This is a continuation of the previous lecture “Interceptive orthodontics “ Please refer to the slides while reading the script

Crowding:

As you know is the space against the leeway space.

How can we gain space?
1- Space management 2- Serial extraction 3- 1st molar extraction 4- 2nd molar extraction 5 - Premolar extraction 6- Lower incisal extraction 7- Molar slicetion
* Leeway space: Is the difference between the mesio-distal width of C, D,E & 3,4,5

1- Space management:
- Utilization of leeway space to relieve anterior crowding Since the primary teeth are larger than the permanent teeth eventually we’ll get space, this space is used to relive anterior crowding, to hold the space we use space maintainer. The most common space maintainer we use is (LLHA) = lower lingual holding arch.

*Indications for space maintainers:
1- When molar relationship is class 1, can use leeway space to change it to class 2 molar relationship,
Why?

- Because the Upper molars already protruded or the Lower molars retruded (not really retruded but if you remember from development of normal occlusion, changing into class 1 molar relationship means : 1- Mesial movement of lower molar into the primate space which is distal of lower canine. 2- Utilization of Leeway space is larger in lower arch than the upper.
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3- Differential mandibular growth... mandible grows faster than the maxilla at that age. *(remember always this is interceptive treatment)* - These are still present in the crowded side.
How come you want to use leeway space if the Es are extracted or incisally space loss and of course mild crowding (the amount of leeway space is sufficient for minimal crowding but moderate posterior crowding you need something less.

Space maintainer -extract the Es Or Slice the mesial surface of primary canines and molars before eruption of permanent canine and premolars -to solve Anterior crowding so if you slice the mesial surface of the canine first and allowing the laterals to move slightly distally, once the space is closed then you slice the mesial surface of D around the anteriors will move a little bit distally and so on Or you extract the Es and put (LLAH) as space maintainer will the hold those spaces in their place.

2- Serial extractions: “time extraction “
1- We start with Primary canine & primary 1st molar allowing the canine to erupt in the 4th space, so you need to wait until the 4s erupt and then you extract them. Serial extraction is composed of extraction of 12 teeth (Cs, Ds, and 4ths). *we don’t do serial extraction anymore because of: 1- Why to put the kid in experience of 12 teeth extractions. (If eventually I want to extract the 4s “1st premolars”, why not to wait till the permanent dentition to erupt & then start extraction) 2- The drawbacks of serial extraction is in maxilla the 1st premolar erupt before canine but opposite in the mandible canine before 1st premolar. So, it might be successful in the maxilla but in mandible. Very little Recognition of the sequence that will occur unless they move in interval / sequence to leave the intensity of the developing malocclusion.

- Indications for serial extraction:
1- Incisal substation crowding (if we don’t have crowding, we usually eventually extract the 4s which is a permanent tooth, we start with canine before the eruption of the permanent canines and 4s).
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2- Normal arch relationship should be class1 because if it’s class2 for example we need to extract the upper but not the lower or if class3 we need to extract the lower but not the upper.

3- Reduced overbite or normal because extraction in general deepens the bite, if overbite at the beginning is deep, the serial extraction will make overbite deeper than before. 4- All permanent teeth are present and in good position before doing serial extraction

For example if we started the serial extraction and the lower 5 is congenitally missing – it will be canine molar contact.

5- 1st molars should have good prognosis because it’s the first tooth to erupt so if the patient have bad oral hygiene so it will be highly susceptible to caries, otherwise we can extract the 1st molar instead of serial extractions. (One of the interceptive treatment is extraction of 1st molar).

6- First premolar should be close to eruption than canines so it can be right in maxilla but in mandible is problematic Premolar (4s) should erupt before canine, we can’t extract the 4s while the canine still unerupting because it will erupt in the canine position, so crowding will be severe anterior.

- Disadvantages:
1- Lingual tipping of lower incisors.

2- Deepening of the bite.

3- Retarding Future development in the arch.

4- Lack of aesthetics & phonetics of the lip (if you extract the 4s, fallness of the lip).
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5- Rotating incisors do not apply for a muscle ….we are talking about crowding not fixed appliance (Rotation =Fixed appliance) ** Serial extractions, when laterals are erupting in a crowded position, then all deciduous canine extract **All first deciduous molar are extracted when the first premolar roots are about half formed in order to not give time for space loss by (E and 6), so when do you think the tooth start to erupt Ds? When roots of 4s are about 2/3 formed. As soon as the premolars erupts are extracted.

3 - 1st molar extraction: is
interceptive treatment)

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In the upper arch, if we extract the 1st molar while the 2nd molar still in the bone /arch, sometimes seeing full closure in the arch BUT In the lower arch sometimes we can’t see full closure in the arch so there will be spaces all around. ** Poor prognosis of the 1st molar sometimes is indicated for extraction, When? Answer: if the upper 1st molar is decayed (a carious tooth) and we extracted it so no need to extract the lower 1st molar, WHY? When the 7th erupts it erupts within the bone first which means it erupts mesial inside the bone & when the lower residual space the upper 7 erupts. While in the lower the 7 erupts then infra-eruption of the upper, it prevents the mesial drifting BUT if the caries was in the lower 1st molar and we extracted it, then we have to extract the upper 1st molar, WHY? Simply because of the supra-eruption of the upper 1st molar.

Indications for 1st molar extraction:
1- The 1st molars are poor prognosis. ((At least/ no need to replace)). 2- Crowding in the erupting quadrant. ((If we don’t have crowding why should extract, this is interceptive treatment)).

3- Development of 2nd molar roots didn’t reach more than half-way. ((the roots of the 7th still erupting not reaching their half-way , if it’s more than half-way, which means it’ll soon will erupt & it’ll close the space)). 4- No any missing teeth.

5- Normal Arch relationship = class1.
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6- Overbite not deep because the extraction deepen the bite. 7- The 2nd premolar is contained within the roots of the E’s. ((The 5 should already been erupted/present within the arch)), WHY? Because it will prevent from (mesial drifting/ moving foreword of the 7 & closure of the 2nd premolar space). 8- Gives more space for the 3rd molar eruption.

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- Disadvantages:
1- Uncertainty of the time of contact of the 7 &5 together. ---- We can’t guaranty that the 5 & the 7 will come in contact together (touch each other) there’re residual space & extraction space which may need later on fixed orthodontic appliance. To close the space lift between the 5&7, avoid future treatment (minimize future malocclusion). 2- Good contact point between 5&7 will give buccal segment crowding according to studies. 3- Having 3rd molars, WHY? Because they will push mesially. (It’s better if we extracted it earlier, if late spontaneous space closure is less.

If we extract the lower there’ll be supra-eruption of the upper which prevents the lower 7th from moving forward (interference).

Compensatory extraction: extraction within different arches. (For example: if you extract the lower RT 6 you need to extract the upper RT 6)
** NEW RULE** As we mentioned previously if we extract the lower we have to extract the upper BUT if we extract the upper no need to extract the lower.

Balancing extraction: extraction within the same arch. ( for example : if you extract the lower 6 you need to extract the contralateral 6 BUT if C you can extract the contra-lateral c “ because it’s more close to the midline” , D maybe but the 6s are a little bit far) this is not used anymore.
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***** By this we end our last lecture in the 1st semester & now we’ll start the 1st topic in the 2nd semester.
Please refer to the slides while reading the script

Removable orthodontic Appliance
Definition:

It’s an appliance that can be removed and inserted by the patient to give simple tooth movement and correct simple malocclusion where teeth can be tipped by a fulcrum in the middle of the root (Tipping movement = rotation around centre of movement).
- Labio-lingual tipping will give mesio-distal tipping. Consist of:1- Acrylic baseplate. 2- Expansion screws.

- The design of any removable appliance should consist of 4 things:

A
Active

R
retentive

A

B
baseplate

anchorage

1) – Active component: pressure source – used to desire movement. 2) – Anchorage: used to spread the force, it eliminates the unwanted tooth movement. 3) – Retentive source: To hold the appliance in the patient’s mouth. (Usually, more likely in the form of a clasp). 4) – Baseplate: To hold all the component together.

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1) – Active component:
Pressure source could be: A- Strength/ spring B- Labial bow fewest problem) C- Screw D- Elastics (made of stainless steel wire Co-Cr 18-8%) (like Robert’s retractor, palatal spring give the (Maxillary expansion) (used only in well-defined
(should be used only with head gears)

circumstances because of their expense and bulk)

-----------------------------------------------------------------------------A- Strength: - Made of stainless steel wire Co-Cr. - (18-8) % = 18% Cr & 8% Ni. - Elasticity -- Because of elasticity we can bend wires but I eliminate this elasticity by activation of the wire. - Malleability. - Tasteless. (If tasty no one can tolerate it) - Corrosion. ‫الصدأ‬ (Cr forms a layer chromium oxide on the surface layer which eliminates corrosion) That’s why is was named STAINLESS STEEL = doesn’t corrode.
Malleability: ‫التطرق‬
It is the ability of a solid to bend or be hammered into other shapes without breaking. Examples of malleable metals are gold, iron, aluminium, copper (to a degree ) and lead. Wikipedia

- The property of a metal to be deformed by compression

Elasticity:
Is the tendency of solid materials to return to their original shape after being deformed. ** Wikipedia - Within the range of elasticity but if we bend more than that range, we’re beyond elasticity = permanent deformation.

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Deflection
Scientifically the connection between the length, the thickness & the amount of deflection of a cantilever spring of a round section is influenced by the force - Cantilever spring (bridge): is connected from one side and free from the other side. - Most of the components of removable orthodontic appliance is a cantilever spring because one side is attached to the acryl and the other side is attached on the tooth. - The force (Pressure) that I can get from a cantilever spring is guided by the thickness = gauge of the wire (0.5, 0.6, and 0.7), the Length of the wire, the material of the wire and the amount of deflection (‫ = )كم بنثني‬range of binding.

(Slides)
D P L T
- Deflection

Deflection Pressure Length Thickness of the wire (diameter) is proportionate to the pressure and length.

E – modulus of elasticity F – force of given deflection - length r – radius

- Deflection is inversely proportionate to the thickness of the wire. Long wire gives you higher force than short wire - If we increase the diameter, the pressure will increase. - If the deflection increases the pressure will increase. - So according to this formula, the deflection of a cantilever spring will be doubled if we double the pressure, will increase by 8 times if the length was doubled and will increase 3 times if the thickness was reduced to the half. - The reason why incorporate loops, Coils for adjustment, increase the length, effectiveness, reduce their deflection and pressure. - Coils should be 2.5 mm in diameter, why not more or less than 2.5mm? - In order to control the attachment point of spring in the Acryl.

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- Location of the Coil: Sometimes for example in the buccal canine retractor or palatal linear spring the active point can be straight or curved because we’re controlled by the direction of the tooth movement which should be almost perpendicular to the Tangent of my force. The doctor showed a picture: - In which the tooth will move distally also buccally and he did a curve to change the Tangent (‫)المماس‬. Still with contact point the tooth will move distally and within the line of the Arch. From the point of contact, with a tooth contacted by a spring at a single point, it will move in the direction of the resultant force which is perpendicular to the Tangent at the point of the contact with tooth. - So you need to adjust the contact point between the Active component and the tooth to make sure that the tooth will move within the line in the arch.

Tooth movement = Tipping movement.

2-Anchorage Component
We don’t have something specific for anchorage component in removable orthodontic appliance, so the other component can act as Anchorage component like for example:

1- Base plate is a connecting component but (act also as retentive component) 2- Adam’s Clasp.

Robert’s Retractor – retract the proclined upper incisors.

The direction of desired tooth (wanted) movement is Retro-clination. Anchorage Loss = Unwanted tooth movement (reactionary Force) =movement of molars foreword, for example: If we have spacing anteriorly and we minimize this space by retraction of upper incisors back, there is force of unwanted tooth movement (movement of molars and premolars foreword) we call it Anchorage Loss if they moved.
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The Adam’s clasps on the 6s on each side and attached to the baseplate can act as Anchorage component. 3-Retentive component Used for retention, to hold the appliance in its place and it has to be distributed anteriorly and posteriorly because of the fulcrum of movement (rotation) like in RPD (will provide retention both posteriorly & anteriorly) to prevent rocking or tipping of the appliance like:-

1 - Labial Bow (ant)

2 – Clasps (post, ant) – can act as retentive and as anchorage component.

4- Baseplate:
Connect all the component together

(Removable) appliance 1- Types of movement 2- Advantage Tipping 1- Easy to wear 2- Good maintenance. 3- More aesthetic. 4- Cheaper. 5- easy to adjust. 1- Not useful for all type of tooth movement 2-Needs patient’s cooperation 3- Less retentive in lower arch. (encroach on the tongue space)

(fixed) Appliance All types of movement 1- Useful for all types of tooth movement 2- Offer better control over anchorage. 1- OH is difficult 2- More-time consuming 3- Require special training of the operator

3- Disadvantages

Done by: Rawan Yousef Makahleh
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