ORIGINAL ARTICLE

Comparative study of the Frankel (FR-2) and

bionator appliances in the treatment of Class II
malocclusion
Marcio Rodrigues de Almeida, DDS, MSc, PhD,a Jose Fernando Castanha Henriques, DDS, MSc, PhD,b and
Weber Ursi, DDS, MSc, PhDc
Bauru, Lins, and Sao Jose dos Campos, Brazil

The purpose of this investigation was to compare the dentoalveolar and skeletal cephalometric changes
produced by the Frankel (FR-2) and bionator appliances in persons with Class II malocclusion. Lateral
cephalograms were available for 66 patients of both sexes, who were divided into 3 groups of 22. The control
group included untreated Class II children, with an initial mean age of 8 years 7 months; they were followed
without treatment for 13 months. The FR-2 appliance group had an initial mean age of 9 years; those children
were treated for a mean period of 17 months. The bionator group initially had a mean age of 10 years 8
months; on average, they were treated for 16 months. The results demonstrated no significant changes in
maxillary growth during the evaluation period. Both appliances showed statistically significant increases in
mandibular growth and mandibular protrusion, with greater increases in patients treated in the bionator
group. Both experimental groups showed an improvement in the maxillomandibular relationship. There were
no significant changes in growth direction, while the bionator group had a greater increase in posterior facial
height. Both appliances produced similar labial tipping and protrusion of the lower incisors, lingual
inclination, retrusion of the upper incisors, and a significant increase in mandibular posterior dentoalveolar
height. The major treatment effects of bionator and FR-2 appliances were dentoalveolar, with a smaller, but
significant, skeletal effect. (Am J Orthod Dentofacial Orthop 2002;121:458-66)

M
any investigators have claimed that a Class
II molar relationship occurs in a variety of
skeletal and dental configurations. Some
studies1-7 have shown that the components of Class II
malocclusion can be categorized into 4 main groups:
anterior position of the maxilla, anterior position of the
maxillary dentition, mandibular skeletal retrusion in
absolute size or relative position, and excessive or
deficient vertical development. McNamara8 stated that
most Class II patients present a deficiency in the
anteroposterior position of the mandible. If the contem-
a
Associate Professor at Lins Dental School, Methodist University of Piracicaba.
b
Professor and Chairman, Department of Orthodontics, Bauru Dental School,
University of Sao Paulo.
c
Associate Professor, Department of Orthodontics, Sao Jose dos Campos
Dental School, Sao Paulo State University.
Supported by CNPQ (Brazilian National Research Foundation).
Based on research submitted by Dr Marcio Rodrigues de Almeida in partial
fulfillment of the requirements for the PhD degree in orthodontics, University
of Sao Paulo, Bauru Dental School.
Reprint requests to: Marcio Rodrigues de Almeida, Department of Orthodon-
tics, Bauru Dentistry School, University of Sao Paulo, R. Octavio Pinheiro
Brizolla, 9-75 BauruSao Paulo CEP: 17012-901 Brazil; e-mail,
marcioalmeida@uol.com.br.
Submitted, July 2001; revised and accepted, October 2001.
Copyright 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 0 8/1/123037
doi:10.1067/mod.2002.123037
458
plated treatment option includes correcting the compo-
nent most deviated from normal, then several treatment
strategies should be considered. One that has gained
interest and generated heated controversies over the last
2 decades is the so-called functional jaw orthopedic
appliance. Several types of these functional appliances
are currently in use for Class II treatment aimed to
improve skeletal imbalances, arch form, and orofacial
function. The expected effects of these appliances
include alteration of maxillary growth, a possible
change in mandibular growth and position, and an
improvement in dental and muscular relationships. It
has been claimed that forward growth of the maxilla
may be either inhibited,9-11 redirected downward,12 or
unaffected.13-15 Some authors have suggested that man-
dibular growth can be increased with functional appli-
ance treatment,16-20 but others believe that mandibular
length cannot be altered by such treatment.21,22 Many
studies agree that the most significant treatment effects
are restricted to dentoalveolar changes.23,24 Two of the
most popular functional appliances used today are
Balters bionator25,26 and Frankels Function Regulator
(FR-2).27-30 Few studies provide a direct comparison
between the soft tissue-borne FR-2 and the primarily
dentally borne bionator. The purpose of this research
American Journal of Orthodontics and Dentofacial Orthopedics Almeida, Henriques, and Ursi 459
Volume 121, Number 5

Table I. Average starting ages and average treatment/

observation time

Average treatment
Groups N T1 T2 observation

Controls 22 8y 7m 9y 8m 13m
FR-2 22 9y 10y 5m 17m
Bionator 22 10y 8m 12y 16m

was to cephalometrically compare the possible ef-

fects of the FR-2 and the bionator appliances on the
skeletal and dentoalveolar components in a sample of
patients with Class II Division 1 malocclusion with
an untreated control sample of persons with similar
malocclusion.

MATERIAL AND METHODS

A control group, obtained from the files of the
Longitudinal Growth Study of the University of Sa o
Paulo at Bauru, comprised 22 subjects (11 boys and 11
girls) with Class II Division 1 malocclusions with an
initial mean age of 8 years 7 months (Table I). This
sample had no previous orthodontic treatment and was
observed for 13 months.
The FR-2 sample included 22 children (11 boys and
11 girls) with an initial mean age of 9 years treated in
the orthodontic graduate program at the University of
Sa o Paulo at Bauru. They were chosen from a parent
sample of 50 based on best results obtained and
compliance level from among the broader sample after
10 months in treatment. Initially, all patients had a
Class II Division 1 malocclusion with at least an
end-to-end Class II molar relationship and minimal or
no crowding; they were treated for a mean period of 17
months (Table I). The patients were instructed to wear
the appliances 4 hours a day the first week, 8 hours a
day the second week, 12 hours a day the third week,
and 24 hours a day thereafter (except for eating and
playing certain sports) until the end of treatment. The
FR-2 appliances worn by patients were fabricated
according to the principles of McNamara and Huge.31
On average, the FR-2 advanced the mandible forward 5
mm and opened the bite 5 mm from the intercuspal
position. When the overjet was larger than 7 mm, the
mandible was advanced gradually 2 to 3 mm, following
Falck and Fra nkel.32
The 22 patients (11 boys and 11 girls) in the
bionator sample were treated with that appliance for a
mean period of 16 months; they had an initial mean age
of 10 years 8 months (Table I). They were treated in the
same clinic as the FR-2 patients and chosen by the same
inclusionary criteria as used in an original parent
Fig 1. Angular measurements: 1, SN.PP; 2, SN.GoMe;
3, Ar.GoMe; 4, SNA; 5, SNB; 6, ANB; 7, NAP; 8, max
central incisor.PP; 9, IMPA; 10, max central incisor.NA;
11, mand central incisor.NB.
sample of 35 patients. They were instructed to wear the
appliances 24 hours a day, except for eating and
playing certain sports. The bionator appliances were
constructed according to Ascher.26 The acrylic was
extended to cover the incisal edges, to avoid labial
tipping of the lower incisors.33 Similar to the FR-2
sample, the mandible was brought forward 5.0 mm, and
the bite was opened 5.0 mm from the intercuspal
position. When necessary, a second appliance was
constructed to readvance the mandible until the overjet
was eliminated.
Methods
The 132 lateral cephalograms were traced on ace-
tate paper by 1 investigator (M.R.A.) and verified by a
second (J.F.C.H.). The cephalometric measures are
shown in Figures 1 through 3. Any disparities in
landmark position were resolved by mutual agreement.
The cephalograms were digitized (DT-11 digitizer,
Houston Instruments, Austin, Tex). The data were then
stored on a computer and analyzed with the Dentofacial
Planner 7.0 (Dentofacial Planner Software Inc, To-
ronto, Ontario, Canada), which corrected the 6% image
magnification factor of the control group and the 9.2%
magnification of the experimental groups.
460 Almeida, Henriques, and Ursi
Fig 2. Skeletal linear measurements: 1, Ar-Go; 2, Go-
Gn; 3, Ar-Gn; 4, Co-A; 5, Co-Gn; 6, LAFH; 7, S-Go; 8,
A-FHp; 9, B-FHp; 10, ENA-FHp; 11, Pog-FHp.
Statistical analysis
All statistical analyses were performed with a
commercial statistical package (SIGMA STAT, Statis-
tical Software for Windows, Version 1.0; SPSS Sci-
ence, Chicago, Ill).
About 4 weeks later, 20 randomly selected tracings
were retraced and remeasured by the same examiner
(M.R.A.) to assess the error of localizing the reference
points and the digitizing procedure. Casual errors were
assessed with Dahlbergs formula, and systematic er-
rors were ascertained with paired t tests similar to the
recommendations of Houston.34 The casual error of the
method (Dahlberg formula) did not exceed 0.77 or
0.56 mm. Paired t tests showed statistically significant
differences only in 5 measurements (SNB, SN.GoMe,
IMPA, B-FHp, and S-Go) for systematic errors.
Means and standard deviations for the 3 groups,
isolated according to sex and then grouped together,
were calculated for all cephalometric variables.
Sexual dimorphism in the 3 groups was evaluated
with paired t tests. The starting forms of the 3 groups
(T1) were compared by using an analysis of variance
(ANOVA). When differences occurred, Scheffe multi-
ple comparison tests were used to determine which
groups were statistically different. Because the length
of treatment varied among groups, they were adjusted
to the time interval of the control sample13 months.
American Journal of Orthodontics and Dentofacial Orthopedics
May 2002
Fig 3. Dental linear measurements: 1, max central in-
cisor-NA; 2, mand central incisor-NB; 3, max central
incisor-FHp; 4, 1, mand central incisor-FHp; 5, max first
molar-PP; 6, mand first molar-GoMe.
RESULTS
The results showed no sexual dimorphism at T1 for
the 3 groups. There was only 1 statistically significant
difference between boys and girls for the FR-2
groupa linear measurement, Co-A. Once this was
determined, the sexes were grouped and evaluated
together.
The equivalence of the starting form was deter-
mined by comparing pretreatment cephalometric values
among the 3 groups (Table II). In general, craniofacial
evaluations, particularly linear measurements, tended
to favor, as expected, the older groupthe bionator
patients. Maxillary and mandibular sagittal positions
compared favorably in the 3 groups, as well as the
resulting ANB and NAP angles. Growth direction was
predominantly vertical in the 3 groups, with larger
linear measurements for the bionator group. The upper
incisors were more proclined in the experimental
groups, but the lower incisors were not statistically
significantly different for any of the measurements
used.
No statistically significant effect was observed for
maxillary skeletal measures (Table III). The minimal
effect should then be attributed to the 2 functional
appliances as it relates to their influence on maxillary
sagittal growth and position. Mandibular protrusion,
American Journal of Orthodontics and Dentofacial Orthopedics Almeida, Henriques, and Ursi 461
Volume 121, Number 5

TABLE II. Comparison of starting forms

Control (n 22) FR-2 (n 22) Bionator (n 22)

Cephalometric measures Mean SD Mean SD Mean SD C-F C-B F-B

Maxillary skeletal
SNA () 80.1 2.2 82.2 2.9 81.7 2.8 * NS NS
Co-A (mm) 84.3 3.8 86.5 3.6 90.0 3.8 NS ** **
A-FHp (mm) 65.7 3.6 66.6 3.4 68.5 3.4 NS * NS
ANS-FHp (mm) 71.1 4.0 71.0 3.6 74.1 3.7 NS * *
Mandibular skeletal
SNB () 75.3 2.8 76.3 2.8 75.9 2.5 NS NS NS
Ar-Go (mm) 40.5 3.3 41.5 4.3 42.5 3.3 NS NS NS
Go-Gn (mm) 69.5 3.2 69.5 3.6 72.8 5.2 NS * *
Ar-Gn (mm) 99.3 4.1 100.8 5.2 104.4 5.3 NS ** **
Co-Gn (mm) 103.4 4.6 106.1 6.2 110.8 4.9 NS ** **
B-FHp (mm) 56.3 5.2 56.8 5.4 58.1 4.7 NS NS NS
Pog-FHp (mm) 56.8 5.4 57.8 6.2 58.7 5.7 NS NS NS
Ar.GoMe () 128.1 4.8 129.5 4.2 129.2 5.9 NS NS NS
Maxilla to mandible
ANB () 4.8 1.6 5.8 1.7 5.7 1.9 NS NS NS
NAP () 8.5 3.6 10.0 3.7 10.0 5.1 NS NS NS
Vertical
SN.GoMe () 35.5 3.6 34.8 4.0 35.6 4.7 NS NS NS
SN.PP () 8.9 2.1 6.5 3.1 7.8 2.5 * NS NS
LAFH (mm) 81.4 4.6 63.1 4.1 65.4 4.2 NS * NS
S-Go (mm) 66.9 4.6 69.4 6.1 72.0 4.6 NS ** NS
Maxillary dental
max central incisor.PP () 111.9 6.0 114.3 6.6 117.5 5.2 NS ** NS
max central incisor.NA () 22.8 5.1 25.6 5.6 27.9 5.6 NS * NS
max central incisor-NA (mm) 4.3 1.5 6.0 1.4 6.7 1.9 ** ** NS
max central incisor-FHp (mm) 69.2 4.0 72.4 5.1 74.8 4.5 ** ** NS
max first molar-PP (mm) 19.5 1.8 19.7 1.6 21.7 2.3 NS ** **
Mandibular dental
IMPA () 94.5 6.4 94.4 6.5 94.0 6.3 NS NS NS
mand central incisor-NB () 25.4 5.7 25.5 4.8 25.5 6.6 NS NS NS
mand central incisor-N-B (mm) 4.4 1.3 5.2 1.1 5.6 2.2 NS NS NS
mand central incisor-FHp (mm) 63.1 5.1 64.0 4.8 66.0 3.7 NS NS NS
mand first molar-GoMe (mm) 27.0 1.7 27.5 2.6 28.2 1.4 NS NS NS

*P .05; **P .01.

C, Control; F, FR-2; B, bionator, NS, not significant.

evaluated by SNB angle and B-FHp and Pog-FHp,
however, increased significantly in the bionator pa-
tients. Mandibular size was significantly positively
influenced in both the FR-2 and the bionator groups,
particularly in patients treated with the latter. The
effective mandibular length increased 3.0 mm in the
control group, 3.9 mm in the FR-2 group, and 4.9 mm
in the bionator group. Overall, bionator therapy pro-
duced a larger and more significant effect on growth
and position of the mandible than did FR-2 treatment.
Considering the maxillomandibular measures (ANB,
NAP), both therapies produced similar reductions in the
sagittal Class II discrepancy, while the control group
remained basically unchanged. Mandibular plane ori-
entation was unaffected by treatment, while the palatal
plane rotated significantly more clockwise in the treated
groups. The control group actually rotated counter-
clockwise. No difference in increase in lower anterior
face height was noted between the 3 groups, while
bionator therapy induced significant increases in the
total posterior facial height (S-Go), about twice as
much as the control group. Only the upper dentoalve-
olar component presented more significant changes,
with incisor retractions from 4.8 to 5.5 and linear
retractions of about 2.3 mm (the control group moved
forward 0.9 mm and the treated groups moved back 1.4
mm) for the maxillary incisor-NA evaluation. The
upper molars did not differ significantly when extrusion
to the palatal plane was evaluated. The lower incisors
proclined significantly in the treated groups about 3
more than did the controls, or about 0.7 mm, depending
on the variable evaluated. The lower molars extruded
462 Almeida, Henriques, and Ursi American Journal of Orthodontics and Dentofacial Orthopedics
May 2002

TABLE III. Differences mean changes (T1 to T2) standardized to 13 months among 3 groups

Control (n 22) FR-2 (n 22) Bionator (n 22)

Cephalometric measures Mean SD Mean SD Mean SD C-F C-B F-B

Maxillary skeletal
SNA () 0.2 1.4 0.3 0.7 0.0 1.2 NS NS NS
Co-A (mm) 1.7 2.0 1.3 1.3 1.5 2.0 NS NS NS
A-FHp (mm) 0.5 1.2 0.5 0.9 1.1 1.3 NS NS NS
ANS-FHp (mm) 0.5 1.5 0.8 0.9 1.1 1.6 NS NS NS
Mandibular skeletal
SNB () 0.0 1.2 0.4 0.7 1.4 1.3 NS ** **
Ar-Go (mm) 1.5 3.1 1.6 1.8 3.1 2.7 NS NS NS
Go-Gn (mm) 0.8 1.8 1.7 1.2 2.0 1.9 * * NS
Ar-Gn (mm) 2.1 1.4 3.1 1.4 4.9 2.4 ** ** *
Co-Gn (mm) 3.0 2.1 3.9 1.4 4.9 2.4 * ** **
B-FHp (mm) 0.5 2.1 1.3 1.2 3.1 2.3 NS ** *
Pog-FHp (mm) 0.7 2.3 1.3 1.2 3.2 2.5 NS ** **
Ar.GoMe () 0.2 2.3 0.2 1.5 0.6 2.1 NS NS NS
Maxilla to mandible
ANB () 0.2 0.8 0.8 1.1 1.4 0.9 ** ** NS
NAP () 0.8 2.1 1.4 2.2 2.8 2.1 NS ** **
Vertical
SN.GoMe () 0.2 1.2 0.2 1.3 0.3 1.8 NS NS NS
SN.PP () 0.7 1.8 0.3 1.1 0.2 1.3 * * NS
LAFH (mm) 1.6 1.5 1.5 1.1 2.1 2.1 NS NS NS
S-Go (mm) 2.1 1.8 2.2 1.2 3.7 2.6 NS ** **
Maxillary dental
max central incisor.PP () 0.4 4.6 4.9 3.5 5.2 4.3 ** ** NS
max central incisor.NA () 1.4 4.7 4.8 3.3 5.5 4.3 ** ** NS
max central incisor-NA (mm) 0.9 1.4 1.1 1.1 1.4 1.1 ** ** NS
max central incisor-FHp (mm) 1.3 1.9 0.6 1.2 0.2 2.0 ** * NS
max first molar-PP (mm) 0.3 1.1 0.4 1.0 1.0 1.2 NS NS NS
Mandibular dental
IMPA () 0.4 4.1 2.0 2.8 2.6 3.6 NS NS NS
mand central incisor.NB () 0.6 3.3 2.7 2.8 3.7 3.9 ** ** NS
mand central incisor-NB (mm) 0.4 0.9 0.8 0.7 1.3 1.0 * ** NS
mand central incisor-FHp (mm) 1.0 1.9 2.1 1.3 4.0 2.3 * ** *
mand first molar-GoMe (mm) 0.7 1.1 1.1 0.4 1.4 1.0 * * NS

*P .05; ** P .01.
C, Control; F, FR-2; B, bionator; NS, not significant.

significantly more (0.4-0.7 mm) in the treated groups
than in the controls.
DISCUSSION
Changes in maxillary skeletal component
The results of this study showed that there were no
significant changes in any of the 4 variables used to
evaluate maxillary growth in the experimental groups;
this result agrees with other studies35-43 of activator and
bionator appliances that also showed no significant
restriction of maxillary growth. In contrast, other in-
vestigators44-51 noted some restrictive effect, particu-
larly when the SNA angle was used. However, as
Mills41 pointed out, this effect could be related to the
lingual inclination of the upper incisors and the accom-
panying posterior remodeling of Point A. The lack of
maxillary skeletal effects in the FR-2 sample in the
present study agrees with most other evaluations of
FR-2 treatment.52-56 Falck and Fra nkel32 concluded
that 1 group treated with the FR-2 in their study did not
present maxillary restriction because the mandible was
advanced in small increments. When the mandible was
brought forward in the 1-large-step protocol, the so-
called headgear effect was observed. The average bite
advancement of both the FR-2 and the bionator groups
(5.0 mm) might have been too small to result in a
maxillary skeletal inhibition from the headgear effect.
Changes in the mandibular skeletal component
A statistically significant increase in mandibular
protrusion and length was observed in both experimen-
tal groups, particularly patients treated with the biona-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 121, Number 5
tor. This finding, of increased mandibular growth after
functional appliance treatment, agrees with the results
of a number of investigations involving the bionator or
activator appliance,57-65 although others47,66 did not
support such an increase.
The increase in effective mandibular length should
be discriminated considering ramus height and corpus
length. Numerically larger changes, but without statis-
tical significance, occurred in the ramus height (Ar-Go)
of both experimental groups. Mandibular body length,
however, particularly in the bionator group, seemed to
contribute more to the effective mandibular length,
consistent with the results of other investigators55,65;
however, it does not agree with the results of Mc-
Namara et al,67 who found no evidence of a statistically
significant increase in mandibular body length in pa-
tients treated with the FR-2. Ramus height, defined here
as the distance Ar-Go, depends, to a certain extent, on
the position of the mandible. Thus, when the condyles
are forward, Ar may be defined as more posterosupe-
rior, and measurements made with this reference will
be larger than if the condyles are in centric relation.
The more significant increase in mandibular length
in the bionator group may be attributed to its older
average age than the other groups. The initial mean age
was 10 years 8 months, and the final mean age was 12
years. The more chronologically and probably skele-
tally mature bionator sample could have been closer to
the pubertal growth spurt than were the other 2 groups.
FR-2 therapy did not produce statistically signifi-
cant increases in the SNB angle compared with the
control group. Similar observations were reported by
others68-70 in patients treated with the same appliance.
Minimal changes in the SNB angle in the FR-2 patients
are probably related to the concomitant increase in
lower anterior facial height during treatment, as men-
tioned by Toth and McNamara.52 As they pointed out,
every millimeter of increased lower anterior facial
height camouflages a millimeter of mandibular length
increase causing the chin to rotate downward and
backward. The bionator group, however, even with
numerically (but not statistically significant) increases
in LAFH compared with the FR-2 group, produced a
significantly more anterior position of the mandible.
There was no evidence of a morphologic change in the
mandible, as measured by the gonial angle (Ar.GoMe)
among the groups; this agreed with the results of
Schulhof and Engel.65
Changes in maxillomandibular skeletal relationship
The maxillomandibular relationship showed
marked improvement in both the bionator and the FR-2
groups compared with the control group (Table III),
Almeida, Henriques, and Ursi 463
with no statistically significant difference between the
treated groups. Improvement in basal bone relation-
ships resulted from small changes in maxillary anterior
growth and by the anterior positioning of the mandible
in the experimental groups. Similar findings were found
with bionator or activator therapy by some au-
thors42,43,46 and also for the FR-2.71 Changes of ANB
angle in the treated groups were a result of several
small but cumulative effects on dentofacial structures
associated with normal craniofacial growth that were
not sufficient to correct or improve the skeletal Class II
relationship in the untreated group.
Vertical component
Righellis49 and McNamara et al67 reported that
functional appliances do not change the craniofacial
growth pattern, although facial height has been noted to
increase, as mentioned by Nielsen.72 Although an
increase in lower anterior facial height was observed in
all 3 groups, there were no statistically significant
differences between the control and the experimental
groups. This result is probably related to the posterior
bite opening that occurs when the mandible was
brought forward in the experimental groups and the
molars are encouraged to erupt. Posterior facial height
(S-Go) increased in all 3 groups, showing a statistically
significant difference among the groups. Despite the
greater increase in the FR-2 group (2.2 mm), there was
no statistical difference with the control group (2.1
mm). In contrast, the greater increase in the bionator
group (3.7 mm) reached almost 2 times more than the
values for the control group, a result also found by
Lange et al.46
As a result of the observed interplay of both the
anterior and the posterior facial heights, the mandibular
plane was not significantly affected. There was a
greater tendency for a clockwise rotation of the maxil-
lary plane (SN.PP) during FR-2 and bionator therapy
compared with the control group; this did not adversely
affect the lower anterior facial height.
Maxillomandibular dentoalveolar components
As shown by many other investigators for almost all
functional appliances, both the bionator and the FR-2
produced a lingual tipping of the upper inci-
sors.35,36,51,58 This effect was expected because both
appliances have a labial wire that may come in contact
with the incisors during sleeping hours, causing them to
retract.73
Some proclination of the lower incisors was pro-
duced by both bionator and FR-2 treatments. This
effect is probably consequent to the resultant mesial
force on the lower incisors induced by the protrusion of
464 Almeida, Henriques, and Ursi
the mandible. This finding corroborates other studies
for the FR-265,68,73 and the bionator or activator39,51,58
appliances. However, Wieslander and Lagerstro m14
and Bolmgren and Moshiri35 reported that treatment
with the activator appliance does not alter the position
of the lower incisors. It could be inferred that care
should be taken when the bionator and the FR-2 are
used in patients with proclined mandibular incisors
because this condition could become more pronounced.
In the untreated group, the upper first molars
extruded 0.3 mm, which was not statistically different
from the FR-2 (0.4 mm) and the bionator (1.0 mm)
groups. Toth and McNamara52 also reported similar
findings, where significant differences in the vertical
eruption of the maxillary molars were not evident in
comparison with the controls or the patients treated
with the FR-2 appliance.
The vertical eruption of the lower first molars
(mandibular first molar-GoMe), however, was greater
in both appliance groups (FR-2, 1.1 mm; bionator, 1.4
mm) than the controls (0.7 mm). This effect has also
been reported with the FR-2 appliance16,67,69 and the
bionator or activator appliance.51,58
The acrylic in the bionator group must be trimmed
away in the posterior inferior region so that there is no
contact with the posterior lower teeth. In the FR-2
group, the advancement of the mandible contributes to
opening the bite in the posterior region. This procedure
allows a greater vertical increase of the lower posterior
teeth and helps to correct the overbite, the Class II
molar relationship, and the deep curve of Spee. Mc-
Namara et al16 described this theory as the differential
eruption principle of Harvold. It has been hypothesized
by Toth and McNamara52 that tissue-borne appliances,
such as the FR-2, produce less dentoalveolar change
than tooth-borne appliances such as the bionator or the
Twin-block. Similar to the results of Toth and Mc-
Namara52 comparing the Twin-block with the FR-2,
this study reports greater dental changes in the bionator
group (tooth-borne appliance) than in the FR-2 group
(tissue-borne appliance). Based on these findings, it
might be expected that the FR-2 appliance would have
a greater skeletal effect than the bionator in Class II
correction. However, this investigation did not support
this consideration, because there were greater skeletal
effects in the bionator group than in the FR-2 group.
Overall, it was concluded that the major effects of
the bionator and the FR-2 appliances were dentoalve-
olar, with a smaller, but significant, skeletal effect.
CONCLUSIONS
The present study suggests that Class II correction
can be achieved with either appliance system evaluated
American Journal of Orthodontics and Dentofacial Orthopedics
May 2002
here. We concluded that the skeletal and dental effects
produced by the FR-2 and the bionator appliances were
as follows:
1. No significant restriction of maxillary growth was
observed in either functional appliance group.
2. Both appliances provided statistically significant
increases in mandibular growth and in the degree of
mandibular protrusion, with greater increases in
patients treated with the bionator appliance.
3. There was a similar significant improvement of the
anteroposterior relationship between the maxilla and
the mandible in the FR-2 and the bionator groups.
4. There were no statistically significant differences in
craniofacial growth patterns among the groups. The
bionator group showed a greater increase in poste-
rior facial height.
5. Both appliances produced a similar labial tipping
and linear protrusion of the lower incisors and a
lingual inclination and retrusion of the upper inci-
sors. In addition, there was a significant increase in
mandibular posterior dentoalveolar height and no
extrusion of the upper molars in either treatment
group.
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