Frankel appliance /certified fixed orthodontic courses by Indian dental academy

FRANKEL APPLIANCE

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Dr. Rolf. F. Frankel (1908 – 2001)

Dr. Rolf Frankel (1908-2001)
The pioneer behind the appliance was from town Leipzig,
East Germany,which was behind, the iron curtain at that time
Draw backs of the existing appliances, like, the Anderson’s
activator,Bimler’s fixed functional, Stockfisch’s kinetor, Balter’s
bionator and other appliances led to the development of a
new appliance during 1960’’s

Funktions regler, translated as “Functional
Regulator”.


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

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.
Before this, there was relative skepticism among the
clinicians and amongst the existing functional Jaw
Orthopedic appliances.


Introduction
One of the oldest concepts in orthodontics
is the importance of muscle function in the
etiology of the treatment of malocclusion
This concept has evolved into 2 different
strategies:
Myofunctional exercises
Use of appliances to alter the
mandibular position and muscle function.

Frankels theory is based on the theories of
Moss, Hotz and Kraus
The phrase functional orthopedics was coined
by Roux in 1985 .
It stems from the concept of functional
adaptation which states that by altering the
environment, the osseous tissue would change
it’s form.


The term orthopedics derived from Greek, means
proper education.
This concept, with the sense of education,
strongly supports the rational of an early therapeutic
intervention.


The FR (Frankels Regulator) is basically not an
orthodontic appliance used for the correction of
malocclusion
Treatment with this appliance is not directed
primarily towards the teeth and skeletal tissues
but, rather towards functional disorders,
associated with dento skeletal malformation.


Postural behaviour is the functional factor, playing
the primary role in causing skeletal deformities.
Orthopedic approach is concerned with an early
recognition of the non-physiological conditions,
which may adversely influence the, basic growth
process in the cephalic growth sites.


Therapeutically the primary aim is to
eliminate the functional disorders that might
interfere with the normal course of the dentoskeletal development.
The Frankels appliance is removable and is
used during the mixed and early permanent
dentition stages
It is used to effect changes in the anteroposterior, transverse and vertical jaw
relationships.

He had designed it by utilizing the concept of
mandibular forward posturing.
His design was inspired by the Concept of Oral
Screen by Klaus and by reducing the size of
the oral screen


HISTORY
The basic aim of FJO (Functional Jaw
Orthopedics), is to make the appliance more
tolerable to the patient and so to improve the
patient acceptance and wearing time.
The trend was towards designing an appliance
which could essentially be worn full time.
In the early 1960’s Dr. Rolf Frankel revealed
about his functional appliance development. It
was the most complete of all the FJO
appliances.

•


The vestibular shields remove the
restrictions to growth by removing adverse
effects of the external restraining force, called
“buccinator mechanism” allowing the teeth to
spread “inside out” and by inducing growth
increments in the alveolar process.


Treatment results showed that considerable
widening occurred
It was not restricted to the dental-arch alone.
The apical base and the palate also broadened.


• The premolars and the canines were, bodily placed in a well

developed alveolar base. Inter canine distance increased significantly.

• Frankel suggested that for good results the treatment should be
undertaken, before the permanent lateral incisors have fully erupted, which
also signals the end of the main growth spurt of arch width.
•


• Rolf Frankel concluded that hyper tonicity

of the circum oral muscle band, due to
environmental factors, may restrain, the
physiological process of decrowding,
during eruption.


•He suggested that the development of the skeletal disorders is basically due
to the postural performance pattern of the related musculature
•He correlated with Moss’s functional matrix theory, to
demonstrate the functional
inter-relationship with spatial disorders of the oronasopharyngeal spaces.


Faulty muscle posture of the orbicularis oris is
the primary cause of the skeletal open bite ands
this stressed the importance of lip seal therapy
in FR IV therapy in the treatment of open bite.


In 1984, Frankel in his article, mentioned the
causes of failures by other clinicians, in FR therapy,
i.e.
Improper notching
Improper construction bite
The lingual cross over wire, should not exceed, 1
mm in diameter. These act as a ‘safety device”,. Where
bite construction was taken with the mandible more
forward than 3mm


Frankel showed the effect of vestibular
shield of the eruptive path of premolars and
canines, using postero-anterior cephalogram
.


This supports the capsular matrix concept of
Moss which states
that the size and shape of the external soft
tissue capsule, play an important role in the
dentitional development.


Frankel Philosophy
Major part of the Frankels appliance is
restricted to the oral vestibule.
Buccal shields and lip pads held the buccal and
labial musculature away from the teeth and
investing tissues eliminating any restrictive
influences that the functional matrix may have.
Buccinator mechanism and orbicularis oris
complex have a potentially restraining effect on
the outward development of the dental arches,
particularly during the transitional period of
development.

Abnormal perioral muscle function, exerts a
deforming action that prevents the optional
growth and development pattern, in contrast to
the conventional “push out from within” action of
the other removable appliances which expand
without relieving the external muscle forces and
force the dento alveolar morphology to adapt.


Frankel visualized his vestibular construction as an artificial “ought to
be” matrix, that allows the muscles to exercise and adapt to the fact that when
the buccinator mechanism pressures are screened from the dentition. Significant
expansion may take place in the inter-canine dimension.

This relieves the crowding, which is the basis for the removal
of the first permanent premolars.


Vestibular shield enables us to expand the orofacial capsule, when necessary.
The mechanical effect of the appliance is not
directed towards
teeth or alveolar bone but towards the “capsular
matrix”.
Adequate size and shape of the oral
functioning space is achieved.


Rolf Frankel believes, that his appliance is
basically an exercising device
aimed at stimulating physiological
functions, while eliminating the lip trap;
hyperactive mentalis and aberrant
buccinators and orbicularis oris action
.


•
For this purpose a full time and not just
night time wear, and daily functional exercise is
important for the success of the appliance.
•
With anterior lip seal and posterior oral
seal, provided by the lips, and the soft palate,

• during the deglutition process a negative
atmospheric pressure is set up within the oral
cavity.

The cheeks are actually sucked into the
inter occlusal space : as the mandible
returns to the postural rest position ; in
the terminal phase of the swallowing
process.
Thus there’s both a constricting effect on the dento-alveolar process and
also prevention of eruption of the buccal segments due to the interposed
check tissue.


The potential vacuum created inside the arch has the momentary
effect of the great external pressure off setting the intrinsic force potential of
the tongue.

The Frankels buccal shields, prevent the pressure of the buccinator
mechanism, exerted on the dento- alveolar area, both during deglutition and
at rest.


The total (net) effect is the outward expansion of
the “ought to be”
acrylic shield functional matrix.
When worn at a critical time in dental
development with the maximum
eruption in the direction of least resistance. It
can include optional
downward and outward movement of both the
teeth and the investing tissues.

The forward posturing of the mandible is maintained, by the
lingual wire loops/ lingual pads more as a proprioceptive signal and
pressure bearing area ;for the maintenance of mandibular propulsion.
Extension of the shields / pads into the actual,depth of the
vestibule can put the tissue under tension, without irritating it.
This exerts a pull over the contiguous osseous structures, and because
of this pull;


the maxillary basal bone widening takes
place; as the thin alveolar shell over the
erupting teeth proliferates laterally.


The frankels appliance is firmly anchored in to the maxilla, and if
this is not done, failure can, result due to incisor proclination and tissue
damage.

Indications of Frankel’s Appliance
• Growing Individuals
• Retrognathic mandible
• Normal maxillary position in the sagital and the vertical dimensions.
• Normal or reduced facial heights.
• Mild crowding in the mandibular arch or both arches.


Contra Indications
– Non-growing patients (Adults in whom – the growth is
complete.
– Vertical growth pattern.
– Intractable mouth breathing or digital sucking
– Poor patient co-operation.
– Gross intra arch irregularities and rotations
– A tendency for cross bite


Types of Frankels Appliances
Basically there are four basic variation
FR I, II, III, IV.
Type I has 3 types – 1a, 1b and 1c
Indications of FR
With regard to treatment, timing, a distinction is, made between
Early Treatment
Which is initiated in the early, mixed dentition. (Average age
6 ½ - 8 years).
Late Treatment
Not before the, permanent premolars have, erupted


INDICATIONS OF FR 1
Early Treatment
In cases with normal over bite, along with, discrepancy
between teeth size and arch size.
Late Treatment
Mild crowding with an adequate apical base where expansion of the
arch is
expected, due to a spontaneous up righting of the permanent teeth.
Malocclusions with, arch, size, deficiencies, require, mechanotherapy, and
removal
of permanent teeth if needed.


INDICATIONS FR II
Early Treatment
Deep bite with arch size deficiency and a forward, rotational pattern
of the mandible.
Late Treatment
Deep bite without irregularities of the dental arches.


INDICATIONS FOR FR III
Indicated for class III mal occlusions.
Early Treatment
Maxilly retrusion and / or Mandibular protrusion ; possibly accounted
by space deficiency in dental arches.
Late Treatment
Mandibular protrusion and maxillary, retrusion, without irregularities.
Pre-treatment mechanotherapy is needed in patients, with crowded
teeth.
Skeletal Open-bite FR-3
Early and late treatment of cases of skeletal, open bite associated
with
class III.
INDICATION FR-IV
Early treatment
For the skeletal open bite and bimaxillary protrusion

As a Retainer
Last appliance in the active treatment period should be worn as a retainer.
After any kind of mechanotherapy, for stabilizing the corrected configuration,
the appropriate FR should be worn.
After oral surgery, the FR-as an exercising, device for preventing relapse.
McNamaras Indications of FR
FR-1 =

Some open bite cases,class I malocclusion.

FR-2 =

class II Div-1,class II Div 2, open bite.

FR-3 =

class III malocclusion

FR-4 (open bite).


A general Description of the Parts of the FR
Acrylic
Parts
Buccal
shields
Labial
pads
Lingual
shields

Wire
compounds
Vestibular
wires
Palatal bow
Canine loop
Lower lingual
wire
Cross over
wires

Description of the acrylic parts
Buccal shield
•Should extend deep into the sulci.
•Should be away from the lateral aspects of the teeth and the alveolus
whenever expansion of dental arch and the, alveolar process is required.
•For comfort – the thickness shouldn’t exceed 2.5 mm.
Action (Physiotherapy).
It expands the circum-oral capsule in the lateral direction, therefore, forcing the
respective, soft tissues to adapt in structure
.
Muscles of the cheeks, are forced to adapt their, functional performances
with relation to the outer, surface of the buccal shields.


A

B
C

D

F
E
G

A Labial bow
B Canine Loop
C Upper Lingual Wire
D Lingual Crossover Wire
E
Support For Lip Pads
F
Buccal shields
G
Lip Pads

Labial Pads
•Rhomboid in shape and fits the labial surface of the, lower frontal, alveolar
process.
•It is tear drop shaped in cross section, for proper, seating in the vestibule.
•Upper edges should have a distance of at least, 5 mm, from the gingival
margin to prevent the stripping of the labial gingiva.
•Distal edges, shouldn’t overlap the labial protruberances,of the, canine root,
which render , speaking difficult and irritates the mucosa of the lower lip.
Actions

• Supporting effect on the lower lip.
• Smoothening out of the mento-labial sulcus.
• Improves lip posture.
• Helps in the establishment of a competent lip seal : thus forming a he
• closure, of the oral functioning space and negative (sub-atmospheric
pressure conditions in the oral cavity.


Lingual Shield
If lies lingually, below the gingival margin, of the mandibular teeth , and
distal to the roots of the second premolars distally.
Lingual cross over wires, stabilize and secure, the position of the lingual
shield by connecting it with the buccal shields on either side.
Actions of Lingual Shield
In the lingual aspect of the alveolar process ;
It acts by providing a pressure, sensation, whenever the mandible
tries to slid back into it’s original retruded position.
This “sensory input” is expected to be established, only if the
mandibular advancement is carried out step by step.
The initial construction bite should not be taken, with the mandible
forward no more than 2 mm – 3 mm.
Now the appliance can be expected to operate, as an exercise device
inducing changes in the postural performance of the muscles suspending the
mandible.

Wire Parts
Vestibular wires:
They are not located within the acrylic shields.
Should be at an appropriate distance from the outer, aspect of the alveolus not
exceeding 1 ½ mm.
They follow the depression of the labial surface of the alveolar process.

Aim & Function
They connect the lip pads and the buccal shields and secure their position in the
vestibule.


Labial Wire
Lies in the middle of the labial surfaces of the maxillary incisors and runs
gingivally at right angles in the natural depression between the roots of
the lateral incisor and the canine.
Forms a gentle curve, distally at the height of the middle of the canine root.
Aims
•Connecting and stabilizing.
•Tooth movements, whenever it contacts the maxillary incisors.
•This action is utilized, in the treatment of Class II division 1, for the
correction of incisor proclination.
•The curves at either side, enable us to provide, a gradual retraction of the
incisors.


Palatal Bow
•It crosses the palate with a slight curve in the distal direction and runs,
inter dentally between the maxillary first molar and second promolar.
•Forms a loop in the buccal shield, and emerges to form an “occlusal rest”
on the buccal cusps of the molars.
Actions
•Connecting and stabilizing
•Inter proximal portion provides, intermaxillary anchorage.
•Prevents superior, displacement, preventing a displacement, in the vertical
direction.


Canine Loop
It’s embedded with it’s tags, in the buccal shield, at the level
of the occlusal plane and has to rise steeply to the gingival
margin, of the maxillary first premolar.
It runs palatally to the lingual surface of the canine for a
distance of about
1 mm and then crosses the interproximal contact between the
canine and the lateral incisors.
Actions
Labial portion keeps perioral tissues, away from the canine, and provides
space for the lateral movement of the canine.
Used for the tooth movement of anteriorly or bucally displaced cuspids.
Serves as a guide to prevent it’s malpositioning during eruption.
Contact of this wire with the mesial aspect, of the first molar is, essential
for securing inter-maxillary anchorage.

Lower Lingual Wires
Two lower lingual wires, have been attached to the lingual shield to pass
along the lingual surface of the incisors, at the level of the cingulum
Action
•Stabilize the mandibular incisors against lingual movement ;and in
deep bite to prevent further eruption.
•Sometimes towards the end of treatment, they help in, the leveling
of the bite by causing a depressing action.
•When mandibular incisors are retruded, they contact their lingual
surfaces to produce the needed labial movement.


Cross Over Wires
•Connect the lingual shield with the buccal shield ; and run over,
between the mandibular first and second, premolars without touching
these teeth.
•They shouldn’t be allowed to lodge interdentally, as mandibular
buccal segments are moved, forward, resulting in the crowding of
incisors and the overlapping of the canines, over the lateral incisors
• So FR fails to act as an orthopedic exercise device, as the training effect
on the suspending muscles, can’t be achieved


Differences between, FR1a, FR1b
and FR1c
Actually the differences are very minimal
FR1a

•This has a lingual wire loop, instead of an acrylic, lingual
mandibular pad
.
•It’s used in Class I division 1 cases, with minor crowding
• Frankel Recommended it’s use for Class I deep bite
cases, with proclined maxillary and retruded mandibular
incisors.
•Sometimes in Class II division 1 cases, where over jet
doesn’t exceed 5 mm.

FR1b
•It has a lingual acrylic pad, instead of the loop in FR1a.
•Frankel suggested it’s use in Class II deep bite cases, over jet
not exceeding 7mm
FR1c
•Similar to 1b except that the heavy, lingual crossover wires connecting
lingual pads and buccal shields is horizontal.
•Used in Class II division 1 malocclusion, with an over jet
exceeding 7mm.


FR2
•FR2 differs from FR1 only, by the addition of an upper lingual wire,
and by
modified canine loop.
•Other acrylic parts and wires are similar to FR1
•The upper lingual wire runs between the maxillary canine and the
first premolar originating from the buccal shields.
•This is for stabilizing it against the maxilla
•This also prevents the tipping of the protruded, maxillary incisors,
lingually
•In class II division 1, lingual wire lies on the cingulum of the
incisors – to prevent their further eruption.
•When labial bow is activated, it also causes the retrusion of the
incisors.

FR3
•It consists of two upper lip-pads, 2 buccal shields and various
wires.
• Here the lip pads are much larger, than FR1 and FR2 and
extends superiorly into the sulcus.
•They should be parallel to and standing away from the
alveolus by 2.5 mm
•The superior extension of the lip pulls on the septo-maxillary
ligament and the periosteum
• Enhances bone deposition, and frees the pressure sensitive
membranous bone, from the adverse lip pressures .


Mode of action of FR-3
The abnormal insertion of the muscles at the level of
the lower aspect of the nasal septum, and anterior nasal spine plays an
important role in restricting the maxillary development.
The vestibular shields of the FR3, enable the clinician to directly interfere
with these tissues, between muscles, and bone at the maxillary sulci.
Mandibular prognathism is due to increased condylar growth rate, which
in part may be due to excessive mandibular translation.


FR4
•It has 2 lower lip pads, buccal shields, a palatal bow, an upper labial
wire and four, occlusal rests.
•The mode of action of the lip pads and the buccal shields, are the
same as in FR1 and FR2
.
•The main function of the acrylic components, is to interfere with the
aberrant functions of the cheek and lip musculature
•To establish, the structural and functional balance between, various
muscle groups, of the circum oral capsule.


Mode of action
•FR4 reverses the aberrant muscle activity, which create
open bite problems, and redirects growth, more vertically.
•To be used during the active growth period with a longer period
of wear extending, into the permanent dentition.
•Lip seal exercises are very important for FR4, without which the
appliance might be a failure.


Modifications of Functional Regulator
FR system has been refined to 3 appliances by Harry S. Orton.
•Reduced FR2
•Capped FR2
•FR 3 with modified Kingston buccal shields.
They are not applicable for patients with severe overjet, 12-14 mm range.
Not in higher FMPA patients
Works well through the whole of the mixed dentition period, into the
early permanent dentition.
Appliances, are largely tissue borne, produce little interference
with the natural exfoliation of the primary dentition
 The more mature the full permanent dentition, the less effective the
appliance becomes.
Well tolerated by the patient.

GENERAL INDICATIONS
Reduced / Smaller FR2
•Average MPA
•Imbricated lower incisors
•Incomplete overbite.

Capped FR2
•Average to low MPA
•Lower incisor alignment
•Deep overbite


Modifications in reduced FR2
2 major, design features causing reduced patient acceptance for FR2
•Excessive sagittal activation and vertical overextension.
•The reduced appliances, were, under extended, bucally, as well as labially
•and are better tolerated, to produced results comparable to Frankel’s
design.
•3-4 mm less peripheral extension, than those produced by, Frankel’s
formula.
•Dental tissue isn’t removed to accommodate, cross over wires. If separation
is needed then elastic modules are used.


Capped Frankel Appliance
•Here lower labial capping of lingual acrylic of the FR 2 is extended to
•cover the incisal 1/3rd, of the lower incisors and cuspids.
•Capping serves as – “articulating bite locator” for the lower anterior
teeth, and controls, undesirable tipping.
•Lower lingual wires of conventional FR2 are omitted.
•.
•FR2 has clinical advantages like, enhanced vertical and sagittal
control of the lower labial segment.
•General principles of, under extension should be followed.


ndications of Capped FR2
Basically used where patient tolerance is doubtful.
Deep incisor over bite cases
Class II division 2 malocclusions
Where lower incisor, proclination must be avoided.
Capped Frankel prevents, lingual plate fracture
Fracture prevention is due to greater depth of lingual acrylic.
Positive seating of incisal tips in acrylic, holds mandible in exact
registered construction bite position eliminating lateral movements
and tissue irritation.

Disadvantages
As treatment progresses, capped FR-2 has to be advanced
The capping impinges on to the upper incisor
Sufficient posterior separation is required to accommodate 2 mm of
incisal acrylic.
Due to plaque accumulation – oral hygiene is reduced,


Functional Objectives of Capped and Reduced
FR2
•Sagittal restraint of maxillary dentition.
•Vertical restraint of maxilla and maxillary dentition.
•Freedom for buccal movement of the upper buccal segments.
•No vertical constraint to lower buccal segment eruption.
•Maximised increments of condylar growth mechanisms.
•Minimised uprighting of upper incisors.
•Minimized, proclination of the lower incisors.
•Some unfurling of labio mental fold and relaxed lip seal without
•conscious effort.
•Class I incisal relationship, with a reduced overjet and a reduced
• but complete overbite

FR3 with Kingston modified buccal shields
Indications
•Class III malocclusion with average to low FMPA
• Aligned arches, bimaxillary proclination, a mild to moderate
class III skeletal base
•Early mixed dentition
•Difference from conventional FR3, is that the non-functional
part of the buccal shield is removed leaving, lower edge of the
shield 2-3mm, below the lower buccal gingival margins.


Functional Component Objective
•Total occlusal, buccal and labial restraint of the mandibular dentition
.
•Freedom for maxillary dentition to erupt, downwards and outwards.
•Lateral expansion of the maxillary buccal dentition.
•Lateral constraint of mandibular buccal dentition.
•Overall induction of class I incisal relationship, with tendency to an
increased, positive overjet and increased overbite.


Other Modifications
•Inclusion of Jack Screw, in buccal shields to facilitate advancement of
the lip pads
•Frankel’s with facebow appliance
•Extra oral force is provided as there is little function during sleep for
class II malocclusions with maxillary protractions.
•Appliance is anchored on to the maxilla with a light oblique, or vertical
pull, force which can be tolerated without dislodgement.
•Horizontal buccal tubes are embedded for, extra oral traction in buccal
shield at the deciduous second molar area.


Treatment Management
Treatment time varies between 15-24 months, such that patient is in,
permanent dentition.
Treatment occurs in three phase:
•Initial phase
•Active phase and
•Retention phase.


Initial Phase
•For getting used to the appliance, and to handle it like an exercise device
combined with lip seal training.
•Day time wear, is 4-6 hours for 3 weeks, as long as the appliance is
comfortable.
•At night after 4 weeks, except during meals
•Takes 3-4 months for patient to get adjusted to full time wear.


Active Phase
•Patient is to be checked. After 3-4 weeks intervals.
•Mucosa of the vestibule is examined; as is the stabilization in the
maxillary arch of FR1 and FR2.
•Actual exercise can be prescribed along with lip seal regime, which
use isometric contractions of the perioral musculature like grasping
the Frankel’s in the vestibule.


Retention Phase
•Essential aim of FR now is to stabilize the straining effect of the exercise
device, that has been accomplished in the active treatment period.
•If treatment was started during the permanent dentition phase then, a 2-3
year, retention period is required as in, Class II division 2, Class III and
open bite cases.
•In simple cases FR – wear is 2 hours in the afternoon and night for 6
months.
•Then only at night for further 12 months.
•As a general rule the last retainer, used in the retention phase should be a
FR appliance.


Conclusion
Apart from a possibility of reducing the need for extractions,
except in severely crowded cases, the FR can, also reduce the time
needed for fixed appliance therapy and improves facial results.


REFERENCES
1. Dentofacial Orthopedics with Functional Appliances --Graber, Rakosi,Petrovic
2. Orthodontics –Graber
3. Atlas Of Functional Appliances—H.O Orton
4. BDJ vol 26, No 2 JUNE 1999
5. BDJ vol 21, No 2 MAY 1994
6. BDJ vol 18, No 4 NOV 1991
7. BDJ vol 17, No 3 AUG 1990
8. ORTHO IN 3RD MILLENIA –AJO vol 129 2006

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