Você está na página 1de 52

The Basics Two of the most important aspects of orthodontic treatment are bracket positioning and arch width

control. First, let's discuss bracket positioning. Bracket Placement Review A prominent orthodontic educator recently stated that "In the 1960's, the best orthodontics was done by the best wire benders. Today, the best orthodontics is done by the best bracket positioners." I couldn't agree more with this statement. Horizontal Positioning of Brackets Visualize center of tooth directly from the facial surface, then look down long axis of the tooth May need to use a mirror for bicuspids Placement errors lead to rotations

Rotational(axial) errors Cause unwanted tipping Keep incisal edge of bracket parallel to incisal edge of tooth use same visualization techniques as for horizontal placement

Excess bonding agent under the bracket may cause rotational errors To avoid these, push bracket firmly onto tooth

Vertical errors Cause excessive extrusion or intrusion

Check the same tooth on the other side of the arch and make sure the inciso-gingival position is the same on both sides- this prevents occlusal plane tipping

Mesio-distal position Position bracket on the mesio-distal center of the tooth for all upper and lower centrals, laterals, and cuspids -In most cases, position the brackets in the mesio-distal center of all molar and premolar teeth

Inciso-gingival position

Deep bite patients Position brackets 1 to 2 mm incisal to the center of the tooth Open bite patients Position brackets 1 to 2 mm gingival to the center of the tooth The pictures on the right show ideal anterior bracket placement for average bite (top), deep bite (middle), and open bite (bottom).

Occluso-gingival placement of premolars

Deep bite cases Position brackets 1 to 2 mm gingival to the center of the tooth Open bite cases

Position brackets 1 to 2 mm occlusal to the center of the tooth Upper molar bracket (or band) position Anterior portion of bracket bisects the MB cusp Final band seat is accomplished with lingual pressure Bracket in the occluso-gingival center for all cases Lower molar bracket (or band) position Bracket always placed in the center of tooth Final band seat is accomplished with buccal pressure Posted Blocked out teeth It is important to create space for blocked out teeth and get them into the arch very early in treatment. I start all my fully bracketed cases in either .014 or .016 nickel titanium archwires. I pack coil (.010x.030 stainless steel) to create space for any tooth that does not have enough space to fit into the arch. Before I go into the details of packing coil, let's discuss this space creation. When packing coil, space is created by allowing the teeth to move anteriorly in the arch. If you are treating a case non-extraction, you must be willing to accept the fact that space will be gained at the expense of anterior teeth moving forward. For every millimeter that teeth move forward, about 2mm of space will be gained. If you decide to use a non-extraction treatment approach, you must understand and be comfortable with the fact that the anterior teeth will move forward during the initial aligning. If you are comfortable with this forward movement, non-extraction therapy is a good choice. So, how do you pack coil? Here are the steps. 1. Visualize the arch from an occlusal view. If a tooth doesn't have enough space to fit in the arch form, you need to pack coil in that area. 2. Pack a section of coil that is 2mm longer than the distance between the adjacent brackets. For example, if the lower right lateral incisor is blocked out, pack a piece of coil that is 2mm longer than the distance between the distal of the bracket on the central, and the mesial of the bracket on the canine. 3. See the patient in 4 weeks and evaluate. If the space create can accommodate the tooth, engage the tooth. If the space is not big enough, pack a piece of coil that is 2mm longer than the one previously used. 4. Repeat step 3 until enough space is created.

Arch Width Control

Along with good bracket positioning, good arch width control is one of the most important parts of quality orthodontic treatment. Proper arch width control starts with a good diagnosis. Does the patient require arch expansion, arch contraction, or maintenance of the existing arch form? Once this question is answered, some simple steps performed throughout treatment allow the practitioner to reach the treatment goals. I alter all stainless steel archwires to help give the patient the desired arch form. If no expansion is desired, here is how I co-ordinate archwires.

1. Draw a line on the lower pretreatment model from the buccal cusps of the posterior teeth through the incisal edges of the anterior teeth 2. Co-ordinate the lower wire so it is 3mm wider than this line throughout

the circumference of the wire. 3. Co-ordinate the upper wire with the lower.

If no expansion is desired, make the upper wire 3mm wider than the lower.

4. About 6mm of expansion (3mm per side)can be obtained with archwires alone. Simply expand each stainless steel wire used to the desired amount of expansion. If expansion in only one arch is needed (for example, correction of a narrow upper arch), just expand the archwires for that

particular arch. 5. Any cases requiring more than 5-6mm of expansion need an expansion appliance (RPE,quad helix, or Schwarz plate). This should be determined during the initial diagnosis. 6. Molar area expansion is much less reliable than is bicuspid area expansion when using only archwires. A future posting will describe techniques for expanding the molar area with archwire

bends. 7. Use a hollow chop pliers (or finger pressure) when forming the wires. The hollow chop is shown here. Good arch width control techniques result in good interdigitation of teeth as the treatment progresses. Less elaborate finishing techniques and faster treatment will be the end result if these techniques are used. Anchorage Control in the Early Phase of Bicuspid Extraction Treatment In extraction treatment, every effort must be made to prevent the anterior teeth from moving forward during initial leveling and aligning. As the teeth are aligned using a flexible low-load deflection wire (such as a nickel-titanium alloy) the teeth tend to move forward (through air) rather than backward (through bone) into the extraction site. In addition, when using a pre-adjusted appliance,the tip built into the bracket is also expressed while using the initial archwire. Tipped teeth take up more space than do teeth that are upright. This space is also gained by the teeth moving forward. This forward movement and resulting increase in protrusiveness is one of three aspects of the malocclusion that often worsen during the initial phase of extraction treatment. The second unfavorable side-effect that often occurs early in extraction cases is unwanted bite deepening. The canines often erupt in an upright position in crowded cases. If a light straight wire is placed into a canine bracket when the tooth is upright, placing that wire through the incisor brackets will cause over eruption of the incisors and hence bite deepening. This is contra-indicated in most cases.The figure below demonstrates how this happens.

Third,the molar relationship often drifts toward Class II early in these cases. This is how it happens. When an archwire is tied in to all the brackets, friction between bracket and wire plus the elastic or steel ties make the entire arch behave as one unit. Since the upper anterior teeth have more total tip than the lower anterior teeth, the upper teeth will move anteriorly more than will the lower anteriors. As the uppers move forward, they drag the molars with them (Remember, friction makes the arch act as one unit. The anteriors and posteriors move together.) The lower anteriors, because they have less tip, don't advance as much as the uppers, so the lower molars don't advance as much as the uppers. As a result, the molar relationship moves toward Class II. These undesirable movements can be minimized by using anchorage control, which is defined as the maneuvers used to restrict undesirable changes during the initial phase of treatment so that leveling and aligning is achieved without the key features of the malocclusion worsening. Two maneuvers make up anchorage control. The first technique is called a bendback. To use a bendback, simply bend back the archwire distal to the last banded (or bonded) tooth. This keeps the amount of wire from molar to molar constant, which helps prevent the teeth from advancing.

The second, and more important anchorage control technique, is called a laceback. Lacebacks consist of .010 ligature wire tied in a figure 8 fashion around the bracket on the last bracketed tooth up to the canine. The figure below illustrates how a laceback is engaged.

Lacebacks are tied in before engaging the archwire.Tie in the laceback, then tie in the archwire over the laceback. Tighten the laceback so it exerts pressure on the canine. This pressure not only prevents the canine from tipping forward (which would increase protrusiveness and deepen the bite) but also encourages the canine to move distally against the periodontal ligament.This creates about 1mm of space in the quadrant where the laceback is used.This space is then used as the teeth are aligned and correctly tipped. Clinically, light nickel-titanium archwires are capable of correcting about 2mm of crowding per month. This is exactly the amount of space one laceback in each quadrant will create. The

space,because it is close to the crowding, is available for relief of crowding. Clinically, the crowding is relieved by using this readily available space rather than the the teeth moving labially.

After the canine is moved distally, the laceback loses its tension. This gives the teeth a chance to move into the created space. When the patient returns for a 4 week recall, tighten the lacebacks. This will create another millimeter per side (2mm total), that will be used for aligning and tip control. The lacebacks are tightened at 4 week intervals until aligning is complete. When the patient is ready for a wire progression, the lacebacks can be removed. The net effects of lacebacks are the use of the extraction sites to relieve crowding and to allow the expression of tip, discourage bite deepening, and prevent the molar relationship from becoming more ClassII. Here is an example of a laceback.

Lacebacks not only inhibit forward canine movement, but they are an effective way of distalizing the canines. This occurs because the lacebacks tip the canines

at the gingival aspect of the alveolar crest. Due to the leveling effect of the archwire,the tooth rebounds as the roots tip distally.(1) A study by S N Robinson of 57 extraction cases showed lacebacks result in a net distal movement of incisors during resolution of crowding. This movement averaged over 1mm (remember, crowding was also relieved).In extraction cases without lacebacks the incisors moved forward almost 2mm. The bottom line is that lacebacks make additional molar support (headgear, TPA's, or lower molar anchorage) unnecessary in most cases. Six to seven mm of arch length discrepancy can be corrected using this technique. Questions 1) If the force exerted by a laceback cause the canines to move distally, why don't the molars move mesially because of the reciprocal force? Answer- Clinically, it has been found the molars just don't move forward. The force level provided by the laceback is not enough to affect the large molar teeth. 2) Why not just use a chain elastic? It sure is a lot easier to tie in a piece of chain instead of having to manipulate the long steel ligature tie.

Lacebacks are effective because they don't produce continual forces. The space is created, then they stop working until they are re-activated. This light, intermittent force is probably the reason the molars are unaffected. Also, the heavier forces produced by chain will cause teeth to tip into the extraction sites (see photo). Lacebacks do not cause this worsening of the malocclusion. Basic Considerations for Orthodontic Treatment It is always beneficial to review the basics. A firm understanding of the basic tenets of orthodontic treatment enables the practitioner to achieve excellent results in most cases. The following rules are based heavily on the treatment philosophy of Drs. Bennett, McLaughlin, and Trevisi, who are the architects of the MBT treatment system. Basic #1- Emphasis on dento-alveolar change Orthodontic treatment predominately affects dento-alveolar structures. Growth modification (even if accomplished with functional appliances) results primarily in dento-alveolar development. It is true that some patients experience orthopedic changes, but the majority of change is still dentoalveolar. Basic #2- The use of Light, Continuous Forces Intermittent forces move teeth inefficiently. Heavy forces have been shown to damage root structure. Therefore, light, continuous forces maximize treatment efficiency. How can a practitioner

be sure that he/she is using light, continuous forces? First never, never try to speed up treatment by forcing a wire into the bracket slot. Second, use a light, flexible wire until teeth are completely aligned (one of the most common mistakes I see is practitioners abandoning nitinol before alignment occurs). And third, use a wire progression that provides a slow increase in wire diameter so no wires are forced into the bracket slots. Basic #3- Leveling and Aligning If cases are leveled and aligned properly, mechanics become more efficient. About 1/2 the treatment time in a typical case is used to level and align (this includes bite opening or closing-see below). The following techniques aid in the leveling and aligning process: -Use of nickel titanium archwires to relieve crowding. -Use of bendbacks and lacebacks to control forward movement of incisors in extraction cases. -Use of open coil springs to create space for blocked out teeth. When using open coil with the initial archwires, use only enough coil to provide a light force (the coil used is about 2mm wider than the space between the brackets where the coil is used). This will minimize distortion of the arch form. -Early establishment and maintenance of arch form. Basic #4- Overbite control Getting the bite opened to the desired level before initiating other mechanics is a basic that many practitioners do not do. Strict adherence to this basic will really improve treatment results. The following procedures help the practitioner control overbite: -Differential bracket positioning can account for about 5mm of bite opening, or 3mm of bite closing. -In deep bite cases, bracket the 2nd molars early in treatment. -Use of reverse and compensating curve (rocking chair curve) when the overbite is 6-9mm. -Use tipbacks in a 2x4 or 2x6 set-up when the overbite is 10mm or greater. -Be aware that in most cases, leveling and bite opening are not complete until rectangular wires have been in place for at least one month. -Avoid leveling the Curve of Spee in open bite cases. Differential bracket positioning will greatly aid in maintaining the Curve of Spee. Basic #5- Space Closure A .019x.025 rectangular wire in a .022 bracket slot enables the practitioner to use sliding mechanics while minimizing archwire deflection and loss of torque control. In most cases, en-masse space closure is preferred over canine retraction. Many effective ways of providing force for space closure exist; elastics, chain, coil springs, and tie backs are most commonly used. Basic #6- Overjet Correction ClassII correction is accomplished by using a combination of ClassII elastics and functional appliances. ClassIII elastics work well for mild to moderate ClassIII discrepancies. Continuous forces on the dento-alveolar processes provide the best opportunity for overjet correction. Basic #7 Finishing and Retention Finishing involves correction of mistakes made earlier in treatment, particularly bracket position. Let cases settle in light wires for at least 6 weeks prior to debanding. Many practitioners advocate removing archwires for an additional 4-6 weeks to help determine retention needs for the case. Retention is usually accomplished by using bonded retainers for the lower anterior segment, and acrylic full coverage upper retainers. Wrap around upper retainers are used in cases that need additional settling; retainers with bite planes are use to retain deep bite corrections. Final Considerations

#1 Position brackets properly. Pay attention to bracket positioning. Reposition brackets twice during treatment- after leveling and aligning (6-9 months into treatment) and before beginning finishing (4 months before removal).Use a panographic x-ray to evaluate bracket position when repositioning. #2 Control arch width. Be aware of what you are trying to accomplish with arch width control (expansion, contraction, or maintenance of arch width). Co-ordinate all stainless steel archwires to accomplish your desired goals. Comments on Space Closure I often receive questions on space closure mechanics; I will take this opportunity to address issues regarding space closure. First, and most important, the biology of tooth movement is more important in determining the rate of space closure than the particular technique used. Osteoclasts and osteoblasts must do their job; human premolar and molar roots can move bodily through bone at the rate of about 1mm per month. In most cases, movement faster than this amount means teeth are tipping into the extraction site. This type of movement is usually counter-productive. Second, the arch must be completely leveled before space closure can occur. That means the practitioner must leave the working wires (usually .019x.025 st.steel in a .022 slot) in the arch passively for at least a month. Once the arch is leveled, space closure can commence. Third, many practitioners inform me they prefer to close space on a round working wire (most commonly .020 st. steel in a .022 slot). They claim that friction due to the rectangular wire filling the slot inhibits space closure. I believe this is false. Closing space on round wire is usually not indicated for the following reasons: 1) Loss of torque control. Torque is the weak link of the pre-adjusted appliance. Closing space without torque control uprights anterior teeth. This gives the completed extraction case a rabbitted appearance- the teeth end up too upright. This is especially problematic in upper bicuspid extraction cases, as the uprighted maxillary anteriors can occlusally interfere with the lower anteriors. 2) Speed of space closure. The rate of ostoblastic and osteoclastic activity, not the amount of friction, determines the speed of space closure. (1) Controlled force levels on a rigid wire eliminate nearly all of the potentially deleterious side-effects associated with space closure mechanics. Remember, if the rate of space closure exceeds 1mm per month, the teeth are probably tipping into the extraction site. This is detrimental to the orthodontic result. Fourth, many practitioners ask what is the best force system to use. Many systems work well, as the big issue is to provide adequate amounts of force after the arch has been leveled. I prefer enmasse space closure (moving the 6 anterior teeth as 1 unit) to canine retraction. En-masse closure takes full advantage of the principle of sliding mechanics, which is one of the big advantages of the pre-adjusted appliance. As for force application, many effective methods exist. Nitinol coil springs or active tie-backs are very effective. However, I like to use elastics. The proper force is usually provided by " medium Class I elastics when the exraction site is larger than 4mm.When the site is 2-4 mm wide, switch to 3/16" medium. For the last mm or 2 of space closure, use chain elastic. My patients wear the elastics full time and change them every 12 hours. They attach the elastic from the hook on the canine bracket to the hook on the last bracketed molar. The anterior 6 teeth are held together (as 1 unit) by chain elastic or a figure-8 steel ligature tie.

Using elastics to close space provides the practitioner the flexibility to deal with many situations that arise during space closure. For example, if the molars are a little Class II, space closure can be accomplished by applying the elastics in a Class II direction. In fact, the practitioner can apply the elastics in virtually any configuration to close the space in the manner required in the individual case.

Delays in space closure A couple of reasons exist which can cause delays. Often, upper premolar brackets are placed too gingivally. This results in over eruption of the premolars, resulting in occlusal interferences. Also, gingival tissue can build up in the extraction site, causing delays. In addition, dented or bent tubes or bracket slots can inhibit sliding. So if the space is not closing appropriately, check these three items. Chances are, you will discover the problem. Important Orthodontic Studies For anyone practicing orthodontics, keeping up with the literature is essential. There are many ways to do this, but one of the easiest methods is to subscribe to Practical Reviews in Orthodontics. (http://www.cmeonly.com/programdetails.cfm/2/44/2) Each month you receive an audio CD and a written synopsis of the most germane orthodontic articles from all the major orthodontic journals. The reviewers do a great job of summarizing all that is new and important in the orthodontic literature. Try this service; you will not be disappointed. The orthodontic practitioner should not only keep abreast of current orthodontic literature, but also be aware of the studies that have shaped how orthodontics is practiced today. I believe the study performed by Professor Arne Bjork while he was the chairman of the Orthodontic Department of the Royal College of Dentistry in Copenhagen is the single most valuable study ever done in the field of orthodontics. Professor Bjork practiced orthodontics for about 20 years before accepting the previously mentioned teaching position in 1950. For the next 15 years, he worked on this study. Bjork placed titanium implants in the maxillas and mandibles of 240 children. He then took yearly records, performing no other treatment on these patients. This research is valuable because it can never be duplicated. Todays medical ethics prevent researchers from placing implants for observation only. In addition it is now unethical to watch and not treat severe malocclusions. Because the scope of medical ethics was so different in the 1950s than it is today, Bjork was able to provide the

orthodontic community with a valuable body of data. So, whats the big deal? Why is this information so precious? Well, by superimposing cephalometric x-rays on the implants, Bjork was accurately able to determine how faces changed with growth. When superimposing cephs without implants, it is nearly impossible to discern the difference between growth and bone remodeling. Interpretation of Bjorks data lead to some interesting conclusions. The driving force responsible for facial growth seems to be the condyles. If cellular proliferation is near the anterior surface of the head of the condyle, the mandible rotates in a forward direction (counter- clockwise, if one views the chin in profile). See figure below.

If cellular proliferation is near the posterior surface of the head of the condyle, the mandible rotates in a backward (clockwise) direction. See figure below.

As the mandible moves due to the cellular proliferation, the sling of muscles that encapsulate the mandible are responsible for pressures and tension directed onto the bone. These forces result in apposition and resorption of mandibular bone. Therefore, mandibular morphology is different for forward and backward mandibular rotation.

Because of the way the muscles act (as well as some other factors), forward rotators are referred to as strong muscled patients, and backward rotators are called weak muscled patients. Almost all orthodontic mechanics result in extrusive forces on the teeth. Strong muscled patients resist this extrusive tendency, while weak muscled patients tend to not resist this tendency. This leads us to a very important concept: the same brackets, bands and wires will produce different treatment results in different patients. Muscle strength (which can vary by a factor of 6 between strong and weak muscled patients) is the main reason for these variable treatment responses. So, how do we use this knowledge to improve treatment? Weak muscled patients tend to be open bite patients; the extrusive component of orthodontic mechanics is often expressed. Conversely, it is often very difficult to open the bite in strong muscled patients (who tend to be deep bite patients). By looking at the shape (morphology) of the mandible, the practitioner can determine if bite opening or closing will be a problem. A specific treatment plan for the individual patient can then be devised. Some other facts stemming from Bjorks work are very important. First, the distribution of growth cells on the head of the condyle follows a bell shaped curve. That is, not all patients are entirely strong or weak muscled. About 85% of patients are predominately strong muscled (good thing, because weak muscled, open bite patients are difficult to treat). Many patients have some strong and some weak muscled characteristics. The most difficult cases are the very strong, and especially very weak muscled patients. These cases are often easy to pick out because the mandibular morphology is very diagnostic. The difficult part is to monitor the borderline cases to see if vertical control becomes problematic. Graber states in his textbook that controlling vertical dimension in borderline patients is one of the most important aspects of good treatment.

Second, forward or backward rotation is a highly genetic phenomenon. Condylar growth direction depends on the location of the growth cells; this is an inherited trait. However, growth patterns can be affected by the environment. For example, airway blockage, habits, allergies, etc. can change

the normal position of the mandible, allowing different parts of the growth center to be more fully expressed. So, according to Bjork, environment influences growth while genetics controls it. Bjork used knowledge of apposition and resorption of bone based on muscular pressures and tensions to determine muscle strength based on mandibular morphology. I like to use five characteristics to point out the morphological differences between strong and weak muscled patients. Not all these characteristics are visible on all patients, and previous growth direction does not insure that future growth will continue in the same direction. But despite these limitations, mandibular morphology is a useful predictor of both future growth and response to treatment mechanics. Lets explore the specific morphological characteristics I use. First, the gonial angle will be more acute in strong muscled patients and more obtuse in weak muscled patients. Second, the shape of the lower border of the mandible is a good predictor. In weak muscled patients, apposition below the symphysis and resorption anterior to the gonial angle produces a concavity throughout the lower border. In strong muscled patients, anterior rounding is absent. In addition, notching occurs anterior to the gonial angle. This results in an "S" shaped curve on the lower border. The third predictor I like to use is the density of bone at the symphysis. A thick symphysis indicates strong muscles, while a thin symphysis means the muscles are weak. Fourth, the inclination of the symphysis is a reliable predictor of muscle strength. In strong muscled patients, the inclination is relatively acute, while the norm for weak muscled patients is a more obtuse inclination. The final indicator I use is the inclination of the condyle.In strong muscled patients, the condyle will incline anteriorly, while in weak muscled patients, the condyle will have a posterior inclination. This trait is not always visible on the ceph because of superimposition of structures over the condyle on ceph x-rays.

There are many other predictors of mandibular growth rotation.Many clinicians rely solely on mandibular plane angle to predict muscle strength (and, hence, treatment response). Although weak muscled patients usually have higher mandibular plane angles than do strong muscled

patients, this measurement can be deceiving. If the clinician uses more than one measurement to arrive at a diagnosis, the diagnosis will probably be more accurate. Using all the available data will help insure that the patient will receive the best diagnosis possible. In addition to maxillary and mandibular growth rotation (the maxilla follows the same basic rotational pattern as the mandible), Bjork also described the intramatrix rotation. He defined the intramatrix as the maxillary and mandibular teeth and alveolar processes. Bjork described three types of intramatrix rotation, two which can occur in strong muscled patients, and one which occurs in weak muscled patients. To understand intramatrix rotation, one must understand Bjork's definition of the fulcrum. The fulcrum is simply the most anterior contact point of teeth in occlusion. Type I intramatrix rotation occurs in strong muscled patients when the fulcrum exists at the incisal edges of the maxillary and mandibular anterior teeth. This combination of mandibular and intramatrix rotation leads to normal downward and forward growth of the cranio-facial complex. This results in the best possible growth for the patient. Type II intramatrix rotation occurs when mandibular rotation is forward without an incisal edge fulcrum. This lack of incisal edge fulcrum often results from tongue or lip habits, or from early exfoliation of primary teeth.The fulcrum now exists in the middle of the arch. This pattern leads to over eruption of maxillary and mandibular anterior teeth, a deep bite, and collapse (lingual movement) of the maxillary anterior segment-a classic Class II, Division II malocclusion. Type III intramatrix rotation occurs in weak muscled patients where the fulcrum is on the posterior teeth. If sufficient eruption occurs in the anterior segments, the result is a long face with good occlusion. If something (tongue, lip, fingers) interferes with anterior eruption, an open bite results.

Understanding cranio-facial growth rotation leads to many interesting diagnostic conclusions. In Type I and Type II intramatrix rotation, teeth move forward and laterally on the alveolar processes. The opposite occurs in Type III intramatrix rotation. Therefore, expansion and arch length gaining treatment may be more successful in Type I and II intramatrix rotation than in Type III intramatrix rotation. Crowding that can be corrected by expansion in a strong muscled patient may require extractions in a weak muscled patient. In fact, every decision you make regarding a patient's treatment will be influenced by the patent's muscle strength. Extraction vs. non-extraction, bracket position, composition of arch wires used, and type of retainer used are all greatly influenced by a

patent's muscle strength. It is clear that an understanding of Bjork's research will change the way you look at orthodontic diagnosis. Posted by Jim P Frequently asked questions In space closure, if after a couple of months of space closure, we still have a couple of mm of space in the upper anteriors and no spacing in the lower arch, the occlusion is a solid ClassI with little or no overjet, is it correct to assume that we have a tooth size discrepancy? There seems to be 2 ways to deal with this remaining space, either bond composite to the upper teeth to close it or perform ARS on the lowers? What would you do in this situation? Studies show that in 60% of cases, there is a tooth size discrepancy where there is more tooth mass on the lower arch than on the upper. This is usually due to small upper laterals or large lower laterals. We call this the 60% problem. The solution to this is to do what you suggest. In 20% of all cases, there is excess tooth mass on the upper. This is called the 20% problem; it can also be corrected by IPR, but in this situation, it is the upper arch that is reduced. In my practice, I often do the ARS on the premolars because stripping in that area does not affect the esthetics as much. The interesting point about this discussion is that only 20% of all cases have no tooth size- arch length discrepancy, so the problem you describe is present in a lot of cases. However, in many cases with a discrepancy the problem is too small to be clinically relevant, so not all of the cases with a discrepancy need interproximal tooth reduction or bonding. If we are to call the diagnostic arch length the existing mandibular form, taken from the molar buccal cusp tips and anterior incisal edges, and not expand, how do we substantial crowding? Another way to put my question-when we unwind all of the crowding, don't we need a longer arch length, or distal drive the molars? Creating a Roman arch form and advancing anteriors will not strictly maintain this existing arch length, right? If you keep your arch length the same, the only way you can relieve crowding is to remove tooth structure. Tweed wrestled with this problem 70 years ago and ended up extracting 4 bis in 90% of his cases. We base our arch width on a line 3mm wider than the cusp tips/incisal edges to account for bracket thickness. We can change arch form (expand or labially advance teeth) to relieve crowding. How much of this can you do? Different practitioners will alter arch form different amounts. The more you change arch form, the less stable the final result will be, but the more you alter arch form, the less extractions you have to do. From a philosophical standpoint, I am not a big fan of distalization, especially on the lower. I don't like pre-determined arch forms, and I don't like to do a lot of expansion. This is why I extract teeth. Over the last 15 years, I extracted some combination of bicuspids in a little over 21% of my cases. This is a little bit lower than the 26% national average as reported by the AAO, but as a GP doing ortho, I do refer some of the more difficult cases that present in my office. These difficult cases are usually extraction cases, so factoring in these cases to my overall percentage would bring my extraction percentage closer to the national average. I have evaluated cases involving Class II elastics and I remember what you said about the use of Class II elastics,that is, Class II elastics really work but if you use them you may be "selling your soul because of some of the side effects that may occur. I've looked at a few of my cases and I think you meant Class II elastics may distort everything we've worked to achieve up to this point in treatment. I see mostly lateral open bites, especially molars out of occlusion. So what should or could we do to remedy the ill effects of Class II elastics? Do we use single elastics on each side and use less aggressive means (I've been using 2 elastics on each side 3/16 med full time wear)? Do we accept this problem as side effects of Class II elastics and deal with it after the Class II has been corrected? I'm thinking using Class II finishing elastics with vertical elastics on the 6's or maybe

even bracketing the 7's. What are your thoughts on this matter? There are certainly many side effects associated with Class II elastics. To minimize the side effects, I try to use them only in .019x.025 st steel with the bite opened to the desired level. Then,the elastics act as minor repositioning devices. This, hopefully, will eliminate the lateral open bite problem. If lateral open bite still occurs, go to a lighter wire after the Class II is corrected and the occlusion should settle. I like to use medium elastics, with full time wear. This provides a constant repositioning force and maximizes the speed of correction. If correction doesnt occur with this force, I increase the force by using 2 elastics per side, but this may lead to the side effects you described, especially in weak muscled patients. Vertical finishing elastics are a good way to close lateral open bites; bracketing the 7s in cases that can tolerate the bite opening will also help. The bottom line is Class II elastics are a good way to correct Class II, IF you can stand the side effects. Many ways exist to handle the side effects, but these ways may be a bit mechanically complex. I noticed that a case of mine has a tooth size discrepancy, with wide mand lateral incisors, and wide mand second bi's. Much more crowing exists on the lower than the upper, and the molars are Class I, but with only 2 mm of overjet in the anteriors. Initial leveling and aligning will probably advance the lower anteriors. Do we wait to do IPR on these type of cases after crowding and rotations are relieved, or can do IPR before initial aligning? She is not a weak muscled patient, but I still would prefer not creating edge to edge in anteriors and opening the bite. But I guess that it comes with the territory that the teeth may look worse before they look better. Good job in picking out the tooth size discrepancy before treatment starts. I like to align before I do IPR, even if it means the occlusion will be edge to edge for awhile. The reason I do it this way is because when the teeth are aligned, it is easier to strip the contact points and shape the teeth correctly. When crowding exists it is tough to get at the contact points accurately. In addition you never quite know how the leveling and aligning will play out, so I always like to get things lined up before I do something irreversible. So, get into at least .016st steel before doing any reduction. Temporary Anchoring Devices or mini implants are something we've never talked about. They are gaining in popularity among orthodontists. Are you currently using them? Do you think this will decrease treatment time? What kind of cases are they indicated, deep bites cases, open bite cases ? What are your feelings towards TAD? TAD's are all the rage these days. They are easy to insert and remove and provide reliable anchorage. They are used for space closure, distalization, intrusion, as well as attachment points for interarch elastics so the mechanical advantage of the elastics is greater. They are often used for bite opening and bite closing. I see their use greatly increasing over the next few years. Posted by Jim Prittinen,

Frequently asked questions, part 2 I'm using lacebacks on an extraction case. One question: when the lacebacks are tied in, with the wire on top, is there enough room around the brackets for elastic ties or would you have to use the ligature ties to tie everything in place? I use elastic ties when engaging the wire. There is plenty of room on the bracket tie wings for both the laceback and the elastic tie. What kind of burs do you use for IPR?

I use Essix burs. Find them here- http://www.essix.com/orstore/default.aspx . The specific burs I like are the 55000 for anterior reduction and the 699LC and 848MD for posterior teeth. An issue that I am struggling with is re-bracketing. In the first scenario, a patient breaks a bracket, say in the 020 or rect wire stage. Some tooth movement seems to have occurred since the break. How far do we have to go back in wire progression to catch up? I have found that I'm often using 016 Niti to get the new bracket and tooth in line. But what then? Second, after repositioning for second order movement in mid-course, I'm going to 016 Niti, but then can't seem to get right to the rect niti next month because it won't fit that tooth position. Is there a certain way to reposition brackets that will speed the process? What if a patient is breaking brackets every other appointment? Biting fingernails? The first rule in re-bracketing or repositioning is to be efficient. In your 1st case, even if you were in .020, I would re bracket that tooth at the same time I repositioned. If I had time, I'd do it that day. If not, leave the tooth unbracketed and schedule a longer appt. for repositioning in a month. One of the beauties of ortho is you can delay or speed up things depending on your schedule at that particular time. This is not the case with most other dental procedures. To answer your 2nd question, if you can't go directly to 019x025 niti from 016 niti, use an 016 st steel wire for a month. Again, not all patient's teeth move exactly the same way, so sometimes we have to adjust on the fly. Position the brackets correctly (there is no magic here) and use the wires you need. Breaking brackets is a whole different issue. Poor coop takes all the fun out of ortho. Look in my "policies" handout which I gave out in the last course. We charge the pt $20 per bracket after they have broken off 10 (most orthodontists start charging after 5). You will be surprised how quickly the situation improves after the parents get a few extra bills. 1) The bracket on LR4 has come off between just about every adjustment; however no other bracket has come off! FYI, I do have a few ortho cases going and haven't had problems with brackets coming off...this is starting to frustrate me! Any troubleshooting advice? (I have even placed a NEW bracket, just to be sure) 2) Do you have any info on how to place koby hooks? 3) According to USDI guidelines, the consolidate stage is to close posterior spacing, so if it's a nonextraction case, do you generally skip this stage? And are lacebacks your preferred method of closing space? I have heard of k-modules, chain elastics, etc. Which ones work best in which situations? Brackets consistently coming off is a frustrating problem. It's usually related to occlusion. When you re bracket, make sure it is not interfering. You can relieve interferences by adjusting the bracket (usually a tie-wing is the culprit) and by also doing a minor adjustment on the opposing tooth. I usually place Koby hooks under the archwire. Then you don't have to remove them on every wire change. Just tie it in like you would a steel tie. Be sure to pull tightly on the pigtail as you twist. After tightening, deflect the hook to where you want it to go by using a ligature director. Then tie the wire in as usual over the hook. The Koby hook gains stability when the wire is tied in. Lacebacks are used early in extraction cases to control anchorage (that is initial retraction of cuspids into the extraction site without any forward molar movement) so, technically, they are not a method of space closure. Any elastic force can be used to close space. Power chains, k-modules, elastics, open coil springs, etc. all work. Use what works best in your hands. Personally, I use elastics (1/4" or 3/16" medium ) until the space is about 2 mm. Then I use power chain. I think the archwire used is more important than the type of force. To maintain good torque control, I like to use heavy rectangular wire during space closure. Finally, if there is no space to close, consolidation is essentially complete, so, yes, you technically

skip this stage in those situations. What are the things to look for in the prefinishing check list? Prefinishing Checklist Name _________________________ Date ___________ Initial bracketing date ____________ 1. Goals of treatment a. _________________________ accomplished yes ___ no ___ b. _________________________ accomplished yes ___ no ___ c. _________________________ accomplished yes ___ no ___ d. _________________________ accomplished yes ___ no ___ Explanation of no answers __________________________________ __________________________________ __________________________________ 2. Static Occlusion 6 keys a. molar relationship......acceptable yes ___ no ___ b. tip.....................acceptable yes ___ no ___ c. torque..................acceptable yes ___ no ___ d. rotations...............acceptable yes ___ no ___ e. spaces..................acceptable yes ___ no ___ f. curve of Spee...........acceptable yes ___ no ___ Explanation of no answers __________________________________ __________________________________ __________________________________ 3. Functional occlusion a. Left lateral working ______ balancing interferences ___________ b. Right lateral working _____ balancing interferences ___________ c. Protrusive ______________ interferences ___________________ Is functional occlusion acceptable yes ___ no ___ CR = CO? yes ___ no ___ Equilibration required yes ___ no ___ If unacceptable, why? _____________________________________________ ________________________________________________________________ Ready for de-banding? Yes ___ no ___ If no, how long? ______________ Fee paid yes ___ no ___ If not, how much is owed? ____________

I have some anterior open bite cases I'm treating. In some of these cases the bite closes by just going through the wire progression while others require 019x025 nitinol rocking chair curve (RCS wire) coupled with heavy elastics from upper to lower canines. The problem with this is patient cooperation; patients will not apply the heavy anterior elastics because they hurt and instead of

closing anterior bite we now have more bite opening. So, I'm wondering instead of using the RCS wire maybe I can use just a regular 19x25 nitinol with lighter anterior elastics (1 or 2 elastics instead of 3) . So, if the patient doesnt wear the elastics the open bite wont worsen. Would this work? What do you think? Welcome to the wonderful world of ortho. One of the advantages of GP ortho is you get to pick the cases you want (and don't want) to treat. With diagnostic experience comes the ability to pick out these tougher cases before you begin treatment. You can then either charge more or refer. If you have an open bite in the bicuspid area as well as in the anterior, a flat wire will not easily solve the entire open bite problem. In these cases, there is no way around the difficult mechanics of RCS plus heavy elastics. However, if the bite is closed (or nearly closed) in the bicuspid area, then lighter anterior elastics on a wire without curve should do the job. Remember, a little (1 to 1.5mm) lateral open bite may respond to differential bracket position. Get those bis bracketed gingivally, and eruption (and hence lateral open bite closure) may occur. That being said, RCS plus heavy elastics is still one of the most reliable methods of open bite closure. Posted by Jim Pr More Questions I want to ask you how to correct a bilateral crossbite in a 42 year-old patient. I do not think I can use a palatal expander. Is there any way to correct it? These situations are tough. You can't split the palate without surgery; the sutures are too mature. That leaves us with tipping teeth. You can probably get about 3mm per side of expansion by tipping. If the amount of crossbite is 2mm or less, expanding the archwires during the wire progression may do the trick. If the amount of crossbite is approaching 3mm, a Schwarz plate (which I personally don't like to use) or a quad helix (which I like) will get you to your goal. In any adult crossbite case, always consider leaving the patient in crossbite. Sometimes the best answer is the most simple. One other question: I have some patients' moms discussing ortho in their young kids, who still have many deciduous teeth. Is it usually best to wait until these have exfoliated? I understand that growth curves favor early intervention, but waiting for permanent bis to erupt may prolong treatment. Do orthodontists routinely wait for all the deciduous molars to exfoliate prior to starting ortho? Are there certain malocclusions that most practitioners treat early? You are touching on a very controversial topic. Many practitioners swear BY early treatment-they say it is always better to treat early- while many practitioners swear AT early treatment- they say it is worthless. The answer is probably somewhere in between. The more severe the malocclusion, the more early intervention seems to help. FYI, most of the orthodontic literature demonstrates there is not a whole lot of value in early (two phase) treatment as compared to more traditional single phase treatment. The bottom line is that with experience you will develop a treatment philosophy that probably will include some early treatment. When are vertical (triangular) elastics used in the finishing phase? Would that be in weak muscled patients? Do you routinely use elastics for finishing, or mainly rely on settling forces and arch wire bends? I use finishing elastics in about 20% of my cases. They tend to be helpful on weaker muscled patients, where the muscles are unable to provide adequate settling forces. I try bends before adding elastics in most cases. If the bends provide good interdigitation, I'm done; if not I add elastics. I am finishing up a case in which all teeth interdigitate well with the molars in solid Class I

occlusion. I had the patient use Class II elastics for 3 months. However, some overjet remains in the anterior. Since all teeth are in contact, I do not think it is a good idea to do IPR on the anterior teeth and retract them with chain elastics. I might improve the overjet, but teeth might not interdigitate well as a result. What is your call on this? I think you are faced with a tooth size discrepancy. Upward of 80% (that's right 80%) of patients have some sort of discrepancy. This case probably has excess tooth structure in the maxillary. This often presents as good posterior interdigitation combined with overjet. In these cases I often do a little ARS in the upper. I usually strip 1mm distal to each cuspid. Then I close the space with 6-6 chain. I find that this retracts the anterior segment a bit without changing the posterior occlusion. Because the space closure is minor, it can be done on the finishing wires (.018st steel), although it is always better to close spaces on .019x.025 stainless steel wires.

I have a case in which I could not close the space of about 1 mm between the bicuspids with elastic chain. I am thinking of using closing coil; however I have never used it. I learned that there are niti and stainless steel closing coils. These coils can be purchased in spools, or in different lengths with hooks at the ends (to engage the hooks on brackets). I prefer spools of stainless steel coil. I have not ordered any and want your recommendation. Please recommend the type and the steps of how to choose the length of the coil for a particular span from one bracket's hook to another. If you happen to recommend the one that comes in a spool, please advise me how to form a "hook" at both ends of the coil, so I am able to engage it on the bracket hooks. When I use closing coil (which is rarely), I use stainless steel coil off of a spool. I like to stretch the coil about 1.5 times its resting length measured from the distance between the two attachment points. I use a bird beak and grab the last link of the coil, turn it up 90 degrees, and shape it to make a loop at right angles to the rest of the coil. (If you experiment with this, you will find this to be very easy to do.)I then use a Koby hook on the bracket of the teeth to be engaged if it doesn't already have a hook on the bracket. Stretch the coil, and slide the loops over the hooks. Remember, any method of force application should work. I would be more inclined to look at why the space is not closing, not changing the method of space closure. Some possible culprits: 1) overbite is too deep 2)bracket position is off 3) sinus on the upper is low-cortical bone of sinus wall is interfering with root movement 4)friction in space closing set up Usually, for the last mm or so, friction is the culprit. You could have a bracket whose tie wing is bent, a slot that is a bit constricted, or numerous other issues. I usually will try (if I have eliminated the other above possibilities)going to .020 stainless steel and closing the remaining space on round wire with chain. I know this violates one of my rules, and we are risking the expression of sideeffects, but for a mm or so in a stubborn case, the risk is worth it. Remember, you have to know the rules before you can break them. I have always bracketed all upper teeth at same height from the incisal with the cuspids and centrals .5 mm longer than the laterals. I know you position brackets by finding the center of the teeth. I am just not too comfortable at doing it your way. I read old lectures, not yours, and came across one that said to bracket all teeth at same height from the incisal with the laterals .5 mm shorter. What are your thoughts on these different ways of bracket positioning? You are touching on the art vs. the science of orthodontics. Any consistent way to get brackets positioned properly is vital to getting a good result. Changing how brackets are positioned will give you different smile lines and esthetics. Understanding this means you are starting to understand the art of orthodontics. Positioning the anterior brackets a little incisally will result in some intrusion and, therefore, a little less tooth display than positioning the anterior brackets more

gingivally. So each of these techniques may be appropriate in different situations. Incisal positioning may look a little nicer in a patient who already has excessive gingival display. Gingival positioning may be appropriate for a patient who doesn't show a lot of teeth while talking or smiling. My point is each case is different, and if you truly want to provide the best results for your patients, you must, at times, deviate from the ideal. Understanding how different bracketing techniques result in different esthetic results will allow you to change bracket positions with confidence. I find that I'm spending a lot of time coordinating my 19x25 stainless steel. When I try to conform the 19x25 steel to my initial wire I use my fingers to match the wire. Do you use pliers to do this? On one case I elected to leave the 19x25 niti because my steel was not accurate. If I do leave the 19x25 niti instead of the steel how long should I wait? If the 19x25 niti fits passively after 2 to 4 months is that a sign that it has served its purpose? I coordinate .019x.025 st steel with a hollow chop pliers(in the Ortho Organizers cat. it is Endura #201-401). It is tough coordinating these, but with practice, it can be done. In some cases, I don't use .019x.025 stainless steel when there are no mechanics to do. If there is no space closure, midline shift, or Class II or Class III correction, I often skip the .019x.025 st steel and stay in . 019x.025 niti. This has to stay in at least 3 months to provide torque expression. When it is passive, it has done its job. However, don't do complex mechanics on niti, because the side-effects of these mechanics are more easily expressed on the low-load deflection archwires. Thank you for the reply, regarding the wire progression. Mechanics should not be done with any 19x25 niti wire at all? What about space closure and elastics use? The low load deflection arch wire (niti) is not strong enough to overcome the side-effects of commonly used orthodontic mechanics. For example, if you use Class II elastics, the patient usually hooks the elastic to the hook on the lower 1st molar band. The elastic provides a vertical force on the molar. The low-load deflection niti wire will be overpowered by the elastic, resulting in extrusion of the molar. The result is loss of vertical control. If the same mechanics are done with . 019x.025 stainless steel wire, the strong arch wire will prevent extrusion of the molar. The result here is better vertical control. I have two concerns. First,I have a case which I expanded both upper and lower arches due to severe lingually inclined teeth. After the teeth are uprighted, do I need new upper and lower models to coordinate the wires? How do I coordinate arch wires, lower 3 mm wider than what is indicated on the new model and upper 3 mm wider than lower? Or do I make the lower arch width 6-7 mm wider than what is indicated on the new model,with the upper 3 mm wider than lower? Second, you said Class II elastics will reduce about 4 mm of overjet. I'm using Class II elastics on a case that needs 8mm of Class II correction. After correcting 4 mm of overjet (I still need 4 mm more of overjet correction),can I hold the bite where it is after the first correction of 4 mm overjet for six months, to give the condyle and the fossa time for bone remodeling and muscle adaptation?. Then, after the rest period,can I use a second round of Class II elastics for the remaining 4 mm of overjet correction? I'm referring only to using Class II elastics, with no other means of Class II correction, such as extraction or ARS. When coordinating arch wires,I look at how much expansion is needed (for this look at pretreatment models) and coordinate all my stainless steel arch wires to this position. In the example you gave, I would not take another model just for the purpose of arch wire coordination. If my arch widths are where I want them , I simply continue to coordinate based on the pre-treatment model. Because the arch widths are correct, you are using the correct arch width coordination. There is no reason to complicate matters by changing how you are coordinating the arch wires.

I rarely use Class II elastics for more than 5mm of Class II correction, even in very strong muscled patients. The issue is not a TMJ issue-the condyle and fossa can adapt to the new condylar position. In fact, when using repositioning appliances, we expect condyle and fossa adaptation for even larger horizontal corrections. The issue is the side effects that Class II elastics cause to the occlusion. For example, if you try to correct 8mm of overjet with Class II elastics, the vertical forces placed on the lower molars will extrude them. This will result in occlusal plane tipping and downward and backward rotation of the mandible, tipping of the upper occlusal plane inferiorly in the anterior, which results in increased gingival display. A rest phase does not change the total time you need to use Class II elastics; the net side effects will still be there. The bottom line is this: Class II elastics are very effective in correcting small and moderate amounts of Class II, especially in strong muscled patients. But, the side effects are real, and can ruin an otherwise nice result. Don't fall into the trap of using Class II elastics in severe Class II situations in an effort to avoid more difficult treatment options that may be better for the patient. Be aware of potential side effects, and understand which patients will not respond well to the elastics. Also understand what specific side effects will be detrimental to the patient that is being treated with Class II elastics, and watch carefully for the first signs of the particular side effects. Posted by Jim Prittinen,D Another Round of Questions What should be corrected first- overjet, overbite, or midline discrepancies? Do you correct one at a time or all at the same time? Answer: 1) Always correct overbite before overjet. Overbite is corrected during the wire progression (.014,.016, and .020 stainless steel). Use curve if the pre-treatment overbite is 6mm or greater. 2) Overjet, midline correction, space closure, and other aspects of the malocclusion (except for overbite, which is done earlier) are corrected in the mechanics phase- after the wire progression. Correct these aspects of the malocclusion in .019x.025 stainless steel, because this wire provides very good control. By following these guidelines, most malocclusions can be corrected efficiently. I have created enough space by using coil springs and have engaged the crowded teeth. I have used .016 Niti for 3 weeks since coil springs were removed. The lower centrals have flared excessively. This concerns me. I have used .016 Niti for 5 months. Is this too long? Also, should I be doing anything at this point the get those lower centrals back where they belong? How do I do this? Do I use power chain? Answer: You were probably a little too aggressive in your use of coil springs; that is, the coil springs you used may have been a little long. Short term excessive flaring of the lower incisors is usually not a problem, unless anterior gingival recession occurs. If recession has occured, use chain to retract the anteriors. If no recession is apparent, align the incisors (remember to use steel ties if the wire is not fitting passively into the slot when you are using .016 niti), then begin the wire progression. The incisors may settle back on their own. Don't use chain until you are in a much heavier wire (.019x.025 stainless steel is best) because the force levels exerted by chain are very high. Five months is not too long to be in .016niti- a mistake I often see is doctors progress out of niti too quickly. Remember, open coil spring is used to tease the teeth apart; you don't need to pack a lot of coil to gain space. As a general rule, the coil is 2mm longer than the distance between the adjacent brackets. Every month, use a spring that is 2mm longer than the coil used in the previous month. Discontinue coil and engage the tooth when there is enough space in the arch to fit the previously blocked out tooth.

After using 016 niti for 6 months, I started a wire progression on a 13 yr old patient. Everything

looks OK on the upper (coil springs to create space). But the lower left lateral, even after all this time, still is rotated. Additionally about 1.5 mm of crowding still exists. I was not sure what to do, so I started a wire progression (.014 ss). The wire is slightly kinked in (I had to push it slightly to fit into the bracket slot). I know that the wire has to be passive to maintain arch integrity. As of now, the crowding will not allow the LL2 to fit in the arch. Did I not create enough space with the open coil? Should I have done IPR before progressing to 014ss? Did I progress to .014stainless steel prematurely? Could I pack coil later, say in .020 stainless steel, and create space? Does this method create space too late? Is it as efficient as creating space in .016 niti? Answer: If, as you say, there is still 1.5mm crowding, you have not yet created enough space to bring this tooth into the arch. Use coil to gain more space. Rotations are nearly impossible to correct if there is not enough space in the arch. If there is enough space, it is much easier to engage the tooth with niti. Then the correction of the rotation will proceed uneventfully. Many doctors will progress up a wire progression, bypassing severely rotated teeth. Once they get to a heavier wire (.016 stainless steel or heavier), they will pack coil a little more aggressively to create enough space for the rotated tooth. Then after enough space is created they will step back to niti and engage the rotated tooth. This method results in less arch distortion, but it takes a little longer. You never want to kink a stainless steel wire. It will not return to its original shape so it will not move the teeth efficiently. IPR is an option in this case. If the tooth is thinner, it will fit into a smaller space. The problem with IPR on rotated teeth is the inability to access the contact point, which is the area where you want to do IPR. So do the IPR only after space is created and you can get at the contact point. After full banding, can we give the patient a bite plane until an anterior crossbite is corrected, or is it OK just to let the braces move the teeth? Answer: In general terms, a bite plane will, because it eliminates interferences, allow the teeth to move more quickly. In my experience, patients in braces don't wear bite planes very well. The teeth move a little, and, as a result, the bite plane doesn't fit. That being said, a lot of orthodontists use bite planes. I prefer to open the bite by bonding composite to the occlusal surface of the lower molars. The bonding can be done quickly, it is not removable by the patient, and it is easily removed by the doctor after the occlusion improves. Kids tolerate the change in occlusion well, but adults hate it. So I'm a bit more discriminating when I'm considering this on adult patients. I've been putting second molar brackets on my patients, and find that they report a lot of soft tissue irritation. I know about using ortho wax, and I always encourage patients to use it to intercept problems before irritation occurs. Do you have soft tissue problems with second molar brackets, and do you use the smaller ones, or the larger first molar brackets to get more surface area for bonding? Answer: I usually use the smaller bracket because of irritation issues. Remember, on the upper it's OK to use 1st and 2nd molar brackets interchangeably, but on the lower it is not. The prescription is different on the lower 1st and 2nd molars-more lingual crown torque is present in the lower 2nd molar brackets than the lower 1st molar brackets. How do I change the molar relationship from a full cusp (8mm) ClassII relationship to a ClassI molar relationship in a non-growing patient? Answer: In a non-growing patient, it is very difficult to change a full cusp (8mm) Class II molar relationship to ClassI molar relationship. So most of the time we dont try (don't fight molar relationship, especially in non-growers, is a statement with which most orthodontists would strongly agree). Usually in these kinds of cases, keep the molars in ClassII. Do this by taking out only the upper 1st

bicuspids and retracting the anterior segment. The molars stay in ClassII, but the canines end up in ClassI and the overjet is corrected. Typically in these cases, the upper anteriors are protrusive, so taking out upper bicuspids provides space for retraction of the upper anteriors. Often, problems arise with these cases if the bite is deep. It is more difficult to open the bite in extraction cases than in non-extraction cases. Anchorage control is very important in upper bicuspid extraction cases. The molar relationship is ClassII, so additional mesial movement of the upper molars is contraindicated. In addition to lacebacks in the initial stage of treatment, some method to prevent this forward upper molar movement must be used during space closure. Trans-Palatal Arches, Nance buttons, headgear, and banding or bonding the upper 2nd molars are all treatment modalities that are used to increase posterior anchorage during space closure. What do you use to rotate a tooth? Recently, I bought some rotation wedges. Do you recommend using these and how do you use them? Answer: I'm not a fan of rotation wedges. They are tough to put in and they don't stay in very well.I prefer to create space with coil, then after space is created, while still using a flexible arch wire such as . 016niti, tie the tooth in tightly with a steel tie. I have a case where tooth #7 was in lingual cross-bite. I brought the crown into the arch, but the root did not translate- that is,the root is still facially inclined. First, I repositioned the bracket several times and I placed a .016x.022 stainless steel wire, but the lingual root torque has not occurred. How do I correct the root torque? I think some doctors place the lateral brackets upside down in these situations. I did that for a few months in the .016 niti, but the root just did not move lingually. This is very frustrating. Do you have any thoughts on this? Answer: You need lingual root torque on the lateral. The lateral incisor bracket that I use has 10 degrees of labial crown torque (which is the same as -10 degrees of lingual root torque) so the bracket will not move a root lingually very easily (the bracket prescription does not encourage lingual root movement). If you put the lateral bracket on upside down, the torque changes to -10 degrees, which results in a situation that encourages lingual root movement. Remember, for torque to be expressed, you must use a rectangular wire. You cannot torque teeth on a round wire. Even a . 016x.022 does not fill the slot enough to affect torque very quickly. Get into .019x.025 (preferably stainless steel) and torque will be expressed. I have a patient that started with 7mm of overbite. I curved the upper wires, and the bite has not opened enough. Should I use .016x.022 rectangular wire with curve? Answer: As a rule, I don't like to curve rectangular wire. If the bite needs further opening, try curving the . 020st steel a little more, and use .020 stainless steel with a little deeper curve on the lower as well. Stubborn deep bites are the result of an incomplete leveling of the curve of Spee. Lower curves will solve this. If, after a couple of months, the bite is not open, bracket the 7's (I usually direct bond them). Erupting 2nd molars often is the best way to get the bite opened. A word of advice: do not do any other mechanics until the bite is opened. Do what it takes (and be patient!) to get the bite opened before progressing in the case. You will save a ton of time in the long run. S ATU RD AY, AU GUST 8, 2009 Still More Questions I'm treating a 12 yr old female with mild crowding, ClassI dental and skeletal, deep overbite, some rotations, and a low mandibular plane angle. I've bracketed and banded, with differential bracket placement, and propped the bite open slightly with composite on the occlusal surface of the lower molars to accommodate the mandibular brackets. Ive used 016 Niti for a couple of months. Now I

notice the second molars are in crossbite. Do I bracket these now or wait? Any problems with merely bracketing these 7s at the next appointment? Or should I make some type of temporary bite plate to unlock the occlusion while I move them? I would bracket the 7's asap, because not much will happen as far as correction of the deep bite/crossbite until you have control of the 7's. This happens a lot, and bracketing the 7's will solve the problem. There are no problems with waiting a month, but you are just not making any progress toward finishing if you don't bracket. I have a question regarding differential bracket placement. I noticed that there is a line in McLaughlin's book outlining this, but in general he does not routinely use this procedure. Don't we want the brackets to be placed ideally relative to the incisal edge at the end of treatment to achieve a flat curve of Spee and ideal marginal ridge alignment? His technique seems to imply that ideal placement will usually flatten the curve and open the bite appropriately by that procedure only, perhaps followed by reverse curve in rectangular ss if needed. Is there a disadvantage to placing brackets differentially at the start of treatment? McLaughlin does not use differential bracket positioning as much as I do. However, the last time I saw him speak (18 mo ago) he said he was leaning toward more differential bracket positioning, especially in the anterior. If you wait long enough, a flat wire with ideal bracket position will level the curve. In strong muscled patients, this may take a long time. I don't like curving rectangular wire (this does level the curve very quickly) because of the side-effects it produces. I have found no disadvantages to differential bracket positioning. I continue to use this technique as I have for the last 20-plus years. In fact, I probably place my anterior brackets a little incisally on most cases, even those that do not require bite opening. My bias toward incisal anterior bracket positioning is due to the fact that the more incisally the bracket is placed, the more torque (positive labio-lingual inclination) is expressed. Since torque expression is the "weak link" of the pre-adjusted appliance, this incisal bias results in helping solve the most difficult problem (torque expression) in using the pre-adjusted appliance. I heard a comment at a seminar regarding "round tripping. I'm thinking that I should have used more bendbacks to inhibit the mandibular incisors from flaring forward. Do bendbacks inhibit open bites and excessive anterior flaring? If we want to control the mandibular arch length and shape, maybe bendbacks are appropriate. McLaughlin mentions bendbacks, and also mentions IPR. Perhaps he is thinking about preventing flaring of the mandibular incisors. If we do bendbacks, how do we correct rotations and crowding especially if we use open coil springs? The space has to be gained somewhere! Maybe he's doing an arch length analysis, then IPR immediately in non-extraction cases, rather than gaining space through anterior tipping of the incisors, unless a more protrusive appearance is called for. You have said that you like to be in control. Maybe I need to control this incisor position more effectively, particularly in the mandibular arch during the first step. But how is this done? When you treat a case non-extraction, you must be willing to accept the fact that to unravel the crowding, the teeth will move forward. If you don't want the teeth to move forward, then you must gain some space some way- stripping, extraction, expansion and/or distalization. Each of these modalities has problems associated with it. Moving teeth forward to unravel crowding is not round tripping, because, if the diagnosis is correct, you will not plan on moving the teeth back to their original position. The big issue is diagnosis-where will the teeth end up with the plan you choose and is this right for the patient? There are many ways to get the teeth where you want to get them, but figuring out where they belong is the most important part. I just started a case with an RPE. Last week the appliance fell out and the patient waited a couple of days to come in the office. I had a very difficult time recementing the appliance. Is this due to relapse? Patient activated appliance for 2 weeks and it is now passive. The appliance may fall out

again. What should I do in this situation? If you can' t get the appliance to fit well, first determine if the problem is lack of space for the molar bands. You could try placing spacers for a day or so before attempting recementation. If the actual expansion relapsed, turn the screw backwards for a couple of turns, then recement. If you are satisfied with the amount of expansion you currently have, make a Hawley retainer. Have the patient wear it full time for a few months. Then, bracket as usual. I have a question regarding reverse and compensating curve. I placed curve in the maxillary arch. A month later, after I took out the 014ss there was no curve on the wire. Does the curve disappear after a month? Is there supposed to still be a curve after I take it out? There is a small space between 8 and 9; I take it that is from the flaring so I assume that the curve did do something. I tried to think back to your lectures but could not remember if you mentioned what the wire would look like after removing it. Often the lighter wires will straighten out a little because they are held in a straight position (tied in) for a month. I would be more concerned with results- reduction of overbite- than how the wire looks when it is removed. That being said, the biggest problem most doctors have when using curve is they don't put enough curve into the wires, especially the lighter wires. Bottom line- what you have is probably OK. Just make sure you curve the .014's enough. I'm working on a 4-bi extraction case. One of the max 2nd molars is partially buried with a 45% angle to the distal of the first molar. Do I attempt to bracket this now, and upright with Niti, or wait until space closure? Should I use another uprighting procedure? Will this issue resolve itself with slight mesial movement of the molar during space closure? If the case is moderate anchorage, close the extraction space and the space gained in the posterior will allow for eruption. If it needs to be aligned, bracket the 7 during finishing. I have a question regarding intraoral elastics. For Class II correction, what size do you usually use? I most often use 1/4" medium, 1 elastic per side, full time wear, patient changes elastics every 12hrs, and eating with them in is optional. When is the correct time to start the wire progression? What if brackets are improperly positioned? Do you reposition brackets before starting the wire progression? Begin the wire progression when the niti arch wire fits passively into all slots. If brackets are improperly positioned, don't worry yet. You will reposition after a few months of wire progression. Your goal is to progress to larger arch wires. When the bracket slot is full (or nearly full), you will be able to see malpositioned brackets. It is much more efficient to reposition all brackets that need it at once, rather than doing one now, one next month, etc. I find that I'm spending a lot of time coordinating .019x.025 st. steel. When I try to conform the 19x25 st. steel to my initial wire I use my fingers to shape it. Do you use pliers to do this? Because I am having a hard time accurately coordinating these wires, on one case I elected to leave the 19x25 niti in for the mechanics phase. If I do use 19x25 niti instead of the steel how long should I use it? If the 19x25 niti fits passively after 2 to 4 months, is that a sign that it has served its purpose? I coordinate .019x.025 st steel with hollow chop pliers. (In the Ortho Organizers cat. it is Endura

Pliers #201-401) It is tough coordinating these, but with practice, it can be done. Often, I don't progress to rectangular stainless steel when there are no mechanics to do. If, for example, there is no space closure, midline shift, or Class II or Class III correction to do, I often skip the .019x.025 st steel and stay in .019x.025 niti. This has to stay in about 3 months to provide torque expression. When it is passive, it has done its job. However, don't get into the habit of doing complex mechanics on niti, because the side-effects of these mechanics are more easily expressed on the low-load deflection archwires. More Questions How do you decide when to use arch wire curves as opposed to tip-back bends when the bite needs to be opened? The amount of gingival display often dictates what method of bite opening to use. If the patient has a gummy smile I would rather intrude incisors (tip-backs do this more efficiently than curves) which results in a reduction of gingival display. If the smile is not gummy, erupting molars (curves often do this more efficiently than tip backs) will open the bite without reducing the gingival display. It is easy to envision that a toe-in bend for maxillary molars helps correct the mesio-lingual rotation of the molars. But how does the toe-in bend applied to the mandibular molars counteract the lingual movement which is often a consequence of eruptive forces produced by tip backs? Also, do you do the toe-in and tip-back bends together or one at a time? A toe-in results in buccal crown movement. An eruptive force (the tip back) in one plane of space becomes a buccal force (the toe in) in another plane of space. Look at the photo, courtesy of Dr. Tom Mulligan.

Although some practitioners use both bends simultaneously, I don't. I like to keep my forces as simple as possible. The toe in is used to counter the potential negative side effect of bite opening, which is lingual crown movement. If the side effect isnt expressed when using the tip back, there is no need for a toe-in. So I wait to see if I need it. Remember, when using toe-in or tip-back bends, for eruptive(tip-back) or horizontal (toe-in) forces to be produced, the bends must be asymmetric. In other words, the distance between where the wire is bent and where the wire is first engaged must be different on both sides of the wire.If this condition is met, use Mulligan's long and short segment rule (see photos or go to http://www.commonsensemechanics.com/CourseContent.htm )to determine the forces that will be imparted by the wire.

Now Im a little confused. The toe-in is used to prevent rolling in of the mandibular molars. Why does this rolling in of the mandibular molars occur? A side-effect of molar eruption (or any extrusive force for that matter) is lingual crown torque. This force often results in lingual molar movement. Because the wires used for tip backs (usually .016 or.020 stainless steel) are round, in a .022 slot no torque control occurs. Additionally, if rectangular wires are used, the pre-adjusted appliance prescription for the lower molars has lingual crown torque built in. These factors contribute to rolling in, or lingual tipping, of the lower molars. A toe-in bend counteracts these tendencies by providing a buccal force. Ideally, the "bad" forces are cancelled by the "good" forces and the net result is a molar that is upright, not rolled in. I have another question for you: Why do practitioners who use utility arches expand the upper arch by 5-10 mm by flattening the anterior bridge to correct ClassII Div 1 and 2 patients? Is the

expansion necessary? Upper arch expansion combined with distally rotating the upper molars has been a technique used to correct Class II for over a century (It is often done when using headgear by adjusting the inner bow). The expansion creates the environment where the lower arch can be positioned forward (many ClassIIs are the result of a narrow upper arch which results in the lower arch being positioned, or trapped, distally). This is combined with distal rotation of the upper 1st molar, which places the palatal cusp of the upper 6 in a more anterior position. In ideal occlusion, the upper 6 palatal cusp occludes with the central pit of the lower 6. When the upper 6 palatal cusp is positioned more anteriorly, the lower molar (and hence the whole lower arch) is guided forward. The expanded upper arch allows the mandible to reposition forward, which results in Class II correction. Whats the easiest way to flare lower incisors forward to gain arch length? You can do this by manipulation of a utility arch, which has been popularized by Dr. Len Carapezza (http://www.igdpd.com). You could also use a straight wire, leaving the 3's, 4's and 5's unbracketed, packing coil between the 2's and 6's. Make the coil about 2mm longer than the distance between the distal of the bracket on the 2, and the mesial of the bracket on the 6. The force will push the anteriors forward and the molars back. The anterior teeth move forward much more easily than the molars distalize, so the net effect is forward incisor movement. Every month, pack a new piece of coil which is 2mm longer than the coil used in the previous month. Continue until the incisors are where you want them. The same effect can also be achieved by placing stops in the arch wire near the molars so there is a little extra wire length from molar to molar. If you do it this way, you must change the arch wire to gain additional forward movement of the incisors, so this method may be more cumbersome than packing coil. I have a question about molar uprighting. I have a few adult patients that have lost their lower first molars and I would like to upright their 2nd molars. In order to do this could I simply place a tip back bend just distal to the 2nd premolars rather than just mesial to the molar band? Any suggestions you have on how to upright molars would be greatly appreciated. Molar uprighting is tough. In theory a center bend (technically an occlusally directed gable bend) will parallel the roots and all vertical forces will cancel. In reality it is very difficult to make the bend a center bend because the bracket position- and hence wire angle of entry- is different on the teeth adjacent to the bend (one bracket is relatively straight, the other is tipped). This contributes to making the bend asymmetric. Unlike a center bend, where vertical forces cancel, the asymmetric bend leads to expression of vertical forces. The big challenge in molar uprighting is to prevent eruption of the molar which often contributes to unwanted bite opening. Uprighting without eruption occurs with a center bend. You may also get eruption because the bend is usually not precisely a center bend.. Occlusal adjustments must be made so the bite doesn't excessively open. Often, the molar needs to be crowned because so much eruption occurs. Orthodontists have designed uprighting springs that mitigate the eruptive forces. They are kind of hard to use. Many are now using temporary anchorage (TAD's) to get a more direct force on the molar. All in all, uprighting is tough. Don't promise your patient much, because you never really know how successful it will be. A combination of a small amount of uprighting, followed by a small amount of mesial movement repeated over and over can yield acceptable results. This is cumbersome and time consuming. I have a case where, during the initial stage of leveling and aligning, I cannot place the bracket on tooth # 4 in an ideal position. The tooth is blocked out of the arch and also slightly under erupted.

Should I continue on to the next stage and wait for this tooth to come in a little more? Don't go up the wire progression until you get that tooth aligned. Try packing coil for a month; that should free up the tooth to let it erupt. After creating space, get a bracket on it as best you can. If you have to place the bracket too occlusally, thread the initial arch wire (usually this is .012, .014, or .016 nickel titanium) under the gingival tie wings and engage the wire as usual on all the other teeth. This will help erupt the tooth. After a month, reposition the bracket if necessary and tie it in as usual. Once it is aligned, you can move up the wire progression. I am working on a case where I extracted lower 1st bicuspids to camouflage a Class III occlusion. You suggested to do a tieback right away with .016Niti. Will this move the canine distally into the extraction site? If so, why do I not wait until I am in stronger wire(as suggested in some literature) such as 020ss or rectangular wire?. I have been trying the tieback for about 3 months and still do not see any significant changes. Should I use chain from 3-6 for a month or two instead of the tieback? Can I use the tieback and the power chain from 3-6 at the same time? Thanks again for all your help The tieback (from here on I will refer to it as a laceback) prevents forward movement of incisors during the initial stages of treatment. Without lacebacks in extraction cases, aligning of a crowded arch results in anterior movement of incisors as the crowding is relieved.(For examples of laceback use, see here http://multimedia.3m.com/mws/mediawebserver? mwsId=66666UuZjcFSLXTtM8TamXTyEVuQEcuZgVs6EVs6E666666-- ) This is especially important on the lower arch in ClassIII cases because anterior lower incisor movement is contraindicated. In these cases, you probably won't see much retraction of the canine (it has to do with lack of tip built into preadjusted lower incisor brackets) but the incisors will not move forward. Using a chain instead of a steel tie is not a good idea because the chain is too powerful. It will tip the teeth into the extraction site which makes leveling more difficult. Once you have completed the initial aligning, remove the laceback and go through a wire progression. When you get into a rigid wire, begin space closure. I prefer en-masse space closure; that is, I retract all 6 anteriors together. In most cases, close space on 019x025 stainless steel; however in many ClassIII's I use .020 stainless steel to do space closure in the lower arch. Space closure mechanics on round will result in de-torquing of the anterior teeth. This is usually beneficial on the lower arch in ClassIII cases because the de-torqued incisors help mask the underlying skeletal ClassIII occlusion. Question: On a deep bite patient, I can't put brackets on the lower anterior teeth because the bite is too deep. Do you usually open up the bite by using bite opening techniques on the upper arch before bracketing the lower, or do you open up the bite using occlusal composites and bracket the lower at the same time as the upper? Answer: I usually bond composite to the occlusal surface of the lower molars and bracket the lowers, then gradually reduce the amount of composite as the bite opens. Question: Often, when I finish a case I have overbite problems. Why is this happening? I am bracketing 4.0 mm from the incisal edge on all teeth except for upper laterals, on which I place 3.5mm from the incisal edge. Do you think that is my problem? Answer:It is probably more a mechanics problem than a finishing problem. Brackets must be positioned based on the characteristics of the case, not some pre-set number. If the bite is deep pre-treatment the anterior brackets must be placed incisally and the premolar brackets must be positioned gingivally. This will allow you to open the bite and keep it open. During the wire progression, slightly overcorrect the overbite. Get it to 1 or 2mm. This is impossible to do if you position the brackets in the center when the pretreatment overbite is deep. Often many docs place the lower incisal brackets too gingivally in an effort to prevent occlusal interferences. This cannot

be done; the bite will deepen. To avoid interferences, bond composite to the occlusal surfaces of the lower molars. Successful resolution of many aspects of malocclusions depend upon getting the bite open before progressing to other mechanics. If you are not getting overbite corrected, you will have difficulty in correcting other aspects (overjet, midline, spacing) of the malocclusion. Question: When I bonded a LR3, the patient felt it interfering. Should I lower the bracket for now or should I open the bite temporarily by placing occlusal composite? Where should I place it? Answer: Do not change bracket position. NEVER compromise bracket position. A small amount of composite bonded to the occlusal surface of the lower molars will help clear the bite. TMJ/Ortho relationship statement (references available upon request) 1) There is no evidence to show that any type of orthodontic treatment done reasonably well has anything more than a minor effect on the health of the TMJ. 2) There is no evidence available that shows that performing orthodontic treatment for the main purpose of improving TMJ health is a valid reason to do treatment. Orthodontic treatment does not seem to predispose subjects to TMD problems nor is it indicated as an initial therapy for TMD patients. 3) The connection between occlusion and TMJ problems is a very weak connection. Patients should be told the following statement: I don't want to lead you to believe that straightening teeth will eliminate jaw problems. However, people with straight teeth do have fewer problems. 4) There are some occlusal factors that show a higher risk for future TMD problems. They are Skeletal open bite Overjet greater than 7mm CR/ICP discrepancy greater than 4mm Unilateral cross bite 6 or more permanent teeth missing Absence of anterior guidance is also linked (weakly) to future TMD probs. To help make sure the patient has the best odds of not developing future TMD problems, if possible these malocclusions with one or more of these characteristics should be corrected. But, to say a particular type of treatment is better from a TM health standpoint is not a valid statement. Question: In extraction cases, why do you go through all of the wire progression before doing mechanics? I have heard some practitioners suggest to do mechanics at .020ss stage, then continue on with .019x.025 niti and stainless steel after the mechanics are complete. Also what is the difference if I use a posted wire and K-module from lateral hook to the molar hook to retract the anterior teeth vs. using chain elastics 3-3 and then hooking the K-module to the canine hook and the molar hook? Which is better? Answer: Wire progression is one of the hot topics in orthodontics today. Personally, I like to do all (or most) of my mechanics on rectangular wire because of the torque and arch width control it provides. Some docs prefer space closure on 020 because it is quicker and requires less anchorage control. They say that there is less friction with a round (as compared to a rectangular) wire (anecdotal evidence supports this statement, but no well designed studies have shown a significant difference in friction between the two methods). Those who close space on rectangular wire believe the arch width and torque control that filling the slot provides is more important than reducing friction. Take your pick (choose on a case by case basis) but know that most orthodontic graduate programs teach rectangular wire space closure. The force system you use really doesn't matter as long as it is the correct force. I like 200-250g for space closure. Power chain starts off with an initial force that is too strong for efficient space closure. Then the force level rapidly decays, which is why my use of it is limited to areas where I don't have to stretch it too much. K modules provide a more consistent force over a long period of time, so the system you described is a good way to close space

. No space closure method is necessarily better, but each system has advantages and disadvantages. Your job is to understand these and choose the method of space closure accordingly. Question: I am trying to close a 1mm diastema in between 8 and 9 on a 30 year old patient. Can I bracket 3-3 only or do I have to band the molars as well? Also, do I have to go through all of the wire progression? Answer: Bracketing 3-3 (or 2-2 or even 1-1) only is often appropriate when closing a diastema. A limited wire progression is also OK. Finally, an occlusally directed gable bend placed between the centrals when closing the space will help place the roots in a position where relapse may not as easily occur. Question: After bonding a LR2 I could not deflect the wire enough to engage the wire fully into the slot. Can I bypass this tooth and pack open coil to create a little more space? Answer: Bypassing teeth on initial tie-in is an OK thing to do. You could also try a lighter wire (014 or 012 niti) instead of 016 niti. Question: I have a 18y/o female patient who has a deficient maxilla and high palate. She has a bilateral posterior crossbite, and has Class I molars. I plan to use rapid palatal expander. Is it appropriate? If so, how many turns of screw are necessary? Answer:I don't think it is appropriate to use an RPE in a physically mature patient, unless you perform surgically assisted rapid palatal expansion. If you must expand, use an appliance that tips teeth, as that is all you are going to get anyway. I like the quad helix for this situation. Question: To perform an arch width analysis on the mandible, what is the distance I should measure according to USDI guidelines? Do I measure at the first or second premolars? Answer: USDI guidelines for ideal upper arch width use buccal pit to buccal pit the first bicuspids. The measurement is 6 to 8 mm wider (depending on facial type) of the sum of the width of 4 incisors compared to the width of pit to pit. Width of the mandibular arch is more controversial. Not a lot of quantitative measurements exist. My personal opinion (supported by the vast majority of ortho literature) is that mandibular expansion in an adult (in fact, on any child over 9 years old) is not indicated. If you choose to expand the lower arch, you should prescribe lifetime retention Root Resorption Reference-Evaluation of the risk of root resorption during orthodontic treatment. Eur J Orthod 10 (1): 30-38. Author: Eva Levander Undiscovered root resorption is one of the main reasons for orthodontic litigation, so it is important that doctors performing ortho are aware of how to handle root resorption. Informed consent- tell patients that there is a chance that treatment will have to be stopped early if the roots become damaged. Panorex on all orthodontic patients 6 months into treatment -Especially check upper front teeth If all roots look normal, take follow up xray in about 1 year Panorex 3 months into treatment on patients whose roots look fragile

-Fragile looking roots mean short, blunt, pipette shaped roots Follow up xray in 6 months for fragile looking roots If you discover root resorption, first stop active treatment for 3 months. Dont take the braces off, but leave in a passive round wire with no forces (no rubber bands, chain, etc). Be especially concerned about forces on the upper cuspids, because forces on the cuspids can be easily transferred to the laterals, which seem to be the teeth most susceptible to resorption. After 3 months, get a p-a x-ray of teeth in question. If resorption has stopped (usually the case), continue treatment. If resorption has continued, remove the braces. Diagnosis and treatment of mesially rotated upper 1st molars Often, a Class II molar relationship develops because the upper 1st molars are mesially rotated. Recent studies show that mesial molar rotation exists in over 80% of Class II malocclusions (1). The importance of molar rotation in the development of Class II occlusion has been recognized for well over a century. In 1906 Angle wrote that the upper 1st molar is the key to development of good occlusion (2). Strang, the author of the 1950 edition of the Textbook of Orthodontics, writes, Rotation of teeth often appears in the maxillary archand the mesio-lingual cusp of the maxillary molar resists displacement so strongly that the crown often rotates bodily around this root" (3). In the June, 2003 issue of the Angle Orthodontist, authors Gunduz et al. described the etiology of upper molar rotation: The space between the buccal and lingual cortical plates becomes narrow anterior to the firstmolar roots. When the upper first molar drifts mesially, the large lingual root contacts the lingual plate and allows the two buccal roots to rotate mesio-lingually. The occlusal surface of the first permanent molar is trapezoidal in shape, with the long diagonal from distolingual to mesiobuccal. Therefore, more mesio-distal space is used in the dental arch when this tooth rotates mesially with the lingual root as the axis. By correction of these rotations, one to two mm of arch length per side and partial Class II correction can be achieved. These corrections also are needed to provide good intercuspation."(4) Ricketts (5) proposed a method of diagnosing mesial rotation of the upper first molar. This method has been widely used for the last 30 years. To determine if mesial rotation exists, view the upper arch from the occlusal and draw a line from the distal buccal through the palatal cusp of the upper molar. That line should pass through the opposite canine.

The figure above shows a correctly rotated molar. The line as described by Ricketts passes through the canine on the opposite side of the arch. Compare that picture to the one below, which shows mesially rotated molars.

Ricketts line passes through the opposite bicuspids. The molars are mesially rotated. This results in a Class II molar relationship.

The same patient after molar distal rotation has been accomplished. Ricketts line passes through the opposite canine. The molar relationship is Class I. Why this is important In normal occlusion, the palatal cusp of the upper 1st molar occludes with the central pit of the lower 1st molar. When the upper molar is mesially rotated, the palatal cusp is in a posterior position. This forces the mandible into a posterior (Class II) position. By distally rotating the molars the palatal cusp is positioned anteriorly. Upper palatal cusp/lower central fossa occlusion encourages forward positioning of the entire mandibular dentition. This results in a more anterior (Class I) mandibular position. Therefore, proper molar rotation results in correction of many Class II malocclusions. Many clinicians further encourage forward mandibular positioning by expanding the upper arch. The rationale for this is the wider maxilla will accept the mandible in a more forward (Class I) position. Expansion and distal rotation of upper 1st molars has been used to correct Class II malocclusions for over a century. Many appliances can be used to make this correction. Proper manipulation of the inner bow of a headgear has been one of the most often used methodologies. Today, since the use of headgear is declining in most treatment systems, many clinicians simply use arch wires. There are other advantages to proper upper molar positioning. Correctly rotated molars occupy less space than do molars that are incorrectly rotated. Up to 2 mm of space per side can be gained by correctly rotating the upper molars.

Correct molar rotation (left) and incorrect rotation (right). Notice the amount of space required in each situation. Bracket position and its effect on molar rotation Bracket position is critical in the effort to achieve proper upper molar rotation. Whether a band or direct bond bracket is used, the position of the bracket is evaluated by viewing the bracket from the occlusal. If the most anterior portion of the bracket bisects the mesio-buccal cusp, the bracket is placed correctly. When the upper molar band fits well, the bracket is automatically placed in the correct position. Problems arise when a band that is too large is used. The most common reason for using too large a band is insufficient space for band seating. Lack of space is almost always caused by incorrect use of spacers. When the contacts are tight, the clinician is forced to wiggle the band through the contacts to seat it. This is impossible to do with a band that is the correct size. Only a band that is too large may be wiggled into place. Bands that are too large result in poor position of the attachment. Poor bracket positioning means that sufficient distal rotation cannot be accomplished with a straight arch wire. To insure sufficient distal rotation, fit the bands correctly. If a bracket is bonded, carefully evaluate the bracket position from the occlusal view. If the bracket is not in the correct position, reposition the band or bonded bracket immediately. The pictures below show an incorrectly placed band (top) and a correctly placed band (bottom).

Incorrect band size leads to incorrect bracket position. Proper molar position is impossible to attain

with a straight wire.

Correct band position leads to correct bracket position. A straight wire results in good molar position. Archwire bends to achieve distal molar rotation When a patient presents with severely mesially rotated molars, good bracket position may not be enough to gain proper rotation. Toe-in bends are routinely used to correct severely mesially rotated molars. A 2X4 set-up with 45 degree bends mesial to the molars is an effective molar rotator. This also promotes upper arch expansion, as a toe-in close to the molar not only distally rotates the molar but also expands it by moving the crown buccally. Remember, for these mechanics to be effective, the bend must be an off-center bend. This means that the lateral segments must be bypassed (either left unbracketed or bypassed with a utility arch type bend).

Note: the shaded molar in the picture shows the movement that the 1st molar will experience. An additional benefit of lateral segment bypass is arch development. This is due to the Frankel effect. Frankel appliances, which were developed in East Germany immediately after World War II, correct malocclusions by upsetting muscle balance. They consist of flanges that push muscles

away from the arches in an effort to develop the arches(6). For instance a Frankel appliance to correct a Class III occlusion has flanges in the anterior vestibule on the upper arch. These flanges push the upper lip away from the teeth. The created muscular imbalance encourages the arches to develop into the void. The Frankel effect has proven to be reliable, especially in young patients. When using an arch wire that bypasses the lateral segments, the wire pushes the cheeks away from the arch. This allows lateral development of the arches into the void created by the wire. Here is an example of how distal molar rotation is used to achieve a Class I molar relationship:

Pretreatment diagnosis: 4mm Class II as a result of mesially rotated molars

Treatment description: The phase 1 treatment consisted of a 2X 4 set up in both arches. After leveling and aligning, expansion (using an expanded arch wire) and distal rotation (using bilateral toe-in bends) of the upper molars was accomplished. This corrected the ClassII molar relationship. These arch wires were kept in until the canines and bicuspids erupted. At this point the patient is ready for phase 2, which will consist of simply leveling and aligning, then using Class II elastics if necessary to correct any lingering ClassII relationship. Because the lateral segments must be bypassed for toe-ins to be effective, this set-up is ideally suited for early treatment. Establishing the correct distal rotation of the upper molars is one of the most important benefits of early treatment. Proper rotation of the upper molars is an essential aspect of a Class I relationship. By establishing the correct molar relationship in the mixed dentition, a childs growth and development can proceed normally. In conclusion, proper distal rotation of the upper 1st molar is critical in the development and maintenance of a Class I molar relationship. Mild mesial rotation can be corrected by proper bracket positioning. Severe rotations call for more aggressive intervention. Bypassing the lateral segments and using toe-in bends mesial to the molars aid in the correction of even the most severe rotations. Without proper upper molar position, ideal occlusion is difficult to obtain.

References 1) Mesial rotation of upper first molars in Class II division 1 malocclusion in the mixed dentition: a controlled blind study. Progress in Orthodontics Vol12 issue 2 pp107-113 Nov, 2011. 2) Angle, Edward H.: The Upper First Molar as a Basis of Diagnosis in Orthodontics. Items of Interest, Vol. 28, June, 1906. 3) Strang, R.H. : Textbook of Orthodontics, Third Edition, 1950. 4) Gndz, A. G. Crismani, H. P. Bantleon, Klaus D. Hnigl, and Bjorn U. Zachrisson (2003) An Improved Transpalatal Bar Design. Part II. Clinical Upper Molar DerotationCase Report. The Angle Orthodontist: June 2003, Vol. 73, No. 3, pp. 244-248. 5) Ricketts RM. Occlusion-the medium of dentistry. J Prosthet Dent 1969; 21:39-60. 6) Prabhu, N. Interception of class II div.1 malocclusion by phase 1 treatment with Frankel appliance. JIADS: Vol 2 Issue 2. April 2011, p62. Anterior labial root torque When upper anterior teeth, particularly lateral incisors, are in cross bite, they often need labial root torque. Normally positioned lateral incisor brackets, due to the torque built into those brackets, encourage the expression of lingual root torque. In cases where labial root torque is desired, the laterals never look quite right when normal torque expression occurs. My answer to this problem is to place the lateral incisor brackets on upside down. Flipping the brackets changes the torque expression from predominately lingual root torque to predominately labial root torque when rectangular wire is used.

Flipped upper lateral incisor bracket (top) Normally positioned upper lateral incisor bracket (bottom) The procedure to encourage labial root torque is as follows: 1) Create space in the arch form for the blocked out lateral incisor. This can be done on the initial arch wire by packing open coil spring between the central and canine in non-extraction cases, or by using a combination of coils and/or lacebacks in extraction cases. Remember not to pack too much coil on the initial arch wire (my coil springs are usually about 2mm longer than the space between the brackets on the adjacent teeth). This helps prevent distortion of the arch form. Be patient; use a slightly larger (about 2mm) piece of coil each month until enough space in the arch form is created to accommodate the blocked out tooth.

Blocked out upper right lateral. Labial root torque will be needed.

Creating space with lacebacks and coil spring. 2) Once sufficient space is created, bracket the blocked out tooth (in our example, the upper lateral incisor). Place the bracket on upside down and engage the tooth. A light flexible arch wire must be used because that wire must be deflected a significant amount to engage the tooth. Often, as in the case shown here, a tandem arch wire set up is used. Additionally, in patients with deep bites, the bracket on the blocked out tooth may cause severe occlusal interferences. If this is the case, temporarily prop the bite open by bonding composite to the occlusal surface of both lower 1st molars. Remove the composite after the crossbite is corrected.

The lateral can be moved into the arch form after space is created. Note how composite is used to temporarily eliminate the occlusal interferences. 3) This set-up will result in labial movement of the crown. Because round wire is being used, no torque expression occurs as a result of torque in the bracket slot. At this stage of treatment it doesn't matter what the torque in the bracket slot is. Once the crossbite is corrected, remove the composite from the occlusal surface of the lower molars. The overbite will help retain the labial crown movement.

Crown is now in place. Note the need for labial root torque.

4)Once initial aligning is complete, begin torque expression by using a low load deflection rectangular arch wire. I often use 019x025 heat activated nickel titanium (HANT) followed by 021x025 HANT. Filling the slot encourages the expression of torque. The upside down bracket means the torque in the bracket slot encourages labial root/lingual crown torque. Because of anterior overbite, occlusion helps the crown retain its position while labial root torque occurs. Usually about 10 weeks of 021x025 HANT is necessary to achieve full torque expression. Leave the bracket on upside down for the whole treatment. That way correct torque expression is

encouraged throughout the whole treatment.

Rectangular wire (021x025HANT) fills the slot. Note expression of labial root torque. The treatment photos below (courtesy of Dr. Gerald Samson) demonstrate how much improvement in root position is possible with this technique.

October, 1999 Practical Techniques for Achieving Improved Accuracy in Bracket Positioning En Espaol Accuracy of bracket positioning is essential, so that the built-in features of the bracket system can be fully and efficiently expressed. This helps treatment mechanics and improves the consistency of the results. The authors use the following techniques, and recommend them. Bonding and Banding Technique The use of light-cured systems for bonding brackets and cementing bands is helpful. Light-cured systems avoid time pressure on the orthodontist when setting up cases. The bonding materials should be carefully used exactly to the makers recommendations, with plenty of good quality light. This will reduce breakages. Errors can be introduced when replacing loose brackets. The bonding agent should be thick enough to prevent floating of the brackets during positioning. Bracketing and banding should always be performed by the orthodontist. Setting up of the case is the most important aspect of the treatment, after correct diagnosis and treatment planning. Banding and bonding should therefore not be delegated. When bonding brackets, if possible it is helpful to avoid viewing the incisor teeth from the side, or from above or below. This will require the patient to turn the head, and the orthodontist to change seating position from time to time (Fig. 1). Figure 1.

When placing brackets it is important to view the teeth from the correct aspect. The Use of Gauges Vertical accuracy can be greatly improved by the use of gauges and a bracket positioning chart (Fig. 2a,b). This will deal with difficulties such as tooth length discrepancies, labially and lingually displaced roots, partly erupted teeth, and gingival hyperplasia. The technique has previously been reported (ref. 1, 2). Figure 2a. Recommended bracket positioning chart.

Figure 2b. Bracket positioning gauges.

The bracket placement gauges are used in slightly different ways in different areas of the mouth. In the incisor regions the gauge is placed at 90 to the labial surface (Fig. 3). In the canine and premolar regions the gauge is placed parallel with the occlusal plane (Fig. 4a, 4b, 4c). In the molar region the gauge is placed parallel with the occlusal surface of each individual molar (Fig. 5a, 5b, 5c). Figure 3. In the incisor region, the gauge is placed at 90 to the labial surface.

Figure 4a. In the canine and premolar regions the gauge is placed parallel with the occlusal plane.

Figure 4b. Parallel placement on UL Cuspid.

Figure 4c. Lower bicuspid placement.

Figure 5a. In the molar region the gauge is placed parallel with the occlusal surface of each individual molar.

Figure 5b. Molar attachment positioned parallel to occlusal surface.

Figure 5c. Parallel gauge placement to molars occlusal surface.

Modified Bracket Placement Charts If the treatment plan involves extraction of four first or second premolars, a modified bracket positioning chart may be used (Fig. 6). This will ensure good vertical relationships between the marginal ridges of canines and second premolars. Figure 6.

If the treatment plan involves extraction of four first molars, a modified bracket positioning chart may be used as shown in figure 7. This will help to achieve good vertical relationships between the marginal ridges of second premolars and second molars. Second molar bands and tubes are used for the second molars, even though they will occupy the first molar positions. Figure 7.

If the patient demonstrates a deep anterior overbite, the brackets on the upper and lower centrals, laterals and cuspids can be placed 0.5mm more occlusal to assist in bite opening. Conversely, if the patient demonstrates an anterior open bite, these brackets can be placed 0.5mm more gingival to assist in bite closure. Chipped or Worn Teeth It is advisable to make adjustments for chipped or worn teeth, or those with unusual anatomy, at the time of bonding and banding. The use of gauges and a bracket positioning chart will not deal with chipped or worn teeth, or teeth of abnormal anatomy, such as pointed canines. For example, if a central incisor has a 0.5mm chip at the start of treatment, the bracket may be placed 0.5mm more gingivally than shown on the bracket positioning chart. Enamel shaping can then be carried out later in the treatment, leaving good coordination of incisal edges (Fig. 8). Figure 8.

If a central incisor has a 0.5mm chip at the start of treatment, the bracket may be placed 0.5mm more gingivally than shown on the bracket positioning chart. If upper canines are very pointed, and it is planned to re-shape the teeth later by 1mm, it is correct to anticipate this, and position the brackets 1mm more gingivally than shown on the bracket positioning chart (Fig. 9). Figure 9.

If upper canines are very pointed it is often helpful to position the brackets 1mm more gingivally than shown on the bracket positioning chart. Rotations Slight roto bonding is helpful when bracketing rotated incisors. On a rotated tooth the bracket can be bonded slightly more mesially or distally, sometimes with a very small amount of excess composite under the mesial or distal of the bracket base (Fig. 10, 11a, 11b). In this way full correction of the rotation can be achieved with no special measures. Also, viewing canines, premolars, molars, and rotated incisors occlusally or incisally with a mouth mirror helps bracket positioning relative to the vertical long axis of the crown. Figure 10.

On a rotated tooth the bracket can be bonded slightly more mesially or distally, and in this way full correction of the rotation can be achieved. Figure 11a.

A clinical example of roto bonding. Full correction of rotations can be achieved during the early stages of treatment, without any other special measures. Also see Figure 11b. Figure 11b.

Special Care With Molars Special attention is needed in the relationship between the lower first molar and the lower second premolar. This is the most difficult relationship in orthodontics. Special attention is needed to carefully place the lower second bicuspid bracket, because it is well back, and prone to contamination with saliva. A common mistake is to seat the mesial of the molar band too low, and this should be avoided (Fig. 12a, 12b). Figure 12a.

The mesial of the lower first molar band should not be seated too low. This is a common error. Figure 12b.

Parallel seating of the bands occlusal surface. Care is needed to avoid positioning the lower first molar band with the bracket too mesially. It should straddle the buccal groove (Fig. 13). Figure 13.

The lower molar tube should straddle the buccal groove, mesio-distally. If there is a close bite on the lower first molars, the molar bracket should be at the correct height, as recommended in the bracket placement chart. It should not be positioned more gingivally. A lower second molar band and tube can be used in this situation, as part of the versatility of the MBT Appliance System (Fig. 14). Also, temporary bonding material on the occlusal of the molars, or an acrylic bite plate can be used to avoid bracket interferences. Figure 14.

A lower second molar band and tube can be used on the first molar if the bite is close. If the treatment plan involves extraction of upper premolars only, the upper first molar band should be seated a little more gingivally on the mesial. This will help tooth fit with a class II molar relationship (Fig. 15). Figure 15.

If the treatment plan involves extraction of upper premolars only, the upper first molar band should be seated a little more gingivally on the mesial. Re-positioning Any positioning errors should be corrected before moving into wires heavier than .014 steel or .019 x .025 Nitinol Heat-Activated Wire. Re-aligning can then be done, before going into heavier wires. When working with small clinical crowns, either due to partial eruption, or gingival hyperplasia, stepping of .014 round wires is helpful. The tooth can be bracketed with the bracket too incisal. At the .014 round steel stage the crown length can be increased by stepping the wires. At the next visit the tooth can be bracketed correctly and a larger wire inserted. In this way, treatment time can be reduced (Fig. 16). Figure 16.

Stepping of .014 round wires can be helpful when working with small clinical crowns, either due to partial eruption or gingival hyperplasia. There is also an opportunity to replace any wrongly positioned brackets when banding or bracketing newly erupted teeth, because normally it will be necessary to go back to light aligning wires. Also, if a patient comes in with a loose bracket which needs rebonding, it is worth checking the position of all other brackets. This is an opportunity to correct errors elsewhere.

The authors take time and care to try to achieve accurate bracket positioning at the set-up appointment. During treatment bracket positions are monitored and reviewed at adjustment visits. Using the techniques described and recommended in this article it is possible, in most cases, to avoid the need to change bracket positions in the later stages of treatment. This improves the efficiency of the treatment and the quality of the results. References 1 J. Bennett, R. P. McLaughlin: Bracketplazierung und Straightwire-Apparatur Informationen aus Orthodontie & Kieferorthopdie 4 Quartal 1995 : 447-462. 2 J. Bennett, R. P. McLaughlin: Orthodontic Management of the Dentition with the Preadjusted Appliance, ISBN 1 899066 Isis Medical Media 1997. The OC thanks the authors and 3M Unitek for providing this article.

Você também pode gostar