The Wisdom of the Bioprogressive

Philosophy
Robert M. Ricketts

This article provides a brief overview of the history of orthodontic practice

and comments on the "era of limitations" that exemplified orthodontic
thinking in the 1930s. In contrast, the Bioprogressive philosophy of orthodon-
tic treatment which developed 2 decades later resulted from an attitude of
academic and clinical freedom. The Bioprogressive philosophy brought
many aspects of biology and function into the arena of orthodontic therapy.
This technique does not follow a series of rigidly fixed treatment steps, but
rather stresses a number of orthodontic principles that have stood the test of
time. This article revisits and updates the Bioprogressive principles in line
with the latest developments in biology and orthodontic materials. (Semin
Orthod 1998;4:201-209.) Copyright © 1998 by W.B. Saunders Company

he first wave, or first m o v e m e n t , in m o d e r n resulted in a plethora of p r e m o l a r extraction

T clinical orthodontics was based on the con-
cept of "functionalism." Orthodontists who prac-
ticed in this era believed strongly that the dental
arches could be e x p a n d e d to a c c o m m o d a t e all of
the p e r m a n e n t teeth. 1,2 At the same time, they
relied largely on m a n d i b u l a r posturing as the
sole modality to correct maxillomandibular dis-
harmonies. They accepted the idea of maxillary
and u p p e r first m o l a r dominance. T r e a t m e n t
was t h o u g h t to stimulate mandibular, and in fact,
total facial growth. This stimulation theory was
carried further and was actively i n c o r p o r a t e d
into the fixed appliances of the time.
A r o u n d the 1930s, the period of functional-
ism m a d e way for the second wave of fixed
edgewise appliances. This second wave of mod-
ern orthodontic appliances r e p r e s e n t e d an era
of traditionalism. In this orthodontic era, the
edgewise m e t h o d in keeping with o t h e r fully
fixed appliance techniques, was advocated essen-
tially for use in patients with fully developed
dentitions. -~ By restricting fixed o r t h o d o n t i c
therapy to patients with most of their p e r m a n e n t
teeth in place, the profession entered a period of
"limitation." At the same time, this doctrine
From the American Institutefor BioprogressiveEducation.
Address correspondence to Robert M. Ricketts, DDS, MS, 7430
Butherus Dr, Scottsdale, AZ 85620.
Copyright © 1998 by W.B. Saunders Company
1073-8746/98/0404-000258.00/0
patterns to prevent or correct dental crowding
a n d / o r dental protrusion. T h e traditional be-
liefs inculcated into the second wave of m o d e r n
orthodontic therapy developed a dogma, that
has essentially c o n t i n u e d as the "straight wire"
philosophy. During all of these developments
there was not always c o n c o r d a n c e of opinion
between the clinicians of the day and the or-
thodontic educators.
The Possibility Doctrine
T h e Bioprogressive philosophy of orthodontic
t r e a t m e n t followed the " e r a of limitation" and
resulted f r o m an attitude of academic freedom.
It represents a therapeutic innovation that devel-
o p e d essentially over a period of 25 years. It
arose, after careful scientific study, as an attempt
to improve on the previous theories and meth-
ods of orthodontic treatment.
T h e Bioprogressive philosophy of o r t h o d o n -
tic t r e a t m e n t is based on principles that were
recognized a n d given f o r m in the late 1950s. 4-7
T h e further d e v e l o p m e n t of the Bioprogressive
principles into a complete orthodontic diagnos-
tic a n d t r e a t m e n t system represents the third
wave in the d e v e l o p m e n t of m o d e r n orthodontic
therapy. As time goes on, technology as we know
it now will change a n d advance, but the general
concepts that f o r m the integrated principles on

Seminars in Orthodontics, Vol 4, No 4 (December), 1998: pp 201-209 201

202 Robert M. Ricketts
which the Bioprogressive philosophy was founded
will not change.
T h e traditional orthodontic m o v e m e n t that
started in the 1930s u n d e r e m p h a s i z e d the impor-
tance of the functional e n v i r o n m e n t in which
the teeth are located. It was a major goal of
traditional orthodontic t r e a t m e n t to place the
teeth in a close relationship with the m a n d i b u l a r
alveolar ridge. T h e teeth were " c e n t e r e d " over
the jawbones because it was not considered
possible to modify "basal b o n e " in a meaningful
manner, s T h e r e was also a general belief that the
functional e n v i r o n m e n t of the oral cavity was
difficult to alter. Certainly, forecasting the out-
c o m e resulting f r o m the single or c o m b i n e d
effects of growth and t r e a t m e n t was d e e m e d a
fantasy. O r t h o g n a t h i c surgery was frequently
advocated as being the principal means of correct-
ing a b n o r m a l jaw relationships. Efforts to in-
trude teeth were limited to the u p p e r incisors.
Diagnosis and t r e a t m e n t planning often began
with the u p p e r incisor position; h e n c e the u p p e r
jaw was the focus of attention for m a n y o r t h o d o n -
tists. T h e Bioprogressive m o v e m e n t a t t e m p t e d to
reconcile m a n y aspects of oral function and
biology with the practice of clinical orthodontics.
The Scientific Method
From the outset, it was acknowledged that the
continued d e v e l o p m e n t of the Bioprogressive
philosophy h a d to be based on scientific m e t h o d -
ology, and that this in turn required that the
concepts underlying the philosophy be well orga-
nized. T h e result was the formulation of prin-
ciples because it was recognized that it is rare to
find absolute laws or truths in biology. T h e
presentation of each principle was a c c o m p a n i e d
by d e m a n d s f r o m colleagues to present "docu-
m e n t a t i o n " in support of the principle.
T h e records of a single patient may indicate
possibilities, those of a representative g r o u p of
patients probabilities, while also raising reason-
able expectancies. Those who are skeptical by
nature frequently use the word anecdotal to reject
new ideas or methodologies on the basis that an
anecdote represents an unique occurrence and
that it has no universal application. However,
when a n u m b e r of patients respond in a consis-
tent m a n n e r and when statistical findings sup-
port the observations m a d e in these patients,
then "science" is served. U n d e r these conditions
it is possible to develop principles that have
substance.
Principles
During its genesis, m o r e than 100 verified and
c o r r o b o r a t e d principles were f o r m u l a t e d in sup-
p o r t of the Bioprogyessive philosophy of orth-
odontic treatment. For the sake of order, the
principles that were originally taught as being
part of the Bioprogressive logic were divided into
the following four "sciences":
1. Social. This g r o u p of principles covers aspects
of sociology, patient motivation, psychology,
practice m a n a g e m e n t , and aesthetics. 913 Orth-
odontists should be aware of the possibility
that their own individual perceptions of facial
aesthetics may influence their selection of
dental and soft tissue t r e a t m e n t goals. T h e
c o m p l e x study of beauty is governed by social
values that place facial h a r m o n y in a domi-
n a n t position within the orthodontic profes-
sion.
2. Biological. This aspect of the Bioprogressive
philosophy was always at the forefront of its
development. 14,15 Risk factors and relapse fall
largely within this domain.
3. Clinical. Any record taken, any m e a s u r e m e n t
recorded, and any value j u d g e m e n t decision
m a d e on a living patient falls within the
clinical area. Cephalometrics, f r o m simple
metrical evaluation to colnplicated analysis,
provides a language for clinical communica-
tion and education. The language of cephalo-
metrics provides for diagnosis, prognosis, the
d e t e r m i n a t i o n of t r e a t m e n t objectives, the
m o n i t o r i n g o f progress, and the evaluation of
results obtained. 1~1s Last, but by no means
least, this language also provides, through
research, the discovery and elucidation of the
unknown.
4. Mechanical. Myofunctional therapy, behav-
ioral modification, or awareness training are
all natural c o m p o n e n t s of the Bioprogressive
technique. T h e correction of nasal and oral
functions are considered to be p r i m a r y to the
Bioprogressive p h i l o s o p h y of o r t h o d o n t i c
treatment. 19,2° However, sophisticated me-
chanical techniques are used to achieve major
dental and skeletal corrections as well as, and
perhaps particularly, to provide controlled
finishing.
 BioprogressivePhilosophy 203

Phasing Table 2. Stages and Steps Involved

in the Bioprogressive Treatment Sequence
The timing of orthodontic treatment, t e r m e d
Stage Steps
phasing, illustrates a m a j o r difference in the
thinking between the Bioprogressive philosophy Stage Steps
1. Awareness
and other edgewise o r t h o d o n t i c techniques. Commence- training
O r t h o d o n t i c t r e a t m e n t can be classified into ment 2. Early treat-
four types according to when it is b e g u n in ment
3. Intra-arch
relationship to one of four stages in dental correction Bioprogressive
d e v e l o p m e n t (Table 1). These types are preven- Continuation 4. Inter-arch
tive (deciduous dentition), interceptive (mixed correction
dentition), corrective (early p e r m a n e n t denti- 5. Integration
tion), and rehabilitative (adult). T h e r e is a basic Consolidation a n d torquing
ongoing a r g u m e n t a m o n g orthodontists as to 6. Idealization
and coordina-
when to start treatment. Traditionally, o r t h o d o n - tion
tic t r e a t m e n t with the edgewise technique is not
7. Finishing a n d Straight wire
started before the eruption of the majority of the
over-treat-
p e r m a n e n t teeth, at a b o u t 12 years of age. ment
Protagonists of the straight-wire appliances tend Completion 8. Retention
to follow this t r e a t m e n t timing, but some of t h e m a n d stabiliza-
tion
may delay t r e a t m e n t until the second p e r m a n e n t
molars are in place. Effectively, these two edge- NOTE. T h e Bioprogressive philosophy of t r e a t m e n t encom-
passes all eight t r e a t m e n t steps, whereas straight-wire treat-
wise techniques restrict their t r e a t m e n t options
m e n t addresses steps 5 t h r o u g h 8.
somewhat by waiting for most of the p e r m a n e n t
teeth to e r u p t before beginning treatment. Advo-
cates of the Bioprogressive technique t e n d to
start t r e a t m e n t for their patients at an earlier age m e n t with a leveling arch. They usually aim first
when possible, in order to obviate or simplify full at accomplishing orthopedic correction, con-
t r e a t m e n t at a later stage. trolled arch length increase, and deep bite correc-
tion by anterior tooth intrusion. This latter
t r e a t m e n t sequence, also called staging (Table 2),
Modalities establishes o r d e r and increases t r e a t m e n t effi-
A further significant difference between the ciency.
traditional and progressive orthodontic tech- In a clinical sense, three b r o a d fields of
niques deals with not when to, but how to start knowledge guide orthodontists in their attempts
orthodontic treatment. Not all, but certainly a to treat their patients: biology, diagnostics, and
fair n u m b e r of supporters of the straight wire mechanics. It is t e m p t i n g to emphasize the
philosophy of orthodontic treatment, following i m p o r t a n c e of " m e c h a n i c s " in specialty orth-
edgewise tradition, align the teeth as soon as odontic education, a course that m a n y would
possible "in order to gain control." Bioprogres- prefer, whereas a sound understanding of biol-
sive practitioners rarely begin orthodontic treat- ogy and diagnosis takes time and effort to ac-
quire. Biology, however, underlies every aspect of
orthodontics.
Table 1. Four Phases in Dental Development From the outset, biological principles have
played a m a j o r role in d e t e r m i n i n g the develop-
Preventive (3-6 years)
Interceptive (7-10 years)
m e n t of the Bioprogressive philosophy of orth-
Bioprogressive Corrective ( 11-13 years $ ) ] odontic treatment. An u n d e r s t a n d i n g of biologi-
Straight wire
Rehabilitative (11-13 cal principles makes it clear that no medical or
years c~) dental p r o c e d u r e is without risk and, that even
NOTE. This table shows four phases of orthodontic treat- when the very best t r e a t m e n t modalities are
m e n t based on the age of the patient at initiation of used, there is no absolute guarantee of success.
treatment. Bioprogressive t r e a t m e n t includes all four phases,
whereas straight-wire t r e a t m e n t encompasses the latter two Classification yields o r d e r in biology but every
stages of treatment. patient, and for that matter every orthodontist, is
204 Robert M. Ricketts

unique. An understanding that variation in facial 120 55 75 75 40 50

form and function is the rule, places the spe-

cialty of orthodontics in a unique position within
the health care professions. It should not be
M-D
forgotten that orthodontics is a health care
profession and that total patient well-being is a
basic consideration. In this sense, iatrogenics is a
greater factor than previously understood, par- 110 60 60 80 25 25
ticularly in relation to the t e m p o r o m a n d i b u l a r
joints in growing patients and susceptible adults. 105 135 50 50 70 40 50 65 70

Biology plays a role in origin of disease in

general, but also more specifically, in the etiol-
ogy of malocclusion and other facial abnormali-
B-L
ties. The causes of any h u m a n condition are
either genetic or environmental. 19 Genetic con-
trol will tend to dominate until catastrophic
environmental insults on the system prevail. 95 105 60 60 70 25 25 50 50

Anatomy forms the basic reference for all

clinical work, and the identification of structures 70 80 30 30 45 30 40

both hard and soft is germaine to the subject.

Different orthodontic treatment modalities may
produce widely different effects on the teeth,
jaws, and soft tissues of the face. This is why the
Bioprogressive orthodontic philosophy requires
that its practitioners have a detailed understand-
ing of the anatomy of the craniofacial structures.
Its cephalometric analyses, both lateral and pos-
teroanterior, d e m a n d the recognition of anatomi-
cal landmarks that depict fine craniofacial de-
tails. These same landmarks may change in
shape and position u n d e r the influence of
growth. The concepts of polar and gnomic
growth are basically biological in their nature
and they have a marked influence over attempts
to forecast the outcomes of facial growth.aa
Root Ratings
Most, if not all, aspects of orthodontics are in
one way or a n o t h e r affected by the physiology of
the oral surroundings. In this environment, the
soft tissues are d o m i n a n t over the bones and over
the teeth. In the end, the oral soft tissues
including the periodontal ligament determine
how stable orthodontic results are. The periodon-
tal ligament (PDL) forms the interface between
the dental roots and their respective bony sock-
ets. The Bioprogressive philosophy recognizes
the importance of the PDL and it is for this
reason that a root rating system (Fig 1) was
developed2 °-22 The root rating system provides
clinicians with data that indicate the correct
P#glleoo
Og 4144 e e
75 85 30 30 35 20 20
Figure 1. Root ratings. The root surface area of
individual teeth is shaded in black. The number next
to the root of each tooth is the force in grams required
to move that tooth in the specified direction. The
force in g/mm e required to move individual teeth
orthodontically in a mesiodistal direction (top). The
force in g/mm 2 required to move individual teeth
orthodontically in a buccolingual direction (middle).
The force in g/ram 2 required to orthodontically
intrude individual teeth (bottom).
force levels to be used for the different tooth
movements, and also to obtain cortical anchor-
age.
In the PDL, resistances to force have a hierar-
chy and a sequence that is based on the capillary
blood pressure within the periodontal mem-
brane. Accordingly, it has been calculated that to
provide the most efficient tooth movement, the
forces within the alveolar bone should be in the
order of 1 g / m m 2 of cancellous bone. 22 When
these force levels are increased significantly,
doubled or quadrupled, the bone subjected to
these high pressures becomes sclerosed. The
latter principle is used to provide anchorage in
the Bioprogressive technique. When ridge alter-
ation is required, the force levels are lowered to
0.5 g / m m 2. It is recognized that tipping forces
make it difficult to equalize force levels over the
 Bioprogressive Philosophy
whole of the pressure side of a tooth being
moved. It is also admitted that clinicians have to
show " b o n e sense" in that not all b o n e is equally
m a t u r e or vascularized. Bone and tissue sense are
terms that describe the ability of the o p e r a t o r to
apply forces below the level of tissue eschaemia.
Diagnosis: The Determination
Resolution Process
Perhaps orthodontic diagnosis should be seen in
a slightly different light to diagnosis as applied in
disease states. Malocclusion is not a life-threaten-
ing condition, but if severe, it may handicap
patients physically and also in terms of self-
perception. Consequently, in orthodontics, a
diagnosis is m a d e with respect to a d e p a r t u r e
f r o m the ideal. T h e n o r m b e c o m e s the basis for
analysis, while the t r e a t m e n t objectives derived
as a result of the diagnostic process, d e t e r m i n e
the degree of treatment difficult,/of the malocclu-
sion.
A case in point is presented by a patient in
w h o m it is necessary to establish the vertical and
horizontal location of the maxilla in relationship
to the rest of the face. The answers to these
questions have a significant influence over the
type of t r e a t m e n t modality that is ultimately
chosen for such a patient. In young patients, it
may be feasible and desirable to reposition the
jaws with orthopedic appliances. In m o r e m a t u r e
patients, it may be possible only to a d a p t their
dentitions to the skeletal parts of their jaws. The
orthodontic needs of a third g r o u p of patients
could be better served by a c o m b i n a t i o n of
orthodontic and surgical treatment. In different
situations, any or combinations of all three of
these t r e a t m e n t options may be reasonable. The
Bioprogressive philosophy of t r e a t m e n t pro-
poses early intervention to prevent the develop-
m e n t of an excessive disharmony of maxilloman-
dibular relationships. Early t r e a t m e n t may also
lessen the n e e d for p r e m o l a r extractions and
surgical orthodontic treatment. Clinicians n e e d
to make full use of their diagnostic skills to
maximize the possibilities presented by intercep-
five, preventive, or developmental orthodontic
treatment.
In the minds of m a n y clinicians, the diagnos-
tic process has b e e n b r o a d e n e d to include prog-
nosis and also aspects of t r e a t m e n t planning. For
instance, the question arises, " H o w do you treat
205
high m a n d i b u l a r plane angle cases?" The impli-
cation is a prognosis of vertical growth and an
absence of forward growth of the mandible, and
therefore a r e q u i r e m e n t for either extraction,
intrusion of u p p e r molars, or surgical interven-
tion, or all three. T h e Bioprogressive philosophy
separates diagnosis, prognosis, treatment, and
t r e a t m e n t m o n i t o r i n g into distinct divisions
rather than loose, b r o a d assumptions.
Different clinicians may favor specific ap-
proaches to diagnosis, but their diagnostic rou-
tine should at least take each patient's functional
oral e n v i r o n m e n t into account. Specifically, orth-
odontists should be cognizant of their patient's
p r e d o m i n a n t m o d e of respiration and whether
destructive tongue habits are present.
T h e Bioprogressive philosophy of diagnosis
uses the visual t r e a t m e n t objective (VTO) to test
the impact that the fourth dimension of time will
make on the o t h e r three dimensions. Data taken
f r o m the study casts are i n c o r p o r a t e d into the
data g a t h e r e d f r o m the lateral a n d frontal head-
plates. T h e m e a n dimensions (Fig 2) of arch
d e p t h f r o m first m o l a r to incisor, and arch widths
at the cuspids, first bicuspids and first molars, are
p e r t i n e n t to the diagnosis. These m e a s u r e m e n t s
in c o m b i n a t i o n with those obtained f r o m the
frontal analysis (Fig 3) make it possible to make
comparisons between the widths of the dental
arches, the alveolar arches, and the jaws.
According to the Bioprogressive philosophy
of orthodontic diagnosis, once all the diagnostic
54.2±2.4
1.4
25.3
±1.6
Figure 2. The representation of the mean measure-
ments of arch width in the mandibular dentition
between the cuspid teeth, first bicuspid teeth, second
bicuspid teeth, and the first molar teeth. The arch
depth is measured perpendicularly from the midline
contact point of the incisors to a line joining the
mesial contact points of the first molar teeth.
206 Robert M. Richetts

Nc
A g e 3 = 22.0 Age I0 = 25.5 Age 17 = 29.0
4 = 22.5 11 = 26.0 18 = 29.5
5 = 23.0 12 = 26.5 19 = 30.0
6 = 23.5 13 = 27.0 20 = 31.5
7 = 24.0 14 = 27.5 21 = 32.0
8 = 24.5 15 = 28.0 22 = 32.5
9 = 25.0 16 = 28.5 23 = 33.0

Ag

AR
A g e 3 = 58.2 Age 10 = 77.7 Age 17 = 87.1
4 = 59.6 11 = 79.1 18 = 88.5
5 = 70.9 12 = 80.1 19 = 89.8
6 = 72.3 13 = 81.7 20 = 91.2
7 = 73.6 14 = 83.1
8 = 75.0 15 = 84.4
9 = 76.1 16 = 85.3

F i g u r e 3. S o m e o f the d i m e n s i o n s u s e d in the frontal r a d i o g r a p h i c analysis c o r r e l a t i n g t h e m to the age o f the

patient. T h e s e values d e p i c t the average distances f r o m the m o s t s u p e r i o r m i d l i n e p o i n t in the nasal cavity to
points Nc a n d Ag at specific ages. Nc r e p r e s e n t s the m o s t lateral i n f e r i o r p o i n t o f t h e nasal cavity, whereas Ag
r e p r e s e n t s the right a n d left a n t e g o n i a l n o t c h e s . T h e n u m b e r s 55, 60, 65, a n d 70 indicate the distances b e t w e e n
the left a n d r i g h t J points.
 Bioprogressive Philosophy
N
Figure4. Nasion (N) is a midline point at the level of
tile frontonasal suture. Basion (Ba) lies precisely
between the two occipital condyles and is located at
the anterior most point of the foramen magnum. The
anterior nasal spine (ANS) is the anterior most point
in the midline of the maxilla. A point (A) is a midline
point that lies at the deepest curvature of the contour
below the ANS. It is considered to represent the
junction of the alveolar process with the maxillary
basal bone. Pterygoid point (Pt) is located where the
foramen rotundum enters into the sphenopalatine
fossa. The cranial center (Cc) is a constructed point at
the location where the facial axis crosses the Basion-
Nasion line. The protuberance menti (Pro) is a mid-
line point that is located where the cortical plate of the
mandibular symphysis ends and the supramental con-
tour begins. Pogonion (Po) is the most anterior
midline point on the outline of the mandibular
symphysis. Gnathion (Gn) is the most anterior and
inferior midline point on the outline of the mandibu-
lar symphysis. Xi point (Xi) is a constructed point
representing the center of the mandibular ramus. It is
a bisection of the lines connecting the anterior border
of the ramus at the narrowest point to the posterior
border of the ramus at the narrowest point, and the
most inferior point of the sigmoid notch to the most
inferior point of the ramus. The height and depth of
the ramus are bisected and the common point is
termed Xi point.
data have been gathered, they can be subjected
to five levels of analysis d e p e n d i n g on the level of
sophistication desired by the clinician.
Descriptive Cephalometrics
The first level of analysis is abbreviated and
provides only four measurements in the lateral
perspective. They are the lower facial height
207
(Pm, Xi, ANS), the total facial height (the angle
between the lines Pm, Xi and Ba, N), the facial
axis (the anterior/inferior angle between the
lines Ba, N and Pt, Gn), and facial convexity
(perpendicular distance from A to the line N-
Po).23 These four measurements provide a brief
but useful description of a patient's major facial
skeletal features as seen in a lateral cephalomet-
ric radiograph (Fig 4).
The next, more complex level of cranial
analysis requires 14 measurements in the lateral
planes and 15 measurements in the frontal facial
planes. The more complex three levels of facial
analysis require c o m p u t e r support as they com-
pare the patient's data with those provided by a
wide source of clinical information. They pro-
vide for m a x i m u m facial and dental beauty and
also analyze the m o r p h o l o g y of the patient's
t e m p o r o m a n d i b u l a r j oints.
The VTO
With the growth arc of the mandible better
understood, 16 it became possible to predict the
growth of the mandible to maturity with remark-
able accuracy. Even with the possibility of m i n o r
errors arising during the prediction process, this
tool still has amazing application in orthodontic
diagnosis. The beauty of the long-range growth
forecast lies therein that treatment can be coordi-
nated with the effects of growth. The dimension
of time is now truly part of the orthodontic
diagnostic process.
An objection to the VTO may be that it was
developed with "Bioprogressive" aesthetics in
mind. The VTO "places" the dentition within
the jaws, as grown by means of the forecast, and
the soft tissues are then draped according to
dimensions d e t e r m i n e d during the prediction
process. Some clinicians believe that the VTO
limits their ability to express their own concepts
of aesthetics. The issue revolves a r o u n d the
ultimate achievement of beauty, which after all is
what most patients seek in the first place.
Changes that are possible with one technique
may not be achieved with another. At the same
time, if orthodontists do not believe, for ex-
ample, that orthopedic jaw movements are pos-
sible, nor that teeth can be intruded, then they
will not plan for these movements to take place
in their patients. Therefore, if an objective is
r e n d e r e d on paper, the real problem lies in
208 Robert 3/1. Ricketts
developing all of the skills required to r e p r o d u c e
p l a n n e d t r e a t m e n t objectives in the respective
patients.
Careful evaluation of the results obtained with
new and old orthodontic t r e a t m e n t modalities
have m a d e it possible to establish new t r e a t m e n t
objectives. This feedback process continued for
nearly 4 decades in the Bioprogressive move-
m e n t until the technique reached a state of
" o r d e r and progression" that is unique in den-
tistry, but perhaps even in health care.
Progression
T h e idea of t r e a t m e n t progression started with
limited b a n d i n g and controlled o p e n i n g of space
for the correction of crowding. T h e principle of
" u n l o c k i n g " led to an unlocking of the bite as
well as an unlocking of the functional environ-
m e n t of the oral cavity. Correction of "malfunc-
tion" b e c a m e a priority before the details of
tooth relations were to be attended to.
As orthopedics and vertical control of the
mandible were studied, the use of cervical trac-
tion, facial protraction, and the quad helix
e m e r g e d as p r i m a r y appliances in the Bioprogres-
sive technique. 23,24In Bioprogressive therapy, the
effort to control " s e g m e n t s " led to a sectioning
of the arch. "Utility arch" therapy was started in
1960.
Simultaneously, a strong belief that o r t h o d o n -
tic forces had to be kept within biological limits,
led to the d e v e l o p m e n t of a combination of the
Siamese bracket (1953) and the .018" slot (1956-
1958). P r e f o r m e d bands, angulated and torqued,
as well as brackets and angulated tubes followed
in 1959. These developments set the stage for the
p r o d u c t i o n of standardized, preadjusted, orth-
odontic appliances, with specific "prescrip-
tions," that were linked to particular t r e a t m e n t
techniques. T h e straight wire appliance was a
d e v e l o p m e n t of the Bioprogressive technique
which advocates this f o r m of t r e a t m e n t for m o r e
straightforward orthodontic problems.
During the past 30 years, the Bioprogressive
prescription has r e m a i n e d m u c h the same as
originally conceived, and yet, it has u n d e r g o n e
some significant change in some i m p o r t a n t ar-
eas. T h e maxillary anterior brackets are still
" h i g h torque" although this r e q u i r e m e n t is var-
ied in patients in w h o m there is a n e e d to reduce
the incisor torque. T h e n e e d for lower torque
may be for aesthetic or stability reasons. The
u p p e r m o l a r segments are without torque in the
latest version of the Bioprogressive prescription.
This allows better p o s t t r e a t m e n t seating of the
lingual cusps without having to rely on "settling"
to accomplish this function. T h e lower cuspid
torque has b e e n altered f r o m + 7 ° to + 2 ° which
provides a better relationship between the u p p e r
and lower cuspid teeth than was the case with the
original prescription.
T h e wire of choice for the Bioprogressive
technique remains .016" square blue Elgiloy,
(Rocky Mountain Orthodontics, Inc, Denver,
CO) whereas the p r e f e r r e d arch shapes (penta-
morphic) are similar to those described in the
1960s and 1970s. 23,24 Sectional arch mechanics
was originally developed to assist with canine
retraction in extraction cases. During retraction,
sectional arches are able to keep cuspids away
f r o m the cortical b o n e of the jaws in a m a n n e r
that is difficult to achieve with a straight wire
system. The frictionless loop assemblies of the
Bioprogressive technique avoid m u c h of the
anchorage loss that accompanies space closure
with techniques using sliding mechanics. Unitiza-
tion, sectionalization, and segmentation result in
a segregation of parts of the arch. These require
integration which is accomplished by various
loops, but now also by using some of the new
superelastic wires.
T h e Ricketts-Gugino classical Bioprogressive
philosophy calls for cortical anchorage as well as
cortical avoidance, the placing of teeth to avoid
relapse, the n e e d for overtreatment, the setting
in motion of the natural settling process, the
occlusal plane being m a i n t a i n e d at or below Xi
point (Fig 4), mutual support of the lips and the
teeth in the u p p e r canine and incisor area, and a
functional cuspid guidance.
T h e Bioprogressive philosophy, e m b r a c i n g
early treatment, was developed for greater effi-
ciency in orthodontic treatment. Early t r e a t m e n t
in suitable patients requires less work, is less
costly, and can be effective for m a n y m o r e
children. Sequences and efficiency in the chair
are aimed at reducing even full t r e a t m e n t to 4
hours of chair time with Bioprogressive proce-
dures. In addition, although up to 5% to 7% of
children grow out of Class II malocclusions, and
most patients over time improve f r o m o p e n bite
relationships, the d e e p bite Class II or protrusive
dentures worsen with growth, on average. Inter-
 BioprogressivePhilosophy
vention at age 5 years or age 8 years may prevent
that worsening maldevelopment.
The ultimate objectives o f the Bioprogressive
orthodontic philosophy are to work in h a r m o n y
with growth, to achieve p e r m a n e n t orthopedic
changes, and to set the stage for lifelong enjoy-
ment, in every sense o f o n e o f nature's miracles-
the natural dentition.
References
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