Orthodontics

Fifth Class College of dentistry

Dr Firas Lecture no 7

Space creation

Treatment planning involves initially visualizing the tooth movements

needed and assessing what space required to bring them about. If done
formally, this is known as space analysis and can greatly assist in the process of
treatment planning because it provides a numerical value for the space required
within each dental arch, aid in deciding whether teeth need to be extracted and
how the mechanics and anchorage are managed to ensure the treatment aims
are achieved.
Space analysis or visualized treatment objective is an essential part of
orthodontic treatment planning. The first assesses space requirements in each
dental arch. The second is an assessment of how space will be created and used
in treatment. If the analysis has been correctly done, the balance of space
required and how this is created and used should equal zero. If not, the
treatment aims should be reviewed and modified appropriately.

There is an international rule about the space available and space required:
If there is 3 mm and less arch deficiency; no need of extraction or
distalization. But if the deficiency is 4 mm and more; so, extraction and other
means of space gaining is the choice.

There are essentially four methods available to the orthodontist for the creation
of the space within the dental arches:
• Extraction of teeth
• Transverse expansion of the dental arch
• Anteroposterior lengthening of the dental arch
(Distalization).
• Reduction of tooth size

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 Extraction of teeth
One of the most effective ways to create space is by the extraction of teeth. However,
the decision to extract and the choice of teeth will depend upon a number of factors:

Degree and site of crowding

Dental crowding most commonly manifest in the incisor region, but it's not
routine practice to remove these teeth, particularly in the maxillary arch,
because they are integral to both dental and smile aesthetic. If the degree of
crowding is severe enough to require extraction, teeth are usually removed
Buccal segment: The canine, premolar and molar teeth.
from the buccal segments. The further a tooth is situated from the site of
crowding; the less space will be available for tooth alignment. So, if we have
severe crowding its simpler to extract teeth closer to the site of the crowding.

Inappropriate extraction of first premolars in cases with mild crowding can

lead to excessive space and over-retraction of the labial segments following
space closure with fixed appliances. Therefore, if dental crowding is mild,
consideration should be given to extraction of second premolars, or non-
extraction treatment if possible. In the upper arch, second molar extraction
provides little mesial space, but does facilitate distalization of the buccal
segments with head gear and is associated with more reliable third molar
eruption.

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Type of malocclusion
In class I malocclusion requiring premolar extraction to relieve crowding in
the mandibular arch, the corresponding premolar teeth are usually extracted
from the maxillary arch. This helps maintain the buccal segment relationship as
class I
In a class II malocclusion, one of the aims of treatment will be to correct the
incisor relationship. But a common extraction pattern for class II cases involves
upper first premolars and lower second premolars, which aids in both molar
and incisor correction, or we can do just upper premolar extraction and finish
the case with class II molar relation.
For the class III cases, if premolar extractions are needed, it is usual practice
to extract lower first premolars and upper second premolars, but sometimes we
do extract just the lowers and finish the case with class III molar relation.

Presence and position of teeth

In cases of hypodontia as congenital missing of lateral incisor we have an
option of removing the remaining lateral incisor to maintain arch symmetry,
especially if it's diminutive in form. This involves modifying the shape of
maxillary canine crowns to more resemble lateral incisor.

Maxillary canines are commonly associated with impaction; if the

malocclusion require space provision in the maxillary arch and one or both
canines are in poor position, and also the teeth are well aligned, consideration
can be given to their removal.

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Dental health of teeth
Heavily restored, carious or hypoplastic teeth should always be considered
for elective extraction. During planning for orthodontic extractions, a
potentially compromised tooth should always be removed in preference to
healthy one. First permanent molars are not a routine choice for orthodontic
extraction, but if they have a poor long-term prognosis so we can remove them
as a choice of extraction.

Arch expansion
Increasing dental arch dimensions, in both the Anteroposterior and transverse
planes can create space. Problems with this strategy can arise because the teeth
occupy a zone of equilibrium between the soft tissue forces of the tongue on
one side and the lips and cheeks on the other. If the teeth are moved
excessively in their buccal or labial directions, they will move outside this zone
of stability and potentially be subjected to unbalanced forces that tend to return
them to their previous position.

Anteroposterior space can also be created by proclination of the incisors. This

would be an attractive option, particularly in the lower arch where crowding
often occurs.

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Reduction of tooth widths
Space can also be created within the dental arch by reducing the width of
individual teeth. This is usually done directly by removing enamel with
handheld polishing strips, discs with slow handpiece or fine tungsten carbide
and diamond burs with an air turbine. Reduction not be undertaken on parallel-
sided teeth that have contact points extending subgingivally.
The disking is only useful for the mild crowding and the amount of tooth
reduction is from 0.1 mm and up to 1.0 mm depending on the position of teeth,
buccal or labial.

Distalization of teeth
Correction of class II malocclusion without extraction requires maxillary
molar distalization by means of intraoral or extraoral forces. For cases with
minimal arch length discrepancy and mild class II molar relationship associated
with a normal mandibular arch, molar distalization is of significant value.
Conventional extraoral traction has been successful in correcting class II
malocclusion, either by restraining forward growth of the maxilla or by
distalizing maxillary molars. However, these appliances rely partially or totally
on patient cooperation. This is why clinicians often prefer intraoral distalization
appliances that minimize the need for patient cooperation.
Numerous alternative intraoral noncompliant appliances, such as
pendulum, the distal jet, the K-loop molar distalizer, double loop NiTi and C

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space regainer have been developed, and many well-documented studies have
substantiated their effects. These appliances have drawbacks of anchor loss,
proclination of the maxillary incisors, tipping of the maxillary molars and
difficulty in keeping the molars in position following distal movements.

Space is easier to gain in the maxillary arch than in the mandible because of
increased trabecular structure of supporting bone and increased anchorage
afforded by palatal vault.

Ended