11. Guide lines:
• 8mm/less of crowding-mild to moderate space requirement.
• Severely mesially and lingually tipped posterior teeth
• constricted arches(no skeletal component of malocclusion).
• No need to alter the facial profile.
• Co-operative patient.
• Growing patients-afford more space.
12. SLOW EXPANSION DEVICES
● Walter Coffin – 1875
● It is a removable appliance capable of slow dento alveolar expansion
● The appliance consists of an omega shaped wire of 1.25mm thickness,
placed in the mid palatal region
● The free ends of the omega wire are embedded in acrylic covering the
slopes of the palate
● The spring is activated by pulling two asides apart manually
13. NI TI EXPANDER
● It generates optimal ,constant
expansion forces
● Its central component is made
of a thermally activated ni ti
alloy and rest of component id
made of stainless steel
15. QUAD HELIX APPLIANCE:
● Basically, the appliance is
constructed of 0.038 inch wire
and soldered to bands which
are cemented to either the
maxillary first permanent
molar or the deciduous
second molars, depending on
the age of the patient.
27. The most common reason-
ø Advanced caries
ø Periodontal compromise
ø Supernumerary tooth
ø Orthodontic therapeutic extraction
ø Infection prone teeth before radiation therapy
ø 3rd molar extraction – prophylactic or
orthodontic consideration
INDICATIONS
28. Factors affecting choice of extraction
1. Treatment objectives
2. Type of malocclusion
3. Esthetics (large chin button, prominent nose)
4. Growth pattern.
5. Conditions of teeth.(caries, multifilled teeth,
impacted, ectopic, severe rotation)
6. Health of supporting tissues.
29. ø The most commonest tooth to be extracted for therapeutic procedures.
ø It is more convenient to remove as its at the junction of the anterior and
posterior segments
ø Space created by its removal can be used for anterior as well and posterior
segment crowding.
European Journal Of Orthodontics 1996;18:485-489
1st PREMOLAR
30. Less resistance –
distal movt
More resistance –less
mesial movt
Helpful for
extreme
crowding
1nd PMs
INDICATIONS
ø Class II Div I and Class III
ø For incisor retraction.
ø For maximum anchorage protection.
ø Overjet correction
ø Openbite correction
31. 1nd PMs
ADVANTAGES:
ø Moderate to severe cases with anterior crowding can benefit from
1st Premolar extractions
ø Lesser tooth material is sacrificed.
ø Space for anterior and posterior segment crowding.
ø Fairly good contact between canine and 2ndPremolar
ø Helps establish a more vertical position of mandibular incisors to
the mandibular plane
Austrailian Orthodontic Journal 1987;10(2): 90-97
37. MANAGEMENT OF
DEEP BITE
● Deep bite has been considered one of the
most common malocclusion.
● An unfavorable sequelae of this malocclusion
predisposes a patient to periodontal
involvement. Abnormal function, improper
mastication, excessive stresses, trauma,
functional problems, bruxism, clenching and
temporomandibular joint disturbance
38. EITOLOGY
OF DEEP
BITE
developmental deep
bite (inherent)
acquired deep bite
1) Muscular habits
2) Changes in tooth position
3) The loss of posterior supporting tee
4) Lateral tongue thrust habit.
1. Tooth morphology
2. Skeletal pattern & malocclusion
3. Condylar growth pattern
39. DEEP
BITE
DENT.AL
V
SKELET
AL
Deep overbite caused by infraocclusion molars
Deep over bite caused by over eruption of the
incisors
Deep over bite is caused by the marked
horizontal growth direction of the mandible
both jaws convergent.
both jaws rotating in same direction.
45. REVERSE CURVE OF SPEE:
● Both extrusion and flaring may be unstable
movements in many patients due to their effect on
the facial neuromuscular balance.
Biomechanics and Esthetic Strategies in Clinical Orthodontics, Nanda.
48. ANTERIOR SINGLE POINT CONTACT
Intrusion arch is not placed directly into the brackets of
the teeth to be intruded
Deep overbite correction by Intrusion, AJO 1977, 1-22
Biomechanics of Deep Overbite Correction, vol 7, 2001, Seminars in
51. K-SIR ARCHWIRE.
( KALRA SIMULTANEOUS INTRUSION AND RETRACTION )
● It is a continuous .019"
X .025" TMA archwire
with closed at the
extraction sites.
Simultaneous Intrusion and Retraction of the Anterior Teeth,
JCO 1998, VOL 32 : No 9 : Pg 535-540
52. ● Appliance Design:
Simultaneous Intrusion and Retraction of the Anterior Teeth,
JCO 1998, VOL 32 : No 9 : Pg 535-540
• To obtain bodily movement and prevent tipping of the teeth
into the extraction spaces, a 90º V-bend is placed in the
archwire at the level of each U-loop
53. Simultaneous Intrusion and Retraction of the Anterior Teeth,
JCO 1998, VOL 32 : No 9 : Pg 535-540
• A 60 degree V-bend located posterior to the center of
the interbracket distance produces an increased
clockwise moment on the first molar which augments
molar anchorage as well as the intrusion of the anterior
teeth.
54. ● To prevent the buccal segments from rolling
mesiolingually due to the force produced by the loop
activation, a 20 degree anti rotation bend is placed in
the arch wire just distal to each U-loop
Simultaneous Intrusion and Retraction of the Anterior Teeth,
JCO 1998, VOL 32 : No 9 : Pg 535-540
55. • In neutral position, the U-loop
will be about 3.5mm wide. The
archwire is inserted into the
auxiliary tubes of the first molars
and engaged in the six anterior
brackets.
• It is activated about 3mm, so that
the mesial and distal legs of the
loops are barely apart.
ACTIVATION
56. Appliance Design
An .036” lower lingual arch is soldered to first molar bands.
Modification of Lingual Arch For Deep Bite
Developed by Winston Senior
58. • Open bite is the failure of a tooth or teeth to meet their
• antagonist in the opposite arch.
• By Robert Moyers
● Absence of vertical incisal overlap Absence of occlusal stop
65. BRACKET POSITION
1. The placement point for incisor brackets may vary in cases of
infraocclusion.
2. In cases of open bite, placing anterior brackets 1 mm more towards the
gingival side.
70. ● No serious side effects.
● Simplified treatment mechanics.
● Shortened treatment period.
● Control of the level of occlusal plane.
● Minimum discomfort.
●
Advantages of SAS :
72. Rx OF CLASS II MALOCCLUSION
GROWING PATIENT [PERPUBERTAL] ADULT PATIENT [POSTPUBERTAL]
SKELETAL
DENTOALVEOLAR
FUNCTIONAL APPLIANCE
SURGERY
SKELETAL
MODEL ANALYSIS
EXTRACTION NON EXTRACTION
REMOVABLE
v/s
FIXED
FIXED
FUNCTIONAL
MAXILLARY MANDIBULAR
LEFORT I
MAX. IMPACTION/
RETROPOSITIONING
BSSO
MAND.
ADVANCEMENT
USE OF CLASS II ELASTICS
ORTHOPAEDIC APPLIANCE
BI-JAW
77. ● No treatment is required unless:
– Severe skeletal discrepancy
– Crossbite is present
– Undue concern to the patient’s parents
– Persistence of habits beyond 4-5 yrs
78. ● TREATMENT:
– CORRECTION OF HABITS
● COUNSELLING
● HABIT BREAKING APP
– CORRECTION OF POSTERIOR CROSS BITE
● JACKSCREW
● QUADHELIX
● COFFIN SPRING
– CORRECTION OF SKELETAL DESCREPANCY
● FUNCTIONAL APPLIANCE
80. ➢ Elimination of abnormal peri-oral muscle function by
elimination of functionally induced retrusion
➢ Anterior positioning of the mandible and concomitant growth
stimulation
➢ Growth inhibition of the maxilla
82. ● Class II malocclusion due to abnormal musculature presents with large overjet,
proclined upper incisors, retroclined lower incisors and constricted upper arch
in intercanine region
● Indicated in abnormal peri-oral musculature.
● Works on the concept of force elimination.
● Also can be used to correct tongue, finger sucking and mouth breathing habits.
SCREENING THERAPY
87. The basic methods of growth modulation are as follows
1. Absolute increase or decrease in size.
2. Acceleration / Retardation of rate of jaw growth.
3. Reposition / Redirect jaws in space with little to moderate
growth effect.
4. Functional appliances make use of 2nd & 3rd method to effect
treatment.
97. PATIENT COMPLIANCE
Facts :
▪ Percentage of poor compliance --- 50%
▪ Both patients and families mis-represent the extent of
compliance
▪ Compliance decreases the longer the patient is treated
109. Clinically class I molar relation was achieved
probably due to
✓ An increase in the mandibular length.
✓ Distal movement of the maxillary molars.
✓ Mesial movement of the mandibular molars.
110. A decrease in the overjet & overbite was observed
probably because of
➢Increase in mandibular length.
➢Labial movement of mandibular incisors resulting in opening of bite.
➢Extensive dental changes occur in the maxilla & the mandible during the
fixed functional therapy.
112. MAXILLARY EXCESS
( A-P AND VERTICAL)
Excessive growth of the maxilla in children with class II malocclusion often has a
vertical as well as an anteroposterior component (downward and forward growth)
The effect is to prevent mandibular growth from being expressed anteriorly
The goal of the treatment is to restrict growth of the maxilla
113. ● To be effective, head gear should be worn regularly for at least
10-12 hrs per day
● Early evening to next morning – growth hormone – circadian
rhythm – 8 pm to 1 am
● Current recommended force 12 to 16 ounces or 350 to 450 gms
per side
115. LONG FACE (SKELETAL OPEN BITE)
VERTICAL MAXILLARY EXCESS
● Two major diagnostic criteria
● Short mandibular ramus
● Rotation of the palatal plane (more posterior growth)
● Most common approach
Restraining maxillary vertical development&
Encouraging antero -posterior mandibular growth
118. ● Growth modification would be more successful when more
growth remains
● As a general guideline, even in the most favorable
circumstances it is unlikely that half of the changes needed to
correct Class II malocclusion in an adolescent would be gained
by differential growth
GROWTH MODIFICATION IN ADOLESCENTS
119. ● Head gear is compatible with fixed appliances but most functional appliances
are not.
● If a functional appliances is desirable for adolescent treatment, often a fixed
functional is the best choice.
GROWTH MODIFICATION IN ADOLESCENTS
In late treatment occlusal stability will be favored, as all permanent teeth have
erupted, allowing them to be locked in a stable Class I cuspal interdigitation
122. Rx OF CLASS III MALOCCLUSION
GROWING PATIENT [PERPUBERTAL] ADULT PATIENT [POSTPUBERTAL]
SKELETAL
DENTOALVEOLAR
FUNCTIONAL APPLIANCE
SURGERY
SKELETAL
MODEL ANALYSIS
EXTRACTION NON EXTRACTION
REMOVABLE
v/s
FIXED
MAXILLARY MANDIBULAR
LEFORT I
MAX. ADVANCEMENT
BSSO
MAND. SETBACK
USE OF CLASS III ELASTICS
BI-JAW
ORTHOPAEDIC APPLIANCE
123. “CLASS III MALOCCLUSION OCCURRED WHEN THE LOWER TEETH
OCCLUDED MESIAL TO THEIR NORMAL RELATIONSHIP THE WIDTH OF
ONE PREMOLAR OR EVEN MORE IN EXTREME CASES”.
- ANGLE (1899)
129. CLASS III BIONATOR
BALTERS BIONATOR III can be used in patients with
skeletal Class III malocclusion. The use of this
appliance causes some skeletal changes through
neuromuscular modifications.
Garatinni et al AJODO 1998
130. FRANKEL III APPLIANCE
• Upper lip pads
• Lower labial bow
• Protrusion bow in the upper arch
131. REVERSE TWIN BLOCK
MODE OF ACTION
MODIFICATIONS
• WITH UPPER LIP PADS
• WITH REPELLING MAGNETS
139. The most common indication for maxillary surgery is vertical skeletal dysplasia
The maxilla can be moved upwards by 10 – 15 mm with excellent stability
140. Clinical
presentation:-
Increased lip to tooth relation
Increased gingival display
Increased inter labial gap relation
Relative mandibular deficiency
Anterior open bite (may be compensated
by hyper eruption of teeth)
145. MAXILLARY ADVANCEMENT
The maxilla can be moved forward up to 10 mm.
Clinical indications:-
Decreased pharyngeal airway
Excessive submental adipose tissue
Decreased malar convexity
Increased nasolabial grooves
154. SARPE-Surgically assisted rapid palatal expansion
•Surgically assisted because, cuts in lateral buttress
of maxilla would decrease the resistance for
expansion in older patients.
•All the osteotomy cuts are similar to LeFort I
osteotomy except for down fracture of the maxilla
in SARPE.
156. Mand Deficiency with normal or reduced facial height
• Horizontal growth pattern
• Class II molar and Canine relationship – often with a
div. 2 pattern.
• Excessive curve of spee in the lower arch.
• Incisor crowding
• Deep bite – usually causing some gingival irritation
• Chin button well developed
• Deficiency near the lower lip region – seen as a
deep mentolabial sulcus, a curl of the lower lip and
an aged appearance
161. • Rotation of mandible chin moved back and incisors
forward
• Genioplasty if needed
– Reduce chin prominence
– Further increase face height
• No maxillary surgery to increase face height
Mand Deficiency with normal or reduced
facial height
169. GENIOPLASTY
● Lack of surrounding anatomic structures, moment of the chin in all 3 planes
of space is possible.
● The chin can be moved in every direction
178. Alar cinch
Collins and Epker identified patients who may develop undesirable
nasal aesthetic changes as those who have normal or wide
frontonasal aesthetics before surgery.
These observations led to the development of techniques to ensure
an esthetic reconstruction of alar bases.
The suture is passed from transverse nasalis muscle on one side of
The alar base to the other side and tied to a pre determined width
179. NASAL DORSAL HUMP REDUCTION
Dorsal nasal hump is one of the features seen in class ll patients.
Surgical reconturing or the osteoplastic procedure of the dorsal surface of
the nose helps in improving mid facial esthetics.
This is most commonly done with combination of lefort l fracture of the
maxilla for superior repositioning.
180. RHINOPLASTY
Maxillary surgery via LeFort I osteotomy rarley has a positive effect on
the appereance of the nose, most often may compromise it. Moving maxilla
up and forward has 2 major delterious effects on the nose, they are
•Rotation of the nasal tip upwards resulting in deepening of the supra tip
depression.
•Widening of the alar base.
Cases with cleft lip and palate are also benefited with Rhinoplasty
181. MALAR AGUMENTATION
Implants on the surface of the bone can greatly improve soft tissue
contours, and is of major intrest in patients with paranasal deficiency, facial
syndromes (hemifacial microsomia) and maxillary deficiency.
Patients own bone, freez-dried cadaver bone or alloplastic materials can
be used as onlay grafts.
182. LIP LENGTHENING
Lip lengthening is an alternative approach to reduce gumminess in those patients
who have short lip length.
Temporary lengthening:- Injection of collagen material in to the lip.
Permanent lengthening:- Can be done by using alloderm or patients own soft tissue
harvested during simultaneous face lift procedure. These are placed by creating a
tunnel beneath the mucosa and threading the material in to the space.
183. LIP REDUCTION
•Lip reduction is rarely performed, but it can
greatly improve outcomes for those patients who
have extremly thick and prominent lips.
•It is done by passing an intraoral incisions
parallel to the vermilion boarder of lip and
excision of soft tissue, including the submucous
glands. Excision of muscles should be avoided.
