BY,

Dr. Prachi S Hundiwale

 INTRODUCTION
• The bionator is the prototype of a less bulky appliance.
• Balters (1960) developed the original appliance
• According to Balters, the equilibrium between the tongue
and circumoral muscles is responsible for the shape of the
dental arches and intercuspation
• This hypothesis supports the early function and form
concepts of van der Klaauw and the later functional
matrix theory of Moss
• The tongue was the most important factor in
treatment. A dis co-ordination of its functions could
lead to abnormal growth and actual deformation.
• The principle of treatment with the bionator is not to
activate the muscles but to modulate muscle activity,
thereby enhancing normal development of the
inherent growth pattern and eliminating abnormal and
potentially deforming environmental factors
 CONSTRUCTION BITE
The bionator does not make allowances for facial
pattern and growth direction
The bite must be positioned in an edge to edge
relationship. If the overjet is too large, however, the
forward posturing can be done step by step but should
not open the bite.
Balters reasoned that a high construction bite could
impair tongue function and the patient could actually
acquire a tongue-thrust habit
• Myotactic reflex activity with isotonic muscle
contraction is stimulated, and the loose
appliance works with kinetic energy
• This wax bite is the blueprint for the appliance
and determines just how the power of the
appliance will be delivered to the tissues.
• Anderson recommended a 2 to 4 mm opening between
molars The first to oppose this view was Selmer –
Olsen who said muscles couldn’t be stimulated at night.
• Will not have a passive, truly functional appliance.

• Grude said if an appliance was constructed within the

physiologic rest position, it worked according to
Andersen’s theories; if beyond the limit it worked
according to Selmer
• Herren said there were many rest positions
while sleeping
• Harvold said go active, he took the construction bite
with the jaw 8 – to – 10 mm vertical opening beyond
the rest position.
• Woodside was to go even further, 12 to 15 mm
beyond rest.
• Grabber and Neuman said use of combination of bite
opening and protrusion to equal 10 mm.
• . Witzig recommends using a bite with 2 –to – 3mm
interincisal clearance at the centrals or laterals and a
mandibular advancement such that the lower centrals
are 2 to 3 mm protruded beyond the upper centrals or
laterals.
• Schmuth, on the other hand, reverts back to the
original construction bite of Andersen, a concept well
over a half century old.
• First have a set of study models handy .
• Use the molars as a guide
• But if the incisors are in reasonably normal
position, they may act as the best guide.
• The lower jaw should be positioned forward
just enough so that the lower incisal edges are
protruded about 2 to 3 mm beyond the upper
incisal edges. So, you have a 2- to 3 –mm
open bite in the anteriors and a protrusion of 2
to 3 mm of the lowers past the uppers.
Construction bite may be varied according to
certain facial types and growth patterns
• With the study models handy, have the patient
practice closing to the desired construction –
bite position. Guide the patients’ jaw to this
position with your hands while standing
behind him and having him watch himself in a
hand mirror. Demonstrate using the model’s
or your own teeth as a guide.
• A means if obtaining water at approximately
138°F is desirable for warming the wax.
• Several methods prove effective for preparing
the wax into a bite block.
• (1) First can be heated for five to eight
seconds in the 138°F water bath and folded
into thirds, the resultant oblong again folded in
half and roughly hand – shaped to fit the study
casts which should still be handy. Reheat the
wax again and trim it so it is not contacted by
the anterior teeth when the bite is taken
• (2) Another method is to fold the wax sheet
into thirds and then curl in the edges so the
wax block just fits lengthwise across the
mandibular arch.
• (3) A third method advocates rolling the wax
into a tube the size of your little finger to be
your guide.
• Once the bite block is prepared and properly
heated place it on the lower posterior teeth and
have the patient, with the aid of a hand mirror
and the doctor’s hands, close into the desired
position and hold still for ten seconds. This
will allow the wax to cool in the mouth just
enough that it might be carefully removed
without distortion.
• As the patient opens, a very slight audible
“snap” will be heard as the teeth break loose
from the suction of the indentations they made
with the wax. Remove the bite either by
taking hold of it manually or having the
patient push it out into your hand with their
tongue. Chill in cool water for one minute. It
is wise to take several bites. Send the best one
to the laboratory along with the models
• When constructing a Bionator for the purposes of increasing
the vertical dimension only, a slightly different type of bite is
taken The bite is registered in an open position without the
mandible being protruded quite as far. When the mandible is
merely rotated downward, it retrudes itself, only dentally, by
opening in an arc. If allowed to erupt from this slightly
retruded point, the mandibular posterior segments could
possibly come upward into a slight dental Class II situation.
To compensate for this, slight mandibular protrusion is
employed in taking the construction bite.
 Bionator types

• Three basic constructions are common in the

bionator:
• The standard
• The open bite
• The reversed or Class III
 Standard Appliances

• The standard appliance consists of a lower horseshoe

–shaped acrylic lingual plate extending from the distal

of the last erupted molar around to the corresponding

point on the other side. For the upper arch the

appliance has only posterior lingual extensions that

cover the molar and premolar regions.

• The anterior portion is open from canine to canine.

The upper and lower parts, which are joined

interocclusally in the correct construction bite

relationship, extend 2mm above the upper gingival

margin and 2mm below the lower gingival margin.

 DESIGN
• The upper anterior portion is kept free. However,
tongue function is controlled by the edge –to – edge
incisal contact relationship, leaving no space for
thrusting activity. If establishing this relationship is
possible, no acrylic capping of the lower incisors is
done. If some space exists between the upper and
lower incisors in the construction bite, acrylic can be
extended to cap the lower incisors.
• The function and posture of the lips and
cheeks are guided by two wire construction,
the palatal bar and the labial bow with buccal
extensions. The palatal bar is formed of
1.2mm hard stainless steel wire extending
from the top edges of lingual acrylic flanges in
the middle area of the deciduous first molars.
 PALATAL BAR

• The palatal bar lies approximately 1mm away from the

palatal mucosa and runs distally as far as a transpalatal

line between the distal portions of the maxillary

permanent first molars to form an oval, posteriorly

directed loop that reinserts on the opposite side.

 PALATAL BAR
• The cross palatal bar stabilizes the appliance and
simultaneously orients the tongue and mandible
anteriorly to achieve a Class I relationship. The
forward orientation of the tongue, according to
Balters, is accomplished by stimulating its dorsal
surface with the palatal bar. This is the reason
for the posterior curve of the palatal bar.
 LABIAL BOW
• It is the most passive and truly functional unit
• The labial bow, made of 0.9mm hard stainless steel
wire, begins above the contact point between the
canine and deciduous upper first molar (or premolar).
It then runs vertically making a rounded 90 bend to
the distal along the middle of the crowns of the
posterior teeth and extends mesial to the first molar.
• Making a gentle curve it runs anteriorly to about the
same distance. From there at a sharp angle it extends
obliquely upwards to the upper canine and bends at
about the incisal third and extends to the canine on
the opposite side. It ends in a mirror image form on
the opposite side and gets inserted into the acrylic. It
should be about 1 mm away from the incisors.
• This position of the wire produces a negative pressure

with the wire supporting lip closure. In the course of

treatment, however, the wire should move the

incisors upright and provide extra space when the

dental arch is widened. The posterior portions of the

labial bow are designed as buccinator loops,

screening muscle forces in the vestibule.

• The loops are sufficient far from the teeth to allow for

expansion but not far enough to cause discomfort to

the cheeks. The buccinator loops screen the

buccinator muscles, and the lingual acrylic parts

prevent both the cheeks and tongue from interposing

in the interocclusal space. Thus stimulating selective

eruption is possible with proper trimming.

 FUNCTIONS
• Forward positioning of the mandible
• Produces a distal drive
• Pulls the premaxilla down
 Open – Bite Appliance

• The open –bite appliance is used to inhibit abnormal

posture and function of the tongue. The construction
bite is as low as possible, but a slight opening allows
the interposition of posterior acrylic bite blocks for
the posterior teeth, to prevent their extrusion.
• To inhibit tongue movement, the acrylic
portion of the lower lingual part extends into
the upper incisor region as a lingual sheild
closing the anterior space without touching the
upper teeth. The palatal bar has the same
configuration as the standard bionator .
 LABIAL BOW
• The labial bow is similar in form to that of the
standard appliance, differing only in that the wire
runs approximately between the incisal edges of the
upper and lower incisors. The labial part of the bow
is placed at the height of correct lip closure, thus
stimulating the lips to achieve a competent seal and
relationship. The vertical strain on the lips tends to
encourage the extrusive movement of the incisors,
after eliminating the adverse tongue pressure.
 REVERSED BIONATOR
• The Class III or reversed bionator – type appliance is
used to encourage the development the maxilla. The
construction bite is taken in the most retruded
position possible. To allow labial movement of the
maxillary incisors and simultaneously exert a slight
restrictive effect on the lower arch.
• The bite is slightly opened, creating about 2mm of
interincisal space for this purpose. The lower acrylic
portion is extended incisally from canine to canine.
This extension is positioned behind the upper
incisors, which are stimulated to glide anteriorly
along the resultant inclined plane. The acrylic is
trimmed away behind the lower incisors about 1mm
to prevent tipping the lower incisors labially.
 LABIAL BOW
• The labial bow runs in front of the lower
incisors rather than in front of the upper
incisors, as occurs in the standard appliance.
It emerges from the acrylic in the same manner
as in the standard appliances, but the labial
part runs along the lower incisors without a
bend in the canine region. The wire touches
the labial surfaces lightly or stands away at a
distance of the thickness of a sheet of paper.
 PALATAL BAR
• The palatal bar configuration runs forward instead of
posteriorly, with the loop extending as far as the
deciduous first molars or premolars. From this point
the wire extends back to the upper margin of the
acrylic posterior to the distal surface of the permanent
first molar, where it enters the acrylic with a right –
angle bend. The tongue is supposedly stimulated to
remain in a retracted position in its proper functional
space. It should contact the anterior portion of the
palate, encouraging the forward growth of this area.
 ANCHORAGE OF THE
APPLIANCE

• Because the bulk, volume, and extension of

the appliance are reduced, special
requirements exist for anchorage.
• In the incisal margins of the lower incisors, by
extending the acrylic over the incisal margin
as a cap.
• Loading areas, because the cusps of the teeth fit
into the respective grooves in acrylic
• Deciduous molars, which can always be used
as anchor teeth
• Edentulous areas, after premature loss of the
deciduous molar.
• Noses in the upper and lower interdental spaces
• Labial bow, which if correctly placed, prevents
posterior displacement of the appliance
 Trimming the Bionator

• Balters’ terminology refers to simulation of

eruption as unloading or promotion of growth
and prevention of eruption as loading or
inhibition of growth. Trimming of the acrylic
tooth beds and elimination of the influence of
tongue and cheeks allow the teeth to erupt until
they reach the articular plane. Once there, they
should be prevented from erupting further so
that the loading can be accomplished by the
addition of self –curing acrylic as needed.
• The appliance can be trimmed or ground
periodically until the teeth reach the desired
relationship with the articular plane. Because
of the need to anchor the appliance, this
procedure cannot be performed in all areas at
the same time. Thus periodic loading and
unloading of the same areas are necessary.
This means that the same tooth can function as
an anchor and later be allowed to erupt.
 Types of anchorage-Ascher 1968
Dentition Anchorage

1,2,III-V,6 IV,V Upper and Lower V and space

after IV

1,2,III-V,6 IV,V Upper and Lower V and space

after IV

1,2,II-6 Alveolar process-IV,V

1,2,III,4-6 6 and alveolar process

 CLINICAL MANAGEMENT OF
BIONATOR TREATMENT

• Indications for bionator therapy

• Standard bionator is indicated under the following
conditions:
• The dental arches are well aligned originally.
• The mandible is in a posterior position (i.e.,
functional retrusion).
• The skeletal discrepancy is not too severe
• A Labial tipping of the upper incisors
• Cases of deep overbite also can be
successfully managed with the standard
bionator.
• Malocclusions with crowding should not be
treated with the bionator. Open bite cases can
be handled with the open – bite bionator
• The bionator is not indicated if the following
• The Class II relationship is caused by
maxillary prognathism.
• A vertical growth pattern is present.
• Labial tipping of the lower incisors is evident.
Anterior posturing of the mandible with
simultaneous uprighting of the lower incisors
cannot be performed with the bionator.
 BIONATOR AND
TEMPOROMANDIBULAR JOINT
CASES

A special use for the bionator, which has been

quite successful, is in temporomandibular joint
(TMJ) problems. Wearing a bionator at night
tends to relax the muscle spasms that occur,
particularly in the the lateral pterygoid muscle
(LPM).
• The main purpose is to prevent the riding of
the condyle over the posterior edge of the disk,
which causes the clicking. The clicking
usually disappears in these cases when the
mandible is opened in the forward posture.
This means that the condyle no longer rides
over the posterior disk margin, onto the
retrodiscal pad. The patient must were the
appliances indefinitely as a splint at night for
this to happen.
 Advantages
• The main advantage of the bionator lies in its
reduced size, which allows it to be worn day
and night. The appliance exerts a constant
influence on the tongue and perioral muscles
because of the screening effect on the labial
bow and its lateral extensions.
• Because unfavorable external and internal
muscle forces are prevented from exerting
undesirable and restrictive effects on the
dentition and supporting structures for a longer
time, the bionator’s action is faster than that of
the classic activator
• Constant wear results in more rapid sagittal
adjustment of the musculature the forward
mandibular posture because the mandible
retracts only during eating.
 DISADVANTAGES
• The main disadvantage of the bionator lies in
the difficulty of correctly managing it. This
difficulty stems from the simultaneous
requirements of stabilization of the appliance
plus selective grinding for eruption guidance.
In the case of skeletal disturbances, however,
the effectiveness of the Balters bionator is very
limited, as it is for any functional appliance.
• A correct differential diagnosis is essential for
successful bionator treatment, and treater cases
must be functional –type retrusions with
relatively normal skeletal potential and
sufficient growth increments to permit a
favorable change. A further potential
disadvantage, shared with other skeletonized
activators (the Bimler appliance particularly),
is the vulnerability to distoration, which occurs
because far less acrylic support exists in the
alveolar and incisal region.
 Rutter and Witt-AJO1990

• The correction of two Class II, Division 2

malocclusions during the mixed dentition
phase with the use of a Bionator appliance is
presented. The suggestion that correction of
Class II, Division 2 malocclusions may be
achieved in the absence of fixed appliances is
supported in these case reports.
• An 8-year, old male patient, was accepted for
treatment for correction of a Class II, Division 2
malocclusion
• Posttreatment records showed dentition after
treatment was near ideal. Temporomandibular joint
function was without complication. Cephalometric
records revealed an excellent skeletal pattern and a
marked improvement in facial profile. Third molar
teeth have subsequently been removed.
Mandibular response to orthodontic treatment with the Bionator
appliance Mamandras and Allen 1990AJO

A group of 20 subjects who underwent successful Bionator treatment.

Success was judged not on the final occlusion but on the posttreatment
position of skeletal pogonion. The successful group experienced 3.5 mm
advancement , whereas the less successful group had less than 3 mm of
advancement of this point.The results of this study suggest that persons
who have small mandible may benefit more from functional appliance
therapy than patients with normal-sized mandibles. The subjects with
delayed growth may experience more mandibular development .
• Anteroposterior skeletal and dental changes after early classII
treatment with bionator and head gear-Keeling and wheeler
AJO 1998.

• Children aged 9.6 were studied with early treatment of classII

malocclusion.It revealed that both bionator and headgear
reduced overjet and apical base discrepancy and caused
posterior maxillary tooth movement.There was enhanced
mandibular growth that was stable even 1 year after the

treatment but the dental movements relapsed.

• A prospective evaluation of
BASS,BIONATOR and TWIN BLOCK-
Morris and Robert T Lee EJO 1998
• A prospective study of 47 patients of 3
different functional appliance groups were
established and compared.
• Both bionator and twin block demonstrated
increase in mandibular length with anterior
movement of pogonion and point B. The twin
block group showed the least forward
movement of point A.
• Significant changes occurred in the soft tissues
namely the lower and total facial height were
increased. It was more in the twin block group
when compared with the bionator
• Skeletal and dental modifications produced by
Bionator III-Garattini and Levrini AJO 1998
• The sample group included 39 growing patients with
a dentoskeletal class III malocclusion.The 2 year
study showed that the bionator III is effective
especially when the malocclusion is the result of a
mid face deficiency and when there is a
hypodivergent growth pattern.
• Efficacy trials of Bionator classII treatment-
Thomas Jacobs- AO2002
• Reviewing publications of efficacy trials on
classII malocclusion shows molar correction
in13% untreated cases and 38% in bionator
treated cases and 50% in combination head
gear bite plane treated cases.Only 5% of half
cusp cases were found to resolve by
themselves whereas it was 30% in bionator
and 40% in headgear treated cases.
• Nocturnal suprahyoid and masseter muscle
activity induced by bionator Hiyama and
Takashi-AO2002
• Electromyographic activities of 10 healthy
Japanese men were studied. The results
concluded that there was a decrease in the
activity of the muscles when the bionator was
worn in the night.
• An evaluation of combination second molar
extraction and functional appliance therapy
Whitney and Sinclair- AJO 1987.
• The pre treatment and post treatment
cephalometric and cast records of 30
consecutively treated classII div1 cases were
evaluated.Results showed that there was
normal forward mandibular growth and
inhibiting force on the maxilla.There was no
tipping of maxillary and mandibular molars but
there was increase in the inter molar width.The
third molar position tended to improve.
• Combination of Bionator and High pull head
gear in a skeletal open bite case Luciane closs
AJO 1996
• A 10 year old female patient was treated with
the combination. The final evaluation showed
that the ANB had reduced from 6 to 3.There
was increase in the mandibular length. The
maxillary incisors were slightly uprighted and
lower incisors were proclined for dental
compensation for overjet. An Angle class I
with acceptable overjet and overbite was
achieved without surgery.
• A new type of elastic functional appliance
Aurelio Levrini JCO1996
• Since the efficacy of functional appliance is
based on the modification of neuromuscular
behavior any system that increases the muscle
activity should be more effective.In a study of
hard and soft splints Okeson demonstrated that
soft splints increased the activity of the
muscle.Hence elastic functional appliance are
more effective.
• Thermoplastic elastomeric resin is a co polymer of
ethylene and vinyl acetate.The elastomers are
macromolecular structures that are easily stretched
with light forces to double their length without
breakage and return back to their original state.
• Thermoplastic pads can be added to bionators. Minor
dental movements can also be done.It can also be
trimmed like an acrylic.The resin can be
mechanically or chemically attached to the
appliance.The occlusal pads stimulate the patients to
clench frequently and forcefully thereby improving
the treatment.