Methods of gaining space 1. /certified fixed orthodontic courses by Indian dental academy

METHODS OF GAINING
SPACE.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


1

Key-stoning procedureHarry G.Barrer JCO Aug 1975

A. Malposed incisors

B. interproximal relationship after key stoning

Rounded surfaces slip and
rotate.

2

Key-stoning procedure:


3

Nonsurgical rapid maxillary alveolar
expansion in adults:a clinical evaluation.
Chester S. Handelman, Angle Orthodontist, 1997 vol 67
•Late teens and early 20’s questionable.
•Sutures: rigid and fuse.
•SA-RME.

Non Surgical Maxillary expansion:
Pain, swelling, ulceration, flared posterior teeth, bite opening,
gingival recession, and perforation of the buccal alveolus.

Vanarsdall: in children, gingival recession and dehiscence of bone


4

• 5 adults with transverse deficiency- treated
nonsurgically using Haas appliance.
•RMAE- expansion centered in the alveolar process of
maxilla rather than the body.(lateral walls of the
palate)
•Bilateral/unilateral crossbites, arch constriction.
2 quarter turns/day
Haas appliance

Later 1 quarter turn/day
U 1 no separation.
12 weeks retention.

5

Displaces the alveolus with the teeth rather than
expanding the teeth through the alveolus.


6

bilateral


7

Unilateral
crossbite –
left


8


9


10

RMAE acceptable alternative to SA-RME in adults for maxi deficiency.

11

Nickel-Titanium Palatal expander.
2 properties: Shape memory & superelasticity.
Exists in more than 1 crystal structure.
Lower temp-martensite.
temp:94degree

Transition

Higher temp-austenite {phase transition}


12

MOLAR DISTALIZATION


13

Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch
length of about 2mm on each side.

2. Late mixed dentition
-

When lower E space –utilized for relief of
anterior crowding,

-

Upper molars distalized to get a class I
relation

14

3. Non-growing patient
-

To regain lost arch length

-

Blocking out of canines

4. Upper second molar extraction
-

Lower arch normal


15





Class I malocclusion- with highly placed canine/impacted
canine
Lack of space for eruption of premolars due to mesial
migration of permanent first molars


16




Good soft tissue profile



Borderline cases



Mild to moderate space discrepancy with missing
3 rd molars/2 nd molars not yet erupted



End on molar relation with mild to moderate
space requirement.



Cases with less than full cusp class II molar
relation.

17

Case selection
1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary
tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars

placed normally- buccopalatally.

4. 3rd molars-absent –stacking of upper molars – unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effect

18

Classification
1.

Location of appliance


Extra-oral



Intra-oral

2. Position of appliance in mouth


Buccal



Palatal

3. Type of tooth movement


Bodily movement



Tipping movement

19

Classification
4. Compliance needed from patient
 Maximum compliance
 Minimum or No compliance
5. Type of appliance


Removable



Fixed

6. Arches involved
Intra-arch
Inter-arch


20

Various appliances used for
Molar Distalization :











Head gears
Pendulum appliance.
Coil springs Niti and S.Steel
Distal jet
K loop
Jones Jig
Magnet
Wilson’s Bimetric loop
Use of super elastic NiTi
Franzulum appliance.


21

Various appliances used for Molar
Distalization











ACCO
Crozat appliance
Crickett appliance
Modified Nance lingual appliance
Schmuth and Muller double plates
Claspring
Removable molar distalization splint
Fixed piston appliance
Using implants
Fixed functional appliance


22

Distalization using Headgears


Very efficient



Reciprocal forces are not transmitted to other teeth



Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force


23

Biomechanics of Headgears:



C Res



Moments


24

Cervical Headgear






Short face Class II
maxillary protrusive
cases with low MPA
& Deepbites
Extrusive & distalizing
effect
Lower anterior facial
height is less.


25

High pull Headgear








Produces intrusive &
Posterior direction of pull
Long face class II
patients with high MPA
Force through C Res –
Intrusion & distal
movement of molar
6-8 months – class IIclass I


26

Straight pull headgear


Class II Malocclusion with
no vertical problems



Prevent anterior
migration of maxillary
teeth, translate them
posteriorly

Adv-effective, no reciprocal forces
Disadv- Patient compliance


27

Modification of the Bimetric arch


Class II correction- Distalization + expands caninepremolar area- unlocks the occlusion



A mild-moderate class II div 2 with normal mandibular
arch-easily corrected


28

Modification of the Bimetric arch
Archwire design:
 .016”premium wire
 Premolars bonded if
expansion is
required
 Teardrop shaped
loop
 Bite opening bend
 Mild toe-in
 2mm activation

29

Elastic load reduction principle:


Class II elastics – used sequentially
T.P Green – 1st week
Pink - 2nd week
Yellow – next 2-3 weeks



Initial heavy force- to resist forward
pushing force of new wire- force
transferred distally



Later Molar uprights-mesially directed
archwire force decreases- support with
light forces.



Extrusive component of class II- kept
to a minimum www.indiandentalacademy.com



1mm/month.wire
activated for 3
visits.



Borderline
cases –Non Ext

30

K-Loop molar distalizing
appliance Valrun Kalra – JCO 1995


K-loop – forces - .017 x .025 TMA



Nance button – anchorage



8mm long , 1.5 mm wide



Legs- 20 degree bend



Inserted into molar and first
premolar tube, marked



Stops bent 1mm distal , 1mm
mesial



Stops- 1.5mm long

31



Reactivated by 2mm 6-8 weeks later.



molars move by 4mm, premolars by 1mm



Anchorage can be reinforced by headgear


32

K- loop Appliance


33

Distalization of Molars with
Repelling Magnets Gianelley etal JCO 1988


Anchorage – Modified Nance
appliance



Wire extending from 1st
premolars



Acrylic button anteriorly
contacting the incisors



Auxiliary wire with a loop at its
end soldered - premolars bands


34

Distalization of Molars with
Repelling Magnets


Incisor brackets – passive
sectional wire- maintain incisor
alignment



Repelling surfaces of magnets
brought into contact by passing
an .014 ligature through the loop,
then tying back a washer anterior
to the magnets



Force- 200-225 gms , dropped as
space opened



3mm in 7 weeks



Anchor loss – 1mm


35

Molar distalization with Superelastic
NiTi wire
Gianelly JCO 1992


100gm Neosentalloy upper
archwire



3 markings



Stops crimped, hook added



Insert wire such that posterior
stop abuts mesial end of molar
tube, anterior stop abuts distal of
premolar.Xs wire deflected gi



Anchorage reinforced by class II,
or Nance appliance

100g

36

Molar distalization with
Superelastic NiTi wire
Case report :


12 yr / F



Unilateral class II



Class II elastic against
upper 1st premolar



Overcorrected- 4 months


37

NiTi Double Loop system for simultaneous
distalization of first and second molars
Giancotti JCO 1998


Mandibular molars and 2nd premolars
banded, other teeth bonded



Lip bumper- prevent extrusion



Maxillary molars and bicuspids –
banded, aligned



80 gm Neosentalloy – maxillary
archwire placed – marked

1.

Distal to 1st premolar

2.

5mm distal to 1st molar tube



Stops crimped on markings

38

NiTi Double Loop system for
simultaneous distalization of first and
second molars


2 Sectional NiTi archwires
– crimp stops

1.

Mesial and distal to 2nd
premolar

2.

5mm distal to 2nd molar
tube



Uprighting springs on 1st
bicuspids



Class II elastics



Simultaneous, bodily
movement

39

24yr/f, class II div I
5months- overcorrected

40

NiTi Double Loop system for simultaneous
distalization of first and second molars


Useful technique – Class II div I



Minimal patient co-operation



Ideal for simultaneous distalization U7 easier ‘.’ anatomy.



Due to stretching of transeptal fibers, 1 st molars can be distalized using
lighter 80 gm force



Anchorage easily controlled , without need for TPA/Nance’.’light forces


41

NiTi Open Coil Springs

Dia 0.012”
Lumen 0.030


42

Pendulum Appliance for class II noncompliance therapy
JAMES J.HILGERS,JCO 1992


Nance button for anchorage



.032” sTMA springs-light
continuous forces



Broad swinging arc
(Pendulum) of force from
midline of palate to upper
molars

43

Pendulum Appliance
Fabrication :
Pendulum springs
consist
Recurved molar insertion
wire
1.
Horizontal adjustment
loop
2.
Closed helix
3.
Loop for retention in
acrylic button

Springs- close to center
of Nance button

44

Springs close to center of
palatal button:to maxi range
of action, easy insertion.
Retaining wire is soldered to
the U4 and extended into
acrylic.


45

Pendulum Appliance


Nance button- extend to about 5mm
from teeth



Anterior retention loops fixed on
model, later soldered to bicuspid
bands



Acrylic pressed against the palatal
vault



Pendulum springs inserted


46

Pendulum Appliance
Pend-X
Expansion needed:
Jack-screw-One-quarter turn
every 3 days


47

Pre activation and placement
After cementation,before
activation:
Springs prefabricated to lie
parallel to midsagittal plane,
Which produces 60* of
activation after insertion.

As the molar distalizes it
moves on an arc towards
midline-counteracted by
opening horizontal loop


48

Intra oral reactivation:
Center of helix held with bird
beak plier while, spring is
pushed distally & reinsert.

Stabilization:
•Nance button
•Upper utility arch- anterior segment- anchorage.
•Full arch bonding:continuous wire with omega loop.
•Head gears ?

49

Pendulum Appliance


Unilateral correction


50

Pendulum Appliance
Conclusion :


Excellent patient tolerance



Upto 5mm distalization in 4 months



Distalization + Expansion



Patient compliance not needed


51

Franzulum appliance
Friedrich Byloff et al


Anterior anchorage : acrylic
button-5mm wide



Rests on canine and
premolars - .032”S.Steel
wire



Tube from acrylic button to
receive active component



NiTi coil springs-100200g/side



JCO2000 sep

J-shaped wire inserted into
tube

52

Franzulum appliance:
Niti spring over J shaped
wire
Inserted into tube of anterior
anchorage unit
•Anchor unit bonded
with composite.
•Close to CR of molarpure bodily movement.
compressed

Tied into lingual sheath


53

Case report

11yrs 10mts / M













end on molar relationship
Space deficiency in both the
arches
Premolars blocked out
Fixed appliance with cervical
headgear and Cl II elastics
End of treatment; Class I molar
relation, no significant change in
facial profile
U6:3mm,L6:6mm Lower incisors
proclined. Extrusion of U&L 6
Long term stability????

54

Distal jet Appliance
Aldo Carano, Mauro Testa JCO 1996



Lingual molar distalizing
appliance



Appliance design :
Wire extending from acrylic
through tube ends in a bayonet
bend-inserted into lingual sheath





Coil spring clamped on tube



Clamp



Anchor wire to 2nd premolar

.036” int dia
55




Reactivation- sliding clamp
closer to first molar,once a
month.



After distalization –
- clamp-spring assemblyacrylic,
- premolar arms cut off.

56

Case report

18/F, Class II div I

No skeletal abnormalities

Non-extraction therapy (3rd molars
removed)

Distal jet

4 months- Class I ,2mm-L, 3mm-R


57

Advantages :
 Bodily movement
 Easy insertion
 Well tolerated
 Esthetic
 Unilateral, Bilateral
 Permits simultaneous use of full bonded appliances.


58

Open Coil Jig
Jones, White –JCO 1992 Oct
NiTi springs 70-75g
Nance button attached to
U5

Assembly tied in place


59

Open Coil Jig
3
1.

Fixed Sheath

4.

Hook

5.

Sliding Sheath

6.

5

Light wire

3.

6

Heavy round wire

2.

4

1

Open coil spring

4-5mm of distal
movement.
2

60

Conclusion






Borderline cases
Space gaining procedures
Simplicity
Clinical effectiveness
Patient compliance factor


61

Distraction Osteogenesis:










New bone formation b/w the surfaces of bone
segments gradually separated by incremental traction.
Tension-stimulates new bone parallel to vector of
distraction.
tension in surrounding soft tissues, initiating a
sequence of adaptive changes termed as distraction
histogenesis.
Skin, fascia, bl vessels, nerves, muscles, cartilage,
periosteum.

Illizarov.

62

Mandibular Sympyseal distraction.











Mandibular symphyseal distraction- space gaining.
Intra oral mandibular distraction device.
More stable results.
Corticotomy.
Latent period.5-7days.(fibro vascular bridge)
Activation.optimum rate: 1mm/day(0.5mm-premature
ossification,2mm-fibrous CT , ischemia)
Consolidation (remodeling) concomitant soft tissue
expansion.
Retention.

63

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