CASE REPORT Hong Kong Dental Journal 2005;2:45-8 HK

DJ
Modified trimming of the van Beek
headgear activator
Ricky Wing-Kit Wong *, BDS, MOrth, PhD, MOrthRCS, FRACDS,
FHKAM (Dental Surgery), FCDSHK (Orthodontics)
Michael Stephen Cooke †, BChD, LDS, DDPHRCS, DOrthRCS, FDSRCS, FFDRCS, PhD,
FHKAM (Dental Surgery), FCDSHK (Orthodontics)
Wayne Robinson *, LIBST, DipEd

ABSTRACT The van Beek activator is used to correct class II malocclusion by inhibiting the downward and forward
growth of the maxillary body and stimulating mandibular growth in an anterior direction. The principles and techniques
used to trim an activator have been described in detail elsewhere. An alternative trimming approach has been used
successfully in many patients, such as the class II division I patient described herein.

Introduction many patients, including the following class II division

The van Beek activator was first described by van
Beek in 1982 1,2. It combines an activator with two
outer bows supplying hooks for high-pull headgear
attachment. Instead of labial bows, the anterior teeth
are covered labially with acrylic. Class II malocclusion
is corrected by the inhibition of downward and forward
growth of the maxillary body and the stimulation of
mandibular growth in an anterior direction. The
principles and techniques used to trim an activator
have been described in detail 3. With the van Beek
activator, there is usually no grinding of the acrylic of
the upper arch; the palatal halves of the occlusal surfaces
are covered in the molar and premolar regions 1,2. If
expansion is necessary, the indentations are ground
free in a lateral direction, maintaining the sagittal contour.
In the lower arch, the acrylic is ground lingual of the
incisor region to prevent incisor proclination. In cases
of a deep curve of Spee, the acrylic is ground in lower
premolar regions to accommodate the eruption of
the lower premolars. We describe an alternative
trimming approach that has been used successfully in
I patient.
Case report
Diagnosis
A 12-year-old Chinese girl presented with the chief
complaint of irregular spacing of the teeth (Figure 1).
She was premenarche and her medical history was
clear. She had a convex lateral profile and retrognathic
mandible; the lips were incompetent. There was
anterior crowding in the lower arch, and the Spee
curve was increased. In the upper arch, there was
spacing between teeth 11 and 12 caused by a thick
labial frenum, and the midline was shifted. Tooth 23
was unerupted and crowded buccally. The molar
relationships were class II, and the incisor relationship
was class II division I with a 10-mm overjet and a 5-mm
overbite. Preoperative cephalometric analysis (Table)
revealed skeletal class II, protruding maxilla, proclining
incisors, protruding upper lip, and low mandibular plane
angle.

Treatment plan
* Faculty of Dentistry, The University of Hong Kong, Hong Kong
†
Private practice as Specialist in Orthodontics
Patient was skeletal class II and the mandible was
Correspondence to: deficient. The patient had not started menarche and
Dr. Ricky Wing-Kit Wong had not passed the growth spurt, so a growth modifica-
Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, tion approach using a headgear activator was adopted.
Hong Kong
Tel : (852) 2859 0554
Fixed appliances were used to finalize the occlusion.
Fax : (852) 2559 3803 Frenectomy was needed for closure of the median
e-mail : fyoung@hkucc.hku.hk diastema.

Hong Kong Dent J Vol 2 No 1 June 2005 45

Wong et al

(a) (b)

Figure 1 Pretreatment: (a) front view and (b) lower arch form

Table Cephalometric data

Parameter Norm Pretreatment After wearing Post-treatment

activator
Hard tissue
ANSBa (o) Ο -130.0 138.7 141.6 -142.3
ASNA (o) Ο -082.0 088.5 086.8 -085.8
ASNB (o) Ο -079.0 082.3 080.4 -079.1
ASNPg (o) Ο -081.0 081.9 079.6 -078.9
AANB (o) Ο -003.0 006.2 006.4 -006.7
ASN/MnPl (o) Ο -034.0 024.6 032.4 -032.9
ASN/MxPl (o) Ο -008.0 006.9 006.5 -010.0
AMxPl/MnPl (o) Ο -026.0 017.7 025.9 -022.9
AN-MxPl (o) Ο -054.0 048.3 051.2 -053.3
AMe-MxPl (o) Ο -064.0 065.1 069.7 -069.5
Ο
AU1/MxPl (o) -118.0 130.6 118.6 -107.7
AL1/MnPl (o) Ο -097.0 114.3 114.5 -108.3
Ο
AInterincisal (o) -115.0 097.4 101.0 -121.1
AL1 to A-Pg (mm) 00-5.5 009.2 011.0 00-7.1
AA, B on OP (mm) 00-4.5 003.7 003.8 00-1.7
Soft tissue
AUpper lip to E (mm) -003.0 007.1 003.7 00-0.2
ALower lip to E (mm) -004.0 005.5 001.8 -002.4
NSBa=nasion-sella-basion angle, SNA=sella-nasion-A point angle, SNB=sella-nasion-B point angle, SNPg=sella-nasion-pogonion angle, ANB=A
point-nasion-B point angle, SN/MnPl=sella-nasion/mandibular plane angle, SN/MxPl=sella-nasion/maxillary plane angle, MxPl/MnPl=maxillary
plane/mandibular plane angle, N-MxPl=nasion-maxillary plane angle, Me-MxPl=menton-maxillary plane angle, U1/MxPl=upper incisor/maxillary
plane angle, L1/MnPl=lower incisor/mandibular plane angle, L1 to A-Pg=distance of lower incisor to A point-pogonion line, A, B on OP=Wits
analysis (OP=occlusal plane), and E=esthetic line

Treatment progress
Treatment began with the headgear activator using a
modified van Beek trimming approach (Figure 2). Initially,
only light extraoral force was applied to the headgear,
and the duration of wearing was progressively increased.
After several weeks, the upper occlusal surfaces distal to
the canines of the headgear activator were trimmed flat,
the extraoral force was increased to above 500 g, and the
duration of wearing was increased to 14 hours a day. Four
months into treatment, the lower occlusal surfaces (distal
to the canines) of the headgear activator were also
trimmed. Six months into treatment, the overjet was
0.5 mm and the molar relationship was class I.
The facebow of the headgear activator was sectioned, and
the activator was only worn during bedtime as a
retainer. Later, extractions of teeth 14, 24, 34, and 44
were performed. Tooth 23 was left to erupt and drift
distally. Ten months into treatment, upper and lower
preadjusted 0.022-inch slot, edgewise appliances were

46 Hong Kong Dent J Vol 2 No 1 June 2005

 Modified trimming of the van Beek headgear activator

(a) (b)

Figure 2 (a) Patient wearing headgear activator and (b) close-up view

(a) (b)

(c) (d)

Figure 3 Fixed appliance treatment: (a) initial alignment with NiTi wire, (b) continued alignment with NiTi wire, (c) space
closure with NiTi closed coil springs and class II elastics, and (d) finishing stage

issued (Figure 3). Teeth 13 to 22 were aligned, and II elastics. Twenty-seven months into treatment, Hawley
frenectomy was performed. After alignment, the space retainers were issued. A fixed lingual retainer for teeth
closure was performed using a sliding mechanic and class 11 to 21 was bonded for additional retention (Figure 4).

Hong Kong Dent J Vol 2 No 1 June 2005 47

Wong et al
(a)
Figure 4 Post-treatment: (a) front view and (b) lower arch form
Figure 5 Trimming of headgear activator, lower occlusal
plane, outer bows removed for clarification
Discussion
This modified activator trimming provided an effective
alternative growth modification treatment for this patient
with class II malocclusion. In the lower arch, the acrylic
covering the occlusal surfaces of the buccal teeth was
trimmed flat so that only the canine tip and the distal
cusp tips of the molars contacted the acrylic (Figure 5). In
order to flatten the curve of Spee, the acrylic lingual to the
buccal segment was also trimmed so that it touched only
the most lingual areas of the buccal teeth. In the upper
arch, the acrylic touching the upper buccal teeth (from the
canines back) was trimmed flat to allow the upper teeth to
move buccally (Figure 6). In order to prevent loss of
occlusal support, care was taken not to trim the acrylic
touching the cusp tips by marking the cusp tip indentations
48 Hong Kong Dent J Vol 2 No 1 June 2005
(b)
Figure 6 Trimming of headgear activator, upper occlusal
plane
in the acrylic before trimming. The acrylic palatal to the
buccal segment was also trimmed so that it touched only
the most palatal areas of the buccal teeth, allowing more
efficient buccal movement of the upper buccal teeth during
activator treatment. This trimming approach can be
adapted to other functional appliances, and clinical
experience has shown that it is highly effective.
References
1. van Beek H. Overjet correction by a combined headgear and
activator. Eur J Orthod 1982;4:279-90.
2. van Beek H. Combination headgear-activator. J Clin Orthod 1984;
18:185-9.
3. Rakosi T. Trimming of the activator. In: Graber TM, Rakosi T, Petrovic
AG, editors. Dentofacial orthopedics with functional appliances.
2nd ed. St. Louis: MosbyCo; 1997:194-213.