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The preadjusted orthodontic appliance has improved the efficiency and effectiveness of the orthodontist in
achieving good final results for patients in general. However, the orthodontist is limited in achieving excellent
final results because of individual patient variation from the prescription of the preadjusted appliance as well
as the orthodontist’s ability to precisely place the appliance. This article presents a comprehensive system
of evaluation of the individual patient to be used during the finishing stage of treatment and a written system
of notation that can guide the orthodontist in producing an excellent finished result for each patient. In this
system the orthodontist considers multiple aspects of esthetics, occlusion and function, periodontal health
and root alignment, and stability. Every feature of these characteristics is examined and desired changes
are noted on the “Detailing Form” resulting in a written plan that guides the orthodontist to achieve
excellence in finishing. This written form can also act as a final checklist of obtainment of the goals of
orthodontic treatment. This system of finishing can improve the efficiency of the individual orthodontist and
assist in communication in multidoctor practices. (Am J Orthod Dentofacial Orthop 1999;115:476-87)
A A
B B
Fig 2. Finishing wires are marked interproximally with a Fig 3. A, Panorex illustrates the need for several root
wide mark at the midline, smaller interproximal marks, adjustments and because of this, the patient is not ready
and a solid mark at the right end to distinguish right from for final detailing procedures. B, Notations are made in
left. A black marker is used in the maxillary arch, and a the wire changes section of the Detailing Form where
red marker is used in the mandibular arch. wire adjustments are needed to align the roots of the
teeth. Notation is made in the same direction as the
bend will be made in the wire and indicates the degree
be flipped) are made. If there are any torque changes to of bend to be made.
be made in the wire, it is best to use a 0.019 × 0.025
titanium molybdenum alloy (TMA) (Ormco Corpora-
tion, Orange, Calif) finishing wire in a 0.022 slot. A what degree to make root angle bends. The notation is
0.017 × 0.025 TMA wire can be used in a 0.018 slot. drawn on the form in the same manner that the bend
This wire is still flexible and will engage the slot ade- will be made in the wire. A “V” bend in the maxillary
quately to deliver the desired movement. However, this wire would bring excessively divergent roots together.
wire is brittle and can break easily if one places too For example, when the maxillary central incisors’
many bends. In addition, this wire tends to collapse roots are too divergent, the proximal contact is located
with strong closing mechanics and may not hold arch too incisally and an unesthetic triangular black space is
form as well as a stainless steel wire. A 0.019 × 0.025 created. The orthodontist should make notations on the
stainless steel wire in a 0.022 slot is usually too heavy Detailing Form to make a “V” bend in the wire to
to make very many adjustments and still be able to upright the central incisors’ roots bringing them together
fully engage it into the slot without debonding the moving the proximal contact gingivally creating a nor-
bracket or causing excessive pain to the patient. mal gingival embrasure. If adjacent roots are too close
together, a “tent” bend is made to move them apart.
EXAMINATION OF THE PANORAMIC RADIOGRAPH Another common problem area is in root angulation of
FOR ROOT ANGLE BENDS maxillary second premolars and maxillary first molars.
A panoramic radiograph is obtained. While the For example, when evaluating the marginal ridges of the
assistant is preparing the wires, the orthodontist exam- maxillary second premolar and the maxillary first molar
ines the panorex (Fig 3A) for root parallelism and notes one may notice that the distal marginal ridge of the sec-
on the Detailing Form (Fig 3B) where, how, and to ond premolar is much more gingival than the mesial
American Journal of Orthodontics and Dentofacial Orthopedics Poling 479
Volume 115, Number 5•
A
Fig 5. Notations on TMJ findings are noted in the TMJ
section of the Detailing Form. In this patient, centric rela-
tion equals centric occlusion, there is canine disclusion
bilaterally, and there is incisal guidance in protrusive
excursion with a balancing interference between the
maxillary right lateral and the mandibular right canine.
A
Fig 8. Evaluation of maxillary right occlusal table.
A
Fig 9. Small maxillary second premolar.
cial attention in the second molar area (Fig 8). The ortho-
dontist should check the alignment of the central fossae
and the alignment of the functional lingual cusps. Often
the second premolar is smaller faciolingually and a com-
promise might have to be made in aligning the facial sur-
face of the tooth or in the position of the functional lin-
gual cusp of this second premolar (Fig 9). Notations
regarding changes to be made in the finishing wire are
made in the wire changes section of the Detailing Form. B
The same analysis of torque, parallel contours of
the facial surfaces, cusp length, occlusal table, central Fig 10. A, Evaluation of the occlusal table of mandibular
right segment. B, Notations of necessary wire changes.
fossae alignment, and lingual cusps alignment for the
Torque adjustments are indicated by a “T” notation;
maxillary left quadrant is completed, and notations
arrow shows direction of desired movement of tooth.
regarding changes to be made in the finishing wire are
noted in that section of the Detailing Form.
tours of the facial surfaces, need for torque changes for
EVALUATION OF THE MANDIBULAR ANTERIOR improvement in buccolingual inclination, alignment of
SEGMENT the functional buccal cusps, and cusp tip height (Fig
The mandibular anteriors canine to canine (Fig 7A) 10A). The alignment of the fossae and the flatness of the
are evaluated for even height of the four incisors, long occlusal table are also checked especially at the second
axis of the crowns, and normal triangular embrasures, molars. The flatness of the curve of Spee is evaluated.
rotations, and ideal torque. Torque of all four incisors Needed tooth position changes are noted in the wire
should be the same for the best stability especially if changes section of the Detailing Form (Fig 10B).
there were significant discrepancies in the labiolingual The focus is shifted to the left posterior segment
positions of the incisors initially. The mandibular and alignment of the facial surfaces, crown torque,
canines are checked making them a little higher than the alignment and height of the functional buccal cusps,
other more posterior functional buccal cusp tips for the central fossae alignment, and the flatness of the
best canine disclusion. The mandibular canine may be occlusal table are evaluated. Needed changes are noted
rotated out slightly on the mesial for the most stable con- on the Detailing Form.
tact with the mandibular lateral to resist the tendency for
lingual collapse and relapse. Appropriate notations are INTRAORAL EVALUATION OF ALIGNMENT AND
made in the wire changes section of the Detailing Form. INTERDIGITATION OF THE OCCLUSION
The next stage of the finishing process is an intrao-
EVALUATION OF THE MANDIBULAR RIGHT AND ral evaluation with the patient in a supine position. The
MANDIBULAR LEFT POSTERIOR SEGMENTS orthodontist evaluates dental alignment and need for
The orthodontist should then focus from the correction of rotations especially in the upper premolar
mandibular canine posterior to the molars on the area in positioning the maxillary functional lingual
patient’s mandibular right checking for parallel con- cusps to articulate into the distal fossae of the
American Journal of Orthodontics and Dentofacial Orthopedics Poling 483
Volume 115, Number 5•
mandibular premolars. The orthodontist should check It is most efficient to do all the bends at one
torque of the incisors with a mirror looking along the appointment although the patient is sore for 1 or 2
long axis of the tooth comparing torque with the adja- days. First, the orthodontist should place root angle
cent incisors. Next, the marginal ridge heights of the bends, then vertical and in/out bends starting in the
posterior teeth should be evaluated. maxillary wire. Finally, torque changes are made. If
The final evaluation step and the most important is both wires are being inserted at the Final Detailing
to view the occlusion with a mirror looking up under appointment, the finishing bends are made first in the
the buccal cusp tips and incisal edges of the maxillary maxillary wire, then the wire should be adjusted for
teeth and checking the meshing of the mandibular buc- flatness and coordinated with the mandibular wire.
cal cusps and lower incisal edges into the fossae of the Next, the mandibular wire is bent using the same
maxillary arch (Fig 11). Changes that need to be made sequence, adjusting flatness, and coordinating it with
to improve interdigitation should be noted in the wire the completed maxillary wire. Using this sequence pre-
changes section of the Detailing Form. serves the initial arch form of both wires.
If there is any question regarding the cusp to fossa Both wires are inserted and tied in with wire liga-
relationship or the occlusion in function, horseshoe tures using a snub nose plier to fully insert the wire into
articulating paper (Bausch Articulating Paper, Pulpdent the bracket slot and a wire director (Wire and Ligature
Corp, Watertown, Mass) (Fig 12) can be used to check Director No. 05, Dentronix Corporation) to completely
occlusal contacts. The orthodontist may prefer to eval- hold the wire ligature against the detail wire in the slot.
uate the patient’s centric relation-centric occlusion Full slot seating is desired. Closing mechanics may be
coincidence with the patient in the supine position; this used if there is concern about space reopening.
could be performed at this time.
FOLLOW-UP DEBAND CHECK APPOINTMENT
BENDING AND INSERTION OF THE “DETAIL” WIRE When the patient returns in 4 to 6 weeks for a
When all desired changes have been noted, the Deband Check appointment, the assistant will untie the
orthodontist must decide whether to bend the detailing wire completely, mark interproximals of each wire and
wire immediately with the patient present or whether to remove the wires. The orthodontist again will check
do so during nonpatient time. Bending a detailing wire the occlusion, and the assistant will note desired
during nonchair time is simplified by having all of the changes on the Detailing Form using another ink color
notes written on the Detailing Form for bends that need and noting the date with that same ink color (Fig 13).
to be made in the finishing wires. The bends are very The orthodontist makes the desired bends and the wire
subtle, and the orthodontist should be cognizant of the is inserted and completely tied in. When no more
potential undesirable side effects of each bend. Small changes are needed, appliance removal is scheduled.
subtle bends can be made using an AEZ Arch Bending
Plier (AEZ Arch Bending Plier, No. 803-0403, Ormco PROCEDURES AFTER REMOVAL OF THE
Corporation, Orange, Calif) that has blades 1.27 mm APPLIANCES
thick. If a snub-nosed plier with thick blades is used, When the appliances are removed (Fig 14), the
subtle bends will be difficult to make. Usually each orthodontist should check centric contacts with articu-
wire should have no more than ten adjustment bends. lating paper, equilibrate the occlusal contacts for even
484 Poling American Journal of Orthodontics and Dentofacial Orthopedics
May 1999
A
Fig 13. Use of another ink color at the Deband Check
appointment.
DISCUSSION B
Each orthodontist develops a vision of an ideal
result for every patient whenever a treatment plan is
developed, an appliance is selected and placed, and a
method of retention is planned. In the process of deter-
mining what will be an ideal result for the patient, the
orthodontist must consider factors in four major areas:
(1) esthetics, (2) occlusion and function, (3) periodon-
tal health and root alignment, and (4) stability. These
four areas are interrelated and often conflicting. Usu-
ally, the orthodontist has to prioritize the importance of
one desired result over a conflicting consequence of
treatment. For instance, an orthodontist may choose to C
“expand” a patient’s arch form to correct an arch length
deficiency, a dentoalveolar retrusion, and enhance Fig 14. Final occlusion.
esthetics, but then plan long-term fixed retention meth-
ods to allow for the compromise in stability that results
from expansion of arch form. deficient facial proportion and integumental form.
Margolis3 suggests a systematic method of analyzing
Esthetics the face and dentition in developing an orthodontic
First, in the area of esthetics, the orthodontist must treatment plan for adults.
make decisions regarding facial form and harmony, In his classic article on denture esthetics, Lom-
smile line characteristics, gingival display, incisor dis- bardi4 discusses several factors that also apply to
play, arch form, dental alignment and inclination, and esthetics of the natural dentition that the orthodontist
individual tooth characteristics. The major decisions should consider. In the evaluation of the patient, the
regarding esthetics are made when the treatment plan is practitioner should make an analysis of the shape of the
developed. Mack2 in a review of facial esthetics and mouth, especially the features of width and height and
treatment planning noted that a comprehensive evalua- location of the commissures when the mouth is in a
tion that relates the facial soft tissues to underlying smiling position. The orthodontist must consider these
skeletal form is necessary in planning correction of characteristics when finalizing arch form. If the ortho-
American Journal of Orthodontics and Dentofacial Orthopedics Poling 485
Volume 115, Number 5
dontist selects a very broad square arch form, the first ever, the orthodontist must decide what specific char-
premolar may be a key tooth in a natural transition acteristics the occlusion will have in three areas: (1)
from anterior to posterior. A natural gradual transition temporomandibular joints, centric relation, and centric
from front to back is critical for the best esthetics, and occlusion, (2) final occlusal pattern of maximum inter-
care should be taken to maintain a natural gradation of cuspation or achievement of the six keys of a normal
facial contour, height, and length. If the maxillary first occlusion,6 and (3) functional pattern of canine disclu-
premolar has excessive labial crown torque, is too short sion or group function.
gingivally, or too inset, the overall composition will be In the first occlusion area, current literature reveals
disrupted and will be unesthetic. In addition, if arch very limited interaction of morphologic and functional
form is too tapering, the maxillary central incisors will occlusal factors with temporomandibular dysfunction.7
be excessively dominant and could appear too promi- Nevertheless, a harmonious relationship between the
nent, even protrusive. occlusion and the temporomandibular joints should
Lombardi4 emphasizes the concepts of formal and exist.8 The orthodontist must evaluate if centric rela-
informal balance considering the visual weights over a tion is coincident with centric occlusion, if it is desir-
centrally located fulcrum. “Formal balance” requires sym- able to have these positions be coincident, if it is pos-
metry of the visual weights on both sides of the fulcrum, sible to achieve coincidence, and what occlusal
whereas “informal balance” exists when the visual changes could be made to bring about coincidence.9
weights are equal but not symmetric. When considering The second occlusion area to be evaluated and
the dental midline, Lombardi emphasized that the dental planned is the final occlusal pattern achieved in centric
midline should be placed in a stable position, and the occlusion. The orthodontist must decide if maximum
visual weights on either side should be in a state of equi- intercuspation10 with incisor contact is desirable and
librium. Uneven lengths of the maxillary anterior teeth achievable. Alternatively, the orthodontist may prefer to
can detract from this balance and esthetic harmony of the follow the principles of the “six keys to a normal occlu-
composition. There are also several “lines” to be consid- sion” as presented by Andrews.6 In achievement of this
ered in the esthetics of the dentition: the lines produced by final occlusal pattern, the orthodontist would focus on the
the occlusal plane in relation to the lips and smile line,5 the interdigitation of the maxillary first molar distobuccal
lines due to the shapes of the teeth, the lines from the rela- cusp into the mandibular second molar mesial marginal
tionships of adjacent teeth with regard to torque and angu- ridge. The clinician may prefer a “lingualized” occlu-
lation, the lines produced by lengths of the teeth and gin- sion.11,12 In determining ideal intercuspation, the ortho-
gival height, and lines produced by rotations of the teeth. dontist must consider every aspect of position of the
Parallel lines exhibit the most harmony. Lombardi4 further functional cusps and fossae, including axial inclinations,
discusses the impact of “negative” space in the composi- marginal ridges, and previous occlusal wear. Use of a
tion of the “positive” space. One should evaluate the smile systematic method of evaluation and planning changes
focusing on the negative space created at the commissures that are part of an integrated approach are facilitated by
of the lips as well as that between the arches. Also, treat- the use of the finishing system proposed in this article.
ment of the interarch negative space can impart age, sex, The third occlusion area to examine is the functional
and personality characteristics. For instance, straight, flat, pattern of occlusion.13,14 The orthodontist must decide
incisal edges with sharp corners can give the illusion of an the most ideal functional pattern for each patient, be it
older worn dentition. (1) canine disclusion in lateral excursions, (2) “group
Finally, the color and illumination of the dentition function” in lateral excursions and the extent of the
should be evaluated. Color enhancement through teeth involved in group function, and (3) positions of
bleaching or restorative procedures should be part of the incisors for anterior guidance.15 During finishing,
the finishing treatment plan. Use of the finishing sys- the orthodontist should examine the functional pattern
tem presented in this article will assist the orthodontist of the patient, make notations in the TMJ section of the
in focusing on the esthetic factors and design changes Detailing Form (Fig 5), and then note wire changes to
to achieve an excellent harmonious result. be made to adjust the positions of the teeth to bring
about the ideal functional pattern for that patient.
Occlusion and Function
The second major area the orthodontist must con- Periodontal Health and Root Alignment
sider in finishing is the final occlusion of the patient A third major area for the orthodontist to consider
and acceptability of function. As with overall esthetics, in the finishing stage of treatment is in periodontal
much of the general characteristics of the final occlu- health and root alignment. The orthodontist should
sion will be determined by the treatment plan. How- evaluate root proximities, interproximal alveolar bone
486 Poling American Journal of Orthodontics and Dentofacial Orthopedics
May 1999
crest and cementoenamel junction alignment, vertical such as when second molars are banded, there is a
bone defects, open triangular gingival embrasures or record on the Detailing Form of the necessary bends to
“black triangles,” gingival recession, gingival contours be made. If needed, a new wire can be marked with the
and ideal scalloping, pseudopocketing and gingival dis- patient present, bent during nonchair time and inserted
play, and fibrous frenula.16 In developing the original at the next appointment.
treatment plan, initial placement of the orthodontic In multidoctor practices, the Detailing Form can be
appliance, and in monitoring progress in treatment, the a communication tool among the orthodontists regard-
orthodontist must constantly be aware of root positions ing what finishing bends have been made in the wire.
of the teeth and condition of the periodontal tissues. In At the first Final Detailing appointment, the first ortho-
all adults, a thorough examination of the periodontium dontist can examine the patient and make the notations
including probing should be completed before develop- for the finishing procedures that need to be done. At the
ing the treatment plan and at the end of treatment. The next appointment, the second orthodontist can easily
panoramic radiograph should be used when the ortho- read the results of the detailing examination, determine
dontic appliance is placed as a guide for the best align- what changes in the patient’s occlusion have occurred,
ment of the roots. Although incisor root position has note additional adjustments to continue the finishing
not been shown to have long-term deleterious effects process so the next orthodontist will easily understand
on periodontal health,17 more ideal esthetics, function, the changes and progress that has been made.
and stability are enhanced through good root align- An orthodontist can do a miniature clinical research
ment. Additional periodontal procedures such as project if he or she wants to be aware of recurring prob-
frenectomies, gingivectomies,1 and circumferential lem areas in the placement of brackets or the weak-
fiberotomies should be considered to improve esthetics nesses in the preadjusted appliance being used. By col-
and stability. lecting several Detailing Forms of past patients and
analyzing them for notations that are common to all the
Stability patients, one can determine repeating patterns and
The final major area for consideration by the ortho- adjust bonding methods or appliance design.
dontist in finishing the patient’s orthodontic treatment Some orthodontists feel more comfortable reposi-
is in the stability of the result. Several factors con- tioning brackets to achieve a better result. Occasionally,
tribute to this stability, some are determined by the a bracket may have been placed so early that good
treatment plan, and some are a result of finishing and bracket placement was not possible, such as with par-
retention methods. tially erupted maxillary second premolars. In such a
Stability is affected by the decisions made during case, it is best to reposition a bracket. However, some
treatment planning, such as extraction of teeth, alter- orthodontists routinely use multiple bracket reposition-
ation of arch form, expansion of intercanine width, and ing to achieve better finishing with a straight wire.
treatment mechanics. Often the orthodontist may be Often this is done because the orthodontist is concerned
faced with a compromise in stability for improvement about making multiple bends in a wire that will not only
in an esthetic area. For example, the orthodontist may move the tooth in question, but also have undesirable
choose to expand arch form and intercanine width to effects on the adjacent teeth. A major problem of repo-
enhance esthetics yet make the result less stable. When sitioning brackets is that one still creates undesirable
the orthodontist has chosen such a compromise, he may side effects and there is no exact record of how the
select a fixed “permanent” retainer to improve reten- bracket was repositioned. In addition, if a tooth needs a
tion. During finishing, the orthodontist may “overcor- very minor adjustment, one is less likely to reposition
rect” some teeth that were severely rotated initially.18 the bracket and may just accept the minor rotation.
The orthodontist may select a “splint” retainer in a Sometimes a bracket may be repositioned, and it is still
patient who has a bruxism habit. The Detailing Form not in the desired position. Also, repositioning the
facilitates the evaluation of factors that may influence bracket causes a weakening of the bond besides etching
stability and impact the selection of the best method of the tooth an additional time. Finally, repositioning a
retention for each patient. bond on one tooth here and another tooth there, does not
allow one to “see” the whole picture evaluating facial
Improved Efficiency and smile esthetics as well as function and TMJ health.
In addition to the comprehensive integrated
approach that this method of finishing allows, there are CONCLUSION
also other procedures that are facilitated improving The system of finishing proposed in this article
efficiency. If there is need to bend a new finishing wire, forces the orthodontist to consciously examine, ana-
American Journal of Orthodontics and Dentofacial Orthopedics Poling 487
Volume 115, Number 5•
lyze, decide, and implement adjustments in the four 7. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and
temporomandibular disorders: a review. J Orofac Pain 1995;9:73-90.
major areas of esthetics, occlusion, periodontal health 8. Buhner WA. The gestalt of occlusion: a clinical appraisal. J Prosthet Dent
and root alignment, and stability to bring about that 1980;44:545-51.
9. Timm TA, Herremans EL, Ash MM Jr. Occlusion and orthodontics. Am J Orthod
vision of the ideal result. This method of finishing also 1976;70:138-45.
improves the efficiency of the orthodontist in achieving 10. Haeger RS, Schneider BJ, BeGole EA. A static occlusal analysis based on ideal inter-
arch and intraarch relationships. Am J Orthod Dentofacial Orthop 1992;101:459-64.
excellence. 11. Parr GR, Ivanhoe JR. Lingualized occlusion: an occlusion for all reasons. Dent Clin
North Am 1996;40:103-12.
12. Reitz JV. Lingualized occlusion in implant dentistry. Quintes Interna 1994;25:177-80.
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