This script includes all the information that was mentioned in the slides, the pictures are from

other sources than the slide as no soft copy is available.

Fixed Appliances
Today we will talk about fixed appliances, last time we talked about removable appliances, now before starting discussion, let's know the benefits and risks of these appliances.

Fixed appliances benefits and risks

So, what do you think the benefits for orthodontics treatment for the patient? Improving esthetics and appearance of patient: it is a psychological effect. According to studies, 60% of children teased about their teeth were upset by this. So, improving the teeth appearance will improve their psychological, self esteem and self confidence. Second benefit is dental health: now, in theory; well-aligned teeth are easier to clean (it's easier to brush teeth when they're well aligned).

So, malalignment of teeth will make it difficult to brush, and more susceptibility to dental caries and periodontal problems. But, is it true in reality according to studies? NO! Because tee th brushing and oral hygiene depends on patients attitude towards oral hygiene, many patients are with well aligned teeth but with very poor oral hygiene, and many patients with malaligned teeth but with good oral hygiene. So, in theory, well aligned teeth will be easier to clean, but very little evidence showed that well aligned teeth will suffer less pathology. Now what are the risks on the other hand? Decalcification/demine ralization which is the earliest stage of dental caries, and then they may develop caries. As a result of excess tooth movement or heavy forces to the tooth from appliances, they may get root resorption. If you move teeth outside of neutral zone, you may get periodontal problem by gingival recession. Also, any orthodontic movement is susceptible to relapse. If the patient doesnt wear retainers. That is why we ask our patient to wear retainers to prevent relapse. Also it may interfere with medical problems , if the patient has very serious medical problem unless it is under control and the patient is aware of it.

This is decalcification (whiting or white spot lesions) after wearing orthodontic appliances; in severe cases it may develop cavitations which is caries. It is around the bracket.

Definition of fixed appliance

It is appliance that fixed to the teeth and cannot be removed by the patient . So, compared to removable appliance, the patient can take appliances out, and put it back again, while fixed appliances is bonded to the teeth and cannot be removed by the patient.

Mode of action
Now, what is the mode of action? In case of removable appliances, when you give single forces through the active component, you will get tipping movement. But in case of fixed appliances, you give mechanical forces couple to crown which can achieve bodily movement, (Couple it means 2 points not single point), so it's not single contact (which results in tipping). In conjunction with single force it can achieve rotation, apical and bodily move ment.

Reasons of fixed appliance

Why do we use fixed appliance? Precision: If you need accurate tooth positioning, you need fixed appliance, removable appliance can't achieve perfect alignment, if you need perfection then you need to use fix appliance. Correction of rotation: If there is very severe rotation, like 90 degrees rotation, you need fixed appliances. Multiple tooth movement :. So, if patient have multiple tooth problem, you need multiple tooth movement. Full range of tooth movements : you need to move the tooth body.

Inability to re move the appliance : if the patient is incomplainant and every time you give him a removable appliance, the patient doesnt wear it, you can use fixed so the patient can't remove it. Essential in lowe r arch: because it inconvenient to use removable appliances in the lower arch because of the tongue, it will cause discomfort and it won't be as retentive as in the upper arch.

Indications of fixed appliances

Tooth movement that is not possible with re movable appliances; which only can make tipping of teeth, so if you need other movement (rotate, torque, bodily movement) you need fixed appliances. If you need to close a space, you need to move the crown as well as the root , when you use removable appliance, you make tipping of teeth which means you move the crown to one side but the root is moving to the other side, if you want to move them parallel, you need fixed appliance. Multiple tooth movement is required. Overbite reduction by intrusion of incisors : remember when we talked about anterior bite plane? So removable appliance can achieve overbite reduction however mainly by overeruption of posterior teeth. But, if you want to reduce overbite by intrusion of incisors, because the patient has gummy smile for example, you'll need fixed appliance.

Instructions to the patient

Maintain high level of oral hygiene otherwise the patient will get decalcification, caries and depressed dental health such as gingival recession. Avoid hard or sticky food because hard food will result in breakage of fixed appliance. Avoid consumption of sugar containing food between meals to prevent caries. Coope rate fully with wearing headgear or elastic traction if required: if you asked the patient to wear head gear for anchorage control and stabilization he must cooperate, otherwise he'll need to do extraction. Attend regularly to have the appliance adjusted.

Components of fixed appliances

Bands : which is cemented on molar teeth and made of stainless steel.

Brackets : which is bonded on labial and buccal surface of teeth, but nowadays there is lingual brackets. Bracket material could be stainless steel, plastic or ceramic.

base

tie-wings

slot (Ceramic and plastic are esthetic brackets because they are tooth colored). Archwire : to move teeth, in orthodontics there are many types, but mainly we use nickel titanium and stainless steel, in the past we used to use gold archwires.

- Auxiliaries : anything that you use to hold archwire, apply force, open spaces or whatever. The material is ligatures or elastics.

The Archwire moves the teeth and the brackets tell (guide) the archwire where the teeth must move. So the arch wire will be in brackets' slot, when the Archwire is deflected it will try to go back to its original position (because it's elastic), so it will move the teeth with it until the wire is fixed in the bracket slots then the archwire will stop moving the teeth.

Brackets:
It is rectangular in shape, thats why it is a couple force applications, it has three components: Horizontal slot (bracket slot) : where the archwire fits. Tie-wings : gingival and occlusal, to which ligature ties are attached to hold the Archwire in place. Bracket base : bonded on the labial surface. It should be rough/mesh type for mechanical retention with the composite resin; you bond these bases to enamel.

Brackets material can be stainless steel, plastic, ceramic or titanium, gold, Co-Cr but usually it's made of stainless steel.

Plastic bracket tend to stain and distort during treatment. That's why nowadays we don't use plastic bracket. Ceramic bracket usually don't stain but have other disadvantages: Brittle and easily fracture especially the tie wings. Extre mely hard and can cause wear of opposing enamel : If you bond the lower teeth with ceramic brackets and they bite on the palatal surfaces of upper incisors they don't break, they'll cause wear of the opposing enamel (abrasion). Increased risk of enamel damage at debonding (taking off the braces) because of high bond strength between ceramic and enamel (it's higher than bonding between metal and enamel). Increased friction: when the tooth moves there will be friction between the archwire and the slot of the bracket, so if there is high friction tooth movement will be slow, the friction with ceramic is higher than with stainless steel, to overcome this problem they made the bracket from ceramic but the slot from metal (e.g. Clarity), still this technique has a disadvantage because the junction between the metal and the ceramic is weak, so it can be easily broken. More expensive than metal brackets.

Sometimes, there is patient with smile zone only shows upper anterior teeth, and they request esthetics brackets, despite the disadvantages of ceramic, you may use them only for the upper anterior teeth and the rest you'll use metal brackets as a combination of both, or we can use ceramic brackets for all teeth, except if we have deep bite, then we can't use ceramic brackets on the lower incisors because the touch the palatal surface of the upper incisors and this will cause tooth wear.

Types of brackets by location:

Buccal fixed

palatal fixed

Buccal fixed appliances : most common, advantages of buccal type are: Good access for the orthodontist to work and good access for the patient to clean. Ease of work and reduced working time.

Excellent finishing and detailing because we can see the buccal and the labial surface directly but for palatal and lingual surface it's difficult to see directly.

The disadvantages are poor esthetics , because it's on the labial side, and if there is caries or decalcification it will be visible . Lingual fixed appliances : advantages of lingual types are good esthetics and if decalcifications develop it will not be visible . Other benefit is good bite opening, when you put bracket on palatal surface, the lower incisors will occlude on the brackets, so it will act as anterior bite plane. So, it's good for bite opening.

Disadvantages are poor access, difficulty in working, reduced interbracket span (it's a disadvantage because the length of the wire will be reduced so there will be less flexibility), increased working time, patient discomfort (the tongue may be traumatized so there will be pain and ulcerations) and poor finishing and detailing.

Types of brackets by fixed appliance techniques:

1- Standard edge wise : developed by Edward angle in 1928.

Slot orientation is horizontal. Slot dimension is 0.022x0.028 to allow control of tooth position in 3 plane spaces. Same bracket or band is applied to every tooth that is why it's called "standard" edgewise. They used to use bands on every tooth in the past, but when we started to use bracket without bands? When composite developed.

Precise control of tooth position and angulations is achieved by placing bends into Archwire . Advantages: the first appliance to allow precise control of tooth position to be achieved relatively simply. Edward angle is the father of orthodontics; he is the first person to be professionally work with orthodontic movement; however Arab talked about orthodontic tooth movement long time before him.

Disadvantages : Tooth position is dependent on operator's skills to place bends in Archwire , so if you want the canine to have eminence or the incisors to be slightly mesially tipped, you have to achieve this with wire bending, if you have skill to bend the wire, you'll be a good orthodontist, otherwise you'll be a bad one. Wire bending is time consuming in the clinic.

2- Begg appliance :

Described by P.R Begg in 1956: this system tips the teeth first then upright them. Base on the use of light forces and tipping teeth. For example if you extracted U4 and you want to move the canine distally (bodily movement), in standard and pre-ajdusted systems you can move it directly, but in Begg you tip the canine distally first (tilt tooth) then move the root to upright the tooth. Bracket has vertical slot in which Archwire is secured with brass pins. Reduced friction in this system because we use tipping movement.

3- Pre-adjusted edge wise:

Philosophy based on ideal bracket system and ideal force delive ry system (sliding mechanics). Slot size: 0.018x0.028 (working archwire is 0.016x0.022) or 0.022x0.028 (working archwire 0.019x0.025) (the standard was only 0.022x0.28). Prescription: pre-ajdusted is ready for every single tooth. Amount of tip, torque and inout is adjusted already in the bracket; amount of these things diffe rs from system to system. So, this is called prescription, a numbe r of prescriptions are available: Andre w's, Roth's, Alexander, Bennett and McLaughlin. Tip: is the position of the tooth mesio-distally (5 degree or 0 degree for example), in the slide it's called (correct crown angulation). Torque: is the position of the tooth labio- lingually, in the slide it's called (correct crown inclination). In-out: is the position of the tooth in and out (I think it means in the arch and out of it). Note: For tip and torque the Dr used the term "position", I think it's better to use the terms "angulation and inclination" respectively to understand the difference between the torque and the in-out (the in-out is the one which actually describes position, not inclination).

Origin of Straight-Wire (or the preajdusted): introduced in 1972 by Lawrence F Andrews. He defined 6 keys to normal occlusion:1. Molar relationship Class 1: In angle's classification the buccal cusp of U6 should bite in the buccal groove of L6, here it's the same but also the distal cusp of U6 should bite in the embrasure between the L6 and L7. 2. Correct crown angulation (tip). 3. Correct crown inclination (torque). 4. No rotations. 5. Tight interproximal contacts, no s paces. 6. Flat occlusal plane with curve of spee (almost flat).

Advantages (of preajdusted or straight wire): Less wire bending. You do nt need to precise bending the wire compared to Standard Edgewise which needs accurate, precise bending. Sliding mechanics allowe d: so the bracket and the tooth will slide along the wire. Good finis hing.

Disadvantages: Ignores biological variability of the forces, because the size is different between teeth. Now, you are using archwire for all the teeth. So, the same force will be applied to all teeth, Do you think small lateral incisor can receive same forces as big molars? NO, because root surface area of lateral incisor is less than molar. Increased friction hence anchorage consideration.

Previously they were using multi-stranded stainless steel, these days we use Ni-Ti archwires.

This is the different prescription for every single tooth, each one has different inclination, that's why every single tooth has its own bracket and each bracket has different prescription, to achieve different position for every tooth. 4- Tip-edge :

Has horizontal slot but it's cut from certain areas (triangle from each side) to allow the tooth tipping, so it combines the advantages of preajdusted and Begg appliances as Begg allows tipping, so in Tip-edge you tip the tooth first and then upright it, once it's upright Tip-edge is straight wire appliance again. 5- Self ligating :

How do we ligate the Archwire? In the conventional fixed appliance, we use elastics, so the elastic will keep the archwire touching the base of the bracket, and this produces friction, but in self ligating you don't need elastics because the bracket itself has a door to ligate the wire. The biggest advantage

of theses brackets is that the treatment time is reduced as the friction is eliminated or reduced. The friction like we talked about, when we bend the Archwire, the friction of Archwire to the slot is increased. So if this is a door, the friction will be decreased. There are many types of self- ligating like Damon, speed and 3m smart clip and others. The Damon bracket is self ligating, meaning it has a built in sliding door that secures the bracket to the wire, this allows the wire to slide through the braces freely (no friction).

Archwires
Now we will go to another component of fixed appliances which is the archwire. They are many type of archwire, but what we use in orthodontics mainly titanium and stainless steel, in the past they used to use gold and cobalt-chromium. There are two types of archwire: 1. Active: Archwire is deflected on tying in to the bracket so that the forces move the teeth. 2. Passive: Archwire is not deflected; the forces are applied by elastics or auxiliary spring. In above case, when the archwire is bended there is deflection, do you think this archwire will apply forces? YES! But when it's straight wire do you think it is active? NO! It is passive archwire to maintain the arch form from getting forces from other directions or something else other than archwire. So when it applies force, it is active, but when it doesnt apply forces, it is passive.

Elastic behavior of archwires

Now to understand how archwire apply force to teeth, you need to understand something called "elastic behavior" of the Archwire. Elasticity: the ability of the material to recover following the removal of an applied force . Elastic behavior is defined in terms of stress-strain response of any material. Stress: force per unit of area. So you apply the force on the object from outside, inside the object it will receive stress (because there will be force which is equal in amount and opposite in direction inside the material). Strain: deflection per unit of length. It's internal distortion produced by applied load. Conclusion: stress and strain are from internal; force and deflection are from external.

Force deflection curve

So, in force deflection curve or stress-strain cure, there are 3 major properties of Archwire material that are critical in defining their clinical usefulness: strength, springiness (elasticity, the inverse of stiffness) and range (how much can I bend it). Strength = stiffness x range

How stiff the wire is, and what is the range the wire can withstand by deflection before it distorts, these are governed by the proportional limit, yield strength and ultimate tensile strength So this graph represents stress (force) proportional to strain (deflection) :

Proportional limit: the point at which the wire starts to deform, the wire will react elastically until proportional limit is reached, where the wire will bend and elasticity doesn't apply. Yield strength: the point at which 0.1% deformation is measured. Ultimate tensile strength: maximum load that archwire can sustain before failure (fracture). Stiffness= 1/springiness . It's the opposite of springiness; springy wire means that its flexibility or elasticity is high, stiff wire means more solid wire. Each value is proportional to the slope of the elastic portion of the force defection curve. The more horizontal the slope the springier the wire. The more vertical the slope the stiffer the wire. Modulus of elasticity (slope). Slope represents the stiffness. Wire with increasing stiffness: NiTi<TMA<SS<Co-Cr (Co-Cr is the stiffest one), what is important to you that stainless steel is stiffer than nickel-titanium. TMA is Titanium molybdenum. Resilience surface area under the stress-strain curve until the proportional limit. It represents energy storage capacity of the wire which is a combination of strength and springiness. Formability: the surface area under the curve from yield strength to fracture point.

It's the amount of permanent deformation that the wire can withstand before breaking, I.e. deformation without breakage, so if you bend a formable wire it will not go back to it's original position.

Properties of an ideal archwire

High strength, good spring back, large range of action, high resilience, low stiffness, formable, joinable which means we can solder/weld it, low friction (so the sliding is better), biocompatible, low cost, superelasticity, shape memory and aesthetic . You have to understand just the properties that were explained. What is the most biocompatible material? It is Titanium molybdenum alloy (TMA)

Types of archwire material

Gold alloy, stainless steel, cobalt chromium, nickel titanium, titanium molybdenum alloy (TMA), composite plastics.

Esthetics Archwire
There are esthetic archwire; however we dont like to use them for many reasons These will be either: Coated metal wires : coated stainless steel or Niti. The coating can be a white epoxy resin or Teflon coating. This means the wire itself is metal but it is coated by white material for better esthetics. The disadvantage of metal coated archwire is that with time, it will be worn out and only metal is left without white epoxy resin and Teflon coating. Non-metallic materials: without metal, full composite plastics .

Auxiliaries
It is components other than archwire and bands/bracket. Elastomeric modules: round modules to hold the archwire in the bracket slot (it comes in different colors).

Ligature wire: it has the same function as elastomeric modules . Sometimes we prefer these because the elastomeric is elastic and will not make a 100% accurate movement

(torque, bodily movement, angulation or anything else) to the teeth, its gauge (the ligature wire) is (0.09 to 0.1).

Coil s pring: it is either open or closed. It's open if we want to open the space, and closed if we want to close the space, it's either stainless steel or nickel titanium.

Hooks: either crimpable (it's stretched and attached to the wire), or sliding (moves along the wire).

Elastomeric chain (powe r chain): to close the spaces . It can be spaced or non-spaced (in spaced there is increased distance between the circles, which can be short or long) it is related to the amount of forces that we need.

Non spaced Short spaced Long spaced

Inte rmaxillary elastics : Many of our patient wearing intermaxillary elastics between upper and lowe r teeth to correct the relationship between them. And it's called class II and class III depending on direction of tooth movement that you want. If you have class II canine and molar, and want to change into class I, you have to use class II elastics, from upper canine to lower molar, this elastic (class II) will move the upper anterior backward and lowe r posterior forward. Next, Class III elastic is from lower canine to upper molar this elastic (class III) will move the upper posterior forward and lowe r anterior backward.

Class II

Class III

It comes in different size; the force is dependent on the size that we chose, you have to measure the force with force gauge, to make sure, because sometimes when you get it from the company it's written that it gives 4.9 oz (which is around 140 g) but when you measure it, it may not be 140, so ideally you have to make sure before using it.

Stages of Fixed Appliances treatment

These are the stages from the moment of the beginning of the treatment to the moment of deboning: 1. Anchorage control : which is the prevention or resistance of the unwanted tooth movement; it's expressed as Newton's 3 rd low of motion "every action has and equal and opposite reaction", so in orthodontic treatment when a wire moves a tooth in one direction there is an unwanted equal force in the opposite direction. There is anchorage demanding and non-anchorage demanding. For example if you extracted the U4 what is the anchorage loss that will happen? Movement of posterior teeth forward to the extraction space, so you need to assess do you need the whole amount of the extraction space for the anterior teeth? If yes then you need maximum anchorage, what can we use to reinforce anchorage? Trans-Palatal Arch TPA or Nance appliance for intraoral and Head gear for extraoral (when intraoral is insufficient). Headgear should be worn for 10 hr/day for anchorage and for 12-14 hr/day traction (when distal movement is required).

Transpalatal arch

Nance appliance

headgear

2. Leveling and aligning : Bracket heights leveled, up righting, rotational correction, labiolingual movement. 3. Overbite control : if it is increased, you need to reduce it. If it is reduced, you need to CONTROL it. We control the overbite before the overjet because sometimes we can't modify the overjet until we open the bite, overbite reduction can be done either by extrusion of buccal segment teeth or by intrusion of incisor teeth. 4. Overjet reduction: by using elastomeric chain or coil spring. It will move the upper anterior teeth back and also it will move the molar forward, unless you hold the molar by using anchorage device. This coil spring is located from anterior to posterior; it can move molar forward and anterior teeth backward. If I need the space and I cannot afford for any 1 mm movement of molar forward, you need to hold the molars by using head gear for example or any anchorage device (normal overjet ~ 3 mm) 5. Space closure: achieved by bodily movement, if there are any residual spaces you have to close them.

6. Finishing: If there is any minor details to be adjusted; you need to finish it, like the canine relationship and the molar relationship, after this you debonded the appliance. 7. Retention: after debonding, if there is no retention there will be relapse.

Features of fixed appliance

More complex: require specialist More time-cons uming. Demand excellent oral hygiene. Require well motivated patient. More expensive. Less effect on speech than re movable (because there is no acryl).

Disadvantages of fixed appliance

Requires more time. Repairs are more time-consuming. Non esthetics, sometimes it's esthetic, like ceramic or if it's from the lingual side . When damaged can cause discomfort. Need excellent oral hygiene.

THE END
This script is dedicated to my partner M.Husam Droubi, Prince of moisture control.

Done by: Ammar Aldawoodyeh