Nanda Esthetics and Biomechanics

Pregnancy:
1. Radiographs not recommended
2. Gingival hyperplasia due to hormonal imbalance
3. Mother’s nutrition is affected

Asymmetric gingival display:

1. Cant in maxillary skeletal base
2. Different amounts of tooth eruption
3. Asymmetrical smiles
4. Dental midline
Black triangles:

 If distance of tooth contact is less than 5mm to crestal bone, then papilla is present
 Triangular teeth
 Lower incisor extraction
 Incisors with wider middle 3rd than incisal 3rd
TMDs are divided in internal derangements and myofasical pain dysfunction.
Internal derangements:
1. Stage I: Initial incoordination between the condyle and the disc during opening
2. Stage II: Anterior displacement of disc
3. Stage III: Anterior displacement of disc without recapturing
4. Damage to retro discal tissues
Myofascial pain dysfunction:
1. Unilateral origin
2. Limited jaw opening
3. Masticatory muscle tenderness
4. No radiographic or clinical evidence of joint degeneration
Cephalometric analysis for Orthognathic Surgery (COGS)
1. Cranial base:
a. Sella to Nasion Length
b. Saddle angle: Sella-Nasion-Articulare
2. Maxilla:
a. ANS-PNS mm
b. Nasion to A point mm
c. PNS to PTM
d. ANS-PNS-Palatal Plane Angle
e. ANS-Me
f. ANS to Nasion: ANS-Me:ANS-Nasion Ratio should be 55%
3. Mandible:
a. Co-Gn
b. Co-Me
c. Ar-Me
d. Ramus height: Ar-Go
e. Corpus length: Go-Me
f. N-B to Mcnamara mm
g. N-Pog to Mcnamara mm : Length of hard tissue chin
h. MPA
i. Gonial angle: Ar-Go-Me
j. ANS-ME:PNS-Go
k. Cranial base to maxilla and mandible:
i. A-B-OP
ii. S-Gn angle and length: y axis
iii. N-A-Pog: angle of convexity
4. Dental:
a. Upper incisor-FH
b. UI-Palatal plane
c. LI-MP
d. I-I
e. UI-ANS mm
f. LI-Me mm
5. Soft tissue:
a. Angle of convexity
b. Soft tissue maxilla: true vertical/maxilla
c. Soft tissue mandible: True vertical/mandible
d. Lip protrusion:
i. S-line to upper and lower lip
e. Nasolabial angle
f. Mentolabial angle
g. Upper lip inclination: Sn-ULipe/FH
h. Lower lip inclination: Soft tissue point B-Lower lip/FH
i. Nasolabial sulcus depth
j. Mentolabial sulcus depth
Chapter 3:
Important characteristics of smile:
1. Crown lengths of upper and lower incisors
2. Incisal edge contours
3. Position and symmetry of gingival margin levels
4. Axial inclinations of all anterior teeth
5. Midline
6. Connector areas
7. Symmetry and degree of crown torque
8. Harmony of front to back tooth display
Smile types:

 Average smile type: 75% to 100% of incisors

 Low smile: less than 75%
 High smile: 100% of incisors plus a band of gum
 Gummy smile: Greater than 4mm of gum show
Smile arc:

 Parallel
 Straight
 Reverse
Clinical guidelines:

 Vertical dimension:
o Study the patients dentition directly from the front. Move the patient’s head to the side of the
headrest which allows eye to eye perspective
o Routinely take extra oral photographs with lips at rest. Short video showing the patient
speaking and smiling joyfully to record gingival display
o Cure of maxillary incisors parallel to the lower lip
o Avoid active maxillary incisor intrusion
o Establish an age appropriate incisal display
 Midlines:
 o Vertical line from nasion to base of philthrum is a practical guide
o Precise dental midline is not necessary for optimal esthetics
o Moderate maxillary midline deviation is acceptable as long as angulation is not canted
o Optimal connector areas with 50-40-30 rule
o Connector area between maxillary incisors is long, vertical and parallel
o Mandibular midline is less important
 Transverse:
o Symmetrical labiolingual inclination of canines and premolars
o Crown inclination asymmetries between contra lateral teeth are common and must be
recognized early and corrected by torqueing
o Terminal tooth in smile should be upright. Usually 1st or 2nd premolar
o Smooth gradual front to back curve laterally provides harmony and beauty
o Avoid tipping mandibular canines, premolars and molars lingually
o Learn to see important details in dentition
Chapter 5:
Kinetics of orthodontic tooth movement:

 Displacement phase:
o Movement of tooth in pdl space
o Affected by:
 Loss of alveolar bone
 Age:L greater youngs modulus of pdl in older people
 Delay phase:
o Absence of clinically viable tooth movement
o Can result in either partial obstruction or complete obstruction of pdl vessels
o Faster in young patients
o This phase is the reason for slower tooth movement in adults
 Acceleration and Linear phase:
o Rapid tooth displacement
o Low forces allow lesser lag time and faster movement
o High forces lead to a very long lag time
 Ankylosis:
o Absent PDL fibers
 Correlation and interpretation of results of
differing rates of tooth movement is
complicated by:

 Age
 Pubertal stage
 Growth velocity
 Mineral accrual
 Hormonal regulation
 Nutritional status
 Circadian variation

Chapter 6:
Anchorage:

 Absolute anchorage: if all movement is seen in the active unit. SAS

 Group A; Majority of the movement of the active unit
 Group B: Movement shared equally among the two units
 Group C: Majority of movement by the passive unit
Differential moments:
Loops for space closure:

 Loop height: As loop height increases M/F increases.

o Loop cannot have a higher M/F than its height
o Limited by patient discomfort and bending difficulties
 Loop shape:
o T loops generate more than vertical loops
 Loop placement:
o Higher moment at bracket close to loop
Segmental Mechanics:
1. Canine retraction:
a. Preactivation by giving alpha and beta bends
b. Movement
i. Phase I :
1. Tipping
2. High forces and moments
3. mc/mf of less than 1
ii. phase II:
1. Translation:
2. Force levels drop
3. Mc/mf of 1
iii. Phase III:
1. Root movement
2. Mc/mf is greater than 1
3. Molar mesial movement can occur
2. Incisor retraction:
a. More moment must be made for posterior unit
Sliding mechanics:
1. Canine retraction:
a. Phase I:
i. Due to play between bracket and wire
ii. Uncontrolled tipping
b. Phase II:
i. Play between wire and bracket is eliminated
ii. Two point contact
iii. Controlled tipping
c. Phase III:
i. Magnitude of Mc increases due to the deformation of wire
ii. Bodily movement
d. Phase IV:
i. Restorative phase of canine retraction
ii. Force decay
2. Incisor retraction:
a. More amount of play.
b. Play is in 3rd order whereas it is in 2nd order in canine retraction
c. Avoid tipping:
i. V bend
ii. Placing a curve in the main archwire
iii. Torquing the archwire
iv. Increasing the stiffness and size of archwire
3. Effect of canine retraction on incisors:
a. AS canine retraction goes into phase I to III the wire undergoes elastic deflection
b. This causes extrusion of anterior teeth
4. Effect of canine retraction of molars: Presence of lateral open bite due to tipping of canine and molars
Chapter 8: Deep bite
Chapter 9: Open bite
Chapter 10: Molar and incisor positioning
Importance of Maxillary 1st molars:
1. Loss of permanent molar leads to tipping of adjacent teeth
2. Strong ridge present in 1st molar area which allows distribution of forces. Limit mesial movement of
1st molar
3. Maintain intermolar width. Loss of efficient chewing surface
4. Maintain vertical level
Master and Slave arches:

 Master arch: More stable during relative movement of inter-arches. Established first and fixed with a
rigid wire
 Slave arch: Movement of teeth is achieved gradually
 In class I and II lower arch is the master arch
o Mandibular incisors are uprighted as early as possible
o Mandibular arch is an important factor in maintaining oral function
o Mandibular arch is the form over which the maxillary arch in molded
 In class III, maxillary arch is the master arch
WALA ridge:
An anatomic ridge on the mandibular alveolar process that delimits the soft tissue band immediately
superior to the mucogingival junction
Approximates the superior inferior position of the horizontal centers of rotation of teeth in an arch
Chapter 11:
Biomechanics of functional appliancesL

 Mandibular and glenoid fossa growth enhancement

 Maxillary growth inhibition
 Posterior biteplate effect
o Myodynamic approach: Small forward posturing and 2-3mm of opening. Stimulates their
continuing contraction
o Myotonic approach: Mandible is postured forward and opened to a greater amount. Inherent
elasticity of the tissues put traction on the mandible
 Guidance of eruption
 Stimulation of bone deposition in areas of stretched periosteum
 Class II elastic effect
 Altering soft tissue forces

Chapter 12:
Patient selection:
1. Class II dental and minor Class II skeletal
2. Mesial migration of upper molar due to early loss of deciduous is preferred
3. Minimal or no mandibular TSALD
4. Mesofacial or brachyfacial faces
5. Remaining growth potential
6. Low mandibular plane angle
Maxillary molar distalization:
Extra oral: headgear (cervical, occipital or high pull)
Intraoral:

 Inter arch:
o Fixed: herbst, twin force bite corrector, jasper jumper and SAIF spring
o Removable: Class II elastics with jig, Bimetric arch (Wilson appliance)
 Intra arch: transpalatal arch, coil springs, repelling magnets, K-loop, pendulum, jones jig, distal
jet
Vertical Holding appliance:

 Combined VHA and high pull headgear

 High angle patients
 0.040 inch wire with a helix just dital to each maxillary first molar
 Two more helices at the center separated by a V bend with an acrylic button
 Palatal button between 1st molars, 2-5mm away from palate
 Intrusion and distalization
 Forces placed by the tongue
Jig:

 Used to correct uni or bilateral class II

 Tied in using niti coil springs with an external tubing to minimize discomfort
Bimetric Wilson Arch:

 Labial arch made of 0.040 posterior section and an 0.020 anterior section
 Hooks soldered on anterior end for elastics
 Omega loop in the premolar region
 Open coil spring between omega loop and maxillary first molar
 Continued activation by opening the omega loop
 Important to stabilize mandibular molars while applying elastics
o Fixed lingual arch
o Removable lingual arch
o Lip bumper: uprights mandibular molars

Pendulum appliance:

 Non compliant patients

 Expands the maxilla and and simultaneously rotates and distalizes maxillary molars
 Continuous forces
 Palatal acrylic button 25cmm in diameter with distalization springs made of 0.032 beta titanium wire
 Bonded to 1st and 2nd premolars with wires embedded in acrylic
 One time activation of 60-70 degrees
 Force of 230g/side
 Patients with erupted 2nd molars experience extrusion of bite which causes increase in
o Mandibular plane angle
o LAFH
o Reduced overbite
 Distal tipping of 1st molar and mesial tipping of premolars
 Anterior displacement of anterior teeth
 Advantages:
o Ease of activation
o One time activation
o Adjustment of the springs
o Patient acceptance

Distal Jet:

 Bilateral piston and tube arrangement

 Tube embedded in acrylic palatal button and attached to 1 st and 2nd premolars
 Bayonet wire extended into lingual molar tubes
Jones Jig:

 Modified nance button banded to 2nd premolars

 Paltal acrylic button 0.50 inch diameter andchored to the 2 nd premolars with a bonded 0.036 wire
 One arm of jig fits into 0.045 headgear tubes
 2nd arm fits into 0.018 tube on 1st molar
 Activation delivered through 0.018 NiTi coil springs
 70 – 75g of force/side
 6 months

Chapter 13: TFBC

 Hybrid fixed push-type semirigid FFA

 Made up of two 15mm telescopic parallel cylinders\
 Withiun the cylinder is a NiTi coil spring that is activated when the patient occludes
 Plunger is incorporated at the end of each cylinder
 At the end of the plunger, hex nuts are present to attach the appliance to the archwires mesial to the
upper molars distal to the lower canine
 210g/side
 Effects:
o Intrusive and distal forces on the maxillary posterior dentition
o Mesial and intrusive force of mandibular anterior segment
o Clockwise moment but lesser in maxillary arch
o Buccal expansive force on maxillary molar
o Point A moved back 0.5mm and 1.7mm inferiorly
o Palatal plane rotated 0.5 degres
o 2.1mm increase in mandibular length
o Upper incisor distal crown tipping of 7 degrees, upper molar distalized 0.7mm
o Lower incisor flaring 7.3 degreesn lower molar mesialized 1.8mm
 Protocol:
o Archwires progressed to 19x25 SS in upper and 21 x 25 SS in lower arch
o Cinching of the wires is done for consolidation and for the prevention of flaring
o MBT prescription is advised
o 3-4 months, till patient has an overcorrected class I
 Timing:
o Peak height velocity
o Post pubertal phase

Chapter 14:
Treatment of developing class III:
1. Expansion and partial fixed appliances:
a. `Expansion using a Hyrax screw can lead to forward movement of 1.5mm of the maxillary
incisors
2. Protraction Facemask:
a. Effects:
i. Maxilla
1. Moves downward and forward
2. Counterclockwise rotation of palatal plane
3. Posterior teeth extrude
4. Upper incisor proclination
ii. Mandible;
1. Downward backward rotation
2. Retroclination of lower incisors
3. Increased lower facial height
b. Prescription:
i. Bonded hyrax in long face, deep overbites. Activated twice daily for 7-10 days
ii. 30 degrees downward pull from occlusal plane
iii. 300-600g/side
iv. 12 hours/day
v. Retention using Frankel III
c. Timing:
i. At the time of eruption of maxillary incisors
ii. Primary or early mixed dentition
3. Chin cap
 a. Effects:
i. Redirects mandibular growth
ii. Downward and backward rotation of mandible
iii. Closure of gonial angle
iv. Shortening of mandibular length
v. Bending of condylar neck
vi. Remodeling of glenoid fossa
vii. Opening of cranial base angle
b. Limitations:
i. Long tx time
ii. Response to treatment depends on facial pattern
iii. Increases lower facial height
4. FR III:
a. Effects:
i. Early mixed dentition
ii. Forward movement of maxillary skeletal and dental landmarks
iii. Backward rotation of mandible
iv. Increased lower anterior facial height
v. Proclination of maxillary and retroclination of mandibular incisors

Treatment of non growing class III:

 Conventional edgewise therapy

 Multi loop edgewise archwire (MEAW) with class III and vertical elastics
 Retraction of lower dentition using springs from mandibular microimplants
 Retraction and uprighting of lower posterior teeth using class III elastics from maxillary
microimplants