Treatment of malocclusion

Part 2
MOHAMED E. AMER, BDS, MSC
Orthopedic treatment
 Orthopedic
C. Orthopedic treatment

 A developing skeletal malocclusion if detected at an earlier stage can be intercepted so

as to decrease its severity and may even end by normal occlusion. This approach is
known as functional orthopedics treatment.
 Functional orthopedics appliance is defined as the skeletal correction of antero-
posterior, transverse and vertical jaw relations through impeding, enhancing or
redirecting jaw growth during adolescent’s period.
 It is removable or fixed appliance; which changes the positions of the mandible so as
to transmit forces generated by the stretching of the muscles through the acrylic and
the wire framework on the dentition and the underlying skeletal structures.
 Orthopedic
C. Orthopedic treatment

Examples of Orthopedic treatments

1. Headgear
2. Facemask
3. Chin cup
4. Myofunctional appliances (Monoblock, Twinblock, Frankel appliance,
Fixed functional, etc…)
5. Skeletal Expanders
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A. Maxillary excess
Headgear (Cervical or Occipital pull)
Uses:
1. Restrict growth of maxilla
2. Distalize upper molars
3. Anchorage reinforcement
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A. Maxillary excess
Head gear (Cervical or Occipital pull)
Components:
1. Molar tube
2. Face bow (inner bow & outer bow)
3. Head strap
4. Force module
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A. Maxillary excess
Head gear (Cervical or Occipital pull)
Some combination of skeletal and dental
changes occur, and, in most instances,
tooth movement changes exceed skeletal
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A. Maxillary excess
Head gear (Cervical or Occipital pull)
For orthopedic changes forces used are in the range of 250 to 500 gram/side.
For dental movement they are in the range of 100 to 200 gram/side
Headgear should usually be worn for at least 14 hrs/day to achieve successful results.
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A. Maxillary excess
Head gear
Cervical pull headgear:
• Extraoral anchorage is at the back of the neck
• Causes extrusion of the upper first molars so
used in correction of class II cases with deep
bite
 Orthopedic
1. Headgear

➢ Anteroposterior problems
A.Maxillary excess

Head gear
Occipital pull headgear:
• Anchorage at the back of the head on the
occipital bone
• Used in Class II correction in which
controlling anterior open bite tendencies is
part of the problems.
 Orthopedic
2. Facemask

➢ Anteroposterior problems
B. Maxillary deficiency
Protraction head gear
Also known as Facemask or
reverse pull headgear
 Orthopedic
2. Facemask

➢ Anteroposterior problems
B. Maxillary deficiency
Protraction head gear
 is used for skeletal and dental protraction of
the maxilla in Class III malocclusions caused
by a maxillary deficiency.
 Protraction headgear exerts a mesial force on
the maxilla below the center of resistance with
an equal and opposite reciprocal force on the
chin and forehead.
 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup
 The objective of early treatment with the use
of a chin cup is to provide growth inhibitor or
redirection and posterior positioning of the
mandible.
 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup
The orthopedic effects of a chin cup on the mandible
include:
1-Redirection of the mandibular growth vertically.
2-Backward repositioning (rotation) of the mandible.
3-Remodeling of the mandible with closure of the gonial
angle.
 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup
Early correction of an anterior cross-bite with chin cup
appliance prevents retardation of antero-posterior
maxillary growth
 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup
• Most of the reported studies recommended an
orthopedic force of 300 to 500 g per side.
• Patient are instructed to wear the appliance 14hr/day.
• Orthopedic force is usually directed either through the
condyle or below the condyle.
 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup

Occipital-pull chin cup. Vertical-pull chin cup

 Orthopedic
3. Chin cup

➢ Anteroposterior problems
C. Mandibular excess
Chin cup
Vertical-pull chin cup: used in patients presenting with
a steep mandibular plane angle and excessive anterior
facial height.

Vertical-pull chin cup

 Orthopedic
4. Myofunctional appliances

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
The force in these appliances is derived from: the
function of the oro-facial and masticatory muscles.
Myofunctional appliances could be used for:
◼ growth modification.
◼ tooth movement.
◼ Both.
 Orthopedic
4. Myofunctional appliances

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
• Monoblock
• Twinblock
• Fixed functional appliance
 Orthopedic
4. Monoblock (Activator)

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
• Monoblock (Activator, Andersen appliance)
It is used for growth modification in cases of
developing Class II div.1 malocclusion.

The theory of its action is that by constantly

positioning of the mandible in a more favorable
forward position, it will allow all remaining growth to
be expressed forward.
 Orthopedic
4. Monoblock (Activator)

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
• Monoblock
 Orthopedic
4. Twinblock

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
•Twinblock
The bite blocks acts as a guiding mechanism
causing the mandible to be displaced downward
and forward
 Orthopedic
4. Fixed Functional appliances

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
• Fixed functional appliance
Due to the bulk and inconvenience, removable functional
appliance failed to attract patients cooperation. In addition
their intermittent wear does not elicit continuous muscle
activity which is essential for promoting skeletal change
 Orthopedic
4. Fixed Functional appliances

➢ Anteroposterior problems
D. Mandibular deficiency
Functional appliances
• Fixed functional appliance
 Orthopedic
5. Skeletal expanders

➢ Transverse problems
Maxillary expansion
Hyrax expander
Hyrax Rapid Palatal Expander RPE. The
Rapid Palatal Expander (RPE) is one of the
best orthopedic appliances available in
orthodontics. It works by widening the bone
in the upper arch through the mid palatal
suture
 Orthopedic
5. Skeletal expanders

➢ Transverse problems
Maxillary expansion
Hyrax expander
 Orthopedic
5. Skeletal expanders

➢ Transverse problems
Mandibular expansion
 In the lower jaw there is no cartilage suture that can be
used to widen the lower jaw, so any expansion that
occurs is generally expansion of only teeth
 Most of expansion protocols depends on surgically
assisted expansion
 Orthopedic
5. Skeletal expanders

➢ Transverse problems
Mandibular expansion
 Recently some expanders like those used in the upper
arch have been used to expand the mandible before
puberty (i.e., Schwartz appliance)
Orthodontic treatment
 Orthodontic
A.Removable appliances

made from a plastic plate with wires coming from the sides that can be removed by the patient.
Components of removable appliances
1. Active components
2. Retentive components
3. Acrylic base plate
 Orthodontic
A.Removable appliances

Advantages of removable orthodontic appliance

 Removable nature of appliance make it possible for the patient to maintain good oral
hygiene during treatment
 Take less chair side time for orthodontics , as they are fibricated in labrotary
 Damaged appliances can be removed by patients .
 Apparently simple to fabricate, use and adjust.
 Less orthodontic scars and deleterious effect compared to fixed appliances such as
decalcification, caries under molar bands and white spots around bonded brackets and
gingivitis.
 Cost-effective
 Orthodontic
A.Removable appliances
 Orthodontic
A.Removable appliances

Components of removable appliances

1. Active components:
➢ Labial bows
➢ Springs
➢ Screws
➢ Elastics
 Orthodontic
A.Removable appliances

1. Active components:
Labial bows: Bows are active components that are
mostly used for incisor retraction (less than 4mm)
➢ Short labial bow: They are constructed using
0.7mm hard round stainless steel wire . It
consist of bow that make contact with the most
prominent labial teeth and two U loops that ends
as retentive arms distal to the canine . The short
labial bow is activated by compressing the U
loop
 Orthodontic
A.Removable appliances

1. Active components:
Labial bows: Bows are active components that
are mostly used for incisor retraction
➢ Long labial bow: similar to the short labial
bow except that it extends from one first
premolar to opposite first premolar . The distal
arms of the U loops are adapted over the
occlusal embrasure between the two premolars
to get embedded in the acrylic plate
 Orthodontic
A. Removable appliances

1. Active components:
Labial bows: Bows are active components that
are mostly used for incisor retraction
➢ Wrap around labial bow: used mainly in
extraction cases to avoid space opening of the
extracted premolar. The wire extend distal to
the 2nd molar or maybe soldered on adam’s
clasp
 Orthodontic
A. Removable appliances

1. Active components:
Labial bows: Bows are active components that are mostly used for incisor retraction
Activated labial bow appliance without sufficient relief of acrylic base plate for incisor
retraction is a common mistake . The palatal acrylic is so trimmed that it would allow
greater movement of incisors at the cingulum , thereby minimising tipping at incisal edge
The conventional labial bow should uniformly touches labial surface of all the teeth being
retracted . To retract the single malpositioned incisor , labial bow activation should be
minimal and gentle . heavy force can produce pain , pulpitis and non-vital tooth .
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
Active components which are used to achieve
various tooth movement in. the direction of
tooth movement is determined by the point of
contact between the spring and the tooth
flexibility of the spring to a large extent
depends upon diameter of wire. force can be
decreased by increasing the length of wire .
Thus springs that are longer are more flexible
and remains active for long duration of time
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
➢ Finger spring
Also called single cantilever spring as one end is fixed
in acrylic and the other end is free . It is constructed
using 0.6mm wire . It consist of active arm of 12-
15mm length ,a helix of 3mm internal diameter and
retentive arm of 4-5 mm length .
It is used for mesio distal tooth movement when teeth
are located correctly in bucco lingual direction. it is
activated by moving active arm toward the teeth
intended to be moved .
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
➢ Z spring
The ‘z’ spring is also called double cantilever
spring . It is made up of 0.5mm wire . The spring
consist of two coil of very small internal diameter
.it should be placed perpendicular to palatal
surface of tooth . The spring can be made for
movement of single incisor or two incisor . It is
activated by opening helices by about 2-3 mm at a
time
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
➢ T spring
It is made of 0.5 mm wire . The spring consist of t
shaped arm whose arm are embedded in acrylic. It is
used for buccal movement of premolar and some
canine . It is activated by pulling the free end of the t
toward the intended direction of tooth movement
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
➢ Canine retractor
It is indicated in bucally placed canine and canines
placed high in the vestibule . They are used to move
canine in distal as well as palatal direction . It consist
of a coil of 3mm diameter , an active arm and a
retentive arm .
 Orthodontic
A. Removable appliances

1. Active components:
Springs:
➢ Canine retractor
For distal canine retraction , enough acrylic should
be removed in the alvelous are to accommodate large
buccolingual dimension of the distally moving
maxillary canine.
To minimize tipping and rotation during canine
retraction, the point of contact of activated spring
arm should be as gingival as possible without
damaging the gingiva .
 Orthodontic
A. Removable appliances

1. Active components:
➢ Screws:
Active component that can be incorporated in a
removable appliance . Screw can be activated by
the patient at regular intervals using a key.
Removable appliances having a screw usually
consist of split acrylic plate and adam’s clasps on
the posterior teeth. The screw is placed connecting
the split acrylic plate .
 Orthodontic
A. Removable appliances

1. Active components:
➢ Screws:
Screw can bring about three types of movement :-
(a) expansion of arch
(b) movement of one or a group of teeth in a
buccal or labial direction
(c) movement of one or more teeth in a distal or
mesial direction
 Orthodontic
A. Removable appliances

1. Active components:
➢ Screws:
 Orthodontic
A. Removable appliances

1. Active components:
➢ Elastics
Elastics as active components are seldom used
along with removable appliances. They are
mostly used in conjunction with fixed
appliances.
 Orthodontic
A. Removable appliances

2. Retentive components:
They are the component that help in keeping the
appliance in place and resist displacement.
Adequate retention of a removable appliance is
achieved by incorporating certain wire component
that engage undercuts on the teeth. These wire
components that aid in retention of a removable
appliance are called clasp .
 Orthodontic
A. Removable appliances

2. Retentive components: Requirement of ideal clasp

1. It should offer adequate retention.
2. It should permit usage in both fully erupted as well as partially erupted teeth.
3. They should not themselves apply any active force that would bring about undesired tooth
movement of the anchorage teeth.
4. It should be self cleansable.
5. It should be easy to fabricate.
6. It should not impinge on the soft tissues.
7. It should not interfere with normal occlusion.
 Orthodontic
A. Removable appliances

2. Retentive components:
➢ Adams clasp
The clasp is constructed using 0.7mm hard round
stainles steel wire . Adams clasp is made up of
three parts (a) two arrowheads (b) bridge (c) two
retentive arms
Two arrow heads engage the mesial and the distal
proximal undercuts. The arrow heads are connected
to each other by a bridge that is at 45 degree to the
long axis of the root
 Orthodontic
A. Removable appliances

2. Retentive components:
➢ Adams clasp Advantages of adams clasp
• It is rigid and offers excellent retention
• It can be fibricated on decidious as well as permanent teeth.
• They can be used in partially or fully erupted teeth.
• It can e used on molars, premolars and on incisors .
• No special instrument is needed .
• It is small and occupies minimum space .
• The clasp can be modified in a number of ways
 Orthodontic
A. Removable appliances

2. Retentive components:
➢ Circumferential clasp
It is also known as three-quarter clasp or `C’ clasp . They
are simple clasp that are designed to engage the bucco-
cervical undercut.
This clasp cannot be used in partially erupted teeth
where the cervical undercut is not avilable for clasp
fabrication .
 Orthodontic
A. Removable appliances

2. Retentive components:
➢ Jackson’s clasp
It is also called full clasp or ‘U’ clasp . The clasp engage
the buccocervical undercut and also the mesial as well as
distal proximal undrecuts.
This clasp cannot be used in partially erupted teeth. Also
it is hard to be adapted to the tooth clinically.
 Orthodontic
A. Removable appliances

2. Retentive components:

Ball Clasp Arrow Clasp Finger Clasp

 Orthodontic
A. Removable appliances

3. Acrylic base plates:

The bulk of removable appliance is made of the
acrylic base plate. The prime function of the base
plate is to incorporate all the components together
into the single function unit.
 Orthodontic
A. Removable appliances

3. Acrylic base plates: Uses of base plates

(a) The base plate unites all the components of the
appliance into one unit.
(b) Helps in anchorage
(c) It provides support for the wire components.
(d) Helps in distrubting the forces over a larger area.
(e) Bite planes can be incorporated into the plate to treat
specific orthodontic problems.
(f) Baseplate of 1.5 to 2mm thickness offers adequate
strength.
 Orthodontic
B. Fixed appliances

The most common type of orthodontic appliances in use today.

They consist of small brackets that are attached onto the front surface of the teeth with a dental
adhesive.
They enable the orthodontist to accurately move the teeth into the desired position.
 Orthodontic
B. Fixed appliances

Advantages of fixed orthodontics

a) Retention presents no problem,
b) Less skill is required from the patient.
c) It is possible to bring about tooth movements with fixed appliances, which are not
possible with removable appliances (torque and bodily movement).
d) Many teeth could be moved at the same time.
 Orthodontic
B. Fixed appliances

Disadvantages of fixed orthodontics

a) Appliances fixed to the teeth are more difficult to clean than removable appliances,
and it is more difficult to maintain oral health during appliance treatment.

b) The possibility of producing adverse tooth movement.

 Orthodontic
B. Fixed appliances

Fixed or removable appliance

1-Cooperation and intelligence of patient and parents.

2-Type of tooth movement required.
3-Individual preference of the operator.
4-The amount of adequate supervision possible.
5-The general condition of the mouth and teeth.
 Orthodontic
B. Fixed appliances
Components of Fixed appliance
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

1) Attachments: (brackets, tubes & auxillaries)

Brackets Tubes
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

1) Attachments: (brackets, tubes & auxillaries)
Brackets are the small metal squares
that are attached to the front and side
teeth. They act like handles that allow
us to grab onto the teeth to move
them. They are bonded directly to the
enamel of the tooth with a special
adhesive.
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

1) Attachments: (brackets, tubes & auxillaries)

Brackets

Traditional esthetic
Self ligating
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

1) Attachments: (brackets, tubes & auxillaries)

Auxillaries
 Orthodontic
B. Fixed appliances

Elastic seperators (spacers)

The purpose of spacers is to create a little space between certain teeth, usually molars, so that
orthodontist can install metal bands around those teeth
 Orthodontic
B. Fixed appliances

Elastic seperators (spacers)

 Orthodontic
B. Fixed appliances

There are two ways to fix the attachment on the tooth surface:
a) The brackets or tubes are welded to a stainless steel band that fit around the tooth and is cemented to it
or
b) By using acid etch & composite; the tooth surface is etched and the base of the bracket or tubes has a
meshwork for mechanical retention.
 Orthodontic
B. Fixed appliances

There are two ways to fix the attachment on the tooth surface:
Orthodontic bands
 Orthodontic bands are made from stainless steel and are cemented in place with glass ionomer
cements. Glass ionomer is the cement of choice due to its fluoride releasing properties.
 Molar bands are part of some orthodontic treatments involving braces, but they're not necessary for
everyone
 Orthodontic
D. Orthodontic treatment

There are two ways to fix the attachment on the tooth surface:
Orthodontic bands
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

2) Arch wires
According to the material used:

a) Stainless Steel alloys.

b) Nickel Titanium alloys (NITI)

 Orthodontic
B. Fixed appliances

Components of Fixed appliance

2) Arch wires
a) Stainless Steel alloys:
Used for most orthodontic wires

• Resistance to corrosion
• Low cost
• Excellent formability
• Good mechanical properties
• Can be soldered and welded for the fabrication of complex appliances
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

2) Arch wires
b) Nickel Titanium alloys (NITI):

• Useful during the initial orthodontic alignment.

• Can apply a light force over a large range of activations.
• Shape memory
• Superelasticity
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

Round
2) Arch wires
According to the cross section:

a) Round.
b) Rectangular or square Rectangular

c) Multistrand or braided.

multistrand
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

3) Ligature ties
An elastic tie (a type of ligature) is the rubber tie that fits
around brackets. With some types of braces, this elastic tie is used to
hold the arch wire in place
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

3) Ligature ties

It could be separated O ties

Or
Continuous power chain
 Orthodontic
B. Fixed appliances

Components of Fixed appliance

3) Ligature ties
+ Fixed
1-Precise control over force distribution to
individual teeth means that rotation and
controlled root movement are possible
2-Multiple tooth movements can be
performed simultaneously.
3-Complex to make and use, so special
training is needed
4-Chair side time is comparatively long.
5-Components are costly.
6-Oral hygiene is made more difficult.
Removable
1-Single point application of forces
means that only tipping movements are
readily produced.
2-Usually only a few teeth should be
moved on any one time.
3-Comparatively simple and should be
within the scope of the dental practitioner
for carefully selected cases.
4-chair side time is short but laboratory
time greater than for fixed appliances.
5-Components are cheap.
6-As the appliance is removable the
problems of oral hygiene should not be
increased
 Camouflage
D. Camouflage orthodontic treatment

It is the procedures of correction of dental malocclusion in adult by orthodontic appliance aiming to

mask for skeletal discrepancy.
 Adjunctive
E. Adjunctive orthodontic treatment

Adjunctive orthodontic treatment

These are orthodontic tooth movements carried out facilitate other dental treatments as
conservative, prosthodontic and implant. Also it improves periodontal condition and function.

• Uprighting of posterior teeth.

• Alignment of anterior teeth and gaining space for single tooth implant.
• Cross bite correction.
• Forced eruption.
 Orthognathic
E. Orthognathic surgery

Orthognathic surgery
A team clinical work between orthodontic and surgeon for correction of skeletal problems in adults.
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