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Journal o f Oral R ehabilitation 1997 24; 841-848
Cephalometric evaluation of dento-skeletal changes during
treatment with the Bionator Type 1
C. C A R E L S , A . R E Y C H L E R , & F . P . G . M . V A N D E R L I N D E N *
Catholic University o f Leuven, Leuven , Belgium and ^Department o f Orthodontics, University o f Nymegen, Nymegen, the Netherlands
su m m a ry T r e a tm e n t e ffe c ts of th e
fu n c tio n a l a p p lia n c e w e r e s tu d ie d on t h e pre- and
p o s t-tr e a tm e n t c e p h a lo g r a m s o f 49 Class II, D ivision
1 cases. A fte r tr e a tm e n t, a sig n ifica n t m o r e ventral
lo ca liza tio n of th e a n te r io r t
stru ctu res
m a n d ib le w a s r ec o r d e d in co m p a riso n w it h th e pre
tr e a tm e n t s itu a tio n . The p r o c lin a tio n
m axillary in ciso rs w as r ed u ced . No
Introduction
Functional treatm en t has its roots in Western Europe
(Andrksen, 1936; A ndresen etaL, 1953; Eschler, 1952;
Herren, 1959; Balters, 1964; Bimler, 1964; Frankel,
1969; Stockfisch, 1971), w here it has served for many
years as an accepted approach for the correction of
particularly Class II, Division 1 malocclusions, before it
gained geographically w ider acceptance (Schulhof &
Engel, 1982; Gianelli etaL, 1983'; Righellis, 1983;
McNamara, 1985). The results obtained from the many
studies of treated cases differ considerably, as do the
opinions expressed on the effect of treatm ent with
functional appliances, and on their mode of action
(Carels & van der Linden, 1987).
A distinct. effect o n the position and inclination of
the teeth was show n about in most studies (orthodontic
effects). Several investigators concluded that treatment
effects are limited to the d e n t o -alveolar area (Bjork,
1951; Harvold & Vargervik, 1971; Janson, 1977;
Creekmore & Radney, 1983; Robertson, 1983) and that
the correction of th e distal occlusion w ith functional
treatm ent could partly be ascribed to an increase in the
*
1997 Blackwell Sdence Ltd
1
Department o f Orthodontics.
B ionator in h ib ito r y e ffe c t o n m axillary gro w th w a s o b serv ed .
In t h is s tu d y no significant d ifferen ces in t h e
m e a su r e d tr e a tm e n t effects on c e p h a lo m e tr ic
ra d io g ra p h s co u ld b e d em o n stra ted in cases w ith a
of th e t e n d e n c y to sk e le ta l o p en b ite fro m th o s e w ith a
t e n d e n c y to s k e le ta l d eep b ite a ccord in g to t h e
of th e criteria u s e d in th is stu d y
ab solu te
m andibular alveolar height in the molar region (Harvold
& Vargervik, 1971; Ahlgren & Laurin, 1976).
It has been show n that functional treatm ent can have
a restricting influence on the growth of the maxilla
(Ahlgren & Laurin, 1976; Bookstein, 1982; Baum rind
etaL, 1983a). In a comparative investigation of several
facial orthopaedic treatm ent approaches, it was found
th at in an activator-treated group, the distal
displacement of th e maxillary molars had about equal
orthodontic and orthopaedic contributions (Baumrind
etaL, 1983a). A study in which untreated Class II cases
served as controls, showed that functional treatm ent
has the effect of compressing the facial polygon in th e
anteroposterior direction and enlarging it in the vertical
direction (Bookstein, 1982).
Different opinions have also been expressed
concerning the effect of functional treatm ent on th e
grow th of the mandible. Some investigators assumed
that condylar grow th is not influenced by treatm ent
(Bjork, 1951; Jakobsson, 1967; Harvold & Vargervik,
1971). Others concluded that the growth of th e
m andible is the distinguishing aspect of functional
treatm en t w ith respect to other therapeutic procedures
(Reey & Eastwood, 1978; Owen, 1981).
841
842 C. C A R E L S et al
Class II, Division 1 malocclusions are those most
suited for functional treatm ent. However, it has been
argued (Teuscher, 1978) that the underlying skeletal
pattern has to be taken into account in deciding w hether
the application of functional therapy is justified. After
identifying 15 subgroups in Class II anomalies, Moyers
etaL (1980) and Moyers etaL (1976) postulated that
patients of the same facial type not only look alike, but
also grow alike, have similar treatm ent needs and
probably respond to the same treatm ent in a similar
fashion.
The various skeletal types are brought about by
different skeletal grow th patterns. Facial skeletal growth
largely contributes to the developm ent of occlusal
relationships (Marschner & Harris, 1966; Bjork, 1969;
van der Linden, 1986). Bjork (1969) demonstrated that
the positioning, and repositioning, of the mandibular
dentition relative to the maxillary dentition and the
skull during growth and during treatment, depends
chiefly on the m andibular grow th rotation. According
to van der Linden (1986), the growth pattern of the
dentofacial complex is mainly determ ined by the intra-
and extra-oral functional components.
Several authors stressed the effect of functional
therapy on craniofacial grow th (Bj6rk, 1951; Ricketts,
1960; Jakobsson, 1967; Williams & Melsen, 1982a,b;
Frankel & Frankel, 1983; Nielsen, 1984). As to the
growth direction expressed at the chin, an increase of
the X-axis has been recorded (Brechtold etaL, 1981),
while an average decrease of the facial axis was found
in another study (Reey & Eastwood, 1978). However,
it also has been stated that the mandible continues its
normal growth pattern and thus is not affected by the
functional treatm ent (Ulgen, 1981).
Cases with vertical hyperdevelopm ent of the lower
third of the face, have frequently been considered as
reacting unfavourably to the application of functional
therapy since it w ould stimulate further the vertical
development of the face. However, it can be questioned
w hether certain types of functional therapy that have
a specific training effect on the orofacial and masticatory
musculature would redirect the facial growth pattern.
From this point of view, it could be argued that the
resulting vertical dimensions of the face might not
exceed those from the undisturbed growth. An
argum ent in favour of this hypothesis is provided by
Frenkel & Frankel (1983), w ho showed a decrease of
the m andibular plane angle and only m oderate increases
of the lower face height in skeletal open bite cases
1997 Blackwell Science Ltd, Journal of Oral Rehabilitation 24; 841-848
treated with the Functional regulator. An answ er to the
question w hether certain types of functional th erap y
would redirect the facial growth pattern is relevant for
the indication of functional treatm ent in subjects w ith
a divergent skeletal pattern.
The purpose of this investigation was; first to study
the influence of Bionator treatm ent on the dentofacial
complex in a Class II, Division 1 sample including
subjects w ith various skeletal patterns, and secondly, to
evaluate w hether there is a differential influence of
Bionator treatment on some selected dentofacial
characteristics in subjects w ith a 'skeletal deep bite'
compared to those with a 'skeletal open bite'.
Materials and methods
A cephalometric study was performed on pre- a n d p o st
treatm ent standardized lateral headplates available from
49 Class II, Division 1 cases (23 boys an d 26 girls)
successfully treated with the Bionator in the late m ixed
or early perm anent dentition. The m ean age of the
subjects at the start of treatm ent was 11 years and 5
m onths (s.d. = 1 year, 5 months). The average
treatm ent duration was 1 year and 7 m onths (s.d. = 9
months). Before treatment, all children presented a
Class II, Division 1 malocclusion with various degrees
of severity and various degrees of crowding. The first
maxillary premolars were extracted in three cases a n d
the second in two cases.
All children had been treated by the second a u th o r
w ith the Bionator type 1 appliance, according to the
concepts of Balters (1964). The bionators w ere
m
constructed as illustrated in Fig. 1a & b. The construction
bite for the appliances was taken w ith the incisors in
the edge-to-edge position and with the m andibular
in an overcorrected neutro- or even m esio-occlusion.
Initially, the occlusal surfaces of the posterior teeth in
both jaws were completely covered w ith acrylic. After
1-3 months, the acrylic was removed from the occlusal
surfaces of the mandibular first molars and, n e a r th e
end of the treatment, also at the m andibular prem olars
sites. This resulted in a selective eruption of teeth,
contributing to the sagittal and vertical correction of
the Class II, Division 1 malocclusions.
All exposures for the cephalograms w ere tak en by
one operator in the same headholder. The distance
between the focus and the median plane of the head
was fixed at 4 m and the film was put as close as
possible to the subjects head.
 C E P H A L O G R A M S U S I N G T H E B I O N AT 0 R T Y P E 1 8 4 3

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F i g . L (a & b) T h e Bionator t y p e I a p p l i a n c e u s e d i n ail the s u b j e c t s ; (c & d) t h e m a n d i b l e is p o s i t i o n e d in incisal edge-to-edge relation

w h e n I lie a p p l i a n c e is in t h e m o u t h .

1997 Blackwell Science Ltd* Journal o f Oral Rehabilitation 24; 8 4 1 - 8 4 8

844 C . C A R E L S et al.
Fig. 2 . Localization of the anatomical landmarks used in this study
on the tracing of the lateral cephalogram.
Cephalometric landmarks and tracings were digitized
(Fig. 2) and the values for 22 angular and linear
variables (Table 1), were calculated by the" computer*.
A univariate statistical analysis^ of the variables in
the pre- and post-treatment samples was performed.
The distribution appeared to be normal and therefore
a paired i-test was used to quantify differences between
pre- and post-treatment measurements and between
the pre- and post-treatment measurements to the norms
for age with this group. (Table 1.)
To investigate the possible differential responses to
Bionator treatment in subjects with varying types of
craniofacial skeletal morphology (Fig. 3), a discriminant
analysis was performed to evaluate whether there are
differences between each time two subgroups
characterized by percentile criteria of 10 different
m are characteristic for each time two types of skeletal
cephalometric variables. The upper and lower quartiles
of the distribution curve, of 10 variables, served as
selection criteria for the composition of each of the
subgroups. The number of cases included in the
subgroups and the criteria for selection, are given in
Table 2.
Results
g
The pre- and post-treatment data were compared to the
norms matched for age and sex with our patients. The
*Quick Ceph, Orthodontic Processing, Chula Vista, C, U.S.A.
+SAS, Institute Inc., Cary, North Carolina, U.S.A.
results of this comparison are displayed in Table 1. The
data with the average values standard deviations and
the P-values of the differences between pre- and post
Bionator treatment of the whole sample are presented
in Table 2.
In this sample, Bionator treatm ent resulted in a
significant absolute reduction of the maxillary incisor
proclination (var 16 : ISN). In accordance, the
interincisal angle (var 22 : 1 i) increased considerably.
The maxillary length (var 14: CoA) as well as the
mandibular length (var 17: CoGn) increased
significantly. The anterior part of the mandible was in
a more ventral position (var 18: SNB), while the sagittal
position of the maxilla (var 15: SNA) did not change
significantly. The facial plane (var 19: NPo FH) showed
a small but significant increase; the conicity (var 20:MP
NPo) decreased.
The angular lower facial height (var 10: ANS Xi Pm)
increased significantly, as did the linear lower facial
height (var 11: ANS Me). The posterior and anterior
facial heights (var 13: S Go and var 12: NMe) both
became significantly larger and in about the same
proportions (respectively 9 and 8%).
No significant differences were shown for the other
variables, including the mandibular plane angle to the
anterior cranial base (var 1: SN MP), the mandibular
plane to the Frankfort plane (var 3: PP MP and var 4:
OP MP), the saddle angle (var 5: N S Ar), the articular
angle (var. 6: S Ar Go), the gonial angle (var. 7: Ar Go
Me), the modified Y-axis (var 8: NS Gn) and the facial
axis (var 9: Ba CC Gn).
A discriminant analysis was used to evaluate the
differences between each of 10 subgroups. The 10
variables used as criteria for composing the subgroups
patterns. Each first subgroup included cases showing a
tendency for a skeletal deep bite, hypodivergence of the
skeletal bases (var 2: FMPA), a low anterior to posterior
facial height (var 12: NMe/var 13: S IGo) or a low
anterior lower facial height (var 7: Ar Go Me, var 10:
ANS Xi Pm). Each second subgroup included cases
showing a tendency for a skeletal open bite with the
opposite characteristics. The results of the discriminant
analysis were negative for each of the created subgroups
according to the selected criteria. The changes associated
with the treatment did not differ significantly between
the subgroups for any of the selected criteria.
1997 Blackwell Science Ltd, Journal of Oral Rehabilitation 24; 841-848
 C E P H A L O G R A M S U S I N G T HE B I O N A T O R T YP E I 845

Table 1 Changes in the cephalometric variables in 49 Class II, Division 1 cases before and after treatment with the Bionator. The level
of significance of the difference calculated by means of the paired /-test, is indicated by *** (P < 0*001), ** (P < 0-01) and * (P < 0*05).
The abbreviations of the variables are described in the Results section

Before After

Variable m ean s.d. m ean s.d. Significance level of the difference

1. SN MP 33*2 4*7 32*8 5*5 /

2. PMPA 25-2 4*7 25*7 '5-3 /
3. PP MP 26*3 4*8 26*1 6-0 /
4. OP MP 15-2 4*6 14*9 4*3 /
5. NS Ar 125*6 5*2 124*8 5-5 /
6. S Ar Go 142*6 6*4 143*6 6*4 /
7. Ar Go Me 125*0 5*6 124*7 6-6 /
8. NS GN 68 -8 3*1 68*8 3*7 /
9, Ba CC Gn 89*5 3*5 89*1 3-7 /
10 . ANS Xi PM 43*5 4*8 44*9 4*8 ***
11. ANS Me 57*9 m m 4*6 63*2 m m 4*9 ***
12 . NMe 107*4 m m 6-8 115-4 m m 8*0 ***
13. S Go 72*2 5-7 78*6 7-0 ***
14. CoA 83*5 4*9 87*0 5*4 ***
15. SNA 82* 1 3*6 82-4 3 -,8 /
16. ISN 106*2 9*5 97*1 8-3
17. CoGn 1014 6*3 108*9 7*0 ***
18. SNB 75*5 3*5 76*9 3*6 **
19. n po m 84*9 3*2 85-6 3*5 *
20 . MP NPo 70*1 4-1 69*3 4*5 **
21. i MP 94*2 8*3 95*9 8*1 *
22 . Ii 125*9 12*6 132-7 11*2 'k'k'k

Discussion know n from several longitudinal studies of non-treated

As was found in other studies on the effects of functional
appliances treatm ent (Harvold & Vargervik, 1971;
Janson, 1977; Wieslander & Lagerstrom, 1979;
Creekmore &Radney, 1983; Robertson, 1983; Pancherz,
1984; Bolmgren & Moshiri, 1986), our data show that
in growing children, Bionator treatm ent brings about
a num ber of significant changes relative to th e pre
treatm ent situation. These significant changes include
the reduction of the proclination of the maxillary
incisors, the increase of the angular lower face height
(var. 10: ANSX:PM), the increase of the linear anterior
lower face height (var, 11: ANS Me), the increase in
total anterior face height (var, 12: N Me), the increase
in posterior total face height (var. 13: SGo), the increase
children that during the undisturbed (untreated) growth
of the face some similar cephalometric changes could
occur to various degrees (e.g. Moyers e t a l , 1976). The
only changes that could not possibly be attributed to
grow th alone, are the observed dento-alveolar changes.
O ur data did not reveal an absolute more posterior
position of the maxilla (var. 15: SNA). Also the maxillary
length has increased significantly in absolute terms. In
the sagittal direction, maxillary growth does not seem
to be inhibited absolutely by the Bionator therapy. This
could be explained by the absence of any contact with
maxillary incisors (in contrast, for example, with the
activator and w ith the headgear-activator). Clinically,
this could imply that, if an absolute inhibition of the

in linear m easurem ent representing the maxillary
length (var. 14: CoA), the increase of the length of the
mandible (var. 17: CoGn) the more anterior position of
the mandible relative to the skull base and relative to
other skeletally based reference lines of the skull (var.
18: SNB; var. 19: NPo-FH and var. 20: MPNPo). It is
maxillary forward growth is desired, a functional
appliance w ith a frontal dental overcapping, combined
w ith a headgear is indeed preferable (Bass, 1982; Van
Beek, 1982).
It also could be argued however, that point A was
advanced by dento-alveolar changes at the incisor

1997 Blackwell Science Ltd, Journal of Oral Rehabilitation 24; 841-848

i
846 C. C A R E L S etal.

Table 2 Discriminating variables and selection criteria for

partitioning the sample into each time consecutively two
subgroups

Group I Group II
Discriminating
variable Value n Value n

1. FMPA 22-5 11 28*0 13

2. PP MP 22*5 11 29-8 12
3. NS Ar 123-3 12 129*0 12
4. Ar GO Me 121-3 12 129*8 10
5. NS Gn 66-5 15 71*5 14
6. Ba CC Gn 92-0 14 87-0 11
7. ANS Xi Pm 40-0 11 47*0 14
8. ANS Me 54*5 mm 10 60*9 mm 10
9. NMe 101*7 mm 10 111*9 mm 12
10 . S Go 68-1 mm 10 76-5 mm 12

is significant, no conclusion can be drawn, as is also the

case for the other variables, concerning the possibility
of stimulating mandibular growth by means of the
Bionator therapy, since no control group of untreated
Class II cases was available for comparison. The
significant increases of SNB, MP NPo and NPo FH
indicate that on average the anterior part of the
mandible is more anteriorly positioned after a
combination of normal growth and functional
treatment. This is in accordance with the results of
Baumrind e t a l (1983b) and in agreement with the
Bionator treatm ent effects observed after a short period
of treatm ent which constitute a forward mandibular
f

positioning (Carels & van Steenberghe, 1986). However,

Fig. 3. Two types of Class II, Division 1 anomalies with different
skeletal patterns: (a) with tendency towards skeletal deep bite and
(b) with tendency towards skeletal open bite. Both children were
drawn from the present sample of children treated with a Bionator.
region, since a palatal tipping of the maxillary incisor
crowns was accompanied by the ventral displacement
of their apices. This could mask a possible restraining
effect on maxillary growth. In the same light, the
observed increase in maxillary length (CoA) can be
attributed to anterior displacement of point A. The same
comments apply to the SNA measurement.
Although the recorded increase in mandibular length
the consideration that they have to be compared with
changes occurring in non-treated Class II children, in
order to separate treatment effects from growth changes
also applies to these results.
The findings of the present study do n o t indicate that
the overall morphology of the dentofacial complex is
significantly altered by Bionator treatm ent. Indeed, the
ventral displacement of the anterior part of the mandible
was accompanied by vertical changes. However, the
facial axis and the F-axis did not change significantly,
and Bionator treatm ent was not associated with a
noticeable posterior rotation of the mandible on the
average; both the anterior and the posterior part of
the lower face height increased in about the same
proportion.
Our observations are in agreement with the
recordings from Ulgen (1981), w ho also did not find an

1997 Blackwell Science Ltd, Journal of Oral Rehabilitation 24; 841-848

 C E P H A L O G R A M S U S I N G T H E B I O N A T O R T YP E 1
influence on the overall morphology of the mandible
using the headgear activator. Reey & Eastwood (1978)
using the passive activator found an average decrease
of the facial axis of 1-0 whilst an average increase of
the 7-axis of 0-1 was also recorded by Brechtold etal.
(1981). During facial growth, the facial axis remains
relatively stable (McNamara, Bookstein & Shaughnessy,
1985a). Compensatory remodelling of the lower border
of the mandible could, however, be of importance in
this respect.
Since treatment responses did not significantly differ
*
between the two subgroups, a more optimistic attitude
should be advocated toward the treatment with the
Bionator of Class II Division 1 anomalies with tendency
to skeletal open bite. In our sample, the average bite
raising effect of functional appliances in subjects with
tendency for skeletal open bite was not significantly
different from that in subjects with a tendency for
skeletal deep bite. This finding is in contrast with the
generally accepted idea regarding the influence of the
forces exerted by the jaw muscles. Subjects with a
tendency to skeletal deep bite are thought to exhibit
less vertical development during therapy than those
with a tendency to skeletal open bite. The reason that
this difference in bite raising effect between the two
skeletal types does not show up in our study, might lay
in the fact that the variability of the skeletal morphology
of our patients did not show real extremes. Fr&nkel &
Frankel (1983) showed that skeletal open bite cases
could be corrected towards average skeletal norms by
means of the functional regulator. They attributed the
underlying anteriorly directed mandibular skeletal
growth pattern, to changes in the orofacial musculature
induced by the functional appliance.
To provide definitive evidence that skeletal open bite
tendencies are no contra-indication for the application
of Bionator therapy, probably more extreme cases
should be included in future investigations.
Finally, future studies should also include data on
patients which are out of therapy for a num ber of years,
as clinical observations reveal that distinct changes still
take place after the treatment is completed. In that
respect it would therefore be interesting to reobserve
the patients of the present sample 5, 10 and 15 years
out of retention, to evaluate which changes remained
stable over the long-term and to find out in which
cases unfavourable craniofacial developments occurred
afterwards.
1997 Blackwell Science Ltd, Journal o f Oral Rehabilitation 24; 841-848
847
Conclusion
It can be concluded that during the treatment with the
Bionator maxillary incisors become more upright, that
no absolute dorsal effect has been observed on the
maxilla and that no significant differential effect can be
observed between patients with tendency to open or
deep bite skeletal patterns.
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Correspondence: Dr C. Carels, Department of Orthodontics,
Katholieke Universiteit te Leuven, Kapucijnenvoer 7, B-3000
Leuven, Belgium.