Bioprogressive Therapy

Bioprogressive Therapy

OUTLINE
 About Dr. Ricketts
 The Bioprogressive philosophy
 Evolution of the Bioprogressive therapy
 10 Principles of Bio-Progressive Therapy
 Different type of Bracket design & Buccal tube used in
Bioprogressive Therapy
o Brackets with rotation arm
o Siamese type or dual bracket
o Some other variations in bracket design
o Factors in Molar tube & Auxiliary design
 Mechanics
o Utility arch- Evolution, fabrication and its uses
 Sectional arch treatment
 Sequence of mechanics:
o Stabilization of upper and lower molar anchorage
Retraction and uprighting of cuspids with sectional arch
mechanics
o Retraction and consolidation of upper and lower incisors
o Continuous arches for details of ideal and finishing occlusion

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 Bioprogressive Therapy

 Finishing check list

o Mandibular arch
o Maxillary arch
 The Bioprogressive appliances
o The basic Bioprogressive
o Full Torque Bioprogressive
o Triple Control Bioprogressive
 Rickett’s triple control Bioprogressive prescription

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About Dr. Robert Murray Ricketts

Robert Murray Ricketts, DDS, MS, NMD (1920-2003)

 Dr. Ricketts became a graduate with honors from the School of

Dentistry at Indiana University in 1945.

 He earned a Masters Degree in orthodontics and radiology in 1950

from the University of Illinois.

 He was clinical professor of orthodontics at the University of South

California and Loma Linda University.

 He was given the Merit Award from the American Society of

Dentistry for Children.

 His research won the Second Prize in the American Association of

Orthodontics Essay Contest in 1950.

 He was a Diplomat of the American Board of Orthodontics.

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 Bioprogressive Therapy

 Dr. Rickett’s contribution to orthodontics started in 1950 when

attention was drawn to the clinical application of cephalometry.
Ricketts published 2 papers in 1960 giving a detailed account of the
clinical use of cephalometrics using 1000 cases treated by him, and
for the first time studied the possibility of growth forecasting.

 Dr. Ricketts was simultaneously involved with the new concept of

Esthetics, the law of lip relations and the importance of chin point, B
point and lower incisors in treatment and stability.

His contributions have been to the new concept of occlusion, the

introduction of the Fibonacci numbers from the Hindu- Arabic numerical
system.

Among Dr. Ricketts research and design achievements were:

 Development of the first cephalometric diagnostic system to project

treatment plus growth in treatment planning (VTO);

 Utilizing the growth studies of Bjork, Moss, Scott, Petrovic and others
to develop a computer generated method of predicting growth (Long
Range Forecasting);

 Pioneered the use of "composite tracings" to better understand normal

growth patterns in various facial types;

 Development of computer generated cephalometric diagnostics (RMO

Data Systems);

 Development of 5-arch forms used to individualize treatment

outcomes (Pentamorphic Arches);

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 Development of "root ratings" based upon the works of Miura and

Brian Lee to quantify the forces necessary to move teeth in any plane
of space;

 Developed a hierarchy of anchorage in recognition that growth, the

muscles, then cortical anchorage, and then traditional tooth-based
anchorage prevailed in treatment mechanics;

 Developed with Ruel Bench and Carl Gugino, new appliance

systems used world wide including quad-helix, utility arches,
sectionalization, and orthopedic correction with cervical headgear;
and

 Developed with Ruel Bench and Carl Gugino the Bioprogressive

Philosophy, a biological approach to diagnosis and treatment.

Bioprogressive Philosophy11:

Dr. Robert Murray Ricketts introduced Bioprogressive Therapy. It

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 teeth or occlusion.

It involves a broad concept of total treatment rather than a sequence of

technical and mechanical steps. It takes advantage of biological progression
including growth, development, and function, and directs them in a fashion
that normalizes function and enhances aesthetic effect.

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 Bioprogressive Therapy

Thus, according to Bio-progressive therapy, the clinician needs to

base his treatment mechanics on the results he wants to achieve with the
goals and objective he has in mind. He should then select the mechanical
procedure or device that will accomplish his goals, rather than follow a
mechanical technique blindly and settle for whatever result it may arrive at.
Thus the priorities were sought and movements of teeth were selected in
keeping with the forces of occlusion, the forces of growth and the forces of
nature. This accounts for the prefix “bio” being used to suggest the strong
biological implication to be constantly borne in mind with this technique.

Priorities of this new approach:

 Keeping with the forces of occlusion, growth and nature.

 Main principle based on growth.

 Mission – To treat the total face rather than the narrower objective of
teeth or the occlusion.

 Appropriate application of orthodontic therapy.

 Primary concern of musculature.

Ricketts in 1965 published 2 papers which dealt with some of the

muscular or functional factors involved in esthetic considerations. His work
dealt with the chin, the lower alveolus and the environmental condition. He
called these three structures the “Key Stone Triad”.

Ricketts enumerated 9 factors which should be considered in the

analysis of oral soft tissues and said that specific attention should be given to
the area of tongue and lip balance.

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1. The correlation of morphology and function is implicit in most

conditions of lip relations. He feels what looks good works well.

2. The tongue interacts with the lips in all functions such as mastication,
speech, and deglutition and even in tonicity at physiological rest.

3. Lip and tongue function is read from the cephalometric X- ray film.

4. It is recognized that the lips are influenced by the teeth or conversely

the teeth are influenced by the lips.

5. The lips are viewed in perspective or considered in multiple

dimensions.

6. A distinction should be made between mouth disharmonies and lip

imbalances.

7. Combination of conditions are recognized in the context of patterns as

the conditions are isolated, classified and then correlated into patterns
for intelligent understanding.

8. Lip and mouth conditions are considered longitudinally because more

lip prominence or more recessive mouth characteristic may develop as
the patient grows.

9. A flamboyant outgoing personality will frequently accept a more

prominent and forward denture and it is possible that recessive
dentures are more suitable for withdrawn persons, although these
ideas are not totally acceptable.

Ricketts after a lot of research on normal values described the “Law of

lip relations”, which includes both functional and esthetic considerations and
stated that the lips of white adults are contained within a line from the nose

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to the chin (E- line), the lower lip is closer to the line than the upper, the lips
are smooth in contour and the mouth is closed with no strain.

Evolution of the Bioprogressive therapy:

Bioprogressive therapy may be considered as an evolution from the

edgewise technique, with features of certain light wire methods
incorporated.

By 1950, certain edgewise clinicians became concerned with some of

the results such as:

 Some amount of root resorption was not uncommon.

 The use of round wires in the leveling stage in cases with deep bite led
to protrusive dentitions.

 Extractions were often advocated only on therapeutic grounds.

 Even in some cases where extractions were carried out for lower
incisor stability, imbrication developed post treatment.

To avoid these problems, some modifications were made in the full banded
edgewise technique:

1. Large round headgear tubes were soldered on strips prior to banding

because the double tube setup on upper molar came to be
commonplace.

2. The use of complicated second order bends were not used in the
treatment of Class II malocclusion. Straight arches with sliding hooks

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and methods to slide the teeth on an archwire were introduced to

move the buccal segments distally.

Management Umbrella concept11

The Management umbrella includes the following steps:

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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
appliance specific to each individual patient.

Principles of Bio- Progressive Therapy12

1) The use of a systems approach to diagnosis and treatment by the

application of visual treatment objective in planning treatment,
evaluating anchorage and monitoring results.

 To plan properly for the change that will occur, the clinician must
understand the present condition, anticipate growth and know the
specific effect of his orthodontic- orthopedic treatment.

 This treatment forecast, developed by Ricketts and called as VTO by

Holdaway, allows the orthodontist to visualize the changes that
should occur and to prescribe the necessary treatment to cause it to
happen. Usually during two years of treatment, 70-80% of the change
is due to the treatment prescribed and 20-30% of change is due to
growth.

 For this purpose the VTO is like a blueprint or design of the final
results. Thus VTO allows the clinician to evaluate the inter
relationship of the various changing parts as they affect each other in
the proposed adjustment………

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1 chin, 2 maxilla, 3 lower incisor, 4 lower molar, 5 upper molar, 6

upper incisor, 7 soft tissue.

Chin Maxilla Lower Incisor

& Lower molar

Upper Incisor & Molar Soft Tissue

We must consider the inter- relationships, first with the chin and its
effect upon the maxilla, then their combined effect on the lower molar, then
the effect of lower molar change on the upper molar, upper incisor and the
soft tissue profile.

The above seven areas of evaluation are used to determine the major
moves needed to accomplish the forecast objectives and to design treatment
with a priority sequence for quality results and maximum efficiency.

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2) Torque Control throughout treatment

According to Bio- Progressive Therapy, movement of teeth can be

more effective when control of direction of root movement is available.

The edgewise bracket slot - .018" x .030" is used in order to keep the
bracket and wire size smaller, but still have torque control available through
the various stages of treatment.

Following are four treatment situations where torque control of root

movement is necessary:

1. To keep the roots in vascular trabecular bone – To keep roots away

from denser, thicker cortical bone for rapid tooth movement through
trabecular bone, for beginning movements such as incisor intrusion or
cuspid retraction.

2. To keep roots against dense cortical bone – For anchorage.

3. Torque to remodel cortical bone-

When movement of teeth in dense cortical bone is required.

The examples include:

 Mesial movements of lower molar to close the extraction space.

 Impacted upper canine.

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Here very light sustained force is required under directional

control to keep the roots properly positioned during this critical time
of treatment.

Lack of control may cause excess tipping and then again

recovery, in turn delaying the effective movement.

4. Torque during positioning teeth in final occlusal details -

Here proper fit of teeth requires proper root alignment for

proper function and better stability.

3) Muscular Anchorage / Cortical Bone Anchorage

Muscular Anchorage

Anchorage here is considered in terms of stabilizing the molars during

various stages of orthodontic treatment and is countered by posterior
muscles of mastication, primarily masseter and temporalis.

It was seen that those facial types, which exhibit stronger musculature,
are characterized by deep bite, lower mandibular plane angle and
brachyfacial structure. While those which exhibit weak musculature are
characterized by high mandibular plane angle, vertical growth pattern, open
bite and dolichofacial structure.

The treatment procedure in the latter cases must be closely monitored

or modified to respect the weak anchorage support as orthodontic treatment
tends to open the bite and rotate the mandible clockwise, further lengthening
the face and taking the mandible back.

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 Bioprogressive Therapy

Cortical Bone Anchorage

Teeth move slowly through the cortical bone due to more dense and
laminated pattern and limited blood supply. Tooth movement is further
delayed when excess force against the cortical bone can press off the blood
supply and thus limit physiologic tooth movement.

This biology of cortical bone is used to enhance lower molar

anchorage by expanding lower molar roots into the dense cortical bone on
their buccal surface by excessive buccal root torque in the arch wire.

4) Movement of any tooth in any direction with the proper application

of pressure

The key factor to the rate at which tooth movement will occur, is the
blood supply that sustains the physiological action that takes place within
the bone itself. The force that is too heavy causes ischemia and tooth
movement is delayed. Any appliance that delivers light continuous force is
the most effective for optimum tooth movement.

0.016" X 0.016" chrome alloy arch wires have been found to apply
light continuous forces required. Thus bio- progressive therapy is designed
to respect the supporting bony structure and size of the roots of individual
teeth.

5) Orthopedic Alteration

Bioprogressive therapy anticipates and plans for orthopedic changes,

as a part of its treatment procedure. Some of the examples of orthopedic
changes include:

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 Alteration of maxillary growth direction by use of Headgear.

 Widening of the maxillary arch by using lateral forces across the

suture.

 Advancement of the mandible in class II patients with a deficient

mandible using functional appliances.

An understanding of how these basic structures grow and develop

normally without treatment is essential in evaluating the changes that can be
effected by various appliances.

6) Treat the overbite before the overjet

Bioprogressive therapy states that incisor intrusion is the treatment of

choice for best results not only during treatment but also for stability of
results.

By treating incisor overbite before overjet, interference is avoided and

posterior teeth remain in normal stable occlusion, preventing their extrusion
and thus future relapse tendency in low angle cases is reduced, while it also
prevents an increase in the vertical facial height in high angle cases.

Hence sectional arches are used to stabilize the buccal occlusion in

conjunction with the spanning utility arch to the incisor teeth, where a light
continuous force can be applied to the incisors for their intrusion or root
torquing movement.

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7) Sectional Arch Treatment

It is a basic treatment procedure of Bioprogressive therapy.

Benefits of the Sectional Arch treatment:

 It allows lighter continuous forces to be directed to individual teeth

for their efficient movement.

 More effective root control in basic tooth movements.

 It supplements maxillary orthopedic alteration.

 It reduces the binding and friction of brackets as they slide along the
archwire.

8) Concept of Overtreatment

Bioprogressive therapy suggests following areas where overtreatment

may help compensate for the anticipated post treatment adjustments.

To overcome muscular forces against the tooth surfaces

For example,

 Force of buccal musculature in RME.

 In cases of open bite- force of the tongue.

 In cases of increased overjet- force of lower lip biting habit.

Root movements needed for stability

For example,

 By overintrusion and over torquing of teeth in deepbite cases.

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 Bioprogressive Therapy

 Paralleling roots of teeth adjacent to extraction site for stability of the

space closed.

 Over de-rotating the rotated teeth to help compensate for relapse

effect.

To overcome orthopedic rebound

 Some rebound effects are beneficial.

For example,

In class II cases the rebound effect, which closes the bite and
rotates the chin forward will help in class II correction and therefore it
is beneficial.

 However most tend to complicate the problem.

For example,

In class III treatment forward rotation of chin and closure of the

mandible will worsen the problem.

Hence over-treatment is in anticipation of these post treatment adjustments.

To allow settling in retention

Over-treatment of individual teeth within the arches allows them to

settle into functional occlusion.

For example,

Class II correction begins with the molars by over-treating them into

super class I through distal rotation of the upper first molar behind an
upright distally rotated lower molar.

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9) Unlocking the malocclusion in a progressive sequence of treatment in

order to establish or restore more normal function

Bio- progressive therapy feels that many malocclusions are a result of

abnormal function. This form of treatment usually recommends conformity
to the present arch form in order to maintain the alignment of teeth to the
present function for proper occlusion and stability of results. For example, if
crowding exists, extraction is usually necessary in order to maintain present
arch form, which is thought to be stable.

10) Efficiency in treatment with quality results, utilizing a concept of

prefabrication of appliances

One must pay attention to the fine details that are necessary to render
service of the highest quality.

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DIFFERENT BRACKET DESIGNS AND BUCCAL TUBES USED IN

BIOPROGRESSIVE THERAPY

Two principle bracket designs.

1. Brackets with rotation arm.

2. Siamese type or dual brackets.

1. Brackets with rotation arm

Advantages:

 Light force can be delivered.

 Wide inter bracket distance.

 Less friction during sliding.

 Rotation arms with slots or extensions can be used as uprighting arms.

 May take the place of a loop in the wire.

 Ease with straight wires.

 Decreased need for buccal or labial contouring for band adaptation.

2. Siamese type or dual brackets

Advantages:

 Yields positive control.

 Easy to keep clean.

 More effective rotation control.

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 Bioprogressive Therapy

 Provide greater wire purchase.

 Permits double tipping.

 More efficient with light wire.

 Tying of only one wing of one bracket for de-rotation.

 Permits exotic bends.

 Distributes force.

 Provides a lug for easier banding.

 Prevents wire distortion.

 Allows wire to be used as an uprighting spring.

Some other variations in bracket design.

 Dr.Cecil Steiner and Dr. Lang suggested 0.016" x 0.016" slot, which
was later, changed to 0.019" x 0.025" slot.

 Then Dr. Ricketts changed it to - 0.0185" x 0 .030" slot.

 Dr. Ivan Lee used torque slot, to get rid of Third order bends.

 Dr. Reed used bracket angulations to reduce need for second order
bends.

Other specific aspects of Bracket design

a) Advantages of increasing the slot depth (0.030"):

 Permits two light arch wires to be placed at once.

 Permits a bevel at the box entrance to fabricate wire seating.

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 Permits bracket profile to be raised for lever access beneath the

wings.

 Provides more adequate distance for torque grooves.

b) Wide incisal gingival wings:

 Provides easy access for tie wires.

 Single wing of one wire can be used as a staple.

 Permits auxiliary light wire to be placed underneath the wing.

 Can be used for rubber elastic traction.

 Provides accessibility for cement removal under the wings.

c) Softer material:

 Permits closing of the bracket for rotation with later reopening

during finishing.

 Will not fracture or chip teeth.

 Can be pinched close around narrower arches for absolute wire

engagement.

Two wires accommodated

Wire placed underneath

the wings

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Factors in Molar tube & Auxiliary design

Innovation of pre-attachment of tubes:

Tube design for upper molar:

 The upper molar band should be driven down to the distal marginal
ridge.

 Gingivally placed headgear tube with a middle round slot and an

occlusal 0.022" x 0.028"edgewise rectangular slot.

Tube design for lower molar:

 Buccal extension of the distal aspect of the tube with a 120 rotation.

 0.018" x 0.025” twin tube type.

 Hook in the center for elastic traction.

 50 tip.

o Occlusal 0.022" x 0.028" edgewise rectangular slot.

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MECHANICS

Bioprogressive therapy utilizes the concept of prefabrication and has

appliances readymade for clinical application. This allows the clinician to
direct his energies in the details of their application rather than in their
construction.

The Utility arch forms the basis of the bioprogressive mechanics.

Evolution of the utility arch13

 Contemporary, full banded edgewise orthodontic approaches utilized

light, continuous, round arches in the initial phases of treatment for
rotation corrections and leveling the Curve of Spee.

 But, this led to extrusion of lower bicuspids, uprighting of lower

molars, and forward tipping of lower incisors.

 To avoid this, the arches were cinched back.

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 Bioprogressive Therapy

 But as the Curve of Spee in the round arches expressed itself, the roots
of lower incisors were thrown against the dense lingual cortical bone,
which acted as an anchor leading to the same forward movement of
the incisors, and forward movement of the lower molars.

 To counteract the forward movement of the lower arc, Class III

elastics were used.

 To counteract the eruptive forces of the Class III elastics,

headgears were used.

 When even the smallest continuous round arches are tied into place
for leveling, an expansive movement is placed on the buccal segment
teeth which tips them up and out to unfavourable axial inclinations.

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 In extraction cases, forward tipping of the molar teeth and

intrusion of the second bicuspids is seen.

 The lower incisors, often brought forward during the leveling must
be roundtripped in their retractive movement.

Development of the Utility arch

In the 1950s Dr. Ricketts attempted to counteract the tipping that

occurred in the buccal segments in extraction cases by using the lower
incisors as an anchor unit to hold the lower second bicuspids and molars in
their upright position during retraction.

Round arch segments were laced from the lower molars and bicuspids
to the lower incisors as the cuspids were retracted.

After trying various modifications, Ricketts advocated 0.018 bracket

slot, double molar tube, light forces to prevent the flaring of lower incisors,
and 0.016 x 0.016 blue Eligloy (chrome- cobalt wire) wire was designed.

Passive utility arch

Physiological Vs. Mechanical Responses

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In order to describe why the lower utility arch is fabricated as it is, it

is important to understand the biological or physiological responses that
occur when activations of tipback, torque, and expansion are applied to the
lower molars; and actions of intrusion, torque, and alignment are applied to
the lower incisors:

1) 30° to 45° Tip-back Applied to the Lower Molars

 Due to the fact that dense cortical bone supports the lower molar on
the buccal and the relative position of the erupted or erupting lower
second molar, a tip-back applied singularly to the lower molars will
upright these teeth bringing their roots mesially (the lower molar will
tip around a center of resistance near the top of its mesial root) and the
crown distally.

 Since the lower molar is supported on the buccal by a heavy cortical

plate and at the distal by the lower second molars, the most usual
movement of this tooth with a straight uprighting force is a distal
rotation.

 In extraction cases, where there is both a mesial component of force

(the retraction section) and an uprighting component of force, a
definite distal rotation must be placed to avoid a mesial rotation of the
lower molars.

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 There is a difference between the nonextraction case utility arch and

the extraction case utility arch. Therefore, in nonextraction cases,
fabricating the distal leg of the lower utility arch with definite distal
rotation applied to the lower molar will quite often cause an excessive
over-rotation of these teeth, due to the nature of the posterior buttress
of the second molar and the buccal buttress of the external oblique
ridge.

2) 30° to 45° Buccal Root Torque Applied to the Lower Molar

 Buccal root torque is required to position the roots against the buccal
cortical plate for anchorage enhancement.

 When a 45° buccal root torque is placed on the distal legs of the utility
arch, the amount of movement of the root to the buccal is
proportionate to the amount of movement of the crown to the lingual.

 The only way that buccal root torque can be expressed by buccal
movement of the root and stabilization of the crown is by expansion
of the arch.

 Both for enhancing the cortical bone support to the lower molar
(anchorage), and for regulating or allowing normal arch width, it is
important that the distal legs of the utility arch be generously
expanded prior to placement in the mouth.

3) Long Lever Arms Applied to the Lower Incisors.

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Along with the intrusion of the lower incisors, there is a labial tipping
which occurs.

In most cases, a slight labial root torque (5° to 10°) will free the apex
of the lower incisor teeth from the lingual cortical plate and allow its
intrusion without labial flaring.

4) 75 Grams of Intrusive Force Applied to the Lower Incisors

 The mandibular utility arch is best fabricated from .016 ´x .016 Blue
Elgiloy wire in order to create a lever system that will deliver a
continuous force to the lower incisors in the range of 50 to 75 grams.

 The design of the mandibular utility arch is dictated by the

requirement that this light force be delivered in a continuous manner
off a long lever arm from the molar to the incisors.

 The arch is stepped down at the molar, lies in the buccal vestibule, and
is stepped back up at the incisors to avoid interference from the forces
of occlusion that would distort it.

 This buccal bridge section is flared slightly buccally to prevent tissue

irritation opposite the vertical steps as the arch approaches the tissue
and the incisor teeth are intruded.

Although the mandibular utility arch is a continuous arch from molar

to molar, it should be considered a sectional arch in its function. Each molar

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is treated separately as to torque, tip-back, and rotation, as are the buccal

segments, as well as the lower incisors.

Fabrication of the Mandibular Utility Arch

1) Step Height

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 The vertical step height in the lower utility arch is from 3mm to 5mm.

 The only function of the vertical step is to bring the malleable .016 ´ x
.016 Blue Elgiloy wire out of the occlusion to avoid deformation with
functional movements.

 Although the buccal vestibule is most often deep enough to easily

allow the 5mm stepdown, problems with tissue irritation can be
avoided by keeping the step height at 3mm.

2. Placement of Labial Root Torque

 The wire is bent back up at the mark made distal to the lower lateral
incisor bracket and, at this point, , rather than being bent straight
down and maintained in the same plane of space the wire is bent at a
slight inward angle (in the same direction as the curvature of the
mouth).

 When the wire is bent gently inward 10° to 15°, labial root torque is
being applied to the anterior portion of the utility arch. Holding the
wire at the anterior vertical step, the anterior arch form is then
contoured by sweeping the anterior portion of the arch between the
forefinger and the thumb.

3) Finishing the Opposite Side

 The left side of the utility arch, having been completed, is laced over
the lower incisors and a mark made 2mm to 3mm distal to the
opposite lateral incisor bracket.

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 Again, a 3mm to 5mm step is made on the right side of the arch.

 By measuring the span on the right side, either in the mouth or from
the previously measured left side, the last vertical step is made at the
mesial of the opposite side first molar.

4) Contouring the Buccal Bridges

 The buccal bridges are then gently contoured with the fingers or with
a contouring plier, to account for the gentle curvature of the arch
along the buccal segment where the utility arch will lie.

 Sometimes slightly more contour is needed to circumvent the cuspid

prominences.

 The anterior (torqued) segment of the utility arch is then held with a
How plier and the buccal bridges flared to the buccal.

 This will allow the buccal portion of the utility arch to avoid tissue
impingement as the anterior portion of the arch moves gingivally and
will also start to place some of the buccal root torque at the lower
molars.

 At the same time, holding the anterior vertical leg of the utility arch,
the buccal bridges are generously expanded to assure that a buccal
root movement will be applied to the lower molars, rather than a
lingual crown movement.

5) Activation of the Distal Legs.

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 Proper activations in the distal legs of the utility arch are placed in
order to maintain torque control, to begin to align the lower incisors,
and to upright the lower molars.

 Care should be taken to make sure the proper amount of torque has
been placed as well as buccal flaring of the bridge and the vertical
steps to avoid tissue impingement.

 The activation to intrude the lower incisors and upright the lower
molars (tip-back) is placed by holding the posterior vertical step with
the How plier at its last bend. The posterior legs are then tipped back
approximately 45° and are symmetrically aligned parallel to each
other.

 When the lower molar is uprighted, it will also rotate distally, so that
placement of a distal rotation bend in the nonextraction utility arch
will quite often overrotate the lower first molar. This is very
individual, however, and is dictated by the needs of each particular
case.

6) Final Arch Form and Activation Characteristics.

 The anterior arch form is tightly contoured to the lower incisor teeth.

 This will allow the lower incisors, especially the lower lateral incisors,
to intrude without advancing their crowns (thereby throwing the roots
into the lingual planum alveolare and preventing easy intrusion).

 A 5° to 10° labial root torque will counteract the forward tipping

action quite common with intrusive arches and will both bolster

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anchorage (by virtue of the reverse torque) and allow the lower incisor
roots to avoid the cortical bone at their apices.

 The buccal bridges are flared to avoid tissue impingement and are
expanded liberally in order to avoid lingual crown movement of the
lower molars.

 The posterior legs are parallel to each other, and 45° buccal root
torque has been placed to maintain the buccal cortical support in the
lower molar region.

Activation of the mandibular Utility arch

B: Cinch- back to prevent lower incisor flaring

C: Gable bend

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 Bioprogressive Therapy

Forces produced by utility arch activation

Roles and functions of the lower utility arch:

1) Position of the lower molar to allow for cortical anchorage- Use of

utility arch maintains the position of the lower molar during leveling,
so that the molar roots are in contact with the buccal cortical plate.

2) Manipulation and alignment of the lower incisors segment- When

treated as a segment; the lower incisors can be retracted without
disturbing the cuspids or the bicuspids.

3) Stabilization of the lower arch -allowing segmental treatment of the

buccal segments- in most Class II cases, where the lower incisors and
the canines are extruded, the buccal segments, especially the canines
should be treated segmentally in order to take advantage of the most
direct movement of these teeth towards their final position.

4) Physiologic role of utility arch- When there is a loss of

proprioception in the incisor region by removing the lower incisors
from palatal or incisal occlusion, the mandible reacts by reaching
forward to search for proprioceptive input. This ‘activator’ effect
allows the mandible to be thrust forward allowing a beneficial
muscular response for the correction of Class II malocclusion. Early
intrusion of the lower incisors maintains the principle of correcting the
overbite before the overjet.

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 Bioprogressive Therapy

5) Overtreatment

6) Role in the mixed dentition- The utility arch allows incisor

alignment and molar control during the mixed dentition, by stepping
around the deciduous buccal occlusion.

7) Arch length control: Increase in arch length can be brought about by:

- Uprighting of lower molar

- Advancement of lower incisors

- Expansion in the buccal segment

- Utilization of the ‘E’ space

Sectional Arch Treatment14

 Extraction mechanics in Bioprogressive Therapy takes advantage of

sectional arch treatment.

 Sectional arch treatment is characteristic of all of Bioprogressive

Therapy treatment procedures whether nonextraction treatment, mixed
dentition treatment, adult treatment, or extraction treatment.

 By breaking up the arches into the various segments during treatment,

it is possible to evaluate all three planes of space: the
anterior/posterior movement, the vertical movements, and the
buccolingual or transverse movements.

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 Maxillary orthopedics, with adjustments at the midpalatal suture and

posterior pterygoid buttress verifies the need to consider the segments
of the maxilla in its applied mechanics.

 Upper and lower incisor movements of intrusion, retraction,

advancement, and torquing, further suggest that sectional arch
treatment mechanics can best deliver the proper force application,
both in direction and amount, through the use of the utility arch to the
anterior segment.

 Cuspid retraction around the corner is also best handled on a sectional

arch in order to respect the supporting structures and avoid the
complication of full arch mechanics.

 Wax typodont demonstrations fail to show the limitations of full arch

treatment since wax is homogeneous and doesn't reflect the variations
in bony anatomical structure.

 Treatment mechanics that are designed to respect the variations in

anatomical structure are much more efficient. Biomechanical
principles should respect and appreciate these factors.

Sequence of mechanics in Bioprogressive therapy

The extraction sequences 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.

1. Stabilization of upper and lower molar anchorage.

2. Retraction and uprighting of cuspids with sectional arch mechanics.

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3. Retraction and consolidation of upper and lower incisors.

4. Continuous arches for details of ideal and finishing occlusion.

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1. Stabilization of the upper and lower molar anchorage

Upper Molar Anchorage

The upper molar is stabilized and anchored in various procedures

from maximum anchorage where the molars are not allowed to progress
forward, to a minimum anchorage where they may be advanced the whole
distance of the extraction site.

Maximum upper molar anchorage

 A modification of the Nance lingual arch is used in maximum upper

molar anchorage planning.

 The modification to the Nance lingual arch, with the plastic button
against the rugae region of the palate, is the addition of a distal loop
on the mesial lingual of the upper molar bands, which allows the
molar teeth to be expanded and rotated more easily.

 The expansion and rotation of the upper molars present three

advantages in treatment:

o Expansion places the molar roots out under the zygomatic

process where cortical bone support resists change and thus
anchors and limits their movement.

o The molars, placed in distal rotation, tend to resist the forward

mesial pull as the cuspids are being retracted on sectional arch
springs.

o The third value is the distal rotation of the molar crowns for
final positioning in the finishing occlusion. The finishing

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alignment and details of occlusion should be kept in mind even

in the first basic treatment movements.

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.

 It also can produce the additional value of distal rotation of the

molars.

 The lingual arch limits molar eruption and vertical height

development.

 The use of an upper utility arch during cuspid retraction with or

without the lingual arch has a moderate anchorage effect to the upper
molars, since the intrusion action to the upper incisors produces a
tipback to the upper molars, which acts to stabilize them.

 Intermittent headgear wear will provide moderate anchorage in

extraction treatment.

 Full time headgear wear in Bioprogressive Therapy is used where

orthopedic correction is prescribed.

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 or
even more.

 Class III extraction treatment usually calls for upper second bicuspid
extraction with advancement of the upper molar. Since upper molar

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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.

 However, the forward migration of the upper molar usually carries it

into mesial rotation, and treatment mechanics will need to compensate
by uprighting with distal rotations for a better final fit and occlusion.

Lower molar anchorage

 Lower molar anchorage also considers the need for complete

maximum anchorage versus a moderate and minimum anchorage,
where differing mechanics are needed in varying facial types and
muscular patterns.

 Strong, muscular, deep bite facial types seem to exhibit a natural

anchorage that needs to be appreciated and considered in selecting
appropriate procedures.

 Thus, the moderate anchorage concepts are used in the strong muscle
patterns and the more maximum anchorage concepts in the vertical
pattern where the musculature gives least support.

Maximum lower molar anchorage is maintained through the action of the

long lever arm of the lower utility arch.

 During cuspid retraction on sectional arches, the utility arch is used in

extraction mechanics to intrude or stabilize the incisors, while the

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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:

o 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 .016x .016 Elgiloy wire.

o Buccal expansion of the molar section of 10mm on each side is

necessary to support the buccal torque.

o 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.)

o 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.

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 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.

In minimum anchorage mechanics the lower molar is being advanced to

close spaces forward as in a lower second bicuspid extraction procedure or
when lower first molars may be missing.

 To advance the lower molar forward the four anchoring factors of

torque, tipback, expansion and rotation are minimized.

 Round wire in the molar tube may be used to eliminate the binding
and torquing to the molar and thereby reduce the anchorage.

 Elastic string adds the continuous force needed when advancing the
lower molar.

2. Retraction and uprighting of cuspids with sectional arch mechanics

 Bioprogressive Therapy proposes segmented arch treatment and

retracts the cuspids on sectional arch retraction springs.

 Since the cuspid is located at the "corner" of the arch, it presents

special problems during treatment.

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 In its retraction it must be allowed to turn the corner in order to avoid

the cortical bone support in both the upper and lower arches.

 In the lower arch, the planum alveolare on the lingual supports the
cuspid.

 In the upper arch, the cortical bone on the lingual palatal surface of
the alveolar process supports the cuspid lingually.

 Severe tipping of the cuspids which allows the root tip to move
forward will complicate its retraction. The cuspids need to be kept in
the narrow trough of trabecular bone and avoid the severe tipping or
displacement into the cortical bone.

 When cuspids are retracted on sectional arch retraction springs they

are free moving and not limited by the binding restrictions of a
continuous archwire.

 Therefore, care must be exercised in sectional arch treatment to

compensate for the tipping and rotational control in sectional arches.

 Extreme 90° gable and 90° offset antirotation bends are placed before
the springs are placed and activated for the cuspid retraction.

 The activation of the cuspid retraction springs should produce 100 to

150 grams of force for cuspid retraction.

 Only 2-3mm of activation is required to produce the desired force.

 Heavier forces allow excess tipping and loss of control.

 Lingual string can assist in rotational control in the final one-third of

cuspid retraction, after it has retracted around the corner.

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 Bioprogressive Therapy

 Cuspid uprighting and rotational correction may be necessary

following retraction.

 Tipping may occur when the retraction forces have been too high, in
excess of 150 grams.

 Cuspid uprighting springs are preactivated with 90° of activation in

order to generate a light continuous force to upright and parallel the
roots adjacent to the extraction site.

 The crowns need to be ligated together during uprighting in order to

prevent their separation from returning.

3. Retraction and consolidation of upper and lower incisors

 Utility arches treat the overbite before retraction.

 While the cuspids are being retracted with sectional retraction springs,
the upper and lower incisors can be aligned and either intruded or
extruded for better overbite control before their retraction.

 Upper and lower utility arches which span from the gingival tube of a
double tube on the molar to the incisors are effective in producing the
light continuous forces for incisor intrusion and alignment.

 In the cases where the treatment objective shows little need for incisor
intrusion, the utility arch would require very little tipback bend, but
can still be stopped against the molar tube with the other three
activations for molar anchorage.

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 Bioprogressive Therapy

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.

 Heavy forces will anchor the roots against movement and produce
tipping and extrusion of the incisors. 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.

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.

 Incisor positioning and torque control usually begins by treating the

overbite with incisor intrusion before retraction or overjet correction.

 The upper incisors can be retracted by a regular contraction utility

arch when directed consolidation is required.

Bioprogressive extraction and nonextraction treatment stays

segmented as long as possible in order to take full advantage of the

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efficiency that segmented treatment allows in accomplishing the basic

moves that allow the unlocking of the malocclusion and moving to establish
a more normal function. The basic moves include, for the most part,
alignment of the buccal occlusion, incisor overbite and torque control.

The positioning of the buccal occlusion includes molar rotation,

buccal expansion, crossbite correction, as well as the anterior/posterior
alignment. Incisor overbite and torque control are best accomplished by the
use of the utility arch.

 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 and finishing arch mechanics are consistent with the basic
principles of occlusion.

 In the anticipation of the expected rebound effect, a concept of

overtreatment is a principle of Bioprogressive Therapy. This evaluates
the need for overtreatment from the original malocclusion.

 Thus, the Class II correction is overtreated.

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 Deep incisor overbite is treated to an edge-to-edge occlusion. Open

bite cases are left in deep overbite overtreatment where possible. The
stability of overbite correction is dependent on incisor torque.

FINISHING CHECK LIST15

Mandibular Arch

1. Arch width across second molars.

2. Distal of first molar rotated lingually until the distobuccal cusp

approximates the mesial sliceway on the 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.

8. Over rotation of the incisors & smooth arc.

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 Bioprogressive Therapy

Maxillary Arch

1. Width across first and second molars.

2. Distal rotation of first molar so that a line drawn through distobuccal

and mesiolingual cusp 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 (2-3 mm.) To avoid first area of prematurity.

6. Upper cuspid brought into contact with lower cuspid and premolar to
establish cuspid rise.

7. Lateral incisor left labial to allow over treatment of buccal segment.

8. Smooth arc across incisors.

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 Bioprogressive Therapy

The Basic Bioprogressive Appliances

The Standard Bioprogressive appliance used since 1962 has had

torque in the brackets of the upper central and lateral incisors as well as all
four cuspids.

 The upper laterals, all cuspids, and the lower molars have also had
angulation or tip placed in the brackets.

 This setup, along with the offsets and torque placed in the archwire,
was designed to accomplish the objectives of overtreated orthodontic
occlusion.

 The torque that is placed in the archwire also gives the added control
that is required during the various basic treatment movements before
the final continuous arches and finishing details are considered.

The Full Torque Bioprogressive appliance adds additional torque to the

original Standard Bioprogressive setup, by placing torque in the lower 2nd
bicuspids and the lower 1st and 2nd molars.

 This added torque is used in the final ideal arches in accomplishing

the same objectives as the original standard appliance.

 However, during the basic movements that unlock the malocclusion,

additional torque may be required in anchorage planning. The basic
lower utility arch may apply up to 45° torque in its original placement.

 Rotation was also placed in the lower first and second molars of the
Full Torque Bioprogressive appliance.

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The Triple Control Bioprogressive appliance now combines the

offset first order bends with the second order tip, and the third order torque,
to present the complete "triple control" needed to place the teeth in all three
planes of space to accomplish the necessary movements to reach the
objective of the overtreated orthodontic occlusion.

 This allows a continuous arch to be used as the final ideal finishing

arch.

 With the Triple Control appliance, the finishing archwire does not
require the offsets or torque, since they are now built into the
appliance.

 Additional rotation or torque may still be required in the basic arches

when they are used in unlocking the original malocclusion and
establishing anchorage support during treatment.

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Ricketts’ triple control Bioprogressive prescription

Angulation Inclination
Tooth
( Tip ) ( Torque )

Maxillary

Central incisor 00 220

Lateral incisor 80 140

Canine 50 70

First premolar 00 00

Second premolar 00 00

First molar 00 00

Second molar 00 00

Mandibular

Central incisor 00 00

Lateral incisor 00 00

Canine 50 70

First premolar 00 00

Second premolar 00 140

First molar 50 220

Second molar 50 220

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