methods of gaining space 1. / orthodontic courses by indian dental academy

www.indiandentalacademy.com 1

METHODS OF GAINING SPACE.

INDIAN DENTAL ACADEMY

Leader in continuing dental education

www.indiandentalacademy.com

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Key-stoning procedure- Harry G.Barrer JCO Aug 1975

A. Malposed incisors B. interproximal relationship after key stoning

Rounded surfaces slip and rotate.www.indiandentalacademy.co

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Key-stoning procedure:


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Nonsurgical rapid maxillary alveolar expansion in adults:a clinical evaluation. Chester S. Handelman, Angle Orthodontist, 1997 vol 67

•Late teens and early 20’s questionable.

•Sutures: rigid and fuse.•SA-RME.

Non Surgical Maxillary expansion:Pain, swelling, ulceration, flared posterior teeth, bite opening, gingival recession, and perforation of the buccal alveolus.Vanarsdall: in children, gingival recession and dehiscence of bone


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Haas appliance

• 5 adults with transverse deficiency- treated nonsurgically using Haas appliance.

•RMAE- expansion centered in the alveolar process of maxilla rather than the body.(lateral walls of the palate)

•Bilateral/unilateral crossbites, arch constriction.2 quarter turns/day

Later 1 quarter turn/day U 1 no separation.

12 weeks retention.www.indiandentalacademy.co

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Displaces the alveolus with the teeth rather than expanding the teeth through

the alveolus.


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bilateral


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Unilateral crossbite –

left


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RMAE acceptable alternative to SA-RME in adults for maxi deficiency.www.indiandentalacademy.co

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Nickel-Titanium Palatal expander.

2 properties: Shape memory & superelasticity.

Exists in more than 1 crystal structure.

Lower temp-martensite. Transition temp:94degree

Higher temp-austenite {phase transition}


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MOLAR DISTALIZATION


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Indications for Molar distalization

1. In a growing child

- to relieve mild crowding

- causes permanent increase in arch length of about 2mm on each side.

2. Late mixed dentition- When lower E space –utilized for relief of

anterior crowding,- Upper molars distalized to get a class I

relationwww.indiandentalacademy.co

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3. Non-growing patient

- To regain lost arch length

- Blocking out of canines

4. Upper second molar extraction

- Lower arch normal


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Class I malocclusion- with highly placed canine/impacted canine

Lack of space for eruption of premolars due to mesial migration of permanent first molars


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Good soft tissue profile

Borderline cases

Mild to moderate space discrepancy with missing

3rd molars/2nd molars not yet erupted

End on molar relation with mild to moderate

space requirement.

Cases with less than full cusp class II molar relation.


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Case selection1. Normal or near normal mandibular arch

2. Late mixed dentition-ideal

- Early permanent dentition-growth still left in maxillary tuberosity area.- 16-17 yrs-males

14-15 yrs-females

3. Molars placed normally- buccopalatally.

4. 3rd molars-absent –stacking of upper molars – unsuitable

5. Profile considerations- well developed nose & chin

6. High MPA- contraindicated-wedging effectwww.indiandentalacademy.com

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Classification1. Location of appliance

Extra-oral Intra-oral

2. Position of appliance in mouth Buccal Palatal

3. Type of tooth movement Bodily movement Tipping movementwww.indiandentalacademy.co

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Classification4. Compliance needed from patient

Maximum compliance Minimum or No compliance

5. Type of appliance

Removable Fixed

6. Arches involvedIntra-archInter-arch www.indiandentalacademy.co

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Various appliances used for Molar Distalization :

Head gears Pendulum appliance. Coil springs Niti and S.Steel Distal jet K loop Jones Jig Magnet Wilson’s Bimetric loop Use of super elastic NiTi Franzulum appliance.


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Various appliances used for Molar Distalization

ACCO Crozat appliance Crickett appliance Modified Nance lingual appliance Schmuth and Muller double plates Claspring Removable molar distalization splint Fixed piston appliance Using implants Fixed functional appliance


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Distalization using Headgears

Very efficient Reciprocal forces are not transmitted to other teeth Molar movements depends on direction of force in relation to

the C Res of the molar & magnitude of force


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Biomechanics of Headgears:

C Res Moments


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Cervical Headgear Short face Class II

maxillary protrusive cases with low MPA & Deepbites

Extrusive & distalizing effect

Lower anterior facial height is less.


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High pull Headgear Produces intrusive &

Posterior direction of pull

Long face class II patients with high MPA

Force through C Res – Intrusion & distal movement of molar

6-8 months – class II-class I


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Straight pull headgear Class II Malocclusion with

no vertical problems Prevent anterior

migration of maxillary teeth, translate them posteriorly

Adv-effective, no reciprocal forces

Disadv- Patient compliancewww.indiandentalacademy.com

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Modification of the Bimetric arch

Class II correction- Distalization + expands

canine-premolar area- unlocks the occlusion

A mild-moderate class II div 2 with normal

mandibular arch-easily corrected


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Modification of the Bimetric archArchwire design: .016”premium wire Premolars bonded if

expansion is required

Teardrop shaped loop

Bite opening bend Mild toe-in 2mm activation


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Elastic load reduction principle: Class II elastics – used sequentially

T.P Green – 1st week

Pink - 2nd week

Yellow – next 2-3 weeks Initial heavy force- to resist forward

pushing force of new wire- force transferred distally

Later Molar uprights-mesially directed archwire force decreases- support with light forces.

Extrusive component of class II- kept to a minimum

1mm/month.wire activated for 3 visits.

Borderline cases –Non Ext


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K-Loop molar distalizing appliance Valrun Kalra – JCO 1995

K-loop – forces - .017 x .025 TMA Nance button – anchorage 8mm long , 1.5 mm wide Legs- 20 degree bend Inserted into molar and first

premolar tube, marked Stops bent 1mm distal , 1mm

mesial Stops- 1.5mm long


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Reactivated by 2mm 6-8 weeks later. molars move by 4mm, premolars by 1mm Anchorage can be reinforced by headgear


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K- loop Appliance


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Distalization of Molars with Repelling Magnets Gianelley etal JCO 1988

Anchorage – Modified Nance appliance

Wire extending from 1st premolars

Acrylic button anteriorly contacting the incisors

Auxiliary wire with a loop at its end soldered - premolars bands


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Distalization of Molars with Repelling Magnets

Incisor brackets – passive sectional wire- maintain incisor alignment

Repelling surfaces of magnets brought into contact by passing an .014 ligature through the loop, then tying back a washer anterior to the magnets

Force- 200-225 gms , dropped as space opened

3mm in 7 weeks Anchor loss – 1mm www.indiandentalacademy.co

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Molar distalization with Superelastic NiTi wire Gianelly JCO 1992

100gm Neosentalloy upper archwire

3 markings Stops crimped, hook added Insert wire such that posterior

stop abuts mesial end of molar tube, anterior stop abuts distal of premolar.Xs wire deflected gi

Anchorage reinforced by class II, or Nance appliance

100gwww.indiandentalacademy.com

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Molar distalization with Superelastic NiTi wire

Case report : 12 yr / F Unilateral class II Class II elastic against

upper 1st premolar Overcorrected- 4 months


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NiTi Double Loop system for simultaneous distalization of first and second molars

Giancotti JCO 1998

Mandibular molars and 2nd premolars banded, other teeth bonded

Lip bumper- prevent extrusion Maxillary molars and bicuspids –

banded, aligned 80 gm Neosentalloy – maxillary

archwire placed – marked

1. Distal to 1st premolar

2. 5mm distal to 1st molar tube Stops crimped on markings


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2 Sectional NiTi archwires – crimp stops

1. Mesial and distal to 2nd premolar

2. 5mm distal to 2nd molar tube

Uprighting springs on 1st bicuspids

Class II elastics Simultaneous, bodily

movement www.indiandentalacademy.com

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24yr/f, class II div I

5months- overcorrectedwww.indiandentalacademy.co

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Useful technique – Class II div I

Minimal patient co-operation

Ideal for simultaneous distalization U7 easier ‘.’ anatomy.

Due to stretching of transeptal fibers, 1st molars can be distalized using

lighter 80 gm force

Anchorage easily controlled , without need for TPA/Nance’.’light forces


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NiTi Open Coil Springs

Dia 0.012”

Lumen 0.030


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Pendulum Appliance for class II non- compliance therapy

JAMES J.HILGERS,JCO 1992

Nance button for anchorage

.032” sTMA springs-light continuous forces

Broad swinging arc (Pendulum) of force from midline of palate to upper molars


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Pendulum Appliance

Fabrication :Pendulum

springs consist Recurved molar insertion

wire1. Horizontal adjustment

loop2. Closed helix3. Loop for retention in

acrylic button Springs- close to center

of Nance buttonwww.indiandentalacademy.co

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Springs close to center of palatal button:to maxi range

of action, easy insertion.

Retaining wire is soldered to the U4 and extended into

acrylic.


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Pendulum Appliance Nance button- extend to about 5mm

from teeth Anterior retention loops fixed on

model, later soldered to bicuspid bands

Acrylic pressed against the palatal vault

Pendulum springs inserted


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Pendulum Appliance

Pend-XExpansion needed:Jack-screw-One-quarter turn

every 3 days


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Pre activation and placement

After cementation,before activation:

Springs prefabricated to lie parallel to midsagittal plane,

Which produces 60* of activation after insertion.

As the molar distalizes it moves on an arc towards midline-counteracted by opening horizontal loop


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Intra oral reactivation:

Center of helix held with bird beak plier while, spring is pushed distally & reinsert.

Stabilization:•Nance button

•Upper utility arch- anterior segment- anchorage.

•Full arch bonding:continuous wire with omega loop.

•Head gears ?www.indiandentalacademy.co

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Pendulum Appliance Unilateral correction


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Pendulum ApplianceConclusion : Excellent patient tolerance Upto 5mm distalization in 4 months Distalization + Expansion Patient compliance not needed


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Franzulum applianceFriedrich Byloff et al JCO2000

sep Anterior anchorage : acrylic

button-5mm wide

Rests on canine and premolars - .032”S.Steel wire

Tube from acrylic button to receive active component

NiTi coil springs-100-200g/side

J-shaped wire inserted into tube


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Franzulum appliance:

Niti spring over J shaped wire

Inserted into tube of anterior anchorage unit

Tied into lingual sheath

•Anchor unit bonded with composite.

•Close to CR of molar-pure bodily movement.

compressedwww.indiandentalacademy.com

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Case report 11yrs 10mts / M

end on molar relationship Space deficiency in both the

arches Premolars blocked out Fixed appliance with cervical

headgear and Cl II elastics End of treatment; Class I molar

relation, no significant change in facial profile

U6:3mm,L6:6mm Lower incisors proclined. Extrusion of U&L 6

Long term stability????www.indiandentalacademy.co

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Distal jet Appliance Aldo Carano, Mauro Testa JCO 1996

Lingual molar distalizing appliance

Appliance design : Wire extending from acrylic

through tube ends in a bayonet bend-inserted into lingual sheath

Coil spring clamped on tube Clamp Anchor wire to 2nd premolar

.036” int dia


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Distal jet Appliance

Reactivation- sliding clamp

closer to first molar,once a

month.

After distalization –

- clamp-spring assembly-

acrylic,

- premolar arms cut off.www.indiandentalacademy.co

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Distal jet ApplianceCase report 18/F, Class II div I No skeletal abnormalities Non-extraction therapy (3rd

molars removed) Distal jet 4 months- Class I ,2mm-L, 3mm-R


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Distal jet ApplianceAdvantages : Bodily movement Easy insertion Well tolerated Esthetic Unilateral, Bilateral Permits simultaneous use of full bonded

appliances.


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Open Coil JigJones, White –JCO 1992

Oct

NiTi springs 70-75g

Nance button attached to U5

Assembly tied in place


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1. Heavy round wire

2. Light wire

3. Fixed Sheath

4. Hook

5. Sliding Sheath

6. Open coil spring

4-5mm of distal movement.

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1

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5 6 4

Open Coil Jig


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Conclusion Borderline cases Space gaining procedures Simplicity Clinical effectiveness Patient compliance factor


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Distraction Osteogenesis: New bone formation b/w the surfaces of bone

segments gradually separated by incremental traction.

Tension-stimulates new bone parallel to vector of distraction.

tension in surrounding soft tissues, initiating a sequence of adaptive changes termed as distraction histogenesis.

Skin, fascia, bl vessels, nerves, muscles, cartilage, periosteum.

Illizarov.www.indiandentalacademy.co

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Mandibular Sympyseal distraction.

Mandibular symphyseal distraction- space gaining. Intra oral mandibular distraction device. More stable results. Corticotomy. Latent period.5-7days.(fibro vascular bridge) Activation.optimum rate: 1mm/day(0.5mm-premature

ossification,2mm-fibrous CT , ischemia) Consolidation (remodeling) concomitant soft tissue

expansion. Retention.


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methods of gaining space 1. / orthodontic courses by indian dental academy

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