Professional Documents
Culture Documents
Patient Name
Date
Skeletal
Normal Beg
End
No.
Age
Sex
Good
Indifferent
Dental
Race
Poor
Normal Beg
SNA
(angle)
82
OCC to SN
(angle)
SNB
(angle)
80
Upper Incisor to NA
(mm)
ANB
(angle)
Upper Incisor to NA
(angle)
22
SL
(mm)
51
Lower Incisor to NB
(mm)
WITS
(mm)
-1+3
Lower Incisor to NB
(angle)
25
(mm)
60+5
GoGn to SN
(angle)
32
Po to NB
(mm)
varies
Y-AXIS
(angle)
66
AP to Lower Incisor
(mm)
+3-2
Po to NB
(mm)
2-5
End
14
131
Dentition:
Initial Occlusion:
Schwarz Analysis
Class:
starting
ideal
difference
Overjet ____ mm
II
III
Division:
Overbite _____ mm
II
Midline _____ mm
4.4
_______ m m
______ m m
_______ m m
Crossbite _____________________________________________
6.6
_______ m m
______ m m
_______ m m
Molar Relation:
Left _________
Right ______
5.5
_______ m m
______ m m
_______ m m
Cuspid Relation:
Left _________
Right ______
6.6
_______ m m
______ m m
_______ m m
Left
Right
Popping
Left
Right
Range of Motion:
Backward ____________ mm
Y-Axis ________
SL ________ mm
Counterclockwise _________________
Habits:
Thumb
Tongue
Lip Sucker
Other: _________________________________________
Airway Problems:
Tonsils
Adenoids
Other ________________________________________________
Appliances Needed:
Transpalatal
Lip Bumper:
Wide
Thin
MDA:
Upper
Lower
NiTi Expander
Retention:
Hawley
Vertical ________________________ mm
Lower Lingual
____________________________________________________
____________________________________________________
63
Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
End
Normal
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
22
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +3
L-Inc. to NB
(angle)
25
LFH
(mm)
60
U-Inc. to L-Inc.
(angle)
131
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
66
AP to L-inc.
(mm)
TREATMENT OPTION 1
Beg.
End
+3 to -2
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
64
Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
85
Occ to SN
(angle)
15
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
24
SL
(mm)
51
L-Inc. to NB
(mm)
11
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
38
LFH
(mm)
60
U-Inc. to L-Inc.
(angle)
114
GoGn (angle)
to SN
38
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)
TREATMENT OPTION 1
Beg.
End
0
8.5
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
65
Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
81
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
67
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)
TREATMENT OPTION 1
Beg.
End
2
3
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
66
Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
78
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
67
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)
TREATMENT OPTION 1
Beg.
End
+2
+3
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
67
Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
72
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)
TREATMENT OPTION 1
Beg.
End
+2
+3
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
68
Although the angular and linear positions of the mandibular incisors can be useful guides as to what positions
will be stable for them, they are far from absolute. If the mandibular incisors have been permitted to shift to a far
more lingual position because of premature extraction of the mandibular canines, positioning the denture
anteroposteriorly according to the position of the lower incisors at the time of taking original orthodontic records
will certainly result in a flattening of the profile and disharmonious facial asthetics. The concept that mandibular
83
84
H. P. Hitchcock, Orthodontics for Undergraduates, (Philadelphia, Lea & Febiger, 1974) p. 255.
B. H. Mueller et al., The Effect of Primary Canine Extraction on the IMPA, J Dent Child, 45 (1978),
461-464.
C. J. Hill, H. W. Sorenson, J.R. Mink, Space Maintenance in a Child Dental Care Program,
JADA, 90 (1975), 811.
C. F. Moorrees and J. M. Chadha, Available Space for the Incisors During Dental Development:
A Growth Study Based on Physiologic Age, Angle Orthodontist, 35 (1965) 12-22.
J. R. Jarabak and J. A. Fizzell, Technique and Treatment with Light-Wire Edgewise Appliances,
2d ed., (St. Louis; C. V. Mosby Co., 1972), pp. 139-158.
J. R. Isaacson et al., Extreme Variation in Vertical Facial Growth and Associated Variation in
Skeletal and Dental Relations, Angle Orthodontist, 41 (1971) 219-229.
85
Crossbites
1. Correct crossbites anterior or posterior as soon as they are diagnosed.
2. Crossbites are more easily corrected on the younger patient (3 years or older).
3. It is very difficult to correct posterior crossbites on patients 17 years or older.
4. You can use a removable appliance (Schwarz, 3-way etc.) or a fixed appliance
(quadhelix, transpalatal, nickel titanium expander etc.) to correct crossbites in the
early or mixed dentition.
5. Correction of crossbites in permanent or late dentition usually requires rapid palatal
expansion.
Figure G
Before minimum
growth spurt
86
Maximum
growth spurt
After maximum
growth spurt
Cephalometric Interpretation
ANB Difference Defined
SNA Measurement
SNA (82o +or- 4o) is in the normal range. SNA is the anteroposterior
relationship of the maxilla to the anterior cranial base.
SNB Measurement
SNB (80o +or- 4o) is in the normal range. SNB is the anteroposterior
relationship of the mandible to the anterior cranial base.
ANB Difference
ANB (0o to 4o) is in the normal range. ANB is the relationship of the
maxilla to the mandible in an anteroposterior relationship.
87
Skeletal Classifications
0 to 4
5 or More
0 or Less
88
Normal
Convex
Concave
Figure I
89
N-B Line
The lower incisor to pogonion in at least a 1 to 1 ratio
will usually result in a stable dentition and pleasant facial
appearance.
The lower incisor is measured from the NB line to the
most labial portion of the incisor in millimeters.
Pogonion is measured from the NB line in millimeters.
The lower incisor is +4mm to the NB line and pogonion
is +4mm resulting in a 1 to 1 ratio.
The lower incisor should be positioned at least at a 1 to
1 ratio with pogonion or the lower incisor should be
positioned 1 to 3 mm anterior of pogonion.
90
Pogonion
The Importance of Determining Pogonion
It is important to determine how much the pogonion will grow. Once we determine
how far the pogonion is from the NB line, we can then decide where to place the lower
incisor.
Dentition that has a 1 to 1 ratio between the lower incisor and the pogonion will
usually have the best facial aesthetics and will be stable.
The other important aspect of knowing where the pogonion will grow is in determining how much crowding cephalometrically you will have with the lower incisors.
BOYS
GIRLS
10
--
0 to 3-4mm
11
--
0 to 2-3mm
12
0 to 3-5mm
0 to 1-2mm
13
0 to 2-4mm
0 to -1mm
14
0 to 1-2mm
0 to 0mm
15
0 to -1mm
--
16
0 to 0mm
--
Figure H
age 12
age 16
age 12
age 16
91
Age 11
Pg = 0mm
AGE 13
Pg = 0mm
92
Age 14
Pg = 2-3mm
AGE 14
Pg = -1mm
AGE 12
Pg = 0mm
Age 14
Pg = 1-2mm
Age - 10.6
3mm
Age - 14
7mm
6mm
93
94
32o 5o
27o or Less
37 or More
95
SL Growth Indications
S
Y - Axis
L
S
Y - Axis
SL 57mm or Greater
Counter Clockwise Growth
Skeletal Closed Bite
Y - Axis
96
SL 44mm or Less
Clockwise Growth
Skeletal Open Bite
AP to = +3mm
AP to = -4mm
AP to = +8mm
97
Wits Analysis
Apical Base Class I
98
Cephalometric Diagnosis
1. The age tells me if the patient is in a growth spurt and how much pogonion
may still grow.
2. Check SNA & SNB to see if both are within normal range.
ANB difference to see how the maxilla and mandible are related.
99
Schwarz Analysis
S.I. = ______ mm (Upper Centrals and Laterals)
(S.I. stands for Sum of the Incisors, mesial-distal width in mm)
S.I. + the Following = Ideal
Narrow Face
Normal Face
Wide Face
Upper Arch
Measurement Points
Distal Pits
of 1st Premolars
Central Pits
of 1st molars
100
Lower Arch
Measurement Points
Central Part
of Middle Buccal
Cusps of 1st Molars
Mesio-Labial
Marginal
Ridge Points
of 2nd Premolars
Diagnostic Summary
Panorex
Cephalogram
Models
1. Cuspid apexification
1. Age - Sex
1. Dental classification
2. Dental age
2. Skeletal classification
2. Crossbites
3. Third molars
3. Constrictions
4. Crowding
5. Impacted teeth
(molars or cuspids)
5. GoGn to SN
(mandibular plane angle)
101
Mixed Dentition
1. Almost all cases started in the mixed dentition can be treated non-extraction for several
reasons:
a. Approximately 2 to 3mm per side can be gained if you do not allow the permanent
1st molars to come forward at all while the deciduous cuspids, 1st and 2nd molars are
being lost and replaced by the permanent teeth.
b. You can usually move the lower anteriors forward to gain arch length.
c. Expand laterally.
d. The MDA appliance allows you to distalize the 1st and 2nd molars.
2. During the mixed dentition, a lip bumper or fixed lingual arch can be placed on the lower
first permanent molars to maintain the space from the deciduous molars.
a. If lateral expansion is desired, the lip bumper or fixed lingual arch can be activated to
achieve this.
b. In severely crowded cases, it may be necessary to distalize the lower first molars
using class III elastics to the lip bumper.
c. If class III elastics are used, it will be necessary to place a transpalatal arch on the
upper for anchorage.
3. In mixed dentition cases with severe crowding, it is advantageous to bracket the primary
dentition to aid in arch development.
a. In constricted cases, much space and lateral development can be accomplished by
bracketing the primary cuspids, first and second molars and progressing through an
archwire sequence.
b. Place cuspid, first and second bicuspid brackets on these primary teeth.
c. Placement of these brackets is not critical (ideally place them as gingival as possible).
d. When crowding has been eliminated, debracket and place upper hawley and fixed
lower lingual to maintain until permanent dentition.
4. In mixed dentition with Skeletal discrepancies, functional appliance therapy can be
instituted in an effort to change the skeletal features while waiting on the permanent
teeth.
a. Reverse Face Mask can be used for class III malocclusion.
The Transpalatal Bar has been designed for:
1.
2.
3.
4.
5.
102
Rotation
103
104
105
Key IV - Rotations
1. Teeth should be free of undesirable rotations. If rotated, a
molar or bicuspid occupies more space than normally, a
condition unreceptive to normal occlusion. A rotated incisor
can occupy less space than normal.
106
Fig. 3.15. Key I: Optimal interarch relationships and occlusal interfacing. A, Interarch relationships of molars and premolars:
a, marginal-ridge occlusion; b, molar cusp-groove relationship; c, premolar cusp-embrasure relationship. B, Mesial perspective of occlusal interfacing of molar or premolar: d, cusp-fossa relationship. C, Lingual perspective of occlusal interfacing:
e, cusp-fossa occlusion of molars; f, cusp-fossa occlusion of premolars. D, Interarch relationships of canines and incisors.
107
Fig. 3.17. From the mesiobuccal perspective the inclination of the crowns permits indirect judging of occlusal interfacing.
A, Correct inclination and correct occlusal interfacing: a, mesiobuccal perspective; b, lingual perspective; c, inclination
correlated with occlusal interfacing. B, Incorrect inclination and incorrect occlusal interfacing: A, mesiobuccal perspective; b, lingual perspective; c, inclination correlated with occlusal interfacing. Vertical lines on crowns indicate the axes;
junctions of vertical and horizontal lines indicate FA points.
Fig. 3.18. Positive FACC angulation for each tooth type in the optimal sample. Wires are glued at the FA points, parallel to
each crowns FACC.
108
109
Fig. 3.21. Maxillary crown inclinations. Central incisors (A) are more positive than lateral incisors (B); posterior
teeth are negative (C). Wires are glued at the FA points, parallel to each crown FACC.
Fig. 3.22 Mandibular crown inclinations. Central and lateral incisors (A) have the same inclination (generally
slightly negative). The posterior teeth are increasingly negative from the canines through the molars (B). Wires
are glued at the FA points, parallel to each crowns FACC.
110
Fig. 3.23. Maxillary arch (A) and mandibular arch (B) showing no rotations and no interdental spacing. Dots indicate contact
points.
Fig. 3.24. Mandibular arch with a curve of Spee within the 0-2.5mm depth range.
111
(A) Frontal view of an ideal occlusion in the skeletal remains of an adult. (B) Lateral view of the same
skull. The vertical axial line passing through the mesiobuccal cusp tip of the maxillary first molar meets
the vertical axial line passing through the buccal groove of the mandibular first molar. The vertical axial
line passing through the cusp tip of the maxillary canine meets the vertical line bisecting the embrasure
between the mandibular canine and first premolar.
112
Malocclusion Classification
A-C
Class II Division
I
D-F
Class II Division
II
G-I
Class III
A-C, Class II, Division I. D-F, Class II Division II. G-I, Class III. The vertical axial lines passing
through the mesiobuccal cusp tips of the maxillary first molars have different relationships with the
vertical axial lines passing through the buccal grooves of the mandibular first molars in different
malocclusion classes. A similar variation among malocclusion classes is observed in the relationships between the vertical axial lines passing through the cusp tips of the maxillary canines and the
vertical lines bicsecting the embrasures between the mandibular canines and first premolars.
113
114
115
116
NOTE: Do not engage labial or blocked out cuspids, upper or lower, into the archwire
sequence until you have gained sufficient space for their position in the arch.
117
OVERJET
Bringing in high cuspids when there is insufficient space, causes the anterior teeth to
flare forward creating overjet.
118
AFTER
NOTE THE AMOUNT OF OVERJET AND ANTERIOR FLARING. THE PREMOLARS REMAIN CLASS II AND THE ANTERIOR TEETH
MOVE OUT.
BEFORE
119
120
AFTER
BEFORE
Final results of treatment to correct the improper management of the blocked out anterior teeth.
121
122
In this case, the lower cuspids have erupted mesially and are rotated allowing the lower posterior teeth to
drift mesially. Because of this, the posterior teeth appear to be slightly class I. Once the lower posterior
teeth are distalized so that there is sufficient room to rotate the cuspids into the proper position, the true class
II dental relationship will be obvious. On the upper arch, the cuspids do not have sufficient space for eruption and the right cuspid has erupted to the labial.
Note that once the lower arch was established, the posterior teeth exhibit full class II occlusion. Notice that the upper cuspids have never been
bracketed or incorporated into treatment because there was not sufficient space for them in the arch. Once the lower arch is established, the
upper posterior teeth will be repositioned to allow space for the cuspids. This type treatment sequencing will avoid round tripping and
reduce treatment time.
TREATMENT: The lower molars and premolars were distalized to provide the proper space for the cuspids. After gaining sufficient space,
the cuspids and incisors were incorporated into an archwire sequence and the lower arch was leveled, aligned and rotated. If the cuspids had
been initially incorporated into the archwire sequence, they would have rotated into position at the expense of the lower anterior teeth going
forward.
123
124
Archwire Sequence
Archwire sequence is going through the archwires listed below in proper sequence:
Wire Size
Approximate Time
.0175
.016
.018
.020
2 months
2 months
1 month
1 month
2 months
1 month
1 month
ARCHWIRE IDENTIFICATION
Archwires are identified by (3) black midline dots on the upper and (1) black midline dot on the lower.
If in doubt, the maxillary archwire always has a larger circumference than the
mandibular.
Some items to look for when going through the archwire sequence:
1. Do not go to the next larger size wire until the last archwire lies passive in the
brackets.
2. Introduce the rotating wedges during the .0175 twisted, usually the second wire,
and try to have 90% of the rotations out before going to the .016 wire.
3. Start placing AC - Accentuated Curves, RC - Reverse Curves, and CB Cinchbacks in the .016 archwire when needed.
4.
125
Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.
Before
Anterior irregularities
After
126
Treatment Summation
2. Use the Multi-Distalizing Arch (MDA) to move the maxillary four posterior teeth
(molars and premolars) to fit the lower four posterior teeth into Class I occlusion.
Before
Class II Occlusion
Class II Occlusion
After
127
Treatment Summation
3. Retract the maxillary cuspids into a Class I relationship. Use .020 round archwire and chain elastics
for spacing of 3mm or less. Use .016 x .022 with pletcher springs to retract cuspids more than 3 mm.
Before
After
128
Treatment Summation
4. Retract the maxillary anterior teeth if necessary using an .018 x .025 stainless steel
archwire with accentuating curve, pletcher springs to the posts, and Class II elastics.
Before
Anterior overjet
After
129
Treatment Summation
5. Rebracket any teeth as necessary to correct bracket placement errors. Place a .019 x .025 braided
archwire. You should also do individual root torque as needed in this size wire.
Before
Paralleling/Axial bracket
placement error
After
130
Rebracketing to level
Treatment Summation
6. Use posterior finishing elastics to lock in occlusion. Wear (1) 5/16 elastic as illustrated to
finalize the bite and add additional labial root torque to the posterior teeth.
After
Elastic
Wear
Occlusion Finalized
Robert G. Gerety - Produced by Kay C. Gerety CDA
131
#1
The easiest and most simple way to establish the lower arch is with bracketing and archwire
sequence. Provided there is minimal to no crowding, this would be the treatment indicated. If
there is crowding present, the archwire sequence will move the anterior teeth forward and expand
the premolar area. In order to use this type of treatment, the profile must tolerate forward movement of the anterior teeth. From the ceph, can the lower teeth come forward? Look at the profile
and also the ratio of the lower incisor position to the chin button (pogonion). 75% of the time the
anterior teeth need to move forward and the premolars need to expand.
#2
(E space is the mesial-distal width in millimeter difference of the deciduous second molar and the permanent second premolar.)
The next treatment consideration for establishing the lower arch would be to use a thin lip bumper
or lower 3-D lingual arch to maintain lower first molar position and take advantage of all the E
space. In treatment planning, you encounter slight to moderate crowding on the lower arch, a thin
lip bumper or lingual arch should be placed on the first permanent molar to freeze these molars
and allow the permanent teeth to erupt and drift to the distal, therefore, utilizing the available
space. No other teeth are bracketed on the lower arch and no archwire is in place. The crowding
correction comes from the teeth being allowed to drift distally and resolve the crowding.
#3
With moderate to severe crowding and permanent teeth in place without the presence of E
space, it will be necessary to place a thick lip bumper on the lower first molars and use Class III
elastics to distalize the posterior teeth to eliminate the crowding. If lower second molars are
present, they should be banded/bracketed and stabilized with a segmental .019 X .025 direct braid
archwire. The upper arch will need to be supported with either a transpalatal arch and/or an .018
X .025 stainless steel archwire for anchorage to use the Class III, 1/4 elastics to the lower lip
bumper. It will be advantageous to remove third molars if they are present. Place occlusal composite on the first molars to free the bite to that you can distalize the molars. It may be necessary
to mechanically retract the bicuspids and canines with power chains. You can gain approximately
4mm per side using the thick lip bumper with Class III elastics with the thirds removed.
132
#4
With severe crowding (more than 4mm per side, blocked out teeth and in the full permanent dentition) it
will be necessary to place a MDA distalizing arch or a CD Distalizer on the lower to eliminate the
crowding. Treatment sequencing for a lower MDA is identical to upper MDA with the arches and
forces reversed. Do not round-trip the lower incisors by bracketing, flaring them out to align them, and
then retracting. The upper arch must be up to an .018 X .025 or a transpalatal for anchorage of the
elastics. Lower seconds must be banded or bracketed and incorporated into an .019 X .025 direct braid
segmental. Lower third molars should be removed prior to distalization. If using the CD Distalizer, no
arch set up is required. You can begin to distalize the lower molars immediately while doing an
archwire sequence on the upper.
#1 Archwire Sequence..................... ...............................................Lower Arch .018 x .025 SS
#2 Lip BumperArchwire Sequence.................................................Lower Arch .018 x .025 SS
#3 Lip Bumper/Class III Elastics/Archwire Sequence......................Lower Arch .018 x .025 SS
#4 CD Distalizer or Lower MDA/Archwire Sequence .....................Lower Arch .018 x .025 SS
Once the lower arch is level and aligned and the archwire size is .018 X .025 stainless steel, then you
make the upper arch fit the lower with the MDA on the upper.
133
.016
1. Continue to level align and rotate.
2. Place your AC - RC - CB in the archwires
if needed.
3. Continue to round out the arches.
.018
1. Continue with AC and RC to level.
.020
1. Continue with AC - RC - CB
2. The arches should have good arch form.
134
Arch Leveling
.0175 Twisted
1. Start to level - align and
rotate.
2. Get some extrusion of
premolars and intrusion
on anteriors - labial
movement of the four
incisors in crowded
cases.
3. Usually takes at least 2
twisted arch wires.
.016
1. Start to place AC & RC
to continue to level.
Extrusion of premolars
and intrusion of
anteriors and flaring.
.018
1. Continue to place AC RC - CB if needed.
2. All rotations should be
complete.
3. Can start open coil
spring to open spaces
for blocked out teeth if
necessary
4. Continue to round out
the arches.
Robert G. Gerety - Produced by Kay C. Gerety CDA
135
.016 x .022
1. Continue with AC &
RC if needed to
level.
.018 x .025
1. Continue with AC &
RC to get final
leveling.
136
Normal
#1 Evaluate soft tissue profile and lower incisor to
NB and pogonion relationship from the ceph. Can
the profile afford the teeth to move forward? Is
the amount of crowding significant enough to
Convex
Concave
Concave Profile
Archwire sequence
beginning with .0175
.018 X .025
Stainless Steel
137
AMANDA HENDRICKSON
AGE: 11.9
07-19-90
# 1018
36
24
75
35
68
AP= +1
75
71
4
143
68
+1
22
12
BEGINNING CEPH
139
AMANDA HENDRICKSON
AGE: 13.11
09-01-92
# 1018
38
23
77
AP= +4
35
73
132
74
71
3
70
-1
22
25
TREATMENT COMPLETION
CEPH
141
Option # 2
Thin Lip Bumper or 3-D Lingual Arch to Utilize Available
E Space
Indications for Utilizing Treatment Option #2
Normal Profile
Lower incisor to NB measurement will not allow forward movement of incisors
Moderate crowding
Mixed dentition with second deciduous molars present
Normal Profile
144
Crowding Eliminated
145
146
147
148
KRISSI INGRAM
AGE: 16
02-14-95
# 973
Retention Ceph
151
Normal Profile
Molar Distalization
Retract Cuspids
152
Retract
2nd 2nd
Bicuspids
Retract
Bicuspids
Archwire Sequence
Crowding Resolved
153
SHERI McCARTY
AGE: 11.1
05-11-87
# 898
Beginning Ceph
154
SHERI McCARTY
AGE: 11.9
01-11-88
# 898
Ceph after
Lip Bumper
and before
Archwire
Sequence
155
SHERI McCARTY
AGE: 17.7
11-09-93
# 898
Retention Ceph
157
Normal Profile
Molar Distalization
Retract Cuspids
160
Archwire Sequence
Lower MDA
Crowding Resolved
161
CLARISSA ARMSTRONG
AGE: 10
03-13-84
# 783
Beginning Ceph
162
CLARISSA ARMSTRONG
AGE: 12.2
09-23-85
# 783
163
CLARISSA ARMSTRONG
AGE: 14.2
09-02-87
# 783
Treatment
completion
Ceph
165
Tate Williams
AGE: 13
07-07-98
# 1369
169
Pre-Treatment
Post Retraction
Post CD Distalizer
Post Treatment
171
Tate Williams
AGE: 15.9
04-17-01
# 1369
Finished
Ceph
172
As documented by Hans Pancherz, DDS, Odont.2 maintaining an anterior posterior correction in the mixed
dentition is difficult, if not impossible, due to the flat
plane occlusion of the primary teeth. In order to
maintain the correction, appliances will need to be
worn as a retainer until the permanent teeth erupt
allowing the dental intercuspation to retain the correction. Flared anteriors or class II division I cases can be
improved by tipping the maxillary teeth lingually for
esthetics and prevention of trauma while waiting for
the class II correction during the permanent dentition.
This conservative approach will allow you to resolve
the primary concerns within a reasonable treatment
time of 9-12 months. While correction of the dental
and skeletal class II malocclusion can be completed in
the mixed dentition, the treatment time can be excessive due to the retention phase necessary to maintain
the correction.
1. Journal of Orthodontics Volume XXXI Number 9 September 1997
2. Seminars in Orthodontics Volume 3 Number 4 December 1997
1.
2.
3.
4.
5.
6.
Band first permanent molars and place brackets on all primary teeth. Use cuspid brackets on the primary
cuspids and first and second premolar brackets on the first and second deciduous molars. Bracket
placement on primary teeth is not critical. Place brackets as gingival as possible.
Progress through routine archwire sequence of .0175, .016, .018 round.
Once you are up to the .018 archwire, introduce open coil spring where needed to gain sufficient space
or regain lost space.
Once you have gained adequate space, bracket the blocked out teeth & engage a flexible archwire such
as .0175 or .016 thermal and progress back through the archwire sequence of .016, .018 and .020.
Once the arches are developed and the crowding has been eliminated, place an upper hawley retainer and
a fixed lower lingual for retention. On the lower, place a fixed bonded lower lingual on the four permanent
incisors if there are no missing teeth. If there are missing teeth, or arch space to be maintained, place a
fixed lingual arch from permanent first molar to first molar, retaining the arch length and any spaces.
The upper retainer is worn for 6 months full time and can then be discontinued. The lower lingual arch
should be worn until the exfoliation of the primary teeth.
175
176
Thomas Kelly
AGE: 8.9
07-05-91
# 1058
Beginning
Ceph
177
179
Thomas Kelly
AGE: 12.5
03-27-95
# 1058
Beginning of
Phase II Ceph
180
181
OPTION # 5:
PHASE I/INTERCEPTIVE MIXED DENTITION TREATMENT
If in the mixed dentition it is determined that there is insufficient space to accommodate the
eruption of permanent teeth, orthodontic intervention is appropriate. In the past, it was customary to deliver removable appliances such as a schwarz or cross-bite appliance for expansion. The recommended type of treatment is now with fixed appliances so that lost and
broken appliances are no longer a concern. With removable appliances, the outcome of your
treatment is dependent upon cooperation from the patient. If they dont wear the appliances,
nothing happens. With fixed therapy, you take control of the treatment and also you are able
to individually address tooth position rather than just expand the arches.
THOMAS KELLY CASE # 1058
TREATMENT SYNOPSIS
08-08-89
Bracketed all primary teeth and placed bands on all first molars. Archwire
sequence beginning with .0175 up to .018.
10-24-89
Placed open coil spring to make space for both upper laterals and lower left
lateral.
01-16-90
Placed brackets on blocked out teeth and passively engaged them into the
archwire. Progressed through the archwire sequence up to .020 to engage
blocked out teeth.
05-30-90
Removed bands and brackets and seated upper hawley and bonded lower
lingual.
182
Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.
Before
Anterior irregularities
After
183
Treatment Summation
2.
Use the Multi-Distalizing Arch (MDA) to move the maxillary four posterior teeth (molars and
premolars) to fit the lower four posterior teeth into Class I occlusion.
Before
Class II Occlusion
After
184
Treatment Summation
3. Retract the maxillary cuspids into a Class I relationship. Use .020 round archwire and
chain elastics for spacing of 3mm or less. Use .016 x .022 with pletcher springs to
retract cuspids more than 3 mm.
Before
After
185
Treatment Summation
4. Retract the maxillary anterior teeth if necessary using an .018 x .025 stainless
steel archwire with accentuating curve, pletcher springs to the posts, and Class
II elastics.
Before
Anterior overjet
After
186
Treatment Summation
5.
Rebracket any teeth as necessary to correct bracket placement errors. Place an .019 x .025
braided archwire. You should also do individual root torque as needed in this size wire.
Before
Paralleling/Axial bracket
placement error
After
Rebracketing to level
187
Treatment Summation
6.
Use posterior finishing elastics to lock in occlusion. Wear (1) 5/16 elastic as illustrated to
finalize the bite and add additional labial root torque to the posterior teeth.
After
Elastic
Wear
Occlusion Finalized
188
Choose one of the treatment options to establish the lower arch to an .018 X .025 stain
less steel archwire.
(2)
Use the MDA appliance to fit the upper first and second premolars to the lower first and
second premolars and molars into ideal class I occlusion.
(3)
Retract the maxillary cuspids if necessary using .016 x .022 and pletcher springs to
cuspid hooks. For more than 3 mm of space closure, use pletcher springs. For less than 3
mm, use .020 round archwire and chain elastic to retract cuspids.
(4)
Retract anterior teeth if necessary using posted .018 x .025 with pletcher
springs,accentuated curve and class II elastics.
(5)
Rebracket any teeth as necessary and use .019 x .025 direct braid archwire.
(6)
While using the .019 x .025 direct braid archwire, place individual root torque as needed.
(7)
Use up and down posterior finishing elastics with segmental archwire in anteriors only to
lock in the posterior occlusion.
(8)
189