Original Article

Twenty-year follow-up of functional treatment with a bionator appliance:

A retrospective dental cast analysis
Rebecca Jungbauera; Vasiliki Koretsia; Peter Proffb; Ingrid Rudzkic; Christian Kirschneckd

ABSTRACT

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Objective: To investigate changes in dental arch configuration, relationship, and malocclusion
directly after Class II malocclusion treatment with a Balters bionator modified by Ascher as well as
20 years after treatment.
Materials and Methods: Orthodontic dental cast analysis of 18 patients with skeletal Class II
treated with a bionator without any additional fixed therapy was performed with a digital caliper at
three stages: before (T0), after (T1) and 20 years after (T2) treatment. Arch perimeter and depth,
intermolar and intercanine distance, overjet, overbite, sagittal molar and canine relationship,
mandibular incisor irregularity (Little’s index), and malocclusion (PAR index) were assessed.
Results: During treatment (T0–T1), upper arch perimeter significantly increased with a significant
decrease in the upper and lower arch perimeter long-term (T1–T2), whereas corresponding arch
depths changed only slightly in both periods. Transverse intermolar width increased significantly
during treatment, remaining almost constant from T1 to T2. Lower intercanine distance remained
fairly unchanged during treatment, but decreased significantly during follow-up. Lower incisor
irregularity improved slightly during treatment but increased significantly long-term. After treatment,
sagittal molar relationships on both sides were improved, overjet and overbite reduced; these
significant changes remained stable long-term. The peer assessment rating (PAR) index was
significantly lower after treatment and increased insignificantly during follow-up.
Conclusions: 20 years after bionator treatment without additional fixed appliances, the improved
sagittal relationship and the reduced overjet and PAR index remained fairly stable. Long-term
changes are most likely due to physiological aging processes and are not associated with bionator
treatment. (Angle Orthod. 2020;90:209–215.)
KEY WORDS: Bionator; Long-term follow-up; Functional treatment

INTRODUCTION tion for orthodontic treatment.1 The bionator according

Class II malocclusion is a common finding among
orthodontic patients and an important medical indica-
a
Junior Researcher, Department of Orthodontics, University
Medical Centre Regensburg, Regensburg, Germany
b
Professor and Chairman, Department of Orthodontics,
University Medical Centre Regensburg, Regensburg, Germany
c
Professor Emeritus, Faculty of Medicine, LMU University of
Munich, Munich, Germany
d
Associate Professor, Department of Orthodontics, University
Medical Centre Regensburg, Regensburg, Germany
Corresponding author: Dr. Rebecca Jungbauer, Orthodontist,
Junior Researcher, Department of Orthodontics, University
Medical Centre Regensburg, Franz-Josef-Strauß-Allee 11,
93053 Regensburg, Germany
(e-mail: rebecca.jungbauer@ukr.de)
Accepted: June 2019. Submitted: April 2019.
Published Online: September 4, 2019
Ó 2020 by The EH Angle Education and Research Foundation,
Inc.
to Balters is a functional orthopedic appliance to treat
Class II malocclusion in growing patients with skeletal
harmony of the jaws or when skeletal harmony can be
expected due to an inherited favorable growth potential
and direction of the upper and lower jaw.2,3 This kind of
appliance is especially applicable in patients with
orofacial dysfunctions such as persisting sucking
habits or habitual mouth breathing and is supposed
to harmonize tongue, lip, and cheek muscles.2 Ascher
modified Balters’ bionator by adding an acrylic lower
incisor capping to prevent the lower incisors from
protruding.4 Although bionator treatment during prepu-
berty mainly causes dentoalveolar adaptation, skeletal
effects are possible during pubertal growth.5–8 It seems
that bionator treatment displaces the mandible anteri-
orly but limits its normal counterclockwise rotation by
changing the direction, but not the amount of condylar
growth.9 Nevertheless, upper incisor retroclination and

DOI: 10.2319/042419-292.1 209 Angle Orthodontist, Vol 90, No 2, 2020

210 JUNGBAUER, KORETSI, PROFF, RUDZKI, KIRSCHNECK

lower incisor proclination are to be expected as side

effects despite the capping of the lower incisors.2
Long-term stability of treatment results is a key to
successful orthodontic treatment. Additionally, it is
essential to understand the difference between relapse
after treatment and physiological processes related to
aging.10–12 Several studies have evaluated cephalo-
metric and morphometric long-term changes after
bionator therapy followed by fixed appliances.5–7,13,14
Francisconi et al. reported that therapy with a bionator

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followed by fixed appliances produced favorable
results in apical base and molar relationships, overjet,
and overbite that remained stable 10 years post-
treatment.15 Only a few studies, however, investigated
long-term changes of dental arches after functional
treatment more than 15 years after treatment. There is
no study assessing long-term stability of bionator
therapy that was not supplemented by fixed applianc-
es. Therefore, the aim of the present study was to
assess treatment effects and their long-term stability of
Class II bionator therapy with the Balters bionator
modified by Ascher based on patients’ dental casts
before, directly following, and 20 years after treatment.
MATERIALS AND METHODS
Study Design
Orthodontic records of patients treated with a Balters
bionator modified by Ascher2,4 were retrospectively
collected in 2018 from the archives of the Department
of Orthodontics, University Medical Centre Munich,
Bavaria, Germany. Bionator treatment was initiated
between 1973 and 1979 and exclusively conducted by
one experienced orthodontist (IR). Mean patient age
before treatment (T0) was 9.8 years (SD: 1.5), after
bionator treatment (T1) 13.3 years (SD: 1.9) and after
20 years of follow-up (T2) 33.3 years (SD: 2.3). The
facial type of each patient was evaluated according to
Individualized Cephalometrics with a ceph template
and a harmony box according to Segner and Hasund
(retrognathic ,798, orthognathic 798–858, prognathic
.858).16 The following eligibility criteria were applied:
(1) treatment with a Balters bionator modified by
Ascher,2,4 (2) no treatment with fixed appliances at
any time, (3) skeletal Class II defined as ANB . 48 in
an orthognathic facial type and ANB . 28 in a
retrognathic facial type,16 (4) available dental casts at
all time points: T0, T1, and T2, (5) no orthodontic
extraction therapy, space closure, or opening. Ortho-
dontic records were collected for treatment purposes at
the start (T0) and end (T1) of treatment. In addition,
long-term assessment was performed 20 years after
the end of treatment (T2). Ethical approval was
obtained from the ethics committee of the University
of Munich (77/97) and patient consent for the data
Figure 1. Bionator according to Balters modified by Ascher.
collection at T2 was also obtained. From T1 to T2,
patients received no orthodontic treatment or retention.
Protocol of Bionator Functional Treatment from T0
to T1
Alginate impressions (Kaniedenta, Herford, Ger-
many) were taken of the upper and lower dental arch
and a wax construction bite of the therapeutically
desired jaw relation was made without disrupting
patients’ postural resting position in the vertical plane
(lip closure without muscular activity). The latter was
taken in the sagittal plane in an edge-to-edge incisor
relationship and in the vertical plane with or without a
slight vertical opening. In the transverse plane, the
mandibular midline was positioned to coincide with the
maxillary and facial midlines. The bionator appliance
consisted of an acrylic monobloc with extensions as
small as possible, a palatal bar (coffin spring), and a
buccinator loop. Following Ascher’s modification, the
lower incisors were covered with acrylic with slight
impressions of the upper incisors for stabilizing them
vertically (Figure 1). If necessary, bionators were
adjusted to raise the bite. Patients were asked to wear
their appliances 24 h/d apart from eating and tooth-
brushing. Actual usage times were self-recorded by the
patients on adherence cards. As soon as Class I at the
first molars and overjet reduction were evident clinical-
ly, wearing time was reduced to 12 h/d (night).
Dental Cast Analysis
Measurements on patients’ dental casts of the upper
and lower dental arches were undertaken by one
experienced orthodontist (RJ). A digital caliper (HSL
246-15, Hammacher, Solingen, Germany) was used
with a precision of 0.01 mm. All data were, however,
rounded to the first decimal prior to statistics. All
outcome variables measured are listed in Table 1,
corresponding to standard parameters in orthodontic

Angle Orthodontist, Vol 90, No 2, 2020

TWENTY-YEAR FOLLOW-UP OF BIONATOR TREATMENT 211

Table 1. Recorded Measurements (Outcome Variables) on Dental Casts at T0, T1, and T2

Upper arch perimeter [mm]
Lower arch perimeter [mm]
Upper arch depth [mm]
Lower arch depth [mm]
sum of the distances mesial contact point of first upper molars to the distal contact point of the
lateral upper incisors and then to the mesial contact point of the central upper incisors at
both sides of the dental arch
sum of the distances mesial contact point of first lower molars to the distal contact point of the
lateral lower incisors and then to the mesial contact point of the central lower incisors at
both sides of the dental arch
perpendicular distance from the mesial contact points of the central upper incisors to a line
connecting the midpoints of the central grooves of the first upper premolars or the distal
fossae of primary upper first molars
perpendicular distance from the mesial contact points of the central lower incisors to a line
connecting the contact points between the first und lower second premolars on each side of

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Upper intermolar distance [mm]
Lower intermolar distance [mm]
Lower intercanine distance [mm]
Mandibular incisor irregularity [mm]
Overjet [mm]
Overbite [mm]
Weighted PAR index (PAR)
M1 molar relationship [premolar widths]
C canine relationship [premolar widths]
the dental arch or the distobuccal cusp tips of primary lower first molars
transversal distance between the midpoints of the central fossae of the first upper molars
transversal distance between the disto-buccal cusp tips of the first lower molars
transversal distance between the cusp tips of the mandibular permanent or primary canines
sum of the linear horizontal displacement between proximal contact points of the lower
incisors and canines
maximum sagittal distance between the incisal edges of antagonist upper and lower incisors
maximum vertical distance between the incisal edges of antagonist upper and lower incisors
assessment of displacement scores in the upper and lower anterior dental segment including
impaction, buccal occlusion (transversal, vertical, sagittal), overjet, overbite and centerline
sagittal relationship of the upper and lower first molars according to Angle’s definition,
recorded in premolar widths
sagittal relationship of the upper and lower canine, recorded in premolar widths

dental cast analysis and characterizing the dental
arches, their relationship, as well as the degree of
crowding (Little’s irregularity index),17 and malocclusion
(PAR index).18
Measurement Error
To determine intra- and interrater reliability, 30 casts
were selected randomly and measurements performed
a second time after a time interval of 4 weeks by the
same (RJ) as well as a different experienced investi-
gator (VK). To calculate casual and systematic errors,
Dahlberg’s formula and the intraclass correlation
coefficient (ICC; two-way mixed, absolute agreement)
were used.
Statistical Analysis
Data were analyzed using the software IBM SPSS
Statistics 23 (IBM, Armonk, NY, USA). Mean (M) and
standard deviation (SD), as well as median (MD) and
interquartile range (IQR) were reported as descriptive
statistics. More than 5% of the data showed a non-
normal distribution. Therefore, nonparametric Fried-
man’s two-way analysis of variance by ranks was
performed and pairwise comparisons calculated with
Dunn’s post hoc tests. A P value of .05 was
considered statistically significant. Effect sizes were
calculated as Pearson’s r and interpreted according to
Cohen.19

Figure 2. Flow chart of retrospectively screened, available, and
statistically analyzed patients.
RESULTS
Based on the inclusion criteria, 18 patients (nine
males and nine females) and their corresponding
dental casts at T0, T1, and T2 were available for
analysis (Figure 2). A total of 134 available patient
records with bionator treatment were assessed for
eligibility. 98 patients were excluded due to nonpartic-
ipation in the follow-up study, while 18 of the remaining
36 patients needed to be excluded due to not meeting
the inclusion criteria. Baseline characteristics of the 18
included study patients are displayed in Table 2.
According to Individualized Cephalometrics by Segner

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212 JUNGBAUER, KORETSI, PROFF, RUDZKI, KIRSCHNECK

Table 2. Baseline Data of Patients Prior to Orthodontic Bionator whereas the lower intercanine distance did not
Treatment (T0)a increase significantly. Arch perimeter was significantly
Variable M SD greater after treatment in the upper, but not in the lower
Age (years) 9.8 1.5 dental arch (Table 3). There was a slight, but not
ANB retrognathic (8) 4.6 1.3 significant, decrease in arch depth in the upper arch
ANB orthognathic (8) 5.2 1.6 and an increase in the lower arch. Overjet, overbite,
Index (%) 80.4 7.2
ML-NL (8) 27.5 4.4
and PAR index showed a significant decrease during
Overjet (mm) 5.5 2.1 bionator treatment (T0–T1). Mandibular incisor irregu-
a
M indicates mean; SD, standard deviation; Index, Index
larity decreased slightly, but not significantly. The
according to Hasund (anterior facial height: open/deep relation sagittal relationship at the first molars improved

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,71/.89%); n ¼ 18.
and Hasund,16 61.1% (n ¼ 11) had a retrognathic facial
type, and 38.9% (n ¼ 7) were orthognathic. At the end
of treatment (T1), the average age was 13.3 6 1.9
years and at follow-up (T2) 33.3 6 2.3 years. Total
average treatment time was 3.5 6 1.4 years. According
to the personal adherence cards, the actual daily
wearing time ranged between 12 and 14 hours. 50% of
all patients (n ¼ 9) had been treated with active
removable appliances prior to bionator treatment, and
50% (n ¼ 9) had not received any appliance apart from
the bionator.
Nonparametric Friedman’s two-way analysis of
variance showed significant overall changes from T0
to T2 for all parameters except for lower arch depth and
sagittal relationship of left canines (Table 3).
Pairwise comparisons revealed that there was a
significant increase in transverse intermolar distance in
the upper and lower arches during treatment (T0–T1),
significantly from 0.5 premolar widths distal occlusion
to neutral occlusion at both sides, with a similar, but not
significant tendency for the canine relationship on the
right side.
In the course of the follow-up period of 20 years (T1–
T2), the upper and lower intermolar distance de-
creased, but not significantly (Table 3). Lower inter-
canine distance as well as upper and lower arch
perimeter decreased significantly with a similar ten-
dency for upper and lower arch depth. There was also
a slight, not significant increase in overjet, overbite,
and PAR index as well as a significant increase in
mandibular incisor irregularity. Sagittal relationships of
first molars changed not significantly from neutral
occlusion to -0.1 premolar widths mesial occlusion.
On the right side, distal occlusion of canines improved
slightly toward neutral occlusion with occlusion at the
left canines remaining unchanged.
The method error ranged from 0 to 0.8 as calculated
by Dahlberg’s formula. Intrarater and interrater reliabil-

Table 3. Descriptive and Analytical Statistics of Measured Outcome Parameters in Dental Cast Analysis Before (T0), After (T1) And 20 Years
After (T2) Bionator Treatmenta,b
T0 T1 T2

Variables N MD [IQR] M 6SD MD [IQR] M 6SD MD [IQR] M 6SD

Upper arch perimeter [mm] 18 74.4 [5.3] 75.4 64.3 76.8 [7.3] 77.8 63.8 75.1 [6.0] 75.4 64.0
Lower arch perimeter [mm] 18 66.3 [6.2] 66.8 64.3 66.7 [6.5] 67.2 64.2 63.0 [3.3] 62.8 62.9
Upper arch depth [mm] 15 18.5 [1.9] 18.0 61.7 17.8 [2.3] 17.9 61.5 16.8 [2.4] 17.1 61.7
Lower arch depth [mm] 15 14.9 [3.6] 14.2 62.0 15.5 [1.5] 15.2 61.6 14.2 [3.8] 14.6 61.9
Upper intermolar distance [mm] 18 45.4 [5.2] 45.4 63.3 49.0 [4.2] 48.6 62.6 48.2 [4.2] 47.9 63.2
Lower intermolar distance [mm] 18 47.2 [4.6] 46.9 62.9 49.9 [3.7] 49.6 63.0 48.6 [4.3] 48.3 62.7
Lower intercanine distance [mm] 16 25.7 [2.3] 25.8 62.3 26.0 [3.0] 26.3 61.9 24.4 [3.7] 24.6 61.9
Overjet [mm] 18 5.5 [1.8] 5.5 62.1 2.7 [0.7] 3.1 61.4 3.1 [2.0] 3.5 61.4
Overbite [mm] 18 3.8 [1.7] 3.8 61.2 2.6 [2.4] 2.8 61.4 3.3 [1.5] 3.3 61.2
Mandibular incisor irregularity [mm] 18 2.3 [1.1] 2.4 61.2 2.0 [1.5] 2.5 61.9 3.7 [2.5] 4.1 62.3
PAR index 18 18.0 [12.0] 19.9 69.9 6.5 [6.0] 7.7 67.4 12.0 [13.0] 12.3 68.3
M1 molar relationship, right side [premolar widths] 18 þ0.5 [0.6] þ0.5 60.3 0.0 [0.3] -0.1 60.3 -0.1 [0.5] -0.2 60.4
C canine relationship, right side [premolar widths] 11 þ0.5 [0.5] þ0.3 60.2 þ0.3 [0.3] þ0.2 60.1 0.0 [0.3] þ0.1 60.3
C canine relationship, left side [premolar widths] 11 þ0.3 [0.5] þ0.3 60.3 þ0.3 [0.0] þ0.2 60.1 0.3 [0.3] þ0.2 60.2
M1 molar relationship, left side [premolar widths] 18 þ0.5 [0.3] þ0.6 60.3 0.0 [0.3] -0.1 60.3 -0.1 [0.5] -0.1 60.4
a
T0 indicates before treatment; T1, end of treatment; T2, 20 years after treatment; N, numbers analyzed; MD, Median; IQR, interquartile range;
M, mean; SD, standard deviation; df, degrees of freedom; M1, first molars; C, canines; þ, distal (class II) sagittal relationship; -, mesial (class III)
sagittal relationship; 0, class I sagittal relationship.
b
Global changes were tested with non-parametric Friedman’s two-way analysis of variance by ranks and pairwise comparisons calculated by
Dunn’s post hoc tests.
* P , .05; ** P , .01; *** P , .001; r is effect size calculated as Pearson’s correlation coefficient (, 0.3 small effect, 0.3–0.5 medium effect,
. 0.5 large effect).

Angle Orthodontist, Vol 90, No 2, 2020

TWENTY-YEAR FOLLOW-UP OF BIONATOR TREATMENT 213

ity of dental cast measurements were substantial, with
ICC ranging from 0.8 to 1 for all outcome variables.
DISCUSSION
The aim of this retrospective cast analysis was to
evaluate long-term changes of dental parameters after
treatment with a functional orthopedic appliance
(Balters bionator modified by Ascher) not followed by
treatment with fixed appliances. Therefore, dental
casts were analyzed before, at the end of bionator
taking physiological changes due to aging into consid-
eration.
The median PAR index was reduced 63.1% after
treatment (T0–T1). Comparing the median of the PAR
index before treatment and after long-term observation,
there was still a reduction of 33.3%. Francisconi et al.
found a higher reduction (81.8%) after treatment with a
bionator and fixed appliances15 and 4.9% relapse 10
years after treatment. Bock et al. reported an increase
of the PAR index (þ4.8) more than 15 years after

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treatment, and 20 years after treatment.
The results of the present study showed that overjet
was reduced significantly during bionator therapy (T0–
T1) as well as sagittal molar and canine relationship
were improved toward Class I. Overjet showed a small,
not significant increase in the long-term observation
(T1–T2), but all parameters remained reasonably
stable 20 years after the end of treatment with only
arch perimeter and lower intercanine distance de-
creasing and mandibular incisor irregularity increasing
significantly. Several longitudinal studies on physiolog-
ical development of dental arches and maturation have
shown that, without any treatment, overjet decreases
only a very small amount.10–12 Other studies reported
similar results on long-term outcomes of bionator
treatment based on measurements of dental casts.15
However, this study was the first to evaluate long-term
effects of bionator treatment without follow-up treat-
ment with fixed appliances, thus enabling an assess-
ment of the long-term stability of bionator therapy itself,
treatment with the Herbst appliance.20 In the present
study, þ5.5 relapse in the median of the PAR index 20
years after treatment was observed. The fact that there
was no treatment with fixed appliances and no
retention with fixed retainers could explain, why less
reduction of the PAR index and more relapse was
detected in the current investigation compared to other
studies.
Maxillary and mandibular arch perimeter increased
during treatment with the increase in the upper arch
being significant. This effect was most likely a result of
age-dependent physiological development (aging), but
there might also have been a small distalizing bionator
effect on the upper molars. Long-term, a significant
decrease of arch perimeter in both arches was
observed, most likely due to age-dependent physio-
logical changes.11,12
There were no significant changes in upper and
lower arch depth, neither during treatment nor long-
term. After bionator treatment, upper arch depth was

Table 3. Extended

Global Friedman ANOVA Dunn’s Post Hoc Tests

Adjusted P Value Adjusted P Value Adjusted P Value
P Value F df T1–T0 r T2–T1 r T2–T0 r
.006** 10.333 2 .037* 0.24 .008** 0.20 1.000 –
,.001*** 21.444 2 1.000 – ,.001*** 0.33 ,.001*** 0.30
.015* 8.373 2 .946 – .204 – .014* 0.27
.420 1.733 2 – – – – – –
,.001*** 20.111 2 ,.001*** 0.34 .730 – .005** 0.25
.006** 10.111 2 .005** 0.25 .200 – .547 –
.001** 14.625 2 .867 – .001** 0.33 .024* 0.23
,.001*** 22.333 2 .001** 0.35 .952 – .001** 0.28
.042* 6.333 2 .037* 0.20 .952 – .401 –
.031* 6.958 2 1.000 – .047* 0.19 .112 –
,.001*** 19.913 2 ,.001*** 0.33 .634 – .008** 0.24
,.001*** 27.269 2 .001** 0.29 1.000 – ,.001*** 0.33
.029* 7.091 2 .329 – 1.000 – .076 –
.099 4.629 2 – – – – – –
,.001*** 30.032 2 ,.001*** 0.32 1.000 – ,.001*** 0.37

Angle Orthodontist, Vol 90, No 2, 2020

214
smaller and lower arch depth higher. This was possibly
the result of a distalizing bionator effect on the upper
molars and a slight protrusion of the lower incisors. The
latter, however, was not significant, most likely due to
the covering of the incisors according to Ascher’s
modification, which is supposed to prevent lower
incisors from protruding. A minor decrease of arch
depth 20 years later is, according to most authors, a
result of physiological processes related to aging.10–12
After the first observational period, there was a
significant increase in arch width in both arches
posteriorly. The gain in transverse width can most
likely be attributed to development and growth.
Mandibular intercanine distance, by contrast, in-
creased only to a minor degree. Transverse develop-
ment is associated with the eruption of teeth and
mandibular intercanine distance is, most likely, the
first transverse distance to remain stable during
growth.21 In agreement with the findings of Pancherz22
and others10–12 intercanine distance decreased signif-
icantly over the long-term period (T1–T2). Again, this
was most likely related to aging. The current study
involved patients, who were only treated with biona-
tors and no fixed appliances. Therefore, no therapeu-
tic expansion of the dental arches was performed at
any time, which could otherwise have accounted for
this observation due to transverse relapse.
Mandibular incisor irregularity improved slightly
during treatment, probably due to additional space in
the anterior segment achieved by the physiological
increase in transverse widths and the slight protrusion
of incisors, which might be attributable to bionator
treatment. After the long-term follow-up (T1–T2),
however, there was a significant increase in lower
incisor irregularity, which was most likely associated
with the significant decrease in both lower arch
perimeter and intercanine width, in agreement with
reports after treatment with the Herbst appliance22 and
with published data on physiological growth chang-
es.10–12
Although this study provided data for the first time on
long-term effects of bionator treatment without follow-
up treatment with fixed appliances, there were some
limitations to note. In general, follow-up studies are
inherently biased, as it is not possible to locate all
potential study participants and not every patient
located is willing to participate. Furthermore, patients
willing to participate tend to be those satisfied with
treatment. Another limitation was the reduced number
of study patients available for assessment, which of
course limited study power and generalizability. In
retrospective, long-term studies, however, this problem
is commonly unavoidable due to patients not being
available for follow-up examination or heterogeneity of
the initially treated patient collective. Since study
Angle Orthodontist, Vol 90, No 2, 2020
JUNGBAUER, KORETSI, PROFF, RUDZKI, KIRSCHNECK
parameters could not be predetermined prospectively,
strict inclusion criteria were required to reduce biasing
factors and to achieve a homogeneous patient sample
and, thus, sufficient generalizability of results. Addi-
tionally, results of the treatment changes and long-term
effects of bionator treatment reported in this study need
to be interpreted in view of the naturally occurring aging
processes of the dentition, which most likely also
contributed to treatment effects and long-term stability.
Due to ethical reasons, no control group with compa-
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rable dental and skeletal configuration at T0, but left
untreated, could be analyzed. The matching of patient
data to a historical control group as a possible solution
can, however, introduce serious bias,23 thus limiting its
usefulness.
Although bionator treatment cannot replace fixed
appliances, as many treatment goals can only be
achieved with these appliances, poor oral hygiene and
development of white spot lesions are a common
finding following fixed therapy and related to its
duration.24–26 Bionator treatment prior to fixed ortho-
dontic therapy could thus be a reliable option to reduce
treatment time with fixed appliances, as Class I
occlusion can already be stably achieved in advance.
CONCLUSIONS
 After treatment with a Balters bionator modified by
Ascher, overjet and PAR index were significantly
reduced and sagittal first molar relationship signifi-
cantly improved. These treatment results remained
reasonably stable in the long term, 20 years after
treatment.
 Significant long-term changes such as a decrease in
dental arch perimeter, decrease in intercanine
distance, as well as an increase in mandibular incisor
irregularity, are most likely due to physiological, age-
related processes and not associated with the
bionator treatment itself.
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Angle Orthodontist, Vol 90, No 2, 2020