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Bioprogressive Therapy PDF
Bioprogressive Therapy PDF
Introduction
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
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
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
PRINCIPLES OF BIOPROGRESSIVE THERAPY
Ten principles have been developed in an attempt to communicate an understanding of the mechanical
procedures that Bio-Progressive Therapy may use in developing a treatment plan, including appliance
selection and application, specific to each individual patient.
#1. The use of a systems approach to diagnosis and treatment by the application
of the visual treatment objective in planning treatment, evaluating anchorage, and
monitoring results.
It is a cephalometric setup similar to a plaster setup in order to anticipate those changes expected in the
individual patient.
This treatment forecast was developed by Ricketts and called a Visual Treatment Objective by
Holdaway
It helps in assessing those changes that are going to be helpful in the correction of the problem and
respect those growth factors that will make the problem worse or severely complicate treatment.
During the average two-year treatment experience, treatment changes will account for 70-80% of the
change, while growth changes are limited to 20-30%.
It is a management tool to permit evaluation of change that is proposed in each area, and the effect that
change will have upon the other areas.
#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.
Planning for the unlocking of the malocclusion begins at the initial exam and evaluation.
1. To describe the malocclusion and visualize the position of the teeth in terms of what functional
influences have been responsible for their present alignment.
2. To describe the facial type and skeletal structure from the cephalometric x-rays, and the implied
description of function.
3. To describe the present abnormal functional influences upon the dental arches; if not abnormal, then
lack of normal development by default.
The following process of evaluation is used in setting up a treatment plan and prescribing the various
appliances and treatment:
First: Functional influences and their correction.
Second: Orthopedic alterations that may be necessary.
Third: Arch form— arch length, extraction needs.
Fourth: Tooth movements and anchorage planning.
Fifth: Case management, with key factors to monitor during treatment.
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.
THE VISUAL TREATMENT OBJECTIVE
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.
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.
VTO — Mandibular Growth Prediction—Condylar Axis Growth & Corpus Axis Growth
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.
12. Slide back along the corpus axis superimposing at new and old PM. Trace the symphysis and draw
in mandibular plane.
13. Construct the facial plane from NA to PO.
14. Construct facial axis from CC to GN (where facial plane and mandibular plane cross).
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.Superimpose interincisal 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.
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.
With Evaluation Area 2, we determine whether we wish to use an orthodontic or an orthopedic force
on the maxilla with a headgear.
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.
It is important to describe the basic facial and dental characteristics of the classical orthopedic problem
Bimler described Class II skeletal malocclusion as Micro Rhino Dysplasia
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.
Force Direction
Forces applied to the maxillae through the face bow are either
a. Restrictive (retard downward and forward growth)
b. Rotational
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.
Mechanical Application of The Cervical Headgear
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.
C. Stabilization of the lower arch allowing segmental treatment of the buccal segment
Acts to maintain arch stability while canines are intruded and positioned separately.
Allows use of segmented arch mechanics with cuspid retraction against anchorage of all other teeth.
Stabilizes the lower arch for Class II elastics to upper segmented or utility arches.
Allows rotation and alignment of the teeth in the buccal segment.
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
2. Advancement of the lower incisors when lingually placed: Steiner‘s rule would dictate that for each
1mm that the lower incisors are brought forward 2mm of arch length is gained.
3. Expansion in the buccal segment: Ricketts rule dictates that for each 1mm of expansion across the
bicuspids or deciduous molars, ½ mm of arch length is gained and for each 1 mm of expansion across
the molars 1/3 mm of arch length is gained.
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‖.
I. Resolve Functional Problems: The practical definition of a functional problem is anything that
disturbs the growth, health and function of the tempero-mandibular joint complex.
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:
Cases with stronger mandibular growth turgor have a propensity for upward/forward growth of
the condyle.
Cases with a weak growth turgor demonstrate a more upward/backward growth of the condyle
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
B. Laminagraphic Evaluation: The condyle is typically brought down on the eminence on one side
and is either ideally seated or distally positioned on the opposite side. The opposite side from the shift
acts in a translatory manner while the shifting side condyle is brought into apposition with the greatest
height of the eminence.
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.
D. Timing and method of treatment: Cross mouth interference should be removed as soon as it is
noted. In deciduous dentition, this may mean an equilibration of a posterior tooth, or canine, to
alleviate the shunting. If the problem is due to bilateral constriction of the maxillae, expansion therapy
is indicated usually when the upper first molars have erupted sufficiently to allow placement of the
expansion appliance.
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.
B. Laminagraphic evaluation: When anterior mandibular shunting occurs, often both condyles are
brought down toward the apex of the eminence (i.e., out of the fossae) and, quite commonly, articular
space superior and posterior to the condyles is evidenced.
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.
D. Timing and method of treatment: It should be determined whether the individual case is a true
Class III malocclusion or simply an anterior interference. When the case is simply an anterior
interference, alignment of one or more teeth to prevent the interference is ideal. This is most easily
accomplished prior to full eruption of the incisors or before incisal trauma damages the teeth at the site
of interference.
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.
C. Resultant growth changes: Loss of guidance of the condyle in the fossa causes abrasion or wear
due to the excessive anteroposterior slide. This can result in growth at the apex of the condyle and
increase upward/backward growth.
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.
B. Laminagraphic evaluation: Upon centric occlusion, the condyles will be forward in the fossa,
downward and forward on the eminence, and will quite often reveal flattening of the anterosuperior
surface of the condyle. Excessive joint space superior and distal to the condyles will be evidenced and,
frequently, an upward/backward bend to the neck and the condyles will be seen.
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.
C. Resultant growth changes: Since there is no interference with the antero-superior portion of the
condyles, these cases most often demonstrate normal growth turgor in the condyles. It is felt by some
that it is the lack of normal articulatory pressure at the antero-superior portions of the condyles that
enhances the brachyfacial aspect of these particular cases.
D. Timing of treatment: As the distal displacement is often caused by the vertical eruptive pattern of
the upper and lower incisors, clinical factors which cause this eruptive pose should be avoided.
Early removal of deciduous cuspids in the deep bite, brachyfacial type cases will free the anterior teeth
to move in a lingual direction. This will further deepen the bite and the incisal trauma will slowly seat
the condyles distally in the fossae. When early removal of deciduous cuspids is necessitated by
extreme crowding, it is suggested that a lower lingual arch be placed to prevent excessive
linguoversion of both the upper and lower incisor teeth.
When a vertical inclination of the incisors already exists, early advancement of the upper incisors to
create overjet often will allow the protracting musculature of the mandible to react, dominate, and free
the condyles of the distal displacement.
Over closure of the mandible, with excessive freeway space, will also allow the condyle to seat
distally in the fossa. Long-term, gentle, Class II elastics which help protract the mandible, as well as
allow extrusion of the posterior buccal segments, are most helpful in correction of distal displacement.
Where the extreme brachyfacial type exists, avoidance of extraction is important to assure proper
vertical support in the buccal segment.
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.
C. Resultant growth changes: As in the posterior displacements, there do not appear to be any early
signs of growth alteration due to superior displacement.
D. Timing and method of treatment: Since the superior displacement can be caused by loss of
posterior support, early removal of carious deciduous teeth without proper vertical support can be
influential in creating this abnormal position to the condyles. When a stronger muscular pattern exists,
and numerous deciduous teeth must, by necessity, be removed, replacement of these teeth in a retainer
is important.
The over closure syndrome can take some time to develop and it is quite difficult to restore once the
posterior vertical dimension has been diminished and the retained anterior teeth have adapted to the
abnormal positions of the condyles.
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.
B. Laminagraphic evaluation: When the mandibular teeth have bypassed the maxillary incisors, the
condyles are often downward and forward on the eminence, with excessive space superior and distal to
the condyles in the fossae. A long, thin condylar neck and long, thin ramus is often noted. Where the
lower incisors are locked beneath the upper incisors or the patient physically restrains the mandible,
distal displacement may be noted in the true Class III.
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.
A. Expansion primarily by change in axial inclination: The appliance used to change arch form in
most cases is the quad-helix or W expansion appliance (Ricketts). It is fabricated from .040" blue
Elgiloy wire and is bent with a heavy bird beak plier. The lingual arm of the appliance extends to the
deciduous cuspid and is either soldered to the upper first molar (or bent to fit into a lingual sheath).
The posterior helix is beveled slightly to lie against the palatal vault and is as close to the upper molar
as possible to prevent impingement on the palatopharyngeus muscle. The anterior helices are brought
as far forward as possible and the anterior horizontal arm should generally sit over the incisive papilla,
slightly lingual to the upper incisors to allow for intraoral activations. The anterior segment of the W
expansion should be as wide as possible so that the appliance is maintained away from the swallowing
position of the tongue. This will help avoid tissue impingement of the appliance on the palate or
tongue and can prevent an unwanted tongue thrust created by placement of sections of the appliance in
the tongue space. All of the helices should roll to the top and should be tightly wound to increase their
mechanical efficiency (Fig. 21).
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
B. Expansion by midpalatal disjunction: Where the axial inclination of the upper buccal segments is
more ideal and yet crossbite exists, palatally borne appliances are typically used to enhance midpalatal
disjunction. A Haas-type or modified Nance appliance is used to gain these changes.
Overexpansion of the maxillae is necessary, as the palatal vaults tip buccally and must be allowed to
upright to create normal axial inclinations as well as ensure stability in the expansive process.
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.
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 planum alveolare 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.
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.
Bioprogressive Therapy proposes a concept of overtreatment in order to compensate for the original
malocclusion and the abnormal function that was originally present.
The upper arch is fitted to the lower arch in finishing, and the upper teeth, when treated in patients
with either Class I or Class II malocclusion, are overtreated and positioned to simulate conditions that
follow the normal pathways of eruption.
Overtreatment, is an attempt to reverse the natural biological tendency by overtreatment and then
allow natural function to guide the teeth into the best functioning occlusion for each individual.
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.