BIMAXILLARY PROTRUSION

Cephalomatric analysis:

Sagittal values -ANB Class I.
Vertical values - will determine the type of pull for the headgear.
Dental : protrusion of Maxillary and Mandibular anterior dentition.

Arch length: Severe anterior crowding reflected by protrusive anterior teeth.

TREATMENT PLAN


Skeletal problems:
· Nil.

Dental problems
· objective : to retract the maxillary and mandibular dentition into the basal bones

Treatment plan:
Extract all four first bicuspids retract anteriors into basal bones.


MAXILLARY ARCH.

· Band upper right and left first molars.
· Band upper right and left second bicuspids.
· Attach brackets to all anterior teeth.
(Observe bracket heights).



INITIAL ARCHWIRE.

The initial maxillary archwire is a flexible wire. Use either .0175 or .016 NITI. This helps to unravel the crowding in the anterior region. These flexible wires are used for one to three months. The wire is tied down the first month with O rings, subsequent months they are tied with ligature wires. This allows faster leveling and aligning.
The bracket on the upper 1st molar has a 15 degrees rotation. When the NITI wire is placed into the bracket it is will to derotate the molars from a class ll to a class l position.

MANDIBULAR ARCH.

· Band lower right and left first molars.
· Band lower right and left second bicuspids.
· Attach brackets to all anterior teeth.
(Observe bracket heights).



INITIAL ARCHWIRE.

The mandibular arch is banded and bonded only when a Class l cuspid relationship has been achieved. This is to avoid the impingement of the maxillary cuspid tip upon the mandibular cuspid bracket. It is always advisable to wait for the cuspids to attain class l relationship prior to the commencement of banding and bonding the mandibular arch. Hence maxillary cuspid retraction is carried out completely before mandibular cuspid bracket placement.

The first wire for the mandibular arch is the multi-stranded .0175 or .016 Ni-Ti. Turbo .017 x .025 or D- Rect .017 x .025 which is usually implemented after four to six months of‘ driftodontics’. This very flexible wire needs no adjustment. As torque control to keep the mandibular incisors upright over basal bone is not a major concern you could use the .0175 Respond or .016 Ni-Ti wire. When these wire are used a second initial wire such as .016 stainless steel round wire or an .017 x .025 D-Rect should be used for about 1 to 3 months before utilizing the closing loop wire



SECOND APPOINTMENT.
(One month later).

HEAD GEAR ISSUE.
(Read on head gear issue).

Guideline for applied force:
Initially 8 oz / 224 grams.
Subsequently 16 oz /448 grams.
First the head gear is activated to 8 oz by stretching the elastic module to the first dimple.
The force of application at the first dimple is about 8 oz or 224 grams. At the next visit usually about four to five weeks later the force is increased to 16 oz or 448 grams this is done by stretching the elastic to the second dimple. The force is now maintained at this level throughout the treatment. At every visit the force applied is checked and accordingly adjusted.

FACEBOW ADJUSTMENT

Use special headgear adjusting pliers.

VERTICAL - to center of lips.

TRANSVERSE - Keep inner bow expanded.

SAGITALLY - Enlarge or constrict adjustment loop.
MOLAR ROTATION - maintain molar rotation by adjusting the distal end of the inner bow.

Outer bow is kept parallel to inner bow and parallel to occlusal plane.

Guidelines for direction of pull.

If SN - MP is :
1. Below 35 degrees.
The directional pull is cervical.
2. Between 35 and 42 degrees.
The directional pull is combination.
3. Above 42 degrees.
The directional pull is High.

GUIDELINES FOR HOURS WORN PER DAY.

If ANB is:
1. Less than 3 degrees.
Wear 8 hours (nights only).

2. Between 3 to 5 degrees.
Wear 10 hours per day.

3. More than 5 degrees.
Wear 12 hours per day.

Facebow adjustment

· Outer bow around cheeks.
· Molar intrusion
bend outer bow 20 degrees at first molar.
· Unilateral - molar class II.
Bend outer bow on class ll side outward and lengthen stop on inner bow class ll side.


SECONDWIRE CHANGE.

Maxillary arch.

The second wire is .016 SS wire. It is used to continue leveling and eliminating rotation. It is also an excellent wire for retracting the canines.

Check list:
Adapt wire to template.
Bend omega loops.
Wipe in accentuated curve of spee.
Toe in .
Heat treatment.
Tie back.
Adjust headgears


Fabrication of omega loops.
(Read up on this procedure).



The fabricated .016 round wire is now place into the arch.
Take three unit chain elastic.
Place the first ring around the head gear tube. Do not place it on the hook. Use a hemostat and stretch the third ring of the chain elastic all the way to the cuspid and attach it to the cuspid bracket. Do not engage the middle ring to the bicuspid bracket. You only attach it to the head gear tube and the cuspid. Take regular power O and put it on the bicuspid bracket. This engages the power chain to the bracket. This is a very simple procedure but it is very important to do it the right way. This simple technique will retract the canines very effectively compared to other techniques.



Reasons for cuspid retraction prior to the anterior retraction.
· There is more control over molar anchorage. As only the cuspids are retracted against the bicuspids and molars as opposed to all six anteriors. In retracting all six anterior teeth against four posterior teeth there is a tendency to burn anchorage.

· To get the cuspids into class l position quickly and build the final occlusion around this newly established cuspid position.


There are two important rules to follow.

· Do not change the power chain too often. Change it once every 4 to 5 weeks. If it is changed too often it will move the cuspids too fast and it will get completely of control. Initial tipping will occur and the tooth will not have time to upright and rotate itself back into its normal position after the force of the power chain dissipates.

· Always make sure the .016 round wire remains in the slot as the cuspid is being retracted. If it rotates out which sometimes it does. Take a ligature wire and wrap it around the bracket and re engage the wire into the slot. Place the power chain over the ligature wire. If the wire disengages from the slot of the bracket the cuspid will be totally out of control. It is very important to ensure that the wire is in the slot all the time. When the patient comes in for the appointment and when you remove the old power chain off check and confirm that the wire is in the slot. If it has disengaged and slipped out of the slot, take a ligature wire and tie it back. The wire must not be tied too tight because if it is tied it too tight then the canine will not slide back.

Question: Why do you attach the power chain to the buccal tube and not to the hook?
Answer:
· If attached to the hook it lies to close to the gingival and becomes a food trap causing irritation and gingival tissue swellings.
· The force to the power chain is less if attached to the hook, it is greater if attached to the buccal tubes.
· When warped around the headgear tube the power chain lies on the arch wire all the way to the canine.

It takes about six months to retract the cuspids changing power chain every 4 to 5 weeks.



Mandibular arch:


THE CLOSING LOOP WIRE.


The closing loop wire is the .016 x .22 stainless steel wire designed to the vari-simplex archform.. The purpose of this wire is to close the extraction site. Unlike in the maxillary arch where only the four incisors are retracted, .in


the mandibular arch all six anterior teeth are retracted concurrently. The mandibular closing loop like the maxillary closing loop is tear drop in shape. These teardrops are placed distal to the canine brackets.
If the most posterior tooth banded is the first molar the arch wire is place and activated exactly as in the upper arch. The opening loop is activated about 1 mm by pulling the distal end of the wire as it protrudes through the convertible tube and the distal end is now cinched down at about 45 degrees angle to the horizontal. If the second molar is banded and there is sufficient space distal to the second molar then cinching back is done in a similar way as it is done with the first molar. But most of the time there is insufficient space available distal to the second molar for cinching back the wire. In such situation an omega loop is placed in the archwire just distal to the first molar tube. The slot in the convertible tube on the first molar is removed and the tube is now converted into a bracket. This enables us to place the arch wire with the omega loops. The omega loop is now actively tied back to the second molar hook. It is tied in such a way that it opens up a space about 1 mm in the tear drop section of the wire. The closing loop is activated about 1 mm per appointment. If a severe curve of spee is present for the first time when the wire is placed. The archwire is then not activated but it is activated during the subsequent visits. Due to driftodontics in the lower arch the closing loop is used for a shorter period than in the maxillary arch. In very severe crowding case and due to driftodontics the extraction space is virtually self eliminated and a very small space about 1 mm remains. In such situation a .016 stainless steel round wire is placed and a power chain is applied from the first molar to the first molar on the opposite side. This will help to eliminate all spaces and the mandibular arch could then be consolidated.


Maxillary arch.

THIRD WIRE CHANGE. (The closing loop wire).

Take a flexible millimeter ruler and measure from the distal of the lateral incisor to the distal end of the opposite lateral incisor . The obtained measurement gives the size of the closing loop wire to be selected. The loops are place about a millimeter distal to the lateral bracket. The wire size between the loops is 18x25 and the wire size distal to the loop is a reduced wire size 16x22. This unique wire has two different sizes combined in one wire. A full size wire in the anterior region and a reduced size in the posterior section. This wire is taken to the template and adapted to the arch form.

This wire does not have omega loop and it is not toed in. A slight curve of spee is place distal to the loop. The amount of curve of spee wiped into the wire always depends upon the bite. In deep bite case a large curve is placed and in not so deep bite cases a moderate curve is placed into the wire. This curve of spee is place between the loop and the first molar. The wire is cut at an angle from the outside inwards and the end is sharpened with the help of a bur. This helps to thread the rectangular wire into the slot of the molar bracket. After the wire has been place into the slot it is then activated by cinching back with a cinch back pliers. The distal portion of the wire is grasped with the cinch back pliers it is the pulled back to open the loop. In doing so the loop is activated by about a millimeter. While gasping the distal end the wire is twisted to give a 45 degree bend and this prevents the wire from slipping back into the slot. The activation in now repeated on the opposite side. It is advisable to have the patient bite on a cotton roll while this process is being carried out. It is less traumatic and give more control. The anterior teeth are now consolidated with a continuous ligature tie and the posterior teeth are ligated with individual ligature wires.

Removing the wire:
The wire is cut mesial to the molar bracket on both sides. The anterior portion is removed first then the posterior portion that has been cinched back is removed.

QUESTION: When the anterior teeth are retracted with the rectangular wire will the posterior teeth move forward? That is, will you lose anchorage?
Answer: The 15 degree rotation in the molar tube and the use of the headgear will help to reinforce anchorage. This will help to hold the posterior segment while the anterior segment is being retracted.

QUESTION: Do you use head gear every time you retract the anteriors.
ANSWER: No. You only use headgears when you want to ensure anchorage.
QUESTION : Do you have to ligate the posterior segments together?
ANSWER: No, they will not slide forward.
FINISHING ARCHWIRE

Maxillary arch.

The finishing archwire is the .017 x .025 stainless steel. Omega loops are usually bent into this wire and place just in front of the molar tubes. The omega loop must have an acute angle so that the ligature wire will not slide off when place and tied back to the molar tube.. A slight curve of spee between the omega loop and the cuspid could be wiped in depending upon the amount of deep bite present. Since this wire is a strong wire too much of curve wiped into the wire will open up the bite and get completely out of control Slightly toe in distal to the omega loop. Care is also given not to curve the distal end too much because by this time the molars have quite well rotated so we do not have to toe in the wire a lot. The wire is tied in with ligature wires and tied back at the omega loops. The entire maxillary arch has been consolidated as one unit and the spaces will not open up. This wire is left in position till the end of the treatment. This wire also forms the base for the application of elastics and class ll or class lll mechanics.


Mandibular arch.

Once all the space has been closed , the .017 x .025 stainless steel wire is now utilized which is similar to the one used in the upper arch. At this stage in an extraction case when the wire is placed for the first time there is usually a large curve of spee present. It is not advisable to place any reverse curve of spee at this stage. The wire is just left flat for the first time and a couple of visits later the wire is removed and a slight reverse curve of spee is place in the wire. Omega loops are place in the wire and tied back with the help of ligature wires. It is essential to level the mandibular arch completely. When second molars are banded the omega loop are place about I mm mesial to the second molar tubes for tying back. By tipping the omega loop buccaly torque is built into the wire to compensate for the lack of torque in the second molar tubes..


ELASTIC FORCES:

Application of intra oral forces:
1. To align the maxillary dentition to the mandibular dentition to achieve proper occlusion.
2. To correct cross bite and mid line discrepancies.
3. To aid in the settling of the occlusion at the end of treatment.

Elastic forces are only applied when both the arches are in the finishing .017 x.22 stainless steel wires. Exception being only in class III cases where class III elastic are used early in treatment. And in bimaxillary protrusion cases where we need to upright the lower anteriors and retract them early in treatment.

SKELETAL CLASS TWO DENTAL DIVISION ONE - EXTRACTION CASE.

Cephalomatric analysis:

Sagittal values -ANB more than 3 degrees.
Vertical values - will determine the type of pull for the headgear.
Dental : protrusion of anterior dentition.

Arch length discrepancy : moderate to severe crowding
( unable to treat non-extraction).

Age : Growing patient.


TREATMENT PLAN

Skeletal problems:
· objective- to correct from skeletal class ll to class l
· treatment plan : the use of headgears as an orthopedic appliance. Allow the mandible to grow into class l position.

Dental problems
· objective : to retract the anteriors into the facial bones

Treatment plan:
Extract all four first bicuspids retract anteriors into facial bones.


MAXILLARY ARCH.

· Band upper right and left first molars.
· Band upper right and left second bicuspids.
· Attach brackets to all anterior teeth.
(Observe bracket heights).



INITIAL ARCHWIRE.

The initial maxillary archwire is a flexible wire. Use either .0175 or .016 NITI. This helps to unravel the crowding in the anterior region. There is usually more initial crowding in the maxillary arch than in non-extraction cases hence these flexible wires are used for one to three months. The wire is tied down the first month with O rings, subsequent months they are tied with ligature wires. This allows faster leveling and aligning.
The bracket on the upper 1st molar has a 15 degrees rotation. When the NITI wire is placed into the bracket it is will to derotate the molars from a class ll to a class l position.


SECOND APPOINTMENT.
(One month later).

HEAD GEAR ISSUE.
(Read on head gear issue).

Guideline for applied force:

Initially 8 oz / 224 grams.
Subsequently 16 oz /448 grams.

First the head gear is activated to 8 oz by stretching the elastic module to the first dimple.
The force of application at the first dimple is about 8 oz or 224 grams. At the next visit usually about four to five weeks later the force is increased to 16 oz or 448 grams this is done by stretching the elastic to the second dimple. The force is now maintained at this level throughout the treatment. At every visit the force applied is checked and accordingly adjusted.

FACEBOW ADJUSTMENT

Use special headgear adjusting pliers.

VERTICAL - to center of lips.

TRANSVERSE - Keep inner bow expanded.

SAGITALLY - Enlarge or constrict adjustment loop.

MOLAR ROTATION - maintain molar rotation by adjusting the distal end of the inner bow.

Outer bow is kept parallel to inner bow and parallel to occlusal plane.

Orthopedic correction:
key to success-
· Growth.
· Cooperation.
· Directional pull.
· Force.


Advantage of orthopedic correction with facebow:

Affects growth in all direction.
Sagittal - cervical pull.
Vertical - high pull.
Transverse - expansion of inner bow.

Guidelines for direction of pull.

If SN - MP is :
1. Below 35 degrees.
The directional pull is cervical.

2. Between 35 and 42 degrees.
The directional pull is combination.

3. Above 42 degrees.
The directional pull is High.


GUIDELINES FOR HOURS WORN PER DAY.

If ANB is:
1. Less than 3 degrees.
Wear 8 hours (nights only).

2. Between 3 to 5 degrees.
Wear 10 hours per day.

3. More than 5 degrees.
Wear 12 hours per day.


Facebow adjustment

· Outer bow around cheeks.
· Molar intrusion
bend outer bow 20 degrees at first molar.
· Unilateral - molar class II.
Bend outer bow on class ll side outward and lengthen stop on inner bow class ll side.



SECONDWIRE CHANGE.

The second wire is .016 SS wire. It is used to continue leveling and eliminating rotation. It is also an excellent wire for retracting the canines.

Check list:
Adapt wire to template.
Bend omega loops.
Wipe in accentuated curve of spee.
Toe in .
Heat treatment.
Tie back.
Adjust headgears


Fabrication of omega loops. ( check previous Blog posting.)

The fabricated .016 round wire is now place into the arch.
Take three unit chain elastic.
Place the first ring around the head gear tube. Do not place it on the hook. Use a hemostat and stretch the third ring of the chain elastic all the way to the cuspid and attach it to the cuspid bracket. Do not engage the middle ring to the bicuspid bracket. You only attach it to the head gear tube and the cuspid. Take regular power O and put it on the biscuspid bracket. This engages the power chain to the bracket. This is a very simple procedure but it is very important to do it the right way. This simple technique will retract the canines very effectively compared to other techniques.

Reasons for cuspid retraction prior to the anterior retraction.
· There is more control over molar anchorage. As only the cuspids are retracted against the bicuspids and molars as opposed to all six anteriors. In retracting all six anterior teeth against four posterior teeth there is a tendency to burn anchorage.

· To get the cuspids into class l position quickly and build the final occlusion around this newly established cuspid position.


There are two important rules to follow.

· Do not change the power chain too often. Change it once every 4 to 5 weeks. If it is changed too often it will move the cuspids too fast and it will get completely of control. Initial tipping will occur and the tooth will not have time to upright and rotate itself back into its normal position after the force of the power chain dissipates.

· Always make sure the .016 round wire remains in the slot as the cuspid is being retracted. If it rotates out which sometimes it does. Take a ligature wire and wrap it around the bracket and re engage the wire into the slot. Place the power chain over the ligature wire. If the wire disengages from the slot of the bracket the cuspid will be totally out of control. It is very important to ensure that the wire is in the slot all the time. When the patient comes in for the appointment and when you remove the old power chain off check and confirm that the wire is in the slot. If it has disengaged and slipped out of the slot, take a ligature wire and tie it back. The wire must not be tied too tight because if it is tied it too tight then the canine will not slide back.

Question: Why do you attach the power chain to the buccal tube and not to the hook?

Answer:
· If attached to the hook it lies to close to the gingival and becomes a food trap causing irritation and gingival tissue swellings.
· The force to the power chain is less if attached to the hook, it is greater if attached to the buccal tubes.
· When warped around the headgear tube the power chain lies on the arch wire all the way to the canine.

It takes about six months to retract the cuspids changing power chain every 4 to 5 weeks.



THIRD WIRE CHANGE. (The closing loop wire).

Take a flexible millimeter ruler and measure from the distal of the lateral incisor to the distal end of the opposite lateral incisor . The obtained measurement gives the size of the closing loop wire to be selected. The loops are place about a millimeter distal to the lateral bracket. The wire size between the loops is 18x25 and the wire size distal to the loop is a reduced wire size 16x22. This unique wire has two different sizes combined in one wire. A full size wire in the anterior region and a reduced size in the posterior section. This wire is taken to the template and adapted to the arch form.


This wire does not have omega loop and it is not toed in. A slight curve of spee is place distal to the loop. The amount of curve of spee wiped into the wire always depends upon the bite. In deep bite case a large curve is placed and in not so deep bite cases a moderate curve is placed into the wire. This curve of spee is place between the loop and the first molar. The wire is cut at an angle from the outside inwards and the end is sharpened with the help of a bur. This helps to thread the rectangular wire into the slot of the molar bracket. After the wire has been place into the slot it is then activated by cinching back with a cinch back pliers. The distal portion of the wire is grasped with the cinch back pliers it is the pulled back to open the loop. In doing so the loop is activated by about a millimeter. While gasping the distal end the wire is twisted to give a 45 degree bend and this prevents the wire from slipping back into the slot. The activation in now repeated on the opposite side. It is advisable to have the patient bite on a cotton roll while this process is being carried out. It is less traumatic and give more control. The anterior teeth are now consolidated with a continuous ligature tie and the posterior teeth are ligated with individual ligature wires.

Removing the wire:
The wire is cut mesial to the molar bracket on both sides. The anterior portion is removed first then the posterior portion that has been cinched back is removed.

QUESTION: When the anterior teeth are retracted with the rectangular wire will the posterior teeth move forward? That is, will you lose anchorage?

Answer: The 15 degree rotation in the molar tube and the use of the headgear will help to reinforce anchorage. This will help to hold the posterior segment while the anterior segment is being retracted.

QUESTION: Do you use head gear every time you retract the anteriors.

ANSWER: No. You only use headgears when you want to ensure anchorage.

QUESTION : Do you have to ligate the posterior segments together?

ANSWER: No, they will not slide forward.


FINISHING WIRE.

Since there is no difference in the arch form between non-extraction and extraction arch forms, the difference being only in the arch length. The finishing arch wire is common for both type of cases. That is the .017 x .025 stainless steel. Omega loops are usually bent into this wire and place just in front of the molar tubes. The omega loop must have an acute angle so that the ligature wire will not slide off when place and tied back to the molar tube.. A slight curve of spee between the omega loop and the cuspid could be wiped in depending upon the amount of deep bite present. Since this wire is a strong wire too much of curve wiped into the wire will open up the bite and get completely out of control Slightly toe in distal to the omega loop. Care is also given not to curve the distal end too much because by this time the molars have quite well rotated so we do not have to toe in the wire a lot. The wire is tied in with ligature wires and tied back at the omega loops. The entire maxillary arch has been consolidated as one unit and the spaces will not open up. This wire is left in position till the end of the treatment. This wire also forms the base for the application of elastics and class ll or class lll mechanics.
MANDIBULAR ARCH.

The mandibular arch is banded and bonded only when a Class l cuspid relationship has been achieved. This is to avoid the impingement of the maxillary cuspid tip upon the mandibular cuspid bracket. It is always advisable to wait for the cuspids to attain class l relationship prior to the commencement of banding and bonding the mandibular arch. Hence maxillary cuspid retraction is carried out completely before mandibular cuspid bracket placement.

The first wire for the mandibular arch is the multi-stranded .0175 or .016 Ni-Ti. Turbo .017 x .025 or D- Rect .017 x .025 which is usually implemented after four to six months of‘ driftodontics’. This very flexible wire needs no adjustment. As torque control to keep the mandibular incisors upright over basal bone is not a major concern you could use the .0175 Respond or .016 Ni-Ti wire. When these wire are used a second initial wire such as .016 stainless steel round wire or an .017 x .025 D-Rect should be used for about 1 to 3 months before utilizing the closing loop wire.


Mandibular Closing loop Wire.

The closing loop wire is the .016 x .22 stainless steel wire designed to the vari-simplex archform.. The purpose of this wire is to close the extraction site. Unlike in the maxillary arch where only the four incisors are retracted, .in the mandibular arch all six anterior teeth are retracted concurrently. The mandibular closing loop like the maxillary closing loop is tear drop in shape. These teardrops are placed distal to the canine brackets.
If the most posterior tooth banded is the first molar the arch wire is place and activated exactly as in the upper arch. The opening loop is activated about 1 mm by pulling the distal end of the wire as it protrudes through the convertible tube and the distal end is now cinched down at about 45 degrees angle to the horizontal. If the second molar is banded and there is sufficient space distal to the second molar then cinching back is done in a similar way as it is done with the first molar. But most of the time there is insufficient space available distal to the second molar for cinching back the wire. In such situation an omega loop is placed in the archwire just distal to the first molar tube. The slot in the convertible tube on the first molar is removed and the tube is now converted into a bracket. This enables us to place the arch wire with the omega loops. The omega loop is now actively tied back to the second molar hook. It is tied in such a way that it opens up a space about 1 mm in the tear drop section of the wire. The closing loop is activated about 1 mm per appointment. If a severe curve of spee is present for the first time when the wire is placed. The archwire is then not activated but it is activated during the subsequent visits. Due to driftodontics in the lower arch the closing loop is used for a shorter period than in the maxillary arch. In very severe crowding case and due to driftodontics the extraction space is virtually self eliminated and a very small space about 1 mm remains. In such situation a .016 stainless steel round wire is placed and a power chain is applied from the first molar to the first molar on the opposite side. This will help to eliminate all spaces and the mandibular arch could then be consolidated.



FINISHING ARCHWIRE.

Once all the space has been closed , the .017 x .025 stainless steel wire is now utilized which is similar to the one used in the upper arch. At this stage in an extraction case when the wire is placed for the first time there is usually a large curve of spee present. It is not advisable to place any reverse curve of spee at this stage. The wire is just left flat for the first time and a couple of visits later the wire is removed and a slight reverse curve of spee is place in the wire. Omega loops are place in the wire and tied back with the help of ligature wires. It is essential to level the mandibular arch completely. When second molars are banded the omega loop are place about I mm mesial to the second molar tubes for tying back. By tipping the omega loop buccaly torque is built into the wire to compensate for the lack of torque in the second molar tubes..


ELASTIC FORCES:

Application of intra oral forces:
1. To align the maxillary dentition to the mandibular dentition to achieve proper occlusion.
2. To correct cross bite and mid line discrepancies.
3. To aid in the settling of the occlusion at the end of treatment.

Elastic forces are only applied when both the arches are in the finishing .017 x.22 stainless steel wires. Exception being only in class III cases where class III elastic are used early in treatment. And in bimaxillary protrusion cases where we need to upright the lower anteriors and retract them early in treatment.




CLASS II ELASTIC.

Attachment. Upper laterals to lower 1st or 2nd molars
force. 1/4 inch 6 oz. (Ram).

1 2 3 4 5 6 7

1 2 3 4 5 6 7


Purpose # 1
CLASS II MALOCCLUSION

When
FINISHING ARCHWIRE.

Time
24 HOURS/DAY.

Purpose #2
SLIP LOWER ANCHORAGE
( Caution do not tip lower anteriors forward).


CLASS III ELASTICS

Attachment
Lower laterals to upper 1st molars.

Force
1/4 inch. 3.5oz. (Fox).


1 2 3 4 5 6 7

1 2 3 4 5 6 7


Purpose # 1
CLASS III MALOCCLUSION.

When:
Throughout treatment.

Time: Dependent upon severity.


Purpose # 2
BIMAXILLARY PROTRUSION
(MAXIMUM ANCHORAGE).


When
WEARING COMBINATION FACEBOW
LOWER CLOSING LOOP ACTIVATED


Time.
72 HOURS, THEN NIGHT ONLY WITH FACEBOW.


Purpose # 3.
PREVENT ADVANCING THE LOWER ANTERIORS IN CROWDED NON EXTRACTION ARCH.

When
Initial archwire in lower arch.

Time
36 HOURS, THEN NIGHT ONLY WITH FACEBOW.



CROSS - BITE ELASTIC.

Where: Buccal of one arch to lingual of another arch.

Force: 3/16 inch. 6 oz (impala)

Why: Correct posterior X -bites.
When: Early and / or late in treatment.

Time: 24 hours/day.


MID LINE ELASTICS

Attachment.
Upper lateral diagonally to opposite lower lateral

Force
1/4 inch 6 oz. (Ram).


4 3 2 1 1 2 3 4

4 3 2 1 1 2 3 4

Why: Correct midline discrepancy

When: finishing archwire.

Time: 24 hours/day , except when eating.


ANTERIOR BOX ELASTICS


Class II case.

4 3 2 1 1 2 3 4
________
4 3 2 1 1 2 3 4


Class lll case.

4 3 2 1 1 2 3 4
_____
4 3 2 1 1 2 3 4


LATERAL BOX ELASTICS.

Where: Upper lateral and cuspid to lower cuspid and bicuspid.
Force: 3/16 inch 6 oz (impala).
Why: Increase overbite, improve cuspid position.
When: Finishing archwire, class II malocclusion.
Time: 24 hours/ day.

Lateral box elastics: Class III.
Where: Upper lateral and cuspid to lower lateral and cuspid.
Force: 3/16 inch 6 oz (impala).
Why: Increase overbite, improve cuspid position.
When: Finishing archwire, class III malocclusion.
Time: 24 hours/ day.

BUCCAL BOX ELASTICS.
Where: Upper cuspid and bicuspid to lower bicuspids.Force: 3/16 inch 6 oz (impala)

Omega Loop Fabrication.

TECHNIQUE FOR BENDING THE OMEGA LOOP.

After space closure, what is the best way to keep arch consolidated?
· ANSWER: Place omega loops anterior to terminal tubes.
· Tie back with ligature tying pliers.


After space closure what is the best way to keep arch consolidated ?

· Place omega loop anterior to terminal tubes.
· Tie back with ligature tying plier.


Advantage of tying back with omega loop:
· Active force holds contact points together.
· Small spaces can be closed by tightly tying back.
· Unnecessary to change power chain every month. open.
· Space do not inadvertently open.


How Do You Tie Back
1. Use steiner ligature plier.
2. Use .014 S.S. ligature wire.


Is it necessary to tie back every arch?
Ans: NO.

When placing curve of spee in the maxillary arch
(Round or rectangular wire)
TIE BACK OR FLARE ANTERIORS

When placing reverse curve of spee in mandibular arch using rectangular wire, -5 degrees torque prevents flaring.
When placing reverse curve of spee in mandibular arch using round wire
Tie back or fare anteriors







Maxillary arch No TB Tie Back. Cinch Back

Initial archwire X
Curve of spee X X
Wearing headgear X
Closing loop X
Finishing Archwire X



Mandibular arch No TB Tie Back. Cinch Back

Initial archwire X

Reverse Curve of spee

Round wire X

Rectangular wire Y/N Y/N
Closing loop X X

Elastic X

Finishing Archwire X


WHEN DO YOU TIE BACK?
ANS: WHEN IN DOUBT, TIE BACK.

One of most important principle in the Alexander Discipline is
TYING BACK.

ARCHWIRE LIGATION
· POWER’O’ ELASTOMER.
· STEEL LIGATURE.
1. .010 S.S.
2. .014 S.S
Elastomers are used in early stages of treatment.

ARCHWIRES

NON EXTRACTION ARCHWIRE SEQUENCE.

Maxillary arch.

Intial wire
TYPE: Flexible, Round(.0175 Triple-Flex or .016 NITI.
PURPOSE: Intial leveling and rotation correction
DURATION: ONE TO THREE MONTHS


Transitional wire
TYPE: Intermediate stiffness. (.016SS or 17x25 TMA).
PURPOSE: Continue leveling and rotation correction.
DURATION: TWO TO FOUR MONTHS.


Finishing wire.

TYPE: Stiff rectangular (17x25SS).
PURPOSE: FINALIZE LEVELING ROTATION TORQUE AND ARCH FORM
DURATION: UNTIL END OF TREATMENT




MANDIBULAR ARCH.


Intial wire

TYPE: Flexible rectangular (16x22 or 17x25, d-rect, 17x25 Niti.).
PURPOSE: Intial leveling ,rotation correction, torque control .
DURATION ONE TO THREE MONTHS.


TRANSITIONAL WIRE
TYPE: Intermediate stiffness. (17x25 TMA, 16x22 S.S.)
PURPOSE: Cont leveling, rotation correction, torque control
DURATION: THREE TO SIX MONTHS.
FINISHING WIRE.

TYPE: Stiff rectangular (17x25SS).
PURPOSE: FINALIZE LEVELING ROTATION TORQUE AND ARCH FORM
DURATION: UNTIL END OF TREATMENT



EXTRACTION ARCHWIRE SEQUENCE.

MAXILLARY ARCH.

Intial wire
TYPE: Flexible, Round(.0175 Triple-Flex or .016 NITI.
PURPOSE: Intial leveling and rotation correction
DURATION: ONE TO THREE MONTHS


Transitional wire
TYPE: Intermediate stiffness. (.016 SS ).
PURPOSE: Continue leveling and rotation correction and retract canines.
DURATION: FOUR TO EIGHT MONTHS.


SPACE CLOSING:
TYPE: Stiff rectangular w/ Closing loops ( 18x25 post reduce S.S)
PURPOSE: Close space. .
DURATION: FOUR TO EIGHT MONTHS.


FINISHING WIRE.

TYPE: Stiff rectangular (17x25SS).
PURPOSE: FINALIZE LEVELING ROTATION TORQUE AND ARCH FORM
DURATION: UNTIL END OF TREATMENT


MANDIBULAR ARCH.

Intial wire
TYPE: Flexible, Round(.0175 Triple-Flex or .016 NITI 17X25 D- Rect.
PURPOSE: Intial leveling and rotation correction torque control.
DURATION: ONE TO THREE MONTHS

Transitional wire
TYPE: Intermediate stiffness. (.016 SS or 17x25 TMA).
PURPOSE: Continue leveling and rotation correction and retract canines.
DURATION: TWO TO FOUR MONTHS.


Space closing

TYPE: Stiff rectangular w / Closing loop (16X22 s.s.)
PURPOSE:. Close space
DURATION: FOUR TO EIGHT MONTHS.


FINISHING WIRE.

TYPE: Stiff rectangular (17x25SS).
PURPOSE: FINALIZE LEVELING ROTATION TORQUE AND ARCH FORM
DURATION: UNTIL END OF TREATMENT


HEAT TREAT: ALL STAINLESS STEEL ARCHWIRES






ARCH CONSOLIDATION
Purpose:
· To close all spaces.
· To change 10-12 Independent force components into One Unit.


WHY IS IT INPORTANT
· When extra-oral forces are applied Orthopedic change can occur.e.g Facebow and Facemask.
· Intra-oral elastic attached to ball hooks do not move individual teeth........No space open.............Torque not affected.


TWO WAYS TO CONSOLIDATE:
· Power chain and Round Wire. (Non-Extraction).
· Closing Loop. (Extraction).

4 WAYS TO MAINTAIN CONSOLIDATION
· Power chains.
· Lacing with ligature wires.
· Cinch back.
· Tie back with omega loops.
·
THE DISADVANTAGES OF POWER CHAIN AND CINCH BACK.
· Chains must be changed monthly.
· Very difficult to close space in rectangular wires.
· Cinch back is “Passive” stop.
· Spaces inadvertently open.



TECHNIQUE FOR BENDING THE OMEGA LOOP.



After space closure, what is the best way to keep arch consolidated?
· ANSWER: Place omega loops anterior to terminal tubes.
· Tie back with ligature tying pliers.


After space closure what is the best way to keep arch consolidated ?

· Place omega loop anterior to terminal tubes.
· Tie back with ligature tying plier.


Advantage of tying back with omega loop:
· Active force holds contact points together.
· Small spaces can be closed by tightly tying back.
· Unnecessary to change power chain every month. open.
· Space do not inadvertently open.


How Do You Tie Back
1. Use steiner ligature plier.
2. Use .014 S.S. ligature wire.


Is it necessary to tie back every arch?
Ans: NO.

When placing curve of spee in the maxillary arch
(Round or rectangular wire)
TIE BACK OR FLARE ANTERIORS

When placing reverse curve of spee in mandibular arch using rectangular wire, -5 degrees torque prevents flaring.
When placing reverse curve of spee in mandibular arch using round wire
Tie back or fare anteriors







Maxillary arch No TB Tie Back. Cinch Back
---------------------------------------------------------------------------------------------------------
Initial archwire X
---------------------------------------------------------------------------------------------------------
Curve of spee X X
---------------------------------------------------------------------------------------------------------
Wearing headgear X
---------------------------------------------------------------------------------------------------------
Closing loop X
---------------------------------------------------------------------------------------------------------
Finishing Archwire X
---------------------------------------------------------------------------------------------------------



Mandibular arch No TB Tie Back. Cinch Back
---------------------------------------------------------------------------------------------------------
Initial archwire X
---------------------------------------------------------------------------------------------------------
Reverse Curve of spee
---------------------------------------------------------------------------------------------------------
Round wire X
---------------------------------------------------------------------------------------------------------
Rectangular wire Y/N Y/N
---------------------------------------------------------------------------------------------------------
Closing loop X X
---------------------------------------------------------------------------------------------------------
Elastic X
---------------------------------------------------------------------------------------------------------
Finishing Archwire X
---------------------------------------------------------------------------------------------------------

WHEN DO YOU TIE BACK?
ANS: WHEN IN DOUBT, TIE BACK.

One of most important principle in the Alexander Discipline is
TYING BACK.

ARCHWIRE LIGATION
· POWER’O’ ELASTOMER.
· STEEL LIGATURE.
1. .010 S.S.
2. .014 S.S
Elastomers are used in early stages of treatment.

INDIVIDUAL BRACKET SELECTION.

Single brackets with rotational wings exploit the advantages of the new technology in orthodontic wires.

Specific brackets designed for specific teeth according to size and location on the arch.

Maxillary centrals and laterals.

Brackets include ball hooks for easy elastic attachment.

Advantages of twin brackets on maxillary incisors:
They provide handles for:
· Tying rotation
· Placing power chains.
· Ligating anteriors
· Placing hooks.

Twin brackets on maxillary incisors:
Makes ligation simple because:
· easy access
· flat surface of teeth.
· Adequate interbracket space.

Advantages:
· increased interbracket space.
· Easy ligation.
· Better rotation control.
· Ability to activate wings


Mini wick single bracket.
Specific brackets are placed on small, flat surface teeth. - Mandibular incisors.

Specific brackets are placed on large, round surfaced teeth located at the corner of the arch. - Cuspids.

Activating rotational wings on cuspid brackets.

Specific brackets are placed on large, round surfaced teeth not located at the corner of the arch.
· Bicuspids.

Complete bracket engagement with single wing bracket.

Banded single brackets are more often used on 2nd bicusppids.

Advantages:
· They provide more accurate bracket placement.
· Less bracket failure.

ACTIVATING AND DEACTIVATING WINGS.(IMPORTANT).
Could be over come with accurate bracket placement.

Why place headgear tubes occlusally?
If placed gingivally they:
· Are less visible for patient to see and use.
· Becomes a food trap.
· Block headgear tube unless omega loop is reversed.


Second molar banding.
· In children band upper first molars and lower first and second molars.
· In adults band both upper and lower first and second molars.

TREATMENT DECISION EXTRACTION VERSUS NON EXTRACTION.

On of the most important decision that we make daily in our orthdontic practice is whether to extract teeth or not in our patients.
Do not extract teeth unless you know that , that is the best way to treat the case.


TREATMENT GOALS.
· BALANCED SOFT TISSUE PROFILE.
· NON - EXTRACTION WHEN POSSIBLE.
· MANDIBULAR INCISORS UPRIGHT ON BASAL BONE.
· GOOD INTERINCISAL ANGLE.
· ROOT ARTISTIC POSITIONING.
· MANDIBULAR MOLARS UPRIGHT.
· CUSPIDS NOT EXPANDED.
· NORMAL OB, OJ.
· CLASS L CUSPIDS. FUNCTIONAL OCCLUSSION BALANCED OCCLUSSION.

TREATMENT DECISIONS.

Soft tissue profile.
· Convex ......................................extract
· class ll.
· normal.
· concave.......................................non extraction.

Periodontal condition.
· Normal ....................................non extraction
· compromised.
· Poor .......................................extraction.

Mandibular incisor position.
· Proclined. ........................................extraction
· Upright. ..
· Retroclined.. ......................................non extraction.

Arch length discrepancy.
· Mild.... .........................................non extraction.
· Moderate.
Severe..........................................extract.

Growth potential.
· Present
direction......low angle non extraction .....high angle extraction.
amount
· Border line.
· Past.

Co-operation and growth makes border line case non extraction.

THE PRINCIPLES OF THE ALEXANDER DISCIPLINE.

PRINCIPLE # 1 = Kiss. (Keep It Simple ,Sir).

PRINCIPLE # 2 = Increase bracket space and rotational control with unique bracket design.

· Increased interbracket space.
· wings for rotation correction then control.
· precision pre torqued slot.
· Precision base variation.

PRINCIPLE # 3 = Build treatment into bracket placement.

Precision bracket placement.
· Height. (Measure with gauge).
· Angle
· Mesio-distal position.

PRINCIPLE # 4 = Utilize a systematic approach to treatment.
· Step -by- step sequence.
· Anticipate future appointment.

PRINCIPLE # 5 = Obtain predictable orthopedic correction using facebow or facemask.
· Facebow.
· Facemask.

PRINCIPLE # 6 = In non extraction treatment, initiate treatment in the maxillary arch.
· Consolidate with power chains.

PRINCIPLE # 7 = In non extraction treatment, Control Lower Incisors by utilizing:
· 5 degrees torque - incisors,
· 6 degrees - 1st molars,
· flexible, rectangular arch wires.



PRINCIPLE # 8 = In extraction treatment, initiate treatment in the maxillary arch.
· Retract cuspids on .016 S.S. wire


PRINCIPLE # 9 = In extraction treatment, delay treatment in the mandibular arch
· “Driftodontics.


PRINCIPLE # 10 = In extraction treatment, initiate treatment in the mandibular arch.
· When cuspids are in class I relationship.

PRINCIPLE # 11 = When in doubt, tie back.
· Use omega loop.


PRINCIPLE # 12 = Consolidate arches early in treatment.
· In extraction case use closing loop.
· In non extraction case use power chain.

PRINCIPLE # 13 = Level arch and open bite with accentuated curve of Spee and reverse curve of spee.

PRINCIPLE # 14 = Get into finishing arch wire quickly and “let it cook”.

PRINCIPLE # 15 = Be in finishing archwires before initiating:
· Class II
· Midline elastics.

PRINCIPLE # 16 = Obtain complete bracket engagement.
Ligate finishing archwires with steel ligatures.
· .010
· .012
· .014

PRINCIPLE # 17 = Utilize specific retention plan incorporating.
· Retainer design.
· Time sequence.
· Resolution of wisdom teeth.

PRINCIPLE # 18 = “There are no little things”.


PRINCIPLE # 19 = Motivation.
· Love
· Firmness.
· From vertical to horizontal relationship.

Effort vs result.

CEPHALOMATRIC ANALYSIS

The introduction of radiographic cephalomatrics in 1934 by Hofrath in Germany and Broadbent in
the United States provided both a research and clinical tool for the study of malocclusion and the underlying skeletal disproportions.
Cephalomatric films could be used to evaluate dentofacial proportion and clarify the anatomic basis for a malocclusion. Any malocclusion is the result of an interaction between jaw position and dental compensation or adaptation. It is possible to have a normal occlusion in spite of an underlying jaw discrepancy through the mechanism of dental compensation. or to have a significant dental malocclusion within a normal skeletal pattern. Another possibility is additive rather than compensatory dental and skeletal deviations, so that a combination of moderate jaw discrepancy and moderate dental displacement adds up to a severe malocclusion. Two apparently similar malocclusion as evaluated from the dental casts can turn out to be quite different when evaluated more completely, using cephalomatric analysis to reveal difference in dentofacial proportions.



TECHNIQUE OF TRACING CEPHALOMATRIC RADIOGRAPHS.

It has been found that direct measurements on the headplates are often difficult. For this reason, a 'TRACING' is made. The tracing is a pencilled outline of the major and pertinent structures, made on a semi-transparent sheet of acetate, usually .003" thick, and superimposed on the headplate itself.


MOUNTING TRACING PAPER:

Place the cephalomatric radiograph on the tracing table, with the profile facing to the left. Place a piece of acetate paper on top of the reproduction of the radiograph so that the two edges on the top are even. The dull side of the acetate should be facing you. Now take two pieces of draftman's tape about one to one and one-half inches long and place one piece on the upper left of the acetate sheet and the other one on the upper right side. Leave about half the length extending beyond the upper edge. Bend the free ends of the tape down and seal them to the back of the radiograph. The acetate sheet and the radiograph are now sealed to each other at the top, and open at the bottom. This permits folding the tracing paper up frequently to check directly on structual details while tracing.

TRACING:

1. Trace the soft tissue outline with a sharp pencil. Draw accurately, without erasure if possible.

2. Draw the bony skeleton of the head.

3. Draw the Sella Turcia. This is the pituitary fossa of the sphenoid bone.

4. Draw the mandible and the condylar head.

5. Trace the molars and the central incisors.

6. Tace the porion.

7. Trace the palate and the pterygo-maxillary fissure.

8. Trace the orbit.


.LANDMARKS:

· SELLA TRUCICA (S).
The centre of the Pituitary Fossa of the Sphenoid Bone.

· NASION (N)
The intersection of the Internasal Suture with the Nasofrontal Suture in the midsagittal plane

· ORBITALE (OR)
The most inferior point on the External Border of the Orbital Cavity.

· PORION (PR)
The most surerior point of the External Auditory Meatus.

· IR POINT (IR)
The most convex point along the Inferior Border of the Mandible.

· MENTON (M)
The most Inferior Point of the Symphysis.

· POGONION (PO)
The most Anterior Point of the Mandibular Symphysis.

· GNATHION (GN)
The Point of intersection between the plane connectimg N and Po, and the plane connecting Me and Ir points.

· MOLAR POINT (MP)
The bisection of the over bite of the Upper and Lower Molars as seen on the Lateral Cephalogram.

· A POINT (A)
The deepest point of the curve of the Anterior Maxillary Border between Anterior Spine and the Alveolus. .

· B POINT (B)
The most Posterior Point in the Concavity along the Anterior Borber of the Symphysis as seen in the Lateral Cephalogram .

· A 1 INCISOR (A 1)
The Incisal tip of the Upper Central Incisor.

· AR POINT (AR)
The Root Apex of the Upper Central Incisor.

· B1 INCISOR (B1)
The Incisal tip of the Lower Central Incisor.

· BR POINT (BR)
The Root Apex of the Lower Central Incisor.

· UPPER LIP (UL)
The most Anterior Point on the Curve of the Upper lip.

· LOWER LIP (LI)
The most Anterior Point on the Curve of the Lower Lip.

· CHIN (DT)
The most Anterior Point on the Curve of the Soft Tissue Chin.



LANDMARKS - PLANES.

1. SELLA NASION: - SN

The plane connecting Sella Turcica and Nasion. Known as the Cranial Base, SN defines the Lower Border of the Cranium.

2. FRANKFORT HORIZONTAL PLANE: - FH.

The plane formed by connecting Porion and Orbitale. This plane is approximately parallel to the ground when the patient is looking straight ahead. This plane is often used as a superimposition line for cephalomatric tracing.

3. OCCLUSAL PLANE: - OP

The bisection of points A1 and B1 is connected to the Molar Point to form this plane. Although the patient's actual Occlusal Plane is rarely completely flat, this constructed plane is a useful approximation

4. MANDIBULAR PLANE:- MP

The plane connecting Menton and the Ir Point. This plane defines the Base of the Mandible.

5. APo PLANE:- APo

This plane defines the Anterior Border of the Facial Skeleton. It is formed by connecting A point with Pogonion.

6. SOFT TISSUE LINE:-

A line connecting Dt (chin) and UL (upper lip). This line defines the Anterior Border of the Soft Tissue in the Lower Face.

LANDMARK - ANGLES.

1 SNA:-
The Angle between the SN Plane and a Plane connecting Nasion and A Point. The SNA angle defines the anteroposterior position of point A relative to the anterior cranial base. Its mean value , 81 degrees, indicates a normal relationship between maxilla and anterior cranial base. If the angle is less than normal, the maxilla lies more posterior in relation to the cranial base , if the angle is too large, the maxilla lies more anterior. The angle therefore defines the degree of prognathism for the maxilla. A large SNA angle (greater than 84 degrees ) makes the anteroposterior position of the maxilla prognathic, a small angle (less than 78 degrees) makes it retrognathic.

Variations due to age and sex are minimal with this angle (80.5 - 82 degrees).


2. SNB :-
The Angle between the SN Plane and a Plane connecting Nasion and B Point (NB). The SNB angle determines the anteroposterior position of the mandible in relation to the anterior cranial base, analogous to the SNA angle for the maxilla. This angle defines prognathism for the mandible, the mean value being 79 degrees. If it is greatewr than 82 degrees, the mandible is prognathic relative to the cranial base, if it is less than 77 degrees, the mandible is retrognathic. The mandible is described as orthognathic if the angle is between 77 and 82 degrees.

The size of this angle increases with age (from 76 degrees at 6 years to 79 degrees at 16 years of age). Retrognathism may thus be compensated in the course of growth, and it is often difficult to distinguish the effects of therapy from those of growth when Class II anomalies are treated.


3. ANB :-
SNA minus SNB. This represents the diffrence between the SNA and SNB angles and defines the mutal relationship, in the sagittal plane, of the maxillary and mandibular bases.The SNA is positive if point A lies anterior to NB. If NA and NB coincide, the angle will be zero. If, however, point A lies posterior to NB, ANB will be negative. Apart from establishing the relationship between the maxillary and mandibular bases, the angle also largely determines the position of the incisors. On average, the angle is 2 degrees. High positive occurs in Class II, negative in skeletal Class III.


Comparison of SNA, SNB and ANB
The three angles refered to above (SNA, SNB and ANB) define the relationship of the maxillary and mandibular bases to the anterior cranial base, and also the mutual relationship of the maxillary and mandibular bases. A number of combination are possible.

Normal SNA and SNB
This indicates a normal position of the maxillary and mandibular bases relative to the cranial base and also to each other.


Normal SNA.
Normal SNA angles indicate normal relations between maxilla and cranial base with:
(a) Small SNB angle = mandible retrognathic.
(b) Large SNB angle = mandible prognathic.


Normal SNB
Normal SNB angle indicates normal relationship between mandible and cranial base, with :

(a) Small SNA angle = maxilla retrognathic.
(b) Large SNA angle = maxillprognathic.


4. Angle of Convexity.
The angle defined by the intersection of the line connecting N and A , and the APo plane.


5. SN - MP (Mandibular Plane).
The Angle formed by the intersection of SN and the Mandibular Plane. This angle gives the inclination of the mandible to the anterior cranial base.


6. FMA (Frankfort - Mandibular Angle).
The angle formed by the intersection of the Frankfort Horizontal and the Mandibular Plane.


7. OM (Occulasal - Mandibular Angle).
The angle formed by the intersection of the Occlusal Plane and the Mandibular Plane.


8. Y - Axis Angle.
The Angle between SN and a line connecting Sella Turcica with Gnathion. This angle determines the position of the mandible relative to thr cranial base, as an additionall check. It has a mean value of 66 degrees. if it is greater than that, the mandible is in a posterior position, with growth predominantly vertical. If the angle is less than 66degrees, the mandible is in an anterior position relative to the cranial base, and growth is predominantly anterior.


9. Upper 1 to SN.
The Angle between SN and a line connecting A1 (upper incisor tip) to AR (upper incisor root apex). The posterior angle is measured. It has a mean of 102 degrees +- 2 degrees. Up to the 7th year, it is only 94-100 degrees, with 1o2 angulation achieved only 1 or 2 years after eruption. Large angles usually indicate maxillary incisor protrusion, smaller angles very upright incisors.


10. IMPA.
The Angle between the Mandibular Plane and the line connecting B 1 and BR. It has a mean value of 90 +- 3 degrees. From the 6th to the 12th year the angle increases from 88 to 94 degrees. A wide angle denotes protrusion of the mandibular incisors, a smaller than normal angle, very upright incisors. Treatment planning, even for simple forms of treatment, always calls for diagnostic analysis of lower incisor angulation.


11. Interincisal Angle.
The intersection of the two lines A 1 - AR and B1 - BR. It has a mean value of 135 degrees. A good incisal angle on conclusion of treatment is a major factor in denture stability and prevention of relapse.

LANDMARKS - LINEAR MEASUREMENTS.

1. Lower Incisor to APo.
The linear distance from Point B1 to the APo Plane, measured perpendicular to APo. Apart from determining the angles, linear measurements are also used to assess incisor position. The distance of the lower incisal edges from the APo plane is determined. The average distance being i mm. This figure is of considerable importance in treatment planning. The aim of treatment, at least with the permanent dentition is to achieve those normal relations to the APo plane This particular measurement therefore, is frequently the key factor in deciding:

(a) whether extraction is indicated.
(b) whether the lower incisors can be moved forward.
(c) whether anchorage is critical.

Until the 9th year, the metric relations in the mandible are not sufficent to stabilised to serve as the basis for major diagnostic decisions, In the mixed dentition period, interpretation must consider the phases of active growth still to come.


2. Holdaway Ratio.
The Ratio of the following two distances.
1). The perpendicular distance from Po to the line connecting Points N and B (NB).
2). The perpendicular distance from B1 to the line connecting N and B.


3. Lower Lip to Harmony Line.
The Hormony Line connects DT (Soft Tissue Chin) with UL ( Upper Lip).
The distance from the most anterior point on the lower lip (LT) to the Harmony Line
is measured parallel to FH


4. Wit's appraisal.
The 'Wit's (Univ. of Witwatersrand) appraisal of jaw disharmony, which is a measure of the extent to which jaws are related to each other anteroposteriorly. Perpendiculars lines are drawn on the lateral cephalometric head flim tracing from point A and B on the maxilla and mandible respectively, onto the occlusal plane which is drawn through the region of maximum cuspal interdigitation. The points of contact on the occlusal plane from A and B are labelled AO and BO respectively. It was found that with normal occlusion, point BO was approximately 1mm anterior to point AO. In skeletal Class II jaw dysplasias, point BO would be located well behind point AO, whereas in skeletal Class III jaw disharmonies, point BO will be forward of point AO.

Clinical Examination.

Extra oral : Profile / Frontal view

The profile is an important aspect of the patient's external appearance and give an indication of the underlying orthodontic situation. The examination should be done with the Frankfort Horizontal Plane parallel to the floor. If the chin slopes back or the maxilla and the nose are set forward, the profile is convex. If all of the middle of the face retreats, then the profile is concave. In between convex and concave, the profile becomes straight. There are no set measurement that can be used when assessing the profile - experience is the key.
The profile view allows a lateral evaluation to be made which corresponds to the lateral cephalogram. The following aspects of the face should be viewed and noted in the treatment chart.


1.The lip posture : This is viewed with the patient seated upright in a relaxed position with the lips parted. If the teeth are exposed this reflects that the dentition are positioned forward in the jaws.This could possibly mean need for retraction of the anterior dentition, with an indication for bicuspid extraction. It is also important to note the extent to which the lips are separated when they are relaxed and whether the patient must strain to bring the lips together. When the lips are protrusive and separated at rest by more than 3 to 4 mm, it can be concluded that the lip protrusion results from protrusion of incisors, and that both lip function and facial esthetics would improve if the protruding teeth were retracted. If the lips are protrusive but close over the teeth without strain, on the other hand, retraction of the incisor teeth will result in minimal changes in lip prominence.
Detecting protrusion of incisors (which is relatively common) or retrusion of incisors (which is rare) is important because of the effect of this on space within the dental arches. If the incisors protrude, they align themselves on the arc of a larger circle as they lean forward, whereas if the incisors are retrusive, less space is available to accommodate the canines and premolars. In extreme cases, incisor protrusion in what might have been a patient with severe crowding can produce ideal alignment of the dental arches, at the expense of lips that protrude and are difficult to bring into function over the protruding incisor teeth. This condition can be termed bimaxillary dentoalveolar protrusion, meaning simply that in both jaws the teeth protrude. The condition is often referred to as just bimaxillary protrusion, a simpler term but a misnomer since it is not the jaws but the teeth that protrude.


2. Lip thickness: In patients with very thin lips, the orbicularis oris muscle contract and pull the lips together. In such patients caution must be applied if the anterior teeth are to be retracted. Retraction of the anterior teeth in such cases will cause the lips to retract at approximately a one to one ratio with the dentition. This could result in excessive flattening of the profile, creating a "dished - in" look.
Excessive advancement of the anterior dentition in a tight-lipped should also be handled with caution. In such patients change will initially make the profile more aesthetically pleasing. But , the tight musculature will often cause these teeth to relapse to their original position. In such situation it is wiser to warn the patient prior to the treatment and indicate that lenghty retention procedure will be essential.
When anterior teeth are retracted in the thick lipped patient, for every two millimeters of dental retraction, the lips move distally only one millimeter. Hence, it is more difficult to alter this type of profile dramatically. These patients will usually exhibit tittle lips strain. and the orbicularis oris muscles are more flaccid. Advancement of the incisors in these patients is quite easy, because there is less muscle strain. This also minimizes the chances of relapse.


3. Shape of nose and the naso - labial angle : The naso labial angle is too actue, the upper lip should be retracted. If the angle is too obtuse, the upper lip may need to be advanced.


4. Upper lip lower lip relationship: The anteroposterior relationship between the most anterior surfaces of the upper and lower lip have a great effect on facial esthetics. The relationship of the lips could reflect the skeletal pattern of the patient. When the upper lip is advanced the patient could be a skeletal class II. Retruded upper lip could mean a skeletal class III.This could be confirmed by looking at the cephalomatric readings.


5. Soft tissue pogonion: This indicates whether the lower face is protruded, retruded or in normal relationship to the other facial bones.



6. Facial type: The shape of the face indicates whether the patient has a round , long , short or balanced face.


7. Facial heights: Here it is noted whether the face is equally balanced or unbalanced. Vertical proportions can be seen more clearly in profile. The face is divided into vertical thirds. The inclination of the mandibular plane to a true horizontal line is visualized readily by placing a ruler along the lower border of the mandible. A steep mandibular plane angle correlates with long anterior facial vertical dimensions. A flat mandibular plane angle correlates with short anterior facial height.
There is also an interaction between face height and the anteroposterior position of the mandible. A long face predisposes the patient to Class ll malocclusion, a short face to Class lll.


8. Smile line: The smile line reveals whether the patient has a gummy smile or much more of the mandibular teeth is seen than that should be.With a relatively short upper lip and/or long maxillary alveolar process, a disfiguring amount of gingival tissue is exposed in laughing. This feature can influence the type of treatment and its prognosis. The height of the visible gingivae when laughing is measured from the cervical margin of the maxillary incisors to the inferior margin
of the upper lips .
Intra oral examination:

The routine intra oral examination is conducted with a through examination of the hard and soft tissues of the oral cavity. The presence of caries, hypocalcified teeth , fractured or discoloured teeth are noted. Presence of anomalies and non vital teeth are also looked for.
The soft tissues are examined , the periodontal condition should be evaluated and also look for the presence of abnormal labial , buccal and lingual frenal attachments. The health of the soft tissue and the presence of any soft tissue lesions must be checked
At this juncture it is good to evaluate the various habits such as tongue thrust, lip sucking , thumb sucking or any other oral habits.

Finally the general oral hygiene of the patient is evaluated. The need for oral prophylysis and oral hygiene instructions is noted. Care in oral hygiene, wearing of appliance and keeping to the treatment regime all call for strong motivation, and so it is wise to assess patient cooperation before starting active treatment, particularly when a long-lasting treatment is anticipated.

DIAGNOSIS AND TREATMENT PLANNING

Introduction.

If the patient attends his family general practitioner for orthodontic advice, the dentist because he knows the patient's dental background - will already be acquainted with a number of relevant matters such as dental mindedness, cooperation, family relations and financial circumstances.
On the other hand if the general practitioner is being consulted by a patient he has never seen before the consultation is divided into three visits. A first consultation is when the patient presents himself at the office, during which such matters that the family dentist normally knows are discussed. A separate visit is arranged for a full examination such as the collection of administration data, taking a history the external and intra - oral examination, diagnostic aids such as taking impressions and request for panaromic and cephalomatric radiographs. A through study of all the facts collected is done and a third visit is planned to present the case to the patient and parent and a decision is taken whether to treat or not to treat the patient.


DIAGNOSTIC TREATMENT CHART

A good comprehensive examination is carried out by having a check list of points that may need investigation. Relevant finds should be recorded and all information obtained from the various diagnostic aids be collected before a decision is made. A Diagnostic treatment chart serves as a record into which all the diagnostic data are entered. This aids in the diagnosis, treatment planning and presentation of the particular case. Notations are made in the record as the treatment is carried through. At the completion of the treatment the Diagnostic treatment chart is filed complete with all the finishing data recorded along with initial and final photographs and cephalomatric tracings.
(The Diagnostic treatment chart used for the patient is the one used by the members of The Alexander Discipline Study Club of Malaysia.) For the convenience of the reader, a loose-leaf version is added which can be perused in conjunction with the text that follows in the remainder of this book.

ADMINISTRATIVE DATA.

Administrative data are generally entered by the dentist's chair side assistant. Most of the points are self explanatory.


Informed Consent: The purpose of this section is to enlighten the practitioner with a basic understanding of the concept of informed consent and why this must become an essential part of the orthodontic records. At the end of this section a sample of customized document entitled, “Information and Informed Consent", is added.

Definition of Informed Consent: This is consents obtained after disclosure of all information which are sufficiently complete and accurate so that a reasonable, competent person can make an intelligent decision on their future treatment The patient must be given sufficient information to make a informed decision regarding his treatment No treatment should commence without the patient's or parent's total agreement and cooperation.


Criteria for informed consent

Following are some of the information that must be given to the orthodontic patient in order for him to make an intelligent decision regarding the giving of consent of treatment.

1. The diagnosis and treatment plan must be thoroughly explained.
2. Discuss the benefits of the treatment.
3. Inform the risks involved.
4. Alternate treatment plan if any
5. The prognosis of the case if no treatment is done.
6. Information must be presented in an organized, systematic manner and easily understood by the patient.
7. Document must be signed by the patient or parent.


Diagnosis and treatment plan

Orthodontic is a time consuming treatment which can take several years or months. All details of the diagnosis, prognosis and the treatment plan must be explained to the patient. It is also important to discuss with the patient the different phases of the treatment and what the practitioner intents to accomplish at the end of each phase. It is also essential to discuss the treatment charges for each phase


Benefits of treatment

A pleasing smile, straight teeth, less TMJ symptoms, improved nasal breathing, improved profile, pleasing appearance, improved self esteem etc. are some of the benefits of treatment. These should be conveyed to the patient.


Risk of Orthodontic Treatment.

Possible risk associated with orthodontic treatment to be discussed with the patient is one of the essential parts of the informed consent procedure. Some of the associated risks are:-

1. Increase incidence of caries.
2. Periodontal diseases.
3. Decalcification due to poor oral hygiene.
4. Loss of tooth vitality especially when the tooth has been previously traumatized.
5. Occurrence of TMJ problems.
6. Relapse.
7. Need for further treatment such as orthognathic surgery.
8. Difficulty in the management of functional problems such as persistent anterior tongue which could result in anterior open bite.


Limitation of treatment.

Patient must emphasized that orthodontic is not a perfect science and the result may not last a life time. Limitation to the success of treatment can be due to several factors such as.
1. Compliance problems.
2. Severe skeletal problem
3. Relapse problem.
4. Severity of malocclusion.


Alternate treatment plan.

There are always different options to treat an orthodontic case. It could be the conventional approach, functional approach, a combination, extraction or non extraction approach. Whichever approach is chosen. All treatment philosophies and treatment techniques must be discussed with the patient prior to the commencement of treatment.


Prognosis if no treatment is done.

The patient must be informed frankly and honestly the consequences of not undergoing treatment. This could depend on the severity of the malocclusions.


Patient asks questions.

At the end of the procedure the patient is encouraged to ask questions and communicate freely with the doctor regarding his future treatment. Hence it is ideal to set this appointment at the end of the day when there will be no interruptions.


Conclusion

The importance of informed consent is discussed. This procedure does not end with the patient signing the document Infect this is only the beginning of the Doctor patient relationship which must continue throughout the entire treatment. Dentist by training and by patient expectation, are primarily therapists and so they often launch into action before rendering a complete diagnosis. For many patients, the etiologies and remedies of problems are obvious, and the ensuring progress of treatment and management causes few problems. But whenever the diagnosis is obscure or difficult, patients will suffer from our haste and the practitioner is often baffled about ineffective regimens. The most grievous mistake one can make is that from misdiagnosis. One can easily overcome errors of mechanics, but have much more trouble correcting a wrong diagnosis. Nevertheless, a sound diagnosis remains the foundation of all successful therapy, and it remains the primary responsibility of conscientious clinicians


Patient History

Orthodontic treatment must only be iniciated on patients who are in good health. It is unwise to subject an unhealthy patient to the demands of the orthodontic treatment as there bound to be compliance problems broken appointments due to illness and at times neglected oral hygiene.

At this point it is also essential to note if the patient is on any medication or if he is undergoing any treatment. it ia appropiate to throughly discuss the situation with the patients parant and his physician


Medical History

In this section, the practitioner should note any existing medical condition such as allergies , tonsillitis or sinus related condition that may hinder orthodontic treatment. The severity of the condition should be noted and it is a good habit to consult the patient's physician before iniciating any treatment.


Dental History

A through dental history is essential for the success of the orthodontic treatment. It is important to look into the possibilities of existing habits such as mouth breathing, tongue thrust, thumb or finger sucking, lip sucking or biting , use of dummies abnormal lip position and activity and other habits.


TMJ Analysis.

Look for the existence of TMJ signs and symptoms. It is essential to note the presence of pain trigger spots clicking of the joints or the presence of crepidus. Deviation of the mandible on closing is noted and recorded. The maximum opening of the jaws is measured and noted.It is essential to inquire the presence of tension headache and whether the patient is under treatment or otherwise.


Panaromic Radiographs.

The applications of panaromic x - ray are as follows:
· Determination of the dentition present.
· Teeth that will be erupting.
· Missing teeth and supernumerary dentition noted.
· Impacted teeth usually upper cuspids or upper and lower third molars.
· The current status of the third molars is evaluated.
· The root apex of each tooth is examined in order to analyze possible potential for root resorption.
· Pre - treatment bone loss espcially in adult patients who might be having periodontal conditions.
· Any other patholigical conditions.

Introduction

The purpose of this Blog is to guide the General Practitioner in the management of their Orthodontic patients.

It is advisable for the General Practitioner to have the basic understanding of principles of Orthopedic and Orthodontic prior to introducing Orthodontics into their practice. In this Blog a great emphasis is placed on DIAGNOSIS AND TREATMENT PLANING. It is essential for every G.P doing Orthodontics to undergo courses on CEPHALOMATRIC ANALYSIS, DIAGNOSIS AND TREATMENT PLANNING, ORTHOPEDIC MANAGEMENT OF PATIENTS AND BASIC ORTHODONTIC.

The intent of this Blog is to lay the basic foundation of the understanding of Orthodontic Management in Private Practice. It is my hope that every G.P will up grade their knowledge by attending the various courses conducted, join a study club and subscribe to the various orthopedic / orthodontic journals.

Welcome to GPORTHO Blog and please give your comments to enable us to advance this Blog further