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Abstract It has been widely recognized for many years that proper finishing is of critical importance in
achieving an excellent occlusal result after orthodontic appliance removal. This clinical
presentation deals with defining finishing goals and achieving them with the appropriate
treatment mechanics for optimal esthetics, function and stability. It highlights certain occlusal
- static and dynamic - periodontal as well as esthetic parameters that provide useful guidelines
for finishing in both the adolescent and adult orthodontic patient.
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Alignment
Proper alignment of teeth has been a fundamental
objective of any orthodontic treatment approach. In July
of 2000, the American Board of Orthodontics 4 further
clarified and quantified the static occlusal goals by
providing a grading system for study casts and
Fig. 1: Establishing normal marginal ridge relationships.
panoramic radiographs. In the mandibular arch, the
labioincisal edges of the incisors and canines are the these teeth and the first molar. This also leads to a lack
determinants of anterior alignment. This is because of occlusal contact in the posteriors 4
when labioincisal edges are aligned properly, the teeth
look the best esthetically and they are the functioning Transverse relationship of posteriors
surfaces of the mandibular anterior teeth. In the
During the finishing stage, it is of paramount importance
maxillary anterior segment, the lingual surfaces of the
to evaluate the buccolingual inclination of the posterior
maxillary incisors and canines are used as a guideline
teeth to achieve good intercuspation and prevent
to establish proper alignment. This is based on the fact
interferences during mandibular movements. This should
that, these surfaces are the functioning surfaces and
be assessed by evaluating the relationship between the
when aligned properly, the anteriors appear to be in
bu ccal and the lingual cusps of the maxillary and
their best esthetic relationship.
mandibular premolars and molars - called the 'Curve
In the mandibular posterior segment, the buccal cusps of Wilson'. In normal situation, the lingual cusp should
of mandibular premolars and molars represent the be at the same level or within a millimeter of the same
functioning surfaces and they are easy to visualize level as the mandibular buccal CUSpS4. This relationship
intraorally. Therefore, these landmarks are used to makes the occlusal tables of posterior teeth relatively
establish the proper alignment in the posterior segments, flat, therefore, promoting better contact of the maxillary
within the patient' s acceptable archform. In the lingual cusps with the fossae of the mandibular posterior
maxillary posterior segments, central grooves of the teeth .
maxillary premolars and molars are used to access
The extreme amount of mandibular posterior lingual
proper alignment. Again, these are used since they
crown torque found in many preadjusted appliance
represent the functioning surfaces of the maxillary
prescriptions leads to "rolled-in " mandibular posterior
posterior teeth, and are easy to observe intraorally.
teeth as a result of expressed torque&'? (Fig. 2).
Marginal Ridges
In the maxillary buccal segment, the palatal cusps of
The marginal ridges can be used as a key to achieve the first and second molars are generally slightly longer
relative vertical positioning of the posterior teeth4. and extend slightly more occlusal than the buccal
During the finishing stage, it is important to make sure CUSpS.4 With the common use of expansion treatment
that the marginal ridges of adjacent posterior teeth are often using over-expanded, commercial arch blanks or
positioned at the same level (Fig. 1). This will position a limited amount of maxillary posterior expressed
the cusps and fossae of those teeth at the same level. buccal root torque, palatal cusps extend occlusally
Once the marginal ridges of the posterior teeth are beyond their normal limits (Fig. 2). This promotes
positioned at the same relative level, then the inappropriate interdigitation between maxillary and
cementoenamel junctions are also at the same relative mandibular posterior teeth, producing cross arch
level. This will lead to the bone levels between the balancing interferences in the lateral mandibular
adjacent teeth being flat, producing a much healthier excursions8 . Therefore, the buccolingual relationship of
periodontal situation for the patient. posterior teeth should be improved by flattening the
curve of Wilson , minimizing or eliminating the
The lack of distal root tip in the maxillary second discrepancies in the posterior overjet, and avoiding the
bicuspids expressed during the finishing stage leads to prominence of palatal cusps by reducing the lower
discrepancy in the marginal ridge matching between posterior torque and increasing the upper. 7
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Asho k Ka rad
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/ L{) ~ J Ind Orthod Soc 2006; 39:126-138
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;. . - , The overall inclination of the maxillary and mandibular
C anterior teeth is best evaluated with a lateral
cephalometric radiograph. The interincisal angle plays
an important role in esthetics, function and stability
Anterior Inclination and should not be based on averages. 12 Growth
direction, esthetics and overbite should also be
Optimal positioning of maxillary and mandibular
considered in determining ideal torque in the maxillary
incisors at the conclusion of treatment is the prime
and mandibular arch. In short, it should be
objective of any orthodontic treatment plan (Fig. 4&5).
individualized.
A lso, the control of undesirable incisor movement
i nherent with the routine orthodontic treatment If uncontrolled flaring of the lower incisors is permitted,
mechanics would reduce amount of fine-tuning of then increased labial crown torque of the maxillary
incisor position during the finishing stage. AIQabandi incisors would be required to maintain appropriate
et al 9 reported 6°_7° of lower incisor flaring when simply overbite/overjet and in the process, more bimaxillary
leveling the curve of spee with fixed appliances. protrusive results will be produced, which will be
Reports have described the limitations of controlling detrimental to facial esthetics.
the labial proclination of lower incisors during leveling,
even with rectangular wires, especially when using Molar position
d ass II elastics. 9 ,10
Insufficient thickness of maxillary second bicuspids
Qleigh Williams ll , suggested certain guidelines to causes first molar to rotate mesially upon initial wire
'mally position mandibular incisors and canines for engagement, causing an increase in Class II tendency
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Ashok Karad
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Fig. 3: Limited amount of maxi ll ary Fig. 4 : Improved bucco lingual Fig. 5: Norm al interin c isal relation-
posterior buccal root torque relationship of posterior teeth shi p, overjet and overbite
and the extreme amou nt of by redu cing the lowe r ac hi eved by optimal inc isor
mandibul ar posterior buccal posterior torque and increas- torque contro l.
root torq ue, lead ing to ing the upper.
imprope r interd igitatio n,
increased buccal overjet, and
bal ancing interferences.
(Courtesy - Dr. Jay Bowman)
Fig. 6 : Optimal lower inc isor Fig. 7: Positio n of max ill ary second bicuspid - a key to a properly treated
positioning with progressive maloccl usion.
distal root spread.
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and buccal movement of second bicuspid. Also, the
J Ind Orthod Soc 2006; 39 :126-138
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Ashok Karad
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J Ind Orthod Soc 2006; 39:126-138
commonly found in patients with peg-shaped lateral challenge to an esthetic solution. For a long time, many
incisors. Even after getting the teeth perfectly aligned clinicians had suggested an alternative treatment
and the arch forms properly establ ished with approach by moving the entire lateral segment mesially
orthodontic treatment, the abnormal shape and smaller to place the cuspid in the lateral incisor position,
size of lateral incisor pose esthetic problems. However, this approach ends up with compromised
results that do not fulfill the esthetic requirements of
The Golden proportion can be called the building blocks good orthodontic treatment, since the cuspid has a very
of nature itself. This ratio is an ideal ratio that can be different crown and root shape to that of the lateral
mathematically defined as 1 :1.618 (Fig. 12). It has been incisor, as well as a darker shade. When missing lateral
observed that when this rule of good proportion is incisor space is closed by moving the entire lateral
followed, the result is something that is naturally segment mesially, lateral excursions are made using
attractive and pleasing to the eye. Smiles can be mad e bicuspids, which have shorter, thinner roots; thus,
attractive by following these mathematical rules of functional requirements are also not fulfilled either.
nature to create harmony, symmetry, and proportion. 16,2 7
If fixed restoration is the treatment of choice, it requires
We can use the proportion to define the length: width reshaping neighboring teeth, with consequent removal
for each tooth, Also the width of central incisor is in of varying amounts of enamel, and eventual risk of
golden proportion to the lateral incisor width which in gingival recession , caries etc. The osseo-integrated
turn is in proportion with the mesial width of the implant is the most conservative and biological
Canine 26. method , since the missing tooth can be replaced
without damaging the neighboring teeth.
,6 1.0 1.6 1.6 1.0 .6
If the use of implants is the part of treatment plan for
the missing lateral incisors, it is necessary to decide
the exact placement of implants, evaluate the smile
line and gingival contour. When the lateral incisors
are missing, there is usually no adequate space to
restore them due to drifting of the adjacent teeth (Fig.
16). In such cases, it is essential to gain adequate space
Fig. 13: The Golden proportion-an ideal ratio can be with orthodontics for the placement of implant and
mathematically defined as 1:1.618. crown restoration for good esthetic result (Fig, 17). The
It is therefore imperative to restore the size of the exact amount of space created should be according to
malformed lateral incisors after the completion of the proposed size of lateral incisors, which should be
orthodontic treatment for good overall treatment result proportionate to the width of the central incisors, After
(Fig. 13 & 15). Duringthe finishing stage of orthodontic opening up of sufficient space, acrylic teeth may be
treatment, if excessive space exists in the anterior selected closer to the shade of the patient's teeth,
segment, it should be redistributed to restore the proper bracketed and attached to the arch wire for esthetic
crown width (Fig. 14). If insufficient space exists to purposes. Before the orthodontic appliances are
restore these teeth, an adequate space should be gained removed it is important to evaluate radiographically
which will permit the restoration of proper crown width. the position of the roots of adjacent teeth
To determine the space required to restore the crown
The roots of the central incisors and canines on either
width, during the treatment planning stage, construction
side in case of bilaterally missing laterals should be
of a diagnostic wax-up is an important step to visualize
parallel to each other with adequate space between
the final result. After removal of the fixed orthodontic
the roots for implant placement (Fig. 18 & 19). Before
appliances, provisional restorations should be given
removal of orthodontic appliances, it is common to
before final restorations to avoid relapse.
see adequate space for the prosthesis and inadequate
space between the roots of the adjacent teeth for an
Replacement of missing laterals with implants
implant. This usually occurs due to tipping movement
Dental agenesis occurs quite frequently, espeCially of of adjacent teeth, which requires proper uprighting of
the maxillary lateral incisors, and it presents a true the roots during the finishing stage of orthodontic
135
~ Ashok Karad
Fig. 14: Class 1 maloccl usion with disproportionate crow n w idths of anteriors due to peg-shaped laterals.
Fig. 15 : Proper distribution of anteri or spaces to restore no rm al widths of latera l incisors.
Fig. 16: Peg-shaped latera ls are restored w ith ceramic veneers in a golden proportion with adj acent teeth.
Fig. 17: M axi llary lateral incisor is missing and the adj acent teeth are drifted into
the space.
Fig. 18: Sufficient space has been created orthodonti ca ll y to resto re maxill ary
right lateral inc isor.
Fig. 19: Intraora l periapical radiograph shows adequate space between the roots
of the central inc isor and canine. Note th e paralle lism of roots of the
adjacent teeth.
Fig. 20: Osseointegrated imp lant placement in the latera l inc isor reg ion.
treatment. The minimum space of 6.5mm between provided certain occlusal - static and dynamic -
adjacent roots is required to place a standard implant periodontal as well as esthetic parameters that outline
of 3mm width. useful guidelines for finishing in both the adolescent
and adult orthodontic patient. Also, choosing the best
Gingival Architecture possible treatment options from other specialties and
combi ni ng them as a part of the optimal treatment plan
Color, contour and the health of the gingival tissues
based on scientific rationale should be the aim for the
provide the framework and backdrop for the esthetic
benefit of the patient.
smile. Even if the case is well finished with orthodontic
treatment, abnormal ity of the gi ngiva either in the form Acknowledgements
of loss of papilla, asymmetrical pattern and excessive
display. leads to a poor result. It is therefore essential I thank Dr. Ratnadeep Patil for his clinical assistance
to have proper gingival architecture and display to in rendering Perio-restorative treatment when indi-
achieve a maximum esthetic result. As a general rule, cated. Sincere thanks to Ms. Arlene Fernandes, Dr.
a line drawn at the level of the free gingival margin of Kavita Ramanathan and Dr. Ken DCunha for their pro-
the anterior segment will show the free gingival margin fessional assistance in preparing this manuscript, and
of the centra l incisors and the cuspids to be at the same Mr. Nikhil Patel for his assistance in imaging.
height and that of the lateral incisors to be slightly
coro nal 28 (Fig. 20). Communications
Furthermore, the most apical point of the gingiva or Dr. Ashok Karad, BDS, MDS, M.OrthRCS [Edinl
the gingival zenith is located just distal of the long Diplomate, Indian Board of Orthodontics
ax is of the central incisors and cuspids, whereas the Director, Smile Care, India
gi ngival zenith for the lateral incisors coincides with Smile Care, 13, Geetanjali, 234, S.v. Road,
their long axis l 6 ,29 (Fig. 20). In other words, the height Bandra (west), Mumbai 400050. India
of the gum lin e across the face of the tooth should be Tel: 022-26431670/71 Fax: 022-6416342 e-mail:
centered on the lateral incisors, and positioned in the smile@bom7.vsnl.net.in
dista l 1/3rd of the face of the tooth for the centrals and
ca nines. This gives the gingiva a semi-circular References
ap peara nce for lateral incisors and an elliptical 1. Ronald H Roth . Functional occlusion for the
appearance for central incisors and canines. orthodontist KO 1981 ; 1:32-50.
2. Andrews LF. straight wire - the concept and the
During the process of eruption the whole periodontal
appliance, in Valleau J, Olfe JT reds] : straight wire.
paratus is carried with the erupting tooth . When there
Wells Co. LA: 1989, 32-33.
- asymmetric eruption of the teeth it will also result in
3. Richard P Mclaughlin , John C Bennett. Finishing
repancies in heights of the underlying crestal bone.
with the preadjusted orthodontic appliance. Semin
is, in turn, results into asymmetries in gingival Orthod 2003; 9: 165-183.
'ghts (gingival zenith) from one side of the arch to 4. Casko J, Vaden J, Kokich V, et al. American Board
other. This type of a clinical situation can be of Orthodontics objective grading system for dental
aged orthodontically by intrusion or extrusion of casts and panoramic radiographs. Am J Orthod
(Fig. 21, 22 & 23). Dentofacial Orthop 2000; 114: 530-532.
5. Vincent G Kokich. Excellence in finishing:
Modifications for the perio-restorative patient.
Semin Orthod 2003; 9: 184-203.
rn orthodontic treatment is aimed at creating the
6. Ricketts RM et al. Bioprogressive therapy, Rockey
p oss ible occlusal relationships within the Mountain Orthodontics, Denver, Co., 1979.
w ork of acceptable facial esthetics and stability 7. McLaughlin RP, Bennett K, Trevisi HJ. Systematized
occlusa l result. It is extremely important for a Orthodontic treatment Mechanics, Mosby, St. Louis,
- 'an to define finishing goals at the begining of MO., 2001 .
ent and continue to focus on them till the 8 . Bowman SJ. Addressing concerns for finished cases.
i ng stage, in order to achieve them with The development of the Butterfly bracket system. J
pr iate treatment mechanics. This article has Ind Orthod Soc, 2003; 36: 73-75.
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