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Bionator /certified fixed orthodontic courses by Indian dental academy

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Bionator /certified fixed orthodontic courses by Indian dental academy

  1. 1. BIONATOR INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Introduction Functional jaw orthopaedics is the system of orthodontic treatment which makes use of the forces which act in and about the human dentition during the activities of the masticatory face Functional appliances are considered primarily as a orthopedic tool to influence the facial skeleton of the growing child in the condylar and sutural area.They harness natural forces which is transmitted to the teeth and the alveolar bone in a predetermined direction. Function is inherent in all cells, tissues, and organs and influence these media as a functional stimulus. The goal of functional dental orthopedics is to use this functional stimulus channeling it to the greatest extent, the tissues, jaws, condyles and teeth allow. The uniqueness of functional appliances lie in their mode of force application
  3. 3. Principles of functional jaw orthopedics Roux-1883 According to Roux and Wolff form was intimately related to function. Changes in functional stress would produce changes in internal bone architecture and external shape. . Haupl -1938 According to haupl et al tissue forming stimuli originate from the activity of the tongue,lips ,facial and masticatory muscles .These stimuli are transmitted to the teeth ,paradental tissue, alveolar bone and mandibular joint through a passive ,loose fitting appliance inserted between the teeth,the result being that the transmitted stimuli induce desired changes in the tissues affected.
  4. 4. Force in orthopedic procedures Forces employed in orthodontic and orthopedic procedures are Compressive Tensile Shearing Mechanical appliances use compressive forces and pressure strain Functional appliances use tensile forces causing stress and strain
  5. 5. Forces are 1.External forces (primary) 2.Internal forces (secondary) External forces are i.Occlusal forces on the dentition ii.Muscle forces from the tongue, lips and cheeks. Internal forces Reaction of tissues to primary forces Internal forces strain the contiguous tissue leading to deformation and bracing of the alveolar process
  6. 6. Two treatment principles in the use of forces in functional jaw orthopaedics Force elimination Here abnormal and restrictive forces and environmental influences are eliminated ,allowing optimal development Eg, lip bumper and frankel buccal shield Force application In this compressive stress and strain act on the structures involved resulting in secondary adaptation to all active removable appliances
  7. 7. Force Application Various parameters of force application are  Duration of force in most functional appliances is interrupted because they are usually worn for 12 to 14 hours a day. The bionator is worn continuously except during mealtimes and sports.  Direction –It should be consistent in a particular direction  Magnitude-Magnitude of force in functional appliance is usually very small. If the induced strain is to great ,patient will have difficulty wearing the appliance.
  8. 8. Forces acting on the erupting teeth are   Bucco-lingual forces from the musculature of the lips cheeks and tongue Mesiodistal forces adjacent to the teeth. Forces generated by the muscles are 1.Passive forces–due to the muscle tonus which is continous but very light 2.Active forces- due to muscle activity which is always intermittent
  9. 9. Mode of action of various functional appliances –the causal chain 1.Increased contractile activity of the lateral pterygoid muscle 2.Intensification of the repetitive activity of the retrodiscal pad 3.Increased in growth stimulating factors  .Enhancement of local mediators  .Reduction of local regulators 4..Change in condylar trabecular orientation  .Additional growth of condylar cartilage  .Additional subperiosteal ossification 5.Supplementary lengthening of the mandible
  10. 10. Evolution of the bionator The bionator was introduced by Balter in germany in 1950 The bionator is a modification of the activatior It is the skeleton of the activator because it has more of metal components . Bionator differs from the activator in 1.It is less bulky than the activator. 2.It lacks the part covering the anterior section of the palate. Therefore children are able to speak normally 3..Bionator can be worn at day and night except mealtimes.
  11. 11. Principles of bionator therapy Theories upon which the bionator is based  1.Based on the works of Robin, Andresen,and Haupl 2.The early function and form concepts of Van der Klaaw and the functional matrix theory of Moss The Functional matrix theory According to van der klauw Functional matrix means the non osseous structures of the craniofacial skeleton.They function in the form of a matrix by stimulating and holding things together. The soft tissue unit is the functional matrix The skeletal unit is the functional cranial component
  12. 12. Principles of bionator therapy…. The functional matrix theory ….. There are two types of functional matrix 1.Periosteal functional matrix Which comprises of the muscles, blood vessels, nerves and glands. 2.The capsular matrix Which consists of the cerebral matrix and the facial matrix (eg. Neural, optical and orbital masses) According to van der klauw the presence or absence of soft tissue structures produce a response in the bone affecting it’s soft tissue morphology
  13. 13. Principles of bionator therapy…. The functional matrix theory ….. Also the functional matrix theory states that two factors are responsible for growth The intrinsic factor (genomic factor The extrinsic factor (epigenetic factor) The epigenetic factor which are the extraskeletal factors and processes are the primary cause of adaptive and secondary changes.
  14. 14. Principles of bionator therapy … To quote balter , The equilibirium between the tongue and the circumoral muscles especially between the tongue and the lips in the hieght , breath and width in a oral space of maximum size and optimal limits providing functional space for the tongue is essential for natural health of the dental arches and their relation to each other .Every disturbance will deform the dentition and during growth that may be impeded too. The tongue is the essential factor for the development of the dentition .It is the center of reflex cavity in the oral cavity.
  15. 15. Balters treatment objectives 1.To accomplish lip closure and bring the back of the tongue into contact with the soft palate. 2.To enlarge the oral space and to train its function 3.To bring the incisors into edge to edge relationship 4.To achieve an elongation of the mandible which will enlarge the oral space and make improved tongue position possible 5.To achieve an improved relationship of the jaw , tongue and dentition as well as the surrounding tissues.
  16. 16. Role of tongue in bionator therapy The tongue is the most important factor in treatment using the bionator A discoordination of the function could lead to abnormal growth and actual deformation The purpose of the bionator is to establish good functional coordination and eliminate these deforming and growth restricting aberrations
  17. 17. According to Balter a class II malocclusion is due to a backward positioning of the tongue ,disturbing the cervical region. Respiratory function in the region of the larynx is impeded and there is faulty deglutition associated with mouthbreathing. Winder’s research-1958 Tongue exerts 3 to 4 times as much pressure on the dentition as does the buccal and labial muscultare.This supports ballter’s hypothesis that the tongue is the chief cause of malocclusion. Abnormal tongue development can be secondary ,adaptive or compensatory because of skeletal maldevelopment. 
  18. 18. Position of the tongue vs malocclusion caused     Posterior displacement of the tongue-Cl II Malocclusion Low anterior displacement of the tongue-Cl III Malocclusion Hyperactivity and forward posturing of the tongue –open bite Diminished outward pressure during both postural rest and function as opposed to the forces of the buccinator mechanism on the outside - Narrowing of the arches with resultant crowding particularly in the maxillary arch
  19. 19. Mechanism of action of Bionator The bionator modulates the activity of the muscle thereby  1.Enhances normal development of inherent growth pattern  2.Eliminating abnormal and potentially deforming environmental factor
  20. 20. Indications for bionator therapy In actively growing children for the management of class II division 1 or class II division2  In class I malocclusion with deep bite  In class III Treatment of ClassII division I malocclusion in the mixed dentition is indicated only under the following conditions. 1.The dental arches are well aligned originally. 2.The mandible is in functional retrusion. 3.The skeletal discrepancy is not to severe. 4.A labial tipping of the upper incisors is evident. 
  21. 21. Contraindications to bionator therapy The bionator is not indicated in the following conditions 1. The class II relationship is caused by maxillary prognathism. 2.A vertical growth pattern is present. 3.Labial tipping of the lower incisors is evident. Anterior posturing of the mandible with simultaneous up righting of the lower incisors cannot be performed with the bionator. 4. Children with neuromuscular diseases such as poliomyelitis and cerebral palsy cannot be successfully treated with functional appliances because functional appliance therapy depends on neuromuscular response
  22. 22. Assessment to be made before planning treatment The following assessment are to be made before planning treatment  Whether malocclusion is skeletal or dental  Whether malocclusion is functionally true or functional retrusion  Forecasting of growth direction  Assessment of growth potential and growth increments  Differentiation of hereditary malocclusion and neuromuscular dysfunction.
  23. 23. Cephalometric criteria The following are the chepalometric criteria  -The relationship of the maxilla to the cranial base is considered  -The position and size of the mandible  -The axial inclination and position of the incisors  -The growth pattern
  24. 24. Functional criteria for treatment planning for class II malocclusion The functional criteria include  -The assessment of relationship between rest position and occlusion to differentiate between functional retrusion and forced bite malocclusion.  -The examination of relationship between overjet and function of the lips.  -The posture and function of the tongue should be assessed  -assessment of mode of breathing
  25. 25. Types of Bionator There are three basic types 1.Standard bionator for class II division malocclusion 2.Openbite bionator 3.Reversed or Class III bionator
  26. 26. Standard Bionator Uses of a standard bionator 1.In the treatment of class II division I malocclusion in order to correct the backward position of the tongue and its consequences. 2.For the treatment of narrow dental arches of class I malocclusion Components parts 1.Labial bow 2.Palatal bar 3.Construction bite or acrylic portion
  27. 27. Standard Bionator…. The vestibular wire or labial bow It is made of 0.9mm stainless steel wire .It emerges from the acrylic below the contact point between the upper canine and the premolar .it rises vertically and then bent at right angle to go distally along the middle of the crowns of the upper premolar just below the mesial contact of the first molar the wire is fashioned in a round bend towards the lower dental arch from here it runs anteriorly at about the same position with respect to the buccal surface of the lower posterior teeth as far as the lower canine
  28. 28. From there it at a sharp angle it extends obliquely upwards towards the upper canine , bends to a level line at approximately the incisal third of the incisors and extends to the canine of the opposite side .it ends in a mirror image form of the opposite side and inserts in acrylic.The labial surface of the bow should be away from the incisors by approximately the thickness of writing paper
  29. 29. Standard Bionator…. Function of labial bow in standard bionator 1.To guide the posture and function of the lips and cheeks 2.The posterior portion of the labial bow are designed as buccinator loops They keep the soft tissue away of the cheeks which is normally drawn into the interocclusal space.the construction bite may be trimmed facilitation eruption of the buccal segment. They actually move the surface of the orobuccal capsule laterally ,.this remval of inhibitory influence favours expansion or transverse developmwent of the maxillary dentition.
  30. 30. Function of labial bow in standard bionator………… 3.The position of the wire provides a negative pressure supporting lip closure.In course of treatment the wire uprights the incisors and provides for extra space when the arch is to widened 4.The labial bow similar in function to the acrylic shields of frankel
  31. 31. Standard Bionator…. The palatal bar  It made of 1.2mm stainless wire .It emerges from the upper margin of the acrylic, approximately opposite to the middle of the first premolar .it follows the contour of the palate at about 1mm from the mucosa .It forms a wide arch that reaches the distal surfaces of the first molars and it forms a mirror image curve to insert on the opposite side.
  32. 32. Standard Bionator…. Function of palatal bar 1.Stimulates the distal aspect of the tongue 2.Simulteanously orients the tongue and mandible anteriorly to achieve class I relationship 3.It stabilises the appliance 4.It is not intended for expansion of the arch
  33. 33. Standard bionator ….. Construction bite It consists a of horse shoe shaped acrylic lingual plate extending distal to the last erupted tooth on either side in the lower arch. For the upper arch the appliance is open from the canine to the canine region with aryclic in the posterior section that cover the molar and premolars..The bite should not be opened and must be positioned in an edge to edge position. If some space is present between the upper and lower incisors the acrylic is extended to cap the lower incisors If the ovejet is to large the forward positioning is done step by step but should not open the bite. Edge to edge relationship of all the teeth or at least the lateral incisors provides maximal functional space for the tongue. A construction bite must always be taken on the patient and not on the cast.
  34. 34. Standard Bionator…. Function of construction bite 1.It prevents the cheek and tongue from interposing in the interocclusal space 2.Proper trimming will facilitate eruption of teeth.
  35. 35. Open bite appliance Uses of open bite appliances 1.To close the aperture in the anterior or in the lateral dentition 2.Used in TMJ dysfunction cases Component parts  1.Labial bow  2.Palatal bar  3.Construction bite or acrylic portion
  36. 36. Open bite appliance.... Function of labial wire 1.It is placed at the height of correct lip closure to stimulate the lip to achieve a competent seal and relationship 2.Vertical strain on the lips tend to encourage the extrusive movements of the incisors which facilitates closure of the open bite after eliminating the adverse tongue pressures.
  37. 37. Open bite appliance…. The palatal bar is constructed similar to a standard appliance. Function of palatal bar is to move the tongue into a more caudal and posterior position Construction bite the construction bite is kept as low as possible with a slight opening which allows for interposition of the posterior acrylic bite blocks thereby preventing eruption of the posterior teeth
  38. 38. Class III bionator or reversed bionator It is used in the treatment of classIII malocclusion by encouraging development of the maxiila.  Component parts labial bow The labial bow runs in front of the lower incisors. It prevents labial tipping of the lower incisors.
  39. 39. Class III bionator or reversed bionator…. The palatal bar The palatal bar is reverse in position to that of the standard bionator. This stimulates the tongue to remain in a retracted position in its proper functional space. It contacts the anterior portion of the palate encouraging the forward growth of the area. Construction bite The construction bite is taken in the most retruded position. The construction bite is similar to that of the standard bionator except that it is extended in the behind the lingual surface of the upper incisors which are stimulated to glide along the upper inclined plane.The acrylic behind the lower teeth is trimmed by 1 mm to prevent labial tipping of the lower incisors.
  40. 40. Trimming the bionator The trimming of the occlusal surface of the bionator is essential to allow certain teeth to erupt further while preventing fully erupted teeth from further eruption through contact with the acrylic. Balter refers to Stimulation of eruption as unloading or promotion of growth and Prevention of eruption as loading or inhibition of growth
  41. 41. Terminology in trimming the bionator…….. 1.Articular plane-this plane extends from the cusps of The upper molars,premolars, and canines to the mesial margin of the upper incisors. It is parallel to the alatragal is important for the assessment of growth
  42. 42. Terminology used in trimming the bionator appliance…….. 2.Loading area-The palatal or lingual cusps of the deciduous molars and permanent first molars are relieved in acrylic . this enhances the anchorage of the appliance.
  43. 43. Terminology used in trimming the bionator appliance…….. Tooth bed Some parts of the loading area are trimmed away to the articular plane. This acrylic surface is called the tooth bed
  44. 44. Terminology used in trimming the bionator appliance…….. Ledge A reduced plastic extension placed on the occlusal third of the interdental area is called a ledge.this lies between the premolars or decidous molars. This acts as a guiding surface for the eruption of teeth
  45. 45. Terminology used in trimming the bionator appliance…….. NOSE Between the tooth beds, Interdentally acrylic finger like projections called noses can be fabricated. These extensions act As guiding panes and sources of anchorage.
  46. 46. Trimming the bionator…. Unloading of the upper and lower molars cause extrusion.
  47. 47. Trimming the bionator….  Loading of the upper and lower molars cause a expansion effect on the upper teeth
  48. 48. Trimming the bionator…. loading of the upper molars and unloading of the lower molars cause eruption of the upper molars.
  49. 49. Stabilization of the bionator The appliance is stabilized -In the mixed dentition by having the upper and lower deciduous molars occlude on the acrylic. - In the permanent dentition this is accomplished by having the maxillary premolars occlude in the acrylic -The occlusal part of the acrylic bite block will be ground flat to allow for transverse expansion of the dental arch. -No acrylic covers the first molars which permits for further eruption and leveling of the bite.
  50. 50. Stabilization of the bionator…. The following teeth can be used for stabilization depending on the presence or absence of teeth. Teeth present anchorage 1,2,III,IV,V, 6 IV,V upper and lower 1,2,III,-,V,6 V and space after 1V 1,2,II,-,6 alveolar process-IV,V 1,2,III,4,-,6 6 and the alveolar process
  51. 51. Anchorage of the appliance Stabilisation or anchorage is provided by Insical margin of the lower incisors,by extending the acrylic over the incisal margin as a cap. In the loading area the cusps of the teeth fit into the respective grooves in acrylic. Decidous molars and edentulous spaces serve as areas of anchorage. Noses in the upper and lower interdental spaces. Labial bow when it is correctly placed prevent posterior displacement of the appliance.
  52. 52. Bionator and the TMJ Tmj problems are associated with bruxism and clenching during the REM period of sleep Mechanism of action-Bionator relaxes muscle spasm particularly that of the lateral pterygoid muscle. Design of the appliance-Similar to a standard appliance except the construction bite need not move the mandible forward Purpose of the appliance-To prevent riding of the condyle over the posterior edge of the disc and thereby prevent clicking . Function of the bionator-to maintain the mandible in a forward position and prevent deleterious parafunctional effects at night. .
  53. 53. Bionator and the TMJ…… Construction biteIt is opened slightly and the lower incisors are capped. No grinding is done When the acrylic is worn it loads both the upper and lower buccal segment guiding the mandible forward during the clencing or bruxing activity. Bionator therapy with local application of heat and muscle relaxants provide immediate relief
  54. 54. Bionator and the TMJ….. Adult Class II patients learn a accomodative forward positioning of the mandible as the muscles adapt to the new position The adaptation is due to a foreshortening of the protracting muscles of t he mandible. Duration of wear -the appliance should be worn indefinitely as a splint at night.
  55. 55. Causes of failures due to bionator therapy 1.Lack of patient co-operation 2.Wrong diagnosis 3.Poor growth direction 4.Inadequate growth increments 5.Poor treatment timing
  56. 56. Clinical management of bionator treatment The appliance should be loose and should fall when the mouth is open. The time interval between office visits is 3 to 5 weeks depending upon the state of eruption of the tooth. The labial bow should be checked to ensure that it touches the teeth only lightly. The buccinator loops should be away from the decidous first molars but should not irritate the cheeks. In accordance with the plan of anchorage an growth promotion,loading and unloading of acrylic areas can be done depending o the teeth to be stimulated. Any modifications are done in the following order The lower premolars secondly The upper premolars in the end. These areas are alternately loaded or unloaded for anchorage
  57. 57. prognosis bionator therapy Bionator therapy is successful in actively growing children -with class II division1,and class II division2. -Class I malocclusion with deep-bite -Pseudo class III -Maloccusion caused due to lip sucking,lip and tongue interposition,or cheek biting Favourable outcome is limited In the presence of skeletal discrepancies such as skeletal open bite mandibular prognathism and transverse basal arch disharmony. In patient in whom facial growth has been completed. Marked crowding that requires extraction for alignment.
  58. 58. Patient instructions It should be worn both during the day and night except during meals and during sports. The appliance should be worn while giving short speeches The appliance is removed b shing it oih the tongue
  59. 59. Advantages and Disadvantages of the bionator The main advantages is the reduced size.So it can be used day and exerts a constant influence on the tongue and musclature because of the longer duration of wear the correction of malocclusion is faster because the mandible only during mealtimes Disadvantages of the bionator Correct management of the appliance is necessary. Stabilization of the appliance and selective grinding of etive gidnce is done simltenos limited effectiveness in skeletal distbnces. Vlneble to distortion since thee is less lic in he alveol and incisl region No llonce fo veicl goth comonent excet tht it llos fo giding etion of osteio teeth.
  60. 60. Modification of bionator
  61. 61. Modification of bionator-the biomodulator of fleischer   The following are modifications in bionator design The Acrylic body of the bionator is reduced in size extending along the alveolar process than the original design.
  62. 62.  A maxillary buccolingual arch wire and a separate labial wire is used instead of the labial wire with buccinator loops  The transpalatal arch opens in the distal direction  Sagittal anchorage is reinforced with spurs locted mesial to the maxillary canine or the maxillary first molar.
  63. 63. Modification of the bionatorThe bio-M-S appliance This appliance is similar to a biomodulator but in addition to the other co incorporates a metal occlusal bite plane into the bionator to facilitate correction of deep bite.
  64. 64. Acrylic body The upper margin of the acrylic along the palatal margin of the incisors tapers to a thin edge to facilitate pronunciation of s sound .The anterior part of the bionator is slightly concave to leave maximal space for the tongue.
  65. 65. Transpalatal bar It is made of 1.2mm wire. Opens in the distal direction Parallel to the occlusal plane near the palatal aspect of the molars.
  66. 66. Maxillary labial bow Made of 0.9mm wire Contoured along the labial surface of the incisors at the level of the interdental papilla Between the canine and the premolar a loop is formed approximately 10mm in diameter. The retentive part is bent lingually. The labial arch wire is kept about 1mm to 3mm away from tha labial surface of the teeth.
  67. 67. Mandibular labial bow It is made of 0.9mm wire -In the area of the premolars it has a u shaped loop 8mm in diameter -The wire enters the acrylic distal to the canine close to the occlusal plane. -To avoid irritation to the lip a wave like pattern is given to the labial bow or the wire can be covered wire soft elastic acrylic.. In class III malocclusion the labial wire is placed near the incisal edge of the incisors to to avoid interference with the occlusally directed forces to
  68. 68. Wire stops Stops at the mesial surface of the maxillary molars serve as auxiliaries for sagittal anchorage.the wire is turned gingivally into a small loop approximately 3mm in diameter.and placed on the mesiobuccal aspect of the first molar
  69. 69. C stops Used when the canines have not erupted fully. It’s placed on the mesial surface of the maxillary canine.
  70. 70. Metal bite plane Made of 0.5mm stainless steel sheet metal adapted to the shape of the individual dental arches Purpose of a metal guide plane -as a guide for vertical development -Promotes vertical equilibration of the occlusal surface of premolars and molars by allowing teeth that do not touch the bite plane to erupt further while restricting the eruption of teeth that touch the bite plane. - correction of deep bite. 
  71. 71. L stops It’s a small metal plate fitted onto the labial surface of the metal occlusal bite plane to provide for sagittal anchorage In the anterior region has a retruding effect on the incisors. In the buccal surface of molars and premolars can be used in the correction of cross bite.
  72. 72. The construction bite It serves as a guide for vertical development and correction of deep bite. In a class II division 2, a flat plane permits differential control of eruption. Lower premolars in infraocclusion,reduction in excessive curve of spee. Advantages of a metal occlusal plane It eliminates the tedious procedure of trimming the acrylic as in conventional functional appliances.
  73. 73. Journal Review
  74. 74. Effectiveness of early treatment with haedgear/biteplane vs the bionatorAJO2002 When factors such as sex, race, intial molar severity and compliance is taken into account headgear treatment is superior to bionator treatment although relapse after phase I therapy is greater with headgear than with bionator. phase I therapy is considered to be successful if molar correct from a full cusp classII to to a one fourth cusp class II
  75. 75. Frankel vs the bionatorAJO 2002 A significant increase in mandibular growth and degree of mandibular protrusion with the increase greater in the bionator  Anterioposterior relationship between the maxilla and the mandible increased significantly in both the bionator and frankel  Both appliances produce similar labial tipping and linear protrusion of the lower incisors,lingual inclination and retrusion of the upper incisors.  A significant increase in mandibular posterior dentoalveolar hieght and not extrusion of the upper molars in both group  No significant on craniofacial growth and restriction of maxillary growth 
  76. 76. Chepalometric markers to be considered in the treatment of classII division I malocclusion with bionator AJO 2001 Important indicators of good result are 1.Horizontal growth pattern It should be close to the normal anterio- posterior relationship between the maxilla and mandible. 2.Upright mandibular incisors 3.Retrusive lower lip-protrusion of the lower lip was the most important factor in the determination of treatment results.
  77. 77. Anterioposterior skeletal and dental changes after early class II treatment with bionator and headgear AJO1998 The headgear/biteplane and bionator do not affect maxiilary growth during treatment in 9-10 years. Both appliances enhance mandibular anterior growth.
  78. 78. Mandibular response to orthodontic treatment with the bionator applianceAJO 1990 The subjects with delayed growth may experience more mandibular development than those with average growth during treatment under the favourable growth environment created by the functional appliance. Patient with small mandible may experience more benefit than patients with normal mandible. Changes in condylar position indicated a more distal post-treatment condylar position in patient with a greater mandibular advancement Compared to patient who had a small mandibular advancement. Thus the anterior positioning of the condyle that takes place with functional appliance therapy may be diminished with greater mandibular advancement.
  79. 79. Conclusion  The bionator is the most commonly used modification of the activator.It is the appliance of choice for begginner in functional appliance therapy as it has very little wire components.With proper case selection ,diagnosis and treatment planning the bionator can be used as an effective functional appliance during the period of active growth
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