FUNCTIONAL APPLIANCES :

ACTIVATOR AND
BIONATOR
 CONTENTS
❖ Introduction
❖ Functional appliances
❖ Development of functional appliances
❖ Classification of functional appliances
❖ Treatment principles
❖ Indications and contraindications of functional appliances
❖ Activator – History
• Mode of action
• Skeletal and dental effects of activator
• Diagnostic preparation
• Indications and contraindications of activator use
• Fabrication of activator and Management of activator
• Modifications of activator
• Rationale of selection of activator
• Limitations
❖ BIONATOR
• Balters philosophy
• Mode of action
• Indications and contraindications of bionator
• Types of bionator
• Construction bite for bionator fabrication
• Trimming of bionator
• Rationale for selection of bionator
• Limitations
❖ Conclusion
❖ References
 INTRODUCTION

 A functional appliance is one that uses the facial muscles

and masticatory muscles to produce changes in the
position of the individual teeth or arches.
 Any oral appliance causing a change in the forces of
occlusion and alteration in muscular activity is likely to
produce displacement of individual teeth or arches.
 Therefore such appliances can be either removable,
inducing a displacement of the mandible by a process of
interference or by stimulating an avoidance reflex, or
fixed, involving the use of a mechanism causing the
mandible to be held in a different position for function.
 FUNCTIONAL APPLIANCES

Myofunctional appliances are those appliances, which

harness the muscle pressure to their advantage and thereby
affect tooth movement.
 DEVELOPMENT OF FUNCTINAL
APPLIANCES

 The biological basis for growth modification was

proposed by Wilhelm Roux, a who concluded that bone
adaptation was a ‘quantitative self‐regulating
mechanism’.
 Roux suggested that bone development was secondary to
both nutrition and functional stimuli. Consequently, the
possibility that environmental changes including
alteration in jaw posture might induce bony changes
became more tenable.
 An early form of functional appliance was the bite
jumping plane appliance, developed by Norman Kingsley
in New York in 1880.
 Pierre Robin, based in Paris, is credited as the first
clinician to undertake functional orthopaedics
therapeutically. Robin developed a monobloc appliance
geared at advancing the mandible in patients with
glossoptosis syndrome.
 A removable appliance was developed by Andresen in
Norway in 1908 and subsequently popularized as the
Andresen–Häupl appliance.
 CLASSIFICATION

According to Tom Graber ( removable appliances):

• Group A : Tooth supported appliances
Appliances that transmit muscle force directly to teeth.
E.g – Catalan's appliance, inclined planes.
• Group B : Tooth/ Tissue supported appliance
Appliances that reposition the mandible & resultant force is
transmitted to the teeth & other structures. E.g – Activator,
Bionator.
• Group C : Vestibular positioned appliances with isolated
support from tooth/ tissue. E.g –Frankel appliances, Lip
bumper.
With advent of fixed functional appliances:
Removable functional appliances – Activator, Bionator, Frankel Regulator
Semi fixed functional appliances – Den Holtz, Bass appliance Fixed functional
appliances – Herbst, Jasper Jumper, Churro Jumper, MARA.
According to Profitt:
 Tooth borne passive appliances – Myotonic appliances
No intrinsic force generating components such as screws or springs
E.g : Activator, Bionator
 Tooth borne active appliances – Myodynamic appliances
Modifications that include expansion screws or springs
E.g : Bimler’s appliance
 Tissue borne passive appliance – Located in vestibule
E.g : Oral screen, Lip bumpers
 Tissue borne active appliance- Frankel appliance
Based on transmission of force:
• Group I Appliances- Appliances that transmit the
muscular force directly to the teeth. E.g. Inclined
planes
• Group II Appliances- Appliances that reposition the
mandible & the resultant force is transmitted to the
teeth & other structures. E.g. Activator & Bionator
• Group III Appliances- These appliances also
reposition the mandible but their area of operation
is vestibule outside the dental arch. Eg. Frankel
Appliance & Vestibular Screen
 TREATMENT PRINCIPLES

 FORCE APPLICATION: Compressive strain act on

the structures involved, resulting in primary alteration
of form with a secondary adaptation in function. All
active fixed or removable appliances work by this
principle.
 FORCE EIMINATION: Abnormal and restrictive
environment influences are eliminated, allowing
optimal development. Function is rehabilitated and
followed by a secondary adaptation in form. Lip
bumper and Functional regulator work by this
principle.
 TIMING FOR TREATMENT

 A key principle in dentofacial orthopedics is in the timing

of its application. It is widely accepted that for treatment
to be effective, it should be timed to include the pubertal
growth spurt.
 Functional appliance treatment should be coincident with
periods of active growth. Most agree that it should be
initiated during the middle to late mixed dentition.
INDICATIONS FOR FUNCTIONAL
APPLIANCE

They are most effective in treating dental and skeletal

Class II malocclusions, particularly in cases with
mandibular deficiencies.
 Patient should be in growing age.
 Well aligned dental arches.
 Posteriorly positioned mandible.
 Severe skeletal discrepancy.
 Lingual tipping of mandibular incisors.
 Favourable growth pattern.
 CONTRAINDICATIONS FOR
FUNCTIONAL APPLIANCE

 Class II skeletal due to maxillary prognathism.

 Vertically directed grower.
 Labial tipping of lower incisors.
 Crowding
ACTIVATOR
 HISTORY

 KINGSLEY introduced "Jumping of the bite” in 1879 -

to correct sagittal relationship between upper and lower
jaws.
 HOTZ modified the Kingsley's plate into a vorbissplate
and used it for deep bite and mandibular retrognathism.
 A removable appliance was developed by Andresen in
Norway in 1908 and subsequently popularized as the
Andresen–Häupl appliance.
 Andresen, who was a general dentist, fitted a vulvanite
removable appliance in his daughter with the intention
of retaining her post‐orthodontic result.
 However, the appliance inadvertently involved 3–4 mm
of forward activation, and night‐time wear over a period
of months resulted in sagittal occlusal change.
 PIERRE ROBIN - monobloc to position the mandible
forward to prevent occluding the airway in patients of
GLOSSOPTOSIS.
 KARL HAUPL became convinced that appliance
induced growth changes in a physiological manner.
 Then the name ACTIVATOR or Norwegian system was
coined.
 HOW ACTIVATOR WORKS

 The original Andresen activator was rigid, tooth‐borne and

loosely fitting. It was a bulky appliance, with acrylic blocks
covering the palate and both arches. There were grooves to
produce mesial tipping of lower teeth and distal tipping of
upper posterior teeth.
 It was constructed to hold the mandible in a protrusive
position, or to cause the mandible to occlude in a protrusive
position.
 Essentially, patients cannot occlude in the normal retruded
position, but rather into a more normal, forward position,
with an associated reduction in the overjet and an improved
position of the mandible.
 The appliance was loosely fitting based on the premise
that it would activate the mandible to bite in a forward
position, inducing muscular activation with these forces
transmitted to the teeth and the tongue being stimulated
by the appliance dropping against it.
 Conceptually, the patient would therefore intermittently
bite in a more forward position, training the mandible to
develop more normally.
 1. RE-EDUCATION OF THE
MUSCULATURE

 Continually holding the mandible forward in Class II

cases the muscles would be obliged to learn a new
functional pattern.
 Gradually the teeth and jaws would adapt to the new
jaw relationship prescribed by the appliance.
 2. LATERAL PTERYGOID MUSCLE
STIMULATION

 Obligatory mandibular protrusion has been found, in

experimental animals, to be associated with increased
electromyographic activity in the superior head of the
lateral pterygoid muscle.
 Coordination of electromyographic readings with
measurements of condylar growth reveals a close
relationship, indicating that skeletal adaptation proceeds
until muscle activity is restored to normal levels.
3. DECREASED BIOCHEMICAL FEEDBACK

 Stutzmann and Petrovic (1979) found that the zone of

functional chondroblasts in the rat condyle normally
secretes a substance which retards mitotic activity of the
stem cells.
 When the lateral pterygoid is activated by an appliance, the
functional chondroblasts mature more quickly,
consequently secreting less "negative feedback” substance.
By removal of this biochemical "brake", acceleration of
condyle growth is permitted.
4. UNLOADING OF THE MANDIBULAR
CONDYLE

 The mandibular condyle is normally subjected to pressure

which is one component of the local homeostatic
mechanism controlling its growth.
 When an appliance is used which distracts the condyle
from the fossa this pressure restraint is removed, thereby
facilitating an increased rate of growth.
5. TRANSDUCTION OF VISCO-ELASTIC
FORCE

 Some authorities are skeptical of the efficacy of the

muscle generated forces created by increased biting and
swallowing when an activator is in place.
 Instead, they harness the passive tension arising from the
inherent elasticity in muscle, skin and tendonous tissues
and transmit this to the maxillary teeth engaged in the
appliance.
 Accordingly, extreme vertical registrations are frequently
employed.(Woodside, 1977).
 6. DIFFERENTIAL ERUPTION

 Harvold (1974) has shown that the divergent directions

of eruption of the maxillary and mandibular molars can
be altered by the appliance to create the molar
relationship desired.
 For example, in Class II treatment, the acrylic platform
can be adapted to arrest maxillary molar eruption, yet
allow concomitant mandibular molar eruption into Class
1 relationship.
 In Class III activator treatment, the converse would be
applied.
CLASSIFICATION OF VIEWS OF MODE OF
ACTION OF ACTIVATOR

 First group of authors PETROVIC , MCNAMARA

substantiated the ANDRESEN-HAUPL CONCEPT that
opening of the bite of upto 4mm not beyond postural rest
position creates myotatic reflex activity and isometric
contractions that induce musculoskeletal adaptation by
introducing a new mandibular closing pattern.
 Second group of authors - SELMER-OSLEN,
HERREN.HARVOLD, AND WOODSIDE- do not
accept myotatic reflex activity with isometric
contractions induce skeletal adaptation .
 According to them the viscoelastic properties of muscles
and the stretching of soft tissues are decisive for activator
action.
 They divided the viscoelastic reaction into the following
stages:
 Emptying of vessel
 Pressing out of interstitial fluid
 Stretching of fibres
 Elastic deformation of bone
 Bioplastic adaptation
 Woodside opened the mandible with construction bite as
much as 10 –15 mm beyond the postural rest vertical
dimensions.
 ESCHLER 1952 refers to opening the vertical
dimension beyond 4mm in construction bite as the
"muscle stretching method" which works alternatively
with isotonic and isometric contractions.
 SKELETAL EFFECTS OF ACTIVATOR

 Two divergent growth vectors propel the jaw bases in an

anterior direction .
 The spheno-occipital synchondrosis moves the cranial
base and nasomaxillary complex up and forward.
 The condyles translates the mandible in a downward and
forward direction.
 The activator is most effective in controlling the lower
lower vector.
 This effect also can be designated as articular, because
condylar growth is promoted or redirected.
 Johnston (1976) attributes this response to UNLOADING
THE CONDYLE

 Activator brings alteration in vertical skeletal relationship

by downward displacement of the midface area, this
decreases the SNA and also by changing maxillary base
inclination .
DENTAL EFECTS OF ACTIVATOR

 It is brought by trimming of the acrylic contiguous to

selected teeth. With proper trimming of the appliance ,
different movements can be performed and the eruption
of the teeth can be guided.
 The dentoalveolar effect of the activator is to control
tooth eruption and alveolar bone apposition.
 For this it is most effective in early mixed dentition
phase.
 Most predominate tooth movement observed during use
of activator is labial tipping of lower incisors.
 DIAGNOSTIC PREPARATION

 STUDY MODEL ANALYSIS

 FUNCTIONAL ANALYSIS

 CEPHALOMETRIC ANALYSIS
 CONSTRUCTION BITE

 The extent of forward positioning of mandible is related to

amount of bite opening. The greater the bite opening, the less
should be the planned forward movement of condyle.
 1) In a forward positioning of mandible of 7-8mm , vertical
opening must be slight to moderate ( 2-4mm)
 2) If forward positioning is no more than 3-5 mm, then vertical
opening should be 4-6 mm.
 Lower midline shifts can be corrected by the activator only if
there is actual lateral translation of mandible itself.
 H - ACTIVATOR

 The mandible is positioned anteriorly to achieve an edge to

edge relationship parallel to the functional occlusal plane.
 A general rule is that construction bite should be at least
3mm posterior to the most protrusive positioning possible.
 The mandible should remain with in limits of interocclusal
clearance and not exceed its postural rest position for vertical
registration.
 INDICATION- CLASS II by mandibular overclosure that
results in functional retrusion
 Class II , div I malocclusion with posterior positioning
positioned mandible .
 V- ACTIVATOR

 The mandible is positioned less anteriorly only upto 3 to

5 mm ahead of habitual occlusion position.
 Vertical dimension is opened upto 4 to 6 mm, a maximum
of 4mm beyond the postural rest-vertical dimension.
 INDICATION- class II , div I with vertical growth
pattern.
Construction bite without forward
mandibular positioning

VERTICAL PROBLEMS
DEEP OVERBITE MALOCCLUSIONS-
 DENTOALVEOLAR TRUE DEEPBITE- moderate or
high construction bite is registered.
 PSEUDO DEEPBITE- high construction is
contraindicated.
 Skeletal deep bite- high construction bite is registered.
OPEN BITE MALOCCLUSION-the bite is opened 4 to
5mm to develop a sufficient elastic depressing force and
load the molars that are in premature contact.
Construction bite with opening and posterior
positioning of the mandible

 The construction bite is taken by retruding the mandible.

 PSEUDO CLASS III- vertical opening is done far
enough to clear the incisal guidance for construction bite.
 An edge to edge bite relationship can be achieved with the
posterior teeth still out of contact.
 SKELETAL CLASS III MALOCCLUSION – vertical
opening for construction bite depends on possibility of
achieving an end to end incisal relationship.
 INDICATIONS

1. Dento-alveolar Class II malocclusions. The activator is employed

as a form of Class II intermaxillary traction to initiate dento-alveolar
remodelling.
2. Moderate skeletal dysplasia between the midfacial area and the
mandible, where moderate amounts of maxillary incisor retraction
and moderate amounts of mandibular growth would combine to yield
a successful result.
3. Class II malocclusions resulting from environmental influences
such as thumb sucking and chronic mouth breathing, providing some
growth still remains and the oral habit can be eliminated.
4. Non-extraction deep overbite cases in which it is desirable or
permissible to exert a forward pull on the lower dental arch. Many
Class II division II cases belong in this category.
 CONTRAINDICATIONS

1. Non-growing patients.
2. Vertical growth patterns.
3. Intractable mouth breathing or digit sucking.
4. Poor cooperation.
5. Cross bite tendency.
6. Gross intra-arch irregularities and rotations.
7. Marked spacing of the upper incisors. Activators are not
capable of parallel space closure.
8. Retroclined upper incisors.
 FABRICATION OF ACTIVATOR

 WIRE ELEMENTS-
 Labial bow- consist of horizontal section and 2 vertical
loops .
 Horizontal section contacts the four incisors. Depending
on vertical dimension bow crosses the incisors above or
below the area of greatest convexity.
 Vertical loops U shaped and pass though canine and
deciduous first molar embrasure.
 ACRYLIC PORTION-Consist of upper, lower and
interocclusal part.
 Upper part consist of flanges 8 to 12mm high in gingival
area and cover alveolar crest.
 Lower part consist of flange of 5 to 10 mm wide .
 Other elements such as jackscrew can be added.
 MANAGEMENT OF THE APPLIANCE

 Trimming is done chairside with no trimming for first

week to allow patient to get used.
 The appliance is worn 2 to 3 hours during day for the
first week.
 During second week the patient sleeps with the appliance
in place and wears it for 1 to 3 hours a day.
 Appliance is checked after 3 weeks .
 Guide plane contact areas should be shiny if appliance is
being worn.
 If patient is wearing appliance correctly, 6 weeks
checkup should be done.
 TRIMMING OF THE ACTIVATOR

TRIMMING THE ACTIVATOR FOR

VERTICAL CONTROL -

INTRUSION OF TEETH-
 INCISORS INTRUSION-Load the incisal
edges of the teeth.
 Bow is positioned below area of greatest
convexity or on the incisal third.

 MOLAR INTRUSION- Load only cusps.

 Grind acrylic away from fossas and fissures.
EXTRUSION OF TEETH
 INCISOR EXTRUSION- Load above area
of greatest convexity in maxilla
and below in mandible.

 EXTRUSION OF MOLARS-
Load the lingual surfaces of these teeth
above the area of the greatest convexity
in maxilla and below this area in mandible.
TRIMMING FOR SAGITTAL CONTROL

PROTRUSION
 Loading the lingual surface with acrylic
contacts.
 Screening away lip strains with passive
labial bow or lip pads.
 Auxilliaries used are Protrusion springs
(0.8mm),Wooden pegs, Guttapercha
may be added to the lingual acrylic.
RETRUSION
 Acrylic trimmed away from behind the
incisors.
 Active labial bow is incorporated.

FOR DISTAL MOVEMENT OF THE

POSTERIORS
 Guide planes should be on the mesio
lingual surfaces. Stabilizing wires or
spurs can be used.
 Active open springs.
 Asymmetric construction bite is registered.
 Guide planes loading and trimming.
 Jackscrew are incorporated.
 SELECTIVE TRIMMING OF THE
ACTIVATOR

During selective trimming only the upper or lower molars

are extruded. After erupting, eruption of antagonist can be
controlled. Eruption pathway of the molars should be
considered. “
 CONTROLLED DIFFERENTIAL
ERUPTION GUIDANCE

It must be employed for the best interdental and occlusal plane

relationship, particularly in case of flush terminal plane
relationships, proper selective grinding can convert an
impending class II or class III MO into class I interdigitation.
 MODIFICATIONS OF ACTIVATOR

1. Kinetor Activator (1951)

2. Bow Activator of A.M Schwarz (1956)
3. Herren’s Activator (1953)
4. Elastic Open Activator of G. Klammt (1960)
5. Nite-Guide / Occlus-o-Guide/Ortho-T Activators
6. Harvold / Woodside Activator (1971)
7. Bimler Appliance
8. Palate Free Activator (1974)
9. Propulsor (1980)
9 . U Bow Activator
10. Wunderer Activator
11. Hamilton Expansion Activator
12. Cybernator or Reduced Activator
13. LM-Activator
 THE KINETOR

 It was designed by Dr. Hugo Stockfish .

 It is a type of elastic activator.
 It was combination of functional principles with active
operation of various screws and springs added to the
appliance.
 It has the capacity to expand in all three directions. This
appliance had latex tubing between the upper and lower
parts to stimulate function.
 BOW ACTIVATOR

 Bow activator of AM Schwarz (1956)

 The bow activator consist of maxillary and mandibular
portion connected by an elastic bow. It is a horizontally
split activator which allows stepwise sagittal
advancement of the mandible by adjusting the bow.
 It can be used in subdivision cases by activating only the
bow on the side of unilateral disto-occlusion. Expansion
can be attempted by activating the screws
 HERREN SHAYE ACTIVATOR

 The mandible is advanced forward

3-4 mm beyond the neutral
relationship by compensating the
sagittal positioning in construction
bite.
 Jackson clasp, Duyzing clasp or
Triangular arrowhead clasp are
used for retention of the appliance
on maxillary dentition.
 The posterior teeth were allowed to
erupt occlusally whereas eruption
of lower incisors was impeded by
acrylic plane thus levelling the
curve of spee.
 ELASTIC OPEN ACTIVATOR

• This appliance was designed by G. Klammt. Acrylic

bulk is reduced and is replaced by wire.
• Wire components increases the flexibility of the
appliance.
• Reduction in the acrylic components increases wear
time. Isotonic muscle contractions are allowed due the
flexible design.
 HARVOLD/ WOODSIDE ACTIVATOR

• This activator formed by construction bite which

allowed the bite to open around 10-15 mm beyond
the postural rest position of the mandible.
• Muscular adaptation and changes were seen due to
the viscoelastic properties of soft muscles and
elasticity of soft tissues.
• Their sagittal opening was around 3-5 mm distal to
maximum protrusion of one’s jaw.
 BIMLER APPLIANCE

Bite former, Bimler stimulator (1949)

 This appliance was designed by H.P. Bimler. There are
three kinds of Bimler appliance:
 1. Type A – For treating Class II Division-1
Malocclusion
 2. Type B -Class II Division-2 Malocclusion
 3. Type C - Class III Malocclusion.
 CUT OUT OR PALATE-FREE ACTIVATOR

 This modification is given by Metzelder which combines

advantages of bionator and activator.
 The maxillary portion has acrylic on the palatal aspect of buccal
teeth and small part of adjoining gingiva while the palate is free.
 In the narrow anterior portion of appliance a small screw is
incorporated. Protrusion springs can be added in class II div 2
cases for lingually tipped upper incisors.
 The mandibular portion is same as regular activator. Due to
increase wear time success should be greater with the palate free
activator.
 PROPULSOR

 This modification had no wire connecting the upper and

lower parts. Acrylic connected the upper and lower parts
with acrylic flanges.
 This type of activator was designed by Muhlemann and
refined by Hotz. This appliance is also known as the hybrid
appliance because of features of vestibular screen and
monobloc.
 Commonly used in maxillary dento-alveolar protrusion.
 WUNDERER MODIFICATION

 It is horizontally splitted appliance with upper and lower

parts connected by a screw which is embedded in
mandibular portion.
 When the screw is opened it causes maxillary portion to
move forward and reciprocal posterior movement in the
mandibular portion.
REDUCED ACTIVATOR OR CYBERNATOR
OF SCHMUTH

 Cybernator similar to bionator has reduced acrylic part in

maxillary anterior area leaving a small flange of acrylic on
palatal slope.
 The two parts are connected by omega shaped palatal
wire. The lower acrylic part is splitted to permit
expansion. The appliance is made more resistant by a
lower labial bow.
 LOUISIANA STATE UNIVERSITY

 It is a modification of Herren activator by R Shaye.

 Increase in the forward positioning of the mandible
causes stretch in the retractor muscles whereas the
protractor muscles (lateral pterygoid) are slackened. This
new positioning of lower jaw leads to a new sensory
engram.
 According to Herren wearing of this appliance would not
increase lateral pterygoid muscle (LPM) activity.
 KARWETZKY MODIFICATION

 It consists of upper and lower active plates joined in the

first molar region by ‘U’ bow. U bow has one short leg
and one long leg, depending on which arch to be moved
both the legs are embedded accordingly.
 By constricting the U bow horizontal movements are
created.
 TEUSCHER STOCKLI ACTIVATOR/
HEADGEAR COMBINATION

It is a modified activator in combination with a high pull headgear.

At the level of maxillary 2nd premolar or first molar buccal headgear
tubes are incorporated in the inter-occlusal acrylic.
VAN BEEK ACTIVATOR
 ELASTIC ACTIVATOR FOR TREATMENT
OF OPEN BITE

• In this type of modification the

intermaxillary rigid acrylic is
replaced by elastic rubber tubes.
• The elastic activator intrudes upper
and lower posterior teeth, by
stimulating orthopaedic gymnastics
(chewing gum effect). It can be
also used for eliminating habits by
incorporation of cribs.
NOCTURNAL AIRWAY PATENCY
APPLIANCE
• It was fabricated to keep the airway
patent during sleep by posturing the
tongue more anteriorly by mandibular
protrusion.
LEHMAN ACTIVATOR:
• It is a combination activator-headgear
appliance. The design comprises of a
maxillary acrylic plate to which rigid
outer bows are attached and a
mandibular lingual shield.
• A head strap is attached to the outer
bows through which occipital traction is
applied. Maxillary plate and mandibular
shield connected by means of two heavy
S- shaped wires.
 RATIONALE FOR SELECTION OF
ACTIVATOR

SKELETAL FEATURES:
 There should be significant amounts of facial growth
remaining.
 The maxilla may exhibit mild prognathism but must not
show any features of vertical maxillary excess.
 The mandible should show mild to moderate skeletal
retrusion.
 The vertical facial proportions should err on the side of
decreased lower face height.
 The facial axis should be equal to, or greater than, 90
degrees.
 DENTAL FEATURES:
 The dental arches should be free of crowding and
individual tooth irregularities such as rotation and poor
axial inclination.
 A deep incisor overbite is preferable to an open-bite
tendency.
 The mandibular dental arch should be retruded on the
basal bone and preferably should show spacing rather
than crowding.
 The maxillary incisors should be slightly proclined.
 A slight scissor bite tendency is favourable.
 LIMITATIONS

 The bulk of the appliance renders full-time wear difficult,

and with night-time wear only, the threshold for adaptive
remodeling at the condyles may not be reached in all
cases.
 Apart from a reduction in the time of application of the
stimulus, there is reduced protractor muscle activity
during sleep.
 Since the activator is tooth-borne, in contrast to the
Functional Regulator, tooth movement may lead to
occlusal correction before the desired skeletal changes
have been achieved.
 Continued pursuit of the skeletal goals would produce a
Class III dental malocclusion.
 Inappropriate case selection or improper appliance
manipulation can lead to a posterior rotation of the
mandible.
BIONATOR
 BALTER’S PHILOSOPHY

 The equilibrium between tongue and circumoral muscles is

responsible for the shape of dental arches and
intercuspation.
 So, functional space for tongue is essential to the normal
development of the orofacial system.
 For Balter’s it is the tongue which is the center of reflex
activity in the oral cavity.
 A disco-ordination of its function could lead to abnormal
growth and actual deformation.
 Bionator establish good functional coordination and
eliminate these deforming, growth-restricting aberrations.
 Class II malocclusions are the result of a backward
position of the tongue.
 The main objective of Class II treatment with the Bionator
is to bring the tongue forward.
 This is achieved partly by stimulation of the distal aspect
of the dorsum of the tongue by the posteriorly directed
palatal arch wire, and partly by anterior development of
the mandible induced by the edge-to-edge construction
bite.
• Class III malocclusions, conversely, are ascribed to a
forward position of the tongue and therefore, in the Class
III Bionator the palatal arch is inverted, with the round
bend directed anteriorly.
 MODE OF ACTION

The principle of treatment is to modulate muscle activity,

thereby enhancing normal development of the inherent growth
pattern and eliminating abnormal and potentially deforming
environmental factors.
So, bionator falls between screening appliances and the
activator.
 ADVANTAGE OF BIONATOR

• The main advantage of bionator is its reduced size, so it can

be worn day and night time.
• Constant wear makes its action faster than activator and also
results in more rapid sagittal adjustment of musculature to
forward mandibular posture.
 INDICATIONS

 It is useful in class II malocclusion with mandibular

retrognathism, some open bite and class III cases.
 The Bionator is useful in the treatment of Class II division
I malocclusions in the mixed dentition, particularly those
associated with habits and abnormal tongue function.
 The Bionator has an important role as a retention
appliance.
 The Bionator has greater patient acceptance in this
application than the activator, which, because of its bulk,
looms as a major treatment phase.
 CONTRAINDICATIONS

 The Class II relationship which is due to maxillary

prognathism.
 A vertical growth pattern is present.
 Labial tipping of the lower incisors is evident.
 Deep overbite cases with a strong horizontal growth
pattern.
 Deep overbite caused by supra occlusion of the incisors .
 Malocclusions with crowding.
 Open-bite problems with skeletal etiology.
 Children with neuromuscular disease.
 TYPES OF BIONATOR

1) The standard Bionator

2) The open bite Bionator

3) The reversed or Class III

Bionator
 STANDARD APPLIANCE

Consists of-
ACRYLIC COMPONENTS-
• lower horseshoe -shaped acrylic lingual plate from distal of
last erupted molar of one side to other side.
• Upper arch – posterior lingual extension that cover molar &
premolar region, anterior part is open.
• Two parts are joined by interocclusal acrylic.
 WIRE COMPONENTS

❖ PALATAL BAR
• 1.2 mm wire hard ss wire.
• Kept ~ 1mm away from palatal mucosa, extends from
deciduous first molar to permanent 1st molar then cross to
other side of palate forming posteriorly directed loop.
• Function- orients the tongue & mandible anteriorly to
achieve class I relationship by stimulating dorsal surface of
tongue with palatal bar.
❖ LABIAL BOW WITH BUCCAL EXTENSION
• Made of 0.9 mm SS wire
• Begins above contact point between canine and upper
1st premolar.
• Labial portion of bow should be at a paper thickness
away from the incisors and should lie in incisal third of
the incisors.
• Lateral part – buccinator loops.
• They screen buccinator mucles and allow expansion .
 OPEN – BITE APPLIANCE

WIRE COMPONENTS
LABIAL BOW
 Made of 0.9 mm wire hard ss wire.
 Labial bow runs between the upper and lower incisors at the
height of lip closure to stimulate the lips to achieve a
competent seal and relationship.
 PALATAL BAR
ACRYLIC PART-
Open bite appliance is used to
inhibit abnormal tongue posture
and function of the tongue.
So, the acrylic portion of the
lower lingual part extends into the
upper incisor region as a lingual
shield, closing the anterior space
without touching the upper teeth.
 REVERSE BIONATOR

WIRE COMPONENTS-

• LABIAL BOW
In front of lower incisors, wire slightly touches the labial
surface lightly.
• PALATAL BAR
Runs forward with loop extending as far as deciduous 1st
molar or premolars.
Function- tongue to contact anterior portion of palate ,
encouraging forward growth of this area.
ACRYLIC PORTION
 lower acrylic extends incisally from canine to canine and
positioned behind the upper incisors.
 Acrylic is trimmed away by 1mm behind the lower
incisors to prevent tipping the lower incisors labially.
 USES- Correction of class III, by encouraging the
development of the maxilla.
 CONSTRUCTION BITE

 STANDARD TYPE
 If edge to edge incisal contact is possible, this should be
registered by the working bite. With an exceptionally
severe overjet, a more relaxed working position is used,
based on correct canine relationships.
 In these cases, the lower incisors should be capped to
prevent their further eruption and tilting.
 Later, the appliance should be re-made to an edge to edge
bite, without capping.
OPEN BITE APPLIANCE
 Construction bite- is as low as possible with a slight
opening for interposition of posterior bite blocks to
prevent their extrusion.
REVERSE APPLIANCE
The working bite is taken in the most retruded position
possible and allowing bare interincisal clearance for the
correction of the anterior crossbite.
 TRIMMING OF BIONATOR

Balters has introduced certain terms for trimming

of bionator -
 Articular plane
 Loading area
 Tooth bed
 Nose
 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

 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.
 TOOTH BED AND NOSE

TOOTH BED –
 Some parts of the loading areas are
trimmed away to the articular plane

NOSE-
 Between tooth bed interdental
acrylic fingerlike projections
 They serve as guiding surfaces
and provide anchorage in the
sagittal and vertical plane
 Nose is mostly on the mesial margin
of lower 1st permanent molar
 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 between premolars
or deciduous molars.
 SELECTIVE TRIMMING

For extrusion of posterior teeth

 Acrylic is 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 movement
For intrusion in case of open bite –posterior
teeth are fully loaded
 RATIONALE FOR SELECTION OF
BIONATOR

 The rationale of Bionator is to train the tongue by

proprioceptive stimuli to remain in a more retracted
position.
 Class II malocclusion with backwardly positioned tongue
 Pseudo Class III problems with the upper incisors tipped
lingually causing anterior mandibular displacement on
closure from postural rest to habitual occlusion.
MODIFICATIONS IN STANDARD
BIONATOR DESIGN
 BIONATOR PLUS J-HOOK
HEADGEAR

 The therapeutic bite position is secured during the

night by inserting elastics .
 It prevented mandible from dropping out during the
night
 Extraoral traction to retain bimaxillary appliance and
growth- inhibiting effect on maxilla.
 Attachments bonded on mandibular canine, or first
premolars for vertical elastics.
 Elastics run from attachments to J- hooks, ball, or
the buccinator extensions of bionator
 MODIFIED BIONATOR APPLIANCE

CASE REPORT- A 12-year and 8 months old female

patient.
Extra oral examination reveals convex facial profile having
posterior divergence of the face due to retrognathic
mandible.
On Intraoral Examination Angle’s class 2 molar and canine
relationship were present on right & Left side. Maxillary
arch was “V” shaped with proclined maxillary anteriors &
spacing.
The nasolabial angle was obtuse & lower lip was in everted
position.
In dental occlusion, Full cusp angle’s class II molar
relationship with increased overjet of 7 mm and overbite of
4 mm. ANB=5º,NA- Pog 5º
PRE- TREATMENT PHOTOS
 Modified bionator was used to stimulate
mandibular growth.
 Lip pads were incorporated for additional
periosteal pull in labial vestibule.
 This stage lasted for 10 months.
AFTER MANDIBULAR ADVANCEMENT
PHASE 2 WITH PRE-ADJUSTED
EDGEWISE
POST -TREATMENT
 LIMITATIONS

 Bionator produces primarily dento-alveolar changes.

 Difficulty in managing the appliance.
 Difficult to stabilize and selective grinding of the
appliance.
 It is vulnerable to distortion, because less support in the
alveolar & incisal region.
 CONCLUSION

 The functional appliance is quite effective in

treating mandibular retrognathism in patients with
horizontal growth patterns.
 It should not be considered a stand alone regimen,
a method for correction of all malocclusions.
 The degree of success in treating skeletal problems
depends on growth timing, direction, and
magnitude.
 Dentoalveolar change are best accomplished
during the eruption of teeth.
 REFERENCES

• Dentofacial Orthopedics with Functional Appliances- T.M . Graber,

Thomas Rakosi, A.G. Petrovic
• Orthodontic Functional Appliances Theory and Practice Dr Padhraig
Fleming
• REMOVABLE MYOFUNCTIONAL APPLIANCES - WHICH,
WHEN, WHY- Koli et al. International Journal of Creative Research
Thoughts
• The activator and its modification - A review , Aameer Parkar et al.
Indian Journal of Orthodontics and Dentofacial Research
• Long Term Stability of Skeletal Class II Treatment with Modified
Bionator Followed by Fixed Appliance - A Case Report, Joshi et al. J
Evolution Med Dent Sciences
• The temporomandibular joint and the disc-condyle relationship after
functional orthopedic treatment: a magnetic resonance study, Nezar
Watted, Emil Witt and Werner Kenn. European Journal of
Orthodontics.
THANK YOU