The addition of these screws eliminates the need for construction of a second appliance (in severely retruded skeletal Class II or TMJ-involved cases). After the third or fourth month of wear (when the patient’s muscles have readjusted to their new position), the screws can be activated. Turning them in unison moves the anterior cap forward. This allows the mandible to be advanced even further as treatment progresses. The Orthopedic Corrector I is used to increase the vertical in deep overbite cases, while the Orthopedic Corrector II is used to close open bites. Note: Wax bite requirements for this appliance remain the same as for the regular Bionator.

Over time, the repositioning of the mandible forward eliminates the overjet. When acrylic is removed from the upper block, eruption of the lower first molars occurs — thus eliminating the overbite. When treatment with the Twin Block is complete, the first molars will be in contact and the maxillary and mandibular incisors will be nicely coupled. In the mixed dentition, the lower molars will usually erupt passively. In the permanent dentition, the lower molars often need to be erupted actively (with vertical elastics). To ensure that the patient does not end up with a dual bite, the appliance must be worn a minimum of 7 to 9 months. When the patient’s bite is stable, retrusion of the mandible should not be possible without causing patient discomfort. Once the first treatment phase is completed and the case is at the desired vertical and AP position, it is necessary to place a Phase 2 or “Support Appliance.”

The Standard Twin Block has an upper block that covers the second primary molar or bicuspid, first molar and second molar. The lower block covers the first primary molar and two thirds of the second primary molar. It is vital to the success of the Twin Block treatment that the lower block be held ahead of the upper block at all times. To accomplish this, the blocks must be at least 5 to 6 mm thick. If they are not, adjusting them (to allow for the eruption of the lower first molars) will destroy the interlocking effect of the two blocks. Appliance retention is also critical to the success of this appliance. If you do not have first primary molars that are going to be present for 7 to 9 months –or first bicuspids that are sufficiently erupted — it is better to choose another appliance…or delay treatment until the first bicuspids have erupted and adequate retention is available. Note: The expansion screw added to this design can be used at the same time to initiate lateral arch development.

It can be used to effectively treat skeletal Class II malocclusions with normal maxillas, retrognathic mandibles, and deep overbites (where the AP correction needed is 4mm or less). The Rick-A-Nator consists of a maxillary anterior inclined plane, placed on a lingual wire that is attached to molar bands. The arch wire can be soldered to the bands or attached with vertical brackets — to facillitate easy removed for cleaning. The incline is made to hold the mandible in the exact AP position desired, but if the overjet is greater than 4mm, it can be stepped forward in segments as treatment progresses. Ideally, cases presenting with Division 2 anteriors should be pre-treated,. However, when patient compliance is a problem, lap springs can be added to correct the retroclined incisors as the mandible is being translated. As with the Spahl Appliance, vertical elastics can be used to reduce treatment time when the patient has an excessively closed vertical relationship. Note: The incline incisal ramp must be partially tooth-born and tissue-born — to provide proper support without causing sensitivity to the teeth or the soft tissues. This appliance can be fabricated with a flat plane so that the inclined portion can be generated chair side or ( if a construction bite is provided), the lab will complete the appliance in every detail.

ADVANTAGES OF THE RICK-A-NATOR (OVER REMOVABLE FUCTIONAL APPROACHES):

• Patient compliance is not an issue
• Esthetically, the appliance is virtually undetectable
• It can be worn during active straight wire therapy
• Impact on speech is minimal
• Treatment is reduced (can be worn 24 hours per day)
• It can be used as a TMJ appliance (provides for mandibular advancement and vertical opening)

Their base of operation is the acrylic that is lingual to the dentition. This particular appliance is designed to open a closed bite in Class I and Class II malocclusions, and to correct Class II skeletal relationships. To accomplish this, the lower anterior teeth are covered with acrylic to act as a bite plane, hold the bite open, and prevent anterior super-eruption. An extended labial bow acts as a buccal shield to keep the buccal musculature away from the posterior teeth. Controlling these muscles encourages eruption. The lingual acrylic prevents the tongue from interposing in the inter-occlusal space. Upon delivery of the appliance, the posterior acrylic is carefully ground-in to permit controlled eruption of the molars and bicuspids until the closed bite is corrected.

The posterior teeth are covered with acrylic to prevent their eruption, while the acrylic is kept away from the incisors to permit closure of the open bite. Note: Like the Balters Bionator to Open, this appliance has an extended labial bow and no midline expansion screw. The enlarged Coffin Spring is available on all designs.

Its primary function is to correct skeletal Class II malocclusions — without changing the vertical dimension. Acrylic covers both the anterior and posterior occlusal surfaces to ensure that the vertical dimension remains unchanged as the skeletal problem is corrected.

The lower anterior teeth are covered with acrylic to act as a bite plane, to hold the bite open, and to prevent anterior super-eruption. The posterior acrylic is carefully ground-in to permit controlled eruption of the molars and bicuspids until the closed bite is corrected. Opening the midline expansion screw aids in posterior eruption by relieving tight interproximal contacts — also allowing for a limited amount of arch development (when necessary).

Its primary function is to correct Class II malocclusions without changing the vertical dimension. Note: The “Balters Type” labial wire can be used on any Bionator design and can act to enhance lateral arch width development when a midline expansion screw is included in the design.

This causes patients to experience “burnout” due to prolonged treatment times. Dr. Lynn developed the Bio-Finishing appliances to help address and overcome this problem. The Bio-Finisher is basically a Bionator with the addition of two buccal rakes. The rakes are placed into the body of the appliance at the plane of ideal occlusion. Small hooks are placed on the rake in line with the vertical axis of each of the opposing posterior teeth. Elastics (1/8”) are then placed from each hook to the opposing bracketed tooth in order to extrude the teeth at a faster rate than is possible with the standard Bionator. Compared to many other functional appliances, the Bio-Finisher allows the doctor to control the time of treatment with far more accuracy and confidence. Designed to be worn only at night, it offers excellent control of posterior eruption — in terms of both direction and amount.

A daytime appliance is to be used in conjunction with the Bio-Finisher. It is to be worn all day — even while eating. The normal design of the daytime appliance includes lingual ball clasps for retention and an anterior bite plane to encourage posterior vertical eruption. Because the bite is being held open, bilateral tongue cribs are used to prevent a lateral tongue thrust and to stop the tongue from resting between the posterior teeth.

Left untreated, this pseudo Class III can become a permanent skeletal defect over time. The Han Appliance is an excellent tool for correcting said defect. It ties the posterior aspect of the maxilla and the entire mandibular arch together, creating sufficient anchorage for the use of sagittally-placed expansion screws in developing the premaxillary segment labially. Turning the screws, develops the premaxilla and tips the anteriors labially. Once the anterior segment is developed sufficiently to create a positive overjet, the appliance can typically be replaced with a simple Hawley Retainer. Note: A carefully taken construction bite is essential for the proper fit and function of this appliance. The construction bite must be taken in the most retruded arc of mandibular closure possible, making sure that the patient does not posture forward. This is important because these patients will want to posture their lower jaw forward to avoid the incisal interference that is created in an end-to-end bite.

CONSTRUCTION BITE:
A carefully taken construction bite to the desired vertical and A/P (anterior/posterior) relationship is required for the proper fit and function of this appliance. For the HAN appliance, the construction bite is registered in the most retruded arc of mandibular closure possible. This negates the patient posturing their lower jaw forward out of habit (during construction bite registration) to avoid incisal interference in the end-to-end bite. Adequate vertical opening is also required when taking the construction bite. This provides the necessary clearance for anterior crossbite correction.

This design utilizes the standard 70-degree occlusal bite blocks to initiate a functional correction of a skeletal Class II — while the anterior teeth are left slightly out of contact with the appliance to encourage reduction of the open bite. Leaving all posterior teeth in contact with the blocks prevents their eruption. Every time the patient swallows, lip action works to close the open bite. The labial bow can also be adjusted to actively move the anteriors lingually. In this example, the upper appliance has tongue loops — positioned lingual to the upper anterior teeth — to inhibit the effects of an anterior tongue thrust. In addition, a transpalatal wire with spinner is added to help retrain tongue position and control tongue thrust.

The crown contours are carefully placed on the buccal/labial aspect of the retention teeth and an impression is taken in the normal manner. At the lab, a sheet of clear acrylic material is formed over the teeth (including crown contours) and the remainder of the appliance is fabricated with traditional acrylics. The result is an appliance that “snaps” into place over the teeth, thereby achieving optimum retention — without the use of wire clasping. This technique is quite versatile and can be applied to a variety of appliances. Note: It is essential that the crown contours are clearly represented — no bubbles or “drag” evidenced in the impression — on the working model.

Clasping is, however, quite unique. Composite ledges (blue acrylic) create undercuts that provide superior retention for circumferential clasps. This technique is particularly useful when the teeth that are used for retention have short clinical crowns. If desired, the free end of the circumferential clasps can be finished in a loop, making it easy for the patient to remove the appliances for cleaning.

Vertical changes are often easier when the majority of orthodontic corrections are performed first. Because multiple ball clasps are used for retention, this appliance can be used while the patient is still in full brackets. The placement and number of ball clasps needed for a given case is dependent upon the type of orthodontic corrections needed to finalize treatment. Of course, midline expansion screws can be added, if needed.

First, the lower 70-degree incline block is moved forward — just distal of the cuspids rather than distal to the second premolars. This creates less need for a support phase appliance, because the premolars are allowed to erupt during the initial treatment phase. To help the patient masticate, the lower incisors are “capped” with clear acrylic. Capping the incisors in this manner prevents lower incisor flaring — and helps to reduce overbite by exerting intrusion forces on the upper and lower incisors. Anchorage and stability of the lower block are also improved by extending the lingual flanges distal of the terminal molar. “C” clasps are often placed around the distal of the terminal molar to further enhance retention. The anchorage unit of the upper block is improved by the addition of a labial bow — which results in adding the incisors and cuspids into the anchor system. Because he considers Delta Clasps less prone to failure, Dr. Mahony prefers using them for the retention function.

The simplest design involves merely bonding the Twin Block Incline components directly to the posterior dentition. The teeth to be bonded must be secure. If the blocks are placed on primary molars, it is important that they are expected to be stable for at least 9 months. This technique is used primarily when only mandibular advancement is needed. It is difficult to adjust the blocks intraorally to accomplish vertical changes. The molars are banded and “C” clasps are placed on the first bicuspids — making the appliance easy to seat (by eliminating any path-of-insertion problems), while adding the option of increasing retention (by bonding the “C” clasps to the bicuspids). Since the Twin Block portions are not bonded to the occlusal surfaces, appliance removal after treatment is easy. Again, this fixed design is best used to accomplish mandibular advancement when the patient has adequate vertical dimension. Molar bands and occlusal acrylic prohibit vertical eruption to correct deep bites.

The Spahl Split Vertical consists of separate upper and lower devices.

The upper has a simple bite plane that is designed to hold the arches at the ideal vertical relationship. This bite plane is placed on a lingual wire attached to the first molar bands via a vertical removable bracket assembly. Because the upper is to be worn 24 hours per day, the bite plane should be kept to a minimum (to allow for comfort and ease of speech).

The lower is a wire-bodied appliance composed of an anterior bite block that covers the four lower anteriors and a pair of posterior bite blocks which cover the last molar on each side of the arch. Bonded hooks, buttons, or brackets are placed on the upper and lower cuspids, bicuspids, and first molars. When the lower appliance is in place, vertical elastics are used to initiate eruption of these teeth. By wearing this device a minimum of 12 hours a day (evenings and during sleep) eruption will occur much faster than it could through passive eruption alone.

Distal extensions support acrylic pads that cover the occlusal surface of the maxillary second molars. The purpose of these pads is to provide a “tripod effect” — when the mandibular anteriors are contacting the incisal ramp, the lower second molars are also contacting the posterior acrylic pads.

This feature is extremely important — especially if the patient exhibits signs and symptoms of TMJ dysfunction. The tripod effect generates the posterior support needed to prevent the condyles from moving superiorly (and causing the discs to become displaced). These pads also allow for the addition of posterior-vertical mechanics with inter-arch elastics — without risk of rotating the condyle superiorly and posteriorly.

One of the benefits appliance is that it can be removed for social functions — although it obviously needs to be worn as much as possible…especially during the application of vertical mechanics. This appliance provides the same condylar support function as the Fixed Rick-A-Nator 2. Note: Because it is removable, this design is not recommended for TMD patients who need continual condylar support.

Design is similar to the upper part of the Spahl appliance — with the exception that Crozat Clasps are used on the molars (instead of molar bands). Typically, the Modified Rick-A-Nator is used as a maintenance appliance — once functional repositioning has occurred and passive settling of the posteriors is desired. It can, however, be used in any procedure where a Rick-A-Nator would be the appliance of choice. For example, it can be used — with the addition of posterior pads and inter-arch elastics — to actively erupt the lower posteriors.

Since the advent of modern functional appliances, e.g. Twin Blocks, Bionators and Ortho Correctors (to name a few), the Incline Plane has been relegated to the position of a maintenance appliance.

After correction of a patient’s Class II skeletal relationship, this appliance is used as a “reminder” to help the patient function in the forward position during initial retention. Lingual loops have been added to keep the tongue from inhibiting bite closure in the bicuspid region.

Although the Bonded Maxillary Face Mask/Expansion Appliance is — within the context of facial mask therapy — very similar to a bonded rapid maxillary expansion appliance, the expansion effect of this appliance is quite different. Simply put, it disrupts the maxillary sutural system and enhances the effect of the orthopedic facial mask by making sutural adjustments occur more readily.

Midfacial orthopedic expansion has also been shown to be beneficial in the treatment of Class III malocclusions. Rapid palatal expansion can produce a forward movement of “Point A” with a slightly downward and forward movement of the maxilla. In the mixed detention, the bonded occlusal part of this appliance usually covers the first and second deciduous molars and the permanent first molars. The hooks for the elastics are placed in the anterior aspect of the appliance — in the region of the upper first deciduous molars.In cases where only the deciduous detention is present, the splint typically covers the cuspids and the deciduous molars. In this instance, the hooks for the elastics are placed adjacent to the upper cuspids. In late mixed or early permanent dentition cases, the occlusal coverage portion of the appliance may require the following modifications:

If permanent second molars are erupted, it is necessary to place occlusal rests against these teeth to prevent them from erupting during appliance wear. The framework itself does not extend to the second molars because of the danger of opening the bite due to placement of acrylic on the occlusal surface of the upper second molars.

In all cases, the occlusal acrylic can be finished with either a flat occlusal surface or with light general indexing of the lower posteriors. Many doctors prefer the light indexing, as it is believed to make mastication easier. Please indicate your preference when ordering.

As described by Dr. Frankel, the action of the appliance is to “influence arch development by changing the pressure created by surrounding soft tissue.” It has proven effective as a primary treatment appliance in Class III patients with mild, moderate, or severe dentoalveolar, skeletal and/or neuromuscular imbalances — affecting the skeletal, the dentoalveolar, and the soft tissue components simultaneously. Patient compliance with the Frankel III is typically quite high. It improves the soft tissue profile of the patient with maxillary skeletal retrusion. The purpose of the vestibular shields and upper labial pads are to counteract the forces of the surrounding musculature that tend to restrict forward maxillary skeletal development and cause a retrusion of the maxillary anteriors. The vestibular shields need to be positioned away from the alveolar process of the maxilla, but must fit closely to the tissue of the mandible. This results in stimulation of maxillary alveolar development and restriction of mandibular alveolar development. Because of the importance of growth to the success of the Frankel technique, best results are obtained before the permanent bicuspids and cuspids come into position. Young patients seem to tolerate the appliance very well, allowing treatment to be started at a very early age.

The posterior teeth are covered with acrylic to prevent their eruption, while the acrylic is kept away from the incisors to permit closure of the open bite. The mid-line expansion screw can be used for arch development, when indicated. Adding a “Balters Type” labial wire will also enhance lateral arch width development. Note: If desired, the lower incisors can be capped with acrylic if you wish to prevent their eruption. If so, please be sure to include this on your lab prescription.

The anterior placement of the expansion screw provides controlled expansion of the entire arch, with the majority of the development being in the cuspid and bicuspid region. This addition to the Rick-A-Nator is very helpful in treating “V” shaped arches.

It is used to treat deep bite cases, especially during fixed orthodontic therapy when lower anteriors need bracketing as the bite is opened and the occlusal planes are being levelled. The wire can be attached via horizontal removable brackets on the lingual of the molar bands if desired.