BITE OPENING APPLIANCES

There are several types of bite opening appliances, and each type has a specific purpose:

Bite Turbos

Most often used. These are to correct deep bites, when the front teeth overlap too much, by keeping the back teeth slightly apart so they can “grow taller.”  There are two types of bite turbos, metal or tooth colored plastic, some patients call them “glue blobs” or “fangs” on the back of the teeth. Both types are glued onto the backs of the two front upper teeth. Bite turbos remain on the teeth until the back teeth no longer have space between them, and they fully touch. Once the back teeth come together, the deep bite is improved, and the bite turbos are removed.

Bite Blocks

These are used mostly when a patient bites down and a tooth touches a bracket. If a tooth is touching or “biting” on a bracket, the bracket will be repeatedly broken off, so bite blocks are placed to prevent unnecessary breakage of brackets. Bite blocks are blue dots of glue placed on the lower back molar teeth. Once the teeth have moved, and are no longer colliding with the braces, the bite blocks are removed.

Bite Plate

Bite plates are removable retainers, designed to specifically open the bite and to be worn with the braces. Because they are removable, and prone to being lost, bite plates are only used when turbos or bite blocks will not be adequate for the severity of the bite. They are used for bites that are too deep and the lower jaw is set too far back to make turbos large enough to hold the bite open. The bite plate is worn until the bite is properly corrected, or improved enough for turbos to work adequately.

COMMON SIDE EFFECTS:

All of the bite opening appliances take a little getting used to. Because your teeth do not fit together properly at first, eating and chewing is more difficult.  Within a few days of the bite block, turbo, or plate being placed, patients adjust to the modified chewing surface and have no problems. In order to lessen initial frustrations, patients should avoid hard-to-chew foods for the first few days, i.e. steak and other chewy meats. After the adjustment period, only the regular food restrictions for braces (the NO NO list) need to be observed.

Bite turbos and bite blocks are placed in pairs, so if one breaks off, you have a back up.  If both come off, they need to be replaced, so call the office to schedule to an appointment.

REASONS TO UTILIZE BITE OPEN APPLIANCES:

1. A patient has too deep of a bite, and it needs to be opened.
2. To prevent breakage from teeth colliding with braces when a patient bites down.

HOW TO CLEAN:

Brush your turbos and bite blocks just as you do your teeth and braces. Bite plates are a specific type of retainer, and require the same care as a retainer. See retainer instructions for more information.

FORSUS

Springs attached to braces that correct horizontal misalignment of the bite, or overbite.

REASONS TO UTILIZE FORSUS:

1. Provides a better bite by aligning the upper teeth with the lower teeth.
2. Attaches to the braces, limiting the need for patient compliance.
3. Can correct more severe misalignment than rubber bands can.
4. Pushes upper molars backwards, allowing to make more room for front teeth.

HOW IT WORKS:

The FORSUS is attached to the upper, back braces, and between two lower side teeth on the wires. There can be one or two FORSUS placed depending on the needs of the bite.

They apply gentle, steady pressure and gradually push the upper arch of teeth backwards and lower arch of teeth forwards, eventually aligning the front teeth until the proper amount of overbite is achieved.

They are attached to the braces, until Dr. Hirsh deems the bite corrected. They are on 24/7, therefore, the bite is corrected faster than with rubber bands.

COMMON SIDE EFFECTS:

During the first few days after insertion, you may feel any number of the following side effects:

• The appliance may feel bulky
• Speech might be impaired
• Scratching of the cheeks
• A little discomfort or pressure
• Difficulty chewing

We recommend taking a little Tylenol to help with any initial discomfort and wax on the bracket areas near the cheeks to help with the initial scratching of the cheeks.

HOW TO CLEAN FORSUS:

Patients should continue to brush and floss as they usually do with their braces.

WHAT CAN I EAT?

The NO NO list for braces must continue to be followed.  There are no additional food restrictions.

FIXING THE FORSUS AT HOME:

On occasion when yawning or eating, the FORSUS can become detached.  It is easy to put the two parts back together eliminating the need to come to the office.

1. Compress the coil spring portion that is attached to the upper arch, pushing it as tightly together as possible.
2. Open your mouth wide.
3. Take the stiff lower pole, attached to the lower archwire, and place it inside the center of the upper coil spring.
4. Release the coil spring and then open and close several times to ensure it is attached properly to the pole.
5. Call the office if you have any further problems.

MARA

Mandibular Anterior Repositioning Appliance is used to stimulate forces of growth, and encourage faster growth of the lower jaw.

REASONS TO UTILIZE A MARA:

• Corrects severe overbite or “buck teeth.”
• Provides a better bite by aligning the upper teeth with the lower teeth.
• Facial profile is not in balance, lower jaw is receded.
• Fixed appliance prevents loss and assists with non compliance by patient.
• Can be used to expand the arches as well.
• Can be used in conjunction with braces.
• Prevents extractions and jaw surgery.

HOW IT WORKS:

The MARA is a passive appliance that is glued into the mouth. Thus, lessening the need for patient compliance, and limiting the chances for patients to lose or break. It has metal crowns with bars attached to the upper and lower first molars. The bars work together to remind the patient to push their lower jaw forward and to keep it held there.  Acting as a reminder for the patient, there is no force used to push the lower jaw forward, making it much more comfortable.

By holding the lower jaw forward for a prolonged period of time, typically a full year, while the patient is growing, allows remolding and reshaping of the jaw bones, condyles, and muscles. Advancing the whole lower arch of teeth and the jaw, the patient “grows” a more balanced facial profile. The lower jaw is no longer receded, showing a stronger chin.

COMMON SIDE EFFECTS:

During the first few days after insertion, you may feel any number of the following side effects:

• The appliance may feel bulky
• Speech might be impaired
• More saliva than usual
• Scratching of the cheeks
• A little discomfort or pressure if you are turning a built in palatal expander
• Difficulty chewing

We recommend taking a little Tylenol to help with any initial discomfort and wax on the back areas near the cheeks to help with the initial scratching of the cheeks. Warm salt water rinses several times a day help to heal the scratches on the cheeks.

HOW TO CLEAN THE MARA:

Patients should continue to brush and floss as usual. We also recommend a water pick to reach the area between the appliance and the roof of the mouth where food gets trapped, and around the back bar areas. It usually helps to have another person aim the jet of water into the area under the palatal expander area, if the MARA has one. If a patient is experiencing bad breath regularly it is usually due to trapped food in that palate area.

WHAT CAN I EAT?

Most foods can be eaten with the MARA; however the following foods must be avoided:

• Popcorn
• Gum
• Ice
• And ANY HARD food that may break the bars, ie. Nuts, lollipops, jawbreakers

HOW TO TURN THE PALATAL EXPANDER, IF ONE IS BUILT IN:

1. The “key” is attached to a blue plastic, flat, stick that makes the turning process much easier and does not allow for the parent to push too hard and poke the palate area.

2. Carefully insert the key into the hole or slot in the middle of the appliance.

3. Gently and steadily push the key from the front toward the back of the mouth. Remove the key by pushing down and backwards toward the throat, ensuring you do not pull the key back, unturning the screw. You will see the next keyhole when you have fully turned the screw, and it is ready for the next activation.

TADs

A TAD, or temporary anchorage device, is a miniature screw, made of medical grade Titanium alloy that is placed in specific areas of the jaw bone, inside the mouth.

REASONS TO UTILIZE TADs:

1. No need for headgear, lip bumpers and other auxiliaries.
2. Speeds treatment and drastically reduces compliance required.
3. Can eliminate the need for extractions or surgery.
4. Greater control of movement.
5. More leverage to upright teeth or pull entire arches of teeth without reciprocal force.

HOW IT WORKS:

TADs serve as an anchor for moving specific teeth in the most controlled and predictable way possible. Temporary anchorage devices provide Dr. Hirsh a fixed, immovable anchor for space closure, molar uprighting, correction of anterior open bites and deep bites, correct gummy smiles, pulling entire arches of teeth forward or backward and many other tooth movements, without any reciprocal force to the well positioned teeth or arches.  Because TADs have revolutionized Orthodontic treatment, Dr. Hirsh is able to get results that may not have been accomplished with braces alone.

COMMON SIDE EFFECTS:

During the first few days after insertion, you may feel any number of the following side effects:

• The TAD may feel bulky
• Scratching of the cheeks
• A little discomfort or pressure from the tooth movement
• Minor swelling or bleeding of the gum tissue around the TAD

We recommend taking a little Tylenol to help with any initial discomfort. If a TAD is to become excessively loose, it may need to be reinserted. Dr. Hirsh can evaluate if a TAD needs to be reinserted, but the oral surgeon who originally placed will need to correct it.  It is most important to keep the area around the TAD very clean, and to ensure you are brushing and cleaning properly in the area of the TAD.

HOW TO CLEAN THE TADS:

Rinse with chlorhexidine, or other rinses the oral surgeon provides you with, two to three times per day for the first seven days.  Dip a soft toothbrush in the chlorhexidine and brush lightly around the TAD during the first week.  Brush the TAD as if it is a tooth thereafter. Contact the oral surgeon’s office if you experience any swelling or persistent pain.

HOW THE TADS ARE PLACED:

Dr. Hirsh will send a request to the oral surgeon or dentist who will be placing your TAD with specific instructions of where he needs them to be placed.  The doctor placing your TAD will review all procedures in detail, but a quick overview is:

1. Topical anesthetic is placed on the area where the TADs are to be placed.
2. The TADs are screwed in with a special tool with gentle pressure through the gums and into the bone between the teeth.
3. Slight pressure is felt but no pain. IT IS PAIN FREE!!
4. Entire procedure takes only a few seconds per TAD
5. After the TADs are placed, Dr. Hirsh wants to see you back very soon, so he can begin to utilize the TAD.

TWIN BLOCK APPLIANCE

The Twin Block Appliance is a removable appliance that used to help a receded lower jaw grow forward to match the upper jaw, due to the lower jaw is not growing at the same speed as the upper jaw.  This slow growth can be a result of several factors: thumb sucking, mouth breathing, tongue thrusting, or just genetics.  As a result, there is a large overbite or “buck teeth.”  In addition to bite misalignment, the facial profile is not in balance. When the lower jaw is receded, the chin is then set back, making it appear as a “weak chin.”  With the bite misalignment, receded chin, there are often narrow arches.

REASONS TO UTILIZE THE TWIN BLOCK APPLIANCE:

1. Large overbite aka “Buck Teeth”
2. The chin is set far back from the rest of the face, and the facial balance is not in harmony, “weak chin”
3. The arches are very narrow

HOW IT WORKS:

During the growth process, the bones and muscles are very malleable, allowing for manipulation with little force.  The Twin Blocks are two separate removable retainers with an extra portion, or block, of built up acrylic material that fit together in a way that requires the patient to push their lower jaw forward in order to close properly.  The blocks are passive and act as a reminder to hold the jaw forward; therefore, limiting pain and discomfort from any pressure forces.  While the jaw is being held forward, the jaw bones, condyles, and muscles are able to change and reform to the new proper position. If the patient does not push forward properly, they will not be unable to close their lips together all the way.  If the arches are also narrow and teeth do not have enough room to erupt, expander screws are added to the Twin Blocks.  This allows for widening the arches at the same time as “growing” the lower arch.  The Twin Blocks will correct the overbite, while balancing the facial profile, and expanding the arches.

COMMON SIDE EFFECTS:

During the first few days after insertion, you may feel any number of the following side effects:

• The appliance may feel bulky
• Hard to chew
• Speech might be impaired
• More saliva than usual
• Scratching of the cheeks
• Muscle tightness in the jaws
• If expanding, a little discomfort or pressure after turning

We recommend taking a little Tylenol to help with any initial discomfort and muscle tightness.  Eating softer, easier to chew foods (i.e. rice, pasta, soups), will help to adjust to the new biting position and chewing surfaces.

HOW TO WEAR TWIN BLOCKS:

Twin Blocks are worn at all times, 24/7, including sleeping and eating.  The Twin Blocks are only removed for brushing, flossing, contact sports, and swimming in the ocean.  When the Twin Blocks are out of the mouth, they are to be in a case to prevent breakage and loss.  After a period of time of full time wear, Dr. Hirsh will instruct the patient to wear the Twin Blocks at night time only.  This is typically after 8-12 months after diligent full time wear, while waiting for remaining permanent teeth to erupt.

HOW TO CLEAN THE TWIN BLOCKS:

Brush the Twin Blocks every time you brush your teeth with cool water, toothbrush, and toothpaste.  If white plaque buildup is forming on the Twin Blocks, they can be soaked in a retainer cleaner, or vinegar and water mixture for an hour.  This should be done occasionally to keep them from developing buildup or foul odors.

WHAT CAN I EAT?

Most foods can be eaten with the Twin Blocks; however the following foods must be avoided:

• Popcorn
• Gum
• Sticky/gooey foods, like caramel

HOW TO TURN THE TWIN BLOCKS:

1. Carefully insert the key into the hole or slot in the middle of the appliance.

2. Gently and steadily push the key from the front toward the back following the arrow. When removing the key, ensure you do not pull the key back, unturning the screw. You will see the next keyhole when you have fully turned the screw, and it is ready for the next activation.

3.  Typically, the Twin Block is turned 1 turn, 2 times a week.

LIP BUMPER

The lip bumper is a rubber coated, thin wire that lies along the outside of lower teeth against the lip and cheeks. It is a passive appliance that makes room for crowded teeth to erupt properly. The lip bumper simply holds the pressure of the lower lip off of the front teeth. By alleviating this pressure, the tongue can then, gradually push the lower teeth forward and out in a wider U shape.

REASONS TO USE THE LIP BUMPER:

To widen the lower arch to help with crowding of the lower teeth.
To move the six-year molars back in the mouth.
Significantly more gentle than a lower expander appliance.
Uses patient’s own muscle pressure to do all the expanding.

HOW OFTEN TO WEAR:

The lip bumper stays in 24 hours per day. You DO NOT remove it to eat meals. You only remove it to brush your teeth. If you play the trumpet, clarinet, trombone, baritone, or tuba, remove the lip bumper only during the time you are actively playing the instrument. For all other instruments, leave the lip bumper in while playing. When it is out of your mouth, place it in a retainer case.

HOW TO CLEAN THE LIP BUMPER:

Brush the plastic on the lip bumper every morning and night. Place bristles of your brush on the lip bumper and gently scrub.

COMMON SIDE EFFECTS:

Canker sores often develop on the gum tissue by the back bands and along the lip bumper area during the first few days following insertion. During the first few days, patients have a hard time getting the lip bumper in and out of the bands and may need help from parents to maneuver it. If appointments have been missed, the front teeth and gums can begin to rub on the bumper causing mild irritation.

We recommend using wax to cover the scratchy areas of the lip bumper bands, and if canker sores have started, a warm salt water rinse three times a day will help them heal. Ensure that all appointments are kept, and that the lip bumper is brought to each appointment to be adjusted.

TO REMOVE THE LIP BUMPER:

Slide the lip bumper out of the bands by pulling forward one side at a time.

TO PUT THE LIP BUMPER IN:

Make sure the loops are facing down. One side at a time, place the end of the lip bumper into the tube on the band. Locate the tube on other side, and place the end of the loose side of the lip bumper into the other side’s tube. Push with one finger on the front of the lip bumper to push the lip bumper all the way into the tubes.

PALATAL EXPANDERS

This palate widening appliance is a specially made device used to expand the upper arch, or roof of the mouth.

REASONS TO UTILIZE AN PALATAL EXPANDER:

Provides a better bite by aligning the upper teeth with the lower teeth.
Allows for easier breathing through the nose on patients who have a high palate and a narrow arch that restrict the breathing passages.
Makes more room for crowded teeth to align better.
Creates a more attractive, bright smile with less “dark triangles” at the corners of the mouth.

HOW IT WORKS:

The expanding action of the appliance gently separates the elastic membrane in the center of the palate. Once the palate has been expanded fully, new bone tissue fills that space.

Once the orthodontist has cemented the palate-widening device in place, the turning, or expanding is done at home. This is done once every day. At the cementing appointment an adult should be present for the assistant to teach them how to turn or activate the appliance.

The upper arch is usually expanded sufficiently in 4-6 weeks, however, the appliance must remain in the month for at least three months after expanding has stopped, while new bone is generating in the expanded arch. This is the stabilization period. Once the expander is removed, the patient will be given a removable retainer to hold the width.

COMMON SIDE EFFECTS:

During the first few days after insertion, you may feel any number of the following side effects:
The appliance may feel bulky
Speech might be impaired
More saliva than usual
Scratching of the cheeks
A little discomfort or pressure when turning
Itch or tingling under the appliance
Feeling like you need to blow your nose

We recommend taking a little Tylenol to help with any initial discomfort and wax on the bracket areas near the cheeks to help with the initial scratching of the cheeks.

HOW TO CLEAN THE PALATAL EXPANDER:

Patients should continue to brush and floss as usual. We also recommend a water pick to reach the area between the appliance and the roof of the mouth where food gets trapped. It usually helps to have another person aim the jet of water into the area. If a patient is experiencing bad breath regularly it is usually due to trapped food in that palate area.

WHAT CAN I EAT?

Most foods can be eaten with the expander; however the following foods must be avoided:
Popcorn
Gum
Sticky/gooey foods like caramel

HOW TO TURN THE PALATAL EXPANDER:

1. The “key” is attached to a blue plastic, flat, stick that makes the turning process much easier and does not allow for the parent to push too hard and poke the palate area.

2. Carefully insert the key into the hole or slot in the middle of the appliance.

3. Gently and steadily push the key from the front toward the back of the mouth. Remove the key by pushing down and backwards toward the throat, ensuring you do not pull the key back, unturning the screw. You will see the next keyhole when you have fully turned the screw, and it is ready for the next activation.

After a few days or weeks of turning, you will notice that widening the palate has caused a temporary gap in the front teeth. Do not be alarmed. This is a sign that the expansion is occurring, and the space will naturally close during the stabilization period.