American Journal of ORTHODONTICS

Volume 70, Number

ORIGINAL

4, October,

1976

ARTICLES

Bioprogressive therapy as an answer

to orthodontic needs
Part II
Robert

Murray

Ricketts,

Pacific Palimdes,

D.D.S.,

MS.

Cazif.

art I of this article dealt with theory and studies of orthodontic force
on teeth. Developments leading to the design of preformed bands and formulas
for first-, second-, and third-order control in the fixed apparatus were also discussed.
Part II is a continuation of the article?aimed at explaining the activating
mechanism and some treatment principles. A review of fundamental aspects in
planning anchorage will also be presented.
Developments

in prefabrication

of the activating

mechanism

All the details or rationale behind developments in wire form cannot be discussed at this writing; however, certain designs will be explained. Because force
values are needed and the 0.016 by 0.016 inch Elgiloy wire is used extensively
for movements in the bioprogressive method, the gross analysis of force delivery
with the blue wire is shown in Fig. 19.
By preforming arches and sections and either having technicians make them
up prior to appointments or obtaining them commercially, a standard control
is offered and the clinician has a better way of understanding forces delivered
and of being consistent with his activation. Through the use of such mechanisms,
efficient treatment is attained and healthy tissues result because the force values
are calculated in the design.
With the fixed apparatus standardized for bioprogressive therapy, slight individual adaptation of bands can be made to make it a very efficient and economical procedure for routine clinical use-thus its flexibility. Second-order (tip)
359

360

Am. J. Orthod.
October
1976

Ricketts

0A

CAPACITY

OF BLUE ELGILOY

CONCLUSION:
LENGTH

@
@
@
@
@
@
@

30mm
25mm
2Omm
1Omm
5mm
4mm
3mm

Around

2,000

WIRE

grams

FORCE
OF BENDING

+
+
+
+
+
+
+

VALUES
ROUNOED
IN THE MOUTH.

70
80
100
200
400
500
600

grams
grams
grams
grams
grams
grams
grams
OFF

FOR CLINICAL

ESTIMATES

An uprighting
action
in the Omega
helical
looped wctional
arch is effective in uprighting
lower molars.
The
SeCtiOnal

arch

is tied

onto

Fig. 19. A, Chart

showing
blue Elgiloy
wire
before
distances
it will withstand
the lever
tion of
and
(2)
amount
a lever
back-action

the arch.

the rough
bench
tests on the capacity
it will reach
its proportional
or elastic
up to 600 Gm. of force before
it will

of the 0.016
inch square
limit.
Note that
in short
bend
and that the longer

arm, the less force

it takes
to make
a permanent
set in the wire.
The introduca loop between
two teeth
accomplishes
two
purposes:
(1) it cuts down
the force
it increases
the range
of action
in the adiustment.
6, Illustration
showing
the
of force that would
be exerted
with a blue Elgiloy
wire,
not heat-treated,
used as
from
the molar
to the canines.
C, Another
application
of the reduction
of a short
loop for the purpose
of uprighting
the lower
second
molar.

and third-order
(torque) control are supplied in the bracket and tube designs
and their prefabrication
(as discussed in Part I).
First-order control will always be required of a clinician-if
not for simple
offset bends, certainly for arch-form variation and individualization.
However,
to reduce time-consuming arduous tasks at the chair while at the same time producing better standardized
and controllable mechanisms of superior quality,
many recommendations were made for commercial production of arch forms and
sections or for raising of certain brackets for a triple-control
arrangement.
The arch sizes were organized in the bioprogressive system (Fig. 20). In
order to select an arch wire for the individual patient, a measurement is made
from the distal margin of the lateral incisor to the same point on the opposite
side and converted to a numbered arch. The system is standardized so that the
same numbered arch for each individual can be used throughout treatment with-

vozume

Number

Bioprogressive

70
4

MAXILLARY
TORQUING

ANTERIOR
RETRACTOR

FINISHING

IDEAL

ARCHES

DOUBLE
CLOSURE

UTILITY

therapy

361

ARCHES

DELTASPACE
ARCH
LEVELER

ARCHES

Fig. 20. The standard

wires
preformed
to accompany
the preformed
bands
and
prefabricated
assemblies.
These
wires
come
in various
sizes,
and the millimeter
reading
is
that
which
is measured
between
the distal
aspects
of the two
lateral
incisors
in the
typical
patient.
The utility,
the double
delta,
the closed
helix,
the ideal,
and the finishing
arches
are common
sequences
employed.

out changing sizes in the five continuous arch types provided. In other words,
a No. 5 ideal arch size would be followed by a No. 5 finishing arch. The arch types
are the ideal, utility, double-delta, closed-helix, and finishing, which are shown
later.
Provision

in the standardized

ideal

arch

for

aid

in detailing

(fhzt-order

control)

As stated before, the ideal arch principle is used essentially to perfect the
individual arch. As the upper arch is coordinated to the lower (the lower is the

362

Ricketts

Am. J. Orthod.
October
1976

NON-EXTRACTION

EXTRACTION

0D
Fig. 21. Throughout
the evolution
of edgewise
therapy
the edgewise
arch took on various
forms,
starting
with
Angle
in 1929
(A), described
by Wright
in Andersons
textbook
in
the 1930s
(B), by Tweed
in his textbook
and practice
in the 1940s
and 1950s
(C), and
on to the bioprogressive
forms
as described
by Ricketts
in the 1960s
and
1970s
(D).
The conventional
patterns
are fashioned
following
the trifocal
elliptical
principle
of Brader
and the biparameter
catenary
curve
of Schulhof.

fig.

22.

and

triple

A,

the

initial

intruding
at

action

of

the

utility

and

the

use

of

phases

of

Class

II

effect

night

are

The
tubes,

in three

only.

E, F, and

shown.

H,

trusion

of

upper

Upper

utility

elastics

for

off
Class

The

G, The

upper

intruding

before
first

II correction.

and

6,

Note

D,

all

of

whom

effect

on

of
distal

the
of

arch,

in the

and

molar
space

lower

C,

intrusion

placement

permanent

the
section

examples,

section

incisors

in

straight

correction.

different

buccal

arches
the

Intraoral
upper

wearing

incisors
incisors

an

integrating

and

lower

arch
off

construction
buccal

of
segment

photographs

were

upper

to upper

the
upper

second

deciduous

applications

retraction.

shown
deciduous

the

headgear

other

before
as

during

showing
cervical

and

double

in

I,
Fig.

molar

23.

InJ,
and

molar.

base) ant1 brought together with intermaxillary

traction, a finished occlusion will
allegedly result with the edgewise arch philosophy.
To help minimize the thickness of bulky brackets and to help simplif,v invclitory and procedures, first-order control (step bends) arc provided in preformrti
arches. Loops and controlled activations are needed particularly
for cfficicl:t
treatment. During treatment the ideal arch is employed for near-final alignment
and arch form. The essential differences between the design offered here! and the
traditional cdgcwise ma>- he seen in Fig. 21.

364

Ricketts

Am. J. Orthod.
October
1976

DOUBLE DELTA SPACE

CLOSURE ARCH LEVELER

MAXILLARY
TORQUING

ANTERIOR
RETRACTOR

Fig. 23.

The application
of integrating
arches.
The double-delta
loop
serves
as a space
reducer
and
is used
to level
and
integrate
the arches
(A). Note that the intermaxillary
traction
should
be placed
over the mesial
bracket
rather
than
over the anterior
loop in
anchorage
problems.
Too much
force
on the anterior
loop
scleroses
these
teeth
and
inhibits
convenient
correction.
If the elastic
is to the anterior
teeth,
it should
be very
light
and the total
force
should
not exceed
300 Gm. at any time.
For retraction
of the
upper
anterior
teeth,
90 Gm.
is sufficient
for each
central
incisor
and 70 Gm.
for each
lateral
incisor.
Intraoral
photographs
(B and C) before
and
after
activation
on Patient
K. B. (3-week
interval)
show
the same setup
in actual
clinical
experience;
a T series
can
also be seen. D shows
a vertical
helix being
used for torquing
incisors.

First of all, the over-all type for the lower arch is more of a catenary curve
than one of a square or parabolic type. The upper arch follows a trifocal ellipse,
as described by Brader,40 although his studies support that form for both arches.
The bioprogressive arch form is characterized by flattening the canine area rather
than boxing out at the canine eminence. A slight gable is used mesial to the canine
and a definite buccal step is used at the distal aspect of the canine for the first

Volume

Number

70

Bioprogressive

Fig. 23, B-D.

For legend,

see opposite

therapy

365

page.

premolar in both arches. Finally, definite step bends (and rotations if rotation
tubes are not used) are made for the molars. This includes the lower rotation (12
degrees average) as well as the upper rotations (15 degrees average). With the
bioprogressive method, these step bends may be placed by the clinician, technician, or assistant41 With the triple-control
bioprogressive setup, these step
bends are essentially eliminated.
Other

preformed

arches

The utility arch. This vertically offset arch is employed for a variety of
purposes. It is commonly a starting appliance but can be employed any time
throughout treatment. Its application will be discussed later because of its profound relation to progressive therapy (Fig. 22).
The double-delta arch. This arch is used for integration
of buccal and anterior segments or for space closure following segmented therapy (Fig. 23).
The vertical closed-helix arch (torquing).
This arch is used for space closure
but, used upside down in the upper arch, is very efficient for torquing with space
closure of upper incisors (Fig. 23). It may, however, be used in the conventional
manner (loop to the gingival side).
The finishing arch (horizontal loops included). This 0.018 by 0.022 inch arch
is used for space closure, torque, arch-form control, and overtreatment
at progressive debanding. This size of wire is employed because of spaces spanned in
the arch (Fig. 24).

366

Ricketts

Am. J. Orthod.
October
1976

MAXILLARY

MAYDIBULA8

fig. 24. Progressive

debanding
is usually
employed,
the goals
being
space
closure
and
overtreatment.
The drawings
(A) show
the setup
for extraction
and nonextraction.
B and C,
The actual
arches
in the mouth;
the lower
loops
are opened
approximately
1 to 1.5 mm.,
and finishing
in Class
II cases is usually
accomplished
by distal
retraction
of the upper
incisors
from
the pull of intermaxillary
elastics
off the lower
incisors.
This will
keep
the
upper
buccal
segments
from
jerking
forward.
If the buccal
segments
are adequately
overtreated,,
then
conditions
will
permit
tiebacks
or activation
of the upper
loops
from
the
stability
of the upper
molars.

Volume
Number

Bioprogressive

70
4

MAXILLARY

CUSPID

CUSPID

CUSPID

Fig. 25.
retraction
triple

or quad

Prefabricated

OR UPRIGHTER

and
ideal
T

sections

modules
buccal

sections

(Fig.

auxiliaries

SECTIONS

T SERIES

used
sections,
are

with
bioprogressive
canine-intruding

available.

The

horizontal

or

therapy.
Upper
and
uprighting
sections,
helix

section

is not

lower
and
shown.

25)

These sections include

retractor, the ideal buccal
series, and the horizontal
space will not permit their
Other

BUCCAL

RETRACTOR

INTRUDER

The sections
sections,

367

RETRACTOR

IDEAL

MANDIBULAR

therapy

in prefabrication

the maxillary canine retractor, the mandibular canine

section, the back-action uprighter or intruder, a T
helix. Each of these requires some understanding,
but
discussion.
and

preforming

procedures

(Fig.

26)

The laser-welded and plastic-covered face-bow. This will be discussed later in

the article.
The quad-helix appliance. Special application of each of these appliances is
also needed. Some explanation of their use will be discussed as treated cases are
reviewed.
The bumper or buccal bar. This large round wire is adaptable for bumper
use in the lower arch and can be used in the upper arch as a traditional
E
arch, particularly
for rotation, expansion, or contraction of upper molars.
The lingual retainer bar. This 0.038 inch blue Elgiloy bar is adapted and was
designed for making the 4 4 retainer
t

directly in the mouth.

368

Ricketts

RICKETTS

FACE

BOW

u
u
LIP BUMPER

Fig. 26.
bumpers

Developments

Am. J. Orthod.
Octohel197F

Auxiliaries
and buccal

for the bioprogressive

bars,
and the lingual

in theory

QUAD

HELIX

PALATAL

APPLIANCE

L
MANDIBULAR
procedures:
the
retainer
blank.

face-bow,

LINGUAL
the

RETAINERS
quad

helix,

the

of possibilities

Departure
from belief in immutability
of skeletal structure. Among the
changes emerging in the early 1950s was the observation that extraoral traction
against the maxillary molar teeth (and later-determined
results from vigorous
intermaxillary
traction)
could effect changes beyond the alveolar structure.
Cephalometric findings in patients treated with primary and secondary edgewise
appliances had not suggested this to be true, and most planning prior to this time
was conceived on the basis of alveolar modification only. In a series of fifty-five
consecutive patients, presented with story-board analysis in 1955, I observed behavior of the midface not predicted or observed previously in cephalometric
studies (Fig. 27) .43 With this option, a new view was possible from a mechanical
standpoint in treatment.
One of the recognized problems in all kinds of treatment was the previously
mentioned rotation of the mandible or the downward and backward dropping of
the chin in treatment resulting from either extraoral traction or tooth extrusions
from intermaxillary
forces or even with simple bite plates. Prevention of incisor
interferences, therefore, became a new problem in mechanics.
Identificatiort
of tooth intrusion.
As early as 1948 I witnessed what appeared to be successful depression of the lower incisors.44 Direct intrusion had
seldom been noted, and not enough was known then about stable landmarks for
measuring changes to permit one to draw conclusions. During extraction
therapy, a deepening of the curve of Spee in the lower arch was often difficult
to prevent. Careful tracings during extraction treatment showed the lower second

Volulne
Number

Bioprogressive

70
4

NJ.

therapy

369

Fig. 27. Tracings

of Patient
N. J., a girl 8 years
3 months
of age. In A the patient
has a 9
mm. convexity,
an average
position
of the chin, and an extreme
Class
II, Division
1 openbite relationship.
The patient
was treated
with extraoral
traction
alone
in the upper
arch,
and treatment
was later
finished
with
full bands
and intermaxillary
elastics
(B). In C the
four-position
analysis
of treatment
is shown,
demonstrating
that
the chin closed
down
somewhat
as the upper
molar
was
moved
downward
and
backward.
Note
that
the
maxillary
angle
was reduced
6 degrees
and the palate
was tipped
5 degrees
downward
and backward.
Note
in position
3 that the teeth
were
hardly
moved
in the maxilla
and
that the correction
was made
essentially
by maxillary
skeletal
alteration.
Note
in 4, the
position
of the corpus
axis,
that
the lower
incisor
was
moved
forward
slightly
but the
lower
arch was stabilized.

370

Ricketts

Am. J. Orthod.
October
1976

Fig. 28. The retraction

section
setup
for a first-premolar
extraction
case. We try to activate
two or three
times
for upper
canine
retraction
and three
to four
times
for lower
canine
retraction
to help prevent
excessive
tipping
of the canines.
At no time do we try to exceed
150 Gm. of force
in the canine-retraction
action.

premolar to move downward toward the lower mandibular border during space
closure as the molar tipped forward in rapid space closure.
A profound evidence of the ability to intrude teeth directly-to
me, at leastwas the measured intrusion of the lower second premolar in extraction cases. It
appeared that preservation of anchorage or stability of the lower molar was
therefore contingent upon holding the molar upright, as the premolar could not
do it alone.
Space closure in the use of the edgewise applicance in extraction cases had
come to be handled in sections with push coils, pull coils, or loop designs in an
effort to produce efficient and independently
controlled canine movements,
especially to preserve anchorage. There appeared to be a depression in the arch as
a deep curve often developed during this phase of extraction therapy, leading
many to believe that deep-bites were caused by extraction.
In seeking a method for maintaining the lower first molar upright during the
canine-retraction
stages, we thought that the lower incisor teeth could be
utilized for anchorage if they could be mechanically connected or associated.45
The lower incisor teeth are often supraerupted
in deep-bites. Therefore, if a
countermoment
could be placed against the tipping force on the lower molar

Volume
Number

70
4

Bioprogressive

TWIN

BUCCAL

TUBES

TRIPLE

BUCCAL

therapy

371

TUBE

Fig. 29. A, Diagram

of a common
setup
for a Class
II, Division
2 case. Note the intrusion
of the lower
incisor
with
the utility
arch and the canine
brought
down
with
the canine
intruder;
however,
a direct
nylon
thread
or plastic
thread
is preferable,
as shown
in
B and C. intermaxillary
elastics
are used off the lower
molar
to retract
the buccal
section.
The utility
arch is placed
and activated
by high-pull
headgear.
Usually
we try not to
activate
the upper
incisor
segment
more
than a total
of 150 Gm. to prevent
sclerosing
of
the area
and alteration
of the entire
palatal
floor.
D, Detail
of the twin
buccal
tubes
employed
with
the technique
and the upper
triple-buccal
tube.
A rotation
upper
buccal
tube
may be employed
if desired.

372

Fig.
The

Ricketts

Am. J. Orthod.
October
1976

30. Patient
S. R., a girl, from
the ages of 9 years
7 months
to 12 years
7 months i. A,
beginning
condition
of the deep-bite,
Class
II, Division
1, with
crowding
in both the
er
and
lower
incisors.
6,
The
case
after
the
initial
expression
of
the
utility
arch and
PP
the headgear.
Note
that the convexity
has been
reduced
from
6 mm. to about
1.5 mm.
I
in tl iis stage.
The patient
still has lip strain;
this is the conclusion
of the first stage.
C, The
:al sections
banded,
a continuation
of the upper
headgear,
and the patient
now re !ady
for canine
I
retraction
off buccal
sections
in the upper
arch. D, The case following
the us e of
i nte rmaxillary
traction
on the buccal
sections;
the teeth
are banded
in preparation
for
rtreatment.

Bioprogressive

Fig.

30,

C md

D. For

legend,

see

opposite

therapy

373

page.

by the use of these extruded incisor teeth, it would be advantageous. Consequently, an uprighting lever or spring was placed against the lower mola .r from
the incisors in an arch (Fig. 28). The original purpose was to mainti Cn the
molar; however, the lower incisor was observed to intrude dramatically as shown
in the mouth and cephalometrically.
This set off a series of investigation 1s.
Birth of utility
therapy. As a consequence, double tubes for the lower -molar
were designed. The utility arch was born as a new approach to treatment. M This
arch was so named with the observation that this approach offered a wide : range

374

Fig.

Ricketts

31.

progressive

debanding
B shows

lower

arch.

mm.,

together
curve

It shows

of

narrowed
good

S. R. A,

relationship

retention.

with
idealism

and
patency

J. Orthod.

October

Patient

end-to-end

the

Am.

the
in the

The

overtreated

with

full-banded

and
the

space

patient
an

the

airway.

closure.

The

to

the

the

patient

D,

the

plane

case.
Frontal

C,

well

the

almost
is

now

denture

premolar

to

from

is holding

and
which

is

view

with

the

after

treatment

1 mm.,
film

in retention.

to

an

ready

premolar

of
Frontal

head

brought
patient

of

from
that

APO

is holding

patient

flattening

retainer

orthodontic

narrowed.

the

exercised;

relationship

incisor
treated

Note
a fixed

intermaxillary

arch

showing

therapy

wearing

lower

in the
upper

stage

1976

for

now

to

in

the

convexity
the

of
peak

nasal
showing

1
of

cavity
a

Volume

Number

Bioprogressive

70

Fig.

31,

C and

D. For legend,

see

opposite

therapy

375

page.

of usefulness and served much as a wide variety of uses in a technique. Control

and treatment of lower incisor overbite by intrusion, therefore, also was introduced as a method of treatment in nonextraction
cases (Fig. 29). Deep-bites
could now be treated to the level of the premolars rather than by premolar
extrusion. This made anchorage appear in a different light. The true occlusal
plane was drawn through the buccal occlusion and not the bisection of the incisor overbite (Figs. 30, 31, and 32 represent a patient treated according to
this theory.)
Reduction of wire sizes. By this time the size of the wire was reduced to a
0.016 inch square to be used routinely in the 0.018 by 0.030 inch Siamese brackt4.
This technique and appliance provided a method for maintaining
three-dimensional control at all times, especially at the very beginning. A return to Angles
original principle of three-plane controlled forces throughout
treatment
was
made. By employing the 0.016 by 0.016 inch blue Elgiloy utility arch with incisor
depression, upper incisor extrusion was avoided during space closure, incisor
traction, and intermaxillary
traction.47 (Fig. 33 shows the analysis of treatment
in Patient S. R. to augment this explanation.)
Techniques were designed to prevent the elongation of the lower molars
(just contrary to the prescribed effect of the Class II activator). In addition,
efforts to prevent some of the extrusion of the upper molars was also made in
certain open-bite or long-face cases during treatment. New designs for the extraoral appliance were made for checking extrusion of the maxillary molar in

376

Ricketts

Am. J. Orthod.
October
1976

Fig. 32. Patient

S. R. before
and
after
retention.
A, Crowding
in lower
incisor
area
but
space
in lower
right
premolar
area
with
recent
loss of deciduous
molar.
6, Note
overjet
and fractured
upper
right central
incisor.
C, Class
II deep-bite.
D, Occlusion
during
retention. E, Fractured
incisor
complicated
treatment
but occlusion
off center
very
slightly.
Patient
wearing
F, Action
of

Ricketts
type
of upper
retainer
retainer
to guide
upper
left canine

and
lower
distally.

premolar-to-premolar

retainer.

specific cases.** Upper molar extrusion, however, was not observed to be as hazardous as some investigators seem to imply. Oblique directional pull is advised in
patients proved to be growing vertically but usually requires more continuous
action.4g-52
Sectional arch progression. In conjunction with problems in molar control, a
distinct difficulty was recognized with the use of continuous arch application
to other teeth. In the control of the canines in one plane of space, the incisors
in another direction of space, and the buccal teeth in still another plane, many
teeth were observed to be locked or bound when movements and forces with
straight continuous arches were critically studied.
As a result, techniques were sought and methods were designed to break up the
arch and to accomplish gross sectional or unit movements during the primary treatment stages. (See Figs. 22, 23, 25, and 28.) Anchorage considerations could then
be developed as never before as individual teeth or units could be calculated, once
this possibility of breaking up the continuous arch was recognized!53 Individual
rotating and buccal control could be handled by preformed T looped sections,
by straight round, or with woven wires. Consolidation and complete arch integration were delayed until a later stage of treatment with double-delta arches (see
Fig. 23).
Control in this sense did not mean working up to and rigidly fixing ideal
arches and then forcing massive arch correction. Many edgewise clinicians witnessing this new approach for the first time clinically, without an explanation, are
horrified when receiving the transfer case at this progressive stage (Fig. 34). The

Volume
Numaer

Bioprogressive

70
4

Fig. 33. Patient

S. R. Four-position
tracted;
3, incisors
retracted,
molars
molars
forward
1.5 mm.

longitudinal
erupted;

4,

therapy

analysis.
1, Chin
closed;
2, maxilla
lower
incisors
intruded
and retracted

377

reand

fig. 34. A, Patient

having
had utility
on lower
and still lack of space
receiving
push coil
for space opening
and elastics
off section.
integration
will follow.
6, Very
severe
Class
II
malocclusion
in a 15year-old
girl wearing
elastics
to buccal
section
only;
note the effects
prior
to banding
of upper
incisors;
lower
arch is at ideal
stage.
C, Class
II treatment
off
lower
utility
and upper
section.
D same
as C with
lower
canine
banded
and ligated
for
intrusion.
Upper
lateral
incisor
is peg shaped.

378

Ricketts

Am. J. Orthod.
October
1976

0C
FSg.

35.

t )ends
C III

Arch

form

the

upper

in
four

scheme

lateral
for

the

in

nonextraction

molars,

incisors
tripie-control

the
in

each
setup

(A)
step
arch
for

bends
with
extraction

and

an

for
the

the

extraction

(B)

upper

premolars,

standard
case.

Note

case.

bioprogressive
nonbent

Note
and

wire.

the
the
setup.

bayonet
gable
C,

for
The

Volunte
Number

70
4

Bioprogressive

NORM

AGE

13

therapy

Fig. 36. The 13-year

norm
as programmed
in the computer.
At age 13 there
is very
morphologic
difference
between
males
and females.
Cut-offs
for growth
start at age
for girls while
in boys growth
continues
to the average
age of 19. Note
that the
incisor
is at +l to +2 mm. ahead
of the APO plane.

379

little
141/z
lower

double-delta arch levels and integrates the arch, often in one appointment,
and
this observation need not be disturbing.
The same idealization
conditions prevail in extraction therapy, which I
find necessary in slightly less than one-third of my practice (Fig. 35). Sections
are employed together with holding or utility arches in the early phase of therapy
in extraction as well as nonextraction cases.
Summary

of bioprogressive

development

Industrial technology in orthodontics led to preformed bands. With the development of prewelds, the field gradually moved away from one simple bracket
or tube to a torque-tip rotation setup for individual teeth. These were explained
briefly in Part I.
With these developments, the same general philosophy was extended into
providing
preformed
continuous arches, performed sections, and predesigned
modules to further eliminate work at chairside while increasing control, efficiency, and standardization.
The study of forces and wire capacity led to the design of loops which fit into
an organized group in natural progression. While these can only be listed and
shown as technical measures, their application needs to be extended. For this
reason, theoretical possibilities were included to help guide the clinician in the
selection of the therapy described herein.
There is no such thing as an automatic appliance ; Nature is too variable. As it
was realized that orthopedic change was possible and that maxillary alteration
could be controlled, new application of the headgear was made. The upper in-

380

Fig. 37.
selected

Am. J. Orthod.
October
1976

Ricketts

A,
for

The composite
Class
II, high

of a group
of thirty-one
convexity.
In comparison

patients
at
to the normal

the mandible
is slightly
shorter
and tetraded
and the
gesting
that
Class
II malocclusion
is a combination
problems.
B, A cephalometric
setup
for the average
of
growth
added
to include
change
for 2 years.
Note,
convexity
and the placement
of the lower
incisor
at
which
satisfies
the esthetic
equilibrium
and
apparent

age 8 years
composite
for

8 months
that
age,

maxilla
is slightly
protrusive,
sugof both
mandibular
and
maxillary
that group
with
2 years
of natural
for the ideal,
the reduction
of the
+l,
22 degrees
to the APO plane,
functional
equilibrium
of the soft

tissues.
C, The analysis
of changes
needed
for treatment
in the foregoing
typical
Class
II
case. In CJ the chin growth
is downward
and forward
5.2 mm. and the facial
axis is not
changed.
The upper
molar
is moved
approximately
4 mm. downward
and 2 mm. backward.
Note,
in b, the alteration
of the palate
and
the movement
of the upper
incisor
together
with
the palate,
as would
be exhibited
by the use of cervical
traction
in this
condition.
In c the beforeand after-treatment
tracings
are superimposed
over the corpus
axis at Pm. Note
that
the lower
incisor
is intruded
and
brought
forward;
the molar
is
shifted
forward
approximately
2 mm. to account
for the arch-form
change
that
usually
accompanies
treatment.
Note
point
A is brought
backward

also
over

the
the

relative
chin.

change

in the

cant

of

the

APO

plane

as

cisors were deliberately not banded until the later phases of treatment. When it
was observed that any of the teeth could be intruded, deep-bites were treated to
the level of the premolars rather than extruding the posterior teeth which rotated
the mandible backward. As it was realized that permanent expansion was possible
through the premolar and molar areas and that changes in arch depth could
be quite significant to the prognosis, a whole new attitude developed with regard
to sophisticated treatment planning. These were shown in order to demonstrate
their application.
Biologic

and

mechanical

factors

Let us now review some of the factors in planning anchorage and movements
with the appliances already described. Anchorage factors possess physiologic or
biologic overtones which make treatment planning more than an application of

Volume

Number

70

Bioprogressice

Fig.

37,

C. For

legend,

see

opposite

straight physics or mechanics. (I have in preparation

covering the subject in greater detail.)
Anchorage

therapy

381

page.

nine books in three volumes

considerations

Although sixty features of this technique have been listed,54 for the purposes of anchorage consideration
only five major distinctive qualities are
covered here. These are orthopedic or skeletal alterations, the use of growth,
the concept of cybernetic feedback in planning, and muscle consideration. Although cortical bone was discussed in Part I, more respect and discussion for
cortical bone is thought to be important enough to warrant further attention.
Extraoral traction (skeletal anchorage). The normal lower incisor varies but
balances homeostatically
to both jaws (Fig. 36). The incisor is convenientl?
measured between pogonion and point A (the anterior limit of the denture base!,
from which areas the mouth muscles originate. These points change and are
changeable with treatment. Thus, the calculation of original anchorage needs
is related to two skeletal factors-the
mandible (represented by Pm) and the
maxilla (represented by point A). The essence in planning is the consideration of
the skeletal relations that will be present at treatments end and at maturity together with functional equilibrium of the lips.
A first major factor in the calculation of anchorage needs is the determination
of tooth movement needed for the lower incisor. This calculation starts with
the amount of orthopedic change desired in point A or a change in convexity
(Fig. 37). In a growing patient, however, the need for skeletal point A alteration

302

Fig.

Am. J. Orthod.
October
1976

Ricketts

38.

Patient

M.

F., a girl.

A, At

age

9 there

is a Class

crowded
dentition
treated
with
modified
secondary
intermaxillary
elastics
with
slippage
and
elevation
space
closure
and Class
II traction.
C, The behavior
extraction
and space
closure.
If the bite were
closed,
have
tilted
extensively.

I malocclusion

with

edgewise
in 1954.
6, The
of the lower
molar
as a
of the occlusal
plane
as a
the occlusal
plane
would

open-bite;
effects
of
result
of
result
of
probably

is first contingent upon the amount of convexity reduction caused by mandibular

behavior. The learned orthodontist
is therefore obliged to make some sort of
estimate of ultimate facial morphology at maturity, whether he calls it a prediction, a prognosis, or whatever.
The amount of change desired in the midface (point A and also the soft-tissue
nose) affects the decision for the choice of direction of force, its duration, and
the timing of extraoral anchorage. Certain appliances are not known to affect
skeletal behavior; others have been shown to produce effects. The needs decided
upon affect the decision for anchorage preparation and amount of force to be employed later with maxillary traction. The convexity factor is to be considered

Volume
Number

Fig.
wax
the

39.

A,

Renderings

impression
4 mm.

based
cast
Note

or

convexity,

protrusion.

B,
on

rendering

The

feedback
of

with

therapy

Bioprogressit~e

70
4

the

ultimate

questionable

of
the

Patient

S. R. with

photographic

the

elevation

printout

of

shows

information
short-range

the
the

from
forecast

arch

form

third

molar

and

the

processed

groups

size

relationship

of

and
the

and

length
cast

the

comprehensive
of

the

form

copy
incisor,

clinical
with

space.

lower

arch

treated

treatment
based

as copies

as

shown

excessive

from

below.
maxillary

cephalometric
cases
design.
upon

of
D,

requirements

the
Note

dental
description

similar

The

383

kind.

long-range
of

C,
fore-

the

case.

384

Ricketts

Am. J. Orthod.
October
1976

COMPREHENSIVE
LATERAL

CEPHALDMETRIC
DESCRIPTICh
BEFORE
TREATMENT

FACTOR

FIELD

MOLAR

THE

MEASURED
VALUE

DENTURE

FIELD
II
CONVEXITY
LOWER

THE

FACIAL

SKELETAL

0.8
3.3

MM
Pot

11.1

MM

4.9
6.2
115.5

PP
MP
DEG

PROBLEM

4.7
HEIGHT

44.9

FIELD
I I I
DENTURE
TO SKELETON
UPPER
MOLAR
POSITION
LB.8
HAND
INCISOR
PROTRUSION
9.5
MAX
INCTSOR
PROTRUSION
11.6
HAND
INCISOR
INCL INATION
19.5
MAX
INCISOR
XNCLINATION
45.1
-2.2
OCCLUSAL
PLANE-RAMUSt
XI 1
OCCLUSAL
PL
INCLINATION
25.1
FIELD
IV
ESTHETIC
LIP
PROTRUSION
UPPER
LIP
LENGTH
LIP
EMBRASURE-OCC

PROBLFM

0.1
27.9
-2.5

PL

FIELD
V
THE
OETERMINATION
FACIAL
DEPTH
FACIAL
AXIS
FACIAL
TAPER
MAXILLARY
DEPTH
MAXILLARY
HEIGHT
PALATAL
PLANE
(FH)
MANDIBULAR
PLANE
i Fti)

0B

(LIP

39,

CLINICAL

DEVIATIONS
FRCM kCRC

RELATIDIU)
-3.0
-2.c
2.5
2.5
1.3
130.0

MM
PC
MM
CC
cc
DEG

(MAXILLO-PANDIBULAR
MM
1.8
MM
OEG
46.8
DEG

Mt
PP
1JP
DEG

12.9

1.0

OEG
PC
DEG

MP

HP

3.5
22.0
26.C
c.5
23.Q

CM
DEG
DEG
IVP
DEG

-2.2
25.1
-3.4

CF
PP
cc

6. For

legend,

1.3
1.8
3.4
1:;
-2.4

*
*
***
*
**
**

RELATION)
1.4
*
0.0

2.0
-0.2
3.7

*
***

-0.6
4.8
-0.9
0.5

***

RELATICN)

MM
PC
PM

PROBLEM
(CRAhTC-FAC141
87.3
DEG
86.8
DEG
9C.2
DEG
9G.L
CEG
68.8
DEG
68.0
OEG
92.0
DEG
90.0
DEG
OEG
53.4
DEG
51.6
DEG
1.0 DEG
8.4
23.9
OEG
25.8
DEG

THE
INTERNAL
STRUCTURE
FIELD
VI
31.8
CRANIAL
DEFLECTION
66.0
CRAN I AL LENGTH
AN TER IOR
POSTERIOR
FACIAL
HEIGHT
56.0
82.9
RAMUS
POSITION
PORION
LOCAT
ION
L TMJ )
-38.2
MANDIBULAR
CORPUS
LENGTH ARC
68.0
21.3
fig.

hICAL

NCRM

lOCCLUSAL

PROBLEM

RELATION

CANINE
RELATION
INCISOR
OVERJET
INC ISOR
OVER6
I TE
LOWER
INCISOR
EXTRUSION
INTER
INC I SAL
ANGLE

CL1

PROBLEM
(DEEP
DEG
27.0
DEG
PM
57.8
PC
CP
58.2
Ml
DEG
76.0
DEG
-40.3
PP
Mb
DEG
PM
68.8
26.5
MM
OEG
see

1.2

RELATION)
0.1
0.0
0.2
0.7
4.6
2.1
-0.3
STRUCTURE)
1.6
2.3
-0.5
2.5
0.8
-1.3
-0.2

*
*

**

*
**
**
*

p. 383.

even in simple Class I extraction therapy. Therefore, a cephalometric setup-or,

at least, the orthopedic thought form-is
required in practically all cases for
complete sophistication (Fig. 37, B).
Natural growth as a factor in dental anchorage. Natural growth expectancyif understood-is
a primary basis for planning. Orthodontics involves a plan for

Volume

Number

Bioprogressive

70
4

COHPREHENSIVF
FRONTAL

CEPHALOMFTRIC
BEFORE
TQEATMENT

FACTOR

MEASURED
VALUE

FIELD
I THE DENTURE
MCLAR
RELATION
LEFT
MCLAR
HELAT
ION Q IGCT
INTERHnL4H
WICTH
INTFRCPN
iNF
w ICTH
CENTUQE
MlCLfNF

FIELC
ii
MAX-MAND
WAX-MANC
MAY-uhlD

THE
SKELETAL
WIDTH
LEFT
w ICTH K IGt-T
M IDL INE

FIECC
111 CfNTURE
TO
YDLAR
TCl J.4W
(LEFT)
!GLAQ
TU JAW
(R iGHT1
DENTURE-JAW
MTOL INES
OCCCUSAL
PLANE
TILT

FIELC
FOSTUQAL

PROBLEM

Fig.

39,

RELATICNI
1.5
VP
1.5
cc
54.c
WC

26.2
2.8

24.e
0.c

ATIOhS
hCRP

-0.6
0.2
-0.6

CP
rr

0.5
1.9

-11.1
-11.1

PC
fJy

c.0

DFG

-0.3
0.0
0.8

{MAXILLC-CANDIRCLAR

4:

RELATIChI

-11.8

MM

-11.0

1.5

MM
DEG

6.4

YM

6.9

Clu

-0.2

MM
MM
M*

6.5
0.c
p.c

ww
ww
wc

-0.6

SKELETON
5.6
0.2
-0.6

THE
CETEK!iNATiCN
SYMYETPY

THE
INTEPNAL
FIELG
Vi
NAS4L
MIDTH
hASAL
PPOPDRT
ION
MAX ILL 4 PK0PORT
ION
M6kC I PL E PHOP0R.T
IClN
FAC i4L
PRCIPDRT
l\lN

CLIhICAl
LEVI
FRCF

IOCCLUSAL
0.7
MM
1.8
YM
52.9
MM

PROBLEM

385

DESCRIPTION

CLINICAL
NGRP

MM
MP

therapy

PRCRLEM

3.6

STRUCTURE

(CRANIC-FACIAL
C.!!
OEG

PROBLEM

?C.5
t2.y
lC3.7
51.4

M"1
CEG
DEG
DFG

97.5
B (Contd).

OFG

For

CEG
legend,

(DEEP

25.7
59.2
102.7
88.1

DEG
DFG

97.3
see

PW
DEG
GEG

RELATiCI\o

L.8

STRUCTUREI

2.4
0.8
0.2
-1.7
0.1

**
+

p. 383.

either maintaining
or moving the molar teeth. This is obvious in Class II and
Class III cases, but even in Class I cases with extraction an issue may revolve
around the amount of slippage forward of molars permitted in space closure
(Fig. 38).
Very simply, the effort is made to determine the contribution that growth (or

386

Am.

Ricketts

TREATMENT

J. Orthod.
October
19i6

MSIGN

Figi. 39,

C and

D. For legend,

see

p. 383.

physiologic rotational change) can make toward the correction or to the detraction of the case (see Figs. 30 to 33). Use of the growth forecast plus the added
visualized treatment objective in a graphic form results in the treatment design.
From this, the clinician may determine whether an arch needs to be moved 01
left alone. He can further, with a cephalometric setup, determine that portion
of the arch needing movement or needing to be maintained and can plan the
anchorage accordingly. A computerized work-up on Patient S. R. showing needed
movements is displayed in Fig. 39. This is similar to those manually produced for
the past 25 years.
Mandibular
growth contributes to anchorage planning in that the jaw movement through growth carries the entire arch and thereby reduces lower anchorage
need (see Figs. 37 and 39). On the other hand, unfavorable growth or behavior
increases anchorage problems and further complicates the plan. Growth, included
in the setup, is therefore equated to mechanical anchorage and is a very real
phenomenon. A treatment
design with cephalometrics is quite fundamental,
even when no growth is expected or when the patient is an adult or a growing
child with a Class I malocclusion (Figs. 39 and 40). Anchorage needs are further
complicated by two dental factors: the needs of the upper arch and the needs
of the lower arch.
Factors of feedback information
ill plnwni~~g. Expected results are presumed
on the basis of probabilities learned from successful treatment of like cases. The
details of the plan are contingent upon a successful chain of events. Treatment is
planned in light of the success in the first stages of treatment itself. Presumptions
or estimates must be drawn under any circumstances.
For instance, if the maxilla is carried posteriorly, it takes with it the maxillary denture. In turn, as the maxillary base is moved backward, point A is reduced. As point A is reduced, the lower incisor now also must be considered

vozunae
Number

70
4

therapy

&ioprogressive

TRERTMENT

LIESI i.M

CWUIOF: ItI IlRXiLLRRY TEETH

0
1

ImFrlf:

tw*cL

rlnlruaw

Kw -uI

Fig.

-u1d

40.

A,

The

comparisons
natives

treatment

of
on

the

right

required

by

at

maturity.

Note

as

the

is

that

chin

the

with

tinuing

lower

treatment

with

was

lary

traction

followed,

B, The

ship
pare
as

between
the
against

the

computer
2 years

the

in

the

moved

and

planned
to
plan).

the

be

(in

on
up

the
to

Patient
by
actual

lower

in the

S. R. as
the

with

and
as

need

made

to

be

followed

and

the

actually
at

short

con-

upper.

II intermaxil-

with

showing

starting
by

in the

Class

2
from

intruded,
of

a section

mm.

position

change

finalization

produced

results
4

consisted

and

that

treatment

esthetic

from

arch,

intrusion

treated,

computer
changes

will

lower

and

for
the

the

plan

lower

idealization

alter-

Note

also

incisor

the

from

treatment

approximately
1).

treatment
on

upper

of

backward
Note

The

constructed

The

programmed

position

distally.

utility

9.54,

a comparison

moved

4 the

age

findings
is

premolars

leading
of

left

stabilized.

the

by a utility

analysis

rendering

be

on

arch,

treatment

downward

arch

banding

actual

and

In position

to

upper

upper

is to

3).

needs

at

prognoses.

certain

the

molar
are

a girl,

long-range

with
On

incisors

position

in turn,

on the

stripping.

CHlUKdEIN lW4BXBULRR TEETH

S. R.,

and

noted,

forward

molar
on

Patient

kind.

upper

upper
(in

be

this

the

growing

headgear

This

will
of

that

alteration
the

side

and

for

short-range,

patients

maxilla

alveolar
while

design

beginning,

as

=Sown

B--m

progressive

strong
produced.
range

relaticnCom(3 years

Am. J. Orthod.
October
1976

30% Ricketts

S.R. Q
9-7

l-o 12-7

Fig.

40,

,B. For legend,

see

p, 387.

reciprocally for the best chances of ultimate homeostasis because it is related to

point A functionally.
The same thinking applies to the upper incisor as that
tooth reciprocally relates to the chin or pogonion.
Likewise, expansion of the upper arch in premolar width requires expansion
of the lower arch for proper occlusion. A similar thinking applies to the molar.
Thus, growth, physiologic change, orthopedic change, and arch integration are
all connected cybernetically in a plan of anchorage (Fig. 41).
Under this principle, cybernetically
seven key considerations must be integrated : (1) skeletal-mandibular
change; (2) skeletal-maxillary
change ; (3)
dental-lower
incisor change; (4) dent.al-lower
arch change; (5) dental-lower
molar change; (6) dental-upper
incisor change; and (7) Dental-upper
molar
change.
Muscular effects on anchorage. Another major factor in anchorage is the observation of muscular anchorage-muscle,
first of all, from the labiolingual or
buccolingual complex as demonstrated by the bumper techniques but, further,
the kinetic chain of muscles concerned with the opening or closing of the bite
and the rotation of the mandible. Physiologic stabilization of the mandible,
therefore, becomes a part of the consideration in applying a technique for treatment.
These observations go all the way back to my training experience in 1948.
A particular patient (E. R.) at the University of Illinois had one of the most
severe lip-sucking habits ever witnessed. 56 I happened to have the experience of
trying to get a plaster impression on this patient for the waiting list! The lower

Volume
Number

therapy

Bioprogressive

70
4

389

Fig. 41. The cybernetic

circle
for planning
anchorage.
The logic of this circle
is that each
change
is contingent
upon or related
to other
changes.
In the planning
cycle the amount
of required
distal
movement
is related
to the forward
position
of the chin (PO [Pm]);
the
amount
of chin
movement,
in turn,
is related
to the amount
of maxillary
orthopedics
needed
(point
A]. This,
in turn,
changes
the APO plane
which
is related
to lower
incisor
positioning
and
the
assessment
of labiolingual
equilibrium.
As the
lower
incisor
is
positioned,
the arch
length
is affected
as related
to increase
in premolar
width
which
ultimately
determines
the position
of the lower
molar.
This is another
determinant
for the
upper
first molar
behavior.
In this manner
it can be seen
how
the computer
can pass
through
steps.

these

steps

in

logic,

much

as

the

orthodontists

mind

might

go

through

these

lip had pushed the lower incisors backward so far that all eight of the lower
anterior teeth appeared to be almost in a straight line (Fig. 42). The patient was
treated by Robert R. McGonagle as a student. In the planning of this case, Allan
G. Brodie, Department chairman, decided to place a lip shield over the edgewise
arch in an effort to break the lip habit. This habit was so vicious that the shield
became embedded in the lip. The results of that case, studied 3 years after
treatment, strongly suggested that, even after the arch had been fully banded
and only intermaxillary
elastics had been used in treating the Class II anterior
relations, the resulting end product was a distally positioned lower molar. It appeared from detailed cephalometric study that the lip was strong enough to influence the entire dentition to a position more backward than anticipated normally.
Later work in a series of clinical experiments led to the use of a 0.045 inch

390

Elicketts

Am. J. Orthod.
Octobel
1976

-n

Fig. 42.

A, The effects of a bumper

and the influence
of lip musculature
on the lower
dentition
of a girl (Patient
E. R.) at the age of almost
13 years.
The patient
was treated
with a shield
followed
by intermaxillary
traction.
6, The patient
at almost
age 17. C, The
analysis
suggests
that arch
length
increase
in the lower
jaw by this technique
actually
pushed
the lower
molar
2 mm.
backward,
despite
the fact
that
intermaxillary
traction
had
been
used
to correct
a marked
overjet.
This case strongly
suggests
that
muscular
anchorage
is a strong
factor
to be considered
in anchorage
response.

wire placed around the arch and downward toward the sulcus ; this was labeled a
bumper. Observations of that technique led to the conclusion that the lower lip
alone was effective enough to move the lower molar distally, followed by distal
drift of lower premolars. This was clear evidence of the effectiveness of muscles
of the perioral area not only to retract the anterior teeth but also to produce
inhibition of forward development of the entire lower denture in anchorage (Fig.

43, A).
The bumper came to be used infrequently
because the utility arch both intrudes the incisors and increases arch length (Fig. 43, B). This muscle principle

set
about

3 mm.

first

of

permanent

plastic

and

stopped

crown

of

another
incisor

as
at

the

patient

the

lip

of

aspect
8,

only

the

lip
of

moved

molar

arch.

the

Intrusion
lower

inch

placed
lower
and

molar

distally.

deciduous

0.045

and

on

the

molar

second

from

effect

utility

lower

lower

force
the

Similar

actually

the

the

the

mesial

lip

moving

in

between

incisor.

with

lower

bumper
up

result

the

lower

treated

against

opened

molar

of

the

of

space

wire

near
first

Note

molar
the

distally,

with

cervical

third

molar
of

as

the

covered

permanent

advancement

that

and

the

shown

in

lower
in

this

of

the

exhibit.

Fig.
the

A, A sectioned

44.

lower

first

therefore

on

skull

second

distribution

exhibited
and

and

of
the
can

molars
bone

on

labial

aspect.

be

employed

showing

the

in a patient
the

lingual

amount
at
aspect

Cortical

bone

as

anchor.

an

the

of

bone

age

of

of
offers

the
greater

displayed

to

the

approximately
lower

incisor
resistance

10

buccal
years.

in

contrast

to

tooth

B, Note
to

that

movement

392

Ricketts

Fig. 45. A, Case demonstrating

the effect
Class
II, Division
1 case treated
without
position
of the lower
molar.
At one time
maxillary
elastic
pull.
(The cephalometric
grees)
double-tube
design
with
utility

Am. J. Orthod.
October
1976

of cortical
bone
on anchorage.
This was a full
banding
of the premolars.
Note
the anchor
500 Gm. on each
side was exercised
in interanalysis
is seen in Fig. 46.) B, Torque
(22 deengaged.
C, Another
case
showing
inter-

maxillary
elastics
used
off
the
buccally
torqued
lower
molar
while
at the
same
time
the
lower
canine
is being
ligated
downward
as the
upper
buccal
section
is
being
reduced.
D, Upper
and lower
utilities
working
to intrude
the upper
and
lower
incisors
as elastics
are employed
to reduce
the Class
II malocclusion.
Note
that
premolars
are as yet not banded.
E, Buccal
root
torque
on molar
also
helps
to prevent
forward
displacement
during
space
closure
in extraction
case. F, Uprighting
of molar
will tend
to
occur
naturally
with
normal
forces
of occlusion,
but finishing
should
be conducted
in
preparation
for this event.

is further recognized with splints and retainers ; also, it is an effective force in

prolonged use of the positioner and activator type of appliances.
Cortical anchorage as a fundamental factor. The fifth matter of direct concern
is cortical anchorage. Compact bone not only offers resistance to the tooth movement but, conversely, it can be used for anchorage and is recognized and employed to advantage (Fig. 44). This is accomplished by situating the teeth behind
the heavy compact elements of bone so that the pressure of the root is almost
in direct contact with bone incapable of easy backward resorption.
This has proved to be a main source of anchorage for intermaxillary
elastics or
for anchorage for retraction of teeth when it is desired that units within the same
arch be moved (Fig. 45).
As movements were routinely studied, teeth did not always move as had been
anticipated under usual prescriptions. In the analysis of these situations it was
discovered that the roots did not move when teeth were brought into high-pressure
contact with the cortical plate of bone. Consequently, a study was conducted in
which cortical bone was investigated at different stages of development. As the
lower molar was tipped buccally at its roots and trapped beneath the external

Volume
Number

70
4

Bioprogressive

therapy

393

Fig. 46. The analysis

of Patient
R. V., case shown
in Fig. 45, A. Class
II reduced
by elastics
and
no premolars
banded.
A, Before
treatment,
at age
13 years
2 months.
6, After
Class
II traction,
at 13 years
11 months.
C, Four years
later
at 17 years
8 months.
D,
Analysis
shows
orthopedics
of maxilla
and only
very
slight
displacement
of molar
with
distal
root movement
during
uprighting.

oblique ridge of external alveolar plate of bone in the mandible, better stability
was observed (Fig. 45). Anchorage, therefore, seemed to be effectively enhanced
by a procedure for holding or producing buccal root torque while at the same
time slightly expanding.
As the lower molar was tipped distally, the root seemed to be trapped beneath
the buccal plate and consequently became the anchor site. The crown was observed to move distally by a tip-back bend on the molar at the same time that it
was buccally expanded, particularly
with the utility arch free of premolar hantling (Fig. 46).
The foregoing action may explain why the lower molar crown is often moved
distally and drags the lower anterior teeth distally without Class III elastic trar-

394

Am. J. Orthod.
October
19iF

Ricketts

R.V.

13-2

Fig.

46,

To 14-8

D. For

legend,

tion from the upper arch or extraoral

see analysis of Patient S. R.)

see

opposite

traction

page.

on the lower (Fig.

47). (Also

Summary

From the foregoing discussions, it may be recognized that a new, lighter, and
sequential order of force applications is recommended. Accordingly, ih order for
the clinician to apply the new technique with the intelligence, he must realize that
many biologic factors form the fundamental
criteria of its application. We have
attempted to examine these factors and place them in their appropriate hierarchy
of significance.
While edgewise was the background, sufficient departure from traditional
edgewise therapy has been made to warrant a new label, bioprogressive therapy.
It was so named because of the practice of progressive banding and a planned
progression of events in sequential order. Eight steps usually form the frame of
reference. Ironically, it can be applied in the very young and in the very old.
It is difficult to appreciate these views and practices in the beginning because
the method may be difficult to envision on the typodont or as simply a laboratory
mechanical exercise due to the fact that cortical bone, growth, and muscle are not

Volume
Number

Fig. 47.

70
4

A, Beginning
tracing
of Patient
gressive
tracing
showing
the effects
of
of cervical
headgear
on the maxilla.
C,
note that
no intermaxillary
Class
III
anchorage
preparation
changes
in the

Bioprogressive

therapy

395

D. A., a boy 8 years

9 months
of age.
B, Proutility
on the lower
arch,
together
with
the effects
Analysis
of the behavior
of the lower
arch. Please
traction
was
used
to effect
these
uprighting
and
lower
arch.

present in an artificial medium. In order to fully apply the recommendations of

the proponents of this method, mechanical forecasting, physiologic forecasting,
and growth forecasting principles are all employed. Even as a simple mechanical
regime, however, it rates with or better than any other current multibanded
method as a practical and efficient clinical procedure.
Size 0.016 by 0.016 inch blue Elgiloy wire is commonly but not exclusively
used. Loops or forms are bent in the wire for lighter and more continuous pressures on teeth to be moved. Soldering of auxiliaries has been eliminated, as well
as the heat treating of wires. The 0.016 by 0.016 inch to 0.016 by 0.022 inch yellow
Elgiloy is used for detailing near the end of treatment. The 0.018 by 0.022 inch is
the largest wire employed, and it is used for spanning distances between teeth in
the progressive debanding phases.
Anchor teeth are stabilized against cortical bone ;: hence, cortical anchorage.
In order to position and control the teeth behind or away from cortical bone OI
against or away from muscle or to intrude into or extrude away from the bony
alveolus, three-plane control is utilized. A limited use of round wire is employed
with this technique except for specific isolated conditions in which there is a place
for tipping or simple alignment and rotation of teeth. We try to avoid leveling
with round wires, for reasons that have been explained. Used as a triple-control

396

Ricketts

Am. J. Orthod.
October
1976

technique, the bioprogressive method excels in proper overtreatment and for delivery of anchorage.
A continuous arch is broken up into segments or sections so that movements
in desired planes of space are not complicated and aqachorage ca.n be shifted in
favor of the desired move.
The technique usually involves orthopedic correction, particularly
in the
maxilla, when such corrections are needed. When this technique is combined with
the activator or mandibular
posturing devices, an application can be made to
provide an anchorage approach to include growth and maxillary and mandibular
orthopedics.
Muscle anchorage definitely is considered in anchorage planning and utilized
in its fullest application, even to posttreatment
rebound.
The leveling of the arch by the extrusion of the premolars is considered to be
contraindicated.
Thus, intrusion of anterior teeth, either upper or lower, is a
practiced art with a bioprogressive technique.
With this approach, a tremendously wide range of flexibility is possible, and
overtreatment
is the byword. This flexibility permits the clinician to overcome
tooth-size discrepancies, as overtreatment of a part of the arch can easily be attained.
The light square wire allows the clinician a wide range of intraoral adjustments. This procedure reduces the clinicians chair time, is much less painful
and trying to the patient, and at the same time provides even greater control in
the strictest sense of the word. This is an art to be learned by the individual
clinician.
Another virtue of the progressive
approach to treatment is particularly
thought provoking: absolute standardization
is not appealing and is not the aim.
Rather, a body of principles has been developed. In depth diagnosis, prognosis,
and designing are advocated for the patient, depending upon his particular individual needs. The orthodontist is still in command because anchorage preparation, differences in extraction and nonextraction,
and various arch-form differences make absolute straight wire misleading.
Visual objective designing with cephalometrics as a reference for planning
is strongly recommended, although intuitive
planning
is practiced with this
method as well as others. In applying specific progressive therapy to its greatest
potential,
however, the biologic and mechanical principles are put together
cephalometrically
for each individual
patient only after his unique personal
requirements
are determined. In this manner, the philosophy and science of
orthodontics can be practiced with the spirit of the artist.
REHRENCES

40. Brader,
A. C. : Dental
arch form related
with intraoral
forces : PR=C,
AM. J. ORTHOD. 61:
541-561,
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R. M., Bench,
R. W., and Hilgers,
J. J.: Sequence
of mechanics
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Class II, Division
1, deep-bite
cases, Found.
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3: 1-4, July,
1971.
42. Gugino,
Carl:
An orthodontic
philosophy,
Rocky
Mountain
Communicators,
Denver,
Colo.,
pp. 107-122.

Volu?ne
Number

TO
4

Bioprogressiue

therapy

397

43. Ricketts,
R. M.: The growth
prediction
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Hotel,
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R. M.:
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984

illonument

When
one
individuals

St.

(90278)

has arrived
at a point
of good
judgment
are

where
justified

begins.
. . . He must
study
constantly
related
fields
in order
to maintain
changing
relations
of his field to the
dontists,
in general,
have
recognized
tice. (Casto,
F. M.: Orthodontics
as a
1927.)

not he himself
in calling
him

nor his friends

but disinterested
a specialist,
then the real battle

not only
in his specialty
but also
in general
and
a condition
of mind
to appreciate
the constantly
general
field and to other
special
fields.
.
. Orthothis responsibility
and have
carried
it out in pracProfessional
Pursuit,
J. Am.
Dent.
A. 14: 978-983,