bionator

contents
Introduction
Principle
Parts and types
Construction bite
Trimming and anchorage
Indication, contraind
Advantage and disadvantage
Clinical management
Bionator and TMJ
Modification
Journals

Introduction
Norman Kingsley 1879 Vulcanite palatal plate
Pierre Robin 1902 Monobloc
Viggo Andresen 1908 Activator
Wilhelm Balter 1960 Bionator
Rolf Frankel 1967 FR
William Clark 1977 Twin block
3

Introduction
• Bulkiness of activator
• Limitation to nightime wear
• Attain greater potential of growth
guidance
• Balters (1960) – bionator
• Prototype of less bulky appliance
which could be worn all the time

Bionator
• Lower portion is narrow
• Upper has only lateral
extensions
• Palate is free for
proprioceptive contact with
tongue
• Crosspalatal stabilizing bar
• Buccinator wire loops to hold
away potentially deforming
muscular action

principles
• Equilibrium b/w tongue and circumoral
muscle is responsible for the shape of the
dental arch and intercuspation
• Functional space of the tongue is essential for
normal development of the orofacial system

• For balters, the tongue was the most important
factor in treatment, neuromuscular envelope
being secondary
• A discoordination of its function could lead to
abnormal growth and deformation
▫ Posterior displacement of tongue – class II
▫ Low anterior displacement – class III (buccinator
mechanism)
▫ hyperactivity and forward tongue – open bite

• Winders in 1958 – tongue excerts 3 or 4 times as
much force on the dentition as does the labial
and buccal musculature
• Convinced of tongues dominant role, balters
decided to take advantage of the tongue posture

appliance to position the mandible
anteriorly to an edge-edge position
Bringing the mandle forward-
enlarge the oral space
Bringing the dorsum of the tongue
to contact the soft palate
Help accomplish lip seal
Help patients learn normal
functional pattern

• Correction of class II
▫ Headgear effect on the maxillary complex produced by
distal forces generated by musculature during
advancement
▫ Mesial migration of mand dentition and distal
migration of maxillary dentition by eruption facets
▫ Mandibular anterior repositioning , as an expression
of condylar growth and gleniod fossa remodeling
▫ Neuromuscular adaptation

• Does not activate, rather modulates muscle
activity, thereby enhancing normal development
of inherent growth pattern and eliminating
abnormal and deforming forces
• (somewhere between a screening appliance and
an activator)

Parts appliance
Acrylic
component
Wire
component
Cross palatal
bar
Labial bow
with buccinator
loops

Bionator
types
Standard Open bite
Reversed
or class III

• Acrylic component
▫ Horse shoe shape
▫ Extending till last erupted molar
▫ Upper arch – posterior lingual extension covering
premolar and molar
▫ Anterior portion open from canine to canine
▫ Extendes 2mm beyond the gingival margin
Standard appliance

• Acrylic component
▫ If edge-edge incisal contact – no incisal capping
▫ If space exists b/w upper and lower teeth, incisal
capping on lowers done to prevent labial tipping
(partially successful)
Standard appliance

• Wire component
▫ Palatal bar
 1.2mm hard SS
 From lingual flange of
middle deciduous first molar
 1mm away from palatal mucosa
 Distal portion of permanent 1st molar
 Forms an oval and reinserts to the other side
 Stabilizes and orients the tongue and mand anteriorly
Standard appliance

• Wire component
▫ Labial bow
 Anterior part - labial wire
 Lateral part - buccinator bends
• Objectives of buccinator bends
 To keep soft tissue away from the teeth –
so the bite is leveled & eruption proceed in buccal segment
 Moves cheeks laterally , which favor expansion or transverse
development of dentition
Standard appliance

• Wire component
▫ Labial bow
Standard appliance
0.9mm SS
Begins from contact of canine and dec.
Molar (pm)
Runs vertically to make a rounded 90 bend
distally along the middle of the crowns
Extends till dec 2nd molar and perm 1st
molar
Gentle down
and forward
curve, runs
anteriorly at
same position
of lower teeth
till the canines
Sharp bend it extends obliquely
upwardtowards the upper canine
Bends to a level line of incisal 3rd of
incisors
Thickness of paper sheet away from the
incisors

OPEN – BITE APPLIANCE
22
 Purpose of this appliance is
to inhibit abnormal posture
and functional of the tongue
 Acrylic part-
 The lower lingual part extends into the upper
incisor region as a lingual shield , closing the
anterior space without touching the upper teeth

23
 Wire component
 Palatal bar
•Has the same configuration of standard
•Moving the tongue to a more posterior or
claudal position

24
 Wire component
 Labial bow
 Labial bow runs between the upper and lower
incisors at the height of lip closure.
 At the height of correct lip closure
 Stimulating competent lip seal

 Wire component
 Labial bow
 Vertical strain on lips tends to encourage the
extrusive movement of the incisors after
eliminating the adverse tongue posture

REVERSED BIONATOR
 Encourage development of maxilla
 Bite opened 2mm for this
purpose
Acrylic portion
Extends incisally from canine to
canine behind the upper incisors
Acrylic is trimmed away by 1mm
behind the lower incisors

REVERSED BIONATOR
 Palatal bar
 The palatal configuration runs forward
instead of posteriorly
 Stimulate the tongue is in a retracted
position in its normal functional
space
 should contact the anterior palate
to encourage forward growth
of maxilla

REVERSED BIONATOR
 Labial bow
 The labial bow runs along the lower incisors instead
of upper.
 similar to that of standard except that the labial bow
does not bend obliquely at the canine and runs
through the lower incisors

Introduction
Principle
Parts and types
Construction bite

32
Construction bite
Horizontal considerations
 incisors in edge to edge relationship/ molars in classI
 Excessive overjet-step wise posturing of the mandible
 Edge to edge with lateral incisors when centrals are
mal positioned

33
Construction bite
Vertical considerations
 bite is not opened/incisors in edge to edge
 high construction bite impairs tongue function and or
acquire tongue thrust habit.

34
Construction bite
In Standard Bionator
 To achieve a cIass I relation
 Edge to edge relation of incisors – to provide
maximum functional space for tongue
 If overjet is too large – step by step procedure is
followed

35
Construction bite
In Open Bite Bionator
 Construction bite-is as low as possible with a slight
opening for interposition of posterior bite blocks to
prevent their eruption.
In Reverse Bionator
 Construction bite- taken in more retruded position so
as to allow labial movement of maxillary incisors &also
to exert restrictive force on lower arch

Following points to be considered
(JCO 1985, Altuna& Niegel)
Horizontal plane
 Advancing about one premolar width is tolerable
Profile should be esthetically pleasing
lateral plane
 Condyles on both sides move symmetrically.
Midlines used as reference lines
Vertical plane
 2-3 mm opening between C.I
36

Terminology in trimming
• Articular plane
• Loading area
• Tooth bed
• Nose
• ledge

Articular plane:
This plane extends from the
tips of the cusps of the upper 1st
molars,premolars & canines to
the mesial margins of the
central incisors , running
parallel to the ala-tragal line.
Used to assess the mode of
trimming.

Loading area:
The palatal or lingual cusps of the
deciduous molars (premolars) are
relieved in the acrylic part of the
appliance.
The grinding of the acrylic here
enhances the anchorage of the
appliance.

Tooth bed :
Some parts of the loading
areas are trimmed away
to the articular plane.

Nose:
The interdental acrylic fingerlike projections b/w tooth beds
They serve as guiding surfaces and provide anchorage in the
sagittal and vertical plane.

Ledge :
•Depending on the tooth movement
required the appliance acrylic is
trimmed and the nose is reduced .
•This reduced extension placed only
on the occlusal 3rd of the interdental
area is called a ledge.
•The nose is mostly on the mesial
margin of 1st perm.molar & ledges
are b/w premolars or deciduous
molars.

Selective trimming
 prevention of eruption as loading
or inhibition of growth
 stimulation of eruption as
unloading or promotion of growth
44

Selective trimming
 Appliance can be trimmed until teeth reaches desired
relationship with the articular plane
 Due to consideration for anchorage, appliance cannot
be trimmed in all areas at same time
 Periodic loading and unloading of same area done
47

SELECTIVE TRIMMING
48
For extrusion of posterior teeth
Acrylic left between level of Articular plane –Tooth bed
 Upper &lower molars trimmed first
 Then lower premolar’s trimmed while molars loaded
 Then upper premolar’s unloaded while lower premolar’s
&molars loaded
 Occlusal surfaces of bionator trimmed for transverse movt
 For intrusion in case of open bite –posterior teeth
are fully loaded

Anchorage of appliance
1. Acrylic cap over incisal margins of lower incisors
2. Loading areas as cusps of teeth fit into respective
grooves in acrylic
3. Deciduous molars are used as anchor teeth
4. Edentulous areas after early loss of primary
molars
5. Noses in the upper & lower interdental spaces
6. Labial bow prevents posterior displacement
49

Ascher (1968)proposal
 Deciduous teeth if present are used as anchorage
and Ascher (1968)proposed the following types of
anchorage.
50

• According to the plan on anchorage and growth
promotion,loading and unloading of acrylic is done.
• In first stage of treatment rapid horizontal and vertical
changes in mandibular position are common.
• The 1st change is muscular adaptation to new position
with shortening of the lateral pterygoid (petrovick et al
1972).

• These rapid changes lead to open bite in posterior
segments.
• Articular and dentoalveolar adaptation occur following
neuromuscular adaptation.
• Open bite in the deciduous molars persist until the
premolars are guided into occlusion.

contents
Introduction
Principle
Parts and types
Construction bite
Clinical management
Bionator and TMJ

Clinical management, indication
contra-indication, advantage and
disadvantage

Indications
• Dental arches well aligned
• Mandible in posterior position
• Skeletal discrepancy not severe
• Labial tipping of upper incisors evident
• Deep bite with accentuated c.o.s
• Class III where reverse bionator can be used
• Open bite
55

Contraindications
• Class II – if caused by max prognathism
• Vertical growth pattern
• Labial tipping of mandibular incisors
• Deep bite – supracclusion of incisors
56

Advantages
• Worn day and night
• Reduced size
• Constant influence of tongue and perioral muscles
• More rapid saggital adjustment of the musculature to
forward mandible posture

Disadvantage
• Difficulty of correctly managing it
• Simutaneous requirement of stabilization and selective
grinding
• Limited effectivness for skeletal correction
• Vulnerability to distortion due to far less acrylic support
in the alveolar and incisal regions (modified)

CLINICAL MANAGEMENT
59
 Appliance must be worn day and night except while
brushing, eating, contact sports, language lessons and
playing certain wind instruments .
 Few days of accommodation before wearing to school
 Appliance should be worn in mouth when giving
short replies.
 If they have to read or speak longer, use the tongue to
push the appliance out of the mouth into the left hand
which then holds it and reinsert rapidly.

CLINICAL MANAGEMENT
60
 Pt recalled after 1 wk to check sore points
 Interval b/w visits 3-5 weeks based on the eruption of
the teeth.
 It takes 1- 11/2 yrs to achieve correction
 Labial bow away from the incisors.
 Buccinator loops away from 1st & 2nd molars, should
not irritate mucosa.

CLINICAL MANAGEMENT
61
 Same appliance is used for retention can be worn
only at night
 If correction was achieved speedily, daytime wearing
not be abandoned
 Length of retention : 6m- 1yr
 Worn again more frequently if muscular tension is
felt

Bionator in Adult Patients
62
 Petrovic has shown that protracted wear in adults can
permanently shorten the LPM and thus help the
patient maintain a protracted mandibular posture
even during the day time
 Thus clicking sound and pain disappears

Bionator and TMJ
63
 Can be used for treating TMJ problems in adults
 TMJ problems have coincident bruxism and clenching
during sleep.
 The bionator relaxes the muscle spasm at LPM.
 It prevents riding of the condyle over the posterior edge of
the disk which causes clicking.
 Bionator positions the mand forward so prevents the
deleterious effects at night
 Bionator & local heat application with muscle relaxants
provides immediate relief for patients

Introduction
Principle
Parts and types
Construction bite
Clinical management
Bionator and TMJ
Modification
Journals

Combination of bionator and high pull
head gear
66
They are used in class II skeletal malocclusions characterised
by slight mandibular deficiency, tipped up palatal plane ,
anterior open bite and a vertical growth pattern.
Luciane closs, & Valmy Pangrazio ( A J O – 1996 )

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
• The high labial bow is bent depending on the
modification high into the vestibule and
soldered onto the buccinator loop.

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.

Lower labial pads
• Labial pads in the lower jaw: To
achieve an anterior-posterior
development, the labial pads can
also be incorporated in the
mandible

Upper Labial pads
• Labial pads in the upper jaw: It is also possible to
add labial pads in the upper jaw, here in a reverse
appliance. These pads or shields are made
following the same principles as in the making of
the function regulator according to Fränkel.

Modification by Williamson &Hamilton
 3mm cover for max inc from L.I to L.I
 This is to secure the position of max inc
 This modification made from construction
bite
 This also prevents tipping of lower incisors
71

BIO- M-S
73
BY ERICH & ANNETTE FLEISHER
 MODIFICATIONS ARE-
 Acrylic body reduced in size
 Instead of long labial bow –
Maxillary buccolabial arch wire and
mand labial arch wire
 Transpalatal bar opens in distal direction as in CI III
bionator
 Wire spurs used to reinforce anchorage

Bionator I (to open)
• Class II malocclusion and a deep bite.
• While the appliance holds the mandible in a protruded
position with acrylic, there is no coverage of the
posterior teeth.
• Instead there are fluted channels angled facially cut into
the acrylic that guide the eruption of posterior teeth.
• This allows for the correction of a deep bite while also
expanding the arches dentally.

Bionator I (to open)
• An acrylic cap covers the mandibular incisors and the
maxillary incisors contact this cap on a flat plane.
• This prevents the undesirable eruption of the anterior
teeth while also controlling flaring of the mandibular
incisors which can occur as a result of the forces exerted
on the mandible.
.

Bionator II (to close)
• The Bionator II is also used to treat patients with a
Class II malocclusionwith an anterior open bite.
• Full acrylic coverage of the posterior teeth is used to
prevent undesirable eruption in this area and to
hold the protrusive position of the mandible.
• The anterior teeth are left uncovered allowing them
to erupt.

California bionator
81
This type bionator helps in
eruption of post teeth in
patients with decreased
vertical dimension

Flexible bionator
• Flexible Elast-Acryl™ material into a Bionator style
configuration,which helps stabilize and enhance completed
Fixed Functional therapy
• The patient is seen every four to six months.
• The Flexible Bionator is an extremely comfortable and
effective retainer for the maintenance of dental and skeletal
correction.
• It is kind to the TM joints, allows for adjustment, and
eruptions.

Skeletal and dento-alveolar effects of twin block and
bionator appliances in treatment of Cl II
malocclusion AJODO 2006
 Both appliances was efficient in restricting forward
growth of maxilla, Both appliances restricted forward
movt of max molars
 Both appliances resulted in mesial movt of mand
molars & helped in correction of molar relation –twin
block corrected more efficiently
 Both reduced overjet but twin block appliance better
than bionator
84

Treatment effects by bionator appliance – comparison with
an untreated cl II sample
Almeida et al EJO- 2004
85
 No changes in forward growth of max in both groups
 Increase of mand length in bionator group
 Significant improvement in anteroposterior
relationship between max &mand in bionator group
 Bionator produced- labial tipping of incisors
- retrusion of upper incisors
- increase in post dentoalveolar height due to
extrusion of lower posteriors, no extrusion of upper
molars seen

Adaptive condylar growth and mand remodelling
changes with bionator appliance-an implant study
ARAUJO et al EJO 2004
 Alters the direction of growth but not the amount of
growth
 Produces greater than expected posterior drift of bone
in condylar and gonial region
 Displaces mand anteriorly but limits the amt of true
mand forward rotation that would normaly occur
86

references
• Removable orthodontic appliances – graber and neumann
• Dentofacial orthopaedics with functional appliances – Thomas M
Graber, Thomas Rakosi, Alexandre G. Petrovic
• Orthodontics and dentofacial orthopaedics – McNamara and Brudon
• Current priciples and techniques (3 ed)- Thomas M Graber, Robert L.
Vanarsdall
• Atlas of dentofacial orthopaedics for growing child – Marc Saadia,
Jeffrey H. Ahlin
• Atlas of orthodontic and orofacial orthopedic technique – o atlas
dentaurum

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