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


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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

  1. 1. Space gaining in orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. • • • • • • • • Extraction Expansion Molar distalization Enamel stripping Uprighting of molars Derotation of posterior teeth Proclination of anteriors Distraction osteogenesis
  3. 3. • Contemporary Extraction Guidelines: – For Class I crowding / protrusion: • < 4mm of arch length discrepancy with no vertical discrepancy: nonextraction. • Arch length discrepancy – 5-9mm • Non-extraction – transverse expansion of premolar segment. • Extraction – any pattern depending on hard and soft tissues.
  4. 4. • > 10mm : Extract • 1st choice – 4 4 4 4 4 4 2 2 • 5 5 & 6 6 - rarely satisfactory • 5 5 6 6
  5. 5. • I] Indications for extraction of 1st premolars (Tweed and Begg): • Maximum anterior retraction and camouflage of Class II div I. • Less taxing of anchorage – maximum anchorage. • Eruptive sequence – space for canines. • Space discrepancy > 10mm for Class I M.O. – crowding.
  6. 6. • II] Indications for 2nd premolar extraction: Nance, Carey, Dewey and Thompson (Begg) • Good profile and mild crowding. • Straight profile and moderate crowding. • Class II div. 1 dental on class I skeletal with mild mandibular crowding. • Mild Class III and mild maxillary crowding Class III - 5 5 Niwa et al. • Case of maxillary set back surgery. • Crowded and out of arch. • Correction of molar relation.
  7. 7. • III] Indications for incisor extraction: • Severely crowded mandibular arch –Severe protrusion. • Periodontal breakdown. • Severely fractured. • Bolton discrepancy.
  8. 8. • • • • • Maxillary central incisors: Caries. Fracture. Dilacerated. Badly impacted. • Maxillary lateral incisor: a. Crowding in incisor region with mesial displacement of root apices of 3 3
  9. 9. • IV] Indications for 1st molar extractions (Wilkinson): • Carious / endo treated/ multifilled. • Esthetic considerations with properly developed 2nd and 3rd molars – large nose and chin – 4 4 dished face. • Open bite cases? • Supraerupted teeth. • Crowding in premolar region and incisors in good relation.
  10. 10. • V] Indications for canine extractions: (Creekmore): • Periodontally involved. • Horizontally impacted – tooth movement? • Distally tipped/ severely rotated / grossly displaced buccally/palatally.
  11. 11. • VI] Indications for 2nd molar extraction: • Mild –moderate arch length discrepancy with good esthetics. • Distalization of first molar. • Relieve lower incisor crowding. • Relieve impaction of 2nd premolar. • Severely carious / ectopically erupted / rotated. • Passed average physiologic age of eruption and 5 5 are normal – size, shape and root area.
  12. 12. • VII] Single arch extraction: – Class II div 1 – •Perfect lower arch alignment, but growth expected inadequate for non-extraction. • With mild anterior open bite. •Minimal patient cooperation. •Vertical growth pattern – no molar distalization. •Minimal growth expectation.
  13. 13. • • • • • • • Factors affecting choice of extraction: Treatment objectives. Potential stability. Occlusion. Esthetics. Type of malocclusion. Growth pattern.
  14. 14. Enamel Stripping
  15. 15. Contents • • • • • • • • • • • • • Definition Current Trends Indications Peck and Peck Analysis Amount of Enamel Stripping Methods of Enamel Stripping Technique Fluoride Remineralization Precautions Advantages Disadvantages Controversies Summary
  16. 16. • Enamel stripping is a method by which the proximal surfaces of the teeth are sliced in order to reduce the mesio-distal width of the teeth. Definition • Reproximation – Peck and Peck, 1972. Tooth reproximation is a clinical procedure involving the reduction, anatomic recontouring, and protection of the mesial and/or distal enamel surfaces of a permanent tooth.
  17. 17. Individuals with – Good oral hygiene Indications – Class I arch length orthognathic profiles discrepancies with – Minor class II dental malocclusions (particularly non-growing patients) – Bolton tooth size discrepancies – Arch length discrepancies less than the size of two premolars – Peck and Peck slenderization. ratio indicating need for
  18. 18. Peck and Peck Analysis • Harvey Peck and Sheldon Peck in 1972. • Naturally well-aligned mandibular incisors possess distinctive dimensional characteristics. These teeth are significantly smaller mesiodistally and significantly larger faciolingually, when compared with average population tooth dimensions. • It appears, therefore, that tooth shape (mesiodistal and faciolingual dimensions) is a determining factor in the presence and absence of lower incisor crowding.
  19. 19. Peck and Peck Analysis • Index = Mesiodistal crown diameter X 100 Faciolingual crown diameter • Well-aligned mandibular central incisors 88.4 ± 4.3 well-aligned mandibular lateral incisors 90.4 ± 4.8
  20. 20. • Clinical application Peck and Peck Analysis – The observed relationship between mandibular incisor shape and the presence and absence of mandibular incisor crowding had significant clinical relevance. – The MD/FL index provides an effective clinical method for diagnosing tooth shape deviations which influence and contribute to mandibular incisor crowding. – This data helps in determining whether a lower incisor is favorably or unfavorably shaped relative to good alignment. – The following ranges are employed as clinical guidelines for the maximum limit of desirable MD/FL index values for the lower incisors: Mandibular central incisor --- 88-92 Mandibular lateral incisor --- 90-95
  21. 21. • Clinical application Peck and Peck Analysis – Lower incisors within or below these ranges are considered favorably shaped. Any lower incisor with an MD/FL index above these ranges, however, is considered to have a crown shape deviation which may influence or contribute to the crowding phenomenon. – However, an MD/FL index in excess of 100 for any of the lower incisors represents a severe shape deviation, characteristic of existing or potential tooth irregularity. – Patients whose mandibular incisors have MD/FL indices above the desired ranges may well be candidates for the removal of some mesial and/or distal tooth substance in conjunction with orthodontic therapy – "reproximation"
  22. 22. Methods of Proximal Stripping • Two steps: 1. Initial reduction 2. Polishing
  23. 23. Methods of Proximal Stripping 1. Mechanical • • Abrasive strips (hand held / motor driven) • • Abrasive disks • • • • • Abrasive linen strips Diamond coated metal Safe sided carborundum disks (mounted on contraangle handpiece) Perforated diamond coated disk (in an oscillating handpiece) (Zhong et al, 1999) Thin double sided diamond disc (Carter, 1989) Ultrasonic unit using an aluminum hydroxide paste and special reducing tips Long thin burs • • Diamond coated Tungsten carbide (Sheridan, 1985; Lucchese et al, 2001) 1. Chemical 2. Combination techniques
  24. 24. Methods of Proximal Stripping
  25. 25. Methods of Proximal Stripping Polishing • Tungsten carbide burs • Oscillating Elastrips (fine/ultrafine) • Sof-Lex XT disks (fine/ultrafine)
  26. 26. • Air Rotor Stripping • Modified ARS (for anterior teeth) Techniques • Combination technique (mechanical and chemical)
  27. 27. • John J. Sheridan -1985, 1987 Air Rotor Stripping (ARS) • A technique which enables the clinician to remove a precise amount of interproximal enamel to create space, primarily in the buccal quadrants, for aligning or retracting teeth. • Upto 8.9 mm of space can be obtained in an arch using ARS.
  28. 28. • Align the teeth The ARS Technique • Gain an open field – visual access to the interproximal area. – a thick separator is useful if an archwire has not yet been placed. – if an archwire is in position, a tightly compressed coil spring between the brackets will prevent the possibility of lost separators.
  29. 29. The ARS Technique • By the next appointment, the coil spring should have opened space so that the proximal surfaces are clearly visible.
  30. 30. The ARS Technique • To prevent nicking the papilla during ARS, place a .020" brass wire between the tissue and the bur. When placed below the arch wire, this shield will also retract the lip and keep the tongue out of the way during ARS.
  31. 31. The ARS Technique • Robert Lokar (JCO, 2000) suggested the use of Stim-U-Dent Plaque Removers instead of brass wire as he found them often clumsier and too thick for anterior interdental spaces.
  32. 32. • Removal of enamel The ARS Technique – The bur of choice for the initial reduction is a 699L, a small, tapered crosscut fissure carbide bur with an extended cutting area. – Water spray
  33. 33. The ARS Technique • The ARS bur in an airrotor handpiece is placed on the indicator wire and moved parallel to the plane of the wire occlusally or incisally with a light wiping motion. • Because the field is open, the reduction can be done on either or both proximal surfaces.
  34. 34. • Finish and contour with a 135-EF stilettoshaped ultrafine finishing diamond bur. The ARS Technique • The enamel surfaces adjacent to the ARS site should be sculptured so that the tooth appears natural without an excessively angular contact area when the spaces are closed.
  35. 35. The ARS Technique • Reduce additional contact points on subsequent visits, working usually from posterior to anterior in the buccal segments. After the proximal surfaces of one site are reduced, the mesial tooth is retracted into the space by advancing the open coil spring to the next mesial contact point. This in turn opens the next ARS site.
  36. 36. The ARS Technique • As teeth are distalized, ligate them to the anchor teeth. The archwire need not be removed— only the ligatures needed to advance the open coil spring along the wire. • The coil spring can be stretched along the archwire if more force is needed to separate the teeth at subsequent ARS sites.
  37. 37. The ARS Technique
  38. 38. • A modified ARS procedure uses a reducing bur in an air-turbine handpiece in combination with a metal abrasive strip. Modified ARS • This modification is useful for the removal of smaller amounts of interproximal enamel and is usually reserved for the lower anterior teeth, where thin interproximal enamel permits less mesiodistal reduction.
  39. 39. Modified ARS • The interproximal enamel is reduced with a 699L stripping bur on the lingual and facial surfaces until the contact area is a knifeedge of enamel. • This enamel is then removed with the handheld abrasive strip.
  40. 40. Modified ARS • The advantage of this two-stage procedure is that the air-rotor reduces the bulk of the enamel so that less force is required with the hand-held abrasive strip. • This procedure is most efficient before or after treatment, when the teeth are not mobile.
  41. 41. Combined Technique • Advocated by V. P. Joseph, P. E. Rossouw and N. J. Basson after their study on ‘Orthodontic microabrasive reproximation’ (AJO, 1992) • Combined mechanical stripping method. and chemical
  42. 42. Combined Technique • Chemical stripping in restorative dentistry – 18% HCl – for removal of white spot lesions (upto 100 µm). • But it is caustic, hence in orthodontics 37% phosphoric acid can serve as a good alternative.
  43. 43. Combined Technique • In this technique, the mechanically reduced proximal surface is treated with phosphoric acid. • The furrows created by the mechanical reduction are more or less flattened by this acid etch procedure producing a surface which can better ‘heal itself’ by remineralisation.
  44. 44. Combined Technique • Artificial remineralization of the etched enamel surface is possible as shown by crystal growth. A low concentrate calciumfluoride solution produced this growth in a time dependent fashion.
  45. 45. Fluoride Remineralization • Fluoride Remineralization – Any stripping procedure removes the cariesresistant, fluoride-rich layer of surface enamel. This can readily be reestablished with commercially available, office-applied fluoride rinses.
  46. 46. • Though proximal stripping is a procedure restricted to the enamel, extra care must be taken while performing the procedure in young individuals as they have larger pulp horns hence are more likely to develop sensitivity. Precautions • If the procedure is done properly and the teeth are contoured to acceptable morphology and moved into arch form, they appear so natural that there is a danger of repeating the ARS procedure if more space is needed. To prevent this situation, chart all ARS and combination technique sites, noting the date and approximate amount of reduction.
  47. 47. • Ledging of the enamel should be avoided. Precautions • Use separation. In broadening the contact areas, one should avoid slice cuts which may produce an unstable arch form. Adequate separation allows for consideration of arch curvature where slightly more reduction of enamel may be obtained on the lingual than on the labial areas of the proximal surfaces.
  48. 48. Advantages of Stripping 1. Possible to avoid extraction in borderline cases. Especially beneficial when treating adult non-growing patients. 2. A more favorable overbite and overjet relation can be established by eliminating tooth material excess in either of the arches, improving anterior function in the mutually protected occlusion. 3. Begg has stated that reduction of the widths of the upper and lower incisors and canines for orthodontic purposes conforms more closely to basic biologic requirements than does orthodontic tooth extraction.
  49. 49. Advantages of ARS 1. Removal of precise amount of interproximal enamel to create space, primarily in the buccal quadrants, for aligning or retracting teeth. 2. In selected cases, ARS can resolve significant differences in ratios of tooth size to arch length, and the technique can become an alternative to extraction or expansion. Upto 8.9 mm of space can be obtained in an arch using ARS.
  50. 50. Advantages of ARS 3. ARS can create substantially more space than is usually obtained by conventional interproximal reduction procedures. 4. The lower incisors have less proximal enamel than posterior teeth, and lower incisor irregularity generally increases naturally at an age when most orthodontic cases are in retention. Anterior interproximal reduction of more than 2-3mm would virtually eliminate the option of further reduction to eliminate post-treatment crowding, simply because there would be little if any enamel remaining on the lower incisors.
  51. 51. 5. Advantages of ARS In lower incisor extraction cases, a tooth material disproportion is created between upper and lower anteriors leading to unfavorable overjet. Stripping in the upper anteriors only can lead to unesthetic shapes. ARS helps in redistributing the tooth material reduction (Sheridan and Hastings, JCO 1992).
  52. 52. Disadvantages of Stripping 1. The technical concern in reproximation procedure is the precision removal of substantial interproximal enamel, following which the completed reduction site should have smoothly finished enamel walls without undercuts, and the reduced surfaces should be reshaped to resemble the original interproximal morphology. 2. Space opening occurs infrequently in an ARS site and the majority of the space closes during retention, but it is a possible long-term effect of the ARS procedure.
  53. 53. Disadvantages of Stripping 3. Irreversible. Hence should be done with utmost caution and responsibility. 4. The technique should be selectively used on patients with good oral hygiene and low caries susceptibility.
  54. 54. Controversies ?
  55. 55. • Amount of stripping ? Controversies • Best method ? • Susceptibility to Caries and Periodontal Disease ?
  56. 56. • Enamel Stripping is a skilful procedure which when judiciously used can prove to be a boon to the orthodontist. Summary • All that is required is the correct knowledge, some skill, and confidence. • Von der Heydt : "Dental crowding is amenable to a corrective procedure which is too seldom undertaken despite the simplicity and effectiveness of the procedure. A little more knowledge and courage to offer this to the public would be of value to all concerned."
  57. 57. Thank you For more details please visit