orthodontic treatment, comprehensive orthodontic treatment

2. THIRD STAGE OF
COMPREHENSIVE
TREATMENT
Presented by:-
Dr.KUMAR ADARSH

3. Contents
• Introducton
• Adjustment of individual Tooth Positions
• Correction of Vertical Incisor Relationships
• Final "Settling" of Teeth
• Positioners for Finishing
• Special Finishing Procedures to Avoid Relapse
• Micro-esthetics procedures in finishing

4. Introduction
• Comprehensive orthodontic treatment implies an effort to make the patient’s
occlusion as ideal as possible, repositioning all or nearly all the teeth in the
process.
• The idea of dividing treatment into stages was emphasized by Raymond Begg.
• These major stages of comprehensive treatment are:
alignment and leveling,
correction of molar relationship and space closure, and
finishing.

5. End result of second stage
The teeth should be well aligned
Extraction spaces should be closed
Tooth roots should be reasonably parallel
The teeth in the buccal segments should be in a normal Class I
relationship.
In the Begg technique, major root movements of both anterior and
posterior teeth still remained at the end of Stage 2, to obtain root
paralleling at extraction sites and proper torque and axial inclination
of tipped incisors.

6. Objective of stage 3
Much less treatment
remains
Minor versions of these same
root movements
Marginal ridges level
Obtain precise in-out
positions of teeth within the
arches
Overcome any discrepancies
produced by errors in either
bracket placement or
appliance prescription.
Vertical relationship of
incisors (either correcting
moderately excessive
overbite or closing a mild
anterior open bite).

7. The sequence of arch wire
(1)The most efficient arch
wires should be used, so as
to minimize clinical
adjustments and chair time;
and
(2)It is necessary to fill the
bracket slot in the finishing
stage with appropriately
flexible wires to take full
advantage of the modern
appliance.

8. Adjustment of individual
Tooth Positions
Midline discrepancy
Tooth size
discrepancy
Root paralleling
Torque

9. Midline discrepancy
Cause
Minor
discrepancy
Large
discrepancy
Skeletal
asymmetry
Lateral shift

10. Tooth size discrepancy
Normal
acceptable
discrepancy
Increased
discrepancy
Decreased
discrepancy
More
generalized small
deficiency

11. Root paralleling
Decision after OPG Begg’s uprighting spring
MBT-bracket
position

12. Wireselection
• With the 18-slot appliance, the typical finishing archwire is either 17
x 22 or 17 x 25 steel.
• These wires are flexible enough to engage narrow brackets even if
mild tipping has occurred, and the archwire will generate the
necessary root paralleling moments.
• If a greater degree of tipping has occurred, a more flexible full-
dimension rectangular archwire is needed.
• To correct more severe tipping, a beta-titanium (beta-Ti) or even a
nickel- titanium (M-NiTi) 17 x25 wire might be needed initially, with a
steel archwire used for final expression of torque.

13. • With wider 22-slot if teeth have tipped even slightly into the
extraction space or if other root-positioning is needed, even
undersized steel archwires ( I9 x 25 steel) are much too stiff.
• A 21 x 25 beta-Ti wire is the best choice for a finishing archwire under
most circumstances and if significant root positioning is needed, 21 x
25 M-NiTi should be used first.
• The great advantage of A-NiTi is its very flat load-deflection curve,
which gives it a large range.
• In the finishing stage, however, appropriate stiffness at relatively
small deflections, rather than range, is the primary consideration .

14. • A-NiTi wires may deliver less force than their M-NiTi counterpart.
• M-NiTi almost always is the better choice for rectangular nickel-
titanium wires.
• Occasionally, a severely tipped tooth will be encountered and a
longer range of action is needed. This may indicate using a
rectangular A-NiTi wire initially, then M-NiTi.

15. • A root-paralleling moment is a crown-separating moment in edgewise technique
just as it is in Begg or any other technique.
• Either the teeth must be tied together or the entire archwire must be tied back
against the molars to prevent spaces from opening.
• Not only extraction sites, but also maxillary incisors must be protected against
this complication.
• When a full-dimension rectangular wire is placed in the maxillary arch, spaces are
likely to open between the incisors in non-extraction as well as extraction cases.
• Tying the maxillary incisors together, which can be done conveniently with a
segment of elastomeric chain from the mesial bracket of one upper lateral incisor
across to the mesial bracket of the other, is necessary during finishing.

16. Torque
• Lingual root torque of incisors
• Buccal root torque of premolars and molars

17. Lingual root torque of incisors
• If protruding incisors tipped lingually while they were being retracted, Iingual
root torque as a finishing procedure may be required.
• In the Begg technique, the incisors are deliberately tipped back during the
second stage of treatment, and lingual root torque is a routine part of the
third stage of treatment.
• Like root paralleling, this is accomplished with an auxiliary appliance that fits
over the main or base archwire.
• The torquing auxiliary is a "piggyback arch" that the labial surface of the
incisors near the gingival margin, creates the necessary couple with a
moment arm of 4 to 5 mm.
• The auxillary arch is bent into a tight circle initially, exerts force against the
roots of the teeth as it is partially straightened out to normal arch form.

18. Burstone torqueing arch
• Class ll division2 cases where maxillary central incisors need a large amount of torque.
• The torqueing auxiliary is full dimension steel wire (21x25 or 17 x 25,in 22 or 18-slot
brackets respectively) that fits in the brackets only on the incisors.
• It can be used only on the centrals or on the centrals and laterals.
• The base rectangular archwire extends forward from the molars through the canine or
lateral incisor brackets, then steps down and rests against the labial surface of the teeth
to be torqued.
• When the torqueing auxiliary is passive, its long posterior arms are up in the buccal
vestibule.
• lt is activated by pulling the arms down and hooking them beneath the base archwire
mesial to the first molar.
• The segment of the base arch that rests against the labial surface of the central incisors
prevents the crowns from going forward, and the result is efficient lingual root torque.

19. • Because of the long lever arm, this is the most effective torquing
auxiliary for use with the edgewise appliance.
• It is equally effective with the l8- or 22-slot appliance.
• If all four incisors need considerable torque, a wire spanning from the
molar auxiliary tube to the incisors, with a V-bend so that the incisor
segment receives the greater moment, is a highly efficient approach.

20. Class II elastic
• A torquing force to move the roots lingually is also a force to move
the crowns labially.
• In a typical patient with a Class II malocclusion, anchorage is required
to maintain overjet correction while upper incisor roots are torqued
lingually.
• For that reason, Class II elastics are likely to be necessary when active
torque is needed during the final stage of Class II treatment.

21. Factor determining amount
of torque expression
• Torsional stiffness of wire
• Inclination of bracket slot relative to
archwire
• Tightness of fit b/w archwire &
bracket
• With the l8-slot appliance a, 17 x25
steel archwire has excellent properties
in torsion, and torque with this archwire
is entirely feasible.

22. (-)ve torque of canine &
premolar
Affect smile
Arch expansionBuccal crown torque
Buccal root torque of premolars and molars

23. Correction of Vertical Incisor Relationships
Excessive
overbite
Incisor
display
Anterior face
height
Anterior
openbite
Lip vs upper
incisor
relation
Anterior face
height

24. • If intrusion is indicated and a rectangular finishing archwire is already in place,
the simplest approach is to cut this archwire distal to the lateral incisors and
install an auxiliary intrusion arch.
• When a maxillary auxiliary intrusion arch is used, a stabilizing transpalatal lingual
arch may be needed to maintain control of transverse relationships and prevent
excessive distal tipping of the maxillary molars.
• The greater the desired vertical change in incisor position, the more important it
will be to have a stabilizing lingual arch in place, and vice versa.
• Small corrections during finishing usually do not require placing a lingual arch.
• Alternatively, if slight elongation of the posterior teeth is indicated, step bends in
a flexible archwire would be satisfactory.
• The intermediate arch wire before the final torqueing archwire is the one for
implementation of these step bends (17 x 25 TMA with the l8-slot appliance, 17 x
25 M-NiTi with the 22-slot appliance).

25. Methods of settling of teeth
Replacing rectangular wire at the very end
of t/t with light round arches that provide
some freedom for movement of the teeth
& using light vertical elastics to bring teeth
together.
Using laced posterior vertical
elastics after removing posterior
segment of the archwires
After the bands & brackets
have been removed, using a
tooth positioner

26. Control of rebound and posturing
Rebound vs
posturing
•Rebound is a 1 to 2 mm phenomenon ;posturing can
lead to 4 to 5 mm relapse.
Overcorrection
•After class II or III correction, particularly if interarch elastics have been used, the teeth tend to
rebound back towards their initial position despite the presence of rectangular archwires.
•Because of this, it is important to slightly overcorrect the occlusal relationships.
Guideline for
finishing treatment
when interarch
elastics
•When an appropriate degree of overcorrection has been achieved, the force used with the
elastics should be decreased & continued full time for another appointment interval.
•Interarch elastics should be discontinued,4-8 weeks before the orthodontic appliances are
removed, so that changes due to rebound or posturing can be observed.
•If the occlusion is stable, the teeth should be brought into a solid occlusal relationship without
heavy archwires present.

27. Removal of Bands
• Removal of band is accomplished by
breaking the cement attachment & then
lifting the band off the tooth .
• For upper molar & premolars, band
removing instrument is placed first on lingual
then buccal surface.
• For lower posterior sequence of force is just
reversed: band remover is applied first on
buccal, then the lingual surface.

28. Debonding
• Done by creating a fracture within resin bonding material or between the
bracket & resin and then removing the residual resin from enamel surface.
• For metal brackets-safest method is to apply cutting plier to the base of
bracket, so that bracket bends. This method has disadvantage of bracket
destruction so cant be reused.
• Ceramic bracket have little or no ability to deform. So shearing stress are
applied to the bracket to remove it, which is alarmingly large. This leads to
more chance of enamel damage.

29. Approaches
for
debonding
ceramic
bracket
Modify interface (chemical
bonding) between bracket
and bonding resin to
increase the chance that
when force is applied, the
failure will occur between
the bracket and the bonding
material.
Heat to soften the bonding
resin, so that bracket can be
removed by lower force –
electrochemical or laser
instrument
Modify the bracket-metal
slot in ceramic bracket.

30. Timing:
4-6 week
before the
planned
removal
of
appliance
Lab
procedure
trim band
&
brackets-
include all
erupted
teeth-
bring each
tooth into
desired
final
relationshi
p
Advantage
early
removal of
appliance
gingival
massage,
open bite
tendency
Disadvant
age
expensive,
increase
overbite,
not
maintain
rotated
teeth,
pt.coopera
tion
Contraindi
cation
severe
malalignm
ent &
rotated
teeth,
deep bite
tendency,
uncoopera
tive
patient
Schedule
Full time
wear for
first 2
days,
At least 4
hrs during
day &
during
sleep,
Produce
changes
within 2-3
weeks
Positioners for finishing

31. Special Finishing Procedures to Avoid Relapse
• Control of unfavorable growth
• Control of soft tissue rebound

32. Control of Unfavorable growth
• Changes resulting from continued growth in a Class II, Class III, deep
bite or open bite pattern contribute to a return of the original
malocclusion, and so are relapse in that sense.
• For patients with skeletal problems who have undergone orthodontic
treatment "active retention" takes one of two forms.
• One possibility is to continue extraoral force in conjunction with
orthodontic retainers (high-pull headgear at night in a patient with a
Class II open bite growth pattern).
• The other appropriate option is to use a functional appliance rather
than a conventional retainer after the completion of fixed appliance
therapy.

33. Control of Soft Tissue Rebound
• A major reason for retention is to hold the teeth until soft tissue
remodeling can take place.
• There are two ways to deal with this phenomenon:
(1) overtreatment, so that any rebound will only bring the teeth back
to their proper position, and
(2) adjunctive periodontal surgery to reduce rebound from elastic
fibers in the gingiva.

34. Overtreatment
Correction of Class II or Class III Malocclusion
• After headgear or elastics have been discontinued, it can be expected that
the teeth will rebound I to 2 mm relatively quickly.
• Especially when elastics are used, the patient should be taken to a slightly
overcorrected position, and elastics discontinued for 3-4 weeks to allow
rebound to occur, before appliances are removed.
• Particularly when a patient has been wearing Class II elastics, he or she may
begin to posture the mandible forward, so that the malocclusion looks
more corrected than it really is.

35. • For this reason it is important to allow a period of time without
elastics before ending active treatment, to be sure that the patient
really has been corrected and is not just posturing.
• The best plan is to reduce the force on Class II elastics when the
apparently correct degree of overcorrection has been achieved but
maintain them full-time for 3-4 weeks, then wear them just at night
for another appointment period, and finally discontinue them
completely for at least 4 weeks before removing the appliances.

36. Crossbite Correction
• Whatever the mechanism used to correct crossbite, it should
be overcorrected by at least I to 2 mm before the force
system is released.
• If the crossbite is corrected during the first stage of
treatment, the overcorrection will gradually be lost during
succeeding phases of treatment, but this should improve
stability when transverse relationships are established
precisely during the finishing phase.

37. Irregular and Rotated Teeth
• It is wise to hold the teeth in a slightly overcorrected
position for at least a few months, during the end of the first
stage of treatment and the second stage.
• As a general rule, however, it is not wise to build this
overcorrection into rectangular finishing archwires.
• Maintaining an over rotated position can be done by
adjusting the wings of single brackets, or by pinching shut
one of a pair of twin brackets.
• Rotated teeth should be maintained in an overcorrected
position as long as possible.

38. • A major cause of rebound after orthodontic treatment is the network
of elastic supracrestal gingival fibers.
• As teeth are moved to a new position, these fibers tend to stretch,
and they remodel very slowly.
• If the supracrestal fibers are sectioned and allowed to heal while the
teeth are held in the proper position, relapse caused by gingival
elasticity is greatly reduced.
• It can be carried out by either of two approaches. (circumferential
supracrestal fibrotomy & papilla dividing procedure)
Adjunctive periodontal surgery

39. Circumferential supracrestal fibrotomy
• Originally developed by Edwards
• After infiltration with a local anesthetic, the procedure consists of
inserting the sharp point of a fine blade into the gingival sulcus down
to the crest of alveolar bone.
• Cuts are made interproximally on each side of a rotated tooth and
along the labial and lingual gingival margins unless, as is often the
case, the labial or lingual gingiva is quite thin, in which case this part
of the circumferential cut is omitted.
• No periodontal pack is necessary and there is only minor discomfort
after the procedure.

40. Papilla dividing procedure
• Incision in the center of each gingival papilla, sparing the margin but separating
the papilla from just below the margin to 1 to 2mm below the height of the bone
buccally and lingually.
• This modification is said to reduce the possibility that the height of the gingival
attachment will be reduced after the surgery, and it is particularly indicated for
esthetically sensitive areas( i.e., the maxillary incisor region).
• Nevertheless, there is little if any risk of gingival recession with the original CSF
procedure unless cuts are made across thin labial or lingual tissues.

41. • Neither the CSF nor the papilla-dividing procedure should be done
until malaligned teeth have been corrected and held in their new
position for several months, so this surgery is always done toward
the end of the finishing phase of treatment.
• It is important to hold the teeth in good alignment while gingival
healing occurs.
• The surgery should be done a few weeks before removal of the
orthodontic appliance
• If it is performed at the same time the appliance is removed, a
retainer must be inserted almost immediately.

42. • An advantage of the papilla-dividing procedure may be that it is
easier to perform with the orthodontic appliance still in place.
• The only problem with placing a retainer immediately after the
surgery is that it may be difficult to keep the retainer from contacting
soft tissue in a sore area.
• Experience has demonstrated that sectioning the gingival fibers is an
effective method to control rotational relapse but does not control
the tendency for crowded incisors to again become irregular.
• The primary indication for gingival surgery therefore is a tooth or
teeth that were severely rotated. This surgery is not indicated for
patients with crowding without rotations.

43. Micro-esthetics procedures in finishing
Recontouring the gingiva to improve tooth proportion and display-
Height-width ratios of the teeth are affected by the extent to which gingiva
covers the upper part of the crown.
Reshaping the teeth for enhanced esthetics-Enamel recontouring should
not be done until after the initial phase of orthodontic alignment because, if a
tooth rotation is corrected, the perception of its width is changed while the
height is not, giving a misleading height-width ratio.
• After alignment, reshaping of the teeth can be carried out as desired but should
be completed before the end of the finishing stage of treatment.

44. Micro-esthetic consideration on
clinical evaluation

45. Ref:-Sarver DM; Enameloplasty and esthetic finishing in orthodontics – identification and treatment of microesthetic
features in orthodontics part – 1; J Esthet Rstor Dent 23:296-302,2011

47. Steps for enameloplasty to improve smile appearance
Establish height Address the width
Check the length
of the connector
Round the
line angle
Close the space created by
interproximal
enameloplasty
Create & refine
embrasures
Polish to finish
Ref:-Sarver DM; Enameloplasty and esthetic finishing in orthodontics – identification and treatment of microesthetic
features in orthodontics part – 1; J Esthet Rstor Dent 23:296-302,2011

48. References
• Contemporary orthodontics,5th edition
• Sarver DM; Enameloplasty and esthetic finishing in orthodontics –
identification and treatment of microesthetic features in
orthodontics part – 1; J Esthet Rstor Dent 23:296-302,2011