Professional Documents
Culture Documents
D. C. D. - D. S. O. - D. U. O.
Edited by
GAC International
MICHEL LANGLADE
D. C. D. - D. S. O. - D. U. O.
Edited by
185 Oval Drive Central Islip. N. Y. 11722 - 1402 Fax: (516) 582 57 04
January 2000
DIAGNOSTIC ORTHODONTIQUE
Prface Ruel W. BENCH 768 Pages - 552 Photos - 1981.
THERAPEUTIQUE ORTHODONTIQUE
Prface Robert M. RICKETTS 3rd Edition - 1986
Italian editor:
Brazilian editor: SANTOS EDITORIA 701 rua Dona Brigida 04111 081 Sao Paulo S. P. BRAZIL Tl.: (5511) 574 - 1200 Fax: (5511) 573 - 8774
TABLE OF CONTENTS
CHAPTER I: Definitions..............................................................
Definitions Presentation of orthodontic elastics Elastics force use
p1
CHAPTER II: History of Elastics Forces...................................... CHAPTER III: Classification of Orthodontic Elastic Forces........
Classification Clinical statement Force delivery Classification of forces Basis for prescribed pressures Anchorage
p5 p7
p 20
p 32
p 53
p 83
p 97
Elastics and dental asymmetries - Canted anterior occlusal plane - Unilateral posterior cross bite - Midline shift deviation - Asymmetric arch form Elastics in condylar fractures
p 128
p 159
CONCLUSION............................................................................ BIBLIOGRAPHY........................................................................
p 178 p 180
CHAPITER I
Definitions
CHAPTER I: Definitions
DEFINITIONS
ELASTICITY:
It is the property of a material to return to its original form.
ELASTIC MATERIAL:
Presents usually 3 properties: 1 - a distorsion not going beyond its limit of elasticity 2 - physically homogeneous 3 - isotrop, giving the same force in any direction ( see Fig I. 1 ).
LIMIT OF ELASTICITY:
It is the amount of forced distorsion without deterioration and loss of elasticity .
ELASTOMERS
General term encompassing materials returning to their original dimensions immediately after substantial distorsion. Under this term are: - natural rubber or latex coming from hevea trees - synthetic rubber polymers such as styren butadien rubber, butyl, polyisopren, polybutadien, ethylpropylen, teflons, hypalon, silicons. 1
CHAPTER I: Definitions
Some Ortho manufacturers have even proposed mint flavoured elastics in order to improve patient compliance in elastic wear. Orthodontic elastics can be designated as: - intraoral - extraoral
Usually,the prescribed force is obtained when the elastic is stretched out three times its diameter.
To check the elastic forces, the orthodontist can use CORREX or DONTRIX gauges ( see Fig I.3 ).
ADVANTAGE OF ELASTICS:
placed and removed by the patient discarded after worn out no activation required by the orthodontist effect increased by mandibular movements ( mastication, phonation ) can be changed upon prescription one, two, three times a day or even worn at night.
DISADVANTAGE OF ELASTICS:
The orthodontist must be aware of: deterioration and loss of elasticity: Any elastic worn in mouth is affected by: PH of oral environment saliva 2
CHAPTER I: Definitions
After 2 hours in the mouth, the module elastic force decreases about 30%, and after 3 hours about 40%.
It means that in clinical uses, elastics must be changed regularly according to the orthodontists prescription.
Fig I.2: Percentage of elastic force lost in mouth from E. HIXON 5 et. al. A. J. O. Vol 57 N 5. p 481 1970. 3
CHAPTER I: Definitions
Fig I.3: To check the elastic forces the Orthodontist can use CORREX or DONTRIX gauges. 4
CHAPITER II
CHAPTER II: History of Elastics Forces The first known elastic was the natual rubber used by INCAN and MAYAN civilizations extracted from Hevea trees.
Pierre FAUCHARD in his book Le Chirurgien Dentiste ou Trait des Dents proposed to close anterior diastema with silk ligature.
P. BOURDET used a bandeau with golden or silk ligatures to move teeth, prefiguring the straightwire era.
F. CELLIER introduced for the first time the Chin Cup Fround with rubber bandages.
J. M. A. SCHANGE, in his Prcis sur le redressement des dents published in Paris, used elastic threads to move teeth.
Calvin CASE was the first to use intermaxillary elastic forces to correct malocclusions.
H. BAKER published in the International Dental Journal an article entitled Treatment of protruding and receding jaws by the use of intermaxillary elastics .
1907:
Edward H. ANGLE in his book Treatment of malocclusion of teeth proposed a classification of malocclusions and the use of corresponding elastic forces: Class I ; Class II ; Class III.
1948:
Charles TWEED initiated the Class III elastic use to reinforce the anchorage preparation of Class II malocclusion before using Class II elastics.
1958:
Fred SHUDY recommended short Class II elastics coming from the upper first molar and in association with a high pull anterior extraoral force in order to control the vertical sense.
1963:
J. JARABAK and FIZZEL in their book Technique and treatment with the light wire appliance page 70 to 82 from Mosby were describing the biomechanics of Class II elastics for the first time. 5
1965: 1964-1970:
R. BEGG in his book Begg orthodontic theory and technique used Class II elastics which were changed every five days.
Robert M. RICKETTS originated the Bioprogressive segmented light square wire technique advising the closing elastics conduct in open bite cases.
1972:
Ron ROTH recommended short Class II intermaxillary elastics to help the curve of SPEE leveling associated with high pull headgear to control the vertical sense.
1973-1996:
Michel LANGLADE developed the clinical applications of elastic forces in different situations such as occlusal elastics or controlateral crossbite elastics, proposing biomechanics comparison in clinical uses.
Elastomers
Intraoral Elastics
Only pure, natural latex is used in producing GAC elastics. Precise wall thickness and predictable forces are consistent characteristics of our full line of elastics. Our Travel Pack recognition system makes it fun and easy for patients to remember the correct size and force. In addition to size and force designation, each smudge-proof bag has a landmark, symbol, or activity associated with a specific country. Each pack of GAC intraoral elastics contains a bright white placer to help patients properly and easily use their elastics.
EXTRAORAL Heavy
Blue/4oz
Medium
Green/2.7oz 11-101-03 Germany 11-101-04 Mexico 11-101-06 USA 11-101-08 Italy 11-101-10 Spain
Super Heavy
Black/6oz
XH
Brown/6oz
XXH
Black/8oz
11-102-03 India 11-102-04 Switzerland 11-102-06 Japan 11-102-08 Scandinavia 11-102-10 France
11-100-16 Ireland
11-104-08 Greece 11-104-10 Greece 11-104-12 Greece 11-104-14 Greece 11-104-16 Greece 11-104-18 Greece
Light, Medium, Heavy, and SH are packaged in boxes of 50 zip lock bags of 100 elastics. XH and XXH are packaged in boxes of 25 zip lock bags of 50 elastics.
Light
Red/1.8oz.
1/8" 3/16" 1/4" 5/16" 3/8" 5/8" 11-200-06 11-200-08 11-200-10 11-200-16 / / / /
Medium
Green/2.7oz.
11-201-03 / Panama
Heavy
Blue/4oz.
11-202-03 / Columbia
Super Heavy
Black/6oz.
11-201-04 / Belgium Philippines 11-201-06 / Russia Singapore 11-201-08 / Indonesia Malaysia 11-201-10 / Finland Guatemala
11-202-04 / Brazil 11-203-04 / So. Africa 11-202-06 / Chile 11-203-06 / Saudi Arabia 11-202-08 / Luxembourg 11-203-08 / Hungary
CHAPITER III
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
Class I Monomaxillary
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
NO
Monomandibular
Class II
Regular
Extrusion
Closing
Open bite
Class II
Class II
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
Class III
Dental and Class II and Skeletal Class III Skeletal open bite ( normal vertically )
Regular
Extrusion
Closing
Class II and
Class III
Extrusion
Short closing
Open bite
Class II and
Class III
Class III
deep bite
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
Class II Oblique pull and extrusion Class III canine relationship open bite Midline correction Skeletal
Anterior
9
Diagonal Oblique Anterior Triangular
Oblique pull
Midline
extrusion
shift correction
Oblique pull
extrusion
with
Deep bite ?
of one side
midline shift
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
Posterior
Dental
triangular
deep bite
Open bite
Class II
Class II
10
Anterior
Extrusive
U shape
force
open bite
Contraction Anterior and rectangular extrusion open bite Dental Deep bite
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
Intermaxillary
Extrusive
vertical elastic
force
extrusion
Extrusive force
11
Vertical extrusion W and M Extrusive to elastic force squeeze the bite open bite Skeletal
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
Accordion
Contraction ++++
elastic
Extrusion ++++
Posterior
12
triangular
Class III
Class III
ELASTIC DISPOSITION
ELASTIC CLASSIFICATION
MOVEMENT FORCE
INDICATION
COUNTER INDICATION
cross bite
cross bite
open bite
Too buccal O shape Tranversal ectopic tooth occlusal elastic contraction position
13
Class I + Class II Class I + Cross bite Class II + Cross bite Etc.......( see chapters ).
elastics
CLINICAL STATEMENT
Name:
N:
Date:
A / TRANSVERSAL:
RIGHT Maxillary Mandible
Grade by a figure 1, 2, 3 the malposed teeth
Crossbite
NORMAL
Crossbite
B / VERTICAL:
3SD 2SD 1SD Class : Skeletal Dental
Grade by 1 SD, 2 SD, 3 SD . Use an arrow for tendency
Deep bite
C / SAGITTAL: Right
A N C H O R A G E yes no Loose yes no yes no Mini yes no yes no Mean yes no
Maxilla
yes no Maxi yes no yes no Maxi yes no yes no Mean yes no yes no Mini yes no yes no Loose yes no
Left
A N C H O R A G E
Right
Mandible
14
Left
FORCE DELIVERY
Force application plays a strategic influence on orthodontic movement by means of wires and elastic rubber bands. Histologicaly optimum orthodontic movement had been related to an intact vascular supply. An optimum force should not exceed the capillary blood pressure ( 20 to 25 gm/cm2 ). If forces are above this level, clinical observations demonstrate possible ligament strangulation and sometimes root resorption.
Many authors had concluded that one of the major factors, if not the principal, governing bone resorption during tooth movement is the presence of an intact vascular system. Z. DAVIDOVITCH 3 had proposed intermittent forces as more suitable because their duration would not be sufficient to produce anoxic destruction of the ligament. According to this author, osteoclasts, which were stimulated to function by the force application, would continue to resorb bone for a brief period of time mobilizing the necessary bone removing cells.
Sunburst Elastics
GACs Sunburst Elastics are made from the finest quality latex. They are clean-cut, durable, hygienic, and made with regulation coloring. Available in a wide range of sizes and force values, Sunburst provides the precise degree of required control with a continuous force. Like our regular intraoral elastics, Sunburst is packaged with a bright white placer in each bag for easier use and greater patient cooperation. Colors are randomly assorted and are not available in specific colors. Sold in boxes of 50 zip bags, 100 elastics per bag.
Description
2.7 oz. 4.0 oz. 6.0 oz.
3/16"
11-001-04 11-002-04 11-003-04
Elastics Racks
Our aluminum anodized elastics rack is durable, light weight, and has holes for mounting on a wall. Holds four boxes of GAC elastics. Aluminum Elastics Rack 97-300-30
15
CLASSIFICATION OF FORCES
OUNCES
GRAMS
FORCE
O R T H O D O N T I C
O R T H O C P E D I
0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 32 48
14.17 28.35 56.6 84.9 113.2 141.5 169.8 198.1 226.4 254.7 283.0 311.3 339.6 367.9 396.2 424.5 453.6 907.2 1360.8
Table III.1
O R T H O D O
medium
N T I C
heavy
O R T P E D I
very heavy
H O C
16
180
85
110
115
60
75
175
90
90
115
40
40
Root surface
1.10
.60
.60
.75
.25
.25
Total 3.55 g.
The size of enface root surface exposed to sagittal movement is measured in square centimeters. Every tooth can be evaluated as to the necessary force based on its root surface involved. That means, on average, a force of: 635 g. in maxilla 550 g. in mandible to move all of the teeth. With friction, continuous archwires used with ceramic bracketts, its easy to understand that heavy forces may be needed to move teeth. In order to use lighter forces, a frictionless biomechanic system may be advised with segmented archwires. Doing so, orthodontic movement with elastic forces should be faster and more efficient. 17
75 50 60 90
75 50 60 90
105 70 70 105
100 65 50 75
105 70 50 75
.95
1.05
.60
.70
.50
.50
105 70 95 140
45 30 60 90
45 30 60 90
65 45 70 105
45 30 50 75
60 40 50 75
.95
1.05
.60
.70
.50
.50
ANCHORAGE
>
FRICTION LESS
CONTINUOUS ARCHWIRES
SEGMENTED ARCHWIRES
MEASURABLE
NON MEASURABLE
MECHANIC
BIOLOGIC
LIGHT FORCES
Table III.5 19
CHAPITER IV
- Girls are usually more cooperative than boys. Of 10 studies relating gender to various aspects of compliance, 5 reported that girls were more cooperative, but 5 found no sex difference. - Children under age of 10 years are more cooperative than older children. - Socio-economic status may be a predicting factor. Less cooperation is experience with patients from lower socio-economic status; but that does not mean that high class patients are more concerned. - Personality is a better factor to consider for uncooperative patients, characterized as being concerned with appearance, having conflicts with a mother, a father, or both, and needing the presence of authority to enforce ethical behaviour. - Cooperation is not related to severity of the malocclusion. - Embarrassment may be given as an excuse, forgetfulness, nuisance for low motivation, or apathy. - Pain is sometimes underestimated in the clinical setting of elastics bearers. Its importance should not be dismissed since pain is one of the most frequent reasons for not wearing intra oral or extra oral rubber bands. Some patients will require more communication regarding the amount of discomfort and progressive elastic forces to get accustomed with.
2 Explain
3 Explain
20
Fig IV.I
21
CHAPTER IV: Elastics Wearing Motivation Elastics prescription needs: 1 - a written prescription on a motivation card to reinforce the message . 2 - to explain why, when, and how to wear elastics (see Fig IV.3 ). 3 - to check that the patient understands well the message and is able to place properly the prescribed elastics (see Fig IV.4 ). 4 - to keep an eye on motivation, ask to the patient to put on his elastics in front of you. 5 - to evaluate patient cooperation with: weakness of progress correction improvement of motivation means threats of complications: increased treatment time possibilities of extractions possibilities of surgery increased fees ...
Please follow your elastics prescription exactly as we asked you: youll get faster and better results . Change them and wear them as indicated. Stay with your elastics even if you have some discomfort particularly during the first two days ( as with a new pair of shoes ) . Remember that well worn elastics mean you are speeding your treatment time .
Bring back your worn out elastics at each visit , said R. BEGG 27, as a good way to educate a recalcitrant patient. 22
CHAPTER IV: Elastics Wearing Motivation FRONT of Motivation card Dr. STRAIGHT
1057 Paradise Av.
L. A. CALIFORNIA
INSTRUCTIONS FOR ELASTICS WEARING Now you have elastics to wear to help us to straighten your teeth. They are used to exert light forces to move dental arches. The different elastics sizes and prescription correspond to various tractions that will be used in succession of the correction of your teeth. At the beginning of elastic wearing, you may have some light tenderness during one or two days. Dont be afraid, go on wearing them, youll be accustomed to them very quickly !
If you have any difficulties in placing them, please come back to our office. We will help.
In order to brush your teeth and your gums correctly, remove the elastics and put them back on immediately after brushing. Always have some extra elastics in your pocket to use in the event of breakage.
FAILURE to follow instructions may result in biomechanic complications and POSTPONE the FINAL RESULT. BACK of Motivation card
PLACE ON your elastics IN FRONT of a MIRROR. Wear them: Change them: t day and night ______ time(s) a day t only at night. If you need elastics, please call our office immediately.
Fig IV. 2: Example of an elastic worn around two upper incisors with initial diastema. The elastic went up in the gingiva with periodontal damage.
Fig IV.3: Clinical example of an exaggerated movement given by Class II elastics changing a Class II in Class III. 24
Fig IV.4: Example of a misunderstood prescription of elastics. To correct the Class II canine we need a closing Class II elastic.
Fig IV.5: A supply of elastics on the watch of a well motivated patient. During school hours, elastics can be changed. 25
Skeletal Class I
every 8 wks 8 wks 6 wks/ 4 wks 2 wks X3 per day X2 per day X1 per night
Dental Class II
Dental Class I
every 6wks 4 wks 2 wks Elastics changes: X2 per day X1 per night Table IV.1 26
CHAPTER IV: Elastics Wearing Motivation 2- The clinical goal to reach The Orthodontist may advise the patient to schedule his next visit only when the goal will be reached. For instance, if the patient has to wear a delta elastic to bring down an upper ectopic canine, you can ask him or her to wear elastics until the canine contact with antagonists, and then call for a new visit.
Be carefull: Badly or incorrectly hooked elastics may change biomechanics effects and complicate the treatment.
Risks of excessive elastics wear: an excessive correction ( a Class II becoming a Class III as shown in fig IV.3 ). an exaggerate tipping of lower or upper incisors ( backward / forward ). anchorage lost. undesirable extrusion / overbite. 27
CHAPTER IV: Elastics Wearing Motivation exaggerate rotation. parodontal problem, such as Class II worn too much, may give lower incisors dehyscence.
Be carefull: To dual bite Class II elastics wearing for a long time may simulate a corrected malocclusion. The patient may exhibit a misleading convenience bite ( dual bite ).
So, check centric relation at any appointment before any elastics prescription.
28
29
5 - Discomfort is temporary; wear your appliance faithfully. 6 - Use your score card to keep record of the number of hours you are wearing your appliance night and day. 7 - Recording the wearing hours allows your orthodontist to determine needed forces for proper correction. 8 - To put on your headgear is quite simple in front of a mirror, or have someone help you. 9 - Dont twist or distort your inner or outer bow by playing with it. 10 - Please dont wear your headgear during rough play, sports, cycling.... This could result in injury to you.
Very important: Remember to bring your appliance to any appointment to give us a chance to properly adjust it.
30
Please score how many hours you have worn your headgear per 24 hours Name: Adress:
Elastics Placers
Our bright white Elastics Placer helps patients properly place their elastics, and the easier it is for them to do, the greater the patient cooperation. Available in bags of 100.
Description
Elastics Placers
Catalog Number
11-999-99
31
CHAPITER V
1 - Definition
The Class I elastic can be a chain, a rubber band, a ring or a thread placed on a single arch and having a vertical or a horizontal force movement. The Class I elastic has a reciprocical biomechanic action in a straight line
2 - Disposition
The Class I elastic can be placed: one tooth to another tooth one tooth in opposite way as a couple of forces one tooth to an archwire, a loop one point to another point of the archwire one tooth to an auxilary appliance such as Quad Helix, a palatal bar, a bite plate etc... The Class I elastic is a monomaxillary or monomandibular elastic which can be used with other elastics in the same time.
STABLE force
>
MOBILE force
That means, for example, that if you have, as in Fig V.8, to move distally a 41 and to close a diastema, an elastic thread ligature around 42 and 41 will move both equally in the space. To move distally the 41 you should placed the thread elastic on two or more teeth or thru the utility helix to keep the stable force higher than the mobile one.
Be careful: Elastics not well hang on or worn by the patient can complicate treatment objectives.
32
Fig V.2: Buccal upper incisor tipping for adult in typical Class II.2. The elastic thread is tied on a .045 wire.
Fig V.3: Intrusion of a molar or cuspid with a thread elastic, tied on utility arch.
Fig V.4: Intrusion of lower incisors in adult, with a thread elastic, on a R. BENCH lower arch.
34
Fig V.5: Class I elastic ligature used to rotate and bring forward the left lateral incisor in the opened space by the M utility.
Fig V.6: Class I elastic to slide backward the right lower lateral incisor. The elastic is changed 3 times a day. 35
Fig V.7: Example of elastic ligatures tied to rotate the 24 with an opposing force couple.
Fig V.8: Example of a Class I elastic ligature thru an utility Helix to close a lower incisor diastema in moving distally the 41. 36
Fig V.9: Example of Class I elastic chain and ligature to rotate a canine and an upper first premolar with a force couple.
Fig V.10: Example of Class I elastics on a bite plate to correct a midline deviation and close diastemas. 37
Fig V.11: Example of a tongue thruster who had reopened a diastema after a treatment. Class I elastic is placed on a bite plate.
38
Fig V.13: Class I elastic ligature tied on the 4T4 to close the lower diastema. The patient was already in retention.
Fig V.14: Result obtained with the Class I cross elastic and lower elastic ligature. Permanent retention with Ribbond was made. 39
Fig V.15: Example of space reopened after treatment. The patient does not want to have braces any more.
Fig V.16: A bonded hook is made distal to the upper lateral incisor. 40
Fig V.17: An upper bite plate with an O occlusal elastic is worn to close the diastema.
Fig V.18: Detail of the O occlusal elastic used to close the diastema. 41
Fig V.19: Frontal view showing the diastema closure with the O elastic.
Fig V.20: The bonded hook is removed and the upper incisors are splinted with a ribbond wire. 42
Fig V.21: Class I elastics used on a crossway on a bite plate ( intraoral view ) for space closing.
Fig V.22: Class I elastics used on a crossway on a bite plate for space closing.
43
CHAPTER V: Class I Elastics Forces Influence of elastic association used - in extraction cases - on continuous archwires
Fig V.23: A: A Class I elastic on maxillary arch to retract the upper canine can certainly move it backward, but a slight forward movement of the upper molar can be seen if M1 is not anchored by an auxilary such as a palatal bar, a headgear... B: A Class I elastic on maxillary arch anchored on the second molar is a better anchorage than can achieve a retraction of the upper canine. C: A Class I elastic used simultaneously on maxilla and mandible moves forward the upper molar with the lower during the retraction of the upper canine. 45
Fig V.24: D: The association of a maxillary Class I with a Class II elastic moves forward slightly the maxillary molar when the lower goes forward E: The association of a bimaxillary Class I elastic with a Class II one moves the molar forward and the upper canine backward. F: The association of a maxillary Class I with a short Class II allows retraction of the upper canine without moving the upper molar. Then the lower molar can be brought forward without losing maxillary anchorage. 46
CHAPTER V: Class I Elastics Forces 6 - ROTATION with one Class I or with force couple of two opposed Class I ( see Fig V.9 ). 7 - STRENGTHENING FORCE such as to increase: the loosening anchorage, a Class I can be added to a Class II or III according to the clinical objectives. the maximum anchorage, a Class I can be also added for differential forces to increase the stable force. the midline shift correction.
7 - Elastomeric chains
Polyurethane chain elastics are commonly used in daily orthodontics as Class I elastics. They are made by Ortho manufacturers in: - long filament chain - short filament chain - closed loop chain. Elastomeric chains are mainly used for intra arch tooth movement and for spaces closing, because placement and removal requires little chairtime and no patient cooperation. More than 50 studies had been done on elastomeric chains; a consensus of clinicians may be summarized as follow: a permanent deformation may result after extension of plastic module the degradation of force is increased over time the force exerted is unpredictable and inconstant the configuration of chain affects the behaviour of the force after 3 weeks, the residual force is generally about 5 %. oral environment ( such as PH, light, saliva, drinks, foods, dental plaque ) has been associated with degradation of the polyurethane elastomer extension or prestretching has been advocated before inserting the chains the elastomeric chains must be kept in a container and protected from light.
47
Fig V.25: Configuration of elastomeric chains: A - long filament chain B - short filament chain C - closed loop chain.
The longer the chains filament, the lower the initial force
As with any system in Orthodontics, Class I elastics may give complications such as: - abnormal tipping - exaggerated rotation - exaggerated extrusion - anchorage lost - minor or insufficient displacement... Since more and more practitioners are using straight wires, some of them have undesirable effects in using a continuous elastic chain on too light archwire < 0.016. 48
Undesirable effects of continuous elastic chain 1 Mesial molar rotation with too light wires 2 Light wires do not sustain the chain force 3 Posterior expansion of archwire 4 Wilsons curve is threatened ( molar crossbite ) 5 Undesirable root tipping 6 Increased Class II elastic forces 7 Risk of weakening anchorage 8 Molar tipping interferences 9 Incisors extrusion Torque lost 10 Lateral pterygod tenderness 11 Lower incisor retroversion with mandibular arch contraction 12 Increased overbite.
Fig V.26: Occlusal elastic placed on upper canine to correct a retarded occlusal contact function. The light contraction is usually obtained in a week.
Fig V.27: Correction of a too buccal position of first upper bicuspids with an occlusal elastic. 50
Fig V.28: Clinical example of the application of an occlusal elastic worn on the lower molar which became too buccal. This kind of O elastic is worn during night only and for a short time ( 2 to 3 weeks ) to correct the lower buccal cross bite degree 2 (see text ).
With a mandibular reverse arch curve, dont use a continuous elastomeric chain... Prefer a segmented chain to allow a buccal tipping of retruded incisors !
Elastics Placers
Our bright white Elastics Placer helps patients properly place their elastics, and the easier it is for them to do, the greater the patient cooperation. Available in bags of 100.
Description
Elastics Placers
Catalog Number
11-999-99
51
Fig V.29: Clinical example of bilateral buccal upper canine corrected with cross O shape elastics. 52
CHAPITER VI
1 - Definition
Class II elastics are intermaxillary elastics placed on the maxilla anteriorly, and on the mandible posteriorly.
2 - Disposition
Class II elastics may be placed differently on: the mandibular arch posteriorly buccally, lingually or simultaneously from: different teeth M2, M1, Pm2, Pm1 distal to a molar tube a hook a loop a JARABAK or KAYABASHI ligature tie a buccal hook coming from a lingual arch a bite plate with a distal hook. the maxillary arch anteriorly from: a sectional archwire a Class II utility arch a continuous archwire with anterior loop a sliding hook a JARABAK or KAYABASHI ligature tie a bracket hook a Jig a Class II headgear a reciprocal archwire 0.45 with hooks a reciprocal Mini Chin Cup.
Centric occlusion
Opening 10 mm
Opening 25 mm
Fig VI.1: Biomechanic influence of mouth opening on Class II elastic force ( see text ). 54
CHAPTER VI: Class II Elastics Forces With a mouth open 10 m/m at the incisors level, the force varies with different angulation of the Class II elastic and has different effects upon: - the maxillary arch The vertical component of extrusion is: 160 X sin 29 = 77.60 g. because the elastic has now a 29 angulation with the upper arch ( see Fig VI.1 ). The horizontal component of distalization is: 160 X cos 29 = 139.90 g. - on the mandible The elastic has a 35 degree angulation with the lower archwire. So we have: A forward component force of: 160 X cos 35 = 131 g. A vertical component of extrusion force which is: 160 X sin 35 = 91.8 g.
With a mouth open 25 m/m, which can happen when the patient is speaking, smiling or yawning, the elastic force can be again increased to 190 grams. But this force cannot be constant and is going to decrease with time, in the saliva. This maximum force occasionally exerted has again different effects upon: - the maxillary arch The vertical component of extrusion force is: 190 X sin 38.5 = 118.3 g. The horizontal distalizing force is: 190 X cos 38.5 = 148.7 g. - the mandibular arch The horizontal forward force is: 190 X cos 52.5 = 115.7 g. The vertical component of extrusion force is: 190 X sin 52.5 = 150.7 g.
From those figures, it is now easy to notice that by opening of the mouth from 10 to 25 m/m, the forward mandibular force drops down from 131 to 115.7 g.That means it decreased about 10% despite the patient opened his mouth more. Notice also that the extrusive mandibular force went from 91.8 to 150.7 g. That means it increased 64% ! From this biomechanic explanation, the clinician must understand that the use of Class II intermaxillary elastics has to take into account the facial type in order to avoid a facial pattern aggravation.
During day: Intermaxillary elastics have a vertical component of extrusion that is much more significant than the horizontal component. During night Intermaxillary elastics have an equivalent vertical and horizontal component.
55
Fig VI.2: Facial type influence with Class II elastic use and consequences on the antero superior occlusal plane when using continuous archwires. ( See text ). 56
Fig VI.3: Ch. TWEEDs Class II elastics are worn on continuous arches (with tip back) and headgear.
Fig VI.4: F. SHUDYs Class II elastics are placed on three points in a closing way with High Pull Headgear to control anterior occlusal plane and reinforce maxillary anchorage.
Fig VI.5: R. ROTHs Class II elastics are short and used with headgear according to the facial type.
57
Fig VI.6: The R. RICKETTSs bioprogressive technique. Class II elastic on sectional maxillary archwire.
Fig VI.7: R. RICKETTSs utility arch with Class II hook for maximum anchorage.
Fig VI.8: J. PHILIPPEs circummandibular arch to protract the mandibular arch. Unfortunately, when the patient opens his mouth, the Class I elastic becomes a Class II with extrusion consequences.
58
Fig VI.9: Example of a Class II elastic placed on a sliding hook to compress a spring for minor distalization.
Fig VI.10: Example of a Class II elastic placed on a sliding Jig to correct a molar relationship.
60
Fig VI.11: Example of a Class II elastic placed on a Class II utility arch to correct a midline shift.
Fig VI.12: Example of a Class II elastic placed on a contraction utility arch to correct an upper incisor protrusion and close anterior spaces. 61
Fig VI.13: Example of a Class II elastic placed on a continuous archwires.This kind of intermaxillary elastic has an extrusion component on the occlusal plane ( see text ).
Fig VI.14: Clinical case of one Class II elastic placed on the upper sectional to settle the canine relationship and one other Class II elastic placed on the contraction utility archwire to help the incisor retraction and torque. 62
Fig VI.15: Clinical example of a Class II canine relationship associated with a Class I molar relationship before treatment.
Fig VI.16: After treatment of a Class II elastic placed on a sectional maxillary arch.
63
Fig VI.17: Example of clinical dental Class II 1 deep bite before treatment. Notice the canine Class II relationship.
Fig VI.18: After 3 months the canine relationship had been corrected with a Class II elastic worn on a reciprocal maxillary arch. 64
In incisor overclosure, the use of Class II elastics is recommended only after: the correction of the vertical sense ( overbite ) the segmentation of the maxillary archwire.
Remember:
correct the overbite before the overjet level the curve of Spee before using the Class II elastic segment the maxillary arch.
In some cases, the bite plate can help to open the bite when using intermaxillary elastics. open bite: in those cases the use of Class II elastics must be avoided because their effects increase the mandibular rotation even when using closing Class II. Its better to use Class I elastics associated with judicious extraction strategies and/or surgery. The vertical component of Class II elastics extrusion depends on: the facial type the occlusal plane orientation the curve of Spee cases with or without extraction the mandibular anchorage posterior point of the elastic( M2, M1, Pm2, Pm1 ) the force exerted ( day and/or night ).
65
Be aware of the DUAL BITE ! The Class II elastic wearing can simulate a corrected malocclusion and disappoint someones hopes.
Some patients have worn Class II elastics for so long that they can develop a convenience bite and cheat their Class II correction. Before stopping Class II elastics check the centric relationship and look at the patient occlusion.
The Class II elastics with mandibular tripod must consider: to segment the maxillary arch segmented tripod to keep posterior wedges to distalize lateral segments, try to obtain overcorrection to intrude incisors to advance the lower arch.
66
The orthodontic management of cases with lack of posterior support involves: 1 - reestablishment of the vertical support 2 - elimination of the anterior excessive contacts due to overbite. This can be done by: uprighting posterior teeth extruding posterior teeth intruding incisors and/or? buccal tipping of incisors to correct incisal angulation and overbite surgery.
67
to maintain a good skeletal relationship during healing and consolidating phase to overcorrect dental relationship to correct midline deviation to seat the canine occlusal relationship.
The practitioner must consider the patient on an individual basis and the kind of surgery undertaken. The Class II elastics should be used: to avoid bone mobilization, even in rigid fixation cases to segment the surgerised arch to its opposing arch, if possible to prefer short closing Class II elastics to use segmented archwires instead of continuous ones, with frictionless forces. to keep posterior wedges and avoid posterior mandibular rotation.
In orthognatics cases, the control of the vertical sense is fundamental in maintaining the advantages of sagittal correction.
CHAPTER VI: Class II Elastics Forces FRICTIONLESS Using an archwire with an activated M loop with tip back, we can place the Class II elastic: 4 - behind the lower molar to advance the whole mandibular arch with less extrusion than in Fig. n 1. 5 - on the mesial hook of the lower molar to help the activation of the M loop and open the Pm2 space and advance the mandibular arch with more efficiency than in Fig. n 2. 6 - distal to Pm 1 on a KOBAYASHI tied ligature, the Class II elastic is going to help the M loop to give a reciprocal effect in opening quickly the Pm2 space and advancing the mandibular arch in a very efficient way.
There are other biomechanic systems that could be used such as segmented arches with utility arch etc; but the principle remains mainly the same.
In LINGUAL TECHNIQUES all biomechanic principles remain the same, except that elastics are placed on lingual side.
69
WITH FRICTION
FRICTIONLESS
Fig VI.19: Influence of biomechanic archwires systems and the hooked point of the Class II elastics ( see text ).
70
Fig VI.20: Biomechanics of Progressive Torque with the RICKETTSs utility arch. The Class II elastic pulls downward and backward the anterior loop which raises the anterior segment of the arch increasing progressively the torque with the contraction. A bodily movement of the upper incisors is the result. See text.
71
Fig VI.21: Clinical example of Class II elastics placed on a Class II utility maxillary archwire and a sectional to correct Class II molar and canine relationship on one side.
Fig VI.22: Clinical example of Class II elastic on right side to correct a midline deviation and help to close the space between upper canine and lateral incisor. 72
Fig VI.23: Clinical example of U shape anterior elastic to close the bite. Notice the controlateral crossbite elastic to move the first bicuspid palatally.
Fig VI.24: Clinical example of closing Class II elastics to help closing the bite. Notice the extrusion Class I elastic placed from right to left hook of the lateral maxillary sectional archwires. 73
14 - How to diminish the extrusion component force with the Class II elastics use
According to many authors, about 15% of Class II Div.1 malocclusions have a potentially vertical excess dimension. Some of those cases are usually treated with extraction of bicuspids that results, when using Class II elastics, in an increased extrusion component force ( see Fig VI.28 ). There are different means to diminish the extrusion force such as: wearing elastics only during sleeping hours more horizontal elastics with hooked point more posterior in the mandible and more anterior for the maxilla.
In using: molar M2 banding Class II headgear .045 reciprocal arch reciprocal mini chin cup.
Before RETRACTION, the more vertical the upper incisors are, the more TORQUE is needed.
74
Fig VI.26: Class II molar extrusion elastic indicated in deep bite cases.
Fig VI.27: Triangular Class II elastic with a double component of Class II and extrusion for deep bite tendency cases.
75
Fig VI.28: Influence of the hooked point of the Class II elastic: A - In extraction case. B - In non extraction case from M1. C - In non extraction case from M2. Notice the difference of the vertical component of extrusion. 76
77
Fig VI.30: D, E, F, After correction with Class II elastics placed on an . 045 upper reciprocal arch.
78
Fig VI.31: Example of oblique and Class II elastics to correct midline shift with a segmented frictionless mechanism. 79
Fig VI.32: Example of a Class II elastic headgear with anterior welded hooks opened anteriorly.
Fig VI.33: Intraoral example of unilateral Class II elastic headgear for midline shift and Class II correction. 80
Fig VI.34: M. LANGLADEs reciprocal maxillary arch used with a Class II elastic on a .016 X .022 lower utility arch.
Fig VI.35: With a maxillary sectional arch and a LANGLADEs reciprocal arch the patient can wear two Class II elastics on each side.
Fig VI.36: With the same system we can add a LANGLADEs reciprocal mini chin cup to reinforce the Class II effect according the degree of difficulty of the clinical case (3 X 100 g. force on each side mandibular protraction effect ). See Chapter IX.
81
Fig VI.37: KAPRELIAN K 2 P . A split elastic positioner, worn with Class II elastics, during home hours and sleeping.
82
CHAPITER VII
1 - Definition
Class III elastics are intermaxillary elastics placed posteriorly on the maxillary arch and anteriorly on mandibular arch.
2 - Disposition
According to the clinical problem, Class III elastics may be placed: Posteriorly buccally palatally to help expansion buccally and palatally to increase the force from the distal part of the archwire ( Fig VII.4 ) from a molar hook ( Fig VII.5 ) before the maxillary molar, even from Pm2 or Pm1 from a Class III headgear from a bite plate distal upper hook. Anteriorly a loop on archwire a JARABAK or KOBAYASHI ligature from a Class III bite plate with anterior hooks and inclined plane to help to jump the bite ( see Fig VII.6 ).
Centric occlusion
Opening 10 mm
Opening 25 mm
Fig VII.2: Influence of conventional Class III elastics on the occlusal plane tilting when using continuous archwires ( see text ). 85
Fig VII.3: Influence of conventional Class III elastic forces with facial type and consequences on the vertical component of extrusion, when using continuous archwires. See text. 86
CHAPTER VII: Class III Elastics Forces Influence of Class III elastics on occlusal plane tilting with continuous archwire: When a regular Class III is placed distally to the upper molar and mesially to the lower canine with continuous arches, the resulting force depends on the tilting of the occlusal plane -in other words on the facial type: - in a normal vertical dimension the resultant is a 50% forward movement of the maxilla of applied Class III elastic ( see Fig VII.3A ) with an extrusion on upper molar and an extrusion with lingual tipping of the lower incisors. - the more the vertical dimension is increased ( see Fig VII.3B and C ), the less the mesial movement of the upper molar from 33% to 25% with an increased extrusion worsening the open bite. So, it is very important to keep the posterior wedge in a patient with a potential borderline open bite. Segment the arch behind the first upper premolar and use short closing Class III elastics. The vertical component of extrusion of Class III elastics depends on: the curve of Spee the cases with or without extractions the point where the elastic is placed the facial type: the more the open bite, the greater the extrusion component
Class III elastics have a counterclockwise effect on the occlusal plane anteriorly and posteriorly.
87
Camouflage with posterior mandibular rotation in Class III squeletal pattern depends on: growth potential (use Long Range growth Forecast ) dental overbite collapsed labial esthetics ( see Table VII.1 ) 88
CHILDREN
ADULTS
GROWTH POTENTIAL
NO GROWTH
CANINE FUNCTION
limited by
POSTERIOR ROTATION
DENTAL OVERBITE
T.M.J.
VERTICAL DIMENSION
LABIAL ESTHETICS
89
Fig VII.4: Conventional Class III elastic placed behind the upper molar. A high component of extrusion exists on the occlusal plane.
Fig VII.5: Regular Class III elastic placed on maxillary mesial molar hook. The extrusion component force still exists. 90
Fig VII.6: Example of Class III elastics placed on behind the maxillary molar posteriorly and on anterior hook of a lower inclined bite plate in order to bring forward the upper arch and jump the bite.
91
Fig VII.8: In this Class III, almost edge to edge incisor relationship, the vertical sense is critical and must not be opened. The posterior wedge must be kept.
Fig VII.9: Notice that the arch is segmented behind the 14th, and the patient is wearing a closing short Class III elastic to jump the bite. 92
The deeper the overbite, the better the prognosis in Class III malocclusions.
94
to maintain a good skeletal relationship healing and consolidating phase to overcorrect dental relationships to correct midline deviation to seat the canine occlusal relationship.
Most of the time the orthodontist has to consider the patient on an individual basis without forgetting the kind of surgery undertaken. Class III elastics should be used: to avoid bone mobilization, even in rigid fixation cases, using light forces to segment the antagonist arch to the surgerised one, if possible to prefer short closing Class III elastics to keep posterior wedges to control vertical dimension to use segmented archwires instead of continuous ones with frictionless forces.
In orthognatics cases: Extrude teeth on an unitarianly way in order to avoid moving bone fragments.
TONGUE INTERPOSITION,
vertical intermaxillary elastics can be
LINGUALLY placed on
cleat lugs, bonded buttons, to provide an
ANTI-TONGUE SCREEN.
95
Centric occlusion
Opening 10 mm
Opening 25 mm
Fig VII.10: Triangular Class III biomechanics with a _, light elastic in 10 cm opened mouth. We have: at the maxilla: an extrusion force of 119.1 g. a forward force of 32 g. at the mandible: an extrusion force of 115.1 g. a backward force of 44.3 g. 96
CHAPITER VIII
CHAPTER VIII: Particular Intermaxillary Elastics Many intermaxillary elastics may be used for a specific extrusion component associated in conjunction with others such as contraction, in a horizontal or vertical way. Among them let us see:
2 - THE
U SHAPE ELASTIC
The U shape elastic has a contraction and extrusion effect on only one arch. So it can be used with a segmented arch to the antagonist arch and can be used in U shape or upside down ( see Fig VIII.1 ). Most of the time, this elastic is used anteriorly, but it can also be used posteriorly.
4 - THE
V SHAPE ELASTIC
This elastic has a vertical component of extrusion without a light contraction. It can be worn to bring a tooth on the occlusal plane in a V shape or upside down according to the clinical need.
5 - THE
M OR W SHAPE ELASTICS
These elastics are used for extruding a group of teeth in order to squeeze the bite in an effective closing way. Heavy elastic up to 300 g. may be used ( see Fig VIII.3 and 4 ).
Fig VIII.1: Example of the U shape vertical closure elastic on segmented arch. 98
Fig VIII.2: From R. M. RICKETTS and al. Bioprogressive Therapy. RMO Editor. 1979 99
Fig VIII.3: Example of M and W elastics to close the bite faster than locking up the maxillary teeth in a straight wire.
Fig VIII.4: Two weeks later, the bite is closed with the M and W vertical elastics.
100
Fig VIII.5: Clinical example of a squeeze of the bite with M and W shape elastics ( see text ).
Fig VIII.6: Post surgery TMJ patient wearing a splint with lateral rectangular elastics to extrude lower molar and first bicuspid. 101
Fig VIII.7: Example of an upside down V elastic to bring down a right upper canine instead of locking it up with a straight wire.
9 - SQUEEZE ELASTICS
In some borderline surgery open bite cases, R. M. RICKETTS 2 had advocated heavy elastics forces ranging from 800 to 1500 g. to close the bite (see Fig VIII.5 ). Those elastics are worn 24 hours a day, and changed three times during two weeks, to obtain the bite closure.
MAXILLA: UB3 = upper buccal 3 cross bite UB2 = upper buccal 2 cross bite UEE1 = upper edge to edge 1 UL2 = upper lingual 2 cross bite UL3 = upper lingual 3 cross bite
MANDIBLE: LB3 = lower buccal 3 cross bite LB2 = lower buccal 2 cross bite LEE1 = lower edge to edge 1 LL2 = lower lingual 2 cross bite LL3 = lower lingual 3 cross bite
103
Table VIII.1
Fig VIII.8: Differential posterior cross bite occlusion diagnosis must distinguish A - a dental malocclusion B - a narrow maxilla C - a mandibular latero deviation ( functional shift ). 105
Intermaxillary homolateral cross bite elastic can be used: in normal or deep bite skeletal cases in deep bite cases where expansion is desired.
106
Occlusion
Open 30 mm
Fig VIII.9: Biomechanics of homolateral cross bite elastics ( see text ). 107
L A T E R A L In mandible In maxilla C O N T R O L A T E R A L
Fv extrusion: 171.7 g.
Fh transversal: 273.3 g.
108
Fig VIII.11: Short vertical elastics have a tendency to narrow the transversal dimension
Fig VIII.12: GRUMMONS double cross bite used for molar extrusion in TMD patients to unload the condyle.
109
CHAPTER VIII: Particular Intermaxillary Elastics Clinical applications: The clinical application of this kind of controlateral cross bite elastic suggests it is helpful in various transverse corrections, more especially in posterior unilateral crossbite situations. In 1990, M. LANGLADE 39 did a comparative study on cross bite correction of unilateral palatal upper molar in two degree cross bite wearing a Quadhelix with or without the help of a controlateral cross bite elastic (see Table VIII.3 ). The treatment time was shortened from approximately 270 to 60 days with the controlateral elastic !
Unilateral expansion Quadhelix Maxillary lingual degree 2 cross bite Without any elastics 8 Male 4 Female Average age: 12.4 years Transverse unwedging 4.91 mm Range from 3 to 6 mm Treatment time 267.25 days N12 N12 Average age: 10.9 years Transverse unwedging 5.58 mm Range from 3 to 7 mm Treatment time 60.33 days With controlateral elastics 6 Male 6 Female
Table VIII.3: Comparison of Unilateral posterior cross bite correction from M. LANGLADE. Foundation for Orthodontic Research 1990.
The intermaxillary controlateral cross bite elastic is very helpful in correcting unilateral posterior cross bite.
Clincal indications of the controlateral cross bite can be summarized as: mandibular functional side shift posterior unilateral cross bite: 1 - for helping an expansion 2 - for helping a contraction 3 - for helping an expansion and a contraction 4 - for helping a contraction and an extrusion. 110
Fig VIII.13: Use of a controlateral cross bite elastic to correct a right maxillary buccal degree 2 with a unilateral contraction Quadhelix. The elastic is reinforcing the stable force and helping to increase the moving force.
Fig VIII.14: The controlateral cross bite elastic has a double action on the unilateral movement of the Quadhelix by: 1 - increasing the molar anchorage on the right side 2 - increasing the expansion force of the Quadhelix with a transversal elastic helping to jump the left molar bite ( mobile force ). 111
Fig VIII.15: Controlateral cross bite elastic used to correct a lingual maxillary molar degree 2 with a unilateral expansion Quadhelix.
In DISTRACTION OSTEOGENESIS, the practitioner can use all biomechanic principles in order to correct maxillo mandibular anomalies using intermaxillary elastics such as:
U N I L A T E R A L
q vertical rectangular, M, W etc q diagonal, oblique etc q controlateral cross bite q homolateral cross bite q Class I, Class II, Class III q combination
B I L A T E R A L
112
Fig VIII.16: Example of buccally ectopic canines with anterior open bite.
Fig VIII.17: A cross controlateral elastic is going to palatally move each canine in a week. 113
Fig VIII.18: One week later the bite is closed and the upper canines are settled transversally and vertically ( see Fig VIII.16 and 17 ).
Fig VIII.19: Example of a controlateral elastic helping the correction of a cross bite degree two with a unilateral Quadhelix force. 114
Fig VIII.20: The palatal ramp unilateraly on a bite plate can be used to guide the mandible in functional shifts: A - without occlusal plate B - with bilateral bite plate C - with unilateral bite plate. Controlateral or intermaxillary elastics can be placed to help the midline shift correction. 115
Continuous archwires dont work in a dental asymmetric arch or with facial asymmetry.
Mandibular functional shifts can be corrected with the help of a guiding bite plate (see Fig VIII.20) and controlateral cross bite or associated intermaxillary elastics. Usually the cross bite elastic is placed in opposition to the side of mandibular shift (see Fig VIII.22) 116
Q Check Mdb centric relation. Q Set the Mid sagittal plane of reference. Q What has caused the Midline deviation ? Q How does the deviation affect the occlusion ? Q Is it necessary to correct it ? and how ? Q Do 4 D dental arches analysis.
Mandibular reposition with: q functional appliance q palatal Ramp ( Fig VIII. 20 ) q surgery ? Dental arch coordination: q particular extraction (controlateral ? unilateral ? ) q reproximation / stripping q segmented archwires q asymmetric mechanics ( transversal loop ) q special intermaxillary elastics
117
N: Normal: Check CR
A: Opposed midline deviation: oblique elastics Class II / III elastics cross bite elastics cross stripping ?
B: Unilateral bimaxillary midline deviation ( Right ): left extractions ? left Class II elastics right Class III elastics unilateral stripping ?
C: Unilateral maxillary midline deviation ( Left ): right max extraction ? right Class II elastics left Class III elastics ? unilateral Mx stripping ?
D: Mandibular midline deviation check CR ? bite plate with ramp ? Class III left elastics ? + cross bite elastics unilateral Mdb stripping ?
Fig VIII.21: Elastics use and possibilities of correction. Check: - Fronto facial / profile esthetics - Frontal cephalometric analysis - CR occlusal relationships. 118
A:
2) Use Class III elastic on opposite side to the Mdb shift ? 3) Unilateral Mdb maximum anchorage on opposite side Mdb shift. 4) Unilateral Mdb stripping opposite to Mdb shift ? 5) Combination ?
B:
2) Mx extraction on opposite to midline deviation, and also 3) Maxi anchorage. 4) Class I elastic on opposite side to midline deviation. 5) Unilateral Mx stripping on opposite midline deviation.
C:
2) Mx extraction on opposite midline deviation. 3) Unilateral arch advance on side of midline deviation. 4) Class III elastic on opposite to Mdb shift (anterior diagonal + vertical). 5) Cross stripping ?
D:
2) Mx and Mdb unilateral extractions on side of Mdb shift. 3) Class II elastics on Mdb deviation side. 4) Unilateral stripping on opposite midline deviation. 119
E:
2) Mdb extraction on Mdb side shift ? 3) Class III elastic on opposite side of Mdb shift. 4) Unilateral Mdb arch maximum anchorage. 5) Stripping and/or combination of above.
F:
2) Unilateral Mx and Mdb extraction on side of Mdle shift. 3) Class II elastic ( anterior or diagonal ) on Mdb side shift. 4) Unilateral Mx maximum anchorage opposite to Mx midline deviation. 5) Stripping and/or combination.
G:
2) Cross extractions 14 / 34. 3) Cross maximum anchorage. 4) Anterior diagonal elastic and/or Class II elastic on opposite side of Mdb shift. 5) Stripping and/or combination.
H:
2) Mx unilateral extraction on opposite side of Mdb shift. 3) Latero vertical and/or Class I elastics. 4) Unilateral stripping on opposite side Mdb shift. 5) Stripping 120
121
CHAPTER VIII: Particular Intermaxillary Elastics A: Inclined divergent: segmentation of archwires triangular anterior elastics
C: Maxillary anterior open bite: U shape elastics segmentation of archwires anterior squeeze elastics rectangular anterior elastic
Fig VIII.23:
D: Inclined convergent: bite plate segmentation of archwires unilateral triangular elastics Class II / III elastics
F: Deep anterior overbite: anterior bite plate utility intrusion archwires segmentation Class II elastics and/or postero rectangular elastics
Fig VIII.23:
123
A: Anterior and left closing Class II elastics with unilateral left segmented maxillary archwire. Objectives: to correct left Class II to close the bite and correct maxillary midline.
B: Triangular anterior elastic and anterior segmented maxillary archwire. Objectives: to close the bite and to close lower incisors spaces.
C: Oblique and left Class II elastics with maxillary segmented archwire. Objectives: to correct midline deviations and close the bite.
D: Triangular anterior elastic and segmented utility Class II in a left maxi anchorage. Objectives: to correct left Class II, to close the bite and correct maxillary midline.
Fig VIII. 24: Elastic use in canted anterior occlusal plane: 1 - check sagittal plane of reference 2 - determine midline deviation 3 - look at vertical dimension 4 - prefer maxillary archwire segmentation 5 - use elastics combination. 124
In the growing patient, treatment for the fractured condylar, either unilateral or bilateral, is usually a conventional functional appliance.
In the adult case, elastics may be a part of an orthodontic treatment such as:
A / IN UNILATERAL CONDYLAR FRACTURE where the condylar neck is anteromedialy displaced with an opening deflexion on the affected side ( see Fig VIII. 25 ). The treatment should be: q a unilateral bite plate on the controlateral fractured side, to help condylar distraction. q segmented archwires on affected side with q rectangular vertical elastics.
B / IN BILATERAL CONDYLAR FRACTURE the mandible is rapidly rotating posteriorly with an anterior open bite and limited mouth opening ( see Fig VIII. 26 ). The treatment should be: q a bilateral posterior bite plate to help the condylar distraction for healing. q anterior segmented archwires with q anterior vertical elastics.
In any case, the elastics are worn for two to three months and progress can be checked with Xrays.
125
Fig VIII. 25: ELASTICS AND UNICONDYLAR FRACTURES ( see text ). q a unilateral bite plate on controlateral fractured side, to help distraction. q segmented archwires on affected side with q rectangular vertical elastics. 126
Fig VIII. 26: ELASTICS AND BILATERAL CONDYLAR FRACTURES ( see text ). q bilateral posterior bite plate to help the condylar distraction for healing. q anterior segmented archwires with q anterior vertical elastics. 127
CHAPITER IX
128
The convexity reduction decreases with age; after 12 years the reduction in point A is about 1 mm only.
In high convexity cases with a protrusive maxilla, its advisable to begin E. O. F. before 8 years old.
129
Fig IX. 1: The same malocclusion can be seen in different facial types. A different extra oral pull must be appropriate to it. 130
Long
Medium
Short
High
Horizontal
Low
Lo
rac wt
tion
131
Long
Medium
Short
High
Low
132
gh Hi c tra
High
Horiz.
Low
n tio
Long
Mediu
Short
133
Fig IX. 5: Recommended geometric configuration of power-arm unilateral face bow. The long arm should be placed on the favored side to receive the greater distal force and should terminate posteriorly near the first molar. It should extend laterally so that it clears the cheek by two inches when in an activated state. The short arm is placed on the other side and terminates near the canine tooth. It should extend laterally just enough to allow its tip to gently touch the soft tissue of the cheek, allowing the traction strap on that side to approximately parallel the midsagittal plane of the patient.
( From H. G. HERSHEY et. al. A. J. O. Vol 79 N 3 page 230-249. 1981 ).
134
FORCE SYSTEM
GENERALIZED RESPONSE
1 - Cervical headgear
Mesofacial through brachyfacial Mesofacial through brachyfacial Mesofacial through dolichofacial Mesofacial through dolichofacial
12 - 14 Long term
400 +
12 - 14 Long term
400 +
3 - Combination headgear
12 - 14 Long term
1000 +
20 + Short term
1000 +
Open facial axis Maxillary response Upright lower molars Expansion Hold or close facial axis Maxillary response Mandibular setback Expansion Hold facial axis Maxillary response No mandibular response Expansion Hold facial axis Maxillary response No mandibular response Hold arch form
From R.M. RICKETTS et. al. Bioprogressive Therapy. Book 1. R.M. 1979.
Elastics Racks
Our aluminum anodized elastics rack is durable, light weight, and has holes for mounting on a wall. Holds four boxes of GAC elastics. Aluminum Elastics Rack 97-300-30
135
Fig IX. 7: Clinical example of a Class II malocclusion corrected with only a Class I headgear elastic. Correction of canine relationship and incisor protrusion had been obtained at the same time (see text ). 137
138
Fig IX. 8: Example of a Class III elastic headgear. Notice the welded hook mesial to the upper molar, on which the closing Class III elastic is placed ( see text ).
Fig IX. 9: Typical Class III elastic headgear. The Class III elastic force has no influence on posterior occlusal plane ( see text ).
139
Fig IX.11
Fig IX.12
141
CHAPTER IX: Elastics and ExtraOral Forces The action of the facial mask which supplies a vertical counter clockwise rotation of the upper molar and palatal plane, what ever, high, horizontale, is known as the postero anterior pull.
Any sagittal movement goes with a vertical one, from which its impossible to escape
Disposition: This appliance is used to protract forward the retruded maxilla from: a welded buccal hook on a labio lingual wire cemented on the first premolars and first molars. the distal maxillary archwire. The advised force: According to different clinicians, heavy elastics can range from 1000 to 2000 g. Whatever the protraction force is, it should be: parallel to the occlusal plane 20 upward as DELAIRE and VERDON suggested, or 20 downward as T. ITOH and S. J. CHACONAS 49 et. al. proposed. The resulting effect ( see Fig IX.13 to15 ) is an extrusion of the posterior palatal plane, a counter clockwise rotation of the occlusal plane, and a backward mandibular rotation. The effect: The facial mask effect is accompanied by: at the maxillary level: a limited advancement of point A from 1 to 3 mm maximum, with a downward descent a downward and forward movement of posterior palatal spine ( see Fig IX.15 ). For every forward millimeter of the point A, the posterior palatal plane goes downward 4 mm. an upper molar extrusion of 5 mm for 1 mm of point A advancement. at the mandibular level with a postero anterior traction with a chin support it gives: a posterior condylar compression more or less tolerated which creates an alleviation attempt by the digastric muscle with a posterior rotation of the mandible an aggravation of prognathic growth tendencies of the mandible in the growing patient. 143
CHAPTER IX: Elastics and ExtraOral Forces at the dental level: a downward movement of the antero superior occlusal plane an opening of the bite with an aggravation of the anterior incisal open bite and, sometimes, a tongue interposition as concluded the P. H. BUSCHANG et. al. studies. The use: The facial mask use shows that the more the point A goes forward, the more the anterior open bite increases. This alleviation tongue interposition reflex phenomenon is a response of the muscular chains to the posterior condylar compression. The TMJ by its numerous receptors is the regulation mechanism of the mandibular growth. By those facts, the facial mask use is much more limited than some authors had declared.
Instead of a choice in uncertain future, the orthodontist must use a RICKETTSs Long Range Growth Forecast to begin with the end in mind . If you have a 7 year old patient with anterior cross bite, how can you make a decision at present time, if you ignore the final growth pattern of this patient ? Are you going to treat him immediately with a facial mask ? By orthopedics or with Class III elastics ? And run for a useless jump of the bite during many years to finally use surgery to treat him ?
In orthodontics, profits and winnings, as losses and relapses, are not given by the diagnosis only, but also by the prognosis. After your decision, you may suffer the consequences of your treatment, if you have no image of the final growth pattern ( see Table IX. 1 ). In using the long range growth forecast, you can predict: the convexity the mandibular corpus length the mandible in the face the esthetic profile with the three prognosis key factors: 1 - Long Range Growth Forecast 2 - anterior overbite 3 - collapsed lower facial height. You may use dental compensation or dental camouflage in some Class III cases, as D. WOODSIDE 59 or P. TURLEY 60 had shown ( see Table VII. 1 ). 144
Fig IX. 13: The facial mask use has a triple chain reaction: A - a lowering down of posterior palatal plane with a DOWNWARD and forward maxillary dental arch advancement. B - a posterior condylar loading which unlatch by reflex track. C - a posterior mandibular rotation allowing a sagittal increase of prognathic growth. Please remember that it is the vertical sense in TMJ that gives opportunity to the mandible to grow SAGITTALLY. 145
Fig IX. 14: According to R. M. RICKETTS 2, the maxillary growth is much more vertical posterior than anterior. This natural phenomenon must be taken into account in the facial mask use.
Fig IX. 15: Any kind of facial mask pull always involves a downward movement of the posterior palatal plane, increasing the vertical sense with consequences on mandibular overgrowth. 146
CHAPTER IX: Elastics and ExtraOral Forces SKELETAL CLASS I SKELETAL CLASS I Pseudo Class III SKELETAL CLASS III True Class III 1SD 2SD 3SD 4SD DENTAL CLASS III Elastics correction Functional shift dental Borderline Post mandible rotation Extractions Surgery skeletal
The face mask produces orthodontic instead of orthopedic effect in most of the cases. Dental and skeletal relapse will happen due to continued mandibular growth .
JONG HIN 58 et. al. 1993.
In deep overbite Class III cross bite: Use anterior bite 45 inclined plate, with Class III elastics. Bond maxillary incisors upside down to advance point A. Procline maxillary incisors ( use M loops ). Retrocline mandibular incisors close diastema use stripping of distal 33T43 extractions of 34T44 ? ? ( surgery ) Extrude posterior maxillary teeth.
In Class III, the deeper the overbite, the better the prognosis.
147
CHAPTER IX: Elastics and ExtraOral Forces q H. PETITs Face Mask This appliance is a little modification of DELAIRE - VERDON facial mask, with an apparent simplified wire frame work. q D. GRUMMONSs Face Mask 29 This is a modified face mask having a support from the forehead and cheeks instead of the chin, allowing the maxilla or the mandible arch or both to be brought forward. The author recommends a 12 hours wearing with 400 g. intra oral elastics on each side. Because this face mask has no support on the mandible, there is no impact on the T. M. J.
Fig IX.16: D. GRUMMONS 29 face mask. See text. q NANDAs Reverse Headgear 41 This appliance, according to his author, is recommended for maxilla retrusion. It goes posteriorly to the maxilla molar tube and is worn with the extra oral elastics placed on a HICKHAM 53 Chin Cup with postero anterior elastic forces in order to bring forward the maxilla ( see Fig IX.17 to 19 ). With a hook welded in front of the molar, an intra oral Class III elastic can be added to increase the maxilla protraction with: - intra oral forces = 150g. - extra oral forces = 500g. 148
Fig IX. 17: R. NANDA reverse headgear with a mesial molar hook for a Class III elastic to reinforce postero anterior maxilla protraction.
Fig IX. 18: R. NANDA reverse headgear worn in mouth with complementary Class III elastics on a lower Class III hooked bite plate. 149
Fig IX. 19 B: The NANDA postero anterior headgear is worn with a HICKHAM Chin Cup to bring forward the maxilla.
150
Fig IX. 20: The HICKHAM chin cup for maxillary protraction.
Fig IX. 21: The HICKHAM chin cup for maxillary protraction is worn with postero anterior intra and extra oral elastics placed on a head cup. 151
Fig IX. 22: The reciprocal mini chin cup with: 1 - a reciprocal maxillary arch worn full time with Class II elastics 2 - a mini chin cup, worn at home and during sleeping hours with postero anterior elastics. 153
CHAPTER IX: Elastics and ExtraOral Forces This appliance is not cumbersome and may help to bring forward the retruded mandibular arch and open the bite despite the spaces closing. The reciprocal mini chin cup advantages are: appliance is prefabricated quickly adjusted ( only 5 minutes ) does not require special bands no lab assistance needed easily inserted and removed well tolerated by children and adults invisible, not cumbersome easily worn 24 hours a day reinforces Class II elastics effects may avoid headgear use. Actions of this appliance: block / move back upper molar control palatal plane advance lower incisors during space closing advance lower arch even in non extraction cases ( reciprocal effect ) appliance of choice for rough cases with missing teeth, agenesia, or anodontia in mandibular arch supplemental chance for conservative treatment plan in borderline extraction/surgical cases.
This appliance is most effective for its reciprocal effect allowing use two, three, or even four intermaxillary Class II elastics. Usually the reciprocal mini chin cup is worn during a short time ( from two to five months ), even in adults cases. 154
Fig IX. 23: The LANGLADEs prefabricated maxillary reciprocal arch which is worn 24 hours a day with Class II elastics using a bumper effect. See text.
Fig IX. 24: The LANGLADEs prefabricated reciprocal mini chin cup which goes in the lateral tubes of the maxillary reciprocal arch which can be used with two to three Class II elastics and a postero anterior Class I elastic. This appliance is very effective and easily worn by adults. 155
Fig IX.25: Clinical example of dental Class II malocclusion with a retruded mandibular arch corrected in three months with a Reciprocal Mini Chin Cup. Notice the sagittal and vertical overcorrection ( before and after ).
156
The deeper the overbite, the better the prognosis in Class III malocclusions.
157
Fig IX.26 : The two piece corrector from G. EGANHOUSE 57 is constructed with a sliding guide and worn with closing Class III elastics and Chin Cup. From J. C. O. Vol. XXXI. N 4. pages 246 - 250. 1997.
158
CHAPITER X
CHAPTER X: Rationale for Elastics Prescrition Even with the knowledge of all elastic possibilities, it is sometimes difficult for the clinician to decide on the best elastic treatment.
Separate the different clinical objectives: - take notice of primary objective - accept or refuse, for a while, the secondary objectives.
159
Refer to the skeletal pattern and to the Long Range Growth Forecast. Look at the occlusal bite. If you have an edge to edge incisor relationship your priority will be to close the bite absolutely; so in that case you must use closing elastics and/or eventually extractions. 2 - Observe the transversal sense afterwards:
Look at the centric occlusion: Is it a normal occlusion relationship ? How are the median lines ? Is there a midline shift ? Which one must be corrected ? Do you have a cross bite ? If yes, what is the degree of the cross bite 1, 2, or degree 3 ? Do you need an expansion on one side ? Do you need a contraction on one side ? Do you need cross bite elastics ? Closing elastics ? Do you need a bite plate to jump the bite ? For example, a lingual crossbite relationship of a maxillary canine may be corrected in placing on the Class II elastic palatally to correct in the same time the transversal and sagittal sense. A midline shift clinical case can suggest increasing the Class II elastic force on one side by: changing three times the elastic on one side and only one time per day the other side or, using a closing elastic force on one side and a regular one on the other side or, using a heavy elastic on one side and a lighter on the other.
Right
A N C H O R A G E yes no Loose yes no yes no Mini yes no yes no Mean yes no
Maxilla
yes no Maxi yes no yes no Maxi yes no yes no Mean yes no yes no Mini yes no yes no Loose yes no
Left
A N C H O R A G E
Right
Mandible
2 - Archwire with friction + Extra Oral forces: t yes u no u yes u no
Left
3 - Frictionless segmented archwires: u yes 4 - Needed cooperation: u maximum u mean u minimum u no u asymmetric...
In using arrows on the chart and after determining the needed anchorage on each side of the maxilla, the archwires may be chosen with the elastics forces which must be used to reach clinical goals. 161
C: Lay down the problem ! Come up with the objectives to reach. Use arrows:
162
CLINICAL EXAMPLE
A - Observe this dysfunctional patient with a painful left TMJ ( Fig X. 1A ): - on right side she has a Class II lingual degree 2 cross bite and a Class II canine relationship. - a midline shift of 3 mm with an edge to edge incisor relationship. - on left side she has an open bite with a Class III canine relationship.
C - Solution ( Fig X. 1B ): on right side, a triangular Class II cross bite elastic is going to correct the Class II and jump the bite. anteriorly a closing Class III elastic is going to correct the midline shift, bring forward the left upper canine, and close the bite ! on left side, we are keeping the posterior wedge so we dont need any elastic. D - After 8 weeks ( Fig X. 1C ): The correct prescription of elastics corrected the majority of the malocclusion and the patient is pain free.
163
Fig X. 1
164
q QA -
q QB -
q QC -
q QD -
Remember to follow the rationale for elastic prescription: 1 - Observe the problem. 2 - Establish the clinical statement of each case. 3 - Write down the occlusal chart on a paper. 4 - Lay down the problem 5 - Draw the needed biomechanical archwires, and your elastic prescription. 6 - After your answer, go to the solution; youll be rewarded. 165
QUIZ A
A - Observe Fig X. 2A, 2B, 2C ): John has three missing teeth: 12 - 22 and 23. - on right side notice the Class II canine relationship: well have to open the lateral upper incisor space for a future implant. - anteriorly we have an open bite tendency edge to edge with a 2 mm maxillary midline shift. - on left side 22 and 23 are missing and we have a Class II edge to edge position of the first bicuspid, we would like to use for canine function. We also need to keep a space for the upper left incisor implant. B - Let us write down the problem:
C - Solution ( Fig X. 3A, 3B, 3C ): on right side, we need a maximum Class II anchorage with two Class II elastics, one on the sectional arch, the other on the Class II utility arch. to correct the midline shift, we can add an oblique elastic worn during night. to bring forward the first left bicuspid, we need a Class III elastic which is also going to help the midline shift correction.
To increase elastics efficiency, we could also use closing elastics in this case... but we dont need too much overbite with future implants.
166
Fig X. 2
QUIZ A
167
Fig X. 3
SOLUTION A
168
QUIZ B
A - Observe ( Fig X. 4A, 4B, 4C ): Jeromes clinical problem: - on right side we have a 2 mm Class II canine relationship. - anteriorly, the mandibular midline shift is off 2 mm on the left. - on left side we are in Class II canine and premolar relationship. B - Let us write down the problem:
We need a maximum anchorage on left side. C - Solution ( Fig X. 5A, 5B, 5C ): Evidently segmentation may use: on right side, a sectional with a Class II elastic placed the canine worn only at night. on left side, well use a double Class II elastic worn 24 hours a day and changed three times.
Notice that one elastic is placed the utility Class II and the other on the left sectional, so we have a maximum anchorage on that side, which is also going to correct the mandibular midline !
169
Fig X. 4
QUIZ B
170
Fig X. 5
SOLUTION B
171
QUIZ C
A - Observe ( Fig X. 6A, 6B, 6C ): Look at Sophies clinical problem: - on right side, we are in Class I molar and premolar, but with a mesial space in front of the first bicuspid, the right upper canine is in total Class II relationship. - anteriorly, there is a distal diastema to the upper right lateral incisor; a maxillary midline deviation of 4 mm. - on left side, we have a maxillary ectopic canine, however in Class I, because the upper left incisor is edge to edge with the lower left canine. B - Let us write down the problem:
We need a maximum anchorage on the right side. C - Solution ( Fig X. 7A, 7B, 7C ): on right side, a sectionnal retractor with a Class II elastic and a Class II utility arch with again a Class II elastic, worn 24 hours a day and changed three times. notice that the utility arch is cut behind the left central for placing on oblique elastic during sleeping hours. on left side, a sectional retractor with a Class II elastic worn 24 hours a day and changed three times is going to bring downward and backward the left upper canine.
172
Fig X. 6
QUIZ C
173
Fig X. 7
SOLUTION C
174
QUIZ D
A - Observe ( Fig X. 8A, 8B, 8C ): Sylvains clinical problem: - on right side, the upper right canine is missing, and we would like to use the first bicuspid for canine function. - anteriorly, we have a light open bite, with a light midline maxillary deviation of 2 mm and an upper incisor protrusion. - on left side, we have a Class II canine tendency.
C - Solution ( Fig X. 9A, 9B, 9C ): With straight wires we may use closing elastics; but with the frictionless segmented technique we can use: on right side, an M loop to bring forward the first bicuspid; and a closing loop behind the upper lateral incisor to contract the incisor protrusion. on left side, we can have a contraction utility arch wire to close the bite and to contract the incisor protrusion with the help of a double Class II elastic, the second one placed on the canine in order to correct the Class II tendency and close the distal diastema.
175
Fig X. 8
QUIZ D
176
Fig X. 9
SOLUTION D
177
CONCLUSION
1) In treating your patient, use a whole philosophy rather than a technique. 2) Evaluate all patients functions: respiration - swallowing - occlusion mastication - phonation - growth - ... - and personality. 3) Individualize the patient by a 4 D diagnosis including growth potential with the long range forecast: Begin with the END in mind . 4) Do an early diagnosis of the risky patient to postpone orthodontics until after surgery. 5) Set a long range visualization of treatment objectives (the short range VTO is not enough ! ). 6) Progressive banding or bonding makes scheduling easier and reduces stress on both the patient and the doctor. 7) Take advantage of pretorqued, preangulated brackets. The double buccal tubes on the lower molars and the triple buccal tubes on the upper molar provide archwire combinations and flexibility. 8) Unlock the malocclusion in a progressive sequence and establish more normal function and growth. 9) Use expansion first, before sagittal correction. 10) Choose FRICTIONLESS biomechanics with light forces:
Resistance to sliding mechanics such as friction and binding reduces the efficiency of a fixed appliance; resist the urge to increase the FORCE which will result in excessive pain and lost anchorage along with unwanted tooth movement.
Your patient tells you: Please use frictionless and light mechanics to increase efficiency and comfort .
178
11) Treat the overbite before the overjet. 12) Prefer Progressive Torque control throughtout the treatment. 13) Increase the ease and efficiency of tooth movement with segmented archwires. 14) Diminish anchorage problems with the use of utility archwires which also allow more cases to be treated on a non-extraction basis in recovering the Lee way. 15) Use elastics forces carefully to get a mobile force without threatening anchorage. 16) In the mixed dentition malocclusion, to get early canine function, use provocation of sequences of teeth eruption ( E the first, D the second and C the last ). 17) Use the ideal patient arch form according to the facial type. 18) Recognize the benefit of the segmented technique to get intraoral adjustments and optimize elastic forces. 19) Overtreat the malocclusion. 20) Use selective retention devices to maintain treatment results until the patient reaches maturity.
179
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This book provides a comprehensive detailed description of orthodontic elastic usage. A compendium of possibilities heretofore never been collectively presented.
Prof. Ram S. NANDA - DDS - MS - PhD Chairman of departement of Orthodontics University of Oklahoma
Dr LANGLADE has brought to us a sophistication in the application of this very important modality.
Prof. Robert M. RICKETTS - DDS - MS American Institute for Bioprogressive Education
This is a fantastic book for Orthodontic Residents, Orthodontists and Ortho assistants who want to take their skills and knowledge to a higher level.
Dr Alex AXELRODE - DDS - MS Pinole. California
Dr LANGLADE has taken on a monumental task in the production of this text. Orthodontists and Students would all benefit in reviewing this book. Its unique.
Prof. Joseph CARUSO - DDS - MS Chairman of Orthodontic Department Loma Linda University. California
This book provides significant knowledge and pratice efficiency for each reader. Mans mind once stretched by his new ideas, can never regain its original dimension.
Dr Duane GRUMMONS - DDS - MSD Board Director Foundation for Orthodontic Research