Finishing & detailing in orthodontics / fixed orthodontics course

Seminar on ,
Finishing and Detailing.
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Definition : Finishing in contemporary orthodontics can be defined as
The correction of errors made before finishing
and detailing , over correction as needed, and settling of the case.
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Goals of Treatment:
During the final stage of finishing and Detailing, it is
important to focus on treatment goals,
These goals are:
• Condyles in a seated position- in centric relation.
•Relaxed healthy musculature.
•A six keys class I occlusion with 3mm of overjet and overbite.
•Ideal functional movements- a mutually protected occlusion.
• Good Periodontal health.
•Best possible esthetics.
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Goals according to American board of orthodontics (July 2000)
ABO clarified and quantified the goals of static
occlusion by providing a grading system for study casts and panoramic
radiographs
Emphasis was placed on self assessment of seven features of dental casts,
these features include
1.Tooth alignment (Incisal edges of anterior teeth , mesiobuccal and
distobuccal cusps of mandibular posterior teeth and central fossae of
maxillary posterior teeth should be well aligned).
2.Marginal ridges (Marginal ridges of adjacent teeth should be at the
same vertical level or within 0.5 mm of the same level.Radiographically
the CEJ should be at the same relative height, resulting in a flat bone level
between adjacent teeth)
3.Bucco lingual inclinations (There should not be significant difference
between the buccal and lingual cusps of maxillary and mandibular
premolars and molars with all cusps within 1mm of straight edge)
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Cont….
4. Occlusal relation ship: The mesiobuccal cusp of maxillary first molar
must coincide with in 1mm of buccal groove of the mandibular 1st molar
and buccal cusps of maxillary molars ,premolars , and canines must align
within 1mm of the interproximal embrasures of mandibular posterior teeth.
5.Occlusal contacts: Maximum intercuspation should be established
between the buccal cusps of mandibular posterior teeth and lingual cusps
of maxillary posterior teeth .Each functional cusp should be in contact
with the opposing arch.
6.Overjet: Posteriorly ,the mandibular buccal cusps and the maxillary
lingual cusps are used to determine proper position within the fossa of
the opposing arch. Anteriorly , the Incisal surfaces should lightly
contact the lingual surfaces of maxillary anterior teeth.
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7. Interproximal contacts: All the spaces within the dental arches
should be closed.
8.Root angulation: Generally the roots of maxillary and mandibular
teeth should be parallel to each other and perpendicular to the
Occlusal plane,as viewed in panoramic radiograph.
If roots are properly angulated sufficient bone will be present between
adjacent roots ,an important consideration in periodontal health.
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Andrews six keys to normal occlusion :
Key I : Molar relationship: Distal surface of the distobuccal cusp
of the upper first permanent molar occluded with the mesial
surface of the mesiobuccal cusp of the lower second molar.
The closer the distal surface of distobuccal surface approaches the
the mesial surface of mesiobuccal cusp of lower second molar
the better opportunity for normal occlusion.
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Key II. Crown angulation (tip). The gingival portion of the long
axis of all crowns was more distal than the incisal portion.
crown tip is expressed in degrees, plus or minus.
The degree of crown tip is the angle between the long axis of the
crown (as viewed from the labial or buccal surface) and a line
bearing 90 degrees from the occlusal plane.
A "plus reading" is awarded when the gingival portion of the long
axis of the crown is distal to the incisal portion. A "minus reading"
is assigned when the gingival portion of the long axis of the crown
is mesial to the incisal portion.
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Key III : Crown inclination (labiolingual or buccolingual inclination).
The third key to normal occlusion is crown inclination
crown inclination is expressed in plus or minus degrees, representing
the angle formed by a line which bears 90 degrees to the occlusal
plane and a line that is tangent to the bracket site (which is in the
middle of the labial or buccal long axis of the clinical crown, as
viewed from the mesial or distal).
A plus reading is given if the gingival portion of the tangent line (or of
the crown) is lingual to the incisal portion,
A minus reading is recorded when the gingival portion of the tangent
line (or of the crown) is labial to the incisal portion.
Anterior teeth has positive crown inclination where as posterior teeth
has negative crown inclination.
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Key IV :Rotations. The fourth key to normal occlusion is that the teeth
should be free of undesirable rotations.
Key V: The contact points should be tight (no spaces)
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Key VI: Occlusal plane : Occlusal plane should be flat
Intercuspation of the teeth is best when the plane of occlusion
is flat.
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Factors to be considered in finishing and detailing:
Doughtry ( 1976) outlined 17 factors to be considered in
finishing and detailing.
1.Correction and over correction of antero posterior jaw relation ship.
2.Establish correct tip of upper and lower anterior teeth.
3.Establish correct torque of upper and lower anterior teeth.
4.Coordinating arch forms and arch widths.
5.Establish correct posterior crown torque.
6.Establishing marginal ridge relation and contact points.
7.Correction of midline discrepancies.
8.Establishing interdigitation of teeth.
9.Checking cephelometric objectives.
10.Checking root parallelism .
11.Maintaining closure of all spaces.
12.Evaluating profile and facial esthetics.
13.Checking for TMJ dysfunction's like clicking and locking.
14.Checking functional movements .
15.Determining of all habits have been corrected.
16.Correction of rotations and overcorrection when needed.
17.Establishing flat occlusal plane.
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Two rules in finishing treatment :
1.Inter arch elastics and head gear should be discontinued , and
the rebound from their use allowed to express itself ,4-8 weeks
before the orthodontic appliances are removed.
2.Teeth to be brought into solid occlusal relationship without
heavy arch wires.
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During closing stages of treatment attention is given to following
considerations:
•Horizontal
•vertical.
•Transverse
•Dynamic
•Cephelometric and Esthetic.
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Horizontal considerations :
•Coordination of teeth fit.
•Establishing correct tip of the anterior and posterior teeth.
•Providing adequate incisor torque.
•Establishing correct posterior torque.
•Management of tooth size discrepancy.
•Controlling rotations.
•Maintaining closure of all spaces.
•Horizontal over correction.
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Horizontal considerations:
These include,
a)Coordination of tooth fit :
A major finishing consideration is
coordination of tooth fit in anterior and posterior areas.
It was found that
In approximately 20% cases anterior and posterior teeth fit
well with little or no adjustment.
In approx 60% of cases there is mandibular anterior tooth excess.
In remaining 20% show excess of maxillary anterior tooth material
excess and patient shows some excessive overjet when posterior
segments are in a class I relationship.
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B) Establishing correct tip of anterior and posterior teeth:
Tip is one of the strengths of PEA, especially when twin
brackets of adequate width are used.
With the PEA if proper mechanics with light forces are used
there should be little need to modify the tip measurements as obtained
by Andrews non-orthodontic study models.
Bracket tip is one of the main factor that influence the amount of space
occupied by each tooth ,
A tooth which is tipped occupies more space relative to the tooth which
is upright.
When using anterior brackets with original Andrews tip measurements
a total of 40 deg tip is placed in upper anterior segment and only a
6 deg of tip in the lower anterior segment , the resulting 34 deg of tip
differential helps to increase the upper anterior segment and decrease
the size of lower anterior segment, this helps to achieve improved
fit in 60% of cases having increased lower mandibular anterior excess.www.indiandentalacademy.c
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Increased tip requires additional space
Tipping incisors which are Triangular or barrel shaped will have little
effect on arch length occupied.
Triangular
Rectangular
Barrel
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C) Providing adequate incisor torque:
Torque is the weakness of PEA since approximately
1mm segment of rectangular steel wire is placed in bracket of about
same dimension is required to carry out tooth movement involving
movement of entire portion of root through alveolar bone.
A full size wire is normally not used because such wires do not
slide effectively through posterior bracket slots.
Because majority patients are either classI or class II the general
tendency to place additional palatal root torque in the upper incisor
brackets and additional labial root torque in the lower incisor
brackets.
It is frequently necessary to add palatal root torque( upto 20 deg)
in upper arch wire and 10-15 deg of labial root torque to the
lower arch wire.
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In overjet reduction in moderate to severe class II torque is lost in
upper anterior segment and lowers are angulated forward ,
additional
torque is needed in arch wires to correct incisor angulation.
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Anterior inclination:
Relative inclination of maxillary and mandibular incisors:
Maxillary and mandibular central and lateral incisors
should be in same relative plane compared with one another.
If they are in different planes may cause relapse .
During finishing this can be evaluated using 4 criteria.
1.Incisal edges.
2.Clinical crown length of contralateral teeth ( in unworn dentition)
3.Root prominence.
4.Occlusal prospective (cingulum more prominent on improperly
inclined incisor.)
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D)Establishing correct posterior torque:
Correct posterior torque is essential in preventing
posterior interference's and allowing for seating of centric cusps.
There is often a tendency for upper palatal overhanging cusps ,
requiring posterior buccal root torque.
In lower arch 1st and 2nd molar can show undesirable lingual
tipping and it may be necessary to add buccal crown torque.
Additional buccal root torque needed to adjust upper molars during finishing.www.indiandentalacademy.c
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Posterior inclination:
In 1999 ,casko and codirectors of ABO defined the
relationships between buccal and lingual cusps of maxillary and
mandibular premolars and molars.
According to them , Mandibular lingual cusp should be at the same level
or within a millimeter of the same level as mandibular buccal cusps.
This permits flat occlusal plane and good cusp fossae relation ship of
posterior teeth.
In maxillary posterior teeth ,palatal cusps of the first and second molars
are generally slightly longer and extend slightly more occlusally
than buccal cusps , this is regarded by ABO as normal, however maxillary
palatal cusps should not extend beyond 1mm since it is difficult to
achieve proper occlusal contact between maxillary and mandibular
posterior teeth with out producing cross arch balancing interferences in
lateral mandibular excursions.
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E) Management of tooth size discrepancy :
Tooth size is actually the seventh key to normal occlusion.
Tooth size discrepancy may be corrected
either by reducing tooth mass in one arch with interproximal enamel
reduction (usually lower incisors) or by addition of tooth mass with
restorative material in the opposing arch.
It is more common to find an excess tooth substance in lower arch. If
the Bolton analysis confirms this ,it is often advisable to carry out
interproximal stripping in the lower anterior region in initial stages of
treatment, as finishing stage is approached the relative tooth mass in
upper anterior segment is evaluated and interproximal reduction is
carried on if necessary .
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Controlling rotations:
Rotation control is an important aspect of
finishing and detailing .
The in out compensation built into PEA combined
with correct bracket positioning is most effective in controlling
rotations.
Gingival surgery (preferably CSF procedure) is indicated in patients
who has severe anterior rotations.
CSF procedures are carried 1-4 months before appliance removal after
their alignment.
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Maintaining the closure of all spaces:
In extraction cases during settling stage figure 8
ligature wires should be placed across the extraction site to keep them
closed.
Maintaining space closure using
passive tie backs.
Figure 8 ligation across premolar
extraction site during settling stage
to prevent space reopening.
Figure 8 ligation to maintain
diastema closure.
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Horizontal over correction:
It is often necessary to consider horizontal over correction
of class II and class III cases.During finishing stages of treatment it is
important to fully correct the anteroposterior position of dentition using
class II elastics or class III elastics or headgear.
Immediately after debonding with buccal segment override
Final functional settling of teeth 2 weeks post treatment.www.indiandentalacademy.c
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Alignment:
Proper alignment should be a fundamental objective of any
orthodontic treatment plan.
American Board of orthodontics established guidelines and objective
parameters for assessing anterior and posterior dental alignment.
In mandibular anterior sextant Labioincisal edges of the mandibular
incisors and canines are used to establish proper alignment
This surface was considered since it is the functioning surface of
mandibular teeth and these teeth look best esthetically if there
labioincisal edges are aligned properly.
In maxillary anterior region lingual surfaces of maxillary incisors and
canines are used to assess proper alignment.
This surface was chose since it is the functioning surface of the
maxillary
anterior teeth.If these surfaces align properly maxillary incisors appear
to be in proper esthetic relation ship.www.indiandentalacademy.c
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Alignment: Upper anterior palatal surfaces and lower labioincisal surface
are used to establish proper alignment.
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Posterior alignment:
In mandibular posterior sextant , the buccal cusps
of the mandibular premolars and molars are used to determine
proper tooth position.
This was chosen since it represents the functioning surface of mandibular
posterior teeth and easy to visualize intraorally .
In maxillary posterior sextant central grooves of the
maxillary premolars and molars are used to assess proper alignment.
This landmark was chosen since it represents the functioning surfaces
of maxillary posterior teeth and easy to observe intraorally.
Buccal cusps of premolars
and molars are used to assess proper
alignment.
Central grooves of
maxillary premolars and
molars are used to assess
proper alignment.
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Vertical considerations :
•Correct crown lengths ,marginal ridge relations and contact points.
•Final management of curve of spee.
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Vertical consideration:
Correction of vertical crown positions , marginal
relationships and contact points should be completed during rectangular
stage of treatment, if these are not done then it should be done in
finishing and detailing stage of treatment.
It is often necessary to correct these early in treatment than during
finishing stage for better stability.
Therefore correct bracket placement is essential for achieving these
relations.
Incorrect bracket placement
with compensatory step in
arch wire.
Bracket repositioned and
0.016 wire in place.
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Curve of spee:
In low angle cases it is beneficial to level the entire curve of spee since
excess curve of spee makes it difficult or impossible to complete final
space closure in upper arch and to keep these spaces closed.
In high angle cases it is important to leave some curve of spee at the
back of the arch to prevent the risk of open bite.
Early banding of second molars greatly aids in bite opening
and leveling curve of spee in deep bite low angle cases.
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Marginal ridges : Marginal ridges are used to assess the proper
vertical relationships of maxillary and mandibular posterior teeth.
If the marginal ridges of adjacent posterior teeth are
positioned at the same level then the cusps of those teeth are also at the
same level and even the fossae are positioned at same level.
If the marginal ridges are at the same relative level
then CEJ are at same relative level and bone levels between adjacent
teeth are flat and this produces a much healthier periodontal situation for
the patient.
These are true in cases of non worn ,non restored and
non periodontically involved adolescent dentition.
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But in adult patients with periodontal problems ,tooth abrasion and
existing restorations , the marginal ridges are not a good guide for
posterior vertical tooth position.
In these situations one should rely on bone levels between the teeth
to determine the correct vertical position of adjacent teeth.
It is advantageous to erupt the tooth with bone loss during orthodontics ,
this will level the bone and reduce pocket depth eliminate the
hemiseptal defect, followed by compensatory occlusal reduction.
Alignment of lower incisors with significant bone loss
In these cases it is best to maintain the level of bone
and equilibrate the incisal edges.www.indiandentalacademy.c
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Transverse considerations :
•Arch form
•Transverse overcorrection
•Transpalatal elastics.
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Transverse consideration :
Arch coordination:
Upper and lower arches should be coordinated
right from the early stages of treatment, this helps to eliminate the
occurrence of troublesome crossbites in finishing stage..
In general this is achieved by adjusting the upper arch wire so that
it is 3mm wider anteriorly and posteriorly than the lower archwire.
This helps to establish the correct 3mm of overjet anteriorly and
posteriorly .
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Upper and lower arches are 3mm separated in all dimensions.
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Transverse overcorrection:
The cases showing narrow maxillary arches should be over expanded
and held in over expanded position for an extended period of time.
If the expansion is carried at the beginning
of orthodontic treatment, a palatal bar should be placed after the
expansion procedures and can remain in position until the
rectangular stainless steel wires in place,
Additional buccal root torque in the arch wire is beneficial to allow
posterior segments to settle properly
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Trans palatal elastics ( Buffalo elastics) :
These elastics are some times used for coordination of
the arches at the end of treatment.
These elastics are used to constrict the maxillary arch by producing
trans palatal force on maxillary arch.
These are attached to ball hooks on the maxillary first premolar
bands.
They are prescribed for night time wear as they interfere with speech.
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Dynamic considerations :
Establishing centric relation and checking functional movements:
It is necessary to monitor and to reevaluate the
centric relation position of the mandible and additional corrections
done
prior to finishing of the case ( using inter maxillary elastics).
Patients should be checked for Interferences in protrusive and lateral
excursions.
During protrusive movement lower most anterior teeth make contact
with the upper six most anterior teeth with no posterior contact.
During lateral excursions the patient should experience cuspid rise with
slight anterior contact and disocclusion of posterior teeth on both
working and balancing sides.
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Protrusive, working, and balancing excursions in a mutually
protected occlusion. Note absence of posterior contact
on all excursions.
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Final stage of finishing :
During closing stages of treatment much
lighter wires are used since rectangular stainless steel wires are
restrictive for settling of teeth in closing stages of treatment.
Typically .014 or.016 heat activated Ni-Ti is used in the lower arch
coordinated with upper arch.
In the upper arch a .014 round sectional arch can be placed from
lateral incisor to lateral incisor( if canines are displaced labially then
extended up to canines) . These wires can be accompanied by the use
of vertical triangular elastics when settling needs to occur.
The better the bracket placement the less elastics need to be used.
It is beneficial to retain all bands and brackets on the teeth during
settling so that if any unwanted changes occur these can be corrected.www.indiandentalacademy.c
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Serpentine wiring :
This is done about one week prior to appliance
removable.
Purpose : For settling of occlusion without any interdental spacing
Method: Upper and lower arch wires are removed but the TPA and
molar bands are left in place, teeth are ligated in a serpentine fashion
from second premolar to second premolar with standard ligature wire.
The patient is instructed to chew gum as much as possible .
This method is ideal if there are only minimal discrepancies remaining
in tooth position.
Indication : class II div 2 malocclusion.
Serpentine wires from second premolar to second premolar.www.indiandentalacademy.c
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Vertical Spaghetti elastics:
These are used one week before appliance removal ,
Maxillary and mandibular arch wires are removed, 0.016 ss wire
is placed in mandibular arch and no arch wire is placed in the
upper arch brackets.
Using elastics of 3/16 , 2-3.5 ounce elastics a series of triangular
elastics are placed between the two dental arches
Patient is instructed to wear the spaghetti elastics on almost full
time basis for a week before appliance removal.
These elastics are useful in patients whom there is difficulty in
closing the bite whether anteriorly or posteriorly,
Contraindicated in malocclusions presented originally presented
with deep bite ( Class II div2).
Spaghetti elastics in incisor area.
Vertical spaghetti elastics
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Settling Elastics:
Elastics with class II pull:
Elastics with class III pull :
Class II settling elastics class III settling elastics.
M with a tail configuration
for open bite and class III
tendency.
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Cephelometric and esthetic considerations:
The most important factors to be evaluated with the
cephelometric head films taken approximately 3-4 months
before debonding
these are
A)soft tissue profile.
B)Antero posterior position of incisors.
C) Torque of incisors
D)Changes in mandibular plane.
E)Success in correcting the horizontal skeletal and dental
components .
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Evaluation of esthetic Factors of anterior teeth:
These are analyzed by sitting or standing in front
of the patient.
Theses are
•Crown lengths of maxillary and mandibular incisors.
•Incisal edge contours
•Axial inclination of all maxillary and mandibular incisors.
•Midlines( upper ,lower.facial and labial)
•Crown torques.
•Smile line ( rest position and full smile)
•Right -left symmetry of crown shapes and sizes of gingival marginal
levels.
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Crown width :
Maxillary lateral incisors are the most variable teeth
in size and shape.
If malformation is unilateral or mesio distal width
discrepancy is significant, esthetics and occlusion could be adversely
affected if the malformed tooth are ignored.
Therefore during orthodontic treatment space
should be maintained or created to built the crown and restore it to
normal size and shape.
Space between right central and canine is opened and restored.www.indiandentalacademy.c
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Gingival levels:
The relationship of the gingival margins of six
maxillary anterior teeth plays an important role in esthetic appearance of
the crowns.
Four characteristics contribute to ideal gingival form .
A)Free gingival margin of the two central incisors should be at the same
level.
B)Gingival margins of central incisors should be positioned more apically
then laterals and at the same level as canines.
C)The contour of labial gingival margins should mimic the CEJ of teeth.
D)There should be a papilla between each tooth and the height of
tip of the papilla is usually halfway between Incisal edges and labial
gingival height of contour over the center of each anterior tooth
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Gingival marginal discrepancies between the adjacent teeth could be
caused by abrasion of Incisal edges or delayed migration of gingival
levels.
These gingival marginal discrepancies can be corrected either by
orthodontic tooth movement or surgical correction of gingival
margin discrepancy.
Four criteria to make correct decision :
1.Patients lip line when the patient smiles ( if smile line is below the free
margin then requires no correction)
2.Labial sulcular depth :If the shorter tooth has a deep sulcus, excisional
Gingivectomy may be appreciated to move the gingival margins of shorter
tooth apically.
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3.Evaluate the relationship between shortest central incisor and adjacent
lateral incisor: If the short central incisor is longer than laterals then it is
possible to extrude the Longer tooth and equilibrate the incisal edge.
4.If the incisal edges are attrited and tooth had supra erupted , then
the best method to correct the gingival discrepancy is to intrude the
short central incisor and building restoration of incisal edges
Intrusion of short central incisor and building restoration incisal edges.
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Gingival form :
The presence of papilla between the maxillary central
incisors is a key esthetic factor in any individual.
Occasionally adults will have open gingival embrasures or black
triangles spaces above contact areas that look unesthetic .
This spaces is usually due to
1.Tooth shape.
2.Root angulation.
3.Periodontal bone loss.
In case of periodontal bone loss and papilla is receded extrusion of
selected teeth and equilibration and align the roots.
If triangular tooth shape is the cause then flatten the incisal contact
and closing the space.
If the roots are angulation is divergent causing excessive space
they should be corrected to descend the papilla down and overcome
the dark triangular spaces.
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Open gingival embrasure caused by tooth shape (Triangular teeth).
The solution is to reshape the tooth and close the space and eliminate
the open gingival embrasure.
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Implication of bracket selection and Bracket placement on finishing
Details:
Selection of buccal tubes : It is desirable to place mandibular first molar
buccal tube with out distal offset since that seems to deliver proper
contact relationship between the mandibular first and second molar.
Effect of distal offset on the
first molar tube in the mandibular
arch, causing distolingual rotation
and break in contact point.
Contact point when the
first molar tube with
out
distal offset is used.
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Torque value on maxillary molars :
It is advisable to have buccal tubes
with more buccal root torque on maxillary second molars than maxillary
first molars to prevent undesirable extension of lingual cusps of second
molars into occlusal plane creating balancing interferences resulting
in inadequate settling of posterior occlusion.
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Implications of vertical placement on expressed torque:
There is a definite impact on expressed torque with
vertical position of bracket.
The intensity of expressed torque on the vertical position of bracket
depends on the degree of convexity of the labial surface of the teeth.
Therefore maxillary central incisor which has mild degree of convexity
on the labial surface ,the change in vertical bracket positioning results
in change in vertical position of tooth relative to archwire but only a
Slight change in expressed torque.
Whereas maxillary canine which has greater degree of convexity of
labial surface ,even a slight change in vertical bracket positioning results
in extrusion and marked degree of labial root torque is expressed.
Therefore it is important to place brackets at correct vertical position,
in cases of attrition of cusps of canines the bracket should be
placed considering the amount of attrition .
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Varying vertical positions of the
bracket on maxillary central incisor
causes change in vertical position
and minimum change in lingual
root torque.
Change in bracket position on
canine tooth by 2mm causes
extrusion and significant increase
in the labial root torque.
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Correction of midline discrepancies :
Bilateral Class II component: double
Class II elastics on right side, single
Class II elastic on left.
Case with Class II molar relationship on
right side and Class I on left: single Class
II elastic on right side.
Class II molar relationship on right
side and Class III on left: Class I dental relationship on right side
and Class III on left: single Class III elastic
on left side
Discrepancy primarily in anterior segment: anterior cross elastic.www.indiandentalacademy.c
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Occlusal check list in Finishing : ( Bio progressive therapy)
An occlusal check list including eight areas
in each arch is used in establishing the ideal finishing arch configuration
and individualized tooth rotation in our over treated orthodontic
finishing occlusion. This check list procedure is used in gaining the
final completed details necessary in accomplishing the desired
finishing objectives.
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MAXILLARY ARCH :
1. Width across first and second molars.
2. Distal rotation of first molar so that line drawn through
distobuccal and mesiolingual cusps points to the distal third
of the opposite side cuspid ( in extraction case mesial of canine)
3. Mesial offset (large) on molar.
4. Mesial rotation of lingual cusp of first bicuspid to seat in
distal fossa of lower first bicuspid.
5. Premolar offset (2-3mm) to avoid first area of prematurity.
6. Cuspid brought into contact with lower cuspid and premolar
to establish cuspid rise.
7. Lateral incisor left labial (until retainer) to allow overtreatment
of buccal segments; then tucked in.
8. Smooth arc across incisors.
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Check list for maxillary arch :
1.Arch width : Arch width should be checked at
first and second molar region. They should be well expanded to
compensate narrowness present at the beginning of treatment This width
increase is necessary to allow and encourage an improved torque and
function.
2. Upper first molar rotation: A line drawn from the
tip of the distal buccal cusp extended through the mesiolingual cusp tip
should pass through the canine of the opposite side. The upper first molar
should be distally rotated until its distal buccal cusp can contact the
mesial buccal cusp of the lower second molar.
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The upper first molar is rotated 15 ° distally,
so that a line drawn through its distobuccal cusp would
point at the distal of the opposite cuspid
Roots inclined
slightly to lingual
There is a slight distal root tip as the
upper first molars settle into a normal
Class I occlusion.
Maxillary first
molars:
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3.Upper second bicuspid:
This is considered the key to finishing
because the lower 1st molar and the upper 1st molar both must be
correct before its proper position can be attained.
Care should be exercised to make certain the distal margin
of the upper bicuspid is well occlusal to the marginal ridge
of the upper first molar.
The upper second bicuspid may appear to be slightly inclined mesially.
The upper first bicuspid :
It should be parallel to the occlusal plane
buccolingually. It may also appear to be slightly distally inclined
because the mesial marginal ridge is lower than the
distal marginal ridge.
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As with the maxillary first molar, buccal root torque assures
that the roots can be slightly to the lingual
and supported by the dense cortical bone of the palate— particularly
when expansion is part of the treatment mechanics.
A mesial root tip of -5° in extraction cases facilitates root paralleling.
Maxillary bicuspids:
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Maxillary canines :
Another key tooth in finishing is the upper canine.
The tooth is overtreated in the finishing stages
of Class I and Class II malocclusion corrections.
It should be reversed and overtreated forward toward the Class II side in
Class Ill malocclusions.
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Maxillary Canines :
Consistent with a 134° intercanine angle, the upper cuspid
should be torqued slightly to the lingual
The torque differential between the upper laterals and canines (14° to 7°)
should be kept to a minimum to maintain integrity
of the labial surface contours.
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Lateral incisors :
The upper lateral incisor is kept labially. Overtreatment of the
upper buccal segment and the labial position of the lower lateral
requires that the upper lateral not be stepped lingually.
A gingival step of ½ to 1 mm would be required to clear the longer
cusp of the lower cuspid in excursions of the mandible.
The upper lateral would therefore have to be depressed excessively or
else placed forward in its final position. This forward position is
preferred to the intruded position by the patient because of the esthetics
Finally the upper central's contacts are considered.
Upper and lower midlines should be coincided and the tooth size and
mass can be checked for their final settling potential.
The roots are torqued to a 134° interincisal angle and the long axis is
aligned to closely parallel the cephalometric facial axis.
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Maxillary incisors :
Lingual root torque with interincisal angle of 134 deg.
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With full arch wire engaged active torque
brings all upper roots into support by dense
lingual cortical bone of palate.
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MANDIBULAR ARCH:
1. Arch width across second molars.
2. Distal of first molar rotated lingually until the distobuccal
cusp approximates mesial sluice way on second molar.
3. Large buccal offset at mesial of first molar.
4. Check inter-bicuspid width for necessary expansion.
5. Proper buccal arch form and contour.
6. Premolar offset to bring it in contact with distal lingual
incline of upper canine (2-3mm).
7. Mesial of cuspid tucked slightly behind lateral incisor
distal of the cuspid buccal.
8. Over-rotation of incisors; smooth arc.
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Finishing check list in lower arch :
1.Second molar : Molar width at Lower second molar and check for
uprightness and any rotations.
.
The lower second molar should be tipped (5 deg )distally during treatment
because it will settle mesially as the distobuccal cusp of the upper first molar settles into
the lower first and second molar embrasure.Rotated distally(12 deg) and have labial root torque.
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Mandibular First molar :
First molar distal contact should be at least 1/3
inward from the buccal on the marginal edge of the second molar.
The lower first molar is checked for uprightness and the mesial is
slightly outward in preparation to accommodate the distal incline
of the upper second bicuspid
In an ideal final position, the mandibular first molar
has 5 degree distal crown tip
and rotated distally(12 deg )
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3.Second premolar:
Distal contact of the lower second bicuspid
would appear to be slightly depressed for the preparation
of the seat for the upper second bicuspid.
Each tooth in the lower arch is progressively narrowed
in a smooth catenary curve.
.
The lower second bicuspid should have buccal root torque
symmetrical with the lower first and second molars,
because their main cortical bone support is through
the external oblique ridge. And with zero degree tip, but in extraction cases 5 deg mesial
tip for root paralleling.
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4.First premolar : The lower first premolar is very critical.
This tooth should appear to be buccal to the lower canine and should
be well elevated. The mesial contact should be to the buccal.
This will serve as a point of relation for canine contact.
If this tooth is not far enough to the buccal, a tendency for
prematurity will be experienced in occlusion with the upper 1st bicuspid.
.
The buccal cusp seats in the distal fossa of the upper first bicuspid,
allowing the lower first bicuspid to act as a posterior tooth and to
function as a masticator.
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5.Canine : Canine is critical in mechanical and proprioceptive function
This tooth is principally to change arch shape.
The typical position produced is a smooth corner of the catenary curve.
In wide arches, a cuspid eminence is present, but in tapered arches this
tooth is held inwardly on the mesial contact of the lower first bicuspid,
which may rotate forward
Has 5 degree tip and seven degree torque and 0.5 mm lingual
to lateral incisor.
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6. Incisors :
In finishing, we overlap the lateral incisor distal
contact slightly to the labial of the mesial contact point of the canine.
This lapping permits adjustment of canine labiolingually and vertically
in finishing and locks the lower anterior segment and stabilizes
the lateral incisor.
The ideal torque of the lower incisor— as with the upper incisor— varies
with facial type. However, a torque of -1° allows enough flexibility
for increase or decrease in torque as required by dolichofacial or
brachyfacial types.
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Settling of teeth :
Final step of finishing is called settling,
Purpose : Bring all teeth into solid occlusal relationship before
teeth patient the patient is placed in retention.
How to settle the occlusion : There are 3 ways to settle the
occlusion.
1.By replacing rectangular wires at the very end of treatment with
with light round arch wires that provide some freedom for
movement of teeth.
2.With laced vertical elastics after removal of posterior segments
of the arch wires .
3.With the use of tooth positioner.
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Using light round wires Replacing rectangular wires :
This was the original method for settling ,recommended
by Tweed in 1940.
According to him : These light wires must have first and second order
bends as used in rectangular wires.These light arch wires will quickly
settle the teeth into final occlusion and should remain in place for
only a few weeks at most.
vertical elastics are used only if needed.
Disadvantages : Precise control of anterior teeth is lost by using
light continuous round wires .
Latter in 1980s the above method was replaced with Removing only
the posterior part of rectangular wire ,leaving the rectangular wire in
anterior segment ( Typically canine to canine or premolar to premolars).
Using laced elastics to bring posterior teeth into tight contact.
Disadvantage : Since this method do not have control over posterior
teeth therefore should not be used in patients having major rotations or
posterior cross bites.
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Elastics : Elastics for settling are laced around tubes and brackets .
A typical arrangement is to use light 1/4 -inch elastics with
class II or class III depending on whether slightly more correction
is desired.
These elastics should not remain in place for more than 2 weeks, one
week is usually enough to accomplish desired settling.
Vertical triangular elastics for settling of occlusionwww.indiandentalacademy.c
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Triangular elastics aid in improving class I cuspid intercuspation
and closing minor open bites of 0.5 to 1mm.
Anterior vertical elastics with class II with class III pull
Finishing Elastics in case with open bite :
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Positioners for finishing :
An alternative to segmental elastics or light
round arch wires for settling is a rubber or plastic tooth positioner.
Advantages :
•It allows the fixed appliance to be removed somewhat quickly than
otherwise would have been, therefore some finishing that could have
been done with final arch wires can be left to positioner.
•It serves not only to reposition the teeth but also to massage the
gingiva and promote the inflamed gingiva to rapid return to normal
gingival contours.
•Advantage if the initial problem is an open bite.
Disadvantages: Increased lab work, Expensive, Needs good patient
cooperation
•Positioner tends to increase the overbite more than when compared to
settling with light elastics so cannot be used in patients with initial
deep bite.
•Cannot maintain the correction of rotations(ie minor rotations recur)
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Positioners :
Indications : 1.Gingival condition with more than usual degree of
inflammation and swelling at the end of active orthodontics.
2.Cases with an open bite tendency ,so that settling by mild
depression rather than elongation of posterior teeth is needed.
Contraindications :Severe malalignment and rotated teeth.
Deep bite tendency
Uncooperative patient.
Duration of wear:
Positioner should be worn at least 4 hours during day
time and during sleep.
Positioner in a cooperative patient will produce any
changes it is capable of with in 3 weeks, beyond that time it serves as a
retaining devise than a finishing device.
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Finishing and detailing in Refined Begg :
Finishing with Begg appliance is difficult but
not impossible.
Difficulties in finishing with Begg appliance arose
because of use of round arch wires in the Begg bracket.This
combination is efficient in first order (rotational)detailing
and adjust the vertical levels of the teeth but lacks the
second order(mesio-distal) control and third order(torque) control
which are vital ingredients of finishing and detailing.
Hence during finishing one must provide these missing ingredients
by a continued use of the third stage auxiliaries or use a
rectangular (ribbon or square) finishing wire for torque control.
Rectangular wire finishing has added advantage of
being able to apply torque to any or all posterior teeth.
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Round Finishing arch wires :
0.020’’ stage III wires can be used for finishing
unless large vertical displacements of teeth are required for settling
of teeth.
If large vertical movement (more than 0.5 mm) then 0.018’’ can be
used which provides greater freedom for vertical movement and
more wire flexibility.
If the entire segment of the teeth to be moved significantly vertically
(as in closing an open bite) ,in this case 0.020’’wire can be sectioned
either in upper or lower arch , and appropriate elastics are applied.
Some additional first and second order bends may be required in
the arch wires.
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First order adjustments :
1.Proper labio-lingual position of upper lateral incisors,
.Upper laterals are slightly tucked lingually with horizontal
offsets to compensate for difference in then labiolingual thick ness
of central and lateral incisors. This provides proper alignment and occlud
well with labio-incisal edges of the four lower incisors.
2.Canine off set for upper canine prominence.
3.Offset between premolar and molars to compensate for different
buccal contours is continued in finishing stage.
4.Toe-in for Upper first molar for distolingual rotation in order to
obtain good class I molar relationship.
5. Curvature between upper canines and molars is flattened if the
upper premolars are expanded more than required.
6.In cases of severe lower anterior crowding the canines are tucked in
by inset between lower lateral incisors and canines and offset between
canines and premolars.
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Second order adjustments :
1. Upper laterals are shorter than central incisors and canines , vertical
arch wire steps may be required if the bracket height is not correct.
2.The molar section of the arch wire is given a mild occlusal (tip down)
bend since a slight mesial angulation of upper first molar for seating
its distobuccal cusp against mesiobuccal cusp of corresponding second
molar according to Andrews.
3. Upper canines are slightly more mesially angulated to make their
cusp tips occlude with distal half of labial surface of lower canine,
not in the embrasure between lower canine and premolar.
4.Levels of lower canines and lateral incisors are to be adjusted if
necessary , by a step in the arch wire between them.
It is necessary to over tip and over torque by 10-15%
so that they settle to their correct tip and torque during finishing.
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Finishing arch wires with
First order bends in
upper laterals ,canines ,
lower canines and all molars.
Finishing arch wires with
second order bends in posterior
areas.
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Rectangular finishing wires in refined Begg :
Rectangular molar tubes can be used from beginning
using combination tubes or they can replace round tubes during
finishing stage.
It is preferable to use alpha-titanium 0.022’’ x 0.018’’ ribbon wire
for finishing due to following reasons :
It is possible to build the precise degree of torque in the anterior
segment and because of slight play of the wire in the bracket
mild over torque is built in the wire compared to the actually required
torque.
Its vertical dimension 0.022’’ gives enough clearance in
the 0.040’’ Begg vertical slot for vertical settling of the teeth.
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Finishing time :
Actual amount of Finishing and detailing time
can be increased in situations like :
1. Variations in the shape and size of the patient's teeth relative to the
average measurements used for the pre adjusted appliance.
2. Inaccuracies or shortcomings in appliance design relative to its
measurement goals (in other words, whether the three-dimensional
forces delivered by the appliance correspond to the measurements used
in its design).
3. Utilization of force levels that "overpower" the selected appliance
design.
4. Inaccuracies in appliance placement relative to the design of the
appliance.
5. Failure to allow sufficient time for the bracket system to express itself.
(Leaving the appliance in place for an additional three months after
major corrections are complete, and retying at monthly intervals, will
often produce further favorable tooth movements.)
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Conclusion:
The concept of occlusion requires detailed
study of stomatognathic function such as mastication ,speech ,
deglutition, as well as careful investigation of inter relation ship
of morphology of a particular stomatognathic organ and resultant
function of overall stomatognathic system. When in harmony
these two elements can produce both a pleasing appearance
and ongoing optimal health of component parts of system.
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Finishing & detailing in orthodontics / fixed orthodontics course

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