Contemporary Fixed Orthodontics

8/15/2017 1haPPy Smile

“The eyes sees only what the mind is prepared to comprehend”

Seminar submitted to DEPARTMENT OF ORTHODONTICS

Seminar submitted by SACHIN SUNNY OTTAFINAL YEAR PART 1

FIXED ORTHODONTIC

APPLIANCES


From the history…Most of the early appliance were of removable

type.Actually , they were modified dentures. Early fixed appliance were usually crude metal bands that were ligated to teeth with brass or silver wire. They were outstanding for their inefficiency & their ability to trap food.So KINGSLEY,ANGLE & CASE realised that for any effective tooth movement,some means must be devised to control individual teeth.This led to the development of attachments that were soldered on modified crowns or bands…!


What Are Fixed Appliances?

Appliances that are fixed or fitted on to the

teeth by the operator & cannot be removed by

the patient at will.

They are very versatile and can be used to

treat most

malocclusions.


ADVANTAGES:

1.Orthodondist need not depend on patient cooperation on timely wear.

2.Any type of tooth movements are possible.

3.Multiple tooth movements possible simultaneously.

DISADVANTAGES:

1.Oral hygiene maintenance

2.Time consuming to fix and adjust

3.Damaged appliance deliver mis-directed forces

4.Regular visits

5.Expensive

6.Esthetically not pleasing


Tooth movements possible

TIPPING –crown moves in direction of force

BODILY MOVEMENT – equal movement

TORQUING – root in lingual direction

UPRIGHTING – mesio distal movement

ROTATIONS – rotation around long axis

EXTRUSION

INTRUSION


UPRIGHTING ROTATION

INTRUSION EXTRUSION


OPTIMUM ORTHODONTICFORCE

The force that produce maximum tooth

movement in the desired direction with

minimum damage to supporting tissue &

without any discomfort to patient.

It should be in range of 20-26gm/cm sq of

root surface

It should not occlude blood vessels in PDL.


Fixing attachment to teeth

BANDING

Technique of fixing attachments to band

is referred as BANDING.

Uses thin stainless steel strips called

bands that are wrapped around teeth &

cemented to teeth.

Posterior bands are wider & stiffer

where anterior band is thinner &

narrower.


Indications for banding:

1.Posterior teeth which receive heavy Occlusal force & moisture control is required.

2.Teeth that require buccal & lingual attachments

3.Teeth with short clinical crowns

Steps in banding:

1.Separation of teeth – using elastomeric rings(doughnut),separating springs(1 week),Keslings separator.

2.Selection of band material,thickness & width

3.Band placed around tooth & pinched

4.Spot weld

5.Fixing the attachments

6.Cementation 8/15/2017 13haPPy Smile

BONDING The method of fixing the attachment directly over

the enamel using adhesive resin

Advantage over banding: enhance esthetics & oral hygiene maintenance.

PRETREATMENT OF ENAMEL BEFORE BONDING:

1.Etching the enamel enhance surface energy

2.Etching enhance porosity & hence greater bond strength.

ADVANTAGES:

1.Esthetics

2.Faster to bond

3.Better oral hygiene

4.Risk of caries under loose bands are eliminated


DISADVANTAGES:

1.Weaker than banded attachments

2.Etching increases risk of demineralisation

3.Enamel fracture can occur during debonding

TYPES OF BONDING:

1.Direct bonding :direct attachment of bracket to pretreated teeth.

2.Indirect bonding: bonding with the help of transfer tray

DIRECT BONDING

1.Cleaning – pumice & bristle brush

2.Moisture control – saliva ejectors & cotton rolls. Methantheline 50mg per 45kg bdy wt 15 min before bonding.


3.Enamel pretreatment – 30-50% phosphoric acid (gel or liquid) for 15-30 sec. appearance of etched enamel is “matte,dull,whitish & lightly frosted”

4.Sealant application

5.Bonding – using bonding material (bis-GMA).Light cure adhesives also used.Excessiveadhesive material removed using scaler.

INDIRECT BONDING

1.Brackets are positioned & applied over the model

2.Transfer tray (thermoplastic sheet or silicone putty) is adapted over the model to incorporate bracket.


3.Bonding resin applied to mesh side of bracket

4.Tooth surface is pretreated

5.Bonding tray is positioned over patient `s

mouth

6.Light cured

ADVANATAGES:

1.Accurate placement of brackets

2.Clinical chair side time reduced


Components of fixed appliances

ACTIVE COMPONENTS

1.Arch wire

2.Springs

3.Elastics

4.Separators

PASSIVE COMPONENTS

1.Bands

2.Brackets

3.Buccal tubes

4.Lingual attachments

5.Lock pins

6.Ligature wire


bands Help to fix attachments to teeth.

Made of soft stainless steel

Preformed bands or custom made bands are

available

Inner surface has matt finish to aid in

retention of cement.


BRACKETS Handles of attachment to tooth that transmit

force from active component (arch wire)

Classification:

1.Based on material

Metallic & Ceramic

2.Based on attachment

to tooth

Weldable & Bondable

3.Based on mode of securing arch wire

Self ligating & that require ligation

4.Based on technique

Edgewise , Ribbon arch , Tip edge type


EDGEWISE : have a

horizontal slot labially.

They accept wires of rectangular

cross section.

Greater control over tooth.

RIBBON ARCH: have vertical slots facing

occlusal or gingival direction.Used

with round wires.Permit tipping of

teeth in labiolingual & mesiodistal

direction.Used in Beggs appliance.


WELDABLE & BONDABLE BRACKETS

METALLIC BRACKETS:

recycled,sretilized,resist deformation,least

friction at wire-bracket interface.Not

esthetically pleasing.


CERAMIC BRACKETS: aluminium oxide or

zirconium oxide.Dimensionally stable,durable

& resist staining.They are very brittle &

exhibit greater friction at wire-bracket

interface.


PLASTIC BRACKETS: improve esthetic

value.They tend to discolor & offer poor

dimensional stability.Very high friction.

SELF LIGATING BRACKETS: have inbulit

metal labial face that can be opened & closed

to secure arch wire.Exhibit very low friction


EVOLUTION OF

BRACKETS


BUCCAL TUBES Attachment generally used in

molars(molar tube)

They are weldable or bondable

Round or Rectangular in cross section

Single , Double & Triple.


Lingual attachment

Attachments to be fixed lingually.

Used to engage elastics.

Lingual cleats Lingual buttons

Eyelets

Ball end hook


Ligature wire To secure arch wire to

bracket(ligation) in edge wise brackets.

Stainless steel wire of

0.009-0.011 inch diameter

Lock pins Small pins to secure arch wire

to ribbon arch bracket.

Made of brass


Arch wire Gold wires replaced by stainless steel wires due to high

cost & mechanical inefficiency

Titanium wires also used due to high elastic properties.

Ideal requirements:

1.Spring back-how far deflected without permanent

deformation

2.Stiffness-low stiffness apply low constant force over time

3.Formability-be high to bend in any configuration

4.Resilience-amount of force wire can withstand without

deformation.

5.Biocompatability

6.Joinability

7.Friction-very low


Gold & gold alloys: low spring back & high cost

Stainless steel:18-8 stainless steel

Nitinol :high spring back, high working range &

low stiffness.Cannot be soldered or welded.

Beta tiatnium: T.M.A wires.High range of action &

spring back.High formability & can be welded.

Elgiloy : cobalt chromium nickel alloys

Optiflex arch wires: made of clear optical fibre &

hence highly esthetic.High resilience.Cannot

accept sharp bends.

Multistranded arch wire:made of number of

thinner wires.Increased flexibility.

Arch form termed as “Parabolic Shaped”8/15/2017 41haPPy Smile

Elastics & elastomerics

ELASTICS

Latex rubber

Force delivered depend on diameter of

elastics

Color coded


Applications:

1.Class 1 elastics: intra arch

elastics.Used for space closure &

retraction of teeth.


2.Class 2 elastics :inter maxillary elastics

stretched between lower molars &upper

anteriors.Used in treatment of class II

malocclussion.


3.Class 3 elastics:intermaxillary elastics

stretched between upper molars & lower

anteriors.Used in treatment of class III

malocclusion.


4.Cross bite elastics:to treat molar cross

bite.Extend between palatal surface of

upper molars & buccal surface of lower

molars or vice versa.


5.Box elastics:treat anterior open

bite.elastic is stretched between upper &

lower anteriors like a box.Forced

eruption of upper & lower anteriors.


ELASTIC CHAINS (E-CHAINS)

Elastics available as long chains of interconnected rings

Made of synthetic polyurethene

material

Used in closure of space between

teeth.

ELASTIC THREAD

Made of core of latex rubber surrounded by woven silk

Tied around two teeth for space closure or to derotate a tooth.

ELASTIC MODULE

Two elastic rings separated by variable distance

Used for space closure & derotation of tooth


ELASTIC

THREAD

ELASTIC

MODULE


LIGATING RINGS

To secure arch wire to bracket

Available in various colors

Alternative to ligature wires.

Springs Uprighting spring:move root in mesial or

distal direction

Torquing springs:move root in lingual or palatal direction

Open coil spring:coil compressed between two teeth to open space between them

Closed coil spring:stretched between two teeth to close space.


UPRIGHTING

SPRINGS

TORQUING

SPRINGS


CLOSED COIL

SPRING

OPEN COIL

SPRING


separators To open up a gap in interdental area for easy

banding & patient comfort.

BRASS WIRE SEPARATOR

0.5-0.6mm diameter brass wire

RING SEPARATOR

Elastic rings passed via contact using applicator

DUMBBELL SEPARATORS

Dumbbell shaped elastic stretched into contact

Stretched separator tries to regain original length hence indirectly separates the teeth.

KESLING`S SPRING SEPARATOR

Have a coil & two arms- shorter arm passed below contact while longer arm rests above the contact.


E-ARCH Expansion arch by Angle

Had bands on molars with an expansion arch

threaded to buccal aspect of molar bands

Individual teeth were ligated to expansion arch

Deliver only heavy interrupted force


PIN & TUBE APPLIANCE Consist of bands with vertical tubes placed

on all teeth. Arch wire carried soldered pins

inserted into vertical tubes

Tooth movement achieved by altering

placement of pins.

Require high precision & skill


EDGEWISE APPLIANCE

“Metal bracket having rectangular slot facing

labially received a rectangular arch wire “

It enabled control of tooth movement in all

three plane of space

Angle`s last contribution

It incorporated FIRST , SECOND & THIRD

ORDER BENDS.


Comprises of lateral inset,canine offset & molar offset

Correct buccolingual position by moving the roots


Advantages:

1.Ability to move teeth in all three planes

of space

2.Bodily movement of teeth possible

3.Good control

Disadvantages:

1.Need to apply heavy force

2.Need for complex wire bending

3.Increased friction

4.Difficult to open deep bites


RIBBON ARCH APPLIANCE

First appliance to use a true bracket having

vertical slot facing occlusaly

Used archwires with good spring qualities

Poor control of root position

Used rectangular wires than round wires

Enabled rotation control,bucco lingual &

incisogingival tooth movement


BEGG APPLIANCE

Concept of differential force & tipping of teeth

rather than bodily movement

Modification of ribbon arch appliance

Treatment is under 3 stages:

1.Alignment, correction of crowding, rotation

correction, closure of anterior space &

achieving an edge to edge anterior bite.

2.Closure of extraction space & maintenance

3.Root Uprighting & torquing


Advantages:

1.Use of light continuous force over

physiological limits

2.Do not strain the anchorage

3.Minimal friction

4.Extra oral force not required to conserve

anchorage.


STRAIGHT WIRE APPLIANCE

Pre adjusted edgewise appliance

Programmed brackets to eliminate the

complex bends.

Bodily movement of tooth achieved

Stages of treatment:

1.Initilal aligning & leveling of arch with

crowding correction.

2.Space closure & establish class I molar

relation with normal over jet

3.Finishing & detailing


By passing the bends..

1.First order bends – varying the thickness of

base of bracket

2.Second order bends – angulating bracket

base or bracket slot

3.Third order bends – inclined bracket slots


BAKERS ANCHORAGE Use of inter maxillary rubber bands

Adjust the teeth by pitting the upper arch

against lower arch

Used in class II & class III malocclussion

cases


LINGUAL ORTHODONTICS Technique involving placement of bracket &

other attachments on lingual surface of teeth.

Appliance not visible & hence donot affect esthetics(Invisible orthodontics)

Begg`s & edgewise principle can be incorporated

Indications:

1.Mild incisor crowding with anterior deep bite

2.Long & uniform lingual tooth

surface without fillings,crowns or

bridges

3.Good gingival & periodontal

health8/15/2017 73haPPy Smile

Drawbacks:

1.Difficult to place bracket in lingual aspect

2.Tooth control not very effective

3.Limited scope for complex problems

4.Difficult in short crowns

5.Expensive

Indirect bonding is

mandatory due to

difficult visualization &

bracket height.

Moisture control is difficult.


TIP EDGE APPLIANCE

Combine advantages of straight wire & begg

appliance

Initial stage: Tip edge bracket allow tipping of

tooth(round arch wire)

Final stage: Better degree of control over

tooth (rectangular arch wire)


Stages of treatment

Leveling & alignment

Overbite reduction

Overjet reduction

Space closure

Final tooth positioning


1.LEVELING & ALIGNMENT

In vertical & horizontal planes

All rotations are corrected

2.OVERBITE REDUCTION??

By intrusion of anteriors or extrusion of

posteriors depending on skeletal growth

pattern,lip configuration & inter occlusal

clearance

Intrusion of anteriors – intrusion utility arches &

arch wires with anti curve of spee in mandibular

& exaggerated curve of spee in maxillary arch .

Posterior extrusion – bite planes & vertical

elastics


OVERBITE CORRECTION8/15/2017 79haPPy Smile

3.OVERJET REDUCTION & SPACE CLOSURE

To obtain class 1 canine relation

Close any residual space occurred due to extraction

Mechanics of anterior retraction :

1. Friction or sliding mechanism - aligned brackets allow wire to slide through posterior bracket slots. Thick rectangular stainless steel wires are used

2. Friction less or loop mechanics – Depends on spring and loop design for anterior retraction or posterior protraction depending upon anchorage need . Various loops are T loop ,Omega loop , Key hole loop and Tear drop loop


KEY HOLE LOOP


En mass retraction – Entire anterior segment is

retracted

Canine retarction followed by incisal retraction –

Enhances posterior anchorage control during

space closure

4.FINAL TOOTH POSITIONING

Finishing and occlusal detailing

Smaller diameter wire ( 0.016inch stainless steel

or rectangular beta titanium) is used

Minor arch wire bends in 1st 2nd or 3rd order may

be used

Vertical settling elastics is used for settling of

occlusion 8/15/2017 82haPPy Smile

FINAL STAGE


DEBONDING

removal of orthodontic attacthment and adhesive resins .

To restore the surface of teeth as closely as possible to pre traetment conditions

Metal brackets debonded using twin beak debonding plier and brackets are cut off at tooth bonding base interface

Thermal debonding csn be done when barcketsare exposed to heat source (softening of adhesive)

Laser debonding

Ceramic brackets debonded by lifting the brackets of using bracket removing plier ??


Residual adhesive is removed using burs and

contra angle hand piece

Dome shaped tungsten carbide burs at

30000rpms using light painting stokes can

remove adhesive

Ultra fine diamond burs

Teeth is polished with prophylaxis paste


Tungsten Carbide bur used for cleaning of adhesive


EXTRACTION IN CONJUGATION WITH

ORTHODONTIC THERAPY

Teeth returned to their original positions of

malocclusions after the retaining appliance were

removed

In such case removal of one or more teeth made

the problem of correction much easier

Removal of first cuspids permit the normal

occlusion with greater ease and post treatment

stability

It was an antagonism with Angle’s followers .


FIXED FUNCTIOAL APPLIANCES Functional appliances that are fitted on teeth by

the orthodontist and cannot be removed at will by the patient

Non compliance class II correctors

Advantages:

1. 24 hours usage

2. smaller size

3. better adapted to functional movements

4. overall treatment time is reduced

Classified as : 1 . Flexible fixed functional apliance ( FFFA) 2. Rigid fixed functional appliances (RFFA)


FFFA Inter maxillary torsion coils of fixed springs

Allows greater movements of mandible

Elasticity and flexibility

Disadvantages : fracture of appliance, tendency to chew the appliance ,mucosal ulceration of springs

Uses : class II div 1 and 2 , class 3 malocclusions

Example : Jasper jumper ,Klapper super spring ,Churro jumper


RFFA Advantages : after fixing appliance ,do not

permit the patient to close the centric

relation which creates 24 hours stimulus

for mandibular growth

Examples : herbest appliance,

cantilevered bite jumper ,MALU herbst

appliance ( mandibular advancement

locking unit), flip lock herbst appliance


Problems during orthodontic treatment

1.Caries & decalcification

2.Deformed bands


3.Soft tissue problems

Ulcerations

Inflammation & enlargement of gingival

papillae

Recession


Care your teeth during

treatment!!1.Orthodontic brushes


2.Digital gum massage

3.Interdental stimulation

4.Waterpik


With the help of….

Graber`s textbook of orthodontics-Sridhar Premkumar (4th edtn)

Contemporary orthodondics-William.R. Proffit (4th edtn)

Orthodontics the art & science-Bhalajhi

Orthodontics exam preparatory manual for undergraduates-Sridhar Premkumar(2nd edtn)



“ONCE YOU LEART TO

QUIT, IT BECOMES A

HABIT”

Contemporary Fixed Orthodontics

Education

Transcript of Contemporary Fixed Orthodontics