National Orthodontics Programme Module 22 Functional Appliances

British Orthodontic Society 1

National Orthodontics Programme

British Orthodontic Society

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Functional Appliances

About the National Orthodontics Programme

The National Orthodontics Programme was launched in December 2004 following a successful British
Orthodontic Society Foundation Award application. A primary aim of the project was to develop a modular
learning resource housed in a Virtual Learning Environment for postgraduates in orthodontics
(www.ole.bris.ac.uk). This consists of 40 online modules and a series of online assessments. The resource
aims to maximize the use of academic staff time and significantly reduce the amount of traveling to teaching
bases by Specialist Registrars.
The resource has been developed by all UK dental schools as authors or coauthors. It is at the discretion of
each dental school as to how the resource is best used in their courses.
We hope you enjoy using this unique and pioneering resource.
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Personal Welcome
A warm welcome to Module 22. I hope you find it interesting and sufficiently clear. The content is designed
to be varied and interesting as well as covering all the necessary aspects of functional appliance treatment.

At the end of this module, you should feel confident about understanding and explaining:
• The scope and limitations of functional appliances
• Indications and contraindications for their use
• The timing of treatment with functional appliances
• The design and construction of various types of functional appliance
• An understanding of the relative merits of Andresen, Harvold, Bionator, Teuscher, Frankel, Twin-
block, Dynamax and Herbst appliances
• The integration of functional with fixed appliances

For module content support and guidance, please refer to the discussion board for this module available on
Blackboard.

Module Authors
Nigel Harradine

Peer-Reviewer
Jayne Harrison

Assessment
Assessment will be made through a combination of tasks for self-directed learning that are distributed
through the module and an essay.

The essay title is:

Describe the variations of functional appliances in use at present. Discuss
the selection, use and mode of action of functional appliances in clinical
orthodontic practice.

This title is a suggestion for this module, please contact your supervisors for more information.
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Timing
The approximate total time required for the Module and assessment is 13 hours. A majority of
this time will be spent reading relevant literature.

References
• A full list of references is included at the end of the module. Each reference in the text is hypertext-
linked to the full reference in the reference list, so that you can immediately check the full reference.
• Remember that if you wish to immediately return from the reference list to your place in the text,
then click the large green arrow pointing to the left on the left end of the toolbar near the top of the
screen.
• If, however, you wish to view the actual paper or its abstract on-line, then all references in the
reference list are hypertext-linked to the most useful web-based source. Some of these links only
lead to a medline reference with no abstract but may still be useful. The icons used for the links are
coded to show the source and extent of the linked reference.
Most of these icons are intuitive. In addition:

Indicates a Pubmed reference with an abstract

Indicates a Pubmed reference with no abstract

Some full references will also be found within individual sections of the module.

Section 1 – What is a functional appliance ?

Aims of this section:
• To understand what makes an appliance a functional appliance.
• To have a perspective of the historical background to functional appliances.
• To meet in outline a number of well-known types of functional appliances.
• To have guidance on the consensus view about which malocclusions are most suitable for their use.

Time required for this section: 45 minutes

Definition of a functional appliance:

Definitions vary, but a useful definition is that a functional appliance achieves its effect through forces
arising from the masticatory and facial muscles. This is a contrast to other appliances which achieve their
effects through forces stored within the appliance – in wires, elastics or screws. It will be seen that the exact
cause and effects of the improvements achieved with functional appliances has been – and to a lesser extent
remains - the subject of varying opinion, but forces arising from the facial soft tissues are undoubtedly the
source of the main tooth movements.
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Introduction and history

At this point, it is helpful to read brief and general summaries of the development and variety of type of
functional appliance.

Recommended sections of general orthodontic texts:

o Houston WJB, Stephens CD, Tulley WJ. A textbook of Orthodontics Pub. 2nd edition
Wright London: 1992; Chapter 17: 323.

Another excellent text to summarise the essentials of functional appliances is:

o Isaacson KG Reed RT, Stephens CD. Functional Orthodontic Appliances. 1990; Blackwell
Scientific, Oxford.

o Unfortunately, copies seem hard to come by.

Malocclusions suitable for treatment with a functional appliance

Functional appliances are designed to change the antero-posterior relationship of the upper and lower
arches. By far the commonest direction of desired change is to correct class 2 relationships, although there
is a minority usage of these appliances to correct class 3. This later case is the subject of a section in this
module and all other sections assume that class 2 malocclusions are being treated. A summary view of the
general place of these appliances in current practice is as follows:

Indications for functional appliances in class 2 division i malocclusions

‘CLASSIC' FUNCTIONAL APPLIANCE CASES
Some cases can be treated to an extremely acceptable result with functional appliances alone. These cases
have a mild class 2 skeletal pattern, proclined upper incisors and no anterior or premolar crowding. Few
such cases are found in the British Isles. Leaving aside for now the possibility that functional appliances
may offer a qualitatively different mode of correction in Class 2 cases, a functional appliance in these cases
is offering the potential for longer hours of wear than headgear and thus faster or more certain correction.
INTERCEPTIVE TREATMENT
Functional appliances are frequently advocated for early treatment. This is partly because a growth-
enhancing effect is felt by some to be more likely at a younger age, partly because early treatment with
fixed appliances before the permanent teeth have erupted is clearly problematic and partly to reduce the
overjet early and reduce the chances of incisal trauma.
COMPROMISE TREATMENT
Some cases are not suitable for fixed appliance treatment because of, for example, poor oral hygiene. A
functional appliance can offer an acceptable degree of occlusal and facial improvement.
ANCHORAGE REINFORCEMENT
Functional appliances are also a traditional means of gaining anchorage at the start of a case requiring fixed
appliances, turning a testing class II case into an easy class 1 case. They are extremely good at rapidly
correcting class 2 molar relationships and are frequently used for this purpose. In addition, if there were
features of the case that might place them in one of the above categories, (e.g. good arch alignment,
doubtful oral hygiene, a patient still in the mixed dentition), then functional appliances would seem even
more appropriate. Conversely, where molars are significantly less than a full unit class 2 and there is
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substantial irregularity requiring extensive fixed appliance alignment, the patient may be more appropriately
treated with fixed appliances from the start.

Section 2 – How do Functional Appliances work?

The aims of this section are:
• To review the range of views on this question
• To examine and understand the best evidence on the mode of action of functional appliances
• To summarise the current consensus view

Time required for this section: Two hours

Mode of action of functional appliances

The eternal speculation, assertion and investigation concerning this topic continue unabated, although better
and better evidence is becoming available. It is accepted that a substantial proportion of the changes are
achieved as for any other appliance which places force on teeth and causes resorption and deposition of
alveolar bone. This effect is usually described as dento-alveolar change. Functional appliances can, however,
correct class 2 relationships with great rapidity and this has prompted the thought over the years that a
qualitatively different mode of action is also at work.
Many authors (e.g. the reviews by Mills (1978 and 1983)) find a 1-2 mm apparent average increase in
mandibular growth during active treatment in addition to the larger dentoalveolar changes. The small
mandibular growth increment found in many studies could well be real, although the possibility of slight
mandibular posturing must be noted.
Condylar position and changes during treatment
With appliances such as the twin block that are worn virtually full-time, or fixed functional appliances of the
Herbst type, the rate of correction is sometimes faster than can be accounted for without attributing some of
the correction to a temporary though very convincing change in condylar position. This seems very probable
in the earlier results published by Pancherz (1991) showing the very short term effects of Herbst treatment
and then the partial relapse over the following year. However, more recent work by the same author shows
that most of the relapse is due to a reversal of the incisor tipping in both jaws (but more in the lower
incisors) and that the condyle does not on average change its position within the fossa. A careful MRI
analysis on two slightly small groups (20 twin-blocks and 20 controls) by Chintakanon et al. (2000), also
found that the condyles were essentially unchanged by functional treatment in their concentricity within the
fossa. Although there was a hint in the statistics that after treatment the condyles remained slightly further
forward than their initial position. An MRI study by Ruf and Pancherz (1998) showed no mean change in
condylar position within the fossa. More recent studies by Pancherz and co-authors (Baltromejus et al. 2002
and Panchstmerz and Fischer 2003) have employed the concept of “effective temporomandibular joint
growth”. This term combines the effects on mandibular position of condylar growth, glenoid fossa
displacement and condylar position within the fossa. These papers have concluded that even with this wider
consideration of condylar changes, “the amount and direction of TMJ changes were effected favourably
although only temporarily in an anterior direction by Herbst appliances”.

Prospective randomised clinical trials (RCTs)

Investigators into the mode of action have sometimes been divided into those with enthusiasm but no
controls and those with controls but no enthusiasm. This factor certainly muddies the evidence, as do the
specific methodological drawbacks highlighted by Tulloch et al. (1990). The importance of good controls is
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highlighted by her study (Tulloch et al. 1997a), which showed that favourable, or highly favourable short-
term mandibular growth was exhibited by 83% of functional appliance cases but also by 31% of the
untreated controls. The prospective studies that she advocates are however challenging to complete
successfully, but provide by far the most valid control groups for any therapeutic intervention.
The recent MRC-funded multicentre prospective study had the necessary skilful design, suitable funding and
involved random assignment of class 2 division i cases to treatment or no treatment (for at least fifteen
months). This RCT compared early treatment with a twin-block and no early treatment (O’Brien et al.
2003b) and found exactly 1 mm of additional horizontal mandibular growth. This was 14% of the average
overjet correction. O’Brien et al. (2003a) describes the skeletal and dental effects of Herbst and twin-block
cases randomly assigned in a second RCT to each appliance in older patients in the permanent dentition The
skeletal pattern enhancement in these RCTs can be described as very modest. These cases are now being
followed in the longer term and the long-term results will also be reported.
It is worth noting that as long ago as 1967, Jakobsson in one of the very few prospective studies of cases
randomly assigned to functional appliances, or headgear or no treatment, found no average enhancement of
mandibular growth. A more recent similar study by Nelson et al. (1993) also failed to find any mandibular
growth enhancement by Harvolds or Frankels. The well known prospective randomised studies currently in
progress and based at the University of Northern Carolina (UNC) and reported by Tulloch et al. (1997b and
1998) showed a small (0.6 degrees/year) enhancement of mandibular growth in the short term, but none in
the longer term. The RCT reported by Ghafari (1998), in Philadelphia, compared Frankel treatment to
headgear, but had no untreated controls. It reported a modest absolute (no untreated controls)
improvement in ANB of 1.3 degrees with the Frankel appliance. The RCT reported by Keeling et al. (1998),
from Gainsville and Seattle found an average apical base relationship improvement (Johnston’s pitchfork
analysis) of 0.8 mm. To date the RCTs in this field have not convincingly revealed a substantial gain in the
skeletal correction of class ii malocclusion.
Authors continue to use descriptive text to describe the skeletal effects of appliances, which do not seem to
be fully justified by the figures. For example, Manfredi et al. (2001) report “The mandible underwent a
remarkable forward positioning”. Their figures show that the increase in SNB was 0.25 degrees greater than
the control group with 99% confidence limits from 0.03 to 0.53 degrees.

The loss of growth benefits with time

There is also considerable evidence that long term growth enhancement of the mandible is very much less
than the short-term effects. Wieslander (1993) has demonstrated very encouraging short-term growth
enhancement, which in the long term almost disappeared. This has also been shown by De Vincenzo
(1991), Pancherz and Hansen (1986) and Pancherz and Fackel (1990). In the 1991 article, DeVincenzo
wrote “This study found highly significant increases in mandibular length still present 2 years after
treatment, diminished but still significant gains after 3 years, and no significant difference after 4 years”. The
latest results from the UNC study (Tulloch et al. 1998) also support these data. The authors write “The
preliminary data from this trial suggest that the skeletal effects of early treatment are not maintained.”
Keeling et al. (1998), concluded that both the Bionator and headgear treatment resulted in skeletal pattern
improvement which was “maintained”, but as has been mentioned above, one year after active treatment,
the average apical base relationship improvement was only 0.8 mm. compared to the untreated controls.
Pancherz, Ruf and Kohlhas (1998) also found impressive short-term growth enhancement followed by
subsequent reduced rate of growth. This fascinating paper revealed in excellently clear graphs that in the
long term the antero-posterior change in pogonion was actually less than in Bolton study patients matched
for age and sex, although the vertical chin growth was slightly greater in the patients treated with the
Herbst appliance. The short-term average growth enhancement may usefully assist overjet and molar
correction, but does not appear to result in a significant long-term increase in mandibular anterior growth
Optimistic reports of short-term orthopaedic effect must be viewed in this light.

Method of measurement
A less frequently appreciated factor is the importance of the method of measurement of the mandibular
growth increment. Many studies measure changes in mandibular length condylion-gnathion (Co-Gn) and
frequently report impressive short-term growth increments. However, the measures which are much more
relevant facially and occlusally are those which relate to the component of growth in an antero-posterior
direction - e.g. parallel to the occlusal plane or perpendicular to a vertical from Nasion or the angle SNB.
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Also, these latter three measures will automatically include any remodelling of the glenoid fossa or forward
repositioning of the condyle within the fossa. All studies in which both Co-Gn and a more antero-posterior
measurement are used (e.g.: McNamara et al. 1985) confirm that the antero-posterior effect is significantly
smaller than the increase in mandibular length. For example, Mills and McCulloch (1998) studying short
term effects of twin block appliances found an impressive average enhancement of total mandibular length
of 4.2 mm. compared to controls, but B point only moved 2.1mm more anteriorly and SNB was enhanced
only by an average 1.6 degrees. The follow-up paper on these patients (Mills and McCulloch 2000) reported
further post-treatment growth in mandibular length of 2.0 mm per year in the twin block group and 2.4 mm
per year in the control group. They reported that “most of the positive gain in mandibular size achieved
during the active treatment was still present three years post-treatment”. However, in antero-posterior
terms, the mandibular enhancement of 2.1 mm. shrank to 1.5 mm. after this further three years - worth
having, but not a large enhancement. These measurements again suggest that short-term skeletal benefit
subsequently diminishes, but an important point is that the method of expressing growth clearly matters.

Maxillary growth
Slightly surprisingly, both the study by Weislander (1993) and one by Pancherz and Margareta Anehus-
Pancherz (1993) showed that maxillary growth restraint actually increased relative to controls after the end
of active treatment. Many other studies have found short-term maxillary restraint although this is not a
universal finding. Nelson et al. (1993) and Courtney et al. (1996) both found no significant maxillary
restraint, nor did Keeling et al. (1998) with the Frankel appliance or the UNC study with a modified Bionator.
Several studies have shown equal or greater maxillary restraint by headgear. Maxillary restraint is usually
measured via A point which is of course partly influenced by tooth movement. The balance of evidence
suggest that maxillary restraint is modest, but less prone to subsequent dilution compared to the mandibular
response
Variability of response
So far, this section has mainly considered mean responses and differences. This is sensible because there
are no useful predictors of individual change of skeletal pattern, but the data show a very wide range of
response. This is frequently under-emphasised. Two papers by Tulloch (1997a and 1997b), show a very
wide range of skeletal response. The unpredictability of growth and of growth enhancement must be
remembered in each individual case. It may well account for some of our cases going particularly well and
others struggling for class 2 correction.

Face height and the response to functional appliances

As Tulloch points out, there is a widespread belief that children who grow vertically will respond less well to
class 2 treatment, but this is not well documented or understood. The study by Ruf and Pancherz (1997)
found no evidence to support this view. The “hyperdivergent” cases in fact showed 1 mm. better
mandibular response than the “hypodivergent” cases although this was not statistically significant. This
evidence suggests that ‘high angle’ cases are no reason to avoid functional appliances because of the
potential effects on growth.

Incremental advancement
Functional appliances which can be easily advanced incrementally have been advocated on various grounds
• enhancement of mandibular growth

• less dento-alveolar effect because lower force levels are placed on the teeth.

• better patient compliance

There is very little evidence to support the first of these hypotheses. The extremely fastidious and useful
study by DeVincenzo and Winn (1989), showed that there was no difference between the effects produced
by one 6 mm advancement and two sizes of smaller incremental advancements. Very small incremental
advancements produced very similar but much slower cephalometric changes. A paper presented at the
2002 British orthodontic conference by Phil Banks reported on the neat advancement mechanism he had
developed for incremental advancement of twin-blocks (Carmichael et al. 1999). The study he reported
revealed no differences between the effects of these appliances and conventional twin-blocks.
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Du, Hagg and Rabie (2002) reported on a study comparing step-by-step advancement of a Herbst appliance
with maximal mandibular protrusion with a Herbst. Unfortunately, the comparison was rendered much less
effective by the addition of headgear to the incremental group and not to the other group. The differences
found between the groups (slightly more maxillary restraint and slight closing of the MMA in the incremental
group) were very consistent with the previously reported effects of addition of headgear to a functional
appliance.
Two reports of a recent RCT study (Gill et al. 2002 and Sharma et al. 2002) compared the hard and soft
tissue effects of a conventional twin-block with a single large advancement and a modified twin-block named
the Mini block which incorporated progressive advancement and an incisor torquing spur. The only
differences of significance were that the conventional Twin-block retroclined the upper incisors a little more
and advanced hard and soft tissue Pogonion approximately 2mm more on average. Lower incisor
proclination was very similar.

Summary
The clinical implications of the evidence concerning the effects of functional appliances on skeletal pattern
currently seem to be as follows:
• it is probable that an average 1-2 mm. of extra short-term mandibular growth can be
obtained. This is clinically worthwhile, but it would not be sufficient to obviate
orthognathic surgery in those cases deemed to require it before the start of treatment

• the increasing evidence is that the long-term gain in mandibular growth is very small

• an average 1-2 mm. of long-term maxillary restraint seems possible, although many
studies fail to find this. In contrast to the mandibular effect, there is some evidence that
this does not relapse after active treatment, but may continues and even increase.
Headgear may well be more effective for maxillary restraint.

• we should remember the large variability of growth - both with and without treatment.

• we should employ the very large occlusal benefits of functional appliances in the
knowledge that a large proportion of their effect is via upper incisor retroclination and
distal movement of upper molars.

• we must remember and measure the effects of reciprocal forces causing anchorage loss
and specifically lower incisor labial movement.

• Perhaps, research should now focus on the underlying mechanisms responsible for the
great variation in growth, so that we may be able to either predict the favourable growers
or actually influence the specific growth mechanisms to advantage.

In addition to any of the above references you may already have looked at, the
following are recommended as representative papers to be fully read:

o Pancherz, Ruf and Kohlhas (1998) since this is a good example of the important body of
work by Pancherz.

o Two very succinct reviews of the literature by Aelbers and Dermaut (1996), are
recommended. They are a little in the past now, but describe some of the potential
methodological problems and the clinical significance of the findings very well.

o O’Brien et al. (2003a) As an example of a modern RCT investigating this topic

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Section 3 – Functional Appliances in Class 3 malocclusions

Aims of this section:
• Knowing the types of functional appliance which are proposed for correction of Class 3
• Understanding the proposed mechanisms for benefit from these appliances
• Knowing the essentials of the cephalometric changes which have been reported
• Putting these appliances in the context of other orthodontic treatments for Class 3

Time required for this section: 1 hour

Functional appliances for Class 3 remain a minority sport, but it is important to know the aspects outlined as
the aims of this section.
Only two types of functional appliance have been advocated for Class 3
• Frankel FR3
• Class 3 twin-blocks

Frankel FR3

A good paper to start with is McNamara and Huge (1985). This very clearly shows the
construction of the appliance and mentions some of the thinking behind it. The two vital
components according to Frankel were the permitting of eruption of lower molars and the
holding away of the soft tissues from the upper incisors. Frankel felt that the latter would
stimulate maxillary growth through stretching the periosteum. As McNamara says, there is no
evidence for that, but the lip bumper effect can certainly permit proclination of the upper
incisors.

What do you think about patient compliance with this appliance?

Next, I recommend reading the paper by Kerr and Ten Hoeve (1989) which reports on
cephalometric changes in a group of class 3 cases. It is important to look at the modest
size as well as the qualitative nature of the changes.

How do you think Frankel 3 appliances produce their effects?

Class 3 twin-blocks

The other functional appliance to be considered is the Class III Twin Block. As with the FR3, the challenge
for a class 3 functional appliance is to posture the mandible in a way which puts posterior force on the
mandible and anteriorly directed force on the maxilla. In this case, the mechanism is a reversal of the
conventional orientation of interlocking blocks used to posture the mandible forward in class 2 cases.
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This paper uses the OPAL averaging function to clearly show the average expectation
with these appliances.

Kidner G, DiBiase A, DiBiase D. Class III twin-blocks: a case series. J Orthod 2003; 30:
197-201.

Lastly, It is sensible to put the effects and effectiveness of class 3 functional appliances into the context of
other orthodontic biomechanics for class 3 cases, namely, reverse-pull headgear and chin-cap therapy.

Proffit WR. Contemporary Orthodontics 3rd edition: 511-518. This does not go into great
detail about the effects of reverse-pull headgear, but is sufficient to put class 3 functionals
into context.

Section 4 – Treatment timing

The aims of this section are:
• To review the evidence on treatment timing
• To understand the clinical implications of treatment at different ages and stages of dental
development

Time required for this section: 1 ¼ hours

Timing of Functional Appliance Treatment

This should depend on a consideration of factors relating to
• dental development
• growth
• psychological development.

Dental factors
Since the teeth we wish to move are the permanent teeth, it follows that the best time to start in relation to
dental development is when the permanent teeth have erupted - especially if a fixed appliance phase is to
follow. A substantially earlier start because of other factors risks prolonging the treatment, since there will
need to be a pause whilst teeth erupt. Also, treatment whilst deciduous teeth are being shed may pose
minor problems of appliance retention, discomfort or a delay in the shedding of deciduous teeth.
Trauma
A definite potential advantage of starting treatment early is the reduced incidence of trauma to prominent
upper incisors. It is however hard to weigh this against the other factors discussed here. Studies are often
not clear on the degree of incisal trauma. We would feel differently about a small enamel chip and a lost
incisor. On balance I feel that the other factors usually outweigh the potential reduction in dental trauma
which starting at say the age of 9 years of age would confer. Perversely, O’Brien et al. (2003b) found a
trend to increased incisor trauma in those patients who had early reduction of overjet compared to the
controls. Further data is required to better assess the risk ratios for specific degrees of damage in this
respect, but it is possible that to show a reduction in dental trauma from early treatment, we would need to
start treatment as soon as the upper permanent incisors erupt and this is very early indeed.
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Growth
The principal issue in this area is whether it is sensible to try to synchronise treatment with the pubertal
growth spurt.
Pubertal growth spurt: - predictability
An important point is that the growth spurt cannot be predicted with clinically useful accuracy. Even with
longitudinal monitoring of stature, Sullivan (1983), has shown that our prediction will still be more than one
year incorrect in 33% of cases. Other methods such as hand-wrist radiographs and cervical spine maturity
indicate that the pubertal spurt can only be accurately charted once it in full swing. These methods therefore
enable good retrospective studies, but not clinical prediction.
Pubertal growth spurt: - amount
The maxillae may grow 2-5 mm more per year at the peak of the spurt than in the year before the spurt,
but the size of the spurt is again very unpredictable. Is this difference worth delaying the start of treatment
for in someone who is ready from the psychological and dental development viewpoints? Also, the later
growth spurts tend to be smaller. The average patient - whether male or female - will be in the very late
mixed dentition or early permanent dentition when the growth spurt is at its peak.
Pubertal growth spurt: - influence on orthopaedic effects of treatment
The limitations of our ability to manipulate the increased rate of growth to our advantage must also be
remembered. Headgear and functional appliances can on average retard maxillary growth to a modest but
useful extent. Kopecky and Fishman (1993), using hand wrist radiographs showed that cervical headgear
was more effective at retarding A point at the peak of pubertal growth than before or after. The difference
was only small (1 mm average) between the earlier and peak growth groups but the older patients (up to 17
years) were on average 2 mm worse off than the peak growth group. Functional appliances may also
promote mandibular growth on average to a small extent. It would be anticipated that these effects would
be greater when growth is more rapid, but this has not been convincingly demonstrated. Pancherz and
Hagg (1985), found that somatic maturation did indeed have a significant effect on the mandibular skeletal
and dental response, but Pancherz and Anehus-Pancherz (1993), found no such effect in relation to the
maxilla. Hansen, Pancherz and Hagg (1991), found that timing in relation to the growth spurt did not
influence the long-term changes, but later treatment was associated with substantially greater stability. In a
more recent paper comparing patients treated before and after peak pubertal growth rate, Konik, Pancherz
and Hansen (1997), found the Herbst appliance to be equally effective at molar relationship and overjet
correction in both groups. However, there was approximately 2 degrees more tipping of both upper and
lower incisors in the ‘late’ group.
Omblus et al. (1997), found very little difference in the response to the Bass appliance in relation to age and
growth periods. Tulloch in the May 1997 paper also concluded that there was little to be gained from
precisely timing early treatment to specific age/maturity markers. Ghafari et al. (1998), concluded that
treatment in late childhood was as effective as that in mid-childhood. A recent study by Baccetti et al.
(2000), reported a larger orthopaedic effect in a group treated at or just after the onset of the pubertal
growth spurt than in a group (average 10 years of age) before the pubertal spurt. However the differences
were very small indeed - e.g. pogonion advanced 2.5 mm. in the early group and 2.6 mm. in the pubertal
spurt group. It seems far from proven that coinciding treatment with the growth spurt is of significant
benefit.

Psychological factors
Many papers have addressed this aspect but none have shed convincing light on the best age for patient
motivation for and ability to co-operate with orthodontic treatment. The paper by Tung and Kiyak (1998), is
representative. The studies by O’Brien et al. (2003a and 2003b) did however show a lower failure-to-finish
rate in the younger patients when treated by the same operator with the same appliance. O’Brien et al.
(2003c) also reported on the psychosocial effects of early twin-block treatment and found a significant
benefit from treatment in terms of increased self-concept scores and reduced negative social experiences.
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Treatment efficiency and treatment timing

Treatment at a particular age or stage of dental development would be preferred if it could be demonstrated
that this timing lead to one or more of the following:
• A better qualitative result
• More rapid treatment with less appointments
• A higher success rate

The first two of these questions have been addressed in a paper by Lysle Johnston (Livieratos and Johnston
1995). In two groups of non-extraction class 2 division i patients matched by discriminant analysis and all
treated by one operator, they compared two-stage treatment involving a Bionator followed by standard
edgewise (using Tweed mechanics) with patients treated with edgewise, headgear and class 2 elastics
alone. Both groups were, on average, cephalometrically indistinguishable at the end of treatment but the
two-stage patients had been in treatment for an average of eighteen months longer with an average of 10
more appointments. This is a salutary finding, supporting the evidence for a relative lack of extra skeletal
benefit from functional appliances, but several features of the samples in their study are important to note.
Firstly, the patients in the two-stage group averaged 10.4 years of age at the start of treatment, which is
significantly younger than we would usually recommend, and this lead to an average treatment time of four
years. This timing is reflected in another paper by Gianelly (1995), which refers to two- phase treatments
and takes for granted a substantial gap between the two treatment periods. Gianelly argues against such
scheduling. Secondly, as Johnston (Livieratos and Johnston 1995), acknowledges, these are comparatively
mild cases (average overjet of 8 mm and average ANB of 6 degrees) and although in more severe cases the
biological response would not be expected to be qualitatively different, the ability of functional appliances to
be worn almost full-time would be expected to have a relatively greater influence on speed of treatment in
more severe cases when compared with the demands of headgear wear over a long period. Interestingly,
the lower incisors were moved labially an average of 1 mm more in the one-stage treatment, perhaps
indicating a relatively large role for class 2 traction in this particular group.
Tulloch et al. (1998), reported similar findings: no
Stage Average Range of significant differences in the morphology of the final result
duration duration and lengthy two-phase treatment. A study of 204 patients
(months) (months) by von Brennan and Pancherz (2002) also concluded that
Twin-block 8 3-14 treatment in the permanent dentition was quicker and
Nights-only twin- 2 1-4 better. However, some opportunities to shed detailed light
block
on this were missed. The paper did not differentiate
Fixed appliances 15 10-23
between active treatment and any mid-treatment pause.
Total 25 18-33 There was little detail about the relative severity of the
cases treated at the various dental stages – for example
Treatment durations of 120 consecutive cases – the starting overjet or skeletal discrepancy. The age range
Harradine and Gale (2000) was from 5 to 36 years.
In all of these studies, the combined sequential functional and fixed appliance treatments were each
significantly longer than is the case if treatment is started at an older age - as illustrated in the table below
of 120 consecutive cases from those in the study by Harradine and Gale (2000).
These treatment times were slightly longer than the simultaneous Herbst and fixed appliance group in the
study by von Brennan and Pancherz. Nevertheless it is a point well made that two-stage treatment can very
easily drag on if started too soon. Also, in milder cases (and especially if there is substantial arch
irregularity), it may well be quicker and simpler to get straight ahead with fixed appliances. As with any
appliance, functional appliances can be overprescribed.
Patient Cooperation and age
The third factor listed above relates to age effect on cooperation. There are not many good papers on this
topic. An exception is the pair of RCTs recently reported in which twin-block appliances were used by the
same operators in a very real-world scenario. The results of O’Brien et al. (2003b) for older patients showed
unusually high failure rates (34%) compared to younger patients O’Brien et al. (2003a) which was 19%. This
later rate was similar to the results of Harradine and Gale(2000). Clinical experience suggests that almost all
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 13

failure with removable functional appliances is explained by failure to wear the appliance. More studies are
needed to examine this factor. At present the evidence suggests it is probable that other factors outweigh
possible better cooperation at an earlier age.

Timing of treatment - summary

Skeletal response seems to be only marginally related to the pubertal growth spurt, so other factors are
more important. We usually want to start treatment as soon as the eruption of the permanent teeth permits
and this is in the late mixed dentition. When using functional appliances at the start of treatment this may
be slightly earlier than with treatment using fixed appliances from the start. An earlier start in large class 2
discrepancies may be advantageous in terms of dental trauma and co-operation, although these points have
yet to be well supported, but it also has potential drawbacks: long treatment, loss of patient motivation and
a slower growth rate. We therefore recommend resisting the temptation to start too early. We should not
wait for the growth spurt if the permanent teeth are already there and we prefer to finish cases before
growth stops in order to take advantage of the better occlusal settling.

Section 5 – Types of functional appliance

The aims of this section are:
• To familiarise further with a variety of designs
• To understand the potential advantages and drawbacks of various designs
• In particular to review and understand the problem of patient compliance with different functional
appliances

Time required for this section: 1 ½ hours

Several papers are well worth a scan in order to understand a little more about the design of several
appliances and the relative morphological effects of different appliances. Some of these papers are fairly old
and will need a physical journey to a library rather than a journey of mouse clicks.

o Fränkel R. The treatment of Class II, division 1 malocclusion with functional

correctors. Am J Orthod 1969; 55: 265-75.
There is no on-line version of this, so a trip to the library is needed.

This is the original set of ideas from the horse’s mouth. Rolf Frankel was stranded on the wrong side of the
iron curtain at the end of WW2. His appliance system and philosophy derived from two sources. Firstly, he
drew on the long tradition of removable and functional appliances in Germany which continued until very
recently at the expense of fixed appliances. Secondly, he was not able to obtain in East Germany the
modern brackets and wires necessary for effective fixed appliance treatment. The USA only began to pay
serious attention to functional appliances when people such as Frankel began to travel there in the 1970s.
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 14

o McNamara JA, Howe RP, Dischinger TG. A comparison of the Herbst and Frankel
appliances in the treatment of class II malocclusions. Am J Orthod Dentofac Orthop
1990; 98: 134-144.
This paper compares two very different appliances – one rather old-fashioned and
the other now very much more popular.

o Teuscher U. A growth related concept for skeletal class II treatment. Am J Orthod

1978; 74: 258-275.

Teuscher advocated two significant design features – torquing spurs on the upper incisors to prevent
retroclination and headgear to produce more vertical control and anterior restraint on the maxilla. This
slightly venerable paper summarizes the concept and design. The hypertext link is only to the abstract, so a
trip to the library is needed.

o Cura N, Saraç M, Öztürk Y, Sürmeli N. Orthodontic and orthopaedic effects of

activator, activator-headgear combination appliances and Bass appliances. A
comparative study. Am J Orthod Dentofac Orthop 1996; 110: 36-45.

This paper illustrates and compares three representative modern types of functional appliance. The effects
of the addition of headgear are again assessed. The lack of contact with lower incisors which is a feature of
the Bass appliance can be seen to be associated with less lower incisor proclination and slower overjet
correction.
Lastly, a recent and potentially popular appliance has been described in the Journal of Clinical Orthodontics
by Neville Bass. This is the Bass Dynamax.

o Bass NM, Bass A. The Dynamax system: a new orthopedic appliance. J Clin
Orthod 2003; 37: 268-77.

The JCO needs a subscription to view on-line.

The illustrations below show the main features of the design. Like the twin-block, it is a two part appliance,
but the interlock takes place lingual to the occlusion instead of on the occlusal surfaces. The lower half can
be fixed – lingual arch – or removable. This design therefore has some of the attributes of the appliances
considered in the next two sections.
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The Dynamax can have fixed or removable lower halves

The acrylic component provides a useful biteplane The ‘hangers’ are easily adjusted to provide
and occlusal disengagement more forward posture

The ‘hangers’ engage behind the lower ‘insteps’. Dynamax Appliance – upper half
Trauma to the soft tissues is not a problem
National Orthodontics Programme Module 22 Functional Appliances
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A substantial RCT involving this appliance and a twin-block appliances is starting in the UK and should clearly
reveal whether incremental advancement with this appliance produces more mandibular growth and less
dento-alveolar effect as well as assessing all the other aspects of treatment effectiveness. One less-
mentioned but definite advantage of an appliance with incremental advancement is the lack of requirement
for a postured bite. The retruded and completely closed bite registration required (as for study models) is
much more rapid and much more reproducible
A personal suggested list of potential advantages is:
• Minimal mouth opening – which may increase patient acceptance, especially in high angle cases
• No need for a postured bite
• A fixed lower half permits simultaneous fixed appliance treatment in the lower
• Easy incremental advancement which may increase cooperation in some patients

Patient compliance with removable functional appliances

Lastly, in this section, it is convenient to consider the question of patient compliance with functionals and
with different designs. The potential advantage of functionals - when compared with headgear - of full time
wear and a possibly greater growth modification, is balanced by the possibility that the bulky functional
appliance may prove less acceptable to the patient and that treatment may therefore fail. For example,
Cohen (1981), found that 34% of patients made no progress with an Andresen appliance and a further 31%
only partially reduced the overjet. Many earlier studies on this subject featured Andresen appliances – a
simple one-piece appliance. More recently, Ghafari (1998), defined uncooperative children as those who
refused to continue with treatment despite all efforts to retain them and found that 42% of girls and 24% of
boys fell into that category with Frankel appliances. (This compared with 5% of girls and 25% of boys who
did not co-operate with headgear). This is a major drawback with the Frankel appliance.
Failure rates with Twin-block and Bass appliances
A study by Harradine and Gale (2000), of 200 consecutively started twin block cases revealed 35 patients
where the overjet failed to completely reduce to <4 mm - a rate of 17.5%. Approximately half of these 35
reduced the overjet to 4-6 mm. and went uneventfully to a successful finish, leaving 9% who were in
essence a complete failure, never reducing the overjet below 6 mm. Morris et al. (1998), found an “overall
discontinuation rate” of 14% with twin-blocks which is probably comparable with the 9% failure to reduce
the overjet to < 6 mm. in the study by Harradine and Gale. Morris also found a significantly higher
discontinuation rate of 28% with the Bass appliance. A similar rate of failure with the Bass appliance was
also reported by Malmgren et al. (1987), whilst McDonagh et al. (2001), again reported a failure rate with
the Bass appliance (41%) which was twice that for twin-blocks (23%). The relatively high compliance rate
with twin-blocks is the prime reason for making these appliances a popular choice, although the results of
O’Brien et al. (2003a) for older patients showed unusually high failure rates (34%) and only the result for
younger patients (O’Brien 2003a) which was 19% was similar to the results of Harradine and Gale (2000)
Clinical experience suggests that almost all failure with removable functional appliances is explained by
failure to wear the appliance, although it should be noted that Tulloch et al. (1998), found that the statistics
in the UNC study support the view that co-operation explained little of the variation in treatment response.
This may reflect the difficulties of measuring degrees of co-operation in a linear manner.
Wheeler et al. (2002), compared success rates at correction of molar relationships (not overjet) between
bionators and headgear at a relatively early age. 100% molar relationship correction was only achieved in
42% of the bionator group and in 62% with headgear. If <¼ unit class 2 was considered a success, the
success rates went up to 83% with the bionator and 100 with headgear. The current trend to pessimism
about the success rates with headgear are put into a useful perspective by this study. One-piece removable
functional appliances are not well tolerated.
Predictors of failure
Barton and Cook (1992), reviewed the literature on predictors of treatment outcomes with functional
appliances and found few predictors. The following paper by Caldwell and Cook (1999), on twin-blocks
found that success could only be statistically related to increase in initial overbite and larger SNB angles. It
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 17

is possible that the reduced overbite factor is partially related to a dislike by some patients of the
appearance of the large anterior open bite, which may result with a twin-block in such a patient. We have a
distinct clinical impression that patients for whom the twin-block necessarily gives a large anterior open bite
because of the need to have blocks of sufficient height, are less likely to wear the appliance on grounds of
poor facial appearance (the ‘goldfish’ look). One advantage of the Dynamax appliance is that the lock
between the upper and lower appliances is lingual to the teeth and not between the occlusal surfaces. This
permits a much lower occlusal separation. Most studies of cooperation available for review involve the
Andresen appliance.

Section 6 – Twin-Block Appliances

The aims of this section are:
• To understand the principles of twin-block design
• To appreciate the potential indications for choosing specific design features
• To be able to fabricate the wire-work and participate in the overall construction of a twin-block
appliance

Time required for this section: 3 hours including time in the laboratory

Twin-block type appliances

These appliances were originally described by William Clark (1982 and 1988). Twin-block appliances are
two-piece functional appliances and have become very popular for several reasons.
• relatively well tolerated by the patient; Harradine and Gale (2000) and Morris et al. (1998)

• robust and easy to repair

• fairly easy to advance – add an acrylic button to the lower blocks

• compensatory expansion is easy – a midline screw

• concurrent headgear easy – embedded tubes in the acrylic

• suitable for mixed or permanent dentition.

Problems with twin-block type appliances

This list seems genuinely shorter than the list of advantages.

The Lower Appliance

The unusual feature that makes twin-block type appliances so acceptable to patients is the division of the
appliance into two firmly retained halves. This greatly facilitates speech and a comfortable mandibular
posture. However, this does require a lower appliance that fits well and is well retained. Lower teeth are
not so well endowed with undercut for cribs as are uppers - particularly in a younger age group. Also, the
shedding and associated mobility of deciduous teeth interfere more with a well-retained appliance than with
those functional appliances that have a looser relationship with the teeth. The lingual arch of the semi-fixed
Dynamax has a potential advantage in these respects.
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Factors which reduce problems with the lower appliance.

• cribs on 4s and 6s - wait until these teeth are there.

• avoid treating in the presence of multiple loose deciduous teeth - wait a little or remove
them

• have an excellent impression and technician

• a short interval between impression and fit.

• lower incisor capping and /or ball-ended incisor clasps aid retention and stability.

Posterior open bite

One of the few features that require specific consideration is the tendency to posterior open bite during
treatment. This is not a big problem. The prime cause is the lack of ability of these appliances to open the
bite in some cases at anything approaching the rate of overjet correction. This can be exacerbated by the
extrusion of upper incisors that accompanies retroclination. The ‘basic’ twin-block appliance has no
component that prevents this extrusion.

Solutions to posterior open bite

• lower incisor capping and upper incisor capping or 'torquing' spurs

• trimming /undermining the blocks

• a period of nights-only wear after overjet reduction

• when overjet reduced, place URA with very steep anterior biteplane to reduce overbite and
hold mandible and lower incisors forward

• subsequent fixed appliances

One intriguing thought arises from recent work by Lee and Proffit (1995), showing that nearly all human
tooth eruption occurs between 8 pm and midnight. Should we get our patients to wear the twin block just
in the mornings once the overjet is reduced and the remaining posterior open bite can usefully settle at
night when teeth erupt?

Control of upper incisor movement

It is frequently advantageous to design the appliances to minimise upper incisor retroclination and extrusion.
Minimising these movements reduces the temporary posterior open bite and the need for upper incisor
torque with fixed appliances. Several other types of functional appliances have upper incisor capping and
the Bass (1982), and Teuscher (1978) appliances are notable for their incisor torquing springs. Trenouth
(2000) and Harradine and Gale (2000), found the same average retroclination (14 degrees) with a labial
bow. Harradine and Gale demonstrated a clinically worthwhile effect in reducing upper incisor tipping (to an
average of 7 degrees) and also modest (1 mm.) but definite reduction in upper incisor extrusion by
incorporating torquing spurs on the upper incisors in place of a labial bow. There was no additional
anchorage loss in terms of lower incisor labial movement in this study. A minor potential problem with some
of these modifications is the median diastema that opens when a midline screw is used in conjunction with
anterior Southend clasps. Torquing spurs which can slide distally over the central incisors during the
expansion phase are therefore preferred if expansion is not carried out with a separate preliminary
appliance.
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Authors Labial wire Average OJ UI retroclination

reduction (degrees)
(mm)

Harradine and Gale (2000) Bow 8.4 14.1

Harradine and Gale (2000) Spurs 7.6 6.9

Trenouth (2000) Bow 7.2 14.4

Parkin et al. (2001) Bow 7.8 11

Parkin et al. (2001) Spurs 9.6 6.9

Mills and McCulloch (1998) None 5.6 2.5

Illing et al. (1998) None 5.7 9.1

Upper incisor retroclination with different designs of Twin-block labial wirework

Interestingly, Mills and McCulloch (1998), reported very little retroclination with no labial wirework at all,
but Illing et al. (1998), also with no labial wirework, found an average of 9 degrees of retroclination.
Results clearly vary for reasons not yet fully explained. Bill Clark advocates appliances with no labial
wirework. Sometimes the differential molar and incisor distal movement is a nuisance with this
arrangement. However, if the labial segment is mildly crowded, leaving the upper incisors with no
attachment can provide relativedistal molar movement and gain useful space within the arch.

Currently favoured design features

A national UK survey in 2000 by Katy Spicer in Bristol discovered that the following was the most popular.
URA
cribs on the upper first premolars and the upper first permanent molars. A labial bow. Midline screw, blocks.
LRA
cribs on lower first premolars and lower first molars, incisor capping, blocks. The division between
upper and lower blocks at a steep angle of 70 degrees to the occlusal plane and should be mesial to the
lower first molars, permitting removal of the lower molar crib and grinding of the upper block if
accelerated eruption of these teeth is required.

One common feeling is that secure retention of both appliances is likely to secure higher rates of patient
compliance and that this outweighs many other considerations - hence secure cribbing. Lower incisor
capping is favoured to prevent overeruption of these teeth, deepening of the overbite and of the lateral
open bite. Lower ball-ended clasps are effective at increasing lower appliance retention and are particularly
useful if the premolars are not available for retention.
Taking the bite
As a general rule, the bite is taken horizontally either at an edge to edge incisor relationship or at the
maximum forward posture minus 2 mm - whichever is the smallest forward posture. This recipe therefore
takes into account the variation in a patient’s ability to protrude the mandible. Vertically, the dimension that
matters most with twin blocks is the height of the blocks and a vertical separation of the buccal teeth (and
hence height of blocks) of approximately 5 mm is advised. Blocks of smaller height run the risk that the
patient may comfortably be able to avoid forward posture when closing the teeth together. Taller blocks
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intrude unnecessarily on the patient’s freeway space, comfort and ability to seal the lips. The vertical incisor
separation will vary with the depth of overbite.
The actual method of taking the bite is a distinct matter of personal preference and experience, but the
‘Projet’ or ‘Exactobite’ plastic jigs are a simple and effective aid if difficulties are being encountered in
routinely obtaining the desired position at the first attempt. They do have the disadvantage of reducing the
ability to customise the A-P and vertical dimensions of the bite to the needs of a particular patient, but the
different vertical and horizontal options provided cater for the large majority of patients.

The question of incremental advancement was covered in section 2.

What twin-block design features would you specifically choose in a patient

a) with an anterior open bite?
b) With upright upper incisors (not proclined)?
c) In the early mixed dentition?
d) With a very deep overbite?

Having given this your full reflection, have a look at the suggested answers in the Appendix section A

In collaboration with the laboratory which makes your appliances, liase closely in all stages of
the construction of a twin-block. I suggest you fabricate the wirework and involve yourself
closely in the fabrication of the acrylic. Discuss aspects of the design or construction which
are more challenging than others from the laboratory viewpoint and what alternative designs
or methods of construction might be employed.

Section 7 – Fixed Functional Appliances

The aims of this section are:
• To appreciate the history of these appliances
• To review the evidence on the relative merits of this category of functional appliance
• To know about the development of partially fixed functional appliances

Time required for this section: 1 hour

The Herbst appliance

This appliance is almost - but not quite – synonymous with fixed functionals. It was first described by Dr
Herbst at the start of the 20th century, but never became widely known or used until its reintroduction by
Hans Pancherz and the many publications by him on most aspects of the use and effects of this appliance.
In spite of the attractiveness of a functional appliance that is fixed to the teeth, this group of appliances has
been slow to gain popularity in Great Britain. This has been partly due to reports of difficulty with
robustness and cement retention of the appliance, partly to concerns about patient acceptance of a fixed
device and partly due to insufficient dissatisfaction with other removable functionals – in particular the twin-
National Orthodontics Programme Module 22 Functional Appliances
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block. The recent availability of commercially produced pistons and sleeves, which also permit more lateral
mandibular movement, has encouraged wider use.

Cast chrome Herbst showing the piston and sleeve which is the definition of a Herbst.

A Fliplock Herbst attachment on a full fixed appliance

Fixed functionals are not immune from failure to complete treatment. The most recent version of the Herbst
appliance as personally recommended by Hans Pancherz was used in the MRC-funded multicentre study
(O’Brien et al. 2003a) and the rate of failure to complete overall treatment was very similar in the twin-block
and Herbst groups, although the failure rate during the functional phase was surprisingly high in the twin-
block group – 34% - and much lower in the Herbst group – 13%. The PhD thesis by Tse (1994) –
supervised by Urban Hagg in Hong Kong, reported a very high dislodgement rate with cast Herbst appliances
and a very high breakage rate with banded Herbst appliances. However, an increasing number of highly
regarded clinicians are sufficiently happy with the incidence of problems to make the Herbst appliance their
only functional and to use it extensively. More recent versions have more freedom of movement and seem
more user-friendly. The version of this appliance which best meets the requirements of being inexpensive,
rapid to fit, robust and almost never coming uncemented, will probably be much clearer in the near future.
More recently, there has been a trend to the use of Herbst attachments on a fully banded/bonded fixed
appliance.

Combining the extensive research literature on the Herbst with clinical experience produces the following
summary of common current views.
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 22

• the Herbst appliance reduces almost all overjets in 6 months which compares to an average of nine
months with twin-blocks
• patients find the appliance comfortable and not excessively intrusive after the first week – similar to
a twin block
• there is an inconveniently high rate of decementation with cast Herbst appliances. All potential
users should be prepared for a problem in this respect
• conversely, etching the enamel and using resin-reinforced glass-ionomer cements can make removal
of the cast Herbst extremely difficult. Subsequent cement removal prior to placement of bonds is
then rather lengthy
• possibly due to these cementation considerations, the Herbst appliance is recommended by Hans
Pancherz to be used only in the permanent dentition
• piston assemblies can come detached through mechanical failure or separated into their two halves
through wide yawning. This is a moderate rather than major nuisance and varies with the particular
make and attachment mechanism
• some literature supports the view that there is more lower incisor proclination with the Herbst than
with most other functional appliances which are less tooth-borne e.g. McNamara 1990 This may lead
to more extractions as part of the treatment. However, it must be remembered that with Herbst
appliances, a full lower fixed appliance is usually included during the functional phase and this will
produce lower incisor proclination that would happen anyway at a later stage with more sequential
use of functional and then fixed appliances.
• arch expansion during the functional phase requires intra-oral screw turning as with rapid maxillary
expansion devices. Some patients find this a task which parents need to carry out
• a functional appliance that can be rapidly and reliably added to a conventional fixed appliance will
probably prove very popular. Such a Herbst appliance is aiming at very similar needs as the forms of
fixed class ii traction discussed in the chapter on anchorage. We have more recently been using a
Flip-Lock Herbst assembly with the ‘male’ attachments welded to rectangular tubing, which is slid
over a rectangular archwire. This mechanism is very simple to install and to date is encouragingly
robust.

Fixed Twin-Blocks
Meanwhile, a very interesting development is a practicable fixed twin-block appliance being developed by
Mike Read (2001). There are two large potential advantages of this type of fixed functional when compared
to a Herbst or to a fixed form of class 2 traction.
• The appliance is on the occlusal plane and not in the buccal sulcus and therefore not
confined by the narrow zone between the teeth and the cheek. This should assist
robustness and patient comfort

• Because the two halves of the appliance are not permanently linked together, the
problems of leverage on the fixation points does not arise

An area of potential weakness in the design is the need for lower premolar bands to remain securely
cemented. It remains to be seen how well this appliance passes the tests of being quick and easy for all
clinicians to make, fit and adjust as well as robustness. As with all new appliances, technical development
and extra experience are continually bringing improvements.

Other Fixed Functional Appliances

Other types of fixed functional appliances for exist. The MALU appliance has interdigitating metal ‘wedges’
on the buccal aspect of molar bands which interlock in occlusion as per the twin-block or Dynamax. Also
there are many types of fixed class 2 traction, such as the Bite fixer or Twin-Force appliances. These have
very similar effects to a functional appliance, but store the force in the elasticity of the device rather than in
the muscles and ligaments as is the case for fixed functionals.
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 23

A recommended fairly early paper on the Herbst appliance is Pancherz (1991). A browse
through one or two of the other papers mentioned in this one will give a view of the use and
effects of this appliance.
The other paper, which will not take long to read, and which should be familiar is the paper
by Read referred to earlier.

Section 8 – Integration of Functional Appliances with Fixed

Appliances
The aims of this section are:
• To understand the potential problems when switching from functional to fixed appliances
• To understand the main choices relating to a switch to fixed appliances
• To explore the question of choosing extractions as part of functional appliance treatment

Time required for this section: 45 minutes

Potential problems

The most important potential problem is the potential for relapse of the overjet correction.
Causes of a return of overjet
• Uprighting of distally tipped teeth. All the upper teeth will frequently be distally angulated /
retroclined relative to their starting angulation/inclination and the consequent uprighting with fixed
appliances is an immediate anchorage demand. This distal tipping is variable.
• A false condylar position. If the functional appliance has caused a temporary, but undetected,
anterior position of the condyles, the rebound of this effect will put an additional demand on
anchorage at this stage.
• Relapse of proclined lower incisors. This is less likely whilst a fixed appliance is in place, but may
contribute.
• Halting of favourable growth enhancement. This is possible, as has been discussed in section 2, but
cannot be the cause of a rapid effect on overjet. It may have a significant effect over, say, a 9-
month period.
• A long gap between the end of functional and the start of fixed treatment. The question of timing
has been discussed above. A long mid-treatment gap increases the chances of cessation of retention
by the patient and relapse.

Dealing with a return in overjet

• Prevention through over-correction. An edge-to-edge incisor relationship is preferable to an overjet
of 4 mm at the end of the functional phase.
• ? establishing a good buccal interdigitation before placing fixed appliances. There is no good
evidence on this, but it may be a factor.
National Orthodontics Programme Module 22 Functional Appliances
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• If there is some rebound of overjet in the early stages of fixed appliance treatment, there is usually
some class 2 traction available and particularly when lower teeth have been extracted. Some
operators place light class 2 elastics at an early stage on light wires to keep overjet control.
• Headgear can easily be added if required, or as a precaution, it can be continued through the
changeover stage, but this is not currently very fashionable.
Choices when switching to fixed appliances
• Immediate continuation or a pause before fixed appliances
• Emphasis on establishing buccal interdigitation or not
• A period of retention with the functional appliance or a new retainer, possibly with an inclined bite
plane
• Start with fixed appliances whilst still in the active functional appliance phase or wait till later.
• Early class 2 elastics or not
• Headgear or not
• Extractions or not

Lower incisor proclination and extraction decisions

Lower incisor proclination is a feature of almost all functional appliance treatment. Studies show a wide
range of proclination with any given appliance and a wider range between different appliances. Appliances
which are tooth -borne, such as the Herbst
Author Appliance Proclination appliance, seem to produce greater
(degrees) proclination as might be expected (average 2.4
Hansen et al. (1997) Herbst 11 mm. for class 2 division i cases in Obijou and
Pancherz et al. (1989) Herbst 8.9 Pancherz (1997), 3.2 mm. or 11 degrees in
Lund and Sandler (1998) Twin-Block 7.9 Hansen, Koutsonas and Pancherz(1997). It
Mills and McCulloch Twin-Block 5.2 should be remembered that fixed functional
(1998) permit simoultaneous fixed appliance treatment
Harradine and Gale Twin-Block 4.6 to the lower incisors and the figures for Herbst
(2000) appliances may therefore reflect proclination
Ghafari et al. (1998) Frankel 2 2.2 which will occur at a later stage with other
Trenouth (2000) Twin-block 1.3 appliances.
Cura and Sarac (1997) Bass/HG 0

Average lower incisor proclination with functional At the other end of the table, there is evidence
appliances from several papers (e.g. Cura et al. (1996),
Cura and Sarac (1997), Illing et al. (1998), that
the Bass appliance which places no direct
pressure behind the lower incisors can produce very little labial incisor movement, albeit with slower overjet
reduction. Pancherz and Hansen (1988), demonstrated the effects of various modifications of the Herbst
appliance, all of which failed to prevent lower incisor proclination. Lund and Sandler (1998), reported
average proclination of 8 degrees with a large standard deviation of 7 degrees. This is a little more than
values found by Harradine and Gale (mean 4.6 degrees or 1.7 mm. and s.d. 4.0 degrees) and these
differences may be related to slight differences in design - e.g. the appliances in the latter study all had
lower incisor capping. Mills and McCulloch used a lower labial ‘squasher’ of acrylic on their twin blocks and
reported average proclination of 5.2 degrees sd 3.9 degrees. Trenouth (2000) used Southend clasps on the
lower incisors and reported almost no lower incisor proclination. The important fact is that the proclination
is remembered and even more, that the variability is remembered, because it should clearly influence
extraction decisions when continuing with fixed appliances.
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 25

Factors influencing extraction decisions in functional appliance cases

In addition to the usual principal factors of crowding and profile, there should be one less factor and at least
two additional factors which would not have applied at the start of the treatment.

Write down the answers to these questions and then page down to the Appendix section B
for the suggested answers.
1. What factor which normally influences extraction decisions should not apply at the
end of functional appliance treatment?
2. What additional factors will probably be present which were not present at the start
of functional treatment?
3. How exactly would you assess the factors in question 2?
4. How are these factors in question 2 likely to influence your treatment from the end of
the functional phase?

Section 9 Bibliography
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National Orthodontics Programme Module 22 Functional Appliances
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Dermaut LR, Aelbers CMF. Orthopedics in orthodontics: Fiction or reality. A review of the
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National Orthodontics Programme Module 22 Functional Appliances
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McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental changes following
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National Orthodontics Programme Module 22 Functional Appliances
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Appendix

A. Suggestions relating to the reflections in section 6

What twin-block design features would you specifically choose in a patient
a. With an anterior open bite?
b. With upright upper incisors (not proclined)?
c. In the early mixed dentition?
d. With a very deep overbite?

a) You would probably avoid any acrylic or wirework which prevented eruption of the incisors. This
would mean no torquing spurs on the upper incisors and no acrylic or ball-clasps on the lowers.
In addition, you might wish to fit high-pull headgear to help control vertical growth of the
maxilla.
b) You would probably opt for torquing spurs to minimise further retroclination of the upper
incisors
c) In the absence of premolars to crib, you might well opt for features giving more retention on the
incisors such as upper torquing spurs or even Southend clasps and lower ball-clasps +/- acrylic
capping
d) Wirework to impede further eruption of the upper incisors would be sensible such as torquing
spurs and in the lower appliance, incisor capping and an absence or early removal of molar cribs
in order to permit eruption of the molars to level the curve of Spee at an earlier stage.

B. Answers to the self-test in section 8

1. The overjet should be fully reduced and no longer a factor.
2. a) Upper incisor retroclination
b) Lower incisor proclination
c) Distal tipping of other upper teeth
d) Differential growth of the jaws during the functional phase
3. A cephalometric radiograph to measure all these factors.
National Orthodontics Programme Module 22 Functional Appliances
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4. 2a,b,c, will influence towards extraction or a more anchorage-providing extraction pattern or headgear.
2d is related and may reveal that overjet correction has been largely due to favourable growth as
opposed to lower incisor proclination and that extractions are less indicated.

A cephalometric lateral skull radiograph is therefore extremely useful when planning extractions at the end
of the functional phase. The lower incisors vary significantly in their labial movement during functional
treatment. Only a lateral cephalometric radiograph can reveal this and appropriately inform the extraction
decision. It is of interest that in the UNC study reported by Tulloch (1998), 30% of the functional cases had
extractions even in a climate of non-extraction fashion and in a treatment regimen where people might be
tempted to extract less often.

Visit the discussion board to discuss any of the thoughts outlined above
National Orthodontics Programme Module 22 Functional Appliances
British Orthodontic Society 31

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