Activator & Bionator

By Dr. Nilofer

Contents

Introduction Classification Of Myofunctional Appliance Advantages, Disadvantages, Indications, Contraindications Prologue Activator Classification of views Mode of action of activator Force analysis in activator therapy Construction bite Fabrication and management of the activator Trimming of the activator Modifications of Activator The Bionatora Modified Activator. Fabrication and management of Bionator. Trimming of the bionator. Modifications of Bionator Frankel Appliance Twin Block

Introduction
he term Functional appliance" refers to a variety of

removable appliances designed to alter the arrangement of various muscle groups that influence the function and position of the mandible in order to transmit forces to the dentition and the basal bone. Typically these muscular forces are generated by altering the mandibular position sagittaly and vertically, resulting in orthodontic and orthopedic changes.

An Appliance

is a dental/surgical device designed to perform a therapeutic/ corrective function.

 Myofunctional Therapy

Myofunctional therapy is defined as the treatment that transmits climates /guides natural forces of the orofacial musculature that are transmitted to the teeth &alveolar bone through the media of loose fitting passive appliances to achieve changes in Jaw position and tooth alignment.

Classification
Removable /Fixed Functional Appliance.
Myotonic /Myodynamic Appliance. Based On Appliance Platform By Profitt & Fields

a} Passive tooth borne appliance : Monobloc , Activator,Bionator , Twin Block b} Active tooth borne appliance : Expansion screws ,modification Of activator & Bionator . c} Tissue borne appliances : Oral Screen Frankel Appliance

 Group I ,Group II , Group III Appliances

Group I Transmit muscle force directly to the teeth for the purpose of correction of malocclusion . Group II Reposition the mandible & resultant force transmitted to teeth . Eg Activator Group III Reposition mandible but area of action is vestibule .

Advantages ,Disadvantages , Indication, Contraindications

Advantages 1. Larger Patient load . 2. Auxillary personnel can be trained and can operate under supervision . 3. Can perform Preventive/ interceptive role . 4. Have more potential for growth and development . 5. Used in conjunction with fixed appliances . 6. Avoids psychlogical disturbances 7. Normal oral hygiene can be maintained 8. Reduced chairside time & frequency of adjustment .

 Indications 1.

2.
3. 4.

5.
6. 7.

8.
9. 10.

Patients only in active growth phase can receive this form of treatment . Mild to moderate sagittal discrepancy corrections. Reduced normal / moderately increased anterior facial height . Anticipated downward & forward growth of the mandible . No missing teeth . No severely rotated /tipped teeth Lower incisors well aligned to profile . minimal excess of space / crowding . Nasal breather . Adequately Motivated .

 Contra-Indications 1. 2. 3. 4. 5. 6. 7.

Neuromuscular problems are a contraindication Adults / Post Pubertal growth patients Unfavourable facial morphology { Vertical growth pattern /increased anterior lower facial height } Severely malposed teeth . Severe crowding / spacing Lack of cooperation Patient is a mouth breather /adenoids or has known allergies / speech problems .

Prologue The Active Plate

In Orthodontics used to control the direction and the amount of

the force applied are under complete control and secure anchorage is provided . Non orthodontic uses Surgical splint ,Periodontal splint Orthodontic uses With expansion screws With springs , bows etc Retainer etc

The Guide Plane Plate

It is basically a forward biting plate / removable inclined plane

plate . Functions a) Bite opening . b) Mandibular propulsion. c) Transverse maxillary arch expansion ( if expansion screw added ) . d) Retraction of the maxillary incisors and space closure .

Activator
SYNONYMS : - Biomechanic working retainer ( Andresen ) - Andersen appliance - Nocturnal airway patency appliance. - Norwegian appliance.( Andresen and Haupl ) - Monobloc ( Robin ) - Kingsley or bite jumping appliance
Works using Myostatic muscle activity stimulation casing

isometric muscle contractions this muscle force transmitted by the appliance moves teeth thus appliance works using Kinetic energy .

Indications
It is primarily used in actively growing individuals with favorable growth

pattern. The maxillary and mandibular teeth should be well aligned. The mandibular incisors should be upright over the basal bone.

The following are some of the indications for the use of activator :

1. Class II, Division 1 malocclusion 2. Class II, Division 2 malocclusion 3. Class III malocclusion 4. Class I open bite malocclusion 5. Class I deep bite malocclusion 6. As a preliminary treatment before major fixed appliance therapy to improve skeletal jaw relations 7. For post-treatment retention 8. Children with lack of vertical development in lower facial height.

 A study done on the Influence of the activator on

electromyographic activity of mandibular elevator muscles by Rodolfo Miralles, DDS, Barbara Berger, Ricardo Bull, MD, Arturo Manns, DDS, Raul Carvajal, DDS showed treatment with the activator should be started at an early age.
Integrated electromyographic (IEMG) activity was recorded in 15 children with Class II, Division 1 malocclusion undergoing treatment with an activator. EMG activity was recorded with surface electrodes from anterior temporal and masseter muscles, with and without the activator in the postural mandibular position, during saliva swallowing and maximal voluntary clenching. Similar IEMG activity in the postural mandibular position and during maximal voluntary clenching, with and without activator, was observed. During saliva swallowing, the activity in both muscles was significantly higher with the activator. This supports the rationale for diurnal wear of the activator. Simple linear regression analysis showed a significant negative correlation between the change of masseter muscular activity during saliva swallowing and age of the children (r = -0.51), suggesting that treatment with the activator should be started at an early age.

Contraindications
1. The appliance is not used in correction of Class I problems of crowded teeth caused by disharmony between tooth size and jaw size, 2. The appliance is contraindicated in children with excess lower facial height and extreme vertical mandibular growth. 3. The appliance is not used in children whose lower incisors are severely procumbent. 4. The appliance cannot be used in children with nasal stenosis caused by structural problems within the nose or chronic untreated allergy. 5. The appliance has limited application in non-growing individuals.

Classification of Views
1 )According to the original Andresen-Haupl concept, the forces

generated in activator therapy are caused by muscle contractions and myostatic reflex activity which cause musculoskeletal adaptation . A loose appliance stimulate the muscle and the moving appliance moves the teeth. The muscles function with kinetic energy and intermittent forces are clinically significant. Petrovic 1984 , McNamara 1973 Agreed to this view Grude stated that this mode applicable only if the construction bite taken with in 4mm ..else works by stretching of soft tissues / relying on viscoelastic properties of muscles.

2) According to the second working hypothesis, supported by

Selmer Olsen, Herren (1953 ) Harvold (1974 ) Woodside (1973) The stretching of soft tissues and the viscoelastic forces are decisive for activator function . the appliance is squeezed between the jaws in a splinting action. The appliance exerts forces that move the teeth in this rigid position. The stretch reflex is activated, inherent tissue elasticity is operative, and strain occurs without functional movement. The appliance works using potential energy.
An efficient stretch action is achieved by overcompensation and the viscoelastic properties of the contiguous soft tissues

 Accordingly the Viscoelastic reaction can be divide d into the

following stages Emptying of vessels . Pressing out of interstitial fluid. Stretching of fibres . Elastic deformation of bone. Bioplast adaptation.

3) It can be called a transitional type of activator action , which

alternatively uses muscle contraction and viscoelastic properties of soft tissues.

The stretch reflex resulting from activators in this group is seen as a long lasting contraction. The intermittent forces induced by the constructions are less pronounced than those induced in the original construction.

Eschler ( 1952 ) observed the occurrence of both isotonic and isometric contractions when this appliance construction was used.

SKELETAL AND DENTOALVEOLAR EFFECTS OF THE ACTIVATOR

The Activator affects the 3rd level of articulation.

1. Any skeletal effect from the activator depends on the growth potential.
Two divergent growth vectors propel the jaw

bases in an anterior direction A The sphenoccipital synchondrosis moves the cranial base and nasomaxillary complex up & forward. B The condyle translates the mandible in a downward and forward direction. lower vector or the downward and forward growth of the mandible.

The activator is most effective in controlling the

Johnston (1976) attributes this response to unloading the condyle." Only the upward and backward growth of the condyle is capable of moving the mandible anteriorly

 If the mandible cannot be positioned anteriorly, maxillary

growth can be inhibited and redirected.

Changing the maxillary base inclination can compensate for

rotations of mandibular growth vectors.

A downward displacement of the maxillary base allows the

maxilla to adapt to a vertical rotation of the mandible.

unfavorable, activator therapy cannot be completed successfully.

If the rotation of the jaw bases during growth is

 If the activator is constructed with a vertical opening of the bite only or with minimal sagittal change, the effect is primarily on midfacial development in the subnasal area. Both vertical maxillary growth and eruption of the teeth are restricted.

2. The dentoalveolar efficiency of the activator helps achieve, a primary treatment objective. Teeth and bones fill in the space between the two divergent growth vectors. The dentoalveolar effect of the activator is to control tooth eruption and alveolar bone apposition. For this reason the activator is most effective if used in the early mixed dentition. With proper trimming of the appliance, different movements can be performed and the eruption of the teeth can be guided.

Force Analysis in Activator Therapy

Static forces

They do not appear simultaneously with movements of the mandible.

The forces of gravity, posture and elasticity of soft tissues and muscles are in this category

Dynamic forces Interrupted Forces

They appear simultaneously with movements of the head and body and have a higher magnitude than static forces.

The frequency of these forces also depends on the design and construction of the appliance and patients reaction

Rhythmic Forces
They are synchronous with breathing and their amplitude varies with pulse.

The mandible transmits rhythmic vibrations to the maxilla.

The applied forces are intermittent and interrupted.

Force application to the teeth and mandible is intermittent.

 The types of force employed in activator therapy may be categorized as

follows: 1 The growth potential, including the eruption and migration of teeth, produces natural forces. These can be guided promoted, and inhibited by the activator. 2. Muscle contractions and stretching of the soft tissues initiate force when the mandible is relocated from its position by the appliance. The activator stimulates and transforms the contractions. Whereas forces may be functional (muscular) in origin, their activation is artificial. Various active elements (e.g., springs, screws) can be built into the activator to produce an active biomechanic type of force application.

 These artificially functioning forces be effective in all three planes: In the sagittal plane the mandible is propelled down and forward, so that

muscle force is delivered to the condyle and a strain is produced in the condylar region.
A slight reciprocal force can be transmitted to the maxilla during this

maneuver
A vertical plane the teeth and alveolar processes are either loaded with or

relieved of normal forces.

 If the construction bite is high, a greater strain is produced to

the contiguous tissues.

If transmitted to maxilla these forces can inhibit growth increment and direction and influence the inclination of

maxillary base.
In the transverse plane, forces also can be created with midline corrections

CONSTRUCTION BITE
Proper activator fabrication requires the determination and

reproduction of the correct construction or working bite.

The purpose of this mandibular manipulation is to relocate the jaw in

the direction of treatment objectives. This creates artificial functional forces and allows assessment of the appliance's mode of action.

Study Model Analysis

Before constructing the activator , the clinician must consider the following factors : First permanent molars relationship in habitual occlusion. Nature of the midline discrepancy . Symmetry of the dental arches. Curve of spee. Crowding and any dental discrepancies.

1. 2. 3. 4.

5.

Functional Analysis
Precise registration of the postural rest position in the natural head position. Path of closure from postural rest to habitual occlusion ( any sagittal or transverse deviations are recorded).

Occlusal interferences and resultant mandibular displacement.

Sounds such as clicking and crepitus in the TMJ. Interocclusal clearance or freeway space. Respiration.

Cephalometric analysis
Direction of growth Average , Horizontal or vertical. Differentiation between position and size of the jaws bases. Morphological pecularities , particularly of the mandible. Axial inclination and position of the maxillary and mandibular

incisors.

General rules for the construction bite

In a forward positioning of the mandible of 7 to 8 mm the vertical opening must be slight to moderate (2 to 4 mm). 2. If the forward positioning is no more than 3 to 5 mm the vertical opening should be 4 to 6 mm.

3. The activator can correct lower midline shifts or deviations only if actual lateral translation of the mandible itself exists. If the midline abnormality is caused by tooth migration, no asymmetric relationship exists between the mandible and maxilla. An attempt to correct this type of dental problem could lead to iatrogenic asymmetry. Functional crossbites in the functional analysis can be corrected by taking the proper construction bite.

 Anterior positioning of the mandible: The usual intermaxillary relationship for the average Class II problem is end-to-end

incisal. However, it should not exceed 7 to 8 mm, or three quarters of the mesiodistal dimension of the first permanent molar, in most instances.
However,Anterior positioning of this magnitude contraindicated if any of the following pertain: 1.The overjet is too large: 2.Labial tipping of the maxillary incisors is severe

is

3.An incisor (usually a lateral) has erupted markedly to the lingual: The mandible must be postured anteriorly to an edge-to-edge relationship with the lingually malposed tooth; otherwise, labial movement of this tooth will be impossible.
Eschler (1952) termed the condition a pathologic construction bite. As with severely proclined upper incisors, use of a short

prefunctional appliance to improve alignment of lingually malposed teeth is advisable before starting activator treatment, thereby eliminating the need for the pathologic construction bite.

 Opening the bite : Maintaining a proper horizontal-vertical relationship and determining the height of the bite are guided by the following principles: 1. The mandible must be dislocated from the postural resting position in at least one directionsagitally or vertically. This

dislocation is essential to activate the associated musculature and induce a strain in the tissues. 2.If the magnitude of the forward position is great (7 or 8 mm), the vertical opening should be minimal so as not to overstretch the muscles. This type of construction bite produces an increased force component in the sagittal plane, allowing a forward positioning of the mandible.

 3. If extensive vertical opening is needed, the

mandible must not be anteriorly positioned. If the bite opening exceeds 6 mm, mandibular protraction must be very slight . Myotatic reflex activity of the muscles of mastication can then be observed, as can a stretching of the soft tissues. The vertical relationship, either deep bite or open bite,can be therapeutically affected by the activator. include the difficulty of wearing the appliance and adapting to the a new relationship. Muscle spasms often occur, and the appliance tends to fall out of the mouth. The high construction bite also makes lip seal difficult if not impossible.

Disadvantages of a wide-open construction bite

The ultimate reestablishment of normal lip seal is essential in functional appliance therapy.

Execution Of the Construction Bite

A horseshoe shaped wax bite rim is

prepared for insertion between the maxillary and mandibular teeth. the operator asks the patient to sit upright in a relaxed posture while gently guiding the mandible into the predetermined position.

Before taking the wax bite registration

When the operator is relatively sure the

patient can replicate the exercise , the softened wax bite rim is placed in the mouth and wax should not be too soft. operator controls the edge to edge incisal relationship and midline registration.

During the closing movement the

Technique for a Low Construction Bite

The mandible is positioned anteriorly to achieve an edge to edge

relationship parallel to the functional occlusal plane.

The mandible should remain within the limits of the interocclusal

clearance and not exceed its postural rest position for the vertical registration.
When the mandible moves mesially to engage the appliance , the

elevator muscles of mastication are activated.

When the teeth engage the appliance the myotactic reflex is

activated.
In addition to the muscle force arising during biting and

swallowing , the reflex stimulation of the muscle spindles also elicits reflex muscle activity.

Horizontal H Activator Mandible can be postured forward without tipping the lower incisors labially.
The maxillary incisors can be positioned upright and the anterior growth vector of the maxilla is slightly inhibited. This appliance is most effective if an anterior sagittal relationship of the mandible. Most commonly indicated in Class II , Division 1 Malocclusion

Actions Of A H -Activator
Activates the elevator group of muscles.
On teeth engaging the appliance the myotactic reflex is activated. Mandible can be positioned forward without tipping the lower

incisors labially. Maxillary incisors can be positioned upright. Anterior growth vector of the maxilla can be slightly inhibited.

Indicated when sagittal relationship of the mandible is of primary concern.

Technique for a High Construction Bite with Slightly Anterior Mandibular Positioning
In a high construction bite the mandible

is positioned less anteriorly ( only 3 to 5 mm ahead of the habitual occlusion position ). interocclusal space , the vertical dimension is opened 4 to 6 mm , a maximum of 4 mm beyond the postural rest vertical dimension registration.

Depending on the magnitude of the

The greater opening of the vertical

dimension in the construction bite allows the myotatic reflex to remain operative even when the musculature is more

Vertical V Activator
The goal of activator treatment is minimal forward positioning of the mandible because of the vertical growth pattern but an actual adaptation of the maxilla to the lower dental arch.

This goal can be only achieved by a retroclination of the maxillary base.

This skeletal adaptation must be supported by dentoalveolar compensation which requires differential guidance of eruption of maxillary buccal segment eruption, lingual tipping of the maxillary incisors and labial tipping of the mandibular incisors.

Actions
Stretch reflex activation influencing the inclination of the

maxillary base.. Minimal forward positioning of the mandible along with : Actual adaptation of the maxilla to the lower dental arch. Partial retroclination of the maxillary base. Dentoalveolar compensation differential guidance of eruption of the buccal segments lingual tipping of the maxillary and labial tipping of the mandibular incisors.

Technique for a construction bite without forward Mandibular Positioning

A forward positioning of the mandible is not indicated in activator construction if a sagittal correction is unnecessary . Such appliances are used primarily in vertical dimension problems and selected cases of crowding.

Deep overbite malocclusion

When infraocclusion of molars construction bite may be either moderate or high, depending on the size of the freeway space.
Activators designed and trimmed to permit extrusion can be used to treat deep overbite cases.

Supraocclusion of the incisors

The activator should not be designed with a high construction bite in these cases. Intrusion of the incisors is possible to only limited extent when an activator is being used.

Any correction is obtained by loading the incisal edges with an acrylic cover.

Depression is relative rather than absolute because the other are free to erupt and accomplish the predetermined growth pattern.

 Skeletal deep overbite malocclusion usually has a horizontal

growth pattern for which forward inclination of the maxillary base can compensate. Construction bite should be high enough to exceed the patients postural rest vertical dimension. This height enlists stretch reflex response and the viscoelastic properties of the muscles and soft tissues as they are stretched.

Arch length deficiency problems

Malocclusions with crowding can be treated with activators.
The construction bite is low because

jaw positioning and growth guidance by selective eruption of teeth are not desired.
The treatment objective is expansion using appliance established by intermaxillary relationships.

Construction bite with opening and posterior positioning of the mandible

Tooth

guidance or functional protrusion Class III malocclusion enough to clear the incisal guidance for construction bite. This eliminates the protrusive relationship with the mandible in centric relation.

The vertical dimension is opened far

The prognosis for pseudo class III

malocclusions is good especially if therapy begins in early mixed dentition.

Skeletal Class III malocclusion with a normal path of closure from rest to habitual occlusion
The opening of the vertical dimension for the construction bite depends on the possibility of achieving an end-to-end incisal relationship. Indications for functional treatment of true Class III problems are limited. Usually combined therapy such as with fixed and removable appliances and maxillary orthopedic protraction is likely to be successful.

If the treatment is initiated in the early mixed dentition and if the bite can be opened ,incisal guidance established , adaptation of the maxillary base to the prognathic mandible can be expected to a certain degree.

Fabrication of the Activator

Labial Bow : primary element of the

activator with upper and lower labial bows. They consists of horizontal middle sections,two vertical loops,and wire extensions . The bow can be active or passive depending on the prescription . The passive labial bow influences the soft tissue without touching the teeth . Depending on the vertical dimension , the wire crosses the incisors above or below the area of greatest convexity.

 The vertical U shaped loops of the upper labial bow start with a 90 degree bend at lateral incisor canine embrasure , form gentle continues curves above the gingival margin and pass freely through canine first

deciduous molar or premolar embrasures to anchor in the lingual acrylic.

The wire approximates the mesial marginal ridge of the first deciduous molars in case to exert distalization force vector on these teeth.

 The lower labial bow is similar in configuration to the upper. The

middle horizontal portion is longer because the bend for the vertical loops starts distally in the mesial third of the canines. The gauge of the wire is different for active and passive labial bows.
For the active bow the spring hardened type of stainless steel wire is 0.9 mm thick for the passive bow it is only 0.8 mm thick.

Fabrication of the acrylic portion

The activator consists of upper , lower and interocclusal parts. In the upper and lower dental parts the dental and gingival portions can be differentiated ; the gingival portion can be extended

posteriorly.

If the construction bite is high as it is in a vertical activator , the extension of the flanges is greater than for a horizontal type of activator that positions the mandible more anteriorly.

 The flanges for upper part are 8 to

12 mm high in the gingival area and cover the alveolar crest. The palate is not covered.
The lower acrylic plate is generally 5 to 10 mm wide although it is sometimes wider in the molar area

with flanges of 10 to 15 mm.

 The principles of force application in the trimming process are determined by the type, direction and the magnitude of force created by the loosely fitting activator : Intermittent force application allows dynamic and rhythmic forces to act in concert thus works by kinetic energy. The direction of desired force is determined by selective grinding of the acrylic surfaces that contact the upper and lower teeth The magnitude of the force delivered can be estimated by determining the amount of acrylic contact with tooth surfaces.

Trimming of activator for vertical control

INTRUSION/EXTRUSION Intrusion of teeth

It can be achieved by loading incisal edges of teeth.

If they are grounded properly , they become the only loaded or contacting surfaces with no other contact between the incisors and acrylic even in the alveolar area. Intrusion of molars is performed by loading only the cusps of these teeth. The fossae and fissures are free of acrylic. Molar depression and loading are indicated in open bite problems if minimal or nonexistant interocclusal clearance is apparent.

Extrusion of teeth extrusion of incisors requires loading their lingual surfaces above the area of greatest concavity in the maxilla and below this area in the mandible. Extrusion of molars can be done by loading the lingual surfaces of these teeth above the area of greatest convexity in the maxilla or below this area in the mandible. Molar and premolar extrusion is indicated in deep bite

Trimming of activator for sagittal control

Protrusion and retrusion of incisors

can be accomplished only through grinding of the acrylic and guide planes and adjustment of the labial bow wires.
If labial touches the teeth , it can

either tip them lingually or retain them in position. In these it is called an active bow.
If it is positioned away from the

teeth and prevents soft tissue contact , it is called a passive bow.

Protrusion of Incisors : Loading can be accomplished by either of two methods :

The entire lingual surface is

loaded.only the interdental acrylic projections are trimmed to avoid opening spaces between the teeth.
This method allows the incisors to

be moved labially with a low magnitude of force because the applied force is spread over a large surface.

 The incisal third of the lingual surface

is loaded. This variation results in labial tipping of the incisors with a greater degree of force because the contact surface is small.

 Protrusion Springs : Continuous or closed

springs of fairly heavy wire ( 0.8 mm) are activated only when the teeth are closed into the appliance.
Wooden pegs : Small wooden pegs are

inserted with minimal projection into the lingual acrylic.The protrusion springs or wooden sticks usually contact the incisors in the middle or gingival third of the lingual surfaces.
Guttapercha : Guttapercha may be added to

the lingual acrylic.This traditional approach has been supreseded by the use of thin layers of soft acrylic applied where desired.

Retrusion of incisors : The acrylic is trimmed away from the backs of the incisors o be retruded. The active labial bow, which contacts the teeth during functional movements provides the force for moving these teeth.
If the labial bow touches the teeth in the

incisal margin region,the center of rotation approaches the apex.

If the labial bow contacts the gingival

third of the incisors the centrum is moved coronally toward the junction of the apical and middle thirds.

 The gingival position can elongate the

incisors depending on the degree of labial convexity.

This type is desirable only in open bite cases

in which both retrusion and elongation are desired.

If an axis of rotation in the middle third of

the incisors is desired the acrylic is trimmed away only in the coronal region leaving a cervical contact point or fulcrum.
The labial bow contacts the incisal third of

the labial surfaces providing some motivational force and preventing incisor extrusion during retraction.

Movements of the posterior teeth in the sagittal plane

The buccal segment teeth can be moved mesially or

distally by activator.
If the activator therapy is started in the early mixed

dentition , the permanent first molars should be sagittaly controlled by the appliance.
For distalizing movements the guide planes load the

molars on the mesiolingual surfaces. The guide plane extends only to the area of greatest convexity in the mesiodistal plane.

 In class II malocclusions the guiding planes for the lower posterior teeth are ground not for mesial movement but for the expansion or extrusion.
A mesial component force is already is present because of the intermaxillary anchorage created by the construction bite and the influence of the stretched retractor muscles on the anteriorly positioned mandible.

A mesial driving force could aggravate labial inclination of lower incisors. (Bjork 1951)

 Stabilizing wires or spurs are rigid (0.9 mm ) projections from the lingual acrylic that contact the mesial surface of the permanent

molars interproximally. If the treatment is begun with headgear or lip bumper and continued with an activator stabilizing wires should be used to prevent mesial migration of the first molar teeth. Distalizing guidance of maxillary molars is also possible with active open springs.

Movements of the teeth in the Transverse plane

The

lingual acrylic surfaces opposite the posterior teeth must be in contact with the teeth. If a higher level of force is required in one dental arch or tooth area , this can be achieved by adding a thin layer of self curing soft acrylic. The expansion screw is placed in the anterior intermaxillary portion of the appliance to achieve a symmetric force applications.

 Single teeth also can be moved laterally.

If a crossbite condition is apparent for one or more teeth , the malocclusion can be corrected with two springs and corresponding grinding of the appliance.
The upper molar is moved buccally with a

closed loop spring and the lower molar in buccal crossbite is moved lingually with a frame loop.

 The acrylic is ground away on the lingual of the lower molar.

Transverse mesiodistal movements for single teeth in the incisor region can be achieved using guide wires or rigid wire

elements.

Selective trimming of the Activator

During selective trimming procedures only

the upper and lower molars are extruded.

If selective grinding is planned the path of

eruption of the molars must be considered.

In cases with vertical growth patterns and

tendencies to open bite , the distal position of the molars can be altered before final eruption.

 After the lower molars have erupted the distal surfaces of the upper second molars may be sliced permitting the upper molars to migrate slightly to the mesial , closing the bite and reducing the mandibular retrognatism. If the eruption of the upper molars are stimulated and lower molar eruption is inhibited, the upper molars move mesially.this can be used to correct mild Class III malocclusions .

The Open Activators In General.

Reduced anterior palatal region
Restores exteroreceptive contact between tongue and palate. More comfortable Disadvantages

1. Construction bite cant be opened too wide vertically.

far

2. If high vertical construction bite leads to tongue thrust. 3. A modification by Klammt causes lack of support in the cutaway portion.

 The appliances with cross palatal wire components (Balters ) are

supported / anchored dentally and has limited function though the labial bow causes elimination of abnormal muscle function.
Some activators have 2parts u/l joined by wire components which

increase flexibility in all directions along with reinforcing muscle components.

The rigid activator allows only isometric contractioons with no

muscle shortening. Isometric contractions have more tension than isotonic ones

Wunderers Modification
This is an activator modification that is mostly used in treatment of Class III malocclusion. This type of activator is characterized by maxillary and mandibular portions connected by an anterior screw. By opening the screw the maxillary

portion is moved anteriorly with a reciprocal backward thrust on the mandibular portion.

The Bow activator of A.M Schwarz :

The bow activator is a horizontally split activator having a maxillary portion and a mandibular portion connected together by an elastic bow. This kind of modification allows step wise sagittal advancement of the mandible by adjustment of the bow. The independent maxillary and the mandibular portions can have a screw

incorporated to allow arch expansion.

Reduced activator or cybernator of Schmuth :

This modification of the activator is proposed by Professor G.P.F. Schmuth. This appliance resembles a bionator with the acrylic portion of the activator reduced from the maxillary 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.

Cut out or Palate free activator

This is a modification proposed by Metzelder to combine the advantages of bionator and the Andresen's activator. The mandibular portion of the appliance resembles an activator while the maxillary portion has acrylic covering only the palatal aspect of the buccal teeth and a small part of the adjoining gingival. The palate thus remains free of acrylic thereby making the appliance more convenient for patients to wear the appliance for longer hours. Due to the greater amount of wearing time, success should be greater with the palate free activator.

The Karwetzky modificaton

This consists of maxillary and mandibular

plates joined by a 'U' bow in the region of the first permanent molar.

Type I: This is used in the treatment of

Class II, Division 1. In this modification, the larger lower leg is placed posteriorly. Thus when the two arms of the U bow are squeezed the lower plate moves sagittally forwards
Class III malocclusion. In this appliance the larger lower leg is placed anteriorly. Thus when the U bow is squeezed the mandibular plate moves distally.

Type II : This is used for the treatment of

Type III: They are used in bringing about

asymmetric advancements of the mandible. The U bow is attached anteriorly on one side and posteriorly on the other side to allow asymmetric sagittal movement of the mandible

Hyperpropulsor Activator
GEORGES Jun JCO

GAUMOND, 1986

The hyperpropulsor activator,developd from the monobloc of Robin, consists of a bimaxillary block of acrylic made with the bite open and the mandible

in a forward position.

The incisal edges of the upper and lower incisors should be separated

12-15mm, with the only limit to hyperpropulsion being the discomfort of the patient. Extraoral force is used with the appliance, which is worn only at night.

Elastic open activator

A modification of the activator developed by G. Klammt. The

appliance has reduced acrylic bulk, facilitating increased appliance wear. The acrylic is replaced by wires which increase the flexibility of the appliance. The flexible design allows isotonic muscular contractions (in contrast to rigid appliances, which only allow isometric contractions).

Herren activator (L.S.U. activator):

A modification of the activator developed by P. Herren (also known as the Louisiana State

University modification of the same appliance). It is essentially an activator made to a construction bite that positions the mandible forward and downward to a significant degree. According to P. Herren, the wearing of this appliance is not supposed to increase the activity of the lateral pterygoidmuscle

Lehman appliance (Lehman activator)

A

combination activator-headgear appliance developed by R.Lehman. It consists of a maxillary acrylic plate that carries two rigidly fixed outer bows and a mandibular lingual shield.

The acrylic plate covers the palate and

it extends over the occlusal and incisal surfaces of the maxillary teeth, up to the occlusal third of their buccal and labial surfaces.
arch is possible by appropriately activating the two transverse expansion screws (one anterior and one posterior) that are embedded in the plate.

Selective expansion of the maxillary

 Occipital traction is applied through a

headstrap attached on the outer bows, which are fixed at the anterior aspect of the appliance. The mandibular lingual shield is connected to the maxillary plate by means of two heavy S-shaped wires. Unlike many activator type appliances which are constructed with the mandible in a protruded position, this appliance is made from a bite registration taken in centric occlusion. According to R.Lehman, the S-shaped wires are activated by approximately 2 mm every 4 to 6 weeks, to achieve a gradual advancement of the mandible.

Teuscher-Stockli activator/headgear combination appliance A modified activator used in combination with a high-pull headgear. The appliance was introduced by U.M. Teuscher and P.W. Stockli as a means to avoid the detrimental profile effects of cervical traction when treating Class II malocclusions in growing individuals. Buccal headgear tubes are incorporated in the interocclusal acrylic at the level of the maxillary second premolar or first molar.

Nocturnal airway patency appliance

By Peter T George (JCO)1987 NAPA was designed to keep the airway

open during sleep by Posturing the tongue more anteriorly. inhibiting wide jaw opening. assuring adequate air intake through the mouth when ever nasal obstruction exists.
The mandible was postured forward to

advance the tongue relative to the posterior pharyngeal wall. Because the genioglossus originates at the inner surface of the mandibular symphysis and inserts into the tongue,the mandibular protrusion brings the tongue forwards.

Open Semiflexible activator

By Levrini .A (JCO 1996) The OSA is a modified bionator that incorporates principles developed by Bimler, Klammt,Stockfisch, and Woodside. It is a composite myodynamic functional appliance, with a rigid frame of acrylic resin and

stainless steel wires connected to elastomeric occlusal pads.

 Traditional headgear with high pull head gear can also be used.

Activator With High Pull Headgear

A study published by Ajo-Do in Vol 133 issue 4 titled Effects of

Class II activator and Class II activator high-pull headgear combination on the mandible: A 3-dimensional finite element stress analysis study done by ar Ulusoya, Nilfer Darendelilerb concluded that both functional appliances can cause morphologic changes on the mandible by activating the masticatory muscles to change the growth direction.

Activators As Retainers
[JCO 1980 Aug(529 - 545)]:

Many severe Class II cases are treated with fixed appliances to

completion before jaw growth is completed.

The posttreatment growth pattern occasionally causes the case to

relapse back into a Class II relationship. The activator is very useful for retaining these cases, especially where there was a deep bite involved. A strong relapse tendency will also require directional headgear

Management Of Appliance
The initial appliance review done in 3 weeks time if found normal

review done at 6 weeks time. Procedure All guide planes should be ground & all tooth surfaces checked for shiny areas. Reshaping of acrylic portions to improve function. Resealing of contours Wire components checked for deformation. Sulcus checked for irritation . If jack screws then activated in 2 weeks time.

 Alteration of construction bite if required by

Direct method Indirect Method separation of upper and lower segment and rejoining in the new position.

 The Bionator is a prototype of a less bulky appliance

The Bionator :

which may be worn all the time except during mealtimes. The differences - Narrower lower portion. - The upper portion only has leteral extensions with a cross- stabilizing bar. - Buccinator wire loops are present. These buccinator wire loops hold the potentially deforming muscular actions away .

 The palate is free for proprioceptive contact with the tongue. The orginal appliance was developed by Balters (1964).

At the same time Bimler was developing skeletonized activator. According to Balters the functioning space of the tongue is important for the normal development of the Orofacial system. The purpose of the Bionator was to establish good functional coordination & eliminate these deforming, growthrestricting aberrations.

 The abnormal positioning of the tongue can lead to several

problems eg Posterior Displacement of the tongue can lead to Cass II and a low anterior displacement can cause Class III.
Balters deviced the Bionator to take advantage of the tongue

posture. He took the construction bite in an edge to edge relationship, which he considered important for natural bodily orientation This posturing of the mandible enlarged the oral space, bringing the dorsum of the tongue into contact with the soft palate and helped lip closure. This appliance was built to help the patient achieve normal oral functions.

 Apart from the significant design differences between activator &

Bionator there is one more major difference in that the bionator does not allow for facial pattern and growth direction by variations in vertical dimension. The bite cannot be opened and must be positioned in an edge to edge relationship.

Indications Of Bionator
Class II Div 1 cases with : 1. The dental arches are well aligned originally. 2. The mandible is in a posterior position . 3. The skeletal discrepancy is not too severe.
4.

The labial tipping of the upper incisors is evident.

Deep Overbite cases :

more effective in infraocclusion than if premolar eruption guidance.

Open Bite Conditions

The Open Bite Bionator is specifically successful for Open bite due to finger sucking, retained infantile deglutition and aberrant tongue function.

Pseudo Class III

Class II I bionator only results in pushing the incisors forward and no Basal maxillary growth occurs

Also Patients with TMJ problems show a remarkable response to Bionators . When asked to wear at night they aid in relaxing muscle spasms and consequent clenching / grinding during REM period of sleep. The Bionator especially aids in the muscle spasms occuring due to LPM. The construction bite with this does not place the mandible as forward but doesopen the bite slightly otherwise the design is similar to that of Standard Appliance. The main purpose is to prevent the riding of the condyle over the posterior edge of the disc which causes clicking .

Contra- Indications :
1. 2. 3.

4.

A vertical growth pattern . The class II relationship caused by maxillary prognathism. If labial tipping is evident.Since anterior positioning of the mandible is not possible with simultaneous uprighting. Cases with Crowding

The Principle Of Treatment With Bionator

-Not to activate the muscles but to modulate muscle activity . - Enhancing normal muscle development of the inherent growth pattern . - Ignoring/overcoming abnormal & potentially harmfull growth patterns. - With the onset/correction of function ..desired changes occur

 If the overjet is too large then the augmentation is done

stepwise but the Bite Is NEVER OPENED . Bite opening was not done because Balters thought that this would impair tongue opening and could also lead to the development of a tongue thrust habit.
Myotactic reflex activity with isotonic muscle contraction is stimulated .

The appliance works on Kinetic energy .

 Sagittal/ Vertical changes can occur in patients with certain

sucking habits. We now know that abnormal tongue functioning is secondary adaptive/ compensatory to skeletal maldevelopment a fact unknown at that time.
Advantages

1.Reduced size. 2. Can be worn day and night. 3. Screening effect of labial bow and lateral extensions give a constant influence. 4. Unfavorable influences held at bay for a longer time. 5. Action of Bionator faster than action of Activator.

 Disadvantages

Difficulty in management. Simultaneous grinding for stabilisation of the appliance plus eruption guidance. 3. Effective only for normalisation of growth pattern only and no environmental influences to prevent accomplishment of that pattern. 4. Skeletal interferences limited action.
1. 2.

Types Of Bionator
Standard Appliance.
Open Bite Appliance. Class III/ Reversed Bionator.

The Standard Appliance Consists of a lower horseshoe shaped acrylic lingual plate extending to distal of the last erupted molar on both sides. Upper arch has posterior lingual extensions that cover the molar & premolar. The anterior portion is open from canine to canine.

 The flanges should extend 2mm above &below the upper & lower

gingival margins respectively. Palatal area is kept free however tongue posture here is kept in control by the by edge to edge incisor contact if some space exhists Acrylic can be made to extend over lower incisal edges .
The Wire Components :

Palatal Bar (1.2 mm round wire ). Labial Bow With Buccal Extensions (0.9 mm ).

 The Palatal bar must start somewhere between the center of the

2nd deciduous molar. Lies 1 mm away from the palatal mucosa. Upto an imaginary transpalatal line extending distally between 1st permanent molars.

Function 1. Stabilises the appliance. 2. Orients the tongue and the mandible anteriorly. 3. According to Balters the forward positioning of the tongue is due to the stimulation of the dorsal surface by the palatal bar.

 Labial Bow

Begins in between the canine and deciduous 1st molar(or premolar). Runs vertically making a rounded 90 deg bend between the deciduous 2nd molar and permanent 1st molar. Making a gentle round downward & forward curve runs as far as the lower canine. At a sharp angle extends obliquely upward toward the upper canine. Bends at a level line at the incisal third of the incisors. The labial bow should be a sheet thickness away from the incisors.

Function The wire produces negative pressure, with the wire supporting lip closure. Later the wire should move the incisors upright. Should provide extra space when the when the dental arch is widened . Labial bow posterior portions designed as Buccinator loops, screening muscle forces in the vestibule.

The lingual portion shields from the cheek and tongue interpositioning. The stimulation of selective eruption is possible with proper trimming.

 The Open Bite Appliance :

This is used to inhibit abnormal positioning & functioning of the tongue. Very low opening of the construction bite ..with slight opening to permit interocclusal bite blocks in the posterior region to prevent the extrusion of the teeth. The extension of the lower lingual parts extends into the upper incisor region as a lingual shield closing the anterior space and preventing abnormal tongue movements. The palatal bar pushes the tongue more caudally.

 The labial part of labial bow placed at the level of the correct lip

closure to stimulate the lip pads to achieve a competent lip seal and closure. The Vertical strain on the lips tends to extrude the incisors after adverse tongue pressure is eliminated.

In patients with tongue dysfunction, the labial wire is located in the middle between the upper and lower incisors. This bow hinders the introduction of the lower lip between the arches.

The acrylic base appliance is closed in the front but it should not contact the incisors or the dentoalveolar margin so that the open bite can close. This area can be blocked out with wax before the application of the acrylic or be trimmed

 A study published in Ajo Do Volume 132, Issue 5, Pages 595-598

(November 2007) done on Early orthodontic treatment of skeletal open-bite malocclusion with the open-bite bionator: A cephalometric study by Efisio Defraiaa, Andrea Marinellib, Giulia Baronic, Lorenzo Franchid, Tiziano Baccettie showed that
The bionator treatedgroup had a significantly smaller palatal planemandibular plane angle (1.9) and a greater overbite (+1.5 mm) associated with a significantly smaller overjet when compared with the control group. Conclusions: Based on the analysis of this sample, early treatment of skeletal open bite with the open-bite bionator appears to produce a modest effect that mainly consists of significant improvement in intermaxillary divergence.

 Class III or Reversed Bionator

Used to encoursge maxillary growth . Construction bite taken in the most retruded position to a) Allow labial movement of maxillary incisors . b) Have a slight restrictive influence on the mandible. Bite is slightly opened with 2mm interincisal space

Lower acrylic portion extended incisally from canine to canine and is positioned behind the upper incisors which are stimulated to glide anteriorly on the upper incline plane.

The acrylic is trimmed 1mm behind the lower incisors so that they do not tip labially.

The labial bow runs in front of lower incisors instead of pper incisors. There is no bend in the canine region.

In the anterior region the acrylic base of the reverse appliance is vertically elongated to influence the upper incisors labially, as with an inclined plane. This bite plane serves as protrusion element for the maxillary anterior teeth.

 Balters main intention was to load the mandibular teeth and

unload the maxillary alveolar portion where growth stimulation is desired . The objective was a functional loading of the maxillary lingual area by the tongue causing . Thats why the palatal bar was reversed . However Rakosis study in 1977 that the reverse palatal bar mainly aided in flattening the Dorsum of the tongue and does not move it anteriorly. Only tipping of the maxillary anterior teeth finally occurs.

The Trimming Of The Bionator

It is a crucial step because the anchorage of the appliance is

enhanced by selective trimming of the same. Balters introduced the following terms Articular Plane : Tips of the cusps of upper 1st molars premolars canine to mesial margin of upper central incisors. Runs parallel to Alatragal line. Mode of trimming assessed from this. Loading Area : Palatal /lingual cusps of deciduous molars or premolars and permanent molars are relieved in the appliance and this enhances the anchorage of the appliance.

 Tooth Bed :

Some parts of the loading areas are trimmed away to the articular plane . Acrylic surfaces prepared in this manner are termed as tooth bed. Nose : These are acrylic fingerlike interdental projections which act both as guiding processes and sources of anchorage for the appliance in the sagittal and vertical plane. Ledge : Depending on the tooth positions required the appliance acrylic is trimmed and the nose reduced . A reduced plastic extension placed only on the occlusal third of the interdental area is called the ledge . The nose is in the molar region whereas this is in the deciduous molar / premolar region.

Anchorage Of The Appliance

Some planes are used for anchorage some to achieve the desired

tooth movement. Anchorage for the appliance is obtained from the following medias 1. Incisal margins of the lower incisors, by extending the acrylic over the lower incisors like a cap. 2. Loading areas because the cusps of the teeth fit into the respective grooves. 3.Deciduous molars which can always be used as anchor teeth. 4. Edentulous areas after premature loss of deciduous molars. 5. Noses in the upper & lower interdental spaces. 6. Labial bow prevents the posterior displacement of the appliance.

Trimming The Bionator

As in the Activator trimming of the occlusal surface is done such

that certain teeth are allowed to erupt whereas other fully erupted teeth are prevented from supra-eruption. Balters terminology for stimulation of eruption is unloading or Promotion of growth and prevention of eruption as loading or inhibition of growth.

Teeth are allowed to erupt by the trimming of acrylic tooth bedsand elimination of influence of tongue and cheeksuntil they reach the articular plane.

 To prevent eruption they are loaded with acrylic as needed. The appliance can be trimmed or ground periodically until the

teeth reach the desired relationship with the articular plane. Due to anchorage problems all areas cant be performed simultaneously thus periodic loading & unloading is required in certain areas . Therefore the same tooth can be allowed to function as an anchor and later be allowed to erupt. The difficulty in Classic Bionator is the requirement of anchoragw which causes some areas to be loaded on a visit and then same areas maty be required to be trimmed on the next.

 The types of Anchorage According to Ascher (1968)

Dentition 1,2,III-V,6 1,2,III V ,6 1,2,II 6 1,2, III, 4-6

Anchorage IV- V upper & lower V and space after IV Alveolar process IV, V 6 and alveolar process

If premolars are erupting then they have to be loaded and unloaded as necessary. -

 Main differences from the trimming of a Bionator 1. For Extrusion of Posteriors some acrylic is left interdentally at the

level of Articular plane forming what is known as a tooth bed. The upper & lower molars are trimmed first followed by trimming of Acrylic for lower premolars while the molars are loaded finally the upper premolars are stimulated while lower premolars and molars are loaded.

2. The noses are left untouched action similar to stabilizing Spurs

of Activator and exert a distilising effect on the 1st permanent molars. They prevent the mandible from dropping back .In place of Acrylic o.8mm/0.9mm wire can be used. 3. Occlusal surface of Bionator is trimmed for transverse movement,cusp tips should remain in contact. In case of Open Bite Posteriors completely loaded for intrusion.

Transverse skeletal base adaptations with bionator therapy: A pilot implant study conducted by Adriano Marotta Araujo, DDS, MS, Peter H. Buschang, PhD, Ana Claudia Moreira Melo, DDS, MS published in AJO-Do Vol 126 issue 6 showed that transverse skeletal base adaptations occur as a result of Bionator therapy.

Clinical Management
Must instruct the patient to wear it day and night. Recall : Every 3 to 5 weeks. The labial bows must touch the teeth very lightly if at all and

Buccinator loops should be away from the posteriors If Expansion (minor ) required the palatal part is activated and closing of spaces achieved with the retraction of the bow. Stimulation of teeth movement as required by loading /unloading and any modifications to be performed on first molars first then lower premolars (if + ) upper premolars.

 During The First Phase Of Treatment (Neuromuscular

Adaptation) Rapid Horizontal & Vertical Changes In Mandibular Position Common. Petrovic et al 1972 showed this as a muscular adaptation of LPM to the new position due to its shortening. This rapid change leads to a open bite in the posterior section. During The Second Phase Of Treatment Articular & Dentoalveolar Adaptation In the Second deciduous molar region the open bite persists so this is corrected only with the eruption guidance of premolars.

Modifications
A Monoblock appliance, the Bionator incorporating a lateral

adjustment screw lingual to the lower incisors.

 The Orthopedic Corrector continues to gain acceptance as effective

appliances for use in both mixed and permanent dentition. The Orthopedic Corrector, essentially identical in design to the Bionator, features the addition of two side screws; one is placed in each of the lower lingual posterior quadrants.

REFERENCES : 1.Araujo, Buschang, Melo: Transverse skeletal base adaptation with Bionator therapy: A Pilot Implant Study. AJO December 2004,Vol 126 page 666-671
2. Graber, Rakosi & Petrovic: Dentofacial Orthopedics with Functional Appliances,1995

3. Carels and Vander Linden:Concepts on functional appliances mode of action. AJO 1987; 92 : 162-8.
4. Woodside, Metaxas, Altura: Influence of functional appliance therapy on glenoid fossa remodeling. AJO 1987 92; 181. 5. Bendens, Hagg, Rabie:Growth and treatment changes in patients treated with a headgear activator appliance. AJO 2002; 121 : 376-84.

14. Valiathan et al: Effect of Herbst appliance on orofacial musculature A quantitative EMG study. JIOS 1993; 24 : 93-99. 15. Hagg, Rabie: Initial and late treatment effects of headgear Herbst appliance with mandibular step-bystep advancement. AJO 2002; 122 : 477-485. 16. Ruf & Pancherz:TMJ remodeling in adolescents and young adults during Herbst treatment : A prospective longitudinal magnetic resonance imaging and ceph. Investigation. AJO 1999; 115 : 607-18.
17. Vondouris et al: Condyle-fossa modifications and musle interactions during Herbst treatment. Part 2. Results and conclusions. AJO 2003; 124 : 13-29.

18.M.Almeida, Henriques, R.Almeida, Ursi: Treatment effects produced by the Bionator appliance. Comparison with an untreated sample. Ejo vol26 2004 19.Sharma,Naini, Jones: The twin block appliance for the correction of class II malocclusion. Dental Update 2005;32:158-168