NONEXTRACTION TREATMENT by NORMAN M. CETLIN, RAFFAELE SPENA DR.MUHAMMAD SAOOD
Nov 08, 2014
NONEXTRACTION TREATMENT
by NORMAN M. CETLIN, RAFFAELE SPENA
DR.MUHAMMAD SAOOD
OUTLINE
Treatment Planning and Sequence Phase Sequences Phase I: Space-Gaining Phase
Upper Arch Lower Arch
Evolution of the Technique Comparison of Two Distalization Methods: Pendulum versus Palatal
Bar Plus Pendulum Molar Uprighting and Vertical Control after Distalization with the
Pendulum Segmental Alveolar Corticotomy to Enhance Upper Molar
Distalization Phase II: Space Utilization
Introduction
Extractionists and nonextractionists still debate the best way of
treating an orthodontic malocclusion with crowding, but clinical
research has thus far failed to demonstrate that one treatment is
better than the other.
No difference in terms of the final dental and facial aesthetic result,
functional result and stability, because of the great variability and
unpredictability from patient to patient.
Nonextraction approach that is divided into two phases:
Space-gaining phase
Space-utilization phase
Treatment Planning and Sequence
The objectives of the first phase are:
To increase space and change the original malocclusion into a
“super Class I” malocclusion. Molar rotation, inclination, and
crossbite are corrected, and the curve of Spee is leveled.
The objectives of the second phase are:
To achieve Andrews’ six keys to normal occlusion . Overbite,
overjet, and all dental malpositions are corrected. The final
objective is a mutually protected occlusion with canine and
incisal guidance.
This approach is most suitable for treating Class I and II
malocclusions with upper and lower crowding.
The best patients are those who are growing and who are in the late
mixed dentition stage because this stage offers several advantages:
I. The leeway or “E” space is still available.
II. Facial growth is at its peak.
III. Tissues respond better to mechanical deformation and remodel
more quickly.
IV. Patient compliance is usually good.
THE ORIGINAL CETLIN APPROACH
The Cetlin approach were used to gain space and, in a
growing patient, allow growth to reach its potential.
Gaining space in the upper and lower arch is the key phase of any
nonextraction treatment.
The objectives of this initial part
Correction of molar inclination, rotation, and crossbite
Overcorrection of molar relationship
Generalized spacing in both the upper and lower arch.
10 ways to create space in an arch via orthodontics
Distolateral rotation of mesially rotated and constricted upper
molars (found in most of Class I and II malocclusions with
crowding)
Distalization of upper molars (in both Class I and II malocclusions)
Distal and buccal uprighting of lower molars (as leveling of the
curve of Spee occurs)
Distal rotation of ovoid premolars
Maintenance of the leeway space
Modification of the arch width (orthopedic/ orthodontic transverse
increase in the maxilla)
Modification of the archform (an initial constricted, tapered
archform needs to be changed)
Selective stripping on trapezoid teeth or teeth with interproximal
fillings or teeth with abnormal anatomy.
Incisor repositioning (depending on periodontal, aesthetic,
skeletal, and dental features of the patient)
Extraction of teeth (the last option)
Phase I: Space-Gaining Phase
Space was gained in the upper arch through the use of three
appliances:
The Palatal Bar (PB): helped to correct maxillary constriction,
rotation, distalization, and torque of both first and second upper
molars; it also controlled them vertically.
The Extraoral Forces were used to control the roots and the vertical
dimension of the upper molars.
The removable Cetlin Plate, with two distalizing springs against the
first molars, tipped the crowns distally while maintaining a good
control of anterior anchorage.
Palatal Bar
The PB was introduced by R. H. Goshgarian as an anchorage
appliance. Cetlin modified it as removable tooth-moving appliance.
The PB is made of a 0.036-inch SS wire, doubled back at the ends
to be inserted in a 0.036- × 0.072-inch horizontal lingual sheath.
lingual sheaths have an 8-degree mesial offset that facilitates
insertion and removal of the PB
A gingival hook help to tie back the PB and aid in insertion of intra-
arch or interarch elastics.
The “U-shaped” coffin loop is positioned generally toward the
mesial for two reasons:
To make the PB more comfortable and
To incline molar roots distally because of forces exerted by
tongue during speech and swallowing anterior to the center of
resistance (CR) of molars.
The loop is left distal if intrusive force is desired posterior to the
center of resistance to tip molar crowns distally.
Uses of PB
Distalization
Rotation
Expansion or constriction
Vertical control
Torque
Anchorage reinforcement
Distalization
Distalization is done with only unilateral activation of the PB. It can
be used in two clinical situations:
Class II molar relation on one side
When both upper molars must be distalized and the patient does
not want to wear headgear
In unilaterally Class II cases, rotation on the Class I side is controlled with a headgear with an inner bow that has a toe-out or an edgewise wire extended at least to the controlateral premolar.
Rotation
Distal rotation of upper molars may gain as much as 3 mm of space
per side
If the palatal cusps still seat in the central fossa, the faulty molar
relationship is easier to correct; however, if occlusion occurs mesial
to the central fossa, the Class II molar relationship is more difficult
to solve.
Rotation of Upper 2nd molars should be corrected because it
facilitates distalization of the first molars.
Expansion or Constriction
Transverse corrections should be made before rotating or
distalizing the molars.
Activation should be in the range of 1.0 to 1.5 mm of expansion or
constriction per side and per activation until the problem has been
corrected.
Lateral movement of upper molars can be either coronal tipping or
bodily movement. If bodily movement is required, buccal-root
torque (when expanding) or lingual-root torque (when constricting)
must be added.
Vertical Control: Intrusion
The PB, alone or with a high-pull headgear, can be used to take
advantage of the intrusive force exerted by the tongue during
chewing, swallowing, and speech.
The PB is kept low in the oral cavity, 4 or 5 mm away from the
palatal vault.
To increase the surface on which the tongue will be acting, two
extra loops or an acrylic button can be added to the Coffin loop.
Torque
The PB allows an excellent control of upper molar torque. Buccal
root torque is more often required because it helps keep palatal
cusps high and away from occlusal interference.
If control of the extrusive component is needed, the PB should be
kept low and/or a high-pull headgear could be added to upper
molars.
Anchorage
After space has been created, control of the upper molars is crucial.
In this biomechanical sequence, three-dimensional control is
achieved with the BP alone or with the use of extraoral forces.
Extra-oral Forces
During the space-gaining phase, headgear was applied with the
PBs and eventually with the removable plate to distalize upper
molars in a bodily fashion.
During the second phase, when the spaces were used to finish up
the case, extraoral forces helped to maintain posterior anchorage.
Occipital Force
High-pull (occipital force) headgear traction force was exerted from
above the occlusal plane and thus had both distalizing and intrusive
effects.
The high pull was applied to upper first molars by means of a
facebow with the outer bow of the same length of the inner bow.
The inner bow was passive to the molar tubes; the outer bow was
bent upward so that the point of force application and the line of
force lay above the upper molar center of resistance.
Cervical force
The cervical gear traction force was exerted from below the
occlusal plane and had extrusive as well as distalizing effects.
The appliance consisted of a facebow in which the outer bow was
longer than the inner bow and was bent upward so that both the
point of force application and the line of force lay above the upper
molar center of resistance.
When this appliance was combined to the removable plate, the
molars were moved bodily backward and downward.
Clinical Management of Headgear
Extraoral forces were applied to upper first permanent molars as
soon as the molars had been rotated with PBs, when facebows
could be easily inserted into molar tubes.
When headgear was used together with a PB, the inner bows had
to be passive to molar tubes.
When the headgear was used alone, the inner bows of high-pull
device should have been slightly constricted, whereas those of low
pull should have been expanded to prevent the upper molars from
rolling out or in.
Facebows had to lie on lower lip. This confirmed that desired
moment was being applied to the molars.
If the facebow had two canine hooks on their inner bows, a
light elastic (L10) could be applied to fit on the labial screen of
the Cetlin plate to increase anterior anchorage.
Extraoral forces had to be about 150 g per side to exert
orthodontic and not orthopedic effects. The devices had to be
worn at least 12 to 14 hours a day.
The Removable Distalizing Plate
The removable distalizing plate was used to continue distalization
of the upper molars when a “super Class I” relationship could not be
obtained using only PBs and headgear.
This plate was designed to apply a gentle, constant force of
approximately 30 g to the upper first permanent molars with minimal
reaction on the upper front teeth.
However, its forces might tend to incline molar crowns distally and
extrude the molars. For this reason, it always had to be used in
conjunction with an extraoral force to control molar roots, ensure
vertical control, and thus obtain the desired distal bodily movement
of the molars.
Components of active plate
The active part: Two 0.028-inch SS distalizing springs with arms
that lay against the mesial surface at the gingival level of the U6’s.
The retention part: An anterior 0.017- × 0.025-inch arch covered by
a labial screen and having two Adams clasps on the first premolars
or the first deciduous molars.
The anterior bite plane: Disclusion aids in the distal movement of
the upper molars and in the leveling of the curve of Spee by the lip
bumper.
Clinical Management of the Distalizing Plate
The distalizing plate had to be worn 24 hours a day except for
meals and hygiene. It always had to be used with the extraoral
force to control molar roots and obtain a distal bodily movement.
An activation of 2.0 to 2.5 mm per side gave approximately 30 g of
distal force either bilaterally or adjusted on alternate sides, as it was
done with the PB.
After the first permanent molars have been brought to a super
Class I relationship, the Adams clasps and the acrylic palatal to the
canines and first premolars was trimmed to allow spontaneous
distal movement of these teeth through the action of the transeptal
fibers, with no strain on the anchorage.
Retention was then provided by the labial shield, which was relined
with cold-cure acrylic.
END OF PART 1
Lower arch
Space gaining in the lower arch was gained with the lip bumper.
Dentoalveolar widening occurred through a combination of
uprighting and lateral growth of the dental arches and alveolar
bone.
Lip bumper could change the neuromuscular factors that determine
the form and the dimension of the lower arch, create space by
lateral dentoalveolar growth, and allow spontaneous reduction of
the lower crowding and of the curve of Spee.
Lip bumper gave support to the lower lip, improving lip competence,
which was an important factor in mandibular growth.
The lip bumper transmitted lower lip force to the lower molars,
allowing achievement of upright positioning and rotation.
The objectives of the first phase of Cetlin’s nonextraction approach
in the lower arch were …
Rotations correction and upright positioning of the lower molars
Leveling of the curve of Spee
Encouraging lateral growth of the arch and
Creating space to align all the teeth.
The lip bumper is a fixed functional orthodontic appliance. It works
by altering the equilibrium between cheeks, lips and tongue and by
transmitting forces from perioral muscles to the molars.
The lip bumper has been used for various purposes:
Molar anchorage
Therapy of habits
Space gaining in the lower arch
Characteristics of the Lip Bumper
Two molars bands cemented to first or second molars with 0.045-
inch tubes.
4-degree mesial offset to facilitate insertion and a step-out to
prevent gingival impingement.
Removable part: composed by of 0.045- inch SS wire.
Loops: two at the molar level and two at the canine level in modified
form. The two additional loops give a better shielding effect in the
canine region and allow the use of Class III elastics in more severe
cases.
Fitting the Lip Bumper
The lip bumper must keep cheeks and lip away from the lower
dentoalveolar area.
It should be wider buccally and flatter anteriorly the natural
archform is desired..
The lip bumper should not exert any expansion or contraction on the molars.
Guidelines for obtaining an optimal adaptation of the appliance:
Transverse position: The wire must be 2.0 mm from the lower
canines and 3.0 to 4.0 mm from the premolars. Protection of the
canine area is crucial.
Sagittal position: The lip bumper should not be more than 1.0 to
2.0 mm away from the labial surface of lower incisors.
Vertical position: In the lateral segments, the wire must be positioned generally at the middle third of premolar and canine crowns.
If good vertical control is necessary, the bumper can be adapted to rest deeper in the vestibule.
The bumper can be positioned at three different levels with respect
to the incisor crowns, depending of overbite.
Incisal edge: this position usually is used during the initial phase of
treatment. It helps to upright mesially inclined molars.
Middle third: this is the position to use when a shielding effect on
incisors is desired. The lower lip is kept away from the teeth,
altering the equilibrium in favor of the tongue.
Gingival level: this level is used when the orthodontist does not
want to alter the equilibrium forces. Because the incisors are still
under the lower lip action, they maintain their position. The lip
bumper must be kept very close to the incisors.
Activating the Lip Bumper
Lip bumper can be activated to correct the rotation of the lower
molars.
A slight lingual bend is placed in one terminal (or both, if
necessary), adding approximately 1.0 mm of expansion to
counteract the lower molar tendency to tip lingually.
To prevent any change in the activation, the bumper is tied in with
an elastic chain.
In a few circumstances, the appliance can be expanded if
the lower molars are lingually inclined.
Clinical Management of the Lip Bumper
The appliance must be worn 24 hours a day and should be
removed only for meals and hygiene.
If cooperation is a problem, the appliance can be tied to molar
hooks with an elastic chain.
If the appliance has been well fitted, a red line can be seen
on the inside of the cheeks and the lower lip where the wire
runs.
If the lip bumper is too distant from the teeth, ulcers may appear. In
such cases, the appliance is removed for a day or two, lesions heal,
and treatment is restarted with an appliance that runs closer to the
teeth.
The patient may be given a card showing the positions of the two
terminals and should be advised always to check these positions
before inserting the appliance..
Class III Mechanics
If the upper arch has been overcorrected and the upper molars are
in super Class I relationship but space is still needed in the lower
arch, the lip bumper’s action can be enhanced by the use of light (2
to 3 ounces per side) Class III elastics that are driven from upper
first molars to the bumper’s hooks at the canine level.
Anchorage on the upper molar can be controlled with a PB, an
extraoral force, or both.
Evaluation of the Technique
Limitations of Cetlin mechanics.
The distalizing plate: Need full-time wear to obtain a bodily
movement of the upper permanent molars.
Continuous disclusion between the two arches is necessary to
achieve mandibular growth, leveling of the lower curve of Spee, and
lateral dentoalveolar growth in both the upper and lower
molar/premolar area, and
The headgear has often been a difficult-to-accept appliance.
Various modifications have been done to overcome these problems
of compliance.
The Pendulum Appliance presented by Dr. Hilgers has replaced the
Cetlin Distalizing Plate and, partly, the headgear.
Comparison of Two Distalization Methods: Pendulum Versus Palatal Bar Plus Pendulum
A clinical study has been carried out at the University of Ferrara
Aim was to find out whether the combination of the two appliances,
first the PB to rotate distolaterally and then the pendulum to
distalize the upper first molars, could lead to more bodily movement
and therefore minor loss of anterior anchorage , and
To verify whether the use of a PB prior to the application of
a pendulum would result in less extrusion and better
vertical control of the permanent molars.
The study group consisted of 20 consecutively treated
patients whose nonextraction therapy was started with a
PB and continued with a pendulum to attempt a bodily
distal movement of the same teeth. The pendulum used in
this group had bonded occlusal rests only on the upper first
premolars.
The control group consisted of patients treated with the
Hilgers pendulum alone. Lateral cephalograms were taken
before (T1) and immediately after (T2) distalization.
The T test of the cephalometric data revealed that only the
measurement of inclination of the molar axis was
significantly altered during distalization in both patient
groups.
The use of the PB to initiate molar movement reduced the
anterior anchorage needed since the modified pendulum
bonded only on the first premolars and produced the same
anchorage loss of the classically pendulum designed on all
four upper premolars.
Moreover, the combined use of PB and modified pendulum
gave a better molar vertical control and a faster
distalization of the lateral upper segment (molars plus
premolars).
Molar Uprighting and Vertical Control After Distalizationwith the Pendulum
The distalization of the upper molars with the intraoral
distalizing appliances may produce molar distal tipping and
extrusion.
These undesirable effects are corrected with a PB with a
large “biscuit-like” acrylic button around the Coffin loop .
The appliance is kept in place until molars are uprighted,
the marginal ridges discrepancy is corrected, and vertical
molar control is recovered.
In another study conducted at the University of Ferrara,
growing patients (mean age, 9.5 to 13.8 years) with Class II
malocclusions treated with an initial palatal bar, a
pendulum, and a PB with this large acrylic button to control
molars were analyzed on cephalograms;
Results have shown that ANB and Sn-GoGn decreased on
average, respectively, 3.32 and 1.3 degrees.
Segmental Alveolar Corticotomy to Enhance Upper MolarDistalization
Corticotomy has long been used in orthodontic treatment to
accelerate dental movement and improve its efficacy, and to reduce
the appearance of undesired phenomena such as root resorption,
loss of vitality and relapse of the corrections carried out.
Suya suggested that most of the therapeutic procedures be carried
out in the first 3 to 4 months, before fusion of the tooth-bone units.
In 2001, Wilcko et al published a case report in which corticotomy
was used in conjunction with resorbable alloplastic grafts of
demineralized freeze-dried bone.
They found that the fast orthodontic tooth movement was due to a
cascade of physiological events (area of transitory secondary
osteoporosis and greatly reduced bone density) described by Frost
as regional accelerated phenomena (RAP).
Protocol
The protocol consisted of an initial phase of leveling and aligning
(straight-wire appliance with 0.022 slot) up to a 0.018- × 0.025-inch
SS wire.
At this moment, the segmental corticotomy was arranged.
Local anesthesia: Lidocaine 2% with epinephrine 1 :
100,000
Buccal and palatal (lingual) sulcular incisions were
made,Full-thickness flaps were reflected.
Decortication was then produced using a rounded bur under
irrigation. Vertical cuts were produced between the roots of the
teeth (first and second permanent molars) to be moved
orthodontically and were then connected by horizontal cuts beyond
the apices. The cuts ended 1 to 2 mm before the alveolar crest
Scraping of the cortex was then produced both buccally
and palatally to create a bleeding bed for the graft.
Bio-Oss was then placed only buccally to cover the
decorticated areas .
In more recent protocols, new piezoelectric blades are
being used instead of burs on surgical handpiece. Grafting
is being modified by adding VEGF (Vascular Growth
Factors).
The flaps were sutured with nonresorbable silk 4-0.
After 1 week, on removal of the sutures, two 200 g nickel-
titanium springs (Sentalloy red, GAC) were positioned
bilaterally between the permanent first upper molars and
the second upper premolars on the 0.018× 0.025-inch steel
wire to distalize the molars.
Following molar distalization, the retraction of the upper
anterior group was carried out in 4 weeks by use of Class II
elastics on an 0.018-inch Australian Special Plus Begg-Type
upper archwire with two helices between lateral incisors
and canines.
The necessary distalization of the permanent first and
second molars was achieved generally in 8 weeks, without
needing any anterior anchorage accessories (Class II
elastics, Nance buttons, etc.).
The results of these clinical studies showed that
corticotomy helped accelerate distalization of the upper
molars and promoted a more bodily movement with less
need for anterior anchorage.
The use of a sliding mechanic, however, requires optimal
alignment and leveling of both arches to minimize the
friction generated as the molar tubes slide along the wire
used (0.018- × 0.025-inch stainless steel) and the occlusal
interference created by the lower molars.
These mechanics may be difficult to apply in cases in which
alignment and leveling of the entire arches cannot be
carried out before distalization of the molars.
In these situations, segmental corticotomy may be
associated with appliances to distalize the upper molars
before applying brackets and wires on the premolars,
canines, and incisors.
Space Utilization
Once maxillary molars had been distalized, a generally long period
followed to wait for spontaneous drift of premolars and canines.
No apparent active treatment was carried out. Bonding of the arch
was contraindicated because friction of brackets and archwires and
ligatures would have compromised the spontaneous movement of
teeth in an improved position and would have caused anchorage
loss.
The new self-ligating brackets combined with the light small wires
seem to overcome these problems and allow bonding of the arches
earlier without compromising spontaneous changes.
At present, the self-ligating brackets are the best way to
standardize force application, wire seating and decrease friction.
The light forces also seem promising in reducing the need for
intrusion mechanics.
Conclusions
Nonextraction treatment mechanics as described by Cetlin has
been proved to be a successful way of treating Class I and II
malocclusions with crowding.
The original mechanics needed to be updated to overcome
problems related to patient cooperation and to take advantage of
the new appliances and methods.
Clinical research will continue to improve the efficacy of this unique
therapeutic approach.
THE END