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www.indiandentalacademy.com 1
METHODS OF GAINING SPACE.
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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Key-stoning procedure- Harry G.Barrer JCO Aug 1975
A. Malposed incisors B. interproximal relationship after key stoning
Rounded surfaces slip and rotate.www.indiandentalacademy.co
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Key-stoning procedure:
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Nonsurgical rapid maxillary alveolar expansion in adults:a clinical evaluation. Chester S. Handelman, Angle Orthodontist, 1997 vol 67
•Late teens and early 20’s questionable.
•Sutures: rigid and fuse.•SA-RME.
Non Surgical Maxillary expansion:Pain, swelling, ulceration, flared posterior teeth, bite opening, gingival recession, and perforation of the buccal alveolus.Vanarsdall: in children, gingival recession and dehiscence of bone
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Haas appliance
• 5 adults with transverse deficiency- treated nonsurgically using Haas appliance.
•RMAE- expansion centered in the alveolar process of maxilla rather than the body.(lateral walls of the palate)
•Bilateral/unilateral crossbites, arch constriction.2 quarter turns/day
Later 1 quarter turn/day U 1 no separation.
12 weeks retention.www.indiandentalacademy.co
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Displaces the alveolus with the teeth rather than expanding the teeth through
the alveolus.
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bilateral
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Unilateral crossbite –
left
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RMAE acceptable alternative to SA-RME in adults for maxi deficiency.www.indiandentalacademy.co
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Nickel-Titanium Palatal expander.
2 properties: Shape memory & superelasticity.
Exists in more than 1 crystal structure.
Lower temp-martensite. Transition temp:94degree
Higher temp-austenite {phase transition}
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MOLAR DISTALIZATION
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Indications for Molar distalization
1. In a growing child
- to relieve mild crowding
- causes permanent increase in arch length of about 2mm on each side.
2. Late mixed dentition- When lower E space –utilized for relief of
anterior crowding,- Upper molars distalized to get a class I
relationwww.indiandentalacademy.co
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Indications for Molar distalization
3. Non-growing patient
- To regain lost arch length
- Blocking out of canines
4. Upper second molar extraction
- Lower arch normal
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Indications for Molar distalization
Class I malocclusion- with highly placed canine/impacted canine
Lack of space for eruption of premolars due to mesial migration of permanent first molars
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Indications for Molar distalization
Good soft tissue profile
Borderline cases
Mild to moderate space discrepancy with missing
3rd molars/2nd molars not yet erupted
End on molar relation with mild to moderate
space requirement.
Cases with less than full cusp class II molar relation.
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Case selection1. Normal or near normal mandibular arch
2. Late mixed dentition-ideal
- Early permanent dentition-growth still left in maxillary tuberosity area.- 16-17 yrs-males
14-15 yrs-females
3. Molars placed normally- buccopalatally.
4. 3rd molars-absent –stacking of upper molars – unsuitable
5. Profile considerations- well developed nose & chin
6. High MPA- contraindicated-wedging effectwww.indiandentalacademy.com
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Classification1. Location of appliance
Extra-oral Intra-oral
2. Position of appliance in mouth Buccal Palatal
3. Type of tooth movement Bodily movement Tipping movementwww.indiandentalacademy.co
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Classification4. Compliance needed from patient
Maximum compliance Minimum or No compliance
5. Type of appliance
Removable Fixed
6. Arches involvedIntra-archInter-arch www.indiandentalacademy.co
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Various appliances used for Molar Distalization :
Head gears Pendulum appliance. Coil springs Niti and S.Steel Distal jet K loop Jones Jig Magnet Wilson’s Bimetric loop Use of super elastic NiTi Franzulum appliance.
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Various appliances used for Molar Distalization
ACCO Crozat appliance Crickett appliance Modified Nance lingual appliance Schmuth and Muller double plates Claspring Removable molar distalization splint Fixed piston appliance Using implants Fixed functional appliance
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Distalization using Headgears
Very efficient Reciprocal forces are not transmitted to other teeth Molar movements depends on direction of force in relation to
the C Res of the molar & magnitude of force
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Biomechanics of Headgears:
C Res Moments
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Cervical Headgear Short face Class II
maxillary protrusive cases with low MPA & Deepbites
Extrusive & distalizing effect
Lower anterior facial height is less.
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High pull Headgear Produces intrusive &
Posterior direction of pull
Long face class II patients with high MPA
Force through C Res – Intrusion & distal movement of molar
6-8 months – class II-class I
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Straight pull headgear Class II Malocclusion with
no vertical problems Prevent anterior
migration of maxillary teeth, translate them posteriorly
Adv-effective, no reciprocal forces
Disadv- Patient compliancewww.indiandentalacademy.com
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Modification of the Bimetric arch
Class II correction- Distalization + expands
canine-premolar area- unlocks the occlusion
A mild-moderate class II div 2 with normal
mandibular arch-easily corrected
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Modification of the Bimetric archArchwire design: .016”premium wire Premolars bonded if
expansion is required
Teardrop shaped loop
Bite opening bend Mild toe-in 2mm activation
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Elastic load reduction principle: Class II elastics – used sequentially
T.P Green – 1st week
Pink - 2nd week
Yellow – next 2-3 weeks Initial heavy force- to resist forward
pushing force of new wire- force transferred distally
Later Molar uprights-mesially directed archwire force decreases- support with light forces.
Extrusive component of class II- kept to a minimum
1mm/month.wire activated for 3 visits.
Borderline cases –Non Ext
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K-Loop molar distalizing appliance Valrun Kalra – JCO 1995
K-loop – forces - .017 x .025 TMA Nance button – anchorage 8mm long , 1.5 mm wide Legs- 20 degree bend Inserted into molar and first
premolar tube, marked Stops bent 1mm distal , 1mm
mesial Stops- 1.5mm long
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Reactivated by 2mm 6-8 weeks later. molars move by 4mm, premolars by 1mm Anchorage can be reinforced by headgear
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K- loop Appliance
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Distalization of Molars with Repelling Magnets Gianelley etal JCO 1988
Anchorage – Modified Nance appliance
Wire extending from 1st premolars
Acrylic button anteriorly contacting the incisors
Auxiliary wire with a loop at its end soldered - premolars bands
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Distalization of Molars with Repelling Magnets
Incisor brackets – passive sectional wire- maintain incisor alignment
Repelling surfaces of magnets brought into contact by passing an .014 ligature through the loop, then tying back a washer anterior to the magnets
Force- 200-225 gms , dropped as space opened
3mm in 7 weeks Anchor loss – 1mm www.indiandentalacademy.co
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Molar distalization with Superelastic NiTi wire Gianelly JCO 1992
100gm Neosentalloy upper archwire
3 markings Stops crimped, hook added Insert wire such that posterior
stop abuts mesial end of molar tube, anterior stop abuts distal of premolar.Xs wire deflected gi
Anchorage reinforced by class II, or Nance appliance
100gwww.indiandentalacademy.com
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Molar distalization with Superelastic NiTi wire
Case report : 12 yr / F Unilateral class II Class II elastic against
upper 1st premolar Overcorrected- 4 months
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NiTi Double Loop system for simultaneous distalization of first and second molars
Giancotti JCO 1998
Mandibular molars and 2nd premolars banded, other teeth bonded
Lip bumper- prevent extrusion Maxillary molars and bicuspids –
banded, aligned 80 gm Neosentalloy – maxillary
archwire placed – marked
1. Distal to 1st premolar
2. 5mm distal to 1st molar tube Stops crimped on markings
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NiTi Double Loop system for simultaneous distalization of first and second molars
2 Sectional NiTi archwires – crimp stops
1. Mesial and distal to 2nd premolar
2. 5mm distal to 2nd molar tube
Uprighting springs on 1st bicuspids
Class II elastics Simultaneous, bodily
movement www.indiandentalacademy.com
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24yr/f, class II div I
5months- overcorrectedwww.indiandentalacademy.co
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NiTi Double Loop system for simultaneous distalization of first and second molars
Useful technique – Class II div I
Minimal patient co-operation
Ideal for simultaneous distalization U7 easier ‘.’ anatomy.
Due to stretching of transeptal fibers, 1st molars can be distalized using
lighter 80 gm force
Anchorage easily controlled , without need for TPA/Nance’.’light forces
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NiTi Open Coil Springs
Dia 0.012”
Lumen 0.030
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Pendulum Appliance for class II non- compliance therapy
JAMES J.HILGERS,JCO 1992
Nance button for anchorage
.032” sTMA springs-light continuous forces
Broad swinging arc (Pendulum) of force from midline of palate to upper molars
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Pendulum Appliance
Fabrication :Pendulum
springs consist Recurved molar insertion
wire1. Horizontal adjustment
loop2. Closed helix3. Loop for retention in
acrylic button Springs- close to center
of Nance buttonwww.indiandentalacademy.co
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Springs close to center of palatal button:to maxi range
of action, easy insertion.
Retaining wire is soldered to the U4 and extended into
acrylic.
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Pendulum Appliance Nance button- extend to about 5mm
from teeth Anterior retention loops fixed on
model, later soldered to bicuspid bands
Acrylic pressed against the palatal vault
Pendulum springs inserted
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Pendulum Appliance
Pend-XExpansion needed:Jack-screw-One-quarter turn
every 3 days
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Pre activation and placement
After cementation,before activation:
Springs prefabricated to lie parallel to midsagittal plane,
Which produces 60* of activation after insertion.
As the molar distalizes it moves on an arc towards midline-counteracted by opening horizontal loop
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Intra oral reactivation:
Center of helix held with bird beak plier while, spring is pushed distally & reinsert.
Stabilization:•Nance button
•Upper utility arch- anterior segment- anchorage.
•Full arch bonding:continuous wire with omega loop.
•Head gears ?www.indiandentalacademy.co
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Pendulum Appliance Unilateral correction
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Pendulum ApplianceConclusion : Excellent patient tolerance Upto 5mm distalization in 4 months Distalization + Expansion Patient compliance not needed
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Franzulum applianceFriedrich Byloff et al JCO2000
sep Anterior anchorage : acrylic
button-5mm wide
Rests on canine and premolars - .032”S.Steel wire
Tube from acrylic button to receive active component
NiTi coil springs-100-200g/side
J-shaped wire inserted into tube
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Franzulum appliance:
Niti spring over J shaped wire
Inserted into tube of anterior anchorage unit
Tied into lingual sheath
•Anchor unit bonded with composite.
•Close to CR of molar-pure bodily movement.
compressedwww.indiandentalacademy.com
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Case report 11yrs 10mts / M
end on molar relationship Space deficiency in both the
arches Premolars blocked out Fixed appliance with cervical
headgear and Cl II elastics End of treatment; Class I molar
relation, no significant change in facial profile
U6:3mm,L6:6mm Lower incisors proclined. Extrusion of U&L 6
Long term stability????www.indiandentalacademy.co
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Distal jet Appliance Aldo Carano, Mauro Testa JCO 1996
Lingual molar distalizing appliance
Appliance design : Wire extending from acrylic
through tube ends in a bayonet bend-inserted into lingual sheath
Coil spring clamped on tube Clamp Anchor wire to 2nd premolar
.036” int dia
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Distal jet Appliance
Reactivation- sliding clamp
closer to first molar,once a
month.
After distalization –
- clamp-spring assembly-
acrylic,
- premolar arms cut off.www.indiandentalacademy.co
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Distal jet ApplianceCase report 18/F, Class II div I No skeletal abnormalities Non-extraction therapy (3rd
molars removed) Distal jet 4 months- Class I ,2mm-L, 3mm-R
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Distal jet ApplianceAdvantages : Bodily movement Easy insertion Well tolerated Esthetic Unilateral, Bilateral Permits simultaneous use of full bonded
appliances.
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Open Coil JigJones, White –JCO 1992
Oct
NiTi springs 70-75g
Nance button attached to U5
Assembly tied in place
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1. Heavy round wire
2. Light wire
3. Fixed Sheath
4. Hook
5. Sliding Sheath
6. Open coil spring
4-5mm of distal movement.
3
1
2
5 6 4
Open Coil Jig
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Conclusion Borderline cases Space gaining procedures Simplicity Clinical effectiveness Patient compliance factor
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Distraction Osteogenesis: New bone formation b/w the surfaces of bone
segments gradually separated by incremental traction.
Tension-stimulates new bone parallel to vector of distraction.
tension in surrounding soft tissues, initiating a sequence of adaptive changes termed as distraction histogenesis.
Skin, fascia, bl vessels, nerves, muscles, cartilage, periosteum.
Illizarov.www.indiandentalacademy.co
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Mandibular Sympyseal distraction.
Mandibular symphyseal distraction- space gaining. Intra oral mandibular distraction device. More stable results. Corticotomy. Latent period.5-7days.(fibro vascular bridge) Activation.optimum rate: 1mm/day(0.5mm-premature
ossification,2mm-fibrous CT , ischemia) Consolidation (remodeling) concomitant soft tissue
expansion. Retention.
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Thank you
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