FIXED FUNCTIONAL APPLIANCE: POWERSCOPE -A CASE SERIES

I J C D C FIXED FUNCTIONAL APPLIANCE: POWERSCOPE -A CASE SERIES ABSTRACT Patient cooperation has long been recognised as an important factor in te outcome of orthodontic treatment. Failure to adhere to prescribed schedules of removable appliance wear will result in slow treatment response or no response at all. To reduce these factors the fixed functional appliances were developed. These are effective for24 hour a day with minimal patient compliance. They are also referred to as non-complaince Class II devices, mainly indicated in patient of a class II malocclusion with a retrognathic mandible. Their selection varies according to the clinician preference, type of the anomaly and growth pattern. SOme of the commonly used appliances are Herbstm Jasper Jumper, MARA, Powerscope and Forsus Fatigue Resistant Device. The present case series depicts the use of Powerscope in patient of class II malocclusion. /Date of Submission : 03-10-17 Date of Acceptance :10-11-17 JAN- JUNE 2018 VOL 8 ISSUE 1 Indian Journal of Comprehensive Dental Care 1. Shilpa Gupta 2. Parvinder Singh Dhingra 3. Anubhav Khanna 4. Navneet Dhillon 5. Rajiv Kumar, 1 M.D.S., Reader, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar. 2. M.D.S., Senior Lecturer, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar. 3. M.D.S. Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar. 4. M.D.S. Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar. 5. M.D.S. Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar Corresponding author: Name: Dr. Shilpa Gupta M.D.S., Reader, Department of Orthodontics and Dentofacial Orthopaedics, Sri Guru Ram Das Institute of Dental Sciences and Research, Amritsar INTRODUCTION 3 displacement was first demonstrated by Herbst in 1934. Numerous studies have shown that the herbst appliance Skeletal class II malocclusion is most frequently occurring produces anterior displacement of the mandible and a malocclusion in a growing patient mainly as a consequence 1 posterosuperior displacement of the maxilla similar to the of mandibular retrusion. Either small size of the mandible 4-8 effects as seen from the headgear treatment. or posterior placement of condyle in glenoid fossa is responsible for the retrusion. Age and the severity are the Orthodontists can currently select from the wide range of key factor in management of this malocclusion; therefore a fixed appliances such as the Herbst appliance, its derivatives large number of appliances were designed to increase such as the Cantilever Bite Jumper, Mandibular Corrector 2 mandibular growth by forward positioning of the mandible. Appliance and semi fixed such as, Jasper Jumper, Flex Developer, Bite Fixer, Eureka Spring, Forsus Nitinol Spring Various treatment approaches involving removable and/or and Forsus device and Twin Force Bite Corrector. These fixed appliances with/without extractions have been are commonly known as "non-compliance Class II described during the last decades. Among these mandibular Indian Journal of Comprehensive Dental Care 1061

correctors", as these are non-removable, requires less patient co-operation and a full time wear. These are reported to correct Class II skeletal problems by encouraging 9-10 mandibular growth in condylar or sutural region. For Class II correction Powerscope is one such latest innovation which is a direct derivative of the Herbst Type II appliance. Dr. Andy Hayes worked in conjunction with American Orthodontics to develop PowerScope. This appliance addresses critical needs of the orthodontist Figure 1- Pre-treatment Extra oral photographs Figure 2- Pre-treatment Intra oral photographs Figure 3- Pre-treatment Lateral cephalograph Figure 4- Intra oral photographs with appliance Figure 5- Post treatment photographs Figure 6- Pretreatment extra oral photographs Figure 7- Pretreatment Intra oral photographs Figure 8 - Pretreatment lateral cephalogram Figure 9- Intra oral photographs with Powerscope Figure 10- Post fixed functional therapy photographs Indian Journal of Comprehensive Dental Care 1062

Table 1: Cephalometric evaluation of skeletal, dentoalveolar and soft tissue changes MEASUREMENTS PRE-TREATMENT POST-TREATMENT SKELETAL CHANGES SNA 80 0 79 0 SNB 72 0 74 0 ANB 8 0 5 0 WITS appraisal 6mm 4mm GoGn-Sn 32 0 33 0 Articular angle 152 153 Basal plane angle 24 0 24 0 Y-axis 62 0 65 0 Schwarz maxillary 41 mm 42 mm Schwarz mandibular 61 mm 64 mm DENTOALVEOLAR AND SOFT TISSUE CHANGES Maxillary Incisor U1-NA(angle) 6 0 15 0 U1-NA(mm) 1mm 3mm U1-SN angle 73 0 93 0 U1-PP 83 0 78 0 Mandibular Incisor IMPA 97 0 99 0 L1-NB (angle) 25 0 32 0 L1-NB(mm) 3.5mm 5.5mm Inter-incisal angle 152 0 130 0 L1-Apog line 0 mm 3 mm Soft-Tissues Nasolabial angle 117 121 S line-upper lip 2 mm -0.5 mm S line-lower lip 1 mm 2 mm Indian Journal of Comprehensive Dental Care 1063

MEASUREMENTS PRE-TREATMENT POST-TREATMENT SKELETAL CHANGES SNA 84 0 84 0 SNB 77 0 80 0 ANB 7 0 4 0 WITS appraisal 7mm 4mm GoGn-Sn 28 0 25 0 Articular angle 147 143 Basal plane angle 20 0 21 0 Y-axis 62 0 63 0 Schwarz maxillary 57mm 55mm Schwarz mandibular 67mm 70mm DENTOALVEOLAR AND SOFT TISSUE CHANGES Maxillary Incisor U1-NA(angle) 21 0 24 0 U1-NA(mm) 0mm 4mm U1-SN angle 108 0 108 0 U1-PP 67 0 65 0 Mandibular Incisor IMPA 101 0 103 0 L1-NB (angle) 27 0 27 0 L1-NB(mm) 4mm 4mm Inter-incisal angle 125 0 123 0 L1-Apog line 1mm 1mm Soft-Tissues Nasolabial angle 83 95 S line-upper lip 0mm -1mm S line-lower lip 1mm 0mm including the patient comfort and acceptance, extensive range of motion and simple installation. In the present paper, non-extraction management of skeletal Class II malocclusion in growing patients using the Powerscope will be shown by series of case reports. Case selection for fixed functional appliances: Indian Journal of Comprehensive Dental Care 1064

The patient should be of growing age with favorable facial FMA angle and positive VTO (Figure6). growth pattern, class II skeletal pattern with mandibular The patient had a Class II malocclusion on left side, end on deficiency, Angle's class II molar relationship, Visual molar relation on right side, class II canine relationship, Treatment Objective (VTO) should be positive, maxillary and Rotated 13,44, Proclined 21,31,32,41,42, Retroclined 11,22, mandibular teeth should be well aligned and upright over the 9mm over jet, 67% deep bite and deep curve of spee basal bone, lack of vertical development of lower face height. (Figure7). Case 1 The lateral cephalometric evaluation shown in figure 8 A 13 years pubertal female reported with a chief complaint of revealed orthognathic maxilla, retrognathic mandible, Class irregular position of upper front teeth. Clinical examination II skeletal relationship with average growth pattern with revealed patient had athletic built, mesomorphic body type, horizontal tendency, proclined upper and lower incisors, competent lip posture, brachycephalic shape of head, retruded upper and normally placed lower incisors, normally mesoproscopic facial form, convex profile, posterior facial placed both upper and lower lips (Table 2). divergence, recessive chin, normal mandibular plane, Table 2: Cephalometric evaluation of skeletal, dentoalveolar average clinical FMA and positive VTO (Figure 1). and soft tissue changes. On Intraoral examination, patient had U-shaped maxillary and mandibular arches, Angle's class II div 2 malocclusion, Treatment plan class II canine relationship,100% deep bite, maxillary midline MBT 0.022x0.028" preadjusted appliance was placed to level shifted to left by 1.5mm, normal overjet and deep curve of and align both arches. After eight months, the leveling and spee (Figure 2). alignment was achieved. 0.019"? 0.025" stainless steel The lateral cephalometric evaluation revealed class II skeletal working archwires was placed. To reinforce anchorage, 0 pattern with orthognathic maxilla (SNA-79 ) and retrognathic Nance palatal arch was cemented in upper arch. Figure of 0 mandible (SNB-74 ) with average growth pattern (GoGn-SN eight ligation was done from first molar to first molar in both 0 0 33 ), retroclined maxillary incisors (U1-NA 15 ), average arches. 10 of lingual root torque was given in lower anteriors 0 mandibular incisors (L1-NB 25 ), protruded upper lip (S-line to prevent the flaring of lower anteriors, the Powerscope was to upper lip 2mm) and average lower lip (S-line to lower lip placed to improve the mandibular retrognathism and 1mm). (Figure 3) achieve Class I relation as shown in Figure 9. After eight months, the Powerscope appliance was removed (Figure 10) Treatment plan and was followed by finishing and detailing and retention A nonextraction approach using MBT 0.022 slot preadjusted period. appliance was planned. Normal sequences of wires was DISCUSSION followed from 0.012, 0.014, 0.016 niti to rectangular 0.016x0.022 Niti and SS wire to achieve leveling and Among all malocclusions, Orthodontists pose constant 11 alignment for 8 months; which was followed by 0.017x0.025 challenge during treatment of Class II malocclusion. SS and working 0.019x0.025 SS wire in both the arches. Redirecting and modifying mandibular growth is the main Powerscope appliance was used for correction as shown in goal in a Class II treatment which can be achieved with help of Figure 4. A 5 labial root torque was given in mandibular various functional appliances. They produce skeletal archwire to prevent the flaring of the lower anterior. A correction by initiating remodeling changes at the 12 substantial improvement in the patients profile was noted mandibular condyle and glenoid fossa. The advantage of after the mandibular advancement. Since the appliance was these appliances is that they overcome need for extraction anchored onto the orthodontic wire, no debonding of lower and provide excellent facial aesthetics. Functional appliances canine bracket/upper buccal tube was observed during the are further categorized as fixed functional appliance and treatment with Powerscope appliance. removable functional appliance.fixed functional appliances are preferred over removable appliances due its many After 20 months of active treatment, skeletal and dental 12 advantageslike full time wear and excellent compliance. Class I relationships was achieved and the fixed appliances was removed as shown in Figure 5. Finishing and detailing Among various fixed functional appliances powerscope is was continued for 2 month followed by retention period. commonly used appliance. It offers many advantages over other fixed functional appliances like full time wear, Case 2. providing continuous stimulus for mandibular growth. Also A 16 year old post-pubertal female presented with the chief its compact, concise and small size design permits better complaint of irregularly placed upper front teeth. adaptation to functions such as a mastication, swallowing, speech and breathing. Hence, better patient compliance is Clinical examination revealed ectomorphic built, seen. mesocephalic shape of head, mesoproscopic facial form, acute nasolabial angle, lip competence, everted lower lip, Powerscope is delivered as a one size fits all appliances slightly convex profile, flat mandibular plane, low clinical preassembled with attachment nuts for quick and easy chair Indian Journal of Comprehensive Dental Care 1065

side application.the appliance allows intermaxillary wire-to- 4. Laecken RV, Martin CA, Dischinger TR, Ngan P. Treatment wire installation using a nut with hexagonal screw. Ball and effects of the edgewise Herbst appliance: a socket joint to maximize the lateral movements improving cephalometric and tomographic investigation. Am J patient comfort. The appliance consists of a telescopic Orthod Dentofacial Orthop.2006;130:582 593. mechanism consisting of inner shaft/push rod, middle and 5. Pancherz H. Treatment of Class II malocclusion by outer tubing. There is a nickel-titanium (NiTi) spring 13 jumping the bite with the Herbst appliance: a delivering constant 260 g force. This appliance delivers cephalometric investigation. Am J Orthod Dentofacial unmatched patient comfort, eliminates the need for Orthop.1979;76:423 441. headgear tubes or special band assemblies, and can be used with either banded or bonded molar tubes. 6. Pancherz H, Pancherz MA. Headgear effect of the Herbst appliance: a cephalometric long term study. Am J Orthod In present case reports post appliance therapy skeletal Dentofacial Orthop. 1993;103:510 520. changes were observed; SNB was increased, ANB was decreased, advancement of BO in wits appraisal was also 7. Karacay S, Akin E, Huseyin A, Umit G, Sagdic D. Forsus observed. Also the increase in mandibular length was Nitinol Flat Spring and Jasper Jumper correction of Class 14 confirmed by Schwarz analysis. II division 1 malocclusion. Angle Orthod. Dental changes showed that lower incisor angulation was 2006;76:666 672. increased whereas upper incisor angulation remained 8. Croft RS, Buschang PH, Jeryl D, Meyer R. A cephalometric unchanged. Soft tissue changes showed favorable position of and tomographic evaluation of Herbst treatment in the the lower lip. On completion of treatment, the patient's facial mixed dentition. Am J Orthod Dentofacial Orthop. profile changes to orthognathic because of the soft-tissue 1999;116: 435 443. changes and the mandibular advancement. 9. Panigrahi P, Vineeth V. Biomechanical effects of fixed Some side effects seen with the appliance are lower incisors functional appliance on craniofacial structures. The proclination, rotation of lower canines, buccal rotation of Angle orthod. 2009 Jul;79(4):668-75. maxillary molars are seen after fixed functional treatment. 10. Perinetti G, Primožic J, Furlani G, Franchi L, Contardo L. This can be taken care of by full slot rectangular stainless steel Treatment effects of fixed functional appliances alone or archwires, cinching of the lower arch wire, arch locks/stops in combination with multibracket appliances: a posteriorly, negatively torque lower anterior brackets and systematic review and meta-analysis. The Angle Orthod. many more.due to its one size fit along with other 2014 Sep 4;85(3):480-92. advantages excellent results can be acheived with the use of powerscope by taking appropriate appliance considerations. 11. Cetlin NM, Ten Hoeve A. Nonextraction treatment. J Clin Orthod 1983;17:396-413. CONCLUSION 12. Pancherz H, Ruf S, Kohlhas P. Effective condylar growth Class II malocclusion resulting from mandibular retrusion and chin position changes in Herbst treatment: a was well benefitted by the Powerscope fixed functional cephalometric roentgenographic long-term study. Am J appliance therapy. The use of this appliance minimized the Orthod Dentofacial Orthop. 1998 Oct 31;114(4):437-46. need of extraction. This appliance proved to be best treatment options for Class II correction, especially in 13. Paulose J, Antony PJ, Sureshkumar B, George SM, noncompliant patients with a favorable improvement in the Mathew MM, Sebastian J. PowerScope a Class II soft tissue profile and esthetic appearance of the patient by corrector A case report. Contemporary clinical the sagittal forward displacement of mandible ensuring dentistry. 2016 Apr;7(2):221. excellent long-term stable results. BIBLIOGRAPHY 1. McNamara Jr JA. Components of Class II malocclusion in children 8 10 years of age. The Angle orthod. 1981 Jul;51(3):177-202. 2. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA. Mandibular changes produced by functional appliances in Class II malocclusion: a systematic review. Am J Orthod Dentofacial Orthop. 2006 May 31;129(5):599-e1. 3. VanLaecken R, Martin CA, Dischinger T, Razmus T, Ngan P. Treatment effects of the edgewise Herbst appliance: a cephalometric and tomographic investigation. Am J Orthod Dentofacial Orthop. 2006 Nov 30;130(5):582-93. 14. Textbook of radiographic cephalometric by Alexander Jacobson. A practical evaluation of the X-ray headplate by A Martin Schwarz (original article) (AJO Aug 1961). Indian Journal of Comprehensive Dental Care 1066