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

INDIAN DENTAL ACADEMY
Leader in continuing dental education
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SPACE GAINING IN
ORTHODONTICS
1.

Molar distalization

2. Expansion
3. Proximal stripping
4.

Extraction

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

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


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.

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.

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

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


•K-Loop Molar distalizer
• Distal Jet
• NiTi coil Springs
• Fixed palatal expander
• Super spring II
• Franzulum Appliance
• C – Space regainer

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.

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.

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.

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 outwww.indiandentalacademy.com
upper canine

Expansion can be broadly classified into 2 types:
1. Rapid expansion
2. Slow expansion.


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


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 www.indiandentalacademy.com

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

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.

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


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.

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


Types of Slow Expansion devices

     JACK SCREW

      COFFIN SPRING

       QUAD HELIX


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


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.

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

Coffin spring Quad helix


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

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.


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.

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.

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

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

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.


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.

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

 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

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

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



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

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



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.

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


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



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 forwww.indiandentalacademy.com
any orthodontic appliance

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

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



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



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.

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.

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

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

•

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

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

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.


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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