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Contents 1. Introduction 2. Review of literature 3. Roths concept of finishing 4. Doughertys factors in finishing 5.

Factors affecting the finishing phase 6. Biomechanical strategies for optimal finishing 7. Final Settling of teeth 8. Finishing to ABO requirements 9. Removal of Bands and bonded attachments 10. Positioners for finishing 11. Special finishing procedures to avoid relapse 12. Conclusion 13. Bibliography

Introduction Man has always tried to attain perfection in all his endeavours. In recent times, great deal of emphasis is placed on achieving perfect finishing of the orthodontic treatment so that the results are pleasing to the eye and hopefully are more stable and conducive to an improved function and health. Although, the earlier authors like Tweed did mention finishing of a case, the impetus to this concept was given by Andrews, who expressed his dissatisfaction with the hundreds of completed cases that he saw at various meetings and which he felt were lacking in perfect occlusion. His own study of 120 non-orthodontic models led him to formulate the "six keys to normal occlusion ". Finishing is considered to be very difficult and time consuming in Conventional Begg therapy. But the same has become very easy with the PEA systems. If the tip, torque and inout compensation built into the appliance is accurately suited to the patients dentition, and if the brackets are properly positioned, then only minimal wire bending should be required to complete the treatment. Finishing : It is the last step, before active treatment is discontinued, of ensuring that the teeth and related structures are positioned in such a way as will lead to a better stability of results, enhancement of esthetics, optimised functions of the stomato-gnathic system and an improvement of the health of the periodontium. Detailing : It is the achievement of the ideal positions of every tooth in the vertical and horizontal planes with particular reference to the individual in-out, rotation, tip and torque adjustments. Evolution of the concept of finishing The concept of finishing has changed from that of the earlier authors who primarily relied on nature to achieve final finishing in each individual case.

1. According to Angle, "the best the orthodontist can do is to secure normal relations of the teeth and correct the general forms of the arch, leaving the finer adjustment to individual type form to be worked out by nature, which must, in any event, finally triumph". 2. Tweed relied primarily on placement of the lower incisors over basal bone. He also stressed the importance of artistic (second order) bends in the archwire. 3. Rickett's laid emphasis on the importance of arch form and the placement of lower incisor in relation to the A-Pog line. 4. Begg's philosophy on finishing emphasized the routine over movement and overcorrection of all aspects of the malocclusion (e.g. Deepbites were finished in edge to edge or slight open bite, class II cases were finished in super class I, class III). So that teeth would settle into proper positions after tissue rebound.

5. Kesling writes, " Considerable attention is presently being directed to the illusionary problem of precision finishing in Begg technique. The concern however is misplaced indeed when appliance are removed, the results should be different from one another as were the original malocclusions".

6.

Merrifield belief of finishing also plans stress on overcorrecting major problems so that changes seen during denture recovery would move occlusion towards ideal. It is doubtful whether many clinicians would agree to his concept of finishing treatment. Merrifields concept of finishing a case

7.

According to Bench et al The natural forces of eruption and natural forces of

occlusion combine with those of physiology and growth to settle teeth functionally into the best position for each individual's characteristics.

8.

Andrew's in 1972 published six keys to normal occlusion. This study established normal values for in out, tip and torque for each individual tooth which were then built into the edge wise brackets for the straight wire appliance. Roths concept of finishing Roth added the goals of gnathologic finishing as part of orthodontic treatment. He found that Andrews brackets were very well suited to achieve these objectives. Hence with slight modifications, he accepted these brackets. He further elaborated on the relapse tendencies of the teeth as follows:

1. 2. 3. 4. 5. 6. 7.

Teeth will move after appliance removal, no matter where they are placed. The cause of space will return or depress after appliance removed.

Teeth that are slightly tipped distally in the buccal segment will tend to settle better than teeth that are already mesially angulated. As teeth in the buccal segments settle, they will tip mesially and rotate mesially. As band spaces close, there is corresponding lose of torque of the anterior teeth.

Teeth adjacent to the extraction sites are found to tip and rotate into the extraction site. Maxillary lingual cusps will tend to migrate downwards until they find an occlusal stop against the opposing teeth (since the maxillary lingual cusps are centric supporting cusps of the upper teeth).

He tried to build over treatment in his appliance to neutralize these relapse tendencies.

Doughertys factors in finishing In 1976, Dougherty described 17 factors that should be considered in the finishing and detailing stage of orthodontic treatment. 1)Correction and overcorrection of A.P. jaw relationship Proffit and Ricketts recommends over treatment of Class II and Class III malocclusion to overcome rebound of 1-2 mm. Zachrisson overcorrects rotations and labiolingual displacements of individual teeth to 10 /10th overmovement.

McLaughlin and Bennett contend that Class II case with deep bites benefit from
overcorrection to an end-to-end position, and maintenance of that position with night time Class II elastics for six to eight weeks, which is followed by settling into an ideal Class I relationship.

Other corrected Class II cases occasionally show a Class III growth tendency in
retention and clearly do not benefit from overcorrection in the finishing stage of treatment. 2) Establishing correct tip of upper and lower anterior teeth. Upper teeth

Roth, Hilgers and Ricketts give upper anteriors a mesioaxial angulation, although
recommendation of Roth is more than others for cuspid tip.

Mollenhauer's suggests for different angulations in males and females.


Anterior Tip Lower Ant. Tip Author 1 2 3 Upper Ant. Tip 1 2 3

Roth

+2

+2

+5

+5

+9

+11to+13

Hilgers

+5

+5

+ 8

+10

Ricketts

+8

+5

Alexander 0 Andrews MBT +2 0

0 +2 0

+6 +5 3

+5 +5 4

+8 +9 8

+10 +11 8

Lower teeth

Williams states lower incisor apices should be spread distally to the crowns and the
apices of the lower lateral incisor must be spread more than those of the central incisor.

The apex of the lower cuspid should be positioned distal to the crown. Roth agrees but Ricketts is in slight disagreement here as he feels that the lower
cuspids should be placed upright at the end of the treatment. 3) Establishing correct torque of upper and lower anterior teeth Placement of the tip of lower incisors Roth,Williams and Hamula place their lower incisors 1 mm ahead of the APog line.

Ricketts places them 2.5 mm ahead of APog line. In his study, he found that the lower incisors varied from -1 to 6 mm ahead of the APog line". Zachrisson prefers placing lower incisors 2 mm ahead of APog line based on his study of the Scandinavian population. Lower anterior torque Hilgers places slight lingual root torque on lower incisors and favours lingual root torque on lower cuspids as he feels that the roots of the lower cuspid should contact the, lingual cortex to support disarticulation. Williams and Roth state that all four lower incisor apices should be in the same labiolingual plane but both prefer labial root torque of the lower cuspids in contrast to Hilgers. Anterior Torque Lower Ant. Torque Author 1 2 3 Upper Ant. Torque 1 2 3

Roth

-1

-1

-11

+12

+8

-2

Hilgers

-1

-1

+7

+14

+22

+7

Ricketts

+7

+22

+14

+7

Alexander -5 Andrews MBT -1 -6

-5 -1 -6

+7 -11 -6,0,+6

+14 +7 +17

+7 +3 +10

-3 -7 +7,0,-7

Williams feels that this prevents occlusal forces from moving root lingually towards the space reserved for lower incisors. Mollenhauer advises placing labial root torque on lower incisors since he has found that the apices distalize post treatment. Alexander has labial root torque placed on lower incisors to aid in keeping them upright. Upper anterior torque

Roth states that upper anteriors should have sufficient torque so that six upper
anterior teeth can contact six lower anterior teeth and the upper cuspids can lift off the lower bicuspids in protrusive excursions.

Hilgers advocates that the upper cuspids be torqued slightly to the lingual as the
labial inclination of upper cuspids supports the comers of the mouth. Also the maxillary incisors should have lingual root torque to achieve a normal interincisal angle.

Mollenhauer indicates buccal root torque in the upper cuspids to establish a canine
eminence. Interincisal angle

Although Andrews does not specifically mention the interincisal angle, if calculations
are done according to the diagrams in his book, then the interincisal angle works out to 1400.

Zachrisson aims for a smaller interincisal angle because he feels that smaller
interincisal angles seem to have a greater tendency to remain unchanged over long periods of time. In Class II cases, aim is to finish below 132 rather than above. His contention is that larger the interincisal angle, greater the chance for deep overbite to relapse. Interincisal Angle Author Alexander Hilgers Zachrissonn II A 132 126 125

Bench et al Andrews

125 140

4) Coordinating arch widths and archform

Roth recommends that the archform should be a catenary curve consisting of five
separate radii- one for front of the arch, one for each cuspid-bicuspid area and one for each buccal segment from first bicuspid distally. The widest point of the lower arch would be at the mesiobuccal cusp of mandibular first molar, and at first bicuspids. Widest point of the upper arch should be at the mesiobuccal cusp of the first molars.

Alexander, Hamula, Sheridan and Root agree on maintaining original normal


mandibular cuspid width.

Bench et al recommend a bolder buccal position of first premolars with


overlapping of lower first premolar buccal to the canine. This manouver tucks the canine inward and prevents its overexpansion.

McLaughlin and Bennett prefer widening the archform in the bicuspid area, so
that mesial of lower bicuspid contacts distal of upper cuspids and therefore the lower eight most anterior teeth make contact with upper six most anterior teeth during protrusive movements. 5) Establishing correct posterior crown torque and crown tip Mclaughlin and Bennett state that correct posterior crown torque is essential to prevent posterior interferences from developing and to allow seating of centric cusps. a) Mandibular posterior torque Lower posterior torque AUTHOR ROTH HILGERS ALEXANDER ANDREWS

4 7 -11 -11 -17

5 -22 -22 -17 -22

6 -30 -27 -22 -26

7 -30 -27 -27 -31

MBT

-12

-17 -14

-20 -22

-10 -32

RICKETTS(BIOPROGR) 0

Zachrisson has no torque on lower second molars because if they are inclined too
much lingually, upper molars erupt to occlude with them and create balancing interferences. He feels that the lingual cusps of mandibular first and second molars should be high enough to give a flat curve of Wilson.

Roth gives progressive buccal root torque close to Andrews measurements for
establishing curve of Wilson that would allow seating of the centric cusps but clearance upon excursions.

Hilgers places buccal root torque on mandibular second premolar. Even though root
support for lower first bicuspid is mainly from the lingual, there must be buccal root torque placed to passively accommodate the greater buccal crown curvature. b) Maxillary posterior torque

McLaughlin and Bennett recommend buccal root torque of the upper posteriors.

Hilgers feels that roots of the upper first molars (and of the entire upper buccal segment) should be inclined slightly to the lingual so that forces of occlusion will be directed across heavy cortical bone of palate and back through buttress of key ridge. However, buccal root torque must be placed on the upper buccal segment to allow for exaggerated buccal curvature of these teeth. Upper posterior torque AUTHOR ROTH HILGERS ALEXANDER

4 -7 -7 -7

5 -7 -7 -7

6 -14 -10 -10

7 -14 -10 -10

ANDREWS MBT

-7 -7

-7 -7 0

-9 -14 0

-9 -14 0

RICKETTS(BIOPROGR) 0

Roth calls for non-progressive buccal root torque in the buccal segments from cuspids distally. c) Mandibular posterior tip

Roth uprights lower buccal segments from their normal mesial angulation.

Hilgers tips back the mandibular first molars. According to him, in most Class II cases, lower second molar erupts with a decided mesial crown tip. If not treated orthodontically, this can lead to occlusal interferences often causing disarticulation of the condyle. So lower second molar should be tipped distally during treatment because it will settle mesially. Posterior Tip Upper Post. Tip Author Roth Hilgers 4 0 0 0 Ricketts 0 +2 0 0 +2 0 0 +5 5 5 0 0 0 6 0 0 0 0 0 0 -5 -5 +5 7 0 0 Lower Post. Tip 4 -1 0 5 -1 0 6 -1 -5 7 -1 -5 3 +11to+ 13 +10

Alexander Andrews MBT

0 +5 5

0 +2 2

0 +2 2

-6 +2 2

-6 +2 2

+10 +11 8

d) Maxillary posterior tip

Hilgers delivers distal root tip to upper first molars as they settle into a normal
Class I occlusion. Similarly upper second molar roots are tipped back slightly, as they settle in much the same way as the first molars.

Roth feels that upper first and second molars should have sufficient mesioaxial
angulation and buccal root torque so as to fit with lower molars. Upper bicuspids are uprighted from their normal mesial angulation. 6) Establishing marginal ridge relationship and contact points

Maintaining the heights of brackets and tubes as recommended by authors in their


prescriptions greatly facilitates finishing procedures.

To prevent lower incisor crowding, Bench et al and Zachrisson place the lower
incisors outside of the cuspids with the lower lateral incisor-overlapping labial to the cuspids. Upper lateral and central incisors should be almost equal in incisal edge length with no more than 0.5mm height differential. Alexander and Mollenhauer also support this view of 0.5mm height differential.

McLaughlin and Bennet rely on the FACC of Andrews for placing their brackets.
Facial Axis of the Clinical Crown (FACC) for all the teeth, except molars, is the most prominent portion of the central lobe on each crown's facial surface. For molars the buccal groove that separates the two large facial cusps is the FACC.

Roth has the lower incisors aligned contact point to point and the incisal tip of the
lower cuspids 1 mm higher than the incisal edge of lateral incisor.

Williams, Barrer and Tuverson advise slenderising mandibular anterior teeth to


establish broad contact points which tend to resist labiolingual crown displacement.

Hilgers keeps upper lateral incisor flush with central incisor during overcorrection
process and then tucks in the lateral incisor during the retention phase. 7) Correction of midline discrepancies

Most minor midline discrepancies of 3mm or less can be easily corrected in the
finishing stage.

Greater discrepancies require attention earlier in treatment.

Mollenhauer recommends overcorrection of midline discrepancies. McLaughlin and Bennett have used various elastic wear combinations for
specific situations in the correction of midline discrepancies. 8) Establishing the interdigitation of teeth

Different authors use different configuration of elastics for final seating of


occlusion. The elastics are worn after rectangular arches are changed to light round wires so that teeth can settle more comfortably.

Alexander also recommends chewing sugarless gum to get good interdigitation of


teeth. 9) Checking cephalometric objectives

McLaughlin and Bennett recommend that progress headfilms should be taken


about halfway through treatment to allow time for reassessment of anchorage and possible changes in division of treatment time.

They prefer to take final cephalogram three or four months before debonding
rather than at the end so that minor tooth position corrections can still be made. Important factors to evaluate with progress and final cephalograms include anteroposterior position of incisors, incisor angulations, changes in the occlusal plane and success of correction of horizontal and skeletal components of the ease. Mollenhauer also recommends taking prefinishing cephalograms for achieving minor tooth corrections before debonding.

10) Checking the parallelism of roots

A panoramic X-ray should be taken before debonding to evaluate root parallelism. Roth has evolved a strategy to his view lower cuspids should have a slightly exaggerated mesial rotation, while some distal rotation in the upper bicuspids is given whereas upper cuspids must have mesial rotation of 4 degrees in an extraction case.

Hilgers advises 5 mesial tip for mandibular second bicuspids and mesial root tip of -5
degrees for maxillary bicuspids in extraction cases to facilitate root paralleling.

Alexander has roots parallel at extraction sites. Hickham overparallels the roots at the extraction site.

Zachrisson advises against over paralleling roots at the extraction site because he
states that "if you overcorrect the axial inclination in extraction sites, these teeth may never correct themselves". 11) Maintaining the closure of all spaces

McLaughlin and Bennett prefer passive tiebacks in finishing stage especially in


extraction cases to maintain space closure. Also lacebacks are routinely used.

Lingual ligature ties from molars to cuspids, in addition to cinching of the distal end
of archwire, have been in routine use to maintain space closure. 12) Evaluating facial and profile esthetics

Esthetic evaluation is an ongoing process during all stages of orthodontic treatment. A


projection of esthetic goals should be made a part of the treatment plan according to McLaughlin and Bennett.

Roth suggests that the tip of upper incisors should be 2-2.5mm below the lip
embrasure of the upper and lower lips and 1mm of attached gingiva should be showing on full smile.

Artistic positioning of the upper anterior teeth has been recommended by Tweed,
Mollenhauer and recently by Sheridan. Mollenhauer has the following rules for a feminine finish: a) Upper centrals more upright. b) Lateral incisor above central. c) Rounded distoincisal corners but whole incisal edge not round. d) More bimaxillary protrusion.

Incisal edge recontouring also can be done, if not done at beginning of treatment, to achieve esthetic shape of the anterior teeth.

13) Checking for TMJ dysfunctions such as clicking & locking McLaughlin and Bennett recommend that the clinician:

a) Document any evidence of TMJ dysfunction prior to treatment and inform the
paticnt that such symptoms exist.

b) Monitor the patient for symptoms of TMJ dysfunction during treatment. If problems

are managed before development of true internal derangement, then joint function can often be reestablished without permanent damage.Such treatment often involves a short phase of splint and physical therapy concurrent with orthodontic treatment till symptoms are eliminated. Headgear and elastic force should be stopped while managing TMJ problems. c) Monitor patients for TMJ dysfunction during retention. Taking tomographs before treatment as well as two to three months before debonding is helpful in detecting irregularities within the joint and in evaluating clinical position of the condyle. It is generally accepted that orthodontic patients benefit from establishment of a seated and reasonably concentric condylar position. 14) Checking functional movements

C o i n c i d e n c e of centric relation with centric occlusion is a goal for various authors


like Alexander, Sheridan, Hamula and Roth.

Zachrisson prefers a bilateral contact in the glide from centric relation to centric
occlusion.

Sheridan and Zachrisson aim for cuspid protected occlusion on the working side
but feel that group function occlusion functions equally well long term.

Authors like Hickham, Tuverson, Gaylord, Hamula feel that all finished cases need
occlusal rehabilitation to establish good cusp to fossa home base relationship.

McLaughlin and Bennett state that in lateral excursion, patient should experience
cuspid rise with slight anterior contact and disocclusion of posterior teeth on both working and balancing sides. Kokich and McLaughlin and Bennett advise checking for interferences during protrusive movements and lateral excursions.

15) Determining if all habits have been corrected :

Habits such as tongue thrusting will usually correct before finishing stage, according to McLaughlin and Bennett or have to be eliminated by the finishing stage according to Hickham. He feels that any habit that does not allow teeth to come into centric occlusion while the patient swallows prevents occlusion from settling in.

Tuverson promotcs nasal breathing and utilises teeth together swallowing instructions although he prefers to give tongue spurs.

Mclaughlin and Bennett have observed that about 80 per cent of tongue thrust habits correct themselves before finishing stage and they advise that patients with severe habits should be referred for myofunctional therapy early in treatment or even before treatment. 16) Correction of rotations and overcorrections where needed:

Mclaughlin and Bennett state that most rotations will be eliminated before finishing
stage particularly if force levels are kept low. They have given three methods of correcting remaining rotations during finishing stage:

a) Rubber rotation wedges under rectangular wire.


b) Steiner rotation wedges. c) Lingual elastics.

Mollenhauer overcorrects rotations to 10 I/2/ 10th overmovement.

Roth, Hilgers and Ricketts favour a slight distolingual rotation of maxillary and
mandibular first molar.

Hilgers recommends that when viewed from the occlusal, distobuccal cusp of lower
first molar is rotated partially through the mesial marginal ridge of the lower second molars.

The maxillary first molar rotated 15 degrees distally so that a line drawn through
its distobuccal cusp would point at the distal of opposite cuspid.

Maxillary molars rotated 15 degrees distal so that a line drawn through distobuccal cusp and mesiolingual cusp will point at distal of opposite cuspid.

When lower molar is not rotated distally, there is an opening in the inclined plane relationship between upper and lower molars tending to bring upper molar back into mesial rotation.

Roth also favours slight distolingual rotation of lower bicuspids.


17) Establishing a relatively flat plane of occlusion

Flattened or level occlusal plane is advocated by authors like Gaylord, Hamula


(except in open bite cases where he and Mollenhauer prefer a positive overbite) and Mclaughlin and Bennett.

Zachrisson overcorrects deep bites to 1mm overbite and then lets them relapse 2-3
mm for final overbite of 3-4 mm. Factors affecting the finishing phase Acc. to McLaughlin and Bennet: The actual amount of finishing and detailing required in any given case may be increased by any of the following variables.

1. Variation in the shape and size of the patients teeth relative to the average
measurements used for the preadjusted appliance.

2. Inaccuracies or shortcomings in appliance design. As a result the threedimensional force delivered by the appliance do not produce accurate tooth positioning.

3. Utilization of force levels that "overpower" the selected appliance design. 4. Inaccuracies in appliance placement.

5. Failure to follow sufficient time for the bracket system to express itself. (Leaving the appliance in place for a further three months after main corrections are complete, and retying at monthly intervals, will often allow time for the brackets to produce additional favorable tooth movements.)