FRANKEL’S FUNCTIONAL REGULATOR
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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FRANKEL’S FUNCTIONAL REGULATOR Introduction Frankel’s philosophy Fabrication of the appliance Appliance delivery & Clinical handling FR in class 2 and class 3 Modification of FR Studies on FR Comparison b/w FR and other functional appliances 3
Rolf frankel Zwichau- Germany 1967 functional regulator
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FRANKEL’S PHILOSOPHY Moss Functional 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 7
FRANKEL’S PHILOSOPHY
Functional space deficiency in transverse and vertical planes
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FRANKEL’S PHILOSOPHY Perioral muscles had restraining effect on dental arches Insertion of appliance –expands capsule and allows for new functional adaptation of muscles Activator – ‘ push from within’ FR – ‘ought to be matrix’ All activities of oral cavity – muscle training 9
FRANKEL’S PHILOSOPHY Buccal 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 FR FR1 Types a , b and c FR 2 FR3 FR4 MODIFICATIONS OF FR
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FR 1
Acrylic components Buccal shield Lip pads Lingual shield 13
Buccal shields Extension Thickness 2.5mm Expansion of the capsule
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Lip pads extension and Tear drop shape Smoothen sulks Lip 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 shields
extension Over comes the poor posture of mandibular muscles Different action from activator Action only in step advancement
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Wire components of FR 1
Palatal bow
Labial bow Canine loop
Cross over wire
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Wire components of FR 1
Cross over wires
Labial bow Palatal bow
Canine loop
Lower lingual wires
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Labial bow Position and extension Stabilizing Connecting ‘Function activated’
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Palatal bow Extension Occlusal rest on maxillary molar Stabilizing action Intermaxillary anchorage
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Canine loop Extension Guide eruption of canine Intermaxillary anchorage
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Lower lingual wires Extension Prevent lingual movement of incisors Function activated element in deep bite and retruded anteriors 23
Cross over wires Run b/w 1st and 2nd premolars Not to be lodged interdentally Cause movement of buccal segments No training effect 24
FR1a
and FR1 b Lower lingual loops Overjet 5mm
Lower lingual shield Overjet 7mm 25
FR 1C Step by step opening in the anterior and vertical direction
Overjet > 7mm
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FR 2 Canine loop and labial bow
Upper lingual wire
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Upper lingual wire Runs b/w canine and lateral Stabilizing effect Prevents lingual tipping of anteriors in div 2 cases corrected in pre fr phase 28
Upper lingual wire Preferred in class2 div 2 with horizontal growth pattern Bite opening action similar anterior bite plane/activator Bite opening effect also due to buccal shields 29
FR 3 Upper lip pads Lower labial wire
Upper lingual wire
Occlusal rests
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Buccal shields in FR 3 Stand away from maxilla but not from mandible
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Lip pads in FR 3 Larger in size Stands away from alveolar process Expansion of capsule and correction of postural imbalance 32
Palatal bow and occlusal rests Palatal bow not lodged interdentally Additional occlusal rest on lower molar in deep bite 33
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 34
FR 4
Lower labial pads and buccal shields
4 occlusal rests
upper labial bow
Palatal bow 35
Construction of the FR appliance
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Impression technique Reproduce whole alveolar process and depth of the sulcus Tray selection Adequate base
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construction bite Differs from other functional appliances Advancement 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 39
Preparation of the casts seating 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 casts seating grooves
Seating grooves in maxillary model for permanent dentition Notching in the deciduous dentition 41
Preparation of the casts Sulcus trimming and position of lower lip pads
Extension of lower lip pads
12 mm
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Preparation of the casts wax relief: Wax padding under the buccal shield to allow for dentoalveolar expansion
Maximum thickness of wax padding under buccal shield 43
Wire fabrication Labial bow 0.9mm , canine loop 0.8mm and palatal bow 1mm
Correct position of wires on the maxillary work model
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Wire fabrication Palatal bow
Canine loop
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Wire fabrication
Correct position of lip pads and lingual shields and wires Lo-la 0.9mm Lo –li 0.8mm 46
Wire fabrication Correct position b/w wires and wax up -0 .75mm
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Wire fabrication
Single piece
3 separate pieces
Lingual wires 0.8mm Extension arm of cross over wire 1mm 48
Wire fabrication Future 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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Wire fabrication - FR 3
Bite registration - most comfortable retruded position 51
Preparation of modelsFR 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 55
Wire fabrication - FR 3 Occlusal rest below palatal bow
Mandibular labial bow
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Timing of treatment 7-8 ½ years Best therapeutic effect when mandibular lateral incisors erupt Class2 div I with mandibular retrusionmales till a 15-16 years Not start during circum pubertal growth period /late mixed dentition.
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Treatment phases with FR Initial phase Active phase Retention phase
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Initial phase Appliance delivery Check Smoothness of margins Lip pad –tear drop Separation b/w teeth In mixed dentition make notches 59
Initial phase Appliance delivery Check appliance fit Overextension of shields Palpate face to to check for sharp edges
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Initial phase Wearing the appliance Success of treatment – lip seal Emphasis on lip exercises Duration of wear Ist week – 1-3 hrs in afternoon only 2nd week – 4-6 hrs 3 – 4 months – full time wear 61
Active phase Check after every 4 weeks Mucosal irritation Stability of appliance Impingement of cross over wires Appliance adjustments Canine loop -occlusally Molar rests – gingivally
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Active phase Appliance adjustments Labial bows & lingual wires-retract /close spaces Lingual wires – towards cingula Further advancement in severe cases
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Active phase After 3 months of full time wear Check Expansion Overjet Overbite molar relationship-(6-8 months) Leveling of curve of spee Decrease in mentalis activity
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Retentive phase Different from fixed appliances Labial and lingual wires can hold altered tooth positions Used as retainer in pts where the training effect not satisfactory Fixed treatment may be required 2 hrs in afternoon 6 months 6 hrs in night Only night – i year
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FR in treatment of class II Mandible displaced anteriorly- retractor muscle force –600gms Activator-force transmitted to single teeth Bjork : rapid reaction in the dental system TMJ unaffected Major dental changes – Proclination of lower incisors
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FR in treatment of class II Activator treatment
before
after 67
FR in treatment of class II Mode of action of activator in the treatment of mandibular retrusion
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FR in treatment of class II Suspending muscles relax during sleep Mandible drops inferiorly and backwards Proclination of lower anteriors 2-3mm advancement initial afternoon wear
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FR in treatment of class II Post –sup elongation of condyle Remodeling 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 by Expanding the oral space Suspending muscles of mandible provide dynamic force Correct immature patterns b/w protractors and retractors Keep mandible forward but not mechanically 72
FR in the treatment of class 2 Change in position brought by lingual shields Initial 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 shields Suspending muscles are not overstrained Activator –extreme alteration of mandibular position –occlusal instability & TMD FR 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 capsule Related to structural and postural imbalance of muscles Lingual volume not to be diminished 75
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 bodily FR3 promotes max basal bone development and translates maxilla forward Appliance should not be locked in the maxilla by wires 77
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 closed Acc to Frankel tongue thrust is compensatory 78
Modifications of FR appliance
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Modifications of FR appliance 1. Capped frankel appliance-OTTON et al 2. 3. 4. 5. 6.
1992 Modified functional regulator for VME -Owen1985 Change in the angulation of cross over wire –Chate 1986 Hybrid appliance –activator –FR combination -1986 KINGSTON modified buccal shields Fr with continuous buccolabial shield and palatal acrylic support – Haynes 1986 80
CAPPED FR controls tipping Indicated in deep bite cases
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CAPPED FR Disadvantages - 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 85
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 86
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 blocks Added head gear tubes 88
Modified FR for VME 25 pts av age 7 yrs 3 months,bite 3-4 mm assessed after 19 months U1 retracted No proclination of L1 Horizontal movement of the chin AFH decreased Gumminess of smile reduced 89
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 planes 2. Shields and screens 3. Construction and working bite 90
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 1986 To eliminate lip trap No pressure on the gingival dentoalveolar tissues
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Studies on Frankel‘s appliance
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N.R.E Robertson AJO 1983 12 cases with FR2 and FR3 using cephs and conclude the principle changes were dentoalveolar MC NAMARA AJO 1984 3 adult patients with class 2 malocclusion with mandibular retrusion Length of mandible not increased but vertical dimensions increased Adaptation minimal not sufficient to overcome malocclusion 96
FACIAL GROWTH DURING TREATMENT WITH FR APPLIANCE Leth Nielsen AJO 1984 10 pts treated with FR showed maxilla retrognatic No indication that mandibular growth was promoted Changes more in vertical plane Not necessarily improved the profile 97
Skeletal and dental changes following FR therapy on class II patients MC NAMARA AJO 1985
100 pts treated for 24 months and compared with controls No change in maxilla If considered pt A then slight retrusion of maxilla U6 forward movement reduced but not vertical L6 vertical movement 98
Skeletal and dental changes following FR therapy on class II patients MC NAMARA AJO 1985
U1 tipped posteriorly some tipping of L1 Downward 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 1995 20 treated and 20 controls Useful in treatment Diminished AFH ,growth rate of AFH (3.9 mm)decreased ,& PFH increased (4.5 mm). Caused forward and upward rotation of mandible Reduction in mandibular plane angles i.e SnGoMe,AnsPns-GoMe 100
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 101
Comparison of FR with other functional appliances
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FR Vs twin block toth/mc namara AJO 1999 4O PTS WITH TWIN BLOCK AND FR COMPARED TO CONTROLS Results Increase in mandibular length Twin block – 3mm > controls FR – 1.9MM Vertical dimension & dentoalveolar changes TB > FR TB -mandibular skeletal & dentoalveolar changes FR – more skeletal and less dentoalveolar 103
FR Vs herbst appliance mc namara ,howe ajo 1990 45 herbst and 41 FR pts compared with controls Results Both appliance – no effect on maxilla herbst – prevented vertical eruption and caused posterior movement of u6 U1 lingual tipping- both Lower proclination L1 – herbst > FR mandibular length Control - 2.1mm/yr Herbst - 4.8mm FR – 4.3mm 104
FR Vs fixed mechanotherapy CREEKMORE,RADNEY AJO 1983 FR compared to edgewise with headgear Edgewise had greater retractive force on maxilla Retraction of u1 > FR Retraction of L1 Backward growth of condyle But 1.2mm < FR Pog 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 months To treat collapsed maxilla and cross bite Results Not clinically useful in cleft patients
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Frankelâ&#x20AC;&#x2122;s functional regulator
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The occipital reference system Orientation to the earthâ&#x20AC;&#x2122;s surface
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The occipital reference system
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The occipital reference system
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Case 1 Class2 Mandible retruded No lip seal + VTO FR 1
8 yrs 4 months
1 1/2 year post retention 111
Case 1
Pre treatment
After FR
1 ½ years post retention
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Case 1 bjork
Occipital reference system
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Case 2 Class 2 Mandibular retruded open bite no lip seal
8 yrs 5 months
22 yrs .9 years post retention 114
Case 2
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Case 2
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Case 3 12 yrs 16 yrs
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Case 3
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Case 3
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Case 4 6 yrs 5 Class 3 months Maxillary retrusion Mandibular prognatism 7 yrs 3 No lip seal months Flaccid lips
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Case 4
After FR
7 yrs post retention
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Case 4
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Case 5 Class 3 Incompetent 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 6 Class 2 div 1 skeletal open bite Lips habitually parted
9 yrs 10 months
20 yrs
hypotonic 126
4 yrs 11 months
9 yrs
Case 6
After FR
At 20 yrs
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Case 7
Pre FR
Post FR
7 years post retention
Stability of transverse dimensions in post retention periods 128
Case 7
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Case 8
Pre FR 8 yrs
Post FR
17 yrs 130
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