Finishing and detailing in orthodontics /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Finishing and detailing in orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. Finishing and detailing INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Introduction Finishing and detailing , which is the last stage in treatment, it is important to continue focus on the treatment goals. They are Condyles in a seated position – in centric relation. Relaxed healthy musculature. Andrews Six keys.
  3. 3. Ideal functional movements – a mutually protected occlusion. Periodontal health Best possible esthetics.
  4. 4. Dougherty – 1976. outlined 17 factors to be considered in finishing and detailing. Correction and Overcorrection of the A-P Jaw Relationship The tip and torque - anterior brackets – demand for anchorage, - upper arch, total anchorage - anteroposterior correction is about the same for all appliances. Overcorrection of the Class II case is the greatest challenge in this area.
  5. 5. Establishing Correct Tip of the Upper and Lower Anterior Teeth Tip in face- eliminates the need for 2nd-order bends - treatment more efficient. Wire bending reqiured when: improper bracket placement relative to the vertical reference lines of the anterior teeth irregularly shaped anterior teeth -peg-shape LI present.
  6. 6. Establishing Correct Torque of the Upper and Lower Anterior Teeth The anterior torquing needs of patients vary - no single set of bracket torque values can meet the needs of all the cases . Adjust the torque in the upper and lower anterior segments - various stages of treatment . Eg. overjet correction of the moderate-to-severe Class II case
  7. 7. torque is frequently lost in the upper anterior segment  lower incisors are angulated forward compensate by adding lingual root torque to the upper anterior teeth and labial root torque to the lower anteriors
  8. 8. Coordinating Arch Widths and Archform Coordination of archwires - from beginning through the rectangular wire phase -prevent crossbites from developing. asymmetry cases -distorted anterior archforms, (cuspid regions). To correct - during the finishing stage, • cross-elastics - cuspid areas, • archwires canted in the direction opposite to the asymmetry.
  9. 9. Cross-elastics in cuspid areas used to compensate for asymmetrical upper archform (symmetrical arch indicated by dashed line). Modified upper archform (dotted line): archwire canted in direction opposite to asymmetry.
  10. 10. Establishing Correct Posterior Crown Torque Built in torque- preadjusted posterior brackets -eliminates wire bending. a tendency for upper palatal cusps to be situated below the occlusal plane, posterior buccal root torque - rectangular finishing wires. In the lower arch, 1st & 2nd molars- undesirable lingual tipping, - buccal crown torque to the rectangular archwires.
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  12. 12. Establishing Marginal Ridge Relationships and Contact Points Proper marginal ridge relationships - finishing stage - function of bracket height. Incorrect bracket height - apparent early . effective to reposition brackets as early as possible. An .014" round wire can be used to step any improperly positioned brackets.
  13. 13. Upper central incisor with incorrect bracket height and compensating step in .014" archwire. Bracket repositioned at next appointment, with .016" archwire.
  14. 14. Correction of Midline Discrepancies minor discrepancies -3mm or less 5 methods of elastic wear A single Class II elastic on one side and a double Class II elastic on the other, for cases with a bilateral Class II component A single Class II elastic on one side only, when the overjet results in a slight Class II relationship on that side and the opposite side is in a Class I position.
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  16. 16. Class III elastics on one side and Class II elastics on the other, for cases with the corresponding dental relationships. A single Class III elastic on one side only, when that side is in a Class III position and the opposite side has a Class I dental relationship . An anterior cross-elastic, when the discrepancy occurs primarily in the anterior segments.
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  18. 18.  Establishing the Interdigitation of Teeth rectangular wires - the teeth unable to settle . Settling before debonding - L/.014" & U/ .014" round sectional wire from lateral incisor to lateral incisor + vertical triangular elastics . Adv. - establish an individual archform.
  19. 19. Checking Cephalometric Objectives Progress headfilms - halfway through treatment reassessment of anchorage & changes in the division of treatment time. final cephalometric headfilms- 3 or 4 months before debonding.
  20. 20. Important factors to evaluate with progress and final cephalometric x-rays include • AP posn. of the incisors • incisor angulations, • changes in the occlusal plane, • the degree to which vertical dev. - occurred or restricted, & • the success of the correction of horizontal and skeletal components of the case.
  21. 21. Checking the Parallelism of Roots The tip built into preadjusted brackets - proper root paralleling. A panoramic x-ray - before debanding to evaluate root parallelism. If crown-root angulation is beyond normal standards, bracket repositioning or archwire bending may be required to modify the root positions.
  22. 22. Maintaining the Closure of All Spaces space closure be maintained - extraction cases passive tiebacks in the finishing stage.
  23. 23.  Evaluating Facial and Profile Esthetics Esthetic evaluation - ongoing process during all stages of orthodontic treatment. A projection of esthetic goals - made as part of the treatment plan.
  24. 24. Checking for TMJ Dysfunctions such as Clicking and Locking Document - TMJ dysfunction prior to treatment, Monitor - TMJ dysfunction during treatment. Problems – if managed before the development of true internal derangement, - joint function - reestablished without permanent damage. Monitor the patient for symptoms of TMJ dysfunction during retention.
  25. 25. Checking Functional Movements Before debonding, - checked for interferences during protrusive movements and lateral excursions. lower eight most anterior teeth make contact with the upper six most anterior teeth during protrusive movements. requires - slight widening of archform - bicuspid area, - mesial of the lower bicuspids contacts the distal of the upper cuspids.
  26. 26. Determining if All Habits Have Been Corrected Habits such as tongue thrusting - been corrected before the finishing stage . because as the patient grows, airway size increases and the tongue can assume a more posterior position.
  27. 27.  Correction of Rotations and Overcorrection Where Needed Most rotations - eliminated before finishing stage. Any remaining rotations can be corrected during finishing by one of three methods: Rubber rotation wedges under the rectangular archwire. Steiner rotation wedges— these are useful because they can be placed after the archwire is in position. Lingual elastics—the most effective method.
  28. 28. Establishing a Relatively Flat Plane of Occlusion Reasons for completing cases to a relatively flat occlusal plane, according to Andrews, proper fit of the upper dentition against the lower dentition.
  29. 29. According to McLaughlin, Bennet & Trevisi, attention should be given to the following considerations during the finishing stages of treatment. Horizontal Vertical Transverse Dynamic Cephalometric & esthetic.
  30. 30. Horizontal Considerations Coordination of tooth fit. A major consideration – coordination of tooth fit in ant. and post. areas. Ant. & post. teeth fit well – 20% of cases. Crowns of upper ant. teeth do Not occupy enough space 60% of cases. Relative to the lower ant. teeth Excess of upper ant. tooth substance – 20% of cases.
  31. 31. Mandibular excess in 60% cases will be evidenced by Post. space closure – difficult in upper arch – maintaining correct overjet. Overjet is correct, buccal segments – mild to moderate class II. Ant. space closure – upper arch – difficult while maintaining the correct overjet. Horizontal plane  difficulty relates primarily to factors of tip in the ant. teeth, incisor torque & tooth size.
  32. 32. Establishing the correct tip of the anterior & posterior teeth. Main factor – influence amount of space occupied by each tooth. Andrew’s prescription – 40° tip- upper ant. seg, 6° tip – lower ant. seg. 34° tip differential - size of upper ant. seg. & lower.  Improved tooth fit – 60% disc. cases. Shape of incisor crowns: • Barrel or  shaped – tipping – little effect
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  34. 34.  Providing adequate incisor torque Torque control – weakness of PAE.  Approx. 1mm seg. of wire – in a bracket slot – same dimension – required to carry out difficult root movement.  Full size wires – not used, to permit sliding.  effectiveness relative to torque control.  U/L torque needs vary greatly. Additional palatal root torque – upper incisor br. Addnl. labial root torque – lower incisor br.
  35. 35. Management of tooth size discrepancies. Tooth size – ‘seventh key’ – normal occlusion. Common – lack of tooth mass – u/ant. seg. relative to l/ant. seg. Excess tooth mass – L/ ant. seg – adv. to carry tooth redcn. – initial stages of trt. Controlling rotations. In out compensation built into br. + correct br. positioning  effective in controlling rotns. Beneficial in class I & Cl. II cases – Pm br. 0.5 mm to mesial  buccal cusps rotate – distally to class I, palatal cusps – mesially – occlude accurately.
  36. 36. Lower canine br. – slight mesial. Labial rotn. of mesial aspect – better contact with distal aspect of lower laterals. Maintaining closure of all spaces. Passive wire tie backs – when rect wires in place, Lacebacks – molar – cuspids – when light wires used. In extn. cases – figure of 8 liagature ties –across extn. site – to keep it closed.
  37. 37. Horizontal overcorrection. Cl II & Cl III cases – consider overcorrection. Fully correct the A/P position of dentition – using elastics, head gear etc. After correction – these methods discontinued/ worn part time – 6-8 weeks. If stable – appl. removed. Relapse – horizontally overcorrected.
  38. 38. Vertical Considerations Correct crown lengths, marginal ridge relationships and contact points. Correction – completed – rect. NiTi stage of trt. If not done early, in finishing stage – minor archwire bends. Does not ensure stability. These relns. to be corrected 1-2 yrs, before br. removal.
  39. 39. Final management of the Curve of spee. Low angle cases: Beneficial to level the entire curve of spee. This include banding 2nd molars. Upper bite plate retainers – in cases showing a tendency for bite deepening – retention. High – angle cases: High angle cases – with open bite tendencies – impt. to leave some curve of Spee in back of the arch.
  40. 40. Vertical overcorrection – deep bite and open bite cases: Br. On ant. teeth – 0.5 mm more gingival – open bite. - 0.5 mm more incisally – deep bite. Bite opening curves – cases resistant to bite opening finishing stage. Towards end of trt. – 1-2mm over bite, settle to 3-4mm. Openbite cases – impt. to evaluate – tongue position & tongue habits.
  41. 41. Transverse Considerations. Arch form. Single arch form for every patient – efficiency in arch form management. Accuracy or stability – not achieved. For balance b/w efficiency & accuracy – 3 std. Templates( square, tapered & ovoid) – to establish arch form – early stages of trt. Use of a wax template – compressed over br. In lower arch, before placement of rect. SS wire. Allowing – settle with light wire – last trt. Procedure.
  42. 42. Archwire Coordination. In all wire sizes – lower arch form established. Upper coordinated – lower wire, 3mm wider ant. & post. than the lower wire. Post. Torque considerations – beneficial to widen upper arch – post. Segments – 5mm. Minor maxillary narowing – finishing stages of trt. ‘Jockey wire’. – 0.045 arch wire coordinated – upper arch, widened 6mm/side. Secured to head gear tubes
  43. 43. Establishing posterior torque. Progressive buccal crown torque – appliance system – lower post. Seg. Slight widening tendency – lower arch. Upper molars – provided with additional buccal root torque. Important to have adequate width maxillary bone – buccal roots – not compressed against the cortical plate.
  44. 44. Transverse over correction. Cases – showing narrowing – over expanded & maintained. Maxilla expanded – palatal cusps of upper arch are in contact with buccal cusps of lower arch. Palatal bar – maintain expansion – till rect. SS wire. Torque in post. Br. + torque in arch wire – allow post. seg. to settle.
  45. 45. Dynamic Considerations  Establishing centric relation and checking functional movements. Evaluate orthodontic cases – CR noted at beginning of trt. Re-evaluate mandibular posn. as finishing stage of trt. commences. Patients – checked for interference – protrusive & lateral excursions. Protrusion – lower eight most ant. teeth – contact with upper six most ant. teeth. Lateral excursions – cuspid rise – slight ant. contact, disclusion of post. teeth , working & balancing sides.
  46. 46. Checking for TMJ dysfunction. Document any evidence of TMJ dysfunction prior to trt. Monitored during ortho trt. – if symptoms develop. Normal TMJ fn. reestablished – if managed prior too true int. derangement. Seated & reasonably centred condyle position – most beneficial posn. during ortho trt.
  47. 47. Cephalometric & Esthetic Considerations Cephalograms – taken half way through assess – anchorage factors - help revisions in trt. planning as trt. progress. Final ceph. film – evaluate – AP position of incisors. Changes in the mandibular plane Vertical dev. Success in correcting horizontal, sk. & dental components of the problem.
  48. 48. Settling the Case Rect. wires restrictive for settling of teeth – closing stages of trt. 0.014 or 0.016 round wire – lower arch 0..014 round sectional wire – LI to LI / upper. Vertical  elastics – settling needs to occur. Full time wear for first 2 weeks, then night wear for next 2 weeks
  49. 49. Variations: Cuspids labially displ. – extend sectional wire in upper ant. seg – to hold them in posn. Diastemas – areas tied lightly with elastic thread or ligature wires. Teeth extd. – figure of 8 ties –across extn. sites. Palatal expansion – small removable palatal plate – 0.018 wires extending interproximally in the gingival areas Moderate to severe Cl II/I, upper full arch wire, wire bend back distally. Settling longer than 6weeks – lower rect. wire used
  50. 50. Conclusion. With the built in features of the preadjusted appliance and the correct bracket placement, moving teeth to their finished positions begins as soon as the brackets have been placed and the first archwires tied in. There is a gradual flow towards the finishing stage with less work required at the end. Bennet & Mclaughlin has redefined finishing & detailing as the correction of errors made prior to finishing & detailing, over correction as needed and settling of the case.
  51. 51. Thank you Leader in continuing dental education