removable myofunctional appliance partial

7/28/2019 Removable Myofunctional Appliance Partial

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Activator & Bionator

ByDr. Nilofer


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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


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Introduction

The termFunctional appliance"refers to a variety ofremovable appliances designed to alter the arrangement of various

muscle groups that influence the function and position of the mandiblein 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.


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Myofunctional TherapyMyofunctional therapy is defined as the

treatment that transmits climates /guides

natural forces of the orofacial musculature thatare transmitted to the teeth &alveolar bone

through the media of loose fitting passive

appliances to achieve changes in Jaw positionand tooth alignment.


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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


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Group I ,Group II , Group III Appliances

GroupI

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 IIIReposition mandible but area of action is vestibule .


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Advantages ,Disadvantages , Indication,

ContraindicationsAdvantages1. 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 .


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Indications

1. Patients only in active growth phase can receive this form oftreatment .

2. Mild to moderate sagittal discrepancy corrections.

3. Reduced normal / moderately increased anterior facial height .

4. Anticipated downward & forward growth of the mandible .

5. No missing teeth .

6. No severely rotated /tipped teeth

7. Lower incisors well aligned to profile .8. minimal excess of space / crowding .

9. Nasal breather .

10. Adequately Motivated .


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Contra-Indications

1. Neuromuscular problems are a contraindication2. Adults / PostPubertal growth patients

3. Unfavourable facial morphology { Vertical growth pattern

/increased anterior lower facial height }

4. Severely malposed teeth .

5. Severe crowding / spacing

6. Lack of cooperation

7. Patient is a mouth breather /adenoids or has known allergies /speech problems .


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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 usesSurgical splint ,Periodontal splint

Orthodontic uses

With expansion screws

With springs , bows etcRetainer

etc


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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 .


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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 Kineticenergy .


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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 malocclusion2. Class II, Division 2 malocclusion

3. Class III malocclusion

4. Class I open bite malocclusion

5. Class I deep bite malocclusion6. As a preliminary treatment before major fixed appliance therapy

to improve skeletal jaw relations7. For post-treatment retention8. Children with lack of vertical development in lower facial height.


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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 wasrecorded 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 significantlyhigher 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.


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Contraindications

1. The appliance is not used in correction ofClass I problems ofcrowded teeth caused by disharmony between tooth size and jawsize,

2. The appliance is contraindicated in children withexcess lowerfacial height and extreme vertical mandibular growth. 3. The appliance is not used in children whoselower incisors areseverely procumbent. 4. The appliance cannot be usedinchildren withnasal stenosis

caused by structural problems within the nose or chronicuntreated allergy.

5. The appliance has limited application innon-growingindividuals.


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ClassificationofViews1)According to the originalAndresen-Haupl concept, the forces

generated in activator therapy are caused bymusclecontractions and myostatic reflex activity which causemusculoskeletal adaptation .

A loose appliance stimulate the muscle and the movingappliance moves the teeth.

The muscles function withkinetic energyand intermittent forcesare 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.


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2)According to the second working hypothesis, supported bySelmerOlsen, 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 usingpotential energy.An efficient stretch action is achieved by overcompensation

and the viscoelastic properties of the contiguous soft tissues


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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.


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3)It can be called atransitional type of activator action , whichalternatively uses muscle contraction and viscoelastic properties

of soft tissues.

Thestretch reflex resulting from activators in this group is seenas a long lasting contraction.

The intermittent forces induced by the constructions are lesspronounced than those induced in the original construction.

Eschler ( 1952 ) observed the occurrence of both isotonic andisometric contractions when this appliance construction wasused.


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SKELETAL AND DENTOALVEOLAR EFFECTS OF THE

ACTIVATOR

The Activator affects the 3rdlevel of articulation.

1. Any skeletal effect from the activator depends onthe growth potential.

Two divergent growth vectors propel the jaw

bases in an anterior directionA The sphenoccipital synchondrosis moves thecranial base and nasomaxillary complex up &

forward.B The condyle translates the mandible in adownward and forward direction.

The activator is most effective in controlling thelower vector or the downward and forward

growth of the mandible.


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

mandible anteriorly


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If the mandible cannot be positioned anteriorly, maxillarygrowth can be inhibited and redirected.

Changing the maxillary base inclination can compensate forrotations of mandibular growth vectors.

A downward displacement of the maxillary base allows themaxilla to adapt to a vertical rotation of the mandible.

If the rotation of the jaw bases during growth is

unfavorable, activator therapy cannot be completedsuccessfully.


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If the activator is constructed with a vertical opening of the

bite only or with minimal sagittal change, the effect is

primarily onmidfacialdevelopmentinthesubnasalarea. Bothvertical maxillary growth and eruption of the teeth are

restricted.


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2. The dentoalveolar efficiency of the activator helps achieve, aprimary 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.


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ForceAnalysisinActivatorTherapy

Staticforces

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


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DynamicforcesInterrupted 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


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RhythmicForces

They are synchronous with breathing and their amplitude varies withpulse.

The mandible transmits rhythmic vibrations to the maxilla.

The applied forces are intermittent and interrupted.

Force application to the teeth and mandible is intermittent.


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

follows:1 The growth potential, including theeruption and migration of teeth,produces natural forces. These can be guided promoted, and inhibited bythe activator.

2. Muscle contractions and stretching of the soft tissues initiate forcewhen the mandible is relocated from its position by the appliance. Theactivator stimulates and transforms the contractions. Whereas forces maybe functional (muscular) in origin, their activation is artificial.

3 Various active elements (e.g., springs, screws) can be built into theactivator to produce an activebiomechanic type of force application.


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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 thismaneuver

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

relieved of normal forces.


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


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CONSTRUCTIONBITE

Proper activator fabrication requires the determination andreproduction of the correct construction or working bite.

The purpose of this mandibular manipulation is to relocate the jaw inthe direction of treatment objectives. This creates artificial functional

forces and allows assessment of the appliance's mode of action.


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StudyModelAnalysis

Before constructing the activator , the clinician mustconsider the following factors :

1. First permanent molars relationship in habitual occlusion.

2. Nature of the midline discrepancy .

3. Symmetry of the dental arches.

4. Curve of spee.5. Crowding and any dental discrepancies.


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FunctionalAnalysis

Precise registration of the postural rest position in the naturalhead 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 asclicking and crepitus in the TMJ. Interocclusal clearance or freeway space.

Respiration.


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Cephalometricanalysis

Direction of growthAverage , 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 mandibularincisors.


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General rules for the construction bite

In a forward positioning of the mandible of 7 to 8 mm thevertical opening must be slight to moderate(2 to 4 mm).

2. If the forward positioning is no more than 3 to 5 mm thevertical opening should be4 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 toiatrogenic asymmetry. Functional crossbites in the functional analysis can be corrected by taking theproper construction bite.


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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 iscontraindicated if any of the following pertain: 1.The overjet is too large:

2.Labial tipping of the maxillary incisors is severe


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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 constructionbite.As with severely proclined upper incisors, use of a shortprefunctional appliance to improve alignment of lingually

malposed teeth is advisable before starting activator treatment,

thereby eliminating the need for the pathologic construction bite.


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Opening the bite : Maintaining a proper horizontal-vertical relationship and determining the height of the bite are guided bythe following principles:

1. The mandible must be dislocated from the postural resting

position in at least one directionsagitally or vertically. Thisdislocation is essential to activate the associated musculatureand 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 overstretchthe muscles. This type of construction bite produces an increased

force component in the sagittal plane, allowing a forward

positioning of the mandible.


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3. Ifextensive vertical opening is needed , themandible must not be anteriorly positioned. Ifthe bite opening exceeds 6 mm, mandibularprotraction must be very slight . Myotatic reflexactivity of the muscles of mastication can thenbe observed, as can a stretching of the softtissues. The vertical relationship, either deep bite

or open bite,can be therapeutically affected bythe activator.

Disadvantages of a wide-open construction biteinclude the difficulty of wearing the applianceand adapting to the a new relationship. Muscle

spasms often occur, and the appliance tends tofall out of the mouth. The high construction bitealso makes lip seal difficult if not impossible.

Theultimate reestablishmentofnormal lip sealisessential infunctional appliancetherapy.


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Execution Of the Construction Bite

A horseshoe shaped wax bite rim isprepared for insertion between the

maxillary and mandibular teeth. Before taking the wax bite registration

the operator asks the patient to situpright in a relaxed posture while gentlyguiding the mandible into the

predetermined position.

When the operator is relatively sure thepatient can replicate the exercise , thesoftened wax bite rim is placed in themouth and wax should not be too soft.

During the closing movement theoperator controls the edge to edge incisalrelationship and midline registration.


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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 , theelevator muscles of mastication are activated.

When the teeth engage the appliance the myotactic reflex isactivated.

In addition to the muscle force arising during biting and swallowing , the reflex stimulation of the muscle spindles alsoelicits reflex muscle activity.


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Horizontal H Activator

Mandible can be postured forward without

tipping the lower incisors labially.

The maxillary incisors can be positionedupright and the anterior growth vector of

the maxilla is slightly inhibited.

This appliance is most effective if ananterior sagittal relationship of the

mandible.

Most commonly indicated in Class II ,Division 1 Malocclusion


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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 lowerincisors 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.


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Technique for a High Construction Bite with Slightly

Anterior Mandibular Positioning

In a high construction bite the mandibleis positioned less anteriorly ( only 3 to 5mm ahead of the habitual occlusionposition ).

Depending on the magnitude of theinterocclusal space , the vertical dimension is opened 4 to 6 mm , amaximum of 4 mm beyond the postural

restvertical dimension registration.

The greater opening of the vertical dimension in the construction bite allowsthe myotatic reflex to remain operative

even when the musculature is more


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Vertical V Activator

The goal of activator treatment is minimalforward positioning of the mandiblebecause of the vertical growth pattern butan actual adaptation of the maxilla to the

lower dental arch.

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

This skeletal adaptation must be supportedby dentoalveolar compensation which

requires differential guidance of eruptionof maxillary buccal segment eruption,

lingual tipping of the maxillary incisorsand labial tipping of the mandibular

incisors.


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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 labialtipping of the mandibular incisors.


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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.


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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 extrusioncan be used to treat deep overbite cases.


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SupraocclusionoftheincisorsThe activator should not be designed with a high construction bite in

these cases.

Intrusion of the incisors is possible to only limited extent when anactivator is being used.

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

Depression is relative rather than absolute because the other are free

to erupt and accomplish the predetermined growth pattern.


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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 patientspostural rest vertical dimension.

This height enlists stretch reflex response and the viscoelastic

properties of the muscles and soft tissues as they are stretched.


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Arch length deficiency problems

Malocclusions with crowding can be

treated with activators.

The construction bite is low becausejaw positioning and growth guidance

by selective eruption of teeth are not

desired.

The treatment objective is expansion

using appliance established by

intermaxillary relationships.


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Construction bite with opening and posterior

positioning of the mandible

Tooth guidance or functional

protrusion Class III malocclusion

The vertical dimension is opened far

enough to clear the incisal guidancefor construction bite. This eliminates

the protrusive relationship with the

mandible in centric relation.

The prognosis for pseudo class III

malocclusions is good especially if

therapy begins in early mixed

dentition.


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Skeletal Class III malocclusion with a normal path of closure fromrest to habitual occlusion

The opening of the vertical dimension for the construction bite dependson the possibility of achieving an end-to-end incisal relationship.

Indications for functional treatment of true Class III problems arelimited. Usually combined therapy such as with fixed and removableappliances and maxillary orthopedic protraction is likely to be

successful.

If the treatment is initiated in the early mixed dentition and if the bitecan be opened ,incisal guidance established , adaptation of themaxillary base to the prognathic mandible can be expected to a

certain degree.


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Fabrication of the Activator

Labial Bow : primary element of theactivator with upper and lower labial

bows.

They consists of horizontal middle

sections,two vertical loops,and wireextensions .

The bow can be active or passive depending

on the prescription .

Thepassive labial bow influences the softtissue without touching the teeth . Depending on the vertical dimension , the

wire crosses the incisors above or below the

area of greatest convexity.


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The vertical U shaped loops of theupper labial bow start with a 90 degreebend at lateral incisor canineembrasure , form gentle continues

curves above the gingival margin and

pass freely through canine firstdeciduous 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.


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The lower labial bow is similar inconfiguration to the upper. Themiddle horizontal portion is longerbecause 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 wireis0.9 mm thickfor thepassive bowit is only0.8 mm thick.


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Fabrication of the acrylic portion

The activator consists of upper ,lower and interocclusal parts. Inthe upper and lower dental partsthe dental and gingival portionscan be differentiated ; the

gingival portion can be extendedposteriorly.

If the construction bite is high as

it is in a vertical activator , theextension of the flanges is greaterthan for a horizontal type of activator that positions themandible more anteriorly.


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The flanges forupper part are 8 to12 mm high in the gingival areaand cover the alveolar crest. The

palate is not covered.

Thelower acrylic plate is generally5 to 10 mm wide although it issometimes wider in the molar areawith flanges of 10 to 15 mm.


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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


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INTRUSION/EXTRUSIONIntrusion of teeth

It can be achieved byloading incisal edges of teeth.If they are grounded properly , they become the only

loaded or contacting surfaces with no other contactbetween the incisors and acrylic even in thealveolar area.

Intrusion of molarsis performed byloadingonly the

cusps of these teeth. Thefossae and fissures arefree of acrylic.Molar depression and loading are indicated in open

bite problems if minimal or nonexistant

interocclusal clearance is apparent.


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Extrusion of teethextrusion of incisors requires loading their

lingual surfaces above the area of greatest

concavityin 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 belowthis area in the mandible.

Molar and premolar extrusion is indicated in

deep bite


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Trimming of activator for sagittal control

Protrusion and retrusion of incisorscan 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.


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Protrusion of Incisors : Loading can be accomplished by

either of two methods :

The entire lingual surface isloaded.only the interdental acrylicprojections are trimmed to avoidopening spaces between the teeth.

This method allows the incisors tobe moved labially with a lowmagnitude of force because theapplied force is spread over a large

surface.


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The incisal third of the lingual surface

is loaded. This variation results inlabial tipping of the incisors with a

greater degree of force because the

contact surface is small.


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Protrusion Springs : Continuous or closed springs of fairly heavy wire ( 0.8 mm) areactivated only when the teeth are closed into the appliance.

Wooden pegs : Small wooden pegs areinserted with minimal projection into thelingual acrylic.The protrusion springs orwooden sticks usually contact the incisorsin the middle or gingival third of the lingualsurfaces.

Guttapercha :Guttapercha may be added tothe lingual acrylic.This traditional approachhas been supreseded by the use of thin layers

of soft acrylic applied where desired.


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Retrusion of incisors :

The acrylic is trimmed away from the

backs of the incisors o be retruded. Theactive 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


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The gingival position can elongate the

incisors depending on the degree of labial

convexity.

This type is desirable only in open bite casesin 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 ofthe labial surfaces providing some

motivational force and preventing incisor

extrusion during retraction.

Movements of the posterior teeth in the sagittal plane


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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.


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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


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Stabilizing wi es o spu s a e igid

(0.9 mm ) projections from the

lingual acrylic that contact the

mesial surface of the permanentmolars 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.


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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.


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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.


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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 wireelements.

SelectivetrimmingoftheActivator


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During selective trimming procedures onlythe upper and lower molars are extruded.

If selective grinding is planned the path oferuption of the molars must be considered.

In cases with vertical growth patterns andtendencies to open bite , the distal positionof the molars can be altered before final eruption.


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After the lower molars have erupted the distal surfaces of theupper second molars may be sliced permitting the upper molarsto migrate slightly to the mesial , closing the bite and reducing the mandibular retrognatism.

If the eruption of the upper molars are stimulated and lowermolar eruption is inhibited, the upper molars movemesially.this can be used to correct mild Class IIImalocclusions .


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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 far

wide vertically.

2. If high vertical construction bite leads to tonguethrust.

3. A modification by Klammt causes lack of

support in the cutaway portion.


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The appliances with cross palatal wire components (Balters ) aresupported / anchored dentally and has limited function thoughthe 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 musclecomponents.

The rigid activator allows only isometric contractioons with no

muscle shortening. Isometric contractions have more tension thanisotonic ones


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WunderersModification

This is an activator modificationthat 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.


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The Bow activator of A.M Schwarz :

The bow activator is a horizontallysplit activator having a maxillary

portion and a mandibular portionconnected together by an elastic bow.

This kind of modification allows stepwise sagittal advancement of the

mandible by adjustment of the bow.

The independent maxillary and themandibular portions can have a screw

incorporated to allow arch expansion.


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Reduced activator or cybernator of Schmuth :

This modification of the activator is proposed by ProfessorG.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


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This is a modification proposed byMetzelder to combine the advantages of bionator and the Andresen's activator.

The mandibular portion of the applianceresembles an activator while the maxillaryportion has acrylic covering only thepalatal aspect of the buccal teeth and a

small part of the adjoining gingival. The palate thus remains free of acrylic

thereby making the appliance moreconvenient for patients to wear theappliance for longer hours.

Due to the greater amount of wearing time,success should be greater with the palatefree activator.

The Karwetzky modificaton


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This consists of maxillary and mandibularplates joined by a 'U' bow in the region ofthe 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 aresqueezed the lower plate moves sagittallyforwards

Type II :This is used for the treatment ofClass III malocclusion. In this appliancethe larger lower leg is placed anteriorly.Thus when the U bow is squeezed themandibular plate moves distally.

Type III: They are used in bringing aboutasymmetric advancements of the mandible.The U bow is attached anteriorly on oneside and posteriorly on the other side toallow asymmetric sagittal movement of

themandible

Hyperpropulsor Activator


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HyperpropulsorActivator GEORGES GAUMOND, 1986Jun JCO The hyperpropulsor

activator,developd from themonobloc of Robin, consists of abimaxillary block of acrylic made

with the bite open and the mandiblein a forward position.

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

12-15mm, with the only limit tohyperpropulsion being thediscomfort of the patient. Extraoral

force is used with the appliance,which is worn only at night.

Elastic open activator


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Elastic open activator

A modification of the activator

developed by G. Klammt. Theappliance has reduced acrylic

bulk, facilitating increased

appliance wear.

The acrylic is replaced by wireswhich 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):


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( ) A modification of the activator

developed by P. Herren (alsoknown as the Louisiana StateUniversity modification of thesame appliance).

It is essentially an activator made

to a construction bite thatpositions the mandible forwardand downward to a significantdegree.

According to P. Herren, thewearing of this appliance is notsupposed to increase the activityof the lateral pterygoidmuscle


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Lehman appliance (Lehman activator) A combination activator-headgear

appliance developed by R.Lehman. Itconsists of a maxillary acrylic platethat carries two rigidly fixed outerbows and a mandibular lingual shield.

The acrylic plate covers the palate andit extends over the occlusal and incisalsurfaces of the maxillary teeth, up tothe occlusal third of their buccal and labial surfaces.

Selective expansion of the maxillaryarch is possible by appropriatelyactivating the two transverseexpansion screws (one anterior and one posterior) that are embedded in

the plate.


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Occipital traction is applied through aheadstrap attached on the outer bows,which are fixed at the anterior aspect of theappliance.

The mandibular lingual shield is connected to the maxillary plate by means of two

heavy S-shaped wires. Unlike manyactivator type appliances which areconstructed with the mandible in aprotruded position, this appliance is madefrom a bite registration taken in centric

occlusion. According to R.Lehman, the S-shaped wires

are activated by approximately 2 mm every4 to 6 weeks, to achieve a gradual advancement of the mandible.


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Teuscher-Stockli activator/headgear combination appliance

A modified activator used incombination with a high-pull headgear.

The appliance was introduced byU.M. Teuscher and P.W. Stocklias a means to avoid thedetrimental profile effects of cervical traction when treatingClass 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


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Nocturnalairwaypatencyappliance 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 nasalobstruction 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

rotrusion brin s the ton ue orwards.

OpenSemiflexibleactivator


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ByLevrini .A (JCO 1996)

The OSA is a modified bionator that incorporatesprinciples developed byBimler, Klammt,Stockfisch,and Woodside.

It is a compositemyodynamic functionalappliance, with a rigid frame of acrylic resin andstainless steel wiresconnected to elastomericocclusal pads.

A ti t With Hi h P ll H d


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Activator With High Pull Headgear Traditional headgear with high

pull head gear can also be used.

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 arUlusoya,Nilfer Darendelilerb concluded that both functional appliancescan cause morphologic changes on the mandible by activating the

masticatory muscles to change the growth direction.
http://www.google.co.in/imgres?imgurl=http://barronbraces.com/images/dento2.jpg&imgrefurl=http://barronbraces.com/dento.html&h=159&w=322&sz=31&tbnid=dMAuYbPmckeaAM:&tbnh=58&tbnw=118&prev=/images%3Fq%3Dhigh%2Bpull%2Bheadgear&hl=en&usg=__EPcZ1RYnhNCRHpUOkIkrQWC-L3U=&ei=tb9lS8elHoHg7APGytUY&sa=X&oi=image_result&resnum=3&ct=image&ved=0CA0Q9QEwAg


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ActivatorsAsRetainers[JCO 1980Aug(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


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Management Of Appliance The initial appliance review done in 3 weeks time if found normalreview done at 6 weeks time.

Procedure

All guide planes should be ground & all tooth surfaces checkedfor 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.


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Alteration of construction bite if required by

Direct method

Indirect Method

separation of upper and lower segment and rejoining in the

new position.

h


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The Bionator : The Bionator is a prototype of a less bulky appliance

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 .


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The palate is free for proprioceptive contact with the tongue.

The orginal appliance was developed by Balters (1964).

At the same timeBimler 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, growth-

restricting aberrations.


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The abnormal positioning of the tongue can lead to several

problems eg Posterior Displacement of the tongue can lead toCass 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.


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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


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Indications Of BionatorClass 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 fingersucking, retained infantile deglutition and aberrant tongue function.

Pseudo Class III

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

maxillar rowth occurs


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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 dueto LPM.

The construction bite with this does not place the mandible as

forward but doesopen the bite slightly otherwise the designis 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 .


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Contra- Indications :1. A vertical growth pattern .

2. The class II relationship caused by maxillary prognathism.

3. If labial tipping is evident.Since anterior positioning of the mandible

is not possible with simultaneous uprighting.4. Cases with Crowding


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The Principle Of Treatment With Bionator

-Not to activate the muscles but to modulatemuscle 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


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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 thiswould 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 .


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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 factunknown 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.


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Disadvantages

1. Difficulty in management.

2. 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 ofthat pattern.

4. Skeletal interferences limited action.


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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.


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The flanges should extend 2mm above &below the upper & lowergingival margins respectively.

Palatal area is kept free however tongue posture here is kept incontrol 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 ).


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Labial Bow

Begins in between the canine and deciduous 1stmolar(or

premolar).

Runs vertically making a rounded 90 deg bend between the

deciduous 2ndmolar and permanent 1stmolar.

Making a gentle round downward & forward curve runs asfar 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.


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Function

The wire produces negative pressure, with the wire supportinglip 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.


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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 posteriorregion 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.

Th l b l f l b l b l d h l l f h l


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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


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

(November 2007) done onEarly orthodontic treatment of skeletalopen-bite malocclusion with the open-bite bionator: Acephalometric study by Efisio Defraiaa, Andrea Marinellib,Giulia Baronic, Lorenzo Franchid, Tiziano Baccettie showed that

The bionator treatedgroup had a significantly smaller palatal plane-

mandibular plane angle (1.9) and a greater overbite (+1.5 mm)

associated with a significantly smaller overjet when compared with thecontrol group. Conclusions: Based on the analysis of this sample, earlytreatment of skeletal open bite with the open-bite bionator appears to

produce a modest effect that mainly consists of significant improvement

in intermaxillary divergence.

Cl III R d Bi t


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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.


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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


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Balter s main intention was to load the mandibular teeth andunload 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 wasreversed .

However Rakosis study in1977 that the reverse palatal barmainly aided in flattening the Dorsum of the tongue and does not

move it anteriorly.

Only tipping of the maxillary anterior teeth finally occurs.


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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 termsArticular Plane : Tips of the cusps of upper 1stmolars premolars

canine to mesial margin of upper central incisors.

Runs parallel toAlatragal line.Mode of trimming assessed from this.

Loading Area : Palatal /lingual cusps of deciduous molars orpremolars and permanent molars are relieved in the appliance and

this enhances the anchorage of the appliance.


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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.


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Anchorage Of The Appliance

Some planes are used for anchorage some to achieve the desiredtooth 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.


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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 terminologyfor stimulation of eruption is unloading or Promotion of growth and prevention of eruption as loadingor inhibition of growth.

Teeth are allowed to erupt by the trimming of acrylic tooth bedsandelimination of influence of tongue and cheeksuntil they reach the

articular plane.


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To prevent eruption they are loaded with acrylic as needed.

The appliance can be trimmed or ground periodically until theteeth 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.


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The types of Anchorage According to Ascher (1968)

Dentition Anchorage1,2,III-V,6 IV- V upper & lower

1,2,IIIV ,6 V and space after IV

1,2,II6 Alveolar processIV, V

1,2, III, 4-6 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


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Main differences from the trimming of a Bionator

1. For Extrusion of Posteriors some acrylic is left interdentally at the

level of Articularplane 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.


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2. The noses are left untouched action similar to stabilizing Spursof 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 transversemovement,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, PeterH. 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.

Cli i al Ma ag t


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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.


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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

LPMto 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.


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Modifications A Monoblock appliance, the Bionator incorporating a lateral

adjustment screw lingual to the lower incisors.


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TheOrthopedic Correctorcontinues 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

d t ti ith Bi t th A Pil t I l t St d


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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 functionalappliances 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;


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q y ;

24 : 93-99.

15. Hagg, Rabie:Initial and late treatment effects of

headgear Herbst appliance with mandibular step-by-

step advancement. AJO 2002; 122 : 477-485.

16. Ruf & Pancherz:TMJ remodeling in adolescents andyoung 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


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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

removable myofunctional appliance partial

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