Bionator and frankel appliances types , uses , clinical management ,modification and its concepts with journal review

1. FRANKEL FUNCTIONAL REGULATOR
AND
BIONATOR
PRESENTED BY,
Ashok kumar A
1ST YEAR PG

2. SYNOPSIS
• Introduction
• History
• Philosophy
• Treatment objective
• Advantages & disadvantages
• Indication & contraindication
• Types
• Construction of the appliance
• Clinical management
• Modifications
• Conclusion
• References 2
BIONATOR AND FRANKEL FUNCTION REGULATOR

3. INTRODUCTION
3
Proffit – “ Functional appliance is one that changes the posture of the mandible,
holding it open or open & forward. Pressures created by the stretch of the muscles
& soft-tissues are transmitted to the dental & skeletal structures, moving teeth &
modifying growth.”
• They act by either harnessing the muscular forces or by preventing
aberrant muscular forces from acting on the dentition.
• Also called as functional jaw orthopaedic appliances.

4. 4
PRINCIPLES OF FUNCTIONAL JAW ORTHOPEDICS
Roux-1883
• According to Roux and Wolff form was intimately related to function.
• Changes in functional stress would produce changes in internal bone architecture and
external shape.
Haupl -1938
• According to Haupl et al tissue forming stimuli originate from the activity of the
tongue, lips, facial and masticatory muscle .
• These stimuli are transmitted to the teeth, paradental tissue, alveolar bone and
mandibular joint through a passive, loose fitting appliance inserted between the teeth, the
result being that the transmitted stimuli induce desired changes in the tissues affected.

5. BIONATOR
5

6. HISTORY
6
• In the early 1950’s - Dr. Wilhelm Balter of
Germany .
• The bionator is a modification of the activator
• It is the ‘skeleton of the activator’

7. PRINCIPLES OF BIONATOR THERAPY
7
Theories upon which the bionator is based:
1.Based on the works of Robin, Andresen and Haupl.
2.The early function and form concepts of Van der Klaaw and the
functional matrix theory of Moss.
BALTER’S PHILOSOPY:
• Equilibrium between the tongue and the circumoral muscles –
shape of dental arches and intercuspation.
• The essential part of Robin’s concept is function whereas for
Balter’s it is the tongue
(which is the center of reflex activity in the oral cavity).

8. POSITION OF THE TONGUE VS malocclusion CAUSED
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• Posterior displacement of the tongue-Class II malocclusion
• Low anterior displacement of the tongue-Class III malocclusion
• Hyperactivity and forward posturing of the tongue – Open bite
• Diminished outward pressure during both postural rest and function as opposed to the
forces of the buccinator mechanism on the outside - Narrowing of the arches with
resultant crowding particularly in the maxillary arch

9. BALTER’S TREATMENT OBJECTIVE
• Accomplish lip Closure and bring the back of the tongue into contact with
the soft palate
• Enlarge the oral space and train its function
• Incisors into an edge to edge relationship
• Achieve an elongation of the mandible
• Improved relationship of the jaw, tongue and dentition as well as the
surrounding tissues
9
It Acts By Modulating The Muscle Activity.

10. ADVANTAGES DISADAVANTAGES
10
• Reduced size
• It can be worn both day and night
• Action faster than activator –
unfavourable forces are avoided
acting on dentition for longer time
• Constant wear so more rapid
adjustment of musculature
• Difficulty in managing it
correctly .
• Difficult to stabilize and
selective grinding of the
appliance .
• It is vulnerable to distortion –
because less support in the
alveolar & incisal region

11. INDICATIONS CONTRAINDICATIONS
11
• Treatment of Class II division 1
malocclusion having features ,
1.Well aligned dental arches .
2.Retruded mandible .
3.The skeletal discrepancy is not too severe.
4.A labial tipping of the upper incisors
• Deep bite with accentuated curve of spee .
• In Class III cases
• In open bite cases
• The Class II relationship is caused
by maxillary prognathism.
• A vertical growth pattern.
• Labial tipping of the lower incisors .
• Anterior crowding
• Children with neuromuscular
diseases such as poliomyelitis and
cerebral palsy.

12. TYPES OF BIONATOR
• Standard appliance
• Open bite appliance
• Class III or Reverse bionator
12

13. STANDARD APPLIANCE
USES:
• Class II division 1 malocclusion
• Narrow dental arches of Class I
malocclusion
13
ACRYLIC COMPONENTS:
• Lower horse shoe shaped acrylic lingual
plate from distal of last erupted molar of
one side to other side
• Upper arch – lingual extension that
cover molar & premolar region only

14. WIRE COMPONENTS
PALATAL ARCH
• 1.2 mm SS wire
• Extends from top edges of the lingual acrylic
flanges in the middle area of the deciduous 1st
molars.
• 1mm away from palatal mucosa
Function:
14
- Orients the tongue & mandible anteriorly
by stimulating its dorsal surface
- Stabilizes the appliance.

15. VESTIBIULAR ARCH
• 0.9 mm hard SS wire
• Begins above contact point between upper canine and 1st premolar –runs vertically
• Labial portion of bow should be at a paper thickness away from the incisors
Anterior part - labial wire
Lateral part - buccinator bends
OBJECTIVES OF BUCCINATOR BENDS:
• To prevent the cheek pressures from acting on the buccal segments, which cause passive
expansion of the arch.
15

16. OPEN – BITE APPLIANCE
Purpose of this appliance is to eliminate abnormal
tongue activity in open bite cases.
COMPONENTS:
ACRYLIC PART
The lower lingual part extends into the upper incisor region as a
lingual shield, Closing the anterior space without touching the
upper teeth
WIRE ELEMENTS
Labial bow runs between the upper and lower incisors at the
height of lip Closure.
16

17. REVERSE BIONATOR
• Encourage development of maxilla
ACRYLIC PORTION
• Lower acrylic Extends incisally from canine to canine,
positioned behind the upper incisors
• Acrylic is trimmed away by 1mm behind the lower incisors
WIRE COMPONENTS
PALATAL BAR
• Runs forward with loop extending as far as deciduous 1st
molar or premolar - tongue to contact anterior portion of
palate
LABIAL BOW
• In front of lower incisors
17

18. CONSTRUCTION BITE
OBJECTIVE:
 To achieve a Class I relation
 Edge to edge relation of incisors – to provide maximum
functional space for tongue
 If overjet is too large – step by step procedure is followed
• IN OPEN BITE BIONATOR
Construction bite-is as low as possible with a slight opening
for interposition of posterior bite blocks to prevent their
eruption.
• IN REVERSE BIONATOR
Construction bite- taken in more retruded position so as to
allow labial movement of maxillary incisors & also to exert
restrictive force on lower arch
18

19. TRIMMING OF BIONATOR
• As the volume of the appliance is reduced its anchorage is difficult and
trimming must be selective because of simultaneous anchorage requirements
Balters introduced the following terms:
1-ARTICULAR PLANE
2-LOADING AREA
3-TOOTH BED
4-NOSE
5-LEDGE
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20. ARTICULAR PLANE LOADING AREA
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21. TOOTH BED NOSE
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22. LEDGE
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23. ANCHORAGE OF APPLIANCE
1. Acrylic cap over incisal margins of lower incisors
2. Loading areas as cusps of teeth fit into respective grooves in acrylic
3. Deciduous molars are used as anchor teeth
4. Edentulous areas after early loss of primary molars
5. Noses in the upper & lower interdental spaces
6. Labial bow prevents posterior displacement
23

24. Dentition Anchorage
1,2,III-V,6 IV & V both U / L
1,2,III-V,6 V & space after IV
1,2,II-6 alveolar process-IV,V
1,2,III,4-6 6 & alveolar process
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• Deciduous teeth if present are used as anchorage .
ASCHER (1968)PROPOSAL

25. SELECTIVE TRIMMING
Balter refers:
 Prevention of eruption as loading or inhibition of growth
 Stimulation of eruption as unloading or promotion of growth
For extrusion of posterior teeth:
Acrylic left between level of Articular plane
Upper &lower molars trimmed first
Then lower premolar’s trimmed while molars loaded
Then upper premolar’s unloaded while lower premolar’s
& molars loaded
For transverse movement:
Occlusal surfaces of bionator trimmed
For intrusion in case of open bite:
Posterior teeth are fully loaded
25

26. BIONATOR AND TMJ CASES
Mechanism of action- Bionator relaxes muscle spasm particularly that of the
lateral pterygoid muscle
Design of the appliance- Similar to a standard appliance except the
construction bite need not move the mandible forward
Purpose of the appliance- To prevent riding of the condyle over the posterior
edge of the disc and thereby prevent Clicking .
Function of the bionator- To maintain the mandible in a forward position and
prevent deleterious parafunctional effects at night.
Construction bite- It is opened slightly and the lower incisors are capped.
No grinding is done
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27. CLINICAL MANAGEMENT
• The appliance should be loose and should fall when the mouth is open.
• The time interval between office visits is 3 to 5 weeks depending upon the state
of eruption of the tooth.
• The labial bow should be checked to ensure that it touches the teeth only lightly.
• The buccinator loops should be away from the deciduous first molars but should
not irritate the cheeks.
• In accordance with the plan of anchorage an growth promotion, loading and
unloading of acrylic areas can be done depending on the teeth to be stimulated.
27

28. MODIFICATIONS OF
BIONATOR
28

29. 29
MODIFICATION by
WILLIAMSON & HAMILTON
• 3mm cover for maxillary incisor
• This is to secure the position of max incisors
• This modification made from construction bite
• This also prevents tipping of lower incisors
TEUSHER’S
MODIFICATION - 1978
• Face bow tubes
• Lower lip pads

30. BY ERICH & ANNETTE FLEISHER
MODIFICATIONS ARE:
• Acrylic body reduced in size
• Instead of long labial bow – Maxillary buccolabial arch wire and
mandibular labial arch wire
• Transpalatal bar opens in distal direction as in Class III bionator
• Wire spurs used to reinforce anchorage
BIO- M-S
30

31. 2 dimentional screws bilaterally to Schmuth’s bionator.
• Correct Class II to Class I
• Excellent result in skeletal Class II cases
• Mixed dentition or permanent dentition treatment
ORTHOPEDIC CORRECTOR I
31

32. ORTHOPEDIC CORRECTOR II
32
• Correct Class II to Class I without vertical growth
• In mixed dentition
• Correct open bite
• Enlarges dental arches in case of crowding
• In mixed dentition –TMJ pain patients – repositions
mandible without increasing vertical height
• To achieve forward growth of mandible in open bite
tendency cases

33. This type bionator helps in eruption of post teeth in patients with
decreased vertical dimension
CALIFORNIA BIONATOR
33

34. Treatment Effects By Bionator Appliance – Comparison With
An Untreated Class II Sample Almeida Et Al EJO- 2004
• Increase of mandibular length in bionator group ( additional 1.5mm )
• Significant improvement in anteroposterior relationship between maxillary &
mandibular in bionator group
• Bionator produced
- labial tipping & linear protrusion of lower incisors
- retrusion of upper incisors
- increase in post dentoalveolar height due to extrusion of lower posteriors,
no extrusion of upper molars seen
34

35. 35
• Alters the direction of growth but not the
amount of growth
• Produces greater than expected posterior
drift of bone in condylar and gonial region
• Displaces mandibular anteriorly but limits
the amount of true mandibular forward
rotation that would normaly occur
Adaptive condylar growth and mandibular remodelling
changes with bionator appliance-an implant study
Araujo et al - EJO 2004
35

36. FRANKEL FUNCTIONAL
REGULATOR
36

37.  Frankel appliance
 Vestibular appliance
 Oral gymnastic appliance
 Exercise device
 Orofacial orthopedic appliance
37
FUNKTIONS REGLER FUNCTIONAL REGULATOR
Tissue borne type of removable functional appliance
Dr. Rolf. F. Frankel (1908 – 2001)
HISTORY

38. PHILOSOPHY OF FRANKEL APPLIANCE
1.Vestibular arena of operation
2.Sagital correction via tooth borne maxillary anchorage
3.Differential eruption guidance
4.Buccal shields,lip pads- periosteal pull
5. Minimal maxillary basal effect
38

39. VTO AS A DIAGNOSTIC TEST
39

40. FRANKEL’S TREATMENT OBJECTIVE
• Increase of sagittal and transverse intraoral space.
• Increase of vertical intra oral space
• Forward positioning of the mandible.
• Improve the muscle tone & proper oral seal with new neuromuscular
patterns
40

41. TYPES OF FRANKELAPPLIANCE
1)FR 1 ---- Class I and Class 2 division 1 malocclusion
- FR 1a ---- Class II malocclusion with minor crowding,Class I with deep bite.
- FR 1b ---- Class II division 1 malocclusion with overjet less than 5 mm.
- FR 2c ---- Class II division 2 malocclusion with overjet more than 7mm.
2)FR ---- Class II division 1 and division 2 malocclusions.
3)FR 3 ---- Class III malocclusions.
4) FR 4 ---- Open bite and bimaxillary protrusion.
5)FR 5 ---- High mandibular plane and vertical maxillary excess
41

42. CONTRAINDICATIONS
• Non growing patients
• Vertical growth pattern
• Intractable mouth breathing and digit sucking
• Poor patient co-operation
• Gross intra arch irregularities and rotations
• A tendency for cross bite
42

43. ADVANTAGES DISADVANTAGES
43
Elimination of abnormal
muscle function
Treatment at Early age
Frequency of visit less
Good Oral hygiene status
Less - chair side time &
duration
Bulky
Cannot be used in adult
patients
Need Fixed appliance therapy
No Individual tooth movement

44. CONSTRUCTION OF FUNCTION REGULATOR
• Impression
• Placing Of Separators / Seating Grooves
• Construction Bite
• Preparation Of Work Models
• Wax Relief
• Wire Fabrication
• Fabrication Of Acrylic Shields
• Trimming Of The Appliance
44

45. PLACING OF SEPARATORS / SEATING GROOVES
45

46. CONSTRUCTION BITE
46
• For minor sagittal problems (2-4mm)
construction bite is taken in an end to
end incisal relationship.
In Class II correction :
• Frankel advocates minimal sagittal or
forward advancement. Mandible is
advanced by 2.5 to 3 mm.
• Vertical opening is also minimal, just
enough for the interocclusal wires to
pass through.
In Class III correction :
• Retrusive bite with mandible in edge
to edge relationship is taken.
• Vertical opening is minimum.

47. PREPARATION OF WORK MODEL
47
• Model base must extend
away from alveolar process
by at least 5 mm
• Lower relief should be 12
mm below gingival margin.
• Sulcular depth must be 10-
12 mm above the gingival
margin of posterior teeth.

48. WAX RELIEF
48

49. FABRICATION OF THE COMPONENTS
49
ACRYLIC
PARTS
FUNCTIONAL REGULATOR
WIRE PARTS
BUCCAL SHIELDS
LIP PAD
LINGUAL SHIELD
VESTIBULAR WIRE
LABIAL WIRE
PALATAL BOW
CANINE LOOP
LOWER LINGUAL
WIRES
CROSSOVER WIRES

50. BUCCAL SHIELDS
50
Helps in unrestricted dento-alveolar development
Cause periosteal bone deposition

51. LIP PADS
51
•Rhomboid in shape
•It is tear drop shaped in cross section, for proper, seating in the vestibule.
•Upper edges should have a distance of at least, 5 mm from the gingival margin
•Distal edges, shouldn’t overlap the labial protruberances of the canine root,.

52. LINGUAL SHIELD
52
Proprioceptive trigger for postural maintenance of the mandible

53. VESTIBULAR WIRES
53
Connecting lip pads & buccal
shield – secure the acrylic
LABIAL WIRE
Connecting, Stabilizing
V shaped to accommodate labial
frenum
19gauge
/
0.036inc
h

54. LINGUAL WIRE
54
• Stabilizing the mandibular incisors
• Levelling of the bite
PALATAL BOW
• Connecting and Stabilizing
• Intermaxillary anchorage
• Prevents superior displacement
16gau
ge/
0.051i
nch
21gaug
e/
0.028in
ch
18gaug
e/
0.040in
ch

55. CROSSOVER WIRES
55
CANINE LOOP
• Keeps away the perioral tissue –
provides space for cuspid
• Serves as guide to prevent
malpositioning during eruption
Connects the buccal shield and
lingual shield
19gaug
e/
0.036i
nch

56. FUNCTION REGULATOR FR-1
56
FR 1a

57. FR 1b
57
Lingual acrylic pad instead of the loop in FR 1a &
lower lingual springs are added

58. FR 1c
58
Buccal shields is split horizontally & vertically into two parts for
increamental advance

59. FUNCTION REGULATOR FR-2
59
• FR2 differs from FR1 only, by the addition of an upper
lingual wire, and modified canine loop.
•This is for stabilizing it against the maxilla
• This also prevents the tipping of the protruded maxillary
incisors lingually
• In class II division 1, lingual wire lies on the cingulum of
the incisors – to prevent their further eruption.
• When labial bow is activated, it also causes the retrusion of
the incisors.

60. FUNCTION REGULATOR FR-3
60
• It consists of two upper lip-pads, 2 buccal shields
and various wires.
• Here the lip pads are much larger, than FR1 and
FR2 and extends superiorly into the sulcus.
• The superior extension of the lip pulls on the septo-
maxillary ligament and the periosteum
• Enhances bone deposition, and frees the pressure
sensitive membranous bone, from the adverse lip
pressures .

61. FUNCTION REGULATOR FR-4
61
• It has 2 lower lip pads, buccal shields, a palatal bow, an
upper labial wire and four occlusal rests.
• The main function of the acrylic components, is to
interfere with the aberrant functions of the cheek and lip
musculature
• To establish, the structural and functional balance
between, various muscle groups, of the circum oral
capsule.

62. CLINICAL MANAGEMENT OF THE APPLIANCE
Initial
treatment
phase
3-4
months
Delivery
of the
appliance
Wearing of
the
appliance
• Margin – smoothness
• Proper shape and fit
• Peripheral portions contact
without blanching
• After insertion – speak – loosen
the musculature
• 2 to 3 hours – first 2 weeks
• Lip together exercises
• Check up after 2 weeks
• Next 3 weeks 4 to 6 hours day
time

63. Active
treatment
phase
• Before night time wear – check
facial muscle balance
• Change in overcoming the
hyperactivity of the muscle.
• Adjustments of wires
• After 3 months of full time wear –
expansion evident
• In 6-8 months – Class II to Class I
Retention
treatment
phase
• 2 hours in the day – 6 hours in the
night for 6 months
• Followed by night only for 12
months

64. Comparative study of the Frankel (FR-2) and bionator appliances in
the treatment of Class II malocclusion AJODO 2002;121:458-66)
• No significant changes in maxillary growth during the evaluation period.
• Both appliances showed statistically significant increases in mandibular growth and
mandibular protrusion, with greater increases in patients treated in the bionator group.
• There were no significant changes in growth direction, while the bionator group had a greater
increase in posterior facial height.
• Both appliances produced similar labial tipping and protrusion of the lower incisors, lingual
inclination, retrusion of the upper incisors, and a significant increase in mandibular posterior
dentoalveolar height.
• The major treatment effects of bionator and FR-2 appliances were dentoalveolar, with a
smaller, but significant, skeletal effect. 64

65. CONCLUSION
• The global demand for orthodontics without braces continues to
grow. It's an option that many parents and patients would prefer.
• Myofunctional orthodontics offers a viable alternative to
traditional orthodontic methods.
• •A functional appliance is an appliance that produces all or part
of its effect by altering the position of the mandible/maxilla.
65

66. REFERENCES
1. Removable orthodontic appliances: T.M. Graber,
Bedrich Neumann
2. Dentofacial orthopaedics with functional
appliances: Thomas M.Graber, Thomas Rakosi,
Alexandre G. Petrovic
3. Orofacial orthopaedics with function regulator:
Frankel R., Frankel C.
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