Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Orthodontic Appliances
Orthodontic technology is a specialty of dental technology that is concerned with the design and fabrication of dental appliances for the treatment of malocclusions, which may be a result of tooth irregularity, disproportionate jaw relationships, or both.

General requirements of an orthodontic appliance It should be: 1. Comfortable to wear and acceptable by the patient. 2. Produce the desired force that cause a well controlled tooth movements. 3. Firmly positioned in the mouth, with no tendency to be inadvertently dislodged by the patient. 4. Fabricated from a biocompatible material that is well tolerated by the patient. 5. Cleansable by the patient with no hazard to the oral health. Types of orthodontic appliances: 1-Fixed: Fixed orthodontic appliances includes those appliances which can not be removed by the patient. These appliances are capable of bringing multiple movements with limited patient co-operation. It may be: a-Aesthetic (ceramic, polycarpoxylate, composite or lingual orthodontic (metal brackets b-Nonaethetic (metallic brackets, gold or st. st. ) 2-Removable: Removable orthodontic appliances are those that can be inserted and removed by the patient. 3-Semi-fixed: Appliances have some part of the appliance fixed on the tooth surfaces which the patient can not remove but the rest of the appliance can be removed (lip bumper).

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Direction of tooth movements Biomechanical factors and tissue reaction.

1-Force magnitude: Light force and heavy force. 2-Force duration: Intermittent, continues interrupted. 3-Force direction: Tipping, rotation, bodily, torque, intrusion, and extrusion. Force magnitude
The optimum force is one which move the tooth rapidly, Light force, frontal bone resorption Heavy force and undermining bone resorption Force direction 1- Simple tiping movement: A removable appliance most commonly delivers its force through a single point of contact. Simple tilting movements can be easily come out and teeth may be tipped mesially, distally, buccally, or lingually & the apex will move, in the opposite direction. The fulcrum of rotation is about one third of the root length from the apex. Retraction of an inclined tooth, which requires uprighting, can give a good result. If a tooth is at the correct inclination, some degree of tilting will have to be accepted. If a tooth is already inclined further movement in the direction of its inclination is unstable. continuously, with minimal tissue damage and clinical discomfort

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

2- Rotation: Central or lateral incisors can often be corrected with removable appliances, if the problem is only simple rotation of up to 45. Multiple rotations, more severe individual rotations, and teeth with crowns which are round in cross section (e.g. premolars and canines) are impossible to correct with a removable appliance alone. 3-Intrusive movements Intrusive movements of a single tooth are hardly ever required. Intrusion of the lower anterior teeth can be obtained in the growing patients for correction of incisal deep bite. 4-Extrusive movements: That type of movements is impossible to obtain using removable appliance alone. If can be facilitated by the attachment of a hook, either on a band or directly bonded to the enamel. 5-Apical and bodily movements: Generally speaking these are not possible with removable appliance. 6- Leveling arch: This is usually not possible with a removable appliance, except the use of an anterior bite plane in a growing patient to permit molar extrusion. 7- Closure arch: The use of a removable appliance for this purpose should be limited to carrying out local movement and to cases where over jet reduction is required, as a contribution to space closure.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Force duration
A.

Continuous: Forces that are maintained between activations of orthodontic appliances, even though the force decline, but it does not reach to zero.

B.

Interrupted: Forces level decline steadily to zero between activations. Both continuous and interrupted forces can be produced by fixed appliances.

C.

Intermittent: Force level decline abruptly to zero when the patient removes the orthodontic appliance. Intermittent forces are produced by all patient-activated appliances, such as removable appliance, headgear and elastics. So the appliance should maintained enough hours to produce tooth movement, if a removable appliance is worn less than 6 hours per day, it will produce no orthodontic effects. This is because animal experiments indicate that increased levels of cyclic AMP, the second messenger for many important cellular functions including cell differentiation, appear after about 6 hours of sustained pressure.

Advantages & disadvantages of fixed appliances: 1. Good control and distribution of force (i.e. rotation & controlled root movements are possible) 2. Multiple tooth movement can be performed simultaneously 3. Complex to make and use, so special training is needed 4. Costly 5. Long chair- side time 6. Oral hygiene is made more difficult 7. Sticky and hard foods may damage the delicate orthodontic appliance.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Removable orthodontic appliance

Definition: *A removable appliance is one that can be easily inserted and removed by the patient from the mouth. *Removable appliance will be only performing their function satisfactory if they are worn continuously with the exception of certain functional appliances and retainers. *This means that patients cooperation and a good tolerable design of appliance are very essential for successful treatment. Indication of removable appliances: Limited (Tipping) tooth movements. Growth modification during the mixed dentition. Retention after fixed appliance treatment. Requirements: 1. Easily inserted and removed by the patient. 2. Stay firmly in the correct position in the mouth. 3. Comfortable to wear. 4. Designed with avoiding pain or discomfort. 5. Not bulky or complex that it interferes seriously with speech and eating. Advantages of removable appliances:
1. Malocclusions which require simple tipping of teeth can be

satisfactorily treated by removable appliances.

2. Tipping and overbite reduction can be under taken as readily with a

removable as with a fixed appliance.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010). 3. Removable appliances can incorporate bite platforms to eliminate

occlusal interference and displacement. This is not possible with fixed appliance.
4. With removable appliance, a few teeth moved with a simple type of

movement. So anchorage control is less complex than with fixed appliance.

5.

The general dental practitioner who has received adequate training in diagnosis and treatment planning can treat simple malocclusions.

6. Removable appliance is manufactured in the laboratory and

adjustments take less chair side time.

7. It is inexpensive when comparing with fixed appliance. 8. It can be removed by the patient for cleaning their teeth and the

appliance. So difficulties of oral hygiene are not increased.

9. The appliance may damage and the patient is in pain, then it, can be

removed for a short period of time until the operator can see the patient. Disadvantages of removable appliance: 1. Appliance can be left out.
2. Limited types of malocclusion could be treated (requiring only tipping

movements because of the single point application of forces) 3. Inefficient for multiple individual tooth movements. 4. Good technician are required. 5. Affects speech. 6. Intermaxillary traction is not practicable. 7. Lower removable appliances are difficult to tolerate.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Classification of removable appliances: I.Mechanical (Active): Mechanical forces are generated from the active components: springs bows, screws, elastics. II.Myofunctional: The muscle forces are transmitted from the muscles of orofacial musculature to the dental arches and even jaw bones to treat malocclusions.
1. Activator. 2. Oral screen. 3. Lip bumper. 4. Lower inclined plane. 5. Biteplanes.

III.Passive: To maintain the teeth in the corrected position until ultimate hard & soft tissues reorganization.

Compononts of removable appliances

1. Active part. 2. Retentive part. 3. Base plate. 4. Anchorage.

I-Active components
They are the components of the removable appliances which apply forces to the teeth to bring about the desired tooth movement. The active components include: Springs, Bows, Screws, Elastics.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

1-Springs
Types of springs 1. Springs for buccal movement ( palatal springs) : Finger spring. Z spring. 2. Springs for Mesio-distal movement: Helical coil spring. 3. Springs for arch expansion : Coffin spring. 4. Buccal spring: Buccal canine retractor.

General principles

The force should be delivered at right angles to the long axis of the tooth to avoid yielding a vertical component of force. The force should be applied through a surface which is parallel to the long axis of the tooth. An example of this may be seen during activation of a palatal spring against the sloping lingual surface, (cingulum) of incisor. Intrusion of the tooth, indention to displacement the appliance may occur.

The flexibility of a spring depends on the length wire used and F is the force exerted by an orthodontic spring r is the radius of the wire, and L is the length of the spring.

its diameter: Fr4/L3

Where:

So doubling the length reduce the force applied 8 times, while doubling diameter increase the force 16 times.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

The space available within the mouth is limited, and for light forces the spring should made as long as possible. So incorporating a helicle into the design of a spring increases the length of wire and therefore results in the application of a smaller force for a given deflection.

Finger springs are adjusted using either Adams or round/flat pliers.

Grip the 'finger' as it leaves the loop of the spring and bend the wire using your finger as close as possible to the pliers.

2- Screws
An orthodontic screw doesn't contact the teeth but embedded at both ends into the acrylic which is split with a saw. Indications: 1. Unilateral cross bite 2. Bilateral cross bite 3. Distal movement of molars 4. Anterior posterior expansion ( class III treatment ) The most commonly used type consists of two halves on a threaded central cylinder turned by means of a key (activation) which separates the two halves by a predetermined distance, usually about 0.2 mm for each quarter turn. Disadvantages: 1. They are bulky and expensive.
2.

The patient is responsible for activation.

Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Screw positioning: To provide arch expansion, the screw should be placed in the midline in horizontal position. Wrong placement of the screw (parallel to the palatal mucosa) will disengage the acrylic from the teeth.

3-The labial Bow

The labial bow wire is commonly formed from 0.7mm diameter round stainless steel wires. The labial arch contains two loops buccal to the canines that allow adjustment in the anteroposterior position of the wire adapted to the incisors.

Indications:

Reduction of small overjet ( < 4 mm ). Generalized anterior spacing caused by excessive labial tipping of anterior teeth can be used as a retainer following active treatment.

Can be used in an appliance bearing palatal finger spring.

Adjustment **To reduce an overjet, the bow is adjusted at the U loops. **Adjustment must be small, the bow should be displaced palatally by only 1 mm and the acrylic base is trimmed to allow the teeth to move as intended.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

4-Elastics
Special intra-oral elastics are manufactured for orthodontic use. These elastics are usually classified by their size, ranging from 1/8 inch to 3/4 inch, and they are designed to be used mainly with fixed appliance.

II- Retentive components

Retention: resistance of an appliance to displacement.
Importance of retention: 1. It maintains the mechanical efficiency of the appliance by ensuring that the springs are continuously held accurately in position
2. The appliance is firmly fit so the patient adapts to it more

readily (good cooperation) 3. Initial difficulties with speech and eating are minimized and habit movements are discouraged 4. Extra oral traction can be added without the risk of displacement 5. The anchorage (from the fit of the appliance against the teeth and mucosa) is maximized by preventing forward sliding of the acrylic down the curvature 6. Its bridge of Adms' clasp provides a site to which the pt can apply pressure with the fingertips during removal of the appliance In removable appliance, retention is provided by the undercuts on the teeth which are engaged by clasps and bows.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Clasps: C clasp, ball, Delta, Adams clasp, Southend clasp Adams clasp This is one of the most efficient clasps used for retentive purposes.

This crib was designed to engage the undercuts present on a fully

erupted first permanent molar at the mesiobuccal & distobuccal undercuts The crib is usually fabricated in hard 0.7 mm stainless steel wire and should engage about 1 mm of undercut

Adjustment:
Retention components should be adjusted only if this is necessary.
1.

Where the arrowhead lies occlusal the buccal undercut, adjustment to the clasp should be made where the tag emerges from the base plate. Where the arrowhead is correctly placed but does not fully engaged the undercut, adjustment should be made adjacent to the arrowhead. Correctly adjusted Adams clasp should be passive but in contact with the tooth surface when the appliance is fully inserted. Active clasp will exert a palatal force and the appliance will tend to spring out rather than fully seated.

2.

3.

4. The patient removes the appliance by pulling on the clasps and so they may become deformed. Adjustment should be made to compensate for this deformation during visits.

Adams clasp used on other teeth

It is useful to clasp the premolar for additional retention. A clasp on the canine can be useful from time to time .In the mixed dentition; it may be necessary to clasp a deciduous first molar or canine, using .6m rather.7m.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Southend clasp
This clasp is designed to utilize the undercut beneath the It is usually fabricated in 0.7 mm hard stainless steel wire. contact point between two incisors.

Circumferential clasp
This is one of the most commonly used clasps for retention of removable orthodontic appliances. It should be especially designed to take advantage of the undercuts found mesially and distally on the buccal aspect of the permanent molars. Accordingly, when this type of molar clasp is used, a maximum length of wire should lie along the gingival area of the tooth in order to take full advantage of all the existing undercuts on the mesial, distal, and buccal surfaces of the tooth.

Clasp or half Jackson crib

It could be used on the deciduous canine and molar.

Ball ended clasp

Also used where the molar don't provide sufficient retention by Adams clasp. Blanks may be obtained from dental supply companies.

Triangular (Delta) clasp

This clasp engages the proximal undercuts between the 2 posterior teeth and is carried over the occlusal embrasure to end as a retentive arm on the palatal aspect.

III-The acrylic part

1. It acts as a foundation into which the remaining components of the removable appliance are embedded. 2. It serves as anchorage during the course of active tooth movement. 3. It can be used as an active element of the appliance itself e.g. anterior bite plane and posterior bite plane.
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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010). 4. protect the palatal spring if they are boxed in.

Bite plates: 1-Anterior bite plane: Is a thickened platform of acryle, palatal to the upper incisor onto which the lower incisors occlude. It is prescribed when the overbite needs to be reduced in class II malocclusion. Overbite reduction is obtained by accelerated dento-alveolar development of the lower buccal segments, and little intrusion of the lower incisors. Relapse will often occur when attempting to reduce overbites in adults. 2-Posterior bite plane The coverage of the occlusal surface of the posterior teeth is occasionally necessary in the corrections of anterior cross bite (upper posterior coverage). Construction and adjustment of posterior bite plane:
The parts of clasp which cross the embrasure should not be

incorporated into the acrylic covering the occlusal surface of the teeth.
Articulating paper should be used to aid reduction the height of both

in sides.
The posterior bite plane should be reduced until just clearance of

occlusion is occurred with even occlusal contact on both sides and minimal separation.
The bite plane may be perforated over the molar cusps but this does

not matter.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Heat vs. cold cure acrylic resin:

heat cured acrylic resin is recommended for:

Appliances with bite planes that will be loaded heavily.

Lower appliance, which are weak in the section behind the incisors.

The use of cold cure acrylic resin is used most commonly

because: It is simpler for the technician More economy No risk of thermal distortion N.B.

Clear acrylic preferred by patients and has the advantage that any areas of undue pressure can be detected by observing blanching of the palatal mucosa when the appliance in the mouth.

The recommended thickness is equal to one sheet of modeling wax. The acrylic plate should fit closely around the necks of those teeth which are not be moved while it may be trimmed away to permit movement or eruption of individual teeth.

It should cover the entire palate to the distal side of the first molar because: This type of design is stronger and provides more anchorage than the horseshoe, which only partially covers the palate.

The tongue is less likely to catch and dislodge the appliance under a complete acrylic palate.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

IV-Anchorage
Anchorage is the resistance to unwanted tooth movement. According to Newton's third law of motion, For every action, there is an equal and opposite reaction. Every spring pressing against the tooth develops force in the same quantity against the baseplate of a removable orthodontic appliance. After the directions of the tooth movement are carefully analyzed, it is necessary to assess the reaction which will be produced and to make plans for suitable teeth to resist it. Anchorage loss : movement of the anchor teeth When space is not critical, some anchorage loss is accepted.

In other instances preservation of all space is very essential. Anchorage control in the removable appliance:

I- Keeping forces light. I I - Increasing the resistance of the anchor tooth through the following: 1-The base plate: Keeping the acry1ic fitted around as many teeth as possible may maximize this. Through the contact of the appliance with the mucosa of the vault of the palate, particularly that part which has a significant vertical inclination (used basal bone and teeth as anchorage). So, any forward component of force could be transmitted from the appliance to the basal bone underlying it. 2-Cuspal interlock. 3-The labial bow.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

4-Extra oral traction. This is the most useful method of improving anchorage in a removable appliance.

Sample instructions to patients for removable appliances

Your appliance should be worn all the time 1- At meal time. 2-For tooth cleaning 3-During vigorous sports (when it should be stored in a

except :

strong container) It is usual to experience some discomfort and a little difficulty with speech initially, but this should pass in a few days as you become accustomed to wearing the appliance. It is important to avoid hard or sticky foods If you cannot wear your appliance as and chewing gum.

instructed, or if it becomes damaged or causes pain, please contact immediately.

Instruction on appliance wear

Instruction on the oral hygiene by given and general information on the wear of appliance should be given on the visit before the fitting of the appliance.
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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Practical points. e.g. cleaning the teeth and

appliance and its insertion and removal should be demonstrated to the patient and then practiced under supervision in the clinic. Ask the child to repeat the instructions. Also demonstrate them to the parent and make sure that they can do so unaided. Ideally, a leaflet containing the same Children wearing functional appliance and instructions in writing should also be given to the parent.

headgear which should be worn as many hours as possible. At each visit, progress should be compared of the account of wear, and praise or reproach given according to the result.

Follow up the visits

First of all chat to the patient, asking whether they have had any problems. Do not ask leading questions as ,whether the appliance has been worn as instructed, because almost inevitably the replay will be affirmative, and it may then be difficult for them to retract this when clinical evidence suggests that the appliance has not, in fact, been worn correctly. Observe whether speech is affected by the appliance. Most patients adapt to appliances within a few
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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

days. If speech continues to be affected, this may be a sign that the appliance is not worn full time. A thorough inspection of the general oral condition, with the appliance removed. Exam the oral mucosa for trauma or ulceration from the appliance. Check the teeth for plaque or caries. Any deficiency in general oral car is discussed with the patient. The orthodontic review begins with an assessment of the changes that have occurred since the previous occasion. A comparison with previous measurements gives an indication of whether or not the teeth are moving at the rate anticipated. If the teeth have moved less than expected, a series of points should be checked: Are the teeth free to be moved? The base plate, wire contact, or contact with opposing teeth may impede tooth movements. Is the spring correctly activated? The spring or bow may be passive, or may be excessively active, and both faults may impede tooth movement. Is there any reason to expect a slow rate of movements? Buccally placed tooth or dense cortical bone surrounding the tooth, may result in very slow movement. Provided that light forces are used, tooth movements will be progressive but slow.

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Dr. Safaa Ghobashy: Assis. Prof .of Orthodontics (2010).

Is the appliance being worn as instructed?

The patient may placed the spring incorrectly, or the appliance may be left out. Even short periods of non wear may greatly delay progress. MONITORING PROGRESS

Ideally, patients wearing active removable

appliances should be seen every 4 weeks. Activation of an appliance more frequently than this will increase the risk of anchorage loss and root resorption.

The exception to this guideline is the screw

appliance where only a small amount of activation is possible at a time and therefore more frequent small activations are required.

Passive appliances can be seen less

frequently, but it is advisable to check, and if necessary adjust, the retention of the clasps every 3 months.

en.wikipedia.org

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