The third stage of comprehensive treatment

The Third Stage of
Comprehensive Treatment:
Finishing
Done by Me :- Dr WesaM alsaaDi
supervision:-
Dr ahMaD altaraWneh
Dr raeD alrbata
Dr nancy alsarayrah
Always Remember to
Keep smiling

Definition
•The Correction of errors made prior to finishing
and detailing, over correction as needed, and
settling the case

Finishing Stage
• Finishing Starts at the moment of fitting the
appliance and it is part of planed treatment strategy

The American Board of Orthodontics
• ABO has introduced a grading system for models and
panoramic radiographs. This is oriented toward
occlusal detail
• A measurement instrument has been devised to ensure
reliability in measurements.

• Things ABO examine and grade
1. Alignment
2. 2. marginal ridges
3. Buccolingual inclination
4. Occlusal contacts
5. Occlusal relationship
6. Overjet
7. Interproximal contact
8. Root angulation

• In general a case which loses more than 30 points will
fail and a case that loses less than 20 points will
probably pass .

Finishing Stage
• By the end of the second stage of treatment:-
- The teeth should be well aligned
- extraction spaces should be closed
- Teeth roots should be reasonably parallel
- The teeth in the buccal segments should be in a normal Class I
relationship.

Finishing Stage
• In Begg technique, major root movements remained to
be done in the 3rd stage
• With contemporary edgewise technique much less
treatment remains to be acomplished at finishing
stage, because of :-
- The built in features of the preadjusted appliance
- Emphasis on bracket placement

Finishing Stage
Most cases require:
- Some adjusmtments of tooth position to get marginal
ridges levelled
- obtain precise in-out position of teeth within arches
- Overcome any discripancies produced by errors in
either bracket placementor appliance prescription
- Some cases, it is neccessary to alter vertical
relationship of incisors too

Aims of Finishing Stage
Enhance Aesthetic
Enhance Individual Tooth Position within arches
Enhance Occlusion
Enhance Stability

Aesthetic Aims
1- Extra oral Aims
It mainly involve
a) correct position of Upper incisors to APog plane "
-1 to 5 mm"
b) Lower incisor position in relation to Apog plane
and MP

Aesthetic Aims
2- IntraOral Aims
a) Tooth Size Discripancy
- It is the 7th key to normal occlusion
- As a general rule, 2mm tooth size discripancy noted
from Bolton analysis is the threshold for clinical
significance (othman2007)

Tooth Size Discripancy
• Managment to this problem could be
1- Reduction of interproximal enamel (stripping) is the
usual strategy to compensate for discrepancies caused
by excess tooth size.
* It is more common to be found in Lower teeth , in this
case IPR can be carried out in initial stages
* If its in the upper teeth, IPR done in late stage of
treatment, other wise it could lead to spacing

• Topical Fluoride treatment is always recommended
immediately after stripping is done

2- When the problem is tooth size deficiency, it is
necessary to leave space between some teeth, which
may or may not ultimately be closed by restorations.
• In case of peg shaped laterals, 2/3 of the space should
be distal to lateral and 1/3 mesial. (for best aesthetic,
Kokich 2003)

• More generalized small deficiencies can be masked by altering
incisor position in any of several ways.
• To a limited extent, torque of the upper incisors can be used to
compensate: leaving the incisors slightly more upright makes
them take up less room relative to the lower arch and can be used
to mask large upper incisors,
• while slightly excessive torque can partially compensate for small
upper incisors.

• These adjustments require third-order bends in the
finishing archwires. It is also possible to compensate
by slightly tipping teeth or by finishing the
orthodontic treatment with mildly excessive overbite
or overjet, depending on the individual circumstances.

IntraOral Aesthetic Aims
b) Gingival Levels
Four characteristics contribute to ideal gingival form.
1. First, the gingival margins of the two central incisors should be at the
same level.
2. Second, the gingival margins of the central incisors should be positioned
more apically than the lateral incisors and should be at the same level as
the canines.
3. Third, the contour of the labial gingival margins should mimic the
cementoenamel junctions of the teeth.
4. Last, there should be a papilla between each tooth

Gingival Level
• The cause of These discrepancies could be Abrasion of
the incisal edges delayed migration of the gingival
margins.
• The proper solution for the problem:
- orthodontic movement to reposition the gingival
margins or
- surgical correction of gingival margin discrepancies.

Intra Oral Aesthetic Aims
c) Gingival Form
1. The presence of a papilla between the maxillary
central incisors is a key aesthetic factor in any
individual. Occasionally, adults will have open
gingival embrasures or black triangles between their
central incisors. These unsightly areas are often
difficult to resolve with periodontal therapy.

Gingival Form
2. This space is usually due to one of three causes:
a - tooth shape (corrected by IPR or composite
restoration)
b - root angulation (corrected by uprighting)
c - or periodontal bone loss (corrected by orthodontic
extrusion to relocate the papillae)

II. ENHANCE INDIVIDUAL TOOTH
POSITION WITHIN ARCHES
 At the finishing stage of treatment, if the bracket
positioning were perfect, such adjustments would be
unnecessary.
 When the bracket is poorly positioned, usually it is
time-efficient to rebond the bracket rather than place
compensating bends in archwires

 After the bracket is rebonded, a flexible wire must be placed
to bring the tooth to the correct position.
 Rectangular steel finishing wires are too stiff in bending for
tooth positioning.
 In the 18-slot appliance, 17 x 25 beta-Ti usually is
satisfactory;
 in the 22-slot appliance, 21 x 25 M-NiTi often is the best
choice, “21 x 25 beta-Ti too stiff in bending”.

 Placing bends in the finishing archwire to enhance tooth
position should be placed in a flexible full- diminution wire. The
next to last wire in the typical sequence
 17 x 25 beta-Ti used in 18 – slot appliance
 21 x 25 M-NiTi used in 22 – slot appliance
 Any step bends must be repeated in the final wire that is used
for torque adjustments
 17 x 25 steel in 18 – slot appliance
 21 x 25 beta-Ti used in 22 – slot appliance

II. ENHANCE INDIVIDUAL
TOOTH POSITION WITHIN
ARCHES
1. Correct Prominence of Teeth “first order bend”
Prominence includes both in-out and rotation
According to the American Board of
Orthodontics (ABO, 1998) (Kokich 2003).
a) In the mandibular anterior sextant, the incisal edges of
the mandibular incisors and canines are used to establish
proper alignment.

1. CORRECT FIRST ORDER BEND
 b) In the mandibular
posterior sextants, the
buccal cusps of the
mandibular premolars
and molars are used to
determine proper tooth
position.

1. CORRECT FIRST ORDER
BEND
 c) While in the maxillary anterior region, the lingual
surfaces of the maxillary incisors and canines are
used to assess proper alignment. This surface was
choosing because it is the functioning surface of the
maxillary anterior teeth, and if these surfaces are
aligned properly, the maxillary incisors appear to be
in their proper aesthetic relationship

BEND
 D) In the maxillary
posterior sextants, the
central grooves of the
maxillary premolars and
molars are used to assess
proper alignment.

BEND
 Errors in prominence arise from unusual tooth
anatomy or poor base adaptation
 Correction of these errors can be done by first order
bend
 Typical Location
- mesial to lateral incisor “ inset or step in bends
- canines “ offset , step out bends
- First molars “ offset, step out bends”

 Methods to correct rotation
 At initial stages by exaggerated bracket positioning, partial
ligation of aligning AW, piggy back, sectional cantilever
spring (Whip), couple moment using elastic, TPA or even HG,
open coil spring, or surgical replantation or luxation but with
high risk of ankylosis.

For final deroataion and over correction use:
•Steiner rotation elastic
•Repositioning the bracket
•Wire bending
•Abrahamian techniques: This involves placing a figure of eight
elastomeric ligature over the tie wing which it is desired to move
away from the archwire and tying in the other tie wing with a
steel ligature.

 2. Correct Teeth Angulation and root paralleling “second
order bends”.
 In contemporary edgewise practice, it has been almost totally
abandoned in favor of angulated bracket slots that produce
proper root paralleling when a flexible full-dimension
rectangular wire is placed

2. CORRECT SECOND ORDER
BENDS
 Root angulation should be checked using an
orthopantomogram once rectangular wires are placed ,
no need to wait until working stailess steel archwires
are in place
 This check comes normally around 6 months of
treatment, and can be combined with an evaluation of
any signs of early root resorption

2. CORRECT SECOND ORDER BENDS
 when some crown angulation need to be corrected second order
bends will achieve that.
 While its more time effient to do bracket repositioning in earlier
stage .

BEND
 If a small amount of tipping will occur in some patients
during space closure, and therefore some degree of root
paralleling at extraction sites often will be necessary

2. CORRECT SECOND ORDER BEND
 With the 18-slot appliance, the 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 x 25 wire might be
needed initially, with a steel archwire used for final
expression of torque.

 With wider 22-slot brackets on the canines and premolars and
with the use of sliding rather than loop mechanics to close
extraction sites,
 A 21 x 25 beta-Ti wire is the best choice for a finishing
archwire under most circumstances
 if root positioning is needed, 21 x 25 M-NiTi should be used
first.

 A root-paralleling moment is a crown-separating moment in
edgewise technique just as it is in Begg or any other
technique.
 To Avoid this effect; Either the teeth must be tied together
or the entire archwire must be tied back against the molars to
prevent spaces from opening.

BENDS
 Not only extraction sites but also maxillary incisors must be
protected against this complication. Also 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.

 3) Correct Tooth Torque “ third order bend”
 The overall inclination of the maxillary anterior teeth is best
evaluated with a lateral cephalometric radiograph.
 The importance of correct teeth inclination are:
 Aesthetic purpose
 Functional purpose
 Stability
 PD health

3. CORRECT THIRD ORDER BEND
 The errors in the third order bend could be Known by
assessing:
 The incisal edges of the anterior teeth. If a discrepancy exists in
anterior inclination, the incisal edges of the anterior teeth will not be
in the same plane. Even in-setting or offsetting the incisors relative to
one another will not correct the problem.
 A second criterion to evaluate is the clinical crown length of
contralateral teeth. If contralateral teeth are different lengths, the
cause could be relative discrepancies in the inclination of contralateral
incisors.

 The third criterion to evaluate is root prominence
 The fourth and final criterion is best evaluated from an
occlusal perspective. When the incisors are viewed from
an occlusal perspective, the cingulum of an improperly
inclined incisor is more prominent or more visible.

 Ligual Root Torque of Incisors
 If protruding incisors tipped lingually while they were being
retracted, lingual root torque as a finishing procedure maybe
required.
 lingual root torque is accomplished with an auxiliary
appliance that fits over the main or base archwire.
 The torquing auxiliary is a "piggyback arch" that contacts the
labial surface of the incisors near the gingival margin,
creating the necessary couple with a moment arm of 4 to 5
mm

 These piggyback torquing arches can be used in edgewise
technique in the same way as in Begg technique . Although
they come in a number of designs, the basic principle is the
same:
 the auxiliary arch, bent into a tight circle initially, exerts a
force against the roots of the teeth as it is partially
straightened out to normal arch form.

 Torquing auxiliary
archwires exert their effect
when the auxiliary,
originally bent in a tight
circle as shown, is forced to
assume the form of a base
archwire over which it will
be placed. This tends to
distort the base archwire,
which therefore should be
relatively heavy—at least
18 mil steel.

 Other method same like the above but include bending a loops
parallel to occlusal plane in 016 or 014ss. This has been described
by Sandler in the Art Meets Science course.

 A torquing force to move the roots lingually is also, of
course, a force to move the crowns labially. For that
reason, Class II elastics are likely to be necessary when
active lingual root torque is needed during the final
stage of Class II treatment

 Another method is to use the built in torque and express it
with full dimension AW or adding torque to the wire or
sometime inverting the brackets.
 Three factors determine the amount of torque that will be
expressed by any rectangular archwire in a rectangular slot:
the inclination of the bracket slot relative to the archwire,
 the tightness of the fit between the archwire and the
bracket.
Torsional stiffness of the wire

 With 18-slot appliance, a 17 x 25 steel archwire has
excellent properties in torsion, and torque is entirely
feasible
 While in 22-slot appliance full dimension steel
rectangular wires are far too stiff for effective torque
 So with 22 – slot some prescriptions have extra built in
torque to compensate for rectangular finishing archwires
that will have more clearance
 For Full expression of torque built into 22-slot bracket,
use 21 x 25 beta-Ti

 Torque control is the weakness of the preadjusted appliance
system , and this is related to 3 factors
 1. to have a good torque expression , play degree should be
of 1mm , and this will make tooth movement difficult
 2. to have some sliding of the wire within bracket , we go
for smaller size wires, which reduces torque expression
effectiveness
 3. the upper and lower anterior torque needs of patients
vary greatly

 To over come this problem
specially when it is related
to a single tooth “e.g
palatally erupted maxillary
lateral incisor”
 Third order bends of the
wire can be done
 Using torqueing plier

 Buccal root torque of premolars and molars
 Zachirson has pointed out that negative torque “
lingual crown torque” has a negative effect on
smile esthetic
 To obtain a broader and more pleasing smile, is not
to further expand across the premolars” with risk
of relapse “ , but to use buccal crown torque so
that crowns are uprighted

III. Enhance Occlusion
 1) Anteroposterior Correction
 It is often necessary to consider horizontal overcorrection of
class II and class III cases
 Overcorrection can be done with class II , clsass III elastics
and headgear “for ex” .

1) Anteroposterior Correction
 After correction has been completed, these methods can be
discontinued or worn on a part time
 Patient is then observed for a period of 6-8 weeks
 If the case appear to be stable , the appliance can be
removed

 2) Correction Of Vertical Incisor Relationship
 A) Excessive overbite
 Before attempting to correct excess overbite at the finishing
stage of treatment, it is important to carefully assess why
the problem exists
 particularly to assess two things: the vertical relationship
between the maxillary lip and maxillary incisors, and
anterior face height

2) Correction Of Vertical Incisor
Relationship A) Excessive overbite
 If the display of the maxillary incisors on smile is appropriate, it is
important to maintain this and make any overbite correction by
repositioning the lower incisors.
 If display is excessive, intrusion of the upper incisors would be
indicated.
 If face height is short, elongating the posterior teeth slightly (the
lower posterior teeth) would be acceptable
 If face height is long, intrusion of incisors would be needed

Relationship 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.
 Remember that 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.

Relationship
 If slight elongation of posterior teeth in indicated , step
bends in a flexible archwire would be satisfactory
 The intermediate archwire before final torquing archwire is
the one for imlemintation of these step bends
 For 18- slot appliance , 17 x 25 TMA wire
 For 22-slot appliance , 21 x 25 M-NITI

Relationship B) Anterior Open Bite
 It is important to analyze the source of the difficulty if an
anterior open bite persists at the finishing stage of treatment,
 To Determine what to do :-
• The Upper incisor relation to upper lip should be checked
• Anterior face height

Relationship
 Excessive use of inter arch elastic could lead to such an
open bite, by extruding molars
 Using a triangular Class III elastic, helps to control the
open bite tendency. Use of these elastics, lead to elongation
of the molars and incisors is acceptable.

Relationship Mild Open bite can be due to excessively levelled lower arch
 This condition is managed best by elongating lower incisors ,
but not upper .
 Steps
1. Use flexible lower arch
2. Maintain stiffer upper arch
3. supplemented with light
vertical elastics

Relationship
 If display of the upper incisors is inadequate, elongation
of those teeth to close the bite would be indicated, and the
same approach with the flexible / stabilizing archwires
reversed would be indicated.
 Elongation of lower incisors to close moderate AOB is a
stable procedure compared to elongation of upper incisors

 3) Correction of Midline
 The common problem at the finishing stage of treatment is
a discrepancy in the midlines of the dental arches.
 This can result either from a preexisting midline
discrepancy that was not completely resolved at an earlier
stage of treatment or an asymmetric closure of spaces
within the arch.
 Minor midline discrepancies at the finishing stage are no
great problem

3) Correction of Midline
 it is important to establish as clearly as possible exactly
where the discrepancy arises.
 dental midlines are a component of functional occlusion
 If a dental midline discrepancy results from a skeletal
asymmetry, it may be impossible to correct it
orthodontically, and treatment decisions will have to be
made in the light of camouflage vs. surgical correction

 caused only by lateral displacements of maxillary or
mandibular teeth accompanied by a mild Class II or Class
III relationship on one side.
 the midline can be corrected by using asymmetric Class II
(or Class III) elastic force.
 As a general rule, it is more effective to use Class II or
Class III elastics bilaterally with heavier force on one side
than to place a unilateral elastic.

 a combination of Class
II, Class III, and
anterior diagonal
elastics are being used,
with a rectangular
archwire in the lower
arch and a round wire
in the upper arch,
attempting to shift the
maxillary arch to the
right

 Prolonged use of Class II or Class III elastics during the
finishing stage of treatment should be avoided.
 Problem with anterior diagonal elastic, it may cause lower
incisor crowding , ligating these teeth together wil reduce
this undesirable side effect

 4) Settling of Teeth
 "arch-bound" phenomenon:- They found that with
fitting wires, it was almost impossible to get every tooth
into solid occlusion, although one could come close.
 .As a final step in treatment, the teeth should be brought
into a solid occlusal relationship without heavy archwires
present.This is called Settling

4) Settling of Teeth
 Feature of optimal interdigitation:
 1. The buccal cusps of the mandibular premolars and
molars should contact the fossae or marginal ridges of the
maxillary molars and premolars.
 2. The lingual cusps of the maxillary premolars and molars
should be in contact with the marginal ridges or fossae of
the mandibular premolars and molars.

 Methods for Settling the Teeth
 1) By replacing the rectangular archwires at the very end
of treatment with light round arches that provide some
freedom for movement of the teeth (16 mil in the 18-slot
appliance, 16 or 18 mil in the 22-slot appliance) and using
light vertical elastics to bring the teeth together. It was
the original method for settling, recommended by Tweed in
the 1940s. The difficulty with undersized round wires at
the end of treatment is that some freedom of movement for
settling of posterior teeth is desired, but precise control of
anterior teeth is lost as well.

 2) Using laced posterior vertical elastics after removing
the posterior segments of the archwires.
 It should not be used in patients who had major rotations
or posterior crossbite. For the majority of patients who
had well-aligned posterior teeth from the beginning,
however, this is a remarkably simple and effective way to
settle the teeth into their final occlusion. These elastics
should not remain in place for more than 2 weeks, and 1
week usually is enough to accomplish the desired settling.

 Use of laced elastics
for settling the teeth
into final occlusion
at the end of
treatment.
 The Light elastics
can be used either
with light round
archwires, or
(usually preferred)
with rectangular
segments in the
anterior brackets

 3) By using a tooth positioner after the bands and
brackets have been removed

 A positioner is most effective if it is placed immediately on
removal of the fixed orthodontic appliance. Normally, it is
fabricated by removing the archwires 4 to 6 weeks before the
planned removal of the appliance, taking impressions of the
teeth and a registration of occlusal relationships, and then
resetting the teeth in the laboratory, incorporating the minor
changes in position of each tooth necessary to produce
appropriate settling
 The positioning device is then fabricated by forming an elastic
material (formerly rubber, now usually polyurethane) around the
repositioned and articulated casts

 Asking the patient to wear it as nearly full time
as possible for the first 2 days. After that, it can
be worn on the usual night-plus-4 hours
schedule. The patient is advised to wear the
appliance and practice repeated cycles of
clenching then relaxation to encourage the
desired tooth movements.

IV. ENHANCE STABILITY
• At the conclusion of class II or class III correction,
particularly if interarch elastics have been used, the teeth
tend to rebound back toward their initial position despite
the presence of rectangular archwires
• Rebound is a 1 to 2 mm phenomenon; posturing can lead to
4 to 5 mm relapse, and obviously it is important to detect
it and continue treatment to a true correction.

• Relapse after orthodontic treatment has two major
causes:
• 1. Continued growth by the patient in an unfavourable pattern:
this need an “active retention” takes one of two forms.
• One possibility is to continue extraoral force in conjunction with
orthodontic retainers (high-pull headgear at night, for instance, in a
patient with a class ii open bite growth pattern).
• The other, which often is more acceptable to the patient, is to use a
functional appliance rather than a conventional retainer after the
completion of fixed appliance therapy.

• 2. Tissue rebound after the release of orthodontic force.
There are two ways to deal with this phenomenon:
• A) Overtreatment, so that any rebound will only bring the
teeth back to their proper position,
• B) Adjunctive periodontal surgery to reduce rebound from
elastibc fibres in the gingiva.

• Adjunctive periodontal surgery
• Surgery to section the supracrestal elastic fibres
1.The first method, originally developed by edwards is called
circumferential supracrestal fibrotomy (CSF).
No periodontal pack is necessary, and there is only minor discomfort
after the procedure.

• 2. An alternative method is
papilla-dividing procedure to
make an incision in the centre of
each gingival papilla, sparing the
margin but separating the papilla
from just below the margin to 1
to 2 mm below the height of the
bone buccally and lingually

REFRENCES
• CONTEMPORARY ORTHODONTIC, FIFTH EDITION , WILLIAM
PROFIT “ CHAPTER 16”
• EXCELLENCE IN ORTHODONTICS 2012, DIVIDE BRINIE,
CHAPTER 23
• SYSTEMISED ORTHODONTICS TREATMENT MECHANICS,
MCLAGHLIN & BENNET.
• AMERICAN BOARD OF ORTHODONTICS GRADING SYSTEM
FOR DENTAL CASTS AND PANORAMIC RADIOGRAPHS 2012

KEY PAPERS
1. KOKICH VG (2003)
2. MCLAUGHLIN RP AND BENNETT JC (1991)
3. MCLAUGHLIN RP AND BENNETT JC (2003)
4. POLING (1999)

The third stage of comprehensive treatment

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