Bionator and its modification /certified fixed orthodontic courses by Indian dental academy

THE BIONATOR
&
ITS MODIFICATIONS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

“A functional appliance harnesses natural forces
which it transmits to the teeth and alveolar bone in a
pre determined direction”.
(White, Gardiner, Leighton)
“Functional appliances are passive (loose fitting)
appliances by themselves, which make use of the
naturally occurring forces generated by the orofacial
& masticatory muscles and the forces of occlusion to
bring about changes in dento alveolar & craniofacial
structures”.
These appliances Guide, Eliminate, or Transmit
these naturally occurring forces to bring about
correction.

Functional appliances

Fixed
Ex : jasper jumper

Removable

Active
Ex : inclined plane


Passive
Ex: activator

The bionator is a functional
appliance developed by Balters in
1956.
The bionator is a generic term that
refers to a family of appliances used
to treat malocclusions characterized
in part by mandibular deficiency.

Activator----------------Bionator


Principles

The theoretical principles of Balters
are based on the works of Robin,
Anderson and Haupl but it differs
from that of the activator.
The essential part of Robin’s concept
is function and Balters is the role of
the tongue.

“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.The tongue is
the essential factor for the
development of the dentition and
it is the centre of reflex activity in
the oral cavity”

-the

functional space for the tongue
is essential for normal development
of the orofacial system.
-the equilibrium b/w the tongue and
circumoral muscles is responsible
for the shape of the dental arches
and intercuspation.

-a discoordination of its function could
lead to abnormal growth & actual
deformities


Winders (1958)-the tongue exerts
3-4 times more force on the
dentition than the buccal and
labial musculature and these
findings support Balters thesis,
provided resting forces and other
factors are not considered.

Lip seal importance

Balters technique requires lip
closure for treatment of all kinds of
malocclusion.
It’s a precondition for the free
development of growth potential
that’s been impeded by abnormal
function..

Tongue and malocclusions

classI-weak tongue compared with the
strength of the buccinator mechanism.
classII-backward position of the tongue
classIII-low anterior displacement
Open bite-hyperactivity of forward
posturing of the tongue

Objectives for treatment of various
malocclusions are,
classI-muscular training to make the tongue
stronger.
classII/I-bring the tongue forward/achieved
by stimulating the distal part of the dorsum
of the tongue.
classIII-get the tongue to into a more
backward and higher position.

Balters constructed his appliance to achieve
the following,
-accomplish lip seal & bring dorsum of tongue
into contact with softpalate
-bring incisors into edge to edge relationship
- enlarge oral space & train tongue functions
-improve relationships of jaws,tongue&teeth
-designed to help patients learn normal
functional patterns

The principle of the bionator is not to
activate the muscles but to
• modulate muscle activity,
• enhance normal development of
the inherent growth pattern and
• eliminate abnormal and deforming
environmental factors.

Construction bite registration
Horizontal considerations:
1-incisors in edge to edge relationship/

molars in classI
2-excessive overjet-step wise posturing
of the mandible
3-edge to edge with lateral incisors
when centrals are mal positioned.

Vertical considerations:
1-bite is not opened/incisors in
edge to edge
2-high construction bite
impairs tongue function and or
acquire tongue thrust habit.

Lateral considerations:
1-condyles on both sides should move
symmetrically in the glenoid fossa
/reference lines-upper and lower
midlines & frena.
2-midline deviations due to functional /
dental / skeletal problems have to be
analyzed and diagnosed first.

Types of appliances:
1-The Standard Bionator
2-Class-III / Reverse
Bionator
3-The Open Biteappliance

The standard appliance:
1-Acrylic part
-Horse shoe shaped lower lingual plate
-upper arch –lingual extensions to cover
the molars & premolars / anterior part free
2-wire elements
-palatal bar
-labial bow with buccal extensions

Wire elements:
Palatal bar1.2 mm s.steel wire
Extends from middle of 1st premolar to a line
joining distal of 1st perm-molars
Egg shaped and the curve is directed
distally
To stimulate the distal part of the tongue
and effect forward orientation of the tongue
and mandible.

The vestibular wire:
0.9mm s.steel wire.
Anterior part-labial wire
Lateral part-buccinator bends
-keep the cheeks away thus leveling the bite
and allows eruption to proceed in this
region.
-favors expansion / transverse development
of maxillary dentition.

Skeletal, Dentoalveolar and Soft tissues
changes with the standard bionator.(Varun
Kalra AJO-95)
Skeletal changesMandible-pt.B is moved forward
-length of mandible (Ar-Go) is
increased
DentitionOverjet and overbite is decreased
Soft tissuesFacial convexity is decreased
Uncurling of the lower lip.

Indications for standard bionator:

Actively growing children with the following
malocclusions
classII / I in mixed dentition
classI malocclusion with classII/I symptoms
with lip trap
In classII/I -dental arches - well aligned
-the mandible in posterior
position
-the skeletal discrepancy not very
severe

Indicated in deep bite cases due to infra
occlusion of molars and premolars
because of lateral tongue posture.
Not indicated if
Class II due to prognathic maxilla
Labially tipped lower incisors
Vertical growth pattern
Not used in deep bite cases with strong
horizontal growth pattern

Class III / Reverse Bionator
Is used to encourage development of the
maxilla.
Construction bite-taken in the most retruded
position possible to allow labial movement of
the maxillary incisors and simultaneously
exert a slight restrictive influence on
mandible.
Bite opened slightly –2mm between incisal
edges.

Acrylic partlower acrylic part extended incisally from canine
to canine behind the upper incissors
.acrylic is trimmed away by 1mm behind the lower
incissors


Rakosi et al (1997)-palatal bar only
flattens the dorsum of the tongue but does
not move it forward.
Reverse appliance only tips the maxillary
incisors labially and does not stimulate
basal bone forward.
Its indicated in pseudo-class III problems
with the upper incisors tipped lingually
causing anterior mandiblular displacement
on closure from postural rest to habitual
occlusion.

The Open Bite Appliance
Construction bite-is as low as possible with a slight
opening for interposition of posterior bite blocks to
prevent their eruption.
Acrylic partThe lower lingual part extends into the upper incisor
region as a lingual shield , closing the anterior space
without touching the upper teeth
Wire elementsLabial bow runs between the upper and lower incisors at
the height of correct lip closure.
.


Trimming of the bionator

The basic purpose of the appliance is to
correct function,proper trimming of the
acrylic can affect tooth eruption and
position.
Since the volume of the appliance is
reduced its anchorage is a major concern
and trimming must be selective because
of simultaneous anchorage requirements.

Balters introduced the
following terms:
1-ARTICULAR PLANE
2-LOADING AREA
3-TOOTH BED
4-NOSE
5-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.

Anchorage of the 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

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

Anchorage

1,2,III-V,6
1,2,III-V,6

IV & V both U / L
V & space after IV

1,2,II-6

alveolar processIV,V

1,2,III,4-6

6 & alveolar process

Trimming of the occlusal surfaces is
essential to allow certain teeth to erupt
further, while fully erupted teeth are
prevented from eruption through
contact with acrylic.
Balters refers to stimulation of
eruption as unloading or promotion of
growth & prevention of eruption as
loading or inhibition of growth.

The types of teeth eruptions possible
by planned trimming of the bionator
are,
Vertical eruption
Buccal eruption
Mesial or distal eruption of the
buccal segments
Mesial migration of anterior teeth.

Vertical eruption of the buccal segments.
Some acrylic is left at the level of the
occlusal plane (tooth bed) interdentally
Upper and lower molars are unloaded 1st
Lower premolars are unloaded while U / L
molars are loaded
Upper premolars are unloaded while U /L
molar and L-premolar regions are loaded.

Acrylic projections b/w the teeth are
left untouched or are replaced with
selfcure acrylic becos they serve as
stabilizing spurs.
The noses in the lower molar region
must be well defined to prevent the
mandible from dropping back

DISTAL ERUPTION .

For distal eruption of the buccal segments
the eruptive path is inclined distally.
Acrylic should touch the mesial aspect of
the teeth and the distal part is free.

Mesial eruption.
The eruptive path is mesially inclined and
acrylic should touch the distal part of the
teeth.

EXPANSION OF THE BUCCAL
SEGMENTS:
The eruptive path of maxillary &
mandibular molars is trimmed with a
buccal slope.
When trimmed for transverse movement
cusp tips should be in contact with tooth
bed on closure.
In open bite cases posterior teeth are fully
loaded for intrusion.

Clinical management:
Appliance must be worn day and night
except while eating.
Interval b/w visits 3-5 weeks based on
the eruption of the teeth.
Labial bow away from the incisors.
Buccinator loops away from buccal
segments.

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.

Bionator modifications
Minor
Major- Bio-M-S Appliance
-Bionator I,II,II
-Orthopedic corrector I,II

Minor modifications :
1-Williamson & Hamilton
3 mm wide cover for max.incisors
2-Teusher (1978)
Face bow tubes
Lower lip pads

Major modifications:
Bio-M-S appliance -Erich & Annette
Fleischer
acrylic body reduced in size
maxillary buccolabial arch wire
mandibular labial arch wire
wire spurs
metal occlusal bite plane.


Construction bite:
improvement in soft tissue profile
tolerable and acceptable to the patient.
If edge to edge bite results in
unfavorable increase in LFH then
mandibular incisors should be in
contact with lingual surfaces of
maxillary incisors.

Modified bionator of Schmuth
(reduced activator of Schmuth)
acrylic part similar to bionator
labial guide bow of the original AndersonHaupl
midline jack screw in the lower lingual
plate
acrylic side plates
anterior cap


CALIFORNIA BIONATOR


Bionator I
acrylic part similar to bionator
labial guide bow of the original
Anderson-Haupl
lingual retention wire
midline jack screw in the lower lingual
plate
acrylic side plates & anterior cap

Orthopedic corrector
-I:
side screws
permits forward
repositioning of the
front half .

Bionator II


Orthopedic corrector II


Bionator II – is used to close open bite
in the anterior region due to
protruding pre maxilla and labially
flared incisors.
Bionator III- is a lower arch advancing
appliance.
Its purpose is to advance the mandible
from class II to class I

The Bionator and TMJ problems
Its been very successful in treating TMJ
problems especially adults.
TMJ problems have coincident bruxism
and clenching during sleep.
The bionator relaxes the muscle spasm.
It prevents riding of the condyle over the
posterior edge of the disk which causes
clicking.

Clinically check habitual occlusion
and then the mandible is
positioned forward to determine
the amount of forward placement
to eliminate clicking on the
opening maneuver.
Bionator therapy with local heat
application and muscle relaxants
can provide immediate relief for
the patients..

Petrovic has shown that
protracted wear in adults can
permanently shorten the LTM
and thus help the patient
maintain a protracted
mandibular posture even during
the day time.
Clicking and other unfavorable
TMJ sequelae disappear

Disadvantages of theBalters Bionator
-indications are reduced because there is no
allowance for vertical component except
allowing posterior teeth to erupt.
-abnormal tongue function can be
secondary ,adaptive or compensatory because
of skeletal mal development.
Difficulty in correctly managing it.
A correct differential diagnosis is essential.
Chances for distortion.

Advantages of Balters Bionator.
It can be worn both day and night.
It has a constant influence on the tongue and
perioral muscles
Action is faster than the activator.
Constant wear results in rapid sagittal
adjustment of the musculature to forward
mandibular position

Conclusion:
• 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.

Thank you
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