1. UNIVERSITY OF GLASGOW
Finishing stage
Mohammed Almuzian
1/1/2013
.

2. Mohammed Almuzian, University of Glasgow Page 1
Table of Contents
Key papers ....................................................................................................................................... 3
A. Aesthetic aims......................................................................................................................... 3
a) Extra oral aims:....................................................................................................................... 3
1. Static aims ........................................................................................................................... 3
2. Dynamic smile aims ............................................................................................................ 3
b) Intraoral aims .......................................................................................................................... 3
I. Tooth Size Discrepancies.................................................................................................... 3
II. Gingival Levels ................................................................................................................... 4
Four characteristics contribute to ideal gingival form. .................................................................... 4
To make the correct decision, it is necessary to evaluate 3 criteria................................................. 4
III. Gingival Form.................................................................................................................. 5
I. Levelled Marginal Ridges. .................................................................................................. 5
II. Correct first order bend ....................................................................................................... 5
According to the American Board of Orthodontics (ABO, 1998) (Kokich 2003). ......................... 5
One of the methods to correct rotation is......................................................................................... 6
III. Correct second order bend: this can be done by wire bending or rebonding and
correcting root parallelism............................................................................................................... 6
IV. Correct third order bend: ................................................................................................. 7
The importance of correct teeth inclination are:.............................................................................. 7
The errors in the third order bend could be assessed by assessing:................................................. 7
V. Alter the vertical relationship of incisors as a finishing procedure, either correcting
moderately excessive overbite or closing a mild anterior open bite................................................ 8
Normal OB is essential for: ............................................................................................................. 8
VI. Correct the OJ.................................................................................................................. 9
Normal OB is essential for: ............................................................................................................. 9
A slight increase in the OJ is acceptable when................................................................................ 9
VII. Correct the ML relationship............................................................................................. 9
VIII. Buccal Root Torque of Premolars and Molars .............................................................. 10
IX. “Settling” of the teeth .................................................................................................... 10
Feature of optimal interdigitation:................................................................................................. 10
Methods for Settling the Teeth ...................................................................................................... 11
Indication of positioner.................................................................................................................. 11
Some variations to this general settling technique are as follows: ................................................ 12

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X. Control of Rebound and Posturing.................................................................................... 12
D. Periodontal aims.................................................................................................................... 13
I. Root Angulation................................................................................................................ 13
II. Bone level.......................................................................................................................... 14
Special Finishing Procedures to Avoid Relapse ............................................................................ 14
Relapse after orthodontic treatment has two major causes:........................................................... 14
Surgery to section the supracrestal elastic fibres........................................................................... 15
The AB for grading system for SM involve 1998 ......................................................................... 16

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Finishing stage
Key papers
 Kokich VG (2003)
 McLaughlin RP and Bennett JC (1991)
 McLaughlin RP and Bennett JC (2003)
 Poling 1999
Aims of the finishing stage
A. Aesthetic aims
a) Extra oral aims:
1. Static aims
It mainly involved correct position of U in relation to APog plane and L incisors in relation to
APog plane and MP.
2. Dynamic smile aims
b) Intraoral aims
I. Tooth Size Discrepancies
• Tooth size discrepancy must be taken into account when treatment is planned initially, but
many of the steps to deal with these problems are taken in the finishing stage of treatment.
• As a general guideline, a 2 mm tooth size discrepancy noted from Bolton analysis is the
threshold for clinical significance (Othman 2007)
• Reduction of interproximal enamel (stripping) is the usual strategy to compensate for
discrepancies caused by excess tooth size.
• When the problem is tooth size deficiency, it is necessary to leave space between some teeth,
which may or may not ultimately be closed by restorations. In case of a diminutive laterals, 2/3 of
the space should be distal to lateral and 1/3 mesial. (for best aesthetic, Kokich 2003)
• More generalized small deficiencies can be masked by altering incisor position in any of several
ways. To a limited extent, torque of the upper incisors can be used to compensate: leaving the
incisors slightly more upright makes them take up less room relative to the lower arch and can be
used to mask large upper incisors, while slightly excessive torque can partially compensate for

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small upper incisors. These adjustments require third-order bends in the finishing archwires. It is
also possible to compensate by slightly tipping teeth or by finishing the orthodontic treatment
with mildly excessive overbite or overjet, depending on the individual circumstances.
• Most of the cases have TSD with ULS smaller than LLS, so MBT used a total of 40 degree tip in
all upper ULS while LLS have only 6, the difference is 34 which means that ULS occupy more
space than LLS.
II. Gingival Levels
Four characteristics contribute to ideal gingival form.
1. First, the gingival margins of the two central incisors should be at the same level.
2. Second, the gingival margins of the central incisors should be positioned more apically
than the lateral incisors and should be at the same level as the canines.
3. Third, the contour of the labial gingival margins should mimic the cementoenamel
junctions of the teeth.
4. Last, there should be a papilla between each tooth
• The cause of These discrepancies could be Abrasion of the incisal edges delayed migration of
the gingival margins.
• The proper solution for the problem: orthodontic movement to reposition the gingival margins
or surgical correction of gingival margin discrepancies.
To make the correct decision, it is necessary to evaluate 3 criteria.
1. First of all, the relationship between the gingival margin of the maxillary central incisors
and the patient’s lip line should be assessed when the patient smiles. If a gingival margin
discrepancy is present, but the patient’s lip does not move upward to expose the discrepancy, it
does not require correction. If a gingival margin discrepancy is apparent, the next step is to
evaluate the labial sulcular depth over the two central incisors.
2. If the shorter tooth has a deeper sulcus, excisional gingivectomy may be appropriate to
move the gingival margin of the shorter tooth apically. However, if the sulcular depths of the
short and long incisors are equivalent, gingival surgery will not help. So orthodontic extrution
with selective grinbding or intrusion with build up will help.
3. Torque of the tooth

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4. Vertical tooth discrepancy
5. The third step is to determine if the incisal edges have been abraded. This is best
appreciated by evaluating the teeth from an incisal perspective. If one incisal edge is thicker
labiolingually than the adjacent tooth, this may indicate that it has been abraded, and the tooth
has overerupted. The best method of correcting the gingival margin discrepancy is to intrude the
short central incisor
III. Gingival Form
1. The presence of a papilla between the maxillary central incisors is a key aesthetic factor in
any individual. Occasionally, adults will have open gingival embrasures or black triangles
between their central incisors. These unsightly areas are often difficult to resolve with periodontal
therapy.
2. This space is usually due to one of three causes: tooth shape (corrected by IPS or
composite restoration), root angulation (corrected by uprighting), or periodontal bone loss
(corrected by orthodontic extrusion to relocate the papillae)
B. Functional aims
To provide a mutually protected occlusion.
C. Occlusal aims like
I. Levelled Marginal Ridges.
II. Correct first order bend
According to the American Board of Orthodontics (ABO, 1998) (Kokich 2003).
1. In the mandibular anterior sextant, the incisal edges of the mandibular incisors and canines are
used to establish proper alignment.
2. While in the maxillary anterior region, the lingual surfaces of the maxillary incisors and canines
are used to assess proper alignment. This surface was choosing because it is the functioning
surface of the maxillary anterior teeth, and if these surfaces are aligned properly, the maxillary
incisors appear to be in their proper aesthetic relationship.
3. In the mandibular posterior sextants, the buccal cusps of the mandibular premolars and molars
are used to determine proper tooth position.

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4. In the maxillary posterior sextants, the central grooves of the maxillary premolars and molars are
used to assess proper alignment.
Methods to correct rotation
At initial stages by exaggerated bracket positioning, partial ligation of aligning AW, piggy back,
sectional cantilever spring (Whip), couple moment using elastic, TPA or even HG, open coil
spring, or surgical replantation or luxation but with high risk of ankylosis.
For final deroataion and over correction use:
 Steiner rotation elastic
 Repositioning the bracket
 Wire bending
 Abrahamian techniques: This involves placing a figure of eight
elastomeric ligature over the tie wing which it is desired to move
away from the archwire and tying in the other tie wing with a
steel ligature.
III. Correct second order bend: this can be done by wire bending or rebonding and correcting
root parallelism
• In contemporary edgewise practice, it has been almost totally abandoned in favor of angulated
bracket slots that produce proper root paralleling when a flexible full-dimension rectangular wire
is placed. A root-paralleling moment is a crown-separating moment in edgewise technique just as
it is in Begg or any other technique. It is important to remember this effect. Either the teeth must
be tied together or the entire archwire must be tied back against the molars to prevent spaces
from opening. Not only extraction sites but also maxillary incisors must be protected against this
complication. Also tying the maxillary incisors together, which can be done conveniently with a
segment of elastomeric chain from the mesial bracket of one upper lateral incisor across to the
mesial bracket of the other, is necessary during finishing.
• In the Begg technique, the moments necessary for root positioning were generated by adding
auxiliary springs together across extraction sites.
• In the modified Begg technique using the Tip-Edge appliance, root paralleling is accomplished
with uprighting springs, very much as it was with traditional Begg treatment. The rectangular

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wire is used primarily for torque (faciolingual root movement), not the mesiodistal root
movement needed for root paralleling after teeth were allowed to tip during space closure.
IV. Correct third order bend:
The overall inclination of the maxillary anterior teeth is best evaluated with a lateral
cephalometric radiograph.
The importance of correct teeth inclination are:
a) Aesthetic purpose
b) Functional purpose
c) Stability
d) PD health
e) Increase the success of any adjunctive restorative procedure after orthodontic. Eg in
missing lateral, the increased torque of adjacenet teeth might reduce the intra-radicular space for
implant (wagon wheel effect) as well as making the retention of RBB poor.
The errors in the third order bend could be assessedby assessing:
A. The incisal edges of the anterior teeth. If a discrepancy exists in anterior inclination, the
incisal edges of the anterior teeth will not be in the same plane. Even in-setting or offsetting the
incisors relative to one another will not correct the problem.
B. A second criterion to evaluate is the clinical crown length of contralateral teeth. If
contralateral teeth are different lengths, the cause could be relative discrepancies in the
inclination of contralateral incisors.
C. The third criterion to evaluate is root prominence.
D. The fourth and final criterion is best evaluated from an occlusal perspective. When the
incisors are viewed from an occlusal perspective, the cingulum of an improperly inclined incisor
is more prominent or more visible.
 In the Begg technique, the incisors are deliberately tipped back during the second stage of
treatment, and lingual root torque is a routine part of the third stage of treatment. This is
accomplished with an auxiliary appliance that fits over the main or base archwire. The torquing
auxiliary is a “piggyback arch” that contacts the labial surface of the incisors near the gingival
margin, creating the necessary couple with a moment arm of 12/1.

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 These piggyback torquing arches can be used in edgewise technique in the same. Although they
come in a number of designs, the basic principle is the same: the auxiliary arch, bent into a tight
circle initially, exerts a force against the roots of the teeth as it is partially straightened out to
normal arch form. A torquing force to move the roots lingually is also, of course, a force to move
the crowns labially. For that reason, Class II elastics are likely to be necessary when active
lingual root torque is needed during the final stage of Class II treatment.
 Other method same like the above but include bending a loops parallel to occlusal plane in 016
or 014ss. This has been described by Sandler in the Art Meets Science course.
 Another method is to use the built in torque and express it with full dimension AW or adding
torque to the wire or sometime inverting the brackets.
 The Burstone torquing arch. It can be particularly helpful in patients with Class II, division 2
malocclusion whose maxillary central incisors are severely tipped lingually and require a long
distance of torquing movement, while the lateral incisors need little if any torque.
V. Alter the vertical relationship of incisors as a finishing procedure, either correcting
moderately excessive overbite or closing a mild anterior open bite.
Normal OB is essential for:
• Aesthetic
• Stability of treatment

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• Normal PD health support
• The amount of overbite has some effect on anterior restorative dentistry, especially the
placement of a resin-bonded anterior bridge.
• Functioning by incising the food: Normal OB is essential for mutually protected occlusion. The
purpose of overbite is to permit the anterior teeth to function or incise food in protrusive jaw
position, while the posterior teeth are out of occlusal contact. Therefore, the amount of overbite
necessary to accomplish the task of disoccluding the posterior teeth is actually determined by the
length of the cusps of the premolars and canines. Some premolars have shallow cuspal anatomy,
and therefore the overbite required to disclude this type of tooth anatomy would be small,
perhaps one to two millimeters. However, some patients have long cusps on the maxillary and
mandibular premolars and canines. In this situation the anterior overbite must be greater, perhaps
3 to 4 mm, to disclude the posterior teeth. If the overbite is not deep enough, then the patient
would only contact the posterior teeth in protrusive jaw position, making it impossible to incise
food.
a) Anterior deep Bite
• Before attempting to correct excess overbite at the finishing stage of treatment, it is important
to carefully assess why the problem exists and particularly to evaluate two things: (1) the vertical
relationship between the maxillary lip and maxillary incisors and (2) anterior face height.
VI. Correct the OJ
Normal OJ is essential for:
 Aesthetic
 Stability
 Function
A slight increase in the OJ is acceptable when
• Treatment is compromised
• RBB will be used
• Abraded or eroded teeth that will be resored and the restorative need some clearance
VII. Correct the MLrelationship
• The midline often can be corrected by using asymmetric Class II (or Class III) elastic force.

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• It is more effective to use Class II or Class III elastics bilaterally with heavier force on one side
than to place a unilateral elastic.
• It is also possible to combine a Class II or Class III elastic on one side with diagonal elastic
anteriorly to bring the midlines together. (a “parallel elastics” arrangement),
• An important consideration in dealing with midline discrepancies is the possibility of a
mandibular shift on occlusion.
VIII. Buccal Root Torque of Premolars and Molars
IX. “Settling” of the teeth
The final step of bringing the teeth into occlusion, appropriately called “settling” of the teeth, has
been needed.
Feature of optimal interdigitation:
1. The buccal cusps of the mandibular premolars and molars should contact the fossae or
marginal ridges of the maxillary molars and premolars.
2. The lingual cusps of the maxillary premolars and molars should be in contact with the
marginal ridges or fossae of the mandibular premolars and molars.
3. The exceptions are the lingual cusps of the maxillary first premolars, which may not
establish contact with the mandibular first premolar because of the lack of an adequate occlusal
table. In addition, the disto-palatal cusps of the maxillary first and second molars may not contact
the mandibular teeth if the cusps are diminutive in size or in situations where posterior teeth have
worn significantly and will be restored with full crowns after orthodontic treatment

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Methods for Settling the Teeth
1. Artistic bend
2. Positioner especially in premature forced debonding (but expensive and require patient
compliance)
3. Begg or Hawley retainer (questionable)
4. Bracket repositioning (controllable but not accurate)
5. Customised wire bending “SureSmile”
6. By replacing the rectangular archwire at the very end of treatment with light round arches
that provide some freedom for movement of the teeth (16 mil in the 18-slot appliance, 16 or 18
mil in the 22-slot appliance) and using light vertical elastics to bring the teeth together. It was the
original method for settling, recommended by Tweed in the 1940s. The difficulty with undersized
round wires at the end of treatment is that some freedom of movement for settling of posterior
teeth is desired, but precise control of anterior teeth is lost as well.
7. By replacing the rectangular SS archwire at the very end of treatment with light multistrand
NiTi arches that provide some vertical flexibility and settling.
8. Using laced posterior vertical elastics after removing the posterior segments of the archwire. It
should not be used in patients who had major rotations or posterior crossbite. For the majority of
patients who had well-aligned posterior teeth from the beginning, however, this is a remarkably
simple and effective way to settle the teeth into their final occlusion. These elastics should not
remain in place for more than 2 weeks, and 1 week usually is enough to accomplish the desired
settling. Some variations to this general settling technique are as follows:
 If cuspids were labially displaced in the upper arch, the sectional wire in the upper anterior
segment can be extended to the cuspids to hold them in position.
 If diastemas is present in the upper and lower anterior segments, these areas should be tied
together lightly with elastic thread or ligature wires
 If teethhave been extracted, figure-8 ligature wires should be placed across the extraction sites
to hold them closed.
 If palatal expansion was carried out, a small removable palatal plate, with .018 wires extending
inter-proximally in the gingival areas, can be used to maintain expansion during the settling
phase
 When finishing moderate to severe Class 11/1 malocclusions, it is not wise to use a small
sectional wire for the upper anterior segment, because some return of the overjet can be expected.
In this situation, a full upper .014 archwire can be used in settling and this wire can be bent back

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behind the most distal molars. This controls the overjet, but inhibits settling of the posterior teeth
somewhat. Archwire bends may therefore be placed where individual teeth need to settle.
 If it is intended that settling may take longer than approximately 6 weeks, it is beneficial to leave
the lower rectangular steel wire in position during this extended settling phase. This will help to
maintain lower arch form.
 An example of this might be a difficult posterior open bite that will require a more extended
period of time for settling. When it is anticipated that only 4 to 6 weeks of treatment is remaining,
a normal lower .014 steel or .016 heat-activated wire can be placed.
Indication of positioner
1. As a retainer
2. For patients who have shown excellent cooperation
3. Provide further minor correction following deboned and thus "guide" the settling of the
occlusion.
4. They were particularly beneficial at the end of Begg treatment in which stage III (the
finishing phase) is difficult.
5. They may also be useful in instances when the desired finish was not achieved or the case
had to be discontinued early.
6. For patients with persistent anterior or posterior tongue habits. A properly constructed
positioner can have a bite-closing effect.
7. It is not indicated in deep bite cases
X. Control of Rebound and Posturing
• After Class II or Class III correction, particularly if interarch elastics have been used, the teeth
tend to rebound back toward their initial position despite the presence of rectangular archwires.
Because of this, it is important to slightly overcorrect the occlusal relationships. In a typical Class
II anterior deep bite patient, the teeth should be taken to an end-to-end incisor relationship, with
both overjet and overbite totally eliminated, before the headgear or elastic forces are discontinued.
This provides some latitude for the teeth to rebound before final settling is accomplished.

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• Sometimes when Class II elastics are used, patients begin to posture the mandible forward so
that the occlusion looks more corrected than it really is and if the appliances are removed at that
point, they are likely to slip back toward a Class II molar relationship and increased overjet. This
should not be confused with rebound, which is due only to tooth movement.
• Rebound is a 1 to 2 mm phenomenon; posturing can lead to 4 to 5 mm relapse, and obviously it
is important to detect it and continue treatment to a true correction.
These considerations lead to the guidelines for finishing treatment when interarch elastics have
been used:
• When an appropriate degree of overcorrection has been achieved, the force used with the
elastics should be decreased while the light elastics are continued full time for another
appointment interval;
• At that point, interarch elastics should be discontinued, 4 to 8 weeks before the orthodontic
appliances are to be removed, so that changes due to rebound or posturing can be observed. It is
better to tell the patient that he or she is getting a vacation from the elastics and that some further
elastic wear may be necessary if changes are observed, rather than saying that elastics are no
longer needed. If changes do occur, that makes it easier for patients to accept that the vacation is
over and another period of elastics is needed.
• If the occlusion is stable, as a final step in treatment, the teeth should be brought into a solid
occlusal relationship without heavy archwires present, using one of the methods described above.
D. Periodontal aims
I. Root Angulation
• During finishing, orthodontists typically use a panoramic radiograph to determine if the roots of
the teeth are oriented properly relative to adjacent roots.
• In theory, if the roots of adjacent teeth are perpendicular to the occlusal plane, and parallel with
one another, then there will be sufficient bone between the roots of teeth.
Some important aspects of root parallelism must be discussed. Kokich 2003
• First of all, is a panoramic radiograph an accurate depiction of the root angulations of adjacent
teeth? Researchers have evalucated this questions and conclude that there are distortions
produced with a panoramic radiograph, especially in the maxillary and mandibular canine/first

15. Mohammed Almuzian, University of Glasgow Page 14
premolar regions, where the archform curves. However, recognizing these minor inadequacies,
the panoramic radiograph is probably a reasonable screening tool in general. In specific situations,
it is beneficial to take supplemental periapical radiographs to accurately assess root angulations
and root proximity.
• A second aspect that requires discussion is whether close root proximity will actually cause
detrimental long-term effects. This question was investigated, and the authors concluded that
close root proximity did not produce detrimental effects in their sample. These authors cautioned
that their sample was relatively young, and was not a sample of patients that were susceptible to
periodontal disease. Whether or not close root proximity enhances interproximal bone destruction
in a sample of periodontal patients is not known. However, close root proximity after orthodontic
treatment will cause problems in certain restorative patients.
II. Bone level
• In the adolescent, the orthodontist should align the incisal edges of non-worn, non-restored
anterior teeth and the marginal ridges of nonworn, nonrestored posterior teeth, and in this way
the cementoenamel junctions and interproximal bone will be at the appropriate level.
• In adult patients with prior periodontal disease and interproximal bone loss, the incisal edges or
marginal ridges of the teeth are not reasonable guides for vertical positioning of adjacent teeth. If
the patient has horizontal bone loss in the maxillary or mandibular anterior regions , it is best to
align the bone levels rather than adjacent teeth. In these situations, the orthodontist must
equilibrate the incisal edges as the bone is leveled to establish the correct incisal edge position,
occlusion, and crown-to-root relationships.
Special Finishing Procedures to Avoid Relapse
Relapse after orthodontic treatment has two major causes:
I. Continued growth by the patient in an unfavourable pattern: This need an “active retention”
takes one of two forms.
 One possibility is to continue extraoral force in conjunction with orthodontic retainers (high-
pull headgear at night, for instance, in a patient with a Class II open bite growth pattern).
 The other, which often is more acceptable to the patient, is to use a functional appliance rather
than a conventional retainer after the completion of fixed appliance therapy.
II. Tissue rebound after the release of orthodontic force. There are two ways to deal with this
phenomenon:

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• Overtreatment, so that any rebound will only bring the teeth back to their proper position,
• Adjunctive periodontal surgery to reduce rebound from elastic fibres in the gingiva.
Surgery to section the supracrestal elastic fibres
It can be carried out by either of two approaches.
1. The first method, originally developed by Edwards is called circumferential supracrestal
fibrotomy (CSF). After infiltration with a local anesthetic, the procedure consists of inserting the
sharp point of a fine blade into the gingival sulcus down to the crest of alveolar bone. Cuts are
made interproximally on each side of a rotated tooth and along the labial and lingual gingival
margins unless, as is often the case, the labial or lingual gingiva is quite thin, in which case this
part of the circumferential cut is omitted. No periodontal pack is necessary, and there is only
minor discomfort after the procedure.
2. An alternative method is papilla-dividing procedure to make an incision in the centre of
each gingival papilla, sparing the margin but separating the papilla from just below the margin to
1 to 2 mm below the height of the bone buccally and lingually. See beow.
• This modification is said to reduce the possibility that the height of the gingival attachment will
be reduced after the surgery, and it is particularly indicated for esthetically sensitive areas (e.g.,
the maxillary incisor region). Nevertheless, there is little if any risk of gingival recession with the
original CSF procedure unless cuts are made across thin labial or lingual tissues. From the point
of view of improved stability after orthodontic treatment, the surgical procedures appear to be
equivalent.

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• It is easier to do the CSF procedure after the orthodontic appliances have been removed,
although it can be carried out with appliances in place. An advantage of the papilla-dividing
procedure may be that it is easier to perform with the orthodontic appliance still in place.
• Neither the CSF nor the papilla-dividing procedure should be done until malaligned teeth have
been corrected and held in their new position for several months. This means that either the
surgery should be done a few weeks before removal of the orthodontic appliance or, if it is
performed at the same time the appliance is removed, a retainer must be inserted almost
immediately.
The AB for grading systemfor SM involve 1998
1. Aligned incisor edges
2. Aligned incisors labial surface
3. Buccal cusp of all teeth aligned
4. Central fossae aligned
5. Marginal ridge levelled
6. Correct torque
7. Good interdigitation
8. Canine and MR class I
9. Correct OJ and OB
10. Tight contact
11. OPT show parallel roots