REVIEW ARTICLE

Concepts on functional appliances’ mode of action

Carine Carels, D.D.S., Ph.D.,* and Frans P. G. M. van der Linden, D.D.S., Ph.D.**
Nymegen, The Netherlands

Several working hypotheses have been conceived to explain the mode of action of various functional
appliances. A review of the different concepts is presented and these concepts are tested by
means of data from basic scientific research. Furthermore, a general concept is postulated that could
unite the working principles of several functional appliances. Finally, the clinical relevance of
scientific research in this area is evaluated. (AM J ORTHOD DENTCIFAG ORTHOP 1987;92:162-8.)

I n the last 20 years, functional appliance

therapy has become a generally accepted method to treat
severe and moderate discrepancies of sagittal jaw re-
lations in children. Until now, functional appliance ther-
apy had its greatest application and success in Class II
malocclusions.
A variety of different functional appliances is avail-
able.’ The appliance selected for the treatment can be
adapted to the type of anomaly and to the growth pat-
tern. The growth direction, the growth amount, and the
timing are relevant to the ultimate success of the treat-
ment. Consequently, diagnosis and case selection are
critical for functional treatment.
Each proponent of the different functional appli-
ances has conceived more or less his own concept and
working hypothesis: Andresen, Haupl, and Petrik,’
Herren and Harvold4 for the activator; Baiter? for
the Bionator; FAnke16 for the functional regulator;
Stockfisch’ for the Kinetor; and Bimle? for the Ge-
bissformer. This also applies to Pancherz’ for the Herbst
appliance and to those who advocate the combination
of functional appliances with extraoral appliances:
Pfeiffer and Grobety” for an activator with a cervical
headgear; Teuscher,” and Lehman and van Beck” for
the combination of an activator-type appliance with a
high-pull headgear; van Beek13 for the activator-head-
gear; BassI for a Frankel-type appliance with a high-
pull headgear; and Wieslander” for a combination of
the Herbst appliance with a high-pull headgear.
It is the aim of this article (1) to present a review
of the different concepts on functional appliance ther-
From the Department of Orthodontics, University of Nymegen.
*Research Assistant of the National Fund for Scientific Research, Department
of Orthodontics, Leuven, Belgium; Trainee, Department of Orthodontics, Ny-
megen, The Netherlands.
**Professor and Chairman, Department of Orthodontics, University of Ny-
megen, The Netherlands.
apy, (2) to put these concepts to test by means of data
from basic scientific research, and (3) to postulate a
general concept, based on the first author’s research,
that could unite the working principles of several func-
tional appliances.
GENERAL CONSIDERATIONS
The theoretical basis of functional treatment in gen-
eral is the principle that a “new pattern of function,”
dictated by the appliance, leads to the development of
a correspondingly “new morphologic pattern.”
The “new pattern of function” can refer to different
functional components of the orofacial system-for ex-
ample, the tongue, the lips, the facial and masticatory
muscles, the ligaments, and the periosteum. Depending
on the type of appliance, its proponent puts more em-
phasis on one of these different functional components.
The “new morphologic pattern” includes a different
arrangement of the teeth within the jaws, an improve-
ment of the occlusion, and an altered relation of the
jaws. It also includes changes in the amount and di-
rection of growth of the jaws, and differences in the
facial size and proportions.
Where fixed orthodontic mechanotherapy predom-
inantly relies on the delivery of forces, a major part of
functional appliance therapy makes use of force re-
moval systems also.
CONCEPTS ON FUNCTIONAL APPLIANCES’ MODE
OF ACTION: CREATING A “NEW PAlTERN
OF FUNCTION”
In this respect the central question is as follows:
What is the impact of functional appliances on the dif-
ferent functional components of the orofacial complex?
One of the earliest functional appliances was called
the activate? because it was supposed to activate the
masticatory, facial, lip, and tongue musculature. An-

162
Volwle 92
Number 2
dresen believed that the protractor muscles of the man-
dible especially were stimulated by the use of the ac-
tivator. However, Ahlgren’6“8 claimed that only day-
time use of the activator stimulates the protractors and
that during the night its stimulation effect disappears.
The appliance would thus become effective during day-
time with the contraction of the protracting masticatory
muscles. The forces produced by these muscle con-
tractions would be transmitted to selective teeth and
their periodontia, to the jaws, and to the temporoman-
dibular joints. However, Eschler” stated that the re-
tractor muscles were stimulated because of the stretch-
ing of these muscles by the activator.
With its large forward bite registration, the Herren
activator is claimed to act as a splint. During mouth
closure the mandible is guided anteriorly; when the
appliance is in place, the masticatory muscles are in
a forced lengthened or shortened condition compared
to their rest length. The resulting tonus alteration of
the musculature would cause the mandible to turn
back to its original position during rest, but this is re-
stricted by the activator’s forced guidance. The turning
back powers would be intercepted by the activator’s
support3.”
The Harvold,-Woodside activator was designed to
affect the recruitment of certain masticatory and facial
muscles and to control the eruption of teeth.*‘.** In con-
trast to the Andresen activator, it is constructed to in-
terfere with the postural position of the mandible and
with the vertical distance between the jaws. The acti-
vator should serve to stretch certain selected muscle
groups using the elastic properties of the muscles and
the isometric contractions elicited by the appliance.
This activator keeps the mandible extended beyond the
rest position and the elasticity of the muscles moves
the mandible toward the rest position. The forces can
then be transmitted to the teeth in order to correct mal-
positions even though the patients are relaxed and
asleep. The isometric contractions, which result from
the stretching, exercise the muscles, thus changing the
muscle matrix. All the muscles that are selectively
stretched are affected in this fashion. By keeping the
mandible at a level extending beyond the rest position,
the activator strengthens the facial muscles, particularly
the buccinators and the lips. According to Harvold,4
the activator does not elicit responses in the mechanisms
controlling the growth of the jaw bones, but merely
induces changes in the musculature supporting the man-
dible relative to the maxilla and finally a rearrangement
of the muscle attachments.
To meet the bulkiness of the activator and its lim-
itation to nighttime wear, a number of modifications of
Functional appliances’ mode of action 163
this appliance have been made that have been called
collectively the “open activators.” The Bionator is one
of these less bulky appliances. According to Baiters,’
the equilibrium between the tongue and circumoral
muscles is responsible for the shape of the dental arches
and for the intercuspation. Balters contends that the
Bionator can establish good functional coordination
between the internal and external muscles, thereby
enhancing normal development of these muscles and
eliminating deforming, growth-restricting aberrations.
Other examples of open activators are the Kinetor’ and
the Bimler appliance.8
A functional appliance that has recently been the
object of intense evaluation is the one developed by
FrHnkel.6 Frankel’s functional regulator is worn pri-
marily in the lingual and dental regions, and uses the
vestibule as the operational base in contrast to all of
the previously mentioned functional appliances.“~‘4 It
is claimed that the system of labial, lingual, and buccal
pads and shields directly affects the level of postural
activity in the facial and masticatory muscles by means
of a training effect. The buccal and labial shields placed
highly in the vestibule would also indirectly put traction
onto the periosteum. This traction would stimulate bone
growth in the apical subperiosteal areas” and provide
a guidance of eruption for the teeth.”
Although it is in fact a fixed bite-jumping appliance,
the Herbst appliance is discussed with functional ap-
pliances because its biologic mode of action includes
effects on the masticatory musculature. When the ap-
pliance is inserted, the EMG activity from both the
temporal and the masseter muscles is temporarily re-
duced. When the appliance is removed and 12 months
posttreatment, the muscular activity exceeds pretreat-
ment values. Hence, it was claimed that treatment with
the Herbst appliance affects the function of the masti-
catory musculature.”
The simultaneous use of activator-like appliances
and headgear implies both a “functional” component
and a mechanical force application. The treatment phi-
losophy of the functional part of the combination ap-
pliances is that temporary additional condylar growth
should likely be induced, that the mandible must be
deblocked from its habitual position, that occlusal trans-
fer of distally oriented headgear forces from the maxilla
to the mandible must be avoided,” and that specific
muscles should be trained. I4 Van Beck’* claims that the
mandibular hyperpropulsion with his appliance is elic-
ited by the mucosal contact in the lower premolar region
giving rise to a postural avoidance reflex of the man-
dible. The mechanical force application from the head-
gear traction results in a dorsal and cranially directed
164 Carels and van der Linden
force on either the nasomaxillary complex against the
direction of maxillary sutural growth and/or on the max-
illary dentition.
Although it is clear that the indication for combining
the Herbst appliance with a high-pull headgear lies in
severe Class II, Division 1 malocclusions in the mixed
dentition, Wieslander” does not claim a differential
functional mode of action to this appliance and the
noncombined Herbst appliance.
CLINICAL EVIDENCE OF MODE OF ACTION OF
FUNCTIONAL TREATMENT
Most of the evidence on functional appliances’
mode of action relies on dental cast study and on the
roentgen-cephalometric evaluation of the functional
treatment effects in the clinical situation by means of
cephalometric analysis. In these studies the lateral head
plates have been analyzed predominantly and only a
few authors report on the analysis of anteroposterior
head plates.
From these studies it appears that most authors agree
that dentoalveolar adaptations contribute to the correc-
tion of Class II malocclusions with functional appli-
ances. These dentoalveolar changes include an inhibi-
tion of mesial migration of maxillary teeth, an inhibition
of maxillary alveolar height increase, a change in po-
sition of the upper and lower incisors, an intrusion of
maxillary and mandibular incisors, and a mesial move-
ment of mandibular teeth. Some authors found that
functional treatment effects are limited to the dentoal-
veolar area. ‘929-3’
Although the mandibular structures are shown to
come significantly forward during treatment,32 conflict-
ing opinions still exist in the literature concerning the
effect of different functional appliances upon the growth
of the mandible. Some authors indicate that the increase
in mandibular growth is the distinguishing aspect of
functional treatment with respect to other treatment
procedures23.27.33-37; others maintain that increased man-
dibular length does not result from functional appliance
treatment.21.22,29.31.38
Recently, evidence has also been
provided that functional treatment has an effect on the
location of the glenoid fossa, giving rise to a relocation
of the mandible in an anterior direction.‘5,22,27
Combination appliances of the activator-headgear
type consistently have an inhibitory effect on the for-
ward growth of the maxilla and provide the possibil-
ity of controlling the vertical development of the max-
illa.‘0-‘2~28~39~40 An orthopedic effect with a restricting
and redirecting influence upon the growth of the maxilla
has, however, also been achieved with activator-type
appliances. 22,34,4’
Am. J. Orthod. Dentofac. Orthq.
August 1987
Analysis of posteroanterior head plates and dental
casts also has revealed an extensive transverse effect of
some functional appliances, especially the Frankel ap-
pliance.424
EXPERIMENTAL EVIDENCE ON FUNCTIONAL
APPLIANCES’ MODE OF ACTION
In search for biologic and physiologic explanations
for the clinical observations (successful results with
functional appliance therapy in many cases and total or
partial failure in others), up to now mostly animal ex-
periments have been performed to test hypotheses pro-
posed for the mechanisms underlying the observed re-
sponses to functional appliance therapy. All these ex-
periments were performed on animals with normal
sagittal jaw relations.
McNamara and his co11eagues24,4’pointed out from
their experiments in Mucaca muluttu primates that an-
terior displacement of the mandible was capable of in-
ducing altered postural activity in the pterygoid mus-
cle, which consecutively induced additional condylar
growth. Although McNamara concluded from his ex-
periments that the FrHnkel appliance showed the most
resemblance to his experimental appliance in monkeys,
no gradual advancement of the mandible had been ap-
plied during these experiments.
From their experiments on rats, Petrovic and his
colleagues4,47 also claimed that the enhanced activity
in the pterygoid muscle during mandibular hyperpro-
pulsion induced supplementary growth in the mandib-
ular condylar cartilage. Experimental evidence also has
been provided that the Frankel lateral vestibular shields
bring about an enhanced and supplementary widening
of the upper jaw in rats. The appliance would essentially
act by stimulating the midpalatal suture and, to a lesser
extent, by enhancing bone apposition on the external
subperiosteal layer of the maxilla. Simultaneous pres-
sure on the tongue side and relief of pressure from the
cheek side would produce this effect.48
The change in the activity of the pterygoid muscle
is indeed a “new pattern of function,” which in exper-
imental animals leads to a “new morphologic pattern.”
However, the enhanced postural activity in the ptery-
goid muscle could not be demonstrated in patients
treated with the Hen-en activator.*’
Concerning the impact of the appliances on the other
functional components of the craniofacial system (as
discussed previously), currently no scientific evidence
has been provided and thus the subject remains for the
most part in the area of wishful thinking.
The available experimental evidence therefore lends
support to the general theoretical concept that functional
Volume 92
Number 2
appliance therapy indeed dictates a “new pattern of
function,” but it appears that up to now only a small
part of what has been postulated is scientifically veri-
fied. It is also still questionable as to what are the
minimal requirements for a functional appliance to elicit
a new pattern of function in the clinical situation and
how to quantify it.
Although it has been generally accepted that the
orofacial musculature has a profound influence on the
development of the. face and dentition,& it may be very
difficult to evaluate and quantify this effect as it relates
to the morphology, to the relative position, and to the
functional behavior of the muscular components. The
importance of the lateral pterygoid muscle has conclu-
sively been demonstrated in the experiments of Mc-
Namara,24,25 Petrcvic,46.47 and their respective col-
leagues, but it must be kept in mind that 20 other facial
or masticatory muscles are attached to the mandible and
that these muscles are all mechanically linked by means
of the mandible. Thus, a change in the activity of one
muscle, giving rise to a change in mandibular posture,
must always be accompanied by lengthening or short-
ening of other muscles attached to the mandible. Con-
sequently, since the distribution of force in the muscles
and at the bone-muscle interface is changed, the process
of adaptation can begin in both systems: the muscle-
adaptation to a new functional length and the bone
remodeling to new stress distribution at its surface. The
degree of adaptation varies in the different parts of the
dentofacial system .50
Theoretically, one also expects a neurally mediated
contribution to the force generation in a muscle after
its lengthening by Imeans of the autogenetic tonic stretch
reflex-especially in the elevator muscles-as was also
proposed by Stockli and Teuscher.40 However, this
probably does not hold true in the trigeminal area since
Yemm5’ could not record any action potentials from the
masseter in rest.
THE PROPOSAL OF A NEW
FUNCTIONAL CONCEPT
Recently, changes in neuromuscular reflexes were
recorded by the first author in children before and during
their treatments with the Bionator,52 and it appeared
that during this functional treatment specific jaw re-
flexes elicited in a standardized way were altered tran-
siently (Fig. 1). These changes in reflexes were asso-
ciated in time with improvements in the sagittal jaw
relation during the functional treatment (Fig. 2) and
it was postulated that they might provide a clue for
the mechanism underlying functional jaw orthopedic
treatment.
Functional appliances’ mode of action 165
Fig. 1. Schematic representation of the experimental setup for
eliciting the neuromuscular reflexes in children being treated
with the Bionator functional appliance. The stimuli for eliciting
the reflexes were soft taps delivered to a vital maxillary central
incisor by means of an electromagnetically driven pendulum
(a). The EMGs were recorded with surface ekctrodes placed
bilaterally over the masseter muscles. After processing 72 raw
EMG sweeps, the so-called poststimulus EMG complex (PSEC)
appears. In (b) the PSECs from before and during functional
treatment are superimposed.
The hypothesis was proposed that during the first
phase of functional treatment, reflexes in jaw muscles
are transiently brought into a state of imbalance. This
phase of imbalance could act as a trigger for the man-
dible to attain a new functional position, which sub-
sequently leads to morphologic changes. The fact that
in these experiments neuromuscular changes and a fa-
vorable clinical response were always simultaneously
registered does not mean, however, that no lapse of
time could exist between the neuromuscular changes
and the morphologic changes.52.J4Indeed, the neuro-
muscular changes might have occurred first and trig-
gered the morphologic changes, as was also suggested
by McNamara and co11eagues,45who observed an in-
terval of 2 weeks between the onset of the muscular
response and the morphologic changes in histologic
preparations of the mandibular condyle of Macaca mu-
lafra. It may well be that full-time wearing of the ap-
pliance is of importance in this respect since a contin-
uous anterior functioning might elicit the muscle re-
sponse more rapidly than a discontinuous one. In view
of these considerations, functional appliances that are
166 Carels and van der Linden
Fig. 2. A, Before Bionator functional appliance therapy, trigem-
inal neuromuscular reflexes are in a kind of balance. In this
state of equilibrium, an interaction exists among the afferent
input from the periodontium, the musculature, and the tempo-
romandibular joint. When reflexes were elicited in this situation,
a short latency reflex was never observed in the poststimulus
EMG complex (PSEC, see AM J ORTHOD DENTOFAC ORTHOP
1988;90:410-9) as is indicated in the plot. B, During the first
8 months of functional treatment, the changes in the relationship
of the jaws were associated in time with an imbalance in the
neuromuscular reflexes. The afferent input to the brain stem
also changes (which is indicated with a A on this figure). A
short latency excitatory burst of EMG activity is then present in
the PSEC.
worn full-time (Herbst appliance) or nearly full-time
(eg, Frlnkel’s functional regulator, Bionator) could be
expected to have a greater net result than those worn
only part-time (eg, activator).
It also appeared from the first author’s investigation
on neuromuscular reflexes in Bionator-treated casesthat
the more the mandible was placed in an anterior position
Am. J. Orthod. Dentofac. Orthop.
August 1981
by the appliance, the larger was the forward positional
response of the mandible and the larger was the ac-
companying muscle response. These data do not indi-
cate the need for a gradual mandibular advancement by
the appliance (as has been advocated for Frankel’s func-
tional regulator, for example). In these findings the
muscle response was larger in the subjects with an ex-
tensive overjet who underwent a larger anterior posi-
tioning by the appliance than in those subjects with a
moderate overjet. In other words, the larger the anterior
positioning by the appliance, the larger the muscle re-
sponse, the larger the positional response, and probably
the larger the morphologic change also.
Contact between the antagonistic incisors during the
wear of the appliance might also play a role since it
could serve as a reference for the patient-who then is
deprived of the interdigitation of the posterior teeth-
by providing sensory information onto the required an-
terior development of the mandible.
IMPACT OF RESEARCH ON THE CLINICAL USE
OF FUNCTIONAL APPLIANCES
Orthodontists probably agree that it would be de-
sirable to consistently achieve the same responses and
effects on the orofacial structures in patients treated
with a specific functional appliance in whom the oc-
clusal conditions and treatment goals are the same, and
to vary the responses according to the malocclusions to
be treated. It is argued by some authors that this can
be done to some extent by variations in appliance design
and by the addition of other appliances-as, for ex-
ample, a high-pull headgear-simultaneously used,37
but it cannot be overlooked that the treatment response
is inherent to the individual growth pattern. A specific
way of growing may well be associated with another
treatment response. To elucidate this question, in future
studies on functional treatment effects investigators
should always try to differentiate among experimental
subgroups with divergent skeletal features who are
treated identically; no comparative studies of this kind
have been made until now. In studies of this type, the
variability in the responses will probably be smaller
than the ones observed until now in clinical studies and
indications of the optimal appliance design might
emerge in any of the subgroups.
Although a gradual advancement of the mandible
by means of the functional appliance has been consid-
ered preferable to a one-step advancement of the man-
dible,10.32,53until the current study” no conclusive ex-
perimental evidence has been provided in favor of this
treatment modality. It can indeed be imagined that a
gradual advancement is more favorable for the patient’s
 Functional appliances’ mode of action 167

comfort; however, aside from a slight discomfort for porary orthodontics. In: Johnston LE, ed. New vistas in ortho-
3 to 4 days after appliance insertion, no adverse biologic dontics. Philadelphia: Lee & Febiger, 1985.
24. McNamara JA Jr. Dentofacial adaptations in adult patients fol-
reactions have been attributed to the one-step advance-
lowing functional regulator therapy. AM J ORTHOD 1984;85:
ment. Perhaps animal experiments could further elu- 57-71.
cidate this matter. 25. Falck F. Miiglichkeiten der sagittalen Nachentwicklung maxil-
liirer Strukturen mit dem Funktionsregler Typ Ill. Zahn Mund
REFERENCES Kieferheilkd 1981;69:465-71.
1. Graber TM, Rakosi AG, Petrovic A, eds. Dentofacial orthope- 26. Frlnkel R. Biomechanical aspects of the form/function relation-
dics with functional appliances. St Louis: The CV Mosby Com- ship in craniofacial morphogenesis: A clinician’s approach. In:
pany, 1985. McNamara JA, Ribbens KA, Howe RP, eds. Clinical alteration
2. Andresen V, Haupl K, Petrik L. Das Verhalten der Muskulatur of the growing face. Monograph 14, Craniofacial Growth Series.
bei Behandlungen mit dem Aktivator. In: Barth JA, ed. Funk- Ann Arbor: 1983. Center for Human Growth and Development,
tionskieferorthopadie. Munich: Verlag, 1957. University of Michigan.
3. Herren P. The activator’s mode of action. AM J ORTHOD 27. Pancherz H. The Herbst appliance-its biologic effects and clin-
1959;45:512-27. ical use. AM J ORTHOD 1985;87:1-29.
4. Harvold EP. The activator in interceptive orthodontics. St Louis: 28. Van Beek H. Combination headgear-activator. J Clin Orthod
The CV Mosby Company, 1974. 1984;18:185-9.
5. Balters W. Die Technik und Ubung der allgemeinen und spe- 29. Wieslander L, Lagerstriim L. The effect of activator treatment
ziellen Bionator I herapie. Die Quintessenz 1964;1:77-85. on Class 11 malocclusions. AM J ORTHOD 1979;75:20-6.
6. Frlnkel R. Decrowding during eruption under the screening in- 30. Robertson NR. An examination of treatment changes in children
fluence of vestibular shields. AM J ORTHOD 1974;65:372-406. treated with the function regulator of Frlnkel. AM J ORTHOD
7. Stockfisch H. Possibilities and limitations of the Kinetor bimax- 1983;83:299-310.
illary appliance. ‘Trans Eur Orthod Sot 1971;47:317-28. 3 1. Bjiirk A. The principles of the Andresen method of orthodontic
8. Bimler HP. Indikation der Gebisrfotmer. Fortschr Kieferorthop treatment: a discussion based on cephalometric x-ray analysis of
1964;25:121-44. treated cases. AM J ORTHOD 195 1;37:437-58.
9. Pancherz H. Treatment of Class 11 malocclusion by jumping the 32. Baumrind S, Kern EL, lsaacson RJ, West EE, Molthen R. Su-
bite with the Herbst appliance. AM J ORTHOD 1979;76:423-42. perimpositional assessment of treatment-associated changes in
10. Pfeiffer JP, Groblity D. Simultaneous use of cervical appliance the temporomandibular joint and the mandibular symphysis.
and activator: an orthopedic approach to fixed appliance therapy. AM J OR~HOD 1983;84:443-65.
AM J OR~I~O~ 1972;61:353-70. 33. McNamara JA Jr, Bookstein FL, Shaughnessy TG. Skeletal
I 1. Teuscher II. A grllwth-related concept for skeletal Class 11 treat- and dental changes following functional regulator therapy on
ment. AM J ORTEIOD 1978;74:258-75. Class 11 patients. AM J ORTHOD 1985;88:91-I 10.
12. Lehman R. van Beek H. Die orthodontisch-orthopldische Kom- 34. Liider HU. Skeletal profile changes related to two patterns of
binazionsbehandlung bei grosser Frontzahnstufe. Fortschr Kie- activator effects. AM J OR~HOD 1982:81:390-6.
ferorthop 1984;4? :465-74. 35. Owen AH. Morphologic changes in the sagittal dimension using
13. Van Beek H. Ovzrjet correction by a combined headgear and the Frtinkel appliance. AM J OR~HOD 198 1;80:573-603.
activator. Eur J Orthod 1982;4:279-90. 36. Reey RW, Eastwood A. The passive activator: case selection,
14. Bass NM Dento-facial orthopaedics in the correction of treatment response, and corrective mechanics. AM J ORTHOD
Class 11 malocclusion. Br J Orthod 1982;9:3-31, 1978;73:578-83.
15. Wieslander L. Intensive treatment of severe Class 11 malocclu- 37. Meach CL. A cephalometric comparison of bony profile changes
sions with a headgear-Herbst appliance in the early mixed den- in Class 11, Division 1 patients treated with extraoral force and
tition. AM J ORTYOD 1984;86:1-13. functional jaw orthopedics. AM J ORTHOD 1966;52:353-70.
16. Ahlgren J. Early and late electromyographic response to activator 38. Jakobsson SO. Cephalometric evaluation of treatment effect on
treatment with activators. AM J ORTHOD 1978;74:88-93. Class 11. Division 1 malocclusions. AM J ORTHOD 1967;53:
17. Ahlgren J. The neurophysiologic principles of the Andresen 446-55.
method of functional jaw orthopedics. A critical analysis and 39. Pfeiffer JP, Grob&y D. The Class 11 malocclusion: differential
new hypothesis. S wed Dent J 1970;63: l-9. diagnosis and clinical application of activators. extraoral traction,
18. Ahlgren J. Bendeus M. Changes in length and torque of the and fixed appliances. AM J OR~HOD 1975;68:499-544.
masticatory muscles produced by the activator appliance. A 40. Stiickli PW, Teuscher VM. Combined activator headgear ortho-
cephalometric study. Swed Dent J [Suppl] 1982;15:27-35. pedics. In: Graber TM, Swain BF, eds. Orthodontics. current
19. Eschler J. Das Andresen-Htiupl’ sche Behandlungssystem (Die principles and techniques. St Louis: The CV Mosby Company,
Muskelreflcxmethode). In: Hansel C, ed. Die funktionelle Or- 1985.
thopLdie des Kausystems. Munich: Verlag, 1952. 41. Pancherz H. A cephalometric analysis of skeletal and dental
20. Auf der Maur HJ Electromyographic recordings of the lateral changes contributing to Class 11 correction in activator treatment.
pterygoid muscle in activator treatment of Class 11, Division 1 AM J OR~HOD 1984;85:125-34.
malocclusion cases. Eur J Orthod 1980;2:161-71. 42. Graber TM. Evolution of concepts underlying craniofacial
2 1. Harvold EP, Vargcrvik K. Morphogenetic response to activator growth regulation. In: McNamara JA Jr, Ribbens KA, Howe
treatment. b.M J ORTHOD 1971;60:478-90. RP, eds. Clinical alteration of the growing face. Monograph
22. Vagervik K, Harvold EP. Response to activator treatment in 14, Craniofacial Growth Series. Ann Arbor: 1983:313-9.
Class 11 malocclusions. AM J ORTHOD 1985;88:242-51. Center for Human Growth and Development. University of
23. McNamara JA Jr. The role of functional appliances in contem- Michigan.
166 Carels and van der Linden Am. .I. Orthod. Dent&c. Orthop.
August 1987

43. McDougall PD, McNamara JA Jr, Diekes JM. Arch width de- 50. Van der Linden FPGM. Facial growth and facial orthopedics.
velopment in Class II patients treated with the Frlnkel appliance. Chicago: Quintessence, 1986.
AM J ORTHOD 1982;82:10-22. 51. Yemm R. The muscles of mastication: the properties of their
44. Brieden CM, Pangrazio-Kulbersch V, Kulbersch R. Maxillary motor units, and length tension relationships of the muscles. In:
skeletal and dental change with Frlnkel appliance-an implant Anderson DJ, Matthews B, eds. Mastication. Bristol, England:
study. Angle Orthod 1984;54:226-32. Wright & Sons, 1976.
45. McNamara JA Jr, Connelly TG, McBride MC. Histological 52. Carels C, van Steenberghe D. Changes in neuromuscular reflexes
studies of temporomandibular joint adaptations. In: McNamara in the masseter muscles during functional jaw orthopedic treat-
JA Jr, ed. Determinants of mandibular form and growth. ment in children. AM J ORTHOD DENTOFAC ORTHOP 1986;90:
Monograph 4, Craniofacial Growth Series. Ann Arbor: 1975. 410-9.
Center for Human Growth and Development, University of 53. Frankel R. Personal communication, 1985.
Michigan. 54. Carels C. Neuromuscular reflexes in the masseter muscle and
46. Charlier JP, Petrovic A, Stutzmann JJ. Effects of mandibular their relation to jaw position in man [Ph.D. thesis]. Leuven,
hyperpropulsion on the prechondroblastic zone of young rat con- Belgium: Catholic University of Leuven, 1985.
dyle. AM J ORTHOD 1969;55:71-4.
47. Petrovic AG. Research findings in craniofacial growth and
the modus operandi of functional appliances. In: Graber TM, Reprint requests to:
Rakosi T, Petrovic AG, eds. Dentofacial orthopedics with func- Dr. Carine Carels
tional appliances. St. Louis: The CV Mosby Company, 1985. Department of Orthodontics
48. Stutzmann J, Petrovic A, Graber TM. Effects of the lateral ves- University of Nymegen
tibular shields on the widening of the upper jaw. An experimental Philips van Leydenlaan, 25
investigation in the rat. Stomatol DDR 1985;33:753-66. 6500 HB Nymegen
49. Graber TM. The three MS: muscles, malformation, and mal- The Netherlands
occlusion. AM J ORTHOD 1963;49:418-50.

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