Correction of Class II, Division 2 malocclusions through the use of the Bionator appliance Report of two cases Richard R. Rutter, DDS,* and Emil Witt, Dr. Med. Dent.**
Wiirzburg, West Germany The correction of two Class II, Division 2 malocclusions during the mixed dentition phase with the use of a Bionator appliance is presented. The suggestion that correction of Class II, Division 2 malocclusions may be achieved in the absence of fixed appliances is supported in these case reports. (AM J ORTHOP DENTOFACORTHOP 1990;97:106-12.)
T h e great majority of orthodontists who have received traditional fixed-appliance training in American university programs lack first-hand exposure
From the Department of Orthodontics, Universityof Wfirzburg. *Senior Resident, Department of Orthodontics. **Professorand Chairman, Department of Orthodontics. 814110425
to the functional appliances routinely used by most European orthodontists. ~3 To acquaint the American reader with the potential offered by one of these appliances (the Bionator) in the correction of Class II, Division 2 malocclusions, two case reports are presented here. The Bionator differs from the classic activator in that the extent of acrylic is greatly reduced to allow normal tongue function and speech. The ap-
1 •
!
1
Fig. 1. A and B, Basic construction of Bionator appliance. C and D, Bionator appliance modified with protrusion spring. 106
Volume 97 Number 2
Case report
107
Fig. 2. A and B, Pretreatment facial photographs of patient G.B. at 8 years, 5 months of age.
Fig. 3. A through E, Pretreatment study models of patient G.B. at 8 years, 5 months of age.
pliance can therefore be worn at all times, except while eating. The Bionator as described by Baiters 4 and as modified by Witt 5 is constructed so as to position.the mandible foward, with interarch relationships near normal. It is desirable to position the mandible beyond normal rest position so as to elicit a muscular responseY The extent of this positioning is kept within the limits of unstrained lip closure. Each patient treatment regimen involved a Class
II, Division 2 malocclusion intercepted during the mixed dentition phase of dental development. As is commonly required in Bionator treatment, and because of the individual characteristics and physiologic responses of the malocclusions, two or more appliances were used in each of these cases during the combined periods of active and retentive care. No bands or brackets were used at any stage of treatment. The basic configuration of the Bionator appliance is shown in Fig. 1, A and B. In a Class II, Division I
108
Am. J. Orthod. Dentofac. Orthop. FebruaO" 1990
R u t t e r a n d Witt
A Fig. 4. A and B, Posttreatment facial photographs of patient G.B. at 18 years, 6 months of age.
Fig. 5. A through E, Post-treatment study models of patient G.B. at 18 years, 6 months of age.
correction, extraoral traction is applied directly to the Bionator, and the appliance often includes a labial wire to control lip position. 8 In the Class II, Division 2 treatment reviewed here, a special spring (Fig. 1, C and D) was used to protrude the lingually inclined maxillary incisors. During the active phase of treatment, patients wore the Bionator appliance approximately 15 to 18 hours a day.
CASE REPORTS CASE 1 (Figs. 2 through 6)
G.B., an 8-year, 5-month-old male patient, was accepted for treatment at the University of Wiirzburg for correction of a Class 1I, Division 2 malocclusion exhibiting typical dental relationships without extreme cephalometric values. The dentition presented permanent incisors and first molars in all four quadrants. A Bionator appliance was introduced when the patient
Volume 97
Number 2
Case report
GB. 12.77 SNA SNB ANB SN-MP FAC CONVEX INTERINCISAL
2.86 ...........
79 ° 74 ~" 5° 360
3,Smm 1/,0 °
81 o 79,5 ° 1,5 ° 330 -lmm
J'I!
140,5 °
3
:..,...-"
/
g
i .
-....
>"
..oF
..--
~ "°%°'-..
.
.:
i
...... ..-°'°
Fig. 6. Superimposition of pretreatment and posttreatment cephalometric tracings of patient G.B. on sella-nasion line registered at sella. FAC CONVEX, Facial convex profile.
A
B
Fig. 7. A and B, Pretreatment facial photographs of patient J.S. at 10 years, 3 months of age.
109
110
Rutter and Witt
Am. J. Orthod. Dentofac. Orthop~ February 1990
Fig. 8. A through E, Pretreatment study models of patient J.S. at 10 years, 3 months of age.
t ~.. . . . .
B
A
,M Fig. 9. A and B, Posttreatment facial photographs of patient J.S. at 17 years, 10 months of age.
was 8 years, 6 months old. A second Bionator appliance was constructed for the patient at 10 years, 6 months of age, and, later, a third Bionator appliance was used for passive retention. All appliances were discontinued when the patient was 16 years, 5 months old. Posttreatment records shown here were obtained 2 years after all retention appliances had been discontinued. With the exception of slight rotations of the maxillary left second premolar and mandibular left lateral incisor, the dentition after treatment was near ideal. Temporomandibular joint function
was without complication. Cephalometric records (Fig. 6) revealed an excellent skeletal pattern and a marked improvement in facial profile. The growth pattern, under the influence of Bionator therapy, appears to have been most favorable. Third molar teeth have subsequently been removed. Case 2 (Figs. 7 through 11)
J.S., a 10-year, 3-month-old male patient, was accepted for treatment at the University of Wi.irzburg for correction of
Volume 97 Number 2
Case report
Fig. 10. A through E, Posttreatment study models of patient J.S. at 17 years, 10 months of age.
J[.S.
SNA SNB ANB SN-MP FAC CONVEX INTERINCtSAL
12.79 - -
1.88 .......:-.
80,5 o 7/,, 6,5 ° 34,5 ° 5ram 147,5 :
82 o 80 ° 2° 27 • 1ram 128 * -
\ ::. ".
•
i
,.-....." :
..........,.,--~......;.........
..".."
.-
.-"
Fig. 11. Superimposition of pretreatment and posttreatment cephafometdc tracings of patient J.S. on sella-nasion line registered at sella. FAC CONVEX, Facial convex profile.
111
112
Am. J. Orthod. Dentofac. Orthop. Februat)' 1990
Rutter a n d Witt
a Class II, Division 2 malocclusion of classic description. The mixed dentition presented permanent incisors and first molars in all four quadrants. A Bionator appliance was introduced when the patient was I0 years, 5 months old. A second Bionator appliance was used for the patient at 12 years, 5 months of age. Orthodontic treatment was discontinued when the patient was 15 years old, except for intermittent wear at night while the third molar teeth were under continued observation. Posttreatment records were obtained 2 years after the discontinuation of all appliances. With the exception of a slight diastema at the maxillary midline, the dentition presents an occlusion near ideal. ,Temporomandibularjoint function is without complication. Cephalometric records (Fig. 11) reveal excellent skeletal relationships and improved facial profile. Under the influence of Bionator therapy, a most favorable development of the occlusion has taken place. It has been demonstrated that the resolution of Class II, Division 2 malocclusion in the growing child is indeed within the capability of Bionator therapy. 9 The correction of minor rotations or diastemata with fixed appliances remains a patient option. The health of the individual teeth and their supporting structures, of course, is subjected to far less stress during functional appliance therapy than when full banding and bracketing is used. We will soon report on Class II, Division 1 correc-
tion with a modified Bionator to which extraoral traction is directly applied. REFERENCES I. EschlerJ. Die funktionelleOrthoptidie des Kausystems. Munich: Carl Hanser, 1952. 2. Sander G. Zur Frage der Biomechanikdes Aktivators: Entwicklung und Erprobungneuer Untersuchungsmethoden.Wiesbaden: Westdeutscher Verlag GmbH, 1980. 3. Graber TM, Neumann B. Removable orthodontic appliances. Philadelphia: W.B. Saunders, 1977. 4. Balters W. Leitfadender Bionator-Technik.Monograph, 1964. 5. Witt E. Grundprinzipiender Aktivator und Bionator-therapie. Zahn~irztlPrax 1971;22:1-5. 6. Petrovic A, Gasson N, Oudet C. Wirkung tier iibertriebenposturalenVorschubstellungdes Unterkiefersauf das Kondylenwachstum der normalen und der mit Wachstumshormonbehandelten Ratte. Fortschr Kieferorthop 1975;36:86-97. 7. Witt E. Muscular physiologicalinvestigationsinto the effect of bi-maxillaryappliances. Trans Eur Orthod 1973;448-50. 8. WittE, Gehrhe M-E, Shaye R. Removableappliancefabrication. Chicago: Quintessence, 1987. 9. Schmuth GPF. Milestones in the developmentand practical application of functionalappliances.AM J ORTtlOD1983;84:48-53. Reprint requests to:
Professor Dr. Emil Witt PoliklinikFtirKieferorthop~die Pleicherwall 2 8700 Wi~-.-.zburg West Germany
Wiirzburg, West Germany The correction of two Class II, Division 2 malocclusions during the mixed dentition phase with the use of a Bionator appliance is presented. The suggestion that correction of Class II, Division 2 malocclusions may be achieved in the absence of fixed appliances is supported in these case reports. (AM J ORTHOP DENTOFACORTHOP 1990;97:106-12.)
T h e great majority of orthodontists who have received traditional fixed-appliance training in American university programs lack first-hand exposure
From the Department of Orthodontics, Universityof Wfirzburg. *Senior Resident, Department of Orthodontics. **Professorand Chairman, Department of Orthodontics. 814110425
to the functional appliances routinely used by most European orthodontists. ~3 To acquaint the American reader with the potential offered by one of these appliances (the Bionator) in the correction of Class II, Division 2 malocclusions, two case reports are presented here. The Bionator differs from the classic activator in that the extent of acrylic is greatly reduced to allow normal tongue function and speech. The ap-
1 •
!
1
Fig. 1. A and B, Basic construction of Bionator appliance. C and D, Bionator appliance modified with protrusion spring. 106
Volume 97 Number 2
Case report
107
Fig. 2. A and B, Pretreatment facial photographs of patient G.B. at 8 years, 5 months of age.
Fig. 3. A through E, Pretreatment study models of patient G.B. at 8 years, 5 months of age.
pliance can therefore be worn at all times, except while eating. The Bionator as described by Baiters 4 and as modified by Witt 5 is constructed so as to position.the mandible foward, with interarch relationships near normal. It is desirable to position the mandible beyond normal rest position so as to elicit a muscular responseY The extent of this positioning is kept within the limits of unstrained lip closure. Each patient treatment regimen involved a Class
II, Division 2 malocclusion intercepted during the mixed dentition phase of dental development. As is commonly required in Bionator treatment, and because of the individual characteristics and physiologic responses of the malocclusions, two or more appliances were used in each of these cases during the combined periods of active and retentive care. No bands or brackets were used at any stage of treatment. The basic configuration of the Bionator appliance is shown in Fig. 1, A and B. In a Class II, Division I
108
Am. J. Orthod. Dentofac. Orthop. FebruaO" 1990
R u t t e r a n d Witt
A Fig. 4. A and B, Posttreatment facial photographs of patient G.B. at 18 years, 6 months of age.
Fig. 5. A through E, Post-treatment study models of patient G.B. at 18 years, 6 months of age.
correction, extraoral traction is applied directly to the Bionator, and the appliance often includes a labial wire to control lip position. 8 In the Class II, Division 2 treatment reviewed here, a special spring (Fig. 1, C and D) was used to protrude the lingually inclined maxillary incisors. During the active phase of treatment, patients wore the Bionator appliance approximately 15 to 18 hours a day.
CASE REPORTS CASE 1 (Figs. 2 through 6)
G.B., an 8-year, 5-month-old male patient, was accepted for treatment at the University of Wiirzburg for correction of a Class 1I, Division 2 malocclusion exhibiting typical dental relationships without extreme cephalometric values. The dentition presented permanent incisors and first molars in all four quadrants. A Bionator appliance was introduced when the patient
Volume 97
Number 2
Case report
GB. 12.77 SNA SNB ANB SN-MP FAC CONVEX INTERINCISAL
2.86 ...........
79 ° 74 ~" 5° 360
3,Smm 1/,0 °
81 o 79,5 ° 1,5 ° 330 -lmm
J'I!
140,5 °
3
:..,...-"
/
g
i .
-....
>"
..oF
..--
~ "°%°'-..
.
.:
i
...... ..-°'°
Fig. 6. Superimposition of pretreatment and posttreatment cephalometric tracings of patient G.B. on sella-nasion line registered at sella. FAC CONVEX, Facial convex profile.
A
B
Fig. 7. A and B, Pretreatment facial photographs of patient J.S. at 10 years, 3 months of age.
109
110
Rutter and Witt
Am. J. Orthod. Dentofac. Orthop~ February 1990
Fig. 8. A through E, Pretreatment study models of patient J.S. at 10 years, 3 months of age.
t ~.. . . . .
B
A
,M Fig. 9. A and B, Posttreatment facial photographs of patient J.S. at 17 years, 10 months of age.
was 8 years, 6 months old. A second Bionator appliance was constructed for the patient at 10 years, 6 months of age, and, later, a third Bionator appliance was used for passive retention. All appliances were discontinued when the patient was 16 years, 5 months old. Posttreatment records shown here were obtained 2 years after all retention appliances had been discontinued. With the exception of slight rotations of the maxillary left second premolar and mandibular left lateral incisor, the dentition after treatment was near ideal. Temporomandibular joint function
was without complication. Cephalometric records (Fig. 6) revealed an excellent skeletal pattern and a marked improvement in facial profile. The growth pattern, under the influence of Bionator therapy, appears to have been most favorable. Third molar teeth have subsequently been removed. Case 2 (Figs. 7 through 11)
J.S., a 10-year, 3-month-old male patient, was accepted for treatment at the University of Wi.irzburg for correction of
Volume 97 Number 2
Case report
Fig. 10. A through E, Posttreatment study models of patient J.S. at 17 years, 10 months of age.
J[.S.
SNA SNB ANB SN-MP FAC CONVEX INTERINCtSAL
12.79 - -
1.88 .......:-.
80,5 o 7/,, 6,5 ° 34,5 ° 5ram 147,5 :
82 o 80 ° 2° 27 • 1ram 128 * -
\ ::. ".
•
i
,.-....." :
..........,.,--~......;.........
..".."
.-
.-"
Fig. 11. Superimposition of pretreatment and posttreatment cephafometdc tracings of patient J.S. on sella-nasion line registered at sella. FAC CONVEX, Facial convex profile.
111
112
Am. J. Orthod. Dentofac. Orthop. Februat)' 1990
Rutter a n d Witt
a Class II, Division 2 malocclusion of classic description. The mixed dentition presented permanent incisors and first molars in all four quadrants. A Bionator appliance was introduced when the patient was I0 years, 5 months old. A second Bionator appliance was used for the patient at 12 years, 5 months of age. Orthodontic treatment was discontinued when the patient was 15 years old, except for intermittent wear at night while the third molar teeth were under continued observation. Posttreatment records were obtained 2 years after the discontinuation of all appliances. With the exception of a slight diastema at the maxillary midline, the dentition presents an occlusion near ideal. ,Temporomandibularjoint function is without complication. Cephalometric records (Fig. 11) reveal excellent skeletal relationships and improved facial profile. Under the influence of Bionator therapy, a most favorable development of the occlusion has taken place. It has been demonstrated that the resolution of Class II, Division 2 malocclusion in the growing child is indeed within the capability of Bionator therapy. 9 The correction of minor rotations or diastemata with fixed appliances remains a patient option. The health of the individual teeth and their supporting structures, of course, is subjected to far less stress during functional appliance therapy than when full banding and bracketing is used. We will soon report on Class II, Division 1 correc-
tion with a modified Bionator to which extraoral traction is directly applied. REFERENCES I. EschlerJ. Die funktionelleOrthoptidie des Kausystems. Munich: Carl Hanser, 1952. 2. Sander G. Zur Frage der Biomechanikdes Aktivators: Entwicklung und Erprobungneuer Untersuchungsmethoden.Wiesbaden: Westdeutscher Verlag GmbH, 1980. 3. Graber TM, Neumann B. Removable orthodontic appliances. Philadelphia: W.B. Saunders, 1977. 4. Balters W. Leitfadender Bionator-Technik.Monograph, 1964. 5. Witt E. Grundprinzipiender Aktivator und Bionator-therapie. Zahn~irztlPrax 1971;22:1-5. 6. Petrovic A, Gasson N, Oudet C. Wirkung tier iibertriebenposturalenVorschubstellungdes Unterkiefersauf das Kondylenwachstum der normalen und der mit Wachstumshormonbehandelten Ratte. Fortschr Kieferorthop 1975;36:86-97. 7. Witt E. Muscular physiologicalinvestigationsinto the effect of bi-maxillaryappliances. Trans Eur Orthod 1973;448-50. 8. WittE, Gehrhe M-E, Shaye R. Removableappliancefabrication. Chicago: Quintessence, 1987. 9. Schmuth GPF. Milestones in the developmentand practical application of functionalappliances.AM J ORTtlOD1983;84:48-53. Reprint requests to:
Professor Dr. Emil Witt PoliklinikFtirKieferorthop~die Pleicherwall 2 8700 Wi~-.-.zburg West Germany
