Professional Documents
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Bioprogressive Therapy - 2
Bioprogressive Therapy - 2
CONTENTS
Introduction
The Management Umbrella
Principles of Bioprogressive Therapy
Visual Treatment Objective
The Use of Superimposition Areas
Orthopedics in Bioprogressive Therapy
The Utility and Sectional Arches
Bioprogressive Mixed Dentition Treatment
Mechanics Sequence for Extraction Cases
Mechanics Sequence for Class II Division 1 Cases
Mechanics Sequence for Class II Division 2 Cases
Finishing Procedures and Retention
Conclusion
INTRODUCTION
Bioprogressive Therapy was originated by Drs. Robert Ricketts and Ruel Bench who
combined contemporary edgewise mechanics with solid diagnostic principles and an
innovative approach to sectional mechanics.
Bio-Progressive Therapy is not strictly an orthodontic technique but, more importantly, it
encompasses a total orthodontic philosophy. It accepts as its mission the treatment of the total
face rather than the narrower objective of the teeth or the occlusion. Although the teeth and the
occlusion are of critical importance in achieving the broader goal of treating and improving the
face, orthodontic therapies must be designed to be applied appropriately to specific facial
types, muscular patterns, and functional needs of individuals. A primary concern, therefore, is
the musculature of the chin and lips and the function of the tongue as its posture reflects the
respiratory needs of the individual.
The relationship of the jaws to each other, with the resulting convexity or concavity of the
profile, suggests the orthopedic alteration that will be required to achieve the desired result.
The progressive unfolding of these arches, in conjunction with the purposeful alterations
resulting from orthodontic therapy, combine to produce the desired outcomes as they relate to
aesthetic effect and occlusal and respiratory function. Basic to an understanding of these
potential changes is the dynamics of growth and function under normal relationships with an
appreciation for a range of variation from the normal as applied to the individual with his
specific needs and potential.
Dr. Ricketts' orthodontic philosophy and therapy involves a broad concept of total treatment,
rather than a sequence of technical and mechanical steps. Referred to as Bio-Progressive
Therapy, it takes advantage of biological progressions including growth, development, and
function, and directs them in a fashion that normalizes function and enhances aesthetic effect.
The management of the total practice ultimately determines the degree of efficiency and
effectiveness with which the orthodontist solves individual patient problems.
Diagnostic Programming
1. Clinical examination
2. Describing the malocclusion
3. Describe the face
4. Describe the functional requirements
Nasopharyngeal airway
Musculature
Habits
Soft Tissue
5. Lower VTO and Arch form
#4.Movement of any tooth in any direction with the proper application of pressure
Bioprogressive Therapy maintains that forces that are lighter allow for the blood supply to
sustain cell physiology enabling more efficient tooth movement as compared to heavier
forces.
Brian Lee, following the work of Storey and Smith in Australia, has suggested that the most
efficient force for tooth movement is based upon the size of the root surface of the tooth to be
moved, which he called the enface root surface or the portion of the root that is in the direction
of movement.
Bio-Progressive Therapy suggests that the force can be reduced by one half, to 100gms/cm2
of enface root surface.
Density of the supportive bone is also an influencing factor in the rate of tooth movement.
Arch wires and loop systems that will deliver lighter and more continuous forces are the most
effective in eliciting the biological response that we desire. The smaller .016 ´ .016 chrome
alloy arch wires, with designs that allow more wire either through spanning arches, sectional
arches, or multiplelooped arches, have been found to apply the lighter continuous force
required
Vertical face patterns respond earlier and faster to molar extrusion and further worsen the
appearance. Increase in lower anterior face height, lip strain compounds the problem of a
short upper lip.
The short anterior vertical facial height type with a low mandibular plane and the most
extreme incisor overbites are those that would best benefit from mandibular rotation, but their
strong musculature function resists the molar extrusion that allows this type of opening. Often
Another complication of overbite interference during treatment is the distal displacement of
the condyle in the fossa resulting in temperomandibular joint dysfunction and incisor
instability due to traumatic interference of the incisor deep bite occlusion.
Bio-Progressive Therapy mechanics finds that incisor intrusion is the treatment of choice for
the best results not only during treatment, but also for stability of results and optimizing
function
When the incisor overbite is not corrected before incisor retraction, the incisors come into
interference resulting in a proprioceptive input that affects the patient's ability to close the
posterior teeth. When this neuromuscular interference limits the patient's ability to occlude
the posterior teeth, the molars are allowed to extrude and vertical opening occurs. When we
have incisor interference, headgear will more easily extrude the upper molar and Class II
elastics will extrude the lower molars.
In the final finishing of orthodontic treatment, if incisors are in deep overbite the interference
will usually not allow a good buccal occlusion.
4. It reduces the binding and friction of the brackets as they slide along the arch wire.
A segmented arch applied to the cuspids only, reduces the friction even more on the short
segment and allows for its efficient retraction.
.
Sectional arch treatment allows the erupting buccal occlusion to erupt more freely into the
functions of the face by reducing those limiting factors that restrict the normal development. It
also maintains arch length.
#8 Concept of overtreatment.
It is necessary for the clinician to anticipate changes that will follow when all
appliances are removed and the post treatment adjustments begin to occur.
Bio-Progressive Therapy suggests four areas where the concept of overtreatment may
help compensate for the anticipated post-treatment adjustments:
1. To overcome muscular forces against the tooth surfaces.
a) In cases of expansion of a narrow collapsed upper arch overtreatment is necessary
considering the relapse that might occur under the influence of the buccal musculature.
Over expansion also encourages the tongue to elevate and function in support of the
dental arches.
b) Overclosure of an anterior open bite is appropriate to compensated for the rebound
effect of abnormal tongue function and the increase in lower anterior face height as seen
in excessive vertical facial types.
c) Overtreatment of the incisor overjet and interincisal angle is critical in lip sucking
habits, where mentalis function and short upper lip continue to influence the position
and stability of the incisors.
Situations where treatment changes alter the environment, which then allow an
improved function to support it.
1. Upper Arch Expansion.
2. Incisor Protrusion Correction.
3. Temperomandibular Joint Dysfunction. Further restriction of a collapsed upper arch
can develop into a functional crossbite where occlusal interference now blocks upper
arch development and produces condylar shifts and changes in the temporomandibular
joint function and development.
#10 Efficiency in treatment with quality results utilizing a concept of
prefabrication of appliances.
In an attempt to relieve some of the burden imposed by the myriad of procedures that
are required in the construction and fabrication of orthodontic appliances, Bio-
Progressive Therapy utilizes the concept of prefabrication and has appliances ready-
made for clinical application, so that the clinician directs his expertise to diagnosis and
treatment planning.
It is a visual plan to forecast the normal growth of the patient and the anticipated
influences of treatment, to establish the individuals objectives we want to achieve for
that patient.
CONSTRUCTION OF THE VTO
The VTO construction is divided into the following steps:
I. The cranial base prediction
II. The mandibular growth prediction
III. The maxillary growth prediction
IV. The occlusal plane position
V. The location of the dentition
VI. The soft tissue of the face
In constructing the VTO, these factors must be taken into consideration in deciding
what can be expected to happen to the facial axis.
6. Superimpose at Basion along the Basion-Nasion plane. Rotate "up" at Nasion to open
the bite and "down" at Nasion to close the bite using point DC as the fulcrum. This
rotation depends on anticipated treatment effects (whether treatment can be expected to
open or close the facial axis).
7. Trace Condylar Axis, Coronoid Process, and Condyle.
8. On condylar axis, make mark 1mm per year down from point DC.
9. Slide mark up to the Basion-Nasion plane along the condylar axis. Extend the
condylar axis to XI point, locating a new XI point.
10. With old and new XI points coinciding, trace corpus axis, extending it 2mm per
year forward of old PM point. (PM moves forward 2mm/year in normal growth.)
11. Draw posterior border of the ramus and lower border of the mandible.
15. To locate the "new" maxilla within the face, superimpose at Nasion along the facial
plane and divide the distance between "original" and "new" Mentons into thirds by
drawing two marks.
16. To outline the body of the maxilla, superimpose mark #1 (superior mark) on the
original Menton along the facial plane. Trace the palate (with the exception of point A).
VTO — Soft Tissue — Lower Lip, Point B, and Soft Tissue Chin
In constructing the lower lip, we bisect the overjet and overbite of the original tracing
and mark the point. We then bisect the overjet and overbite of the VTO and mark the
point.
OVERBITE, ORIGINAL , VTO , OVERJET
31.Superimposeinterincisal points, keeping occlusal planes parallel. Trace lower lip and
soft tissue B point. The soft tissue below the lower lip remains in the same relation to
point B as in the original tracing. Soft tissue point B drops down as the lower lip
recontours.
Eleven factors of the basic facial and skeletal structures are recorded from the
cephalometric tracing to describe the chin, maxilla teeth and soft tissue profile.
Five areas of superimposition within which seven areas of evaluation are used to
evaluate.
Eleven Factor Summary Analysis
The Eleven Factor Summary Analysis is divided into four areas:
1. Locating the chin in space.
2. Locating the maxilla through the convexity of the face.
3. Locating the denture in the face.
4. Evaluating the profile.
From the Eleven Factor Summary Analysis, five angles are used to describe the face:
1. The Facial Axis Angle. This gives us the direction of growth of the chin and
expresses the ratio of facial height to facial depth. In addition, the upper six-year molar
grows down the facial axis.
2. Facial Angle. This locates the chin horizontally in the face. It is a facial depth
indicator; and it determines if a skeletal Class II or Class III is due to the mandible.
3. Mandibular Plane Angle. A high mandibular plane angle implies that a skeletal
open bite is due to the mandible. A low mandibular plane angle implies that a skeletal
deep bite is due to the mandible.
4. Lower Facial Height. This describes the divergence of the oral cavity. Skeletal open
bites have high values; skeletal deep bites have low values.
5. Mandibular Arc. This describes the mandible. It tells us whether we have a square
growing mandible or an obtuse growing mandible.
These five angles determine the facial pattern. It is important to establish what the facial
type is because the reaction to treatment mechanics and the stability of the denture is
dependant upon the analysis of the facial pattern.
Brachyfacial patterns show a resistance to mandibular rotation during treatment and can
accept a more protrusive denture, whereas Dolichofacial patterns tend to open during
treatment and require a more retracted denture in order to assure posttreatment stability.
.
Five Superimposition Areas
The five superimposition areas are used to evaluate the face in the following order:
1. The chin.
2. The maxilla.
3. The teeth in the mandible.
4. The teeth in the maxilla.
5. The facial profile.
Superimposition Area 3 (Evaluation Areas 3 and 4)
(Corpus Axis at PM)
Together evaluate any changes that take place in the mandibular denture.
In normal growth, the lower denture remains constant with the APO Plane (the denture
plane).
In Evaluation Area 3, we evaluate whether we are going to intrude, extrude, advance or
retract the lower incisors, which helps us determine what type of utility arch we will
use.
In Evaluation Area 4, we evaluate the lower molars to determine what type of
anchorage we need and whether we wish to advance, upright or hold the lower molars.
By definition orthopedics implies any manipulation that alters the skeletal system and
associated motor organs.
From a practical standpoint in a growing individual orthopedic alteration would be any
manipulation which would change the normal growth of the dentofacial complex in
either direction or amount.
Normally the palatal plane is parallel to or slightly tipped downward to the FH line.
In MRD the tip of the palatal line with the ANS is tipped upwards towards the FH plane
The upward cant is accompanied by a short vertical height to the nose, an upward cant
to the nares and a small upper face
The long drawn out maxillary dentition is tapered progressively toward the midline
which allows sufficient overjet so that in resting posture, the lip is carried underneath
the upper incisor teeth.
Vault space for the tongue which is severely restricted due to narrow arch form creates
an ideal environment for anterior tongue thrust.
Molars are in Class II typically in mesial rotation, lower arch width and form are
restricted.
MRD is not related to the facial type and this allows us to select the proper headgear to
resolve maxillary protrusion in different growth pattern.
In strong muscular patterns some mild mandibular rotation occurs but the amount of
maxillary response compensates for this by 3-4 times.
a. Restrictive forces occur when the vectoral sum of forces lies above the centre of
resistance of the maxillae
b. Rotational forces occur when the vectoral sum of forces lie below the centre of the
resistance of the maxillae.
A vectoral sum of the forces that lie above the centre of resistance of upper molar will
produce rotation of the maxilla and intrusion of the molar.
A vectoral sum of the forces that lie below the centre of resistance of the molar will
provide a rotational effect on the maxilla but extrude the molar.
1. Force Level
A force level above 400 grams is ideal. In most patients, forces up to 1000 grams can
easily be tolerated and should be applied when possible.
2. Intermittent Wear
(a) A heavy, intermittent force to the upper molars will create a sclerotic condition
around the roots of these teeth limiting orthodontic effect and enhancing orthopedic
effect.
(b) Rebound is permitted which allows for muscular adaptation and arch form/ width
changes.
(c) Since more growth occurs at night and more function occurs in the day (where the
teeth come into contact upon swallowing), it is ideal that the cervical headgear be worn
mostly in the evening and sleeping hours.
(d) Patient acceptability is enhanced
4. Expansion-Rotation
It is essential to continually expand the inner bow of the cervical headgear, not only to
correct the tendency to crossbite but also to allow a functional development of the lower
arch.
In considering the efficiency of forces used in Bioprogressive Therapy there are four
areas of interest.
1. Size of the root surface involved: The enface surface of the root exposed to
movement is the area to be considered in selecting the proper amount of force needed.
2. Amount of Applied force: It depends on the size of the root. Where the area is
known the application of the long lever arm and additional wire in the loop design can
reduce the applied force, allowing it to be lighter and more continuous.
3. Cortical Bone Support: Cortical bone anchorage implies that, to anchor a tooth
roots are placed in proximity to the dense cortical bone under a heavy force that will
further squeeze out blood supply and this anchors the tooth by reduced physiologic
activity.
For efficient movement mechanics should steer the roots away from the dense cortical
bone and through the less dense channels of vascular trabecular bone.
In order to avoid lingual cortical bone at the incisors 15-20° of buccal root torque is
applied by the utility arch which aids in intrusion.
During cuspid retraction lingual cortical bone must be avoided to prevent straining of
the molar anchorage.
Lower bicuspids and molars are expanded so as to pit the roots against the buccal
cortical bone to aid in anchorage.
The maxilla in contrast to the mandible is a laminated structure with cortical bone
supporting four cavities – nasal, orbital, oral and sinus cavities.
a) The lower face height angle (47°±4°) is a angular reflection of the musculature
function between the upper and lower jaws.
b) Mandibular arc angle (27°±4°) describes the internal structure of the mandible.
UTILITY AND SECTIONAL ARCHES
Historical Perspective
It had long been felt that intrusion of the lower incisors as a medium for leveling the
deep curve of Spee was an impossibility.
In the 1950’s Ricketts and others attempted to counteract the tipping that occurred in
the buccal segments in extraction cases by utilizing the supposedly immutable.
Lower 2nd premolar and molars upright in the retraction process.
Single tubes were still in use as a simple 016 round wire was formed as a continuous
arch, placed under the bicuspid bracket and looped over the molar tube at the end to be
locked down behind the extension of the sectional retractor.
This move before activation put the forward part of the arch downward toward the
sulcus and as it was raised and engaged into the lower incisors it exerted an elongating
effect on the bicuspid as a lever against the molars.
Design Principle
The principle of the long lever arm, from the molars to the incisors is applied to deliver
a light continuous force.
The utility arch is stepped down to avoid interference from the forces of occlusion.
The buccal bridge section is flared bucally to prevent tissue irritation, opposite the
vertical steps as the arch approaches the tissue and as the incisor teeth are intruded.
Molar Adjustment
Should be made on the posterior vertical step or adjacent to it on the buccal bridge.
Should be kept 90° to the molar section.
To produce more molar tip back and anterior intrusion two areas of activation are most
effective:
1. The posterior vertical step
2. The buccal bridge is front of the posterior vertical step.
Incisor Adjustment
Should be made on the anterior vertical step or adjacent to it on the buccal bridge.
Activation in the incisor area is made parallel to the incisor section either on
1. Anterior vertical step
2. The buccal bridge next to the step.
These activations are more effective to advance with labial crown torque or to retract
with lingual crown torque than to intrude the incisor.
Intrusion is activated at the molar step.
Roles and Functions of the lower utility arch
E. Over treatment
Allows end to end incisor relationship as over treatment in deep bite cases.
Over treatment of buccal occlusion and cuspid relationships via segmented arch
treatment.
Over treatment of rotations in buccal occlusion
4. Saving E space: Space gained when the lower deciduous molars are lost.
Bioprogressive treatment in the mixed dentition aims at the natural tendency to alleviate
the problem when it is noticed and the somewhat overstated concept of “interception
versus correction”.
II. Resolve arch length discrepancy: so that those cases within the bounds of non
extraction therapy can be approached in a manner that allows for their successful
conclusion without removal of permanent teeth.
The wide variety of the research involving the growth of the condyle and the mandible
the following conclusions may be derived:
Morphology alone suggests that the upward/forward cant or bend of the condyle
and neck in brachyfacial types and the upward/backward cant and bend of the
condyle and neck in dolicofacial types delineates ultimate vertical growth and
forward posture of the chin in the face.
Anything which jeopardizes the normal upward and forward growth of the condyle
resulting in a temperomandibular joint dysfunction is worthy of intervening treatment,
this forms the basis of treatment in the mixed dentition.
Laminographic Studies:
In the early 1950’s Ricketts et al began to set standards for normal variations in the
TMJ as determined by body section x-rays (laminography).
It was found that in centric relation occlusion, the condyle took a “centered” position
whereby the antero-superior surface of the condyle articulated in a specific relation to
the eminence.
It was also noted that a joint space superior and distal to the condyles existed in normal
centric relation occlusion.
The space between the condyle and the eminence (1.5 ± 0.5 mm) gives the clinician
some idea as to the most ideal articulation between the condyle articulated in a specific
relation to the eminence.
The space between the condyle and the roof of the fossa was found to be (2.5 ± 1.0
mm).
The space between the condyle and the meatus was found to be 7.5 mm on an average.
It should be noted that the normal joint is charactierized by a condyle centered in the
fossa, surfaces free of rough edges (smooth edges), and absence of excessive thickening
of the subchondral layers.
In order to enhance the clarity of laminagraphic sections, submento vertex x-rays are
taken to evaluate exact inclination of the long axis (mediolateral) of the condyle to the
midsagittal plane. This measurement becomes especially important when accurate
representation of the position of the condyle in the fossa is needed and in a young child
with small condyles, this measurement becomes critical.
In a laminagraphic section a narrowing of the articular spaces along with sclerosis or
subcondylar thickening of the bone at the articulating surfaces is commonly suggestive
of beginning TMJ pathology.
1. Cross-mouth interferences
2. Anterior cross bite
3. Open bite- Lack of incisal guidance
4. Excessive range of function
5. Distal Displacement
6. Loss of posterior support – Superior displacement
7. Finger Sucking/ Lip sucking/ Tongue thrusting
8. Breathing and Airway problems
9. True Class III Growth patterns
1. Cross- mouth interferences
A. Clinical Evaluation: Cases where one or more teeth cause shunting of the mandible
in a lateral direction upon final closure. These can be detected by watching mandible
closure. Typically there will be a lateral shunt a ‘comfort occlusion”, or a broad arc of
closure toward one side or the other. In the wide open posture usually the midline will
align at wide open, and upon closure there will be a midline shift as guided by neuro-
muscular reflexes.
C. Resultant growth changes: The translatory condyle may remain normal in growth
but the opposite side condyle will commonly demonstrate restricted growth on its
antero-superior surface and increased growth in the posterosuperior surface will ensue.
Long term growth effects will demonstrate a cant in the occlusal plane, abnormal ramal
heights, abnormal alveolar process heights, and abnormal chin positioning.
2. Anterior crossbite
A. Clinical evaluation: When one or more anterior teeth are severely malposed, the
mandible may be guided forward by the anterior interference. Clinically, when the
mandible is nudged gently in a distal direction and closed, the area of anterior
interference can easily be detected. It is not uncommon to experience anterior
displacement in cases with extreme crowding and/or situations of ectopic eruption of
incisors.
C. Resultant growth changes: As both condyles have been brought down on the
eminence, upward-backward growth of the condyles is bilaterally enhanced. This can
increase effective mandibular length and is believed to be a contributing factor in Class
III malocclusion.
B. Laminagraphic evaluation: The condyles are usually forward in the fossae, down
on the eminence, and often there is flattening and irregularity of the antero-superior
surfaces of the condyles.
D. Timing and method of treatment: This is certainly the most difficult of all
functional problems to correct early, as the etiologies of open bite are multiple. At this
point, there are several basic areas to explore in early correction of open bite:
1) Evaluate airway for possible tonsillectomy and/or adenoidectomy;
2) Orthopedically expand and rotate the maxillae to improve tongue space, increase
vertical height to the nasal complex, and change inclination of the maxillae, especially
in severe Class II malocclusions;
3)Evaluate allergy symptoms;
4) Early alleviation of severe anterior crowding to allow normal incisor eruption;
5) Evaluate tongue size, posture, and tongue thrusting pattern.
C. Resultant growth changes: Pressure atrophy and sclerotic changes at the antero-
superior surface of the condyles enhances the upward/backward growth and produces a
more dolicofacial type of growth experience.
D. Timing and method of treatment: Although it is not critical that the entire Class II
malocclusion be corrected, it is important that the maxillae and/or teeth be moved
distally enough to allow the mandible to close without bringing the condyles downward
and forward on the eminence. It is not unusual, following initial headgear therapy, to be
able to cephalometrically measure a distal movement of the maxillae without
appreciable correction of the Class II molar relation. This can be the result of a distal
movement of the mandible, as the condyles drop back into the fossae. This may be the
most important functional change which occurs with headgear therapy.
5. Distal displacement
A. Clinical evaluation: The true distal displacement, in which the condyle is located in
the posterior aspect of the temporomandibular joint, is quite commonly caused by a
vertical inclination of the upper and lower incisor teeth, especially evidenced in Class II
Division II malocclusion. Although it is possible for distal displacement to exist due to
the inclines of the functioning buccal occlusion, incisal interferences are usually the
culprits. These are typically the first functional problems to demonstrate pain in the
temporomandibular joint complex and it is possible to have crepitation, tinnitus, and
early loss of mobility in a relatively young child.
B. Laminagraphic evaluation: The condyles are seated distally in the fossae with
excessive space anterior and superior to the condyles. The posterior portion of the
condyles is often seen to abut the tympanic plates and petrotympanic fissure of the
temporal bone. Usually no irregularities in the condyles are evidenced.
B. Laminagraphic evaluation: The superior portion of the condyles seat near the apex
of the fossae and excessive space is seen mesial to the condyle.
D. Timing and method of treatment: The approach toward the functional muscular
problem should begin as a conservative suggestion to the child that the activity should
be ceased. If the child is unable to control the habit pattern, expansion/thumb appliances
should be placed when the upper and lower incisors and first molars are erupting. Due
to the fact that these habit problems often cause constriction and posterior crossbite,
expansion appliances should be incorporated at the same time the digit habit is being
alleviated.
C. Resultant growth changes: Because the tongue is held low in the oral cavity to
increase air uptake, these cases are prone to maxillary collapse and crossbite. While
holding the tongue low and the mouth open, the condyles are cantilevered down on the
eminence, allowing the suprahyoid musculature to dominate, holding the chin down and
back. This action creates wear on the upward/forward portion of the condyle and, again,
allows upward/backward growth to dominate. Dominant upward/backward growth
allows for a more receded chin posture in the face, worsening the open bite, and
accentuating the functional muscular aberration.
D. Timing and method of treatment: Although the oral and nasal passages increase in
size as the child grows, and tonsils and adenoids atrophy with age, long-term breathing
problems that create open bite and potentially affect condylar growth, should be
evaluated at an early age. It is not unusual to suggest tonsillectomy and/or
adenoidectomy, allergy evaluation, and early orthodontic therapy to increase the size of
the nasal airway.
C. Resultant growth changes: The true Class III has an inherent tendency for
functional displacement and genetic overgrowth.
D. Timing and method of treatment: When the true Class III growth pattern is
detected early, it is usual to treat only the maxillary deficiency. Quite often early dental
treatment of true Class III results in linguoversion of the lower incisors and proversion
of the upper incisors, which can make successful surgery at a later time difficult without
retreatment. Relatively few true Class III's lend themselves to purely orthodontic
treatment alone. Maxillary expansion and advancement, in an attempt to reduce
maxillary deficiency, is the usual treatment of choice.
The overall expansive process should take not more than three months. Although this is
long enough to allow for arch form changes, axial inclination changes, and spacing
occurring in the upper arch, it is not adequate time to allow for the reciprocal responses
that we expect to occur in the lower arch. The arch form and axial inclination changes
that occur with the W expansion also occur in long-term headgear therapy with an
expanded inner bow
Retention Procedures
This places a tremendous importance on case selection and proper case management to
reach a known objective.
Although headgear can be continued over protracted periods of time to maintain molar
relationship and orthopedic reduction, thereby reducing physiologic rebound, in many
cases such long-term cooperation is difficult to achieve.
The retainer that is most commonly used after first phase therapy is the Hawley retainer
with an inclined plane. The Hawley bow acts to hold upper incisor alignment and
position, while the inclined plane holds the lower incisor alignment both from the labial
(by the upper incisors) and the lingual (by the incline plane). The labial bow is
fabricated from .028" blue Elgiloy wire and the vertical loop is short and is situated
between the upper lateral incisor and the deciduous canine as this is the only open
contact in the mixed dentition. Ball clasps are placed to the upper molars and any space
created between the upper first molar and deciduous second molar is maintained with an
acrylic bridge
At times, when extreme advancement of the lower incisors has been achieved and arch
length is critical, a lower lingual arch is placed. The patients are instructed to wear the
upper Hawley retainer full time during the first year after treatment and usually are
instructed to wear the retainer at night time during the second and/or third year of
retention therapy. Only in very selected cases are the headgears maintained for
extremely long periods of time, thus minimizing the amount of therapy that the majority
of patients might receive.
THE BRACKET SYSTEM
The treatment planning for extraction cases should include the following logical
sequence:
1. Functional Correction
2. Orthopedic need
3. Arch length analysis
4. Anchorage requirements
5. Management Summary
The extraction sequence in Bioprogressive Therapy can best be organized into four
general procedures that can be individually evaluated and analyzed as to the needs of
the specific case.
I) Stabilization of upper and lower molar anchorage
II) Retraction and uprighting of cuspids with sectional arch mechanics
III) Retraction and consolidation of upper and lower incisors
IV) Continuous arches for details of ideal and finishing occlusion.
Moderate upper molar anchorage may not need to hold the upper molar completely
stable, but will allow it to be advanced forward up to half of the extraction space during
the treatment procedure. A distal looped lingual arch or a palatal bar without the plastic
button support will stabilize the molar and give moderate anchorage support.
Minimum upper molar anchorage may occur in a case in which the upper molar
needs to be advanced the whole distance of the extraction space.
Class III extraction treatment usually calls for upper second bicuspid extraction with
advancement of the upper molar. Since upper molar has a natural tendency to rotate and
migrate mesially as it erupts, the advancement of upper molars is a matter of
encouraging and supporting this natural process. A vertical closing loop or double delta
loop will assist in its forward closure.
Lower molar anchorage
Maximum lower molar anchorage is maintained through the action of the long lever
arm of the lower utility arch as described. During cuspid retraction on sectional arches,
the utility arch is used in extraction mechanics to intrude or stabilize the incisors, while
the various molar anchorage needs are met by modification to the basic utility arch.
Four mechanical adjustments are placed against the molars in establishing a maximum
anchorage effect:
1. Buccal root torque that places the roots against the cortical support to limit their
movement. Up to 45° of buccal root torque is placed in a .016 ´ .016 Elgiloy wire.
2. Buccal expansion of the molar section of 10mm on each side is necessary to support
the buccal torque.
3. Tipback of 30°-40° keeps the molar upright and resists the forward pull in response
to the cuspid retraction springs. The tipback is the reciprocal action that acts to intrude
the lower incisors. (The molar step for maximum anchorage should be kept against the
molar tube.)
4. Distal molar rotation of 30°-45° is also placed in the molar section of the utility arch
in extraction cases. The molar needs to be positioned to resist the forward drag on it
during cuspid retraction, as well as to be positioned to receive the upper molar in a
proper functioning occlusion.
Moderate lower molar anchorage modifies the lower utility arch mechanics to allow
the molar to come forward during cuspid and incisor retraction. A contraction utility
arch stepped ahead of the molar tube modifies the four components of molar anchorage
and utilizes the incisor retraction force to advance the molar. A proposed 3-4mm
forward lower molar movement must respect the musculature which reflects the facial
type.
In the extreme vertical pattern open bite cases, 3mm forward movement would still
require maximum anchorage to hold; while 3-4mm forward movement in a strong, deep
bite brachyfacial type would be minimum anchorage and require special efforts to
advance the molar. The facial type which reflects this muscular anchorage is a critical
factor in influencing the treatment prescribed.
Lower Incisor.
Lower incisor retraction must respect the cortical bony support on the lingual
planumalveolare as the teeth are being retracted. Very light continuous forces (150
grams) need to be applied in order that the cortical bone can be remodeled.
The contraction utility is used in lower incisor retraction. Its construction and activation
allow light activation forces and limited extrusion because of the molar tipback loop.
The double delta retraction loop can be used for lower incisor consolidation either to the
incisors from the molar as an overlay on top of the sectional arch or as a continuous
arch through the buccal segments with the closing loop between the cuspid and incisors.
The double delta loop produces more extrusion of the incisors and is used where incisor
bite closure is desirable.
Upper Incisor.
When upper incisor retraction is begun, it is important to remove the Nance lingual arch
to allow the alveolar process to remodel. Upper incisor retraction and consolidation has
the additional problem of maintaining upper incisor torque control while the incisors are
being retracted. The torque is applied through the long lever arm and loop on the utility
arch from the molar.
The long axes of the upper incisors are torqued until they parallel the facial axis line.
This allows for incisor alignment that is individualized to the facial type.
The upper incisors can be retracted by a regular contraction utility arch when directed
consolidation is required. Where additional lingual root torque is necessary during
incisor consolidation, then a torquing contraction utility arch is used. An upside down
vertical closing loop gives additional torque when activated. Lingual root torque results
as the loop expresses its activation.
Following the consolidation of the incisor segments to the buccal occlusion, the arch
form and finishing occlusion are established with continuous arches. Slight variations in
vertical height of the various segments as they are brought together can be
accomplished by the double delta loop which has a vertical leveling component as well
as a horizontal consolidating component. For slight variation, multistrand continuous
arches are effective. Where slight overbites have developed during incisor retraction
and consolidation, the standard utility is again used for minor leveling and intruding
procedures for a period of time.
Ideal continuous arches are placed following incisor consolidation to complete the
details of occlusion. Molar, bicuspid, and cuspid offset bends are placed in the
continuous arches.
Finishing arches are placed during the final two weeks of treatment. The bands have
been removed from the buccal segments in order to close the band space and handle the
final finishing details.
The final finished occlusion in an extraction case shows the molar rotation, buccal
occlusion, and occlusal arch form that are important to the proper function and stability
of the case. It is important to have the finished occlusion in mind when the first
activations for molar rotation and cuspid retraction are placed.
MECHANICS OF SEQUENCE FOR CLASS II DIVISION 1 CASES
Forgetting about the upper arch which is usually undergoing orthopedic reduction with
a head gear the lower arch is leveled and aligned as early as possible.
Type C: Incisors are extruded and the lower molars are tipped mesially with no
extrusion of the canines
Treatment involves the leveling of the arch by first placing a utility arch and then a
simple overlay arch to align the lower buccal segment teeth.
Cuspid Intrusion
This is accomplished by lightly tying these teeth to the stabilizing utility arch with an
elastic thread. The elastic thread should completely encircle the cuspid bracket and a
knot tied behind the base of the bracket. Normal intrusion time for the cuspids should
not be more than 1 month.
When the upper buccal segment teeth are treated as a section, and the Class II is
corrected in a segment, overcorrection can be accomplished without having a
detrimental effect upon the upper incisor.
Traction Sections
Tractions are utilized to counteract some of the negative responses that occur with Class
II elastics to the buccal segment.
The tendency for the downward pull of the Class II elastics to extrude and throw the
root of the canine mesially is countered by placing a small closed helix distal to the
upper cuspid teeth with a gable or tipback of 30°. The anterior portion of the segment
should also be rotated mesially 45° and often a horizontal closed helix is placed at the
molar region to maintain or accentuate distal molar rotation.
The traction section also stabilizes the upper buccal segments against the impending
intrusion and torque in the upper incisors.
As the buccal segments are moved distally this allows for some functional realignment
of the anterior segment.
A contoured anterior segment if used to level the upper central and lateral incisors and
to close anterior spaces prior to intrusion and retraction.
An upper utility arch is then placed and the upper incisors are torqued and intruded as
necessary prior to their final retraction.
An upper ideal arch, fabricated from .016 x .016 blue Elgiloy, .017 x .017 blue Elgiloy,
.016 x .022 Nitinol, or .017 x .025 Nitinol, is utilized to place final arch form and torque
adjustments in the upper arch.It is important that Class II elastic wear be discontinued at
least two months before final debanding/debonding. This period will allow for
physiologic rebound and is essential in the determination of centric relation.
Quite often two light round arches (.014 or .016) bent in ideal arch form are utilized to
allow for function to seat the occlusion. These light round arches are also quite
beneficial in making minute adjustments for the band/bracket height discrepencies that
are present in most situations.
MECHANICS SEQUENCE FOR CLASS II, DIVISION 2 CASES
In general there are three treatment possibilities in a Class II, Division 2 malocclusion:
1. Distalizing the upper arch
2. Advancing the lower arch
3. A reciprocal movement, advancing the lower arch and the distalizing the upper arch
at the same time.
There are six functions necessary in treating Class II, division 2 malocclusions, which
are general considerations for evaluating the mechanics sequence:
I. Advancement, torque control and intrusion of the upper incisors.
II. Intrusion of the lower incisors and cuspids.
III. Alignment of the buccal segments and Class II correction.
IV. Consolidation of the upper incisors.
V. Idealizing the arches
VI. Finishing.
4. Torque Control
Due to the fact that many Class II, Division 2 patterns are brachyfacial and, therefore,
have a high facial axis angle and resulting horizontal growth, by putting the upper
incisors parallel to the facial axis the interincisal angle is decreased which will help to
maintain the overbite correction experienced in many Division 2 cases. There should be
early torque control in the maxillary denture in all cases.
II. Intrusion of the Lower Incisors and Cuspids
The lower incisors are intruded using a mandibular utility arch
There are two ways of accomplishing this:
1. Using an .016 × .022 stabilizing utility arch and tying the elastic ligature lightly from
the cuspid bracket to the utility arch in the bridge section
2. The second possibility after the intrusion of the lower incisors is to place an .016 ×
.016 utility arch with a 45° tipback at the molar and allow the anterior section, when it
is placed in the molar bracket, to extend down into the mucobuccal fold (this will give
approximately 60-75 grams of force); then tie the elastic ligature from the cuspid
bracket to a notch bent into the utility arch bridge section and elevate the anterior
section, by tightening the elastic ligature, until it is level with the incisor brackets. The
opposite side will be down slightly, and tying the elastic ligature on the opposite side
can be carried out in the same manner. When the anterior section is level with the
incisor brackets, it is then tied into the brackets.This can usually be accomplished in one
appointment and will insure that there will not be an extrusion force on the incisors.
It is possible at this stage of treatment to band/bond the upper maxillary cuspids and
premolars, if not previously done, and place a traction section.
If advancing the lower incisors is necessary, one of the modified utility arches may be
constructed.
Ricketts interpreted Angle's line of occlusion to include a line drawn through the
contact points of the posterior teeth and slightly below them through the contact
embrasures of the anteriors. The line is suggested as the line to which our brackets can
be placed on the individual teeth in order to allow the cusp/marginal ridge function that
our occlusal stops produce.
Prefabrication of Appliances
Prefabrication is a basic principle of Bioprogressive Therapy in order to be more
efficient in obtaining quality results. Thus, the evolution from Standard Bioprogressive
which originally contained torque and tip in the upper incisors and all cuspids, through
Full Torque for the bicuspids and molars, now to the offset in the Triple Control has
been a natural progression consistent with our basic principles.
Mandibular arch
1. Arch width across second molars.
2. Distal of first molar rotated lingually until the distobuccal cusp approximates mesial
sluiceway on second molar.
3. Large buccal offset at mesial of first molar.
4. Check inter-bicuspid width for necessary expansion.
5. Proper buccal arch form and contour.
6. Premolar offset to bring it in contact with distal lingual incline of upper canine (2-
3mm).
7. Mesial of cuspid tucked slightly behind lateral incisor distal of the cuspid buccal.
8. Over-rotation of incisors; smooth arc.
Maxillary arch
1. Width across first and second molars.
2. Distal rotation of first molar so that line drawn through distobuccal and mesiolingual
cusps points to the distal third of the opposite side cuspid .
3. Mesial offset (large) on molar.
4. Mesial rotation of lingual cusp of first bicuspid to seat in distal fossa of lower first
bicuspid.
5. Premolar offset (2-3mm) to avoid first area of prematurity.
6. Cuspid brought into contact with lower cuspid and premolar to establish cuspid rise.
7. Lateral left labial (until retainer) to allow overtreatment of buccal segments; then
tucked in.
8. Smooth arc across incisors.
Long time retention needs to consider late growth changes and other influences that will
continue to affect the alignment of the teeth. These will depend upon original tooth
movements necessary to correct the malocclusion, the muscular function and growth
changes consistent with the original musculature, and facial type.
CONCLUSION
This seminar attempted to present the basic tenets of the Bioprogressive Therapy. It began
with a systems approach diagnosis and treatment planning and an overview of the
management procedures used to implement and carry out the logic process employed in our
treatment. Various treatment sequences were suggested that could be applied to a total course
of therapy, rather than a cookbook technique blindly followed in every case. Orthopedic
alteration, optimum orthodontic forces and combination of mechanics were suggested that
would unlock the malocclusion in a progressive sequence in order to establish more normal
function for optimum health and stability of the denture. Bioprogressive Therapy approaches
an in-depth analysis of the basic malocclusion, the underlying morphology with its functional
variations, then attempts to treat them to as normal a function and esthetic relationship as is
possible for the long range health and stability of the denture. Each case is approached
individually because of its individual morphology, physiology and malocclusion and the
prescribed treatment sequence is selected to accomplish quality results with efficiency.