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Fixed appliance

  1. 1. Fixed orthodontic appliane BY PROF DR MAHER FOUDA Faculty of dentistry Mansoura Egypt
  2. 2. Ceramic brackets • Fracturing away of the wings of the ceramic bracket makes tying in the archwire difficult , and in addition the brackets tend to break up during removal of the appliance . A fractured, single-crystal ceramic bracket (star-fire, “A” Company, CA), caused by the brittle nature of the material.
  3. 3. Ceramic brackets • The hardness of ceramic brackets can lead to wear of opposing teeth; therefore using ceramic brackets for lower incisors is inadvisable. The hard ceramic can also notch the archwire, which makes sliding the teeth along the wire difficult. Ceramic brackets after patients an esthetic smile while undergoing orthodontic treatment.
  4. 4. Ceramic brackets Special instruments are recommended by various manufacturers to debond ceramic appliances. This instrument, by Unitek/3M should be fully and firmly seated before the debonding force is applied.
  5. 5. Ceramic brackets Colored jugs aid the practitioner in the correct placement of the ceramic appliances. These jigs are removed after the adhesive has set.
  6. 6. Ceramic brackets Initiation of cuspid retraction using a rectangular, superelastic NeoSentalloy (GAC) wire immediately after racket placement. Three months into treatment. The extraction space is closed. Space closure occurred rapidly due to the presence of osteoclastic activity brought about by the extraction of the bicuspid: 30% of this closure was the result of the tipping of the teeth.
  7. 7. Ceramic brackets Five months into treatment, the tipped teeth have uprighted into a solid class I occlusion simply by holding them tied together (with a ligature figure-8 pattern) as the prescription in the preadjusted appliance bracket system is given the time to “work-out” in relation to the wire. Regardless of the bracket type used, brackets should all be placed in the middle of each tooth, at the same distances (x) from the incisal edge, with the exception of the cuspids, which should be 1mm more gingivally (x+1mm), and molar teeth, which should be 1mm more occlusally (x – 1mm). This bracket placement ensures cuspid guidance at the end of treatment and minimizes the extrusion of the molar teeth, which may otherwise lead to interferences.
  8. 8. Ceramic brackets Ceramic brackets
  9. 9. Ceramic brackets The rectangular superelastic NeoSentalloy (GAC) archwire provides the greatest archwire flexibility available today, as well as control of torque from the onset of treatment. The same patient after 1 month. Note that the cuspid has almost reached the occlusal plane (5 mm movement). No patient discomfort was expressed.
  10. 10. Orthodontic adhesives • The most popular cement for cementing bands is glass ionomer mainly because of its fluoride releasing potential and affinity to stainless steel and enamel . Glass ionomer cement.
  11. 11. Orthodontic adhesives • Glass ionomer can also be used for retaining bonded attachments, but unfortunately the bracket failure rate with this material is greater than that with composite . Glass ionomer cement.
  12. 12. Orthodontic adhesives • Use of the acid- etch technique with a composite produces clinically acceptable bonded attachment failure rates of the order of 5 – 10 per cent for both self and light cured materials. After isolation with cheek retractors (for both arches) or cotton rolls (for single- tooth procedures), the teeth are pumiced and adequately rinsed, followed by acid etching with a disposable brush for 15 seconds.
  13. 13. Orthodontic adhesives • Although conventional self cured composite can be used for bonding, a modification has been manufactured specially for orthodontics to circumvent the problem of air bubbles which would compromise bond retention . Thorough rinsing and drying are absolutely necessary in order to obtain the chalky-white etched tooth surface that allows for a good bond. At this point, the tooth is ready to receive the bracket.
  14. 14. Orthodontic adhesives • No – mix orthodontic composites comprise an activator which is painted onto both the bracket base and the tooth surface ( after etching) . Following this , a small amount of the composite itself is applied to the bracket which is then placed on the tooth surface under pressure . Most adhesives come with two parts: a liquid form and a paste form.
  15. 15. Orthodontic adhesives • Squeezing the sandwich of composite and catalyst into a thin layer mixes the two components, and the material usually sets within few minutes . The liquid part is applied onto the tooth surface with a brush by the clinician.
  16. 16. Orthodontic adhesives • Whatever material is used , any excess should be cleared from the perimeter of the bracket before the final set to reduce plaque retention around the bonded attachment . The paste is placed onto the bracket base by the chairside assistant.
  17. 17. Orthodontic adhesives The bracket is then placed on the center of the tooth with a special holding plier or even a pair of cotton pliers. The clinician then aligns the bracket along the long axis of the tooth at a specific distance from the incisal edge.
  18. 18. Orthodontic adhesives This is more easily done for the twin and deltoid brackets with the perio probe, due to the convenient shape of these appliance. At the end, as a final check, the bracket is checked with a mouth mirror to ensure that it is aligned properly.
  19. 19. Bracket positioning
  20. 20. Bracket positioning
  21. 21. Attachments for bonding on to displaced teeth. Cleat, button and eyelet.
  22. 22. Auxiliaries • Very small elastic bands, often described as elastomeric modules, or wire ligatures are used to secure the archwire into the archwire slot. Elastic modules are quicker to place and are usually more comfortable for the patient, but wire ligatures are often preferred, particularly in the later stages of treatment, as they can be tightened to maximize contact between the wire and the bracket. Intra-oral elastics.
  23. 23. Auxiliaries
  24. 24. Intraoral elastics Cut from pure surgical latex tubing for the highest elasticity and resistance to oral liquid. All packages indicate the diameter size and the elastic pull which comes into force when the elastic is stretched to the three times its diameter. All packages are differently color coded for easy reference. Box of 10 bags, 100 elastics each bag. Intraoral colored elastic High elasticity and fatigue resistance Extraoral elastics Cut from pure surgical latex. Prepackaged in bags of 100 Extraoral elastics kit Assorted box of 10 bags, 1 each diameter and pull force, 100 elastics each bag.
  25. 25. Applicator for intraoral elastics
  26. 26. Power chain Elastic chains kit K6429-93 transparent K6469-93 grey K6489-93 Ivory Prepackaged with 6 spools of assorted elastic chains, three short, two closed and one long, conveniently organized on a plexyglass rack. Available in three colors.
  27. 27. Auxiliaries • Intra – oral ( latex ) elastics for traction are commonly available in 2 oz and 3.5 oz strengths and a variety of sizes , ranging from 1/8 inch to ¾ inch .For most purposes they should be changed every day.
  28. 28. Auxiliaries • Palatal or lingual arches: they can be used to reinforce anchorage or to achieve expansion (the quadhelix appliance). Some designs have the additional advantage of being removable, thus facilitating adjustment . Brackets bonded to palatally placed canines, allowing the application of orthodontic forces to the teeth. The circle hook in the sectional buccal archwire acts as a guide for the elastic thread and ensures the correct application of the force to bring the canine buccally.
  29. 29. Auxiliaries A palatal arch, called a Nance bulb, which is used to help provide additional anchorage in the upper arch by helping to resist forward movement of the molars. A proprietary removable quadhelix. The distal aspect of the arms of the helix slot into the lingual sheaths (also shown) which are welded onto the palatal surface of bands on the upper molars.
  30. 30. Archwires • In the initial stages of treatment a wire which is flexible with good resistance to permanent deformation is desirable , so that displaced teeth can be aligned without the application of excessive forces . A Sentalloy (GAC) round NiTi wire is placed as the initial archwire in the maxillary arch. A 0.012-inch, round, stainless steel wire is placed in the lower arch. The upper lateral incisors and bicuspids were not incorporated in this alignment phase in order to avoid unnecessary tipping of these teeth.
  31. 31. Archwires
  32. 32. Archwires • In the later stages of treatment rigid archwires are required to engage the archwire slot fully and to provide fine control over tooth position while resisting the unwanted effects of other forces, such as elastic traction. After 3 months of treatment, the cuspid has reached the occlusal plane. A 0.016- inch round wire is the next size of stainless steel wire that is placed in the lower arch.
  33. 33. Physical properties of archwires (1) Springback: This is the ability of a wire to return to its original shape after a force is applied. High values of springback mean that it is possible to tie in a displaced tooth without permanent distortion. Anterior view. The cuspid teeth have been brought into the arch without any side effects (the overbite is still 3 mm). The diastema has almost closed. Had the two central incisor teeth been wire tied together with a ligature tie, the diastema would not have been created
  34. 34. Physical properties of archwires ( 2 ) Stiffness: The amount of force required to deflect or bend a wire. The greater the diameter of an archwire the greater the stiffness. Six months into treatment, 0.016x0.022- inch 2 stainless steel finishing wires are placed in both arches.
  35. 35. Physical properties of archwires (3) Formability: This is the ease with which a wire can be bent to the desired shape, for example the placement of a coil in a spring, without fracture . Anterior view. Elastic chains help in closing of any remaining spaces in the lower arch.
  36. 36. Physical properties of archwires (4) Resilience: This is the stored energy available after deflection of an archwire without permanent deformation (5) Biocompatibility. Eight months into treatment, a figure-8 configuration of ligature wire (from the left first molar to the right one) consolidates and keeps the teeth in contact after space closure.
  37. 37. Physical properties of archwires (6) Joinability: This is whether the material can be soldered or welded (7)Frictional characteristics: If tooth movement is to proceed quickly a wire with low surface friction is preferable. Initiation of cuspid retraction using a rectangular, superelastic NeoSentalloy (GAC) wire immediately after bracket placement.
  38. 38. Archwires Properties of some of the more commonly used archwire materials SS. stainless steel: NiTi, nickel titanium: TMA, β-titanium: CoCr, cobalt chromium. CoCr wires can be manipulated in the softened state and then heat-treated to increase resistance to deformation. SS NiTi TMA CoCr* Springback Low High Medium Low Stiffness High Low Medium High Formability Good Poor Good Good Resilience Low High Medium Low Biocompatibility Good ? Good Good Friction Low Medium High Medium
  39. 39. Archwires • The most popular wire is stainless steel because it is inexpensive, easily formed and exhibits good stiffness. Because of these characteristics, stainless steel is particularly useful in the later stages of treatment. More flexible stainless steel wire have been developed which consist of three or more strands of fine stainless steel wire twisted or braided together. There are known as multistrand or twistflex wire and they are more flexible than a solid stainless steel wire of comparable diameter. Multistrand wires can exert too high a force , and be distorted if tied into a markedly displaced tooth. The most popular archwire material is stainless steel which is available in straight lengths, as a coil on a spool or pre-formed into archwires. Three months into treatment. The extraction space is closed. Space closure occurred rapidly due to the presence of osteoclastic activity brought about by the extraction of the bicuspid; 30% of this closure was the result of the tipping of the teeth.
  40. 40. Archwires Multistrand wire: wound onto a coil and as an initial archwire to align the upper arch.
  41. 41. Archwires • Nickel titanium wire has a greater resistance to deformation and greater flexibility. Nickel titanium archwires are capable of applying a light force without deformation , even when deflected several millimeters, but this alloy is more expensive than stainless steel. Nickel titanium wires provide less control against the unwanted side-effects of auxiliary forces . Nickel titanium wire. Five months into treatment, the tipped teeth have uprighted into a solid class I occlusion simply by holding them tied together (with a ligature) as the prescription in the preadjusted appliance bracket system is given the time to “work-out” in relation to the wire.
  42. 42. Archwires • Cobalt chromium can be readily formed , and the stiffness and rigidity can be improved by heat treatment. B-titanium or TMA (tungsten molybdenum alloy), has properties midway between stainless steel and nickel titanium. B-titanium wire exerts half the force of a stainless steel of comparable diameter.
  43. 43. Archwires • Archwires are described according to their dimensions. An archwire described as 0.016 inches (0.4 mm) is around archwire, and an 0.016 X 0.022 inches (0.4X0.55), is a rectangular archwire . Patient before treatment. Note the good buccal intercuspation of teeth. Development of posterior open bite from incorrect bracket placement and arch incoordination.
  44. 44. Archwires • Archwires are available in straight lengths, as coils, or as performed archwires which is more costly to buy but saves chairside time. Patient in fixed appliances during
  45. 45. Archwires • There are a wide variety of archform shapes ; however , regardless of what design is chosen . Some adjustment of the archwire to match the pretreatment archform of the patient will be required . The amount of adjustment required to a pre- formed lower archwire, as taken from the packet, to ensure that it conforms to the patient’s pretreatment archform and width. Incorrect bracket placement, lack of coordination in the archwires, and lingual tipping of teeth during space closure led to the development of this open-bite situation.
  46. 46. Ready-made Archwires Preformed round and rectangular archwires: Standard preformed. Made out of extra spring hard wire for higher resiliency. Marked at the midline, black for upper and red for lower. Marking pencils for arches, bite planes, etc. Standard arches holder
  47. 47. Archwires • The force exerted by a particular archwire material is given by the formula : Where d is the distance that the spring / wire is deflected ,r is the radius of the wire , and l is the length of the wire . Archwire “skewed” to the left.
  48. 48. Ligation of Archwires The placement of the elastomeric modules (“O” rings) over the bracket is done with a hemostat. The module is hooked around one wing and then with the baseball “horme-run” twisting motion, all four rings of the twin bracket are engaged.
  49. 49. Ligation of Archwires
  50. 50. Ligation of Archwires
  51. 51. Ligation of Archwires For the hook-up of the elastic chains, the procedure is quite similar: on insertion of one of the loops, the chain is stretched and the rest is tied in a similar manner.
  52. 52. Ligation of Archwires To secure the archwire in the bracket slot tightly, a ligature wire-tie is used. It is placed beneath first the mesial wings of the bracket and then the distal ones while sliding along the main archwire. At this point, the two legs are crossed over, twisted by hand a few times, and then securely tightened with a hemostat. The excess ligature is cut off and the remaining 3-mm twisted part is placed beneath the main arch wire. When removal of a ligature wire-tie is desired, a ligature-cutter plier may be used to cut the wire and, without letting go of it, the ligature the is removed with the same plier.
  53. 53. Ligation of Archwires Eight elastomeric module
  54. 54. Metal ligatures for securing the archwire into the bracket slot. This patient’s upper archwire has been tied into place with wire ligatures in the upper arch and with elastomeric modules in the lower arch.
  55. 55. Archwires • Increasing the diameter of the archwire will affect the force applied to the teeth. • Increasing the length or span of wire between the brackets will inversely affect the applied force . Deactivated coil spring after significant distal molar movement.
  56. 56. Archwires • The distance between the brackets can be increased by reducing the width of the brackets, but the interbracket span can also be increased by the placement of loops in the archwire . Starting 0.016-inch stainless steel archwires. A maxillary looped archwire was used to bring down the canine. A molar stop preserved arch length. Light (2 oz) class II elastics helped open the bite and corrected the class II interarch relationship. A mandibular preformed looped 0.016- inch, stainless steel archwire, alleviated crowding. A “plain” maxillary 0.016-inch archwire with molar stops preserved space for canines.
  57. 57. Archwires • Prior to the introduction of the newer more flexible alloys, multilooped stainless steel arhwires were used in the initial stages of treatment. Loops are still utilized in retraction archwires and where a combination of a rigid archwire (to resist unwanted forces) with localized flexibility is required . Lack of space for the second mandibular premolar Nickel-Titanium wire in a bell shape curve note the position of the stops. Note the space opening amount after 8 weeks with a single activation. The Nickel- Titanium wire is flat and enough space is created for the un-erupted premolar.
  58. 58. Archwires • When a fixed appliance is first placed a flexible archwire is advisable to avoid applying excessive forces to displaced teeth , which can be painful for the patient and result in bond failure. The coil spring can be easily reactivated without taking out the main archwire, simply by compressing it distally with a sealer and adding the residual springs from the adjacent interbracjet area. The clinician should try to avoid cutting the springs in a way that may impringe on the soft tissue. As soon as all posterior teeth and the cuspid have been sequentially brought back with the coil springs, the four incisor teeth can then be retracted with elasiomeric chains. The distal movement of the bicuspid teeth can be reinforced with a sentalloy (GAC) closed coil spring that extends from the first molar hook to a hook on the bicuspid bracket. The stop in the archwire right in front of the first molar prevents its movement mesially.
  59. 59. Archwires • Either a multistrand stainless steel archwire or a preformed nickel titanium archwire is used to achieve initial alignment. Alternatively , loops can be placed in a stainless steel archwires, to increase the span of wire between brackets and thus increase flexibility. This approach is useful if a rigid archwire is desirable in other areas of the arch .
  60. 60. Archwires Anterior view. Compare the vertical activation of more than 7 mm of the Sentalloy (GAC) round wire in the maxillary arch to the 0-5 mm of activation of the 0.012-inch stainless steel wire in the mandibular arch. Move on from the initial aligning archwires as soon as alignment is achieved, as by virtue of their flexibility they do not afford much control of tooth position . After 1 month of treatmen. The cuspid tooth has come down 3 mm. A 0.014-inch rounf wire is placed in the lower arch as the next step of stainless steel mechanotherapy. Full bracket engagement should be achieved before proceeding to a more rigid archwire. It is usual to progress through round archwires of increasing diameter to achieve progressively better intra-arch alignment .
  61. 61. Archwires If tooth alignment alone is required, for example in a Class I malocclusion with rotations, a stiff round archwire which nearly fills the bracket slot will suffice. Correction of inter-arch relationships and space closure is best carried out using rectangular wires for apical control. The exact archwire sequence will depend upon the dimensions of the archwire slot and operator preference. Anterior wire. Note that there is a slight diastema that has opened between the central incisors as these teeth moved slightly mesially from the reaction to the cuspid movement. After 2 months of treatment. The initial activation of the upper wire has brought the cuspids 5mm more occlusally.
  62. 62. Mesiodistal tooth movement • Mesiodistal tooth movement cab be achieved by: (1) Moving teeth with the archwire by incorporating loops into the archwire, which, when activated, move a section of the archwire and the attached teeth. A traction ligature to apply a force from the molar hook to the archwire. A sectional archwire to retract /3.
  63. 63. Mesiodistal tooth movement (2) Sliding teeth along the archwire under the influence of elastic force. A greater force is required to overcome friction between the bracket and the wire, and therefore places a greater strain on anchorage. This type of movement is known as sliding mechanics . Sliding teeth along the archwire using a nickel titanium coil spring. Compressed coil spring to open space.
  64. 64. Mesiodistal movement • Sliding mechanics is more applicable to pre–adjusted appliances where a straight wire is used. In the edgewise appliance the first- second- and third order bends necessary in the archwire make sliding teeth along it difficult . After only 5 weeks, on return of the patient for her first adjustment appointment. the molar had moved distally more than 4 mm! The cuspid was still in a class I occlusion and the overjet was the same as before, thus emphasizing that the adverse effects of this system (increase in the overjet, flaring of the anterior teeth) are kepi to a minimum or that they do not have the time to express themselves before the desired distal molar movement takes place.
  65. 65. Adjustment of fixed appliance • Adjustment to the appliance need to be made on a regular basis , usually every four to six weeks. Once space closure is complete and incisor position corrected, a more flexible full–sized archwire is tied on in conjunction with vertical elastic traction to help sock–in the buccal occlusion. In order to overcome the tendency for relapse of rotational and apical movements, overcorrection should done. Anterior view. The overbite has decreased by 1 mm due to the patient’s slight vertical growth pattern.
  66. 66. Fixed appliance system • Preadjusted appliances: The need for first, second and third order bends in the archwire during treatment is reduced because the brackets are manufactured with the slot cut in such a way that these movements are built in. Therefore plain preformed archwires can be used so that the teeth are moved progressively from the very start of treatment to their ideal position. Hence they are also known as the straight wire appliance. Upper right canine ovation bracket. Compond contour base and slot aligment with reference point on the tooth crown.
  67. 67. Pre – adjusted fixed appliances • As individual tooth positions are built into the bracket , it is necessary to produce a bracket for each tooth , but the time saved in wire bending and the superior results achieved compensate for the cost of brackets . Difference between preadjusted edgewise (A) and fully adjusted appliances (B).
  68. 68. Pre – adjusted fixed appliance • The pre–adjusted bracket system will not eliminate the need for wire bending as only average values are built into the appliance, and often additional individual bends need to be placed in the archwire. Original Roth Rx appliance (1975) (left) and Andrews standard straight wire appliance (right).
  69. 69. Pre – adjusted fixed appliance • There are many different opinions as to the correct position of each tooth, the result is several pre – adjusted systems, all with slightly differing degrees of torque and tip. Of these the best known is the Andrews’ system. Right side of patient’s mouth with Ormco/”A” Co. appliance with Roth Rx. Left side of patient’s mouth with GAC Roth Rx appliance.
  70. 70. Looped archwire Space-holding loop, which may be adjusted for vertical or horizontal movements. Box loop, activated. Vertical arms may also be formed to engage the brackets of adjacent teeth for space opening. An inverted box loop will provide light, well- controlled buccolingual force. The wire shown is .018 inch (.45 mm), with the base tightly wrapped with ,020-inch (.5-mm) soft brass wire to provide stiffness for arch form control across the loop. This loop will move a single tooth out of crossbite with minimum adjustments and good vertical control. A delta-shaped loop, with or without the helices shown here, provides good flexibility in all vertical and horizontal directions.
  71. 71. Pre – adjusted fixed appliance Mesh base on Ovation bracket (left) and Ormco/”A” Co, bracket (right). Ovation bracket (left) and Ormco/”A” Co, appliance (right), both with Roth Rx. GAC maxillary premolar Ovation bracket (top) and Ormoc/”A” Co. bracket (bottom), both with Roth Rx.
  72. 72. Overjet reduction. Fixed appliances have been used to retract the incisors bodily.
  73. 73. Begg fixed appliance • Named after its originator , the Begg appliance is based on the use of round wire which fits fairly loosely into a channel at the top of the bracket . Apical and rotational movement is achieved by means of auxiliary springs or by loops placed in the archwire . Three stage begg bracket
  74. 74. Begg fixed appliance • Begg used ‘differential force systems’ to accomplish tooth movement, claiming that the intra–oral forces were adjusted so that they were optimal for movement of the anterior segment teeth whilst ensuring that the posterior segment teeth acted as an anchorage unit . Transfer patient. The small button on the upper right cuspid will not retain a class II or horizontal elastic and should be replaced by a cleat. Elastic thread attached to lingual cleats for rotation.
  75. 75. Begg fixed appliance • The Begg appliance was often used in conjunction with extractions to provide intra–oral anchorage so that reliance was not placed on the patient’s wearing headgear. However, patient compliance with wearing elastics for the duration of treatment was required. Combining anterior and horizontal elastics. A, Anterior elastic placed from the lock pin of the upper right central to the helical intermaxillary hook on the left side for space closure of the upper incisors. B, Horizontal elastic placed from the buccal tube to the intermaxillary hook to complete space closure in the upper buccal segment and assure that the anterior elastic force will move the upper centrals to the patient’s left in order to correct the midline relationship. Note: A class II elastic was also placed to complete closure of the lower first molar extraction space and also to help assure midline correction. C, Overcorrection of midline relationship at band removal. D, Midline relationship at time of final records.
  76. 76. Begg fixed appliance • Apart from the problems experienced by patients cleaning around the auxiliary springs favoured in the Begg technique, the main drawback to this appliance is that it is difficult to position the teeth precisely at the end of treatment .
  77. 77. Begg fixed appliance • Ahybrid between the Begg appliance and a pre–adjusted bracket was introduced to overcome incorrect positioning of teeth at the end of treatment. This hybrid is called Tip – edge appliance which serves to highlight the advantages of the pre – adjusted systems . Begg appliance-uprighting springs on the canines and torqucing auxillary on the incisors.
  78. 78. Decalcification and fixed appliances • Placement of a fixed appliance upon a tooth surface leads to plaque accumulation. In addition, if a diet rich in sugar is consumed this results in demineralisation of the enamel surrounding the bracket and occasionally frank cavitation. The incidence of decalcification with fixed appliances has been variously reported as between 15 and 85 per cent . Decalcification after fixed appliance treatment, which is particularly marked around the gingival margins of 2/ 4/ Decalcification associated with a loose molar band.
  79. 79. Decalcification and fixed appliances • Reducing decalcification can be attained by: (1) Fluoride mouth rinses for the duration of treatment. (2) Local fluoride release from fluoride – containing cements and bonding adhesives. Glass ionomer cements have been shown to be effective at reducing the incidence of decalcification around bands, whilst achieving equal or better retention than conventional cements .Although glass ionomer cements appear effective at reducing decalcification around bonded attachments, this is at the expense of poorer retention rates.
  80. 80. Decalcification and fixed appliances Plaque accumulation around the direct bonded orthodontic bracket visualized by disclosing solution. a,b,c,: Successive degrees of hampering of the oral hygiene around the direct bonded orthodontic bracket. d: Red coloring of the border composite-enamel.
  81. 81. Decalcification and fixed appliances
  82. 82. Reducing enamel decalcification (3) Brushing and flossing .
  83. 83. Plak control-Battery (D4) •9.600 Oscillating per minute. •1 EB4 brush head with interdental tips. •Travel cap for bursh head. •Supplied with two duracell batteries giving 3 months use when used twice a day. Plak control Ultra Rechanrgable (D9) •7.600 Oscillating movements per minute. •New green flexisoft bristles with a unique dual structure, bend when in contact with water. 3D Rechanrgable (D15) •Supplied with 1 EB15 flexisoft brush head. •7.600 Oscillation movements per minute. •20.000 pulsating movements per minute. •Pressure sensor system. •2 minute memory timer. 3D excel Rechanrgable (D17) •Stoarge tower for 4 brush heads. •Supplied with 2 EB17 flexisoft brush heads and 2 IP17 interspace brush head. •2 speeds. •7.600 Oscillation movements per minute. •20.000 pulsating movements per minute. •Pressure sensor system. •2 minute memory timer. •Travel case for handle and two brush heads.
  84. 84. Oral care centre (OC15) •Combines Bran oral-B trush and Oxyjet oral irrgator technology. •A complete oral care solution in s ingle appliance. OxyJet (MD15) •Micro bubble technology (mixes air and water using an air filter to form microbubbies). •Multi-function jets producing two different water streams. •Adjustable water pressure control. •Wall mounting bracket.
  85. 85. Reducing enamel decacification (4) Dietary advice. • Patients are advised to avoid chewy sweets during treatment. They should be also advised avoiding sugared beverages and fizzy drinks between meals . A persistent rough enamel surface after a terminated orthodontic treatment with fixed bonded appliances. Discoloration of the enamel surface due to diffusion of corrosion products from the bracket base into the tissue.
  86. 86. Reducing enamel decacification Damage to the labial surface contour of the central incisors after debonding plastic brackets. White spot formation around the direct bonded bracket caused by inadequate oral hygiene.
  87. 87. Reducing enamel decacification Caries and cavity formation around the direct bonded bracket in a case of extremely neglected oral hygiene. Disclosing solution identifies the plaque retention at the edge of the resin adhesive, where cleaning is difficult.
  88. 88. Hyrax ® Expansion screws For mid-palatal suture separations by means of fixed appliances without the need for acrylic plates. Metal frame-work used in combination with preformed bands which are soldered to the retention arms. The appliance works quickly and is easy to keep clean. Laser marked arrow, indicating the opening direction. Expansion: 602-807 = 7 mm 602-813 = 11 mm 1 x = 0.90 mm Laser marked arrow, indicating the opening direction. Safetly key for hyrax ® Expansion screws Because of its size the key is not likely to be swallowed. Included with every Hyrax ® expansion screw. SPECIAL EXPANSION SCREWS All expansion screws are marked with an arrow indicating the opening direction Locking device for a removable palatal arch. Quahelix
  89. 89. Lower lip bumper to restrict forward movement of lower molars.
  90. 90. Mandibular advancer. It is sometimes more effective to rotate a tooth into alignment in successive in successive stages, rather attempt to force it bough it broadside through a limited space. A delta-shaped loop, with or without the helices shown here, provides good flexibility in all vertical and horizontal directions.
  91. 91. The Jones jig appliance, start of treatment. Maxillary molars distalized with Jones jip appliance.
  92. 92. The light labial arch appliance (2-by-4 appliance) with adjustment loop can be used for labial repositioning of the maxillary as well as mandibular incisors. (A) Right and (B) buccal views.
  93. 93. (A) An 8-year-old child with anterior crossbite of the maxillary left lateral incisor. (B) Light labial arch (2-by-4) appliance was used to reduce the anterior crossbite. (C) Sometimes an open coiled spring and a posterior bite plane may be added to facilitate the crossbite correction. (D) An anterior inclined plane in combination with the light labial arch for correction of more than one incisor in crossbite.
  94. 94. (A) An 11-year-old child with a class II division 2 malocclusion. The maxillary incisors are retroclined, causing interferences on closure. The mandible is shunted backward causing the condyles to seat distally in the fossae. This child also exhibits signs of early temporomandibular joint dysfunction. (B) treatment of vertically inclined maxillary incisors with utility arches. (C) lateral cephalogram showing the deep bite.
  95. 95. Modification of the Andresen activator after Bjork. The lingual wings have been reduced for patient comfort. The appliance is anchored to the teeth by modified ball clasps at the first molars. The advantage of this modification is that the appliance is fixed to the teeth and does not fall down during speech. The disadvantage is that some patients do not hold their mandible forward in the appliance during sleep.
  96. 96. The function regular (FR2) by Frankel. (A) The appliance has large shields to keep the cheeks, with the buccal musculature, away from the dental arches in order to promote transverse arch development. The buccal shields are extended maximally into the mucobuccal fold to stretch the periosteum and promote bone development in this area. (B) Lateral view of the appliance showing the extension of the buccal shield. The lower labial lip pads are placed as deep as possible in the sulcus to stretch the tissues and help in stabilizing the appliance. (C) Lingual view of the appliance with the lower lingual pad that is placed below the teeth and the marginal gingiva. The intention with the lingual pad is to exert pressure on the sensitive mucosa if the patient brings the lower jaw back from the postural position. The cross-over wires connect the lingual pad with the buccal shields without contacting the lower teeth. (D) palatal view of the function regulator. The transpalatal wire stabilizes the appliance against the first molars and adds strength to the appliance to minimize breakages. There are occlusal stops at the maxillary first molars to control their eruption ad stabilize the appliance vertically. Notice the heavy crossover wires at the first bicuspids. Lingual to the maxillary incisors, a palatal wire prevents the eruption of these teeth and supports them against lingual tipping.
  97. 97. The pfeiffer-Grobety appliance. (A) frontal view of the appliance showing acrylic coverage of the lower incisors to prevent proclination. (B) The lateral view shows a posterior bite opening of 3 to 4 mm and the Dominique retention springs. The springs are extended forward to facilitate appliance insertion and removal. (C) lateral view showing the deep lingual wings and the Dominique springs. The areas where acrylic is trimmed away to permit eruption are indicated on the appliance. (D) Palatal view showing the expansion screw often used to increase the arch widths and eliminate minor crowding.
  98. 98. Herbst appliance with lower acrylic splint.
  99. 99. Frankel appliance