nov;62(6):436-50.



The occlusal plane was rotated by 4.2 degrees in clockwise
direction as a result of intruding the lower incisors and the
upper molars. The maxillary and mandibular arches were
expanded at the front and rear during treatment. Evaluation
of a questionnaire filled in by the patients after 2 months
of treatment showed that approximately half of them had
experienced difficulties in brushing their teeth.



The main problem, however, was the restriction
experienced in the ability to yawn. Overall, two thirds of
the adolescents found the Forsus spring better than the
appliance previously used to correct their Class II
malocclusion, such as headgear, activator or Class II
elastics.



CONCLUSION: The Forsus spring has stood the test in
clinical application. It is a good supplement to the Class II
appliance systems already available.



William Wogt JCO June 2006 reports a case
where a 12 year old male with class II division 1
and moderate overjet of 7mm was corrected
successfully with the Fatigue resistant device in
6months after which it was used as an anchorage
unit for the retraction of the maxillary anterior
segment.


Conclusion :


Fixed functional appliances form an useful
addition to the clinician’s orthodontic
armamentarium. But many of these appliances
need further studies to substantiate the claims
made by their respective originators. With this in
mind, clinicians must take great care in selecting
the right patient and also pay attention to every
detail in the manipulation, to attain successful
results with these appliances.


References:












Orthodontic treatment of the class II noncompliant
patient – Moscos A. Papadopoulos
Dentofacial Orthopedics With Functional Appliances
– Graber , Rakosi , Petrovic.
Orthodontics And Dentofacial Orthopedics – Mc
Namara , Brudon , Kokich.
Contemporary Orthodontics – Proffit , Fields ,
Sarver.
Orthodontics , Current Principles And Techniques –
Graber , Vanarsdall , Vig
Larry.W. White :Current Herbst Appliance
Therapy:JCO 1997,May(296 - 309)

Kinzinger, Oestheimer, Deidrich: Development of a new
fixed functional appliance for treatment of skeletal class II
malocclusion.J. Orofac Orthop 2002 63:384-399
Ken Hansen: Treatment and posttreatment effects of the
herbst appliance on the dental arches and arch relationships.
Semin Orthod 2003 March,page 67-73
Kinzinger, Deidrich: Bite jumping with the functional
mandibular Advancer, JCO December 2005 page 696-700
Hans Pancherz :History, Background, and Development of
the Herbst Appliance, Semin Orthod 2003,March page3-11
Filho C.M. Clinical Applications of the Mandibular
Protraction Appliance. J. Clin. Orthod. 1997; 31: 92 – 102.

William Vogt:The Forsus Fatigue Resistant Device,
JCO 2006 June page 368-376
Heinig N, Goz G: Clinical application and effects of
the Forsus spring. A study of a new Herbst hybrid, J
Orofac Orthop. 2001 Nov;62(6):436-50.
Sabine Ruf:Short and Longterm effects of the Herbst
appliance onTemporomandibular joint function,Semin
Orthod 2003 March page 74-86.
Castañon R., Valdes M., White L.W. Clinical use of
the Churro Jumper. J. Clin. Orthod. 1998; 32: 731 – 45.
Miller R.A. The Flip-lock Herbst Appliance. J. Clin.
Orthod. 1996; 30: 552 – 58.

Sabine Ruf, Hans Pancherz: When is the ideal period
for Herbst therapy-Early or Late? Semin Orthod
2003,March,page 47-56
Carlos Martins Coelho Filho. Mandibular Protraction
Appliances for Class II Treatment. JCO, 1995, May;
319-336.
Carlos M. Coelho Filho. The Mandibular Protraction
Appliance No.3. JCO, Volume 1998, June; 379-384.
Carlos M. Coelho Filho. Mandibular Protraction
Appliance IV. JCO, Vol. 35, Jan. 2001, 18-24.
ET JE Sanden, Hans Pancherz, Ken Hansen.
Complications during Herbst Appliance Treatment.
JCO, Vol. 38, March, 2004, No.3, 130-133.

Kurt Popowich, Brian Nebbe, Paul W. Major. Effect
of Herbst treatment on temporomandibular joint
morphology : A systematic literature review.
AJO,Vol.123, No.4, 2003 Apr. 388-394.
Larry W. White. Current Herbst Appliance Therapy.
JCO, Vol. 1994 May, 296-309.
Lewis Klapper. The SUPER spring II : A New
Appliance for Non-Complaint Class II Patients. JCO,
1999, 33, No.1, 50-54.
Norris M. Langford JR. The Herbst Appliance. JCO,
Vol 1981, Aug, 558-561..
Philip Goodman, Paul Mckenna. Modified Herbst
Appliance for the Mixed Dentition. JCO, Vol. 1985
Nov. 811-814.

John Devincenzo. The Eureka Spring : A New
Interarch Force Delivery System. JCO, Vol. 1997, Jul,
454-467.
Raymond P. Howe. The Bonded Herbst Appliance.
JCO, Vol. 1982 Oct. 663-667.
Raiph M. Clements, Alex Jacobson. The MARS
appliance. Report of a case. AJO-DO, Vol. 1982 Dec.
445-455.
Richard P. West. The Adjustable Bite Corrector. JCO,
Vol. 1995 Oct. 650-657.
Robert A. Miller. The Flip-Lock Herbst Appliance.
JCO, Vol. 1996, Oct, 552-558.
Tarek Zreik. A Fixed-Removable Herbst Appliance.
JCO. Vol. 1994 Apr. 246-248.
Xavier Calvez. The Universal Bite Jumper. JCO. Vol.
1998, Aug. 493-500.

Thank you
Leader in continuing dental education


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