Frankel appliance/ dental implant courses by Indian dental academy

FRANKEL APPLIANCE

INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

Dr. Rolf. F. Frankel (1908 – 2001) www.indiandentalacademy.com

Dr. Rolf Frankel (1908-2001) The pioneer behind the appliance was from town Leipzig, East Germany,which was behind, the iron curtain at that time Draw backs of the existing appliances, like, the Anderson’s activator,Bimler’s fixed functional, Stockfisch’s kinetor, Balter’s bionator and other appliances led to the development of a new appliance during 1960’’s

Funktions regler, translated as “Functional Regulator”.

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The factors that inspired Frankel were: Bulkiness of the appliance Gross demand for patient co-operation Inability to control individual tooth movements Inordinately lengthy treatment Partial results Unsupported claims of significant expansion www.indiandentalacademy.com

His contributions attracted little attention as contributions were mainly in German.

This changed later, as Dr. Frankel, learnt English and translated it Dr. T.M. Graber invited him to the U.S. to present, his philosophy and treated cases and also recognized his significant contributions.

Before this, there was relative skepticism among the clinicians and amongst the existing functional Jaw Orthopedic appliances.

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Introduction One of the oldest concepts in orthodontics is the importance of muscle function in the etiology of the treatment of malocclusion This concept has evolved into 2 different strategies: Myofunctional exercises Use of appliances to alter the mandibular position and muscle function. www.indiandentalacademy.com

Frankels theory is based on the theories of Moss, Hotz and Kraus The phrase functional orthopedics was coined

by Roux in 1985 .

It stems from the concept of functional adaptation which states that by altering the environment, the osseous tissue would change it’s form.

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The term orthopedics derived from Greek, means proper education.

This concept, with the sense of education, strongly supports the rational of an early therapeutic intervention.

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The FR (Frankels Regulator) is basically not an orthodontic appliance used for the correction of malocclusion Treatment with this appliance is not directed primarily towards the teeth and skeletal tissues but, rather towards functional disorders, associated with dento skeletal malformation.

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Postural behaviour is the functional factor, playing the primary role in causing skeletal deformities.

Orthopedic approach is concerned with an early recognition of the non-physiological conditions, which may adversely influence the, basic growth process in the cephalic growth sites.

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Therapeutically the primary aim is to eliminate the functional disorders that might interfere with the normal course of the dentoskeletal development.

The Frankels appliance is removable and is used during the mixed and early permanent dentition stages It is used to effect changes in the anteroposterior, transverse and vertical jaw relationships. www.indiandentalacademy.com

He had designed it by utilizing the concept of mandibular forward posturing.

His design was inspired by the Concept of Oral Screen by Klaus and by reducing the size of the oral screen

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HISTORY The basic aim of FJO (Functional Jaw Orthopedics), is to make the appliance more tolerable to the patient and so to improve the patient acceptance and wearing time.

The trend was towards designing an appliance which could essentially be worn full time.

In the early 1960’s Dr. Rolf Frankel revealed about his functional appliance development. It was the most complete of all the FJO appliances.

•

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The vestibular shields remove the restrictions to growth by removing adverse effects of the external restraining force, called “buccinator mechanism” allowing the teeth to spread “inside out” and by inducing growth increments in the alveolar process.

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Treatment results showed that considerable widening occurred It was not restricted to the dental-arch alone.

The apical base and the palate also broadened.

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• The premolars and the canines were, bodily placed in a well

developed alveolar base. Inter canine distance increased significantly.

• Frankel suggested that for good results the treatment should be undertaken, before the permanent lateral incisors have fully erupted, which also signals the end of the main growth spurt of arch width. •

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• Rolf Frankel concluded that hyper tonicity

of the circum oral muscle band, due to environmental factors, may restrain, the physiological process of decrowding, during eruption.

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•He suggested that the development of the skeletal disorders is basically due to the postural performance pattern of the related musculature •He correlated with Moss’s functional matrix theory, to demonstrate the functional inter-relationship with spatial disorders of the oronasopharyngeal spaces.

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Faulty muscle posture of the orbicularis oris is the primary cause of the skeletal open bite ands this stressed the importance of lip seal therapy in FR IV therapy in the treatment of open bite.

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In 1984, Frankel in his article, mentioned the causes of failures by other clinicians, in FR therapy, i.e.

Improper notching Improper construction bite The lingual cross over wire, should not exceed, 1 mm in diameter. These act as a ‘safety device�,. Where bite construction was taken with the mandible more forward than 3mm

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Frankel showed the effect of vestibular shield of the eruptive path of premolars and canines, using postero-anterior cephalogram .

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This supports the capsular matrix concept of Moss which states that the size and shape of the external soft tissue capsule, play an important role in the dentitional development.

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Frankel Philosophy Major part of the Frankels appliance is restricted to the oral vestibule.

Buccal shields and lip pads held the buccal and labial musculature away from the teeth and investing tissues eliminating any restrictive influences that the functional matrix may have.

Buccinator mechanism and orbicularis oris complex have a potentially restraining effect on the outward development of the dental arches, particularly during the transitional period of development. www.indiandentalacademy.com

Abnormal perioral muscle function, exerts a deforming action that prevents the optional growth and development pattern, in contrast to the conventional “push out from within� action of the other removable appliances which expand without relieving the external muscle forces and force the dento alveolar morphology to adapt.

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Frankel visualized his vestibular construction as an artificial “ought to be� matrix, that allows the muscles to exercise and adapt to the fact that when the buccinator mechanism pressures are screened from the dentition. Significant expansion may take place in the inter-canine dimension.

This relieves the crowding, which is the basis for the removal of the first permanent premolars.

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Vestibular shield enables us to expand the orofacial capsule, when necessary.

The mechanical effect of the appliance is not directed towards teeth or alveolar bone but towards the “capsular matrix�.

Adequate size and shape of the oral functioning space is achieved.

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Rolf Frankel believes, that his appliance is basically an exercising device aimed at stimulating physiological functions, while eliminating the lip trap; hyperactive mentalis and aberrant buccinators and orbicularis oris action .

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• For this purpose a full time and not just night time wear, and daily functional exercise is important for the success of the appliance.

• With anterior lip seal and posterior oral seal, provided by the lips, and the soft palate,

• during the deglutition process a negative atmospheric pressure is set up within the oral cavity. www.indiandentalacademy.com

The cheeks are actually sucked into the inter occlusal space : as the mandible returns to the postural rest position ; in the terminal phase of the swallowing process.

Thus there’s both a constricting effect on the dento-alveolar process and also prevention of eruption of the buccal segments due to the interposed check tissue.

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The potential vacuum created inside the arch has the momentary effect of the great external pressure off setting the intrinsic force potential of the tongue.

The Frankels buccal shields, prevent the pressure of the buccinator mechanism, exerted on the dento- alveolar area, both during deglutition and at rest.

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The total (net) effect is the outward expansion of the “ought to be� acrylic shield functional matrix.

When worn at a critical time in dental development with the maximum eruption in the direction of least resistance. It can include optional downward and outward movement of both the teeth and the investing tissues. www.indiandentalacademy.com

The forward posturing of the mandible is maintained, by the lingual wire loops/ lingual pads more as a proprioceptive signal and pressure bearing area ;for the maintenance of mandibular propulsion.

Extension of the shields / pads into the actual,depth of the vestibule can put the tissue under tension, without irritating it.

This exerts a pull over the contiguous osseous structures, and because of this pull;

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the maxillary basal bone widening takes place; as the thin alveolar shell over the erupting teeth proliferates laterally.

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The frankels appliance is firmly anchored in to the maxilla, and if this is not done, failure can, result due to incisor proclination and tissue damage.

Indications of Frankel’s Appliance • Growing Individuals • Retrognathic mandible • Normal maxillary position in the sagital and the vertical dimensions.

• Normal or reduced facial heights.

• Mild crowding in the mandibular arch or both arches.

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Contra Indications – Non-growing patients (Adults in whom – the growth is complete.

– Vertical growth pattern.

– Intractable mouth breathing or digital sucking – Poor patient co-operation.

– Gross intra arch irregularities and rotations – A tendency for cross bite

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Types of Frankels Appliances Basically there are four basic variation FR I, II, III, IV. Type I has 3 types – 1a, 1b and 1c Indications of FR With regard to treatment, timing, a distinction is, made between Early Treatment Which is initiated in the early, mixed dentition. (Average age 6 ½ - 8 years).

Late Treatment Not before the, permanent premolars have, erupted

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INDICATIONS OF FR 1 Early Treatment In cases with normal over bite, along with, discrepancy between teeth size and arch size.

Late Treatment Mild crowding with an adequate apical base where expansion of the arch is expected, due to a spontaneous up righting of the permanent teeth.

Malocclusions with, arch, size, deficiencies, require, mechanotherapy, and removal of permanent teeth if needed.

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INDICATIONS FR II Early Treatment Deep bite with arch size deficiency and a forward, rotational pattern of the mandible.

Late Treatment Deep bite without irregularities of the dental arches.

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INDICATIONS FOR FR III Indicated for class III mal occlusions.

Early Treatment Maxilly retrusion and / or Mandibular protrusion ; possibly accounted by space deficiency in dental arches.

Late Treatment Mandibular protrusion and maxillary, retrusion, without irregularities.

Pre-treatment mechanotherapy is needed in patients, with crowded teeth.

Skeletal Open-bite FR-3 Early and late treatment of cases of skeletal, open bite associated with class III. INDICATION FR-IV Early treatment For the skeletal open bite and bimaxillary protrusion www.indiandentalacademy.com

As a Retainer Last appliance in the active treatment period should be worn as a retainer.

After any kind of mechanotherapy, for stabilizing the corrected configuration, the appropriate FR should be worn.

After oral surgery, the FR-as an exercising, device for preventing relapse.

McNamaras Indications of FR FR-1 =

Some open bite cases,class I malocclusion.

FR-2 =

class II Div-1,class II Div 2, open bite.

FR-3 =

class III malocclusion

FR-4 (open bite).

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A general Description of the Parts of the FR Acrylic Parts Buccal shields Labial pads Lingual shields

Wire compounds Vestibular wires Palatal bow Canine loop Lower lingual wire Cross over www.indiandentalacademy.com wires

Description of the acrylic parts Buccal shield •Should extend deep into the sulci.

•Should be away from the lateral aspects of the teeth and the alveolus whenever expansion of dental arch and the, alveolar process is required.

•For comfort – the thickness shouldn’t exceed 2.5 mm.

Action (Physiotherapy).

It expands the circum-oral capsule in the lateral direction, therefore, forcing the respective, soft tissues to adapt in structure .

Muscles of the cheeks, are forced to adapt their, functional performances with relation to the outer, surface of the buccal shields.

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A

B C

D

F E G

A Labial bow B Canine Loop C Upper Lingual Wire D Lingual Crossover Wire E Support For Lip Pads F Buccal shields G Lip Pads www.indiandentalacademy.com

Labial Pads •Rhomboid in shape and fits the labial surface of the, lower frontal, alveolar process.

•It is tear drop shaped in cross section, for proper, seating in the vestibule.

•Upper edges should have a distance of at least, 5 mm, from the gingival margin to prevent the stripping of the labial gingiva.

•Distal edges, shouldn’t overlap the labial protruberances,of the, canine root, which render , speaking difficult and irritates the mucosa of the lower lip.

Actions

• Supporting effect on the lower lip.

• Smoothening out of the mento-labial sulcus.

• Improves lip posture.

• Helps in the establishment of a competent lip seal : thus forming a he • closure, of the oral functioning space and negative (sub-atmospheric pressure conditions in the oral cavity.

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Lingual Shield If lies lingually, below the gingival margin, of the mandibular teeth , and distal to the roots of the second premolars distally.

Lingual cross over wires, stabilize and secure, the position of the lingual shield by connecting it with the buccal shields on either side.

Actions of Lingual Shield In the lingual aspect of the alveolar process ; It acts by providing a pressure, sensation, whenever the mandible tries to slid back into it’s original retruded position.

This “sensory input” is expected to be established, only if the mandibular advancement is carried out step by step.

The initial construction bite should not be taken, with the mandible forward no more than 2 mm – 3 mm.

Now the appliance can be expected to operate, as an exercise device inducing changes in the postural performance of the muscles suspending the mandible. www.indiandentalacademy.com

Wire Parts Vestibular wires: They are not located within the acrylic shields.

Should be at an appropriate distance from the outer, aspect of the alveolus not exceeding 1 ½ mm.

They follow the depression of the labial surface of the alveolar process.

Aim & Function They connect the lip pads and the buccal shields and secure their position in the vestibule.

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Labial Wire Lies in the middle of the labial surfaces of the maxillary incisors and runs gingivally at right angles in the natural depression between the roots of the lateral incisor and the canine.

Forms a gentle curve, distally at the height of the middle of the canine root.

Aims •Connecting and stabilizing.

•Tooth movements, whenever it contacts the maxillary incisors.

•This action is utilized, in the treatment of Class II division 1, for the correction of incisor proclination.

•The curves at either side, enable us to provide, a gradual retraction of the incisors.

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Palatal Bow •It crosses the palate with a slight curve in the distal direction and runs, inter dentally between the maxillary first molar and second promolar.

•Forms a loop in the buccal shield, and emerges to form an “occlusal rest” on the buccal cusps of the molars.

Actions •Connecting and stabilizing •Inter proximal portion provides, intermaxillary anchorage.

•Prevents superior, displacement, preventing a displacement, in the vertical direction.

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Canine Loop It’s embedded with it’s tags, in the buccal shield, at the level of the occlusal plane and has to rise steeply to the gingival margin, of the maxillary first premolar.

It runs palatally to the lingual surface of the canine for a distance of about 1 mm and then crosses the interproximal contact between the canine and the lateral incisors.

Actions Labial portion keeps perioral tissues, away from the canine, and provides space for the lateral movement of the canine.

Used for the tooth movement of anteriorly or bucally displaced cuspids.

Serves as a guide to prevent it’s malpositioning during eruption.

Contact of this wire with the mesial aspect, of the first molar is, essential for securing inter-maxillary anchorage. www.indiandentalacademy.com

Lower Lingual Wires Two lower lingual wires, have been attached to the lingual shield to pass along the lingual surface of the incisors, at the level of the cingulum Action •Stabilize the mandibular incisors against lingual movement ;and in deep bite to prevent further eruption. •Sometimes towards the end of treatment, they help in, the leveling of the bite by causing a depressing action. •When mandibular incisors are retruded, they contact their lingual surfaces to produce the needed labial movement.

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Cross Over Wires •Connect the lingual shield with the buccal shield ; and run over, between the mandibular first and second, premolars without touching these teeth.

•They shouldn’t be allowed to lodge interdentally, as mandibular buccal segments are moved, forward, resulting in the crowding of incisors and the overlapping of the canines, over the lateral incisors • So FR fails to act as an orthopedic exercise device, as the training effect on the suspending muscles, can’t be achieved

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Differences between, FR1a, FR1b and FR1c Actually the differences are very minimal FR1a

•This has a lingual wire loop, instead of an acrylic, lingual mandibular pad .

•It’s used in Class I division 1 cases, with minor crowding • Frankel Recommended it’s use for Class I deep bite cases, with proclined maxillary and retruded mandibular incisors.

•Sometimes in Class II division 1 cases, where over jet doesn’t exceed 5 mm. www.indiandentalacademy.com

FR1b •It has a lingual acrylic pad, instead of the loop in FR1a.

•Frankel suggested it’s use in Class II deep bite cases, over jet not exceeding 7mm FR1c •Similar to 1b except that the heavy, lingual crossover wires connecting lingual pads and buccal shields is horizontal.

•Used in Class II division 1 malocclusion, with an over jet exceeding 7mm.

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FR2 •FR2 differs from FR1 only, by the addition of an upper lingual wire, and by modified canine loop.

•Other acrylic parts and wires are similar to FR1 •The upper lingual wire runs between the maxillary canine and the first premolar originating from the buccal shields.

•This is for stabilizing it against the maxilla •This also prevents the tipping of the protruded, maxillary incisors, lingually •In class II division 1, lingual wire lies on the cingulum of the incisors – to prevent their further eruption.

•When labial bow is activated, it also causes the retrusion of the incisors. www.indiandentalacademy.com www.indiandentalacademy.com

FR3 •It consists of two upper lip-pads, 2 buccal shields and various wires.

• Here the lip pads are much larger, than FR1 and FR2 and extends superiorly into the sulcus.

•They should be parallel to and standing away from the alveolus by 2.5 mm •The superior extension of the lip pulls on the septo-maxillary ligament and the periosteum • Enhances bone deposition, and frees the pressure sensitive membranous bone, from the adverse lip pressures .

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Mode of action of FR-3 The abnormal insertion of the muscles at the level of the lower aspect of the nasal septum, and anterior nasal spine plays an important role in restricting the maxillary development.

The vestibular shields of the FR3, enable the clinician to directly interfere with these tissues, between muscles, and bone at the maxillary sulci.

Mandibular prognathism is due to increased condylar growth rate, which in part may be due to excessive mandibular translation.

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FR4 •It has 2 lower lip pads, buccal shields, a palatal bow, an upper labial wire and four, occlusal rests.

•The mode of action of the lip pads and the buccal shields, are the same as in FR1 and FR2 .

•The main function of the acrylic components, is to interfere with the aberrant functions of the cheek and lip musculature •To establish, the structural and functional balance between, various muscle groups, of the circum oral capsule.

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Mode of action •FR4 reverses the aberrant muscle activity, which create open bite problems, and redirects growth, more vertically.

•To be used during the active growth period with a longer period of wear extending, into the permanent dentition.

•Lip seal exercises are very important for FR4, without which the appliance might be a failure.

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Modifications of Functional Regulator FR system has been refined to 3 appliances by Harry S. Orton.

•Reduced FR2 •Capped FR2 •FR 3 with modified Kingston buccal shields. They are not applicable for patients with severe overjet, 12-14 mm range. Not in higher FMPA patients Works well through the whole of the mixed dentition period, into the early permanent dentition. Appliances, are largely tissue borne, produce little interference with the natural exfoliation of the primary dentition  The more mature the full permanent dentition, the less effective the appliance becomes. Well tolerated by the patient. www.indiandentalacademy.com

GENERAL INDICATIONS Reduced / Smaller FR2 •Average MPA •Imbricated lower incisors •Incomplete overbite.

Capped FR2 •Average to low MPA •Lower incisor alignment •Deep overbite

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Modifications in reduced FR2 2 major, design features causing reduced patient acceptance for FR2 •Excessive sagittal activation and vertical overextension.

•The reduced appliances, were, under extended, bucally, as well as labially •and are better tolerated, to produced results comparable to Frankel’s design.

•3-4 mm less peripheral extension, than those produced by, Frankel’s formula.

•Dental tissue isn’t removed to accommodate, cross over wires. If separation is needed then elastic modules are used.

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Capped Frankel Appliance •Here lower labial capping of lingual acrylic of the FR 2 is extended to •cover the incisal 1/3rd, of the lower incisors and cuspids.

•Capping serves as – “articulating bite locator” for the lower anterior teeth, and controls, undesirable tipping.

•Lower lingual wires of conventional FR2 are omitted.

•.

•FR2 has clinical advantages like, enhanced vertical and sagittal control of the lower labial segment.

•General principles of, under extension should be followed.

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ndications of Capped FR2 Basically used where patient tolerance is doubtful.

Deep incisor over bite cases Class II division 2 malocclusions Where lower incisor, proclination must be avoided.

Capped Frankel prevents, lingual plate fracture Fracture prevention is due to greater depth of lingual acrylic.

Positive seating of incisal tips in acrylic, holds mandible in exact registered construction bite position eliminating lateral movements and tissue irritation. www.indiandentalacademy.com

Disadvantages As treatment progresses, capped FR-2 has to be advanced The capping impinges on to the upper incisor Sufficient posterior separation is required to accommodate 2 mm of incisal acrylic.

Due to plaque accumulation – oral hygiene is reduced,

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Functional Objectives of Capped and Reduced FR2 •Sagittal restraint of maxillary dentition.

•Vertical restraint of maxilla and maxillary dentition.

•Freedom for buccal movement of the upper buccal segments.

•No vertical constraint to lower buccal segment eruption.

•Maximised increments of condylar growth mechanisms.

•Minimised uprighting of upper incisors.

•Minimized, proclination of the lower incisors.

•Some unfurling of labio mental fold and relaxed lip seal without •conscious effort.

•Class I incisal relationship, with a reduced overjet and a reduced www.indiandentalacademy.com • but complete overbite

FR3 with Kingston modified buccal shields Indications •Class III malocclusion with average to low FMPA • Aligned arches, bimaxillary proclination, a mild to moderate class III skeletal base •Early mixed dentition •Difference from conventional FR3, is that the non-functional part of the buccal shield is removed leaving, lower edge of the shield 2-3mm, below the lower buccal gingival margins.

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Functional Component Objective •Total occlusal, buccal and labial restraint of the mandibular dentition .

•Freedom for maxillary dentition to erupt, downwards and outwards.

•Lateral expansion of the maxillary buccal dentition.

•Lateral constraint of mandibular buccal dentition.

•Overall induction of class I incisal relationship, with tendency to an increased, positive overjet and increased overbite.

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Other Modifications •Inclusion of Jack Screw, in buccal shields to facilitate advancement of the lip pads •Frankel’s with facebow appliance •Extra oral force is provided as there is little function during sleep for class II malocclusions with maxillary protractions.

•Appliance is anchored on to the maxilla with a light oblique, or vertical pull, force which can be tolerated without dislodgement.

•Horizontal buccal tubes are embedded for, extra oral traction in buccal shield at the deciduous second molar area.

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Treatment Management Treatment time varies between 15-24 months, such that patient is in, permanent dentition.

Treatment occurs in three phase: •Initial phase •Active phase and •Retention phase.

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Initial Phase •For getting used to the appliance, and to handle it like an exercise device combined with lip seal training.

•Day time wear, is 4-6 hours for 3 weeks, as long as the appliance is comfortable.

•At night after 4 weeks, except during meals •Takes 3-4 months for patient to get adjusted to full time wear.

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Active Phase •Patient is to be checked. After 3-4 weeks intervals.

•Mucosa of the vestibule is examined; as is the stabilization in the maxillary arch of FR1 and FR2.

•Actual exercise can be prescribed along with lip seal regime, which use isometric contractions of the perioral musculature like grasping the Frankel’s in the vestibule.

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Retention Phase •Essential aim of FR now is to stabilize the straining effect of the exercise device, that has been accomplished in the active treatment period.

•If treatment was started during the permanent dentition phase then, a 2-3 year, retention period is required as in, Class II division 2, Class III and open bite cases.

•In simple cases FR – wear is 2 hours in the afternoon and night for 6 months.

•Then only at night for further 12 months.

•As a general rule the last retainer, used in the retention phase should be a FR appliance.

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Conclusion Apart from a possibility of reducing the need for extractions, except in severely crowded cases, the FR can, also reduce the time needed for fixed appliance therapy and improves facial results.

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REFERENCES 1. Dentofacial Orthopedics with Functional Appliances --Graber, Rakosi,Petrovic 2. Orthodontics –Graber 3. Atlas Of Functional Appliances—H.O Orton 4. BDJ vol 26, No 2 JUNE 1999 5. BDJ vol 21, No 2 MAY 1994 6. BDJ vol 18, No 4 NOV 1991 7. BDJ vol 17, No 3 AUG 1990 8. ORTHO IN 3RD MILLENIA –AJO vol 129 2006 www.indiandentalacademy.com

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