Bioprogressive theraphy

Bioprogressive philosophy treatment

1. BIOPROGRESSIVE THERAPHY N.MOTHI KRISHNA I MDS DEPARTMENT OF ORTHODONTICS

2. CONTENTS INTRODUCTION MANAGEMENT UMBRELLA PRINCIPLES V.T.O ORTHOPAEDICS IN BIOPROGRESSIVE THERAPHY FORCES USED IN BIOPROGRESSIVE THERAPHY UTILITY AND SECTIONAL ARCHES BIOPROGRESSIVE IN MIXED DENTITION TREATMENT MECHANICAL SEQUENCE FOR MIXED DENTITION MECHANICAL SEQUENCE FOR CLASS II DIV I & DIV II FINISHING AND RETENTION

3. INTRODUCTION Bioprogressive theraphy developed from Edgewise technique also contain some elements of light wire technique. -Primary -Secondary -Teritary Other research talks on advantage of light forces in contrast to heavy forces(1950).

4. 1950 - Robert Murray Ricketts. All these stages of the edgewise technique development have served as the basis for the development of bioprogrssive method. Ricketts proposes the bioprogressive technique as an answer to the needs of orthodontic theraphy

5. Why the name bioprogressive theraphy ? BPT was so named because it progressively includes particular groups of teeth into the theraphy . First the molars and the incisors followed by canines and premolars. Therapeutic interventions applied in planned sequence .

6. Bioprogressive Philosophy Philosophy Face should be treated as a whole rather than focussing once attention on just teeth and occlusion. WISDOM SOCIAL CLINICAL BIOLOGICAL MECHANICAL 100 verified or corroborated

7. Bioprogressive therapy is not strictly an orthodontic technique but more importantly it encompasses a total orthodontic philosophy. BPT accepts as its mission the treatment of the total face rather than narrower objective of the teeth or the occlusion. It’s a therapy which takes advantage of biological progressions including growth , development and function and directs them in a fashion that normalizes function and enhances aesthetic effects . Dr.Ricketts orthodontic philosophy and theraphy involves a broad concept of total treatment rather than a sequence of technical and mechanical steps.

8. Management umbrella Concept The initiation of this series with a discussion of management at the begining rather than at the end. Dr Ricketts states that management is a unique skill; it is the ability to get other people to work with you and for you, to accomplish common objectives. In an orthodontic practice, getting the subordinates to work with you and for you is to treat the patient to happy ending, and to manage the patient so that he gives full cooperation in his treatment.

9. As per Dr Ricketts management system for orthodontists should include the following three things; 1. Quality : This includes quality of treatment result. 2. Quantity : This includes the number of patients treated. 3. Effectiveness :This includes the effectiveness treatment design and office management.

10. According to Ricketts good management system should allow the increase of all these factors at the same time. Naturally, a system proceeds form some basic premises, which underlie the approach selected. The basic premises as per Dr Ricketts are as follows: 1. Primary goal in orthodontics is satisfactory outcome . Diagnosis and treatment management is really the means to the end. Results come first. The question is how to do we get our results. 2. The practice of orthodontics in the future may be different from what it is today or has been in the past.

11. 3. Orthodontics being the oldest specialty in dentistry should be the leader in initiating true preventive procedures for the future. 4. Early treatment has to be a part of futuristic orthodontic planning since it is essential to preventive procedures for the future. 5. The orthodontist should be an authority on occlusion, including temporomandibular joint function. 6. Quantity is not necessarily an enemy of quality, if quality comes first. 7. The orthodontists needs better communication with patient’s parents, dentists and the public. 8. Time is one of our most valuable asses. It is reason in itself to become involved in a total management process.

12. The system which Ricketts used is the Lewis A. Allen Management System, which is based on a simple formula to plan organize, lead and control. 1. Planning: The work performed predetermines a course of action to be followed. 2. Organizing: The work performed to arrange and relate the tasks to be accomplished. 3. Leading: The work performed to insure that people act in such a way as to complete our objectives. 4. Controlling: The work performed assesses and regulate results.

13. PRINCIPLES OF BIOPROGRESSIVE THERAPHY

14. PRINCIPLES OF BIOPROGRESSIVE THERAPHY 1. The use of systems approach to diagnosis and treatment by the application of the visual treatment objective in planning treatment , evaluating anchorage monitoring results : A planned systematic approach is followed in constructing a cephalometric setup in order to anticipate those changes expected in an individual patient. For this, an understanding of the present condition, the expected growth and the specific effect of the orthodontic-orthopaedic is essential.

15. 2.Torque control through out treatment Bioprogressive therapy suggests that movement of teeth can be more efficient and various treatment procedures more effectively carried out when control of the direction of root movements is available. Four treatment situations where torque control of root movement is necessary: 1. Keep roots in vascular trabecular bone – for efficient movement. During tooth movements such as incisor intrusion or cuspid retraction, torque control allows steering the roots away from the denser, thicker cortical bone, and through the less dense vascular trabecular bone. The lower incisors are supported by the lingual cortical bone and require buccal root torque for their efficient intrusion through the trabecular bone.

16. 2. Place roots against dense cortical bone - for anchorage. 3. Torque to remodel cortical bone - certain tooth movements often require that the roots be moved into dense, less vascular cortical bone structure. Such movements include incisor retraction, upper incisor root torquing , impacted upper canine and forward movement of lower molars to close spaces created by missing or extracted teeth. 4. Torque used to position teeth in final occlusion details - for proper function and better stability.

17. 3.Muscular and Cortical bone Anchorage . Muscular anchorage Stabilizing the teeth against the horizontal movements and vertical (extrusive) forces produced by a cervical headgear to the upper molars, as well as the effect of Class II elastics on lower molars is countered by the posterior muscles of mastication, mainly the masseter and temporalis . Brachyfacial types, characterized by deep bites and low mandibular planes exhibit stronger musculature, and are better able to overcome the adverse orthodontic treatment forces that tend to open the bite and rotate the mandible, when compared to their dolicofacial conterparts .

18. Cortical bone anchorage The cortical bone is dense and laminated, with a very limited blood supply. Due to this, tooth movement through this bone is slower. Bioprogressive therapy advocates the application of excessive force against the cortical bone to press out the blood supply and further limit the tooth movement through this bone, thus increasing the anchorage potential.

19. Lower molar anchorage is enhanced by expanding the molar roots into the cortical bone on their buccal surface. Excessive buccal root torque and expansion is placed in the archwires for this. The upper molar is adjacent to the zygomatic ridge, the maxillary sinus and the cortical bone shelves of the alveolar process. The heavy forces of the orthopedic headgear expand the roots into the cortical bone. For this, the inner bow of the headgear is expanded 5-10mm before placement.

20. 5. Orthopedic alteration. Bioprogressive therapy subscribes to, anticipates and plans for orthopedic change as part of its treatment procedures. This changes the relationship of the basic supporting jaw structure, in contrast to localized tooth movement in the alveolar process. Use of headgears to alter the position of maxilla and lateral forces for separating and widening the mid-palatal suture are examples of the orthopedic alterations achieved.

21. 6 . Treat the overbite before the overjet . Incisor overbite can be corrected by two methods: Extrusion of posterior teeth – increases lower facial height by mandibular rotation. Intrusion of upper or lower incisor teeth – little or no rotation. Vertical facial patterns respond best to extrusion of posterior teeth for overbite correction. However, this further increases the already excessive lower anterior face height, thus compounding lip strain.

22. On the other hand, the short anterior vertical facial height type with low mandibular plane would benefit best from molar extrusion, but their strong musculature resists this type of movement. Due to these considerations, incisor intrusion is considered the treatment of choice for overbite correction. By treating the incisor overbite before the overjet , incisor interference is avoided and the posterior teeth remain in their normal stable vertical occlusion established by the musculature. Incisor intrusion is achieved using a spanning arch called a utility arch.

23. 7. Sectional arch treatment. This is a basic treatment procedure of Bioprogressive 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. Benefits of the sectional arch treatment: It allows lighter continuous forces to be directed to the individual teeth. More effective root control in the basic tooth movements. It supplements maxillary orthopedic alteration. It r educes the binding and friction of the brackets as they slide along the archwire .

24. 8 . Concept of overtreatment . In order to help overcome the tendency for relapse, provisions for the post-treatment rebound as well as post-treatment growth changes need to be appreciated and planned fo r anticipated post-treatment adjustments: To overcome muscular forces against the tooth surfaces – the muscular influences of the tongue, lips and cheeks against the surfaces of the teeth require overtreatment to compensate for the post-treatment changes, resulting due to the continued influence of these muscles as they adapt to the new occlusion. Root movements needed for stability – overtreatment may be necessary in cases involving correction of incisor deep overbite by intrusion and torquing , paralleling of roots of teeth adjacent to extraction sites and de-rotation of severely rotated teeth.

25. 3. To overcome orthopedic rebound – overtreatment is done in anticipation of the rebound of the orthopedic changes, when the heavy restrictive forces involved in these movements are lessened or eliminated. 4. To allow settling in retention – overtreatment of the individual teeth within the arches allows them to “settle” into a functioning occlusion.

26. 9 . Unlocking the malocclusion in a progressive sequence of treatment in order to establish or restore more normal function. Bioprogressive therapy suggests that many malocclusions are a result of abnormal function. The present malocclusion, while stable under the present abnormal function, may never have had the opportunity for normal development. Bioprogressive therapy proposes treatment sequences that progressively unlock the malocclusion in order to restore or establish a more normal environment that will allow a more normal function to occur.

27. 10 . Efficiency in treatment with quality results utilizing a concept of pre-fabrication of appliances. Bioprogressive therapy uses appliances ready-made for clinical application. This allows the clinician to direct his energy in the details of their application, rather than their construction.

28. Diagnosis and Treatment Planning

29. Visual treatment objective VTO is a cephalometric tracing representing the changes that are expected (desired) during the treatment . It includes expected growth, any growth changes induced by the treatment, and any repositioning of the teeth from orthodontic tooth movement.

30. Is like a blueprint used in building a house. Visual plan to forecast normal and to anticipate influence of treatment. In establishing individual objectives. Helps in developing a alternate treatment plan. Helps to evaluate treatment progress. Valuable tool for the orthodontist’s self improvement.

31. STEPS: Ba -Na plane Construction of the new mandible position ( mandibular rotation) Construction of the new maxillary position Position of the dentition. Final soft tissue profile.

32. The first superimposition (Basion-Nasion at CC Point) establishes Evaluation Area 1 Amount of growth of the chin. Any change in chin in an opening or closing direction that may result from our mechanics. The second superimposition area (Basion-Nasion at Nasion) establishes Evaluation Area 2 to show Any change in the maxilla (Point A). The Basion-Nasion-Point A Angle does not change in normal growth.

33. In Evaluation Area 3- lower incisors. In Evaluation Area 4- lower molars In Evaluation Area 5, the upper molars In Evaluation Area 6, we evaluate the upper incisors

34. Orthopedics in Bioprogressive Therapy

35. Orthopedics in Bioprogressive Therapy By definition, orthopedics implies any manipulation that alters the skeletal system and associated motor organs. In the growing child, orthopedic alteration would be any manipulation which would change the normal growth of the dentofacial complex in either direction or amount.

36. Orthopedic alteration is a major tenet of Bioprogressive therapy. Prior to the defined orthodontic movements to create the ideal occlusion, an acceptable symmetry between the upper and lower jaws is needed to allow the ultimate framework upon which an esthetic, functional and stable occlusion can be built. This is achieved through the use of cervical or combination headgear.

37. Generalized orthopedic response with cervical headgear When a vector of force is applied below the center of resistance of the maxilla (located near the apex of the pterygomaxillary fissure), a rotational orthopedic effect is seen in the maxilla. The maxillary complex rotates in a clockwise direction and all points on the maxilla appear to arc in a concentric fashion . This maxillary rotation results in: - reduction in maxillary protrusion - downward canting of the palatal plane. - the nasal bone pivots downward and backward at the frontonasal suture.

38. In normal and strong muscular growth patterns , i.e. brachyfacial patterns, mild mandibular rotation may occur, but the amount of maxillary response compensates for this mandibular rotation by 3 to 4 times. In weak muscular growth patterns, the extrusive effects of cervical headgear result in a negative response in the mandible (i.e. orthopedic in nature). In strong muscular growth patterns, the extrusive forces of cervical headgear are seen as responses in the dentition (i.e. orthodontic in nature).

39. Generalized orthodontic response with cervical headgear. The downward and backward force of the cervical headgear intermittently extrudes the upper molars and carries them distally. The upper incisors tip lingually from the apex. This occurs when the overjet has been reduced enough for the lower lip to close over the upper incisors, causing a functional retraction of these teeth. The lower molars upright and move distally, as they are carried by the incline planes of the upper molars. The lower incisors tip labially as they are free of the restrictive effect of the lower lip. The tongue starts to dominate the labial positioning of these teeth.

40. The Reverse Response When a cervical headgear is combined with a lower utility arch, the maxilla shows the classical orthopedic response. However, the mandible shows a response different from the usual The mandibular plane and facial axis are stabilized in normal and dolicofacial types. In brachyfacial types, the mandible rotates in a counterclockwise direction, resulting in closure of lower face height, mandibular plane and facial axis.

41. When the upper molar is extruded and distalized intermittently, its inclined planes upright and distalize the lower molar. This is accentuated by the tipback in the utility arch and the labial root torque at the lower incisor. The vertical pull of the masseter and pterygoid muscles stabilizes lower molar eruption and limits upper molar eruption. The net result is a limited eruption/intrusion of the lower molar and a distal movement of the lower incisor, with concomitant changes in the occlusal plane.

42. Soft tissue esthetic changes. With normal growth, the soft tissue nose grows concentrically approx. 1mm. per year at the tip. Following headgear therapy, the nose crosses over at the bridge, lengthens vertically and the upward cant to the nares is tipped down to a more horizontal position.

43. Forces used in Bioprogressive Therapy

44. Loop design for force control Bioprogressive therapy suggests that an applied force of 100gms. per square centimeter of enface or exposed root surface area is optimum for tooth movement. When an archwire is ligated across short spans, very high forces can result that are much above the optimum levels.In order to lessen the applied force, the concept of long lever arm is applied. By placing more wire between the teeth the applied force is lowered and the length of time of activation is increased. For this purpose, Bioprogressive mechanics incorporate more wire in its loop design, thus producing lighter forces that are more continuous in their action.

45. Simple loop designs incorporate more wire between teeth and reduce the amount of force applied.

46. Compound loop designs use combination of simple loops and add additional wire to further reduce the amount of force, while making it more continuous. Also, these loops can be compressed during activation.

47. Concept of cortical bone anchorage The concept of cortical bone anchorage implies that, to anchor a tooth, its roots are placed near the dense cortical bone under a heavy force that will further squeeze out the already limited blood supply and restrict the physiologic bone remodeling in this area. On the other hand, in order to move a tooth, a route should be followed through the less dense trabecular bone where under a light force a generous blood supply can be maintained that will produce the physiologic osteoclastic reaction of bone resorption needed for movement.

48. Teeth in the mandible. The mandible has cortical bone support running along its length. The cortical bone structure forms around its tubular shape and extends to the alveolar, coronoid and condylar processes. Lower incisors – Cuspids – First Bicuspids. These teeth are supported on the lingual by the cortical bone of the planum alveolar.

49. During lower incisor intrusion, their roots should be moved buccally, away from the lingual cortical plate. For this, a utility arch, applying a buccal root torque of 15 ° - 20° is used. This applies a force of 80 grams on the incisors (round leveling wires apply 300 grams of force and tip the incisor roots into the cortical bone). During lower incisor retraction, the incisor roots should be moved through the cortical bone using even lighter, more continuous forces. This al l ows for remodeling of the bone. During lower cuspid retraction also, the roots must be moved through the trough of trabecular bone.

50. Lower 2 nd Bicuspids and Molars : These teeth are supported by the cortical bone on their buccal surface. Lower molars are anchored by expanding and torquing their roots buccally into the buccal cortical bon e.

51. Teeth in the maxilla. The nasal, orbital, oral and sinus cavities of the maxilla are lined with cortical bone that gives them support. The roots of the maxillary teeth lie adjacent to these cavities and are influenced by the cortical bone lining them. The maxillary teeth are supported within the alveolar process with cortical bone on the palatal surface as well as along the facial surfaces. The maxilla supports four cavities – orbital, nasal, oral and sinus cavities. The cortical bone support in the maxilla surrounds these cavities as well as the alveolar process containing the teeth. g the facial surface.

52. Maxillary Incisors. - These are intruded along their long axis into the broadest area of the alveolar process. - Utility arch mechanics for intrusion first advances the crowns and locates the root tip a way from the interference of the labial cortical bone. Maxillary Cuspids . - These should be moved around the corner during their alignment and retraction, and their movement should be contained within the trough of trabecular bone. - Excessive tipping can expose the root tip through the buccal cortical bone, thus making uprighting and torquing alignment extremely difficult.

53. Maxillary Bicuspids and Molars. - The bicuspids are supported in the alveolar process between the buccal and lingual cortical plates. - The roots of the 2 nd bicuspids and molars are often involved with the cortical bone lining the floor of the maxillary sinus. Thus, intrusion of these teeth should be done using light and continuous forces. - The roots of the maxillary molars are anchored by expanding and rotating them into the buccal cortical bone. - Headgear therapy that applies heavy forces ( >500gms), expands the molars into the cortical bone where they become “anchored”.

54. Muscular Anchorage. In cases where the musculature is strong as characterized by deep bite, low mandibular plane, brachyfacial type, the teeth demonstrate a “natural anchorage”. In the open bite, vertical dolicofacial patterns, the musculature is weaker and less able to overcome the molar-extruding and bite-opening effect of treatment mechanics. Thus, anchorage enhancement is required in these cases.

55. To summarize, for efficient tooth movement, Bioprogressive therapy suggests consideration of the following: Size of root surface involved. Amount of force applied. Cortical bone support. Muscular support – reflected by the facial type.

56. The Utility and Sectional Arches in Bioprogressive therapy mechanics

57. Historical perspective Contemporary edgewise orthodontic approaches assume that the most efficient method of effecting rotations and leveling the deep curve of Spee in the initial phase of treatment is through the use of a series of light, continuous round arches. However, the use of these arches results in some detrimental responses, to counteract which several distinct moves have been developed.

58. Dental reactions to continuous round wire with reverse curve of Spee . Dental reactions to continuous round wire with reverse curve of Spee and tieback. Dental reactions to continuous round wire with Class III elastics and hi-pull facebow .

59. Late in the 1950’s, Robert Ricketts and others attempted to counteract the tipping that occurred in the buccal segments in extraction cases by utilizing the lower incisors as an anchor unit to hold the lower second premolars and molars upright in the retraction process. Round arch segments were laced from the lower molars and premolars to the lower incisors as the canines were retracted. They noted that not only were the buccal segments maintained in an upright position, but the lower incisors intruded with this light, continuous pressure. This led to the development of what is now classically described as the step-down base arch, or Ricketts’ Lower Utility Arch.

60. Roles and Functions of the lower utility arch. 1. Position of the lower molar to allow for cortical bone anchorage. Following uprighting of the lower first molars, the mesial root of the lower molar should be palpable in its ideal axial inclination following utility arch therapy. 2. Manipulation and alignment of the lower incisors segment. When treated as a segment, the four lower ini cis ors are manipulated from the lower molar to align and either hold, intrude or extrude these teeth in the initial phases of therapy. Also, by altering the design of the lower utility arch, the lower incisors can be advanced or retracted without disturbing or depending upon the canines and premolars.

61. 3. Stabilization of the lower arch, allowing segmental treatment of the buccal segments. Following early maint e nance of anchorage at the molars and proper positioning of the lower incisors, separate rotations and leveling can occur in the buccal segment teeth – especially the canines – without disturbing the idealized location of the other segments. 4. Physiological roles of the lower utility arch. Intrusion of the lower incisor segment results tin disclusion in the anterior segment. This leads to: Prevention of interferences that commonly retard the easy movement of the dentition. Loss of proprioception in the incisor region. The mandible reacts to this by reaching forward to search out proprioceptive output. This “activator” or “reaching” effect allows a muscular response that can be benefial in correction of Class II malocclusion. Creates space for the maxilla which is moving downward and backward, under the influence of headgear therapy. This helps to close the overjet .

62. 5. Overtreatment . By treating the incisors and buccal segments as separate entities, it is possible to treat the overbite (by intrusion of upper and lower incisors) at the same time that the buccal segment teeth are being corrected. Thus, it is not necessary to tie the overbite control to the overjet control.

63. 6. Role in mixed dentition. The utility arch allows incisor alignment and molar control during the transient dentition by stepping around the deciduous buccal occlusion. Thus, arches can be leveled out without depending upon extrusion of the buccal segment teeth. 7. Arch length control. The lower utility arch serves as a determinant of arch length maintained, gained or lost by: Uprighting the lower molar. Advancement of the lower incisors. Expansion in the buccal se g ment teeth. Saving “E” space.

64. Physiological vs. Mechanical Responses I.) 30 ° to 45 ° tip-back applied to the lower molars . A tip-back applied to the lower molars uprights these teeth by bringing their roots mesially and the crown distally. In extraction cases where there is both a mesial and uprighting component of force a distal rotation must be placed to avoid mesial rotation of the molars . However in non-extraction , cases a distal rotation applied to the lower molar causes an over-rotation of these teeth .

65. II .) 30° to 45° buccal root torque applied to the lower molar. Both for enhancing the cortical bone support to the lower molar and for regulating normal arch width, the distal legs of the utility arch can be expanded prior to placement in the mouth. III.) Long lever arm applied to the lower incisors. If there is 0° torque at the lower incisors when a long lever arm works at the lower molars, then as the arch intrudes, there is a slow progressive change to place a lingual root torque.

66. IV.) 75 grams of intrusive force applied to the lower incisors. The mandibular utility arch is best fabricated from 0.016x0.016 Blue Elgiloy wire in order to create a lever system that will deliver a continuous force to the lower incisors in the range of 50 to 75 grams.

67. Treatment in the Mixed D entition Phase

68. Bioprogressive Mixed Dentition Treatment Four basic objectives- Resolve functional problems. Resolve arch length discrepancy. Correct vertical problems. Correct overjet problems.

69. 1. Resolve functional problems Anything that disturbs the growth, health and function of the TMJ complex. In 1950’s Ricketts –used body section x rays (laminagrphy ) Lack of rough surface , excessive thickening

70. Submento -vertex analysis - Individual condylar inclinations and width Nine general categories- Cross mouth interferences. Anterior crossbite . Open bite. Excessive range of function. Distal displacement. Loss of posterior support - superior displacement Habits. Breathing and airway problems. True Class III Growth pattern.

71. 2. Resolve Arch Length Discrepancy This is accomplished by three ways- Lateral expansion of the molars. - Depends on the inclination of the posterior teeth. Expansion primarily by change in axial inclination : - Rickett’s quad helix - .040 blue elgiloy wire.

72. With 1cm expansion in the upper molars –anterior segment are expanded 3cm overall . Long term functional expansion for atleast a year or more for stable and demonstrable changes to occur in the lower arch. Arch length gained is result slow natural expansive response created by muscles Expansion by mid palatal dysfunction: Hass type or modified Nance type expansion appliance. 2. Advancement or forward movement of the lower incisors: If the VTO and physiologic factors warrant. Expansion utility arch. 1mm forward movement of LI yields 2mm of arch length.

73. 3. Correct Vertical/Overjet Problems This is done after functional and arch length corrections are achieved. Includes different approaches are used for the first phase of non extraction treatment. Orthopedic problems- In cases where good alignment of lower arch exists and Class II is on account of Max.protrusion . Orthopedic problems with lower arch therapy- - with maxillary protrusion but incisors and molars in deep bite or need advancement.

74. Orthopedic problems with minor incisor interferences. - Upper utility arch with headgear. Orthodontic problems alone. - Upper utility arch with Class II elastics.

75. Mechanics Sequence for Extraction Treatment

76. Extraction Mechanics Four general procedures : 1 . Stabilization of upper and lower molar anchorage. 2 . Retraction and uprighting of cuspids with sectional arch mechanics. 3 . Retraction and consolidation of upper and lower incisors. 4 . Continuous arches for details of ideal and finishing occlusion.

77. 1. Stabilization of upper and lower molar anchorage : Maximum upper molar anchorage. Nance arch with modifications. Headgear .

78. b) Moderate upper molar anchorage: Palatal bar. Quad helix. Upper utility arch. c) Minimum upper molar anchorage: Vertical closing loop. Double delta loop.

79. Maximum lower molar anchorage: Lower utility arch-four mechanical adjustments Moderate lower molar anchorage: Lower utility with adjustments. Minimum lower molar anchorage: Eliminate the four mechanical factors. Round wires may be used.

80. 2. Retraction and uprighting of cuspids with sectional arch mechanics. Cuspids need to be kept in the narrow trough of trabecular bone and avoid the severe tipping or displacement The activation of the cuspid retraction springs should produce 100 to 150 grams of force

81. 3. Retraction and consolidation of upper and lower incisors. Lower incisors: Very light continuous forces (150 grams) Contraction utility Double delta retraction loops Upper Incisors : Regular contraction utility. Upside down vertical closing loop. Double delta loop.

82. Mechanics Sequence for Class II Div I Sequence: Lower Incisor intrusion. Lower Cuspid intrusion. Alignment of the lower buccal segment. Alignment of the upper buccal segment. Segmental correction of Class II with elastics. Upper incisor alignment and intrusion.

83. Upper arch –orthopedic reduction of the maxilla. Lower arch-treatment starts with levelling the spee .-utility arch

84. Lower stabilizing utility arch-after initial purpose of the utility arch is accomplished –it no longer serves as an efficient function 16 x 22 stabilizing arch is placed Alignment of the lower buccal segment starts: .015 or .0175 Twistoflex .012,.014 of 018 wires 16x 16 triple T section .016 or.018 nitinol

85. Upper arch alignment: Incisors are not included. Upper molars starts Distalizing-opening spaces in the buccal segment. a) Consolidation section b) Stabilizing section

86. Segmental correction with Class II elastics: Three detrimental effects: Skidding effect. Tendency for a deep bite. Difficult to overcorrect buccal segment. Tractions Sections- Gable bend distal to canine. Rotation bend in the anterior portion. Molar bayonet bend Functions – Counteract downward backward pull Stabilizing function in the upper buccal segment.

87. Upper incisors alignment and Intrusion Upper incisors are aligned before placement with light round wires. 16 X 22 utility arch is placed . Consolidation of Upper Incisors Retraction of the upper incisors . Over treatment -2mm Closing utility/upside down closing arch/vertical helical arch.

88. Idealization of arches and finishing. 16 or 17 square,16 x 22 or 17 x 25 nitinol . Class II elastics to be discontinued atleast 2 months. Light round wires finishing

89. Mechanics Sequence for Class II Div II

90. Three treatment possibilities: 1. Distalizing the upper arch. 2. Advancing the lower arch. 3. A reciprocal movement.

91. 1. Advancement, torque control, and intrusion of the upper incisors. 2. Intrusion of the lower incisors and cuspids. 3. Alignment of the buccal segments and Class II correction. 4. Consolidation of the upper incisors. 5. Idealizing the arches. 6. Finishing.

92. Advancement, torque control, and intrusion of the upper incisors . X Principle of bite before jet Jet is created followed by intrusion. 16x22 utility arch Amount of pressure: 125-160 gms 16 x 22 Stabilization of the molars: Quad helix TPA Stab. sections

93. 2. Intrusion of lower incisors: 16 x 16 utility arch. 65-75 gms. This is followed by cuspid intrusion. Advancement of the lower denture: 1. Utility arch with 4 helical loops 2. Using three vertical loops

94. Alignment of the buccal segment: a) Stabilizing section would function in levelling. b)consolidation section help close spaces developed c)traction section for distalizing buccal section If buccal segment are not aligned “T” sections Twistoflex wire Cable wire 4. Consolidation of the maxillary incisors: there is a need for additional torque in the upper incisor and slight consolidation.

95. Idealization and arches and finishing

96. Finishing and Retention “Begin with the end in mind”. Every orthodontist has a visual picture in his mind of the ideal occlusion into which the teeth should fit and mesh in the final finished occlusion. Bioprogressive proposes the concept overtreatment…. No clinician can position teeth as delicately as the functioning incline plane and cusp action can accomplish naturally when it is adequately set up to operate correctly. Allow natural function to guide the teeth into the best functioning occlusion for each individual OCCLUSION

97. Two phases of retention: Guiding changes during initial adjustments. Supporting bony sutural and muscular accommodations to changing environment and considering long range influences.

98. Initial stage of retention : First six weeks following appliance removal Retainers inserted-designed not to hold but to guide the teeth in settling.

99. Labial frame of typical upper retainer (Ricketts) passes between the lateral and cuspid and has a distal loop at each end to tuck in the distal of the expanded overtreated upper cuspid Lower arch: Fixed first bicuspid retainer is placed. -maintain cross arch bicuspid width. -lower cuspid freedom of adjustment against upper occlusion. -maintain lower incisor alignment and rotation correction.

100. Stabilizing stage of retention: First year following active treatment. Lower retainer is kept in place and upper is worn most of the time.

101. DEVELOPMENT Standard Bioprogressive Appliance Used since 1962. “Second-order” movement was built in by angulating the bracket. All four canines, lower molar tubes and brackets angulated at 5°. Maxillary lateral incisor brackets were angulated at 8°. Brackets for all other teeth were given no angulation (0°). Lingual root torque was built into the brackets of upper central incisors (22°), upper laterals (14°) and all canines (7°).

102. Full Torque Bioprogressive Appliance In this, additional torque was added to the Standard Bioprogressive appliance, by placing torque in the lower second premolars (14°) and the lower first and second molars (22°). A 12° rotation was added to the tube and brackets on the lower first molar.

103. Zero Base Bioprogressive Developed by Gugino, the Zero Base logic system adds an organizational capability to the Bioprogressive philosophy. The term zero base originated from the bell-shaped statistical curve of distribution of a sample of normal data. The peak of the bell-shaped curve represents the neutral position or zero base. Those patients with less deviant, or mesofacial morphology represent the middle two-thirds of the population. The further a given patient deviates from the zero base of facial type, the more difficult the treatment is likely to become.

104. Triple – Control Bioprogressive The Triple-Control Bioprogressive appliance now combines the offset first-order bends with the second-order tip, and the third-order torque, to present the complete “triple-control” needed to place the teeth in all three planes of space to accomplish the necessary movements to reach the objective of the overtreated orthodontic occlusion.

105. CONCLUSION The Bioprogressive philosophy, embracing early treatment, was developed for greater efficiency in orthodontic treatment. The ultimate objectives of this philosophy are to work in harmony with growth, to achieve permenent orthopedic changes, and to set the stage for lifelong enjoyment, in every sense of one of nature’s miracles – the natural dentition.

106. REFERENCE Textbook of bioprogressive theraphy by ricketts. Bioprogressive Therapy and Diagnostics Acta Stomat Croat 461-464;2003. Virtual setup: application in orthodontic practice J Orofac Orthop Bioprogressive therapy as an answer to orthodontic needs -Part I Bioprogressive therapy as an answer to orthodontic needs -Part II