Ricketts’ Bioprogressive Technique

Ricketts’ Bioprogressive Technique

Bioprogressive technique refers to an overarching concept of a broad therapeutic philosophy developed by Robert Ricketts (1920-2003) in the late 1950s. It was long called the “Light Square Progressive Technique.”

It belongs to the “second generation” fixed therapies derived from the classic Edgewise ; it borrowed from the latter the work on the wire field, from Begg the use of light forces and from Burstone the segmentation of the arches.

Its uniqueness is its progressiveness: “Segment by segment with light force.” It owes its name to bioprogressive treatment because groups of teeth are gradually included in the treatment: the first molars and incisors followed by the canines and premolars.

2. GOALS
   1. Aesthetics:

From the front:

• Symmetry respected with respect to the PSM.
• Parallelism of horizontal lines.
• The corners should be located halfway between the two lowered vertical lines of the external wings of the nose and pupils.
• A full, fleshy smile with a dental arch filling the space uncovered by the two lips.
• At rest, the upper incisors appear 2 or 3 mm below the free labial edge.

In profile

Ricketts describes two lines:

• Line E : (joining the tip of the nose and the most anterior point of the chin) at which the upper lip is slightly set back and the lower lip is flush with it.
• Line C : (tangent to the protrusion of the chin and the curve of the cheek) which allows the length of the nose to be judged. “The more this length increases, the less the lips should approach line E”.

2. Occlusals:

In static:

• Ideally, BMI is the same as CR.
• Ideal “cusp – embrasure” relationships in Class I of canine and molar angle.
• Perfect meshing with correct overlap: the maxillary incisors cover one third of the clinical crowns of the mandibular incisors
• 30 occlusal contact points per hemi-arch.

In dynamics:

Ricketts is a follower of the gnathology concept and accepts the principle of immediate disocclusion.

The objective is freedom of mandibular movements in propulsion and laterality while preserving perfect integrity of the TMJs, therefore; harmonious growth, joint sustainability and postural neutrality.

3. Periodontal:

The health of the dental organ associated with good occlusal balance is the key to longevity of the masticatory system because good alignment:

• Facilitates oral hygiene.
• Optimizes the transmission of occlusal forces to the ligaments.
• Protects against root recessions and fenestrations.

4. Neutralization of the functional envelope:

At rest or in function, the dental arches are located in neutral pressure zones. Therefore, during dysfunction or parafunction, morphogenetic changes occur.

In order to ensure the sustainability of our treatments over space and time, we must first standardize their functions.

3. PRINCIPLES:

These are the commandments of bioprogressive therapy proposed by Ricketts, twelve in number (12), we find:

• Patient awareness and motivation education: “Psychophysiology”;
• Progressive unlocking of malocclusions to normalize functions;
• Segmentation of the arches according to the “degree of difficulty” of the case;
• Orthopedic correction of base shifts: The earlier the treatment, the more the face will adapt to your therapeutic concept”;
• Anchoring in cortical bone: teeth move very slowly when the roots of the molars are placed in the dense cortical bone (Torque + expansion);
• Muscle anchoring: Muscle tone can serve as an anchor depending on the typology;
• Preliminary idealization of the mandibular arch: Choice of the shape of the mandible according to the patient and the five pentamorphic forms of Ricketts;
• Completion of each step before starting the next: Compliance with unlocking VAT priorities;
• Treatment of the incisal covering before the overjet;
• Overcorrection: Prevents the natural tendency to relapse;
• Control of applied forces: principle of four D (Direction, degree, distribution and duration);
• OVT and superposition: by integrating future growth with the expected effects of therapy for a short period equal to the treatment period.

4. SEGMENTATION OF ARCADES:
   1. Birth of segmentation:

” Two major trends have marked the history of orthodontics: one which sought maximum control by developing devices with good rigidity , and the other which sought to obtain more constant dental movement with devices with maximum elasticity .” (Fontenelle).

Indeed, after Angle and Edgewise of 1928, research focused on the proven difficulty of controlling the occlusal plane, the position of the mandibular incisor and the height of the lower face on continuous arches. The search to solve this equation ended with the emergence of a brilliant idea which consisted of the sectoral treatment of the dental arches, segmentation was born.

2. Principles:

The segmentation of the arch was considered by Ricketts to overcome the technical difficulties inherent in the use of continuous arches: he found a match between the segmentation and the biological sectorization of human teeth which results in:

• Rhythm of the phases of establishment of the teeth (M – Inc – C and PM).
• Functional specialization of each group.
• Difference in muscle and bone environment.

The arch is thus divided into an active unit and another passive unit which bring together one or more teeth assimilated to a large multi-rooted one.

The section of the wire used varies depending on whether the device is “Stabilization” (rectangular) or an active system (square).

3. Benefits :

• Start treatment early in mixed dentition.
• Control (intensity and constancy) of the forces and moments applied.
• Better control of tooth movements.
• Progressive leveling of the Spee curve (bioprogressive).
• Better control of the vertical direction than on a continuous arc (egression).
• Compatibility with weakened periodontium (light strength).

4. Anchoring methods:

In the segmented technique, the teeth of the lateral sectors are first aligned and then secured using a rigid archwire that can be kept until the end of treatment. Therefore, the passive unit must be constructed before any movement mechanics.

Anchoring can be passive or active:

1. Passive anchoring : This is the natural resistance to movement:

Periodontal anchorage : This is the resistance offered by a tooth through its ligamentous attachment to the bone.

Muscle anchoring : This is the set of limits that the envelope imposes on dental movements (weak in dolicho and strong in bracky).

Cortical anchorage : Teeth move very slowly when the molar roots are placed in the dense bony cortex (Torque + expansion).

2. Active anchoring : This is the mechanical anchoring induced by the device:

The arches themselves with their section, alloy quality and their anti-version and anti-rotation curvatures.

Auxiliary devices that selectively strengthen it in three directions:

• Transverse: Transpalatine, lingual arch, quad helix or bihelix.
• Vertical: FEO with ingressive occipito-parietal or egressive cervical support.
• Sagittal: Nance, palatal or lingual arch, lip bumper or horizontal FEO.

5. THERAPEUTIC MEANS
   1. The fasteners

Originally, only the maxillary incisors, canines and mandibular molars carried torque and angulation information. With the advent of shape memory wires, the use of pre-information has become widespread across all teeth.

All brackets are double-posted for rotation control without aids. The groove is 0.030” x 0.018” to accommodate two overlapping archwires.

At the molar level, the tubes have a lumen of .0185” x .025”. The band has three tubes in the maxilla and two in the mandible.

2. The sons

Initially, the Elgiloy alloy (Co 40% and Cr 20%) presented a real revolution. Delivered in four colors (blue, yellow, green and red), only the first two are used in bioprogressive technique in square section 0.016” x 0.016” or rectangular 0.016” x 0.022”

0.017” x 0.022” or 0.017” x 0.025”.

Currently, titanium alloys, including TMA with significant elastic qualities, are replacing Elgiloys.

Ear recommends the use of:

• Blue Elgiloy .016” x .016” for the basic bow and these variations.
• Yellow Elgiloy .016” x .022” for finishing.
• TMA for canine retraction and molar straightening sections.
• Niti for leveling and superimposing with the base arch.
• Steel is reserved for stabilization.

3. The auxiliaries

The use of intra- and extra-oral auxiliary devices serves to optimize the control of anchoring units (sometimes for expansion);

• Sagittal direction: Nance, palatine, lingual and FEB.
• Transverse direction: Transpalatine, Quad helix and Bi helix.
• Vertical direction: FEO high or low on face bow.

4. Different types of bows
   1. Basic Arcs

Descriptions : Its shape is simple, its main characteristic is to gingivally contour the canines and premolars thanks to a vertical recess, it is made of Elgiloy .016 × .016 or TMA .0175 × .0175.

Its shape is simple: Its distal part is introduced into the gingival tube of the molar. The posterior recess is formed by

two 90° plications over a height of 03 to 04 mm. The anterior detachment is carried out distal to the lateral incisor.

Variation of the basic bow: 

1. Basic Ingression Arc:

It is used without coils, built in abutment at the molars and folded distally to maintain the length of the arch. It is made of Elgiloy .016X.016 square wire or rectangular wire

.018X.025, usable in mixed and permanent dentition.

2. Ingression arch with shortened incisal segment:

In the case of a more pronounced overbite on the central incisors, the anterior vertical offset between the central and lateral incisors is limited to maintain bioprogressiveness and avoid the laterals moving back and forth (include them at the agreed time when the central incisors are at the same level).

3. Basic egression arc:

This arch will be made in its anterior and lateral parts like the basic arch of incisor intrusion, except that the tip-back will be replaced by a tip-forward.

4. External coil arch: contraction arch

It is a retraction or contraction arch, with an external turn on each angle, longer molar segments and shorter gingival segments, indicated mainly for the retraction of the incisors.

5. Internal coil arch: expansion arch

It is an advancement and lengthening of the arch by vestibulating the incisors on a molar support, indicated essentially to advance the incisor group, it has four internal loops, and a longer lateral segment.

NB. These expansion and contraction arches allow the arch length to be varied according to the incisal repositioning planned in the OVT.

To oppose molar version movements, the 12-year-old tooth should be part of the lateral segments whenever possible.

2. The sectionals

Canine Retractor : Originally designed in blue Elgiloy with a square section of .016” x .016” with a double closed loop with so-called “Las Vegas” helicals. Currently, modern low modulus alloys (TMA) have allowed them to be abandoned in favor of T-loops.

Leveling Section: The leveling of the arch is carried out by rectilinear arch segments or often including loops, the most used of which is the T-shaped one.

Stabilizing sectional: Once leveled, the lateral sectors are secured by rigid rectilinear sectionals made of yellow Elgiloy .017”x.025” which will sit in place until a continuous ideal arch is installed.

3. Continuous arcs

They are applied alone or in combination with the basic arch, at the beginning or end of TRT, they are round or rectangular in section and affect the entire arch . They are either:

• Leveling: They can be mounted with a basic arch in anterior superposition.
• Ideal Arches: On Elgiloy .016” x .022”, include all the idealization curves of the Edgewise whose purpose is to perfect the intercuspation of the two arches.

6. CONCLUSION

The bioprogressive technique is based on a concept that affirms the primacy of clinical examination and diagnosis in the planning and implementation of treatment. It combines the possibility of interception at a young age (segmentation) with the requirements of adult treatment (Light Force).

Arch segmentation is a highly coherent system of thought and work developed by its founders Ricketts and Burstone . It simplifies work through individualization of treatment objectives with standardization of clinical and therapeutic sequences .

7. BIBLIOGRAPHY

• ATTIA. Y. Edgewise EMC (Editions Scientifiques et Médicales Elsevier SAS, Paris), Odontology/Dentofacial Orthopedics 23-490-D10.1985.
• Bassigny F. Manual of Dentofacial Orthopedics. Paris: Masson, 1991.
• Boileau MJ. Orthodontics for children and young adults. Volume 2, Volume 2,. 2012.
• Charles J. Burstone: “Simultaneous Segmented Approach to Intrusion and Space Closure”

“Biomechanics of the Three-Piece Basic Arch Apparatus,” DDS. AJO-DO 1995 Feb (136-143) Baltimore, MD, Richmond and Farmington.

• Unblock. LB Petitpas. Biomechanics of incisor intrusion and its control using the segmented Burstone technique. Odf Review.vol 31. 1997.183-199.
• Edith Lejoyeux. Dentofacial orthopedics. A bioprogressive approach. Quintessence International. 1999.
• Ismail Ali. Segmented Techniques Symposium 2009.

Ricketts’ Bioprogressive Technique

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Ricketts’ Bioprogressive Technique