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BIONATOR

CONTENTS:
Part 1
Introduction
Appliance philosophy
Case selection
Appliance types
Impression technique
Construction bite
Fabrication of bionator
Trimming of bionator

Part II
Clinical handling
USP of bionator
Drawbacks of bionator
Bionator in TMJ cases
Modifications
Review of literature and recent studies
Conclusion
References

Prof. Dr. Wilhelm


BALTERS (1893-1973)
The father of bionator
with dental technician
Fritz Geuer

He was a physician, dentist, teacher,


researcher and clinician
but above all
he was a healer.
He was among first to realise the importance
of psychosomatic medicine and functional
orthopedics.

A Non Random Relationship


between
Malaligned teeth

General health

Impairments

http://www.kfo-online.de/profile03c.html

Balters defined nine therapeutic areas:


1.Lip closure

2.The contact of the dorsum of tongue


and the soft palate.
. http://www.dr-tilch.de/leistungen/kieferorthopaedie/bionator.htm

3.Edge to edge position of the incisors(considered their


functional position by many including Begg)

4..The displacement of the mandible & space


obtained, which is important for the re-orientation of the
tongue.

5.The reorientation of the tongue, jaw, teeth


and surrounding soft tissues.

6.The normalization of blood flow and fluid


exchange of blood and lymph.
7.Increased metabolism, which also leads to an
increase in detoxification of the tissues.

8.Position of the head and the consequent


impact on the entire spine and posture.
9.The relaxation of the jaw muscles.It prevents
unilateral muscle contractions and the resulting
deformation.

SALIENT POINTS OF BALTERS PHILOSOPHY

Correction of disharmonious dentofacial


relationships should be acheived through
Self regulation.
Because mouth is a complex sense organ and
is capable of adjustment in posture of lip ,
tongue and mandible.

Appliance Philosophy

Tongue
Essential factor in development of
dentition

The centre of reflex activity in oral


cavity

Balters said
Class II malocclusions are consequence
of backward position of tongue

Disturbing the cervical region

Respiratory function impeded in region


of larynx
&
Thus, there is
Faulty deglutition
Mouth breathing

Hakan El and Juan Martin Palomo

Airway volume for different dentofacial skeletal patterns


(Am J Orthod Dentofacial Orthop 2011;139:e511-e521)

Used CBCT
&
IVD(in vitro
dental
program)

They concluded that


The OP airway volumes of Class II patients were
smaller when compared with Class I and Class III
patients.
Hence mandibular position with respect to cranial
base had an effect on the OP airway volume.
Smaller NP volume observed for the Class II
group.

Fatih Ylmaz, Deniz Sa gdc, Seniz Karacay, Erol Akin, and Nail Bulakbas
Tongue movements in patients with skeletal Class II malocclusion evaluated with real
time balanced turbofield echo cinemagnetic resonance imaging
(Am J Orthod DentofacialOrthop2011;139:e415-e425)

They made linear measurements on MRI


They concluded that
1. Dentofacial morphology affects the position
of the tongue and its deglutitive movements.
2. In patients with Class II malocclusion, the
tongue is positioned more superiorly, and the
tongue tip is positioned more posteriorly than
in those with skeletal Class I malocclusion

Serkan Gorgulu,Deniz Sa gdc,Erol Akin,Seniz Karacay, and Nail Bulakbas


Tongue movements in patients with skeletal Class III malocclusions evaluated with realtime turbofield echo cine magnetic resonance imaging
(Am J Orthod Dentofacial Orthop 2011;139:e405-e414)

They concluded that


1.Dentofacial morphology affects the position of
the tongue and movements during deglutition.
2. In patients with Class III malocclusion, the
tongue is positioned more inferiorly and anteriorly
than in
those with skeletal Class I malocclusion.

3. The manner of bolus transfer is different in


patients with skeletal Class III and Class I
malocclusions.
Linear motion of the tongue - with Class III
malocclusion, and
A fluctuation motion of the tongue - with Class
Imalocclusion

Graber, Neumann : Removable orthodontic appliances. 2nd edition, Philadelphia, WB


Saunders. Page 157
Average tongue position and standard deviations in class II and class III evaluated
cephalometrically

Graber, Newmann : Removable orthodontic appliances. 2nd edition, Philadelphia, WB


Saunders. Page 157
Average tongue position and standard deviations in class II and class III evaluated
cephalometrically

Graber, Newmann : Removable orthodontic appliances. 2nd edition, Philadelphia, WB


Saunders. Page 157
Average tongue mobility and standard deviations in class II and class III evaluated
cephalometrically

Objective of treatment in Class II div 1


malocclusion:
Stimulation of distal part of dorsum of tongue
Tongue is brought forward
This helps in developing mandible in anterior
direction

Balters said
Cervical viscera may also be brought forward
This will enlarge respiratory pathway

Enhance reflex deglutition which will become


normal

By the same analysis Balters reasoned that

Serkan Gorgulu,Deniz Sa gdc,Erol Akin,Seniz


Karacay, and Nail Bulakbas

Tongue movements in patients with skeletal


Class III malocclusions evaluated with real-time
turbofield echo cine magnetic resonance imaging
(Am J Orthod Dentofacial Orthop 2011;139:e405e414)

They concluded that


1.Dentofacial morphology affects the position of
the dorsal tongue and movements during
deglutition.
2. Class III malocclusion-the tongue is
positioned more inferiorly and anteriorly than
in those with skeletal Class I malocclusion.

3.The

manner of bolus transfer is different in


patients with skeletal Class III and Class I
malocclusions.
4.Linear motion of the tongue with Class III
malocclusion, and
5. fluctuation motion of the tongue occurs in
patients with Class I malocclusion

Balters said , in class III malocclusions move


tongue more backward and higher
He said
It will reduce cervical overdevelopment.

For Class I malocclusion Balters said that-

In Class I malocclusion,
transverse
underdevelopment may be
reduced by
MUSCULAR TRAINING
which makes
tongue stronger.
A NEW EQUILIBRIUM
between tongue and
lip is established .

Balters technique requires


LIP CLOSURE
for treatment of all kinds of
malocclusions to harness
uninhibited growth potential.
This is made possible by end to
end incisal biting position.

Balters developed bionator (during late 40s &


early 50s ) with his dental technician Fritz Geuer.
A Bionator made in orthodontic laboratory
Geuer in Waldbrl

For normalising the function of stomatognathic


system, his was Holistic total child approach
which included
Reinforcement of patients image
Over all wellbeing

Hence he became a pioneer in HOLISTIC


ORTHODONTICS
His method requires
Awareness of psychosomatic inter
relationships
Knowledge of developmental psychology
TALENT to communicate with the young
patient

Because treatment succeeds only with


optimal patient orthodontist inter relationship
psychological support
As treatment takes around 3 years to
complete

KANTOROWICZ termed bionator as


The skeleton of activator
His assessment is correct because
Bionator is less bulky than
activator
It lacks anterior part covering
anterior section of palate which is
contiguous with tongue

TREATMENT OBJECTIVES :
1. Lip closure
2. Bring back the tongue in contact with the
soft palate
3. Bring incisors in edge to edge(like Begg
he feels that this is natural body
orientation)

4. Achieve elongation of the mandible


and hence enlarge the oral space and
make improved tongue position possible
5. Achieve improved relationship of the
jaws, tongue and dentition as well as
surrounding soft tissues

CASE SELECTION

Class II division 1 malocclusions in mixed dentition with


following features:
1.

Well aligned arches

2.Mandible in posterior position (functional


retrusion)
3. Skeletal discrepancy not too severe

4.Labial tipping of upper incisors is


evident
5.Upright
and
well
mandibular incisors

6.

positioned

Cases of deep overbite caused by


infraocclusion of premolars and
molars(a large freeway space )
caused primarily by lateral tongue
posture or thrust

7.Considered by many operators to be the most


effective appliance for treatment of sequelae of
sucking habit (spacing and protrusion of upper
incisors , class II tendency and the narrow inter
canine width are responsive to correction)

Visual treatment objective


diagnostic test

Before making a
decision
First Habitual
position
Then posture
mandible in correct
sagittal position

If profile improves
Bionator is indicated.
Profile becomes worse
e.g in shallow bite Class II
excessive anterior facial height,
Vertical growers.

-8.Open bite cases can be


handled with open bite
bionator
- -clinically this would be
seen as maxillary anterior
dentoalveolar
deformation
-buccal segment teeth are
loaded for all possible
intrusive stimulus

Bionator is useful while


treating open bite
caused by habits
like finger sucking,
retained infantile
deglutition pattern ,and
abberant tongue function
Open bite cases with
skeletal etiology are a
containdication

9.While treating class


III bionator use is
limited to Pseudo
class III where
upper incisors are
tipped lingually, and
mandible occludes
anteriorly due to
functional interferance

10.Bruxism , periodontal disease and


temporomandibular joint disorders

CONTRAINDICATIONS
deep overbite due to extrusion of anteriors
skeletal openbite
Crowded arches

Patients with pronounced vertical growth pattern


are a relative contraindication for functional
therapy ,this growth pattern is indicated by
1.Large articular angle

.Large gonial angle

.Large saddle angle

4.Jarabak s ratio less than 62%

5.Lesser anterior cranial base length


6.Lesser posterior cranial base length

7.Large base plane angle

8.Short ramus

9.Morphology of mandible :retrognathic mandible

10.Mandible built in skull in posterior position by


morphogenetic pattern

Treatment
Timing

Faltin KJ, Faltin RM, Baccetti T, Franchi L, Ghiozzi B, McNamara JA Jr


Long-term effectiveness and treatment timing for Bionator therapy
Angle Orthod. 2003 Jun;73(3):221-30

Two groups according to their skeletal maturity as


evaluated by the cervical vertebral maturation (CVM)
method.
The early-treated group
-initiated treatment before the peak in mandibular
growth, which occurred after completion of Bionator
therapy.
-The late-treated group received Bionator treatment
during the peak.

Treatment effective and stable when performed


during the pubertal growth spurt.
Optimal timing to start treatment with the
Bionator iswhen a concavity appears at the lower borders
of the second and the third cervical vertebrae
(CVMS II).

In the long-term, the amount of significant


supplementary elongation of the mandible in
subjects treated
-during the pubertal peak is 5.1 mm more than in
the controls, and it is associated with a
backward direction of condylar growth.
Significant increments in mandibular ramus
height also were recorded.

APPLIANCE TYPES
1. Standard Bionator
2. Class III Bionator
3. Open Bite Bionator

Standard Bionator
Indications :
1. Class II division I conditions to correct
backward position of tongue and its
consequences

2.Narrow dental arches in class I


malocclusion

&

STANDARD APPLIANCE

Wire
Elements

Palatal arch
Vestibular wire

Palatal Arch

1.2 mm diametre
stainless steel wire
Emerges from upper
margin of acrylic
approximately
opposite the middle
of first premolar

Originally termed lingual arch because of its


function to stimulate the tongue

Then it follows the


contour of the palate,
at about 1 mm
distance from the
mucosa
The arch forms a
wide curve that
reaches a line joining
the distal surface of
the first permanent
molars

Then it follows identical


mirror image curve to
insert on the opposite
site
Configuration of palatal
arch is like the shape of
an egg

BALTERS says,
task of palatal arch is to
stimulate distal aspect of
tongue
Hence the arch is curved
posteriorly to effect forward
orientation of the tongue as
well as the mandible into
class I relationship

Balters philosophy of functional loading of


maxillary lingual area by increased tongue
function under the effect of the palatal bar
has been questioned by Rakosi et al
(1977)
who stated that palatal bar only flattens
the tongue and does not move it
anteriorly

Additionally Balters says


that if the palate is deep ,
tongue is prevented to
touch it as it would
originally do
Hence there is
subsequently flattening of
palate which conceivably
would improve breathing
through nose

The development of the frontal and maxillary


sinuses in connection with the oral cavity
development

Vestibular wire

Made up of 0.9 mm stainless steel wire


Emerges from the acrylic below the contact
point between upper canine and first
premolar

Rises vertically and is bent


at right angle to go distally
along the middle of the
crowns of upper premolars
Just anterior to mesial
contact point of upper first
molar the wire is bent into
a round fashion towards
the lower dental arch

It maintains a constant
level at the height of the
papillae ,parallels upper
portion anteriorly to the
mandibular canine

At this point the wire is bent to reach the


upper canine, nearly touches the incisal
third of the incisors and from there a mirror
image of the side already fabricated
proceeds posteriorly to the acrylic on the

Labial portion of the


vestibular wire is kept
away from surface of
incisors by the thickness
of a sheet of paper

Lateral portions of
vestibular wire are
sufficiently away from
the premolars to allow
expansion of the dental
arch BUT not enough
cause discomfort to the
cheek

Theory is that between the


incisors and mucosa SLIGHT
NEGATIVE PRESSURE is
created
In course of treatment this
should help upright incisors
Provide space for them when
dental arch is widened
laterallly and sagitally and
have favourable influence on
the development of the
region of apical base

Anterior portion of
vestibular wire is called
the LABIAL WIRE
Lateral parts are called
BUCCINATOR BENDs

BUCCINATOR BENDS
have two objectives
1. Keep away soft tissue of
the cheek preventing
their drawing into
interocclusal space
hence bite is levelled
and eruption will
proceed in the buccal
segments

They move orobuccal


capsule laterally
increasing oral space by
virtue of the forward
positioning of the mandible
ralaxes the musculature
while vestibular wire holds it
away from the alveolar
mucosa

Balters said: removal of


this inhibitory influence of
circumoral capsule will
favour expansion or
transverse development of
the maxillary dentition
(Frankel with his pertinent
research indicates these
objectives are attainable)

ACRYLIC BODY
Slender acrylic body
fitted to lingual aspect
of arches

Extends from a
point distal to first
permanent molar to
corresponding
point on opposite
side

Maxillary part
covers only
molars to
premolars
Anterior maxillary
part from canine
to canine remains
open

Relative position of joined upper


and lower acrylic portions is
determined by construction bite

Acrylic should
extend 2 mm below
gingival margin and
about the same
distance above
maxillary gingival
margin

It must
remain rather
thin so as not
to interfare
with function
of tongue

Interocclusal space
of some buccal teeth
is filled with acrylic
extending over half of
occlusal surface of
teeth for
STABLIZATION ON
BIONATOR

The appliance is stabilized in mixed


dentition by having upper and lower
deciduous molars occlude in acrylic
In permanent dentition maxillary
premolars occlude in acrylic
No acrylic covers first molars :to
permit further eruption and levelling of
bite in this region

CLASS III
APPLIANCE

Wire Elements
PALATAL ARCH
Fabricated of 1.2 mm wire
Round bend is positioned
in inverted position,
extending from a line
connecting the middle of
first premolars

From this point, the wire


runs parallel on both sides to
the upper margin of the
acrylic, extending
posteriorly to the distal
surface of the first molar
At this point , the wire enters
the acrylic at a right angle
bend

Buccinator bend is
fabricated in the same
manner as in standard
appliance
The wire goes distal until it
reaches a point just behind
second premolar
From here with a round
bend it bends forward

As labial wire it is in proximity


of lower incisors remaining a
thickness of sheet away from
labial surfaces

Acrylic part of the class III


appliance is similar to
standard type
Mandibular plate and two
lateral maxillary parts
extending from the first
premolar to the first premolar
are joined ,opening the bite
just enough to allow upper
incisors to move labially past
the lower incisors

Opening of bite should


provide a space less then 2
mm between the edges of
anteriors
The space is covered
towards the tongue by an
extension of the mandibular
portion of the plate from
canine to canine

The edges of upper


incisors extend beyond the
upper margin of acrylic
about 2mm
Maxillary incisors are
positioned directly in front
of acrylic barrier , which
does not exert any
pressure

About 1 mm of acrylic is
removed from behind the
mandibular incisors
This barrier blocks any
forward movement of tongue
towards the vestibule
Teaches the tongue by
proprioceptive stimuli to
remain in its retracted &
proper functional space

Tongue will now contact


the uncovered anterior
portion of the palate,
stimulating the forward
growth component of this
area

OPEN BITE APPLIANCE


PURPOSE: close open bite
In majority of cases , tongue
is believed to be
perpetuating infraocclusion
of maxillary and
mandibular teeth allowing
overeruption of buccal
segments

WIRE ELEMENTS
Palatal and vestibular wires
are same as for standard
type of bionator
Labial bow runs between
the incisal edges of anteriors
It is placed at the height of
correct lip closure to
stimulate lips to achieve
competent seal

Vertical strain on lips tends


to encourage extrusive
movement of incisors after
eliminating adverse tongue
pressures
However in some cases the
lip and the cheek , particularly
lower lip may be drawn into
open bite which would
interfere with correction of

To prevent this from occurring,


a lip shield may be added
It is placed in the vestibule
and is anchored to the
appliance by acrylic or wire
extension over and slightly
inside buccinator bends
This effect instant closure of
oral cavity

Lip shield can also be helpful


to prevent hyperactive
mentalis when there is
confirmed lip trap with marked
overjet

There is little or no
interocclusal clearance in
such cases
It is important to prevent the
tongue from inserting into the
aperture
For this the maxillary parts of
the acrylic are joined
anteriorly,in contradistinction
to other two types

However anterior part is not


in contact with the teeth or
alveolar bone, since it must
not interfare with the
growth changes
It is hoped that the
treatment response will not
only improve the occlusion
but will transform the
adjacent alveolar parts

Maxillary and mandibular


acrylic portion are joined by
slight bite blocks which have
indentations of teeth to
prevent posterior teeth from
erupting
Anterior teeth are allowed to
erupt freely

This re-establishes the inter


occlusal clearance and
postural vertical dimension
that is in harmony with
occlusal vertical dimension
Blocks must not be so thick
to prevent lip seal

Impression technique
Accurate
reproduction
Particularly soft tissue
in lower lingual
region
Standard aluminium
tray -no
impingement esp. In
lower lingual area

CONSTRUCTION BITE
Free way space :
Vertical dimension at rest Vertical dimension
in occlusion
At rest elevators and depressors of mandible
are in a state of minimal tonic contraction
opening of the construction bite approximately
2 mm in excess of individuals resting position
is optimal

In most individuals , freeway space is


2mm to 3 mm in molar area
So an opening of 4 to 5 mm in molar areas
will be desired

Unlike construction bite for activator, bionator


cannot accommodate variations in
vertical opening according to growth
patterns.
Bite registration is essentially edge to edge.
Myotatic reflex activity comes into action
with isotonic muscle contraction and the
loose appliance works with kinetic energy,

For standard appliance


1. Preference to edge to
edge relationship of all
or atleast lateral
incisors--- to achieve
maximum functional
space for tongue

2.Patient also finds the


contact established
between incisors
convenient

Registration of correct
construction bite is vital
Have the patient practice
holding the incisors in an
end to end relationship with
no change in mid line relation
from habitual occlusion

A roll of softened bite


wax is fashioned into
horseshoe shape and
gently placed on lower
occlusal surfaces of
the lower work model
Still softened wax rim is
placed on patients
arch

Mandible is gently
guided in predetermined
and practiced end to end
incisal position
Any interfaring incisal
wax is cut to check wax
bite rim and correct it

2.If overjet is too large


and edge to edge bite
is not possible
Step by step
protraction
Mandibular incisors
must be covered by a
grooved rim

In any event exaggerated forward


movement of mandible should be
avoided
After reduction of overbite is achieved ,
a new appliance with edge to edge
incisor relationship should be made

3. An additional maxillary
incisal margin acrylic
restraint may be used
(made in cold cure by
chair side )
4. It is cut and finished into
a 3mm wide groove on
maxillary incisors and
extends from one lateral
incisor to other

Secures position of upper incisors


Intruding force exerted on them may be
desirable too
Wire hooks mesial to
lower first molars can be
used for added
stabilization

3 dimensional changes achieved by a correct


construction bite for a full class II division 1
malocclusion

BIONATOR
FABRICATION

acrylic portions may be


heat cured or made more
easily with cold curing
acrylic
Teeth and part of wires are
covered with base plate
wax leaving little boxes for
acrylic

The casts are then


mounted on a fixator
Wax covering of both
the casts is joined by
melting the wax with a
heated instrument
and cold cure acrylic is
applied

The appliance can


then be handled as
any removable
wire and acrylic
combination
carefully polished
to prevent
distortion of wires

TRIMMING
OF BIONATOR

TRIMMING OF BIONATOR
Terminology used in trimming of bionator
appliance
1. Articular plane
2. Loading area
3. Tooth bed
4. Nose
5. Ledge

ARTICULAR PLANE
Extends from tip of upper
first molars ,premolars,
canines to mesial margin of
upper central incisors
Runs parallel to ala tragal
line
Is important in assessment
of mode of trimming

LOADING AREA: palatal or lingual cusps of


deciduous molars or premolars and
permanent molars are relieved in acrylic part
of the appliance,enhances anchorage of the
appliance

TOOTH BED: some parts of the loading area


are trimmed away from the articular
plane.Acrylic surfaces prepared in this manner
are called TOOTH BED

NOSE: between the tooth beds interdentally ,


acrylic finger like projections
Act as source of anchorage and guiding
surfaces for the appliance in saggital and
vertical planes
Nose (acrylic interdental
projection ) before lower first
molar region

LEDGE: depending on tooth movement desired , the


appliance acrylic is trimmed and nose reduced
A reduced plasic extension on OCCLUSAL THIRD of
interdental area is called ledge
Nose is mostly on mesial margin of first permanent
molar, while ledge is between premolars or
deciduous molars

ANCHORAGE OF APPLIANCE
Because bulk , volume and extension of appliance is
reduced , special requirement exists for anchorage
When treatment begins , trimming of all guiding
acrylic planes simultaneously for all the areas is not
possible
Some acrylic surfaces are used to stabilize the
appliance
Others are ground as need be to effect desired
stimulus for tooth movement

Stabilization is obtained from following areas


1. Lower incisal capping
2. Loading areas because cusps of teeth fit into
the respective grooves in acrylic
3. Deciduous molars- used as anchor teeth
4. Edentulous areas after premature loss of
deciduous molars
5. Noses in upper and lower interdental spaces
6. Labial bow if correctly placed , prevents
posterior displacement of appliance

VERTICAL STABILITY
- To avoid tissue impingement and soft tissue loss
lingual to the mandibular incisors.
-If vertical stability is incorrect, the appliance will rock in
the oral cavity every time the patient opens and closes:
occlusal forces may be distributed unevenly over the soft
tissue and cause irritation spots and a poor fit.
G. Altuna S. Niegel : Bionators in class II treatment.
JCO 1985,19,3; 185-193

vertical stability is established as follows:


1. In the permanent dentition, the acrylic is trimmed so
that acrylic protrusions or ZUNGE lie on top of the
interproximal regions in the lingual and palatal areas of
the maxilla and mandible .
2. Acrylic is left between the upper and lower incisors, if
necessary, to prevent their eruption.

Types of anchorage ( Ascher,1968)


Dentition-

Anchorage

1,2,III-V,6

IV, V upper
& lower

1,2,III,V,6

V & space for


VI

1,2,III,6

Alveolar
process IV,
V

1,2,III,4-6

6 and alveolar
process

ANCHORAGE permits anterior posturing of


mandible
Balters terminology:
Stimulation of eruption = unloading or
promotion of growth
Prevention of eruption =loading or inhibition
of growth

Trimming of acrylic tooth beds and elimination of the


influence of tongue and cheek allow the teeth to erupt
until they reach the articular plane
Once there , they are prevented from erupting further
by loading with self cure acrylic
Periodic loading and unloading of same area is
necessary and same tooth which functions as anchor is
later allowed to erupt
DEEP OVERBITE cases require adequate space to
allow full eruptive potential of teeth

To facilitate transverse
movement,occlusal
surfaces of bionator are
trimmed, on closure
cusp tips should remain
in contact with tooth
bed
Upper and lower
molars should be
trimmed first
Then lower premolars
trimmed when molars
are loaded

Finally upper premolars are


stimulated while lower
premolars and molars are
loaded
Noses have distalizing effect on
permanent first molars(at their place 0.8 /
0.9mm guide wire scan be used esp. when
space opening or treatment with extraoral
force is planned)

Noses in the area of lower


molars must be well defined
to prevent mandible from
dropping

End of part I
Thank you

BIONATOR

CONTENTS:
Part 1
Introduction
Appliance philosophy
Case selection
Appliance types
Impression technique
Construction bite
Fabrication of bionator
Trimming of bionator

Part II
Clinical handling
USP of bionator
Drawbacks of bionator
Bionator in TMJ cases
Modifications
Review of literature and recent studies
Conclusion
References

CLINICAL
HANDLING

For maximal beneficial effect bionator should be worn


day and night
Starting with 3 to 4 hours a day (during breaking in
period , patient practices speaking by reading aloud
and pronouncing words clearly),
gradually increasing to full time wear
Appliance should be worn full time during day before
starting at night to establish neuromuscular reflex
that will help maintain mandible in forward position
After insertion the return appointment should be given
in a week to check for sore spots

Worn during all times except meals , tooth


brushing , language lessons, contact sports
Read aloud half hour per day untill normal
speech can be accomplished
Time interval between office visits : 3 to 5
weeks (depending on state of eruption of
teeth)

At each appointment ,eruption facets are


checked with an explorer to ensure that the
maxillary and mandibular teeth are free to
erupt distally and mesially respectively

Overjet is checked in centric relation to determine


ammount of correction obtained and patient
compliance
If further advancement is needed a new appliance
needs to be fabricated
For patients exibiting good compliance , advancement
of bionator every 3-6 months may be necessary

Further advancement
should be considered
only when there is good
muscle response or
mandible could not be
repositioned distally
when checking
occlusion The
pterygoid response

Patient education
Children are advised to retain the appliance in
mouth when giving a short reply
If they have to speak longer and feel
hampered , they should use tongue to push
appliance out of the mouth into the left hand
which will hold it
They generally learn to accomplish this
manoeuvre easily
The appliance is reinserted equally rapidly

This technique is preferable to using fingers to


remove the appliance as then labial wire is to be
grasped and hence can get distorted
Labial bow should touch teeth only lightly if at all
Buccinator loops should be away from deciduous
molars and should not irritate the cheek
In final stages minor spaces can be closed by active
retraction of the bow

Some soreness of lower


incisors is expected initially
due to pressure of acrylicpatient should be told that
this is only temporary and
he should not discontinue
the appliance

During first phase of treatment, occurrence of


rapid horizontal and vertical changes in mandibular
position is common
First change is a muscular adaptation to new
position, with shortening of lateral pterygoid muscle
(petrovik et al 1972)

Rapid changes lead to open bite in posterior


segment

Articular and dentoalveolar adaptation


occurs in second stage following
neuromuscular adaptation

Dentoalveolar changes in first molar area are often


insufficient, thus posterior open bite in this area
persists until the premolars can be guided into full
occlusion under corrective eruptive guidance of the
appliance

In an average case 1 year to 1.5 years would be


reasonable estimate of time needed to achieve
correction

INTRATREATMENT ASSESSMENT OF
GROWTH RESPONSE

Measured growth increments are compared with the


average values,differentiated according to the
morphogenetic pattern
This assists in determining whether growth
increments and direction at that point in treatment
are
high or low
Favourable or unfavourable
in skeletal areas of greatest concern

Table

The distance Ar Pog is measured and


distance Ar- Point A is subtracted from this
value
If mandible is positioned anteriorly , this
coefficient increases

RETENTION
Same appliance can be used for retention and
is worn only during night
If correction is achieved very rapidly , day time
wear should not be abandoned at once (keeping
in mind need for muscular adaptation in this
kind of treatment)
Duration of retention:6 months to 1 year
The appliance is gradually worn less and less
frequently at night

The patient must be instructed to wear more


frequently again if after an interval slight tension
is felt when appliance is inserted

Representive cases treated with


bionator
Class II division 1 case

Class II division 2 malocclusion treated with


bionator

Open bite case treated with open bite bionator


in six months(post treatment photograph was
taken after eruption of second molars,
indicating good retention of results)

Class III malocclusion in a 6 year old girl


treated with class III bionator in 6 months
without application of any external force

USP of bionator
Best type of functional jaw orthopedic appliance
to start with for a neophyte orthodontist
Simple construction
Relatively few problems encountered
Day time wear gives it better opportunity to
achieve correction and prevent relapse(added
advantage over activator)

Less bulky than activator


Because it does not cover anterior palate ,
children are almost immediately able to speak
normally though the appliance fits loosely in
mouth

Can be used during late mixed dentition


period
Worn effectively during transition from
deciduous to permanent dentition, hence
providing the clinician ability to treat
patient orthopedically in spite of unstable
occlusion

DRAWBACKS
Balters belief that only the role of tongue
is decisive and giving secondary
consideration to the neuromuscular
envelope is questionable.Researchers
now know that abnormal tongue
function can be secondary,adaptive, or
compensatory because of skeletal
maldevelopment,Balters didnt consider
this in original version of his appliance

Winders in 1958 (AO)concluded after research


that tongue exerts 3 to 4 times as much force
on dentition as does buccal and labial
musculature
Robert V Winders,Forces exerted on the dentition
during by the perioral and lingual musculature
during swallowing,AO 1958,28,4,227

He concluded that at rest , there are no


pressures on lingual surface of maxillary,
mandibular central incisors
During swallowing no pressure against
labial surface of maxillary and mandibular
central incisors except open bite
In normal dentition , perioral musculature
doesnt normally contract during swallowing

In class II patients who can form anterior seal


when teeth occlude ,perioral musculature
doesnt contract during swallowing
Perioral musculature contraction is
apparent only in dentition that cant seal
itself in occlusion(net pressure against
anterior teeth is not remarkable)
Though during function , there is imbalance
of myometric forces, tongue exert much grater
force than perioral musculature

Tongue thrust is not the only cause of


anterior open bite
Inadequacy or arrest in condylar growth
,habits may be considered
Tongue thrust may be secondary to a
primary cause

These findings support Balters hypothesis


only partially if other factors like tissue rigidity ,
elastic index , atmospheric pressures ,
intercuspation are not considered
In case of skeletal disturbances bionators
efficacy is limited
Vulnerability to distortion
Potential of procumbency of lower incisors:
as labial wire doesnt contact them and
capping is only partially successful in
preventing labial tipping

As teeth erupt and acrylic support wears


out the appliance tends to sink causing
sore spots and gingival recession

BIONATOR IN TMJ CASES

It has been quite successful in managing


TMJ problems especially in adult patients
TMJ problems coincide with clenching and
bruxism during REM sleep
Wearing Bionator at night relaxes the
muscle spasms that occur particularly
in lateral pterygoid

DESIGN

Similar to standard appliance


Construction bite need not move mandible
as far forward
It is opened slightly
Lower incisors are capped
No grinding done
Purpose: prevent riding of condyle over
posterior edge of disk which causes clicking

Operator can determine clinically , how far


the mandible must be brought forward to
eliminate clicking on opening
clicking usually disappears when
mandible is opened in forward posture
Condyle no longer rides over the posterior
disk margin onto the retrodiskal pad
Bionator maintains forward position
Prevents deleterious parafunctional effects
at night

Bionator therapy + local heat applications


+muscle relaxants provide immediate ,
dramatic relief for patients

Accomodative forward position


Petrovic has shown that protracted wear
of bionator can cause permanent
shortening of lateral pterygoid, thus
helping patient maintain protracted
mandibular posture even during day
Clicking and other unfavourable TMJ
sequelae dissappear

Appliance must be worn indefinitely as


splint at night for this to happen
Adult class II patients learn
accommodative forward position as
muscles adapt
Patients often become so accustomed to
wearing the appliance that they are reluctant
to discontinue its nocturnal wear,&
complain they can not sleep with out it

Modifications

BIONATOR MODIFICATION
THE Bio-M- S THERAPY
-Erich and Annette Fleischer

MODIFICATIONS
Acrylic body of bionator reduced in size
extending less along the alveolar process than
the original design
Upper edge of acrylic margin tapers to a thin
edge this detailing helps pronounce S sound
more easily
Concavity provides greatest
possible tongue space with
sufficient appliance strength

Separate maxillary buccolabial arch wire and


mandibular labial arch wire

Transpalatal bar opens in distal


direction
Sagittal anchorage is reinforced
with wire spurs located mesial to
maxillary molars or canines

Metal occlusal bite plane to facilitate


correction of deep over bite

Maxillary buccolabial arch wire


Madibular labial bow
Wire stops :molar stops(also distalise 6) and
c stops(used when canines are erupting)

Variations in mandibular labial bow

Position
Protection

Auxilliary appurtenances
oGuidance of lips with soft elastic plastic or acrylic
strip(lip trap)

oLight springs made with 0.6 or 0.7 mm spring


hardened wire incorporated in acrylic body for
movement of single tooth

L stops :prevent sliding of bionator (those with


metal plates) in distal direction
Provide additional sagittal anchorage
Retruding effect on incisors

Metal bite plane(0.5 mm stainless steel sheet)


A guide for vertical development
Correction of deep overbite
Stabilizes edge to edge position of incisors
Prevents the appliance from tipping or tilting
as it extends into molar region

In each patient incorporate three dimensional


curve into bite plane following normal curvature of
occlusal plane and adapt to shape of dental arch
In class II div 2 malocclusion flat plane is used to
permit differential control of eruption
Notched or punched for retetion

Metal plane promotes vertical equilibration


of occlusal surfaces of premolars and molars
Because teeth touching it are prevented
from erupting further while other teeth can
erupt until they contact it
Differential control of tooth eruption can be
obtained by careful placement of metal
occlusal plane within interocclusal
clearance between both arches

Need for tedious trimming of acrylic for tooth


eruption is eliminated
Unobstructed view of dentition when
appliance is being checked in mouth
Some discomfort may be there in mandibular
anterior region with bionator with metal bite
plate during first few days but it dissappears
soon

CALIFORNIA BIONATOR

Differentiating feature
Maxillary labial wire
Maxillary lingual wireprovides support for
bionator using lingual
surfaces of maxillary
anterior teeth for
anchorage

ACTIVATOR WITH
EXPANSION SCREWS
In North America, expansion
screws are added between
cuspids and bicuspids to
advance lower jaw gradually
and avoid making multiple
appliances
Occlusal surfaces of upper
teeth are covered with acrylic

Lower buccal segments do not touch acrylic


and are free to erupt
Mandibular lingual flanges are kept 3-4 mm
longer,hence appliance is larger than
european design

Disadvantages
May create sore spots if insufficient
vertical support present
Vertical support by long flanges is not
enough and can cause pressure on soft
tissues and recession
Screws used for advancement do not
duplicate natural forward movement of
jaws

Gingival recession on lingual of lower anterior


teeth due to wear of bionator with
advancement screws

Cybernator (by-Schmuth)

Smaller variation of bionator


Uses normal labial wire from cuspid
to cuspid
Labial shelf of mandibular incisors
are covered by a thin shelf of
acrylic 2 mm wide to prevent
anterior tipping
Because of its smaller size
cybernator can be tolerated more
easily

Coffin spring- its judicious


use has widening effect
especially when inserted
during or soon after eruption
of lower incisors
Breaking of slender anterior
acrylic part avoided by
splitting it in midline
Schmuth prefers customary
construction bite of
activator to edge to edge
bite of bionator

FUNCTIONAL INTERCEPTOR
APPLIANCES(FIA) G P F SCHMUTH
Reverse palatal bar
Maintenance of vertical dimension in canine
region

FIA Modifications

Bionator with active springs


Springs are added to achieve
simple individual tooth
movement
They are activated lightly so
that there is no interference
with movements of bionator

Spring soldered to labial archwire


to achieve slight tooth movement

Bionator with Adams Clasp


-Bionator with Adams clasp and wire on
palatal of incisors for anchorage
-Headgear tubes can be added between
upper and lower molar areas or soldered
onto the Adams clasps, if they are
present.
-Patients can wear a high-pull headgear
in combination with the bionator.

Bionator with Head Gear Tube

Including HG-tubes in height of the


second deciduous molars or the
second premolars.
A precondition is a sufficient
vertical opening which should be
considered during the realization
of the construction bite. The HG
tubes can be integrated into the
interocclusal acrylic during its
polymerization or they can be
incorporated afterwards.

High labial bow


b) High labial bow:
If the patient has problems
maintaining the appliance
in position while speaking
or even in its rest position,
a high labial bow can be
added onto the labial arch
Acrylic is covered with heat
protection paste during
soldering

Lateral shields
) Lateral shields:
If the vertical opening is
wide, the buccinator loops
can present a longer
distance than 1 cm. In
order to avoid the
interposition of the
cheek, the loops are
covered with acrylic

Labial pads

Class III

Class II

Inserted on same principle as function


regulator

BIONATOR WITH PROTRUSION SPRING


In one of the modifications by RICHARD RUTTER and
EMIL WITT, a special protrusion spring has been used
successfully to protrude lingually inclined maxillary
incisors in case of class II DIV 2 . (AJO,VOL 97, 1990)

A case treated with Will and Rutters


modification of bionator

Treatment regimeIst bionator -8y 6m


IInd bionator- 10 y 6m
IIIrd bionator -for retention discontinued at
16 y 5m

Review of literature
&
Recent studies

Stephen D. Keeling, Timothy T. Wheeler, Gregory J. King, Cynthia W. Garvan, David A.


Cohen, Salvatore Cabassa, Susan P. McGorray, Marie G. Taylor
Anteroposterior skeletal and dental changes after early Class II treatment with
bionators and headgear ,American Journal of Orthodontics and Dentofacial
Orthopedics, Volume 113, Issue 1, January 1998, Pages 40-50

3 treatment groups namely


1. Head gear and a flat plane maxillary acrylic anterior
bite plane with labial bow and molar circumferential
wires, designed to disocclude posterior teeth group
worn 14 hours a day
2. Bionator group instructed to wear 22 hours a day
3. Control group

3 phases in study
1. Class II treatment / observation
2. Retention/non-retention
3. Follow-up
CONCLUSIONS:
4. Combined skeletal and dental measures
showed significantly greater correction in
both of treated groups over controls

2.The head gear /biteplane and bionator both


enhanced mandibular growth without
detectable relapse year after end of active
treatment
3.Any relapse observed during 6 month follow up
period without appliance was clearly dental
4.Skeletal changes achieved were stable

5.During 6 months retention period (retention


regime was wearing the appliance every
alternate night), there was no effect on skeletal
and dental changes except molar discrepancy
in non retained head gear group
.Head gear group showed significant dental
class II correction by the maxillary molar and
incisor
.Significant molar relapse during 6 months
retention phase in head gear group

6.Any relapse observed during 6 month follow


up period without appliance was clearly dental
7.As during both retention and follow up
phases, relapse was dental, retention regime
of every alternate night wear cant be
considered effective
8.And longer retention with the appliances until
phase II treatment might prevent relapse of
dental unit

Carina Ferlin Antunes, Renato Bigliazzi,


Francisco Antonio Bertoz, Cristina Lcia Feij
Ortolani, Lorenzo Franchi and Kurt Faltin Jr
Morphometric analysis of treatment effects of the
Balters bionator in growing Class II patients-AO
Used digitized lateral cephalogram
TPS(thin plate spline) deformation grid(to detect
location and mode in which change in shape and
size occur)

TPS enables
comprehensible
viewing of
changes in
shape, highlights
regions where
these changes
occur

significant shape changes in


the mandible that could be
described as a mandibular
forward and downward
displacement.
displacement was more
evident at the mandibular
symphysis as it was associated
with a mandibular elongation
that was depicted by a
horizontal extension of the
grid in the middle portion of
the mandible between the
condyle and the symphysis.

These changes contributed


significantly to the sagittal
and vertical correction of the
dentoskeletal Class II
relationships

A slight extension on both


the horizontal and vertical
axes could be recorded at
the gonial angle.
A constriction on
the horizontal axis in the
region of the upper incisors
was also evident

A constriction in the region of


the upper incisors indicating a
retroclination of these teeth was
found
It should be emphasized that in
the standard Balters bionator used
in this study, the buccal shield did
not touch the upper incisors and did
not have inferior incisal coverage
which can play a role in dental
compensation rather than
orthopedic correction.

The dentoalveolar
compensation in the
bionator was probably
related to a new
neuromuscular pattern
(lip closure and
improvement of tongue
position) induced by the
appliance.

TPS analysis showed that treatment with the


bionator is able to produce favorable mandibular
shape changes contribute significantly to the
correction of the Class II dentoskeletal imbalance

This study contradicts a study by


Lux who, using TPS, found small
vertical and anteroposterior
skeletal mandibular displacement
in the activator compared with
control group.
Lux et al.found that the correction
of the Class II problem was
sustained mainly by a strong
dentoalveolar component with
retroclination of the upper incisors
and proclination of the lower
incisors.

Maninder S Sidhu, Sunanda, O P Kharbanda, S


S Sidhu;Cephalometric evaluation of short term
treatment changes produced by bionator and
activator in class II division I malocclusion; Indian
Journal of Orthodontic Society;vol 26:number
1:January ,1995
Bionator had useful negative effect on growth of
maxilla as SNA decreased,also indicated by
distal positioning of ANS:Activator had almost no
effect on maxillary effect

Favourable forward sagittal positioning occurs with


bionators both points B and Pg moved anteriorly;
Activator:limited anterior shift
ANB decreased with Bionator (p<0.01,-1.76o )
It produced highly significant change (p=0.001) in
overall improvement of maxilla and mandible
It produced reduction in facial axis angle(0.870 )
showing the desirable anticlockwise rotation effect
in contrast to activator which has tendency to
reverse effect

Condylar head
-Moved slightly posteriorly with bionator
-Showed downward descent with activator
With bionator vertical shift is minimum
Increase in Effective length of mandible= 3.83
mm(twice as that with activator(1.73 mm))
Gonial angle opens with bionator,where as
activator shows no change

Dentitional changes
Overjet reduction
Bionator=6.6mm(p<0.001)
Activator=3.72mm(p<0.01)
Overbite reduction with bionator= 2.1mm
Upper incisor retraction with
Bionator=3.15mm
Activator=2.66mm

Magnitude of molar correction


-Greater with bionator
-Activator caused greater distal tipping of
maxillary molars
-Vertical changes in molars were also greater
with activator
Uppers extruded 3.4mm
Lowers extruded 1.4mm

Bionator resulted in greater skeletal


changes in correction of class II malocclusion
Bionator resulted in effective increase in
length of mandible
Diferences were mainly due to longer
period of bionator wear which produced
better skeletal and dental changes

Sahm
.
G, Bartsch A, Witt E; Micro-electronic
monitoring of functional appliance wear. Eur J
Orthod. 1990 Aug;12(3):297-301
They used magnet system bonded to lingual
aspect of lower 6 and Reed switch timing
device embedded in bionator
Recordings taken every 3-4 weeks, for 4.5
months
Result:Avg =7.65 hrs wear per day fulfilling 50
to 60 % of orthodontists requirement

Decline in compliance rate

Ashok Kumar Jena ,Rittu Duggal , Hari Prakash


;Skeletal and dentoalveolar effects of twin block and
bionator appliances in treatment of class II malocclusion;
American Journal of Orthodontics and Dentofacial
Orthopedics, Volume 130, Issue 5, November 2006,
Pages 594-602
Mandibular growth in twin block subjects was
significantly greater
In twin block upper 6 moved distally, in bionator upper 6
moved mesially

In both treatment gps. more than half of the overjet


correction was due to anteroposterior change in
relationship change in relationship between maxilla
and mandible
Statistically significant mandibular growth with bionator
and twin block prove that functional therapy does
increase Mandibular growth
On the contrary ,O brien reported more mandibular
growth occurs with bionator compared to twin block
72 to 74 % of sagittal correction in this study in both
twin block and bionator was skeletal

The greatestchange in apical base (ABCH) occurred in the


Twin-block group (3.69 mm), followed by the bionator
group(2.86 mm) and the control group (1.39 mm)
Greater lower incisor proclination with bionator than twin
block .
controls had uprighting of lower incisors due to labial
musculature
Overjet reduced maximum with twin block, majorly
because of anteroposterior change in relationship
change in relationship between maxilla and mandible(27
to 57% overjet correction can be considered skeletal)

Marcio Rodrigues de Almeida,Jose Fernando


Castanha Henriques, Comparative study of the
Frankel (FR-2) and bionator appliances in the
treatment of Class II malocclusion .Am J Orthod
Dentofacial Orthop 2002;121:458-66
Both appliances showed statistically significant
increases in mandibular growth and mandibular
protrusion, with greater increases in patients
treated in the bionator group.
Both experimental groups showed an
improvement in the maxillomandibular
relationship.

There were no significant changes in growth


direction, while the bionator group had a greater
increase in posterior facial height
Both appliances produced similar labial tipping
and protrusion of the lower incisors, lingual
inclination, retrusion of the upper incisors, and a
significant increase in mandibular posterior
dentoalveolar height.
The major treatment effects of bionator and FR-2
appliances were dentoalveolar, with a smaller, but
significant, skeletal effect

No statistically significant effect was observed for


maxillary skeletal measures in either of the two
groups

Nezar Watted, Emil Witt , Werner


Kenn.The temporomandibular joint and
disc condyle relationship after functional
orthopedic treatment: an MRI study. EJO
2001.23.683-693
Therapeutic bite position in which bionator
was constructed was secured in night
with<100 gm force vertical elastics extending
from j hook of bow of Bionator to buccinator
loops or bracket or button attachments

After 1 year bite jumping pt were given


disoccluding splint in form of bite plane for
2 weeks to deprogramme the muscles ,to
see if the correction achieved was solely
muscular or growth adaptation of bony
stuctures
After bite plane was removed and
occlusion stabilised in class I,MRI was
taken

FINDINGS:
Mandibular growth and morphological
translation occur upon insertion of functional
appliance particularly when mandible is
secured with elastics
Successful bite jumping implying bone and
muscle adaptation result in normal position
of mandibular fossa, condyles and disc
condyle relationship due to adaptation and
remodelling of joint structures following
displacement

Christopher S. Freeman,James A. McNamara,


Jr,Tiziano Baccetti,Lorenzo Franchi,Theodore W.
Graff. Treatment effects of the bionator and highpull facebow combination followed by fixed
appliances in patients with increased vertical
dimensions. (Am J Orthod Dentofacial Orthop
2007;131:184-95)
24 subjects with high-angle skeletal relationships(mean
MPA value 30) treated consecutively first phase of
bionator and high-pull headgear treatment followed by a
second phase of fixed appliance therapy

no significant differences in sagittal relationships, were


found between treated subjects and controls at the end of
the 2-phase treatment for all measurements.
Counterintuitively, the bionator and high-pull headgear
combination worsened the hyperdivergent facial pattern to
a clinically significant level, as shown by analysis of
final facial forms.
The treated group exhibited a significantly larger MPA
value than controls (2.5) as well as a larger inclination of
the Frankfort horizontal to the occlusal plane (2.8).
this therapeutic protocol does not appear to be a
recommendable option for treatment of subjects with
increased vertical dimensions.

C. RESTREPO, A. SANTAMARIA, S. PELA EZ & A.


TAPIAS,

Oropharyngeal airway dimensions after treatment


with functional appliances in class II retrognathic
children ; Journal of Oral Rehabilitation 2011;38;
588594
Treatment was done by Klammt elastic open
activator or Bionator

Before and after treatment , the nasopharynx


area,which is closed to the location of the
adenoid tissue,became bigger after the
advancement of the mandible,although there
were children in the growth peak of the adenoid
tissue.
A small airway during the growth peak leads to
problems such as mouth breathing, bruxism and
skeletal class II owing to retrognathism or
micrognathism.

To advance the mandible before the growth peak


could avoid this kind of problems.
Additionally, a possible solution for airway
obstructions, using functional appliances, was
established in this study

Yen-Chun Lin, Hsiang-Chien Lin, Hung-Huey Tsai


;Changes in the Pharyngeal Airway and Position
of the Hyoid Bone After Treatment
With a Modified Bionator in Growing Patients
With Retrognathia
J Exp Clin Med 2011;3(2):93e98

The anteroposterior dimensions of the pharyngeal


airway did not change after the modified bionator
treatment, except for the nasopharynx area in both
genders and the hypopharynx area in males.

Vertically, the hyoid bone remained in a constant


position relative to the mandible and third cervical
vertebra through the four stages in both genders.
Horizontally, the hyoid bone moved forward
during treatment but returned to a posterior
position after use of the modified bionator was
stopped.

Conclusions:Even with mandible advancement


by the modified bionator in growing patients with
retrognathia, therewere no significant changes in
the anteroposterior dimensions of the pharyngeal
airway, and the hyoid bone remained in a vertical
position relative to the mandible during the
pubertal growth phase

Shigetoshi Hiyama, Gen Kuribayashi, Takashi


Ono, Yasuo Ishiwata; Takayuki Kuroda
Nocturnal Masseter and Suprahyoid Muscle
Activity Induced by Wearing a Bionator
(Angle Orthod2002;72:4854.)
no significant changes in the maximal EMG
activities of these muscles
the maximal EMG activity of suprahyoid muscles
tended to decrease while wearing the bionator.

The number of events over 40% maximal


voluntary contraction (MVC) tended to decrease
in these muscles with a bionator(not statistically
significant).
These findings indicate that there are no
significant changes or there is only a tendency
to decrease the activities of the masseter and
suprahyoid muscles while wearing a bionator
during sleep

Nicole J. Siara-Oldsa; Valmy Pangrazio-Kulbersh;


Jeff Berger; Burcu Bayirli; Long-Term
Dentoskeletal Changes with the Bionator, Herbst,
Twin Block, and MARA Functional Appliances;
(Angle Orthod2010;80:1829.)
(1)Temporary restriction of maxillary growth was
found in the MARA group .
(2)SNB increased more with the Twin Block and
Herbst groups when compared with the
Bionator and MARA groups.

(3) The occlusal plane significantly changed in


the Herbst and Twin Block groups.
(4) The Twin Block group expressed better
control of the vertical dimension
(5) The overbite,overjet, and Wits appraisal
decreased significantly with all of the appliances.
(6) The Twin Block group had significant flaring
of the lower incisors at the end of treatment.

The significant reduction in the overbite in the


Bionator group is to be anticipated, as the
mandible migrates forward along the lingual
inclines of the maxillary incisors.
The greatest amount of lingual crown tipping
of the maxillary incisors was shown in Bionator
treatment group and could be attributed to
pressure from the labial bow.

The Bionator group showed


significant opening ofthe gonial angle (Ar-GoMe) after functional treatment.
This 2o per year increase in the gonial angle
was greater than any of the untreated and treated
samples and is most likely attributed to the
growth direction of the condyle and remodeling of
the posterior border of
the ramus.

Adriano Marotta Araujo,Peter H. Buschang, Ana


Claudia Moreira Melo, Transverse skeletal base
adaptations with
Bionator therapy: A pilot implant study(Am J
Orthod Dentofacial Orthop 2004;126:666-71)
hypothesized that patients treated with the Bionator
appliance would experience greater increases in
interimplant width than untreated controls
Transverse maxillary and mandibular changes were
evaluated cephalometrically according to 4 bilateral
maxillary and 2 bilateral mandibular implants

RESULTS:

(1)Statistically

significant increase in the posterior


maxillary base width but no increase in the
anterior and mandibular interimplant distances,
and
(2) Greater than expected transverse
expansion of the maxillary skeletal base with
Bionator appliance therapy, indicating skeletal
base adaptations to Bionator therapy.

Conclusion

Though active plates and fixed appliances are


important in obtaining proper arch form, the
proper inter arch alignment is an important
facet of functional appliances
And to date bionator towers above all others
in this respect and as a result it forms a
corner stone in modern day functional jaw
orthopedic therapy
Decreased bulk helps achieve greater
compliance from the patient

REFERENCES

Graber, Rakosi , Petrovic : Dentofacial


Orthopedics with functional appliances.2nd
edition, Mosby
Graber, Neumann : Removable
orthodontic appliances. 2nd edition,
Philadelphia, WB Saunders

James A. McNamara, William L. Brudon,


Vicent G. Kokich, Needham Press, 2001
Stephen D. Keeling, Timothy T. Wheeler,
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