By Kassaw M.

Ortho. resident
1
Objectives
At the end of this class students are able to
List different methods of space gaining
Describe mechanisms of each method
Decide the choice of space gaining .

2
METHODS OF SPACE
GAINING
Introduction
For the resolution of a majority of
malocclusions space is required.
For achieving treatment objectives space
has to be created with in the jaws

3
Objectives of space gaining
Alignment of crowded teeth
Retraction of proclined teeth
Correction of molar relationship
Derotation of anterior teeth
Leveling the curve of Spee
Intrusion
4
 Methods of space gaininig
Proximal stripping
Arch expansion
Distalization of molars
Uprighting of tilted teeth
Derotation of posterior teeth
Proclination of anterior teeth
Extraction
5
PROXIMAL STRIPPING (REPROXIMATION
Proximal stripping or reproximation involves
the selective reduction of the mesiodistal width
of certain teeth to create space.
it is also called slenderization, disking or
proximal slicing.

6
 :
The teeth selected depend upon

i. The location of excess tooth material

ii. The amount of discrepancy.
iii. The thickness of enamel present on the
teeth.
iv. The carious or oral hygiene status of
the patient.

7
 INDICATION FOR PROXIMAL STRIPPING

Done when space requirement is minimal (2.5-

3 mm).
Generally undertaken when there exists a
Boltons tooth material excess (less than 2.5 mm).
Usually when the excess exists in the mandibular
anterior segment, this does not mean that it
cannot be performed in other parts of the
dentition.

8
CONTRAINDICATIONS FOR PROXIMAL
STRIPPING
Patients who are susceptible to caries.
Proximal stripping is avoided in young
individual as their teeth may possess large
pulp chambers.

9
Amount of enamel stripped
To assess the thickness of the enamel, it is
advised to take intraoral periapical views of
the region.
The long-cone technique is favored as the
amount of distortion is less.
No more than half the thickness of enamel can
be removed.10

10
Enamel stripping is generally
performed using
Metal abrasive strips
Perforated diamond disks
Safe sided corborundum disc
Thin fissure burs Thin straight
or tapered burs

11
 ARCH EXPANSION
HISTORICAL BACKGROUND

The narrow maxilla has been recognized for

thousands of years but for obvious scientific
reasons, no effective treatment was possible
A number of slow expansion techniques were
employed by early dental practitioners like
Fauchard (1728) Bourdet (1757), Fox (1803),
Delabarre (1819), Robinson (1846), White
(1859).
12
 HISTORICAL BACKGROUND
The procedure probably originated in United
State with Angell in (1860) who placed a screw
appliance between maxillary premolars of a
girl age 14.5 years and widened her arch one
quarter inch in two weeks.
In the year 1889, the president of the
American Dental Association J. H. McQyillen
protestation against Angell. Such protestations
was responsible for Angells future silence
13
 HISTORICAL BACKGROUND
Barnes (1956), with 20 years
experience in treatment
observed that most successful
results of expansion were
achieved in deciduous arches
when treatment was started
between 4-7 years of age
Wertz (1967), confirmed the
advantage of RPE in improving
nasal air flow
Timms (1973),
Lehman and Hass (1984),
Glassman et al (1984),
Morton S. Wintener (1991),
Wendell V. Arndt (1993),
introduced the Nickel titanium
palatal expander
14
 CLASSIFICATION
Expansion can be divided into various arbitrary categories
including
orthodontic,
passive, and
orthopedic.
Or
Rapid and slow maxillary expation
15
 CLASSIFICATION
Orthodontic Expansion:
It is well known that expansion of the dental arches can be
produced by a variety of orthodontic treatments, including
those that employee fixed appliances.

16
 CLASSIFICATION
Passive Expansion
When the occlusion is shielded from
the forces of the buccal and labial
musculature, a widening of the dental
arches often occurs.
This expansion is produced by
intrinsic forces such as those produced
by the tongue.
17
 CLASSIFICATION
Orthopedic Expansion:
Rapid maxillary expansion (RME) appliances are
the best examples of true orthopedic expansion .
i.e . changes are produced primarily in the
underlying skeletal structures rather than by the
movement of teeth through alveolar bone

18
DIFFERENCE BETWEEN ORTHOPEDIC AND
ORTHODONTIC EXPANSION

ORTHODONTIC FORCE ORTHOPEDIC FORCE

By use of this force Result in major
the teeth alone are change occurring in
supposed to move . basal structures of
Adaptive changes in mandible & maxillae.
specific alveolar bone Involves
adjacent to moving interaction between
teeth. basal bone & alveolar
bone.
19
SLOW EXPANSION DEVICES
Active plate. This serves as a base in which
screws or springs are embedded and to which
clasps are attached.
Most screws open 1mm per complete
revolution, so that a single quarter turn
produces 0.25mm of tooth movement

20
SLOW EXPANSION DEVICES
Quad Helix Appliance:
History:
Farrar & Coffin 1875 .To treat Cleft
palate
Nance button 1947.
In order to widen the range and yield more
flexibility , helix loops were introduced.

21
 Quad Helix Appliance:
Basically, the appliance is
constructed of 0.038 inch wire
and soldered to bands .
First permanent molar or the
deciduous second molars, are
uded depending on the age of
the patient.

22
 Quad Helix Appliance:
All cross- bites in which the upper arch needs to be
widened
Mild expansion in the mixed dentition which
frequently exhibit lack of space for the upper
laterals and in which the long range growth forecast
is favorable.
Class III Expansion needed
Class II cases
Thumb sucking or Tongue thrusting cases
Cleft palate conditions either unilateral or bilateral.

23
 Coffin Spring
It is an ideal appliance to treat unilateral cross
bites.
It has an advantage of differential expansion
The appliance consists of an omega shaped 1.2 mm
diameter wire .
Two separate acrylic wings are made around the
wire framework on the slopes of the palate, these
also contain the retentive clasps

24
Coffin Spring
Simply pulling the wings apart
activates the appliance. \
This should be done first in the
premolar region and then in the
molar region.
Ideally marking holes should be
drilled on the two wings and a
divider should be used t measure
the amount of activation given .

25
 R.M.E

In subjects, demonstrating severe maxillary

construction,
RME is an appliance of choice for expansion
of maxillary halves when maxillary bases are
constricted.
RME causes a relative reduction in the nasal
airway resistance by disarticulating the maxilla
from other bone particularly septal and palatine
bone
26
 INDICATION & CONTRAINDICATION OF
R.M.E
REDUCTION OF NASAL AIRWAY RESISTANCE
The extent of which RME will change the
mode of respiration is complex owing to wide
variations in both NAR (nasal airway
resistance) reduction and the point at which an
individual subject will switch from nasal to
oronasal breathing.
Nilnimmar et al 1980
Study by Dale
The recommendation of RME for purely
respiratory reasons can not be advocated on a
risk/benefit Basis.
27
 CONTRA INDICATIONS FOR RME

Patients who do not cooperate with the clinician.

Patients who have single tooth in cross bite probably do
not need RME.
Patients who have anterior open bite.
Patients with steep mandibular plane and convex profits
are generally not suited for RME.
Patients who have skeletal asymmetry of the maxilla or
mandible.
Adults with server anteroposterior and vertical skeletal
discrepancies are not good candidates for RME.

28
 SLOW EXPANSION RAPID EXPANSION
Slow expanders like Quad R.M.E. 0.2 / 1.5 mm / day
Helix & W-Spring can Intermolar width 10mm
transmit forces ranging Skeletal changes 50%
from several ounces to 2 1 4 weeks.
pounds.
They can separate maxillae,
particularly in the deciduous
& mixed dentitions. 0.4 /
1.1 mm / week
Intermolar width 8mm 2
6 mons
Skeletal changes 16 30%

29
DISTALIZATION OF MOLARS
Distalizing of molars gained popularity, as it
was sometimes difficult to convince the patient
for extraction of otherwise healthy teeth.
Basically the procedures involved have one
purpose, i.e. to push the maxillary and/or
mandibular terminal molars posteriorly.
This increases the arch length by the same
length as the amount of distalization achieved.

30
DISTALIZATION
The distalization procedures are usually
undertaken before the eruption of the
second permanent molars.
It is definitely much easier to move one
molar distally as compared to two (i.e.,
first and second permanent molars).

31
DISTALIZATION
The appliances used for the purpose of
distalization of molars can be classified
as:
i. Extraoral distalizing appliances
ii. Intraoral distalizing appliances.

32
EXTRAORAL DISTALIZING APPLIANCES

The most frequently used extraoral

distalizing appliances are the headgears.
The headgear assembly consists of
Force delivering unitface-bow, J hook

Force generating unit

Anchor unithead cap, neck strap.

33
EXTRAORAL DISTALIZING APPLIANCES
Bilateral as well as unilateral distalization is
possible using headgears.
The forces can be so adjusted that the molars
undergo bodily or a distal tipping movement in
the posterior direction.
A distal tipping movement is only
recommended in cases with horizontal growth
pattern cases with a square face and deep bites in
excess of normal.

34
EXTRAORAL DISTALIZING APPLIANCES
The treatment using headgears is most effective
before the eruption of the second permanent
molars.
patient compliance is critical for successful
results to be achieved.
A minimum of 12 to 14 hours of wearing is
recommended for orthopedic effect and 18-20
hours for orthodontic (molar distilization) effect.

35
 INTRAORAL METHODS OF DISTALIZING MOLARS
Intraoral methods were devised for the purpose
of patient compliance
Intraoral appliances generate tooth-moving
forces by mainly three methods
the use of screws, open coil springs or wire
springs incorporating helices.
Magnets have been designed for intraoral use for
distalizing, but are not very popular.

36
INTRAORAL METHODS OF DISTALIZING MOLARS

The intraoral appliances take anchorage

from the palate and the anteriorly placed
premolars.
Efficiency of the appliances is more
before the eruption of the second
permanent molars.

37
intraoral distalizing appliancesinclude:
Schwartz plate
Sagittal appliance
First class
Veltribilateral and monolateral sagittal screws
Open coil springs
Jones jig
Distal jet appliance
Fast back appliance
Pendulum appliance
Intraoral magnets
Jasper jumper
Lip bumper
38
Schwartz Plate
This is an early forerunner
of the sagittal appliance,
and was also referred to as
the Y plate
It is rarely used nowadays.

39
 Sagittal Appliance
This is a removable appliance
with a screw incorporated for
the distalization of the first
permanent molars .
The anchorage is gained by the
remaining teeth anterior to the
first permanent molars.
Retention clasps are used to
hold the appliance in place.
40
First Class
This is a screw-based appliance .
The anchorage is gained by a palatal plate,
which is fixed to extensions from the first
premolar bands.
Activation of the screw causes a 0.1 mm
movement of the molars in a distal direction.
The recommended activation is one turn
everyday till over correction is achieved.

41
42
Veltribilateral and Monolateral
Sagittal Screws
The bilateral sagittal screw is used to achieve
bilateral distalization of the maxillary first
permanent molars .
The appliance consists of a Nance button
attached to the premolar segment of the screw
.
The monolateral screw design is different, but
the appliance is constructed in the same
manner.
43
 Open Coil Springs
Various clinicians for the purpose of distalization
of molars have assembled appliances using open
coil springs.
The appliances are basically soldered to bands
cemented to premolars and the molar teeth.
Usually a buccal and/or palatal wire containing
an open coil spring is used to achieve the desired
forces.
A palatal button is usually added to the
premolars to augment retention.

44
 Jones Jig
Itconsists of an open coil spring placed on the
buccal aspect, which generates the required forces
when it is compressed.
Anchorage support is provided with a Nance
appliance.
It can be used for both unilateral as well as
bilateral distalization.
It has been shown to distalize molar teeth even
after the eruption of the permanent second molars.
45
46
 Distal Jet Appliance
The Distal Jet appliance is a piston and
tube-based appliance .
The appliance is capable of distalizing the
maxillary second permanent molars.
The manufacturers claim the appliance
generates a purely translatory movement.

47
 Fast Back Appliance
It is a type of open coil spring appliances .
It is by far the most advanced version among such
appliances.
It uses two different strength nickel-titanium springs
(200 and 300 gm).
The appliance also has a self-locking terminal stop,
which makes the appliance fully programmable and
considerably increases its safety during use.
Fixed appliance can be initiated without having to
wait until distalization is complete
48
Fast Back Appliance

49
 Intraoral Magnets
For the purpose of
distalizing they are used in
repulsion mode along with
a Nance button for
retention .
Magnets are not the
preferred mode of
distalizing molars due to
cost, size and rapid force
decay over distance moved.
50
 Lip Bumper Appliance
The lip bumper is a simple appliance, which extends
slightly beyond the mandibular incisors and connects
distally onto the mandibular molars .
It generally has a labial plastic sleeve or acrylic cover in
the anterior region.
It should be used early in the mixed dentition phase to
bring about minor distalization
A modification of the lip bumper is used to distalize the
maxillary molars and is called the Denholz appliances.
The functioning of the appliance is similar.
The amount of actual distalization achieved is limited.
51
52
 UPRIGHTING OF TILTED POSTERIOR TEETH
Tilted posterior teeth always occupy more space.
Molars tend to tip mesially when the deciduous second
molars are lost early or decay.
A delayed eruption of the first or the second molar may
also cause the posterior teeth to tilt mesially.
Uprighting of molars can lead to an arch length gain of 1-
1.5 mm.
Fixed appliances are ideally used for the purpose.
. The lip bumper and its modifications can also achieve
good results.
53
 DEROTATION OF POSTERIOR TEETH
Rotated posterior teeth occupy more space
Derotation of these teeth can help regain this space.
Derotation can be best achieved using a couple
(forces equal in magnitude but opposite in
direction) on the lingual and buccal surfaces of the
tooth.
Any fixed appliance system with a two point
contact has more efficient rotation control .

54
PROCLINATION OF ANTERIOR TEETH
Proclination of anterior teeth can be undertaken in
cases where these teeth are retroclined or their
proclination will not effect the soft tissue profile or
the stability of the results.
Any of the proclining springs (Z spring, mattress
spring) or screws (medium-, mini-, or micro-
screws) or fixed appliances can be used for the
purpose.

55
 EXTRACTION

Painless removal of teeth from its socket is

termed as Extraction.
It is one of the most common methods of
gaining space in the arch.

56
 HISTORICAL BACKGROUND

As early as 1771, John Hunter recognized the

role of extraction in orthodontics in his book
Natural History of the Teeth.
Extraction in orthodontics has remained a
subject of speculation and contention over a
long period of years.

57
HISTORICAL BACKGROUND

According Angle , if crowded teeth were

aligned in correct relation to each other,
improved function of the masticatory apparatus
would result in growth of the jaws, creating
adequate space for the dentition.
Therefore, he advocated expansion of arches in
all orthodontic patients.

58
HISTORICAL BACKGROUND
Calvin Case (Angell`s student) contended that teeth may
be extracted occasionally to produce lasting results.
They reasoned that jaw growth does not depend on
function and if the jaws are too small to accommodate
teeth, then extraction would nbe required to relieve
irregularity of teeth.
Neither esthetics nor stability would be satisfactory in the
long run for patients undergoing expansion for
alignment.
This led to the Great Extraction Controversy of the 1920s
between the two schools of thought.
59
HISTORICAL BACKGROUND

By the late 1940s, extraction was reintroduced

into orthodontics by Charles Tweed who found
post treatment occlusion more stable in patients
treated with extractions.
By the early 1960s, more than half the
orthodontic patients had extractions of some
teeth as part of their orthodontic treatment.

60
 THE NEED FOR EXTRACTION
Arch LengthTooth Material Discrepancy
Guidelines for extraction in class I crowding/ protrusion:
Less than 4 mm arch length discrepancy
extraction rarely indicated.
5-9 mm arch length discrepancynon-extraction

or extraction possible; depends on the details of

the therapy.
10 mm or more arch length discrepancy
extraction almost always required.

61
 Correction of Sagittal Interarch Relationship
Abnormal sagittal malrelationship such as Class
II / III malocclusion may require extraction to
achieve a normal interarch relationship.
In a Class I malocclusion (normal sagittal
interarch relationship) it is preferable to extract in
both the arches
In most Class II cases with abnormal upper
proclination, normal alignment of the lower teeth
and where A point is abnormally forward relative
to the B point, it is advisable to extract teeth only
in the upper arch . 62
 Correction of Sagittal Interarch
when the lower arch is crowded or molars
are not in full cusp Class II molar
relationship, it might be preferable to
extract in both the arches.
Class III cases are usually treated by
extracting teeth only in the lower arch.

63
 Extraction for the Relief of Crowding
Extraction for the relief of crowding will be
governed by:
Condition of the teeth .
Position of the crowding
Position of the teeth Grossly malpositioned teeth

The position of the apex of the tooth must be

considered as it is more difficult to move the
apex than the crown.
64
DIFFERENT EXTRACTION PROCEDURES
i. Balancing extractions
ii. Compensating extractions
iii. Phased extractions
iv. Enforced extractions
v. Wilkinson extractions
vi. Therapeutic extractions

65
 CHOICE OF TEETH FOR EXTRACTION
Choice of teeth to be extracted depends on local conditions
which include:
Direction and amount of jaw growth
Discrepancy between size of dental arches and
basal arches
State of soundness, position and eruption of teeth
Facial profile
Degree of dentoalveolar prognathism
Age of patient
State of dentition as a whole.
66
Ist Premolar extractions

67
 Indications for I st premolar extraction:

1. Convex profile with severe crowding.

2. Class II div I with deep anterior bite.
3. Class I with severe crowding.
4. Class I with bimaxillary protrusion.

68
Indications for I st premolar extraction.

69
Extraction of Ist premolars.
ADVANTAGES :
Strategically located close to the incisors.
Center of each half of arch .. Ant & post
crowding.
Protraction of molars not required.
4 Xn adequate anchorage for retraction of 6
teeth.
Contact b/w canine and 2nd premolar
satisfactory.
70
Problems with Xn of 4s:
Tipping, opening of space (5 small to
fill the space)
Mesial tipping of 6, hanging palatal
cusp

71
II nd Premolar extractions

72
 INDICATIONS FOR 2ND PREMOLAR EXTRACTION

1.Good profile+mild crowding

2.Flat profile+moderate crowding
3.Class II div 1 on skeletal class I
+mild crowding.
4. Mild Class III inter-arch
relation+mild crowding in U arch.
5.Congenitally missing,impacted.
6. Grossly destructed/heavy restn.
7. Abnormal root morphology.
8. Open bite.

73
 ADVANTAGES:

1. Original facial contours retained without

reduction of lip profile.

Extraction of 2nd premolars:

74
 ADVANTAGES:

U 4 more esthetic along side canine.

Lesser tendency for extraction space to
open in L arch.
Easy correction of Class II molar to Class
I molar relation.

75
Atypical Extractions

76
 Ist Molar Extraction:
Avoided:
Not provide adequate space in the ant
region.
5 & 7 may tip in the Xn space.

Deepening of bite.

Masticatory inefficiency.

77
 Indications:

Carious- beyond restoration

RCTreated - than a perfectly good premolar.
Multi filled teeth- crown.
Premature Xn of 6, to preserve symmetry.
Facialconsiderations: large chin buttons&/
prominent nose
Open bite cases.

78
Wilkinsons Extraction: 1942

8 to 9 yrs. Extraction of all Ist molars.

Caries prone crowded dentition.
Basis:
1.Additional space for eruption of 8s.
2.Crowding of lower arch minimized.
3.Reduced caries risk
79
Disadvantages-
1.Offers little space for the alleviation of anterior
crowding
2.Position of 2nd & 3rd molar varies
3.Mesial tipping of 2nd molar with improper
interproximal contact food accumulation,
periodontal problems, caries
4. Anchorage potential of buccal segment is reduced

80
2nd MOLAR EXTRACTION:

81
 2nd MOLAR EXTRACTION:
ADVANTAGES AND INDICATIONS
Disimpaction of 3rd molars, faster eruption
Prevention of dished-in profile at the end of facial
growth
Prevention of late incisor imbrication/overlaping /
Facilitation of 1st molar distalization
Distal movement only as needed to correct the overjet
Fewer residualspaces at the end of Rx
Less likelihood of relapse
Good functional occlusion
Good mandibular arch form
Overbite reduction.
82
 Disadvantages:
Too much tooth substance removed in Cl I mal
occlusion with mild crowding.
Location far from area of concern.
No help in correction of A-P discrepancy
without patient cooperation .
Possible impaction of 3rd molars even with 2nd
molar Xn
Unacceptable positions of erupted 3rd molars
second, late stage of fixed therapy.
9-20% missing 3rd molars.
83
 Timing for mandibular 2nd molar extraction:

Kokich:
1. 3rd molar crowns completely formed, Xn
before roots begin to develop
2. to the occlusal plane
3. 3rd molars in close proximity to 2nd molar-drift.
Halderson, Huggins, Lehman and Smith.
Before radiographic evidence of root formn.(12-
14yrs)

84
 3rd Molar Extraction:

Xn to prevent lower anterior crowding?

Distal movement of 6,7 impaction of 8.

Contraindications:
1st or 2nd molars are extracted.

85
 Incisor Extraction:
Mandibular incisors- therapeutic value
1st sign of incipient malocclusion
Difficult to treat as they relapse easily.

Not a new idea.

Jackson (1904)
Riedel : Xn of 2 lower
Incisors-arch form without
Expn of intercanine width
Angle:
Inexcusable.disharmony b/w
Occlusal planes, abnormal overbite
86
 Incisor extraction: Indications:-
For mandibular incisors:
Extreme crowding / protrusion.
Gingival recession & loss of
overlying bone on labial surface.
Lateral incisors severely # in young
children.
Rarely-discrepancy in sizes of U &
L incisors themselves, 1 incisor can
be removed.
Reidel- Rx time reduced.
min facial change.

87
Incisor extraction:
Advantages:
1. Maintains/ reduces intercanine
width
2. General arch form is maintained
greater stability
3. Retention period- less
4. Anterior segments can be
retracted readily if need be.
5. Immediate solid tooth support of
entire buccal segments.
6. Easy reduction of overbite-
intrusion, reshaping
7. Mechanotherapy is simplified.
Space closure quick.
88
 Incisor extraction:
Disadvantages:-
Reopening of space . Central Incisor.
Danger of creating Boltons discrepancy.
Deepening of the overbite
Color difference of canine.
Lingual tipping of lower incisors

89
 Upper Incisor Extraction:
Rarely indicated.
Unfavorable impaction of U incisor.
Bu/Li blocked out lateral, with good contact b/w central
and canine.
Congenital missing of 1 lateral incisor
Dilacerated tooth.
Extreme bone loss
Grossly decayed

90
 Extraction of Canines:
Not extracted. Profile.
Long path of eruption.

Conditions where indicated:

Impossible to bring in alignment.
Gross displacement Bu/Li
4 in contact with 2 & does not show palatal cusp.
Decision : position of apex.
Extreme decay

91
Commonly Extracted teeth
To

Central incisor 1%
Lateral incisor 3%
Canine 4%
First premolar 59%
Second premolar 13%
First molar 12%
Second molar 7%

92
summary
Different mechanisms of space gaining are available.
Proximal stripping has to be don care fully.
Arch expansion may be slow or rapid.
Distalization is is based on either screw,coil spring or
springs with helx.
Extraction depends on
Location

Degree of descripancy
Amount of enamel

Caries status

93
References
1) Gurkeerat S.Text book of orthodontics.2nd Edition.
2) S.I. Bhalajhi.Orthodontics the art and Science.3rd
Edition.

94
Thank
you
95