COPYRIGHT 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.

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47
Hassan Noroozi, DDS, MSc
Researcher Faculty of Dentistry University of Tehran and Dental Research Center Shahid Beheshti University Tehran, Iran

Extrusion-based leveling with segmented arch mechanics

Hassan Moeinzad, DDS

Researcher Faculty of Dentistry University of Tehran Tehran, Iran

Reprint requests:
Dr Hassan Noroozi #3.15, Bazgeer Alley Karoon Street, Azadi Avenue Tehran, Iran 1354865611 E-mail: noroozih@yahoo.com

Leveling of the dental arch may be accomplished through anterior intrusion, posterior extrusion, or a combination. Posterior extrusion is usually preferred in vertically balanced adolescents and in surgical-orthodontic treatment of adults suffering from deep bite and mandibular deficiency. A major disadvantage of posterior extrusion, when accomplished by continuous archwires, is incisor flaring. Here a segmented arch arrangement is proposed for posterior extrusion that combines the clinical simplicity of continuous mechanics with better control of incisor position. (Int J Adult Orthod Orthognath Surg
2002;17;4749)

Int J Adult Orthod Orthognath Surg Vol. 17, No. 1, 2002

Leveling of the curve of Spee is one of the important aspects of comprehensive orthodontic treatment. It is usually accomplished by anterior intrusion or posterior extrusion. Each method has advantages and disadvantages. Segmented arch mechanics is an efficient way to achieve anterior intrusion. With this approach, forces and moments can be accurately adjusted to prevent incisor flaring or downward and backward mandibular rotation. Therefore, in an adult patient with less ver tical growth potential, anterior intrusion within the physiologic limitsseems the likely choice to level the dental arch because any posterior extrusion in such a patient is prone to relapse. But anterior intrusion has its own disadvantages. Compared with posterior extrusion, it is more complex mechanically and needs more chair time. From a periodontal perspective, it is more hazardous than posterior extrusion.1 Anterior intrusion may cause apical root resorption, 2,3 the amount of which is greater than the whole root resorption that has been reported in comprehensive orthodontic treatment.4 Therefore, in an adolescent patient with a horizontal or normal vertical growth pattern, posterior

extrusion may be a better choice. In surgical-orthodontic treatment of a deep bite mandibular deficient adult, it is also preferred to level the dental arch by posterior extrusion. Since posterior extrusion is usually accomplished with continuous archwires, which may cause incisor flaring, it is suggested to leave some space in the dental arch in presurgical orthodontics to compensate for this side effect in postsurgical leveling.5 Cervical headgear, anterior bite plate, intermaxillary elastics, and a continuous archwire (into which a curve may be incorporated) all can cause posterior extrusion. The continuous archwire does not need patient cooperation and does not have any unwanted effects on the opposing arch. However, its main disadvantage is the flaring of incisors. It is widely accepted that leveling the dental arch, when there is an excessive curve of Spee, increases arch length requirements and results in incisor protrusion.69 It has been suggested that 1 mm of space is needed to level each 1 mm of the curve of Spee.10 Dale proposed the addition of 0.5 mm to the mean depth of the curve of Spee in the left and right sides of the mandible to determine the needed

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48 Noroozi/Moeinzad

Fig 1 Left intraoral view of segmented arch mechanics to level the mandibular dental arch by posterior extrusion.

space,11 but according to calculations of Erskine,12 Germane et al,13 and Kirschen et al,14 they may be overestimations. When a curve flattens, its length will be greater than its planar projection. This characteristic has been considered the cause of incisor protrusion when a continuous archwire levels the dental arch. But Woods15 and Braun et al16 showed that this is not the major cause. Rather, the mechanics involved in a continuous archwire become the most important factor. Since the continuous archwire delivers the force to the incisors anterior to their center of resistance, they flare forward. Many techniques have been proposed to minimize the unwanted effects of leveling with continuous archwires. In the original Tweed technique, for instance, Class III elastics were used in conjunction with second-order molar tipback bends to drive the mandibular arch posteriorly while leveling the curve of Spee. The Class III elastics were supported by high-pull facebows to prevent extrusion of the upper molars.17 But we can use segmented mechanics to level the arch by posterior extrusion without incisor flaring.

Biomechanical considerations
Segmented arch mechanics have previously been used for anterior intrusion.18 It can also be used for posterior extrusion. This method is especially useful in those patients for whom posterior extrusion is preferred but incisor flaring is not desirable. In this method, there are 1 anterior and 2 posterior segments (Fig 1). During

the leveling, the wires of the posterior segments slide over the anterior segment wire without increasing the incisor protrusion. Since the contacts of the anterior and posterior wires are distal to the lateral incisors (close to the center of resistance of the anterior segment), anterior flaring is eliminated or diminished. The force is not very light because of the small interbracket spans; thus, posterior extrusion dominates anterior intrusion. The ends of the wires can be bent to prevent tissue irritation. In this technique, the canine teeth can be incorporated to the anterior segment to increase the posterior extrusion/anterior intrusion ratio. One of the disadvantages of this method is that the extrusive force is not evenly distributed among the posterior teeth. The same problem also exists when a continuous archwire is used. To solve this problem, Braun et al16 have suggested a more complex segmented arrangement. In fact, the method described in our article is somewhere between pure continuous technique and pure segmented technique. It combines the clinical ease of continuous mechanics with the control of incisor position, though it is not as well defined as pure segmented mechanics in terms of forces and moments and is less elegant from an engineering perspective. Proffit and Fields warn against the use of a rectangular archwire with an exaggerated curve of Spee, because the curve creates torque to move the incisor roots lingually. 19 On the other hand, Ferguson believes that introducing a reverse curve in a rectangular archwire does not necessarily have any adverse effects on final mandibular incisor inclination.20 Anyway, both round and rectangular continuous archwires cause incisor protrusion when they level the curve of Spee and there is no difference between them in this regard.21 But in segmented mechanics, both round and rectangular wires (with or without a reverse or accentuated curve) can be used for posterior extrusion without worry because single-point contacts between the anterior and posterior wires prevent any adverse effects on incisor torque. Clinically one can follow the following steps:

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Int J Adult Orthod Orthognath Surg Vol. 17, No. 1, 2002

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1. Insert the ends of the continuous archwire into the molar tubes and tie the wire to the incisor brackets. 2. Cut the wire just mesial to the canine brackets. 3. Pull the posterior segments of the wire a bit forward over the anterior wire. 4. Tie the posterior wires to the brackets of the canines and premolars. 5. Bend the ends of the wires if they bother the patient.

Conclusion
Segmented arch mechanics can be used for both anterior intrusion and posterior extrusion to level the dental arch without causing incisor protrusion. The choice depends on the patients orthodontic conditions. Leveling the dental arch does not necessarily increase arch length requirements. On the contrary, with sectional mechanics, about 3 mm to 4 mm of total arch length may be gained by leveling a deep curve of Spee through molar uprighting.22 Therefore, when clinicians want to treat more borderline cases without extractions, the use of segmented mechanics may allow the curve of Spee to be of less importance when deciding how much arch perimeter is actually required.

References
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4. Nanda R. Biomechanics in Clinical Orthodontics. Philadelphia: Saunders, 1996:97. 5. Proffit WR, White RP Jr. Surgical-Orthodontic Treatment. St Louis: Mosby, 1991:351. 6. Baldridge DW. Leveling the curve of Spee: Its effect on mandibular arch length. J Clin Orthod 1969;3:2641. 7. Bell W, Proffit WR, White RP Jr. Surgical Correction of Dentofacial Deformities. Philadelphia: Saunders, 1980:167. 8. Graber TM, Swain BF (eds). Orthodontics: Current Principles and Techniques, ed 3. St Louis: Mosby, 1985:64. 9. Garcia R. Leveling the curve of Spee: A new prediction formula. J Charles H. Tweed Int Found 1984;13:6572. 10. Rakosi T, Jonas I, Graber TM. Orthodontic Diagnosis. New York: Thieme Medical Publishers, 1993:224. 11. Graber TM, Vanarsdall RL Jr (eds). Orthodontics: Current Principles and Techniques, ed 5. St Louis: Mosby, 2000:419. 12. Erskine RB. Space required for arch leveling. J Clin Orthod 1992;26:474476. 13. Germane N, Staggers JA, Rubenstein L, Revere JT. Arch length considerations due to the curve of Spee: A mathematical model. Am J Orthod Dentofacial Orthop 1992;102:251255. 14. Kirschen RH, OHiggins EA, Lee RT. The Royal London Space Planning: An integration of space analysis and treatment planning. Part I: Assessing the space required to meet treatment objectives. Am J Orthod Dentofacial Orthop 2000;118: 448455. 15. Woods M. A reassessment of space requirements for lower arch leveling. J Clin Orthod 1986;20: 770778. 16. Braun S, Hnat WP, Johnson BE. The curve of Spee revisited. Am J Orthod Dentofacial Orthop 1996;110:206210. 17. Tweed CH. A philosophy of orthodontic treatment. Am J Orthod 1945;31:74113. 18. Burstone CR. Deep overbite correction by intrusion. Am J Orthod 1977;72:122. 19. Proffit WR, Fields HW. Contemporary Orthodontics, ed 3. St Louis: Mosby, 2000:546. 20. Ferguson JW. Lower incisor torque: The effects of rectangular archwires with a reverse curve of Spee. Br J Orthod 1990;17:311315. 21. AlQabandi AK, Sadowsky C, BeGole EA. A comparison of the effects of rectangular and round arch wires in leveling the curve of Spee. Am J Orthod Dentofacial Orthop 1999;116:522529. 22. Bench RW, Gugino CF, Hilgers JJ. Bioprogressive therapy, Part 7. J Clin Orthod 1978;12:192207.