MODE OF ACTION OF

FUNCTIONAL APPLIANCES
CONTENTS (PART I)
INTRODUCTION
PRINCIPLESOF FUNCTIONAL
APPLIANCE THERAPY
CRANIOFACIAL GROWTH
COMPLEX RESPONSE
LPM RESPONSE
NEUROMUSCULAR RESPONSE
FORCES
Function is inherent in cells,tissues and organs and
influences these media as a functional stimulus.

The goal is to use this functional stimulus

,channeling it to the greatest extent the
jaws,tissues,condyles and teeth allow.

The uniqueness of the functional appliances lies in

their mode of force application.

They transmit,eliminate and guide the natural

forces.
Skeletal effects
Optimisation of condylar growth and forward
positioning of the mandible.
Enhanced growth of the head of the condyles.
Deflection in ramal form and reduction in gonial angle.
Remodelling of the CGF complex followed by
relocation.
Redirecting /restraining vertical and sagittal growth of
the maxilla.
Increase in lower anterior face height and improvement
in the overall ratio of the total anterior to posterior face
height.
Dentoalveolar changes
Mandibular dentoalveolar vertical development
and change of inclination in the occlusal plane.

Reduction in proclination of maxillary anterior

teeth and remodelling of the alveolus.

Transverse development of the maxilla and arch

expansion.
 PRINCIPLE
They help in furthering the growth of jaw bones
and thereby correct malocclusion when the
mandible is small or retrognathic or positioned
backward.

Stimulate and regulate perioral muscles and

muscles of stomognathic system thereby creating
favorable environment for growth of facial bones
and dentition.
Bring about orthopaedics changes,the philosophy
which was founded by Andersen and Haupel
(1936) called as functional jaw orthopaedics.

The TMJ of young indivisuals can adapt to new

positions acquired by mandible when it is held by
the appliance in a new position.

Induce skeletal growth modifications when used

during periods of active growth of a child.
 CAUSAL CHAIN
 Functional appliance

 Increased contractile activity of the LPM.

 Intensification of the repetitive activity of the retrodiscal

pad (bilaminar zone)

 Increase in growth stimulating factors

 Enhancement of local mediators

 Reduction of local regulators(factors having negative
feedback effects on cell multiplication rate)
 Change in condylar trabecular orientation.
 Additional growth of condylar cartilage.
 Additional subperiosteal ossification of the
posterior border of the mandible.

Supplementary lengthening of the mandible.

Temporary opening of the Stutzmann’s angle

 CGF REMODELLING
Recent studies evaluating the effect of functional
appliance therapy on CGF remodelling using MRI
have documented both internal and external
rearrangements of the CGF caused by FA’s.

Condyle assumes an anterior position during the

therapy .

Italso alters its internal relation with articular disk

and CGF complex.
This position when maintained during stabilization
period relocates the CGF in a relatively anterior
position which normalises the condyle fossa
relation and internal arrangements with disk and
soft tissues.
The retrodiscal pad also called as the “metabolic
pump” of the articular disc controls mandibular
growth in two ways-

Its vascular component controls the condylar

cartilage growth rate and endochondral
ossification rate.
An increase in iterative activity of the
retrodiscal pad produces an increase in condylar
cartilage growth and endochondral ossification.
The increase in the iterative activity of the disk
produces an accentuation of the ramus posterior
border concavity and a local increase in bone
apposition.

Italso produces accentuation of the ramus

anterior convexity and a local increase in bone
resorption.

Italso partly mediates the stimulating effect of

the contractile activity of the LPM on the
condylar cartilage growth.
CONDYLAR HEAD MORPHOLOGY
The appearance of notching in the anterior aspect.

Rounding of posteriosuperior surface of the condyle

head.

FA therapy doesnot cause any long regenerative or

degenerative change in the CGF complex.

Instead it inhibits the natural posteior inferior growth

and causes it to relocate in a more anterior position in
the cranium.
 GROWTH RELATIVITY
HYPOTHESIS
Itrefers to the growth that is relative to the displaced condyle
from actively relocating fossae.

Voudouris and Kuftinec hypothesised that when condyle is

displaced from the fossa extrinsic signals are derived from
tissues surrounding it.

Which serve as stimulus to the fibrocartilage on the condylar

head to undergo growth modification.

Itsupports the fact that the enhanced condylar growth is a result

of some extra condylar signals following growth of soft tissues.
The foundation of growth relativity is based on
following three main foundations-

 Displacement affects fibrocartilage lining in the

glenoid fossa to induce bone formation.
 Followed by stretch of non viscoelastic tissues.
 Non viscoelastic tissues incluse all non calcified
tissues;synovial fluids and retrodiscal
tissues,fibrous capsule including LPM
,perimysium,TMJ tendons and ligaments.
 New bone formation some distance from the
actual retrodiscal attachment in the fossa.
The CGF modification that occurs is the outcome
of a combination of factors,stimulus to which is
derived from extrinsic stimulus in the following
sequence-

Displacement of the mandible from temporal fossa.

Viscoelastictissue extension forces to the condyle

through several attachments.

Transduction of forces radiating beneath the

fibrocartilage of the glenoid fossa and codyle.
 LOCAL SIGNALS AFFECTING
CONDYLAR CARTILAGE
Electron micrographs show-

Cytoplasmic junctions between skeletoblasts become

quantitatively reduced.

Consequently inhibitory intercellular communications

are reduced;the cell division rate increases.

Rate of prechondroblast differentiation also increases.

Consistent transmembrane ion flux variations are
seen

 Intracellular Na˖conc is raised

 Intracellular K˖ conc is lowered
 Discharge of H˖ from prechonroblasts is increased
 Leading to an increase in intracytoplasmic pH
Calmodulin and Calcium,Magnesium –
ATPase,H˖-Adenosine triphosphatase ativities
are promoted.

Whereas cAMP,fibronectin,heparan sulfate and

glucosaaminoglycan activity is reduced.

The cumulative effect being that of cell division.

Intensificationof retrodiscal pad activity is
associated with an increase in blood and lymph
flow.

Decrease in cell catabolite concentration and

negtive feedback factors.

These changes enhance the supplementary

growth of the condylar cartilage caused by
functional appliances.
LPM RESPONSE
 LPM is considered as the major intermediary in
maintaining the optimum occlusal adjustments during
growth and in facilitating the action of functional
appliance.

 Petrovic and coworkers and Mc Namara have

demonstrated that the increased activity of the LPM is
associated with enhanced condylar growth response.

 However some other investigators have reported a

initial decrease in activity of LPM from 6th to 18th week
following insertion of appliance.
The superior head of LPM appears to be the
principle muscle to function as forward
positioner of the mandible which is evident by
enhanced EMG activity.

This new functional pattern first appears in

association with phasic activities such as
swallowing and then during tonic functions as
maintenance of mandibular postural position.

Then there is a gradual return towards the

preappliance levels of muscle activity.
Petrovicet al (1982) showed the adaptive response
of muscle to hyperpropulsion of the mandible by
means of foreshortening the LPM to hold the
forward posture.

Mc Namara 1973 described the reaction of the

condylar structures to muscle strain in the
compensatory adaptibility and reestablishment of
the original muscle activity.

This reactive process is not only biomechanic but

also is a neurotrophic response.
 Experimental studies were carried out by James McNamara
on animals.

 The EMG studies of temporal ,orbicularis oris ,suprahyoid

muscles and the superior head of the LPM were taken at
intervals during observation.

 Findings suggested that the changes in maxillomandibular

relationship were outcome of adaptations that occurred
throughout the craniofacial complex.

 The superior head of the LPM appeas to be the principle

muscle to function as forward positioner of the mandible as
evident by enhanced EMG activity.
Studies carried out at the University of Toronto
with chronically embedded implants have shown
that LPM activity remains depressed for 18 weeks
following insertion of functional appliance.

Sessle et al demonsrated that with functional

appliances the activity of the superior and the
inferior heads of the LPM ,anterior digastric and
masseter muscle remains significantly decreased
upto 6 weeks and then gradually returned to
normal.
Controversies
concering increased activity of the
LPM have long been debated.

There are reports on increased activity of the

superior head of the lateral pterygoid muscle on
EMG recordings and contradictory reports on
reduced EMG activity with chronically implanted
electrodes.
 Neuromuscular response
 The success of functional appliance therapy depends on
neuromuscular response.

 Children with neuromuscular diseases such as polioyelitis

and cerebral palsy cannot be treated with functional
appliance therapy.

 The insertion o functional apliance causes alteraton of the

exteroceptive and proprioceptive stimuli from orofacial
area.

 The muscles of mastication ,suprahyoid and in and around

oral cavity including tongue and soft tissues that drapes the
face are forced to assume new position.
The muscles that have been elongated within
physiologic limits would try to re establish a
functional harmony by a continuation of
following mechanism.

 Elongation of muscles fibres themselves

 Occurrence of changed muscular dimensions due
to displacement and rotation of bony elements.
 Migration of muscle attachments along bony
surfaces.
 Establishment of new neuromuscular feedback
mechanism.
FORCES
All functional appliances take advantage of the
interaction between mechanical function and
morphologic design
Use the common mechanisms of bone turnover
rhythm,activation,resorption and formation.

The forces employed in orthodontic and orthopaedic

procedures are
 Compressive
 Tensile
 Shearing
Mechanical appliances usually use compressive
forces and pressure strain.

Tensileforces cause stress and strain in function

appliance therapy.

They also alter the stomognathic muscle balance

.
Both external(primary) and internal (secondary) forces
can be observed in each force application.

Externalforces are the primary motivating influences

harnessed by functional appliances.

They include various forces acting on the dentition

such as occlusal and muscle forces from the tongue,lip
and cheeks.

A primary objective of the FA is to take advantage of

the natural forces and transmit them to selected areas
to produce the desired change.
Internal forces are the reaction of tissues to primary
forces.

They strain the contiguous tissues, leading to the

formation of an osteogenetic guiding structure(i.e.
deformation and bracing of the alveolar process).

This reaction is important for secondary tissue

adaptation.

The strain and deformation in tissue results in

remodelling,displacement and all the other alterations
that can be achieved by loading and unloading of the
teeth in alveolar process.
A force can produce the desired orthodontic effect
only if it has a certain-
 Duration
 Magnitude
 Direction
Duration of the force in most functional appliances is
interrupted because the appliance is usually not worn
constantly (12-16 hours per day).

Direction of the force for the movement of the teeth

should be consistent whether a stress or strain.

Functional forces may stimulate the tooth movement in

one direction but the forces of intercuspation and
occlusion may drive the teeth in the opposite direction
while the appliance is not being worn-JIGGLING
EFFECTS.

Need to be eliminated
The Magnitude of force is small in functional
appliance therapy.

Ifthe induced strain is too great ,the patient has

difficulty wearing the appliance.

Aplication of heavy forces(headgear)is not

feasible for pure functional appliances.
 TREATMENT PRINCIPLES
Applied force can be compressive or tensile.

Depending on the type applied two treatment

principles can be differentiated

 Force application
 Force elimination
Force application
Compressive stress and strain act on the
structures involved ,resulting in a primary
altertion in form with a secondary adaptation in
function.

Allactive fixed and removable appliances work

according to this principle.
Force elimination
Abnormal and restrictive environmental influences are
eliminated ,allowing optimal development.

Function is rehabilitated and followed by a secondary

adaptation in form.

During the elimination of pressure a tensile strain can arise

as a result of the viscoelastic displacement of periosteum
and the bone forming response in affected areas.

Tension can be more effective than pressure because most

bony structures are designed to resist pressure but not
tension.
 Tooth movement may be achieved using either of these
principles .

 The teeth move if the balance of the forces acting on the

them is altered.

 Balance can be altered by the application of a

complementary artificial force of mechanical or muscular
origin.

 If one of the compenents of the total force acting on teeth

in three planes is eliminated ,the teeth respond to the
reduced force by setting up a new balance (the force
elimination).
Both the force elimination and force application
can cause alteration of the strain distribution in the
bone and the induction of bone remodeling and
tooth movement.

Functional forces can incite sensory stimulations

to trigger a neuromuscular response.

Ifthe posture of the mandible is altered

,neuromuscular adaptibility to the new spatial
skeletal relationship is possible only with the help
of sensory input.
 ACTIVATOR
Andresen developed a mobile loose fitting
appliance that transferred functioning muscle
stimuli to the jaws,teeth and supporting tissues.

Impressed with the result obtained by Andresen’s

functioning retainer Haupl got associated with him.

Haupl believed the clinical validation of the

appliance and they both termed it as an Activator
;because of its ability to activate the muscles.
The mandibular growth promotion by the activator
is qualified by the term INDIVISUAL OPTIMUM.

That is the activator cannot create a large mandible

from a small one ,but it can help the patient
achieve the optimal size consistent with the
morphogenetic pattern.

Haupl considered this as the goal of the treatment

of activator.
Rigid one piece appliance
 Do not permit muscle shortening and therefore the
contractions that arise are isometric.
 A long lasting tonic stretch reflex contraction is
elicited.

Elastic appliance
 Permit muscle shortening
 Less force is required
 Stretch produces a transient phase reflex
contraction.
 Efficacy of activator
Effective in exploiting the interrelationship between
function and changes in internal bone structure.

Induces musculoskeletal adaptation by introducing a new

pattern of mandibular closure.

Condylar adaptation to the anterior positioning of the

mandible consists of growth in upward and backward
direction to maintain the integrity of the TMJ structures.

This adaptation is induced by a loose appliance.

The construction of the bite does not open the
mandible beyond postural rest position (i.e.
generally not more than 4mm or a small bite
opening).

Myotactic reflex activity is stimulated ,causing

isometric muscle contractions.

Thismuscle force transmitted by the appliance

moves the teeth.

Thus the appliance works by using kinetic energy.

 Classification of views
Petrovic 1984 and McNamara 1973 substantiated
the Andresen -Haupl concept that myotactic reflex
activity and isometric contractions induce
musculoskeletal adaptation by introducing a new
mandibular closing pattern.

Such adaptation is only possible with a small bite

opening(upto 4mm,Grudge).

The superior heads of the LPM have the most

important roles in this adaptation because they
assist in skeletal adaptations by activating the
condylar heads.
This effect is brought about by the loose fitting or
the nonsplinting type of appliance design.

An appliance rigidly holding the mandible

anteriorly cannot activate the muscles and hence
no stimulus is provied to the condyle for growth.
Second working hypothesis Selmer-Oslen-Herren
1953 Harvold 1974 and Woodswide 1973.

According to them the visoelastic properties of

muscle and the stretching of soft tissues are
decisive for activator action.

Secondary forces arise in the tissues introducing a

bioelastic process.

Depending on the magnitude and duration the

visoelastic reaction can be divided into the
following stages.
 Emptying of vessels

Pressing out of interstitial fluid

Stretching of fibers

Elastic deformation of bone

Bioplastic adaptation
The proponents of this theory recognize only a modest
skeletal adaptation in the vertical plane and no
alteration in the sagittal plane.

According to Woodside eliciting a stretch of the soft

tissues primarily requires dislocating the mandible
anteriorly or opening beyond the postural rest vertical
dimension(Herren incisal crossbite and woodside 10-
15mm).

The overextended activator,stretching the soft tissues

like a splint ,induces no myotactic reflex activity but
instead applies a rigid stretch and creates a buildup of
potential energy.
A third approach applies the modes of action of the
preceding two.
It can be called a transitional type of activator
action.
The appliance in this group have a greater bite
opening than Andresen and Haupl recommend ,but
they do not overcompensate as Woodside
recommends.
The stretch reflex resulting from activators in this
group is seen as a long lasting contraction.
Both the occurrence of isometric and isotonic
contractions are observed in this design.
They use an opening of 4-6mm believing that the
ultimate decision as to whether the force delivered
is kinetic energy or potential energy or a
combination of both depends on
 Nature of malocclusion
 Interocclusal clearance
 Head posture
 Skeletal effects
Any skeletal effect from the activator depends on
the growth potential.

Two divergent growth vectors propel the jaw bases

in an anterior direction-
 The sphenooccipital synchondrosis moves the
cranial base and nasomaxillary complex up and
forward(upper growth vector)
 The condyle translates the mandible in a downward
and forward direction(lower growth vector)
The activator is most effective in controlling the
lower vector or the downward and forward growth
of the mandible.

Thiseffect is designated as Articular since the

condylar growth is redirected.

Johnston(1976) attributed this response as to

“Unloading the condyle”.
Activtor can control the upper growth vector only
to a limited degree.

Upper growth vector supplied by the

sphenoccipital synchondrosis which moves the
maxillary base forward.
Types of force employed

1. The growth potential ,including the eruption and

migration of teeth –produce natural forces.

2. Muscle contractions and stretching of the soft

tissues-initiate forces when the mandible is
relocated from its postural rest position by the
appliance
 The activator transforms and stimulates the
contractions.
 These can be effective in all the three planes
Sagittal plane

 Mandible is propelled down and forward.

 Muscle force is directed to the condyle and strain

is produced in the condylar region.

 A slight reciprocal force can be transmitted to the

maxilla during this maneuver.
Vertical plane

Teeth and alveolar processes are either loaded with or

relieved of normal forces.
If the construction bite is high ,a greater strain is
produced in the contiguous tissues.
If transmitted to the maxilla ,these forces can inhibit
growth increment and direction and influence the
inclination of the maxillary base.

Transverse plane

• Forces can also be created with midline corrections.

 Construction bite
Mode of force application magnitude and direction
depend on 3D dislocation of the mandible which is
determined by the construction bite.

This allows mandibular manipulation to relocate

jaw in the direction of treatment and creation of
artificial functional force.
General rules
Forward positioning of the mandible of 7-8mm
and vertical opening must be 2-4mm.

Ifthe forward positioning is no more than 3-5mm

vertical opening should be 4-6mm.

However it should not exceed 7-8mm or three

quarters of the mesiodistal dimension of first
permanent molar.
Ifmagnitude of forward position is great, vertical
opening should be less so as to not overstretch the
muscles.

Lower midline shifts can be corrected only if

actual lateral translation of the mandible exists.

Usual intermaxillary relationship for average class

II problem is end to end incisal relationship.
 Low construction bite with markedly
forward mandibular positioning
H activator
Mandible positioned anteriorly to achieve edge to
edge relationship.
Constructed with a low vertical opening.
Mandible can be postured forward without tipping
tha lower incisor labially and the maxillary incisor
can be positioned upright and the anterior growth
vector is inhibited.
Mandible moves mesially to engage the
appliance ,the elevator muscles mastication are
activated.
Reflex stimulation of the muscle spindle generates
High construction bite with slightly anterior
positioning
V activator
Mandible is positioned less anteriorly only 3-5mm
ahead of habitual occlusal position.
Vertical dimension is opened 4-6mm.
Indicated in cases with vertical growth pattern.
Appliance induces myotactic reflexes in muscles of
mastication.
Stretching of muscles and soft tissues elicits force.
Response of visoelastic properties of soft tissue and
stretch reflex activation due to increase vertical
dimension(even when the patient is relaxed)
 Construction bite without forward
mandibular positioning
Indicated in cases of deep bite and open bite.

Deep bite-the opening is beyond 5-6mm freeway

space (WOODSIDE,1984).

Open bite-the bite is open 4-5mm to develop a

significant elastic depression force.
 Construction bite with opening and posterior
positioning of the mandible

Class lll
Bite is taken by retruding the mandible
Mandibular incisors approximate in an end to end
contact
Vertical dimension is opened far enough to clear
the incisor guidance(3mm)
Allows the condyle to drawback in the fossa.
 FRANKEL REGULATOR-The
philosophy
 A larger part of the appliance is confined to the oral
vestibule.
 The buccal sheilds and the lip pads hold the buccal and labial
musculature away from the teeth and investing tissues
eliminating any possible restrictive influence from the
functional matrix.
 Frankel concieves his vestibular constructions as an artificial
“ought to be” matrix that allows the muscles to exercise and
adapt.
 Protection from constant neuromuscular constriction of the
dentition particularly mesial to the decidous second molars
provides the possibility of expansion.
Buccinator mechanism pressures are screened
from the dentition.

Significant expansion may occur in the critical

intercanine dimension.

Exercise device stimulating normal function while

eliminating the lip trap ,hyperactive mentalis and
aberrant buccinator and orbicularis oris action.
 Buccal sheilds and Lip pads
The FR buccal shields prevent the pressure of the
buccinator mechnaism on the dentoalveolar area.

The net effect is outward expansion to the “ought to be”

acrylic shield functional matrix.

The pad serves as a proprioceptive signal and pressure

bearing area for maintenance of mandibular propulsion.

The vestibular acrylic and wire configuration augment this

propioceptive trigger hence maintain forward posturing.
Buccal shields and lip pads prevent deforming muscle action and
permit the teeth to erupt down and outward.

Shield and pads are extended into the depth of the vestibule
putting the tissue under tension.

Thistension exerts a pull on the periosteal issue of the maxillary

bone.

And this elicits increase bone activity in the contiguous osseous

stuctures.

The maxillary bone is widened as the thin alviolar shell over the
erupting teeth proliferates laterally.

Hence apical base widening is seen.

Likethe buccal shields the lip pads eliminate
abnormal perioral muscle activity particularly
hyperactive mentalis activity.

Periostal pull occurs labially from the lip pad

pressure in the anterior vestibular depth that exerts a
bone growth stimulus reducing mentolabial sulcus.

Another function is by forming the labial boundary

of the mandibular posturing trough with the lingual
loops,(acrylic pads) ,maintain mandible in forward
construction bite.
Lip pads in FR lll are situated in the labial
vestibular sulcus of the upper incisor segment
instead of the lower segment.

The purpose are three fold-

 To eliminate restrictive pressure of upper lip on the
under developed maxilla.
 Exert tension on the tissue and periosteal
attachment in the depth of the maxillary sulcus for
stimulation of bone growth.
 To transmit upper lip force to the mandible by the
low labial arch for a retrusive stimulus.
 Mandibular lingual bow
Objectiveis to provide a proprioceptive signal to
the mandible in a forward position.

Mandible is held forward by the protracting

muscles and not the appliance itself.

There is bilateral foreshortening of the LPMs and

leads to permanent change in the muscles.
 BIONATOR
Balters in 1960 developed the original appliance
on the theoretic principles of Robin,Andresen and
Haupl.

Appliance was designed to take advantage of the

tounge posture.

The tongue acted as the center of reflex activity in

the oral cavity and was the most important factor
in the treatment.
Bionator positions the mandible anteriorly with the
incisors in an edge to edge relationship.

Forward positioning of the mandible enlarges the

oral space ,bringing the dorsum of the tongue into
contact with the soft palate and helped accommplish
lip closure.

The principle of treatment with the bionator is not to

activate the muscles but to modulate the muscle
activity thereby enhancing the normal development
of the inherent growth pattern.
Myotactic reflex activity with isotonic muscle
contraction is stimulated and the loose appliance
works with kinetic energy.

The visoelastic properties are generated only in the

sagittal direction.

The appliance exerts a constant screening effect on

the perioral muscles and the tongue because of the
labial bow and the its lateral extension.
 TWIN BLOCK
Are simple bite blocks that effectively modify the
occlusal inclined plane.

Functional mechanism is very similar to that of

natural dentition.

Appliance achieves rapid functional correction of

the malocclusion by transmitting favourable
occlusal forces to the occlusal inclined planes
covering the posterior teeth.
Correction of maxillomandibular relationship by
guiding the mandible(occlusal inclined planes)
forward into the correct occlusion.

Designed for full time wear so that maximum

advantage of all the functional forces applied to
the dentition can be taken.
The unfavorable cuspal contacts of distal occlusion
are obstructions to normal forward mandibular
translation in function.

They restrict the mandible to achieve its optimal

genetic growth potential.

Moreover in a mandible occluding in a distal

relationship the inclined planes formed by the
cusps of the upper and the lower teeth in occlusion
represent a “servo mechanism” that locks the
mandible in a posteriorly occluding functional
position.
Functional
therapy by the twin block is based on
the FORM AND FUNCTION PHILOSOPHY.

The challenge is to maximize the genetic potential

of growth and guide the growing face and the
developing dentition.

The occlusal forces transmitted in the forwardly

positioned mandible provide constant
proprioceptive stimuli to influence the growth rate
and trabecular structure of the supporting bone.
The twin block technique has two stages-

 Active phase- use posterior inclined planes to

adjust the vertical dimension and correct the
malocclusion by functional mandibular
positioning.

 Support phase -an anterior inclined plane is used

to retain the corrected incisor relationship until the
buccal segment occlusion is fully established.
 Bite registration
A protrusive bite is registered to reduce the overjet and
distal occlusion by 5 to 10 mm on initial activation.

Onthe incisors the bite is activated edge to edge with a

2mm interincisal clearnce .

In vertical dimension this 2 mm clearnce is equal to 5-

6mm clearance in the 1st premolar region and 2mm
clearance distally in the molar region.

Larger overjets(more than 10mm) require reactivation.

 Reactivation
Larger overjets >10 mm ,that cannot be corrected
by a single activation(beyond the physiological
limits of the musculature).

Initial
construction bite is taken to partially correct
the overjet.

Reactivation is achieved by adding cold cure

acrylic to extend the anterior incline of the upper
twin block mesially.
First activation is in the range of 7-10 mm.

Second activation is done by bringing the incisors

in an edge to edge relationship.
 Control of vertical dimension
Deep bite
Edge to edge incisor relationship with intericisal
clearance of 2mm.
Overbite reduction is done by trimming the
occlusal cover on the upper twin block
occlusodistally to encourage the eruption of the
lower molars.
The occlusion over the lower molars is cleared by
1-2mm only.
This clearance is sufficient to allow eruption of
lower molars but not for the tongue to pass between
the teeth and impede their eruption.
Openbite

All posterior teeth must be in occlusal contact with

the opposing bite blocks to prevent overeruption.

Ifsecond molars erupt distal to the appliance , their

eruption should be controlled by placing occlusal
rests or by extending the upper twin block distally.
 Clinical response
Within a few days of fitting the appliance the position
of the muscle balance is altered.
Patient experiences pain while retracting the
mandible-PTERYGOID RESPONSE(McNamara
1980)
Or the formation of a “tension zone” distal to the
condyle (Harvold and Woodside)
The response is due to tissue proliferation to fill in the
area behind the condyle.
Connective tissue and blood vessels apparently
proliferate in the retrodiscal attachment within minutes
or hours of fitting a full time functional mechanism
activated to advance the mandible.
 Angulation of the inclined planes
Normal angulation of the inclined planes is at 70
degrees
This angle applies a more horizontal component of
force.
Such a force encourages more horizontal
mandibular growth.
In cases where the patient has difficulty in forward
posturing of the mandible the angulation can be
reduced to 45degrees.
In this case an equal amount of downward and
forward component of force is applied.
 Conclusion
Simple and sturdy functional appliance designs
are more effective and acceptable.

Activator and twin block have an advantage in

this regards unlike the Frankel regulator.

Vertical control is the key element,

Advantage of a functional appliance is the in

general is the control of eruption they provide.