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.
PURPOSE

The purpose of this mandibular manipulation is to

relocate the jaw in the direction of treatment objectives.
This creates artificial functional forces and allows
assessment of the appliance's mode of action.

GOAL

The goal of the construction bite is to produce maximum

physiological response with minimum trauma to the
tissues and discomfort to the patient.
DIAGNOSTIC PREPARATION

Patient compliance is essential. Therefore the clinician must

not only assess clinically the somatic and psychologic
aspects of the patient but also determine the patient's
motivation potential.

Creating an "instant correction" - i.e moving the

mandible forward into an anterior, more normal sagittal
relationship- may help motivate patients with Class II
malocclusions. 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.
 Video imaging also augments patient motivation. As
Frankel (1983) points out, performing this clinical
maneuver at the beginning of treatment also indicates
to the clinician whether the therapeutic goal is really
an improvement. In some problems of maxillary
protrusion and excessive vertical dimension and
reduced symphyseal- prominence, a forward
positioning does not improve the appearance of the
profile. Other therapeutic measures may be required.
 STARTERS
Before taking the construction bite, the clinician must
prepare by making a detailed study of the plaster casts,
cephalometric and panoral head films, and the patient's
functional pattern.

1. Study model analysis:

1. First permanent molar relationship in habitual occlusion.

2. Nature of the midline discrepancy.
3. Symmetry of the dental arches.
4. Crowding and any dental discrepancies.
2. Functional analysis:

1. Precise registration of the postural rest position in

natural head posture.
2. Path of closure from postural rest to habitual
occlusion.
3. Prematurities, point of initial contact, occlusal
interferences, and resultant mandibular displacement.
4. Sounds such as clicking and crepitus in the TM].
5. Interocclusal clearance or freeway space.
6. Respiration.
 Epipharyngeal lymphoid tissue deserves particular attention.
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, the patient will
not be able to tolerate the appliance.
3. Cephalometric analysis:

The diagnostic tool of cephalometric analysis enables

clinicians to identify the craniofacial morphogenetic pattern
to be treated. The most important information required for
planning the construction bite is the following:

1. Direction of growth.
2. Differentiation between position and size of the jaw bases.
3. Morphologic peculiarities, particularly of the mandible.
4. 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.
Anterior positioning of the mandible

The usual intermaxillary relationship for the average

Class II problem is end to end incisal. However, it
should not exceed 7 to 8 mm, or three quarters of the
mesiodistal dimension of the first permanent molar, in
most instances.
 Anterior positioning of this magnitude is contraindicated if
any of the following pertain:

1. If overjet is too large.

2. Labial tipping of the maxillary incisors is severe.

3. 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; otherwise, labial movement of
this tooth will be impossible. Eschler (1952) termed this
condition as pathologic construction bite. 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, thereby eliminating the need for the pathologic
construction bite.
Opening the bite:

Vertical considerations are as important as the sagittal

determination and are intimately linked to it. Maintaining a
proper horizontal-vertical relationship and determining the
height of the bite are guided by the following principles:

1. The mandible must be dislocated from the postural resting

position in at least one direction-sagittally or vertically. 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. This type of construction bite
produces an increased force component in the sagittal plane,
allowing a forward positioning of the mandible.
According to Witt (1971), 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.
 3. If extensive vertical opening is needed, the mandible must
not be anteriorly positioned. If the bite opening exceeds 6 mm,
mandibular protraction must be very slight. Myotatic reflex
activity of the muscles of mastication can then be observed, as
can a stretching of the soft tissues. A more extensive bite
opening is possible in functionally true deep-bite cases.

If the bite registration is high, both the muscles and the

viscoelastic properties of the soft tissues are enlisted. The
vertical force is increased, and the sagittal force is decreased.
This type of construction bite is obviously not effective in
achieving anterior positioning of the mandible, but it can
influence the inclination of the maxillary base. One possible
indication for such a construction bite is a case with a vertical
growth pattern. The vertical relationship, either deep bite or
open bite, can be therapeutically affected by the activator.
 Disadvantages of a wide-open construction bite include the
difficulty of wearing the appliance and adapting to the new
relationship. Muscle spasms often occur, and the appliance
tends to fall out of the mouth. The high construction bite
also makes lip seal difficult if not impossible.
GENERAL RULES FOR CONSTRUCTION BITE

The assessment of the construction bite determines

the kind of muscle stimulation, frequency of
mandibular movements, and duration of effective
forces.

1. In a forward positioning of the mandible of 7 to 8 mm,

the vertical opening must be slight to moderate (2 to
4mm).
2. If the forward positioning is no more than 3 to 5 mm,
the vertical opening should be 4 to 6 mm.
3. Functional appliances like activator can correct lower
midline shifts or deviations only if actual lateral
translation of the mandible itself exists. If the midline
abnormality is caused by tooth migration, and no
asymmetric relationship exists between the mandible
and maxilla, and an attempt to correct this type of
dental problem could lead to iatrogenic asymmetry.
Functional crossbites in the functional analysis can be
corrected by taking the proper construction bite.
 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), the frequency of
maximal biting into a 6 mm-high construction bite is 12.5% of
the sleeping time, whereas in an 11 mm-high construction
bite, it is only 1.1%, and if this is increased to 13 mm, as
prescribed by Harvold, it is only 0.8%.
METHODS OF BITE REGISTRATION

1. FREE HAND TECHNIQUE

2. GEORGE BITE REGISTRATION GAUGE

1. FREE HAND TECHNIQUE
A construction bite prepared on casts may have the
following disadvantages:

It may not fit.

Asymmetric biting may have occurred on it.
The patient may not be really comfortable and may be
disturbed more frequently during sleep.
The likelihood of unwanted lower incisor procumbency
may be greater, because the appliance exerts undue stress
on these teeth.
2. 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. How close this
position comes to the ideal depends on the orthodontist's
knowledge, skill, and ability to communicate, plus the patient's
ability to comprehend the instructions and coordinate the
muscles. Each of these variables can introduce error.

In addition, the incisors are unreliable indicators because of

their variation in angulation. An end-to-end relationship, for
example, would be insufficient advancement for some patients
and an impossible strain for others. A percentage of the range
of protrusion would obviously be a better indicator of the
amount of tension created within the tissues.
 An instrument that can provide a registration, independent of
the variables that affect traditional methods has been
introduced.

The George Gauge can locate and register the construction

bite with less reliance on operator competence and patient
cooperation than the traditional freehand method. It enables
the orthodontist to register the bite relative to the range of
the protrusive path, regardless of the angulation of the
central incisors. It can also be used to relate the bite, by a
specific number of millimeters, to the incisors, centric
relation, or full protrusion.
Description

The adjustable George Gauge can be preset to guide

the mandible into the desired construction bite
position, relative to either the incisors or the
protrusive path. It also serves as a vehicle for the bite
registration material.
Parts
Registration Technique
 Most functional appliances for the correction of Class II,
division 1 malocclusions position the mandible somewhere
between 50 and 75 % of the distance from centric occlusion
to full protrusion. Now that there is an instrument that
accurately registers and records the bite position.
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.

General rule for construction bite.

MODUS OPERANDI

When the mandible moves mesially to engage the

appliance, the elevator muscles of mastication are
activated. When the teeth engage the appliance, the
myotatic reflex is activated. In addition to the muscle
force arising during biting and swallowing, the reflex
stimulation of the muscle spindles also elicits reflex
muscle activity.
 The activator constructed with a low vertical opening
registration and a forward bite is appropriately
designated the horizontal H activator. With this
type of appliance the mandible can be postured
forward without tipping the lower incisors labially.
The maxillary incisors can be positioned upright, and
the anterior growth vector of the maxilla is slightly
inhibited. The maxillary base is not affected,
however.

As might be expected, this type of appliance is most

effective if an anterior sagittal relationship of the
mandible is the primary treatment objective. It is
indicated in Class II, division 1 malocclusions with
sufficient overjet.
 Additional indication for the horizontal H activator is
patients with Class II, 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, planning for lingual tipping
of the maxillary incisors and pretreatment labial tipping of
the lower incisors is advantageous.

Treatment is more difficult in patients with labially inclined

lower incisors, but posturing the mandible forward while
simultaneously positioning upright the labially tipped
lower incisors is possible.
2. 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). Depending on the magnitude of the
interocclusal space, the vertical dimension is opened 4
to 6 mm, a maximum of 4 mm beyond the postural rest-
vertical dimension registration.
MODUS OPERANDI

The appliance induces myotatic reflexes in the muscles of

mastication. Possibly the stretching of the muscles and soft
tissues elicits an additional force, causing a response of the
viscoelastic properties of the soft tissues involved. 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.,
while the patient is sleeping).

The stretch reflex activation with the increased vertical

dimension may well influence the inclination of the maxillary
base. This appliance is indicated in cases with vertical
growth patterns and can be properly designated as the
vertical V activator.
3. Technique for a Construction Bite without
Forward Mandibular Positioning

Indications
A. Vertical problems
1. Deep overbite malocclusions

Deep overbire malocclusions can be of either

dentoalveolar origin or skeletal in nature.

In dentoalveolar overbite problems, the deep overbite

can be caused by infraocclusion of the buccal segments
or supraocclusion of the anterior segment. The
construction bite may be either moderate or high,
depending on the size of the freeway space.

In deep overbite cases caused by supraocclusion of the

incisors, the interocclusal space is usually small. The
activator should not be designed with a high construction
bite in these cases. Intrusion of the incisors is possible to
only a limited extent when an activator is being used.
 The skeletal deep overbite malocclusion usually has a
horizontal growth pattern, for which forward inclination
of the maxillary base can compensate. Loading the
incisors can achieve a slight forward inclination, as with
supraocclusion of the incisors. The acrylic cap engages
these teeth while freeing the molars to erupt. With this
therapeutic approach the construction bite should be high
enough to exceed the patient's postural rest vertical
dimension.

This height enlists stretch reflex response and the

viscoelastic properties of the muscles and soft tissues as
they are stretched.
A dentoalveolar compensation is simultaneously possible
by extrusion of the lower molars and distal driving of the
upper molars with stabilizing wires.
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.
B. Arch length deficiency problems

Malocclusions with crowding can sometimes be treated

with activators. In the mixed dentition period,
problems of anchorage with regular expansion plates
can occur. The activator can accomplish the desired
expansion because it is anchored intermaxillarily.

The appliance works in a manner similar to that of two

active plates with jackscrews in the upper and lower
parts. The construction bite is low because jaw
positioning and growth guidance by selective eruption
of teeth are not desired. The treatment objective is
expansion using an appliance stabilized by
intermaxillary relationships.
 The force application from this type of appliance is
reciprocal, an advantage in situations in which the
demands are usually bilateral. With the same appliance
a reciprocal force also can be developed in the sagittal
plane. If the incisors are lingually inclined and the
molars must be moved distally to increase arch length,
the protrusive force loading the incisors can be
directed onto the stabilizing wires that fit in the
contact embrasures, producing a molar distalization
response.
4. 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. In
Class III malocclusion the goal is posterior positioning
of the mandible or maxillary protraction. The
construction bite is taken by retruding the lower jaw.
The extent of the vertical opening depends on the
retrusion possible.
A. Tooth guidance or functional protrusion Class III
malocclusions.

The assessment of a possible forced bite is relatively easy. The

mandibular incisors approximate prematurely in an end-to-end
contact, and the mandible slides anteriorly to complete the
occlusal relationship. The vertical dimension is opened far
enough to clear the incisal guidance for the construction bite.
This eliminates the protrusive relationship with the mandible in
centric relation. An edge-to-edge bite relationship can be
achieved with the posterior teeth still out of contact.

The prognosis for pseudo-Class III malocclusions is good,

especially if therapy begins in early mixed dentition. At this
stage the skeletal manifestations are not usually severe; the
malocclusion develops progressively. If holding the mandible in
a posterior position and guiding the maxillary incisors into
correct labial relationships are possible, a good incisal guidance
can be established. If done in early mixed dentition, the maxilla
adapts to the prognathic mandible, creating a balance.
B. Skeletal Class III malocclusion with a normal path of
closure from postural rest to habitual occlusion.

Treatment with functional appliances is not always possible

or desirable. The opening of the vertical dimension for the
construction bite depends on the possibility of achieving an
end-to-end incisal relationship. If the overjet is large, the
construction bite requires a larger opening. Indications for
functional treatment of true Class III problems are limited.

Usually only combined therapy such as with fixed and

removable appliances and maxillary orthopedic protraction
is likely to be successful. Even then, orthognathic surgery is
always possible to achieve proper sagittal and transverse
relationships. However, if treatment is initiated in the early
mixed dentition, improvement can be achieved. If the bite
can be opened and incisal guidance established, adaptation
of the maxillary base to the prognathic mandible can be
expected to a certain degree. Correct incisal guidance
prevents anterior displacement of the mandible during
treatment.
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.
FR II

The need for bite opening is greater in class II, div 2

malocclusions. Therefore the FR II can and must be used to
enhance selective eruption of the lower buccal segment.

In some cases of deep bite class I or class II, div 2

malocclusions, with deep over bite and infraocclusion of
lower posterior segments, in which lip length and contact
are ample, the vertical dimension can be opened to a
greater degree without endangering lip seal.
FR III

Successful treatment of early correctional class III

malocclusion is more likely with combination protraction-
retraction extra oral force, the FR III or any functional
appliance is not usually the appliance of choice. However it
can be used for mild early mixed dentition, or even
deciduous dentition cases.

The construction bite procedure involves clinically retruding

the mandible as much as possible, with the condyle
occupying the most posterior position in the fossa.

The vertical dimension is opened only enough to allow the

maxillary incisors to move labially past the mandibular
incisors for crossbite correction. The bite opening is kept to
a minimum to allow lip closure with minimal strain
 To obtain the maximal posterior condylar position, 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. 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.

Deep-bite problems require a wider opening of the vertical

dimension for the construction bite. This is done so the
appliance can be fabricated to stimulate posterior eruption of
the maxillary teeth.
THE TWIN BLOCK

Twin blocks developed by William J. Clark are simple bite-

blocks that effectively modify The occlusal inclined planes;
these devices use upper and lower bite-blocks that engage
on occlusal inclined planes. Twin block appliances achieve
rapid functional correction of malocclusion by transmitting
favorable occlusal forces to the occlusal inclined planes
covering the posterior teeth.
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. This degree of
"activation allows an overjet as large as 10 mm to be
corrected without further activation of the twin blocks.

In growing children with overjets as large as 10 mm, 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.

In the vertical dimension, 2 mm of interincisal clearance is

equal to approximately 5 or 6 mm of clearance in the first
premolar region. 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.
 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. Larger overjets invariably
require partial correction, followed by reactivation after
initial correction.

The amount of initial activation for an individual patient is

related to the ease with which the patient postures forward
into a protrusive bite; in choosing the amount of activation,
the clinician should consider the effect of forward posture on
the profile. If the patient postures forward easily, an edge-to
-edge occlusion is commonly activated. This occlusion is
reproduced most easily by the patient and is equivalent to
biting edge to edge on the incisors.
 In considering guidelines for activation of functional
appliances, Roccabado observed that the position of maximal
protrusion is not a physiologic position. 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.
 Patients who may have difficulty in maintaining an
edge to edge position in protrusion must be identified.
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. The
difference between these two measurements is the
total protrusive path. 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