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Original article
Naoko Sakai *, Ken Miyazawa, Takeo Tsutsui, Masako Tabuchi, Momoko Shibata,
Shigemi Goto
Department of Orthodontics, School of Dentistry, Aichi Gakuin University, Nagoya, Japan
Article history: Purpose: The purpose of this investigation was to compare and evaluate the treatment
Received 27 November 2014 effects of two commonly used removable functional appliances.
Received in revised form Materials and methods: The subjects, 12 children, were all diagnosed as having maxillary
17 September 2015 protrusion. They were divided into two treatment groups: the bionator group, comprising 3
Accepted 18 September 2015 boys and 3 girls, mean age 11.3 years at the start of treatment; and the bite jumping
Available online xxx appliance (BJA) group, comprising 5 boys and one girl, mean age 10.9 years at the start of
treatment. Lateral cephalograms in the intercuspal position were taken both at the begin-
Keywords: ning and at the end of use of each appliance.
Bite jumping appliance Results: In comparison of treatment effects between both groups, the BJA group showed
Bionator greater lingual inclination of the maxillary incisors and labial inclination of the mandibular
Functional appliance incisors compared with the bionator group. Also, the BJA group showed a significantly
greater forward and downward change in the inclination of the occlusal plane than did the
bionator group.
Conclusions: In terms of treatment mechanics, the bionator and BJA are quite different.
Therefore, the proper use of each depends on symptoms, sequence of use, and time of
initiation of therapy in order to provide the most effective treatment of Class II malocclu-
sions.
# 2015 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.
* Corresponding author at: Department of Orthodontics, School of Dentistry, Aichi Gakuin University, 2-11, Suemori-Dori, Chikusa-Ku,
Nagoya 464-8651, Japan. Tel.: +81 52 751 7181x5378; fax: +81 52 751 8900.
E-mail address: [email protected] (N. Sakai).
http://dx.doi.org/10.1016/j.odw.2015.09.001
1344-0241/# 2015 Elsevier Ltd and the Japanese Orthodontic Society. All rights reserved.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
[11–13], the activator [14], and the Frankel appliance [15], while having maxillary protrusion, and using a bionator or BJA. From
the latter includes twin block [16] and bite-jumping appliances the initial 105 patients, we selected 12 patients who met all the
(BJA) [17–20]. following conditions: having more than it in 5 mm of overjet,
The effects and functional mechanisms of the different angle Class II malocclusion and being at Hellman’s dental
appliances noted above have been compared. For instance, stage III B or III C. In addition, there was no use or combined
Illing et al. [21] reported that the twin block appliance exerted an usage of other orthodontic appliances before and during use of
inhibiting effect on the maxillary growth, while Jena et al. [9] and each appliance, and no patients with congenital anomaly or
Siara-Olds et al. [22] reported that the effect was small. jaw deformity were included in this study. The patients were
Regarding the use of the bionator on the anterior mandibular divided into two treatment groups (the bionator (Fig. 1) group,
growth acceleration, Jena et al. [9] and Siara-Olds et al. [22] comprising 3 boys and 3 girls, mean age 11.3 years at the start
reported that there was no significant effect. In contrast, of treatment, mean treatment period 18.8 months; and the BJA
Almeida-Pedrin et al. [23] and Illing et al. [21] reported a (Fig. 2) group, comprising 5 boys and one girl, mean age 10.9
significant effect on anterior mandibular growth acceleration. years at the start of treatment, mean treatment period 18.7
Furthermore, Siara-Olds et al. [22] reported that significant months). This clinical study was reviewed and approved by
labial inclination of the mandibular incisors occurred with twin the Institutional Board of Aichi Gakuin University (approved
block appliance use compared with Herbst appliance use, while number: 53).
Baysal and Uysal [24] reported that for improvement of Class II Lateral cephalograms in the intercuspal position were
Division 1 malocclusions, twin block appliances mainly induced taken at the beginning of use (T0) and end of use (T1) of each
anterior mandibular growth whereas Herbst appliances often appliance. T1 was defined as at the point in time when overjet
controlled the movement of maxillary and mandibular incisors. and overbite became <3 mm or the bilateral mandibular
Despite the comparisons, the functional mechanisms of the second molars erupted. In addition, there was no use or
appliances differ, as do the treatment results. Accordingly, combined usage of other orthodontic appliances before and
there has been no united opinion [22,25–28]. In addition, during use of each appliance, and no patients with congenital
selection criteria for the most efficient functional appliance anomaly or jaw deformity were included in this study.
have not been established for different types of maxillary For fabrication of both the bionator and the BJA, the
protrusion. Thus, in order to establish selection criteria for use construction bite taken from the patients was positioned so
in the treatment of maxillary protrusion, the present paper the distance between the maxillary and mandibular incisors
examines the treatment effects between the one-piece bionator (overbite) was in the range of 2–4 mm, the mandible had been
and the two-piece type-BJA, two commonly used removable guided anteriorly from 5 to 8 mm, and the midlines of the
functional appliances which are very different in the form. maxilla and mandible had been matched, as proposed by
Graber et al. [29]. In construction bite taking, it was decided to
complete position of the mandible based on the recommenda-
2. Materials and methods tions of DeVincenzo and Winn [30] and Kumar et al. [31].
2.1. Subjects and reference materials 2.2. Methods of analysis and measurements
The 12 subjects were patients at the Orthodontic Department, We measured the necessary items on the traced lateral
School of Dentistry, Aichi Gakuin University, diagnosed as cephalograms taken before (T0) and after (T1) of bionator (B)
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
and BJA (J) treatments for comparison between the pre- 4. U1 to SN angle
treatment bionator (BT0) and BJA (JT0) groups. Next, we 5. L1 to mandibular plane angle
made a comparison between before and after treatment in 6. L1 to SN angle
each group (BT1 vs. BT0, JT1 vs. JT0). In addition, we 7. U1 to SN angle
compared the change in amount between before and after 8. SN-palatal plane angle
treatment in the two groups (comparison of BT1–BT0 with 9. SN-occlusal plane angle
JT1–JT0). The measurements are shown in Table 1 and 10. SN-Y axis angle
Fig. 3. 11. SN-mandibular plane angle
The angles and linear distances measured using lateral
cephalograms are as follows: 2.4. Liner measurements
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
Table 1 – Landmark and plane definitions. used for evaluating the equivalence of age at the start of
Landmark Definition treatment and treatment duration between the two groups. In
addition, the Wilcoxon signed-rank test was used for
S (sella turcica) The midpoint of the fossa hypophysealis.
evaluating the changes (BT1–BT0 vs. JT1–JT0) before and after
N (nasion) The anterior point at frontonasal suture.
A The deepest anterior point in concavity of the treatment in each group. The treatment changes between the
maxilla. two groups were compared using the Mann–Whitney U test.
B The deepest anterior point in concavity of the
mandible.
ANS (anterior The most anterior point in of the anterior 4. Results
nasal spine) nasal spine.
PNS (posterior The most posterior point in of the hard
nasal spine) palate.
4.1. Demographic information in the bionator and BJA
Me (menton) The most inferior point in of the mandible. groups
Gn (gnathion) A point on the chin determined by bisecting
the angle formed by the facial and Table 2 shows the demographic information of age at the start
mandibular planes. of treatment and treatment duration in the two groups. There
Cd (condylion) The most posterior superior point of the
was no significant difference between the two groups for these
condyle.
two items.
Mou The midpoint between the mesial and distal
crown surface of the upper first molar.
Mol The midpoint between the mesial and distal 4.2. Comparison of pre-treatment skeletal measurements
crown surface of the lower first molar. between the two groups (Table 3)
Ms The middle point of the occlusal surface of
the upper first molar reflected by palatal When comparing the pre-treatment (T0) skeletal measure-
plane.
ments between the two groups, no significant difference was
Mi The middle point of the occlusal surface of
shown in any measurement items.
the lower first molar reflected by mandibular
plane.
Is The tip of the upper incisor. 4.3. Comparison of skeletal measurements between before
Is’ The point of the tip of the upper incisor and after bionator treatment (BT1–BT0) (Table 4)
reflected by palatal plane.
Ii The tip of the lower incisor. In terms of anteroposterior positional changes in angular
Ii’ The point of the tip of the lower incisor
measurements, there were no changes in SNA angle. However,
reflected by mandibular plane.
Go-L (gonion) The middle point of the angle of mandible
a significant increase in SNB angle was observed, and thereby
part on the mandibular plane. a significant decrease in ANB angle was observed. In terms of
SN plane A line from the sella trucica to the nasion. vertical linear measurements, there was a significant increase
Palatal plane A line from ANS to PNS. in height in the maxillary molars (Mou-Ms), but there were no
Occlusal plane A line bisecting the occlusion of the first great changes in heights in the mandibular molars (Mol-Mi). In
molars and central incisors (Downs, Steiner).
terms of dental changes in the incisors, there was no
Mandibular A line at the lower border of the mandible
significant difference in inclination between the maxillary
plane tangent to the gonial angle and the profile
image of the symphsis (Downs, Ricketts). and mandibular incisors. Also, the inclination of the occlusal
Y axis A line from the sella trucica to the gnathion. plane was decreased with no significant difference. Among the
When double projection gives rise to 2 points, the midpoint is
other measurements, only mandibular length (Gn-Cd) was
used. significant increased.
Mean SD Mean SD
Age (months) 136.000 18.5472 130.667 14.9755 0.4225 NS
Treatment duration (months) 18.833 4.8751 18.667 5.2409 0.9360 NS
* P < 0.05, NS: not significant.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
Mean SD Mean SD
SNA (8) 78.75 1.29 79.91 1.43 0.1050 NS
SNB (8) 74.10 1.59 74.80 3.50 0.6879 NS
ANB (8) 4.67 1.75 5.17 3.52 0.9360 NS
U1 to SN (8) 108.17 5.16 110.75 12.01 0.8723 NS
L1 to mand.P. (8) 91.58 10.99 96.08 5.01 0.6310 NS
L1 to SN (8) 51.83 10.28 49.35 6.64 1.0000 NS
Interincisal (8) 114.83 10.20 117.00 11.28 0.8095 NS
SN-palatal P. (8) 9.42 2.06 9.08 3.57 0.7475 NS
SN-occlusal.P. (8) 21.83 3.78 20.08 6.31 0.8099 NS
SN-Y axis (8) 73.17 2.38 72.67 3.01 0.5704 NS
Mand.P. (8) 36.58 7.15 34.58 8.11 0.5732 NS
Mou-Ms (mm) 19.08 3.11 19.17 3.01 0.1453 NS
Mol-Mi (mm) 31.92 2.46 31.75 2.44 0.8723 NS
Is-Is’ (mm) 29.75 2.82 29.42 2.33 0.8719 NS
Ii-Ii’ (mm) 43.17 2.89 43.58 2.85 0.6242 NS
Gn-Cd (mm) 113.25 2.32 110.25 7.81 0.1720 NS
NS: not significant.
* P < 0.05.
effect of the SNA and SNB angles resulted in a significant 4.5. Comparison of the change amount between before
decrease in ANB angle. and after treatment in the two groups (Table 6)
In terms of alveolar changes, the inclination of the
maxillary incisors to the SN plane (U1 to SN) was decreased In comparison of treatment effects between both groups, the
(105.25–110.758) and lingual inclination of the maxillary BJA group showed greater lingual inclination of the maxillary
incisors was observed without significant difference, while incisors and labial inclination of the mandibular incisors
labial inclination of the mandibular incisors was observed compared with the bionator group. While there was no
with significant difference. In vertical measurements, both significant difference in Mol-Mi, the change of volume in the
Mou-Ms and Mol-Mi showed a significant increase. Also, the BJA group was 2.3 times greater than that in the bionator
BJA group showed a significant increase (20.08–21.928) in the group. This meant that the BJA group showed a greater dental
inclination of the occlusal plane compared with the bionator change in both incisors and molars compared with the
group, a forwardly and downwardly inclined occlusal plane. bionator group. Also, the BJA group showed a significantly
Among the other measurements, only mandibular length (Gn- greater forward and downward change in the inclination of
Cd) was significant increased. the occlusal plane than did the bionator group. While ANB
Mean SD Mean SD
SNA (8) 78.75 1.29 78.75 1.57 0.00 1.000 NS
*
SNB (8) 74.10 1.59 75.10 1.93 1.00 0.031
*
ANB (8) 4.67 1.75 3.67 2.07 1.00 0.031
U1 to SN (8) 108.17 5.16 107.83 4.78 0.33 0.500 NS
L1 to mand.P. (8) 91.58 10.99 91.42 12.33 0.17 0.906 NS
L1 to SN (8) 51.83 10.28 51.92 11.92 0.08 0.906 NS
Interincisal (8) 114.83 10.20 115.00 10.53 0.17 0.844 NS
SN-palatal P. (8) 9.42 2.06 9.33 2.36 0.08 1.000 NS
SN-occlusal.P. (8) 21.83 3.78 21.08 3.99 0.75 0.250 NS
SN-Y axis (8) 73.17 2.38 73.08 2.69 0.08 1.000 NS
Mand.P. (8) 36.58 7.15 36.67 7.15 0.08 1.000 NS
*
Mou-Ms (mm) 19.08 3.11 21.91 3.01 2.83 0.031
Mol-Mi (mm) 31.92 2.46 33.42 3.11 1.50 0.125 NS
Is-Is’ (mm) 29.75 2.82 31.17 3.59 1.42 0.062 NS
Ii-Ii’ (mm) 43.17 2.89 44.42 3.68 1.25 0.062 NS
*
Gn-Cd (mm) 113.25 2.32 119.33 2.71 6.08 0.031
NS: not significance.
*
P < 0.05.
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
Mean SD Mean SD
SNA (8) 79.91 1.43 79.58 1.16 0.33 0.375 NS
SNB (8) 74.80 3.50 76.30 2.72 1.50 0.062 NS
*
ANB (8) 5.17 3.52 3.33 2.94 1.83 0.031
U1 to SN (8) 110.75 12.01 105.25 9.10 5.50 0.062 NS
*
L1 to mand.P. (8) 96.08 5.01 101.50 6.82 5.42 0.031
*
L1 to SN (8) 49.35 6.64 43.33 5.28 6.02 0.031
Interincisal (8) 117 11.28 116.83 9.04 0.17 0.812 NS
SN-palatal P. (8) 9.08 3.57 10.42 4.18 1.33 0.062 NS
*
SN-occlusal.P. (8) 20.08 6.31 21.92 6.05 1.83 0.031
SN-Y axis (8) 72.67 3.01 72.83 3.01 0.17 0.500 NS
Mand.P. (8) 34.58 8.11 35.17 8.73 0.58 0.188 NS
*
Mou-Ms (mm) 19.17 3.01 21.33 3.16 2.17 0.031
*
Mol-Mi (mm) 31.75 2.44 35.25 1.33 3.50 0.031
Is-Is’ (mm) 29.42 2.33 30.5 2.72 1.08 0.062 NS
Ii-Ii’ (mm) 43.58 2.85 44.17 2.84 0.58 0.250 NS
*
Gn-Cd (mm) 110.25 7.81 117.67 6.52 7.42 0.031
NS: not significance.
*
P < 0.05.
involved in the anteroposterior change among the skeletal functional appliances [32,33], making it difficult to evaluate
changes showed a decreasing trend in both groups, no the effects of functional appliances alone. For case selection in
significant difference was shown in comparison of the change this study, we excluded all cases for which pretreatment or
volume between the two groups. In addition, there was no concomitant therapy with appliances other than functional
significant difference in other measurements, including SNA appliances was made, and we chose only those cases for
and SNB. which treatment was made with a bionator or a BJA from the
time of the initial treatment in order to isolate the effects of the
functional appliances.
5. Discussion However, number of cases has turned out little. It was
because of being limited to cases which were no significant
5.1. Clinical data used in this study differences in the patient’s age, duration of appliance use, and
at the time of the initial examination. In addition, in cases with
In orthodontic practice, headgear, sectional arches, or lingual severe skeletal maxillary protrusions, bionators or BJAs are
arches are often combined and employed prior to the use of often combined with headgears. Therefore, this study targeted
relatively slight maxillary protrusions.
The future investigation was needed to increase number of
Table 6 – Comparison of treatment changes between two cases and include the severe skeletal maxillary protrusion.
groups.
T1–T0 (B) T1–T0 (J) B vs. J 5.2. Treatment effects in each group and comparison of
Mean Mean P value Significance treatment change volume between the two groups
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
ODW-228; No. of Pages 9
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malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001
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Please cite this article in press as: Sakai N, et al. Comparative study of the treatment effects of bionator and bite jumping appliances on Class II
malocclusions. Orthod Waves (2015), http://dx.doi.org/10.1016/j.odw.2015.09.001