Components of fixed orthodontic appliance --PRE ANGLE PHASE--

1. Pierre fauchard,a French dentist and the author of Le Chirurgien Dentiste are the originator of
angles E-arch and the modern banding of the teeth.
2. Art of Dentist written by Etienne Bourdet. William Dwinelle introduced Jack Screw.
3. Father of American orthodontics the writer of treatise on irregularities of the teeth and their
correction John Nutting Farrar .
4. A treaties of oral deformities by Dr Norman w kingsly is considered the first Textbook of
scientific treatment of irregularities of the teeth.
5. The use of intermaxillary Elastic with rubber bands to correct protrusion was advocated by Henry
A Baker which was popularly called Baker encourage.
--Angle era--
Angles first invention E-arch consisted of clamp bands and attached expansion arch and
ligature to tie the teeth. Demerits of the system being poor control on tooth movement. the next
appliance was to add a tube on the tooth and Solder pins on the main rigid wire.However the
appliance offered a pure rotational control.
So by cutting half of the tube in the length to house a flat wire the first ever bracket made
with a vertical slot called Ribbon arch applianc was made.The gold Ribbon arch (1916) of
0.0 to 2 inch or 0.036 inch dimensions was secured firmly with pins this appliance offered
an e
ffective rotational control but poor in control of Mesiodistal tooth movement as a result pre
molar teeth could not be body removed.

1. In the year 1928 angle introduced the latest a marvelous piece of precious metal (gold
alloy) .050 inch dimensions that has a slot like cut running in it mesial to distal
directions and one which could house a piece of .022*.028 inch wire inserted in its
slot at edge To deliver a three-dimensional control on the teeth.
2. In 1933 Raymond begg Developed a bracket which was essentially a ribbon arch
bracket turned upside down which was the first system to employe single round
stainless steel wire of 0.016 inch diameter or less.
3. Begg also developed a highly resistant stainless steel A ustralian where in 1940
replacing the precious metal and formulated t he differential light force technique in 1956.

4. In 1949 Brainerd F swain In order to achieve better rotational control attached two
edgewise brackets into a single base at distance and called them the Twin or Siamese
bracket.
 5. Bioprogressive therapy by Robert Murray ricketts .
Brackets
1. The difference between standard edgewise brackets and contemporary preadjusted orthodontic
bracket is that Standard brackets are either single or twin without any slot angulations or
provision of variable thickness Or labiolingual position of teeth in the arch or the labiolingual
inclinations of their roots But on other hand pre adjusted brackets is individualized in its
labio lingual thickness to influence the labio lingual position of the tooth in the arch; Has
bracket slot cut in angle in mesiodistal direction the determine the anatomic tip of the tooth
and has built in torque at the base of the bracket that governs the labia lingual inclination of
the tooth crown and root.
2. Most of the conventional metal brackets are made up of high quality stainless steel 316
and 318 types ; New low Nickel stainless steel 2205 alloys have shown less crevice
corrosion when coupled with Nickel Titanium and beta Titanium.
3. Non metal brackets with metal slot have been developed to overcome high resistance
offered by porcelain surfaces and in plastic brackets to overcome their deformation.
4. Examples of non metal brackets being porcelain , zirconium polycrystalline
,Alumina ,single crystal Alumina ,polycarbonate brackets .. MOnocrystaline brackets
most aesthetically pleasing.
Bracket base
The bondable surfaces modified to provide mechanical retention either by building undercuts
or 60 gauge wire mesh welded on the base. the bracket with the circular concave base design
produced greater Bond strength then the brackets with mesh bases. larger the mesh spacing more
the bond strength.
Bracket body n slot
Original edgewise brackets were of 0.050 inch width made in gold. the slot was milled to
size of .022*.028 inch .
Bracket wings
Bracket body has Wings in occlusal and gingival margins for holding the ligature wires or
modules to hold the wire.
Bracket body base interface
Bracket body is joined to the bracket base with the low fusing brasing alloy. Intermediary
brasing alloy contains cadmium which is cytotoxic so used in living tissues should be
avoided. the low fusing alloy also undergoes corrosion that can detach the bracket body from
base.
Modern orthodontics brackets are either laser welded ( eliminating intermediary metal
phase) or by metal injection molding process (MIM) higher porosity greater corrosion.
Power arm
An extension of distal wings with a rounded ball end in gingival direction Provides and
arm close to the centre of resistance of tooth to which retraction spring or elastics can be
engaged.
Bracket identification
Most manufacturers place the identification mark on the distal gingival wing of the
bracket.And maxillary mandibular brackets are distinguished by different colours.
Buccal tube
1. Usually.025 inch long with internal dimension of point .022 *.028 inch long.
2. On maxillary molars often double tube are used consisting of rectangular edgewise and
round tube ; For headgear internal diameter of the tube is generally .045 inch
 3. Buccal tube has got a variable thickness thinnest at the mesial end thickest at the distal end
(in build offset) w hich is expressed in distoangular rotation of the molar when an
archwire is inserted in the tube.
4. Tipped mesiogingivaly there by producing sufficient torque for normal buccolingual
inclination of the molars.
Self ligating brackets Stolzenberg 1934
Advantages are reduced anchorage demand due to reduced fraction between where and
holding clip Most prominent disadvantage being bulky (except few like speed).
Width of molarband
Lower incisors . 125 *.003 inch.
maxillary incisors canines and premolars : .125 * .004 inch
Molars .150 x .004 inch / .160*0.006 inch .
Open coil springs are made up of stainless steel or Cobalt chromium Nickel alloys , with .009
or .010 inch.
Open coil springs are usually compressed to 60% of the initial length.

Dentofacial orthopedics for class 2 malocclusion with vertical maxillary excess

Features of skeletal class 2 being
1. Long face or So called vertical growth pattern
2. vertical maxillary descent in buccal region
3. Palatal plane on cephalogram shows upward tilt in the region of anterior nasal spine
but inclined downward in the molar region
4. Mandible is retrognathic with a thin recessive chin
5. Growth of ramus inadequate with open gonial angle leading to backward growth
rotation and increased anterior facial height.
-------So for these patients treatment modalities Being encouraging
sagittal mandibular advancement, restraining vertical Descent of buccal segment of maxilla
thereby allowing mandible and the chin to rotate towards maxilla.
Rationally of combined therapy
Skeletal class II vertical growth pattern patients if alone treated with either Conventional
activator or high pull headgear therapy Will Worsen and their profile due to unwanted
backward rotation of the mandible.
EXPLANATION; The activator treatment in addition to restrain in sagittal growth of the maxilla is also
known to increase posterior maxillary vertical height ( By introducing distal inclination of
maxillary buccal teeth,mesial and vertical eruption of mandibular buccaL teeth combined
with anterior displacement of mandible)
Most of the orthodontic mechanotherapies are extrusive leading to 2.5 degree of opening of
mandibular plane angle with each millimetre of extrusion of the molars
So a combined therapy with a highpulll Facebow (Restrict maxillary growth) Attached to the
activator or such an appliance is expected to provide greater skeletal growth adaptation.
Dental class 2 situations with the skeletal class 1 profile must not be treated with this appliance
therapy Which can be easily done with camouflaging therapy.

Indication of activator headgear setup
1. Skeletal class 2 malocclusion in growing subjects in which and anterior movement of the chain
prominence is desirable and at least some posteriorly directed maxillary
dentoalveolar reaction is acceptable.
 2. high angle cases with moderate vertical excess. 3. Retention of corrected class 2..
Timing the best developmental stage is the early mixed dentition when all incisors have
erupted and the deciduous teeth are still firm enough to provide good Anchorage.
Contraindications
1. Class II horizontal Growers and Dental class II situation in skeletal class I ..
2. Patient with hypo divergent skeletal patterns such as --- class II division 2 and And of
the Deckbiss type with severe vertical deficiencies , Class 2 division 2 with severe deep
bite having prominent pogonion chin button.
3. Deciduous teeth in buccal segmental loose or most of them are lost.

### N.B ; A very severe Class II div 2 phenotype, characterized by concealment of the mandibular
incisors (overbite alongwith crowding) in occlusion, has been called D eckbiss in German, or
cover-bite.
A combined activator headgear therapy has been described by Ullrich Teuscher in 1978
.Advocated the use of high pull headgear with the activator to counteract the undesired
maxillary side effect of headgear alone. therapy is also called headgear activator Teuscher
appliance (HATA). (Headgear when used alone can transfer distally directed forces from the
maxilla by dentition to the mandible which will prevent its forward relocation)
Effects of combined therapy on maxilla and mandible
Maxilla Mandible

i nhibition of maxillary sagittal and vertical Unlocking the occlusion

growth vectors .

Restrain on maxillary dentition and selective vertical eruption of mandibular

maxillary basal structure molar

stimulation and Redirection of condylar

growth inducing a laser backward and more
download remodeling pattern for glenoid
fossa.

Bite recording with vertical displacement of mandible slightly beyond Freeway space and
anterior displacement not more than 6 millimetre is done.
Before therapy children with narrow Maxilla can undergo maxillary expansion.
application of external force

1. According to teuscher The centre of resistance of Nasomaxillary Complex is a point
just below the zygomaticomaxillary buttress and that of maxillary dental arch is
somewhat between roots of upper premolars.
2. Another study States the CR of Nasomaxillary complex is on the posterior superior
ridge of the pterygomaxillary fissure.
3. Another study states that the bodily translation of Nasomaxillary complex is only
possible when force vector passed by the area of key ridge.
force levels
Full mixed dentition force range of 300 to 400 grams is used.
For situations of mixed dentition during exfoliation of buccal teeth force levels in
the range of 150 to 200 grams is recommended.
Wearing schedule and follow up
For first few days 2 hours wear schedule day time is recommended
after that it is increased gradually 2 night time wear
if possible initially a 14 hour schedule later depending upon the treatment response wearing
time should be reduced to 10 to 12 hours.
First visit 1 or 2 weeks after appliance delivery
Follow up visit are made every 6 weeks or so and if no activation necessary in between this
period and cooperation is good the recall visits can be scheduled at 8 weeks interval.
After attaining full collection of class 2 and if class 1 relationship has corresponded to centric relation
for several months then the wearing time is reduced step by step initially to every other night and
letter to twice a week..
Second phase of therapy
is carried out at the stage of late mixed or establishment of permanent dentition with full fixed
appliance,
class 2 correction is maintained with long class 2 elastics.

## Recent study shows improvement of the pharyngeal space by Activator headgear
therapy.
Van beek Activator
Limitation of a HATA Being
poor control on maxillary incisors,
possible proclination of the lower incisors
possibly a limited intrusive effect on molars due to small vertical displacement of the
mandible in recording the bite.
Aforementioned limitations have been overcome by the m odifications made by van beek
High occlusal bite of six to eight millimetre in molar area.
instead of using labial bow or talking spring full coverage on the labial surface of the
maxillary anteriors by acrylic. Releasing mandibular lingual side from acrylic and
embracing mandibular Buccal side by acrylics.
The point of external force application is at the level of maxillary canines.

Management o
f c
lass I I m
alocclusion w
ith fixed appliance
Non extraction treatment Camouflage treatment without an extraction in mild cases where
arch length discrepancy is minimum and upper dental arch can accommodate full
complement of teeth without any adverse effects on facial profile.
extraction treatment
in situations where large overjet class 2 full cusp molar relation and minimal crowding of
the lower arch.Camouflaging may be possible with extraction of first premolar in upper
arch only and thereby maintaining cls 2 molar relations.
For mild to moderate plus 2 cases all first premolars or a combination of upper first
and lower second premolar extraction can be done.
teeth of Choice for extraction
Second premolar extraction in mandibular arch is preferred over First premolars in cases for
full cusp class 2 molar relations where no Little Space will be needed for correction of
malocclusion in anterior segment and majority of extraction space is utilised for the mesial
movement of the lower first molars..
N.B ;## In cases where patient has full upper lips (significant overjet) and only a relative
mandibular deficiency that is lower arch with minimal or no crowding ,extraction of only
maxillary premolars with the goal of finishing with functional class 2 molar and class 1
canine is a viable functional compromise..

N.B; ## Combination of Orthognathic surgery indicated for dolichocephalic p atients with

crowding and protrusive lower incisors and steep occlusal plane angle and proneness for clockwise
mandibular rotation.
treatment sequence
Phase 1
Levelling and alignment with objectives to correct the intra arch vertical tooth position, axial
inclination of each tooth and to attain a good arch form. Conservation of maxillary Anchorage
by use of curve of spee and figure of eight ligature ties between second premolar and molar
teeth. In lower arch treatment objective is mainly mesial Migration of molars.
giving a gentle reverse curve of spee in the lower arch that keeps the mandibular molars upright
and helps to flatten the curve of spee result in bite opening.
Phase 2
Retraction of maxillary anterior teeth
the rate of canine retraction is
about 0.9mm
per
month
which takes
about 8 months to complete the
canine retraction.
Upper Incisor extraction is done with frictionless mechanism with an asymmetrical T
loop which can be supported with class 2 elastics.
This phase of therapy lasts for 8 to 10 months in this period the lower arch becomes
an anchorage unit where Simultaneously retraction of upper anterior segment and
movement of lower molars forward happens.
So achievements at the end are
normal overjet overbite
extraction space closure in both the arches
class 1 sagittal relations
normal labiolingual inclination of maxillary anterior segment

Class 2 elastics
Classically used when levelling and alignment is complete and the patient is on upper and
lower rigid Steel wireds that is after completion of phase 1.
In nonextraction cases it correct class 2 sagittal dental Relationship by helping the
mandible posture forward
in extraction situation main objective to enhance lower mesial molar movement or
burn d Anchorage.
For maxillary canine or en mass retraction of maxillary anteriors
Short elastics attached to lower second Pre molars could simultaneously level the
curve of spee. --ROTH
short class 2 elastics also used to resolve the CR-CO discrepancy and settling the
occlusion
prevent unwanted labial flaring of maxillary incisors.
In order to keep lower molars upright it is necessary that the molar tube should have built in
provision for distal tip that is mesial end of the tube is tilted mesiogingivally. Or alternatively a
mild second order bend is incorporated in the archwire mesial to Buccal tube on either side.
Intermaxillary class 2 elastic of moderate force levels (6 ounce / 150 grams) are used on
either side, the medium strength elastics of 3 / 16 inch, 4 / 16 inch and 5 / 16 inch sizes are
most commonly used.
The force in the elastic is measured by Dauntrix gauge.
Elastic should be there for 24 hours a day and should be changed every 12 hours..
phase 3
Maintaining fine tuned individual tooth position and good interarch relation.

Class II division 2 malocclusion
Have a high incidence of familial inheritance. Distal occlusion of the teeth in both lateral
halves of the lower dental arch. deep bite in these patients is due to the Infra occlusion of the
molars.
Subtypes
Excessive Freeway space with the lack of posterior alveolar development and anterior
alveolar overgrowth.
cases with normal Freeway space.
Facial features Squarish/round pleasing face, prominent chin, Deep labiomental sulcus,
hyperactive lower lip, a high lower lip line, thin upper lip, s mall gonial angle and horizontal
type of face.
Masseter and temporalis muscles are wide and these subjects have a higher biting force.
Lack of vertical development of the face below the nose.
Dental features
Class 2 molar and canine relationship. deep traumatic bite.
retroclined central with labial inclination of the laterals .

Cephalometric features
Based on anterior cranial base length and sagittal position of maxilla in class II
division 2, it is normal relative to class I and class II division 1 malocclusion.
While in class II division 2, a shorter or normal mandibular length w ith sagittal position
retruded, chin being prominent and lower posterior facial height increased in class II
division 2.
 Horizontal growth pattern with flat mandibular plane h ypodivergent facial pattern.
Acute gonial angle
Deep overbite due to Extreme skeletal mandibular counterclockwise rotation rather than
dentoalveolar over eruption.
According to Peck & Peck th ese are heritable pattern of small teeth in well developed jobs.
The pattern of strong vertical posterior development of mandible with upward and forward
rotation.
Treatment considerations
Scenario 1 patient with hypodivergent facial pattern redundant lips and Flat mandibular plane
angle Molar extrusion in growing patients increase lower anterior facial height and allow
favourable mandibular growth int urn increased low official height will correct the deep bite
and the facial aesthetics along with correction of Lip redundancy or increase facial
convexity..
though molar extrusion is not recommended for adult patients cause stability is
highly questionable
Scenario 2 mixed dentition treatment Take advantage of dental Eruption leeway space and
normal growth pattern
Logical Sequencing of early treatment being 1. resolve functional problems and arch length
discrepancies to achieve vertical correction and finally 2. achieving overjet correction.
Basic treatment format
Relief of maxillary crowding ,development of maxillary arch length for Incisor root torque
,Crown advancement.
Now maxillary incisors when in proper axial inclinations in medullary bone ,m axillary
intrusion can be accomplished.
At this point of class II division 1 malocclusion is achieved.
Next step is intrusion of the mandibular incisors and canines
Aligning buccal segments with distalization of maxillary buccal dentition to correct
class 2 malocclusion.
finally consolidation of maxillary anteriors, buccolingual correction and finishing
achieved.
Stability and retention
In adult patients vertical development of buccal segments cannot be expected and the
stability of bite opening his questionable because of the strong muscular pattern .
It has been reported that deep Bite cases in which lower face height is increased during
treatment exhibited less relapse than cases in which little or no increase occurred during
treatment.
Class III malocclusion in growing patient

Class III malocclusion in India was reported to be 3.4% .
Etiology
Inheritance of class III skeletal parameters follow an autosomal pattern of inheritance
with both males and females being affected.
Environmental factors include macroglossia, mouth breathing and presence of
functional forward shift.
habitual posture excessive mandibular growth resulting from forward mandibular
posture, as condylar distraction maybe a growth stimulus
Studies have reported at least 30 to 40% of skeletal class III malocclusion have a significant
component of maxillary deficiency. conversely mandibular prognathism as a primary cause
was found in 19% of cases.
A class 3 malocclusion due to an underlying maxillary deficiency is not as serious is a
mandibular prognathism.
treatment modalities
(A) Intersection of problem through dentofacial orthopedics
1. Appliances to restrain growth of the mandible Chin Cup with headgear
2. Appliances primarily directed for Orthopaedic effect on maxilla
P rotraction face mask
Henry pettit Chin cup and frontal pad.
Jean Delaire frontal pad, Chin cup.
Grummons reverse pull headgear frontal pad and cheek pads with no chin support.
3.A ppliances which affect both the jobs byaltering growth
F unctional appliances
## Frankel FR III ## reverse twin block ## class III bionator
(B) Camouflage treatment (C) Orthognathic surgery
Interception of malocclusion
Positive dental and skeletal changes that can be achieved with the use of protraction face
mask for class III correction
Rapid maxillary expansion normalisation of buccal crossbite
Forward displacement of maxilla & counterclockwise rotation of maxilla Result in a
downward and backward rotation of mandible to maintain the occlusion.
increasing angle SNA , decrease angle SNB , improved angle ANB .
proclination of upper incisors
Maxillary protraction appliance (1875 by Jean Delaire)
Mainly indicated fine maxillary hypoplasia is a major component of class III deformity alone
or in combination with mandibular prognathism.
appliance usually not indicated after 89 years of age 1 maxillary growth is expected to
complete
A short period (7 to 10 days) of rapid maxillary expansion is recommended at the
commencement of protraction facemask treatment.Where maxillary expansion increases
forward growth modification potential of maxilla.
Banded or bonded appliance

Banded design has its own limitations of use in deciduous and mixed dentition where as a b onded
protraction and expander may be used in any stage of the dentition and during late mixed phase
where there is adequate root length.
Appliance Manipulation
At first appointment maxillary Banded or bonded expander is inserted, neither the
expansion not the protraction face mask is commenced this will allow the patient to
get accustomed.
At second appointment forward traction and Rapid expansion is started with rate of
expansion of 0.5 mm per day that is one quarter turn twice daily.
Most clinician suggest for one week of expansion prior to start protraction
Expansion is either stopped after one week if posterior crossbite does not exist or
when over correction of the transverse problem has been achieved.
Schedule of facemask where is on average 10 to 12 hours maximum although
recommended for 14 hours use. forces are applied in range of 200 grams on each
side. ( 350- 400 gms/side say some authors)
Direction of force The point of force application depicted below

Mean average forward movement of maxilla during the treatment 8 + - 3 months is about
2.1 mm and the overjet increases by 5.5 mm..
Retention with a class 3 bionator or a Frankel fr3 is Must. normalisation of orofacial function
should be insured..
Orthodontic treatment of borderline class III malocclusion
Class III malocclusion is essentially described as supernormal class 1 o r Frank mesial-molar
relationship accompanied by an Incisor edge to edge bite or a negative overjet.
Clinical features of a class III face
Extraorala concave face, deficient maxilla, Malar deficiency resulting into flat Midface.
increased lower anterior faceheight. anatomically large lower lip length.
intraoral
Zero Or Negative overjet
narrow maxillary arch with crowding
unilateral or bilateral posterior crossbite
proclined maxillary incisors and retroclined mandibular incisors
wide lower arch with buccal segment showing compensation to accommodate narrow
maxillary arch
Low tongue posture
flat curve of spee

Jean Delaire Classified class III malocclusion taking into account Maxilla and mandibular
anomalies into sagittal plane only. grouped them in 9 types.
Glenoid fossa and cranial base
Shape of the cranial base differs in subjects with class III malocclusion compared to the
normal class I configuration.
individuals with class III malocclusion are brachycephalic:
more upright basicranial floor and a closed flexure angle Which decreases the effective
anteroposterior dimension of the middle cranial fossa.
The facial result is More posterior placement of maxilla and shorter horizontal length of
nasomaxillary complex.
Growth considerations in treatment of class III patients
class III skeletal pattern is Apparent much early in postnatal life by the age of 6 to 8 years.
In females maximum changes of facial characteristics occurs between average ages of 11 and
12 years and continued after the age of 15 years and beyond 17 years in contrast to class I
subjects where growth is essentially ceased.
peak mandibular growth CS3 to CS4
In male subject peak mandibular growth occurs between 12.8 and 14 years which corresponds
to CS3 to CS4. The increase in mandibular length continues at a significant rate from CS4 to
CS5 and upto CS5-cs6 .duration of growth is longer by 6 months in both male and female classes
objects then in individuals with normal occlusion.
Cevical vertibrea maturation stages 1-6 (CS1-CS6)

Cs6 shows the timing that you should send the patients for orthognathic surgery But with
an exception for class III patients for whome cs6 is not the point of cessation of growth.

Pseudo class III

Results from prematurities in occlusion leading to anterior shift of mandible Path
of closure of mandible will be upword & forward.
Discrepancy in occlusion at centric relation and centric occlusion.
in contrast to true class III the profile of pseudo class III can be straight in centric relation
and prognathic or concave in centric occlusion. where as the profile will be prognathic or
concave in both CR and CO in case of true class III.
Cephalometric considerations in borderline class III
Rabie et al Suggested that the h
oldaway angle ( H Angle ) can be a reliable guide in determining the
treatment modalities for patients who represent borderline class 3 surgical cases. the threshold
value was 12 degree which meant that if one patient had holdaway angle of greater than 12
degree ,he or she was likely to be treated successfully by orthodontics.

Good Cases for camouflage treatment
A class 3 with mild to moderate severity & subject who have passed the active growth
period for Orthopaedic treatment of maxillary protraction and Chin Cup therapy
absence of skeletal facial asymmetry
hypo divergent class 3 pattern
No or mild posterior crossbite.
Contraindication for camouflage treatment
Acute nasolabial angle further proclination of maxillary anteriors will Worsen the
profile.
Large Negative overjet
family genetic etiology
significance skeletal facial asymmetry and jaw deviation
open gonial angle, open bite and vertical growers
Non extraction treatment approach
Done when skeletal dentoalveolar arches in its are sufficient to accommodate total tooth
substance.Expansion of upper jaw and retroclination of lower incisors.
The MEAW technique Dr. Young H. Kim at 1987
Multi loop edge wise archwire
This technique has been successfully applied to treat severe open bite malocclusion
Lower buccal segment can be distally tipped with multiloop edgewise archwire technique.

Distalization of lower arch using Anchorage derived from Mini implants.
Extraction approach
Extractions are done only for relieving the crowding and for correction of negative
overjet and overbite
In class III cases there is already chin prominent. so if lower Incisor retraction is
done after extraction in lower arch retraction of the lower lip increasing the
chin prominent.
Limits for upper / lower Incisor movement to compensate in camouflage treatment in class
III cases can be 120 degree to SN plane and 80 degree to mandibular plane respectively.
Extraction choices
Mandibular incisors (When crowding is not large or situations of Bolton discrepancy. only
disadvantage could be a upper / lower midline mismatch and need for long-term rigid lingual
retainer as mandibular arch with three incisors has a tendency to lingually collapse)
upper second and lower first premolar (Need toresolve large mandibular crowding and
to induce significant tipping ofmandibular arch)
only lower first premolar.
Mandibular second molar.

 Acc. to Mora et al . advantages of 2nd molar xtrction are

Time of therapy of fixed appliance reduced.
Rapid eruption of third molar and avoiding complications of surgically removing
impacted third molar.
less residual space left at the end of the treatment.
reduction of probability of relapse given the intercuspation between the bicuspids are
retaining.
Easy to move first molar and anterior dentition distally when overjet has to be corrected.
Retention protocol
Continued night time wear of Chin cap along with the use of Frankel 3 / reverse twin block appliance
well beyond 16 years in girls and 18 years in boys is recommended in all class III patients who have
undergone growth modification or camouflage treatment...

 Orthodontic treatment with contemporary fixed appliance
The sequential step of the treatment are
levelling and alignment
bite opening
space closure
finishing and detailing
L evelling and
alignment
by
sectional arches
In case of initial crowding where a continuous arch is not possible to ligate due to limitations
posed by the nature of malocclusion or traumatic bite.
Shape Memory Arch wires
Levelling and alignment of whole arch is usually initiated with highly Resilient Shape Memory
archwire with a low load deflection rate.
Initial leveling is usually undertaken with smaller dimension where like. 01 4 inch NITI wires
(for blocked out or high labially placed canines ) or flexible spiral wire Gradually progressing
for higher size wires up to .020 inch steel or rectangular rigid Steel wires.
Main disadvantage of using NITI system is difficulty in controlling the arch form.
Multiple loop archwires
This approach is also called friction free when activated.
Made with .016 inch blue Elgiloy or 0.014 inch special plus or special Australian Archwire. (easy
formability )
Loops & Helices
Loop was first made by Robinson in 1915.
Double vertical loop contoured on each side of a given tooth and can be used to move a
Labio or lingually displaced tooth into a line. Also can be used for correction of rotation of
tooth.
Closed vertical loop Used primarily to close a space in the dental arch.
Horizontal loop/L loop Its incorporation in wiree design permits the force reduction in
vertical or ocular gingival direction.
Its other uses are in levelling a segment of the arch by depressing or elevating the anterior or
posterior segment & in bite opening.
double horizontal loop Most efficient when working on an individual tooth above or below
the line of occlusion.
Can be effective in tipping of the tooth root mesially or distally.
Omega loop It tends to distribute stress more evenly through the curvature of the loop
instead of concentrating the stress at the base of the loop. used to g ive the last tooth in the arch
a bodily root thrust to enhance molar anchorage.
Box loop
a combination of vertical and horizontal levers it increases the total amount of effective wire
length which enables greater force reduction capability and greater range of action than any
other loop.
Tooth movement and moment of force ratio
Controlled tipping ----------- 7 : 1
translational movements------- 10: 1
root movement ---------------12: 1 or more.
Bite
Opening
Method of deep bite correction can be broadly grouped as
Levelling of curve of spee maxillary Incisor intrusion mandibular Incisor intrusion
Levelling of curve of spee
By using anterior bite plate in growing children, it may have adverse effect by causing undue
proclination of the mandibular incisors.
Reverse curve wires
Made of superelastic alloys such as Nickel Titanium. delivered gentle intrusion force on
incisors and extrusion on buccal segment.

Disadvantages difficulties in controlling

proclination of anteriors a
nd p
oor c
ontrol on extrusion of buccal segment and arch form.
Second order bends
1. Mild second order bends perform distal tip of the mesially tipped molars.
2. Tip back bends if given At molars insert intrusive forces at the incisors

N.B; ###
First ordered bend second order bend Third Order bend

In and out bends Tip bends Torque

buccolingual / labiolingual Mesio-distal movements
& rotational movement

Maxillary and mandibular Incisor intrusion

Intrusion with Step Up bend
1. Indicated when there is a step
between the anterior and
posterior occlusal plane.
2. in cases with moderate to
minimal Incisor display & class I
occlusion cases.
3. main drawbacks indiscriminate
posterior extrusion versus
anterior intrusion.
Ricketts utility arch
Passive active

Maintains arch length in mixed for active intrusion of maxillary and

dentition and prevents worsening of the mandibular anteriors
vertical bite

help to obtain proper transverse i ntrusion and protraction such as the

development of maxillary dentition by demand in class II division 2.
keeping Arch from deleterious influence of
buccinator mechanism

i n permanent dentition preserve i t can be used during retraction or even

encourage and maintain bite at finishing

used.
Intrusion utility arch is activated by making a 45 degree anchor bend at the molars.
A gentle cinch on the molar segment light refraction of lingual force prevents undue
flaring of incisors while true intrusion is taking place.

intrusion arch by Burstone
Made up of 0.017*0.025 inch TMA wire to generate consistently low Force for longer
duration for effective intrusion (Less number of reactivation appointment)
Burstone Continuous intrusion arch causes extrusion of molars and intrusion of the anterior
segment.
10 to 20 gram of force/tooth is advocated for maxillary anterior intrusion.

Figure --Burstone Continuous intrusion arch

Three piece intrusion arch
Indicated where a continuous type of intrusion arch is contraindicated. like when incisors
are undue flared, the application of intrusive force at the brackets will Worsen the axial
inclination.

t hree piece intrusion arch consists of (1)post Anchorage unit (2) anterior segment with
posterior extension (3)intrusion cantilevered and (4) a power chain / elastic

Connecticut intrusion arch (CTA)

It uses of preformed nickel-titanium wire. recent advances is using NiCKEL free beta III
CNA. CTA arches are expected to give a force of 50 gram apically along the centre of resistance to
perform anterior intrusion

Intrusion with Anchorage derived from Mini screw
NiTi closed coil springs can generate intrusion force of 80 gram.
2 min screws of usually 1.2 mm in diameter and 6 millimetre in length are placed
distal to maxillary Lateral Incisor at mucogingival Junction.
 Space Closure
Canine retraction and anterior space closure
(A) Canine retraction on a continuous Wire or by friction method --Using a rigid wire of
.022 inch Steel prerequisites to prevent depenning of the bite and maintaining an arch form.
Anchorage reinforcement done with activated distal stop that is activated distal tip of
15 to 30 degree in standard edgewise system and figure of eight ligature tie of second
premolar unit with first molar.
Canine distalization force is about 150 gram which can be generated by two methods

Push Method Pull method

Using open coil spring of lumen 0.030 inch Using elastomeric ring or closed coil spring
Tweed comments use of full size base archwire that is 0.022 *.028 inch wire which is reduced in
anodizer to .019* .025 inch dimensions distal to V bend.

(B) Sectional method or frictionless method --

To avoid distopalatal rotation of crown and collapse of the arch as seen in translation of
canine using Springs researchers have developed canine retraction loops.
T- Loops

0.016*0.022 inch ss wire used though beta Titanium is the material of choice for its

excellent spring back & good formability.
T loop can deliver 250 gram of force to produce canine retraction @. 87 mm per
month.
No new activation required until 3 millimetre of space closure is produced.
Spring left without activation will produce exaggerated root correction followed by
increased Space at the extraction site.
Rickets canine retraction spring
Combination of double closed helix
(2 mm diameter each ) and a crossed
T loop.
loop design delivered 30 -50 gram
of force per millimetre of activation
when produced in 0.016*0.016 inch
blue ElGiloy wire.
Spring is activated by Digital
clinching.

Gjessing Canine retraction spring
R esist rotational and Tipping
tendencies during retraction.
activation to 140 to 160 gram
of force is obtained by pulling
the wire distal to the molar
tube until the two sections of
the double helix separated by 1
mm
activation repeated every 4
weeks
Canine expected to undergo
approximately 1.5 mm of
controlled movement with each
activation.

Opus Loop
It is a closing loop capable of achieving
inherent constant M:F ratio of 8.0-9.1 mm
without residual moments
so when deactivated this
design of loop can produce a true rest period.
(Advantage over other loops)

## T loop offers a higher M:F ratio (5.3) than vertical loop.

## A vertical loop ( by Dr. Robert W Strang ) has high load / deflection ratio whereby any activation
above 1.4 mm causes its permanent deformation.

Retraction of incisors with friction method

Using base arch of 0.019*0.025 inch Steel which will offer adequate control on arch
form and yet have freedom to slide through the buckle tube and brackets.
Standard edgewise appliance
Bidimensional technique
1. Here two brackets of two different slot sizes are used. ( central lat. receive
0.018*0.022 inch / molar pm receives 0.022*0.028 inch ) .
2. The main advantage of this system is excellent torque and axial control over on
incisors while space closure is instituted without a need for reduction of size of main
archwire in the buccal segment.
Preadjusted appliance.
Continuous T-loop
Asymmetrical T archwire
closing verticle loop
Bull loop
 Invented by Dr. Harry bull. Radiation
of standard vertical loop.
Loops legs are tightly abutting each
other.
.0215*.025 SS made.
Loops are activated by cinching the
wire at distal of tube so as to
separate the loops to the thickness of
dime that is about 1.5 to 2 min m

Rickets Incisor retraction technique

Utilisation of sectional arch mechanics.
## O
pus loop Have several advantages over other loops for closing spaces. it has an
acceptable moment:force ratio and it does not need any pre activation Bends thus making it
possible to obtain the desired tooth movement and to provide periods for the periodontium to
recover.
Mushroom loop space closing archwires ( Nanda )

Made from CNA- beta Titanium with archial

configuration decreased load
deflection rate produces gentle
continuous force.
Loops activated up to 5 millimetre and
reactivated every 6 to 8 weeks.

KSIR (Kalra Simultaneous intrusion and refraction archwire )

En masse retraction of all first six

Anteriors can be done in first
premolar extraction cases that
require maximum anchorage as well
as intrusion of the anterior teeth to
correct Deep overbite.
Made up of closed verticle loop of
0.019*0.025 inch beta titanium wire.

Segmented archwire mechanics ( by Burstone )

Utilizes two B
uccal and one anterior segment of the Arch to level and house full size
rectangular wires.
T-Loop on auxiliary buccal tube on first molars to retract anterior segment.
 Right and left buccal segments are connected with TPA or lingual arch creating a
single large posterior unit
Limitation of segmental mechanics
complexity of loop formation and need for a special bracket on canines.
possible loss of arch form.
poor control on occlusal plane.
Discomfort with loops.

N.B ####
Ideal loop design should most notably accommodate large activation, delivered low
and nearly constant force and comfortable and easy to fabricate.
Author recommends the use of T-Loop or preformed mushroom loop for an efficient
mechanism for Incisor retraction.