Leveling & Aligning /certified fixed orthodontic courses by Indian dental academy


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  • Leveling & Aligning /certified fixed orthodontic courses by Indian dental academy

    1. 1. Leveling And Aligning www.indiandentalacademy.com
    2. 2. The Principles In Choice Of Leveling And Aligning Wires The wire should provide light and continuous force to produce the most efficient tipping tooth movement. Heavy forces, in contrast, are to be avoided. www.indiandentalacademy.com 2
    3. 3. The Principles In Choice Of Leveling And Aligning Wires For Mesio-distal sliding along an archwire at least a Clearance of 0.002” is needed, and 0.004” would be ideal. That is For the Slot size of Clearance needed is Ideal wire size is 0.018” 0.022” - 0.004” - 0.004” 0.014” 0.018” www.indiandentalacademy.com 2
    4. 4. The Principles In Choice Of Leveling And Aligning Wires It is better to position the crowns than to cause root displacement. Although a highly resilient wire such as 0.017” x 0.025” A-NiTi could be used during this stage, it is not advisable Rectangular archwire will create unnecessary and undesirable root movements which may delay the alignment process and increase the possibility of root resorption. www.indiandentalacademy.com 3
    5. 5. The Principles In Choice Of Leveling And Aligning Wires Wires should have Excellent strength, Good springiness, Long range of action and Low loaddeflection. The titanium based NiTi and beta titanium (TMA) wires offer a better combination of strength and springiness than stainless steel. NiTi is both springier and stronger in small cross sections than beta (TMA). For these reasons A-NiTi is particularly useful as an initial wire in leveling and aligning. www.indiandentalacademy.com 3
    6. 6. The Principles In Choice Of Leveling And Aligning Wires Changing the diameter of a wire greatly affects its properties. For initial leveling and aligning, the smallest diameter wire that has adequate strength would be preferred. When the diameter of a wire is doubled, the strength increases by 8 times, the springiness decreases by 16 times and the range decreases by half. www.indiandentalacademy.com 3
    7. 7. Key points during leveling & Aligning Forces should be kept as light as possible.  Sagittal, vertical and lateral anchorage need should be identified for each case.  Lacebacks and bend backs to be used in the initial stages to avoid unwanted tooth movement.  Posterior segment should be supported with headgears / TPA in maximum anchorage cases. www.indiandentalacademy.com  2
    8. 8. The Archwire sequencing: www.indiandentalacademy.com
    9. 9. The Archwire sequencing: The archwires used with the standard edgewise appliance and during the early years with the pre-adjusted appliance were round and rectangular stainless steel wires. Round wires were available in sizes .014, . 016, .018, and .020. Rectangular wires were available in a number of sizes, with .018x.025, .019x.025 and .0215x.025 being the most popular wires www.indiandentalacademy.com used with the .022 bracket slot.
    10. 10. The Archwire Sequencing One of the earlier attempts at producing greater archwire flexibility was accomplished by twisting strands of very small stainless steel wires into what have been referred to as multistrand wires. These wires in sizes .015 and .017 were used as initial wires, prior to the use of the .014 round wire, in cases with significant tooth malalignment. www.indiandentalacademy.com
    11. 11. The Archwire Sequencing The introduction of Nitinol wires provided a possible substitute for multistrand and round wires during the leveling and aligning stage of treatment. Their flexibility provided for a substitution of approximately two sizes of stainless steel wires. Given their higher cost, their significance was therefore considered questionable by many clinicians. They were also mistakenly used during procedures that required the rigidity of a rectangular stainless steel wire, such as complete arch leveling and overbite control, space closure, overjet reduction with intermaxillary www.indiandentalacademy.com elastics.
    12. 12. The development of heat-activated nickel titanium wires, provided a wire with significantly greater flexibility. As a result these wires could be used as a substitute for three of the traditional stainless steel wires in certain situations, which was a significant improvement! The normal warmth of the oral cavity allows for significant activation of the wire and very efficient tooth movement. www.indiandentalacademy.com
    13. 13. Surprisingly, patients do not seem to complain of added discomfort, most likely due to the light forces that are introduced. Instead of replacing wires on a per visit basis during leveling and aligning, a coolant can be applied to the wire in the areas where full bracket engagement has not been achieved and the wire can be retied for complete engagement. www.indiandentalacademy.com
    14. 14. The substitution sequence: Traditional wires 0.015 Multistrand 0.017 Multistrand 0.014 S.S. 0.016 S.S 0.018 S.S 0.020 S.S. 0.0195 x 0.025 S.S Heat activated wires 0.016 Thermal Niti 0.0195X0.025 Thermal Niti 0.0195 x 0.025 S.S www.indiandentalacademy.com
    15. 15. The substitution sequence: This sequence has dramatically reduced chair time and has significantly increased the efficiency of tooth movement due to the minimizing of permanent archwire deflection. Because of their flexibility, there are clinical situations where heat activated wire substitutions are not recommended or where some stainless steel wires should also be used. These clinical situations can be described as follows: www.indiandentalacademy.com
    16. 16. Initial wires in cases with severe malalignment of teeth: It is a service to the patient to place a multistrand wire as the first wire in such cases. The permanent deflection that occurs with these wires reduces the overall force levels and provides for less discomfort during this initial “experience with braces”. Also, some wire bending in addition to the normal arch form may be required and is easily accomplished with multistrand wires. www.indiandentalacademy.com
    17. 17. Use of lacebacks for cuspid retraction in crowded extraction cases: The use of lacebacks minimizes the tipping of the cuspids into the extraction sites. However, with the continued use of flexible heat-activated wires, some tipping can occur. To reduce this possibility, an .018 or .020 stainless steel wire should be used as early as possible when using lacebacks. www.indiandentalacademy.com
    18. 18. Use of open coil spring in the anterior or posterior segments to create space for blocked out teeth Because of the flexibility of heat-activated wires, the use of open coil springs on these wires can cause significant distortions in arch form. Thus, open coil springs should not be used until . 018 or .020 round wires are in place. www.indiandentalacademy.com
    19. 19. Complete arch leveling and overbite control: While heat-activated wires are excellent for individual tooth alignment, they are not effective for complete arch leveling and subsequent bite opening. Hence, the transition from even the rectangular heat-activated wire to the rectangular stainless steel wire is sometimes impossible. An .020 round wire is often required prior to the use of the rectangular stainless steel wire. www.indiandentalacademy.com
    20. 20. Torque control  While rectangular heat-activated wires do initiate the process of torque control, this difficult tooth movement is best completed with a rectangular stainless steel wire. www.indiandentalacademy.com
    21. 21.  The introduction of heat-activated wires has provided a beneficial substitute for a number of traditional stainless steel wires and can dramatically improve the efficiency of orthodontic treatment.  This substitution is, however, beneficial for initial tooth alignment procedures only.  Their excellent flexibility can actually be detrimental in a number of other clinical situations as described above.  It is important that the orthodontist separate the situations that require archwire flexibility from those in which archwire rigidity. www.indiandentalacademy.com
    22. 22. Deep Overbite www.indiandentalacademy.com
    23. 23. Deep Overbite Although moderate deep overbite cases get corrected as a result of routine leveling and aligning procedures, the severe deep overbite cases require different corrective procedures. Deep overbite can be divided into two types. 1. True deep bite 2. Pseudo deep bite www.indiandentalacademy.com 2
    24. 24. Deep Overbite 1. True deep overbite- Is mostly due to the infra eruption of posterior teeth. 2. Pseudo deep overbite- Is due to the supra eruption of anterior teeth. A majority of cases will be due to the combination of both. www.indiandentalacademy.com 3
    25. 25. Modalities Of Treatment In Deep Overbite Correction 1. 2. 3. 4. 5. Extrusion or Uprighting of posterior teeth. True intrusion of upper and lower anteriors. Increasing the inclination of upper and lower anteriors. Combination of extrusion of molars and intrusion of incisors. Combination of two or more of the above procedures. www.indiandentalacademy.com
    26. 26. Extrusion or Uprighting of posterior teeth:Indication:  Patients with a horizontal growth pattern,  Growing individuals  True deep overbite cases. Methods:  Anterior bite plane.  Including II molars in the arch setup  Sweep in the archwire. www.indiandentalacademy.com
    27. 27. Proclination of upper and lower anteriors:Indication:  This can be done only if the soft tissue profile permits it or in cases with retroclined anteriors. Methods:  Not using lacebacks and bendbacks.  Use of open coil spring between retroclined teeth and posterior teeth. www.indiandentalacademy.com 4
    28. 28. In patients with vertical skeletal growth pattern any extrusion of posterior segment is going to swing the mandible backwards worsening the situation.  In such cases, bite should be opened by true intrusion of upper and lower anteriors.  www.indiandentalacademy.com 2
    29. 29. True intrusion of upper and lower anteriors:Indication:  Bite opening by true intrusion although can be used in both grown and growing individuals, it is effective in growing individuals.  True intrusion of incisors is indicated in cases of pseudo deep bite where the incisors are supra erupted. www.indiandentalacademy.com 2
    30. 30. True intrusion of upper and lower anteriors:Methods:  Utility arches.  Burstone Intrusion arches.  Three piece intrusive arch www.indiandentalacademy.com 3
    31. 31. Utility Arches This has multiple uses in various stages of orthodontic treatment.  This wire has been developed according to biomechanical principles described by Burstone and refined for incorporation into Bioprogressive therapy by Ricketts.  www.indiandentalacademy.com 2
    32. 32. Utility Arches Although it is a complete arch extending across both buccal segments,the utility arch engages only the two molars and four incisors.  It is commonly known as 2 x 4 appliance (Two by Four appliance).  www.indiandentalacademy.com 2
    33. 33. Burstone Intrusion arches. Originally proposed by Burstone, these springs are made of 0.017” x 0.025” TMA wire.  The upper and lower arches have to be leveled and aligned and a rigid stainless steel wire, preferably of 0.017” x 0.025” dimension should be engaged.  www.indiandentalacademy.com
    34. 34. Burstone Intrusion arches. The anchor molars are reinforced with a TPA in the upper and a lingual holding arch in the lower arch. The intrusion springs are made from 0.017” x 0.025” TMA wire without a helix or 0.017” x 0.025” stainless steel wire with a helix so that the forces can be made optimal for intrusion. www.indiandentalacademy.com
    35. 35. Burstone Intrusion arches. The wire is bent gingivally, mesial to the molar tube and then a helix is formed. The mesial end of the spring is bent into a hook and is engaged onto the main archwire distal to the lateral incisors which, according to Burstone, is the approximate centre of resistance of the four incisors. The mesial end of the spring lies passively at the height of the mucobuccal fold and the spring is activated by pulling the hook down and engaging it onto the archwire. www.indiandentalacademy.com
    36. 36. Three piece intrusive arch It consists of the following parts:  The posterior anchorage unit  The anterior segment with posterior extension  Intrusion cantilevers www.indiandentalacademy.com
    37. 37. Three piece intrusive arch The anterior segment is bent gingivally distal to the laterals and then bent horizontally creating a step of approximately 3mm. The distal part extends posteriorly to the distal end of the canine bracket where it is formed into a hook. The anterior segment should be made of 0.021” x 0.025” stainless steel wire to prevent side effects created by bending of the wire during force application. www.indiandentalacademy.com
    38. 38. Three piece intrusive arch The intrusion cantilever is fabricated from 0.017” x 0.025” TMA. The wire is bent gingivally mesial to the molar tube and a helix is formed. The mesial end of the cantilever is bent into a hook. The cantilever is then activated by making a bend mesial to the helix at the molar tube, such that the anterior end with the hook lies passively in the vestibule. www.indiandentalacademy.com
    39. 39. Three piece intrusive arch This is then brought down and engaged onto the horizontal portion of the anterior segment. This allows further distal placement of the intrusive force, i.e., lateral to the lateral incisor, so that the resultant forces are made to pass through the centre of resistance of the anterior teeth. An elastic chain can be attached to the hook to facilitate simultaneous intrusion and retraction or to redirect the forces more parallel to the long axis of the incisors. www.indiandentalacademy.com
    40. 40. Suggestion The general guidelines in leveling and aligning have been presented here. However, every patient is unique and should be treated by those methods most suitable for him. www.indiandentalacademy.com
    41. 41. Thank you Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com