Frankel’s Functional Regulator / orthodontic courses by Indian dental academy
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Transcript of Frankel’s Functional Regulator / orthodontic courses by Indian dental academy
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FRANKEL’S FUNCTIONAL REGULATOR
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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FRANKEL’S FUNCTIONAL REGULATOR
IntroductionFrankel’s philosophyFabrication of the applianceAppliance delivery & Clinical handlingFR in class 2 and class 3Modification of FRStudies on FRComparison b/w FR and other functional appliances
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Rolf frankel
Zwichau- Germany
1967 functional regulator
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FRANKEL’S PHILOSOPHYMossFunctional performance of the muscular portions of the capsule influence the developing functional spaces
Functional spaces also influence by atmospheric pressure
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FRANKEL’S PHILOSOPHY
Pressure on soft tissue
Muscular forces
Sub atmospheric pressure
Studies of Mobius During swallowing Vacuum in oral cavity
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FRANKEL’S PHILOSOPHY
‘ SPACE FACTOR’ important aspect of epigenetic regulation
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FRANKEL’S PHILOSOPHY
Functional space deficiency in transverse and vertical planes
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Perioral muscles had restraining effect on dental archesInsertion of appliance –expands capsule and allows for new functional adaptation of musclesActivator – ‘ push from within’FR – ‘ought to be matrix’All activities of oral cavity – muscle training
FRANKEL’S PHILOSOPHY
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FRANKEL’S PHILOSOPHYBuccal shields and lip pads exert periosteal pull exp not verified this effect Graber (1988) exp- on primates showed that this effect is temporary
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FRANKEL’S PHILOSOPHY The mechanical effect of the appliance directed to the capsular matrix and not to teeth / alveolar process.
MOYERS‘altering the condition that determine the pattern of occlusal development rather than altering the occlusion directly.’
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Classification of FRFR1Types a , b and cFR 2 FR3FR4MODIFICATIONS OF FR
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FR 1
Acrylic componentsBuccal shield Lip pads Lingual shield
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Buccal shields
ExtensionThickness 2.5mmExpansion of the capsule
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Lip padsextension and Tear drop shape Smoothen sulksLip posture and seal seal
5 mm
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Lip pads and buccal shields
Concomitant action in mandibular retrusion
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Lingual shieldsextensionOver comes the poor posture of mandibular musclesDifferent action from activatorAction only in step advancement
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Labial bow
Canine loop
Palatal bow
Cross over wire
Wire components of FR 1
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Wire components of FR 1
Lower lingual wires
Cross over wires
Labial bowPalatal bow Canine loop
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Labial bowPosition and extensionStabilizingConnecting‘Function activated’
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Palatal bowExtensionOcclusal rest on maxillary molarStabilizing action Intermaxillary anchorage
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Canine loop
ExtensionGuide eruption of canineIntermaxillary anchorage
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Lower lingual wires
ExtensionPrevent lingual movement of incisorsFunction activated element in deep bite and retruded anteriors
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Cross over wiresRun b/w 1st and 2nd premolarsNot to be lodged interdentally Cause movement of buccal segmentsNo training effect
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FR1a and FR1 b
Lower lingual loops
Overjet 5mm
Lower lingual shield
Overjet 7mm
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FR 1CStep by step opening in the anterior and vertical direction
Overjet > 7mm
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FR 2Canine loop and labial bow
Upper lingual wire
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Upper lingual wireRuns b/w canine and lateralStabilizing effectPrevents lingual tipping of anteriors in div 2 cases corrected in pre fr phase
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Upper lingual wirePreferred in class2 div 2 with horizontal growth patternBite opening action similar anterior bite plane/activatorBite opening effect also due to buccal shields
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FR 3
Lower labial wire
Upper lingual wire
Upper lip pads
Occlusal rests
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Buccal shields in FR 3Stand away from maxilla but not from mandible
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Lip pads in FR 3
Larger in sizeStands away from alveolar processExpansion of capsule and correction of postural imbalance
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Palatal bow and occlusal rests
Palatal bow not lodged interdentally
Additional occlusal rest on lower molar in deep bite
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Upper lingual wire and lower labial bow
Upper wire not touch the anteriors but can be activated to protrude incisors
Lower labial bow must touch the incisors
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FR 4
4 occlusal rests
Palatal bow
Lower labial pads and buccal shields
upper labial bow
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Construction of the FR appliance
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Impression techniqueReproduce whole alveolar process and depth of the sulcusTray selectionAdequate base
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construction biteDiffers from other functional appliancesAdvancement only by 2-3mm in first step
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Preparation of the casts
Gauge to measure the correct depth of the sulcus
Properly carved working models
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Preparation of the castsseating grooves:
Seating grooves are cut in the maxillary model in FR 1 and FR 2 in the permanent dentition
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Preparation of the castsseating grooves
Seating grooves in maxillary model for permanent dentition
Notching in the deciduous dentition
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Preparation of the casts
Sulcus trimming and position of lower lip pads
12 mm
Extension of lower lip pads
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Preparation of the castswax relief:
Maximum thickness of wax padding under buccal shield
Wax padding under the buccal shield to allow for dentoalveolar expansion
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Wire fabrication
Correct position of wires on the maxillary work model
Labial bow 0.9mm , canine loop 0.8mm and palatal bow 1mm
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Wire fabricationPalatal bow
Canine loop
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Wire fabrication
Correct position of lip pads and lingual shields and wiresLo-la 0.9mmLo –li 0.8mm
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Wire fabrication
Correct position b/w wires and wax up -0 .75mm
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Wire fabrication
Lingual wires 0.8mm
Extension arm of cross over wire 1mm
Single piece 3 separate pieces
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Wire fabricationFuture splitting of buccal shield with use of metal sheet
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Wire fabrication – FR 2
Palatal bow and upper lingual bow (0.9mm) in FR 2 seated inter proximally for locking
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Bite registration - most comfortable retruded position
Wire fabrication - FR 3
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Preparation of models- FR 3
Trimming of maxillary casts
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Wax relief – FR 3
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FR 3
CORRECT POSITION OF THE UPPER LIP PADS
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Wire fabrication - FR 3
Correct position of protrusion and palatal bow
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Wire fabrication - FR 3
Occlusal rest below palatal bow
Mandibular labial bow
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Timing of treatment7-8 ½ yearsBest therapeutic effect when mandibular lateral incisors eruptClass2 div I with mandibular retrusion- males till a 15-16 yearsNot start during circum pubertal growth period /late mixed dentition.
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Treatment phases with FRInitial phase
Active phase
Retention phase
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Initial phaseAppliance delivery
CheckSmoothness of marginsLip pad –tear dropSeparation b/w teeth In mixed dentition make notches
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Initial phaseAppliance delivery
Check appliance fitOverextension of shieldsPalpate face to to check for sharp edges
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Initial phaseWearing the appliance
Success of treatment – lip sealEmphasis on lip exercisesDuration of wearIst week – 1-3 hrs in afternoon only2nd week – 4-6 hrs3 – 4 months – full time wear
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Active phaseCheck after every 4 weeks
Mucosal irritationStability of applianceImpingement of cross over wires
Appliance adjustmentsCanine loop -occlusally Molar rests – gingivally
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Active phaseAppliance adjustmentsLabial bows & lingual wires-retract /close spacesLingual wires – towards cingula
Further advancement in severe cases
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Active phaseAfter 3 months of full time wearCheck
ExpansionOverjet Overbite molar relationship-(6-8 months)Leveling of curve of speeDecrease in mentalis activity
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Retentive phaseDifferent from fixed appliances Labial and lingual wires can hold altered tooth positionsUsed as retainer in pts where the training effect not satisfactoryFixed treatment may be required
2 hrs in afternoon6 hrs in nightOnly night – i year
6 months
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FR in treatment of class IIMandible displaced anteriorly- retractor muscle force –600gmsActivator-force transmitted to single teethBjork : rapid reaction in the dental system TMJ unaffectedMajor dental changes – Proclination of lower incisors
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FR in treatment of class IIActivator treatment
before after
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FR in treatment of class IIMode of action of activator in the treatment of mandibular retrusion
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FR in treatment of class IISuspending muscles relax during sleepMandible drops inferiorly and backwardsProclination of lower anteriors2-3mm advancement initial afternoon wear
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FR in treatment of class IIPost –sup elongation of condyleRemodeling at ramal-corpus junction- elongation of corpus
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The adjustive function of the ramus
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FR in the treatment of class 2
Mandibular retrusion to be overcome byExpanding the oral spaceSuspending muscles of mandible provide dynamic forceCorrect immature patterns b/w protractors and retractorsKeep mandible forward but not mechanically
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FR in the treatment of class 2
Change in position brought by lingual shieldsInitial bite 2-3 mm Advancement in small steps for biologic reasons.
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FR in the treatment of class 2
Step by step advancement by splitting the buccal shieldsSuspending muscles are not overstrainedActivator –extreme alteration of mandibular position –occlusal instability & TMDFR advancement in steps stability in post retention periods
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FR in the treatment of class 3
Characterized by diminished volume of the superior part of the oro-facial capsuleRelated to structural and postural imbalance of musclesLingual volume not to be diminished
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FR in the treatment of class 3
Expansion of upper oral space
Tongue space not diminished
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FR in the treatment of class 3
Septo premaxillary ligament pull translates upper incisors bodilyFR3 promotes max basal bone development and translates maxilla forwardAppliance should not be locked in the maxilla by wires
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FR in the treatment of skeletal open bites
Aimed at correcting the poor lip valve mechanism.Marked activity of temporalis and masseter when lips are closedAcc to Frankel tongue thrust is compensatory
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Modifications of FR appliance
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Modifications of FR appliance1. Capped frankel appliance-OTTON et al
19922. Modified functional regulator for VME -
Owen19853. Change in the angulation of cross over wire
–Chate 19864. Hybrid appliance –activator –FR
combination -19865. KINGSTON modified buccal shields6. Fr with continuous buccolabial shield and
palatal acrylic support – Haynes 1986
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CAPPED FR controls tippingIndicated in deep bite cases
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CAPPED FRDisadvantages- need of sufficient posterior separation- capping may impinge on U1 as treatment progresses- difficult to clean
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Change in the angulation of cross over wire
Strictly horizontal advancement results in incisal movements of the lower wire and shields
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Change in the angulation of cross over wire
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Change in the angulation of cross over wire
Difficulty in establishing normal lip functions
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Change in the angulation of cross over wire
In cases with step advancement FR to be constructed so that it be parallel to the downward and forward repositioning of the mandible
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Modified FR for VME Posterior part of maxilla –important for vertical growth control ½ -1/3 mm posterior eruption increases AFH by 1mm.Molars intruded chin translated forward improving profile
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Modified FR for VME
Modified FR for VME by adding posterior bite blocksAdded head gear tubes
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Modified FR for VME25 pts av age 7 yrs 3 months,bite 3-4 mm assessed after 19 monthsU1 retractedNo proclination of L1Horizontal movement of the chinAFH decreasedGumminess of smile reduced
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HYBRID FUNCTIONAL APPLIANCE (fr and activator
combination)Hybrid appliances are those that are specifically and individually tailored to exploit the natural process of growth and development
1. Bite planes2. Shields and screens3. Construction and working bite
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HYBRID FUNCTIONAL APPLIANCE (fr and activator
combination)
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HYBRID FUNCTIONAL APPLIANCE (fr and activator
combination)
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FR with kingston modified buccaL SHIELDS
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Modified Fr with continuous buccolabial shield and palatal acrylic support- haynes
ajo 1986To eliminate lip trapNo pressure on the gingival dentoalveolar tissues
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Studies on Frankel‘s appliance
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N.R.E Robertson AJO 198312 cases with FR2 and FR3 using cephs and conclude the principle changes were dentoalveolarMC NAMARA AJO 19843 adult patients with class 2 malocclusion with mandibular retrusion Length of mandible not increased but vertical dimensions increasedAdaptation minimal not sufficient to overcome malocclusion
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FACIAL GROWTH DURING TREATMENT WITH FR APPLIANCE
Leth Nielsen AJO 1984
10 pts treated with FR showed maxilla retrognaticNo indication that mandibular growth was promotedChanges more in vertical planeNot necessarily improved the profile
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Skeletal and dental changes following FR therapy on class II patients
MC NAMARA AJO 1985
100 pts treated for 24 months and compared with controlsNo change in maxillaIf considered pt A then slight retrusion of maxillaU6 forward movement reduced but not verticalL6 vertical movement
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Skeletal and dental changes following FR therapy on class II patients
MC NAMARA AJO 1985
U1 tipped posteriorly some tipping of L1Downward movement of mandible noticed Some forward movement noticed in some pts
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The effect of FR 4 in class 1 skeletal anterior open bite
ELIT ERBAY AJO 199520 treated and 20 controlsUseful in treatment Diminished AFH ,growth rate of AFH (3.9 mm)decreased ,& PFH increased (4.5 mm).
Caused forward and upward rotation of mandibleReduction in mandibular plane angles i.e Sn-GoMe,AnsPns-GoMe
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Frankel-post vestibular shields caused inferior translation of mandible,growth at condyle increase in ramal length
Anterior part of mandible rotated upward because of the lip seal
Erbay’s study noted FR inhibited posteriors and improved the axial inclination of U1
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Comparison of FR with other functional
appliances
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FR Vs twin blocktoth/mc namara AJO 1999
4O PTS WITH TWIN BLOCK AND FR COMPARED TO CONTROLSResultsIncrease in mandibular length
Twin block – 3mm > controlsFR – 1.9MM
Vertical dimension & dentoalveolar changes TB > FRTB -mandibular skeletal & dentoalveolar changesFR – more skeletal and less dentoalveolar
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FR Vs herbst appliancemc namara ,howe ajo 1990
45 herbst and 41 FR pts compared with controlsResults Both appliance – no effect on maxillaherbst – prevented vertical eruption and caused posterior movement of u6U1 lingual tipping- bothLower proclination L1 – herbst > FR mandibular length
Control - 2.1mm/yrHerbst - 4.8mmFR – 4.3mm
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FR Vs fixed mechanotherapy
CREEKMORE,RADNEY AJO 1983FR compared to edgewise with headgearEdgewise had greater retractive force on maxillaRetraction of u1 > FR Retraction of L1Backward growth of condyle But 1.2mm < FRPog forward 1mm< FR
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Fr therapy in cleft palate patients
keere,welch ajo 1981
9 pts treated with Fr for 6-18 monthsTo treat collapsed maxilla and cross biteResultsNot clinically useful in cleft patients
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Frankel’s functional regulator
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The occipital reference system
Orientation to the earth’s surface
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The occipital reference system
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The occipital reference system
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Case 1Class2 Mandible retrudedNo lip seal+ VTOFR 1
8 yrs 4 months
1 1/2 year post retention
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Case 1
Pre treatment After FR 1 ½ years post retention
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Case 1bjork
Occipital reference system
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Case 2
Class 2Mandibular retruded open bite no lip seal
8 yrs 5 months
22 yrs .9 years post retention
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Case 2
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Case 2
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Case 312 yrs
16 yrs
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Case 3
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Case 3
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Case 4Class 3Maxillary retrusion Mandibular prognatismNo lip seal Flaccid lips
6 yrs 5 months
7 yrs 3 months
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Case 4
After FR 7 yrs post retention
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Case 4
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Case 5Class 3Incompetent lip valve retruded maxilla
5 years 7 months
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Case 5
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Case 5
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Case 6Class 2 div 1 skeletal open biteLips habitually parted hypotonic
9 yrs 10 months
20 yrs
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Case 64 yrs 11 months
9 yrs
After FR
At 20 yrs
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Case 7
Stability of transverse dimensions in post retention periods
Pre FR Post FR 7 years post retention
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Case 7
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Case 8
Pre FR
8 yrsPost FR 17 yrs
Thank you
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