Dr.Saurav Mishra

2. LIP BUMPER , QUAD HELIX &TONGUE CRIB
TPA ,NANCE ,
Presented By:-
Dr. Saurav kumar
JR 1
Department of
Orthodontics
Guided By:-
Dr. D K Agarwal(Prof. &HOD)
Dr. Preeti Bhattacharya (Prof.)
Dr. Ankur Gupta (Reader)
Dr. Juhi Ansar (Senior Lect.)
Dr. Ravi Bhandari (Senior Lect.)
Dr. Shivani Singh (Senior Lect.)

3. Introduction
• Described by Nance in 1947
• It is simply a Modified maxillary lingual arch
that does not contact the anterior teeth, but
approximates the slope of anterior palate
The Transpalatal Arch: An Alternative to the
Nance Appliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent
2007;29:235-8

4. Design
• .036 SS wire running along palate connecting upper molars.
• The palatal portion incorporates an acrylic button resting on
slope of anterior palate that provides resistance to anterior
movement of the posterior teeth

5. Indication
1. Provide anchorage during Alignment & levelling
•By Palatal vault and Cortical anchorage

6. 2.To maintain the position of the second molars where the first
molars have been extracted.

7. 3. A modified Nance appliance modified with an
anteriorly positioned acrylic button can provide a
fixed acrylic flat anterior bite plane for the treatment
of anterior deep overbite.

8. 4. Antero Posterior Anchorage in a case of canine
retraction

9. 5. Offset Nance button to accommodate the palatally placed
lateral incisor with loops to allow adjustment.

10. Diadvantages
1. Oral hygiene difficulties: Nance appliances result in
deterioration of oral hygiene beneath the acrylic plate
leading to inflammation of the palate.
2.Poor patient tolerance in comparison to the standard
TPA

11. 3.
Nance Appliance induced Pathology

12. Trance Palatal Arch
Mar. 21, 1922 -Dec. 4, 1992
Robert Ara Goshgarian

13. INTRODUCTION
Described by Robert Ara Goshgarian in 1972.Owing to the versatile
design TPAs can provide passive and active orthodontic forces in all 3
planes

14. Design
• .036 mm ss wire that goes across the palatal contour
from one molar or premolar to contralateral molar or
premolar
• Wire soldered to molar band at mesiolingual line
angles
• Or by insertion in the lingual sheath in molar band
(Wilson or Mershon attachments)

15. Major indication in mixed dentition is to prevent mesial
migration of upper first molar during transition from second
deciduous molar to 2nd premolar
Graber Vanarsdall Vig 5th ed. Pg 484
Rationale :
• When permanent maxillary molars move anteriorly, they
rotate mesiolingually around the large lingual root.
• TPA reduces anterior molar movement by coupling the right
and left permanent molars together and, thus, preventing
any possibility of rotations.

16. INDICATION in Transverse Plane
1. Anchorage and arch width stabilization during
orthodontic treatments or surgery
2. Retainer after active maxillary expansion
3. To Avoid Molar Tipping
4. Habit breaking appliance
5. Minimally expand dental arches

17. Transverse Plane :
1.Transverse anchorage and arch width stabilization when aligning
palatally impacted maxillary canines
Ref: Baccetti T, Sigler LM, McNamara JA. An RCT on treatment of palatally
displaced canines with RME and/or a transpalatal arch. Eur J Orthod 2011; 33:
601−607

18. 2.TPA is also effective as a holding appliance or as a retainer after
active maxillary expansion

19. •
3. TPA & temporary anchorage devices (TADs) combination to
correct anterior open bites .
TPA is useful in controlling molar tipping during such clinical
situation

20. 4. Habit deterrent for persistent thumb and digit-sucking
habits. This requires the soldering/welding of a crib to the
TPA.

21. 5. Bilateral space maintenance following premature loss
of primary molars.
• Prevent loss of Leeway space and potential crowding
of the premolars where extractions of the deciduous
molars are planned.

22. 6. TPAs can be used actively to minimally expand dental arches.
• Expanded by 3−4 mm to provide a force of around 200 gm.

23. INDICATION in Anteroposterior Plane
Anteroposterior anchorage :The loop is directed posteriorly if the
TPA is to provide antero-posterior anchorage

24. Derotation of molars
• Bent-back end of the arch was gripped with pliers and
twisted relative to the main arch.
• If the moments on both sides are the same, the
Mesio-distal force will be zero.
Moments and forces delivered by transpalatal arches for symmetrical first
molar rotation Bengt Ingervall et al

25. Complications of TPA
1. Anchorage loss :
Type B Anchorage
2.5 mm of mesial movement of the upper first permanent molars in
TPA while the TADs group provided Absolute anchorage
Feldmann I, Bondemark L. Anchorage capacity of osseointegrated and
conventional anchorage systems: a randomized controlled trial. Am J Orthod
Dentofac Orthop 2008
2.Increase of risk of root resorption :
As TPA positions the root of anchor units against The cortical
bone plate

26. 3.Breakage and cementation failure is approximately 2% and 30%,
respectively
4.The loop of the TPA can cause palatal trauma

27. Expansion and derotation activation
placed in one side of the quad helix,
distalizes the molar on the opposite side
Modified to use one entire buccal
segment of the arch to a single molar
on the opposite side.

28. A quad helix can be activated to derotate a maxillary molar on
one side of the arch provides a distalizing force at the molar on
the opposite side of the same arch.
By extending the palatal arms of the appliance on one side, it can
involve more teeth on that side to act as anchorage in the distal
movement of a single molar on the opposite side of the arch.

29. VHA has intrusive effect on maxillary molar eruption.
Orthodontist must usually guard against further anterior
bite opening during leveling and aligning procedures in
patient with increased lower anterior facial height.
An ideal treatment goal for a patient with an acceptable
pretreatment overbite would be to at least maintain the
same amount of overlap throughout treatment.
Evaluation of the vertical holding appliance in treatment of high-angle patients Marc
DeBerardinis et al :Am J Orthod Dentofacial Orthop 2000;117:700-5)

30. INDICATION in Vertical plane
Positioned 4-5 mm away from the palate
Fabricated with banded maxillary permanent first molars with
connected acrylic button at the sagittal and vertical level of the
gingival margin of the molar bands.
Four helices were incorporated into the wire configuration for
flexibility.

31. QUAD HELIX
• Introduction
• Design
• Types
• Indications
• Mode of action
• Activation
• Disadvantages
• Clinical Management

32. Introduction
Evolved from Coffin’s vulcanite expansion appliance
• Described by Ricketts in 1975 :
• Earlier "W" appliance was used
• Quad helix was used with great success in the early treatment of cleft
palate patient with collapsed / narrow maxilla
• Quad helix design provided Wide range
of continuous controlled force

33. Design
Pair of anterior helices
Pair of posterior helices
Anterior bridge.
Palatal bridge
Posterior loops should be 2mm distal to banded molar
but not extending to pterygomandibular raphe

34. Each of the helical loops adds an about additional 25
mm of wire to the appliance which lightens the force
magnitude, rendering a more continuous action.

35. • Frank et al: Forces in the range of 0.5 to 1.5 lbs (200 to
600 g).
• Palatal separation of .92 mm average intermolar
expansion was 5.88 mm.
• With the quad helix appliance there was a 6:1 ratio
between the orthodontic and the orthopedic expansion.
The Quad Helix Appliance Ruel W. Bench

36. Types
• Custom made: 1 - 0·9mm stainless steel
• Preformed ready type
• Fixed : retained by bands cemented on the permanent first molars.
Adjustment ease with properties of .036 blue ELGILOY
(Co,Cr,Ni, Mo, Mn)

37. Ricketts RM. Bioprogressive technique lecture notes

38. Action
Fan-like sweeping action :buccally expand and distally
rotate the maxillary molar teeth
Jones SP et al: Anterior arms of the appliance affect
both the forces produced by the appliance as well as
the force couples operating on the molar teeth. This
results from the fact that the anterior arms are a rigid
part of the whole appliance.

39. Importance of fan like action
• Parallel expansive force, larger amount of tensile strain was
recorded in the molar region.
• Fan type of expansive force by Quad helix, larger amounts of
tensile strain were observed in the canine region.
A reduction occurred as the strain was measured back toward
the molar teeth.
T. M. Graber. Jpn. Orthod. So. 42:442-453, 1983

40. • Parallel expansive force:
Frontal view: maxillary bones were expanded laterally
Occlusal view: palate and alveolar processes were expanded
laterally in the molar region.
• Fan type of forcer by quad helix: Palatal and alveolar
expansion was noted more in the canine region.
• Since many Class II malocclusions are characterized by
maxillary arches that are narrowest in the canine region, it
would follow that the fan type of appliance would be most
effective.
T. M. Graber. Jpn. Orthod. So. 42: 442-453, 1983

41. Fan like sweeping action for molar de rotation
• With this appliance,molar derotation is best
accomplished by leaving the arms of the quad helix
away from the lingual surfaces of the cuspid teeth. As
the molar teeth derotate, the arms will come to push
against the cuspid teeth and they will then expand
together with the rest of the maxillary teeth. The
advantage of activating the quad helix appliance in
this manner lies in the fact that the maxillary teeth are
expanded in a differential manner that "sweeps" them
into the ovoid arch form.
The Quad Helix Appliance Ruel W. Bench

42. Indications
1. Correct cross bites by Upper arch expansion
2. Case needing mild expansion with lack of space for
upper laterals
3. Molar Rotation correction

43. 4. Correction of mild class II Malocclusion in which upper arch
need to be widened & upper molar rotated distally

44. 5. Class III condition In which upper arch needs to be widened
&advanced with class III elastics
6. Habbit breaking aplpliance
Thumb sucking: Palatal bar forward & bended downward
Tongue thrusting: Spikes Soldered on bar & extending downward

45. 7. Unilateral & bilateral cleft palate: The quad helix
Expands the buccal segment

46. 8. With face mask
8.extension of .045" wire through the headgear tube of the molar band
enables the quad helix appliance to be used in conjunction with a
protraction face mask.

47. Sometimes advantageous to place a bi-helix appliance in the
mandibular arch to obtain and maintain a balance in the
dimensions of the maxillary and mandibular arches

48. Practical Application
• Bands are placed on upper second deciduous molar
for young case or 1st permanent molar . Particular
care is taken to adapt the lingual surface of bands
because this is strong purchase area of appliance
• Most appropriate size is selected
• Original cast is used & wire is formed with the
finger together with three pong plier to adapt wire
according to patients need

49. •Soldering spot is marked in front of posterior loops
depending on the adaptation of arms
•The band is picked up in the tong & approximated as
solder is flowed into position
•Desired activation is given
•Appliance is cemented making sure the bands are
well seated

50. Activation

51. (1) Anterior adjustments produce expansion in the posterior molar area
on both sides
(2) Lateral adjustment expands and rotates the molar on the activated
side. The molar on opposite side is distalized. Activation on both sides
causes the rotation & expansion to be on both sides
(3) Adjustments to the buccal arm expands the bicuspids and cuspids.
When held away from the teeth it allows the molars to rotate.
(4) Adjustments through the distal loop gives expansion to buccal arms.
The Quad Helix Appliance
Ruel W. Bench

52. Clinical Management
• Patients should be reviewed on a six-weekly basis for
activation.
• Intra Oral adjustment can be done in subsequent visits
• Widening of molars can be activated by pinching between
anterior loops.
• Care is taken to give only little activation is of anterior
arms and wire is left out of contact with anterior teeth
until molar rotation is achieved

53. Retention after the expansion
• At least three-month retention period
• Achieved expansion should be retained with an upper
removable appliance.
• If fixed appliances are being used, the quadhelix can
be removed and replaced by TPA.

54. Disadvantages
• The limited amount of skeletal change &
palatal relapse.
• Opening of the bite due to molar buccal
tipping.
• Outward positioning of upper buccal tooth by
an attempt of nature to upright the root.
• Downward Backward appliance posture
restrict tongue functions , so adaptation should
be 2-3 mm of palatal tissue

55. LIP BUMPER
• Introduction
• Components
• Types
• Indications
• Effect
• Clinical Management

56. • The lip bumper is a fixed functional orthodontic
appliance that works by altering the equilibrium
between cheek, lip, and tongue and by transmitting
forces from perioral muscles to the molars where it is
applied.
Orthodontic current principle and techniques ( Graber,Vanarsdall,Vig)

57. Components
The lip bumper has a removable part and a fixed part.
The fixed part :
• Composed of two molars bands cemented to first
molars with 0.045-inch tubes.
The removable part
• Stainless steel wire with U loop that runs in the
lower vestibule from molar to molar between
teeth, lip, and cheek.
• Acrylic pad

58. Types
• Cetlin has described two different lip bumpers."
1)Custom made for each patient has two loops at the molar level
that allow modifications of the appliance therapy.

59. 2) The second type is preformed and available in
different sizes and has four loops: two at the molar
level and two at the canine level.
The two additional loops give a better shielding effect in the canine region
and allow the use of class III elastics in more severe cases.

60. Indication
The lip bumper has been used for various purposes:
• Molar anchorage
• Interception of abnormal habits
• Space gaining in the lower arch

61. Incisial edge: This position is used to upright mesially
inclined molars because the lower lip tends to lift the
anterior part of the bumper, creating a long lever effect on
the molars.
Middle third: This is the position to use when shielding
effect on incisors is desired. The loop is kept away from
the teeth, altering the equilibrium in favor of the tongue.
The incisors slowly translate labially.
Gingival level: This level is used to maintain the
position of corrected molars and incisors. The lip
bumper must be kept close to the incisors.
• In the anterior region, lip bumper can be positioned at three different
levels of incisor crown.

62. Effects Of The Lip Bumper
• Flaring of the lower incisors
• Increases arch length through passive lateral
and anterior expansion & upright the lower
molar distally, adding to the available arch
length
• According to Grabers : In patients with very
hypertonic soft tissue the lip bumper is the
appliance of choice

63. Clinical management
• Appliance can be tied to molar hook with elastic chain.
• If lip bumper is well fitted : red line can be seen on the inside
of cheeks and lips where the wire runs.
• Must keep the cheeks and lip away from the lower
dentoalveolar area
• Patient with lip bumper therapy must be monitored so as to
avoid impacting the erupting second molar.

64. TONGUE CRIB
• The tongue Crib appliance is a mechanical, habit-
breaking appliance that is utilized to eliminate
adverse habits such as tongue thrusting or thumb
sucking.
Dentofacial Orthopedics with Functional Appliances second edition (Graber , Rskosi, Petrovic)

65. • Removable crib
• Fixed crib
•Fixed tongue crib is also used for the correction of open bite by
banding to the abutment teeth (molars).

66. • Thumb sucking :They are designed to disrupt the
placement of the thumb and fingers within the mouth,
thus preventing the suckling action against the palate.

67. • Open bite due to tongue thrusting
The length of the crib should be sufficient to restrict the
contact of tongue to anterior teeth but the spurs of crib
should not contact the mandibular anteriors.
• The crib used with a removable appliance for an anterior
open bite consists of a palatal plate.
• Elimination of such habits is vital for the normal
development and maturation of the facial structures
Removable orthodontic appliances second edition Graber, Neumann

68. • Posterior (lateral) tongue cribs appliances can be used as part
of removable appliances in patients with unilateral or bilateral
posterior open bite, by preventing the lateral thrust of the
tongue.

69. 1. Ricketts : Bio Progressive therapy
2. Orthodontic current principle and techniques (Graber, Vanarsdall,Vig)
3. Lip bumper therapy for gaining arch length Am j orthod dentofac orthop 1991;100:330-6.
4. Contemporary Orthodontics William R Proffit fourth edition
5. The Quad Helix Appliance Ruel W. Bench
6. T. M. Graber. Jpn.Orthod. So. 42: 442-453, 1983
7. Dentofacial Orthopedics with Functional Appliances second edition (Graber , Rskosi, Petrovic)
8. Removable orthodontic appliances second edition Graber, Neumann
• 2.Influence of’ arch, shape on the transverse eff’cts of transpalatal arches of the Goshgarian type
during
• application ofbuccal root torque G. Baldini and H. ‘U. Luder
• 3.The Transpalatal Arch: An Alternative to the Nance
• Appliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent 2007;29:235-8
• American Journal of Orthodontics and Dentofacial Orthopedics hl memorianl 561 Volume 103, No.
6 Robert Ara Goshgarian 1922-1992
• Transpalatal, Nance and Lingual Arch Appliances:Clinical Tips and Applications Ortho Update
2015; 8: 92-100
REFERENCES