Space gaining in fixed orthodontics /certified fixed orthodontic courses by Indian dental academy


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Space gaining in fixed orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. SPACE GAINING IN ORTHODONTICS 1. Molar distalization 2. Expansion 3. Proximal stripping 4. Extraction
  3. 3. Necessity of space regaining in orthodontics To correct:  anterior proclination  crowding  anterior cross bite  posterior cross bite  Curve of spee  Rotated anterior teeth  Narrow dental arch  Molar relationship
  4. 4. Localized Space Regaining (3mm or less) After premature loss of primary tooth, space maybe lost from the drift of other teeth. Upto 3mm of space can be re – established in a localised area with relatively simple appliances and a good prognosis
  5. 5. Maxillary space regaining Generally space regaining is easier in maxillary arch than in mandibular arch. Permanent maxillary first molar can be tipped distally. A removable appliance retained with Adam’s clasp and incorporating a helical finger spring adjacent to the tooth to be moved is very effective. This appliance is ideal design for tipping one molar. One posterior tooth can be moved up to 3mm distally during 3 – 4 months.
  6. 6. Mandibular Space Regaining If space has been lost on one side of the mandibular arch the appliance of choice is removable lingual arch incorporating a loop that can be opened to provide the necessary distal force. An alternative fixed appliance for mandibular space regaining is a lip bumper, which is a labial appliance fitted to the molar teeth. The idea is that the appliance against the pressures of the lip which creates a distal force to tip the molars posteriorly.
  7. 7. Molar Distalization Criteria for molar distalization:  Class II or end to end molar relationship  Maxillary dental protrusion  Mild to moderate crowding  Midline discrepancies  End on or full Class II molar relationship due to impacted cuspid
  8. 8. Types of appliances INTRA ORAL METHODS • Repelling Magnet • Super elastic NiTi wires • Jones Jig • Lokar molar distalizer • Pendulum appliance • Modified pendulum appliance • Fixed piston appliance
  9. 9. •K-Loop Molar distalizer • Distal Jet • NiTi coil Springs • Fixed palatal expander • Super spring II • Franzulum Appliance • C – Space regainer
  10. 10. Repelling magnets Intra arch repelling magnet used to distalize molar where introduced by Gianelly et al in 1988. These are pre fabricated repelling Samarium – Cobalt magnets with pole face 2x5 mm the magnets are attached to the head gear tube of maxillary first molar bands and repelling surfaces are bought into contact by 0.014 ligature wire. Anchorage is reinforced by Nance appliance and Class II elastic against a 0.016 x 0.022 sectional arch wire.
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  12. 12. Superelastic NiTi Wire This is also referred to as Neosentalloy and has shape memory. Locatelli et al 1992 used a 100gm Neosent alloy wire with shape memory for molar distalization. Crimp stop just distal to the first molar bracket are placed 5-7mm distal to anterior opening of molar tube and hooks between the lateral incisor and canine. Excess wire is deflected gingivally. As wire returns to the original shape it exerts 100gm distal force against the molar. Anchorage is controlled by placing Class II elastics and is reinforced with Nance appliance cemented to the pre molars.
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  14. 14. EXPANSION AS A MEANS OF SPACE GAINING Arch expansion : defined as the enlargement of the dental arches by the lateral movement of buccal segments. It is one of the non-invasive methods of space gaining. It is usually undertaken in a patient having constricted maxillary arches or in a patient with unilateral cross bite. It can be skeletal or dental. Skeletal expansion involves splitting of the mid palatal suture while dentoalveolar a dental expansion with no skeletal change.
  15. 15. Indication of expansion • Class II div II cases • Collapsed maxillary arch • Unilateral crossbite • Bilateral crossbite • Maxillary rotated upper molars • A tapered anterior arch from • Any cleft palate • Abnormal muscle activity • Blocked upper canine
  16. 16. Expansion can be broadly classified into 2 types: 1. Rapid expansion 2. Slow expansion.
  17. 17. RAPID MAXILLARY EXPANSION   RME was first described by Emerson C Angell  in 1860 by using screw appliance. Maxillary expansion  had long be reported in the medical literature as a  modality to manage ENT of impaired nasal airflow,  DNS, etc. but its used in orthodontic fraternity was  marked by the reports published by Hass (1961 – 65).  The prime objective for an orthodontist of palatal  expansion is to co ordinate the maxillary and  mandibular denture base
  18. 18. Indication of RME Marked maxillary arch narrowing Unilateral and bilateral cross bite Prognathism, reduced anterior development of maxillary Denture base Steep palate with septum deviation and mouth breathing Cleft lip and palate Posterior crossbite
  19. 19. Contra - Indication of RME      Patient who cannot co – operate       Patient with single tooth cross bite      Patient with anterior open bite, steep mandibular  planes and convex profile      Skeletal asymmetry of the maxilla and the mandible  and adults with severe anterior, posterior and  vertical discrepancies      Without the completion of fusion o mid palatine  suture
  20. 20. Age and the prognosis with RME 7 – 15 yrs GOOD 15 – 20 yrs GOOD, although the patient is recalled daily or every other day to check opening of the suture 20 – 30 yrs Possible but frequent recall is necessary, danger that suture does not open and overloading the posterior segment, ulceration of the mucosa.
  21. 21. Types of Rapid Maxillary Expansion 1. Removable                         A removable type of RME device consist of  split acrylic plate with a midline screw. The appliance is  retained with clasps on the posterior teeth 2. Fixed a. Tooth borne                              b. Tooth and tissue borne Issacson type                                         Derichsweiler type  Hyrax type                                              Hass type                                                   Bidernan type
  22. 22. SLOW EXPANSION   This method has been advocated more recently  (HICK). In this method the total force builds up is less.  It appears that approximately 1mm per week is the  maximum rate at which the tissue of the mid palatal  suture can adapt to produce expansion at this rate 2 – 4  pounds of force appears optimal. Unlike in RME,  where the treatment is completed in 1 – 2 weeks, slow  expansion may take as much as 2 – 5 months. Slow  expansion has traditionally been termed as  DENTOALVEOLAR EXPANSION.
  23. 23. Indication for Slow Expansion   •  Full cusp cross bite with skeletal component •  Some degree of dental as well as skeletal  constriction •  No pre existing dental expansion •  No open bite tendency
  24. 24. Types of Slow Expansion devices        JACK SCREW         COFFIN SPRING          QUAD HELIX
  25. 25. Jack Screw The various Jackscrews used for the RME can be used for  the SME but with more spread out activation. In addition  these screws may have a smaller pitch than those used for  RME
  26. 26. Coffin Spring It is designed by Walter Coffin. It is a  removable appliance capable of slow expansion. It  consists of an omega shape wire of 1.2mm thickness  in the midpalatal region. The free ends of the wire  are embedded in acrylic covering the slope of the  palate. Activation is done by pulling the two sides  apart. 3 prong plier can be used for activation.
  27. 27. Quad Helix It consists of a pair of anterior helices and a pair of  posterior helices. Wire between anterior helices is called  bridge and between the posterior and anterior helices is  called palatal bridge. The arm rest against the lingual  surface of the teeth which requiring expansion
  28. 28. Coffin spring                  Quad helix
  29. 29. Comparison of RME and SME       RME                                                      S M E                                                                                  Fixed appliance                               Removable appliance  Orthopedic movement                    Orthodontic movement  Widening of about 10mm in           Widening of per week  4 weeks time about                           0.5 – 1.0mm per week
  30. 30. Arch expansion using fixed appliances   In patient undergoing fixed mechanotherapy  mild arch expansion is possible by expanding the arch  wire. In addition appliances such Quad helix and Coffin  spring may be used.
  31. 31. Uprighting of Molars as a space gaining method Derotation of posterior teeth as a space gaining procedure Proclination of anterior teeth In some cases the anterior teeth might be retroclined. By proclination of such type of teeth we can gain some space but it should not affect patient’s soft tissue profile.
  32. 32. Proximal stripping It is a method by which the mesio-distal width of the teeth is reduced to gain the space. It is also known as reproximation, disking or proximal slicing. This procedure is mainly carried out in lower anteriors but it can be done in buccal segments of the upper and lower arch.
  33. 33. Indication of proximal stripping: • It is generally carried out when the space required is minimal i.e. 0 – 2.5mm. • If the Bolton analysis shows very minimal excessive tooth material Contraindication: • It is not carried out in a young patient because of large pulp chamber which increases the risk of pulpal exposure Patients who are very susceptible to caries
  34. 34. Advantage of proximal stripping: • In borderline cases when the space required is minimal to avoid the extraction • A more favorable overbite and overjet can be established by eliminating tooth material excess in either of the arch. Disadvantage: • High risk of plaque accumulation due to roughened enamel surface • Caries susceptibility increased due to the roughened surface • • Patient might feel sensitivity Tooth morphology might be altered
  35. 35. Extraction To extract or not to extract’ has always been the key question in planning of orthodontic treatment. The extraction controversy in 1920 was based upon the thought of two pioneer in orthodontics namely Edward angle and his student Charles tweed. Edward angle believe that all individuals is capable of 32 teeth in normal occlusion and orthodontic treatment can be carried out by arch expansion.
  36. 36. Extraction Guidelines Ideally arch length and tooth material should be in harmony with each other. The presence of excess tooth material can result in crowding, proclination etc. in that case extraction is compulsory.  Less than 4mm arch length discrepancy – extraction rarely indicated.  Arch length discrepancy 5 – 10mm – both extraction and non- extraction treatment is possible  Arch length discrepancy 10mm or more – extraction is required.
  37. 37. Extraction of upper incisors  Extraction of upper incisors are rarely carried out in orthodontic therapy but in some cases upper incisors may have to be sacrificed.  Conditions where upper incisors is extracted  Impacted – prognosis is not good cant be brought to normal alignment.  Grossly Carious - which is not restorable.  Trauma – cannot be repaired
  38. 38.  missing the other side lateral incisor can be extracted to maintain the symmetry.  Dilacerated Root-cant be moved by orthodontic treatment .  Buccaly or lingually blocked out lateral incisors with good contact between central incisors and canine
  39. 39. Extraction of Lower Incisor  It should be avoided as far as possible which may lead to  collapse of the lower arch by reducing inter canine width  remaining anterior teeth tend to imbricate  deep bite  Retroclination of lower incisors
  40. 40. INDICATIONS Conditions where lower incisor extraction may be carried out :  if one of the incisors is completely out of the arch and the remaining teeth have good contact.  traumatized or severe bone loss  in mild Class III cases with crowding  Class I with anterior dental cross bite due to lower anterior crowding and lower incisor protrusion 
  41. 41. CONTRA – INDICATIONS  Deep bite cases with horizontal growth pattern  All cases which require upper first pre molar extraction while canines are in Class I relationship  Bimaxillary crowding cases with no tooth size discrepancy in incisor area  Cases having anterior discrepancy due to either a small lower incisor or large maxillary incisor
  42. 42. Extraction of Canine Canine plays an important role in facial esthetics, so extraction of canine is rarely indicated.  Conditions where canine may be extracted :  if the canine is placed completely out of the arch and good contact is present between laterals and premolars  canines are highly susceptible to ectopic eruption or impaction. If they are placed in unfavorable position they maybe extracted.  ankylosis or internal or external root resorption or dilaceration 
  43. 43. Extraction of Premolars       Premolars are the most commonly extracted teeth in the orthodontic therapy. ANCHORAGE – when maximum anchorage is needed then first premolar can be extracted. When minimum anchorage is needed then second bicuspid may be extracted. GROSSLY CARIOUS – a heavily restored or endontically treated premolar should be chosen for extraction. MALPOSITION – malposed bicuspid should be chosen for extraction. IMPACTION – impacted premolar whose prognosis is not good should be chosen for extraction. ARCH LENGTH AND TOOTH MATERIAL DISCREPANCY – if the discrepancy is minimal the second premolar should be extracted if the discrepancy is maximum first premolar should be extracted.
  44. 44. Extraction of First Molars The 1st permanent molar has been esteemed as untouchable from the very beginning of the history of orthodontics. It is considered as the consistence of the dentition always at its right position in the arch. It is said that it should never be removed.  Extraction of 1st molar avoided because:  it does not give adequate space in the incisor region  deepening of bite  poor contact relation between 2nd premolar and 2nd molar  2nd premolar and 2nd molar may tip into extraction space  mastication is affected 
  45. 45. INDICATIONS minimum space requirement for correction of anterior crowding or mild proclination  decayed or periodontally compromised having a poor long term prognosis  impaction or abnormal developmental position  high maxillary or mandibular plane angle  anterior open bite 
  46. 46. Wilkinson’s extraction        Wilkinson advocated extraction of all 1st permanent molars in between the age of 8 ½ - 9 ½ years. The basis of such extraction is the fact that the first molar are highly susceptible to caries. The other benefits of extracting 1st molar at an early age are : the extraction provides additional space for eruption of 3rd molars. Thus impaction of 3rd molars can be avoided in general, crowding of the arch is minimized, thus the other teeth are at a low risk of caries DRAWBACKS: The extraction of first molar offer limited space to relieve crowding The 2nd bicuspid and 2nd molar rotate and may tip into the extraction space The removal of the 1st molar deprives the orthodontist of adequate anchorage any orthodontic appliance
  47. 47. Extraction of Lower Second Molars  Lower second molar is often not removed for the relieve of crowding. Its position at the end of dental arch means that it is usually removed from the site of crowding and is not itself actually not malpositioned through crowding but extraction maybe indicated in the following cases:  to relieve the impaction of 2nd premolar  to relieve the impaction of mandibular 3rd molar  severely carious ectopically erupted or severely rotated
  48. 48. Extraction of Maxillary Second Molars  Indications: in mildly crowded cases where less than 3- 4mm space is required for the labial segment  to make the space for crowded 2nd premolar by retraction of 1st molar  when permanent 2nd molar are impacted against the permanent first molar 
  49. 49. Contra indication of extraction maxillary second molars Maxillary third molars are too high in tuberosity or show delayed eruption  Undersized crown or root  Absence of third molar buds 
  50. 50. Third Molars  Extraction of third molars during orthodontic treatment doesn’t yield space that can be used for decrowding or reduction of proclination. Although there are some conditions where third molars can be extracted, grossly impacted third molars that are unable to erupt into the ideal position  dilacerated roots  The erupting mandibular third molars have been implicated to the cause of late lower anterior crowding.
  51. 51. SERIAL EXTRACTION It is an interceptive orthodontic procedure usually carried out in the early mixed dentition period. Its purpose is to reconcile a persisting discrepancy between the amount of tooth material present and the available jaw space. It involves the extraction of deciduous and permanent teeth to increase the available space thereby permitting remaining permanent teeth to assume a more normal position and occlusal relationship.
  52. 52. Indications for serial extractions: In Class I malocclusion showing harmony between skeletal and muscular system Arch length deficiency as compared to the tooth material is the most important indication of serial extraction. Arch length deficiency is indicated by presence of any one of the following
  53. 53. Contraindication of serial extraction  Spaced dentition  Anodontia / oligodontia  Class II or Class III with skeletal abnormalities  Midline diastema  Class I malocclusion with minimal space deficiency  Open bite - should be treated before undertaking serial extraction
  54. 54. • Absence of physiologic space • Midline shift of mandibular incisor due to displaced lateral incisor • Abnormal or asymmetric primary canine root resorption • Lingual eruption of lateral incisors • Mesial migration of molars • Flaring of lower anteriors
  55. 55. Procedure for Serial extraction DEWEL’S METHOD Dewel’s method has proposed a 3 step procedure Step I: the deciduous canine are extracted to create space for alignment of incisor at the age of 8 years Step 2: a year after first step the deciduous first molar are extracted so that the eruption of first pre molar is accelerated Step 3: the erupting first pre molar are extracted to permit canine to erupt in their place
  56. 56. TWEED’S METHOD This method involves the extraction of deciduous first molar around eight years of age followed by extraction of first pre molar and deciduous canine.
  57. 57. NANCE’ S METHOD This is similar to Tweed's technique and involves the extraction of deciduous first molars followed by the extraction of the first pre molar and deciduous canine.
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