This document discusses leveling and aligning teeth during the initial stage of orthodontic treatment. The goals of leveling and aligning are to bring teeth into proper alignment and correct vertical discrepancies by leveling out the dental arches. Light continuous forces of around 50 grams are ideal for initial alignment to encourage efficient tooth tipping movement without causing harm. Special challenges like asymmetric crowding, crossbites, impacted teeth and diastemas are also addressed. The document outlines different wire sequences and mechanics to achieve proper leveling and alignment based on different orthodontic concepts and specific patient presentations.

1. LEVELING AND ALIGNING
PRESENTING BY:
DR RAHUL TIWARI

2. CONTENTS:
• GOALS OF THE FIRST STAGE
• CHOICE OF ARCHES
• ALIGNMENT IN SYMMETRIC CROWDING
• ALIGNMENT IN ASYMMETRIC ARCHES
• CROSSBITE CORRECTION
• UNERUPED TEETH
• DIASTEMA CLOSURE
• LEVELING BY EXTRUSION
• LEVELING BY INTRUSION

3. According to Raymond Begg, the major
stages of comprehensive orthodontic
treatment are ;
• alignment and leveling,
• correction of molar relationship and space
closure,
• finishing.
Tooth leveling and aligning is normally
the first orthodontic objective during the

4. GOALS OF THE FIRST STAGE OF
TREATMENT
• In almost all patients with malocclusion, at
least some teeth are initially malaligned.
• The great majority also have either excessive
overbite, resulting from some combination of
an excessive curve of Spee in the lower arch
and an absent or reverse curve of Spee in the
upper arch,
• or (less frequently) anterior open bite with
excessive curve of Spee in the upper arch
and little or none in the lower arch.

5. The goals of the first phase of treatment are to
bring the teeth into alignment and correct
vertical discrepancies by leveling out the
arches.
For proper alignment, it is necessary not only to
bring malposed teeth into the arch, but also to
specify and control the anteroposterior position
of incisors, the width of the arches posteriorly,
and the form of the dental arches.
Similarly, in leveling, it is important to determine
and control whether leveling occurs by
elongation of posteriors, intrusion of anteriors or
a combination of these two

6. Current Trend :
• In the past the usual method of regulating the
magnitude of force from an orthodontic
appliance was primarily variation in the cross
sectional dimensions of the wires used.
Although configurations such as loops have
been used to lower forces, small wires were
used for light forces and large wires for heavier
ones. Hence traditional orthodontics may be
described as "variable cross section
orthodontics".

7. • Further development of materials in
orthodontics was influenced by the
orthodontist's demands to have appliance
systems that were relatively resistant to
permanent deformation, thus providing a
large range of activation. This blend of
characteristics required the use of materials
that had high yield strength to elastic
modulus ratio, as demonstrated by NiTi and
TMA. With the introduction of these
materials to orthodontics, a new clinical
strategy evolved, namely the "variable
modulus orthodontics".

8. • The generation of superelastic and
thermodynamic nickel-titanium wires like
neo-sentalloy, Cu-NiTi, etc, represents
another major advance from the previous
concepts.
• By taking advantage of the body
temperature, and by setting the alloy's
transformation temperature for the
martensitic transformation, precise control
of the memory phenomenon can be
effected. This is called "variable
transformation temperature orthodontics".

9. WIRE SEQUENCE
ACCORDING TO DIFFERENT
ORTHODONTIC CONCEPTS :

11. ALIGNMENT

12. • In nearly every patient with malaligned teeth,
the root apices are closer to the normal
position than the crowns, because
malalignment almost always develops as the
eruption paths of teeth are deflected.
• To bring teeth into alignment, a combination
of labiolingual and mesiodistal tipping guided
by an arch wire is needed, but root
movement usually is not.

13. Several important consequences for
orthodontic mechanotherapy follow
from this :
Initial arch wires for alignment should provide
light, continuous force of approximately 50
grams, to produce the most efficient tipping tooth
movement. Heavy force, in contrast, is to be
avoided.

14.  The arch wires should be able to move freely
within the brackets. For mesiodistal sliding
along the archwire, atleast 2 mil clearance is
needed, 4 mil is desirable and beyond that
provides no advantage.
 This means that the largest initial arch wire
that should be used with an 18-slot edgewise
bracket is 16 mil, whereas 14 mil would be
more satisfactory. With the 22 slot bracket, an
18 mil arch wire would be close to ideal from a
bracket clearance point view.

15. • Rectangular arch wires, particularly those
with a tight fit within the bracket slot so that
the position of the root apex could be
affected, normally should be avoided.
A, Diagrammatic representation of the alignment of a malposed lateral
incisor with a round wire and clearance in the bracket slot. With minimal
moments created within the bracket slot, there is little displacement of the
root apex. B, With a rectangular archwire that has enough torsional
stiffness to create root movement, back-and-forth movement of the apex
occurs before the tooth ends up in essentially the same place as with a
round wire. This has two disadvantages: it increases the possibility of root
resorption, and it slows the alignment process.

16. • The springier the alignment arch wire, the more
important it is that the crowding be at least reasonably
symmetric. If only one tooth is crowded out of line a rigid
wire is needed that maintains arch form except where
springiness is required, and an auxiliary wire should be
used to reach the malaligned tooth.

17. PROPERTIES OF ALIGNMENT
ARCHWIRES
• The flat load deflection curve of superelastic NiTi makes
ideal for initial alignment. Under most circumstances
initial alignment can be accomplished simply by tying 14
or 16 mil A-NiTi that delivers about 50 gm into the
brackets of all the teeth.
• NITI has the property of delivering light forces over a
long range
• Other options are
– multistranded niti---lower force values with and
higher fracture resistance
– Copper niti- 15, 27, 35, 40
– Bioforce- graded thermodynamic niti

19. Alignment in Premolar Extraction
Situations
• In patients with severe crowding of anterior
teeth, it is necessary to retract the canines into
premolar extraction sites to gain enough space
to align the incisors. In extremely severe
crowding, it is better to retract the canines
independently before placing attachments on the
incisors. Sliding the canines produces more
stress on the posterior anchorage, so critical
anchorage is an indication for the retraction
loops.

20. • In more typical and less extreme crowding,
it is possible to simultaneously tip the
canines distally and align the incisors. The
same independent distal movement of the
canines now can be obtained with an A-
NiTi arch wire, and A-NiTi coil springs from
the first molars or active tiebacks to tip the
canines distally. When this is done, the
spring should be chosen to deliver only 50
gm, and an arch wire preformed by the
manufacturer to have an exaggerated
reverse curve of spee should be chosen,
to limit forward tipping of the molars.

21. Alignment in Non-extraction Situations :
Alignment in non extraction
cases requires increasing
arch length, moving the
incisors further from the
molars. In this circumstance,
just tying a superelastic wire
into the bracket slots is
ineffective.
Crimp a stop ahead of the
molars
Don’t cinch back

22. Alignment of Asymmetric Crowding
• If a niti archwire is tied into an
asymmetrically maligned arch, teeth distant
to the site of malalignment will be moved
• Tie superelastic wire as an auxilliary to a
heavier wire

25. ANCHORAGE CONTROL
DURING LEVELING AND
ALIGNING

26. LACEBACKS FOR A/P CANINE
CONTROL
Lace backs are 0.010 or 0.009 ligature wires which
extend from the most distally banded molar to the
canine bracket. They restrict canine crowns from
tipping forward during leveling and aligning.
The initial purpose of lace backs was to prevent
canines from tipping forward, but it was observed
that, where necessary, these ligature wires were an
effective method of distalizing the canines without
causing unwanted tipping
Lace backs are normally continued throughout the
leveling and aligning arch wires sequence. .

27. BENDBACKS FOR A/P INCISOR
CONTROL :
• If the arch wire is bent back immediately behind
the tube on the most distally banded molar, this
serves to minimize forward tipping of incisors.
• In cases where it is necessary to increase arch
length during leveling and aligning and where
A/P incisor control is not required, bend backs
should be placed 1 or 2 mm distal to molar
tubes.

28. A/P ANCHORAGE SUPPORT AND
CONTROL FOR MOLARS
• Headgears
• TPA- only for transverse and rotation
control
• Nance palatal arch
• Lingual arch

29. Vertical Control of the Incisors
The effect of bracket tip is more extreme in the upper
arch, and care is needed if the canines are distally
tipped in the starting malocclusion.
In such cases, as the arch wire passes through the
canine bracket slot it will lay incisally to the incisor
bracket slots. If the wire is fully engaged into the
incisors, it will tend to cause extrusion of these teeth,
which is undesirable in most cases.
This effect can be avoided either by not bracketing the
incisors at the start of treatment, or by not tying the arch
wire into the incisor bracket slots, but allowing it to lay
incisally to the brackets until the canine roots have been
uprighted and moved distally, under the control of the
lace backs. The incisors can then be engaged without
causing unwanted extrusion.

30. SPECIAL PROBLEMS IN
ALIGNMENT

31. Individual Teeth Displaced into Anterior
Crossbite
• Correction of the crossbite requires first
opening enough space for the displaced
teeth, then bringing them into proper
position in the arch
• It may be necessary to use a bite plate
temporarily to separate the posterior teeth
and create the vertical space needed to
allow the teeth to move.

32. Correction of Dental Posterior Crossbite :
Three approaches to correction of less severe dental
crossbite are feasible :
• a heavy labial expansion arch,
• an expansion lingual arch, or
• cross elastics.
Removable appliances, although theoretically
possible, are not compatible with comprehensive
treatment and should be reserved for the mixed dentition
or adjunctive treatment.
Minimal molar crossbite can usually be corrected in the
final stage of leveling and aligning using rectangular
wires which are slightly expanded from the normal form.

33. • The inner bow (36 or 40 mil) is simply
adjusted at each appointment to be sure
that it is slightly wider than the headgear
tubes and must be compressed by the
patient when inserting the facebow. The
effect of the round wire in the headgear
tubes, however is to tip the crowns outward,
and so this method should be reserved for
patients whose molars are tipped lingually.

34. • If anchorage is of no concern, a highly
flexible lingual arch, like the quad helix
design, is an excellent choice for correction
of a dental crossbite. When the lingual arch
is needed for both expansion and
anchorage, however, the choices are 36 mil
steel wire with an adjustment loop.

35. • The third possibility for dental expansion is
the use of cross-elastics, typically running
from the lingual of the upper molar to the
buccal of the lower molar. These elastics
are effective, but their strong extrusive
component must be kept in mind.

36. • Care is needed to avoid arbitrary correction of
molar crossbite by tipping movements. This
allows extrusion of palatal cusps and unwanted
opening of the mandibular plane angle in
treatment of high angle, and even routine, Class
II/I problems. Whenever possible, molar
crossbite should be corrected by bodily
movement.

37. Cases with Unerupted Teeth, or
Teeth Significantly Out of the Arch
Form

38. • Such teeth can be left unbracketed until
adequate space is provided for their
movement and positioning. Once space is
created, these teeth can be bracketed and
lightly tied with elastic thread to the main arch
wire. The creation of adequate space allows
bodily movement of these teeth into the arch
form and more correct root positioning,
reducing the treatment needs in the finishing
phase.

39. Surgical Exposure of
unerupted/impacted teeth:
• It is important for a tooth to erupt through the
attached gingiva, not through alveolar mucosa,
and this must be considered when flaps to
expose an unerupted tooth are planned.

40. Surgical Procedures: 2 basic types
• 1. Closed eruption – full thickness muco-periosteal
flap is raised and crown exposed, attachment is
fixed & flap sutured back over crown leaving only a
twisted wire passing through the mucosa to apply
orthodontic traction
• 2. Open eruption:
a) Punch incision is made on crown to make window
& cemented pack is placed on it
According to Johnston, Gaulis & Joho:
• For Palatally impacted tooth: Closed eruption
indicated
• For Labially impacted tooth : Open eruption is
indicated with repositioned mucoperiosteal flap to
avoid any future mucogingival problem (Vanarsdall

41. • Vanarsdall and Corn suggested that flap containing the
keratinized tissue be placed to cover the CEJ & 2-3mm of
crown
• METHODS OF ATTACHMENT:
1. Lasso technique
2. Threaded posts
3. Bonded brackets/ button
4. Magnets

42. Mode of Traction:
1. Ligature wire
2. Elastomeric chain
3. Coil springs
4. K9 spring
5. Elastic thread
6. Killroy spring
7. Cantilever spring
8. Niti arch wire

43. • Occasionally, an unerupted tooth will start to
move and then will become ankylosed,
apparently held by only a small area of fusion. It
can sometimes be freed to continue movement
by anesthetizing the area and lightly luxating the
tooth, breaking the area of ankylosis. If this
procedure is done, it is critically important to
apply orthodontic force immediately after the
luxation, since it is only a matter of time until the
tooth re-ankylosis.

44. Midline diastema:
• Diagnosis-
• Early fibrotomy
• Late fibrotomy
• Recommended
procedure by
Edwards

45. LEVELINGLEVELING

46. The correction of deep overbite involves :
• Eruption / extrusion of posterior teeth.
• Distal tipping of posterior teeth
• Proclination of incisors
• Intrusion of incisors
• A combination of two or more of the above tooth
movements

47. • INTRUSION OF ANTERIORS
• Burstone23
defined intrusion as, “Apical movement
of the geometric center of root (centroid) in respect
to the occlusal plane or a plane based on long axis
of the tooth.”
• Intrusion of incisors is commonly indicated in
pseudo deep bite cases or the cases with
increased anterior face height.
• It is also indicated in cases where there is an
excessive gingival display during speaking or
smiling.

48. • 2. EXTRUSION OF POSTERIOR TEETH20
• Extrusion of posterior teeth is commonly indicated in
patients with decreased lower anterior face height.
• It is also indicated in true deep bite cases.
• If the incisal edges of the maxillary anterior teeth are
positioned above the inferior margin of upper lip, in these
cases extrusion of posterior teeth is indicated.
• Extrusion of molars of an average of 1mm results in 2 to
2.5 mm of bite opening.

49. PROCLINATION OF INCISORS
• Numerous deep bite cases present with
retroclinated incisors.
• Proclination of incisors is indicated when
there is an increased nasolabial angle and
retruded lip.
• So soft tissue should be evaluated before
proclinating the incisors.

50. NON-EXTRACTION TREATMENT :
• Non-extraction treatment generally favors bite
opening. This is because distal tipping of
posterior teeth and proclination of incisors
normally occurs in these cases. There are a
number of mechanical factors that lead to arch
leveling and control of the deep overbite.

51. Initial Arch wire Placement
• When flat arch wires are placed into dental
arches with curves of Spee, the arch wires
attempt to return to their original shape and this
starts the bite-opening process. Also,
expression of the tip in the brackets begins the
bite opening process.

52. The Bite Plate Effect :
Introducing the bite plate effect in deep
bite cases is helpful in the bite opening
process in three ways :
• It allows for early placement of brackets on lower
incisors, which begins their movement.
• Anterior bite plates can produce an intrusive
force on lower incisors which limits any future
extrusion of these teeth.
• Anterior bite plates allow for the eruption,
extrusion, and/or uprighting of posterior teeth.

53. • METHODS:
• Anterior bite plane
• Direct bonding
material on upper
incisors
• Occlusal blocks

54. Bite-Opening Curves :
• In the great majority of cases after rectangular
stainless steel wires have been in place for 6
weeks, the arches are normally level and
adequate bite opening has been achieved. If
this is not so, then bite opening curves can be
placed into the rectangular steel wires.

55. Auxilliary leveling arch- 0.017x 0.025 ss

56. LEVELING BY INTRUSION

57. • Burstone in 1977, suggested 50 gram of intrusive
force for upper central incisors, 100 gram force for
centrals and laterals and 200 gram for six upper
anteriors. He advocated use of 40 gram for four
lower incisors and 60 gram for all six lower anterior
intrusion.
• Ricketts in 1980 advocated the use of 125 gram to
160 gram of force for upper incisor intrusion and 60
to 75 gram for lower incisors.
• Karanth and Shetty in 2001 advocated 60 gram of
force for four upper incisors and 100 gram of force
for six anteriors; where as 40 gram of force for
lower four incisors and 80 gram for six lower
incisors.
• Thus the force ranges on an average from 15 -
20 gm for each upper incisor and 10 - 15 gm for

58. Bypass Arches :
• This approach to intrusion is most useful in
patients who will have some growth (i.e. who are
in either the mixed or early permanent
dentitions). This is based on the same
mechanical principle : uprighting and distal
tipping of the molars, pitted against intrusion of
the incisors.

59. Intrusion arches:

60. Antero-Posterior Issues and
Elastics :
• Inter-maxillary elastics can contribute to the bite-
opening effect by assisting in the extrusion of
molars as the A/P problem is corrected. They
are beneficial in the treatment of most growing
patients. If possible they should be avoided in
most non-growing and adult high angle cases.

61. SKELETAL ANCHORAGE
• Miniscrews
• Absolute anchorage
• Incisors to be tied back to prevent tipping

62. Quick facts:
• Photobiomodulation (The surface of the
cheek irradiated with near-infrared light
with a continuous 850-nm wavelength and
a power density of 60 mW/cm2
for 20 or 30
min/day or 60 min/week) has shown to
hasten leveling and alignment
(Kau et al. Progress in Orthodontics 2013,
14:30 )

63. Quick facts:
• Nagar et al proposed a modification in the
K9 spring to prevent lingual tipping of
molars (Contemporary Clinical Dentistry, Vol. 5,
No. 2, April-June, 2014, pp. 272-274)
• No stastical difference was seen in the
leveling and aligning phase with self
ligating and conventional brackets.
(Comparison of self- and conventional-ligating
brackets in the alignment stage. Wahab, EJO,
2011)

64. • Pain exprienced in the first phase was rather
more during archwire removal and insertion in
the SLB group than in the CB group. (Pain
Experience during Initial Alignment with a Self-
Ligating and a Conventional Fixed Orthodontic
Appliance SystemA Randomized Controlled
Clinical Trial. P. S. Fleminga.
The Angle
Orthodontist: January 2009, Vol. 79, No. 1, pp.
46-50.)

65. THANKYOU =)