Professional Documents
Culture Documents
Finishing stage
Mohammed Almuzian
.
Table of Contents
Key papers........................................................................................................................................3
A. Aesthetic aims..........................................................................................................................3
a) Extra oral aims:........................................................................................................................3
1. Static aims............................................................................................................................3
2. Dynamic smile aims.............................................................................................................3
b) Intraoral aims...........................................................................................................................3
I. Tooth Size Discrepancies.....................................................................................................3
II. Gingival Levels....................................................................................................................4
Four characteristics contribute to ideal gingival form......................................................................4
To make the correct decision, it is necessary to evaluate 3 criteria.................................................4
III. Gingival Form..................................................................................................................5
I. Levelled Marginal Ridges....................................................................................................5
II. Correct first order bend........................................................................................................5
According to the American Board of Orthodontics (ABO, 1998) (Kokich 2003)...........................5
One of the methods to correct rotation is.........................................................................................5
III. Correct second order bend: this can be done by wire bending or rebonding and
correcting root parallelism................................................................................................................6
IV. Correct third order bend:..................................................................................................6
The importance of correct teeth inclination are:..............................................................................6
The errors in the third order bend could be assessed by assessing:.................................................7
V. Alter the vertical relationship of incisors as a finishing procedure, either correcting
moderately excessive overbite or closing a mild anterior open bite................................................8
Normal OB is essential for:..............................................................................................................8
VI. Correct the OJ...................................................................................................................9
Normal OB is essential for:..............................................................................................................9
A slight increase in the OJ is acceptable when................................................................................9
VII. Correct the ML relationship.............................................................................................9
VIII. Buccal Root Torque of Premolars and Molars...............................................................10
IX. “Settling” of the teeth.....................................................................................................10
Feature of optimal interdigitation:..................................................................................................10
Methods for Settling the Teeth.......................................................................................................10
Indication of positioner..................................................................................................................11
Key papers
Kokich VG (2003)
McLaughlin RP and Bennett JC (1991)
McLaughlin RP and Bennett JC (2003)
Poling 1999
A. Aesthetic aims
1. Static aims
It mainly involved correct position of U in relation to APog plane and L incisors in relation to
APog plane and MP.
b) Intraoral aims
• As a general guideline, a 2 mm tooth size discrepancy noted from Bolton analysis is the
threshold for clinical significance (Othman 2007)
• When the problem is tooth size deficiency, it is necessary to leave space between some teeth,
which may or may not ultimately be closed by restorations. In case of a diminutive laterals, 2/3 of
the space should be distal to lateral and 1/3 mesial. (for best aesthetic, Kokich 2003)
• More generalized small deficiencies can be masked by altering incisor position in any of several
ways. To a limited extent, torque of the upper incisors can be used to compensate: leaving the
incisors slightly more upright makes them take up less room relative to the lower arch and can be
2. Second, the gingival margins of the central incisors should be positioned more apically
than the lateral incisors and should be at the same level as the canines.
3. Third, the contour of the labial gingival margins should mimic the cementoenamel
junctions of the teeth.
• The cause of These discrepancies could be Abrasion of the incisal edges delayed migration of
the gingival margins.
• The proper solution for the problem: orthodontic movement to reposition the gingival margins
or surgical correction of gingival margin discrepancies.
2. If the shorter tooth has a deeper sulcus, excisional gingivectomy may be appropriate to
move the gingival margin of the shorter tooth apically. However, if the sulcular depths of the
short and long incisors are equivalent, gingival surgery will not help. So orthodontic extrution
with selective grinbding or intrusion with build up will help.
5. The third step is to determine if the incisal edges have been abraded. This is best
appreciated by evaluating the teeth from an incisal perspective. If one incisal edge is thicker
labiolingually than the adjacent tooth, this may indicate that it has been abraded, and the tooth
has overerupted. The best method of correcting the gingival margin discrepancy is to intrude the
short central incisor
2. This space is usually due to one of three causes: tooth shape (corrected by IPS or
composite restoration), root angulation (corrected by uprighting), or periodontal bone loss
(corrected by orthodontic extrusion to relocate the papillae)
B. Functional aims
To provide a mutually protected occlusion.
III. Correct second order bend: this can be done by wire bending or rebonding and correcting
root parallelism
• In contemporary edgewise practice, it has been almost totally abandoned in favor of angulated
bracket slots that produce proper root paralleling when a flexible full-dimension rectangular wire
is placed. A root-paralleling moment is a crown-separating moment in edgewise technique just as
it is in Begg or any other technique. It is important to remember this effect. Either the teeth must
be tied together or the entire archwire must be tied back against the molars to prevent spaces
from opening. Not only extraction sites but also maxillary incisors must be protected against this
complication. Also tying the maxillary incisors together, which can be done conveniently with a
segment of elastomeric chain from the mesial bracket of one upper lateral incisor across to the
mesial bracket of the other, is necessary during finishing.
• In the Begg technique, the moments necessary for root positioning were generated by adding
auxiliary springs together across extraction sites.
• In the modified Begg technique using the Tip-Edge appliance, root paralleling is accomplished
with uprighting springs, very much as it was with traditional Begg treatment. The rectangular
wire is used primarily for torque (faciolingual root movement), not the mesiodistal root
movement needed for root paralleling after teeth were allowed to tip during space closure.
b) Functional purpose
c) Stability
d) PD health
D. The fourth and final criterion is best evaluated from an occlusal perspective. When the
incisors are viewed from an occlusal perspective, the cingulum of an improperly inclined incisor
is more prominent or more visible.
In the Begg technique, the incisors are deliberately tipped back during the second stage of
treatment, and lingual root torque is a routine part of the third stage of treatment. This is
accomplished with an auxiliary appliance that fits over the main or base archwire. The torquing
auxiliary is a “piggyback arch” that contacts the labial surface of the incisors near the gingival
margin, creating the necessary couple with a moment arm of 12/1.
These piggyback torquing arches can be used in edgewise technique in the same. Although they
come in a number of designs, the basic principle is the same: the auxiliary arch, bent into a tight
Other method same like the above but include bending a loops parallel to occlusal plane in 016
or 014ss. This has been described by Sandler in the Art Meets Science course.
Another method is to use the built in torque and express it with full dimension AW or adding
torque to the wire or sometime inverting the brackets.
The Burstone torquing arch. It can be particularly helpful in patients with Class II, division 2
malocclusion whose maxillary central incisors are severely tipped lingually and require a long
distance of torquing movement, while the lateral incisors need little if any torque.
• Stability of treatment
• Functioning by incising the food: Normal OB is essential for mutually protected occlusion. The
purpose of overbite is to permit the anterior teeth to function or incise food in protrusive jaw
position, while the posterior teeth are out of occlusal contact. Therefore, the amount of overbite
necessary to accomplish the task of disoccluding the posterior teeth is actually determined by the
length of the cusps of the premolars and canines. Some premolars have shallow cuspal anatomy,
and therefore the overbite required to disclude this type of tooth anatomy would be small,
perhaps one to two millimeters. However, some patients have long cusps on the maxillary and
mandibular premolars and canines. In this situation the anterior overbite must be greater, perhaps
3 to 4 mm, to disclude the posterior teeth. If the overbite is not deep enough, then the patient
would only contact the posterior teeth in protrusive jaw position, making it impossible to incise
food.
• Abraded or eroded teeth that will be resored and the restorative need some clearance
• It is more effective to use Class II or Class III elastics bilaterally with heavier force on one side
than to place a unilateral elastic.
Indication of positioner
1. As a retainer
3. Provide further minor correction following deboned and thus "guide" the settling of the
occlusion.
4. They were particularly beneficial at the end of Begg treatment in which stage III (the
finishing phase) is difficult.
5. They may also be useful in instances when the desired finish was not achieved or the case
had to be discontinued early.
6. For patients with persistent anterior or posterior tongue habits. A properly constructed
positioner can have a bite-closing effect.
• Sometimes when Class II elastics are used, patients begin to posture the mandible forward so
that the occlusion looks more corrected than it really is and if the appliances are removed at that
These considerations lead to the guidelines for finishing treatment when interarch elastics have
been used:
• When an appropriate degree of overcorrection has been achieved, the force used with the
elastics should be decreased while the light elastics are continued full time for another
appointment interval;
• At that point, interarch elastics should be discontinued, 4 to 8 weeks before the orthodontic
appliances are to be removed, so that changes due to rebound or posturing can be observed. It is
better to tell the patient that he or she is getting a vacation from the elastics and that some further
elastic wear may be necessary if changes are observed, rather than saying that elastics are no
longer needed. If changes do occur, that makes it easier for patients to accept that the vacation is
over and another period of elastics is needed.
• If the occlusion is stable, as a final step in treatment, the teeth should be brought into a solid
occlusal relationship without heavy archwires present, using one of the methods described above.
D. Periodontal aims
I. Root Angulation
• During finishing, orthodontists typically use a panoramic radiograph to determine if the roots of
the teeth are oriented properly relative to adjacent roots.
• In theory, if the roots of adjacent teeth are perpendicular to the occlusal plane, and parallel with
one another, then there will be sufficient bone between the roots of teeth.
• First of all, is a panoramic radiograph an accurate depiction of the root angulations of adjacent
teeth? Researchers have evalucated this questions and conclude that there are distortions
produced with a panoramic radiograph, especially in the maxillary and mandibular canine/first
premolar regions, where the archform curves. However, recognizing these minor inadequacies,
the panoramic radiograph is probably a reasonable screening tool in general. In specific
• A second aspect that requires discussion is whether close root proximity will actually cause
detrimental long-term effects. This question was investigated, and the authors concluded that
close root proximity did not produce detrimental effects in their sample. These authors cautioned
that their sample was relatively young, and was not a sample of patients that were susceptible to
periodontal disease. Whether or not close root proximity enhances interproximal bone destruction
in a sample of periodontal patients is not known. However, close root proximity after orthodontic
treatment will cause problems in certain restorative patients.
• In adult patients with prior periodontal disease and interproximal bone loss, the incisal edges or
marginal ridges of the teeth are not reasonable guides for vertical positioning of adjacent teeth. If
the patient has horizontal bone loss in the maxillary or mandibular anterior regions , it is best to
align the bone levels rather than adjacent teeth. In these situations, the orthodontist must
equilibrate the incisal edges as the bone is leveled to establish the correct incisal edge position,
occlusion, and crown-to-root relationships.
• This modification is said to reduce the possibility that the height of the gingival attachment will
be reduced after the surgery, and it is particularly indicated for esthetically sensitive areas (e.g.,
the maxillary incisor region). Nevertheless, there is little if any risk of gingival recession with the
original CSF procedure unless cuts are made across thin labial or lingual tissues. From the point
of view of improved stability after orthodontic treatment, the surgical procedures appear to be
equivalent.