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Newmarket
Auckland
NEW ZEALAND 1001

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Widening the upper jaw with removable othodontic appliances will stop bed wetting in 80% of children who suffer this problem

home : orthodontics : functional ortho

To see what is right and not do it is cowardice.
He who learns but does not think is lost.
He who thinks but does not learn is in great danger.
- Confucius

We must warn you that this page will get a rather technical - simply because it will be a bit controversial with 'traditional' dentists. So we will be offering researched references directed to reading dentists. If you are a patient or parent and find this all a bit boring, then I apologise. Just go and look at something else instead! I mean, dentistry is inherently boring anyway - isn't it??

First of all, a few definitions:

functional jaw orthpaedics is treatment with functional appliances making use of forces created by the head and neck musculature to bring about the desired dental, facial, and functional changes

functional appliances are removable or fixed [cemented] appliances that alter the posture of the mandible [lower jaw] and transmit the forces created by the resulting stretch of the muscles and soft tissues and by the change in the neuromuscular environment to the dental and skeletal tissues to produce movement of the teeth and modification to the growth of the jaws and lower face

At Alpers Dental we tend to use the bionator, twin block, and biobloc removable functional appliances and the MARA fixed functional appliance from amongst the many type of functional appliances available to us. But - and this is important - we certainly don't use functional appliances for evey patient - as some dentists would have you believe! Perhaps we would use them in 40% of our cases - and that's only in those patients with an 'overshot' or 'undershot' jaw. Where teeth are crowded, but the jaw size and relationship is o.k., then functional appliances are neither recommended nor used.

The Bionator appliance is a present day version of the Andresen Monoblock first used 100 years ago. The Bionator is designed to hold the lower jaw in its correct [class 1] relationship with the upper jaw. Over the 12 month period the bionator is worn, the muscles adapt to the corrected bite position while, depending on the version of the Bionator we prescribe, the lower jaw moulds into its new position. Remember that the the child's head is growing - we don't 'grow jaws' with functional appliances - we modify the jaw growth to the optimal shape and relationship - and that may enhance the jaw size over that of an untreated child. The Bionator 'floats' in the mouth. It is not normally clipped onto any teeth. Therefore it is the ideal appliance for the child to wear while the baby teeth are falling out and being replaced by permanent teeth [over the 8 to 12 year age period]. The Bionator is worn full time - day and night - apart from swimming, active sports, and eating. If the appliance is not worn at least 20 hours a day, then it simply will not achieve the changes we require.

The Twin Block appliance, like the Bionator, corrects the irregular jaw relationship into a correct [class 1] relationship. The Twin Block appliance was developed by Dr William Clark, a Scottish Orthodontist, over the 1970s and 80s. It consists of upper and lower jaw removable appliances that have plastic blocks covering the back teeth. These blocks force the lower jaw to bite into the ideal relationship with the upper jaw. It is usually worn for twelve months and, because it is in two parts and is clasped to the teeth, it should be worn during eating. We also use the Twin Block frequently for adult patients who have jaw joint disorders

The Biobloc appliance was developed by Dr John Mew, an English Orthodontist, and truly a man ahead of his time. The Biobloc is an ideal appliance for correcting the receeding lower jaw in the younger child - the 6 to 8 year old. Nic is taking an in-depth course on the Biobloc in the United States at this time. We will give you more up to date information on this excellent appliance once he has completed the course

In the past we have been labelled as "functional orthodontists". This is far from the truth. First and foremost, we never refer to ourselves as "orthodontists" of any sort! At Alpers Dental we are general dentists who have a special interest in providing orthodontic treatments in many techniques - including, but certainly not restricted to, functional appliances.

The Specialist Orthodontists in our area tend to limit themselves to treatments with fixed appliances [braces]. Braces are very good at moving teeth, but are not very good at modifying the jaw shapes or relationships. Removable appliances - including functional appliances - are designed to do just this. Therefore, while other dentists may say "your teeth are too big for your jaw [now that's nonsense if I ever heard it!] and we will have to "sacrifice" [aka extract!] some of them", we are able to say "your jaws haven't grown properly so now your teeth don't fit. Let's modify the shape and relationships of your jaws so your teeth fit - without removing any of the teeth".

And the functional group of appliances come into their own where the jaws don't line up. For example, the 'undershot' jaw, which is commonly the result of thumb sucking or the deviate swallow, can be easily corrected with functional appliance techniques. However, those orthodontists who choose not to use this simple and effective therapy are likely to recommend surgery to the jaws to correct the 'weak chin' appearance. This is an extremely invasive and expensive procedure with all the risks of surgery attached. Which would you prefer for your child: $20,000 for surgery or $5,000 for 12 months wearing a somewhat bulky but effective dental appliance?

Here is Flynn. Flynn came to us with an extremely crowded mouth and with his upper incisors hanging over his lower lip. Another dentist had told Flynn he would need an operation at about 18 years and there was nothing that could be done until then

Flynn looked like this when treatment was completed about 3 years later. Some of his side teeth still needed to settle into their final positions when these photos were taken

We developed Flynn's upper jaw for 4 months with a removable plate. Then we used a bionator for 12 months to align his jaws. Finally we straightened his teeth with braces that were worn for 6 months

The important thing here is the vast improvement to Flynn's profile. His lower jaw is now is a balanced relationship to his upper jaw. This was achieved with a functional appliance - no extractions and no surgery!

To see more of our patients who have completed functional appliance techniques look at Alex and Meredith.

now we are coming to the boring bit!

The web site of the NZ Association of Orthodontists has this to say about functional appliances:

"Functional appliances have been the source of some controversy because it is claimed they can make bone grow [especially of the lower jaw] and enlarge the jaws enough to make extraction of adult teeth unnecessary and to improve the top to bottom jaw relationship.
Unfortunately, these claims have no scientific evidence to support them. As a treatment choice they are better used for a relatively rare type of malocclusion [bad bite] rather than for every sort of bite or cosmetic problem.
Using functional appliances or 'removable plates' without thinking of their problems or limitations may mean longer treatment times and/or poorer results which often require the use of 'braces' to complete the treatment"

The writer of these opinions is either deliberately presenting disinformation against colleagues he presumably considers to be his opposition, or else he is so ignorant of basic internationally accepted orthodontic procedures that he has no right to call himself a specialist.

Lets look at those comments on this 'official site of the NZ Association of Orthodontists'. We shall use references from the American Journal of Orthodontics and Dentofacial Orthopedics - the most widely read orthodontic journal in the world, and a journal which every New Zealand Orthodontist reads:

...it is claimed they can make bone grow... Firstly, as I have already said, dentists using functional appliances do not claim to 'make bone grow'. We reposition the mandible [lower jaw] and allow normal growth plus enhancement by muscular and soft tissue forces to effect tooth, jaw, and facial changes. The American Association of Orthodontists' Council on Scientific Affairs looked at this 'bone growth' issue had this to say: The Council "specifically addressed whether functional appliances can stimulate increased mandibular growth in the long term, and not whether functional appliances are useful for correcting malocclusion [my italics]. Functional appliances might have effects on the maxilla, the glenoid fossa, and the dentoalveolar structures. They might also result in postural changes of the mandible....functional appliances might have several mechanisms of action which, when taken collectively, can assist with the correction of class II malocclusions" [AJODO 2005;128:271-2]. However, Rabie et al [AJODO 2003;123:40-48] found "functional appliance therapy accelerates and enhances condylar growth by accelerating the differentiation of mesenchymal cells into chondrocytes leading to an earlier formation and increase in amount of cartilage matrix. This enhancement of growth did not result in a subsequent pattern of subnormal growth for most of the growth period; this indicates that functional appliance therapy can truly enhance condylar growth".

...enlarge the jaws enough to make extraction of adult teeth unnecessary and to improve the top to bottom jaw relationship. A study by 21 British Specialist Orthodontists [thats right - 21 Specialists!] stated "...early treatment with Twin-block appliances resulted in reduction of overjet, correction of molar relationships, and reduction in severity of malocclusion. Most of this correction was due to dentoalveolar change, but some was due to favourable skeletal change" [AJODO 2003;124:234-43] In a further study, the same authors stated "early orthodontic treatment...with a Twin-block appliance results in higher self concept scores and fewer negative social experiences. The patients also reported treatment benefits that might be related to improved self esteem" [AJODO 2003;124:488-95]

Unfortunately, these claims have no scientific evidence to support them... There is no way to camouflage this statement - it is a straightforward lie. I have just referred to several scientific articles in the world's most widely read orthodontic Journal. There are dozens of other articles supporting functional appliance techniques in the refereed literature. Here, for example, is another one:
Dr Christine Mills and Dr Kara McCulloch, Specialist Orthodontists in Vancouver, Canada, state "during active treatment phase, the Twin Block [research] group experienced an average increase in mandibular length of 6.5 mm over 14 months. In comparison, the control group experienced a 2.3 mm increase in mandibular unit length during the 13 month observation period...much of the significant increase in mandibular length achieved during the active phase of treatment with the Twin Block appliance was still present 3 years later..." [AJODO 2000;118:24-33].
In a subsequent letter to the same Journal [AJODO 2001;119:10A-11A], Dr Mills states "I often wonder why headgears and other mechanical systems that distalize the maxillary arch are placed in patients in whom the class II malocclusion is due to a retrognathic mandible. Similarly, extracting the upper first premolars in these patients with the intention of correcting a Class II discrepancy by retracting normally positioned upper incisors to meet a receding lower jaw seems contrary to diagnostic findings. Current publications on soft-tissue esthetics emphasize the need to maintain fullness in the upper arch rather than constricting the dentoskeletal support and producing the effect of premature aging. Any orthodontic treatment that we undertake should improve the patient's profile appearance and not risk a decline in the esthetic situation...at age 9 surgery is not an option. Is it realistic to put treatment for these skeletal Class II patients on hold until they are in their late teens and old enough for jaw surgery? This would mean subjecting them to the psychosocial trauma associated with having a skeletal malocclusion throughout their adolescent years. In addition, not every patient wants surgery, and the cost of surgery limits its available to many". What a marvellous statement by Dr Mills - she is right on the money!!

Using functional appliances or removable plates...may mean longer treatment times and/or poorer results which often require the use of 'braces' to complete the treatment" As I have already said, we may start treatment from the age of 4 years. Our most frequent age for starting treatment is 8 to 9 years. By the time all the permanent teeth have erupted - that's when the traditional orthodontists want to start treatment - it's too late for a lot of the simple corrections that could reduce or eliminate the necessity for fixed appliances [braces] through those important teenage years. But certainly starting with a 4 or 8 year old may mean 'longer treatment times' because we aren't finished until the last of the permanent teeth are firmly in position. But who cares? Most of that treatment time, the patient is wearing simple, comfortable, removable plates - frequently only at night times. It is no big deal. Some children have all their permanent teeth by age 9. Others still have baby teeth hanging around until 14 or 15. We can't accurately know when the adult teeth will erupt - no one can. But then, if we are placing braces, the fixed appliances are usually only required for 6 months - just to allow us time to tuck the teeth into their ideal positions - and our patients really love that!
And we certainly dont use braces because of 'poorer results'. If the teeth are crowded - as opposed to jaw discrepancies - then we will tell the patient/parent at the very first [consultation] appointment that braces will be needed [for 6 months!] to complete treatment.

Our orthodontic treatment commonly consists of three phases - each phase only used where it is necessary:
1. mould the individual jaws size and shape with removable appliances containing screws or springs so the teeth will be accomodated - without extractions
2. align the two jaws with a functional appliance
3. straighten the teeth with braces

Did you notice that the first two phases are aimed at jaw - rather than tooth - correction? So these phases may be carried out while the baby teeth are still present. That means that we can complete most of the treatment before the adult teeth have finished erupting. So then we only have 6 months of braces to finish treatment [but of course followed by retainers to maintain the final result]. We do find that in many cases where we use functional appliances without a braces phase, that the teeth appear to be less likely to relapse following treatment than after treatments using braces.

So that article on Functional Appliances in the NZ Association of Orthodontists' web site is full of inaccuracies, half truths, and lies. I apologise that I have gone to such lengths to respond to their comments, but, quite simply, the Specialist Orthodontists of New Zealand need to become more professional and ethical and understand that General Dentists who undertake orthodontic procedures are not their enemies, and it is time for the continuing antagonism to stop. One New Zealand dentist has already commited suicide following charges orchestrated by an Orthodontist. Another dentist suffered severe Bells Palsey, necessitating months off work, following a different court case, again engineered by a local Orthodontist, possibly jealous of the dentist's standing and support in the town.

And here's a final comment on the negative attitude of the 'traditional' orthodontists to functional appliances. Dr Nigel Harradine, Consultanat Orthodontist at the Bristol Dental Hospital, England, was a keynote speaker at the NZ Dental Association conference in Auckland in September 2006. This conference was attended by almost all the NZ specialist orthodontists. Dr Harradine said he had a success rate of over 80% with functional appliance treatments. So with this endorsement by an internationally respected specialist, hopefully we can expect some common sense from the local orthodontists in the future.

I look forward to the day when we can once again respect our specialist colleagues and welcome them back into a partnership providing our patients with quality orthodontics.