REVIEW
Australian Dental Journal 2000;45:(3)173-178
Current concepts on functional appliances and
mandibular growth stimulation
A. R. Collett*
Abstract
The mode of action of functional appliances,
particularly in relation to stimulating mandibular
growth, is a controversial subject. Many of the
reports concerning growth effects of functional
appliances have been characterized by poor
methodology. In assessing functional appliances,
results from prospective randomized clinical trials
should be given prominence. On the basis of
available evidence, it cannot be concluded that
functional appliances are effective in stimulating
and increasing mandibular growth in the long term.
Although favourable growth changes have been
reported following phase 1 therapy, they are
generally not substantial and long term stability
appears to be poor.
Key words: Class II treatment, dentofacial orthopaedics,
functional appliance, mandibular growth.
(Received for publication August 1999. Revised March
2000. Accepted March 2000.)
Introduction
Functional appliances have become part of
contemporary orthodontic practice, however, their
mode of action is still controversial. The ability of
functional appliances to reduce overjets by means of
modifying dental relationships (incisor angulation
and position) is not in dispute. The controversy
surrounds the ability of the appliances to increase
mandibular growth, and thus result in a long-term
change in the skeletal pattern. The mandibular
growth aspect is of particular interest as most skeletal
Class II patterns have as their main component
mandibular retrognathia.1 Cephalometric landmarks
used in mandibular growth analysis are shown in
Fig. 1.
Much of the earlier literature relating to functional
appliances has been criticized on the basis of
scientific methodology.2 Tulloch et al.2 stated there
are many examples in the health sciences where
opinions based on the observation of a few patients
or studies that used relatively weak design have been
*Orthodontist.
Australian Dental Journal 2000;45:3.
responsible for suggesting spurious associations and
promoting useless treatments. It should be borne in
mind that the path to introducing a new drug into
the market place involves a prospective randomized
clinical trial.3,4 Yet, for many years, the orthodontic
profession has accepted certain claims regarding the
clinical efficacy of appliances, in the absence of any
scientific evidence. A very unflattering observation
was made by Johnston5 who wrote: No biological
basis? No evidence? No matter. Facial growth, surely
one of the most complex of all biological processes,
is now thought to have yielded without a struggle
and in some unknown way to the ministrations of
small, eponymous pieces of plastic. Sackett,6 an
epidemiologist who assessed the orthodontic
literature for scientific validity, wrote in 1986 . . . in
terms of the number of published randomized trials,
orthodontics was behind such treatment modalities
as acupuncture, hypnosis, homeopathy, and
orthomolecular therapy and on a par with
scientology . . .. More recently, in 1995, Sackett7
noted the increase in randomized trials in orthodontics
and applauded the move to evidence-based
orthodontics. Although Sackett6,7 has argued for
acceptance of the randomized clinical trial, others
have proposed alternative approaches to research,
largely due to the cost of randomized trials as well as
their labour intensive and time consuming nature.8,9
However, there is overall agreement the randomized
trial is the best method for minimizing biases and
detecting differences between treatments.
Previous studies
In the 1970s and 80s there was an increase in the
numbers of papers published in refereed journals
supporting functional appliance stimulated
mandibular growth.
The question of whether the effect of mandibular
forward positioning appliances in increasing
mandibular growth in animal studies10-13 can be
reproduced in humans has been widely addressed by
many, with inconsistent findings. Functional
173
 Fig. 2. Modified Bionator type appliance. Headgear tubes allow
application of extra-oral traction.

Fig. 3. Teuscher appliance. Note the characteristic anterior

torquing springs which are adjusted to minimize upper incisor
Fig. 1. Cephalometric landmarks used for mandibular growth proclination.
analysis. Ar-articulare; Co-condylion; Gn-gnathion; N-nasion; Po
pogonion; S-sella.

appliances are varied and diverse in design (Table 1,

Fig. 2-5) with their proponents often having a
proprietary interest in the appliance. Claims as to
the efficacy of the appliances by clinicians with a
financial interest should be treated with caution.
Presentations which consist of carefully chosen cases
may not necessarily reflect the actual results seen
over a large number of consecutively treated
Fig. 4. Frankel FR-2 appliance.
patients. It is attractive to believe in functional
appliance stimulated growth for, as Johnston14
poor methodology (Table 2), or are simply anecdotal
noted, it is a very good idea and also has the
case reports.2 The problem has been recognized and
advantage of removing some of the decision making
acknowledged by the profession, with steps taken to
in treatment planning if all Class II cases can be
rectify the situation. When assessing the effects of
treated the same way.
appliances, the hierarchy of evidence shown in Table
Many of the reports concerning growth effects of 3 should be borne in mind. Case reports, although at
functional appliances have been characterized by the lower end of the hierarchy, do serve a useful
purpose. Case reports may identify a possible effect
Table 1. Examples of various functional (or adverse effect) of a therapy, and a body of such
appliances
Andresen Activator
Bass appliance Table 2. Common problems with clinical
Bionator (and variants)
Elastic Bite-block research studies concerning growth effects
Elastic Open Activator of functional appliances
Frankel FR-2 Functional Regulator
Harvold Activator Conclusions from isolated cases
Herbst appliance Lack of suitable controls
Herren Activator Compliance measurement
Modified Bionator Inadequate sampling
Orthopaedic corrector (1 and 2) Retrospective observations
Stockli Type Activator Data measurement and evaluation
Robin Monobloc Detecting minimal changes
Teuscher appliance Biological variation
Twin Block Experimental versus clinical significance
Woodside Type Activator Lack of long-term studies

174 Australian Dental Journal 2000;45:3.

Table 3. Hierarchy of clinical evidence for
assessment of the effects of functional
appliances
Prospective randomized clinical trial
Prospective study non-random
Retrospective study pretreatment selection criteria
Retrospective study post-treatment selection criteria
Case report
Opinion of expert
reports provokes further investigation. Numerous
case reports do not constitute definitive evidence
and a well conducted prospective randomized
clinical trial(s) must be given a higher ranking. A
notable shortcoming of clinical retrospective studies
is the selection of only those patients who completed
treatment.15-19 Clinicians do not generally persist
with treatment that is not producing the desired
response. It is easy to assume a lack of cooperation,
however, it is also possible the appliance had no
significant therapeutic effect and the study simply
selected patients experiencing favourable growth.
Table 4 lists papers which are representative of
studies concerning functional appliances.This table is
not intended to be all-inclusive, but rather an example
of what has been published over the last 30 years.
Mandibular growth
While some reports in the literature conclude that
functional appliances are effective in increasing
mandibular length,2,20-29 other studies have concluded
that functional appliances do not affect mandibular
growth.30-36 The studies reporting a positive effect on
mandibular growth still leave this question
unanswered due to characteristics such as lack of a
control group,21,27 clinically minimal effects20 and
patients being retained with a mandibular positioning
appliance.20,25
The clinical significance of a measured increase in
mandibular length needs to be considered in terms
of forward chin positioning. The increase in length
may be negated by clockwise mandibular rotation.
For example, in the studies of McNamara et al.,22-24
despite giving an increase in mandibular length, the
Frankel appliance did not increase anterior chin
projection compared with the control, although the
Herbst appliance did demonstrate this effect.24

Table 4. Representative studies 1967-1998 concerning functional appliances

Citation Reference Number Comments

Adenwalla and Kronman, 1985 53 Retrospective; FR versus edgewise

Bishara and Ziaja, 1989 28 Review
Creekmore and Radney, 1983 32 Retrospective; successfully treated malocclusions
Derringer, 1990 15 Retrospective; Andresen, successful cases studied
DeVincenzo, 1991 18 Retrospective; successful cases studied
Drage and Hunt, 1990 31 Retrospective; successful cases, relapse studied

Erverdi and Ozkan, 1995 20 Elastic bite-blocks, retention with Bionator
Fidler et al., 1995 16 Retrospective; successful cases studied
Ghafari et al., 1998 21 Prospective randomized clinical trial; no control group
Gianelly et al., 1984 54 Retrospective; compliant cases
Illing et al., 1998 46 Clinical trial; Bass, Bionator, Twin Block
Jakobsson, 1967 30 Prospective randomized study; Activator
Johnston, 1999 5 Review
Johnston, 1996 14 Review
Johnston, 1986 55 Retrospective; Bionator, Activator, Sagittal appliance
Keeling et al., 1995, 1998 47, 48 Prospective clinical trial
Lai and McNamara, 1998 38 Retrospective; Herbst appliance
Lange et al., 1995 17 Retrospective; successfully treated cases, Bionator
Livieratos and Johnston, 19?? 56 Two phase therapy versus phase 1 therapy
Lund and Sandler, 1998 45 Prospective studies, not randomized; Twin Blocks
Mamandras and Allen, 1990 19 Retrospective; successful cases, Bionator
McNamara, 1985 11 FR-2, cooperative patients
McNamara et al., 1985 22 Retrospective; FR-2
McNamara et al., 1990 23 Retrospective radiographic study; FR-2 , Herbst
McNamara et al., 1996 24 Retrospective study; FR-2
Mills and McCulloch, 1998 44 Prospective radiographic study; Twin Blocks
Nelson et al., 1993 33 Prospective, randomized; FR, Harvold and control groups
Pancherz et al., 1979, 1990, 1991, 1997 37, 39-42 Herbst appliance effects and long-term follow-up
Perillo et al., 1996 25 Retrospective; some cases retained with Activator
Righellis, 1983 26 Retrospective; successfully treated to molar Class I
Robertson, 1983 34 Prospective; FR-2, emphasized need for RCT
Rudzki-Janson and Noachtar, 1998 35 Initial prospective study with post-retention follow-up
Tulloch et al., 1990 2 Review
Tulloch et al., 1995, 1997, 1998 49-52 Prospective randomized clinical trial
Tuncay and Tulloch, 1992 29 Review
Weiland et al., 1997 27 Retrospective; radiographic study
Wieslander, 1993 43 Retrospective; available post-retention records analysed
Wieslander and Largerstrom, 1979 36 Patient sample compared with retrospective control group

Increased weighting should be given to prospective randomized clinical trials.

Australian Dental Journal 2000;45:3. 175

Fig. 5. Twin Block appliance.
Also, initial mandibular changes need to be
evaluated carefully. Johnston5,14 has suggested that
what may be interpreted as growth in fact amounts
to mandibular displacement or a combination of the
two. In addition, analyses that rely on the measure-
ment articulare15,18 are unable to discriminate
between growth and displacement.
Full-time functional appliance wear
Does the lack of appreciable growth in some
studies relate to a lack of full-time use? One variant
of the functional appliance that is worn for 24 hours
is the Herbst appliance. Many of the reports relating
effects of the Herbst appliance have been authored
by Pancherz. Pancherz37 initially claimed the
appliance increased mandibular growth and an
associated increase in the SNB angle was noted.
Unfortunately, the long-term results were not so
encouraging.38-43 Subsequently, Pancherz concluded
that the inherent morphogenetic pattern dominates
over the treatment procedure.41
Twin Blocks are also promoted as virtually full-
time wear appliances. Results from Twin Block
studies are inconclusive. While short-term data44
have suggested increased chin projection with the
appliance, other studies have been unable to
demonstrate this effect.45,46
Mandibular growth and results of prospective
randomized clinical trials
Illing et al.,46 Keeling et al.47,48 and the University of
North Carolina (UNC)49-52 have recently undertaken
prospective randomized clinical trials of Class II
appliances. A randomized clinical trial has also been
conducted by Ghafari et al.,21 however, their lack of
a control group is a drawback. An earlier prospective
study was conducted by Jakobsson30 and, as
mentioned above, the conclusion was that activators
do not bring about an increase in mandibular growth.
Tulloch et al.50 concluded on the basis of the UNC
two-phase randomized trial that early treatment
(phase 1) followed by later comprehensive treatment
(phase 2), on average, does not produce major
176
differences in the jaw relationship or dental
occlusion, compared with later one-stage treatment.
The UNC group also attempted to objectively
measure compliance by incorporating timing devices
into some of the appliances. Although favourable
skeletal changes were noted in the functional
appliance group following phase 1 therapy, the
changes were not maintained. This finding agrees
with previous studies that also failed to demonstrate
any benefits in terms of skeletal change with early
phase 1 therapy.53-56 Johnston5 reduced this debate to
the simple statement: Absent a ponderable
difference in outcome, the inescapable fact that a
two year treatment is three years faster than a five
year treatment may speak for itself.
The study of Keeling et al.48 concurred with that of
Tulloch et al.50 in that functional appliances brought
about some favourable skeletal change following
phase 1 treatment. The change in mandibular length
was greater in the functional group than the control
and amounted to a little less than 1 mm per year. In
Keelings study the changes appeared to be stable 12
months after therapy, although further long-term
(and post-phase 2) data have yet to be collected.
The clinical trial of Illing et al.46 also lacks long-
term data. The trial examined the responses to
treatment with Bass, Bionator and Twin Block
appliances. The treatment and control groups
consisted of patients with mandibular retrusion and
an ANB angle of greater than 6. Of the three
appliances, the Bionator and Twin Block gave an
increase in mandibular length (or mandibular
displacement), as measured from articulare to
gnathion, compared with the control. However, the
effect on the profile seemed to be negated by an
increase in facial height. Also, only the Bionator
recorded a significant increase in mandibular length
as measured from condylion to gnathion. None of
the appliances were successful in increasing either
the SNB angle or the forward projection of pogonion,
compared with the control group.
Length of treatment
In cases where functional appliances are utilized,
the patient usually requires further detailing with
fixed appliances.57 Although early functional
appliance therapy has been reported to decrease the
time in fixed appliances (phase 2), the total treat-
ment time is generally increased over that for fixed
appliances only.50,56,58
Maxillary restraint
A restraining effect on the maxilla has also been
reported with use of functional appliances.30,38,44 Of
course, maxillary change is generally measured to A
point, which is a dento-alveolar landmark rather
than true skeletal point. Thus, observed maxillary
restraint does not necessarily reflect skeletal
Australian Dental Journal 2000;45:3.
modification. In various prospective studies45,46,48,50
such an effect on the maxilla could not be
demonstrated. A similar negative outcome was
observed in a follow-up of patients treated with the
Herbst appliance.41 In the study of Livieratos and
Johnston,56 headgear treated patients were found to
have undergone more maxillary change, while those
treated with a Bionator demonstrated more
mandibular change (growth or displacement) after
phase 1 therapy. However, these changes were no
longer evident at the completion of phase 2 fixed
appliance therapy. As Johnston5 noted, regardless of
the appliance a common outcome is likely, implying
a common mechanism. The prime candidate is
normal facial growth.
Clinical applications
In terms of practical clinical applications, a lack of
significant skeletal change with functional appliances
does not diminish their use in correcting overjets.
The appliance is still a useful orthodontic tool for
correcting Class II malocclusions, although not
unique in this regard. Of relevance are the
concluding remarks of Livieratos and Johnston,56
who wrote: We suspect that the decision to use
functional appliances is fundamentally a practice-
management problem . . . Recent findings underpin
the importance of correct diagnosis and being able
to differentiate between the skeletal and dental
components of a malocclusion. For a patient who
has a severe retrognathic profile with a deficient chin
where surgery may be required, the use of a
functional appliance is unlikely to change the long-
term surgical needs. However, in many cases
favourable profile changes can occur. The overall
facial profile is the result of skeletal, dental and soft
tissue contributions. Improving dental relationships
may result in an improved profile due to more
favourable soft tissue drape. For example, consider
the patient with a Class II division 1 pattern with a
large overjet and lower lip habit (the lower lip at rest
being positioned behind the upper labial segment).
Reduction of the overjet can result in a substantial
improvement in facial aesthetics, without altering
the skeletal base relationship. After reduction of the
overjet, the lower lip can rest and function in front of
the upper teeth.
Conclusion
On the basis of available evidence, it cannot be
concluded that functional appliances are effective in
stimulating and increasing mandibular growth.
Despite claims to the contrary, the superior
functional appliance has yet to be demonstrated.
Although favourable growth changes have been
reported following phase 1 therapy, they are generally
not substantial and long-term stability appears to be
poor. The positive reports as to functional appliance
stimulated growth show only minor improvements
Australian Dental Journal 2000;45:3.
in anterior chin positioning, indicating that these
appliances do not provide an option to surgery in
severe Class II cases. Evidence suggests the modest
skeletal changes revert with time. In assessing
functional appliances, results from prospective
randomized clinical trials should be given
prominence.
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Address for correspondence/reprints:
Dr A. R. Collett,
7 Dawson Street,
Upper Ferntree Gully, Victoria 3156.
Australian Dental Journal 2000;45:3.