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Published by: aru_dz524 on Sep 26, 2008
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Index words:
Anteriorcrossbite, Bionator III,pseudo-Class III
Pseudo-Class III malocclusiontreatment with Balters’ Bionator
A. Giancotti, A. Maselli, G. Mampieri and E. Spanò
University of Rome ‘Tor Vergata’, Rome, Italy
The aim of this article is to show the use of the Balters’ Bionator in pseudo-Class III treatment.The importance of differentiating between true Class III and pseudo-Class III is emphasized. Thetherapeutic results of a Balters’ Bionator appliance are presented in three case reports of subjectsin the mixed dentition. In this stage of development it is possible to correct an isolated problem.The use of the Bionator III in this kind of malocclusion enabled the correction of a dentalmalocclusion in a few months and therapeutic stability of a mesially-positioned mandibleencouraging favourable skeletal growth.
Received 10 January 2002; accepted 6th December 2002
Skeletal, aesthetic, and occlusal characteristics of pseudo-Class III have been highlighted in different articles, andhave been compared with normal occlusion, Class Imalocclusion, or skeletal Class III malocclusion.
The incidence of Class III malocclusion is variable anddepends upon the different methods of classificationused. Class III malocclusion in white subjects occurs infewer than 1 per cent of the population, while frequencyin the Japanese population is approximately 10 per cent.
However, the incidence of pseudo-Class III malocclu-sion in a sample of 7096 Chinese children was estimatedto be 2–3 per cent.Nakasima
has reported that the incidence of anteriorcrossbites has a strong ethnic distribution, particularlyhigh in Japanese subjects and Ferguson
has reportedthat an anterior crossbite could be observed in 3 per centof patients in the United States.
Dental features, diagnosis, andaetiology
Mesio-occlusion is an anteroposterior dentoalveolarrelationship characterized by a more anterior position of the mandibular dentition compared to the maxillarydentition.
Clinically, there are two types of mesio-occlusion. The first type is considered to be a positionalform, as a result of a mesial displacement of the mandibleinto an anterior position and has been named in adifferent ways (pseudo, functional or apparent…). Theother form of mesio-occlusion is a true skeletal Class III.The characteristics of this malocclusion result from acombination of skeletal and dentoalveolar features.Careful clinical evaluation of Class III malocclusionalways requires checking anterior and posterior dentalrelationships with the mandible in centric relation.Moyers proposed the pseudo-Class III relationship as apositional malocclusion with an acquired neuromuscularreflex, and considered the hypothesis that the positionalrelationship in ‘apparent Class III’ may occur with anearly interference with the muscular reflex of mandibularclosure.
Subjects with pseudo-Class III malocclusionsmainly present with Class I or mild Class III skeletalrelationships, while the mandible appears morphologic-ally normal. However, anterior crossbite and negativeoverjet are constantly present due to the anterior man-dibular displacement. Usually, the soft tissues tend tocamouflage the skeletal discrepancy and the patient’sprofile appears normal or slightly concave in centricocclusion. Different aetiological factors have been sug-gested in pseudo-Class III malocclusion.
Dental factors
Ectopic eruption of maxillary central incisorsPremature loss of deciduous molars
Journal of Orthodontics, Vol. 30, 2003, 203–215
Address for correspondence: Dr Aldo Giancotti, Via Barnaba Tortolini 5, 00197 Rome – Italy. E-mail: giancott@uniroma2.it
204A. Giancotti
et al.Clinical SectionJO September 2003
Functional factors
Anomalies in tongue positionNeuromuscular featuresNaso-respiratory or airway problems
Skeletal factors
Minor transverse maxillary discrepancyIt has also been suggested that these sequelae occurmore frequently in subjects with a prognathic mandible(primary cause) and the mandibular shift can be con-sidered a functional (environmental) factor, therefore thepostnatal causative factors may not be the primarycause.
Management of pseudo-Class IIImalocclusion
The pseudo-Class III malocclusion involves both per-manent teeth and the deciduous dentition.Because a malocclusion may be regarded as an aestheticproblem, parents often inquire whether or not therapymight be required. Several clinicians believe in theadvantages of early intervention and have suggested anumber of reasons for early correction of anterior cross-bite even in the deciduous dentition. The optimum periodfor the treatment suggested to be between the ages 6–9years.
Many practitioners however still avoid early correctionof pseudo-Class III in the deciduous dentition becauseof poor stability of correction and unfavourable experi-ences with the behaviour of young patients. Patients maydevelop a crossbite once again during the transitionaldentition, thus requiring further treatment and this mayrepresent a possible disadvantage of treatment at earlystage.Some practitioners prefer to wait for the permanentmaxillary incisors to erupt before initiating therapy dueto the natural tendency of teeth to erupt in a lingualposition during dental arch development. Sometimes,functional deciduous anterior crossbites occasionallycorrect themselves spontaneously.White has suggested intervention in cases of pseudo-Class III malocclusion in the mixed dentition when themaxillary and mandibular incisors have erupted.
Thisallows the permanent teeth to erupt into a better positionand improves the dental aesthetics.The benefits attributed to the treatment of pseudo-Class III malocclusion in the mixed dentition are:preventing unfavourable growth of skeletal compon-ents (in fact, early treatment of anterior crossbite canhelp to minimize adaptations that are often seen insevere late adolescent malocclusion);
preventing functional posterior crossbite and habits,such as bruxism that can develop from anterior orposterior interferences;
gaining space for eruption of canines (lack of spacecould be caused by retro-inclination of upper incisorsfrequently found in pseudo or Class III malocclusion);
avoiding the risk of periodontal problems to man-dibular incisors caused by the traumatic occlusion dueto the crossbite.
Use of Bionator in Pseudo-Class IIImalocclusion in mixed dentition
Several studies have suggested that almost 20 per cent of patients presenting with a Class III malocclusion can betreated during the mixed dentition. At this stage of development it is possible to correct an isolated problemor provide preliminary treatment.
Anterior crossbite inthe mixed dentition should be corrected to allow normaldental development and subsequent favourable skeletalgrowth.Studies have confirmed the efficiency of the Bionator inthe treatment of Class III malocclusions. Clinical experi-ence has shown the importance of differential diagnosisand suggested that individualization of the applianceis important for good results.
Functional orthopaedicappliance therapy is one approach to the treatment of pseudo-Class III malocclusion. The Bionator, developedby Balters is a derivative of the Activator.His design has a palatal wire and also a wire with‘buccinator wings’ to reduce cheek pressure, while theamount of acrylic is reduced. The Bionator can be wornboth day and night.
The reverse Bionator or Bionator III is a modifiedversion of the traditional bionator and can be used inthe treatment of Class III malocclusion. The modifiedBionator differs in various characteristics from the ori-ginal appliance. The lingual wire is in a different positionto control the position of the tongue up to the upper firstmolar. The labial arch is placed in the middle of the lowerteeth (Figure 1). The acrylic should be made as small aspossible in order to occupy minimal space and shouldhave a concave form to accommodate the tongue. Theocclusal acrylic should be thick enough to obstructtongue movement between the posterior segments.The vertical occlusal height should be enough to correct
JO September 2003Clinical Section
Malocclusion treatment with Balter’s Bionator205
the anterior crossbite, but should not exceed 3–4 mm. Theconstruction bite is taken by positioning the mandibleposteriorly into centric relation.Finally the acrylic vestibular lateral shields should bepositioned to allow lateral alveolar growth in order topermit expansion of the maxillary arch.
Case reports
Case report 1
A female patient, age 8 years 10 months, presented withan anterior crossbite from the upper right deciduouscanine to the upper left deciduous canine and a 1-mmdeviation of the mandibular midline to the right (Figure.2). The patient had a good profile with a slight mid-faceconvexity and the lower lip appeared protruded (Figures2 and 4). She was in the mixed dentition and the initialpanoramic radiographs revealed that all permanent teethwere present. The upper anterior teeth were retroclinedand the upper right lateral incisor was missing, while thelower anterior teeth were protrusive. The molars were in aClass I relationship. The lower arch was in the late mixeddentition and ‘E’ space was present; right and left man-dibular second primary molars had exfoliated (Figure 2).Pre-treatment cephalometric analysis showed an in-creased mandibular plane angle (40 degrees), with anormal ANB, but a high Wits measurement (
6 mm)and the lower incisor inclination was 29 degrees to NB.Angular and linear measurements of mandibular skeletalgrowth were normal. Clinical evaluation of the occlusalrelationship in centric relation showed an early inter-ference of the upper left central and lower left centralincisors (Figure 3).
Treatment progress
. An early treatment goal was toeliminate the mandibular displacement and treatmentwas initiated with a Balters’ Bionator III. In order toconstruct the Bionator a wax bite was taken by distallyrepositioning the mandible in centric relation. This useof the Bionator III thus enabled the tongue to move freelyin the anterior part of the palate, pushing it against theupper front teeth. The vertical thickness of the bite was3–4 mm with sliding guides in the posterior zone.The patient had to wear this Bionator for 16 hours a day(Figure 4).
. The incisors were beyond edge-to-edge after 9weeks, but use of the Class III Bionator was continued.Eleven months after the beginning of treatment thepatient had a normal occlusion with 2-mm overjet anda Class I molar relationship. Final records showedexcellent occlusal and aesthetic results, and the profilewas relatively normal with a good lower lip position(Figure 5). Cephalometric tracing demonstrated a reduc-tion of 3 mm in the Wits measurement and a retro-inclination of the lower incisors with a reduction of theangular and linear measurements (22 degrees, 3 mm toNB; Table 1).
Case report 2
The second case report was a 9-year-old girl presenting aconvex profile, protruding lower lip and anterior cross-bite. She had a Class III malocclusion in the mixeddentition (Figure 6).An anterior interference was evident when evaluatingthe occlusal relationship in centric occlusion (Figure 7).Cephalometric analysis revealed a Class I skeletalrelationship with ANB
2 degrees. Angular measure-ments of the maxilla could be considered normal, butlinear measurements suggested mandibular protrusion
Fig. 1
Balters’ Bionator described in this article.
Table 1
Case 1 cephalometric summaryMeasurementNormalInitialFinalSNGOGN32
AoBo0.3 mm
6 mm
3 mm1/NA4 mm3 mm4 mm1/NA22
1/NB4 mm5 mm3 mm1/NB25

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