Comprehensive

Orthodontic
Treatment
 Introduction
Comprehensive Treatment

Involves controlled application of forces on teeth and

periodontium.

These forces are generated by the activation of wires,

springs and elastics to produce the desired tooth
movement.
Steps in Comprehensive
Treatment
— Initial Alignment and Leveling
— Correction of Torque
— Correction of Overbite
— Correction of Overjet
— Space Closure
— Finishing
— Debond
— Retention
 Insertion of Orthodontic
Appliances
— After comprehensive assessment and treatment planning, the
client is booked for their bonding appointment
— The insertion of bands, brackets, appliances and wires per
orthodontist’s treatment plan
— Treatment notes indicate bonding heights (for open or deep
bite), teeth to omit, tips or torque to observe, coil, ligation
instruction...
— Initial wires are inserted and ligated, OB/OJ measured and
recorded, initial OH recorded, hard tissue observations
— Appliance reviewed, OH is reviewed and demonstrated
— Client returns for routine adjustment appointments in 2 – 10
weeks intervals depending on the treatment requirements
 Types of Brackets
• Many companies manufacture brackets
• Many different types of brackets available
• Be familiar with the brackets being used in your practice
• There are some common elements amongst all brackets
• Lower anteriors are usually universal – same bracket
is used on all 4 lower anterior teeth – the gingival
portion of the base is usually narrower or rounded
• Most cuspid brackets have hooks on the distal
gingival wing
• All brackets have a marking on the distal gingival
wing – either a colored dot or engraved mark – to
indicate the distal gingival wing
• Most upper first and second bicuspid brackets are
interchangeable
Metal Brackets Ceramic Brackets

Lingual Brackets Self Ligating Brackets

 Initial Archwires

• After banding and bonding is completed an initial arch wire is placed.

• It can be a sectional wire or a full wire. Not all teeth have to be
engaged
• Treatment always starts with a very light round wire, this starts the
process of tooth movement.
 Alignment and Leveling
• Initial gross movement of teeth into a nice arch shape.
• Progression from an initial thin round, flexible wire to progressively
thicker, less flexible wires.
• Correction of heights, tips and rotations occur at this stage.
Rotation Correction
Tying in archwires into a rotated tooth will allow for rotation correction to
be expressed.

• Once initial alignment

begins, rotation errors
become more apparent.
• Repositioning after initial
alignment is more efficient
than placing archwire Lateral too distal Bicuspid brackets
and cuspid too too distal
bends.
mesial
Tip correction
Initial wires will start correction of tips on teeth.
After initial alignment, if there is an obvious error in bracket placement, it
is easier to reposition than to place a bend in archwire.

Upper Centrals with

brackets placed incorrectly
– tip is not corrected.

It is important that archwires are left in place long enough

to achieve the correction required.
If removed too soon, the tips will not be corrected
especially on teeth with longer roots.
Leveling
Correcting the vertical height of teeth so that they align properly.

It is at this stage that bracket height errors become apparent.

Height on bicuspid too gingival.

Repositioning bracket will be easier
than placing a bend in archwire.
Initial archwire placement at the banding and bonding appointment

Alignment and leveling 8 weeks after initial placement

 Archwires
Archwires are made out of various materials and each one is available
in multiple gauges.

Common types used are:

1) Coaxial or Braided Wires

2) Nickel Titanium Wires

3) Stainless Steel Wires

4) TMA or Beta Wires

Each type of wire comes in various sizes and shapes to accommodate

all common arch forms.
 Archform

OVOID SQUARE TAPERED

Archform is predetermined by the client’s study model.
Archform is based on anatomic dimensions and the
craniofacial skeleton.
Orthodontic treatment is more stable if the original archform and
width is maintained throughout treatment.
 Archwire Properties
Coaxial Archwires
§Very flexible wires
§Stainless steel strands either twisted
together or twisted over a core wire
§Provides light continuous forces
§Distorts easily

Braided Archwires
§Very flexible wires.
§Usually 8 strands of wire braided and
compressed into a rectangular form
§Resists distortion more than coaxial
Nickel Titanium Archwires
§Very elastic wires with built in
memory
§Manufactured in preformed
upper and lower arch shape
§Cannot be bent
§Available in a large range of
gauges
§Provides consistent continuous
force
§Does not distort easily
§Ideal for initial alignment and
leveling
Stainless Steel Archwires
§No elasticity to wires
§Manufactured in preformed upper
and lower arch shape
§Available in a large range of gauges
but the thicker the wire the less
flexibility
§Can place bends in wire
§The heavier gauge wires do not
distort easily
§Used for latter stages of treatment,
especially space closure
 TMA or Beta Archwires
§Manufactured in preformed upper and lower arch shape
§Available in a large range of gauges
§Can place bends in wire
§Much stronger than stainless steel yet more flexible
§Used as a finishing wire

Types of wires used and sequence in placing the wires

– is orthodontist specific.
Each orthodontist will have his/her own wire selection
preference.
Different stages of treatment will require different wires
 Curve of Spee
The curve of Spee was described by F. Graf von Spee in 1890
Today, in orthodontics, the curve of Spee refers to the arc of a curved
plane that follows the incisal edges and the buccal cusp tips of the
mandibular dentition
Suggested that the curve of Spee has a biomechanical function during
food processing by increasing the crush/shear ratio between the
posterior teeth and the efficiency of occlusal forces during mastication

Curve of Spee
Curve formed by drawing a line
through the occlusal contact
from posterior to anterior teeth
Could be slightly convex or
relatively straight depending on
the overbite.
 Correction of Bite
• Deep bites and open bites are corrected after initial alignment and
leveling is done
• Exaggerated curve of Spee is frequently observed in dental
malocclusions with deep overbites
• Curve of Spee needs to be corrected first before retraction can begin.

https://www.youtube.com/watch?
v=W84KFJVR1IU&pp=ygUlZXhwbGFpbiBjdXJ2ZSBvZiBzcGVlIGluIG9ydG
hvZG9udGljcw%3D%3D

Kumar, K. P., & Tamizharasi, S. (2012). Significance of curve of Spee: An orthodontic review. Journal of pharmacy & bioallied sciences, 4(Suppl 2), S323–S328. https://doi.org/
10.4103/0975-7406.100287
Steep curve of Spee
Occurs when there is a deep anterior bite
or an open bite
-Occlusal Plane is not relatively flat
more steep in anterior and posterior areas
-Thicker wires will help to flatten the
occlusal plane
-Adding opposite curve to the wire helps
level the occlusal plane

Reverse Curve of Spee (RCS) https://youtu.be/1Lf9VAePIJw

- used on the mandibular arch
- The wire will intrude the mandibular
middle posterior area

- The anterior and posterior segments are

intruded
Curve Of Spee Also Implicated In Open Bite Cases

Accentuated Curve of Spee (ACS)

- wire will intrude the maxillary middle

posterior area

- The anterior and posterior segments are

extruded

This will reduce the anterior Open Bite

 How To Correct Overbite?
Needs to be a combination of intruding and extruding the anterior
and posterior segments.
For deep bites – extrude middle, intrude anterior and posterior
For open bites – intrude middle, extrude anterior and posterior
 Turbos or Occlusal Wedges
Sometimes brackets cannot be placed when there is a deep bite.
In these cases bonding an occlusal wedge or turbo helps to open the bite
to allow for bonding of all brackets.

Posterior Turbos
Use a colored adhesive like BandLok and
bond it to the occlusal surface of the lower or
upper molars.

Anterior Turbos
Use a colored adhesive like BandLok or a tooth
colored resin and bond it to the lingual surface
of the upper centrals.

As bite improves in posterior, turbos can be reduced and eventually removed.

 Overjet Correction
Goal is to achieve a normal overjet and Class I molar relationship.
Overjet correction involves retraction of upper anterior segment or
correction of torque of upper anterior segment.

Anteroposterior correction focuses on

1) the position of upper anteriors in
relation to lower anteriors
2) the upper and lower cuspid
relationship
3) the upper and lower molar relationship

The ideal result of orthodontic treatment

is Class I Molar and Cuspid with normal
overjet and overbite.
Intraoral elastics
Flexible elastics that are attached
from one tooth or segment or arch
to another.
Elastics are available in non latex and vinyl.
They come in various thicknesses and diameters.
Also available in neutral colour or an assortment of colours.

They are categorized depending on their purpose, location and orientation.

Class I Elastics
Also known as intramaxillary
elastics.
Elastic traction between teeth or
groups of teeth in the same arch.
Useful in assisting with minimal
space closure.
Class II Elastics
Intermaxillary elastics that connect from an
upper anterior tooth to a lower posterior tooth.

Can be used unilaterally or bilaterally.

Used to aid in Class II correction and to

reduce overjet while assisting with
intermaxillary anchorage during maxillary
anterior retraction.
Class III Elastics
Intermaxillary elastics that connect from an
upper posterior tooth to a lower anterior tooth.

Can be used unilaterally or bilaterally.

Used to aid in Class III anterior correction,
anterior crossbite correction, maxillary posterior
protraction and assisting with intermaxillary
anchorage during mandibular anterior retraction.
Triangular Elastics
Anterior Box Elastics

Various types of Vertical elastics

Posterior Box Elastics
Intermaxillary elastics used for extrusion of
various teeth. Connects from one or more of
the upper teeth to one or more of the lower
teeth.

Can be used unilaterally or bilaterally.

Used to improve interdigitation of teeth in the
final stages of active treatment.
 Torque Correction
ØType of activation that is placed on a rectangular wire
ØIntended to add movement of the root of the tooth or teeth either in a
labiolingual or buccolingual direction
ØTorque usually does not affect much movement on the crown

Cuspid root too Cuspid root at correct

Rectangular wire with torque
mesial, central inclination and lateral
added. Wire will need to be
and lateral too and central with slight
held and twisted slightly prior
upright lingual root inclination
to insertion.
When tying in an archwire, the crown of the
lower left lateral will move labially first.

Once the crown has positioned itself labially,

the root will start to align itself but still tends to
remain slightly lingual.

Red line - position of the crown in relation to the

root after initial alignment.

In order to achieve proper and stable correction

of the lateral, buccal root torque needs to be
added to the rectangular wire.

Green line - position of the crown in relation to

the root after torque adjustment in final stages
of active treatment.
 Space Closure
Normally refers to extraction cases, although space closure is sometimes
needed in non extraction cases.
Bilateral bicuspid extraction = 7mm of space in each quadrant

Benefits of extractions:
1) relief of anterior
crowding which will
achieve a stable alignment
of the dentition

2) retraction of upper
anterior teeth to
correct the overjet
 3) retraction of lower
anterior teeth to assist in
correction of Class III
cases

4) retraction of upper
and lower incisors to
improve facial aesthetics

5) mesial movement of molars facilitating room for wisdom teeth

 Methods of Space Closure
Space closure needs to be accomplished with anchorage balance.
Closure of extraction spaces is not considered complete until root
alignment is accomplished as well.

Various types of space closure are available.

Important during space closure

to not put too much pressure on
the crowns of the teeth.
If force is too strong on the
crown the teeth will tip towards
each other and result in
excessive root tip.
With any type of space closure, there will be a certain amount of friction
working against the space closure force.

Friction
A force resisting the relative displacement of two contacting bodies, in a
direction tangent to the plane of contact. A portion of the mechanical
energy intended for the movement of the two bodies is dissipated as
thermal energy. (Daskalogiannakis)
Goal: involves the movement of teeth along an archwire with as little
friction as possible.

Different ties and different wires produce different levels of friction.

Elastic ligature > friction than steel tie.
Elastometric chain > friction than elastometric thread
1) Elastometric chains

vAvailable in many colours and different sizes

Closed chain
vCut desired number of units of the chain
vIf there is a large space a loop can be skipped
in between 2 brackets (photo A)
Narrow or open chain
vElastic is stretched over one bracket at a time
starting at one side of the mouth and finishing at
the opposite side
vThe terminal tooth needs to be tied in with a
steel ligature, if it is not a band, prior to inserting
the chain (photo B)
A

Since the elastic chain is tied directly over

the brackets individually, it will add a
certain amount of friction to the archwire.

B
2) Active lace back wires
Use of a stainless steel ligature tie passively tied from molar to cuspid will
start the initial alignment of the root of the cuspid.

vHook ligature tie over the gingival

hook on the terminal tooth (either the
1st or 2nd molar)
vTwist the tie a couple of turns tight
onto the hook
vFigure 8 the tie around the bracket on
the next tooth and continue to the
cuspid
vUsing the hemostat, twist the ends of
the ligature tie tight, cut off end and
tuck in pigtail
vInsert archwire overtop and ligate
3) Closing coils
Nickel Titanium spring made of fine orthodontic wire wound into a tight coil.
Coil springs are used to generate forces for retraction of teeth or space
closure.

B A B A

vHook one eyelet over the hook on the terminal tooth - A (the hook will
need to be crimped slightly)
vStretch the eyelet and hook the opposite end (B) onto the hook of an
anterior bracket or the hook on the archwire
vA lace tie can be attached to the anterior end of the eyelet and tied
around the anterior bracket - this way it can be reactivated at subsequent
appointments.
4) Posted archwires
Stainless steel archwires that are ideal for space closure.
Pre welded posts on archwire usually distal to the laterals. Are available in
a variety of sizes based on the distance between the right and left lateral.

The brass posts are soldered onto the

archwire. Once inserted the posts are
bent into a ‘L’ shape for elastics insertion.

An elastometric thread or a
section of an elastometric
chain is tied from the terminal
tooth to the brass post on the
archwire.

This type of space closure adds minimal friction to the archwire

thereby allowing the teeth to slide along the archwire and the spaces
to close.
5) Closing loop archwires
Archwires with specific loops built in or added in that, once activated,
generate a force in the direction of the activation.
These loops come in many different designs.

L Loop T Loop Teardrop Loop

In their passive state, they do not cause any additional force. Once the
archwire is inserted past the terminal tooth and cinched tight, the loop is
opened and starts to generate the force that has been activated.
 Finishing and Detailing
During this last phase of orthodontic treatment, the focus is on ensuring
that the initial goals of treatment are met.
A new panorex is taken usually 6 months before the braces are removed
in order to re-evaluate the positions of the roots of all of the teeth.
The client is accessed for the following:
1) Does the musculature look relaxed or is there some strain?
2) Is the occlusion stable? (Class I preferred)
3) Are there ideal functional movements?
4) Do the midlines coincide?
5) Have the best aesthetics been achieved?
6) Is the occlusal plane relatively flat?
 What is finishing?
The final stage of fixed appliance orthodontic treatment, during which final
detailing takes place to idealize individual tooth position. (Daskalogiannakis)

Each tooth is examined – new problem are documented, and further

treatment is prescribed related to making the needed corrections.
At the end of treatment, adjustments to the wires may need to be made in
order to move specific teeth to their ideal position.
This is attained by making specific bends in the wires to make these minor
adjustments.

These bends are classified as first, second and third order bends.
 First Order Position
ØLabiolingual position of a tooth in relation to the other teeth in the
arch or vertical position of a tooth in relation to the other teeth in the
arch
If there are discrepancies, a first order bend can be placed in the final wire.
Simple in out bends either labial/buccal - lingual/palatal or occlusal/incisal –
gingival are made on the archwire with a Bird Beak plier

Step in bend on #12

Step up bend
on #45
 Second Order Position

ØPosition of the tooth angulation mesial-distal

If there are discrepancies, a second order bend can be placed in the final
archwire to correct the position.
Tip bends either mesial root/distal crown tip or distal root/mesial crown tip

Upper left lateral with correct tip

Upper right lateral with incorrect tip
(purple)
Correct position for root of upper right
lateral (green)

1 - step down on distal side of the tooth

2- step up on mesial side of the tooth
1 2
 Third Order Position

ØPosition of the tooth in the alveolar process

If there are discrepancies, a third order bend can be placed in the final
archwire to correct the position.
Torque bends either buccal root/lingual crown torque or lingual root/buccal
crown torque
Red lines - incorrect torque on centrals. Upper central too
labial and lower central too lingual
Green lines - correct torque on centrals.

Cross section of wire with torque added

to the section of wire
 Debonding
Once the teeth are all correctly aligned, it is time to debond!!!

When braces are off, the patient enters the retention phase of treatment.
‘The phase following active orthodontic treatment, aimed at stabilization
of the achieved orthodontic correction.’ (Daskalogiannakis)
• The teeth, gingiva and periodontal ligaments need time to
reorganize
• Fixed and removable retainers have been pre-determined by the
orthodontist in consultation with client needs.
• Options exist for removable retainers, they are typically worn at
nights only.
• Clients are advised to never discontinue retainer wear in an attempt
to reduce potential for relapse.
 The gingival fibers tend to cause slight relapse in the teeth.
At times a fibrotomy or frenectomy may be recommended. This usually
happens when the teeth were initially rotated or if there was a diastema.

Frenectomy
- recommended when there is a tight frenum
- important to do frenectomy only after space has been closed

Circumferential Supracrestal Fibrotomy

- involves severing gingival and transseptal fibers around the
tooth
- helps to reduce the rotation relapse tendency.
- fibers will automatically reconnect to new dental position.
 At The End Of Treatment
The Goals Are:
• good functional occlusion
• cuspid protection
• incisal guidance
• no posterior interferences
• good overbite and overjet
• good interdental contacts between the teeth
• good alignment of all the teeth

And a happy and satisfied client and/or parent!!!

Everyone
smiles
at
their
debond!!!!
 Risks of Orthodontic
Treatment
• Tissue damage
• Enamel damage: enamel fracture, delamination
• Periodontial concerns: gingival hyperplasia, pseudo pocketing,
bone loss
• Soft tissue damage: a) direct damage by removable or fixed
components (ie mucosal trauma) or b) indirect damage by allergic
reactions to nickel and latex c) iatrogenic damage
• Pulp damage – transient pulp ischemia, pulp death
• Root Damage – root resorption
• Treatment failure: patient non-compliance, incorrect diagnosis,
incorrect management (ie: retention related relapse)
• Greater predisposition to dental disorders: TMJ, periodontal

Ellis, P.E. and Benson, P.E. (2002) Potential Hazards of Orthodontic Treatment – What Your Patient Should Know. Dental Update, 29. pp. 492-496. ISSN
0305-5000
 Relapse
Without retention there is a tendency for the teeth to return to their
initial position.

Littlewood, S. J., Millett, D. T., Doubleday, B., Bearn, D. R., & Worthington, H. V. (2016). Retention procedures for stabilising tooth position after
treatment with orthodontic braces. The Cochrane database of systematic reviews, 2016(1), CD002283. https://doi.org/
10.1002/14651858.CD002283.pub4
 Retention

The passive treatment period following

active orthodontic correction during
which retaining appliances may be
used.
- Daskalogiannakis
The Rationale For Holding The Teeth In
Their Treated Position Is To:

• allow for reorganization of the gingival and

periodontal tissues

• minimize changes due to growth

• permit neuromuscular adaptation to the corrected

tooth position

• maintain teeth in unstable positions (sometimes

necessary due to compromise
or esthetics).
 Retention Options
Retention options include:
• Fixed bonded permanent retainers
• Removable retainers
• Adjunctive procedures
 Fixed Retainers
Engineered wire bonded permanently to the lingual surface of anterior teeth

Coaxial Round

Braided Chain
 Removable Retainers
• Molded thermoplastic: Essix or Vivera style

• Hawley
 Considerations
• Oral hygiene considerations may dictate retention options
• Prosthetic or restorative components of treatment
• Client responsibility/management

Instructions
• Retention is the client’s responsibility!
• Wear instructions
• Eating instructions
• Use of OH aids: floss threaders, sulca brush
• Dish soap and tooth brush
• Caution about soaking and temperature