Bionator

Bionator
Prepared by Yasmin Hammad
Supervised by prof dr Maher Fouda
Faculty of Dentistry Mansoura Egypt

Introduction1
History2
Treatment objectives3
Types of bionator4
Trimming of bionator5
6 Clinical management & Case Reports
7 Modifications of Bionator

• FUNCTIONAL APPLIANCE
Definition:
• Is one that changes the posture of the mandible,
holding it open or open and forward (proffit)
Graber and Neumann Classification
– Those that displace the mandible to a moderate
degree and are intended to stimulate muscle
activity i.e. myodynamic – Bionator
3

Functional appliances are considered to be primarily
orthopedic tools to influence the facial skeleton of the
growing child. The uniqueness of these appliances lies in
the fact that instead of applying active forces, they transmit,
eliminate and guide the natural forces (e.g. muscle activity,
growth, tooth eruption) to eliminate the morphological
aberrations and try to create conditions for the harmonious
development of the stomatognathic system.
Most of the functional appliances are intraoral devices,
and nearly all of them are tooth borne or supported by
teeth.
4

5
FUNCTIONAL
APPLIANCE
Fixed
Removable
Activator
Bionator
According to Proffit:
 Tooth borne passive appliance (activator, bionator)
 Tooth borne active appliance
 Tissue borne passive appliance (oral screen, lip
bumper)
 Tissue borne active appliance (Frankel appliance)

Introduction1
History2
Types of bionator4
6 Clinical management

 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
7

8
The bionator, developed by Balters, is a
functional jaw orthopedic appliance. Its primary
purpose is to stimulate growth of a deficient
mandible, but it can also stimulate alveolar
growth in deep overbite cases, gain space in
moderately crowded cases in mixed dentition,
as well as correction of open bite cases in
mixed dentition.
The essential part of robin’s concept is function
whereas for Balter’s it is the tongue (which is
the center of reflex activity in the oral cavity)

It is similar in design to the activator but
much less bulky, the bionator can be worn
day and night except during meals. Studies
have shown greater orthopedic effect on the
growing jaws with full time wear, whereas
part time wear results primarily in dental
change. Therefore, full time use of the
bionator makes possible the improvement
of deformed faces and jaw structure in the
growing child that was previously not
possible with the use of fixed appliances or
part time orthopedic devices.
9
Activator
Bionator

Quoted by Balter
10
 “The equilibrium b/w the tongue and cheeks,
especially b/w the tongue and lips in height, breadth
and depth in an oral space of maximum size and
optimal limits, providing functional space for the
tongue ,is essential for the 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.”

It works by modulating muscle activity
12
Enlarge oral space
& train tongue
functions
To achieve
elongation of
mandible
Bring incisors into
edge to edge
relationship
Accomplish lip
seal & bring
dorsum of tongue
into contact with
soft palate
Improve
relationships of
jaws, tongue &
teeth

13
 Reduced size
 It can be worn both day and night
 Action faster than activator –unfavorable forces
are avoided acting on dentition for longer time
 Constant wear so more rapid adjustment of
musculature

14
 Difficulty in managing it.
 Difficult to stabilize and selective grinding of the
appliance .
 It is vulnerable to distortion – because less
support in the alveolar & incisal region

15
 Dental arches well aligned
 Mandible in posterior position
 Skeletal discrepancy not severe
 Labial tipping of upper incisors
evident
 Deep bite
 Class III where reverse bionator
can be used
 Open bite

16
 Class II – if caused by maxillary prognathism
 Vertical growth pattern
 Labial tipping of mandibular incisors

19
1. THE STANDARD BIONATOR (Bionator I)
2. THE OPEN BITE BIONATOR (Bionator II)
1. CIass III OR REVERSED BIONATOR (Bionator III)

The standard Baltrers Bionator appliance, used in
the treatment of class II, division I malocclusions
with excessive overjet and deep overbite.
20

21
Consists of
 acrylic components
- lower horse shoe shaped
acrylic lingual plate from distal
of last erupted molar of one
side to other side
- Upper arch - lingual
extension that cover molar &
premolar region

WIRE COMPONENTS
22
 PALATAL BAR
 LABIAL BOW WITH BUCCAL EXTENSION
 PALATAL BAR
- 1.2 mm wire
- extents from a line connecting distal
surface of first permanent molars to
middle of 1st premolar’s
- ~ 1mm away from palatal mucosa
Function- orients the tongue & mandible
anteriorly by stimulating its dorsal surface
with palatal bar

WIRE COMPONENTS
23
 LABIAL BOW
-0.9 mm wire
- begins above contact point between canine and
upper 1st premolar –runs vertically
- labial portion of bow should be at a paper thickness
away from the incisors

WIRE COMPONENTS
24
 Anterior part - labial wire
 Lateral part - buccinator bends
Objectives of buccinator bends
 To keep soft tissue away from the cheeks –so the
bite is leveled & eruption proceed in buccal segment
 Moves cheeks laterally , which favor expansion or
transverse development of dentition

25
 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.
*The purpose of this appliance is to close
the anterior space.

Wire elements
26
 Labial bow runs between the upper and
lower incisors at the height of lip
closure.

The Bionator II (to close bite):
The Bionator II is designed to correct
anterior Open bites in Class I and
Class II malocclusions.
The posterior teeth are covered with
acrylic to prevent their eruption. The
acrylic is kept
away form the incisors to allow closure
of the open bite. The midline
expansion screw can
be used for arch development when it
is indicated
27

28
 Encourage development of max
 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

Palatal bar
29
Runs forward with loop
extending as far as decduous 1st
molar or permanent premolars.
Function – tongue to contact
anterior portion of palate ,
encouraging forward growth of this
area.
Wire elements

Labial bow
30
 In front of lower incisors
 Wire slightly touches the labial surface
lightly.
Wire elements

34
Def: is one of a group of functional, removable, tooth-
borne appliances that depend on the stretch of soft
tissue caused by mandible being positioned forward
and downward together with muscle activity generated
by the mandible attempting to return to its original
position to achieve the desired dental and skeletal
effects.
{orthodontics principle and practice -Phulari}

Standard Bionator:
used in the treatment of class II, division
I malocclusions with excessive overjet
and deep overbite orients the tongue &
mandible anteriorly by stimulating its
dorsal surface with palatal bar.
36

Labial bow: begins above contact point between canine and upper 1st
premolar –runs vertically
37

Openbite Bionator:
• Posterior teeth are covered
with acrylic to prevent their
eruption. The acrylic is
kept away form the incisors to
allow closure of the open bite.
38

Labial bow runs between
the upper and lower
incisors at the height of lip
closure.
39

Reverse Bionator:
• Correction of class III
Tongue contact anterior portion of palate ,
encouraging forward growth of the
maxilla.
40

Labial bow slightly
touches the labial surface
of the lower incisors
41

Bionator general indication
• The dental arch is well aligned originally
• The mandible is in a posterior position
• The skeletal problem is not too severe
• A labial tipping of the upper incisors is
evident
• Note: labial bow: 0.9mm st.st wire
Palatal bar: 1.2mm st.st wire
42

CONSTRUCTION BITE
44
Def: it is an intermaxillary wax record used to relate the
mandible to the maxilla in the 3 dimensions of space, they are
used to reposition the mandible in order to improve the
skeletal inter-jaw relationship.

Objective:
 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.
45

• The bite registration involves
repositioning the mandible in a forward direction as
well as opening the bite vertically.
• In most cases the mandible is advanced by 4-5 mm
and the bite is opened to the extent of 2-3mm.
46

• General consideration for construction bite:
1- in case the overjet is too large, forward
positioning is done step wise in 2-3 phases.
• 2- in case of forward
positioning of the
mandible by 7-8 mm,
the vertical opening
should be slight to
moderate i.e: 2-4mm.
• 3- if the forward positioning is not more that 3-
5mm, then the vertical opening can be 4-6mm
47

Various techniques are now used to record the bite to the
favoured mandibular position:
1- Horseshoe waxblock. 2- Exactobite / Projet bite .
3- George gauge. 4- Andra Gauge…etc.
48

Steps for bite registration
49
• 1- the amount of sagittal and
vertical advancement is
planned.
• 2- a horse shaped wax block
is prepared for insertion
between upper and lower
teeth. It should be 2-3mm
thicker than the planned
vertical opening. Should be
heated in warm water bath.
•

• *NOTE*: other materials may be used; e.g: heavy putty
base impression material is used and allowed to set for 2
minutes, or injectable registration material, e.g: FUTAR,
O-Bite .
50

• 3- The patient is made to sit in an upright relaxed
position.
• 4- Guiding the mandible into planned sagittal position
without force or pressure.
• 5- patient is asked to practice placement of jaw at the
desired position few times before registration of bite.
• 6- The wax block is placed on the lower jaw and patient
is asked to close in desired sagittal position.
51

• 7- Remove the wax
registration and chill the wax
under cold running water, cut
away the wax as shown in the
canine/premolar region
• 8- Place back into the mouth
to check the registration is
correct - the lateral opening
and that the center lines are
correct.
52

Exactobite.
• Use either a thick or thin 'bite fork'.
The 'ProJet' bite forks are available
in thick for when an overbite needs
reducing and thin for normal or
reduced overbites.
*the thick one is yellow
and the thin is blue.
• Explain to the patient what is
required, ie that they posture
forward to the required occlusion.
54

• Place the bite fork into the mouth
and ask the patient to practice biting
into the required position
NB Do not over posture the patient
or place them into a class III
relationship. Place the single notch
down and the middle notch to locate
the upper teeth (this is opposite to
the ProJet instructions, but is much
easier for patient and operator)
55

• Soften a sheet of pink modeling wax in
hot water, folding them into the bite fork
to give 3-4 layers on both sides, top and
bottom, but keeping the notches clear..
• Place the bite fork and soft wax into the
mouth asking the patient to close into the
postured position. Excess wax can be
moulded to aid location of the bite for the
laboratory. You must ensure that the
center lines are correct.
56

• Remove the bite fork and chill the wax
under cold running water.
• Place back into the mouth to check the
registration is correct.
57

Construction bite
64
In Open Bite Bionator
 Construction bite-is as low as possible with
minimal vertical 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, the bite is opened to
clear the bite & also to exert
restrictive force on lower arch.
Generally, a vertical opening of
5mm and a posterior positioning
of about 2 mm is required.
65

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 Central incisors
66

TRIMMING OF BIONATOR
69
As the volume of the appliance is reduced its
anchorage is difficult and trimming must be
selective because of simultaneous anchorage
requirements
Balters has introduced certain terms
1. Articular plane
2. Loading area
3. Tooth bed
4. Nose
5. ledge

ARTICULAR PLANE:
71
 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:
72
 Palatal or lingual
cusps of the
deciduous molars
(or premolars) are
relieved in the
acrylic part of the
appliance.
 The grinding
enhances the
anchorage of the
appliance.

TOOTH BED
73
 Some parts of the
loading areas are
trimmed away to the
articular plane

NOSE:
74
 Between tooth bed
interdental acrylic
fingerlike projections
 They serve as guiding
surfaces and provide
anchorage in the
sagittal and vertical
plane
 NOSE mostly on the
mesial margin of lower
1st permanent molar

LEDGE :
75
 Depending on the tooth
movement required the
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.
 LEDGES are b/w premolars
or deciduous molars

BALTERS REFERS
77
 prevention of eruption as
loading or inhibition of growth
 stimulation of eruption as
unloading or promotion of
growth

78
 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
is done

SELECTIVE TRIMMING
79
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
movement
 For intrusion in case of open bite –posterior teeth
are fully loaded

Why Trimming ???
1.vertical control
• For dolichofacial patients:intrude molars,
extrude incisors
• For branchfacial patients: intrude incisors,
extrude molars
80

• 2.sagittal control
81
Retrusion of incisors
Distal movement of
molars
Mesial movement of
molars

Ascher (1968)proposal
Dentition Anchorage
1,2,III-V,6 IV & V both U / L
1,2,III-V,6 V & space after IV
1,2,II-6 alveolar process-IV,V
1,2,III,4-6 6 & alveolar process
83
 Deciduous teeth if present are used as anchorage
and Ascher (1968)proposed the following types of
anchorage.

ANCHORAGE OF APPLIANCE
84
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

Introduction1
History2
Types of bionator4
6
Clinical management & Case Reports

CLINICAL MANAGEMENT
87
 Appliance must be worn day and night except while
eating.
 Pt recalled after 1 week to check sore points
 Interval between 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.

Treatment of Angle Class II malocclusions with a
newly modified bionator combined with headgear
J Dent Sci 2009;4(2):87−95
Yen-Chun Lin, Hsiang-Chien Lin
Case 1
The patient was an 11-
year 6-month-old boy.
He had a Class II
division 1 type
malocclusion with a
hypodivergent facial
type, a half cusp
distoclusion of the
posterior segments,
and an overjet of 10mm
89

• There was no crowding in the lower arch, but mild
crowding of the upper anterior teeth was noted. The
upper deciduous second molars were retained, and the
upper and lower permanent second molars had not yet
erupted.
90

• An initial lateral cephalometric evaluation showed a
Class II skeletal relationship characterized by a A
point−nasion−B point (ANB) angle of 7.3‫,؛‬ due to
maxillary prognathism and mandibular retrognathism.
91

His treatment plan involved both
upper and lower molar distalization
and forward advancement of the
mandible using the newly modified
bionator combined with high-pull
headgear, with approximately 450 g
of force adapted to the tubes in the
appliance. During the active phase of
treatment, the patient was instructed
to wear the headgear 10 hours a day
at night and the bionator appliance
24 hours a day, except during meals.
92

After Bionator
The patient was
advised to keep
his lips together to
form a lip seal
when the
appliance was
being worn. At
each monthly
visit, the occlusion
was checked for
correction of the
arch relationships.
93

During the retention
phase, the patient was
instructed
to wear a tooth
positioner every night
tobed, approximately
10 hours each day, for
2 years.
94
After retention

95
Before treatment, during and after..

Long-term Effectiveness and
Treatment Timing for Bionator
Therapy.
FALTIN, FALTIN, BACCETTI, FRANCHI
Angle Orthodontist, Vol 73, No 3, 2003
((Of a study on Bionator therapy followed by fixed appliances in class-II
patients indicate that this treatment protocol is effective and stable
when it is initiated immediately before the pubertal growth spurt.
Optimal timing to start treatment with the Bionator is when a concavity
is evident at the lower borders of both 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 with the Bionator during the pubertal
growth spurt is 5.1 mm more than that in untreated subjects with class-
II malocclusion.))
96

The functional treatment of anterior-
open bite: three case reports
Banu Dinçer* / Serpil Hazar**
J Clin Pediatr Dent 25(4): 275-286, 2001
Case 2
A patient whose skeletal age is 9 years 2
months and chronological age is 10 years 3
months was presented to the clinic.
The patient had the typical facial characteristics
of the open bite anomaly with the dolicephalic
face, convex facial profile and the increase of
the inferior facial height. It was noted that he
had difficulty closing his mouth from the
wrinkling of the muscles in mental region when
he closed his mouth.
98

He had a finger sucking habit. He was
advised to quit the sucking habit.
Nevertheless, when this was not
sufficiently accomplished, the patient
worked with a child psychologist to quit
the habit.
Diastemas in lower and upper teeth
region were observed as well as 4 mm.
open-bite. Together with this, he had
an overjet of 7.5 mm. The
cephalometric evaluation showed
Class II skeletal pattern (ANB=7).
99

The patient wore the open-
bite bionator. He used the
appliance a minimum of 18
hours a day. In 10 months,
the elimination of the open-
bite was obtained and a
2mm normal overbite
relation was achieved,
which was 4 mm
open-bite before the
treatment.
100

a decrease in the vertical development was obtained. The
patient began to close his mouth more easily. The difficulty
in muscles were eliminated
101

•Before treatment
•After treatment
102102102

The cephalometric super impositions before and
after using the appliances
103
- - - - - - After ttt
Before ttt

“Long-Term Dentoskeletal Effects and Facial
Profile Changes Induced by Bionator
Therapy”
- The bionator appliance, over a long-term period, did not induce a restraining
effect on the maxilla, while it produced a significant enhancing effect on
mandibular length (3.3 mm more than untreated Class II controls).
- The bionator improved significantly the overjet and the molar relationship,
with a significant reduction of the overbite associated with an increase in
LAFH.
- The soft tissue profile was favorably altered by bionator therapy in the long
term: the chin was advanced 2.5 mm more than that of untreated controls.
Luciana Abrao Maltaa; Tiziano Baccettib.
Angle Orthodontist, Vol 80, No 1, 2010
104

Pseudo-Class III malocclusion
treatment with Balters’ Bionator
Journal of Orthodontics, Vol. 30, 2003, 203–215
A. Giancotti, A. Maselli
Case 3:
A female patient, age 8 years
10 months, presented with an
anterior crossbite from the
upper right deciduous canine
to the upper left deciduous
canine and a 1-mm deviation
of the mandibular midline to
the right. The patient had a
good profile with a slight mid-
face convexity and the lower
lip appeared protruded.
106

The upper anterior teeth were retroclined and the upper
right lateral incisor was missing, while the lower anterior
teeth were protrusive. The molars were in a Class I
relationship. The lower arch was in the late mixed dentition
and ‘E’ space was present.
107

Pre-treatment cephalometric analysis
showed an increased mandibular plane
angle (40 degrees), with a normal ANB,
but a high Wits measurement (6 mm)
and the lower incisor inclination was 29
degrees to NB. Angular and linear
measurements of mandibular skeletal
growth were normal. Clinical evaluation
of the occlusal relationship in centric
relation showed an early interference of
the upper left central and lower left
central incisors
108

• An early treatment goal was to eliminate
the mandibular displacement and
treatment was initiated with a Balters’
Bionator III. In order to construct the
Bionator a wax bite was taken by distally
repositioning the mandible in centric
relation. This use of the Bionator III thus
enabled the tongue to move freely in the
anterior part of the palate, pushing it
against the upper front teeth. The vertical
thickness of the bite was 3–4 mm with
sliding guides in the posterior zone.
109
**The patient had to
wear this Bionator for
16 hours a day.

The incisors were beyond edge-to-edge after 9 weeks, but
use of the Class III Bionator was continued. Eleven months
after the beginning of treatment the patient had a normal
occlusion with 2-mm overjet and a Class I molar
relationship.
110

Final records showed
excellent occlusal and
aesthetic results, and the
profile was relatively
normal with a good lower
lip position.
111

Bionator and TMJ
113
 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

Bionator in Adult Patients
114
 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

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
118

Modification by Schmuth
119
 Cybernator
 Normal labial bow in the
max arch – from canine to
canine
 Mandibular incisors
covered with thin 2mm
acrylic

BIO- M-S
120
BY ERICH & ANNETTE FLEISHER
 MODIFICATIONS ARE-
 Acrylic body reduced in size
 Instead of long labial bow –
Maxillary buccolabial arch wire and mandibular labial
arch wire. Aid in correction of deep bite.
 Transpalatal bar opens in distal direction as in CI III
bionator
 Wire spurs used to reinforce anchorage.

Orthopedic corrector I
124
INDICATION
 Cl II to cl I
 Excellent result in
skeletal cl II cases
 Mixed dentition or
permanent dentition
treatment
 Upper incisors contact
lower incisor acrylic
capping
WITZIG incorporated 2dimentional screws bilaterally to Schmuth’s bionator.

Orthopedic corrector II
125
 Correct Cl II to cl I without vertical
growth
 in mixed dentition
 Correct open bite
 enlarges dental arches in case of
crowding
 In mixed dentition –TMJ pain
patients – repositions mandible
without increasing vertical height
 To achieve forward growth of
mandible in open bite tendency
cases

California bionator
126
This type bionator helps in
eruption of post teeth in
patients with decreased
vertical dimension

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
128

Treatment effects by bionator appliance – comparison
with an untreated cl II sample
Almeida et al EJO- 2004
129
 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
130

CONCLUSION
131
The bionator is effective in treating functional or mild skeletal
class II malocclusions in the mixed and transitional
dentitions, provided that the appliance is chosen after a
careful diagnostic study, it is made correctly and managed
properly by loading and unloading different areas as
indicated during the eruption of the premolars , and the
patient complies in both daytime and night time wear.

Bionator

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