Alignment and Leveling PDF

Section 6
Comprehensive Orthodontic
Treatment In The Early Permanent
Dentition
SARANG SURESH HOTCHANDANI
Introduction Comprehensive
Orthodontic Treatment
• Definition; It is process in which patient’s occlusion is made as ideal
as possible by repositioning all or nearly all teeth.
• Ideal time for Comprehensive Orthodontic Treatment; (When to

Perform Comprehensive Orthodontic Treatment)
• Adolescence – when permanent teeth just erupted.
• Some vertical & antero posterior growth of the jaw remains.
• Social adjustment to orthodontic treatment is no great problem
SARANG SURESH HOTCHANDANI 2

Introduction Comprehensive
Orthodontic Treatment
• During comprehensive treatment complete fixed appliance consists
of brackets is used.
• Comprehensive orthodontic treatment consists of following 4

stages; - this concept was given by Raymond Begg
• Alignment & Levelling
• Correction of Molar Relationship & Space Closure
• Finishing
• Retention

Alignment &
Levelling
(Chapter 14) 1st Stage of Comprehensive Treatment

Goals of 1st Stage of Treatment
• The goal of 1st phase of comprehensive treatment is to bring teeth
into alignment & correct vertical discrepancy by levelling out arches.
• PROPER ALIGNMENT OF TEETH CAN BE ACHIEVED BY;

• Bring malposed teeth into arch
• Control the antero posterior position of incisors, width of arches posteriorly,
form of dental arches.

Goals of 1st Stage of Treatment
• LEVELLING OF ARCHES • Excessive overbite results from;
CAN OCCUR BY; • Excessive curve of spee in lower
arch.
• Elongation of posterior • Absent or reverse curve of spee in
teeth upper arch.
• Intrusion of incisors
• Combination of two. • Anterior open bite results from;
• Excessive curve of spee in upper
arch
• Little or no curve of spee in lower
arch

Alignment

PRINCIPLES IN THE CHOICE OF
ALIGNMENT ARCHES
•During alignment phase, only

combination of labio – lingual & mesio
– distal tipping of teeth is needed.
• Root movement during alignment phase is not needed.
(Reason mentioned in notes)

Principles in the Choice of
Alignment Arches
Continuous force of 50g needed for alignment
2 – 4 mil of space b/w archwire & bracket slot for tipping
Round NiTi wire for alignment are preferred
Springier Wire for Symmetric Crowding
• Rigid wire with auxiliary wire for Asymmetric Crowding

ALIGNMENT ARCHES
• There should be 2 – 4 mil of space
• Archwires in alignment b/w archwire & bracket.
phase should provide • 14 – 16 mil wire will be placed in 18 mil
bracket. OR
continuous force of • 16 – 18 mil wire will be placed in 22 mil
approx. 50 gm for bracket.
tipping.
• Avoid heavy force during • The reason of creating space b/w bracket &
archwire is that archwire should be able to
alignment phase move freely during tipping for alignment.

ALIGNMENT ARCHES
• Always use ROUND NiTi for
alignment phase.
• Why Rectangular NiTi wires are not
Used during Alignment?
• Tight fit in bracket cause resistance to
sliding.
• Produces back & forth movement
of root apices during alignment.
• Increases root resorption A. Round Wire
B. Rectangular Wire
• Slow the alignment process

ALIGNMENT ARCHES
• Springier wire will be used for alignment of Symmetric Crowding.
• Symmetric Crowding; degree of crowding is similar on two sides of arch.
• While in asymmetric crowding, springier wire will distort the arch form
during alignment.
• Asymmetric Crowding; all or nearly all crowding on one side of arch. e.g. impacted
canine, single displaced tooth.
• Here in this condition Rigid archwire will be needed on normal side & to prevent the
distortion of arch form while springy archwire is needed for crowding side.

Use of an auxiliary super elastic wire
for incisor alignment in a patient with
asymmetric crowding.
A. Crowding expressed largely as
displacement of one lower lateral
incisor in an adult with periodontal
bone loss for whom light force was
particularly important.
B and C, After space was opened for

the right lateral incisor, a super elastic
wire segment tied beneath the
brackets was used to bring the lateral
incisor into position, while arch form
was maintained by a heavier archwire
in the bracket slots.
D. Alignment completed. This

approach allows use of optimal force
on the tooth to be moved and
distributes the reaction force over the
rest of the teeth in the arch
PROPERTIES OF
ALIGNMENT ARCHWIRES
• Wire for initial alignment phase
should have;
• High strength •Ideal archwire material
• High springiness for INITIAL ALIGNMENT
• High range
• Deliver about 50gm of is A – NiTi wire
force

ALIGNMENT OF SYMMETRIC
CROWDING
• Super elastic NiTi is ideal for initial
alignment in symmetric crowding.
• Alignment requires opening space for
teeth that are crowded in the arch.
• Spaces can be created with following 2
ways
• Folded stops
• Hold the archwire slightly advanced
relative to crowded incisors
• Compressed Coil Springs

Compressed Coil Spring

Travelling of
Archwire
• One problem with super elastic wires for
initial alignment is their tendency to
“travel” so that the wire slips around to
one side, protruding distally from the
molar tube on one side and slipping out of
the tube on the other.
• The most effective way to prevent travel is to

• tightly crimp a split tube segment onto the wire
between two adjacent brackets.
• The location of the crimped stop, here between the left
central and lateral incisors, is not critical.
• dimple in the midline to prevent the archwire
from sliding excessively.
This panoramic radiograph shows archwire travel to the point that on one side it
penetrated into the ramus, almost to the depth of an inferior alveolar block injection
(interestingly, the patient reported only mild discomfort).

Alignment in
pre-molar extraction space
• Patients with sever crowding of anterior teeth sometimes require
extraction of premolar to gain space for alignment of incisors.
• After this extraction, canine is retracted by one of two methods;

• Independent retraction of canine followed by alignment of incisors
• Simultaneous distal tipping of canine along with alignment of incisors
• A NiTi coil spring for canine retraction
• A NiTi archwire for incisor alignment

Alignment in
pre-molar extraction space
(Independent Method)
When anchorage is critical for retraction of canines to
allow alignment of incisors, bone screws placed in the
alveolar process between the molar and premolar
roots are the most effective way to obtain the
Direct Method
necessary space.
A. The anchorage can be direct, with an elastomeric
chain or NiTi spring from the bone screw
providing the force to retract the canines or
B. indirect, with an attachment from the bone screw
to the first molar to keep those teeth from moving
forward when an attachment from the posterior
teeth is used to retract the canine. Indirect Method

Alignment in
Alignment of severely crowded lower
pre-molar extraction space incisors with the super elastic
(Simultaneous equivalent of the original
“drag loop.”
Method)
a) Occlusal view prior to treatment.
b) Canine retraction with super
elastic coil springs that provide 75
gm of force, and alignment of
incisors with a super elastic NiTi
wire that incorporates an
accentuated reverse curve of Spee
and delivers 50 gm.
c) and D, Completion of canine retraction
and incisor alignment after 5 months of
treatment.
Cross Bite Correction

Individual Teeth into Anterior
Cross bite
• Correction of a dental anterior cross bite, as
in this young adult, requires
• opening enough space for the displaced teeth
followed by
• attempting to move it facially into arch form.
• At that point, a biteplate to obtain vertical

clearance often is required because;
• patient can bite on the bracket placed on displaced tooth
so for preventing this, posterior teeth are separated
temporarily
• Occlusal interference prevents the facial movement of that
displaced tooth SARANG SURESH HOTCHANDANI 23
Transverse Maxillary Expansion by
Opening the Mid Palatal Suture
• Widening of maxilla by opening mid palatal suture is easy in
young age, but it becomes difficult in as the patient become
older.
• Patient who require opening of mid palatal suture will also

need extraction of premolar.
• Expansion is done 1st after that extraction or alignment of teeth is
performed.
• Because 1st premolar teeth are useful for anchorage & lateral expansion.

• If the maxillary width is normal, expansion should be avoided.
• It should be used for correcting skeletal cross bite.
• After the age of 15 or in older patients, maxillary expansion by opening mid

palatal suture should be achieved with Rapid Activation of expansion screw
(2 turns initially & 2 turns per day until suture opens) – 10 – 20 pounds of
force is applied.
• Patient will feel pop apart
• If the suture at this age with rapid expansion does not open within 2 – 3 days, surgical
expansion is only possibility after that.
• Slow activation in this age will produce only dental expansion.
• There are two appliance for this transverse maxillary expansion;
• Bonded expander
• Banded expander Normal Face Height Persons can be given
any of two expanders
• Bonded Expander
• Indicated in patients with excessive anterior face height.
• Does not cause downward & backward rotation of mandible.
• Banded Expander
• Mostly given in patient with short anterior face height
• Cause downward & backward rotation of mandible resulting long face.

Banded Expander Bonded Expander

Correction of Dental Posterior
Cross Bites
• 3 methods of correcting less sever dental cross bite;
• Heavy labial expansion arch
• Inner bow Face bow in case of headgear wearer
• Expansion lingual arch
• Cross elastics

Heavy Labial Expansion Arch
• A heavy labial archwire (usually 36 or 40

mil steel) placed in the headgear tubes on
first molars can be used for a small amount
of expansion and to maintain arch width
after palatal suture opening while the
teeth are being aligned.
• This is more compatible with fixed

appliance treatment than a removable
retainer and does not depend on patient
cooperation.

Trans Palatal
Lingual Arch
If anchorage is of no
concern, highly
flexible lingual arch
like quad helix
design is used to
correct dental cross
bite.
Trans Palatal Lingual Arch
• If expansion & anchorage both are needed, the
choices are;
• 36 mil steel wire with adjustment loop
• Use of 32 x 32 TMA or Steel wire

A and B, Mandibular stabilizing lingual
arch. It is easier to insert a heavy lingual
arch of this type from the distal of a
horizontal tube on the first molar bands.
Note that the lingual arch is contoured
away from the incisors, so that it does not
interfere with aligning and retracting them.
C and D, A maxillary lingual arch can be
active, typically to rotate the maxillary
molars, or passive for stabilization. An
active lingual arch can be placed in a
horizontal tube or ligated into a special
bracket on the molars, as shown here.
Ligation into a bracket makes it easier to
remove and adjust the lingual arch, but
over time, gingival overgrowth can make
re-ligation difficult

Cross Elastics
• They run from lingual or upper
molar to the buccal of lower molar.
• Cause extrusion of teeth and

downward & backward rotation of
mandible.

Impacted or Unerupted
Teeth Alignment

Treatment of
Unerupted/Impacted Tooth

Surgical Exposure
• Before surgery to expose the tooth, it precise position should be
known. It can be obtained by on of the following radiographs;
• CBCT (Small Field of View)
• Vertical Parallax Method

• Combination of OPG & Occlusal View.
• Lateral Cone Shift Method

• Multiple Periapical Views.
Surgical Exposure
• When exposure of impacted tooth is planned, it is important for tooth to
erupt through attached gingiva no through alveolar mucosa.
• If an impacted canine is on the labial, removing tissue to expose the crown for
bonding an attachment can be done conveniently with a diode laser.
• If the unerupted tooth is more apically positioned, a flap should be reflected

from the crest of alveolus and sustured.

Surgical Exposure
A C
B
A. The permanent canine was slow to erupt. Probing showed that exposure of 4 mm of the crown could be done
without violating the biologic width of the attachment apparatus.
B. Immediately after crown exposure with a laser.
C. The tooth brought to the occlusal level with a super elastic wire, ready for placement of a bracket in ideal
position.

Method of Attachment
• Best approaches are;
• Bonding of button or hook to
which gold chain is tied and
extending into mouth.
• Other approaches;
• Placement of pin in a hole prepared in crown.
• Wire ligature around crown instead of gold chain.
• Results in loss of PDL support.
• Increases chances of ankyloses
Mechanical Approaches for
Aligning Impacted Tooth
• Orthodontic traction to move an unerupted tooth away from other
permanent tooth roots & then toward the line of arch should begin
ASAP after surgery.
• Brackets should be applied to other teeth before surgery so that force

can be applied immediately.
• If it is not possible, then force should be given within 2 – 3 weeks post
surgically.
• The reason for pre-surgical bracket is to create space for that impacted tooth
to erupt into arch.

Mechanical Approaches for
Aligning Impacted Tooth
• As we know impacted tooth is example of
asymmetric crowding, so for that purpose;
• At least 18 mil steel rectangular
wire should be in place as heavy
stabilizing wire followed by
auxiliary A NiTi wire for moving
impacted tooth.

A. For this patient with palatally positioned
bilateral impacted maxillary canines, a
soldered lingual arch has been placed for
better anchorage control; a heavy labial
archwire is in place after space for the
canines has been opened; and an auxiliary A-
NiTi wire is tied to attachments (preferably, a
segment of gold chain) that were bonded to
the canines at the time they were exposed.
B. Progress in the same patient, with the A-NiTi

auxiliary now placed over a button that was bonded
on the facial surface of the canine after it was
brought down enough to allow this.
C. When the tooth has elongated enough, the button is

replaced with a standard canine bracket and
alignment is complete.
D. A vertical spring bent into a 14 mil steel archwire is

an alternative approach to bring down an impacted
canine. The spring is a loop of wire that faces
downward before activation and is rotated 90
degrees for attachment to the impacted tooth or
teeth. This method is effective but less efficient than
using a super elastic auxiliary wire.

Unerupted/Impacted Lower 2nd
Molar Alignment
• Impaction of lower 2nd molar usually develops during
orthodontic treatment.
• Mesial tipping of lower 2nd molar instead of eruption occurs when
mesial marginal ridge of lower 2nd molar catches against the distal
surface of 1st molar or on the edge of 1st molar band.
• Lower Molar distalization also increase the chances of

impaction of lower 2nd molar.

Unerupted/Impacted Lower 2nd
Molar Alignment
• Correction of an impacted 2nd molar require tipping the
tooth posteriorly & uprighting it.
• This can be achieved by;

• Use of separators
• Use orthodontic force by arch wire
• Surgical uprightening

Unerupted/Impacted Lower 2nd Molar Alignment
– with SEPARATORS
• For a second molar that is caught on the edge of a first
molar band, a simpler approach is uprighting achieved
with a 20 mil brass wire OR SEPARATORS tightened
around the contact.
• Usually it is necessary to anesthetize the area to place a
separator of this type.
• Uprighting and distal movement obtained with the

brass wire separator. A spring clip (one type is sold as
the Arkansas de-impaction spring) can be used in the
same way, but both brass wire and spring clips are
effective only for minimal molar uprighting.

– with Ortho WIRES
When a second molar is banded or bonded relatively late in treatment, often
it is desirable to align it with a flexible wire while retaining a heavier archwire
in the remainder of the arch.
Repositioning a maxillary second molar, using a

straight segment of rectangular A-NiTi wire
that fits into the auxiliary tube on the first molar
and the tube for the main archwire on the second
molar.

– with Ortho WIRES
In both arches, after the repositioning, a continuous archwire can extend to
the second molar.
Repositioning a mandibular second molar, using a

segment of steel wire with a loop that extends
from the auxiliary tube on the first molar.

Surgical Uprighting
Surgical uprighting of impacted mandibular second molars sometimes is the
easiest way to deal with severe impactions.
A, Age 12, prior to loss of the second primary molars, with the permanent
A
second molars tipped mesially against the first molars. Teeth in this position
often upright spontaneously when the first molars drift mesially after the
primary molars are lost.
B, Age 14, severe impaction one year after the beginning

of orthodontic treatment.
B C, Age 14, after surgical uprighting of the second molars, which are rotated
around their root apex into the space created by third molar
extraction. Loss of pulp vitality
usually does not occur when this is
done.
D, Age 16, after completion of
orthodontic treatment. Note the
C D excellent fill-in of bone between
the first and second molars
DIAS TEMA Closure

Management of Midline
Diastema
• If midline diastema is due to high Frenum; frenectomy
should always be performed after closing the space
orthodontically.
• Treatment starts with; aligning the teeth together by

figure 8 wire ligature before frenectomy followed by
removal of Frenum & placement of bonded retainer as
shown in figure.
Management of a maxillary midline diastema.
D
C
B
A E
A. Facial appearance, showing the protruding maxillary incisors caught on the lower lip.
B. Intraoral view before treatment.
C. Teeth aligned and held tightly together with a figure-8 wire ligature, before frenectomy.
D. Appearance immediately after frenectomy, using the conservative technique advocated
by Edwards in which a simple incision is used to allow access to the interdental area, F
the fibrous connection to the bone is removed, and the frenal attachment is sutured at a
higher level.
E. Facial appearance 2 years after completion of treatment.
F. Intraoral view 2 years after treatment.
G. Bonded retainer, made with .0175 steel twist wire. It is important for the wire to
be flexible enough to allow some displacement of the incisors in function—a
rigid wire is much more likely to break loose. F
L E V E LLI NG

Levelling
There are three possible ways to level a lower arch with
an excessive curve of Spee:
A. ABSOLUTE INTRUSION
B. RELATIVE INTRUSION, achieved by preventing
eruption of the incisors while growth provides
vertical space into which the posterior teeth erupt;
and
C. EXTRUSION of posterior teeth, which causes the
mandible to rotate down and back in the absence of
growth.
• Note that the difference between B and C is whether

the mandible rotates downward. This is determined by
whether the ramus grows longer while the tooth
movement is occurring.
Curve of Spee
EXCESSIVE CURVE OF SPEE; restrict the amount
of space available for upper teeth results in
crowding. Excessive Curve of Spee
FLAT CURVE OF SPEE; most receptive for normal

occlusion. (the mandibular curve of spee should
not be deeper than 1.5 mm)
Flat Curve of
Reverse Curve Spee
of Spee
REVERSE CURVE OF SPEE;
creates excessive space in
upper jaw
Levelling by Extrusion
(Relative Intrusion)
• After initial alignment by A NiTi wire, arch wire is changed for Levelling.
• Resilient & springy arch wire is needed for alignment while,
• Stiffer Wire Is Needed For Levelling.
• The choice of wire for levelling depends on the bracket used;

• Either the bracket is 18 slot size or 22 slot size.
• The wire which is placed for levelling after removal of alignment wire should have
following features if the levelling is to performed by Relative Intrusion method;
• Excessive curve of spee in maxillary archwire
• Reverse curve of spee in mandibular archwire
18 S l o t , Narrow B r a c k e t
Here the 2nd wire for levelling phase in this bracket is

almost always
16 MIL STAINLESS STEEL ROUND Wire
with excessive curve of spee in upper arch & reverse
curve of spee in lower arch.

• In some patient, particularly in non extraction treatment of
older patients who have little or non remaining growth will
need an archwire heavier than 16 mil (probably 17 – 18 mil).
• However, in them instead of using of heavy wire, we can add

auxiliary leveling arch wire of 17 x 25 mil TMA or Steel
Rectangular wire.
• This auxiliary arch wire inserts into tubes beneath the 16 mil base
arch
A B
A, Auxiliary leveling wire prior to and after activation (B) by tying it beneath a continuous mandibular
archwire.
The appropriate force in this instance is approximately 150 gm, and the expected action is leveling by
extruding the premolars rather than intruding the incisors.
For absolute intrusion, light force (approximately 10 gm per tooth) is necessary.
This requires use of archwire segments and an auxiliary intrusion arch.
(C)Intrusion arch prior to and after activation (D) by bending it downward and tying it to the
segment to be intruded.
The force delivered by the intrusion arch can be measured easily when it is brought down to the
level at which it will be tied

(E)Auxiliary leveling arches for extrusion in the maxillary arch and

(F) for incisor-canine intrusion in the mandibular arch.
Note that the mandibular base arch is segmented, creating a separate incisor segment, while a continuous archwire is in place
in the maxillary arch and the auxiliary leveling arch is tied into the anterior brackets on top of it.
Intrusion requires a segmented base arch and a light intrusive force (here, with six mandibular incisors in the anterior
segment, approximately 50 gm would be used). Extrusion can be done with a segmented or continuous base archwire, using
about 50 gm/tooth in the segmented to be extruded.SARANG SURESH HOTCHANDANI 61
2 2 – S l o t W I D E R B R AC K E T
• Initial alignment wire – A NiTi wire
• Wire for Levelling in 22 Slot Bracket

• Initially 16 mil steel wire with reverse or accentuated
curve of spee
• Later 18 mil round steel wire to complete levelling.
• No 20 mil or auxiliary wire needed.

NOTE !!
Never use Rectangular base wire in levelling phase.
Never use excessive curve of spee wire in mandible.
• Curve will cause torque on incisor roots lingually.

• Rectangular wire would be acceptable in upper arch if
lingual torqueing of upper incisors is needed.

Levelling by INTRUSION
• The key to successful intrusion is Light Continuous Force
Directed Towards Apex.
• Avoid Pitting intrusion of one tooth against extrusion of its

neighbor.
• TWO METHODS of Levelling by Intrusion

• Bypass Arches Method
• Segmented Arches Method
B y p a s s A r ch e s M e t h o d
• In this
Continuous Archwire That Bypasses The Premolar (& Frequently
Canine) Teeth is used
• This method is most useful for

Patients Who Have Some Growth (Mixed Or Early Permanent
Dentition).
• Mechanism of Action - Bypass Arch Method;

• Uprighting & Distal Tipping Of The Molar, Pitted Against
Intrusion Of Incisors.
Diagrammatic Representation of Bypass Method
• Diagrammatic representation of the forces for a leveling arch that bypasses the premolars, with an anchor
bend mesial to the molars.
• A force system is created that elongates the molars and intrudes the incisors.
• The wire tends to slide posteriorly through the molar tubes, tipping the incisors distally at the expense of
bodily mesial movement of the molars.
• An archwire of this design is used in the first stage of Begg treatment but also can be used in edgewise
systems.
• A long span from the molars to the incisors isSARANG
essential.
SURESH HOTCHANDANI 66
Mechanical Arr angements
Bypass Arches Method
There are 3 Techniques available by which we can intrude the teeth for
levelling with Bypass Method
1ST STAGE OF BEGG TECHNIQUE; bodily movements of anchor molars

were pitted against tipping of movement of anterior teeth.
Here premolar teeth were bypassed & loose tie was made to canine.
2 X 4 EDGEWISE APPLIANCE; only 2 molars & 4 incisors included in appliance
RICKETT’S UTILITY ARCH
Produce complex mechanical system that is difficult to control, that’s why utility
arches are now replaced by segmented arch approach as mentioned in next slides
2x4 Edgewise Appliance
A and B, The long span of a 2 × 4 appliance makes it possible to create the light force necessary for
incisor intrusion and also makes it possible to create unwanted side effects. The 2 × 4 appliance is
best described as deceptively simple.
When incisor intrusion is desired before other permanent teeth can be incorporated into the
appliance, a trans palatal lingual arch for additional anchorage is a good idea.
Rickett’s Utility Arches

B y p a s s A r ch e s M e t h o d
• Success of bypass method depend on KEEPING FORCES LIGHT.
• These light forces can be achieved by;

• USING SMALL DIAMETER WIRE
• Weather bracket is 18 Or 22 Slot, Wire Heavier Than 16 Mil Should Not Be
Used. – size of bracket slot is irrelevant
• Ricketts used 16 x 16 cobalt chromium wire for his utility arches.
• IN MODERN UTILITY ARCHES; 16 X 22 BETA TITANIUM rectangular wire is used.
• USING LONG SPAN B/W INCISORS & 1ST MOLAR.

(WEAKNESS)
• Only 1st molar is available for anchorage which results extrusion of this
tooth which compromises the intrusion the anterior teeth.
• This extrusion is not a major problem in growth patients with good facial pattern.
• However, molar extrusion should be avoided in non growing patients with poor facial
pattern.
• Intrusive force against incisors is applied anterior to the center of resistance

and therefore INCISORS TEND TO TIP FORWARD as they intrude.

A. When the incisor segment is viewed from a lateral perspective, the center of resistance (X) is lingual to the point at
which an archwire attaches to the teeth. For this reason, the incisors tend to tip forward when an intrusive force is
placed at the central incisor brackets.
B. Tying an intrusion arch distal to the midline (for instance, between the lateral incisor and canine, as shown here) moves
the line of force more posteriorly and therefore closer to the center of resistance. This diminishes or eliminates the
moment that causes facial tipping of the teeth as they intrude.
C. Intrusion arch tied in the midline as only the central incisors are intruded, so that the incisors will tip facially as they
intrude.
D. In the same patient later, an intrusion arch now is tied between the central and lateral incisors to intrude all four incisors
while reducing the amount of facial tipping.
(WEAKNESS)
• This forward tipping of incisors can be prevented by;
• Anchor bend at the molar in bypass arch creating closing effect that restrains forward
movement of incisors.
• Activation of utility arch like closing loop.

S e g m e n t e d A r ch M e t h o d
• Developed by Burstone.
• In this approaches brackets are placed on all teeth.
• Here for intrusion of anterior teeth, posterior segment are

stabilized & point of force application against anterior teeth
is controlled.

• Posterior teeth are stabilized for better control of anchorage. Which can be
achieved by;
• Placing full dimension archwire into bracket slots of 2nd premolar, 1st molar
& 2nd molar on both sides of arches which act as single segment.
• After that both sides are connected by a heavy lingual arch made either 36 mil
round or 32 x 32 rectangular stainless steel wire.
• A resilient anterior segmental wire is used to align the incisors while the
posterior segments are being stabilized.
• Wire for ANTERIOR TEETH; BRAIDED RECTANGULAR WIRE OR
RECTANGULAR TMA
• For intrusion, an auxiliary arch placed in auxiliary tube on the 1st molar is used to
apply intrusive force against anterior segment.
• This arch should Always Be Rectangular so that it does not twist in tube, and
made from either one mentioned below.
• 18 x 25 steel wire with 2 ½ turn helix
• 17 x 25 or 19 x 25 TMA wire without helix
• Preformed M – NiTi
• This wire should be
placed gingival to
incisors & apply
light force of 10 gm
per tooth.
Segmented Arch Method
M e t h o d s t o R e d u c e Fo rwa r d
Incisors Tipping
• Two strategies available;

• Similar to bypass arches, a space closing force
can be created by tying the auxiliary arch back
against posterior segments.
• Change the point of force against incisors.
• Tying an intrusion arch distal to the midline
(for instance, between the lateral incisor and canine,
as shown here) moves the line of force more
posteriorly
and therefore closer to the center of resistance.
This diminishes or eliminates the moment that causes
facial tipping of the teeth as they intrude.

Levelling by INTRUSION
• Although both act by intrusion of incisor with
extrusion & distal tipping of posterior segments.
But;
• With segmented arch technique; 4x as much
incisor intrusion as molar extrusion in non growing
adults is possible. WHILE
• The ratio of anterior intrusion to posterior
extrusion is much less favorable with bypass
technique. SARANG SURESH HOTCHANDANI 78
T h e K E Y i s T y i n g Au x il iary
Archwire where Intrusion
is required.
• It is quite possible to intrude asymmetrically;

• Only adjusting the teeth that are placed in
stabilizing & intrusion segments and tying the
auxiliary intrusion arch where intrusion is required.

A. In this adult patient, the maxillary left
central and lateral incisors and
particularly the canine had super
erupted. Asymmetric intrusion of those
teeth was needed.
B. An auxiliary intrusion arch delivering

about 30 gm was tied to the elongated
canine, while preliminary alignment
with an A-NiTi wire was employed. The
result was leveling of the maxillary arch
with a component of intrusion on the
elongated side. Asymmetric intrusion
can be accomplished either by
asymmetric activation of an intrusion
arch that spans from one first molar to
the other or by use of a cantilever
intrusion arch on one side only.
Summary
of 1st Stage of Treatment
• The arches should be level
• Teeth should be aligned to the point that rectangular steel archwires

can be placed without excessive curve & without generating
excessive force.
• The duration of 1st stage of Tx. Is determined by severity of both

horizontal & vertical component of initial malocclusion.

THE END
Final Year BDS, Bibi Aseefa Dental College, SMBBMU, Larkana, Sindh, PAKISTAN
Email: hotchandanisarang@gmail.com
Twitter: www.twitter.com/fetusdentista

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Section 6

• Ideal time for Comprehensive Orthodontic Treatment; (When to

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• Comprehensive orthodontic treatment consists of following 4

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• PROPER ALIGNMENT OF TEETH CAN BE ACHIEVED BY;

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•During alignment phase, only

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2 – 4 mil of space b/w archwire & bracket slot for tipping

Round NiTi wire for alignment are preferred

Springier Wire for Symmetric Crowding

• Rigid wire with auxiliary wire for Asymmetric Crowding

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B and C, After space was opened for

D. Alignment completed. This

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• The most effective way to prevent travel is to

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• After this extraction, canine is retracted by one of two methods;

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• At that point, a biteplate to obtain vertical

• Patient who require opening of mid palatal suture will also

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• After the age of 15 or in older patients, maxillary expansion by opening mid

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• A heavy labial archwire (usually 36 or 40

• This is more compatible with fixed

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• Cause extrusion of teeth and

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• CBCT (Small Field of View)

• Vertical Parallax Method

• Lateral Cone Shift Method

• If the unerupted tooth is more apically positioned, a flap should be reflected

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B. Immediately after crown exposure with a laser.

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• Brackets should be applied to other teeth before surgery so that force

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B. Progress in the same patient, with the A-NiTi

C. When the tooth has elongated enough, the button is

D. A vertical spring bent into a 14 mil steel archwire is

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• Lower Molar distalization also increase the chances of

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• This can be achieved by;