LOGO

“ Add your company slogan ”

BIONATOR

AJITHESH KV

Contents

Introduction1

History2

Treatment objectives3

Types of bionator4

Trimming of bionator5

6 Clinical management

References

7 Modifications of Bionator

82

INTRODUCTION

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

CLASSIFICATION

FUNCTIONAL

APPLIANCE

FixedRemovableActivator Bionator

Tooth borne passive appliance (activator, bionator)Tooth borne active appliance Tissue borne passive appliance - FR

4

HISTORY

Norman Kingsley 1879 Vulcanite palatal platePierre Robin 1902 MonoblocViggo Andresen 1908 ActivatorWilhelm Balter 1960 BionatorRolf Frankel 1967 FRWilliam Clark 1977 Twin block

5

PRINCIPLE OF BIONATOR

Less bulky than activator 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)

6

Balter Quotes

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.

7

It works by modulating muscle activity 8

Treatment objectives

Accomplish lip seal & bring dorsum of tongue into

contact with soft palate

Enlarge oral space & train tongue functions

Bring incisors into edge to edge relationship

To achieve elongation of

mandibleImprove relationships

of jaws, tongue & teeth

Advantages

Reduced size It can be worn both day and nightAction faster than activator –unfavorable forces

are avoided acting on dentition for longer timeConstant wear so more rapid adjustment of

musculature

9

Disadvantage

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

10

INDICATIONS

Dental arches well alignedMandible in posterior positionSkeletal discrepancy not severeLabial tipping of upper incisors evidentDeep bite with accentuated c.o.s

Class III where reverse bionator can be usedOpen bite

11

CONTRAINDICATIONS

Class II – if caused by max prognathismVertical growth patternLabial tipping of mandibular incisors

12

TYPES OF BIONATOR

1. THE STANDARD BIONATOR

2. THE OPEN BITE BIONATOR

3. CI III OR REVERSED BIONATOR

14

THE STANDARD APPLIANCE

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

15

WIRE COMPONENTS

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

16

WIRE COMPONENTS

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

17

WIRE COMPONENTS

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

18

OPEN – BITE APPLIANCE

Purpose of this appliance is to

close the anterior space

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

19

Wire elements

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

20

REVERSED BIONATOR

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

21

Palatal bar

Runs forward with loop extending as far as dec 1st m or pmFunction – tongue to contact anterior portion of palate , encouraging forward growth of this area.

22

Labial bow

In front of lower incisors Wire slightly touches the labial surface

lightly / it is at a paper thickness away

23

CONSTRUCTION BITE

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

24

Construction bite

In Open Bite Bionator Construction bite-is as low as possible with a

slight opening for interposition of posterior bite blocks to prevent their eruption.

In Reverse Bionator Construction bite- taken in more retruded

position so as to allow labial movement of maxillary incisors &also to exert restrictive force on lower arch

25

Following points to be considered(JCO 1985, Altuna& Niegel)

Horizontal plane Advancing about one premolar width is tolerable Profile should be esthetically pleasing

lateral plane Condyles on both sides move symmetrically. Midlines used as reference lines

Vertical plane 2-3 mm opening between C.I

26

TRIMMING OF BIONATOR

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

27

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

28

LOADING AREA:

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.

29

TOOTH BED

Some parts of the loading areas are trimmed away to the articular plane

30

NOSE:

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

31

LEDGE :

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

32

BALTERS REFERS

prevention of eruption as loading or inhibition of growth

stimulation of eruption as unloading or promotion of growth

33

Appliance can be trimmed until teeth reaches desired relationship with the articular plane

Due to consideration for anchorage, appliance cannot be trimmed in all areas at same time

Periodic loading and unloading of same area done

34

Ascher (1968)proposal

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

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

35

ANCHORAGE OF APPLIANCE

1. Acrylic cap over incisal margins of lower incisors2. Loading areas as cusps of teeth fit into respective

grooves in acrylic3. Deciduous molars are used as anchor teeth4. Edentulous areas after early loss of primary

molars5. Noses in the upper & lower interdental spaces6. Labial bow prevents posterior displacement

36

SELECTIVE TRIMMING

For extrusion of posterior teeth

Acrylic left between level of Articular plane –Tooth bed Upper &lower molars trimmed first Then lower premolar’s trimmed while molars loaded Then upper premolar’s unloaded while lower premolar’s

&molars loaded

Occlusal surfaces of bionator trimmed for transverse movt For intrusion in case of open bite –posterior teeth

are fully loaded

37

CLINICAL MANAGEMENT

Appliance must be worn day and night except while eating.

Pt recalled after 1 wk to check sore points Interval b/w visits 3-5 weeks based on the eruption of

the teeth. It takes 1- 11/2 yrs to achieve correction Labial bow away from the incisors.

Buccinator loops away from 1st & 2nd molars, should

not irritate mucosa.

38

Bionator and TMJ

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

39

Bionator in Adult Patients

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

40

Modifications of Bionator

41

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

42

Modification by Schmuth

Cybernator Normal labial bow in the max arch – from

canine to canine Mand incisors covered with thin 2mm acrylic

43

BIO- M-S

BY ERICH & ANNETTE FLEISHER MODIFICATIONS ARE- Acrylic body reduced in size Instead of long labial bow –

Maxillary buccolabial arch wire and

mand labial arch wire Transpalatal bar opens in distal direction as in CI III

bionator Wire spurs used to reinforce anchorage

44

BIO- M-S

45

BIO- M-S

46

Orthopedic corrector I

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

47

WITZIG incorporated 2dimentional screws bilaterally to Schmuth’s bionator.

Orthopedic corrector II

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

48

California bionator

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

49

Teusher’s modification

50

51

COMBINATION OF BIONATOR AND HIGH PULL HEAD GEAR

THEY ARE USED IN CLASS II SKELETAL MALOCCLUSIONS CHARACTERISED BY SLIGHT MANDIBULAR DEFICIENCY, TIPPED UP PALATAL PLANE , ANTERIOR OPEN BITE AND A VERTICAL GROWTH PATTERN.

Luciane closs, & Valmy Pangrazio ( A J O – 1996 )

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

52

Treatment effects by bionator appliance – comparison with an untreated cl II sample

Almeida et al EJO- 2004

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

53

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

54

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.

55

REFERENCES

Dentofacial orthopedics with functional appliances –GRP

Removable orthodontic appliances –Graber & Neumann

orthodontics and dentofacial orthopedics – James A Mc Namara

Contemporary orthodontics – William R Proffit

56

LOGO

“ Add your company slogan ”

Bionator is