Fixed appliance design, function and construction

Fixed appliances are preferred for treating malocclusions because (a) patient
cooperation is not needed (b) they are used to treat more complicated cases of
malocclusion and (c) they capable of effecting greater tooth movements than
removable appliances (d) the results are more predictable and of a higher
standard than those obtained by other methods.
Removable orthodontic appliances can only effect tipping movement, fixed
appliances produce any type of tooth movement by application of controlled
forces to the tooth crown to effect apical and bodily movements, rotations as
well as controlled intrusion and extrusion of teeth. Although they are widely
used fixed appliances are expensive than removable appliances, less
aesthetically pleasing, more complicated therefore requiring training and they
are difficult to keep clean.
D Roberts-Harry & J Sandy (2004) states, There are a variety of fixed
appliances available they all operate in a similar way producing a fixed point of
attachment to control the position of the teeth. Brackets are attached to the teeth
and wires (arch wires) are placed in the bracket slots to move the teeth. The
closer the fit of rectangular arch wires in a rectangular slot on the bracket the
greater the control of the teeth. As treatment progresses, thicker rectangular
wires are used to fully control the teeth in three dimensions. However, they are
relatively complex appliances to use and further training in these devices is
essential.

Fixed orthodontic appliances are clinically or laboratory constructed.

1. Laboratory
Space maintainers these are employed to maintain space between
teeth and prevent crowding so as to allow permanent teeth to erupt
Space regainers function to regain space between drifted teeth to
allow the eruption of permanent successor teeth to early lost
deciduous teeth.
Retainers are appliances used to prevent tooth movement from
relapsing after treatment and they can be removable or fixed.
 Fixed Retainer
Source: http://www.luvmysmile.com/blog/wp-
content/uploads/2016/11/thumbs_pt1after1.jpg
Transpalatal Arch(TPA)

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The TPA is used during mixed dentition to prevent mesial drift of
upper molars during transition from deciduous to permanent
dentition. Furthermore it prevents the rotation of molars, reinforce
posterior anchorage as well as establish and maintain arch width.
Components
The orthodontic bands are for retention and the arch wire is
either passive or active depending on the design and purpose of the
TPA i.e. when the wire is a simple arch the TPA is mainly for
anchorage and retentive purpose but becomes active when a
compound design is used for the arch wire. The active arch may be
used for maxillary expansion and prevention of molar rotation.
2. Components of Fixed Orthodontic Appliances
The principal components of fixed orthodontic appliances are:
Orthodontic Bands
Orthodontic bands have several purposes during the treatment of a
malocclusion:
(a) they protect the tooth from caries
 (b) orthodontic bands serve as attachments for the application of
orthodontic, and sometimes orthopaedic forces.
Attachments

Objects welded or soldered to an orthodontic band are called

attachments.
The attachments serve as points for attaching the arch wires and various
devices for force application.
The commonest attachments are the brackets and tubes which are utilised
for the insertion of the labial arch wires.
The type of attachments utilized in fixed orthodontic therapy depends on
the type of appliance and treatment philosophy of the clinician,
according to the website
http://www.homesteadschools.com/dental/courses/OrthodonticsII/Chapter
02.html

Brackets

There is a wide variety of brackets in use and one commonly used is the edgewise
bracket which is rectangular in shape and the slot is between 0.18 and 0.022 inch
wide and a depth of between 0.025 and 0.032 inch. The rectangular slot
accommodates a rectangular wire in an edgewise fashion, hence the name of
the bracket and technique.

Modification of the shape of the bracket affects tooth movement e.g. narrow
brackets allow the span of arch wire between the brackets making the appliance
more flexible but with wide brackets the span of the arch wire is shorter thus
greater control of rotational and mesio-distal movement of teeth.

Types of Edgewise Brackets

 Single edgewise bracket. Single edgewise bracket
with vertical slot.

Single edgewise bracket Twin edgewise bracket

with vertical slot and with vertical slot.
narrow ligature slot.

Source:
http://www.homesteadschools.com/dental/courses/OrthodonticsII/Chapter02.
html

Twin edgewise bracket with vertical slot is the one in most common use by
orthodontic specialists.

Bonding of Brackets

Brackets were soldered or welded onto orthodontic bands, and the bands were
then cemented to the teeth but these days it is usual now to bond the brackets
directly to the anterior teeth with various acrylic bonding systems.

Tubes

The most posterior teeth on which orthodontic bands are placed get the tubes, and
all other teeth have brackets as attachments.

Maxillary Tubes

Two or three tubes are placed on the upper molar band, one is for the insertion of
the head gear, and the other tube/s receives the labial arch wire/s.

Head gear tube

.

Headgear to reinforce anchorage of upper molars.

This round tube, is used for anchoring headgear apparatus

Arch wire tubes and Mandibular Tubes receive rectangular arch wire are the same
size as the brackets used in the edgewise appliance.

Auxiliaries

Other attachments can be added to the fixed appliance dependent on the treatment
being undertaken e.g. a ball or hook on the facial surface of the band for the
placement of intermaxillary elastics during the treatment of Class II or Class III
malocclusions.

Arch wires.

The requirements of Orthodontic Wires

Non-corrosive
Easily formed
Maintain shape
Controlled and reproducible force delivery

Stainless steel alloy is usually used in modern orthodontics because it is easy to

manipulate and non-corrosive in the oral cavity, and it is capable of an effective
controlled force delivery system. Other alloys such as cobalt-chromium-nickel
and nickel-titanium wire are used to produce the arch wires. The nickel-titanium
alloy is used to make light round wires used during the initial stages of therapy.

Shapes of Orthodontic Wires

Round wires are most commonly used at the outset of orthodontic treatment for
such things as levelling the arch and tooth rotation. When a round wire is placed
in rectangular edgewise a lot there is greater control of mesio-distal tilt, vertical
height and rotational position of teeth.

Upper and lower round arch wires used for initial stages of treatment

Rectangular wires when used after round wires allow the clinician to control the
movement of the tooth in all planes of space. The size of rectangular wires vary
greatly but there is a direct correlation between the size of the arch wires and the
force transferred to the teeth.

Rectangular arch wires used for later stages of treatment.

Segmented or Sectional Wires

These are used in fixed orthodontic cases when only a limited number of teeth
need to be moved.

Upper and lower segmented or sectional arch

wires.

Ligature Wires
The ligature wires are used to secure the arch wire to the bracket so that the proper
forces can act on the tooth. The arch wire can also be fixed to the bracket is with
elastic modules called alastics. This is often done during the final stages of
treatment, or when small forces are required to move a tooth, since the rubber
material tends to stretch and lose its effectiveness.

Elastic modules used to secure the arch wire to the brackets.

Principles of Edgewise System

As previously stated earlier the Edgewise system depends on brackets which
have a rectangular slot, into which a rectangular wire fits so by modifying the
shape of the bracket, and angle of the slot, tooth movement can be achieved. .
The use of rectangular arch wires in conjunction with these brackets can achieve
tooth movements in all three planes of space; these movements are achieved by
the types of bends that are incorporated in an arch wire to produce individual
movements.
FIRST ORDER BENDS
These are made in the plane of the arch wire to compensate for differing
tooth width and bucco-lingual position.
A first order bend between a pre-molar and a molar is called anti-rotation
or toe-in bend and its size varys from individuals to individual. First order
bends in the maxillary and mandibular arch must be coordinated.
In the pre-adjusted edgewise appliance system, first order bends are built
in the bracket bases and buccal tube base. However these may have to be
bent depending on individual requirements of a malocclusion or while
finishing.

SECOND ORDER BENDS

These are made in the vertical plane to achieve the correct mesio-distal
angulation/tilt of the tooth
 For incisors, second order bends (artistic bends) provide the ideal
angulation to these teeth while in the posterior region, second order bends
maintain the distal tipping of the pre-molars and molars and cause bite
opening (pseudo bite opening).
THIRD ORDER BENDS
These bends are only applicable to rectangular arch wires only and they
are formed by twisting the plane of the wire so that when inserted into the
rectangular slot of the bracket a bucco-lingual force acts the tooth apex
generating torque movement.
There are two types of torque movements depending on the type of tooth
movement Buccal (Labial) / Palatal (Lingual) root torque. Buccal
(Labial) / Palatal (Lingual) crown torque.
Torque may be passive or active and also it can be continuous or
progressive torque.
Continuous torque is considered best for the mandibular incisor region
where as progressive torque is recommended in the posterior region.
Active torque - Torque in an arch wire is active when it is capable of
affecting a torque movement of teeth in a segment.
Passive torque in an arch wire is said to be present when it does NOT
produce torque movement on full engagement of the wire. The purpose of
the passive torque is to maintain the already achieved torque.
In pre-adjusted edgewise appliance system, torque values are built-in in the
brackets. However, a variation of torque in a segment or for an individual tooth
may require for finishing. The pre-adjusted systems advantage is that the
amount of wire bending required is reduced but wire adjustments are still
required and also a large inventory of brackets is required for each individual
tooth since each tooth has different requirements for tipping, torque and other
movements.
Lingual orthodontics- this is when orthodontic appliances are fixed at the back
of teeth.
The mechanics of lingual orthodontics are different from those of labial
orthodontics since labial appliances relieve crowding as the arch wire is on the
outside pulling the teeth towards it and so creating space for alignment. In
lingual appliances the tendency is to pull in and therefore increase crowding
hence expansion has to be built into the arch wire.
Lingual appliances are difficult and expensive to install for example it is not
enough to place and align brackets on the lingual aspect of teeth just like on the
labial side because they have thickness and therefore an a acceptable result
wont be achieved but various special methods bracket placement overcomes
the problems.
Lingual Orthodontics has a number of advantages:
i. Aesthetics the appliances are hidden from view and adults prefer them
ii. There is no risk of enamel decalcification
iii. Some of the brackets create a bite plane effect on upper incisors and
canines hence making the useful for treating deep over bites.
Disadvantages
i. The appliances can interfere with speech
ii. Patient tongue discomfit
iii. Technically demanding on the dentist hence longer chair time and
increased cost.
iv. Dentist has to be highly skilled as indirect bonding of brackets is required
as rebonding of failed brackets can be difficult.
v. There is increased bracket loss.

STRAIGHT WIRE TECHNIQUE

 The aim of the standard straight-wire appliance is to move teeth to their
desired location in the ideal arch form. This is done by using straight wire
brackets (standard edgewise) together with a series of preformed arch
wires.
Straight wire brackets are pre-adjusted to effect ideal tipping, torque,
angulation/tilting and in/out positioning movement of each tooth.
When the bands and brackets are cemented and bonded in their ideal
position, the first arch wire is flexed by the dentist to fit into the bracket
slots and ligated it into place.
As the arch wire attempts to return to its original shape (elastic memory)
it exerts a corresponding force on the individual teeth until it lies passive
within the brackets.
By progressively changing the arch wire the normal occlusion is achieved
and after alignment of the teeth, the teeth are retained in position by
replacing the round arch wire with a rectangular arch wire in the medium
term.
Some of the advantages of this system are:
There is limited or no arch wire bending
Shorter overall treatment time which improves patient cooperation
Consistent quality of end results.
Since the ideal tooth position is built into the brackets, once they are
placed correctly, less chair time is required as treatment progresses

Task 3
 Transpalatal Arch Appliance (TPA)
Nance Appliance

Transpalatal Arch Appliance (TPA) - The TPA is manufactured with a solid

transpalatal bar or with an omega loop. The Transpalatal Arch is a wire that
goes across the roof of the palate with bands attached onto the two upper first
molar teeth. The TPA is used during mixed dentition to prevent mesial drift of
upper molars during transition from deciduous to permanent dentition.
Furthermore it prevents the rotation of molars, reinforce posterior anchorage as
well as establish and maintain arch width.
Effectiveness
Samira Diar-Bakirly et al (2017) in their study concluded that, The TPA alone
should not be recommended to provide maximum anchorage during retraction
of anterior teeth in extraction cases. Therefore for this purpose the TPA should
be used with other appliances such as head gear to provide the best anchorage.
Zablocki et al (2008) also concluded while effective during routine orthodontic
treatment for such as molar rotation, buccal root torque, stabilization of the
transverse dimension posteriorly, and maintenance of space in the maxilla, the
use of the TPA as an anchoring device in extraction patients, with the maxillary
first molars splinted together by the connecting wire or bar of the appliance,
reduces forward movement of the maxillary first molars during retraction of
anterior teeth was not substantiated.
Therefore from these studies it can be concluded the TPA is effective in all its
role except as an anchor on its own but can be used in conjunction with other
appliances.
Nance Appliance - The appliance is designed to prevent arch length loss by
sustaining the position of the maxillary molars. Bands are placed on the two
back molars of the upper arch, one on each side, with a wire connecting the
insides of the bands. An acrylic pad covers the wire that touches the roof of the
mouth. The Nance is commonly used to keep the upper molars from drifting
forward. It is also frequently used during full banding and bracketing to create
an anchorage unit.
Effectiveness
Studies have shown that the Nance appliance is widely considered to be an
efficient method of anchorage reinforcement but Al-Awadhi EA et al (2015)
found out that, The Nance appliance did not provide absolute anchorage, but
there was significantly less anchorage loss with it than in the control group. The
majority of anchorage loss occurred during the first 10 weeks in the Nance
group. This was after setting out to assess the amounts of anchorage loss and
desired tooth movement associated with the Nance appliance.
Ari Kupietzky et al (2007) says about the Nance appliance, The appliance is an
effective space maintainer, but soft tissue irritation can be a problem. The
accumulation of bacteria and food debris will often result in palatal
inflammation and, in many cases, pain. The acrylic portion can become
embedded in the soft tissue if the palatal tissue hypertrophies because of poor
oral hygiene or if the appliance is distorted
The Nance appliance is effective but it has disadvantages associated with
prolonged use and other methods should be considered in its place.
Task 4 Compile brief notes which discuss and correlate the processes required
to manufacture laboratory constructed fixed orthodontic appliances from given
prescriptions. Consideration should be given to: band positioning; arch
manufacture; welding and soldering; resin work if applicable; finishing and
polishing techniques.

Construction of the Transpalatal Arch

Materials required, dental model, 0.9mm stainless steel wire, orthodontic
stainless steel bands, pliers, wax, solder and flex material
1. The dental model is soaked in water and using a sharp
scalpel the first molar teeth a shaped until tight fit with the
orthodontic bands is achieved.
2. The bands should be position on the molars such that the
cusps protrude over the bands.
3. The bands are then removed and using a small tungsten burr
the molars are carved and drilled to make a cavity open on
the lingual side and this will facilitate welding of the arch
wire.
4. The arch is made from 0.9mm stainless steel wire or nickel
titanium wire and a loop is incorporated at middle of the
wire before it is contoured to the shape of the palatal arch.
5. Tags are formed at both ends of the wire

6. As the arch is be contour a strip of 1mm wax is placed on the

palate so that a gap is left between the wire and the palate
surface. This will prevent the wire from digging into the soft
mucosal tissue leading to irritation and infection
7. Once the arch has been made it is welded to the bands using
an electric welded making sure that the current is not too
powerful to form holes in the bands
8. The assembly is then placed back on the cast model and wet
aluminium flux is applied to the weld joints after which the
joints are then soldered using a hot flame
9. The joints are allowed to cool for a second before being
plunged in cold water which has the effect of exfoliating the
flux due to rapid temperature change.
10.The soldered assembly is removed from the cast, polished by
a burr to smooth out any projections and remove any
residual flux. The assembly is then polished and waxed.
Reference
1. D Roberts-Harry & J Sandy, Orthodontics. Part 5: Appliance choices,
British Dental Journal 196, 9 - 18 (2004)
2. https://www.slideshare.net/drtonypious/lingual-orthodontics-52120497
3. http://www.homesteadschools.com/dental/courses/OrthodonticsII/Chapter
02.html
4. Charles H. Tweed (1941) The Application of the Principles of the Edge-
wise Arch in the Treatment of Malocclusions: II.. The Angle
Orthodontist: January 1941, Vol. 11, No. 1, pp. 12-67.
5. Samira Diar-Bakirly, Murilo Fernando Neuppmann Feres, Humam
Saltaji, Carlos Flores-Mir, and Tarek El-Bialy (2017) Effectiveness of the
transpalatal arch in controlling orthodontic anchorage in maxillary
premolar extraction cases: A systematic review and meta-analysis. The
Angle Orthodontist: January 2017, Vol. 87, No. 1, pp. 147-158.
6. Heather L. Zablocki, James A. McNamara Jr, Lorenzo Franchi, and Tiziano
Baccettic, Effect of the transpalatal arch during extraction treatment
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 6, June 2008
7. Al-Awadhi EA, Garvey TM, Alhag M, Claffey NM, O'Connell B,
Efficacy of the Nance appliance as an anchorage-reinforcement method.
Am J Orthod Dentofacial Orthop. 2015 Mar;147(3):330-8
8. http://www.aapd.org/assets/1/25/235-8.pdf
9. Ari Kupietzky, DMD MSc1 Eli Tal, DMD2 The Transpalatal Arch: An
Alternative to the Nance Appliance for Space Maintenance, PEDIATRIC
DENTISTRY V 29 / NO 3 MAY / JUNE 07