Methods of Gaining Space by Dr Anmol Asghar Dean Faculty of dentistry Adal medical university.pptx

for BDS Students

1. Methods of gaining space DR ANMOL ASGHAR ALI BDS, PG ORAL IMPLANTOL, ADA CERTIFIED PG ORTHODONTICS AND DENTOFACIAL ORTHOPEDICS USC SPAIN ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 1

2. Methods of space gaining ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 2

3. Need for gaining space? ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 3

4. Proximal Stripping A method by which the proximal surfaces of the teeth are sliced in order to reduce the mesio -distal width of the teeth. Also called as reproximation , slenderization, disking and proximal slicing. Location- Lower anterior - Upper anterior - Buccal segments of the upper and lower arches. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 4

5. Indications of proximal stripping Minimal i.e. 0-2.5 mm space required. If Bolton’s analysis show mild tooth material excess in either of the arches. Aid to retention in lower anterior region. Cases where individual tooth sizes prevent a Class I molar & canine relationship. To obtain a more favorable overbite an overjet. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 5

6. Contraindications of proximal stripping In young patients, as they possess large pulp chamber, which increases the risk of pulpal exposure. Patients who are susceptible to caries or those who have a high caries index. Avoided on small teeth with enamel hypoplasia. Patients who refuse to accept slenderization as a treatment option (informed consent is imperative) Patients with poor oral hygiene and high bacterial plaque index. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 6

7. Diagnostic aids for proximal stripping Arch Perimeter analysis / Carey’s analysis – Tooth material excess of 0-2.5 mm over the arch length is a diagnostic criteria favouring reproximation . Bolton’s analysis- Minimal inter-arch tooth material discrepancy can also be corrected. Intra-oral periapical radiographs- IOPA gives idea of the enamel thickness & a rough estimate of the amount of the enamel that can be removed from the proximal surface, without exposure of the pulp chamber. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 7

8. Amount of proximal stripping Not more than 50% of the enamel thickness should be reduced by proximal stripping. Whenever reproximation is undertaken in a segment of an arch, it is advisable to equally distribute them over all the teeth. According to Sheridan 0.4 mm reduction per each surface of posterior teeth and 0.25 mm in the anterior teeth can be performed thereby gaining in total about 8.9 mm. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 8

9. Instruments used for proximal stripping Diamond interproximal strips – very thin strips (0.08 mm) Made of surgical grade stainless steel with electrolytically bonded diamonds. Resist stretching or breaking. Autoclavable and reusable. Strip holders are available that holds these strips. Abrasive strips are available in either single or double sided coating and come in three grades i.e. fine, medium and coarse. Perforated strips are available that allow optimal visibility and minimize clogging. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 9

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11. Procedure for proximal stripping ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 11

12. Advantages of proximal stripping In borderline cases where space requirement is minimal extraction can be avoided because of potential consequences of extraction: Difficulties in completing space closer. Difficulties in paralleling the roots next to extraction sites. Need for greater anchorage reinforcement than in slenderization cases. Possibility of space re-opening. Unwanted profile changes related to retroclining incisors hence closing extraction spaces. 2. More favorable overbite and overjet can be established. 3. More stable result can be obtained by broadening the contact area. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 12

13. Disadvantages of proximal stripping The stripping procedure creates roughened proximal surface that attracts plaque. Caries susceptibility is increased as part of the enamel is removed, leaving behind a roughened area. Patients may experience sensitivity of teeth. Improper procedure can result in alteration of morphology of the teeth. Loss of contact between adjacent teeth may result in food impaction. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 13

14. Periodontal considerations of proximal stripping Compressing the interradicular tissue by closure of space following slenderization could be a precursor to periodontal distress. But recent studies show no increase in pocket depth, recession or bone loss after reproximation . ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 14

15. Sequence of clinical steps for proximal stripping 1. Pre- treatment 2. Comprehensive panning 3. Access to the interproximal areas 4. Interproximal enamel removal 5. Finishing and polishing of enamel surfaces 6. Topical fluoride application ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 15

16. Sequence of clinical steps for proximal stripping Comprehensive planning - Study mode measurements can determine the required amount of stripping. Ideally a diagnostic set-up will supplement treatment planning and visualization the final position and morphology of teeth. The use of calibrated radiographic images to determine the exact amount of enamel that can be removed may be done. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 16

17. Access to the interproximal areas – Visibility and mechanical access to the proximal surfaces is required for efficient stripping of the interproximal area. This can be aided by the initial phase of levelling and aligning and correction of rotations. In addition mechanical separation of the teeth can be a valuable aid. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 17

18. Interproximal enamel removal – Interproximal enamel reduction is performed by either manual or mechanical methods. This can involve use of metallic strip system, diamond discs or by use of long burs. The orthodontist is generally advised to be conservative in initiating stripping procedures. Small enamel amounts should be ground symmetrically from all contact areas before maximum acceptable removal per site is reached. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 18

19. Finishing and polishing of enamel surfaces – Sof-lex disks and finishing diamond burs can be used to finish and contour the surfaces that have been stripped. Topical fluoride application – Topical fluoride application is recommended to help in remineralization of the abraded proximal surfaces. It is prudent to prescribe a fluoride gel . In case of sensitivity following senderization fluoride containing mouth rinse can be prescribed. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 19

20. Fluoride application The increased caries susceptibility after slenderization is managed by a comprehensive fluoride programme following the procedure. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 20

21. Expansion As A Method Of Gaining Space Expansion is one of the non-invasive methods of gaining space. Undertaken in patients having constricted maxillary arch or in patients with unilateral or bilateral cross bite. Expansion can be skeletal or dento -alveolar. Skeletal expansion involves splitting of the mid-palatal suture. Dento -alveolar expansion produces a dental expansion with no skeletal change. Various appliances- jackscrew or springs. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 21

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23. Extraction As A Method Of Gaining Space Extraction that is undertaken as a part of orthodontic treatment is called therapeutic extraction. Premolars are the most frequently extracted teeth as part of orthodontic treatment. Extraction of molars or lower incisors are done during orthodontic therapy. Extraction of canines and upper incisors is usually avoided. Extraction provide space for correction of crowding / proclination . ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 23

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25. Distalization One of the popular technique of recent time is distalization of molars. This technique is aimed at moving the molars in a distal direction to gain space. This approach is becoming popular due to the fact that extractions can be avoided. Distalization of maxillary molars- significant value in the treatment of mid to moderate class II molar relation associated with a normal mandible. Ideal timing for distalization – mixed dentition period prior to the eruption of the second permanent molars. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 25

26. Indications for distalization - Best done in moderate maxillary skeletal / dento -alveolar protrusion. Moderate arch-length deficiencies. When extraction of the maxillary teeth is not indicated. Contraindication for distalization - In severe protrusive profiles and severe incisor proclination . In case of high mandibular plane angle and anterior open bite. Severe crowding (more then 6mm) Patients with insufficient seating of the Nance button because of reduced palatal vault inclination. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 26

27. Distalization can be brought about by following methods- Extra – oral methods Intra – oral methods Extra – oral methods- Headgears deriving anchorage from the cervical or cranial region. Headgear assembly consists of a face bow that is made of an inner and an outer bow. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 27

28. The inner bow is fixed to buccal tubes present on the molars. The outer bow is attached to the extra- oral head cap or neck strap. Use of extra-oral forces for distalization has following disadvantages: Patients co-operation is essential for timely wear of the appliance. The appliances are usually not worn continuously. Intermittent in there action resulting in prolonged treatment time. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 28

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30. Intra-oral methods: In order to overcome drawback of extra-oral appliance intra-oral appliances were introduced. Intra-oral appliances are fixed on to the teeth and Produce a continuous effect. e.g. 1. Sagittal appliance 2. Pendulum appliance- a. Hilgers pendex b. T- Rex appliance c. The Hilgers PhD appliance 3. Distalization using intra-oral magnets 4. use of open coil springs to distalize molars 5. Jones Jig 6. Distal Jet 7. ACCO appliance 8. The fast Back appliance 9. Transpalatal Arch for distalization 10. Use of Fixed Functional Appliances for Molar Distalization. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 30

31. Sagittal expansion appliance Removable appliances incorporating jackscrews. Appliance consist of split acrylic plate joined together by a jackscrew. Acrylic plate is sectioned in such a way that the tooth that is to be distalized is isolated, while rest of arch is used for the purpose of anchorage. Appliances are retained using Adams clasps on molars and premolars. Used both in the upper and lower arches. Jackscrews are positioned in such a way that their long axis is parallel to the occlusal plane as well as the buccal surface of the molars. Most effectively done with extraction of second molar. Use: 1. Correct crowding 2. Used for distalization of only one tooth at a time to avoid undue strain on anchorage. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 31

32. Pendulum appliance Pendulum Appliance Hilgers pendex T-Rex Appliance The Hilgers PhD Appliance Introduced by Hilgers Modified Nance button for purpose of anchorage. Consists of a stainless steel or TMA wire. A helix, the distal end of which is inserted into a sleeve on the palatal aspect of the molars to be distalized . Same components and function as pendulum appliance Midline appliance is added Expansion can be initiated post distalization or simultaneously with distalization. Modified pendulum appliance with midine screw for expansion. Also includes locking wires which are soldered to mesial aspects of molar bands. Expansion using a hygienic rapid maillary expansion screw. Goshgarian locks are soldered underneath the body of the screw which engages the TMA pendulum springs. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 32

33. Distalization using intra-oral magnets Intra-oral repelling magnets can e use to distalize molars. Repelling magnets placed on the molar to be distalized and the tooth anterior to it. Anterior anchorage can e reinforced using a Nance holding arch. Consists of repelling magnets that slide over a thick wire that inserts into the molar tube on buccal aspect of the molar to be distalized . A sliding yoke that is ligated to the second premolar is used to bring the repelling magnets together thereby applying a distal force on the molar. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 33

34. Use of open coil spring to distalize molars Open coil nickel titanium spring compressed between the molar and the anterior segment. Anterior anchorage is reinforced by use of a Nance button that rests against the anterior part of the palate. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 34

35. Jones jig The Jones Jig is a simple, but effective appliance for distalizing upper molars. It may be used for bilateral or unilateral corrections. The mainframe is inserted into the buccal tube and ligated. The super-elastic coil spring is slid onto the mainframe wire and secured by the sliding eyelet tube. Force is obtained by compressing the spring and ligating the eyelet to the bicuspid bracket. Anchorage support is provided with a Nance appliance. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 35

36. The Distal Jet A lingual distalization appliance. The line of force running close to the center of resistance of the molar. Consist of bilateral piston and tube arrangement, with tube embedded in a modified acrylic Nance palatal button. Compressing coil spring generates a distally directed force. Advantage: Less distal tipping Easily converted into a Nance Holding arch to maintain distalized molar position ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 36

37. ACCO appliance The acrylic cervical occipital appliance (ACCO) Introduced by Dr. Herbert I. Margolis. Modification of the Hawley retainer, with addition of finger springs mesial to the maxillary molars and combining the use of a headgear. Anteriorly there is a labial bow over the incisors which can be embedded in acrylic for optimum retention. Adam clasps on first premolars for retention. Finger spring is placed mesial to first molar to provide the distal tipping force. Acrylic palatal section for retention also as anterior bite plane to disocclude posterior dentition and allow movement of molar. Bodily molar distalization with extra-oral traction or loops on the labial bow. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 37

38. The Fast Back Appliance Appliance consist of a Nance palatal button for anchorage. Two special screw, one on either side with anterior part embedded in acrylic. A small tube of 1.1 mm diameter is soldered onto palatal surface of the bands on molars to be distalized . An open coil spring is added to the arm as it slide into the tube and delivered required force. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 38

39. Transpalatal arch for distalization Transpalatal arch or TPA spans the paate from the palatal aspect of one molar to the opposite molar. Use - for anchorage -Correction of molar rotation Unilateral distalization of molar. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 39

40. Fixed functional appliances for molar distalization Fixed functional appliance such as Herbst appliance and Jasper jumper that have been used in the correction of class II malocclusion have been found to produce a certain amount of distal movement of the maxillary molar. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 40

41. UPRIGHTING OF MOLARS Premature loss of a second deciduous molar or extraction of a second premolar can cause mesial tipping of the first permanent molar. Mesially tipped molars occupies more space than an upright molar. Molars can be uprighted using molar uprighting springs or some form of space regainer . ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 41

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43. Derotation of posterior teeth Rotated posterior teeth occupies more space than normal spaced teeth. Derotation is best achieved with fixed appliances by incorporating springs or elastics using a force couple. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 43

44. PROCLINATION OF ANTERIOR TEETH Proclination of a retruded anterior results in gain of arch length. Indicated – 1. where teeth are retroclined . 2. Where protracting the anteriors will not affect the soft tissue profile of the patients. ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 44

45. This Photo by Unknown Author is licensed under CC BY-NC ADAL MEDICAL UNIVERSITY, BORAMA, SOMALILAND 45