102533323 Bioprogressive Therapy s2gx

CONTENTS

 Introduction  The Management Umbrella  Principles of Bioprogressive Therapy  Visual Treatment Objective  The Use of Superimposition Areas  Orthopedics in Bioprogressive Therapy  The Utility and Sectional Arches  Bioprogressive Mixed Dentition Treatment  Mechanics Sequence for Extraction Cases  Mechanics Sequence for Class II Division 1 Cases  Mechanics Sequence for Class II Division 2 Cases  Finishing Procedures and Retention  Conclusion

INTRODUCTION Bioprogressive Therapy was originated by Drs. Robert Ricketts and Ruel Bench who combined contemporary edgewise mechanics with solid diagnostic principles and an innovative approach to sectional mechanics. Bio-Progressive Therapy is not strictly an orthodontic technique but, more importantly, it encomes a total orthodontic philosophy. It accepts as its mission the treatment of the total face rather than the narrower objective of the teeth or the occlusion. Although the teeth and the occlusion are of critical importance in achieving the broader goal of treating and improving the face, orthodontic therapies must be designed to be applied appropriately to specific facial types, muscular patterns, and functional needs of individuals. A primary concern, therefore, is the musculature of the chin and lips and the function of the tongue as its posture reflects the respiratory needs of the individual. The relationship of the jaws to each other, with the resulting convexity or concavity of the profile, suggests the orthopedic alteration that will be required to achieve the desired result. The progressive unfolding of these arches, in conjunction with the purposeful alterations resulting from orthodontic therapy, combine to produce the desired outcomes as they relate to aesthetic effect and occlusal and respiratory function. Basic to an understanding of these potential changes is the dynamics of growth and function under normal relationships with an appreciation for a range of variation from the normal as applied to the individual with his specific needs and potential. Dr. Ricketts' orthodontic philosophy and therapy involves a broad concept of total treatment, rather than a sequence of technical and mechanical steps. Referred to as Bio-Progressive Therapy, it takes advantage of biological progressions including growth, development, and function, and directs them in a fashion that normalizes function and enhances aesthetic effect.

MANAGEMENT UMBRELLA CONCEPT The management of the total practice ultimately determines the degree of efficiency and effectiveness with which the orthodontist solves individual patient problems. The management umbrella comprises of the following 1. Planning 2. Organizing 3. Leading 4. Controlling Planning: Everything that takes place before treatment is considered as planning. Factors involved in planning are: A) Forecasting- predicting normal growth B) Developing Objectives – Individual treatment objectives/ VTO C) Programming – Determining the actions necessary to achieve desired results (Sequence of mechanics) D) Scheduling – Time required to accomplish the program. E) Budgeting – Resources to carry out the programs within time limits.

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. TEN PRINCIPLES OF BIO-PROGRESSIVE THERAPY 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. 2. Torque control throughout treatment. 3. Muscular and cortical bone anchorage. 4. Movement of all teeth in any direction with the proper application of pressure. 5. Orthopedic alteration. 6. Treat the overbite before the overjet correction. 7. Sectional arch therapy. 8. Concept of overtreatment. 9. Unlocking the malocclusion in a progressive sequence of treatment in order to establish or restore more normal function. 10. Efficiency in treatment with quality results, utilizing a concept of prefabrication of appliances. #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 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. #2. Torque control throughout treatment. Bioprogressive Therapy mentions four treatment situations where torque control of the root movement is necessary: 1. Keep roots in vascular trabecular bone— for efficient movement. For beginning movements, such as incisor intrusion or cuspid retraction— where movement through a less dense trabecular bone structure is desired because it is more efficient— torque control allows us to steer the roots away from the denser, thicker cortical bone, and through the less dense channels of the vascular trabecular bone. The lower incisors are ed by the lingual cortical bone and require buccal root torque for their efficient intrusion through the more vascular trabecular bone.

2. Place roots against dense cortical bone— for anchorage. Torque control of teeth being anchored or stabilized against movement is done by placing their roots in juxtaposition against the more dense cortical bone. 3. Torque to remodel cortical bone Repositioning of the teeth often require that the roots must be moved into the dense, less vascular cortical bone structure. Examples of such situations are: a. Upper and lower incisor retraction through the dense lingual cortical plates; b. Upper incisor root torquing movements; c. Impacted upper cuspids, either in the palate or high in the labial vestibule; d. Forward movement of lower molars to close spaces created by missing or extracted teeth. Movements of this nature require adequate torque control using light forces so as to prevent excessive tipping which may further complicate treatment. 4. Torque used to position teeth in final occlusion details. The fourth situation where torque control of the root is desired is during the final stages of treatment where the final details of occlusion are being established, where fit and mesh of the teeth require proper root alignment for proper function and better stability. #3. Muscular and cortical bone anchorage Muscular Anchorage Stabilizing the teeth against the horizontal movements and also against vertical or extruding forces produced by a cervical headgear to the upper molars is countered by the posterior muscles of mastication, primarily the masseters and temporalis. Treatment procedures in individuals with weaker muscular should be monitored and modified to compensate for weaker anchorage . Cortical Bone Anchorage Tooth movement can be further delayed where excess forces against the cortical bone can press out the blood supply and limit the physiology and the tooth movement. Bio-Progressive Therapy applies this principle of cortical bone anchorage in stabilizing the teeth in those areas where it desires to limit their movement. Lower molar anchorage is enhanced by expanding the molar roots into the dense cortical bone on their buccal surface. Excessive buccal root torque and expansion is placed in the arch wires to locate the roots into the cortical bone. The upper molar that is adjacent to the zygomatic ridge, the maxillary sinus, and the cortical bone shelves of the alveolar process needs to be anchored and stabilized for use in orthopedic alterations #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 ive 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 #5. Orthopedic alteration Orthopedic alteration changes the relationship of the basic ing jaw structure, as contrasted to tooth movement in the more localized area of the alveolar process. Orthopedic change or alteration of the ing structure usually is associated with treatment of the younger child Orthopedic alteration brings about changes in the maxilla and compensatory changes in the mandible and TMJ. Expected mandibular rotation and facial type usually dictate the kind of headgear prescribed. #6 Treat the overbite before the overjet. For stability in function and retention it is vital that the deep bite incisor relationship be corrected, to establish the proper interincisal relationship of overbite to overjet and interincisal angles. When the incisors are left with an overbite and a vertical interincisal angle. Incisor overbite correction can be accomplished by two methods. 1. Extrusion of posterior teeth, which increases the lower face height by mandibular rotation. 2. Intrusion of the upper or lower incisor teeth, with little or no mandibular rotation. 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 t 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. #7 Sectional arch treatment. Sectional arch treatment is a basic treatment procedure of Bio-Progressive Therapy in which the arches are broken into sections or segments in order that the application of force in direction and amount will be of more benefit in the efficient movements of the teeth. There are four benefits of sectional arch treatment: 1. It allows lighter continuous forces to be directed to the individual teeth (for their efficient movement).

As the arches are segmented and the buccal occlusion is sectioned from the incisors, very light continuous forces can be directed to the incisors through the long lever arm created by the utility arch, which spans from the molars to the incisors, bying the bicuspids and cuspids. Segmented arches allow the molars to be stabilized and ed by the bicuspids and cuspids against the torquing movement directed to the molars by the intrusion action of the long-levered utility spanning arch. 2. More effective root control in the basic tooth movements. Segmented arch treatment allows us to torque the lower incisor roots away from the lingual cortical bone which aids in their intrusion and the cuspids can then be intruded separately along a route of least resistance and still maintain molar torque and rotational control for anchorage . 3. It supplements maxillary orthopedic alteration. Full arch wires through the incisors tie the maxillary segments together and limit the adjustment and expansion desired in maxillary orthopedic treatment. Class II sectional arch treatment allows the expansion without interference. 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 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. 2. Root movements needed for stability. Incisor deep overbite treatment benefits in its stability by over intrusion and overtorquing. Paralleling of the roots of the teeth adjacent to extraction sites is important to the stability of space closure. Severe rotation, where periodontal ligaments exhibit elastic action that can have prolonged posttreatment influence, needs over-rotation of the roots to help compensate for the relapse effect. 3. To overcome orthopedic rebound. Rebound of orthopedic corrections may be beneficial or may compound the problem.

In Class II treatment the rebound effect which closes the bite and rotates the chin forward will help in Class II correction. In Class III treatment correction this rotation would compound the problem. 4. To allow settling in retention. Overtreatment of the individual teeth within the arches allows them to "settle" into a functioning occlusion. In Bioprogressive Therapy, retainers then are considered active appliances and are adjusted to allow this settling action to take place, rather than to just hold or maintain teeth. Overtreatment of the typical Class II correction begins with the molars by overtreating them into a "super Class I" through distal rotation of the upper first molar behind an uprighted distally rotated lower molar. #9 Unlocking the malocclusion in a progressive sequence of treatment in order to establish or restore more normal function. Bio-Progressive Therapy maintains that many malocclusions have resulted because of abnormal function, and that the present malocclusion, while stable under its present abnormal function, may never have had the opportunity for normal development. Bio-Progressive Therapy proposes treatment sequences that progressively unlock the malocclusion in order to restore or establish a more normal environment. 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 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 it. 1. Upper Arch Expansion. 2. Incisor Protrusion Correction. 3. Temperomandibular t 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 t function and development.

#10 Efficiency in treatment prefabrication of appliances.

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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. CONSTRUCTION OF THE VTO The VTO construction is divided into the following steps: I. The cranial base prediction II. The mandibular growth prediction III. The maxillary growth prediction IV. The occlusal plane position V. The location of the dentition VI. The soft tissue of the face I. VTO — Cranial Base Prediction Place the tracing paper over the original tracing and starting at CC point, follow these steps to construct the cranial base: 1. Trace the Basion-Nasion Plane. Put a mark at point CC. 2. Grow Nasion 1mm/year (average normal growth) for 2 years (estimated treatment time). 3. Grow Basion 1mm/year (average normal growth) for 2 years (estimated treatment time). 4. Slide tracing back so Nasions coincide and trace Nasion area. 5. Slide tracing forward so Basions coincide and trace Basion area. II.VTO — Mandibular Growth Prediction — Rotation The construction of the mandible and its new position start with the rotation of the mandible. The mandible rotates open or closed from the effects of the mechanics used and the facial pattern present. The average such effect of mechanics on mandibular rotation is as follows: 1. Convexity Reduction— Facial Axis opens 1°/5mm. 2. Molar Correction — Facial Axis opens 1°/3mm. 3. Overbite Correction — Facial Axis opens 1°/4mm. 4. Crossbite Correction— Facial Axis opens 1°-1½°. Recovers half the distance 5. Facial Pattern— Facial Axis opens 1°/1 S.D. dolichofacial; 1° closing effect against mechanics if brachyfacial. 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. VTO — Mandibular Growth Prediction — Symphysis Construction 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). III. VTO — Maxillary Growth Prediction 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 — Maxillary Growth Prediction — Point A Change Related to BA-NA These are the maximum ranges of Point A change with various mechanics: Point A is altered as a result of growth and mechanics. Point A and a new APO plane are drawn by the following steps: 17. Point A can be altered distally with treatment. Place according to orthopedic problem and treatment objectives. For each mm of distal movement, Point A will drop ½mm. 18. Construct new APo plane. IV. VTO — Occlusal Plane Position 19. Superimpose mark #2 on original Menton and facial plane, then parallel mandibular planes rotating at Menton. Construct occlusal plane (may tip 3 degrees either way depending on Class II or Class III treatment). V. VTO — Dentition — Lower Incisor The lower incisor is placed in relationship to the symphysis of the mandible, the occlusal plane and the APO plane. The arch length requirements and realistic results dictate its location. 20. For this exercise, superimpose on the corpus axis at PM. Place a dot representing the tip of the lower incisor in the ideal position to the new occlusal plane, which is 1 mm above the occlusal plane and 1 mm ahead of the APO plane. 21. Aligning over the original incisor outline or using a template, draw in the lower incisor in the final position as required by arch length. The angle is 22° at +1mm to the APo plane and + 1 mm to occlusal plane, but the angle increases 2° with each mm of forward compromise. VTO — Dentition — Lower Molar Without treatment, the lower molar will erupt directly upward to the new occlusal plane. With treatment, 1mm of molar movement equals 2mm of arch length. We moved the lower incisor forward 2mm in this case. There was also 4mm of leeway space. Therefore, the following calculation allows us to move the lower molar forward 4mm on each side: lower incisor

forward 2mm = +4mm arch length leeway space = +4mm arch length +8mm arch length (lower molar forward 4mm on each side) 22. Superimpose the lower molar on the new occlusal plane at the molar (*), slide forward 4mm, upright molar and draw it in. VTO — Dentition — Upper Molar 23. Trace the upper molar in good Class I position to the lower molar. Use the old molar as a template. VTO — Dentition — Upper Incisor Place upper incisor in good overbite-overjet position (2½mm overbite, 2½mm overjet) with an interincisal angle of 130° ± 10°. Open bite patterns at a greater angle, deep bite patterns at a lesser angle. 24. Trace the upper incisor in its proper relationship, aligning over the original incisor or by use of a template. VI. VTO — Soft Tissue — Nose 25. Superimpose at Nasion along the , facial plane. Trace bridge of nose. 26. Superimpose at anterior nasal spine (ANS) along the palatal plane. 27. Move prediction "back" 1mm per year (therefore, 2mm in this case) along the palatal plane. Trace tip of nose fading into bridge. VTO — Soft Tissue — Point A and Upper Lip 28. Superimpose along the facial plane at the occlusal plane. Using the same technique as for marking the symphysis, divide the horizontal distance between the "original" and "new" upper incisor tips into thirds by using two marks. 29. Soft tissue Point A remains in the same relation to Point A as in the original tracing. Superimpose new and old bony Point A, and make a mark at soft tissue Point A. 30. Keeping the occlusal planes parallel, superimpose mark # 1 (posterior mark) on the tip of the original incisor (slide forward 2/3rds). Trace upper lip connecting with soft tissue 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. VTO — Completed Visual Treatment Objective 32. Superimpose on the symphysis, and arrange the soft tissue of the chin. It "drops down" and should I be evenly distributed over the symphysis taking into consideration reduction of strain and bite opening.

USE OF SUPERIMPOSITION AREAS TO ESTABLISH TREATMENT DESIGN It is necessary to understand the following to draw up an effective treatment plan. 1. Describe the basic facial, skeletal and dental structures 2. Understand the anticipated normal growth in amount and direction in various areas of the face and jaws. 3. Understand the response of individual skeletal and facial structures to various treatment mechanics. Eleven factors of the basic facial and skeletal structures are recorded from the cephalometric tracing to describe the chin, maxilla teeth and soft tissue profile. Five areas of superimposition within which seven areas of evaluation are used to evaluate. Eleven Factor Summary Analysis The Eleven Factor Summary Analysis is divided into four areas: 1. Locating the chin in space. 2. Locating the maxilla through the convexity of the face. 3. Locating the denture in the face. 4. Evaluating the profile. Describing the Face There are three basic facial patterns: 1. Mesofacial, which is the most average facial pattern; 2. Brachyfacial, which is a horizontal growth pattern; and 3. Dolichofacial, which is a vertical growth pattern. From the Eleven Factor Summary Analysis, five angles are used to describe the face: 1. The Facial Axis Angle. This gives us the direction of growth of the chin and expresses the ratio of facial height to facial depth. In addition, the upper six-year molar grows down the facial axis. 2. Facial Angle. This locates the chin horizontally in the face. It is a facial depth indicator; and it determines if a skeletal Class II or Class III is due to the mandible. 3. Mandibular Plane Angle. A high mandibular plane angle implies that a skeletal open bite is due to the mandible. A low mandibular plane angle implies that a skeletal deep bite is due to the mandible. 4. Lower Facial Height. This describes the divergence of the oral cavity. Skeletal open bites have high values; skeletal deep bites have low values. 5. Mandibular Arc. This describes the mandible. It tells us whether we have a square growing mandible or an obtuse growing mandible. These five angles determine the facial pattern. It is important to establish what the facial type is because the reaction to treatment mechanics and the stability of the denture is dependant upon the analysis of the facial pattern. Brachyfacial patterns show a resistance to mandibular rotation during treatment and can accept a more protrusive denture, whereas Dolichofacial patterns tend to open during treatment and require a more retracted denture in order to assure posttreatment stability.

. Five Superimposition Areas The five superimposition areas are used to evaluate the face in the following order: 1. The chin. 2. The maxilla. 3. The teeth in the mandible. 4. The teeth in the maxilla. 5. The facial profile.  Superimposition Area 1 (Evaluation Area 1) (Basion-Nasion at CC Point) Evaluate the amount of growth of the chin in millimeters; Any change in chin in an opening or closing direction that may result from our mechanics; Any change in upper molar. In normal growth, the chin grows down the facial axis and the six year molars also grow down the facial axis. Changes in the facial axis as per mechanics used have been mentioned previously.

 Superimposition Area 2 (Evaluation Area 2) (Basion-Nasion at Nasion) To show any change in the maxilla (Point A). The Basion-Nasion-Point A Angle does not change in normal growth. The following are considered the maximum range of Point A change with various mechanics: Mechanics Maximum Range 1. HG – 8 MM 2. Class II Elastics – 3 MM 3. Activator – 2 MM 4. Torque – 1-2MM 5. Class lIl Elastics +2-3MM 6. Facial Mask +2-4MM With Evaluation Area 2, we determine whether we wish to use an orthodontic or an orthopedic force on the maxilla with a headgear.  Superimposition Area 3 (Evaluation Areas 3 and 4) (Corpus Axis at PM) Together evaluate any changes that take place in the mandibular denture. In normal growth, the lower denture remains constant with the APO Plane (the denture plane). In Evaluation Area 3, we evaluate whether we are going to intrude, extrude, advance or retract the lower incisors, which helps us determine what type of utility arch we will use. In Evaluation Area 4, we evaluate the lower molars to determine what type of anchorage we need and whether we wish to advance, upright or hold the lower molars.

 Superimposition Area 4 (Evaluation Areas 5 and 6) (Palate at ANS) Which together evaluate any changes that take place in the maxillary denture. In normal growth, upper molars and upper incisors grow on their polar axis. In Evaluation Area 5, we evaluate what we are going to do with the upper molars— hold, intrude, extrude, distallize or bring them forward. In Evaluation Area 6, we evaluate what we are going to do with the upper incisors— intrude, extrude, retract, advance, torque or tip them.  5th Superimposition Area (Evaluation Area 7) (Esthetic plane at the crossing of the occlusal plane) Evaluate the soft tissue profile. In normal growth, the face becomes less protrusive with reference to the esthetic plane.

ORTHOPEDICS IN BIOPROGRESSIVE THERAPY 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. Analysis of an orthopedic problem 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 Micro Rhino Dysplasia General Characteristics of MRD 1. Upward tilt of the palate 2. Short Vertical height of the nose 3. Upward cant of the nares 4. High convexity (+6mm or more) 5. Excessive anterior overjet 6. Finger, tongue or lip habits 7. Hypertonic lower lip 8. Retruded Lower Arch 9. Fractured Upper Incisors 10. Hypotonic Upper Lip 11. Blocked Upper Laterals and Canines 12. Mandible apparently unrelated 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. CLASSICAL RESPONSES WITH DIFFERENTIAL HEADGEAR THERAPY Generalized Orthopedic Response With Cervical Headgear Alone The general orthopedic response in the mandible is highly variable, depending upon facial growth type, the maxillae invariably respond in a highly predictable way to a line of force directed at the level of, or below, the rotational center of the maxillae.

At a point which roughly approximates the top of the pterygomaxillary fissure, the maxillary complex rotates in a clockwise direction This rotational effect s for the reduction in maxillary protrusion, a downward canting of the palatal plane and concomitant nasal changes. In weaker muscular patterns (in general, the dolichofacial patterns) the extrusion of both the maxillary molar and the maxillae causes a reciprocal clockwise rotation of the mandible, opening of the facial axis and mandibular plane, and a diminishing effect on forward chin posture. In strong muscular patterns some mild mandibular rotation occurs but the amount of maxillary response compensates for this by 3-4 times. Generalized Orthodontic Response With Cervical Headgear Alone Extrusion of the upper molars occur, the effect of which is primarily dictated by the facial growth pattern. The upper incisor will tip lingually (from its apex) - after overjet has been reduced enough to allow the everted lower lip to close over the upper incisor The lower molars upright and often move distally when carried by the incline planes of the extruded upper molar. The lower incisor, without the inhibiting effect of the lower lip, will quite often tip labially as the upper and lower lips start to reach equilibrium, and the tongue starts to dominate the labial positioning of these teeth. The Reverse Response In those cases where a cervical headgear is utilized in combination with a lower utility arch, the maxillary orthopedic response is the same however the mandibular orthopedic response differs. The mandibular plane and facial axis will be somewhat stabilized and, in strong muscular patterns (brachyfacial types), the mandible may rotate in a counterclockwise direction, resulting in a closure of the lower face height, mandibular plane and facial axis. This unusual orthopedic response in the mandible can be traced back to the dentition, and its response to this combination of mechanics. The extruding upper molar will, as it is moved distally, again pick up (through incline plane effect) the lower molar and upright that tooth in a distal direction. This effect is enhanced by the tipback in the utility arch. As the lower molar uprights, the distalizing force is translated, through the utility arch, to the lower incisors. These teeth will first intrude and then start to follow the lower molar distally eventually become encased in heavy cortical bone preventing further intrusion. The intermittent extrusion of the upper molar, in conjunction with the strong muscular pattern, results in stabilizing (and often distalizing) the entire lower dentition. This action is referred to as the reverse response of the lower utility arch and can be utilized to set back the lower arch, for anchorage and for arch length. Expansive Responses With Headgears In the Class II pose, the anterior portion of the maxillae generally is tapered toward the midline and the buccal occlusion would be in lingual crossbite if the maxillae were moved straight back into a Class I position over the present mandibular arch form. The constrictive effect of the caninus muscle complex creates an environment conducive to ectopic eruption of the entire upper dentition.

From the mechanical standpoint a progressive widening and tipping of the alveolar base is accomplished by a widening of the inner bow of the face bow. This expansive process provides for several distinct considerations: 1. Reciprocal expansion of the lower arch. This can be observed as an anterior movement of the lower incisor and in the horizontal plane increases in arch width occurs. 2. Preventing impacted second molars. When the upper first molar is translated distally without expansion, the incline planes of that tooth start to reciprocally constrict the lower molars, carrying them to the lingual. This tends to either impact the lower second molar or force them buccally. Soft Tissue Esthetic Changes Following headgear therapy the nose is seen to cross over at the bridge, lengthen vertically and the upward cant to the nares is tipped down to a more horizontal position. Normal function is established in the upper lip once overjet is reduced. Reduction of maxillary protrusion also allows the soft tissue chin to distribute evenly over the symphysis. Generalized Response With Combination Type Headgears In dolichofacial patterns, it often is desirable to create a rotational orthopedic effect in the maxillae and at the same time maintain mandibular stability. Long-term directional headgear therapy (part time wear), where the force is applied below the center of resistance of the maxillae, again allows the classical orthopedic response, but without the upper molar extrusion. If the force applied moves the maxillae distally without overriding musculature, and is in conjunction with mandibular growth, the lower face height can be closed or maintained while achieving a reduction of the maxillary protrusion. Factors affecting orthopedic change The direction and duration of force are equally significant as the amount of force applied. 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 upon swallowing), it is ideal that the cervical headgear be worn mostly in the evening and sleeping hours. (d) Patient acceptability is enhanced 3. Outer Bow Length and Position A rigid outer bow extending beyond the molars and tipped up 15° to the ala of the ear will prevent propping open the bite by excessive tipping at the molars and will maximize orthopedic effect by pitting the roots against cortical bone. 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. 5. Freedom of Movement of the Maxillae Factors Causing Excessive Mandibular Rotation 1. Weak Muscular Pattern 2. Not Retarding Effective Eruption of The Lower Molars Retarding the normal upward forward development of the lower molar will have a tendency to counteract the overall rotational effect on the mandible. 3. Severe Tipping of Upper Molars Maintaining a slight upward cant to the outer bow will minimize this tipping effect. Severe tipping also is seen in those cases where effective growth has been completed . 4. Full Arch Therapy Without Freeing Anterior Occlusion— Incisal Trauma 5. Fulltime Cervical Headgear Therapy

FORCES USED IN BIOPROGRESSIVE THERAPY 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 : 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 ing four cavities – nasal, orbital, oral and sinus cavities. 4. Muscular – Reflected by facial type Where the musculature is strong as characterized by the deep bite, low mandibular plane angle, brachyfacial type- the teeth demonstrate a ‗natural anchorage‘. Two cephalometric measurements beginning at Xi point in the centre of the ramus of the mandible describe mandibular morphology and its muscular function. 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 The most recognizable single entity in Bioprogressive is the utility arch. It forms the base unit around which the mechanics in all types of cases can be employed. 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. Construction specifications of the mandibular utility arch The mandibular utility arch is best fabricated from 0.016‖ x 0.016‖ blue elgiloy wire in order to create a force system that delivers a continuous force that is light enough to be in the range of 50-75 gms. 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. Fabrication of the Mandibular Utility Arch 1) Vertical Step Height In the lower arch it is 3-5mm The only function of the vertical step is to bring the malleable 0.016 x 0.016 elgiloy wire out of the occlusion to avoid deformation with functional movements. It is usually formed with a hoe plier. The posterior vertical step is constructed first and should be stopped against the molar tube in order to prevent bending by the forces of occlusion and to effect better molar and incisor movement. The anterior vertical step should be extended far enough beyond the lateral incisor brackets (2-3 mm_ to allow unraveling and alignment of the incisors. 2) Placement of Labial Root Torque. When the wire is bent at the anterior vertical step 10° - 15° of lanial root torque is incorporated. The anterior arch form is then contoured using a small turret/arch forming plier. 3) Finishing the Opposite Side. The same procedure is continued in reverse order after lacing into anterior brackets. No attempt is made to compensate for labial root torque.

The right side segment will lie slightly lingually which can be adjusted later. 4) Contouring the Buccal Bridges. The stepped down buccal bridge section has a buccal contour that stands way from the alveolus and acts as a bumper against the buccinator muscle. The buccal bridge section is flared outward approximately 1cm per side. By flaring the buccal bridge section at the anterior vertical step, the posterior vertical step is also flared bucally and establishes the 45° buccal root torque. 5) Activation of the Distal Legs. The molar section that extends into the molar tube has a 45° buccal root torque, 30°-45° distal lingual rotation with a 30°-45° tip back bend. Molar uprighting and incisor intrusion 6) Final Arch Form and Activation Characteristics. The precisely contoured anterior arch form will allow the incisors to intrude without advancing. 5°-10° labial root torque will counteract the forward tipping action and allow the incisor roots to avoid cortical bone. The posterior legs are parallel to each other and 45° buccal root torque has been placed to maintain the buccal cortical in the lower molar region. Placement of the mandibular utility arch Upon placement of the activated lower utility arch in the lower molar tubes, the anterior section will rest at the bottom of the labial sulcus When it is raised to the level of the incisor brackets it should measure 50-75 gms of force directed to intrude incisor teeth. In order to allow the molar to upright the wire should extend through the molar and should not be bent down distal to the tube. This prevents the crown from uprighting. The posterior vertical step should not be advanced ahead of the molar tube since it will be distorted by the forces of occlusion. Care should be taken to flare bucally the anterior vertical steps. If this step should become intruded into the tissues at the corners, care must be taken during its adjustment so that molar control is not altered or distorted. Intra Oral Adjustments These can be made with loop forming pliers or a small three prong plier. Care should be taken during these adjustments so as to not distort the original torque incorporated. Molar Adjustment Should be made on the posterior vertical step or adjacent to it on the buccal bridge. Should be kept 90° to the molar section. To produce more molar tip back and anterior intrusion two areas of activation are most effective: 1. The posterior vertical step 2. The buccal bridge is front of the posterior vertical step. Incisor Adjustment Should be made on the anterior vertical step or adjacent to it on the buccal bridge. Activation in the incisor area is made parallel to the incisor section either on 1. Anterior vertical step

2. The buccal bridge next to the step. These activations are more effective to advance with labial crown torque or to retract with lingual crown torque than to intrude the incisor. Intrusion is activated at the molar step. Roles and Functions of the lower utility arch A. B. C. D. E. F. G.

Position of the lower molar to allow for cortical anchorage Manipulation and alignment of the lower incisor segment Stabilization of the lower arch allowing segmental treatment of the buccal segment Physiological roles of the lower utility arch Over treatment Role in mixed Dentition Arch length control

A. Position of the lower arch to allow for cortical anchorage In their normal eruptive positions, the lower molars do not need to be moved bucally or torqued bucally to put them in their ideal anchorage positions. Distal uprighting of the molars is done to enhance anchorage. Torquing of the molar roots bucally under the oblique ridge of the cortical bone. B. Manipulation and alignment of the lower incisor segment Intrusion/extrusion of the incisors to the level of the buccal functioning occlusion Advancement/retraction of the incisors in either expansion or non expansion cases. Leveling and rotational control of the individual incisor teeth. Axial inclinational control by labial or lingual crown torque. 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. D. Physiological roles of the lower utility arch Buccal arm acts as a cheek bumper causing expansion of the buccal occlusion. Activator effect by eliminating the proprioceptive interferences to the lower incisors. Allow better buccal teeth eruption by removing functional interferences. Corrects overbite before overjet thus avoiding incisor interference Maintains the physiologic arch form and/ or molar width. 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 F. Role in mixed Dentition Incisor and molar control during transitional stage of buccal dentition. Allows distal eruption of the lower second bicuspid when deciduous molars are uprighted.

Rotational correction of the bicuspids and cuspids during eruption. G. Arch length control 1. Uprighting the lower molars: using the tip back bend of the utility arch uprighting of the molar results in a 2mm gain of the arch length on each side along with leveling of the curve of Spee. 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. Modifications of the Basic Utility arch 1. Expansion Utility arches Moves the incisors forward. Posterior vertical step should be against the buccal tube. 1 mm 85 gms 2mm 140 gms 3mm 205 gms The vertical loop is placed inside or behind the anterior vertical step when the incisors are to be advanced. 2. Contraction utility arch Utility arch with helical loops to retract the incisors Posterior step should be 5mm or more forward of the buccal tube to allow for distal movement of the incisor. 1 mm 50 gms 2mm 150 gms 3mm 230 gms 4mm 300 gms The loop is placed forward of the anterior vertical step. 3. Utility arch with T or L horizontal loops To rotate and level incisors Height of the horizontal L or T loops should be kept between 5-7 mm in order to prevent tissue irritation in the sulcus of the lower lip. Horizontal loops allow flexibility and full bracket engagement. 4. Contraction or Advancing utility arches A vertical loop placed along the buccal bridge has the facility of being adjusted intra orally to expand or contract the arch. When placed opposite the lower cuspids, it is useful in their intrusion by tying elastic ligations to the cuspid brackets.

BIOPROGRESSIVE MIXED DENTITION TREATMENT 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‖. Objectives of early treatment I. Resolve Functional Problems: The practical definition of a functional problem is anything that disturbs the growth, health and function of the tempero-mandibular t 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. III. Correct Vertical Problems: IV. Correct Overjet Problems: Concepts of the growth of the mandible and the condyle 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 t 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 t 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 t 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. I. Resolve Function al problems Nine general categories of functional problems can be detected by clinical or roentgenographic examination of the patient at an early age: 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 – Superior displacement 7. Finger Sucking/ Lip sucking/ Tongue thrusting 8. Breathing and Airway problems 9. True Class III Growth patterns 1. Cross- mouth interferences A. Clinical Evaluation: Cases where one or more teeth cause shunting of the mandible in a lateral direction upon final closure. These can be detected by watching mandible closure. Typically there will be a lateral shunt a ‗comfort occlusion‖, or a broad arc of closure toward one side or the other. In the wide open posture usually the midline will align at wide open, and upon closure there will be a midline shift as guided by neuro- muscular reflexes. 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, upwardbackward 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. 3. Open bite— Lack of incisal guidance A. Clinical evaluation: During active eruptive phases, all cases at one point or another exhibit either anterior or posterior open bite. Once the eruptive process of the upper and lower incisors has been abbreviated (usually by with the soft tissue lip or tongue) and active eruption no longer exists, lack of proprioceptive guidance from the anterior teeth to position the condyles in the fossae allows for excessive mobility of the mandible. Clinically, these patients commonly show difficulty in finding centric occlusion. There is generally a forward shunt of the mandible (to reach out for incisal proprioception) and quite commonly the mandible can be manipulated distally by extending the thumb from the lower incisors to the upper incisor teeth. 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. 4. Excessive range of function A. Clinical evaluation: Extreme maxillary prognathism causes the mandible to "reach" forward in order to create a "comfort" centric occlusion. These cases are referred to as "super Class II" malocclusions, as the mandible must reach forward to gain even a Class II molar relationship. Clinically, severe Class II malocclusion in which the mandible can be nudged gently back into centric relation and, upon closure, shows a more severe maxillomandibular dental relationship, is evidence of abnormal range of function. 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 t 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 t, 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 t 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 in the buccal segment. 6. Loss of posterior superior displacement A. Clinical evaluation: In cases where there are numerous congenitally missing or extracted posterior teeth, it is not unusual for the remaining posterior teeth to tip mesially as the vertical pull of musculature overrides the posterior which holds the jaws apart. The result is a superior and distal movement of the condyles and, as in distal displacements, there can be an early onset of pain. Although this functional problem is seldom seen in the mixed dentition, ankylosis of numerous deciduous teeth and/or numerous congenitally missing teeth can create superior displacement. Superior displacement is most commonly seen, however, in the adult patient where anterior teeth have been retained, posterior teeth have been extracted, and proper vertical in the buccal segments has not been maintained. Superior displacements are also seen in open bite cases where only a posterior occlusion exists. The condyles are seated superiorly in the fossae as the mandible pivots off of the limited posterior s. 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 , early removal of carious deciduous teeth without proper vertical 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. 7. Finger sucking /Lip sucking/Tongue thrust A. Clinical evaluation: An open bite syndrome that is commonly initiated by the finger, aggravated by the lip, and maintained by the tongue can be considered a functional problem in that these habits may cause the development of, or accentuate, an open bite. It is not unusual for youngsters to suck on digits up to five or six years of age. However, when the permanent incisors start to erupt, deformation of the anterior alveolar process with dental protrusion and open bite can occur. Once the open bite

occurs, the tongue and lip oppose during the act of swallowing, aggravating and continuing the open bite pattern. B . Laminagraphic evaluation: Same as open bite. C. Resultant growth changes: Same as open bite. 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. 8. Breathing and airway problems A. Clinical evaluation: When it is observed at initial examination that the child breathes through his mouth, a close evaluation of airway deficiency should be made. The parent will quite often attest to the fact that the child is a mouth breather and, when a hand is placed over the oral cavity, these children may have a difficult time breathing through the nasal ageway. Concomitant allergies and facial characteristics (allergic shiner, allergic salute) as well as large tonsillar and adenoid masses indicate the tendency for mouth breathing. B. Laminagraphic evaluation: Usually the same as with open bite. 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 ages 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. 9. True Class III Growth Patterns A. Clinical evaluation: True Class III growth patterns represent the epitome in functional problems. They quite often exhibit a number of the functional aberrations previously mentioned as well as a genetic propensity for extreme upward/backward condylar growth, increasing the overall effective length of the mandible. This, in conjunction with maxillary deficiency, can be mistaken for the simple anterior crossbite or vice versa. When true Class III is suspected, a family history as well as early cephalometric evaluation is warranted. Several cephalometric measurements can be utilized to evaluate the possibility that a Class III growth pattern exists. B. Laminagraphic evaluation: When the mandibular teeth have byed 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. II. Resolve Arch Length Discrepancy Arch length gain in the lower arch occurs three ways. 1. Lateral expansion of the lower buccal segments Many cases, especially those of a Class II nature, demonstrate the possibility for arch length gain by lateral expansion of the lower buccal segments. This is a functional type of expansion, which proceeds in a slow, meticulous manner. The arch length gained through the natural expansive response in the lower arch is created by muscle and, as such, is extremely stable. This expansion occurs as the upper arch form is changed to bring the maxillary teeth and alveolar process into normal axial inclinations. As the upper arch is expanded and moved distally (and held in its expanded form for a long period of time), the lower arch responds, through muscular adaptation and function, reciprocally to expand. The lower arch also demonstrates a change in axial inclination that can begin at the deciduous canines and extend through the permanent molars. Primarily, this functional expansion in the lower arch is dependent upon the feasibility of expansion in the upper arch. This, in turn, is dependent upon the original axial inclination and arch form existent in the malocclusion. Upper arch form changes, when indicated, occur quickly mainly by alveolar warping. In situations where the upper first molars and deciduous buccal segment are inclined lingually, (i.e., demonstrate a reverse curve of Monson), it is desirable to expand the upper arch by means of an outward tipping of the upper buccal segment as the alveolar process is bent or warped out into a more normal inclination. This should be distinguished from true maxillary deficiency where the upper buccal segments have good axial inclination but there is a generalized narrowness to the maxillary vault..The arch form changes, expansive changes, and axial inclination changes that occur in the lower arch are merely a positive by-product of like changes in the upper arch. Although the reciprocal response in the lower arch occurs with many approaches, they are planned for and incorporated into early treatment procedures in the Bioprogressive Therapy. It should also be noted that since the reciprocal expansion in the lower arch occurs over a prolonged period of time, the arch form and axial inclination changes of the upper arch should be manifested as rapidly as possible to allow for the long-term responses to occur in the lower arch. 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). Following expansion with the W appliance the following should occur, The upper molars should be rotated distally The upper buccal segments expanded, A more normal upper arch form created Increased space for erupting upper central and lateral incisor teeth. On frontal head film some midpalatal disjunction will also be noted. 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. 2. Advancement or forward movement of the lower incisors When the visual treatment objectives and physiologic factors warrant (i.e., symphysis size, shape, and form; muscle position; esthetic considerations), retruded lower incisors can be gently intruded and advanced to reach a more favorable esthetic relationship to the APo line. This type of forward movement of the lower incisors is attempted in the brachyfacial type case, where bite opening should partially occur by virtue of incisor intrusion, as well as change in axial inclination of these teeth. Each 1mm of forward movement of the lower incisors will yield 2mm of arch length gain (Steiner).

3. Uprighting and/or distal movement of the lower molars With routine use of the utility arch in deep bite situations, the simple uprighting of the lower molars will allow the roots of these teeth to come forward while yielding space in the arch. When mesial tipping of the lower molars is evident, 2mm per side of arch length is gained by this simple uprighting effect. Further distal movement or intrusion of the lower molars can create problems with the erupting second molars. It is usually ideal to stabilize the lower molar once it has reached a normal position upright at 5° to the occlusal plane.

III . Correct Vertical Problems— Correct Overjet Problems 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 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 bioprogressive bracket system evolved over three main designs 1. Ricketts Standard Bioprogressive ( 1950‘s) 2. Ricketts‘s Full Torque Bioprogressive (1960‘s) 3. Ricketts Triple Control Bioprogressive (1970‘s) 1. Rickett’s Standard Bioprogressive With the advent of pre formed bands band material was designed and bracket angulations were considered so that ‗second order‘ moves were built in by angulating the brackets. In the original design it was decided that a bracket should be angulated to 5° or not at all. This s for the original prescription of 5° on all canines and 5° on the lower molar tubes and brackets. In addition it was decide on 8° for the maxillary laterals. All the rest were straight on to the margin of the band leaving to the orthodontist the 1° to 4° changes in angulation of the bracket by fitting the band as required for the individual patient needs. It soon became evident that control of torque simultaneously with placement of loops was difficult so Rickett‘s incorporated torque values of Jarabak and Holdaway into the brackets. Upper incisor of 22°, laterals 14° and cuspids at 7° of lingual root torque. 2. Rickett’s Full Torque Bioprogressive With the standard bioprogressive system difficulty was experienced in placing enough torque on the lower molar area, particularly in view of the need for anchorage. The same angulations of 7°, 14°, 21° were incorporated into the lower anterior segment, in addition the lower first molar had a rotation of 12°. 3. Rickett’s Full Torque Bioprogressive Following the idea of the straight wire concept of Andrews Ricketts decided that the step bends in the arch wire could be eliminated by building in as much of the treatment into the fixed apparatus. In order to this it meant placing raised brackets on certain teeth which would in effect, step these teeth inward or set the adjacent teeth outward. Certain brackets had to be raised or thickened at the base or what they called ‗deep base‘. Due to the buccal surface of the lower molars and the angulation of the lower tube, it was necessary to provide a right and left to meet that need. An average 15° rotation was incorporated into the upper molar tube to prevent the outward flaring. The raising of the brackets moved the upper bicuspids and upper canines inward, which in effect stepped the first bicuspid outward. Therefore raised brackets for the lower second bicuspid and canines were designed. Breakaway convertible lower molar tubes were designed which made it easier to band the lower second molar later in treatment and convert the occlusal tube to a bracket. A second molar tube was developed with 32° torque and a 6° rotation, 5° angulation for anchorage purposes. A new upper second molar band and tube. In order to handle the average Curve of Spee the upper rectangular tube was to be placed 1.75 mm below the level of the first molar tube. This procedure permitted the upper molar to be positioned with the non bent wire. In the four bicuspid extraction case the upper and lower bicuspids are not raised, which is the only difference from non extraction.

Arch Forms Factors taken into in the research of arch forms included:  Arch correlation  Consideration of size  Arch length  Where the arch was to be measured  details  Final determination of form at the bracket location Twelve arch forms were originally identified, which were narrowed down to nine by computer work. Studies of other normal and stable treated patients resulted in five arch forms. These were labeled Penta Morphic Arches 1. Narrow ovoid 2. Tapered 3. Normal ideal 4. Ovoid 5. Narrow tapered

MECHANICS SEQUENCE FOR EXTRACTION CASES 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. I) 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. 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. 1. Expansion places the molar roots out under the zygomatic process where cortical bone resists change and thus anchors and limits their movement. 2. The molars, placed in distal rotation, tend to resist the forward mesial pull as the cuspids are being retracted on sectional arch springs. 3. The third value is the distal rotation of the molar crowns for final positioning in the finishing occlusion. The finishing 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 will stabilize the molar and give moderate anchorage . 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 ing this natural process. A vertical closing loop or double delta loop will assist in its forward closure. Lower molar anchorage Maximum lower molar anchorage is maintained through the action of the long lever arm of the lower utility arch as described. During cuspid retraction on sectional arches, the utility arch is used in extraction mechanics to intrude or stabilize the incisors, while the various molar anchorage needs are met by modification to the basic utility arch. Four mechanical adjustments are placed against the molars in establishing a maximum anchorage effect: 1. Buccal root torque that places the roots against the cortical to limit their movement. Up to 45° of buccal root torque is placed in a .016 ´ .016 Elgiloy wire. 2. Buccal expansion of the molar section of 10mm on each side is necessary to the buccal torque. 3. Tipback of 30°-40° keeps the molar upright and resists the forward pull in response to the cuspid retraction springs. The tipback is the reciprocal action that acts to intrude the lower incisors. (The molar step for maximum anchorage should be kept against the molar tube.) 4. Distal molar rotation of 30°-45° is also placed in the molar section of the utility arch in extraction cases. The molar needs to be positioned to resist the forward drag on it during cuspid retraction, as well as to be positioned to receive the upper molar in a proper functioning occlusion. Moderate lower molar anchorage modifies the lower utility arch mechanics to allow the molar to come forward during cuspid and incisor retraction. A contraction utility arch stepped ahead of the molar tube modifies the four components of molar anchorage and utilizes the incisor retraction force to advance the molar. A proposed 3-4mm forward lower molar movement must respect the musculature which reflects the facial type. In the extreme vertical pattern open bite cases, 3mm forward movement would still require maximum anchorage to hold; while 3-4mm forward movement in a strong, deep bite brachyfacial type would be minimum anchorage and require special efforts to advance the molar. The facial type which reflects this muscular anchorage is a critical factor in influencing the treatment prescribed. II) Retraction and uprighting of cuspids with sectional arch mechanics. Bioprogressive Therapy proposes segmented arch treatment and retracts the cuspids on sectional arch retraction springs. 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 arch wire. 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. 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.

III. Retraction and consolidation of upper and lower incisors. While the cuspids are being retracted with sectional retraction springs, the upper and lower incisors can be aligned and either be 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. Lower Incisor. Lower incisor retraction must respect the cortical bony 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. Leveling of the Lower arch Type A: Incisors are extruded with mesial tipping of the molar Treatment involves uprighting the lower molars as a reciprocal moment to intruding the lower incisors and cuspids using a standard stabilizing utility arch. Type B: Incisors are extruded with upright molars and bicuspids Treatment involves stabilizing the lower molars to the lower bicuspids, which are then pitted against intrusion of both the incisors and cuspids. 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. Alignment of the lower buccal segments Depending upon the amount of rotation, space, and/or crowding evident in the lower buccal segments, a series of light leveling arches are overlayed to the stabilizing utility arch in order to achieve final buccal segment alignment. The arches typically used for the alignment are .015 Twistoflex, .0175 Twistoflex, .012 round, .014 round, .018 round, .016 x .016 triple T sections and .016 or .018 Niti. Buccal elastomers or lingual elastic thread is utilized to close spaces, effect rotations and assist in alignment of the lower buccal segments. Once leveling is completed a lower ideal arch is placed. Upper Arch alignment A series of sectional wires similar to those used in the mandibular arch are use for aligning the upper arch. These arches are contoured ideally and have a bayonet on the upper molar as well as bicuspid offsets and a small helix mesial to the upper canine teeth. Segmental correction of the Class II with elastics. Pitting upper and lower arches with continuous archwire against each other has several detrimental effects. 1. Skidding effect that simply throws the lower arch forward while extruding and retracting the upper arch.

2. With a tendency for deep bite the class II elastics can bring the upper incisors back and start ‗jamming‘ the lower incisors as they are retracted. 3. It is difficult to overcorrect the upper buccal segment without bringing the upper anterior teeth into lingual cross bite. 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. Upper incisor alignment and intrusion 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. Consolidation of the upper incisors It is necessary to over treat the overbite in order to overcorrect the buccal segments. There should be in effect a 2mm step between the cuspid bracket and the incisor bracket in order to create this relationship. The most commonly used arch used to accomplish this is a closing utility arch, but it is possible to continue torque on the upper incisors with the upside down closing arch or a very simplistic vertical helical closing arch. Idealization of arches and finishing details 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. I. Advancement, torque control and intrusion of the upper incisors There are four basic factors in upper incisor intrusion: 1. The direction of force 2. The amount of pressure 3. The stabilization of the molars 4. Torque control and timing of torque control in relation to growth factors. 1. The Direction of Force In Class II, Division 2 malocclusion, due to the original lingual version of the upper incisors, if these teeth are intruded initially, they will be forced into labial cortical bone, thereby limiting intrusion. It is, therefore, necessary to create overjet first and then correct the overbite. To do so, distinct functions are required — advancement of the upper incisors, torque control of the upper incisors, and intrusion of the upper incisors. The archwire used to carry out these functions is the maxillary utility arch, which is generally constructed of .016 × .022 blue Elgiloy or Nitinol wire. The maxillary utility arch has three activations in the molar section: 1. Tipback of 45° - distal tipping of the molar with intrusion of the incisors 2. Distolingual rotation of 10-20° - establishment of occlusal objectives 3. Expansion of approximately 1 cm on each side – only where expansionis required It is essential that the posterior vertical step of the utility arch be against the molar buccal tube and that there be an anterior deflection of 5mm or more of the anterior section. Many Class II, Division 2 malocclusions have the upper central incisors in lingual version locked behind the lateral incisors. To accomplish this, the anterior section of the utility arch must be well contoured and advanced. It may help to think of a "V" shape to the wire to obtain the necessary contour in the anterior arch form to advance the incisors . 2. The Amount of Pressure It takes approximately double the force to intrude the upper incisors, compared to the lower incisors (125 to 160 grams). This is one of the reasons for using the .016 × .022 blue Eligiloy or Nitinol maxillary utility arch in the initial phase of treatment. The second reason is that the span between the

upper molars and the incisors is a greater distance and, therefore, decreases the force delivered to the maxillary incisors. 3. The Stabilization of the Molars The use of the .016 × .022 utility arch in order to create the added force needed to intrude the maxillary incisors has an adverse tipping effect on the maxillary molars. The use of Quad-Helix, Lingual Arch, or Tranpalatal Bar will help stabilize the maxillary molars. The best way is to band/bond the bicuspids and cuspids and place a stabilizing leveling sectional arch in the occlusal molar tube, which will avoid excess tipping of the upper molars, This will, in effect, pit the entire upper buccal segments (and therefore muscle function) against the intrusion of the upper incisors. The stabilizing section is .016 × .016 or .016 × .022 with a tip-forward (down) bend in the molar section. This bend will keep the molar upright and, therefore, help in the Class II correction. 4. Torque Control Due to the fact that many Class II, Division 2 patterns are brachyfacial and, therefore, have a high facial axis angle and resulting horizontal growth, by putting the upper incisors parallel to the facial axis the interincisal angle is decreased which will help to maintain the overbite correction experienced in many Division 2 cases. There should be early torque control in the maxillary denture in all cases. II. Intrusion of the Lower Incisors and Cuspids The lower incisors are intruded using a mandibular utility arch There are two ways of accomplishing this: 1. Using an .016 × .022 stabilizing utility arch and tying the elastic ligature lightly from the cuspid bracket to the utility arch in the bridge section 2. The second possibility after the intrusion of the lower incisors is to place an .016 × .016 utility arch with a 45° tipback at the molar and allow the anterior section, when it is placed in the molar bracket, to extend down into the mucobuccal fold (this will give approximately 60-75 grams of force); then tie the elastic ligature from the cuspid bracket to a notch bent into the utility arch bridge section and elevate the anterior section, by tightening the elastic ligature, until it is level with the incisor brackets. The opposite side will be down slightly, and tying the elastic ligature on the opposite side can be carried out in the same manner. When the anterior section is level with the incisor brackets, it is then tied into the brackets.This can usually be accomplished in one appointment and will insure that there will not be an extrusion force on the incisors. It is possible at this stage of treatment to band/bond the upper maxillary cuspids and premolars, if not previously done, and place a traction section. If advancing the lower incisors is necessary, one of the modified utility arches may be constructed. III. The Aligning of the Buccal Segments The leveling of the maxillary and mandibular buccal segments may have been accomplished in the previous steps. If so, then Class II mechanics can proceed. There are three basic types of sections: 1. The stabilizing section, which also would function in leveling. 2. The consolidation section, which may be used to help close any spaces that have developed. 3. The traction section for distalizing the buccal sections with Class II elastics. The molar section would have a horizontal helical loop and bayonet bend mesial to the molar bracket. The cuspid section would have a horizontal helical loop with a gable and tip-up bend.

IV. The Consolidation of the Maxillary Incisors In many Class II, Division 2 malocclusions, there is a need for additional torque in the upper incisors and slight consolidation. The arch most frequently used is the maxillary torquing utility arch. This is an .016 × .016 blue Elgiloy utility arch with a vertical helix facing occlusally. The anterior section of this arch can be bent gingivally to increase its torquing action. The tipback also gives you additional torque, as does the activation. The amount of activation is just enough to cross the vertical legs of the helix. The arch has intrusion, retraction, and excellent torque control of the incisor segment. The second modification would be the maxillary contraction utility arch. The third modification would be the double delta utility arch. V) Idealizing the Arches At the completion of the previous stages, before inserting the ideal arches, a maxillary and mandibular utility arch should be placed with ideal sections, or a square twist wire for one visit, to allow leveling. An .016 × .016 blue Elgiloy or an .016 × .022 blue Elgiloy ideal arch can then be placed. In the use of tractional control, a straight ideal arch with ideal arch form would be placed. VI) The Finishing Stage The bands on the cuspids, first and second bicuspids are removed, and .018 × .022 finishing arches placed. The lower arch is activated. The upper arch is not activated, but Class II elastics are used to close the band spaces. After the spaces are closed, impressions are taken for a maxillary Ricketts retainer and a mandibular 4×4 lingual retainer. In today's direct bonding procedures, this step will be changed as there will be no necessity for band space closure. The impressions for retainers could be taken immediately. The mesiolingual of the acrylic portion of the retainer is ground to allow muscle function to settle in the buccal occlusion. The molar portion of the retainer is ground at the distolingual to maintain molar rotation. The lower arch has a 4×4 lingual retainer placed to maintain the upright position of the first bicuspids and the slight labial position of the distal of the lateral with the mesial of the cuspids.

FINISHING PROCEDURES AND RETENTION Ricketts interpreted Angle's line of occlusion to include a line drawn through the points of the posterior teeth and slightly below them through the 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. Differing Occlusal Concepts There are many concepts of occlusion describing the proper fit and mesh of the teeth. 1) Ideal occlusion, perhaps not quite ever found in Nature, represents an occlusion in which there is perfect size and fit of the individual teeth and the teeth are in ideal arch form, balance, and harmony; an occlusion in which every incline and stop is perfect and every tooth is in an ideal location within its arch and functions perfectly with its opponent teeth in the opposite arch. 2) Normal occlusion would be an untreated natural occlusion that is within an expected normal range of variation in all of the measurements thought to be critical in evaluating occlusion. The normal range of variation represents two-thirds of the population and eliminates those extremes on either end of the normal bell curve distribution. 3) Reconstructed occlusion represents those occlusions that are being restored, where the ability to critically record the various jaw movements is essential. The occlusion is designed to accommodate to the pathways of function recorded for the individual case and the teeth can be "constructed" to function properly in all movements in the specific case. 4) Orthodontic finishing occlusion is the topic of this article and is represented by the occlusion that is desired at the time of band or active appliance removal. 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. Function Influences Finishing and Retention The proper location and function of the condyle in the temporomandibular t is essential to the health and stability of the occlusion. A normal airway which effects the basic respiratory process and influences the tongue posture and function is important to the stability of the denture. Lip function and its variations have an influence upon the incisor alignment and stability. The buccal and facial musculature along with the muscles of mastication, which are reflected in the facial type as described by our cephalometrics, are also critical influences, and are considered during the original diagnostic criteria.

Bioprogressive Therapy, which proposes unlocking the malocclusion and establishing a more normal function to the occlusion, must be continually aware of the physiology and its influences in all stages of treatment, particularly during the finishing and retention stage. Occlusal Check List in Finishing An occlusal check list including eight areas in each arch is used in establishing the ideal finishing arch configuration and individualized tooth rotation in our overtreated orthodontic finishing occlusion. The patient at this stage is seen at two-week appointments, for the adjustments are more delicate and controlled. During the final two-week adjustment the cuspid and bicuspid bands may be removed to allow closing of the band space. New bonding procedures that eliminate the interproximal band material may not require the stage of final finishing. 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 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 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. Three Separate Phases of Retention Retention in Bioprogressive Therapy is the process that sustains and guides the settling from the overtreated or orthodontic occlusion into the final functioning occlusion. It first guides these changes during the initial adjustments, and then s the bony sutural and muscular accommodations to the changing environment. Finally, retention should consider the long range influences which involve changes created by growth, tooth eruption, and function, characterized by the different facial types. The Initial Stage of Retention The initial stage of retention, perhaps the most obvious and critical, occurs during the first six weeks following the conclusion of the active phase of treatment when the appliances are removed and the teeth are "turned loose" to erupt along their normal eruptive paths into the functioning occlusion.

Retainers inserted at this initial phase are not designed to hold, but to assist in guiding this settling process. The adjustments in the upper retainer include relieving the lingual to: (1) close the anterior band space between the central and lateral incisors (buccal band space is closed with finishing arches), (2) allow the tucking in of the distal of the upper cuspids following their expansion and overtreatment, and (3) sustain the settling distal rotation of the upper molar as it functions with the lower rotated molar occlusion. In the lower arch, a fixed first bicuspid retainer is placed in order to (1) maintain the cross arch bicuspid width and the first bicuspid against the upper cuspid and bicuspid function, (2) allow the lower cuspids the freedom of adjustment against the upper occlusion, and (3) place a lingual bar against the incisal third of the lower incisors to maintain their alignment and rotational connection. The fixed lower retainer being back on the bicuspids is easily acceptable to the patient and can be maintained longer. The Stabilizing Stage of Retention The stabilizing stage of retention involves the ongoing phase over the first year following active treatment when the sutural adjustment, transseptal fibers, functioning occlusion and muscle physiology need to be considered in ing the new occlusion. During this period the lower fixed retainer is kept in place and the upper retainer is worn most of the time. Following the 1st year, if the functioning occlusion remains stable, the retainer is worn only part time, during sleeping . Positioner Use in Bioprogressive Therapy Positioners have become popular in recent years as an appliance for use primarily during the initial phase of retention when the teeth are the most susceptible to change, particularly minor adjustments following band removal. In the construction of a positioner, a face bow mounting is essential. A face bow registration is desirable in being able to give an accurate articulator mounting and setup for the positioner. One technique is to maintain the lower fixed 1st bicuspid to 1st bicuspid retainer and alter the positioner to only cover the incisal one third of the lower arch. The setup is individualized to maintain the proper buccal occlusion arch form, and interincisal angle. For the best results, the positioner is placed immediately at band removal and worn full time or as much as possible the 1st forty-eight hours. Settling is thus more controlled and accomplished faster than that expected with the retainer, which may require four to six weeks to direct these initial changes. 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.