m Study Model Analysis:

" The "st permanent molar relationship


Nature of midline discrepancy if any
 3 Symmetry of the dental arches is determined
  Curve of spee is checked to see if it can be leveled with the
activator
  Crowding and any dental discrepancies
m îunctional Analysis:-
 " Rest position

Path of closure
 3 Prematurities
  THJ examination
  Interocclusal clearance
 6 Respiration
m Cephalometric Analysis
 " The direction of growth

The difference between the position and the size of the Jaw
bases
m ANDRESEN'S first activators did not displace mandible
beyond the physiologic rest position relative the vertical
and was 3 mm short of the limit of the patient's tolerance
relative to the protrusion
m îirst to oppose was SELMER-OSLEN
 " Muscles couldn't be stimulated at night, for this was
the time nature used to give them rest

îorces delivered to the teeth by the appliance were
a form of potential energy and not kinetic energy
 3 Andresen's
- mm opening in molar region is
beyond physiologic rest position
  He said Andresen is wrong if he thought an
appliance holding the jaws a
mm beyond is a truly
functional passive appliance
m PAUL HERREN- activator didn't work according to
Andresen's theories at all, even if it was constructed
within the physiological limits of rest position His
construction bite is in sagittal direction, the mandible is
positioned in an overcompensated by 3- mm Vertical
opening -
- mm plus the deep bite that is already
present

m The Louisiana state university acivator of ROBERT

SHAYE ("
 essentially follows the same design and
principles

m HARVOLD (" said you have got to go Stretch the

muscles, the more stretch, the better His construction
bite - 3 mm short of patient's limit of tolerance in
protrusive position but with a -" mm vertical opening
beyond the rest Position
m -OODSIDE ("- - said to go even further
beyond rest position to "
-" mm
m GRABER and NEUMANN said use a
combination of bite opening and protrusion to
equal to " mm In other words, if you open the
bite  mm between the occlusions posteriorly
then advance the mandible by 6 mm
m BALTERS of Germany advocated protrusive
incisal end-to end with an interincisal opening of

-3 mm
m Construction s/b made considering vertical,
horizontal & transverse planes
" The original sagittal jaw relationship may be maintained

Mandible may be positioned forward to change the sagittal
relationship equally on both sides
3 The bite is changed on one side but is maintained as much
as possible on the other side as with a unilateral Class II Div
" or class II Div
or class III This means that a normal
midline relationship exists in postural rest, but a midline swing
to the side that is forced in the habitual occlusal relationship
 The mandible is postured backward as much as possible in
the fossa, opening the bite enough to try for an end to end
Incisal relationship or as close to this as possible, in class III
malocclusions
m Dependent on three major considerations:

 (" The kind dysgnathic problem (Sagittal and vertical

relationships, morphogenetic growth pattern
 (
 the developmental state, sex, and age of the patient
(potential incremental change
 and (3 the type of appliance to be used
m Different sagittal and vertical dysplasias require
different construction bite registrations
m îor example, in deep bite Class II, Division

and Class III malocclusions, it is necessary to
record the vertical distance between Incisal of
lower incisors the upper and margins
determining how wide open the construction bite
should
m In permanent dentition cases (specifically in
Class II Division
malocclusions or class I
Division
symptoms, or in anterior cross bites,
e g , Class III malocclusions, it is best to open
the bite for the construction registration a
distance of " mm to 3 mm, vertically beyond
the Incisal edges
m In the mixed dentition, it should be increased to
 mm to  mm Thus, the original overbite is a
determining factor
m In the Class II, Division
malocclusion and in
the permanent dentition, the bite may have to be
opened up to  mm in the molar region and
occasionally more
m -oodside feels it improves the chances of
retention during sleep and enlists the
viscoelastic properties of the stretched soft
tissues
m The reason the bite can be opened so far is that
type of Class II, Division
malocclusion most
frequently has a palatal plane that is tipped down
anteriorly along with a deep bite and an excessive
curve of spee A large bite opening can improve the
maxillary incisor inclination because the anterior end
of the palatal plane is withheld or tipped up and this
also reduces the deep overbite because the lower
incisors are under intrusive action as the maxillary
base rotates upward and forward
m The wide open construction bite brings the mandible
out of the range of any tooth guidance and resultant
retrusive effect on the condyle and the path of
closure
m Also such cases usually do not have a severe
sagittal malrelationship and usually have a good
chin-button morphological appearance so rocking
open the bite, which drops the symphysis down and
back, does not have a deleterious effect on the
profile
m This is particularly true since in most of these cases
there is a horizontal growth pattern The large
vertical opening improves the growth direction and
allows the full eruption of the posterior teeth, which
are usually in marked infraocclusion
m If only mandibular positioning is needed, or a
small anterior posturing is required the (only
maxillary teeth spaced & labially inclined  , the
vertical opening should be rised more in order to
elicit more positive functional and viscoelastic
response from musculature
m Class II, Division " problems demanding more
horizontal posturing to establish correct
maxillomandibular relationship, a smaller vertical
opening is needed,
m In cases with a more vertical growth direction and
a deep overbite, a larger bite opening is desirable
for the construction bite registration This allows
some downward and backward compensation of
maxillary growth (and palatal plane to fit the
mandibular growth pattern
m In Class II, Division I malocclusions in which
 (" the sagittal malrelationship is the width of a whole
premolar;
 (
 there is a severe curve of Spee
 (3 the lower incisors are over erupted, impinge on the
palatal mucosa, the construction bite should not be
higher than vertical end to end relationship
m This is because the interocclusal distance in the
molar region, with infraocclusion of the molars
and supraocclusion of the lower incisors, might
exceed  mm which would be excessive
because of the possible lateral spread of the
tongue

m If moderate curve of Spee vertical opening s/b

increased to allow for posterior eruption &
getting favorable muscle balance In such
cases, mm Between incisal edges is desirable,
and it can occasionally be even more
m In the case of a synchronous downward and
backward archform growth pattern and an average
incisor overbite, caution is the watchword, so as not
to accentuate the molar eruption too much, which
will create a more retrusive profile and possibly
induce an anterior open bite that will be difficult to
close

m The interocclusal space should not exceed  mm in

the molar region The same applies to anterior open
bite problems The interocclusal acrylic table or
tooth bed should not be ground away in such cases,
but rather should maintain constant intrusive contact
on the upper and lower posterior teeth in both
arches
m If the upper and lower midlines do not coincide, a
determination must be made as to the fault -
maxillary or mandibular The patient is observed in
postural rest position to check the midlines and is
then asked to slowly close the mouth into full
habitual occlusion
 " Midlines of postural rest position and occlusion coinciding
- construction bite no change

Postural rest position coincides with midlines while
occlusal position does not, this is due to shift from one side
to other, occlusal interferences should be checked
Construction bite should follow the resting Position midline
relationship
 3 Midlines of both in rest and occlusion - caused by
shifting of teeth in one jaw or the other The construction
bite should line up with the midlines of maxilla and
mandible regardless of shifting of teeth Dental midline
discrepancies caused by shifting and malposition of the
teeth can be corrected late with the fixed appliances
Occasionally a short pretreatment fixed appliance to
correct midline
m The purpose of the construction bite is to fabricate
an appliance that induces the following effects:
 (" to bring the lower jaw into a tolerable forward position
with every occluding action of the mandible
 and (
 to "block the bite³ depressing the lower anterior
teeth and stopping their eruption, while attempting to
stimulate eruption of the posterior segments
m Taking the construction bite one should look at the
bite in three different planes of space: sagittal ,
vertical and frontal

m Therefore it is first necessary to clarify three points

using the procedure developed by Schwartz
m The usual intermaxillary relationship for the Class
II problem is that of end to end an average incisal
relationship However it should not exceed  mm
to mm Or quarters of the mesiodistal dimension
of the first permanent molar Anterior positioning of
this magnitude is contraindicated in the following
instances:
m If the overjet is too large (in extreme cases
approach " mm the anterior positioning
becomes a stepwise progression to be
accomplished in two or three phases

m If there is severe labial tipping of the maxillary

incisors they should probably be uprighted first if
possible by a prefunctional appliance
m If one of the incisors usually the lateral incisor 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 would not
be possible Eschler termed this a "pathological"
construction bite
m In a normal case, the maximum forward
movement of the mandible averages -"mm,
but as little as 6-mm The optimal forward
movement of the mandible for the construction
bite is usually half the individual¶s maximum
range There are three reasons for this ±
 more uncomfortable for the patient
 The distance of mm is approximately is the same as
that between the points of the buccal cusps of the first
molars This is the amount of distance necessary to
change a class II malocclusion into a class I occlusion
 It is claimed that one of the best positions for obtaining
the desired histological transformation of the TMJ from a
Class II malocclusion into a Class I is approximately half
the distance that the condyle can move forward along the
anterior wall of the fossa to the articular tubercle
m There are some guiding principles in maintaining a
proper horizontal vertical relationship and
determining the height of the bite-
 The mandible must be dislocated from the resting
position in at least one direction - sagittally or vertically
This is essential in order to activate the associated
musculature and induce a strain in the tissues
 If the magnitude of the forward position is great (mm-
mm, the vertical opening should be minimal so as not
to overstretch the muscles This type of construction bite
means an increased force component in the sagittal
plane, enabling a forward positioning of the mandible
The primary neuromuscular activation is in the elevator
muscles of the mandible
 If the vertical opening must be extensive, the mandible
must not be anteriorly positioned If the bite opening is
more than 6 mm, mandibular protraction must be very
slight Myotatic reflex activity of 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 not
effective in achieving anterior positioning of the
mandible, but the inclination of the maxillary base can
be influenced
m One possible indication of this type of construction
bite is in the case vertical growth pattern In such
cases, the vertical relationship, either deep bite or
open bite, can be therapeutically affected by the
activator
m The disadvantages of a wide construction bite are
the difficulty in wearing appliance, with increased
difficulty of patient to adaptation Muscle spasms
often occur in such cases, and appliance tends fall
out of mouth The wide open construction bite also
makes the lip seal difficult Yet the reestablishment
of a normal lip seal is essential requisite of
functional appliance therapy
m Clinical experience indicates that the opening of
construction bite in excess by approximately
mm
individual's position is optimal
m Resting individuals the interocclusal clearance
amounts to
mm to 3mm in the molar area and
mm to mm in the incisor area
m An opening of  mm to mm in the Molar area and
6mm to mm in the incisor area frequently will
desired
m As we know from the study of rest position when
mandible is open beyond this position the condyle
moves downward and forward on the articular
eminence Thus the bite open more than  mm in
the molar area, forward movement of mm will
suffice
m Highly experienced clinicians such as Petrik and
Herren entirely disregard the rest position

m Petrik ± The upper and lower incisal edges should

meet in as close to an to edge relationship as
possible in a horizontal plane This maneuver will
generally leave the incisors "mm to mm Apart at
most, with a posterior bite opening of mm to mm
Contrary to many other clinicians, Petrik also given
preference to bring the mandible forward to the
complete desired distance at once, not in stages
m The configuration of the original malocclusion
and the movability of the mandible must be
studied carefully before deciding which
technique to follow

m Taking the construction bite is a most important

step in the treatment It should be done directly
in the patient's mouth No articulator duplicates
the exact condylar pathway as in the patient
m If the forward positioning of the mandible is mm to
mm the vertical opening must be slight to
moderate(
mm-mm
m If the forward positioning is not more than 3mm to
mm the vertical opening should be mm to 6mm
m Lower midline shifts or deviations can be corrected
by the activator only if there is actual lateral
translation of the mandible itself îunctional cross
bites that are observed in the functional analysis
can be corrected by taking the proper construction
bite
m Both experimental research and clinical
experience have shown that an increase in
muscle activation with overextended appliances
does not increase the efficiency of the activator

m Acc to Sander- the frequency of maximal biting

into a 6mm high construction bite is "

percent of the sleeping time, whereas in an
""mm construction bite it is only " " percent of
the time If the height is increased to "3mm as
prescribed by Harvold, maximal biting takes
place only   percent of the time
m îirst, a horseshoe-shaped wax bite rim is prepared for
insertion between the maxillary and mandibular teeth (
-
3mm thicker than required

m Choice to keep bite on lower or upper arch

m If the rim is placed on lower arch ±easy to guide
mandible into desired position ±class II

m On the upper arch-mandible

can be moved easily into
retruded position required
for construction of Class III
activator
m Before taking the wax bite registration, the patient
is seated in an upright position The posture
should be relaxed and not strained The mandible
is then gently guided the predetermined position
The operator guides but not force the jaw into the
desired sagittal relationship This exercise is
repeated three or four times
m The patient is asked to repeat the exercise alone
and then hold the forward position for a while to
set up an exteroceptive engram that can be
replicated when wax is placed between the teeth
m After the operator is relatively sure that the
patient can replicate the exercise, the softened
wax bite placed in the mouth in the manner
already described
m -ax should not be too soft During the closing
movement, the operator controls the edge to
edge incisal relationship and the midline
registration
m To visualize the midlines & to establish correct
reproduction of the incisal relationship, wax
should be cut away from the labial surface of the
central incisors
m In the final step, the wax is carefully removed
from the mouth without distorting and is checked
on the upper and the lower models and chilled
m After it has been fitted on casts, the margins are trimmed
with a scissors, so the operator can be sure the wax is in
close approximation to all the cusps of the teeth
m The hardened wax bite is then checked once again in
the mouth
m The following step by step procedure for taking the construction bite
is suggested:
" Reproduce the maximum forward movement of the mandible and the
correct occlusal clearance of postural rest Observe whether a
functional lateral shift occurs and register the true mandibular
midline with a pencil on the labial surfaces of the upper and lower
incisors on the casts and in the patient's mouth

Determine the amount of mesial and vertical mandibular

displacement necessary for the construction bite It is helpful to
mark the amount of mesial shift with a pencil on the buccal surfaces
of the first molars

3 Show the patient on the casts and in the mirror in which direction the
mandible should be moved Practice the forward mandibular
movement by gently guiding the mandible in the desired direction
m Advise the patient to move the jaw slowly according to
the verbal instructions and to stop movement
immediately when asked to do so Talk to the patient in a
calm, reassuring manner

 Soften a sheet of beeswax and make a tight roll,

approximately " cm in diameter

 Shape the roll to conform to the lower dental cast,

leaving the seam on the inside Press the softened roll of
wax on the lower arch so that only the buccal teeth are
covered In the front, the wax roll lies just lingual to the
lower incisors Make a groove on the wax to indicate the
midline Remove any excess wax that extends onto the
retromolar tissue The distal half of the last molar tooth
should not be covered with wax
¦







  
 


 




 












 



 




 



 



 
 



   






 




 



 
 


 






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m Low CB with marked mandibular positioning
m High CB with slight mandibular positioning
m CB without forward mandibular positioning
m Posterior CB
 BIONATOR

-3 mm interincisal clearance at the centrals or

laterals and a mandibular advancement so that
lower centrals are
-3 mm protruded beyond
upper centrals or laterals
Mixed dentition S:
mm V :
mm for
hr wear
Permanent dentition S:3mm V: 3mm for "
hr or more
î



  
 


  

   

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