Cephalometric changes during treatment with the

open bite bionator

Jonathan R. Weinbach, DDS, MS,* and Richard J. Smith, DMD, PhD**
St. Louis, 31o.

Lateral cephalometric radiographs of 39 patients who were treated with an open bite bionator, also
known as a "bionator to close the bite," were obtained from six private orthodontic practices.
Comparisons of pretreatment cephalometric values with published standards indicate that clinicians
do not generally use this appliance for patients who have marked excessive anterior vertical
dimension. Rather, the cases appear to be Class II with mild anterior open bites or with some
indication of open bite tendency, such as a steep mandibular plane angle. Changes in cephalometric
values during treatment with the appliance were compared with normal growth standards. Patients
exhibited a reduction in facial convexity and overjet, reduced eruption of maxillary molars, and less
of an increase in facial height than expected. The appliance appears to be effective for Class II
correction in patients who require control or improvement of moderately excessive vertical
dirrlension. (AM J ORTHOODENTOFACORTHOP 1992;101:367-74.)

B ionator/activator-type functional appli- ordered the appliance and requested permission for the in-
ances are often designed to allow eruption of maxillary vestigators to contact them. Practitioners who gave permis-
a n d / o r mandibular posterior teeth. Control of the path sion were contacted by telephone and letter and were re-
of eruption is used as one mechanism for achieving -quested to provide original pretreatment and posttreatment
correction of dentoalveolar Class II relationships, t~ in cephalometric radiographs for evaluation.
addition to opening deep anterior overbites. The criteria for patient selection were (i) treatment with
a bionator having posterior oeclusal acrylic coverage of both
Another type of bionator is constructed with both
arches, (2) prebionator and postbionator cephalometric ra-
the maxillary and the mandibular posterior dentitions digraphs; the postbionator radiograph was taken before be-
covered by acrylic, with or withoutacrylic coverage o f ginning any treatment with fixed appliances, and (3) no fixed
the incisors. This "open bite bionator" or "bionator to appliances used during bionator treatment.
close the bite" has been described in some recent The average age at the beginning of bionator treatment
publications .6 and is listed on the prescription forms for these 39 patients was 10 years, with a range of 7 years 1
o f many commercial orthodontic laboratories. How- montfi to 12 years l I months. Thirteen patients had high-pull
ever, we are aware of no studies examining the treat- headgear used in conjunction with the functional appliance,
ment results obtained with this appliance. The purpose whereas the remaining 26 wore the appliance alone. Average
o f the present investigation is to document skeletal treatment time with the appliance was 20.48 months (1.71
years), with a range of 5 to 46 months.
changes accompanying treatment with the open bite
bionator. Data collection
MATERIALS AND METHODS All cephalometric radiographs were traced by a single
Sample investigator. Tracings were digitized on a Numonics 2400
(Lansdale, Pa.) digitizer. Point coordinates were stored in an
The records of 39 white patients (27 boys and 12 girls),
IBM-AT computer (IBM, Boca Raton, Fla.) with the Orthodig
were obtained from a total of six private orthodontic practices. program. 7
Practices were located with the assistance of a commercial
Twenty-eight points were digitized on each radiograph.
dental laboratory (Allesee Orthodontic Appliances, Sturte-
From these coordinates, 34 measurements were calculated.
vant, Wis.). The laboratory contacted practitioners who had The definitions of all landmarks and measurements are re-
corded by Riolo et al? Table I gives the variable reference
From the Deparlment of orthodontics, Washington University School of Dental
Medicine.
number used by Riolo et al? for each measurement in this
The opinions or assertions contained herein are those of the authors and are study.
not to be construed as official, or as reflecting the views of the United States
Air F~rce or that of the Dental Cows at large. Statistical analysis
*Major, United States Air Force.
"*Professor, Department of Anthropology, Washington University.
The Orthodig program' was used to convert digitized land-
8 / !/28801 marks to cephalometric measurements. Measurements were

367
368 IVeinbach a n d Smith Am. J. Orthod. Dentofac. Orthop.
April 1992

Table I. E f f e c t s o f h e a d g e a r o n t r e a t m e n t c h a n g e s

No headgear
Headgear (n = 13) (n = 26)
Reference
number* Measurement Mean SD Mean SD p value

2 SNA (angle) -0.7 1.32 -0.6 1.67 0.74

3 SNB (angle) 1.3 1.22 1.5 1.22 0.59
4 ANB (angle) -2.0 0.82 -2. I 1.72 0.91
52 N-A-Pg (angle) - 4.3 2.22 - 3.6 3.54 0.53
i Overjet (mm) -3.7 2.10 -4. I 2.42 0.63
i Overbite/openbite 2.0 2.68 1.0 2.50 0.24
I 1"* SN-MxOP (angle) 0.4 4.71 -0.8 3.30 0.33
i 1 ** SN-MnOP (angle) 0.5 4.68 - 0.3 2.80 0.45
13 SN-MP (angle) - 0.8 2.11 - 0.5 2.02 0.65
9 SN-PP (angle) 0.4 1.98 0.2 2.15 0.77
15 Y axis to S-N (angle) -0.5 1.40 -0.2 1.43 0.54
50 Art-Go-Me (angle) 0.05 2.66 1.2 2.88 0.23
14 S-N to Art-Go (angle) -0.9 2.24 -1.7 3.19 0.39
160 N-Me (mm)(ANt) 5.2 3.70 4.5 3.09 0.53
130 N-ANS (mm)(UAFH) 3. I 2.31 2.2 1.89 0.19
158 ANS-Me (mm)(LAFH) 1.6 2.99 2.0 2.25 0.66
173 S-Go (mm)(PFH) 4.6 3.24 4.1 2.35 0.58
174 S-Art (mm) 1.5 1.77 1.2 1.83 0.63
88 Art-Go (mm) 3.7 2.29 3.5 2.48 0.82
-- UAFH/LAFH 0.03 0.05 0.01 0.03 0.21
i PFH/AFH 0.01 0.02 0.01 0.02 0.89
94 Go-Me (mm) 3.3 2.47 2.1 2.42 0.15
i 34 U I-PP (mm) F.7 2.26 1.6 2.13 0.81
101 LI-MP (nun) 1.6 1.92 0.9 0.93 0. I 1
136 U6-PP (mm) 0.6 1.70 0.8 1.61 0.80
98 L6-MP (mm) 1.5 1.16 1.0 1.67 0.36
144 UI-NA (mm) -0.9 2.07 - 1.0 1.56 0.90
108 LI-NB (ram) 0.8 1.03 0.7 1.28 0.86
60 IJ 1-NA (angle) - 4.4 4.15 - 4.4 4.05 0.97
73 LI-NB (angle) 0.3 2.42 1.5 4.45 0.34
61 UI-LI (angle) 6. I 5.52 5.0 4.80 0.50
56 UI-PP (angle) -4.7 4.96 -4.8 3.87 0.95
71 LI-MP (angle) - 0.1 3.46 0.6 3.98 0.58
i 15 LI-APg (mm) i.7 0.97 2.0 1.64 0.53

*Variable identification number in Riolo et al?

**The maxillary occlusal plane is defined by Riolo et al) landmark 19 (upper molar mesial cusp tip) and landmark 7 (upper incisor incisal
edge). The mandibular occlusal plane is defined by corresponding landmarks, identified in Riolo et al. as landmark 18 and landmark 6.

then transferred to the Systat statistical package (Systat, Inc., standards.' The change expected during 24 months of normal
Evanston, I11.) for analysis, also on an IBM-AT computer. growth were compared with the changes in the sample using
Descriptive statistics were calculated for pretreatment val- single sample t tests.
ues, posttreatment values, and the changes during treatment, Comparisons with normal growth were also made by cal-
which were defined as the postlreatment value minus the culating the number o f patients showing either increased or
prelreatment value for each patient. The pretreatment ceph- decreased values for each measurement, and comparing these
alometric values for the sample were compared with published values with the direction expected during normal growth.
norms using single sample t tests? '9
Differences between the sexes and the effects o f headgear RESULTS
on treatment were evaluated with t tests. The change in each
measurement during treatment was correlated with age at the Tables I and II indicate the use o f h e a d g e a r during
start of treatment, total bionator treatment time, and the pre- b i o n a t o r t h e r a p y h a d no significant e f f e c t o n c h a n g e s
treatment cephalometric value for that measurement. during t r e a t m e n t , a n d there w e r e no significant differ-
To compare treatment effects with normal growth, the e n c e s b e t w e e n th.e b o y s and the girls. O f 68 separate
treatment changes were compared with published longitudinal t tests, n o n e w e r e statistically significant at p < 0 . 0 5 .
Volume 101 Cephalometric changes with open bite bionator 369
Number 4

Table II. Sex differences in changes during treatment

Boys (n = 27) Girls ( n = 12)

9Measurement Mean I SD Mean [ SD p vahte

SNA (angle) -0.5 1.63 -0.8 !.39 0.59

SNB (angle) 1.7 1.25 1.1 1.08 0.22
ANB (angle) -2.1 1.47 - 1.9 1.50 0.66
N-A-Pg (angle) - 3.8 3.16 -3.9 3.27 0.93
Overjet (mrn) -4.0 2.38 -3.9 2.19 0.85
Overbite/openbite 1.0 2.49 1.9 2.75 0.31
SN-MxOP (angle) - 0.8 3.07 0.5 5.15 0.30
SN-MnOP (angle) -0.06 2.76 - 0.03 4.94 0.98
SN-MP (angle) - 0.6 2.12 -0.7 1.91 0.82
SN-PP (angle) 0.1 2.12 0.8 1.92 0.29
Y axis to S-N (angle) -0.3 i.47 -0.3 1.34 0.98
Art-Go-Me (angle) 0.5 2.67 1.5 3.17 0.32
S-N to Art-Go (angle) - l.l 3.01 -2.2 2.59 0.26
N-Me (mm)(AFtl) 5.0 3.66 4.2 2.22 0.52
N-ANS imm)(UAFH) 2.5 2.15 2.6 1.90 0.89
ANS-Me (mm)(LAFII) 2.1 2.77 1.2 i .61 0.31
S-Go (n~m)(PFtt) 4.4 2.81 4.1 2.36 0.76
S-Art (mm) 1.1 1.92 1.7 1.43 0.30
Art-Go (mm) 3.7 2.58 3.4 1.96 0.71
UAFH / LAFtt 0.0 i 0.04 0.03 0.04 0.33
PFH/AFIt 0.01 0.02 0.01 0.02 0.72
Go-Me (mm) 2.7 2.56 2.2 2.32 0.52
U I-PP (mm) 1.7 2.35 1.5 1.70 0.80
LI-MP (mm) 1. I 1.46 1.2 1.16 0.95
U6-PP (mm) 0.7 1.59 0.7 ! .76 0.99
L6-MP (mm) 1.2 1.61 1.2 1.36 0.90
UI-NA (mm) -0.8 1.51 - 1.5 2.1 i 0.25
LI-NB (mm) 0.8 1.31 0.6 0.90 0.62
U I-NA (angle) - 4.1 3.69 -5.1 4.81 0.49
LI-NB (angle) 1.2 3.99 0.9 3.88 0.83
UI-LI (angle) 5.0 4.99 6.1 5.20 0.56
U I-PP (angle) - 4.6 4.18 -5.1 4.41 0.73
LI-MP (angle) 0.2 3.7 i 0.6 4.11 0.77
LI-APg (ram) 2.0 1.36 1.5 1.65 0.34

Therefore, for the remainder of the study, all patients Table IV compares the changes in cephalometric
were evaluated as a single group. values during bionator treatment with the changes ex-
Table III shows comparisons of initial mean values pected during normal growth. The "expected change"
for the bionator patients with published cephalometrie was calculated by averaging the standard values s for
norms. 8 As a group, patients exhibited a strong ten- boys and girls at age l0 years, again at age 12 years,
dency for a Class I1 skeletal pattern and some evidence and finding the difference.
of excessive anterior vertical dimension. The largest The mean treatment change in the SNA angle was
deviations from normal standards, measured as per- a decrease of 0.6 ~ (Table IV). A decrease of this angle
centages, are in the ANB and the N-A-Pg angles. An- was noted in 25 of 39 patients. The SNB angle increased
terior facial height (ANS-Me) is slightly larger (102%) an average of 1.4 ~ with only 3 of the 39 patients show-
than normal, and the average mandibular plane angle ing a decrease. Thus the overall change in the ANB
exceeds standards by 3.3 ~ (109%). The S-Go, S-Art, angle was a net decrease of 2.1 ~ compared with a
and Art-Go measurements are all less than normal, in- decrease of 0.3 ~ for the normative data. The distance
dicating a shorter vertical ramus height and a posterior from the maxillary central incisor edge to the NA line
facial height. Other indications of excessive vertical decreased an average of 1 mm, with a decrease shown
dimension include statistically significant differences in b y 26 of the 39 patients. All of these changes were
the Y-axis angle, U6-PP distance, and upper facial significantly different (p <. 0.05) from normal growth
height/lower facial height (UAFH/LAFH) ratio. values. The distance from the lower incisor to the NB
370 Weinbach and Smith Am. J. Orthod. Dentofac. Orthop.
April 1992

Table III. Comparison of cephalometric standards with pretreatment mean values

I Mean value
Mean normal value beginning Sample
- - x 100%
Measurement age 10 yrs* bionator treatment Normal t value

SNA (angle) 80.7 8 I. I I00 0.85

SNB (angle) 76.6 74.3 97 -4.97**
ANB (angle) 4.1 6.8 164 9.43**
N-A-Pg (angle) 7.5 12.8 170 8.20**
SN-MxOP (angle) 19. I 21.5 112 3.76**
SN-MnOP (angle) 19. l 22.3 116 4.86**
SN-MP (angle) 35.0 38.3 109 5.05**
SN-PP (angle) 6.8 7.7 113 2.07**
Y axis to S-N (angle) 67.3 69.7 103 4.29**
An-Go-Me (angle) 127.7 127.9 I00 0.00
S-N to Art-Go (angle) 87.3 90.4 103 3.22**
N-Me (mm)(AFtl) i 16.9 116.9 100 0.00
N-ANS (mm)(UAFtl) 52.2 51.3 98 - 1.88
ANS-Me (mm)(LAFH) 67. ! 68.6 102 1.76
S-Go (mm)(PFH) 71.9 70.7 98 - 1.53
~.S-Art (mm) 33.1 32.9 99 - 0.49
:Art-Go (mm) 42.9 40.9 95 -4.00**
UAFIt/LAFtl 0.78 0.75 96 - 3.00**
PFIt/AFtt 0.62 0.60 97 -2.00
Go-Me (mm) 69.3 68.8 99 - 0.57
UI-PP (mm) 28.3 28.0 99 -0.67
LI-MP (mm) 40.9 40.5 99 - 1.09
U6-PP (mm) 20.5 21.3 104 2.25**
L6-MP (mm) 30.8 30.4 99 -0.92
UI-NA (ram) 4.1 4.7 ! 13 2.00
LI-NB (mm) 4.8 4.8 100 0.00
UI-NA (angle) 24.5 24.5 100 0.00
LI-NB (angle) 26.4 25.6 97 -0.88
UI-LI (angle) 125.0 123.1 98 - 1.48
UI-PP (angle) 112.0 113.3 101 1.44
LI-MP (angle) 94.8 92.9 98 - 1.79
LI-APg (mm) 1.9 0.2 11 -4.00**

*Calculated as the mean of male and female means reported by Riolo et al. s for age 10 ),ears.
**p < 0.05.

line increased an average of 0.7 mm, with an increase reflects a clinically significant lingual tipping of upper
found in 31 subjects. incisors. The lower incisors were proclined, but only
During treatment, facial convexity (as measured by moderately. The mandibular incisal edge advanced 1.9
the N-A-Pg angle) decreased an average of 3.9 ~ with mm relative to the APg line, whereas the angulation of
36 patients showing a decrease. The data on normal the lower incisor to the mandibular plane increased
growth suggest that a I ~ change in this measurement 0.3 ~.
should be expected. The ratio of UAFH to LAFH im- The mean dental overjet was improved from 9.0 to
proved from 0.75 to 0.77, with 29 of 39 patients show- 5.0 mm, with some reduction demonstrated in all but
ing this relative decrease in lower facial height. Simi- one patient. Open bite was also markedly improved,
larly, the ratio of PFH to AFH showed a slight increase with a mean decrease of 1.3 mm. Twenty-six patients
froin 0.61 to 0.62, with a change in this direction in showed an increase in overbite (or decrease in open
32 of 39 patients. bite). It should be noted that the appliance was not used
Dental changes were substantial. The interincisal exclusively in patients with anterior dental open bite,
angle increased an average of 5.4 ~ whereas the normal and some clinicians used appliances in which incisor
change between ages 10 and 12 years was an increase_ eruption was prevented by acrylic coverage.
of only 1.3 ~ The angle U I to PP decreased 4.7 ~ as The appliance appears to restrict eruption of max-
opposed to an expected increase of 0.2 ~. This change illary molars (Table IV). The upper molars are expected
Volume 101
Number4
Cephalometric changes with open bite bionator 371

Table IV. Comparison of expected growth with changes during treatment

I Expected I Bionator Patients Patients
Measurement change change decrease bwrease t vahte
SNA (angle) 0.5 -0.6* 25** 14 -4.68***
SNB (angle) 0.9 1.4 3 36 2.79***
ANB (angle) - 0.3 - 2.1 38 1 - 7.12"**
N-A-Pg (angle) - 1.0 -3.9 36 3 -5.74***
Overjet (mm) - 4.0 38 1
Overbite/openbite 1.3 13 26
SN-MxOP (angle) - 1.4 - 0.4 26 13 ! .70
SN-MnOP (angle) - 1.4 - 0.05 25 14 2.50***
SN-MP (angle) - 1.0 - 0.6 24 15 1.2 !
SN-PP (angle) 0.6 0.3 18 21 0.88
Y axis to S-N (angle) -0.3 -0.3 27 12 0.00
Art-Go-Me (angle) - 1.4 0.8* 18 21"* 4.93***
S-N to Art-Go (angle) 0.2 - 1.5" 24** 15 - 3.66***
N-Me (mm)(AFH) 3.9 4.7 i 38 1.42
N-ANS (mm)(UAFH) 2.1 2.5 3 36 1.33
ANS-Mr (mm)(LAFH) 1.7 1.8 9 30 0.38
S-Go (n~n)(PFH) 3.7 4.3 0 39 1.45
S-Art (mm) 1.0 i.3 9 30 0.79
Art-Go (mm) 2.9 3.6 3 36 1.89
UAFH / LAFH 0.01 0.02 I0 29 1.66
PFH/AFH 0.01 0.01 7 32 0.00
Go-Me (mm) 3.0 2.5 5 34 - i.13
UI-PP (mm) 1.0 1.6 8 31 1.88
Ll-MP (ram) i.2 1.2 8 31 -0.41
U6-PP (mm) 1.7 0.7 12 27 -3.69***
L6-MP (mm) 1. I 1.2 6 33 0.37
UI-NA (ram) 0.2 - !.0" 26** 13 -4.11"**
LI-NB (mm) 0.3 0.7 8 31 2.31'**
UI-NA (angle) - 1.0 -4.4 35 4 -5.28***
LI-NB (angle) -0.2 1.1' 18 21"* 2.03***
UI-LI (angle) 1.3 5.4 8 31 5.01"**
UI-PP (angle) 0.2 -4.7* 31"* 8 -7.30***
LI-NIP (angle) 0. I 0.3 20** 19 0.39
LI-APg (ram) 0.2 1.9 0 39 7.08***

*Mean value of change during bionator treatment opposite to that expected during normal growth.
**Majority of patients exhibit change during treatment opposite to that expected during normal growth.
***p < 0.05.

to erupt 1.7 mm between the ages of I0 and 12 years? for the pooled data is presented in Table V and indicates
Patients examined in this study had an average of only generally low correlations between treatment changes
0.7 mm eruption (p < 0.05). The appliance did not and age at start of treatment, length of treatment, and
appear to alter the normal magnitude of lower molar initial cephalometric values. There are several negative
eruption. correlations between pretreatment measurements and
Several variables changed in directions opposite to treatment effects. Thus the trend seems to be that pa-
that expected during normal growth. Maxillary incisors tients with smaller initial measurements have greater
normally become slightly more procumbent with changes during functional treatment. This must be in-
growth. However, during treatment these teeth signif- terpreted with caution, however, since several of the
icantly retroclined, as measured by U I-NA and U I-PP. changes are measured as negative values. There were
The SNA angle is expected to increase slightly with also several negative correlations between age at the
growth, but was found to decrease an average of 0.6 ~. start of treatment and treatment effects. These results
The mandibular incisor flared during treatment, while may suggest that the appliance is more effective in
during normal growth, the L1-NB angle typically ex- yOU.lager patients. Overall, the correlations between the
hibits a slight decrease. length of treatment and the cephalometric changes in-
A summary of the Pearson correlation coefficients dicate that longer functional treatment results in greater
372 Weinbach and Smith Am. J. Orthod. Dentofac. Orthop.
April 1992

Table V. Correlations of changes during treatment with selected variables

Change Durhtg Treatment Correlations
Length of [ Pretreatment
Measurement Mean SD Age at start treatment [ vahte

SNA (angle) -0.6 1.55 0.21 -0.12 0.02

SNB (angle) ! .4 1.21 0.13 - 0.01 0.18
ANB (angle) - 2.1 1.47 0.12 - O. 12 - 0.58
N-A-Pg (angle) - 3.9 3.15 0.15 - 0.28 - 0.33
Overjet ( m m ) - 4.0 2.30 0.04 0.04 - 0.67
Overbite/openbite 1.3 2.57 - 0.25 0.18 - 0.68
SN-MxOP (angle) - 0.4 3.81 - 0.07 - O. 13 - 0.27
SN-MnOP (angle) - 0.05 3.50 - 0.14 - O.Ol - 0.35
SN-MP (angle) - 0.6 2.03 - 0.03 - 0.12 - 0.03
SN-PP (angle) 0.3 2.07 O. ! 1 0.19 0.09
Y axis to S-N (angle) -0.3 1.41 -0.07 0.08 0.04
Art-Go-Me (angle) 0.8 2.83 0.25 - 0.26 - 0.49
S-N to Art-Go (angle) -1.5 2.90 -0.27 0.17 -0.32
N-Me (mm)(AFH) 4.7 3.27 - 0.22 0.71 - 0.2 !
~N-ANS ( m m ) ( U A F H ) 2.5 2.05 -0.22 0.60 -0.33
;ANS-Me ( m m ) ( L A F H ) 1.8 2.49 - 0.02 0.36 - 0.02
S-Go ( m m ) ( P F H ) 4.3 2.65 - 0.07 0.69 - 0.03
S-Art (mm) 1.3 1.79 - O . 19 0.44 - O. 17
Art-Go (mm) 3.6 2.39 O. 12 0.47 - 0.08
UAFH / LAFH 0.02 0.04 - O. 14 0.24 - 0.04
PFti/AFil 0.01 0.02 0.08 0.20 - 0.05
Go-Me (mm) 2.5 2.47 - 0.40 0.62 - 0.5 I
UI-PP (mm) 1.6 2.]5 -0.34 0.37 -0.55
LI-MP (mm) 1.2 1.36 - 0.24 0.57 - 0.32
U6-PP ( m m ) 0.7 1.62 -0.21 0.56 -0.48
L6-MP ( m m ) 1.2 1.52 -0.07 0.41 -0.33
U I - N A (mm) - 1.0 1.72 -0.03 0.22 -0.26
LI-NB (mm) 0.7 1.19 - 0.25 0.33 - 0.55
U I - N A (angle) -4.4 4.03 O. I0 0.04 -0.19
L I - N B (angle) I. 1 3.91 - 0.07 0.12 - 0.55
U I - L I (angle) 5.4 5.01 -0.06 -0.09 -0.38
U I-PP (angle) - 4.7 4.20 0.12 0.09 - 0.20
L I - M P (angle) 0.3 3.78 - 0.09 0.19 - 0.29
L I-APg (mm) 1.9 1.45 - 0.11 O. I 0 - 0.54

changes. The only correlation coefficient to reach 0.7 than a bionator, particularly the appliances that had
is between the length of treatment and the increase in occlusal coverage of both anterior and posterior teeth
total facial height (N-Me). This relationship reflects of both arches. This appliance can no longer be con-
both treatment effects and normal growth. sidered to meet one of Balter's basic concepts in the
design of the bionator, namely, to allow the appliance
DISCUSSION freedom of movement within the oral cavityY ~
The majority of "activators" and "bionators" used For the present study, the open bite bionator was
in clinical practice today differ substantially from the defined simply as a bionator that had posterior occlusal
appliances described by Andreason and Baiters) ~ The coverage. That definition allows for appliances that
original appliances coincided with .specific concepts have full occlusal coverage, headgear tubes, lip pads,
concerning the role of the tongue, buccal and labial and other modifications. Since posterior occlusal cov-
musculature, eruption of teeth, and maxillary and man- erage is the critical component of this appliance, and
dibular growth in the causes of malocclusions. Appli- cases were furnished from several practices, it was de-
ances used today are frequently better described as hy- cided to make posterior coverage the only criterion for
brid appliances, as discussed by Vig and Vig. ~2 Thus inclusion in the study. Furthermore, the appliances were
an "open bite bionator," as used in the present study, all ordered from art established commercial laboratory,
may appear to some readers as more of an activator and each was made on the basis of a prescription on
Volume 101 Ceplmlometric changes with open bite bionator 373
Number 4

which the clinician had requested an "open bite relapse. I n a study of 50 activator patients 2 years after
bionator." treatment, Ahlgren ~9 also found no evidence of relapse.
The posterior occlusal coverage of the open bite However, longer term observations by Pancherz, 2~who
bionator may function as a bite block. In a study of followed 19 patients treated with the activator for 10
nonhuman primates, Altuna and Woodside ~3 noted that to 20 years after treatment, indicated substantial relapse
the thickness of posterior bite blocks was important in of overjet in nine patients, and found that this was
determining the magnitude o f maxillary horizontal re- associated with open bite a n d / o r tongue thrust in most
modeling. Variations in this parameter could affect cases. However, no posterior occlusal coverage was
some cephalometric changes during treatment. used, and backward rotation of the mandible occurred
Two reports '~.~ have made brief mention of the frequently.
construction and indications for the open bite appliance, Many techniques used in conventional edgewise
but present no clinical or experimental treatment data. mechanics are ineffective or counterproductive in treat-
The results of the present investigation confirm that the ing cases that exhibit both open bite and Class II prob-
open bite bionator can assist in the correction of a Class lems. v For example, cervical headgear, tip-back bends,
1I malocclusion while not leading to bite opening, and intermaxillary elastics, bite planes, and leveling me-
often decreasing the open bite tendency. It should be chanics can all produce unwanted molar extrusion,
noted from Table IV that between the ages of 10 and making an open bite worse. The results described here
12 years, th'e upper molars erupt an average of 1.7 mm suggest that the open bite bionator can be helpful in
reative to tlie palatal plane. In the cases examined here, treating growing patients presenting with this difficult
the average eruption was only 0.7 mm and nearly one malocclusion.
third (12 of 39) of the patients showed a decrease in 9 We thank David AUesee of A.O.A. Laboratory, Sturte-
the distance from the upper molar to the palatal plane. vent, Wisc., for assistance in locating practitioners for par-
Our general impression from a visual examination ticipating in this study, and Drs. Charles Collins, Indianola,
of the cephalometric radiographs, which was confirmed Iowa; J. Kendall Dillehay, ~fCichita, Kan; Loring Ross, Myrtle
by the pretreatment analyses of cephalometric mea- Beach, S.C.; Michael Johnson, Bedford, Texas; Fay Ward-
surements (Table III), was that clinicians do not use law, Little Rock, Ark; and Michael Matlof and Robert Waxier,
St. Louis, Mo., for contributing records for this study. We
the open bite bionator for severe skeletal anterior open
also thank Mr. David Hertweck for assistance with digitizing
bite cases; rather, the appliance is used for Class II
radiographs and with data analysis, and Ms. Rita Kuehler for
correction in patients for whom the clinician is con- preparation of the manuscript.
cerned that posterior eruption would be undesirable,
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AAO MEETING CALENDAR

1992--St. Louis, Mo., May 9 to 13, St. Louis Convention Center
1993--Toronto, Canada, May 15 to 19, Metropolitan Toronto Convention Center
1994--Orlando, Fla., May 1 to 4, Orange County Convention and Civic Center
1995--San FranciscO, Calif., May 7 to 10, Moscone Convention Center
(International Orthodontic Congress)
1996--Denver, Colo., May 12 to 16, Colorado Convention Center
1997--Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center
1998--Dallas, Texas, May 16 to 20, Dallas Convention Center
1999--San Diego, Calif., May 15 to-19, San Diego Convention Center