102533323 Bioprogressive Therapy

8/20/2019 102533323 Bioprogressive Therapy

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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


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INTRODUCTION

Bioprogressive Therapy was originated by Drs. Robert Ricketts and Ruel Bench who combin

contemporary edgewise mechanics with solid diagnostic principles and an innovative approach

sectional mechanics.

Bio-Progressive Therapy is not strictly an orthodontic technique but, more importantly, it encompass

a total orthodontic philosophy. It accepts as its mission the treatment of the total face rather than t

narrower objective of the teeth or the occlusion. Although the teeth and the occlusion are of critic

importance in achieving the broader goal of treating and improving the face, orthodontic therapi

must be designed to be applied appropriately to specific facial types, muscular patterns, and function

needs of individuals. A primary concern, therefore, is the musculature of the chin and lips and th

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 profi

suggests the orthopedic alteration that will be required to achieve the desired result. The progressi

unfolding of these arches, in conjunction with the purposeful alterations resulting from orthodont

therapy, combine to produce the desired outcomes as they relate to aesthetic effect and occlusal an

respiratory function. Basic to an understanding of these potential changes is the dynamics of grow

and function under normal relationships with an appreciation for a range of variation from the norm

as applied to the individual with his specific needs and potential.

Dr. Ricketts' orthodontic philosophy and therapy involves a broad concept of total treatment, rath

than a sequence of technical and mechanical steps. Referred to as Bio-Progressive Therapy, it tak

advantage of biological progressions including growth, development, and function, and directs them

a fashion that normalizes function and enhances aesthetic effect.


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MANAGEMENT UMBRELLA CONCEPT

The management of the total practice ultimately determines the degree of efficiency and effectivenewith which the orthodontist solves individual patient problems.

The management umbrella comprises of the following1. Planning2. Organizing

3. Leading4. 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/ VTOC) Programming – Determining the actions necessary to achieve desired results (Sequence

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 malocclusion3. Describe the face

4. Describe the functional requirements

Nasopharyngeal airway Musculature

Habits

Soft Tissue

5. Lower VTO and Arch form


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PRINCIPLES OF BIOPROGRESSIVE THERAPY

Ten principles have been developed in an attempt to communicate an understanding of the mechanic procedures that Bio-Progressive Therapy may use in developing a treatment plan, including applian

selection and application, specific to each individual patient.

TEN PRINCIPLES OF BIO-PROGRESSIVE THERAPY1. The use of a systems approach to diagnosis and treatment by the application of the visual treatme

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 restomore 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 applicatio

of the visual treatment objective in planning treatment, evaluating anchorage, an

monitoring results.It is a cephalometric setup similar to a plaster setup in order to anticipate those changes expected in t

individual patient.

This treatment forecast was developed by Ricketts and called a Visual Treatment Objective bHoldaway

It helps in assessing those changes that are going to be helpful in the correction of the problem anrespect those growth factors that will make the problem worse or severely complicate treatment.During the average two-year treatment experience, treatment changes will account for 70-80% of th

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 thchange will have upon the other areas.

#2. Torque control throughout treatment. Bioprogressive Therapy mentions four treatment situations where torque control of the root moveme

is necessary:

1. Keep roots in vascular trabecular bone —

for efficient movement.For beginning movements, such as incisor intrusion or cuspid retraction — where movement throughless dense trabecular bone structure is desired because it is more efficient — torque control allows us

steer the roots away from the denser, thicker cortical bone, and through the less dense channels of th

vascular trabecular bone.

The lower incisors are supported by the lingual cortical bone and require buccal root torque for theefficient intrusion through the more vascular trabecular bone.


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2. Place roots against dense cortical bone — for anchorage.

Torque control of teeth being anchored or stabilized against movement is done by placing their roo

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 vascul

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 excessitipping 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 treatmewhere the final details of occlusion are being established, where fit and mesh of the teeth requi

proper root alignment for proper function and better stability.

#3. Muscular and cortical bone anchorageMuscular AnchorageStabilizing the teeth against the horizontal movements and also against vertical or extruding forc

produced by a cervical headgear to the upper molars is countered by the posterior muscles mastication, primarily the masseters and temporalis. Treatment procedures in individuals with weak

muscular support should be monitored and modified to compensate for weaker anchorage support.

Cortical Bone Anchorage

Tooth movement can be further delayed where excess forces against the cortical bone can press out t blood supply and limit the physiology and the tooth movement.

Bio-Progressive Therapy applies this principle of cortical bone anchorage in stabilizing the teeth 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 the

buccal surface.

Excessive buccal root torque and expansion is placed in the arch wires to locate the roots into thcortical bone.

The upper molar that is adjacent to the zygomatic ridge, the maxillary sinus, and the cortical bon

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 pressureBioprogressive Therapy maintains that forces that are lighter allow for the blood supply to sustain ce

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 efficieforce for tooth movement is based upon the size of the root surface of the tooth to be moved, which

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 enfaroot surface.

Density of the supportive bone is also an influencing factor in the rate of tooth movement.


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Arch wires and loop systems that will deliver lighter and more continuous forces are the most effecti

in eliciting the biological response that we desire. The smaller .016 ´ .016 chrome alloy arch wire

with designs that allow more wire either through spanning arches, sectional arches, or multipleloopearches, have been found to apply the lighter continuous force required

#5. Orthopedic alteration

Orthopedic alteration changes the relationship of the basic supporting jaw structure, as contrasted tooth movement in the more localized area of the alveolar process.

Orthopedic change or alteration of the supporting structure usually is associated with treatment of th

younger childOrthopedic alteration brings about changes in the maxilla and compensatory changes in the mandib

and TMJ. Expected mandibular rotation and facial type usually dictate the kind of headge

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,

establish the proper interincisal relationship of overbite to overjet and interincisal angles. When th

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 appearanc

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 incisoverbites are those that would best benefit from mandibular rotation, but their strong musculatu

function resists the molar extrusion that allows this type of opening. Often

Another complication of overbite interference during treatment is the distal displacement of t

condyle in the fossa resulting in temperomandibular joint dysfunction and incisor instability due traumatic interference of the incisor deep bite occlusion.

Bio-Progressive Therapy mechanics finds that incisor intrusion is the treatment of choice for the be

results not only during treatment, but also for stability of results and optimizing functionWhen the incisor overbite is not corrected before incisor retraction, the incisors come into interferen

resulting in a proprioceptive input that affects the patient's ability to close the posterior teeth. Wh

this neuromuscular interference limits the patient's ability to occlude the posterior teeth, the molars aallowed to extrude and vertical opening occurs. When we have incisor interference, headgear w

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 w

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 th

arches are broken into sections or segments in order that the application of force in direction anamount 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 efficiemovement).


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As the arches are segmented and the buccal occlusion is sectioned from the incisors, very lig

continuous forces can be directed to the incisors through the long lever arm created by the utility arc

which spans from the molars to the incisors, bypassing the bicuspids and cuspids.Segmented arches allow the molars to be stabilized and supported by the bicuspids and cuspids again

the torquing movement directed to the molars by the intrusion action of the long-levered utili

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 cortic

bone which aids in their intrusion and the cuspids can then be intruded separately along a route of learesistance and still maintain molar torque and rotational control for anchorage support.

3. It supplements maxillary orthopedic alteration.Full arch wires through the incisors tie the maxillary segments together and limit the adjustment an

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 an

allows for its efficient retraction..

Sectional arch treatment allows the erupting buccal occlusion to erupt more freely into the functions

the face by reducing those limiting factors that restrict the normal development. It also maintains arclength.

#8 Concept of overtreatment.It is necessary for the clinician to anticipate changes that will follow when all appliances are remove

and the post treatment adjustments begin to occur.

Bio-Progressive Therapy suggests four areas where the concept of overtreatment may help compensafor 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 th

relapse that might occur under the influence of the buccal musculature.

Over expansion also encourages the tongue to elevate and function in support of the dental arches.

b) Overclosure of an anterior open bite is appropriate to compensated for the rebound effect abnormal tongue function and the increase in lower anterior face height as seen in excessive vertic

facial types.

c) Overtreatment of the incisor overjet and interincisal angle is critical in lip sucking habits, whe

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. Parallelinof 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 pos

treatment 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.


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In Class II treatment the rebound effect which closes the bite and rotates the chin forward will help

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 functionin

occlusion.In Bioprogressive Therapy, retainers then are considered active appliances and are adjusted to allo

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"super Class I" through distal rotation of the upper first molar behind an uprighted distally rotat

lower molar.

#9 Unlocking the malocclusion in a progressive sequence of treatment in order

establish or restore more normal function.Bio-Progressive Therapy maintains that many malocclusions have resulted because of abnorm

function, and that the present malocclusion, while stable under its present abnormal function, m

never have had the opportunity for normal development.Bio-Progressive Therapy proposes treatment sequences that progressively unlock the malocclusion

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 terms of what function

influences have been responsible for their present alignment.2. To describe the facial type and skeletal structure from the cephalometric x-rays, and the impliedescription of function.

3. To describe the present abnormal functional influences upon the dental arches; if not abnormal, the

lack of normal development by default.

The following process of evaluation is used in setting up a treatment plan and prescribing the vario

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

support it.

1. Upper Arch Expansion.2. Incisor Protrusion Correction.

3. Temperomandibular Joint Dysfunction. Further restriction of a collapsed upper arch can develo

into a functional crossbite where occlusal interference now blocks upper arch development an produces condylar shifts and changes in the temporomandibular joint function and development.


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#10 Efficiency in treatment with quality results utilizing a concept o

prefabrication of appliances.

In an attempt to relieve some of the burden imposed by the myriad of procedures that are required the construction and fabrication of orthodontic appliances, Bio-Progressive Therapy utilizes t

concept of prefabrication and has appliances ready-made for clinical application, so that the clinicia

directs his expertise to diagnosis and treatment planning.


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THE VISUAL TREATMENT OBJECTIVE

It is a visual plan to forecast the normal growth of the patient and the anticipated influences

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 predictionIV. The occlusal plane positionV. The location of the dentition

VI. The soft tissue of the face

I. VTO — Cranial Base PredictionPlace the tracing paper over the original tracing and starting at CC point, follow these steps 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 — RotationThe construction of the mandible and its new position start with the rotation of the mandible. T

mandible rotates open or closed from the effects of the mechanics used and the facial pattern presen

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

brachyfacial.

In constructing the VTO, these factors must be taken into consideration in deciding what can

expected to happen to the facial axis.

6. Superimpose at Basion along the Basion-Nasion plane. Rotate "up" at Nasion to open the bite an"down" at Nasion to close the bite using point DC as the fulcrum. This rotation depends on anticipate

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 Growt

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 X

point, locating a new XI point.


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10. With old and new XI points coinciding, trace corpus axis, extending it 2mm per year forward

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 drain 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 an

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 Mento

along the facial plane. Trace the palate (with the exception of point A).

VTO — Maxillary Growth Prediction — Point A Change Related to BA-NAThese 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 th

following steps:17. Point A can be altered distally with treatment. Place according to orthopedic problem an

treatment objectives. For each mm of distal movement, Point A will drop ½mm.

18. Construct new APo plane.

IV. VTO — Occlusal Plane Position19. Superimpose mark #2 on original Menton and facial plane, then parallel mandibular plan

rotating at Menton. Construct occlusal plane (may tip 3 degrees either way depending on Class II Class III treatment).

V. VTO — Dentition — Lower IncisorThe lower incisor is placed in relationship to the symphysis of the mandible, the occlusal plane and tAPO 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 th

lower incisor in the ideal position to the new occlusal plane, which is 1 mm above the occlusal plan

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 fin position as required by arch length. The angle is 22° at +1mm to the APo plane and + 1 mm

occlusal plane, but the angle increases 2° with each mm of forward compromise.

VTO — Dentition — Lower MolarWithout treatment, the lower molar will erupt directly upward to the new occlusal plane. Wi

treatment, 1mm of molar movement equals 2mm of arch length. We moved the lower incisor forwa

2mm in this case. There was also 4mm of leeway space. Therefore, the following calculation allows to move the lower molar forward 4mm on each side:

lower incisor


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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 Molar23. Trace the upper molar in good Class I position to the lower molar. Use the old molar as a templat

VTO — Dentition — Upper IncisorPlace upper incisor in good overbite-overjet position (2½mm overbite, 2½mm overjet) with

interincisal angle of 130° ± 10°. Open bite patterns at a greater angle, deep bite patterns at a less

angle.

24. Trace the upper incisor in its proper relationship, aligning over the original incisor or by use oftemplate.

VI. VTO — Soft Tissue — Nose25. 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. Trac

tip of nose fading into bridge.

VTO — Soft Tissue — Point A and Upper Lip28. Superimpose along the facial plane at the occlusal plane. Using the same technique as for markin

the symphysis, divide the horizontal distance between the "original" and "new" upper incisor tips in

thirds by using two marks.29. Soft tissue Point A remains in the same relation to Point A as in the original tracing. Superimpo

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 toriginal incisor (slide forward 2/3rds).

Trace upper lip connecting with soft tissue Point A.

VTO — Soft Tissue — Lower Lip, Point B, and Soft Tissue ChinIn constructing the lower lip, we bisect the overjet and overbite of the original tracing and mark th

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 point. The soft tissue below the lower lip remains in the same relation to point B as in the origin

tracing. Soft tissue point B drops down as the lower lip recontours.

VTO — Completed Visual Treatment Objective32. Superimpose on the symphysis, and arrange the soft tissue of the chin. It "drops down" and shou

I be evenly distributed over the symphysis taking into consideration reduction of strain and bi

opening.


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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 an 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 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 AnalysisThe 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 FaceThere are three basic facial patterns:

1. Mesofacial, which is the most average facial pattern;

2. Brachyfacial, which is a horizontal growth pattern; and3. 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 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 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

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 hav

high values; skeletal deep bites have low values.

5. Mandibular Arc. This describes the mandible. It tells us whether we have a square growin

mandible or an obtuse growing mandible.

These five angles determine the facial pattern. It is important to establish what the facial type

because the reaction to treatment mechanics and the stability of the denture is dependant upon t

analysis of the facial pattern.Brachyfacial patterns show a resistance to mandibular rotation during treatment and can accept a mo

protrusive denture, whereas Dolichofacial patterns tend to open during treatment and require a mo

retracted denture in order to assure posttreatment stability.


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.

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 th

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 Range1. HG – 8 MM

2. Class II Elastics – 3 MM

3. Activator – 2 MM4. 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 for

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 tlower 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 an

whether we wish to advance, upright or hold the lower molars.


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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, intrud

extrude, distallize or bring them forward.

In Evaluation Area 6, we evaluate what we are going to do with the upper incisors — intrude, extrudretract, 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.


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ORTHOPEDICS IN BIOPROGRESSIVE THERAPY

By definition orthopedics implies any manipulation that alters the skeletal system and associat

motor organs.From a practical standpoint in a growing individual orthopedic alteration would be any manipulatio

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 probleBimler described Class II skeletal malocclusion as Micro Rhino Dysplasia

Micro Rhino Dysplasia General Characteristics of MRD

1. Upward tilt of the palate2. Short Vertical height of the nose

3.

Upward cant of the nares4. High convexity (+6mm or more)5. Excessive anterior overjet

6. Finger, tongue or lip habits

7. Hypertonic lower lip8. Retruded Lower Arch

9. Fractured Upper Incisors

10. Hypotonic Upper Lip

11. Blocked Upper Laterals and Canines12. 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 an

a small upper face

The long drawn out maxillary dentition is tapered progressively toward the midline which allowsufficient 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 ide

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 resol

maxillary protrusion in different growth pattern.

CLASSICAL RESPONSES WITH DIFFERENTIAL HEADGEAR THERAPY

Generalized Orthopedic Response With Cervical Headgear AloneThe general orthopedic response in the mandible is highly variable, depending upon facial grow

type, the maxillae invariably respond in a highly predictable way to a line of force directed at the levof, or below, the rotational center of the maxillae.


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At a point which roughly approximates the top of the pterygomaxillary fissure, the maxillary compl

rotates in a clockwise direction

This rotational effect accounts for the reduction in maxillary protrusion, a downward canting of th palatal plane and concomitant nasal changes.

In weaker muscular patterns (in general, the dolichofacial patterns) the extrusion of both the maxilla

molar and the maxillae causes a reciprocal clockwise rotation of the mandible, opening of the faci

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 maxilla

response compensates for this by 3-4 times.

Generalized Orthodontic Response With Cervical Headgear AloneExtrusion of the upper molars occur, the effect of which is primarily dictated by the facial grow

pattern.

The upper incisor will tip lingually (from its apex) - after overjet has been reduced enough to allow teverted lower lip to close over the upper incisor

The lower molars upright and often move distally when carried by the incline planes of the extrud

upper molar.

The lower incisor, without the inhibiting effect of the lower lip, will quite often tip labially as thupper and lower lips start to reach equilibrium, and the tongue starts to dominate the labial positionin

of these teeth.

The Reverse Response In those cases where a cervical headgear is utilized in combination with a lower utility arch, th

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 patter(brachyfacial types), the mandible may rotate in a counterclockwise direction, resulting in a closure

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 respon

to this combination of mechanics.The extruding upper molar will, as it is moved distally, again pick up (through incline plane effect) th

lower molar and upright that tooth in a distal direction. This effect is enhanced by the tipback in th

utility arch.As the lower molar uprights, the distalizing force is translated, through the utility arch, to the low

incisors. These teeth will first intrude and then start to follow the lower molar distally eventual

become encased in heavy cortical bone preventing further intrusion.The intermittent extrusion of the upper molar, in conjunction with the strong muscular pattern, resu

in stabilizing (and often distalizing) the entire lower dentition. This action is referred to as the rever

response of the lower utility arch and can be utilized to set back the lower arch, for anchorage and fo

arch length.

Expansive Responses With Headgears In the Class II pose, the anterior portion of the maxillae generally is tapered toward the midline and t buccal occlusion would be in lingual crossbite if the maxillae were moved straight back into a Class

position over the present mandibular arch form.

The constrictive effect of the caninus muscle complex creates an environment conducive to ectoperuption of the entire upper dentition.


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From the mechanical standpoint a progressive widening and tipping of the alveolar base

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 plan

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 too

start to reciprocally constrict the lower molars, carrying them to the lingual. This tends to either impa

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 th

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 th

symphysis.

Generalized Response With Combination Type HeadgearsIn dolichofacial patterns, it often is desirable to create a rotational orthopedic effect in the maxillae an

at the same time maintain mandibular stability.Long-term directional headgear therapy (part time wear), where the force is applied below the cent

of resistance of the maxillae, again allows the classical orthopedic response, but without the upp

molar extrusion.If the force applied moves the maxillae distally without overriding musculature, and is in conjunctiowith mandibular growth, the lower face height can be closed or maintained while achieving

reduction of the maxillary protrusion.

Factors affecting orthopedic changeThe direction and duration of force are equally significant as the amount of force applied.

Force DirectionForces 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 th

maxillae

b. Rotational forces occur when the vectoral sum of forces lie below the centre of the resistance of t

maxillae.

A vectoral sum of the forces that lie above the centre of resistance of upper molar will produ

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 providerotational effect on the maxilla but extrude the molar.


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Mechanical Application of The Cervical Headgear

1. Force LevelA force level above 400 grams is ideal. In most patients, forces up to 1000 grams can easily b

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

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 in

contact upon swallowing), it is ideal that the cervical headgear be worn mostly in the evening an

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 preve propping open the bite by excessive tipping at the molars and will maximize orthopedic effect b

pitting the roots against cortical bone.

4. Expansion-RotationIt is essential to continually expand the inner bow of the cervical headgear, not only to correct th

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 MolarsRetarding the normal upward forward development of the lower molar will have a tendency

counteract the overall rotational effect on the mandible.

3. Severe Tipping of Upper MolarsMaintaining a slight upward cant to the outer bow will minimize this tipping effect. Severe tippin

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


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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 movementthe 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 tapplication of the long lever arm and additional wire in the loop design can reduce the applied forcallowing it to be lighter and more continuous.

3. Cortical Bone Support: Cortical bone anchorage implies that, to anchor a tooth roots a placed in proximity to the dense cortical bone under a heavy force that will further squeeze out blo

supply and this anchors the tooth by reduced physiologic activity.For efficient movement mechanics should steer the roots away from the dense cortical bone an

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 tutility arch which aids in intrusion.

During cuspid retraction lingual cortical bone must be avoided to prevent straining of the mol

anchorage.Lower bicuspids and molars are expanded so as to pit the roots against the buccal cortical bone to ain anchorage.

The maxilla in contrast to the mandible is a laminated structure with cortical bone supporting fo

cavities – nasal, orbital, oral and sinus cavities.

4. Muscular support – Reflected by facial typeWhere the musculature is strong as characterized by the deep bite, low mandibular plane angl

brachyfacial type- the teeth demonstrate a ‗natural anchorage‘. Two cephalometric measurements beginning at Xi point in the centre of the ramus of the mandib

describe mandibular morphology and its muscular function.

a) The lower face height angle (47°±4°) is a angular reflection of the musculature function betwethe upper and lower jaws.

b) Mandibular arc angle (27°±4°) describes the internal structure of the mandible.


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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 PerspectiveIt had long been felt that intrusion of the lower incisors as a medium for leveling the deep curve Spee was an impossibility.

In the 1950‘s Ricketts and others attempted to counteract the tipping that occurred in the buccsegments 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, placeunder the bicuspid bracket and looped over the molar tube at the end to be locked down behind th

extension of the sectional retractor.

This move before activation put the forward part of the arch downward toward the sulcus and as it w

raised and engaged into the lower incisors it exerted an elongating effect on the bicuspid as a levagainst the molars.

Construction specifications of the mandibular utility archThe mandibular utility arch is best fabricated from 0.016‖ x 0.016‖ blue elgiloy wire in order to creaa force system that delivers a continuous force that is light enough to be in the range of 50-75 gms.

Design PrincipleThe principle of the long lever arm, from the molars to the incisors is applied to deliver a ligcontinuous 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 t

arch approaches the tissue and as the incisor teeth are intruded.

Fabrication of the Mandibular Utility Arch1) Vertical Step HeightIn 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 th

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

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.


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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 an

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 flar 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 lingu

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 avo

cortical bone.The posterior legs are parallel to each other and 45° buccal root torque has been placed to maintain t

buccal cortical support in the lower molar region.

Placement of the mandibular utility archUpon placement of the activated lower utility arch in the lower molar tubes, the anterior section w

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 intrude incisor teeth.

In order to allow the molar to upright the wire should extend through the molar and should not be be

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 b

the forces of occlusion.Care should be taken to flare bucally the anterior vertical steps. If this step should become intrude

into the tissues at the corners, care must be taken during its adjustment so that molar control is naltered 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


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2. The buccal bridge next to the step.

These activations are more effective to advance with labial crown torque or to retract with lingu

crown torque than to intrude the incisor.Intrusion is activated at the molar step.

Roles and Functions of the lower utility arch

A. Position of the lower molar to allow for cortical anchorage

B. Manipulation and alignment of the lower incisor segment

C. Stabilization of the lower arch allowing segmental treatment of the buccal segmentD. Physiological roles of the lower utility arch

E. Over treatment

F. Role in mixed Dentition

G. 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 torqu

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 segmentIntrusion/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 DentitionIncisor and molar control during transitional stage of buccal dentition.

Allows distal eruption of the lower second bicuspid when deciduous molars are uprighted.


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Rotational correction of the bicuspids and cuspids during eruption.

G. Arch length control1. Uprighting the lower molars: using the tip back bend of the utility arch uprighting of the mol

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 ea1mm 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 th

bicuspids or deciduous molars, ½ mm of arch length is gained and for each 1 mm of expansion acrothe 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 b

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 th

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 incisorsHeight of the horizontal L or T loops should be kept between 5-7 mm in order to prevent tissuirritation in the sulcus of the lower lip.

Horizontal loops allow flexibility and full bracket engagement.

4. Contraction or Advancing utility archesA vertical loop placed along the buccal bridge has the facility of being adjusted intra orally to expan

or contract the arch. When placed opposite the lower cuspids, it is useful in their intrusion by tyinelastic ligations to the cuspid brackets.


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BIOPROGRESSIVE MIXED DENTITION TREATMENT

Bioprogressive treatment in the mixed dentition aims at the natural tendency to alleviate the problewhen 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 thdisturbs the growth, health and function of the tempero-mandibular joint complex.

II. Resolve arch length discrepancy: so that those cases within the bounds of non extraction theracan be approached in a manner that allows for their successful conclusion without removal

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 followinconclusions may be derived:

Cases with stronger mandibular growth turgor have a propensity for upward/forward growth the condyle.

Cases with a weak growth turgor demonstrate a more upward/backward growth of the condyl

Morphology alone suggests that the upward/forward cant or bend of the condyle and neck brachyfacial types and the upward/backward cant and bend of the condyle and neck dolicofacial types delineates ultimate vertical growth and forward posture of the chin in t

face.

Anything which jeopardizes the normal upward and forward growth of the condyle resulting intemperomandibular joint dysfunction is worthy of intervening treatment, this forms the basis

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 determin

by body section x-rays (laminography).It was found that in centric relation occlusion, the condyle took a ―centered‖ position whereby th

antero-superior surface of the condyle articulated in a specific relation to the eminence.

It was also noted that a joint space superior and distal to the condyles existed in normal centric relatiocclusion.

The space between the condyle and the eminence (1.5 ± 0.5 mm) gives the clinician some idea as

the most ideal articulation between the condyle articulated in a specific relation to the eminence.


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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 joint is charactierized by a condyle centered in the fossa, surfacfree 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 evalua

exact inclination of the long axis (mediolateral) of the condyle to the midsagittal plane. Th

measurement becomes especially important when accurate representation of the position of tcondyle in the fossa is needed and in a young child with small condyles, this measurement becom

critical.

In a laminagraphic section a narrowing of the articular spaces along with sclerosis or subcondylthickening of the bone at the articulating surfaces is commonly suggestive of beginning TM

pathology.

I. Resolve Function al problems Nine general categories of functional problems can be detected by clinical or roentgenograph

examination of the patient at an early age:

1. Cross-mouth interferences2. Anterior cross bite

3. Open bite- Lack of incisal guidance

4. Excessive range of function5. Distal Displacement

6. Loss of posterior support – Superior displacement

7. Finger Sucking/ Lip sucking/ Tongue thrusting8. 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 laterdirection upon final closure. These can be detected by watching mandible closure. Typically there w

be a lateral shunt a ‗comfort occlusion‖, or a broad arc of closure toward one side or the other. In twide open posture usually the midline will align at wide open, and upon closure there will be a midli

shift as guided by neuromuscular reflexes.

B. Laminagraphic Evaluation: The condyle is typically brought down on the eminence on one sidand is either ideally seated or distally positioned on the opposite side. The opposite side from the sh

acts in a translatory manner while the shifting side condyle is brought into apposition with the greate

height of the eminence.

C. Resultant growth changes: The translatory condyle may remain normal in growth but the opposiside condyle will commonly demonstrate restricted growth on its antero-superior surface and increas

growth in the posterosuperior surface will ensue. Long term growth effects will demonstrate a cant the occlusal plane, abnormal ramal heights, abnormal alveolar process heights, and abnormal ch

positioning.

D. Timing and method of treatment: Cross mouth interference should be removed as soon as it

noted. In deciduous dentition, this may mean an equilibration of a posterior tooth, or canine,

alleviate the shunting. If the problem is due to bilateral constriction of the maxillae, expansion therap


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is indicated usually when the upper first molars have erupted sufficiently to allow placement of th

expansion appliance.

2. Anterior crossbite

A. Clinical evaluation: When one or more anterior teeth are severely malposed, the mandible may

guided forward by the anterior interference. Clinically, when the mandible is nudged gently in a dist

direction and closed, the area of anterior interference can easily be detected. It is not uncommon experience anterior displacement in cases with extreme crowding and/or situations of ectopic eruptio

of incisors.

B. Laminagraphic evaluation: When anterior mandibular shunting occurs, often both condyles a

brought down toward the apex of the eminence (i.e., out of the fossae) and, quite commonly, articul

space superior and posterior to the condyles is evidenced.

C. Resultant growth changes: As both condyles have been brought down on the eminence, upwar

backward growth of the condyles is bilaterally enhanced. This can increase effective mandibul

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 tr

Class III malocclusion or simply an anterior interference. When the case is simply an anteriinterference, alignment of one or more teeth to prevent the interference is ideal. This is most easi

accomplished prior to full eruption of the incisors or before incisal trauma damages the teeth at the si

of interference.

3. Open bite — Lack of incisal guidance

A. Clinical evaluation: During active eruptive phases, all cases at one point or another exhibit eith

anterior or posterior open bite. Once the eruptive process of the upper and lower incisors has beabbreviated (usually by contact with the soft tissue lip or tongue) and active eruption no longer exist

lack of proprioceptive guidance from the anterior teeth to position the condyles in the fossae allows f

excessive mobility of the mandible. Clinically, these patients commonly show difficulty in findin

centric occlusion. There is generally a forward shunt of the mandible (to reach out for incis proprioception) and quite commonly the mandible can be manipulated distally by extending the thum

from the lower incisors to the upper incisor teeth.

B. Laminagraphic evaluation: The condyles are usually forward in the fossae, down on th

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 we

due to the excessive anteroposterior slide. This can result in growth at the apex of the condyle an

increase upward/backward growth.

D. Timing and method of treatment: This is certainly the most difficult of all functional problems

correct early, as the etiologies of open bite are multiple. At this point, there are several basic areas

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

the nasal complex, and change inclination of the maxillae, especially in severe Class II malocclusion

3)Evaluate allergy symptoms;4) Early alleviation of severe anterior crowding to allow normal incisor eruption;


28/47

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

order to create a "comfort" centric occlusion. These cases are referred to as "super Class I

malocclusions, as the mandible must reach forward to gain even a Class II molar relationshi

Clinically, severe Class II malocclusion in which the mandible can be nudged gently back into centrrelation and, upon closure, shows a more severe maxillomandibular dental relationship, is evidence

abnormal range of function.

B. Laminagraphic evaluation: Upon centric occlusion, the condyles will be forward in the foss

downward and forward on the eminence, and will quite often reveal flattening of the anterosuperi

surface of the condyle. Excessive joint space superior and distal to the condyles will be evidenced anfrequently, 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 surfa

of the condyles enhances the upward/backward growth and produces a more dolicofacial type growth experience.

D. Timing and method of treatment: Although it is not critical that the entire Class II malocclusio be corrected, it is important that the maxillae and/or teeth be moved distally enough to allow t

mandible to close without bringing the condyles downward and forward on the eminence. It is n

unusual, following initial headgear therapy, to be able to cephalometrically measure a distal movemeof the maxillae without appreciable correction of the Class II molar relation. This can be the result of

distal movement of the mandible, as the condyles drop back into the fossae. This may be the mo

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 posteri

aspect of the temporomandibular joint, is quite commonly caused by a vertical inclination of the upp

and lower incisor teeth, especially evidenced in Class II Division II malocclusion. Although it possible for distal displacement to exist due to the inclines of the functioning buccal occlusion, incis

interferences are usually the culprits. These are typically the first functional problems to demonstra

pain in the temporomandibular joint complex and it is possible to have crepitation, tinnitus, and earloss of mobility in a relatively young child.

B. Laminagraphic evaluation: The condyles are seated distally in the fossae with excessive spaanterior and superior to the condyles. The posterior portion of the condyles is often seen to abut th

tympanic plates and petrotympanic fissure of the temporal bone. Usually no irregularities in t

condyles are evidenced.

C. Resultant growth changes: Since there is no interference with the antero-superior portion of t

condyles, these cases most often demonstrate normal growth turgor in the condyles. It is felt by som

that it is the lack of normal articulatory pressure at the antero-superior portions of the condyles thenhances the brachyfacial aspect of these particular cases.

D. Timing of treatment: As the distal displacement is often caused by the vertical eruptive pattern

the upper and lower incisors, clinical factors which cause this eruptive pose should be avoided.


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Early removal of deciduous cuspids in the deep bite, brachyfacial type cases will free the anterior tee

to move in a lingual direction. This will further deepen the bite and the incisal trauma will slowly se

the condyles distally in the fossae. When early removal of deciduous cuspids is necessitated bextreme crowding, it is suggested that a lower lingual arch be placed to prevent excessi

linguoversion of both the upper and lower incisor teeth.

When a vertical inclination of the incisors already exists, early advancement of the upper incisors

create overjet often will allow the protracting musculature of the mandible to react, dominate, and frthe condyles of the distal displacement.

Over closure of the mandible, with excessive freeway space, will also allow the condyle to se

distally in the fossa. Long-term, gentle, Class II elastics which help protract the mandible, as well allow extrusion of the posterior buccal segments, are most helpful in correction of distal displacemen

Where the extreme brachyfacial type exists, avoidance of extraction is important to assure prop

vertical support in the buccal segment.

6. Loss of posterior support superior displacementA. Clinical evaluation: In cases where there are numerous congenitally missing or extracted posteri

teeth, it is not unusual for the remaining posterior teeth to tip mesially as the vertical pull musculature overrides the posterior support which holds the jaws apart. The result is a superior an

distal movement of the condyles and, as in distal displacements, there can be an early onset of pai

Although this functional problem is seldom seen in the mixed dentition, ankylosis of numerodeciduous teeth and/or numerous congenitally missing teeth can create superior displacemen

Superior displacement is most commonly seen, however, in the adult patient where anterior teeth hav

been retained, posterior teeth have been extracted, and proper vertical support in the buccal segmenhas not been maintained. Superior displacements are also seen in open bite cases where only

posterior occlusion exists. The condyles are seated superiorly in the fossae as the mandible pivots o

of the limited posterior contacts.

B. Laminagraphic evaluation: The superior portion of the condyles seat near the apex of the foss

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 earsigns of growth alteration due to superior displacement.

D. Timing and method of treatment: Since the superior displacement can be caused by loss posterior support, early removal of carious deciduous teeth without proper vertical support can

influential in creating this abnormal position to the condyles. When a stronger muscular pattern exis

and numerous deciduous teeth must, by necessity, be removed, replacement of these teeth in a retainis important.

The over closure syndrome can take some time to develop and it is quite difficult to restore once th

posterior vertical dimension has been diminished and the retained anterior teeth have adapted to t

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, aggravat by the lip, and maintained by the tongue can be considered a functional problem in that these hab

may cause the development of, or accentuate, an open bite. It is not unusual for youngsters to suck

digits up to five or six years of age. However, when the permanent incisors start to erupt, deformatio

of the anterior alveolar process with dental protrusion and open bite can occur. Once the open b


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occurs, the tongue and lip oppose during the act of swallowing, aggravating and continuing the op

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 shou

begin as a conservative suggestion to the child that the activity should be ceased. If the child is unab

to control the habit pattern, expansion/thumb appliances should be placed when the upper and lowincisors and first molars are erupting. Due to the fact that these habit problems often cause constricti

and posterior crossbite, expansion appliances should be incorporated at the same time the digit habit

being alleviated.

8. Breathing and airway problemsA. Clinical evaluation: When it is observed at initial examination that the child breathes through h

mouth, a close evaluation of airway deficiency should be made. The parent will quite often attest to tfact that the child is a mouth breather and, when a hand is placed over the oral cavity, these childre

may have a difficult time breathing through the nasal passageway. Concomitant allergies and faci

characteristics (allergic shiner, allergic salute) as well as large tonsillar and adenoid masses indicathe 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 a

uptake, these cases are prone to maxillary collapse and crossbite. While holding the tongue low an

the mouth open, the condyles are cantilevered down on the eminence, allowing the suprahyomusculature to dominate, holding the chin down and back. This action creates wear on th

upward/forward portion of the condyle and, again, allows upward/backward growth to dominat

Dominant upward/backward growth allows for a more receded chin posture in the face, worsening t

open bite, and accentuating the functional muscular aberration.

D. Timing and method of treatment: Although the oral and nasal passages increase in size as t

child grows, and tonsils and adenoids atrophy with age, long-term breathing problems that create op bite and potentially affect condylar growth, should be evaluated at an early age. It is not unusual

suggest tonsillectomy and/or adenoidectomy, allergy evaluation, and early orthodontic therapy

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 problem

They quite often exhibit a number of the functional aberrations previously mentioned as well asgenetic propensity for extreme upward/backward condylar growth, increasing the overall effecti

length of the mandible. This, in conjunction with maxillary deficiency, can be mistaken for the simp

anterior crossbite or vice versa. When true Class III is suspected, a family history as well as earcephalometric evaluation is warranted. Several cephalometric measurements can be utilized

evaluate the possibility that a Class III growth pattern exists.

B. Laminagraphic evaluation: When the mandibular teeth have bypassed the maxillary incisors, thcondyles are often downward and forward on the eminence, with excessive space superior and distal


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the condyles in the fossae. A long, thin condylar neck and long, thin ramus is often noted. Where th

lower incisors are locked beneath the upper incisors or the patient physically restrains the mandibl

distal displacement may be noted in the true Class III.

C. Resultant growth changes: The true Class III has an inherent tendency for functional displaceme

and genetic overgrowth.

D. Timing and method of treatment: When the true Class III growth pattern is detected early, it

usual to treat only the maxillary deficiency. Quite often early dental treatment of true Class III resu

in linguoversion of the lower incisors and proversion of the upper incisors, which can make successfsurgery at a later time difficult without retreatment. Relatively few true Class III's lend themselves

purely orthodontic treatment alone. Maxillary expansion and advancement, in an attempt to redu

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 segmentsMany cases, especially those of a Class II nature, demonstrate the possibility for arch length gain b

lateral expansion of the lower buccal segments. This is a functional type of expansion, which proceein a slow, meticulous manner. The arch length gained through the natural expansive response in th

lower arch is created by muscle and, as such, is extremely stable. This expansion occurs as the upp

arch form is changed to bring the maxillary teeth and alveolar process into normal axial inclinationAs the upper arch is expanded and moved distally (and held in its expanded form for a long period time), the lower arch responds, through muscular adaptation and function, reciprocally to expand. Th

lower arch also demonstrates a change in axial inclination that can begin at the deciduous canines an

extend through the permanent molars.

Primarily, this functional expansion in the lower arch is dependent upon the feasibility expansion in the upper arch. This, in turn, is dependent upon the original axial inclination and arc

form existent in the malocclusion. Upper arch form changes, when indicated, occur quickly mainly b

alveolar warping. In situations where the upper first molars and deciduous buccal segment are inclinelingually, (i.e., demonstrate a reverse curve of Monson), it is desirable to expand the upper arch b

means of an outward tipping of the upper buccal segment as the alveolar process is bent or warped o

into a more normal inclination. This should be distinguished from true maxillary deficiency where thupper buccal segments have good axial inclination but there is a generalized narrowness to th

maxillary vault..The arch form changes, expansive changes, and axial inclination changes that occur

the lower arch are merely a positive by-product of like changes in the upper arch. Although th

reciprocal response in the lower arch occurs with many approaches, they are planned for an

incorporated into early treatment procedures in the Bioprogressive Therapy. It should also be notthat since the reciprocal expansion in the lower arch occurs over a prolonged period of time, the arc

form and axial inclination changes of the upper arch should be manifested as rapidly as possible

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

most cases is the quad-helix or W expansion appliance (Ricketts). It is fabricated from .040" blElgiloy wire and is bent with a heavy bird beak plier. The lingual arm of the appliance extends to t

deciduous cuspid and is either soldered to the upper first molar (or bent to fit into a lingual sheath


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The posterior helix is beveled slightly to lie against the palatal vault and is as close to the upper mol

as possible to prevent impingement on the palatopharyngeus muscle. The anterior helices are broug

as far forward as possible and the anterior horizontal arm should generally sit over the incisive papillslightly 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 swallowin

position of the tongue. This will help avoid tissue impingement of the appliance on the palate

tongue and can prevent an unwanted tongue thrust created by placement of sections of the appliance the tongue space. All of the helices should roll to the top and should be tightly wound to increase the

mechanical efficiency (Fig. 21).

Following expansion with the W appliance the following should occur,

The upper molars should be rotated distallyThe 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 enoug

to allow for arch form changes, axial inclination changes, and spacing occurring in the upper arch, itnot adequate time to allow for the reciprocal responses that we expect to occur in the lower arch. Th

arch form and axial inclination changes that occur with the W expansion also occur in long-ter

headgear therapy with an expanded inner bow

B. Expansion by midpalatal disjunction: Where the axial inclination of the upper buccal segments

more ideal and yet crossbite exists, palatally borne appliances are typically used to enhance midpalat

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

upright to create normal axial inclinations as well as ensure stability in the expansive process.

2. Advancement or forward movement of the lower incisorsWhen the visual treatment objectives and physiologic factors warrant (i.e., symphysis size, shape, an

form; muscle position; esthetic considerations), retruded lower incisors can be gently intruded an

advanced to reach a more favorable esthetic relationship to the APo line. This type of forwamovement of the lower incisors is attempted in the brachyfacial type case, where bite opening shou

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 molawill allow the roots of these teeth to come forward while yielding space in the arch. When mes

tipping of the lower molars is evident, 2mm per side of arch length is gained by this simple uprightin

effect. Further distal movement or intrusion of the lower molars can create problems with the eruptinsecond molars. It is usually ideal to stabilize the lower molar once it has reached a normal positi

upright at 5° to the occlusal plane.


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III . Correct Vertical Problems— Correct Overjet Problems

Retention Procedures

This places a tremendous importance on case selection and proper case management to reach a knowobjective.

Although headgear can be continued over protracted periods of time to maintain molar relationsh

and orthopedic reduction, thereby reducing physiologic rebound, in many cases such long-tercooperation is difficult to achieve.

The retainer that is most commonly used after first phase therapy is the Hawley retainer with a

inclined plane. The Hawley bow acts to hold upper incisor alignment and position, while the inclin plane holds the lower incisor alignment both from the labial (by the upper incisors) and the lingual (b

the incline plane). The labial bow is fabricated from .028" blue Elgiloy wire and the vertical loop

short and is situated between the upper lateral incisor and the deciduous canine as this is the only op

contact in the mixed dentition. Ball clasps are placed to the upper molars and any space creat 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

critical, a lower lingual arch is placed. The patients are instructed to wear the upper Hawley retain

full time during the first year after treatment and usually are instructed to wear the retainer at nigtime during the second and/or third year of retention therapy. Only in very selected cases are th

headgears maintained for extremely long periods of time, thus minimizing the amount of therapy th

the majority of patients might receive.


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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 weconsidered 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 accounts for the original prescription of 5° on all canines and 5° on the lower molar tubes an 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° chang

in angulation of the bracket by fitting the band as required for the individual patient needs.

It soon became evident t

Documents

102533323 Bioprogressive Therapy