Bioprogressive therapy

BIOPROGRESSIVE
THERAPY
DR.ROBERT MURRAY RICKETTS
www.indiandentalacademy.com

HISTORY
 Bench , Gugino , Hilgers –1979
Extended seminars in this philosophy
 Priorities of this new approach-keeping
with the forces of occlusion, growth and
nature
 Main principle based on growth

THE MANAGEMENT
UMBRELLA
 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



CONCEPT
 Management in the beginning rather
than at the end
 The methods of systems engineering,
operations and management science
and their applications
 Ability to get other people to work with
you and for you

MANAGEMENT SYSTEMS-3
FACTORS
 Quality – this would be the quality of our
result
 Quantity – this would be the number of
patients that we treat
 Effectiveness – this would be the
effectiveness of our treatment design
and office management

Basic premises
 Satisfactory outcome
 Practice effeciency
 Initiation of true preventive procedures
for the future
 An authority on occlusion ,including
TMJ function
 Quantity but after quality

 Communication – parents , patients ,
dentists and public
 Time
 The umbrella system is also called the
LEWIS.A.ALLEN MANAGEMENT
SYSTEM

Factors of the system
 Planning
 Organization
 Leading
 controlling

Planning-functions
 Forecasting
 Developing objectives
 Programming
 Scheduling
 Budgeting

PRINCIPLES
 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
 Torque control

 Muscular and cortical bone anchorage
 Movement of any tooth in any direction
with proper application of pressure
 Orthopedic alteration
 Treat the overbite before the overjet
 Sectional arch therapy

 Concept of over treatment
 Unlocking the malocclusion in a
progressive sequence of treatment in
order to establish or restore normal
function.
 Efficiency in treatment with quality
results,utilizing a concept of
prefabrication of appliances

VTO
 A blue print
 A visual plan to forecast the normal
growth of the patient and the
anticipated influences of treatment,to
establish the individual objectives we
want to achieve for that patient

USE OF SUPERIMPOSITION
 To forecast and draw up an effective
treatment design it is necessary:
- to understand individual patients basic
facial,skeletal and dental structures
- to understand response of his individual
skeletal and facial structures to various
treatment mechanics

- to understand his anticipated normal
growth in amount and direction in the
various areas of his face and jaws
 TOOLS
- x-ray cephalometrics and tracings
 Four objectives
- basic description of the cranial
structures
- Analysis of normal growth change

- A treatment design
- An evaluation of growth and treatment
results
11 factors of basic facial and skeletal
structures recorded from the tracings
1. Facial axis
2. Facial angle
3. Mandibular plane
4. Facial taper
5. Lower facial height

5. Mandubular arc
6. Convexity of point A
7. Lower incisor to APO
8. Mandibular incisor inclination
9. Upper molar to PTV
10. Lower lip to E plane
 Five areas of superimposition within
which seven areas of evaluation are
used to evaluate amount ,
direction,change in normal growth and

change occurring from treatment
alteration

ORTHOPEDICS
 Definition – orthopedics implies any
manipulation that alters the skeletal
system and associated motor organs
 Method of evaluation by using the
superimpositional areas

Analysis of an orthopedic
problem
 Bimler described the classical severe
convexity problem as a micro rhino
dysplasia(negative factor four)
 Normally the palatal line is parallel or
slightly canted downward to the FH
plane.
 In microrhino dysplasia –an
upward,outward tip with the ANS tipped
toward FH at least 4 degrees or more

 Sufficient maxillary overjet
 Hyperactive lower lip
 Restrictive vault space
 Protrusive upper incisors

Classical responses
 Generalized orthopedic response with
cervical headgear alone:
- direction of force
- Rotational effect
- Effect in dolichofacial and brachyfacial
types

 Generalized orthodontic response with
cervical headgear:
- downward and backward effect
- factors that dictate response
- effect on the upper and lower incisors
and lower molars
 The reverse response:
- in combination with lower utility arch
- effect on the upper and lower molar

MAXILLARY CENTER OF ROTATION

REVERSE RESPONSE

 Expansive responses:
- the class 2 pose
- expansion of the midpalatal suture
 Considerations for expansion
- reciprocal expansion of the lower arch
- preventing impacted second molars

Soft tissue changes
 Normal growth
 Growth following orthopedic alteration
of the maxilla
 Lip and chin changes
 Tongue posture

SOFT TISSUE CHANGES

orthopedic vs orthodontic
movement
 Force differentiation:
- magnitude
- duration
- site of application
 Growth restrictive forces and rotational
forces

 Nature of bone surrounding dentition
- sinus development
- distal root tip
- stacking factors
- sutural freedom
 Mechanical application of cervical head
gear:
- force level
- intermittent wear
- outer bow length and position

- expansion , rotation
- freedom of movement of maxillae
 Factors causing excessive mandibular
rotation(during cervical head gear
therapy)
- weak muscular pattern
- not retarding effective eruption of the
lower molars
- severe tipping of upper molars

- full arch therapy without freeing anterior
occlusion-incisal trauma
- full time cervical head gear therapy

FACTORS IN HEADGEAR TYPE
SELECTION
Indicators for strong functional response
1.
2.
3.
4.
5.
Mandibular plane 25 degrees and under
Facial axis 90 degrees and above
Lower facial height 45 degrees and below
Mandibular arc 25 degrees and above
Condylar growth patternupward and forward

Forces in bioprogressive
therapy
 Key factor in efficient tooth movement-
blood supply
 Brian Lee – evaluated the optimum
force during cuspid retraction
 Measured the surface of the root being
exposed and called it the enface
surface of the root

 Proposed 200 gms/cm square of enface
root surface
 Bioprogressive therapy suggests 100
gms / cm square of enface root surface
 Utility arch mechanics for intrusion of
the lower incisors have shown efficient
intrusion with forces of 15 – 20 gms per
lower incisor
 that is 0.2 cm square of cross section
root surface for each tooth

 So 0.2 multiplied by 100 gms / cm
square would be equal to 20 gms / cm
square
 Upper incisors root surface is twice as
large so 40 gms / tooth
 CONTROL OF FORCES
Thurow has shown that a force of 650
gms is produced in deflecting an 0.018
round chrome wire 3mm across a span
of ½ inch

Whereas steel wire force is doubled to
over 1000 gms
Concept of long lever arm
Lighter continous force
The utility arch- spanning arch principle
Span in lower arch from molar to
incisors – 25 to 30 mm- produces 80
gms of force

 Span in the upper arch is 35 to 40 mm
to produce 160 gms
 LOOP DESIGN FOR FORCE
CONTROL
 Advantages
- amount of wire increased
- compression of wire during activation
 Some Compound loops designed to
compress the wire are:

 Vertical helical closing loop
 Double vertical helical closing loop
 Double delta closing loop
 “L” loop crossed “T” closing loop
 Double vertical helical extended
 Crossed “T” closing loop

HELICAL AND VERTICAL OPEN LOOP

OPEN HORIZONTAL BOOT LOOP AND
HORIZONTAL “T” OPEN LOOP

VERTICAL CLOSED HELIX LOOP AND
DOUBLE DELTA CLOSING LOOP

DOUBLE VERTICAL CROSSED “T”
CLOSING LOOP AND DOUBLE
VERTICAL HELICAL CLOSING LOOP

DOUBLE CLOSED EXTENDED
HELICAL LOOP

 MANDIBULAR CUSPID RETRACTION
SPRING
 Compound spring with a double vertical
helical closing loop
 60mm of wire size 16 by 16 blue elgiloy
 Produces 75 gms of force per mm of
activation
 MAXILLARY CUSPID RETRACTION
SPRING
 Double vertical helical extended
crossed

“T” closing loop spring
 70 mm of wire
 Produces 50 gm per mm of activation
 LOWER CONTRACTION UTILITY
ARCH
 Compound loop with an “L” loop and an
expanded crossed “T” loop
 40 mm of wire

 DOUBLE DELTA RETRACTION LOOP
 36 – 50 mm of wire
 Force more here due to less wire

THE UTILITY AND
SECTIONAL ARCHES
 HISTORICAL PERSPECTIVE
 The use of round arch wires initially
 The reverse curve of spee wires
 Class 3 elastics
 Treatment in extraction and non
extraction cases

 DEVELOPMENT OF THE UTILITY
ARCH
 Problem faced in the 1950’s
 Round arch segments
 Step down base arch formed
 ROLES AND FUNCTIONS
1. Position of the lower molar to allow for
cortical anchorage
2. Manipulation and alignment of the
lower incisors segmentwww.indiandentalacademy.com

SIDE VIEW

FRONT VIEW

TOP VIEW

3. Stabilization of the lower arch allowing
segmental treatment of the buccal
segments
4. Physiological roles of the lower utility
arch
5. Over treatment
6. Role in mixed dentition
7. Arch length control:
a. uprighting the lower molar
b. advancement of the lower incisors

UPRIGHTING EFFECT OF UTILITY
ARCH

c. expansion in the buccal segment
d. saving “E” space

PHYSIOLOGICAL vs MECHANICAL
RESPONSES
 30 degrees to 45 degrees tip back
applied to the lower molars
 30 to 45 degrees buccal root torque
applied to the lower molars
 Long lever arms applied to the lower
incisors
 75 gm of intrusive force applied to the
lower incisors

FEATURES OF
BIOPROGRESSIVE
THERAPY
 FACTORS IN BAND DESIGNING AND
BONDING
 Limited pre shaping by manufacturer
 Initial wide and bulky bands
 Later thin strong and malleable bands
 Light tapping required
 Trained assistant ,nurse or student

OVER CONTOURED BANDS

 Problem if over contoured
 Produces the need for wider inter dental
spacing and needless crowding
 Arch length and banding consideration
 Canine bands more wider
 Mandibular molar bands narrow
festooned,pre shaped
 Maxillary bands provided with a notch
 Undercuts recognized
 Adapted to the height of contour

HEIGHT OF CONTOUR

FACTORS IN BRACKET
DESIGN
Need for 3D control
Design by Edward H Angle
 Initial gold wires of .022 by .028
 Later round wires
 TYPES OF BRACKETS USED
 Bracket with staple
 Placing of two single brackets mesially
and distally-

Bracket with a connection between the
two
Dual bracket with welding flanges
Brackets with soldered bars on the
bands

HORIZONTAL SLOT BRACKET

STAPLE BRACKET

SINGLE MESIAL AND DISTAL
BRACKETS

CONNECTION BRACKET

BRACKETS WITH SOLDERED BARS

ROTATION BRACKET

 LATER DEVELOPMENTS
 Superior quality metals
 Preformed bands
 Improved methods of seating and
adapting
 Lighter forces
 Angulation of bracketsS

 Two principle bracket designs
1. Bracket with rotation arm
2. Siamese type or dual bracket
 Dr.cecil steiner and Dr. Lang -.016
square box
 Later on - .019 by .025 slot
 Ricketts - .0185 with .030 depth
 Dr.Ivan Lee – torque slot
 Dr.Reed – bracket angulations

SLOT DIMENSIONS

 ADVANTAGES OF THE ROTATION
BRACKET AND THE SIAMESE
BRACKET
 ROTATION ARM BRACKET
- lighter force
- push or pull
- wide inter bracket distance
- less friction during sliding
- can be used as uprighting arms
- may take the place of a loop

- ease with straight wires
- decreased need for buccal or labial
contouring for band adaptation
 SIAMESE TYPE
- yields positive control
- easy to keep clean
- more effective rotation
- provide greater wire purchase
- permits double tipping
- more efficient with light wire

- tying of only one wing of one bracket for
rotation
- bracket can be tied for counter rotation
- Crimping of one bracket provides a
lever in the event of over
rotation
- permits exotic bends
- distributes force
- provides a lug for easier banding
- prevents wire distortion
- allows wire to be used as an uprightingwww.indiandentalacademy.com

- easier band removal
 OTHER FACTORS OF BRACKET
DESIGN
 Deep slot ( .030 )
 Permits two light arch wires to be
placed at once
 Permits a bevel at the box entrance
 Permits bracket profile to be raised
 Provides more adequate distance for
torque grooves

TWO LIGHT ARCHES ACCOMADATION

PLACEMENT UNDERNEATH THE WING

 Wide incisal gingival wing
- provides easy access for tie wires
- single wing of one wire can be used as
a staple
- permits auxiliary light wire to be placed
- used for rubber elastic traction
- provides accessibility for cement
removal under the wings

 Softer material
- permits closing of the bracket for
rotation
- will not fracture or chip teeth
- can be pinched close around narrower
arches for absolute wire engagement.

MAXILLARY ARCH
TOOTH TORQUE TIP
Central incisor + 22 degrees 0 degrees
Lateral incisor + 14 degrees + 8 degrees
Canine + 7 degrees + 5 degrees
First premolar 0 degrees 0 degrees
Second
premolar
0 degrees 0 degrees
Molar 0 degrees 0 degrees

MANDIBULAR ARCH
TOOTH TORQUE TIP
Central incisor 0 degrees 0 degrees
Lateral incisor 0 degrees 0 degrees
Canine +7 degrees +5 degrees
First premolar 0 degrees 0 degrees
Second
premolar
o degrees 0 degrees
Molar 0 degrees +5 degrees

FACTORS IN MOLAR TUBE
AND AUXILLARY DESIGN
 Innovation of pre-attachment of tubes
 Tube design for upper molar
- band should be driven down to the
distal marginal ridge
- gingivally placed head gear tube with a
middle round slot and an occlusal .022
by .028 edgewise rectangular slot

OCCLUSAL APPEARANCE OF
DISTOBUCCAL CUSP

IMAGINARY LINE

 Tube design for lower molar
- buccal extension of the distal aspect of
the tube with a 12 degree rotation
- .018 by .025 twin tube type
- hook in the center for elastic traction
- 5 degree tip

THREE TUBE PLACEMENT

10 TO 30 DEGREES TORQUE

DISTAL 12 DEGREES FOR LOWER
MOLAR ROTATION

FINISHING AND RETENTION
 Stephen Covey- four main values,
when we “begin with the end in mind”
1. To know “where you intend to end
up”,you must know where you are now
2. How to get from where you are now to
where you want to be
3. Mentally creating our desired outcome

4. Accomplish our objective
DIFFERENT OCCLUSAL CONCEPTS
1. Ideal occlusion
2. Normal occlusion
3. Reconstructed occlusion
4. Orthodontic finishing

FUNCTION INFLUENCES FINISHING
AND RETENTION
 Respect various elements of normal
physiology and function
 Condyle location and function
 Normal airway
 Lip function
 Buccal and facial musculature

FINISHING CHECK LIST
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 the incisors;smooth
arc

MANDIBULAR CHECK LIST

MAXILLARY CHECK LIST
1. Width across first and second
molars
2. Distal rotation of first molar so
that 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 pre maturity
6. Cuspid brought into contact with lower
cuspid and premolar to establish
cuspid rise
7. Lateral left labial to allow over
treatment of buccal segments;then
tucked in
8. Smooth arc across incisors

MAXILLARY CHECK LIST

3 STAGES OF RETENTION
 INITIAL STAGE
 THE STABILIZING STAGE
 POSITIONER USE IN
BIOPROGRESSIVE THERAPY

CASE REPORT
 SEQUENCE OF MECHANICS IN
CLASS 1 EXTRACTION CASES
 Stabilization of the upper and lower
molar anchorage
 Retraction of cuspids with sectional
springs
 Uprighting and alignment of the
retracted cuspids

 Retraction and consolidation of the
upper and lower incisors
 Idealize arches
 Finishing arches

BIOPROGRESSIVE
THERAPY ,THE
NATURAL THERAPY

Bioprogressive therapy

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