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BITE REGISTRATION FOR VARIOUS

FUNCTIONAL APPLIANCES

 INTRODUCTION

 DIAGNOSTIC PREPARATION

 TREATMENT PLANNING

 GENERAL RULES FOR BITE REGISTRATION

 METHODS OF BITE REGISTRATION

 BITE REGISTRATION FOR VARIOUS FUNCTIONAL APPLIANCES

 ACTIVATOR
 BIONATOR
 FRANKEL
 TWIN BLOCK

 CONCLUSION

INTRODUCTION

 The most critical factor in the construction of a
functional appliance is the bite registration.

 Proper functional appliance fabrication requires the
determination and reproduction of the correct
construction or working bite.

 The mode of force application, magnitude and
direction depends on the 3dimensional dislocation of
the mandible, which is determined by the construction
bite.

GOAL The goal of the construction bite is to produce maximum physiological response with minimum trauma to the tissues and discomfort to the patient. This creates artificial functional forces and allows assessment of the appliance's mode of action. .PURPOSE The purpose of this mandibular manipulation is to relocate the jaw in the direction of treatment objectives.

.i. Therefore the clinician must not only assess clinically the somatic and psychologic aspects of the patient but also determine the patient's motivation potential.e moving the mandible forward into an anterior.  Creating an "instant correction" . The patient sees the objectives of the correction to be made by the functional appliance and is more likely to work toward this goal than merely to realize the dental health and functional improvement.DIAGNOSTIC PREPARATION  Patient compliance is essential.may help motivate patients with Class II malocclusions. more normal sagittal relationship.

. As Frankel (1983) points out.prominence. In some problems of maxillary protrusion and excessive vertical dimension and reduced symphyseal. a forward positioning does not improve the appearance of the profile. performing this clinical maneuver at the beginning of treatment also indicates to the clinician whether the therapeutic goal is really an improvement. Other therapeutic measures may be required. Video imaging also augments patient motivation.

Nature of the midline discrepancy. Symmetry of the dental arches. Crowding and any dental discrepancies. First permanent molar relationship in habitual occlusion. and the patient's functional pattern. 3. cephalometric and panoral head films. 2. Study model analysis: 1. 1. . the clinician must prepare by making a detailed study of the plaster casts. 4. STARTERS  Before taking the construction bite.

Interocclusal clearance or freeway space. 3. point of initial contact. 6. 5. Functional analysis: 1. . 2. 4. Prematurities.2. Sounds such as clicking and crepitus in the TM]. and resultant mandibular displacement. occlusal interferences. Path of closure from postural rest to habitual occlusion. Precise registration of the postural rest position in natural head posture. Respiration.

the patient will not be able to tolerate the appliance. The size of tonsils and adenoids should be recorded. even if nasal breathing does not seem to be affected. If the tonsils are enlarged and the tongue has assumed a compensatory anterior position to maintain an open airway. Epipharyngeal lymphoid tissue deserves particular attention. .

Direction of growth. Differentiation between position and size of the jaw bases. Morphologic peculiarities. .3. 3. The most important information required for planning the construction bite is the following: 1. 2. particularly of the mandible. 4. Cephalometric analysis:  The diagnostic tool of cephalometric analysis enables clinicians to identify the craniofacial morphogenetic pattern to be treated. Axial inclination and position of the maxillary and mandibular incisors.

TREATMENT PLANNING  The next step after accumulating and analyzing the diagnostic information is planning for the construction bite. The extent of anterior positioning for Class II malocclusions and Posterior positioning for Class III malocclusions should be determined. .

in most instances.Anterior positioning of the mandible  The usual intermaxillary relationship for the average Class II problem is end to end incisal. . it should not exceed 7 to 8 mm. or three quarters of the mesiodistal dimension of the first permanent molar. However.

Eschler (1952) termed this condition as pathologic construction bite. otherwise. An incisor (usually a lateral) which has erupted markedly to the lingual: The mandible must be postured anteriorly to an edge-to-edge relationship with the lingually malposed tooth. . thereby eliminating the need for the pathologic construction bite. If overjet is too large. Anterior positioning of this magnitude is contraindicated if any of the following pertain: 1. 3. labial movement of this tooth will be impossible. Labial tipping of the maxillary incisors is severe. As with severely proclined upper incisors. use of a short prefunctional appliance to improve alignment of lingually malposed teeth is advisable before starting activator treatment. 2.

The mandible must be dislocated from the postural resting position in at least one direction-sagittally or vertically. . Maintaining a proper horizontal-vertical relationship and determining the height of the bite are guided by the following principles: 1. This dislocation is essential to activate the associated musculature and induce a strain in the tissues. 2. If the magnitude of the forward position is great (7 or 8 mm). the vertical opening should be minimal so as not to overstretch the muscles.Opening the bite:  Vertical considerations are as important as the sagittal determination and are intimately linked to it. allowing a forward positioning of the mandible. This type of construction bite produces an increased force component in the sagittal plane.

the approximate sagittal force that develops is in the 315 to 395 g range. whereas the magnitude of the vertical force approximates 70 to 175 g. The primary neuromuscular activation is in the elevator muscles of the mandible.According to Witt (1971). .

This type of construction bite is obviously not effective in achieving anterior positioning of the mandible. the mandible must not be anteriorly positioned. 3. can be therapeutically affected by the activator. . The vertical force is increased. The vertical relationship. both the muscles and the viscoelastic properties of the soft tissues are enlisted. but it can influence the inclination of the maxillary base. If the bite opening exceeds 6 mm. as can a stretching of the soft tissues. mandibular protraction must be very slight. and the sagittal force is decreased. A more extensive bite opening is possible in functionally true deep-bite cases. Myotatic reflex activity of the muscles of mastication can then be observed. If extensive vertical opening is needed. either deep bite or open bite. One possible indication for such a construction bite is a case with a vertical growth pattern.  If the bite registration is high.

and the appliance tends to fall out of the mouth. Disadvantages of a wide-open construction bite include the difficulty of wearing the appliance and adapting to the new relationship. . Muscle spasms often occur. The high construction bite also makes lip seal difficult if not impossible.

frequency of mandibular movements. 1.GENERAL RULES FOR CONSTRUCTION BITE  The assessment of the construction bite determines the kind of muscle stimulation. In a forward positioning of the mandible of 7 to 8 mm. . and duration of effective forces. the vertical opening must be slight to moderate (2 to 4mm).

2. the vertical opening should be 4 to 6 mm. If the forward positioning is no more than 3 to 5 mm. .

and no asymmetric relationship exists between the mandible and maxilla. Functional crossbites in the functional analysis can be corrected by taking the proper construction bite. If the midline abnormality is caused by tooth migration. and an attempt to correct this type of dental problem could lead to iatrogenic asymmetry.3. . Functional appliances like activator can correct lower midline shifts or deviations only if actual lateral translation of the mandible itself exists.

the frequency of maximal biting into a 6 mm-high construction bite is 12. Both experimental research and clinical experience have shown that an increase in muscle activation with overextended appliances does not increase the efficiency of the functional appliance. According to Sander (1983).1%. .5% of the sleeping time. and if this is increased to 13 mm. as prescribed by Harvold. whereas in an 11 mm-high construction bite. it is only 1.8%. it is only 0.

GEORGE BITE REGISTRATION GAUGE . FREE HAND TECHNIQUE 2.METHODS OF BITE REGISTRATION 1.

FREE HAND TECHNIQUE .1.

because the appliance exerts undue stress on these teeth. • The likelihood of unwanted lower incisor procumbency may be greater. . • The patient may not be really comfortable and may be disturbed more frequently during sleep. • Asymmetric biting may have occurred on it.A construction bite prepared on casts may have the following disadvantages: • It may not fit.

for example. How close this position comes to the ideal depends on the orthodontist's knowledge. A percentage of the range of protrusion would obviously be a better indicator of the amount of tension created within the tissues. An end-to-end relationship. Each of these variables can introduce error. skill. would be insufficient advancement for some patients and an impossible strain for others. the incisors are unreliable indicators because of their variation in angulation. and ability to communicate. plus the patient's ability to comprehend the instructions and coordinate the muscles. . GEORGE GAUGE – JCO 1992  The traditional wax bite registration involves relating the mandible to the maxilla in three planes of space by having the patient protrude and elevate the jaw until the incisors reach a predetermined position in the softened wax.2.  In addition.

. to the incisors. It enables the orthodontist to register the bite relative to the range of the protrusive path. centric relation. An instrument that can provide a registration.  The George Gauge can locate and register the construction bite with less reliance on operator competence and patient cooperation than the traditional freehand method. or full protrusion. independent of the variables that affect traditional methods has been introduced. regardless of the angulation of the central incisors. by a specific number of millimeters. It can also be used to relate the bite.

Description  The adjustable George Gauge can be preset to guide the mandible into the desired construction bite position. . It also serves as a vehicle for the bite registration material. relative to either the incisors or the protrusive path.

Parts .

Registration Technique .

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. Now that there is an instrument that accurately registers and records the bite position. division 1 malocclusions position the mandible somewhere between 50 and 75 % of the distance from centric occlusion to full protrusion. Most functional appliances for the correction of Class II.

.  General rule for construction bite.MAIN COURSE CONSTRUCTION BITE FOR VARIOUS TYPES OF FUNCTIONAL APPLIANCES ACTIVATOR 1. Technique for a Low Construction Bite with Markedly Forward Mandibular Positioning  Edge to edge incisal.

In addition to the muscle force arising during biting and swallowing.MODUS OPERANDI  When the mandible moves mesially to engage the appliance. . the elevator muscles of mastication are activated. the myotatic reflex is activated. When the teeth engage the appliance. the reflex stimulation of the muscle spindles also elicits reflex muscle activity.

division 1 malocclusions with sufficient overjet. The activator constructed with a low vertical opening registration and a forward bite is appropriately designated the horizontal H activator. and the anterior growth vector of the maxilla is slightly inhibited. The maxillary base is not affected. however. It is indicated in Class II. With this type of appliance the mandible can be postured forward without tipping the lower incisors labially.  As might be expected. . this type of appliance is most effective if an anterior sagittal relationship of the mandible is the primary treatment objective. The maxillary incisors can be positioned upright.

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but posturing the mandible forward while simultaneously positioning upright the labially tipped lower incisors is possible. planning for lingual tipping of the maxillary incisors and pretreatment labial tipping of the lower incisors is advantageous. . division 1 malocclusions with posterior positioning of the mandible caused by growth deficiency but with the likelihood of a future horizontal growth pattern are suitable candidates for treatment with the H activator. In these cases.  Treatment is more difficult in patients with labially inclined lower incisors. Additional indication for the horizontal H activator is patients with Class II.

the vertical dimension is opened 4 to 6 mm. Technique for a High Construction Bite with Slight Anterior Mandibular Positioning  In a high construction bite the mandible is positioned less anteriorly (only 3 to 5 mm ahead of the habitual occlusion position).2. a maximum of 4 mm beyond the postural rest- vertical dimension registration. Depending on the magnitude of the interocclusal space. .

causing a response of the viscoelastic properties of the soft tissues involved. while the patient is sleeping). This greater opening of the vertical dimension in the construction bite allows the myotatic reflex to remain operative even when the musculature is more relaxed (i.. .e. This appliance is indicated in cases with vertical growth patterns and can be properly designated as the vertical V activator. Possibly the stretching of the muscles and soft tissues elicits an additional force.MODUS OPERANDI  The appliance induces myotatic reflexes in the muscles of mastication.  The stretch reflex activation with the increased vertical dimension may well influence the inclination of the maxillary base.

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Technique for a Construction Bite without Forward Mandibular Positioning  Indications .3.

the deep overbite can be caused by infraocclusion of the buccal segments or supraocclusion of the anterior segment. Vertical problems 1. .  In dentoalveolar overbite problems.  In deep overbite cases caused by supraocclusion of the incisors. The activator should not be designed with a high construction bite in these cases. Deep overbite malocclusions  Deep overbire malocclusions can be of either dentoalveolar origin or skeletal in nature. depending on the size of the freeway space. Intrusion of the incisors is possible to only a limited extent when an activator is being used. the interocclusal space is usually small.A. The construction bite may be either moderate or high.

 The skeletal deep overbite malocclusion usually has a horizontal growth pattern. as with supraocclusion of the incisors. for which forward inclination of the maxillary base can compensate.  This height enlists stretch reflex response and the viscoelastic properties of the muscles and soft tissues as they are stretched. Loading the incisors can achieve a slight forward inclination. A dentoalveolar compensation is simultaneously possible by extrusion of the lower molars and distal driving of the upper molars with stabilizing wires. . With this therapeutic approach the construction bite should be high enough to exceed the patient's postural rest vertical dimension. The acrylic cap engages these teeth while freeing the molars to erupt.

2. Open-bite malocclusions An anterior positioning of the mandible is not necessary or desirable if the skeletal relationship is orthognathic. The bite is opened 4 to 5 mm to develop a sufficient elastic depressing force and load the molars that are in premature contact. .

The activator can accomplish the desired expansion because it is anchored intermaxillarily. In the mixed dentition period. .  The appliance works in a manner similar to that of two active plates with jackscrews in the upper and lower parts. problems of anchorage with regular expansion plates can occur. The treatment objective is expansion using an appliance stabilized by intermaxillary relationships. The construction bite is low because jaw positioning and growth guidance by selective eruption of teeth are not desired.B. Arch length deficiency problems  Malocclusions with crowding can sometimes be treated with activators.

. With the same appliance a reciprocal force also can be developed in the sagittal plane. the protrusive force loading the incisors can be directed onto the stabilizing wires that fit in the contact embrasures. If the incisors are lingually inclined and the molars must be moved distally to increase arch length. an advantage in situations in which the demands are usually bilateral. producing a molar distalization response. The force application from this type of appliance is reciprocal.

In Class III malocclusion the goal is posterior positioning of the mandible or maxillary protraction. Technique for a Construction Bite with Opening and Posterior Mandibular Positioning  The construction bite's sagittal change depends on the malocclusion category and treatment objectives. The construction bite is taken by retruding the lower jaw.4. The extent of the vertical opening depends on the retrusion possible. .

This eliminates the protrusive relationship with the mandible in centric relation. and the mandible slides anteriorly to complete the occlusal relationship. If holding the mandible in a posterior position and guiding the maxillary incisors into correct labial relationships are possible. . If done in early mixed dentition. creating a balance. Tooth guidance or functional protrusion Class III malocclusions. At this stage the skeletal manifestations are not usually severe. the maxilla adapts to the prognathic mandible. a good incisal guidance can be established. The vertical dimension is opened far enough to clear the incisal guidance for the construction bite.A. The mandibular incisors approximate prematurely in an end-to-end contact.  The prognosis for pseudo-Class III malocclusions is good. An edge-to-edge bite relationship can be achieved with the posterior teeth still out of contact.  The assessment of a possible forced bite is relatively easy. the malocclusion develops progressively. especially if therapy begins in early mixed dentition.

Correct incisal guidance prevents anterior displacement of the mandible during treatment. the construction bite requires a larger opening.  Treatment with functional appliances is not always possible or desirable. Skeletal Class III malocclusion with a normal path of closure from postural rest to habitual occlusion. The opening of the vertical dimension for the construction bite depends on the possibility of achieving an end-to-end incisal relationship.  Usually only combined therapy such as with fixed and removable appliances and maxillary orthopedic protraction is likely to be successful. Indications for functional treatment of true Class III problems are limited. orthognathic surgery is always possible to achieve proper sagittal and transverse relationships. If the bite can be opened and incisal guidance established. If the overjet is large.B. . Even then. adaptation of the maxillary base to the prognathic mandible can be expected to a certain degree. However. if treatment is initiated in the early mixed dentition. improvement can be achieved.

BIONATOR  Balters philosophy  Bionator Types  Bionator in TMJ Cases .

FRANKEL FUNCTIONAL REGULATOR

 The function regulator appliances, developed by ROLF
FANKEL, are the orthopedic exercise devices that aid in
maturation, training and 'reprogramming' of the orofacial
neuromuscular system.

 Frankel has designed four basic variations of the FR
appliance:

FR I
FR II
FR III
FR IV

CONSTRUCTION BITE
FR I
 For minor sagittal problems (2 to 4 mm) the
construction bite is taken in an end-to-end incisal
relationship, as with the bionator, exercising extreme
care to prevent the obvious strain of facial muscles.

 Frankel recommends that the construction bite not
move the mandible farther forward than 2.5 to 3 mm.
The vertical opening should be only large enough to
allow the cross over wires through the interocclusal
space without contacting the teeth.

 If an end-to-end relationship, or no more than 6 mm forward
posturing, is used, the incisal contact determines the vertical
opening. A clearance of at least 2.5 to 3.5 mm in the buccal
segments is necessary to allow the crossover wires to pass
through in the Frankel appliance, so the incisal vertical
relationship usually results in discluding these teeth. A
tongue blade is sometimes placed between the teeth during
taking of the construction bite to establish sufficient vertical
clearance for the crossover wires.

 For the Frankel appliance, if 6 mm of sagittal movement is
needed to correct the anteroposterior relationship, a
construction bite of 3 mm forward posturing permits easy
adaptation by the patient and reduces the likelihood of
dislodgment during both day and night, muscle strain or
fatigue, and unwanted proclination of lower incisors.

Therefore the FR II can and must be used to enhance selective eruption of the lower buccal segment. . div 2 malocclusions. with deep over bite and infraocclusion of lower posterior segments. the vertical dimension can be opened to a greater degree without endangering lip seal. div 2 malocclusions. in which lip length and contact are ample.FR II  The need for bite opening is greater in class II.  In some cases of deep bite class I or class II.

The bite opening is kept to a minimum to allow lip closure with minimal strain . or even deciduous dentition cases. the FR III or any functional appliance is not usually the appliance of choice.FR III  Successful treatment of early correctional class III malocclusion is more likely with combination protraction- retraction extra oral force. However it can be used for mild early mixed dentition. with the condyle occupying the most posterior position in the fossa.  The construction bite procedure involves clinically retruding the mandible as much as possible.  The vertical dimension is opened only enough to allow the maxillary incisors to move labially past the mandibular incisors for crossbite correction.

. This is done so the appliance can be fabricated to stimulate posterior eruption of the maxillary teeth. The clinician continues tapping gently and then asks the patient to close slowly and guides the final closure with posterior pressure applied by the thumb against the symphysis and the forefinger under the chin. the clinician gently taps on the patient's mandible with the flexed knuckles of the dominant hand while the patient opens the bite approximately 1 cm. To obtain the maximal posterior condylar position.  Deep-bite problems require a wider opening of the vertical dimension for the construction bite.

Clark are simple bite- blocks that effectively modify The occlusal inclined planes.THE TWIN BLOCK  Twin blocks developed by William J. . Twin block appliances achieve rapid functional correction of malocclusion by transmitting favorable occlusal forces to the occlusal inclined planes covering the posterior teeth. these devices use upper and lower bite-blocks that engage on occlusal inclined planes.

This usually leaves 2 mm of clearance distally in the molar region and ensures that space is available for vertical development of posterior teeth to reduce the overbite.  In growing children with overjets as large as 10 mm.  In the vertical dimension.BITE REGISTRATION  In Class II. division 1 malocclusion a protrusive bite is registered to reduce the overjet and distal occlusion by 5 to 10 mm on initial activation of twin blocks depending on the freedom of movement in protrusive function. . the bite may be activated edge to edge on the incisors with a 2-mm interincisal clearance if the patient can posture forward comfortably to maintain full occlusion on the appliances. 2 mm of interincisal clearance is equal to approximately 5 or 6 mm of clearance in the first premolar region. This degree of "activation allows an overjet as large as 10 mm to be corrected without further activation of the twin blocks.

in choosing the amount of activation. If the patient postures forward easily. This method of activation allows an overjet as large as 10 mm to be corrected on the first activation without further activation of the twin blocks. . This occlusion is reproduced most easily by the patient and is equivalent to biting edge to edge on the incisors. followed by reactivation after initial correction. an edge-to -edge occlusion is commonly activated.  The amount of initial activation for an individual patient is related to the ease with which the patient postures forward into a protrusive bite. the clinician should consider the effect of forward posture on the profile. Larger overjets invariably require partial correction.

. He concluded from examination of the function of the mandibular joint that the range of physiologic movement of the mandible is no more than 70% of the total protrusive path. Thus the maximal activation of a functional appliance should not exceed 70% of the total protrusive path of the mandible. Roccabado observed that the position of maximal protrusion is not a physiologic position. In considering guidelines for activation of functional appliances.

 Patients who may have difficulty in maintaining an edge to edge position in protrusion must be identified. The difference between these two measurements is the total protrusive path. Freedom of movement in forward posture is assessed by measuring the total protrusive path of the mandible. The overjet is measured in the fully retruded position and then in the position of maximal protrusion. Measuring the protrusive path helps identify patients who have a limited range of protrusive movement and would therefore be unable to maintain contact on the inclined planes if activation exceeds the physiologic range of movement. .

PROCEDURE .

DESSERTS  Andresen & Haupl – Activator  Bimler – Bionator  Rolf Frankel – FR  W.J Clark – Twin Block .