Bio progressive therapy

Introduction.
Umbrella concept
Principles of Bioprogressive therapy.
Visual treatment objective.
Orthopedics in Bioprogressive therapy.
Forces used in Bioprogressive therapy.
Sectional and utility arches.
Synopsis of extraction and non-extraction treatment mechanics.
Bioprogressive therapy appliances
Conclusion

1. BIO PROGRESSIVE THERAPY By : Miliya PArveen

2. Contents 2 Introduction. Umbrella concept Principles of Bioprogressive therapy. Visual treatment objective. Orthopedics in Bioprogressive therapy. Forces used in Bioprogressive therapy. Sectional and utility arches. Synopsis of extraction and non-extraction treatment mechanics. Bioprogressive therapy appliances Conclusion

3. Introduction The Bioprogressive technique is a fixed orthodontic technique, developed in 1950s by Dr . Robert Murray Ricketts . It was developed from edgewise technique, also contains elements of light wire technique . It takes advantage of biological progressions including growth, development and function and directs them in a fashion that normalizes function and enhances aesthetic effect. 3

4. 4 Orthodontic therapies must be designed to be applied appropriately to specific facial types , muscular pattern & functional needs of individual. Bioprogressive therapy (BPT) accepts as its mission the treatment of the total face rather than narrower objective of the teeth or occlusion. BPT was so named because it progressively include particular groups of teeth into the therapy (first molars & incisors, followed by canines & premolar ) with their therapeutic interventions applied in a planned sequence.

5. Management of Umbrella Concept Bioprogressive therapy functions well within an efficient management system and management should not be considered an add on component to a series of technical procedures, which ultimately determines the efficiency and effectiveness of treatment. A management system for orthodontists would include the following three things: 1. Quality — This would be the quality of the result. 2. Quantity— This would be the number of patients that are treated 3. Effectiveness — This would be the effectiveness of the treatment design and office management.

6. 6 The system used is Lewis A Allen management system . Based on simple formula - PLANNING – work performed to predetermine a course of action to be followed. ORGANIZING - work performed to arrange & relate the tasks to be accomplished LEADING - work performed to ensure that people act in such a way as to complete our objectives . CONTROLLING - work performed to assess & regulate results.

7. Principles of Bio-progressive therapy The use of systems approach to diagnosis and treatment planning by application of the visual treatment objective in planning treatment, evaluating anchorage and monitoring results It was developed by R icketts & called a VTO by Holdaway . Allows orthodontist to visualize the changes that should occur and to prescribe the necessary treatment to cause it to happen . Helps in understanding the interrelationship of various changing parts and the influence that one area has upon another . 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

8. Torque control throughout treatment Some treatment techniques have designed brackets for a limited contact between the archwire and the bracket or recommended the use of round wires in an attempt to limit the control and allow more freedom of movement of the tooth . Bioprogressive therapy suggest that movement of teeth can be more efficient and various treatment procedures can be more effectively carried through when control of direction of root movement available . The edgewise slot brackets are used in order to keep the bracket and wire sizes smaller, but still have torque control throughout various stages of treatment.

9. 9 Four situation where torque control of root is necessary: Keep roots in vascular trabecular bone during initial stages of treatment for efficient movement of teeth . Place roots against dense cortical bone for anchorage . Torque to remodel cortical bone for U/L incisor retraction. Torque to position teeth in final occlusion.

10. 10 3. Muscular and cortical bone anchorage Muscular Anchorage - Anchorage here is considered in terms of stabilizing the molars and positioning teeth against movement during various stages of orthodontic treatment . Stabilizing the teeth against the horizontal movements and also against vertical or extruding forces produced by cervical headgear to the upper molar is countered by the posterior muscles of mastication like Masseter and Temporalis . In certain facial patterns these musculature seems stronger and able to overcome most orthodontic forces while in others these musculature seems to be weaker and easily overpowered by orthodontic forces.  

11. 11 Recent evaluations of morphology of mandible and lower face structures suggest Cephalometric measurements that are describers of facial types and alert us to those types which may require modification of our treatment procedures. Xi point also becomes the apex of an angle describing the lower face height from the corpus axis of the mandible as its lower boundary to the anterior nasal spine of the palate as the upper limit. During normal growth this angle of lower facial height does not change and therefore gives a good indication of the present status as well as future potential of oral form and physiology.

12. 12 Cortical Bone Anchorage - Cortical bone is more dense and laminated with very limited blood supply therefore the physiological process is delayed and tooth movement is slower . Tooth movement can be further delayed where excess forces against the cortical bone can press out the blood supply and limit the physiology and tooth movement . Bioprogressive 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 dense cortical bone on their buccal surface.

13. 13 4 . Movement of any teeth in any direction with proper application of pressure Rate of tooth movement is dependent on blood supply that sustains the physiological action that takes place within bone. Brain Lee, 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 as Enface root surface or the portion of root that is in the direction of tooth movement . He expressed that force as 200 gm/sq.cm of enface root surface area is optimum for efficient tooth movement. Bio progressive therapy suggest this force as 100gm/sq.cm . Density of bone is also an influencing factor in rate of tooth movement through laminated dense cortical bone require even less forces to allow an adequate blood supply .

14. 14 5. Orthopedic alteration Orthopedic forces changes the relationship of the basic supporting jaw structure as contrasted to tooth movement in localized area. It also affects areas associated with supporting structures like condyles of mandible and palatal plates of maxilla Ex ; Headgear , RME . Orthopedic change /alteration of supporting structure is usually associated with treatment of young child where treatment is more effective because of development still associated with these basic structures. Expected mandibular rotation and facial types usually dictate the kind of headgear prescribed.

15. 15 6. Treat the overbite before the overjet correction For stability in function and retention it is vital to correct deep bite relation so as to get proper overjet , and inter incisal relationship. Methods of Deep bite correction – Extrusion of posterior teeth- increases LFH (unstable in horizontal pattern because of strong muscle force ) Intrusion of anterior teeth. Bio progressive therapy recommends this as best choice- stability of result optimizing function & prevent interferences.

16. 16 Bite before jet – avoids incisor interferences & posteriors remain in normal stable vertical occlusion established by muscles. Incisor interference- results in proprioceptive input/ neuromuscular interferences that affects patients ability to close posterior teeth, molars allowed to extrude & vertical opening occurs. Utility arches and Sectional arch therapy is used to aid in incisor control so that tooth movement can occur in proper force system

17. 7. Sectional arch therapy It is the basic treatment procedure of BPT. In sectional arch treatment the arches are broken into sections or segments in order to produce efficient tooth movements. Four benefits of sectional arch treatment , It allows light continuous force to be directed for efficient tooth movement . More effective root control in basic tooth movements . It allows us to torque lower incisors away from lingual cortical bone. It supplements maxillary orthopedic alteration . It reduces binding & friction of brackets as they slide along the archwire . In continuous arch because of the short span between their brackets , very heavy forces of a short duration are usually applied .

18. 18 8 . Concept of overtreatment It is necessary for the clinician not only to appreciate the changes to bring the teeth into properly aligned functional occlusion , but to anticipate changes that follow when all the appliances are removed and post treatment adjustments begin to occur. In order to overcome the tendency of relapse , provisions for post treatment rebound as well as post treatment growth changes need to be appreciated & planned for.

19. 19 Bioprogressive therapy suggest four areas where the concept of overtreatment may help : To overcome the muscular forces against the tooth surface in n arrow upper arches , a nterior open bite, u pper anterior protrusion due to lip sucking. Root movements needed for stability: deep bite, paralleling of roots adjacent to extraction sites, severe rotations To overcome orthopedic rebound as heavy forces are eliminated, the basic supportive structures may rebound. To allow settling in retention over treatment of the individual teeth within the arches allows them to settle into a functioning occlusion.

20. 20 9. Unlocking the malocclusion in a progressive sequence of treatment in order to establish or restore more normal function It is necessary during initial examination & evaluation to consider these area of diagnosis: To describe the malocclusion and visualize the position of the teeth in terms of what functional influences have been responsible for their present form . To describe the facial type and skeletal structure . To describe the present abnormal functional influences upon dental arches, or the lack of abnormal development by default. Ex: Upper arch expansion, incisor protrusion correction, TMJ problems

21. 21 10. Efficiency in treatment with quality results, utilizing a concept of prefabrication of appliances Allows the clinician to direct his energies in details of appliance application, diagnosis and treatment planning rather than in their construction.

22. Visual treatment objective It is like “Blue print for building a house ”. Its a visual plan to forecast the normal growth of the patient & anticipated influences of treatment so as to establish the individual objectives for that patient . Helps orthodontist to take advantage of growth. By superimposing a progress tracing between tracing & forecast goal, orthodontics may evaluate progress along a definitely prescribed route . Any deviation from expected progress will become apparent immediately & need for mid course corrections. 22

23. 23 STEPS IN CONSTRUCTION OF VTO Cranial base prediction Mandibular growth prediction Maxillary growth prediction Occlusal plane position Location of dentition Soft tissues of the face

24. 24 VTO-CRANIAL BASE PREDICTION Place the tracing paper over the original tracing, starting at CC point, follow these to construct the cranial base : Trace the Basion-Nasion plane. Put mark at point CC Grow Nasion 1mm/ yr for 2yrs . Grow Basion 1mm/ yr for 2yrs Slide tracing back so Nasions coincide and trace Nasion area . Slide tracing forward so Basions coincide and trace Basion area.

25. 25 VTO MANDIBULAR GROWTH PREDICTION-ROTATION The mandible rotates open or closed from the effects of the mechanics used and the facial pattern present . Mechanics : Convexity reduction- Facial axis opens 1deg/5mm. Molar correction – facial axis opens 1deg/3mm. Overbite correction – Facial axis opens 1deg/4mm. Cross bite correction – Facial axis opens 1- 1.5 deg. Recovers half the distance . Treatment mechanics may open facial axis as in class II mechanics or close with high pull head gear and extraction

26. 26 Facial pattern – facial axis opens 1deg in dolichofacial and vice versa. 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 . Trace condylar axis , coronoid process, and condyle

27. 27 VTO- MANDIBULAR GROWTH PREDICTION - CONDYLAR AXIS GROWTH On condylar axis make mark 1mm/ year down from point DC. Slide tracing along condylar axis so that new mark on Ba-N plane. Extend condylar axis to Xi point and locate a new Xi point. With old and new Xi points coinciding, trace corpus axis, extending it 2mm/ yr forward of old PM point. CORPUS AXIS GROWTH Draw posterior border of ramus and lower border of mandible

28. 28 VTO- MANDIBLE GROWTH PREDICTION – SYMPHYSIS CONSTRUCTION Slide back along the corpus axis super imposition at new and old PM. Trace the Symphysis and draw in mandibular plane . Construct the facial plane from NA to Pog . Construct facial axis from CC to Gn

29. VTO- MAXILLARY GROWTH PREDICTION- 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 To outline the body of the maxilla, superimpose mark ≠1 on the original menton along the facial plane. Trace the palate (with the exception of point A)

30. 30 VTO- MAXILLARY GROWTH PREDICTION – POINT A CHANGE RELATED TO BA-NA These are the maximum ranges of point A change with various mechanics : Mechanics Maximum range HG -8mm Class ll elastics -3mm Activator -2mm Torque -1 to -2mm Class lll elastics +2 to +3mm Facial mask +2 to +4mm Construct new Apo plane  

31. 31 VTO- OCCLUSAL PLANE POSITION For each mm of distal movement point A will drop ½ mm Superimpose mark ≠2 on original menton and facial plane, then parallel mandibular planes rotation at menton . Construct occlusal plane (may tip 3 deg either way depending on class II or class III treatment)

32. 32 DENTITION - LOWER INCISOR The lower incisor is placed in relation to Symphysis Occlusal plane APO plane 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 1mm above the occlusal plane and 1mm ahead of the APO plane . Draw in the lower incisor in the final position as required by the arch length. The angle is 22deg at +1mm to the Apo plane and + 1mm to occlusal plane , but the angle increases 2deg with each mm of forward compromise.

33. 33 LOWER MOLAR Without treatment the lower molar will erupt directly upward to the new occlusal plane. With the treatment - it moves forward 1mm of forward movement equals 2mm loss of arch length. Movement decided based on lower incisor position.

34. 34 UPPER MOLAR Trace the upper molar in good class I position to the lower molar. Use the old molar as a template. UPPER INCISOR Place upper incisor in good overjet and overbite(2.5mm)with lower incisor with an interincisal angle of 130º+/- 10º. Openbite patterns at a greater angle, deepbite pattern at a lesser angle.

35. 35 VTO SOFT TISSUE NOSE Superimpose at nasion along the facial plane and palatal plane. Move prediction back 1mm/ yr along the palatal plane . Trace tip of nose fading into bridge.

36. 36 SOFT TISSUE POINT A & UPPER LIP Divide the horizontal distance b/w original & new upper incisor tips into 3 rds by using 2marks. Superimpose along the facial plane at the occlusal plane. Soft tissue thickness of upper lip will not change . Superimpose new & old bony point A & make a mark at soft tissue point A is traced. Keeping the occlusal plane parallel, superimpose mark # 1 (posterior mark).Trace upper lip connecting with soft tissue point A

37. 37 LOWER LIP, POINT B & SOFT TISSUE CHIN In constructing the lower lip , bisect the overjet & overbite of the original tracing & mark the point. Superimpose inter-incisal points keeping occlusal planes parallel. Trace lower lip & soft tissue B point. Soft tissue thickness of lower lip will remain the same. Eliminate lip strain if any

38. 38 VTO COMPLETED Superimpose on the Symphysis & arrange the soft tissue of chin. It drops down & should be evenly distributed over the Symphysis taking into consideration reduction of strain & bite opening.

39. Forces used in Bioprogressive therapy The physiologic process of resorption by osteoclastic cells is the basic activity for tooth movement . Since these osteoclastic cells are carried by blood to the site of activity , the key factor in the efficient teeth movement seems to be blood supply that carries these cells & sustain their activity. When generous blood supply can be maintained by applying a light force , tooth movement is more efficient .

40. 40 Bioprogressive therapy suggests consideration of followings aspects for efficient teeth movement - Size of the root surface involved Cortical bone support Amount of applied force Muscular support –reflected by facial type

41. 41 Force would vary depending on the size of the root surface involved & the direction of movement being planned. Bioprogressive therapy’s evaluation of applied forces suggests 100 gms /cm2 of enface /exposed root surface as optimum. Surface of root exposed to movement called the enface surface of root. Mesiodistal size of the root surface is evaluated when the tooth is being moved antero -posteriorly in buccal segment.

42. 42 CONTROL OF FORCE: When traditional procedures used in edgewise mechanics are evaluated (round wires to align incisors & reverse curve of spee ) it was found that forces almost 10 times as high as those recommended were currently being used. These heavy forces physically squeeze out the blood supply to the area & limit the biological response & efficient tooth movement. Thus in clinical situation when we ligate arch wires across short spans very high forces can result.

43. 43 In order to decrease the force being delivered to a single tooth / group of teeth the concept of long lever arm (utility arch) / incorporates more wire (loop design) is applied. Utility arch uses long lever arm spanning from molar to incisor with distance from 20-40mm in upper arch , 25-30 in lower arch ( produces desired 80 gms of force for intruding lower incisors )depending on arch length & malocclusion. With longer distance of 35-40 mm in upper arch a larger wire (16x22) is necessary to produce required 160gm for upper incisor intrusion.

44. 44 SIMPLE LOOP DESIGNS: Incorporates more wire between the teeth & reduce the amount of force COMPLEX LOOP DESIGNS: It uses the combination of simple loops & adds additional wire to further reduce the amount of force while making it more continuous The root surface theory of tooth movement works well for the individual teeth but when inter-arch mechanics & reciprocal factors are analyzed, it becomes apparent that other factors need to be considered in total evaluation of teeth movement i.e physical characteristics of supporting bone through which teeth are being moved

45. 45 Concept of cortical bone support The concept of cortical bone anchorage implies that, to anchor a tooth, its root are placed in proximity to dense cortical bone under a heavy force that will further squeeze out the already limited blood supply & thus anchor the tooth by restricting the physiological activity in an area of dense laminated bone. For efficient movement our mechanical procedures should steer the roots away from denser cortical bone & through the less dense channels of vascular trabecular bone.

46. 46 Lower incisors, canines and Premolars : These are supported on lingual aspect by cortical bone of planum alveolar . During various tooth movements like incisor intrusion /canine retraction, treatment mechanics must be modified to move the their roots labially away from this denser heavier support . If the heavier forces are applied to the incisor /canine retraction , then roots being adjacent to cortical bone become anchored . This anchoring will strain molar anchorage , tip & extrude the incisors around planum alveolar bone fulcrum which creates deep bite problems often associated with extraction mechanics.

47. 47 Lower 2 nd Premolars and Molars : The lower 2 nd PM & molars are supported from the buccal by the cortical bone which runs along their buccal surface into the external oblique ridge . To anchor lower molar , the roots are expanded & torqued into this denser avascular cortical bone . Clinical observation have demonstrated that when the lingual cusps are kept down (roots expanded & torqued buccally ) good molar anchorage is being maintained.

48. 48 Maxillary incisors : These are best intruded along their long axis into broadest area of alveolar process . If the roots tips are forward as in class 2 div 2 crowns must be advanced & the roots retracted before intrusion so that they can avoid the cortical bone around point A in maxilla .

49. Maxillary Canines : The canine root tip is often precariously located between the constricting alveolar process on the buccal-lingual corner, the canine fossa & the cortical bone lining the lateral corner of nasal aperture. If too much tipping is allowed root tip become exposed through buccal cortical bone. To keep upper canines in trough of trabecular bone, the cortical bone on lingual & labial plates of alveolar process need to be respected & the roots guided around the corner in their retraction.

50. 50 Maxillary bicuspids and Molars: The roots of 2 nd PM & Molar are often involved with the cortical bone lining the floor of sinus . During intrusion of teeth in this area we must appreciate the sinus & its location in relation to root tips . When heavy lateral orthopedic forces are applied , teeth in the maxillary buccal segment become anchored & much of adjustments occur in the mid-palatine suture as is the case of palatal separating appliances . When molar distalization desired, molars should be kept narrower in trabecular trough area & the forces lighter & more continuous for orthodontic movement.

51. Where the musculature are strong as characterized by deep bite , low mandibular plane angle, brachycephalic type, teeth demonstrate “natural anchorage”. In open bite, dolicofacial pattern, muscles seems weaker & less able to overcome molar extruding & bite opening effect of treatment mechanics. MUSCULATURE ANCHORAGE

52. BPT of Mixed dentition treatment OBJECTIVES OF EARLY TREATMENT Resolve functional problems -Anything that disturbs the growth, health and function of the temporomandibular joint complex or Anything that jeopardizes the normal direction of growth in the individual case Resolve arch length discrepancy- So that the borderline cases can be managed without extractions . Correct vertical problems - Deep bite or Open bite, “Bite before Jet ”. Correct overjet problems - To create an acceptable maxillo -mandibular balance, by combination of orthopedic – orthodontic movements

53. Factors in bracket and band design Due to tooth variation Adaptation, stretching , drawing and final fitting should be done at the chair. Thin, strong yet malleable material and narrower band would permit more precise fitting to the tooth all around In order to adapt a band for its best fit, a light tapping of the band is recommended - This completes shaping and provides correct adaptation to each individual tooth

54. 54 If the band is too wide results in folding or creasing the band material. Wide band may damage the periodontal attachment . Under cuts of tooth anatomy are recognized and all bands are drawn by adapting to height of contour . If the band is too soft on its margin , it will distorts easily and move away from the tooth on its occlusal margin . A narrow band gingivally seated will free the incisal edge and yield maximum esthetic value.

55. 55 Factors in bracket design For 3-D control of arch dimension Dr. Edward. H. Angle designed the rectangular slot and provided winged flanges for wire ligation. Narrow single bracket .022 x.028 size was designed to be replaced in the center of buccal or labial surface of tooth. Eyelets or staples for rotational control came later . The treatment wires recommended by Angle were gold wires of .022x.028 inch.

56. 56 Movements were to be intermittent in order to produce the least permanent damage to root and soft tissue . The staple was difficult to engage & sometimes buried under the gingiva . The placing of 2 single brackets mesially & distally was one of the lst efforts to solve this problem . A bracket was ultimately designed so that a connection was made b/w the two . Dual brackets with welding flanges became available for band / bracket combination.

57. 57 Brackets came to be mesially & distally offset instead of centered & bars were soldered on the band for rotation of the tooth . These were the forerunner of the rotation bracket, which added arms to the bracket . Rotation & uprighting forces thus were anchored off the narrow bracket attachment . This bracket required a strong central attachment & a tight fitting band was necessary.

58. 58 Other developments affecting bracket design:- Development in metals of superior quality . Preformed bands were gaining more acceptance . Methods of seating & adopting were improving . Lighter forces were being shown to be of advantage . Angulation of brackets were proven useful.

59. Consequently, 2 principle bracket designs became available : First – Rotation arm Second- Varying lengths & width of twin brackets ie ; Siamese brackets / Dual brackets Advantages of rotation arms : A light force can be delivered. A push /pull can be utilized. A wide inter-bracket distance is available which helps to keep forces lightened. Wide inter-bracket distance makes loop position less critical in multi-looped arches. Sliding of the tooth on the wire is thought to take place with less friction.

60. 60 Advantages of Siamese type brackets : Bracket yields positive control. A simple bracket is easier to keep clean. Bracket gives more effective rotation due to the inter-bracket distance. Bracket is more efficient with very light wire. 1 of the brackets can be tied as a counter rotation during enmasse movement. Closing / crimping of 1 bracket provides a lever in the event of needed over rotation thus same advantage of a rotation arm. By employing the top of one and bottom of the next a wire can be used easily as an uprighting spring.

61. 61 Other factors pertinent to Rickets bracket design : Deep slots - It permits 2 light arches to be employed at once . It permits a chamfer / bevel at the box entrance to facilitate wire seating . It permits bracket profile to be raised for lever access beneath the wing . It provide more adequate distance for torque grooves to be placed.

62. 62 Wide incisal gingival wing - It provides easy access for tie wires. It permits auxiliary light wire to be placed underneath the wing. Can be used for rubber elastic traction. Provides accessibility for cement removal under wings . Softer bracket material - The softer but not annealed material permits closing of bracket for rotation with later reopening at finishing. It can be pinched close around narrower arches for absolute wire engagement.

63. Factors in head gear design Head cap was described by Kingsley 1866 & Farrar in 1870s Objective was limited to retraction of upper anteriors . Angle in 1888 described his extra oral attachment. A long pin soldered to E arch in midline, which rested on central incisor bands where cleats were attached. He recommended it, to be t worn during sleeping hours . Intra-maxillary elastic bands were used for traction during day time. 63

64. 64 Recognizing the need for downward pull at the ends of the outer bow, Ricketts working with Downs applied only the neck straps portion of the Kloehn head cap. This was followed by Downs designing a full elastic neck strap / the cervical anchorage still popular today. Finally full arch was banded & h igh pull headgear was reintroduced to intrude the upper incisors – Mc C ulloch 1960

65. 65 FEATURES TAKEN INTO ACCOUNT IN DESIGN OF NEW RICKETTS HEADGEAR. Neck strap with force of 500gms will produce orthopedic effects. This led to the introduction of strong bow, unannealed to prevent bending/ breakage & laser welding. Headgear tube is kept gingival to keep the force closer to the center of root so that less extrusion force is produced . Banding the anterior teeth & placing a continuous arch tends to bind the 2 halves of the maxilla together & prevents convenient permanent expansion. If these teeth were banded the continuous arch wire were not to be used as the dental bow can rest under the incisal bracket wing Extra anterior elastic is not employed because of tendency of deep bite.

66. Orthopaedics in Bioprogressive Therapy Any approach to headgear therapy is right if it accomplishes the result we desire for that one individual case . There is a vast difference between correcting jaw position and correcting tooth position . We need to think more in terms of a differential treatment of Class II malocclusion . The Visual Treatment Objective, is the most helpful medium we have for evaluating where we want to be, by demonstrating the methods for reaching that goal.

67. 67 METHOD OF EVALUATION Most significant changes induced by headgear therapy are evaluated by means of progressive lateral head films . Practically in the growing child , orthopedic alteration would be any manipulation which would change the normal growth of the dento -facial complex in either direction or amount . For the sake of simplicity, it is important to closely evaluate only four basic areas of superimposition . The first two areas of superimposition are to define specific orthopedic change (i.e. a change in growth direction or amount, or both, of basilar bone ). The second two areas of superimposition are utilized to define specific tooth movements on the denture base ( i .e. orthodontics)

68. 68 ANALYSIS OF THE PROBLEM Bimler partially described the classical , severe convexity problem as a Micro rhino dysplasia . In a sampling of over 234 Class II malocclusions, over 60 percent of the cases with high convexity (+6 mm or more) demonstrated most of the characteristics of micro rhino dysplasia . The micro rhino dysplasia has an upward, outward tip of the palatal line with Anterior Nasal Spine (ANS) tipped toward Frankfort Horizontal (FH) at least 4° or more. The upward, outward tip of the palate lends itself to severe maxillary protrusion

69. 69 The upward cant to the palate is accompanied by a short vertical height to the nose, an upward cant to the nares and a disproportionately small upper face compared to lower face height. The long , drawn-out maxillary dentition, tapered progressively toward the midline, allows sufficient overjet so that, in resting posture, the lip is carried underneath the upper incisor teeth . The hyperactive lower lip, resting in the anterior overjet, often retrudes the lower dentition . Vault space for the tongue, which is severely restricted due to the narrow arch form, creates an ideal environment for anterior tongue thrust

70. 70 The molars, in Class II occlusion, are typically in mesial rotation and the tapered upper arch form defines and restricts lower arch width and form . The most important characteristic of microrhino dysplasia, however, is that it is apparently unrelated to facial growth type. The severe maxillary protrusion characteristics are just as evident in Class II brachyfacial types (strong mandibular growth postures) as in Class II dolichofacial types (weak mandibular growth postures).

71. 71 Generalized orthopaedic response with cervical headgear Maxilla invariably respond in a 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 pterygo -maxillary fissure, the maxillary complex rotates in a clockwise direction and all points on the maxilla will appear to arc in an almost concentric fashion.

72. 72 The downward and backward pressure of the cervical headgear, to the upper molars alone extrudes these teeth . This response is dictated more by the muscular pattern, the length of the outer bow, the occlusion of inclined planes (upper molar vs. lower molar) and the length of wear each day . The upper incisor will tip lingually (from its apex ) The lower molars upright and often move distally when carried by the incline planes of the extruded upper molar, which also is being carried distally . The lower incisor, without the inhibiting effect of the lower lip, will quite often tip labially

73. Utility and Sectional Arches Historical prospective - When a flat round wire / with reverse curve of spee is placed on lower arch , response was extrusion of lower PM, lower molar uprighted (tip back) , lower incisors tipped forward(cinch back ). As the reverse curve of spee in round arches expressed , roots of lower incisors thrown against dense cortical bone of lingual planum of Symphysis leading to anchor loss.

74. 74 Class III elastics - To prevent lower arch from forward movement with this type of leveling procedure class lll elastics superimposed to hold the lower incisors back as the lower arch was levelled. Eruption of lower incisors & upper molars counteracted with high pull headgear.

75. 75 Development of Utility Arches - Late in 1950s Robert Ricketts & others attempted to counteract the tipping that occurred in buccal segment in extraction cases by utilizing lower incisors as an anchor unit to hold lower 2 nd pm & molars upright in retraction process . It was noted that not only buccal segments maintained in upright position but the lower incisors intruded, this led to the development of step down base arch / Ricketts lower utility arch

76. 76 Step Down Base Arch Or Ricketts Lower Utility Arch Functions, Position lower molar to allow for cortical bone anchorage . Manipulation and alignment of the lower incisors segment Lower utility arch can intrude or extrude or hold lower incisors in the initial phase of therapy . By alteration of design it is possible to advance or retract the lower incisors without disturbing / depending on canines & pm . Pressures ideally suited for aligning & intruding of lower incisors are difficult to deliver when they are not treated as separate unit /segment.

77. Physiologic Vs Mechanical Response 77

78. BASIC BPT APPLIANCES 78 Evolution from standard BPT which originally contained torque & tip in the upper incisors & all canines through full torque for PM & Molars now to the offset in the triple control has been a natural progression consistent with our basic principles Standard BP appliance Full torque BP appliance Triple control BP appliance

79. 79 Standard BPT appliance Used since 1962, torque was included in the upper incisors & all 4 canines . Torque was to be placed in lower buccal segments with all step bends . Torque incorporation & arch form made by the operator.

80. 80 Full torque BPT appliance It included additional torque to the standard setup ,by placing torque in the lower 2 nd bicuspid and lower 1 st and 2 nd molars. The additional torque were adopted for the technique to eliminate excessive torqueing in the wire needed for finishing stages but they were augmented for anchorage.

81. 81 Triple control BPT appliances for non extraction cases It includes features of over treatment of certain torque , overtreatment of rotations & provisions for overtreatment of upper buccal segments. The raised bracket was designed for all canines & 2 nd pm so that a non stepped wire could be used as the ideal final arch wire.

82. Mechanics sequence for extraction cases Treatment plan and sequence of mechanical procedures are planned in progressive stages that will unlock the malocclusion and establish a more normal function . Draw V.T.O that includes changes that are expected with - Normal growth Orthopedic alteration Alignment of teeth Functional and soft tissue changes

83. 83 EXTRACTION MECHANICS Sequence can be best ordered into four g eneral procedure s, Stabilization of upper and lower molar anchorage. Retraction and uprighting of cuspids with sectional arch mechanics. Retraction and consolidation of upper and lower incisors. Continuous arches for details of ideal and finishing occlusion.

84. 84 STABILIZATION OF UPPER AND LOWER MOLAR ANCHORAGE Upper molar anchorage A . Maximum upper molar anchorage : Nance p a latal arch in addition to the distal loop on the mesial lingual of the upper molar bands, which allows the molar teeth to be expanded and rotated.

85. 85 B. Moderate upper molar anchorage: B. Moderate upper molar anchorage : F orward advancement up to half of the extraction space during the treatment procedure A distal looped lingual arch or a palatal bar without the plastic button support Upper utility arch during cuspid retraction with or without lingual arch

86. C. Minimum upper molar anchorage Where the upper molar needs to be advanced the whole distance of the extraction space( 2nd pm extraction ). Class III elastics Double delta loop Vertical closing loop

87. 87 Lower molar anchorage More moderate anchorage concepts in the strong muscle patterns and more maximum anchorage concepts in the vertical pattern where the musculature gives weak support . Maximum lower molar anchorage Maximum lower molar anchorage Lower utility arch with , 45 deg buccal root torque Buccal expansion of 10mm to support buccal torque Tip back 30 – 40 deg Distal molar rotation of 30-45 deg Long lever arm

88. 88 B. Moderate lower molar anchorage Contraction utility arch with stepped ahead of the molar tube C. Minimum lower molar anchorage Four anchoring factors Torque , Tip back , Expansion and Rotation are reduced. Round wire in the molar tube may be used to eliminate the binding and torquing to the molar and thereby reduce the anchorage.

89. 89 RETRACTION AND UPRIGHTING OF CUSPIDS WITH SECTIONAL ARCH MECHANICS Canine is located in the corner of the arch so need to be kept in the narrow trough of trabecular bone, which is difficult with continuous wire . Severe tipping of canine allows the root tip to move forward will complicate its retraction.

90. 90 RETRACTION AND CONSOLIDATION OF UPPER AND LOWER INCISORS: Lower Incisor Very light continuous force of 150gm need to be applied so that cortical bone can be remodelled . Heavy force- produce tipping & extrusion of incisors. Contraction utility arch –incisor retraction with light force-limited extrusion Upper Incisor Remove the Nance lingual arch to allow the alveolar process to remodel. Torque has to be maintained, upper incisors are torqued till the long axis parallel to facial axis.

91. 91 CONTINUOUS ARCHES FOR DETAILS OF IDEAL AND FINISHING OCCLUSION: Continuous and multistranded wires. Finishing arches are placed in final 2 weeks of active treatment . The bands have been removed from buccal occlusion in order that band space closure can allow finer details in occlusion

92. Finishing procedures and Retention The finishing & retention procedures of the BPT are considered, from the beginning stages of treatment as a part of total scheme of treatment. The Cephalometric setup of the VTO becomes an important tool of visualizing final finishing procedures. BPT proposes a concept of overtreatment in order to compensate for the original malocclusion & the abnormal function that was originally present.

93. 93 Occlusal checklist in finishing An occlusal check list including 8 areas in each arch is used in establishing ideal finishing arch configuration . The patient at this stage is seen at 2 week appointments . During the final 2week adjustment the c uspid & PM bands may be removed to allow closing of the band space. Only the lower arch is activated & light class 2 elastics maintained the overtreatment.

94. 94 Occlusal checklist in mandibular arch Arch width across 2nd molars. Distal of l molar rotated lingually until the disto -buccal cusp approximates mesial on 2 nd molar. Large buccal offset at mesial of l molar. Check inter-bicuspid width for necessary expansion. Proper buccal arch form & contour. PM offset to bring it in contact with distal lingual incline of upper canine . Mesial of canine tucked slightly behind lateral incisors, distal of the cuspid buccal . Over rotation of incisors “smooth arc”

95. 95 Occlusal check list in maxillary arch Width across 1 & 2 nd molars. Distal rotation of 1 molar so that line drawn through disto -buccal & mesio -lingual cusps points to the distal 3 rd of the opposite side cuspid . Mesial offset on molar. Mesial rotation of lingual cusp of l pm to seat in distal fossa of lower l pm. PM offset 2-3mm to avoid lst area of prematurity. Cuspids brought into contact with lower cuspid & pm to establish cuspid raise. Lateral is left labial to allow overtreatment of buccal segment then tucked in. Smooth arc across incisors

96. Conclusion The basic principles of the Bioprogressive Therapy were listed as statements of purpose and objectives of the various treatment procedures that were being prescribed. Bio progressive 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.

97. 97 THANK YOU

98. REFERENCES Bioprogressive therapy as an answer to orthodontic needs Part I Ricketts, Robert Murray American Journal of Orthodontics, Volume 70, Issue 3, 241 - 268 Bioprogressive therapy as an answer to orthodontic needs Part II Ricketts, Robert Murray , American Journal of Orthodontics, Volume 70, Issue 4, 359 - 397 The wisdom of the bioprogressive philosophy Ricketts, Robert M. Seminars in Orthodontics, Volume 4, Issue 4, 201 - 209 98