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Frankel appliance

Dr Farisha Mohammed

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Frankel appliance

  2. 2. CONTENTS ◂ Introduction ◂ History ◂ Principles of functional regulator ◂ Indications and contra indications ◂ Advantages and disadvantages ◂ Types ◂ Clinical handling ◂ Modifications of FR ◂ References
  3. 3. INTRODUCTION 3 ◂ Functional appliance ◂ Loose fitting or passive appliance which harness natural forces of the oro-facial musculature that are transmitted to the teeth & alveolar bone through the medium of the appliance
  4. 4. FRANKEL’S FUNCTIONAL REGULATOR ◂ Orthodontic device developed by Rolf Fränkel (Zwickau) in 1961 in the form of a skeletonized oral shield that, while not in contact with the underdeveloped parts of the jaw, is intended to bring about their development. ◂ Because the plate elements remain free, the tongue is unhindered within the oral cavity so that its shaping force can exert its full effect. 4
  5. 5. ◂ At the same time, the lips are supported in the region of the nasolabial and mentolabial fold by frontal pads resulting in normalisation of lip closure. After application of wires and screw spindles, the functional regulator can also solve individual problems such as gap openings and malposition of individual teeth and groups of teeth in a mechanical orthodontic manner. 5
  6. 6. SYNONYMNS ◂ Encircle device ◂ Functional corrector ◂ Functional regulator ◂ Vestibular appliance ◂ Oral gymnastic appliances ◂ Orofacial orthopedic appliance 6
  7. 7. HISTORY 7
  8. 8. DR ROLF F.FRANKL 8 👤
  9. 9. Dr. Rolf Frankel (1908-2001) ◂ From town Leipzig, East Germany ◂ In the early 1960’s-wrote of his functional appliance development. ◂ Frankel drew form the concept of mandibular forward posturing plus the oral screen ◂ Frankel designed the appliance to be worn full time called functional regulator or frankel appliance. 9
  10. 10. 10 The factors that inspired Frankel were: ◂ Bulkiness of the appliance ◂ Gross demand for patient co-operation 😭 ◂ Inability to control individual tooth movements ◂ Inordinately lengthy treatment ◂ Partial results 😒 ◂ Unsupported claims of significant expansion
  11. 11. 11 ◂ His contributions attracted little attention as contributions were mainly in German. ◂ This changed later, as Dr. Frankel, learnt English and translated it ◂ Dr. T.M. Graber invited him to the U.S. to present his philosophy and treated cases and also recognized his significant contributions.
  12. 12. 12 Concept was not new… ◂ 1892-WOLF-Transformation law "Soft tissue shapes hard tissue" ◂ 1895–ROUX- Law of functional adaptation: "Function is dependent on the functional demand, morphology is function become form" ◂ The term "functional orthopaedics" goes back to Roux
  13. 13. 13 ◂ 1954 – BALTERS- Considered the "space function" important for orofacial development ◂ 1968/1969 – MOSS- Concept of the "functional matrix": Cranial development is not subject to direct genetic control but is induced by the 'functional matrix' (theory is controversial).
  14. 14. 14 ◂ 1970/1972/1983 - VAN LIMBORGH‘ Epigenetic regulation': principle of induction, familiar from embryology
  15. 15. EQUILIBRIUM THEORY 15 ◂ A stationary body subjected to unequal forces. ◂ From this perspective, we can say the dentition is in equilibrium, when the muscle forces of the tongue and those forces of the lips and cheeks are balanced except under certain cases of muscular imbalances.
  17. 17. 17 Vestibular area of operation Sagittal correction via tooth borne maxillary anchorage Differential eruption guidance Minimal maxillary basal effect Periosteal pull by buccal shields and lip pad
  18. 18. Vestibular area of operation ◂ Shields of the appliance extend to the vestibular and this prevents the abnormal muscle function. 18
  19. 19. Sagittal correction via tooth borne maxillary anchorage ◂ Appliance is fixed on the upper arch by grooves mesial to the 1st permanent molar and distal to the canine in the mixed dentition period. – ◂ Presence of the lingual pad acts as stimulator and helps in the forward posturing of the mandible. 19
  20. 20. Differential eruption guidance ◂ Frankel is placed on the upper teeth. - Mandibular posterior teeth are free to erupt and their unrestricted upward and forward movement contributes to both vertical as well as horizontal correction of the malocclusion. 20
  21. 21. Minimal maxillary basal effect ◂ Downward and forward growth of maxilla seems to be restricted, even though lateral Maxillary expansion in seen. 21
  22. 22. Periosteal pull by buccal shields and lip pad ◂ Presence of buccal shields and lip pads exert the periosteal pull which helps in bone formation and lateral expansion of the maxillary apical base. 22
  23. 23. 23 MODE OF ACTION OF FR 1. Increase in transverse and sagittal direction - by use of buccal shields and lip pads. 2. Increase in vertical direction - by allowing the lower molar to erupt freely because appliance is fixed to the upper arch
  24. 24. 24 3. Muscle adaptation ◂ Development of new patterns of motor function by buccal sheilds and lip pads of FR can b achieved by a) massaging the soft tissues b) loosening the tight muscles c) Improving the blood circulation d) improving muscle tonicity e) Providing new functional matrix for peri oral muscle to act upon it- ‘Ought-to-be matrix’
  25. 25. 25 4. Mandibular forward positioning- Position of mandible can be changed by gradual training of the protractor and retractor muscles followed by condylar adaptation
  27. 27. INDICATIONS  Mixed dentition period with growth spurts.  Skeletal class II malocclusion with prognathic maxilla and retrognathic mandible (Positive VTO)  Functional class II malocclusion.  In a horizontal or neutral growth vector case.  Class III malocclusions.  Bimaxillary protrusion and open bite problems.
  28. 28. 28 CONTRA INDICATIONS  Class I malocclusion with severe crowding  Thumb sucking habit.  Severe dentoalveolar problems in permanent dentition.  Uncoperative patients.
  29. 29. 29 ADVANTAGES 1. It enables elimination of abnormal muscle function thereby aiding in normal development. 2. Treatment can be initiated at early age . 3. Less chair side time is spent. 4. The frequency of the patients visit is less. 5. They do not interfere with oral hygiene status. 6. Duration of treatment is comparatively less. they deal with skeletal as well as dent alveolar problems.
  30. 30. 30 1. The appliance is bulky and the cooperation of the patient is essential. 2. They cannot be used in adult patients were the growth has ceased. 3. Cannot be used to bring about individual tooth movement and in cases of crowding. 4. Fixed appliance therapy may be required at the termination of treatment for final detailing of the treatment. DISADVANTAGES
  33. 33. 33
  34. 34. BUCCAL SHEILD ◂ They should extend deep into the sulcus, particularly in the apical region of maxillary first premolar and maxillary tuberosity. ◂ The shield must be at an appropriate distance from the lateral aspect of the teeth and alveolus for expansion. The thickness of the shield should not exceed 2.5mm in order to make the wearing of the appliance comfortable. 34
  35. 35. 35 PURPOSE OF BUCCAL SHEILD 1. To restrain the cheek musculature 2. The action of the tongue, acting from within the oral cavity brings about an expansion of the dental arches 3. The sheilds -first premolar and maxillary tuberosity area- stretches the periosteum - cause tension -deposition of bone along the lateral aspects of maxilla
  36. 36. 36 ◂ The vestibular shield creates tension at the depth of the mucobuccal fold in a lateral direction. ◂ This tension is directed at influencing the erupting permanent teeth to erupt further laterally than normal, thereby resulting in arch expansion. ◂ Notice that less influence is seen on fully erupted teeth, as shown by the open arrow.
  37. 37. LABIAL PAD ◂ These pads are rhomboid in shape . ◂ In crossection they should be tear drop in shape. ◂ The upper edges of the lip pads should be at a distance of 5mm from gingival margin. ◂ The distal edge should not overlap the labial protuberance of canine root 37
  38. 38. 38 Operational purpose: ◂ The lip pads when correctly positioned in depth of sulcus,have a supporting effect on lower lip smoothing the mentolabial sulcus and improving lip posture. ◂ Thus the lower lip makes a normal contact with the upper lip which is important for establishment of competent lip seal.
  39. 39. 39 Forced training: ◂ The main purpose of lip pads is to prevent hyperactive mentalis muscle ◂ This inhibitory action is necessary in order to achieve a training effect on lip muscles which are designed to bring about physiological lip seal.
  40. 40. LOWER LINGUAL PAD ◂ It lies lingually below the gingival margin of mandibular teeth and extends distally to the roots of lower second premolar. Operational Purpose: ◂ Forced Training: It is used to overcome poor postural performance of muscles suspending the mandible 40
  41. 41. PALATAL BOW 41
  42. 42. • It originates in the central groove of maxillary first molar forming an occlusal rest that is parallel to the occlusal plane so as to allow expansion of molars laterally. • The wire makes a loop in the buccal shield and recurve to cross in the interproximal groove between maxillary second premolar and first molar. 42
  43. 43. ◂ The wire then crosses the palate with a posterior curve that approximates between hard and soft palate. From there it recurves in a similar manner. ◂ It is constructed by 1mm gauge of wire. ◂ It is used for posterior appliance stability and intermaxillary anchorage. 43
  44. 44. CANINE LOOP 44
  45. 45. 45 • Canine loop is embedded in the buccal shield at the level of the occlusal plane. • It rises sharply to the gingival margin of maxillary first deciduous molar, and fits in the embrasure between the deciduous first molar and the canine to lock the appliance in place on the maxilla.
  46. 46. • The loop wraps around the lingual surface of the canine and emerges labially in the canine-lateral incisor embrasure, curving distally over the canine cusp. • The free end can be bend 46
  47. 47. ◂ In the mixed dentition stage the wire embedded in the acrylic can be adjusted to prevent interference with the proper eruption of the canine and first premolar. ◂ It is fabricated by 0.9mm gauge of wire. ◂ It helps in canine guidance and proper stabilization of the appliance. 47
  48. 48. LABIAL BOW ◂ It operates as a “function-activated “ element i.e. it transmit forces generated by the orofacial muscles on the teeth. ◂ The labial wire turns gingivally at right angle between the maxillary lateral incisors and canine to form the canine loops. 48
  50. 50. ◂ They are fabricated by 0.9mm gauge of wire. ◂ It supports the lip pads in proper position. ◂ The average distance between the labial wires embedded in the lip pads and gingival margin is 7mm. 50
  51. 51. ◂ Three wires are used for fabrication of labial wires. ◂ The central wire is bend in the shape of inverted “V” and must be high enough to prevent irritation of labial frenum. 51
  52. 52. • Lateral wire emerges from the buccal shields in slightly inferior direction approximating the middle of canine root, about 1.5mm away from mucosal surface to prevent gingival laceration. Lateral wire ends at lateral incisor embrasure. • Lateral wire are positioned 0.75mm away from wax relief in order to ensure that they will be firmly embedded in the future buccal shield. 52
  54. 54. 54 • The central wire is used to reinforce the lingual shield at the midline in order to prevent breakages. • It follows the contour of lingual apical base at approximately 1mm to 2mm from the mucosa and 3mm to 4mm below the lingual gingival margin of incisors, to allow the addition of the acrylic.
  55. 55. ◂ It is fabricated by 0.8mm gauge of wire. ◂ Three pieces of wires are used for fabrication. ◂ Two lingual springs emerges from the lingual shield occlusally and are contoured to the lingual surface of the lower incisors right above the cingulum of the lower incisors. 55
  56. 56. • In the treatment of deep bite, they can be bend inferiorly to open the bite and allow the buccal teeth to erupt. ◂ If they are to be used as “function-activated” element they may be placed on the lingual surface of lower incisors superior to the cingulum.This should only be done in severely tipped lower incisors. 56
  58. 58. ◂ The lingual contour of the wire is positioned 1mm away from the mucosa. It should run posteriorly , and the free ends, about 9mm to 10mm below the lingual gingival margin ,are then bend at right angle to secure a firm seat in the acrylic. • It is important that the wire pass interocclusally without contacting upper and lower teeth. 58
  59. 59. • They are then bend laterally to insert in buccal shield. • The lateral end of the wire are parallel to the occlusal plane because they will be used as guides when lower anterior section of appliance is advanced to change mandibular position step by step. • For this purpose the portion of the wire embedded in the acrylic should be straight so that it can slide through the acrylic of the shield. 59
  60. 60. ◂ Crossover wire passes between the occlusal surface at the embrasure between the first and second deciduous molars. ◂ It is fabricated by 1mm gauge of wire. ◂ Crossover wire connects the lingual shield with the buccal shields. 60
  61. 61. Clinical procedures Visual Treatment Objective Impression Making Construction bite Pre- Frankel appliance fixed/ removable mechanotherapy
  62. 62. Visual treatment objective Class II Div 1 malocclusion 3mm of mandibular protraction 6 mm of mandibular protraction
  63. 63. Impression making ◂ Thermo sensitive tray or a custom fabricated tray , with proper beading to improve details. ◂ Successful therapy depends on the fit & comfort of the appliance ◂ Impressions should reproduce the whole alveolar process to the depth of the sulci, including maxillary tuberosities.
  64. 64. ◂ Metal flanges of the tray should not reach too far into the sulcus. ◂ Approx. 15mm from the bottom of the tray to the top is as far as the tray should extend. ◂ Ideal impression-  maximum extension vertically  Minimum extension laterally & anterio-posteriorly
  65. 65. Construction bite ◂ Advancement only by 2.5-3mm ◂ Vertical opening only large enough to allow crossover wires through the interocclusal space without contacting the teeth ◂ Anteriorly, not more than end-to-end bite.
  66. 66. ◂ “Step-by-step” activation produces a better and more continuous tissue reaction, rather than the “great leap forward” ◂ Histologic research by Petrovic confirms that step wise correction of sagittal discrepancy is more effective for both tissue response and patient adjustment to the forward posturing. ◂ Many studies , one of Schmuth et al in 1995 notes that patient can easily tolerate 4-6 mm of advancement
  67. 67. Frankel uses an adapted baseplate to which wax is added and softened for construction bite. Leaves the anterior region open to visualize midlines
  68. 68. TYPES OF FR
  69. 69. 69 FR FR I FR I-a FRI-b FR I-c FR II FR III FR IV FR V
  70. 70. 70 S.NO. CLASSIFICATION INDICATION 1 FR I Class I and Class II div 1 malocclusion 2 FR Ia Class I with deepbite, Class I with minor to moderate crowding or arrested development of basal arches 3 FR Ib Class II div 1- Overjet >5mm 4 FRIc Class II div 1- Overjet >7mm 5 FR II Class II div 1 and div 2 6 FR III Class III 7 FR IV Openbite 8 FR V Vertical maxillary excess+ high mandibular plane angle in long face patients ( along with headgear)
  71. 71. FR - I 71 Used in treatment of class I and Class II division 1 malocclusion
  72. 72. Indications ◂ Angle class I and crowding ◂ Angle class II div 1 (distal occlusion) with normal overbite or open bite ◂ Moderate labial inclination of the upper incisors ◂ Underdevelopment of the apical bases (primary crowding symptoms) 72
  73. 73. › FR 1a : Used for class I malocclusions where there is minor to moderate crowding and also in class I deepbite cases. › FR 1b : Used for class II division 1 malocclusion where overjet does not exceed 5mm. › FR 1c : Used for class II division 1 malocclusion in which the overjet is more than 7mm. 73
  74. 74. FRI a Components ◂ Acrylic parts ◂ 1. Vestibular shields. ◂ 2. lip pads. ◂ Wire components: ◂ 1. Palatal bow. ◂ 2. labial bow. ◂ 3.Labial support wire. ◂ 4. Lingual bow. ◂ 5. Canine loops
  75. 75. Lingual bow •In FR Ia a wire loop is used instead of an acrylic lingual pad that helps in the forward position of the mandible forward. • It extends downward to the floor of the mouth which fit against the lingual tissue below the incisors.
  76. 76. Palatal bow Convexity facing distally with lateral extensions crossing the occlusal surface in the embrasure mesial to the first molar. Lip pads It eliminates the hyperactive mentalis activity.
  77. 77. FR I b ◂ Uses ◂ CL II DIV I with a deep bite and an over jet of not more than 7mm. ◂ Wire forming ◂ Palatal bow 1.0mm wire is used ◂ Tooth moving wire 0.8 mm wire is used. ◂ Lower lingual support wire. ◂ 3 components soldered together or 1 continuous wire. ◂ Wire member follows the contours of the lingual apical base ◂
  78. 78. Lower lingual springs Surface of the lower incisors right above the cingula . Lower labial wire It supports the Skelton for the lip pads .
  79. 79. Palatal bow • It provides some extra wire length to facilitate a lateral expansion adjustment. •The wire should cross the occlusal surface in the embrasure Mesial to the first molar. •Locking of the appliance on the maxillary arch is mainly due to this insertion on the embrasure.
  80. 80. Labial bow The bow originates in the buccal shield and lies in the middle of the labial surfaces of incisors , turning gingivally at right angles between maxillary lateral incisors and canines.
  81. 81. Canine loop The loop wraps around the lingual surface of the canines .It is embedded in the buccal shield at the occlusal plane level. It rises sharply to the gingival margin And fits in the embrasure.
  82. 82. Fabrication of the acrylic parts • After wires are properly adapted to the models they are secured with sticky wax. Shields • The total thickness of the shields and pads should not be more than 2.5mm. •The lingual surface of the shield should be smooth. Lip pads • The upper edges of the lip pads should be at least 5mm from the gingival margin.
  83. 83. FRI c Uses ◂ In more severe CL II DIV 1 malocclusion in which the overjet is more than 7mm and disto-occlusion exceeds an end to end cusp relationship. ◂ It is seldom used.
  84. 84. Component parts The buccal shields are split horizontally and vertically into 2 parts – Anteroinferio portion contains the wires for lingual acrylic pressure pad or shield and for the lower lip pads. Vertical split is opened to the desired position by a 2 to 3 mm advancement and is then filled with acrylic.
  85. 85. FR II They are used for the treatment of CLII div I and II malocclusions. They are the most widely used. Acrylic components a. buccal shields. b. lip pads. c. lower lingual pad. Wire components. a. palatal bow. b. labial bow. c. canine extensions. d. upper lingual wire. e. lingual cross over wire. f. support wire for lip pads. g. lower lingual springs.
  86. 86. CONSTRUCTION The steps are 1. Separators.
  87. 87. Seating grooves in maxillary model for permanent dentition Notching in the deciduous dentition
  88. 88. 2.. Impression Very important clinical procedure so that impression reproduces the whole alveolar process up to the depth of the sulci.
  89. 89. • The purpose of this mandibular manipulation is to relocate the jaw in the direction of treatment objectives. •This creates artificial functional forces and allows assessment of the appliance's mode of action. 3.Constuction bite.
  90. 90.  For minor sagital problems (2-4mm) the construction bite is taken in an end to end incisal relationship.  Horizontal and vertical requirements.  Construction bite should not move the mandible forward further than 2.5 mm to 3mm .  End to end incisal relationship or no more than 6mm forward.  Positioning the edge to edge contact will determine the vertical opening.
  91. 91.  Frankel appliance design and construction permits a further advancement of the mandible after a favorable response to the treatment from the construction bite .  Optimal prechondroblastic activity in the condyle is observed by staged construction bite.
  92. 92. 4.Working model pour up and trimming. Models should extend away from the alveolar process at least 5mm to permit application of wax. 5.Cast carving. Casts are carved for accommodating the buccal shield and lip pads .
  93. 93. Trimming for buccal shields ◂ Sulcular depth must be 10-12 mm above the gingival margin of the posterior teeth ◂ Allows optimal extension of the buccal shields for all possible apositional growth 10-12 mm
  94. 94. Trimming for lip pads Real depth of sulcus Sulcus reproduced in impressions Adequate amount of carving Inadequate carving • Prevents complete extension of lip pads into the sulcus • Prevents periosteal pull • Lip mucosa invaginates into the space   Alveolar surface should be nearly vertical after carving. Lowest border is 12 mm from the gingival margin 12mm 5-7 mm
  95. 95. 6. Work model mounting . mount the models on the straight line fixators.
  96. 96. Wax relief. o Wax padding under the buccal shield to establish space between the tissue and the appliance. o Wax is thicker in the maxillary sulcus than in the mandibular sulcus o Thickness should not exceed more than 3mm. o Wax covering important in the region of the first deciduous molar o Waxing is done separately on maxillary and mandibular cast and then joined together
  97. 97. Wax relief: Maximum thickness of wax padding under buccal shield for FR1 Wax padding under the buccal shield to allow for dentoalveolar expansion
  98. 98. Wire forming The FR II is modified by adding a stainless steel protrusion bow (0.8mm )behind the maxillary incisors , which serves to maintain the prefunctional alignment and also stabilizes the appliance.
  99. 99. Lingual stabilizing bow. •It originates in the vestibular shield and passes through the canine –first deciduous molar embrasure. • Wire forms loops that approximate the palatal mucosa and recurve vertically to contact the incisors at the canine lateral embrasure. • A 90 degree bend allows the wire to follow the lingual contours of the four incisors , right above the cingula .
  100. 100. Canine loops  Originate in the buccal shield but they embrace the canine buccal instead of lingually.  By placing these wires 2 to 3mm away from the canine the restrictive muscle function is eliminated .
  101. 101. Fabrication of acrylic parts:  Wires are bent and properly adapted to the models and they are secured with sticky wax .  Buccal shields and lip pads and lingual pads are fabricated in self cure acrylic. Shields:  Should extend to the vestibule.  lingual surface of the shields should be smooth. Lip pads: Upper edges of the lip pads should be at least 5mm from the gingival margin.
  102. 102. FR III Treatment of CL III malocclusions. Lip pads • Situated in the maxillary instead of the Mandibular in labial vestibular sulcus. •It eliminates the restrictive pressure of the upper lip . •To exert tension on the periosteal attachments in the depth of the maxillary sulcus, to stimulate bone growth.
  103. 103. Labial bow • It extends across the six mandibular anterior teeth just above the inter dental papillae. •After a 90 degree bend downward at the distal edge of the lower canine , another horizontal bend is made approximately 5mm below the gingival margin. Buccal shields •Stands away some 3mm from maxillae Posterior dento alveolar structures. •They are in contact with mandibular teeth and the mandibular apical base
  104. 104. Occlusal rests Occlusal rests originates in the vestibular shield and is adapted to lie in the occlusal fissure of the last mandibular molar. Palatal bow • It pass directly distal to the last molar tooth before inserting in the buccal shields . • It is capable of delivering a forward force vector to the maxillary dentition.
  105. 105. Mode of action: The proposed method of action of the FR-3 appliance. The distracting forces of the upper lip are removed from the maxilla by the upper labial pads. The force of the upper lip is transmitted through the appliance to the mandible because of the close fit of the appliance to that arch (after Fränkel1).
  106. 106. 107
  107. 107. Construction bite The procedure of taking the construction bite is done by retruding the mandible as much as possible with the condyle in its most posterior position. The vertical opening is kept to a minimum to allow lip closure with minimal stress. Wax relief No wax is applied to the mandibular arch.
  108. 108. Fabrication of acrylic parts same as FR I and FR II. Finished appliance
  109. 109. FR IV • Correction of open bite and bimaxillary protrusion. • Exclusively confined to mixed dentition
  110. 110. o As a result of treatment of these anomalies with the FR- 4 appliance and lip seal training, the growth and development pattern of the mandible was altered. oThe spontaneous downward and backward growth direction of the mandible was changed to a upward and forward direction by FR-4 therapy, allowing the skeletal anterior open bite to be successfully corrected through upward and forward mandibular rotation. o MODE OF ACTION OF FR IV
  111. 111. FR V Modification of Frankel by Albert H Owen (1985 –JCO) INDICATED- Long face syndrome having a high mandibular plane angle and vertical maxillary excess .
  112. 112. 113
  113. 113.  The appliance consists of addition of posterior acrylic bite blocks to arrest molar eruption.  It also has head gear tubes that accept a face bow for an occipital pull headgear.
  114. 114. Advantages in combination of frankel with head gear. 1.The vertical dimension can be decreased through intrusion of the molars. 2.Increased mandibular growth. 3.Significant lateral expansion may reduce the need for expansion.
  115. 115. MODIFICATIONS 116
  116. 116. Note palatal acrylic support and continuous buccolabial acrylic construction, which replaces conventional function regulator with separate buccal shields and lip pads. The appliance is not "locked" into the mesial embrasure of the maxillary first molars by a cross-palatal bar. 1.Modified function regulator S. Haynes, Edinburgh, Great Britain
  117. 117. 2.Capped Frankel appliance. ◂ Given by Raymond Otto in 1992 ◂ Indicated in deep bite cases ◂ Controls labial tipping of mandibular incisors ◂ Disadvantages ◂ Need of sufficient posterior separation ◂ Capping may impinge on maxillary incisors as treatment progresses ◂ Difficult to clean
  118. 118. 3. HYBRID FUNCTIONAL APPLIANCE (FR 2 and activator combination) •Given by Dr. Peter Vig and Dr. Katherine Vig in 1986 •Hybrid appliances are specifically and individually tailored for every patient. •Problems of every patient is recognised and •Instead of using a “named” appliance for the treatment of a class of malocclusion, various components of different functional appliances can be used to make a composite appliance. •So, appliance designs that uniquely match the needs of individual patients.
  119. 119. HYBRID FUNCTIONAL APPLIANCE (FR and activator combination) Buccal shield (one side)of an FR but maxillary posterior bite plane and mandibular incisor capping like in an activator is used
  121. 121. Stabilizing the appliance at the delivery is absolutely essential Pre placement, all margins are checked for smoothness .  Check vertical dimension.  Over extension of the labial ,lingual, lip and buccal pads causes tissue irritation . So the extension should be correct.
  122. 122. Wearing time  For the first two weeks the appliance should be worn for 2 to 4 hours during the day.  During the next 3 weeks the time is extended to 4 to 6 hours.  it usually takes 2 months before the appliance is worn at night.  The appliance and treatment progress should be checked at 4 weeks interval.  An initial end to end molar relationship is corrected in 6 months.
  123. 123. 124 Treatment timing Optimum time to start the treatment is the mixed dentition period. (8 to 10 year age)
  125. 125. INSTRUCTIONS FOR THE PATIENT:  A little discomfort is to be expected initially.  Salivation may be increased but it should not be a problem.  Outline the duration of wear expected.  Instruction on appliance care and oral hygiene maintenance .  Demonstrate the lip seal exercise .  Ask the patient to speak a few words and reassure that speech would normalize.  Wearing time should be correctly followed.
  126. 126. Studies on Frankel’s appliance
  127. 127. 1. Mc Namara et al in 1985 Studied 100 patients treated with FR therapy and compared them with untreated class II cases • Greater mandibular growth development. • Absence of maxillary growth changes • Increase in lower facial height • Greater vertical development of the mandibular molars • Palatal tipping of the maxillary incisors, • Labial tipping of the mandibular incisors McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental changes following functional regulator therapy on Class II patients. American journal of orthodontics. 1985 Aug 1;88(2):91-110
  128. 128. U S 2. Falck F, Fränkel in 1989 • Studied 120 patients undergoing FR II therapy • 60 pts : stepwise advancement • 60pts : single advancement • Compared them with untreated class II cases • Significant increase in mandibular length • Forward and downward rotation of mandible. • Increase in lower facial height. • No relative changes in maxillary base. • No significant difference when advancement is done stepwise or at once. Falck F, Fränkel R. Clinical relevance of step-by-step mandibular advancement in the treatment of mandibular retrusion using the Fränkel appliance. American Journal of Orthodontics and Dentofacial Orthopedics. 1989 Oct 1;96(4):333-41.
  129. 129. 3. McNamara et al in 1990 •Studied 45 patients treated with Herbst appliance and 41 patients treated with FR2 appliance. •Compared cephalometric data with 21 untreated Class II cases. Results : •Both appliance influenced growth of craniofacial complex and showed skeletal changes •Both showed increase in mandibular length and lower facial height. •BUT •Greater dentoalveolar changes were seen in the Herbst group. McNamara JA, Howe RP, Dischinger TG. A comparison of the Herbst and Fränkel appliances in the treatment of Class II malocclusion. American Journal of Orthodontics and Dentofacial Orthopedics. 1990 Aug 1;98(2):134-44.
  130. 130. 4. Hamilton & Sinclair (AJO 1987) in a cephalometric, tomographic and dental cast evaluation of 25 patients treated with Frankel therapy reported 1.Treatment results were primarily dental, with little skeletal or condylar alteration. 2.And NO head gear type restraining effect was seen in the maxilla. -Hamilton SD, Sinclair PM, Hamilton RH. A cephalometric, tomographic, and dental cast evaluation of Fränkel therapy. American Journal of Orthodontics and Dentofacial Orthopedics. 1987 Nov 1;92(5):427-34.
  131. 131. 5. Janson et al (2003) studied 18 patients undergoing FRII therapy for a period of 28 months. • Statistically significant increase in the mandibular body compared to the maxilla. • Increase in lower face height which induced greater vertical development of the mandibular molars • Reduced the overjet and overbite • Improvement in the molar relation. • BUT No changes in maxillary development, No changes in the growth pattern. Therefore it was concluded that the effects of the FR in the correction of Class II malocclusions are primarily dento-alveolar, with a smaller participation of skeletal changes. Janson GR, Toruño JL, Martins DR, Henriques JF, De Freitas MR. Class II treatment effects of the Fränkel appliance. The European Journal of Orthodontics. 2003 Jun 1;25(3):301-9.
  132. 132. Nielsen IL. Facial growth during treatment with the function regulator appliance. American journal of orthodontics. 1984 May 1;85(5):401-10 5. Nielsen et al 1984 Facial growth was examined in ten patients who had completed one year of treatment with the function regulator 2 (FR-2) •Showed maxilla became retrognatic –or there was no changes in maxilla. •No indications were found that FRII promoted forward growth of the mandible. •Changes were more in vertical plane •Not necessarily improved the profile
  133. 133. References •Dentofacial orthopedics with functional appliances .Graber, Rakosi, Petrovic •McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental changes following functional regulator therapy on Class II patients. American journal of orthodontics. 1985 Aug 1;88(2):91-110 •Falck F, Fränkel R. Clinical relevance of step-by-step mandibular advancement in the treatment of mandibular retrusion using the Fränkel appliance. American Journal of Orthodontics and Dentofacial Orthopedics. 1989 Oct 1;96(4):333-41.
  134. 134. 135 •McNamara JA, Howe RP, Dischinger TG. A comparison of the Herbst and Fränkel appliances in the treatment of Class II malocclusion. American Journal of Orthodontics and Dentofacial Orthopedics. 1990 Aug 1;98(2):134-44. •Hamilton SD, Sinclair PM, Hamilton RH. A cephalometric, tomographic, and dental cast evaluation of Fränkel therapy. American Journal of Orthodontics and Dentofacial Orthopedics. 1987 Nov 1;92(5):427- 34.
  135. 135. •Owen 3rd AH. Modified function regulator for vertical maxillary excess. Journal of clinical orthodontics: JCO. 1985 Oct;19(10):733-49. •Vig PS, Orth D, Vig KW. Hybrid appliances: a component approach to dentofacial orthopedics. American Journal of Orthodontics and Dentofacial Orthopedics. 1986 Oct 1;90(4):273-85. •Haynes S. A cephalometric study of mandibular changes in modified function regulator (Frankel) treatment. American Journal of Orthodontics and Dentofacial Orthopedics. 1986 Oct 1;90(4):308-20.
  136. 136. Thank you !