ACTIVATOR

Kingsley in 1879 devised a vulcanite palatal plate to be used in patients having

retruded mandible. This vulcanite plate consisted of an anterior incline that guided the mandible to a forward position when the patient closed on it. Hotz devised a !orbissplatte which was a modified form of Kingsley s plate. This was used to treat retrognathism associated with deep bite. "t was also used to treat retrognathism associated with lingually inclined lower incisors. #ierre $obin devised an appliance called %onobloc made up of a single bloc& of vulcanite. He used it to position the mandible forward in patients with glossoptosis and severe mandibular retrognathism. 'y positioning the mandible. (orward it reduced the ris& of airway obstruction.

INDICATIONS AND CONTRAINDICATIONS OF ACTIVATOR

1 *. ,. -. .. /. )lass "". division 1 malocclusion )lass ""+ division * malocclusion )lass """ malocclusion )lass l open bite malocclusion )lass 1 deep bite malocclusion 0s a preliminary treatment before ma1or fi2ed appliance therapy to improve s&eletal 1aw relations 7. 8. (or post3treatment retention )hildren with lac& of vertical development in lower facial height

CONTRAINDICATIONS
1. The appliance is not used in correction of )lass " problems of crowded teeth caused by disharmony between tooth size and 1aw size. *. The appliance is contraindicated in children with e2cess lower facial height and e2treme vertical mandibular growth. , -. The appliance is not used in children whose lower incisors are severely rot mbent. The appliance cannot be used in children with nasal stenosis caused by structural problems within the nose or chronic untreated allergy. .. The appliance has limited application in nongrowing individuals.

!iggo 0ndresen in 1948 in 5enmar& develope a loose fitting app

lance which he first used on his daughter. He made a modified Hawley type of retainer on the ma2illary arch to which he added a lower lingual horse shoe3 shaped flange which helped in positioning the mandible forward 6fig /7. He made this appliance on his daughter who was going on a , month vacation. 8n her return , months later+ he found a mar&ed sagittal correction and improvement of the facial profile. 0ndresen called it biomechanical wor&ing retainer. 9ater 0nd resen moved over to :orway and teamed up with Karl Haupl and brought about lot of changes in his device. They called it (unctional ;aw 8rthopaedics. 0s 0ndresen and Haupl were in :orway while developing the appliance+ it became &nown as :orwegian appliance. They later called it the activator due to its ability to activate muscle forces.

Indications of activator
"t is primarily used in actively growing individuals with favorable growth pattern. The ma2illary and mandibular teeth should be well aligned. The mandibular incisors should be upright over the basal bone. $efer to table , for the indications and contraindications of activator.

Advanta es of activator thera!y

1. *. ,. -. .. "t uses e2isting growth of the 1aws. 5uring treatment the patient e2periences minimal oral hygiene problems. The intervals between appointments is long. The appointments are usually short due to need for minimal ad1ustments. 5ue to the above reasons they are more economical.

Disadvanta es of activator thera!y

1. *. $e<uires very good patient co3operation. The activator cannot produce a precise detailing and finishing of the occlusion. Thus post3treatment fi2ed appliance therapy maybe needed for detailing of the occlusion. ,. "t may produce moderate mandibular rotation 6anteriorly downwards7. Thus activators are not used in cases of e2cessive lower face height.

"ode of action of activator

0ccording to 0ndersen and Haupl+ the activator induces musculos&eletal adaptation by introducing a new pattern of mandibular closure. The appliance loosely fits into the mouth. The patient has to move the mandible forwards to engage the appliance. This results in stretching of the elevator muscles of mastication which starts contracting thereby setting up a myotactic refle2. This generates &inetic energy which causes. a. #revention of further forward growth of the ma2illary dento3alveolar process. b. %ovement of the ma2illary dento3alveolar process distally. c. 0 reciprocal forward force on the mandible. "n addition to this myotactic refle2+ a condylar adaptation by bac&ward and upward growth occurs.

0 third factor is the force generated while swallowing and during sleeping. 0ccording to ( Harvold+ =oodside and Herren passive tension caused by stretching of muscles+ soft tissue+ tendinous tissue+ etc.+ are responsible for the action. They called it the#viscoelastic !ro!erty#.

Construction bite
The construction bite is an interma2illary wa2 record used to relate the mandible to the ma2illa in the three dimensions of space. They are used to reposition the mandible in order to improve the s&eletal inter31aw relationship. The bite registration involves repositioning the mandible in a forward direction as well as opening the bite vertically. "n most cases+ the mandible is advanced by -3. mm and the bite opened to the e2tent of *3, mm beyond the freeway space.

T$% &%N%RA' CONSID%RATIONS FOR CONSTR(CTION )IT% AR%*

1. "n case the over1et is too large+ the forward positioning is done step wise in *3, phases. *. "n case of forward positioning of the mandible by 738 mm+ the vertical opening should be slight to moderate i.e. *3- mm. ,. "f the forward positioning is not more than ,3. mm+ then the vertical opening can be -3/ mm.

'O+ CONSTR(CTION )IT% +IT$ "AR,%D "ANDI)('AR FOR+ARD -OSITIONIN& *

This &ind of construction bite is characterized by mar&ed forward positioning of the mandible but minimal vertical opening. 0s a rule of thumb the anterior advancement should not e2ceed more than , mm posteriorto the most protrusive position. !ertically the opening is minimal and is within the limits of the inter3occlusal clearance. This &ind of activator constructed with mar&ed sagittal advancement but minimal vertical opening is called an H activator . The H activator is indicated in a patient with )lass ""+ division 1 malocclusion having a horizontal growth pattern.

$I&$ CONSTR(CTION )IT% +IT$ S'I&$T "ANDI)('AR FOR+ARD -OSITIONIN& *

The mandible is positioned anteriorly by ,3. mm only and the bite is opened vertically by -3/ mm or a ma2imum of - mm beyond the resting position. This &ind of

activator constructed with minimal sagittal advancement but mar&ed vertical opening is called a ! activator . The ! type of activator is indicated in a )lass ""+ division 1 malocclusion having a vertical growth pattern.

CONSTR(CTION )IT% +IT$O(T "ANDI)('AR FOR+ARD -OSITIONIN& *

>ometimes a construction bite without forward positioning of the mandible is made in cases such as deep bite and open bite.

CONSTR(CTION )IT% +IT$ O-%NIN& AND -OST%RIOR -OSITIONIN& OF T$% "ANDI)'% *

"n )lass """ malocclusion+ the bite is ta&en after retruding the mandible to a more posterior position. "n addition+ the bite is opened sufficiently to clear the bite. "n general a vertical opening of . mm and a posterior positioning of about * mm is re<uired.

FA)RICATION OF ACTIVATAR
"mpressions ? "mpressions of the upper and lower arches are made to construct * pairs of models? 1. *. >tudy models =or&ing models

)IT% R%&ISTRATION
1. The amount of sagittal and vertical advancement of the mandible is planned. *. 0 horse3shoe shaped wa2 bloc& is prepared for insertion between the upper and lower teeth. "t should be *3, mm thic&er than the planned vertical opening. ,. -. The patient is made to sit in an upright rela2ed and non3strained position. The mandible is guided to the desired sagittal position. The operator should merely guide the mandible using the thumb and forefinger. He should not use pressure or force. .. The patient is as&ed to practice placement of mandible at the desired sagittal position a few times before registration of the bite. /. The horse3shoe shaped wa2 bloc& is placed over the occlusal surface of the lower cast and is gently pressed so as to form the indentations of the lower buccal teeth. 7. The wa2 bloc& is placed on the lower 1aw and the patient is as&ed to bite at the desired sagittal position.

8. 9.

"t is then removed and placed on the models and chec&ed. "f found all right+ it is chilled and once again tried on the cast. The e2cess wa2 is trimmed off.

14.

The hardened wa2 bloc& is again tries the patient s mouth.

ARTIC('ATION OF T$% "OD%' *

The wa2 bite registration is placed on the occlusal surface between the upper and lower models. The models are then articulated in a reverse direction so that the anterior teeth face the hinges. This &ind of articulation ensures sufficient access to the palatal surface of the upper and lingual surface of lower models during the fabrication of the appliance.

-R%-ARATION OF T$% +IR% %'%"%NTS *

The usual design re<uires an upper labial bow. The labial bow is made with 4.8 or 4.9 mm wire and consists of a horizontal section with * vertical loops. The ends of the vertical loops enter the acrylic body between the canine and deciduous first molar 6or first premolar7. The labial bow can be active or passive.

FA)RICATION OF T$% ACR.'IC -ORTION *

The a!!liance consists of three !arts. a. %a2illary part b. %andibullar part c. "nter3occlusal part

The appliance can be fabricated by usinc+ either heat cure resin or cold cure resin. "n case of heat cure resin the models are first wa2ed anc then they are flas&ed.

%anagement of the appliance 1. The patients should be sufficiently convinced about the benefits he is going to derive by using the activator. "n this respect a good patient3doctor relation is essential. The dentist can ma&e use of video tapes+ boo&lets etc.+ to motivate the patient. *. The patient is also taught how to use+ place and remove the appliance by

himself. ,. @sually the patient is as&ed to wear the appliance for *3, hours a day

during the day time for the first wee&. 5uring the second wee& the patient is as&ed to wear it for , hours during the day as well as while sleeping. "n case the patient has difficulty in using it the whole night+ more daytime use is prescribed until the patient can use it for the entire night. -. 0 trimming plan should be developed based on the individual needs of the patient. >ome orthodontists prefer the appliance to be worn for a wee& without any grinding so that the patient can get used to it.

TRI""IN& OF T$% ACTIVATOR *

0fter fabrication of the activator it is usually found to fit tightly as acrylic is interposed between the upper and lower occlusal surfaces. #lanned trimming of the appliance in tooth contact area is carried out to bring about dento3alveolar changes so as to guide the teeth into good relation in all the , planes of space. >elective trimming of acrylic is done in the direction of tooth movement. The acrylic surfaces that transmit the desired force by contact with the teeth are called

guiding planes. The areas of acrylic that contact the teeth become polished. 0ppro2imate trimming can be done on the plaster casts. However+ final trimming should be done at the chair side.

TRI""IN& OF ACTIVATOR
Trimmin of activator for vertical control >elective trimming of the activator can be done to intrude or e2trude the teeth. "ntrusion of teeth ? "ntrusion of the incisors are achieved by loading the incisal edge of these teeth with acrylic. "n case labial bows are used+ they should be placed below the area of greatest conve2ity i.e. incisally+ to aid in the intrusion. "n case intrusion of posteriors is needed then only the cusp tips are loaded with acrylic. The fossae and fissures are free of acrylic. This applies a vertical intrusive force on the mo. lars. A2trusion of teeth? "n case of e2trusion of the incisors+ the lingual surface is loaded above the area of greatest conve2ity in the ma2illa and be. low the area of greatest conve2ity in the mandible. The e2trusive movement can be enhanced by placing a labial bow above the area of greatest conve2ity i.e. in the gingival 1B, of the labial surface. "n case of molars+ e2trusion is brought about by loading the lingual surface above the area of greatest conve2ity in ma2illa and below the area of greatest conve2ity in mandible.

TRI""IN& CONTRO'

OF

T$%

ACTIVATOR

FOR

SA&ITTA'

>elective trimming of the activator can be done to protrude or retrude the anterior teeth and also to improve the molar relation of the buccal teeth. #rotrusion of incisors ? "n case the incisors should be protruded+ lingual surface of the teeth is loaded with acrylic and a passive labial bow is given that is &ept away from teeth to prevent perioral soft tissues contacting the teeth. This acrylic loading of the lingual surface can be of two types. a. Antire lingual surface is loaded. >ince the area of contact is more the force for proclination is also low. b. 8nly the incisal portion of the lingual surface is loaded. 0s acrylic contact is small greater degree of force is generated to tip the incisors labially.

R%TR(SION OF INCISORS*
The acrylic is trimmed away from the lingual surface and an alive labial bow is used to bring about retrusion of the incisors. %ovement of posterior teeth in sagittal plane The teeth in the buccal segment can be moved mesially and distally to help in treating )lass "" and )lass """ malocclusion. "n )lass "" malocclusion+ the ma2illary molars are allowed to move distally while the mandibular molars are allowed to move mesially by loading the ma2illary mesiolingual surface and mandibular disto3lingual surface.

"OV%"%NT OF T%%T$ IN TRANSV%RS% -'AN%

"t is possible to trim the activator to stimulate e2pansion of the buccal segment. This is done by allowing the contact of the acrylic on the lingual surfaces of the teeth to be moved transversely. 'ut better e2pansion is possible by placing a 1ac& screw in the activator.

"ODIFICATIONS OF ACTIVATOR
8ver the years a number of modifications of the classical activator have been described.

T$% )O+ ACTIVATOR OF A.". SC$+AR/ *

The bow activator is a horizontally split activator having a ma2illary portion and a mandibular portion connected together by an elastic bow. This &ind of modification allows step wise sagittal advancement of the mandible by ad1ustment of the bow. "n addition this design allows certain amount of transverse mobility of the mandible. The independent ma2illary and the mandibular portions can have a screw incorporated to allow arch e2pansions.

+(ND%R%R#S "ODIFICATION *
This is an activator modification that is mostly used in treatment of )lass """ malocclusion. This type of activator is characterized by ma2illary and mandibular portions connected by an anterior screw. 'y opening the screw the ma2illary portion is moved anteriody+ with a reciprocal bac&ward thrust on the mandibular portion.

T$%

R%D(C%D

ACTIVATOR

OR

C.)%RNATOR

OF

SC$"(T$ *
This modification of the activator is proposed by #rofessor C.$( >chmuth. This ap3 pliance resembles a bionator with the acrylic portion of the activator reduced from the ma2illary anterior area leaving a small flange of acrylic on the palatal slopes. The two halves may be connected by an omega shaped palatal wire similar to bionator.

T$% -RO-('SOR *
This is an activator modification conceived by %uhlemann and refined by Hotz. This appliance can be said to be a hybrid appliance that combines the features of both the monobloc and the oral screen. The propulsor is devoid of any wire components and consists of acrylic that covers the ma2illary buccal portion li&e an oral screen. This acrylic portion e2tends into the inter3occlusal area and also as a lingual flange that helps position the mandible forward.

C(TO(T OR -A'AT% FR%% ACTIVATOR *

This is a modification proposed by %etzelderto combine the advantages of bionator and the 0ndresen s activator. The mandibular portion of the appliance resembles an activator while the ma2illary portion has acrylic covering only the palatal aspect of the buccal teeth and a small part of the ad1oining gingiva. The palate thus remains free of acrylic thereby ma&ing the appliance more con3

'%NI%NT FOR -ATI%NTS TO +%AR T$% A--'IANC% FOR RO&%R $O(RS.

5ue to the greater amount of wearing time+ success should be greater with the pal 3 otefree activator. 0ccording to 5r Klaws %etzelder teappliance is e2cellent in mandibular positioning in T%; dysfunction cases.

T$% ,AR+%T/,. "ODIFICATION *

This consists of ma2illary and mandibular plates 1oined by a @ bow in the region of the first permanent molar. The ma2illary and mandibular plates not only cover the lingual tissues and lingual aspect of teeth+ it also e2tends over the occlusal aspect of all teeth. This type of activator allows stepwise +dvancement of the mandible by ad1ustment of rye @ loop. The @ loop has a larger and a shorter 7rm. 'ased on their placement pattern we can lave three types of Karwetz&y activators Type " ? This is used in the treatment of )lass ""+ division 1. "n this modification+ the larger lower leg is placed posteriorly. Thus when the two arms of the @ bow are s<ueezed the lower plate moves sogitallyforwards.

DType "" ?

This is used for the treatment of )lass """ malocclusion. "n this appliance the larger lower leg is placed anteriorly. Thus when the @ bow is s<ueezed the mandibular plate moves distally.

Type "ll ?

They are used in bringing about asymmetric advancements of the mandible. The @ bow is attached anteriorly on one side and posteriorly on the other side to allow asymmetric sagital movement of the mandible.

This activator allows mobility of the mandible and therefore ma&es the activator more comfortable to wear. The appliance allows gradual and se<uential forward pcsitioning of the lower 1aw.

$%RR%N#S "ODIFICATION OF T$% ACTIVATOR*

Herren modified the activator in two ways 1. 'y over3compensating the ventral position of the mandible in the construction wa2 bite. *. 'y seating the appliance firmly against the ma2illary dental arch by means of clasps 6ar rowhead+ triangular or ;ac&son s7.

The construction bite is ta&en in a strong mandibular protrusion. Herren recommends ma2imum forward positioning of the mandible reaching sometimes the feasible ma2imum. This advanced position of the mandible causes the retractor muscles to try to bring the mandible bac& to original position. This causes a bac&wardly directed force on the upper teeth and a mesial directed force on the lower teeth. 0ccording to Herren+ with every 1 mm increase of forward position of the mandible+ the sagittal force on the 1aws will increase by 144 gm. The amount of for3 ward positioning of the mandible is ,3- mm beyond the neutral occlusion i.e. in case of )lass "" molar relation the mandible is brought forward to )lass " molar plus an additional ,3- mm forward. 0 vertical opening of *3- mm is recommended. Triangular or ;ac&son s clasps are used to firmly seat the appliance to the ma2illary dentition. A2pansion screws can be used for e2pansion.%obility of the mandible is restricted by e2tending the lingual flange of the activator as far as possible towards the floor of the mouth.