Ce 2008 m Lekic Use of Functional Appliances in Interceptive Orthodontics

8/3/2019 Ce 2008 m Lekic Use of Functional Appliances in Interceptive Orthodontics

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Functional appliancesFunctional appliances


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BackgroundBackground

Functional appliances are conceptually based on MossFunctional appliances are conceptually based on Mossfunctional matrix theoryfunctional matrix theory

Functional matrix theory proposes that functionalFunctional matrix theory proposes that functionalmatrices, tissues like muscles and glands influencematrices, tissues like muscles and glands influenceskeletal units such as jaw bones and ultimately controlskeletal units such as jaw bones and ultimately controltheir growththeir growth


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Form follows functionForm follows function


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Functional appliance typesFunctional appliance types

Orthodontic functional appliances may be active orOrthodontic functional appliances may be active orpassive:passive:

Active appliances reposition the mandible so that the condyleActive appliances reposition the mandible so that the condyle

is forced out of the glenoid fossa and this in turn is thoughtis forced out of the glenoid fossa and this in turn is thoughtto stimulate the posterior/superior growth of the condyleto stimulate the posterior/superior growth of the condyle

Passive appliances act by repositioning the musculaturePassive appliances act by repositioning the musculatureassociated with the mandible so that the jaw bone itselfassociated with the mandible so that the jaw bone itself

responds by growing to the new equilibrium positionresponds by growing to the new equilibrium position


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Passive functional appliancesPassive functional appliances

FrankelFrankel


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Active functional appliancesActive functional appliances

Fixed active functional appliancesFixed active functional appliances

HerbstHerbst


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Removable active functional appliancesRemovable active functional appliances

BionatorBionator


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Woodside activatorWoodside activator


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TwinTwin--block applianceblock appliance


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Duration and timing of wearDuration and timing of wear

Functional appliance treatment should be startedFunctional appliance treatment should be started

before the pubertal growth spurtbefore the pubertal growth spurt

This is the time when the mandible may exhibitThis is the time when the mandible may exhibitincreased growth which may be influencedincreased growth which may be influenced

Functional appliances should be worn for atFunctional appliances should be worn for at

least 10least 10--12 hours a day12 hours a day

These appliances should be worn at nighttime asThese appliances should be worn at nighttime asthis is when growth takes placethis is when growth takes place


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Evidence of clinical effectivenessEvidence of clinical effectiveness

A Cochrane review, published in 2008, studiedA Cochrane review, published in 2008, studiedorthodontic treatment for prominent upper teeth inorthodontic treatment for prominent upper teeth inchildrenchildren

The study concentrated on primary outcomes including theThe study concentrated on primary outcomes including theprominence of upper front teeth and the relationshipprominence of upper front teeth and the relationshipbetween upper and lower jawsbetween upper and lower jaws

The secondary outcomes compared included selfThe secondary outcomes compared included self--esteem,esteem,

injury to teeth, joint problems, patient satisfaction and theinjury to teeth, joint problems, patient satisfaction and thenumber of appointments during active treatmentnumber of appointments during active treatment


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It has been shown that when front teeth stick out byIt has been shown that when front teeth stick out bymore than 3mm, they are twice as likely to be injuredmore than 3mm, they are twice as likely to be injured

The Cochrane review included eight clinical trials, basedThe Cochrane review included eight clinical trials, based

on data from 592 patients with Class II Division 1on data from 592 patients with Class II Division 1 Three trials, evaluating 432 patients, compared earlyThree trials, evaluating 432 patients, compared early

treatment (before the age of 10) with a functionaltreatment (before the age of 10) with a functionalappliance compared to no treatmentappliance compared to no treatment

It was found that functional appliance treatmentIt was found that functional appliance treatmentresulted in significant decreases in overjet and the ANBresulted in significant decreases in overjet and the ANBangleangle


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When the same patients received the second phase ofWhen the same patients received the second phase oftreatment (full fixed treatment) and when they weretreatment (full fixed treatment) and when they werecompared to patients who only received one phase ofcompared to patients who only received one phase of

treatment in adolescence, it was found that there weretreatment in adolescence, it was found that there wereno significant differencesno significant differences

Other reviews have also found that although the overallOther reviews have also found that although the overalleffect of early treatment was not significant, theeffect of early treatment was not significant, the

patients did have a milder malocclusion at the start ofpatients did have a milder malocclusion at the start offull fixed treatmentfull fixed treatment


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A systematic review by Cozza et.al. included 18A systematic review by Cozza et.al. included 18retrospective longitudinal controlled clinical trialsretrospective longitudinal controlled clinical trials

It was found that functional appliances did result in aIt was found that functional appliances did result in a

significant elongation of mandibular length (>2mm)significant elongation of mandibular length (>2mm)

It was concluded that the effect of growth modificationIt was concluded that the effect of growth modificationis the greatest during the pubertal growth peakis the greatest during the pubertal growth peak


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What does this mean?What does this mean?

According to the evidence one should not useAccording to the evidence one should not usefunctional appliances as they are not necessarily morefunctional appliances as they are not necessarily moreefficient than one phase treatmentefficient than one phase treatment

Should we rely only on evidence in guiding our clinicalShould we rely only on evidence in guiding our clinicaldecisions?decisions?

I would argue that although sound scientific evidence isI would argue that although sound scientific evidence isthe most important aspect of clinical practice, it is notthe most important aspect of clinical practice, it is notthe only factor to considerthe only factor to consider


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What does all this mean?What does all this mean?

Indeed, care for our patients extends beyond allIndeed, care for our patients extends beyond all

the evidence availablethe evidence available

True care also includes:True care also includes: HonestyHonesty

EmpathyEmpathy

Being genuineBeing genuine

Patient centered approachPatient centered approach


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ReferncesRefernces

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http://farm1.static.flickr.com/47/154578698_6011a485ce.jpghttp://farm1.static.flickr.com/47/154578698_6011a485ce.jpg http://www.sleepingtiger.org/blog/wphttp://www.sleepingtiger.org/blog/wp--

content/uploads/2007/08/maxyawns.jpgcontent/uploads/2007/08/maxyawns.jpg

http://imagecache2.allposters.com/images/146/PP0195.jpghttp://imagecache2.allposters.com/images/146/PP0195.jpg http://www.nimrodental.co.uk/appliances/media/functional5.jpghttp://www.nimrodental.co.uk/appliances/media/functional5.jpg http://coloradospringsortho.com/Web%20site/About%20braces_files/herbhttp://coloradospringsortho.com/Web%20site/About%20braces_files/herb

st_appliance.jpgst_appliance.jpg https://reader009.{domain}/reader009/html5/0507/5af0347b49a0d/5af03488b6152https://reader009.{domain}/reader009/html5/0507/5af0347b49a0d/5af03488b6152 http://www.tanos.co.uk/braces/bkb/images/activatorwoodside.jpghttp://www.tanos.co.uk/braces/bkb/images/activatorwoodside.jpg http://www.orthodentlab.com/products/images/photos/TwinBlock1.jpghttp://www.orthodentlab.com/products/images/photos/TwinBlock1.jpg


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ReferencesReferences

Harrison JE, OBrien KD, Worthington HV. Orthodontic treatment for prominentHarrison JE, OBrien KD, Worthington HV. Orthodontic treatment for prominent

upper front teeth in children (review). The Cochrane Collaboration. John Wiley &upper front teeth in children (review). The Cochrane Collaboration. John Wiley &Sons, 2008.Sons, 2008.

Nguyen QV, Bezemer PD, Habets L, PrahlNguyen QV, Bezemer PD, Habets L, Prahl--Andersen B. A systematic review of theAndersen B. A systematic review of therelationship between overjet size and traumatic dental injuries. European Journal ofrelationship between overjet size and traumatic dental injuries. European Journal of

Orthodontics 1999;21(5):503Orthodontics 1999;21(5):503--515.515.

Pavlow SS, McGorray SP, Taylor MG, Dolce C, King GJ, Wheeler TT. Effect of earlyPavlow SS, McGorray SP, Taylor MG, Dolce C, King GJ, Wheeler TT. Effect of early

treatment on stability of occlusion in patients with Class II malocclusion. Americantreatment on stability of occlusion in patients with Class II malocclusion. AmericanJournal ofOrthodontics and Dentofacial Orthopedics 2008;133:235Journal ofOrthodontics and Dentofacial Orthopedics 2008;133:235--244.244.

Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. American Journal ofDolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT. American Journal of

O

rthodontics and DentofacialO

rthopedics 2007;132:481O

rthodontics and DentofacialO

rthopedics 2007;132:481--489.489. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA. Mandibular changesCozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA. Mandibular changes

produced by functional appliances in Class II malocclusion: a systematic review.produced by functional appliances in Class II malocclusion: a systematic review.

American Journal ofOrthodontics and Dentofacial Orthopedics 2006;129:599.e1American Journal ofOrthodontics and Dentofacial Orthopedics 2006;129:599.e1--599.e12.599.e12.

Ce 2008 m Lekic Use of Functional Appliances in Interceptive Orthodontics

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