distalization appliances

1. 1 Distalization appliances Distalization appliances Prepared by: Prepared by: Dr. Mohammed Alruby Dr. Mohammed Alruby Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Introduction History of distalization Classification of distalization appliances Indication of distalization Contraindication of distalization Appliance selection criteria Extraction of second molars Headgear distalization appliance Distal jet appliance (open coil spring) Jones Jig appliance First class appliance Rapid molar distalizer Cetlin appliance Pendulum appliance Wilson appliance Lip bumper appliance Magnets distalizer Transpalatal arch TPA Zygoma gear appliance Herbest appliance Jasber jumper appliance Eruka spring Twin force bite corrector Forsus appliance Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 Introduction: Modern orthodontic viewpoint has been directed towards conservative regimen approach i.e., to avoid the need for extraction. Class II malocclusion treatment plans avoiding extraction demands upper molar distalization method to achieve class I relationship. This method requires patient compliance when treated with headgear or elastics. However, thoroughly outlined intraoral appliance exclude the requirement for patient consent History: = William kingsley 1890 == headgear = Oppenheim: advocated the position of mandibular teeth is most corrected and correction of class II done by molar distalization without disturbing the mandibular teeth position –1944 = Kloehn 1947: started a long and beneficial series of investigation and clinical application of cervical anchorage to the maxillary dentition = Renfroe 1956: reported that lip bumper primarily devised to hold hypertonic lower lip caused distal movement of lower molars sufficient to change class I to class II = Gould 1957: was the 1st person discuss unilateral distalization of molars by extra-oral force = Graber TM 1969: extracted the maxillary 2nd molar and distalize the 1st molar to correct the molar relationship to class I = In 1999, A Modified Hilgers Pendulum appliance was introduced, known as the “M-Pendulum appliance” to remove unwanted tipping of maxillary molars by Hilgers = In 2000 a new non-integrated implant-supported device called the Graz Implant- Supported Pendulum (GISP) was introduced. It distalize maxillary 1st & 2nd molars in adults. It consisted of 2 parts: the anchorage plate, which is fixed to the palatal bone via 4 mini-screws, and the removable part, which is a pendulum-type appliance. = In 2005, Kinzinger modified the standard pendulum appliance by integrating a distal screw into its base and by special pre-activation of the pendulum springs, called Pendulum K appliance. Classification of distalization appliances: The APPLIANCES used for molar distalization can be divided into: 1. Removable appliances 2. Fixed appliances. Removable appliances: -Extra oral traction -Head gear -Removable appliances -Sliding jigs with inter-maxillary elastics. -The Cetlin appliance -Acrylic cervical occipital appliance (ACCO) Fixed appliances -Intra Oral – Maxillary Molar Distalizer -K Loop Molar Distalization Appliance -Hilgers Pendulum Appliance -Super Elastic Niti Wire -Niti Coil Springs -Open Coil Jig Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 -Distal Jet Applince -First Class Appliance -Fixed Piston Appliance -Magnets -Space Regainers -TPA Transpalatal Arch -Wilson Rapid Molar Distalizer -Mandibular Molar Distalizer -Franzulum Appliance -Lip Bumper -Mandibular Jones Jig Intra-maxillary appliance: -Wislon’s 3D appliance -Repelling Magnets -The pendulum appliance -Niti based appliances: arch wires – single loop, double loop; Compressed coil springs -Jones jig -Distal Jet -Fixed piston appliances -IBMD -K-loop -Distalix -Franzulum appliance -Lokar appliance -First class appliance -Carriere’sDistalizer Inter-maxillary appliance: -Herbst appliance -Jasper Jumper -Eureka Spring -Klapper super spring -IMPLANT supported distalization Success rate: There are 3 age related patient’s group and success rate and prognosis differ for each; - Mixed dentition age – Procedure is 90%+ successful and molar correction can be completed within 6-8 months. -Adolescent dentition age- cusp to cusp molar relationships are corrected reasonably well. Full class II relationships are difficult to resolve. (presence of 2nd molars). -Adult dentition age – success rate is highly variable and more failures are noted. Indications: The indications are common in any non-extraction procedures in general 1- Straight profile 2- Normal healthy TMJ and correct mandible to maxillary relationship 3-Skeletal class I Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 4-Normal or short lower face height 5-Normal transverse width of maxilla 6-Skeletal closed bite 7-An end to end or full class II molars relationship due to maxillary cuspids being either impacted unerupted or erupted labially and high in vestibule 8-Fully erupted 1st molars with second molar reached the crest height 9-Patient with permanent dentition who have a normal too near normal mandibular arch with upright or slight retroclined lower incisors, no crowding with flat curve of spee 10-Full class II molars relationship due to maxillary protrusion with upper molar placed normally bucco-palatally in the cancellous bone 11-Mesial tipping / migration of maxillary first molars and loss of arch length due to caries in primary molars, premature extraction in of deciduous second molars 12-Discrepancy anterior to 1st molars does not exceed 2-3mm on either side and when there is no evidence of developing posterior crowding 13-Midline discrepancy case Contraindication: 1-Retrognathic profile 2-More signs of TMJ symptoms, posteriorly and superiorly displaced condyle 3-Class II skeletal with an end on or full class II molar relationship due to retrognathic mandible 4-Skeletal openbite 5-Excess lower face height 6-Constricted maxillary arch 7-Class I or III molar relationship 8-Dental open bite 9-Maxillary 1st molar distally inclined 10-Posterior crowding Appliance selection criteria: 1-If maxillary skeleton needs to be corrected so extra-oral appliances are used 2-If the mandibular dentition is needs to be mesialised along with distalization of maxillary dentition, then inter-arch appliance like Herbst or Jasper Jumper is used If mandibular arch not need to be disturbed the intra-arch appliance is used like Pendulum or distal Jet 3-TPA finds limited application if arch length to be gained is below 2 – 3mm but if need a greater amount so Herbst and headgear is the choice followed by Pendulum, Wilson 4-Best time to start distalization is late mixed dentition and it may be too late after eruption of second molar Extraction of second molars: Is often used in conjunction with distalization of 1st molar Advantages: 1-Reduction in amount and duration of appliance therapy 2-Facilitation of treatment using removable appliance 3-Faster eruption of 3rd molar / surgical removal avoided 4-Facilitation of 1st molar distal movement 5-Mild premolar crowding is corrected without mechanotherapy Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 6-Less likelihood of relapse 7-Good functional occlusion 8-Natural contact area from canine to 1st molar retained 9-Results are stable as tongue space has not been compromised 10-Since premolar are not extracted so more teeth available for chewing Disadvantage: 1-Too much tooth substances removed 2-Extraction site located far from area of concern in moderate to severe anterior crowding 3-Possible impaction of 3rd molar even with 2nd molar extraction Headgears Extra-oral appliance, in 1822, Gunnel first described Extra-oral anchorage. In 1866, Guilford used the headgear for correcting protruding maxillary teeth. Further, in 1892 Norman William Kingsley reported remodeling of class II molar relationship to class I using headgear. Later, Klein Phillip in 1957 assessed the outcome of cervical traction for correcting class II malocclusion. The headgear assembly consists of the following parts: -Force delivery unit: face bow, J hooks -Force generating unit: usually elastic strap -Anchor unit: head cap or neck strap Advantages: 1-The anchor unit is situated outside the oral cavity 2-Bilateral as well as unilateral distalization are possible by using extra-oral appliances 3-The amount of distalization on either side can be controlled individually The use of extra-oral forces for distalization has the following disadvantages: 1-Patient compliance is critical for timely wear of the appliance. Minimum 12 to 14 hours wearing appliance is recommended for the desired results 2-The appliances are usually not worn continuously; their action is intermittent in nature resulting in prolonged treatment times Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 Distal Jet appliance Open coil spring Fixed intra-oral, intra-maxillary non-compliance appliance. Canara and Testa 1st described the distal jet appliance that require non-compliance from patients 1996. = It is a new system to distalize upper 1st and 2nd molars = Apply the distalizing force close to the center of resistance = Less tipping in molars during distalization = Does not reduce the inter-molar distance during distalization = Can be used to de-rotate the molars = Does not require patient compliance The original appliance has some modifications and now consists of: -Bilateral piston and tube arrangement 0.036 diameter -Tube is embedded in acrylic palatal button supported by attachment to 2nd premolars -This tube is extended distally adjacent to the palatal tissue and parallel to the occlusal plane to the 1st molars -Baynot wire inserted into the lingual sheath of the 1st molar bands extended into the tube, much like a piston -Super elastic is placed around this piston and tube arrangement -An activation collar is used to compress the spring distally once every 4 -6 weeks -After completion of distalization of molars, the appliance is converted to palatal holding arch by removing the coil spring and locking the activation collar over junction of tube and piston - Indications: 1-Class II with upper crowding. 2-Class II dental-alveolar maxillary protrusion. 3-No major skeletal abnormalities. 4-No lower crowding or dental protrusion. 5-Non-compliant patients for minimum dental alveolar compromises. = studies conducted at university of Oklahoma revealed that distal jet was a good tool for distalizing maxillary molars Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

8. 8 Jones Jig appliance Open coil spring = Available distalizing spring type for upper molars, it contains a nickel titanium coil spring placed on buccal segment, that generate optimum force when it is compressed to 2nd premolars bracket = Can be easily fabricated on chair side and used to correct unilateral or bilateral defect = anchorage supported by using Nance appliance or modified Nance = can distalize molars even after 2nd molars eruptions = force applied between 70 – 75gm with average treatment time 7 months = introduced by Dr. Richard Jones which study on a sample of 72 patients: 26 males and 46 females with average age 13+_4 = the result showing molar correction for class II to class I due to distal movement: 2.5mm distal tipping: 7.5 degree mesial tipping of premolars: 4.7 degree reciprocal mesial movement of premolars 2.0mm maxillary 1st molar extrude 0.14mm maxillary premolars extrude: 1.8mm = it can distalize the maxillary 1st molars effectively but it has some negative effect when compared with headgear = the use of full palatal coverage and class II elastics minimize the loss of anchorage during treatment = there is another option when using headgear during night to allow good improvement of the cases Design: described by Richard Jones at 1990. Palatal button was 0.5 inch in diameter and anchor to maxillary second molar as modified Nance with 0.036 inch ss wire = after cementation of Nance, one arm of Jones Jig was fitted on the 0.045-inch molar headgear tube and other arm fit on the slot of 1st molar band Then activate the appliance by tying the activation loop back with 0.010-inch ligation wire of anchor tooth bracket = force applied 70 to 75gm delivered by 0.040-inch Nickel titanium spring = coils activated at 4 to 5 intervals until the desired changes is obtained == Vilanova et al studied the skeletal and dentoalveolar changes of class II by Jones Jig and compared with distal jet, they found: 1-There is no significant difference in soft tissue changes in both appliances Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

9. 9 2-Both show clock wise rotation and greater mesial tipping of maxillary 2nd molars 3-Both appliances are effective in treatment of class II -------- (Angle 2018) == David et al 2000: evaluate Jones Jig appliances and they found that: Jones Jig is more effective to achieve distal movement of 1st maxillary molars ------------- (AMJ 2000) According to Jones and White 1992; rapid molar correction can take place in 90 – 120 days in cases where class III dental relationship is primarily due to the mesiobuccal rotation of maxillary 1st molar Other studies revealed that both Jones Jig and distal Jet groups showed occlusal plane clock wise rotation and greater mesial tipping of the axillary second molars when compared with untreated group In more severe cases: the correction may be take 120 – 180 days Children with more horizontal growth tendency may take a longer treatment time. First Class appliance Rapid molar distalizer Intra-oral, intra-maxillary fixed distalizing appliance – noncompliance Introduced by Lion company in Italy. Used for unilateral and bilateral non-compliance distalization of maxillary molars Consists of: 4 bands 2 on maxillary 1st molars and 2 in 2nd deciduous molars and premolars 2 buccally activation positioned screws 10mm long that soldered to the 1st molar bands and seated into closed ring seated on the 2nd deciduous molar or 2nd premolar Large butterfly Nance shaped button, buccal and palatal tube {nickel titanium coil spring 10mm long} Two 0.045-inch wire embedded in the acrylic to connect the Nance to the bands, these wires are soldered from palatal surface of bands Nance button is large to entrance during active phase of treatment Open nickel titanium coil spring are fully compressed between the soldered joint The activation is occurring turn / day until over correction is achieved = Athanasios et al 2010 found an efficient distalization of 1st molar and there is distal tipping of molars and mesial movement of premolars Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

10. 10 Cetlin appliance Several different treatment modalities may be employed to distalize the posterior dentition. This possibility includes removable appliance such as Cetlin appliance. This appliance has high acceptance from adult patients because of it facilitate good oral hygiene and allow patient adaptation to lingual appliance during the initial phase Please note that for effective treatment with this appliance it must be fully seated Design: -2 Adams clasp on the 1st premolars -Distalizing springs on 2nd premolars and 1st molars -Anterior bite plane The key to successful treatment with the appliance is to ensure that the metal spring/clip that goes between the back teeth is seated properly. This will provide consistent gentle pressure to the upper molars which will in turn produce the desired tooth movements. If the spring/clip is not seated fully the spaces will close and treatment will be prolonged as separation will be required again. After wearing the appliance for 3-4 days, it will feel more comfortable, and it will become easier to completely seat the appliance Pendulum appliance = Intra-oral inter-maxillary fixed non-compliance appliance = Introduce by JJ Hilgers in 1992 to expand maxilla and simultaneously rotate and distalize the maxillary 1st molars = Delivered continuous force and require little patient cooperation Design: = palatal acrylic button that is about 0.025mm is diameter with distalization spring made of 0.032 Beta titanium wire that originate from the palatal acrylic and engaged on the lingual sheath of maxillary 1st molars bands = an expansion screw can be added in case where expansion was needed and this version is called (pend –x) Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

11. 11 = Nance button provides anchorage for molar distalization covers midpoint of the palate and connected to upper and 2nd premolars through the occlusal rests. The two posteriorly directed TMA springs are also attached to it. One-time activation 60- 70 degree producing force 200 to 230gm / side A loop within each spring allow some expansion of the arch and prevent tendency to maxillary molars to move lingually Once the molars are distalize, they may be stabilized with Nance on 1st molars, a headgear or fixed appliance, then 2nd premolars are released to be freely to drift distally According to Hilgers 1992 it is usually to see 5mm distal molar movement in 3-4 months of treatment when the appliance is placed before eruption of 2nd molars, 2/3 of space is due to distal movement and 1/3 forward movement of anchor unite But if the 2nd molars are erupted so the space is created is 2/3 due to anchor unit movement and 1/3 due to distal movement of molars Ghosh and Nanda 1996 found the Pendulum is reliable method for distalization of molars Molar movement: 3.4mm Distal tipping: 8.4 degree Mesial movement of premolars: 2.5mm For every movement of 1mm molar distally, there is 0.75mm premolars movement mesially Advantages: -Minimal cooperation -Ease of fabrication -One time of activation -Patient acceptance -Can correct transverse problems Pendulum modifications: A-Pendex appliance: Introduced by Dr Hilgers in which the design is similar to the original Pendulum except the presence of palatal expansion screw in midline Used in case of class II malocclusion where transverse expansion is needed to correct the constricted maxilla Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

12. 12 B-M- Pendulum: It was given by Scuzzo et al 1999, in which Omega loops are inverted for bodily movement of maxillary molars Loop can be activated by opening it and it results buccal and / or distal uprighting of molars roots, thus producing bodily movements of maxillary molars C-Modified pendulum with removable arms: Wilson arch (bi-metric) Intra-oral, intra-maxillary distalizing appliance, Robert C Wilson introduced Bi-metric in 1955 Design: = labial arch made of 0.040 inch in posterior section and 0.020 inch in anterior section = hooks for class II elastics and soldered to the anterior part of wire at posterior end of 0.020- inch diameter = omega loop is placed at premolar region of 0.040-inch section = arch tight to bracket placed on anterior teeth by heavy ligature wire, open coil spring is placed between the omega loop and 1st maxillary molars = the activation is done by opening the omega loop and enhanced by using of class II elastics with lower arch = class I occlusion can be obtained from 6 -12 weeks, both distal movement and distal tipping of molar is observed = to enhance the mandibular anchorage: -Removable lower lingual arch -Fixed lingual arch -Lip bumper is added Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

13. 13 Elastics should be worn 24 hours a day removed only for eating and brushing. This appliance is cemented in place so it will remain in the mouth at all times. Treatment length will vary with each individual case and complexity Lip bumper (lip plumber) Spring made in the arch wire Functional appliance, combined fixed removable appliance, intra-oral, intra-maxillary Mode of action: altering the equilibrium between cheeks, lips, and tongue and transmitting forces from perioral muscles to the molars as it is applied Most commonly used in lower arch, in upper arch it is called Danholtz appliance Uses: 1-Treatment of lip sucking habits 2-Treatment of biting habit 3-Used as molar anchorage 4-Used for space opening in lower arch 5-Distalization of 1st molars before eruption of 2nd molars 6-Help in alignment of lower anterior teeth in case of hyper-active mentalis muscle, because it prohibits the activity of lower lip and allow labial tilting of lower anterior by the force of tongue ------------- decrease overjet 7-It should be early used in the mixed dentition phase to bring about minor distalization 8-Uprighting the mesially tipped mandibular molars to gain space in the arch 9-An inactive lip bumper is used as retentive appliance Design: Custom made appliance from 0.9mm or 1.2mm hard round ss wires that present in variable sizes Extended from molars in one side to molar tube in other side with loop located in the front of molars and it is adjustable It is placed in lower jaw from the right molar to the left molar, the curve of this lip bumper is located to the gingival margin direction -+3mm from the labial surface The anterior area can be covered by elastics or acrylic which function to help the adaptation of lip and check muscles so the pressure on lip muscles on teeth will decrease The cross section of acrylic labial shield is tears drop shape = The appliance must be worn 24 hours /day and should be removed only for meals and hygiene = Lip plumber should not exert any expansion or contraction on the molars and must easy for clinician and patient to insert and remove = The forces are transmitted from the lip directly on the buccal segment = The lip bumper is better used 24 hours / day within 6 to 18 months’ period depending on tooth movement and treatment goal Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

14. 14 Coil spring Fixed, intra-maxillary, intra-oral appliance used for distal movement of molars Use Nickel titanium open coil spring to achieve the desired force on heavy wire to allow distal movement Nance button is used to enhance anchorage in anterior part of the palate Gianelly et al 1991 obtained 1.5mm/month by coil spring Magnets distalizer Fixed intra-oral, intra-maxillary appliance, repelling magnets, used for distalize molar Consists of pair of repelling magnets, one placed on molars to be distalize and other on anterior teeth to it Anterior anchorage is reinforced using Nance holding arch It can be used inter-maxillary to distalize molars Magnets used: Samarium ---- cobalt magnets Neodymium ---- boron magnets Gianelly et al; stated that by using repelling magnets the distalization takes longer time with 2nd molars in occlusion and anchorage loss is 20% Other studies reported anchorage low 30% - 50% Erucli et al 1997: when compared between magnets and nickel titanium spring found that: 1-By magnets: molar movement ---2.1mm Molar tipping ---------7.6 degree 2-By spring: distal movement -------3.8mm Distal tipping ---------- 9.9 degree Other studies reported disto-buccal rotation with magnetic force Transpalatal arch TPA Can be used also unilateral distalization of maxillary molars but the movement is difficult to control Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

15. 15 Zygoma gear appliance = Described by Nur and colleagues 2010, it is modified version of conventional inner face bow = Hook is soldered to the bow on each buccal region and upper bend is placed mesial to the upper 1st molar on each side. Then adjusted to headgear tube, so, the anterior component is about 3mm from the anterior teeth = Zygoma gear is anchored by titanium miniplate in zygomatic process of maxilla Advantages: -Less molar inclination than other appliances -Force vector pass through the center of resistance of 1st molars Disadvantages: -Two minor surgical procedure and need to insert and remove the miniplate Treatment protocol: 1-The plates are titanium miniplates with three holes which continue into a round bar 2-Miniplates were placed at the zygomatic buttress of maxilla under local anesthesia and adjusted in lower face of each zygomatic process: length—5.0mm, diameter ---- 2.0mm 3-Adjustment of inner bow (1.1mm) and away from anterior teeth by 3mm 4-Three weeks after surgery, a distalization force of 300gm / side was applied to 1st molar via closed coil spring attached to 0.01inch stst ligature wire 5-Force is checked and calibrated with gm – force gauge during the initial activation and at 4 weeks’ intervals 6-All anchor plates were used for anchorage control during retraction of the premolars and anterior teeth, if required then they removed after debonding Nur et al 2012: 1-Maxillary molars were distalize into class I in short time 2-Rate of distal movement is 0.8mm / month without anchorage loss while distal tipping is 3.3 degree Dogan et al 2016: 1-Good unilateral molar distalization with anchorage loss 2-Amount of distal movement 5.3mm, 0.9mm / month 3-There is slight intrusion and distal tipping 4- Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

16. 16 Herbst appliance Fixed functional, intra-maxillary, intra-oral appliance, most popular in US introduced by Emil Herbst in 1900 and introduced at international congress at Berlin 1905 this appliance was forgotten and has been popularized by Hans Puncherz at 1970 design: stst bilateral telescopic mechanism attached to orthodontic bands keeping the mandible in forward position. Each telescopic device consists of: tube, plunger,2 pivots, 2screws -Pivot for tube: soldered to maxillary permanent 1st molars band -Pivot for plunger: soldered to the maxillary 1st premolar bands -Screws prevent the telescopic parts from slipping of the pivots The length of the tube determines the amount of bite jumping The length of the plunger is kept at maximum in order to prevent it from slipping out the tube when mouth is opened wide If the plunger is too long, however it may protrude far behind the tube and injurie the buccal mucosa distal to the maxillary permanent 1st molars The mechanisms permit vertical opening movements and, when properly constructed allow also lateral movement of the mandible Modifications: I- Class II collapsed maxillary arch, expansion was performed in connection with Herbest soldered to Quad helix arch II- In case of unerupted 1st premolars, the permanent canine can be used as anchorage teeth, but the buccal mucosa at the corner of mouth prone to ulceration when lower canine is used as an attachment tooth for the plunger III- In deciduous or early mixed dentition, the bonded type is used Indications: 1-Dental class II malocclusion 2-Skeletal class II with mandibular deficiency before pubertal and when teeth are aligned 3-Instead of activator when it interferes with breathing 4-In case of uncooperative patient 5-In case with: Retruded mandible, -------- small mandibular plane angle, ------- deep bite, --- normal or reduced lower facial height. Contraindications: 1-Cases predispose to root resorption 2-Dental and skeletal open bites 3-Vertical growth with high mandibular plane angle and excess lower face height Commercial Herbest types: 1-The cantilevered bite jumper (Oramco 1717 west Collins Avenue-Orange CA92867) 2-MA / U Herbst appliance (SAGA dental supply A /S ) 3-Flip – lock Herbst appliance 4-The magnetic telescopic device Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

17. 17 Advantages: 1-Not removed by the patient, action produced are continuous 2-Treatment duration is short due to continuous nature of action 3-Less patient cooperation in patient who are at the end of their growth 4-Used in patient with mouth breather habit Disadvantages: 1-Minor functional disturbances are masticatory system which are temporary and gradually disappear 2-Increased risk for development of dual bite 3-Repeated breakage and loosening of the appliance occurs especially in lower premolar area 4-Plaque accumulation and enamel decalcification occurs specially in the splint type of appliance 5-Tendency for posterior open bite at termination of therapy Anchorage preparation: == maxillary 1st premolars and 1st permanent molars are banded and are connected on each side of arch half round wire lingual or buccal (1.5 x 0.07) == mandibular 1st premolars are bonded and cemented with half round wire (1.5 x 0.07) lingual wire touch lingual surface of anterior teeth Studies and effects: Effects collected from sample of puncherz of 22 patients with appliance for 6 months’ class II patients Dental skeletal effects: 1-Mandibular incisors proclined with average 6.6 degree during 6 months 2-Maxillary incisors move very slightly backward 3-Maxillary 1st molars moved distally 2.8mm while lower moves mesially 1mm Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

18. 18 4-The A point moves posteriorly 0.4mm while B point moved anteriorly 2.5mm ----- ANB lower than 2 degree 5-Total mandibular length (condylon – Gnathion) increased 3 times more than untreated cases 6-Reduced overjet by 5mm 7-Molar relation corrected to class I Vertical effects: 1-Edge pf lower incisors were intruding 1.8mm (may be due to proclination) 2-Edge of upper incisors are unaffected 3-Lower 1st molar extrude 1.3mm 4-Upper 1st molars intrude 1.0mm TMJ effects: = puncherz and Hagg found that the sagittal growth at the condyle in patient treated with Herbst appliance at peak in pubertal growth was twice that observed in patients treated 3 years before or 3 years after the peak = the treatment may lead to recovery of pre-treatment TMJ clicking, this may be due to repositioning of the anterior displaced disc in relation to condyle head Muscular effects: = Generally, activities of masticatory muscles are impaired in class II patients = Muscle activities is reduced at start of treatment and after 3 months, the activities is almost return to their pre-treatment levels = in first 7 to 10 days, there is chewing difficulty but it reduced due to patient adaptation over the 1st 3 months, and after increase in dental intercuspation, the chewing efficiency increase = most improvement is occurring in post- treatment when full dental occlusal and maximum intercuspation is established N: B: TMJ and muscular tenderness increase in first 3 months of treatment and then decreased markedly, but it usually returns to its pre-treatment level after 12 months Variation in treatment in class II: In division 1: start orthopedic type of treatment to correct the basal relationship and then start orthodontic phase of treatment to correct the irregularities and arch deficiency problems with bracket system either extraction or non In division 2: start orthodontic treatment firstly to align the incisors irregularities followed by orthopedic phase to correct the basal relationship then orthodontic stage to correct the tooth irregularities and alignment. N: B: = Can use activator as retentive device after Herbst treatment to adapt the new position of mandible and main musculature but in some case with breathing problem can use Hawley retainer = stability depend on the good interdigitation of cusps Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

19. 19 Bite registration of Herbst appliance: = there is no universal amount of forward mandibular movement to bite recording, most clinician agree end to end incisors bite registration for cases with overjet 7mm or less. But if overjet is greater than 7mm, registration represent half of overjet distance is obtained for initial appliance fabrication, then reactivate the appliance every 2 – 3months with 2 – 3mm until end to end incisal relationship is obtained Failure rate: 13%: Herbest 34%: Twin block Mac Namara et al 1990, studied the effect of acrylic splint of Herbest and Frankel appliance and concluded that, both appliances: -Have measurable treatment effect in dental and skeletal -Increase amount of mandibular length -Varying increase in lower anterior facial height -Greater dento-alveolar effect in Herbest than Frankel Jasper Jumper Intra-oral fixed appliance, inter-maxillary class II malocclusion correction appliance Introduced by James Jasper in 1980, it can be deliver bite jumping distalizing force, elastic like force or combination of these. Indications: 1-Dental class II malocclusion 2-Skeletal class II with maxillary excess as opposed to mandibular deficiency 3-Deep bite with retroclined mandibular incisors Contraindication: 1-Cases predispose to root resorption 2-Dental and skeletal openbite 3-Vertical growth with high mandibular plane angle and excess lower facial height 4-Minimum buccal vestibular spaces Effects: 1-Intrusion and distalization of upper molars with slight opening the posterior bite similar to Herbst and headgear 2-Some indications in condylar growth 3-Anterior migration of mandibular teeth through alveolar bone 4-Intrusion in lower incisors 5-Expansion of upper molars if it is collapsed Design: Constructed of stst coil and cap covered by poly urethane for hygienic and comfort Jasper introduced in seven sizes ranging from 26mm to 38mm in length. The end cap is attached to maxillary posterior and mandibular anterior region: -Attached in upper arch by ball pin pass through face bow tube of upper 1st molars -Attached in lower arch distal to mandibular canine by small bayonet and Lexan head The length of force module is selected by adding 12mm to the measured length Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

20. 20 = fabrication measured length from tube of U6 to distal aspect of L3 and excess length about 12mm to give required optimum force that produce mesial force in lower arch and distal force on maxillary one Effects: 1-Skeletal effects: 40% Displace maxilla distally Shift A point distally Clock wise rotation of mandible Condyles moves forward 2-Dental effects: 60% Posterior tipping and intrusion of molars Anterior tipping of mandibular teeth Intrusion of mandibular incisors Advantages: 1-Produce continuous force 2-Do not require patient compliance by time of wear 3-Allow greater degree of mandibular freedom than Herbst appliance 4-Oral hygiene is easier to maintain Disadvantages: 1-Unattached bicuspids tend to erupt above the occlusal plane, as the anterior teeth intruded 2-Replacement of broken Jumper require removal of the entire arch wires 3-Removing of the Jumper for an occlusal check is time consuming 4-Limited opening Studies: = MacNamara concluded that skeletal and dental components of class II corrections are approximately equals = Weild and Bantleon: only 38% is skeletal changes = Jasper stated that class II correction with appliance is about: -20% maxillary skeletal straining -20% backward dentoalveolar movement of maxilla -20% forward dento-alveolar movement for mandible -20% condylar stimulation -20% downward and forward remodeling of glenoid fossa Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

21. 21 N: B: = A heavy arch wire with lingual root torque is used in the mandibular dental arch in order to maintain lower anchorage. = usually 6 – 9 months of Jumper wear is necessary in order to correct a mild additional problem in patient who still have some growth remaining Usual results from Jasper: 1-Intrusion and distalization of upper molars with opening of posterior bite similar to Herbst 2-Some condylar growth 3-Anterior migration of mandibular teeth through alveolar bone 4-Intrusion of lower incisors 5-Expansion of upper molars Eureka spring Fixed functional intra-oral inter-maxillary appliance, introduced by Deincenzo in 1997 with heavy arch wire Components: Piston and plunger assembly loaded with spring which is available in two force ranges 150gm and 210gm Appliance designed to use with heavy rectangular arch wire = labial root torque to lower incisors and buccal root torque for upper 1st molar should apply for anchorage enhancement = can use transpalatal arch for anchorage purpose = has the opposite action of class II elastics Indications: 1-Dental class II malocclusion 2-Deep bite with retroclined mandibular incisors Contraindications: 1-Class II with anterior openbite 2-Proclined lower anterior 3-Deep buccal over bite or posterior cross bite 4-Minimal buccal vestibular spaces Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

22. 22 Forsus appliance (3 M uniteck) Designed to use with fixed appliance = Supplied as prefabricated with different 5 lengths: 25mm, 29mm, 32mm, 35mm, 38mm = Optimum length is measured by put the mandible in forward positon in class I molar and remove the distance from maxillary molars tubes distally to distal of canine lower with disposable ruler with the kit = The appliance is inserted after upper and lower arches are aligned for minor crowding = Lower arch have lower lingual arch and upper has TPA for 1st molar to prevent tipping or flaring Twin force bite corrector appliance (Ortho-organizer company) Is fixed functional appliance, intra-oral, inter-maxillary clamped to the arch wire in both the upper and lower arches bilaterally Used for class II and class III correction (dental occlusion) Design: 1-Telescopic parallel cylinder 2-Within the cylinder a nickel titanium coil spring that is activated when patient occludes 3-Plunger is incorporated at the end of each cylinder on both sides 4-At the ends of each plunger, hex nuts are present to attached the appliance to the arch wire mesial to upper molars and distal to lower canine 5-At full compression a force approximately 210gm is delivered on each side by compression of coil spring Force direction and mechanics: Individual force component exerted by the appliance is an intrusive movement and distal to the posterior upper and mesial movement and intrusion for lower anterior segment Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

23. 23 At time force bite corrector, the point of force application is closer to the center of resistance of maxillary dentition when compared with ortho-fixed functional appliances whereas the point of force application in maxilla is distal to upper molars SO: lesser clock wise movement is generated with appliance on maxillary arch The force applied buccal to the center of resistance of maxillary molars (trifurcation of molar) so, buccal expansion force is experienced Advantages: 1-Easy to use; every placement and removal of this single piece appliance can be done chair side in few seconds 2-Fits firmly to the arch wire without removal and no head gear tube is needed 3-Universal orientation: appliance is bidirectional so, eliminate placement confusion 4-No patient cooperation required: maximum results with minimal patient cooperation 5-Only two sizes: small and standard Types: 1-Twin bite force corrector with anchor wire (TBFC): For class II: Measure from the distal edge of lower cuspid bracket to the distal end of upper molar face bow tube For class III: Measure from the distal edge of upper cuspid bracket to the distal end of lower 1st molar tube Available in two sizes: 27mm ---36mm, or 32mm ---- 48mm 2-Twin bite force corrector with double lock: (TBCC): Class II: measure from the distal edge of lower cuspid bracket to the mesial end of upper 1st molar Class III: measure from the distal edge of upper cuspid bracket to the mesial end of lower 1st molar tube Available in two sizes: 23mm ------ 32 or, 27mm ------ 36mm Treatment protocol: 1-Initial levelling and alignment 2-Upper arch 19 x 21 stst Lower arch 21 x 25 stst 3-Both arches are cinched to consolidate the arches into single unit to avoid any spaces developing or flaring of incisors Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby

24. 24 4-To minimize the lower incisors flaring, MBT bracket with -6 degree torque for lower anterior can used 5-TPA arch can used to counter the buccal forces exerted by TBFC 6-The appliance is attached by helx nuts to arch wire mesial to maxillary molars and distal to lower canine in forward position 7-After 3 to 4 months from appliance placement, the patient is usually over corrected to class I molars and canine relationship and helps to over compensate for any relapse that may occurs after appliance removal 8-Finishing and detailing for both arches 9-De-bonded and retainer lower fixed lingual and upper removable wrap- around retainer Effect of twin force bite corrector: = Nanda et al 2003: short and long term treatment results show that correction of class II more stable and favorable = Cample 2003, concluded that: -Improvement by TBFC is both skeletal and dental effect -Distal molar movement -Mesial molar movement -Moved A point 0.5mm posteriorly and 1.7mm inferiorly -Palatal plane rotates clockwise 0.5 degree =Nanda 2013, there is a relapse in over jet correction about 38% Treatment time: = Generally: the optimum treatment time for removable functional appliance appear to be during or slightly after the onset of peak of growth velocity For rigid functional appliance such as, Herbst, most effective in treatment of young adults during their peak height velocity stage of growth = Nanda et al: TBFC: recent studies: post-pubertal phase is preferred phase for class II intervention when compared between two groups, pre-pubertal and post-pubertal study Long term stability and its effects; = Puncherz, studied the long term retention related to rigid Herbst appliance and concluded that most of relapse related to dental changes or unstable occlusal relationship = studies the long term effect of TBFC in patient with class II div 1 malocclusion: age 12 years at beginning of treatment and evaluate the cases before treatment. After end of treatment and 2 years after retention, there is little changes effects either in dental or skeletal so correction is stable in general Distalization appliances Distalization appliances Dr. Mohammed Alruby Dr. Mohammed Alruby