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Appliance
Richard P. McLaughlin and John C. Bennett
With the preadjusted orthodontic appliance, there is a gradual progression
toward finishing, rather than an abrupt stage of tedious wire bending.
Therefore, the fewer the errors made as treatment progresses, the less work
required during finishing. There are horizontal, vertical and transverse factors to be considered relative to finishing, as well as dynamic, cephalometric
and esthetic factors. Horizontally, it is important to establish the correct tip
of the anterior and posterior teeth. Adequate torque of the incisors must be
controlled and all spaces should be closed, unless restorations are indicated.
Vertically, crown lengths, marginal ridge relationships and contact points
must be adjusted. Final correction of the curve of Spee must be established.
Transversely, arch form and arch wire coordination must be set up, and
posterior torque must be corrected. From a dynamic standpoint, the condyles should be in centric relation when the teeth occlude, and functional
movements should be established. By this stage, habits should be corrected.
And finally, cephalometric objectives should be reviewed, as well as esthetic
objectives. (Semin Orthod 2003;9:165-183.) 2003 Elsevier Inc. All rights
reserved.
uring the final stage of orthodontic treatment, finishing and detailing, it is important to continue to focus on treatment goals.
The generally accepted goals of treatment are as
follows:
Tooth alignment: The incisal edges of the anterior teeth should be well aligned, as should
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Horizontal Considerations
Coordination of Tooth Fit
A major finishing consideration in the horizontal plane is the coordination of tooth fit between
the anterior and posterior segments. The anterior and posterior teeth fit well, with little or no
adjustment required, in approximately 20% of
cases. However, in approximately 60% of cases,
as the finishing stage approaches, the crowns of
the upper anterior teeth do not occupy enough
space mesio-distally, relative to the crowns of the
lower anterior teeth. Examples of this are seen
in the following situations:
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Figure 1.
tooth fit.
Figure 2. Figures for anterior tip for the Andrews1 nonorthodontic normal models, the original Andrews1
Straight-Wire ApplianceTM and the original Roth2 ApplianceTM.
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Figure 4. Case showing correct overjet, upright upper incisor, and a slight Class II posterior relationship on
each side. After correcting the incisor torque, Class II elastics can be used to bring the posterior segments to a
Class I position with correct overjet.
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Figure 6. A case showing slight anterior crowding, where interpoximal reduction was used to avoid overexpansion, while treating on a nonextraction basis. It is beneficial to complete reduction at the beginning of
treatment in the lower arch, and toward the end of treatment in the upper arch, when overjet can be reviewed
with the lower arch set up properly and the posterior segments in a Class I relationship. Lower incisors were not
advanced in this patient.
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Figure 6. (Continued)
segment, it is often advisable to carry out interproximal enamel reduction in the lower anterior
region in the initial stages of treatment (Fig 6).
Only minimal amounts of tooth mass should
be removed from the upper anterior segment
early in treatment. If enamel reduction is done
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tooth mass as a result of lower tooth mass reduction, then interproximal enamel reduction procedures can be performed in the upper anterior
segment.7
Controlling Rotations
The in-out compensation built into the preadjusted appliance, combined with correct bracket
positioning, is reasonably effective in controlling
rotations. The most obvious example of this is
the 10 of rotation that is introduced into the
brackets of the upper molars, and the 0 of
rotation placed in the lower molars. This combination is most beneficial in allowing the upper
molars to occlude properly in a Class I position
with the lower molars.
If anterior teeth show rotations at the beginning of treatment, it is beneficial to place the
bracket slightly in the direction of the rotation
to aid in their correction. Also, it is beneficial to
place lower canine brackets slightly to the mesial. This rotates the mesial aspect labially and
provides better contact with the distal aspect of
the lower lateral incisors.
It is beneficial in Class I and Class II cases to
place upper premolar brackets approximately
1/2 mm to the mesial.8 This allows the buccal
cusps of the upper premolars to rotate distally
toward a Class I position, and the palatal cusps of
these teeth to rotate mesially so that they occlude more accurately into the fossae of the
lower arch (Fig 7).
Horizontal Over-Correction
It is often necessary to consider horizontal overcorrection of Class II and Class III cases. During
the finishing stages of treatment, it is important
to fully correct the A/P position of the dentition
using methods such as Class II or Class III elastics, or headgear, for example. After correction
has been completed, then these methods of
tooth movement can be discontinued or worn
on a part-time basis. The patient may then be
observed for a period of six to eight weeks. If the
case appears to be stable, the appliances can be
removed. If not, these cases can be horizontally
over-corrected.
In Class II cases the anterior teeth can be
brought to an edge-to-edge position and held
for approximately six to eight weeks with nighttime elastics. After this, case settling can be observed (Fig 9).
Class III cases can be horizontally over-corrected by producing 3 to 4 mm of additional
overjet, and this may then be held and observed
in a similar manner to Class II cases (Fig 10).
Even if these over-correction techniques are
carefully followed, problems can occur during
retention. These can be due to late aberrant
growth, or reestablished tongue or finger habits,
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Vertical Considerations
Establishing Correct Crown Lengths, Marginal
Ridge Relationships and Contact Points
Correct bracket positioning is the single most
important mechanical step performed by the
Figure 9. In Class II cases, the anterior teeth can be brought to an edge-to-edge position and held for
approximately six to eight weeks with nighttime elastics. After this, elastics can be discontinued and case settling
can be observed.
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Figure 10. A Class III case that was horizontally over-corrected by producing 3 to 4 mm of additional overjet,
this was held and observed in a similar manner to the above Class II case.
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Transverse Considerations
Archform and Archwire Coordination
There is ample evidence in the literature that
expansion in the lower arch, particularly in the
canine region is unstable,10 and little or no evidence to the contrary. When the lower arch is
rolled in lingually, as occurs in most palatal expansion cases11 and many deep bite cases,12 then
buccal uprighting in the lower arch is indicated
for stability (Fig 14).
Evaluating the original cuspid position and
the curve of Wilson in the lower arch is important in determining the correct lower archform.
By the finishing stage of treatment, the lower
archform should be accurately established in the
rectangular archform. The upper archwire
should be accurately coordinated with the lower,
and should be approximately 3 mm wider than
the lower archwire in all dimensions (Fig 15).
Minor widening of the upper wire posteriorly is
recommended for cases with a relatively narrow
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Figure 11. Case in which tedious wire bending was being performed in the finishing stages of treatment, due
to incorrect bracket placement. Numerous visits were required in this effort. Bracket repositioning will lead to
rapid completion of treatment with little or no archwire bending.
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Transverse Over-Correction
Cases that show narrowing in the maxilla should
be adequately over-expanded and held in the
expanded position for an extended period of
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Figure 14. Case showing deep overbite, upright incisors, and a lower arch that is inclined in lingually (a deep
curve of Wilson). Nonextraction treatment was performed with slight advancement and buccal uprighting of the
lower arch.
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Correction of Habits
Approximately 70% to 80% of tongue thrusting
and tongue posturing habits will be corrected
before the finishing stages of treatment. This is
for two main reasons:
Dynamic Considerations
Establishing Centric Relation, Checking
Functional Movements and Reviewing TMJ
Needs
It is important to evaluate orthodontic cases in
centric relation at the beginning of treatment,
monitor this position throughout treatment,
and re-evaluate mandibular position as the finishing stage of treatment commences. Patients
with occlusion in a Class I position and with the
condyles in centric relation can then be checked
for interference during protrusive and lateral
excursions. If the patient has a history of clenching, TMJ sounds or muscle dysfunction, it may
Severe problems can be referred to the myofunctional therapist when the patient is first examined. With minimal to moderate problems, if
the habit is not under control by the time rectangular stainless steel wires are placed, then a
referral for myofunctional therapy is appropriate. In addition, it may be beneficial to consider
the use of tongue spurs (Fig 16). While these
may be considered to be a bit barbaric by some
(these authors included!), the patient adjusts to
them within 24 to 48 hours with little difficulty,
and they do serve as a reminder for correct
tongue position. They can be used in conjunction with basic myofunctional therapy instructions, which include:
Placement of the tongue in the neutral position on the palate, away from the incisors;
Lips together; and
Muscle strengthening exercises, including bilateral chewing with lips together.
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Figure 16. Tongue spurs can be used in conjunction with myofunctional therapy for patients with persistent
tongue habits. These consist of 4 to 5 spurs soldered to a lingual arch and extending approximately 2 to 3 mm
above the lower incisors and just behind the upper incisors. No contact should occur with the upper incisors or
palatal tissues. These spurs can be left in place for three or four months and gradually reduced in length.
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Figure 17. With the patient in natural head posture, a vertical line through subnasale is constructed. This line
is referred to as the true vertical line in the Arnett analysis. The normal male values for upper lip, lower lip and
pogonion are shown. The normal values for upper and lower incisor torque relative to the maxillary and
mandibular occlusal plane are also shown (A). Many Class III cases show adequate facial balance despite their
high angle and dental compensation, because they have long mandibles (B).
Figure 18. Class II/2 cases often show adequate facial balance, because the major upper incisor movement
involves torque rather than retraction. Therefore, the upper lip is not significantly affected (A). Class II/1 cases
can show poor facial balance if treated orthodontically alone, because of excessive retraction of the upper
incisors. These are diagnostically very challenging cases. The Arnett analysis is able to predict when significant
facial imbalance will occur if only treated orthodontically (B).
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Figure 20. If palatal expansion was performed, a small removable palatal plate, with 0.018 wires extending
interproximally in the gingival areas, can be used to maintain expansion during the settling phase.
References
1. Andrews LF. Straight wirethe concept and the appliance, in Valleau J, Olfe JT (eds): Straight Wire. Wells
Co., LA: 1989, p 385.
2. Andrews LF. Straight wirethe concept and the appliance, in Valleau J, Olfe JT (eds): Straight Wire. Wells
Co., LA: 1989, pp 32-33.
3. American Board of Orthodontics. Objective grading system for dental casts and panoramic radiographs. Am J
Orthod 1998;114:589-599.
4. McLaughlin RP, Bennett JC, Trevisi HJ. Systemized
Orthodontic Treatment Mechanics. London: Mosby
(ISBN 072343171X), 2001, pp 4, 6, 281.
5. Roth RH. The straight-wire appliance 17 years later.
J Clin Orthod 1987;21:632-642.
6. Bolton WA. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. Angle
Orthod 1958;28:113-130.
7. Bennett J, McLaughlin RP. Orthodontic Management of
the Dentition with the Preadjusted Appliance. Oxford:
8.
9.
10.
11.
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13.
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