Evidence based dentofacial orthopedics (2) /certified fixed orthodontic courses by Indian dental academy

EVIDENCE BASED DENTOFACIAL
ORTHOPEDICS
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education

CONTENTS
Introduction
Historical purview
History of evidence based health care and
evidence based dentistry
History of dentofacial orthopedics - Origin
and philosophy of functional appliances
and growth modification concept
Status of functional appliances in Europe
and United States

CONTENTS
Principles of functional appliances
Review of literature
Literature regarding treatment of Class
II malocclusion
Literature regarding treatment of Class
III malocclusion
Literature regarding treatment of
Transverse Maxillary Expansion

CONTENTS
Functional appliances and
mandibular growth
Stepwise advancement of mandible
V/s maximal jumping of bite
Summary and Conclusions

INTRODUCTION

There is only one disease –
malocclusion. The medicine is force,
and there are a number of ways to
apply that force.
Weinstein (1971)

Evidence based treatment
Treatment procedures should be
chosen on the basis of clear evidence
that the selected method is the most
successful approach to that
particular patient’s problem(s).
Better evidence fortifies the decision.

There are trends and fashions,
controversies and claims in
orthodontics just as in other
specialties in medicine.
One such controversy is that which
is surrounding Functional Jaw
Orthopedics.

Functional appliances were always
questioned regarding their efficacy to
bring about skeletal changes.

HISTORICAL PURVIEW

Evidence-based health care is said to
have its origins in the middle of the
19th century in Paris, when young
graduates started challenging the
validity of clinical decisions based
solely upon personal experience.
An even earlier origin in China has
been suggested.
A structured and formal introduction
can be traced to McMaster University
in Canada (1985).

The American College of Physicians
followed suit little later.
A formal initiative on the continent
was taken by the establishment of
Center for Evidence-Based Medicine
in Oxford, UK in 1995.
The Centre for Evidence-Based
Dentistry was not far behind in its
establishment.
The movement is catching up and
has spread to Spain; and now to
India (CEBD-i)!

Criticism has ranged from evidence-
based medicine being old-hat to it
being a dangerous innovation,
perpetrated by the arrogant to serve
cost-cutters and suppress clinical
freedom.
The first International Conference on
Evidence Based Dentistry was held
on November 2003 in Atlanta.

The purpose of using an EB(evidence
based) approach in clinical care is to
close the gap between what is known
and what is practiced, and to
improve patient care based upon
informed decision-making.

The Age of Expert and the Age of
Professionalism was followed by the
Age of Science leading to the present,
which some now call the Age of
Evidence.

HISTORY OF DENTOFACIAL
ORTHOPEDICS

Nicolas Andry is credited as the first
to coin the term ORTHOPAEDIC.
Andry derived the word orthopedie
from the Greek words ORTHO
(straight) and PED (child) referring to
the art of Correcting and Preventing
Deformities in Children.

Bone may be one of the hardest
tissues in the human body but it is
also one of the most responsive to
environmental stimuli.
Bone has always been tried to be
modified to produce favorable
results.

European orthodontists suggested
the use of muscular forces to correct
the various dentofacial deformities.
The original name Andresen used for
this type of Treatment was
Biomechanical Orthodontics.
later, after teaming up with Häupl,
was the name changed to
Functional Jaw Orthopedics.

Wolff and Roux (1883) - Theories on
bone plasticity.
Working hypothesis - “shaking of the
bones.”
In 1880, Kingsley introduced the
term and concept of “jumping the
bite” for patients with mandibular
retrusion.
Hotz modified the Kingsley plate and
called it “vorbissplatte.”

In 1900’s, the German physiologist
Wolff stated that “the internal
architecture of bones represents the
stress pattern on them”.
Benninghoff made an exhaustive
study of the architecture of the
cranial and facial skeleton, and of
the so called stress trajectories.

The hard palate, the walls of the
orbits, the zygomatic bones, the
palatine bones and the lesser wings
of the sphenoid act as crossbeams
and buttresses of the face.

In 1902, Pierre Robin of France used
a monobloc to posture the mandible
forward when it was underdeveloped
or retruded.
The activator as known today was
devised by a Dane, Viggo Andresen.

Repetition of the new mandibular
closure pattern induced a
musculoskeletal adaptation and
resulted in the re-education of the
orofacial musculature.
Described as an exercise appliance.

Tooth-moving force produced due
not to the kinetic energy of muscle
function but to the potential energy
of stretched tissues.
Woodside et al were to refer to this
later as the “visco-elastic” properties
of the tissue.
AJO 1983

Numerous authors modified the activator
appliance like Karwetsky, Wünderer,
Harvold, Woodside, Herren, Muhlemann
to name a few.
The bulkiness of the activator and its
limitations to nighttime wear caused the
development of many similar appliances.
E.g. Bimler’s appliance in 1946; Bionator
by Balters in 1960; Functional Regulator
of Rolf Fränkel in 1967; Twin Block
Appliance by William J. Clark in 1977 .

In Berlin in 1909, Emil Herbst
presented a fixed Bite-jumping
appliance Called the Scharnier, or
joint.
The Herbst Appliance continuously
keeps the mandible in a protruded
position both when the jaws close
and the teeth are not in occlusion.
Jasper jumper, FOMA, MARA,
Forsus, etc.

Extraoral force to the maxilla
(headgear) was utilized by the
pioneer American orthodontists of
the late 1800s, who found it
reasonably effective.
Although headgear was reintroduced
in 1940s and came to be widely used
in Class II treatment, it was seen
primarily as a tooth-moving device .

American orthodontists were slow to
recognize the idea that mandibular
as well as maxillary growth could be
manipulated clinically.

One of the oldest orthodontic
appliances is the palatal expansion
apparatus.

Isaacson and Ingram (1964) showed
that single activations produce forces
ranging from 3 to 10 pounds and
that multiple daily activations, as
commonly practiced, can cause
cumulative residual loads of up to 20
or more pounds. AJO 1978

STATUS OF FUNCTIONAL
APPLIANCES IN EUROPE
AND
UNITED STATES

The philosophical outlook of
orthodontists was determined by
which side of the Atlantic Ocean they
lived and practiced on.
American orthodontists had been
slower to realize the benefits of
removable and functional appliances

Functional appliances were introduced to
North American orthodontics in the mid
1950s primarily under the influence of Dr.
Egil Harvold.
These alternating phases of reciprocal
influence or swing of the pendulum have a
time interval of about 15 years between
Europe and the USA.

Sem-2

PRINCIPLES OF
FUNCTIONAL APPLIANCES

In 1918, Alfred P. Rogers recommended
"exercises for the development of the
muscles of the face, with a view to
increase their functional activity."

Functional appliances are considered by
most authorities to be primarily an
orthopedic tool to influence the facial
skeleton of the growing child in the
condylar and sutural areas.
These appliances also exert orthodontic
effects on the dentoalveolar area.

Functional appliances don’t act on the
teeth in a similar manner to conventional
appliances, which use mechanical
elements
It rather harness, transmit, eliminate, and
guide natural forces (e.g., muscle activity,
growth, and tooth eruption).

The goal of dentofacial orthopedics is to
use this functional stimulus, channeling it
to the greatest extent the tissues, jaws,
condyles and teeth allow.
Force deprivation also plays a role in
functional appliance (FA) therapy,
particularly with the Fränkel and Balters
appliances.

Appliance systems that rely on muscle
mass and resting pressure are termed
"myotonic" and those using muscle
activity or movement are called as
"myodynamic" appliances.

The adaptations in the functional pattern
caused by the activator also include and
affect the condyles.
Condylar adaptation to the anterior
repositioning of the mandible consists of
growth in an upward and backward
direction to maintain the integrity of the
TMJ structures.

Myotatic (stretch) reflex activity is
stimulated, causing isometric muscle
contractions. This muscle force
transmitted by the appliance moves the
teeth.
Selmer-olsen interpreted the activator
action as a stretching of the muscles,
fascial sheets, and ligaments when the
mandible was opened beyond postural
resting position.

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Evidence based dentofacial orthopedics (2) /certified fixed orthodontic courses by Indian dental academy

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