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Cephalometric Interpretation

with Diagnosis and Treatment


Planning

Straight Wire Concepts: Diagnosis & Technique

Patient Name
Date

Attitude Toward Treatment:

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

LOWER FACIAL HEIGHT

(mm)

60+5

Upper Incisor to Lower Incisor (angle)

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

Deciduous _______ Mixed _____ Permanent _____

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

Apexification of cuspids ________________________________


ANB _____________________________________________ degrees
Skeletal Classification _____________________________________

Missing Teeth: ___________________________________________


Impacted Teeth: _________________________________________
Wisdom Teeth Present: ___________________________________
Tooth Size Discrepancy: ___________________________________

Soft Tissue Profile ________________________________________


Pogonion to NB Line ___________________________________ mm
How much will Pogonion grow? ________________________ mm
Lower incisor to NB now _______________________________ mm
Does lower incisor need to be moved? _______________________
Forward ____________ mm

Initial TMJ Evaluation: ___________


Pain

Left

Right

Popping

Left

Right

Range of Motion:

Backward ____________ mm

Right Deviation ________________________ mm

How much crowding cephalometrically? ____________________


AP Line ____________________________________________ mm
Is this an extraction case? __________________________________

Transcranial position of the condyle:


Anterior _________ Posterior ________ Superior __________

Which teeth need to be extracted? __________________________


GoGn to SN _________
Type of Growth:

Y-Axis ________

SL ________ mm

Neutral _________ Clockwise ___________

Counterclockwise _________________

Habits:

Thumb

 Tongue

Lip Sucker

Other: _________________________________________
Airway Problems:

Tonsils

Adenoids

Other ________________________________________________

Appliances Needed:
Transpalatal

Reverse Face Mask

Lip Bumper:

Wide

Thin

MDA:

Upper

Lower

NiTi Expander

Rapid Palatal Expansion

ENT Evaluation Advised _________________________________


Prognosis _____________________________________________
____________________________________________________
Lip Seal Exercises ______________________________________
Patient's Treatment Objectives: ____________________________

Retention:
Hawley

Vertical ________________________ mm

Left Deviation _________________________ mm

Lower Lingual

____________________________________________________
____________________________________________________

Treatment Goals and Plan:

RGG Form 92/2


Robert G. Gerety DDS - Produced by Kay C. Gerety

63

Straight Wire Concepts: Diagnosis & Technique

Caucasian Cephalometric Norms


Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:

Good

Poor

Indifferent

Patients Chief Complaint: ________________________________________________________________________

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)

ANB ________ Degrees WITS ____________ mm


Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise

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

DIAGNOSIS AND TREATMENT PLAN:


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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64

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

African American Cephalometric Norms


Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:

Good

Poor

Indifferent

Patients Chief Complaint: ________________________________________________________________________

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)

ANB ________ Degrees WITS ____________ mm


Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise

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

DIAGNOSIS AND TREATMENT PLAN:


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Robert G. Gerety DDS - Produced by Kay C. Gerety

65

Straight Wire Concepts: Diagnosis & Technique

Hispanic Cephalometric Norms


Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:

Good

Poor

Indifferent

Patients Chief Complaint: ________________________________________________________________________

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)

ANB ________ Degrees WITS ____________ mm


Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise

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

DIAGNOSIS AND TREATMENT PLAN:


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

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Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

Chinese Cephalometric Norms


Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:

Good

Poor

Indifferent

Patients Chief Complaint: ________________________________________________________________________

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)

ANB ________ Degrees WITS ____________ mm


Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise

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

DIAGNOSIS AND TREATMENT PLAN:


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Robert G. Gerety DDS - Produced by Kay C. Gerety

67

Straight Wire Concepts: Diagnosis & Technique

Japanese Cephalometric Norms


Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:

Good

Poor

Indifferent

Patients Chief Complaint: ________________________________________________________________________

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)

ANB ________ Degrees WITS ____________ mm


Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise

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

DIAGNOSIS AND TREATMENT PLAN:


_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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_______________________________________________________________________________________________

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Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction of Mandibular Primary Canines


(cont.)
The ironic aspect of this situation is that patients who generally appear to require early extraction of the
mandibular primary canines because of initial crowding of the mandibular incisor teeth are too often the very patients
who should not have these teeth extracted. Many of these patients, particularly those with low mandibular plane
angles (20o to 25o) have a hyperactive mentalis muscle, which creates some flattening of the profile through
retroclination of the mandibular incisors. The extraction of the primary canines then permits even further distolingual
repositioning of the mandibular incisors. This may cause the orthodontist to treat an already over-retracted
mandibular incisor position that was established before active treatment is undertaken. Thus, the first and decisive
step toward flattening of the profile is often taken before the orthodontist becomes a part of the decision-making
process.
Also, if the root of the primary canine acts as a functional matrix for the formation and maintenance of alveolar
bone, then it is evident that in a lateral dimension there would be less alveolar bone and therefore less available space
for eruption of the permanent canines after removal of their primary analogs. The overly crowded case, therefore,
would hardly benefit from early removal of the roots of the primary canines. Other remedial procedures, such as
disking of the primary canine, primary first molar or primary second molar should definitely be attempted first in
these cases.
The clear admonition to the orthodontist who treats casesaccording to the axiom of positioning the mandibular
incisors labiolingually where they are foundis obvious. The history and development of the malocclusion of the
individual patient must first be reevaluated. The requirements of cases that have iatrogenic over-lingualization of
the mandibular anterior teeth might change from an extraction to a non-extraction treatment plan, provided an
adequate dental history is obtained and thorough scrutiny of the orthodontics records (including a thorough
cephalometric analysis) is completed.
It can be determined from the cephalometric analysis if a child has a strongly clockwise or strongly
counterclockwise growth pattern according to the method advanced by Bjork6. It has been proposed that patients
having strongly counterclockwise growth patterns generally benefit from a non-extraction treatment approach7. If
the patient has a strongly counterclockwise growth pattern, premature extraction of primary canines could be
disastrous for the patient, resulting in a permanently increased vertical overbite or a concave facial profile. Early
limited mechanotherapy involving interrupted or segmental lower arches, headgear or lower bumpers may be
indicated in certain of these cases, to prevent or recover from over-distilization of the mandibular anterior teeth.

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

continued on next page

Robert G. Gerety DDS - Produced by Kay C. Gerety

83

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction Of Mandibular Primary Canines


(cont.)
incisors cannot be moved labially because that will be an unstable position for them has to be subject to question
in cases in which mandibular primary canines have been extracted prematurely. It is my opinion that labial
advancement is not only stable, but highly preferable in many of these cases. Also, the concept that space
maintenance is indicated in the mandibular arch only in the event of loss of the primary first molars or secondary
molars is open to question and does not take into consideration the possible lingual movement of the lower incisors
following early loss of the mandibular primary canines.
The value of an early orthodontic case analysis, treatment plan and consultation can not be overesti-mated. It
may result in the complete modification of a treatment plan which, otherwise, the operator may have become
committed to too early and which would be doomed to eventual failure anyway; elimination of the need for loss of
four or more teeth, shortening of time required to accomplish full-banded treatment or the elimination of the need
for full-banded treatment altogether.
In dealing with these cases over the past six years, I have observed that four things consistently happen when
the mandibular canines are extracted early; the mandibular incisors move distally and lingually, the vertical overbite
deepens, the horizontal overjet increases and the facial convexity is increased. Lip incompetence may be created
or exacerbated as a result of this procedure. Another possibility is that the mandibular permanent canines may
become impacted, necessitating the extraction of permanent first pre-molars. At best, early extraction of the
mandibular primary canines generally only accomplishes two purposes; a temporary realignment of the permanent
mandibular incisors and creation of the illusion in the minds of the parents that no serious crowding problem exists.
It is open to question how many adult Class II, Division I malocclusions may have been exacerbated by extraction
of their primary mandibular canines at age 7 or 8. I have never seen a case in which 1 mm of arch length was gained
from early extraction of the mandibular primary canines; nor was any case made easier to treat in the permanent
dentition. In virtually every case, extraction of the canines made a bad situation worse and increased the severity
of the arch length discrepancy.
There are cases in which extraction of the mandibular primary canines is indicated. Severe gingival stripping of
the erupted mandibular incisors, or the existence of an arch length discrepancy so great that it results in the complete
blockage of one or both permanent lateral incisors would constitute such indications.
Conclusions
Early crowding of the mandibular incisor teeth, gingival stripping or the development of a deep anterior overbite
are all primary indications for an early orthodontic evaluation and consultation. Cephalometric analysis including an
evaluation of the growth pattern (clockwise vs. counterclockwise) and linear and angular measurements of the
position of the mandibular incisors should be done for all children who show early signs of mandibular anterior
crowding before extractions. Extractions of mandibular primary canines should not be undertaken merely at the
request of concerned parents.

continued on next page

84

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction Of Mandibular Primary Canines


(cont.)
Dr. Atkinson is Associate Clinical Professor, Department of Orthodontics, Medical College of Georgia
School of Dentistry. Send requests for reprints to Dr. Atkinson, 215 West Poinsett St., Greer, SC 29651.
1

T. M. Graber, Orthodontics: Principles and Practice, 3d ed. (Philadelphia, W. B. Saunders Co.,


1972) p. 363.

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.

Robert G. Gerety DDS - Produced by Kay C. Gerety

85

Straight Wire Concepts: Diagnosis & Technique

When to Begin Treatment


Patient Selection Criteria for the Beginning Doctor
1. Dont treat adults.
2. Dont do one arch treatment except in the mixed dentition (Phase I)
3. Dont treat TMJ patients.
4. Treat patients with an ANB difference of 0-8 degrees.
5. Treat patients with mandibular plane angle (GoGn to SN) of 37o or less (neutral or
horizontal growth).
6. Treat all cases non-extraction for at least nine months. This will enable you to work
through an archwire sequence.

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.

Lower Cuspids Caucasion Only

Figure G

Before minimum
growth spurt
86

Maximum
growth spurt

After maximum
growth spurt

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

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.

Robert G. Gerety DDS - Produced by Kay C. Gerety

87

Straight Wire Concepts: Diagnosis & Technique

Skeletal Classifications
0 to 4

Class I Skeletal Configuration


When the ANB difference is 0o to 4o, the maxilla and the mandible will usually
be related well enough so that it will not be necessary to change the skeletal
relationship.

5 or More

Class II Skeletal Configuration


When the ANB difference is 5o or more, the maxilla, the mandible or a little of
both can be at fault.
In a class II skeletal discrepancy, it will be necessary to place an
auxiliary appliance (MDA, headgear, orthopedic corrector, etc.) to
retard and/or retract the maxilla and allow the mandible to grow to its
full potential.

0 or Less

Class III Skeletal Configuration


When the ANB difference is 0o or less, a rapid palatal expansion appliance can
be used to bring the A point forward to help the Class III skeletal configuration.
This rapid palatal expander will most often be used in conjunction with a
Reverse Face Mask.

88

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

Soft Tissue Profile Analysis


The horizontal soft tissue profile is an aid in diagnosis. A line is drawn from the soft tissue of the chin
through the middle of the nose. The lips should fall on or slightly in front of this line to achieve a
pleasing profile.
If the lips fall in front of this line, the face has a convex appearance. In these patients, expansion
should be avoided as it would push the lips further forward and worsen the convexity. If the lips fall
behind this line, the face has a concave appearance. In these patients, extractions are generally
avoided because any distalization of the anterior segments will worsen the concavity.
Clinical studies have documented that the convexity of the profile will lessen with age. This is true of
all individuals, male and female, regardless of treatment. Finishing cases somewhat full is not a
concern because the patient's profile will continue to flatten.

Normal

Convex

Concave

Figure I

Robert G. Gerety DDS - Produced by Kay C. Gerety

89

Straight Wire Concepts: Diagnosis & Technique

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.

The lower incisor is behind the NB line -2mm probably


causing a concave appearance with pogonion at +4mm.
Extractions generally are avoided because it is undesirable to worsen the concavity of the lower face.
The lower incisor could be moved anteriorly improving
the facial appearance and gaining lower arch length. This
anterior movement is usually done by crown tipping to
avoid any stripping.

The lower incisor is forward to the NB line by +8mm and


pogonion only +4mm.
With the lower incisor at +8mm and if the lower dentition
is already crowded then to get back to a 1 to 1 ratio, you
must distalize using either a lower Wilson or lip bumper.
Either of these will aid in lateral expansion as well.
To move the lower incisor back to +4mm to the NB line,
the same as +4mm as pogonion, there is 8mm of crowding.

90

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

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.

Differences in Boys and Girls


Boys mature about 2 years later
than girls and grow longer. With boys
you start treatment about 12 to 12
years of age. Girls are usually mature
by 13-14 years of age. With girls you
start treatment about 10 to 10 years
of age. (See Figure 3-A below)

Possible Pogonion Growth


AGE

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

Boys - Expected Growth


Age 12
Pogonion Growth: 3mm to 5mm
Pogonion Growth: 4mm to 6-7mm
Pogonion Growth: 5mm to 7-8mm

age 12

age 16

Boys age 12 with a 0 pogonion will generally get


a 3 to 5mm increase by age 16.

Robert G. Gerety DDS - Produced by Kay C. Gerety

age 12

age 16

Boys age 12 with a pogonion of 3 to 5mm will


at least double to 6 to 8mm by age 16.

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Straight Wire Concepts: Diagnosis & Technique

Girls - Expected Growth


Age 10
Pogonion Growth: 1mm to 4 or 5mm
Pogonion Growth: 3mm to 6 or 7mm
Pogonion Growth: 4mm to 8 or 9mm

In a girl with a 0 pogonion at age 10, the best you


generally will get is a 3 to 4mm increase in the
growth of the pogonion (closer to 3mm).

Age 11
Pg = 0mm

AGE 13
Pg = 0mm

92

Age 14
Pg = 2-3mm

AGE 14
Pg = -1mm

The pogonion increases less after age 10. A


patient that has a pogonion of 4mm age 14 will
have that the rest of her life.

Girls with a pogonion of 3 to 4mm at age 10 will


usually double to 6 to 8mm by age 14.

AGE 12
Pg = 0mm

Age 14
Pg = 1-2mm

A patient that has a 0 pogonion at age 14 will not


get an increase in the pogonion. The pogonion will
remain 0.

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Straight Wire Concepts: Diagnosis & Technique

Establishing Incisor to NB Relationship


1. Look at the age of the patient first.
2. Then look at expected pogonion growth chart
to determine how much pogonion will grow.

Age - 10.6

3. Then you can decide where to place the lower


incisor.
4. If this patient had 8mm of dental crowding,
then you could eliminate this by moving the
lower incisor forward to 7mm.
3mm

3mm

1. Pogonion has grown to 6mm.


2. The crowding has been eliminated by moving
the lower incisors forward.

Age - 14

3. This has produced a nice soft tissue profile.

7mm

6mm

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Straight Wire Concepts: Diagnosis & Technique

Determining Crowding Cephalometrically

For every mm you decrease the lower incisor to the


NB line, you decrease the arch length by 1mm. This
total must be doubled because the lower arch will be
retracted.
There is no crowding cephalometrically in this example
because the lower incisor to the NB line is within
normal limits to the NB line.

There is no crowding cephalometricaly in this example


with the lower incisor to the NB line of -2mm.

The lower incisor is +8mm to the NB line present


ing a total of +8mm of crowding cephalometrically.
The lower incisor retracted to +4mm to the NB line
will decrease the arch length by 4mm on each side
of the arch. This totals -8mm cephalometrically.

94

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Straight Wire Concepts: Diagnosis & Technique

Skeletal Classifications (Growth Pattern)

Skeletal Average Bite


GoGn to SN is 32o +or- 5o

32o 5o

Skeletal Closed Bite


GoGn to SN is 27o or less

27o or Less

Skeletal Open Bite


GoGn to SN is 37o or more

37 or More

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Straight Wire Concepts: Diagnosis & Technique

Growth Indicator Measurements


Y-Axis Growth Indications

SL Growth Indications

S
Y - Axis

Y-Axis 65o +or- 5o


Neutral Growth
Skeletal Average Bite

SL 51mm +or- 5mm


Neutral Growth
Skeletal Average Bite

L
S
Y - Axis

Y-Axis 60o or Less


Counter Clockwise Growth
Skeletal Closed Bite

SL 57mm or Greater
Counter Clockwise Growth
Skeletal Closed Bite

Y - Axis

Y-Axis 71o or Greater


Clockwise Growth
Skeletal Open Bite

96

SL 44mm or Less
Clockwise Growth
Skeletal Open Bite

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Straight Wire Concepts: Diagnosis & Technique

A-P Line Analysis


The position of the incisal edge of the lower incisor in
relation to the A-P line or diagnostic line is important to facial aesthetics and the stability of the dentition. The lower incisor should be on or slightly in
front of the A-P line. Use of the AP line for
diagnosis is accurate only when the patient has
a class I skeletal relationship.

AP to = +3mm

The normal range of the lower incisor to the A-P


Line is +2, +3, +4mm. This range usually results
in a nice, stable lower dentition and pleasing
facial aesthetics.

The lower incisor to the A-P line in this example


would lean toward non-extractions. The lower
dentition could gain between 10 to 12mm in arch
length. The lower incisor could be brought from
a -4mm to a +3mm, gaining a total of 7mm on
each side of the arch for a total of +14mm.

The lower incisor to the A-P line in this example


would lean toward distalization. The lips should
not be any fuller so you would want to treat any
crowding with lateral expansion and distalization
rather than any anterior movement.

AP to = -4mm

AP to = +8mm

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Straight Wire Concepts: Diagnosis & Technique

Wits Analysis
Apical Base Class I

-1mm to +3mm Wits = Skeletal Class I


00 to 40 ANB = Skeletal Class I

Apical Base Class II

+3mm Wits or Greater = Skeletal Class II


50 and Over ANB = Skeletal Class II

Apical Base Class III

98

Less than -1mm Wits = Skeletal Class III


-10 and Below ANB = Skeletal Class III

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Straight Wire Concepts: Diagnosis & Technique

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.

3. Check soft tissue profile.


4. Check Pogonion to see if it will grow, which may allow us to move the lower
incisors forward to eliminate crowding.

Check the lower incisor to NB to see if it needs to be moved forward,


backward or remain the same.

5. Check GoGn to determine if this patient is a clockwise, counter-clockwise or


neutral grower.

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Straight Wire Concepts: Diagnosis & Technique

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

6mm 1st Premolar


12mm 1st Molar

Normal Face

7mm 1st Premolar


14mm 1st Molar

Wide Face

8mm 1st Premolar


16mm 1st Molar

Upper Arch
Measurement Points

Distal Pits
of 1st Premolars

Central Pits
of 1st molars

S.I. + 8mm = 1st Premolar


S.I. + 16mm = 1st Molar

100

Lower Arch
Measurement Points

Central Part
of Middle Buccal
Cusps of 1st Molars
Mesio-Labial
Marginal
Ridge Points
of 2nd Premolars

S.I. + 8mm = 1st Premolar


S.I. + 16mm = 1st Molar

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Straight Wire Concepts: Diagnosis & Technique

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. Soft Tissue Profile

3. Constrictions

4. Congenitally missing teeth

4. Lower incisor to NB and


NB to pogonion relationship

4. Crowding

5. Impacted teeth
(molars or cuspids)

5. Overjet and overbite

5. GoGn to SN
(mandibular plane angle)

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Straight Wire Concepts: Diagnosis & Technique

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.

Rotation of 1st and 2nd molars.


Expansion.
Distalization.
Torque.
Crossbites.

Expansion and Contraction

102

Rotation

Buccal Root Torque


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Straight Wire Concepts: Diagnosis & Technique

Phase I Interceptive Treatment


Phase I or interceptive orthodontic treatment should be considered when there is moderate crowding,
loss of space due to extraction or premature exfoliation, or severely rotated or malaligned teeth
erupting. Literature published by Bjorn Zachrisson, DDS,MSD,PHD1 emphasizes the importance of
treating crowded or rotated teeth at an early age to improve stability. Resolving the issues of crowding
and constrictions in the mixed dentition lessens the severity of the comprehensive orthodontic
treatment during the permanent dentition. Patients and parents are concerned with the malaligned
teeth. By addressing these concerns with fixed appliannces, you not only develop the arches and make
room for the permanent teeth, you individually correct the position of the teeth for esthetics. With
removable appliances, it is not always possible to tip, align and rotate the teeth to the esthetic level
that both you and the parent are hoping to obtain. Anterior-posterior or skeletal class II correction is
not recommended in the mixed dentition.
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
and 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

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Straight Wire Concepts: Diagnosis & Technique

Phase I Technique (cont.)


1. 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.
2. Progress through routine archwire sequence of .0175, .016, .018 round.
3. Once you are up to the .018 archwire, introduce open coil spring where needed to gain sufficient
space or regain lost space.
4. 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.
5. 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.
6. 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.

Step 1. Bracket the entire


dentition and use archwire
sequence.

104

Step 2. During the .018


archwire, introduce open
coil spring where teeth are
crowded or blocked.

Step 3. When you have gained


adequate space, bracket
blocked out teeth and place a
flexible wire to engage.

Step 4. Remove all


brackets &bands. Seat
retainers awaiting eruption
of permanent teeth.

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Straight Wire Concepts: Diagnosis & Technique

The Six Keys to Optimal Occlusion


Key I - Molar Relationship
1. The distal surface of the distal marginal ridge of the
upper first permanent molar contacts and occludes with
the mesial surface of the mesial marginal ridge of the
lower second molar.
2. The mesio-buccal cusp of the upper first permanent
molar falls within the groove between the mesial and
middle cusp of the lower first permanent molar.
3. The mesio-lingual cusp of the upper first molar seats in
the central fossa of the lower first molar.

Key II - Crown Angulation - The Mesio-Distal


Tip
1. In normally occluded teeth, the gingival portion of the
long axis of each crown is distal to the occlusal portion
of that axis. The degree of tip varies with each tooth
type.

Key III - Crown Inclination - The Labio-Lingual or


Bucco-Lingual Torque
Crown inclination is the angle between a line 90 degrees to
the occlusal plane, and a line tangent to the middle of the
labial or buccal clinical crown.
1. Anterior crowns (central and lateral incisors): In upper
incisors, the occlusal portion of the crown's labial
surface is labial to the gingival portion. In all other
crowns, the occlusal portion of the labial or buccal
surface is lingual to the gingival portion. In the nonorthodontic normal models, the average interincisal
crown angle was 174 degrees.
2. Upper posterior crowns (cuspids through molars).
Lingual crown inclination is slightly more pronounced
in the molars than in cuspids and bicuspids.
3. Lower posterior crowns (cuspids through molars):
Lingual inclination progressively increases.

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Straight Wire Concepts: Diagnosis & Technique

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.

Key V - Tight Contacts


1. In the absence of such abnormalities as genuine tooth-size
discrepancies, contact points should be tight.

Key VI - Curve of Spee


A flat occlusal plane should be a treatment goal.
Measured from the most prominent-cusp of the lower
second molar to the lower central incisor, no curve
was deeper than 1.5mm in the non-orthodontic
normals.
1. A deep curve of Spee results in a more
confined area for the upper teeth, creating
spillage of upper teeth mesially and distally.
2. A flat curve of Spee is most receptive to
normal occlusion.
3. A reverse curve of Spee results in
excessive room for the upper teeth.

106

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Straight Wire Concepts: Diagnosis & Technique

The Six Keys to Optimal Occlusion


Key I: Interarch Relationships
Key I is the first of the six significant characteristics that were consistently present in the sample of 120
dental casts with optimal occlusion. Key I pertains to the occlusion and the interach relationships of the
teeth. This key consists of seven parts.
1. The mesiobuccal cusp of the permanent maxillary first molar occludes in the groove between the
mesial and middle buccal cusps of the permanent mandibular first molar as explained by Angle.
2. The distal marginal ridge of the maxillary first molar occludes with the mesial marginal ridge of the
mandibular second molar.
3. The mesiolingual cusp of the maxillary first molar occludes in the central fossa of the mandibular
first molar.
4. The buccal cusps of the maxillary premolars have a cusp-embrasure relationship with the mandibular
premolars.
5. The lingual cusps of the maxillary premolars have a cusp-fossa relationship with the mandibular
premolars.
6. The maxillary canine has a cusp-embrasure relationship with the mandibular canine and first premolar. The tip of its cusp is slightly mesial to the embrasure.
7. The maxillary incisors overlap the mandibular incisors, and the midlines of the arches match.

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.

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Straight Wire Concepts: Diagnosis & Technique

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.

Key II: Crown Angulation - The Mesio-Distal Tip


Essentially all crowns in the sample have a positive angulation* (Fig. 3.18). All crowns of each tooth
type are similar in the amount of angulation. In normally occluded teeth, the gingival portion of the long
axis of each crown is distal to the occlusal portion of that axis. The degree of tip varies with each tooth
type.

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

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Straight Wire Concepts: Diagnosis & Technique

Key III: Crown Inclination


As they do in angulation, consistent patterns also prevail in crown inclination, with the following characteristics for individual teeth.
1. Most maxillary incisors (81.5%) have a positive inclination (Fig. 3.19A,B); mandibular incisors have
a slightly negative inclination (Fig. 3.19A,C). In most of the optimal sample, the interincisal crown
angle is less than 180: The crowns of maxillary incisors are more positively inclined, relative to a line
90 to the occlusal plane, than the mandibular incisors are negatively inclined to the same line (Fig.
3.20).
2. The inclinations of the maxillary incisor crowns are generally positive-the centrals more positive than
the laterals. Canines and premolars are negative and quite similar. The inclinations of the maxillary first
and second molars are also similar and negative, but slightly more negative than those of the canines and
premolars (Fig.3.21). The molars are more negative because they are measured from the groove instead
of from the prominent facial ridge, from which the canines and premolars are measured.
3. The inclinations of the mandibular crowns are progressivley more negative from the incisors through
the second molars (Fig. 3.22)

Fig. 3.19. Incisor inclination. Maxillary incisor inclination is


consistently positive (A,B); mandibluar incisor inclination is
consistently negative (A,C).

Robert G. Gerety - Produced by Kay C. Gerety CDA

Fig. 3.20. Interincisal crown angle for the majority of the


optimal sample was less than 180.

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Straight Wire Concepts: Diagnosis & Technique

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

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Straight Wire Concepts: Diagnosis & Technique

Key IV: Rotations


The fourth key to optimal occlusion is an absence of tooth rotations (Fig. 3.23).

Key V: Tight Contacts


Contact points should abut unless a discrepancy exists in mesiodistal crown diameter (Fig. 3.23).

Fig. 3.23. Maxillary arch (A) and mandibular arch (B) showing no rotations and no interdental spacing. Dots indicate contact
points.

Key VI: Curve of Spee


The depth of the curve of Spee ranges from a flat plane to a slightly concave surface (Fig. 3.24).

Fig. 3.24. Mandibular arch with a curve of Spee within the 0-2.5mm depth range.

Summary -- Six Keys to Optimal Occlusion


1. Molar Relationship
2. Crown Tip
3. Crown Torque
4. Absence of Rotations
5. Absence of Spaces
6. Flat plane of Occlusion

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Straight Wire Concepts: Diagnosis & Technique

Class I Occlusion as defined by Andrews

(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.

The mesialbuccal cusp of the upper


first molar occludes with the groove
between the mesiobuccal and middle
buccal cusp of the lower first molar.
The distobuccal cusp of the upper first
molar contacts the mesiobuccal cusp
of the lower second molar.

112

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Straight Wire Concepts: Diagnosis & Technique

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.

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Straight Wire Concepts: Diagnosis & Technique

Evaluate Premolar Position


If the upper premolars are in the embrasures of the lowers on one side, but are
riding up the inclines of the lower
premolars on the other side, two things
will be apparent in the occlusion. You
will have a midline discrepancy and/or an
overjet problem. The average width of a
lower premolar is 8mm. If the premolars
have end on end occlusion, you will have
to move the upper premolars distally
approximately 4mm to establish the solid
Class I occlusion and nice overjet. If you
have full Class II occlusion, you will
have to move the upper premolars distally
approximately 8mm. You should take
into account whether or not there is a
tooth size discrepancy.

114

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Straight Wire Concepts: Diagnosis & Technique

Correct Premolar Occlusion


To achieve the proper overbite, overjet and correct midline the premolars have to fit in the
embrasures of the lower premolars and molar. When the upper premolars start to ride up the
inclines of the lower premolars then you will not be able to get the proper overjet or correct
midline.

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Straight Wire Concepts: Diagnosis & Technique

Full Class II Occlusion


If you have an ANB of 0 to 8 and the upper premolars are end on end or full Class II,
the
quickest way to achieve the solid Class I occlusion is to distalize the molars with the
MDA.

116

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Straight Wire Concepts: Diagnosis & Technique

Management of Blocked out or


Labially Positioned Cuspids
In considering treatment options for leveling, aligning and rotating the arches, upper or
lower, you must consider the resultsof an archwire sequence. If the cuspids are blocked
out or in labial version, upper or lower, progressing through an archwire sequence will
always move the anterior teeth forward. There are situations where you would like to
move the anteriors forward (Class II, Division II or lingually inclined lower incisors) and it
would be appropriate to engage the cuspids and move the anteriors forward. More often
than not, it will not be desirable to move the anteriors forward and you will want to initiate
treatment mechanics to make room for the cuspids through distalization.
By engaging blocked out or labially positioned cuspids on the upper, you will create
unwanted overjet because the cuspids will come down at the expense of moving the incisors out. This treatment is considered round tripping. The anteriors are moved out and
then have to be retracted. This anterior movement is not of any advantage and should be
avoided.
On the lower arch, the most likely cause of the mesial or labial position of the cuspids is
due to premature loss of the deciduous teeth and the cuspids have drifted forward. Engagement of these cuspids on the lower will have the same effect on the anteriors by
moving them forward. This anterior movement is not desirable and will position the
incisors too far labially and this round tripping should be avoided.

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.

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Straight Wire Concepts: Diagnosis & Technique

Results of Engaging Blocked Out Cuspids


Do not engage blocked out or labially positioned cuspids into the archwire sequence.
The posterior teeth will not move distally. The cuspids will come down at the expense of
the anterior teeth. Engaging the cuspids will cause the anterior teeth to intrude and flare
forward.

INTRUSION AND FLARING


Engagement of labially positioned blocked out cuspids, upper or lower, will cause
the anterior teeth to intrude and move forward.

OVERJET
Bringing in high cuspids when there is insufficient space, causes the anterior teeth to
flare forward creating overjet.
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Robert G. Gerety - Produced by Kay C. Gerety CDA

INCORRECT TREATMENT OF BLOCKED


OUT/LABIALLY POSITIONED CUSPIDS

AFTER

NOTE THE AMOUNT OF OVERJET AND ANTERIOR FLARING. THE PREMOLARS REMAIN CLASS II AND THE ANTERIOR TEETH
MOVE OUT.

BEFORE

Straight Wire Concepts: Diagnosis & Technique

119

120

AFTER

TREATMENT: This case exhibits an error in treatment sequencing. An archwire sequence


incorporating the upper cuspids and laterals was used before making space for cuspids and
laterals in the arch. Engaging blocked out teeth into an archwire sequence prior to making
space for them always results in the anterior teeth being blown out or flared. This is called
round-tripping and increases treatment time significantly. To correct, the posterior teeth
need to be repositioned into a proper class I relationship allowing adequate space for the anterior teeth to be retracted to eliminate the overjet and flaring. This entire phase of treatment
could be avoided by establishing the posterior relationship, gaining adequate space for the
blocked out teeth, and then incorporate them into the arches.

BEFORE

Straight Wire Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA

Final results of treatment to correct the improper management of the blocked out anterior teeth.

Straight Wire Concepts: Diagnosis & Technique

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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.

CORRECT TREATMENT OF BLOCKED OUT/LABIALLY POSITIONED CUSPIDS

Straight Wire Concepts: Diagnosis & Technique

Robert G. Gerety - Produced by Kay C. Gerety CDA

Robert G. Gerety - Produced by Kay C. Gerety CDA

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.

Straight Wire Concepts: Diagnosis & Technique

123

Final results of proper treatment sequencing to manage blocked out


and labially positioned teeth avoiding round tripping.

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

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

Approximately 6 Months to Round Out the Arches


.016 x .022
.018 x .025

2 months
1 month

Approximately 9 Months to Level the Arches


019 x .025 Braided

1 month

Archwire Used for Re-bracketing and Fine Tuning

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.

Start open coil spring on the .018 wire.

5. The arches should be rounded out by the .020 wire.


6. The arches should be close to level by the second .016 x .022 wire.
7. Start Class II elastics in conjunction with the MDA on .018 x .025 wire - the
arches should be level.

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Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.

Before

Deep curve of Spee

Arch constrictions and rotations

Anterior irregularities

After

Curve of Spee leveled

126

Arch aligned and rotated

Anterior teeth leveled

Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

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

MDA to establish Class I Occlusion

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Straight Wire Concepts: Diagnosis & Technique

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

Class II cuspid relationship

After

Cuspid retraction to Class I

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Straight Wire Concepts: Diagnosis & Technique

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

Anterior retraction and final bite opening

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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

Height placement error

After

Rebracketing to correct tip

130

Rebracketing to level

Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

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.

Before Elastic Wear

Elastic wear for two weeks

Elastic wear for two weeks

After
Elastic
Wear

Occlusion Finalized
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Treatment Methods to Establish the Lower Arch


In treatment planning and sequencing, it is recommended that you establish the position of the
lower teeth and arch first. You must decide and determine the position of the lower incisors,
premolars and molars in order to fit the maxillary teeth to the lower arch. The lower arch is
always the diagnostic arch. Establishing the lower arch means leveling, aligning and rotating all
the teeth that are available...second molar to second molar if possible.

#1

Bracketing with Archwire Sequence

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

Thin Lip Bumper or 3-D Lingual Arch to Utilize Available E Space

(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

Thick Lip Bumper with Class III Elastics to Distalize

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.

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Straight Wire Concepts: Diagnosis & Technique

#4

Lower MDA or CD Distalizer

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.

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Rounding Out the Arches


.0175 Twisted Wire
1.
2.
3.
4.
5.

First archwire to be placed.


Archwire to get full bracket engagement.
Starts to level, align and rotate.
Place your rotating wedges to help rotate.
Start to get arch form because usually the
four anteriors and premolars will round
out to the cuspids and molars.
6. Usually it will take at least 2 twisted
wires which is 2 months before you go to
.016. Sometimes it will take up to 6
months with twisted in adult cases.

.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.

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Straight Wire Concepts: Diagnosis & Technique

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.
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Straight Wire Concepts: Diagnosis & Technique

Arch Leveling (cont.)


.020
1. Continue with AC &
RC to level.
2. May want to take a
study model to check
bracket alignment
and height if your
bite is not opening
up.

.016 x .022
1. Continue with AC &
RC if needed to
level.

.018 x .025
1. Continue with AC &
RC to get final
leveling.

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Straight Wire Concepts: Diagnosis & Technique

Diagnosing the Correct Treatment Method to Establish


the Lower Arch: Four Treatment Options
#1 Bracketing with Archwire Sequence to .018 X .025 SS

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

cause the lower teeth to move forward? Are


permanent cuspids mesial to the four anterior
teeth? #2. Will moving the lower teeth forward
result in a stable position to pogonion?

Indications for Utilizing Treatment Option #1


Concave profile
Lower incisor to NB measurement less than Pogonion
Minimal to moderate crowding

Concave Profile

Archwire sequence
beginning with .0175

Robert G. Gerety - Produced by Kay C. Gerety CDA

.018 X .025
Stainless Steel

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Straight Wire Concepts: Diagnosis & Technique

Case # 1018: Option 1 Bracketing with Archwire Sequence.


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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

Straight Wire Concepts: Diagnosis & Technique

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139

Straight Wire Concepts: Diagnosis & Technique

Case # 1018: Option 1 Post Treatment Models


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AMANDA HENDRICKSON
AGE: 13.11
09-01-92
# 1018

38

23

77

AP= +4

35

73

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132

74
71
3

70

-1

22

25

TREATMENT COMPLETION
CEPH

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

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

Thin Lip Bumper

Normal Profile

144

Thin Lip Bumper

Crowding Eliminated

Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

Case # 973: Option 2 Thin Lip Bumper to Utilize Available E Space.

Robert G. Gerety - Produced by Kay C. Gerety CDA

145

Straight Wire Concepts: Diagnosis & Technique

146

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Straight Wire Concepts: Diagnosis & Technique

Case # 973: Option 2 Post Treatment Models

Robert G. Gerety - Produced by Kay C. Gerety CDA

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Straight Wire Concepts: Diagnosis & Technique

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KRISSI INGRAM
AGE: 16
02-14-95
# 973

Retention Ceph

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

#3 Thick Lip Bumper with Class III Elastics to Distalize


Indications for Utilizing Treatment Option #3
Normal Profile
Lower incisor to NB measurement will not allow forward movement of incisors
Moderate crowding
Permanent dentition

Normal Profile

Molar Distalization

Retract Cuspids

152

Class III Elastics

Thick Lip Bumper

Retract
2nd 2nd
Bicuspids
Retract
Bicuspids

Archwire Sequence

Retract 1st Bicuspids

Crowding Resolved

Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

Case # 898: Option 3 Lip Bumper with Class III Elastics.


Robert G. Gerety - Produced by Kay C. Gerety CDA

153

SHERI McCARTY
AGE: 11.1
05-11-87
# 898

Beginning Ceph

Straight Wire Concepts: Diagnosis & Technique

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SHERI McCARTY
AGE: 11.9
01-11-88
# 898

Ceph after
Lip Bumper
and before
Archwire
Sequence

Straight Wire Concepts: Diagnosis & Technique

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155

Straight Wire Concepts: Diagnosis & Technique

Case # 898: Option 3 Post Treatment Models


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SHERI McCARTY
AGE: 17.7
11-09-93
# 898

Retention Ceph

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

#4 Lower MDA or CD Distalizer


Indications for Utilizing Treatment Option #4
Normal Profile
Lower incisor to NB measurement will not allow forward movement of incisors
Severe crowding
Permanent dentition
Molars need to be distalized more than 4mm per side to eliminate crowding

Normal Profile

Molar Distalization

Retract Cuspids

160

Archwire Sequence Using Available Teeth


Progressing Up to .020

Retract 2nd Bicuspid

Archwire Sequence

Lower MDA

Retract 1st Bicuspid

Crowding Resolved

Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

Case # 783: Option 4 Lower multi-distalizing arch.


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161

CLARISSA ARMSTRONG
AGE: 10
03-13-84
# 783

Beginning Ceph

Straight Wire Concepts: Diagnosis & Technique

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CLARISSA ARMSTRONG
AGE: 12.2
09-23-85
# 783

Ceph taken prior


to placement of
upper distalizing
arch

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

Case # 783: Option 4 Post Treatment Models


164

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CLARISSA ARMSTRONG
AGE: 14.2
09-02-87
# 783

Treatment
completion
Ceph

Straight Wire Concepts: Diagnosis & Technique

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165

Straight Wire Concepts: Diagnosis & Technique

Case # 1369: Option 4 Lower CD Distalizer


168

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Tate Williams
AGE: 13
07-07-98
# 1369

Straight Wire Concepts: Diagnosis & Technique

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169

Straight Wire Concepts: Diagnosis & Technique

Pre-Treatment

Post Retraction

Post CD Distalizer

Lower Arch Leveled to .018 x .025

Post Treatment

Lower arch sequencing using the CD Distalizer.


170

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Straight Wire Concepts: Diagnosis & Technique

Case # 1369: Option 4 Post Treatment Models

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171

Tate Williams
AGE: 15.9
04-17-01
# 1369

Finished
Ceph

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

Phase I Interceptive Treatment


Phase I or interceptive orthodontic treatment should be
considered when there is moderate crowding, loss of
space due to extraction or premature exfoliation, or
severely rotated or malaligned teeth erupting. Literature published by Bjorn Zachrisson, DDS,MSD,PHD1
emphasizes the importance of treating crowded or
rotated teeth at an early age to improve stability.
Resolving the issues of crowding and constrictions in
the mixed dentition lessens the severity of the comprehensive orthodontic treatment during the permanent
dentition. Patients and parents are concerned with the
malaligned teeth. By addressing these concerns with
fixed appliances, you not only develop the arches and
make room for the permanent teeth, you individually
correct the position of the teeth for esthetics. With
removable appliances, it is not always possible to tip,
align and rotate the teeth to the esthetic level that both
you and the parent are hoping to obtain. Anteriorposterior or skeletal class II correction is not recommended in the mixed dentition.

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.

Step 1. Bracket the entire


dentition and use archwire
sequence.

Step 2. During the .018


archwire, introduce open
coil spring where teeth are
crowded or blocked.

Robert G. Gerety - Produced by Kay C. Gerety CDA

Step 3. When you have gained


adequate space, bracket
blocked out teeth and place a
flexible wire to engage.

Step 4. Remove all


brackets &bands. Seat
retainers awaiting
eruption of permanent
teeth.

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Straight Wire Concepts: Diagnosis & Technique

Option 5: #1058 Phase I Interceptive

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Thomas Kelly
AGE: 8.9
07-05-91
# 1058

Beginning
Ceph

Straight Wire Concepts: Diagnosis & Technique

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177

Straight Wire Concepts: Diagnosis & Technique

Option 5: #1058 Phase I Interceptive


Post Treatment
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Straight Wire Concepts: Diagnosis & Technique

Option 5: #1058 Beginning of


Phase II Treatment
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179

Thomas Kelly
AGE: 12.5
03-27-95
# 1058

Beginning of
Phase II Ceph

Straight Wire Concepts: Diagnosis & Technique

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Straight Wire Concepts: Diagnosis & Technique

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181

Straight Wire Concepts: Diagnosis & Technique

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.

ACTIVE TREATMENT TIME FOR PHASE I: 9 MONTHS

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Straight Wire Concepts: Diagnosis & Technique

Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.

Before

Deep curve of Spee

Arch constrictions and rotations

Anterior irregularities

After

Curve of Spee leveled

Robert G. Gerety - Produced by Kay C. Gerety CDA

Arch aligned and rotated

Anterior teeth leveled

183

Straight Wire Concepts: Diagnosis & Technique

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

MDA to Establish Class I Occlusion

184

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Straight Wire Concepts: Diagnosis & Technique

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

Class II cuspid relationship

After

Cuspid retraction to Class I


Robert G. Gerety - Produced by Kay C. Gerety CDA

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Straight Wire Concepts: Diagnosis & Technique

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

Anterior retraction and final bite opening

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Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

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

Height placement error

After

Rebracketing to correct tip

Robert G. Gerety - Produced by Kay C. Gerety CDA

Rebracketing to level

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Straight Wire Concepts: Diagnosis & Technique

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.

Before Elastic Wear

Elastic wear for two weeks

Elastic wear for two weeks

After
Elastic
Wear

Occlusion Finalized

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Robert G. Gerety - Produced by Kay C. Gerety CDA

Straight Wire Concepts: Diagnosis & Technique

Comprehensive Orthodontic Treatment Sequencing


Diagnosis and Treatment Summation
(1)

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)

Seat upper hawley and bonded lower lingual, cuspid to cuspid.

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