Activator and its modifications

Contents
• Introduction
• Activator
 Introduction
• In the past 20 years there has been increasing awareness of
growth modifications produced by functional appliances
among orthodontists.

1. FORM & FUNCTION

2. NEUROMUSCULAR INVOLVEMENT
3. IMPORTANCE OF AIRWAY
4. understanding of HEAD POSTURE AND ITS ROLE
 HISTORY AND EVOLUTION OF
ACTIVATOR
• KINGSLEY introduced "Jumping of the bite”1879 - to
correct sagittal relationship between Upper and lower
jaws.

• HOTZ modified the kingsley's plate into a vorbissplate

(used it for deep bite and retrognathism).

• From Kingsley's concept, VIGGO ANDRESEN 1908

developed a loose fitting appliance on his daughter as a
retainer during summer vacations which gave remarkable
results. He called it BIOMECHANICAL RETAINER.
• PIERRE ROBIN - monobloc to position the mandible
forward to prevent occluding the airway in patients of
GLOSSOPTOSIS.

• KARL HAUPL (a periodontist and histologist) became

convinced that appliance induced growth changes in a
physiological manner.

• Then the name ACTIVATOR or Norwegian system was

coined.

• This paved way for a series of modifications and an array

of functional appliances and opened a new area in the field
of orthodontics-functional jaw orthopedics.
 Indications
• Actively growing individual with favorable (horizontal)
growth pattern.
• Well aligned maxillary and mandibular teeth
• Mandibular incisors should be upright over the basal bone.

Used In
• Class II Div 1
• Class II Div 2 after aligning the incisors
• Class III
• Class I open bite
• Class I deep bite
• For cross bite correction (Trimming done in such a way
that maxillary molars are moved laterally and mandibular
molars lingually).
• Preliminary before Fixed appliance to improve skeletal jaw
relationship.
• For post- treatment retention
• Used for opening the space for 1st or 2n premolars by using
jack screws.
• Simultaneously serves as a space maintainer in mixed
dentition, the acrylic is extended into the space of missing
tooth.
• Treatment of snoring. Found to be more effective than soft
palate lifter mouth shield (Swedish dental journal - 1996 -
20 (5))
 CONTRA INDICATIONS
1. Class I crowding, due to tooth size jaw discrepancy
2. Increased lower facial height.
3. Extreme vertical mandibular growth
4. Severely procumbent lower incisors
5. Nasal stenosis.
6. Non growing individuals
 Efficacy of Activator:
According to Andresen & Haupl,
 Activator is effective in exploiting the interrelationship
between FUNCTION and changes in INTERNAL BONE
STRUCTURE.

 During GROWTH, there is also interrelationship between

FUNCTION and EXTERNAL BONE FORM.

 The CONDYLAR ADAPTATION to the anterior

positioning of the mandible consists of growth in an
upward and backward direction to maintain the integrity
of TMJ. This adaptational process in induced by the loose
fitting appliance.
 Classification of views
₰ PETROVIC (1984): McNAMARA (1973)
Andresen Haupl's Concept that MYOTATIC reflex activity
and ISOMETRIC CONTRACTION induce
musculoskeletal adaptation by introducing a new
mandibular closing pattern.

• Superior head of lateral pterygoid plays an important role

in assisting the skeletal adaptations.

• Pertovics research on condylar cartilage growth

stimulation is by activating the lateral pterygoid.
₰ SELMER - OLSEN, HERREN 1953, HARVOLD 1974 &
WOODSIDE 1973 do not agree with the myotactic reflex.

According to their views,

• VISCOELASTIC PROPERTIES OF MUSCLE AND
STRETCHING OF SOFT TISSUES are decisive for
activator action.

• Each application of force induces secondary forces in

tissues which inturn introduces a bio-elastic process and
that is important in stimulating skeletal adaptation.
Stages of Visco-Elastic Reaction (Depends on magnitude
and duration of applied force)

 Empting of vessels
 Pressing out of interstitial fluid
 Stretching of fibres
 Elastic deformation of bone
 Bioplastic adaptation

• Woodside recommends opening the mandible upto 10-

15mm with the construction bite.
• SCHMUTH, WITT AND KOMPOSCH feel displacing
mandible 4 - 6 mm below intercuspal position to be ideal.
Observed long periods of continuous pressure from
mandibular teeth against the activator.

• ESCHLER 1952 refers to opening the vertical dimension

beyond 4mm in construction bite as the "muscle stretching
method" which works alternatively with isotonic and
isometric contractions.
 Force analysis in activator
therapy
• When functional appliance activates the muscles, various
types of forces are created - STATIC , DYNAMIC and
RHYTHMIC forces.

 Static forces are permanent (eg. force of gravity, posture,

elasticity of soft tissues and muscles)
 Dynamic forces are interrupted (eg. movements of head
and body, swallowing)
 Rhythmic forces are associated with respiration and
circulation. Mandible transmits rhythmic vibrations to the
maxilla.
Effectiveness of activators during
sleep
• Serves as a "Night Guard" preventing deleterious nocturnal
parafunctional activity and stimulating normal muscle
activity

• Protracted, unloaded condyle enhances condylar growth

increments and favourable upward and backward growth
direction.
• HOTZ, PETROVIC, OUDET, STUZMANN stated that
growth increments were greater at night due to increased
growth hormone secretion.

• SELMER-OLSEN said that the muscles could not be

stimulated during sleep as nature has designed them to be
at rest. Swallowing occurred only 4-8 times in an hour
during night.

• Electromyographic study of temporalis and masseter

with and without activators (AJO - Aug 1998)
• It is observed that there was
1. Similar postural activity for both muscles with or without
activator.
2. During swallowing of saliva, muscle activity was higher
with the activator.
3. During maximal clenching similar activity in anterior
temporalis with or without activator. Higher activity in
masseter muscle with the activator.
• Two principles employed in modern activator

– FORCE APPLICATION - the source is usually

muscular
– FORCE ELIMINATION - dentition is shielded from
normal and abnormal functional tissue pressures by
pads, shields and wires.
 TYPES OF FORCES EMPLOYED IN
ACTIVATOR THERAPY
• Growth potential includes eruption and migration of teeth
which produces natural forces and those can be
guided, promoted and inhibited by the activator.
• Muscle contraction and stretching of soft tissues produces
artificial forces effective in all three planes. Sagittal plane
- mandible propelled down and forward so that force is
delivered to the condyle. Vertical plane - teeth and
alveolar process either loaded or relieved of normal forces.
Transverse plane - forces can be created with midline
reactions.
According to WITT,
• Approximate sagittal force 315 - 395gms.
• Optimal vertical force 70 - 175 gms.

• In a study by NORO et al (AJO - 94 Feb) magnitude of

forces generated by passive tension of soft tissues
increased from 80 - 160 gms in class II patients and 130 -
200 gms in class III patients when the construction bite
heights changed from 2 to 8mm.
 DIAGNOSTIC PREPARATION
• Treatment Timing: - MIDDLE to LATE MIXED
DENTITION.
• : Study Model Analysis
• FUNCTIONAL ANALYSIS
• CEPHALOMETRIC ANALYSIS
• VTO -
 construction bite
• ANTERIOR POSTIONING OF MANDIBLE
• The usual intermaxillary relationship for average class
II problems is END TO END INCISAL. It should not
exceed 7 to 8mm or 3/4 of mesiodistal dimension of first
permanent molar.
OPENING THE BITE
• To determine the height of the bite
• Mandible should be dislocated from its postural rest
position in atleast one direction - SAGITTAL or
VERTICAL

• If the forward positioning is great, vertical opening should

be minimum (for example - when the forward positioning
is 7 to 8mm vertical opening should be 2 to 4 mm. If the
forward positioning is reduced to 3 to 5 mm vertical
opening is increased to 4 to 6 mm ).
 ANDRESON APPLIANCE

• Vertical opening is within the limits of free way space ( 2

to 4 mm).

• Mandibular advancement being 3 to 5 mm.

• Used for less severe class II MO with deep bite and upright
or lingually inclined lower incisor.
 MODUS OPERANDI
• The appliance induces activation of MYOTACTIC
REFLEX & ISOMETRIC CONTRACTIONS. These
muscle forces are transmitted by the appliance to move the
teeth. Thus the appliance uses KINETIC ENERGY.

• REFLEX CONTROL OF SKELETAL MUSCLE

CONTRACTION
• MECHANISM OF STRETCH OR MYOTACTIC
REFLEX
• Stretch reflex when elicited causes contraction of the
stretched muscle. Muscle stretch receptors are
proprioceptive nerve endings called muscle spindles
situated within the muscle.
 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.

 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 encountere

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.
 H - ACTIVATOR
• Activator constructed with LOW VERTICAL OPENING
and a markedly forward mandibular positioning is
designated as horizontal or 'H' activator
Indications:
1. Class II Div 1 with sufficient overjet
2. Class II Div 1 MO where there is mandibular overclosure
that results in a functional retrusion of the mandible. In such
cases activator can act in the sense of "Jumping the bite"
3. Class II Div 1 MO with posteriorly positioned mandible
due to growth deficiency with horizontal growth pattern.
• As a mandible moves mesially to engage the appliance, elevator
muscle of mastication get activated.

• When teeth engage the appliance MYOTACTIC REFLEX is

activated.

• In addition muscle force arising during biting and swallowing

causes stimulation of muscle spindles which elicits reflex muscle
activity.
 Effects of H - activator
1. Mandible can be postured forward without tipping the
lower incisors labially.
2. LIP TRAP got eliminated
3. Maxillary incisors can be positioned upright or lingualy
4. Anterior growth vector of maxilla is slightly inhibited.

Class II Div 1 MO with vertical growth pattern when treated

with H activator results in DUAL BITE.
 V-ACTIVATORS
• Activator with large vertical opening and minimal anterior
positioning is designated as V activator.

• Mandible is positioned anteriorily only 3-5mm ahead of

habitual occlusion.

• Vertical opening 4 to 6mm beyond the postural rest position.

 MODUS OPERANDI

• Induces myotactic reflex activity.

• The greater vertical opening thus allows the myotactic

reflex to remain operative even when the musculature is
more relaxed ( that is when the patient is sleeping).

• Stretching of muscles and soft tissue elicits an additional

force - the viscoelastic force. This stretch reflex influences
inclination of maxillary base.
 Deep bite MO.
• In dentoalveolar problems, the deep overbite may be due to
infra-occlusion of buccal segments or supra - occlusion of
anterior segments.

• Construction bite may be moderate or high depending on

the free way space.

• If it is due to supra - occlusion of anterior segments,

interocclusal space is usually small and should resort to
high construction bite.

• Intrusion of incisors is possible to only a limited extent

when an activator in being used.
• Skeletal deep bite MO's have a horizontal growth
pattern, for which forward inclination of maxillary base
can compensate.

• Loading the incisors can achieve a slight forward

inclination of the maxillary base as well as frees the molars
to erupt.

• Here the construction bite is high (5 to 6mm beyond the

free way space ).

• A dento alveolar compensation is possible by extrusion of

lower molars and distal driving of upper molars with
stabilizing wires.
 Open bite MO
• Anterior positioning of mandible is necessary if the
skeletal relationship is orthognathic.

• Bite is opened 4 to 5mm to develop a sufficient elastic

depressing force and load the molars that are in premature
contact.
 Arch length deficiency problems
• MO with crowding can sometimes be treated with the
activator and can accomplish the desired expansion
because it is anchored intermaxillarly.

• The appliance works in a manner similar to that of two

active plates with jackscrews in upper and lower parts.

• Construction bite should be low.

 Construction bite for CLASS III
MO
• Goal is posterior positioning of mandible or maxillary
protraction.

• The construction bite taken by retruding the lower jaw.

Extent of vertical opening depends on the retrusion possible.

• In PSEUDO CLASS III, functional deviation is present where

the forced bite is easily achieved.
• In these cases vertical opening is for enough to clear the
incisal guidance for construction bite. Here it is possible to
achieve edge to edge bite relationship with posterior teeth still
out of contact.
 Fabrication of the activator
• Primary wire elements are the UPPER OR LOWER
LABIAL BOW.
• Upper (U) loop starts in lateral incisors canine embrasure
area.
• Lower canine loops starts more distally is mesial third of
the canines.

• Labial bows can be active or passive.

• If active made out of 0.9mm if passive made out of

0.8mm.
• Fabrication of the acrylic parts consist of UPPER ,
LOWER AND INTER OCCLUSAL PARTS.
• Upper and lower parts consist of DENTAL AND
GINGIVAL PORTIONS.

• Flanges of upper part extends 8 to 12 mm high in gingival

area and covers the alveolar crest. Flanges of lower part
extends 5 to 12mm in gingival area.

• Flange extention is greater in V activators as the patients of

this category have open mouth postures.
 Trimming of the activator
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:
1. Loading the lingual surface with acrylic contacts.
2. Screening away lip strains with passive labial bow or lip
pards. Auxiliaries used are
3. Protrusion springs (0.8mm)
4. Wooden pegs
5. 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.
 TRANSVERSE PLANE
• 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 THE
ACTIVATOR
• Broadly categorized into 2 types
1. Appliances with ONE RIGID ACRYLIC MASS for
maxillary and mandible arches but with reduced volume
or bulk.
– Reduced volume in anterior palatal region to restore
contact between tongue and palate eg. ELASTIC OPEN
ACTIVATOR
• Disadvantages : construction bite cannot be opened too
much vertically
– Reduction in alveolar region and with a cross-palatal
wire instead of full acrylic plate. Eg. BIONATOR
• Appliance consisting of 2 parts joined by wire bows.
Muscle impulse are reinforced by wire elements in the
design. Eg. SCHWARZ DOUBLE PLATE.
Following are the modifications :
1. Eschler's modification
2. Herren's activator (1953)
3. Herren's shage activator – LSU activator
4. The bow activator of Schwarz
5. Reduced activator of Cybernator of Schmuth
6. The Karwetsky appliance
7. The propulsor
8. The cutout (or) palate free activator
9. Elastic open activator of Klammt
10. Stockfish's Kinetor
11. Hamilton expansion activator system. (or) Bonded
activator
12. Bionator
13. Combined activator /HG Orthopaedics.
14. MAD – Magnetic Activator Device.
 ESCHLER'S MODIFICATION
• ESCHLER'S MODIFICATION of labial bow the
improved the intermaxillary effectiveness.

• One part was active moving the teeth, other

passive, holding soft tissues of lower lip away and this
enhancing the tooth movement desired
 HERREN ACTIVATOR 1953
• Herren's concept was in complete opposition to be Kinetic
concept of Andersen Haupl.

1. Triangular clasps to maxillary dentition.

2. A maximum forward positioning in essential with the
construction bite around 8-10mm.
3. Garber referred this appliance as a SPLINT and a
"MYOTNIC" appliance and claimed to exert 500gms of
continuous force due to stretched muscle.
 L.S.U. or Activator of Shaye
• LOUISIANA STATE UNIVERSITY ACTIVATOR is
essentially a modification of Herren activation.
• In this appliance the lower incisor bite on a plane formed
by the acrylic.

• Hence growth in occlusal direction is impeded. The

eruption of premolars and molars are achieved by selective
grinding and the occlusal plane is leveled.

• Acc to AUF DE MAUR (1978) & HERREN (1953)

wearing of this appliance does not bring about any
increased activity of LPM.
• Herren and L.S.U. activator exert their actions mainly
through sagittal repositioning of the mandible. These
appliances have 2 step effects.

1. During wear the more forward positioning of the

mandible is the cause of reduced growth of LPM
(Simultaneously) a new sensory engram is formed for the
new positioning of the lower jaw.

2. When not worn the mandible functions in a more forward

position in such a way, the retro-discal pad is much more
stimulated as a result of which earlier beginning of
condylar chondroblast hypertrophy – and consequently an
increased growth rate of condylar cartilage takes place.
 WUNDERER'S MODIFICATIONS
• Wunderer's modifications is used for class III MO.
Consists of an activator which was split horizontally, the
upper and lower halves are connected with a screw which
is situated in a extension of the mandibular portion behind
the maxillary incisors.

• By opening the screw, maxillary portion is moved

anteriorly with a reciprocal backward thrust on the
mandibular portion.
• To enhance the appliance retention, occlusal surface of
buccal teeth are covered with acrylic. The construction of
such an appliance is facilitated by a screw designed by
WEISE.
 THE BOW ACTIVATOR OF
SCHWARZ
• A.M. Schwarz in 1956. He was influenced by the elastic
properties of Bimler's appliance and some contributions from
the Wunderer's appliance.

• It consisted of an activator split into half horizontally and

connected by an elastic metal bow with a safety pin curve –
to absorb the shock of jaws during closing. There is a
possibility of activating only the bow on the side of a
unilateral distoclusion.

• Construction bite is minimal forward positioning of the

mandible. Appliance gets easily distorted and so results
achieved are minimal.
 THE REDUCED ACTIVATOR (OR)
CYBERNATOR OF SCHMUTH
• This was designed by Professor G.P. Schmuth of Bonn.
• Acrylic part is reduced for a manner similar to that of
bionator.
• Consists of labial wire and coffin spring (1.1mm)
• Slender acrylic part is split in the midline. This avoids
frequent breakages.
• Construction bite similar to that of an activator was
preferred. Head-gear tubes may be incorporated into the
appliance.
 THE KARWETSKY APPLIANCE
• Constructed with an improved technique and an apparently
increased efficiency

• Consists of maxillary and mandibular active plates joined

by a 'U' bow in region of 1st permanent molars. The plates
are extended over the occlusal surfaces.

• The height of construction bite is equal to inter occlusal

clearance.
Depending on the placement of the ends of the 'U' Bow 3
types have been created.

1. Type–I for Class II MO

2. Type–II for class III
3. Type–III to influence the mandible in a transverse
direction. Used in facial asymmetry (or) lateral cross-bite
cases.
• The appliance exerts a delicate influence on the dentition
and on the TMJ.

• Can be combined simultaneously with fixed appliance

particularly when there are severe rotations.

• With patient co-operation correction can be achieved rather

quickly 5 – 8 months in favourable cases.

• Duration of wear : atleast 3 hours during the day and

during sleeping hours.
 CUTOUT OF PALATE FREE
ACTIVATOR
• Developed by Metzelder.

• He combines bionator with original Anderson Haupl

activator.
• Mandibular part is the same as activator. In maxillary portion
acrylic covers only palatal or lingual aspect of buccal teeth.
There is no palatal coverage and coffin springs to lend
strength and stability.
• It can be worn both during day and night. Bite taken in edge
to edge incisal relationship. Different types of possibilities of
treatment are made according to the principles established by
Balter.
 ELASTIC OPEN ACTIVATORS
• This another daytime activators designed by G. Klammt of
Gorlitz The appliance consists of bilateral acrylic parts (an
upper and lower labial wire, a palatal arch and guide wires
for the upper and lower anteriors).

• EOA can be used for various MO including extraction

cases. Flat acrylic surface permits closure of spaces created
by extraction since there is no interference in the
interproximal area.
 ELASTIC ACTIVATOR FOR
TREATMENT OF OPEN BITE
BJO 1999 – Stellzig, Steegmayer
• The rigid intermaxillary acrylic of lateral occlusal zones is
replaced by elastic rubber tubes.

• By stimulating the orofacial muscular system by

ORTHOPEDIC GYMNASTICS (chewing gum effect).
Activators intrudes upper and lower posterior teeth.

• Possibility of eliminating habits by supplementary

incorporation of a CRIB.
• Treatment started in the mixed dentition.
• Worn for 14 hours per day, closure of the open bite
occurred within 8 months of treatment.
• Can be used alone or with HG or FA or as a retention
appliance.
• A noticeable counter clock-wise rotation of the mandible
was accomplished by a decrease of gonial angle.
 THE KINETOR

• It is also an elastic activator developed by Dr. HUGO

STOCKFISH in 1951.

• It was combination of functional principles with active

operation of various screws and spring added to the
appliance.

• It has the capacity to expand the arches in all 3 directions.

 THE PROPULSOR
• this was conceived by MUHLEMAN and refined by HOTZ.
It is described as a HYBRID APPLIANCE with features of
both monobloc and simpler oral screen or mask.
• Advantage of the propulsor over activator like appliances :Is
wide coverage and ability to effect changes in the alveolar
process.
• Useful in MAXILLARY DENTOALVEOLAR
PROTRUSION.
• Eliminating any functional retrusive tendencies and offsets
any functional dominance of posterior temporalis fibers seen
in class II div 1 MO.
• Construction bite : Similar to an activator but taken in a
more forward position
• No wire configuration are used with the propulsor
• As intermaxillary relation improves, the appliance is
reactivated (or) modified by adding acrylic to the area that
contacts the upper anterior segment.
• Acrylic between the occlusal surface of the first molars
serves to stabilize the appliance.
• As treatment progresses, acrylic is removed progressively
to allow for unhindered eruption of molar, thereby
reducing in the overbite.
 HYPER PROPULSOR ACTIVATOR
1985 Feb – George Gaumond)

• The splint hyperpropulsor activator combined with extra oral

force is useful in young children with severe overjet and
overbite who suffer from fractured maxillary incisors at an
early age (between 6 to 9).

• Appliance is simple, sturdy, well tolerated, acts quickly (6 to

10 months), inhibits thumb sucking, minimizes tipping of
incisors and occlusal plane and achieve stable results.

• Consists of a BIMAXILLARY BLOCK OF ACRYLIC

• One must register in wax the relationship of mandible with
maxilla in maximum hyper propulsion and mouth wide
open (the only limit the discomfort of the patient) incisal
edges of upper and lower incisors should be separated by
12 – 15 mm.
• By virtue of the thickness of acrylic (12-15mm) and a
high – pull E.O. force, this appliance works efficiently at
night and does not require day time wear.
• An anterior opening is built into the appliance to facilitate
breathing.
• Favours mandibular growth, it also inhibits maxillary
growth. Mandible is displaced anteriorly by the appliance
and exerts a posterior force on the mandible.
• Upper and lower incisor axes were not altered; occlusal
plane was not tipped due to the addition of E.O. force.
• Vertical dimension remained unchanged because acrylic
prevents molar eruption.
• Petrovic et al (1981) showed that HP is effective if
retrognathism is associated with anterior growth rotation.
 BONDED ACTIVATOR
• Designed by HAMILTON who termed it as an expansion
activation approach.

• This achieves dramatic and rapid correction.

• It is bonded to the maxillary arch and the forward guidance of

the mandible is achieved by proprioceptive guidance from the
lingual flanges of the appliances.

• There is no actual joining of maxillary and mandibular

arches. It is also useful in mixed dentition phase.
 COMBINED ACTIVATOR / HG
ORTHOPEDICS

• Prime target of treatment concept employing activator and

HG combination is to restrict developmental contributions
that tend towards a Skeletal class II and to enhance
developmental contributions that tend to harmonize the AP
relations of maxillo mandibular structures

• Hasmond introduced this concept in 1969.

• Pfeiffer Grobety (1975) attached facebow directly to the
activator and applied occipital traction (to prevent the
undesirable

• Kloehn effect of molar eruption and downward pull of

anterior end of palatal plane when cervical traction is used)
to achieve better vertical and rotational control during
orthopedic class II treatment.
• Thurow incorporated removable acrylic splint in the upper
arch to obtain enmasse control.

• Face bow was directly incorporated and occipital pull

applied to restrain downward and forward displacement of
maxillary complex

• Janson combines bionator with HG.

 Indications
• Correction of SK Class II discrepancy in growing patients
is the operational field of A/HG appliance.

• Reduction of anterior growth vector of maxillary complex

can be produced relatively well. HG treatment to upper
arch with heavy forces up to 1000gm per side for 16 hours
can elicit a maximal maxillary contribution.

• Indicated in SK Class II in which anterior movement of

chin prominence in desirable and atleast some posteriorly
directed maxillo dentoalveolar reaction is acceptable.
• Used for class II correction in deciduous, mixed and
permanent dentition

• High angle cases are particularly domain of this

combination.

• A/HG – well suited for RETENTION of a corrected class

II. Stability of the result will depend on the balance
between growth components of maxilla, dento alveolar
process and growth contribution of the condyles and
glenoid fossa. RELAPSE occurs if discordination persists
after treatment.
 Contraindications
• Dental class II situation with a SK. Class I profile should
not treated with this setup.
• Excessive vertical growth due to structural, muscular or
functional disturbance cannot be totally regulated with this
appliance.

• Best treatment timing – will be the EARLY MIXED

DENTITION stage.
• E.O. force levels
• 1. Full mixed dentition 300 to 400mg
• 2. Mixed dentition during exfoliation 150 to 250mg
• in the upper buccal segments
• 3. Full permanent dentition 400 to 600mg
• 4. Retention 150 – 400mg
• Two commonly used A/HG combination are
• 1. Pfeiffer Grobetty combination therapy.
• 2. Stockli Teuscher activator therapy.

• A sequence (or) a combination of sequences may be

required.
1. Preparatory intra-maxillary treatment (W-appliance, rapid
expansion (RME), utility arches).
2. Sk. Class II correction with A/HG.
3. Intra maxillary detailing and inter-maxillary co-ordination
(Full FA).
4. Retention of corrected class II with A/HG.
• Frequent combinations 1 & 2 or 3 & 4. In severe cases-
1,2, 3 & 4.
 MAD – MAGNETIC ACTIVATOR
DEVICE.
• Magnetic activator device can be used for correction of
• 1. Mandibular lateral deviation (MAD I)
• 2. Class II MO (MAD II)
• 3. Class III MO (MAD III)
• 4.Open bite cases (MAD IV)

• Magnetic force ranges from 150 – 600gms preside and

skeletal vs. dental response depends on the intensity of
magnetic force used.
• Optimum force for 7 to 12 yrs – 300 gms per side.
 MAD II – (AJO 1993 : 103 : Ali
Darendeliler and Jean Pierre Joho)

• Samarium Cobalt (Sm2 Co17) magnets of 4 x 4 x 6x 1 mm

dimensions were used.

• 30o inclination of occlusal surface of magnet to the basal

surface produces an OBLIQUE FORCE VECTOR to correct
class II MO.

• 4mm – buccolingual thickness is only 1mm larger than a std

edgewise br of the magnet – so size and shape are compatible
with vestibular shape.
• In class II cases with normal vertical proportions, magnets
are placed distal to upper canine and distal to lower first
premolars

• In class II deep bite situations, inclination of the magnets

and subsequent magnetic force orientation is such that to
produce dental extrusion in premolar – molar area located
more posteriorly and produce an ATTRACTING FORCE
between them
• In class II open bite situation, 2 pairs of lateral magnets is a
repelling configuration can be used posteriorly – to
produce molar and premolar intrusion, some distal
movements in upper arch, pushes the mandible downward
and forward.
• A pair of attracting magnets located at the retroincisal area
- help to achieve symmetry, align the upper and lower
midlines, stabilise the appliace against rippling forces.
 MAD IV for skeletal open bite (JCO 1995-
Sep Darendeliler & Semayuksel

• Consists of removable upper and lower plates.

• Uses NEODYMIUM (Nd2Fe17B) magnets coated with
stainless steel.
• Consists of 4 posterior repelling magnets which generates a
force of 300 gms each for introducing the molars.
• 2 anterior attracting midline magnets also generates 300 gms
force.
• It guides the mandible into centered midline position.
• Exerts an anterior closing effect.
• Enhances ANTERIOR ROTATION OF THE MANDIBLE.
• MAD IVa – used where anterior segment of maxilla is
vertically correct. (or) overdeveloped gummy smile.
Anterior magnets in contact.

• MAD IVb – used when additional extrusive effect is

needed in the maxillary anterior region. Anterior
magnets placed 2mm apart, posterior magnets in contact
• MAD IVc – used when only anterior extrusion is needed
posterior magnets are omitted. Anterior magnets 1-2mm
open

• SKELETAL OPEN BITE cases with high mandible plane

angles and overbite of –5mm to –1.5mm got reasonably
well corrected after wearing MAD IV on full-time basis
(except during meals).
 Conclusion
• The individualization of the basic concept of Andersen
night time application has given a number of clinicians the
opportunities to express their own biomechanical ability
and personal preferences for tooth moving appurtenances.

• It is believed that experience will dictate subsequent

modifications of functional appliances in achieving facial
balance and harmony during formative years of facial and
dental development.
 References
1. Dentofacial orthopedics with functional appliances (
Thomas - M.Graber, Thomas Rakosi, Alexander
petrovic)
2. Removable Orthodontic appliances (T.M.Grater Bedrich
Neumann)
3. Current orthodontic concepts and Techniques
(T.M.Graber, Brainerd .F.Swain)
4. Orthodontics - Current Principles and Techniques
(T.M.Graber, Robert L.Vanarsdall)
5. The Clinical management of Basic maxillofacial
Orthopedic Appliances (Terrance J.Spahl, John
W.Witzig)
6. Orthodontic and Orthopedic Treatment in the mixed
dentition (James -A. Mc.Namara, William L.Brudon).
• Activator's mode of action (AJO July 1959 Volume 45.
Paul Herren)
• Activator and Electromyographic study - (AJO - Aug 1988)
• Magnitude of forces generated by passive tension of soft
tissues (AJO -94-Feb)
• Effects of Activator therapy on Dentofacial structures (AJO
1989 - March. Final review - Bishara & Ziaji)
• Muscle activity during activator treatment (AJO - 1991 -
April) (Ingervall & Thuer)
• Dual bite - Phantum Activator phenomenon (JCO - 1983
May - Robert Shaye)
• Effect of Early Activator treatment in patients with class II
MO. (Evaluated by thin plate Spline Analysis)
(Christopher.J.Lux, Jan Rubel, Komposch - AO -
2001:71:120 - 126)