ACTIVATOR AND IT’S MODIFICATIONS

CONTENTS
• Introduction

• Development, Construction, And Mode Of Action

• Efficacy of Activator

• Classification of Views

• Skeletal & Dento-alveolar Effects

• Force Analysis

• Construction Bite

• Treatment Planning

• Management Of Activator

• Conclusion

• Modifications of activator

• Advantages and disadvantages of activator

• Comparative studies of activator with other appliances

INTRODUCTION:

The 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 trasmit forces to the
dentition and the basal bone.

Typically these muscular forces are generated by altering

the mandibular position sagittally and vertically, resulting
in orthodontic and orthopedic changes.

MUSCLES INVOLVED IN MASTICATION

• Masseter
• Temporalis
• Medial pterygoid
• Lateral pterygoid
HISTORY OF ACTIVATOR
• 1880, KINGSLEY ;"jumping the bite"
Placed a Vulcanite palatal plate consisting of anterior
incline to guide the mandible in a forward position. This
maneuver corrected the sagittal relationship without
tipping the lower incisors forward.

• HOTZ used the appliance vorbissiplatte (modified kingsley

plate) in cases of deep bite retrognathism.
IN CASES WHERE
1. deep bite retrognathism
2. overbite would cause functional retrusion
3. lower incisors lingually inclined by hyperactivity of
mentalis.

 ANDRESEN(1908) :mobile, loose fitting appliance that

transferred functioning muscle stimuli to the jaws, teeth,
and supporting tissues.

The progenitor of the appliance was a modified Kingsley

plate that Andresen used as a retainer over summer
vacation for his daughter after he removed fixed
appliances used to correct a distocclusion. Seeing the
continued improvement with this retainer, he called it a
biomechanic working retainer.
• ROBIN : monobloc, as he called it (because it was a single
block of vulcanite)
Patients with glossoptosis and severe mandibular
retrognathism who risked occluding their airways with
their tongues

forward mandibular posture reduced this hazard and also

led to significant improvement in the jaw relationship.
The problem, usually associated with cleft palate, became
known as the Pierre Robin syndrome

 ROUX: shaking-the-bonding-substance-of-bone
hypothesis,

the time Andresen and Haupl teamed up to write about

their appliance, they called it an activator, because of its
ability to activate the muscle forces

• NEUROMUSCULAR RESPONSE

Children with neuromuscular diseases such as

poliomyelitis and cerebral palsy cannot be treated
successfully with functional appliance therapy
ACTIVATOR

SYNONYMS :
- Biomechanic working retainer
- Andersen appliance
- Nocturnal airway patency appliance.
- Norwegian appliance.
- Monobloc
- Kingsley or bite jumping appliance

• The first removable functional appliance, developed by

V.Andresen.

• Historically, the term "activator" was introduced to

describe the "activation of mandibular growth," to which
the achieved correction of a Class II malocclusion was
attributed.
• These appliances position the mandible forward,
promoting a new mandibular postural position.
• The reactive forces from the stretch of the muscles and
soft tissues are transmitted to the maxillary dentition and
through that, to the maxilla.

The acrylic body of the Andresen activator covers part of

the palate and the lingual aspect of the mandibular
alveolar ridge.
A labial bow fits anterior to the maxillary incisors and
carries U-loops for adjustment.
 On the palatal aspects of the maxillary incisors, the acrylic
is relieved to allow their retraction.

• EFFICACY OF THE ACTIVATOR

• According to Andresen and Haupl (1955), the activator is
effective in exploiting the interrelationship between
function and changes in internal bone structure.

activator

functional pattern
musculoskeletal neuromuscular that affects the
adaptation adaptation ( to condyles
(new pattern of increased distance (growth in upward
mandibular closure) and direction) and backward
direction)

• This adaptation is induced by a loose appliance. The

construction bite does not open the mandible beyond
postural rest position
• Myotatic reflex activity is stimulated, causing isometric
muscle contraction. This muscle force transmitted by the
appliance moves the teeth. Thus the appliance works by
kinetic energy.
 CLASSIFICATION OF VIEWS

• Depending on the construction of the appliance, the

activator can initiate myotatic reflex activity, induce
isometric muscle contractions (sometimes also inducing
isotonic contractions), or rely on the viscoelastic
properties of the stretched soft tissues.

According to the mode of action, two main principles

apply. A third approach combines the two rationales.

• Andresen-Haupl concept:
Loose fitting appliance that works on Myotactic reflex
activity principle and works by Kinetic Energy.
Activity of LPM permits condylar growth.
Small bite opening was suggested
Petrovic and McNamara

MUSCLE SPINDLES

2-15 THIN INTRAFUSAL NUCLEAR BAG REGION

MUSCLE FIBERS (non contractile

Impulses arise

Group I A sensory
fibre

'' efferents

supply the extra fusal

muscle fibre

CONTRACTION OF
STRETCHED
MUSCLE.
Second group of authors:
Selmer-Oslen,Herren,Harvold and Woodside
DID NOT ACCEPT!!
Viscoelastic properties of muscles and stretching of soft
tissues decisive for activator action.

Application of force-- secondary forces arise in tissues—

bioelastic process..
Stages of viscoelastic reaction
Emptying of vessels
Pressing out of interstitial fluid
Stretching of fibres
Elastic deformation of bone
Bioplastic adaptation

Woodside—beyond postural rest

Herren—overextends in saggital plane
10 to 15mm beyond postural rest.
Muscle tension buildup because of stretching of tissues
Buildup of Potential Energy

• The appliance works using potential energy.

• For this mode of action an overcompensation of the
construction bite in the sagittal or vertical plane is
necessary.
• An efficient stretch action is achieved by
overcompensation and the viscoelastic properties of the
contiguous soft tissues.

THIRD APPROACH
4modes of action preceding two. Transitional type of
activator action
Alternately uses muscle contraction and viscoelastic
properties of soft tissues.
Bite opening greater than andreson and Haupl but does not
overcompensate.
SKELETAL AND DENTOALVEOLAR EFFECTS OF THE
ACTIVATOR
• Any skeletal effect from the activator depends on the
growth potential.
• Two divergent growth vectors propel the jaw bases in an
anterior direction
• The sphenoccipital synchondrosis moves the cranial base
and nasomaxillary complex up & forward.
• The condyle translates the mandible in a downward and
forward direction.
• The activator is most effective in controlling the lower
vector or the downward and forward growth of the
mandible.

• Johnston (1976) attributes this response to "unloading

the condyle."
• the LPM plays a decisive role in this growth.
Forward posturing of the condyle

activates the superior head of the LPM.

cell proliferation in the condyle and a growth response.

• The activator can, to a limited degree control the upper
growth vector, supplied by the sphenoccipital
synchondrosis, which moves the maxillary base forward.
• If the mandible cannot be positioned anteriorly, maxillary
growth can be inhibited and redirected.
• activator also must assess and, if necessary, alter the
vertical skeletal relationship.
• Changing the maxillary base inclination can compensate
for rotations of mandibular growth vectors.
• Williams & Melsen (AJO 1982)- demonstrated
backward rotation of mandible due to increase in
posterior maxillary height.
• Forseberg & Odenrik (EJO 1981) noted a significant
decrease of the SNA angle
• Vagervik & Harvold (AJO 1985)- inhibited horizontal
growth of maxilla by 2mm
• Pancherz (AJO 1984) found restriction by 1.7mm.
• A downward displacement of the maxillary base allows
the maxilla to adapt to a vertical rotation of the mandible.

• If the rotation of the jaw bases during growth is

unfavorable, activator therapy cannot be completed
successfully.
• 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.
HARVOLD WOOD-SIDE ACTIVATOR
• The mandible is placed approximately 3mm distal to the
most protrusive position sagitally and vertically an
extreme separation of 10 to 15mm beyond the free way
space.
• MODUS OPERANDI:Here the mandible is opened beyond
4mm so it does not work in the same manner as
Anderson's activator but by stretching of soft tissue - THE
VISCO ELASTIC EFFECT. In such cases CLASP - KNIFE
REFLEX plays a role
• Mechanism of clasp knife reflex or autogenic inhibition
Example: Spastic limb
Resistance encountered

Hyperactive reflex contraction

Limb collapses readily

This phenomena is called CLASP KNIFE RIGIDITY (i.e.

muscle first resists and then relaxes)

• Stimulus is EXCESS stretch when elicited leads to muscle

relaxation. Receptors are Golgi tendon organs situated in
the muscle.

• Impulses conducted by group I B sensory nerve fibre act

on motor neuron or '' efferent supplying the stretched
muscle .
• It is a DISYNAPTIC REFLEX ARC because an inter neuron
is interposed between sensory and motor neuron.
• Functional significance :- is to protect overload by
preventing damaging contractions against strong
stretching force.

• 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.
• Activators with special construction can influence
grwowth and translation of maxillary complex. Maxillary
growth can be influenced by headgears.

• FORCE ANALYSIS IN ACTIVATOR THERAPY

• When the functional appliance activates the muscles
various types of forces are created—
• static
• dynamic
• rhythmic.

Two principles are employed in the modern activator:

• Force application —the source is usually muscular.
• Force elimination —the dentition is shielded from normal
& abnormal functional and tissue pressures by pads,
shields, and wire configurations.

The types of force employed in activator therapy may be

categorized as follows:
• The growth potential, including the eruption and
migration of teeth, produces natural forces. These can be
guided, promoted, and inhibited by the activator.
• 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.
These artificially functioning forces be effective in all
three planes:
 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

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.

transverse plane, forces also can be created with midline

corrections.
Various active elements (e.g., springs, screws) can be built
into the activator to produce an active biomechanic type
of force application.

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. Before
taking the construction bite, the clinician must prepare by
 making a detailed study of the plaster casts,
cephalometric and panoral head films, and the patient's
functional pattern.

Diagnostic Preparation
• Creating an "instant correction"—moving the mandible
forward into an anterior more normal sagittal
relationship—may help motivate patients with Class II
malocclusions.

• STUDY MODEL ANALYSIS

– Before constructing the activator, the
clinician must consider the following factors,
based on the cast analysis:

1. First permanent molar relationship in

habitual occlusion
2. Nature of the midline discrepancy, if any
3. Symmetry of the dental arches
4. Curve of Spee
5. Crowding and any dental discrepancies

FUNCTIONAL ANALYSIS. ''

Before the construction bite is taken,a functional analysis
 is performed to obtain the following information:
1. Precise registration of the postural rest position in
natural head posture (because the vertical opening of the
construction bite depends on this)

2. Path of closure from postural rest to habital

occlusion(any sagittal or transverse deviations are
recorded)

3. Prematurities, point of initial contact, occlusal

interferences, and resultant mandibular displacement, if
any (some of these can be eliminated with the activator,
but some require other therapeutic measures)

4. Sounds such as clicking and crepitus in the TMJ (might

indicate a functional abnormality or the need for some
modification of appliance design)

5. Interocclusal clearance or freeway space (should be

checked several times and the mean amount recorded)

6. Respiration (with allergies or disturbed nasal

respiration, the patient cannot wear a bulky appliance; in
such cases an open activator or twin block may be used,
or the respiratory abnormalities may be eliminated first)

TREATMENT PLANNING
• The extent of anterior positioning for Class II malocclusion
and posterior positioning for Class III malocclusions
should be determined.
• 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.
Anterior positioning of this magnitude is contraindicated
if ??

.An incisor (usually a lateral) has erupted markedly to the

lingual: The mandible must be postured anteriorly to an
eidge-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:

1. The mandible must be dislocated from the postural

resting position in at least one direction—sagittally 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.
High construction bite can affect the maxillary base
inclinaton.
Disadvantages of a wide-open construction bite 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.

The ultimate reestablishment of normal lip seal is

essential in functional appliance therapy.
 GENERAL RULES FOR THE CONSTRUCTION BITE.
• The assessment of the construction bite determines the
• kind of muscle stimulation,
• frequency of mandibular movements, and
• duration of effective forces.

MANAGEMENT OF THE APPLIANCE

• If the patient is wearing the activator without difficulty
and following instructions, checkup appointments should
be scheduled every 6 weeks.
1. All guide planes that have been ground and all areas
in contact with the teeth should be observed for
shiny surfaces that indicate whether the appliance is
being worn correctly and is working properly.

2. Reshaping of acrylic guide areas may be required

after initial trimming to improve function; it also may
be needed during the course of treatment to ensure
continued tooth movement (particularly in the upper
arch) if retrusion or distalization is desired

3. Maxillary change is usually minimal at best, however.

If the permanent teeth are erupting, reshaping also
may be motion of the appliance in the mouth may
change wire configurations and occasionally fatigues
wires sufficiently to cause necessary.
 4. Acrylic contact guide planes often must be resealed
or recontoured to maintain the proper functional
activation on the desired teeth by adding self-curing
soft acrylic in a thin layer. Clinical examination of the
acrylic inclined planes for shiny spots helps
determine the amount of sealing to be done.

The labial bows and any additional wire elements

must be checked for action and possible
deformation. The active bow should touch the teeth.
The passive bow should position away from the teeth
but remain in contact with the soft tissues. The
guiding and stabilizing wires are activated by the
patient's biting into the appliance.

In expansion treatment the jackscrews are normally

activated by the patient at 2-week intervals. The
clinician should check this activation for too-frequent
or infrequent activation. Too much activation
prevents the appliance from fitting properly. The
activation interval may need to be changed.

TRIMMING
• In order to stimulate the functional activity of the perioral
musculature with the loose appliances so that the
movement and eruption of selected teeth can be guided,
certain areas of the acrylic which contact the teeth should
be ground away.
• VERTICAL PLANE
• INTRUSION:- Only limited intrusion is possible. Relative
intrusion is one of the objectives.
• Incisor intrusion: brought about by
Loading the incisal edge.
Labial bow placed in the incisal third.
• Molar intrusion brought about by
Acrylic plate touching only the cusps.
Acrylic plate ground away from fissures and grooves.
If larger occlusal surfaces are loaded, reflex opening
occurs frequently resulting in less depressing action by
the appliance.

EXTRUSION: indicated in open bite problems.

• Incisor extrusion
– Labial bow is placed in the gingival 1/3
– Loading the gingival 1/3 on the lingual surface.
• Molar extrusion
Enhancing eruption by grinding the acrylic plate from the
occlusal surface.
Acrylic contacting the gingival 1/3 on the lingual surface.

SAGITTAL PLANE:
• Protrusion:
 Loading the lingual surface with acrylic contacts.
Screening away lip strains with passive labial bow or lip
pards. Auxiliaries used are
Protrusion springs (0.8mm)
Wooden pegs
• Guttapercha may be added to the lingual acrylic.

• Retrusion:
– Acrylic trimmed away from behind the incisors.
– Active labial bow.

FOR DISTAL MOVEMENT OF THE POSTERIORS

• guide planes should be on the mesio lingual surfaces.
• Stabilizing wires or spurs can be used
• Active open springs.
• In class II div 1 MO with deep bite, acrylic contacts
the mesio gingival surfaces of upper posterior and
distogingival surface of lower posteriors. The upper teeth
are hence guided in downward and backward directions
and lower teeth in an upward and forward directions to
establish the proper sagittal and vertical relations. Acrylic
on the lingual surface of the upper incisors is ground
away and labial bow made active if they are to be
retracted .
 TRANSVERSE PLANE
• To achieve transverse movement lingual acrylic surface
opposite the posterior should be in contact with the
teeth. Higher level of force can be obtained by adding a
thin layer of self cure soft acrylic. More effective
expansion can be achieved with use of jack screws.

SELECTIVE TRIMMING OF THE ACTIVATOR

• During selective trimming only the upper or lower molars
are extruded. After erupting, eruption of antagonist can
be controlled. Thus both sagittal and vertical relationship
can be influenced.
• Eruption pathway of the molars should be considered.
"CONTROLLED DIFFERENTIAL ERUPTION GUIDANCE" must
be employed for the best interdental and occlusal plane
relationship, particularly in case of flush terminal plane
relationships, proper selective grinding can convert an
impending class II or class III MO into class I
interdigitation
 MODIFICATIONS OF ACTIVATOR
• Herren Shaye activator : Herren modified the activator
in two ways :
• 1. By over-compensating the ventral position of the
mandible in the construction wax bite.
• 2. By seating the appliance firmly against the maxillary
dental arch by means of clasps (arrowhead, triangular or
Jackson's).

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.

WUNDERERS MODIFICATION
• This is an activator modification that is mostly used in
treatment of Class III malocclusion.

REDUCED ACTIVATOR OR CYBERNATOR OF SHMUTH :

• 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.

HYPERPROPULSOR ACTIVATOR - GEORGES

GAUMOND, 1986 JUN JCO

• 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.

• INDICATIONS:

• The appliance is most useful in younger children when a

sizable overjet raises fear of incisal fracture.
• The appliance is also effective in Class II, division 1 cases
when a small tooth-to-jaw size relationship would
contraindicate extraction; in cases of missing upper
bicuspids or molars, especially if there is already
 spontaneous space closure; and in cases of poor
cooperation with fixed appliances.
• The appliance can be used in cases of posterior rotation,
since it does not alter the vertical dimension.
• It also permits, to the extent of the individual's growth
potential, a reduction of the discrepancy between the
maxillary and mandibular bony arches— either by acting
on the maxilla through varying the extraoral force, or by
acting on the mandible through acrylic added as soon as
the patient can propulse beyond the initial registration.

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 gingiva.
• 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 sagitally forwards
• Type II : This is used for the treatment of 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 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 sagital movement of the mandible

BIMLER APPLIANCE (BITE FORMER, BIMLER

STIMULATOR)

• A modification of the activator by H.P. Bimler. There are

three main kinds of Bimler appliance:
• type A for patients with Class II Division 1 malocclusions,
• type B for those with Class II Division 2 and
• type C for patients with a Class III malocclusion.

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.
• Selective expansion of the maxillary arch is possible by
appropriately activating the two transverse expansion
screws (one anterior and one posterior) that are
embedded in the plate.
• 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.Accordingto 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.

• NAPA

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.

• INDICATIONS OF ACTIVATOR :

• 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 forthe 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.

• CONTRA-INDICATIONS OF ACTIVATOR THERAPY

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.

• ADVANTAGES OF ACTIVATOR THERAPY

1. It uses existing growth of the jaws.

2. During treatment the patient experiences minimal oral
hygiene problems.
3 .The intervals between appointments is long.
4. The appointments are usually short due to need for
minimal adjustments.
5. Due to the above reasons they are more economical

DISADVANTAGES OF ACTIVATOR THERAPY

1. Requires very good patient cooperation.

2. The activator cannot produce a precise detailing and
finishing of the occlusion.Thus post-treatment fixed
appliance therapy maybe needed for detailing of the
occlusion.
3. It may produce moderate mandibular rotation
(anteriorly downwards). Thus activators are not used in
cases of excessive lower face height.

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

STUDIES OF FUNCTIONAL APPLIANCE THERAPY

• Woodside
• Altuna
• Shapera
• Sessle
• Sectakof & Yamin
• Organ
• Voudouris
• The studies summarized in this chapter have led to the
following conclusions, which may influence the clinician's
approach to functional appliance treatment:
Removable functional appliances used part time do not
routinely create clinically useful increases in mandibular
length.
Redirection of maxillary growth direction may occur with
either a large or moderate vertical opening of the
construction bite
Successful redirection of maxillary growth direction is always
followed by recovery toward the normal path of growth
direction. However, a net restriction in midface position
occurs
Both the function regulator and bionator activator create
similarly increased amounts of LPM activity at appliance
insertion.
The insertion and progressive activation of a functipnal
appliance produce a decrease in the resting and functional
activity of the muscles of mastication
Chronic condylar unloading produces a rapid down ward and
forward relocation of the glenoid fossa; this relocation
contributes to large changes in jaw relationships and
occlusions. Such changes remain stable

Tongue function during activator treatment. A

cephalometric and dynamometric study by Johan
Ahlgren EJO1(1979)251-257
• The results seem to verify Andresen's hypothesis that
tongue activity is stimulated by activators but they do not
support his view that wearing an activator would result in
permanent hypertrophy of the tongue muscles.
 How effective is the combined activator-headgear
treatment By Olav Bondevik (EJO 1991)
• The frequency and possible causes of failure and success
with the combination activator-headgear as the sole
appliance was analysed retrospectively in 32 girls and 46
boys. The subjects comprised all the patients who started
treatment with this combination in the postgraduate
courses in 1972-82. Only 14 subjects completed the
treatment with entirely satisfactory results according to
strict criteria set for an acceptable standard. Among the
most co-operative patients less than 50 per cent ended
with entirely satisfactory results, and no one with
decreasing or poor co-operation had a satisfactory result.
Neither sex, treatment time, nor ossification of the ulnar
sesamoid bone seemed to influence the results
significantly.
 Treatment needs followingActivator-headgear
therapy By Iav Bondevik, ( Angle orthod 1995)
• The purpose of this study was to analyze the types and
prevalence of malocclusions that remain to be corrected
after a period combined activator-headgear treatment.
• Study models of all patients who started treatment with
an activator-headgear appliance in the graduate
orthodontic clinic at the University of Oslo between 1972
and 1982 were screened.
• Results show that the most frequently remaining
problems following activator-headgear treatment were
overbite, overjet and the presence of interdental spaces.
Correction of the Class II skeletal and dental relationship
was achieved in the majority of the cases. The only
predictor for success was age at the time of treatment.
 Combination Headgear-Activator - Dr. Herman Van
BeekJco Volume 1984 Mar(185 - 189):

• Clinical Aspects of Headgear-Activator Treatment

• The headgear-activator has the following modes of
action:
• 1. Intrusion and retraction of upper front teeth
• 2. Distalization of upper molars
• 3. Maxilla retraction
• 4. Mandibular growth stimulation, especially in the
brachyfacial group
• 5. Opening of the facial axis in the brachyfacial group
• 6. Maintenance of the facial axis in the dolichofacial
group
• 7. Minor, if any, tilting of lower incisors
• 8. Stopping lower incisor eruption
• 9. Stopping the descent of the palate
 Activator Treatment - Vargervik and Harvold

• Response to activator treatment in Class II malocclusions

• A clinical study was designed to disclose the effects of
activator treatment in the correction of Class II
malocclusions. The rationale for the use of the activator
appliance was based on the premise that correction of
distocclusion can be achieved by
• (1) inhibition of forward growth of the maxilla,
• (2) inhibition of mesial migration of maxillary teeth,
• (3) inhibition of maxillary alveolar height increase and
extrusion of mandibular molars,
• (4) increased growth of the mandible,
• (5) anterior relocation of the glenoid fossa,
• (6) mesial movement of mandibular teeth,
• (7) combinations of these effects.

• It was therefore concluded that, in addition to the

statistically significant changes, smaller changes occurred
in several areas without being consistent enough or of a
large enough magnitude to become statistically significant
in the analyses of mean values. Comparison of group
averages may mask treatment effects that significantly
contribute to the correction of malocclusions in individual
cases.
 A cephalometric analysis of skeletal and dental
changes contributing to Class II correction in
activator treatment
Hans Pancherz,(Am J Orthod)1984
• The purpose of this investigation was to evaluate
cephalometrically the mechanism of anteroposterior
occlusal changes in activator treatment. The sample
consisted of thirty Class II, Division 1 malocclusion cases
treated successfully with activators during an average
time period of 32 months. Before- and after-treatment
head films in centric occlusion were analyzed. The
occlusal line (OL) and occlusal line perpendicular (OLp)
through sella were used for reference. Linear
measurements were performed parallel to OL..

• The following results were found:

• (1) The improvement in occlusal relationships in the
molar and incisor segments was about equally a result of
skeletal and dental changes.
• (2) Overjet correction averaging 5.0 mm was a result of
2.4 mm more mandibular growth than maxillary growth, a
2.5 mm distal movement of the maxillary incisors, and a
0.1 mm mesial movement of the mandibular incisors.
• (3) Class II molar correction averaging 5.1 mm was a
result of 2.4 mm more mandibular growth than maxillary
growth, a 0.4 mm distal movement of the maxillary
molars, and a 2.3 mm mesial movement of the
mandibular molars.
• (4) When the findings were compared with longitudinal
records of persons with normal occlusion (Bolton
standards), activator treatment seemed to inhibit
maxillary growth, move the maxillary incisors and molars
distally, and move the mandibular incisors and molars
mesially. Mandibular growth appeared not to be affected
by activator treatment
 Effects of Activator Treatment on Class II, Division
1 Malocclusion (JCO) Aug 1989 - DR. CHANG, DR.
KAI-MING WU, DR. KUN-CHEE CHEN,

• This study was undertaken to evaluate the effects of

activator treatment on a group of Class II, division 1
patients with skeletal mandibular retrusion.
• Materials and Methods:
• Nine boy and six girl patients from the Orthodontic
Department, National Taiwan University Hospital, were
selected as the treatment group. All were Chinese, and
they ranged in age from 7.2 to 11.9 years, with a mean of
9.5 years. All were treated exclusively with activators.
• The untreated control group consisted of 21 boys and 14
girls, with similar Class II, division 1 malocclusions,
selected from the growth studies of the School of
Dentistry, National Taiwan University. All were Chinese,
and the mean age was 9.6 years.
• Patients were asked to wear the appliances about 14
hours per day, but no effort was made to measure
cooperation.
• Pretreatment cephalograms of the two groups were
compared statistically to confirm that there were no
significant differences in craniofacial morphology.

• Activator treatment in this study was successful in girls

and boys from age 7 to 12. Children from age 7 to 12 are
highly responsive to praise and positive reinforcement
and therefore tend to be cooperative. Early functional
appliance treatment can correct any abnormal muscular
 habits that might influence later facial development and
form.

Temporal muscle activity during the first year of

Class II, Division 1 malocclusion treatment with an
activator (1991 Apr) Am J Orthod
Bengt Ingerval and Urs Thüer,
• The activity of the anterior and posterior temporal
muscles in response to treatment with a splint type of
activator was studied in children with distal occlusion.
• The effect on muscle activity was compared with that in a
similar group of children being treated with a headgear
and with that in a control group receiving orthodontic
treatment for Class I malocclusion.

• The activity in the rest position was constant during the 1-

year period of observation. During maximal bite the
activity of the posterior temporal muscle decreased
significantly in the group with headgear and the control
group and in a subgroup of children with large
protrusions in the construction bite who had been
treated with activators. This decrease was considered to
be an effect of occlusal instability brought about by the
treatment. There was no evidence of a decrease in the
postural (rest) activity of the posterior temporal muscle,
although such a decrease has been described as a sign of
forward displacement of the mandible during treatment
with a functional appliance.
 Functional treatment of condylar fractures in
adult patients E. K. Basdra,A. Stellzig,
Drmeddent, . 1998 Jun Am J Orthod

• Functional treatment of condylar fractures in adult

patients usually follows the closed
reduction/maxillomandibular fixation approach. Some of
the problems arising when functional appliances (i.e.,
activator) are used have been identified and presented
here, especially in patients where fractured parts are
dispositioned/dislocated.

• They conclude that activators are not the best means of

treating condylar fractures with
displacements/dislocations in adult patients. Therefore
patients who after the removal of the intermaxillary
fixation show good occlusal relationships should be only
treated with the use of intermaxillary elastics. Patients
exhibiting anterior or lateral open bites after
intermaxillary fixation should be treated with biteplates
(half or posterior bilateral), combined with vertical
elastics, to reestablish the initial occlusal relations. A
small group of patients with condylar fractures treated by
the above functional concept has been shown. They
showed good response and reported no complaints or
discomfort 1 year later. The occlusion recovered to the
initial relationship and no selective grinding was
necessary after treatment. This approach seems
promising in the treatment of condylar fractures in adult
patients.
 Skeletal profile changes related to two
patterns of activator effects - Luder Volume
1982 May Am J Orthod

A longitudinal cephalometric study was carried out on

twelve boys and thirteen girls who initially exhibited Class
II, Division 1 malocclusion and who were treated
exclusively with activators. Twenty-four boys and fifteen
girls, corresponding with the experimental subjects with
respect to initial age and observation period, were
selected as controls.

• The aim of the investigation was to examine

cephalometric profile changes associated with two
patterns of effects of activator treatment detected
previously.
• The findings demonstrate that the two types of reaction
bring about similar corrections of both apical base
discrepancy and dental Class II relationship but clearly
differ in their effects on the skeletal profile.
• Whereas the first type of reaction results in an
improvement in mandibular retrognathism, a marked
rotation of the occlusal plane, and good vertical control of
the upper and lower dental arches,
• the second type is distinguished by a significant reduction
of maxillary prognathism, downward and backward
rotation of the mandible, and forward tipping of the
lower incisors. Additional evidence presented further
suggests that the two patterns of effects are due to
differences in the construction bites of the appliances.
According to this hypothesis, a great interocclusal height
 of an activator would lead to the first and a low
construction bite to the second type of reaction.

Orthodontic forces exerted by activators with

varying construction bite heights Takuji Noro,
Kazuo Tanne, and Mamoru Sakuda, AJO-
DO1994 Feb
• The present study was conducted to investigate the
nature of forces induced with activators by measuring
strains, electromyogram (EMG) and
electroencephalogram (EEG) during a 2-hour sleep
period. Fifteen adolescent patients with Class II and Class
III malocclusions, (30 subjects) were used. Four types of
activators were made for each patient with construction
bites taken at incisal edge clearances of 2, 4, 6, and 8 mm
vertically. The magnitude of forces generated by passive
tension of soft tissues increased significantly (p < 0.01)
from approximately in the Class II group and also
increased in the Class III group with varying construction
bite heights from 2 to 8 mm. Higher construction bites
also significantly changed (p < 0.01) the direction of
forces by passive tension from vertical to posterior and
from vertical to anterior in relation to the reference plane
in the Class II and Class III groups, respectively.

• Duration of forces generated by passive tension was most

significantly longer than that of active contraction of the
jaw closing muscles, irrespective of the construction bite
heights. It is concluded that passive tension, derived from
viscoelasticity of soft tissues, plays a more important role
 in inducing changes than phasic stretch reflex during jaw
orthopedic therapy with activators

Predicting functional appliance treatment

outcome in Class II malocclusion– Susi
Barton, and Paul A.

Selecting cases suitable for treatment with a functional

appliance remains a problem as much of the relevant
literature is anecdotal. There are also design and
methodologic differences between the available studies,
and most studies are limited to the Andresen type of
appliance. The literature suggests that functional
appliances are most successful in cases with an overjet of
up to 11 mm, an increased overbite, active facial growth,
and good cooperation. (Am J Orthod Dentofac Orthop
1997;)

REFERENCES
• Dentofacial orthopedics with functional appliances (
Thomas - M.Graber, Thomas Rakosi, Alexander
petrovic)
• Removable Orthodontic appliances (T.M.Grater Bedrich
Neumann)