1985 Australian Orthodontic Journal, Melbourne

C3 1985 Australian Orthodontic Journal, Melbourne
nt question is whether functional appliance therapy is capable of producing

clinically significant changes in the human dento-facial complex under realistic treatment
conditions. Another question is whether the different designs of functional appliances have
differing modes of action, and, if so, how does the clinician select the one most appropriate for the requirements of the
case in hand, and when?
Current knowledge of the responses elicited by functional appliances is reviewed.
Descriptions of the "ideal" patient for each appliance is given, along with indications and contraindications.
Specific associations are emphasized, such as vertical control and Teuschers, decrowding and FfZnkels, Herbst and
breakage prevention, retention and Bionators. Case reports are also presented to help the selection process.
s :functional appliances, selection, timing, activator, Teuscher, Frankel, Herbst, Bionators
deliberate primary impact is delivered to the musculature

with the intention of creating an improved local
The original objective of orthodontic treatment was to environment for the develooinq dental arches and
recreate normal dental occlusion. In contemporary growing jaw bones. The neurokuscular activity generated
orthodontic therapy this remains a fundamental goal, but by functional appliances is tapped to alter stress on the
decades of clinical research has increased rather than teeth and jaws. This represents a comprehensive
decreased the complexity of the problem. The three approach to orthodontic treatment because the three
primary correlates of human dental occlusion are : major developmental processes are subjected to some
1. Dentitional development degree of control.
2. Craniofacial growth Many experimental studies have identified the
3. Neuromuscular maturation and function. close interaction between muscle function and the internal
These three factors, while constantly interrelated in and external structure of bone. (Woodside et al 1983)
function nevertheless develop on different time schedules. One of their conclusions was that "chronic or continuous
The development of occlusion is therefore one of the alteration in mandibular position within the
most fascinating and complicated problems in all of neuromuscular environment produces extensive condylar
developmental biology, presenting the orthodontist with remodelling and change in mandibular size".
a n enormous challenge. The controversy which prevails is not whether
When clinicians focused their attention on only the
first of these factors, appliance systems evolved which
rendered symptomatic treatment for developmental
deviations and irregularities in the oro-facial complex. In
order to move teeth, the physical forces generated by
orthodontic appliances were distributed to the teeth and
this initiated remodelling of the dento-alveolar structures.
Extra-oral forces were added to these intraoral
appliances, originally to supplement anchorage, but
subsequently it was found that there was a modification
of the normal growth behaviour of the maxilla. (Poulton
1967, Weislander 1974)
For a considerable period, this was regarded as the
only orthopaedic possibility in orthodontic treatment.
The size and position of the mandible were
generally agreed to be immutable, and discrepancies in
maxillo-mandibular relationships in Class I1 cases were
routinely treated by modifying the forward growth of the
maxillary teeth and/or the maxilla. This application is
appropriate for patients with prognathic maxillae, but is
quite unsuited to patients with normal maxillae in
combination with deficient mandibles. Moyers (1980)
found that the incidence of this latter group within the
Class I1 population is approximately 70%, a much higher
figure than was formerly recognized. McNamara (1981)
confirmed this finding. Within his group of 277 Class I1
children, only 27% had prognathic maxillae while 50%
had retruded maxillae. Sixty percent of the group were
found to have retruded mandibles.
These findings highlighted the limitations of
conventional orthodontic systems, and led orthodontists
to re-examine the potential of functional appliance
therapy. The feature of functional therapy which sets it
apart from other orthodontic philosophies is that a
Roberts - Functional Appliance selection Aust Orthod J , 9, March 85
alteration in muscle function produces changes in bone

morphology, but rather whether functional appliance
therapy is able to produce clinically significant changes in
the human dento-facial complex under realistic treatment
conditions. Another question arises as to whether the
different designs of functional appliance have differing
modes of action, and, if so, how does the clinician select
the one most appropriate for the requirements of the case
at hand.
These questions will be addressed in a discussion on
treatment experiences with three types of functional
appliance:
1. Activator appliances
2. Ffankel appliances
3. Herbst appliance.
4. Bionator appliance
The first two and last are removable, while the
Herbst appliance is fixed but they all have the effect of
changing the position of the mandible within a muscle
system.
It should be stated clearly that functional appliance
therapy does not stand in opposition to conventional
multi-band fixed appliance therapy. Rather, the two
systems frequently combine to fulfil1 treatment objectives
otherwise unattainable. However, for the sake of clarity,
cases illustrated in this article have been selected because
they show responses to functional appliances only, and
there has been no contribution from fixed appliances to
the stage shown. Subsequently of course some cases
underwent final detailing with fixed appliances.
A
These appliances were so named because they were felt
to activate the muscles, which in turn, activated the
appliance.
There has been a resurgence of interest in the activator in
the last decade or two, encouraged by the attainment of
favourable occlusal and facial changes (Figure 1).
Andresen's original design of 1908 is still in
common use although subsequent innovations have
attempted to either reduce the bulk of the appliance to
enable longer wearing times, o r to supply elastic elements
which reinforce or extend the range of muscular impulses.
The application of directionally controlled extra-oral force
adds an element of sophistication in terms of
management of the maxilla and, in vertically growing
cases, this has a favourable impact on the development
ible, as will be discussed later.
eti
The mode of action of the activator appliances is
controversial, but some of the proposed mechanisms of
action are summarized below;
1. Re-education of the musculature.
Andresen hypothesized that by continually holding the
mandible forward in Class I1 cases the muscles would be
obliged to learn a new functional pattern. Gradually the
teeth and jaws would adapt to the new jaw relationship
prescribed by the appliance.
2. Lateral pterygoid muscle stimulation.
Obligatory mandibular protrusion has been found, in
experimental animals, to be associated with increased
electromyographic activity in the superior head of the
lateral pterygoid muscle. Coordination of
electromyographic readings with measurements of
condylar growth reveals a close relationship, indicating
that skeletal adaptation proceeds until muscle activity is
restored to normal levels. (McNamara et al, 1975).
3. Decreased biochemical feedback.
Stutzmann and Petrovic (1979) found that the zone of
functional chondroblasts in the rat condyle normally
secretes a substance which retards mitotic activity of the
stem cells. When the lateral pterygoid is activated by an
appliance, the functional chondroblasts mature more
quickly, consequently secreting less "negative feedback"
substance. By removal of this biochemical "brake",
acceleration of condyle growth is permitted.
4. Unloading of the mandibular condyle.

The mandibular condyle is normally subjected to pressure
which is one component of the local homeostatic
mechanism controlling its growth. When an appliance is
used which distracts the condyle from the fossa this
pressure restraint is removed, thereby facilitating a n
increased rate of growth.
5. Transduction of visco-elasticforce.
Some authorities are skeptical of the efficacy of the
muscle generated forces created by increased biting and
swallowing when an activator is in place. Instead, they
harness the passive tension arising from the inherent
elasticity in muscle, skin and tendonous tissues and
transmit this to the maxillary teeth engaged in the
appliance. Accordingly, extreme vertical registrations are
frequently employed.(Woodside, 1977)
6. Differential Eruption.
Harvold (1974) has shown that the divergent directions of
eruption of the maxillary and mandibular molars can be
altered by the appliance to create the molar relationship
desired. For example, in Class I1 treatment, the acrylic
platform can be adapted to arrest maxillary molar
eruption, yet allow concomitant mandibular molar
eruption into Class 1 relationship. In Class 111 activator
treatment, the converse would be applied.
There are a number of reports concerning the effects of

the activator on the growing human dento-facial complex.
Marschner and Harris (1966) published results
which suggested that activator therapy permitted a more
rapid rate of mandibular growth in the treated sample.
Meach (1966) found a significant increase in the facial
angle in his activator group. Freunthaller (1967) claimed
that activator treatment produces an increase in
mandibular growth as evidenced by a greater opening of
the angle between the palatal plane and the facial plane.
Demisch (1972) reported that the forward movement of
the upper arch is stopped or reversed by the activator
therapy, while half of his cases showed an increase in the
growth rate of the mandible. Hausser (1973) found an
increase of the Basion to Pogonion distance in activator
patients. He concluded that the activator "can exercise a
lasting influence on the sagittal development of the lower
jaw when it is used early enough in the treatment of
Class I1 malocclusion" and that the results of treatment
"arise mainly from mandibular transformation."
Luder (1981) appears to have been the first to
report a sex difference in the response to activator
treatment. This may explain the variable results from
mixed studies. Boys showed increased condylar growth
expressed in a modified direction, with n o posterior
rotation. Girls experienced a change in the direction of
condylar growth, with n o change in the amount of
growth.
Baumrind et a1 (1981) contrasted the treatment
effects of cervical and high-pull headgears with those of
the activator. They found that the condyle to pogonion
distance increases relative to the Sella-nasion distance at
a more rapid rate in the activator group. A conclusion put
forward was that "these findings argue strongly that the
activator does, in fact, produce biological activity in the
region of the condyle." In a later study [Baumrind et al,
1983 a) they found that of the total displacement of the
maxillary molar, half of the change was orthodontic and
half was orthopaedic. Restraint of the normal
displacement of the anterior nasal spine was also
reported. In their most recent study (Baumrind et a1 1983b)
these workers reported specifically on the movement of
the chin point in response to the three forms of therapy.
When the effects of normal growth were subtracted to
leave treatment effects only, it was revealed that the
largest displacement of pogonion actually occurred in the
cervical headgear group. However the direction of
displacement was primarily vertical, in contrast to the
activator group where the growth was expressed in a

more horizontal direction.
Van Beek (1982) used Harvold's parameters of
facial growth to express his findings. The difference
between the effective mandibular length and the effective
maxillary length increases at a normal rate of 1mm per
year. In Van Beek's activator patients, this distance
increased at a rate of 3mm per year. Birkebaek (1984)
recently measured remodelling changes in the fossa as
well as those involving the condyle. She found that the
activator cases experienced a n increase in the amount of
condylar growth and an anterior remodelling of the fossa.
In summary, the reported anteroposterior effects
of the activator are :
1. A forward displacement of the lower arch
2. A distal movement of the maxillary arch
3. An inhibition of the forward growth of the maxilla
4. A stimulation of condylar growth
5. A remodelling of the mandibular fossa
6. An elimination of interferences which guide the
mandible distally during closure.
The vertical effects of activator treatment have
been studied by Andersson and Ahlgren (1977).
Successful overbite reduction was found to be
accompanied by :
1. Inhibition of lower incisor eruption.
2. Facilitation of molar eruption.
3. Encouragement of forward mandibular rotation.
4. An increase in lower face height.
CASE REPORTS
Case 1 (Figure 2(a)) was a twelve year old boy when be
presented with a full unit Class I1 malocclusion Figure
2(b). Analysis of the cephalogram, Figure 2(c), suggested
that forward movement of the mandible, together with
upward rotation would be a much more appropriate geometry involved in relocating an unexpanded maxillary
arch in relation to an unchanged mandibular arch.
treatment than retraction of the maxilla to the existing
mandibular position. Hence functional appliance therapy Although this is an unwanted effect, (and specific steps
was prescribed rather than extra-oral traction to the may be required to overcome it), it can be used to
maxillary teeth. Since the permanent dentition was advantage in scissor bite cases (Figure 5).
established, an activator was selected rather than a
Frankel appliance. The "profile" of a patient for whom Andresen-type
After 15 months of night timewear, the changes activator therapy would meet currently accepted treatment
produced are shown in Figure 2 (d),(e) and (f). objectives would include the following features:
Favourable dental and facial changes have been 1. Skeletal features:
produced. Serial superimposition of the pre- and post- (a) There should be significant amounts of facial growth
treatment cephalograms shows that there has been 6 mm remaining.
of condylar growth, which has been expressed along the (b) The maxilla may exhibit mild prognathism but must
facial axis. Superimposition on Ba-N registered at N not show any features of vertical maxillary excess.
shows that the maxilla has been displaced downwards (c) The mandible should show mild to moderate skeletal
and backwards. In retrospect, this unwanted change could retrusion.
have been negated by the use of Teuscher's (1978) (d) The vertical facial proportions should err on the side
appliance design, and this would have allowed the of decreased lower face height.
mandibular development to be expressed in a more (e) The facial axis should be equal to, or greater than, 9 0
anterior direction. degrees.
It should be emphasized that functional appliance 2 . Dental features:
treatment, when indicated, should be instituted during the (a) The dental arches should be free of crowding and
growing period. The following case is presented to individual tooth irregularities such as rotation and poor
illustrate the limited response available in non-growing axial inclination.
patients. (b) A deep incisor overbite is preferable to an open-bite
Case 2 (Figure 3(a)) presented at age 14, requesting a tendency.
reduction in her overjet, but specifying that fixed (c) The mandibular dental arch should be retruded on the
appliance therapy in any form was excluded from the basal bone and preferably should show spacing rather
option list! An activator appliance was constructed. The than crowding.
changes after eighteen months of appliance wear are (d) The maxillary incisors should be slightly proclined.
shown. Cephalometric measurements fail to show any (e) A slight scissor bite tendency is favourable.
change in the antero-posterior positions of the mandible 3. Social-behavioural features:
and maxilla, although there has been a slight posterior As with other systems of orthodontic treatment, a well
rotation of the mandible. The occlusal correction is due adjusted, motivated and cooperative patient will be more
entirely to dento-alveolar change, and the long term likely to enjoy a successful resolution of their problem.
stability is uncertain.
One feature of the activator response which ss
deserves mention is shown in Figure 4. Favourable In addition to patients fulfilling the preceding
antero-posterior corrections are sometimes accompanied requirements, a number of specific morphological groups
by the development of posterior crossbites, due to the should be considered for activator therapy.
appliances, should not be used by clinicians who will not

use cephalometric analyses to assist in establishing the
nature of the facial morphology to be treated.
The limited orthopaedic effect reported by several

investigators of activator therapy (Ahlgren 1976,
Pancherz, 1984, Weislander, 1979) may be the result of
several factors:
1. The bulk of the appliance renders full-time wear
difficult, and with night-time wear only, the threshold for
adaptive remodelling at the condyles may not be reached
in all cases. Apart from a reduction in the time of
application of the stimulus, there is reduced protractor
muscle activity during sleep (Witt, 1973) and there may
also be reduced mitotic activity in condylar
prechondroblasts. (Petrovic, 1975). The increasing clinical
use of minimal bulk activators, such as the Bionator,
which can be worn on a full-time basis, may furnish
evidence of a truly orthopaedic effect.
2. Since the activator is tooth-borne, in contrast to
the Functional Regulator, tooth movement may lead to
occlusal correction before the desired skeletal changes
have been achieved. Continued pursuit of the skeletal
goals would produce a Class 111 dental malocclusion.
3. Inappropriate case selection or improper appliance
manipulation can lead to a posterior rotation of the
mandible. This leads us to a discussion of Teuschers'
approach.
S
The untoward vertical effects of activator treatment can be

eliminated or even reversed by the incorporation of
directionally controlled extra-oral force, a s described by
Teuscher (1978). Teuscher points out that normal occlusal
development depends on harmonious coordination
between:
1. Condylar growth
2. Posterior displacement of the mandibular fossa
3. Downward and forward displacement of the
nasomaxillary complex
4. Vertical development of the maxillary and
1. Dento-alveolar Class I1 malocclusions. The mandibular dento-alveolar structures.
activator is employed a s a form of Class I1 intermaxillary From the geometric aspect this balance is very sensitive,
traction to initiate dento-alveolar remodelling. since minor variations in the degree of development and
2. Moderate skeletal dysplasias between the movement of these separate units would lead to full
midfacial area and the mandible, where moderate intermaxillary dis-coordination. Teuscher demonstrated
amounts of maxillary incisor retraction and moderate that a number of orthodontic force systems deliver
amounts of mandibular growth would combine to yield a undesirable vectors to the naso-maxillary complex. In the
successful result. case of the activator alone, the force vector from the
3. Class I1 malocclusions resulting from musculature passes below both the centre of resistance of
environmental influences such as thumb sucking and the maxillary dentition and also that of the maxilla,
chronic mouth breathing, providing some growth still tending to produce a posterior maxillary rotation similar
remains and the oral habit can be eliminated. to that seen in the patient in Figure 2. Unless a patient
4. Non-extraction deep overbite cases in which it is experiences exceptional condylar growth, the mandibular
desirable or permissible to exert a forward pull on the development is deflected into a downward and backward
lower dental arch. Many Class I1 division I1 cases belong direction, detracting from the profile change expected in
in this category. Class I1 correction. However, the Teuscher activator
5. Class I1 cases complaining of (Figure 6) through the medium of extra-oral force
temporomandibular joint pain and dysfunction associated attachment, allows the clinician to control the vector of
with posterior displacement of the condyles. force s o that it passes between the centres of resistance of
the maxillary dentition and the maxilla. A positive control
c S of sagittal maxillary development is thus obtained,
The Andresen-type activator is contraindicated in the ensuring that the mandibular response will be expressed
following situations: horizontally rather than vertically.
1. Non-growing patients.
2. Vertical growth patterns. T
3. Intractable mouth breathing or digit sucking. A new orthodontic philosophy and system of removable
4. Poor cooperation. appliance therapy was developed in East Germany in the
5.Cross bite tendency. late 1950's by Professor Rolf Fi5nkel.
6. Gross intra-arch irregularities and rotations. Although there are four fundamental designs of
7. Marked spacing of the upper incisors. Activators the Fiankel appliance, they are often grouped together for
are not capable of parallel space closure. description as the Function Regulator or FR. The FR is
8. Retroclined upper incisors. not just another appliance suitable for indiscriminate or
9 . Activators, along with other functional routine use, but an exercising device demanding thorough
grounding in orofacial physiology, growth and the view that this applies also to the craniofacial region.
development, as well as orthodontic diagnosis. Moorrees Harvold (1968), Harvold et a1 (1973), and Tomer and
(1984) rightly states; "The FR is not an appliance in the Harvold (1982) have shown that experimentally induced
conventional sense, and it requires a reschooling of alterations in the postural activity of the muscles
orthodontic thinking if one is to understand its indication, suspending the mandible result eventually in measurable
potential handling, and construction as a changes in mandibular shape and position. In Ffankel's
physiotherapeutic device during daytime function." view, the main aim of functional therapy is to identify a
faulty postural performance of the orofacial musculature
B and to correct it by orthopaedic exercises. The essential
Fiankel's approach is based on the importance of the problem for him was to design and construct an "exercise
form-function relationship in craniofacial morphogenesis. device" that would interfere directly with the functional
In general orthopaedics it has been claimed that of all of environment and result in the correction of the poor
the functional factors which play a part in the aetiology of postural behaviour.
skeletal deformities, aberrant postural performance is the Faulty muscle posture is seen as having an
most important. Recent experimental evidence supports adverse environmental effect on:
dento-alveolar remodelling mediated via the periosteal

matrices will favour acceptable vertical, dental and facial
relationships.
The second of Moss's concepts concerns the
capsular functional matrix. Ffankel sees the muscular
portions of the walls of the oral and nasopharyngeal
spaces as forming a capsular matrix, the volume of which
has an important morphogenetic influence on the
development of the dentoalveolar structures.
Specifically, he claims that an aberrant postural
pattern of the external muscular environment may
unfavourably influence the eruptive path and restrain the
normal physiologic process of decrowding and uprighting
of the teeth during eruption. By means of the vestibular
shields of the functional regulators, the erupting dentition
is protected from the adverse forces generated by the
existing perioral musculature, allowing for spontaneous
decrowding of the teeth.
Decrowding is a feature of all of the Frankel appliances

and therefore will be discussed first, before proceeding to
a n outline of the individual features of the four types of
appliance. The distinguishing characteristic of the Fr5nkel
appliances is the use of the oral vestibule as the
operational base. Acrylic vestibular shields are located
bilaterally in the buccal vestibule and anteriorly in the
labial vestibule. This is in contrast to the acrylic palatal or
lingual baseplates employed in conventional activators
and one arch removable appliances. The oral vestibule is
seen as the interface between the facial capsule and the
developing dento-alveolar structures and its use is felt to
offer an opportunity for an interceptive treatment
program.
There are several possible modes of action of the
vestibular shields:
1. The vestibular shields eliminate perioral soft
tissue pressure which arises from:
(a) muscular forces associated with aberrant postural
patterns in the orofacial muscles,
1. The spatial relationships of the maxilla and/or the (b) sub-atmospheric pressure generated in the oral cavity
mandible, that is, the sagittal, vertical and transverse basal which acts to suck the lips and cheeks against the teeth
arch relationships. and into the inter-occlusal space. Elimination of these
2. The development in space of the dento-alveolar restraining muscle pressures allows the inherent bone
structures. inducing potential of the erupting tooth to be expressed in
Frankel applies the functional matrix concept and a more buccal direction. The potential significance of this
terminology of Moss (1970) to explain the basis of design effect can be understood when it is realized that the
of his appliances. When faulty muscle posture is deemed apical base in the mandible translates vertically through
to have compromised the spatial relationships of the some 11mm during the eruption of the permanent
maxilla and mandible in a growing child, the appliance is dentition. The implication for vestibular screen therapy is
designed to alter the biomechanical conditions in the that treatment should commence early in the transitional
periosteal functional matrices of these bones. dentition and be sustained until eruption of the second
a ) 4n the case of a deficient mandible the cause is permanent molars.
considered to be a postural imbalance between the 2. The periphery of the vestibular shield is
retractor and protractor muscles. The FR1 and FR2 deliberately extended into the vestibular reflection s o that
appliances are constructed so that the patient is obliged tension is produced in the soft tissues. This pull on the
to posture the mandible forward in order to achieve a soft tissue is transferred to the periosteum, with two
comfortable jaw position. In this way the periosteal tissues possible effects:
related to the mandibular condyle are subjected to a (a) The tension in the periosteum may contribute
biomechanical stimulus which favours an increased rate of mechanically to an outward bending of the thin buccal
bone deposition until a position of stability is reached, plate, thereby facilitating outward drift of the teeth.
with the mandible relocated in a more anterior position. (b) Direct tension in the periosteum is known to stimulate
(b) In the case of a deficient maxilla, the FR3 appliance is deposition of new alveolar bone (Donnely et al, 1973)
constructed so that periosteal tension is produced at the and this is claimed to occur on the facial aspect of the
superior sulci. The vestibular shields and upper lip pads alveolus in response to FR treatment. The work of
counteract the restricting effect of aberrant posture within Brieden et a1 (1984) supports this hypothesis. A
the labial muscle groups and normal maxillary growth is comparable widening of the apical base could not be
restored. expected in conventional appliance therapy because the
(c) In skeletal open bite development, clinical relevance is expansion force is delivered to the tooth crowns, and the
placed on the poor postural performance of the muscles apices are deflected in a lingual direction.
forming the external soft tissue capsule and of those 3 The outer surfaces of the vestibular shield are
suspending the mandible. Accordingly, therapy with the presented to the musculature as a correct configuration of
FR4 is directed at restoring a competent anterior oral seal the dento-alveolar process. The orofacial musculature is
and establishing a more superior postural position of the trained to function in harmony with the dental arches as
tongue and of the mandible. Subsequent skeletal and they attain correct width and shape.
4. The projecting vestibular screens stretch the

perioral soft tissues. After removal of the appliance, the
peri-oral soft tissue pressure will continue to be reduced
while the tongue pressure is increased because it is
elevated into a palatal position. This favours long term
stability of arch expansion.
5. Bilateral tension on the maxilla at the level of
the sulcus is claimed to stimulate widening of the mid-
palatal suture. The evidence for this is not yet conclusive.
Ghafari (1984) reported sutural changes in rats in
association with the placement of Fiankel-type vestibular
shields but no implants were used. Brieden (1984)
studied the effect of FR-induced widening of the maxillary
dental arch, buccal alveolus and the midpalatal suture in
children. Although the treatment group had tantalum
implants, the control group did not, and it was therefore
not possible to ascertain what proportion, if any, of the
significant arch widening was due to sutural expansion.
6. In contrast to most other functional jaw
orthopaedic appliances, the FR interferes very little with
tongue position, and the tongue is free to exert more
force in a n anterior and lateral direction.
Despite these claims, the number of systematic
studies on arch expansion is very limited. Ffankel (1971)
reported limited data on the upper arch only in 400 FR
patients. The mean expansion between the maxillary first
permanent molars, first bicuspids or first deciduous molars
was 4.5mm. McDougall et a1 (1982) published detailed
studies on 60 FR patients. Only those patients who had
worn the appliance over a three year period experienced
expansion across the molars of the order of 3.5 to
4.2mm. However, the authors acknowledged that their
appliance design at that time did not meet Frankel's
specifications with respect to vestibular extension.
Figure 7 shows the pretreatment and post
treatment casts of a patient who wore an FR1 appliance.
The FR1 appliance is recommended in cases ranging

from Class I malocclusions characterized by crowding and
increased overbite and overjet, to severe Class I1 division I
malocclusions associated with normal maxillae and
retrognathic mandibles. Vertical dysplasias are frequently
unsuitable for this particular design, although minor
vertical discrepancies such as over-eruption of incisors can
be resolved by pre-functional fixed appliance treatment.
The principles of FR1 treatment include
mandibular advancement, arch expansion, overbite
reduction and muscle re-education.
G?
McNamara (1981) and Moyers (1980) showed that a
large number of Class I1 children possess normal maxillae
in combination with retruded mandibles. Therefore the
clinical problem is to eliminate the antero-posterior
discrepancy by stimulation of condylar growth alone.
There must be no retraction of the maxilla or of the
maxillary teeth. Frznkel considers that activators fail to

meet these requirements because there is some
orthopaedic maxillary retraction and also because the
dental system reacts s o rapidly that there is no prolonged
effect on the temporomandibular joint. Cemented splints
produce successful changes in experimental animals but
are not practical in growing children. The FR1 solves this
clinical problem by means of the lingual shield and lower
lip pads, which oblige the patient to produce an anterior
displacement of the mandible yet ensure that there is no
appliance contact with the mandibular teeth. Thus,
changes observed during treatment in the antero-posterior
occlusion of the buccal teeth cannot be explained by
mesial movement of mandibular buccal segments, just as
the correction of the overjet cannot be explained by
proclination of the lower incisors.(Petrovic et al, 1982).
If a patient wearing an FR1 allows the retractors to
bring the mandible back to its position of centric relation,
the lingual shield comes into contact with the alveolar
gingiva and pressure will be felt. The sensory input
provoked by the lingual shield may activate the
nociceptors in the periosteum and stimulate the
protractors to eliminate the disturbing signal. Constant
protractor activity appears to stimulate the compensatory
growth processes in the mandibular condyles. Since
patients are unable to engage the FR1 firmly with their
mandibular teeth, they are unable to apply forces of any
magnitude to the maxilla or its teeth.
Notwithstanding these considerations, several
studies have been reported in the literature in which
changes in arch relationship produced by Fignkel
appliances have been shown to be almost entirely dento-
alveolar in origin. This finding is obviously related to
violation of the following principles of treatment:
(a) Notching of maxillary deciduous teeth
The FR1 must have a firm registration against the maxilla
s o that it is stable during use. If the appliance is free to
slide posteriorly, the labial bow will come into contact
with the maxillary incisors and cause their retroclination
together with unfavourable vectors which would deflect
the maxilla from its normal growth direction. Maxillary
anchorage is secured by lodging the interproximal sections
of the palatal connector and the cuspid wires in notches
cut on the distal aspect of the maxillary second deciduous
molars and between the first deciduous molars and
cuspids respectively. This is an essential procedure in the
construction of the FR1 (and FR2) but was disregarded in
the clinical trials reported by Creekmore (1982) and
Robertson (1983).
(b) Sequential mandibular advancement
In the early period of the development of his functional
concept, FrSnkel found that proclination of the lower
incisors did occur, and that it was associated with the
relatively large mandibular advancements of 5-6mm
registered in the construction bites taken at that time. It
appears that the protractors are unable to sustain these
with the mandible protruded by no more than l-2mm. As

training and adaptation occurs, the anterior segment of
the FR1 containing the lip pads and the lingual shield can
be gradually advanced (by using screws and/or splits in
the vestibular shields) until the desired orthopaedic effect
has been obtained.
(c) Gradual training
The FR1 should be worn for only a few hours per day for
the first month. It is a serious mistake to expect the child
to commence night time wear immediately, because the
protractors will not be sufficiently trained and their
relaxation may lead to incisor proclination as described
above. Preliminary lip seal training is an essential facet of
Fr'ankel therapy, but n o attention was paid to this in the
studies mentioned above.
(d) Treatment timing
Treatment with the FR1 should commence at around the
age of 9 years, if the clinician is to capitalize fully on the
potential for sagittal skeletal change and transverse arch
expansion. Some studies have suggested that the juvenile
growth spurt is of greater clinical utility in terms of
orthopaedic change than the pubertal growth spurt. (Rio10
et al, 1974; Kerr,1979; Lewis et al, 1982;
Weislander,1984). The ages of the patients employed in a
number of studies on the efficacy of the FR would seem
to be beyond this range. (Robertson, 1983; Nielson,
1984; Gianelly, 1984). McNamara (1984) reported that
the wearing of the FR2 in adult patients produced no
skeletal changes and only minimal dental adaptations.
Orthopaedic possibilities with the FR appliances diminish
in proportion to the residual facial growth.
The possible mechanism of arch expansion with the FR1

was previously discussed. The rationale for expansion is:
(a) In the treatment of Class I1 cases by mandibular
advancement, there is a tendency for the development of
a buccal crossbite (Figure 4) unless the maxillary arch
undergoes concomitant expansion. The vestibular shields
are very effective in this regard.
(b) To relieve existing or predicted crowding.
(c) To counteract progressive reduction in mandibular arch
length, which is a feature of normal human development,
and is often interpreted a s post-treatment relapse.
Unfortunately this aspect has not been evaluated because
adequate long term material is not yet available outside
the German Democratic Republic.
Overbite reduction is accomplished by buccal segment

eruption in harmony with the vertical component of facial
growth. The FR1 is not capable of active intrusion of
incisors, and if this movement is required, another
average anterior movement of the maxilla in FR1 treated

cases is 3.4mm compared to 2.5mm in untreated Class I1
subjects. (Frankel 1983). Although, this difference is not
statistically significant, it is clear that the FR1 is superior
to the activator and Herbst appliances in terms of
avoiding reciprocal orthopaedic side effects on
the position of the maxilla.
CASE REPORTS :Figures 8-10
Frankel designed the FR2 for the early orthopaedic
treatment of Class I1 division I1 malocclusions, although
others have adopted this appliance for the treatment of
Class I1 division I problems (McNamara and Huge,1981).
Ffankel cites a study of 114 untreated Class I1
division I1 cases in which serial radiography of the
erupting central incisors showed that the bony layer
covering the labial surface became progressively thinner
as eruption advanced and disappeared completely some
time before clinical emergence. Concomitantly the incisors
became increasingly retroclined even before clinical
eruption. FrZnkel suggests that the tight lower lip and
high lip line, which are characteristic of Class I1 division 11,
may account for this retroclination. If lip seal in normal
individuals is established by the elevation of a relatively
passive lower lip by mentalis muscle activity (Simpson,
1976) then FrZnkel postulates that hyperactivity of the
typically well developed mentalis muscle seen in Class I1
division I1 patients causes excessive postural elevation of
the lower lip s o that it intrudes beneath the upper lip.
(Figure 11(a)). The resulting perioral pressure is said to
have a strong morphogenetic effect on the developing
premaxillary dento-alveolar structures. Leighton (1983)
supported these concepts in a study comparing the
eruptive behaviour of central incisors in Class I, Class I1
appliance system should be employed. That the FrZnkel division I and Class I1 division I1 cases. The initial tooth
appliance is very effective in promoting molar eruption germ orientation was similar in all groups before root
was shown by Rhigellis (1983). formation occurred. Thereafter the Class I1 division I1
cases showed progressive retroclination of the erupting
incisors and also of the labial alveolar plate. Leighton
Function regulator treatment is claimed to accomplish its suggested that the eruptive path of the incisors is
skeletal and dental corrections by modifying behaviour controlled by the sagittal shape of the labial alveolar
aberrations involving the oro-facial musculature. Freeland process which, in turn, may be determined by the
(1979) compared the muscle patterns in a group of
patients before and after treatment with the FR1 to those
of a control group, and concluded that the FR did indeed
affect muscle activity.
Skeletal features:
(a) Normal maxillary position in the sagittal and vertical
dimensions.
(b) Retrognathic mandible.
(c) Normal or reduced lower face height.
Dental features:
(a) Normal relationship of the maxillary denture to the
maxilla in the sagittal and vertical dimensions.
(b) Normal relationship of the mandibular denture to the
mandible in the sagittal and vertical dimensions.
(c) Mild crowding in the mandibular arch or in both
arches is acceptable, but axial rotations a n d bodily
displacements of individual teeth require a separate phase
of fixed appliance treatment.
Maturation:
Early mixed dentition, 7-9 years.
Teuscher(1983) has indicated that disappointment with
the profile change in conventional Class I1 treatment is
directly proportional to the degree of therapeutic midface
restraint, and inversely proportional to the amount of
condylar growth experienced by the patient. Correctly
managed FR1 treatment offers an excellent potential for
profile improvement in Class I1 treatment because there is
n o midface restraint and there is increased condylar
growth. Frankel's long term studies have shown that the
to stimulate maxillary development and to restrict

mandibular development. The upper lip pads supply a
direct intervention at the muscle-tendon junction at the
frontal sulcus and lead to an altered biomechanical
loading of the maxillary structures and nasal cartilages.
The teeth are not notched and it is important that none
of the wire components of the FR3 contact any maxillary
teeth in such a way as to inhibit forward movement
of the maxilla. In contrast to the action of the FR2, where
the skeletal and dental changes are entirely functionally
induced, the FR3 imparts both functional and mechanical
effects:
perioral musculature. He suggested that the retroclination

of the central incisors in Class I1 division I1 cases is
environmentally induced and is therefore amenable to
interception. The incisor inclination may have a restrictive
effect on mandibular development and the lack of vertical
support may facilitate a forward mandibular rotation. The
typical features facing the clinician are incisor
retroclination, a deep overbite, mild mandibular
retrognathism and a decreased lower face height. Prior to
the construction of the FR2 the central incisors should be
proclined (Figure 1 1 0 ) so that when the construction
registration is made, the incisors meet edge-to-edge and
there is sufficient mandibular protrusion to initiate the
biological changes involved in forward transformation of
the mandible (Figure l 1 (c)). Buccal segment eruption will
maintain the increased vertical dimensions. If there is a
scissor bite tendency, this would be accentuated by the
expansion normally induced by the vestibular shields, and
it may therefore be more appropriate to use a
conventional activator. Slagsvold (1977) makes the
observation that many Class I1 division I1 cases are
actually more suited to activator therapy than Class I1
division I malocclusions. The treatment of two cases is
illustrated in Figures 12 and 13.
In functional orthopaedic philosophy, mandibular

retrognathia is interpreted as a manifestation of failure of
volumetric expansion of the inferior part of the oro-facial
capsule. In contrast to this, maxillary retrognathia is
viewed as a consequence of failure of expansion of the
superior part of the oro-facial capsule. Delaires'(1978)
dissections of normal and cleft-lip cadavers led him to
postulate that the nasogenal muscles have a direct
influence on maxillary growth, and that functional
aberrations of these muscle groups may play an important
role in restricting maxillary development.
The FR3 is constructed to interfere directly with
the structural and postural deviations of the external soft
tissue capsule. The vestibular shields stand away from the
maxilla and lie close to the mandible, the objective being
(b) The mechanical aspect of FR3 treatment is mediated

by contact of the lower labial connector with the labial
surfaces of the mandibular incisors. Lip pressure against
the upper lip pads is transferred to the lower incisors
(Figure 14) causing retroclination of these teeth and
frequently a posterior rotation of the mandible. This latter
effect is particularly appropriate in Class I11 malocclusions
associated with reduced lower face height.
Since the FR3 seeks to pre-empt abnormal
development and to restore normal growth rather than to
correct fully established malformation, it is important that
treatment be initiated as early as possible. The appliance
can be readily used in the complete deciduous dentition,
if necessary. Because of the induced adaptations in both
hard and soft tissues during treatment, the ultimate
balance between function and form should favour long
term stability of the result. Freeland (1979) reported that
changes in patterns of activity of the oro-facial muscles
did occur after the wearing of the FR3 for 12 months. In
comparison to the other function regulators the FR3 is
relatively easy to construct and to manage clinically
(Eirew, 1976) and maxillary orthopaedic change is
therefore more likely to be a routine cephalometric
finding. (Robertson 1983)
CASE REPORTS: ~ k u r e s15 -1 7
The FR4 has been used in the treatment of bimaxillary
protrusions and has been found to be particularly effective
in the treatment of open-bite problems. Frankel
developed this design after observing inconsistent
responses to the use of "tongue habit" appliances
formerly employed in the treatment of s o called "tongue
thrust" open bites. Analysis of refractory cases revealed a
marked discrepancy between lip length and lower face
height. The associated deficiency of an oral seal was
attributed to a poor postural behaviour of the facial
musculature, particularly in the lip area. This led Frgnkel
to institute functional therapy using vestibular shields in
conjunction with lip seal training for anterior open-bite
relapse patients.
The clinical observation that an open-bite can be
closed without using any device which interferes with
tongue movements or tongue posture confirmed that
tongue thrust alone may not be the primary cause of that
malocclusion, and that there may be a functional
relationship between the postural behaviour of the tongue
and the lips. It was considered that faulty interdental
posture of the tongue was adopted as a compensatory or
adaptive behaviour which established an anterior oral seal
when the lips were incapable of doing so.
Harvold's work is of significance in this context. In
a series of experiments (Harvold et a1 1973, Harvold
1979, Tomer and Harvold 1982, Vagervik et a1 1984.) it
was shown that closure of the nasal airway in growing
monkeys induced changes in neuromuscular recruitment
patterns which were necessary to establish and maintain
an oral airway. The muscle groups most actively involved
were those of the tongue and suprahyoid area. The
animals developed progressive alteration of their soft
tissue and skeletal morphology, eventually corresponding
to the clinical picture of skeletal open-bite. Following
removal of the nasal airway obstruction, reversals in
skeletal remodelling were observed, but the muscle
patterns and the malocclusions tended to persist. Since
condylar and alveolar growth are not "interstitial" or
"expansive" but rather "appositional" in nature, it is likely
that the altered direction of condylar growth and the
excessive alveolar growth associated with skeletal open-
bite development are a result rather than a cause of
posterior mandibular rotation.
Fiankel reasoned that if alterations in the postural
activity of the oro-facial musculature can lead to skeletal
open-bite, then correction of faulty postural behaviour
might help to correct the associated skeletal deformity. A
fundamental aim of his therapy was to overcome the
This appliance was introduced in 1905 by Professor Emil

Herbst, was widely used in Europe for a number of years
and then was largely forgotten until Pancherz revived
interest in this approach to treatment in 1979.
The Herbst appliance (Figure 21) consists of a
bilateral telescope mechanism attached to orthodontic
bands cemented to the maxillary and mandibular teeth.
The length of the telescope tube is adjusted s o that the
mandible is mechanically held in a continuously
protruded position, usually an edge-to-edge incisal
relationship.
The Herbst appliance is analogous to the activator
insofar as the change in jaw relationship is accomplished
by the interposition of a- rigid structure between the teeth
in each jaw, but the Herbst mechanism is not removable
by the patient and therefore the impact on the
musculature is continuous and not intermittent in nature.
The clinical situation thus corresponds more closely to the
conditions established in animal experiments
(McNamaraJ975) and this may explain why the condylar
changes reported in studies on Herbst treatment are both
appreciable and consistent (Pancherz, 1982 Weislander,
1984).
Placement of a Herbst appliance creates a primary
and significant change in the intermaxillary relationship,
and the expectation is that favourable skeletal and
muscular adaptation will occur s o that the new jaw
positions are permanent. This contrasts with the principle
of Function Regulator therapy, where a primary attempt is
made to normalize the muscular environment of the
deviant pattern of mandibular rotation through re- developing stomatognathic system so that desirable
establishment of nose breathing by correcting the lips- secondary changes occur in basal jaw relationships.
apart condition and faulty tongue posture. In fact, lip-seal The sliding hinges of the Herbst appliance are
training alone, in the absence of any appliance treatment, anchored on the maxillary molars and, using the
has been shown to result in closure of open mandibular first bicuspids as "handles", the mandible is
bites.(Frankel, 1980) However, voluntary training exercises locked in a protruded position and the condyles are
without a n appliance are difficult to sustain for adequate distracted from the fossae. Provided that there is some
daily periods throughout the duration of the growth growth potential remaining, the condyles "grow back" into
phase. Furthermore, the FR4 appliance has additional the fossae within 6-8 months, thereby stabilizing the
working principles which contribute to the desired skeletal artificially created mandibular position. Concomitant
remodelling changes (Figure 18).Correct extension of the changes in muscle activity would minimize any relapse
posterior margins of the vestibular shields determines the tendency.
location of a new centre of rotation for the mandible. Pancherz (1980) has shown that the E.M.G.
From receptors in these areas sensory feedback is said to patterns of the masseter and temporalis muscles, which
cause reflex distraction of the condyle from the are abnormal in Class I1 cases before treatment, are, in
mandibular fossa, while the chin is rotated upwards by fact, normalized by Herbst treatment.
the strengthened anterior vertical muscle chain. The proportion of change attributed to function
Compensatory translative growth may restore the normal per se is difficult to establish. Distal movement of
condyle-fossa relationship and increase ramus height. maxillary molars results from muscle-generated forces
This hypothesis is supported by an 8-year transmitted through the plunger attached to the
evaluation of thirty skeletal open-bite cases treated with
the FR4 (Fiinkel and Fiinkel 1983).The treated group
experienced an increase in ramus height, a decrease in
the gonial angle, a decrease in anterior face height and
an improvement in the ratio of anterior face height to
posterior face height. The respective values for the
untreated control group of eleven subjects remained
unchanged or became worse.
An important question concerning skeletal open-
bite development is the role of neuromuscular maturation.
Functional disorders in the oro-facial area may be
attributed to a failed or incomplete maturation of postural
performances, for which an adverse psychosocial
environment may constitute an important contributary
factor (Frankel, 1983).
Treatment with the FR4 is not commenced until
the patient has shown evidence of good co-operation
with lip-seal exercises during a probationary period of 3-4
months. As with the other function regulators, therapy
should be initiated in the mixed dentition and lengthy
treatment and retention periods are frequently necessary
in the management of these patients.
Figure 19 and Figure 20 show the responses
obtained in two patients treated with the FR4.
Maturation:
Treatment during the pubertal growth period is favoured
by Pancherz (1985) but Weislander (1984) has
demonstrated that the mandibular response in the early
mixed dentition is, if anything, slightly superior.
In comparison to removable functional appliance therapy,

Herbst treatment is relatively invasive and should not be
instituted without adequate patient preparation. However,
there are some patients in every day orthodontic practice
for whom this fixed functional appliance offers the only
possibility for the attainment of an "ideal" result. The
outcome of conventional orthodontic treatment would be,
at best, a compromise.
These patients are grouped thus:
(1)Patients who meet the above criteria but for whom
treatment options are not considered until they have
passed their maximum pubertal growth. Removable
functional appliances, which require 2-3 years of "growing
time", are no longer appropriate, but treatment with the
the condyles from the fossae constitutes an adequate Herbst appliance, which can be completed within 6 to 8
biomechanical stimulus for proliferative change, or months, makes it possible to use the residual growth
whether functional movements in the "new" position are available in these older patients.
important. In addition, reflex contractions of the lateral (2) Patients whose skeletal, dental and maturational
pterygoid muscles as a response to disturbance signals features qualify them for FR or activator therapy, but
from periodontal receptors may make an important where proper wearing of the appliance is unlikely to be
contribution to condylar remodelling, as claimed by satisfactory, either because of nasal airway obstruction or
McNamara (1975) and Petrovic (1975). poor co-operation.
(3) Patients in the mixed dentition who display maxillary
The treatment effects of the Herbst appliance have been prognathism in conjunction with mandibular
reported (Pancherz, 1982 Weislander, 1984). retrognathism. Weislanders' Herbst-head gear approach
There may be some minor variations depending
on the appliance design. For example, the dental
response may vary in accordance with the number of
teeth incorporated in the anchorage unit. The reported
effects are:
(1) Proclination of mandibular incisors (6 degrees).
(2) Distal movement of maxillary molars (2-3mm).
(3) Mesial movement of mandibular molars (lmm).
(4) Restraint of maxillary growth (reduction in SNA of 0.5
degrees).
(5) Stimulation of mandibular growth (increase in SNB of
1.5 degrees, increase in effective mandibular length of
3-4mm).
(6) Reduction in overbite (3mm).
(7) Increase in lower face height (1.8mm). This appears
to be temporary.
(8) An anteroinferior translation of the mandibular fossae,
at least in mixed dentition cases (Weislander, 1984)
Skeletal features:
(a) Normal or slightly prognathic maxilla. In cases where
the amount of maxillary correction required exceeds the
orthopaedic capabilities of the Herbst appliance,
directional extraoral traction can be applied to the upper
component.
(b) Retrognathic mandible.
(c) Anterior growth direction of the mandible (facial axis
more than, or equal to, 90 degrees).
(d) Normal or reduced lower face height.
Dental features:
(a) Class I1 dental arch relationships with increased overjet
and normal or increased overbite.
(b) Well aligned maxillary and mandibular dental arches
which occlude well when advanced to a Class I
relationship.
(c) Minor crowding in the maxillary incisor segment is
quite acceptable because space is made available by distal
movement of the upper buccal segments.
(d) A Class I1 division I1 configuration of the maxillary
incisors is not a contraindication, provided that
orthodontic alignment is carried out prior to the
orthopaedic phase with the Herbst appliance.
Even in the most cooperative of patients the strain on

parts of the Herbst appliance is considerable (Figure 22)
and specific steps should be taken to counteract
breakages. Prefabricated bands are too weak and should
be strengthened by the soldering of a 1.0mm "staple" on
the distal aspect of the mandibular first bicuspids and on
the mesial aspect of the maxillary first permanent molars
(Figure 23). Alternatively, individual bands may be
formed using heavy gauge orthodontic band material.
Wilful appliance breakage creates insurmountable
management problems and precludes attainment of the
desired skeletal changes.
Figures 24 and 25 show cases treated with the Herbst
appliance.
The Bionator was developed by Balters and has much in

common with the Andresen-type activator, although it
has several distinguishing features:
may not be the only alternative available, but may prove

to be the most efficient method of restoring skeletal and
muscular balance for these children.
(1)Non-growing subjects.
Skeletal alterations are minimal and treatment effects are
confined to the dento-alveolar area. There may be a risk
of developing a "dual bite".
(2) Open-bite patients.
There are at least two reasons why the Herbst appliance
should not be prescribed for these patients:
(a) Some incisal support and guidance seems to be
necessary for the patient to feel comfortable during
treatment.
(b) Because of the steep occlusal plane in skeletal open-
bite patients, protruding the mandible to an edge-to-edge
incisal relationship may generate only a mild anterior
condyle translation. Woodside et a1 (1983) indicated that
mandibular advancement per s e is not a necessary
prerequisite for condylar remodelling, and that vertical
distraction from the fossa may be important. In other
words, for these patients, the Herbst appliance is
incapable of repositioning the mandible within its muscle
claimed to be important for the correct function of the

appliance, and differs according to the nature of the
malocclusion under treatment. According to Balters'
philosophy, Class I1 malocclusions are the result of a
backward position of the tongue, which, in turn,
generates faulty deglutition and mouth breathing. The
main objective of Class I1 treatment with the Bionator is
to bring the tongue forward. This is achieved partly by
stimulation of the distal aspect of the dorsum of the
tongue by the posteriorly directed palatal arch wire, and
partly by anterior development of the mandible induced
by the edge-to-edge construction bite. Class I11
malocclusions, conversely, are ascribed to a forward
position of the tongue and therefore, in the Class 111
Bionator the palatal arch is inverted, with the round bend
directed anteriorly. The rationale of this is to train the
tongue by proprioceptive stimuli to remain in a more
retracted position.
The other wire element is the vestibular arch,
which has a labial segment and bilateral buccinator bends.
The buccinator bends are intended to perform functions
similar to the vestibular shields of the Frankel appliances:
(a) They prevent the soft tissues of the cheeks from
intruding into the inter-occlusal space, thereby facilitating
(a) It is considerably less bulky than the activator

rendering normal speech possible and facilitating full-time
wear.
(b) Freedom of movement in the oral cavity is important
and fixation by clasps or extra-oral attachments would be
detrimental to the mode of action.
(c) It is designed to have a specific effect on tongue
function, which is viewed by Balters as the primary
morphogenetic influence on the growth, development and
relationship of the dental arches.
The Bionator consists of a flange of acrylic
covering the lingual aspects of the mandibular dental
arch, but only small palatal areas of the maxillary molars
a n d bicuspids. The traditional palatal plate of acrylic is
replaced by a palatal wire, the configuration of which is
eruption and occlusal plane levelling in the buccal DONNELY,MW ,SWOOPE,CC & MOFFETT,BC (1973)
Alveolar bone deposition by means of periosteal tension
segments. J Dent Res 5 2 6 3
(b) They hold the internal surfaces of the oro-buccal E1REW.H (1976)
capsule laterally, encouraging transverse expansion of the The function regulator of Ffinkel
Brit JOrthod 3 67-70
maxillary dental arch. FREUNTHALLER,P (1967)
Whether or not the Bionator is capable of inducing Cephalometric observations in Class 11 division 1 malocclusions treated with
the activator
clinically significant orthopaedic change in the mandible Angle Orthod 3 7 18-25
remains to be shown. Electromyographic and force- Fl3ANKEL.R (1970)
transducer studies by Witt (1973) suggested that Maxillary retrusion in Class 111 and treatment with the function corrector
Trans Eur Orthod SOC 249- 259
mandibular elongation could be expected insofar as full- FRANKEL R 119711
time wear of the Bionator induced active muscular The guidance of eruption without extraction
Trans EurOrthod SOC 303-315
protrusion of the mandible, in contrast to conventional FRANKEL.R (1980a)
activators which held the mandible forward mechanically. A functional approach to orofacial orthopaedics
However, a recent detailed study on the efficacy of the FRANKEL.R (1980bl
Bionator (Janson, 1983) concluded that this appliance Lip seal training in the treatment of skeletal open bite
produces primarily dento-alveolar changes. Europ JOrthod 2 219-228
FRANKEL,R (1983a)
Course notes,Post-Congress Course,Geneva, 1983
FI3ANKEL.R (1983b)
1. The Bionator is useful in the treatment of Class I1 Biomechanical aspects of the form/function relationship in craniofacial
morphogenesis a clinician's approach Pages 107-130
division I malocclusions in the mixed dentition, In Clinical Alteration of the Growing Face J A McNamara Jr ,K A Ribbens and
particularly those associated with habits and abnormal R PHowe,(Editors) Monograph No 14 Craniofacial Growth Series-Center of
tongue function. Human Growth and Development,University of Michigan, Ann Arbor.
Michigan
2. The Bionator has an important role as a retention FRANKEL,R and FRANKEL,C. (1983)
appliance; A functional approach to treatment of skeletal open bite
Amer JOrthod 8 4 54-68
a ) Following correction of a Class I1 malocclusion FREELANDTD (1979)
in the mixed-dentition with a Bionator, the same Muscle function during treatment with the functional regulator
Angle Orthod 49 247-258
appliance is used for night time retention. GHAFAR1.J (1984)
(b) After correction of Class I1 malocclusions by Palatal sutural response to buccal muscular dis~iacementin the rat
conventional fixed appliance therapy, the Bionator Amer JOrthod 8 5 351-356
G1ANELLY.A A ,BROSNAN,P ,MARTIGNONI,M & BERNSTEINL (1983)
maintains and protects the dento-alveolar changes against ..
Mandibular growth, condvlar oosition and Fr'inkel aooliance theraou
disruption by post-treatment growth. The Bionator has Angle 0rth;d 53-131-142 .
GIANELLY.A A .ARENA.S A & BERNSTEIN.L (19841
greater patient acceptance in this application than the A comparison of Class 11 treatment changes noted with the light wire,
activator, which, because of its bulk, looms as a major edgewise and FGnkel appliances
treatment phase. HARV0LD.E P (1968)
(c) In Herbst appliance treatment, the rapid sagittal The role of function in the etiology and treatment of malocclusion
changes may partially relapse through dental changes or Amer.JOrthod 54883-898
HARV0LD.E P (1974)
unfavourable post-treatment growth. Pancherz (1985) has The Activator in Interceptive Orthodontics
stated that a stable cuspal interdigitation will counteract an The CVMOSBY Company, Saint Louis.1974
HARVOI
- D E P (19791
-
occlusal relapse. If treatment is performed in the mixed Neuromuscular and morphological adaptations in experimentally induced oral
dentition, retention is necessary until permanent teeth respiration Pages 149-164 in Naso-respiratory function and Craniofacial
Growth, J A McNanara Jr (Editor) Monograph No 9, Craniofacial Growth
have erupted to stabilize the occlusion. Furthermore, the Series Center for Human Growth and Develo~ment.Universitv of
musculature may require a training period in excess of six Michigan,Ann Arbor,Michigan
months to accommodate to the new mandibular position. HARV0LD.E P ,VAGERVIK,K & CHIERIC1.G (1973)
Primate experiments on oral sensation and dental malocclusions
The Bionator is a suitable retention device following Amer JOrthod 6 3 494-508
Herbst treatment. HAUSSER,E (1973)
Functional orthodontic treatment with the activator
JANSONJ (1983)
Skeletal and dento alveolar changes in patients treated with the Bionator
during prepubertal and pubertal growth 131-154
AHLGREN,J and LAUR1N.C (1976) In Clinical Alteration of the Growing Face J A McNamara Jr ,K A Ribbens and
Late results of activator treatment A cephalometric study R PHowe,(Editors) Monograph No 14 Craniofacial Growth Series,Center of
Brit JOrthod 3 181-187 Human Growth and Development,University of Michigan, Ann Arbor,
ANDERSSON.1 and AHLGREN,J (1977) Michigan
Vertical growth changes during and after activator treatment
Trans EurOrthod SOC57-68 KERR,W J S (1979)
BAUMR1ND.S and K0RN.E L (1981) A longitudinal cephalometnc study of dento-facial growth from 5 to 15 years
Patterns of change in mandibular and facial shape associated with the use of Brit JOrthod 6 115-121
forces to retract the maxilla LEIGHTON,BC (1983)
Amer J Orthod 8 0 31-47 Incisor inclination in Class 11 division 2 malocclusions
BAUMRIND, S , KORN, E L , ISAACSON, R J , WEST, E E & MOL7'HEN, R. Volume of Abstracts,59th Congress of the European Orthodontic Society Page
,* -,
11QStat
33
Quantitave analysis of the orthodontic and orthopedic effects of maxillary LEW1S.A B ,ROCHE,A F & WAGNER,BETTY (1982)
traction Growth of the mandible during pubescence
Amer JOrthod 8 4 384-398 Angle Orthod 52 325-342
BAUMR1ND.S ,KORN,E L ,ISAACSON,R J WEST,E E & M0LTHEN.R (1983b)
Su~erim~ositional assessment of treatment-associated chanaes in the LUDER,H U (1981)
te&porohandibular joint and the mandibular symphysis Effects of activator treatment-evidence for the occurrence of two different types
Amer J Orthod 8 4 443 -465 of reaction
B1RKEBAEK.L ,MELSEN,B & TERP,S (1984) Europ J Orthod 3 205-222
A laminagraphic study of the alterations in the temporo-mandibular joint MARSCHNER,J F and HARR1S.J E (1966)
followina activator treatment Mandibular growth and Class 11 treatment
Europ arth hod 6 257-266 Angle Orthod 36 89-93
BR1EDEN.C M ,PANGRAZIO-KULBERSH,V & KULBERSH,R (1984) MEACH,C L (1966)
Maxillarv skeletal and dental chanae with Fr'inkel aoipliance therapy A cephalometnc comparison of bony profile changes in Class 11 division 1
Angle 0rthod 5 4 226-232 patients treated with extra oral force and functional jaw orthopedics
CREEKMOREJD and RADNEY,L J (1983) Amer JOrthod 52 353-370
Frgnkel appliance therap Orthopedic or orthodontic?
Amer,JOrthod 8 3 89-108 McDOUGALL,PD ,McNAMARA,J A Jr & D1ERKES.J M (1982)
DELAIRE J (1978) Arch width development in Class 11 patients treated with the Frankel
The potential role of facial muscles in monitoring maxillary growth and appliance
morphogenesis pages 157-180 Amer J Orthod 82 10-22
In Muscle adaptation in the craniofacial region ,D S Carlson and J A McNamara McNAMARA,J A Jr (1981)
Jr (Editors), Monograph No 8, Craniofacial growth series, Center for Human Components of Class 11 malocclusion in children 8-10 years of age
Growth and Development, University of Michigan, Ann Arbor Angle Orthod 51 177-202
DEMISCH A (19721
Effects of activator therapy on the craniofacial skeleton in Class 11 division 1 McNAMARA,J A Jr (1984)
malocclusion Dentofacial adaptations in adult patients following functional regulator therapy
Trans Eur Orthod SOC295-309 Amer.JOrthod 8 5 57-71
Roberts - Functional Appliance selection Aust. Orthod. J., 9. March 85
McNAMARA,J A Jr ,CONNELLY,TG & McBRlDE,MC (1975) WE1SLANDER.L. and LAGERSTR0M.L. (1979)
Histological studies of temporomandibular joint adaptations Pages 209-227 The effect of activator treatment on Class 11 malocclusions
In Determinants of Mandibular Form and Growth J A McNamara,Jr ,(Editor), Amer.J.0rthod. 7590-26
Monograph No4,Craniofacial Growth Series,Center for Human Growth and
DeveIopment,University of Michigan,Ann Arbor,Michigan
.-
WITTF 11973
\- -,
Muscular physiological investigations into the effect of bimaxillary appliances
McNAMARA J A Jr and HUGE S A (1981) Trans EuropOrthod SOC 448-450
The Frankel appliance (FR2) model preparation and appliance construction WOODSIDE DG- 119771
- - -
Amer JOrthod 80.478-495 The ~ctivator chapter i ~ , ~ a 269-336

~ e s
MOORREESC FA (1984) In Removable Orthodontic Appliances, Graber,TM & Neumann,B
Review of "Technik und Handhabung der Funktionsregler" R Frankel W B Saunders & CO, 1977
Amer JOrthod 8 7 82 WOODSIDE,DG ,ALTUNA,G ,HARVOLD,EP,HERBERT,M & METAX1S.A
M0SS.M L (1970) nwii
The differentia! roles of perosteal and capsular functional matrices in orofacial Primate experiments in malocclusion and bone induction
arowth Amer JOrthod 83.460-468
M0YERS.R E ,RIOLO,M L ,GUIRE,K E ,WAlNWRIGHT,R L & This article is based on a paper presented to the 10th
BOOKSTEIN F L (1980) Australian Orthodontic Congress, Melbourne (1984)
Differential diagnosis of Class 11 malocclusions
Amer JOrthod 78 477-494
NIELSEN I L (1984) Dr. G.L.Roberts
Facial growth during treatment with the function regulator appliance 27 Blackburn Rd.,
PANCHERZ,H (1979) BLACKBURN.
Treatment of Class 11 malocclusions by jumping the bite with the Herbst Victoria 3130
ao~liance"a ce~haiometncinvestiaation
PANCHERZ,H (1982)
The mechanism of Class 11 correction in Herbst appliance treatment
PANCHERZ,H (1984)
A ceuhalometnc analvsis of skeletal and dental changes contributinq - to Class
11 correction in activator treatment
Amer JOrthod 85.125-134
PANCHERZ,H (1985)
The Herbst appliance-its biologic effects and clinical use
PANCHERZ,H and ANEHUS-PANCHERZ,M (1980)
Muscle activity in Class 11 division 1 malocclusions treated by bite jumping
. - . studv
with the Herbst auuhance an electromvoara~hic
Amer.J.0rthod 78-321-329
PETROV1C.A ,GASSON,N & OUDET,C (1975a)
Wirkung der ubertriebenen posturalen Vorschubstellung des Unterkiefers auf
das Kondylenwachstum der normalen und der mit Wachstumshormon
behandelten Ratte.
Fortschr Kieferorthop 3 6 86-97
PETR0VIC.A ,STUTZMANN,J & OUDET,C (1975)
Control processes in the postnatal growth of the condylar cartilage of the
mandible Pages 101-153
In Determinants of Mandibular Form and Growth. Monoarauh
No4,Craniofacial Growth Series,J A ~ c ~ a m a r a ( ~ d i t o r ) , ~ efor
n t Human
er
Growth and Development, University of Michigan,Ann Arbor,Michigan
PETR0VIC.A .STUTZMANN.J .OZEROVIC.B & VIDOV1C.Z (1982)
Does the Frankel appliance produce forward movement of the mandibular
premolars?
Europ JOrthod 4-173-183
P0ULTON.D R (1967)
A three year survey of Class 11 malocclusions with and without headgear
therapy
Angle Orthod 34 181-193
R1GHELLIS.E.G (1983)
Treatment effects of Frankel, activator and extra-oral traction appliances
Angle Orthod 53-107-121
R10LO.M L ,MOYERS,R E ,McNAMARA,JA Jr , & HUNTER,W S (1974)
An Atlas of Craniofacial Growth Monograph No2,Craniofacial Growth
Series,Center for Human Growth and Development, University of Michigan,
Ann Arbor, Michigan
R0BERTSON.N R E (1983)
An examination of treatment changes in children treated with the functional
regulator of Frankel
SIMPS0N.M McF (1976)
Lip incompetence and its relationship to skeletal and dental morphology-an
electromyographic investigation
SLAGSVOLD.0 (1977)
Activator Development and Philosophy,Chapter 7,pages 133-182
In Removable Orthodontic Apphances,Graber,TM and
Neumann,B ,W B Saunders and Company 1977
STUTZMANN,J and PETR0VIC.A (1979)
Intrinsic regulation of the condylar cartilage growth rate
Europ JOrthod 141-54
TEUSCHER,U (1978)
A growth related concept of Class 11 treatment
Amer J Orthod 74 258-275
TEUSCHERJJ (19831
Edgewise^therapy with cervical and intermaxillary traction-influence on the
position of the bony chin
Angle Orthod 5 3 212-227
T0MER.B S and HARV0LD.E P (1982)
Primate experiments on mandibular growth direction
VAGERV1K.K ,MILLER,A J ,CHIERICI,G ,HARVOLD,E P , & T0MER.B S
(1984)
Morphologic response to changes in neuromuscular patterns experimentally
induced by altered modes of respiration
VAN BEEK,H (1982)
Overjet correction by a combined headgear and activator
Europ JOrthod 4.279-290
WE1SLANDER.L (1974)
The effect of force on craniofacial development
Amer JOrthod 65-531-538
WE1SLANDER.L (1984)
Intensive treatment of severe Class 11 malocclusions with a headgear Herbst
appliance in the early mixed dentition
Amer J.Orthod 8 6 1-13
178

1985 Australian Orthodontic Journal, Melbourne

Uploaded by

Copyright:

Available Formats

1985 Australian Orthodontic Journal, Melbourne

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1985 Australian Orthodontic Journal, Melbourne

Uploaded by

Copyright:

Available Formats

C3 1985 Australian Orthodontic Journal, Melbourne

nt question is whether functional appliance therapy is capable of producing

s :functional appliances, selection, timing, activator, Teuscher, Frankel, Herbst, Bionators

deliberate primary impact is delivered to the musculature

alteration in muscle function produces changes in bone

4. Unloading of the mandibular condyle.

There are a number of reports concerning the effects of

activator group where the growth was expressed in a

appliances, should not be used by clinicians who will not

The limited orthopaedic effect reported by several

The untoward vertical effects of activator treatment can be

dento-alveolar remodelling mediated via the periosteal

Decrowding is a feature of all of the Frankel appliances

4. The projecting vestibular screens stretch the

The FR1 appliance is recommended in cases ranging

maxillary teeth. Frznkel considers that activators fail to

with the mandible protruded by no more than l-2mm. As

The possible mechanism of arch expansion with the FR1

Overbite reduction is accomplished by buccal segment

average anterior movement of the maxilla in FR1 treated

to stimulate maxillary development and to restrict

perioral musculature. He suggested that the retroclination

In functional orthopaedic philosophy, mandibular

(b) The mechanical aspect of FR3 treatment is mediated

This appliance was introduced in 1905 by Professor Emil

In comparison to removable functional appliance therapy,

Even in the most cooperative of patients the strain on

The Bionator was developed by Balters and has much in

may not be the only alternative available, but may prove

claimed to be important for the correct function of the

(a) It is considerably less bulky than the activator

Amer JOrthod 80.478-495 The ~ctivator chapter i ~ , ~ a 269-336

You might also like