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Fixed Appliances
Today we will talk about fixed appliances, last time we talked about removable appliances, now before starting discussion, let's know the benefits and risks of these appliances.
So, malalignment of teeth will make it difficult to brush, and more susceptibility to dental caries and periodontal problems. But, is it true in reality according to studies? NO! Because teeth brushing and oral hygiene depends on patients attitude towards oral hygiene, many patients are with well aligned teeth but with very poor oral hygiene, and many patients with malaligned teeth but with good oral hygiene. So, in theory, well aligned teeth will be easier to clean, but very little evidence showed that well aligned teeth will suffer less pathology. Now what are the risks on the other hand? Decalcification/demineralization which is the earliest stage of dental caries, and then they may develop caries. As a result of excess tooth movement or heavy forces to the tooth from appliances, they may get root resorption. If you move teeth outside of neutral zone, you may get periodontal problem by gingival recession. Also, any orthodontic movement is susceptible to relapse. If the patient doesnt wear retainers. That is why we ask our patient to wear retainers to prevent relapse. Also it may interfere with medical problems, if the patient has very serious medical problem unless it is under control and the patient is aware of it.
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This is decalcification (whiting or white spot lesions) after wearing orthodontic appliances; in severe cases it may develop cavitations which is caries. It is around the bracket.
Mode of action
Now, what is the mode of action? In case of removable appliances, when you give single forces through the active component, you will get tipping movement. But in case of fixed appliances, you give mechanical forces couple to crown which can achieve bodily movement, (Couple it means 2 points not single point), so it's not single contact (which results in tipping). In conjunction with single force it can achieve rotation, apical and bodily movement.
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Inability to remove the appliance: if the patient is incomplainant and every time you give him a removable appliance, the patient doesnt wear it, you can use fixed so the patient can't remove it. Essential in lower arch: because it inconvenient to use removable appliances in the lower arch because of the tongue, it will cause discomfort and it won't be as retentive as in the upper arch.
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Brackets: which is bonded on labial and buccal surface of teeth, but nowadays there is lingual brackets. Bracket material could be stainless steel, plastic or ceramic.
base
tie-wings
slot (Ceramic and plastic are esthetic brackets because they are tooth colored). Archwire: to move teeth, in orthodontics there are many types, but mainly we use nickel titanium and stainless steel, in the past we used to use gold archwires.
- Auxiliaries: anything that you use to hold archwire, apply force, open spaces or whatever. The material is ligatures or elastics.
The Archwire moves the teeth and the brackets tell (guide) the archwire where the teeth must move. So the arch wire will be in brackets' slot, when the Archwire is deflected it will try to go back to its original position (because it's elastic), so it will move the teeth with it until the wire is fixed in the bracket slots then the archwire will stop moving the teeth.
Brackets:
It is rectangular in shape, thats why it is a couple force applications, it has three components: Horizontal slot (bracket slot): where the archwire fits. Tie-wings: gingival and occlusal, to which ligature ties are attached to hold the Archwire in place. Bracket base: bonded on the labial surface. It should be rough/mesh type for mechanical retention with the composite resin; you bond these bases to enamel.
Brackets material can be stainless steel, plastic, ceramic or titanium, gold, Co-Cr but usually it's made of stainless steel.
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Plastic bracket tend to stain and distort during treatment. That's why nowadays we don't use plastic bracket. Ceramic bracket usually don't stain but have other disadvantages: Brittle and easily fracture especially the tie wings. Extremely hard and can cause wear of opposing enamel: If you bond the lower teeth with ceramic brackets and they bite on the palatal surfaces of upper incisors they don't break, they'll cause wear of the opposing enamel (abrasion). Increased risk of enamel damage at debonding (taking off the braces) because of high bond strength between ceramic and enamel (it's higher than bonding between metal and enamel). Increased friction: when the tooth moves there will be friction between the archwire and the slot of the bracket, so if there is high friction tooth movement will be slow, the friction with ceramic is higher than with stainless steel, to overcome this problem they made the bracket from ceramic but the slot from metal (e.g. Clarity), still this technique has a disadvantage because the junction between the metal and the ceramic is weak, so it can be easily broken. More expensive than metal brackets.
Sometimes, there is patient with smile zone only shows upper anterior teeth, and they request esthetics brackets, despite the disadvantages of ceramic, you may use them only for the upper anterior teeth and the rest you'll use metal brackets as a combination of both, or we can use ceramic brackets for all teeth, except if we have deep bite, then we can't use ceramic brackets on the lower incisors because the touch the palatal surface of the upper incisors and this will cause tooth wear.
Buccal fixed
palatal fixed
Buccal fixed appliances: most common, advantages of buccal type are: Good access for the orthodontist to work and good access for the patient to clean. Ease of work and reduced working time.
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Excellent finishing and detailing because we can see the buccal and the labial surface directly but for palatal and lingual surface it's difficult to see directly.
The disadvantages are poor esthetics, because it's on the labial side, and if there is caries or decalcification it will be visible. Lingual fixed appliances: advantages of lingual types are good esthetics and if decalcifications develop it will not be visible. Other benefit is good bite opening, when you put bracket on palatal surface, the lower incisors will occlude on the brackets, so it will act as anterior bite plane. So, it's good for bite opening.
Disadvantages are poor access, difficulty in working, reduced interbracket span (it's a disadvantage because the length of the wire will be reduced so there will be less flexibility), increased working time, patient discomfort (the tongue may be traumatized so there will be pain and ulcerations) and poor finishing and detailing.
Slot orientation is horizontal. Slot dimension is 0.022x0.028 to allow control of tooth position in 3 plane spaces. Same bracket or band is applied to every tooth that is why it's called "standard" edgewise. They used to use bands on every tooth in the past, but when we started to use bracket without bands? When composite developed.
Precise control of tooth position and angulations is achieved by placing bends into Archwire. Advantages: the first appliance to allow precise control of tooth position to be achieved relatively simply. Edward angle is the father of orthodontics; he is the first person to be professionally work with orthodontic movement; however Arab talked about orthodontic tooth movement long time before him.
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Disadvantages: Tooth position is dependent on operator's skills to place bends in Archwire, so if you want the canine to have eminence or the incisors to be slightly mesially tipped, you have to achieve this with wire bending, if you have skill to bend the wire, you'll be a good orthodontist, otherwise you'll be a bad one. Wire bending is time consuming in the clinic.
2- Begg appliance:
Described by P.R Begg in 1956: this system tips the teeth first then upright them. Base on the use of light forces and tipping teeth. For example if you extracted U4 and you want to move the canine distally (bodily movement), in standard and pre-ajdusted systems you can move it directly, but in Begg you tip the canine distally first (tilt tooth) then move the root to upright the tooth. Bracket has vertical slot in which Archwire is secured with brass pins. Reduced friction in this system because we use tipping movement.
3- Pre-adjusted edgewise:
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Philosophy based on ideal bracket system and ideal force delivery system (sliding mechanics). Slot size: 0.018x0.028 (working archwire is 0.016x0.022) or 0.022x0.028 (working archwire 0.019x0.025) (the standard was only 0.022x0.28). Prescription: pre-ajdusted is ready for every single tooth. Amount of tip, torque and inout is adjusted already in the bracket; amount of these things differs from system to system. So, this is called prescription, a number of prescriptions are available: Andrew's, Roth's, Alexander, Bennett and McLaughlin. Tip: is the position of the tooth mesio-distally (5 degree or 0 degree for example), in the slide it's called (correct crown angulation). Torque: is the position of the tooth labio-lingually, in the slide it's called (correct crown inclination). In-out: is the position of the tooth in and out (I think it means in the arch and out of it). Note: For tip and torque the Dr used the term "position", I think it's better to use the terms "angulation and inclination" respectively to understand the difference between the torque and the in-out (the in-out is the one which actually describes position, not inclination).
Origin of Straight-Wire (or the preajdusted): introduced in 1972 by Lawrence F Andrews. He defined 6 keys to normal occlusion:1. Molar relationship Class 1: In angle's classification the buccal cusp of U6 should bite in the buccal groove of L6, here it's the same but also the distal cusp of U6 should bite in the embrasure between the L6 and L7. 2. Correct crown angulation (tip). 3. Correct crown inclination (torque). 4. No rotations. 5. Tight interproximal contacts, no spaces. 6. Flat occlusal plane with curve of spee (almost flat).
Advantages (of preajdusted or straight wire): Less wire bending. You dont need to precise bending the wire compared to Standard Edgewise which needs accurate, precise bending. Sliding mechanics allowed: so the bracket and the tooth will slide along the wire. Good finishing.
Disadvantages: Ignores biological variability of the forces, because the size is different between teeth. Now, you are using archwire for all the teeth. So, the same force will be applied to all teeth, Do you think small lateral incisor can receive same forces as big molars? NO, because root surface area of lateral incisor is less than molar. Increased friction hence anchorage consideration.
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Previously they were using multi-stranded stainless steel, these days we use Ni-Ti archwires.
This is the different prescription for every single tooth, each one has different inclination, that's why every single tooth has its own bracket and each bracket has different prescription, to achieve different position for every tooth. 4- Tip-edge:
Has horizontal slot but it's cut from certain areas (triangle from each side) to allow the tooth tipping, so it combines the advantages of preajdusted and Begg appliances as Begg allows tipping, so in Tip-edge you tip the tooth first and then upright it, once it's upright Tip-edge is straight wire appliance again. 5- Self ligating:
How do we ligate the Archwire? In the conventional fixed appliance, we use elastics, so the elastic will keep the archwire touching the base of the bracket, and this produces friction, but in self ligating you don't need elastics because the bracket itself has a door to ligate the wire. The biggest advantage
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of theses brackets is that the treatment time is reduced as the friction is eliminated or reduced. The friction like we talked about, when we bend the Archwire, the friction of Archwire to the slot is increased. So if this is a door, the friction will be decreased. There are many types of self-ligating like Damon, speed and 3m smart clip and others. The Damon bracket is self ligating, meaning it has a built in sliding door that secures the bracket to the wire, this allows the wire to slide through the braces freely (no friction).
Archwires
Now we will go to another component of fixed appliances which is the archwire. They are many type of archwire, but what we use in orthodontics mainly titanium and stainless steel, in the past they used to use gold and cobalt-chromium. There are two types of archwire: 1. Active: Archwire is deflected on tying in to the bracket so that the forces move the teeth. 2. Passive: Archwire is not deflected; the forces are applied by elastics or auxiliary spring. In above case, when the archwire is bended there is deflection, do you think this archwire will apply forces? YES! But when it's straight wire do you think it is active? NO! It is passive archwire to maintain the arch form from getting forces from other directions or something else other than archwire. So when it applies force, it is active, but when it doesnt apply forces, it is passive.
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How stiff the wire is, and what is the range the wire can withstand by deflection before it distorts, these are governed by the proportional limit, yield strength and ultimate tensile strength So this graph represents stress (force) proportional to strain (deflection):
Proportional limit: the point at which the wire starts to deform, the wire will react elastically until proportional limit is reached, where the wire will bend and elasticity doesn't apply. Yield strength: the point at which 0.1% deformation is measured. Ultimate tensile strength: maximum load that archwire can sustain before failure (fracture). Stiffness= 1/springiness. It's the opposite of springiness; springy wire means that its flexibility or elasticity is high, stiff wire means more solid wire. Each value is proportional to the slope of the elastic portion of the force defection curve. The more horizontal the slope the springier the wire. The more vertical the slope the stiffer the wire. Modulus of elasticity (slope). Slope represents the stiffness. Wire with increasing stiffness: NiTi<TMA<SS<Co-Cr (Co-Cr is the stiffest one), what is important to you that stainless steel is stiffer than nickel-titanium. TMA is Titanium molybdenum. Resilience surface area under the stress-strain curve until the proportional limit. It represents energy storage capacity of the wire which is a combination of strength and springiness. Formability: the surface area under the curve from yield strength to fracture point.
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It's the amount of permanent deformation that the wire can withstand before breaking, I.e. deformation without breakage, so if you bend a formable wire it will not go back to it's original position.
Esthetics Archwire
There are esthetic archwire; however we dont like to use them for many reasons These will be either: Coated metal wires: coated stainless steel or Niti. The coating can be a white epoxy resin or Teflon coating. This means the wire itself is metal but it is coated by white material for better esthetics. The disadvantage of metal coated archwire is that with time, it will be worn out and only metal is left without white epoxy resin and Teflon coating. Non-metallic materials: without metal, full composite plastics.
Auxiliaries
It is components other than archwire and bands/bracket. Elastomeric modules: round modules to hold the archwire in the bracket slot (it comes in different colors).
Ligature wire: it has the same function as elastomeric modules. Sometimes we prefer these because the elastomeric is elastic and will not make a 100% accurate movement
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(torque, bodily movement, angulation or anything else) to the teeth, its gauge (the ligature wire) is (0.09 to 0.1).
Coil spring: it is either open or closed. It's open if we want to open the space, and closed if we want to close the space, it's either stainless steel or nickel titanium.
Hooks: either crimpable (it's stretched and attached to the wire), or sliding (moves along the wire).
Elastomeric chain (power chain): to close the spaces. It can be spaced or non-spaced (in spaced there is increased distance between the circles, which can be short or long) it is related to the amount of forces that we need.
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Intermaxillary elastics: Many of our patient wearing intermaxillary elastics between upper and lower teeth to correct the relationship between them. And it's called class II and class III depending on direction of tooth movement that you want. If you have class II canine and molar, and want to change into class I, you have to use class II elastics, from upper canine to lower molar, this elastic (class II) will move the upper anterior backward and lower posterior forward. Next, Class III elastic is from lower canine to upper molar this elastic (class III) will move the upper posterior forward and lower anterior backward.
Class II
Class III
It comes in different size; the force is dependent on the size that we chose, you have to measure the force with force gauge, to make sure, because sometimes when you get it from the company it's written that it gives 4.9 oz (which is around 140 g) but when you measure it, it may not be 140, so ideally you have to make sure before using it.
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Transpalatal arch
Nance appliance
headgear
2. Leveling and aligning: Bracket heights leveled, up righting, rotational correction, labiolingual movement. 3. Overbite control: if it is increased, you need to reduce it. If it is reduced, you need to CONTROL it. We control the overbite before the overjet because sometimes we can't modify the overjet until we open the bite, overbite reduction can be done either by extrusion of buccal segment teeth or by intrusion of incisor teeth. 4. Overjet reduction: by using elastomeric chain or coil spring. It will move the upper anterior teeth back and also it will move the molar forward, unless you hold the molar by using anchorage device. This coil spring is located from anterior to posterior; it can move molar forward and anterior teeth backward. If I need the space and I cannot afford for any 1 mm movement of molar forward, you need to hold the molars by using head gear for example or any anchorage device (normal overjet ~ 3 mm) 5. Space closure: achieved by bodily movement, if there are any residual spaces you have to close them.
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6. Finishing: If there is any minor details to be adjusted; you need to finish it, like the canine relationship and the molar relationship, after this you debonded the appliance. 7. Retention: after debonding, if there is no retention there will be relapse.
THE END
This script is dedicated to my partner M.Husam Droubi, Prince of moisture control.
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