Evolution of Functional Appliances

A VERY GOOD AFTERNOON
9/2/2013Functional appliances- I1

Evolution Of Functional Appliances.

Introduction
 Orthodontics presents a philosophical challenge in that both art and
science are of equal importance. A quotation of Edward Angle(1907),
from the turn of the 2oth century, is still pertinent today:
“The study of orthodontia is indissolubly connected with that of art as
related to the human face. The mouth is a most potent factor in making
the beauty and character of the face, and the form and beauty of the
mouth largely depend on the occlusal relations of the teeth.
Our duties as orthodontists force upon us great responsibilities and there
is nothing which the student of orthodontia should be more keenly
interested than in art generally, and especially in its relation to the human
face, for each of his efforts, whether he realizes it or not, makes for beauty
or ugliness, for harmony or inharmony, for perfection or deformity of the
face. Hence it should be one of his life studies.”

Orthodontics & Dentofacial
Orthopaedics
 An essential distinction exists between the terms ‘Orthodontics’
and ‘Dental orthopaedics’. They represent a fundamental variance
in approach to the correction of dentofacial abnormalities.
 By definition, orthodontic treatment aims to correct the dental
irregularity.
The alternative term ‘dental orthopaedics’ was suggested by the late Sir
Norman Bennett. The broader description of ‘dental orthopeadics’
conveys the concept that treatment aims to improve not only dental
and orthopaedic relationships in the stomatognathic system but also
facial balance.
2 September 2013Functional appliances- I4

A fundamental question that we must address in diagnosis is: ‘does
this patient require orthodontic treatment or orthopaedic treatment
,or a combination of both and to what degree?”
alternatively, does the patient require dentofacial surgery, or to what
extent can orthopaedic treatment be considered as an alternative to
surgery?

 If the malocclusion is primarily related to a musculoskeletal
discrepancy we should select an orthopaedic approach to treatment.
 It is in the treatment of muscle imbalance and skeletal disproporation
that functional orthopaedic appliances come into use.
Functional appliances were developed to correct the abrrent muscle
environment- the jaw- to – jaw relationship – and as a result restore facial
balance by improving function, to achieve the best of both worlds it is
necessary to combine the fixed and functional appliance therapy.

Orthodontic Force
 Fixed appliance are designed to apply light orthodontic forces that
move individual teeth. Schwarz (1932) defined the optimum
orthodontic force as 28g per square centimeter of root surface. By
applying light forces with archwires and elasticity traction, fixed
appliances do not specifically stimulate mandibular growth during
treatment.
 A bracket or ‘small handle’ is attached to individual teeth. Pressure
is then applied to those teeth by tightening light wires to the
brackets. The resulting forces applied through the teeth to the
supporting alveolar bone must remain within the level of
physiological tolerance of the periodontal membrane to avoid
damage to the individual teeth and/or their sockets of alveolar
bone.

Orthopaedic Force
 Orthopaedic force levels are not confined by the level of tolerance
of the periodontal membrane but rather by the much broader
tolerance of the orofacial musculature. An orthopaedic approach to
treatment is not designed to move the teeth , but rather to change
jaw position and thereby correct the relationship of the mandible
to the maxilla.
 The forces of occlusion applied to opposing teeth in mastication are
in the range of 400-500 g and these forces are transmitted through
the teeth to the supporting bone. Occlusal forces form a major
proprioceptive stimulus to growth whereby the internal and
external structure of supporting bone is remodelled to meet the
needs of occlusal function. This is effected by reorganization of the
alveolar trabecular system and by periostal and endochondral
apposition.

 Functional appliance by definition is one that changes the posture
of the mandible, holding it open or open and forward. Pressure
created by stretch of the muscles and soft tissues are transmitted to
the dental and skeletal structures, moving teeth and modifying
growth.
 The monobloc developed by Robin in the early 1900s is generally
considered the forerunner of all functional appliances, but the
activator developed in Norway by Andresen in the 1920s was the
first functional appliance to be widely accepted.

The American And European
Controversy
 In the United States, the original removable appliances were rather
clumsy combinations of vulcanite bases and precious metal or
nickel-silver wires.
 In the early 1900s George Crozat developed a removable appliance
fabricated entirely of precious metal that is still used occasionally.
The appliance consisted of an effective clasp for first molar teeth,
heavy gold wires as a framework, and lighter gold finger springs to
produce the desired tooth movement.

 The Crozat appliance attracted a small but devoted following, and
still is used by some practitioners for comprehensive treatment. Its
limitation is that, like almost all removables, it produces mostly
tipping of teeth. It had little impact on the mainstream of American
orthodontic thought and practice, however, which from the
beginning was focused on fixed appliances.
Crozat appliance

 For a variety of reasons development of removable appliances
continued in Europe despite their neglect in the United States. There
were three major reasons for this trend:
(1)Angle's dogmatic approach to occlusion, with its emphasis on
precise positioning of each tooth, had less impact in Europe than in
the United States;
(2) Social welfare systems developed much more rapidly in Europe,
which tended to place the emphasis on limited orthodontic treatment
for and contemporary orthodontic appliances large numbers of
people, often delivered by general practitioners rather than
orthodontic specialists and
(3) Precious metal for fixed appliances was less available in Europe,
both as a consequence of the social systems and because the use of
precious metal in dentistry was banned in Nazi Germany.

 This forced German orthodontists to focus on removable
appliances that could be made with available materials. (Precision
steel attachments were not available until long after World War II;
fixed appliances required precious metal.)
 The interesting result was that in the 1925 to 1965 era, American
orthodontics was based almost exclusively on the Use of fixed
appliances (partial or complete banding), while fixed appliances
were essentially unknown in Europe and all treatment was done
with removables, not only for growth guidance but also for tooth
movement of all types. A major part of European removable
appliance orthodontics of this period was functional appliances for
guidance of growth.

 In the European approach at that time,
removable appliances often were
differentiated into "activators," or
functional appliances aimed at modifying
growth, and "active plates" aimed at
moving teeth. In addition to the functional
appliance pioneers, two European
orthodontists deserve special mention for
their contributions to removable
appliance techniques for moving teeth.
Martin Schwartz in Vienna developed and
publicized a variety of "split plate"
appliances, which could produce most
types of tooth movements.
 Philip Adams in Belfast modified the
arrowhead clasp favored by Schwartz into
the Adams crib, which became the basis
for English removable appliances and is
still the most effective clasp for
orthodontic purposes.
Martin Schwarz

 Functional appliances were introduced into American
orthodontics in the 1960s
• Through the influence of orthodontic faculty members with a
background in Europe (of whom Egil Harvold was prominent),
• And later from personal contact by a number of American
orthodontists with their European counterparts. (Fixed appliances
spread to Europe at the same time through similar personal
contacts.)
A major boost to functional appliance treatment in the United
States came from the publication of animal experiment Results in
the 1970s showing that skeletal Changes really could be produced
by posturing the mandible to a new position and holding out the
possibility that true stimulation of mandibular growth could be
achieved.

 At this point, the controversy between European and American
orthodontics has largely disappeared. European style removable appliances
particularly for growth modification during first-stage mixed dentition
treatment, have become widely used in the United States while fixed
appliances have largely replaced removables for comprehensive treatment
in European elsewhere throughout the world.
Modern removable appliance therapy consists largely of the use of
(1) various types of functional appliances for growth guidance in adolescent
and, less frequently, in children;
(2) active plates for tooth movement in preadolescents;
(3) clear plastic aligners for tooth movement in adults.

 For many years, the exclusive province of
dentofacial orthopedics was Europe, while
North America was firmly rooted in
Angle’s fixed appliance philosophy, yet it
was Norman W. Kingsley who first (1879)
used forward positioning of the mandible
in orthodontic treatment. Kingsley’s
removable plate with molar clasps might
be considered the prototype of functional
appliances, having a continuous labial
wire and a bite plane extending
posteriorly. As he described it, “The object
was not to protrude the lower teeth, but
to change or jump the bite in the case of
an excessively retreating lower jaw.”

 Edward H. Angle used a pair of
interlocking rings, soldered to
opposing first molar bands, much
along the lines of today’s
mandibular anterior repositioning
appliance (Fig 1), to force the
mandible forward.
Edward H. Angle
Fig 1

 As a result of studies on a dolphin’s tail fin, Wilhelm Roux is
credited as the first to study the influences of natural forces and
functional stimulation on form (1883) (Wolff’s law).
 His work became the foundation of both general orthopedic and
functional dental orthopedic principles.
 Later, Karl Häupl saw the potential of Roux’s hypothesis and
explained how functional appliances work through the activity of
the orofacial muscles.

The monobloc
(1902)
 The first practitioner to use functional jaw orthopedics to treat a
malocclusion was Pierre Robin (1902). He was a French
Stomatologist. He was born in 1867 and died in 1949. He wrote his
thesis on role of mastication and follicular sac on eruption of teeth.
In 1923 he published first of his 17 articles on the problem of
glosooptosis and said that he treated this condition with monobloc
which he first described in 1902 and which was used to restore the
normal relationship of the maxillae and the mandible.

 Pierre Robin syndrome (or sequence) is a condition present at
birth, in which the infant has a smaller-than-normal lower jaw, a
tongue that falls back in the throat, and difficulty breathing.
Robin sequence (RS), previously known as Pierre Robin
syndrome.
Fig: these are two illustration from the monograph by Dr Pierre robin

This syndrome consists of the following 3 essential
components:
 Micrognathia or retrognathia
 Cleft palate (usually U-shaped, but V-shape also
possible)
 Glossoptosis, often accompanied by airway
obstruction: The tongue is not actually larger
than normal, but because of the small mandible,
the tongue is large for the airway and therefore
causes obstruction. Rarely, the tongue is smaller
than normal.

 Until 1974, the triad was known as Pierre Robin syndrome;
however, the term syndrome is now reserved for those errors of
morphogenesis with the simultaneous presence of multiple
anomalies caused by a single etiology. The term sequence has
been introduced to include any condition that includes a series of
anomalies caused by a cascade of events initiated by a single
malformation.
 It extended all along the lingual surfaces of the mandibular teeth,
but it had sharp lingual imprints of the crown surfaces of both
maxillary and mandibular teeth. It incorporated and expansion
screw in the palate to expand the dental arches
Treatment would obviously require a total body approach, to
include psychological support, muscular and breathing exercises,
and lip closure, with the monobloc indicated to stimulate the
activity of the facial musculature and to normalize the occlusion.

Myofunctional Therapy
(1906)
 Alfred P. Rogers (1873-1959; Angle School, 1903),sometimes
called the father of myofunctional therapy, also recognized the
importance of the whole orofacial system.
 Rogers grew up on the shores of Canada’s Bay of Fundy and
developed a lifelong interest in nature and conservationism.
 He was the first orthodontist in New England to limit his
practice(1906).
 In addition, he was a strong proponent of the total-child approach
and advocated muscular exercises to improve neck, head, and
tongue posture and encourage nose breathing.

ACTIVATOR
(1908) Viggo Andresen of Norway was familiar with the
writings of American author Norman Kingsley.
 Also on Andresen’s bookshelf was a favorite of his,
the orthodontic textbook of Benno Lischer,
published in 1912. One conclusion to be drawn
from Lisher’s theory is that if compensatory,
adaptive lip and tongue function could exacerbate
excessive overjet in class II- type malocclusions
and if abnormal swallowing and prolonged finger-
sucking habits could create anterior open bite and
narrow maxillary arches, could not the same
muscles be used to correct these and other
problems?
Viggo Andresen

 Impressed with Kingsley’s concepts and appliances . Andresen
developed a mobile loose fitting appliance modification that transferred
functioning muscle stimuli to the jaws, teeth and supporting tissues.
Actually, Andresen was not thinking of “guiding growth” at that time, but
only of eliminating the adverse effects of abnormal function. This
working hypothesis was tested on his own daughter, who was wearing
fixed orthodontic appliances and who was going away to a camp over
the summer. Andresen removed the fixed appliances and placed a
modified Hawley-type retainer on the maxillary arch. However, he added
a lingual horseshoe flange that guided the mandible 3 to 4 mm forward
when teeth were brought into maximal closure allowed by the
interposed acrylic guide plane. This was done to prevent any relapse
over the three month vacation period. On his daughter’s return
Andresen was surprised to see that nighttime wearing of the appliance
not only had eliminated the abnormal neuromuscular compensation but
also had produced a complete sagittal correction and significantly
improved the facial profile.

 The result was stable. Seeing the continuous improvement with the
retainer he called it a biomechanical working retainer. He used it
after the removal of fixed orthodontic appliances, not only as a way
to stabilize the result achieved but also as a biomechanically
functioning appliance, particularly during the summer vacations
when the patients were gone for a longer period of time.
 When Andresen moved from Denmark to Norway, he became
associated with Haupl at the university of Oslo, Haupl, a
periodontist and histologist, was impressed with the results
obtained by Andresen’s functioning retainer. He was particularly
interested in its effect on underlying bone.

 By the time Andresen and Haupl teamed up to write an article about their
appliance, they called it an ACTIVATOR, because of its ability to activate the
muscle forces. The original name Andresen used for this type of treatment
was biomechanical orthodontics.
 Only later , after teaming up with Karl Haupl and doing further work on
concepts and techniques refinements, was the name changed to functional
jaw orthopedics’, which was more descriptive.

 To much of the world, the treatment
became known as the Norwegian
system, even though Andresen was a
Dane and Haupl a German ( both taught
at the dental school in Oslo, Norway).
His findings were supported by later
researchers.
 Andresen and Häupl later collaborated
on a textbook
(Funktionskieferorthopädie) about
their system in1936. Although Häupl’s
complete rejection of fixed appliances
led the profession astray for a time, had
it not been for his promotional efforts,
the activator might have languished into
unknown.
Karl Häupl’s advocacy of
“Norwegian system”
was main deterrent preventing
Europeans’ accepting
fixed appliances

HERBEST APPLIANCE
(1909)
 Herbst was far ahead of his time. Much of what we know about orthodontic
appliances today was already described by him more than 100 years ago (eg,
rapid palatal expansion devices).“ His main contribution to modern
orthodontics was, however, the development of the Okklusionsscharnier or
Retentionsscharnier (Herbst appliance) Scharnier means joint, and the word
retention was added because the upper part of the appliance stowed as a
retainer tot an expanded maxillary dental arch by the incorporation of a
circumferential palatal platinum-gold arch wire.
 At the 5th International Dental Congress Of 1909 In Berlin, Emil Herbst
presented a fixed bite-jumping device called Scharnier, or joint. The idea of
keeping the mandible forward continuously and eliminating the need for
patient compliance, as is required with removable functional appliances,
appealed to clinicians. In 1934 Herbst and Martin Schwaz wrote a series of
articles describing their case selection, experience, problems and solutions.
Patients with retrognathic mandibles and TMJ problems responded best.

 But after this, little appeared in literature until
the concept was brought back to focus by Hans
Pancherz. In 1979, Pancherz’s article in
American Journal Of Orthodontics called
attenetion to the possible stimulation of
mandibular growth. The Herbst appliance can
be compared with an artificial joint between
the maxiila and mandible. The bilateral
telescopic mechanism maintains the
protracted position of the mandible, even
during function.
Hans Pancherz.

The Bimler Appliance
 Just as Andresen’s discovery of the activator
was an accidental outgrowth of his retainer,
so was Hans Peter Bimler’s (1916-2003)
(Fig 4) elastischerGebissformer (elastic bite
former) fortuitous development. As a
surgeon treating jaw injuries during World
War II, Bimler had devised a maxillary splint
for a patient who had lost his left gonial
angle. The splint provided a guide into
which the patient could insert the
remainder of his mandible. Hans Bimler got his
inspiration for Gebissformer
as World War II army surgeon.

 In so doing, however, the pull of scar tissue led to a slight
widening of the maxillary arch. Bimler reasoned that it
might be possible to expand the arch by means of
crosswise mandibular movements, and the Bimler
appliance was born.
 After several modifications, the Bimler
appliance achieved its final form in 1949.
 Also like Andresen, Bimler was attacked by the
functional establishment, in particular Häupl, for his new
ideas, but every functional appliance subsequently
developed has incorporated atleast 1 of his innovations.

The Double Plate
(1956)
 Martin Schwarz (1887-1963) began his career
as an ear, nose, and throat physician but was
diverted into dentistry by famed histologist
Bernhard Gottlieb. He became director of
Kieferorthopaedia, Vienna Polyclinic, and the
jaw orthopedics division of the Viennese
government in 1939, where he expanded
orthodontic service from 100 to more than
3000 patients.

 In 1956, Schwarz attempted to
combine the advantages of the
activator and the active plate by
constructing separate mandibular
and maxillary acrylic plates that
were designed to occlude with the
mandible in a protrusive position.
The double plate resembled a
monobloc or an activator
constructed in 2 pieces.

The Tooth Positioner
(1944)
 In 1944, Harold D. Kesling (1901-
79)developed the tooth positioner. The
technique involved taking impressions of a
patient nearing completion, denuding the
plaster of appliances, and resetting the teeth
into ideal positions (the “diagnostic setup”).
From the new models, a rubber positioner
was made that, if worn enough hours, acted as
a finishing appliance. It could also be used as a
retainer. Harold D. Kesling,
inventor of tooth
positioner.

The Nuk Sauger
(late 1940’s)
 In the late 1940s, Adolph Mueller, a West German
orthodontist, took early treatment to its ultimate when he
designed a pacifier to promote development of babies’ jaws
and facial muscles.
 With a bottle nipple duplicating the shape and texture of a
mother’s nipple, this pacifier would better satisfy an infant’s
natural sucking desire.
 It could also preclude development of the tongue thrust that
was believed to result from a baby’s attempt to block the
copious flow of milk from conventional nipples.

The Functional Regulator
(1957)
 Rolf Fränkel (1908-2001) must be recognized as the inventor of an
appliance that corrects malocclusions with little or no contact with
the dentition. He studied in Leipzig and Marburg, Germany, receiving
his Dr MedDent in 1931 but was treating patients in his office at
Zwickau with Angle’s E-arch as early as 1928. In World War II, he was
a military surgeon involved with jaw and facial injuries.
 Recognizing that stability of treatment can occur only if the structural
and functional deviations of the muscular system are
corrected10,Fränkel designed the function regulator (FR, 1957),
making the oral vestibule the operational basis for his treatment.

 Rolf Frankel probably did more to interest American orthodontist in
functional appliances than any single clinician. His outstanding three
dimensional results, the spectacular improvements that have stood the
test of time and were done with the highest integrity, showed what can be
done with a carefully selected patients, properly designed appliances, and
maximal patient compliance.
 His impeccably researched clinical results are still the gold standard for
all functional appliances, fixed and removable.
 The use of buccal shields to screen off potentially narrowing muscle
forces and of lip pelots in the lower labial vestibule to prevent abnormal
perioral muscle function and lingualizing forces makes eminently good
sense

 Enlow et al, Moffett, Grabber, and others validate the fact that
periosteal pull as created but the frankels buccal shields,, has the
potential to stimulate bone growth.
 Frankels step wise advancement, so easily achieved by the unique
appliance design, has to provide the best and the most stable
results,, and they are applicable to other functional appliances.
 Of all the functional appliances, the functional regulator is the one
that depends most on function, proper fabrication, sufficient length
of wear and cooperation.
 However, the popularity of the pure functional regulator has
waned, not because of questions about the validity of the
philosophy, but because of pragmatic use, more demanding
laboratory procedures, and compliance demands.

Bionator
(1960’s)
 The bionator was developed by Balters, is the prototype of
less bulky appliance. Its lower portion is narrow and its
upper portion has only the labial wire and buccal screening
wire extension, plus a stabilizing cross-palatal bar that
actually can be adjusted for bilateral expansion if needed.
The palate is free for proprioceptive contact by the tongue.
The appliance has be worn all the rime except meals, which
is critical for maximum response.
 Kantorowicz termed the bionator“ the skeleton of an
activator from which there is nothing left but naked
emobodiment of Robin’s thoughts”.

 According to Balter’s, the
equilibrium between the tongue and
the circumoral buccinators
mechanism is responsible for the
shape of the arches and
intercuspation
Wilhelm Balters (1893-1973)

Other Functional Appliances Of The Early
1960s
 In 1952, Hans Mühlemann created the propulsor. Itwas
based on the activator, but it lacked the metal elements.
 The propulsor was later perfected by Hotz. About a year
later, Leopold Petrik(1902-65) introduced an activator
having greater occlusal thickness to increase the vertical
dimension.
 Hugo Stockfisch(1914- ) came out with his kinetor. This
device consisted of 2 movable plates connected by wire
buccinators loops, which keep muscle pressure away from
the cheeks. An unusual feature of the kinetor was the elastic
tubes between the 2 plates that acted not only as shock
absorbers but also as a means of broadening and optimizing
orofacial muscle pressures.

Twin Block
(1977)
 On 7th September 1977, Dr.
William J. Clarks developed Twin
blocks.
 The twin blocks were a natural
progression in the evolution of
functional appliance therapy,
representing a significant
transition from one piece
appliance that restricts the
normal function to a twin
appliance that promotes normal
function.
 Of all the functional appliances,
the bionator and the Clark twin
block are the most popular. The
successful use of bionator in TMJ
disturbances has been
documented.

 It is true that the necessity is the mother of invention.
 Name :- Colin Gove
 Age / Sex :- 7yrs 10 months / Male
 Chief Complaint :- Luxated upper central incisor
 On Examination :- Class II div 1 malocclusion with a 9mm
overjet and a midline shift to right.
 Treatment :- The tooth was re-implanted but due to class II;
lower lip was trapped lingual to the luxated tooth causing
mobility and root resorption to prevent this the appliance
with a Occlusal plane which could place the mandibular
forward into a edge to edge bit was made later a fixed
treatment was done. Later the re-implanted tooth was
crowned and a stable result was obtained at age of 25 years.
It was seen that the overjet reduced from 9mm to 4mm in 9
months.

Magnetic Appliances
(1989)
 Blechman, Bondemark and Kurol and Vardimon et al as well as
Darendelilier et al and Joho and Darendelilier, have been aware of
the potential for using rare earth magnets in orthodontics and
dentofacial orthopaedics for some time.
 Blechman, the true pioneer , has been involve intimately in the
medical and dental use of rare earth magnets. Recent medical
research corroborates his observations that static magnet fields
may have an electric field effect that potentiates tissue response.
 Despite widespread and increasing use of magnetic adjuncts in
general orthopedic problems, in vitro orthodontic research has
produced mixed results thus far.
 May be it’s a question of what to look for? 9/2/2013Functional appliances- I47

 Heightened blood flow is clearly evident, and the alignment
of blood flow is influenced by rare earth magnets,
 but the magnitude or character of force, its duration, and
whether continuous or intermittent force is applied are
questions currently being addressed.

Conclusion
 The past 20 years have seen an increasing awareness of the
potential of functional appliances as valuable tools in the
armamentaria of orthodontists.
 An increasing recognition of the interrelationship of form
and function, the realization that neuromuscular
involvement is vital in treatment, the recognition of the
importance of the airway in therapeutic considerations and a
growing understanding of head posture and the
accomplishments of dentofacial pattern changes are all
factors producing rapid growth in use of functional
appliances.

 Certainly , abnormal and adaptive neuromuscular function
can hinder the accomplishments of an optimal dentofacial
pattern.
 However, the same forces created under control can be used
to eliminate morphologic aberrations resulting from
abnormal lip trap habits, tongue posture and function, and
finger habits that have produced that have produced
deviations from the normal growth and development of the
stomatognathic system.

 One early article in American orthodontic literature, “ the
Three Ms’. Muscles , Malformations and Malocclusions,”, by
Graber (1963) described the effects of function and
malfunction to a mechanistically oriented profession that
was at that time treating patients according to numbers
gleaned from two dimensional cephalograms.

“Orthodontics is not only the appliance, but
which appliances, why, when, and for how
long.”

References
1. Dentofacial orthopedics with functional appliances. In: Graber TM,
Rakosi T, Petrovic AG, editors. Principles of functional appliances. St
Louis: Mosby; 1985.
2. Concepts of functional jaw orthopedics. In: Graber TM, Neumann B,
editors. Removable orthodontic appliances. 2nd ed. Philadelphia:
Saunders; 1984. p. 87.
3. Moorrees CFA. Orthodontics and dentofacial orthopedics: past, present
and future. Part 2. Kieferorthop 1998;12:127-40.
4. Rakosi TR, Graber TM, Petrovic AG. Dentofacial orthopedics with
functional appliances. St Louis: Mosby; 1985.
5. Proffit WR, Fields HW, editors. Contemporary orthodontics. 3rded. St
Louis: Mosby; 2000.
6. Hotz RP. The changing pattern of European orthodontics. Br JOrthod
1973;1:4-8.
7. Salzmann JA, editor. Practice of orthodontics. Philadelphia:Lippincott;
1966.
8. Bimler B. Hans Peter Bimler at age 85. Int J Orthod 2002;13:19-20. 9/2/2013Functional appliances- I53

9. Schmuth GPF. Milestones in the development and practical application of
functional appliances. Am J Orthod 1983;84:48-53.
10. McNamara JA Jr. Rolf Fränkel, 1908-2001 (in memoriam). Am J Orthod
Dentofacial Orthop 2002;121:238-9. 11. Harold D. Kesling (1901-79) (in
memoriam). Am J Orthod 1980;77:574-5.
12. Kesling HD. The philosophy of the tooth positioning appliance. Am J Orthod
Oral Surg 1945;31:297-304.
13. Gerber Medical Marketing. Via e-mail. June 20, 2005.
14. Melo ACM, dos Santos Pinto A, da Rosa Martins JC, Martins LP, Sakima MT.
Orthopedic and orthodontic components of Class II Division 1
malocclusion correction with Balters bionator. World J Orthod 2003;4:237-
42.
15. Levrini A, Favero L. The masters of functional orthodontics. Milan, Italy:
Quintessenz Verlag; 2003.
16. Graber TM. Orthodontics: principals and practice. 3rd ed. Philadelphia:
Saunders; 1972. p. 699.
17. Norman Walh, Orthodontics in 3 millennia. Chapter 9:Functional
appliances to midcentury; AJODO vol 129 page 82 9/2/2013Functional appliances- I54

Thank you
Presented by-
Dr Sneh Kalgotra
2nd year post-graduate student.

Evolution of Functional Appliances

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