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INDIAN DENTAL ACADEMY
Leader in continuing dental education

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Contents
• The Principles of the Alexander Discipline
• Vari-Simplex Appliance Design & Construction
• Non-Extraction Trea...
"Nothing is really new. We only rediscover
for ourselves."
……..Socrates

www.indiandentalacademy.com
Introduction
• It grew out of the Tweed Technique, and today
maintains many of its principles. The present
technique incor...
Salient features
• The specifics that make this technique different
include:
A unique bracket selection with specific desi...
Treat one arch at a time, beginning in the upper arch; in
extraction cases treat the upper arch while allowing the
crowded...
Successfully level lower arches by using a reverse curve in
the arch wire employing the specific prescription.
Attach Clas...
www.indiandentalacademy.com
•

The treatment philosophy retains three fundamentals of
the Tweed technique:
1. Anchorage preparation (uprighting mandib...
•

The object of treatment is to position the mandibular
teeth within the mandibular trough, with four goals in
mind :
1.
...
• In extraction cases, lower incisors are almost always kept up
righted.
• According to the author, lower incisors can be ...
• Others factors affecting diagnosis:
• Age of the patient
• Diagnostic records taken like the intra-oral x-rays, models,
...
• Certain factors observed in the patient himself :
• Palpation of the temporomandibular joint while the patient is
openin...
www.indiandentalacademy.com
• The most important factors in determining the design of the
Vari-Simplex Discipline are the size and shape of the teeth,...
• The system evolved around five factors related to
brackets:
–
–
–
–
–

bracket selection,
bracket height,
bracket angula...
Advantages of the Alexander Discipline Bracket System
• Bracket selection :
– The system is composed of a no. of brackets ...
• Interbracket space:
– Using single brackets with
wings in the lower anterior
and buccal segments allows
maximal inter-br...
• Rotational control:
– Rotation wings on cuspids, bicuspids, and lower
anteriors provide for improved rotational control
...
• Torque:
– Each bracket has a 0.018 × 0.025 inch wire slot.
Slot sizes do not vary from anterior to posterior
brackets an...
• Lower incisor torque:
– (- 5 °) torque is incorporated into lower incisor
brackets.
• This allows for more efficient con...
• Lower first molar tip:
– The mandibular first molar is
also constructed to have a - 6 °
tip incorporated into its design...
– The - 6 ° tip of the molar bands also positively contributes
to a non-extraction philosophy in that it allows distal
mov...
Bracket Selection
• Twin Brackets:

– Used on large, flat-surfaced
teeth (namely, maxillary
central and lateral incisors)....
• Ball hooks for elastic
placement are usually
placed on lateral incisor
brackets.
• The brackets allow for 5 to
6 mm of i...
• Lang Brackets:

– Originally developed by
Dr. Howard Lang.
– Used on large, roundsurfaced teeth at the
corners of the ar...
– The straight wing eliminates interference with complete
arch wire engagement. Thus, the bracket is easily ligated
and in...
• Twin brackets on cuspids are not the brackets of
choice because:
– They decrease the inter-bracket width, making it
more...
• Lewis Brackets:

– Used on round-surfaced teeth not located at the corners of the
arches (maxillary and mandibular bicus...
• The design of the bracket is wedge shaped which
puts the tie wing closer to the tooth occlusally and
far out gingivally
...
An additional benefit offered by the single bracket
with wings is that, on a tooth that is badly rotated,
the wing in the ...
• Molar bands:
– Twin brackets with
convertible sheaths are
used on the first molars.
– Headgear tubes are used
on the max...
– The mandibular first molar bands can be constructed with
convertible arch wire tubes and lip bumper tubes (if
necessary)...
Specifications of the Appliance
• Bracket Height :
– Bracket height in this Discipline, as in any other
technique, is extr...
Maxillary Arch

Mandibular Arch

Centrals

X

Centrals

X – 0.5mm

Laterals

X – 0.5mm

Laterals

X – 0.5mm

Cuspids

X + ...
Special Considerations in Appliance Construction
• Deep Bite Cases :
– The true Alexander Discipline dictates that the
max...
• The bite plate allows immediate placement of
mandibular appliances and also hastens bite
opening by allowing simultaneou...
• Open Bite Cases :
– Special bracket placement of anterior brackets in
an exaggeratedly gingival fashion and more
occlusa...
• Extraction Cases :
– The bicuspid brackets adjacent to the extraction
sites should be tipped so that the roots of the te...
• Bracket Angulation :
• To allow the roots to be properly positioned at the end of the
treatment, care is taken during th...
• Mesiodistal Position :
• On flat-surfaced teeth, the bracket
should be placed in the center of
the clinical crown.
• The...
• Bracket Torques:
– The torque prescriptions used in this technique are
derived from measurement of the torques in the
re...
• These measurements differ from commonly used torques
in three major respects:
• The -3º torque on the max cuspids compar...
www.indiandentalacademy.com
• In Alexander’s discipline a typical non-extraction treatment,
begins with the maxillary arch.
• The incisors, cuspids, a...
• Soon an .016" round wire with omega stops mesial to
the terminal tubes is placed, so that the archwire can be
tied back....
• Purpose of tying back the archwire :
• To consolidate the arch, so that the extra-oral forces act
orthopedically instead...
• All spaces should be closed while the .016" archwire is in place.
In addition to tying back, power chains can be used fr...
Mandibular Arch
•

Bonding/banding the mandibular arch is delayed for the
following reasons:
1. It will avoid interference...
•

The mandibular arch is the key to non-extraction treatment with the
Vari-Simplex Discipline and therefore, holding the ...
• Cases wherein crowding of the mandibular arch prevents unraveling
and uprighting of the lower anteriors— despite the fiv...
• However, the extrusive effect of the Class III elastics on the max
molars should be given due consideration, especially ...
• The next wire is an .017" x .025" stainless steel finishing
archwire. If additional leveling is needed, a reverse curve ...
• Premature use of Class II elastics can cause
•
•
•
•

loss of torque control,
bite closure,
tipping of the occlusal plan...
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Brief History
• Alexander’s interest in the orthopedic forces developed
from the study of the effects of the Milwaukee Bra...
• In an attempt to prevent this undesirable effect, Alexander
advocated a continuous upper arch wire to prevent molar
tipp...
Effects On the Three Dimensions
• Sagittal Dimension
– The Class II sagittal discrepancy can be positively
affected by the...
• Vertical Dimension :

– The goal of the combination and high pull face bow is to
maintain the vertical relationship of t...
• Transverse Dimension :
– Developing or maintaining
the maxillary transverse
dimension is accomplished
with the inner bow...
Advantages of Face Bow Therapy
• It places only a distal force on the maxilla without any
undesired mesial effects.
• No n...
Face Bow Adjustment
• For mesio-lingually rotated 1st
molars, the inner bow can be
adjusted over a period of 6
months to e...
• When the high-pull face
bow is considered
necessary in the treatment
of the patient, the
outerbow is bent in such a
fash...
Treatment Time
• Depending on the diagnosis, the patient will wear the retractor
8-14 hours per day.
• As a general rule,
...
Keys to Optimal Face Bow Results
• Cooperation:
– The face bow should be worn consistently. Eight to 10 hours
every night ...
www.indiandentalacademy.com
Lower anterior vertical facial deficiencies are often
accompanied by over-eruption of anterior teeth
and under-eruption of...
Principles in the Treatment of Vertical
Deficiencies
• Three modalities
– intruding the anterior teeth,
– extruding the po...
• Most deep bite cases can be treated non-extraction
• In cases of moderate crowding, consider
• Inter-proximal enamel red...
• Maxillary Arch Development
– Accomplished by eliminating rotations, closing spaces,
accentuating the curve of Spee, and ...
• Curve of Spee
– After the initial arch wire, an
accentuated curve of Spee is
placed to open the bite
– The curve should ...
• When determining the amount of curve to place in the arch
wire, it is important to look at the patient's "smile line."
•...
• Bite Plate
– If the bite has not opened adequately after a few
months of treatment in the finishing arch wires, a bite
p...
• Mandibular Arch Development
– Treatment initiated approximately 6 months after
the maxillary arch.
– Lower anterior brac...
• Coordination of the Arches
– Both the maxillary and mandibular arch forms are
established by using the Alexander Archfor...
• Elastics
– Elastics are used to further coordinate the arches.
– No elastics should be used until finishing arch wires a...
• Retention
– Retention for vertically deficient patients is similar to
that of other patients except that a bite plate is...
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A typical treatment sequence for a Class II
division 1 case with a 5-8mm discrepancy in the
mandibular anterior arch is de...
• Maxillary Arch :
– After the extraction of the four premolars, separators are left in
place for two weeks to create adeq...
• Four to five weeks later an .016" stainless steel round wire is
placed, usually with omega stops 1-2mm anterior to the m...
•

Reasons for separate canine retraction :
1. less posterior anchorage is lost because fewer
teeth are being retracted, a...
• After maxillary canines have been retracted on the
.016" round wire with the power chain, an .018"
x .025" stainless ste...
• After all maxillary spaces are closed, the fourth
and final archwire is placed. This .017"x .025"
stainless steel wire i...
• Mandibular Arch :
– Treatment in mandible is begun after 6-8 months into active
treatment.
– The advantages of delay in ...
• As the maxillary spaces are closed and the canines are
in a Class I relationship, the mandibular arch is
banded/bonded w...
• The omega stops are not used if only a small amount of
extraction space remains that can be closed with a power chain
st...
• During this period, the amount of extraoral force used depends
on the molar relationship. In a severe Class II, active h...
• Detailed finishing takes three to six months.
• Rotations are tied and the wings on the Lang or
Lewis brackets are activ...
• Elastic Wear :
• Class III elastics are often worn early in treatment either
to correct an anterior crossbite or to prev...
• Midline correction is achieved after all spaces are closed
and final archwires are in place. A midline elastic,
connecte...
• ELASTIC SIZES

•
•
•
•
•
•

Class II
Midline
Class lIl
Up-and-down
Crossbite
Finishing

1/4"
1/4"
1/4"
1/4"
3/16"
3/4"

...
• Palatal and Lingual Arches
– Normally not used because of the use of face bow thru-out the
treatment.
– Palatally, two d...
• In the mandibular arch a lingual holding appliance
is used to preserve the "E" space when needed.
This occurs in nonextr...
www.indiandentalacademy.com
The problem of retention must be solved during
treatment or it will not be solved at all.
Dr. Fred Schudy

www.indiandenta...
• Treatment goals are the same today as they were when
Tweed a wrote them in 1955.
– Pleasing balance and harmony of facia...
• Certain criteria must be met before the patient is ready
for retention. These criteria include :
• Ideal occlusion –Cusp...
– Original lower intercuspid width must be maintained. Expanded
lower cuspids typically constrict after removal of retenti...
• The Countdown to Retention :
– When all the goals of the optimally treated patient are met
and fixed appliance removal t...
Preformed wraparound retainer wire.
www.indiandentalacademy.com
"C" clasp not touching distolingual
cusp of second molar.

Maxillary retainer ready for deliver},.

www.indiandentalacadem...
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Varisimplex2 /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.


Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
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Varisimplex2 /certified fixed orthodontic courses by Indian dental academy

  1. 1. www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Contents • The Principles of the Alexander Discipline • Vari-Simplex Appliance Design & Construction • Non-Extraction Treatment • Face Bow Correction of Skeletal Class II Discrepancies in the Alexander Discipline • The Orthodontic Management of Vertical Deficiencies • Extraction Treatment • Finishing & Detailing www.indiandentalacademy.com
  4. 4. "Nothing is really new. We only rediscover for ourselves." ……..Socrates www.indiandentalacademy.com
  5. 5. Introduction • It grew out of the Tweed Technique, and today maintains many of its principles. The present technique incorporates ideas found from other teachings and techniques, and much was gained from trial and error. • Its originality has grown from many proven ideas and concepts that have been put together in a unique package “The Alexander Discipline” www.indiandentalacademy.com
  6. 6. Salient features • The specifics that make this technique different include: A unique bracket selection with specific designs created for specific teeth. Increased inter-bracket space is created from single brackets to allow more flexibility with stiffer arch wires, resulting in easier engagement and fewer arch wire changes, and Rotational wings give controlled guidance and direction to the teeth. Arch forms have been developed that fit most patients within one standard deviation. www.indiandentalacademy.com
  7. 7. Treat one arch at a time, beginning in the upper arch; in extraction cases treat the upper arch while allowing the crowded mandibular arch to "drift" before placing appliances (driftodontics). Use is made of a cervical face bow to a tied-back arch wire to create an orthopedic response in normal and low-angle skeletal Class II cases. Control lower incisor flaring by -5 ° torque in the incisor brackets and placing an initial rectangular flexible arch wire. Upright the lower first molars with -6 ° tip. Spread lower anterior roots with specific angulated brackets. www.indiandentalacademy.com
  8. 8. Successfully level lower arches by using a reverse curve in the arch wire employing the specific prescription. Attach Class II and Class III elastics on lateral incisors rather than on cuspids to produce a more horizontal vector of force on the arches. Specific arch wire sectioning and elastic attachments finalize posterior occlusion, and by using a unique maxillary wraparound retainer wire design, post-treatment settling is controlled. www.indiandentalacademy.com
  9. 9. www.indiandentalacademy.com
  10. 10. • The treatment philosophy retains three fundamentals of the Tweed technique: 1. Anchorage preparation (uprighting mandibular first molars) 2. Positioning of mandibular incisors over basal bone 3. Orthopedic alteration with headgear • Diagnosis and Treatment Planning :  Case diagnosis is generally reduced to two steps: • • determine the desired position of the mandibular incisors, and then determine the treatment needed to position the maxilla and maxillary dentition over the desired mandibular arch position. www.indiandentalacademy.com
  11. 11. • The object of treatment is to position the mandibular teeth within the mandibular trough, with four goals in mind : 1. 2. 3. 4. • Incisors upright over basal bone Cuspids not expanded Curve of Spee level Nonextraction therapy whenever possible In most cases, in the author's opinion, the best and most stable position for lower incisors is the position in which the patient presents. To keep lower incisors in their original positions is often the treatment goal. www.indiandentalacademy.com
  12. 12. • In extraction cases, lower incisors are almost always kept up righted. • According to the author, lower incisors can be advanced up to 3 ° and remain stable. Beyond that degree, instability is more likely. • The only time the lower incisors are advanced beyond this degree is when they are abnormally retroclined, a situation commonly seen in Class II, Division 2, and Class II, Division 1 deep-bite cases. Richard G. Alexander (Semin Orthod 2001;7:62-66) www.indiandentalacademy.com
  13. 13. • Others factors affecting diagnosis: • Age of the patient • Diagnostic records taken like the intra-oral x-rays, models, cephalograms, photographs, etc • Facial, Skeletal, Dental tissues should be evaluated in all three dimensions i.e. vertical, transverse, and sagittal. • Dentally, the key to sagittal control is the position of the mandibular incisors. In this discipline their position is determined by the A-Po line, the Holdaway ratio, and IMPA (relationship of mandibular incisor to mandibular plane). • The decision to extract or not to extract obviously affects the position of these teeth and, therefore, it is the most important decision made by the orthodontist. www.indiandentalacademy.com
  14. 14. • Certain factors observed in the patient himself : • Palpation of the temporomandibular joint while the patient is opening and closing his jaw. • Patient's gingival health is described in words from observation and, sometimes, from probing • Tendency for tongue thrusting. • Laminagraphic x-rays are taken on every patient who exhibits abnormal TMJ function. • Treatment of a tongue thrust is to first make the patient and parent aware of the problem, then to give the patient simple instructions in proper swallowing. www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16. • The most important factors in determining the design of the Vari-Simplex Discipline are the size and shape of the teeth, especially the mesiodistal width and curvature. • These affect inter-bracket width, which, in turn, affects the ability to rotate the teeth and level the arches. So, in some instances, the optimal bracket design was a single bracket with wings and, in other situations, a twin bracket design was most advantageous. • Another major factor is the accessibility of the tooth and whether it is located in a curved or straight area of the arch. • Finally, the design must take into account patient comfort and the frequency of bracket wing breakage. www.indiandentalacademy.com
  17. 17. • The system evolved around five factors related to brackets: – – – – – bracket selection, bracket height, bracket angulation, bracket torque, and bracket in-out. www.indiandentalacademy.com
  18. 18. Advantages of the Alexander Discipline Bracket System • Bracket selection : – The system is composed of a no. of brackets designs. By creating a variation (hence Vari-) in types of brackets selected, the advantages of each design are used in a singleslot (0.018" X 0.025") design. Frontal view showing bracket selection. Lateral view showing bracket selection. www.indiandentalacademy.com
  19. 19. • Interbracket space: – Using single brackets with wings in the lower anterior and buccal segments allows maximal inter-bracket distance. – This, along with the newer Maxillary occlusal view showing interbracket space and rotational wings. metals available, enables the practitioner to engage stiffer (larger) wires faster, which allows for faster leveling, less discomfort, and improved torque control. This also allows the orthodontist to get into their Mandibular occlusal view showing interfinal arch wires faster. www.indiandentalacademy.com bracket space and rotational wings.
  20. 20. • Rotational control: – Rotation wings on cuspids, bicuspids, and lower anteriors provide for improved rotational control and individual activation of particularly involved teeth. – In those situations in which a single tooth does not respond to conventional mechanics, individual forces can be applied by activating, deactivating, or removing individual wings. www.indiandentalacademy.com
  21. 21. • Torque: – Each bracket has a 0.018 × 0.025 inch wire slot. Slot sizes do not vary from anterior to posterior brackets and, realizing that 5 ° of torque is lost for each 0.001-inch "play" in the slot, final ideal wires (0.017" × 0.025") are constructed to fill the slot as much as possible. www.indiandentalacademy.com
  22. 22. • Lower incisor torque: – (- 5 °) torque is incorporated into lower incisor brackets. • This allows for more efficient control of these teeth during the leveling process • Sets up anterior anchorage in those situations where the mandibular posterior teeth are to be protracted in the correction of Class II malocclusions. • The - 5 ° torque also aids in ideally maintaining the position of these teeth over the mandibular basal bone. – The use of a flexible rectangular arch wire in the lower arch is recommended as soon as possible to optimally control torque in this critical area. www.indiandentalacademy.com
  23. 23. • Lower first molar tip: – The mandibular first molar is also constructed to have a - 6 ° tip incorporated into its design. – This is essential in establishing posterior anchorage in Alexander cases. – This allows the mesial aspect of mandibular molars to be up righted, which, in turn, incorporates leveling mechanics with attention to anchorage demands. www.indiandentalacademy.com
  24. 24. – The - 6 ° tip of the molar bands also positively contributes to a non-extraction philosophy in that it allows distal movement of the molar crowns, which can create additional arch length where needed. – Band placement is also critical on the first molar. • For a typical case the band must be placed, as always, with the occlusal margin of the band parallel with the occlusal surface of the molar at the marginal ridges. • In open bite situations, care must be given to tip the distal aspect of the band gingivally so that the mesial cusp is not supera-erupted and the distal aspect is supported, which minimizes the bite opening effect of the - 6 ° tip of the bracket placement. www.indiandentalacademy.com
  25. 25. Bracket Selection • Twin Brackets: – Used on large, flat-surfaced teeth (namely, maxillary central and lateral incisors). – The flat surfaces of these teeth permit full arch wire engagement in the twin brackets. – There is little trouble tying the wire into these brackets because of their ease of accessibility, and Diamond Twin Brackets www.indiandentalacademy.com
  26. 26. • Ball hooks for elastic placement are usually placed on lateral incisor brackets. • The brackets allow for 5 to 6 mm of inter-bracket width, which is sufficient for flexibility, rotational control, and torquing. • Also, these brackets are smooth and minimize irritation on labial tissues Twin Brackets are Convenient for Ligating Teeth Together & Placing Hooks www.indiandentalacademy.com
  27. 27. • Lang Brackets: – Originally developed by Dr. Howard Lang. – Used on large, roundsurfaced teeth at the corners of the arch i.e. maxillary & mandibular cuspids. – The pad is contoured, which fits on most cuspids. www.indiandentalacademy.com
  28. 28. – The straight wing eliminates interference with complete arch wire engagement. Thus, the bracket is easily ligated and inter-bracket width is maximized. – The wings can easily be activated for rotational control. Lewis Lang When a Lewis or Steiner Bracket is completely tied into a cuspid, there is a tendency to flatten the curvature of the archwire. A Lang bracket avoids this www.indiandentalacademy.com effect, while retaining the rotation wing capability.
  29. 29. • Twin brackets on cuspids are not the brackets of choice because: – They decrease the inter-bracket width, making it more difficult to ligate & control rotations. – It is often impossible to get full- bracket engagement on these teeth early in treatment and, – They can interfere with opposing cusps on occlusion (actually often causing cusp attrition). www.indiandentalacademy.com
  30. 30. • Lewis Brackets: – Used on round-surfaced teeth not located at the corners of the arches (maxillary and mandibular bicuspids) as well as small, flat-surfaced teeth (mandibular incisors). – The Lewis bracket is a fixed-wing single bracket that again contributes positively to the concept of increased inter-bracket width. The wings provide a distinct advantage in having a built-in auxiliary for rotational control, much in the same fashion as those on the Lang brackets. www.indiandentalacademy.com Lewis Brackets
  31. 31. • The design of the bracket is wedge shaped which puts the tie wing closer to the tooth occlusally and far out gingivally – – – – This makes it easy to tie To use as hooks for elastics To keep clean and Often in this technique, up & down elastics on posterior teeth are used for settling, and this wedge shape is excellent for that purpose. www.indiandentalacademy.com
  32. 32. An additional benefit offered by the single bracket with wings is that, on a tooth that is badly rotated, the wing in the direction of the rotation can be removed. The bracket can then be positioned properly, with the remaining wing serving to rotate the tooth into proper position www.indiandentalacademy.com
  33. 33. • Molar bands: – Twin brackets with convertible sheaths are used on the first molars. – Headgear tubes are used on the maxillary molars and are manufactured to be on the occlusal aspect of the band. The latter allows for superior hygiene and accessibly for headgear where indicated. www.indiandentalacademy.com
  34. 34. – The mandibular first molar bands can be constructed with convertible arch wire tubes and lip bumper tubes (if necessary) placed on the gingival aspect of the bracket. This allows the convertibility of the tubes as well as allowing for the placement of lip bumpers in indicated situations. – Single buccal tubes are used on both mandibular and maxillary second molar teeth. – Elastic hooks are located on all first and second molar brackets, and also as distal offsets used for tying back arch wires. – Lingual elastilugs are placed on all molar bands. www.indiandentalacademy.com
  35. 35. Specifications of the Appliance • Bracket Height : – Bracket height in this Discipline, as in any other technique, is extremely important in the construction of the appliance. – Bicuspid bracket height (x) is the key because of its clinical crown height is so variable. – Other bracket heights are calculated in relation to x www.indiandentalacademy.com
  36. 36. Maxillary Arch Mandibular Arch Centrals X Centrals X – 0.5mm Laterals X – 0.5mm Laterals X – 0.5mm Cuspids X + 0.5mm Cuspids X + 0.5mm Bicuspids X Bicuspids 1st Molars X – 0.5mm 2nd Molars X – 1.0mm 1st Molars www.indiandentalacademy.com X X – 0.5mm
  37. 37. Special Considerations in Appliance Construction • Deep Bite Cases : – The true Alexander Discipline dictates that the maxillary arch have appliances placed first, with the mandibular arch having appliances placed when an adequate bite opening has been achieved in order to prevent bracket interference. – However, in some instances, particularly in adult patients, reverse curve wires alone are not sufficient to adequately open the bite. In these situations, the use of a maxillary bite plate is strongly recommended. www.indiandentalacademy.com
  38. 38. • The bite plate allows immediate placement of mandibular appliances and also hastens bite opening by allowing simultaneous molar-bicuspid eruption along with incisor intrusion. • A bite plate can also be used on those patients in whom early initial treatment of the mandibular arch is desired. www.indiandentalacademy.com
  39. 39. • Open Bite Cases : – Special bracket placement of anterior brackets in an exaggeratedly gingival fashion and more occlusal placement of posterior brackets is indicated. – Additional placement of vertical elastics also contributes to open-bite closure. – Mandibular first molars should be placed with the distal aspect seated more gingivally to offset the -6° tip incorporated into the band. This prevents the mesial cusp from supra-erupting, which would be counterproductive in an attempt to close the bite. www.indiandentalacademy.com
  40. 40. • Extraction Cases : – The bicuspid brackets adjacent to the extraction sites should be tipped so that the roots of the teeth are up righted toward the extraction area allowing for improved parallelism with resulting easier retraction of the cuspids. – In molar protraction situations the - 6 ° tip of the molar band is extremely advantageous during the process in that the mesial aspect of the tooth is not "dumped" in a mesial fashion during protraction; hence, ideal uprighting can be facilitated. www.indiandentalacademy.com
  41. 41. • Bracket Angulation : • To allow the roots to be properly positioned at the end of the treatment, care is taken during the bracket placement to ensure that the brackets are placed parallel to the long axis of the clinical crowns. • BRACKET ANGULATIONS Maxillary Arch Banding (Incisal edge Reference) Centrals Laterals Cuspids Bicuspids and Molars Mandibular Arch Banding (Incisal edge Reference) Bonding (Long axis Reference) 3° 6° 6° 5° 8° 10° 0° 0° Centrals Laterals Cuspids Bicuspids 1st Molars 2nd Molars www.indiandentalacademy.com 2° 2° 6° 0° – 6° 0° Bonding (Long axis Reference) 2° 2° 6° 0° – 6° 0°
  42. 42. • Mesiodistal Position : • On flat-surfaced teeth, the bracket should be placed in the center of the clinical crown. • The bracket is placed at the height of the contour on all roundsurfaced teeth. • The molar tubes are placed so that the mesial end of the tube is placed parallel to the mesio-buccal cup of the molar www.indiandentalacademy.com
  43. 43. • Bracket Torques: – The torque prescriptions used in this technique are derived from measurement of the torques in the rectangular archwires used to finish well treated orthodontic cases. BRACKET TORQUES Mandibular Arch Maxillary Arch Centrals Laterals Cuspids Bicuspids Molars 14° 7° – 3° – 7° – 10° Incisors Cuspids 1st Bicuspids 2nd Bicuspids 1st Molars 2nd Molars www.indiandentalacademy.com – 5° – 7° – 11° – 17° – 22° 0° or – 27°
  44. 44. • These measurements differ from commonly used torques in three major respects: • The -3º torque on the max cuspids compared to extremes of +7º to -7º in other appliances, eliminates the need for adjusting the torque later in the treatment. • No torque is placed in the mandibular second molar tubes, because of the use of omega stops, which are always bent out to avoid impingement on gingival tissue & to avoid food trap. This automatically incorporates torque in the wire • -5 º of lingual crown torque or labial root torque in the mandibular incisors. www.indiandentalacademy.com
  45. 45. www.indiandentalacademy.com
  46. 46. • In Alexander’s discipline a typical non-extraction treatment, begins with the maxillary arch. • The incisors, cuspids, and first bicuspids are bonded, and the second bicuspids and first molars are banded. Second molars are banded near the end of treatment only if they are in poor position. • Initially round, multistranded archwires are placed, because maxillary torque control is not critical at this stage. • Two weeks later a facebow, which he calls – the retractor- is given to the patient. • At the third appointment, usually four or five weeks later, www.indiandentalacademy.com rotations are tied, and the retractor is adjusted.
  47. 47. • Soon an .016" round wire with omega stops mesial to the terminal tubes is placed, so that the archwire can be tied back. • This wire further eliminates rotations and continues leveling the arch. • If the case involves a closed bite, enough excess curve of Spee is placed in the archwire to enhance the opening of the bite. www.indiandentalacademy.com
  48. 48. • Purpose of tying back the archwire : • To consolidate the arch, so that the extra-oral forces act orthopedically instead of dentally; and intra-oral elastic forces act on the arch and not on individual teeth. • A consolidated arch eliminates the need to ligate teeth together or to solder hooks to the archwire. • The omega stop, placed 1-2mm mesial to the buccal tube, enables placement of an active tieback force on the archwire. – This can close small spaces that could have developed if the elastic hook were placed on the bracket. www.indiandentalacademy.com
  49. 49. • All spaces should be closed while the .016" archwire is in place. In addition to tying back, power chains can be used from molar to molar to close all spaces. • After all rotations & spacing have been corrected, an .017" x . 025" rectangular stainless steel finishing archwire is placed. • f the bite is still closed at this stage, a bite plate is used so that the mandibular anteriors occlude on the bite plate and free the occlusion • This improves the effectiveness of the maxillary arch wire • Allows the posterior teeth to erupt into a more level occlusion • The pressure of the mandibular anterior teeth on the bite plate will tend to depress them. This will begin to open the bite and level the mandibular arch before it is bonded and banded. www.indiandentalacademy.com
  50. 50. Mandibular Arch • Bonding/banding the mandibular arch is delayed for the following reasons: 1. It will avoid interference of mandibular brackets with maxillary teeth. 2. As the maxillary arch improves, the mandibular curve of Spee improves naturally. 3. If a bite plate is needed, it fits better and is more comfortable after the maxillary arch has been properly aligned. 4. Total time needed to treat the mandibular arch is 6-9 months. 5. It allows more time for the mandibular second molars to www.indiandentalacademy.com erupt.
  51. 51. • The mandibular arch is the key to non-extraction treatment with the Vari-Simplex Discipline and therefore, holding the lower incisors in place is very important. • This is achieved by : 1. A -5° torque on the mandibular incisors that resists anterior flaring of these teeth. 2. Bonding, which eliminates the need for interproximal band space. 3. The use of .017" x .025" D-Rect multistranded, braided archwire which permits torque control in the anterior segment with the initial archwire. 4. A -6° tip on the mandibular first molars which allows distal movement of the molar crowns, which can create additional arch length. 5. Selective inter-proximal enamel reduction. www.indiandentalacademy.com
  52. 52. • Cases wherein crowding of the mandibular arch prevents unraveling and uprighting of the lower anteriors— despite the five factors listed above—Class III mechanics should be considered. • If Class III elastics are used, they must be initiated at the time of the placement of the first wire. • This wire must be round and multistranded because of the excessive anterior crowding. • Without Class III mechanics, the mandibular anteriors will advance labially. A combination of the distal force from the Class III elastics and the uprighting tip on the mandibular first molars will control this advancement. • The angulation of the -6° tip built into the first molars creates an uprighting force, serving the same purpose as a tipback bend. Together with Class III elastics, this allows the first molars to upright farther distally, creating additional arch length and allowing the anterior discrepancy to unravel with little or no advancement. www.indiandentalacademy.com
  53. 53. • However, the extrusive effect of the Class III elastics on the max molars should be given due consideration, especially in open bite or high angle cases. • A high-pull force is added to the face-bow during Class III mechanics to prevent molar extrusion. The high-pull force should, however, be initiated before placement of the first mandibular wire. • Cases with severe discrepancy, slenderization is carried out. • The D-Rect wire is left in place for 2-4 months. However, if all rotations cannot be eliminated,.017" x .025" D-Rect wire may be followed with an .016" x .022" TMA or stainless steel archwire. www.indiandentalacademy.com
  54. 54. • The next wire is an .017" x .025" stainless steel finishing archwire. If additional leveling is needed, a reverse curve of Spee is placed in this final archwire. • With finishing archwires in both the arches, and extra-oral forces continued thru-out, Class I molar relationship should have been achieved. • For final detailing, Class II elastics may be added, if necessary, until normal centric relation is achieved. • Note that Class II mechanics are not initiated until finishing archwires are in place. www.indiandentalacademy.com
  55. 55. • Premature use of Class II elastics can cause • • • • loss of torque control, bite closure, tipping of the occlusal plane, and a false bite. • To correct a midline shift, a midline elastic with a Class II elastic on one side and/or a Class III elastic on the other will help shift the arches into their final positions. • Up-and-down elastics may be used to correct any open bite, or for overcorrection. • Occasionally, one may need crossbite elastics on the posterior teeth to achieve the normal buccal overjet. www.indiandentalacademy.com
  56. 56. www.indiandentalacademy.com
  57. 57. Brief History • Alexander’s interest in the orthopedic forces developed from the study of the effects of the Milwaukee Brace on scoliosis patients. • During this same time, the Kloehnn headgear was gaining popularity in distalizing maxillary first molars. • One of the negative side effects of the Kloehnn headgear was the tipping and extrusion of the molars, causing an opening of the mandible plane angle. www.indiandentalacademy.com
  58. 58. • In an attempt to prevent this undesirable effect, Alexander advocated a continuous upper arch wire to prevent molar tipping while adding tied-back omega loops to reduce their extrusion and keep the arch consolidated • Although this approach prevented the distal movement of the maxillary first molars, another effect was observed: – Results from patients wearing the cervical face bow with the tiedback arch wires indicated that very little maxillary distal movement took place, however, the Class II skeletal problem was being corrected by the forward movement or growth of the mandible. • This effect has been widely recognized and used in the treatment of patients. www.indiandentalacademy.com
  59. 59. Effects On the Three Dimensions • Sagittal Dimension – The Class II sagittal discrepancy can be positively affected by the cervical face bow. – In a growing patient requiring a Class II skeletal correction, the face bow can be used to modify the skeletal development by inhibiting anteriorly directed maxillary growth. – The result is an expression of the genetic potential for mandibular growth and skeletal correction of the Class II skeletal discrepancy. www.indiandentalacademy.com
  60. 60. • Vertical Dimension : – The goal of the combination and high pull face bow is to maintain the vertical relationship of the maxillary posterior teeth and modify maxillary skeletal growth by inhibiting vertical maxillary development. – The vertical relationship can often be difficult to control during orthodontic tooth movement, however, it is imperative that this be done. – In general : • When the mandibular plane angle, (SN-MP), is 36 ° to 41° then a combination headgear is used, but when SNMP is greater than 42 °, a high-pull facebow is recommended to control maxillary molar vertical www.indiandentalacademy.com position.
  61. 61. • Transverse Dimension : – Developing or maintaining the maxillary transverse dimension is accomplished with the inner bow of the face bow. – The inner bow is routinely expanded 3 to 4 mm when a cervical or combination headgear is being used for Class II correction. – Face bows can also be used to hold cross bite corrections. www.indiandentalacademy.com Inner bow expansion.
  62. 62. Advantages of Face Bow Therapy • It places only a distal force on the maxilla without any undesired mesial effects. • No negative affect on the maxillary and mandibular incisor torque, as seen in other intra-oral appliances like Herbst, Jasper Jumper, etc. • The face bow is cost effective and is easy to fit and adjust. • Does not adversely affect speech. • The authors also believe that there is no relapse with successful face bow therapy because it does not posture the mandible forward, the latter which may result in relapse resulting from the muscular action. Correction is accomplished by the forward growth of the mandible, when the headgear is appropriately www.indiandentalacademy.com used, and favorable growth occurs.
  63. 63. Face Bow Adjustment • For mesio-lingually rotated 1st molars, the inner bow can be adjusted over a period of 6 months to effect de-rotation of the molar. • In the cervical or combination face bow, the innerbow and outerbow are adjusted to be parallel to the occlusal plane • This important adjustment allows the forces to be effective sagittally while not causing undesirable vertical forces to the molars. Outerbow parallel to innerbow, both parallel to occlusal plane. www.indiandentalacademy.com
  64. 64. • When the high-pull face bow is considered necessary in the treatment of the patient, the outerbow is bent in such a fashion as to direct the forces in a more vertical fashion (eg, 45 ° to the occlusal plane). High-pull face bow with special adjustment to outerbows. www.indiandentalacademy.com
  65. 65. Treatment Time • Depending on the diagnosis, the patient will wear the retractor 8-14 hours per day. • As a general rule, – if the patient's ANB is 5° or more, the retractor is worn 14 or more hours a day. – If the ANB is 3-5°, retractor wear can be reduced to 12 hours. – If the ANB is less than 3°, the retractor is worn at night only, 8 hours a day. www.indiandentalacademy.com
  66. 66. Keys to Optimal Face Bow Results • Cooperation: – The face bow should be worn consistently. Eight to 10 hours every night is usually adequate. In extreme antero-posterior and vertical discrepancies, more wear can be beneficial. • Growth: – If the patient is not growing, no skeletal changes will occur. • Tie back on continuous arch wire: – If the upper arch wire is not consolidated into one unit, the face bow will individually tip molars distally, resulting in the loss of effective anterior growth expression of the mandible and possible extrusion of upper molars. www.indiandentalacademy.com
  67. 67. www.indiandentalacademy.com
  68. 68. Lower anterior vertical facial deficiencies are often accompanied by over-eruption of anterior teeth and under-eruption of posterior teeth. The result is an excessive curve of Spee in the mandibular arch and a reverse curve in the maxillary arch. This presents as an abnormally increased overbite. The freeway space in such cases is often excessive. www.indiandentalacademy.com
  69. 69. Principles in the Treatment of Vertical Deficiencies • Three modalities – intruding the anterior teeth, – extruding the posterior teeth, or – a combination of the two. • Factors of special importance in Alexander’s philosophy include the final position of the lower incisors. • It is considered most important by advocates of this orthodontic approach to avoid the advancement of the lower anteriors. • The one exception to this rule, however, is in the deepbite patient where the incisors are excessively upright. Increasing anterior torque in both arches is necessary to achieve a normal interincisal angle. www.indiandentalacademy.com
  70. 70. • Most deep bite cases can be treated non-extraction • In cases of moderate crowding, consider • Inter-proximal enamel reduction • For minor crowding in Class II patients, extraction of maxillary bicuspid teeth only may be appropriate. • Extraction of a single mandibular incisor in a severe, lower arch length, discrepancy situation could also be a consideration. www.indiandentalacademy.com
  71. 71. • Maxillary Arch Development – Accomplished by eliminating rotations, closing spaces, accentuating the curve of Spee, and establishing proper torque in the anterior teeth. • Maxillary Bracket Height – In some cases, the maxillary six anterior brackets are placed 0.5-mm more incisally and the posterior brackets are placed 0.5-mm more gingivally. www.indiandentalacademy.com
  72. 72. • Curve of Spee – After the initial arch wire, an accentuated curve of Spee is placed to open the bite – The curve should be placed in the arch wire from mesial to the Omega loop forward to the cuspid area and not beyond. – In the flexible wires (0.016 stainless steel [ss], titanium molybdenum alloy) excessive curve can be placed to encourage bite opening. www.indiandentalacademy.com
  73. 73. • When determining the amount of curve to place in the arch wire, it is important to look at the patient's "smile line." • If the incision-stomion measurement does not show a full clinical crown, then great care must be taken with the amount of curve placed in the arch wire. • When gingival tissue is exposed when smiling, more curve can be placed in the arch wire. • The arch wire is "toed in" slighdy distal to the omega loop to help rotate and control the first molars. • All ss wires are tempered (heat-treated) before inserting. • After the initial wire, all arch wires are tied back by using omega loops. www.indiandentalacademy.com
  74. 74. • Bite Plate – If the bite has not opened adequately after a few months of treatment in the finishing arch wires, a bite plate is placed. – It is not placed until the maxillary arch form is close to completion, usually the month before the lower brackets are placed. – By delaying bite plate placement, fewer bite plate adjustments are needed. – The bite plate is adjusted so that the upper teeth do not touch the lower brackets on closure. – In some cases, special lingual brackets can be bonded to upper incisors to achieve the same bite opening result. www.indiandentalacademy.com
  75. 75. • Mandibular Arch Development – Treatment initiated approximately 6 months after the maxillary arch. – Lower anterior brackets must not be placed more incisally than is usual because this would result in premature con tact with the maxillary incisors when occluding. – Torque control should be maintained from the beginning. www.indiandentalacademy.com
  76. 76. • Coordination of the Arches – Both the maxillary and mandibular arch forms are established by using the Alexander Archform Template – The maxillary first molars have been derotated and mandibular second molars have been constricted, and curves of Spee placed in the arch wires to level the arches. – If the overbite is not opening adequately, the arch wire may be removed after 2 to 4 months for recontouring and/or increasing the amount of curve in it. www.indiandentalacademy.com
  77. 77. • Elastics – Elastics are used to further coordinate the arches. – No elastics should be used until finishing arch wires are in place. – To help level the mandibular arch, box elastics can be used in the bicuspid area. – Class II and midline elastics are used after the overbite approximates normal if the headgear has not resolved the Class II condition. – Finishing elastics are used to finalize the posterior occlusion for long-term stability www.indiandentalacademy.com
  78. 78. • Retention – Retention for vertically deficient patients is similar to that of other patients except that a bite plate is placed on the maxillary retainer and is adjusted so that the posterior teeth are just out of occlusion. – The patient sleeps in the retainer for 2 to 3 years. – The mandibular cuspid-to-cuspid bonded 0.0215 multistranded wire can be worn indefinitely. www.indiandentalacademy.com
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  80. 80. A typical treatment sequence for a Class II division 1 case with a 5-8mm discrepancy in the mandibular anterior arch is described. www.indiandentalacademy.com
  81. 81. • Maxillary Arch : – After the extraction of the four premolars, separators are left in place for two weeks to create adequate space and to allow initial discomfort and soreness of the teeth to dissipate. – The initial archwire— .0175" Respond or .017" x .025" DRect braided wire. – Except in a Class III or bimaxillary protrusion maximum anchorage case, where the mandibular incisors are protrusive and the canines are Class I, we will begin treatment in the maxillary arch and allow the mandibular arch to drift (driftodontics) for six to eight months. – By the time the mandibular arch is ready for bonding and banding, the anteriors will have unraveled by themselves and the mandibular second molars will often have erupted enough www.indiandentalacademy.com for banding.
  82. 82. • Four to five weeks later an .016" stainless steel round wire is placed, usually with omega stops 1-2mm anterior to the molar tubes and canine retraction started. Canine ligation should be done properly to avoid rotation & tipping of the canine. • Face bow is adjusted to ensure adequate anchorage. • In a closed bite case (overbite greater than 3mm), treatment of the mandibular arch is begun as soon as the canines are Class I, to help open the anterior bite. • If the bite is not closed, canine retraction is completed (canines touching second premolars) and incisor retraction is initiated prior to proceeding to the mandibular arch. www.indiandentalacademy.com
  83. 83. • Reasons for separate canine retraction : 1. less posterior anchorage is lost because fewer teeth are being retracted, and, since it's early in treatment, the patient will be more cooperative in wearing his extraoral appliance; 2. by obtaining a Class I canine relationship before the mandibular arch is banded there is no concern for cuspal interference, loose bonds on the mandibular canine, or attrition of the maxillary canine cusp tip; and 3. after canines have been retracted, torque on the maxillary incisors is more easily controlled during their retraction. www.indiandentalacademy.com
  84. 84. • After maxillary canines have been retracted on the .016" round wire with the power chain, an .018" x .025" stainless steel closing-loop archwire is placed for incisor retraction. • This archwire is bent in an ideal arch form with large, teardrop-shaped loops just distal to the maxillary twin lateral bracket. Omega stops are not used, but the wire extends through the first molar tubes and the archwire distal to the closing loops is reduced approximately .001" in the anodic polisher, so that part of the wire can slide through the brackets easily during activation. www.indiandentalacademy.com
  85. 85. • After all maxillary spaces are closed, the fourth and final archwire is placed. This .017"x .025" stainless steel wire is bent with ideal arch form and omega stops and may or may not incorporate an accentuated curve of Spee, depending upon the overbite. www.indiandentalacademy.com
  86. 86. • Mandibular Arch : – Treatment in mandible is begun after 6-8 months into active treatment. – The advantages of delay in banding the mandibular arch in extraction cases are that: • it allows physiological drifting of crowded mandibular anterior teeth, • little posterior anchorage is lost since maxillary molars are being held distally, • while retracting maxillary canines there is no interference and/or attrition on the cusp tips from the mandibular canine brackets, • it allows additional time for the second molars to erupt more fully, and • total time needed to complete mandibular arch treatment is 912 months. www.indiandentalacademy.com
  87. 87. • As the maxillary spaces are closed and the canines are in a Class I relationship, the mandibular arch is banded/bonded with an .017" ´ .025" D-Rect rectangular braided archwire or an .0175" Respond multistranded wire • Next an .016" round stainless steel wire with omega stops 1-2mm anterior to the second molar tubes is used to eliminate rotations, and level the curve of spee. www.indiandentalacademy.com
  88. 88. • The omega stops are not used if only a small amount of extraction space remains that can be closed with a power chain stretched from molar to molar. • If there is too much space to close with a power chain, an .016" x .022" stainless steel rectangular closing-loop archwire is used. • A Bull loop is placed in the extraction site, and omega stops are placed at the distal of the twin brackets on the first molars. • Care must be taken to avoid overactivation of this closing loop, which will cause dumping of the mandibular arch. • If the mandibular arch has a deep curve of Spee, a gable bend is placed at the closing loop. • Space closure takes from two to six months, depending on the amount of space to be closed. www.indiandentalacademy.com
  89. 89. • During this period, the amount of extraoral force used depends on the molar relationship. In a severe Class II, active headgear force for 14 or more hours a day is needed; in a Class I, only night wear is required to hold the maxillary molars in position. • After spaces have been closed in the mandibular arch, the fourth and final archwire is placed— an .017" x .025" stainless steel ideal arch with omega stops 1-2mm anterior to the second molar tubes. • If the arch is not adequately level after one or two months, this archwire is removed, a reverse curve of Spee is placed, and the archwire is retied, being sure it is tied back. www.indiandentalacademy.com
  90. 90. • Detailed finishing takes three to six months. • Rotations are tied and the wings on the Lang or Lewis brackets are activated to finalize rotations. • Midline, Class II, or Class III corrections are made with elastics. www.indiandentalacademy.com
  91. 91. • Elastic Wear : • Class III elastics are often worn early in treatment either to correct an anterior crossbite or to prevent advancement of the mandibular incisors during the initial elimination of rotations in nonextraction treatment. • Class II elastics are rarely worn until both arches have rectangular archwires. Early indiscriminate use of Class IIs can cause loss of anterior torque control, rotation of the occlusal plane, and a deepening of the bite. • Normally, Class II elastics are worn during the last few months of treatment, when both arches have finishing www.indiandentalacademy.com archwires.
  92. 92. • Midline correction is achieved after all spaces are closed and final archwires are in place. A midline elastic, connected from a maxillary lateral to the opposite mandibular lateral, is worn in conjunction with a Class II or Class III elastic to achieve the desired correction. • Crossbite elastics are worn as early as possible, so that the correction can be maintained during treatment. Lingual lugs are placed on all molar bands for this purpose. • Special elastics are worn during the finishing stages of treatment. Anterior and posterior up-and-down elastics are worn to finalize the cuspal interdigitation and overbite. www.indiandentalacademy.com
  93. 93. • ELASTIC SIZES • • • • • • Class II Midline Class lIl Up-and-down Crossbite Finishing 1/4" 1/4" 1/4" 1/4" 3/16" 3/4" 6oz 6oz 3– 1/2oz 6oz or 6oz 2oz www.indiandentalacademy.com 3/16" 6oz
  94. 94. • Palatal and Lingual Arches – Normally not used because of the use of face bow thru-out the treatment. – Palatally, two designs are preferred. • The Nance palatal arch, designed with an acrylic button placed in the anterior center portion of the palate, is used in a case with an extreme discrepancy, a Class I molar relationship, and anterior teeth that are in normal positions. The purpose of the Nance is to hold the anterior and posterior teeth in place while the canines drift into their position. • A transpalatal arch with a Goshgarian design is used on all high angle cases. In addition to maintaining the transverse dimension, the TPA can inhibit vertical alveolar growth, which is desperately needed in high angle cases. The arch bar is designed to be removable, so that it can be expanded, constricted, or adjusted to rotate the molars during treatment. www.indiandentalacademy.com
  95. 95. • In the mandibular arch a lingual holding appliance is used to preserve the "E" space when needed. This occurs in nonextraction cases frequently. In extraction cases, it would be used in a maximum anchorage situation with crowding, while waiting for the remaining teeth to erupt. This lingual arch is used specifically as a holding appliance www.indiandentalacademy.com
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  97. 97. The problem of retention must be solved during treatment or it will not be solved at all. Dr. Fred Schudy www.indiandentalacademy.com
  98. 98. • Treatment goals are the same today as they were when Tweed a wrote them in 1955. – Pleasing balance and harmony of facial lines: no lip strain should be present after treatment. Often lip strain is the determining factor in an extraction decision. Facial maturation, facial growth, and treatment changes in nonextraction treatment can correct lip strain, and, of course, are considered. – Correct occlusion. – Healthy tissues. – Long-term stability. www.indiandentalacademy.com
  99. 99. • Certain criteria must be met before the patient is ready for retention. These criteria include : • Ideal occlusion –Cuspid protected, with centric occlusion and centric relation coincident. • Normal overbite and overjet. • Proper artistic positioning. • Spread out incisor roots, especially the lower incisor roots. • Correct torque of the upper incisors to allow for a good interincisal angle. • Lower incisors balanced over basal bone within 3 ° of their original position. When proclined excessively, the lower incisors tend to upright over time. www.indiandentalacademy.com
  100. 100. – Original lower intercuspid width must be maintained. Expanded lower cuspids typically constrict after removal of retention appliances. – Lower first molars should be upright to maintain a leveled mandibular arch and overbite correction. – Habits should have been eliminated. – Midlines should be coincident and correct. – Correct arch form. – Correct curve of Spee and curve of Wilson should be optimal. • In addition, a circumferential supracrestal fiberotomy is performed on all adults with severely rotated teeth 2 months before fixed appliance removal. Removal of hyperplastic tissue in the maxillary central incisor area is also performed where heavy diastemas are present, especially if they are considered to be familial traits. www.indiandentalacademy.com
  101. 101. • The Countdown to Retention : – When all the goals of the optimally treated patient are met and fixed appliance removal time is approaching, four appointments are made with specific objectives for each appointment. • Appointment 1: Sectioning of wires and finishing elastics. • Appointment 2 (3 weeks later): Occlusal check and final adjustments, and possible sectioning of the opposing arch wire and removal of molar bands. • Appointment 3 (3 weeks later) : Fixed appliances removal. • Appointment 4 (2 days later): Seating of the retainers. www.indiandentalacademy.com
  102. 102. Preformed wraparound retainer wire. www.indiandentalacademy.com
  103. 103. "C" clasp not touching distolingual cusp of second molar. Maxillary retainer ready for deliver},. www.indiandentalacademy.com
  104. 104. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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