Trans Palatal Arch

Nance,TPA, Quad Helix

1. Nance Appliance, Trans Palatal Arch & Quad Helix Guided By : Dr D.K. Agarwal (Prof & H.O.D) Dr. Preeti Bhattacharya (Prof) Dr. Ankur Gupta (Reader.) Dr. Juhi Ansar (Senior Lect.) Dr. Ravi Bhandari (Senior Lect.) Presented By: Asad Yusuf P.G. Ist year Department of Orthodontic

2. CONTENT Nance appliance Trance Palatal Arch Quadhelix Introduction Design Indication Disadvantages

3. Introduction Described by Nance in 1947 It is simply a Modified maxillary lingual arch that does not contact the anterior teeth, but approximates the slope of anterior palate The Transpalatal Arch: An Alternative to the Nance Appliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent 2007;29:235-8

4. Design .036 SS wire running along palate connecting upper molars. The palatal portion incorporates an acrylic button resting on slope of anterior palate that provides resistance to anterior movement of the posterior teeth

5. Indication 1. Provide anchorage during Alignment & levelling By Palatal vault and Cortical anchorage

6. 2.To maintain the position of the second molars where the first molars have been extracted.

7. 3. A modified Nance appliance modified with an anteriorly positioned acrylic button can provide a fixed acrylic flat anterior bite plane for the treatment of anterior deep overbite.

8. 4. Antero Posterior Anchorage in a case of canine retraction

9. 5. Offset Nance button to accommodate the palatally placed lateral incisor with loops to allow adjustment.

10. Diadvantages 1. Oral hygiene difficulties: Nance appliances result in deterioration of oral hygiene beneath the acrylic plate leading to inflammation of the palate. 2.Poor patient tolerance in comparison to the standard TPA

11. 3. Nance Appliance induced Pathology

12. Trance Palatal Arch Mar. 21, 1922 -Dec. 4, 1992 Robert Ara Goshgarian

13. INTRODUCTION Described by Robert A ra Goshgarian in 1972. Owing to the versatile design TPAs can provide passive and active orthodontic forces in all 3 planes

14. Design .036 mm ss wire that goes across the palatal contour from one molar or premolar to contralateral molar or premolar Wire soldered to molar band at mesiolingual line angles Or by insertion in the lingual sheath in molar band ( Wilson or Mershon attachments)

15. Major indication in mixed dentition is to prevent mesial migration of upper first molar during transition from second deciduous molar to 2 nd premolar Graber Vanarsdall Vig 5 th ed. Pg 484 Rationale : When permanent maxillary molars move anteriorly , they rotate mesiolingually around the large lingual root. TPA reduces anterior molar movement by coupling the right and left permanent molars together and, thus, preventing any possibility of rotations.

16. INDICATION in Transverse Plane Anchorage and arch width stabilization during orthodontic treatments or surgery 2. Retainer after active maxillary expansion 3. To Avoid Molar Tipping 4. Habit breaking appliance 5. Minimally expand dental arches

17. Transverse Plane : 1.Transverse anchorage and arch width stabilization when aligning palatally impacted maxillary canines Ref: Baccetti T, Sigler LM, McNamara JA . An RCT on treatment of palatally displaced canines with RME and/or a transpalatal arch. Eur J Orthod 2011; 33: 601−607

18. 2.TPA is also effective as a holding appliance or as a retainer after active maxillary expansion

19. 3. TPA & temporary anchorage devices ( TADs) combination to correct anterior open bites . TPA is useful in controlling molar tipping during such clinical situation

20. 4. Habit deterrent for persistent thumb and digit-sucking habits. This requires the soldering/welding of a crib to the TPA.

21. 5. Bilateral space maintenance following premature loss of primary molars. Prevent loss of Leeway space and potential crowding of the premolars where extractions of the deciduous molars are planned.

22. 6. TPAs can be used actively to minimally expand dental arches. Expanded by 3− 4 mm to provide a force of around 200 gm.

23. INDICATION in Anteroposterior Plane Anteroposterior anchorage :The loop is directed posteriorly if the TPA is to provide antero -posterior anchorage

24. GOOD MORNING

25. Derotation of molars Bent-back end of the arch was gripped with pliers and twisted relative to the main arch. If the moments on both sides are the same, the Mesio -distal force will be zero. Moments and forces delivered by transpalatal arches for symmetrical first molar rotation Bengt Ingervall et al

26. Complications of TPA Anchorage loss : Type B Anchorage 2.5 mm of mesial movement of the upper first permanent molars in TPA while the TADs group provided Absolute anchorage Feldmann I, Bondemark L. Anchorage capacity of osseointegrated and conventional anchorage systems: a randomized controlled trial. Am J Orthod Dentofac Orthop 2008 2.Increase of risk of root resorption : As TPA positions the root of anchor units against The cortical bone plate

27. 3.Breakage and cementation failure is approximately 2% and 30 %, respectively 4.The loop of the TPA can cause palatal trauma

28. Quad helix Described by Ricketts in 1975 Evolved from Coffin’s vulcanite expansion appliance He used with great success in the early treatment of those patients with cleft palate in whom the lateral maxillary segments had collapsed behind the premaxillary processes Wide range of continuous controlled force

29. Frank et al: Forces in the range of 0.5 to 1.5 lbs (200 to 600 g). Palatal separation of .92 mm average intermolar expansion was 5.88 mm. With the quad helix appliance there was a 6:1 ratio between the orthodontic and the orthopedic expansion. The Quad Helix Appliance Ruel W. Bench

30. Design Pair of anterior helices Pair of posterior helices Anterior bridge. Palatal bridge Posterior loops should be 4-5mm distal to banded molar but not extending to pterygomandibular raphe

31. Each of the helical loops adds an about additional 25 mm of wire to the appliance which lightens the force magnitude, rendering a more continuous action due to the greater range of activation provided by the longer wire.

32. Types Custom made: 1 - 0·9mm stainless steel Preformed ready type Fixed : retained by bands cemented on the permanent first molars. Adjustment ease with properties of .036 blue ELGILOY ( Co,Cr,Ni , Mo, Mn )

33. Ricketts RM. Bioprogressive technique lecture notes

34. Action Fan-like sweeping action : buccally expand and distally rotate the maxillary molar teeth Jones SP et al : Anterior arms of the appliance affect both the forces produced by the appliance as well as the force couples operating on the molar teeth. This results from the fact that the anterior arms are a rigid part of the whole appliance.

35. Importance of fan like action Parallel expansive force, larger amount of tensile strain was recorded in the molar region. Fan type of expansive force by Quad helix, larger amounts of tensile strain were observed in the canine region. A reduction occurred as the strain was measured back toward the molar teeth. T. M. Graber. Jpn . Orthod . So. 42:442-453, 1983

36. Parallel expansive force: Frontal view: maxillary bones were expanded laterally Occlusal view: palate and alveolar processes were expanded laterally in the molar region. Fan type of forcer by quad helix: Palatal and alveolar expansion was noted more in the canine region. Since many Class II malocclusions are characterized by maxillary arches that are narrowest in the canine region, it would follow that the fan type of appliance would be most effective. T. M. Graber. Jpn . Orthod . So. 42: 442-453, 1983

37. Fan like sweeping action for molar de rotation With this appliance,molar derotation is best accomplished by leaving the arms of the quad helix away from the lingual surfaces of the cuspid teeth. As the molar teeth derotate , the arms will come to push against the cuspid teeth and they will then expand together with the rest of the maxillary teeth. The advantage of activating the quad helix appliance in this manner lies in the fact that the maxillary teeth are expanded in a differential manner that "sweeps" them into the ovoid arch form. The Quad Helix Appliance Ruel W. Bench

38. Indications Correct cross bites by Upper arch expansion Case needing mild expansion with lack of space for upper laterals Molar Rotation correction

39. 4. Correction of mild class II Malocclusion in which upper arch need to be widened & upper molar rotated distally

40. 5. Class III condition In which upper arch needs to be widened &advanced with class III elastics 6. Habbit breaking aplpliance Thumb sucking: Palatal bar forward & bended downward Tongue thrusting: Spikes Soldered on bar & extending downward

41. 7. Unilateral & bilateral cleft palate: The quad helix Expands the buccal segment

42. 8. With face mask 8.extension of .045" wire through the headgear tube of the molar band enables the quad helix appliance to be used in conjunction with a protraction face mask.

43. Sometimes advantageous to place a bi-helix appliance in the mandibular arch to obtain and maintain a balance in the dimensions of the maxillary and mandibular arches

44. Practical Application Bands are placed on upper second deciduous molar for young case or 1 st permanent molar . Particular care is taken to adapt the lingual surface of bands because this is strong purchase area of appliance Most appropriate size is selected Original cast is used & wire is formed with the finger together with three pong plier to adapt wire according to patients need

45. Soldering spot is marked in front of posterior loops depending on the adaptation of arms The band is picked up in the tong & approximated as solder is flowed into position Desired activation is given Appliance is cemented making sure the bands are well seated

46. Activation

47. (1) Anterior adjustments produce expansion in the posterior molar area on both sides (2) Lateral adjustment expands and rotates the molar on the activated side. The molar on opposite side is distalized . Activation on both sides causes the rotation & expansion to be on both sides (3) Adjustments to the buccal arm expands the bicuspids and cuspids . When held away from the teeth it allows the molars to rotate. (4) Adjustments through the distal loop gives expansion to buccal arms. The Quad Helix Appliance Ruel W. Bench

48. Clinical Management Patients should be reviewed on a six-weekly basis for activation. Intra Oral adjustment can be done in subsequent visits Widening of molars can be activated by pinching between anterior loops. Care is taken to give only little activation is of anterior arms and wire is left out of contact with anterior teeth until molar rotation is achieved

49. Retention after the expansion At least three-month retention period Achieved expansion should be retained with an upper removable appliance. If fixed appliances are being used, the quadhelix can be removed and replaced by TPA.

50. Disadvantages The limited amount of skeletal change & palatal relapse. Opening of the bite due to molar buccal tipping. Outward positioning of upper buccal tooth by an attempt of nature to upright the root. Downward Backward appliance posture restrict tongue functions , so adaptation should be 2-3 mm of palatal tissue

51. References 1.Ricketts : Bio Progressive therapy 2.Influence of’ arch, shape on the transverse eff’cts of transpalatal arches of the Goshgarian type during application ofbuccal root torque G. Baldini and H. ‘U. Luder 3.The Transpalatal Arch: An Alternative to the Nance Appliance for Space MaintenanceAri Kupietzky,Eli Tal,Pediatr Dent 2007;29:235-8

52. American Journal of Orthodontics and Dentofacial Orthopedics hl memorianl 561 Volume 103, No. 6 Robert Ara Goshgarian 1922-1992 Transpalatal , Nance and Lingual Arch Appliances:Clinical Tips and Applications Ortho Update 2015; 8: 92-100

53. Rationale : When permanent maxillary molars move anteriorly , they rotate mesiolingually around the large lingual root. The space between the buccal and lingual cortical plates becomes narrow anterior to the first molar roots.The large lingual root contacts the lingual plate and acts as a pivot, allowing the 2 buccal roots to rotate mesiolingually . The TPA reduces anterior molar movement by coupling the right and left permanent molars together and, thus, preventing any possibility of rotations.

54. In the treatment of narrow restricted maxillary arches,quad helix tip the maxillary molar teeth bucally To counter the tipping : buccal root torque is placed in the molar bands before cementation & leaving the anterior arms of the quad helix away from the lingual surfaces of the cuspid teeth. As the molar teeth derotate , the anterior arms will come to push against the cuspid teeth and they will then expand together with the rest of the maxillary teeth, so the maxillary teeth are expanded in a differential manner that "sweeps" them into the ovoid arch form of the final occlusion.

55. Expansion and derotation activation placed in one side of the quad helix, distalizes the molar on the opposite side Modified to use one entire buccal segment of the arch to a single molar on the opposite side.

56. A quad helix can be activated to derotate a maxillary molar on one side of the arch provides a distalizing force at the molar on the opposite side of the same arch. By extending the palatal arms of the appliance on one side, it can involve more teeth on that side to act as anchorage in the distal movement of a single molar on the opposite side of the arch.

57. VHA has intrusive effect on maxillary molar eruption. Orthodontist must usually guard against further anterior bite opening during leveling and aligning procedures in patient with increased lower anterior facial height. An ideal treatment goal for a patient with an acceptable pretreatment overbite would be to at least maintain the same amount of overlap throughout treatment. Evaluation of the vertical holding appliance in treatment of high-angle patients Marc DeBerardinis et al :Am J Orthod Dentofacial Orthop 2000;117:700-5)

58. INDICATION in Vertical plane Positioned 4-5 mm away from the palate Fabricated with banded maxillary permanent first molars with connected acrylic button at the sagittal and vertical level of the gingival margin of the molar bands. Four helices were incorporated into the wire configuration for flexibility.

59. Nance Provide anchorage during Alignment & levelling Antero Posterior Anchorage in a case of canine retraction To maintain the position of the second molars where the first molars have been extracted. A modified Nance appliance modified with an anteriorly positioned acrylic button can provide a fixed acrylic flat anterior bite plane for the treatment of anterior deep overbite.

60. TPA Anchorage and arch width stabilization during orthodontic treatments or surgery prevent mesial migration of upper first molar during transition from second deciduous molar to 2 nd premolar 3 Retainer after active maxillary expansion 4. Habit breaking appliance Minimally expand dental arches VHA

61. A quad helix can be used to rotate an incisor tooth. In this case, a cleft palate was present