Académique Documents
Professionnel Documents
Culture Documents
Introduction
The Management Umbrella
Principles of Bioprogressive Therapy
Visual Treatment Objective
The Use of Superimposition Areas
Orthopedics in Bioprogressive Therapy
The Utility and Sectional Arches
Bioprogressive Mixed Dentition Treatment
Mechanics Sequence for Extraction Cases
Mechanics Sequence for Class II Division 1 Cases
Mechanics Sequence for Class II Division 2 Cases
Finishing Procedures and Retention
Conclusion
INTRODUCTION
Bioprogressive Therapy was originated by Drs. Robert Ricketts and Ruel Bench who combined
contemporary edgewise mechanics with solid diagnostic principles and an innovative approach to
sectional mechanics.
Bio-Progressive Therapy is not strictly an orthodontic technique but, more importantly, it encompasses
a total orthodontic philosophy. It accepts as its mission the treatment of the total face rather than the
narrower objective of the teeth or the occlusion. Although the teeth and the occlusion are of critical
importance in achieving the broader goal of treating and improving the face, orthodontic therapies
must be designed to be applied appropriately to specific facial types, muscular patterns, and functional
needs of individuals. A primary concern, therefore, is the musculature of the chin and lips and the
function of the tongue as its posture reflects the respiratory needs of the individual.
The relationship of the jaws to each other, with the resulting convexity or concavity of the profile,
suggests the orthopedic alteration that will be required to achieve the desired result. The progressive
unfolding of these arches, in conjunction with the purposeful alterations resulting from orthodontic
therapy, combine to produce the desired outcomes as they relate to aesthetic effect and occlusal and
respiratory function. Basic to an understanding of these potential changes is the dynamics of growth
and function under normal relationships with an appreciation for a range of variation from the normal
as applied to the individual with his specific needs and potential.
Dr. Ricketts' orthodontic philosophy and therapy involves a broad concept of total treatment, rather
than a sequence of technical and mechanical steps. Referred to as Bio-Progressive Therapy, it takes
advantage of biological progressions including growth, development, and function, and directs them in
a fashion that normalizes function and enhances aesthetic effect.
Diagnostic Programming
1. Clinical examination
2. Describing the malocclusion
3. Describe the face
4. Describe the functional requirements
Nasopharyngeal airway
Musculature
Habits
Soft Tissue
5. Lower VTO and Arch form
Arch wires and loop systems that will deliver lighter and more continuous forces are the most effective
in eliciting the biological response that we desire. The smaller .016 .016 chrome alloy arch wires,
with designs that allow more wire either through spanning arches, sectional arches, or multiplelooped
arches, have been found to apply the lighter continuous force required
#5. Orthopedic alteration
Orthopedic alteration changes the relationship of the basic supporting jaw structure, as contrasted to
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 the
younger child
Orthopedic alteration brings about changes in the maxilla and compensatory changes in the mandible
and TMJ. Expected mandibular rotation and facial type usually dictate the kind of headgear
prescribed.
#6 Treat the overbite before the overjet.
For stability in function and retention it is vital that the deep bite incisor relationship be corrected, to
establish the proper interincisal relationship of overbite to overjet and interincisal angles. When the
incisors are left with an overbite and a vertical interincisal angle.
Incisor overbite correction can be accomplished by two methods.
1. Extrusion of posterior teeth, which increases the lower face height by mandibular rotation.
2. Intrusion of the upper or lower incisor teeth, with little or no mandibular rotation.
Vertical face patterns respond earlier and faster to molar extrusion and further worsen the appearance.
Increase in lower anterior face height, lip strain compounds the problem of a short upper lip.
The short anterior vertical facial height type with a low mandibular plane and the most extreme incisor
overbites are those that would best benefit from mandibular rotation, but their strong musculature
function resists the molar extrusion that allows this type of opening. Often
Another complication of overbite interference during treatment is the distal displacement of the
condyle in the fossa resulting in temperomandibular joint dysfunction and incisor instability due to
traumatic interference of the incisor deep bite occlusion.
Bio-Progressive Therapy mechanics finds that incisor intrusion is the treatment of choice for the best
results not only during treatment, but also for stability of results and optimizing function
When the incisor overbite is not corrected before incisor retraction, the incisors come into interference
resulting in a proprioceptive input that affects the patient's ability to close the posterior teeth. When
this neuromuscular interference limits the patient's ability to occlude the posterior teeth, the molars are
allowed to extrude and vertical opening occurs. When we have incisor interference, headgear will
more easily extrude the upper molar and Class II elastics will extrude the lower molars.
In the final finishing of orthodontic treatment, if incisors are in deep overbite the interference will
usually not allow a good buccal occlusion.
#7 Sectional arch treatment.
Sectional arch treatment is a basic treatment procedure of Bio-Progressive Therapy in which the
arches are broken into sections or segments in order that the application of force in direction and
amount will be of more benefit in the efficient movements of the teeth.
There are four benefits of sectional arch treatment:
1. It allows lighter continuous forces to be directed to the individual teeth (for their efficient
movement).
As the arches are segmented and the buccal occlusion is sectioned from the incisors, very light
continuous forces can be directed to the incisors through the long lever arm created by the utility arch,
which spans from the molars to the incisors, bypassing the bicuspids and cuspids.
Segmented arches allow the molars to be stabilized and supported by the bicuspids and cuspids against
the torquing movement directed to the molars by the intrusion action of the long-levered utility
spanning arch.
2. More effective root control in the basic tooth movements.
Segmented arch treatment allows us to torque the lower incisor roots away from the lingual cortical
bone which aids in their intrusion and the cuspids can then be intruded separately along a route of least
resistance and still maintain molar torque and rotational control for anchorage support.
3. It supplements maxillary orthopedic alteration.
Full arch wires through the incisors tie the maxillary segments together and limit the adjustment and
expansion desired in maxillary orthopedic treatment.
Class II sectional arch treatment allows the expansion without interference.
4. It reduces the binding and friction of the brackets as they slide along the arch wire.
A segmented arch applied to the cuspids only, reduces the friction even more on the short segment and
allows for its efficient retraction.
.
Sectional arch treatment allows the erupting buccal occlusion to erupt more freely into the functions of
the face by reducing those limiting factors that restrict the normal development. It also maintains arch
length.
#8 Concept of overtreatment.
It is necessary for the clinician to anticipate changes that will follow when all appliances are removed
and the post treatment adjustments begin to occur.
Bio-Progressive Therapy suggests four areas where the concept of overtreatment may help compensate
for the anticipated post-treatment adjustments:
1. To overcome muscular forces against the tooth surfaces.
a) In cases of expansion of a narrow collapsed upper arch overtreatment is necessary considering the
relapse that might occur under the influence of the buccal musculature.
Over expansion also encourages the tongue to elevate and function in support of the dental arches.
b) Overclosure of an anterior open bite is appropriate to compensated for the rebound effect of
abnormal tongue function and the increase in lower anterior face height as seen in excessive vertical
facial types.
c) Overtreatment of the incisor overjet and interincisal angle is critical in lip sucking habits, where
mentalis function and short upper lip continue to influence the position and stability of the incisors.
2. Root movements needed for stability.
Incisor deep overbite treatment benefits in its stability by over intrusion and overtorquing. Paralleling
of the roots of the teeth adjacent to extraction sites is important to the stability of space closure.
Severe rotation, where periodontal ligaments exhibit elastic action that can have prolonged posttreatment influence, needs over-rotation of the roots to help compensate for the relapse effect.
3. To overcome orthopedic rebound.
Rebound of orthopedic corrections may be beneficial or may compound the problem.
In Class II treatment the rebound effect which closes the bite and rotates the chin forward will help in
Class II correction.
In Class III treatment correction this rotation would compound the problem.
4. To allow settling in retention.
Overtreatment of the individual teeth within the arches allows them to "settle" into a functioning
occlusion.
In Bioprogressive Therapy, retainers then are considered active appliances and are adjusted to allow
this settling action to take place, rather than to just hold or maintain teeth.
Overtreatment of the typical Class II correction begins with the molars by overtreating them into a
"super Class I" through distal rotation of the upper first molar behind an uprighted distally rotated
lower molar.
#9 Unlocking the malocclusion in a progressive sequence of treatment in order to
establish or restore more normal function.
Bio-Progressive Therapy maintains that many malocclusions have resulted because of abnormal
function, and that the present malocclusion, while stable under its present abnormal function, may
never have had the opportunity for normal development.
Bio-Progressive Therapy proposes treatment sequences that progressively unlock the malocclusion in
order to restore or establish a more normal environment.
Planning for the unlocking of the malocclusion begins at the initial exam and evaluation.
1. To describe the malocclusion and visualize the position of the teeth in terms of what functional
influences have been responsible for their present alignment.
2. To describe the facial type and skeletal structure from the cephalometric x-rays, and the implied
description of function.
3. To describe the present abnormal functional influences upon the dental arches; if not abnormal, then
lack of normal development by default.
The following process of evaluation is used in setting up a treatment plan and prescribing the various
appliances and treatment:
First: Functional influences and their correction.
Second: Orthopedic alterations that may be necessary.
Third: Arch form arch length, extraction needs.
Fourth: Tooth movements and anchorage planning.
Fifth: Case management, with key factors to monitor during treatment.
Situations where treatment changes alter the environment, which then allow an improved function to
support it.
1. Upper Arch Expansion.
2. Incisor Protrusion Correction.
3. Temperomandibular Joint Dysfunction. Further restriction of a collapsed upper arch can develop
into a functional crossbite where occlusal interference now blocks upper arch development and
produces condylar shifts and changes in the temporomandibular joint function and development.
with
quality
results
utilizing
concept
of
In an attempt to relieve some of the burden imposed by the myriad of procedures that are required in
the construction and fabrication of orthodontic appliances, Bio-Progressive Therapy utilizes the
concept of prefabrication and has appliances ready-made for clinical application, so that the clinician
directs his expertise to diagnosis and treatment planning.
10. With old and new XI points coinciding, trace corpus axis, extending it 2mm per year forward of
old PM point. (PM moves forward 2mm/year in normal growth.)
11. Draw posterior border of the ramus and lower border of the mandible.
VTO Mandibular Growth Prediction Symphysis Construction
12. Slide back along the corpus axis superimposing at new and old PM. Trace the symphysis and draw
in mandibular plane.
13. Construct the facial plane from NA to PO.
14. Construct facial axis from CC to GN (where facial plane and mandibular plane cross).
III. VTO Maxillary Growth Prediction
15. To locate the "new" maxilla within the face, superimpose at Nasion along the facial plane and
divide the distance between "original" and "new" Mentons into thirds by drawing two marks.
16. To outline the body of the maxilla, superimpose mark #1 (superior mark) on the original Menton
along the facial plane. Trace the palate (with the exception of point A).
VTO Maxillary Growth Prediction Point A Change Related to BA-NA
These are the maximum ranges of Point A change with various mechanics:
Point A is altered as a result of growth and mechanics. Point A and a new APO plane are drawn by the
following steps:
17. Point A can be altered distally with treatment. Place according to orthopedic problem and
treatment objectives. For each mm of distal movement, Point A will drop mm.
18. Construct new APo plane.
IV. VTO Occlusal Plane Position
19. Superimpose mark #2 on original Menton and facial plane, then parallel mandibular planes
rotating at Menton. Construct occlusal plane (may tip 3 degrees either way depending on Class II or
Class III treatment).
V. VTO Dentition Lower Incisor
The lower incisor is placed in relationship to the symphysis of the mandible, the occlusal plane and the
APO plane. The arch length requirements and realistic results dictate its location.
20. For this exercise, superimpose on the corpus axis at PM. Place a dot representing the tip of the
lower incisor in the ideal position to the new occlusal plane, which is 1 mm above the occlusal plane
and 1 mm ahead of the APO plane.
21. Aligning over the original incisor outline or using a template, draw in the lower incisor in the final
position as required by arch length. The angle is 22 at +1mm to the APo plane and + 1 mm to
occlusal plane, but the angle increases 2 with each mm of forward compromise.
VTO Dentition Lower Molar
Without treatment, the lower molar will erupt directly upward to the new occlusal plane. With
treatment, 1mm of molar movement equals 2mm of arch length. We moved the lower incisor forward
2mm in this case. There was also 4mm of leeway space. Therefore, the following calculation allows us
to move the lower molar forward 4mm on each side:
lower incisor
.
Five Superimposition Areas
The five superimposition areas are used to evaluate the face in the following order:
1. The chin.
2. The maxilla.
3. The teeth in the mandible.
4. The teeth in the maxilla.
5. The facial profile.
Superimposition Area 1 (Evaluation Area 1)
(Basion-Nasion at CC Point)
Evaluate the amount of growth of the chin in millimeters;
Any change in chin in an opening or closing direction that may result from our mechanics;
Any change in upper molar.
In normal growth, the chin grows down the facial axis and the six year molars also grow down the
facial axis.
Changes in the facial axis as per mechanics used have been mentioned previously.
At a point which roughly approximates the top of the pterygomaxillary fissure, the maxillary complex
rotates in a clockwise direction
This rotational effect accounts for the reduction in maxillary protrusion, a downward canting of the
palatal plane and concomitant nasal changes.
In weaker muscular patterns (in general, the dolichofacial patterns) the extrusion of both the maxillary
molar and the maxillae causes a reciprocal clockwise rotation of the mandible, opening of the facial
axis and mandibular plane, and a diminishing effect on forward chin posture.
In strong muscular patterns some mild mandibular rotation occurs but the amount of maxillary
response compensates for this by 3-4 times.
Generalized Orthodontic Response With Cervical Headgear Alone
Extrusion of the upper molars occur, the effect of which is primarily dictated by the facial growth
pattern.
The upper incisor will tip lingually (from its apex) - after overjet has been reduced enough to allow the
everted lower lip to close over the upper incisor
The lower molars upright and often move distally when carried by the incline planes of the extruded
upper molar.
The lower incisor, without the inhibiting effect of the lower lip, will quite often tip labially as the
upper and lower lips start to reach equilibrium, and the tongue starts to dominate the labial positioning
of these teeth.
The Reverse Response
In those cases where a cervical headgear is utilized in combination with a lower utility arch, the
maxillary orthopedic response is the same however the mandibular orthopedic response differs.
The mandibular plane and facial axis will be somewhat stabilized and, in strong muscular patterns
(brachyfacial types), the mandible may rotate in a counterclockwise direction, resulting in a closure of
the lower face height, mandibular plane and facial axis.
This unusual orthopedic response in the mandible can be traced back to the dentition, and its response
to this combination of mechanics.
The extruding upper molar will, as it is moved distally, again pick up (through incline plane effect) the
lower molar and upright that tooth in a distal direction. This effect is enhanced by the tipback in the
utility arch.
As the lower molar uprights, the distalizing force is translated, through the utility arch, to the lower
incisors. These teeth will first intrude and then start to follow the lower molar distally eventually
become encased in heavy cortical bone preventing further intrusion.
The intermittent extrusion of the upper molar, in conjunction with the strong muscular pattern, results
in stabilizing (and often distalizing) the entire lower dentition. This action is referred to as the reverse
response of the lower utility arch and can be utilized to set back the lower arch, for anchorage and for
arch length.
Expansive Responses With Headgears
In the Class II pose, the anterior portion of the maxillae generally is tapered toward the midline and the
buccal occlusion would be in lingual crossbite if the maxillae were moved straight back into a Class I
position over the present mandibular arch form.
The constrictive effect of the caninus muscle complex creates an environment conducive to ectopic
eruption of the entire upper dentition.
From the mechanical standpoint a progressive widening and tipping of the alveolar base is
accomplished by a widening of the inner bow of the face bow.
This expansive process provides for several distinct considerations:
1. Reciprocal expansion of the lower arch.
This can be observed as an anterior movement of the lower incisor and in the horizontal plane
increases in arch width occurs.
2. Preventing impacted second molars.
When the upper first molar is translated distally without expansion, the incline planes of that tooth
start to reciprocally constrict the lower molars, carrying them to the lingual. This tends to either impact
the lower second molar or force them buccally.
Soft Tissue Esthetic Changes
Following headgear therapy the nose is seen to cross over at the bridge, lengthen vertically and the
upward cant to the nares is tipped down to a more horizontal position.
Normal function is established in the upper lip once overjet is reduced.
Reduction of maxillary protrusion also allows the soft tissue chin to distribute evenly over the
symphysis.
Generalized Response With Combination Type Headgears
In dolichofacial patterns, it often is desirable to create a rotational orthopedic effect in the maxillae and
at the same time maintain mandibular stability.
Long-term directional headgear therapy (part time wear), where the force is applied below the center
of resistance of the maxillae, again allows the classical orthopedic response, but without the upper
molar extrusion.
If the force applied moves the maxillae distally without overriding musculature, and is in conjunction
with mandibular growth, the lower face height can be closed or maintained while achieving a
reduction of the maxillary protrusion.
Factors affecting orthopedic change
The direction and duration of force are equally significant as the amount of force applied.
Force Direction
Forces applied to the maxillae through the face bow are either
a. Restrictive (retard downward and forward growth)
b. Rotational
a. Restrictive forces occur when the vectoral sum of forces lies above the centre of resistance of the
maxillae
b. Rotational forces occur when the vectoral sum of forces lie below the centre of the resistance of the
maxillae.
A vectoral sum of the forces that lie above the centre of resistance of upper molar will produce
rotation of the maxilla and intrusion of the molar.
A vectoral sum of the forces that lie below the centre of resistance of the molar will provide a
rotational effect on the maxilla but extrude the molar.
The right side segment will lie slightly lingually which can be adjusted later.
4) Contouring the Buccal Bridges.
The stepped down buccal bridge section has a buccal contour that stands way from the alveolus and
acts as a bumper against the buccinator muscle.
The buccal bridge section is flared outward approximately 1cm per side.
By flaring the buccal bridge section at the anterior vertical step, the posterior vertical step is also flared
bucally and establishes the 45 buccal root torque.
5) Activation of the Distal Legs.
The molar section that extends into the molar tube has a 45 buccal root torque, 30-45 distal lingual
rotation with a 30-45 tip back bend. Molar uprighting and incisor intrusion
6) Final Arch Form and Activation Characteristics.
The precisely contoured anterior arch form will allow the incisors to intrude without advancing.
5-10 labial root torque will counteract the forward tipping action and allow the incisor roots to avoid
cortical bone.
The posterior legs are parallel to each other and 45 buccal root torque has been placed to maintain the
buccal cortical support in the lower molar region.
Placement of the mandibular utility arch
Upon placement of the activated lower utility arch in the lower molar tubes, the anterior section will
rest at the bottom of the labial sulcus
When it is raised to the level of the incisor brackets it should measure 50-75 gms of force directed to
intrude incisor teeth.
In order to allow the molar to upright the wire should extend through the molar and should not be bent
down distal to the tube. This prevents the crown from uprighting.
The posterior vertical step should not be advanced ahead of the molar tube since it will be distorted by
the forces of occlusion.
Care should be taken to flare bucally the anterior vertical steps. If this step should become intruded
into the tissues at the corners, care must be taken during its adjustment so that molar control is not
altered or distorted.
Intra Oral Adjustments
These can be made with loop forming pliers or a small three prong plier.
Care should be taken during these adjustments so as to not distort the original torque incorporated.
Molar Adjustment
Should be made on the posterior vertical step or adjacent to it on the buccal bridge.
Should be kept 90 to the molar section.
To produce more molar tip back and anterior intrusion two areas of activation are most effective:
1. The posterior vertical step
2. The buccal bridge is front of the posterior vertical step.
Incisor Adjustment
Should be made on the anterior vertical step or adjacent to it on the buccal bridge.
Activation in the incisor area is made parallel to the incisor section either on
1. Anterior vertical step
Cases with stronger mandibular growth turgor have a propensity for upward/forward growth of
the condyle.
Cases with a weak growth turgor demonstrate a more upward/backward growth of the condyle
Morphology alone suggests that the upward/forward cant or bend of the condyle and neck in
brachyfacial types and the upward/backward cant and bend of the condyle and neck in
dolicofacial types delineates ultimate vertical growth and forward posture of the chin in the
face.
Anything which jeopardizes the normal upward and forward growth of the condyle resulting in a
temperomandibular joint dysfunction is worthy of intervening treatment, this forms the basis of
treatment in the mixed dentition.
Laminographic Studies:
In the early 1950s Ricketts et al began to set standards for normal variations in the TMJ as determined
by body section x-rays (laminography).
It was found that in centric relation occlusion, the condyle took a centered position whereby the
antero-superior surface of the condyle articulated in a specific relation to the eminence.
It was also noted that a joint space superior and distal to the condyles existed in normal centric relation
occlusion.
The space between the condyle and the eminence (1.5 0.5 mm) gives the clinician some idea as to
the most ideal articulation between the condyle articulated in a specific relation to the eminence.
The space between the condyle and the roof of the fossa was found to be (2.5 1.0 mm).
The space between the condyle and the meatus was found to be 7.5 mm on an average.
It should be noted that the normal joint is charactierized by a condyle centered in the fossa, surfaces
free of rough edges (smooth edges), and absence of excessive thickening of the subchondral layers.
In order to enhance the clarity of laminagraphic sections, submento vertex x-rays are taken to evaluate
exact inclination of the long axis (mediolateral) of the condyle to the midsagittal plane. This
measurement becomes especially important when accurate representation of the position of the
condyle in the fossa is needed and in a young child with small condyles, this measurement becomes
critical.
In a laminagraphic section a narrowing of the articular spaces along with sclerosis or subcondylar
thickening of the bone at the articulating surfaces is commonly suggestive of beginning TMJ
pathology.
I. Resolve Function al problems
Nine general categories of functional problems can be detected by clinical or roentgenographic
examination of the patient at an early age:
1. Cross-mouth interferences
2. Anterior cross bite
3. Open bite- Lack of incisal guidance
4. Excessive range of function
5. Distal Displacement
6. Loss of posterior support Superior displacement
7. Finger Sucking/ Lip sucking/ Tongue thrusting
8. Breathing and Airway problems
9. True Class III Growth patterns
1. Cross- mouth interferences
A. Clinical Evaluation: Cases where one or more teeth cause shunting of the mandible in a lateral
direction upon final closure. These can be detected by watching mandible closure. Typically there will
be a lateral shunt a comfort occlusion, or a broad arc of closure toward one side or the other. In the
wide open posture usually the midline will align at wide open, and upon closure there will be a midline
shift as guided by neuro- muscular reflexes.
B. Laminagraphic Evaluation: The condyle is typically brought down on the eminence on one side
and is either ideally seated or distally positioned on the opposite side. The opposite side from the shift
acts in a translatory manner while the shifting side condyle is brought into apposition with the greatest
height of the eminence.
C. Resultant growth changes: The translatory condyle may remain normal in growth but the opposite
side condyle will commonly demonstrate restricted growth on its antero-superior surface and increased
growth in the posterosuperior surface will ensue. Long term growth effects will demonstrate a cant in
the occlusal plane, abnormal ramal heights, abnormal alveolar process heights, and abnormal chin
positioning.
D. Timing and method of treatment: Cross mouth interference should be removed as soon as it is
noted. In deciduous dentition, this may mean an equilibration of a posterior tooth, or canine, to
alleviate the shunting. If the problem is due to bilateral constriction of the maxillae, expansion therapy
is indicated usually when the upper first molars have erupted sufficiently to allow placement of the
expansion appliance.
2. Anterior crossbite
A. Clinical evaluation: When one or more anterior teeth are severely malposed, the mandible may be
guided forward by the anterior interference. Clinically, when the mandible is nudged gently in a distal
direction and closed, the area of anterior interference can easily be detected. It is not uncommon to
experience anterior displacement in cases with extreme crowding and/or situations of ectopic eruption
of incisors.
B. Laminagraphic evaluation: When anterior mandibular shunting occurs, often both condyles are
brought down toward the apex of the eminence (i.e., out of the fossae) and, quite commonly, articular
space superior and posterior to the condyles is evidenced.
C. Resultant growth changes: As both condyles have been brought down on the eminence, upwardbackward growth of the condyles is bilaterally enhanced. This can increase effective mandibular
length and is believed to be a contributing factor in Class III malocclusion.
D. Timing and method of treatment: It should be determined whether the individual case is a true
Class III malocclusion or simply an anterior interference. When the case is simply an anterior
interference, alignment of one or more teeth to prevent the interference is ideal. This is most easily
accomplished prior to full eruption of the incisors or before incisal trauma damages the teeth at the site
of interference.
3. Open bite Lack of incisal guidance
A. Clinical evaluation: During active eruptive phases, all cases at one point or another exhibit either
anterior or posterior open bite. Once the eruptive process of the upper and lower incisors has been
abbreviated (usually by contact with the soft tissue lip or tongue) and active eruption no longer exists,
lack of proprioceptive guidance from the anterior teeth to position the condyles in the fossae allows for
excessive mobility of the mandible. Clinically, these patients commonly show difficulty in finding
centric occlusion. There is generally a forward shunt of the mandible (to reach out for incisal
proprioception) and quite commonly the mandible can be manipulated distally by extending the thumb
from the lower incisors to the upper incisor teeth.
B. Laminagraphic evaluation: The condyles are usually forward in the fossae, down on the
eminence, and often there is flattening and irregularity of the antero-superior surfaces of the condyles.
C. Resultant growth changes: Loss of guidance of the condyle in the fossa causes abrasion or wear
due to the excessive anteroposterior slide. This can result in growth at the apex of the condyle and
increase upward/backward growth.
D. Timing and method of treatment: This is certainly the most difficult of all functional problems to
correct early, as the etiologies of open bite are multiple. At this point, there are several basic areas to
explore in early correction of open bite:
1) Evaluate airway for possible tonsillectomy and/or adenoidectomy;
2) Orthopedically expand and rotate the maxillae to improve tongue space, increase vertical height to
the nasal complex, and change inclination of the maxillae, especially in severe Class II malocclusions;
3)Evaluate allergy symptoms;
4) Early alleviation of severe anterior crowding to allow normal incisor eruption;
Early removal of deciduous cuspids in the deep bite, brachyfacial type cases will free the anterior teeth
to move in a lingual direction. This will further deepen the bite and the incisal trauma will slowly seat
the condyles distally in the fossae. When early removal of deciduous cuspids is necessitated by
extreme crowding, it is suggested that a lower lingual arch be placed to prevent excessive
linguoversion of both the upper and lower incisor teeth.
When a vertical inclination of the incisors already exists, early advancement of the upper incisors to
create overjet often will allow the protracting musculature of the mandible to react, dominate, and free
the condyles of the distal displacement.
Over closure of the mandible, with excessive freeway space, will also allow the condyle to seat
distally in the fossa. Long-term, gentle, Class II elastics which help protract the mandible, as well as
allow extrusion of the posterior buccal segments, are most helpful in correction of distal displacement.
Where the extreme brachyfacial type exists, avoidance of extraction is important to assure proper
vertical support in the buccal segment.
6. Loss of posterior support superior displacement
A. Clinical evaluation: In cases where there are numerous congenitally missing or extracted posterior
teeth, it is not unusual for the remaining posterior teeth to tip mesially as the vertical pull of
musculature overrides the posterior support which holds the jaws apart. The result is a superior and
distal movement of the condyles and, as in distal displacements, there can be an early onset of pain.
Although this functional problem is seldom seen in the mixed dentition, ankylosis of numerous
deciduous teeth and/or numerous congenitally missing teeth can create superior displacement.
Superior displacement is most commonly seen, however, in the adult patient where anterior teeth have
been retained, posterior teeth have been extracted, and proper vertical support in the buccal segments
has not been maintained. Superior displacements are also seen in open bite cases where only a
posterior occlusion exists. The condyles are seated superiorly in the fossae as the mandible pivots off
of the limited posterior contacts.
B. Laminagraphic evaluation: The superior portion of the condyles seat near the apex of the fossae
and excessive space is seen mesial to the condyle.
C. Resultant growth changes: As in the posterior displacements, there do not appear to be any early
signs of growth alteration due to superior displacement.
D. Timing and method of treatment: Since the superior displacement can be caused by loss of
posterior support, early removal of carious deciduous teeth without proper vertical support can be
influential in creating this abnormal position to the condyles. When a stronger muscular pattern exists,
and numerous deciduous teeth must, by necessity, be removed, replacement of these teeth in a retainer
is important.
The over closure syndrome can take some time to develop and it is quite difficult to restore once the
posterior vertical dimension has been diminished and the retained anterior teeth have adapted to the
abnormal positions of the condyles.
7. Finger sucking /Lip sucking/Tongue thrust
A. Clinical evaluation: An open bite syndrome that is commonly initiated by the finger, aggravated
by the lip, and maintained by the tongue can be considered a functional problem in that these habits
may cause the development of, or accentuate, an open bite. It is not unusual for youngsters to suck on
digits up to five or six years of age. However, when the permanent incisors start to erupt, deformation
of the anterior alveolar process with dental protrusion and open bite can occur. Once the open bite
occurs, the tongue and lip oppose during the act of swallowing, aggravating and continuing the open
bite pattern.
B . Laminagraphic evaluation: Same as open bite.
C. Resultant growth changes: Same as open bite.
D. Timing and method of treatment: The approach toward the functional muscular problem should
begin as a conservative suggestion to the child that the activity should be ceased. If the child is unable
to control the habit pattern, expansion/thumb appliances should be placed when the upper and lower
incisors and first molars are erupting. Due to the fact that these habit problems often cause constriction
and posterior crossbite, expansion appliances should be incorporated at the same time the digit habit is
being alleviated.
8. Breathing and airway problems
A. Clinical evaluation: When it is observed at initial examination that the child breathes through his
mouth, a close evaluation of airway deficiency should be made. The parent will quite often attest to the
fact that the child is a mouth breather and, when a hand is placed over the oral cavity, these children
may have a difficult time breathing through the nasal passageway. Concomitant allergies and facial
characteristics (allergic shiner, allergic salute) as well as large tonsillar and adenoid masses indicate
the tendency for mouth breathing.
B. Laminagraphic evaluation: Usually the same as with open bite.
C. Resultant growth changes: Because the tongue is held low in the oral cavity to increase air
uptake, these cases are prone to maxillary collapse and crossbite. While holding the tongue low and
the mouth open, the condyles are cantilevered down on the eminence, allowing the suprahyoid
musculature to dominate, holding the chin down and back. This action creates wear on the
upward/forward portion of the condyle and, again, allows upward/backward growth to dominate.
Dominant upward/backward growth allows for a more receded chin posture in the face, worsening the
open bite, and accentuating the functional muscular aberration.
D. Timing and method of treatment: Although the oral and nasal passages increase in size as the
child grows, and tonsils and adenoids atrophy with age, long-term breathing problems that create open
bite and potentially affect condylar growth, should be evaluated at an early age. It is not unusual to
suggest tonsillectomy and/or adenoidectomy, allergy evaluation, and early orthodontic therapy to
increase the size of the nasal airway.
9. True Class III Growth Patterns
A. Clinical evaluation: True Class III growth patterns represent the epitome in functional problems.
They quite often exhibit a number of the functional aberrations previously mentioned as well as a
genetic propensity for extreme upward/backward condylar growth, increasing the overall effective
length of the mandible. This, in conjunction with maxillary deficiency, can be mistaken for the simple
anterior crossbite or vice versa. When true Class III is suspected, a family history as well as early
cephalometric evaluation is warranted. Several cephalometric measurements can be utilized to
evaluate the possibility that a Class III growth pattern exists.
B. Laminagraphic evaluation: When the mandibular teeth have bypassed the maxillary incisors, the
condyles are often downward and forward on the eminence, with excessive space superior and distal to
the condyles in the fossae. A long, thin condylar neck and long, thin ramus is often noted. Where the
lower incisors are locked beneath the upper incisors or the patient physically restrains the mandible,
distal displacement may be noted in the true Class III.
C. Resultant growth changes: The true Class III has an inherent tendency for functional displacement
and genetic overgrowth.
D. Timing and method of treatment: When the true Class III growth pattern is detected early, it is
usual to treat only the maxillary deficiency. Quite often early dental treatment of true Class III results
in linguoversion of the lower incisors and proversion of the upper incisors, which can make successful
surgery at a later time difficult without retreatment. Relatively few true Class III's lend themselves to
purely orthodontic treatment alone. Maxillary expansion and advancement, in an attempt to reduce
maxillary deficiency, is the usual treatment of choice.
II. Resolve Arch Length Discrepancy
Arch length gain in the lower arch occurs three ways.
1. Lateral expansion of the lower buccal segments
Many cases, especially those of a Class II nature, demonstrate the possibility for arch length gain by
lateral expansion of the lower buccal segments. This is a functional type of expansion, which proceeds
in a slow, meticulous manner. The arch length gained through the natural expansive response in the
lower arch is created by muscle and, as such, is extremely stable. This expansion occurs as the upper
arch form is changed to bring the maxillary teeth and alveolar process into normal axial inclinations.
As the upper arch is expanded and moved distally (and held in its expanded form for a long period of
time), the lower arch responds, through muscular adaptation and function, reciprocally to expand. The
lower arch also demonstrates a change in axial inclination that can begin at the deciduous canines and
extend through the permanent molars.
Primarily, this functional expansion in the lower arch is dependent upon the feasibility of
expansion in the upper arch. This, in turn, is dependent upon the original axial inclination and arch
form existent in the malocclusion. Upper arch form changes, when indicated, occur quickly mainly by
alveolar warping. In situations where the upper first molars and deciduous buccal segment are inclined
lingually, (i.e., demonstrate a reverse curve of Monson), it is desirable to expand the upper arch by
means of an outward tipping of the upper buccal segment as the alveolar process is bent or warped out
into a more normal inclination. This should be distinguished from true maxillary deficiency where the
upper buccal segments have good axial inclination but there is a generalized narrowness to the
maxillary vault..The arch form changes, expansive changes, and axial inclination changes that occur in
the lower arch are merely a positive by-product of like changes in the upper arch. Although the
reciprocal response in the lower arch occurs with many approaches, they are planned for and
incorporated into early treatment procedures in the Bioprogressive Therapy. It should also be noted
that since the reciprocal expansion in the lower arch occurs over a prolonged period of time, the arch
form and axial inclination changes of the upper arch should be manifested as rapidly as possible to
allow for the long-term responses to occur in the lower arch.
A. Expansion primarily by change in axial inclination: The appliance used to change arch form in
most cases is the quad-helix or W expansion appliance (Ricketts). It is fabricated from .040" blue
Elgiloy wire and is bent with a heavy bird beak plier. The lingual arm of the appliance extends to the
deciduous cuspid and is either soldered to the upper first molar (or bent to fit into a lingual sheath).
The posterior helix is beveled slightly to lie against the palatal vault and is as close to the upper molar
as possible to prevent impingement on the palatopharyngeus muscle. The anterior helices are brought
as far forward as possible and the anterior horizontal arm should generally sit over the incisive papilla,
slightly lingual to the upper incisors to allow for intraoral activations. The anterior segment of the W
expansion should be as wide as possible so that the appliance is maintained away from the swallowing
position of the tongue. This will help avoid tissue impingement of the appliance on the palate or
tongue and can prevent an unwanted tongue thrust created by placement of sections of the appliance in
the tongue space. All of the helices should roll to the top and should be tightly wound to increase their
mechanical efficiency (Fig. 21).
Following expansion with the W appliance the following should occur,
The upper molars should be rotated distally
The upper buccal segments expanded,
A more normal upper arch form created
Increased space for erupting upper central and lateral incisor teeth.
On frontal head film some midpalatal disjunction will also be noted.
The overall expansive process should take not more than three months. Although this is long enough
to allow for arch form changes, axial inclination changes, and spacing occurring in the upper arch, it is
not adequate time to allow for the reciprocal responses that we expect to occur in the lower arch. The
arch form and axial inclination changes that occur with the W expansion also occur in long-term
headgear therapy with an expanded inner bow
B. Expansion by midpalatal disjunction: Where the axial inclination of the upper buccal segments is
more ideal and yet crossbite exists, palatally borne appliances are typically used to enhance midpalatal
disjunction. A Haas-type or modified Nance appliance is used to gain these changes.
Overexpansion of the maxillae is necessary, as the palatal vaults tip buccally and must be allowed to
upright to create normal axial inclinations as well as ensure stability in the expansive process.
2. Advancement or forward movement of the lower incisors
When the visual treatment objectives and physiologic factors warrant (i.e., symphysis size, shape, and
form; muscle position; esthetic considerations), retruded lower incisors can be gently intruded and
advanced to reach a more favorable esthetic relationship to the APo line. This type of forward
movement of the lower incisors is attempted in the brachyfacial type case, where bite opening should
partially occur by virtue of incisor intrusion, as well as change in axial inclination of these teeth.
Each 1mm of forward movement of the lower incisors will yield 2mm of arch length gain (Steiner).
Arch Forms
Factors taken into account in the research of arch forms included:
Arch correlation
Consideration of size
Arch length
Where the arch was to be measured
Contact details
Final determination of form at the bracket location
Twelve arch forms were originally identified, which were narrowed down to nine by computer work.
Studies of other normal and stable treated patients resulted in five arch forms.
These were labeled Penta Morphic Arches
1. Narrow ovoid
2. Tapered
3. Normal ideal
4. Ovoid
5. Narrow tapered
the advancement of upper molars is a matter of encouraging and supporting this natural process. A
vertical closing loop or double delta loop will assist in its forward closure.
Lower molar anchorage
Maximum lower molar anchorage is maintained through the action of the long lever arm of the
lower utility arch as described. During cuspid retraction on sectional arches, the utility arch is used in
extraction mechanics to intrude or stabilize the incisors, while the various molar anchorage needs are
met by modification to the basic utility arch. Four mechanical adjustments are placed against the
molars in establishing a maximum anchorage effect:
1. Buccal root torque that places the roots against the cortical support to limit their movement. Up to
45 of buccal root torque is placed in a .016 .016 Elgiloy wire.
2. Buccal expansion of the molar section of 10mm on each side is necessary to support the buccal
torque.
3. Tipback of 30-40 keeps the molar upright and resists the forward pull in response to the cuspid
retraction springs. The tipback is the reciprocal action that acts to intrude the lower incisors. (The
molar step for maximum anchorage should be kept against the molar tube.)
4. Distal molar rotation of 30-45 is also placed in the molar section of the utility arch in extraction
cases. The molar needs to be positioned to resist the forward drag on it during cuspid retraction, as
well as to be positioned to receive the upper molar in a proper functioning occlusion.
Moderate lower molar anchorage modifies the lower utility arch mechanics to allow the molar to
come forward during cuspid and incisor retraction. A contraction utility arch stepped ahead of the
molar tube modifies the four components of molar anchorage and utilizes the incisor retraction force to
advance the molar. A proposed 3-4mm forward lower molar movement must respect the musculature
which reflects the facial type.
In the extreme vertical pattern open bite cases, 3mm forward movement would still require maximum
anchorage to hold; while 3-4mm forward movement in a strong, deep bite brachyfacial type would be
minimum anchorage and require special efforts to advance the molar. The facial type which reflects
this muscular anchorage is a critical factor in influencing the treatment prescribed.
II) Retraction and uprighting of cuspids with sectional arch mechanics.
Bioprogressive Therapy proposes segmented arch treatment and retracts the cuspids on sectional arch
retraction springs.
The cuspids need to be kept in the narrow trough of trabecular bone and avoid the severe tipping or
displacement into the cortical bone.
When cuspids are retracted on sectional arch retraction springs they are free moving and not limited by
the binding restrictions of a continuous arch wire. Care must be exercised in sectional arch treatment
to compensate for the tipping and rotational control in sectional arches.
Extreme 90 gable and 90 offset antirotation bends are placed before the springs are placed and
activated for the cuspid retraction. The activation of the cuspid retraction springs should produce 100
to 150 grams of force for cuspid retraction. Only 2-3mm of activation is required to produce the
desired force. Heavier forces allow excess tipping and loss of control. Lingual string can assist in
rotational control in the final one-third of cuspid retraction, after it has retracted around the corner.
Tipping may occur when the retraction forces have been too high, in excess of 150 grams. Cuspid
uprighting springs are preactivated with 90 of activation in order to generate a light continuous force
to upright and parallel the roots adjacent to the extraction site. The crowns need to be ligated together
during uprighting in order to prevent their separation from returning.
2. With a tendency for deep bite the class II elastics can bring the upper incisors back and start
jamming the lower incisors as they are retracted.
3. It is difficult to overcorrect the upper buccal segment without bringing the upper anterior teeth into
lingual cross bite.
When the upper buccal segment teeth are treated as a section, and the Class II is corrected in a
segment, overcorrection can be accomplished without having a detrimental effect upon the upper
incisor.
Traction Sections
Tractions are utilized to counteract some of the negative responses that occur with Class II elastics to
the buccal segment.
The tendency for the downward pull of the Class II elastics to extrude and throw the root of the canine
mesially is countered by placing a small closed helix distal to the upper cuspid teeth with a gable or
tipback of 30. The anterior portion of the segment should also be rotated mesially 45 and often a
horizontal closed helix is placed at the molar region to maintain or accentuate distal molar rotation.
The traction section also stabilizes the upper buccal segments against the impending intrusion and
torque in the upper incisors.
Upper incisor alignment and intrusion
As the buccal segments are moved distally this allows for some functional realignment of the anterior
segment.
A contoured anterior segment if used to level the upper central and lateral incisors and to close anterior
spaces prior to intrusion and retraction.
An upper utility arch is then placed and the upper incisors are torqued and intruded as necessary prior
to their final retraction.
Consolidation of the upper incisors
It is necessary to over treat the overbite in order to overcorrect the buccal segments.
There should be in effect a 2mm step between the cuspid bracket and the incisor bracket in order to
create this relationship.
The most commonly used arch used to accomplish this is a closing utility arch, but it is possible to
continue torque on the upper incisors with the upside down closing arch or a very simplistic vertical
helical closing arch.
Idealization of arches and finishing details
An upper ideal arch, fabricated from .016 x .016 blue Elgiloy, .017 x .017 blue Elgiloy, .016 x .022
Nitinol, or .017 x .025 Nitinol, is utilized to place final arch form and torque adjustments in the upper
arch.It is important that Class II elastic wear be discontinued at least two months before final
debanding/debonding. This period will allow for physiologic rebound and is essential in the
determination of centric relation.
Quite often two light round arches (.014 or .016) bent in ideal arch form are utilized to allow for
function to seat the occlusion. These light round arches are also quite beneficial in making minute
adjustments for the band/bracket height discrepencies that are present in most situations.
upper molars and the incisors is a greater distance and, therefore, decreases the force delivered to the
maxillary incisors.
3. The Stabilization of the Molars
The use of the .016 .022 utility arch in order to create the added force needed to intrude the
maxillary incisors has an adverse tipping effect on the maxillary molars.
The use of Quad-Helix, Lingual Arch, or Tranpalatal Bar will help stabilize the maxillary molars.
The best way is to band/bond the bicuspids and cuspids and place a stabilizing leveling sectional arch
in the occlusal molar tube, which will avoid excess tipping of the upper molars, This will, in effect, pit
the entire upper buccal segments (and therefore muscle function) against the intrusion of the upper
incisors. The stabilizing section is .016 .016 or .016 .022 with a tip-forward (down) bend in the
molar section. This bend will keep the molar upright and, therefore, help in the Class II correction.
4. Torque Control
Due to the fact that many Class II, Division 2 patterns are brachyfacial and, therefore, have a high
facial axis angle and resulting horizontal growth, by putting the upper incisors parallel to the facial
axis the interincisal angle is decreased which will help to maintain the overbite correction experienced
in many Division 2 cases. There should be early torque control in the maxillary denture in all cases.
II. Intrusion of the Lower Incisors and Cuspids
The lower incisors are intruded using a mandibular utility arch
There are two ways of accomplishing this:
1. Using an .016 .022 stabilizing utility arch and tying the elastic ligature lightly from the cuspid
bracket to the utility arch in the bridge section
2. The second possibility after the intrusion of the lower incisors is to place an .016 .016 utility arch
with a 45 tipback at the molar and allow the anterior section, when it is placed in the molar bracket, to
extend down into the mucobuccal fold (this will give approximately 60-75 grams of force); then tie the
elastic ligature from the cuspid bracket to a notch bent into the utility arch bridge section and elevate
the anterior section, by tightening the elastic ligature, until it is level with the incisor brackets. The
opposite side will be down slightly, and tying the elastic ligature on the opposite side can be carried
out in the same manner. When the anterior section is level with the incisor brackets, it is then tied into
the brackets.This can usually be accomplished in one appointment and will insure that there will not be
an extrusion force on the incisors.
It is possible at this stage of treatment to band/bond the upper maxillary cuspids and premolars, if not
previously done, and place a traction section.
If advancing the lower incisors is necessary, one of the modified utility arches may be constructed.
III. The Aligning of the Buccal Segments
The leveling of the maxillary and mandibular buccal segments may have been accomplished in the
previous steps. If so, then Class II mechanics can proceed. There are three basic types of sections:
1. The stabilizing section, which also would function in leveling.
2. The consolidation section, which may be used to help close any spaces that have developed.
3. The traction section for distalizing the buccal sections with Class II elastics.
The molar section would have a horizontal helical loop and bayonet bend mesial to the molar bracket.
The cuspid section would have a horizontal helical loop with a gable and tip-up bend.
Bioprogressive Therapy, which proposes unlocking the malocclusion and establishing a more normal
function to support the occlusion, must be continually aware of the physiology and its influences in all
stages of treatment, particularly during the finishing and retention stage.
Occlusal Check List in Finishing
An occlusal check list including eight areas in each arch is used in establishing the ideal finishing arch
configuration and individualized tooth rotation in our overtreated orthodontic finishing occlusion.
The patient at this stage is seen at two-week appointments, for the adjustments are more delicate and
controlled.
During the final two-week adjustment the cuspid and bicuspid bands may be removed to allow closing
of the band space. New bonding procedures that eliminate the interproximal band material may not
require the stage of final finishing.
Mandibular arch
1. Arch width across second molars.
2. Distal of first molar rotated lingually until the distobuccal cusp approximates mesial sluiceway on
second molar.
3. Large buccal offset at mesial of first molar.
4. Check inter-bicuspid width for necessary expansion.
5. Proper buccal arch form and contour.
6. Premolar offset to bring it in contact with distal lingual incline of upper canine (2-3mm).
7. Mesial of cuspid tucked slightly behind lateral incisor distal of the cuspid buccal.
8. Over-rotation of incisors; smooth arc.
Maxillary arch
1. Width across first and second molars.
2. Distal rotation of first molar so that line drawn through distobuccal and mesiolingual cusps points to
the distal third of the opposite side cuspid .
3. Mesial offset (large) on molar.
4. Mesial rotation of lingual cusp of first bicuspid to seat in distal fossa of lower first bicuspid.
5. Premolar offset (2-3mm) to avoid first area of prematurity.
6. Cuspid brought into contact with lower cuspid and premolar to establish cuspid rise.
7. Lateral left labial (until retainer) to allow overtreatment of buccal segments; then tucked in.
8. Smooth arc across incisors.
Three Separate Phases of Retention
Retention in Bioprogressive Therapy is the process that sustains and guides the settling from the
overtreated or orthodontic occlusion into the final functioning occlusion.
It first guides these changes during the initial adjustments, and then supports the bony sutural and
muscular accommodations to the changing environment. Finally, retention should consider the long
range influences which involve changes created by growth, tooth eruption, and function, characterized
by the different facial types.
The Initial Stage of Retention
The initial stage of retention, perhaps the most obvious and critical, occurs during the first six weeks
following the conclusion of the active phase of treatment when the appliances are removed and the
teeth are "turned loose" to erupt along their normal eruptive paths into the functioning occlusion.
Retainers inserted at this initial phase are not designed to hold, but to assist in guiding this settling
process.
The adjustments in the upper retainer include relieving the lingual to:
(1) close the anterior band space between the central and lateral incisors (buccal band space is
closed with finishing arches),
(2) allow the tucking in of the distal of the upper cuspids following their expansion and
overtreatment, and
(3) sustain the settling distal rotation of the upper molar as it functions with the lower rotated
molar occlusion.
In the lower arch, a fixed first bicuspid retainer is placed in order to
(1) maintain the cross arch bicuspid width and support the first bicuspid against the upper
cuspid and bicuspid function,
(2) allow the lower cuspids the freedom of adjustment against the upper occlusion, and
(3) place a lingual bar against the incisal third of the lower incisors to maintain their alignment
and rotational connection.
The fixed lower retainer being back on the bicuspids is easily acceptable to the patient and can be
maintained longer.
The Stabilizing Stage of Retention
The stabilizing stage of retention involves the ongoing phase over the first year following active
treatment when the sutural adjustment, transseptal fibers, functioning occlusion and muscle physiology
need to be considered in supporting the new occlusion. During this period the lower fixed retainer is
kept in place and the upper retainer is worn most of the time. Following the 1st year, if the functioning
occlusion remains stable, the retainer is worn only part time, during sleeping .
Positioner Use in Bioprogressive Therapy
Positioners have become popular in recent years as an appliance for use primarily during the initial
phase of retention when the teeth are the most susceptible to change, particularly minor adjustments
following band removal.
In the construction of a positioner, a face bow mounting is essential. A face bow registration is
desirable in being able to give an accurate articulator mounting and setup for the positioner. One
technique is to maintain the lower fixed 1st bicuspid to 1st bicuspid retainer and alter the positioner to
only cover the incisal one third of the lower arch. The setup is individualized to maintain the proper
buccal occlusion arch form, and interincisal angle.
For the best results, the positioner is placed immediately at band removal and worn full time or as
much as possible the 1st forty-eight hours. Settling is thus more controlled and accomplished faster
than that expected with the retainer, which may require four to six weeks to direct these initial
changes.
Long time retention needs to consider late growth changes and other influences that will continue to
affect the alignment of the teeth. These will depend upon original tooth movements necessary to
correct the malocclusion, the muscular function and growth changes consistent with the original
musculature, and facial type.
CONCLUSION
This seminar attempted to present the basic tenets of the Bioprogressive Therapy. It began with
a systems approach diagnosis and treatment planning and an overview of the management
procedures used to implement and carry out the logic process employed in our treatment. Various
treatment sequences were suggested that could be applied to a total course of therapy, rather than a
cookbook technique blindly followed in every case. Orthopedic alteration, optimum orthodontic
forces and combination of mechanics were suggested that would unlock the malocclusion in a
progressive sequence in order to establish more normal function for optimum health and stability
of the denture. Bioprogressive Therapy approaches an in-depth analysis of the basic malocclusion,
the underlying morphology with its functional variations, then attempts to treat them to as normal a
function and esthetic relationship as is possible for the long range health and stability of the
denture. Each case is approached individually because of its individual morphology, physiology
and malocclusion and the prescribed treatment sequence is selected to accomplish quality results
with efficiency.