ODW-228; No.

of Pages 9

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Original article

Comparative study of the treatment effects of bionator and

bite jumping appliances on Class II malocclusions

Naoko Sakai *, Ken Miyazawa, Takeo Tsutsui, Masako Tabuchi, Momoko Shibata,
Shigemi Goto
Department of Orthodontics, School of Dentistry, Aichi Gakuin University, Nagoya, Japan

article info abstract

Article history: Purpose: The purpose of this investigation was to compare and evaluate the treatment
Received 27 November 2014 effects of two commonly used removable functional appliances.
Received in revised form Materials and methods: The subjects, 12 children, were all diagnosed as having maxillary
17 September 2015 protrusion. They were divided into two treatment groups: the bionator group, comprising 3
Accepted 18 September 2015 boys and 3 girls, mean age 11.3 years at the start of treatment; and the bite jumping
Available online xxx appliance (BJA) group, comprising 5 boys and one girl, mean age 10.9 years at the start of
treatment. Lateral cephalograms in the intercuspal position were taken both at the begin-
Keywords: ning and at the end of use of each appliance.
Bite jumping appliance Results: In comparison of treatment effects between both groups, the BJA group showed
Bionator greater lingual inclination of the maxillary incisors and labial inclination of the mandibular
Functional appliance incisors compared with the bionator group. Also, the BJA group showed a significantly
greater forward and downward change in the inclination of the occlusal plane than did the
bionator group.
Conclusions: In terms of treatment mechanics, the bionator and BJA are quite different.
Therefore, the proper use of each depends on symptoms, sequence of use, and time of
initiation of therapy in order to provide the most effective treatment of Class II malocclu-
sions.
# 2015 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.

intermaxillary relationship, particularly for skeletal maxillary

1. Introduction
Recently, there has been a marked increase in the treatment of
maxillary protrusion among Japanese orthodontists [1–4].
Functional orthodontic appliances have been widely
employed because they are effective in improving the
protrusion during the growing period [5–9].
Various functional appliances have been developed for
clinical use. Typical of the fixed type of orthodontic appliances
is the so-called Herbst appliance [10]. In addition, there are
removable orthodontic appliances, which can be divided into
one- and two-piece types. The former includes the bionator

* Corresponding author at: Department of Orthodontics, School of Dentistry, Aichi Gakuin University, 2-11, Suemori-Dori, Chikusa-Ku,
Nagoya 464-8651, Japan. Tel.: +81 52 751 7181x5378; fax: +81 52 751 8900.
E-mail address: nao705@dpc.aichi-gakuin.ac.jp (N. Sakai).
http://dx.doi.org/10.1016/j.odw.2015.09.001
1344-0241/# 2015 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
2 orthodontic waves xxx (2015) xxx–xxx
[11–13], the activator [14], and the Frankel appliance [15], while
the latter includes twin block [16] and bite-jumping appliances
(BJA) [17–20].
The effects and functional mechanisms of the different
appliances noted above have been compared. For instance,
Illing et al. [21] reported that the twin block appliance exerted an
inhibiting effect on the maxillary growth, while Jena et al. [9] and
Siara-Olds et al. [22] reported that the effect was small.
Regarding the use of the bionator on the anterior mandibular
growth acceleration, Jena et al. [9] and Siara-Olds et al. [22]
reported that there was no significant effect. In contrast,
Almeida-Pedrin et al. [23] and Illing et al. [21] reported a
significant effect on anterior mandibular growth acceleration.
Furthermore, Siara-Olds et al. [22] reported that significant
labial inclination of the mandibular incisors occurred with twin
block appliance use compared with Herbst appliance use, while
Baysal and Uysal [24] reported that for improvement of Class II
Division 1 malocclusions, twin block appliances mainly induced
anterior mandibular growth whereas Herbst appliances often
controlled the movement of maxillary and mandibular incisors.
Despite the comparisons, the functional mechanisms of the
appliances differ, as do the treatment results. Accordingly,
there has been no united opinion [22,25–28]. In addition,
selection criteria for the most efficient functional appliance
have not been established for different types of maxillary
protrusion. Thus, in order to establish selection criteria for use
in the treatment of maxillary protrusion, the present paper
examines the treatment effects between the one-piece bionator
and the two-piece type-BJA, two commonly used removable
functional appliances which are very different in the form.
2. Materials and methods
2.1. Subjects and reference materials
The 12 subjects were patients at the Orthodontic Department,
School of Dentistry, Aichi Gakuin University, diagnosed as
Fig. 1 – The structure of bionator.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
having maxillary protrusion, and using a bionator or BJA. From
the initial 105 patients, we selected 12 patients who met all the
following conditions: having more than it in 5 mm of overjet,
angle Class II malocclusion and being at Hellman’s dental
stage III B or III C. In addition, there was no use or combined
usage of other orthodontic appliances before and during use of
each appliance, and no patients with congenital anomaly or
jaw deformity were included in this study. The patients were
divided into two treatment groups (the bionator (Fig. 1) group,
comprising 3 boys and 3 girls, mean age 11.3 years at the start
of treatment, mean treatment period 18.8 months; and the BJA
(Fig. 2) group, comprising 5 boys and one girl, mean age 10.9
years at the start of treatment, mean treatment period 18.7
months). This clinical study was reviewed and approved by
the Institutional Board of Aichi Gakuin University (approved
number: 53).
Lateral cephalograms in the intercuspal position were
taken at the beginning of use (T0) and end of use (T1) of each
appliance. T1 was defined as at the point in time when overjet
and overbite became <3 mm or the bilateral mandibular
second molars erupted. In addition, there was no use or
combined usage of other orthodontic appliances before and
during use of each appliance, and no patients with congenital
anomaly or jaw deformity were included in this study.
For fabrication of both the bionator and the BJA, the
construction bite taken from the patients was positioned so
the distance between the maxillary and mandibular incisors
(overbite) was in the range of 2–4 mm, the mandible had been
guided anteriorly from 5 to 8 mm, and the midlines of the
maxilla and mandible had been matched, as proposed by
Graber et al. [29]. In construction bite taking, it was decided to
complete position of the mandible based on the recommenda-
tions of DeVincenzo and Winn [30] and Kumar et al. [31].
2.2. Methods of analysis and measurements
We measured the necessary items on the traced lateral
cephalograms taken before (T0) and after (T1) of bionator (B)
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orthodontic waves xxx (2015) xxx–xxx 3

Fig. 2 – The structure of bite jumping appliance.

and BJA (J) treatments for comparison between the pre- 4. U1 to SN angle
treatment bionator (BT0) and BJA (JT0) groups. Next, we 5. L1 to mandibular plane angle
made a comparison between before and after treatment in 6. L1 to SN angle
each group (BT1 vs. BT0, JT1 vs. JT0). In addition, we 7. U1 to SN angle
compared the change in amount between before and after 8. SN-palatal plane angle
treatment in the two groups (comparison of BT1–BT0 with 9. SN-occlusal plane angle
JT1–JT0). The measurements are shown in Table 1 and 10. SN-Y axis angle
Fig. 3. 11. SN-mandibular plane angle
The angles and linear distances measured using lateral
cephalograms are as follows: 2.4. Liner measurements

2.3. Angular measurements 1. Height in the maxillary molars: Mou-Ms

2. Height in the mandibular molars: Mol-Mi
1. SNA angle 3. Height in the maxillary incisors: Is-Is’
2. SNB angle 4. Height in the mandibular incisors: Ii-Ii’
3. ANB angle 5. Mandibular length: Gn-Cd

Fig. 3 – Reference points and lines used.

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
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4 orthodontic waves xxx (2015) xxx–xxx

Table 1 – Landmark and plane definitions. used for evaluating the equivalence of age at the start of
Landmark Definition treatment and treatment duration between the two groups. In
addition, the Wilcoxon signed-rank test was used for
S (sella turcica) The midpoint of the fossa hypophysealis.
evaluating the changes (BT1–BT0 vs. JT1–JT0) before and after
N (nasion) The anterior point at frontonasal suture.
A The deepest anterior point in concavity of the treatment in each group. The treatment changes between the
maxilla. two groups were compared using the Mann–Whitney U test.
B The deepest anterior point in concavity of the
mandible.
ANS (anterior The most anterior point in of the anterior 4. Results
nasal spine) nasal spine.
PNS (posterior The most posterior point in of the hard
nasal spine) palate.
4.1. Demographic information in the bionator and BJA
Me (menton) The most inferior point in of the mandible. groups
Gn (gnathion) A point on the chin determined by bisecting
the angle formed by the facial and Table 2 shows the demographic information of age at the start
mandibular planes. of treatment and treatment duration in the two groups. There
Cd (condylion) The most posterior superior point of the
was no significant difference between the two groups for these
condyle.
two items.
Mou The midpoint between the mesial and distal
crown surface of the upper first molar.
Mol The midpoint between the mesial and distal 4.2. Comparison of pre-treatment skeletal measurements
crown surface of the lower first molar. between the two groups (Table 3)
Ms The middle point of the occlusal surface of
the upper first molar reflected by palatal When comparing the pre-treatment (T0) skeletal measure-
plane.
ments between the two groups, no significant difference was
Mi The middle point of the occlusal surface of
shown in any measurement items.
the lower first molar reflected by mandibular
plane.
Is The tip of the upper incisor. 4.3. Comparison of skeletal measurements between before
Is’ The point of the tip of the upper incisor and after bionator treatment (BT1–BT0) (Table 4)
reflected by palatal plane.
Ii The tip of the lower incisor. In terms of anteroposterior positional changes in angular
Ii’ The point of the tip of the lower incisor
measurements, there were no changes in SNA angle. However,
reflected by mandibular plane.
Go-L (gonion) The middle point of the angle of mandible
a significant increase in SNB angle was observed, and thereby
part on the mandibular plane. a significant decrease in ANB angle was observed. In terms of
SN plane A line from the sella trucica to the nasion. vertical linear measurements, there was a significant increase
Palatal plane A line from ANS to PNS. in height in the maxillary molars (Mou-Ms), but there were no
Occlusal plane A line bisecting the occlusion of the first great changes in heights in the mandibular molars (Mol-Mi). In
molars and central incisors (Downs, Steiner).
terms of dental changes in the incisors, there was no
Mandibular A line at the lower border of the mandible
significant difference in inclination between the maxillary
plane tangent to the gonial angle and the profile
image of the symphsis (Downs, Ricketts). and mandibular incisors. Also, the inclination of the occlusal
Y axis A line from the sella trucica to the gnathion. plane was decreased with no significant difference. Among the
When double projection gives rise to 2 points, the midpoint is
other measurements, only mandibular length (Gn-Cd) was
used. significant increased.

4.4. Comparison of skeletal measurements between before

3. Statistical processing
All data were analyzed using JMP5.1.1 (SAS Institute, Cary, NC)
and a non-parametric test at P < 0.05, P < 0.01, and P < 0.001
levels of statistical significance. The Mann–Whitney U test was
and after BJA treatment (JT1–JT0) (Table 5)
In terms of anteroposterior positional changes in angular
measurements, there were no changes in SNA angle, but a
decreasing trend was observed. Also, there were no changes in
SNB angle, but an increasing trend was observed. A synergistic

Table 2 – Demographic information for the 12 subjects in this study.

Bionator (B) BJA (J) P value Significance
n=6 n=6

Mean SD Mean SD
Age (months) 136.000 18.5472 130.667 14.9755 0.4225 NS
Treatment duration (months) 18.833 4.8751 18.667 5.2409 0.9360 NS
* P < 0.05, NS: not significant.

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
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orthodontic waves xxx (2015) xxx–xxx 5

Table 3 – Comparison of pretreatment measurements between two groups.

T0 (B) T0 (J) P value Significance

Mean SD Mean SD
SNA (8) 78.75 1.29 79.91 1.43 0.1050 NS
SNB (8) 74.10 1.59 74.80 3.50 0.6879 NS
ANB (8) 4.67 1.75 5.17 3.52 0.9360 NS
U1 to SN (8) 108.17 5.16 110.75 12.01 0.8723 NS
L1 to mand.P. (8) 91.58 10.99 96.08 5.01 0.6310 NS
L1 to SN (8) 51.83 10.28 49.35 6.64 1.0000 NS
Interincisal (8) 114.83 10.20 117.00 11.28 0.8095 NS
SN-palatal P. (8) 9.42 2.06 9.08 3.57 0.7475 NS
SN-occlusal.P. (8) 21.83 3.78 20.08 6.31 0.8099 NS
SN-Y axis (8) 73.17 2.38 72.67 3.01 0.5704 NS
Mand.P. (8) 36.58 7.15 34.58 8.11 0.5732 NS
Mou-Ms (mm) 19.08 3.11 19.17 3.01 0.1453 NS
Mol-Mi (mm) 31.92 2.46 31.75 2.44 0.8723 NS
Is-Is’ (mm) 29.75 2.82 29.42 2.33 0.8719 NS
Ii-Ii’ (mm) 43.17 2.89 43.58 2.85 0.6242 NS
Gn-Cd (mm) 113.25 2.32 110.25 7.81 0.1720 NS
NS: not significant.
* P < 0.05.

effect of the SNA and SNB angles resulted in a significant
decrease in ANB angle.
In terms of alveolar changes, the inclination of the
maxillary incisors to the SN plane (U1 to SN) was decreased
(105.25–110.758) and lingual inclination of the maxillary
incisors was observed without significant difference, while
labial inclination of the mandibular incisors was observed
with significant difference. In vertical measurements, both
Mou-Ms and Mol-Mi showed a significant increase. Also, the
BJA group showed a significant increase (20.08–21.928) in the
inclination of the occlusal plane compared with the bionator
group, a forwardly and downwardly inclined occlusal plane.
Among the other measurements, only mandibular length (Gn-
Cd) was significant increased.
4.5. Comparison of the change amount between before
and after treatment in the two groups (Table 6)
In comparison of treatment effects between both groups, the
BJA group showed greater lingual inclination of the maxillary
incisors and labial inclination of the mandibular incisors
compared with the bionator group. While there was no
significant difference in Mol-Mi, the change of volume in the
BJA group was 2.3 times greater than that in the bionator
group. This meant that the BJA group showed a greater dental
change in both incisors and molars compared with the
bionator group. Also, the BJA group showed a significantly
greater forward and downward change in the inclination of
the occlusal plane than did the bionator group. While ANB

Table 4 – Before and after treatment by bionator/observation measurements.

T0 (B) T1 (B) Difference P value Significance

Mean SD Mean SD
SNA (8) 78.75 1.29 78.75 1.57 0.00 1.000 NS
*
SNB (8) 74.10 1.59 75.10 1.93 1.00 0.031
*
ANB (8) 4.67 1.75 3.67 2.07 1.00 0.031
U1 to SN (8) 108.17 5.16 107.83 4.78 0.33 0.500 NS
L1 to mand.P. (8) 91.58 10.99 91.42 12.33 0.17 0.906 NS
L1 to SN (8) 51.83 10.28 51.92 11.92 0.08 0.906 NS
Interincisal (8) 114.83 10.20 115.00 10.53 0.17 0.844 NS
SN-palatal P. (8) 9.42 2.06 9.33 2.36 0.08 1.000 NS
SN-occlusal.P. (8) 21.83 3.78 21.08 3.99 0.75 0.250 NS
SN-Y axis (8) 73.17 2.38 73.08 2.69 0.08 1.000 NS
Mand.P. (8) 36.58 7.15 36.67 7.15 0.08 1.000 NS
*
Mou-Ms (mm) 19.08 3.11 21.91 3.01 2.83 0.031
Mol-Mi (mm) 31.92 2.46 33.42 3.11 1.50 0.125 NS
Is-Is’ (mm) 29.75 2.82 31.17 3.59 1.42 0.062 NS
Ii-Ii’ (mm) 43.17 2.89 44.42 3.68 1.25 0.062 NS
*
Gn-Cd (mm) 113.25 2.32 119.33 2.71 6.08 0.031
NS: not significance.
*
P < 0.05.

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
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ODW-228; No. of Pages 9

6 orthodontic waves xxx (2015) xxx–xxx

Table 5 – Before and after treatment by BJA/observation measurements.

T0 (J) T1 (J) Difference P value Significance

Mean SD Mean SD
SNA (8) 79.91 1.43 79.58 1.16 0.33 0.375 NS
SNB (8) 74.80 3.50 76.30 2.72 1.50 0.062 NS
*
ANB (8) 5.17 3.52 3.33 2.94 1.83 0.031
U1 to SN (8) 110.75 12.01 105.25 9.10 5.50 0.062 NS
*
L1 to mand.P. (8) 96.08 5.01 101.50 6.82 5.42 0.031
*
L1 to SN (8) 49.35 6.64 43.33 5.28 6.02 0.031
Interincisal (8) 117 11.28 116.83 9.04 0.17 0.812 NS
SN-palatal P. (8) 9.08 3.57 10.42 4.18 1.33 0.062 NS
*
SN-occlusal.P. (8) 20.08 6.31 21.92 6.05 1.83 0.031
SN-Y axis (8) 72.67 3.01 72.83 3.01 0.17 0.500 NS
Mand.P. (8) 34.58 8.11 35.17 8.73 0.58 0.188 NS
*
Mou-Ms (mm) 19.17 3.01 21.33 3.16 2.17 0.031
*
Mol-Mi (mm) 31.75 2.44 35.25 1.33 3.50 0.031
Is-Is’ (mm) 29.42 2.33 30.5 2.72 1.08 0.062 NS
Ii-Ii’ (mm) 43.58 2.85 44.17 2.84 0.58 0.250 NS
*
Gn-Cd (mm) 110.25 7.81 117.67 6.52 7.42 0.031
NS: not significance.
*
P < 0.05.

involved in the anteroposterior change among the skeletal functional appliances [32,33], making it difficult to evaluate
changes showed a decreasing trend in both groups, no the effects of functional appliances alone. For case selection in
significant difference was shown in comparison of the change this study, we excluded all cases for which pretreatment or
volume between the two groups. In addition, there was no concomitant therapy with appliances other than functional
significant difference in other measurements, including SNA appliances was made, and we chose only those cases for
and SNB. which treatment was made with a bionator or a BJA from the
time of the initial treatment in order to isolate the effects of the
functional appliances.
5. Discussion However, number of cases has turned out little. It was
because of being limited to cases which were no significant
5.1. Clinical data used in this study differences in the patient’s age, duration of appliance use, and
at the time of the initial examination. In addition, in cases with
In orthodontic practice, headgear, sectional arches, or lingual severe skeletal maxillary protrusions, bionators or BJAs are
arches are often combined and employed prior to the use of often combined with headgears. Therefore, this study targeted
relatively slight maxillary protrusions.
The future investigation was needed to increase number of
Table 6 – Comparison of treatment changes between two cases and include the severe skeletal maxillary protrusion.
groups.
T1–T0 (B) T1–T0 (J) B vs. J 5.2. Treatment effects in each group and comparison of
Mean Mean P value Significance treatment change volume between the two groups

SNA (8) 0.00 0.33 0.3889 NS

The bionator group showed no change in the maxilla before
SNB (8) 1.00 1.50 0.3281 NS
ANB (8) 1.00 1.83 0.1031 NS and after treatment, but did show mandibular growth. As
U1 to SN (8) 0.33 5.50 0.0338 * there was little change in the interincisal angle, the only
**
L1 to mand.P. (8) 0.17 5.42 0.0061 skeletal improvement to be observed was the marked effect on
**
L1 to SN (8) 0.08 6.02 0.0065 anterior mandibular growth.
Interincisal (8) 0.17 0.17 0.6279 NS The BJA group showed no significant changes in the
*
SN-palatal P. (8) 0.08 1.33 0.0220
* skeletal anteroposterior jaw relation before and after treat-
SN-occlusal.P. (8) 0.75 1.83 0.0295
SN-Y axis (8) 0.08 0.17 0.2063 NS
ment, but showed a decreasing trend in SNA and an increasing
Mand.P. (8) 0.08 0.58 0.2087 NS trend in SNB. Thus, ANB showed a synergistically significant
Mou-Ms (mm) 2.83 2.17 0.1906 NS decrease. Also, while there was no significant difference in
Mol-Mi (mm) 1.50 3.50 0.0538 NS SNA, as shown in Table 6, the BJA group showed the palatal
Is-Is’ (mm) 1.42 1.08 0.5604 NS and occlusal planes inclined remarkably in a forwardly
Ii-Ii’ (mm) 1.25 0.58 0.1620 NS
downward direction, a result which was not seen in the
Gn-Cd (mm) 6.08 7.42 0.1978 NS
bionator group. These results suggested that compared with
NS: not significance. bionator, the BJA had a growth-inhibiting effect on the maxilla,
*
P < 0.05.
** as well as an effect using headgear, which had a skeletal effect
P < 0.01.
only on the mandible. This supports the so-called headgear

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
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ODW-228; No. of Pages 9
orthodontic waves xxx (2015) xxx–xxx
effect proposed by Sander et al. [18,34]. The reason for this
minor high pull headgear effect seemed to be not only that the
BJA structure was a two-piece appliance, but also that the force
pushing the maxillary arch posterosuperiorly was exerted on
the guide bar.
Furthermore, there were no significant differences in
change of the maxillary incisal angle before and after
treatment at the BJA group, but a decrease in lingual
inclination of the maxillary incisors (from 110.758 to 105.258)
and labial inclination of the mandibular incisors resulted in
improvement of overjet. This suggests that BJA had a stronger
influence on alveolar changes.
Interestingly, both groups showed no significant differ-
ences in the Interincisal angle before and after treatment.
However, while the bionator group showed no changes in the
inclination of the maxillary and mandibular incisors before
and after treatment, the BJA group showed a lingual tipping
trend of the maxillary incisors, and significant labial tipping of
the mandibular incisors before and after treatment. Although
this resulted in maintaining the interincisal angle, this dental
change could have a huge influence on occlusal plane
inclination.
Furthermore, while the bionator group showed flattering of
the occlusal plane during treatment, the BJA group showed
significant inclination of the occlusal plane in a forwardly
downward direction. The reason for this seems to be that
lingual tipping of the maxillary incisors and labial tipping of
the mandibular incisors by BJA treatment facilitated the
change. Furthermore, in comparison between before and after
BJA treatment, a significant increase in height in the
mandibular molars would cause extrusion the mandibular
molars, as well as a change in the maxillary and mandibular
incisors, which would contribute to facilitating the inclination
of the occlusal plane in a forwardly downward direction.
Schudy [35], Li et al. [36], Braun and Legan [37] and Root [38]
have reported that the forwardly and downwardly inclined
occlusal plane was shown to have an effect on the molar
relationship due to the mechanics. Therefore, the forwardly
and downwardly inclined occlusal plane is suggested as
treatment mechanics for improving the Class II molar
relationship to Class I. This was considered to be the reason
why the forwardly and downwardly inclined occlusal plane
during BJA treatment led to improved mechanics for Class II
cases.
The data shown in Tables 4 and 5 suggest that there was a
significant difference between bionator treatment with the
skeletal improvement mechanics of Class II malocclusions
due not only to facilitation of mandibular anterior growth but
also to BJA treatment, which exerted the minor headgear
effect on the maxilla and inclined the occlusal plane forwardly
and downwardly, even though anterior mandibular growth
acceleration is weaker.
Based on our clinical experience, we believe that
BJA treatment can accelerate improvement of the overjet/
overbite and establishment of the Class I molar relationship
compared with bionator treatment. The results of this
study indicated that the bionator demonstrated skeletal
improvement mechanics while the BJA demonstrated
greater dental alveolar improvement mechanics than skele-
tal improvement.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
7
6. Differentiation between the use of the
bionator and BJA in practice
For cases of skeletal Class II malocclusion with retruded
mandible, a condition frequently seem among Japanese [39],
bionator treatment can be very effective when there is a need
to facilitate mandibular anterior growth. On the other hand,
BJA treatment can be effective in dental Class II malocclusions,
particularly for cases with labial tipping of the maxillary
incisors with a lip biting habit, for lingual tipping of the
mandibular incisors, and when there is a need for maxillary
growth inhibition.
Tovestein [40] has reported that successful orthodontic
treatment of Class II malocclusion required distal move-
ment of the maxillary arch and mesial movement of the
mandibular arch, or forward positioning of the mandible
with growth. He also provided orthodontic treatment for 81
patients with Class II malocclusion from 10 to 21 years of
age, and reported that when there was more growth of the
mandible, little inclination of the occlusal plane in a
forwardly downward direction was seen, and when there
was little or no growth, the inclination of the occlusal plane
in a forwardly downward direction improved Class II
malocclusions.
In the present study, bionator treatment showed a
flattering of the occlusal plane due to a slight inclination in
a forward and upward direction, and BJA treatment, in
contrast, showed a significant inclination of the occlusal
plane in a forwardly downward direction. This effect inclining
the occlusal plane anteroinferiorly could play an important
role in improving Class II malocclusions with BJA, and may
suggest differentiation between the use of the bionator and
BJA in practice.
Consequently, bionator treatment should be provided
preferentially in the mandible during growth spurts. In
contrast, when orthodontic treatment with functional appli-
ances is started during eruption of permanent teeth and after
peak skeletal growth of the mandible, BJA treatment with
mechanics resulting in alternation of the occlusal plane is
considered to be effective in improvement of Class II
malocclusions with changes involved in dental arch. Further-
more, for younger patients with both retruded mandible and
labial tipping of the maxillary incisors, bionator treatment,
which allows skeletal improvement, should be provided as
first-line treatment of choice. Thereafter, BJA treatment,
which can affect the interincisal angle and the inclination
of the occlusal plane, should be provided after the peak of
skeletal growth of the mandible. In this way, use of different
functional appliances under a two-stage approach could be
remarkably effective in the initial treatment phase of Class II
cases.
7. Conclusions
1. The bionator, which stimulates the anterior growth of the
mandible and flattens the occlusal plane, is effective for
treatment of Class II cases with returned mandible among
growing patients.
ODW-228; No. of Pages 9
8 orthodontic waves xxx (2015) xxx–xxx
2. The BJA, which has a minor effect on the maxilla and on
treatment mechanics because the occlusal plane rotates
downward and forward, is effective for treatment of the
skeletal Class II jaw-base relationships with maxillary
protrusion, dental maxillary protrusion caused by labial
inclination of the maxillary incisors, lingual inclination of
the mandibular incisors.
3. In terms of treatment mechanics, the bionator and BJA are
thought to be different. Therefore, these results suggested
that the proper use of each depends on symptoms,
sequence of use, and time of initiation of therapy in order
to provide the most effective treatment of Class II
malocclusions.
Conflict of interest
None declared.
references
[1] Kurosawa M, Ando K, Goto S. Class II Division 1
malocclusion with a high mandibular plane angle corrected
with 2-phase treatment. Am J Orthod Dentofacial Orthop
2009;135:241–51.
[2] Horiuchi Y, Horiuchi M, Soma K. Treatment of severe Class
II Division 1 deep overbite malocclusion without
extractions in an adult. Am J Orthod Dentofacial Orthop
2008;133:121–9.
[3] Kondo E. Occlusal stability in Class II Division 1, deep bite
cases followed up for many years after orthodontic
treatment. Am J Orthod Dentofacial Orthop 1998;114:611–30.
[4] Kuroda S, Yamada K, Deguchi T, Kyung HM, Takano-
Yamamoto T, Class II. malocclusion treated with miniscrew
anchorage: comparison with traditional orthodontic
mechanics outcomes. Am J Orthod Dentofacial Orthop
2009;135:302–9.
[5] Wieslander L, Lagerström L. The effect of activator
treatment on Class II malocclusions. Am J Orthod
Dentofacial Orthop 1979;75:20–6.
[6] Pancherz H. A cephalometric analysis of skeletal and dental
changes contributing to Class II correction in activator
treatment. Am J Orthod Dentofacial Orthop 1984;85:125–34.
[7] McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and
dental changes following functional regulator therapy on
Class II patients. Am J Orthod Dentofacial Orthop
1985;88:91–110.
[8] Almeida MR, Henriques JF, Ursi W. Comparative study of
the Fränkel (FR-2) and bionator appliances in the treatment
of Class II malocclusion. Am J Orthod Dentofacial Orthop
2002;121:458–66.
[9] Jena AK, Duggal R, Parkash H. Skeletal and dentoalveolar
effects of twin-block and bionator appliances in the
treatment of Class II malocclusion: a comparative study.
Am J Orthod Dentofacial Orthop 2006;130:594–602.
[10] Pancherz H. Treatment of Class II malocclusions by
jumping the bite with the Herbst appliance: a
cephalometric investigation. Am J Orthod Dentofacial
Orthop 1979;76:423–42.
[11] Balters W. Ergebnisse gesteuerter Selbstheilung von
kieferorthopädischen Anomalien Results of the controlled
spontaneous healing of orthodontic anomalies Dtsch
Zahnärztl Z 1960;15:241–8.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
[12] McNamara JA, Brudon WL, Bradish SK, Skidmore LM.
Orthodontic and orthopedic treatment in the mixed
dentition. USA: Needham Press Inc.; 1995: 243–58.
[13] Almeida MR, Henriques JF, Almeida RR, Almeida RR, Ursi
W. Treatment effects produced by the bionator appliance.
Comparison with an untreated Class II sample. Eur J Orthod
2004;26:65–72.
[14] Williams S, Melsen B. The interplay between sagittal and
vertical growth factors: an implant study of activator
treatment. Am J Orthod Dentofacial Orthop 1982;81:327–32.
[15] Fränkel R. The treatment of Class II Division 1 malocclusion
with functional correctors. Am J Orthod 1969;55:265–75.
[16] Mills CM, McCulloch KJ. Treatment effects of the twin block
appliance: a cephalometric study. Am J Orthod Dentofacial
Orthop 1998;114:15–24.
[17] Sander FG. Indikation für die Anwendung der
Vorschubdoppelplatte Prakt. Fortschr Kieferorthop
1988;2:209–22.
[18] Sander FG, Lassak C. The modification of growth with the
jumping-the-bite plate compared to other functional
orthodontic appliances. Fortschr Kieferorthop 1990;51:
155–64.
[19] Sander FG, Weinreich A. The bite-jumping-appliance.
Dtsch Stomatol 1991;41:195–8.
[20] Sander FG, Wichelhaus A. Skeletal and dental changes
during the use of the bite-jumping plate. A cephalometric
comparison with an untreated Class-II group. Fortschr
Kieferorthop 1995;56:127–39.
[21] Illing HM, Morris DO, Lee RT. A prospective evaluation of
bass bionator and twin block appliances. Part I – the hard
tissues. Eur J Orthod 1998;20:501–16.
[22] Siara-Olds NJ, Pangrazio-Kulbersh V, Berger J, Bayirli B.
Long-term dentoskeletal changes with the bionator, Herbst
Twin Block, and MARA functional appliances. Angle Orthod
2010;80:18–29.
[23] Almeida-Pedrin RR, Almeida MR, Almeida RR, Pinzan A,
Ferreira FP. Treatment effects of headgear bite plane and
bionator appliances. Am J Orthod Dentofacial Orthop
2007;132:191–8.
[24] Baysal A, Uysal T. Soft tissue effects of twin block and
Herbst appliances in patients with Class II Division 1
mandibular retrognathy. Eur J Orthod 2013;35:71–81.
[25] DeVincenzo JP. Changes in mandibular length before,
during, and after successful orthopedic correction of Class
II malocclusions, using a functional appliance. Am J Orthod
Dentofacial Orthop 1991;99:241–57.
[26] Nedeljković N, Sćepan I, Glisić B, Marković E. Dentoalveolar
changes in young adult patients with Class II/1
malocclusion treated with the Herbst appliance and an
activator. Vojnosanit Pregl 2010;67:170–5.
[27] Weiland FJ, Ingervall B, Bantleon HP, Droacht H. Initial
effects of treatment of Class II malocclusion with the
Herren activator, activator–headgear combination, and
Jasper Jumper. Am J Orthod Dentofacial Orthop
1997;112:19–27.
[28] Rosenblum RE, Class II. malocclusion: mandibular
retrusion or maxillary protrusion? Angle Orthod
1995;65:49–62.
[29] Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics
with functional appliances. 2nd ed. Mosby; 1997: 523.
[30] DeVincenzo JP, Winn MW. Orthopedic and orthodontic
effects resulting from the use of a functional appliance
with different amounts of protrusive activation. Am J
Orthod Dentofacial Orthop 1989;96:181–90.
[31] Kumar S, Sidhu SS, Kharbanda OP. A cephalometric
evaluation of the dental and facial–skeletal effects using
the bionator with stepwise protrusive activations. J Clin
Pediatr Dent 1996;20:101–8.
ODW-228; No. of Pages 9

orthodontic waves xxx (2015) xxx–xxx 9

[32] Lall R, Kumar GA, Maheshwari A, Kumar M. A retrospective
cephalometric evaluation of dental changes with activator
and activator headgear combination in the treatment of
skeletal Class II malocclusion. J Contemp Dent Pract
2011;12:14–8.
[33] Türkkahraman H, Sayin MO. Effects of activator and
activator headgear treatment: comparison with untreated
Class II subjects. Eur J Orthod 2006;28:27–34.
[34] Sander FG, Weinreich A. Die Vorschubdopplerplatte. Dtsch
Stomatol 1991;41:195–8.
[35] Schudy FF. Cant of the occlusal plane and axial inclinations
of teeth. Angle Orthod 1963;33(2):69–82.
[36] Li JL, Kau CH, Wang M. Changes of occlusal plane
inclination after orthodontic treatment in different
dentoskeletal frames. Prog Orthod 2014;15(1):41.
[37] Braun S, Legan HL. Changes in occlusion related to the cant
of the occlusal plane. Am J Orthod Dentofacial Orthop
1997;111:184–8.
[38] Root LL. Level anchorage system treatment of Class III
malocclusions. Am J Orthod Dentofacial Orthop
1991;100:562–71.
[39] Kuroda S, Murakami K, Morishige Y, Takano-Yamamoto T,
Severe Class II. malocclusion with facial asymmetry treated
with intraoral vertico-sagittal ramus osteotomy and LeFort
I osteotomy. Am J Orthod Dentofacial Orthop 2009;135:
809–19.
[40] Tovstein BC. Behavior of the occlusal plane and related
structures in the treatment of Class II malocclusion. Angle
Orthod 1955;25(4):189–98.

Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001