Comprehensive Orthodontic Treatment in the Early Permanent Dentition

Comprehensive Orthodontic Treatment In The Early Permanent

Dentition

Section 6

S A R A N G S U R E S H H O T C H A N D A N IS A R A N G S U R E S H H O T C H A N D A N I

Introduction Comprehensive

Orthodontic Treatment

• Definition; It is process in which patient’s occlusion is made as ideal as possible by repositioning all or nearly all teeth.

• Ideal time for Comprehensive Orthodontic Treatment; (When to Perform Comprehensive Orthodontic Treatment)• Adolescence – when permanent teeth just erupted.

• Some vertical & antero posterior growth of the jaw remains.

• Social adjustment to orthodontic treatment is no great problem

SARANG SURESH HOTCHANDANI 2

Introduction Comprehensive

Orthodontic Treatment

• During comprehensive treatment complete fixed appliance consists of brackets is used.

• Comprehensive orthodontic treatment consists of following 4 stages; - this concept was given by Raymond Begg• Alignment & Levelling

• Correction of Molar Relationship & Space Closure

• Finishing

• Retention


Alignment &

Levelling(Chapter 14) 1st Stage of Comprehensive Treatment


Goals of 1st

Stage of Treatment

• The goal of 1st phase of comprehensive treatment is to bring teeth into alignment & correct vertical discrepancy by levelling out arches.

• PROPER ALIGNMENT OF TEETH CAN BE ACHIEVED BY;• Bring malposed teeth into arch

• Control the antero posterior position of incisors, width of arches posteriorly, form of dental arches.


Goals of 1st

Stage of Treatment

• LEVELLING OF ARCHES CAN OCCUR BY;• Elongation of posterior

teeth• Intrusion of incisors• Combination of two.

• Excessive overbite results from;• Excessive curve of spee in lower

arch.• Absent or reverse curve of spee in

upper arch.

• Anterior open bite results from;• Excessive curve of spee in upper

arch • Little or no curve of spee in lower

arch


Alignment


PRINCIPLES IN THE CHOICE OF

ALIGNMENT ARCHES

•During alignment phase, only combination of labio – lingual & mesio – distal tipping of teeth is needed.• Root movement during alignment phase is not needed.

(Reason mentioned in notes)


Principles in the Choice of

Alignment Arches

Continuous force of 50g needed for alignmentContinuous force of 50g needed for alignment

2 – 4 mil of space b/w archwire & bracket slot for tipping2 – 4 mil of space b/w archwire & bracket slot for tipping

Round NiTi wire for alignment are preferredRound NiTi wire for alignment are preferred

• Rigid wire with auxiliary wire for Asymmetric Crowding

Springier Wire for Symmetric CrowdingSpringier Wire for Symmetric Crowding



ALIGNMENT ARCHES

•Archwires in alignment phase should provide continuous force of approx. 50 gm for tipping.• Avoid heavy force during

alignment phase

• There should be 2 – 4 mil of space b/w archwire & bracket.• 14 – 16 mil wire will be placed in 18 mil

bracket. OR

• 16 – 18 mil wire will be placed in 22 mil bracket.

• The reason of creating space b/w bracket & archwire is that archwire should be able to move freely during tipping for alignment.



ALIGNMENT ARCHES

• Always use ROUND NiTi for alignment phase.

• Why Rectangular NiTi wires are not Used during Alignment?

• Tight fit in bracket cause resistance to sliding.

• Produces back & forth movement of root apices during alignment.

• Increases root resorption

• Slow the alignment process

A. Round WireB. Rectangular Wire



ALIGNMENT ARCHES

• Springier wire will be used for alignment of Symmetric Crowding.• Symmetric Crowding; degree of crowding is similar on two sides of arch.

• While in asymmetric crowding, springier wire will distort the arch form during alignment.• Asymmetric Crowding; all or nearly all crowding on one side of arch. e.g. impacted

canine, single displaced tooth.

• Here in this condition Rigid archwire will be needed on normal side & to prevent the distortion of arch form while springy archwire is needed for crowding side.


Use of an auxiliary super elastic wire for incisor alignment in a patient with asymmetric crowding.

A. Crowding expressed largely as displacement of one lower lateral incisor in an adult with periodontal bone loss for whom light force was particularly important.

B and C, After space was opened for the right lateral incisor, a super elastic wire segment tied beneath the brackets was used to bring the lateral incisor into position, while arch form was maintained by a heavier archwire in the bracket slots.

D. Alignment completed. This approach allows use of optimal force on the tooth to be moved and distributes the reaction force over the rest of the teeth in the arch


P R O P E R T I E S O F

A L I G N M E N T A R C H W I R E S

• Wire for initial alignment phase should have;

• High strength • High springiness• High range • Deliver about 50gm of

force

•Ideal archwire material for INITIAL ALIGNMENT

is A – NiTi wire


A L I G N M E N T O F S Y M M E T R I C

C R OW D I N G

• Super elastic NiTi is ideal for initial alignment in symmetric crowding.

• Alignment requires opening space for teeth that are crowded in the arch.• Spaces can be created with following 2

ways

• Folded stops• Hold the archwire slightly advanced

relative to crowded incisors

• Compressed Coil Springs


C o m p r e s s e d C o i l S p r i n g


Travelling of

Archwire

• One problem with super elastic wires for initial alignment is their tendency to “travel” so that the wire slips around to one side, protruding distally from the molar tube on one side and slipping out of the tube on the other.

• The most effective way to prevent travel is to• tightly crimp a split tube segment onto the wire

between two adjacent brackets. • The location of the crimped stop, here between the left

central and lateral incisors, is not critical.

• dimple in the midline to prevent the archwire from sliding excessively.


This panoramic radiograph shows archwire travel to the point that on one side it penetrated into the ramus, almost to the depth of an inferior alveolar block injection (interestingly, the patient reported only mild discomfort).


Alignment in

pre-molar extraction space

• Patients with sever crowding of anterior teeth sometimes require extraction of premolar to gain space for alignment of incisors.

• After this extraction, canine is retracted by one of two methods;• Independent retraction of canine followed by alignment of incisors

• Simultaneous distal tipping of canine along with alignment of incisors• A NiTi coil spring for canine retraction

• A NiTi archwire for incisor alignment


Alignment in


(Independent Method)

When anchorage is critical for retraction of canines to allow alignment of incisors, bone screws placed in the

alveolar process between the molar and premolar roots are the most effective way to obtain the

necessary space.

A. The anchorage can be direct, with an elastomeric chain or NiTi spring from the bone screw providing the force to retract the canines or

B. indirect, with an attachment from the bone screw to the first molar to keep those teeth from moving forward when an attachment from the posterior teeth is used to retract the canine.

Direct Method

Indirect Method


Alignment in


(Simultaneous

Method)

Alignment of severely crowded lower incisors with the super elastic

equivalent of the original“drag loop.”

a) Occlusal view prior to treatment.

b) Canine retraction with super elastic coil springs that provide 75 gm of force, and alignment of incisors with a super elastic NiTi wire that incorporates an accentuated reverse curve of Speeand delivers 50 gm.

c) and D, Completion of canine retraction and incisor alignment after 5 months of treatment.


Cross Bite Correction


Individual Teeth into Anterior

Cross bite

• Correction of a dental anterior cross bite, as in this young adult, requires • opening enough space for the displaced teeth

followed by

• attempting to move it facially into arch form.

• At that point, a biteplate to obtain vertical clearance often is required because;• patient can bite on the bracket placed on displaced tooth

so for preventing this, posterior teeth are separated temporarily

• Occlusal interference prevents the facial movement of that displaced tooth


Transverse Maxillary Expansion by

Opening the Mid Palatal Suture

• Widening of maxilla by opening mid palatal suture is easy in young age, but it becomes difficult in as the patient become older.

• Patient who require opening of mid palatal suture will also need extraction of premolar.• Expansion is done 1st after that extraction or alignment of teeth is

performed.• Because 1st premolar teeth are useful for anchorage & lateral expansion.




• If the maxillary width is normal, expansion should be avoided.• It should be used for correcting skeletal cross bite.

• After the age of 15 or in older patients, maxillary expansion by opening mid palatal suture should be achieved with Rapid Activation of expansion screw (2 turns initially & 2 turns per day until suture opens) – 10 – 20 pounds of force is applied.• Patient will feel pop apart

• If the suture at this age with rapid expansion does not open within 2 – 3 days, surgical expansion is only possibility after that.

• Slow activation in this age will produce only dental expansion.




• There are two appliance for this transverse maxillary expansion;• Bonded expander

• Banded expander

• Bonded Expander • Indicated in patients with excessive anterior face height.

• Does not cause downward & backward rotation of mandible.

• Banded Expander• Mostly given in patient with short anterior face height

• Cause downward & backward rotation of mandible resulting long face.

Normal Face Height Persons can be given any of two expanders

Normal Face Height Persons can be given any of two expanders




Banded Expander Bonded Expander


Correction of Dental Posterior

Cross Bites

• 3 methods of correcting less sever dental cross bite;

•Heavy labial expansion arch• Inner bow Face bow in case of headgear wearer

•Expansion lingual arch•Cross elastics


Heavy Labial Expansion Arch

• A heavy labial archwire (usually 36 or 40 mil steel) placed in the headgear tubes on first molars can be used for a small amount of expansion and to maintain arch width after palatal suture opening while the teeth are being aligned.

• This is more compatible with fixed appliance treatment than a removable retainer and does not depend on patient cooperation.


Trans Palatal

Lingual Arch

If anchorage is of no concern, highly

flexible lingual arch like quad helix

design is used to correct dental cross

bite.


Trans Palatal Lingual Arch

• If expansion & anchorage both are needed, the choices are;•36 mil steel wire with adjustment loop •Use of 32 x 32 TMA or Steel wire


A and B, Mandibular stabilizing lingual arch. It is easier to insert a heavy lingual arch of this type from the distal of a horizontal tube on the first molar bands.

Note that the lingual arch is contoured away from the incisors, so that it does not interfere with aligning and retracting them.

C and D, A maxillary lingual arch can be active, typically to rotate the maxillary molars, or passive for stabilization. An active lingual arch can be placed in a horizontal tube or ligated into a special bracket on the molars, as shown here. Ligation into a bracket makes it easier to remove and adjust the lingual arch, but over time, gingival overgrowth can make re-ligation difficult


Cross Elastics

• They run from lingual or upper molar to the buccal of lower molar.

• Cause extrusion of teeth and downward & backward rotation ofmandible.


Impacted or Unerupted

Teeth Alignment


Treatment of

Unerupted/Impacted Tooth


Surgical Exposure

• Before surgery to expose the tooth, it precise position should be known. It can be obtained by on of the following radiographs;

• CBCT (Small Field of View)

• Vertical Parallax Method• Combination of OPG & Occlusal View.

• Lateral Cone Shift Method• Multiple Periapical Views.


Surgical Exposure

• When exposure of impacted tooth is planned, it is important for tooth to erupt through attached gingiva no through alveolar mucosa.

• If an impacted canine is on the labial, removing tissue to expose the crown for bonding an attachment can be done conveniently with a diode laser.

• If the unerupted tooth is more apically positioned, a flap should be reflected from the crest of alveolus and sustured.


Surgical Exposure

AB

C

A. The permanent canine was slow to erupt. Probing showed that exposure of 4 mm of the crown could be done without violating the biologic width of the attachment apparatus.

B. Immediately after crown exposure with a laser.

C. The tooth brought to the occlusal level with a super elastic wire, ready for placement of a bracket in ideal position.


Method of Attachment

• Best approaches are;

•Bonding of button or hook to which gold chain is tied and extending into mouth.

• Other approaches;• Placement of pin in a hole prepared in crown.

• Wire ligature around crown instead of gold chain.• Results in loss of PDL support.

• Increases chances of ankyloses


Mechanical Approaches for

Aligning Impacted Tooth

• Orthodontic traction to move an unerupted tooth away from other permanent tooth roots & then toward the line of arch should begin ASAP after surgery.

• Brackets should be applied to other teeth before surgery so that force can be applied immediately.• If it is not possible, then force should be given within 2 – 3 weeks post

surgically.

• The reason for pre-surgical bracket is to create space for that impacted tooth to erupt into arch.


Mechanical Approaches for

Aligning Impacted Tooth

• As we know impacted tooth is example of asymmetric crowding, so for that purpose;

•At least 18 mil steel rectangular wire should be in place as heavy stabilizing wire followed by auxiliary A NiTi wire for moving impacted tooth.


A. For this patient with palatally positionedbilateral impacted maxillary canines, asoldered lingual arch has been placed forbetter anchorage control; a heavy labialarchwire is in place after space for thecanines has been opened; and an auxiliary A-NiTi wire is tied to attachments (preferably, asegment of gold chain) that were bonded tothe canines at the time they were exposed.

B. Progress in the same patient, with the A-NiTiauxiliary now placed over a button that was bondedon the facial surface of the canine after it wasbrought down enough to allow this.

C. When the tooth has elongated enough, the button isreplaced with a standard canine bracket andalignment is complete.

D. A vertical spring bent into a 14 mil steel archwire isan alternative approach to bring down an impactedcanine. The spring is a loop of wire that facesdownward before activation and is rotated 90degrees for attachment to the impacted tooth orteeth. This method is effective but less efficient thanusing a super elastic auxiliary wire.


Unerupted/Impacted Lower 2nd

Molar Alignment

• Impaction of lower 2nd molar usually develops during orthodontic treatment.• Mesial tipping of lower 2nd molar instead of eruption occurs when

mesial marginal ridge of lower 2nd molar catches against the distal surface of 1st molar or on the edge of 1st molar band.

• Lower Molar distalization also increase the chances of impaction of lower 2nd molar.



Molar Alignment

• Correction of an impacted 2nd molar require tipping the tooth posteriorly & uprighting it.

• This can be achieved by;

•Use of separators•Use orthodontic force by arch wire• Surgical uprightening



Molar Alignment

– with SEPARATORS

• For a second molar that is caught on the edge of a first molar band, a simpler approach is uprighting achieved with a 20 mil brass wire OR SEPARATORS tightened around the contact. • Usually it is necessary to anesthetize the area to place a

separator of this type.

• Uprighting and distal movement obtained with the brass wire separator. A spring clip (one type is sold as the Arkansas de-impaction spring) can be used in the same way, but both brass wire and spring clips are effective only for minimal molar uprighting.



Molar Alignment

– with Ortho WIRES

When a second molar is banded or bonded relatively late in treatment, oftenit is desirable to align it with a flexible wire while retaining a heavier archwirein the remainder of the arch.

Repositioning a maxillary second molar, using a

straight segment of rectangular A-NiTi wire that fits into the auxiliary tube on the first molar and the tube for the main archwire on the second molar.



Molar Alignment

– with Ortho WIRES

In both arches, after the repositioning, a continuous archwire can extend to the second molar.

Repositioning a mandibular second molar, using a

segment of steel wire with a loop that extends

from the auxiliary tube on the first molar.


Surgical Uprighting

Surgical uprighting of impacted mandibular second molars sometimes is the easiest way to deal with severe impactions.

A, Age 12, prior to loss of the second primary molars, with the permanent second molars tipped mesially against the first molars. Teeth in this position often upright spontaneously when the first molars drift mesially after the primary molars are lost.

B, Age 14, severe impaction one year after the beginningof orthodontic treatment.

C, Age 14, after surgical uprighting of the second molars, which are rotated around their root apex into the space created by third molar

extraction. Loss of pulp vitality usually does not occur when this is done. D, Age 16, after completion of

orthodontic treatment. Note the excellent fill-in of bone between the first and second molars

A

B

C D


DIAS TEMA Closure


Management of Midline

Diastema

• If midline diastema is due to high Frenum; frenectomy should always be performed after closing the space orthodontically.

• Treatment starts with; aligning the teeth together by figure 8 wire ligature before frenectomy followed by removal of Frenum & placement of bonded retainer as shown in figure.


A. Facial appearance, showing the protruding maxillary incisors caught on the lower lip.

B. Intraoral view before treatment.

C. Teeth aligned and held tightly together with a figure-8 wire ligature, before frenectomy.

D. Appearance immediately after frenectomy, using the conservative technique advocated

by Edwards in which a simple incision is used to allow access to the interdental area,

the fibrous connection to the bone is removed, and the frenal attachment is sutured at a

higher level.

E. Facial appearance 2 years after completion of treatment.

F. Intraoral view 2 years after treatment.

G. Bonded retainer, made with .0175 steel twist wire. It is important for the wire to

be flexible enough to allow some displacement of the incisors in function—a

rigid wire is much more likely to break loose.

Management of a maxillary midline diastema.

A

B

CD

E

F

F


LEVELLING


Levelling

There are three possible ways to level a lower arch with an excessive curve of Spee: A. ABSOLUTE INTRUSIONB. RELATIVE INTRUSION, achieved by preventing

eruption of the incisors while growth provides vertical space into which the posterior teeth erupt; and

C. EXTRUSION of posterior teeth, which causes the mandible to rotate down and back in the absence of growth.

• Note that the difference between B and C is whether the mandible rotates downward. This is determined by whether the ramus grows longer while the tooth movement is occurring.


Curve of Spee

Excessive Curve of Spee

Flat Curve of SpeeReverse Curve

of Spee

EXCESSIVE CURVE OF SPEE; restrict the amount of space available for upper teeth results in crowding.

FLAT CURVE OF SPEE; most receptive for normal occlusion. (the mandibular curve of spee should not be deeper than 1.5 mm)

REVERSE CURVE OF SPEE;creates excessive space in upper jaw


Levelling by Extrusion

(Relative Intrusion)

• After initial alignment by A NiTi wire, arch wire is changed for Levelling.• Resilient & springy arch wire is needed for alignment while,

• Stiffer Wire Is Needed For Levelling.

• The choice of wire for levelling depends on the bracket used;• Either the bracket is 18 slot size or 22 slot size.

• The wire which is placed for levelling after removal of alignment wire should have following features if the levelling is to performed by Relative Intrusion method;

• Excessive curve of spee in maxillary archwire• Reverse curve of spee in mandibular archwire



18 S l o t , Narrow B r a ck e t

Here the 2nd wire for levelling phase in this bracket is almost always

16 MIL STAINLESS STEEL ROUND Wire with excessive curve of spee in upper arch & reverse

curve of spee in lower arch.



• In some patient, particularly in non extraction treatment of older patients who have little or non remaining growth will need an archwire heavier than 16 mil (probably 17 – 18 mil).

•However, in them instead of using of heavy wire, we can add auxiliary leveling arch wire of 17 x 25 mil TMA or Steel Rectangular wire.• This auxiliary arch wire inserts into tubes beneath the 16 mil base

archSARANG SURESH HOTCHANDANI 58


A, Auxiliary leveling wire prior to and after activation (B) by tying it beneath a continuous mandibular

archwire.

The appropriate force in this instance is approximately 150 gm, and the expected action is leveling by

extruding the premolars rather than intruding the incisors.

For absolute intrusion, light force (approximately 10 gm per tooth) is necessary.

This requires use of archwire segments and an auxiliary intrusion arch.

A B



(C)Intrusion arch prior to and after activation (D) by bending it downward and tying it to thesegment to be intruded.The force delivered by the intrusion arch can be measured easily when it is brought down to thelevel at which it will be tied



(E)Auxiliary leveling arches for extrusion in the maxillary arch and (F) for incisor-canine intrusion in the mandibular arch.

Note that the mandibular base arch is segmented, creating a separate incisor segment, while a continuous archwire is in placein the maxillary arch and the auxiliary leveling arch is tied into the anterior brackets on top of it. Intrusion requires a segmented base arch and a light intrusive force (here, with six mandibular incisors in the anterior segment, approximately 50 gm would be used). Extrusion can be done with a segmented or continuous base archwire, using about 50 gm/tooth in the segmented to be extruded.SARANG SURESH HOTCHANDANI 61

2 2 – S l o t W I D E R B R ACK E T

• Initial alignment wire – A NiTi wire

• Wire for Levelling in 22 Slot Bracket

• Initially 16 mil steel wire with reverse or accentuated curve of spee

• Later 18 mil round steel wire to complete levelling.

•No 20 mil or auxiliary wire needed.


NOTE !!

Never use Rectangular base wire in levelling phase.

Never use excessive curve of spee wire in mandible.

•Curve will cause torque on incisor roots lingually.

•Rectangular wire would be acceptable in upper arch if lingual torqueing of upper incisors is needed.


L e v e l l i n g by I N T R U S I O N

• The key to successful intrusion is Light Continuous Force Directed Towards Apex.

• Avoid Pitting intrusion of one tooth against extrusion of its neighbor.

• TWO METHODS of Levelling by Intrusion

• Bypass Arches Method

• Segmented Arches Method


Bypass Arches M e t h o d

• In this Continuous Archwire That Bypasses The Premolar (& Frequently Canine) Teeth is used

• This method is most useful forPatients Who Have Some Growth (Mixed Or Early Permanent Dentition).

• Mechanism of Action - Bypass Arch Method;• Uprighting & Distal Tipping Of The Molar, Pitted Against

Intrusion Of Incisors.SARANG SURESH HOTCHANDANI 65

Diagrammatic Representation of Bypass Method

• Diagrammatic representation of the forces for a leveling arch that bypasses the premolars, with an anchor bend mesial to the molars.

• A force system is created that elongates the molars and intrudes the incisors.

• The wire tends to slide posteriorly through the molar tubes, tipping the incisors distally at the expense of bodily mesial movement of the molars.

• An archwire of this design is used in the first stage of Begg treatment but also can be used in edgewise systems.

• A long span from the molars to the incisors is essential.SARANG SURESH HOTCHANDANI 66

Mechanical Ar r angements


There are 3 Techniques available by which we can intrude the teeth for levelling with Bypass Method

1ST STAGE OF BEGG TECHNIQUE; bodily movements of anchor molars were pitted against tipping of movement of anterior teeth.Here premolar teeth were bypassed & loose tie was made to canine.

2 X 4 EDGEWISE APPLIANCE; only 2 molars & 4 incisors included in appliance

RICKETT’S UTILITY ARCHProduce complex mechanical system that is difficult to control, that’s why utility

arches are now replaced by segmented arch approach as mentioned in next slides


2x4 Edge wise Appliance

A and B, The long span of a 2 × 4 appliance makes it possible to create the light force necessary for incisor intrusion and also makes it possible to create unwanted side effects. The 2 × 4 appliance is best described as deceptively simple. When incisor intrusion is desired before other permanent teeth can be incorporated into the appliance, a trans palatal lingual arch for additional anchorage is a good idea.


Rick e tt’s Util ity Arches



• Success of bypass method depend on KEEPING FORCES LIGHT.

• These light forces can be achieved by;

• USING SMALL DIAMETER WIRE

• Weather bracket is 18 Or 22 Slot, Wire Heavier Than 16 Mil Should Not Be Used. – size of bracket slot is irrelevant

• Ricketts used 16 x 16 cobalt chromium wire for his utility arches.

• IN MODERN UTILITY ARCHES; 16 X 22 BETA TITANIUM rectangular wire is used.

• USING LONG SPAN B/W INCISORS & 1ST MOLAR.



( W E A K N E S S )

• Only 1st molar is available for anchorage which results extrusion of this tooth which compromises the intrusion the anterior teeth.• This extrusion is not a major problem in growth patients with good facial pattern.

• However, molar extrusion should be avoided in non growing patients with poor facial pattern.

• Intrusive force against incisors is applied anterior to the center of resistance and therefore INCISORS TEND TO TIP FORWARD as they intrude.


A. When the incisor segment is viewed from a lateral perspective, the center of resistance (X) is lingual to the point at which an archwire attaches to the teeth. For this reason, the incisors tend to tip forward when an intrusive force is placed at the central incisor brackets.

B. Tying an intrusion arch distal to the midline (for instance, between the lateral incisor and canine, as shown here) moves the line of force more posteriorly and therefore closer to the center of resistance. This diminishes or eliminates the moment that causes facial tipping of the teeth as they intrude.

C. Intrusion arch tied in the midline as only the central incisors are intruded, so that the incisors will tip facially as they intrude.

D. In the same patient later, an intrusion arch now is tied between the central and lateral incisors to intrude all four incisors while reducing the amount of facial tipping.



( W E A K N E S S )

• This forward tipping of incisors can be prevented by;• Anchor bend at the molar in bypass arch creating closing effect that restrains forward

movement of incisors.

• Activation of utility arch like closing loop.


Segmented Arch M e t h o d

• Developed by Burstone.

• In this approaches brackets are placed on all teeth.

• Here for intrusion of anterior teeth, posterior segment are stabilized & point of force application against anterior teeth is controlled.



• Posterior teeth are stabilized for better control of anchorage. Which can be achieved by;

• Placing full dimension archwire into bracket slots of 2nd premolar, 1st molar & 2nd molar on both sides of arches which act as single segment.• After that both sides are connected by a heavy lingual arch made either 36 mil

round or 32 x 32 rectangular stainless steel wire.

• A resilient anterior segmental wire is used to align the incisors while the posterior segments are being stabilized.

• Wire for ANTERIOR TEETH; BRAIDED RECTANGULAR WIRE OR RECTANGULAR TMA



• For intrusion, an auxiliary arch placed in auxiliary tube on the 1st molar is used to apply intrusive force against anterior segment.

• This arch should Always Be Rectangular so that it does not twist in tube, and made from either one mentioned below. • 18 x 25 steel wire with 2 ½ turn helix• 17 x 25 or 19 x 25 TMA wire without helix• Preformed M – NiTi

• This wire should be placed gingival toincisors & apply light force of 10 gmper tooth.


S e g m e n t e d A r c h M e t h o d

M e t h o d s t o R e d u c e F o r w a r d

I n c i s o r s T i p p i n g

• Two strategies available;• Similar to bypass arches, a space closing force

can be created by tying the auxiliary arch back against posterior segments.

• Change the point of force against incisors.• Tying an intrusion arch distal to the midline

(for instance, between the lateral incisor and canine, as shown here) moves the line of force more posteriorlyand therefore closer to the center of resistance. This diminishes or eliminates the moment that causes facial tipping of the teeth as they intrude.


L e v e l l i n g by I N T R U S I O N

•Although both act by intrusion of incisor with extrusion & distal tipping of posterior segments. But;•With segmented arch technique; 4x as much

incisor intrusion as molar extrusion in non growing adults is possible. WHILE• The ratio of anterior intrusion to posterior

extrusion is much less favorable with bypass technique.


T h e K E Y i s T y i n g Au x i l i a ry

A r ch w i r e w h e r e I n t ru s i o n

i s r e q u i r e d .

• It is quite possible to intrude asymmetrically;•Only adjusting the teeth that are placed in

stabilizing & intrusion segments and tying the auxiliary intrusion arch where intrusion is required.


A. In this adult patient, the maxillary left central and lateral incisors and particularly the canine had super erupted. Asymmetric intrusion of those teeth was needed.

B. An auxiliary intrusion arch delivering about 30 gm was tied to the elongated canine, while preliminary alignment with an A-NiTi wire was employed. The result was leveling of the maxillary arch with a component of intrusion on the elongated side. Asymmetric intrusion can be accomplished either by asymmetric activation of an intrusion arch that spans from one first molar to the other or by use of a cantilever intrusion arch on one side only.


Summary

of 1st

Stage of Treatment

• The arches should be level

• Teeth should be aligned to the point that rectangular steel archwirescan be placed without excessive curve & without generating excessive force.

• The duration of 1st stage of Tx. Is determined by severity of both horizontal & vertical component of initial malocclusion.


THE ENDFinal Year BDS, Bibi Aseefa Dental College, SMBBMU, Larkana, Sindh, PAKISTAN

Email: [email protected]

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Comprehensive Orthodontic Treatment in the Early Permanent Dentition

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