Clinical Review 2012

CLINICALREVIEW
Orthodontic
Rapid Maxillary
Expansion QUAD HELIX
with Skeletal Anchorage
INNOVATIONS
CLASS II
Corrections Using
Sectional Mechanics
CONTEMPORARY
BIOPROGRESSIVE
DR. RICKETTS THERAPY
TRIBUTE
Controlling the
Vertical Dimension
Remembering
Dr. Ricketts
The last time I saw Dr. Ricketts was
TABLE OF CONTENTS
in Maui, Hawaii 2003 during the F.O.R.
(Foundation for Orthodontic Research) annual
meeting following the AAO in Waikiki. The last
time I spoke with him was while he was on the
massage table getting ready to have dinner with
his family – later that night he had complications
and passed away the next morning. 2 Remembering
Dr. Ricketts
Dr. Ricketts dedicated his life to the Tony Zakhem, CEO 5 Contributors
Doctor Profiles
advancement of orthodontics and it was a
topic that he was always eager to discuss.
Since the very beginning, Dr. Ricketts
realized that it would be a long, tough battle
to bring about change to long held beliefs
concerning orthodontics. In 1973 he wrote
the “Doctrine of Limitations.” To this day,
6 Perspective in
Bioprogressive
the fundamental concepts of this article Therapy
hold true.
Ruel W. Bench, DDS
to never stop learning “keep your mind Appliance differentiation based on facial
Dr. Ricketts was an innovator whose stimulated…” Ricketts also taught us that type – built into brackets and tubes
8 Contemporary 18
thinking was often generations ahead of there is one certainty in life other than Mesofacial
the profession. RMO’s founder Dr. Archie death; it is that change is inevitable, and we Brachyfacial Rapid Maxillary Expansion
Brusse realized this back in 1955. must adapt to the change. Bioprogressive
Dolicofacial
Therapy with Skeletal Anchorage Vs. Bonded
In 1959 Archie instructed his son, Martin Dr. Ricketts collaborated with Dr. Ruel Tooth/ Tissue Born Expanders:
Brusse, to stay close to Dr. Ricketts. Archie Bench and Dr. Carl Gugino, to develop the He also published books and articles to Nelson Oppermann, DDS, MS
A case report comparison utilizing CBCT
said “I don’t understand Dr. Ricketts, but Bioprogressive philosophy. This philosophy support the evolution and improvement of
I know that he has a vision to be realized.” incorporated a biological approach to the Bioprogressive philosophy. Robert L. Vanarsdall, Jr. DDS
Archie also emphasized that Dr. Ricketts diagnosis and treatment options, and
was an inspired and strong person and RMO Dr. Ricketts also had other product related
always looked at the patient as a whole –
should work with him to help make his vision ideas such as:
not just straightening the teeth. In 1981 Dr.
a reality. Rick Jacobson joined Dr. Rickett's practice Self Ligating brackets (from the 1970s)
and even now continues to incorporate the The Snap Channel concept
Now, as we fast forward to 2012, RMO and
the entire orthodontic community continues
to benefit from the original partnership that
basic Bioprogressive principles that Dr.
Ricketts developed.
Ribbon type arch wires
Tooth colored bicuspid bands for lingual 24
Control of Vertical
retainers
was established with Dr. Ricketts. Over the years, I spent a lot of time with Dimension During Sagittal
Dr. Ricketts, including many long flights. Orthopedic Correction:
RMO is very proud to have worked with
I came to know Dr. Ricketts in the early Dr. Ricketts seemed like he never rested, The Death of the Wedge
Dr. Ricketts and to have helped assure
90’s when Martin Brusse decided to send not even on these flights. He was always Effect Theory and the Birth of
that his vision became a reality. RMO will
me to attend a lecture at the Bioprogressive thinking, writing, and considering new the Decompression Theory
continue to work with the co-founders of
Institute in Scottsdale, Arizona entitled concepts. Some of the ideas that he came
the Bioprogressive philosophy and the many
“The Bioprogressive Philosophy Series of up with that RMO incorporated include: Sergio Sambataro, DDS, MS, PhD
clinicians around the world who are dedicated
Courses (6).”
to the same teachings and philosophy.
44 Quad
Computer Aided Orthodontic Diagnosis Helix Innovations:
The journey was an unforgettable learning • Lateral and Frontal Analysis
“On behalf of all the RMO® people Pocket Aces
37
experience and started a long friendship • Long Term Visual Treatment Objective worldwide, we will never forget you;
with Dr. Ricketts. He was a great teacher, (VTO) you will always be in our hearts and Duane Grummons, DDS, MSD
innovator, father, friend, and thinker. He • Growth prediction to maturity on our minds. This Clinical Review is
always had the benefits of others in mind dedicated to you.” Class II Correction with Sectional
especially the patients.
He taught me to always think of the

Adding the dimension of time to
treatment parameters (4D)
Tony Zakhem, Chairman and CEO
Mechanics / Distalization Revisited
Enrique García Romero, DDS
51Tribute to
Dr. Ricketts
patients first and their overall health and
2 Clinical Review Clinical Review 3

rocky mountain orthodonticsTM
Contributors
FAN
Ruel W. Bench, DDS Current Principles and Techniques, 3rd 4th a researcher, Dr. Sambataro trained under Dr.
Become our
Dr. Bench was associated with Dr. Robert and 5th editions as well as Applications of Ricketts and received extensive experience in
M. Ricketts in the practice and teaching Orthodontic Mini Implants, with JS Lee, JK orthodontics and gnatology. Dr. Sambataro
FACEBOOK
of orthodontics. They developed and Kim, Y-C Park, Quintessence Publishing, 2007. actively collaborated with Professor Robert
on taught Bioprogressive therapy and

treatment philosophy and the computerized
cephalometric diagnostics. He served a three
Ignacio Blasi Jr., DDS
Dr. Ignacio Blasi Jr. completed his dental
Murray Ricketts at the American Institute for
Bioprogressive Education in the development
of new brackets and orthodontic wires, while
year preceptorship under Dr. Ricketts in training at the Universitat de Catalunya (UIC) studying facial growth and anthropology
conjunction with UCLA and the American at Barcelona (Spain) in 2007. After 2 years of in depth. He translated scientific texts from
to receive educational information Association of Orthodontics from 1959
to 1962. His thesis, “The Growth of the
private practice, he started his orthodontic
training in 2009 at the Orthodontic
English and he was lecturer and speaker at
different Courses and Meetings in Brazil (São
and monthly promotions Cervical Vertebrae and Related to Tongue Department at the University of Pennsylvania. Paulo), Italy (Bari, Catania, Firenze, Messina,
Poster”, was awarded a Milo Helman He received the Colgate National Award Reggio Calabria, Rimini, Roma, Verona), and
Research Award. He has lectured and given in dental research, has presented at various Spain (Santiago de Compostela).
courses in North America, South America, meetings and published on the effects of
Europe, Africa, Asia and Australia. different types of palatal expanders. His Enrique García Romero, DDS
Along with Rocky Mountain Orthodontics, topics of interest are perio-ortho, esthetics, Dr. Enrique García Romero has been dedicated
he developed a mini edgewise orthodontic multidisciplinary treatment, occlusion, TMD to the clinical application of the Bioprogressive
bracket system using metal injection molding and airways. Therapy and postgraduate teaching for the last
in addition to preformed arch wires for 23 years. He is professor at the Universidad
Bioprogressive therapy. Dr. Bench is currently Marianna Evans, DMD Central de Venezuela and Universidad de
an Associate Professor at Loma Linda. Dr. Marianna Evans is a full-time practicing Carabobo. He is former president of the
orthodontist, periodontist and dental implant Sociedad Venezolana de Ortodoncia and
surgeon. She is a diplomate of the American currently lectures on Bioprogressive topics
Nelson Oppermann, DDS, MS Board of Periodontology and eligible for worldwide. His private practice is in Caracas,
Nelson Oppermann received his Masters the American Board of Orthodontics. Her Venezuela and he is the developer of the
degree in orthodontics in 2003 from SL interdisciplinary training and years of clinical easyceph® online digital cephalometrics. He is
Mandic Dental Research School in Campinas, experience allow her to see the interconnectivity fellow of the WFO and AAO.
Brazil. He worked as an associate professor of gum disease, malocculsion and skeletal
at the at the Associação dos Cirurgiões- function in a way few specialists can. Dr.
Dentistas de Campinas and SL Mandic Dental Duane Grummons, DDS, MSD
Evans is a Clinical Associate at the University of Dr. Grummons is a Board Certified
Research School, Brazil. Dr. Oppermann is Pennsylvania Department of Orthodontics and
a guest lecturer at the University of Illinois orthodontist who has lectured before most
developed several orthopedic and plastic surgical American orthodontic organizations and
and has lectured around the world on many techniques within her specialties. She frequently
orthodontic topics. Dr. Oppermann specializes world-wide. His facial frontal analysis, TMD
lectures on orthodontics, periodontics and dental publications, and space gaining orthodontic
in presenting Bioprogressive ideas and clinical implants both within the United States and
cases both didactically and clinically. He is a appliance innovations are effective and
around the world. extensively utilized. Dr. Grummons is
member of the AAO and the WFO.
internationally recognized for his clinically
Paul Kocian, DDS sensible approaches and knowledge base for
Attended dental school at the University jaw orthopedics, facial asymmetry, 3D Cone
Robert L. Vanarsdall, Jr. DDS of Minnesota School of Dentistry. After Beam leadership, TMD co-management,
Dr. Robert Vanarsdall is Professor of graduation in 2006, he completed a 1-year and non-extraction orthodontic treatments.
Orthodontics and Director of the Division of AEGD residency and 2 years general Stunning smiles and facial harmonies are
Advanced Dental Education at the University practice while serving in the U.S. Navy. His consistent outcomes of his treatments.
of Pennsylvania, School of Dental Medicine postgraduate orthodontic training began Dr. Grummons is Associate Professor of
where he has been teaching full-time for in 2009 at the University of Pennsylvania. Orthodontics at The Loma Linda University
over 40 years. He received his dental degree Additional areas of interest include adult Medical Center Orthodontic Department.
from the Medical College of Virginia and orthodontic treatment, interdisciplinary He has appeared before many dental, surgical
completed his post-doctoral specialty training treatment, improving treatment efficiency with and medical conferences, and has made
at the University of Pennsylvania and is TADs and craniofacial growth. radio/TV appearances. His orthodontic
board certified in both Orthodontics and specialty practice is in Spokane, WA.
Periodontics. In addition to his teaching Sergio Sambataro, DDS, MS, PhD
commitment, he maintains a private practice. Dr. Sambataro received his D.D.S. degree from
For 17 years he served as Editor-in-Chief for the University of Catania, and graduated from
the International Journal of Adult Orthodontics Catania University with an advanced specialty
become a FAN of RMO®’s and Orthognathic Surgery in addition to other certificate and masters degree in Orthodontics;
facebook page! editorial board commitments; he co-authored he also holds a PhD in Interceptive
www.facebook.com/rmortho with Dr. Tom Graber the text Orthodontics: Orthodontics. While at Catania University, as
Clinical Review 5
650 West Colfax Avenue, Denver, Colorado 80204 Synergistic Solutions for Progressive OrthodonticsTM
P 303.592.8200 F 303.592.8209 E [email protected] 800.525.6375 | www.rmortho.com
Perspective in Principles of Bioprogressive Therapy
Bioprogressive Therapy 1. The use of systems approach in diagnosis and treatment by
the application of the visual treatment objective in planning
Ruel W. Bench, DDS treatment, evaluating anchorage, and monitoring results.
2. Managing treatment to unlock the malocclusion in a progressive

sequence and establish more normal function and growth.
A Bioprogressive symposium in resulted in their being intruded. The
August 2011 in Brazil attracted over key factor being a light continuous 3. The availability of torque control throughout treatment, thus
500 Orthodontists, where local force, properly directed. In order to edgewise brackets.
Brazilian teachers and professors of apply the lighter continuous forces that
Bioprogressive Therapy presented effected incisor movements, the multi-
4. Muscular and cortical bone anchorage.
their current Bioprogressive treatment use utility arches that spanned from the
procedures. The French Ricketts molars to the incisors were developed.
Bioprogressive Society has over 700 Bioprogressive Therapy promoted a 5. Movement of all teeth in any direction with the proper
orthodontist members. Bioprogressive concept of sectional arch therapy where application of pressure (force per unit area).
lectures in Mexico attract very breaking up the continuous arch wire
large numbers of Bioprogressive allowed better control of the buccal 6. Orthopedic alteration – point of control.
orthodontists. Bioprogressive Therapy occlusion, upper incisor torque and
is practiced worldwide. midline positioning. 7. Treat the overbite before the overjet correction.
This outpouring of interest in Computerized cephalometrics as a 8. Sectional arch therapy with utility arch mechanics.
Bioprogressive Therapy began in the diagnostic service was developed in
1950’s when Dr. Robert M. Ricketts conjunction with Rocky Mountain
9. Concept of over treatment.
attracted much interest in his early Orthodontics in 1968. This was a
mixed dentition, non extraction challenging new concept at the time,
treatment. His approach included his that today is accepted as a standard 10. Efficiency in treatment with quality results, utilizing a concept of
interest in growth, development and by the whole orthodontic profession. pre-fabrication of appliances.
function as revealed from his study of It brought a whole new concept
the cephalometric x-rays. to cephalometrics that proposed a 11. Masticatory dysfunction (TMD) disorders managed.
coordinate axis from which growth
Rick’s treatment of young cleft palate and treatment changes could be better
children at the University of Illinois analyzed, and described the various
revealed the need for maxillary facial types in their position along the
arch expansion in those cases, and bell curve.
practically all other malocclusions. His “Bioprogressive Therapy is not just a technique
use of the lingual quad helix expansion Bioprogressive Therapy’s use of the but applies biological principles in a progressive
arch invited additional variations “Visual Treatment Objective” in
that addressed the need to develop an treatment planning, has introduced manner throughout the life of the patient.”
expanded, more normal maxillary arch us to the advanced management
form. procedures that can help us achieve the This concept has involved orthopedic Sharing Bioprogressive Therapy
quality results we desire. changes, TMJ function and treatment, around the world and seeing its benefits
Dr. Rickett’s accidental penicillin-like lighter controlled forces, brackets, appreciated has been very satisfying
discovery resulted in the ability to intrude In 1972, I proposed eleven principles appliances and arch wires that support and Rocky Mountain Orthodontics
the lower incisors, that previously were to explain the basic concepts and and sustain the biological principles. has been a very supportive partner in
thought to be impossible to intrude. treatment objectives of Bioprogressive Today’s cone beam images, pin these endeavors over the years.
A tipped lower molar being uprighted Therapy. They have become a implant anchorage and other high tech
against “the anchored lower incisors” standard for over four decades. applications lend support to our basic
Bioprogressive Therapy.
THE CROSS SECTION OF THE CHAMBERED NAUTILUS

ILLUSTRATES THE LOGARITHMIC PATTERN THAT RICKETTS
DEMONSTRATED IN THE GROWTH OF THE MANDIBLE

Contemporary Bioprogressive Therapy
Nelson Oppermann, DDS, MS
In 1950, Dr. Robert Murray Ricketts 1.) Using a systems approach to diagnosis respecting and comprehending the in a physiological growth pattern or 8.) Overtreat. Overtreatment of the
“
published “Variations of the and treatment, by applying the visual intrinsic limits of each individual’s biology not. When abnormal growth exists, the case insures long-term stability. Always
Temporomandibular Joint as Revealed treatment objective (VTO), evaluating and orthopedic function. Mesofacial, mandible always reacts poorly and suffers keep in mind that we are working with The reach of
by Cephalometric Laminagraphy”, anchorage and monitoring results. The Brachyfacial and Dolichofacial patients the most. periodontal ligaments, periosteum, Bioprogressive never
commencing the birth of the Bioprogressive Therapy advocates that it is require distinct anchorage needs. sutures, and muscles. These structures
Bioprogressive Therapy. The orthodontic imperative to implement a comprehensive 6.) Treat the overbite before the tend to return to their original condition ended; in fact it has grown,
community in 19501 was introduced to an diagnostic analysis of the malocclusion to 4.) Movement of all teeth in any direction overjet. The mandible reacts positively and it’s important to note the possibility and currently there are
alternative perspective from the young be treated, taking into account the face with the proper application of pressure. (movement in a counterclockwise of rebound in the case. many orthodontists around
and active mind of a postgraduate student and skull. It is imperative to utilize both Observe the root surface proportions of direction) when it does not encounter
at the University of Illinois, Dr. Robert lateral and posterio-anterior radiographs. every tooth to be moved. anterior / incisor interference. Using bite 9.) Unlock the malocclusion in a the world practicing
Murray Ricketts.
After his initial publication, Dr. Ricketts

It’s important to focus on seven key
parameters of the lateral analysis: a)
5.) Orthopedic alteration/skeletal dysplasia.
Bioprogressive Therapy indicates a proper
jumper appliances, or Class II elastics on
deep over-bite cases before opening the
bite can lead to one of the most common
progressive sequence in order to
establish or restore normal function.
Treating the case in the transverse
”
Bioprogressive principles.
completed more than 300 complementary Anterior Cranial Base, b) Posterior Cranial understanding of the mandible and its clinical mistakes in orthodontics. Using dimension before the vertical dimension,
articles and books that made their way Base, c) Mandible, d) Maxilla, e) Upper adverse reaction to abnormal function, these appliances before opening the bite and the vertical dimension before the
into the orthodontic community. He Teeth, f ) Lower Teeth, g) Soft Tissue. such as cross-bites and deep overbites. can cause interference and premature horizontal dimension, naturally and
only stopped publishing when he passed Always keep in mind adaptation of the Correcting these problems is fundamental contacts between the incisors. biologically unlocks the malocclusion in
away on June 17th, 2003. During his outcome for each patient individually in order to have a positive reaction on a progressive manner. This provides the
journey he built a worldwide network of with attention to: genetics, environment, the mandible and a normal direction 7.) Sectional arch approach. It is logical opportunity for the bony structures and
relationships and colleagues including and individual factors. of growth, leading to a pleasant profile. to design treatment mechanics using the dentition to adapt to a more natural
Dr. Ruel Bench and Dr. Carl Gugino, Bioprogressive Therapy emphasizes a sectional arch approach. Dividing the condition and preserve healthy TMJs.
both influential Bioprogressive maestros. 2.) Maintain torque control throughout careful observation of the functional upper and lower arches in sections, separating
The reach of Bioprogressive never ended, treatment. This is of great value during occlusal plane. The occlusal plane is a the molars, bicuspids, canines and incisors 10.) Utilize quality-fabricated appliances
in fact it has grown, and currently there the mechanics phase of treatment, great indicator that orthopedic problems simplifies the mechanics. Working with the for efficiency and quality results.
are many orthodontists around the world especially in the vertical dimension. may occur, leading to clockwise (poor) sections of the upper arch and lower arch Bioprogressive Therapy continues to
practicing Bioprogressive principles. growth of the mandible. Mandibular in the transverse, then vertical, and finally adapt modern technology and materials,
These principles were generated and 3.) Understand muscular and cortical ramus height, the direction of the growth horizontal dimension; sets up the case for always respecting the fundamental
developed by Bioprogressive Therapy bone anchorage. Understand the limits in the condyle, and the amount of growth using Straight Wire mechanics to create an principles indicated in this article.
practitioners since the 1950s, but in 1979 of orthodontic mechanics and apply this of the coronoid process, are all strong ideal finish for the case.
Ricketts et al 2 stated some of them: concept to control the case orthopedically, indicators if the patient’s face is growing

All of the concepts in this article can After establishing treatment goals in it (2). After addressing the mandible and
be applied to diagnostics and treatment the transverse and vertical dimensions, A Point it’s possible to design the new
mechanics for every case, utilizing them the mandible adapts to a more natural A-Po plane. Using the new A-Po plane as
to design the Visual Treatment Objective forward position. Often the horizontal a reference, place the lower incisors in the
(VTO) before any fixed appliance dimension will need to be addressed in correct position (3). Next, place the lower
treatment. By using lateral and frontal order to drive the case into its finishing molars, keeping in mind the lower arch
cephalograms, and starting with the stage. There are a variety of options for depth and the type of lower anchorage
end of treatment in mind, provides the this phase such as Class II elastics, upper needed. Any movement of the lower
practitioner with the best opportunity molar distalization and/or mesialization molars forward, or burning anchorage,
for success and avoids any unforeseen of the lower molars. The decision to will tend to rotate the mandible in a
events during treatment. In order to utilize one type of mechanics versus counterclockwise direction (4). Once the
fully understand cephalometrics, the another will be based on the information lower molar position is identified, place the
clinician must start by understanding received using the VTO. upper molars according to the treatment Patient: mixed race, female, 12 y and
normal growth concepts. Then, apply plan, typically in a Class I relationship. 02 m of age.
the concepts of proportions, observing When working on the VTO, it is If the case requires distalization of the
principles of “ The Golden Proportions”.3 imperative to recognize and completely upper molars the mandible will tend Chief complaint: Protrusion, chin
understand the relationship and to rotate in a clockwise direction (5). backwards and spacing.
During the phase of working mechanics,
follow the idea of progressive mechanics.
Start in the transverse dimension using
expansion devices, employing rapid or
slow palatal expansion (depending on the
amount of forces desired). As an example,
we use the Wilson 3D Quad Helix, a
prefabricated appliance, to work in the
transverse dimension. The great benefit
of this system is the complete 3D control
of both torque and rotation of the molars
during treatment. Since the appliance is
removable by the orthodontist, the results
are completely predictable. This is a great Patient’s initial pictures, showing lip incompetence and convex profile.
example of how Bioprogressive principles
can be applied using many different types
of appliances.
After addressing the transverse Cybernetic Circle

dimension, work in the vertical dimension
by using appliances such as cervical
headgear to control vertical posterior
dimension on growing patients and the interaction of dental and skeletal Next, check the upper incisor position,
utility arch to control the vertical anterior changes. This is described by a circle adjusting torque and intrusion according
position. In order to control the vertical of reactions named by Dr. Ricketts as to the facial typology. Use the Facial Stone casts models at the beginning of treatment
posterior dimension it is necessary to have the “Cybernetic Circle”, first presented Axis as a reference to place the incisor
full control of anchorage in the lower first in 1976.4 inclination (6).
molars. Tip back, toe in, and torque bends
can be applied to maximize anchorage. The Before placing bands and brackets, The following clinical case shows how to
use of sectional mechanics to stabilize the the practitioner should have a full apply biomechanics using the principles
arch from first molars to the bicuspids or understanding of the “Cybernetic Circle”. of the Bioprogressive Therapy and the
canines is fundamental in Bioprogressive Keeping the end of treatment in mind and “Cybernetic Circle.”
Therapy to avoid undesirable tip back of visualizing the actions and reactions of
the molars. TADs can also be used to help soft tissue and hard tissue helps organize
Time 1 lateral
reinforce the anchorage system. Any type ideas and predicts how treatment will cephalometric radiograph.
of new alloy or technology can be used impact the patient. “During the phase of
in the Bioprogressive Therapy as long working mechanics,
as the basic principles are maintained. An example of how to understand the
For example, the use of nickel titanium Cybernetic Circle is to start with the
follow the idea of
Stone casts models at occlusal Time 1 lateral cephalometric tracing and Ricketts analysis.
or TMA alloys to retract canines is position of the mandible (1). After progressive mechanics.”
view, showing a nice upper molars,
great, keeping in mind the amount and positioning the mandible in the sagittal
transverse dimension of 57mm.
direction of the counter forces produced plane, the 2nd step is to place A Point and
using these types of materials. understand the mechanics that can affect

A summary of the records presents a After careful study of all the records, Option #3) Upper first bicuspid
brachyfacial growing patient with skeletal there are several options of how to treat extractions. This approach would fix
and dental deep overbite. The mandible this case. Possible options include: the overjet issue, but it would not resolve
is well positioned but the maxilla the convex profile. Finishing the case
is positioned forward to Frankfort, Option #1) Distalize upper molars. with a Class II molar relationship would
indicating a mild Class II skeletal This approach would treat the dentition make it harder to have a well balanced
As good as it gets position. The Facial Axis is showing a

slight counterclockwise rotation, which
is not normal on bracyfacial patients.
very well and provide an aesthetic smile.
However, it will not change the profile
of the patient. The patient would finish
occlusion.
Option #4) Burn lower molar anchorage.

RMO®’s Energy Chain is the proven leader in elastomeric chain material, outperforming
TM The upper molars can be distalized, with a Class II profile (convex) at the end This approach corrects the molar
other elastic chains in numerous independent clinical tests. Stain resistant, latex free, 4 sizes indicated by large upper molars to of treatment. relationship and moves the posterior
PTV line distance. The incisors are teeth forward, rotating the mandible in
and a variety of colors.
protruded, indicating extrusion of the Option #2) Four bicuspid extraction. counterclockwise direction, improving the
upper incisors. Lower incisors are well Because of the general spacing already profile and addressing one of the patient’s
positioned for a brachyfacial typology. present in the case, extracting four chief complaints. In order to accomplish
The profile is convex and poor, indicated bicuspids would make it more difficult this approach it is imperative to control the
by 4.5mm of lower lib to E-line. The to close space later in treatment. upper incisor extrusion, avoiding incisor
stone models indicate that this patient Additionally, extracting the bicuspids proprioception by opening the deep overbite.
RMO®’s patented formula provides light, continuous force for weeks resulting in brilliant does not need arch expansion, the upper would amplify the facial typology and
closure and very..very..happy patients. molars are well rotated and both arches make it very difficult to control the Option #4 was implemented and the
have good general spacing. vertical dimension during the retraction treatment sequence and biomechanics
of the incisors. are below:
Lower Utility Arch was used to control the lower incisors. Synergy brackets Ricketts prescription (.0185 x .030) were used. Sectional
arches on the upper arch and Class II 3/16” elastics were placed from upper first bicuspids to the lower first molars.
After achieving Class I molar relationship, retraction arches were placed on the canines. An upper Utility Arch was placed to
reinforce the anchorage. Lower Utility Arch was removed and only four brackets and two bands were used to treat the lower arch.
Energy Chain
TM
Clinical Review 13
Upper incisor retraction starts after achieving Class I canine and molar relationships. Because the case required careful attention to
control torque and intrusion for the upper incisors, it was decided to retract with a contraction Utility Arch.
Final lateral cephalometric radiograph.
The finishing of upper incisor retraction.
Before and after superimpositions.

Note the amount of counterclockwise
rotation of the mandible. Lower molar
anchorage was burned which promoted
the forward movement of the mandible.
Final lateral tracing. Upper molars did not drift mesially and
upper incisors were retracted while
carefully controlling the torque.
Pictures showing the finishing and detailing stage. “L” sectional spring was placed to improve the position the lower left canine.
Four years post treatment.

The mandible continued
to move forward and the
overjet has disappeared.
It’s recommended to finish Class II div. 1 growing Meso to Bracyfacial typology patients with a mild overjet of 2mm – 3mm in order
to leave room for the mandible to keep growing in the proper direction. This helps avoid Class II relapse or future crowding in the Pictures showing the face at debond. Note the profile improvement.
lower anterior region. The patient will reach adulthood with a healthy oral environment.

Conclusions: The Bioprogressive Therapy is not a

“technique”. It is a method of how to approach an
orthodontic case based on biological principles and
customized biomechanics. New brackets designs,
new wires alloys, and new devices can be developed
and used with this method as long as all of the
principles described in this article are followed. The
practitioner can choose to integrate technology into
this approach and take advantage of all benefits
these technologies have to offer to orthodontics and
dentofacial orthopedics.
REFERENCES
1. Ricketts RM. Variations of the temporomandibular

Photograph after 4 years into adulthood. joint as revealed by cephalometric laminagraphy.
Am J Orthod, St. Louis, v. 36, no. 12, p. 877-898,
1950.
2. Ricketts RM, Bench RW, Gugino CF, Hilgers

JJ, Schulhof RJ: Bioprogressive therapy, Book I,
Denver, 1979, Rocky Mountain Orthodontics.
3. Ricketts, R.M. The biological significance of the

divine proportion and Fibonacci series. Am J
Orthod. 1982;81:351–370
4. Ricketts RM. Bioprogressive therapy as an answer to

orthodontic needs part 2. Am J Orthod, St. Louis, v.
70, no. 4, p. 358-397, 1976.
5. Ricketts RM. et al. Orthodontic diagnosis

and planning – their roles in preventive and
rehabilitative dentistry. Rocky Mountain
Orthodontics,: [s.n.],1982. v.1, p.269.
The world’s most powerful curing light.

Before and after profile changes. Mandible has rotated in a Redesigned and loaded with new functions.
favorable direction and significantly improved the patient’s
profile, and fulfilled her treatment expectations.
16 Clinical Review
Rapid Maxillary Expansion with
PALATAL EXPANSION
Skeletal Anchorage Vs. Bonded Tooth/

Tissue born expanders:
A case report Comparison Utilizing CBCT
Robert L. Vanarsdall Jr., DDS, Ignacio Blasi Jr., DDS,
Marianna Evans, DMD, Paul Kocian, DDS
The CBCT provides three dimensional representation of the facial structures including the basal
bone of the maxilla. Maxillary hypoplasia has been an important indication for early treatment.
Unfortunately, RPE has been used When it may be critical to saving the Figure 1
primarily to treat dental crossbites or for natural dentition, we do not want Bone screw
gaining space to prevent extraction with to introduce adverse dental/skeletal anchored
little or no attempt made to coordinate changes, in adolescents and/or patients RPE- Electric
the transverse skeletal patterns1. with advanced periodontal disease. Torque Driver
Traditional maxillary orthopedics has In theory, skeletal anchorage should (Orthonia),
been done using the dental units as permit orthopedic change without battery
anchorage, for example, Haas and Hyrax 2 . adverse dental changes by applying powered
Dental movement has not only limited force directly to the maxillary bone 6 . handpiece
skeletal orthopedic change, but has
caused significant adverse periodontal With all the emphasis on evidenced
and instability side effects3. There is a based orthodontics a most recent CBCT
clear correlation between buccal tooth randomized clinical trial (14 years old)
movement and gingival recession and has reported that bone- anchored
bone dehiscences. These adverse maxillary expanders and traditional
periodontal responses with RPE highlight (Hyrax) rapid maxillary expanders
the importance of early treatment. showed similar results. The tooth born
The beneficial periodontal effects of group exhibited more first premolar
transverse skeletal correction have been a expansion than the bone anchored
main focus of our research for the past 35- appliance and both exhibited significant
40 years4. Krebs used implants to evaluate increase in crown inclinations7.
orthopedic expansion and confirmed
50% dental movement and 50% skeletal The purpose of this report is to compare
movement in children. In adolescence, the treatment response of patients with
however, only 35% of movement was equivalent skeletal severity, sex and
skeletal and 65% was dental5. In addition, similar age from our most effective Figure 2
it is well known that as the patient grows orthopedic tooth/tissue born expander Tooth tissue
older, dental tipping with RPE becomes and the bone anchored maxillary born
greater, which puts teeth at higher risk for expander on the basal bone and the
gingival recession. We have emphasized molar teeth.
the importance of correcting transverse
skeletal discrepancy 4: Materials and Methods
Two 14.5 year old twins with maxillary

A. To prevent periodontal transverse deficiencies (treated in the
problems. orthodontic clinic at the University
of Pennsylvania) were chosen to be
B. To achieve greater dental treated; one with a bone screw anchored
and skeletal stability. RPE and the other with a tooth-tissue
born appliance (Fig 1-2).
“These adverse periodontal C. To improve dentofacial
A pretreatment cone beam CT image
esthetics by eliminating
responses with RPE highlight the or improving lateral was taken before treatment (T1). Scans
importance of early treatment.” negative space. were obtained using an I-CAT machine
for both patients. The bonded maxillary
expander was cemented into place and had

full occlusal and palatal acrylic coverage. Molar Tipping
Figure 5 Significant
Appliances for both twins were made
A significant difference was seen in the adverse dental
by the same laboratory. Expansion was
increase in the molar tipping (Fig. 5). tipping
carried out with two turns per day (0.2mm
per turn) for as long as necessary until No tipping was noted with the skeletal
the required expansion was completed anchorage RPE and significant dental
to normalize the transverse dimension. tipping was exhibited by the dental/
Post expansion cone beam CT image was palatal RPE.
taken the day the expander was stabilized,
(T2). Post-treatment I-CAT scan had a Evaluation of Findings
reduced window and decreased radiation
by ½ (20 sec. to 10 sec.). As interesting and clinically important
60.03 mm 59.13 mm as these preliminary findings are, this
Neither patient received orthodontic report is only on two identical patients.
movement on the maxillary arch until The findings with bone anchorage
T2 records were taken. 79.91 mm demonstrates pure skeletal expansion
79.31 mm
without dental compensation (Fig. 6-7-
The CT images were obtained 8). RPEs with skeletal anchorage have
without the patient positioned in a been used to reduce surgery from 2 jaws
head positioner, therefore before the Figure 3- Before Treatment
to 1 jaw in a large number of cases. But
images were measured, each image was well designed randomized controlled
oriented using Anatomage InVivoDental Basal Bone skeletal anchorage device achieved clinical trials with large numbers of
software. The skulls were oriented in significantly more skeletal change (MX- moderate to severe transverse skeletal Figure 7
three planes of space using frontal view, There was a significant increase in MX) without dental compensation than discrepancy that may be contra-
right lateral and left lateral view. The width of the basal bone as a result of did the dental/palatal anchorage device. indicated for dental/palatal expansion
head was oriented in the frontal view the palatal expanders. Approximately 3mm greater basal should be evaluated to delineate
with the floor of the orbits parallel to maxillary expansion was noted with reproducible treatment potential.
the floor. The right lateral view allowed Comparing skeletal anchorage skeletal vs. dental/palatal anchored Significant evidence in this regard will
placement of the skull so Frankfort vs. dental/palatal tissue treatment RPE (Fig. 4). be reported in the future.
horizontal was parallel to the floor. expansion efficacy both demonstrate
Both right and left posterior borders significant skeletal change. But the
of the ramus and angle of the mandible
were superimposed on each other to the
best possible fit. The left lateral view was Figure 4
also examined to ensure Frankfort was
parallel to the floor and the border of the
ramus and angle of the mandible were
superimposed as best fit8.
3D Skull Measurements
The measurements were calculated from

a 3D Skull view of the patient. Points 1
and 2 are reference points that serve to Figure 8
represent the level of basal bone of the 5 mm skeletal expansion 2 mm skeletal expansion
maxilla (Fig. 3). These landmarks are 60.03mm - 65.05mm 59.13mm - 61.36mm
defined as the most superior aspect of
the concavity of the maxillary bone as Figure 6
it joined the Zygomatic process. Figure
4 shows pre and post expansion at the
first molar and red lines indicate axial
inclinations of the molars 9,10.
65.05 mm 61.36 mm There was a
Results
significant increase
The CBCT technology allows for more in width of the basal
reliable and accurate measurements for
distances between subject’s anatomical
79.92 mm 79.71 mm bone as a result
landmarks11. The maxillary basal change of the TAD palatal
with the skeletal/ bone anchorage device was
significant without dental compensation.
expander.

EASTMEETS
Discussion The CBCT technology allowed for clear guarded or anticipated but the patient
visualization and quantification of the or clinician does not want to commit.
The literature and our initial findings changes in basal bone associated with It may provide an alternative to surgery. New York University Langone
have suggested that a greater magnitude palatal expansion11. In fact, the high
WEST
Medical Center, Institute
of orthopedic change and minimal dental precision of the quantitative analysis on We are presently conducting clinical of Reconstructive Plastic
movement are possible. Both twins CT images contributes to the reliability trials to determine the limit of skeletal
exhibited significant expansion at the of this outcome and makes this case anchorage and palatal expansion. Surgery, Partners with RMO®
level of the maxillary first molar crown report more acceptable. for fellowship program
and root apex. Axial slices indicate the Conclusions
bonded tooth/tissue patient as well as the “These results indicate that
bone anchored patient exhibited midline clinicians can predictably Based upon our present studies and
suture opening in a parallel fashion. This achieve at least 3 mm or more treatment to normalize transverse skeletal
was different from earlier expanders of pure skeletal change using discrepancy a clinician could anticipate at
which have been reported to cause skeletal anchorage expanders least 2-3 mm greater basal expansion with
openings of the midpalatal suture in the in older more mature patients.” the skeletal anchored RPE than with the
area of PNS occurring at a lesser extent tooth tissue born RPE.
then at ANS. In practice the skeletal anchorage may
not be necessary in mild transverse The skeletal anchored RPE produced
Oliveira et. al examined the different discrepancy due to the more invasive less molar tipping than the tooth tissue
effects of a tooth tissue born appliance nature of placing the bone pins, born RPE.
(subjects with a mean age of 11.9 years) potential failure and financial cost. In
with a tooth born only appliance milder discrepancy cases, the dental/ The palatal skeletal change that is
(subjects with a mean age of 11.1 palatal anchorage still remains the best predictably possible remains unknown
years). They reported that the tooth choice. The skeletal anchorage could be and future research is needed. But it is
tissue born expander demonstrated reserved for moderate to severe cases, clear that the envelope of discrepancy has
more orthopedic movement and less periodontally involved, missing teeth been changed for older patients (Fig 9).
dentoalveolar tipping12 . or where the dental/palatal expander is
Figure 9
Treatment Options
Treatment: RPE TAD SARPE
Age: 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2 0
References 7. Lagravère M, Carey J, Heo G, Toogood R, Major P. Transverse,

vertical, and anteroposterior changes from bone-anchored maxillary
1. Gianelly A.: Rapid palatal expansion in the absence of crossbites: expansion vs traditional rapid maxillary expansion: A randomized
Added value? Am J. Orthod Dentofacial Orthop 124:4, 2003. clinical trial. Am J. Orthod Dentofacial Orthod. 137:304, 2010.
2. George C. Chung C and Vanarsdall R.: Dentoalveolar inclinations 8. Christie, K.: Effect of bonded ( tooth-tissue) RPE on the
with Hyrax and Haas palatal expander: evaluation using computer transverse dimension of the maxilla- A CBCT Study, Thesis, First ADA Accredited Craniofacial and
assisted tomography. Thesis, Department of Orthodontia, University University of Pennsylvania, May, 2008.
of Pennsylvania, 2000.
Special Needs Orthodontics Fellowship
9. Podesser B, Williams S, Grismani A, and Bantleon H-P:
3.Garib DG, Henriques JFC, Janson G, et. al.: Periodontal effects of Evaluation of the effects of rapid maxillary expansion in growing NYU and RMO® collaborating to show how
rapid maxillary expansion with tooth-tissue borne and tooth borne children using computer tomography scanning: a pilot study, Europ J
expanders: A computed tomography evaluation. AJO-DO: 129: 749- of Orthodontics 29: 37-44, 2007. partnerships can shape lives
758, 2006.
10. Kilic N, Oktay H. A comparison of dentoalveolar inclination
4. Vanarsdall, R and Secci, A: Chapter 23 Periodontal-Orthodontic treated by two palatal expanders. Eur J Orthod 30: 67-72, 2008.
Interrelationships, In Orthodontics- Current Principles and
Techniques, Fifth Ed., Elsevier Inc, p. 807-841, 2011. 11. Garrett, BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS,
and Taylor GD: Skeletal Effects to the maxilla after rapid maxillary
5. Krebs A.: Midpalatal suture expansion studied by the implant expansion assessed with cone-beam computed tomography, AJODO:
method over 7- year period. Trans Eur Orthod Soc, 40: 131, 1964. 134:8, 2008.
6. Garcia J, Secci A, Vanarsdall R. “ Anclaje esqueletico Y Anclaje 12. Oliveira NL, Da Silveira AC, Kusnoto B, Viana G,: Three
dentario,” Revista Socied Ad Espanola Orthodoncia, 51. No.1 50-58, dimensional assessment of morphologic changes of the maxilla;
2011. a comparison of 2 kinds of palatal expanders. Am J. Orthod
Dentofacial Orthod. 126; 354-362, 2004.
22 Clinical Review
Ricketts22,23,46-48 asserts that cervical headgear to control the vertical vertebral maturation (CVM) method. 51
traction promotes a downward and dimension during Class II correction Orthopedic and orthodontic effects were
backward displacement of the maxillary in the growing patient; and 2) to estimated using lateral cephalometric
Control of Vertical Dimension during complex and through a modest extrusion
of the upper molar, an increase of the
determine the dentoskeletal response in
a) open bite patients when lower incisor
head film.
Sagittal Orthopedic Correction: vertical growth of the mandibular intrusion is treated by cervical headgear Patients and Methods: Cephalometric analysis
ramus with a consequent bite closure and b) deep bite patients when treated
The Death of the Wedge Effect Theory and the and without unfavorable mandibular with a combination of cervical headgear 41 measurements, 25 linear and 16
Birth of the Decompression Theory postero-rotation. and a lower utility arch to open the angular, were taken on the lateral
bite by lower incisor intrusion. This headflim; 37 were selected from the
Sergio Sambataro, DDS, MS, PhD Furthermore, Ricketts22,23,46-48 advocates is performed according to orthopedic Ricketts Analysis52-58 and 4 were
the use of a lower utility arch to open the Class II therapy as suggested by suggested by Baccetti et al. 59
bite in deep bite patients to prevent anterior Ricketts.46-48
interference, which is in part responsible for T he l i ne a r a n d t he a n g u l a r
the mandibular postero-rotation. Strengths of this study include: 1) measurements are reported in Table I.
using untreated Class II patients and
The goals of this research Table
are: 1) to Cephalometric
I. Lateral 2) appraisal Analysis
of stages in individual
This was the birth of the determine the correct use of cervical skeletal maturity by the cervical
“wedge effect theory”
based on anecdotal cases
FUNCTION PARAMETER Table 1
1 Total Facial Height (TFH) Corpus Axis ^ Basion Nasion Lateral
without scientific data. 2 Lower Facial Height (LFH) Corpus Axis ^ Org Line Cephalometric
3 Central Facial Direction (FAX) Facial Axis ^ Basion Nasion Analysis
Extra oral forces have been used for 4 Facial Depth (FD) Facial Plane ^ Frankfort
several clinical applications during 5 Ramus Height (MP) Mandibular Plane ^ Frankfort
the last century.1-3 In 1947, Kloehn4 6 Convexity (C) Point A - Facial Plane
used cervical headgear to treat class 7 Palatal Plane Position (PPP) Palatal Plane - Frankfort
II malocclusions. The main effect of 8 Posterior Cranial Length (PCB) Condylion Posterior - PTV
this appliance was evident when it was 9 Anterior Cranial Length (ACB) Cranial Center - Nasion
used to produce skeletal alteration in 10 Cranial Deflection (Ba-N^FH) Ba-N ^ Frankfort
the growing patient. During the last 50 11 Position of the Maxilla (Ba-N^N-A) Basion -Nasion ^ Nasion – Point A
years, several authors reached opposite 12 Nasal Plane Length (N-A) Nasion - Point A
conclusions about the effects of this 13 Divine Facial Height (A-Pm) Point A - Protuberance Menti
appliance on the vertical dimension. 5-50 14 Mandibular Ramus Horizontal Position (Xi^FH) Xi ^ Frankfort
15 Mandibular Ramus Vertical Position (Xi-FH) Xi - Frankfort
16 Ramus Height (Xi-R3) Xi - R3
Schudy,7 and Creekmore11 considered
17 Condyle Axis Length (Xi-Co) Xi - Condylion
the responsible factor of the mandibular
18 Corpus Axis Length (Xi-Pm) Corpus Axis
postero-rotation, especially in dolicho-
19 Mandibular Arch (MA) Corpus Axis ^ Condyle Axis
facial patients, to be the extrusive Posterior Position of Occlusal Plane (Xi-OP) Xi – Occlusal Plane
20
component. To prevent this effect, 21 Occlusal Plane Inclination (OP ^ Xi-Pm) Occlusal Plane ^ Corpus Axis
many clinicians started to use “high 22 Lower Incisor Position (horizontally) (B1-APo) Incisor Tip – Dental Plane
pull” traction to intrude the upper 23 Lower Incisor Position (vertically) (B1-OP) Incisor Tip - Occlusal Plane
molar during Class II correction in 24 Lower Incisor Inclination (B1Â-Po) B1 ^ Dental Plane
hyper divergent patients, and relegated 25 Depth of Lower Arch (B1-B6) Mesial of the molar B6 - Incisor Tip B1
cervical traction to brachyfacial 26 Molar Relation (B6-A6) Distal of the molar B6 - Distal of the molar A6
patients. Both, the “high pull” and 27 Upper Molar Position (A6-PTV) Distal of the molar A6 - PTV
the “low pull”, were used in meso- 28 Lower Molar Inclination (B6^Xi-Pm) B6 ^ Corpus Axis
facial patients. This was the birth of 29 Upper Molar Inclination (A6ÂNS-PNS) A6 ^ Palatal Plane
the “wedge effect theory”11,12 based 30 Upper to Lower Incisor (A1^B1) Interincisal Angle
on anecdotal cases without scientific 31 Horizontal Incisor Relation (OVJ) Overjet
data. Consequently, in our opinion, the 32 Vertical Incisor Relation (OVB) Overbite
incorrect use of cervical traction drives 33 Lower Lip Protrusion (li-El) Lower Lip - Esthetic Line
the orthodontic profession to believe 34 Upper Lip Protrusion (ls-El) Upper Lip - Esthetic Line
that facial height increase is a side effect 35 Nose Length (ANS-prn) Anterior Nasal Spine - Tip of Nose
36 Chin Thickness (Po-ppo) Pogonion - propogonion
of cervical traction. 5,6,8-10,12-21,27-29,32,33,37,40
37 Hyoid Position (H-PTV) Body of the Hyoid - PTV
38 Anterior Facial Ratio (N-ANS/ANS-Me) N-ANS/ANS-Me
R i c k e t t s 22,23,46-48 others and
39 Maxillary Length (Co-A) Condylion - Point A
fol lowed
2 4 -2 6 , 3 0 , 31, 3 4 -3 6 , 3 8 , 39,41- 45 ,49, 5 0
40 Mandibular Length (Co-Gn) Condylion - Gnathion
Kloehn’s indications and noticed good Gonial Angle (Co-Go^Go-Me) Condylion - Gonion ^ Gonion - Menton
41
vertical control without mandibular
postero-rotation.

Table II. Total Control Group (TCG) at T1.
Patients n= 37 18 m 19 f Table II
VARIABLE Mean St.Dev. Min. Max
Total Control
This study included a total of 77 Total Facial Height (TFH)° 62,41 5,10 48,00 74,00 Group (TCG) at T1
patients. The total control group Lower Facial Height (LFH)°
Central Facial Direction (FAX)°
46,00
87,68
4,19
3,09
33,00
81,00
54,00
95,00
(TCG), 37 patients, did not receive Facial Depth (FD)° 86,73 3,92 80,00 99,00
any appliance; they were followed for Ramus Height (MP)°
Convexity (C)mm
27,54
6,20
4,76
1,38
19,00
4,00
39,00
9,00
1.62 years (Table II); the remaining Palatal Plane Position (PPP)° -1,92 3,16 -8,00 5,00
40 patients (Table III) were treated by Posterior Cranial Length (PCB)mm 28,54 2,57 23,50 33,50
Inaugural Symposium Ricketts orthopedic Class II therapy46-48
Anterior Cranial Length (ACB)mm
Cranial Deflection (Ba-N^FH)°
54,76
28,97
2,89
2,23
49,00
25,00
63,00
35,00
September 14 -15, 2012 | Chicago, Illinois (TTG). The total control group (TCG) Position of the Maxilla (Ba-N^N-A)° 64,08 2,79 59,00 71,00
Nasal Plane Length (N-A)mm 51,03 4,22 45,00 66,00
patients were selected from the files Divine Facial Height (A-Pm)mm 43,66 4,32 35,00 55,00
of the Department of Orthodontics, Mandibular Ramus Horizontal Position (Xi^FH)°
Mandibular Ramus Vertical Position (Xi-FH)mm
76,07
31,97
3,06
2,51
70,00
26,00
82,00
38,00
University of Florence, and consisted Ramus Height (Xi-R3)mm 19,97 1,85 17,00 26,00
of 18 males and 19 females with a mean Condyle Axis Length (Xi-Co)mm
Corpus Axis Length (Xi-Pm)mm
35,35
59,62
3,62
3,93
24,00
54,00
43,00
70,00
age of 8.55 years (range 7.58-10.83), in Mandibular Arch (MA)° 25,27 4,81 17,00 36,00
mixed dentition at T1. The other 40 Posterior Position of Occlusal Plane (Xi-OP)mm
Occlusal Plane Inclination (OP ^ Xi-Pm)°
31,97
21,78
2,51
4,45
26,00
12,00
38,00
36,00
(TTG), 19 males and 21 females, with Lower Incisor Position (horizontally) (B1-APo)mm 0,62 2,57 -4,00 8,00
a mean age of 8.86 years (range 7.43- Lower Incisor Position (vertically) (B1-OP)mm 2,01 1,47 0,00 6,00
Lower Incisor Inclination (B1Â-Po)° 21,54 7,15 3,00 35,00
10.25), in mixed dentition, were treated Depth of Lower Arch (B1-B6)mm 24,78 2,12 20,00 29,00
for 1.55 years, followed for 1.98 years Molar Relation (B6-A6)mm 0,92 1,61 -3,00 3,00
Upper Molar Position (A6-PTV)mm 12,41 3,44 0,00 20,00
and collected from a single orthodontic Lower Molar Inclination (B6^Xi-Pm)° 104,78 17,94 6,00 118,00
practice where the Bioprogressive Upper Molar Inclination (A6ÂNS-PNS)° 105,73 5,54 90,00 115,00
Upper to Lower Incisor (A1^B1)° 125,24 12,63 104,00 158,00
therapy is used. The skeletal age of both Horizontal Incisor Relation (OVJ)mm 5,88 2,41 2,00 12,00
groups corresponding to a pre-puberty Vertical Incisor Relation (OVB)mm 1,50 2,45 -4,00 6,00
Lower Lip Protrusion (li-El)mm 1,39 3,09 -4,00 8,00
stage (CVMSI) was assessed on lateral Upper Lip Protrusion (ls-El)mm 0,43 1,95 -4,00 3,00
cephalograms of the examined subjects Nose Length (ANS-prn)mm 20,57 2,17 15,00 25,00
Chin Thickness (Po-ppo)mm 9,76 2,30 6,00 20,00
according to the cervical vertebral Hyoid Position (H-PTV)mm 0,53 6,69 -13,00 17,00
maturation method.49 In order to evaluate Anterior Facial Ratio (N-ANS/ANS-Me)% 0,92 0,08 0,80 1,11
Maxillary Length (Co-A)mm 81,23 4,55 72,00 93,00
the effects of treatment, differences Mandibular Length (Co-Gn)mm 97,88 6,22 89,00 115,00
between the total treated group (TTG) Gonial Angle (Co-Go^Go-Me)° 130,32 4,94 118,00 138,00
and the total control group (TCG) were

Tabella III. Total Treated Group (TTG) at T1.
identified after treatment (T2). Normal
growth changes were obtained by n= 40 19 m 21 f
Table III
comparing the means at T1 and T2 for VARIABLE Mean St.Dev. Min. Max Total Treated
the total control group (TCG). Total Facial Height (TFH)° 60,86 5,79 37,00 69,00 Group (TTG) at T1
Lower Facial Height (LFH)° 46,14 4,20 38,00 53,00
Central Facial Direction (FAX)° 88,06 3,82 79,00 96,00
The total treated group (TTG) was Facial Depth (FD)° 86,62 2,60 80,00 92,50
divided into 2 subgroups according to Ramus Height (MP)°

Convexity (C)mm
26,61
6,22
4,23
1,50
17,00
3,00
33,00
10,00
the facial type. The open group (OG) Palatal Plane Position (PPP)° -3,13 2,58 -9,00 4,00
consisting of 20 patients, 10 males and Posterior Cranial Length (PCB)mm

30,40
56,57
2,65
2,71
24,00
49,00
37,00
72,00
10 females (Table IV), was treated by Cranial Deflection (Ba-N^FH)° 29,11 1,93 25,00 34,00
Position of the Maxilla (Ba-N^N-A)° 64,26 3,20 56,00 70,00
Nasal Plane Length (N-A)mm 53,32 3,44 46,00 61,00
Divine Facial Height (A-Pm)mm 44,79 3,70 36,60 53,20
Mandibular Ramus Horizontal Position (Xi^FH)° 46,61 4,34 40,00 57,50
Mandibular Ramus Vertical Position (Xi-FH)mm 34,06 3,39 28,50 47,00
Ramus Height (Xi-R3)mm 21,31 1,65 17,28 25,00
Condyle Axis Length (Xi-Co)mm 36,73 4,60 20,00 44,65
Corpus Axis Length (Xi-Pm)mm 62,90 4,10 55,00 72,50
Mandibular Arch (MA)° 27,51 3,85 21,50 40,00
Posterior Position of Occlusal Plane (Xi-OP)mm 1,32 2,27 -4,00 7,00
Occlusal Plane Inclination (OP ^ Xi-Pm)° 21,26 3,23 12,00 29,50
Lower Incisor Position (horizontally) (B1-APo)mm 1,71 2,23 -2,85 7,00
Lower Incisor Position (vertically) (B1-OP)mm 2,15 1,77 -1,50 6,00
Depth of Lower Arch (B1-B6)mm 25,58 2,91 18,00 38,00
Molar Relation (B6-A6)mm 1,01 1,79 -3,00 4,75
Lower Molar Inclination (B6^Xi-Pm)° 110,90 4,70 99,00 119,00
Upper Molar Inclination (A6ÂNS-PNS)° 105,86 4,46 97,00 116,00
www.bioprogressive.org Upper to Lower Incisor (A1^B1)°
Horizontal Incisor Relation (OVJ)mm
120,21
5,49
7,59
2,61
107,00
1,00
142,00
12,50
Vertical Incisor Relation (OVB)mm 1,95 2,26 -5,00 5,00
Lower Lip Protrusion (li-El)mm 2,05 2,79 -5,70 7,00
Upper Lip Protrusion (ls-El)mm 0,64 2,32 -4,00 5,00
Nose Length (ANS-prn)mm 20,43 1,83 17,00 24,50
Hyoid Position (H-PTV)mm 0,50 5,74 -12,00 13,30
Anterior Facial Ratio (N-ANS/ANS-Me)% 0,84 0,10 0,66 1,09
Mandibular Length (Co-Gn)mm 101,98 5,80 91,00 115,20
Gonial Angle (Co-Go^Go-Me)° 127,00 4,42 117,00 135,00
Clinical Review 27
Table IV. Open Group (OG) at T1.
Table IV n= 20 10 m 10 f cervical traction alone for 1.30 years, In the Deep Group (DG) a lower The starting forms of TCG with Results: Comparison of the Starting Forms
Open Group VARIABLE Mean St.Dev. Min. Max
then followed for 1.80 years. The deep utility arch was combined with the TTG, and the OG with the DG were
(OG) at T1 Total Facial Height (TFH)° 61,70 4,92 52,00 69,00 group (DG) consisting of 20 subjects, cervical traction. It was applied on the compared. Craniofacial modifications in In order to assess significant differences
Lower Facial Height (LFH)°
Central Facial Direction (FAX)°
45,95
87,40
4,66
4,57
38,00
79,00
53,00
96,00
9 males and 11 females (Table V), was first molar with the bands placed at the treated groups were compared with between craniofacial starting forms
Facial Depth (FD)° 85,55 2,53 80,00 90,00 treated by cervical traction associated the marginal ridge. Bands used were the growth modifications occurring in at the time of the first observation,
Ramus Height (MP)°
Convexity (C)mm
26,45
5,96
4,54
1,24
17,00
3,00
33,00
8,10
with a lower utility arch for 1.75 Ricketts 4D with -24° of torque, -5° the control group. In particular T1 to T2 comparisons between the groups at
Palatal Plane Position (PPP)° -3,45 2,48 -9,00 0,00 years, then followed for 2.13 years. of tip and -12° of disto-rotation. The changes were analyzed to describe the T1 were performed. No statistically
Posterior Cranial Length (PCB)mm
30,63
56,78
2,73
2.75
25,50
51,77
37,00
62,70
Cephalograms for each patient in all lower utility arch was placed with -10° effects of the active therapy. Composites significant differences were found in
Cranial Deflection (Ba-N^FH)° 29,15 2,16 25,00 34,00 treatment and control groups at T1 and of torque, -5° of toe-in, 10° of tip-back, were manually drawn to visualize the the craniofacial configurations at T1
Position of the Maxilla (Ba-N^N-A)°
Nasal Plane Length (N-A)mm
63,15
52,65
3,22
2,98
56,00
46,00
70,00
58,90
T2 were taken using a standardized 5 mm of expansion each side and in the starting forms (T1 TCG, TTG, OG in the total control group (TCG) when
Divine Facial Height (A-Pm)mm 44,58 3,93 36,60 53,20 protocol. The enlargement factors were molar section. The tip back produced and DG), the growth modifications (T2 compared with the total treated group
Mandibular Ramus Horizontal Position (Xi^FH)°
45,03
33,02
4,23
2,45
40,00
28,50
54,00
38,00
similar among radiographic units (about a force of 60 grams in the anterior TCG) and the modifications obtained (TTG). Whereas, significant differences
Ramus Height (Xi-R3)mm 20,82 1,73 17,28 24,48 8%); thus, no correction was made for section, enabling intrusion of the lower by treatment (T2 TTG, OG and DG), were found in the 2 subgroups of the
Condyle Axis Length (Xi-Co)mm
Corpus Axis Length (Xi-Pm)mm
36,74
62,21
3,10
3,16
31,35
55,57
44,65
69,00
enlargement in the analysis of the films. incisors. and the Rickett’s superimposition total treated group (OG at T1 vs.
Mandibular Arch (MA)° 27,55 4,19 23,00 40,00 analysis 61 of the composites were DG at T1) for vertical dimension,
Posterior Position of Occlusal Plane (Xi-OP)mm
0,94
21,15
2,03
2,48
-4,00
17,00
3,80
25,00
Treatment Protocol Data Analysis performed showing T2 on T1. Mean, skeletal maxillary protrusion, modest
Lower Incisor Position (horizontally) (B1-APo)mm 0,75 1,80 -2,85 3,80 standard deviation, and range were mandibular postero-rotation, open bite
Lower Incisor Position (vertically) (B1-OP)mm
Lower Incisor Inclination (B1Â-Po)°
1,60
24,85
1,79
5,32
-1,50
15,00
5,00
38,00
Each treated patient wore a large Assessment of the error in method calculated for all the groups; in order to and lower dental protrusion; all factors
Depth of Lower Arch (B1-B6)mm 26,11 1,73 23,00 29,00 Rickett’s face bow, with loops in the using cephalometric measurements show differences between samples, the displayed much more in the OG as
Molar Relation (B6-A6)mm
Upper Molar Position (A6-PTV)mm
2,02
13,03
1,75
2,30
-1,50
7,60
4,75
17,00
outer arch and an elastic neck strap, was performed using the Dahlberg 60 Student’s t-test was performed by using showed in Table VI.
Lower Molar Inclination (B6^Xi-Pm)° 110,00 4,92 9,00 116,00 which delivered a force of 500 grams formula on 50 patients (25 CTG and a commercial statistical package (SPSS
Upper Molar Inclination (A6ÂNS-PNS)°
Upper to Lower Incisor (A1^B1)°
106,40
119,65
3,52
6,54
100,00
108,00
111,00
134,00
for no more than 12 hours per day 25 TTG) selected randomly from the for Windows, release 10.0.0, SPSS Inc).
Horizontal Incisor Relation (OVJ)mm 6,53 2,36 2,00 12,35 (night time plus some evening hours). 2 groups. The measurement error for Table VI. Open Group (OG) versus Deep Group (DG) at T1.
Vertical Incisor Relation (OVB)mm
Lower Lip Protrusion (li-El)mm
0,97
1,12
2,39
2,81
-5,00
-5,70
5,00
6,65
The length of the face bow was the linear measurements was an average
Deep Group Open Group
Upper Lip Protrusion (ls-El)mm 0,28 2,01 -3,80 3,30 extended distally to a point just anterior value of 0.47 mm (range 0.3 and 0.67), n=20 n=20 t-test
Nose Length (ANS-prn)mm
Chin Thickness (Po-ppo)mm
20,21
10,54
1,80
1,65
17,00
7,60
22,80
12,35
to the tragus before the neck strap was and 1.5° for the angular measurements. VARIABLE Mean St.Dev. Mean St.Dev. p
Hyoid Position (H-PTV)mm 2,06 5,42 -12,00 13,30 engaged. Bands were positioned on the Total Facial Height (TFH)° 60,09 6,49 61,70 4,92 0,3747
Anterior Facial Ratio (N-ANS/ANS-Me)%
Maxillary Length (Co-A)mm
0,92
82,55
0,06
4,05
0,84
77,20
1,09
91,20
upper first molar at the marginal ridge; Lower Facial Height (LFH)° 46,32 3,84 45,95 4,66 0,7807
Central Facial Direction (FAX)° 88,66 2,97 87,40 4,57 0,2920
Mandibular Length (Co-Gn)mm 100,23 4,66 94,08 115,20 the gingival tube used for the arch bar Facial Depth (FD)° 87,59 2,30 85,55 2,53 0,0092
Gonial Angle (Co-Go^Go-Me)° 128,15 4,22 118,00 133,00
had 15° of disto-rotation. The arch Ramus Height (MP)° 26,75 4,04 26,45 4,54 0,8218
Table V. Deep Group at T1. bar was bent outward at the molar in Convexity (C)mm 6,45 1,70 5,96 1,24 0,2908
Palatal Plane Position (PPP)° -3,25 2,25 -3,45 2,48 0,7853
Table V n= 20 9m 11 f order to serve as a buccal shield and to Posterior Cranial Length (PCB)mm 30,18 2,63 30,63 2,73 0,5913
Deep Group at T1 allow for lateral expansion. The anterior Anterior Cranial Length (ACB)mm 56,39 2,72 56,78 2,75 0,6465
VARIABLE Mean St.Dev. Min. Max
Total Facial Height (TFH)° 60,09 6,49 37,00 67,00 portion, when placed, lay anterior to the Cranial Deflection (Ba-N^FH)° 29,07 1,74 29,15 2,16 0,8927
Lower Facial Height (LFH)° 46,32 3,84 39,00 52,00 incisors by 1.0 to 1.5 mm; it was placed Position of the Maxilla (Ba-N^N-A)° 65,27 2,89 63,15 3,22 0,0299
Central Facial Direction (FAX)° 88,66 2,97 84,00 94,00 Nasal Plane Length (N-A)mm 53,93 3,78 52,65 2,98 0,2326
Facial Depth (FD)° 87,59 2,30 84,00 92,50 near the central third of the incisors at Divine Facial Height (A-Pm)mm 44,98 3,57 44,58 3,93 0,7331
Ramus Height (MP)° 26,75 4,04 19,50 31,00 the lip embrasure (Stomion). At the first Mandibular Ramus Horizontal Position (Xi^FH)° 49,39 9,06 45,03 4,23 0,0564
Convexity (C)mm 6,45 1,70 4,00 10,00
Palatal Plane Position (PPP)° -3,25 2,25 -7,00 0,00 appointment, the arch bar was formed Mandibular Ramus Vertical Position (Xi-FH)mm 35,00 2,45 33,02 2,45 0,0575
Ramus Height (Xi-R3)mm 21,75 1,47 20,82 1,73 0,0673
Posterior Cranial Length (PCB)mm 30,18 2,63 24,00 36,00 to make it essentially passive on each Condyle Axis Length (Xi-Co)mm 36,73 5,71 36,74 3,10 0,9927
Anterior Cranial Length (ACB)mm 56,39 2,72 49,00 60,50
side, and a 150 gram force was applied. Corpus Axis Length (Xi-Pm)mm 63,52 4,79 62,21 3,16 0,3047
{
Cranial Deflection (Ba-N^FH)° 29,07 1,74 26,00 32,50
Position of the Maxilla (Ba-N^N-A)° 65,27 2,89 59,50 70,00 Mandibular Arch (MA)° 27,48 3,61 27,55 4,19 0,9521
Divine Facial Height (A-Pm)mm
53,93
44,98
3,78
3,57
47,0
39,00
61,00
53,00
In this way a child Posterior Position of Occlusal Plane (Xi-OP)mm 1,66 2,46 0,94 2,03 0,3116
49,39
35,00
9,06
3,88
42,00
30,00
87,00
47,00
is able to place it { Occlusal Plane Inclination (OP ^ Xi-Pm)°
Lower Incisor Position (horizontally) (B1-APo)mm
21,36
2,59
3,85
2,27
21,15
0,75
2,48
1,80
0,8337
0,0060
Ramus Height (Xi-R3)mm
Condyle Axis Length (Xi-Co)mm
21,75
36,73
1,47
5,71
19,00
20,00
25,00
43,50
easily, without pain. Lower Incisor Position (vertically) (B1-OP)mm
2,66
24,50
1,64
6,95
1,60
24,85
1,79
5,32
0,0508
0,8567
Corpus Axis Length (Xi-Pm)mm 63,52 4,79 55,00 72,50 Depth of Lower Arch (B1-B6)mm 25,09 3,65 26,11 1,73 0,2609
Mandibular Arch (MA)° 27,48 3,61 21,50 36,00 After four weeks, then monthly for the Molar Relation (B6-A6)mm 0,09 1,29 2,02 1,75 0,0002
Posterior Position of Occlusal Plane (Xi-OP)mm 1,66 2,46 -3,00 7,00 wearing period, four adjustment were Upper Molar Position (A6-PTV)mm 14,80 2,86 13,03 2,30 0,0344
Occlusal Plane Inclination (OP ^ Xi-Pm)° 21,36 3,85 12,00 29,50
Lower Incisor Position (horizontally) (B1-APo)mm 2,59 2,27 -2,50 7,00 made: the arch bar was bent for the Lower Molar Inclination (B6^Xi-Pm)° 111,73 4,44 110,00 4,92 0,2388
Upper Molar Inclination (A6ÂNS-PNS)° 105,36 5,21 106,40 3,52 0,4587
Lower Incisor Position (vertically) (B1-OP)mm 2,66 1,64 0,00 6,00 molar disto-rotation about 2°-3° until the Upper to Lower Incisor (A1^B1)° 120,73 8,56 119,65 6,54 0,6517
Depth of Lower Arch (B1-B6)mm 25,09 3,65 18,00 38,00 bayonets were parallel to each other, and Horizontal Incisor Relation (OVJ)mm 4,55 2,52 6,53 2,36 0,0120
Molar Relation (B6-A6)mm 0,09 1,29 -3,00 2,50 widened about 3 mm until a first molar Vertical Incisor Relation (OVB)mm 2,84 1,75 0,97 2,39 0,0057
Lower Molar Inclination (B6^Xi-Pm)° 111,73 4,44 100,00 119,00 expansion was achieved. The arch form Lower Lip Protrusion (li-El)mm 2,89 2,55 1,12 2,89 0,0388
Upper Lip Protrusion (ls-El)mm 0,98 2,57 0,28 2,01 0,3331
Upper Molar Inclination (A6ÂNS-PNS)° 105,36 5,21 97,00 116,00 was changed from a tapered shape to a Nose Length (ANS-prn)mm 20,64 1,87 20,21 1,80 0,4511
Upper to Lower Incisor (A1^B1)° 120,73 8,56 107,00 142,00
Horizontal Incisor Relation (OVJ)mm 4,55 2,52 1,00 12,50 more standard or even ovoid shape; the Chin Thickness (Po-ppo)mm 9,84 1,78 10,54 1,65 0,1942
Vertical Incisor Relation (OVB)mm 2,84 1,75 -1,00 5,50 applied force was 500 grams at the point Hyoid Position (H-PTV)mm -1,13 5,74 2,06 5,42 0,0828
Lower Lip Protrusion (li-El)mm 2,89 2,55 -2,00 7,00 Anterior Facial Ratio (N-ANS/ANS-Me)% 0,76 0,06 0,92 0,06 3,79-11
Upper Lip Protrusion (ls-El)mm 0,98 2,57 -4,00 5,00 of attachment of the neck strap to the face Maxillary Length (Co-A)mm 84,98 5,17 82,55 4,05 0,1004
Nose Length (ANS-prn)mm 20,64 1,87 17,50 24,50 bow. After a couple of months, the disto- Mandibular Length (Co-Gn)mm 103,57 6,35 100,23 4,66 0,0614
Hyoid Position (H-PTV)mm -1,13 5,74 -10,50 8,00 rotation of the molar and the change of Gonial Angle (Co-Go^Go-Me)° 125,95 4,44 128,15 4,22 0,1091
Anterior Facial Ratio (N-ANS/ANS-Me)% 0,76 0,06 0,66 0,85 the arch form indicated that the arch bar
Mandibular Length (Co-Gn)mm 103,57 6,35 91,00 113,00 was in contact with the upper incisors, Table VI
Gonial Angle (Co-Go^Go-Me)° 125,95 4,44 117,00 135,00 reducing the overjet (OVJ). Open Group (OG) versus Deep Group (DG) at Ti

Table VII. Treatment Changes T2-T1 in the Total Control Group (TCG).
the reduction of the angle Ba-N, Table VII n= 37 18 m 19 f Therefore, the effect of a lower
N-A was statistically significant Treatment
T2-T1=1,98
utility arch is not just intrusion of
(p=4-11): 2.74° in the treated group, Changes T2-T1 in VARIABLE T2-T1 t-test: p Variation the lower incisors. Results show all
and 0.62° in the control group. the Total Control per year
lower dentitions move backward and
Group (TCG) Total Facial Height (TFH)° -0.27 0.811 -
Lower Facial Height (LFH)° -0.43 0.630 - downward. What occurred in patients
3. The upper molar was distalized 1.8 Central Facial Direction (FAX)° -0.47 0.519 - with a deep bite and double protrusion
Facial Depth (FD)° -0.16 0.840 -
mm and extruded 2 mm: the distance Ramus Height (MP)° -0.45 0.688 - was a downward and backward rotation
A6-PTV was reduced; statistically Convexity (C)mm -0.21 0.331 - of the maxilla and an improvement of
Palatal Plane Position (PPP)° -0.08 0.919 -
significant (p=0.0249). The upper Posterior Cranial Length (PCB)mm 0.89 0.144 0.6 the profile. Note the superb control of
incisor moved distally 1mm. Anterior Cranial Length (ACB)mm 1.13 0.110 0.8 the vertical dimension in both groups.
Cranial Deflection (Ba-N^FH)° 0.49 0.323 -
Position of the Maxilla (Ba-N^N-A)° -0.62 0.342 0.4
4. The lower molar was distalized 1 Nasal Plane Length (N-A)mm 2.11 0.044 1.5 Discussion
mm and intruded 2 mm, in fact the Divine Facial Height (A-Pm)mm
1.38
-0.7
0.178
0.924
1
0.5
occlusal plane moved downward; Mandibular Ramus Vertical Position (Xi-FH)mm 1.39 0.027 1 To understand the effects that these
statistically significant (p=0.0004). Ramus Height (Xi-R3)mm 0.88 0.44 0.6
types of appliances have in the growing
Condyle Axis Length (Xi-Co)mm 1.45 0.066 1
Corpus Axis Length (Xi-Pm)mm 2.18 0.025 1.5 patient, it is useful to describe the
Furthermore the length of the mandible Mandibular Arch (MA)° 0.57 0.416 0.4 modifications obtained in different
Posterior Position of Occlusal Plane (Xi-OP)mm 0.07 0.931 -
was increased 2.39 mm more than Occlusal Plane Inclination (OP ^ Xi-Pm)° -0.16 0.859 - parts of the cranium.
the control; statistically significant Lower Incisor Position (horizontally) (B1-APo)mm 0.34 0.560 -
(p=0.00077). The treatment was Lower Incisor Position (vertically) (B1-OP)mm
3.03
0.18
0.667
0.641
2.1
- Cranial Base
Figure 1 as effective in the maxilla as in the Depth of Lower Arch (B1-B6)mm 0.1 0.863 -
mandible that grew downward and Molar Relation (B6-A6)mm
-0.04
1.02
0.913
0.805
-
0.7 Control data revealed the glenoid
forward, without any postero-rotation Lower Molar Inclination (B6^Xi-Pm)° 4.68 0.132 3.3 fossa (Cp) moved posteriorly 0.88 mm
of the mandible. The orthopedic therapy Upper Molar Inclination (A6ÂNS-PNS)° 0.40 0.776 -
per year. The treated cases show an
The Total Control Group (TCG) The behavior of the maxilla and the Upper to Lower Incisor (A1^B1)° -5.48 0.52 3.9
influenced both the teeth and the inhibition of this growth, displaying
mandible as analyzed by McNamara, Horizontal Incisor Relation (OVJ)mm -0.03 0.958 -
The applicability of the Rickett’s profile; in several cases class correction Vertical Incisor Relation (OVB)mm 0.59 0.325 0.4
just 0.65 mm of movement. This result
Baccetti, Franchi is as follows: Lower Lip Protrusion (li-El)mm -0.02 0.984 -
superimposition analysis was confirmed was obtained. The inclination of the Upper Lip Protrusion (ls-El)mm -0.21 0.627 - was previously described by Ricketts46 ,
by studying the changes that occurred occlusal plane downward and backward Nose Length (ANS-prn)mm 1.05 0.051 0.7 who suggested an effect of the cervical
The distance Co-A increases at 1.5 mm
in the total control group (TCG): was also responsible for reduction of Chin Thickness (Po-ppo)mm 0.13 0.759 -
strap in the temporal bone.
per year; t-test: p=0.045. Hyoid Position (H-PTV)mm -1.43 0.111 1
protrusion of the lower incisors. Anterior Facial Ratio (N-ANS/ANS-Me)% 0.02 0.240 -
Maxillary Length (Co-A)mm 2.08 0.052 1.5
Basion-Nasion at Cc. T1= 87.68°; The distance Co-Gn increases at 2.4 Mandibular Length (Co-Gn)mm 3.44 0.025 2.4 Maxilla
The Difference in Treatment (OG versus DG)
T2=87.20°; t-test: p=0.519. The facial mm per year; t-test: p=0.025. Gonial Angle (Co-Go^Go-Me)° -1.02 0.361 0.7
axis doesn’t change.

Table IX. Treatment Changes T2-T1 Open Treated Group (OTG) versus Deep Treated Group (DTG) The angle between the Cranial Plane (Ba-
The angle Co-Go-Me decreases at 0.7° The application of a lower utility arch Table IX Open Treated Deep Treated N) and the Nasal Plane (N-A) is a superb
mm per year; t-test: p=0.361. in patients with a deep bite and double Treatment
Group (OTG)
n=20
Group (DTG)
n=20
t-test Diff. of
treat. parameter to evaluate the position of the
Superimposition 2
protrusion was the therapeutic difference Changes T2 T1
T2-T1=1,80
Treat. Time.=1,32
T2-T1=2,13
Treat. Time.=1,75 upper jaw. This angle is constant during
between the two groups. Differences Open Treated VARIABLE Media Dev.St. Media Dev.St. p
the growth. The value of this angle was
Basion-Nasion at Nasion registered at A The Effect of Treatment (TCG versus TTG) Group (OTG) versus
Total Facial Height (TFH)° 0,45 1,90 0,36 1,61 0,872 -0,09
were statistically significant (p<0.05) due Lower Facial Height (LFH)° 0,10 1,33 -0,30 2,37 0,508 -0,40
the same at T1 in the treated patients
point (Basion-Nasion, Nasion-A). T1= Deep Treated Central Facial Direction (FAX)° 0,10 1,07 0,09 1,36 0,980 -0,01
to treatment, particularly in the DG, and Facial Depth (FD)° 1,13 1,56 0,95 1,43 0,710 0,18
and in the control group. A statistically
64.08°; T2=63.46°; t-test: p=0.342. The The superimposition analysis (Figure 1) Group (DTG) Ramus Height (MP)° 0,55 2,01 0,52 1,93 0,08 -0,03
are reported in Table IX: significant difference was found between
angle Basion-Nasion, Nasion-A doesn’t of the composites (TTG at T2 on TTG Convexity (C)mm
Palatal Plane Position (PPP)°
-2,88
1,70
0,91
1,45
-3,43
1,61
1,76
1,83
0,205
0,863
-0,55
-0,09
change. The point A moves downward at at T1) of the total treated group (TTG) Posterior Cranial Length (PCB)mm 0,23 1,44 1,02 1,62 0,095 0,79 the DG and the OG (p=0.0299); this
suggests that at T1, the DG presented
Anterior Cranial Length (ACB)mm 0,50 1,16 1,64 2,30 0,048 1,14
visualizes the effects of treatment. The 1. The anterior cranial base grew more
1.48 mm per year (t-test: p=0.044). Cranial Deflection (Ba-N^FH)° 0,60 1,47 0,41 1,36 0,658 -0,19
following results were obtained by (p=0.048). Position of the Maxilla (Ba-N^N-A)°

-2,73
3,04
1,67
1,56
-2,75
4,16
1,27
2,11
0,955
0,0613
-0,02
1,12 greater upper protrusion than OG. A
Superimposition 3 studying the superimposition analysis
Divine Facial Height (A-Pm)mm
0,70
-0,13
1,96
2,54
0,93
0,30
2,46
4,18
0,728
0,707
0,23
0,43
statistically significant decrease of the Ba-
2. The lower incisor was intruded
of the composites (TCG on TTG at Mandibular Ramus Vertical Position (Xi-FH)mm 2,47 1,81 2,11 2,97 0,635 -0,36 N, N-A angle was found in the treated cases
(p=7.25-05). Ramus Height (Xi-R3)mm 0,88 1,28 1,52 1,05 0,08 0,64
Palatal plane (ANS-PNS) registered at ANS. T2), the comparison of the differences Condyle Axis Length (Xi-Co)mm 2,08 2,25 2,34 4,32 0,818 0,26 (p=4-11), while no statistically significant
Corpus Axis Length (Xi-Pm)mm 2,81 2,47 4,25 2,99 0,094 1,44
The upper denture moves forward 0.3 mm of the means (T2-T1), and the t-test of 3. Arch length was increased Mandibular Arch (MA)° 0,38 3,26 0,84 2,71 0,627 0,46 difference was revealed between DG and
per year. The molar erupts 0.7 mm per year. the samples (Table VII). (p=0.0117).
Posterior Position of Occlusal Plane (Xi-OP)mm
-2,00
2,43
1,63
2,17
-2,61
2,32
2,79
2,77
0,385
0,887
0,61
-0,11 OG. A statistically significant increase of
The incisor erupts 0.4 mm per year.
Lower Incisor Position (horizontally) (B1-APo)mm
Lower Incisor Position (vertically) (B1-OP)mm
1,48
-0,78
1,58
1,40
0,45
-2,73
2,24
1,49
0,094
7,25-05
-1,03
-1,95
the length of the nasal plane (p=6.9-5)
1. In the total treated group (TTG), 4. Class II correction did not occur Lower Incisor Inclination (B1Â-Po)°
Depth of Lower Arch (B1-B6)mm
4,00
0,77
5,57
1,08
7,23
1,11
8,39
3,08
0,141
0,0117
3,23
0,34
shows tipping of the palatal plane during
(p=2.31-07). distalization of the maxilla. This is one of
Superimposition 4 the mandible grew downward and Molar Relation (B6-A6)mm
-4,18
0,86
1,91
1,71
0,00
0,70
2,44
2,67
2,31-07
0,823
4,18
-0,16
forward as happened in the control Lower Molar Inclination (B6^Xi-Pm)° 2,25 5,45 16,57 9,60 1,72-06 14,32 the factors responsible for bite closure,
5. The lower molar inclined more
group (TCG) and the facial axis closed
Upper Molar Inclination (A6ÂNS-PNS)° -4,85 6,98 -7,93 10,92 0,313 -3,08
emphasizing the role of a utility arch in
Mandibular corpus axis (Xi-Pm) registered distally (p=1.72-06). Upper to Lower Incisor (A1^B1)° -2,50 9,60 -3,23 9,10 0,801 -0,73
more than the control group (TCG);

Horizontal Incisor Relation (OVJ)mm -3,38 1,83 -1,23 2,40 0,002 2,15
deep bite cases. Anterior interference
at Pm. The molar erupts 0.5 mm per year Vertical Incisor Relation (OVB)mm 0,79 1,99 -1,18 1,96 0,002 -1,97
statistically significant (p=0.041). 6. The OVJ was not reduced as in the Lower Lip Protrusion (li-El)mm -0,68 3,41 -1,84 1,64 0,160 -1,16
is one of the causes of the mandibular
for the long the axis along the mesial cusp. Upper Lip Protrusion (ls-El)mm -1,46 3,73 -2,70 1,45 0,151 -1,24
OG (p=0.002). Nose Length (ANS-prn)mm 1,85 2,06 3,11 1,73 0,042 1,26 postero-rotation during the overjet (OVJ)
The incisor erupts 0.3 mm per year and Chin Thickness (Po-ppo)mm 0,44 0,90 1,00 1,81 0,228 0,56
2. The correction of the convexity correction by any type of mechanics.
goes backward 0.2 mm per year.
Hyoid Position (H-PTV)mm -1,04 6,03 -0,51 5,85 0,707 0,53
7. The overbite (OVB) was corrected Anterior Facial Ratio (N-ANS/ANS-Me)% 0,03 0,05 0,01 0,16 0,657 -0,02
was obtained by a backward and (p=0.002).
Maxillary Length (Co-A)mm
Mandibular Length (Co-Gn)mm
1,45
5,16
3,51
4,00
1,11
6,45
2,77
4,43
0,726
0,314
-0,34
1,29
downward movement of the maxilla; Angolo Goniaco (Co-Go^Go-Me)° 0,13 2,76 -0,66 2,24 0,307 -0,79

Mandible chin development. Rickett’s,46-48 data molar extrusion and eruption causing a Conclusion
compiled by Baumrind 24 in 1981, along lowering of the occlusal plane (2.61 mm)
The facial axis is used to describe growth with the results of the present study, and a decreasing of the tipping during Cervical headgear must be considered as
and chin behavior. No difference was have given the impression that at least the therapy. The molar intrusion, or an orthopedic device: the maxilla could
found for the value of the FAX (88°) a temporary increase in posterior ramus stabilization, was statistically significant be moved backward and downward; the
at T1 in the treated patients and the height and chin position with cervical in all groups. This means the extrusive modest extrusion of the upper molar
control group, and a difference of 1° traction and often molar intrusion is a effect of cervical traction on upper could be responsible for incremental
was found between the DG (86.66°) reality. Histology 64 showed how condyle molars prevents eruption of the lower growth of the mandible with good
and the OG (87.40°). During growth, growth was upward and forward. molar, obtaining almost the same effect control of the vertical dimension.
the control group presented a slight Scientific evidence suggests that a as the utility arch. This was seen by
opening of the mandible (-0.47°); compression of this area is a cause of others and it has already been described Our findings agree with
while for the treated patient group, a mandibular undergrowth. On the other by vertical growth of the mandible Ricketts, 22,23,46-48 Baumrind 24 and
statistically significant closure of the hand, a decompression of this area others.24-26,30,31,34-36,38,39,41-45,49,50 We offer the
mandible was found, represented by obtained by an interrupted extrusive Soft Tissues profession a proven technique to manage
the value of the facial axis (p=0.041) force of the upper molar is favorable cervical traction. Further clarification
and also of the facial depth (p=0.019). during Class II correction. Improvement of the soft tissue was is needed regarding the timing of when
These findings, together with the ones statistically significant in all groups. to apply this device to achieve beneficial
used to evaluate the vertical dimension, By separately studying the mandible, The increase of the distance ANS-prn effects on the mandible.
clearly show the beneficial effect of the beneficial effect of this approach is due to the lowering and distalization
this therapy to control the vertical could be seen. A statistically significant of the upper jaw. The difference in Acknowledgments
dimension. This result is controversial increase (p=0.007) of the distance this value in the DG and in the OG
in the literature; it could be explained Xi-Co in the treated patients was does not currently have an acceptable The author wish to thank Prof. Isabella
by the way some clinicians manage found. Ricketts55 showed the golden explanation. The lip protrusion was Tollaro for providing access to patients’
cervical head gear and in the mechanics proportion between the distance Xi- also decreased in all groups. These records and Prof. Mario Caltabiano
they use for craniofacial treatment. Co and Xi-Pm, or equal to 1.618. It findings confirm how the correction for scientific support. This article is
In our opinion the worsening of the is interesting to emphasize that this of the maxillo-mandibular relation dedicated to the memory of Professor
vertical dimension that occurs in value was 1.503 in the control group significantly improves facial esthetics. Robert M. Ricketts.
some patients, as described in the and 1.603 in the treated patients, to
literature, is not due to the direction show how this approach harmonizes REFERENCES
of the force applied on the upper first with mandibular growth. Furthermore 1. Angle EH. The Malocclusion of the Teeth. Angle’s system. 7th ed. Philadelfia: The S.S. White Dental 36. Kim KR, Muhl ZF. Changes in mandibular growth direction during and after cervical headgear treatment.
Manufacturing Company; 1907.
molar but is due to wrong application the total mandibular length increase 2. Brodie AG. Facial Patterns. Angle Orthod 1946; 16: 75-87.
Am J Orthod Dentofacial Orthop 2001; 119: 522-30.
37. Junkin JB, Andria LM. Comparative Long Term Post-Treatment Changes in Hyperdivergent Class II
3. Oppenheim A. Biologic Orthodontic Therapy and Reality. Angle Orthod 1936; 6: 157–167. Division 1 Patients With Early Cervical Traction Treatment. Angle Orthod 2002; 72: 5-14.
of the appliance. Excessive forces of 2.9 mm is statistically significant 4. Kloehn SJ. Guiding Alveolar Growth and Eruption of the Teeth to Reduce Treatment Time and Produce 38. Sambataro S. The effects of cervical headgear in a dolichofacial high convexity female subject. The 2nd
a More Balanced Denture and Face . Angle Orthod 1947; 17: 10. World Edgewise Orthodontic Congress. Florence; 2003;156.
applied, association with the edgewise (p=0.00077), which occurs with some 5. Poulton DR. A three-year survey of Class II malocclusions with and without occipital headgear therapy.
Angle Orthod 1964; 34: 181-93.
39. Lima Filho RMA , Lima AL, Carlos de Oliveira Ruellas A. Mandibular changes in skeletal class II
patients treated with Kloehn cervical headgear Am J Orthod Dentofacial Orthop 2003;124:83-90.
appliance, lack of retention, correction mandibular posturing devices. 6. Sandusky WC. Cephalometric evaluation of the effects of the Kloehn type of cervical traction used as
an auxiliary with the edgewise mechanism following Tweed’s principles for the correction of Class II,
40. Melsen B, Dalstra M. Distal molar movement with Kloehn headgear: Is it stable? Am J Orthod
Dentofacial Orthop Dentofacial Orthop 2003;123:374-378.
of the OVJ without prior correction of division 1 malocclusions. Am J Orthod 1965; 51: 262.
7. Schudy FF. The Rotation Of The Mandible Resulting From Growth: Its Implication In Orthodontic
41. Haralabakis NB, Sifakakis IB. The effect of cervical headgear on patients with high or low mandibular
plane angles and the ‘myth’ of posterior mandibular rotation. Am J Orthod Dentofacial Orthop
the OVB, use of the anterior bite plane, Teeth Treatment. Angle Orthod 1965; 35: 36-50.
8. Meach CL. A cephalometric comparison of bony profile changes in Class II division 1 patients treated
Dentofacial Orthop 2004;126:310-7.
42. Ülger G, Arun T, Sayınsu K, Isik F. The role of cervical headgear and lower utility arch in the control
and full-time wearing, are the principal with extraoral force and fuctional jaw orthopaedics. Am J Orthod 1966; 52: 353-70.
9. Jakobsson SO. Cephalometric evaluation of treatment effect on Class II, Division 1 malocclusions. Am J
of the vertical dimension. Am J Orthod Dentofacial Orthop 2006; 130: 492-501.
43. LaHaye MB, Buschang PH, Alexander RG, Boley JC. Orthodontic treatment changes of chin position
causes of increasing vertical dimension The correction of the molar relation and Orthod 1967; 53: 446-56.
10. Poulton DR. The influence of extraoral traction. Am J Orthod 1967; 53: 8-18.
in Class II Division 1 patients.Am J Orthod Dentofacial Orthop Dentofacial Orthop 2006;130:732-
741.
by using cervical traction. Few authors of the OVJ was statistically significant 11. Creekmore DT. Inhibition or Stimulation of the Vertical Growth of the Facial Complex, Its
Significance to Treatment. Angle Orthod 1967; 37: 285-97.
44. Siqueira DF , Rodrigues de Almeira R, Janson G, Brandão AG, Coelho Filho CM. Dentoskeletal
and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in
used cervical traction alone. This study in the TTG and in the OG for the 12. Kuhn R. Control of anterior vertical dimension and proper selection of extraoral anchorage. Angle
Orthod1968; 38: 340-9.
the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop Dentofacial Orthop
2007;131:447.e21-447.e30.
demonstrates that only an association orthopedic effect of cervical traction, 13. Mays RA. A cephalometric comparison of two types of extraoral appliance used with the edgewise
mechanism. Am J Orthod 1969;55:195-6.
45. Godt A, Kalwitzki M, Göz G. Effects of cervical head gear on overbite against the background of
existing growth patterns. Angle Orthod 2007;77:42-46.
14. Ringenberg QM, Butts W. A controlled cephalometric evaluation of single-arch cervical traction 46. Ricketts RM. Orthodontic treatment in the growing patient. Vol. I,II,III,IV. Scottsdale AZ, USA:
with a lower utility arch in order to and the orthodontic distalization of therapy. Am J Orthod 1970; 57: 179. American Institute for Bioprogressive Education and Ricketts Research Library and learning Center,
15. Merrifield L. Directional forces. Am J Orthod 1970; 57: 435-64. Loma Linda University CA, USA; 1998.
intrude the lower incisors and eliminate the molar and the upper incisors by 16. Weinberger TW. Extra-oral Traction and Functional Appliances - A Cephalometric Comparison. Br J 47. Ricketts RM. Stretching the orthodontic mind to new dimensions. Scottsdale AZ, USA: American
Orthod 1973; 1: 35-9. Institute for Bioprogressive Education and Ricketts Research Library and learning Center, Loma
anterior interferences is correct. contact with the arch bar. In all groups, 17. Wieslander L. The effect of force on craniofacial development. Am J Orthod 1974; 65: 531-83.
18. Graber TM. Extrinsic control factors influencing craniofacial growth :in McNamara JA. Control
Linda University CA, USA; 2002.
48. Ricketts RM. Extraoral Traction – A Phoenix. Scottsdale AZ, USA: American Institute for
the lower incisor moved back, but the mechanisms in craniofacial growth. Monograph 3, Craniofacial Growth Series, Ann Arbor, MI:
Center for Human Growth and Development, University of Michigan. 75:100, 1975.
Bioprogressive Education and Ricketts Research Library and learning Center, Loma Linda University
CA, USA; 2003.
Using implants, Bjork62 (1963) distance 1-APo was increased for the 19. Wieslander L. Early or late cervical traction therapy of Class II malocclusions in the mixed dentition.
Am J Orthod 1975; 67: 432.
49. Siqueira DF , Rodrigues de Almeira R, Janson G, Brandão AG, Coelho Filho CM. Dentoskeletal
and soft-tissue changes with cervical headgear and mandibular protraction appliance therapy in
confirmed Rickett’s finding reported
63
simultaneous pulling back point A. 20. Mills C, Holman G, Graber TM. Heavy intermittent cervical traction in Class II treatment: a
longitudinal cephalometric assessment. Am J Orthod 1978; 74: 361.
the treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop Dentofacial Orthop
2007;131:447.e21-447.e30
in 1952. An upward and forward growth Comparing OG with DG, note that in 21. Melsen B. Effect of cervical anchorage during and after treatment : an implant study. Am J Orthod
1978; 73: 526-40.
50. Godt A, Kalwitzki M, Göz G. Effects of cervical head gear on overbite against the background of
existing growth patterns. Angle Orthod 2007;77:42-46
of the condyle and ramus was consistent the DG the OVJ and molar relation 22. Ricketts RM. JCO interviews: Dr. Robert M. Ricketts on Early Treatment. JCO 1979; 13:115-27 Part II.
23. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive Therapy. Book 1. Denver
51. Baccetti T, Franchi L, McNamara JA The cervical vertebral maturation method: some need for
clarification. Angle Orthod 2002; 72:316-23. 52. Ricketts RM. The evolution of diagnosis to
with forward chin development. A were not corrected and the arch depth CO, USA: Rocky Mountain Orthodontics; 1979.
24. Baumrind S, Korn EL, Molthen R, West EE. Changes in facial dimensions associated with the use of
computerized cephalometrics. Am J Orthod 1969; 55: 795-803.
53. Ricketts RM. The value of cephalometrics and computerized technology. Angle Orthod 1972; 42:
more upward and backward growth was increased due to the distal action forces to retract the maxilla. Am J Orthod 1981; 80:17-30.
25. Boecler PR, Riolo ML, Keeling SD, TenHave TR. Skeletal changes associated with extraoral appliance
179-99.
54. Ricketts RM. Cephalometric Analysis and Synthesis. Angle Orthod 1961; 31: 141-56.
of the condyle was characteristic of a of the lower utility arch in the lower
therapy: an evaluation of 200 consecutively treated cases. Angle Orthod 1987; 59: 263-70.
26. Cangialosi TJ, Meistrell ME, Leung MA, Yang Ko J. A cephalometric appraisal of edgewise Class II
55. Ricketts RM. The Golden Divider. JCO 1981; 15: 752-9.
56. Ricketts RM. Progressive cephalometrics paradigm 2000. Scottsdale AZ, USA: American Institute for
nonextraction treatment with extraoral force. Am J Orthod Dentofacial Orthop 1988; 93: 315-24. Bioprogressive Education and Ricketts Research Library and learning Center, Loma Linda University
more vertical increase in facial height. dentition; the OVB was corrected (-1.97 27. Burke M, Jacobson A. Vertical changes in high-angle Class II, division 1 patients treated with cervical CA, USA; 1998.
or occipital pull headgear. Am J Orthod Dentofacial Orthop 1992; 102: 501-8. 57. Ricketts RM. Understanding the VTO: its construction and mechanics for execution. Vol. I,II.
Our findings have strongly suggested mm; p=0.0002) by tip-back given on 28. O’Reilly MT, Nanda SK, Close J . Cervical and oblique headgear: A comparison of treatment effects. Scottsdale AZ, USA: American Institute for Bioprogressive Education and Ricketts Research Library
Am J Orthod Dentofacial Orthop 1993 ;103: 504-509. and learning Center, Loma Linda University CA, USA; 1999.
that increases in vertical growth the molar section of the utility arch, 29. Braun S, Johnson BE, Hnat WP, Gomez JA. Evaluation of the vertical forces generated by the cervical
biteplate facebow. Angle Orthod 1993; 63: 119-26.
58. Ricketts RM. Provocations And Perceptions In Cranio-Facial Orthopedics. 1st ed. Denver CO, USA:
Rocky Mountain Orthodontics; 1989.
of the condyle or even upward and that determined a distal inclination of 30. Cook AH, Sellke TA, BeGole EA. Control of the vertical dimension in Class II correction using a
cervical headgear and lower utility arch in growing patients. Part I. Am J Orthod Dentofacial Orthop
59. BaccettiT, Franchi L, McNamara Jr, Tollaro I. Early dentofacial features of class II malocclusion: a
longitudinal study from the deciduous trough the mixed dentition. Am J Orthod Dentofacial Orthop
forward growth of the mandibular lower molar without any extrusive effect 1994; 106: 376-88.
31. Loberg EL. Cervical neckgear—villain or savior? Am J Orthod Dentofacial Orthop 1997 ;112: 209-220.
Dentofacial Orthop 1997;11:502-509.
60. Dahlberg G. Statistical Methods for Medical and Biological Students. New York, NY: Interscience
arch produced by posterior increases, of the lower molar, as asserted by some 32. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markovits DL, Laster LL. Headgera versus function regulator
in the early treatment of class II, division 1 malocclusion: a randomized clinical trial. Am J Orthod
Publication; 1940.
61. Ricketts RM. A four step method to distinguish orthodontic changes from natural growth. 1975;9:208-
has been consistent with forward authors. Cortical anchorage prevents dentofacial Orthop 1998; 113: 51-61.
33. Ucem TT, Yuksel S. Effects of different vectors of forces applied by combined headgear. Am J Orthod
228.
62. Björk A. Variations in the growth pattern of the human mandible: longitudinal radiographic study by
Dentofacial Orthop 1998; 113: 316-23. the implant method. J Dent Res. 1963; 42: 400-11.
34. Kirjavainen M, Kirjavainen T, Hurmerinta K, Haavikko K. Orthopedic cervical headgear with 63. Ricketts RM. A study of changes in temporomandibular relations associated with the treatment of Class
expanded inner bow in class II correction. Angle Orthod 2000;70:317-325. II malocclusion. Am J Orthod 1952; 38: 918-33.
35. Gandini MS, Gandini LGJr, Da Rosa Martins JC, Del Santo MJr. Effects of cervical heagear and 64. Furstman L. The early development of the human temporomandibular joint. Am J Orthod 1963; 9:
edgewise appliances on growing patients. Am J Orthod Dentofacial Orthop 2001; 119: 531-9. 672-82.

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Class II correction with sectional mechanics/
Distalization revisited
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The objective of this article is to The sectional distalization mechanics The effect of the class II elastics with
smile on a child's face... and a pair of stunning refresh some Bioprogressive concepts applied with other principles like: a continuous arch produces extrusion
new season Havaianas on your feet, courtesy in the Class II malocclusion treatment, unlocking the malocclusion, using the in the anterior teeth and decreases its
of Rocky Mountain Orthodontics. taking into consideration the facial adequate amount of force to move any torque, it also deepens the bite and
biotype. A contemporary alternative tooth and proper treatment planning, produces gummy smile.
To receive your new Havaianas when combined with Dual-Top ® ortho- allows us to achieve a functional and
donate now at www.thecof.org implants (TADs) is presented. esthetic result in a conservative way. Some orthodontic techniques suggest
that is impossible or unstable to distalize
The basic principles of the Bioprogressive The correction of a Class II malocclusion the buccal segments. This is due, at lease
Sponsored by: technique have a synergistic effect, with a continuous arch and Class II in part, because of the use of continuous
especially if there are combined in a elastics produces, in most cases, loss of arch and an incorrect force levels. The
Colorado Orthodontic
Foundation logic sequence to obtain a solution for anchorage with a collateral advance of clinical Bioprogressive experience has
specializing in orthodontic care for the color ado community
the clinical problems. the lower arch. This occurs because shown that the distalization of the
the upper arch is more resistant to buccal segments is possible and stable
“Therefore, changes occur the distalization movement due to its in the long term no matter which facial
naturally and biologically, greater radicular mass and the cortical biotype is, as shown in Case #1.
without complications.” palatal bone behind the upper incisors.
Clinical Review 37
Mechanics
Case #2: Female, 14.10

years old, brachyfacial, no
gingival exposure, Angle
ass
Long term follow up Cl Class II div 2.
Case #1:tion. Male, 11 years ol
d,
II correc l patter n. Initial phase records.
dolichofacia l Severe Class II brachyfacial
and intraora
it ia l ph as e ex traoral on. patient with deep bite. She
1) In lu si doesn’t show gingiva when
s II malocc
photos. Clas l smiling. Good profile.
II sectiona
onti c st age. Class tics.
1 2) Or th od II el as
with class Unlocking the malocclusion.
correction Torque and incisor intrusion.
13 years
or th od ontic photos.
3) Fi nal mont hs.
ent ti me 20
old. Treatm
Class II buccal correction.

Elastics. Sectional
mechanics.
3
Achieving the Class I molar

relationship.
Overcorrection and finishing.

Sectional therapy significantly changed of the occlusal plane, especially in the Treatment time 16 months.
the incidence of need for extractions dolichofacial patterns, and achieve the
at all ages. The correct cortical and stabilization of the case by lowering the
muscular anchorage, the use of the right occlusal plane, if possible, below the Xi
force for each facial biotype and the point in the posterior segment.
provocation of the normal growth can 6 months post-retention
prevent unwanted vertical changes. The Although the Class II division 2
inclination of the occlusal plane should malocclusion is common in the Final Panoramic X-Ray and
be taken into account in the diagnose brachyfacial and mesofacial patterns, they Cephalometric analysis.
and treatment planning; in general, we can be present in dolichofacials as well.
In this article we are presenting two vertical excess and gummy smile (page 40).
must avoid the clockwise inclination
summarized clinical examples of Class Thus we have to achieve a greater upper
II division 2 malocclusions, with very incisors intrusion. In both cases, we
19 years after different facial biotypes and vertical must place the upper incisors according
treatment intraoral needs. Case #2 has a brachyfacial pattern to the smile line, for aesthetic purposes.
photos. 33 years with no vertical excess or gummy smile. The mechanical differences between
old. Stable class II In this case, the upper incisors intrusion these cases are due, in part, from the
correction. is only temporal, just enough to place relationship between the upper incisors
the lower brackets. Case #3 has a severe and the labial embrasure and the
dolichofacial pattern with maxillary inclination of the occlusal plane.
19 years post-
retention. 33 Final facial
years old. photographs. 6
months after
treatment.

Orthodontic final phase. Deepbite correction achieved mainly by upper incisor
Case #3: Female, 15 years old, intrusion with utility arches to correct or improve the vertical anterior
dolichofacial, vertical excess with excess and gummy smile. The molar class II relationship was corrected with
severe gingival exposure. Angle sectional mechanics as in Case #2.
Class II div 2.
Final records. Notice the improvement

of the previous gummy smile and the
mento-labial sulcus. Vertical pattern
also improved slightly.
Initial records. Notice deepbite and the strong mento-

labial sulcus due to the extrusion of the upper incisors.

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Movement...
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Conclusion: with careful diagnosis

and planning, class II corrections can
be achieved by sectional distalization
mechanics of the buccal segments.
Controlling the vertical side effects
A B with cortical anchorage, along with
utilization of the proper force levels
Class II correction with according to the biotype, leads to
ortho-implants. Dual-Top ® corrections that can be achieved
is placed between second
premolar and first molar with without causing mandibular rotation
NiTi coil spring (A). Notice and other vertical problems.
the amount of distalization
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Closing space phase (C). No
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side effects. C
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The Quad-Helix appliance is superior to a removable expansion

plate in expansion amount, stability, rate and extent of movements
with less treatment time.
The Quad-Helix appliance proves when properly activated provides

effective for increasing widths physiologic forces toward treatment
of intermolar, intercanine, and objectives of efficient orthodontic
dentoalveolar regions and for molar treatment. Maxillary transverse changes
derotation. Maxillary arch reshaping with use of the Quad-Helix appliance
is superbly accomplished by gradual are predictable and impressive. Dental
and comfortable activations over 6-12 tipping is minimized by lighter and
months. The Quad-Helix appliance gradual activations. A significant feature
is superior to a removable expansion is the ability of the quad-helix therapy
plate in expansion amount, stability, to re-model the alveolar process of the
rate and extent of movements with maxillary component with light and
less treatment time. Unlocking the continuous forces during the expansion.
malocclusion (Ricketts, Bench, Gugino, (References available upon request.) Functional Transverse Evaluation Denture Unlocking Properties Quad-Helix Advantages
Hilgers, Caruso, Sellke, Grummons)
1. Clinical Evaluation Typically, a Class II or Class III malocclusion • In the deciduous, mixed or permanent
typically begins with a Quad. Quad-Helix Considerations dentition, the quad provides mild to
a) Facial skeletal features begins with correction of the maxillary
• Age - growing patient moderate expansion.
The Quad-Helix appliance has b) Airway – breathing, tongue, etc. width deficiency. Most Class I cases
versatility to reshape arches, correct • Facial pattern and transverse norm c) Musculature – jaw and peri-oral also require transverse increase in arch • It also provides for:
posterior arch width deficiencies and perimeter. The Quad-Helix is effective in
• Dentoalveolar maxillary transverse hypoplasia d) Habits – tongue, thumb, etc. ˚ Reshaping of maxillary arch form
correct anterior crossbite when auxiliary each of these clinical situations.
• Transverse deficiency requirement: Sutural versus dentoalveolar e) Parafunction, when evident
wires are extended behind the incisor(s). f ) Malocclusion conditions 1. Transverse width - first priority in treatment ˚ Molar derotation (Class II correction)
Crossbite corrections are further helped • Oral hygiene and periodontal conditions favorable
g) Smile esthetics and 2. Vertical control - facial axis management ˚ Anchorage and torque control in
with composite onlay occlusal buildups
disharmonies tandem with archwire
(turbos) in the lower posterior dentition
when indicated. 3. Anterior/posterior sagittal correction
2. Photos and Models Analysis ˚ Incisors alignment and placement
achieved
Intermolar width, intercanine
In aviation, the three planes (pitch, yaw width, arch perimeter, smile ˚ Oral habit correction, when evident
and roll) are well understood. Similarly, Overexpansion of the maxillary arch width
esthetic features is preferred by 20-30%, followed by a ˚ Vertical control - tongue influence
the maxillary first molars position in 3 with slow expansion
planes can be influenced favorably and 3. Frontal Image guided intermolar width contraction with
differentially by strategic and accurate rebound to create optimal molar uprighting ˚ Ease of placement in one appointment
Skeletal and dental transverse axial inclinations and transverse stability (pre-formed RMO Quad)
Quad-Helix activations. Molars can differentiation
derotate the same on each side, or more after the expansion process.
Asymmetry analysis; coronal/
on one side than the other. Molars can frontal renderings
be extruded, held or intruded. Molars
4. CBCT-3D Renderings, if indicated
can be expanded on one or both sides
and differentially, if prescribed.
The pre-formed Quad-Helix (Rocky “Utilizing a Quad Helix is like

Mountain Orthodontics - Ricketts) having an ACE up your sleeve.”

Shallow occlusal composites on the
A
functional cusps of lower primary or
permanent molars assist by unlocking
the malocclusion and clearing deflective
cuspal inclines. This facilitates a
neutral mandible posture as the upper Quad-Helix and Variations
arch Quad-Helix changes occur.
8. 9. 10.
Quad Activations: Arch development during the early or late mixed dentition
phase, or in the permanent dentition are the preferred
1. Distal-lateral molar derotation timings for Quad-Helix therapy. Figs 8, 9, 10: The Quad arms can be shortened during treatment.
2. Lingual arm 1-2 mm from premolar

teeth as molars rotate disto-laterally
3. Ex pa nsion - i nter mola r w idt h

increased; arch perimeter develops
4. Buccal root torque individualized 1. 2.

per patient requirements
11. 12. 13.
Fig 1: Quad-Helix soldered at molars with sweeps behind
Activations should be light and the incisors. Fig 2: Quad-Helix with lateral tongue crib to
intermittent (8-10 weeks) to permit assist in closure of the lateral open-bite from a lateral tongue
controlled and comfortable movements thrusting condition.
with least molar tipping. To derotate
and/or to distalize molars, it is
preferable to adjust one side of the
quad to produce desired movement on
the opposite side of the arch. This is
followed by alternating molar activation 14. 15. 16.
on the opposite side of the arch to
3. 4.
produce controlled molar movement
changes. A midline 3-prong activation Figs 11, 12, 13, 14, 15, 16: Quad-Helix with partial brackets and/or segmental overlay
increases the arch width. Figs 3, 4: Quad-Helix with asymmetric unilateral palatal acrylic archwire with a utility arch. Generally, the quad is kept in place until the upper
support, which produces greater arch widening on the premolars and canines are sufficiently erupted.
Transverse widening while primary molars opposite side.
are still in the arch produces additional
benefits by remodeling wider alveolar bone
for the premolars to erupt into.
5. 6.
Figs 5, 6: Pre-formed Quad-Helix (RMO) individualized and

inserted into the lingual sheath on each first molar. Quad-Helix
with lateral arms to develop arch width of premolars/canines.
Fig 7: Occlusal
composite turbo to
unlock bite.
7. A
Steps for “on the spot” one appointment Quad-Helix
Case Example 1: Quad-
1 7
Helix accomplished arch
development and optimal
molar placement within 8
months. As teeth erupted,
brackets were added and
a stunning nonextraction
result was achieved.
Rocky Mountain Orthodontics
www.rmortho.com
Pre-formed Quad-Helix
Case Example 2:
Removable (Ricketts)
Asymmetric Quad with
2 8
Tru-Chrome ® SS .036 .914 mm one arm which influences
Catalog # A01230 (size 1) contralateral arch
Catalog # A01231 (size 2) reshaping and widening
Catalog # A01232 (size 3) within 16 months resulting
in a symmetric arch
perimeter at the finish of
treatment.
Case Example 3:
3 9
Typical narrow arch form
was expanded within 4
months pre-Invisalign,
and made optimal during
Invisalign treatment.
Case Example 4:
Quad without arms
4 10
created ideal arch form
and a balanced esthetic
perimeter, with ideal molars
3-D placement. Final smile
is stunningly beautiful with
great facial harmonies.
1 Rocky Mountain Orthodontics Quad-Helix
2 Quad-Helix order information Case Example 5: Transverse

development first with an RPE
3 Size 1 RMO pre-formed quad from package for maxillary sutural expansion (8
5 J 4,5 Insertion loop adjusted to angle of

molar sheath in mouth, and add 5-10
degrees of buccal root torque, and to
months). A subsequent maxillary
Quad-Helix was placed in the
late mixed dentition to derotate
molars with optimal symmetric
keep loop away from palatal tissue
positioning, and to establish an
ideal arch width. Full brackets
6,7,8 Arm bent palatally to ease insertion with a nonextraction approach (20
months) followed. An exceptional
9 Midline adjustment to expand at molars smile and fine esthetic zone were
achieved; exceptional treatment
10 3-prong pliers applies intra-oral goals are evident at the finish.
adjustment to add expansion
6 Q
Grummons Signature Smiles SM
J 3-prong can expand or upright
molars more
Q Well-adjusted Quad-Helix in place

The Lingualjet Appliance A TRIBUTE TO A The rest is history and the greatest
adventure of my life.
Today we have also build this. His dream
became my dream and now a reality
LOVED DOCTOR Dr Ricketts taught me about orthodontics in Pacific Palisades (see FaceCenterLa.
A straight-wire lingual system and about life. com) with AAAHC accredited OR on site
with recovery, full service laboratory, 3-D
In many ways he was a visionary. imaging and ongoing onsite CE courses for
I have to thank RMO for introducing me to One example of this was his ability to orthodontists and MD’s monthly. He even
Dr. Ricketts. It was a pivotal introduction, understand the importance of airway, talked about Stem cell and we just received
one that shaped my professional career early interception, and 3D imaging long an IRB from Stanford allowing us to perform
and life forward. before current accurate technology was autologous stromal vascular stem cells
available. Today, 30 years later, we were therapy on patients in need of regenerative
As a senior resident at UCLA, I was on my able, this month, to publish what we hope medicine in our facility.
way to take the Tweed course in Tucson, will be a landmark study....normative data
AZ. Overhearing this, Lindy, from RMO for airway for children through old age. I wish RMR could see it all. He was quite a
pulled me aside quite deliberately, insisting (JOMS June 2012.) Rick gets credit. It was man.
that I would be far better off taking the two his idea. Similarly with laminography and
week advanced Ricketts course in Pacific now we have our 3-D analysis. Later this Richard L Jacobson DMD MS
Palisades first. year we will publish our 3-D simulation VTO FaceCenterLA | Pacific Palisades
with accuracy statistics. I wish Rick was
Obstacles included getting the UCLA alive to see it all. ‘The dream of a lifetime.’
chairman to agree and for RMR to grant
me $3K scholarship award since I was living Rick always talked about a collaborative
off student loans. practice, a multi-disciplinary approach.
Dr. Robert Ricketts personal impact upon lives remains

a flame that burns brightly, and a beacon for learning.
Rick inspired us to do small things in great ways, and with
newness in thinking, spirit, enthusiasm and interest.
Dr. Duane Grummons
Our teacher, our leader, our friend….the man that taught

us when you open your heart is when you find your true
genius inside. Thank you Dr. Ricketts for setting an example
and continuing to feed the minds of so many generations
of orthodontists.
With all our love, Gutierrez / Lopez Velarde Family
Dr Ricketts, my mentor, my inspiration, a
Dr Ricketts, in addition to his abnormal research capacity, friend and truly a genius...
was a great and sweet person. Everyone that had contact Dr. Budi Kusnoto
with him will never forget him. We all miss his passion for our
specialty and every second he dedicated to the non-stop
development of the orthodontic science.
Dr. Nelson J Oppermann
“Ricketts was love, wisdom, strength, art To me, Dr Ricketts was also a great teacher “Becoming an active member of the
and always a big smile. Unforgettable of life and a model to be inspired to. Dr Italian Bioprogressive Society changed my
and unique human being ...” Ricketts thanks for all you’ve done for the professional life. But the most memorable
Dr. Enrique García Romero profession and for making it so exciting. moment was the karaoke with Bob after
Dr. Sergio Sambataro the ceremony.“
Dr. Franco Bruno
Clinical Review 51
650 West Colfax Avenue
Denver, Colorado 80204
Growing Our FLI Orthodontic Systems...
FLI SL FLI Twin FLI CLEAR FLI Composite

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Clinical Review 2012

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CLINICALREVIEW

He taught me to always think of the

2 Clinical Review Clinical Review 3

on taught Bioprogressive therapy and

2. Managing treatment to unlock the malocclusion in a progressive

THE CROSS SECTION OF THE CHAMBERED NAUTILUS

6 Clinical Review Clinical Review 7

After his initial publication, Dr. Ricketts

8 Clinical Review Clinical Review 9

After addressing the transverse Cybernetic Circle

10 Clinical Review Clinical Review 11

As good as it gets position. The Facial Axis is showing a

Option #4) Burn lower molar anchorage.

Final lateral cephalometric radiograph.

The finishing of upper incisor retraction.

Before and after superimpositions.

Four years post treatment.

14 Clinical Review Clinical Review 15

Conclusions: The Bioprogressive Therapy is not a

1. Ricketts RM. Variations of the temporomandibular

2. Ricketts RM, Bench RW, Gugino CF, Hilgers

3. Ricketts, R.M. The biological significance of the

4. Ricketts RM. Bioprogressive therapy as an answer to

5. Ricketts RM. et al. Orthodontic diagnosis

The world’s most powerful curing light.

Skeletal Anchorage Vs. Bonded Tooth/

Two 14.5 year old twins with maxillary

18 Clinical Review Clinical Review 19

The measurements were calculated from

20 Clinical Review Clinical Review 21

References 7. Lagravère M, Carey J, Heo G, Toogood R, Major P. Transverse,

24 Clinical Review Clinical Review 25

and the total control group (TCG) were

divided into 2 subgroups according to Ramus Height (MP)°

consisting of 20 patients, 10 males and Posterior Cranial Length (PCB)mm

28 Clinical Review Clinical Review 29

axis doesn’t change.

following results were obtained by (p=0.048). Position of the Maxilla (Ba-N^N-A)°

more than the control group (TCG);

30 Clinical Review Clinical Review 31

32 Clinical Review Clinical Review 33

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GIVE US WE'LL SEND Enrique García Romero, DDS

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Your donation today will help put a beautiful

Case #2: Female, 14.10

Class II buccal correction.

Achieving the Class I molar

Overcorrection and finishing.

38 Clinical Review Clinical Review 39