DR.MUHAMMAD SAOOD
OUTLINE
Treatment Planning and Sequence Phase Sequences Phase I: Space-Gaining Phase Upper Arch Lower Arch
Introduction
Space-gaining phase
Space-utilization phase
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.
The best patients are those who are growing and who are in the late mixed dentition stage because this stage offers several advantages:
I. II. III.
more quickly.
IV.
Gaining space in the upper and lower arch is the key phase of any nonextraction treatment.
Correction of molar inclination, rotation, and crossbite Overcorrection of molar relationship Generalized spacing in both the upper and lower arch.
Modification of the archform (an initial constricted, tapered archform needs to be changed)
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
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.
A gingival hook help to tie back the PB and aid in insertion of intraarch or interarch elastics.
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
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
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
Expansion or Constriction
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
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
Anchorage
After space has been created, control of the upper molars is crucial.
Extra-oral Forces
During the space-gaining phase, headgear was applied with the
During the second phase, when the spaces were used to finish up
Occipital Force
above the occlusal plane and thus had both distalizing and intrusive
effects.
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
Cervical force
The cervical gear traction force was exerted from below the occlusal
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.
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
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.
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
Extraoral forces had to be about 150 g per side to exert orthodontic and not orthopedic effects. The devices had to be
However, its forces might tend to incline molar crowns distally and
of the molars.
that lay against the mesial surface at the gingival level of the U6s.
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
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.
meals and hygiene. It always had to be used with the extraoral force
to control molar roots and obtain a distal bodily movement.
After the first permanent molars have been brought to a super Class
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.
Lip bumper gave support to the lower lip, improving lip competence,
The lip bumper transmitted lower lip force to the lower molars, allowing achievement of upright positioning and rotation.
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.
Molar anchorage
Therapy of habits Space gaining in the lower arch
inch tubes.
4-degree mesial offset to facilitate insertion and a step-out to prevent gingival impingement.
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.
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.
Incisal edge: this position usually is used during the initial phase of
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.
molars.
A slight lingual bend is placed in one terminal (or both, if necessary), adding approximately 1.0 mm of expansion to
To prevent any change in the activation, the bumper is tied in with an elastic chain.
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..
If the upper arch has been overcorrected and the upper molars are
Anchorage on the upper molar can be controlled with a PB, an extraoral force, or both.
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
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
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
Molar Uprighting and Vertical Control After Distalization with the Pendulum
The distalization of the upper molars with the intraoral distalizing
These undesirable effects are corrected with a PB with a large biscuit-like acrylic button around the Coffin loop .
cephalograms;
Results have shown that ANB and Sn-GoGn decreased on average, respectively, 3.32 and 1.3 degrees.
They found that the fast orthodontic tooth movement was due to a
Protocol
The protocol consisted of an initial phase of leveling and aligning
Bio-Oss was then placed only buccally to cover the decorticated areas .
etc.).
Space Utilization
Once maxillary molars had been distalized, a generally long period
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
The light forces also seem promising in reducing the need for intrusion mechanics.
Conclusions
Nonextraction treatment mechanics as described by Cetlin has
therapeutic approach.
THE END