FRANKEL FUNCTIONAL REGULATOR
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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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CONTENTS. 1. INTRODUCTION. 2. HISTORY. 3. SYNONYMS. 4. PHILOSOPHY. 5. INDICATIONS & CONTRAINDICATIONS. 6. ADVANTAGES & DISADVANTAGES. 7. DIAGNOSIS. 8. TYPES. 9. MODIFICATION. 10.TREATMENT OBJECTIVES. 11. CLINICAL HANDLING 12.INSTRUCTIONS. 13. JOURNAL REVIEW 14.CONCLUSION.
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INTRODUCTION ď ą Functional appliances are
defined as loose fitting or passive appliances which harness or eliminates natural forces of the orofacial musculature that are transmitted to the teeth and alveolar bone through the medium of the appliance .
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INTRODUCTION….. The basis of functional treatment in general is the principle that a “new pattern of function” dictated by the appliance , leads to corresponding “new morphologic pattern”.
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INTRODUCTION….
The functional regulator is a removable orthodontic appliance developed by Professor Rolf Frankel . This appliance is used during the mixed and early permanent dentition stages to effect changes in anteroposterior, transverse, and vertical jaw relationships. The Frankel appliance, as it is more commonly termed, has two main treatment effects. First, it serves as a template against which the craniofacial muscles function. The second effect of the Frankel appliance is its influence on skeletal and dental development
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HISTORY In 1880, Kingsley introduced the term and concept
of "jumping the bite" for patients with mandibular retrusion. Robin in 1902had created an appliance quite
similar in its objectives; The monobloc. Impressed by Kingsley's concepts and appliances,
Viggow Andresen in 1908 developed activator. Frantisek Kraus of Prague used oral screen to
interrupt abnormal muscle force resulting from thumb or tongue sucking . www.indiandentalacademy.com
HISTORY Then Rolf Frankel of Germany developed an appliance in about the middle of this century, which was not only inhibitory but influence function in a more positive way . This initial appliance was just two buccal shields , connected by wires without any clasp . Growth guidance was a vague concept before Frankel’s contribution.
Charles Nord was correct when he called the Frankel method a, “revolution in orthodontic appliances ”. www.indiandentalacademy.com
Synonyms:
Frankel appliance Vestibular appliance Oral gymnastic appliance Functional regulator
Frankel postulates that the increase in crowding is the result of hypertonic muscles in the buccinator mechanism restricting the lateral growth of the teeth and their supporting tissues. One objective of the vestibular shield is to regulate the hypertonic muscles of the buccinator and perioral muscles, thereby giving rise to the name functional regulator. www.indiandentalacademy.com
PHILOSOPHY OF FRANKEL APPLIANCE 1.Vestibular arena of operation Frankel appliance is confined to the oral vestibule and holds away, The buccal and labial musculature from the dentition in those areas in which the pressure on the dento alveolar structures has restricted the outward development of these Structures. Dentition is heavily influenced by 1)Functional matrix. 2)The buccinator mechanism. 3) Orbicularis Oris complex.
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Functional matrix concept of Melvin Moss:
Buccal shields of frankel directly alter the soft tissue configuration, increasing the oral volume, that is the capsular matrix that allows the muscle to exercise and adapt and improve.
The impact of the space increase on the basal development of mandible has been suggested. The term translative growth gives a new credence to the theoretic and therapeutic aspect of orthopedic treatment with frankel. www.indiandentalacademy.com
The functional matrix and the Frankel appliance, OO , Obicularis oris. B, Buccinator. PMR, Pterygomandibular raphe. SPC, Superior pharyngis constrictor. LP, Labial pad. VS, Vestibular shield. The functional regulator provides a larger functional matrix than the teeth. The buccinator mechanism will grow and adapt to whichever functional matrix (soft-tissue capsule) is present in the mouth. This adaptation occurs primarily during growth. After growth is complete, very little, if www.indiandentalacademy.com any, change can be expected.
SCREENING EFFECT OF THE BUCCAL SHIELDS
Buccal shields and lip pads effectively holds the buccal and labial musculature away from the dento -alveolar complex eliminating the restrictive effect of the structures. www.indiandentalacademy.com
2 . Sagital correction via tooth borne maxillary anchorage Forward posturing of the mandible is achieved by an acrylic pad that contacts alveolar bone behind the alveolar segment. 3. Differential eruption guidance. By being free of the mandibular teeth selective eruption of the lower posterior teeth is possible which corrects vertical dimension deficiencies. 4. Buccal shields , lip pads and periosteal pull. There will be an outward periosteal pull by maximum extension of the shields And pads into the depths of buccal and labial vestibule to the point at which the depth of the sulcus is under tension . www.indiandentalacademy.com
The vestibular shield creates tension at the depth of the mucobuccal fold in a lateral direction. This tension is directed at influencing the erupting permanent teeth to erupt further laterally than normal, thereby resulting in arch expansion. Notice that less influence is seen on fully erupted teeth, as shown by the open arrow.
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5)Postural behaviour of muscles . There is considerable evidence that postural disorders of the orofacial musculature play a significant role in the causation of dento facial disharmony . The aim of frankel appliance is to identify the faulty performance of orofacial musculature and to correct it by orthopedic exercises. Therefore frankel appliance is an effective muscle trainer of the orofacial musculature.
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6)Condylar growth The anterior repositioning of the mandible implies on alteration in the TMJ area. .Thus at right age , condylar growth can be successfully stimulated.
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INDICATIONS: AGE GROUP OF 8-10 YEARS (MIXED DENTITION PERIOD)WITH GROWTH SPURTS. SKELTAL CL II MALOCCLUSION WITH PROGNATHIC MAXILLA AND RETROGNATHIC MANDIBLE. FUNCTIONAL CL II MALOCCLUSION. IN A HORIZONTAL OR NETURAL GROWTH VECTOR CASE. CL III MALOCCLUSIOS. BIMAXILLARY PROTRUSION AND OPEN BITE PROBLEMS. FUNCTIONAL RETRUSION , DEEP OVER BITE , AND EXCESSIVE INTEROCCLUSAL PROBLEMS WITH A NORMALLY POSITIONED MAXILLAE.
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CONTRAINDICATIONS Class I MALOCCLUSION WITH SEVERE CROWDING THUMB SUCKING HABIT. SEVERE DENTOALVEOLAR PROBLEMS IN PERMANENT DENTITION. UNCOPERATIVE PATIENTS.
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ADVANTAGES: 1. It enables elimination of abnormal muscle function thereby aiding in normal development. 2. Treatment can be initiated at early age . 3. Less chair side time is spent. 4. The frequency of the patients visit is less. 5. They do not interfere with oral hygiene status. 6. Duration of treatment is comparatively less. they deal with skeletal as well as dent alveolar problems.
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DISADVANTAGES: 1.The appliance is bulky and the cooperation of the patient is essential. 2.They cannot be used in adult patients were the growth has ceased. 3. Cannot be used to bring about individual tooth movement and in cases of crowding. 4. Fixed appliance therapy may be required at the termination of treatment for final detailing of the treatment. www.indiandentalacademy.com
DIAGNOSIS: VISUAL TREATMENT OBJECTIVE DIAGNOSTIC TEST > The VTO for FR therapy is a simple but important clue as to the efficiency of the FR appliance in any clinical case . > It is a functional test , that also helps to establish whether a patient can tolerate a protrusive bite, as well as whether satisfactory esthetic improvement occurs. The patient is asked to posture the mandible forward to the correct sagital relationship. If the outcome of the VTO test is positive, the patient can be adjudged suitable for the Frankel therapy. However a proper cephalometric analysis is the correct way to determine whether FR is the appliance of choice. www.indiandentalacademy.com
Visual treatment objective:
Class II div I with full occlusion
6mm of cuspal advancement into class I relation
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After VTO
Functional analysis. 1. Precise registration of the postural rest position in natural head posture. 2. Path of closure from postural rest to habitual occlusion. 3. Pre-maturities, point of initial contact, occlusal interferences, and resultant mandibular displacement . 4. Sounds such as clicking and crepitus in the TMJ. 5. Interocclusal clearance or freeway space. 6. Respiration .
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Cephalometric analysis: • Enables clinicians to identify the craniofacial Morphogenetic pattern, direction of growth. • Differentiation between position and size of jaw bases. • Morphologic peculiarities. • Axial inclination & position of the maxillary and mandibular incisors
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TYPES OF FRANKEL APPLIANCE: TYPES 1)FR 1 A)FR1a
USES -------
B)FRI b ---C)FRI c ----
CL 1 AND CL 2 DIV 1 MALOCCLUSION. CL 1 MALOCCLUSION WITH MINOR CROWDING CL I WITH DEEP BITE. CL 2 DIV 1 MALOCCLUSION WITH OVERJET LESS THAN 5 mm. CL2 DIV 2 MALOCCLUSION WITH OVERJET MORE THAN 7mm.
2)FR 2
----
CL 2 DIV 1 AND DIV 2 MALOCCLUSIONS.
3)FR3
----
CL 3 MALOCCLUSIONS.
4) FR4
----
OPEN BITE ANDBIMAXILLARY PROTRUSION.
5)FR 5
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HIGH MANDIBULAR PLANE AND VERTICAL MAXILLARY EXCESS www.indiandentalacademy.com
FUNCTIONAL REGULATOR I The FRI of Frankel has 3 modifications a. FRI a b. FRI b c. FRI c A . FRI a uses CL I malocclusion with mild to moderate crowding CL I deep bite cases . Components Acrylic parts 1. Vestibular shields. 2. lip pads. Wire components: 1. Palatal bow. 2. labial bow. 3.Labial support wire. 4. Lingual bow. www.indiandentalacademy.com 5. Canine loops
Lingual bow: In FR Ia a wire loop is used instead of an acrylic lingual pad that helps in the forward position of the mandible forward. It extends downward to the floor of the mouth which fit against the lingual tissue below the incisors.
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Palatal bow Convexity facing distally with lateral extensions crossing the occlusal surface in the embrasure mesial to the first molar. Lip pads It eliminates the hyperactive mentalis activity.
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FR I b
Uses CL II DIV I with a deep bite and an over jet of not more than 7mm. Wire forming Palatal bow 1.0mm wire is used Tooth moving wire 0.8 mm wire is used. Component parts: Lower lingual support wire. 3 components soldered together or 1 continuous wire. Wire member follows the contours of the lingual apical base
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Lower lingual springs Surface of the lower incisors right above the cingula .
Lower labial wire It supports the Skelton for the lip pads .
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Palatal bow It provides some extra wire length to facilitate a lateral expansion adjustment. The wire should cross the occlusal surface in the embrasure Mesial to the first molar. Locking of the appliance on the maxillary arch is mainly due to this insertion on the embrasure.
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Labial bow The bow originates in the buccal shield and lies in the middle of the labial surfaces of incisors , turning gingivally at right angles between maxillary lateral incisors and canines.
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Canine loop The loop wraps around the lingual surface of the canines .It is embedded in the buccal shield at the occlusal plane level. It rises sharply to the gingival margin And fits in the embrasure.
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Fabrication of the acrylic parts After wires are properly adapted to the models they are secured with sticky wax. Shields The total thickness of the shields and pads should not be more than 2.5mm. The lingual surface of the shield should be smooth. Lip pads The upper edges of the lip pads should be at least 5mm from the gingival margin.
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FRI c Uses In more severe CL II DIV 1 malocclusion in which the overjet is more than 7mm and disto-occlusion exceeds an end to end cusp relationship. It is seldom used.
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Component parts The buccal shields are split horizontally and vertically into 2 parts – Anteroinferio portion contains the wires for lingual acrylic pressure pad or shield and for the lower lip pads. Vertical split is opened to the desired position by a 2 to 3 mm advancement and is then filled with acrylic.
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FR II USES They are used for the treatment of CLII div I and II malocclusions. They are the most widely used. COMPONENTS Acrylic components a. buccal shields. b. lip pads. c. lower lingual pad. Wire components. a. palatal bow. b. labial bow. c. canine extensions. d. upper lingual wire. e. lingual cross over wire. f. support wire for lip pads. g. lower lingual springs. www.indiandentalacademy.com
CONSTRUCTION : The steps are 1. separators. Recommended 1 week before taking the impression. Placed between maxillary canine and first deciduous molars or first molar embrasure. The slicing mechanism allows immediate seating of the appliance.
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2. Impression Very important clinical procedure so that impression reproduces the whole alveolar process up to the depth of the sulci.
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3.Constuction bite.
The purpose of this mandibular manipulation is to relocate the jaw in the direction of treatment objectives. This creates artificial functional forces and allows assessment of the appliance's mode of action. Before taking the construction bite, the clinician must prepare by making a detailed study of the plaster casts, cephalometric and pan oral head films, and the patient's functional pattern.
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.Constuction bite………
For minor sagital problems (2-4mm) the construction bite is taken in an end to end incisal relationship. Horizontal and vertical requirements. Construction bite should not move the mandible forward further than 2.5 mm to 3mm . End to end incisal relationship or no more than 6mm forward. Positioning the edge to edge contact will determine the vertical opening.
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Construction bite…… Frankel appliance design and construction permits a further advancement of the mandible after a favorable response to the treatment from the construction bite . Optimal prechondroblastic activity in the condyle is observed by staged construction bite. In the frankel technique construction bite is not open any more than needed to allow the cross over wires to pass through the interdental space. It is necessary for effective lip seal exercises
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4.Working model pour up and trimming. Models should extend away from the alveolar process at least 5mm to permit application of wax. 5.Cast carving. Casts are carved for accommodating the buccal shield and lip pads .
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6. Work model mounting . mount the models on the straight line fixators.
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7. Wax relief. o Wax padding under the buccal shield to establish space between the tissue and the appliance. o Wax is thicker in the maxillary sulcus than in the mandibular sulcus o Thickness is determined individually by the amount of desired expansion needed. should not exceed more than 3mm. o Wax covering important in the region of the first deciduous molar o Waxing is done separately on maxillary and mandibular cast and then joined together
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Wire forming The FR II is modified by adding a stainless steel protrusion bow (0.8mm )behind the maxillary incisors , which serves to maintain the prefunctional alignment and also stabilizes the appliance.
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Canine loops ď ś Originate in the buccal shield but they embrace the canine buccal instead of lingually. ď ś By placing these wires 2 to 3mm away from the canine the restrictive muscle function is eliminated .
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Lingual stabilizing bow. • Improved structural support and gives stability to the maxillary arch. • It originates in the vestibular shield and passes through the canine –first deciduous molar embrasure. • Wire forms loops that approximate the palatal mucosa and recurve vertically to contact the incisors at the canine lateral embrasure. • A 90 degree bend allows the wire to follow the lingual contours of the four incisors , right above the cingula . • Its Objective of preventing lingual tipping of the maxillary incisors.
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Fabrication of acrylic parts: Wires are bent and properly adapted to the models and they are secured with sticky wax . Buccal shields and lip pads and lingual pads are fabricated in self cure acrylic. Shields: Should extend to the vestibule. lingual surface of the shields should be smooth. Lip pads: Upper edges of the lip pads should be at least 5mm from the gingival margin.
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FR III
USE Treatment of CL III malocclusions.
Lip pads Situvated in the maxillary instead of the Mandibular in labial vestibular sulcus. It eliminates the restrictive pressure of the upper lip .To exert tension on the periosteal attachments in the depth of the maxillary sulcus, to stimulate www.indiandentalacademy.com bone growth.
Labial bow. It extends across the six mandibular anterior teeth just above the inter dental papillae. After a 90 degree bend downward at the distal edge of the lower canine , another horizontal bend is made approximately 5mm below the gingival margin.
Buccal shields Stands away some 3mm from maxillae Posterior dento alveolar structures. They are in contact with mandibular teeth and the mandibular apical base www.indiandentalacademy.com
Occlusal rests. Occlusal shield originates in the vestibular shield and is adapted to lie in the occlusal fissure of the last mandibular molar. Palatal bow • It pass directly distal to the last molar tooth before inserting in the buccal shields . • It is capable of delivering a forward force vector to the maxillary dentition.
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Mode of action:
The proposed method of action of the FR-3 appliance. The distracting forces of the upper lip are removed from the maxilla by the upper labial pads. The force of the upper lip is transmitted through the appliance to the mandible because of the close fit of the appliance to that arch (after Fr채nkel1).
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Construction bite The procedure of taking the construction bite is done by retruding the mandible as much as possible with the condyle in its most posterior position. The vertical opening is kept to a minimum to allow lip closure with minimal stress. Wax relief No wax is applied to the mandibular arch.
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Fabrication of acrylic parts same as FR I and FR II.
Finished appliance
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FR IV.
USES • Correction of open bite and bimaxillary protrusion. • exclusively confined to mixed dentition
Components. • Same vestibular configuration as FR I and II with no canine loops and protrusion bows. • There are four occlusal rests on the maxillary first molars, and first deciduous molars to prevent tipping of the appliance. www.indiandentalacademy.com
MODE OF ACTION OF FR IV
As a result of treatment of these anomalies with the FR-4 appliance and lip seal training, the growth and development pattern of the mandible was altered. The spontaneous downward and backward growth direction of the mandible was changed to a upward and forward direction by FR-4 therapy, allowing the skeletal anterior open bite to be successfully corrected through upward and forward mandibular rotation.
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FR V
Modification of Frankel by Albert H Owen (1985 –JCO)
INDICATED Long face syndrome having a high mandibular plane angle and vertical maxillary excess .
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 The appliance consists of addition of posterior acrylic bite blocks to arrest molar eruption.
 It also has head gear tubes that accept a face bow for an occipital pull headgear.
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Advantages in combination of frankel with head gear. 1. The vertical dimension can be decreased through intrusion of the molars. 2. Increased mandibular growth. 3. Significant lateral expansion may reduce the need for expansion.
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MODIFICATIONS 1. By H S ORTON ( JCO 1992) > Vestibular shields have 3 -4mm less peripheral extension than the conventional appliance. Capped Frankel appliance. > Lower labial capping – The lingual acrylic of FR II is extended to cover the incisal 1/3 rd of lower incisors and cuspids.
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2. Modified function regulator S. Haynes, Edinburgh, Great Britain Note palatal acrylic support and continuous buccolabial acrylic construction, which replaces conventional function regulator with separate buccal shields and lip pads. The appliance is not "locked" into the mesial embrasure of the maxillary first molars by a crosspalatal bar.
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TREATMENT OBJECTIVES Frankel produces the following changes in the orofacial complex. 1 .An Increase of sagital and transverse intraoral space. 2. An increase of vertical intra oral space. 3. Forward positioning of the mandible. 4. Muscle function adaptation.
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1. INCREASE IN INTRA ORAL SPACE. ď ś
It is achieved primarily through buccal shields and lip pads which eliminate the harmful mechanical forces on the pressure sensitive membraneous structures.
ď ś
The constant outward pull that is exerted on the connective tissue fibers and muscle attachments in the oral vestibule is transmitted to the alveolar bone by the fibers inserting into the periostium and bone. This aids in the lateral movement.
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2. VERTICAL SPACE INCREASE. ď ś
Increase of vertical intraoral space is possible because the construction bite is taken, so that the bite is opened in the posterior segments as the mandible is held forward.
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3. MANDIBULAR PROTACTION. The position of the mandible is changed through the gradual training of the protractor and retractor muscles followed by condylar adaptation. The effect of the u loop and lingual plate on the mandibular positioning through pressure sensation .
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4. MUSCLE FUNCTION ADAPTATION. Development of new patterns of motor function , improvement of muscle tones and establishment of proper oral seal.
The pads and shields massage the soft tissues improving blood circulation .
The pads and shields stretch the muscles in disto occlusion.
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CLINICAL HANDLING OF THE APPLIANCE Stabilizing the appliance at the delivery is absolutely essential Pre placement, all margins are checked for smoothness . Check vertical dimension. Over extension of the labial ,lingual, lip and buccal pads causes tissue irritation . So the extension should be correct. The appliance should be inserted with a slight rotatory motion. www.indiandentalacademy.com
Wearing time o
Although the Frankel appliance will be worn all the time except for the meals the treatment should be started slowly. o For the first two2 weeks the appliance should be worn for 2 to 4 hours during the day. o During the next 3 weeks the time is extended to 4 to 6 hours. it usually takes 2 months before the appliance is worn at night. o The appliance and treatment progress should be checked at 4 weeks interval. An initial end to end molar relationship is corrected in 6 months.
Treatment timing Optimum time to start the treatment is the mixed dentition period. (8 to 10 year age)
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SUCESSFUL TREATMENT CONSIDERATIONS. 1. PROPER IMPRESSIONS. 2. CONSTRUCTION BITE. 3. APPLIANC FABRICATION. Patient and appliance management.
IMPORTANT PRECONDITIONS THAT SHOULD BE EMPHASIZED. 1. RIGHT INDICATIONS FOR TREATMENT. 2. RIGHT PSHYCOLOGICAL INTRODUCTION OF APPLIANCE 3. COPERATION OF PATIENT AND PARENTS.
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INSTRUCTIONS FOR THE PATIENT: > A little discomfort is to be expected initially. > Salivation may be increased but it should not be a problem. > Outline the duration of wear expected. > Instruction on appliance care and oral hygiene maintenance . > Demonstrate the lip seal exercise . > Ask the patient to speak a few words and reassure that speech would normalize. > Wearing time should be correctly followed.
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Frontal Facial Changes with the Frankel Appliance Albert H. Owen. ANGLE ORTHODONTICS 1988 MARCH
1. Edgewise treatment does not appear to increase the mandibular width more than average growth without treatment. 2. Frankel treatment appears to increase the mandibular width significantly more than either Edgewise or average growth. This phenomenon is most likely due to the action of the vestibular shields. 3. Frankel treatment tends to make the patient more brachyfacial than average growth, as revealed by the frontal facial taper angle.
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4. Brachyfacial individuals appear to have more ideal occlusions ( PLATOU AND ZACHRISSON (1983)28, and perhaps have better stability than less brachyfacial individuals. 5. Brachyfacial faces are more common among models, movie stars, and beauty contest winners than dolichofacial faces, suggesting that brachyfacial individuals have more pleasing esthetics than more narrow-faced people. 6. Untreated Class II individuals do not appear to grow as wide as untreated Class I individuals. The reason for this is unknown.
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Morphologic changes in the sagital dimension using the Frankel appliance – Owen AJO 1981 Dec ďƒ˜The potential improvements have been presented, and their coordination into a multibanded practice seems possible. Whatever results are lacking after treatment with functional appliances could be perfected with fixed appliances of the clinician's choice. ďƒ˜ The possibility of reducing the need for extractions, reducing the time needed for multibanded treatment, and improving the facial results seems to be great enough to justify further investigation of this appliance as to achieving predictable changes.
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Arch width development in Class II patients treated with Frankel appliance McDougall, McNamara, and Dierkes AJO 1982 Jul ď ąSixty treated and forty-seven untreated Class II, Division 1 patients were examined in this study. The patients in the former group were treated with the functional regulator of Frankel (FR-1 or FR-2), while patients in the latter group were not treated but were of similar ethnic and skeletal composition. Sequential dental casts of the treated and untreated groups were examined, and the changes in lingual, buccal, and alveolar arch widths were compared.
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Contd‌
ď ąThe results of this study indicate that expansion of the maxillary and mandibular dental arches and their supporting structure occurs routinely when a functional regulator (FR-1 or FR-2) is conscientiously worn by the patient.
ď ąThe expansion is not limited to a particular region of the dental arch, although in absolute terms the largest expansion values occur in the premolar and molar regions, while lesser values were recorded in the canine region. In addition, this study indicates that in the maxilla narrower arches tend to expand more than wider arches.
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