Finishing

By\ Sahar Emad

 contents
1. Introduction.
2. Adjustment Of Individual Tooth.
3. Midline Discrepancies.
4. Tooth Size Discrepancies.
5. Excessive Overbite & Anterior Open Bite.
6. Settling Of Teeth.
7. Special Finishing Procedures To Avoid Relapse
8. Micro-esthetic Procedures In Finishing
 Introduction
 Finishing is the last phase of “active” treatment
1. Levelling and aligning
2. Overbite correction
3. Spaces are closure
4. The final stage of treatment is to get the details correct.
 Heavily dependent upon the previous stages of treatment.
 Itis extremely difficult to achieve an acceptable result when the
treatment objectives and proper mechanics have not been met
2- Adjustment of Individual Tooth Positions
At the finishing stage , Unnecessary if appliance
prescription and bracket positioning were
perfect
But due to the variations in (tooth anatomy and
bracket placement) some tooth position
adjustment may be needed
If bracket is poorly positioned
1. Rebond the bracket
2. Placing compensating bends in arch wires
1- Rebond the bracket
after bracket rebonding, a flexible wire must be
placed to bring the tooth to the correct position.
Arch wires for tooth positioning in finishing stage:
 2- Step Bends
The first order (in-out / rotation )
 Tight interproximal contacts
 No rotations.
 Allowing the perfect arch form.

 Typical first-order bends are : -

- lateral incisors (insets),
- canines (offsets) and
- first molars (bayonet bends, toe in).
The upper first molar
Mesiobuccal cusp makes
mesial out rotation is
considered to be ideal.
the buccal surface of the
upper first molar should
be parallel to the palatal
suture
The second order ( mesio-distal / tipping)

evaluate the root parallelism and marginal

ridges.

1. (Clinically) The marginal ridges

should be at the same level especially
buccal segments.
2. (Radiograph)root parallelism
important for retention and stability.
 Radiographic Objectives

Panoramic Radiograph
 Recommended before starting the finishing
stage
1. To evaluate root position and root
parallelism.
2. Evaluating root resorption If observed,
that might dictate ending treatment early
or taking a break from the final active
treatment for 3 to 4 months to allow
cementum to heal.
 Problems of second-order
angulation are commonly
found in
1. the upper lateral incisors
2. lower premolars
3. teeth adjacent to the
extraction sites.
 Problems might be related to
1. abnormal tooth morphology
2. bracketing errors
Applications of second order bend:
During space closure phase the goal is to achieve bodily tooth
movement and preventing the crowns from tipping toward each
other.
In case of a small amount of tipping will occur after space
closure
some degree of root paralleling at extraction
sites often will be necessary.
In case of improper bracket positioning
root separation or paralleling may be needed in non extraction
cases (this is most likely on maxillary lateral incisors and
premolars).
In standard
edgewise brackets
Similar to begg
and tip edge
technique That
use springs For
controlling root
tipping
In standard edgewise brackets
may includes a vertical slot
behind the edgewise bracket
allows root tipping using
springs that inserted and
hooked beneath the main
st.st. arch wire.
In preadjusted edgewise brackets
No Uprighting springs and
vertical slots
Angulated bracket slots that
allow proper root paralleling
when a flexible full-dimension
rectangular wire is placed.
With the 18-slot appliance
To correct mild tipping
finishing arch wire is (17 × 22 or 17 × 25) st.st. which
is produce the necessary root paralleling moments.
To correct greater degree of tipping
more flexible rectangular arch wire is needed.
To correct more severe tipping
17 × 25 beta-Ti (TMA)
17 × 25 nickel–titanium (M-NiTi)
With 22-slot brackets
 if teeth have tipped even slightly into an extraction space or if
other root-positioning is needed
Under most circumstances
 21 × 25 beta-Ti wire
if significant root position­ing is needed
 21 × 25 M-NiTi should be used first.
If greater range of action is needed (severely tipped tooth)
A-NiTi wire initially, then M-NiTi.

We can’t use for tipping

 19 × 25 st.st. ( too stiff )
Root parallelism is important for three reasons:
1. To transmit occlusal load of the forces across the
longitudinal axis of the tooth.
2. A greater potential for relapse If only the crown
has been tipped and the root is not in its proper
position.
3. A greater potential for periodontal problems due
to root proximity.
The third order (labiolingual – torque)
 Affect

1. The esthetics of the smile (an extraoral category).

2. The inter-arch objectives (the occlusal relationship)
Are difficult and time consuming as it need extensive bone
remodeling
The third order
Controlling third order can be done by
1. Maintaining a proper moment/force ratio during the
retraction phase in extraction cases.
2. To allow only root correction and prevent incisors from
flaring.
a) 3rd order bend for anterior teeth
b) cinching the arch wires
c) lacing the entire arch.
Mesial migration of upper molar (rowboat
effect) can be generated So use of Class II elastics is
recommended to prevent it.
3. Auxiliary torquing springs
a mild bowing of the anterior segment is
expected
 Root Torque of Incisors

 Ifincisors tipped lingually more than desired while retraction, Lingual

root torque may be required as a finishing procedure.
In the Begg technique
an auxiliary appliance “piggyback arch” over
the main or base arch wire.
The torquing auxiliary is a “piggyback arch”
 contacts the labial surface of the incisors near the gingival
margin creating the necessary couple with a moment arm
of 4 to 5 mm .
 can be used in edgewise technique in the same way

the basic principle of torquing auxiliary :

the auxiliary arch Initially shaped into a tight circle
when it is partially straightened out to normal arch form
It exerts a force against the roots of the teeth
 With a modern edgewise appliance
 onlymoderate additional incisor torque may be
needed during the finishing stage.
With the 18-slot appliance
a 17 × 25 st.st. arch wire
Built-in torque in the bracket slot
 There is no need to place torquing bends in the
arch wire making the accomplishment of torque
as a finishing procedure relatively straight
forward.
With 22-slot brackets with built-in torque
 full-dimension M-NiTi or beta-Ti arch wires can be used (torque built in) reduce
the need for auxiliary arches.
 Not effective For correcting ligually tipped incisors to place a rectangular steel
arch wire only depending on bracket torque-prescription because the wire creates
too much torsional force and has a very limited range.
 for22-slot edgewise torquing auxiliaries have almost disappeared from
contemporary use
except
 when upright incisors are to be corrected by tipping the crowns facially The
auxiliaries are probably the best way to do this.
IN Class II division 2 malocclusion

If maxillary central incisors are severely tipped lingually

require torquing movement while the lateral incisors need
little torque.
Burstone torquing arch is the most effective torquing
auxiliary Because of the long lever arm, It is equally
effective with the 18- or 22-slot appliance.
Three factors determine the amount of torque
that will be expressed by any rectangular arch
wire in a rectangular slot:
1. the torsional stiffness of the wire
2. the inclination of the bracket slot relative to the
arch wire
3. the tightness of the fit between the arch wire
and the bracket.
 Buccal Root Torque of Premolars
and Molars
Can affect smile esthetics
It is common that at the end of
fixed appliance treatment,
maxillary canines and premolars
Roots are tipped facially and
crowns lingually because the
prescription in many modern
brackets provides negative torque
To obtain a broader and more
pleasing smile,
the solution is not to expand
across the premolars but to
use buccal crown torque so
that the crowns are up
righted This gives the
appearance of a broader
smile without the risk of
relapse that accompanies
arch expansion.
 Midline Discrepancies
 The midline objectives should be evaluated in the intraoral and
extraoral finishing category ( specially the upper arch ).
 Midlines should be coincident.
 >2 mm discrepancy should be treated in the early phases of
treatment.
Midline Discrepancies
This can result from
1- Improper planning or mechanics
a) a preexisting midline discrepancy that was not
completely resolved at an earlier stage of treatment
b) asymmetric closure of spaces within the arch.
2- Skeletal Cause
Skeletal asymmetry
the treatment should be camouflage or surgical correction
3- Dental Cause
caused only by lateral displacements of
maxillary or mandibular teeth that
accompanied by a mild Class II or Class
III relationship on one side.
Tipping is the major type of tooth
movement that can be used to correct
midlines
Treated by anterior cross elastics. Or a
combination of Class II elastics on one
side and Class III on the other can be
used.
 Class II or Class III and anterior cross elastic
should be reserved for small discrepancies
long term use side effect occur in the vertical and
transverse planes
thevertical component of the anterior cross elastic force
cause canting of the occlusal planes
In The Transverse plane, rotation of the dental arches around
the y axis with the use of Class II/Class III elastics may
result in a crossbite tendency on one buccal segment and a
Brodie bite tendency on the other
 Tooth Size Discrepancies
A significant tooth size discrepancy exists
between the dental arches
(i.e. a Bolton discrepancy).
Example:
upper lateral incisors
 lower second premolars
As a general guideline
from Bolton analysis the threshold for clinical significance
of tooth size discrepancy is 2 mm.
 So more than 2mm discrepancy will necessitate steps to
deal with it during treatment. And not be delayed at the
finishing stage
Discrepancies due to excess tooth size
Interproximal enamel reduction (IPR). is the usual strategy
to compensate for discrepancies caused by excess tooth size.
A topical fluoride treatment recommended immediately
after IPR.
Discrepancies due to tooth size deficiency
leave space between the diffident teeth
Finally, will be closed by restorations.

1. composite buildup
2. Laminate veneer
3. Delaying restoration
4. Leaving the space
 1- composite buildup The best plan, Should be done during the finishing stage for
easier and Precise finishing
 The lateral incisor root should be close to ideal position before buildup because
change in root position after buildup will change contact points and embrasure
relationships leading to bad esthetics .
2- Laminate veneers should be delayed because bonding and debonding may
damage the it’s surface.
3- Delaying restoration The main reason for waiting until after the orthodontic
appliance has been removed would be to allow any gingival inflam­mation to
resolve itself. So, the restoration should be done during retention phase.
initial retainer to hold the space and new retainer immediately after the
restoration is completed.
4- Leaving the space distal to the lateral incisor can be esthetically and functionally
acceptable
 Excessive Overbite
 evaluate two things:
1- The vertical relationship between the upper lip and maxillary incisors
If Appropriate maxillary incisors display of the on smile
Maintain this relationship
Make any overbite correction by repositioning the lower incisors.
If Excessive maxillary incisors display of the on smile
intrusion of the upper incisors would be indicated.
2- Anterior face height.
With Short facial height
elongating the posterior teeth slightly (the lower posterior teeth) would be
acceptable
With Long facial height
intrusion of incisors would be needed.
For example: for incisors intrusion:
1. a stabilizing trans-palatal arch
needed
2. cutting the rectangular finishing
arch wire distal to the lateral
incisors
3. Making two segment anterior
segment and buccal segment
4. install an auxiliary intrusion arch
5. That is tied to this Anterior
segment in the appropriate place
if slight elongation of the
posterior teeth is indicated
1. step bends in a flexible arch
wire would be satisfactory.
2. The arch wire before the
final finishing arch wire is
used for these step bends
3. (17 × 25 TMA with the 18-
slot appliance, 21 × 25 M-
NiTi with the 22-slot
appliance).
 Anterior Open Bite
 why the problem exists ?
1. excessive eruption of posterior teeth
2. a poor growth pattern
3. excessive use of inter arch elastics can
be very difficult to correct

 Evaluate two things:

1. The vertical relationship between the
upper lip and maxillary incisors
2. Anterior face height.
With severe long face growth pattern.
intrusion of posterior teeth By Using skeletal anchorage to
be more effective. Or Placing miniplates or palatal anchors
A mild open bite with no facial growth pattern problems
This may be due to an excessively leveled lower arch.
This is managed by elongating the lower incisors creating a
slight curve of Spee in the lower arch ,use vertical elastics to
deepen the bite
-flexible lower arch wire, a stabilizing stiffer upper wire
Final “Settling” of Teeth

A. Methods for Settling the Teeth Into Ideal

Occlusion
B. Control of Rebound and Posturing
C. Removal of Bands and Bonded
Attachments
 A. Methods for Settling the Teeth Into
Ideal Occlusion
 There are three ways to settle the occlusion:
1. Replacing the rectangular arch wires with light round
arches and using light vertical elastics to bring the teeth
together
2. Removing the posterior segments of the arch wires And
Using laced posterior vertical elastics
3. Using a tooth positioner after the bands and brackets have
been removed
1. Replacing full-dimension rectangular wires with light round wires
 the original method for settling recommended by Tweed.
the patient wear light posterior vertical elastics, with light arches wires
(16 mil in the 18-slot appliance, 16 or 18 mil in the 22-slot appliance)
light arches wires
 Allowing some freedom for settling movement of posterior teeth and
This will quickly settle the teeth into final occlusion
 Elastics and light wires should used only a few weeks at most.
Disadvantage
 precise control of anterior teeth is lost.
2. Removing only the posterior part of the rectangular
finishing wire
 leaving the anterior segment (typically canine-to-canine)
and using laced elastics to bring the posterior teeth into
tight occlusion
 Light, not heavy, force is needed.
Disadvantage
 This sacrifices a large degree of control of the posterior
teeth .
Contraindicated with
 should not be used in patients who had major rotations or
posterior crossbite
Indicated for
 patients who had well-aligned posterior teeth from the
beginning
 simple and effective way to settle the teeth into occlusion.
3- Positioners for Finishing
an elastic device was used to assist in finishing in the
pre–straight-wire era ,now almost disappeared from
routine use. Now modified aligners are replacement
for conventional positioners
 B- Control of Rebound and Posturing
We should not be confused
between Rebound & Posturing
Posturing:
 With using Class II elastic force or its equivalent ,patients begin to
posture the mandible forward ,so that the occlusion looks more
corrected than it really is.
 if the appliances are removed at that point The patient slip back toward
a Class II molar relationship and increased overjet. This can lead to 4
to 5 mm of relapse. it is important to detect it and continue treatment to
a true correction
Rebound
which is only due to tooth movement. is a 1 to 2 mm
phenomenon
Control of rebound patient with Class II anterior deep bite
before we stop Class II elastics or another type of Class II
corrector.
The teeth should be taken to
1. an end-to-end incisor relationship
2. both overjet and overbite totally eliminated
 This provides some latitude for the teeth to rebound before final
settling is accomplished.
 Guidelines for using inter arch elastics during finishing treatment
1. When overcorrection has been achieved Elastics force should be
decreased, Or the wear interval reduced (8 to 12 hours per day) and
continued for another appointment interval.
2. At that point, inter-arch elastics should be discontinued 4 to 8 weeks
before removal of the orthodontic appliances To observe changes due to
rebound or posturing
 If changes do occur, another period of elastics is needed.
3. Using elastics to achieve stable occlusion
 as a final step in treatment the teeth should be brought into a solid
occlusal relationship without heavy arch wires present by using one of
the methods described earlier.
C- Removal of Bands and Bonded
Attachments
Removal of bands
For upper molar and premolar teeth,
a band-removing instrument is placed so that first the
lingual then the buccal surfaces are elevated .
A welded lingual bar
 is needed on these bands to provide a point of
attachment for the pliers if lingual hooks or cleats are
not a part of the appliance.
For the lower posterior teeth
 the sequence of force is just the reverse
Bonded brackets must be removed
 as possible without damaging the enamel surface Done by creating a
fracture within the resin bonding material Or between the bracket and
the resin and then removing the residual resin from the enamel surface.
Removal of metal brackets
 applying special pliers to the base of the bracket
so that the bracket bends is the safest method.
Disadvantage
 Is destroying the bracket so cannot be reused
Advantage
 protecting the enamel.
Removal of ceramic brackets
 there
were reports of enamel fractures and removal of chunks of
enamel During debonding ceramic brackets
 Enamel damage more likely with ceramic than metal brackets.

There are three approaches for debonding ceramic brackets:

1. Modify the interface between the bracket and the bonding resin
 toallow the failure to occur between the bracket and the bonding
material. Avoiding Chemical bonds between the bonding resin and the
bracket And Using ceramic brackets designed for mechanical bonding.
2. Use heat to soften the bonding resin so that the bracket
can be removed with lower force.
By using Electrothermal and laser instru­ments So less force
is needed when the bracket is heated, there is little patient
discomfort and minimal risk of pulpal damage.
3. Modify the bracket so that it breaks predictably when
debonding force is applied.
One advantage of a metal slot in a ceramic bracket is that
the bracket can be engineered to fracture in the slot area
which makes it much easier to remove.
 Special Finishing Procedures to Avoid
Relapse
A. Control of Unfavorable Growth
B. Control of Rebound After Tooth Movement
i. Overtreatment
ii. Adjunctive Periodontal Surgery: Sectioning Elastic
Gingival Fibers
A. Control of Unfavorable Growth
 Changes resulting from continued growth in
1. Class II
2. Class III
3. deep bite
4. open bite
 the pattern of skeletal growth contribute to a return of the original
malocclusion and relapse not just to tooth movement.
Controlling this type of relapse
 requires a continuation of active treatment after the fixed appliances
have been removed.
This “active retention” takes one of two forms.
1. continue extraoral force in conjunction with
orthodontic retainers
(high-pull headgear at night, like in a patient
with a Class II open bite growth pattern).
2. using of a modified functional appliance rather
than a conventional retainer
which is much more acceptable to the patient
B. Control of Rebound After Tooth Movement
A major reason for retention is to hold the teeth until soft
tissue remodeling can take place. some rebound occurs Even
with the best remodeling
There are two ways to deal with this phenomenon:
i. Overtreatment
 so that any rebound will only bring the teeth back to their
proper position,
ii. adjunctive periodontal surgery
to reduce rebound from elastic fibers in the gingiva.
i. Overtreatment
Positioning the teeth at the end of treatment in a slightly
overtreated position. Because the teeth will rebound slightly
toward their previous position after orthodontic correction
Only a small degree of overtreatment is compatible with
precise finishing
Consider four specific situations:
1. Correction of Class II or Class III malocclusion
2. Crossbite correction.
3. Crowded and irregular teeth.
4. Rotation correction.
Adjunctive Periodontal Surgery: Sectioning Elastic Gingival
Fibers
the network of elastic supra crestal gingival fibers. As teeth are
moved to a new position, these fibers are stretched, and they
remodel very slowly.
If the pull of these elastic fibers could be eliminated, a major
cause of relapse of previously irregular and rotated teeth
should be eliminated.
relapse caused by gingival elasticity is greatly reduced
if the supra crestal fibers are sectioned and allowed to heal
while the teeth are held in the proper position,.
It can be carried out by either of two approaches.
The first method,
1. originally developed by Edwards, is called circumferential
supra crestal fibrotomy (CSF).
2. After infiltration with a local anesthetic,
3. the procedure consists of inserting the sharp point of a fine
blade into the gingival sulcus down to the crest of alveolar
bone.
4. Cuts are made inter proximally on each side of a rotated
tooth and along the labial and lingual gingival margins
An alternative method
1. is to make an incision in the center
of each gingival papilla,
2. sparing the margin but separating
the papilla from just below the
margin to 1 to 2 mm below the
height of the bone buccally and
lingually.
3. This is said to reduce the possibility
of gingival recession after the
surgery
4. and indicated for esthetically
sensitive areas (e.g., the maxillary
incisor region).
CSF or the papilla-dividing procedure
the surgery should be done a few weeks
before removal of the orthodontic appliance
or, if it is performed at the same time the
appliance is removed, a retainer must be
inserted almost immediately.
full-time retention is needed until the soft
tissues heal, and this is accomplished best by
still having the fixed appliance in place.
 Micro-Esthetic Procedures in Finishing
A. Recontouring the Gingiva to Improve Tooth
Proportions and Display
B. Reshaping the Teeth for Enhanced Esthetics
As a general rule,
1. the soft tissue considerations should be dealt with first,
2. Enameloplasty should be deferred until initial alignment has been
achieved and rotations have been corrected.
Soft tissue recontouring
 The first step in treatment.
 Thisallows ideal vertical placement of brackets at the beginning of
treatment
 so
that gingival margins and placement of incisal edges can be
optimized and provides time for healing
 sothat the apparent proportions of the teeth will not be affected by
soft tissue changes.
Enamel recontouring
should not be done until after the initial phase of
orthodontic alignment because if a tooth rotation is
corrected, the perception of its width is changed
while the height is not, giving a misleading height–
width ratio.
After alignment, reshaping of the teeth can be
carried out as desired but should be completed
before the end of the finishing stage of treatment.
References:
1. Contemporary Orthodontics ,6ed (2019)
2. Biomechanics and Esthetic Strategies in Clinical
Orthodontics ,1ed (2005)
3. Andrews, L. F. The Six Keys to Normal Occlusion, Sept.
1972, AJO.
4. Roth, R. H.: Temporomandibular Pain-Dysfunction and
Occlusal Relationships, The Angle Orthodontist, April
1973.
5. A Gnathologic Approach to Orthodontic Finishing, JCO
1975 Jul (405-417)